Blood Ischemia-modified Albumin Levels Research Articles

Ischemic-Modified Albumin in Neonates with Congenital Heart Defects.

Ischemia-modified albumin (IMA) is a new biochemical marker of ischemia. We aimed to search blood IMA levels in neonates with congenital heart defects. During the study period, patients diagnosed with congenital heart disease and newborns with a diagnosis of hyperbilirubinemia as a control group were included in the study. IMA level was analyzed using the IMA absorbance unit (ABSU) method. In total, 57 newborns with congenital heart disease requiring cardiac operation for the study group and 38 newborns for the control group were included. There was no difference between the two groups in terms of gender, mode of delivery, and weeks of gestation. The average IMA values in the control group were 0.19 ± 0.09 ABSU. The prepostoperative mean IMA values of the patient group were 0.22 ± 0.07 and 0.23 ± 0.07 ABSU, respectively. Comparison of the postoperative IMA with the mean of the control group was statistically significant. Preoperative and postoperative IMA values of patients who have died due to primary heart disease and surgical complications were 0.21 ± 0.07 (0.08-0.32) ABSU and 0.25 ± 0.06 (0.12-0.36) ABSU, respectively. IMA levels were not statistically different between the two groups. Hypoxia and ischemia in congenital heart disease in the newborn period both preoperatively and postoperatively were important in prognosis. IMA was higher in the postoperative group. Many comprehensive studies are important in terms of preventing complications and decreasing mortality and morbidity by commenting on prognosis. · IMA is a new biochemical marker of ischemia.. · In the literature, there are no reports about the relation between congenital heart defects and IM.. · The exposure of CHD patients to hypoxia/asphyxia in the preintra and postoperative periods cause neurologic deficits.

Evaluation of Serum Ischemia Modified Albumin in Patients With COVID-19 Pneumonia: A Case-Control Study.

Introduction: Various biomarkers are used when evaluating the hospitalization needs of patients diagnosed with Coronavirus disease (COVID-19). Ischemia-modified albumin (IMA) is a biomarker that causes blood levels to increase as a result of hypoxia and acidosis. We think that an increase in IMA in the blood may be caused by hypoxia stemming from lung damage. This study aimed to compare the mean/median of the blood IMA value in patients with pneumonia due to COVID-19 infection with a control group.Methods: The case group included patients with COVID-19 pneumonia detected by lung imaging and a positive COVID test. Demographic information of the case group, the severity of pneumonia, and their PCR test results were recorded in the data set.Findings: A total of 150 people, 90 of whom were in the case group and 60 of whom were in the control group, participated in the study. No statistically significant differences were found between the blood IMA levels of the case group and the control group. When the blood IMA levels of the case group were compared according to pneumonia severity, no statistically significant differences were found between the mild-moderate and severe pneumonia groups.Conclusion: Blood IMA levels are not a diagnostic biomarker for patients with COVID-19 pneumonia and are not helpful in predicting the severity of pneumonia.

Preeklamptik annelerin bebeklerinde kordon kanı iskemi modifiye albümin düzeyleri ve ortalama trombosit hacminin değerlendirilmesi

Aim: Oxidative stress (OS) is a known cause of placental dysfunction, thus may be causally related to preeclampsia and small for gestational age infant (SGA). We aimed to investigate cord blood ischemia-modified albumin (IMA) and mean platelet volüme (MPV) levels in neonates born to mothers with preeclampsia and correlate the determined levels with beeing SGA. Material and Method: A prospective controlled study was conducted. Fifty infants of mothers with preeclampsia, 40 healthy neonates of healthy mothers were included. Cord blood IMA and MPV levels were measured in infants of mothers with preeclampsia. The role of cord blood IMA levels to predict beeing SGA was also investigated. Results: Cord blood IMA and MPV levels of infants of preeclamptic mothers were significantly higher compared to controls. Serum IMA levels were significantly higher in SGA infants compared to appropirate for gestational age (AGA) infants (p=0.018), however MPV levels were similar in both groups (p=0.735). Conclusion: According to this study cord blood IMA and MPV levels may be considered useful as a simple measure of OS status in infants of mothers with preeclampsia. However, further studies with larger samples will be necessary to determine usefulness of these markers in clinical practice.

Investigation of serum ischemia-modified albumin levels in coronary artery disease patients.

Ischemia-modified albumin (IMA) is a novel marker for the detection of ischemia. The value of this biomarker has been studied in patients with coronary artery disease (CAD). However, the relationship between the severity of coronary stenosis and serum IMA levels remains unknown. Therefore, we aimed to investigate the potential role of serum IMA levels in predicting the severity of coronary atherosclerosis. One hundred and forty-two individuals who underwent coronary angiography for coronary artery disease complaints were included in the study. Participants were divided into three groups based on their diagnosis as control (healthy subjects), group I (subjects with lower Gensini score), and group II (subjects with higher Gensini score). Global Registry of Acute Coronary Events (GRACE) risk score and Gensini scores were calculated after coronary angiogram in the patient groups. Then, venous blood samples were collected from each participant. Serum IMA levels and the levels of routine laboratory markers were measured. The serum lymphocyte, neutrophil, and high-density lipid (HDL) levels were statistically insignificant between the groups. The white blood cell (WBC) count and IMA levels were significantly higher in the patient groups (p < 0.05). The GRACE and Gensini scores were significantly different in the patient groups (p < 0.05). However, there was no significant correlation between the GRACE and Gensini scores and serum IMA levels. Although IMA levels can be a significant predictor for ischemia according to previous reports, this biomarker seems to be insufficient for determining the severity of disease in patients with CAD.

Evaluation of the role of ischemia modified albumin in neonatal hypoxic-ischemic encephalopathy.

BackgroundBirth asphyxia is a leading cause of neonatal mortality. Ischemia-modified albumin (IMA) levels may have a predictive role in the identification and prevention of hypoxic disorders, as they increase in cases of ischemia of the liver, heart, brain, bowel, and kidney.PurposeThis study aimed to assess the value of IMA levels as a diagnostic marker for neonatal hypoxic-ischemic encephalopathy (HIE).MethodsSixty newborns who fulfilled 3 or more of the clinical and biochemical criteria and developed HIE as defined by Levene staging were included in our study as the asphyxia group. Neonates with congenital malformation, systemic infection, intrauterine growth retardation, low-birth weight, cardiac or hemolytic disease, family history of neurological diseases, congenital or perinatal infections, preeclampsia, diabetes, and renal diseases were excluded from the study. Sixty healthy neonates matched for gestational age and with no maternal history of illness, established respiration at birth, and an Apgar score ≥7 at 1 and 5 minutes were included as the control group. IMA was determined by double-antibody enzymelinked immunosorbent assay of a cord blood sample collected within 30 minutes after birth.ResultsCord blood IMA levels were higher in asphyxiated newborns than in controls (250.83±36.07 pmol/mL vs. 120.24±38.9 pmol/mL). Comparison of IMA levels by HIE stage revealed a highly significant difference among them (207.3±26.65, 259.28±11.68, 294.99±4.41 pmol/mL for mild, moderate, and severe, respectively). At a cutoff of 197.6 pmol/mL, the sensitivity was 84.5%, specificity was 86%, positive predictive value was 82.8%, negative predictive value was 88.3%, and area under the curve was 0.963 (P<0.001).Conclusion IMA levels can be a reliable marker for the early diagnosis of neonatal HIE and can be a predictor of injury severity.

Does ischemia-modified albumin level predict severity of obstructive sleep apnea?

Ischemia-modified albumin (IMA) is a newly recognized marker of chronic inflammation used to evaluate oxidative stress status in patients with various diseases. We explored the possible relationship between IMA levels and obstructive sleep apnea (OSA). In this retrospective study, 169 of 216 sequential patients being evaluated for suspicion of OSAS met inclusion criteria. Polysomnography confirmed OSA in 86 patients (51%) while 81 patients (49%) without OSA were categorized as control subjects. All study participants were tested for blood IMA level, neutrophil/lymphocyte ratio (NLR), C-reactive protein (CRP) level, and red blood cell distribution width (RDW). The serum IMA level was significantly higher in patients with OSAS than controls (p = 0.008). The serum IMA level increased significantly as OSAS severity increased (r = 0.50, p < 0.001) and was positively correlated with the AHI (r = 0.41, p < 0.001), CRP level (r = 0.31, p = 0.004), body mass index (r = 0.24, p = 0.022), RDW (r = 0.31, p = 0.03), oxygen desaturation index (ODI) (r = 0.22, p = 0.02), and negatively correlated with the hemoglobin concentration (r = - 0.28, p = 0.04) and minimum hemoglobin oxygen saturation (SpO2) (r = - 0.25, p = 0.02). Receiver operator curve (ROC) analysis showed that the optimal serum IMA, CRP, RDW, and NLR values were not different for predicting OSAS diagnosis (areas under the curves (AUC) = 0.62, 0.59, 0.60, and 0.43, respectively). However, the serum IMA level was superior in reflecting OSAS severity (AUC = 0.78) compared to CRP, RDW, and NLR values (AUC = 0.61, 0.53, and 0.51, respectively) (all p < 0.001). Like other markers of inflammation, blood IMA levels were significantly elevated in patients with OSA. However, blood IMA level was a better predictor of disease severity than the other markers.

Association of cord blood ischemia-modified albumin level with abnormal foetal Doppler parameters in intrauterine growth-restricted foetuses

Objective: To investigate cord blood ischemia-modified albumin (IMA) levels in pregnancies with intrauterine growth restriction (IUGR) and to determine its association with abnormal fetal Doppler findings.Methods: Umbilical cord IMA levels were assessed in 34 pregnant women with IUGR and 32 pregnancies with normal fetal development. Associations of IMA with abnormal umbilical artery Doppler findings, preeclampsia, and oligohydramnios were investigated. IMA was measured using a colorimetric test based on a decrease in cobalt binding.Results: No significant between group differences in maternal age, body mass index, gravida, and parity were identified. The mean gestational age at delivery was earlier in the IUGR group than in the control group (35.7 ± 3.2 versus 38.4 ± 1.2, respectively). The mean cord blood IMA values for the IUGR group were significantly increased compared to those in the control group (0.565 ± 0.22 versus 0.250 ± 0.12, respectively, p = .001). There was a significant positive correlation between umbilical artery pulsatility index and IMA levels in the IUGR group. Patients with preeclampsia, oligohydramnios, and abnormal nonstress test results in the IUGR group had significantly higher IMA levels. Patients with systolic to diastolic ratios >3 and pulsatility index (PI) above the 95th percentile in the IUGR group had significantly higher cord blood IMA levels (p = .001 and p = .007, respectively).Conclusions: Cord blood IMA values may be a useful marker for perinatal asphyxia. Abnormal Doppler findings are associated with increased IMA levels in complicated pregnancies with IUGR.

The association between ischemia modified albumin and placental histopathology in uncomplicated term deliveries.

Ischemia modified albumin (IMA) is a marker of ischemia elevated in different clinical conditions and its use for hypoxia in perinatology is of current interest. We aimed to investigate the association between maternal and cord blood IMA levels and placental histopathological findings in uncomplicated term deliveries. In this study, placental histopathological evaluation in uncomplicated deliveries that ended with healthy newborns revealed 80.6% vasculopathy. The results support the hypothesis that hypoxia exceeding the placental reserve ends with fetal compromise. Moreover, the presence of maternal vasculopathy in placenta is not correlated with maternal and fetal IMA levels.

Serum Ischemia-Modified Albumin in Preterm Babies with Respiratory Distress Syndrome.

Infants with respiratory distress syndrome (RDS) may suffer from severe hypoxia, asphyxia. In this study, we aimed to evaluate serum ischemia-modified albumin (IMA) level as a diagnostic marker for hypoxia in preterm infants with RDS. Thirty-seven premature newborns with RDS were allocated as the study group and 42 healthy preterm neonates were selected as the control group. IMA was measured as absorbance unit (ABSU) in human serum with colorimetric assay method which is based on reduction in albumin cobalt binding. IMA levels were significantly higher in neonates with RDS as compared to the control group (P<0.001). Cut-off value of IMA (ABSU) was 0.72, the sensitivity level was 91.9%, the specificity was 78.6%, positive predictive value was 79.1% and negative predictive value was 91.7% at RDS. Area under curve values was 0.93 (P<0.001; 95% CI, 0.88-0.98) in the receiver operating characteristic curve. We concluded that elevated blood IMA levels might be accepted as a useful marker for hypoxia in newborn with RDS.

The protective effect of quercetin on IMA levels and apoptosis in experimental ovarian ischemia-reperfusion injury

ObjectiveTo investigate the protective effect of quercetin (QE), an anti-inflammatory and anti-oxidant agent, on torsion–detorsion induced histopathological changes and blood IMA levels in experimental ovarian ischemia-reperfusion (IR) injury. Study designTwenty-four female Wistar rats were randomly divided into four groups in this study (n=6). Group I, (sham operation); Group II, torsion–detorsion plus saline (IR); Group III, torsion–detorsion plus solvent (dimethylsulfoxide: DMSO, IR+DMSO); Group IV, torsion–detorsion plus 15mg/kg/bw quercetin (IR+QE) injected intraperitoneally 30min prior to detorsion. After 3h of reperfusion, the right ovaries were removed surgically. The ovary tissue samples were fixed in 10% formalin solution for histopathological and immunohistochemical examination. Blood samples were obtained at the end of the procedures for each group of animals. ResultsOvarian sections in Groups II and III showed higher follicular cell degeneration, hemorrhage, vascular congestion and edema when compared with Group I. Administration of quercetin in rats significantly prevented degenerative changes in the ovary. Significantly less histopathological changes were found in Group IV compared with Groups II and III. Caspase-3 and TUNEL positive cells were detected in the ovarian surface, follicle epithelium, and stromal cells in all experimental groups, and there was a significant increase in Groups II and III compared with Group I (P<0.05). Treatment with quercetin decreased the number of caspase-3 and TUNEL positive cells. IR increased the ischemia modified albumin (IMA) levels in comparison to the sham group (1.06±0.10ABSU and 0.92±0.08ABSU, P<0.05). Quercetin administration before IR reduced the levels of IMA (0.93±0.08ABSU, P<0.05). ConclusionAdministration of quercetin is effective in preventing tissue damage induced by IR injury in ovaries.

Study of cord blood ischemia modified albumin levels in the evaluation of birth asphyxia

Objective: In birth asphyxia several new biochemical markers are now investigated. Recent studies indicate the role of ischemia modified albumin, a biomarker determined by assay of cobalt binding activity of albumin. The aim of this study was to evaluate the role of ischemia modified albumin in birth asphyxia. Materials and methods: 40 newborns with APGAR score less than 7 were selected at random. Low birth weight, premature and newborns from caesarian section were excluded. Ischemia modified albumin was determined by assay of its cobalt binding activity with spectrophotometer. Mothers with history of preeclampsia and preexisting renal disease were kept out of the study. Similar observations were made in 40 normal newborns taken as control. Results: Cord blood ischemia modified albumin levels were higher in asphyxiated newborns compared to controls (55.7±1.7 U/ml compared to 32.44±1.15 U/ml). Raised levels of IMA in those subjects had shown very significant correlations with the APGAR scores of 5 minutes, a finding also observed in case of controls. Conclusion: The findings of the current study indicate that ischemia modified albumin can be a very useful marker in evaluation of birth asphyxia.

Cord blood ischemia‐modified albumin: Is it associated with abnormal Doppler findings in complicated pregnancies and predictive of perinatal asphyxia?

To evaluate the significance of the cord blood ischemia-modified albumin (IMA) level as a diagnostic marker for perinatal asphyxia and to determine the associations of IMA levels with the complexity of pregnancy and abnormal Doppler findings, regardless of perinatal asphyxia. This prospective study included 169 newborns, sixteen of whom had perinatal asphyxia and 33 who were from complicated pregnancies. Doppler measurements were obtained from the uterine, umbilical and middle cerebral arteries, and the cerebro/placental ratio (C/P). IMA was measured by means of commercially available ELISA kits and was expressed as picomoles per milliliter. Ischemia-modified albumin levels were significantly higher in neonates of complicated pregnancies as compared to uncomplicated pregnancies (P < 0.0001). They were higher in newborns with perinatal asphyxia as compared to healthy controls (P = 0.015). The C/P ratio-pulsatility index (PI) showed a significant difference between normal and complicated pregnancies without perinatal asphyxia (P < 0.0001). IMA levels were significantly increased in cases with abnormal C/P ratio-PI. Elevated cord blood IMA levels may be accepted as a useful marker in perinatal asphyxia. Abnormal Doppler examinations are associated with elevated IMA levels in complicated pregnancies.

Maternal and umbilical cord ischemia-modified albumin levels in nonreassuring fetal heart rate tracings regarding the mode of delivery

Objective: To evaluate umbilical cord blood ischemia-modified albumin (IMA) levels in cases of fetal distress (FD) and to explore fetal blood IMA levels regarding the route of delivery. Methods: Umbilical cord and maternal serum IMA concentrations were assessed in term 40 cases with cesarean section (CS) due to FD, 76 cases with elective repeat CS and 85 cases with noncomplicated vaginal delivery. Results: The maternal and umbilical cord IMA levels were significantly lower in vaginal deliveries when compared with CS cases either in FD or previous CS groups (p = 0.02). Although no statistically significant difference was found in IMA levels of CS groups (previous CS vs. FD), cord blood IMA levels tend to be higher in FD group. Neither demographic characteristics nor fetal outcome parameters were found to have any correlation with maternal IMA levels. However, umbilical cord IMA levels were found to be negatively correlated with 1th min Apgar scores (r = –0.143, p = 0.043). Conclusions: IMA seems to be responsive to hypoxic FD showing the highest levels in cases with severe fetal hypoxia. Higher levels of IMA in cases with elective repeat CS might indicate acute transient hypoxia and possible myocardial ischemia in these cases.

Ischemia modified albumin in the differential diagnosis of pleural effusions

The differential diagnosis of pleural effusion often requires invasive procedures. Up to 25 percent of pleural effusions can remain undiagnosed with an unclear pathogenesis. Therefore new biological markers may increase diagnostic yield and provide better understanding of pathogenesis of pleural effusion. We hypothesized that new ischemia biomarker, "ischemia modified albumin (IMA)" would help in both the differentiation of the underlying etiologies and provide a better understanding of pathogenesis of pleural effusions. This study was done between December 2009 and September 2010 in the Department of Pulmonary Diseases of Gaziantep University Hospital. One hundred and sixteen subjects with pleural effusion were included. Pleural and blood IMA levels were measured by ELISA. The underlying etiologies of pleural effusions were as follows: transudates (n = 50), malignancy (n = 32), tuberculosis (n = 12), pulmonary thromboembolism (n = 6), pneumonia (n = 16). The median pleural IMA levels were significantly different between the groups (p < 0.000). There were no such differences in the blood levels of IMA. The most striking difference in the median pleural IMA levels was between transudates and exudates (7986 (25-75%, 5145-56.505) ng/mL; 3376 (25-75%, 1935-4660) ng/mL; respectively, p = 0.000). The area under the ROC curve was 0.837 ± 0.038 for the cut-off level higher than 4711 ng l/mL for the differentiation of transudates from exudates (sensitivity, 82%; specificity, 78%; 95% CI, 0.76 to 0.91; p = 0.0000). In conclusion, the pleural IMA levels are higher in transudates compared to exudates. No such differences were observed in blood levels of IMA suggesting that there are reasons other than ischemia that cause an increase in pleural fluid IMA levels.

Can ischemia-modified albumin be a valuable indicator of tissue ischemia in polycythemia vera?

The red cell expansion in polycythemia vera (PV) causes hyperviscosity affecting blood flow, which plays a major role in the pathogenesis of both microcirculatory disturbances and ultimately thromboses. Ischemia-modified albumin (IMA) is produced during an ischemic states and is present in blood in early and easily detectable levels. This study investigated whether IMA is a useful adjunct in the determination of ischemia in patients with PV, prior to them exhibiting clinical evidence of thrombotic complications. Blood IMA levels were determined in 20 PV patients and in 20 healthy individuals using a method described by Bar-Or. Mean IMA levels in the PV group were significantly higher than those of the control group (P<0·05). At the optimum cutoff point (0·193 absorbance units), the sensitivity and specificity of IMA were 80 and 100% to ischemia, respectively. In conclusion, IMA may be a valuable biochemical marker in predicting tissue ischemia in PV before the signs of vascular disturbances occur.

Ischemia-modified albumin levels in carbon monoxide poisoning

Objectives Ischemia-modified albumin (IMA) is an emerging diagnostic biomarker for many ischemic conditions. This study was conducted to investigate whether there is a change in IMA levels in carbon monoxide (CO) poisoning and, if so, the clinical relevance of IMA levels. Methods This cohort study, performed between November 2008 and April 2009, compared the serum IMA levels of 33 CO-poisoned patients taken at the time of presentation at the emergency department and after 3 hours of treatment and 49 healthy controls. In addition, IMA and carboxyhemoglobin levels were analyzed according to CO poisoning patients' poisoning severity scores. Results Carbon monoxide patients' IMA levels were higher than those of the control group both at time of admission and at the third hour of the treatment, P < .0001. A significant fall was determined in carboxyhemoglobin (CO-Hb) levels at the end of the third hour of treatment, P < .0001. However, there was no significant difference between the IMA levels measured at admission and at the end of the third hour of treatment ( P > .05). There was no significant correlation between IMA and CO-Hb levels in CO-poisoned patients. Also, there was no difference in blood IMA levels in classification according to patients' poisoning severity score and CO-Hb levels. Conclusion Results from this pioneering study established a high level of IMA in CO-poisoned patients, suggesting that IMA may also be sensitive to hypoxia. Considering the preliminary nature of this study, the clinical utility of IMA levels in CO poisoning should be further investigated with more comprehensive studies.

Cord Blood Ischemia‐Modified Albumin Levels in Normal and Intrauterine Growth Restricted Pregnancies

Ischemia-modified albumin (IMA) is a sensitive biomarker of cardiac ischemia. Intrauterine growth restriction (IUGR) may imply fetal hypoxia, resulting in blood flow centralization in favour of vital organs (brain, heart, adrenals—“brain sparing effect”). Based on the latter, we hypothesized that cord blood IMA levels should not differ between IUGR and appropriate-for-gestational-age (AGA) full-term pregnancies. IMA was measured in blood samples from doubly-clamped umbilical cords of 110 AGA and 57 asymmetric IUGR pregnancies. No significant differences in IMA levels were documented between AGA and IUGR groups. IMA levels were elevated in cases of elective cesarean section (P = .035), and offspring of multigravidas (P = .021). In conclusion, “brain sparing effect” is possibly responsible for the lack of differences in cord blood IMA levels at term, between IUGR and AGA groups. Furthermore, higher oxidative stress could account for the elevated IMA levels in cases of elective cesarean section, and offspring of multigravidas.

Ischemia-modified albumin levels in cord blood: A case-control study in uncomplicated and complicated deliveries

Background In the past few years ischemia modified albumin (IMA) has emerged as a new biomarker of ischemia in the area of monitoring acute coronary syndromes. We hypothesized that reduced blood flow, such as that resulting from vascular compression in complicated labors or placental ischemia, may increase IMA. IMA level in cord blood could then serve as an indicator of fetal hypoxia and fetal tissue ischemia and serve as a biomarker of the severity of these conditions. Methods We performed a case-control study with 26 newborns (12 normal term deliveries, Apgar 8–9; and 14 complicated labors or pre-term deliveries, Apgar 5–8). Complications were: prematurity (3), fetal distress (6), premature rupture of membranes (6), intrauterine growth retardation (3), pre-eclampsia (1). We also studied 30 healthy adults. IMA was measured in serum from cord blood (or venous blood for adults) by the decrease in cobalt 2+ binding. Results IMA levels in neonates from non-complicated deliveries are significantly higher (45%, p < 0.005) than those of an adult control population, suggesting that IMA may increase as a consequence of labor. This increased IMA in neonates could not be accounted for by the changes in albumin concentration. It is conceivable that a transient increase in IMA reflects, in part, transient localized tissue ischemia due to the external forces exerted on the fetus during the mechanism of labor. IMA levels in cord blood from neonates from complicated deliveries are 50% higher than in neonates from uneventful deliveries ( p < 0.05) while their albumin values are not significantly different (32 ± 3 vs. 33 ± 2 g/l). Moreover, IMA seems to be responsive to hypoxic fetal distress, showing values more than 300% higher in cases of severe fetal hypoxia (Apgar 5 n = 2: 2.19 ± 0.01 AU vs. 0.64 ± 0.24 for controls). IMA values did not correlate significantly with either lipoperoxides or CRP levels. Conclusions This is the initial reporting of IMA levels in cord blood from normal deliveries compared to healthy adult ranges and neonates from complicated deliveries. Cord blood IMA levels may be an indicator of fetal ischemia and/or hypoxia. This test could become an additional biomarker to be used in conjunction with other markers and/or clinical scores aimed at determining risk of neurological complications of fetal distress.