Non-reassuring Fetal Monitoring Research Articles

Obstetric and perinatal outcome in short-stature patients.

Scarce data exist regarding obstetric complications of short-stature patients. This study aimed to investigate obstetric and perinatal outcomes in women with short stature; specifically, to investigate whether short-stature patients are at an increased risk for cesarean delivery. A population-based cohort study was conducted, including all singletons born between the years 1991 and 2021 at a tertiary medical center. Obstetric and perinatal outcomes of short-stature patients were compared with those of non-short patients. A generalized estimation equation binary logistic model was constructed to adjust for confounders and maternal recurrence in the cohort. The study population included 356 356 parturient; among them, 14 035 (3.9%) were short-stature patients. Short-stature patients had significantly higher rates of cesarean delivery (20.7% vs 13.7%, odds ratio = 1.64, 95% confidence interval 1.57-1.71, P < 0.001), induction of labor, pathologic presentations, prolonged second stage of labor, non-reassuring fetal monitoring, and meconium-stained amniotic fluid. Newborns of short-stature patients had a significantly higher risk of being small for gestational age as compared with those of non-short patients. In the generalized estimation equation models, the association between short stature and risk of cesarean delivery remained significant (adjusted odds ratio = 1.32, 95% confidence interval 1.27-1.38, P < 0.001), as well as the risk of small for gestational age newborns (adjusted odds ratio = 1.51, 95% confidence interval 1.40-1.63, P < 0.001), but not for the other adverse outcomes. Maternal short stature is an independent risk factor for cesarean delivery and is associated with small for gestational age newborns.

Trends in cesarean among low-risk deliveries in the United States, 2000-2019

Current recommendations for safely preventing cesarean delivery include allowing for longer labor prior to diagnosing labor arrest. The objective of this study was to determine temporal trends in indications for cesarean delivery (CD) among low-risk patients over a 20-year period. This repeated cross-sectional study analyzed delivery hospitalizations among women aged 15-54 years at low risk for cesarean using the National Inpatient Sample from 2000-2019. Deliveries at low risk for CD were identified using SMFM criteria. CD indications were analyzed, and included non-reassuring fetal monitoring and labor dystocia/arrest. Labor arrest was further characterized as occurring during the active phase, the latent phase, or the second stage. Temporal trends in CD indications were analyzed using joinpoint regression to estimate the average annual percent change (AAPC) with 95% confidence intervals (CIs). Of 76 million delivery hospitalizations identified, an estimated 42,670,197 deliveries were determined to be at low risk for CD. Of these deliveries, 12.7% (5,420,406) delivered by cesarean. From 2000-2009, low-risk cesareans increased from 10.1% to 14.5%, plateaued, and then decreased from 13.7% to 11.9% from 2012-2019 (Figure 1). From 2000-2005, the AAPC for CD was 6.5% (95% CI 5.3%, 7.7%), 1.1% from 2005-2009 (95% CI -1.3%, 3.6%) and -2.1% from 2009-2019 (95% CI -2.5%, -1.6%). CD for non-reassuring fetal monitoring increased from 3.2% of all deliveries in 2000, to 5.1% in 2019 (AAPC 2.7%, 95% CI 2.2%, 3.3%). CD for labor arrest increased from 3.6% in 2000 to a peak of 4.6% in 2009 before decreasing to 2.7% in 2019 (Figure 2). CD for arrest during the active phase, latent phase, and second stage all increased during the first half of the study from 2000 to 2009 and then decreased from 2010 to 2019. Low-risk cesarean deliveries decreased over the latter years of the study period with cesarean for labor arrest becoming less common. Cesarean delivery for non-reassuring fetal monitoring has continued to increase. These findings support uptake of clinical recommendations.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

7728 Pregnancy Outcomes after Transcervical Fibroid Ablation (TFA) with the Sonata® System

<h3>Study Objective</h3> To describe pregnancy outcomes in women who conceived after undergoing transcervical fibroid ablation (TFA) as treatment for symptomatic uterine fibroids. <h3>Design</h3> Retrospective study. <h3>Setting</h3> Hospitals in Europe, the UK, Mexico and the US. <h3>Patients or Participants</h3> Women who reported pregnancies after undergoing TFA with the Sonata® System. <h3>Interventions</h3> TFA was used to ablate fibroids, both under clinical trial protocol and commercial usage. <h3>Measurements and Main Results</h3> To date, there have been 43 pregnancies representing 25 deliveries among 35 women who were treated with TFA. Five women conceived more than once post-ablation, and four conceived through assisted reproductive technology (ART). Outcomes include 10 vaginal deliveries, 15 Cesarean sections, 4 therapeutic abortions, and 8 first-trimester pregnancy losses. Of the 8 miscarriages, four occurred in a patient with a history of recurrent abortion and an immunologic disorder and she subsequently had a delivery at term. Six women are currently pregnant. All 5-minute Apgar scores were >7 and all neonates weighed >2500 gms. Deliveries occurred at ≥37 weeks, except for one delivery at 35 6/7 weeks. There were no uterine ruptures or abnormal placentation and no reports of postpartum hemorrhage. Cesarean sections were performed for standard obstetric indications, including non-reassuring fetal monitoring in a patient with HELLP syndrome, fetal macrosomia, dystocia and patient choice. On average, 1.4 fibroids were ablated per patient, and these included transmural, submucous and intramural myomata up to 7 cm in diameter. <h3>Conclusion</h3> Normal pregnancy outcomes at term have occurred after TFA with the Sonata System, including in women with recurrent abortion and in those undergoing ART.

Oligohydramnios: how severe is severe?

Objective To investigate whether the severity of isolated oligohydramnios at term is associated with increased rates of adverse perinatal outcome. Study design A retrospective study conducted in a single medical center from 2017 to 2019. All low-risk pregnancies with incidental isolated oligohydramnios at term were included. The degree of oligohydramnios was arbitrarily classified into mild (AFI = 41–50 mm), moderate (AFI = 21–40 mm) and severe (AFI = 0–20 mm). Result A total of 610 women were included: 202 with a mild (33.1%), 287 moderate (47.0%), and 121 severe oligohydramnios (19.8%). Non-reassuring monitor requiring immediate delivery and worse composite neonatal outcome were more common among severe than mild or moderate oligohydramnios (14.0% and 6.4%, 7.3% respectively; p = .039 and 19.8%, 10.9% and 11.8%, respectively; p = .048). Conclusion Low-risk pregnancies with isolated severe oligohydramnios at term have a higher tendency toward non-reassuring fetal monitoring requiring prompt delivery and adverse neonatal outcomes, this calls for close intrapartum surveillance

Meconium peritonitis following intestinal atresia: A case report

Meconium peritonitis is a sterile chemical peritonitis, which frequently occurs after intestinal perforation in utero. Overall mortality rates have drastically decreased with earlier prenatal diagnosis and improved perinatal care. However, perinatal surgical management of meconium peritonitis is largely dependent on individual surgeon experience. We present a case of meconium peritonitis with emergent cesarean section delivery after the patient developed massive meconium ascites, hydrops fetalis, and non-reassuring fetal monitoring. In the immediate post-natal period, the patient was intubated and a peritoneal drain was placed for respiratory and hemodynamic stabilization. He was then taken to the operating room the following day for laparotomy and bowel resection. His post-operative course was uneventful, and he was discharged home in good clinical condition.

Dichorionic twin pregnancy discordant for fetal anencephaly: a case report

Dichorionic twin pregnancy discordant for fetal anencephaly is a serious condition that threatens the normal co-twin's life by causing polyhydramniosis, preterm labor and sudden death of one or both of the fetuses. We report a case of dichorionic twin pregnancy discordant for fetal anencephaly delivered at the 32(nd) week of gestation because of preterm labor and nonreassuring fetal monitoring. The aim of this case report is to summarize management options in this situation.

Abnormal Placental Findings Associated with Non-Reassuring Fetal Monitoring and Excellent Neonatal Outcomes

Objective: Obstetricians, Neonatologists, and Pathologists have studied gross histological analysis of human placentas in search of specific alterations in placental functions that can be correlated with neonatal outcomes. Our study assessed the prevalence of abnormal placental findings associated with non-reassuring fetal monitoring in labor requiring emergent instrumental or cesarean delivery, followed by an excellent neonatal outcome. Study Design: One hundred consecutive emergency deliveries, instrumental or cesarean, performed due to non-reassuring fetal monitoring while in labor were retrospectively evaluated. All patients were low-risk for obstetric complications, and had a singleton, term pregnancy. They had a normal antenatal routine testing and a normal anatomy ultrasound scan at 20 to 22 weeks gestation. Results: There were 35 placentas (35%) with gross placental anomalies at the delivery triage. Additionally 7 placentas (7%) were reported to be abnormal at the pathology examination. Conclusion: The prevalence of abnormal placental findings in our studied population was 42%.

External cephalic version for breech presentation at term.

To assess the success rate of External Cephalic Version (ECV) at term and its effects on measures of pregnancy outcome. A quasi-experimental study. The study was conducted at Hayatabad Medical Complex, Peshawar, from December 2003 to January 2005. A total of 40 patients were offered ECV over a period of fourteen months. All singleton breech presentations with an otherwise normal antenatal course between 36-41 weeks of gestation were included in the study. Exclusion criteria included contraindications to ECV i.e. multiple pregnancy, oligohydramnios, growth retardation, antepartum hemorrhage, rupture of membranes toxemias of pregnancy, non-reassuring fetal monitoring pattern, previous uterine scar, bad obstetric history, any contraindication to vaginal delivery, labour and patient wishes after thorough counseling. Overall success rate of the procedure and its effect on maternal and fetal outcome was determined. Significance of results was determined using Chi-square test. A total of 40 patients were recruited for the trial. Overall success rate was 67.5% with only 30% being primi-gravida (p < 0.05). Multi-gravida showed higher success rate of 80%. Following successful ECV, spontaneous vaginal delivery was attained in 77.7% (n=21), while caesarean section was performed due to various indications in about 6 cases (p < 0.05). Following failed version, 61.5% (n=8) had elective C/S and only 5 delivered vaginally. Route of delivery did not affect the perinatal outcome except for congenital abnormalities. Following successful ECV, there was only one stillbirth. Overall live births associated with successful version was 96.2% (p < 0.05), while in failed version, there were no fetal deaths. ECV at term appears to be a useful procedure to reduce the number and associated complications of term breech presentation. It is safe for the mother and the fetus and helps to avoid a significant number of caesarean sections.

Cord Gas Analysis, Decision-to-Delivery Interval, and the 30-Minute Rule for Emergency Cesareans

The so-called 30-minute rule is that hospitals having obstetric facilities should be equipped to perform an emergency cesarean delivery starting within 30 minutes of the decision to operate. This study examined the relationship between the results of umbilical arterial blood gas analysis and the decision-to-delivery interval in emergency cases with nonreassuring fetal status. Improved outcomes with an interval less than 30 minutes would presumably validate the rule. A retrospective cohort study included all cesarean deliveries done for this reason during a 16-month period in the years 2001 to 2003. Three specialists in maternal-fetal medicine, masked to the outcome, received a synopsis of clinical information that would have been available at the time of delivery as well as the last hour of the electronic fetal heart rate tracing. Emergent deliveries were done as soon as possible and deliveries within 30 minutes of the decision to operate. The series included 117 women, 34 classified as emergent and 83 as urgent. General anesthesia was given significantly more often in emergent cases and epidural anesthesia in urgent cases. The decision-to-delivery time was nearly 14 minutes less in the emergent group. There were no differences in 1- or 5-minute Apgar scores, but both the umbilical arterial pH and base excess were significantly worse in emergent cases. The decision-to-delivery interval was nearly 15 minutes shorter for general than for spinal anesthesia and 13 minutes less than with epidural anesthesia. Apgar scores recorded at 5 minutes (but not at 1 minute) were significantly increased with general anesthesia. Umbilical artery pH values did not differ significantly between groups, but base excess was significantly less favorable with general anesthesia. An increased decision-to-delivery interval correlated with improved umbilical arterial pH and base excess. This correlation did not help to predict when the fetus would develop metabolic acidosis severe enough to increase the risk of long-term neurologic morbidity. A very large majority of fetuses had normal values even after 30 minutes. Seven premature infants had intraventricular hemorrhage; 6 of them survived. Only fair to moderate agreement was found between the 3 specialists. Metabolic acidosis is not sensitively predicted by electronic fetal monitoring. In this study, blood gas values remained normal even when birth took place more than 30 minutes after the decision to operate. In the presence of nonreassuring fetal monitoring, the 30-minute rule is a compromise that does not precisely predict how much time will pass before severe metabolic acidosis develops.

Cord Gas Analysis, Decision-to-Delivery Interval, and the 30-Minute Rule for Emergency Cesareans

Our primary objective was to examine the relationship between umbilical arterial gas analysis and decision-to-delivery interval for emergency cesareans performed for nonreassuring fetal status to determine if this would validate the 30-minute rule. For this retrospective cohort study, all cesarean deliveries performed for nonreassuring fetal status from September 2001 to January 2003 were reviewed. A synopsis of clinical information that would have been available to the clinician at the time of delivery and the last hour of the electronic fetal heart rate tracing prior to delivery were reviewed by three different maternal-fetal medicine specialists masked to outcome, who classified each delivery as either emergent (delivery as soon as possible) or urgent (willing to wait up to 30 minutes for delivery) since immediacy of the fetal condition is the key factor affecting the type of anesthesia used. Of 145 cesareans performed for nonreassuring fetal status during this period, 117 patients met criteria for entry, of which 34 were classified as emergent and 83 as urgent. Kappa correlation was 0.35, showing only fair/moderate agreement between reviewers. In the emergent group, general anesthesia was more common (35.3%, 10.8%, p=0.003), and the decision-to-delivery interval was 14 minutes shorter (23.0+/-15.3, 36.7+/-14.9 minutes, p<0.001). Linear regression showed a statistically significant relationship between increasing decision-to-delivery interval and umbilical arterial pH (r=0.22, p=0.02) and base excess (r=0.33, p<0.001) showing that delivery proceeded sooner for most of those with the worst cord gases, with a gradual improvement over time. For the 13 (11%) neonates with cord gases placing them at increased risk for long-term neurologic sequelae, the decision-to-delivery interval was 24.7+/-14.6 minutes (range 6 to 50 minutes), and 3/13 (23%) were classified as urgent rather than emergent. Electronic fetal monitoring shows considerable variation in interpretation among maternal-fetal medicine specialists and is not a sensitive predictor of the fetus developing metabolic acidosis. There is no deterioration in cord gas results after 30 minutes, and most neonates delivered emergently or urgently for nonreassuring fetal status even when born after 30 minutes have normal cord gases. The 30-minute rule is a compromise that reflects the time it takes the fetus to develop severe metabolic acidosis, our imprecision in its identification, and its rarity in the presence of nonreassuring fetal monitoring.

Non-Immune Hydrops and Superior Vena cava Syndrome due to Diaphragmatic Hernia in One Twin

Background: In a monochorionic twin gestation, hydrops in one fetus often results from placental transfusion, accompanied by intrauterine growth restriction (IUGR) of the non-hydropic fetus. Case: A 35-year-old G11P9 presented with hydrops and IUGR of one of a monochorionic-diamniotic gestation. Extensive testing failed to reveal etiology for hydrops. The patient was delivered at 30 weeks gestation after non-reassuring fetal monitoring. The hydropic baby could not be adequately ventilated and expired in the early post-partum period. A diagnosis of superior vena cava syndrome and pulmonary hypoplasia secondary to right-sided congenital diaphragmatic hernia (CDH) was made neonatally. Conclusion: Right-sided CDH can be difficult to diagnose by sonography at times because of the echogenic similarity of liver and lung, and may be suspected from signs of pericardial effusion and ascites.

Traumatic liver rupture in pregnancy

Two pregnant women, 1 in the second trimester and 1 in the third trimester, sustained blunt liver trauma as unrestrained drivers in motor vehicle accidents. One patient had an overt injury that was apparent on computerized tomography and underwent surgical exploration when nonreassuring fetal monitoring occurred. The second patient, discharged after 23 hours of normal observation, returned a day later with overt intra-abdominal hemorrhage from an obvious liver laceration. (Am J Obstet Gynecol 1999;180:1030-1.)