Arterial Cord Blood Research Articles

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

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

Lutein and Neurodevelopment in Preterm Infants.

Lutein and Neurodevelopment in Preterm Infants.

Role of selected cytokines in the etiopathogenesis of intraventricular hemorrhage in preterm newborns.

Proinflammatory cytokines are essential mediators and indicators of an inflammatory process occurring in the body. Their physiological role is to stimulate the immune response, yet their excessive propagation and interaction with cells outside the immune system may be linked to the risk of organ damage. This is specifically important in the case of immature tissues of fetuses and prematurely born infants. Analysis of the concentrations of specific cytokines in different compartments makes it possible to assess the risk of premature birth, preterm rupture of the membranes, and to determine an existing intrauterine infection. The purpose of this paper is to summarize the existing research concerning the relationships between the concentrations of specific proinflammatory cytokines in different compartments (maternal blood serum, amniotic fluid, umbilical cord blood, arterial and venous blood, and cerebrospinal fluid of the newborn) and the risk of intraventricular hemorrhage (IVH) and the degree of its severity. The paper takes also into account the assessment of the usefulness of cytokines as biomarkers for IVH and its complications (posthemorrhagic hydrocephalus, white matter injury).

Quantitative cardiotocography to improve fetal assessment during labor: a preliminary randomized controlled trial

ObjectiveTo evaluate the effectiveness of a computerized decision support system, referred to as “quantitative cardiotocography” (qCTG), to reduce adverse birth outcomes compared to conventional CTG with fetal blood sampling. Study designA preliminary parallel randomized control trial in a tertiary maternity hospital (Sofia, Bulgaria) was conducted with a sample size of 360 women per trial arm (N=720). Women in labor were recruited between March 2008 and March 2011. Unadjusted relative risks were derived to assess the effect of qCTG on outcomes of interest. A ROC curve was derived to determine the sensitivity and specificity of qCTG to detect acidemia (Clinical trial registration: Current Controlled Trials, http://www.controlled-trials.com/, ISRCTN46449237). Main outcome measuresPrimary outcomes were hypoxia (cord-artery blood pH<7.20), acidemia (umbilical-artery blood pH<7.05), cesarean delivery, and forceps extraction. Secondary outcomes were Apgar score <7 at five minutes, neonatal seizures, and admission to the neonatal intensive care unit (NICU). ResultsReduced risks were observed for all outcomes of interest in women monitored using qCTG. There was a significant reduction in hypoxia (RR: 0.53; 0.33, 0.84), acidemia (RR: 0.31; 95% CI: 0.12, 0.84), cesarean delivery (95% CI: 0.45, 0.85), and admission to the NICU (RR: 0.33; 95% CI: 0.14, 0.77) in women monitored using qCTG versus conventional CTG. ConclusionqCTG may reduce risk of adverse birth outcomes; however, the small sample size and long recruitment period in this trial may overstate the benefits of this intervention. Further large-scale randomized control trials with sufficient sample size to detect rare adverse events are required prior to the adoption of qCTG in daily clinical practice.

Perinatal factors associated with umbilical cord blood pH values

Objetivo: El análisis del pH de sangre arterial de cordón umbilical sigue siendo un criterio objetivo usado para determinar el estado metabólico del recién nacido tras el parto, y por tanto del bienestar fetal. El objetivo de este estudio fue identificar los factores perinatales asociados con los valores de sangre arterial de cordón umbilical.&lt;br /&gt;&lt;br /&gt;Material y métodos: Se realizó un estudio descriptivo y analítico entre Enero de 2010 y Enero de 2013 en un hospital de tercer nivel en el sur de España, con mujeres atendidas por parto. Los criterios de inclusión fueron: embarazo sin complicaciones y parto vaginal único, a término, con presentación cefálica. Las variables independientes con gran significación tras un análisis univariante fueron: edad, paridad, edad gestacional, analgesia epidural, plan de parto, episiotomía, duración de la primera fase del parto, y uso de oxitocina. Como variable dependiente se consideró: los valores de pH de sangre arterial de cordón umbilical (&amp;lt; = 7.24; &amp;gt; 7.24). El número total de mujeres fue de 165. El análisis estadístico se realizó mediante regresión logística múltiple. &lt;br /&gt;&lt;br /&gt;Resultados: La analgesia epidural y la edad gestacional mayor o igual a 41 semanas influyeron negativamente en el pH de cordón umbilical neonatal, mientras que haber presentado un plan de parto tuvo una influencia protectora.&lt;br /&gt;&lt;br /&gt;Conclusiones: Los hallazgos de este estudio proporcionan a los profesionales más evidencias sobre los elementos que pueden influenciar en el bienestar neonatal, con el fin de actuar en consecuencia, anticipándose a las situaciones de riesgo y aplicando una atención más eficaz. &lt;br /&gt;&lt;br /&gt;

The effect of maternal parameters on umbilical artery blood gas values and neonatal well-being in singleton pregnancies

Background. Umbilical cord blood analysis for assessment of the newborn’s acid-base status soon after birth is the most objective way of evaluating the fetal metabolic condition at delivery. We researched the effects of maternal age, multiple gestation, fetal heart rate, gestational age, parity, delivery mode and total duration of labor on fetal well-being as assessed by umbilical cord blood gas parameters. Methods. Prospective study conducted on 67 singleton pregnant women and their off-spring. Maternal age, multiple gestation, fetal heart rate (FHR), gestational age, parity, delivery mode and total duration of labor were recorded. Umbilical artery blood samples were collected at birth. A blood gas analysis was performed on each collected sample. The relationship between maternal parameters and umbilical cord arterial blood gas were investigated. Results. We found positive correlation between pH and gravida and parity ( p =0.026, p =0.049, respectively), whereas negative correlation between total duration of labor and O 2 saturation ( p =0.033). Base deficit was negatively correlated with gravida and parity ( p =0.025, p =0.011, respectively). In linear regression models, FHR and gravida were a significant predictor of pH value ( p =0.029 and p =0.040, respectively). Conclusions. We found no association between maternal age, gestational age, gravida, parity and duration of labor and neonatal acidemia. Thus, maternal age, gestational age, gravida, parity and duration of labor may not be at increased risk of perinatal morbidity. However, the elevation of FHR was related with an increased risk of neonatal morbidity.

Induction of labour at or near term for suspected fetal macrosomia.

It has been brought to the authors' attention that there may be an error in the data (Analysis 1.9). This is currently under investigation, and a correction will be made if the data are found to be incorrect. Details can be found in the comments. Women with a suspected large-for-dates fetus or a fetus with suspected macrosomia (birthweight greater than 4000 g) are at risk of operative birth or caesarean section. The baby is also at increased risk of shoulder dystocia and trauma, in particular fractures and brachial plexus injury. Induction of labour may reduce these risks by decreasing the birthweight, but may also lead to longer labours and an increased risk of caesarean section. To assess the effects of a policy of labour induction at or shortly before term (37 to 40 weeks) for suspected fetal macrosomia on the way of giving birth and maternal or perinatal morbidity. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), contacted trial authors and searched reference lists of retrieved studies. Randomised trials of induction of labour for suspected fetal macrosomia. Review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We contacted study authors for additional information. For key outcomes the quality of the evidence was assessed using the GRADE approach. We included four trials, involving 1190 women. It was not possible to blind women and staff to the intervention, but for other 'Risk of bias' domains these studies were assessed as being at low or unclear risk of bias.Compared to expectant management, there was no clear effect of induction of labour for suspected macrosomia on the risk of caesarean section (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.76 to 1.09; 1190 women; four trials, moderate-quality evidence) or instrumental delivery (RR 0.86, 95% CI 0.65 to 1.13; 1190 women; four trials, low-quality evidence). Shoulder dystocia (RR 0.60, 95% CI 0.37 to 0.98; 1190 women; four trials, moderate-quality evidence), and fracture (any) (RR 0.20, 95% CI 0.05 to 0.79; 1190 women; four studies, high-quality evidence) were reduced in the induction of labour group. There were no clear differences between groups for brachial plexus injury (two events were reported in the control group in one trial, low-quality evidence). There was no strong evidence of any difference between groups for measures of neonatal asphyxia; low five-minute infant Apgar scores (less than seven) or low arterial cord blood pH (RR 1.51, 95% CI 0.25 to 9.02; 858 infants; two trials, low-quality evidence; and, RR 1.01, 95% CI 0.46 to 2.22; 818 infants; one trial, moderate-quality evidence, respectively). Mean birthweight was lower in the induction group, but there was considerable heterogeneity between studies for this outcome (mean difference (MD) -178.03 g, 95% CI -315.26 to -40.81; 1190 infants; four studies; I(2) = 89%). In one study with data for 818 women, third- and fourth-degree perineal tears were increased in the induction group (RR 3.70, 95% CI 1.04 to 13.17).For outcomes assessed using GRADE, we based our downgrading decisions on high risk of bias from lack of blinding and imprecision of effect estimates. Induction of labour for suspected fetal macrosomia has not been shown to alter the risk of brachial plexus injury, but the power of the included studies to show a difference for such a rare event is limited. Also antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed. Nevertheless, induction of labour for suspected fetal macrosomia results in a lower mean birthweight, and fewer birth fractures and shoulder dystocia. The unexpected observation in the induction group of increased perineal damage, and the plausible, but of uncertain significance, observation of increased use of phototherapy, both in the largest trial, should also be kept in mind.Findings from trials included in the review suggest that to prevent one fracture it would be necessary to induce labour in 60 women. Since induction of labour does not appear to alter the rate of caesarean delivery or instrumental delivery, it is likely to be popular with many women. In settings where obstetricians can be reasonably confident about their scan assessment of fetal weight, the advantages and disadvantages of induction at or near term for fetuses suspected of being macrosomic should be discussed with parents.Although some parents and doctors may feel the evidence already justifies induction, others may justifiably disagree. Further trials of induction shortly before term for suspected fetal macrosomia are needed. Such trials should concentrate on refining the optimum gestation of induction, and improving the accuracy of the diagnosis of macrosomia.

Craniofacial tissue oxygen saturation is associated with blood pH using an examiner's finger-mounted tissue oximetry in mice.

Although fetal scalp blood sampling is an examination to assess fetal acidosis during the intrapartum period, it has not been widely used by obstetricians because of its invasiveness. We have developed a small, portable oximetry with a sensor attached to the examiner's finger. Our previous report using this oximetry concluded that fetal head tissue oxygen saturation (StO 2 StO2 ) correlated with umbilical cord artery blood pH. We investigated whether the association between StO 2 StO2 and blood pH in mice could be validated using this oximetry. Eleven the Institute for Cancer Research (ICR) mice were measured using a near-infrared spectroscopy probe at the craniofacial site in a closed polyethylene bag while changing the oxygen concentration. A total of nine blood samples were collected and analyzed for pH. The StO 2 StO2 and tissue blood pH showed a strong positive correlation (r=0.90 r=0.90 and P=0.0009 P=0.0009 ). The StO 2 StO2 and total hemoglobin index also showed a positive correlation (r=0.84 r=0.84 and P=0.0049 P=0.0049 ). Thus, the results of the present study support those of our previous report on clinical cases and allow examiners to easily check the status of fetal acidosis. Fetal management using this oximetry might gain popularity with obstetricians in the near future.

Intraocular pressure in infants and its association with hormonal changes with vaginal birth versus cesarean section.

To investigate cord arterial blood sample and the relationship between birth stress and intraocular pressure in infants at 5min after delivery. The IOP measurements were taken using Tonopen-Avia tonometer to 158 newborns (158 eyes) at 5th min after birth, in a university hospital. Cord blood was collected within 3min after delivery. Intraocular pressure, gender, gestation period, mode of delivery, and birth weight of newborns were noted from medical records. Sixty-two babies were delivered by normal vaginal delivery (NVD) and 96 by cesarian section (C/S). Mean IOP of NVD and C/S groups were 19.56±3.84 and 17.42±3.50, respectively. There was significant difference of mean IOP between two groups. (p<0.001) There were significant differences between two groups regarding APGAR score (p<0.001) and cord blood adrenaline (p=0.003), noradrenaline (p=0.008), and cortisol (p<0.001) levels. There was no difference between infant corneal thickness measurements (p=0.698). In correlation analyses, there is a strong negative correlation between the labor type and postpartum measurements except corneal thickness. Correlation analyses of the 5th min intraocular pressure of the groups individually revealed significant correlation in the NVD group. The conclusion is that the intraocular pressure of newborn infants was higher in NVD delivery compare to C/S. Blood hormonal changes in different anesthesia types and physical stress was thought as the main reason of this result.

Variation in primary cesarean delivery rates by individual physician within a single-hospital laborist model

Laborist practice models are associated with lower rates of cesarean delivery than individual private practice models in several studies; however, this effect is not uniform. Further exploration of laborist models may help us better understand the observed decrease in rates of cesarean delivery in some hospitals that implement a laborist model. Our objective was to evaluate the degree of variation in rates of primary cesarean delivery by individual laborists within a single institution that uses a laborist model. In addition, we sought to evaluate whether differences in rates of cesarean delivery resulted in different maternal or short-term neonatal outcomes. At this teaching institution, one laborist (either a generalist or maternal-fetal medicine attending physician) is directly responsible for labor and delivery management during each shift. No patients are followed in a private practice model nor are physicians incentivized to perform deliveries. We retrospectively identified all laborists who delivered nulliparous, term women with cephalic singletons at this institution from 2007 to 2014. Overall and individual primary cesarean delivery rates were reported as percentages with exact Pearson 95% confidence intervals. Laborists were grouped by tertile as having low, medium, or high rates of cesarean delivery. Characteristics of the women delivered, indications for cesarean delivery, and short-term neonatal outcomes were compared between these groups. A binomial regression model of cesarean delivery was estimated, where the relative rates of each laborist compared with the lowest-unadjusted laborist rate were calculated; a second model was estimated to adjust for patient-level maternal characteristics. Twenty laborists delivered 2224 nulliparous, term women with cephalic singletons. The overall cesarean delivery rate was 24.1% (95% confidence interval 21.4-26.8). In an unadjusted binomial model, the overall effect of individual laborist was significant (P < .001), and a 2.9-fold (1.5-5.4, P = .001) variation between the cesarean delivery rates of the greatest (35.9%) and lowest (12.5%) physicians was observed. When adjusted for hypertensive disease, gestational age at delivery, race, and maternal age, the physician effect remained overall significant (P = .0265) with the difference between physicians expanding to 3.58 (1.72-7.47, P <. 001). Between groups of laborists with low, medium, and high rates of cesarean delivery, patient demographics and clinical characteristics of the population managed were clinically similar and not different statistically. The primary indication for cesarean delivery did not differ between groups. Similarly there were no differences in short-term neonatal outcomes, including Apgar scores, arterial cord blood pH, or the incidence of neonatal encephalopathy. The 3-fold variation in cesarean delivery rates between laborists at the same institution without observed differences in patient characteristics or short-term neonatal outcomes draws attention to the impact of individual physician decision-making on cesarean delivery rates even within a laborist care model. Further exploration of the role of individual physician decision-making on cesarean rates may help to better elucidate the effect of the laborist model.

Uterine artery pulsatility index at 30-34 weeks' gestation in the prediction of adverse perinatal outcome.

To investigate the potential value of uterine artery (UtA) Doppler at 30-34 weeks' gestation in the prediction of adverse perinatal outcome. This was a screening study in 30 780 singleton pregnancies at 30-34 weeks. UtA pulsatility index (UtA-PI) was measured and the values were converted to multiples of the median (MoM) after adjustment for variables relating to maternal characteristics and medical history that affect the measurements. Multivariable logistic regression analysis was used to determine if measuring UtA-PI improved the prediction of adverse perinatal outcome provided by screening with maternal characteristics, medical history and obstetric factors. The detection rate (DR) and false-positive rate (FPR) of screening by UtA-PI were estimated for stillbirth, Cesarean section for fetal distress, umbilical arterial cord blood pH ≤ 7.0 or umbilical venous cord blood pH ≤ 7.1 and 5-min Apgar score < 7. The incidence of adverse perinatal outcome was higher in small-for-gestational-age (SGA) fetuses than in non-SGA fetuses, but the majority of cases with each adverse outcome were in the non-SGA group, including about 70% of stillbirths and more than 80% with Cesarean section for fetal distress, low cord blood pH and low Apgar score. The performance of UtA-PI > 95(th) percentile in screening for each adverse outcome was poor with DR of 6-16% and a FPR of 5-6%. The DR of adverse outcome when screening by high UtA-PI was greater in pregnancies complicated by SGA than in non-SGA pregnancies; 24% vs 13% for stillbirth, 15% vs 5% for Cesarean section for fetal distress, 30% vs 9% for low cord blood pH and 20% vs 3% for low 5-min Apgar score, respectively. High UtA-PI at 30-34 weeks' gestation may be useful in the prediction of adverse perinatal outcome in pregnancies with a SGA fetus, however, in the absence of SGA, UtA-PI is a poor predictor of adverse outcome. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Biophysical and biochemical markers at 30-34 weeks' gestation in the prediction of adverse perinatal outcome

To investigate the potential value of biophysical and biochemical markers at 30-34 weeks' gestation in the prediction of adverse perinatal outcome. This was a screening study in 8268 singleton pregnancies at 30-34 weeks' gestation. Estimated fetal weight (EFW), uterine artery (UtA) pulsatility index (PI), umbilical artery (UA) PI, fetal middle cerebral artery (MCA) PI, mean arterial pressure (MAP), serum placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) were measured. The detection rate (DR) and false-positive rate (FPR) of screening by each biomarker were estimated for stillbirth, pre-eclampsia, delivery of small-for-gestational-age (SGA) neonate, Cesarean section for fetal distress before or during labor, umbilical arterial cord blood pH ≤7.0 or umbilical venous cord blood pH ≤7.1, 5-min Apgar score < 7 and admission to the neonatal unit (NNU). Multivariable regression analysis demonstrated that significant prediction of PE was provided by PlGF, sFlt-1, MAP and MCA-PI, with a DR of 98% for PE delivering < 37 weeks' gestation and 56% for those delivering ≥ 37 weeks, at a 10% FPR. Prediction of SGA was provided by EFW, PlGF, sFlt-1, UtA-PI, UA-PI and MCA-PI, with a DR of 88% for SGA delivering < 37 and 51% for those delivering ≥ 37 weeks' gestation, at a 10% FPR. Prediction of stillbirth was provided by EFW, UtA-PI and MCA-PI, with DR of 30% at 10% FPR. Prediction of Cesarean section for fetal distress before labor was provided by EFW, sFlt-1, UtA-PI and UA-PI, with a DR of 90% at a 10% FPR. Prediction of fetal distress in labor was provided by EFW and sFlt-1, with a DR of 16% at a 10% FPR. There were no significant differences from the normal outcome group in any of the biomarkers for low cord blood pH, low Apgar score or NNU admission for cases other than those with PE and/or SGA. At 30-34 weeks' gestation, biomarkers of impaired placentation and fetal hypoxemia provide good prediction of PE, SGA and fetal distress before labor, but poor or no prediction of stillbirth and adverse events in labor or after birth.

Early functional and morphological brain disturbances in late-onset intrauterine growth restriction

AimsTo determine whether the brain disturbances develop in late-onset intrauterine growth restriction (IUGR) before blood flow redistribution towards the fetal brain (detected by Doppler measurements in the middle cerebral artery and umbilical artery). Further, to evaluate predictive values of Doppler arterial indices and umbilical cord blood gases and pH for early functional and/or morphological brain disturbances in late-onset IUGR. Study designThis cohort study included 60 singleton term pregnancies with placental insufficiency caused late-onset IUGR (IUGR occurring after 34 gestational weeks). Umbilical artery resistance index (URI), middle cerebral artery resistance index (CRI), and cerebroumbilical (C/U) ratio (CRI/URI) were monitored once weekly. Umbilical blood cord samples (arterial and venous) were collected for the analysis of pO2, pCO2 and pH. Morphological neurological outcome was evaluated by cranial ultrasound (cUS), whereas functional neurological outcome by Amiel-Tison Neurological Assessment at Term (ATNAT). Results50 fetuses had C/U ratio>1, and 10 had C/U ratio≤1; among these 10 fetuses, 9 had abnormal neonatal cUS findings and all 10 had non-optimal ATNAT. However, the total number of abnormal neurological findings was much higher. 32 neonates had abnormal cUS (53.37%), and 42 (70.00%) had non-optimal ATNAT. Furthermore, Doppler indices had higher predictive validity for early brain disturbances than umbilical cord blood gases and pH. C/U ratio had the highest predictive validity with threshold for adverse neurological outcome at value 1.13 (ROC analysis), i.e., 1.18 (party machine learning algorithm). ConclusionAdverse neurological outcome at average values of C/U ratios>1 confirmed that early functional and/or structural brain disturbances in late-onset IUGR develop even before activation of fetal cardiovascular compensatory mechanisms, i.e., before Doppler signs of blood flow redistribution between the fetal brain and the placenta.

Arterio-venous differences in cord levels of catecholamines, glucose, lactate and blood gases.

Norepinephrine (NE) and epinephrine (EPI) levels are higher in cord arterial blood relative to venous blood, consistent with active mechanisms of placental-maternal clearance. There are no contemporary studies of cord arteriovenous blood levels of sulfated and non-sulfated catechols. To assess the arteriovenous differences in cord blood levels of dopamine (DA), the sulfated catecholamines and their sulfated and non-sulfated metabolites. To correlate levels of oxygen, H+/CO2, and glucose with cord catecholamine levels. Fifty-seven term infants, delivered by elective cesarean section, were recruited. Cord arterial and venous blood was sampled; levels of glucose, lactate, blood gases, six catechols and their sulfated conjugates were measured. With one exception (DOPA sulfate), mean cord arterial levels of sulfated and non-sulfated catechols were significantly higher than venous levels. Arterial lactate and glucose levels were independently associated with NE levels, but only lactate was associated with levels of EPI and DA. This study establishes that in vivo metabolic parameters of hypoxia, respiratory and metabolic acidosis are associated with catecholamine levels, a key relationship for perinatal adaptation and homeostasis, and findings that are consistent with in vitro studies of the regulators of catecholamine secretion.

To Study the Correlation of Thompson Scoring in Predicting Early Neonatal Outcome in Post Asphyxiated Term Neonates.

Throughout the world each year, an estimated 23% of the 4 million neonatal deaths and 8% of all deaths in <5 years of age are associated with signs of asphyxia at birth. To study the role of cord arterial blood gas analysis at birth and serial Thompson score in predicting the early neonatal outcome in post asphyxiated term neonates. The study was conducted in Department of Paediatrics, in Neonatal Intensive Care Unit (NICU), Hindu Rao Hospital, New Delhi from May 2014 to February. 2015. This study was a prospective cross-sectional study. During this period, a total of 145 post asphyxiated term neonates born in labour room/obstetric operation theatre were recruited. An informed consent was taken from all the parents. The protocol was approved by the institutional ethical committee. Inclusion criteria were full-term babies with low-Apgar score i.e., 1 min score of ≤ 7 National Neonatal Perinatal Database 2010 (NNPD 2010). SPSS 17.0 Software has been used for data analysis. The data were expressed in terms of Means, Standard Deviation and Proportion, followed by comparison between groups through chi-square test or Fisher's-exact test. A p-value of less than 0.05 was considered as statistically significant. The present study was carried out on 145 post asphyxiated full-term babies with low-Apgar score i.e., 1min score of ≤7mild Thompson score on day I,2,3 were 96 (66.2%), 119 (82.06%), 125 (86.20%), moderate Thompson score on day 1,3, 7 were 13 (8.9%), 6 (4.13%), 2 (1.37%) and severe Thompson score on day 1, 3, 7 were 36 (24.8%), 13 (8.96%), 7 (4.82%) respectively. Total 11 patients died out of 145 post asphyxiated full-term babies within 7 days, among 11 patients, 7 died within 3 days. There was clinical improvement among HIE patients as indicated by serial Thompson score done on day 1, 3 and 7. Among 145 patients 62(42.8%) had seizure and 83(57.2%) did not have seizure. Most common type of seizure was subtle seizure in 25 (40.3%) followed by multifocal in 21 (33.9%) and tonic in 16(25.8%). There is statistically significant correlation between morbidity and day 1 Thompson score (p-value 0.024). There is statistically significant correlation between mortality and day 1 Thompson score (p-value 0.001). Thompson score allows a very precise description of infants by assigning a numeric score rather than 'mild', 'moderate' or 'severe'. Inter-rater reliability is very good with a kappa co-efficient of 0.87.

Relationship between immediate postpartum umbilical cord blood pH and fetal distress

Background: Umbilical cord pH is best indicator of fetal hypoxemia. Objectives: To establish relation between cord blood pH and fetal distress, diagnose true fetal distress retrospectively, reduce caesarean section rates. Methods: Prospective study of 30 term women reporting to labour room of department of Obstetrics Gynecology of a rural tertiary care centre of Central India with complaints of labour pains and during labour who developed fetal distress was conducted between April - May 2015. Immediately after delivery, umbilical cord arterial blood sample was collected. Maternal demographic profile, neonatal outcomes in terms of APGAR score, cord pH, immediate ventilation, NICU admissions were recorded. The correlation between non-reassuring fetal hearts, meconium stained liquor and neonatal outcome was analyzed using SPSS version 20. Results: Of 30 cases, 2 (6.67%) women had fetal bradycardia, 13 (43.34%) abnormal non-stress test, 5 (16.67%) meconium stained liquor and 10 (33.34%) fetal bradycardia/tachycardia with meconium stained liquor. Of all delivered babies, 10 (33.34%) had acidosis, with one having severe hypoxemia and acidosis (pH 6.85). Of these, 7 (70%) required NICU admission, one intubated for severe birth asphyxia. Rest 23 (76.67%) were born healthy, cared by mother. Of 13 women having abnormal NST, 10 (76.92%) underwent emergency cesarean section, 3 (23.07%) delivered vaginally. Of these, only 3 (23.07%) babies had acidosis and required NICU admission. All mothers were discharged with their babies healthy. Conclusions: Neither Non-reassuring fetal heart rate, nor thin meconium stained liquor correlate with adverse neonatal outcome. Furthermore NST resulted in unnecessary increased cesarean sections.

Biophysical and biochemical markers at 35-37 weeks' gestation in the prediction of adverse perinatal outcome.

To investigate the potential value of biophysical and biochemical markers at 35-37 weeks' gestation in the prediction of adverse perinatal outcome. This was a screening study in 3953 singleton pregnancies at 35-37 weeks' gestation. Estimated fetal weight (EFW), uterine artery pulsatility index (UtA-PI), umbilical artery (UA)-PI, fetal middle cerebral artery (MCA)-PI, mean arterial pressure (MAP), serum placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) were measured. The detection rate (DR) and false-positive rate (FPR) of screening by each biomarker were estimated for pre-eclampsia (PE), delivery of small-for-gestational-age (SGA) neonates, Cesarean section for fetal distress before or during labor, umbilical arterial cord blood pH ≤ 7.0 or umbilical venous cord blood pH ≤ 7.1, 5-min Apgar score < 7 and admission to the neonatal unit (NNU). Multivariable regression analysis demonstrated that significant prediction of PE was provided by PlGF, sFlt-1 and MAP, with a DR of 73% at a 10% FPR. Prediction of SGA was provided by EFW, PlGF and UtA-PI, with a DR of 63% at a 10% FPR. Prediction of Cesarean section for fetal distress before labor was provided by EFW and UA-PI with DR of 100% at 10% FPR. Prediction of fetal distress in labor was provided by EFW and sFlt-1, with a DR of 15% at a 10% FPR. There were no significant differences between those with a normal outcome and those with low cord blood pH, low Apgar score or NNU admission for any of the biomarkers assessed. At 35-37 weeks' gestation biomarkers of impaired placentation and fetal hypoxemia provide good prediction of PE, SGA and fetal distress before labor, but poor or no prediction of adverse events in labor or after birth.

Umbilical blood gas analysis in preeclamptic versus healthy pregnancies with preterm birth

Objective: Comparing the value of umbilical cord arterial blood gas (UC-ABG) analysis in the prediction of neonatal mortality and morbidity in the preeclamptic versus healthy pregnancies with preterm birth. Methods: Eight hundred sixteen preterm (born at <37 gestational weeks) neonates with no other morbidities who were born by cesarean section were evaluated. Immediately after delivery, UC-ABG analysis was performed and the neonates were followed. Results: Preeclamptic women had lower umbilical cord blood (UCB) pH (7.2 4 ± 0.1 versus 7.2 7 ± 0.08, p = 0.008) and higher UCB base deficit (BD) (3.5 ± 3.7 versus 2.2 ± 3.4, p = 0.005) compared with controls. In the preeclamptic group, UCB metabolic acidosis (pH < 7.15 and B.D > 8) was not independently associated with neonatal morbidity or mortality, while in the control group UCB metabolic acidosis was independently associated with low 10-min Apgar (OR, 4.9; 95%CI 1.37–18.03), respiratory distress syndrome (OR, 2.37; 95%CI 1.05–6.17), intraventricular hemorrhage (OR, 3.01; 95%CI 1.13–7.99), and neonatal mortality (OR, 17.33; 95%CI 4.51–66.53). Conclusions: The preterm neonates born to preeclamptic mothers have lower UCB pH and higher BD. In these neonates, UCB acidosis is not independently associated with any adverse neonatal outcomes. In contrast, in the preterm neonates born to healthy mothers, UCB metabolic acidosis is independently associated with neonatal mortality and morbidity.

Umbilical Cord Blood pH in Intrapartum Hypoxia.

To determine the association of cord arterial blood pH with neonatal outcome in cases of intrapartum fetal hypoxia. Descriptive analytical study. Gynaecology Unit-II, Civil Hospital, Karachi, from September 2011 to November 2012. All singleton cephalic fetuses at term gestation were included in the study. Those with any anomaly, malpresentation, medical disorders, maternal age < 18 years, multiple gestation and ruptured membranes were excluded. Patients with abnormal cardiotocography and/or meconium stained liquor were enrolled as index case and immediate next delivery with no such signs as a control. Demographic characteristics, pH level < or > 7.25, neonatal outcome measures (healthy, NICU admission or neonatal death), color of liquor and mode of delivery recorded on predesigned proforma. Statistical analysis performed by SPSS 16 by using independent-t test or chi-square test and ANOVA test as needed. A total of 204 newborns were evaluated. The mean pH level was found to be significantly different (p=0.007) in two groups. The pH value 7.25 had significant association (p < 0.001) with the neonatal outcome. However, the association of neonatal outcome with severity of acidemia was not found to be significant. Grading of Meconium Stained Liquor (MSL) also did not relate positively with pH levels as 85.7% of grade I, 68.9% of grade II and 59.4% of grade III MSLhad pH > 7.25. Majority (63.6%) cases needed caesarean section as compared to 31.4% controls. There is a significant association of cord arterial blood pH at birth with neonatal outcome at pH < or > 7.25; but below the level of pH 7.25 it is still inconclusive.

Troponin T and NT ProBNP Levels in Gestational, Type 1 and Type 2 Diabetic Mothers and Macrosomic Infants.

This study compares NT proBNP and troponin T levels in umbilical cord arterial blood and postnatal echocardiographic findings for infants of gestational and pregestational diabetic mothers and macrosomic infants. Twenty-seven infants of pregestational diabetic mothers, 61 infants of gestational diabetic mothers and 37 macrosomic infants of nondiabetic mothers were prospectively enrolled in this study along with a control group of 58 healthy infants of mothers without any pregestational or gestational disorders as the control group. All enrollees were born after 34 weeks of gestation. For this study, umbilical cord blood was drawn during delivery to determine NT proBNP and troponin T levels. Echocardiography was performed 24-72 h after the delivery. Umbilical cord troponin T and NT proBNP levels were found to be higher in the diabetic and macrosomic groups than in the control group (all of them p < 0.001). NT proBNP levels were positively correlated with interventricular septum thickness in the pregestational and gestational infants of diabetic mothers groups (r = 0.564 and r = 0.560, respectively, p < 0.01). Both pregestational and gestational diabetic mothers were divided into two groups according to HbA1c levels in the third trimester as good (<6.1 %) and suboptimal (>6.1 %) metabolic control. In the good and suboptimal metabolic control diabetic groups, NT proBNP levels were also positively correlated with interventricular septum thickness (r = 0.536 and r = 0.576, respectively, p < 0.01). In the suboptimal metabolic control diabetic group, NT proBNP was only found to be positively correlated with the left ventricular mass index (r = 0.586, p < 0.01). While there was no correlation in the myocardial performance index between infants of diabetic mothers and the control group, the myocardial performance index of macrosomic infants was lower than that of the control group (p = 0.017). Cardiac biomarkers (NT proBNP and troponin T) were elevated in infants of diabetic mothers and macrosomic infants. While there was a positive correlation between NT proBNP levels and cardiac structure in infants of pregestational and gestational diabetic mothers, there was no relationship between NT proBNP levels and cardiac function.