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King VJ, Bennet L, Stone PR, Clark A, Gunn AJ, Dhillon SK. Fetal growth restriction and stillbirth: Biomarkers for identifying at risk fetuses. Front Physiol 2022; 13:959750. [PMID: 36060697 PMCID: PMC9437293 DOI: 10.3389/fphys.2022.959750] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Fetal growth restriction (FGR) is a major cause of stillbirth, prematurity and impaired neurodevelopment. Its etiology is multifactorial, but many cases are related to impaired placental development and dysfunction, with reduced nutrient and oxygen supply. The fetus has a remarkable ability to respond to hypoxic challenges and mounts protective adaptations to match growth to reduced nutrient availability. However, with progressive placental dysfunction, chronic hypoxia may progress to a level where fetus can no longer adapt, or there may be superimposed acute hypoxic events. Improving detection and effective monitoring of progression is critical for the management of complicated pregnancies to balance the risk of worsening fetal oxygen deprivation in utero, against the consequences of iatrogenic preterm birth. Current surveillance modalities include frequent fetal Doppler ultrasound, and fetal heart rate monitoring. However, nearly half of FGR cases are not detected in utero, and conventional surveillance does not prevent a high proportion of stillbirths. We review diagnostic challenges and limitations in current screening and monitoring practices and discuss potential ways to better identify FGR, and, critically, to identify the “tipping point” when a chronically hypoxic fetus is at risk of progressive acidosis and stillbirth.
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Affiliation(s)
- Victoria J. King
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Peter R. Stone
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
| | - Alys Clark
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
- Auckland Biomedical Engineering Institute, The University of Auckland, Auckland, New Zealand
| | - Alistair J. Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Simerdeep K. Dhillon
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
- *Correspondence: Simerdeep K. Dhillon,
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Katsura D, Takahashi Y, Iwagaki S, Chiaki R, Asai K, Koike M, Tsuji S, Kimura F, Murakami T. Successful amnioinfusion for severe fetal growth restriction with umbilical cord complications: two case reports. J Med Case Rep 2021; 15:416. [PMID: 34325750 PMCID: PMC8320090 DOI: 10.1186/s13256-021-02904-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 05/12/2021] [Indexed: 11/12/2022] Open
Abstract
Background There is no established treatment for fetal growth restriction during pregnancy. We report two cases that represent an example of an amnioinfusion-based management strategy for severe fetal growth restriction with umbilical cord complications. Case presentation We encountered two cases of fetal growth restriction with abnormal fetal Doppler velocity. In one case, fetal ultrasound revealed a hypercoiled umbilical cord with a single umbilical artery and oligohydramnios, while fetal Doppler revealed a reversed end-diastolic flow in the umbilical artery and reversed a-waves of the ductus venosus. Umbilical cord compression was confirmed at 22 weeks and 2 days of gestation, and nine amnioinfusions were performed to relieve the umbilical cord compression. A cesarean section was performed at 31 weeks and 2 days of gestation because of severe preeclampsia. The Asian infant is now a normally developed 6-month-old. In another Asian case, fetal ultrasound revealed a hypercoiled cord, while fetal Doppler revealed a reversed end-diastolic flow in the umbilical artery and intermittent reversed a-waves of the ductus venosus. Umbilical cord compression was confirmed at 24 weeks and 5 days of gestation, and seven amnioinfusions were performed. A cesarean section was performed at 31 weeks and 1 day of gestation because of nonreassuring fetal status. At the age of 1 month, the Asian infant was stable on respiratory circulation. In both cases, fetal Doppler findings improved significantly following amnioinfusions. Conclusions Amnioinfusion is a symptomatic treatment for umbilical cord compression. However, to determine the therapeutic effect of amnioinfusion, complete resolution of the umbilical cord compression should be ascertained by ultrasonography.
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Affiliation(s)
- Daisuke Katsura
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu, 520-2192, Japan. .,Department of Fetal-Maternal Medicine, Nagara Medical Center, 1300-7, Nagara, Gifu, 502-8558, Japan.
| | - Yuichiro Takahashi
- Department of Fetal-Maternal Medicine, Nagara Medical Center, 1300-7, Nagara, Gifu, 502-8558, Japan
| | - Shigenori Iwagaki
- Department of Fetal-Maternal Medicine, Nagara Medical Center, 1300-7, Nagara, Gifu, 502-8558, Japan
| | - Rika Chiaki
- Department of Fetal-Maternal Medicine, Nagara Medical Center, 1300-7, Nagara, Gifu, 502-8558, Japan
| | - Kazuhiko Asai
- Department of Fetal-Maternal Medicine, Nagara Medical Center, 1300-7, Nagara, Gifu, 502-8558, Japan
| | - Masako Koike
- Department of Fetal-Maternal Medicine, Nagara Medical Center, 1300-7, Nagara, Gifu, 502-8558, Japan
| | - Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu, 520-2192, Japan
| | - Fuminori Kimura
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu, 520-2192, Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu, 520-2192, Japan
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Nwabuobi C, Gowda N, Schmitz J, Wood N, Pargas A, Bagiardi L, Odibo L, Camisasca-Lopina H, Kuznicki M, Sinkey R, Odibo A. Risk factors for Cesarean delivery in pregnancy with small-for-gestational-age fetus undergoing induction of labor. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:799-805. [PMID: 31441151 DOI: 10.1002/uog.20850] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To identify risk factors for Cesarean delivery and non-reassuring fetal heart tracing (NRFHT) in pregnancies with a small-for-gestational-age (SGA) fetus undergoing induction of labor and to design and validate a prediction model, combining antenatal and intrapartum variables known at the time of labor induction, to identify pregnancies at increased risk of Cesarean delivery. METHODS This was a retrospective cohort study of non-anomalous, singleton gestations with a SGA fetus that underwent induction of labor, delivered in a single tertiary referral center between January 2011 and December 2016. SGA was defined as estimated fetal weight (EFW) < 10th percentile. The primary outcome was to identify risk factors associated with Cesarean delivery. The secondary outcome was to identify risk factors associated with NRFHT. Univariate and multivariate analyses were used to determine which clinical characteristics, available at the time of admission, had the strongest association with Cesarean delivery and NRFHT during labor induction. The predictive value of the final models was assessed by the area under the receiver-operating-characteristics curve (AUC). Sensitivity and specificity of the models were also assessed. Internal validation of the models was performed using 10 000 bootstrap replicates of the original cohort. The adequacy of the models was evaluated using the Hosmer-Lemeshow goodness-of-fit test. RESULTS A total of 594 pregnancies were included. Cesarean delivery was performed in 243 (40.9%) pregnancies. Significant risk factors associated with Cesarean delivery, and included in the final model, were maternal age, gestational age at delivery and initial method of labor induction. The bootstrap estimate of the AUC of the final prediction model for Cesarean delivery was 0.82 (95% CI, 0.78-0.86). The model had sensitivity of 64.2%, specificity of 86.9%, positive likelihood ratio (LR) of 4.9 and negative LR of 0.41. The model had good fit (P = 0.617). NRFHT complicated 117 (19.7%) pregnancies. Significant risk factors for NRFHT included EFW < 5th percentile, abnormal umbilical artery Doppler studies (pulsatility index > 95th percentile or absent/reversed end-diastolic flow) and gestational age at delivery. The final prediction model for NRFHT had an AUC of 0.69 (95% CI, 0.63-0.75) and specificity of 97.0%. CONCLUSION We identified several significant risk factors for Cesarean delivery and NRFHT among SGA pregnancies undergoing induction of labor. Clinicians may use these risk factors to guide patient counseling and to help anticipate the potential need for operative delivery. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C Nwabuobi
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - N Gowda
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - J Schmitz
- Department of Obstetrics and Gynecology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - N Wood
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - A Pargas
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - L Bagiardi
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - L Odibo
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - H Camisasca-Lopina
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - M Kuznicki
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - R Sinkey
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - A Odibo
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
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Complexity of Cardiotocographic Signals as A Predictor of Labor. ENTROPY 2020; 22:e22010104. [PMID: 33285878 PMCID: PMC7516409 DOI: 10.3390/e22010104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/06/2020] [Accepted: 01/13/2020] [Indexed: 11/17/2022]
Abstract
Prediction of labor is of extreme importance in obstetric care to allow for preventive measures, assuring that both baby and mother have the best possible care. In this work, the authors studied how important nonlinear parameters (entropy and compression) can be as labor predictors. Linear features retrieved from the SisPorto system for cardiotocogram analysis and nonlinear measures were used to predict labor in a dataset of 1072 antepartum tracings, at between 30 and 35 weeks of gestation. Two groups were defined: Group A—fetuses whose traces date was less than one or two weeks before labor, and Group B—fetuses whose traces date was at least one or two weeks before labor. Results suggest that, compared with linear features such as decelerations and variability indices, compression improves labor prediction both within one (C-Statistics of 0.728) and two weeks (C-Statistics of 0.704). Moreover, the correlation between compression and long-term variability was significantly different in groups A and B, denoting that compression and heart rate variability look at different information associated with whether the fetus is closer to or further from labor onset. Nonlinear measures, compression in particular, may be useful in improving labor prediction as a complement to other fetal heart rate features.
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Hoyer D, Schmidt A, Gustafson KM, Lobmaier SM, Lakhno I, van Leeuwen P, Cysarz D, Preisl H, Schneider U. Heart rate variability categories of fluctuation amplitude and complexity: diagnostic markers of fetal development and its disturbances. Physiol Meas 2019; 40:064002. [PMID: 31071684 DOI: 10.1088/1361-6579/ab205f] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE In fetal diagnosis the myriad and diversity of heart rate variability (HRV) indices prevents a comparable routine evaluation of disturbances in fetal development and well-being. The work aims at the extraction of a small set of HRV key indices that could help to establish a universal, overarching tool to screen for any disturbance. APPROACH HRV indices were organized in categories of short-term (prefix s) and long-term (prefix l) amplitude fluctuations (AMP), complexity (COMP), and patterns (PATTERN) and common representatives for each category were extracted. This procedure was done with respect to the diagnostic value in the evaluation of the maturation age throughout the second and complete third trimester of pregnancy as well as to potential differences associated with maternal life-style factors (physical exercise, smoking), nutrient intervention (docosahexaenoic acid (DHA) supplementation), and complications of pregnancy (gestational diabetes mellitus (GDM), intra-uterine growth restriction (IUGR)). MAIN RESULTS We found a comprehensive minimal set that includes [lAMP: short term variation (STV), initially introduced in cardiotocography, sAMP: heart rate increase across one interbeat interval of phase rectified averaged signal - acceleration capacity (ACst1), lCOMP: scale 4 multi-scale entropy (MSE4), PATTERN: skewness] for the maturation age prediction, and partly overlapping [lAMP: STV, sAMP: ACst1, sCOMP: Lempel Ziv complexity (LZC)] for the discrimination of the deviations. SIGNIFICANCE The minimal set of category-based HRV representatives allows for a screening of fetal development and well-being. These results are an important step towards a universal and comparable diagnostic tool for the early identification of developmental disturbances. Novelty & Significance Fetal development and its disturbances have been reported to be associated with a multiplicity of HRV indices. Furthermore, these HRV indices change with maturation. We propose the abstraction of HRV categories defined by short- and long-term fluctuation amplitude, complexity, and pattern indices that cover all relevant aspects of maturational age, behavioral influences and a series of pathological disturbances. The study data are provided by multiple centers. Our approach is an important step towards the goal of a standardized diagnostic tool for early identification of fetal developmental disturbances with respect to the reduction of serious complications in the later life.
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Affiliation(s)
- Dirk Hoyer
- Hans Berger Department of Neurology, Biomagnetic Center, Jena University Hospital, Jena 07747, Germany
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Stumpfe FM, Faschingbauer F, Kehl S, Pretscher J, Stelzl P, Mayr A, Schild RL, Schmid M, Beckmann MW, Schneider MO. Correlation of short-term variation and Doppler parameters with adverse perinatal outcome in small-for-gestational age fetuses at term. Arch Gynecol Obstet 2019; 300:575-581. [PMID: 31214775 DOI: 10.1007/s00404-019-05216-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 06/07/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the association of short-term variation (STV) and Doppler parameters with adverse perinatal outcome in small-for-gestational-age (SGA) fetuses at term. METHODS In this retrospective single-center study 97 patients with singleton SGA fetuses at term (≥ 37 + 0 weeks' gestation) were examined. Inclusion criteria were a birth weight < 10th centile, cephalic presentation and planned vaginal birth. Only cases with available Doppler measurements of umbilical artery (UA) and middle cerebral artery (MCA) with calculated cerebroplacental ratio (CPR) in combination with a computerized CTG (cCTG) and STV 72 h prior to delivery were eligible for analysis. Pulsatility indices (PI) were converted into multiples of median (MoM), adjusted for gestational age. The association between Doppler indices and STV values with mode of delivery [secondary cesarean delivery (CD), operative vaginal delivery (OVD), as well as secondary CD and OVD due to fetal distress] and neonatal outcome [UA blood pH ≤ 7.15 and the need of admission to the neonatal intensive care unit (NICU)] was analyzed using logistic regression analysis. RESULTS There was a significant association between UA PI MoM and the rate of CD. CD due to fetal distress, OVD and OVD due to fetal distress did not show a correlation with the evaluated Doppler parameters. Furthermore, we did not find an association between low UA birth pH and Doppler parameters while neonates with the need of admission to NICU had significant higher UA PI MoM and significant lower MCA PI MoM and CPR MoM. Regarding STV, a significant effect of low STV on NICU admission was found while none of the other assessed outcome parameters were significantly associated with STV. CONCLUSION STV and Doppler parameters in SGA fetuses at term are significantly associated to the rate of NICU admission.
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Affiliation(s)
- Florian M Stumpfe
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Universitätsstraße 21/23, 91054, Erlangen, Germany.
| | - Florian Faschingbauer
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Universitätsstraße 21/23, 91054, Erlangen, Germany
| | - Sven Kehl
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Universitätsstraße 21/23, 91054, Erlangen, Germany
| | - Jutta Pretscher
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Universitätsstraße 21/23, 91054, Erlangen, Germany
| | - Patrick Stelzl
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Universitätsstraße 21/23, 91054, Erlangen, Germany
| | - Andreas Mayr
- Department of Medical Informatics, Biometry and Epidemiology, Medical Faculty, University of Bonn, Bonn, Germany
| | - Ralf L Schild
- Department of Obstetrics and Perinatal Medicine, Perinatalzentrum Hannover, Diakovere Krankenhaus gGmbH, Hannover, Germany
| | - Matthias Schmid
- Department of Medical Informatics, Biometry and Epidemiology, Medical Faculty, University of Bonn, Bonn, Germany
| | - Matthias W Beckmann
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Universitätsstraße 21/23, 91054, Erlangen, Germany
| | - Michael O Schneider
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Universitätsstraße 21/23, 91054, Erlangen, Germany
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Esposito FG, Tagliaferri S, Giudicepietro A, Giuliano N, Maruotti GM, Saccone G, Signorini MG, Magenes G, Campanile M, Zullo F. Fetal heart rate monitoring and neonatal outcome in a population of early- and late-onset intrauterine growth restriction. J Obstet Gynaecol Res 2019; 45:1343-1351. [PMID: 31099119 DOI: 10.1111/jog.13981] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 04/06/2019] [Indexed: 11/29/2022]
Abstract
AIM The early-onset intrauterine growth restriction (IUGR) is associated with severe placental insufficiency and Doppler abnormalities. The late-onset IUGR is associated with mild placental insufficiency and normal Doppler velocimetry. The computerized cardiotocographic (cCTG) monitoring is used to evaluate the fetal well-being in pregnancies complicated by IUGR. Our aim was to investigate the cardiotocographic characteristics of IUGR fetuses and to identify every cCTG difference between Healthy and IUGR fetuses. METHODS Four hundred thirty pregnant women were enrolled starting from the 28th week of gestation until the time of delivery: 200 healthy and 230 IUGR fetuses. Fetal heart rate (FHR) baseline (FHR), short-term variability (STV), long-term irregularity (LTI), delta, interval index (II), approximate entropy (ApEn), high frequency (HF), low frequency (LF), movement frequency (MF), LF/(HF + MF) ratio (LF/(HF + MF)) and number of decelerations were examined. Newborn baby data were also collected. RESULTS The parameters of short- and medium-term variability discriminate between IUGR and healthy fetuses before 36 weeks including FHR, STV, LTI and delta discriminate between each subgroup of IUGR were compared to each one of the other two (P < 0.05). CONCLUSION cCTG is a useful tool for the evaluation of chronic hypoxemia, which causes a delay in the maturation of all components of the autonomic and central nervous system. However, cCTG requires integration with fetal ultrasound and Doppler vessels evaluation to improve the ability to predict the neonatal outcome.
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Affiliation(s)
- Francesca G Esposito
- Department of Obstetrical-Gynaecological and Urological Science and Reproductive Medicine, Federico II University, Naples, Italy
| | - Salvatore Tagliaferri
- Department of Obstetrical-Gynaecological and Urological Science and Reproductive Medicine, Federico II University, Naples, Italy
| | - Antonia Giudicepietro
- Department of Obstetrical-Gynaecological and Urological Science and Reproductive Medicine, Federico II University, Naples, Italy
| | - Natascia Giuliano
- Department of Obstetrical-Gynaecological and Urological Science and Reproductive Medicine, Federico II University, Naples, Italy
| | - Giuseppe M Maruotti
- Department of Obstetrical-Gynaecological and Urological Science and Reproductive Medicine, Federico II University, Naples, Italy
| | - Gabriele Saccone
- Department of Obstetrical-Gynaecological and Urological Science and Reproductive Medicine, Federico II University, Naples, Italy
| | - Maria G Signorini
- Department of Electronics, Information and Bioengineering (DEIB), Politecnico of Milan, Milan, Italy
| | - Giovanni Magenes
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Marta Campanile
- Department of Obstetrical-Gynaecological and Urological Science and Reproductive Medicine, Federico II University, Naples, Italy
| | - Fulvio Zullo
- Department of Obstetrical-Gynaecological and Urological Science and Reproductive Medicine, Federico II University, Naples, Italy
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Ganer Herman H, Kogan Z, Bar-Nof T, Bar J, Kovo M. Cesarean delivery due to nonreassuring fetal heart rate: the effect of phase of labor on subsequent vaginal delivery success. J Matern Fetal Neonatal Med 2019; 33:3798-3803. [PMID: 30821554 DOI: 10.1080/14767058.2019.1586876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: To assess trial of labor and vaginal delivery rates in pregnancies following cesarean delivery (CD) due to nonreassuring fetal heart rate (NRFHR) according to phase of labor at cesarean.Materials and methods: This was a retrospective cohort of deliveries at a university hospital between 2009 and 2016. We compared primary CDs performed due to NRFHR during nonactive labor (cervical dilatation < 5 cm) and active labor (cervical dilatation ≥ 5 cm). Subsequent deliveries were reviewed for trial of labor and vaginal delivery rates, and maternal and obstetric outcomes compared.Results: Two hundred thirty-six patients underwent a CD during the nonactive phase of labor (nonactive phase group) and 126 patients during the active phase of labor (active phase group). Patients with a past active phase CD were more likely to attempt a trial of labor but equally likely to achieve a vaginal delivery. There was a trend for more CDs due to nonprogressive labor in this group. After adjustment, only past vaginal delivery was independently associated with a successful vaginal delivery, but not the phase of labor during which the past CD was performed.Conclusion: Our study points to a similar prognosis for patients with a past CD due to NRFHR, regardless of previous labor course.
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Affiliation(s)
- Hadas Ganer Herman
- Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zviya Kogan
- Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tahel Bar-Nof
- Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob Bar
- Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Kovo
- Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Pels A, Mensing van Charante NA, Vollgraff Heidweiller-Schreurs CA, Limpens J, Wolf H, de Boer MA, Ganzevoort W. The prognostic accuracy of short term variation of fetal heart rate in early-onset fetal growth restriction: A systematic review. Eur J Obstet Gynecol Reprod Biol 2019; 234:179-184. [PMID: 30710764 DOI: 10.1016/j.ejogrb.2019.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 01/03/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Cardiotocography (CTG) is an important tool for fetal surveillance in severe early-onset fetal growth restriction (FGR). Assessment of the CTG is usually performed visually (vCTG). However, it is suggested that computerized analysis of the CTG (cCTG) including short term variability (STV) could more accurately detect fetal compromise. The objective of this study was to systematically review the literature on the association between cCTG and perinatal outcome and the comparison of cCTG with vCTG. STUDY DESIGN A systematic search was performed in MEDLINE, EMBASE and Google Scholar. Studies were included that assessed prognostic accuracy of STV or compared STV to vCTG in patients with FGR. Risk of bias and concerns about applicability were assessed with the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) instrument. RESULTS Of the 885 records identified in the search, five cohort studies (387 patients) were included. We found no randomized studies comparing STV with visual CTG in patients with FGR. The risk of bias of all studies was generally judged as 'low'. One small study found an association of low STV with neonatal acidosis. One study observed no association of STV with long-term outcome. Composite analysis of all five studies showed a non-significant relative risk for acidosis after a low STV of 1.4 (95% CI 0.6-3.2, N = 387). Further meta-analysis was hampered due to heterogeneity in outcome reporting and use of different thresholds. CONCLUSION The evidence from the included studies did not support an association of STV and short or long term outcome. However, available data are limited and heterogeneous, and influenced by management based on STV. Solid evidence from a randomized controlled trial comparing STV with vCTG including long term infant outcome is needed before STV can be used clinically for timing of delivery in patients with FGR.
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Affiliation(s)
- A Pels
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynecology, Meibergdreef 9, Amsterdam, the Netherlands.
| | - N A Mensing van Charante
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynecology, Meibergdreef 9, Amsterdam, the Netherlands
| | | | - J Limpens
- Amsterdam UMC, University of Amsterdam, Medical Library, Meibergdreef 9, Amsterdam, the Netherlands
| | - H Wolf
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynecology, Meibergdreef 9, Amsterdam, the Netherlands
| | - M A de Boer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Obstetrics and Gynecology, De Boelelaan 1117, Amsterdam, the Netherlands
| | - W Ganzevoort
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynecology, Meibergdreef 9, Amsterdam, the Netherlands
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Schmidt A, Schukat-Talamazzini EG, Zöllkau J, Pytlik A, Leibl S, Kumm K, Bode F, Kynass I, Witte OW, Schleussner E, Schneider U, Hoyer D. Universal characteristics of evolution and development are inherent in fetal autonomic brain maturation. Auton Neurosci 2018. [DOI: 10.1016/j.autneu.2018.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Kapaya H, Jacques R, Anumba D. Comparison of diurnal variations, gestational age and gender related differences in fetal heart rate (FHR) parameters between appropriate-for-gestational-age (AGA) and small-for-gestational-age (SGA) fetuses in the home environment. PLoS One 2018. [PMID: 29522541 PMCID: PMC5844551 DOI: 10.1371/journal.pone.0193908] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objective To assess the influence of gender, time of the day and gestational age on fetal heart rate (FHR) parameters between appropriate-for-gestational-age (AGA) and small-for-gestational age (SGA) fetuses using a portable fetal ECG monitor employed in the home setting. Methods We analysed and compared the antenatal FHR data collected in the home setting on 61 healthy pregnant women with singleton pregnancies from 24 weeks gestation. Of the 61 women, 31 had SGA fetuses (estimated fetal weight below the tenth gestational centile) and 30 were pregnant with AGA fetuses. FHR recordings were collected for up to 20 h. Two 90 min intervals were deliberately chosen retrospectively with respect to signal recording quality, one during day-time and one at night-time for comparison. Results Overall, success rate of the fetal abdominal ECG in the AGA fetuses was 75.7% compared to 48.6% in the SGA group. Based on randomly selected episodes of heart rate traces where recording quality exceeded 80% we were able to show a marginal difference between day and night-time recordings in AGA vs. SGA fetuses beyond 32 weeks of gestation. A selection bias in terms of covering different representation periods of fetal behavioural states cannot be excluded. In contrast to previous studies, we neither controlled maternal diet and activity nor measured maternal blood hormone and heart rate as all mothers were monitored in the home environment. Conclusion Based on clinically unremarkable, but statistically significant differences in the FHR parameters between the AGA and SGA group we suggest that further studies with large sample size are required to assess the clinical value of antenatal fetal ECG monitoring.
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Affiliation(s)
- Habiba Kapaya
- Department of Oncology and Metabolism, Academic Unit of Reproductive & Developmental Medicine, The University of Sheffield, Sheffield, United Kingdom
- * E-mail:
| | - Richard Jacques
- Medical Statistics Group, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom
| | - Dilly Anumba
- Department of Oncology and Metabolism, Academic Unit of Reproductive & Developmental Medicine, The University of Sheffield, Sheffield, United Kingdom
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Maršál K. Physiological adaptation of the growth-restricted fetus. Best Pract Res Clin Obstet Gynaecol 2018; 49:37-52. [PMID: 29753694 DOI: 10.1016/j.bpobgyn.2018.02.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 02/14/2018] [Indexed: 01/07/2023]
Abstract
The growth-restricted fetus in utero is exposed to a hostile environment and suffers undernutrition and hypoxia. To cope with the stress, the fetus changes its physiological functions. These adaptive changes aid intrauterine survival; however, they can lead to permanent functional and structural changes that can contribute to the development of serious chronic diseases later in life. Epigenetic mechanisms are an important part of the pathophysiological processes behind this "developmental origin of adult diseases." The dominant cardiovascular adaptive change is the redistribution of blood flow in hypoxic fetuses, with preferential supply of blood to the fetal brain, myocardium, and adrenal glands. The proportion of blood from the umbilical vein to the ductus venosus and foramen ovale increases, which increases the cardiac output of the left heart ventricle. The increased perfusion of fetal brain can be followed with Doppler ultrasound as increased diastolic velocities and decreased pulsatility index in the middle cerebral artery.
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Affiliation(s)
- Karel Maršál
- Department of Obstetrics and Gynecology, Clinical Sciences Lund, Lund University, Skane University Hospital, S-221 85, Lund, Sweden.
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