Neonatal outcomes after the obstetric near-miss events uterine rupture, abnormally invasive placenta and emergency peripartum hysterectomy - prospective data from the 2009-2011 Finnish NOSS study.

INTRODUCTION: Neonatal outcomes after the maternal obstetric near-miss complications of uterine rupture, abnormally invasive placenta, and emergency peripartum hysterectomy were assessed. MATERIAL AND METHODS: This case-control study was conducted as part of the Nordic Obstetric Surveillance Study (NOSS). Data on 211 newborns from 197 deliveries in which an obstetric near-miss complication was involved, were collected prospectively from April 2009 to August 2011 from all Finnish delivery units via questionnaires. Missing cases were obtained from national health registers and confirmed by the clinics. Control populations consisted of all other children born during the same period of time in the Finnish Medical Birth Register (n = 147 551). RESULTS: The number of stillbirths in this cohort was high [n = 8, 3.8% vs. 0.3% among controls, odds ratio (OR) 12.5, 95% confidence interval (CI) 6.32-24.9]. In addition, there were two neonatal deaths. The majority of cases (n = 8, 80%) were connected to uterine rupture. The risk of severe birth asphyxia diagnosis was increased compared with controls (n = 17, 8.1% vs. 0.1%, OR 137, 95% CI 82.7-226). A low umbilical artery pH (<7.05) was also observed among these neonates (28.8% vs. 1.0%, OR 28.7, 95% CI 21.5-38.2). Post-term pregnancies were relatively common among the uterine rupture cases. Adverse neonatal outcomes in the AIP and emergency peripartum hysterectomy cases were associated with preterm deliveries. CONCLUSIONS: The prospective data collected from clinicians, combined with the information gathered from national health registers, provided valuable insights into rare maternal near-miss cases. These complications also predisposed stillbirth and neonatal death. In this study, 75% of fetal losses were associated with uterine rupture.

Effectiveness of electronic fetal monitoring with additional ST analysis in vertex singleton pregnancies at >36 weeks of gestation: an individual participant data metaanalysis.

OBJECTIVE: The purpose of this study was to assess the effectiveness of electronic fetal monitoring (EFM) alone and with additional ST analysis (EFM + ST) in laboring women with a singleton term pregnancy that is in cephalic presentation in the prevention of metabolic acidosis by the application of individual patient data metaanalysis. STUDY DESIGN: We conducted an individual patient data metaanalysis using data from 4 randomized trials, which enabled us to account for missing data and investigate relevant subgroups. The primary outcome was metabolic acidosis, which was defined as an umbilical cord-artery pH <7.05 and a base deficit that had been calculated in the extra cellular fluid compartment >12 mmol/L. We performed 8 explanatory subgroup analyses for 8 different endpoints. RESULTS: We analyzed data from 12,987 women and their newborn infants. Metabolic acidosis was present in 57 women (0.9%) in the EFM + ST group and 73 women (1.1%) in the EFM alone group (relative risk [RR], 0.76; 95% CI, 0.53-1.10). Compared with EFM alone, the use of EFM + ST resulted in a reduction in the frequency of instrumental vaginal deliveries (RR, 0.90; 95% CI, 0.83-0.99) and fetal blood samples (RR, 0.49; 95% CI, 0.44-0.55). Cesarean delivery rates were comparable between both groups (RR, 0.99; 95% CI, 0.91-1.09). Subgroup analyses showed that EFM + ST resulted in fewer admissions to a neonatal intensive care unit for women with a duration of pregnancy of >41 weeks (RR, 0.61; 95% CI, 0.39-0.95). CONCLUSION: EFM + ST does not reduce the risk of metabolic acidosis, but it does reduce the need for instrumental vaginal deliveries and fetal blood sampling.

Interobserver agreement in the assessment of intrapartum automated fetal electrocardiography in singleton pregnancies.

OBJECTIVE: To study interobserver agreement in the assessment of intrapartum automated fetal electrocardiogram ST interval analysis (STAN). DESIGN: Observational study. SETTING: Labor ward in tertiary level university hospital. Sample. Two hundred (140 reassuring and 60 non-reassuring) STAN recordings on non-selected women with singleton, vertex, term pregnancies were selected from our archive. Samples of 60-min were analysed from the end of each recording, excluding the last 30 min before delivery. METHODS: Three consultants, who had undergone STAN training and had clinical experience in using STAN, reviewed the recordings using cardiotocography (CTG) and ST information with no clinical data. The reviewers were asked to follow STAN guidelines and 1 to classify the CTG as normal, intermediary, abnormal, or preterminal, and 2 to make a clinical decision on labor management. MAIN OUTCOME MEASURES: Interobserver agreement evaluated by weighted kappa (kappa(w)) values and the proportion of agreement. RESULTS: In CTG classification, the interobserver agreement between three observers was moderate (kappa(w), 0.47-0.48). The proportion of agreement was 56-59%. In clinical decision-making, kappa(w) values varied from 0.47 to 0.60, and the proportion of agreement was 80-86%. CONCLUSIONS: In non-selected term pregnancies, the interobserver agreement among experienced obstetricians in the classification of CTG and clinical decision-making according to STAN guidelines is moderate at best.

Fetal radiation dose in prophylactic uterine arterial embolization.

PURPOSE: The purpose of the study was to estimate the absorbed dose (AD) to the fetus for pregnant patients with placenta accreta undergoing fluoroscopy imaging during prophylactic catheterization and uterine artery embolization. We hypothesize that after optimizing the use of the radiation, this endovascular method is safe. METHODS: Catheterization was performed for seven women before their elective cesarean section. The correct position of the catheter was confirmed by a radiologist using a small bolus of contrast medium and optimized pulsed fluoroscopy imaging. For the AD measurements of the fetus, four radiophotoluminescence dosimeters were placed in the vaginal fornix. Dose area product (DAP), entrance skin exposure (ESE), fluoroscopy time (Tf), and dose rate also was recorded. RESULTS: The mean values of the radiation exposure for the seven patients were as follows: AD in the vaginal fornix was 11.2 (range 2.2-28.7) mGy, DAP 1,122 (648-2,001) cGy cm(2), ESE 120 (63-184) mGy, Tf 7:31 (5:05-11:35) min:sec, and dose rate 15 (8-21) mGy/min, respectively. CONCLUSIONS: This study revealed that the AD to the fetus due to the endovascular method can be reduced to be below the risk for developmental disorders when pulsed fluoroscopy with an optimized protocol is used without angiography exposures.

ST analysis of the fetal electrocardiogram in intrapartum fetal monitoring: a meta-analysis.

OBJECTIVE: To compare the effects of ST-waveform analysis in combination with cardiotocography with conventional cardiotocography for intrapartum fetal monitoring. DATA SOURCES: We searched MEDLINE, Embase, and PubMed for randomized controlled trials (RCTs) evaluating ST-waveform analysis for intrapartum fetal monitoring. METHODS OF STUDY SELECTION: We identified RCTs that compared ST-waveform analysis and conventional cardiotocography for intrapartum fetal monitoring of singleton pregnancies in cephalic presentation beyond 34 weeks of gestation and evaluating at least one of the following: metabolic acidosis, umbilical cord pH less than 7.15, umbilical cord pH less than 7.10, umbilical cord pH less than 7.05, umbilical cord pH less than 7.00, Apgar scores less than 7 at 5 minutes, admittance to the neonatal intensive care unit, need for intubation, presence of hypoxic ischemic encephalopathy, perinatal death, operative delivery, and number of fetal blood samplings. TABULATION, INTEGRATION, AND RESULTS: Five RCTs, which included 15,352 patients, met the selection criteria. Random-effects models were used to estimate the combined relative risks (RRs) of ST analysis compared with conventional cardiotocography. Compared with conventional cardiotocography, ST analysis showed a nonsignificant reduction in metabolic acidosis (RR 0.72, 95% confidence interval 0.43-1.19, number needed to treat [NNT] 357). ST analysis significantly reduced the incidence of additional fetal blood sampling (RR 0.59, 95% confidence interval 0.44-0.79, NNT 11), operative vaginal deliveries (RR 0.88, 95% confidence interval 0.80-0.97, NNT 64), and total operative deliveries (RR 0.94, 95% confidence interval 0.89-0.99, NNT 64). For other outcomes, no differences in effect were seen between ST analysis and conventional cardiotocography, or data were not suitable for meta-analysis. CONCLUSION: The additional use of ST analysis for intrapartum monitoring reduced the incidence of operative vaginal deliveries and the need for fetal blood sampling but did not reduce the incidence of metabolic acidosis at birth.

Arterial embolization and prophylactic catheterization for the treatment for severe obstetric hemorrhage*.

BACKGROUND: To evaluate indications, efficacy, and complications associated with arterial embolization and prophylactic balloon catheterization in the management of obstetric hemorrhage at a university hospital. METHODS: Twenty-two women underwent arterial embolization between February 2001 and November 2003 for the treatment for primary postpartum hemorrhage resulting from abnormal placentation (n=11), uterine atony (n=7), paravaginal laceration (n=3), and disseminated intravascular coagulopathy (n=1). Blood loss was between 3.2 and 15 l. In seven patients, abnormal placentation was diagnosed prenatally and in these patients balloon catheterization was performed prophylactically before elective cesarean section. RESULTS: Of the seven patients, who underwent prophylactic catheterization, embolization was successful in five resulting in adequate hemostasis. Hysterectomy was performed in three, in two patients for uncontrolled hemorrhage and in one patient for placental invasion to bladder. There were no complications associated with prophylactic catheterization and embolization. The other 15 patients were treated in an emergency setting. In eight patients, embolization was performed as a primary surgery, and it was successful in six. In the other seven patients, hysterectomy was performed as an emergency surgery, but bleeding continued. Of these, in six patients, hemostasis was achieved with embolization. Complications associated with emergency embolization were observed in three patients. These were thrombosis of left popliteal artery, vaginal necrosis, and paresthesia of the right leg. CONCLUSIONS: Arterial embolization is of significant value in treating obstetric hemorrhage. Prophylactic insertion of balloon catheters before cesarean section seems to be a safe and effective method in controlling anticipated bleeding. In patients with persistent bleeding following cesarean section and hysterectomy, embolization could be a primary procedure before re-surgery.