Fetal Distress In Labour Research Articles

Study on Fetal and Maternal Outcome of Postdated Pregnancy

Postdated pregnancy is not so uncommon in obstetric practice. When a pregnancy crosses the expected date of delivery (beyond 280 days) it is called postdated pregnancy. The incidence is about 7% of all pregnancies. This prospective observational study was carried out in 165 postdated pregnancies admitted in the Department of Obstetrics & Gynaecology, during a period of 3 years from January 2021 to December 2023 . Majority of the patients were below 25 years of age (47.88%) and primigravida (41.82%). Most of the patients belonged to rural areas (55.75%) and were middle socio-economic status group (45.45%). The majority of these postdated women were delivered by NVD (52.12%), followed by LSCS (32.72%) and instrumental (15.15%). Postdated pregnancy was associated with perinatal complications like meconium aspiration syndrome, oligohydramnios, fetal birth injuries, septicemia, shoulder dystocia, non-reassuring fetal heart rate status, fetal distress in labour. There was an increased risk of maternal complications like increased caesarean section rate, post-partum hemorrhage (PPH) ,cervical tear, perineal tear. Management of postdated pregnancy is challenging. Careful advice and timely interventions can reduce fetomaternal complications. EWMCJ Vol. 12, No. 1&2, January-July 2024: 94-98

RidStress 2 randomised controlled trial protocol: an Australian phase III clinical trial of intrapartum sildenafil citrate or placebo to reduce emergency caesarean birth for fetal distress in women with small or suboptimally grown infants at term (≥37 weeks)

IntroductionSmall for gestational age (SGA) infants are at increased risk of fetal distress in labour requiring emergency operative birth (by caesarean section (CS), vacuum or forceps). We have previously shown...

Validation of a modified obstetric comorbidity index for prediction of postpartum adverse events including fetal morbidity - a retrospective cohort study from Qatar

BackgroundThe Obstetric Comorbidity Index (OBCMI) is an internationally validated scoring system for maternal risk factors intended to reliably predict the occurrence of severe maternal morbidity (SMM). This retrospective cohort study applied the OBCMI to pregnant women in Qatar to validate its performance in predicting SMM and cumulative fetal morbidity.MethodsData from 1000 women who delivered in July 2021 in a large tertiary centre was extracted from medical records. The OBCMI index included maternal demographics, pre-existing comorbidities, and various current pregnancy risk factors such as hypertension, including preeclampsia, intrauterine fetal death, prolonged rupture of membranes and unbooked pregnancies. SMM was based on the ACOG consensus definition, and the cumulative fetal morbidity (CFM) included fetal distress in labour, low APGAR and umbilical artery (UA) pH, admission to neonatal intensive care (NICU), and hypoxic-ischemic encephalopathy (HIE). A c-statistic or area under curve (AUC) was calculated to determine the ability of OBCMI to predict SMM and CFM.ResultsThe median OBCMI score for the cohort was 1 (interquartile range- 0 to 2); 50% of women scored 0, while 85% (n = 842) had a score ranging from 0 to 2. Ten women (1%) scored ≥ 7; the highest score was 10. The incidence of SMM was 13%. According to the modified scoring system, the mean OBCMI score in those who developed SMM was 2.18 (± 2.20) compared to a mean of 1.04 (± 1.40) in those who did not (median 1, IQR:1–3 versus median 0, IQR: 0–2; p < 0.001). The incidence of CFM was 11.3%. The incidence of low APGAR score, HIE and NICU admission was nearly 1 in 1000. Around 5% of the babies had fetal distress in labour and low UA pH. For every 1 unit increase in OBCMI score, the odds of SMM increased by 44% (OR 1.44 95% CI 1.30–1.59; p < 0.001; AUC 0.66), and CFM increased by 28% (OR 1.28 95% CI 1.15–1.42; p < 0.001; AUC 0.61). A cut-off score of 4 had a high specificity (> 90%); 1 in 4 and 1 in 6 women with OBCMI score ≥ 4 developed SMM and CFM, respectively.ConclusionThe OBCMI performed moderately well in predicting SMM in pregnant women of Qatar and can be effectively used as a risk assessment tool to red-flag high-risk cases so that appropriate and timely multidisciplinary care can be initiated to reduce SMM and maternal mortality. The index is also helpful in predicting fetal morbidity; however, further prospective studies are required to validate OBCMI for CFM.

Glucose level in amniotic fluid as a preclinical marker of chorioamnionitis

The article presents the results of a study amniotic glucose concentration as a potential early indicator of the inflammatory process in the fetal membranes. The main focus was on the analysis of the features of pregnancy and labor in women with premature rupture of membranes (PROM) during full-term and preterm labor according to amniotic fluid glucose levels. Currently, the expectant approach in cases of PROM is widely practiced throughout the world. The objective: to estimate the glucose level in the amniotic fluid as a preclinical marker of chorioamnionitis. Materials and methods. Depending on the glucose concentration in the amniotic fluid at the time of rupture of membranes and the term of rupture of membranes, 97 pregnant women were divided into 4 groups. I and II groups consisted of women with PROM between 24 and 36 weeks and 6 days. In the I group there were 34 pregnant women with a glucose concentration in the amniotic fluid of more than 0.5 mmol/l, and in the II group – 15 pregnant women with the indicator of less than 0.5 mmol/l. III and IV groups included pregnant women with PROM at full-term pregnancy (after 37 weeks). In the III group there were 34 patients with an amniotic glucose concentration of more than 0.5 mmol/l, and in the IV – 14 pregnant women with the indicator of less than 0.5 mmol/l. In all groups, the further course of pregnancy, the time period from the rupture of membranes to the beginning of labor, the need for induction of labor, hyperthermia before the beginning of labor, deviations from the normal course of labor were analyzed (hyperthermia, fetal distress in labor, uterine weakness) and the frequency of operative delivery. Results. The study determined that women with an amniotic glucose concentration below 0.5 mmol/l at the time of hospitalization were more likely to have hyperthermia before and during childbirth. Hyperthermia was most often observed during the first 12 hours after membrane rupture. In addition, these women were more prone to serious birth complications, such as fetal distress, weak labor, and a greater likelihood of needing an operative delivery. Conclusions. 1. A decreased amniotic glucose level less than 0.5 mmol/l is associated with more frequent clinical manifestations of amniotic infection (20% in preterm pregnancies and 14.8% – in full-term pregnancies) than in groups with a glucose content of more than 0.5 mmol/l (8.8% in preterm pregnancies and 5.9% – in full-term pregnancies, p≤0.05). 2. Among patients with a glucose content in amniotic fluid less than 0.5 mmol/l, laboratory manifestations of intra-amniotic infection were detected more often (40% in preterm pregnancies and 42.5% in full-term pregnancies) than among pregnant women with a glucose content of more than 0.5 mmol/l (20% in both full-term and preterm pregnancies, p≤0.05). 3. Determination of the glucose level in amniotic fluid can be considered as an available method of preclinical diagnosis of chorioamnionitis for the individual choice of management tactics in case of premature rupture of the amniotic membranes, which is especially important in premature pregnancy.

Monitoring Intrapartum Fetal Distress by Cardiotocography &amp; Observe its Relation with Umbilical Cord Blood Sampling &amp; Perinatal Outcome

Background: Cardiotocography (CTG) being a simple noninvasive tool has been used more frequently in recent decades to detect fetal distress &amp; to reduce neonatal mortality &amp;morbidity related to fetal hypoxia. On the other hand, umbilical cord blood gas can be used to detect fetal acidaemia due to fetal distress more accurately. This study aimed to correlate fetal monitoring findings by intrapartum CTG with umbilical cord blood pH &amp; lactate level &amp;test the ability of CTG to predict fetal distress &amp; neonatal outcome. Materials and Methods: This prospective cross-sectional observational study was conducted in the Department of Obstetrics and Gynecology of Chittagong Medical College Hospital, Chattogram, Bangladesh for one year from July 2020 to June 2021. It included 80 term singleton pregnancies in active labour. Intrapartum CTG was taken and classified into normal, suspicious and pathological according to FIGO guidelines of CTG monitoring 2015. Mode of delivery, liquor colour, Apgar scores at 1 and 5 minutes, and admission to the neonatal intensive care unit (NICU), adverse neonatal outcomes were observed. Immediately after delivery of the baby 10 cm of the umbilical cord was clamped doubly and 2-3 ml of umbilical cord arterial blood was taken immediately in a pre-heparinized syringe and sent to a laboratory for assessment of pH and lactate to detect fetal acidosis. Antenatal CTG was correlated to neonatal outcomes and cord blood acidosis by statistical analysis. Results: In this study, 40.0% of the women had normal CTG, 38.8% had suspicious CTG, and 21.2% had pathological CTG. There was a significant worsening of neonatal outcomes across these three groups concerning depressed (&lt;7) Apgar scores at 1 minute (40.6%, 80.6%, and 100%; P&lt;0.001), depressed Apgar scores at 5 minutes (3.1%, 22.6%, and 47.1%; P&lt;0.001), and admission to the NICU (9.4%, 38.6%, and 70.7%; P&lt;0.001). When CTG was pathological or suspicious CTG delivery by LSCS was 5.33 times higher (RR: 5.33; 95% CI: 2.09 -13.63) compared to subjects with normal CTG. There was also a progressive worsening of cord blood pH (7.25±0.05, 7.20±0.06, and 7.13±0.09; P&lt;0.001) and a progressive increase in lactate (3.66±1.01 mmol/l, 4.79±1.61 mmol/l, and 6.63±2.18 mmol/l; P&lt;0.001). Conclusions: It should be concluded that pathological CTG which correlates intrapartum fetal hypoxia with cord blood acidaemia and adverse neonatal outcomes. As cardiotocography is a simple, cost-effective noninvasive tool it can be used to detect fetal distress in labour. Continues CTG monitoring can be offered or recommended in every labour room setting to detect fetal distress &amp; early intervention to prevent neonatal morbidity &amp; mortality.

A multicenter study of incidence, risk factors and outcomes of babies with birth asphyxia in Nepal

BackgroundPerinatal events which result in compromised oxygen delivery to the fetus can lead to Birth Asphyxia (BA). While the incidence, risk factors and outcomes of BA have been characterized, less is known in low resource settings.AimTo determine the incidence of Birth Asphyxia (BA) in Nepal and to evaluate associated risk factors and outcomes of this condition.MethodsA nested observational study was conducted in 12 hospitals of Nepal for a period of 14 months. Babies diagnosed as BA at ≥37 weeks of gestation were identified and demographics were reviewed. Data were analyzed using binary logistic regression followed by multiple logistic regression analysis.ResultsThe incidence of BA in this study was 6 per 1000 term livebirths and was higher among women 35 years and above. Predictors for BA were instrumented vaginal delivery (aOR:4.4, 95% CI, 3.1–6.1), fetal distress in labour (aOR:1.9, 95% CI, 1.0–3.6), malposition (aOR:1.8, 95% CI, 1.0–3.0), birth weight less than 2500 g (aOR:2.0, 95% CI, 1.3–2.9), gestational age ≥ 42 weeks (aOR:2.0, 95% CI, 1.3–3.3) and male gender (aOR:1.6, 95% CI, 1.2–2.0). The risk of pre-discharge mortality was 43 times higher in babies with BA (aOR:42.6, 95% CI, 32.2–56.3).ConclusionThe incidence of Birth asphyxia in Nepal higher than in more resourced setting. A range of obstetric and neonatal risk factors are associated with BA with an associated high risk of pre-discharge mortality. Interventions to improve management and decrease rates of BA could have marked impact on outcomes in low resource settings.

Cesarean Audit for fetal distress- A indispensable tool to reduce Obstetrician Distress

Background and Objectives: Overuse of cesarean section and its implications are of growing concern. Suspected fetal distress has been the commonest indication for cesarean in last few decades heart rate changes shown by fetus without being adversely affected and CTG has been criticized to create unnecessary higher rate of operative deliveries. There is need to know which fetal heart rate abnormality is important and leading to two adverse neonatal outcome to decrease unnecessary operative deliveries. Therefore Caesarean Audit was planned. Material and methods: A total of hundred women were included who underwent emergency cesarean section for suspected fetal distress in labour or without labour detected by cardiotocography or intermittent auscultation were included for analysis. Details were noted in pre designated proforma. Results: During the audit period, total number of caesarean done due to fetal distress analysed during the period were 100.The most common fetal heart rate abnormality was nonspecific in form of single or transient deceleration seen in 63% of cases where records were also incomplete, it was followed by persistent deceleration on cardiotocography which was present in 16% of the cases. In 57 women who were primigravida 14 (24%) patients had nonspecific fetal heart rate patterns and intra operative findings were normal in this group. These were avoidable cesareans. Various Intraoperative findings, observed ,maximum no. of cases had meconium stained liquor seen in 63% of the cases followed by abruption in 9 cases followed by other findings like loop of cord around the neck of foetus, thin scar or scar dehiscence . Maternal resuscitation was carried out only in 53% of cases. Detection delivery interval of less than 30 minutes was present in 4% of cases. In fetal outcomes 16% of babies diagnosed with fetal distress, had poor outcome where Apgar score &lt; 7 and 12 babies had asphyxia related NICU admission. 82% of babies had absolutely normal fetal outcome among which majority (78%) did not require any form resuscitation. which were thus avoidable cases. Conclusions: Correct Knowledge about Standardized fetal heart rate interpretations on CTG and there standardized management protocols like Maternal resuscitative measures ,follow up to ensure fast detection delivery interval should be practiced strictly in all cases of non reassuring Fetal Heart rate patterns. There should be consistent efforts in reducing the rate of cesarean sections particularly primary cesarean deliveries and in order to understand the degree to which cesarean delivery is preventable it is important to know no why cesareans are being performed. Therefore caesarean audit is need of the hour

Obstetric and neonatal outcome ofthyroid dysfunction in pregnancy

Background & Objectives: Thyroid dysfunction in pregnancy and its impact on pregnancy outcome has been a topic of discussion for long and there is no consensus regarding it among experts worldwide. The aim of the study was to determine the current prevalence of thyroid dysfunction in normal pregnant women and study its impact on obstetric and neonatal outcome.Methods: 618 pregnant women less than 16 weeks of gestation enrolled for the study. Along with routine obstetrical investigations, TSH was done. Free T3 and Free T4 estimated for patients with abnormal TSH. Patients were evaluated at the time of pregnancy termination and obstetrical and perinatal outcomes noted.Results & Discussion: The prevalence of subclinical hypothyroidism, overt hypothyroidism and overt hyperthyroidism were 13.6%, 6% and 0.8% respectively. Maternal outcomes having significant association with overt hypothyroidism were preeclampsia (36.1% vs 11.7%), Oligohydramnios (19.4% vs 5.4%) and fetal distress in labor (19.4% vs 7.9%). Maternal outcomes having significant association with subclinical hypothyroidism were preeclampsia (26.3% vs 11.7%), placenta praevia (7.9%vs3%), dystocia (10.5%vs4.3%) and fetal distress in labour (15.8% vs 7.9%). Intra uterine growth restriction and Neonatal low birth weight also had significant association with hypothyroidism. Congenital hypothyroidism noted in 0.5% of the neonates.Conclusion: The prevalence of thyroid dysfunction was high in our study with significant associated adverse outcomes. Hence, routine screening of thyroid dysfunction is recommended.

Cerebroplacental ratio assessment in early labor in uncomplicated term pregnancy and prediction of adverse perinatal outcome: prospective multicenter study.

It has been suggested that the use of Doppler ultrasound in term pregnancies with normal-sized fetuses is able to identify those at high risk of subclinical placental function impairment. The objective of this study was to evaluate the relationship between cerebroplacental ratio (CPR) measured in early labor and perinatal and delivery outcomes in a cohort of uncomplicated singleton term pregnancies. This was a prospective multicenter observational study conducted at three tertiary centers between January 2016 and July 2017. Low-risk term pregnancies, defined by the absence of maternal morbidity or pregnancy complication, accompanied by normal ultrasound and clinical screening of fetal growth in the third trimester, with spontaneous onset of labor were included. Umbilical artery (UA) and fetal middle cerebral artery (MCA) Doppler was assessed on admission for early labor. All measurements were performed in between uterine contractions and according to international standards. CPR was computed by dividing MCA pulsatility index by UA pulsatility index and converted into multiples of the median (MoM) in order to adjust for gestational age. Doctors and midwives involved in the clinical management of the women were blinded to the results of the Doppler evaluation. Mode of delivery and perinatal outcome were compared between pregnancies with reduced CPR MoM, defined as CPR MoM within the lowest decile of the study population, and those with normal CPR MoM. Receiver-operating characteristics curve analysis was used to assess the predictive performance of CPR for obstetric intervention due to fetal distress and composite adverse perinatal outcome. Overall, 562 women were included. The rate of obstetric intervention for suspected fetal distress in labor was more than three times higher among cases with reduced CPR MoM compared to those with normal CPR MoM (9/54 (16.7%) vs 28/508 (5.5%); P= 0.004). Furthermore, a significantly higher rate of composite adverse perinatal outcome was found in fetuses with CPR MoM < 10th percentile compared to those with CPR MoM ≥ 10th percentile (6/54 (11.1%) vs 19/508 (3.7%); P= 0.012). CPR had low sensitivity and low positive predictive value for prediction of obstetric intervention due to fetal distress (24.3% and 18.0%, respectively) and composite adverse perinatal outcome (24.0% and 11.1%, respectively). Data on a wide cohort of low-risk term pregnancies in early labor showed that, while reduced CPR is associated with a higher risk of obstetric intervention due to fetal distress and composite adverse perinatal outcome, it is a poor predictor of adverse perinatal outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

A Local Experience of Pregnancy Outcomes in Sickle Cell Disease and Red Cell Exchange

AimPregnancy outcomes in women with Sickle Cell Disease (SCD) have traditionally been poor with rates of both maternal and fetal complications greater than that seen in non-SCD populations (Oteng-Ntim et al, 2015). This association has been demonstrated across both low- and high-income countries with no significant correlation to discrepancies in health care (Boafor et al, 2015). Complications associated with pregnancy in SCD include preterm delivery, intrauterine growth restriction (IUGR), low birth weight, fetal distress in labour, Cesarean section, eclampsia, sickle cell vaso-occlusive crisis, infection, postpartum hemorrhage, and perinatal and maternal death. The introduction of prophylactic Red Cell Exchange (RCE) for high-risk SCD patients has seen a significant reduction in SCD-associated morbidity and mortality (Josephson et al, 2007). Limited studies have examined whether prophylactic RCE also translates to improved pregnancy outcomes in the SCD population with mixed conclusions (Asma et al, 2015). Whilst the association between SCD and adverse pregnancy outcomes has been well characterised in large multi-centre retrospective studies internationally, local data of pregnancy outcomes in SCD, particularly in patients receiving regular RCE, is lacking.MethodWe conducted a retrospective review of pregnancies within the SCD population managed at the Royal Melbourne Hospital between 2001 (date of commencement of regular RCE program) and 2018 to identify pregnancy complications and outcomes. Medical records across two sites (the Royal Melbourne Hospital and the Royal Women's Hospital) were reviewed to identify patient demographics, RCE received, mode and date of delivery, birth weight, fetal and maternal complications, and outcome of pregnancy.ResultsWe identified 10 pregnancies amongst 5 patients with SCD managed during this time. Three patients had HbSS and two HbSC disease. Mean maternal age at time of pregnancy was 27 years. Two patients were receiving regular RCE prior to pregnancy and continued throughout at 3 to 4 week intervals, with a further patient commenced on RCE at 27/40 as per local hospital practice. Of the 3 women receiving regular RCE during pregnancy, all had live births (n=7); 1 via normal vaginal delivery (NVD) and 6 elective Cesarean-section due to cephalopelvic disproportion. Six of these pregnancies were at term, with one induced at 32/40 due to line sepsis as a complication of RCE. Two pregnancies were also complicated by gestational diabetes.Two patients were not managed with regular RCE. The first declined treatment throughout both pregnancies, with pregnancy 1 complicated by intrauterine growth restriction (IUGR) with delivery via NVD at 37/40, and pregnancy 2 complicated by placental abruption and fetal death in utero (FDIU) at 22/40. Both pregnancies were also complicated by gestational thrombocytopenia. The second patient was on hydroxyurea (HU) at time of conception, initially continued during pregnancy in the setting of normal morphology scans and a rare blood phenotype prohibitive of RCE. HU was subsequently ceased at 27/40 due to the development of IUGR. She was commenced on RCE at 30/40 but suffered placental abruption and FDIU at 34/40. No offspring had a haemoglobinopathy of clinical significance.ConclusionRCE was well-tolerated and associated with good and possibly improved maternal and fetal outcomes in this small cohort of sickle cell patients. Larger studies are required to further characterise the benefit of prophylactic RCE during pregnancy in the SCD population. DisclosuresSzer:Alexion Pharmaceuticals, Inc.: Consultancy, Honoraria, Other: Travel Support , Research Funding.

Methods for the prediction of fetal distress in labour

It provides modern methods for the prediction of fetal distress in labour, the disadvantages and advantages of their use.

OP31.08: Fetal middle cerebral artery Doppler at 40 weeks' gestation in the prediction of emergency delivery for fetal distress in labour

OP31.08: Fetal middle cerebral artery Doppler at 40 weeks' gestation in the prediction of emergency delivery for fetal distress in labour

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.

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.

COMPLICATIONS OF OBSTETRIC AND PERINATAL PERIOD IN PREGNANT WOMEN WITH DESTRUCTIVE TREATMENT OF CERVICAL INTRAEPITHELIAL NEOPLASIA IN A HISTORY

Among malignancies Cervical cancer is the second place in the structure of cancer incidence in women. In recent years there has been a negative trend in increasing the frequency of benign disease and cervical cancer in young women. Women with destructive treatment of cervical intraepithelial neoplasia frequency increases a history of infertility, spontaneous abortion, premature birth, fetal infection and other complications in childbirth and the postpartum period. Therefore, pregnancy, development of the embryo and fetus largely depend on the availability of prenatal viral infections, but the data of the literature on this subject is very controversial.The purpose of the study is to examine to complications of obstetric and perinatal period in pregnant women with destructive treatment of cervical intraepithelial neoplasia in a history Materials and methods. To achieve this goal we held clinical-statistical analysis of 100 individual maps of pregnancy, childbirth stories and maps of infants were divided into 2 groups. I group (basic) - 50 patients with cervical intraepithelial neoplasia cervical history and II (control) - 50 somatically healthy pregnant women without this disease in history. All pregnant women conducted a comprehensive survey that included: clinical, microbiological, instrumental, cytological, colposcopic study , definition of vaginal microbiota and the detection of infections transmitted sexually.RCD status placenta and Doppler a.umbilicalis conducted in pregnant women in the group of subjects in different stages of pregnancy.Results and discussion. In the main group 50 women had a history of CIN place varying degrees of severity. It should be noted that women have a history of diagnosed ureaplasmosis, mycoplasmosis and chlamydia, that was not characteristic of the control group. Women and control group there was a history of early abortion threat, the threat of late spontaneous abortion and threatened preterm labor. In a comprehensive survey in the study group revealed: placental dysfunction, fetal distress, intrauterine growth retardation (IUGR) . Polyhydramnios and oligohydramnios. For the control group was characterized by IUGR and oligohydramnios.From anomalies of labor activity in the treatment of pregnant women with CIN destructive history observed: primary weakness of labor activity, secondary weakness of labor and incoordination generic activities. Premature detachment of normally situated placenta diagnosed only in the main group of women and fetal distress in labor (ie in the first and second periods genera). More than half of the main group of women, childbirth ended per vias naturales.The most common indications for caesarean section for the main group were: failure scar on the uterus, premature detachment of normally situated placenta, fetal distress and extragenital pathology. Comparing the two groups Apgar found that newborns of the group worst figure for 1 minute than in the control group. It has been found that of early neonatal period was complicated only in infants who were born to women with CIN treatment destructive in history. Developmental abnormalities in infants were found, as were pregnant timely diagnosis and prenatal screening ultrasound examination as recommended by gynecologists.Conclusions.1. The threat of early termination of pregnancy, late spontaneous abortion and premature birth more common in women of the main group than in the control group.2. Comprehensive examination in the study group revealed placental dysfunction and fetal distress that was not characteristic of the control group.3. Comparing the two groups Apgar found that newborns of the basic group was with worst figure for 1 minute than in the control group.4. The early neonatal period was complicated only in infants who were born to women with a history of CIN.

The influence of cesarean section and vaginal delivery at term pregnancy fetal distress in labor on maternal and neonatal outcomes

Objective To analyze the influence of the cesarean section and vaginal delivery at term pregnancy when fetal distress in labor conditions on maternal and neonatal outcomes .Methods 238 cases of fetal distress in labor when full-term pregnant were selected ,and they were randomly divided into the observation group and control group,119 cases in each group .The control group was given midwifery vaginal delivery ,while the observation group was given cesarean section .The maternal and neonatal outcomes were compared between the two groups . Results 78 cases（65.55%） of neonatal score above 7 or more points and 7 or more points of the control group were 58 cases（48.74%）,the difference was significant （P〈0.05）.The incidence rate of neonatal complications in the observation group was 5.88%, which was significantly lower than 20.16% of the control group （ P 〈0.05 ）. Conclusion Fetal distress in full-term pregnancy in labor , the use of cesarean section has higher neonatal score compared with vaginal delivery ,and it has low incidence rate of neonatal complications ,it is worth to be applied in clinical. Key words: Cesarean section; Vaginal midwifery; Fetal distress; Impact analysis

Reply: Admission cardiotocography: practice based on evidence or assumptions and untested theories?

I thank Pelle Lindqvist for his interest in my commentary 1. The commentary 2 evaluated admission cardiotocography (CTG) from the perspective of clinical epidemiology – this is a part of evidence-based medicine. Lindqvist refers to his own experience, assumptions and untested theories indicating that admission CTG in all women improves outcomes in high-risk pregnancies. It is well known that it is difficult to draw conclusions from experiences on serious outcomes with very low frequencies. The subjective risk estimation is usually much higher than the objective (or epidemiological) risk estimation 3. When there is disagreement about which procedures or treatments are best, it is important to have academic discussions about the topic and to review the research literature carefully. Today the evidence is interpreted differently, as the test is recommended for all women in Finland and Sweden, but only for high-risk women in Denmark, Iceland and Norway. In Great Britain, where the traditions for making evidence-based guidelines are stronger than in the Nordic countries, the guidelines for intrapartum care among healthy women do not recommend admission CTG in low-risk women 4. In my view, the current evidence does not support routine use in low-risk women. It is possible that future research will provide other results but until then we should base our practice on evidence, not assumptions. As to the specific points in Pelle Lindqvist′s letter: The correct definition is of course that the admission CTG was introduced as a screening for fetal distress in labor, as defined by Ingemarsson et al. in 1986 5. Pelle Lindqvist states that admission CTG has never been used to predict later outcome. This is incorrect, and he is obviously not aware of the history on how and why the test was introduced 5. He also states that the commentary does not address perinatal mortality and serious morbidity. This, again, must rely on a misunderstanding. These important issues are addressed, as is the risk of type II errors because of insufficient sample size. The comment about skills in interpreting CTG-tracings was already discussed in a previous author reply 6. Pelle Lindqvist seems to imply that the labor admission test plays an important role in detecting cases of intrauterine fetal deaths (IUFD) upon admission to the hospital. I strongly disagree. If the midwife suspects IUFD after auscultation, the woman should have an ultrasound examination to verify the diagnosis, not a CTG.

The Implications of Diagnosis of Small for Gestational Age Fetuses Using European and South Asian Growth Charts: An Outcome-Based Comparative Study

The antenatal condition of small for gestational age (SGA) is significantly associated with perinatal morbidity and mortality and it is known that there are significant differences in birth weight and fetal size among different populations. The aim of our study was to assess the impact on outcomes of the diagnosis of SGA according to Bangladeshi and European antenatal growth charts in Sri Lankan population. The estimated fetal weight before delivery was retrospectively reviewed according to Bangladeshi and European growth references. Three groups were identified: Group 1-SGA according to Bangladeshi growth chart; Group 2-SGA according to European growth chart but not having SGA according to Bangladeshi growth chart; Group 3-No SGA according to both charts. There was a difference in prevalence of SGA between Bangladeshi and European growth charts: 12.7% and 51.7%, respectively. There were statistically significant higher rates in emergency cesarean section, fetal distress in labour, and intrauterine death (P < 0.001) in Group 1 compared with Group, 2 and 3. No differences of outcomes occurred between Groups 2 and 3. Our study demonstrated that only cases diagnosed as SGA according to population-based growth charts are at risk of adverse outcome. The use of inappropriate prenatal growth charts might lead to misdiagnosis and potential unnecessary interventions.

Obstetric and perinatal outcome in teenage pregnancies

Objective. To compare obstetric and perinatal outcome in teenage and non-teenage pregnancies. Methods. A retrospective analysis of case records of teenage pregnancies from January 2006 to December 2008. The subjects gave birth in the Department of Obstetrics and Gynaecology, University of Malaya Medical Centre, Kuala Lumpur, Malaysia, a referral tertiary care and teaching hospital with over 5 000 deliveries annually. Pregnancy outcomes in girls aged ≤19 years were compared with those in women aged >19 years. A total of 177 teenage pregnancies were compared with 200 pregnancies in older women. Results. The prevalence of teenage pregnancies was 1.1%. Almost all the subjects were in their first pregnancies. The study showed that teenage mothers had a significant risk of delivering low-birth-weight babies. There were no differences in the risk of anaemia, severe pre-eclampsia, caesarean delivery, postpartum haemorrhage or fetal distress in labour compared with the 200 women in the older age group. Of the pregnant teenagers, 26.9% did not receive any antenatal care at all. Conclusion. The findings suggest that the long-held beliefs about the risks related to teenage pregnancy are not all justified. Early booking, adequate antenatal care and delivery by trained personnel should improve the obstetric and perinatal outcome in this age group.

Reply

We agree with Schoorel et al. that the area under the receiver–operating characteristics curve (AUC) for the model described in our paper is particularly high after inclusion of scar information. We were careful to state this in our paper: ‘The AUC for our model is perhaps surprisingly high. This may reflect the relatively small number of women in the study.’1. However, we also say in the paper that, even if we interpret this with caution, it suggests that the scar is a major factor in the behavior of the uterus during a trial of labor. We are unable to agree that it is not plausible that the morphology of the scar may be an important predictor of uterine behavior in labor. The main indications for repeat Cesarean section in the failed vaginal birth after Cesarean (VBAC) group in our paper were fetal distress and failure to progress. It is entirely possible that both these factors are exacerbated by poor scar healing, which in turn may be reflected in the morphological features of a scar on ultrasound. Furthermore, a poorly healed scar may impact on decidualization and subsequent placentation and be associated with a greater likelihood of fetal distress in labor. We investigated prospectively the changes in Cesarean section scar dimensions during pregnancy as well as the influence of previous VBAC on those changes2. Schoorel et al. are incorrect in their assertion that this paper contains an analysis relating scar features to the probability of a successful trial of VBAC. It does not. We do comment on residual myometrial thickness (RMT) in the small number of cases of scar rupture or dehiscence. This is because, after peer review of our paper, we were asked by the Editor of the Journal to insert some brief information on the RMT and delta RMT in cases of uterine rupture or dehiscence to give more clinical relevance to the paper, to which we agreed. However, an association between RMT and successful VBAC in the current study was not investigated prior to variable selection. It is also important to note that third-trimester sonographic measurements of the thickness of the lower uterine segment and scar features have been reported as a predictor of vaginal delivery3. Accordingly, this variable would be considered as a possible factor in any predictive model on the basis of expert knowledge and was the basis of our hypothesis when we planned the study. Hence, we used a priori variable selection based on knowledge, which is in agreement with contemporary methodological guidelines. Having published our data on interobserver variability, we are aware that measurements of RMT may impact on the performance of any model that uses this variable; to what extent this occurs will only become apparent when RMT is measured by other examiners4. We are pleased that Schoorel et al. agree with the emphasis we placed in our paper on the importance of external validation of prediction models, which is a vital step before considering the introduction of such models into clinical practice. As we state clearly in the paper: ‘It is important to highlight that whilst this model and approach show promise, external validation in different units and populations is needed before introduction into clinical practice.’ O. Naji†‡, L. Wynants§¶, A. Smith†, Y. Abdallah†‡, C. Stalder†, A. Sayasneh†‡, A. McIndoe†, S. Ghaem-Maghami*‡, S. Van Huffel§¶, B. Van Calster**, D. Timmerman** and T. Bourne†‡** †Obstetrics and Gynaecology Unit, Queen Charlotte's and Chelsea Hospital, Imperial College, London,UK; ‡Institute of Reproductive and Developmental Biology, Imperial College, London, UK; §Department of Electrical Engineering (ESAT-SCD), KU Leuven, Leuven, Belgium; ¶iMinds Future Health Department, KU Leuven–University of Leuven, Leuven, Belgium; **Department of Development and Regeneration, University Hospitals, KU Leuven, Leuven, Belgium *Correspondence. (e-mail: s.ghaem-maghami@imperial.ac.uk)