Fetomaternal bleeding during attempts at external version

A retrospective study of the success, safety and effectiveness of external cephalic version without tocolysis in a specialised midwifery centre in the Netherlands

BACKGROUND

to evaluate the effectiveness of external cephalic version (ECV) without tocolysis or epidural analgesia, the complications associated with the procedure and the association between the number of ECV attempts and cephalic presentation at birth and caesarean section.

METHODS

retrospective cohort study of all (n=924) ECVs carried out between 1996 and 2000 in a specialised midwifery centre in the Netherlands. After bivariate analysis, those variables with a p value under 0.05 were considered statistically significant and were tested in a logistic regression model using backward stepwise selection. Analyses were carried out separately for first ECV attempts and second ECV attempts.

FINDINGS

in total, 958 ECVs were analysed, 889 first attempts and 69 repeat attempts. Seventy per cent of all first ECVs were carried out before 37 weeks, but half of those were carried out between 36 and 37 weeks. The success rate for first ECV was 41% and for the second ECV 29%. Bivariate analysis showed that the success of the first ECV was positively influenced by parity, non-Dutch origin, higher birth weight, higher age and longer duration of pregnancy. After logistic regression, parity (odds ratio [OR] 2.8, 95% CI 2.1 to 3.7), non-Dutch origin (OR 1.8, 95% CI 1.2 to 2.8) and birth weight (OR 1.7, 95% CI 1.4 to 2.0) remained factors that independently influenced the success of ECV. The odds ratio for duration of pregnancy at first ECV was borderline significant: OR 1.2 (1.0 to 1.4). After an unsuccessful first ECV, only 13% of the women received a second ECV. The prevalence of cephalic presentation at birth increased with 3% after a second ECV. Three cases of complications were reported during or very shortly after the first ECV, and these did not result in serious complications. No complications were reported after a second ECV.

CONCLUSION

ECV without tocolysis is a safe procedure for pregnant women and their babies. Repeat ECV increases the number of cephalic presentations at birth and should be considered after an unsuccessful ECV.

Introducing external cephalic version to clinical practice

A service offering external cephalic version to all women with breech presentations at 36-38 weeks' gestation was introduced at St George Hospital in July 1997. This paper describes how this service was established and reports the clinical outcomes over the first three years; 116 external cephalic versions (ECV) were attempted on 114 women and success was achieved in 58 women (51%). Of the 58 women, 43 (74%) subsequently had vaginal deliveries. There were no fetal deaths, immediate Caesarean sections, or placental abruptions as a result of the ECV procedure. There were two (2%) episodes of transient fetal bradycardia following ECV, both of which returned to normal with a subsequent normal neonatal outcome. Pre- and post-ECV Kleihauer levels were collected with no increase in levels as a result of the ECV ECV is a procedure that can, and should, be provided as part of a public hospital service.

Cell-free fetal deoxyribonucleic acid in maternal circulation as a marker of fetal-maternal hemorrhage in patients undergoing external cephalic version near term

OBJECTIVE

Our aim was to investigate whether external cephalic version performed near term increases the concentration of cell-free fetal deoxyribonucleic acid in maternal plasma.

STUDY DESIGN

Forty-five patients who had singleton male fetuses and were undergoing external cephalic version at or beyond 36 weeks of gestation were recruited during a 20-month period. Maternal venous blood samples were taken before and within 10 minutes after external cephalic version. Deoxyribonucleic acid was extracted from the plasma samples. The amount of fetal deoxyribonucleic acid was quantified by means of the SRY gene on the Y chromosome as a fetal marker. The change in SRY gene concentration before and after external cephalic version was compared by paired sample t test.

RESULTS

There was a significant increase in the concentration of fetal deoxyribonucleic acid in maternal serum after external cephalic version (before, 296 +/- 209 copies per milliliter; after, 369 +/- 228 copies per milliliter; P =.014). This increase in the concentration of deoxyribonucleic acid was most profound among the nulliparous patients after a successful version and in the presence of a posterior placenta. The location of the placenta was found to be the most significant factor accounting for the change in the deoxyribonucleic acid concentration.

CONCLUSIONS

External cephalic version near term imposed a significant disturbance to the maternalplacental interface. Fetal deoxyribonucleic acid is a sensitive marker that is useful in the assessment of subclinical fetal-maternal hemorrhage.

Motor vehicle accident during the second or third trimester of pregnancy

OBJECTIVE

To evaluate the need of immediate treatment, follow-up and consequences of different types of traffic accidents during pregnancy.

METHOD AND MATERIAL

A retrospective analysis covering five years involving thirty-five pregnant women involved in motor vehicle accidents at 22-39 weeks of gestation.

RESULTS

Fifteen of the 35 women were involved in frontal impact collisions, and suffered mild subjective and objective symptoms; all their fetuses survived and were delivered at term. Fifteen other women were involved in broadside collisions; two of these were riding a bicycle. These 15 women had clear objective findings like uterine contractions or tenderness, and some of them needed tocolytic therapy and hospitalization up to eight days. This was significantly longer than in those involved in frontal impact collisions. However, the broadside accidents did not have any adverse effect on pregnancy outcomes either. Five women were involved in serious accidents at speeds of 80-110 km/h, and one mother and her fetus died immediately because of rupture of the uterus and the cervical joint and spinal canal. Four other fetuses were found dead on arrival at hospital or soon after. In all cases the cause of fetal loss was placental abruption. The presence of fetal blood cells in maternal blood was evaluated in 15 of 35 patients, but was positive in only one.

CONCLUSION

Frontal collisions are associated with lower vehicular speed, less trauma and no acute or later effects on pregnancy, whereas broadside collisions and high speed (> 80 km/h) cause more symptoms. The latter type of accidents are associated with high risk of placental abruption and of fetal and maternal death. Fortunately the symptoms are evident immediately after the accident, and early hospital discharge is possible if no abnormalities are present during the first hours.

Fetomaternal haemorrhage after external cephalic version at term

The incidence of fetomaternal haemorrhage after external cephalic version was 1.8% in 167 patients. The occurrence of this complication was not found to be associated with difficult or unsuccessful version, or with any adverse perinatal outcome. We conclude that routine assessment of fetomaternal haemorrhage after external version is not necessary, except in rhesus negative women to detect the 2% in whom the routine dose of 500 iu (100 micrograms) of anti-D immunoglobulin is inadequate.

Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma

Two hundred five consecutive cases of noncatastrophic trauma occurring during the second half of pregnancy were evaluated prospectively. Pregnancy complications as a result of trauma occurred in 18 of 205 patients (8.8%): premature labor (n = 10), placental separation (n = 5), fetal injury (n = 1), and fetal death (n = 2). Multiple regression analysis of the data base showed obstetric findings (contractions, uterine tenderness, and bleeding) on presentation to be highly associated with complications (17/88; 19.3%). In their absence complications were rare (1/117; 0.9%). Detectable fetomaternal hemorrhage was significantly more common in trauma patients (18/205) than in control subjects (2/110) (p less than 0.01), but its role in managing trauma patients was limited to detection of rare massive hemorrhage (1/205) and detection of rare hemorrhage exceeding that covered by the standard Rho (D) immune globulin dose (2/205). Fetomaternal hemorrhage need not be quantitated in patients who lack obstetric findings on presentation. Despite rare reports of delayed abruptio placentae, it is doubtful that prolonged observation (greater than 2 to 3 hours) in the hospital is necessary in patients who lack obstetric findings on initial presentation.

External cephalic version without tocolysis

The increased rate of cesarean section in the United States is in part the result of more liberal use of the operation because of breech presentation. In an attempt to reduce the incidence of breech presentation in labor in a group of private patients, 66 patients underwent 90 attempted external cephalic versions in my office without tocolysis. The success rate of external cephalic version at or before 34 weeks was 74.3%, and only 45.5% after 34 weeks. The overall success rate was 60.6%. Subsequent attempts in five patients who had spontaneous reversion to breech were successful. No fetal or maternal mortality or morbidity occurred. One patient with Rh negative blood may have become isoimmunized as a result of version manipulation. Successful external cephalic version without tocolysis was accomplished with gentle, nonpersistent manipulation at or before 34 weeks.

External cephalic version: a clinical experience

Eighty-five normal women underwent external cephalic version (ECV) for breech presentation in the late 3rd trimester. The protocol included real time ultrasonic scanning and pre- and post-procedure electronic fetal monitoring. Subcutaneous terbutaline sulfate (0.25 mg.) was administered to (43/85 or 50.5%) of ECV candidates and rendered the procedure easier for patient and operator. A single operator, head-over-heels technique assisted by supine Trendelenberg's position was used. Rh negative women were routinely administered 300 mcg of immune globulin. Successful ECV (53/85, 62.5%) was related to maternal parity, but not to gestational age nor eventual delivery weight. In this series only engagement of the breech was reliable in predicting ECV failure. Fifty of 51 (98.1%) successfully verted women delivered a cephalic presentation infant at term. Cesarean section was performed in 5/51 of these patients (9.8%) for routine obstetrical indications. In one case, compound presentation at term resulting in dystocia and eventual cesarean section was believed related to prior successful version. In contrast, 15/30 (50%) of the ECV failure patients went on to operative delivery despite a liberal institutional policy toward term vaginal breech trials. In addition, the only serious fetal complication in this series, meconium aspiration, occurred in a vaginally delivered breech infant. It is unlikely that late 3rd trimester ECV will impact on out overall rate of cesarean delivery. In North America prematurity is the greatest risk factor in malpresentation and our policy increasingly is to permit attempts at term breech vaginal delivery. Nonetheless, ECV deserves serious consideration. When successful, ECV avoids the costs and/or risks of either cesarean section or vaginal trial of breech.(ABSTRACT TRUNCATED AT 250 WORDS)

Fetomaternal hemorrhage following trauma

Fetomaternal hemorrhage can result from different types of trauma and may be followed by fetal anemia, fetal death, or isoimmunization. We prospectively studied the frequency and volume of fetomaternal hemorrhage, fetal well-being, abruptio placentae, and fetal outcome in 32 pregnant patients suffering recent trauma. Fetomaternal hemorrhage occurred in nine of 32 trauma patients (28%) with a mean volume of 16 ml +/- 14.3(SD). There was a statistically significant difference in the frequency and mean volume of fetomaternal hemorrhage in this group over that in gestational-age-matched controls. Neither the nature of the trauma nor the gestational age was related to the frequency or volume of fetomaternal hemorrhage. The outcome in three of the nine trauma patients who sustained fetomaternal hemorrhage was poor; fetal anemia, paroxysmal atrial tachycardia, and fetal death occurred in each one. Maternal trauma remains a significant cause of maternal and fetal morbidity and death, and the use of the Kleihauer-Betke analysis is indicated to identify fetomaternal hemorrhage. Rh-immune globulin therapy should be given to Rh-negative patients with fetomaternal hemorrhage.

A randomized trial of external cephalic version with tocolysis in late pregnancy

The effect of external version under tocolysis with intravenous ritodrine during the 37th week of gestation was studied in a prospective randomized trial comprising 130 consecutive women with a fetus in breech presentation. Version was successful in 41% of the patients, all of whom had a cephalic vaginal delivery. Of the 56 women in the control group in whom version was not attempted; 8 (14%) converted to the vertex presentation spontaneously. Failure of version was significantly correlated with primiparity, location of the placenta on the anterior uterine wall, and maternal weight. The caesarean section rate was significantly lower in the version group (27%) than in the control group (46%) (P less than 0.05). The overall caesarean section rate for a fetus in breech presentation was 50%. There were no serious complications associated with version and the condition of the infants at birth was better in the version group than in the control group. We advise external version under tocolysis in late pregnancy to reduce the frequency of breech presentation in labour.

Effect of external cephalic version in late pregnancy on breech presentation and caesarean section rate: a controlled trial

A prospective randomized controlled trial of external cephalic version (ECV) in late pregnancy is reported. All pregnancies were assessed with ultrasound and cardiotocography. ECV was successful in 29 out of 30 patients (97%). Breech presentation at delivery occurred in 67% of the control group and in 3% of the ECV group. The caesarean section rates were 43 and 20% respectively. Tocolysis was used in seven patients. A new technique of ECV with the steep lateral position is described. Complications were limited to cardiotocographic changes and one patient with unexplained vaginal spotting. The procedure is recommended provided appropriate patient selection and surveillance is practised.