Fetal Heart Tracing Research Articles

Early Onset Severe IUGR: Waiting to Deliver Does Not Appear to Improve Outcome and May Be Harmful [35R

INTRODUCTION: Preterm delivery of IUGR fetuses prior to 32 wks is rarely indicated, occurring in < 1.9% of all pregnancies. We sought to determine if delaying delivery until non-reassuring fetal heart tracing (NRFT) increases adverse outcomes. METHODS: In a cohort of IUGR < 32 wks, two groups were compared: those delivered for abnormal UAD studies and those delivered for NRFT. Fetuses with persistent absent (AEDF) or reversed end diastolic flow (REDF) were placed on continuous monitoring until delivery. Pregnancies were excluded when delivered for maternal deterioration. T-test and Chi-square were performed where appropriate. RESULTS: 43 singletons with IUGR < 32 weeks gestation and abnormal UAD from 2012-2015. Mean GA at diagnosis 24.7 +/-3.1 wks (range 18-30.3 wks). 30 delivered for abnormal UAD and 13 for NRFT. Pregnancy characteristics were similar between groups. Women progressing to urgent delivery due to NRFT were more likely to undergo cesarean (CD) than SVD (p=0.01). 83.9% of both groups were delivered via CD and were significantly smaller compared to those able to be born via SVD (p=0.026). Women with HTN, preeclampsia or GHTN were also more likely to undergo CD than SVD (p=0.04). Expectant management until NRFT of abnormal UAD did not decrease requirement for CPR at delivery or incidence of IVH, RDS, or death. Length of stay was 50.9 days in those delivered for Doppler while 61.2 days in the group delivered emergently (p=0.23). CONCLUSION: Waiting to deliver until there was NRFT does not appear to decrease neonatal morbidity/mortality, increases risk for emergency CD, and may increase length of stay in NICU.

Route of Delivery in Women With Stillbirth: Results From the Stillbirth Collaborative Research Network.

To describe delivery management of singleton stillbirths in a population-based, multicenter case series. We conducted a retrospective chart review of 611 women with singleton stillbirths at 20 weeks of gestation or greater from March 2006 to September 2008. Medical and delivery information was abstracted from medical records. Both antepartum and intrapartum stillbirths were included; these were analyzed both together and separately. The primary outcome was mode of delivery. Secondary outcomes included induction of labor and indications for cesarean delivery. Indications for cesarean delivery were classified as obstetric (abnormal fetal heart tracing before intrapartum demise, abruption, coagulopathy, uterine rupture, placenta previa, or labor dystocia) or nonobstetric (patient request, repeat cesarean delivery, or not documented). Of the 611 total cases of stillbirth, 93 (15.2%) underwent cesarean delivery, including 43.0% (46/107) of women with prior cesarean delivery and 9.3% (47/504) of women without prior cesarean delivery. No documented obstetric indication was evident for 38.3% (18/47) of primary and 78.3% (36/46) of repeat cesarean deliveries. Labor induction resulted in vaginal delivery for 98.5% (321/326) of women without prior cesarean delivery and 91.1% (41/45) of women with a history of prior cesarean delivery, including two women who had uterine rupture. Among women with a history of prior cesarean delivery who had spontaneous labor, 74.1% (20/27) delivered vaginally, with no cases of uterine rupture. Women with stillbirth usually delivered vaginally regardless of whether labor was spontaneous or induced or whether they had a prior cesarean delivery. However, 15% underwent cesarean delivery, often without a documented obstetric indication.

Delivery outcomes of term pregnancy complicated by idiopathic polyhydramnios

ObjectivePolyhydramnios is associated with an increased risk of cesarean section. The aetiology of polyhydramnios and the characteristics of the labour may be confounding factors. The objective was to study the characteristics and mode of delivery in case of pregnancy complicated with idiopathic polyhydramnios. MethodsThis retrospective matched and controlled study included all pregnant women with idiopathic polyhydramnios (amniotic index>25cm or single deepest pocket>8cm) diagnosed at the 2nd or 3rd trimester and persistent at term delivery (>37weeks of pregnancy) in our institution. We excluded pregnancies in which the polyhydramnios could be explained by infection, gestational diabetes, congenital malformation, abnormal karyotype, placental anomalies, alloimmunization as well as pregnancies in which an amniocentesis for the purpose of diagnosis had not been performed. Data were gathered from a tertiary care university hospital register from 1998–2015. Cases of polyhydramnios were matched with the following two women who presented for labour management with spontaneous cephalic presentation, matching for delivery date, maternal age, parity, body mass index. The main outcome measure was the risk of cesarean section. Univariate and multivariate adjusted analysis were performed. ResultsWe identified 108 women with idiopathic polyhydramnios and compared them with 216 matched women. Among them, 94 and 188 attempted a trial of labour. Maternal age, mean term delivery and birthweight were 31 years, 39+5weeks gestation and 3550 g. We did not observe differences in maternal characteristics, epidural analgesia and rate of abnormal fetal heart tracing. Induced labour and non-vertex presentations (forehead, bregma, face) were more frequent in the polyhydramnios group (respectively 57.9% versus 27.8%, P<0.05 and 7.8% versus 1%, P<0.05). Cesarean section rate was higher in the case of polyhydramnios in the overall population (45.4% versus 8%, P<0.05) and remained higher after exclusion of cases of induced labour and non-vertex presentation (38.4% versus 3.8%, P<0.05). Amniotomy was more frequent in pregnancies with polyhydramnios (55.8% versus 39.1%, P<0.05). After adjustment for matching and confounding variables, polyhydramnios was found to be a risk factor for cesarean section (OR 21.02; CI 95% 8.004–55.215, P<0.01). ConclusionIdiopathic polyhydramnios increased the risk of prolonged first stage of labour, non-vertex presentation and cesarean section.

Management of preeclampsia after heart transplant

We present a 20-year-old primiparous patient status post heart transplant at 6 months with long-standing hypertension progressing to super-imposed preeclampsia. Pregnancy and delivery after thoracic transplantation is no longer a rare occurrence, however, these women are at a greater risk of gestational hypertension and preeclampsia.1 Current literature does not provide treatment guidelines for treatment of hypertensive disorders in patients with a transplanted heart. In this case report, we explore the different treatments for maintaining blood pressures in the transplanted neurovascular system, effects of eclampsia prevention on blood pressure, and how fluctuations in blood pressure in a long-standing hypertensive can affect fetal heart tracings. A literature search was conducted using terms “solid organ transplant and preeclampsia”, “Anti-hypertensive drugs post heart transplant”, and “hypertension after heart transplantation”. No reviews on treatment of preeclampsia in cardiac transplant recipients were evident.

Legal Briefs: Did Vacuum Extraction Use Cause Brain Injury?

* Abbreviations: CT, : computed tomography IVH, : intraventricular hemorrhage MRI, : magnetic resonance imaging A 33 4/7 weeks’ gestation, 1,900-g female infant was born to a 21-year-old mother whose pregnancy was complicated by hypertension. The mother was admitted to the hospital and given magnesium sulfate 5 days before delivery. After a course of antenatal corticosteroids, the obstetrician induced labor because of worsening hypertension. Spontaneous rupture of membranes occurred 4 hours after oxytocin was started. Variable decelerations occurred, for which the obstetrician ordered an amnioinfusion. The obstetrician retained by the plaintiff was critical of the amnioinfusion, stating that the salt load given to the mother during this procedure was contraindicated because of the mother's hypertension. Nine hours after oxytocin was started, when the cervix was completely dilated, the mother had 2 brief seizures. The fetal heart tracings were normal during the seizures. Ten minutes later, the obstetrician placed a vacuum device on the fetus and delivered the infant. The plaintiff's obstetrical expert pointed out that the literature and the manufacturer's guideline state that a fetus of less than 34 weeks’ gestation should not have a vacuum-assisted delivery. The treating and defense obstetrician said that the vacuum extraction was warranted because of the mother's seizures. The Apgar scores were 8, 9, and 9 at 1, 5, and 10 minutes, respectively. The infant's physical examination showed molding, cephalohematoma, facial bruising, retinal hemorrhage, a normal head circumference of 32 cm, and a low blood pressure of 53/21 mm Hg with a mean of 31 mm Hg, for which a 20-mL bolus of normal saline was given. The initial hematocrit was 63.9%. The magnesium level was 3.8 mEq/L (1.9 mmol/L). The infant began having more apnea and required intubation at 9 hours because of increasing severity of apnea. The treating and defense neonatologist said the apnea was secondary to the magnesium and/or apnea of prematurity. The plaintiff neonatologist said …

Computed tomographic imaging interpretation improves fetal outcomes after maternal trauma.

Computed tomography (CT) has been validated to identify and classify placental abruption following blunt trauma. The purpose of this study was to demonstrate improvement in fetal survival when delivery occurs by protocol at the first sign of class III fetal heart rate tracing in pregnant trauma patients with a viable fetus on arrival and CT evidence of placental perfusion 50% or less secondary to placental abruption. This is a retrospective review of pregnant trauma patients at 26 weeks' gestation or greater who underwent abdominopelvic CT as part of their initial evaluation. Charts were reviewed for CT interpretation of placental pathology with classification of placental abruption based upon enhancement (Grade 1, >50% perfusion; Grade 2, 25%-50% perfusion; Grade 3, <25% perfusion), as well as need for delivery and fetal outcomes. Forty-one patients met inclusion criteria. Computed tomography revealed evidence of placental abruption in six patients (15%): Grade 1, one patient, Grade 2, one patient, and Grade 3, four patients. Gestational ages ranged from 26 to 39 weeks. All patients with placental abruption of Grade 2 or greater developed concerning fetal heart tracings and underwent delivery emergently at first sign. Abruption was confirmed intraoperatively in all cases. Each birth was viable, and Apgar scores at 10 minutes were greater than 7 in 80% of infants, all of whom were ultimately discharged home. The remaining infant was transferred to an outside facility. Delivery at first sign of nonreassuring fetal heart rate tracings in pregnant trauma patients (third trimester) with placental abruption of Grade 2 or greater can lead to improved fetal outcome. Therapeutic/care management study, level III.

The Labor Games.

To develop and evaluate a simulation laboratory designed to stimulate learning and increase medical students' preparedness for an obstetrics and gynecology clinical clerkship. Ninety-seven medical students participated in the games during their obstetrics and gynecology clerkship in 1 year. Using the resident-as-teacher model, students rotated through seven stations, each with a simulated obstetric task. Points were awarded at each station, and the student with the highest score won. Self-perceived proficiency level and general preparedness for the clerkship were evaluated through paired pregame and postgame assessments. Postassessment results showed statistically significant (P<.001) increases in self-perceived competence performing all tested skills including reading fetal heart tracings, knot-tying, measuring cervical dilation, amniotomy, estimating fetal weight, and estimating blood loss. Approximately 97% enjoyed The Labor Games, 97.9% reported increased knowledge, and 96.9% learned valuable skills. Students also reported feeling more prepared for the obstetrics and gynecology rotation (2.6 compared with 3.3, P<.001). The Labor Games improved medical students' self-confidence and self-perceived skill level on obstetric tasks. Students also felt more prepared for the obstetrics and gynecology clerkship. This study creates a low-cost and reproducible simulation laboratory that is identified as effective by medical students in teaching skills, knowledge, and preparedness for an obstetrics and gynecology clerkship.

Indications for primary cesarean delivery relative to body mass index

Obesity is a known risk factor for cesarean delivery. Limited data are available regarding the reasons for the increased rate of primary cesarean in obese women. It is important to identify the factors leading to an increased risk of cesarean to identify opportunities to reduce the primary cesarean rate. We evaluated indications for primary cesarean across body mass index (kg/m(2)) classes to identify the factors contributing to the increased rate of cesarean among obese women. In the Consortium of Safe Labor study from 2002 through 2008, we calculated indications for primary cesarean including failure to progress or cephalopelvic disproportion, nonreassuring fetal heart tracing, malpresentation, elective, hypertensive disease, multiple gestation, placenta previa or vasa previa, failed induction, HIV or active herpes simplex virus, history of uterine scar, fetal indication, placental abruption, chorioamnionitis, macrosomia, and failed operative delivery. For women with primary cesarean for failure to progress or cephalopelvic disproportion, dilation at the last recorded cervical examination was evaluated. Women were categorized according to body mass index on admission: normal weight (18.5-24.9), overweight (25.0-29.9), and obese classes I (30.0-34.9), II (35.0-39.9), and III (≥40). Cochran-Armitage trend test and χ(2) tests were performed. Of 66,502 nulliparous and 76,961 multiparous women in the study population, 19,431 nulliparous (29.2%) and 7329 multiparous (9.5%) women underwent primary cesarean. Regardless of parity, malpresentation, failure to progress or cephalopelvic disproportion, and nonreassuring fetal heart tracing were the common indications for primary cesarean. Regardless of parity, the rates of primary cesarean for failure to progress or cephalopelvic disproportion increased with increasing body mass index (normal weight, overweight, and classes I, II, and III obesity in nulliparous women: 33.2%, 41.6%, 46.4%, 47.4%, and 48.9% [P < .01] and multiparous women: 14.5%, 20.3%, 22.8%, 27.2%, and 25.3% [P<.01]), whereas the rates for malpresentation decreased (normal weight, overweight, and classes I, II, and III obesity in nulliparous women: 23.7%, 17.2%, 14.6%, 12.0%, and 9.1% [P < .01] and multiparous women: 35.6%, 30.6%, 26.5%, 24.3%, and 22.9% [P < .01]). Rates of primary cesarean for nonreassuring fetal heart tracing were not statistically different for nulliparous (P > .05) or multiparous (P > .05) women. Among nulliparous women who had a primary cesarean for failure to progress or cephalopelvic disproportion, rates of cesarean prior to active labor (6 cm) increased as body mass index increased, accounting for 39.3% of women with class I, 47.1% of women with class II, and 56.8% of women with class III obesity compared to 35.2% for normal-weight women (P < .01). Similar to normal-weight women, the indication of cesarean for failure to progress or cephalopelvic disproportion was the major factor contributing to the increase in primary cesarean in obese women, but was even more prevalent with increasing obesity class. The rates of intrapartum primary cesarean prior to achieving active labor increased with increasing obesity class in nulliparous women.

Improving the Safety of Labor &amp; Delivery With the Use of Telemedicine

INTRODUCTION: In an effort to improve patient safety at our institution, we instituted an electronic Labor and Delivery (eL&D) program for remote electronic fetal monitoring. The aim of this study was to examine nursing attitudes toward eL&D before and after implementation. METHODS: After receiving IRB exemption, labor and delivery nurses completed surveys before and 1 year after initiation of the eL&D. Participation was optional. Surveys were anonymous and included demographic information, personal perceptions of eL&D clinical outcomes and perceptions of changes in workflow. RESULTS: Response rates were 61.7% for initial surveys and 61.2% for final surveys. Questions regarding safety demonstrated a decrease in agreement of eL&D usefulness from initial to follow up surveys. A decrease in the perception that eL&D would improve the number of “good catches” regarding fetal heart tracings; 62.0% (95% CI: 48.1–75.9) versus 32.7% (95% CI: 19.0–46.3) was demonstrated. Questions regarding workflow demonstrated concerns regarding interference with bedside nursing No increase in work load was perceived between the two surveys. Open ended comments expressed concern about eL&D taking away floor staff, eL&D being used as a chart auditing system, and the belief that eL&D would cause interruptions during emergency situations. Overall, 26.5% of respondents felt that eL&D should continue. CONCLUSION: Labor and Delivery nursing staff perceptions suggest limited nursing support of eL&D. These findings should be considered in determining future dissemination plans.

Differences in Interpretation and Management of Computer Screen Versus Paper Fetal Heart Tracings [2M

Differences in Interpretation and Management of Computer Screen Versus Paper Fetal Heart Tracings [2M

Does gender of the fetus have any relation with fetal heart monitoring during the first and second stage of labor?

Objective: To investigate fetal gender and its influences on neonatal outcomes, taking into consideration the available tools for the assessment of fetal well-being.Methods: We conducted a retrospective study comparing maternal, fetal and neonatal outcomes according to fetal gender, in women carrying a singleton gestation.A multivariate analysis was performed for the prediction of adverse neonatal outcomes according to fetal gender, after adjustment for gestational age, maternal age and fetal weight.Results: A total of 682 pregnancies were included in the study, of them 56% (n = 383) were carrying a male fetus and 44% (n = 299) a females fetus. Male gender was associated with a significant higher rate of abnormal fetal heart tracing patterns during the first (67.7% versus 55.1, p = 0.001) and the second stage (77.6 versus 67.7, p = 0.01) of labor. Male gender was also significantly associated with lower Apgar scores at 1' (19.1% versus 10.7%, p < 0.01), as well as lower pH values (7.18 ± 0.15 versus 7.23 ± 0.18, p < 0.001), and significant differences in cord blood components (PCO2, PO2) compared with female fetuses. In the multivariate analysis, male gender was found to be significantly associated with first (OR 1.76, 95% CI 1.28–2.43, p = 0.001) and second stage (OR 1.73, 95% CI 1.20–2.50, p < 0.01) pathological fetal heart tracing patterns, pH < 7.1, and for Apgar scores at 1'< 7.Conclusions: The present study confirms the general trend of a lower clinical performance of male neonates compared with females. In addition, the relation between fetal heart rate patterns during all stages of labor and fetal gender showed an independent association between male fetal gender and abnormal fetal heart monitoring during labor.

Uterine tachysystole in spontaneous labor at term

Objectives: The objective of this study is to determine the incidence of uterine tachysystole and its association with spontaneous labor at term.Methods: A retrospective cohort study of 8008 women in spontaneous labor (without prostaglandins or oxytocin). Fetal heart tracings and uterine activity were recorded every 15 min. Primary outcome: occurrence of tachysystole (> 5 uterine contractions /10 min over 30 min periods). Secondary outcomes: non-reassuring fetal heart tracings (NRFHT), NICU admissions, and cesarean deliveries.Results: About 890 patients (11.1 %) had at least one episode of tachysystole. Non-whites have higher incidence of uterine tachysystole; adjusted odds ratio (aOR) was 1.66 for Hispanics (95% CI 1.28–2.05), 1.58 for African Americans (95% CI 1.05–2.38), and 1.51 for Asians (95% CI = 1.13–2.0). The use of epidural analgesia was higher in the tachysystole group (62.2% versus 40.9%, aOR 1.89, CI 1.58–2.26; p < 0.001). Tachysystole was more frequent among nulliparous women and in women carrying higher weight fetuses. Oligohydramnios (aOR 1.62, CI 0.70–3.72; p < 0.004), and NRFHT were more common in the tachysystole group (4.2% versus 2.5%, p = 0.002). Newborns in the tachysystole group were two times more likely to be admitted to NICU (30 /890 [3.4%] versus 122 /7118 [1.7%], OR = 2, p=0.001). There was no difference in the frequency of meconium-stained amniotic fluid or Apgar scores <7 at 5 min.Conclusion: Uterine tachysystole occurs in more than 10% of spontaneous labors and is associated with NRFHR, increased rate of caesarean deliveries and NICU admissions. It is not associated with low Apgar scores or meconium-stained amniotic fluid.

Case 1: Hypoglycemia, Apnea, and Poor Feeding in a Term Infant

A term male infant born to a primigravida is referred 5 days after birth for recurrent hypoglycemia, hypotonia, difficulty feeding, and subtle dysmorphic features. The pregnancy was complicated by uterine fibroids and preeclampsia in the third trimester. A full fetal survey at 20 weeks’ gestational age was normal. The infant was born via emergent cesarean section for nonreassuring fetal heart tracing, and emerged depressed with a 1-minute Apgar score of 1 (heart rate of 60 beats per minute), but responded well to positive pressure ventilation (5-minute Apgar score of 8) and was subsequently admitted to the newborn nursery. During the first 2 hours after birth, he developed hypoglycemia, with a glucose concentration of 21 mg/dL (1.17 mmol/L) and difficulty feeding, as well as hypotonia, hypothermia, and desaturations. He was transferred to the special care nursery with suspected sepsis and transient hypoglycemia, and mild encephalopathy. He was treated with intravenous dextrose and his symptoms quickly resolved. He received antibiotics for 48 hours, and a blood culture was negative. He was discharged to the newborn nursery on full oral feeds with stable serum glucose concentrations on the fourth day after birth. Later that day, he was again hypotonic, unable to take oral feeds, and having multiple desaturation and apnea episodes. His serum glucose at that time was less than 20 mg/dL (1.11 mmol/L). Intravenous dextrose was restarted and he was admitted to the NICU. On admission, the infant’s weight was 2.86 kg (27%), length 51 cm (78%), and head circumference 33.5 cm (40%). He had a temperature of 97.2°F (36.2°C), heart rate of 114 beats per minute, respiratory rate of 46 breaths …

Retrospective comparison of ephedrine and phenylephrine for the treatment of spinal anesthesia induced hypotension in pre-eclamptic patients

Objective: To compare neonatal acid base status in parturients who underwent cesarean delivery and received either ephedrine or phenylephrine boluses for the treatment of spinal anesthesia induced hypotension. Research design and methods: After institutional review board approval, the perioperative database of the University of Iowa Hospitals and Clinics was used to identify all women diagnosed with pre-eclampsia and had cesarean delivery under spinal anesthesia for the period 1 January 2005 to 31 July 2014. Data retrieved included patient demographics, indication for cesarean delivery, severity of pre-eclampsia, dose of vasopressor, neonatal umbilical artery pH and Apgar scores. Main outcome measures: Primary outcome was umbilical artery pH. Results: Data for 146 patients was included in the analysis. Ephedrine was used in 57 patients (group E) and phenylephrine in 89 (group PE) patients. The median umbilical artery pH was 7.30 (IQR 7.20–7.30) and 7.30 (IQR 7.20–7.30) in the ephedrine and phenylephrine groups respectively (P = 0.41). Non-reassuring fetal heart trace was the only factor significantly associated with lower umbilical artery pH on multivariable regression analysis (β = −0.09, P = 0.002). Conclusions: We found no difference in neonatal umbilical artery pH between ephedrine and phenylephrine when used to treat spinal anesthesia induced hypotension during cesarean delivery in pre-eclamptic patients. Limitations of the study include its retrospective single center design and the fact that the choice of vasopressor was not randomized.

Nurses Count: Tracking Performance to Improve Cesarean Delivery Rates.

Nurses Count: Tracking Performance to Improve Cesarean Delivery Rates.

Decisions to Perform Emergency Caesarean Sections at a University Hospital: Do obstetricians agree?

This study was undertaken to assess the degree of agreement amongst obstetricians regarding decisions to perform emergency Caesarean section (CS) procedures at a university hospital. This retrospective clinical audit was carried out on 50 consecutive emergency CS procedures performed between November 2012 and March 2013 on women with singleton pregnancies at the Sultan Qaboos University Hospital in Muscat, Oman. Data on each procedure were collected from electronic patient records and independently reviewed by six senior obstetricians to determine agreement with the decision. Of the 50 women who underwent CS procedures, the mean age was 28.9 ± 5.1 years and 48% were primigravidae. A total of 65% of the CS procedures were category I. The most common indications for a CS was a non-reassuring fetal heart trace (40%) and dystocia (32%). There was complete agreement on the decision to perform 62% of the CS procedures. Five and four obstetricians agreed on 80% and 95% of the procedures, respectively. The range of disagreement was 4-20%. Disagreement occurred primarily with category II and III procedures compared to category I. Additionally, disagreement occurred in cases where the fetal heart trace pattern was interpreted as an indication for a category II CS. The majority of obstetricians agreed on the decisions to perform 94% of the emergency CS procedures. Obstetric decision-making could be improved with the implementation of fetal scalp pH testing facilities, fetal heart trace interpretation training and cardiotocography review meetings.

Risks of parenteral antihypertensive therapy for the treatment of severe maternal hypertension are low

ABSTRACTObjective: To determine whether the incidence of hypotension or adverse fetal heart tracing (FHT) category change differed following antepartum administration of intravenous (IV) labetalol versus hydralazine. Methods: Blood pressure and FHT categories were assessed one hour before and after medication administration. Hypotension was defined as ≥30% reduction in baseline systolic blood pressure (SBP) or SBP <90 mmHg. Changes in mean arterial pressure (MAP) were also compared. The National Institute for Child Health and Human Development (NICHD) three-tier category system was used to describe the FHT. For all category II tracings, Parer and Ikeda’s system was also used. Results: Sixty-nine women received hydralazine and 31 women received labetalol during the study period. The incidence of hypotension (≥30% reduction in SBP) was similar between the labetalol (10%) and hydralazine (11%) groups (p = 0.98). No women experienced post-treatment SBP <90 mmHg. No association was observed between fetal heart rate category change and drug used. No women required emergent delivery for fetal indications. Conclusions: The incidence of maternal hypotension was low and did not differ following antepartum IV labetalol versus hydralazine use. These data should reassure providers about the use of parenteral labetalol and hydralazine for the treatment of severe hypertension.

Sawtooth fetal heart rate pattern due to in utero fetal central nervous system injury

Case reports We present 3 cases of documented central nervous system (CNS) injury with a characteristic fetal heart rate (FHR) sawtooth-like pattern. In the first case, there was category I fetal heart tracing during labor, which was followed by a sudden onset of fetal tachycardia, unstable and indeterminate baseline, and episodes of a sawtooth FHR pattern (Figure 1). The Apgar scores after a vaginal delivery were 9/9 at 1 and 5 minutes. The magnetic resonance imaging of the neonate, which was performed 48 hours postpartum because of facial twitches, showed infarction of the left cerebral hemisphere because of a middle cerebral artery occlusion/thrombosis; the approximate timing of the fetal stroke coincided with the abrupt onset of the aforementioned FHR changes in labor (Figure 2). In the second case, the patient was admitted with indeterminate FHR baseline and sawtooth FHR pattern (Figure 3). Emergent cesarean delivery was performed and the Apgar scores were 0/3/3 at 1, 5, and 10 minutes; the umbilical artery cord pH was 6.87, partial pressure of CO2 was 186, and base excess was e27.7. Immediately after birth the electroencephalogram was abnormal, and the infant received brain cooling but unfortunately died. In the third case, late FHR decelerations, indeterminate baseline, and periods of sawtooth FHR pattern were noted during the second stage of labor because of excessive uterine activity (Figure 4). The Apgar scores were 3/6 at 1 and 5 minutes, the cord pH was 6.90, partial pressure of CO2 was 73 and base excess was e19.5. A cranial ultrasound of the neonate revealed grade II intraventricular hemorrhage.

Strong ion and weak acid analysis in severe preeclampsia: potential clinical significance

The influence of common disturbances seen in preeclampsia, such as changes in strong ions and weak acids (particularly albumin) on acid-base status, has not been fully elucidated. The aims of this study were to provide a comprehensive acid-base analysis in severe preeclampsia and to identify potential new biological predictors of disease severity. Fifty women with severe preeclampsia, 25 healthy non-pregnant- and 46 healthy pregnant controls (26-40 weeks' gestation), were enrolled in this prospective case-control study. Acid-base analysis was performed by applying the physicochemical approach of Stewart and Gilfix. Mean [sd] base excess was similar in preeclamptic- and healthy pregnant women (-3.3 [2.3], and -2.8 [1.5] mEq/L respectively). In preeclampsia, there were greater offsetting contributions to the base excess, in the form of hyperchloraemia (BE(Cl) -2 [2.3] vs -0.4 [2.3] mEq/L, P<0.001) and hypoalbuminaemia (BE(Alb) 3.6 [1] vs 2.1 [0.8] mEq/L, P<0.001). In preeclampsia, hypoalbuminaemic metabolic alkalosis was associated with a non-reassuring/abnormal fetal heart tracing (P<0.001). Quantitative analysis in healthy pregnancy revealed respiratory and hypoalbuminaemic alkalosis that was metabolically offset by acidosis, secondary to unmeasured anions and dilution. While the overall base excess in severe preeclampsia is similar to that in healthy pregnancy, preeclampsia is associated with a greater imbalance offsetting hypoalbuminaemic alkalosis and hyperchloraemic acidosis. Rather than the absolute value of base excess, the magnitude of these opposing contributors may be a better indicator of the severity of this disease. Hypoalbuminaemic alkalosis may also be a predictor of fetal compromise. clinicaltrials.gov: NCT 02164370.

Safety of Yoga in Pregnancy [37

BACKGROUND: Yoga is recognized for its potential to balance an individual's mental, physical, emotional, and spiritual state. Pregnant patients often ask physicians for permission to participate in yoga. The American Congress of Obstetricians and Gynecologists has no specific recommendations for yoga. The purpose of this study was to examine the safety of yoga in pregnancy. METHODS: Institutional review board approval was obtained. Pregnant women 18–42 years old with uncomplicated pregnancies were recruited. Patients were between 35 and 37 weeks of gestation. No yoga experience was required. A nonstress test (NST) was measured at the beginning and end of the yoga session. The participants assumed 26 yoga poses. In each posture, continuous fetal monitoring, tocometry, pulse oximetry, and vital signs were obtained. All sessions were attended by a certified yoga instructor and experienced obstetrician–gynecologist. RESULTS: A total of 30 women were enrolled; five were excluded for contractions at the initial NST. Twenty-five women completed the study. All participants completed the 26 poses. There were no significant changes in vital signs during the poses. All participants had reactive NSTs before and after the session. All fetal heart tracings demonstrated accelerations and variability, and no decelerations of the fetal heart tracing were seen. No patients had regular contractions during the session. There were no falls or injuries. CONCLUSION: No safety issues were identified. Vital signs, pulse oximetry, uterine tocometry, and fetal heart tracing remained reassuring in all patients in all postures. Yoga is a safe form of physical activity that physicians can recommend to their patients with uncomplicated pregnancies.