Fetal monitoring with computerized ST analysis during labor: a systematic review and meta-analysis.

BACKGROUND: Computerized ST analysis of fetal electrocardiography (ECG) combined with cardiotochography (CTG) has been introduced for intrapartum monitoring and is the prevailing method when ST analysis (STAN®) is used. OBJECTIVE: To assess the evidence that computerized ST analysis during labor reduces the incidence of fetal metabolic acidosis, hypoxic ischemic encephalopathy, cesarean section, instrumental vaginal delivery or the number of instances where fetal scalp blood sampling is used as compared with CTG only. METHODS: Search of PubMed, Cochrane Library, EMBASE, Web of Science, CINAHL and CRD databases. SELECTION CRITERIA: CTG only compared with CTG + computerized ST analysis. DATA COLLECTION AND ANALYSIS: Studies were assessed using pre-designed templates. Meta-analyses of included randomized controlled trials were performed using a random effects model. RESULTS: Risk ratio for cord metabolic acidosis with STAN® was 0.96 [95% confidence interval (CI) 0.49-1.88]. Risk ratio for cesarean sections or instrumental vaginal deliveries for fetal distress was 0.93 (95%CI 0.80-1.08) and for fetal scalp blood sampling 0.55 (95%CI 0.40-0.76). Encephalopathy cases were not assessed due to their low incidence. CONCLUSIONS: There is not enough scientific evidence to conclude that computerized ST analysis reduces the incidence of metabolic acidosis. Cesarean sections and instrumental vaginal deliveries due to fetal distress or other indications are the same, regardless of method, but STAN® reduces the number of instances which require scalp blood sampling.

Aortic dissection in pregnancy: a life-threatening disease and a diagnosis of worth considering.

Acute aortic dissection is a life-threatening disease. To increase the awareness of this diagnosis as a cause of feto-maternal mortality during pregnancy, we have analyzed risk factors using information from five pregnant women admitted for acute aortic dissection to the Karolinska University Hospital over an eight-year period (1999-2007). Four of the women died and only one survived. One fetus was stillborn and all newborn infants showed signs of asphyxia at birth. Of the women, who were on average five years above the mean age for delivery in Sweden, three had hypertension, two had first-degree relatives with aortic dissection which had occurred during the second half of pregnancy (gestational age at diagnosis 26-41 weeks). The most common presenting symptoms were severe back, abdominal and leg pain, and confusion. If a rapid diagnosis is not made, the risk of mortality for both mother and fetus is high. The incidence of aortic rupture during pregnancy in Sweden appears to be 14.5/1,000,000 and the case maternal fatality ratio 4.4/1,000,000.

The Stockholm classification of stillbirth.

OBJECTIVE: To design and validate a classification system for audit groups working with stillbirth. The classification includes well-defined primary and associated conditions related to fetal death. DESIGN: Descriptive. SETTING: All delivery wards in Stockholm. POPULATION: Stillbirths from 22 completed weeks in Stockholm, Sweden. METHODS: Parallel to audit work, the Stockholm stillbirth group has developed a classification of conditions related to stillbirth. The classification has been validated. MAIN OUTCOME MEASURE: The classification and the results of the validation are presented. RESULT: The classification with 17 groups identifying underlying conditions related to stillbirth (primary diagnoses) and associated factors which may have contributed to the death (associated diagnoses) is described. The conditions are subdivided into definite, probable and possible relation to the death. An evaluation of 382 cases of stillbirth during 2002-2005 resulted in 382 primary diagnoses and 132 associated diagnoses. The most common conditions identified were intrauterine growth restriction/placental insufficiency (23%), infection (19%), malformations/chromosomal abnormalities (12%). The 'unexplained' group together with the 'unknown' group comprised 18%. Validation was done by reclassification of 95 cases from 2005 by six investigators. The overall agreement regarding primary diagnosis was substantial (kappa=0.70). CONCLUSIONS: The Stockholm classification of stillbirth consists of 17 diagnostic groups allowing one primary diagnosis and if needed, associated diagnoses. Diagnoses are subdivided according to definite, probable and possible relation to stillbirth. Validation showed high degree of agreement regarding primary diagnosis. The classification can provide a useful tool for clinicians and audit groups when discussing cause and underlying conditions of fetal death.

Diagnostic evaluation of intrauterine fetal deaths in Stockholm 1998-99.

BACKGROUND: To evaluate the diagnostic methods and to elucidate the etiology of intrauterine fetal death. MATERIAL AND METHODS: A prospective study was conducted on all intrauterine fetal deaths occurring in Stockholm County in 1998-99. During a 24-month period, 188 cases of intrauterine fetal death with gestational ages of > or = 22 weeks were investigated in accordance with structured test protocol. All information from antenatal and delivery records as well as all test results were entered in to an Internet-based database for continuous evaluation. RESULTS: A presumptive explanation to the stillbirth was established in 91% of the cases. The most common factors associated with intrauterine fetal death could be identified as infections (24%), placental insufficiency/intrauterine growth restriction (22%), placental abruption (19%), intercurrent maternal conditions (12%), congenital malformations (10%), and umbilical cord complications (9%). CONCLUSIONS: A relevant test protocol in cases of intrauterine fetal death reduces the number of unexplained cases to a minimum. An Internet-based register on test results of fetal deaths may enable a continuous evaluation of the diagnostic tools and etiologic factors in an ever-changing panorama. The results from the present study can serve as a base for a case-control study in Sweden.