Routine Ultrasound at 30th-33rd weeks versus 30th-33rd and 35th-37th weeks in Low-Risk Pregnancies: A Randomized Trial.

INTRODUCTION: The aim of this study was to evaluate the accuracy of 35-37 weeks' ultrasound for fetal growth restriction (FGR) detection and the impact of 30th-33rd weeks versus 30th-33rd and 35th-37th weeks' ultrasound on perinatal outcomes. METHODS: This was a randomized controlled trial that enrolled 1,061 low-risk pregnant women: 513 in the control group (routine ultrasound performed at 30th-33rd weeks) and 548 in the study group (with an additional ultrasound at 35th-37th weeks). FGR was defined as a fetus with an estimated fetal weight (EFW) below the 10th percentile. p values < 0.05 were considered statistically significant. RESULTS: The ultrasound at 35-37 weeks had an overall accuracy of FGR screening of 94%. Spearman's correlation coefficient between EFW and birthweight centile was higher for at 35-37 weeks' ultrasound (ρ = 0.75) compared with 30-33 weeks' ultrasound (ρ = 0.44). The study group had a lower rate of operative vaginal deliveries (24.4% vs. 39.3%, p = 0.005) and cesarean deliveries for nonreassuring fetal status (16.8% vs. 38.8%, p < 0.001). DISCUSSION/CONCLUSION: A later ultrasound (35-37 weeks) had a high accuracy for detection of FGR and had a higher correlation between EFW and birthweight centiles. Furthermore, it was also associated with lower adverse perinatal outcomes compared to an earlier ultrasound.

Fetal growth restriction as the initial finding of preeclampsia is a clinical predictor of maternal and neonatal prognoses: a single-center retrospective study.

BACKGROUND: Preeclampsia (PE) is a hypertensive disorder specific to pregnancy that can cause severe maternal-neonatal complications. The International Society for the Study of Hypertension in Pregnancy revised the PE criteria in 2018; a PE diagnosis can be established in the absence of proteinuria when organ or uteroplacental dysfunction occurs. The initial findings of PE (IFsPE) at the first diagnosis can vary considerably across patients. However, the impacts of different IFsPE on patient prognoses have not been reported. Thus, we investigate the predictors of pregnancy complications and adverse pregnancy outcomes based on IFsPE according to the new criteria. METHODS: This retrospective study included 3729 women who delivered at our hospital between 2015 and 2019. All women were reclassified based on the new PE criteria and divided into three groups based on the IFsPE: Classification 1 (C-1), proteinuria (classical criteria); Classification 2 (C-2), damage to other maternal organs; and Classification 3 (C-3), uteroplacental dysfunction. Pregnancy complications and adverse pregnancy outcomes were assessed and compared among the three groups. RESULTS: In total, 104 women with PE were included. Of those, 42 (40.4%), 28 (26.9%), and 34 (32.7%) were assigned to C-1, C-2, and C-3 groups, respectively. No significant differences in maternal characteristics were detected among the three groups, except for gestational age at PE diagnosis (C-1, 35.5 ± 3.0 weeks; C-2, 35.2 ± 3.6 weeks; C-3, 31.6 ± 4.6 weeks, p <  0.01). The rates of premature birth at < 37 weeks of gestation, fetal growth restriction (FGR), and neonatal acidosis were significantly higher in the C-3 group compared to the C-1 and C-2 groups. Additionally, the composite adverse pregnancy outcomes of the C-3 group compared with C-1 and C-2 represented a significantly higher number of patients. CONCLUSIONS: PE patients with uteroplacental dysfunction as IFsPE had the most unfavorable prognoses for premature birth, FGR, acidosis, and composite adverse pregnancy outcomes.

Accuracy of predicting neonatal distress using a five-level classification of fetal heart rate monitoring.

AIM: To assess the accuracy of neonatal distress prediction using the five-level classification of fetal heart rate (FHR) and management protocol of the Japan Society of Obstetrics and Gynecology (JSOG). METHODS: A case-control study was conducted. Vertex singleton pregnant women who delivered after 37 weeks' gestation from 2013 to 2015 were enrolled. The participants were categorized into two groups; controls were levels 1-3 (n = 1184), whereas cases were levels 4-5 (n = 117) group. Neonatal distress was defined as Apgar score < 8 points at 5 min or umbilical cord artery pH < 7.1. RESULTS: There were 117 cases (9.0%). The frequency of the neonatal distress was observed in 1.3% controls and 6.8% cases (P < 0.01). Diagnostic accuracy of neonatal distress for cases showed a 6.8% positive-predictive value, 34.8% sensitivity, 91.5% specificity and 98.7% negative-predictive value. Among various obstetrical conditions, high sensitivity (100%) for prediction of neonatal distress was observed in women with chromosome abnormalities, placental abruption, umbilical cord abnormalities and excessive labor pain. Conversely, relatively low specificity (<50%) was observed in cases with oligohydramnios and excessive labor pain. CONCLUSION: The five-level classification scheme was efficient for neonatal distress prediction. However, depending on the obstetric condition, the FHR findings and neonatal condition might be independent.

Stomach herniation prior to nonreassuring fetal status in a case of fetal gastroschisis.

The neonatal prognosis in gastroschisis is generally good; however, intrauterine fetal death (IUFD) and nonreassuring fetal status (NRFS) sometimes occur in fetal cases of gastroschisis. Previously, we reported stomach herniation as a possible risk factor for IUFD or NRFS in fetuses with gastroschisis. We report a case of fetal gastroschisis showing stomach herniation and increased velocity of the umbilical venous (UV) flow the day before NRFS by electronic fetal monitoring (EFM). A 27-year-old pregnant woman was followed up from 16 weeks' gestation due to fetal gastroschisis. At 33 + 1 weeks' gestation, EFM displayed a reassuring fetal state, while the ultrasound examination revealed fetal stomach herniation and an increased flow velocity of the UV in the abdomen. One day later, EFM displayed NRFS, and the patient underwent emergency caesarean section. This case showed stomach herniation preceding the occurrence of NRFS. Stomach herniation may be a predictor of NRFS in fetuses with gastroschisis.

Nonreassuring fetal heart rate decreases heart rate variability in newborn infants.

BACKGROUND: Nonreassuring fetal status (NRFS) refers to a compromised fetal condition which implies hypoxia. The influence of intrapartum hypoxia on autonomic nervous system function in early postnatal life is unknown. This study explored the influence of NRFS on the heart rate variability (HRV) of newborn infants. METHODS: Singleton newborn infants delivered through Cesarean delivery (CD) with indications of elective purpose (n = 32), dystocia (n = 29), or NRFS (n = 22), and through vaginal birth (VB) (n = 80) were consecutively collected. HRV parameters including standard deviation of average NN intervals (SDANN), low frequency (LF), high frequency (HF), LF%, HF%, and total power (TP), were obtained for analysis in 3 days postpartum. An independent t-test or one-way ANOVA was used to compare differences in numeric data. RESULTS: SDANN, HF, HF%, and TP of newborn infants in the VB group were significantly higher than those in the CD group. The NRFS group had significantly lower SDANN, HF, and TP than those of the elective group, and significantly lower HF, HF%, and TP than those of the dystocia group. CONCLUSIONS: Newborn infants delivered through Cesarean section had lower HRV, especially those who experienced NRFS during labor. The long-term effects of changes of HRV in neonates require further evaluation.

Are 1st-trimester ß-human chorionic gonadotrophin and pregnancy-associated plasma protein A levels predictive of intrapartum fetal compromise in a selected normal population?

BACKGROUND: The incidence of cerebral palsy in term infants has not changed over the last 30 years. Current intrapartum monitoring techniques are limited by their inherent poor specificity. Changes in fetal haemodynamics in the term fetus, similar to those seen in fetal growth restriction, have been associated with an increased risk of subsequent intrapartum fetal compromise. Alterations in first-trimester ß-hCG and PAPP-A levels are predictive of fetal growth restriction. AIMS: In this study, we aimed to establish whether first-trimester ß-hCG and PAPP-A levels were predictive of fetal compromise in labour and whether these first-trimester markers could be correlated with fetal haemodynamics at term in a low-risk population. MATERIALS AND METHODS: Over a two-year period, 427 women with low risk, uncomplicated pregnancies were recruited to this study. All participants underwent a prelabour ultrasound examination during which fetal biometry and haemodynamics were assessed. First-trimester ß-hCG and PAPP-A levels were recorded from the case notes. All cases were followed up within 48 hours of delivery, and first-trimester ß-hCG and PAPP-A levels correlated with intrapartum outcomes and fetal haemodynamics. RESULTS: No significant relationship between first-trimester ß-hCG and PAPP-A levels and subsequent intrapartum fetal compromise was observed. Weak but significant correlations were observed between ß-hCG levels and umbilical venous flow rate, as well as PAPP-A levels and uterine artery pulsatility index. CONCLUSIONS: ß-hCG and PAPP-A levels measured during the first trimester are not predictive of subsequent intrapartum fetal compromise within a low-risk population.

Nonreassuring fetal status during labor and offspring's childhood neurodevelopment at 3 years of age: The Japan Environment and Children's Study.

OBJECTIVE: Although prior attempts have failed to identify the beneficial effects of intensive fetal monitoring on cerebral palsy, the association between nonreassuring fetal status (NRFS) during labor and the incidence of long-term neurodevelopmental delays in offspring remains unclear. This study aimed to evaluate this association using a nationwide birth cohort. METHODS: Data from 72 869 women with singleton deliveries at and after 37 weeks of gestation from the Japan Environment and Children's Study (2011-2014) were analyzed. Multivariable logistic regression models were used to analyze the odds ratios (ORs) for neurodevelopmental delays using the Ages & Stages Questionnaire (Third Edition) in offspring aged 3 years. RESULTS: The adjusted ORs for personal-social problems were 1.52 (95% confidence interval [CI], 1.06-2.16) for offspring delivered vaginally by nulliparous mothers and 1.51 (95% CI, 1.05-2.18) (for males, 1.70 [95% CI, 1.15-2.50]) for those delivered via cesarean section. No significant changes in adjusted ORs for neurodevelopmental delays were observed among participants without neonatal Apgar scores (ASs) <7 and without umbilical arterial pH (UmA-pH) <7.20. CONCLUSION: NRFS during labor was associated with an increased incidence of personal-social problems in offspring aged 3 years. However, this association was not confirmed after excluding participants with neonatal ASs <7 and UmA-pH <7.20. The association between NRFS and offspring's neurodevelopmental delays might vary based on delivery settings, offspring sex, and short-term neonatal outcomes.

The iPREFACE score is useful for predicting fetal acidemia: A retrospective cohort study of 113 patients who underwent emergency cesarean section for non-reassuring fetal status during labor.

BACKGROUND: The iPREFACE score may aid in predicting fetal acidemia and neonatal asphyxia in emergency cesarean and vaginal deliveries, which may improve labor management precision in the future. OBJECTIVE: This study aimed to assess the score use of the iPREFACE as an objective indicator of the need for rapid delivery in cases of repeated abnormal waveforms without concurrent indications for immediate medical intervention during labor. STUDY DESIGN: This retrospective cohort study was conducted among term (37+ 0 days to 41+6 days) singleton pregnant women who underwent emergency cesarean delivery owing to a nonreassuring fetal status. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery score, calculated from a 30-minute cardiotocography waveform before the decision to perform emergency cesarean delivery, and the integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer score, calculated from a 30-minute cardiotocography waveform before cardiotocography transducer removal, were employed. The primary outcome was the assessment of the predictive ability of these scores for fetal acidemia, whereas the secondary outcomes were differences in umbilical artery blood gas findings and postnatal outcomes between the 2 groups, divided by the cutoff values of the integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography score. RESULTS: The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery and integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer scores demonstrated the capability to predict an umbilical artery blood pH of <7.2. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery and -removal of cardiotocography transducer score, with cutoff values of 37 and 46 points, respectively, exhibited an area under the receiver operating characteristic curve of 0.82 and 0.87, respectively. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer group with ≥46 points had higher incidence rates of an umbilical cord artery blood pH of <7.2, <7.1, and <7.0 and neonatal intensive care unit admissions for neonatal asphyxia. CONCLUSION: The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring, derived from cardiotocography during an emergency cesarean delivery, may enable clinicians to predict fetal acidemia in cases of nonreassuring fetal status. Improved prediction of fetal acidemia and facilitation of timely intervention hold promise for enhancing the outcomes of mothers and newborns during childbirth. Prospective studies are warranted to establish precise cutoff values and to validate the clinical application of these scores.

Intrapartum electronic fetal monitoring features associated with a clinical diagnosis of nonreassuring fetal status.

BACKGROUND: Nonreassuring fetal status detected by continuous electronic fetal monitoring accounts for almost 1 in 4 primary cesarean deliveries. However, given the subjective nature of the diagnosis, there is a need to identify the electronic fetal monitoring patterns that are clinically considered nonreassuring. OBJECTIVE: This study aimed to describe which electronic fetal monitoring features are most commonly associated with first-stage cesarean delivery for nonreassuring fetal status, and to evaluate the risk of neonatal acidemia following cesarean delivery for nonreassuring fetal status. STUDY DESIGN: This was a nested case-control study in a prospectively collected cohort of patients with singleton pregnancies at ≥37 weeks' gestation, admitted in spontaneous labor or for induction of labor from 2010 to 2014 at a single tertiary care center. Patients with preterm pregnancies, multiple gestations, planned cesarean delivery, or nonreassuring fetal status in the second stage of labor were excluded. Cases were identified as having nonreassuring fetal status on the basis of what was documented in the operative note by the delivering physician. Controls were patients without nonreassuring fetal status within 1 hour of delivery. Cases were matched to controls in a 1:2 ratio by parity, obesity, and history of cesarean delivery. Electronic fetal monitoring data were abstracted by credentialed obstetrical research nurses for the 60 minutes before delivery. The primary exposure of interest was the incidence of high-risk category II electronic fetal monitoring features in the 60 minutes before delivery; in particular, the incidence of minimal variability, recurrent late decelerations, recurrent variable decelerations, tachycardia, and >1 prolonged deceleration were compared between groups. We also compared neonatal outcomes between cases and controls, including fetal acidemia (umbilical artery pH <7.1), other umbilical artery gas analytes, and neonatal and maternal outcomes. RESULTS: Of the 8580 patients in the parent study, 714 (8.3%) underwent cesarean delivery for nonreassuring fetal status in the first stage of labor. Patients diagnosed with nonreassuring fetal status requiring cesarean delivery were more likely to have recurrent late decelerations, >1 prolonged deceleration, and recurrent variable decelerations compared with controls. More than 1 prolonged deceleration was associated with 6 times increased rate of nonreassuring fetal status diagnosis resulting in cesarean delivery (adjusted odds ratio, 6.73 [95% confidence interval, 2.47-8.33]). Rates of fetal tachycardia were similar between groups. Minimal variability was less common in the nonreassuring fetal status group compared with controls (adjusted odds ratio, 0.36 [95% confidence interval, 0.25-0.54]). Compared with control deliveries, cesarean delivery for nonreassuring fetal status was associated with nearly 7 times higher risk of neonatal acidemia (7.2% vs 1.1%; adjusted odds ratio, 6.93 [95% confidence interval, 3.83-12.54]). Composite neonatal morbidity and composite maternal morbidity were more likely among patients delivered for nonreassuring fetal status in the first stage (3.9% vs 1.1%; adjusted odds ratio, 5.70 [2.60-12.49]; and 13.3% vs 8.0%; adjusted odds ratio, 1.99 [1.41-2.80]). CONCLUSION: Although multiple category II electronic fetal monitoring features have been traditionally linked to acidemia, the presence of recurrent late decelerations, recurrent variable decelerations, and prolonged decelerations seemed to concern obstetricians enough to surgically intervene for nonreassuring fetal status. A clinical intrapartum diagnosis of nonreassuring fetal status in the setting of these electronic fetal monitoring features is also associated with increased risk of acidemia, suggesting clinical validity to the diagnosis of nonreassuring fetal status.

Effect of maternal age on emergency cesarean section.

Objectives: This study aims to investigate the independent influence of maternal age on the risk of emergency cesarean section (CS) due to nonreassuring fetal heart rate or arrest disorder.Methods: This was a cross-sectional study on women with nulliparous pregnancies, who are attempting vaginal delivery at term and have a cephalic presentation without the indication of elective CS at the onset of labor. The primary outcome was the rate of emergency CS. Independent risk factors were elucidated using multivariate logistic regression analysis.Results: Of 3513 women, 541 (15.4%) delivered by emergency CS during a trial of vaginal delivery, with theses being due to nonreassuring fetal heart rate (N = 150) or arrest disorder (N = 391). In univariate analysis, both individual CS rate due to nonreassuring fetal heart rate or arrest disorder and total emergent CS rate increased with maternal age. The risk of emergency CS was also significantly higher when labor induction was performed (odds ratio (OR) 2.489, 95% confidence interval (CI) 2.043-3.033), while fetal weight was heavier (neonatal weight ≥3.5 kg; OR 2.396, 95% CI 1.956-2.934), and maternal BMI was higher (before pregnancy ≥25 kg/m2; OR 2.751, 95% CI 1.980-3.823, at delivery ≥28 kg/m2; OR 2.375 95% CI 1.915-2.946). Multivariate stepwise regression analysis showed a statistically significant increase in the risk of total emergency CS in mothers over 35 years of age, compared to that in women less than 30 years old (35-39 years group; adjusted OR 1.805 95% CI 1.347-2.418, ≥40 years group; adjusted OR 4.659 95% CI 2.709-8.013). CS due to nonreassuring fetal heart rate increased in mothers over 40 years of age (adjusted OR 5.354, 95% CI 2.386-12.017) and CS due to arrest disorder was also increased in mothers over 30 years of age (30-34 years group; adjusted OR 1.343, 95% CI 1.010-1.785, 35-39 years group; adjusted OR 1.906, 95% CI 1.357-2.679, ≥40 years group; adjusted OR 4.663, 95% CI 2.480-8.768). Similar to the result of univariate analysis, labor induction increased the risk of emergency CS (adjusted OR 2.241, 95% CI 1.828-2.747).Conclusions: Advanced maternal age is an independent risk factor of emergency CS due to nonreassuring fetal heart rate or arrest disorder during the trial of vaginal delivery. The risk of emergency CS was also increased when labor induction was performed. Therefore, the risk of emergency CS needs to be considered, especially when the labor induction is planned, in women aged 40 or more.

Small-for-gestational-age babies of low-risk term pregnancies: does antenatal detection matter?

OBJECTIVES: To compare delivery route and admission rate to neonatal intensive care unit between small- and appropriate-for-gestational-age babies among low-risk term pregnancies. METHODS: A retrospective study was conducted using the database of deliveries in 2014 at a tertiary hospital. Babies delivered at ≥37 weeks with birthweight <10th centile were considered small-for-gestational-age (SGA) and >90th centile were considered large-for-gestational-age. Fetal weight estimation at 30-33 weeks ultrasound <10th centile was considered antenatal detection of SGA. RESULTS: Among 1429 low-risk term pregnancies, 11% (151/1429) had SGA babies and 5% (75/1429) had large-for-gestational-age. SGA babies were associated with higher rate of cesarean sections for nonreassuring fetal status (18/151 versus 8/1202, p < .001) and higher rate of admissions to neonatal intensive care unit (16/151 versus 18/1202, p < .001) compared to appropriate-for-gestational-age. Within SGA group, antepartum detected fetuses were associated with lower rate of operative deliveries for nonreassuring fetal status than undetected group (3/31 versus 39/120, p = .01) Conclusions: In our series, women with SGA term babies were associated with more adverse obstetric and neonatal outcome than appropriate-for-gestational age, especially among those undetected prenatally.

Status epilepticus due to brain tumor during pregnancy.

There is no consensus on the timing of delivery of an infant with nonreassuring fetal status that is associated with maternal status epilepticus. We herein describe a case of status epilepticus due to brain tumor at 28 weeks of gestation.

Mode of delivery has an independent impact on neonatal condition at birth.

OBJECTIVE: Current intra-partum monitoring techniques are often criticized for their poor specificity, with their performance frequently evaluated using measures of the neonatal condition at birth as a surrogate marker for intra-partum fetal compromise. However, these measures may potentially be influenced by a multitude of other factors, including the mode of delivery itself. This study aimed to investigate the impact of mode of delivery on neonatal condition at birth. STUDY DESIGN: This prospective observational study, undertaken at a tertiary referral maternity unit in London, UK, included 604 'low risk' women recruited prior to delivery. Commonly assessed neonatal outcome variables (Apgar score at 1 and 5min, umbilical artery pH and base excess, neonatal unit admission, and a composite neonatal outcome score) were used to compare the condition at birth between babies born by different modes of delivery, using one-way ANOVA and chi-squared testing. RESULTS: Infants born by instrumental delivery for presumed fetal compromise had the poorest condition at birth (mean composite score=1.20), whereas those born by Cesarean section for presumed fetal compromise had a better condition at birth (mean composite score=0.64) (p=<0.001). No difference in composite neonatal outcome scores was observed between babies born by instrumental delivery for a prolonged second stage (no evidence of compromise), and those born by Cesarean delivery for presumed fetal compromise. CONCLUSIONS: Mode of delivery represents a potential confounding factor when using condition at birth as a surrogate marker of intra-partum fetal compromise. When evaluating the efficacy of intra-partum monitoring techniques, the isolated use of Apgar scores, umbilical artery acidosis and neonatal unit admission should be discouraged.