Value of cardiotocography in women with antepartum haemorrhage--is it too late for caesarean section when the cardiotocograph shows ominous features?

Caesarean section is thought to be indicated by an ominous antepartum cardiotocograph (CTG). However, the fear remains that infants delivered for this indication in the presence of antepartum haemorrhage, especially when premature, are destined to have severe hypoxic neurological damage. We therefore reviewed our experience of cardiotocography in women with antepartum haemorrhage (APH) from 1989 to 1992. There were 472 women with APH who had a CTG performed. Of them, 68 had abruptio placentae and 317 had an APH of undetermined cause. For the group with abruptio placentae, the perinatal mortality rate (PMR) was 230.7 per 1,000 when the CTG was abnormal, but only 18.2 per 1,000 if the CTG was normal (odds ratio 16.2, 95% confidence interval [CI] 1.53-171.9, p = 0.02). For APH of undetermined cause, the corresponding rates were 90.9 per 1,000 and 9.8 per 1,000 (odds ratio 10.1, 95% CI 0.96-105.8, p = 0.13). There were no perinatal losses in women with APH due to placenta praevia (87 cases). There were 6 cases of critical fetal reserve identified on a CTG in women with abruptio or APH of undetermined cause. All were delivered by Caesarean section, with 4 surviving infants, 3 with normal neurological outcome and 1 lost to follow-up. There were 3 cases of APH resulting in an infant with cerebral palsy, all of whom had had a normal antepartum CTG. Our data suggest that cardiotocography allows pregnancy to be safely prolonged in pregnancies complicated by abruptio placentae or APH of undetermined cause, and that Caesarean section is an appropriate form of delivery when the CTG becomes abnormal in these cases.

Prospective study of the quality of survival of infants with critical fetal reserve detected by antenatal cardiotocography.

From 1981 to 1986 antenatal cardiotocographic monitoring was performed on 9,992 high-risk pregnancies selected from a total obstetrical population of 31,518 patients (31.7%). A critical fetal reserve pattern was detected in 89 patients (0.9%) whose pregnancies resulted in 68 surviving infants, 19 perinatal deaths and 2 sudden infant deaths. Since 47.4% of the infants who died in the perinatal period did so because of a related congenital malformation, such a defect should be excluded in the fetus with critical fetal reserve, by ultrasonography, before delivery (there is usually insufficient time for fetal karyotyping). Sixty-three (92.6%) of the surviving children were assessed at our Growth and Developmental Clinic and disabilities were detected in 16 (25.4%); however, the disability was major in only 5, including 2 children with Down syndrome. The quality of survival of infants born from pregnancies complicated by critical fetal reserve was satisfactory as 60 of 63 children (95.2%) had neither a major disability related to intrauterine hypoxia identified by the cardiotocographic pattern, or had one likely to significantly interfere with their quality of life. Our results suggest that pregnancies can be continued until the cardiotocographic pattern becomes critical in order to gain fetal maturity, without compromise to the fetal brain.

Antepartum cardiotocography--an audit.

Between 1981 and 1986, 9,840 women were monitored by antepartum nonstressed cardiotocography (CTG). A satisfactory fetal reserve pattern was detected in 91%, a reduced reserve pattern in 8% and a critical reserve pattern in 1%. The incidences of fetal growth retardation, Apgar score less than 6 at 1 minute, perinatal mortality and Caesarean section all increased significantly (p less than 0.001) as the degree of cardiotocographic fetal reserve worsened. Intrauterine growth retardation and/or low urinary oestriol excretion was associated with a highly significantly increased incidence of abnormal CTG traces (14.2%, p less than 0.001). A satisfactory fetal reserve pattern on cardiotocography was a reliable predictor of fetal well-being, since after exclusion of lethal malformations, the perinatal mortality rate in those patients monitored within 7 days of delivery was 3/1,000.

Timely diagnosis by cardiotocography of critical fetal reserve due to fetofetal transfusion syndrome.

In a review of 90 twin pregnancies monitored by antenatal cardiotocography there were 8 cases of subsequently proven fetofetal transfusion syndrome. In 2 of these evidence of severe fetal stress had indicated immediate delivery; the 4 babies survived in circumstances that were perilous. In 1 case there was no evidence of critical fetal reserve but the recipient twin died, this probably representing an acute fetofetal transfusion during labour. In the 5 milder cases with no evidence of stress on cardiotocography, all babies survived and they required minimal or no treatment for problems relating to the fetofetal transfusion. In multiple pregnancy the cardiotocograph offers the additional bonus of detection of fetal compromise due to fetofetal transfusion.