Cardio-Obstetrics de novo: A State-level, Evidence-based Approach for Addressing Maternal Mortality and Severe Maternal Morbidity in Georgia.

Georgia has a high rate of severe maternal morbidity and mortality when compared to the rest of the United States1-6. Evidence gained from the Georgia Maternal Mortality Review Committee identified areas of focus for high yield clinical initiatives for improvement in maternal health outcomes2,7,8. Cardiovascular disease, including cardiomyopathy, coronary conditions, and pre-eclampsia/eclampsia, is the most common cause of pregnancy-related death in non-Hispanic, Black women in Georgia9-11. Development of a Cardio-Obstetrics program is an initiative to advance health equity by decreasing cardiovascular morbidity and mortality. This report describes the following: (1) state-level advocacy for improving maternal health outcomes with funding gained through the legislative process and partnership with a governmental agency; (2) Cardio-Obstetrics program development based on evidence gained from the maternal mortality review process; and (3) implementation of a Cardio-Obstetrics service, beginning with a focused approach for capacity building and understanding barriers to care.

Etiology and Ontogeny of Cerebral Palsy: Implications for Practice and Research.

Cerebral palsy (CP) has been recognized as a group of neurologic disorders with varying etiologies and ontogenies. While a percentage of CP cases arises during labor, the expanded use of electronic fetal monitoring (EFM) to include prevention of CP has resulted in decades of vastly increased interventions that have not significantly reduced the incidence of CP for infants born at term in the USA. Litigation alleging that poor obstetrical practice caused CP in most of these affected children has led to contentious arguments regarding the actual etiologies of this condition and often resulted in substantial monetary awards for plaintiffs. Recent advances in genetic testing using whole exome sequencing have revealed that at least one-third of CP cases in term infants are genetic in origin and therefore not labor-related. Here, we will present and discuss previous attempts to sort out contributing etiologies and ontogenies of CP, and how these newer diagnostic techniques are rapidly improving our ability to better detect and understand such cases. In light of these developments, we present our vision for an overarching spectrum for proper categorization of CP cases into that the following groups: (1) those begun at conception from genetic causes (nonpreventable); (2) those stemming from adverse antenatal/pre-labor events (possibly preventable with heightened antepartum assessment); (3) Those arising from intrapartum events (potentially preventable by earlier interventions); (4) Those occurring shortly after birth (possibly preventable with closer neonatal monitoring); (5) Those that appear later in the postnatal period from non-labor-related causes such as untreated infections or postnatal intracranial hemorrhages.

Improving the interpretation of electronic fetal monitoring: the fetal reserve index.

Electronic fetal monitoring, particularly in the form of cardiotocography, forms the centerpiece of labor management. Initially successfully designed for stillbirth prevention, there was hope to also include prediction and prevention of fetal acidosis and its sequelae. With the routine use of electronic fetal monitoring, the cesarean delivery rate increased from <5% in the 1970s to >30% at present. Most at-risk cases produced healthy babies, resulting in part from considerable confusion as to the differences between diagnostic and screening tests. Electronic fetal monitoring is clearly a screening test. Multiple attempts have aimed at enhancing its ability to accurately distinguish babies at risk of in utero injury from those who are not and to do this in a timely manner so that appropriate intervention can be performed. Even key electronic fetal monitoring opinion leaders admit that this goal has yet to be achieved. Our group has developed a modified approach called the "Fetal Reserve Index" that contextualizes the findings of electronic fetal monitoring by formally including the presence of maternal, fetal, and obstetrical risk factors and increased uterine contraction frequencies and breaking up the tracing into 4 quantifiable components (heart rate, variability, decelerations, and accelerations). The result is a quantitative 8-point metric, with each variable being weighted equally in version 1.0. In multiple previously published refereed papers, we have shown that in head-to-head studies comparing the fetal reserve index with the American College of Obstetricians and Gynecologists' fetal heart rate categories, the fetal reserve index more accurately identifies babies born with cerebral palsy and could also reduce the rates of emergency cesarean delivery and vaginal operative deliveries. We found that the fetal reserve index scores and fetal pH and base excess actually begin to fall earlier in the first stage of labor than was commonly appreciated, and the fetal reserve index provides a good surrogate for pH and base excess values. Finally, the last fetal reserve index score before delivery combined with early analysis of neonatal heart rate and acid/base balance shows that the period of risk for neonatal neurologic impairment can continue for the first 30 minutes of life and requires much closer neonatal observation than is currently being done.

Changing Perspectives of Electronic Fetal Monitoring.

The delivery of healthy babies is the primary goal of obstetric care. Many technologies have been developed to reduce both maternal and fetal risks for poor outcomes. For 50 years, electronic fetal monitoring (EFM) has been used extensively in labor attempting to prevent a large proportion of neonatal encephalopathy and cerebral palsy. However, even key opinion leaders admit that EFM has mostly failed to achieve this goal. We believe this situation emanates from a fundamental misunderstanding of differences between screening and diagnostic tests, considerable subjectivity and inter-observer variability in EFM interpretation, failure to address the pathophysiology of fetal compromise, and a tunnel vision focus. To address these suboptimal results, several iterations of increasingly sophisticated analyses have intended to improve the situation. We believe that part of the continuing problem is that the focus of EFM has been too narrow ignoring important contextual issues such as maternal, fetal, and obstetrical risk factors, and increased uterine contraction frequency. All of these can significantly impact the application of EFM to intrapartum care. We have recently developed a new clinical approach, the Fetal Reserve Index (FRI), contextualizing EFM interpretation. Our data suggest the FRI is capable of providing higher accuracy and earlier detection of emerging fetal compromise. Over time, artificial intelligence/machine learning approaches will likely improve measurements and interpretation of FHR characteristics and other relevant variables. Such future developments will allow us to develop more comprehensive models that increase the interpretability and utility of interfaces for clinical decision making during the intrapartum period.

Uterine contraction frequency in the last hour of labor: how many contractions are too many?

OBJECTIVE: Increased frequency of uterine contractions is a component in the cluster of causal conditions that can lead to fetal hypoxia and acidosis and increase the risk for neonatal neurologic injury. For most international obstetrical societies, 5 contractions per 10 min averaged over 30 min is considered as the upper limit of normal uterine activity. We hypothesize that it might be safer to adopt an upper limit of 4 contractions per 10 min. METHODS: We reviewed our 1970's research database containing 475 patients with closely monitored and well-documented labor and neonatal assessments that included cord blood (CB) pH, base excess (BE), and continuous recording of neonatal heart rate (NHR). Using data segregated by the proportion of the last hour before delivery when uterine contraction frequency (UCF) exceeded 4 and 5 contractions per 10 min respectively, we evaluated outcomes (CB BE, pH, Apgar scores at 1 min, the status of NHR at 16 min after birth, and the proportion of births that did not the result from normal spontaneous vaginal deliveries (NSVDs). ANOVA established relationships between UCF cutoffs and these outcomes. Our sample size is sufficiently large to provide the ability of UCF, per se, to accurately detect an alpha region of .05 88% of the time with an effect size of .15. RESULTS: During the last hour prior to delivery, a UCF cutoff at 4 contractions per 10 min performed better than a UCF cutoff at 5 contractions per 10 min to enable the earlier identification of risks for abnormal outcomes. The longer UCF was increased, the worse were the outcomes that were measured, and the region >4 but ≤5 contractions identifies the beginnings of worsening conditions in a variety of measures of poor outcomes. CONCLUSION: Lowering the recommended threshold for UCF from 5 to 4 contractions per 10-minute period as averaged over 30 min facilitates earlier detection of potentially compromised fetuses and is also an important contributor to a multicomponent contextualized approach to risk assessment.

Current Status of Prostaglandins for Cervical Ripening.

OBJECTIVE: To review the safety and efficacy of administering various prostaglandin formulations to achieve cervical ripening and spontaneous vaginal delivery in women near or at term. STUDY DESIGN: Peer-reviewed clinical research articles in English and searchable on PubMed.com. A thorough literature search was conducted on PubMed.com using the following terms: [misoprostol], [dinoprostone], [prostaglandin E1], [prostaglandin E2], [PGE1], [PGE2], [cervical ripening], [induction of labor]. RESULTS: The review shows conflicting opinions concerning the safety and efficacy of current standard-of-care formulations for cervical ripening. A gold standard option for optimal treatment has not been confirmed. CONCLUSION: While the clinical evidence suggests that prostaglandin E1 (PGE1) and E2 (PGE2) both could be used for cervical ripening when no contraindications are present, PGE2 formulations remain the only commercially available prostaglandin products for cervical ripening approved by the U.S. Food and Drug Administration. We conclude that more research is warranted on the risks of treatment-emergent adverse events and serious complications during induction of labor.

Future perspectives in intrapartum fetal surveillance.

Electronic fetal monitoring (EFM) has aided intrapartum fetal surveillance for more than four decades. In spite of numerous trials comparing EFM with standard fetal heart rate (FHR) auscultation, it remains unclear that this modality has led to improved perinatal outcomes, especially lower rates of perinatal morbidity and mortality. A variety of ancillary methods have been developed to improve the accuracy of EFM for predicting fetal compromise. At present, a limited number of studies have shown that the addition of fetal electrocardiogram (ECG) analysis to visual interpretation of FHR patterns resulted in better fetal outcomes. However, the shortcomings of visual interpretation of FHR patterns persist. Although automated systems for FHR analysis have been developed, they have not been widely used or proven to enhance the value of intrapartum fetal surveillance. This article discusses future directions for novel intrapartum fetal surveillance systems that leverage the long experience gained from EFM to enhance the level of risk assessment and prognosis.

Fetal ECG analysis for intrapartum electronic fetal monitoring: a review.

Computerized analysis of the fetal electrocardiogram has been developed during the past 40 years. A mature system for ST analysis (STAN) has resulted from a series of laboratory and clinical studies. The current STAN system provides adjunctive information to the standard interpretation of fetal heart rate (FHR) patterns. This monograph describes the basis for the STAN methodology, including the derivation of its basic measure, the T : QRS ratio. It summarizes the supporting research and clinical trials that have led to its adoption in obstetric practice. The STAN methodology is outlined according to current fetal heart rate classification and management guidelines. Recent clinical experiences with STAN systems in Europe and the United States are discussed. Finally, future directions for this technology are listed.

Prediction of risk for cesarean delivery in term nulliparas: a comparison of neural network and multiple logistic regression models.

OBJECTIVE: We sought to develop a neural network (NN) to predict the risk for cesarean delivery (CD) in term nulliparas. STUDY DESIGN: Using software (BrainMaker for Windows, Version 3.0; California Scientific Software, Nevada City, CA), we trained an NN with 225 patients obtained by chart review and included for nulliparity, singleton vertex > 36 weeks' gestation, and reassuring fetal heart rate on admission. Training inputs included several maternal and fetal clinical variables. Two logistic regression (LR) models using 225 and 600 patients (LR225 and LR600, respectively) were developed. The NN and LR models were tested for prediction of CD in a set of 100 patients not used for development. RESULTS: The NN, LR225, and LR600 correctly predicted 53%, 26%, and 32% of the patients with CD and 88%, 95%, and 95% of the patients with vaginal delivery, respectively. CONCLUSION: Compared with LRs, the NN was slightly better in predicting CD and was similar for predicting vaginal delivery in nulliparas with term singletons.

Antenatal fetal assessment: contraction stress test, nonstress test, vibroacoustic stimulation, amniotic fluid volume, biophysical profile, and modified biophysical profile--an overview.

Antenatal fetal assessment was introduced into the United States in the 1970s. The initial antepartum test, the oxytocin challenge test, later renamed as the contraction stress test, became the gold standard for fetal surveillance. Its labor intensive requirements and contraindications made it inapplicable to some high-risk pregnancies. Other testing schemes were developed subsequently, the nonstress test and its alternative, vibroacoustic stimulation, the semiquantitative assessment of amniotic fluid volume, the biophysical profile and its modified version, the modified biophysical profile. This article is a brief critical review of these testing methods and focuses on the following: (1) physiologic bases; (2) testing methodologies; (3) supportive evidence from randomized controlled and observational trials; and (4) areas needing further investigation.

Antenatal fetal assessment: multifetal gestation--an overview.

As prevalence of multifetal gestation has increased in the United States, antenatal surveillance of these pregnancies has gained importance. This article focuses on the assessment of twin pregnancy, since critical data are lacking for the surveillance of higher order multiple gestations. Twin pregnancies encounter risks that differ in nature, frequency, and intensity from those seen in singleton pregnancies. Most of these risks stem from subnormal or discordant fetal growth or abnormalities of placentation. Sonographic modalities play key roles in antepartum surveillance. These include fetal biometry, serial growth studies, amniotic fluid volume assessment, Doppler velocimetry of fetal-placental circulation, and biophysical profile testing. Fetal heart rate testing, specifically nonstress testing, has also been used extensively in twin surveillance. This article examines the specific application of these modalities to twin gestation and reviews the best evidence available for their support. Assessment of unique risk conditions of twin-twin transfusion, monoamniotic twinning, and intrauterine death of one twin is addressed. Based on current data, a strategic outline for assessment of twin pregnancy is presented.