The effect of augmentation of labour with syntocinon on the fetal CTG using objective computerised analysis: a nested case-control study.

OBJECTIVE: To investigate the effect of syntocinon augmentation on the fetal cardiotocogram (CTG) using computerised analysis. We hypothesised that syntocinon will have no direct effects on the fetal heart rate if used correctly. STUDY DESIGN: A retrospective, nested case-control study. SETTING: Intrapartum CTG records from the digital archive at the John Radcliffe Hospital, Oxford, UK. SUBJECTS: 110 women with singleton pregnancies of >36 weeks gestation, no known congenital abnormality, spontaneous onset of labour and syntocinon augmentation for failure to progress, with start time of syntocinon recorded, from between August 1998 and December 1999, extensively matched to 110 controls who had normally progressing labours. METHODS: Eight different CTG features were measured during four time points with OxSys, a computerised numerical analysis system. STATISTICAL ANALYSIS: Differences in the CTG features over time in cases and controls using ANOVA and Friedman's ANOVA and at each time point between case-control pairs using Student's t-test and the Wilcoxon signed rank test. RESULTS: After administration, syntocinon increased the frequency, decreased the duration and decreased the resting time between contractions (p<0.001), resulting in no significant difference between normally progressing labours and those requiring augmentation. The case group had a significantly higher signal stability index (SSI) and fewer decelerations compared to the control group - differences which disappeared after augmentation was commenced (p=0.025 and 0.033 respectively). Syntocinon did not affect the baseline heart rate, short term variability (STV) or phase rectified signal averaging (PRSA) (p=0.518, 0.215 and 0.138) in comparison with controls. There was a significant increase in the PRSA in babies born with acidaemia (arterial pH≤7.05) 60-120min after syntocinon was commenced that was not seen with in babies with a normal pH (p=0.002). CONCLUSION: Syntocinon "normalises" ineffective uterine activity without any direct effect on the fetal heart rate. Therefore its administration does not confound objective computerised analysis. There may be a specific response in PRSA shortly after commencing syntocinon augmentation in the fetus which is subsequently born acidaemic which requires further investigation.

Cardiotocographic abnormalities associated with misoprostol and dinoprostone cervical ripening and labor induction.

OBJECTIVE: To characterize the incidence and timing of cardiotocographic (CTG) abnormalities associated with misoprostol and dinoprostone vaginal inserts during labor induction. STUDY DESIGN: This was a secondary analysis of data collected during the misoprostol vaginal insert (MVI) trial, a multi-site, double-masked, randomized trial of women requiring cervical ripening before induction of labor. The timing, incidence and clinical outcomes associated with CTG abnormalities were analyzed among three study groups. RESULTS: 1308 subjects were randomized to receive dinoprostone pessary, misoprostol 50 mcg (MVI 50) or 100 mcg (MVI 100) vaginal insert. 6.8% of MVI 50-treated women had a uterine contractile abnormality (hyperstimulation, hypertonus and/or tachysystole) while the study drug was in situ, compared to 17.4% with dinoprostone insert (p<0.001) and 17.3% with MVI 100 (p<0.001). There was no significant difference in incidence of fetal heart rate (FHR) abnormalities that occurred with the study drug-11.2% with dinoprostone, compared to 9.9% with MVI 50 and 10.7% with MVI 100. Cardiotocographic (CTG) abnormalities while the study drug was in situ occurred later in women treated with MVI 50 (7.5h [6.2-9.8]) compared to dinoprostone (5.5h [4.2-6.6], p=0.003) and MVI 100 (7.0 h [5.7-7.9], p=0.13). Eight participants in MVI 50 group underwent cesarean section secondary to a CTG event that was initially noted with the study drug in situ, compared to eight dinoprostone-treated participants and 16 in the MVI 100 group, but these differences were not statistically significant. CONCLUSION: Cardiotocographic abnormalities were less frequent and occurred after longer exposure with MVI 50 than MVI 100 or dinoprostone. Clinical outcomes were similar among the groups.

Does the anti-hypertensive drug clonidine affect the short-term variation in CTG recordings?

BACKGROUND: Cardiotocographic (CTG) recordings of the fetal heart remain standard obstetric practice among hypertensive women. Changes in the short-term variation (STV) in the fetal heart are often attributed to the effect of anti-hypertensive medications, regardless of the fact that this principle has never been validated. AIM: To assess the STV of CTG recordings pre- and post- the anti-hypertensive medication, clonidine. METHODS: Forty hypertensive pregnant women, already receiving the anti-hypertensive clonidine, were recruited. The CTGs were conducted pre- and post-dose administration. The CTGs were assessed by the Sonicaid Team® automated CTG analysis (Oxford Instruments, UK) to avoid CTG assessor bias. Baseline fetal heart rate (FHR) (delta change from pre- and post-dose) and STV were compared using spss v.14® utilising Student t-tests. RESULTS: No statistical difference was found in the pre- and post-baseline FHRs (P = 0.48). The mean delta baseline heart rate before and after drug administration was -0.54 bpm. The STV of the CTGs recorded pre- and post-clonidine dose was also not affected by administration of the drug (P = 0.34). The mean delta STV before and after drug administration was 0.39 ms. Two women received betamethasone 12 mg intramuscularly within the 12-h period prior to CTG recordings to enhance fetal lung maturity. The mean STV for the fetuses of these women pre-drug was 4.8 ms and 13.2 ms post-administration. This was the largest delta seen in all STVs recorded in this dataset. CONCLUSION: The anti-hypertensive drug clonidine does not alter baseline FHRs or affect the STV of the FHR in hypertensive pregnant women.

[Oral misoprostol against vaginal dinoprostone for labor induction at term: a randomized comparison]. / Prospektiv randomisierte Studie zum Vergleich von Misoprostol oral mit Dinoproston vaginal bei der Geburtseinleitung am Termin.

BACKGROUND: It was the objective of this study to compare the efficacy and safety of oral misoprostol with those of vaginal dinoprostone for the induction of labour at term. PATIENTS AND METHODS: Between 2003 and 2006 224 pregnant women were included in our prospective randomised clinical trial. All of them were admitted for induction of labor at term. Half of the patients received oral misoprostol, initially at a test dose of 25 microg, followed by 50 microg and 100 microg every 4 hours. The control group received 3 mg vaginal dinoprostone every 6 hours. Primary endpoints were time interval until delivery and mode of delivery as well as maternal and neonatal outcome, secondary endpoints were side effects and costs. RESULTS: In the dinoprostone group, the median time interval until delivery was 17.6 hours compared to 24.1 hours in the misoprostol group. Without the test dose, the difference was no longer significant. After dinoprostone induction, more patients had a vaginal delivery within 24 hours (n=60, 53.6%, vs. n=46, 41.1%). The frequencies of spontaneous deliveries and emergency Caesarean sections did not differ between the groups. The rate of vacuum extractions was higher in the misoprostol group (23 vs. 11, i. e. 20.5 vs. 9.8%, p<0.05). With regard to side effects there was no significant difference. No case of hyperstimulation was documented. CONCLUSION: Oral misoprostol is effective and safe for induction of labour at term. In addition, it is much cheaper and independent of storage conditions. At the doses and with the administration intervals used in this study, dinoprostone was slightly more effective than misoprostol.

[Investigation of a fetal heart-rate pattern that shows a reduced oscillation amplitude]. / Silentes CTG--Hypoxie oder Intoxikation?

A fetal heart-rate pattern that has a reduced oscillation amplitude may indicate a physiological fetal dormant period but could also be an indication of fetal hypoxemia. In some rare cases such a fetal heart rate-pattern can be an indicator of cerebral or cardial fetal malformation or of an intoxication caused by sedative drugs. Our patient is a 32-year-old Para III in the phase of 29 weeks and 3 days gestation. Upon admission to the clinic, the fetal heart-rate pattern showed a reduced oscillation amplitude, and there were no signs of fetal movement. The ultrasound examination gave us no reason to suspect fetal malformation, and the results of the Doppler ultrasonography were also normal. However, although the patient had denied taking any medication at all, the results of an toxicological blood test confirmed our suspicion of benzodiazepine intoxication. Throughout the night the fetal heart-rate pattern was continuously measured, and in the early hours of the morning, after breaking down of the oxazepam medication, a normalization of the fetal heart-rate pattern was observed. This case report definitively demonstrates that Doppler ultrasonography is a valuable method for assessing any uncertainty regarding a fetal heart-rate pattern.

Dinoprostone versus misoprostol: a randomized study of nulliparous women undergoing induction of labor.

BACKGROUND: The objectives of the study were to compare the efficacy and safety of intravaginal misoprostol and intravaginal dinoprostone for induction of labor and to quantify the clinical response to suspicious cardiotocographic (CTG) readings. METHODS: One hundred and ninety-one patients were randomized to receive either 50 micro g misoprostol initially then a further identical dose 6 h later or 2 mg dinoprostone initially followed by 1 mg 6 h later, over a period of 24 h. If not in labor after 24 h, then both arms of the study would thereafter receive dinoprostone alone as per hospital protocol. RESULTS: The induction to delivery interval (1047 vs. 1355 min, p = 0.01), delivery within 12 h (35.4% vs. 18.9%, p = 0.02) and delivery within 24 h (83.3% vs. 63.3%, p = 0.01) were all shorter in the misoprostol arm. There were no differences in rates of oxytocin augmentation (p = 0.47), tachysystole (p = 0.32) and hyperstimulation syndrome (p = 0.82). There was an increase in the median number of times a doctor was called to advise on a suspicious CTG in the misoprostol group (1 vs. 2 occasions, p = 0.052), but there was no difference in neonatal outcome. CONCLUSIONS: Intravaginal misoprostol led to a shorter, more efficient labor, and although there was more anxiety related to the CTG, there was no increase in neonatal adverse effects.

Randomized trial in multiparous patients: investigating a single vs. two-dose regimen of intravaginal misoprostol for induction of labor.

BACKGROUND: Multiparous patients have a higher risk of hyperstimulation and uterine rupture than nulliparous patients. The minimum possible dose of uterotonic drug should be used in induction of labor for multiparous patients to avoid excessive uterine activity, which could increase both maternal and fetal risks. METHODS: One hundred and four women were randomized to either a single dose of 50 micro g of intravaginal misoprostol in 24 h, or two consecutive doses of intravaginal 50 micro g misoprostol 6 h apart. RESULTS: The mean induction to delivery interval (789 min [95% CI: 637-941] vs. 576 min [95% CI: 484-667], p = 0.018) and delivery rate within 12 h (63% vs. 83%, p = 0.035) were higher in the two-dose group. The oxytocin augmentation rate (14% vs. 2%, p = 0.03) was higher in the single-dose group. There was a higher rate of clinician input related to suspicious cardiotocographic readings in the single-dose arm (p = 0.04). There was no statistical difference (p > 0.05) between the one- and two-dose regimens with respect to the rates of tachysystole (21% vs. 15%), hyperstimulation (3.9% vs. 0%), and meconium staining at delivery (9.8% vs. 13.2%). CONCLUSIONS: The two-dose regimen was most efficient, but both regimens were well tolerated by the fetuses.

Effect of betamethasone on computerized cardiotocographic parameters in preterm growth-restricted fetuses with and without cerebral vasodilation.

OBJECTIVE: To verify the effects of maternal corticosteroid administration on fetal behavior and heart rate variation using computerized cardiotocography (cCTG) in a selected group of growth retarded fetuses. STUDY DESIGN: Fifty singleton pregnancies complicated by fetal growth restriction were enrolled in the study before 34 weeks of gestation. All of them received two intramuscular injections of 12 mg of betamethasone 24 h apart. Fetal heart rate was recorded by cCTG before the first injection, and every 24 h for the 3 days following the end of the treatment. After Doppler evaluation of cerebral circulation, fetuses were divided into a group with and a group without signs of cerebral vasodilation. Basal heart rate, short- and long-term variation, percentage of time spent in high variability, fetal movements and percentage of small accelerations were evaluated. RESULTS: Basal fetal heart rate did not show significant changes. Short-term variation and percentage of time spent in high variability significantly decreased in fetuses with but not in fetuses without vasodilation. Long-term variation and fetal movements significantly decreased in both groups. CONCLUSIONS: Maternal administration of betamethasone in growth-retarded fetuses with cerebral vasodilation is associated with significant but transitory modifications of fetal heart rate variation.

[Evaluation of the peripartum effects of 2 analgesics: meperidine and tramadol, used in labor]. / Valutazione degli effetti peripartum di due analgesici, meperidina e tramadolo, utilizzati in travaglio di parto.

The need for analgesia to overcome pain in labour is highly requested by women today. Various ways either non pharmachologic e.g. Emotional sustain, psycho-prophylactic preparation, yoga and hypnosis or pharmachologic such as epidural blockade or parenteral are used. Therefore in our study we evaluated the efficacy and tolerability of the two opioids usually used today in parenteral analgesia to reduce pain during labour: Tramadol and Meperidine. We studied two groups of patients each made up of 20 women in labour, all at term and with a physiologic course of pregnancy. 75 mg i.m. of Meperidine chloryhydrate were somministered in the first group while in the second group 100 mg i.m. of tramadol chloryhydrate were somministered. Various maternal, fetal and neonatal parameters were then monitored demonstrating--A moderate maternal analgesic effect in both drugs (evaluated through the analogic grading of pain). In the group to whom Meperidine was given, sedative effects on the mother were observed associated with respiratory depression in the newborn (the latter evaluated through the Apgar index at 1st and 5th minute of life and pH of the blood obtained at the umbilical cord. The data obtained permitted us to conclude that Tramadol in accordance to the obtained in literature gives an analogous analgesic effect, with better tolerability for the absence of collateral effects on the mother, fetus and newborn.

[Kinetocardiotocography--follow-up of diazepam poisoning]. / KCTG--Verlaufsbeobachtung nach Diazepam-Intoxikation.

Report about continuous fetal monitoring of heart rate and movements 9-30 hours after diazepam-intoxication. in an early stage after intoxication fetal movements are associated with FHF-decelerations, later on with accelerations. A sinusoidal like pattern may be caused by fetal suckling movements.

[Premature rupture of fetal membranes at term: an indication for induced labor with prostaglandins?]. / Vorzeitiger Blasensprung am Termin: Eine Indikation zur Geburtseinleitung mit Prostaglandinen?

Premature rupture of membranes (PROM) at term is thought to be related to an increased infection risk for mother and child. A prospective study was conducted to evaluate the efficacy of prostaglandins for induction of labour in 433 cases of PROM presenting after 35 completed weeks of gestation. Intracervical gel or vaginal pessaries were given in dependence on the Bishop-score. Course of delivery and fetal outcome were analysed. In 57.3% single application was sufficient to induce the delivery. Only 1.8% of cases did not respond. 21% of patients were delivered within six hours of the first application and 89.6% during the first 24 hours. The rate of cesarean section was 15.5%. Fetal distress caused by uterine hyperstimulation was observed in 9.9% and required intrapartum tocolysis. A fetal acidosis (pH < 7.15) was present in 4.1%. The neonatal infective morbidity was 0.4%. Severe maternal complications were not observed. We conclude that use of prostaglandins for induction of labour in case of PROM at term seems to be a recommendable measure. In primiparous women or in the presence of an unfavorable cervix-score shorter duration to delivery diminishes the risk of fetal infection.

[Good sense and nonsense in tocolysis]. / Sinn und Unsinn der Tokolyse.

The present paper tries to evaluate the importance of tocolysis with beta-sympathomimetic drugs twenty years after their introduction into obstetrics. Intrauterine resuscitation and short-term tocolysis have proven to be very effective during this period of time. Because of potential side effects long-term tocolysis has to be considered dangerous and apparently not effective. Oral and prophylactic tocolysis are ineffective. When considering prevention of premature delivery one has to be aware of the fact that premature contractions are only ostensible symptoms of a complex event.

[Effect of aminophylline on frequency of blood flow in utero-placental and fetal circulation, on arterial blood pressure and on cardiotocography]. / Wplyw aminofiliny na predkosc przeplywu krwi w krazeniu maciczno-lozyskowym i plodowym, na cisnienie tetnicze krwi oraz na zapisy kardiotokograficzne.

Aminophylline was given (125 mg i.v.) in 24 cases with fetal hypotrophy. Blood flow was measured (Doppler technique) before aminophylline injection, 30 min. and 3-4 hours after. Blood pressure was monitored continuously, CTG was performed many times before and after administration of aminophylline. After administration of aminophylline diastolic blood pressure decreased during 3-4 hours and blood flow in the arcuate artery increased. There were no changes in the blood flow in the umbilical artery and fetal aorta after administration of aminophylline. We didn't observe any changes in CTG before and after administration of aminophylline.

[Uterine activity in primiparous and multiparous women in spontaneous labor and induced labor with oxytocin]. / Uterine Aktivität bei Erst- und Mehrgebärenden bei Spontangeburten sowie nach Geburtseinleitung mit Oxytocin.

An analysis was performed of 5187 intra-amniotically measured labor pressure curves in 40 births with spontaneous labour (20 primiparae and 20 multiparae) and 40 births births in which labor was induced with oxytocin (20 primiparae and 20 multiparae). The dilatation of the os uteri was divided into three phases--Phase 1, dilatation of the cervix to 2 cm; Phase 2, dilatation of the cervix from 2 to 4 cm, and Phase 3, dilatation from 4 cm onwards until complete. During the active phase, from 2 cm until dilatation of the os uteri was complete, no differences were observed between induced and spontaneous labor with regard to frequency and amplitude of contractions. In the induced-labor cases, the parameters for uterine activity, maximum contraction and dilatation speed were higher in all three phases of labor, and those for total duration of labor lower than in the spontaneous labor cases. The contraction/dilatation speed is an important parameter for monitoring the effect of drug-induced stimulation of labor. In the latency phase in spontaneous labor, more contractions were observed in multiparae than in primiparae. This fact which should be reason enough to intensify monitoring of both mother and fetus during this phase. In light of these results it would appear advisable, in the absence of progress in labor, to make a clear distinction between the goals of cervical maturity and promotion of uterine activity, and to institute different drug therapy accordingly.

[Intrauterine therapy of fetal supraventricular tachycardia with digoxin and verapamil]. / Intrauterine Therapie fetaler supraventrikulärer Tachykardien mit Digoxin und Verapamil.

Fetal supraventricular tachycardia may cause intrauterine heart failure and thus require transplacental treatment. During a period of nine years, we treated nine of eleven fetuses (gestational age ranging from the 26th to the 36th week) suffering from paroxysmal supraventricular tachycardia (10) or atrial flutter (1). The remaining two fetuses did not receive antiarrhythmic therapy because of only short lasting supraventricular tachycardia. Two fetuses were hydropic at the onset of therapy. Diagnosis of the rhythm disorder was established by m-mode echocardiography. All nine fetuses treated received digoxin after diagnosis of supraventricular tachycardia. Three of these reverted to sinus rhythm, one remained in supraventricular tachycardia which, however, was well tolerated. Five fetuses (three because of failure of digoxin alone and two because of a severely symptomatic supraventricular tachycardia) were treated with a combination of digoxin and verapamil. All five fetuses responded to the combined treatment, two of them, however, were delivered prematurely because of recurrence of supraventricular tachycardia in one and amnion-infection syndrome in the other. All patients survived and no severe fetal or maternal side effects were observed. Our experience confirms that digoxin and verapamil are usually effective in treating fetal supraventricular tachycardia. Some fetuses with short lasting and self limiting supraventricular tachycardia may not need any treatment, and a few not responding to digoxin and verapamil may require other antiarrhythmic drugs.