Fetal Heart Tracing Research Articles

Uterine Artery Doppler Velocimetry During Individually Prescribed Exercise in Pregnancy.

To evaluate uterine artery blood flow in response to typical exercise sessions performed in pregnancy in accordance with the current recommendations from the American College of Obstetricians and Gynecologists and the U.S. Department of Health and Human Services. This prospective cross-sectional study measured uterine artery Doppler velocimetry in healthy pregnant women after individually prescribed exercise, including 1) moderate-intensity exercise (40-59% of heart rate reserve) in both nonexercisers and regular exercisers and 2) vigorous-intensity exercise (60-84% of heart rate reserve) in women who regularly engage in exercise. Resting uterine artery Doppler measures were obtained after a 20-minute fetal heart tracing; then the exercise session was performed. Immediately after the exercise session ended, the participants returned to the semirecumbent, leftward tilt position for ultrasound examination. Uterine artery measures were obtained 3.4±0.9 minutes (mean±SD) postexercise. Forty-five healthy pregnant women participated in the study: 30 regular exercisers and 15 nonexercisers. For the moderate-intensity session, mean gestational age was 31.1 and 31.7 weeks for the exercisers and nonexercisers, respectively. Mean uterine artery Doppler indices (pulsatility index, resistance index, systolic/diastolic ratio) did not significantly change with exercise. For the vigorous-intensity session, the average gestational age was 31.5 weeks. After vigorous activity, all mean uterine artery Doppler indices showed reductions postexercise, for example, pulsatility index decreased from 0.63±0.12 to 0.58±0.12 (P=.04). Individually prescribed exercise according to guidelines for pregnant women does not adversely alter uterine artery Doppler values, suggesting that uterine blood flow is not reduced as a result of exercise.

Effect of Oxygen vs Room Air on Intrauterine Fetal Resuscitation

Two-thirds of women in labor receive supplemental oxygen to reverse perceived fetal hypoxemia and prevent acidemia. Oxygen is routinely administered for category II fetal heart tracings, a class of fetal tracing used to designate intermediate risk for acidemia. This liberal use of oxygen may not be beneficial, particularly because neonatal hyperoxygenation is harmful. To test the hypothesis that room air is noninferior to oxygen in improving fetal metabolic status among patients with category II fetal heart tracings. This was a randomized, unblinded noninferiority clinical trial conducted between June 2016 and July 2017 in the labor and delivery ward of a single tertiary care center. Women with singleton pregnancies at 37 weeks' gestational age or more who were admitted for delivery were eligible. Of those who met inclusion criteria, the patients who developed category II tracings in labor that necessitated intrauterine resuscitation were randomized in a 1:1 ratio to room air or oxygen. Analyses were intention-to-treat. The oxygen group received 10 L of oxygen per minute by nonrebreather facemask until delivery. The room air group was exposed to room air only without a facemask. The primary outcome was umbilical artery lactate, a marker of metabolic acidosis and neonatal morbidity. Noninferiority was defined as a mean difference between groups of less than 9.0 mg/dL (1.0 mmol/L). Secondary outcomes were other umbilical artery gases, cesarean delivery for nonreassuring fetal status, and operative vaginal delivery. Of the 705 patients who met inclusion criteria, 277 (39.3%) were enrolled on admission. During labor, 114 patients (41.2% of the enrolled patients) developed category II tracings and were randomized to room air (57 patients; 50.0% of the randomized patients) or oxygen (57 patients; 50.0% of the randomized patients). A total of 99 patients (86.8% of the randomized patients) with paired cord gases were included in the modified intention-to-treat analysis. The 99 patients included 76 African American women (77%); mean (SD) age was 27.3 (6.3) years in the oxygen group and 27.8 (5.3) years in the room air group. There was no difference in umbilical artery lactate between the group on oxygen and the group on room air (mean, 30.6 mg/dL [95% CI, 27.0 to 34.2 mg/dL] vs 31.5 mg/dL [95% CI, 27.9 to 36.0 mg/dL]); P = .69). The mean difference in lactate was 0.9 mg/dL (95% CI, -4.5 to 6.3 mg/dL), which was within the noninferiority margin. There was no difference in other umbilical artery gas components or mode of delivery between groups. Among patients with category II fetal heart tracings, intrauterine resuscitation with room air is noninferior to oxygen in improving umbilical artery lactate. The results of this trial challenge the efficacy of a ubiquitous obstetric practice and suggest that room air may be an acceptable alternative. ClinicalTrials.gov Identifier: NCT02741284.

Acute tocolysis for uterine tachysystole or suspected fetal distress

Acute tocolysis for uterine tachysystole or suspected fetal distress

Accuracy of immediate antepartum ultrasound estimated fetal weight and its impact on mode of delivery and outcome - a cohort analysis

BackgroundThe aim of the study was to investigate the accuracy of ultrasound-derived estimated fetal weight (EFW) and to determine its impact on management and outcome of delivery.MethodsIn this single-center cohort analysis, women with a singleton term pregnancy in the beginning stages of labor were included. Women with immediately antepartum EFW (N = 492) were compared to women without ultrasound (N = 515).ResultsEFW was correct (deviation from birth weight ≤ 10%) in 72.2% (355/492) of patients with fetal biometry; 19.7% (97/492) were underestimated, and 8.1% (40/492) were overestimated. Newborns with a lower birth weight were more frequently overestimated, and newborns with higher birth weight were more frequently underestimated. The mean difference between EFW and real birth weight was − 114.5 g (standard deviation ±313 g, 95% confidence interval 87.1–142.0). The rate of non-reassuring fetal heart tracing (9.8% vs. 1.9%, P < 0.001) and of caesarean delivery (9.1% vs. 5.0%, P = 0.013) was higher in women with EFW. Overestimation was associated with an increased risk for delivery by caesarean section (odds ratio 2.80; 95% confidence interval 1.2–6.5, P = 0.017). After adjustment, EFW remained associated with increased non-reassuring fetal heart tracing (odds ratio 4.73; 95% confidence interval 2.3–9.6) and caesarean delivery (odds ratio 1.86; 95% confidence interval 1.1–3.1). The incidence of perineal tears of grade 3/4, shoulder dystocia, postnatal depression and neonatal acidosis did not differ between groups.ConclusionsAntepartum ultrasound-derived EFW does not improve maternal and fetal outcome and is therefore not recommended.

Case 3: Newborn with Asymmetric Crying Face

A 35-week-gestation male infant is delivered by cesarean section in the setting of maternal premature rupture of membrane and fetal nonreassuring heart tracing during the process of labor induction. The mother is a 30-year-old, gravida 2, para 1, healthy woman without significant medical history. Maternal antenatal testing results are normal with unremarkable prenatal complications. The neonate is the product of a nonconsanguineous marriage. At birth, the infant’s head is delivered without instrumental assistance or birth trauma. He is vigorous and cries immediately after birth. Resuscitation efforts include a brief period of continuous positive airway pressure and oxygen support for increased work of breathing and desaturation; however, the infant recovers quickly and is transferred to the sick newborn unit in room air. His Apgar scores are 8 and 9 at 1 and 5 minutes, respectively. Physical examination reveals a nondistressed premature infant with normal vital parameters. His birthweight, length, and occipitofrontal circumference are 1,840 g, 39 cm, and 31.5 cm, respectively. He is found to have an asymmetric crying face. When he is quiet or sleeping, his face appears symmetric. However, when he cries, the left corner of the mouth is drawn to the left and downward while the right corner does not move. The forehead wrinkling, nasolabial fold depth, and eye closure remain intact and equal on both sides (Fig 1). All extraocular muscle movements are intact. He has an overfolded helix with squared superior portion of helix of bilateral ears and microretrognathia (Fig 2). Other physical examination findings are unremarkable. There is no history of a similar condition on both sides of the family. Figure 1. When the infant is at rest, the face appears symmetrical (left). When the …

Risk factors for nonreassuring fetal heart rate tracings after artificial rupture of membranes in spontaneous labor.

We aimed to characterize factors associated with nonreassuring fetal heart (FHR) tracings after artificial rupture of membranes (AROM), during the active phase of labor. Delivery charts of patients who presented in spontaneous labor, at term, between 2015 and 2016 were reviewed. We identified cases in which AROM was performed during the active stage of labor. We compared deliveries with a normal FHR and those who developed nonreassuring FHR. Nonreassuring FHR was defined as fetal tracing that necessitated intrauterine resuscitation, which included: oxytocin withheld, amnioinfusion, or immediate instrumental or cesarean birth. Of 664 deliveries, nonreassuring FHR occurred in 141 (21.2%) and normal FHR in 523 (78.7%). Both groups were notable for similar maternal characteristics and a similar gestational age. Epidural block was significantly more common in the nonreassuring FHR group (P<.001), as was meconium during delivery (P=.01). Deliveries in the nonreassuring FHR group were characterized by significantly lower Bishop scores at AROM. Mean birthweight was significantly lower in the nonreassuring FHR group (3201±418 vs 3342±376g, P<.001), yet, neonatal outcome did not differ between the groups. In a multivariate logistic regression model, nulliparity, AROM at a station lower than -2, and increased birthweight were all significantly associated with a decreased rate of nonreassuring FHR, while prolonged duration from AROM to delivery and oxytocin augmentation significantly increased the risk for nonreassuring FHR. Nonreassuring FHR after AROM during delivery is associated with parity, fetal station at AROM, birthweight, and oxytocin augmentation.

Intrauterine Growth Restriction in the Triad: Understanding Outcomes Associated with Differential Management of Severe Early IUGR

Objective:&#x0D; Preterm delivery of growth restricted (IUGR) fetuses prior to 32 wks is rarely indicated, occurring in &lt;1.9% of all pregnancies. We sought to determine if delaying delivery until non-reassuring fetal heart tracing (NRFT) increases adverse outcomes.&#x0D; Materials and Methods:&#x0D; This is a cohort of pregnant women with IUGR identified prior to 32wks. Serial fetal growth and umbilical artery Doppler (UAD) were assessed. Two groups were compared: those delivered for abnormal UAD studies and those delivered for non-reassuring fetal heart tracing (NRFHT). Fetuses with absent (AEDF) or reversed end diastolic flow (REDF) were placed on continuous monitoring until delivery. Maternal comorbidities, delivery indications, and neonatal outcomes were compared between the 2 groups. T-test and Chi-square were performed where appropriate.&#x0D; Results:&#x0D; 43 singleton gestations with IUGR were identified at &lt;32 weeks gestation from 2012-2015. Pregnancies were excluded for multiple gestation or when delivered for maternal deterioration. Mean GA at diagnosis 24.7 +/-3.1wks (range 18-30.3wks). 30 delivered for abnormal UAD and 13 for NRFT. Pregnancy characteristics were similar between groups. Those women who progressed 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 for abnormal UAD did not decrease requirement for CPR at delivery or incidence of IVH, RDS, or death. Although not statistically significant, the length of stay was 50.9 days in those delivered for Doppler while 61.2 days in the group delivered emergently (p=0.23); see Table 1.&#x0D; Conclusion:&#x0D; Expectant management for fetal growth restriction and 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.

8: Oxygen for category ii intrauterine fetal resuscitation: a randomized, noninferiority trial

Approximately 2/3 of laboring women receive supplemental oxygen (O2) in an attempt to reverse perceived fetal hypoxemia and prevent acidosis. O2 supplementation is routinely used in patients with Category II fetal heart tracings (FHT). However, this liberal use of intrapartum O2 may not be beneficial, particularly since hyperoxygenation in neonates is harmful. We tested the hypothesis that room air (RA) for Category II FHT is not worse than O2 in reducing umbilical artery (UA) lactate, a marker of metabolic acidosis and neonatal morbidity. This was a randomized controlled noninferiority trial conducted from June 2016 to June 2017. Singleton pregnancies ≥ 37 weeks with Category II FHT necessitating intrauterine resuscitation in active labor (≥6cm) were randomized to RA or 10L/min O2 by face mask until delivery. The primary outcome was UA lactate measured by cord gases collected at delivery. Secondary outcomes were other UA gas components, cesarean delivery for nonreassuring fetal status (NRFS), and operative vaginal delivery. Assuming a mean UA lactate of 3.5 ± 1.6 mmol/L in patients with Category II FHT, 98 patients were needed for 90% power to detect non-inferiority with a margin of 30% and 1-sided alpha of 0.025. We increased the sample size to 114 patients to accommodate 15% loss to unattainable cord gases. Noninferiority was declared if the mean difference in lactate between RA and O2 was <1.0 mmol/L. Analysis was by intention-to-treat. Of the 114 patients randomized, 99 with paired cord gases were included in the intention-to-treat analysis; 48 O2 and 51 RA. There was no difference in mean UA lactate between patients randomized to O2 and RA (mean [95%CI], 3.4 [3.0, 3.8] vs 3.5 [3.1, 4.0]), P=0.69). The mean difference in UA lactate was 0.1 mmol/L (95% CI -0.5, 0.7), which is within the non-inferiority margin (Figure). There were no differences in other UA gas components, operative vaginal delivery or cesarean delivery for NRFS between groups (Table). Among patients with Category II FHT in active labor, intrauterine resuscitation with RA is not inferior to O2 in improving UA lactate. (ClinicalTrials.gov number NCT02741284).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

288: Fetal scalp lactate and digital scalp stimulation among those with non-reassuring fetal heart tracings: A decision analytic model

288: Fetal scalp lactate and digital scalp stimulation among those with non-reassuring fetal heart tracings: A decision analytic model

Comparison of 25 Microgram of Sublingual Misoprostol with 25 Microgram Vaginal Misoprostol for Induction of Labour at Term

Comparison of 25 Microgram of Sublingual Misoprostol with 25 Microgram Vaginal Misoprostol for Induction of Labour at Term

Intrapartum factors associated with neonatal hypoxic ischemic encephalopathy: a case-controlled study

BackgroundNeonatal encephalopathy (NE) affects 2–4/1000 live births with outcomes ranging from negligible neurological deficits to severe neuromuscular dysfunction, cerebral palsy and death. Hypoxic ischemic encephalopathy (HIE) is the sub cohort of NE that appears to be driven by intrapartum events. Our objective was to identify antepartum and intrapartum factors associated with the development of neonatal HIE.MethodsHospital databases were searched using relevant diagnosis codes to identify infants with neonatal encephalopathy. Cases were infants with encephalopathy and evidence of intrapartum hypoxia. For each hypoxic ischemic encephalopathy case, four controls were randomly selected from all deliveries that occurred within 6 months of the case.ResultsTwenty-six cases met criteria for hypoxic ischemic encephalopathy between 2002 and 2014. In multivariate analysis, meconium-stained amniotic fluid (aOR 12.4, 95% CI 2.1–144.8, p = 0.002), prolonged second stage of labor (aOR 9.5, 95% CI 1.0–135.3, p = 0.042), and the occurrence of a sentinel or acute event (aOR 74.9, 95% CI 11.9-infinity, p < 0.001) were significantly associated with hypoxic ischemic encephalopathy. The presence of a category 3 fetal heart rate tracing in any of the four 15-min segments during the hour prior to delivery (28.0% versus 4.0%, p = 0.002) was more common among hypoxic ischemic encephalopathy cases.ConclusionProlonged second stage of labor and the presence of meconium-stained amniotic fluid are risk factors for the development of HIE. Close scrutiny should be paid to labors that develop these features especially in the presence of an abnormal fetal heart tracing. Acute events also account for a substantial number of HIE cases and health systems should develop programs that can optimize the response to these emergencies.

Should delivery timing for repeat cesarean be reconsidered based on dating criteria?

Purpose: We sought to examine if the method of pregnancy dating at five increasing term gestational ages is associated with increasing neonatal morbidity.Materials and methods: A cohort of women who underwent elective repeat cesarean delivery at ≥37 weeks’ gestation were identified from the NICHD MFMU Network registry. We excluded women who were in labor, those carrying a fetus with a congenital anomaly, those with a non-reassuring fetal heart tracing, and those with preeclampsia, preexisting chronic hypertension or diabetes. Composite neonatal morbidity was defined for our study as any of the following: NICU admission, hypotonia, meconium aspiration, seizures, need for ventilator support, NEC, RDS, TTN, hypoglycemia, or neonatal death. We compared composite neonatal morbidity rates among infants born at five different gestational age cutoffs according to their method of pregnancy dating.Results: At 39 and 40 weeks’ gestation, the lowest rate of neonatal complications was seen in pregnancies dated by first trimester ultrasound (5.8% and 5.5%, respectively), while those with the highest neonatal morbidity rates were seen when dated by a second or third trimester ultrasound (8.1% and 6.0%, respectively); p < .001. Additionally within each pregnancy dating category, the neonatal morbidity rates declined from 37 to 40 weeks’ gestation and then significantly increased at 41 + 0 weeks’ gestation.Conclusion: Even with suboptimal dating methods, amongst women undergoing elective repeat cesarean delivery, neonatal morbidity was lowest when delivery occurred between 40 and 40 + 6 weeks gestation.

Case 1: Neurologic Effects on a Newborn Exposed to Marijuana in Pregnancy

An early term male neonate was born at 38 weeks of gestation by cesarean delivery due to a category 2 fetal heart tracing found in his 22-year-old mother, who did not receive prenatal care. Prenatal history is significant for maternal marijuana use, cigarette smoking, and group B Streptococcus colonization. At delivery, the infant is vigorous with Apgar scores of 9 and 9 at 1 and 5 minutes, respectively, birthweight of 2,640 g, and no dysmorphic features noted on physical examination. Prenatal marijuana exposure is confirmed by maternal and infant urine toxicology results. In the first postnatal day, despite several attempts at feeding, a poor suck and feeding pattern are noted. The neonate is transferred to the NICU for feeding and further evaluation. In the NICU, the …

A randomised comparison of bolus phenylephrine and ephedrine for the management of spinal hypotension in patients with severe preeclampsia and fetal compromise

BackgroundStudies in healthy patients undergoing elective caesarean delivery show that, compared with phenylephrine, ephedrine used to treat spinal hypotension is associated with increased fetal acidosis. This has not been investigated prospectively in women with severe preeclampsia. MethodsPatients with preeclampsia requiring caesarean delivery for a non-reassuring fetal heart tracing were randomised to receive either bolus ephedrine (7.5–15mg) or phenylephrine (50–100µg), to treat spinal hypotension. The primary outcome was umbilical arterial base excess. Secondary outcomes were umbilical arterial and venous pH and lactate concentration, venous base excess, and Apgar scores. ResultsAmong 133 women, 64 who required vasopressor treatment were randomised into groups of 32 with similar patient characteristics. Pre-delivery blood pressure changes were similar. There was no difference in mean [standard deviation] umbilical artery base excess (−4.9 [3.7] vs −6.0 [4.6] mmol/L for ephedrine and phenylephrine respectively; P=0.29). Mean umbilical arterial and venous pH and lactate concentrations did not significantly differ between groups (7.25 [0.08] vs 7.22 [0.10], 7.28 [0.07] vs 7.27 [0.10], and 3.41 [2.18] vs 3.28 [2.44] mmol/L respectively). Umbilical venous oxygen tension was higher in the ephedrine group (2.8 [0.7] vs 2.4 [0.62]) kPa, P=0.02). There was no difference in 1- or 5-min Apgar scores, numbers of neonates with 1-min Apgar scores <7 or with a pH <7.2. ConclusionsIn patients with severe preeclampsia and fetal compromise, fetal acid-base status is independent of the use of bolus ephedrine versus phenylephrine to treat spinal hypotension.

Autonomic Dysreflexia in the Peripartum Patient: A Multidisciplinary and Interprofessional Simulation Scenario.

This case is one of an eight-case multidisciplinary curriculum designed and implemented at the University of Ottawa by simulation educators with specialty training in obstetrics and gynecology (ob/gyn) and anesthesiology. Consultation with a nurse educator maintained quality and relevance of objectives for nursing participants.The curriculum was prepared to train ob/gyn and anesthesiology residents and nurses to hone crisis resource management skills and to recognize and manage rare/critical medical events in an obstetrical setting. Obstetricians, anesthesiologists, and nurses often work together in acute, high-stakes situations and this curriculum provides a safe environment to practice team-based management of such emergencies.Over an eight-year period, this curriculum has been executed in scenario couplets on a four-year cycle to allow ob/gyn and anesthesiology residents exposure to all scenarios during a five-year residency beginning in their second year. Prospective evaluation data has been positive. For example, over 90% of participants rated these simulations to be 5 out of 5 for “Was an effective use of my educational time” and “Will influence/enhance my future practice”.In this scenario, participants must recognize and manage a parturient with spinal cord injury in active labour who develops autonomic dysreflexia. The fetal heart tracing becomes abnormal and the team must respond with urgent delivery. This scenario requires a mannequin for a pelvic exam and a pregnant abdomen.This simulation case includes a case template, critical actions checklist, debriefing guide, summary of key medical content, and an evaluation form for learners to provide feedback.

Is the New Terminology of “Triple I” For Chorioamnionitis Really Different? [10O

INTRODUCTION: The proposed terminology of “Triple I” was developed to clarify the heterogeneity of manifestations associated with chorioamnionitis. This study aims to evaluate if those with a concordant (both histological and clinical) diagnosis of chorioamnionitis are different from those that do not meet the confirmed “Triple I” criteria. METHODS: Retrospective three-year analysis of term patients with chorioamnionitis classified as: 1) clinical (CCA)–via ICD-9 codes, 2) histological (HCA), 3) concordant. Variables evaluated: age, gravidity, white blood cell (WBC) count, gestational age, Group B Strep, rupture of membranes, epidural, highest temperature, fetal heart tracing prior to cesarean, Apgar score, infant sex, special care nursery (SCN) admission and presence of bandemia in infant. Analysis by multinomial logistic regression. RESULTS: In the CCA, HCA and concordant group there were 27, 51 and 23 subjects, respectively. When compared to the concordant group, three variables had statistical significance (P &lt; 0.05). In CCA and HCA, for every one-unit increase in WBC they are 18.6% (95% CI 0.65-0.95) and 17.3% (95% CI 0.69-0.99) less likely to match with concordant group, respectively. The HCA group is 96.6% (95% CI 0.003-0.387) less likely to be a primigravida and are 12.3 times (95% CI 2.8-53.6) more likely not to have infant in SCN. CONCLUSION: Our analysis finds the concordant group (confirmed Triple-I) is similar to CCA and HCA group. In term patients, the terminology “Triple I” does not bring clarity to the diagnosis of chorioamnionitis. Therefore, additional research is needed to refine the diagnosis criteria. This will improve maternal and neonatal management by providers.

Reduction of Nulliparous Term Singleton Vertex Cesarean Deliveries With Feedback and Monitoring [23Q

INTRODUCTION: Rates of cesarean deliveries have been increasing, and substantial regional variation for total cesarean delivery rates is 22.6% to 39.7%. The objective of this study is to reduce primary cesarean deliveries in nulliparous term singleton vertex (NTSV) births through a feedback and monitoring program. METHODS: This retrospective chart review involves analysis of all nulliparous term singleton vertex cesarean deliveries at Sacred Heart Health System from January 2015 through March 2016. Key components were extracted during chart review based on recommendations by the American College of Obstetricians and Gynecologists/SMFM Obstetrics Consensus. Individual monthly cesarean rates compared to blinded peers were then provided to physicians from June 2016 to present. RESULTS: From January 2015 through October 2015, there were a total of 308 NTSV cesarean deliveries. Indications included labor dystocia (28.1%), non-reassuring fetal heart tracing (NRFHT) (21.6%), and suspected fetal macrosomia (4.9%). In cases of suspected fetal macrosomia, an average birth weight of 4,140 grams was noted. Only 16.7% of the 66 cases of NRFHT had interventions documented prior to cesarean delivery. Of the 86 cases involving labor dystocia, only 10.5% met the definition of labor arrest or prolongation as defined by the American College of Obstetricians and Gynecologists/SMFM Obstetrics Consensus. Operative deliveries were attempted in only 2 cases of labor dystocia prior to cesarean delivery. CONCLUSION: Based on retrospective chart review, modifiable opportunities for decreasing cesarean deliveries in our institute were identified. Planned monthly feedback from June 2016 to June 2017 will be provided to physicians to trend the overall cesarean rates among nulliparous term singleton vertex deliveries.

Hyperreactio Luteinalis: Possible Cause of Intrahepatic Cholestasis and Disseminated Intravascular Coagulation [22B

INTRODUCTION: Hyperreactio luteinalis (HL) is a rare finding in pregnancy consisting of enlarged multicystic ovaries capable of producing excess human chorionic gonadotropin (hCG) and androgens. We present a patient with HL and twin gestation complicated by intrahepatic cholestasis of pregnancy (ICP) who presented to our institution with disseminated intravascular coagulation (DIC). METHODS: Case Report. RESULTS: A 31-year-old gravida 1 para 0 at 35 weeks 5 days gestation with dichorionic/diamniotic twins, presented to our institution for evaluation due to elevated liver enzymes. On presentation, the patient was jaundiced but asymptomatic with normal vital signs. Fetal assessment revealed category three fetal heart tracing for both fetuses. The patient underwent emergent cesarean delivery. During surgery, bilateral enlarged multicystic ovaries were noted and lab values were consistent with disseminated intravascular coagulation. The patient was treated with fresh frozen plasma and cryoprecipitate then transferred to the intensive care unit. Postoperatively, the patient was noted to have elevated bile acids, bilirubin, androstenedione and aldosterone. CONCLUSION: Studies demonstrate that estrogens play a role in development of ICP and can impair bile acid secretion. HL produces high levels of androgens that are converted to estrogens by precursors from the fetal adrenal gland and placental aromatase. We propose estrogens produced by HL lead to the development of ICP. Excess estrogen production throughout pregnancy may lead to chronic bile acid accumulation and contribute to development of DIC.

Are Baseline Elevations in Reactive Non-Stress Testing of Diabetic Mothers an Indicator of Fetal Compromise? [4B

INTRODUCTION: To determine if baseline fetal tachycardia in reactive non-stress test (NST) is an indicator of fetal compromise in diabetic pregnancies. METHODS: Retrospective analysis of 145 diabetic mothers including gestational and pregestational diabetics from 2013-2016. Demographics included age, BMI, race, and gestational age. We reviewed the NST of patients &gt;34 weeks of gestation and within 7 days of delivery. Baseline fetal heart rate (FHR) and the presence of 15x15mm accelerations were noted. Outcome measures included mode and indications for delivery. RESULTS: Of 145 diabetic patients, 55 patients had a baseline &gt;150bpm. 47 of them had reactive tracings. Of those 47 patients, 35 underwent cesarean deliveries (C/S) (74.4%). Two patients with baseline tachycardia were diagnosed with IUFD on subsequent testing. 17 of 47 C/S performed were for non-reassuring tracing (36.17%). In comparison, 92 of 145 diabetic patients had baseline FHR &lt; 150 bpm. 68 of 92 patients had reactive tracings. Of these 68 patients, 40 underwent C/S (58.82%), 8 were for non-reassuring fetal heart tracing (11.76%). The C/S rate for non-reassuring fetal heart tracing was significantly higher in the diabetics with elevated baseline FHR and reactive tracings in comparison to those with baseline FHR &lt; 150bpm and reactive tracings, P &lt; 0.05. CONCLUSION: The C/S rate secondary to non-reassuring fetal heart tracings was significantly higher in diabetics with elevated baseline FHR than those with baseline FHR &lt; 150bpm even in the setting of a reactive tracing. This may be clinically relevant in antenatal testing of diabetic mothers as it implies that elevation in baseline heart rate may indicate fetal jeopardy.

Cesarean Sections for Abnormal Fetal Heart Tracings: Setting Appropriateness Indicators Based on Neonatal Outcome [11N

INTRODUCTION: Fetal distress is often suspected solely on atypical/abnormal cardiotocography which is subject to inter-individual variability. We identified C-sections performed for atypical/abnormal cardiotocography and compared neonatal outcomes to C-sections performed for labor dystocia. Indicators of C-section appropriateness were developed and applied. METHODS: A retrospective cohort study was conducted using data from Ontario's Perinatal database. Primary outcomes were C-section rates for fetal distress and neonatal outcomes (arterial pH, Apgars, neonatal resuscitation, NICU admission). A C-section for abnormal/atypical cardiotocography was “appropriate” if one or more of these outcomes occurred: 1-minute Apgar &lt; 3, 5-minute Apgar &lt; 7, arterial pH &lt; 7.20, resuscitation required, or NICU admission. RESULTS: Between 2006-2014, 146,676 primary C-sections were performed; 20% were performed for atypical/abnormal cardiotocography. Compared with C-sections for labor dystocia, there were significant differences in maternal age, parity, induction of labor, and level of care (p &lt; 0.001). Odds of newborn resuscitation (ORadj 1.48, CI 1.41-1.54) and NICU admission (ORadj 2.21, CI 2.08-2.34) were higher when indication was atypical/abnormal cardiotocography. Less than half (42.3%) of these neonates had at least one of the criteria used to determine C-section “appropriateness.” Rate of “appropriate” C-sections differed by size of center (p &lt; 0.001), induction of labor (p=0.0027), oxytocin use (p &lt; 0.001), level of care (p &lt; 0.0001), and fetal surveillance method (p=0.004). CONCLUSION: In the absence of objective measures of intrauterine fetal well-being, C-sections may be performed for fetal distress when they are not required. Developing indicators for C-section appropriateness may guide strategies to reduce C-section rates.