Fetal Surveillance Research Articles

412: Close fetal surveillance decreased stillbirth rate in pregnancies with fetal Down syndrome

412: Close fetal surveillance decreased stillbirth rate in pregnancies with fetal Down syndrome

Baby on board: what you need to know about pregnancy in the hemoglobinopathies

Abstract Pregnancy poses a unique challenge to patients with sickle cell disease and β-thalassemia, who often have exacerbations of hemolysis or anemia during the gestational period, experience higher rates of obstetric and fetal complications, and may have distinct underlying comorbidities related to vasculopathy and iron overload that can endanger maternal health. Optimal management of pregnant women with hemoglobinopathies requires both an understanding of the physiologic demands of pregnancy and the pathophysiology of disease-specific complications of inherited blood disorders. A multidisciplinary team of expert hematologists and high-risk obstetricians is therefore essential to ensuring appropriate antenatal maternal screening, adequate fetal surveillance, and early recognition of complications. Fortunately, with integrated and targeted care, most women with sickle cell disease and β-thalassemia can achieve successful pregnancy outcomes.

Prediction of neonatal acidosis by ductus venosus Doppler pattern in high risk pregnancies

Abstract Study objective Evaluate whether ductus venosus (DV) Doppler velocimetry might be a good diagnostic tool of neonatal acidosis than umbilical artery (UA) and middle cerebral artery (MCA) blood velocities. Design Prospective observational study. Setting High risk pregnancy unit of Ain Shams University Maternity Hospital. Patients Thirty high-risk pregnant patients in their third trimester. Method Recording of DV, UA and MCA blood velocity in complicated pregnancies referred to umbilical artery (UA) velocimetry as one aspect of fetal surveillance. Measurements and main results DV S/D ratio was not reliable to predict hypoxia (AUC 66%), PI was weak (73%), but RI was reliable to predict hypoxia (AUC 88%). On comparing the diagnostic ability of DV RI and MCA S/D, DV RI showed a diagnostic ability than MCA S/D, AUC 88% and 82% respectively. Conclusion Abnormal DV blood velocity is more frequently recorded in high-risk pregnancies than UA, MCA blood velocities. Ductus venosus resistance index (DV RI) appears to be a better predictor of perinatal outcome than MCA S/D.

Antenatal management and outcomes of gastroschisis in the UK

The birth prevalence of gastroschisis is increasing worldwide, yet little evidence exists concerning the optimal monitoring strategies after diagnosis. The aim of this study was to describe the U.K. prevalence, antenatal management and outcomes of affected pregnancies. Cases were identified throughout the U.K. between October 2006 and September 2007, using three different sources. The overall birth prevalence of gastroschisis was 4.2 cases per 10, 000 total births (95% CI 3.6-4.8). Infants were variably monitored with growth scans (90%), umbilical artery Doppler ultrasound (85%), cardiotocography (65%) and biophysical profile (27%). Bowel measurements were undertaken for only 113 infants (52%). Eighty-nine women (43%) were induced and 63 (31%) laboured spontaneously. Eleven women (5%) had an elective caesarean delivery where the sole indication was fetal gastroschisis. The variability in management and paucity of evidence on antenatal monitoring approaches suggests there may be a place for randomised trials of fetal surveillance strategies in order to develop the evidence to improve outcomes for the at-risk fetus with gastroschisis. This study suggests that case ascertainment by regional congenital anomaly registers is high; extension of the coverage of these registers to the entire cohort of U.K. births would facilitate ongoing surveillance and research.

Independent risk factors for infants who are small for gestational age by customised birthweight centiles in a multi‐ethnic New Zealand population

Infants born small for gestational age (SGA) by customised birthweight centiles are at increased risk of adverse outcomes compared with those SGA by population centiles. Risk factors for customised SGA have not previously been described in a general obstetric population. To determine independent risk factors for customised SGA in a multi-ethnic New Zealand population. We performed a retrospective cohort analysis of prospectively recorded maternity data from 2006 to 2009 at National Women's Health, Auckland, New Zealand. After exclusion of infants with congenital anomalies and missing data, our final study population was 26,254 singleton pregnancies. Multivariable logistic regression analysis adjusted for ethnicity, body mass index, maternal age, parity, smoking status, social deprivation, hypertensive disease, antepartum haemorrhage (APH), diabetes and relevant pre-existing medical conditions. Independent risk factors for SGA included obesity (adjusted odds ratio 1.24 [95% CI 1.11-1.39] relative to normal weight), maternal age≥35years (1.16 [1.05-1.30] relative to 20-29years), nulliparity (1.13 [1.04-1.24] relative to parity 1), cigarette smoking (2.01 [1.79-2.27]), gestational hypertension (1.46 [1.21-1.75]), pre-eclampsia (2.94 [2.49-3.48]), chronic hypertension (1.68 [1.34-2.09]), placental abruption (2.57 [1.74-3.78]) and APH of unknown origin (1.71 [1.45-2.00]). Gestational diabetes (0.80 [0.67-0.96]) and type 1 diabetes (0.26 [0.11-0.64]) were associated with reduced risk. We report independent pregnancy risk factors for customised SGA in a general obstetric population. In contrast to population SGA, obesity is associated with increased risk. Our findings may help identify pregnancies that require increased fetal growth surveillance.

Peripartum Consultations Expand the Role of the Fetal/Neonatal Neurologist

The peripartum period entails the next prenatal interval when novel neuroprotective strategies will be designed and tested. Research development will lead to novel evaluations for maternal-fetal pairs who require inpatient treatment and possible delivery for worsening or acute neurologic problems. Future studies should critically compare serial fetal surveillance assessments with postnatal clinical findings to detect and treat more accurately fetal/neonatal brain disorders that begin or worsen during the peripartum period. Clinical management decisions require an interdisciplinary treatment approach. Protocols may begin before and during parturition, and continue through neonatal resuscitation and early postnatal periods into infancy. Appropriate choices of preventive, rescue, and repair neuroprotective interventions must consider both the timing and etiologies of encephalopathies in the context of maternal, fetal, placental, and neonatal diseases.

Correlation between abnormal placental appearance at routine 2nd trimester ultrasound scan and histological examination of the placenta after birth

Ultrasound imaging of the placenta and its relationship to poor perinatal outcome has been studied since 1973. Studies have predominantly focussed on placental morphology in the third trimester or in high-risk pregnancies. We aimed to correlate abnormal placental appearances identified in the second trimester with histological appearances. We present four cases of abnormal placental morphology detected at the 20 week routine ultrasound scan in low-risk women and relate them to histological origins, which often involved areas of villous infarction. Abnormal placental appearances at routine second trimester anomaly ultrasound scans might identify women with placental dysfunction who merit increased fetal surveillance in the third trimester.

Fetal infection: a pragmatic approach to recognition and management

Viruses and parasites can be transmitted from a pregnant woman to her fetus via the placenta and can affect development of the fetus. Maternal infection is often asymptomatic or mild. The implications for the fetus are dependent on gestation, stage of organogenesis, the presence of maternal immunity and the virus type. Fetal infections are a potentially preventable cause of perinatal morbidity and mortality. Prenatal diagnosis is often initiated due to exposure of mother to an infectious contact. Management involves confirmation of maternal infection and careful consideration of the risks and benefits of fetal diagnosis, fetal surveillance, intrauterine treatment and possibly termination of pregnancy. Empathic and effective counselling of the parents is crucial and a multidisciplinary approach is important for optimal care. This review uses cases of two fetal infections to highlight a pragmatic approach to prenatal diagnosis and management. There is also an overview of three other fetal infections which can potentially cause serious morbidity and mortality.

Ambulatory Management of Chronic Hypertension in Pregnancy

Chronic hypertension in pregnancy is one of the most common medical diseases affecting pregnancy. It is associated with serious maternal and fetal complications, including superimposed pre-eclampsia, fetal growth restriction, premature delivery, placental abruption, and stillbirth. Baseline evaluation as early as possible is important to differentiate women with essential hypertension from those with severe hypertension, coexisting end-organ damage, and secondary causes of hypertension, as their risks of poor outcomes are increased. An optimal plan for maternal treatment and fetal surveillance can then be formulated. Coordination of care after delivery is important for long-term maternal health and future pregnancies.

Corrigendum to “Book Review: L.s. Baker, M.C. Beaves, D.J. Trickey, E.M. Wallace, Fetal Surveillance: A Practical Guide, RANZCOG, Melbourne.” [Women Birth 24 (2011) 137

Corrigendum to “Book Review: L.s. Baker, M.C. Beaves, D.J. Trickey, E.M. Wallace, Fetal Surveillance: A Practical Guide, RANZCOG, Melbourne.” [Women Birth 24 (2011) 137

P08.18: The characteristics of maternal fetal Doppler in congenital heart disease

To detect the hemodynamics characteristics of moternal fetal doppler blood flow surveillance in congenital heart disease (CHD). This is a retrospective study of 132 singleton pregnancy women due to fetal CHD. Detailed maternal fetal Doppler were performed after fetal echocardiography. We noted the PI of fetal venous duct (DV), free segment of umbilical vein (UV) and intra-abdominal segment, middle cerebral artery (MCA), umbilical artery (UA) and bilateral uterine artery (AU) and congenital heart malformations. According to PI of these vessels, the umbilical artery blood flow classification (BFC), uterine artery score (UAS), placental score (PLS) are done. 1. 27 cases with simple septal defect fetus and 51 cases with complex CHD fetus have normal PI fetal UA, DV and MCA (BFC = 0) compared with normal fetus. 2. 38 cases of complex CHD with cardiothoracic ratio > 0.35, TV and MV regurgitation, have significantly increased PI of UA, DV, and PI of MCA reduced. BFC and PLS both > 0 (P < 0.001). 3. There are 9 cases with chronic arrhythmic, BFC > 0 and PLS > 0. The fetal venous system Doppler is the first change, Which give a further demonstration that the abnormality of CHD fetus circulation will cause the fetal-placental circulation corresponding changes, and make the placental function reduce and fetus damage.

P08.19: Perinatal results comparing small for gestational age (SGA) fetuses and intrauterine growth restriction (IUGR) fetuses

Objectives: To detect the hemodynamics characteristics of moternal fetal doppler blood flow surveillance in congenital heart disease (CHD). Methods: This is a retrospective study of 132 singleton pregnancy women due to fetal CHD. Detailed maternal fetal Doppler were performed after fetal echocardiography. We noted the PI of fetal venous duct (DV), free segment of umbilical vein (UV) and intra-abdominal segment, middle cerebral artery (MCA), umbilical artery (UA) and bilateral uterine artery (AU) and congenital heart malformations. According to PI of these vessels, the umbilical artery blood flow classification (BFC), uterine artery score (UAS), placental score (PLS) are done. Results: 1. 27 cases with simple septal defect fetus and 51 cases with complex CHD fetus have normal PI fetal UA, DV and MCA (BFC = 0) compared with normal fetus. 2. 38 cases of complex CHD with cardiothoracic ratio >0.35, TV and MV regurgitation, have significantly increased PI of UA, DV, and PI of MCA reduced. BFC and PLS both >0 (P 0 and PLS >0. Conclusions: The fetal venous system Doppler is the first change, Which give a further demonstration that the abnormality of CHD fetus circulation will cause the fetal-placental circulation corresponding changes, and make the placental function reduce and fetus damage.

What is the gold standard for intrapartum fetal monitoring?

The health authorities of Stockholm county recently published a Health Technology Assessment report: "Fetal monitoring with computerized STAN analysis during labor - a systematic review" with the aim to ensure that high quality research information on costs, effectiveness and broader impact of health technologies is analysed and presented in the most efficient way for those who use, manage and work in this field. The report claims to analyse available research in relation to ST interval analysis of fetal electrocardiogram (STAN) and concludes that scientific evidence for advantages of the STAN technology for maternal and fetal outcome was insufficient and that clinical use cannot be recommended and should be restricted to research protocols. The Norwegian reference group for fetal surveillance points out that the report suffers from two insufficiencies: selection bias by not providing a complete collection of the evidence for the clinical performance of the STAN technology and, secondly, that it does not provide evidence-based alternative methods.

Stillbirth in cases of severe acute maternal morbidity

ObjectiveTo determine the incidence and correlates of stillbirths among women with severe acute maternal morbidity (SAMM). MethodsIn an observational study of 728 women who had SAMM between January 2007 and December 2010 at a referral tertiary health facility in Benin, Nigeria, the incidence of stillbirth, and the clinical and demographic correlates of stillbirth were evaluated. ResultsThe rate of stillbirth among women with SAMM was 210 per 1000 deliveries. The rate among women who had uterine rupture (643 per 1000 deliveries) far exceeded other cause-specific rates of stillbirth. Unbooked status (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.3–3.8), low maternal education (OR, 2.1; 95% CI, 1.2–4.0), vaginal delivery (OR, 8.1; 95% CI, 5.1–13.0), and maternal comorbidity (OR, 12.9; 95% CI, 6.2–26.9) were factors associated with stillbirth after adjusting for confounding variables. ConclusionIn Nigeria, SAMM was found to be associated with an unacceptably high rate of stillbirth. Strategies to improve fetal surveillance among women with SAMM are necessary to address the excessively high incidence of stillbirth among these patients.

Usefulness of fetal monitoring in intrahepatic cholestasis of pregnancy: a prospective study

To study the role of fetal surveillance in intrahepatic cholestasis of pregnancy. A total of 69 women with obstetric cholestasis were included. Fetal surveillance began at 34 weeks or later at diagnosis and included daily maternal record of fetal movements, biophysical profile (i.e., non-stress test, amniotic fluid volume assessment using the four quadrant amniotic fluid index), and Doppler flow velocimetry. Fetal monitoring was done weekly before 36 weeks and biweekly after that. There were no abnormal non-stress test readings and all pregnancies had good biophysical profile. One hundred and sixty Doppler measurements [Systolic-Diastolic (S/D ratio) and Pourcelot index (PR)] were taken from 67 patients at scheduled intervals during the study period. Findings were compared to gestation matched reference values of Doppler flow velocities of umbilical artery of normal pregnant population. Fifty-six out of 160 PR indices and 33 out of 162 S/D ratio readings were above 2 SD and these results were found to be statistically significant. However, there was no significant correlation with the serum levels of alanine transaminase (r=-0.071) or with aspartate transaminase (r=0.058). Further, there was no correlation of Doppler with rates of preterm delivery or meconium-stained liquor. Doppler investigation of the umbilical artery might be of some value in recognition of the specific risk of fetal compromise in pregnancies complicated by intrahepatic cholestasis.

Lactate production as a response to intrapartum hypoxia in the growth‐restricted fetus

To analyse whether the increase in lactate in response to intrapartum hypoxia differs between small- (SGA), appropriate- (AGA) and large-for-gestational-age (LGA) fetuses. Observational cohort study. Ten obstetric units in Sweden. A cohort of 1496 women. A secondary analysis of a randomised controlled trial, in which 1496 women with fetal heart rate abnormalities, indicating fetal scalp blood sampling, were randomised to lactate analyses. After delivery, the neonates were divided according to birthweight for gestational age into SGA, AGA and LGA groups. Lactate concentration in fetal scalp blood. Acid-base balance in cord artery blood and Apgar score <7 at 5 minutes. Median lactate concentrations in the SGA, AGA and LGA groups were 3.8, 3.0 and 2.2 mmol/l, respectively (SGA versus AGA, P = 0.017; LGA versus AGA, P = 0.009). In the subgroups with scalp lactate >4.8 mmol/l (lactacidaemia), the corresponding median (range) values were 6.2 (4.9-14.6), 5.9 (4.9-15.9) and 5.7 mmol/l (5.0-7.9 mmol/l), respectively (no significant differences between the groups). The proportions of neonates with cord artery pH < 7.00, metabolic acidaemia or Apgar score <7 at 5 minutes were similar in all weight groups. SGA fetuses with fetal heart rate abnormalities have the same ability to produce lactate as a response to intrapartum hypoxia as AGA and LGA fetuses. The risk of a poor outcome associated with high lactate concentration is the same in SGA, AGA and LGA fetuses. Scalp blood lactate analysis is therefore a reliable method for intrapartum fetal surveillance of suspected growth-restricted fetuses scheduled for vaginal delivery at ≥ 34 weeks of gestation.

Restricción del crecimiento intrauterino

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Maternal and fetal complications of systemic lupus erythematosus

Key content Systemic lupus erythematosus (SLE) is an autoimmune condition that has multi‐organ involvement. It is approximately ten times more common in women than in men and is often diagnosed during the childbearing years. SLE is known to increase the risk of spontaneous miscarriage; it can also cause fetal growth restriction and increased rates of sudden intrauterine death, pre‐eclampsia and preterm delivery. Management of women with lupus nephritis can be difficult, as the disease may mimic and overlap significantly with pre‐eclampsia. Multidisciplinary management of pregnant women with SLE ensures optimal surveillance of both mother and fetus. Learning objectives To understand how to manage pregnant women with SLE. To understand the importance of pre‐pregnancy counselling for women with SLE. To understand the features and associated risk factors which increase the chance of adverse pregnancy outcome in women with SLE. To understand which therapies for SLE can be used safely in pregnancy and while breastfeeding. To understand the role of the multidisciplinary team in the care of women with SLE, particularly those with underlying organ impairment. Ethical issues When should women with SLE be advised against pregnancy? At what point should termination of pregnancy be considered if there is deterioration in maternal health in early pregnancy?

Identification of cases with adverse neonatal outcome monitored by cardiotocography versus ST analysis: secondary analysis of a randomized trial

To evaluate whether correct adherence to clinical guidelines might have led to prevention of cases with adverse neonatal outcome. Secondary analysis of cases with adverse outcome in a multicenter randomized clinical trial. Nine Dutch hospitals. Pregnant women with a term singleton fetus in cephalic position. Data were obtained from a randomized trial that compared monitoring by STAN® (index group) with cardiotocography (control group). In both trial arms, three observers independently assessed the fetal surveillance results in all cases with adverse neonatal outcome, to determine whether an indication for intervention was present, based on current clinical guidelines. Adverse neonatal outcome cases fulfilled one or more of the following criteria: (i) metabolic acidosis in umbilical cord artery (pH < 7.05 and base deficit in extracellular fluid >12 mmol/L); (ii) umbilical cord artery pH < 7.00; (iii) perinatal death; and/or (iv) signs of moderate or severe hypoxic ischemic encephalopathy. We studied 5681 women, of whom 61 (1.1%) had an adverse outcome (26 index; 35 control). In these women, the number of performed operative deliveries for fetal distress was 18 (69.2%) and 16 (45.7%), respectively. Reassessment of all 61 cases showed that there was a fetal indication to intervene in 23 (88.5%) and 19 (57.6%) cases, respectively. In 13 (50.0%) vs. 11 (33.3%) cases, respectively, this indication occurred more than 20 min before the time of delivery, meaning that these adverse outcomes could possibly have been prevented. In our trial, more strict adherence to clinical guidelines could have led to additional identification and prevention of adverse outcome.

Regimens of fetal surveillance for impaired fetal growth

Policies and protocols for fetal surveillance in the pregnancy where impaired fetal growth is suspected vary widely, with numerous combinations of different surveillance methods. To assess the effects of antenatal fetal surveillance regimens on important perinatal and maternal outcomes. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 February 2012). Randomised and quasi-randomised trials comparing the effects of described antenatal fetal surveillance regimens. Review authors R Grivell and L Wong independently assessed trial eligibility and quality and extracted data. We included one trial of 167 women and their babies. This trial was a pilot study recruiting alongside another study, therefore, a separate sample size was not calculated. The trial compared a twice-weekly surveillance regimen (biophysical profile, nonstress tests, umbilical artery and middle cerebral artery Doppler and uterine artery Doppler) with the same regimen applied fortnightly (both groups had growth assessed fortnightly). There were insufficient data to assess this review's primary infant outcome of composite perinatal mortality and serious morbidity (although there were no perinatal deaths) and no difference was seen in the primary maternal outcome of emergency caesarean section for fetal distress (risk ratio (RR) 0.96; 95% confidence interval (CI) 0.35 to 2.63). In keeping with the more frequent monitoring, mean gestational age at birth was four days less for the twice-weekly surveillance group compared with the fortnightly surveillance group (mean difference (MD) -4.00; 95% CI -7.79 to -0.21). Women in the twice-weekly surveillance group were 25% more likely to have induction of labour than those in the fortnightly surveillance group (RR 1.25; 95% CI 1.04 to 1.50). There is limited evidence from randomised controlled trials to inform best practice for fetal surveillance regimens when caring for women with pregnancies affected by impaired fetal growth.More studies are needed to evaluate the effects of currently used fetal surveillance regimens in impaired fetal growth.