Nonreassuring Fetal Heart Rate Tracing Research Articles

Association between SARS-CoV-2 Infection and Adverse Perinatal Outcomes by Race/Ethnicity in a Large Integrated Health Care System.

Recent studies have reported associations between severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection during pregnancy and adverse perinatal outcomes but the extent to which these associations vary by race/ethnicity remains uncertain. Therefore, we examined how the association between prenatal SARS-CoV-2 infection and adverse perinatal outcomes may be modified by race/ethnicity. A retrospective cohort study was performed using data on 67,986 pregnant women extracted from the Kaiser Permanente Southern California electronic health records between April 6, 2020, and December 31, 2021. Upon admission to labor and delivery, all women were routinely tested for coronavirus disease 2019 (COVID-19) using real-time reverse-transcriptase polymerase chain reaction test. Adjusted odds ratios (aORs) were used to estimate associations. During the study period, COVID-19 was diagnosed in 4,960 (7%) of singleton pregnancies, with the highest rates observed among Hispanics (9.4%) and non-Hispanic Blacks (6.2%). Compared with non-Hispanic Whites, Hispanics (aOR: 1.12, 95% CI: 1.03, 1.21) with SARS-CoV-2 infection had the highest odds of a pregnancy associated with nonreassuring fetal heart rate tracing. Neonates of all races/ethnicities, except for non-Hispanic Blacks, showed significantly increased odds of SARS-CoV-2 infection, with the highest risk observed among Asians/Pacific Islanders (aOR: 10.88, 95% CI: 1.33, 89.04). Non-Hispanic White mothers who tested positive were admitted to intensive care unit (ICU) at a higher rate at delivery and within 7 days of delivery (aOR: 34.77, 95% CI: 11.3, 107.04; aOR: 26.48, 95% CI: 9.55, 73.46, respectively). Hispanics were also at a significantly higher odds of admission to ICU (aOR: 4.62, 95% CI: 2.69, 7.94; aOR: 4.42, 95% CI: 2.58, 7.56, respectively). Non-Hispanic Black, Hispanic, and Asian/Pacific Islander mothers who tested positive for SARS-CoV-2 prenatally, were at increased risk for preeclampsia/eclampsia, and preterm birth as compared to non-Hispanic White mothers. The findings highlight racial/ethnic disparities in the association between SARS-CoV-2 infection and adverse perinatal outcomes. The risk of neonatal SARS-CoV-2 infection was highest for Asian/Pacific Islanders. We also observed a remarkably high risk of ICU admission for non-Hispanic White mothers infected with SARS-CoV-2. · Race/ethnicity influences perinatal outcomes in pregnancies impacted by SARS-CoV-2.. · The risk of neonatal SARS-CoV-2 infection was highest for Asian/Pacific Islanders.. · White mothers had a notably high risk of ICU admission at delivery following SARS-CoV-2 infection..

Primary cesarean section rate among full-term pregnant women with non-previous uterine scar in a hospital of Vietnam

AimThis article aims to determine the contributing indications for primary cesarean sections among full-term pregnant women with non-previous uterine scars and suggests several potential solutions to reduce the cesarean section rate. MethodsThis is a descriptive study with data being retrospectively collected from electronic medical records (EMRs) at Hanoi Obstetrics & Gynecology Hospital, Vietnam, in 2020. We studied 23,631 women at ≥37 weeks of gestation with non-previous uterine scars. Main ICD-10 categories of diagnosis on the EMRs were used to classify the indications. The proportions of indications for primary cesarean sections were calculated, thereby offering potential solutions to reduce the cesarean section rate. ResultsThe proportion of cesarean sections among full-term pregnancies with non-previous uterine scars was 40.7%. The most common indications for primary cesarean sections were non-reassuring fetal heart rate tracing (40%), labor arrest (31%), and maternal request (11%). Among the low-risk pregnant women, the cesarean section rate was 35.9%, of which the percentages of labor arrest and non-reassuring fetal heart rate tracings and maternal request were 13.6%, 17.7%, and 4.6%, respectively. ConclusionsThe proportion of primary cesarean sections among full-term pregnancies with non-previous uterine scars is high; non-reassuring fetal heart rate tracings, labor arrest, and maternal request were three main indications. It is necessary to build the strategies of health organizations regarding the management of clinical practices and the programs improving the knowledge, attitudes, practices of pregnant women and obstetricians regarding cesarean sections.

Third trimester placentitis: an underreported complication of SARS-CoV-2 infection

SARS-CoV-2 related placentitis shows distinctive histological characteristics and its impact on perinatal outcomes is increasingly coming under scrutiny. We present two such cases in the third trimester, following mild maternal clinical symptoms and associated with maternal coagulopathy, reduced fetal movements and non-reassuring fetal heart rate tracing. Both cases resulted in emergency cesarean deliveries. Our cases and a review of the literature highlight that SARS-CoV-2 undermines placental function and thus greatly impacts late-term pregnancies, even in the absence of severe systemic disease.w

Preterm cesarean delivery for nonreassuring fetal heart rate tracing: Risk factors and predictability of adverse outcomes

ObjectiveTo compare adverse outcomes among preterm births that underwent cesarean delivery (CD) for non-reassuring fetal heart rate tracing (NRFHT) versus those that did not. Study designConsortium on Safe Labor Database was utilized for this secondary analysis. Inclusion criteria were non-anomalous, singleton at 23.0 to 36.6 weeks who labored for at least 2 h. Composite adverse neonatal outcomes included any of the following intraventricular hemorrhage grade III or IV, seizures, mechanical ventilation, sepsis, necrotizing enterocolitis 2 or 3, or neonatal death. Composite adverse maternal outcomes included any of the following postpartum hemorrhage, endometritis, blood transfusion, chorioamnionitis, admission to intensive care unit, thromboembolism, or death. ResultsOf 228,438 births, 29,592 (13.0%) delivered preterm, and 16,679 (56.4%) labored for at least 2 hrs. CD for NR FHRT was done in 1,220 (7.3%). The rate of composite adverse neonatal outcome was different among those that had CD for NR FHRT (26.7%) versus those that did not (16.6%; aRR 1.59, 95% CI 1.43–1.76). Composite adverse maternal outcomes did not differ between the groups. The area under the curve for risk factors to identify composite adverse neonatal outcome was 0.81, and for composite adverse maternal outcomes, 0.64. ConclusionsSubsequent to CD for NR FHRT, composite adverse neonatal outcome is 59% higher among preterm births when compared to delivery with reassuring tracing; composite adverse maternal outcomes did not differ between the groups.

Interobserver Agreement and Reliability of Intrapartum Nonreassuring Cardiotocography and Prediction of Neonatal Acidemia

Abstract Objective: To evaluate the agreement and reliability of intrapartum nonreasurring cardiotocography (CTG) interpretation and prediction of neonatal acidemia by obstetricians working in different centers. Methods: A retrospective cohort study involving two tertiary hospitals (The First Affiliated Hospital of Sun Yat-sen University and Perking University Third Hospital) was conducted between 30th September 2018 and 1st April 2019. Six obstetricians from two hospitals with three levels of experience (junior, medium, and senior) reviewed 100 nonreassuring fetal heart rate (FHR) tracings from 1 hour before the onset of abnormalities until delivery. Each reviewer determined the FHR pattern, the baseline, variability, and presence of acceleration, deceleration, sinusoidal pattern, and predicted whether neonatal acidemia and abnormal umbilical arterial pH < 7.1 would occur. Inter-observer agreement was assessed using the proportions of agreement (Pa) and the proportion of specific agreement (Pa for each category). Reliability was evaluated with the kappa statistic (k-Light's kappa for n raters) and Gwet's AC1 statistic. Results: Good inter-observer agreement was found in evaluation of most variables (Pa > 0.5), with the exception of early deceleration (Pa = 0.39, 95% confidence interval (CI): 0.36,0.43). Reliability was also good among most variables (AC1 > 0.40), except for acceleration, early deceleration, and prediction of neonatal acidemia (AC1 = 0.17, 0.10, and 0.25, respectively). There were no statistically significant differences among the three groups, except in the identification of accelerations (Pa = 0.89, 95% CI: 0.83,0.95; Pa = 0.50, 95% CI: 0.41,0.60, and Pa = 0.35, 95% CI: 0.25,0.43 in junior, medium and senior groups, respectively) and the prediction of neonatal acidemia (Pa = 0.52, 0.52, and 0.62 in junior, medium and senior groups, respectively), where agreement was highest and lowest in the junior-level group, respectively. The accuracy and sensitivity of the prediction for umbilical artery pH < 7.1 were similar among the three groups, but the specificity was higher in the senior groups (93.68% vs. 92.53% vs. 98.85% in junior, medium and senior groups, P = 0.015). Conclusion: Although we found a good inter-observer agreement in the evaluation of the most basic CTG features and FHR category statistically, it was insufficient to meet the clinical requirements for “no objection” interpretation for FHR tracings. Further specialized training is needed for standardized interpretation of intrapartum FHR tracings.

The Relationship between Nuchal Cord and Adverse Obstetric and Neonatal Outcomes: Retrospective Cohort Study.

Objective: The twisting of the umbilical cord around the fetal neck is a common phenomenon in the delivery room, and despite the lack of univocal evidence of its negative impact on perinatal events, it causes anxiety and stress in patients. The aim of the study was to assess the prevalence of nuchal cord and its impact on adverse obstetric and neonatal outcomes. Methods: We conducted a retrospective cohort study. All patients who gave birth in the clinic within one year (n = 1467) were included in the study group. We compared the prevalence of nuchal cord in distinct subgroups of patients. In the next stage, we estimated the chance of specific perinatal outcomes and compared the neonatal outcomes between groups with and without nuchal cord. Results: Nuchal cord was present in 24% of labors. It was twice as common among patients giving birth vaginally (32.14%) than among patients giving birth by a caesarean section (16.78%, p < 0.001). Nuchal cord was also more frequent in births with meconium-stained amniotic fluid (33.88% vs. 23.34%, p = 0.009). In the group of patients with nuchal cord, we observed a slight increase in the risk of a non-reassuring fetal heart rate trace (OR = 1.55, CI 95% 1.02–2.36) as an indication of the completion of labor by caesarean delivery. We did not note an increase in the risk of completing natural childbirth by vacuum extraction. In the group of nuchal cord patients, there was a higher chance of a serious or moderate neonatal condition in the first minute of life (Apgar 0–7 points) (OR = 2.00, 95% CI = 1.14–3.49). Conclusions: Nuchal cord increases the risk of a caesarean delivery due to a non-reassuring fetal heart rate trace. Nuchal cord increases the chance of a reduced Apgar score (0–7 points) in the first minute of life. The observed relationships do not translate to neonatal arterial blood gas testing.

Failed induction of labor and associated factors in Adama Hospital Medical College, Oromia Regional State, Ethiopia.

Background:Failed induction of labor continues to be a public health challenge throughout the world. This failed induction of labor is associated with a higher rate of maternal and fetal morbidity because it increases the unwanted effect of emergency cesarean section. It is also associated with an increased risk of numerous adverse maternal and perinatal outcomes such as uterine rupture, nonreassuring fetal heart rate tracing, postpartum hemorrhage, stillbirth, and severe birth asphyxia. Thus, this study was aimed to assess the failed induction of labor and associated factors in the Adama Hospital Medical College, Oromia Regional State, Ethiopia.Methods:A facility-based cross-sectional study was conducted from 1 to 30 December 2020 in Adama Hospital Medical College, Ethiopia. A total of 379 women who underwent labor induction in the Adama Hospital Medical College from December 2019 to November 2020 were enrolled in the study. The participants’ charts were selected using a simple random sampling technique. Data were collected using a pretested and validated structured questionnaire. Descriptive statistics were carried out using frequency tables, proportions, and summary measures. Predictors were assessed using a multivariable logistic regression analysis model and reported using adjusted odds ratio with 95% confidence interval. Statistical significance was considered at a p value <0.05.Results:Of 379 induced labor included in the study, the proportion of failed induction was found to be 29.6% (95% confidence interval (25.2, 34.3)). Prelabor rupture of the membrane was found to be the most common indication for induction of labor (46.4%) followed by a hypertensive disorder of pregnancy (21.6%). In the final model of multivariable analysis, predictors such as: nulliparity (adjusted odds ratio = 2.32, 95% confidence interval (1.08, 5.02)), unfavorable cervical status (adjusted odds ratio = 3.46, 95% confidence interval (1.51, 7.94)), prelabor rupture of membrane (adjusted odds ratio = 2.60, 95% confidence interval (1.14, 5.91)), hypertensive disorder of pregnancy (adjusted odds ratio = 3.01;95% confidence interval (1.61, 558)), preinduction membrane status (adjusted odds ratio = 3.63; 95% confidence interval (1.48, 8.86)), and birth weight of greater than 4000 g (adjusted odds ratio = 4.33; 95% confidence interval (1.44, 13.02)) were statistically associated with failed induction of labor.Conclusion:The prevalence of failed induction of labor was relatively high in this study area because more than a quarter of mothers who underwent induction of labor had failed induction. This calls for all stakeholders to adhere to locally available induction protocols and guidelines. In addition, pre-induction conditions must be a top priority to improve the outcome of induction of labor.

Application of a Proposed Algorithm to Cesarean Deliveries for Nonreassuring Fetal Heart Rate Tracing.

The aim of the study is to evaluate how current management of Category II fetal heart rate tracings compares with that suggested by a published algorithm and whether these differences lead to disparate neonatal outcomes. This is a retrospective observational study from the resident service at an academic-community tertiary care center from 2013 to 2018. We reviewed archived fetal heart rate tracings from patients with cesarean delivery performed for nonreassuring fetal heart rate tracing and interpreted tracings against the algorithm. We assigned tracings to one of three categories: Group A-consistent; Group B-inconsistent too early (algorithm permits the patient to labor longer); Group C-inconsistent too late (algorithm suggests performing the cesarean delivery sooner). Maternal demographics, features of labor, and neonatal outcomes were compared. Of the 110 cases, 27 (24.5%) had a cesarean delivery performed in group A, 49 (44.5%) in group B, and 34 (30.9%) in group C. Baseline characteristics were similar. Of the 49 in group B, 46 (93.9%) violated the algorithm at the same branchpoint. In group C, cesarean deliveries would have been performed on average 244 minutes earlier had the algorithm been used. Neonatal outcomes were not significantly different among the groups, including 5-minute Apgar <7, pH <7.1, and NICU admit. Our retrospective application of the algorithm showed that 44.5% of patients who have cesarean delivery for nonreassuring fetal heart rate tracing may be able to labor longer and that violation at a common decision point on the algorithm (moderate variability or accelerations, but a lack of recurrent decelerations) is responsible for nearly all such cesarean deliveries. More studies are needed to evaluate if cesarean delivery rates for nonreassuring fetal heart rate tracing can be reduced without impacting neonatal outcomes using the algorithm. · There is a potential to further standardize management of Category II fetal heart rate tracings.. · In our practice, 25% of cesareans performed for fetal distress were consistent with the algorithm.. · A subset of patients (45%) with cesarean for fetal distress may have been able to labor longer..

S2739 Successful Use of Plasmapheresis in Concurrent Fulminant Acute Fatty Liver of Pregnancy and COVID-19 Infection

Introduction: Acute fatty liver of pregnancy (AFLP) is a rare condition characterized by maternal liver dysfunction and/or failure during the third trimester or early postpartum period, thought to be caused by defects in fatty acid metabolism during pregnancy. Management includes prompt delivery and supportive care. In the following case, we describe a patient found to have fulminant liver failure after delivery but was unable to undergo liver transplantation due to Coronavirus Disease 2019 (COVID-19) infection. Fortunately, with plasmapheresis, the patient recovered from both fulminant liver failure and COVID-19. Case Description/Methods: A 26-year-old female 38 weeks pregnant with recent diagnosis of COVID-19 infection presented with 3 days of nausea, vomiting, abdominal pain, and polydipsia. Due to non-reassuring fetal heart rate tracings, emergency cesarean section was performed. On post-partum day one, she was noted to be somnolent and jaundiced. Laboratory testing revealed a leukocytosis of 17,800, platelets 168,000, creatinine 3.95 mg/dL, glucose 26 mg/dL, uric acid 8.4 mg/dL, total bilirubin 8.5 mg/dL, AST 234 U/L, ALT 224 U/L, ALP 466 U/L, PT 57.3 s, and ammonia 69 µmol/L. A chest x-ray showed bibasilar opacities; abdominal ultrasound revealed a mildly fatty liver and ascites. Viral, autoimmune hepatitis, hemochromatosis, alpha-1 antitrypsin deficiency, and Wilson’s serologies were unremarkable. Thirteen Swansea criteria were met, thus a diagnosis of AFLP was made. Liver transplantation was initially considered but was high risk due to active COVID-19 infection resulting in respiratory failure requiring intubation. After multidisciplinary discussion, she was started on plasmapheresis. After 6 days of plasmapheresis, liver and renal function improved. She was discharged home on post-partum day 19. Discussion: In the above case, we describe a patient with COVID-19 infection with fulminant liver failure from AFLP. The patient needed a liver transplant due to rapidly worsening liver function. However, due to limited data on the safety of liver transplantation in active COVID-19 infection, it was deemed high-risk. Fortunately, the patient’s condition improved with plasmapheresis, and liver transplant was not needed. Plasmapheresis removes toxins, ammonia, and inflammatory cytokines while replacing coagulation factors, albumin, and biologically active substances that are typically produced by liver cells. The therapy has also been reported to be an effective salvage treatment for severe cases of COVID-19.

Cesarean delivery at term for non-reassuring fetal heart rate tracing: risk factors and predictability

Objective To delineate risk factors for adverse outcomes among those who underwent cesarean delivery (CD) for non-reassuring fetal heart rate tracing (NRFHT) and ascertain whether neonatal or maternal morbidity can be predicted accurately. Methods The Consortium on Safe Labor Database was utilized for this secondary analysis. Inclusion criteria were non-anomalous, singleton gestations between 37.0 and 41.6 weeks who underwent CD for NRFHT. Composite adverse neonatal outcomes (CANO) included Apgar <5 at 5 min, seizures, mechanical ventilation, sepsis, intraventricular hemorrhage, necrotizing enterocolitis or neonatal death. Composite adverse maternal outcomes (CAMO) included endometritis, blood transfusion, wound complication, admission to intensive care unit, thromboembolism, hysterectomy or death. Bivariable analysis and multivariable Poisson regression were used to identify risk factors independently associated with adverse outcomes. Receiver operating characteristic (ROC) curves were created to evaluate the predictive value of the models for adverse outcomes. Results Of 228,438 births in the database, 7310 individuals (3.7%) met inclusion criteria. Among this cohort, CANO occurred 3.8% of the time. CANO was less common among people over 35 years (9.8% versus 18.4% p < .01) but was more common among those with at least high-school education (15.3% versus 11.2%; p < .01), varying by ethnicity (p < .01). CAMO occurred in 3.4% and was less common among those undergoing induction of labor (37.3% versus 49.4%; p < .01) and more common among those with clinical chorioamnionitis (8.4% versus 4.3%; p < .01). The area under the curve (AUC) for ROC curve to identify CANO was 0.63 implying a limited ability to predict neonatal adverse outcomes. The AUC for identifying women with maternal adverse outcomes was 0.69 also indicating a moderate prediction ability. Conclusions Among singletons between 37 and 41 weeks who labored, the rate of CD for NRFHT was about 3.7% and among them CANO occurred in 3.8%. While risk factors for adverse neonatal outcomes following CD for NRFHT are identifiable, they do not suffice to predict them.

198 Cesarean delivery for non-reassuring fetal heart rate tracing: risk factors and predictability of adverse outcomes

Non-reassuring fetal heart rate tracing (NRFHT) is a common driver of cesarean delivery (CD) but data is lacking to predict composite neonatal and maternal adverse outcomes (CNAO and CMAO, respectively). The primary objectives were to identify risk factors for CNAO and CMAO among those who underwent CD for NRFHT and explore predictive models. We conducted a secondary analysis of the Consortium on Safe Labor Database. Eligible subjects included persons with non-anomalous singleton gestations between 37.0 and 41.6 weeks who had CD for NRFHT. Pre-CD variables from the database were used to develop a model to identify those with and without adverse outcomes. Bivariable analysis and multivariable Poisson regression with robust error variance were used to identify independent risk factors. Receiver operating characteristic (ROC) curves were created to evaluate the predictive value of the models for adverse outcomes. Of the 228,438 births, 7,310 (3.7%) met eligibility criteria. Adverse composite outcomes occurred in 3.8% of newborns and 3.4% of mothers following CD for NRFHT. Neonatal sepsis (45%) and the need for intubation (26%) were the most common drivers of CNAO while CMAO was most often due to need for transfusion (39%) and endometritis (31%). 10 maternal characteristics and 17 intrapartum variables were analyzed in bivariable analysis. Three maternal and three intrapartum risk factors were identified for CNAO (AUC=0.62; Table 1). Three maternal and four intrapartum risk factors were identified for CMAO (AUC=0.66; Table 2). For both groups the single most predictive driver of adverse outcome was chorioamnionitis. Neonatal sepsis (45%) and the need for intubation (26%) were the most common drivers of CNAO while CMAO was most often due to need for transfusion (39%) and endometritis (31%). NRFHT was the indication for CD in ∼ 4% of term deliveries and ∼4% have CNAO or CMAO. Though certain demographic and intrapartum factors increase the risk of adverse outcomes they are not clinically useful to predict who will experience them.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

VP45.33: A 41‐year‐old multigravida pregnancy with COVID‐19 infection in third trimester: a case of transient deterioration after Caesarean

Caesarean section in mothers infected with COVID-19 may linked to clinical deterioration. Physiological changes in the cardiovascular, respiratory, and coagulation systems may lead to increased risk of morbidity. Our case had a transient deterioration after Caesarean. A 41-year-old multigravida (G6P5), without any underlying medical disease, was refered to our centre at 36 weeks of gestation with complaints of fever, dry cough, shortness of breath and myalgia on 19 March 2020. Her husband's nasopharynx swab test became SARS-COVID positive and had mild symptoms. He was isolated at home. She was admitted due to suspected COVID-19 pneumonia. She was normotensive, febrile, and tachypneic on admission. Her chest CT on admission had bilateral patchy ground-glass features, nasopharyngeal swab for SARS-COVID had a positive result. The laboratory investigation showed lymphocytopenia, increased liver function tests and CRP levels. Antepartum monitoring was reassuring. Treatment with diphenhydramin, azithromycin and kaletra was initiated. Within 24h of admission, she developed acute hypoxemia, tachypenea and decreased O2 saturation and non-reassuring fetal heart rate tracing. An emergency Caesarean section was performed, leading to birth of a liveborn girl weighing 3,100g, Apgar score was 8/10 and 9/10 at 1st and 5th minute, her neonate was isolated and referred to neonatal centre and nasopharyngeal swab was SARS-CoV2 negative. Our patient was transferred to ICU after delivery and continued on oxygen support. 24h later, she decompensated and was intubated. Mechanical ventilation was continued for 6 days and then she was extubed and was managed by NIV for 48h, then on Day 11 she was transferred to ward. On Day 13 her general condition improved and was discharged from hospital on outpatient orders. The mother and her neonate remained healthy during follow-up.

Effect of embryo stage at transfer on placental histopathology features in singleton live births resulting from fresh embryo transfers

To evaluate the effect of embryo stage at transfer on placental histopathology and perinatal outcome in singleton live births resulting from fresh embryo transfers (ETs). Retrospective cohort study. Not applicable. The study population included all live births after fresh ETs during the period from 2009 to2017. None. Primary outcomes included anatomic, inflammatory, vascular malperfusion, and villous maturation placental features. Secondary outcomes included fetal, maternal, and perinatal complications. A total of 677 live births were included in the final analysis and were allocated to the cleavage-stage (n = 252) and blastocyst (n = 425) ET groups. After the adjustment for confounding factors, the blastocyst group was found to be associated with a higher incidence of circummarginate membranes insertion (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.2-3.4), delayed villous maturation (OR 8.5, 95% CI 1.2-69.3), chorangiosis (OR 2.0, 95% CI 1.2-3.8), parenchymal calcifications (OR 10.6, 95% CI 1.4-80.2), and intrapartum nonreassuring fetal heart rate tracing (OR 2.4, 95% CI 1.3-4.5). Compared with cleavage-stage ETs, live births resulting from the blastocysts were associated with a lower incidence of velamentous cord insertion (OR 0.5, 95% CI 0.3-0.9), retroplacental hematoma (OR 0.3, 95% CI 0.1-0.8), subchorionic thrombi (OR 0.3, 95% CI 0.1-0.8), and avascular villi (OR 0.2, 95% CI 0.03-0.7). Live births resulting from fresh cleavage-stage and blastocyst ETs have different placental histopathology features, with a higher rate of intrapartum nonreassuring fetal heart rate tracing in the blastocyst group.

914: Second stage of labor: Maternal and perinatal outcomes of cesarean versus attempted operative vaginal delivery

Among women who reach the second stage of labor and require operative delivery, little data exists on the maternal and perinatal outcomes based on attempted operative vaginal delivery (OVD) vs cesarean delivery (CD) without attempted OVD. The objective of this study was to compare the maternal and perinatal outcomes among these two groups. This is a secondary analysis of data from a multicenter prospective study for women enrolled in the Cesarean Registry. We compared the maternal and perinatal outcomes based on whether OVD was attempted or CD was performed without attempt. This study includes singleton, at > 37 weeks, pregnancies that were eligible for OVD (10cm dilated and +2 station). Exclusion criteria included those who underwent CD in second stage with primary indication of non-reassuring fetal heart rate tracing and those with anomalous fetuses. Primary outcome was composite maternal morbidity and secondary outcome was composite neonatal morbidity. A multivariable Poisson regression analysis was used to examine the association between attempt of OVD and outcomes, while adjusting for potential confounding factors that were different between groups at a p value of < 0.1 in univariate analysis. A total of 1,432 women met the inclusion criteria: 1,025 (71%) had an attempted OVD and 407 underwent CD without attempt (39%). Women who attempted OVD were more likely to have composite maternal morbidity (aRR 2.93, 95% CI 1.92-4.49), mostly from third and fourth degree perineal lacerations (Table 1). There was no significant difference in rates of composite neonatal morbidity between groups; however, neonatal birth injury was significantly more frequent in the group who had an attempted OVD (aRR 4.79, 95% CI 1.85-12.42)(Table 2). In women reaching the second stage, CD without attempt was associated with lower maternal morbidity and less neonatal birth injury. Given that OVD training is declining in residency programs, these data may have clinical implications regarding counseling of patients eligible for OVD.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Neonatal and maternal outcomes of pregnancies with a fetal diagnosis of congenital heart disease using a standardized delivery room management protocol.

We sought to determine if fetuses with prenatally diagnosed congenital heart disease (CHD) were more likely to undergo cesarean delivery in the setting of a non-reassuring fetal heart rate tracing (NRFHT) and to determine if those fetuses were more likely to have a fetal acidosis. A retrospective cohort study of neonates prenatally diagnosed with CHD from August 2010 to July 2016. The control group consisted of gestational age matched controls without CHD. Each group consisted of 143 patients. The most common reason for cesarean delivery was a NRFHT (control 31% vs CHD 35%, p = 0.67). Fetal acidosis was a rare outcome occurring in only five controls (3.5%) and 11 cases (7.7%) (p = 0.12). These findings demonstrate that with multidisciplinary care coordination, fetuses with a prenatal diagnosis of CHD have similar cesarean rates, labor and delivery management, and delivery room compromise as healthy fetuses.

Assessment of fetal left ventricular modified myocardial performance index and its prognostic significance for adverse perinatal outcome in intrahepatic cholestasis of pregnancy

Objective: To investigate the association between fetal left ventricular modified myocardial performance index (LMPI) and intrahepatic cholestasis of pregnancy (ICP) and to evaluate the value of LMPI in predicting adverse perinatal outcomes in ICP.Study design: In a cross-sectional case–control study, 40 women with ICP were compared with 40 gestational age-matched healthy controls. The isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT), and ejection time (ET) were measured using the Doppler signals of the opening and closing of the mitral and aortic valves. LMPI was calculated as (ICT + IRT)/ET. An adverse perinatal outcome was defined with at least one of the following: non-reassuring fetal heart rate tracing, umbilical cord pH <7.20, the presence of meconium in amnion, and neonatal intensive care unit (NICU) admission.Results: Mean gestational age at delivery and mean birth weight were significantly lower and the incidences of cesarean section rate, non-reassuring fetal heart rate tracing, the presence of meconium in amnion, and NICU admission were significantly higher in the ICP group (p < .01). Mean LMPI, ICT, and IRT values were significantly higher in the ICP group (p < .01). The area under the receiver operating characteristic (ROC) curve for LMPI in prediction of adverse perinatal outcome was 0.740 (95% CI: 0.607–0.873, p = .001) and a cut-off LMPI of 0.41 conferred a sensitivity of 85% and a specificity of 61%.Conclusions: There is an impaired global ventricular function in ICP fetuses demonstrated by increased LMPI. High LMPI is associated with adverse perinatal outcome in ICP.

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.

Female Sexual Function and Perineal Pain Following Median versus Mediolateral Episiotomy in Primiparous Women: A Two-Year Follow up Study

Episiotomy is the most frequently performed surgical procedure for labour management especially when expedited delivery is warranted as in non-reassuring fetal heart rate tracing, a prolonged second stage of labour, or when operative vaginal delivery is indicated [1-3]. Postpartum perineal pain and dyspareunia affect about 42% of primiparous women within the first 2 weeks after vaginal delivery. Pain resolved in the majority of women within 2 months after delivery. Spontaneous second degree tears cause less perineal pain than episiotomies [4].

Accuracy of intrapartum fetal blood gas analysis by scalp sampling

Fetal blood gas analysis (FBGA) using scalp blood is commonly used to identify serious fetal distress. However, there is a lack of data regarding its accuracy and reliability. The aim of this study was to determine the positive predictive value (PPV) and negative predictive value (NPV) of FBGA for predicting postpartum acidosis in case of nonreassuring fetal heart rate tracings (NRFHRT). To this end, we conducted a retrospective cohort study of singleton term deliveries with NRFHRT according to Fédération Internationale de Gynécologie et d’Obstétrique and Fisher cardiotocography scores undergoing FBGA in a university hospital. The PPV and NPV of FBGA regarding neonatal acidosis (defined as a pH value ≤ 7.15 in arterial or venous umbilical cord blood) and Apgar scores indicating neonatal depression (defined as a 5-min Apgar score ≤5) were evaluated. Multivariate analysis was used to determine the influence of cardiotocography variations and the time delay between FBGA and delivery on the accuracy of FBGA. We analyzed 343 deliveries with NRFHRT. In 32 (9%) of these cases, fetal acidosis was confirmed by a postpartum umbilical cord blood pH value ≤ 7.15. In 308/343 (90%) cases, FBGA identified NRFHRT as false positive (as confirmed by nonacidotic postpartum pH values) and thus avoided unnecessary interventions such as operative delivery. The overall test accuracy of FBGA was 91%. FBGA accurately predicted postpartum cord blood pH values with a margin of ±0.2 in 319/343 (93%) cases. On the other hand, the false negative rate of FBGA was 8% (29/343). The PPV and NPV of FBGA for predicting postpartum acidosis were 50% and 91%, respectively. The sensitivity was 9% and the specificity was 99%. In a multivariate logistic regression analysis, maternal body mass index (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.01–1.17; P = .029) and cardiotocography variations (OR 0.80; 95% CI 0.66–0.98; P = .029) independently affected the predictive value of FBGA. The PPV of FBGA regarding neonatal depression according to Apgar scores was low with only 17%. We conclude that FBGA may be used in clinical practice to rule out, but not to rule in, neonatal acidosis in parturients with NRFHRT. It can avoid unnecessary interventions such as cesarean section or operative vaginal delivery in up to 90% of cases, but cannot reliably detect fetal acidosis.

Perinatal Outcomes Associated With Isolated Velamentous Cord Insertion in Singleton and Twin Pregnancies.

To evaluate perinatal outcomes in singleton and twin pregnancies with pathologically confirmed velamentous cord insertion without vasa previa. This retrospective case-control study included all nonanomalous singleton and twin pregnancies with pathologically confirmed velamentous cord insertion delivered in a single institution between January 1, 2005, and July 1, 2015, and having an ultrasound examination by maternal-fetal medicine. For each case, the next 2 consecutive deliveries matched for gestational age at delivery ± 1 week and, in twins, amnionicity and chorionicity served as controls. Primary outcomes included surgical delivery for a nonreassuring intrapartum fetal heart rate tracing, umbilical arterial cord pH of less than 7.2, 5-minute Apgar score of less than 7, birth weight below the 10th percentile, neonatal intensive care unit admission, fetal or neonatal death, and cord avulsion necessitating manual placental extraction. Outcomes were available for 53 singletons with 103 matched controls and 33 twin pregnancies with 65 matched controls. In singletons, velamentous cord insertion was associated with cord pH of less than 7.2 (odds ratio [OR] 3.5; 95% confidence interval [CI], 1.1-11.2; P = .039), 5-minute Apgar score of less than 7 (OR, 5.3; 95% CI, 0.99-28.1; P = .045), and cord avulsion requiring manual placental extraction (7.5% versus 0%; P = .012). Associations were suggested with increased surgical delivery for a nonreassuring intrapartum fetal heart rate tracing (OR, 2.4; 95% CI, 0.9-6.9; P = .14), birth weight below the 10th percentile (OR, 2.1; 95% CI, 0.8-5.9; P = .21), and fetal or neonatal death (3.8% versus 0%; P = .11). Velamentous cord insertions were also associated with placental abruption in singletons (7.5% versus 0%; P = .013). Among twins, velamentous cord insertion was associated with fetal or neonatal death (9.1% versus 0%; P = .036). Isolated confirmed velamentous cord insertion is associated with adverse perinatal outcomes in singleton and twin gestations.