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Ito A, Hayata E, Kotaki H, Shimabukuro M, Takano M, Nagasaki S, Nakata M. The iPREFACE score is useful for predicting fetal acidemia: A retrospective cohort study of 113 patients who underwent emergency cesarean section for non-reassuring fetal status during labor. AJOG GLOBAL REPORTS 2024; 4:100343. [PMID: 38699222 PMCID: PMC11063498 DOI: 10.1016/j.xagr.2024.100343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND The iPREFACE score may aid in predicting fetal acidemia and neonatal asphyxia in emergency cesarean and vaginal deliveries, which may improve labor management precision in the future. OBJECTIVE This study aimed to assess the score use of the iPREFACE as an objective indicator of the need for rapid delivery in cases of repeated abnormal waveforms without concurrent indications for immediate medical intervention during labor. STUDY DESIGN This retrospective cohort study was conducted among term (37+ 0 days to 41+6 days) singleton pregnant women who underwent emergency cesarean delivery owing to a nonreassuring fetal status. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery score, calculated from a 30-minute cardiotocography waveform before the decision to perform emergency cesarean delivery, and the integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer score, calculated from a 30-minute cardiotocography waveform before cardiotocography transducer removal, were employed. The primary outcome was the assessment of the predictive ability of these scores for fetal acidemia, whereas the secondary outcomes were differences in umbilical artery blood gas findings and postnatal outcomes between the 2 groups, divided by the cutoff values of the integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography score. RESULTS The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery and integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer scores demonstrated the capability to predict an umbilical artery blood pH of <7.2. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery and -removal of cardiotocography transducer score, with cutoff values of 37 and 46 points, respectively, exhibited an area under the receiver operating characteristic curve of 0.82 and 0.87, respectively. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer group with ≥46 points had higher incidence rates of an umbilical cord artery blood pH of <7.2, <7.1, and <7.0 and neonatal intensive care unit admissions for neonatal asphyxia. CONCLUSION The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring, derived from cardiotocography during an emergency cesarean delivery, may enable clinicians to predict fetal acidemia in cases of nonreassuring fetal status. Improved prediction of fetal acidemia and facilitation of timely intervention hold promise for enhancing the outcomes of mothers and newborns during childbirth. Prospective studies are warranted to establish precise cutoff values and to validate the clinical application of these scores.
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Affiliation(s)
- Ayumu Ito
- Department of Obstetrics and Gynecology, Faculty of Medicine, Toho University, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
| | - Eijiro Hayata
- Department of Obstetrics and Gynecology, Faculty of Medicine, Toho University, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
| | - Hikari Kotaki
- Department of Obstetrics and Gynecology, Faculty of Medicine, Toho University, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
| | - Makiko Shimabukuro
- Department of Obstetrics and Gynecology, Faculty of Medicine, Toho University, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
| | - Mayumi Takano
- Department of Obstetrics and Gynecology, Faculty of Medicine, Toho University, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
| | - Sumito Nagasaki
- Department of Obstetrics and Gynecology, Faculty of Medicine, Toho University, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Faculty of Medicine, Toho University, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan (Drs Ito, Hayata, Kotaki, Shimabukuro, Takano, Nagasaki, and Nakata)
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Tarvonen M, Markkanen J, Tuppurainen V, Jernman R, Stefanovic V, Andersson S. Intrapartum cardiotocography with simultaneous maternal heart rate registration improves neonatal outcome. Am J Obstet Gynecol 2024; 230:379.e1-379.e12. [PMID: 38272284 DOI: 10.1016/j.ajog.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Intrapartum cardiotocographic monitoring of fetal heart rate by abdominal external ultrasound transducer without simultaneous maternal heart rate recording has been associated with increased risk of early neonatal death and other asphyxia-related neonatal outcomes. It is unclear, however, whether this increase in risk is independently associated with fetal surveillance method or is attributable to other factors. OBJECTIVE This study aimed to compare different fetal surveillance methods and their association with adverse short- and long-term fetal and neonatal outcomes in a large retrospective cohort of spontaneous term deliveries. STUDY DESIGN Fetal heart rate and maternal heart rate patterns were recorded by cardiotocography during labor in spontaneous term singleton cephalic vaginal deliveries in the Hospital District of Helsinki and Uusimaa, Finland between October 1, 2005, and September 30, 2023. According to the method of cardiotocography monitoring at birth, the cohort was divided into the following 3 groups: women with ultrasound transducer, women with both ultrasound transducer and maternal heart rate transducer, and women with internal fetal scalp electrode. Umbilical artery pH and base excess values, low 1- and 5-minute Apgar scores, need for intubation and resuscitation, neonatal intensive care unit admission for asphyxia, neonatal encephalopathy, and early neonatal death were used as outcome variables. RESULTS Among the 213,798 deliveries that met the inclusion criteria, the monitoring type was external ultrasound transducer in 81,559 (38.1%), both external ultrasound transducer and maternal heart rate recording in 62,268 (29.1%), and fetal scalp electrode in 69,971 (32.7%) cases, respectively. The rates of both neonatal encephalopathy (odds ratio, 1.48; 95% confidence interval, 1.08-2.02) and severe acidemia (umbilical artery pH <7.00 and/or umbilical artery base excess ≤-12.0 mmol/L) (odds ratio, 2.03; 95% confidence interval, 1.65-2.50) were higher in fetuses of women with ultrasound transducer alone compared with those of women with concurrent external fetal and maternal heart rate recording. Monitoring with ultrasound transducer alone was also associated with increased risk of neonatal intubation for resuscitation (odds ratio, 1.22; 95% confidence interval, 1.03-1.44). A greater risk of severe neonatal acidemia was observed both in the ultrasound transducer (odds ratio, 2.78; 95% confidence interval, 2.23-3.48) and concurrent ultrasound transducer and maternal heart rate recording (odds ratio, 1.37; 95% confidence interval, 1.05-1.78) groups compared with those monitored with fetal scalp electrodes. No difference in risk of neonatal encephalopathy was found between newborns monitored with concurrent ultrasound transducer and maternal heart rate recording and those monitored with fetal scalp electrodes. CONCLUSION The use of external ultrasound transducer monitoring of fetal heart rate without simultaneous maternal heart rate recording is associated with higher rates of neonatal encephalopathy and severe neonatal acidemia. We suggest that either external fetal heart rate monitoring with concurrent maternal heart rate recording or internal fetal scalp electrode be used routinely as a fetal surveillance tool in term deliveries.
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Affiliation(s)
- Mikko Tarvonen
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland.
| | - Janne Markkanen
- Department of Industrial Engineering and Management, LUT University of Technology, Lappeenranta, Finland; Intensive and Intermediate Care Unit, Helsinki University Hospital, Helsinki, Finland
| | - Ville Tuppurainen
- Department of Industrial Engineering and Management, LUT University of Technology, Lappeenranta, Finland; Helsinki University Hospital Area Administration, Helsinki, Finland
| | - Riina Jernman
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Sture Andersson
- Children's Hospital, Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
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Goda M, Arakaki T, Takita H, Tokunaka M, Hamada S, Matsuoka R, Sekizawa A. Does maternal oxygen administration during non-reassuring fetal status affect the umbilical artery gas measures and neonatal outcomes? Arch Gynecol Obstet 2024; 309:993-1000. [PMID: 36854985 PMCID: PMC9974390 DOI: 10.1007/s00404-023-06952-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/26/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE To clarify whether maternal oxygen administration during vaginal delivery improves umbilical artery (UA) gas measurements and neonatal outcomes. METHODS Singleton pregnancies requiring operative vaginal delivery or emergency cesarean section (CS) due to non-reassuring fetal status (NRFS) during vaginal delivery at our hospital from 2018 to 2021 were retrospectively investigated. Intrapartum fetal wellbeing was evaluated based on the 5-tier fetal heart rate (FHR) pattern which is a delivery management method widely used in Japan. Operative vaginal deliveries or emergency CS was performed under integrated judgment in NRFS. Patients were divided into the oxygen group to whom oxygen (10 L/min) was supplied by a facemask and the room air group. The UA gas measurements and neonatal outcomes were compared. The oxygen administration was classified by conditions before and after the coronavirus disease 2019 pandemic. As a secondary evaluation, stratification of FHR pattern levels and factors associated with UA pH < 7.15 were examined. RESULTS A total of 250 patients required obstetric surgical delivery due to NRFS, including 140 (56%) and 110 (44%) in the oxygen and room air groups, respectively. No differences in maternal background factors were found between both groups, except for maternal age. UA gas measurements and neonatal outcomes also showed no significant differences. No significant factors were extracted in the multivariate analysis for UA pH < 7.15. CONCLUSIONS Trans-maternal oxygen administration for intrapartum NRFS did not affect neonatal cord blood gasses or neonatal outcomes. Thus, routine oxygen administration for intrapartum NRFS may not always be necessary.
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Affiliation(s)
- Mayuko Goda
- Department of Obstetrics and Gynecology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan.
| | - Tatsuya Arakaki
- Department of Obstetrics and Gynecology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Hiroko Takita
- Department of Obstetrics and Gynecology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Mayumi Tokunaka
- Department of Obstetrics and Gynecology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Shoko Hamada
- Department of Obstetrics and Gynecology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Ryu Matsuoka
- Department of Obstetrics and Gynecology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
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Takeshita M, Toyomoto R, Marui K, Ito M, Eto H, Takehara K, Matsui M. Cardiotocography use for fetal assessment during labor in low- and middle-income countries: A scoping review. Int J Gynaecol Obstet 2024. [PMID: 38287690 DOI: 10.1002/ijgo.15390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/31/2023] [Accepted: 01/09/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND The use of cardiotocography (CTG) to improve neonatal outcomes is controversial. The medical settings, subjects, utilizations, and interpretation guidelines of CTG are unclear for low- and middle-income countries (LMICs). OBJECTIVES To assess and review CTG use for studies identified in LMICs and provide insights on the potential for effective use of CTG to improve maternal and neonatal outcomes. SEARCH STRATEGY The databases Medline, CINAHL, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for published and unpublished literature through September 2023. SELECTION CRITERIA Publications were identified which were conducted in LMICs, based on the World Bank list of economies for 2019; targeting pregnant women in childbirth; and focusing on the utilization of CTG and neonatal outcomes. DATA COLLECTION AND ANALYSIS Publications were screened, and duplicates were removed. A scoping review was conducted using PRISMA-ScR guidelines. RESULTS The searches generated 1157 hits, of which 67 studies were included in the review. In the studies there was considerable variation and ambiguity regarding the study settings, target populations, utilizations, timing, frequency, and duration of CTG. While cesarean section rates were extensively investigated as an outcome of studies of CTG itself and the effect of additional techniques on CTG, other clinically significant outcomes, including neonatal mortality, were not well reported. CONCLUSIONS Variations and ambiguities were found in the use of CTG in LMICs. Due to the limited amount of evidence, studies are needed to examine CTG availability in the context of LMICs.
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Affiliation(s)
- Mai Takeshita
- Department of Health Informatics, Graduate School of Medicine / School of Public Health, Kyoto University, Kyoto, Japan
| | - Rie Toyomoto
- Department of Health Promotion and Human Behavior, Graduate School of Medicine / School of Public Health, Kyoto University, Kyoto, Japan
| | - Kanae Marui
- Department of Health Informatics, Graduate School of Medicine / School of Public Health, Kyoto University, Kyoto, Japan
| | - Masami Ito
- Department of Health Promotion and Human Behavior, Graduate School of Medicine / School of Public Health, Kyoto University, Kyoto, Japan
| | - Hiromi Eto
- Department of Reproductive Health, Institute of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Kenji Takehara
- Department of Health Policy, Research Institute, National Center for Child Health and Development, Tokyo, Japan
| | - Mitsuaki Matsui
- Department of Global Health, Nagasaki University School of Tropical Medicine and Global Health, Nagasaki, Japan
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
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Kandahari N, Tucker LYS, Schneider AN, Raine-Bennett TR, Mohta VJ. Fetal heart rate patterns and the incidence of adverse events after oral misoprostol administration for cervical ripening among low-risk pregnancies. J Matern Fetal Neonatal Med 2023; 36:2199344. [PMID: 37031970 DOI: 10.1080/14767058.2023.2199344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
OBJECTIVE Though misoprostol is commonly used for inpatient cervical ripening, its use in outpatient settings has been limited by safety concerns. This study was conducted to assess the association between early fetal heart tracing (FHT) and maternal tocodynamometry patterns and the incidence of adverse fetal and pregnancy outcomes after the administration of oral misoprostol for cervical ripening. METHODS We conducted a retrospective cohort study of 9908 low-risk patients at ≥37 weeks gestation who received oral misoprostol for cervical ripening prior to rupture of membranes between 01/01/2012 and 12/31/2017 at Kaiser Permanente Northern California hospitals as inpatients. We excluded patients who received a different agent for cervical ripening or had any need for additional inpatient monitoring, including hypertensive disorders of pregnancy, diabetes, or intrauterine growth restriction. Abnormal FHT, abnormal uterine activity, and adverse pregnancy or fetal-related events documented in the electronic health record in the four hours after administration of the first and second doses of misoprostol were assessed using descriptive statistics. RESULTS We found that 0.9% of patients experienced tachysystole after the first dose of misoprostol (0.6% without decelerations; 0.3% with decelerations). The incidence of variable decelerations only and other FHT abnormalities (i.e. bradycardia, late or prolonged decelerations, or absent or minimal variability) in the first hour after misoprostol administration were 7.1% and 6.7% respectively, and diminished over time. The need for tocolytic use was 0.2% in the first hour and declined over time to 0.03% in the fourth hour after the first dose. Urgent cesarean delivery occurred in 0.1% of patients after receiving the first dose of misoprostol. Patients who did not experience variable, prolonged, or late decelerations in the first hour after the initial misoprostol dose were less likely to have such FHT abnormalities in the subsequent three hours compared to patients who had other FHT abnormalities (11.8% among patients with no FHT abnormalities vs. 43.7% among patients with other FHT abnormalities; p <.001). The overall trends in outcomes over time were similar after the second dose of misoprostol. CONCLUSION The risk of short-term adverse outcomes associated with misoprostol is low among relatively low-risk patients. FHT abnormalities occurred in up to 32% of patients in the first four hours of monitoring post-misoprostol. Patients with no FHT abnormalities in the first hour after receiving misoprostol had a low risk of developing adverse outcomes and FHT abnormalities on continued monitoring, while patients with any type of deceleration in the first hour were at higher risk of adverse outcomes and FHT abnormalities. Our data may inform the development of protocols for cervical ripening that allow reduced monitoring for a subset of low-risk patients, however, more research is needed to validate findings and develop clinical protocols.
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Affiliation(s)
- Nazineen Kandahari
- School of Medicine, University of California, Berkeley, CA, USA
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | | | | | - Tina R Raine-Bennett
- Division of Research, Kaiser Permanente, Oakland, CA, USA
- Department of Obstetrics and Gynecology, Kaiser Permanente Medical Center, Oakland, CA, USA
| | - Vanitha J Mohta
- Department of Obstetrics and Gynecology, Kaiser Permanente Medical Center, Oakland, CA, USA
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Zullo F, Di Mascio D, Raghuraman N, Wagner S, Brunelli R, Giancotti A, Mendez-Figueroa H, Cahill AG, Gupta M, Berghella V, Blackwell SC, Chauhan SP. Three-tiered fetal heart rate interpretation system and adverse neonatal and maternal outcomes: a systematic review and meta-analysis. Am J Obstet Gynecol 2023; 229:377-387. [PMID: 37044237 DOI: 10.1016/j.ajog.2023.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 04/03/2023] [Accepted: 04/03/2023] [Indexed: 04/14/2023]
Abstract
OBJECTIVE This study aimed to evaluate the rate of adverse neonatal or maternal outcomes in parturients with fetal heart rate tracings categorized as I, II or, III within the last 30 to 120 minutes of delivery. DATA SOURCES The MEDLINE Ovid, Scopus, Embase, CINAHL, and Clinicaltrials.gov databases were searched electronically up to May 2022, using combinations of the relevant medical subject heading terms, keywords, and word variants that were considered suitable for the topic. STUDY ELIGIBILITY CRITERIA Only observational studies of term infants reporting outcomes of interest with category I, II, or III fetal heart rate tracings were included. STUDY APPRAISAL AND SYNTHESIS METHODS The coprimary outcome was the rate of either Apgar score <7 at 5 minutes or umbilical artery pH <7.00. Secondary outcomes were divided into neonatal and maternal adverse outcomes. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale. Random-effect meta-analyses of proportions were used to estimate the pooled rates of each categorical outcome in fetal heart rate tracing category I, II, and III patterns, and random-effect head-to-head meta-analyses were used to directly compare fetal heart rate tracings category I vs II and fetal heart rate tracing category II vs III, expressing the results as summary odds ratio or as mean differences with relative 95% confidence intervals. RESULTS Of the 671 articles reviewed, 3 publications met the inclusion criteria. Among them were 47,648 singletons at ≥37 weeks' gestation. Fetal heart rate tracings in the last 30 to 120 minutes before delivery were characterized in the following manner: 27.0% of deliveries had category I tracings, 72.9% had category II tracings, and 0.1% had category III tracings. A single study, which was rated to be of poor quality, contributed 82.1% of the data and it did not provide any data for category III fetal heart rate tracings. When compared with category I fetal heart rate tracings (0.74%), the incidence of an Apgar score <7 at 5 minutes were significantly higher among deliveries with category II fetal heart rate tracings (1.51%) (odds ratio, 1.56; 95% confidence interval, 1.23-1.99) and among those with category III tracings (14.63%) (odds ratio, 14.46; 95% confidence interval, 2.77-75.39). When compared with category II tracings, category III tracings also had a significantly higher likelihood of a low Apgar score at 5 minutes (odds ratio, 14.46; 95% confidence interval, 2.77-75.39). The incidence of an umbilical artery pH <7.00 were similar among those with category I and those with category II tracings (0.08% vs 0.24%; odds ratio, 2.85; 95% confidence interval, 0.41-19.55). When compared with category I tracings, the incidence of an umbilical artery pH <7.00 was significantly more common among those with category III tracings (31.04%; odds ratio, 161.56; 95% confidence interval, 25.18-1036.42); likewise, when compared with those with category II tracings, those with category III tracings had a significantly higher likelihood of having an umbilical artery pH <7.00 (odds ratio, 42.29; 95% confidence interval, 14.29-125.10). Hypoxic-ischemic encephalopathy occurred with similar frequency among those with categories I and those with category II tracings (0 vs 0.81%; odds ratio, 5.86; 95% confidence interval, 0.75-45.89) but was significantly more common among those with category III tracings (0 vs 18.97%; odds ratio, 61.43; 95% confidence interval, 7.49-503.50). Cesarean delivery occurred with similar frequency among those with category I (13.41%) and those with category II tracings (11.92%) (odds ratio, 0.87; 95% confidence interval, 0.72-1.05) but was significantly more common among those with with category III tracings (14.28%) (odds ratio, 3.97; 95% confidence interval, 1.62-9.75). When compared with those with category II tracings, cesarean delivery was more common among those with category III tracings (odds ratio, 4.55; 95% confidence interval, 1.88-11.01). CONCLUSION Although the incidence of an Apgar score <7 at 5 minutes and umbilical artery pH <7.00 increased significantly with increasing fetal heart rate tracing category, about 98% of newborns with category II tracings do not have these adverse outcomes. The 3-tiered fetal heart rate tracing interpretation system provides an approximate but imprecise measurement of neonatal prognosis.
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Affiliation(s)
- Fabrizio Zullo
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Daniele Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Steve Wagner
- Department of Obstetrics and Gynecology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Roberto Brunelli
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Antonella Giancotti
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Alison G Cahill
- Department of Women's Health, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Megha Gupta
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Vincenzo Berghella
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Sean C Blackwell
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX.
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Thayer SM, Faramarzi P, Krauss MJ, Snider E, Kelly JC, Carter EB, Frolova AI, Odibo AO, Raghuraman N. Heterogeneity in management of category II fetal tracings: data from a multihospital healthcare system. Am J Obstet Gynecol MFM 2023; 5:101001. [PMID: 37146688 DOI: 10.1016/j.ajogmf.2023.101001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/28/2023] [Accepted: 04/30/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Electronic fetal monitoring is widely used to identify and intervene in suspected fetal hypoxia and/or acidemia. Category II fetal heart rate tracings are the most common class of fetal monitoring in labor, and intrauterine resuscitation is recommended given the association of category II fetal heart rate tracings with fetal acidemia. However, limited published data are available to guide intrauterine resuscitation technique selection, leading to heterogeneity in the response to category II fetal heart rate tracings. OBJECTIVE This study aimed to characterize approaches to intrauterine resuscitation in response to category II fetal heart rate tracings. STUDY DESIGN This was a survey study administered to labor unit nurses and delivering clinicians (physicians and midwives) across 7 hospitals in a Midwestern healthcare system spanning 2 states. The survey posed 3 category II fetal heart rate tracing scenarios (recurrent late decelerations, minimal variability, and recurrent variable decelerations) and asked participants to select first- and second-line intrauterine resuscitation management strategies. The participants were asked to quantify the level of influence certain factors have on their choice using a scale from 1 to 5. Intrauterine resuscitation strategy selection was compared by clinical role and hospital type (nurses vs delivering clinicians and university-affiliated hospital vs non-university-affiliated hospital). RESULTS Of 610 providers invited to take the survey, 163 participated (response rate of 27%): 37% of participants from university-affiliated hospitals, 62% of nurses, and 37% of physicians. Maternal repositioning was the most selected first-line strategy, regardless of the type of category II fetal heart rate tracing. First-line management varied by clinical role and hospital affiliation for each fetal heart rate tracing scenario, particularly for minimal variability, which was associated with the most heterogeneity in the first-line approach. Previous experience and recommendations from professional societies were the most influential factors in intrauterine resuscitation selection overall. Of note, 16.5% of participants reported that published evidence did not influence their choice at all. Participants from a university-affiliated hospital were more likely than participants from a non-university-affiliated hospital to consider patient preference when selecting an intrauterine resuscitation technique. Nurses and delivering clinicians differed significantly in the rationale for management choices: nurses were more often influenced by advice from other healthcare providers on the team (P<.001), whereas delivering clinicians were more influenced by literature (P=.02) and ease of technique (P=.02). CONCLUSION There was significant heterogeneity in the management of category II fetal heart rate tracing. In addition, motivations for choice in intrauterine resuscitation technique varied by hospital type and clinical role. These factors should be considered when creating fetal monitoring and intrauterine resuscitation protocols.
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Affiliation(s)
- Sydney M Thayer
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman).
| | - Parisa Faramarzi
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Melissa J Krauss
- Brown School at Washington University in St. Louis, St. Louis, MO (Mses Krauss and Snider)
| | - Elsa Snider
- Brown School at Washington University in St. Louis, St. Louis, MO (Mses Krauss and Snider)
| | - Jeannie C Kelly
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Ebony B Carter
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Antonina I Frolova
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Anthony O Odibo
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
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8
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Brown J, Kanagaretnam D, Zen M. Clinical practice guidelines for intrapartum cardiotocography interpretation: A systematic review. Aust N Z J Obstet Gynaecol 2023. [PMID: 36898674 DOI: 10.1111/ajo.13667] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
BACKGROUND Clinical practice guidelines on intrapartum cardiotocography (CTG) interpretation provide structured tools to detect fetal hypoxia. Despite frequent use of different guidelines, little is known about their comparable consistency. We sought to appraise guidelines relevant to intrapartum CTG interpretation and summarise consensus and non-consensus recommendations. AIMS To compare existing intrapartum CTG interpretation guidelines. MATERIALS AND METHODS We searched PubMed, CINAHL, Cochrane, Embase, guideline databases and websites of guideline development institutions using terms 'cardiotocography', 'electronic fetal/foetal monitoring', and 'guideline' or equivalent term. The search was restricted to English-language articles published between January 1980 and January 2023 and excluded animal studies. The initial search yielded 2128 articles with 1253 unique citations. Guidelines were included if they: used English as the reporting language; included CTG interpretation criteria or guidelines as a primary objective; were published or updated since 1980; and were the most recently updated publications when multiple versions were identified. RESULTS Nineteen studies were considered for full review, and 13 met inclusion criteria. Two reviewers independently assessed guideline quality using the AGREE II instrument, and synthesised consensus and non-consensus recommendations using the content analysis approach. Most guidelines employed a three-tier interpretation framework. There were significant differences between the guidelines for relative importance of key CTG features such as accelerations, decelerations and variability, with respect to the outcome of fetal hypoxia. CONCLUSIONS There are significant differences between key intrapartum CTG interpretation guidelines currently being used. Greater consistency is needed across CTG interpretation guidelines to improve the quality of data, clinical governance, monitoring of outcomes, and to support future developments.
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Affiliation(s)
- James Brown
- Obstetrics and Gynaecology, Westmead Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | | | - Monica Zen
- Obstetrics and Gynaecology, Westmead Hospital, Sydney, New South Wales, Australia
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Tomich MF, Leoni RS, Meireles PT, Petrini CG, Araujo Júnior E, Peixoto AB. Accuracy of intrapartum cardiotocography in identifying fetal acidemia by umbilical cord blood analysis in low-risk pregnancies. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20221182. [PMID: 37194903 DOI: 10.1590/1806-9282.20221182] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the accuracy of intrapartum cardiotocography in identifying fetal acidemia by umbilical cord blood analysis in low-risk pregnancies. METHODS This is a retrospective cohort study of low-risk singleton pregnancies in labor after performing intrapartum cardiotocography categories I, II, and III. The presence of fetal acidemia at birth was identified by analyzing the pH of umbilical cord arterial blood (pH<7.1). RESULTS No significant effect of the cardiotocography category on the arterial (p=0.543) and venous (p=0.770) pH of umbilical cord blood was observed. No significant association was observed between the cardiotocography category and the presence of fetal acidemia (p=0.706), 1-min Apgar score <7 (p=0.260), hospitalization in the neonatal intensive care unit (p=0.605), newborn death within the first 48 h, need for neonatal resuscitation (p=0.637), and adverse perinatal outcomes (p=0.373). Sensitivities of 62, 31, and 6.0%; positive predictive values of 11.0, 16.0, and 10.0%; and negative predictive values of 85, 89.0, and 87.0% were observed for cardiotocography categories I, II, and III, respectively. CONCLUSION The three categories of intrapartum cardiotocography presented low sensitivities and high negative predictive values to identify fetal acidemia at birth in low-risk pregnancies.
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Affiliation(s)
- Michaela Franco Tomich
- Universidade de Uberaba, Mário Palmério University Hospital, Gynecology and Obstetrics Service - Uberaba (MG), Brazil
| | - Renato Silva Leoni
- Universidade de Uberaba, Mário Palmério University Hospital, Gynecology and Obstetrics Service - Uberaba (MG), Brazil
| | - Pedro Teixeira Meireles
- Universidade de Uberaba, Mário Palmério University Hospital, Gynecology and Obstetrics Service - Uberaba (MG), Brazil
| | - Caetano Galvão Petrini
- Universidade de Uberaba, Mário Palmério University Hospital, Gynecology and Obstetrics Service - Uberaba (MG), Brazil
- Universidade Federal do Triângulo Mineiro, Department of Gynecology and Obstetrics - Uberaba (MG), Brazil
| | - Edward Araujo Júnior
- Universidade Federal de São Paulo, Paulista School of Medicine, Department of Obstetrics - São Paulo (SP), Brazil
- Universidade Municipal de São Caetano do Sul, Medical Course - São Paulo (SP), Brazil
| | - Alberto Borges Peixoto
- Universidade de Uberaba, Mário Palmério University Hospital, Gynecology and Obstetrics Service - Uberaba (MG), Brazil
- Universidade Federal do Triângulo Mineiro, Department of Gynecology and Obstetrics - Uberaba (MG), Brazil
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10
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Pruksanusak N, Chainarong N, Boripan S, Geater A. Comparison of the predictive ability for perinatal acidemia in neonates between the NICHD 3-tier FHR system combined with clinical risk factors and the fetal reserve index. PLoS One 2022; 17:e0276451. [PMID: 36264912 PMCID: PMC9584503 DOI: 10.1371/journal.pone.0276451] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 10/06/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Electronic fetal monitoring alone is a poor screening test for detecting fetuses at risk of acidemia or asphyxia. We aimed to evaluation of predictive ability of the National Institute of Child Health and Human Development (NICHD) 3-tier fetal heart rate (FHR) system combined with the maternal, obstetric, and fetal risk factors for predicting perinatal acidemia, and to compare this with the predictive of the NICHD 3-tier system alone, and the Fetal Reserve Index (FRI). METHODS A retrospective cohort study was conducted among singleton term pregnant women. Fetal heart rate tracings of the last two hours before delivery were interpreted into the NICHD 3-tier FHR classification system by two experienced obstetricians. Demographic data were compared using the χ2 or Fisher's exact test for categorical variables and the Student's t test for continuous variables. Logistic regression model was used to identify factors associated with perinatal acidemia in neonates. The Odds ratios (OR) and probabilities with 95% confidence intervals (CI) were calculated. RESULTS A total of 674 pregnant women were enrolled in this study. Using the NICHD 3-tier FHR categories I and II combined with the selected risk factors (AUC 0.62) had a better performance for perinatal acidemia prediction than the NICHD 3-tier FHR alone (AUC 0.55) and the FRI (AUC 0.52), (P<0.01). Improvement of predicting perinatal acidemia was found when NICHD category I was combined with preeclampsia or arrest disorders of labor (OR 3.2, 95% CI 1.30‒7.82) or combined with abnormal second stage of labor (OR 6.19, 95% CI 1.07‒36.06) and when NICHD category II was combined with meconium-stained amniotic fluid (OR 4.73, 95% CI 2.17‒10.31). CONCLUSIONS The NICHD 3-tier FHR categories I or II combined with selected risk factors can improve the predictive ability of perinatal acidemia in neonates compared with the NICHD 3-tier system alone or the FRI.
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Affiliation(s)
- Ninlapa Pruksanusak
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Natthicha Chainarong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
- * E-mail:
| | - Siriwan Boripan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Alan Geater
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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11
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Yu Y, Gao J, Liu J, Tang Y, Zhong M, He J, Liao S, Wang X, Liu X, Cao Y, Liu C, Sun J. Perinatal maternal characteristics predict a high risk of neonatal asphyxia: A multi-center retrospective cohort study in China. Front Med (Lausanne) 2022; 9:944272. [PMID: 36004371 PMCID: PMC9393324 DOI: 10.3389/fmed.2022.944272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/15/2022] [Indexed: 11/29/2022] Open
Abstract
Objective This study aimed to identify various perinatal maternal characteristics that contributed to neonatal asphyxia (NA) in term and late-preterm newborns based on the data obtained from a Chinese birth registry cohort and to establish an effective model for predicting a high risk of asphyxia. Method We retrospectively reviewed and analyzed the birth database from July 1, 2016, to June 30, 2017, in the main economically developed regions of China. Asphyxia was defined as an Apgar score <7 at 5 min post-delivery with umbilical cord arterial blood pH < 7.2 in the infant born after 34weeks. We compared the perinatal maternal characteristics of the newborns who developed asphyxia (NA group, n = 1,152) and those who did not (no NA group, n = 86,393). Candidate predictors of NA were analyzed using multivariable logistic regression. Subsequently, a prediction model was developed and validated by an independent test group. Result Of the maternal characteristics, duration of PROM ≥ 48 h, a gestational week at birth <37, prolonged duration of labor, hypertensive disorder, nuchal cord, and birth weight <2,500 or ≥4,000 g, abnormal fetal heart rate, meconium-stained amniotic fluid, and placenta previa were included in the predicting model, which presented a good performance in external validation (c-statistic of 0.731). Conclusion Our model relied heavily on clinical predictors that may be determined before or during birth, and pregnant women at high risk of NA might be recognized earlier in pregnancy and childbirth using this methodology, allowing them to avoid being neglected and delayed. Future studies should be conducted to assess its usefulness.
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Affiliation(s)
- Yi Yu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetrics & Gynecologic Diseases, Peking Union Medical College Hospital (CAMS), Beijing, China
| | - Jinsong Gao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetrics & Gynecologic Diseases, Peking Union Medical College Hospital (CAMS), Beijing, China
- *Correspondence: Jinsong Gao
| | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetrics & Gynecologic Diseases, Peking Union Medical College Hospital (CAMS), Beijing, China
- Juntao Liu
| | - Yabing Tang
- Department of Obstetrics and Gynecology, Hunan Maternal and Child Health Care Hospital, Changsha, China
| | - Mei Zhong
- Department of Obstetrics and Gynecology, Nanfang Hospital Southern Medical University, Guangzhou, China
| | - Jing He
- Department of Obstetrics and Gynecology, Women's Hospital School of Medicine Zhejiang University, Hangzhou, China
| | - Shixiu Liao
- Department of Obstetrics and Gynecology, Henan Provincial People's Hospital Zhengzhou, Henan, China
| | - Xietong Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Xinghui Liu
- Department of Obstetrics and Gynecology, Sichuan University West China Second Hospital, Chengdu, China
| | - Yinli Cao
- Department of Obstetrics and Gynecology, Northwest Women and Children's Hospital, Xi'an, China
| | - Caixia Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital Affiliated to China Medical University, Shenyang, China
| | - Jingxia Sun
- Department of Obstetrics and Gynecology, The First Clinical Hospital Affiliated to Harbin Medical University, Harbin, China
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12
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Maki S, Tanaka H, Takakura S, Nii M, Tanaka K, Ogura T, Kotera M, Nishimura Y, Tamaru S, Ushida T, Tanaka Y, Kikuchi N, Kinjo T, Kawamura H, Takano M, Nakamura K, Suga S, Kasai M, Yasui O, Nagao K, Maegawa Y, Kotani T, Endo M, Yasuhi I, Aoki S, Aoki Y, Yoshida Y, Nakata M, Sekizawa A, Ikeda T. Tadalafil treatment for fetuses with early-onset growth restriction: a protocol for a multicentre, randomised, placebo-controlled, double-blind phase II trial (TADAFER IIb). BMJ Open 2022; 12:e054925. [PMID: 35701067 PMCID: PMC9198796 DOI: 10.1136/bmjopen-2021-054925] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION TheTADAlafil treatment for Fetuses with early-onset growth Restriction: multicentrer, randomizsed, phase II trial (TADAFER II) study showed the possibility of prolonging the pregnancy period in cases of early-onset fetal growth restriction; however, it was an open-label study. To establish further evidence for the efficacy of tadalafil in this setting, we planned a multicentre, randomised, placebo-controlled, double-blind trial. METHODS AND ANALYSIS This trial will be conducted in 180 fetuses with fetal growth restriction enrolled from medical centres in Japan; their mothers will be randomised into three groups: arm A, receiving two times per day placebo; arm B, receiving one time per day 20 mg tadalafil and one time per day placebo and arm C, receiving 20 mg two times per day tadalafil. The primary endpoint is the prolongation of gestational age at birth, defined as days from the first day of the protocol-defined treatment to birth. To minimise bias in terms of fetal baseline conditions and timing of delivery, a fetal indication for delivery as in TADAFER II will be established in this trial. The investigator will evaluate fetal baseline conditions at enrolment and decide the timing of delivery based on this indication. ETHICS AND DISSEMINATION This study has been approved by Mie University Hospital Clinical Research Review Board on 22 July 2019 (S2018-007). Written informed consent will be obtained from all mothers before recruitment. Our findings will be widely disseminated through peer-reviewed publications. TRIAL REGISTRATION jRCTs041190065.
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Affiliation(s)
- Shintaro Maki
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Sho Takakura
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masafumi Nii
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Kayo Tanaka
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Toru Ogura
- Clinical Research Support Center, Mie University Hospital, Tsu, Mie, Japan
| | - Mayumi Kotera
- Clinical Research Support Center, Mie University Hospital, Tsu, Mie, Japan
| | - Yuki Nishimura
- Clinical Research Support Center, Mie University Hospital, Tsu, Mie, Japan
| | - Satoshi Tamaru
- Clinical Research Support Center, Mie University Hospital, Tsu, Mie, Japan
| | - Takafumi Ushida
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yasuhiro Tanaka
- Department of Obstetrics and Gynecology, Shinshu University Graduate School of Medicine, Matsumoto, Nagano, Japan
| | - Norihiko Kikuchi
- Department of Obstetrics and Gynecology, Shinshu University Graduate School of Medicine, Matsumoto, Nagano, Japan
| | - Tadatsugu Kinjo
- Department of Obstetrics and Gynecology, University of the Ryukyus, Nakagami-gun, Okinawa, Japan
| | - Hiroshi Kawamura
- Department of Obstetrics and Gynecology, Fukui University Graduate School of Medicine, Fukui, Japan
| | - Mayumi Takano
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Otaku, Tokyo, Japan
| | - Koji Nakamura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Sachie Suga
- Department of Obstetrics and Gynecology, National Hospital Organization Nagasaki Medical Center, Omura, Nagasaki, Japan
| | - Michi Kasai
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Osamu Yasui
- Department of Obstetrics and Gynecology, Showa University Graduate School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Kenji Nagao
- Department of Obstetrics and Gynecology, Yokkaichi Municipal Hospital, Yokkaichi, Mie, Japan
| | - Yuka Maegawa
- Department of Obstetrics and Gynecology, Mie Chuo Medical Center, Tsu, Mie, Japan
| | - Tomomi Kotani
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masayuki Endo
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Ichiro Yasuhi
- Department of Obstetrics and Gynecology, National Hospital Organization Nagasaki Medical Center, Omura, Nagasaki, Japan
| | - Shigeru Aoki
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Yoichi Aoki
- Department of Obstetrics and Gynecology, University of the Ryukyus, Nakagami-gun, Okinawa, Japan
| | - Yoshio Yoshida
- Department of Obstetrics and Gynecology, Fukui University Graduate School of Medicine, Fukui, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Otaku, Tokyo, Japan
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University Graduate School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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Berger DS, Crosland A, Newman R, Bosse B, Makhoul J, Chan K, Seet EL. Application of a Proposed Algorithm to Cesarean Deliveries for Nonreassuring Fetal Heart Rate Tracing. Am J Perinatol 2022; 39:342-348. [PMID: 34839476 DOI: 10.1055/s-0041-1739412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES 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. STUDY DESIGN 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. RESULTS 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. CONCLUSION 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. KEY POINTS · 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..
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Affiliation(s)
- Dana Senderoff Berger
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California
| | - Adam Crosland
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California
| | - Rachel Newman
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California
| | - Bradley Bosse
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California
| | - Joshua Makhoul
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California
| | - Kenneth Chan
- Department of Obstetrics and Gynecology, Long Beach Memorial Miller Children's and Women's Hospital, Long Beach, California
| | - Emily L Seet
- Department of Obstetrics and Gynecology, Long Beach Memorial Miller Children's and Women's Hospital, Long Beach, California
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14
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Tournier A, Beacom M, Westgate JA, Bennet L, Garabedian C, Ugwumadu A, Gunn AJ, Lear CA. Physiological control of fetal heart rate variability during labour: Implications and controversies. J Physiol 2021; 600:431-450. [PMID: 34951476 DOI: 10.1113/jp282276] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/25/2021] [Indexed: 11/08/2022] Open
Abstract
The interpretation of fetal heart rate (FHR) patterns is the only available method to continuously monitor fetal wellbeing during labour. One of the most important yet contentious aspects of the FHR pattern is changes in FHR variability (FHRV). Some clinical studies suggest that loss of FHRV during labour is a sign of fetal compromise so this is reflected in practice guidelines. Surprisingly, there is little systematic evidence to support this observation. In this review we methodically dissect the potential pathways controlling FHRV during labour-like hypoxaemia. Before labour, FHRV is controlled by the combined activity of the parasympathetic and sympathetic nervous systems, in part regulated by a complex interplay between fetal sleep state and behaviour. By contrast, preclinical studies using multiple autonomic blockades have now shown that sympathetic neural control of FHRV was potently suppressed between periods of labour-like hypoxaemia, and thus, that the parasympathetic system is the sole neural regulator of FHRV once FHR decelerations are present during labour. We further discuss the pattern of changes in FHRV during progressive fetal compromise and highlight potential biochemical, behavioural and clinical factors that may regulate parasympathetic-mediated FHRV during labour. Further studies are needed to investigate the regulators of parasympathetic activity to better understand the dynamic changes in FHRV and their true utility during labour. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alexane Tournier
- Department of Obstetrics, Universite de Lille, CHU Lille, ULR 2694 - METRICS, Lille, F 59000, France
| | - Michael Beacom
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Jenny A Westgate
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Charles Garabedian
- Department of Obstetrics, Universite de Lille, CHU Lille, ULR 2694 - METRICS, Lille, F 59000, France
| | - Austin Ugwumadu
- Department of Obstetrics and Gynaecology, St George's Hospital, St George's University of London, London, SW17 0RE, UK
| | - Alistair J Gunn
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Christopher A Lear
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
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15
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Zamora Del Pozo C, Chóliz Ezquerro M, Mejía I, Díaz de Terán Martínez-Berganza E, Esteban LM, Rivero Alonso A, Castán Larraz B, Andeyro García M, Savirón Cornudella R. Diagnostic capacity and interobserver variability in FIGO, ACOG, NICE and Chandraharan cardiotocographic guidelines to predict neonatal acidemia. J Matern Fetal Neonatal Med 2021; 35:8498-8506. [PMID: 34652249 DOI: 10.1080/14767058.2021.1986479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Despite its routine use in intrapartum care, the technique of fetal cardiotocography has some limitations. The aim of this study is to analyze the predictive capacity and interobserver agreement in the latest versions of four international cardiotocography guidelines: Federation of Gynecology and Obstetrics (FIGO), American College of Obstetrics and Gynecology (ACOG), the National Institute for Health and Care Excellence (NICE) and Chandraharan, used to predict neonatal acidemia. STUDY DESIGN The last 30 min of 150 cardiotocographic records were analyzed over all the pH ranges and were blindly evaluated by three independent reviewers. The sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve (AUC) were calculated to assess the predictive capacity of each fetal cardiotocographic guideline. The degree of interobserver agreement was evaluated with the Fleiss Kappa coefficient. RESULTS Observers found fetal cardiotocography guidelines to have a variable sensitivity and specificity. The Chandraharan classification reached the highest sensitivity (78.79%), while ACOG had the highest specificity (95.73%). On average for the three observers, Chandraharan had the highest discrimination capacity for neonatal acidemia, although this was only moderate (AUC 0.66; 95%CI, 0.55-0.77) and did not differ significantly from the remaining guidelines. The degree of agreement among the three observers, assessed according to the Fleiss Kappa coefficient, was generally acceptable or moderate for all items and classifications, being highest with the FIGO classification (ĸ = 0.35; 95%CI, 0.28-0.41) and lowest with the ACOG (ĸ = 0.23; 95%CI, 0.16-0.30). CONCLUSION Although all the guidelines have a moderate capacity to predict neonatal acidemia, the Chandraharan guideline has the highest capacity. This follows a different approach from the others in that it relies on interpretations of cardiotocographic traces based on fetal physiology. The degree of interobserver agreement is, in general, acceptable for the four guidelines, and is the highest for FIGO.
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Affiliation(s)
| | | | - Inmaculada Mejía
- Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Luis Mariano Esteban
- Universidad de Zaragoza, Escuela Universitaria Politécnica de la Almunia, C/Mayor s/n, La Almunia de Doña Godina, Spain
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16
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Interpretation of Fetal Heart Rate Monitoring in the Clinical Context. Clin Obstet Gynecol 2021; 63:625-634. [PMID: 32735415 DOI: 10.1097/grf.0000000000000554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Use of intrapartum fetal heart rate (FHR) monitoring has had limited success in preventing hypoxic injury to neonates. One of the most common limitations of FHR interpretation is the failure to consider chronic and acute clinical factors that may increase the risk of evolving acidemia. This manuscript reviews common clinical factors that may affect the FHR and should be considered when determining the need for early intervention based on changes in the FHR.
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17
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Abstract
Management of the category II fetal heart rate (FHR) tracing presents a common challenge in obstetrics. Up to 80% of women will have a category II FHR tracing at some point during labor. Here we propose a management algorithm to identify specific features of the FHR tracing that correlate with risk for fetal acidemia, target interventions to address FHR decelerations, and guide clinicians about when to proceed toward operative vaginal delivery or cesarean to achieve delivery before there is a high risk for significant fetal acidemia with potential for neurological injury or death.
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18
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Olofsson P, Ekengård F, Herbst A. Time to reconsider: Have the 2015 FIGO and 2017 Swedish intrapartum cardiotocogram classifications led us from Charybdis to Scylla? Acta Obstet Gynecol Scand 2021; 100:1549-1556. [PMID: 34060661 DOI: 10.1111/aogs.14201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/11/2021] [Accepted: 05/25/2021] [Indexed: 11/28/2022]
Abstract
In 2015, FIGO revised the 1987 intrapartum cardiotocography (CTG) classification (FIGO1987). A less radical FIGO2015 version was introduced in Sweden 2017 (SWE2017). Now, post hoc simulation studies show that FIGO2015 and SWE2017 are less reliable than (a modified) FIGO1987. FIGO2015 shows significantly better interobserver agreement for normal CTG traces than FIGO1987, but significantly worse for pathological traces. Agreements between templates are moderate to good, but different classifications of mainly variable decelerations and tachycardia cause significant heterogeneities. FIGO2015 shows insufficient sensitivity to identify fetal acidemia compared with FIGO1987. In connection with fetal electrocardiogram ST analysis, one study showed no template was superior in identifying fetal acidemia, but in a series of only academia, FIGO1987 had significantly higher sensitivity than FIGO2015 (73% vs. 43%) and set of an alarm for fetal acidemia considerably earlier. With SWE2017, operative interventions declined significantly in Sweden but several adverse neonatal outcomes increased significantly. It remains to investigate the development with FIGO2015.
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Affiliation(s)
- Per Olofsson
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Cura Mödravård, Malmö, Sweden
| | - Frida Ekengård
- Institution of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Malmö, Sweden
| | - Andreas Herbst
- Institution of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Malmö, Sweden
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19
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Vintzileos AM, Smulian JC. Timing intrapartum management based on the evolution and duration of fetal heart rate patterns. J Matern Fetal Neonatal Med 2021; 35:7936-7941. [PMID: 34121585 DOI: 10.1080/14767058.2021.1938531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
One of the most important challenges in obstetrics is to determine the appropriate time to deliver the fetus without exposing the mother to unnecessary operative interventions. The use of continuous cardiotocography (cCTG) during labor has resulted in dramatic reductions in intrapartum fetal deaths, but fetal central nervous system (CNS) injury and cerebral palsy (CP) rates have remain relatively unchanged as related to the use of cCTG . In our view, this is due to continuing inability to recognize progressive fetal deterioration and intervene promptly prior to the development of fetal CNS injury. Although the 2008 NICHD workshop proposed a 3-tier classification system, most fetuses born with severe (pathologic) acidemia (cord artery pH < 7.00), as well as those who eventually develop CP, will never reach the stage of NICHD Category III fetal heart rate (FHR) pattern. In the present "Clinical Opinion," we promote a concept derived from observations, that the evolution of the FHR changes of the deteriorating fetus can be visually defined by three color "zones" that are clinically recognizable and, therefore, are actionable. In addition, we will review information regarding how long the fetus may be able to tolerate an abnormal FHR pattern before it suffers an adverse perinatal outcome, an area of investigation that has been rarely addressed before. Based on the available evidence, Category III FHR patterns should not be used as screening criteria because of low sensitivity for either fetal CNS injury (45%) or severe (pathologic) fetal acidemia (36-44%). In addition, the duration of the Category III pattern required for the development of severe fetal acidemia is extremely short to allow for a timely preventative operative intervention. On the contrary, the use of our proposed "red" zone, which includes the most advanced stages in the progressive deterioration of Category II patterns and Category III, will identify the overwhelming majority of fetuses who develop severe (pathologic) acidemia (96%) and/or CNS injury during labor (100%); moreover, the detection of fetal jeopardy by the use of the "red" zone occurs much earlier, as compared to using Category III, thus allowing reasonable amount of time for a timely obstetrical intervention. Further research is needed to determine the false positive rate and positive predictive value for a pre-determined period of time in the red zone.
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Affiliation(s)
- Anthony M Vintzileos
- Department of Obstetrics and Gynecology, New York University (NYU) Langone Health-Long Island, NYU Long Island School of Medicine, Mineola, NY, USA
| | - John C Smulian
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA
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20
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Ito A, Hayata E, Nakata M, Oji A, Furukawa T, Nakakuma M, Morita M. iPREFACE score: Integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring. J Obstet Gynaecol Res 2021; 47:1305-1311. [PMID: 33438340 PMCID: PMC8048540 DOI: 10.1111/jog.14652] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/10/2020] [Accepted: 12/26/2020] [Indexed: 11/27/2022]
Abstract
AIM Cardiotocography is used worldwide to evaluate fetal well-being during pregnancy and labor. In past guidelines, the management plan was determined based on the assessment of the most severe waveform. There are no guidelines for evaluating the integrated recurrent decelerations; however, we believe their assessment to be essential for predicting the status of the fetus. The objective of this study was to propose an indicator for performing medical interventions during labor by creating a scoring system that reflects integrated recurrent decelerations. METHODS In this retrospective cohort study, we included data for only full-term single fetus births from vaginal deliveries. The score named the iPREFACE score (integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring) was calculated using cardiotocography findings from continuing 30 min before delivery. We examined the iPREFACE score and fetal acidemia association and calculated the cut-off iPREFACE scores for acidemia using receiver operating characteristic curves. RESULTS The study included 469 delivery cases. Their iPREFACE scores exhibited a significant negative correlation with the umbilical artery blood pH (correlation coefficient; -0.43). The cut-off iPREFACE scores for the umbilical artery blood with pH <7.20, <7.10 and <7.0 were 44, 46 and 67, respectively (the areas under the curve were 0.776, 0.962 and 0.996, respectively). CONCLUSION The iPREFACE score may predict fetal acidemia and could be used as an indicator for timely medical interventions during labor. Because assessments using a cardiotocography are quick and easy to perform, the iPREFACE score could be a valuable tool in clinical practice.
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Affiliation(s)
- Ayumu Ito
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan.,Department of Obstetrics and Gynecology, Ageo Central General Hospital, Ageo-shi, Japan
| | - Eijiro Hayata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Ayako Oji
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Takamasa Furukawa
- Department of Obstetrics and Gynecology, Ageo Central General Hospital, Ageo-shi, Japan
| | - Masahito Nakakuma
- Department of Obstetrics and Gynecology, Ageo Central General Hospital, Ageo-shi, Japan
| | - Mineto Morita
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
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21
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Nakao M, Okumura A, Hasegawa J, Toyokawa S, Ichizuka K, Kanayama N, Satoh S, Tamiya N, Nakai A, Fujimori K, Maeda T, Suzuki H, Iwashita M, Ikeda T. Fetal heart rate pattern in term or near-term cerebral palsy: a nationwide cohort study. Am J Obstet Gynecol 2020; 223:907.e1-907.e13. [PMID: 32497609 DOI: 10.1016/j.ajog.2020.05.059] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 05/20/2020] [Accepted: 05/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND It is crucial to interpret fetal heart rate patterns with a focus on the pattern evolution during labor to estimate the relationship between cerebral palsy and delivery. However, nationwide data are not available. OBJECTIVE The aim of our study was to demonstrate the features of fetal heart rate pattern evolution and estimate the timing of fetal brain injury during labor in cerebral palsy cases. STUDY DESIGN In this longitudinal study, 1069 consecutive intrapartum fetal heart rate strips from infants with severe cerebral palsy at or beyond 34 weeks of gestation, were analyzed. They were categorized as follows: (1) continuous bradycardia (Bradycardia), (2) persistently nonreassuring, (3) reassuring-prolonged deceleration, (4) Hon's pattern, and (5) persistently reassuring. The clinical factors underlying cerebral palsy in each group were assessed. RESULTS Hypoxic brain injury during labor (those in the reassuring-prolonged deceleration and Hon's pattern groups) accounted for 31.5% of severe cerebral palsy cases and at least 30% of those developed during the antenatal period. Of the 1069 cases, 7.86% were classified as continuous bradycardia (n=84), 21.7% as persistently nonreassuring (n=232), 15.6% as reassuring-prolonged deceleration (n=167), 15.9% as Hon's pattern (n=170), 19.8% as persistently reassuring (n=212), and 19.1% were unclassified (n=204). The overall interobserver agreement was moderate (kappa 0.59). Placental abruption was the most common cause (31.9%) of cerebral palsy, accounting for almost 90% of cases in the continuous bradycardia group (64 of 73). Among the cases in the Hon's pattern group (n=67), umbilical cord abnormalities were the most common clinical factor for cerebral palsy development (29.9%), followed by placental abruption (20.9%), and inappropriate operative vaginal delivery (13.4%). CONCLUSION Intrapartum hypoxic brain injury accounted for approximately 30% of severe cerebral palsy cases, whereas a substantial proportion of the cases were suspected to have either a prenatal or postnatal onset. Up to 16% of cerebral palsy cases may be preventable by placing a greater focus on the earlier changes seen in the Hon's fetal heart rate progression.
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Affiliation(s)
- Masahiro Nakao
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Tokyo, Japan; Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan; Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Mie, Japan.
| | - Asumi Okumura
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Tokyo, Japan; Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan
| | - Junichi Hasegawa
- Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan; Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Satoshi Toyokawa
- Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan; Department of Public Health, the University of Tokyo, Tokyo, Japan
| | - Kiyotake Ichizuka
- Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan; Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa, Japan
| | - Naohiro Kanayama
- Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan; Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Shoji Satoh
- Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan; Maternal and Perinatal Care Center, Oita Prefectural Hospital, Oita, Japan
| | - Nanako Tamiya
- Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan; Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Akihito Nakai
- Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan; Department of Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan
| | - Keiya Fujimori
- Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan; Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima, Japan
| | - Tsugio Maeda
- Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan; Maeda Clinic, Incorporated Association Anzu-kai, Shizuoka, Japan
| | - Hideaki Suzuki
- Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan; Department of the Japan Obstetric Compensation System for Cerebral Palsy in Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan
| | - Mitsutoshi Iwashita
- Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan; Department of Obstetrics and Gynecology, Kyorin University School of Medicine, Tokyo, Japan
| | - Tomoaki Ikeda
- Recurrence Prevention Committee, the Japan Obstetric Compensation System for Cerebral Palsy, Public Interest Incorporated Foundation, Japan Council for Quality Health Care, Tokyo, Japan; Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Mie, Japan
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Low sensitivity of the new FIGO classification system for electronic fetal monitoring to identify fetal acidosis in the second stage of labor. Eur J Obstet Gynecol Reprod Biol X 2020; 9:100120. [PMID: 33319210 PMCID: PMC7724159 DOI: 10.1016/j.eurox.2020.100120] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 11/23/2022] Open
Abstract
Cardiotocography interpretation guidelines evaluated during second stage of labor. Case-control study including neonates with cord artery acidosis at vaginal delivery. Low sensitivity of FIGO intrapartum monitoring guidelines to detect acidosis. The Swedish 2009 template had a high sensitivity. The Swedish 2017 template had a high sensitivity with cut-off set at suspicious.
Objective In 2015, new FIGO guidelines for CTG interpretation were presented (FIGO-15). In 2017, the previous Swedish guidelines (SWE-09) were replaced with guidelines adapted to FIGOs (SWE-17). The performance of these three templates had not been scientifically evaluated before its clinical implementation. The objective of this study was to compare the sensitivity and specificity to detect fetal acidosis at birth using these three templates during the second stage of labor. Study design This case-control study included 295 neonates with cord blood pH < 7.05 and 591 controls with pH ≥ 7.15, born 2012−2017. Tracings from the last 30−80 min of labor were classified independently by three assessors (midwives, residents and obstetricians), blinded to group and outcome. Results The classification pathological using FIGO-15 had a sensitivity of 50 % and specificity of 88 % in detecting fetuses with acidosis. For SWE-17, the sensitivity was 62 % and the specificity 85 %. For SWE-09 the sensitivity was 87 % and the specificity 56 %. By combining suspicious and pathological patterns the sensitivity for FIGO-15 increased to 97 %, and for SWE-17 to 83 %, whereas the specificity decreased to 23 % and 68 % respectively. Conclusions The FIGO classification seemed to be insufficiently discriminative in the second stage of labor; most patterns in acidotic cases were classified as merely suspicious with this template, and the sensitivity of pathological patterns was low at 50 %. Combined pathological and suspicious patterns detected fetal acidosis at a specificity that was too low to be useful (23 %). SWE-09 showed the best ability to detect acidosis with pathological patterns (sensitivity 87 %). SWE-17 reached almost the same sensitivity (83 %) with the combination of suspicious and pathological patterns, and at a higher specificity (68 %).
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23
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Keenan E, Udhayakumar RK, Karmakar CK, Brownfoot FC, Palaniswami M. Entropy Profiling for Detection of Fetal Arrhythmias in Short Length Fetal Heart Rate Recordings. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:621-624. [PMID: 33018064 DOI: 10.1109/embc44109.2020.9175892] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The use of fetal heart rate (FHR) recordings for assessing fetal wellbeing is an integral component of obstetric care. Recently, non-invasive fetal electrocardiography (NI-FECG) has demonstrated utility for accurately diagnosing fetal arrhythmias via clinician interpretation. In this work, we introduce the use of data-driven entropy profiling to automatically detect fetal arrhythmias in short length FHR recordings obtained via NI-FECG. Using an open access dataset of 11 normal and 11 arrhythmic fetuses, our method (TotalSampEn) achieves excellent classification performance (AUC = 0.98) for detecting fetal arrhythmias in a short time window (i.e. under 10 minutes). We demonstrate that our method outperforms SampEn (AUC = 0.72) and FuzzyEn (AUC = 0.74) based estimates, proving its effectiveness for this task. The rapid detection provided by our approach may enable efficient triage of concerning FHR recordings for clinician review.
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Tarvonen M, Hovi P, Sainio S, Vuorela P, Andersson S, Teramo K. Intrapartum zigzag pattern of fetal heart rate is an early sign of fetal hypoxia: A large obstetric retrospective cohort study. Acta Obstet Gynecol Scand 2020; 100:252-262. [PMID: 32981037 PMCID: PMC7894352 DOI: 10.1111/aogs.14007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/19/2020] [Accepted: 09/22/2020] [Indexed: 01/01/2023]
Abstract
Introduction The aim of the present study was to identify possible associations of fetal heart rate (FHR) patterns during the last 2 hours of labor with fetal asphyxia expressed by umbilical artery acidemia at birth and with neonatal complications in a large obstetric cohort. Material and methods Cardiotocographic recordings from 4988 singleton term childbirths over 1 year were evaluated retrospectively and blinded to the pregnancy and neonatal outcomes in a university teaching hospital in Helsinki, Finland. Umbilical artery pH, base excess and pO2, low Apgar scores at 5 minutes, need for intubation and resuscitation, early neonatal hypoglycemia, and neonatal encephalopathy were used as outcome variables. According to the severity of the neonatal complications at birth, the cohort was divided into three groups: no complications (Group 1), moderate complications (Group 2) and severe complications (Group 3). Results Of the 4988 deliveries, the ZigZag pattern (FHR baseline amplitude changes of >25 bpm with a duration of 2‐30 minutes) occurred in 11.7%, late decelerations in 41.0%, bradycardia episodes in 52.9%, reduced variability in 36.7%, tachycardia episodes in 13.9% and uterine tachysystole in 4.6%. No case of saltatory pattern (baseline amplitude changes of >25 bpm with a duration of >30 minutes) was observed. The presence of the ZigZag pattern or late decelerations, or both, was associated with cord blood acidemia (odds ratio [OR] 3.3, 95% confidence interval [CI] 2.3‐4.7) and severe neonatal complications (Group 3) (OR 3.3, 95% CI 2.4‐4.9). In contrast, no significant associations existed between the other FHR patterns and severe neonatal complications. ZigZag pattern preceded late decelerations in 88.7% of the cases. A normal FHR preceded the ZigZag pattern in 90.4% of the cases, whereas after ZigZag episodes, a normal FHR pattern was observed in only 0.9%. Conclusions ZigZag pattern and late decelerations during the last 2 hours of labor are significantly associated with cord blood acidemia at birth and neonatal complications. The ZigZag pattern precedes late decelerations, and the fact that normal FHR pattern precedes the ZigZag pattern in the majority of the cases suggests that the ZigZag pattern is an early sign of fetal hypoxia, which emphasizes its clinical importance.
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Affiliation(s)
- Mikko Tarvonen
- Department of Obstetrics and Gynecology, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
| | - Petteri Hovi
- National Institute for Health and Welfare (THL), Helsinki, Finland.,Children's Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
| | - Susanna Sainio
- Finnish Red Cross Blood Transfusion Service, Helsinki, Finland
| | - Piia Vuorela
- Health and Social Welfare Department, Vantaa, Finland
| | - Sture Andersson
- Children's Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
| | - Kari Teramo
- Department of Obstetrics and Gynecology, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
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25
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Ražem K, Kocijan J, Podbregar M, Lučovnik M. Near-infrared spectroscopy of the placenta for monitoring fetal oxygenation during labour. PLoS One 2020; 15:e0231461. [PMID: 32298307 PMCID: PMC7162483 DOI: 10.1371/journal.pone.0231461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 03/24/2020] [Indexed: 11/18/2022] Open
Abstract
Although being the golden standard for intrapartum fetal surveillance, cardiotocography (CTG) has been shown to have poor specificity for detecting fetal acidosis. Non-invasive near-infrared-spectroscopy (NIRS) monitoring of placental oxygenation during labour has not been studied yet. The objective of the study was to determine whether changes in placental NIRS values during labour could identify intrapartum fetal hypoxia and resulting acidosis. We included 43 healthy women in active stage of labour at term. CTG and NIRS parameters in groups with vs. without neonatal umbilical artery pH ≤ 7.20 were compared using Mann-Whitney-U. Receiver-operating-characteristics (ROC) curves were used to estimate predictive value of CTG and NIRS parameters for neonatal pH ≤ 7.20. A computer-based statistical classification was also performed to further evaluate predictive values of CTG and NIRS for neonatal acidosis. Ten (23%) neonates were born with umbilical artery pH ≤ 7.20. Compared to group with pH > 7.20, fetal acidosis was associated with more episodes of placental NIRS deoxygenation (9 (range 2-37) vs. 2 (range 0-65); p<0.001), higher velocity of placental NIRS deoxygenation (2.31 (range 0-22) vs. 1 (range 0-49) %/s; p = 0.03), more decelerations on CTG (25 (range 3-91) vs. 10 (range 10-60); p = 0.02), and more prolonged decelerations on CTG (2 (range 0-4) vs. 1 (range 0-3); p = 0.04). Number of placental deoxygenations had the highest prognostic value for fetal/neonatal acidosis (area under the ROC curve 0.85 (95% confidence interval 0.70-0.99). Computer-based classification also identified number of placental deoxygenations as the most accurate classifier, with 25% false positive and 93% true positive rate in the training dataset, with 100% accuracy when applied to the testing dataset. Placental deoxygenations during labour measured by NIRS are associated with fetal/neonatal acidosis. Predictive value of placental NIRS for neonatal acidosis was superior to that of CTG.
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Affiliation(s)
- Katja Ražem
- Division of Obstetrics and Gynecology, Department of Perinatology, UniversityMedical Centre Ljubljana, Ljubljana, Slovenia
- * E-mail:
| | - Juš Kocijan
- Department of Systems and Control, Jožef Štefan Institute, Ljubljana, Slovenia
- School of Engineering and Management, University of Nova Gorica, Nova Gorica, Slovenia
| | - Matej Podbregar
- Department of Intensive Internal Medicine, General Hospital Celje, Celje, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Miha Lučovnik
- Division of Obstetrics and Gynecology, Department of Perinatology, UniversityMedical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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26
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Abstract
Electronic fetal monitoring (EFM) is the most commonly used tool to screen for intrapartum fetal hypoxia. Category II EFM is present in over 80% of laboring patients and poses a unique challenge to management given the breadth of EFM features that fall within this category. Certain Category II patterns, such as recurrent late or recurrent variable decelerations, are more predictive of neonatal acidemia than others. A key feature among many published algorithms for Category II management is the use of intrauterine fetal resuscitation techniques including maternal oxygen administration, amnioinfusion, intravenous fluid bolus, discontinuation of oxytocin, and tocolytic administration. The goal of intrauterine resuscitation is to prevent or reverse fetal hypoxia. This is most likely to be successful if the etiology of the Category II EFM pattern is identified and targeted resuscitative measures are performed.
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Affiliation(s)
- Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St Louis, Center for Outpatient Health, 10th floor, 4901 Forest Park Ave, St Louis, MO 63110, United States.
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27
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Kikuchi H, Noda S, Katsuragi S, Ikeda T, Horio H. Evaluation of 3-tier and 5-tier FHR pattern classifications using umbilical blood pH and base excess at delivery. PLoS One 2020; 15:e0228630. [PMID: 32027690 PMCID: PMC7004356 DOI: 10.1371/journal.pone.0228630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 01/21/2020] [Indexed: 11/18/2022] Open
Abstract
Objective The relevance between time-series fetal heart rate (FHR) pattern changes during labor and outcomes such as arterial blood gas data at delivery has not been studied. Using 3-tier and 5-tier classification systems, we studied the relationship between time-series FHR pattern changes before delivery and umbilical artery blood gas data at delivery. Methods The subjects were 1,909 low-risk women with vaginal delivery (age: 29.1 ± 4.4 years, parity: 1.7 ± 0.8). FHR patterns were classified by a skilled obstetrician based on each 10 min-segment of the last 60 min before delivery from continuous CTG records in an obstetric clinic. Results The relationship between each 10 min-segment FHR pattern classification from 60 minutes before delivery and umbilical artery blood pH and base excess (BE) values at delivery changed with time. In the 3-tier classification, mean pH of Category I group in each 10 min-segment was significantly higher than that of Category II group. For Category I groups in each 10-minute segment, its number decreased and its average pH increased as the delivery time approached. In the 5-tier classification, there was the same tendency. About each level group in 10 min-segment, the higher the level, the lower the blood gas values, and mean pH of higher level groups decreased as the delivery time approached. Conclusions The relationship between classifications and outcomes was clear at any time from 60 min before delivery in 3- and 5-tier classifications, and the 5-tier classification was more relevant.
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Affiliation(s)
- Hitomi Kikuchi
- Department of Medical Engineering, Aino University, Ibaraki, Osaka, Japan
- * E-mail:
| | | | - Shinji Katsuragi
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Fuchu-shi, Tokyo, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hiroyuki Horio
- Graduate School of Applied Informatics, University of Hyogo, Kobe, Hyogo, Japan
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Furukawa A, Neilson D, Hamilton E. Cumulative deceleration area: a simplified predictor of metabolic acidemia. J Matern Fetal Neonatal Med 2019; 34:3104-3111. [PMID: 31630599 DOI: 10.1080/14767058.2019.1678130] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Fetal monitoring, ubiquitous in obstetrics is used to predict and prevent intrapartum fetal injury. Despite decades of education and nomenclature revision, clinicians show low agreement on key elements, including the types of deceleration and hence their presumed etiology. Cumulative deceleration area is not dependent on deceleration type and could potentially mitigate this problem. Although deceleration area has shown promise as a marker of acidemia, no reports have shown how deceleration area evolves in late labor. Advances in computerization allow for direct measurement of deceleration area and standard fetal heart rate (FHR) patterns. The objective of this study was to compare the evolution and discrimination performance of deceleration area and other FHR patterns in late labor in term neonates with metabolic acidemia (MA) and in those with normal cord gases. METHODS This retrospective cohort study included women with a term singleton (≥37 weeks) in cephalic presentation with cord gas data and FHR tracings available for analysis. MA included neonates with an umbilical artery base deficit >12 mmol/L (n = 132). Controls included those with normal cord gases (base deficit <8 mmol/L) and a 5-minute Apgar score of >6 (n = 1498). Deceleration area and other FHR patterns were summarized and compared in 30-minute segments over the last five hours. Receiver-operating characteristic curves were constructed and AUCs compared. RESULTS Deceleration area had the highest AUC (0.702, 95% CI 0.655-0.749) and was a superior marker of MA compared to baseline (AUC 0.588, 95% CI 0.530-0.645), baseline variability (AUC 0.611, 95% CI 0.558-0.663), and number of late decelerations (AUC 0.582, 95% CI 0.527-0.637). CONCLUSION Cumulative deceleration area reduces the necessity to determine deceleration type. In a single number, it objectively quantifies three important aspects of decelerations; frequency, depth and duration and was a superior marker of MA compared to baseline level, baseline variability and number of late decelerations. The acidemia group had higher deceleration area over the last two hours prior to delivery. This result indicates that the cumulative area and persistence of repetitive decelerations is important clinically.
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Affiliation(s)
- Abby Furukawa
- Department of Obstetrics and Gynecology, Legacy Health System, Portland, OR, USA
| | - Duncan Neilson
- Women's Services, Legacy Health System, Portland, OR, USA
| | - Emily Hamilton
- Department of Obstetrics and Gynecology, McGill University, Montreal, Canada
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Magawa S, Tanaka H, Furuhashi F, Maki S, Nii M, Toriyabe K, Kondo E, Ikeda T. Intrapartum cardiotocogram monitoring between obstetricians and computer analysis. J Matern Fetal Neonatal Med 2019; 34:787-793. [PMID: 31072186 DOI: 10.1080/14767058.2019.1617688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: To investigate the accuracy of computer analysis and its features to be used as a fu fetal heart rate (FHR) interpretation method in clinical settings.Methods: The Trium CTG Online® was used as the computer analysis software. Twenty-six cases of intrapartum FHR tracings (total time, 6900 min) were randomly selected from third-trimester pregnancies. Three obstetricians blinded to the patients' clinical information traced the decelerations, variability, and baseline cardiotocogram (CTG) data. Three obstetrician observer individually interpreted the data and only the waveforms they interpreted were adopted. The agreement between the deceleration and baseline, variability, and level of five-tier system was estimated. Weighted kappa (κ) statistics were used to assess reliability.Results: Based on the observers and Trium's classification, κ was 0.78 and the strength of agreement level was substantial. The obstetricians and Trium mostly agreed on the variability and baseline data. However, κ of each deceleration was approximately 0.65 (0.63-0.66), with substantial strength of agreement.Conclusion: Based on the obstetricians and Trium's interpretation, the latter was found to be excellent for FHR interpretation. However, it was difficult for Trium to interpret specific waveform patterns. Therefore, clinical staff should understand these characteristics to more sensitively evaluate the fetal well-being.
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Affiliation(s)
- Shoichi Magawa
- Department of Obstetrics and Gynecology, Mie University Faculty Medicine, Tsu, Mie, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University Faculty Medicine, Tsu, Mie, Japan
| | - Fumi Furuhashi
- Department of Obstetrics and Gynecology, Mie University Faculty Medicine, Tsu, Mie, Japan
| | - Shintaro Maki
- Department of Obstetrics and Gynecology, Mie University Faculty Medicine, Tsu, Mie, Japan
| | - Masafumi Nii
- Department of Obstetrics and Gynecology, Mie University Faculty Medicine, Tsu, Mie, Japan
| | - Kuniaki Toriyabe
- Department of Obstetrics and Gynecology, Mie University Faculty Medicine, Tsu, Mie, Japan
| | - Eiji Kondo
- Department of Obstetrics and Gynecology, Mie University Faculty Medicine, Tsu, Mie, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University Faculty Medicine, Tsu, Mie, Japan
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Umekawa T, Maki S, Kubo M, Tanaka H, Nii M, Tanaka K, Osato K, Kamimoto Y, Tamaru S, Ogura T, Nishimura Y, Kodera M, Minamide C, Nishikawa M, Endoh M, Kimura T, Kotani T, Nakamura M, Sekizawa A, Ikeda T. TADAFER II: Tadalafil treatment for fetal growth restriction - a study protocol for a multicenter randomised controlled phase II trial. BMJ Open 2018; 8:e020948. [PMID: 30381311 PMCID: PMC6224767 DOI: 10.1136/bmjopen-2017-020948] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION There is no proven therapy to reverse or ameliorate fetal growth restriction (FGR). Sildenafil, a selective phosphodiesterase 5 (PDE5) inhibitor, has been reported to potentially play a therapeutic role in FGR, but this has not been established. Tadalafil is also a selective PDE5 inhibitor. We have demonstrated the efficacy of tadalafil against FGR along with short-term outcomes and the feasibility of tadalafil treatment. Based on the hypothesis that tadalafil will safely increase the likelihood of increased fetal growth in FGR, we designed this phase II study to prospectively evaluate the efficacy and safety of tadalafil against FGR. METHODS AND ANALYSIS This study is a multicentre, randomised controlled phase II trial. A total of 140 fetuses with FGR will be enrolled from medical centres in Japan. Fetuses will be randomised to receive either the conventional management for FGR or a once-daily treatment with 20 mg of tadalafil along with the conventional management until delivery. The primary endpoint is fetal growth velocity from the first day of the protocol-defined treatment to birth (g/day). To minimise bias in terms of fetal baseline conditions and timing of delivery, a fetal indication for delivery was established in this study. The investigator will evaluate fetal baseline conditions at enrolment and will decide the timing of delivery based on this fetal indication. Infants will be followed up for development until 1.5 years of age. ETHICS AND DISSEMINATION This study was approved by the Institutional Review Board of Mie University Hospital and each participating institution. Our findings will be widely disseminated through peer-reviewed publications. TRIAL REGISTRATION NUMBER UMIN000023778.
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Affiliation(s)
- Takashi Umekawa
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Shintaro Maki
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Michiko Kubo
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masafumi Nii
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Kayo Tanaka
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Kazuhiro Osato
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yuki Kamimoto
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Satoshi Tamaru
- Clinical Research Support Center, Mie University Hospital, Tsu, Japan
| | - Toru Ogura
- Clinical Research Support Center, Mie University Hospital, Tsu, Japan
| | - Yuki Nishimura
- Clinical Research Support Center, Mie University Hospital, Tsu, Japan
| | - Mayumi Kodera
- Clinical Research Support Center, Mie University Hospital, Tsu, Japan
| | - Chisato Minamide
- Clinical Research Support Center, Mie University Hospital, Tsu, Japan
| | | | - Masayuki Endoh
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomomi Kotani
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masamitsu Nakamura
- Department of Obstetrics and Gynecology, Showa University Graduate School of Medicine, Tokyo, Japan
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University Graduate School of Medicine, Tokyo, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Japan
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Morokuma S, Michikawa T, Kato K, Sanefuji M, Shibata E, Tsuji M, Senju A, Kawamoto T, Ohga S, Kusuhara K. Non-reassuring foetal status and neonatal irritability in the Japan Environment and Children's Study: A cohort study. Sci Rep 2018; 8:15853. [PMID: 30367151 PMCID: PMC6203769 DOI: 10.1038/s41598-018-34231-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 10/15/2018] [Indexed: 01/05/2023] Open
Abstract
The aim of this study was to investigate whether non-reassuring foetal status (NRFS) affected an infant's temperament, or if the temperament formed prenatally resulted in an excessive heart rate reaction that was diagnosed as NRFS. We examined the correlation between NRFS and difficulty in holding a baby, and the amount of crying in the one month after birth, which was considered an indicator of the newborn's temperament. We divided the cases with NRFS into positive NRFS and false positive NRFS. NRFS was associated with bad mood, frequent crying for a long duration, and intense crying. After adjustment for other covariates, NRFS was associated with bad mood (odds ratio, OR = 1.15, 95% confidence interval, CI = 1.00-1.33), and intense crying (1.12, 1.02-1.24). In the multi-variable model, positive and false positive NRFS were not clearly associated with neonatal irritability. When stratified by parity, NRFS and false positive NRFS were likely to be positively associated with neonatal irritability in parous women. The clear association between NRFS and intense crying was observed in parous women (multi-variable adjusted OR = 1.46, 95% CI = 1.16-1.83), but not in nulliparae (1.01, 0.91-1.12) (p for effect modification <0.01). Similarly, increased odds of intense crying associated with false positive NRFS were only found in parous women (multi-variable adjusted OR = 1.40, 95% CI = 1.09-1.81) (p for effect modification = 0.03). There was no association observed between positive NRFS and irritability; therefore, NRFS has no effect on an infant's temperament.
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Affiliation(s)
- Seiichi Morokuma
- Research Center for Environmental and Developmental Medical Sciences, Kyushu University, Fukuoka, Japan.
- Department of Health Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Takehiro Michikawa
- Environmental Epidemiology Section, Centre for Health and Environmental Risk Research, National Institute for Environmental Studies, Tsukuba, Ibaraki, Japan
| | - Kiyoko Kato
- Research Center for Environmental and Developmental Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Sanefuji
- Research Center for Environmental and Developmental Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Eiji Shibata
- Japan Environment and Children's Study, UOEH Subunit Center, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
- Department of Obstetrics and Gynecology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Mayumi Tsuji
- Department of Environmental Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Ayako Senju
- Japan Environment and Children's Study, UOEH Subunit Center, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
- Department of Pediatrics, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toshihiro Kawamoto
- Japan Environment and Children's Study, UOEH Subunit Center, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
- Department of Environmental Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Shouichi Ohga
- Research Center for Environmental and Developmental Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichi Kusuhara
- Japan Environment and Children's Study, UOEH Subunit Center, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
- Department of Pediatrics, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Fetal heart rate classification in routine use: Do your prefer a 3-tier or a 5-tier classification? J Gynecol Obstet Hum Reprod 2018; 47:477-480. [PMID: 30153507 DOI: 10.1016/j.jogoh.2018.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/30/2018] [Accepted: 08/20/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the current use of a five-tier fetal heart rate (FHR) classification system (National College of French Obstetricians and Gynecologists, CNGOF, 2007) and of a three-tier system (Federation International of Gynecology and Obstetrics, FIGO, 2015). MATERIALS AND METHODS This was a single-center prospective study conducted in April 2016. Midwives were asked to classify FHR hourly during their patients' labors according to two classification systems (CNGOF and FIGO). For each system the midwives rated from 0 to 10 the following elements after delivery: ease of FHR classification, the memorization of the classification, access to routine use, and help with the decision of a second-line examination. Finally, they had to choose which classification system seemed most helpful in their clinical practice. RESULTS Forty-six patients were included in the study. The median score for the ease of FHR classification according to the CNGOF system was 7, versus 8 according to the FIGO system (p<0.05). The median score for the ease of remembering the classification was 4 for CNGOF versus 8 for FIGO (p<0.05). The FIGO classification system was considered the easiest to use in 76% of cases and the CNGOF system was the most helpful in 61% of cases. The CNGOF system was seen as a help in deciding on a second-line examination in 70% of cases and the FIGO was a help in 63% of cases. CONCLUSION The three-tier FIGO classification system seemed easier to use but the five-tier CNGOF classification system was more helpful. The choice of which system to use should be discussed within each medical team.
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Mwansa JC, Tambwe AM, Thaba JN, Ndoudule AM, Museba BY, Thabu TM, Muenze PK. [Study of fetal heart rate abnormalities observed on cardiotocography in Lubumbashi: about a cases followed at the Lubumbashi University Clinic and the General Hospital of the Cinquantenaire]. Pan Afr Med J 2018; 30:278. [PMID: 30637063 PMCID: PMC6317385 DOI: 10.11604/pamj.2018.30.278.13365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 07/22/2018] [Indexed: 12/03/2022] Open
Abstract
Cardiotocography (CTG) has recently come into use in Lubumbashi but no thorough study has yet been conducted to identify its impact on perinatal morbi-mortality. This study aims to determine the frequency of fetal heart rate abnormalities (FHR)in order to identify the associated factors and to propose a suitable management. We conducted a cross-sectional, descriptive study of 411 women in labour over a period of 19 months (March 2015-December 2016). In patients with pathologic FHR abnormalities, sensitivity and positive predictive value of cardiotocography in the screening test for acute fetal distress were 82.95% and 45.35% respectively. FHR abnormalities were found in two women in labour out of five. Decelerations were the most frequent FHR abnormalities observed (50.8%) with a remarkable predominance of late decelerations (22.1% of all abnormalities). The factors associated with pathological FHR abnormalities were prolonged labor (OR = 14.64, CI = 3.91-54.81), chorioamnionitis (OR = 14.56, CI = 3.83-55.34), chronic maternal anemia (OR = 4.99, CI = 1.48-16.85), primiparity (OR = 2.69, CI = 1.49-4.85), prematurity (OR = 2.90, CI = 1.51-5.54) and prolonged pregnancy (OR = 3.22, CI = 1.38-7.52). Intrauterine growth retardation and arterial hypertension were mainly associated with flat lines and late decelerations (OR = 7.79, CI = 2.50-24.30 and OR=2.74, CI = 1.31-5.72). CTG is a screening tool for the identification of acute fetal distress but with high false-positive rate (55%); it should be associated with other second-line screening tests for acute fetal distress in order to reduce this rate. Factors associated with pathologic FHR abnormalities often cause acute fetal distress thus requiring a rigorous analysis of CTG traces.
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Affiliation(s)
- Joseph Chola Mwansa
- Département de Gynécologie-Obstétrique de la Faculté de Médecine de l'Université de Lubumbashi, Republique Démocratique du Congo
- Service de Gynécologie-Obstétrique de l'Hôpital Général du Cinquantenaire Karavia, Lubumbashi, Republique Démocratique du Congo
| | - Albert Mwembo Tambwe
- Département de Gynécologie-Obstétrique de la Faculté de Médecine de l'Université de Lubumbashi, Republique Démocratique du Congo
| | - Jules Ngwe Thaba
- Département de Gynécologie-Obstétrique de la Faculté de Médecine de l'Université de Lubumbashi, Republique Démocratique du Congo
| | - Arthur Munkana Ndoudule
- Département de Gynécologie-Obstétrique de la Faculté de Médecine de l'Université de Lubumbashi, Republique Démocratique du Congo
| | - Baudouin Yumba Museba
- Service de Gynécologie-Obstétrique de l'Hôpital Général du Cinquantenaire Karavia, Lubumbashi, Republique Démocratique du Congo
| | - Thérèse Mowa Thabu
- Service de Gynécologie-Obstétrique de l'Hôpital Général du Cinquantenaire Karavia, Lubumbashi, Republique Démocratique du Congo
| | - Prosper Kalenga Muenze
- Département de Gynécologie-Obstétrique de la Faculté de Médecine de l'Université de Lubumbashi, Republique Démocratique du Congo
- Service de Gynécologie-Obstétrique de l'Hôpital Général du Cinquantenaire Karavia, Lubumbashi, Republique Démocratique du Congo
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Wakui D, Ito H, Takasuna H, Onodera H, Oshio K, Tanaka Y. Surgical removal of an arteriovenous malformation in the anterior perforated substance in a pregnant woman. Surg Neurol Int 2018; 9:117. [PMID: 29963326 PMCID: PMC6000718 DOI: 10.4103/sni.sni_220_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 09/14/2017] [Indexed: 11/17/2022] Open
Abstract
Background: A tailor-made treatment is often required in arteriovenous malformations (AVMs) depending on the individual situation. In most cases, treatment strategy is usually determined according to the patient's Spetzler–Martin grade. However, in the present case, we were not able to treat the patient following the usual guidelines because of neurological symptoms and pregnancy. Case Description: We describe a rare case of a 31-year-old woman in the 15th week of gestation who presented with an AVM in the anterior perforated substance (APS). She suffered a sudden coma and hemiplegia. A computed tomographic scan showed an enhanced mass and a huge hematoma in the basal ganglia and temporal lobe. The hematoma was successfully evacuated in an endoscopic procedure. Angiography showed that a 25-mm nidus in the APS was fed by the anterior choroidal arteries (AChAs) and the lenticulostriate arteries (LSAs). Therefore, we attempted to remove the nidus because the patient became alert with mild aphasia and hemiparesis 10 days after hemorrhage. The feeding arteries were cut under motor evoked potential (MEP) monitoring, and the nidus was totally resected leaving two of four AChAs and a single artery with several LSAs. The postoperative course was uneventful, and she gave birth to a healthy baby by caesarian delivery 122 days after the hemorrhage with only minor sequelae. Conclusions: Surgical strategy with a device-administered anesthesia are suitable for removing large AVMs even in pregnant women and for the successful outcome of their pregnancies. Even after recovering from a coma and hemiplegia, MEP monitoring is effective for removing large AVMs even when located in the APS.
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Affiliation(s)
- Daisuke Wakui
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hidemichi Ito
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hiroshi Takasuna
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hidetaka Onodera
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kotaro Oshio
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yuichiro Tanaka
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
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A Comprehensive Evaluation of the Predictive Abilities of Fetal Electrocardiogram-Derived Parameters during Labor in Newborn Acidemia: Our Institutional Experience. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3478925. [PMID: 29888259 PMCID: PMC5985095 DOI: 10.1155/2018/3478925] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/20/2018] [Accepted: 04/17/2018] [Indexed: 11/17/2022]
Abstract
This study aimed to identify cardiotocography patterns that discriminate fetal acidemia newborns by comprehensively evaluating the parameters obtained from Holter monitoring during delivery. Between June 1, 2015, and August 1, 2016, a prospective observational study of 85 patients was conducted using fetal Holter monitoring at the Beijing Obstetrics and Gynecology Hospital, Capital Medical University, China. Umbilical cord blood was sampled immediately after delivery and fetal acidemia was defined as umbilical cord arterial blood pH < 7.20. Fetal electrocardiogram- (FECG-) derived parameters, including basal fetal heart rate (BFHR), short-term variation (STV), large acceleration (LA), deceleration capacity (DC), acceleration capacity (AC), proportion of episodes of high variation (PEHV), and proportion of episodes of low variation (PELV), were compared between 16 fetuses with acidemia and 47 without. The areas under the curve (AUC) of receiver operating characteristics (ROC) were calculated. Although all the computerized parameters showed predictive values for acidemia (all AUC > 0.50), STV (AUC = 0.84, P < 0.001), DC (AUC = 0.84, P < 0.001), AC (AUC = 0.80, P < 0.001), and PELV (AUC = 0.71, P = 0.012) were more strongly associated with fetal acidemia. Our institutional experience suggests that FECG-derived parameters from Holter monitoring are beneficial in reducing the incidence of neonatal acidemia.
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Frey HA, Liu X, Lynch CD, Musindi W, Samuels P, Rood KM, Thung SF, Bakk JM, Cheng W, Landon MB. An evaluation of fetal heart rate characteristics associated with neonatal encephalopathy: a case-control study. BJOG 2018; 125:1480-1487. [DOI: 10.1111/1471-0528.15222] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2018] [Indexed: 11/30/2022]
Affiliation(s)
- HA Frey
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - X Liu
- Department of Obstetrics; International Peace Maternity & Child Health Hospital; Shanghai Jiao Tong University; Shanghai China
| | - CD Lynch
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - W Musindi
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - P Samuels
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - KM Rood
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - SF Thung
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - JM Bakk
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - W Cheng
- Department of Obstetrics; International Peace Maternity & Child Health Hospital; Shanghai Jiao Tong University; Shanghai China
| | - MB Landon
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
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Electronic Fetal Monitoring Documentation: Connecting Points for Quality Care and Communication. J Perinat Neonatal Nurs 2018; 32:24-33. [PMID: 29240649 DOI: 10.1097/jpn.0000000000000299] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Contemporaneous, complete, and objective documentation is the foundation for continuity of patient care and facilitates communication between all levels of healthcare clinicians. The impact of electronic fetal monitoring on obstetric safety has become a high priority, with documentation being essential to evaluating care quality. Over several decades, electronic fetal monitoring documentation has reached a higher level of precision because paper is being replaced with health information technology that incorporates system's features such as checklists, drop-down boxes, and decision analysis. The intent of this article is to provide a synopsis of important concepts regarding electronic fetal monitoring documentation and liability-reduction strategies for perinatal nurses.
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Nguyen MT, McCullough LB, Chervenak FA. The importance of clinically and ethically fine-tuning decision-making about cesarean delivery. J Perinat Med 2017; 45:551-557. [PMID: 27780155 DOI: 10.1515/jpm-2016-0262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 09/29/2016] [Indexed: 11/15/2022]
Abstract
In obstetric practice, each pregnant woman presents with a composite of maternal and fetal characteristics that can alter the risk of significant harm without cesarean intervention. The hospital's availability of resources and the obstetrician's training, experience, and skill level can also alter the risk of significant harm without cesarean intervention. This paper proposes a clinical ethical framework that takes these clinical and organizational factors into account, to promote a deliberative rather than simplistic approach to decision-making and counseling about cesarean delivery. The result is a clinical ethical framework that should guide the obstetrician in fine-tuning his or her evidence-based, beneficence-based analysis of specific clinical and organizational factors that can affect the strength of the beneficence-based clinical judgment about cesarean delivery. We illustrate the clinical application of this framework for three common obstetric conditions: Category II fetal heart rate tracing, prior non-classical cesarean delivery, and breech presentation.
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Pruksanusak N, Thongphanang P, Chainarong N, Suntharasaj T, Kor-Anantakul O, Suwanrath C, Petpichetchian C. Agreement of three interpretation systems of intrapartum foetal heart rate monitoring by different levels of physicians. J OBSTET GYNAECOL 2017; 37:996-999. [PMID: 28599582 DOI: 10.1080/01443615.2017.1312314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A prospective study was conducted in centre in Southern Thailand, to evaluate agreement in EFM interpretation among various physicians in order to find out the most practical system for daily use. We found strong agreement of very normal FHR tracings among the FIGO, NICHD 3-tier and 5-tier systems. The NICHD 3-tier was more compatible with the FIGO system than 5-tier system. Overall inter-observer agreement was moderate for the NICHD 3-tier system while inter-observer agreement of 5-tier system was fair also the intra-observer agreement was higher in the NICHD 3-tier system. So the 3-tier systems are more suitable than the 5-tier system in general obstetric practice. Impact statement What is already known on this subject: The 3-tier and 5-tier systems were widely used in general obstetrics practice. What the results of this study add: The inter- and intra-observer agreement of NICHD 3-tier system was higher than the 5-tier system. What the implications are of these findings for clinical practice and/or further research: The 3-tier systems were more suitable than the 5-tier systems in general obstetrics practice.
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Affiliation(s)
- Ninlapa Pruksanusak
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
| | - Putthaporn Thongphanang
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
| | - Natthicha Chainarong
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
| | - Thitima Suntharasaj
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
| | - Ounjai Kor-Anantakul
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
| | - Chitkasaem Suwanrath
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
| | - Chusana Petpichetchian
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
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Martí Gamboa S, Lapresta Moros M, Pascual Mancho J, Lapresta Moros C, Castán Mateo S. Deceleration area and fetal acidemia. J Matern Fetal Neonatal Med 2016; 30:2578-2584. [DOI: 10.1080/14767058.2016.1256993] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Vintzileos AM, Smulian JC. Decelerations, tachycardia, and decreased variability: have we overlooked the significance of longitudinal fetal heart rate changes for detecting intrapartum fetal hypoxia? Am J Obstet Gynecol 2016; 215:261-4. [PMID: 27568857 DOI: 10.1016/j.ajog.2016.05.046] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 05/26/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Anthony M Vintzileos
- Department of Obstetrics and Gynecology, Winthrop-University Hospital, Mineola, NY.
| | - John C Smulian
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA; University of South Florida-Morsani College of Medicine, Tampa, FL
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Ayres-de-Campos D, Spong CY, Chandraharan E. FIGO consensus guidelines on intrapartum fetal monitoring: Cardiotocography. Int J Gynaecol Obstet 2016; 131:13-24. [PMID: 26433401 DOI: 10.1016/j.ijgo.2015.06.020] [Citation(s) in RCA: 419] [Impact Index Per Article: 52.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Diogo Ayres-de-Campos
- Medical School, Institute of Biomedical Engineering, S. Joao Hospital, University of Porto, Portugal
| | - Catherine Y Spong
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
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Michikata K, Sameshima H, Urabe H, Tokunaga S, Kodama Y, Ikenoue T. The Regional Centralization of Electronic Fetal Heart Rate Monitoring and Its Impact on Neonatal Acidemia and the Cesarean Birth Rate. J Pregnancy 2016; 2016:3658527. [PMID: 27379185 PMCID: PMC4917700 DOI: 10.1155/2016/3658527] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 03/17/2016] [Accepted: 05/22/2016] [Indexed: 11/23/2022] Open
Abstract
Objective. The improvement of the accuracy of fetal heart rate (FHR) pattern interpretation to improve perinatal outcomes remains an elusive challenge. We examined the impact of an FHR centralization system on the incidence of neonatal acidemia and cesarean births. Methods. We performed a regional, population-based, before-and-after study of 9,139 deliveries over a 3-year period. The chi-squared test was used for the statistical analysis. Results. The before-and-after study showed no difference in the rates of acidemia, cesarean births, or perinatal death in the whole population. A subgroup analysis using the 4 hospitals in which an FHR centralization system was continuously connected (compliant group) and 3 hospitals in which the FHR centralization system was connected on demand (noncompliant group) showed that the incidence acidemia was significantly decreased (from 0.47% to 0.11%) without a corresponding increase in the cesarean birth rate due to nonreassuring FHR patterns in the compliant group. Although there was no difference in the incidence of nonreassuring FHR patterns in the noncompliant group, the total cesarean birth rate was significantly higher than that in the compliant group. Conclusion. The continuous FHR centralization system, in which specialists help to interpret results and decide clinical actions, was beneficial in reducing the incidence of neonatal acidemia (pH < 7.1) without increasing the cesarean birth rate due to nonreassuring FHR patterns.
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Affiliation(s)
- Kaori Michikata
- Department of Obstetrics and Gynecology, Center for Perinatal Medicine, University of Miyazaki Faculty of Medicine, Miyazaki 889-1692, Japan
| | - Hiroshi Sameshima
- Department of Obstetrics and Gynecology, Center for Perinatal Medicine, University of Miyazaki Faculty of Medicine, Miyazaki 889-1692, Japan
| | - Hirotoshi Urabe
- Department of Obstetrics and Gynecology, Center for Perinatal Medicine, University of Miyazaki Faculty of Medicine, Miyazaki 889-1692, Japan
| | - Syuichi Tokunaga
- Department of Obstetrics and Gynecology, Center for Perinatal Medicine, University of Miyazaki Faculty of Medicine, Miyazaki 889-1692, Japan
| | - Yuki Kodama
- Department of Obstetrics and Gynecology, Center for Perinatal Medicine, University of Miyazaki Faculty of Medicine, Miyazaki 889-1692, Japan
| | - Tsuyomu Ikenoue
- Department of Obstetrics and Gynecology, Center for Perinatal Medicine, University of Miyazaki Faculty of Medicine, Miyazaki 889-1692, Japan
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Lear CA, Galinsky R, Wassink G, Yamaguchi K, Davidson JO, Westgate JA, Bennet L, Gunn AJ. The myths and physiology surrounding intrapartum decelerations: the critical role of the peripheral chemoreflex. J Physiol 2016; 594:4711-25. [PMID: 27328617 DOI: 10.1113/jp271205] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 02/17/2016] [Indexed: 11/08/2022] Open
Abstract
A distinctive pattern of recurrent rapid falls in fetal heart rate, called decelerations, are commonly associated with uterine contractions during labour. These brief decelerations are mediated by vagal activation. The reflex triggering this vagal response has been variably attributed to a mechanoreceptor response to fetal head compression, to baroreflex activation following increased blood pressure during umbilical cord compression, and/or a Bezold-Jarisch reflex response to reduced venous return from the placenta. Although these complex explanations are still widespread today, there is no consistent evidence that they are common during labour. Instead, the only mechanism that has been systematically investigated, proven to be reliably active during labour and, crucially, capable of producing rapid decelerations is the peripheral chemoreflex. The peripheral chemoreflex is triggered by transient periods of asphyxia that are a normal phenomenon associated with all uterine contractions. This should not cause concern as the healthy fetus has a remarkable ability to adapt to these repeated but short periods of asphyxia. This means that the healthy fetus is typically not at risk of hypotension and injury during uncomplicated labour even during repeated brief decelerations. The physiologically incorrect theories surrounding decelerations that ignore the natural occurrence of repeated asphyxia probably gained widespread support to help explain why many babies are born healthy despite repeated decelerations during labour. We propose that a unified and physiological understanding of intrapartum decelerations that accepts the true nature of labour is critical to improve interpretation of intrapartum fetal heart rate patterns.
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Affiliation(s)
- Christopher A Lear
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Robert Galinsky
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Guido Wassink
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Kyohei Yamaguchi
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynaecology, Mie University Graduate School of Medicine, Mie, Japan
| | - Joanne O Davidson
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Jenny A Westgate
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Starship Children's Hospital, Auckland, New Zealand
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Parer JT, Ugwumadu A. Impediments to a unified international approach to the interpretation and management of intrapartum cardiotocographs. J Matern Fetal Neonatal Med 2016; 30:272-273. [DOI: 10.3109/14767058.2016.1174207] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Julian T. Parer
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA and
| | - Austin Ugwumadu
- Department of Obstetrics & Gynaecology, St George’s University Hospital NHS Foundation Trust, London, UK
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Cheurfa N, Butruille L, De Joonckhere J, Carbonne B, Deruelle P. Évaluation de la forme simplifiée de la classification du rythme cardiaque fœtal proposée dans le cadre des recommandations pour la pratique clinique « surveillance du travail ». ACTA ACUST UNITED AC 2016; 45:330-6. [DOI: 10.1016/j.jgyn.2015.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 04/19/2015] [Accepted: 04/23/2015] [Indexed: 10/23/2022]
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Abstract
Since its inception, many have questioned the utility of electronic fetal heart rate (FHR) monitoring. However, it arrived without the benefit of clear, standard nomenclature, leading to difficulty interpreting studies regarding its benefit. In 2008, the National Institute of Child Health and Human Development (NICHD) developed standard nomenclature for interpreting eFHR tracings. Understanding what drives the tracings is key to managing them. Category II FHR patterns are by far the most common and most diverse patterns, leading to broad variation in care. Presented here is an algorithm for standardization of management of category II FHR tracings, based on the pathophysiology of decelerations, that can be followed in any labor unit.
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Affiliation(s)
- Audra E Timmins
- Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street #1020, Houston, TX, 77030, USA.
| | - Steven L Clark
- Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street #1020, Houston, TX, 77030, USA
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Shaw CJ, Lees CC, Giussani DA. Variations on fetal heart rate variability. J Physiol 2016; 594:1279-80. [PMID: 26926317 PMCID: PMC4771802 DOI: 10.1113/jp270717] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 05/15/2015] [Indexed: 12/30/2022] Open
Affiliation(s)
- C J Shaw
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - C C Lees
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - D A Giussani
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
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49
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Sharma KJ, Rodriguez M, Kilpatrick SJ, Greene N, Aghajanian P. Risks of parenteral antihypertensive therapy for the treatment of severe maternal hypertension are low. Hypertens Pregnancy 2016; 35:123-8. [PMID: 26910380 DOI: 10.3109/10641955.2015.1117098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine whether the incidence of hypotension or adverse fetal heart tracing (FHT) category change differed following antepartum administration of intravenous (IV) labetalol versus hydralazine. METHODS Blood pressure and FHT categories were assessed one hour before and after medication administration. Hypotension was defined as ≥30% reduction in baseline systolic blood pressure (SBP) or SBP <90 mmHg. Changes in mean arterial pressure (MAP) were also compared. The National Institute for Child Health and Human Development (NICHD) three-tier category system was used to describe the FHT. For all category II tracings, Parer and Ikeda's system was also used. RESULTS Sixty-nine women received hydralazine and 31 women received labetalol during the study period. The incidence of hypotension (≥30% reduction in SBP) was similar between the labetalol (10%) and hydralazine (11%) groups (p = 0.98). No women experienced post-treatment SBP <90 mmHg. No association was observed between fetal heart rate category change and drug used. No women required emergent delivery for fetal indications. CONCLUSIONS The incidence of maternal hypotension was low and did not differ following antepartum IV labetalol versus hydralazine use. These data should reassure providers about the use of parenteral labetalol and hydralazine for the treatment of severe hypertension.
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Affiliation(s)
- Kathryn J Sharma
- a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Cedars-Sinai Medical Center , Los Angeles , CA , USA
| | - Maria Rodriguez
- a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Cedars-Sinai Medical Center , Los Angeles , CA , USA
| | - Sarah J Kilpatrick
- a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Cedars-Sinai Medical Center , Los Angeles , CA , USA
| | - Naomi Greene
- a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Cedars-Sinai Medical Center , Los Angeles , CA , USA
| | - Paola Aghajanian
- a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Cedars-Sinai Medical Center , Los Angeles , CA , USA
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50
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Katsuragi S, Parer JT, Noda S, Onishi J, Kikuchi H, Ikeda T. Mechanism of reduction of newborn metabolic acidemia following application of a rule-based 5-category color-coded fetal heart rate management framework. J Matern Fetal Neonatal Med 2015; 28:1608-13. [DOI: 10.3109/14767058.2014.963044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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