Assessment Of Fetal Well-being Research Articles

Fetal heart rate and fetal heart rate variability in Lipizzaner broodmares.

Monitoring fetal heart rate (FHR) and fetal heart rate variability (FHRV) helps to understand and evaluate normal and pathological conditions in the foal. The aim of this study was to establish normal heart rate reference values for the ongoing equine pregnancy and to perform a heart rate variability (HRV) time-domain analysis in Lipizzaner mares. Seventeen middle- and late-term (days 121-333) pregnant Lipizzaner mares were examined using fetomaternal electrocardiography (ECG). The mean FHR (P = 0.004) and the standard deviation of FHR (P = 0.012) significantly decreased during the pregnancy. FHR ± SD values decreased from 115 ± 35 to 79 ± 9 bpm between months 5 and 11. Our data showed that HRV in the foal decreased as the pregnancy progressed, which is in contrast with the findings of earlier equine studies. The standard deviation of normal-normal intervals (SDNN) was higher (70 ± 25 to 166 ± 108 msec) than described previously. The root mean square of successive differences (RMSSD) decreased from 105 ± 69 to 77 ± 37 msec between the 5th and 11th month of gestation. Using telemetric ECG equipment, we could detect equine fetal heartbeat on day 121 for the first time. In addition, the large differences observed in the HR values of four mare-fetus pairs in four consecutive months support the assumption that there might be 'high-HR' and 'low-HR' fetuses in horses. It can be concluded that the analysis of FHR and FHRV is a promising tool for the assessment of fetal well-being but the applicability of these parameters in the clinical setting and in studs requires further investigation.

Comparison of Nonstress Test and Light stimulation Test and their correlation with fetal outcome

Introduction: Non Stress Test serves an important function in assessment of fetal wellbeing, but false positive results limit its role. Light stimulation stimulates the fetus, speeds up the test and catalyses its rate limiting step. This study has compared simple Non Stress Test and Light stimulation test and there correlation with various fetal outcomes. This study helps us to assess whether light stimulation be used as a better alternative or an adjunct to traditional Nonstress test. Material and Methods: A total of 220 patients above 34 weeks of pregnancy were taken.110 pts underwent 20 minutes of Nonstress test and 110 underwent Halogen light stimulation which was given transabdominally for 10 seconds and it was repeated every 10 minutes for a maximum up to three times. This allocation was done randomly. Non reactive Nonstress test were then stimulated with Halogen light . Results : The test showed that sensitivity of Nonstress test is greater than Light stimulation test, but specificity, positive predictive value, and negative predictive value is lesser than Light stimulation test .Out of 36 Non reactive NSTs after stimulation with light 18 became reactive. Conclusion Nonstress test is considered as a screening test and Light stimulation test can be used as an adjunct to Nonstress test as it decreases the number of false positive results and increases the specificity of the test. Clinical outcomes are more closely related with LST, but more studies are required to arrive at the final conclusions.

A report on omphalocele and associated congenital deformity with intrauterine death: Need for early diagnosis

Omphalocele, a type of anterior abdominal wall defect, is a rare congenital deformity that is infrequently reported, which leads to the emergence of interventions that could be carried out for a better holistic management, for the baby, mother, and the family. We report a case of single dead fetus of 24 weeks gestational age delivered by a 25-year-old primigravida. On examination, it was observed and diagnosed that the baby presented with extrusion of multiple abdominal organs through a midline breach in the continuity of anterior abdominal wall suggesting it to be a case of omphalocele. It had other associated congenital deformities. Of all the investigations, ultrasonographic assessment of fetal structure and well-being is most reliable along with other investigations like genetic screening. The lack in the proper antenatal examination and infrequent routine checkups leads to a large proportion of undiagnosed cases. Proper diagnostic measures and awareness will bring a marked reduction in perinatal morbidity and mortality and avoidance of stigma faced by the patients.

Sonographic parameters for assessment of fetal well-being in mid-gestation in german Thoroughbred mares

Sonographic parameters for assessment of fetal well-being in mid-gestation in german Thoroughbred mares

A novel clinical decision support system using improved adaptive genetic algorithm for the assessment of fetal well-being.

A novel clinical decision support system is proposed in this paper for evaluating the fetal well-being from the cardiotocogram (CTG) dataset through an Improved Adaptive Genetic Algorithm (IAGA) and Extreme Learning Machine (ELM). IAGA employs a new scaling technique (called sigma scaling) to avoid premature convergence and applies adaptive crossover and mutation techniques with masking concepts to enhance population diversity. Also, this search algorithm utilizes three different fitness functions (two single objective fitness functions and multi-objective fitness function) to assess its performance. The classification results unfold that promising classification accuracy of 94% is obtained with an optimal feature subset using IAGA. Also, the classification results are compared with those of other Feature Reduction techniques to substantiate its exhaustive search towards the global optimum. Besides, five other benchmark datasets are used to gauge the strength of the proposed IAGA algorithm.

Anesthesia and the Fetus

Anesthesia and the Fetus

IFPA Gábor Than Award Lecture: Recognition of placental failure is key to saving babies' lives

In high-income countries, placental failure is implicated in up to 65% of cases of stillbirth. Placental failure describes the situation where the placenta cannot meet the fetus' needs and may be the end-result of a variety of underlying pathological processes evident in the placental disc, membranes and umbilical cord. These include lesions with genetic, environmental, infectious, inflammatory, mechanical, metabolic, traumatic or vascular origin. Investigation of placental tissue from stillbirths and from pregnancies at an increased risk of stillbirth has demonstrated changes in macroscopic and microscopic structure which are themselves related to abnormal placental function.A better understanding and identification of placental failure may improve the management of pregnancy complications and of pregnancies after stillbirth (which have a 5-fold increased risk of stillbirth). The majority of current antenatal tests focus on the fetus and its response to the intrauterine environment; few of these investigations reduce stillbirths in low-risk pregnancies. However, some currently used investigations reflect placental development, structure and vascular function, while other investigations employed in clinical research settings such as the evaluation of placental structure and shape have a good predictive value for adverse fetal outcome. In addition, recent studies suggest that biomarkers of placental inflammation and deteriorating placental function can be detected in maternal blood suggesting that holistic evaluation of placental structure and function is possible. We anticipate that development of reliable tests of placental structure and function, coupled to assessment of fetal wellbeing offer a new opportunity to identify pregnancies at risk of stillbirth and to direct novel therapeutic strategies to prevent it.

The value of middle cerebral artery and umbilical artery Doppler indices in assessment of fetal well-being and prediction of neonatal outcome in IUGR and preeclampsia

Objective The purpose of this study was to assess the accuracy of the middle cerebral artery (MCA) and umbilical artery (UA) Doppler indices in predicting fetal outcome in pregnancies complicated by preeclampsia and/or intrauterine growth retardation (IUGR). Study design It was a prospective study. Patients and methods One hundred and twenty-one pregnant women were categorized into four groups: group A, preeclampsia without IUGR group (38 cases); group B, IUGR without preeclampsia group (24 cases); group C, preeclampsia complicated with IUGR group (19 cases); and group D, the control group (40 cases). The perinatal outcomes correlated to the results of UA and MCA Doppler indices and cerebroplacental ratio (CPR). The accuracy of UA and MCA Doppler indices and CPR in the prediction of adverse outcome was calculated. Results Adverse neonatal outcome in group A was significantly correlated to UA-resistance index (RI) and UA-pulsatility index (PI) (r=0.537, P<0.001; r=0.405, P=0.0116, respectively). However, it showed no significant correlation with other parameter of Doppler indices and CPR. In group B, it was significantly correlated to all Doppler parameters indices and CPR. UA-RI and CPR were stronger parameters, to predict adverse neonatal outcome, than other parameters, with r-value of 0.869 and 0.803, respectively. In group C, it was significantly correlated to UA-RI and UA-PI, MCA-RI, and CPR. However, it showed no significant correlation with MCA-peak systolic velocity. CPR and UA-RI were stronger parameters, to predict adverse neonatal outcome, than other parameters, with r-value of 0.677 and 0.631, respectively. In group D, it was significantly correlated to UA-RI, UA-PI, and CPR. However, it showed no significant correlation with other parameters of Doppler indices. UA-RI and UA-PI were stronger parameters, to predict adverse neonatal outcome, than CPR, with r-value of 0.789 and 0.787, respectively. Conclusion The primary aim of antepartum surveillance is timely recognition of fetal compromise to enable appropriate intervention and to prevent further serious complications. MCA and UA Doppler indices are good utilities for the assessment of fetal well-being and prediction of neonatal outcome in pregnant women with IUGR and/or preeclampsia. CPR and MCA-peak systolic velocity are strong parameters to predict the adverse neonatal outcome in pregnant women with IUGR.

Obesity and the challenges of ultrasound fetal abnormality diagnosis

Prenatal ultrasound has become an essential clinical tool for aneuploidy screening, detection of fetal congenital anomalies, and assessment of fetal growth and well-being. Maternal obesity, an increasing global problem, has been shown to decrease the accuracy of ultrasound examination in high-risk pregnancy. The purpose of this review is to provide an evidenced-based perspective on the challenges of performing fetal ultrasound in obese women and to provide a practical guide on how to care for these patients in the ultrasound suite.

OP21.08: CPR 2 as a new Doppler parameter for assessment of wellbeing in fetal growth restricted fetuses

<scp>OP</scp>21.08: <scp>CPR</scp> 2 as a new Doppler parameter for assessment of wellbeing in fetal growth restricted fetuses

Use of a pocket-sized ultrasound machine (PUM) for routine examinations in the third trimester of pregnancy

To evaluate the application of a pocket-sized ultrasound machine (PUM) in a routine antenatal third-trimester scan compared with a high-specification ultrasound machine (HSUM). This was an observational cohort study of 53 unselected women who came for their routine third-trimester ultrasound scan. The first scan was performed by an experienced ultrasonographer on an HSUM for fetal growth, fetal wellbeing and placental location. A second experienced operator performed the measurements on the PUM. Both operators were blinded to the other's findings and measurement results. Fifty-one patients were eligible and scanned at a median gestational age of 31 + 1 (range, 27 + 2 to 36 + 0) weeks. Mean pregestational body mass index was 22.9 ± 3.1 (range, 17.6-35.7) kg/m(2) . In the comparison between measurements made using the PUM and HSUM, perfect agreement was found for fetal position, fetal bladder and stomach visualization (all κ 1.0) and very good agreement was found for placental position (κ 0.86). Measurements of deepest vertical pocket correlated moderately (intraclass correlation coefficient (ICC) 0.38 (95% CI, 0.12-0.59); Bland-Altman bias, 2.43 (95% limits of agreement (LoA), -22.65 to 27.51)). For fetal growth measurements there was very good agreement for biparietal diameter (ICC, 0.93 (95% CI, 0.88-0.96), Bland-Altman bias, -1.06 (95% LoA, -5.07 to 2.95)), and good agreement for femur length (ICC, 0.66 (95% CI, 0.48-0.79), Bland-Altman bias 0.56 (95% LoA, -5.97 to 7.08)) and transcerebellar diameter (ICC, 0.65 (95% CI, 0.46-0.78), Bland-Altman bias, -0.84 (95% LoA, -7.77 to 6.09)). A battery-driven PUM can be used in third-trimester obstetrics for routine assessment of fetal growth (biparietal diameter, transcerebellar diameter and femur length) and for assessment of fetal wellbeing.

Evaluación Crítica, Interpretación, Utilidad y Resultados del Perfil Biofísico Ecográfico. Hospital Guillermo Almenara, Lima-Perú

OBJETIVOS: Evaluar en forma crítica la utilidad del Perfil Biofísico Ecográfico (PBE) en la evaluación del bienestar fetal, definir con precisión sus variables, interpretarlo y proponer un flujograma de manejo de valoración del bienestar fetal de acuerdo al puntaje obtenido en la prueba. MATERIALES Y MÉTODOS: Estudio observacional, prospectivo y ciego en el Servicio de Obstetricia de Alto Riesgo del Hospital Guillermo Almenara - EsSalud en Lima, desde octubre de 1997 a setiembre de 1998. Se incluyó a 120 pacientes con edad gestacional ³28 semanas, cuyo estado requería valoración del bienestar fetal y decisión de culminar el embarazo en forma oportuna. Durante la prueba se evaluó la dificultad y beneficios de medir ultrasonográficamente la frecuencia cardíaca fetal basal y la reactividad cardíaca; la utilidad de evaluar ultrasonográficamente el volumen de líquido amniótico, la senescencia placentaria y el envejecimiento precoz de la placenta, y la utilidad de establecer un puntaje crítico de la prueba que defina una población en riesgo. RESULTADOS: La aplicación de esta estrategia reveló una alta sensibilidad (87,5%) de la prueba, un buen valor predictivo positivo (63,6%) y disminución importante del índice de falsos positivos y negativos (36,3% y 2,0%, respectivamente). CONCLUSIONES: Al establecer un flujograma de evaluación del bienestar fetal según los resultados de la prueba y al individualizar clínicamente cada caso para interpretar sus resultados se hace uso eficiente y eficaz del PBE.

The effect of maternal supine position on umbilical and cerebral blood flow indices

ObjectiveThe brain sparing phenomenon in the fetus is a protective mechanism aimed at maintaining sufficient blood flow towards the brain during chronic or acute fetal stress, such as that caused by hypoxemia or utero-placental insufficiency. In this study we investigated whether the brain sparing effect can also be elicited by a physiological stress associated with maternal posture.Study design Twenty-three low-risk pregnant women participated in the study. Between 36 and 40 weeks’ gestation, Doppler flow velocity waveforms were obtained from the fetal middle cerebral and the umbilical artery in the supine and the left lateral decubitus positions. Pulsatility index, systolic/diastolic index, and peak systolic velocities were measured and comparison was made between the left lateral and supine positions. ResultsThe pulsatility index in the middle cerebral artery decreased from 1.78±0.27 in the left lateral decubitus position to 1.29±0.16 in supine position (p<0.0001). Peak systolic velocity decreased from 46.05±7.85cm/s to 39.43±7.95cm/s, respectively (p=0.001). The pulsatility index in the umbilical artery decreased from 0.89±0.13 in the left lateral position to 0.74±0.11 in the supine position (p<0.0001). ConclusionsThis study demonstrates that the supine position in late pregnancy, causing aortic and venacaval compression, leads to brain auto-regulation that activates the brain sparing effect in the fetus. This protective mechanism, shown here for the first time to be linked to a physiological stress, may provide the basis for a novel approach in the assessment of fetal wellbeing.

Study of Oligohydramnios Cases by Modified Biophysical Profile &amp; Their Perinatal Outcome

Background:Assessment of foetal wellbeing is important, in timely diagnosis of foetalcompromise and management. Oligohydramnios is associated with increasedincidence of adverse perinatal outcomes like foetal distress, meconium stained liquor, lowAPGAR score, low birth weight, NICU admission, perinatal morbidity and mortality.Foetal biophysical profile is a well-established method of antepartumsurveillance. Classical biophysical profile needs two phase testing by ultrasound and external doppler monitor to record foetal heart rate, is more cumbersome, time consuming and expensive. The modified biophysical profile (MBPP) suggested by Nageotte et al combines non stress test (NST) as a short term marker of foetal status and the amniotic fluid index (AFI) as marker of long term placental function is easier to perform and less time consuming than classical biophysical profile. Objectives: 1) To assess the role of modified biophysical profile as a method ofantepartum foetalsurveillance test in predicting perinatal outcome in oligohydramnios cases. 2) To compare the morbidity and mortality with respect to each of the parameters ofmodified biophysical profile, that is NST and AFI individually. Methods:This study was a prospective clinical study which consisted of 60 pregnant women with oligohydramnios. The patients were evaluated with themodified biophysical profile consisting of NST recording for 20mins, followed byultrasound assessment of amniotic fluid volume, using four quadrant technique. Results: • When the Modified biophysical profile is normal, it gives reassurance that thefoetal status is good with good perinatal outcome. • When the MBPP is abnormal there is increased incidence of perinatalmorbidity as well as mortality. When considered individually, abnormal AFI was associated with increasedincidence of perinatal morbidity and abnormal NST was associated with increasedincidence of perinatal morbidity as well as perinatal mortality. Interpretation and conclusion:Modified biophysical profile is an effective method ofantepartum

Correlation between maternal weight and insulin resistance in second half of pregnancy.

Background:In pregnancy, routine measurement of maternal weight gives a crude assessment of maternal and foetal well-being. Excess weight gain in pregnancy is related to increased risk for gestational diabetes mellitus (GDM), hypertension in pregnancy and foetal macrosomia. In the Nigerian context, lack of knowledge of pre-pregnancy weight coupled with late booking of women in pregnancy hinders accurate assessment of weight gain in pregnancy. The absolute maternal weight is often used as surrogate. This study evaluates the relationship between absolute weight in the second half of pregnancy and insulin resistance.Patients and Methods:The weight of hundred pregnant women was measured between 24 to 32 weeks of pregnancy and their insulin resistance was measured using Homeostatic Model Assessment (HOMA-IR) from fasting serum glucose and fasting serum insulin.Results:Twenty-six women had weight ≥95 kg and 74 women had weight of <95 kg. There was a significant positive correlation between weight and HOMA-IR (r = 0.248), fasting glucose (r = 0.198), and fasting insulin (r = 0.228), (P < 0.05). The mean weight, HOMA-IR, fasting glucose and fasting insulin were higher in women with weight ≥95 kg compared to those with less weight. Also maternal weight ≥ 95 kg was associated with severe insulin resistance, (Odds Ratio = 3.1).Conclusion:Absolute weight in pregnancy correlates well with insulin resistance. Women having weight ≥95 kg between 24-32 weeks of gestation were more likely to have severe insulin resistance with implications for increased risk of GDM and other complications.

Experimental Modelling of the Consequences of Brief Late Gestation Asphyxia on Newborn Lamb Behaviour and Brain Structure

Brief but severe asphyxia in late gestation or at the time of birth may lead to neonatal hypoxic ischemic encephalopathy and is associated with long-term neurodevelopmental impairment. We undertook this study to examine the consequences of transient in utero asphyxia in late gestation fetal sheep, on the newborn lamb after birth. Surgery was undertaken at 125 days gestation for implantation of fetal catheters and placement of a silastic cuff around the umbilical cord. At 132 days gestation (0.89 term), the cuff was inflated to induce umbilical cord occlusion (UCO), or sham (control). Fetal arterial blood samples were collected for assessment of fetal wellbeing and the pregnancy continued until birth. At birth, behavioral milestones for newborn lambs were recorded over 24 h, after which the lambs were euthanased for brain collection and histopathology assessments. After birth, UCO lambs displayed significant latencies to (i) use all four legs, (ii) attain a standing position, (iii) find the udder, and (iv) successfully suckle - compared to control lambs. Brains of UCO lambs showed widespread pathologies including cell death, white matter disruption, intra-parenchymal hemorrhage and inflammation, which were not observed in full term control brains. UCO resulted in some preterm births, but comparison with age-matched preterm non-UCO control lambs showed that prematurity per se was not responsible for the behavioral delays and brain structural abnormalities resulting from the in utero asphyxia. These results demonstrate that a single, brief fetal asphyxic episode in late gestation results in significant grey and white matter disruption in the developing brain, and causes significant behavioral delay in newborn lambs. These data are consistent with clinical observations that antenatal asphyxia is causal in the development of neonatal encephalopathy and provide an experimental model to advance our understanding of neuroprotective therapies.

Interval type-2 fuzzy logic based antenatal care system using phonocardiography

The assessment of fetal wellbeing depends heavily on variations in fetal heart rate (FHR) patterns. The variations in FHR patterns are very complex in nature thus its reliable interpretation is very difficult and often leads to erroneous diagnosis. We propose a new method for evaluation of fetal health status based on interval type-2 fuzzy logic through fetal phonocardiography (fPCG). Type-2 fuzzy logic is a powerful tool in handling uncertainties due to extraneous variations in FHR patterns through its increased fuzziness of relations. Four FHR parameters are extracted from each fPCG signal for diagnostic decision making. The membership functions of these four inputs and one output are chosen as a range of values so as to represent the level of uncertainty. The fuzzy rules are constructed based on standard clinical guidelines on FHR parameters. Experimental clinical tests have shown very good performance of the developed system in comparison with the FHR trace simultaneously recorded through standard fetal monitor. Statistical evaluation of the developed system shows 92% accuracy. With the proposed method we hope that, long-term and continuous antenatal care will become easy, cost effective, reliable and efficient.

Timing of admission and selected aspects of intrapartum care: Relationship with caesarean section in the COSMOS (Caseload Midwifery) trial

Interprofessional education (IPE) or ‘learning and teaching together as a team’ is a relatively new concept for postgraduate maternity professional education. In 2007, the NSW Department of Health commenced work on an IPE program ‘Fetal welfare, Obstetric emergency, Neonatal resuscitation Training’ (FONT). This two-day program was designed to improve communication and teamwork around fetal welfare assessment, the management of maternity emergencies and neonatal resuscitation within the maternity clinical settings of NSW. Two hundred and forty clinicians, including obstetricians, general practitioners and midwives were trained as trainers who would provide local education sessions across the state. This paper will report on the results of the fetal welfare education that was part of the FONT program. This is a qualitative study that used a Likert rated questionnaire and unstructured interviews for evaluation. The Likert rated questionnaire was developed and sent to each of the 240 FONT trainers. Opinions were sought on the use of the IPE approach to teaching/learning fetal welfare assessment and the perceived effects of IPE on the maternity clinical environment in relation to communication, teamwork and clinical care. Fifteen of the respondents to the questionnaire were selected to take part in the unstructured interviews to further explore the themes developed from open-ended responses within the questionnaire. The majority of the respondents believed that IPE could work with 97% reporting thatmidwives and doctors learning togetherwas a positive experience, 97% believed that learningwithin amixed professional group was a positive way to learn and 97% appreciated hearing other people’s experiences with clinical decision making. Ninety eight percent (98%) believed that learning together would improve clinical discussion in the workplace and 92% reported the interactive education format improved communication between professional groups.

Communication and teamwork is enhanced through IPE

Interprofessional education (IPE) or ‘learning and teaching together as a team’ is a relatively new concept for postgraduate maternity professional education. In 2007, the NSW Department of Health commenced work on an IPE program ‘Fetal welfare, Obstetric emergency, Neonatal resuscitation Training’ (FONT). This two-day program was designed to improve communication and teamwork around fetal welfare assessment, the management of maternity emergencies and neonatal resuscitation within the maternity clinical settings of NSW. Two hundred and forty clinicians, including obstetricians, general practitioners and midwives were trained as trainers who would provide local education sessions across the state. This paper will report on the results of the fetal welfare education that was part of the FONT program. This is a qualitative study that used a Likert rated questionnaire and unstructured interviews for evaluation. The Likert rated questionnaire was developed and sent to each of the 240 FONT trainers. Opinions were sought on the use of the IPE approach to teaching/learning fetal welfare assessment and the perceived effects of IPE on the maternity clinical environment in relation to communication, teamwork and clinical care. Fifteen of the respondents to the questionnaire were selected to take part in the unstructured interviews to further explore the themes developed from open-ended responses within the questionnaire. The majority of the respondents believed that IPE could work with 97% reporting thatmidwives and doctors learning togetherwas a positive experience, 97% believed that learningwithin amixed professional group was a positive way to learn and 97% appreciated hearing other people’s experiences with clinical decision making. Ninety eight percent (98%) believed that learning together would improve clinical discussion in the workplace and 92% reported the interactive education format improved communication between professional groups.

Quantitative assessment of fetal well-being through CTG recordings: a new parameter based on phase-rectified signal average.

Since the 1980s, cardiotocography (CTG) has been the most diffused technique to monitor fetal well-being during pregnancy. CTG consists of the simultaneous recording of fetal heart rate (FHR) signal and uterine contractions and its interpretation is usually performed through visual inspection by trained obstetric personnel. To reduce inter- and intraobserver variabilities and to improve the efficacy of prenatal diagnosis, new quantitative parameters, extracted from the CTG digitized signals, have been proposed as additional tools in the clinical diagnosis process. In this paper, a new parameter computed on FHR time series and based on the phase-rectified signal average curve (PRSA) is introduced. It is defined as acceleration phase-rectified slope (APRS) or deceleration phase-rectified slope (DPRS) depending on the slope sign of the PRSA curve. The new PRSA parameter was applied to FHR time series of 61 healthy and 61 intrauterine growth restricted (IUGR) fetuses during CTG nonstress tests. Performance of APRS and DPRS was compared with 1) the results provided by other parameters extracted from the PRSA curve itself but already existing in the literature, and 2) other clinical indices provided by computerized cardiotocographic systems. APRS and DPRS indices performed better than any other parameter in this study in the distinction between healthy and IUGR fetuses. Our results suggest this new index might reliably contribute to the quality of early fetal diagnosis.