Abnormal Intrapartum Fetal Heart Rate Research Articles

Cerebroplacental Ratio Prediction of Intrapartum Fetal Compromise according to the Interval to Delivery

Introduction: A controversy exists about the accuracy of the cerebroplacental ratio (CPR) for the prediction of cesarean section for intrapartum fetal compromise (CS-IFC). Our aim was to evaluate whether the interval to delivery modifies the accuracy of CPR either as a single marker or combined with estimated fetal weight centile (EFWc), type of labor onset (TLO), and other clinical variables. Methods: This was a multicenter retrospective study of 5,193 women with singleton pregnancies who underwent an ultrasound scan at 35⁺⁰–41⁺⁰ weeks and gave birth within 1 month of examination, at any of the participating hospitals in Spain, UK, and Italy. CS-IFC was diagnosed in case of an abnormal intrapartum fetal heart rate or intrapartum fetal scalp pH <7.20, requiring urgent cesarean section. The diagnostic ability of CPR in multiples of the median (CPR MoM) was evaluated at different intervals to delivery, alone and combined with EFWc, TLO, and other pregnancy data such as maternal age, maternal body mass index, parity, and fetal sex, for the prediction of CS-IFC by means of ROC curves and logistic regression analysis. Results: The predictive ability of CPR MoM for CS-IFC worsened with the interval to delivery. In general, the best prediction was obtained prior to labor and by adding information related to EFWc and TLO (AUC 0.71 [95% CI: 0.64–0.79], 0.73 [95% CI: 0.66–0.80], and 0.75 [95% CI: 0.69–0.81]; p < 0.0001). Addition of more clinical data did not improve prediction. In addition, results did not vary when only cases with spontaneous onset of labor were studied. Conclusion: CPR MoM prediction of CS-IFC at the end of pregnancy worsens with the interval to delivery. Accordingly, it should be done in the short term and considering EFWc and TLO.

Fetal heart rate patterns in labor and the risk of neonatal encephalopathy: A case control study

ObjectiveTo describe the accuracy of intrapartum fetal heart rate abnormalities as defined by National Institute of Health and Care Excellence guidelines to predict moderate-severe neonatal encephalopathy of apparent hypoxic-ischemic etiology. Study designA case-control study of HIE risk factors was conducted. Eligible babies were born in a single maternity hospital in Dublin, Ireland between September 2006, and November 2017 at ≥35 + 0 weeks’ gestational age. Cases were eligible babies with moderate-severe neonatal encephalopathy of definite or apparent hypoxic-ischemic etiology. Controls were eligible babies born before and after each case with normal Apgar scores.The included subjects who had intrapartum fetal heart rate recordings were identified. Pattern features (baseline rate, variability, accelerations, decelerations [early, late, variable, prolonged], bradycardia, sinusoidal pattern) were manually identified blind to all clinical details by one of the authors. Each 15-minute segment was then algorithmically categorized (uninterpretable, normal, suspicious, pathological). ResultsOf 88 cases and 176 controls, 71 cases (81%) and 146 controls (83%) were admitted to the delivery suite in labor. From that group, intrapartum FHR traces longer than 15 min were available for 52 (73%) cases and 118 (83%) controls.The FHR pattern feature with the largest area under the receiver operating characteristic curve was the maximum number of consecutive segments in which the baseline was >160 bpm (0.71 [95% confidence interval: 0.62–0.80]). The category variable with the highest area under the curve was the number of suspicious segments (0.76 [95% confidence interval: 0.67–0.84]).A tri-variate logistic regression model incorporating the total number of segments, the number of “suspicious” segments classed, and the number of “pathological” segments achieved an area under the curve of 0.78 (95% confidence interval: 0.70–0.86). With 95% specificity, this model correctly identified 17 cases (33%) at a median time before delivery of 2 h and 18 min (interquartile range: 01:19–04:40). ConclusionsThe power of fetal heart rate analysis to predict neonatal encephalopathy is hampered by poor specificity given the rarity of the outcome. When analyzing a suspicious trace, it is beneficial to consider the overall duration of the suspicious pattern.

Which is the best ultrasound parameter for the prediction of adverse perinatal outcome within 1 day of delivery?

Objective To compare the accuracies of several sonographic parameters for the prediction of adverse perinatal outcome (APO) prior to delivery. Methods This was a prospective study of fetuses attending the day hospital unit of a tertiary referral hospital that were scanned at 34-41 weeks and gave birth within 24 h of examination. APO was defined as a composite of abnormal intrapartum fetal heart rate or intrapartum fetal scalp pH < 7.20 requiring urgent cesarean section, neonatal umbilical cord pH < 7.10, 5’ Apgar score <7 and postpartum admission to neonatal or pediatric intensive care units. The accuracies of the middle cerebral, vertebral and umbilical arteries pulsatility index multiples of the median (MoM), the cerebroplacental and vertebroplacental ratios MoM and the EFW in centiles for the prediction of APO was evaluated by means of ROC curves and logistic regression analysis. Results A total of 2140 fetuses were prospectively scanned, however only 182 entered into spontaneous or induced labor and were delivered within 24 h of examination. In this group, MCA PI MoM was the best predictor of APO (AUC = 0.76, 95% CI 0.66–0.85, p < .0001) followed by the CPR MoM (AUC = 0.73, 95% CI 0.63–0.84, p < .0001) and the VPR MoM (AUC = 0.71, 95% CI 0.61–0.81, p < .001). Logistic regression analysis indicated that MCA PI MoM was the only independent determinant for the prediction of APO. Conclusion In a high-risk population of third-trimester fetuses delivering within 24 h of examination, the outcome may be moderately anticipated just with the information provided by the cerebral flow.

The Diagnostic Ability of the Cerebroplacental Ratio for the Prediction of Adverse Perinatal Outcome and Intrapartum Fetal Compromise within One Day of Delivery

Objectives: The objectives of this study were to evaluate the diagnostic abilities of the cerebroplacental ratio (CPR) for the prediction of adverse perinatal outcome (APO) and cesarean section for intrapartum fetal compromise (CS-IFC) within 1 day of delivery. Design: Retrospective observational case-control study. Methods: This was a study of 254 high-risk fetuses attending the day hospital unit of a tertiary referral hospital that underwent an ultrasound examination at 32–41 weeks and gave birth within 1 day of examination. APO was defined as a composite of abnormal intrapartum fetal heart rate or intrapartum fetal scalp pH <7.20 requiring urgent cesarean section, neonatal umbilical cord pH <7.10, 5-min Apgar score <7, and postpartum admission to neonatal or pediatric intensive care units. CS-IFC was defined in case of abnormal intrapartum fetal heart rate or intrapartum fetal scalp pH <7.20 requiring urgent cesarean section. The diagnostic ability of CPR for the prediction of APO and CS-IFC was calculated alone and in combination with estimated fetal weight and gestational clinical parameters, including the type of labor onset, using ROC curves and logistic regression analysis. Results: CPR in multiples of the median (MoM) was a moderate predictor of APO (area under the curve [AUC] = 0.77, p < 0.0001) and CS-IFC (AUC = 0.82, p < 0.0001). The predictive abilities of the multivariable model for APO (AUC = 0.81, p < 0.0001) and CS-IFC (AUC = 0.82, p < 0.0001) did not differ from those of CPR alone . Limitations: The small number of cases and the scarcity of information concerning labor induction. Conclusion: In high-risk pregnancies, CPR MoM is a moderate predictor of APO and CS-IFC when performed within 24 h of delivery.

The Impact of Prenatal Depression in Patients of High Risk Pregnancy Clinic on Obstetric Outcomes.

Prenatal depression is common and has been associated with risky maternal behavior, postpartum depression, and atypical child development. Still, its association with adverse perinatal outcomes is complex. The aim of our study was to look for this potential association in our region. The medical charts of women who were treated at our High-Risk Pregnancy Clinic and gave birth at our hospital were reviewed. The Edinburgh Postnatal Depression Scale (EPDS) was used to discover prenatal depression. Patients who reported past or current mental illness were excluded. We enrolled 202 women at a mean age of 32.81. Twin pregnancy was the most common reason for referral to the clinic (17.3%). The mean EPDS score was 4.63 (±4.66), with 15.3% scoring 10 or more. A significant correlation was found between the EPDS score and intrapartum fetal heart rate abnormalities, as well as with low birth weight. There were significant associations between the EPDS score and the maternal status of genetic disorder carrier, and the number of previous pregnancies, miscarriages, and elective termination of pregnancy. This study demonstrates a significant impact of the maternal psychological state on the obstetric outcome. In addition, we observed a significant association between maternal obstetric history, genetic data, and the risk of prenatal depression. Our study shows that completing the EPDS questionnaire is a very important part of the pregnancy follow-up, as it illuminates risk factors for prenatal depression and adverse perinatal outcomes.

Interventions for Intrapartum Fetal Heart Rate Abnormalities.

Intrapartum fetal heart rate (FHR) decelerations may represent interrupted oxygen transfer to the fetus. In many cases, these interruptions are transient and do not result in progressive fetal acidemia with risk for asphyxia and neurological compromise. When significant FHR decelerations are present, reversible causes of reduced fetal oxygen delivery should be considered and corrective measures should be undertaken to optimize oxygenation. In this review, we describe potential intrapartum causes of reduced fetal oxygen delivery and the efficacy of common interventions for an abnormal FHR tracing.

Incidence, Intrapartum Risk Factors, and Prognosis of Neonatal Hypoxic-Ischemic Encephalopathy Among Infants Born at 35 Weeks Gestation or More.

Neonatal hypoxic-ischemic encephalopathy (HIE) is associated with neonatal mortality, acute neurological injury, and long-term neurodevelopmental disabilities; however, the association between intrapartum factors and HIE remains unclear. This population-based cohort study used linked obstetrical and newborn data derived from the Nova Scotia Atlee Perinatal Database (NSAPD, 1988-2015) and the AC Allen Perinatal Follow-Up Program Database (2006-2015) for all pregnancies with live, non-anomalous newborns ≥35 weeks gestation, not delivered by pre-labour cesarean section. Temporal trends in HIE incidence were described, and logistic regression estimated odds ratios (OR) with 95% confidence intervals (CI) for the association of intrapartum factors with HIE. The NSAPD identified 227 HIE cases in the population of 226 711 deliveries from 1988 to 2015. Women with clinical chorioamnionitis in labour (OR 8.0; 95% CI 3.9-16), emergency cesarean delivery (OR 10; 95% CI 7.6-14), shoulder dystocia (OR 3.5; 95% CI 2.1-5.7), placental abruption (OR 18; 95% CI 11-29), and cord prolapse (OR 30; 95% CI 15-61) were more likely to have newborns with HIE. Two-thirds of newborns with HIE had an abnormal intrapartum fetal heart rate tracing. The mortality rate among infants with HIE was 27% by 3 years of age. Neurodevelopmental outcomes in the surviving infants were normal in 43% and showed severe developmental delay in 40%. Overall, the rate of HIE was low in infants born at ≥35 weeks gestation. The identification of associated intrapartum factors should promote increased surveillance in these clinical situations and emphasize the importance of careful management to optimize newborn outcomes.

Predictive value of Cerebroplacental blood flow ratio for fetal heart rate disturbances and perinatal outcome

Background: Doppler ultrasound velocimetry foetal vessels have become established method of antenatal monitoring, allowing non-invasive assessment of foetal circulation. Aims: To determine the usefulness of Doppler velocimetry, based on cerebroplacental ratio (C/U) evaluation, in predicting intrapartum fetal heart rate abnormalities and adverse neonatal outcome in uncomplicated pregnancies from 36 to 40 weeks. Subjects and Methods: this is prospective study include 300 uncomplicated pregnant women, age ranged from 17 to 45 years, with gestational age 36 to 40 weeks. Results: there was significant relation between CPR and adverse neonatal outcome p-value <0.001 with sensitivity, specificity and PPV, NPPV of CPR in detecting neonatal adverse outcome 100%. Conclusion: better prediction of neonatal outcome can be done by C/U ratio

Predictive value of Cerebroplacental blood flow ratio for fetal heart rate disturbances and perinatal outcome

Background: Doppler ultrasound velocimetry foetal vessels have become established method of antenatal monitoring, allowing non-invasive assessment of foetal circulation. Aims: To determine the usefulness of Doppler velocimetry, based on cerebroplacental ratio (C/U) evaluation, in predicting intrapartum fetal heart rate abnormalities and adverse neonatal outcome in uncomplicated pregnancies from 36 to 40 weeks. Subjects and Methods: this is prospective study include 300 uncomplicated pregnant women, age ranged from 17 to 45 years, with gestational age 36 to 40 weeks. Results: there was significant relation between CPR and adverse neonatal outcome p-value <0.001 with sensitivity, specificity and PPV, NPPV of CPR in detecting neonatal adverse outcome 100%. Conclusion: better prediction of neonatal outcome can be done by C/U ratio

Nuchal cord: impact of umbilical artery Doppler indices on intrapartum and neonatal outcomes: a prospective cohort study

Background/objective: The purpose of this study is to investigate the use of a more biologic parameter for evaluation of the effect of nuchal cord tightness; the study of blood flow in the umbilical arteries of nuchal cord using Doppler ultrasonography.Methods: This prospective cohort study was conducted at Ain Shams University Maternity Hospital, Cairo, Egypt in the period between August 2015 and August 2017. Hundred primigravidas were recruited with nuchal cord diagnosed by Doppler ultrasonography; whereas the rest of the study population was included in the “Control group”. Doppler velocimetry study was then performed on a free-floating loop of the umbilical cord and Doppler indices were calculated. Both groups were followed up during labor: intrapartum events, mode of delivery, and neonatal outcome were recorded.Results: Intrapartum fetal heart rate abnormalities were significantly more common in the nuchal cord group compared to the control group. The overall cardiotocography category was significantly more commonly reflecting abnormal fetal heart rate patterns in the nuchal cord group compared to the control group with 46.74% of the nuchal group patients falling within the “suspicious – pathological – need urgent intervention” categories. Intervention rate was significantly higher in the nuchal cord group than the control group (33.69 versus 21.84%). Moreover, incidence of intrapartum fetal heart rate abnormalities and intervention rate were significantly higher in the nuchal cord with abnormal Doppler subgroup compared to both nuchal cord with normal Doppler subgroup and the control group; with a calculated number needed to harm of 2.11.Conclusions: In view of these results, it might be concluded that umbilical cord tightness affecting fetal hemodynamics (expressed by changes in umbilical artery Doppler) might be a determinate factor affecting the intrapartum course.

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.

The relationship between maternal placental growth factor levels and intrapartum fetal compromise

IntroductionWhilst some cases of intrapartum fetal compromise are the result of unpredictable catastrophic events, the majority arise from an unrecognised reduction in feto-placental reserve in otherwise healthy pregnancies. There is currently no reliable technique prior to labour that identifies the at-risk fetus. We aimed to investigate the relationship between maternal levels of serum placental growth factor (PlGF) and intrapartum fetal compromise in term pregnancies prior to labour. Secondary outcomes were caesarean delivery for intrapartum fetal compromise and adverse neonatal outcomes. MethodsA blinded, prospective, cross sectional study set at Mater Mother's Hospital, Brisbane, Australia. Maternal PlGF concentration was assessed fortnightly from 36 weeks until delivery in 378 low-risk pregnant women. Antenatal and intrapartum care was managed according to local protocols and guidelines, and intrapartum and neonatal outcomes were recorded. ResultsPregnancies that developed intrapartum fetal compromise had lower PlGF than those that did not. PlGF concentration was also lower amongst pregnancies that developed intrapartum fetal heart rate abnormalities, were delivered with abnormal cord gases or Apgar ≤7 at 5 min. Additionally, PlGF levels were lower in pregnancies with an adverse composite neonatal outcome. DiscussionLower maternal PlGF concentration is associated with intrapartum fetal compromise and poorer condition of the newborn. Maternal PlGF levels may be useful as a component of a risk stratification tool for intrapartum fetal compromise in apparently 'low risk' term pregnancies prior to labour.

Impact of a prenatally diagnosed nuchal cord on obstetrical outcome in an unselected population

Objective: Evaluate the outcome of prenatally diagnosed nuchal cord.Methods: A retrospective study on all cases of prenatally diagnosed nuchal cord. Study end points were gestational age at delivery, intrapartum fetal heart rate (FHR) abnormalities, mode of delivery, intrauterine fetal growth retardation (IUGR), intrauterine fetal demise (IUFD), and the rate of labor induction.Results: This study included 44 cases; 86% were diagnosed at second trimester scan, confirmed by Color Doppler and 3D ultrasound. Mean gestational age at delivery was 39 weeks.18/44 cases (41%) underwent labor induction mostly as a result of parental anxiety. Primary cesarean rate was 34% (15/44), and 16% (7/44) had intrapartum FHR abnormalities with no impact for induction of labor. Instrumental vaginal delivery was used in 5 cases. IUGR was present in 7% (3/44), and none had IUFD. Nuchal cord was confirmed at birth in all cases. Correct prenatal diagnosis was in only one case of the 5/44 (11%) with multiple loops.Conclusion: Prenatal diagnosis of nuchal cord is feasible with difficulty in determining multiple loops. Outcome is favorable, but parental anxiety is common and may increase induction rates, without leading to difference in cesarean rates or FHR abnormalities.

Cerebroplacental ratio in prediction of adverse perinatal outcome and fetal heart rate disturbances in uncomplicated pregnancy at 40 weeks and beyond.

IntroductionThe aim of the study was to determine the usefulness of Doppler velocimetry, based on cerebroplacental ratio (C/U) evaluation, in predicting intrapartum fetal heart rate abnormalities and adverse neonatal outcome in uncomplicated pregnancies at 40 weeks and beyond.Material and methodsOne hundred and forty-eight women in uncomplicated pregnancies, between 40 and 42 completed weeks, were divided into control and study groups: with the absence (n = 79) and with the presence of a fetal brain-sparing effect (n = 69), respectively. Pulsatility and resistance indices in the middle cerebral, the umbilical artery and the C/U ratio were evaluated daily by Doppler ultrasonography. C/U < 1.1 was reported as suggestive of a brain-sparing effect. Abnormal flow indices were analyzed and compared to adverse pregnancy and neonatal outcome determinants.ResultsIn the abnormal C/U group the abnormal CTG records were significantly more frequently observed (62.3%) than in normal C/U group (19.0%) (p = 0.0001). The comparison of selected Doppler indices revealed that C/U showed the highest sensitivity in prediction of both the intrapartum abnormal FHR (74.1%) and the adverse neonatal outcome (87.8%).ConclusionsThe C/U index shows the highest sensitivity in prediction of FHR abnormalities and adverse neonatal outcome in uncomplicated pregnancies at 40 weeks and beyond. The C/U index is useful in clinical practice in antenatal monitoring of these women in order to select those at high risk of intra- and postpartum complications.

Association between intrapartum fetal heart rate patterns and neonatal abstinence syndrome in methadone exposed neonates

Objective. Determine whether infants exposed to chronic maternal methadone with abnormal intrapartum fetal heart rate (FHR) patterns are more likely to require treatment for neonatal abstinence syndrome (NAS).Study design. Intrapartum FHR tracings analyzed in 104 pregnancies at ≥34 weeks gestation for FHR variability, accelerations, and decelerations. FHR patterns compared between neonates based on treatment with methadone for NAS. Secondary analysis included relation between maternal methadone dose and intrapartum FHR patterns, initiation of methadone, age at methadone initiation, and total neonatal methadone dose. Study powered to detect 30% increase in NAS incidence in neonates with abnormal FHR tracings.Results. Seventy-six (73%) of 104 neonates required methadone treatment for NAS. Neonates who required methadone had higher average baseline FHR (131 vs. 126 bpm; p < 0.04) in active labor and less likely to have FHR tracings without accelerations (1.7% vs. 20.3%; p = 0.007) in latent labor. No significant associations between neonate's need for methadone and intrapartum FHR variability or FHR decelerations. No association between maternal methadone dose (range 30–280 mg) and treatment for NAS.Conclusion. The need for an infant to require methadone treatment for NAS was not reliably predicted by the intrapartum FHR patterns or the maternal methadone dose.

663: Association between intrapartum fetal heart rate patterns and neonatal abstinence syndrome in methadone exposed neonates

Determine if infants exposed to chronic maternal methadone treatment who have abnormal intrapartum fetal heart rate (FHR) patterns are more likely to require treatment for neonatal abstinence syndrome (NAS).

OC139: Velamentous cord insertion into the lower uterine segment and long aberrant vessels are associated with intrapartum fetal heart rate abnormalities

OC139: Velamentous cord insertion into the lower uterine segment and long aberrant vessels are associated with intrapartum fetal heart rate abnormalities

Reply

To the Editors: We thank Dr Nielsen for his pointed response to our article on boutique fetal imaging. He raises a number of concerns, which we will address in turn. First, Dr Nielsen offers in response some of the opinions of his patients, with whom he shared our opinion piece. Empiric data about patients' attitudes is certainly relevant to ethical analysis of clinical controversies, provided that data about these attitudes are collected and analyzed according rigorous scientific standards.1Skupski D.W. Chervenak F.A. McCullough L.B. Horowitz S. Cesarean delivery for intrapartum fetal heart rate abnormalities: incorporating survey data into clinical judgment.Obstet Gynecol. 1996; 88: 60-64Crossref PubMed Scopus (5) Google Scholar Dr Nielsen failed to do so. His sample is biased because it comes from his own patients, who may have experienced potentially coercive influence from him not to disagree with him. He cites only 3 patients, a very small convenience sample that cannot be generalized beyond itself. After all, 3 patients from another physician's practice might have had very different responses. Second, Dr Nielsen resorts to rhetorical questions about patient autonomy to justify a clinical practice to which we raised substantive, argument-based objections. Rhetorical questions run a serious risk: they can be answered by readers in the opposite way expected by Dr Nielsen. More disabling, rhetorical questions do not count as arguments in ethics and are usually put forward by those who lack argument for their position.2McCullough L.B. Coverdale J.H. Chervenak F.A. Argument-based medical ethics: a formal tool for critically appraising the normative medical ethics literature.Am J Obstet Gynecol. 2004; 191: 1097-1102Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar Third, one of Dr Nielsen's patients asked for proof of our concern about how patients might feel about later decisions about intrapartum management. We offered this as a prudential consideration, ie, the wise obstetrician should want to prevent unnecessary complication of what will already be challenging decisions for both the obstetrician and patient. In the absence of data, prudential arguments are entirely appropriate in ethics. They should be rebutted with an argument showing that boutique fetal imaging does not involve risks that raise prudential concerns about the integrity of clinical practice. Dr Nielsen provides no such argument. Finally, we never used the phrase “filthy lucre,” and its use by Dr Nielsen involves a transparent attempt to distort our argument-based concerns about responsible management of economic conflicts of interest. Unfortunately for Dr Nielsen, the phrase may be relevant, based on what the Geddes Keepsake website itself states: “Geddes Keepsake services are designed to enhance the revenue of an existing medical practice or medical imaging center. We are so confident in the revenue potential of our services that we offer the following: if you have not had a complete payback on the investment within 8 months, we will buy back the equipment for the price you paid less the gross income you earned.”3Geddes Keepsake Ultrasound Images. Available at: http://www.geddeskeepsake.com/medical_professionals.html. Accessed October 1, 2005.Google Scholar Moreover, we did not object to offering “keepsake” images, on the condition that they are provided in the context of a regular ultrasound examination, not something as casual as getting “another look” at the fetus. This phrase could reflect a failure to understand the requirements of professional integrity in obstetric ultrasound examination, a failure that is not masked by the entertaining—but ethically vapid—rhetorical flourish with which Dr Nielsen closes his letter. Keepsake Ultrasounds: More than just another pretty faceAmerican Journal of Obstetrics & GynecologyVol. 194Issue 5PreviewTo the Editors: As a “generalist” Ob/Gyn, I offer keepsake ultrasounds using the Geddes Keepsake (Geddes Keepsake, Inc, Gilbert, AZ) program, which requires strict physician standards for affiliation. I agree that unsupervised keepsake ultrasonography in the malls without onsite physician support is wrong and dangerous. Full-Text PDF

Velamentous cord insertion into the lower third of the uterus is associated with intrapartum fetal heart rate abnormalities

To evaluate the accuracy of sonographic identification of the site of umbilical cord insertion (CI) at 18-20 weeks of gestation, to compare the sensitivities for detection of a velamentous cord insertion (VCI) secondary to a CI into the anterior, posterior or fundal wall, and to compare the intrapartum complications secondary to VCI into the upper, middle or lower third of the uterus. As part of the routine ultrasound scan at 18-20 weeks' gestation we evaluated abnormal CI (VCI and marginal CI) and the location of the CI in the uterus in 3446 pregnancies. In cases of abnormal CI, the location of the CI was further classified as being in the upper, middle or lower third of the uterus. After delivery, the placenta and the umbilical cord were examined and intrapartum complications were compared with the location of the CI. The values for antenatal detection of VCI were: sensitivity, 25 of 40 (62.5%); positive predictive value, 25 of 25 (100%); and negative predictive value, 3406 of 3421 (99.6%). The sensitivity for cases in which the CI was located on the anterior wall was 12 of 13 (92.3%); when it was located on the posterior wall, the sensitivity was 11 of 22 (50.0%); and when it was fundal the sensitivity was 2 of 5 (40.0%). Variable decelerations were frequently observed with a VCI. In lower VCI cases, non-reassuring fetal heart rate patterns and emergency Cesarean sections occurred with a higher frequency than in cases with upper or middle VCI (P < 0.01). After delivery, the length of the aberrant vessels in cases of VCI by pathologic examination was 3.9 +/- 3.3 cm in the upper third, 4.7 +/- 4.6 cm in the middle third, and 10.6 +/- 6.8 cm in the lower third; thus, the aberrant vessel length was significantly greater when the CI was in the lower third of the uterus (P = 0.024). We have demonstrated that VCI with a lower CI site and with longer aberrant vessels is associated with various intrapartum complications. This finding has the potential for improving perinatal outcome.

Intrapartum fetal heart rate monitoring in cases of cytomegalovirus infection

ObjectiveSeveral studies have shown that abnormal intrapartum fetal heart rate patterns are the results from pre-existing fetal brain damage. We evaluated intrapartum fetal heart rate pattern of cytomegalovirus-infected fetuses and correlated the patterns with neurologic outcomes. Study designBetween 1991 and 2001, there were 20 cytomegalovirus-infected fetuses. We selected 40 fetuses as control subjects that were matched for gestational age and birth weight. Fetal heart rate was interpreted according to the guidelines of the National Institute for Child and Human Development. The incidence of abnormal fetal heart rate pattern and umbilical blood gases were compared between both groups. We also investigated the factors that contributed to abnormal fetal heart rate pattern in the cytomegalovirus group. ResultsNonreassuring fetal heart rate patterns (prolonged deceleration and recurrent late deceleration) were observed in 8 of 20 fetuses (prolonged deceleration, 7 fetuses; recurrent late deceleration, 1 fetus) in the cytomegalovirus group and in 3 of 41 fetuses (prolonged deceleration, 1 fetus; recurrent late deceleration, 2 fetuses) in the control group (P<.05, Fisher test). Baseline fetal heart rate variability was minimal in 4 of the 7 prolonged deceleration cases in the cytomegalovirus group. Umbilical pH <7.1 was found for 1 fetus in the cytomegalovirus group. The average umbilical arterial pH values were similar in both the groups. In the cytomegalovirus group, there were no differences in the incidence of contributing factors between 8 fetuses with abnormal fetal heart rate pattern (prolonged deceleration and recurrent late deceleration) and 8 fetuses with no change. There were 3 fetuses with cerebral palsy: 2 fetuses in the no change group and 1 fetus in the prolonged deceleration group. Antigenemia was positive exclusively in 4 cases with abnormal fetal heart rate pattern (P<.05). ConclusionCytomegalovirus-infected fetuses are more likely to show abnormal intrapartum fetal heart rate patterns than low-risk control fetuses, which suggests that the perinatal detection of cytomegalovirus is necessary to distinguish hypoxic-ischemic encephalopathy.