Analysis of antepartum fetal heart rate tracing by physician and computer.

OBJECTIVE: To compare the interpretation of fetal heart rate (FHR) tracings by three obstetricians with that of a computer analysis program. METHODS: Our study population consisted of high-risk pregnant women referred as outpatients for antepartum FHR monitoring. A total of 121 FHR tracings, from a series of 54 consecutive women, were interpreted by three physicians and a computer program (Oxford Sonicaid System 8000, Oxford Sonicaid Ltd., Chichester, UK). The physicians used a modified FHR scoring system to interpret the tracings. Total scores were categorized as 0-4: abnormal, 5-7: questionable, and 8-10: normal. The computer program used overall variation, categorized as normal: longer than 30 ms, abnormal: shorter than 20 ms, and questionable: 20-30 ms. RESULTS: Significant differences were found among the physicians and between the physicians and the computer analysis for the individual elements of FHR tracings. There was very good agreement between two physicians and the computer in the assessment of the FHR baseline. When physicians used a FHR scoring system to classify the tracings as normal, questionable, or abnormal, the agreement was poor (kappa values ranged from -0.037 to 0.28). The computerized analysis identified two FHR tracings as questionable but both were classified as normal by all three physicians. CONCLUSIONS: The level of agreement in the interpretation of FHR tracings was poor among physicians and between physicians and the computer analysis. A FHR scoring system did not improve the level of agreement between physicians.

Exogenous luteinizing hormone (LH) increases estradiol response patterns in poor responders with low serum LH concentrations.

PURPOSE: Our purpose was to investigate whether the addition of exogenous leuteinizing hormone (LH) increases estradiol secretion in LH-depleted women undergoing controlled ovarian hyperstimulation (COH) with purified follicle stimulating hormone (FSH). METHODS: We carried out case series and retrospective analysis of midfollicular serum LH concentrations and estradiol response patterns in COH cycles. All patients initially received gonadotropins containing purified FSH. Human menopausal gonadotropin containing LH was added to poor responders with low midfollicular LH concentrations. RESULTS: The addition of exogenous LH to the COH regimen significantly increased estradiol secretion in poor responders with low midfollicular endogenous LH concentrations. This was confirmed statistically by an average change in the slope of the estradiol patterns from 27.54 to 85.49 after the addition of exogenous LH. Furthermore, patients with midfollicular serum LH concentrations < 3.0 mIU/ml had significantly lower midfollicular and peak estradiol (E2) concentrations compared to patients with LH concentrations > or = 3.0 mIU/ml (352.3 and 2094.3 vs 855.6 and 3757.1 pg/ml, respectively). CONCLUSIONS: The addition of exogenous LH increases E2 response patterns in poor responders with low midfollicular serum LH concentrations. Low midfollicular serum LH concentrations are associated with significantly lower midfollicular and peak E2 concentrations.

Station at onset of active labor in nulliparous patients and risk of cesarean delivery.

OBJECTIVE: To determine whether term nulliparas with an unengaged vertex presentation at onset of active labor have a higher risk for cesarean delivery. METHODS: A retrospective cohort of 1250 randomly chosen nulliparous patients at 37-42 weeks' gestation who delivered between 1988 and 1989 were selected. Four hundred forty-seven patients were excluded because of nonvertex presentation, cesarean delivery before active phase of labor, multiple gestation, delivery at less than 37 weeks' or greater than 42 weeks' gestation, induction of labor, or missing charts. For the purpose of this study, active labor was defined as regular contractions with cervical dilatation of at least 3 cm. The station at onset of active labor was recorded. Engagement was considered to be at station 0 or below. RESULTS: Of the 803 patients in the study group, 567 presented unengaged and 236 patients presented engaged. The cesarean rates differed significantly between the two groups: 14% of those unengaged compared with 5% of those engaged (chi2 = 11.9, P < .001). After adjusting for confounding variables, engagement at the time of onset of active labor was associated with lower risk of cesarean delivery (odds ratio .512, 95% confidence interval .285, .922). CONCLUSION: Eighty-six percent of nulliparas with an unengaged vertex at onset of active labor delivered vaginally. Engaged vertex at the onset of active labor was associated with a lower risk of cesarean delivery.

Complete trisomy 9 in a term fetus: a case report.

Complete trisomy 9 was diagnosed in a 35-week fetus by amniocentesis. Several sonograms had revealed only a two-vessel cord and intrauterine growth restriction. No other abnormalities were noted. A stillborn infant was delivered at 37 weeks gestation after induction of labor.

Accuracy and intraobserver variability of simulated cervical dilatation and effacement measurements.

Objective: To assess the accuracy and intraobserver variability of clinical cervical diameter measurements among obstetric health care providers.Methods: Cervical dilatation and effacement simulators consisting of pelvic blocks composed of synthetic rubber were used for the study. The examiners had to rely solely on proprioception to determine dilatation and effacement.Results: A total of 828 simulated cervical diameter and effacement measurements were obtained from 69 different examiners. The overall accuracy for determining the exact diameter was 48.6%, which improved to 88.8% when an error of +/- 1 cm was allowed. Intraobserver variability for a given diameter measurement was 39.9%, which decreased to 14.0% when an error of +/- 1 cm was allowed. The overall accuracy for determining the exact effacement was 52.9%, which improved to 85.8% when an error of +/- 25% was allowed. Intraobserver variability for a given effacement measurement was 37.0%, which decreased to 7.3% when an error of +/- 25% was allowed.Conclusions: Cervical diameter and effacement measurements obtained by digital exam are precise when an error of +/- 1 cm in diameter and +/- 25% effacement is allowed. Intraobserver variability is > 35% and is an important consideration when evaluating dysfunctional labor.