Cases Of Neonatal Encephalopathy Research Articles

Etiology, clinical profile, and immediate outcome of neonatal encephalopathy in Northeast India: A hospital-based cross-sectional study

Background: Neonatal encephalopathy (NE) is one of the important causes contributing to neonatal death and disability. Knowledge about associated probable risk factors of NE will be helpful in developing strategies for proper intervention and early management. Aims and Objectives: This study aims to describe the etiology, clinical features, and immediate outcomes of NE in the northeastern part of India. Materials and Methods: This hospital-based, cross-sectional observational study included cases of NE beyond 35 weeks of gestation from February 2018 to July 2019. Demographic profiles, risk factors, clinical features, laboratory investigations, imaging, and outcome data were collected and analyzed. Results: A total of 82 patients comprising males (59.7%) and females (40.2%) were included in the study. The mean age of gestation in weeks is 37.60±3.5 SD. Meconium-stained liquor was the most frequent etiology (n=30; 36.5%), followed by dyselectrolytemia (n=8; 9.7%), abnormal hydramnios (oligo or poly) (n=5.6%), and twin pregnancy and instrumental delivery (n=4; 4.8%). Seizures (n=37; 45.1%) were the most common presentation followed by respiratory distress or difficulty (n=25; 30.4%). Around 41.4% suffered from dyselectrolytemia followed by positive sepsis screening of 39%. Most of the cases (87.8%) were discharged after receiving appropriate treatment. Conclusion: The prevalence of neonates with NE as noted in this hospital-based, cross-sectional study was 2.8%. It was found that in most cases, the probable causative factors occurred during the antenatal and intranatal period. Convulsions were the most common clinical presentation among the affected neonates. Most of the admitted neonates had dyselectrolytemia, suggesting that the renal system was predominantly affected, while the immediate outcome was satisfactory.

Maternal Diet, Infection, and Risk of Cord Blood Inflammation in the Bangladesh Projahnmo Pregnancy Cohort.

Inflammation may adversely affect early human brain development. We aimed to assess the role of maternal nutrition and infections on cord blood inflammation. In a pregnancy cohort in Sylhet, Bangladesh, we enrolled 251 consecutive pregnancies resulting in a term livebirth from July 2016–March 2017. Stillbirths, preterm births, and cases of neonatal encephalopathy were excluded. We prospectively collected data on maternal diet (food frequency questionnaire) and morbidity, and analyzed umbilical cord blood for interleukin (IL)-1α, IL-1β, IL-6, IL-8 and C-reactive protein. We determined associations between nutrition and infection exposures and cord cytokine elevation (≥75% vs. <75%) using logistic regression, adjusting for confounders. One-third of mothers were underweight (BMI < 18.5 kg/m2) at enrollment. Antenatal and intrapartum infections were observed among 4.8% and 15.9% of the sample, respectively. Low pregnancy intakes of B vitamins (B1, B2, B3, B6, B9 (folate)), fat-soluble vitamins (D, E), iron, zinc, and linoleic acid (lowest vs. middle tertile) were associated with higher risk of inflammation, particularly IL-8. There was a non-significant trend of increased risk of IL-8 and IL-6 elevation with history of ante-and intrapartum infections, respectively. In Bangladesh, improving micronutrient intake and preventing pregnancy infections are targets to reduce fetal systemic inflammation and associated adverse neurodevelopmental outcomes.

Risk factors for neonatal encephalopathy in late preterm and term singleton births in a large California birth cohort.

The objective was to investigate maternal and pregnancy characteristics associated with neonatal encephalopathy (NE). We queried an administrative birth cohort from California between 2011 and 2017 to determine the association between each factor and NE with and without hypothermia treatment. From 3 million infants born at 35 or more weeks of gestation, 6,857 cases of NE were identified (2.3 per 1000 births), 888 (13%) received therapeutic hypothermia. Risk factors for NE were stronger among cases receiving hypothermia therapy. Substance-related diagnosis, preexisting diabetes, preeclampsia, and any maternal infection were associated with a two-fold increase in risk. Maternal overweight/obesity, nulliparity, advanced maternal age, depression, gestational diabetes or hypertension, and short or long gestations also predicted NE. Young maternal age, Asian race and Hispanic ethnicity, and cannabis-related diagnosis lowered risk of NE. By disseminating these results, we encourage further interrogation of these perinatal factors.

Neonatal cord blood eucapnic pH: A potential biomarker predicting the need for transfer to the NICU

IntroductionThe best biomarker for neonatal metabolic acidosis (NMA) and its related complications is still a matter of debate. Umbilical artery (Ua) cord pH is not sufficiently specific, as is lactatemia, while base deficit is considered to offer no added value. From a physiological point of view, the calculated neonatal eucapnic pH is a more specific marker for neonatal metabolic acidosis and may be a better predictor of birth complications of hypoxic origin, because complications related to asphyxia are always preceded by neonatal depression leading to a transfer to a neonatal intensive care unit (NICU) for close monitoring. ObjectiveThis study aimed to test the hypothesis that in a group of neonates with significant acidemia, neonatal eucapnic pH (pH euc-n) predicts NICU admission better than the Ua cord pH does. MethodsFrom a cohort of 5,392 infants all born at ≥35 weeks’ gestation, we identified a group of 30 cases with Ua cord pH <7.0. We calculated the area under the curve (AUC) for pH euc-n and Ua cord pH using the receiver-operating characteristic (ROC) curve and compared the performance of these biological markers in predicting transfer to the NICU. Cut-off points were determined by selecting the best value of the positive likelihood ratio that maximizes the accuracy of prediction. ResultsFrom the 30 newborns diagnosed with significant acidemia, four infants were transferred to the NICU. No case of neonatal encephalopathy was observed. In these infants, the pH euc-n AUC (0.66) was significantly higher than the Ua cord pH AUC (0.44) (P<0.005), with the best pH euc-n cut-off value at 7.11. ConclusionDespite the study limitations, our results suggest that pH euc-n is a better marker than Ua pH for predicting admission to the NICU in newborns with acidemia at birth. These are preliminary results and further investigations are mandatory in larger population samples to confirm these findings and to determine the optimal cut-off value for pH euc-n for the most accurate prediction of a complicated transition to extrauterine life and, potentially, neonatal hypoxic–ischemic encephalopathy.

Contributory factors and potentially avoidable neonatal encephalopathy associated with acute peripartum events: An observational study

In 25% of affected babies, neonatal encephalopathy results from acute peripartum events, but rigorous review of these cases for quality improvement is seldom reported. New Zealand has maintained a national database of all babies diagnosed with Sarnat moderate and severe neonatal encephalopathy since 2010 under the Perinatal and Maternal Mortality Review Committee. To determine the rate of contributory factors, potentially avoidable mortality or morbidity, and to identify key areas for improvements to maternity and neonatal care among cases of neonatal encephalopathy following an acute peripartum event. Sarnat moderate and severe cases identified from the national collection of neonatal encephalopathy with a history of an acute peripartum event were reviewed using a standardised independent multidisciplinary methodology and a tool for assessing contributory factors and potential avoidability, with the addition of a human factors lens. Forty-seven cases from 2013 to 2015 were reviewed. The most common acute peripartum events were placental abruption (12) and shoulder dystocia (11). Contributory factors were identified in 89%, and the severity of outcome was potentially avoidable in 66%. Key modifiable areas included dynamic risk assessment, preparedness for obstetric and neonatal emergencies, best practice for maternal and fetal surveillance in labour, and documentation. There is significant potential to improve quality and safety in acute peripartum care to reduce the risk of neonatal encephalopathy. Human factors were not well captured by the clinical notes or review tool. Attention to human factors by improved methodology can enhance review of neonatal encephalopathy.

Monitoring of Blood Pressure is not Enough to Avoid Neonatal Postoperative Encephalopathy

Background Neonatal encephalopathy with seizures after general anesthesia not occurring in infants undergoing cardiac or major neurosurgery is very uncommon. An ischemic origin due to cerebral hypoperfusion from perioperative hypotension has been suggested, but there is a lack of a consensus definition for intraoperatory hypotension in neonates. Case Report We report the first case of neonatal encephalopathy with seizures in a neonate with anorectal malformation. He underwent a colostomy with caudal anesthesia combined with light general anesthesia. Intraoperative systolic blood pressure and mean blood pressure values were considered normal. Thirty-two hours after the intervention, the patient presented electroclinical seizures. Diffusion-weighted imaging showed bilateral involvement with reduced diffusivity in the watershed areas of the middle cerebral artery and posterior cerebral artery. Conclusion Perioperative monitoring of blood pressure is not enough in neonatal surgery. Cerebral magnetic resonance imaging should be considered in infants with noncardiac congenital anomalies after neonatal surgery and long-term follow-up is required.

An evaluation of fetal heart rate characteristics associated with neonatal encephalopathy: a case‐control study

We sought to identify fetal heart rate (FHR) characteristics that are associated with neonatal encephalopathy (NE). Retrospective case-control study. A single medical centre in Shanghai, China, 2006-2015. Women delivering a singleton, non-anomalous infant at ≥36 weeks' gestation diagnosed with NE (cases, n = 109) were compared with a group of women with unaffected infants (controls, n = 233). Two physicians blinded to the outcome independently reviewed FHR tracings during the last 30 minutes of tracing prior to delivery. FHR characteristics were compared in the two groups and multivariable logistic regression was used to adjust for confounding. Adjusted odds ratio (aOR) and 95% confidence interval (CI) for the presence of specific FHR categories and characteristics. Category II FHR tracings were observed in 89% of women prior to delivery and were not independently associated with NE. Notably, a category III FHR was observed in 17.4% of women in the NE group compared with 0.9% of women in the control group (aOR 44.99, 95% CI 7.23-279.97). Bradycardia, minimal/absent variability, late decelerations and prolonged decelerations were independently associated with NE, whereas accelerations were protective. Similar findings were found when the cases were limited to NE with arterial cord pH <7.1 and in a subgroup analysis of women with category II tracings. Category III tracings, while infrequent, are not uncommon prior to delivery among fetuses who develop NE. In contrast, most FHR tracings are category II prior to delivery; however, individual FHR characteristics within this category are associated with NE. This research was supported by the Interdisciplinary Programme of Shanghai Jiao Tong University. Category III tracings are not uncommon prior to delivery among fetuses who develop neonatal encephalopathy.

286: Is neonatal asphyxia predictable?

Most cases of neonatal encephalopathy (NE) in term infants are caused by asphyxia and are preceded by ante- or intra-partum risk factors. The role of FHR rate monitoring is controversial. We evaluated how many cases of asphyxia and NE occur in low risk pregnancies. Prospective observational cohort study in a network of 4 hospitals with shared protocols of intrapartum and neonatal care. One Hub center has NICU and offers therapeutic hypothermia. Fetal heart rate (FHR) monitoring was classified according to ACOG and managed using Clark’s algorithm. Umbilical artery (UA) pH was routinely determined. All neonates from July 2014 to June 2016, born at >35 wks, >1800 g, without lethal malformations and with consenting parents were included. Neonatal asphyxia was defined as pH ≤7.0 or BE ≤-12 mMol/L in UA or within 1 h, 10 min Apgar <5, need for resuscitation >10 min. Asphyxiated neonate were monitored with Thomson score. NE was classified according to Sarnat&Sarnat and II-III grades underwent hypothermia. Data regarding pregnancy, delivery, sentinel events, neonatal outcome were collected. Pregnancies were assigned to: low risk (no risk factors), antepartum risk (maternal age >40 years, BMI >30, oligo or polihydramnios, FGR, induction of labor, maternal disease, previous cesarean), intrapartum risk (sentinel event, meconium grade 2-3, fever, tachysystole), both ante and intrapartum risk. Neonatal asphyxia occurred in 21.5‰ cases (321/14,896) and 278 fulfilled the study criteria. Rate of cesarean delivery was 19.8%, of which 70.9% for non-reassuring fetal status. Rate of vacuum delivery was 23.7%. NE occurred in 14/278 (5%) and 10 cases received hypothermia. No NE occurred in neonates not enrolled. The figure shows numbers and severity of NE cases in asphyxiated neonates according to presence of risk factors. Sentinel events occurred in 67/278 asphyxia cases (24%) and in 6/14 (43%) NE cases. ACOG FHR cat. II or III occurred in 140/278 (50.4%) and preceded NE in 9/14 (64%). 115/278 (41.4%) cases of asphyxia and 2/14 (14.3%) cases of NE were not preceded by sentinel events or abnormal CTG. 41.4% cases of asphyxia and 14.3% cases of NE were not preceded by sentinel events or abnormal CTG. 16.2% of asphyxiated and 3/14 (21.4%) NE occurred in low risk pregnancies.

Neonatal Encephalopathy in Calves Presented to a University Hospital.

BackgroundWhile studies have examined bovine dystocia in relation to calf survival, little has been published regarding perinatal morbidity and treatment of newborn calves beyond failure of transfer of passive immunity (FTPI). Neonatal encephalopathy (NE) is a clinical syndrome commonly diagnosed in infants and foals but is poorly described in calves.Hypothesis/ObjectivesTo identify risk factors for development of NE in calves and factors predictive of survival.AnimalsNeonatal calves presented to a University hospital over a 10‐year period.MethodsRetrospective cohort study (2005–2015). Medical records of all neonatal calves presented to the hospital were examined, and cases of NE were identified. Data pertaining to demographics, dam parity, labor, treatment, and outcome were collected and analyzed with univariate and multivariate statistics.ResultsOf 200 calves in the final analysis, 58 (29%; 95% CI: 22.8–35.8%) were classified as NE and 142 calves as non‐NE. In univariate analysis, factors significantly associated with diagnosis of NE included male sex, presence of dystocia, abnormal position in the birth canal, and prolonged labor. In the multivariate model, only orientation of the calf in the birth canal remained significant (OR 2.14; 95% CI: 1.02–4.49; P = 0.044). Overall survival of calves with NE was good (45/58; 77.6%; 95% CI: 64.7–87.5); dam parity and being a twin was significantly associated with nonsurvival.ConclusionsCalves born after dystocia, especially if malpresented, should be closely monitored for nursing behavior within the first 24 hours of life. Prognosis for survival is good, but supportive care might be required for several days.

Umbilical Cord Blood NOS1 as a Potential Biomarker of Neonatal Encephalopathy.

There are no definitive markers to aid in diagnosis of neonatal encephalopathy (NE). The purpose of our study was (1) to identify and evaluate the utility of neuronal nitric oxide synthase (NOS1) in umbilical cord blood as a NE biomarker and (2) to identify the source of NOS1 in umbilical cord blood. This was a nested case-control study of neonates >35 weeks of gestation. ELISA for NOS1 in umbilical cord blood was performed. Sources of NOS1 in umbilical cord were investigated by immunohistochemistry, western blot, ELISA, and quantitative PCR. Furthermore, umbilical cords of full-term neonates were subjected to 1% hypoxia ex vivo. NOS1 was present in umbilical cord blood and increased in NE cases compared with controls. NOS1 was expressed in endothelial cells of the umbilical cord vein, but not in artery or blood cells. In ex vivo experiments, hypoxia was associated with increased levels of NOS1 in venous endothelial cells of the umbilical cord as well as in ex vivo culture medium. This is the first study to investigate an early marker of NE. NOS1 is elevated with hypoxia, and further studies are needed to investigate it as a valuable tool for early diagnosis of neonatal brain injury.

Perinatal death associated with umbilical cord prolapse.

Umbilical cord prolapse occurs when the cord prolapses ahead of or alongside the presenting part. It is an acute obstetric emergency with potential catastrophic effects. We set out to assess incidence of cord prolapse, as well as rates and characteristics of perinatal death associated with the condition. This was a retrospective cohort study. All recorded cases of cord prolapse were included, and rates of perinatal death and encephalopathy, as well as intrapartum and maternal characteristics were examined. There were 156,130 deliveries at the hospital over the 20-year study period. Three hundred and seven cases of cord prolapse were identified (1.9/1000 deliveries). There was a decrease in the incidence of cord prolapse over the course of the study. The rate peaked in 1999 at 3.9/1000 and was just 0.8/1000 of all deliveries in 2007. The majority of cases (216/307, 70%) occurred in multiparas; however, nulliparous parturients were more likely to have a perinatal death [12% (11/91) vs. 4.6% (10/216)]. The rate of perinatal death in cases of cord prolapse was 6.8% (21/307). Over half of perinatal deaths (11/21) occurred in infants of mothers who presented with ruptured membranes, seven of these infants were already dead on reaching hospital. There was just one case of neonatal encephalopathy associated with cord prolapse, giving an incidence of 0.32%. Cord prolapse carries a significant risk of perinatal death, approximately 7%. The corresponding rate of encephalopathy is low. A significant number of deaths were diagnosed on presentation to hospital and were not deemed preventable.

Cerebral palsy and brain cooling

This month in The Journal there are 3 articles that discuss cerebral palsy (CP) and the use of hypothermia to decrease brain injury in newborns. Garfinkel et al used a Canadian CP registry to estimate that about 5% of CP could be prevented with the effective use of therapeutic hypothermia of asphyxiated term infants delivered in Canada. This low effectiveness results from the multiple factors pointed out in the editorial by Berg. Most cases of CP are not the result of the acute sentinel asphyxial events associated with deliveries, and many of the infants do not qualify for hypothermia treatment. Furthermore, the therapy is not highly effective. This discouraging overall effect of therapeutic hypothermia is compounded in low and middle-income countries (LMIC) as pointed out by the Commentary by Tagin et al. Hypoxic ischemic encephalopathy is responsible for an estimated 25% of all neonatal deaths worldwide, and asphyxia is responsible for a large number of fresh stillborns in LMIC countries. Although therapeutic hypothermia is an effective therapy in high resource environments, it has not been demonstrated to be effective in LMIC in a few trials. Although the therapy is relatively simple to deliver in any modern neonatal intensive care unit, there are multiple obstacles to its effective use in LMIC. Identification of the infant that qualifies for hypothermia treatment by the criteria used in high resource environments requires trained personnel and infrastructure, and, thus, is not easily accomplished. More lives could be saved by upgrading obstetric services to decrease stillborns and providing effective resuscitation, than by developing the infrastructure necessary for the rapid identification and treatment of the asphyxiated infant with hypothermia. Therapies to improve outcomes that are effective in one environment may not work in another. Even though therapeutic hypothermia is a major advance as the first treatment that can decrease brain injury in asphyxiated term infants, its overall impact on the incidence of CP and birth asphyxia will be small within the context of worldwide infant mortality. Article page 25▶ Article page 58▶ Editorial page 8▶ Cerebral Palsy after Neonatal Encephalopathy: How Much Is Preventable?The Journal of PediatricsVol. 167Issue 1PreviewTo determine the expected proportion of term cerebral palsy (CP) after neonatal encephalopathy (NE) that could theoretically be prevented by hypothermia and elucidate the perinatal factors associated with CP after NE in those who do not meet currently used clinical criteria required to qualify for hypothermia (“cooling criteria”). Full-Text PDF Neuroprotection for Perinatal Hypoxic Ischemic Encephalopathy in Low- and Middle-Income CountriesThe Journal of PediatricsVol. 167Issue 1PreviewPerinatal hypoxic ischemic encephalopathy (HIE) is associated with approximately one-quarter of global neonatal deaths.1 In 2010, there were an estimated 1.15 million cases of neonatal encephalopathy, of which 96% of were from low- and middle-income (LMI) countries.2 In the developed world, therapeutic hypothermia is now widely accepted as the standard of care for treating newborns with moderate to severe HIE.3 Therapeutic hypothermia has been found to reduce the risk of death or major neurodevelopmental disability at age 18 months (risk ratio [RR], 0.76; 95% CI, 0.69-0.84) and to increase survival with normal neurologic function (RR, 1.63; 95% CI, 1.36-1.95). Full-Text PDF Prevention of Cerebral Palsy: Which Infants Will Benefit from Therapeutic Hypothermia?The Journal of PediatricsVol. 167Issue 1PreviewCan cerebral palsy (CP) be prevented? The answer depends on the etiology of CP. Although the causes of CP are largely related to early brain injury, both the nature of that injury and the later manifestations can differ based on the gestational and postnatal ages at which the injury occurs, as well as its source. Full-Text PDF

Prevalence of bloodstream pathogens is higher in neonatal encephalopathy cases vs. controls using a novel panel of real-time PCR assays.

BackgroundIn neonatal encephalopathy (NE), infectious co-morbidity is difficult to diagnose accurately, but may increase the vulnerability of the developing brain to hypoxia-ischemia. We developed a novel panel of species-specific real-time PCR assays to identify bloodstream pathogens amongst newborns with and without NE in Uganda.MethodologyMultiplex real-time PCR assays for important neonatal bloodstream pathogens (gram positive and gram negative bacteria, cytomegalovirus (CMV), herpes simplex virus(HSV) and P. falciparum) were performed on whole blood taken from 202 encephalopathic and 101 control infants. Automated blood culture (BACTEC) was performed for all cases and unwell controls.Principal FindingsPrevalence of pathogenic bacterial species amongst infants with NE was 3.6%, 6.9% and 8.9%, with culture, PCR and both tests in combination, respectively. More encephalopathic infants than controls had pathogenic bacterial species detected (8.9%vs2.0%, p = 0.028) using culture and PCR in combination. PCR detected bacteremia in 11 culture negative encephalopathic infants (3 Group B Streptococcus, 1 Group A Streptococcus, 1 Staphylococcus aureus and 6 Enterobacteriacae). Coagulase negative staphylococcus, frequently detected by PCR amongst case and control infants, was considered a contaminant. Prevalence of CMV, HSV and malaria amongst cases was low (1.5%, 0.5% and 0.5%, respectively).Conclusion/SignificanceThis real-time PCR panel detected more bacteremia than culture alone and provides a novel tool for detection of neonatal bloodstream pathogens that may be applied across a range of clinical situations and settings. Significantly more encephalopathic infants than controls had pathogenic bacterial species detected suggesting that infection may be an important risk factor for NE in this setting.

Suboptimal care and metabolic acidemia is associated with neonatal encephalopathy but not with neonatal seizures alone: a population‐based clinical audit

To determine the incidence of moderate to severe neonatal encephalopathy (NE) and neonatal seizures without encephalopathy, and the association with metabolic acidemia. Secondly, to investigate the occurrence of suboptimal intrapartum care and its impact on neonatal outcome. Clinical audit. Two university hospitals in Sweden. Neonates ≥34 weeks with moderate or severe NE and neonatal seizures alone, i.e. without encephalopathy, from a population of 71 189 births, where umbilical blood gases were routinely analyzed. Neonates were categorized depending on the presence of metabolic acidemia at birth by umbilical artery pH < 7.00, base deficit ≥12 mmol/L. Records were audited for suboptimal care and a decision was made on whether management was assessed to have impacted neonatal outcome. Encephalopathy and seizures alone. We identified 80 neonates with NE and 30 with seizures alone, of which 48 (60%) and none, respectively, had metabolic acidemia. Suboptimal care could be assessed in 77 and occurred in 28 (36%) NE cases and in one neonate with seizures alone (p < 0.001). In 47 NE cases with metabolic acidemia, suboptimal care occurred in 22 (47%) vs. 6/30 (20%) without metabolic acidemia (p = 0.02). Suboptimal care had an impact on outcome in 18/77 (23%) NE cases but in no cases with seizures alone. Suboptimal care was commonly seen with NE, particularly in neonates with metabolic acidemia, and also affected neonatal outcome. No such associations were found in neonates with seizures alone.

Isolated acute non-cystic white matter injury in term infants presenting with neonatal encephalopathy

We discuss possible aetiological factors, MRI evolution of injury and neuro-developmental outcomes of neonatal encephalopathy (NE). Thirty-six consecutive infants diagnosed with NE were included. In this cohort, four infants (11%)...

The placenta in infants >36 weeks gestation with neonatal encephalopathy: a case control study

ObjectiveTo determine placental characteristics associated with neonatal encephalopathy (NE) and correlate these with short- and long-term neurodevelopmental outcome.DesignCase/control study.SettingNeonatal Intensive Care Unit, Rotunda Hospital, Dublin, Ireland.PatientsNewborns ≥36 weeks gestation, with...

Use of Peripartum ST Analysis of Fetal Electrocardiogram Without Blood Sampling: A Large Prospective Cohort Study

Abstract Objective Fetal peripartum surveillance with ST analysis of fetal electrocardiogram (STAN) alone or in combination with fetal blood sampling (FBS) is a worldwide debate. STAN monitoring without FBS support was implemented in 2000 in the authors’ department when it took part in a European multicentre project. The aim of this study was to evaluate neonatal outcomes associated with peripartum STAN monitoring without FBS support in a large prospective cohort of patients at high risk of peripartum fetal asphyxia. Study design This prospective cohort study included all consecutive high-risk women monitored with STAN technology over a 77-month period, excluding fetuses with congenital anomalies. Outcome variables were fetal metabolic acidosis, umbilical pH ≤ 7.05 and normal extracellular base deficit, transfer to a neonatal intensive care unit, neonatal encephalopathy and neonatal death related to peripartum asphyxia. Cases with metabolic acidosis were reviewed by a referent midwife and referent obstetricians to check whether or not labour management was consistent with the STAN guidelines. Results In total, 3112 women were included in the study. The caesarean section rate for suspected fetal distress was 9.5% [95% confidence interval (CI) 8.5–10.5]. Acid–base status was available for 3067 (98.5%) neonates. There were 14 cases of fetal metabolic acidosis (0.45%; 95% CI 0.2–0.7), 62 cases with umbilical pH ≤ 7.05 and normal extracellular base deficit (2%; 95% CI 1.5–2.5), 27 neonates with 5-min Apgar scores ≤ 7 (0.87%; 95% CI 0.54–1.20) and 16 neonates were transferred to the neonatal intensive care unit (0.51%; 95% CI 0.26–0.76) due to peripartum asphyxia. No cases of neonatal encephalopathy, or fetal or neonatal death occurred. Out of the 14 cases of fetal metabolic acidosis, 11 were not managed in accordance with the STAN guidelines. Specificity was 80.5% and the negative predictive value was 99.9%. Sensitivity was highly affected by medical staff interpretation, varying from 9.1% in the authors’ experience to 90.9% with appropriate labour management according to the STAN guidelines. Conclusions STAN monitoring without FBS support was associated with a low rate of fetal metabolic acidosis. Most cases of fetal metabolic acidosis were not managed in accordance with the STAN guidelines. This study not only supports STAN usage without FBS support, but also warns of possible guideline violations and subsequent adverse neonatal outcomes.

Use of peripartum ST analysis of fetal electrocardiogram without blood sampling: a large prospective cohort study

Objective Fetal peripartum surveillance with ST analysis of fetal electrocardiogram (STAN) alone or in combination with fetal blood sampling (FBS) is a worldwide debate. STAN monitoring without FBS support was implemented in 2000 in the authors’ department when it took part in a European multicentre project. The aim of this study was to evaluate neonatal outcomes associated with peripartum STAN monitoring without FBS support in a large prospective cohort of patients at high risk of peripartum fetal asphyxia. Study design This prospective cohort study included all consecutive high-risk women monitored with STAN technology over a 77-month period, excluding fetuses with congenital anomalies. Outcome variables were fetal metabolic acidosis, umbilical pH ≤ 7.05 and normal extracellular base deficit, transfer to a neonatal intensive care unit, neonatal encephalopathy and neonatal death related to peripartum asphyxia. Cases with metabolic acidosis were reviewed by a referent midwife and referent obstetricians to check whether or not labour management was consistent with the STAN guidelines. Results In total, 3112 women were included in the study. The caesarean section rate for suspected fetal distress was 9.5% [95% confidence interval (CI) 8.5–10.5]. Acid–base status was available for 3067 (98.5%) neonates. There were 14 cases of fetal metabolic acidosis (0.45%; 95% CI 0.2–0.7), 62 cases with umbilical pH ≤ 7.05 and normal extracellular base deficit (2%; 95% CI 1.5–2.5), 27 neonates with 5-min Apgar scores ≤ 7 (0.87%; 95% CI 0.54–1.20) and 16 neonates were transferred to the neonatal intensive care unit (0.51%; 95% CI 0.26–0.76) due to peripartum asphyxia. No cases of neonatal encephalopathy, or fetal or neonatal death occurred. Out of the 14 cases of fetal metabolic acidosis, 11 were not managed in accordance with the STAN guidelines. Specificity was 80.5% and the negative predictive value was 99.9%. Sensitivity was highly affected by medical staff interpretation, varying from 9.1% in the authors’ experience to 90.9% with appropriate labour management according to the STAN guidelines. Conclusions STAN monitoring without FBS support was associated with a low rate of fetal metabolic acidosis. Most cases of fetal metabolic acidosis were not managed in accordance with the STAN guidelines. This study not only supports STAN usage without FBS support, but also warns of possible guideline violations and subsequent adverse neonatal outcomes.

Antepartum and Intrapartum Risk Factors for Neonatal Encephalopathy at Term

We investigated antepartum and intrapartum risk factors for neonatal encephalopathy (NE) in term infants. We performed a case-controlled study in which characteristics of singleton term infants who developed NE from 1993 to 2003 were compared with those of randomly selected controls. Antenatal risk factors (including obesity, diabetes, thyroid dysfunction, previous cesarean delivery, preeclampsia, fetal growth restriction, abnormal amniotic fluid volume, and abnormal fetal heart rate [FHR] tracing before labor) and intrapartum risk factors (acute intrapartum sentinel events and other risk factors like suspicious or ominous FHR tracing and clinical chorioamnionitis) were related to occurrence of NE. From the study cohort of 30,580 infants, 27 (0.09%) developed NE and were compared with 100 controls. Neonates with encephalopathy had more frequent antepartum (74% versus 18%, P < 0.001) and intrapartum (67% versus 19%, P < 0.001) risk factors, including acute intrapartum events (33% versus 2%, P < 0.001), than controls. On the whole, 26% of cases of NE had only antepartum risk factors, 22% had only intrapartum risk factors, and 44% had a combination of the two. In 2/27 (7%) cases, no risk factors were recognizable. In conclusion, 44% of cases of NE following term deliveries can be attributed to a combination of antepartum and intrapartum variables.

Review of the First 1502 Cases of ECG-ST Waveform Analysis During Labor in a Teaching Hospital

Although electronic fetal monitoring has lowered the rate of intrapartum stillbirth, intrapartum asphyxia still is a major cause of long-term deficits in survivors. A recent Cochrane review found less metabolic acidosis, fewer operative deliveries, and a significant reduction in neonatal encephalopathy (NNE) when performing cardiotocography with ST waveform analysis (CTG-ST). This prospective observational study, carried out at a tertiary referral labor ward, evaluated the STAN™ monitoring system of ST-segment analysis in 1502 women who had a suspicious or abnormal CTG or a high-risk pregnancy. Monitoring entails the application of a fetal scalp electrode that provides continuous CTG and fetal ECG analysis. The ST waveform reflects what takes place during ventricular repolarization. STAN analysis deals with the ability of the fetal heart to adapt to hypoxia, as opposed to fetal blood sampling, which is done to detect acidosis. STAN analysis indicated the need for some action in 358 of the 1502 women in the trial-nearly one-fourth of those studied. In 2.4% of cases, traces could not be interpreted. Cord blood gas values were available in 836 cases, in 23 of which (2.8%) metabolic acidosis was documented. STAN monitoring identified 16 of these cases (70%). In all, 14 cases of NNE were monitored by STAN. A retrospective analysis showed the most frequent reasons for a poor outcome to be delay in taking action when an ST event and CTG called for delivery, and lack of intervention after 90 minutes of active second-stage labor with an abnormal CTG trace despite a normal ST trace. In the authors' experience, the use of ECG-ST waveform analysis to monitor high-risk labors has not altered the frequency of either NNE or emergency operative delivery. More intensive training in CTG and ST analysis appears to be needed, emphasizing the need for prompt action when significant CTG and ST-segment changes are present.