Antepartum fetal surveillance: Number 9, October 1999 ( replaces Technical Bulletin Number 188, January 1994 ) Clinical management guidelines for obstetrician-gynecologists

Maternal serum glycosylated hemoglobin and fasting plasma glucose predicts gestational diabetes at the first trimester in Turkish women with a low-risk pregnancy and its relationship with fetal birth weight; a retrospective cohort study

OBJECTIVE

To examine the accuracy of maternal serum glycosylated hemoglobin (HbA1c) and fasting plasma glucose (FPG) levels in predicting gestational diabetes at the first trimester in Turkish women with a low-risk pregnancy and its relationship with fetal birth weight.

METHODS

This cohort study was conducted retrospectively in a tertiary referral hospital from January 2010 to January 2017. HbA1c and FPG serum concentrations were measured in 670 pregnant women at the first-trimester screening. HbA1c and FPG concentrations of women who subsequently developed gestational diabetes mellitus (GDM) were compared to those who did not, and its relationship with fetal weight was investigated.

RESULTS

First-trimester screening was performed on 608 pregnant women, of whom 69 (11.3%) women had developed GDM. Median HbA1c and FPG concentrations were significantly higher in women developing GDM (n = 69) in comparison to those with uncomplicated pregnancies (n = 539) (5.31 ± 0.58% versus 5.01 ± 0.45%, p < .001 and 89.74 ± 8.71% versus 84.09 ± 9.16%, p < .001, respectively). The cut-off value calculated with the highest Youden index was HbA1c levels above 5.6% with a sensitivity of 34.78%, specificity of 89.8%, with a diagnostic accuracy of 83.55%, and FPG levels above 86.85 mg/dl with a sensitivity of 69.57%, specificity of 61.78%, with a diagnostic accuracy of 62.66%. The calculated odds ratio (OR) for HbA1c > 5.6% and FPG > 86 mg/dl were 4.69 (95% CI: 2.66-8.29), and 3.7 (95% CI: 2.15-6.35), respectively. HbA1c and FPG combined had improved the predictive capability for GDM (OR: 7.26, 95% CI: 3.71-14.19). According to correlation analyses, a noteworthy positive correlation was found between HbA1c and, FPG, 50 g GCT, age, BMI, parity, and birth weight. However, there was no correlation between FPG and birth weight.

CONCLUSION

Diagnostic accuracy of HbA1c for GDM prediction in Turkish women with a low-risk pregnancy is 83.55% with a very good negative predictive value of 91.49%. HbA1c and FPG combined enhanced the predictive capability for GDM. In addition, there is a positive relationship between HbA1c and 50 g GCT, and birth weight. However, to suggest HbA1c as a potential screening test for gestational diabetes mellitus, further research is warranted.

Circulatory Changes and Cerebral Blood Flow and Oxygenation During Transition in Newborns With Congenital Heart Disease

This review aims to describe how the complex events of cardiovascular transition may affect the brain of infants with congenital heart disease (CHD). In particular, we describe the vulnerabilities of the neonatal brain in the transitional period during and immediately after delivery and propose management strategies that can potentially influence neurodevelopmental outcomes in this patient population. Delayed brain development has been identified in the third trimester fetus with certain forms of CHD. Neonates with critical CHD are at risk for brain injury even before their neonatal operation. The transitional period from fetal to neonatal life is marked with hemodynamic changes that can affect cerebral blood flow and oxygenation and may exacerbate injury and influence outcome. We propose specific perinatal management strategies tailored to maternal-fetal pairs aimed at optimizing hemodynamic stability, especially cerebral blood flow and oxygenation, to maximize the neurodevelopmental potential of infants with CHD.

Amniotic fluid index, single deepest pocket and transvaginal cervical length: Parameter of predictive delivery latency in preterm premature rupture of membranes

OBJECTIVE

Prediction of delivery latency complicated with preterm premature rupture of membrane (PPROM) is crucial for reducing maternal and neonatal complications. Therefore, we investigated the correlations between latency period and cut-off values of ultrasonographic parameters, ultimately predicting delivery latency.

MATERIALS AND METHODS

The retrospective study was performed on 121 PPROM patients enrolled between March 2010 and July 2015. Parameters including amniotic fluid index (AFI), single deepest pocket (SDP) and transvaginal cervical length (TVCL) were measured in 99 singleton pregnancies with PPROM. Latency was defined as the period from sonographic measurements to delivery day. The parameters were analyzed independently by Wilcoxon rank sum test and Fisher's exact test. Cut-off values were determined using a receiver operating characteristic (ROC) curve.

RESULTS

In delivery latency within 3 days, AFI and SDP were decreased with significantly shorter TVCL. AFI and SDP had the highest sensitivity (82.2%) and SDP combined with TVCL showed the highest specificity (75.9%) in area under curve (AUC) value. The predicted median latency period was less than 2 days within the cutoff value of parameter (AFI ≤ 7.72, SDP ≤ 3.2 and TVCL ≤ 1.69).

CONCLUSION

AFI and SDP combined with TVCL could be useful predictive parameters of the latency interval from PPROM to delivery.

Maternal Apolipoprotein B100 Serum Levels are Diminished in Pregnancies with Intrauterine Growth Restriction and Differentiate from Controls

PURPOSE

Intrauterine growth restriction, a major cause of fetal morbidity and mortality, is defined as a condition in which the fetus does not reach its genetically given growth potential. Screening for intrauterine growth restriction biomarkers in the mother's blood would be of great help for optimal pregnancy management and timing of delivery as well as for identifying fetuses requiring further surveillance during their infancies.

EXPERIMENTAL DESIGN

A multiplexing serological assay based on liquid chromatography-multiple-reaction-monitoring mass spectrometry is applied for distinguishing serum samples of pregnant women.

RESULTS

Assessment of concentrations of apolipoproteins and of proteins that belong to the lipid transport system is performed with maternal serum samples, consuming only 10 μL of serum per multiplex assay from each patient. Of all investigated proteins the serum concentrations of apolipoprotein B100 shows the greatest power for discriminating intrauterine growth restriction from control samples, reaching areas under curves above 0.85 in receiver-operator-characteristics analyses.

CONCLUSIONS

These results indicate the potential of liquid chromatography-multiple-reaction-monitoring mass spectrometry to become of clinical importance in the future for intrauterine growth restriction risk assessment based on maternal apolipoprotein B100 serum levels.

Maternal Serum Endocan Concentration in Pregnancies Complicated by Intrauterine Growth Restriction

OBJECTIVES

Endocan plays a role in the development of vascular tissue in health and disease and is an indicator of endothelial cells activation and angiogenesis. Therefore, this study aimed to investigate the relationship between maternal endocan serum level and intrauterine growth restriction (IUGR) as well as ultrasound Doppler flow measurements indicating placental insufficiency.

METHODS

This study included a group of women with IUGR (n = 37) and a group of healthy pregnant women (controls, n = 37). The endocan serum concentrations were assessed using commercially available enzyme-linked immunosorbent assay kit. Every woman underwent an ultrasound examination with Doppler flow measurements of the uterine arteries, umbilical vessels, and fetal middle cerebral artery. We used the cerebroplacental ratio (CPR) to determine placental insufficiency.

RESULTS

We found significant differences in median (interquartile) endocan serum level (pg/mL) between study and control groups (464 [374-532] vs 339 [189-496], respectively; P < .001). The endocan serum level correlated neither with umbilical cord blood gases nor with Apgar score. Ultrasound Doppler findings revealed significant differences in middle cerebral artery pulsatility index (PI), umbilical artery PI, CPR, as well as mean uterine arteries PI between IUGR group and controls. In the study group, we found significant correlations between the serum endocan and CPR ( R = 0.56, P < .001) as well as between serum endocan and mean uterine arteries PI ( R = 0.46, P = .006).

CONCLUSION

Endocan is likely involved in the pathogenesis of IUGR in pregnant women and possibly is a useful marker of endothelial dysfunction in these cases.

Cardiotocography and the evolution into computerised cardiotocography in the management of intrauterine growth restriction

Timely recognition and appropriate management of high-risk pregnancies, such as intrauterine growth restriction (IUGR), are of paramount importance for every obstetrician. After the initial screening of IUGR fetuses through sonographic fetometry and Doppler, the focus is shifted to the appropriate monitoring and timing of delivery. This can, especially in cases of early IUGR, become a very difficult task. At this point, cardiotocography (CTG) is introduced as a major tool in the day-to-day monitoring of the antenatal well-being of the IUGR fetus. Since the first introduction of CTG up to the nowadays widely spreading implementation of computerised CTG in the clinical practice, there has been great progress in the recording of the fetal heart rate, as well as its interpretation. Focus of this review is to offer an understanding of the evolution of CTG from its early development to modern computerised methods and to provide an insight as to where the future of CTG is leading, especially in the monitoring of IUGR.

Effect of maternal exercises on biophysical fetal and maternal parameters: a transversal study

Objective

To evaluate the acute effects of maternal and fetal hemodynamic responses in pregnant women submitted to fetal Doppler and an aerobic physical exercise test according to the degree of effort during the activity and the impact on the well-being.

Methods

Transversal study with low risk pregnant women, obtained by convenience sample with gestational age between 26 to 34 weeks. The participants carry out a progressive exercise test.

Results

After the exercise session, reduced resistance (p=0.02) and pulsatility indices (p=0.01) were identified in the umbilical artery; however, other Doppler parameters analyzed, in addition to cardiotocography and fetal biophysical profile did not achieve significant change. Maternal parameters obtained linear growth with activity, but it was not possible to establish a standard with the Borg scale, and oxygen saturation remained stable.

Conclusion

A short submaximal exercise had little effect on placental blood flow after exercise in pregnancies without complications, corroborating that healthy fetus maintains homeostasis even in situations that alter maternal hemodynamics.

[Use of fetal movements counting for prolonged pregnancy: A comparative preliminary cohort study before and after implementation of an information brochure]

OBJECTIVES

Compare the number of consultations with the consultation's delay in relation with the sensation of decrease active fetal movements (AFM) in case of late pregnancy, according to the fact if the patients use or not the AFM's count.

MATERIALS AND METHODS

We have compared a "control" group made up of 160 patients who received a classic information and observation (from December 18th, 2013 to February 28th, 2014) versus an "educated" group made up of 160 patients who have been educated to the AFM count (from March 1st, 2014 to August 12th, 2014).

RESULTS

The consultations for AFM decrease, were significantly more frequent in the "control" group than in the "educated" group (36 versus 8, P=0.0009). Inducing labor due to AFM reduction was not statistically different between both groups (13 patients in the "educated group" versus 7 patients in the "control" group P=0.97).

CONCLUSION

Learning a count method seems to decrease the number of consultations for AFM reduction without increasing the perinatal morbidity but maybe at the cost of an increase of obstetric interventions.

Fetal heart rate monitoring: from Doppler to computerized analysis

The monitoring of fetal heart rate (FHR) status is an important method to check well-being of the baby during labor. Since the electronic FHR monitoring was introduced 40 years ago, it has been expected to be an innovative screening test to detect fetuses who are becoming hypoxic and who may benefit from cesarean delivery or operative vaginal delivery. However, several randomized controlled trials have failed to prove that electronic FHR monitoring had any benefit of reducing the perinatal mortality and morbidity. Also it is now clear that the FHR monitoring had high intra- and interobserver disagreements and increased the rate of cesarean delivery. Despite such limitations, the FHR monitoring is still one of the most important obstetric procedures in clinical practice, and the cardiotocogram is the most-used equipment. To supplement cardiotocogram, new methods of computerized FHR analysis and electrocardiogram have been developed, and several clinical researches have been currently performed. Computerized equipment makes us to analyze beat-to-beat variability and short term heart rate patterns. Furthermore, researches about multiparameters of FHR variability will be ongoing.

Perinatal and Delivery Management of Infants with Congenital Heart Disease

Advances in fetal echocardiography have improved prenatal diagnosis of congenital heart disease (CHD) and allowed better delivery and perinatal management. Some newborns with CHD require urgent intervention after delivery. In these cases, delivery close to a pediatric cardiac center may be considered, and the presence of a specialized cardiac team in the delivery room or urgent transport of the infant should be planned in advance. Delivery planning, monitoring in labor, rapid intervention at birth if needed, and avoidance of iatrogenic preterm delivery have the potential to improve outcomes for infants with prenatally diagnosed CHD.

Impact of maternal fasting on fetal well-being parameters and fetal-neonatal outcome: a case-control study

OBJECTIVE

To assess the impact of maternal fasting on fetal well-being parameters and neonatal outcome.

METHODS

Two-hundred ten healthy women with singleton uncomplicated pregnancies at 36-40 weeks' gestation who had fasted for 12-16 h were defined as the study group with 240 healthy non-fasted pregnant women matched for age, parity and gestational age were defined as the control group. Both groups were subjected to tests of fetal well-being in the form of non-stress test (NST), modified biophysical profile and Doppler indices of the umbilical and middle cerebral arteries (MCA). Women were followed-up till delivery to record the obstetric outcome.

RESULTS

There was no significant difference between the two groups regarding the reactivity of NST, modified biophysical scores, Doppler indices of the umbilical and MCA (resistive index, pulsatility index and systolic/diastolic ratio) and the cerebroplacental ratio (p > 0.05). There was no significant difference between the two groups regarding the gestational age at delivery, mode of delivery, neonatal weight, 5-min Apgar scores and admission to neonatal intensive care unit (p > 0.05).

CONCLUSIONS

Short-term maternal fasting has no deleterious effect on fetal well-being parameters or neonatal outcome. Pregnant women who desire fasting, should be reassured regarding the health of their babies.

Transient accelerations of fetal heart rate analyzed by computerized cardiotocography in the third trimester of pregnancy

OBJECTIVE

The aim of this study was to investigate the patterns of transient FHR accelerations (10 bpm and 15 bpm) in the third trimester of pregnancy, comparing the occurrence of this event before and after the 32nd gestational week.

METHODS

This is a prospective study comparing the results of the computerized cardiotocography of 46 low-risk women with singleton pregnancies, maternal age between 18 and 40 years, gestational age between 28 and 40 weeks, absence of maternal morbidity and adequate fetal growth according to ultrasound. Computed Cardiotocography (8002 Sonicaid System and Fetal Care System) was performed for 30 minutes to analyze the variables of FHR.

RESULTS

Twenty-three pregnant women underwent cardiotocography before 32 weeks (mean = 29.9 weeks, SD = 1.4 weeks) and were compared with 23 pregnant women who were examined after 32 weeks (mean = 36.3 weeks, SD = 2.5 weeks). Regarding the characteristics of FHR, fetuses evaluated between 32 1/7 weeks and 40 weeks showed a significantly greater number of accelerations above 15 bpm (median = 5, variation 0-18) than the group of pregnant women from 28 to 32 weeks (median = 4, variation 0 to 10; P = 0.048). There was a significant positive correlation between the number of accelerations above 15 bpm and the gestational age at examination (rho = 0.33; P = 0.026).

CONCLUSION

Computerized cardiotocography showed an association regarding the number of transient accelerations greater than 15 bpm in the assessment of both periods before and after 32 weeks of gestational age, suggesting the influence of the maturation of the fetal autonomic nervous system with pregnancy progression.

Usefulness of fetal urine production measurement for prediction of perinatal outcomes in uteroplacental insufficiency

OBJECTIVES

To evaluate whether fetal urine production measurement is useful for predicting adverse outcomes in patients with uteroplacental insufficiency.

METHODS

We enrolled patients with uteroplacental insufficiency at 24 to 40 weeks' gestation and normal pregnancies matched for gestational age and divided them into 3 groups according to perinatal outcomes: group 1 (n = 141), a control group of normal pregnancies; group 2 (n = 29), uteroplacental insufficiency without adverse outcomes; and group 3 (n = 18), uteroplacental insufficiency with adverse outcomes. An adverse outcome was defined as 1 or more of the following: (1) cesarean delivery because of fetal distress; (2) admission to the neonatal intensive care unit; (3) cord arterial pH less than 7.15 at birth; and (4) low 5-minute Apgar score (<7). The fetal urine production rate was obtained by serial bladder volume measurement using virtual organ computer-aided analysis. For bladder volume determination, we scanned the bladder in the 3-dimensional mode and defined the bladder surface contour in the reference plane, repeating the rotation of the reference plane with an angle of 30° and determining the surface contour on each plane. Statistical methods, including the Mann-Whitney U test, Fisher exact test, χ(2) test, and Kruskal-Wallis analysis of variance, were used.

RESULTS

Group 3 had a lower mean fetal urine production rate than groups 1 and 2, whereas the urine production rate was not different between groups 1 and 2 (group 1, 49.0 mL/h; group 2, 59.4 mL/h; group 3, 20.7 mL/h; P < .001 between groups 1 and 3 and between groups 2 and 3). This difference between groups 2 and 3 remained significant after adjusting for the amniotic fluid index, umbilical artery Doppler pulsatility index, and presence of fetal growth restriction.

CONCLUSIONS

Uteroplacental insufficiency cases with adverse perinatal outcomes had a lower fetal urine production rate than those without adverse outcomes. This difference might be used to predict adverse perinatal outcomes in uteroplacental insufficiency.

Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association

BACKGROUND

The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease.

METHODS AND RESULTS

A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin-twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease.

CONCLUSIONS

Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.

Fetal growth and risk of stillbirth: a population-based case-control study

BACKGROUND

Stillbirth is strongly related to impaired fetal growth. However, the relationship between fetal growth and stillbirth is difficult to determine because of uncertainty in the timing of death and confounding characteristics affecting normal fetal growth.

METHODS AND FINDINGS

We conducted a population-based case-control study of all stillbirths and a representative sample of live births in 59 hospitals in five geographic areas in the US. Fetal growth abnormalities were categorized as small for gestational age (SGA) (<10th percentile) or large for gestational age (LGA) (>90th percentile) at death (stillbirth) or delivery (live birth) using population, ultrasound, and individualized norms. Gestational age at death was determined using an algorithm that considered the time-of-death interval, postmortem examination, and reliability of the gestational age estimate. Data were weighted to account for the sampling design and differential participation rates in various subgroups. Among 527 singleton stillbirths and 1,821 singleton live births studied, stillbirth was associated with SGA based on population, ultrasound, and individualized norms (odds ratio [OR] [95% CI]: 3.0 [2.2 to 4.0]; 4.7 [3.7 to 5.9]; 4.6 [3.6 to 5.9], respectively). LGA was also associated with increased risk of stillbirth using ultrasound and individualized norms (OR [95% CI]: 3.5 [2.4 to 5.0]; 2.3 [1.7 to 3.1], respectively), but not population norms (OR [95% CI]: 0.6 [0.4 to 1.0]). The associations were stronger with more severe SGA and LGA (<5th and >95th percentile). Analyses adjusted for stillbirth risk factors, subset analyses excluding potential confounders, and analyses in preterm and term pregnancies showed similar patterns of association. In this study 70% of cases and 63% of controls agreed to participate. Analysis weights accounted for differences between consenting and non-consenting women. Some of the characteristics used for individualized fetal growth estimates were missing and were replaced with reference values. However, a sensitivity analysis using individualized norms based on the subset of stillbirths and live births with non-missing variables showed similar findings.

CONCLUSIONS

Stillbirth is associated with both growth restriction and excessive fetal growth. These findings suggest that, contrary to current practices and recommendations, stillbirth prevention strategies should focus on both severe SGA and severe LGA pregnancies. Please see later in the article for the Editors' Summary.

Factors that increase reactivity during fetal nonstress testing

PURPOSE OF REVIEW

The most common method of antepartum fetal surveillance is the nonstress test (NST). Although it has satisfactory false-negative rates, dubious nonreactive results may challenge the physician. Any method or factor increasing the reactive NST results or shortening the time to attain a reactive test may be considerably useful.

RECENT FINDINGS

Most of the studies have found no effect of maternal glucose administration on fetal heart rate and fetal activity, specificity of NST, time to reactivity and percentage of reactive NST results when compared with the control group. Maternal intake of 70% cocoa or caffeine had stimulating action on the fetal reactivity, and this effect on the fetal heart rate was more marked with high concentrations of cocoa (80%). Studies on maternal positioning during NST had equivocal results. Fetal manipulation has no impact on the NST reactivity. Vibroacoustic and halogen light stimulation may be associated with a reduction in time to reactivity.

SUMMARY

These methods may increase the reactivity during a NST and may facilitate the antenatal fetal surveillance.

Amniotic fluid as a vital sign for fetal wellbeing

Introduction: Amniotic fluid, once thought to merely provide protection and room for necessary movement and growth for the fetus, is now understood to be a highly complex and dynamic system that is studied as a data point to interpret fetal wellbeing. Methods: Assessment of amniotic fluid volume is now routine when performing a sonographic evaluation of fetal status and is an important consideration in the assessment and management of perinatal morbidity and mortality.1,2 In this review, we will cover the dynamics that affect amniotic fluid volume, review methods for measurement and quantification of volume, review definitions for normative data as related to neonatal outcomes, and provide evidence based guidance on the workup and management options for oligoydramnios and polyhydramnios in singleton and twin pregnancies. Conclusions: When abnormalities of fluid exist, appropriate workup to uncover the underlying etiology should be initiated as adverse fetal outcomes are sometimes associated with these variations from normalcy.

Doppler assessment of the fetus with intrauterine growth restriction

OBJECTIVE

We sought to provide evidence-based guidelines for utilization of Doppler studies for fetuses with intrauterine growth restriction (IUGR).

METHODS

Relevant documents were identified using PubMed (US National Library of Medicine, 1983 through 2011) publications, written in English, which describe the peripartum outcomes of IUGR according to Doppler assessment of umbilical arterial, middle cerebral artery, and ductus venosus. Additionally, the Cochrane Library, organizational guidelines, and studies identified through review of the above were utilized to identify relevant articles. Consistent with US Preventive Task Force suggestions, references were evaluated for quality based on the highest level of evidence, and recommendations were graded.

RESULTS AND RECOMMENDATIONS

Summary of randomized and quasirandomized studies indicates that, among high-risk pregnancies with suspected IUGR, the use of umbilical arterial Doppler assessment significantly decreases the likelihood of labor induction, cesarean delivery, and perinatal deaths (1.2% vs 1.7%; relative risk, 0.71; 95% confidence interval, 0.52-0.98). Antepartum surveillance with Doppler of the umbilical artery should be started when the fetus is viable and IUGR is suspected. Although Doppler studies of the ductus venous, middle cerebral artery, and other vessels have some prognostic value for IUGR fetuses, currently there is a lack of randomized trials showing benefit. Thus, Doppler studies of vessels other than the umbilical artery, as part of assessment of fetal well-being in pregnancies complicated by IUGR, should be reserved for research protocols.

Assessing the optimal definition of oligohydramnios associated with adverse neonatal outcomes

OBJECTIVES

The purpose of this study was to compare the use of an amniotic fluid index (AFI) less than 5 cm to the use of an AFI less than the fifth percentile for gestational age in predicting adverse perinatal outcomes.

METHODS

This was a retrospective cohort study from 1998 to 2008. Patients with an AFI less than 5 cm and those with an AFI less than the fifth percentile were compared to patients with a normal AFI. The primary outcome measure was neonatal intensive care unit (NICU) admission.

RESULTS

A total of 17,887 patients had complete information for analysis. There were 145 NICU admissions in patients with an AFI less than 5 cm (relative risk, 2.2) compared to 235 in patients with an AFI less than the fifth percentile for gestational age (relative risk, 2.37). The sensitivity and specificity for NICU admission using an AFI less than 5 cm were 10.9% and 95.2% compared to 17.6% and 92.5% for an AFI less than the fifth percentile for gestational age.

CONCLUSIONS

Oligohydramnios defined as an AFI less than the fifth percentile better predicts fetuses at risk for adverse perinatal outcomes compared to an AFI less than 5 cm.

Risk factors for intrauterine fetal death (1988-2009)

OBJECTIVE

To determine risk factors for intrauterine fetal death (IUFD).

STUDY DESIGN

A retrospective population-based study, of all singleton deliveries between the years 1988-2009 was conducted. Intrapartum deaths, postpartum death, and multiple gestations were excluded. A multiple logistic regression model was used to determine independent risk factors.

RESULTS

During the study period, out of 228,239 singleton births, 1694 IUFD cases were recorded (7.4 per 1000 births). The following independent risk factors were identified in the logistic regression executed: Oligohydramnios (OR 2.6, 95% CI 2.1-3.2, p-value < 0.001), polyhydramnios (OR 1.8, 95% CI 1.4-2.2, p-value < 0.001), previous adverse perinatal outcome (OR 1.7, 95% CI 1.5-2.1, p-value < 0.001), congenital malformations (OR 2.0, 95% CI 1.8-2.3, p-value < 0.001), true knot of cord (OR 3.7, 95% CI 2.8-4.9, p-value < 0.001), meconium stained amniotic fluid (OR 2.7, 95% CI 2.3-3.0, p-value<0.001), placental abruption (OR 2.9, 95% CI 2.4-3.5, p-value < 0.001), advanced maternal age (OR 1.03, 95% CI 1.02-1.04, p-value < 0.001), and hypertensive disorders (OR 1.24, 95% CI 1.0-1.4, p-value = 0.026). Jewish ethnicity (versus Bedouin - OR 0.64, 95% CI 0.57-0.72, p-value < 0.001), gestational diabetes (OR 0.7, 95% CI 0.5-0.8, p-value = 0.001), previous cesarean section (OR 0.8, 95% CI 0.7-0.97, p-value = 0.019), and recurrent abortions (OR 0.8, 95% CI 0.6-0.9, p-value = 0.011) were negatively associated with IUFD.

CONCLUSION

Several independent risk factors were identified, suggesting a possible cause of death. Other pathologic conditions that facilitate tighter pregnancy surveillance and active management were found protective, pointing the benefit of such management approaches in high-risk pregnancies.

A novel approach to track fetal movement using multi-sensor magnetocardiographic recordings

Changes in fetal magnetocardiographic (fMCG) signals are indicators for fetal body movement. We propose a novel approach to reliably extract fetal body movements based on the field strength of the fMCG signal independent of its frequency. After attenuating the maternal MCG, we use a Hilbert transform approach to identify the R-wave. At each R-wave, we compute the center-of-gravity (cog) of the coordinate positions of MCG sensors, each weighted by the magnitude of the R-wave amplitude recorded at the corresponding sensor. We then define actogram as the distance between the cog computed at each R-wave and the average of the cog from all the R-waves in a 3-min duration. By applying a linear de-trending approach to the actogram we identify the fetal body movement and compare this with the synchronous occurrence of the acceleration in the fetal heart rate. Finally, we apply this approach to the fMCG recorded simultaneously with ultrasound from a single subject and show its improved performance over the QRS-amplitude based approach in the visually verified movements. This technique could be applied to transform the detection of fetal body movement into an objective measure of fetal health and enhance the predictive value of prevalent clinical testing for fetal wellbeing.

Proposed management for reduced fetal movements: five years' experience in one medical center

OBJECTIVE

To assess the management of reduced fetal movements (RFM) based on repeated fetal movement counts, nonstress test (NST), and ultrasound examination.

METHODS

This is a retrospective cohort study carried out in a single tertiary maternity hospital. A total of 2393 women with singleton pregnancies at >28 weeks' were referred to obstetric triage with chief complaint of RFM. Persistent movement counts of <5/h and abnormal results of NST or ultrasound mandated an admission for further evaluation. Women with transient RFM and normal ultrasound and NST were discharged. We compared the outcome between these two groups. Maternal and perinatal parameters were compared between women who were admitted and those who were discharged home after evaluation.

RESULTS

A total of 2393 women were referred to obstetric triage with chief complaint of RFM, of whom 753 (31.5%) were admitted for further evaluation. Their demographic and obstetrical parameters were similar to those of the nonadmitted women, as were the fetal demise rates. NICU admission and cesarean section rates and low Apgar scores were significantly higher among admitted patients.

CONCLUSION

RFM has a clinical significance as a predictor of adverse perinatal outcome. Our study suggests that repeated fetal movement counts, NST, and ultrasonography may identify women at risk for adverse perinatal outcome.

A comparative study of a new cardiotocography analysis program

Cardiotocography (CTG) is a frequently used technique of fetal monitoring to evaluate the well being of the fetus during pregnancy and in labor. The surveillance technique depends on the analysis of characteristic fetal heart rate patterns and uterine contractions. Computerized analyses can mitigate the intra-observer and inter-observer variability of visual CTG recording explanation, decrease the examination time, and the need of additional tests for fetal health. Several studies also showed that the signal processing techniques could help to determine the fetal heart rate (FHR) patterns, but all of them were only suitable for physicians. Following the criteria and consensuses of National Institute of Child Health and Human Development in April 2008, we developed a LabVIEW based FHR and uterine contraction (UC) pattern analysis software. This software has great potential for home-care use. The signal processing methods utilized in this study are median filter and peak/valley detection method. The analysis performance was verified by nineteen pregnant women's data. The accuracy of FHR baseline, baseline variability, early deceleration, UC frequency and NST all reach 100%. The accuracy of acceleration frequency reaches 90%. The accuracy of late and variable decelerations reaches 95%.

Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement

BACKGROUND

Women experiencing decreased fetal movements (DFM) are at increased risk of adverse outcomes, including stillbirth. Fourteen delivery units in Norway registered all cases of DFM in a population-based quality assessment. We found that information to women and management of DFM varied significantly between hospitals. We intended to examine two cohorts of women with DFM before and during two consensus-based interventions aiming to improve care through: 1) written information to women about fetal activity and DFM, including an invitation to monitor fetal movements, 2) guidelines for management of DFM for health-care professionals.

METHODS

All singleton third trimester pregnancies presenting with a perception of DFM were registered, and outcomes collected independently at all 14 hospitals. The quality assessment period included April 2005 through October 2005, and the two interventions were implemented from November 2005 through March 2007. The baseline versus intervention cohorts included: 19,407 versus 46,143 births and 1215 versus 3038 women with DFM, respectively.

RESULTS

Reports of DFM did not increase during the intervention. The stillbirth rate among women with DFM fell during the intervention: 4.2% vs. 2.4%, (OR 0.51 95% CI 0.32-0.81), and 3.0/1000 versus 2.0/1000 in the overall study population (OR 0.67 95% CI 0.48-0.93). There was no increase in the rates of preterm births, fetal growth restriction, transfers to neonatal care or severe neonatal depression among women with DFM during the intervention. The use of ultrasound in management increased, while additional follow up visits and admissions for induction were reduced.

CONCLUSION

Improved management of DFM and uniform information to women is associated with fewer stillbirths.

Do Commonly Used Oral Antihypertensives Alter Fetal or Neonatal Heart Rate Characteristics? A Systematic Review

OBJECTIVE

To examine fetal (FHR) and neonatal heart rate patterns following use of common oral antihypertensives in pregnancy.

METHODS

A systematic review of randomized controlled trials (RCTs), observational studies (N >/= 6 women), and animal studies. Data were abstracted (two reviewers) to determine relative risk (RR) (or risk difference (RD) for low event rates) and 95% CI.

RESULTS

Eighteen RCTs (1858 women), one controlled observational study (N = 22), and seven case series (N = 117) were reviewed. Most hypertension was pregnancy-induced (N = 14 studies). The FHR was assessed by cardiotocogram (CTG) (N = 17 studies (visual interpretation); 1 study (computerized CTG), or umbilical artery velocimetry (N = 4). Four studies examined neonatal heart rate. In placebo-controlled RCTs (N = 192 women), adverse FHR effects did not differ between groups [9/101 (drugs) vs. 7/91 (placebo); RD 0.02, 95% CI (- 0.06, 0.11); chi2 = 1.02]. In six drug vs. drug RCTs (295 women), adverse FHR effects did not differ between groups [29/144 (methyldopa) vs. 42/151 (other drugs); RR 0.72, 95% CI (0.49, 1.07); chi2 = 0.69]. In one labetalol vs. placebo trial, neonatal bradycardia did not differ between groups [4/70 (labetalol) vs. 4/74 (placebo); OR 1.06, 95% CI (0.26, 4.39)], while in three drug vs. drug RCTs, neonatal bradycardia was not observed (0/24 vs. 0/26).

CONCLUSIONS

Available data are inadequate to conclude whether oral methyldopa, labetalol, nifedipine, or hydralazine adversely affect fetal or neonatal heart rate and pattern. Until definitive data are available, FHR changes cannot be reliably attributed to drug effect, but may be due to progression of the underlying maternal or placental disease.

Fetal assessment during pregnancy

Fetal monitoring during pregnancy is used to prevent fetal death. This article addresses the goals of fetal monitoring during pregnancy. Methods of fetal surveillance are reviewed, as well as the meaning of abnormal fetal testing and how these results relate to fetal and neonatal outcome. Overall, pediatricians who understand the goals, methods, and interpretation of fetal testing can communicate more effectively with the delivering obstetric team in anticipation of optimizing obstetric and pediatric outcomes.

Antenatal testing-a reevaluation: executive summary of a Eunice Kennedy Shriver National Institute of Child Health and Human Development workshop

In August 2007, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health Office of Rare Diseases, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics cosponsored a 2-day workshop to reassess the body of evidence supporting antepartum assessment of fetal well-being, identify key gaps in the evidence, and formulate recommendations for further research. Participants included experts in obstetrics and fetal physiology and representatives from relevant stakeholder groups and organizations. This article is a summary of the discussions at the workshop, including synopses of oral presentations on the epidemiology of stillbirth and fetal neurological injury, fetal physiology, techniques for antenatal monitoring, and maternal and fetal indications for monitoring. Finally, a synthesis of recommendations for further research compiled from three breakout workgroups is presented.

Sepsis and acute renal failure in pregnancy

The unique physiology of pregnancy poses several problems for clinicians charged with caring for critically ill pregnant patients. This focused review summarizes two problems encountered in critically ill pregnant patients: pregnancy-related sepsis and acute renal failure. Common causes, and the effects of pregnancy on diagnosis and treatment are discussed.

Timing of elective repeat cesarean delivery at term and neonatal outcomes

BACKGROUND

Because of increased rates of respiratory complications, elective cesarean delivery is discouraged before 39 weeks of gestation unless there is evidence of fetal lung maturity. We assessed associations between elective cesarean delivery at term (37 weeks of gestation or longer) but before 39 weeks of gestation and neonatal outcomes.

METHODS

We studied a cohort of consecutive patients undergoing repeat cesarean sections performed at 19 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network from 1999 through 2002. Women with viable singleton pregnancies delivered electively (i.e., before the onset of labor and without any recognized indications for delivery before 39 weeks of gestation) were included. The primary outcome was the composite of neonatal death and any of several adverse events, including respiratory complications, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit (ICU).

RESULTS

Of 24,077 repeat cesarean deliveries at term, 13,258 were performed electively; of these, 35.8% were performed before 39 completed weeks of gestation (6.3% at 37 weeks and 29.5% at 38 weeks) and 49.1% at 39 weeks of gestation. One neonatal death occurred. As compared with births at 39 weeks, births at 37 weeks and at 38 weeks were associated with an increased risk of the primary outcome (adjusted odds ratio for births at 37 weeks, 2.1; 95% confidence interval [CI], 1.7 to 2.5; adjusted odds ratio for births at 38 weeks, 1.5; 95% CI, 1.3 to 1.7; P for trend <0.001). The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks.

CONCLUSIONS

Elective repeat cesarean delivery before 39 weeks of gestation is common and is associated with respiratory and other adverse neonatal outcomes.

Management of decreased fetal movements

Maternal perception of decreased fetal activity is a common complaint, and one of the most frequent causes of unplanned visits in pregnancy. No proposed definitions of decreased fetal movements have ever been proven to be superior to a subjective maternal perception in terms of identifying a population at risk. Women presenting with decreased fetal movements do have higher risk of stillbirth, fetal growth restriction, fetal distress, preterm birth, and other associated outcomes. Yet, little research has been conducted to identify optimal management, and no randomized controlled trials have been performed. The strong associations with adverse outcome suggest that adequate management should include the exclusion of both acute and chronic conditions associated with decreased fetal movements. We propose guidelines for management of decreased fetal movements that include both a nonstress test and an ultrasound scan and report findings in 3014 cases of decreased fetal movements.

Stillbirth

In the UK, about one in 200 infants is stillborn, and rates of stillbirth have recently slightly increased. This recent rise might reflect increasing frequency of some important maternal risk factors for stillbirth, including nulliparity, advanced age, and obesity. Most stillbirths are related to placental dysfunction, which in many women is evident from the first half of pregnancy and is associated with fetal growth restriction. There is no effective screening test that has clearly shown a reduction in stillbirth rates in the general population. However, assessments of novel screening methods have generally failed to distinguish between effective identification of high-risk women and successful intervention for such women. Future research into stillbirth will probably focus on understanding the pathophysiology of impaired placentation to establish screening tests for stillbirth, and assessment of interventions to prevent stillbirth in women who screen positive.

Gestational age at delivery and Doppler waveforms in very preterm intrauterine growth-restricted fetuses as predictors of perinatal mortality

OBJECTIVE

The aim of this study was to compare gestational age at delivery and the performance of middle cerebral artery (MCA), ductus venosus (DV), and umbilical artery Doppler parameters in the prediction of perinatal mortality and morbidity in intrauterine growth-restricted (IUGR) fetuses delivered at 32 weeks or earlier.

METHODS

The study population consisted of 41 patients with IUGR fetuses. Delivery occurred for maternal or fetal indications. Two-tailed chi(2) and Fisher exact tests, an independent t test, and logistic regression were used for the analysis. P < .05 was considered statistically significant.

RESULTS

Gestational age at delivery ranged between 23.1 and 32 weeks (median, 27.6 weeks). There were 17 perinatal deaths. Ninety-four percent of the perinatal deaths occurred when the fetuses were delivered before 29 weeks. No fetus survived when delivered before 25 weeks. Two parameters predicted the perinatal mortality: gestational age at delivery (odds ratio, 0.52; 95% confidence interval, 0.31-0.88) and the combination of abnormal MCA peak systolic velocity + DV reversed flow (odds ratio, 10.2; 95% confidence interval, 1.8-57). For each week of pregnancy, there was a reduction in perinatal mortality of 48%. No Doppler parameters were significantly associated with perinatal morbidity.

CONCLUSIONS

Gestational age at delivery and the combination of abnormal MCA peak systolic velocity + DV reversed flow in very preterm IUGR fetuses were the best parameters in predicting perinatal mortality. The decreased perinatal mortality that is found for each week IUGR fetuses remain in utero should be taken into account when a decision to deliver an IUGR fetus before 30 weeks is made.

Acute respiratory distress syndrome in pregnancy

OBJECTIVE

To summarize the pathophysiology and treatment of acute lung injury and acute respiratory distress syndrome (ARDS) during pregnancy.

DATA SOURCE

Review of select articles from MEDLINE, including published abstracts, case reports, observational studies, controlled trials, review articles, and institutional experience.

DATA SUMMARY

ARDS occurs in pregnancy and may have unique causes. Despite extensive clinical research to improve the management of ARDS, mortality remains high, and few strategies have shown a mortality benefit. Furthermore, in most published studies, pregnancy is an exclusionary criterion, and thus, few treatments have been adequately evaluated in obstetric populations. The treatment of ARDS in pregnancy is extrapolated from studies performed in the general ARDS patient population, with consideration given to the normal physiologic changes of pregnancy. In general, the best support of the fetus is support of the mother. From the age of viability (24-26 wks at most institutions) until full term, decisions regarding delivery should be made based primarily on the standard obstetric indications.

CONCLUSIONS

Little evidence exists regarding the management of ARDS specifically in pregnancy, and thus, treatment approaches must be drawn from studies performed in a general patient population. A multidisciplinary approach involving maternal-fetal medicine, neonatology, anesthesiology, and intensivist clinicians is essential to optimizing maternal and fetal outcomes.