New possibilities for ST analysis - A post-hoc analysis on the Dutch STAN RCT.

BACKGROUND: The diagnostic value of ST analysis of the fetal electrocardiogram (fECG) during labor is uncertain. False alarms (ST events) may be explained by physiological variation of the fetal electrical heart axis. Adjusted ST events, based on a relative rather than an absolute rise from baseline, correct for this variation and may improve the diagnostic accuracy of ST analysis. AIMS: Determine the optimal cut-off for relative ST events in fECG to detect fetal metabolic acidosis. STUDY DESIGN: Post-hoc analysis on fECG tracings from the Dutch STAN trial (STAN+CTG branch). SUBJECTS: 1328 term singleton fetuses with scalp ECG tracing during labor, including 10 cases of metabolic acidosis. OUTCOME MEASURES: Cut-off value for relative ST events at the point closest to (0,1) in the receiver operating characteristic (ROC) curve with corresponding sensitivity and specificity. RESULTS: Relative baseline ST events had an optimal cut-off at an increment of 85% from baseline. Relative ST events had a sensitivity of 90% and specificity of 80%. CONCLUSIONS: Adjusting the current definition of ST events may improve ST analysis, making it independent of CTG interpretation.

Prediction of neonatal outcome in women with gestational hypertension or mild preeclampsia after 36 weeks of gestation.

BACKGROUND: There is little knowledge about neonatal complications in GH and PE and induction at term, we aim to assess whether they can be predicted from clinical data. METHODS: We used data of the HYPITAT trial and evaluated whether adverse neonatal outcome (Apgar score < 7, pH < 7.05, NICU admission) could be predicted from clinical data. Logistic regression, ROC analysis and calibration were used to identify predictors and evaluate the predictive capacity in an antepartum and intrapartum model. RESULTS: We included 1153 pregnancies, of whom 76 (6.6%) had adverse neonatal outcome. Parity (primipara OR 2.75), BMI (OR 1.06), proteinuria (dipstick +++ OR 2.5), uric acid (OR 1.4) and creatinine (OR 1.02) were independent antepartum predictors; In the intrapartum model, meconium stained amniotic fluid (OR 2.2), temperature (OR 1.8), duration of first stage of labour (OR 1.15), proteinuria (dipstick +++ OR 2.7), creatinine (OR 1.02) and uric acid (OR 1.5) were predictors of adverse neonatal outcome. Both models showed good discrimination (AUC 0.75 and 0.78), but calibration was limited (Hosmer-Lemeshow p = 0.41, and p = 0.20). CONCLUSIONS: In women with GH or PE at term, it is difficult to predict neonatal complications, possibly since they are rare in the term pregnancy. However, the identified individual predictors may guide physicians to anticipate requirements for neonatal care.

Severe cerebral injury in a recipient with twin anemia-polycythemia sequence.

Twin anemia-polycythemia sequence (TAPS) results from slow intertwin blood transfusion through minuscule placental vascular anastomoses and is characterized by large intertwin hemoglobin differences in the absence of amniotic fluid discordance. The optimal management of TAPS is not clear. We report a case of TAPS detected antenatally by Doppler ultrasound examination at 15 + 6 weeks' gestation. After counseling, the parents opted for expectant management. Regular Doppler measurements were performed and these remained fairly stable. An emergency Cesarean section was performed at 34 + 5 weeks following signs of fetal distress. The donor twin was severely anemic while the recipient twin had severe polycythemia-hyperviscosity syndrome. On day 1, the recipient developed respiratory insufficiency and subclinical status epilepticus. Magnetic resonance imaging showed a total loss of gray-white matter differentiation as a sign of severe diffuse cerebral ischemia and bilateral intra- and extra-axial hemorrhages. There was almost complete lack of arterial and venous cerebral blood flow. On day 3 intensive care treatment was withdrawn in view of the severity of the brain injury. This case report demonstrates that TAPS may lead to severe cerebral injury and fatal outcome in the recipient twin, and highlights the importance of antenatal Doppler ultrasound monitoring and choice of management.

Is intrapartum fever associated with ST-waveform changes of the fetal electrocardiogram? A retrospective cohort study.

OBJECTIVE: To investigate the association between maternal intrapartum fever and ST-waveform changes of the fetal electrocardiogram. DESIGN: Retrospective cohort study. SETTING: Three academic and six non-academic teaching hospitals in the Netherlands. POPULATION: Labouring women with a high-risk singleton pregnancy in cephalic position beyond 36 weeks of gestation. METHODS: We studied 142 women with fever (≥38.0°C) during labour and 141 women with normal temperature who had been included in two previous studies. In both groups, we counted the number and type of ST-events and classified them as significant (intervention needed) or not significant, based on STAN(®) clinical guidelines. MAIN OUTCOME MEASURES: Number and type of ST-events. RESULTS: Both univariable and multivariable regression analysis showed no association between the presence of maternal intrapartum fever and the number or type of ST-events. CONCLUSIONS: Maternal intrapartum fever is not associated with ST-segment changes of the fetal electrocardiogram. Interpretation of ST-changes in labouring women with fever should therefore not differ from other situations.

Fetal blood sampling in addition to intrapartum ST-analysis of the fetal electrocardiogram: evaluation of the recommendations in the Dutch STAN® trial.

OBJECTIVES: To evaluate the recommendations for additional fetal blood sampling (FBS) when using ST-analysis of the fetal electrocardiogram. DESIGN: Prospective cohort study. SETTING: Three academic and six non-academic teaching hospitals in the Netherlands. POPULATION: Labouring women with a high-risk singleton pregnancy in cephalic position beyond 36 weeks of gestation. METHODS: In labouring women allocated to the STAN® arm of a previously published randomised controlled trial who underwent one or more FBS during delivery, we assessed whether FBS was performed according to the trial protocol and how fetal acidosis, defined as an FBS pH < 7.20, was related to ST-waveform analysis. MAIN OUTCOME MEASURES: The number of FBS showing fetal acidosis, related to the different STAN® criteria where additional FBS is recommended. RESULTS: Among 2827 women monitored with STAN®, 297 underwent FBS, of whom 171 (57.6%) were performed according to the predefined criteria and 126 were performed in absence of these criteria. In the first group, rates of fetal acidosis (pH < 7.20) were two of 18, none of nine, 12 of 111 and three of 33 when FBS was taken for abnormal cardiotocogram (CTG) at the start, intermediary CTG at the start, abnormal CTG >60 minutes, and poor electrocardiogram quality, respectively. When the predefined criteria were not met and ST-analysis showed no ST-events, only two incidents of fetal acidosis were seen. CONCLUSIONS: The performance of FBS is valuable in the advised STAN® criteria. When these criteria are not met, performance of FBS does not seem helpful in the detection of fetal acidosis.

An economic analysis of induction of labour and expectant monitoring in women with gestational hypertension or pre-eclampsia at term (HYPITAT trial).

OBJECTIVE: To assess the economic consequences of labour induction compared with expectant monitoring in women with gestational hypertension or pre-eclampsia at term. DESIGN: An economic analysis alongside the Hypertension and Pre-eclampsia Intervention Trial At Term (HYPITAT). SETTING: Obstetric departments of six university and 32 teaching and district hospitals in the Netherlands. POPULATION: Women diagnosed with gestational hypertension or pre-eclampsia between 36(+0) and 41(+0) weeks of gestation, randomly allocated to either induction of labour or expectant monitoring. METHODS: A trial-based cost-effectiveness analysis was performed from a societal perspective during a 1-year time horizon. MAIN OUTCOME MEASURES: One-year costs were estimated and health outcomes were expressed as the prevalence of poor maternal outcome defined as either maternal complications or progression to severe disease. RESULTS: The average costs of induction of labour (n = 377) were €7077 versus €7908 for expectant monitoring (n = 379), with an average difference of -€831 (95% CI -€1561 to -€144). This 11% difference predominantly originated from the antepartum period: per woman costs were €1259 for induction versus €2700 for expectant monitoring. During delivery, more costs were generated following induction (€2190) compared with expectant monitoring (€1210). No substantial differences were found in the postpartum, follow-up and for non-medical costs. CONCLUSION: In women with gestational hypertension or mild pre-eclampsia at term, induction of labour is less costly than expectant monitoring because of differences in resource use in the antepartum period. As the trial already demonstrated that induction of labour results in less progression to severe disease without resulting in a higher caesarean section rate, both clinical and economic consequences are in favour of induction of labour in these women. TRIAL REGISTRATION: The trial has been registered in the clinical trial register as ISRCTN08132825.

Limitations of ST analysis in clinical practice: three cases of intrapartum metabolic acidosis.

OBJECTIVE: To examine detailed intrapartum events in cases of neonatal metabolic acidosis despite monitoring using STAN (cardiotocography [CTG] plus ST waveform analysis of fetal electrocardiogram [ECG]). DESIGN: Retrospective case review. SETTING: High-risk pregnancies monitored by STAN. METHODS: Case note review was performed in newborns with metabolic acidosis where no significant ST changes in the fetal ECG occurred prior to birth. MAIN OUTCOME MEASURES: Metabolic acidosis. RESULTS: Detailed review of three cases identified poor signal quality, difficulties in CTG interpretation, failure to comply with STAN clinical guidelines and deterioration of the CTG without ECG alert as the leading causes of these adverse outcomes. CONCLUSIONS: The cases illustrate some of the pitfalls associated with the clinical application of the STAN technology which prevent severe metabolic acidosis being eradicated completely. It may be useful to expand the STAN guidelines protocol towards the identification of exceptional clinical situations, such as in our cases, and towards appropriate additional interventions, as this may lead to a further reduction in adverse neonatal outcomes.

Economic evaluation of misoprostol in the treatment of early pregnancy failure compared to curettage after an expectant management.

BACKGROUND: The increased pressure on health care expenses implies that physicians should consider economic aspects as part of the clinical decision-making process. Direct and indirect costs of a strategy starting with misoprostol in treatment of early pregnancy failure as compared to curettage is therefore performed. METHODS: We performed a cost-minimization analysis alongside a multicentre randomized trial. Clinical data and data on the use of medical resources were obtained from a randomized trial comparing misoprostol and curettage, which had shown that misoprostol reduced the need for curettage in 53%. In a sensitivity analysis the percentage of women who needed curettage after misoprostol varied between 25 and 90%. RESULTS: Direct costs per case were significantly lower in the misoprostol group (mean 433) than in the curettage group (mean 683) (mean difference 250, 95% CI 184 to 316, P < 0.001). These significant differences existed under a wide range of alternative assumptions about unit costs. The differences in direct cost in favour of misoprostol were large for women who had complete evacuation after initial misoprostol treatment as compared to those who needed additional curettage after failed misoprostol. Mean indirect costs were equal for both groups (misoprostol mean 486; curettage mean 428; mean difference 60, 95% CI -61 to 179, P = 0.51). The mean total costs for a strategy starting with misoprostol was 915 versus 1107 for curettage, with a mean difference between both groups of 192 (95% CI 33 to 351, P = 0.04). An increase of the complete evacuation rates for initial misoprostol therapy to 90% in the sensitivity analysis increased the cost difference between misoprostol and curettage to 550. CONCLUSION: The use of misoprostol for early pregnancy failure after failed expectant management is less costly than curettage.

Is the correlation between fetal oxygen saturation and blood pH sufficient for the use of fetal pulse oximetry?

OBJECTIVES: Fetal pulse oximetry was performed during labor in high-risk cases for fetal distress to determine the diagnostic value of this method. METHODS: The fetal SpO2 values were blinded from the obstetrician so that these values did not influence clinical decisions. Mean and lowest SpO2 measurements for the last 30 min prior to either fetal scalp blood sampling or delivery were correlated with scalp pH or pH from the umbilical artery. RESULTS: No significant correlation was found between pH and mean fetal oxygen saturation (correlation coefficient -0.02, p = 0.9). There was no significant correlation between pH and lowest fetal oxygen saturation (correlation coefficient 0.04, p = 0.84). Concerning the feasibility of the method, we found that only 23 of 65 included patients were suitable for analysis; in 20% of cases, we were not able to perform a SpO2 measurement. CONCLUSIONS: None of three cases with pH below 7.05 would have been detected using mean SpO2 over the last 30 min prior to fetal scalp blood sampling or delivery. Only one case would have been detected using the lowest SpO2 measurement over this period. We conclude that fetal SpO2 measurements during labor are of poor diagnostic value, with a disappointing feasibility and therefore are not ready for implementing into daily clinical practice.

Intra- and interoperator repeatability of the nuchal translucency measurement.

OBJECTIVE: The aim of this study was to assess the repeatability of nuchal translucency measurement by well-trained sonographers either experienced or inexperienced with the measurement. METHODS: The nuchal translucency was measured three times by two out of nine operators in 161 pregnant women attending two teaching hospitals. Intra-operator and inter-operator variation was assessed by calculating the standard deviation (SD). Intraclass Correlation Coefficients (ICC) with a 95% lower confidence limit (95% CL) were calculated for each operator and for pairs of operators. Intra- and inter-operator kappa statistics were calculated, after dichotomising the results into a nuchal translucency smaller or larger than 3 mm. RESULTS: The SD of intra-operator difference was 0.35 mm. The intra-operator repeatability showed ICCs varying from 0.83 to 0.95 for the experienced operators and from 0.47 to 0.83 for the inexperienced. The SD of inter-operator differences was 0.56 mm, 0.46 mm and 0.44 mm, based on one, two and three measurements, respectively. The inter-operator repeatability showed a variation in ICC from 0.74 to 0.95 in pairs of experienced sonographers to 0.51 in one pair inexperienced with the measurement. The kappa value expressing the intra and inter-operator repeatability as being > 3 mm or < 3 mm was 0.88 and 0.85, respectively. CONCLUSION: This study supports the finding that the nuchal translucency measurement is reproducible, as long as it is performed by sonographers well trained in the technique of this measurement.

[Extrauterine pregnancy in Netherlands: patient characteristics, treatment, and pregnancy prognosis]. / Extra-uteriene graviditeit in Nederland: patiëntkenmerken, behandeling en zwangerschapsprognose.

OBJECTIVE: To determine the probability of pregnancy after a finished extrauterine pregnancy (EUP) and the length of time in between. DESIGN: Prospective multicentric cohort study. METHOD: Of all patients with an EUP between May 1990 and October 1993, data were collected using a questionnaire from surgeons in five university hospitals and 30 general training and non-training hospitals. During the subsequent 3 years, the patients semi-annually reported on their pregnancy or wish to become pregnant using reply cards. RESULTS: A total of 665 patients with an EUP were reported their mean age was 30.7 years (SD: 4.9). There were 341 patients who during the follow-up desired pregnancy, did not start an IVF procedure and supplied complete follow-up data 207 of them (61%) became pregnant after a median interval of 12 months. Age above 35, previous fertility problems, a Chlamydia antibody titre > or = 1:64 and adnexitis in the anamnesis were correlated with a longer interval until a subsequent pregnancy. The nature of the treatment (laparotomy versus laparoscopy, conservative versus radical and surgical versus pharmaceutical) did not affect the duration of the interval. If the contralateral tube was judged to be abnormal by the operator, pregnancy was still possible, but the occurrence of the pregnancy was delayed. CONCLUSION: The probability of pregnancy after an earlier EUP averages 61%; the interval until the next pregnancy, if any, depends mostly on factors that cannot be influenced at the time of the diagnosis of EUP.

The association between fetal body movements, eye movements and heart rate patterns in pregnancies between 25 and 30 weeks of gestation.

Fetal eye movements, fetal body movements and fetal heart rate patterns were studied in healthy fetuses between 25 and 30 weeks of gestation in 21 recordings with a mean recording time of 83.5 min. In contrast with the older fetus, prolonged periods of absence as well as presence of fetal eye or body movements were uncommon. Especially absence of body movements for more than 15 min is extremely rare at this age. These findings emphasize that for the interpretation of fetal biophysical tests, gestational age should be taken into account. A linkage was demonstrated between fetal eye movements and fetal heart rate pattern and between fetal body movements and fetal heart rate pattern, but not between fetal eye movements and fetal body movements. The existence of fetal behavioural states could not be demonstrated.

Normal umbilical artery Doppler sonography does not exclude fetal distress.

Umbilical artery Doppler sonography is advocated as a method for fetal surveillance. Two cases of fetal distress caused by fetal anemia of non-immune origin are presented. In both cases a normal pulsatility index of the umbilical artery was found. It is emphasized that normal umbilical artery Doppler sonography does not exclude fetal distress.

Intra-uterine cystography for evaluation of prenatal obstructive uropathy.

To evaluate the risk for kidney damage in a male fetus with obstructive uropathy, a percutaneous bladder puncture was performed at 26 weeks gestational age and contrast was injected into the fetal bladder. A clear picture was obtained of the bladder with marked widening of the prostatic urethra and posterior urethral valves, and massive bilateral vesicoureteral reflux could be demonstrated. By adding cysto-urethrography to a diagnostic puncture of the fetal bladder it could be proved that the dilatation of the upper urinary tracts was caused by high-pressure vesico-ureteral reflux incurring progressive damage to the renal parenchyma.

Congenital hemangiopericytoma: report of a case.

A congenital hemangiopericytoma of the lower lip, first detected by prenatal ultrasound, was only partially resected and involuted over the next 20 months.