Abnormal Fetal Heart Rate Patterns Research Articles

Fetal primary volvulus with abnormal heart rate patterns on cardiotocography

Fetal primary volvulus is a rare, life-threatening condition. The authors report a case of fetal primary volvulus which showed abnormal fetal heart rate (FHR) patterns on cardiotocography (CTG). A healthy, multiparous, 29-year-old woman was referred to the present facility due to fetal ascites. Ultrasound sonography (US) showed dilation of the fetal small bowel. CTG showed a non-reassuring FHR pattern and an emergency cesarian section was performed. A female newborn was delivered (1,515 grams, Apgar scores at one and five minutes: 5 and 7, respectively). Emergency laparotomy of the newborn showed necrotic volvulus without malrotation. The volvulus was resected, and a colostomy was performed. The infant was discharged three months after the operation without any complications.

Pulse Pressure and Postepidural Complications in Women With Hypertensive Disorders of Pregnancy [33R

INTRODUCTION: Normotensive women with narrow pulse pressure have increased risk of postepidural complications and benefit from additional fluid volume. We hypothesized that narrow pulse pressure in hypertensive women was associated with increased postepidural intervention. METHODS: Single-center prospective cohort study of women with singleton pregnancies and diagnosis of gestational hypertension (gHTN) or preeclampsia admitted for delivery between December 2016 and January 2018. Mean pulse pressure in the 3 hours prior to test dose was calculated (narrow defined as <45 mm Hg). Primary outcome was a composite of postepidural resuscitative measures including fluid bolus, vasopressors, supplemental oxygen, or intentional maternal position changes. Secondary outcomes included hypotension, defined as a decrease in blood pressure (BP) of 20% from baseline, or fetal heart rate (FHR) decelerations compared to 1 hour prior to epidural bolus. RESULTS: 67 women with hypertensive disorders of pregnancy were included, with 15 (22.4%) having a narrow pulse pressure. Average systolic and diastolic BP prior to epidural for those with narrow vs. normal pulse pressure was 125 ± 11 vs. 137 ± 10 mm Hg (P<.001) and 86 ± 11 vs. 81 ± 8 mm Hg (P=.05), respectively. No observed difference in the need for postepidural resuscitation 13.3 vs. 38.5% (P=.12) or any component of the composite outcome. No observed increased risk of systolic (RR 0.74 [95%CI 0.25-2.25]) or diastolic hypotension (RR 0.89 [95%CI 0.53-1.51]) with narrow pulse pressure, nor were abnormal FHR patterns more frequent (P=.72). CONCLUSION: Narrow pulse pressure was not predictive of postepidural complications or resuscitation in women with gHTN or preeclampsia.

Computerised analysis of intrapartum fetal heart rate patterns and adverse outcomes in the INFANT trial.

To assess if a computerised decision support system reliably identified abnormal fetal heart rate (FHR) patterns in fetuses with adverse neonatal outcomes in the INFANT trial, and whether its use reduced substandard care. Prospective cohort study within a randomised controlled trial. Twenty-four maternity units in the UK and Ireland. A total of 46614 labours between January 6 2010 and August 31 2013 in the INFANT trial. Panelreview of intrapartum and neonatal care in infants with adverse outcome, and an assessment of the effectiveness of computerised interpretation of fetal heart rate in reducing substandard care. Descriptive analysis of other factors associated with adverse outcome. Incidence and detection rate of abnormal fetal heart rate patterns, other characteristics associated with perinatal adverse outcome, and frequency of substandard care. Computer interpretation of FHR patterns was deemed to be completely valid in only 24 of 71 (33.8%) cases of adverse outcome. On a scale of 0-10 (completely invalid to completely valid), 28 cases (39.4%) had a score of 6 or less, mainly due to lack of recognition of decelerations (15 cases), or reduced variability (seven cases), or failure to recognise tachysystole (five cases). There were multiple associated factors that modified the clinical assessment of FHR patterns. There was substandard care in 45/71 cases (63%). A significant proportion of abnormal fetal heart rate patterns were not detected accurately by computer analysis, and its use did not reduce the incidence of substandard care. UK National Institute for Health Research Health Technology Assessment Programme (project number 06.38.01). Improved recognition of abnormal fetal heart rate patterns is insufficient to reduce the incidence of substandard care.

Changes in intrapartum maternal placental growth factor levels in pregnancies complicated by fetal compromise at term

BackgroundIntrapartum fetal compromise (IFC) may result from the gradual decline in placental function during labour and can precipitate adverse neonatal outcomes. Placental growth factor (PlGF) is a biomarker of placental function. This study aims to investigate maternal PlGF levels and adverse perinatal outcomes in term labour. MethodsProspective observational study (Mater Mothers’ Hospital, Brisbane). Eligibility: 37+0– 42+0 weeks gestation, singleton, cephalic, non-anomalous pregnancies. Cases of pre-eclampsia and fetal growth restriction were excluded. Maternal PlGF was sampled at the onset of the first stage of labour (1st PlGF) and again at the second stage (2nd PlGF). ResultsSixty-three participants met inclusion criteria. Women requiring operative delivery (n = 11) for IFC had lower 1st PlGF (90.8 vs. 111.8 pg/ml) and 2nd PlGF (65.8 vs. 83.7 pg/ml) compared to the no-IFC cohort (n = 52). PlGF levels decreased significantly during labour in both the IFC (90.8 vs. 65.8 pg/ml, p = 0.021) and no-IFC (111.8 v 83.7, p < 0.001) cohorts, although the decline in PlGF levels was greater in the IFC cohort (−41.8% vs. −23.4%, p = 0.385). Maternal PlGF levels were significantly lower in those with an abnormal fetal heart rate pattern, cord arterial pH < 7.2, nursery admission and composite adverse neonatal outcome (CANO). PlGF decline was not correlated to duration of labour but was influenced by nulliparity and induced labour. ConclusionsMaternal PlGF levels are lower in pregnancies complicated by IFC and CANO, and declines more sharply during labour compared to the no-IFC cohort. The utility of PlGF as a predictor of IFC should be further investigated with clinical trials.

Is supine exercise associated with adverse maternal and fetal outcomes? A systematic review.

Theoretical concerns regarding the supine position at rest due to the gravid uterus obstructing aorta and vena caval flow may impinge uterine blood flow (UBF) to the fetus and maternal venous return. Systematic review. Online databases up to 11 December 2017. Eligible population (pregnant without contraindication to exercise), intervention (frequency, intensity, duration, volume or type of supine exercise), comparator (no exercise or exercise in left lateral rest position, upright posture or other supine exercise), outcomes (potentially adverse effects on maternal blood pressure, cardiac output, heart rate, oxygen saturation, fetal movements, UBF, fetal heart rate (FHR) patterns; adverse events such as bradycardia, low birth weight, intrauterine growth restriction, perinatal mortality and other adverse events as documented by study authors), and study design (except case studies and reviews) published in English, Spanish, French or Portuguese. Seven studies (n=1759) were included. 'Very low' to 'low' quality evidence from three randomised controlled trials indicated no association between supervised exercise interventions that included supine exercise and low birth weight compared with no exercise. There was 'very low' to 'low' quality evidence from four observational studies that showed no adverse events in the mother; however, there were abnormal FHR patterns (as defined by study authors) in 20 of 65 (31%) fetuses during an acute bout of supine exercise. UBF decreased (13%) when women moved from left lateral rest to acute dynamic supine exercise. There was insufficient evidence to ascertain whether maternal exercise in the supine position is safe or should be avoided during pregnancy.

Contraction-Associated Maternal Heart Rate Decelerations: A Pragmatic Marker of Intrapartum Volume Status.

To define and characterize a maternal contraction-associated heart rate deceleration pattern and evaluate its association with maternal volume status. We performed a prespecified secondary analysis of a prospectively collected cohort from a randomized controlled trial of maternal pulse pressure, epidural coload volume, and postepidural complications. Participants were healthy intrapartum women with nonanomalous singleton gestations at 35 weeks of gestation or greater and a category 1 fetal heart rate (FHR) pattern from admission to epidural placement. Those lacking continuous maternal pulse oximetry data before epidural placement were excluded. Maternal heart rate tracings were evaluated for the presence of a contraction-associated heart rate deceleration pattern before epidural placement. Women with and without a contraction-associated heart rate deceleration pattern were compared using univariable and multivariable analyses. The primary outcome was the frequency of a contraction-associated heart rate deceleration pattern in hypovolemic compared with euvolemic women as defined by admission pulse pressure (less than 45 and 50 mm Hg or greater, respectively). Secondary outcomes included the association of a contraction-associated heart rate deceleration pattern with postepidural complications related to maternal volume status including new-onset category 2 and 3 FHR abnormalities, maternal hypotension, and the need for resuscitative obstetric interventions. Of 414 trial participants, 388 (93.7%) met inclusion criteria, and 124 of these (32.0%) had a contraction-associated heart rate deceleration pattern before epidural placement. The presence of a contraction-associated heart rate deceleration pattern was more frequent among hypovolemic compared with euvolemic women as defined by admission pulse pressure (41.1% vs 13.6%, relative risk [RR] 3.0, 95% CI 1.9-4.8, P<.001). A contraction-associated heart rate deceleration pattern was associated with more frequent postepidural FHR abnormalities (43.5% vs 31.1%, RR 1.4, 95% CI 1.1-1.8, P=.02), diastolic hypotension (63.7% vs 50.0%, RR 1.3, 95% CI 1.1-1.5, P=.01), and the need for resuscitative interventions (33.9% vs 23.1%, RR 1.5, 95% CI 1.1-2.0, P=.03). In multivariable analysis with adjustment for baseline differences between groups, the associations between a contraction-associated heart rate deceleration pattern and abnormal FHR patterns, diastolic hypotension, and the need for resuscitative interventions persisted and were slightly strengthened. The maternal contraction-associated heart rate deceleration pattern is a pragmatic, bedside visual indicator of intrapartum maternal volume status. A contraction-associated heart rate deceleration pattern is threefold more frequent among hypovolemic compared with euvolemic women as defined by admission pulse pressure and is associated with postepidural complications including abnormal FHR patterns, diastolic hypotension, and the need for resuscitative interventions. The contraction-associated heart rate deceleration pattern highlights a novel role for intrapartum maternal heart rate assessment and may inform the individualization of intrapartum fluid management.

Impact of Maternal Obesity and Mobile Phone Use on Fetal Cardiotocography Pattern.

BACKGROUND:The fetal heart rate (FHR) is a good marker of fetal well-being during labour. Cardiotocography is used to record the FHR and uterine contractions and can detect possible fetal hypoxia. Mobile phones use, and obesity is suggested to influence the FHR and cardiovascular development.AIM:The present study aimed to study the differences in FHR pattern between fetuses of obese vs non-obese groups when using a mobile phone.METHODS:We conducted a clinical trial to test the impact of mobile phone use on FHR using a single mobile phone with Specific Absorption Rate rating of 0.99 W/kg for 10 minutes. Data from this clinical trial were analysed to compare the FHR pattern between fetuses of obese women (exposed group) vs those of non-obese women (control group). The two study groups (obese vs non-obese) were compared regarding fourFHR patterns:baseline FHR, variability, acceleration and deceleration scores. Data were analysed by SPSS software version 23.0 using the independent-samples t-tests.RESULTS:Sixty-nine women were included in the final analysis (obese group: n = 22 and non-obese group: n = 47). Fetuses of the obese women had significantly higher baseline FHR and less FHR variability scores when compared with fetuses of the non-obese women (mean difference 2.9 and 3.18, respectively).CONCLUSION:Fetuses of obese women had abnormal FHR pattern compared with fetuses of non-obese women. The use of mobile phone slightly influenced the FHR variability score. These results highlight the importance of proper management of obesity in women within the childbearing period.

Optimal management of umbilical cord prolapse.

Umbilical cord prolapse (UCP) is an uncommon obstetric emergency that can have significant neonatal morbidity and/or mortality. It is diagnosed by seeing/palpating the prolapsed cord outside or within the vagina in addition to abnormal fetal heart rate patterns. Women at higher risk of UCP include multiparas with malpresentation. Other risk factors include polyhydramnios and multiple pregnancies. Iatrogenic UCP (up to 50% of cases) can occur in procedures such as amniotomy, fetal blood sampling, and insertion of a cervical ripening balloon. The perinatal outcome largely depends on the location where the prolapse occurred and the gestational age/birthweight of the fetus. When UCP is diagnosed, delivery should be expedited. Usually, cesarean section is the delivery mode of choice, but vaginal/instrumental delivery could be tried if deemed quicker, particularly in the second stage of labor. Diagnosis-to-delivery interval should ideally be less than 30 minutes; however, if it is expected to be lengthy, measures to relieve cord compression should be attempted. Manual elevation of the presenting part and Vago’s method (bladder filling) are the most commonly used maneuvers. Care should be given not to cause cord spasm with excessive manipulation. Simulation training has been shown to improve/maintain all aspects of management and documentation. Prompt diagnosis and interventions and the positive impact of neonatal management have significantly improved the neonatal outcome.

The relationship between intrapartum cerebroplacental ratio and adverse perinatal outcomes in term fetuses

ObjectivesThe cerebroplacental ratio (CPR) Doppler has been proposed as an instrument for predicting adverse perinatal outcomes particularly during antepartum period. Abnormal CPR is associated with non-reassuring fetal status requiring operative delivery, low Apgar score and neonatal complications. The aim of this study was to assess the role of CPR Doppler in the labor triage suite, so as to identify fetuses at risk for non-reassuring status as well as other adverse perinatal outcomes. MethodsThis was a prospective cohort study of term pregnancies who attended the labor room during the latent phase of labor. Both fetal Middle Cerebral Artery Pulsatility Index (MCA-PI) and Umbilical Artery Pulsatility Index (UA-PI) were measured and these values were converted to CPR values. Non-reassuring fetal status requiring operative delivery and other adverse perinatal outcomes were compared between women with normal and abnormal CPR values. Accuracy of CPR for predicting non-reassuring fetal status and abnormal fetal heart rate patterns were calculated. ResultsA total of 384 women were recruited. Lower CPR values were observed in women who underwent operative delivery for non-reassuring fetal status. However, when dividing women into normal and abnormal CPR groups, using 3 different cut-off values, the rate of non-reassuring fetal status was not significantly different between the groups. There was a significantly higher rate of abnormal fetal heart rate monitoring in fetuses with CPR < 5th percentile and CPR < 1. CPR appeared to have a low positive predictive value (PPV) for predicting non-reassuring fetal heart rate patterns, however, the negative predictive value (NPV) was high. ConclusionsIn term fetuses, lower CPR is associated with non-reassuring fetal status. CPR measurement during the intrapartum period with currently available CPR cut-off values is not a good predictor for adverse perinatal outcomes, with the exception of abnormal fetal heart rate patterns. However, the high NPV may be used to stratify pregnant women who may benefit from continuous fetal heart rate monitoring.

Term Meconium Stained Amniotic Fluid: Maternal and Neonatal Risks [19N

INTRODUCTION: To determine the independent associations of meconium stained amniotic fluid METHODS: This is a retrospective review of 4085 (12.2%) women at 37-42 weeks with meconium staining compared to 29397 (87.8%) women who delivered at a single hospital system from 1/2013-12/2016. The primary outcome was a composite neonatal adverse outcome comprised of five-minute Apgar score &lt; 4, umbilical arterial pH &lt; 7.0, sepsis, seizures, encephalopathy, and respiratory failure. Secondary outcome was neonatal intensive care unit (NICU) admission. Logistic regression and hierarchical regression analysis were used. RESULTS: Prenatal factors which positively independently correlated with meconium staining were African-Americans, nulliparity, BMI and public insurance but negatively associated with male fetal gender and multiple pregnancies. For intrapartum factors, vaginal delivery, epidural analgesia, chorioamnionitis and abnormal fetal heart rate patterns were associated with increased risks while abruption and opioid use were associated with decreased meconium staining. Meconium staining was significantly positively correlated with both neonatal composite adverse outcomes and NICU admission. Hierarchical analysis showed that meconium staining significantly increased albeit by a small percentage the variability accounted for both NICU admission (R2=0.015, R2Adjusted=0.017; p&lt;0.001, β=0.037) and the primary outcome (R2=0.004, R2Adjusted=0.005; p&lt;0.001, β=0.021) when controlled for accelerations, late, variable, and prolonged decelerations, tachycardia, bradycardia and minimal variability. CONCLUSION: Amniotic fluid meconium staining during labor indicates a slightly increased neonatal risk beyond what is explained by abnormal fetal heart rate patterns.

Nuchal cord: impact of umbilical artery Doppler indices on intrapartum and neonatal outcomes: a prospective cohort study

Background/objective: The purpose of this study is to investigate the use of a more biologic parameter for evaluation of the effect of nuchal cord tightness; the study of blood flow in the umbilical arteries of nuchal cord using Doppler ultrasonography.Methods: This prospective cohort study was conducted at Ain Shams University Maternity Hospital, Cairo, Egypt in the period between August 2015 and August 2017. Hundred primigravidas were recruited with nuchal cord diagnosed by Doppler ultrasonography; whereas the rest of the study population was included in the “Control group”. Doppler velocimetry study was then performed on a free-floating loop of the umbilical cord and Doppler indices were calculated. Both groups were followed up during labor: intrapartum events, mode of delivery, and neonatal outcome were recorded.Results: Intrapartum fetal heart rate abnormalities were significantly more common in the nuchal cord group compared to the control group. The overall cardiotocography category was significantly more commonly reflecting abnormal fetal heart rate patterns in the nuchal cord group compared to the control group with 46.74% of the nuchal group patients falling within the “suspicious – pathological – need urgent intervention” categories. Intervention rate was significantly higher in the nuchal cord group than the control group (33.69 versus 21.84%). Moreover, incidence of intrapartum fetal heart rate abnormalities and intervention rate were significantly higher in the nuchal cord with abnormal Doppler subgroup compared to both nuchal cord with normal Doppler subgroup and the control group; with a calculated number needed to harm of 2.11.Conclusions: In view of these results, it might be concluded that umbilical cord tightness affecting fetal hemodynamics (expressed by changes in umbilical artery Doppler) might be a determinate factor affecting the intrapartum course.

The limits of electronic fetal heart rate monitoring in the prevention of neonatal metabolic acidemia

Despite intensive efforts directed at initial training in fetal heart rate interpretation, continuing medical education, board certification/recertification, team training, and the development of specific protocols for the management of abnormal fetal heart rate patterns, the goals of consistently preventing hypoxia-induced fetal metabolic acidemia and neurologic injury remain elusive. The purpose of this study was to validate a recently published algorithm for the management of category II fetal heart rate tracings, to examine reasons for the birth of infants with significant metabolic acidemia despite the use of electronic fetal heart rate monitoring, and to examine critically the limits of electronic fetal heart rate monitoring in the prevention of neonatal metabolic acidemia. The potential performance of electronic fetal heart rate monitoring under ideal circumstances was evaluated in an outcomes-blinded examination fetal heart rate tracing of infants with metabolic acidemia at birth (base deficit, >12) and matched control infants (base deficit, <8) under the following conditions: (1) expert primary interpretation, (2) use of a published algorithm that was developed and endorsed by a large group of national experts, (3) assumption of a 30-minute period of evaluation for noncritical category II fetal heart rate tracings, followed by delivery within 30 minutes, (4) evaluation without the need to provide patient care simultaneously, and (5) comparison of results under these circumstances with those achieved in actual clinical practice. During the study period, 120 infants were identified with an arterial cord blood base deficit of >12 mM/L. Matched control infants were not demographically different from subjects. In actual practice, operative intervention on the basis of an abnormal fetal heart rate tracings occurred in 36 of 120 fetuses (30.0%) with metabolic acidemia. Based on expert, algorithm-assisted reviews, 55 of 120 patients with acidemia (45.8%) were judged to need operative intervention for abnormal fetal heart rate tracings. This difference was significant (P=.016). In infants who were born with a base deficit of >12 mM/L in which blinded, algorithm-assisted expert review indicated the need for operative delivery, the decision for delivery would have been made an average of 131 minutes before the actual delivery. The rate of expert intervention for fetal heart rate concerns in the nonacidemic control group (22/120; 18.3%) was similar to the actual intervention rate (23/120; 19.2%; P=1.0) Expert review did not mandate earlier delivery in 65 of 120 patients with metabolic acidemia. The primary features of these 65 cases included the occurrence of sentinel events with prolonged deceleration just before delivery, the rapid deterioration of nonemergent category II fetal heart rate tracings before realistic time frames for recognition and intervention, and the failure of recognized fetal heart rate patterns such as variability to identify metabolic acidemia. Expert, algorithm-assisted fetal heart rate interpretation has the potential to improve standard clinical performance by facilitating significantly earlier recognition of some tracings that are associated with metabolic acidemia without increasing the rate of operative intervention. However, this improvement is modest. Of infants who are born with metabolic acidemia, only approximately one-half potentially could be identified and have delivery expedited even under ideal circumstances, which are probably not realistic in current US practice. This represents the limits of electronic fetal heart rate monitoring performance. Additional technologies will be necessary if the goal of the prevention of neonatal metabolic acidemia is to be realized.

The influence of different maternal pushing positions on birth outcomes at the second stage of labor in nulliparous women

Objectives: To assess the effects on neonatal and maternal outcomes of different pushing positions during the second stage of labor in nulliparous women.Methods: This prospective study included 102 healthy, pregnant, nulliparous women who were randomly allocated to either of two positions: a squatting using bars (n = 51), or a supine position modified to 45 degree of semi-fowler (n = 51) during the second stage of labor. Duration of the second stage of labor, maternal pain, postpartum blood loss, abnormal fetal heart rate patterns that required intervention, and newborn outcomes were compared between the two groups.Results: The trial showed that women who adopted the squatting position using bars experienced a significant reduction in the duration of the second stage of labor; they were less likely to be induced, and their Visual Analog Scale score was lower than those who were allocated the supine position modified to 45 degree of semi-fowler during second stage of labor (p < 0.05). There were no significant differences with regard to postpartum blood loss, neonatal birth weight, Apgar score at one and five minutes, or admission to the Neonatal Intensive Care Unit.Conclusions: In healthy nulliparous women, adopting a squatting position using bars was associated with a shorter second stage of labor, lower Visual Analog Scale score, more satisfaction, and a reduction in oxytocin requirements compared with adopting the supine position. For Turkish women, the squatting position is easy to adopt as it is more appropriate in terms of Turkish social habits and traditions.

The recognition of abnormal fetal heart rate patterns is improved by knowledge of fetal pH.

The recognition of abnormal fetal heart rate patterns is improved by knowledge of fetal pH.

92: The effect of hindsight and outcome bias on the interpretation and management of intrapartum fetal heart rate (FHR) tracings: A randomized trial

To determine whether obstetricians who are asked to evaluate management decisions regarding abnormal FHR patterns will be more likely to assess the quality of medical care as negligent if they are told that there was an adverse, rather than normal, neonatal outcome. Obstetricians from four institutions were invited to participate in a research study regarding intrapartum management. Each case included clinical details, segments of the intrapartum FHR tracing, and outcomes including umbilical artery pH and presence or absence of neonatal morbidity (Table 1). Reviewers were asked to categorize the FHR tracing, assess the timing for the decision for cesarean delivery (CD), and finally rate the quality of care as either “below standard of care” or “acceptable practice.” All participants received the same clinical data and outcomes for both Case #1 and Case #2. Case #1 involved a scenario with a normal umbilical pH, whereas case #2 resulted in an abnormal umbilical pH (< 7.00). For Case #3, all participants received the same opening clinical vignette and FHR tracings; but then were randomly allocated to receive one of two alternative outcomes (Scenario A = normal umbilical pH and no neonatal complications or Scenario B = metabolic acidemia and neonatal encephalopathy). We estimated that N= 84 would be needed to show a 30% difference in the frequency of the judgment of obstetrical management as “below standard of care” between those receiving alternative outcomes (90% power and 2-sided alpha = 0.05). A total of 128 obstetricians participated; 70 were randomly allocated to Scenario A and 58 to Scenario B for Case #3. There were no differences in the assessment of the appropriateness and quality of care for the first 2 cases (Table 2). For Case #3, belief that there was an adverse outcome resulted in a worse categorization of the FHR tracing, more frequent perception that CD was performed too late, and more likely judgment that the standard of care had been violated (Table 2). The findings were similar regardless of academic institution, attending or trainee status, or MFM subspecialty. This study confirms the significant impact of hindsight and outcome bias on the interpretation of FHR tracings and the retrospective assessment of the quality of obstetrical care.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Prophylactic intravenous ephedrine to minimize fetal bradycardia after combined spinal-epidural labour analgesia: a randomized controlled study.

The combined spinal-epidural (CSE) technique for relief of labour pain offers both rapid onset and superior first-stage analgesia. Nevertheless, the known increased risk for early profound fetal bradycardia (EPFB) following CSE continues to be a concern that often limits its use. The purpose of this study was to determine if giving prophylactic intravenous ephedrine at the time of CSE administration would reduce EPFB. We conducted this clinical trial at a large community hospital and enrolled healthy patients requesting epidural analgesia for labour. Patients were randomly assigned to receive either normal saline placebo or ephedrine 10 mg iv at the time of CSE. The primary outcome of EPFB (defined as bradycardia < 90 beats·min(-1) for > two minutes and occurring within the first 30 min after CSE) was compared between groups. The secondary outcomes included the incidence of urgent cesarean delivery, the requirement for additional doses of ephedrine, maternal blood pressure, uterine hypertonus and tachysystole, and abnormal fetal heart rate (FHR) patterns before and after CSE. There were 299 women randomized to the ephedrine (EPH) group and 297 randomized to the normal saline placebo (NS) group. There was no difference between groups in the incidence of EPFB (2.7% EPH group vs 4.7% NS group; relative risk, 0.57; 95% confidence interval, 0.24 to 1.33; P = 0.184). There was also no difference between groups in the incidence of urgent cesarean delivery, uterine hypertonus, uterine tachysystole, and abnormal FHR patterns. We conclude that prophylactic intravenous ephedrine administration at the time of CSE during labour was ineffective at reducing the risk for EPFB associated with CSE. Nevertheless, a lower than expected rate of EPFB resulted in the trial being underpowered. This trial was registered at ClinicalTrials.gov, identifier: NCT02062801.

Guidelines for the Management of a Pregnant Trauma Patient.

Abstract Objective Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient. Outcomes Significant health and economic outcomes considered in comparing alternative practices. Evidence Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technologyrelated agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Benefits, harms, and costs This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma

A systematic review of the effects of adding neostigmine to local anesthetics for neuraxial administration in obstetric anesthesia and analgesia

BackgroundDrugs used in obstetric patients must accomplish two goals: efficacy and safety for both mother and fetus. Neostigmine has been co-administered epidurally and intrathecally with local anesthetics and other adjuncts in the obstetric setting. The aim of this meta-analysis was to assess the efficacy and incidence of adverse events related to the use of neostigmine in obstetric anesthesia. MethodsA meta-analysis of randomized-controlled human trials was conducted using the data sources Google Scholar and PubMed (updated 1 November 2014). Inclusion criteria were: random allocation to treatment; comparison of neostigmine or neostigmine with local anesthetics and/or other adjuvants versus placebo or placebo with local anesthetics and/or other adjuvants; and approval by an ethics committee. ResultsThe use of neostigmine as an adjuvant in neuraxial anesthesia is associated with a reduction in the dose of local anesthetic during labor analgesia and postoperative analgesia following cesarean section: mean reduction of local anesthetic (ropivacaine or bupivacaine) vs. control −4.08 (95% CI −6.7 to −1.5) mg/h (P=0.002). The risk of nausea was increased vs. control with intrathecal neostigmine (OR 8.99 [95% CI 4.74 to 17.05], P <0.001) but not with epidural neostigmine (OR 0.97 [95% CI 0.46 to 2.05], P=0.94). Use of neuraxial neostigmine was associated with a decrease in the risk of pruritus but there was no increase in the incidence of hypotension, dizziness or sedation and no effect on the incidence of abnormal fetal heart rate patterns or Apgar scores. ConclusionsNeuraxial administration of neostigmine significantly reduces local anesthetic consumption without serious adverse side effects to the mother or fetus. However, neostigmine is only recommended for epidural administration as intrathecal use significantly increases the incidence of maternal nausea and vomiting.

Intrapartum fetal scalp lactate sampling for fetal assessment in the presence of a non-reassuring fetal heart rate trace.

Fetal scalp blood sampling for lactate estimation may be considered following identification of an abnormal or non-reassuring fetal heart rate pattern. The smaller volume of blood required for this test, compared with the more traditional pH estimation, may improve sampling rates. The appropriate use of this practice mandates systematic review of its safety and clinical effectiveness prior to widespread introduction. To evaluate the effectiveness and risks of fetal scalp lactate sampling in the assessment of fetal well-being during labour, compared with no testing or alternative testing. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015). All published and unpublished randomised and quasi-randomised trials that compared fetal scalp lactate testing with no testing or alternative testing to evaluate fetal status in the presence of a non-reassuring cardiotocograph during labour. We used the standard methodological procedures of the Cochrane Pregnancy and Childbirth Group. Two review authors independently assessed the studies. The search identified two completed randomised controlled trials (RCTs) and two ongoing trials. The two published RCTs considered outcomes for 3348 mother-baby pairs allocated to either lactate or pH estimation of fetal blood samples when clinically indicated in labour. Overall, the published RCTs were of low or unclear risk of bias. There was a high risk of performance bias, because it would not have been feasible to blind clinicians or participants.No statistically significant between-group differences were found for neonatal encephalopathy (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.32 to 3.09, one study, 2992 infants) or death. No studies reported neonatal seizures. We had planned to report death with other morbidities, for example, neonatal encephalopathy; however, the data were not available in a format suitable for this, therefore death due to congenital abnormality was considered alone. The three reported neonatal deaths occurred in babies with diaphragmatic hernias (n = 2) or congenital cardiac fibrosis (n = 1). All three babies had been randomised to the pH group and were not acidaemic at birth.There were no statistically significant differences for any of the pre-specified secondary fetal/neonatal/infant outcomes for which data were available. This included low Apgar score at five minutes (RR 1.13, 95% CI 0.76 to 1.68, two studies, 3319 infants) and admission to neonatal intensive care units (RR 1.02, 95% CI 0.83 to 1.25, one study, 2992 infants), or metabolic acidaemia (RR 0.91, 95% CI 0.60 to 1.36, one study, 2675 infants) considered within the studies, either overall or where data were available for those where fetal blood sampling had occurred within 60 minutes of delivery.Similar proportions of fetuses underwent additional tests to further evaluate well-being during labour, including scalp pH if in the lactate group or scalp lactate if in the pH group (RR 0.22, 95% CI 0.04 to 1.30, two studies, 3333 infants;Tau² 1.00, I² = 58%). Fetal blood sampling attempts for lactate and pH estimation were successful in 98.7% and 79.4% of procedures respectively in the one study that reported this outcome.There were no significant between-group differences in mode of birth or operative birth for non-reassuring fetal status, either for all women, or within the group where the fetal blood sample had been taken within 60 minutes of delivery (for example, caesarean section for all enrolled, RR 1.09, 95% CI 0.97 to 1.22, two studies, 3319 women; operative delivery for non-reassuring fetal status for all enrolled RR 1.02, 95% CI 0.93 to 1.11, one study, 2992 women).Neither study reported on adverse effects of fetal scalp lacerations or maternal anxiety. When further testing to assess fetal well-being in labour is indicated, fetal scalp blood lactate estimation is more likely to be successfully undertaken than pH estimation. Further studies may consider subgroup analysis by gestational age, the stage of labour and sampling within a prolonged second stage of labour. Additionally, we await the findings from the ongoing studies that compare allocation to no fetal blood sample with sampling for lactate and address longer-term neonatal outcomes, maternal satisfaction with intrapartum fetal monitoring and an economic analysis.

Prediction of Perinatal Hypoxic Encephalopathy: Proximal Risk Factors and Short-Term Complications

Background: To determine the proximal risk factors associated with perinatal hypoxic encephalopathy signs and its short-term complications. Methods: This is a prospective study conducted in women in labor with medical and obstetrics risk factors at King Abdulaziz University Hospital, Jeddah, Saudi Arabia from May 1, 2010 to May 1, 2011. The abnormal umbilical arterial base deficit levels ( ≥ 12 mmol/L), compared with a normal base deficit level ( < 12 mmol/L) and the neonatal outcomes were studied in both groups. Results: The frequency of fetal acidosis with a cord pH ≤ 7 or a base deficit level of ≥ 12 mmol/L at birth was 31 (5.6%) versus 59 (10.7%), respectively. The intrapartum proximal risk factors were abnormal fetal heart rate patterns (n = 18, 30.5%); prolonged labor duration, vacuum delivery (n = 12, 20.3%); pregnancy-induced hypertension (n = 10, 17%); fetal growth restriction (n = 4, 6.8%); and abruptio placentae (n = 3, 5.1%). The neonatal encephalopathy signs with an abnormal base deficit and proximal risk factors were umbilical arterial cord blood pH (n = 24, 40.7%); low Apgar score at 5 minutes (n = 10, 17%); admission to the neonatal intensive care unit (n = 20, 33.9%); and intubation (n = 9, 15.3%). Conclusion: Fetal metabolic acidemia may predict neonatal encephalopathy signs in association with intrapartum proximal risk factors. J Clin Gynecol Obstet. 2014;3(3):97-104 doi: http://dx.doi.org/10.14740/jcgo267w