Intrapartum Fetal Compromise Research Articles

OC01.01: Reducing intrapartum fetal compromise at term: results of double blind RCT of sildenafil citrate versus placebo

OC01.01: Reducing intrapartum fetal compromise at term: results of double blind RCT of sildenafil citrate versus placebo

OP04.05: Prediction of the risk of intrapartum fetal distress using maternal hemodynamics

The aim was to investigate the predictive accuracy of maternal cardiovascular variables for predicting operative delivery due to presumed fetal compromise in women undergoing induction of labour (IOL). This was a prospective cohort study conducted at St. George's University Hospital in London. Women undergoing IOL were invited to participate in the study. A USCOM-1A monitor was used for the cardiovascular evaluation of eligible women. Cardiac output (CO), cardiac index (CI), stroke volume (SV), stroke volume index (SVI), systemic vascular resistance (SVR) were assessed. Women who delivered via either caesarean or instrumental delivery with an abnormal cardiotocography tracing were evaluated in the operative delivery due to presumed fetal compromise group. A total of 99 women were recruited and four women were later excluded due to elective Caesarean (n=2) and failed IOL (n=2). In the univariate analysis, a CI < 2.9 L/minute (p = 0.043), SV < 65 mL (p = .027), stroke volume index (SVI) < 36 ml/m2 (p = 0.014), SVR > 7.2 logs (p = .020) and SVRI > 7.7 logs (p = 0.023) were significantly associated with the risk of operative delivery. Multiparity was the only maternal risk factor that showed a significant association with the risk of operative delivery in univariate regression model. The baseline model (parity) showed poor predictive accuracy with an area under the curve (AUC) value of 0.67 (95% CI: 0.58-0.77). The addition of SVI < 36 ml/m2, SVR>7.2 logs and SVRI>7.7 logs significantly improved the baseline model (p = 0.012, p = 0.026 and p = 0.012, respectively). The predictive accuracy of models had AUC values of 0.73 (95% CI: 0.64-0.82), 0.73 (95% CI: 0.63-0.84), 0.73 (95% CI: 0.64-0.82) for the combined models with SV, SVR and SVRI respectively. We demonstrated that maternal cardiovascular assessment could be useful for assessing the risk of intrapartum fetal compromise necessitating operative delivery. The addition of SV, SVR and SVRI significantly improved the predictive accuracy of the baseline antenatal model in women undergoing IOL. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Reduced growth velocity at term is associated with adverse neonatal outcomes in non-small for gestational age infants

ObjectivesTo investigate the association between decreased growth velocity at term, measured by estimated fetal weight z-score change, and adverse neonatal outcome and operative birth for intrapartum fetal compromise in a cohort of non-small for gestational age infants. Study designA prospective observational study was conducted at Mater Mothers’ Hospital, Brisbane, Australia. Serial ultrasound assessment was undertaken every two weeks from 36 weeks gestation until delivery to determine estimated fetal weight on 436 women with uncomplicated pregnancies. Intrapartum and neonatal outcomes were recorded. The outcome measures were adverse neonatal outcome [severe acidosis (cord pH < 7.0, base deficit ≤-12 mmol/L and/or lactate >6 mmol/L), low Apgar score (<7 at 5 min) or neonatal intensive care unit admission] and operative delivery for intrapartum fetal compromise. Estimated fetal weight z-score change was compared between those with and without adverse neonatal outcome and operative delivery for intrapartum fetal compromise using Generalised Linear Mixed Models. ResultsThe estimated fetal weight z-score per week declined for infants with the adverse neonatal outcome whilst those without demonstrated an increase [-0.04 (0.18) vs. 0.02 (0.21), p = 0.02]. There was no difference in estimated fetal weight z-score change per week in those with and without operative delivery for intrapartum fetal compromise. ConclusionReduced growth velocity in non-small for gestational age fetuses at term is associated with an increased risk of adverse neonatal outcomes.

An Epworth Sleep Score ≥11 is associated with emergency operative birth and poor neonatal composite outcome at term.

During pregnancy, the Epworth Sleepiness Scale can be used as a surrogate marker for maternal sleep-disordered breathing, a condition that is becoming increasingly prevalent in obstetric populations and is associated with a multitude of pregnancy complications. The aim of this observational study was to investigate the relationship between the Epworth Sleepiness Scale score and indication and mode of delivery during pregnancy. The Epworth Sleepiness Scale was completed by 178 women at Mater Mothers' Hospital, Brisbane, Australia. Women with a score ≥11 were less likely to achieve a spontaneous vaginal delivery (aOR 0.43, 95% CI 0.21-0.88, P=0.02), and were more likely to have an instrumental (aOR 2.81, 95% CI 1.30-6.08, P=0.01) or any operative birth (instrumental and caesarean section aOR 2.32, 95% CI 1.14-4.71, P=0.02). These women were also more likely to have an operative birth for intrapartum fetal compromise (aOR 2.62, 95% CI 1.21-5.69, P=0.015), as well as an infant with poor neonatal outcomes (aOR 2.77, 95% CI 1.09-7.03, P=0.03). These results show that symptoms of sleep-disordered breathing are associated with emergency operative birth, particularly when the indication for operative birth was intrapartum fetal compromise.

Comparison of Cerebroplacental Ratio, Intergrowth-21st Standards, Customized Growth, and Local Population References for the Prediction of Fetal Compromise: Which Is the Best Approach?

Objective: The aim of this work was to compare the accuracy of the cerebroplacental ratio (CPR), Intergrowth 21st standards (IG21), customized growth (CG), and local population references (LPR) in the prediction of intrapartum fetal compromise (IFC). Methods: This was a prospective study of 714 fetuses that underwent an ultrasound examination at 34–41 weeks and were delivered within a 2-week interval. The CPR was converted into multiples of the median and the estimated fetal weight (EFW) transformed into CG, IG21, and LPR centiles. IFC was defined as a composite of abnormal cardiotocogram, intrapartum pH requiring cesarean section, 5-min Apgar score, and admission to pediatric care units. The accuracies of the CPR and the EFW centiles for the prediction of IFC were evaluated alone and in combination with other gestational characteristics using univariate and multivariate analysis. Results: Individually, the CPR was the parameter that best predicted the existence of IFC (AUC = 0.66). The multivariate analysis showed that the best prediction was again achieved with the CPR, alone or in combination with any of the EFW centiles (AUC = 0.74). No significant differences were seen between the different centile methods. Conclusion: The best prediction of IFC is obtained with CPR. Evaluation of CPR should be encouraged in term and late-preterm fetuses.

Risk of operative delivery for intrapartum fetal compromise in small-for-gestational-age fetuses at term: external validation of the IRIS algorithm

Objectives: Small-for-gestational-age fetuses (SGA) are at high risk of intrapartum fetal compromise requiring operative delivery. In a recent study, we developed a model using a combination of three antenatal (gestational age at delivery, parity, cerebroplacental ratio) and three intrapartum (epidural use, labor induction and augmentation using oxytocin) variables for the prediction of operative delivery due to presumed fetal compromise in SGA fetuses – the Individual RIsk aSsessment (IRIS) prediction model. The aim of this study was to test the predictive accuracy of the IRIS prediction model in an external cohort of singleton pregnancies complicated by SGA.Methods: This was an external validation study using a cohort of pregnancies from two tertiary referral centers in Spain and England. The inclusion criteria were singleton pregnancies diagnosed with an SGA fetus, defined as estimated fetal weight (EFW) below the 10th centile for gestational age at 36 weeks or beyond, which had fetal Doppler assessment and available data on their intrapartum care and pregnancy outcomes. The main outcome in this study was the operative delivery for presumed fetal compromise. External validation was performed using the coefficients obtained in the original development cohort. The predictive accuracies of models were investigated with receiver operating characteristics (ROC) curves. The Hosmer–Lemeshow test was used to test the goodness-of-fit of models and calibration plots were also obtained for visual assessment. A mobile application using the combined model algorithm was developed to facilitate clinical use.Results: Four hundred twelve singleton pregnancies with an antenatal diagnosis of SGA were included in the study. The operative delivery rate was 22.8% (n = 94). The group which required operative delivery for presumed fetal compromise had significantly fewer multiparous women (19.1 versus 47.8%, p < .001 in the total study population; 19.0 versus 43.5 and 19.2 versus 49.6%, UK and Spain cohort, respectively), lower cerebroplacental ratio (CPR) multiples of median (MoM) (median: 0.77 versus 0.92, p < .001 in the total study population; 0.77 versus 0.92 and 0.77 versus 0.92, UK and Spain cohort, respectively), more inductions of labor (74.5 versus 60.1%, p = .010 in the total study population; 85.7 versus 77.2 and 71.2% and 53.1, UK and Spain cohort, respectively) and more use of oxytocin augmentation (57.4 versus 39.3%, p = .002 in the total study population; 19.0 versus 12.0 and 68.5 and 50.4%, UK and Spain cohort, respectively) compared to those who did not require operative delivery due to presumed fetal compromise. When the original antenatal model was applied to the present cohort, we observed moderate predictive accuracy (AUC: 0.70, 95% CI: 0.64–0.76), and no signs of poor fit (p = .464). The original combined model, when applied to the external cohort, had moderate predictive accuracy (AUC: 0.72, 95% CI: 0.67–0.77) and also no signs of poor fit (p = .268) without the need for refitting. A statistically significant increase in the predictive accuracy was not achieved via refitting of the combined model (AUC 0.76 versus 0.72, p = .060).Conclusions: Using our recently published model, the predictive accuracy for fetal compromise requiring operative delivery in term fetuses thought to be SGA was modest and showed no signs of poor fit in an external cohort. The IRIS tool for mobile devices has been developed to facilitate wide clinical use of this prediction model.Brief rationaleObjective: To determine the external validity of an intrapartum risk prediction model for suspected small-for-gestational age fetuses.What is already known: Small-for-gestational age fetuses are at increased risk of intrapartum compromise. Fetal weight alone is a poor marker for adverse outcomes and a comprehensive prediction model has been previously suggested.What this study adds: Multivariable prediction model showed good accuracy and calibration in this external validation study. The significance of some variables was different between the original and external validation cohort and there was a small margin for improvement with model refitting. A mobile application has been developed to facilitate clinical use.

Elephantiasis in pregnancy.

A 33-year-old primiparous woman was admitted for induction of labor at 39+2 gestational weeks due to gestational diabetes mellitus, treated with insulin. During physical examination, elephantiasis in both legs was revealed. Most common causes of this condition include infections and lymphadenectomy. In our case it first appeared at the age of seven following an ankle injury. Originally the edema affected only the right leg, but during pregnancy it also affected the left leg, with hypertrophy of the skin and subcutaneous tissues. There was excessive weight gain of 52kg during pregnancy (body mass index on admission: 49.6kg/m2), mainly due to the leg edema. Elephantiasis is neither an indication for intensive fetal monitoring during labor, nor for cesarean delivery. In our case, the woman delivered by emergency cesarean section, due to intrapartum fetal compromise, without any further complications. The edema remained almost unchanged at six weeks’ postpartum evaluation.

Prelabor screening for intrapartum fetal compromise in low‐risk pregnancies at term: cerebroplacental ratio and placental growth factor

To determine the screening performance of low fetal cerebroplacental ratio (CPR), a marker of fetal adaptation to suboptimal growth, and maternal placental growth factor (PlGF) level, both in isolation and in combination, for the prediction of Cesarean section (CS) for intrapartum fetal compromise (IFC) and composite adverse neonatal outcome (CANO). This was a prospective cohort study in low-risk women with uncomplicated singleton pregnancy from 36 weeks' gestation to delivery. CPR and PlGF were assessed fortnightly and intrapartum and neonatal outcomes were recorded. CPR and PlGF values from the final assessment for each woman were corrected for gestational age and assessed for screening performance, firstly as continuous variables and then as binary predictors. Of the 264 women who consented to participate in the study, 207 were included in the final analysis. Seven pregnancies required CS for IFC and 38 had CANO. Pregnancies delivered by CS for IFC had lower CPR and PlGF centiles than those in all other pregnancies. Pregnancies with CANO had a lower PlGF centile. The greatest areas under the receiver-operating characteristics curves (AUCs) for the prediction of CS for IFC (0.92; 95% CI, 0.86-0.97) and CANO (0.64; 95% CI, 0.54-0.74) were achieved by a combination of CPR 20th and PlGF 33rd centile thresholds. This produced sensitivities, specificities and positive likelihood ratios for the prediction of CS for IFC of 100%, 86% and 7.14, respectively, and 34.2%, 87.0% and 2.63, respectively, for the prediction of CANO. There was no statistical difference in the AUC for CS for IFC between the combined model and when CPR was used alone, or for CANO between the combined model and CPR or PlGF in isolation. This pilot proof-of-concept study describes the screening performance of CPR and maternal PlGF level for CS for IFC in low-risk women from 36 weeks' gestation. It was found that CPR and maternal PlGF improved the overall predictive utility for CS for IFC, as well as that for CANO. However, given the lack of significant difference between the combined model and its individual components, it is debatable whether the combined model is a superior screening test. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Emergency caesarean for intrapartum fetal compromise and admission to the neonatal intensive care unit at term is more influenced by fetal weight than the cerebroplacental ratio

Objective: Some studies have suggested that the fetal cerebroplacental ratio (CPR) is an independent predictor of intrapartum fetal compromise and admission to the neonatal intensive care unit (NICU) at term particularly in small for gestational age (SGA) compared to appropriate for gestational age (AGA) infants. The aim of this study was to evaluate the association between the CPR and emergency caesarean for intrapartum fetal compromise (CS IFC) and NICU admission at term after adjusting for estimated fetal weight (EFW) and other confounding factors.Methods: This was a retrospective study of women who birthed at the Mater Mother’s Hospital in Brisbane, Australia between for women who birthed between January 2000 and April 2017. The CPR was measured within 2 weeks of birth in women that delivered at term and assessed for correlation with CS IFC and admission to NICU. The study cohort was also stratified into four categories according to EFW and CPR thresholds. Appropriate for gestational age (EFW ≥10th centile) and normal CPR (≥10th centile), AGA and low CPR (<10th centile), SGA (EFW <10th centile) and normal CPR and SGA and low CPR.Results: Both CPR <10th centile (adjusted odds ratio (aOR) 2.60, 95% CI 1.82–3.71, p < .001) and EFW <10th centile (aOR 2.63, 95% CI 1.85–3.74, p < .001) demonstrated significant associations with CS IFC. EFW <10th centile (aOR 2.23, 95% CI 1.61–3.09, p < .001) but not CPR <10th centile (aOR 1.41, 95% CI 0.99–2.01, p = .06) was predictive of NICU admission. When stratified according to EFW and CPR thresholds, SGA had significant odds ratios for CS IFC and NICU admission regardless of CPR status. However, the AGA and low CPR cohort was only at increased risk of CS IFC (aOR 2.09, 95% CI 1.30–3.34, p = .002) but not of admission to NICU.Conclusions: At term, the CPR is an independent risk factor for CS IFC regardless of fetal weight. However, the CPR was only predictive of NICU admission in an SGA cohort. Overall, our findings suggest that fetal size is a more important variable for both CS IFC and NICU admission.

OP13.01: Risk of operative delivery for intrapartum fetal compromise in small‐for‐gestational‐age fetuses at term: external validation of the IRIS algorithm

OP13.01: Risk of operative delivery for intrapartum fetal compromise in small‐for‐gestational‐age fetuses at term: external validation of the IRIS algorithm

A low fetal cerebroplacental ratio confers a greater risk of intrapartum fetal compromise and adverse neonatal outcomes in low risk multiparous women at term

BackgroundA low fetal cerebroplacental ratio (CPR) and nulliparity have independently been shown to be associated with adverse obstetric and perinatal outcomes. ObjectivesTo assess the effect of parity on the CPR and investigate the utility of a CPR threshold of <10th centile for predicting adverse outcomes. We hypothesised that nulliparous women would have a lower CPR than multiparous women, impacting the diagnostic performance of the <10th centile threshold. This is an important consideration for interpretation of a low CPR in clinical practice. Study DesignThis was a retrospective cohort study of low risk, singleton pregnancies delivering at term in Australia’s largest maternity hospital. The primary outcome was emergency caesarean section for intrapartum fetal compromise (EmCS IFC). Data was dichotomised according to parity and further by CPR <10th centile. Multiple logistic regression was performed. Results4737 women were included for analysis, 2333 were nulliparous and 2404 were multiparous. Overall the z-score (mean [SD])(CPR standardised for gestation) was lower in nulliparous compared to multiparous women (−0.16 [-1.73 – 1.42] vs 0.04 [−1.63 – 1.69], p < 0.001). Multiparous women had a non-significantly lower mean z-score for those who delivered by EmCS IFC than nulliparous women (−0.52 [−2.23 – 2.02] vs −0.45 [−2.22 – 1.1]).Nulliparous women had greater odds of having a CPR <10th centile compared to the multiparous cohort (OR 1.24, 95% CI 1.02–1.5 vs. OR 0.81, 95% CI 0.7–0.98, p < 0.001). A CPR thresholdd <10th centile in nulliparous women was associated with increased odds of intrapartum fetal compromise (IFC), EmCS IFC (aOR 1.72, 95CI 1.2–2.6, p < 0.05) and birthweight <10th centile. A low CPR in multiparous women was associated with increased odds of all adverse perinatal outcomes measured: IFC, meconium stained liquor, EmCS IFC (aOR 4.99, 95%CI 2.5–9.9, p < 0.001), birthweight <10th centile, acidosis, neonatal intensive care admission and severe composite neonatal outcome. These aORs were associated with specificities of >90% and false positive rates of <10% for all outcomes in multiparous women. ConclusionsA CPR <10th centile in multiparous women confers greater odds of adverse perinatal outcomes and as such of the influence of parity should be taken into account when decisions regarding clinical management are made because of a low CPR.

Re: Cerebroplacental ratio thresholds measured within 2 weeks before birth and risk of Cesarean section for intrapartum fetal compromise and adverse neonatal outcome. L. N. Bligh, A. A. Alsolai, R. M. Greer and S. Kumar. Ultrasound Obstet Gynecol 2018; 52: 340–346.

Linked Comment: Ultrasound Obstet Gynecol 2018; 52: 340–346

The value of middle cerebral artery to umbilical artery ratio by Doppler velocimetry in low risk postdate pregnancies

Background and objective: Placental insufficiency is the primary cause of intrauterine growth restriction in normally formed fetuses and can be identified using middle cerebral artery to umbilical artery ratio Doppler velocimetry, and provide an estimate of downstream placental vascular resistance and placental blood flow. There is a strong association between reduced end-diastolic umbilical artery blood flow velocity and increased vascular resistance in umbilical placental microcirculation. Doppler ultrasound can assess the uteroplacental blood flow just before labor. This study aimed to investigate the use of the fetal cerebroumbilical ratio to predict the intrapartum fetal compromise in appropriately grown fetuses. Methods: A comparative cross-sectional study set at Sulaimania Maternity Teaching Hospital, Sulaimania, Iraq, from January to June 2015. The study recruited 121 cases, fetal biometry and Doppler indices were measured before established labor. The intrapartum and neonatal outcome details recorded. Results: Infants delivered by cesarean section for fetal compromise had significantly lower cerebroumbilical ratio than those born by spontaneous normal (none assisted) vaginal delivery and by cesarean section for other intrapartum causes. Infants with cerebroumbilical ratio 10th percentile. A cerebroumbilical ratio >90th percentile appears protective against cesarean section for fetal compromise. Amniotic fluid index of < 5 was associated with an increased cesarean section for fetal indication. Conclusion The cerebroumbilical ratio can identify fetuses at high risk of intrapartum fetal compromise. As a confounding variable, the amniotic fluid index was a useful tool for surveillance in prolonged pregnancy.

Cerebroplacental ratio thresholds measured within 2 weeks before birth and risk of Cesarean section for intrapartum fetal compromise and adverse neonatal outcome

Prediction of intrapartum fetal compromise in uncomplicated, term pregnancies is a global obstetric challenge. Currently, no widely accepted screening test for this condition exists, although the cerebroplacental ratio (CPR) shows promise. We aimed to evaluate prospectively the screening performance of the CPR 10th centile threshold for prediction of Cesarean section for intrapartum fetal compromise (IFC) and composite adverse neonatal outcome (ANO) after 36 weeks' gestation in low-risk women, and to compare this with CPR ≤ 1 and < 5th centile thresholds described previously in the literature. This was a blinded, prospective, observational, cohort study of 483 women with uncomplicated singleton pregnancy who underwent fortnightly CPR measurements from 36 weeks to delivery, and their intrapartum and neonatal outcomes were recorded. The CPR 10th centile threshold screening performance was calculated for emergency Cesarean section for IFC and composite ANO (defined as acidosis at birth, 5-min Apgar score < 7 and/or admission to the neonatal intensive care unit). Comparison of screening performance of CPR ≤ 1 and < 5th and < 10th centile thresholds was also undertaken for these specified outcomes. In total, 437 women were included in the analysis, of whom 4.1% had an emergency Cesarean section for IFC and 17.8% had a composite ANO. Sensitivity and specificity for CPR < 10th centile were, respectively, 55.6% and 87.9% for prediction of Cesarean section for IFC, and 28.2% and 88.0% for composite ANO. Compared with CPR ≤ 1 and < 5th centile, CPR < 10th centile yielded the best overall test performance for detection of Cesarean section for IFC and composite ANO, although its predictive value was only fair for Cesarean section for IFC (area under the receiver-operating characteristics curve (AUC) = 0.72) and poor for composite ANO (AUC = 0.58). The CPR 10th centile threshold may be useful as a component of a risk assessment tool for Cesarean section for IFC in low-risk pregnancies at term. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Predicting intrapartum fetal compromise at term using the cerebroplacental ratio and placental growth factor levels (PROMISE) study: randomised controlled trial protocol

IntroductionIntrapartum complications are a major contributor to adverse perinatal outcomes, including stillbirth, hypoxic–ischaemic brain injury and subsequent longer term disability. In many cases, hypoxia develops as a gradual process due...

Relationship of prelabor fetal cardiac function with intrapartum fetal compromise and neonatal status at term.

To investigate prospectively the relationship of fetal cardiac function and Doppler ultrasound parameters with intrapartum fetal compromise (IFC) in appropriately grown term fetuses. Secondary aims were to correlate prenatal cardiac function with neonatal acid-base status, intrapartum fetal heart rate (FHR) abnormalities and adverse neonatal outcomes. This was a blinded, prospective, observational, cohort study of 270 women with an uncomplicated singleton pregnancy who underwent fortnightly ultrasound assessment from 36 weeks' gestation until delivery at the Mater Mother's Hospital, Brisbane, Australia. Fetal cardiac output and blood flow parameters were assessed and correlated with intrapartum and neonatal outcomes. The primary outcome was need for operative (either Cesarean or instrumental vaginal) delivery for IFC. Secondary outcome measures were acidosis at birth, 5-min Apgar score ≤ 7, suspicious or pathological FHR abnormalities and admission to the neonatal intensive care unit. Two hundred and seventy women were included in the analysis, of whom 51 (18.9%) had an emergency operative delivery for IFC. Fetuses that had emergency delivery for IFC showed lower mean left ventricular cardiac output (LVCO) (560 ± 44 mL/min vs 617 ± 73 mL/min; P < 0.001), lower mean LVCO/right ventricular cardiac output (RVCO) ratio (0.55 ± 0.07 vs 0.64 ± 0.11; P < 0.001), lower mean cerebroplacental ratio (CPR) (1.62 ± 0.3 vs 1.90 ± 0.5; P < 0.001) and higher mean RVCO (1026 ± 105 mL/min vs 978 ± 110 mL/min; P = 0.003) compared with those that did not develop IFC. Additionally, LVCO and CPR were lower in fetuses with adverse neonatal outcome. Term fetuses with estimated fetal weight > 10th centile that develop IFC have evidence of lower LVCO and higher RVCO, which are in turn associated with poorer condition of the newborn. Fetal CPR is positively correlated with LVCO. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Prelabour myocardial deformation and cardiac output in fetuses that develop intrapartum compromise at term: a prospective observational study

Objective: Redistribution of cardiac output is responsible for the “brain sparing” effect seen during periods of acute or chronic fetal stress. We investigated the relationship between prelabour cardiac function in fetuses that subsequently developed intrapartum fetal compromise (IFC).Methods: A blinded, prospective, observational, cohort study, at Mater Mother’s Hospital, Brisbane, Australia. A cohort of 284 women with uncomplicated singleton pregnancies underwent ultrasound every 2 weeks from 36 weeks until delivery. Fetal cardiac output was assessed by conventional Doppler ultrasound and myocardial deformation was measured using velocity vector imaging.Results: Two hundred and seventy three women were included in the final analysis, of which 19% had an emergency operative delivery for intrapartum fetal compromise (IFC). Global left ventricular strain (−12.1%, interquartile ranges (IQR) − 10.3 to −14% versus 13%, IQR −11.3 to −14.2%, p = .01) and strain rate (−1.00, IQR 0.85–1.16 s−1 versus −1.11, IQR −1.00 to −1.21 s−1, p < .001) were lower in fetuses that required any emergency operative delivery for IFC compared to those that did not. Global longitudinal right ventricular strain rate was lower in fetuses that developed IFC (−1.04 ± 0.22 s−1 versus 1.13 ± 0.22 s−1, p < .001), whereas global right ventricular strain did not show any significance differences between the two groups. Additionally, left ventricular cardiac output was lower in fetuses that developed IFC or had a composite neonatal morbidity (560 ± 44 mL/min versus 617 ± 72 mL/min, p < .001) or (581 ± 44 mL/min versus 612 ± 72 mL/min, p < .01), respectively.Conclusion: Lower global left ventricular strain and strain rate and cardiac output are associated with IFC and poorer condition of the newborn. Assessment of fetal cardiac function may be useful for risk stratification for intrapartum fetal compromise in apparently “low risk” term pregnancies.

Systematic review of maternal Placental Growth Factor levels in late pregnancy as a predictor of adverse intrapartum and perinatal outcomes

AimThis systematic review evaluates the utility of maternal Placental Growth Factor (PlGF) when measured in late pregnancy (>20 weeks) as a predictor of adverse obstetric and perinatal outcomes. MethodsPubmed and Embase were searched using the term “placental growth factor” in combination with relevant perinatal outcomes. Studies were included if they measured PlGF levels in pregnant women after 20 + 0 weeks gestation and reported relevant adverse obstetric or perinatal outcomes related to placental insufficiency (excluding pre-eclampsia). ResultsTwenty-six studies were eligible for inclusion with 21 studies investigating the relationship between PlGF and small for gestational age (SGA) and 7 studies investigating PlGF for the prediction of other adverse perinatal outcomes. In all studies, maternal PlGF levels were significantly lower in the SGA group compared to controls. Other outcomes investigated included caesarean section (CS) for fetal compromise, low Apgar score, neonatal intensive care unit (NICU) admission, neonatal acidosis, stillbirth, and intrapartum fetal compromise. The results generally showed a significant association between low PlGF levels and CS for fetal compromise, NICU admission and stillbirth. ConclusionLow maternal PlGF levels in late pregnancy are strongly associated with SGA. Findings across studies were variable in relation to PlGF and the prediction of other adverse intrapartum and perinatal outcomes, however there was a consistent association between low PlGF levels and CS for fetal compromise, NICU admission and stillbirth. This review suggests that the use of PlGF for the prediction of adverse outcomes is promising. Its predictive value may potentially be enhanced if used in combination with other biomarkers or biophysical measures of fetal well-being.

Accuracy of the fetal cerebroplacental ratio for the detection of intrapartum compromise in nonsmall fetuses

Objective: To study the accuracy of the cerebroplacental ratio (CPR) for the detection of intrapartum fetal compromise (IFC) in fetuses growing over the 10th centile.Methods: This was a prospective study of 569 nonsmall fetuses attending the day hospital unit of a tertiary hospital that underwent an ultrasound examination at 36–40 weeks, and were delivered within 4 weeks of examination. IFC was defined as a composite of abnormal intrapartum fetal heart rate or intrapartum fetal scalp pH <7.20 requiring cesarean section, neonatal umbilical cord pH <7.20, 5 min Apgar score <7 and postpartum admission to neonatal or pediatric intensive care units. The accuracy of CPR for the prediction of IFC was calculated alone and in combination with other perinatal parameters using univariate and multivariate logistic regression models, which alternatively included the onset of labor to evaluate the influence of induction of labor (IOL) on IFC, and a brief composite adverse outcome of two parameters to prove the strength of the approach.Results: The incidence of IFC was 17.9%. CPR sensitivity was 30.4% for a false positive rate (FFR) of 10 and 14.7% for an FPP of 5% (AUC = 0.62, p < .001). The multivariate analysis showed that only fetal gender and parity increased the predictive accuracy of CPR alone, although the improvement was poor (AUC = 0.67, p < .001). No differences were observed using any of the alternative models. Finally, IOL had no influence on IFC.Conclusions: Despite their apparent normality, a proportion of fetuses growing over the 10th centile suffer IFC. Some of them are suitable for detection by means of CPR.

Assessment of left ventricular function using the Myocardial Performance Index in term fetuses that develop intrapartum compromise

Objective: To investigate the relationship between the prelabour left ventricular Myocardial Performance Index (LVMPI) and intrapartum fetal compromise (IFC) in low-risk term pregnancies.Methods: A blinded, prospective observational cohort study at the Mater Mother’s Hospital, Brisbane, Australia. A cohort of 284 women with uncomplicated singleton pregnancies underwent fortnightly ultrasound from 36 weeks until delivery. The LVMPI was assessed by conventional Doppler ultrasound and correlated with intrapartum outcomes. The LVMPI was also correlated with other Doppler indices of fetal wellbeing.Results: Two hundred and seventy-three women were included in the final analysis, the median LVMPI was higher in fetuses that required any emergency operative delivery for IFC (0.56, 0.52–0.60 versus 0.54, 0.50–0.58, p = .007). The left ventricular cardiac output (LVCO) and cerebroplacental ratio (CPR) were lower in fetuses that required any emergency operative delivery for IFC compared to those that did not (164 ± 19 ml/min/kg versus 181 ± 30 ml/min/kg, p < .001) (1.63 + 0.30 versus 1.90 + 0.50, p < .001), respectively. The LVMPI was inversely correlated with the CPR (r = −0.20, p < .01), MCA PI (r = −0.29, p < .01), and LVCO (r = −0.22, p < .01).Conclusions: Higher global LVMPI is associated with a higher risk for IFC and poorer condition of the newborn.