Reversal of acute polyhydramnios after fetal renal decompression.

Polyhydramnios and premature labor at twenty-seven weeks secondary to an intrafetal renal cyst are described. Antenatal fetal cyst decompression successfully reversed the polyhydramnios and prevented premature delivery, resulting in a full-term healthy infant delivered vaginally at thirty-nine weeks. Urologic investigation postpartum revealed a probable congenital ureteropelvic junction obstruction.

A survey of pregnancies complicated by decreased amniotic fluid.

Four hundred seventy-one patients undergoing diagnostic ultrasonography were identified as having moderately decreased amniotic fluid or oligohydramnios, and 339 of these cases were reviewed. Ninety-two of the patients were excluded from further statistical analysis because their decreased fluid was attributed to rupture of the membranes only. Of the remaining patients there was a 7% neonatal malformation rate. Decreased amniotic fluid before 27 weeks of gestation was associated with a significantly poor outcome. Of all the live births, infants of patients with oligohydramnios had lower Apgar scores at 1 minute and 5 minutes than did infants of patients with moderately decreased amniotic fluid. Of cases of patients with decreased fluid, 10% involved fetal distress during labor and in 17% meconium was present. Decreased levels of fluid were associated with an increased rate of abdominal deliveries. Preeclampsia was present in 24.7% of patients with decreased fluid. There was no correlation between the quantitative fluid amounts and the severity of the disease. In view of normative data and clinical experience, these observations suggest that the diagnosis of decreased amniotic fluid on routine ultrasonography requires a fetal scan to rule out anomalies, close antepartum observation to detect complications that may arise in the pregnancy, and delivery under conditions that allow appropriate support and intervention on behalf of the fetus.

Selective birth in a case of twins discordant for Tay Sachs disease.

The authors have performed selective birth in two twin pregnancies in the same patient. The couple's first pregnancy resulted in the birth of a male with Tay Sachs disease: their Pergonal-induced second pregnancy was a twin gestation discordant for Tay Sachs disease. A fetal intracardiac puncture, exsanguination, and fetal intracardiac air embolization were then performed. The patient went into premature labor 9 days later and delivered a normal immature infant, who died, and the macerated cotwin. The third Pergonal-induced pregnancy was a singleton with Tay Sachs disease and the pregnancy was terminated. Their fourth Pergonal-induced pregnancy was a twin gestation discordant for Tay Sachs disease. At 20 weeks gestation, fetal intracardiac air embolization was performed with immediate demise of the affected fetus. The pregnancy was followed closely with ultrasonography and coagulation studies and proceeded to term without complication. A normal female and a fetus papyraceous were delivered by cesarean section.

Reversal of polyhydramnios by drainage of a fetal renal cyst. A case report.

At 28 weeks' gestation a patient developed polyhydramnios associated with a large fetal renal cyst demonstrated by ultrasound. Drainage of the cyst was performed, resulting in the disappearance of polyhydramnios. The pregnancy progressed normally to term and resulted in the delivery of a healthy infant.

Intrapartum fetal heart rate monitoring. VIII. Atypical variable decelerations.

A total of 1,996 fetal heart rate (FHR) tracings were analyzed to assess the prognostic significance of variable decelerations. Nineteen percent (186 cases) of 988 tracings with variable decelerations in the last 30 minutes of monitored labor exhibited signs of atypia listed in order of frequency: (1) loss of initial acceleration, (2) slow return to the baseline FHR, (3) loss of secondary acceleration, (4) prolonged secondary acceleration, (5) biphasic deceleration, (6) loss of variability during deceleration, and (7) continuation of the baseline at a lower level. Variable decelerations with one or more of these features were called atypical variable decelerations and predicted a high incidence of fetal acidosis and low Apgar scores. By contrast, adverse fetal outcome was uncommon with pure variable decelerations (p much less than 0.001) irrespective of the duration and amplitude of the deceleration. Both pure and atypical variable decelerations were associated with other FHR abnormalities in over 60% of the cases. However, the particularly unfavorable combination with decreased FHR variability and tachycardia or bradycardia was seen more frequently with atypical than with pure variable decelerations (p much less than 0.001) and predicted the highest incidence of low Apgar scores. It is concluded that atypical features aid greatly in the identification of distress in fetuses with variable decelerations.

Intrapartum fetal heart rate monitoring. VII. The impact of mode of delivery on fetal outcome.

The condition of 1,991 fetuses just prior to delivery was assessed in a semiquantitative manner by means of a fetal heart rate (FHR) score. A comparison between types of delivery was made for groups with identical FHR scores to test the hypothesis that the differences in lower Apgar score rates were consequences of the type of delivery rather than differences in prenatal condition. For each of several FHR scoring categories, the differences in rates of low Apgar scores between spontaneous vaginal deliveries and cesarean sections were consistently different in favor of the vaginally delivered group. No such difference was observed when spontaneous vaginal deliveries were compared with low-forceps deliveries. Breech deliveries, when compared to spontaneous vaginal deliveries, resulted in a higher rate of low 1-minute Apgar scores. Five-minute Apgar scores were significantly different only if the breech delivery was preceded by abnormal FHR patterns.

Intrapartum fetal heart rate monitoring. VI. Prognostic significance of accelerations.

The fetal heart rate (FHR) tracings of 1,996 fetuses were analyzed to assess the prognostic value of accelerations in early labor and just prior to delivery. Accelerations were divided into periodic and sporadic types according to their association or lack of association with uterine contractions. It is shown that two or less sporadic accelerations per 30 minutes are unfavorable. Three accelerations indicate fetal well-being as much as any higher number of accelerations per 30 minutes. FHR abnormalities coexistent with three or more sporadic accelerations were found to have a better prognosis than FHR abnormalities associated with two or less sporadic accelerations. Fetuses exhibiting low FHR variability commonly showed lack of accelerations, whereas normal FHR variability was almost invariably accompanied by sporadic accelerations. The pathogenesis of accelerations is discussed. It is concluded that accelerations are indicators of fetal well-being, whereas the lack of accelerations with lack of reactivity to manipulation of the fetus may be indicative of severe fetal hypoxia with fetal acidemia. This conclusion is supported by fetal outcome and determination of pH from fetal scalp blood.

Intrapartum fetal heart rate monitoring. V. Fetal heart rate patterns in the second stage of labor.

A total of 1,755 fetal heart rate (FHR) tracings of the second stage of labor was analyzed. The FHR patterns were classified according to the behavior of the baseline FHR and are listed in decreasing order of benignity: normocardia, transitory bradycardia, tachycardia, persistent bradycardia, and progressive bradycardia. Each category was further subdivided into four groups on the basis of association or nonassociation with early, variable, or late decelerations. Cord compression pattern were noted in over 50% of the FHR tracings and account for the majority of low Apgar scores and fetal acidosis. FHR abnormalities occurred in 91% of second-stage labor patterns, and were mild in most cases or of too short duration to influence fetal outcome. An effort was made to establish therapeutic guidelines based on the morphologic features, prognostic grading, and the etiology of the FHR patterns in the second stage of labor.

Intrapartum fetal heart rate monitoring. IV. Observations on elective and nonelective fetal heart rate monitoring.

Heart rate tracings and outcome in 919 electively and 1,077 nonelectively monitored fetuses were compared in order to investigate the value of elective surveillance of the fetal heart rate (FHR) in either group. A threefold higher perinatal mortality and a twofold higher number of low 5-minute Apgar scores were observed among patients with risk factors compared to electively monitored pregnancies. In the beginning of monitored labor, fetuses with risk factors exhibited a higher incidence of FHR patterns with low FHR variability than fetuses without risk factors. In the final phase of labor, FHR patterns indicative of hypoxia, i.e., late decelerations and severe and atypical variable decelerations, were found more often in the nonelective than in the elective group. Umbilical cord problems reflected by the occurrence of variable deceleration were responsible for the majority of low Apgar scores observed among electively monitored fetuses. The findings and their implications for FHR monitoring are discussed.

Intrapartum fetal heart rate monitoring. III. Association of meconium with abnormal fetal heart rate patterns.

Fetal heart rate (FHR) tracings of 284 fetuses with meconium-stained amniotic fluid (MSAF) and 1,672 fetuses without meconium staining were compared to investigate the significance of meconium associated with normal and abnormal FHR patterns. MSAF was found to be associated with significantly more low 1- and 5-minute Apgar scores and higher neonatal mortality rates than the control group without meconium. An increase in abnormal FHR patterns in the MSAF group over the control group as well as the postpartum sequelae of meconium itself was likely responsible for the unfavorable outcome. It is concluded that the presence of meconium should be viewed as a warning sign of fetal distress which warrants close intrapartum observation of the patient.

II. Multifactorial analysis of intrapartum fetal heart rate tracings.

The first 30 minutes and the last 30 minutes of 1,996 intrapartum FHR tracings were analyzed for baseline FHR, variability (amplitude and frequency of oscillations), accelerations, and decelerations. A modified FHR scoring system incorporating these FHR features was employed. According to the association between various FHR scores and the incidence of low Apgar scores, FHR patterns were grouped into three basic categories with distinct prognostic significance: (1) normal FHR patterns, (2) compensated distress patterns, and (3) decompensated distress patterns. It is concluded that the prognostic significance of FHR tracings is increased by incorporating several FHR monitoring criteria in the analysis.

Intrapartum fetal heart rate monitoring. I. Classification and prognosis of fetal heart rate patterns.

A total of 1,996 direct fetal heart rate (FHR) tracings in labor were analyzed using the first and last 30 minutes of monitoring in order to evaluate individual FHR characteristics as to their ability to predict the fetal status. Comparisons were made between individual FHR characteristics occurring alone ("uncomplicated") and those occurring in association with others ("complicated") in predicting fetal status as judged by 1 and 5 minute Apgar scores. These comparisons were made separately for the first 30 minutes and the last 30 minutes of monitoring.

Clinical application of a scoring system for evaluation of antepartum fetal heart rate monitoring.

Five hundred-seven passive tests (PT's) on 260 patients and 133 oxytocin challenge tests (OCT's) on 97 of these patients were reviewed. The tracings were categorized according to a proposed modified scoring system based on baseline fetal heart rate (FHR), variability, accelerations and decelerations of FHR, and fetal activity. The scoring system was compared with the usual criteria for fetal compromise currently employed in PT's and OCT's and was found to be superior in accuracy. The usefulness of antepartum FHR monitoring as evaluated throuth the scoring system is discussed. It is concluded that passive testing can largely replace the OCT.