Correlation between anesthetic concentration and low Apgar scores in neonates born via Cesarean sections under general anesthesia.

OBJECTIVES: This study aimed to compare plasma concentrations of anesthetic drugs administered during Cesarean section with low Apgar score in neonates deliveried under general anesthesia and analyze associated risk factors. METHODS: Data from 76 neonates undergoing Cesarean section under general anesthesia with blood concentrations of anesthetic drugs were analyzed. A low Apgar score was defined as ≤ 7. Perioperative maternal and neonatal data were collected and analyzed. Neonates were divided into a control group (Group CON, n = 65) and a low Apgar score group (Group LAS, n = 11) based on Apgar score. RESULTS: There were no significant differences in the plasma concentrations of anesthetic drugs in maternal artery, umbilical vein or umbilical artery blood between the two groups. Risk factors for neonatal low Apgar scores during Cesarean section under general anesthesia were premature delivery (aOR 10.2, 95% CI = 1.8-56.9) and preoperative fetal distress (aOR 9.6, 95% CI = 1.3-69.0). The prediction model was: probability = 1/(e­Y), Y= -4.607 + 2.318× (premature delivery) + 2.261× (fetal distress) (yes = 1, no = 0). The Hosmer-Lemeshow test showed χ²= 9.587, P = 0.213, and the area under the curve (AUC) was 0.850 (0.670 ~ 1.000). With a cutoff value of 0.695, sensitivity and specificity were 81.8% and 87.7%, respectively. CONCLUSIONS: There was no correlation between blood concentration of general anesthetic drugs and Apgar score or occurrence of neonatal low Apgar scores. Premature delivery and preoperative fetal distress were identified as independent risk factors for neonatal low Apgar scores after Cesarean section under general anesthesia.

The association between placenta-associated circulating biomarkers and composite adverse delivery outcome of a likely placental cause in healthy post-date pregnancies.

INTRODUCTION: Post-date pregnancies have an increased risk of adverse delivery outcome. Our aim was to explore the association between placenta-associated circulating biomarkers and composite adverse delivery outcome of a likely placental cause in clinically healthy post-date pregnancies. MATERIAL AND METHODS: Women with healthy singleton post-date pregnancies between 40+2 and 42+2  weeks of gestation were recruited to this prospective, observational study conducted at Oslo University Hospital, Norway (NCT03100084). Placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) were measured in the maternal serum samples closest to delivery. The composite adverse delivery outcome included fetal acidemia, low Apgar score (<4 at 1 min or <7 at 5 min), asphyxia, fetal death, assisted ventilation for more than 6 h, meconium aspiration, hypoxic-ischemic encephalopathy, therapeutic hypothermia, operative delivery due to fetal distress, or pathological placental histology findings. Two study-independent senior consultant obstetricians blinded to biomarker results concluded, based on clinical expert opinion, whether the adverse delivery outcomes were most likely associated with placental dysfunction ("likely placental cause") or not. Means were compared using one-way analysis of variance and Bonferroni corrected pairwise comparisons between groups. Receiver operating characteristic (ROC) curves assessed the predictive ability of PlGF, sFlt-1/PlGF ratio, and PlGF <10th centile after adjustment for gestational age at blood sampling. RESULTS: Of 501 pregnancies reviewed for predefined adverse delivery outcomes and for a likely placental cause, 468 were healthy pregnancies and subsequently assigned to either the "uncomplicated" (no adverse outcome, n = 359), "intermediate" (non-placental cause/undetermined, n = 90), or "complicated" (likely placental cause, n = 19) group. There was a significant difference in mean PlGF and sFlt-1/PlGF ratio between the "complicated", "intermediate", and "uncomplicated" groups (108, 185, and 179 pg/mL, p = 0.001; and 48.3, 23.4, and 24.6, p = 0.002, respectively). There was a higher proportion of PlGF concentration <10th centile in the "complicated" group compared with the "intermediate" and "uncomplicated" groups (42.1% vs. 11.1% and 9.5%, p = 0.001). The largest area under the ROC curve for predicting "complicated" outcome was achieved by PlGF concentration and gestational age at blood sampling (0.76; 95% CI 0.65-0.86). CONCLUSIONS: In clinically healthy post-date pregnancies, an antiangiogenic pre-delivery profile (lower PlGF level and higher sFlt-1/PlGF ratio) was associated with composite adverse delivery outcome of a likely placental cause.

Epidural analgesia during labour and stress markers in the newborn.

Labour and modes of delivery can influence the plasma levels of stress hormones and cytokines involved in pathophysiologic cascade, potentially damaging brain development of the newborn. This prospective observational, single-centre, case-control, non-profit study aimed to detect potential differences in foetal well-being such as stress neuroendocrine responses. Quantitative determinations of the stress markers interleukin (IL)-1ß, IL-8, and ß-endorphin were compared between the control group and the epidural analgesia group. We found higher IL1-ß levels but lower IL-8 and ß-endorphin levels in the epidural analgesia group than in the control group. No significant inter-group differences were observed for any parameters. Our findings demonstrate that epidural analgesia for pain relief during labour does not result in significant differences in blood stress response markers.IMPACT STATEMENTWhat is already known on this subject? We already know that plasma levels of stress hormones and cytokines are influenced by labour and delivery modes. This has a deep impact on the newborn in terms of brain damage, immune system deficits, and altered hypothalamic-pituitary axis responses. We also know that epidural analgesia is a widespread practice that offers pain relief to the woman in labour, but there are few studies on the potentially negative effects of epidural labour analgesia on the unborn child.What do the results of this study add? This study found no significative differences in blood stress response markers between the epidural analgesia group and the control group. Under this study circumstances we found out that epidural analgesia does not significantly influence the newborn's well-being during labour and delivery.What are the implications of these findings for clinical practice and/or further research? These findings must be confirmed by further studies to verify whether epidural analgesia is safe for the newborn's development.

Maternal serum thiol/disulfide homeostasis in pregnancies complicated by fetal hypoxia.

We aimed to evaluate maternal serum thiol/disulphide homeostasis in pregnancies complicated by fetal distress (FD). A total of 100 patients beyond the 34th week of pregnancy were included in this study, and they were divided into two groups. The study group included 50 patients who had been diagnosed with FD; the control group was composed of 50 patients who had shown no signs of FD and who had undergone an elective (previous) caesarean section (CS). The native thiol, total thiol and native thiol/total thiol (%) concentrations were lower in Group 1 patients than Group 2 patients (p < .001). The disulphide, disulphide/native thiol (%) and disulphide/total thiol (%) concentrations were higher in Group 1 patients than Group 2 patients (p < .001). This study suggests that maternal thiol/disulphide homeostasis is impaired in pregnancies complicated by FD.IMPACT STATEMENTWhat is already known about this subject? Oxidative stress (OS) has previously been investigated in FD. This study reports for the first time a new novel and automatic measurement method.What do the results of this study add? This study shows that the thiol balance shifts in the direction of disulphide in the cases of FD.What are the implications of these findings for clinical practice and further research? Thiol balance can be used for the timely diagnosis of FD.

Prediction of adverse perinatal outcome by serum placental growth factor and soluble fms-like tyrosine kinase-1 in women undergoing induction of labor.

OBJECTIVE: To investigate the additive value of serum placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1), measured within 24 h prior to induction of labor, to the performance of screening for adverse perinatal outcome provided by maternal risk factors and the cerebroplacental ratio (CPR). METHODS: This was a prospective observational study of 795 singleton pregnancies undergoing induction of labor at ≥ 37 weeks' gestation. Before induction of labor, Doppler ultrasound was used to measure the pulsatility index (PI) in the umbilical artery (UA) and fetal middle cerebral artery (MCA) and maternal blood was obtained for measurement of serum PlGF and sFlt-1. The measured UA-PI, MCA-PI and their ratio (CPR) were converted to multiples of the median (MoM) after adjustment for gestational age, and the measured PlGF and sFlt-1 were converted to MoM after adjustment for gestational age, maternal characteristics and the machine used for the assays. Univariable and multivariable logistic regression analysis was used to determine factors that provided a significant contribution in the prediction of adverse perinatal outcome, defined as the presence of any one of Cesarean section for non-reassuring fetal status in labor, umbilical arterial or venous cord blood pH ≤ 7 and ≤ 7.1, respectively, 5-min Apgar score < 7 or admission to the neonatal intensive care unit for ≥ 24 h. The detection rate (DR) and false-positive rate (FPR) in screening for adverse perinatal outcome were determined. RESULTS: In pregnancies with adverse perinatal outcome, compared to those without, median serum PlGF MoM was lower (0.44; interquartile range (IQR), 0.30-0.82 vs 0.60; IQR, 0.36-1.07; P = 0.003), but median sFlt-1 MoM was not significantly different (P = 0.080). Multivariable regression analysis demonstrated that, in the prediction of adverse perinatal outcome, there was significant contribution from maternal risk factors and CPR MoM but not PlGF MoM or sFlt-1 MoM. The performance of screening for adverse perinatal outcome achieved by maternal risk factors alone (DR of 28.9% at FPR of 10%) was not improved by the addition of CPR (DR of 33.8% at FPR of 10%) (area under the curve, 0.702; 95% CI, 0.654-0.750 vs 0.712; 95% CI, 0.664-0.760; P = 0.233). CONCLUSION: Serum PlGF and sFlt-1, measured within 24 h prior to induction of labor, do not provide a significant additional contribution to maternal risk factors in the prediction of adverse perinatal outcome. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Relationship between various maternal conditions and lactic acid dehydrogenase activity in umbilical cord blood at birth.

BACKGROUND: Lactic acid dehydrogenase (LDH) is a valuable marker for some of the most important diseases in newborns and the plasma LDH activity in newborns correlates well with conditions such as asphyxia. If LDH should be considered as a useful tool also in obstetric care, key factors associated with maternal health before and during pregnancy which could affect umbilical cord LDH activity need to be known. The aims of this study were to explore relationships between selected maternal conditions and arterial lactic acid dehydrogenase activity (aLDH) in umbilical cord blood at delivery. METHODS: A prospective observational study was conducted at Sodersjukhuset, Stockholm, Sweden. Included in the study were 1247 deliveries, and cord blood samples from each were analyzed for aLDH. Background, delivery and neonatal data were collected from the medical records. RESULTS: Higher median values of aLDH were found (P=0.001) among women with chronic disorders not related to pregnancy but there was no increased frequency of high aLDH levels (>612 µ/L, P=0.30). No difference in aLDH was identified between infants born to women with pregnancy-related disorders compared with healthy women, neither in median values, nor in high values (>612 µ/L, P=0.95). CONCLUSION: Newborn infants born to women with non-pregnancy-related chronic disorders had a somewhat higher median value of aLDH in cord blood at delivery. The influence of common maternal conditions and diseases on umbilical cord arterial LDH levels is small compared to the increase reported in fetal distress and several other critical conditions in the newborn.

An investigation of the effect of placental growth factor on intrapartum fetal compromise prediction in terminduced high risk pregnancies.

OBJECTIVES: To date, there is no available test to predict the risk of intrapartum fetal compromise (IFC) during labor, either starting spontaneously or induced due to obstetrics indications. The aim of this study was to examine the effectiveness of placental growth factor (PIGF) in identifying cases that develop intrapartum fetal compromise (IFC) in term high-risk pregnancies induced for labor. MATERIAL AND METHODS: This prospective cross-sectional study was conducted on 40 IFC+ cases and 40 IFC- cases with high-risk term pregnancy and labor induction started in the Health Sciences University Gazi Yasargil Training and Research Hospital, between January 2018 and April 2018. Comparisons were made between the groups in respect of placental growth factor (PIGF) levels, and obstetric and neonatal outcomes. RESULTS: The PIGF level was found to be statistically significantly lower in the IFC+ cases compared to the IFC- cases. For a PIGF cutoff value of 32 pg/mL for the prediction of IFC+ cases, sensitivity was 74.4%, specificity 73.2%, NPV 75% and PPV 72.5%, with a statistically significant difference determined between the groups. The IFC+ development risk increased 7.91-fold in patients with PIGF ≤ 32 pg/mL. CONCLUSIONS: The PIGF levels in cases of IFC+ high risk pregnancies were found to be statistically significantly lower than those of IFC- cases. However, further, large-scale randomized controlled research is necessary to demonstrate this relationship better.

Umbilical lactate as a measure of acidosis and predictor of neonatal risk: a systematic review.

BACKGROUND: Umbilical cord lactate is one approach to measuring acidosis and intrapartum hypoxia, knowledge of which may be helpful for clinicians involved in the care of women and newborns. OBJECTIVE: To synthesise the evidence on accuracy of umbilical cord lactate in measuring acidosis and predicting poor neonatal outcome. SEARCH STRATEGY: Studies published and unpublished between 1990 and 2014 from PubMed/Medline, EMBASE, Cochrane Central Register of Controlled Trials, and clinicaltrials.gov were assessed. SELECTION CRITERIA: Cross-sectional and randomised studies that assessed fetal acidosis (using lactate as the index test) with or without an assessment of neonatal outcome. DATA COLLECTION AND ANALYSIS: Correlations between index and reference test(s) were recorded, as were the raw data to classify the predictive ability of umbilical lactate for neonatal outcomes. Meta-analysis of correlation was performed. We plotted estimates of the studies' observed sensitivities and specificities on Forest plots with 95% confidence intervals (CI). Where possible, we combined data using meta-analysis, applying the hierarchical summary receiver operating characteristics model and a bivariate model. MAIN RESULTS: Twelve studies were included. Umbilical lactate correlated with pH [pooled effect size (ES) -0.650; 95% CI -0.663 to -0.637, P < 0.001], base excess (ES -0.710; 95% CI -0.721 to -0.699, P < 0.001), and Apgar scores at 5 minutes (ES 0.300; 95% 0.193-0.407, P < 0.001). Umbilical lactate had pooled sensitivity and specificity for predicting neonatal neurological outcome including hypoxic ischaemic encephalopathy of 69.7% (95% CI 23.8-94.4%) and 93% (95% CI 86.8-96.3%). AUTHORS' CONCLUSION: Umbilical cord lactate is a clinically applicable, inexpensive and effective way to measure acidosis and is a tool that may be used in the assessment of neonatal outcome. TWEETABLE ABSTRACT: Umbilical cord lactate: a clinically applicable, inexpensive, effective way to measure intrapartum acidosis.

Cord blood TNF-α and IL-6 levels as diagnostic indicators of brain damage in neonates with non-asphyxia fetal distress.

PURPOSE: We investigated prospectively cord blood TNF-α and IL-6 levels as diagnostic indicators of brain damage in neonates with non-asphyxia fetal distress. METHODS: Eighty neonates delivered by cesarean section from January 2013 to December 2014 were enrolled. Magnetic resonance imaging was conducted to determine brain damage. Neonates were assigned to a healthy control group (n = 30) or, with fetal distress, apportioned to groups with or without brain damage (n = 20 and 30, respectively). After delivery, the umbilical arterial blood of all neonates was harvested. Serum tumor necrosis factor-alpha (TNF-α) and interleukin 6 (IL-6) levels were evaluated to investigate a correlation between cord blood TNF-α and IL-6 levels and brain damage caused by non-asphyxia fetal distress. RESULTS: The TNF-α and IL-6 levels in the cord blood of brain-damaged neonates with fetal distress (75.63 ± 7.68 and 217.95 ± 25.15 pg/mL, respectively) were significantly higher than that of neonates with fetal distress without brain damage (43.67 ± 5.54, 119.08 ± 12.30 pg/mL) or the healthy neonates (42.35 ± 6.63, 128.46 ± 16.15 pg/mL); the latter two groups were comparable for both TNF-α and IL-6. The receiver operating characteristic curve showed that when TNF-α (IL-6) reached 53.23 pg/mL (156.23 pg/mL), the specificity and sensitivity for diagnosis of brain damage was 80.3% (82.5%) and 90.1% (81.5%), respectively. CONCLUSION: Monitoring TNF-α and IL-6 levels in umbilical cord blood may assist early diagnosis of brain damage in neonates with non-asphyxia fetal distress.

Umbilical arterial N-terminal pro-B-type natriuretic peptide levels in preeclampsia, fetal growth restriction, preterm birth and fetal distress.

OBJECTIVE: To evaluate fetal cardiopulmonary stress in pregnancies complicated by preeclampsia (PE), fetal growth restriction (FGR), preterm birth (PT), and fetal distress (FD) using umbilical arterial blood N-terminal pro-B-type natriuretic peptide (NT-proBNP). MATERIALS AND METHODS: The study included 146 blood samples that were drawn from umbilical arteries at the time of delivery (20 cases of PE, 11 cases of FGR, 31 cases of PT, 23 cases of FD, and 61 cases of gestational age-matched controls) and analyzed. The main outcome measures included neonatal birthweight, cord pH, and umbilical arterial NT-proBNP. RESULTS: The umbilical arterial NT-proBNP levels were significantly higher in the PE, FGR, PT, and FD groups than in the control group. The umbilical arterial NT-proBNP levels were negatively correlated with gestational age, birthweight, and umbilical arterial pH. CONCLUSIONS: Umbilical arterial NT-proBNP levels are elevated in stressful fetal conditions and have the potential to be considered as a marker for fetal cardiopulmonary stress.

Intrapartum fetal scalp lactate sampling for fetal assessment in the presence of a non-reassuring fetal heart rate trace.

BACKGROUND: Fetal scalp blood sampling for lactate estimation may be considered following identification of an abnormal or non-reassuring fetal heart rate pattern. The smaller volume of blood required for this test, compared with the more traditional pH estimation, may improve sampling rates. The appropriate use of this practice mandates systematic review of its safety and clinical effectiveness prior to widespread introduction. OBJECTIVES: To evaluate the effectiveness and risks of fetal scalp lactate sampling in the assessment of fetal well-being during labour, compared with no testing or alternative testing. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015). SELECTION CRITERIA: All published and unpublished randomised and quasi-randomised trials that compared fetal scalp lactate testing with no testing or alternative testing to evaluate fetal status in the presence of a non-reassuring cardiotocograph during labour. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures of the Cochrane Pregnancy and Childbirth Group. Two review authors independently assessed the studies. MAIN RESULTS: The search identified two completed randomised controlled trials (RCTs) and two ongoing trials. The two published RCTs considered outcomes for 3348 mother-baby pairs allocated to either lactate or pH estimation of fetal blood samples when clinically indicated in labour. Overall, the published RCTs were of low or unclear risk of bias. There was a high risk of performance bias, because it would not have been feasible to blind clinicians or participants.No statistically significant between-group differences were found for neonatal encephalopathy (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.32 to 3.09, one study, 2992 infants) or death. No studies reported neonatal seizures. We had planned to report death with other morbidities, for example, neonatal encephalopathy; however, the data were not available in a format suitable for this, therefore death due to congenital abnormality was considered alone. The three reported neonatal deaths occurred in babies with diaphragmatic hernias (n = 2) or congenital cardiac fibrosis (n = 1). All three babies had been randomised to the pH group and were not acidaemic at birth.There were no statistically significant differences for any of the pre-specified secondary fetal/neonatal/infant outcomes for which data were available. This included low Apgar score at five minutes (RR 1.13, 95% CI 0.76 to 1.68, two studies, 3319 infants) and admission to neonatal intensive care units (RR 1.02, 95% CI 0.83 to 1.25, one study, 2992 infants), or metabolic acidaemia (RR 0.91, 95% CI 0.60 to 1.36, one study, 2675 infants) considered within the studies, either overall or where data were available for those where fetal blood sampling had occurred within 60 minutes of delivery.Similar proportions of fetuses underwent additional tests to further evaluate well-being during labour, including scalp pH if in the lactate group or scalp lactate if in the pH group (RR 0.22, 95% CI 0.04 to 1.30, two studies, 3333 infants;Tau² 1.00, I² = 58%). Fetal blood sampling attempts for lactate and pH estimation were successful in 98.7% and 79.4% of procedures respectively in the one study that reported this outcome.There were no significant between-group differences in mode of birth or operative birth for non-reassuring fetal status, either for all women, or within the group where the fetal blood sample had been taken within 60 minutes of delivery (for example, caesarean section for all enrolled, RR 1.09, 95% CI 0.97 to 1.22, two studies, 3319 women; operative delivery for non-reassuring fetal status for all enrolled RR 1.02, 95% CI 0.93 to 1.11, one study, 2992 women).Neither study reported on adverse effects of fetal scalp lacerations or maternal anxiety. AUTHORS' CONCLUSIONS: When further testing to assess fetal well-being in labour is indicated, fetal scalp blood lactate estimation is more likely to be successfully undertaken than pH estimation. Further studies may consider subgroup analysis by gestational age, the stage of labour and sampling within a prolonged second stage of labour. Additionally, we await the findings from the ongoing studies that compare allocation to no fetal blood sample with sampling for lactate and address longer-term neonatal outcomes, maternal satisfaction with intrapartum fetal monitoring and an economic analysis.

Blood lactate level and meconium aspiration syndrome.

PURPOSE: Approximately 5% of infants born with a meconium-stained amniotic fluid (MSAF) develop meconium aspiration syndrome (MAS). Early recognition of infants at highest risk for the development of MAS and the prediction of disease severity are important for optimizing the clinical strategies for prevention and treatment. The aim of the present study was to identify the risk factors for MAS and to investigate the effect of blood lactate level on the development of MAS. METHODS: Between January 2011 and January 2012, data were recorded with regard to gender, mode of delivery, gestational week, birth weight, 5-min Apgar score, and need for resuscitation of the meconium-stained depressed infants who underwent tracheal aspiration. Moreover, the number of cases developing MAS, blood pH value, and lactate level in capillary blood gases obtained during the first hour after delivery, duration of oxygen supplementation, the number of cases receiving mechanical ventilation and surfactant therapy, duration of hospital stay, and outcomes of the infants were recorded. RESULTS: The number of live births during the study period was 17,202, and of them, 1,341 (7.8%) infants were born through MSAF. Of 195 infants who were meconium-stained depressed, 90 were girls and 105 were boys. Their mean gestational week was 39.37 ± 0.89 weeks and mean birth weight was 3,426 ± 634 g. Eighty-four of them were born through cesarean section (C/S), and 111 were born via normal spontaneous labor. For 40 infants, Apgar score at fifth minute was less than 6. In total, resuscitation was performed on 43 (22.9%) infants. Of the infants, 141 did not develop MAS and 54 developed MAS. While there were no significant differences between infants with and without MAS with regard to gender, delivery route, gestational week, and birth weight, a significant difference was observed regarding the Apgar score (p = 0.0001). The blood pH value in capillary blood gas analysis was less than 7.25 in 18 (28.5%) cases with MAS and four (3.2%) cases without MAS. There was no significant difference between infants with and without MAS with regard to blood pH levels (p = 0.031). The mean blood lactate level was 8.5± 3.4 mmol/L in the patients with MAS, and there was a significant difference between infants with and without MAS regarding blood lactate level (p = 0.0001). The mean duration of oxygen supplementation was 86.62 ± 66.52 and 44.36 ± 19.03 h in patients with MAS and without MAS, respectively. In total, 30 infants required mechanical ventilation (24 infants with MAS and 6 infants without MAS). In addition to mechanical ventilation, 16 infants with MAS were administered surfactant therapy. The mean duration of hospital stay of infants with MAS was significantly higher than infants without MAS (p = 0.0001). There was a correlation between blood lactate levels, blood pH value, and hospitalization duration (p < 0.05). All of the infants, except one patient, were discharged from the NICU. CONCLUSION: In addition to the blood pH value and 5-min Apgar score, increased blood lactate level may be a risk factor for the development of MAS in infants born with MSAF. This may aid in the early detection of MAS and, with appropriate measures taken sooner, reduce morbidity and mortality. Further studies are needed to elucidate the role of lactate level, which is an important indicator of hypoxia during the development of MAS.

Correlation between oxidative stress and G6PD activity in neonatal jaundice.

Fetal distress represents a pathophysiological condition in which oxygen is not available to the fetus in sufficient quantities. In cases of glucose 6-phosphate dehydrogenase (G6PD) deficiency, under conditions of oxidative stress, the residual G6PD and complimentary antioxidant mechanisms may become insufficient to neutralize the large amounts of ROS and to prevent severe hemolysis. Alteration in the oxidant-antioxidant profile is also known to occur in neonatal jaundice. The study group included 22 neonates presented with fetal distress during labor and 24 neonates with no evidence of fetal distress (control group). Umbilical cord blood samples were taken immediately after delivery, and the following blood tests were carried out after birth and at discharge from the hospital: erythrocyte count, total bilirubin, G6PD activity, and parameters presenting oxidative status [thiobarbituric acid reactive substances (TBARS), NO, O2 (-), H2O2, SOD, CAT, O2 (-)/SOD, and H2O2/CAT]. There were no significant differences in TBARS and NO values among neonates with or without fetal distress. However, the values of O2 (-), H2O2, SOD, O2 (-)/SOD, and H2O2/CAT among neonates born after fetal distress were significantly higher than in neonates without fetal distress (p < 0.01). In neonates with fetal distress, the total number of RBCs at delivery was significantly lower, accompanied with higher bilirubin content. Also neonates with fetal distress had lower activity of G6PD and lower CAT activity. Higher values of oxidative stress parameters in newborns delivered after fetal distress do not indicate strictly what occurred first-oxidative stress or basic lower G6PD activity.

Fetal scalp blood sampling in labor--a review.

During the 1970s and 1980s, electronic fetal monitoring and fetal scalp blood sampling were introduced without robust evidence. With a methodical review of the published literature, and using one randomized controlled trial, seven controlled studies, nine randomized studies of various surveillance methods and data from the Danish National Birth Registry, we have assessed the usefulness of fetal scalp blood sampling as a complementary tool to improve the specificity and sensitivity of electronic cardiotocography. Based on heterogeneous studies of modest quality with somewhat inconsistent results, we conclude that fetal scalp blood sampling in conjunction with cardiotocography can reduce the risk of operative delivery. Fetal scalp blood sampling can provide additional information on fetal wellbeing and fetal reserves at a time before decisions are made concerning the need for and timing of operative delivery and the choice of anesthesia, and be an adjunct in the interpretation of cardiotocography patterns.

Fetal scalp blood sampling during labor: an appraisal of the physiological basis and scientific evidence.

Fetal cardiotocography is characterized by low specificity; therefore, in an attempt to ensure fetal well-being, fetal scalp blood sampling has been recommended by most obstetric societies in the case of a non-reassuring cardiotocography. The scientific agreement on the evidence for using fetal scalp blood sampling to decrease the rate of operative delivery for fetal distress is ambiguous. Based on the same studies, a Cochrane review states that fetal scalp blood sampling increases the rate of instrumental delivery while decreasing neonatal acidosis, whereas the National Institute of Health and Clinical Excellence guideline considers that fetal scalp blood sampling decreases instrumental delivery without differences in other outcome variables. The fetal scalp is supplied by vessels outside the skull below the level of the cranial vault, which is likely to be compressed during contractions. The self-regulated redistribution of oxygenated blood from peripheral to central organs causes peripheral ischemia, thus theoretically bringing into question the scalp capillary bed as representative of the central circulation.

Inter- and intra-observer agreement of non-reassuring cardiotocography analysis and subsequent clinical management.

OBJECTIVE: To quantify inter- and intra-observer agreement of non-reassuring intrapartum cardiotocography (CTG) patterns and subsequent clinical management. DESIGN: Methodological study. SETTING: University Medical Center. POPULATION: CTG patterns of 79 women beyond 37 weeks of gestation with a singleton fetus in vertex position in first stage of labor in whom fetal blood sampling (FBS) had been performed. METHODS: Nine observers assessed CTG patterns, which were formerly clinically classified as non-reassuring and indicative for FBS, according to the guidelines of the International Federation of Gynecology and Obstetrics modified for ST analysis. They also proposed clinical management strategies without and with insight into clinical parameters. Weighted kappa values (κw ) and proportions of agreement (Pa ) were calculated. MAIN OUTCOME MEASURES: Agreement on CTG classification and clinical management. RESULTS: Inter-observer agreement on CTG classification and on clinical management were poor for most observer categories (κw range 0.31-0.50 and 0.20-0.45, respectively). Observers agreed best on abnormal CTG patterns (Pa range 0.28-0.36) and on the clinical management option "continue monitoring" (Pa range 0.32-0.40). Intra-observer agreement was fair to good for most observers (κw 0.33-0.70). Insight into clinical parameters resulted in similar inter- and intra-observer agreement. CONCLUSIONS: There was poor inter-observer agreement and fair to good intra-observer agreement on classification and clinical management of intrapartum CTG patterns, which had been classified as non-reassuring and indicative for FBS during birth.

An investigation of the umbilical artery N-terminal proBrain natriuretic peptide levels of fetuses due to fetal distress in term pregnancies.

OBJECTIVE: This study aimed to investigate umbilical artery N-terminal proBrain natriuretic peptide (NT-proBNP) in fetuses delivered by cesarean section due to fetal distress in term pregnancies. METHODS: This prospective case-control study was conducted at the Antalya Training and Research Hospital Obstetric Department, Turkiye. A total of 140 pregnant women, 70 underwent elective cesarean sections between weeks 37 and 40 of gestation (Group 1, the control group) and 70 underwent cesarean sections due to fetal distress (Group 2, the study group), were included. The participants' sociodemographic and obstetric data and fetal umbilical blood NT-proBNP levels were recorded in a database. RESULTS: Age, body mass index, gestational age, prenatal diagnostic tests, fetal anatomical scanning, and baby gender ratios were comparable between the groups (p>0.05), while statistically significant differences were observed in terms of gravidity (3.0 vs. 1.0, p≤0.001) and parity numbers (2 vs. 0, p≤0.001), baby height (50.36±0.88 vs. 49.80±0.86, p≤0.001) and weight (3422.43±409.16 vs. 3239.86±293.74, p=0.003), 1-min Apgar (9.0±0.1 vs. 8.5±1.3, p≤0.001) and 5-min Apgar (10.0±0.1 vs. 9.8±0.4, p=0.026) scores, umbilical artery pH (7.32±0.05 vs. 7.25±0.07, p≤0.001), umbilical artery base deficit (-2.48±1.23 vs. -4.36±1.09. p≤0.001), and NT-proBNP levels [8.77 (7.72-9.39) vs. 12.35 (9.69-12.92), p<0.001]. CONCLUSION: This study showed that NT-proBNP can be used as an important marker in the diagnosis of fetal distress. Prospective studies with more participants are now needed to confirm the accuracy of our results.

A randomised controlled trial comparing standard or intensive management of reduced fetal movements after 36 weeks gestation--a feasibility study.

BACKGROUND: Women presenting with reduced fetal movements (RFM) in the third trimester are at increased risk of stillbirth or fetal growth restriction. These outcomes after RFM are related to smaller fetal size on ultrasound scan, oligohydramnios and lower human placental lactogen (hPL) in maternal serum. We performed this study to address whether a randomised controlled trial (RCT) of the management of RFM was feasible with regard to: i) maternal recruitment and retention ii) patient acceptability, iii) adherence to protocol. Additionally, we aimed to confirm the prevalence of poor perinatal outcomes defined as: stillbirth, birthweight <10th centile, umbilical arterial pH <7.1 or unexpected admission to the neonatal intensive care unit. METHODS: Women with RFM ≥36 weeks gestation were invited to participate in a RCT comparing standard management (ultrasound scan if indicated, induction of labour (IOL) based on consultant decision) with intensive management (ultrasound scan, maternal serum hPL, IOL if either result was abnormal). Anxiety was assessed by state-trait anxiety index (STAI) before and after investigations for RFM. Rates of protocol compliance and IOL for RFM were calculated. Participant views were assessed by questionnaires. RESULTS: 137 women were approached, 120 (88%) participated, 60 in each group, 2 women in the standard group did not complete the study. 20% of participants had a poor perinatal outcome. All women in the intensive group had ultrasound assessment of fetal size and liquor volume vs. 97% in the standard group. 50% of the intensive group had IOL for abnormal scan or low hPL after RFM vs. 26% of controls (p < 0.01). STAI reduced for all women after investigations, but this reduction was greater in the standard group (p = 0.02). Participants had positive views about their involvement in the study. CONCLUSION: An RCT of management of RFM is feasible with a low rate of attrition. Investigations decrease maternal anxiety. Participants in the intensive group were more likely to have IOL for RFM. Further work is required to determine the likely level of intervention in the standard care arm in multiple centres, to develop additional placental biomarkers and to confirm that the composite outcome is valid. TRIAL REGISTRATION: ISRCTN07944306.

Copeptin: a marker for stress reaction in fetuses with intrauterine growth restriction.

OBJECTIVE: To compare venous cord plasma concentrations of 4 vasoactive peptide precursors: carboxy-terminal proarginine vasopressin, CT-prondothelin (ET)-1, midregional proadrenomedullin, and MR-proatrial natriuretic peptide, between fetuses with intrauterine growth restriction and appropriate for gestational age controls. STUDY DESIGN: Matched-pair analysis of 12 fetuses with significant intrauterine growth restriction and 42 healthy appropriate for gestational age control fetuses. All infants were singletons, delivered by elective section after 34 weeks and without chromosomal abnormalities. RESULTS: Umbilical cord plasma copeptin levels (median [range]) were 4-fold higher in intrauterine growth restriction infants than in matched appropriate for gestational age controls: 23.2 (6.7-449) vs 5.1 (2.5-53) pmol/L (P < .001). Multivariate regression analysis revealed an association between copeptin and umbilical artery resistance index z-score (P = .034). The 3 other precursor peptides showed no changes. CONCLUSION: High copeptin concentrations in the cord blood of intrauterine growth restriction newborns reflect a fetal stress response and support the fetal programming hypothesis.