Evaluation of the efficacy of cervical pessary combined with vaginal progesterone in women with a short cervix and additional risk factors for preterm delivery.

OBJECTIVE: The aim of this study was to examine the efficacy of a combined management with cervical pessary and vaginal progesterone of women with a singleton pregnancy and a short cervix in both low and high risk-cases based on their previous obstetrical history and maternal factors. STUDY DESIGN: This was a prospective cohort study of women with a singleton pregnancy and a sonographically detected mid-trimester cervical length ≤ 25 mm. The high-risk group consisted of women with a history of a previous spontaneous preterm birth (PB), or a second-trimester miscarriage, or a loop electrosurgical excision procedure of the cervix (LEEP) while the low-risk group of women without such a history. All women were managed with cervical pessary and daily vaginal administration of 200 mg of progesterone. The primary outcome measure was spontaneous delivery before 34 weeks (238 days) of gestation. RESULTS: One hundred ninety-six cases with a CL ≤ 25 mm were detected during the study period. Fifty-two women declined to participate in the study. The remaining 144 women were divided into two groups based on the presence (n = 44) or absence (n = 100) of specific risk factors for PB. The rate of PTB < 34 weeks was similar in both low and high-risk pregnancies while a significantly higher rate of sPTB < 37 weeks was found in women with high-risk pregnancies (p = .005). CONCLUSION: The combined treatment of cervical pessary and vaginal progesterone has a similar influence on preterm delivery rate < 34 weeks, in both low and high-risk women, with a mid-trimester short cervix.

Placental volume at 11 to 14 gestational weeks in pregnancies complicated with fetal growth restriction and preeclampsia.

OBJECTIVE: The study aims to evaluate the predictive value of first trimester placental volume in pregnancies destined to develop fetal growth restriction (FGR) and preeclampsia (PE). METHODS: Prospective observational study including placentas from 34 FGR, 12 PE, 15 GH (gestational hypertension) pregnancies, and 265 controls. Placental volume (PV) was obtained using VOCAL technique, and a z score was calculated (z-PV). The association of PV with other first trimester variables and maternal characteristics was assessed with Spearman's correlation. RESULTS: PV increased exponentially with crown-rump length (CRL) and was unrelated to maternal factors (weight, age, parity, and smoking status) as well as first trimester uterine artery Doppler, free ß-hCG, nuchal translucency, or fetal heart rate. However, PV was positively associated with maternal height, CRL, PAPP-A, and birth weight. z-PV was a strong predictor for FGR with abnormal fetal Dopplers (AUC = 0.9472, P < 0.001). z-PV provided moderate prediction of FGR with normal fetal Dopplers (AUC = 0.8396, P < 0.001), PE (AUC = 0.8312, P < 0.001), and GH (AUC = 0.7640, P < 0.001). The addition of maternal weight, PAPP-A, ß-hCG, and uterine artery Doppler improved our models. CONCLUSION: At 11 to 14 weeks, PV is an independent predictor of pregnancy complications related to placental insufficiency, and the predictive ability is greater for FGR pregnancies with abnormal fetal Dopplers.

The influence of delayed cord clamping and cord milking on inflammatory cytokines in umbilical vein and neonatal circulation.

INTRODUCTION: The purpose of the present study was to compare the levels of tumor necrosis factor α (TNF-α), and interleukins (IL) 1, 6, 8 and 10 in the umbilical cord and neonatal circulation among neonates with early and late cord clamping. MATERIAL AND METHODS: A consecutive series of 76 cases of uncomplicated pregnancy and an uneventful parturition was evaluated. In 40 cases, delayed cord clamping was used and in the remaining 36, early cord clamping was practiced. Blood samples were collected from the umbilical vein immediately after cord clamping and at 24 h from the median cubital or basilic vein of the neonate. RESULTS: Significant differences were noted in the hematocrit and hemoglobin levels at 24 h that favored delayed clamping. None of the evaluated markers of inflammation differ between the two groups. Spearman's rho revealed a significant correlation between umbilical cord TNF-α and TNF-α neonatal values at 24 h (r = 0.551, p = 0.022) in the early clamped group. Significant correlations were also noted between umbilical cord TNF-α and TNF-α neonatal values at 24 h (r = 0.728, p = 0.001), umbilical cord IL-10 and neonatal IL-10 at 24 h (r = 0.487, p = 0.047) and umbilical cord IL-1b and neonatal IL-1b at 24 h (r = 0.516, p = 0.034). CONCLUSIONS: Delayed cord clamping or cord milking does not alter the levels of inflammatory cytokines in cord blood and neonatal serum. Future studies should evaluate the impact of delayed cord clamping in selected high-risk pregnancies.

Diabetes mellitus and gynecologic cancer: molecular mechanisms, epidemiological, clinical and prognostic perspectives.

INTRODUCTION: Diabetes mellitus, the prevalence of which has increased dramatically worldwide, may put patients at a higher risk of cancer. The aim of our study is the clarification of the possible mechanisms linking diabetes mellitus and gynecological cancer and their epidemiological relationship. MATERIALS AND METHODS: This is a narrative review of the current literature, following a search on MEDLINE and the Cochrane Library, from their inception until January 2012. Articles investigating gynecologic cancer (endometrial, ovarian, and breast) incidence in diabetic patients were extracted. RESULTS: The strong evidence for a positive association between diabetes mellitus and the risk for cancer indicates that energy intake in excess to energy expenditure, or the sequelae thereof, is involved in gynecological carcinogenesis. This risk may be further heightened by glucose which can directly promote the production of tumor cells by functioning as a source of energy. Insulin resistance accompanied by secondary hyperinsulinemia is hypothezised to have a mitogenic effect. Steroid hormones are in addition potent regulators of the balance between cellular differentiation, proliferation, and apoptosis. Inflammatory pathways may also be implicated, as a correlation seems to exist between diabetes mellitus and breast or endometrial carcinoma pathogenesis, although an analogous correlation with ovarian carcinoma is still under investigation. Antidiabetic agents have been correlated with elevated cancer risk, while metformin seems to lower the risk. CONCLUSION: Diabetes mellitus is associated with an elevation in gynecologic cancer risk. Moreover, there are many studies exploring the prognosis of patients with diabetes and gynecological cancer, the outcome and the overall survival in well-regulated patients.

Reproducibility study of fetal 3-D volumetry in the first trimester: effect of fetal size and rotational angle of VOCAL software.

Intra- and inter-observer reproducibility of fetal volume measurement by 3-D ultrasound scan (using VOCAL [Virtual Organ Computer-Aided Analysis] software) in 27 fetuses at 7 to 13 wk was studied. For intra-observer variability, the mean difference (MD) and 95% limits of agreement (95% LOA) at 12°, 18° and 30° were MD(12) = 0.097, 95% LOA(12) = -0.87 to +1.06; MD(18) = 0.07, 95% LOA(18) = -1.31 to +1.45; and MD(30) = -0.07, 95% LOA(30) = -1.55 to +1.41. The standard deviation of the differences (SD(DIF)) increased with crown-rump length at 12° (p = 0.0016), 18° (p = 0.0011) and 30° (p = 0.02). For inter-observer variability, MD(12) = 0.15, 95% LOA(12) = -1.65 to +1.95; MD(18) = 0.042, 95% LOA(18) = -1.79 to +1.87; and MD(30) = 0.19, 95% LOA(30) = -1.24 to +1.62. SDDIF increased with crown-rump length at 18° (p = 0.0084) and 30° (p = 0.0073). The accuracy of fetal volume measurement was not influenced by rotational angle or fetal size. Precision deteriorated for wider rotational angles and larger fetuses.

Fetal volume at 11-14 gestational weeks: reference ranges and association with first trimester biochemical and biophysical markers.

AIMS: To establish reference ranges for fetal volume (FV) measured by three-dimensional ultrasound (3D-US) at 11-14 weeks of gestation and to examine the possible association of FV with maternal/pregnancy characteristics and biochemical parameters. METHODS: Prospective observational study on 240 fetuses at 11-14 weeks. FV was measured by 3D-US using Virtual Organ Computer-Aided Analysis. Pearson correlation coefficient (cc) and regression analysis were used. RESULTS: FV increased exponentially with crown rump length and was unrelated to maternal weight (cc=-0.137, P=0.071), age (cc=0.009, P=0.899), parity (0.76), smoking status (t-test, P=0.149) and mode of conception (t-test, P=0.8). Z-scores (z) of FV was not associated with z-mean uterine artery pulsatility index (cc=-0.026, P=0.733), log10 multiples of the median (MoM) free beta human chorionic gonadotrophin (cc=0.002, P=0.982), delta value (d) of nuchal translucency (cc=0.072, P=0.331) and d-fetal heart rate (cc=0.009, P=0.902), z-FV was significantly positively correlated with log10 MoM pregnancy associated plasma protein-A (PAPP-A; regression coefficient=1.420976, R2=0.0957, P<0.0001). CONCLUSIONS: FV is strongly related to PAPP-A even after adjustment for crown rump length with a mechanism unrelated to placental perfusion. FV is independent of the vast majority of first trimester parameters; hence, it is a promising marker of early fetal growth.

Monocyte function in the fetus and the preterm neonate: immaturity combined with functional impairment.

It is well known that the innate immunity system, involving the contribution of monocytes and macrophages, may dysfunction in fetuses and preterm neonates. Monocytes are capable of differentiating into dendritic cells (DCs) or into mucosal macrophages during certain infections and of producing inflammatory mediators such as TNF- α (tumor necrosis factor-alpha), nitric oxide, and reactive oxygen species. Fetuses as well as neonates are prone to infections as a result of a defective mechanism within the above mononuclear system. Monocyte function in fetuses and preterm neonates depends on the phagocytic and oxidative capacity of macrophages and their antigen-adhesion ability. Functional rather than anatomical impairment is probably the underlying cause, while a defective production of cytokines, such as TNF-α , IL-6 (Interleukin 6), IL-1ß (Interleukin 1 beta), and G-CSF (Granulocyte Colony-Stimulating Factor), has also been involved. The insufficient production of the above inflammatory mediators and the phenomenon of endotoxin intolerance, which latter occurs during entry of any antigen into the premature neonate, place preterm neonates at higher risk for infections. Existing research data are herein presented which, however, are deficient and fragmental, this accounting for the fact that the precise pathophysiology of these disturbances is not yet fully clarified.

Acute lung injury in preterm fetuses and neonates: mechanisms and molecular pathways.

Acute lung injury (ALI) results in high morbidity and mortality among preterm neonates and efforts have therefore been devoted to both antenatal and postnatal prevention of the disease. ALI is the result of an inflammatory response which is triggered by a variety of different mechanisms. It mostly affects the fetal lung and, in particular, causes damage to the integrity of the lung's alveolar-capillary unit while weakening its cellular linings. Chemotactic activity and inflammatory products, such as proinflammatory cytokines TNF-α, IL-1, IL-6, IL-11, VEGF,TGF-α and TGF-ß, provoke serious damage to the capillary endothelium and the alveolar epithelium, resulting in hyaline membrane formation and leakage of protein-rich edema fluid into the alveoli. Chorioamnionitis plays a major part in triggering fetal lung inflammation, while mechanical ventilation, the application of which is frequently necessary in preterm neonates, also causes ALI by inducing proinflammatory cytokines. Many different ventilation-strategies have been developed in order to reduce potential lung injury. Furthermore, tissue injury may occur as a result of injurious oxygen by-products (Reactive Oxygen Species, ROS), secondary to hyperoxia. Knowledge of the inflammatory pathways that connect intra-amniotic inflammation and ALI can lead to the formulation of novel interventional procedures. Future research should concentrate on the pathophysiology of ALI in preterm neonates and οn possible pharmaceutical interventions targeting prevention and/or resolution of ALI.

Impact of maternal diabetes on epigenetic modifications leading to diseases in the offspring.

Gestational diabetes, occurring during the hyperglycemic period of pregnancy in maternal life, is a pathologic state that increases the incidence of complications in both mother and fetus. Offspring thus exposed to an adverse fetal and early postnatal environment may manifest increased susceptibility to a number of chronic diseases later in life. Compelling evidence for the role of epigenetic transmission in these complications has come from comparison of siblings born before and after the development of maternal diabetes, exposure to this intrauterine diabetic environment being shown to cause alterations in fetal growth patterns which predispose these infants to developing overweight and obesity later in life. Diabetes of the offspring is also mainly the consequence of exposure to the diabetic intrauterine environment, in addition to genetic susceptibility. Since obesity and diabetes are known to increase the risk of cardiovascular disease, cardiovascular sequelae in the offspring of diabetic mothers are virtually inevitable. Research data also suggest that exposure to a diabetic intrauterine environment during pregnancy is associated with an increase in dyslipidemia, subclinical vascular inflammation, and endothelial dysfunction processes in the offspring, all of which are linked with development of cardiovascular disease later in life. The main underlying mechanisms involve persistent hyperglycemia hyperinsulinemia and leptin resistance.

Review: Impact of mediators present in amniotic fluid on preterm labour.

Preterm birth continues to be one of the most important issues in current obstetric medicine, being the single largest cause of perinatal morbidity and mortality. The signals that initiate preterm and term labour remain a mystery. Intrauterine inflammation with the secretion of cytokines is one of the accepted explanations for the mechanism of initiation of preterm labour. This review discusses the current understanding of the molecular mechanisms for the initiation of preterm labour, focusing chiefly on the role of intra-amniotic fluid mediators, whether endogenous or infection-induced, in the regulation of inflammatory response pathways associated with spontaneous preterm labour. Prostaglandins (PGs) are considered to be one of the key mediators of preterm labour, with the concentration of biologically active PGs in the amniotic fluid, particularly PGE(2) and PGF(2α), being significantly higher in women with preterm labour. Cytokines, such as interleukins and tumour necrosis factor alpha, additionally play a dominant role in preterm labour, particularly in association with infection. Elevated amniotic fluid concentrations of extracellular matrix mediators, including metalloproteases, are also implicated in the process of foetal membrane rupture in preterm labour. Allelic variations in the main amniotic fluid mediators may be the key to understanding the disparity in the rates of preterm birth between different ethnic populations. We also discuss the role of other potential mediators such as cell-adhesion molecules, nitric oxide and novel biomarkers found in the amniotic fluid.

Interval routine appendectomy following conservative treatment of acute appendicitis: Is it really needed.

Conservative management of acute appendicitis (AA) is gradually being adopted as a valuable therapeutic choice in the treatment of selected patients with AA. This approach is based on the results of many recent studies indicating that it is a valuable and effective alternative to routine emergency appendectomy. Existing data do not support routine interval appendectomy following successful conservative management of AA; indeed, the risk of recurrence is low. Moreover, recurrences usually exhibit a milder clinical course compared to the first episode of AA. The role of routine interval appendectomy is also questioned recently, even in patients with AA complicated by plastron or localized abscess formation. Surgical judgment is required to avoid misdiagnosis when selecting a conservative approach in patients with a presumed "appendiceal" mass.

Role of adipokines and other inflammatory mediators in gestational diabetes mellitus and previous gestational diabetes mellitus.

Previous Gestational Diabetes Mellitus (pGDM) is a common condition and has been associated with future development of Type 2 Diabetes Mellitus (T2DM) and Metabolic Syndrome (MS) in women affected. The pathogenesis and risk factors implicated in the development of these conditions later in the lives of women with pGDM are not as yet fully understood. Research has recently focused on a group of substances produced mainly by adipose tissue called adipokines, this group including, among others, adiponectin, leptin, Retinol-Binding Protein-4 (RBP-4), and resistin. These substances as well as other inflammatory mediators (CRP, IL-6, PAI-1, TNF-α) seem to play an important role in glucose tolerance and insulin sensitivity dysregulation in women with pGDM. We summarize the data available on the role of these molecules.

Aspirin for in vitro fertilisation.

BACKGROUND: Aspirin is used to improve the outcome in women undergoing in vitro fertilisation despite inconsistent evidence of its efficacy. The most appropriate time to commence aspirin therapy and the length of treatment required are also still to be determined. This is an update of the review first published in 2007. OBJECTIVES: To determine the effectiveness and safety of aspirin for improving the outcome of in vitro fertilisation and intracytoplasmic sperm injection treatment cycles. SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library January 2011), MEDLINE (1966 to January 2011) and EMBASE (1980 to January 2011) databases. We used the research terms: "(aspirin OR acetylsalicylic acid) AND (in-vitro fertilisation OR intracytoplasmic sperm injection)", combined with the Cochrane Menstrual Disorders and Subfertility Group's search strategy, in order to identify randomised controlled trials on aspirin for women undergoing in vitro fertilisation. SELECTION CRITERIA: Randomised controlled trials. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies to include in the review, extracted data and assessed trial quality. MAIN RESULTS: The searches identified 13 trials which were eligible for inclusion in the review, including a total of 2653 participants. No significant differences were found between the treatment and control groups for any of the outcomes assessed. No significant differences were found in the meta-analysis of studies investigating the effect of aspirin compared with control on live birth rate (RR 0.91, 95% CI 0.72 to 1.15; three studies and 1053 participants), clinical pregnancy rate (RR 1.03, 95% CI 0.91 to 1.17; 10 studies and 2142 participants), ectopic and miscarriage rates (RR 1.86, 95% CI 0.75 to 4.63; RR 1.10, 95% CI 0.68 to 1.77) respectively (three and five studies involving 1135 and 1497 participants). AUTHORS' CONCLUSIONS: Use of aspirin for women undergoing in vitro fertilisation cannot be recommended due to lack of evidence from the current trial data. Adequately powered trials are needed. It was proposed in the initial version of this review that a sample size of 350 women in each group would be required in order to demonstrate a 10% improvement from the use of aspirin, with 80% power at the 5% significance level. Until such evidence is available, this treatment can not be recommended.

Gonadotrophin-releasing hormone agonist protocols for pituitary suppression in assisted reproduction.

BACKGROUND: Gonadotrophin-releasing hormone agonists (GnRHa) are used in assisted reproduction technology (ART) cycles to prevent a luteinizing hormone surge. Various protocols have been described in the literature, such as long protocols (continuous and stop or reduce dose, long luteal, or long follicular protocol); short protocols and ultrashort protocols. OBJECTIVES: To determine the most effective GnRHa protocol as an adjuvant to gonadotrophins in ART cycles. SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINHAHL and PsycINFO. Reference lists of relevant articles were also searched. All the searches were updated to August 2010. SELECTION CRITERIA: Only randomised controlled trials comparing any two protocols of GnRHa in in vitro fertilization (IVF) or intra-cytoplasmic sperm injection (ICSI) cycles were included. DATA COLLECTION AND ANALYSIS: The primary outcome measure was live births per women. Secondary outcome measures were pregnancy rate, ongoing pregnancy rate, number of oocytes retrieved and amount of gonadotrophins used. Data were independently extracted in 2 x 2 tables by two authors. Odds ratios (OR) with 95% confidence intervals (CI) were calculated after verifying the presence of homogeneity of treatment effect across all trials. For continuous variables mean differences (MD) were calculated. MAIN RESULTS: Of 29 included studies, 17 compared long with short protocols; two compared long with ultrashort protocols; four compared a follicular versus luteal start of GnRHa; three compared continuation versus stopping the GnRHa at the start of stimulation; three compared continuation of the same dose versus reduced dose of GnRHa and one compared a short versus short stop protocol.There was no evidence of a difference in the live birth rate but this outcome was only reported by three studies.There was evidence of a significant increase in clinical pregnancy rate (OR 1.50, 95% CI 1.16 to 1.93) in a long protocol when compared to a short protocol. That is there is a 50% increase in chance of achieving pregnancy if a long protocol is used as compared to a short protocol, although this difference could range from 16% to 93% increased chance of pregnancy. This difference did not persist when the meta-analysis was done only on the studies with adequate randomisation (OR 1.38, 95% CI 0.93 to 2.05).There was evidence of an increased number of oocytes (MD 1.61, 95% CI 0.18 to 3.04) obtained when a long protocol was used as compared to a short protocol. That is there is a 60% increase in the number of oocytes retrieved when a long protocol is used as compared to a short protocol, although this difference could range from 18% to 304% more oocytes.There was evidence of an increase (MD 12.90, 95% CI 3.29 to 22.51) in the requirement for gonadotrophins in long as compared to short protocols. That is approximately 12.9 more ampoules of gonadotrophins were consumed when a long protocol was used as compared to a short protocol. This difference could range from 3.29 to 22.51 more gonadotrophin ampoules.There was no evidence of a difference in any of the outcome measures for luteal versus follicular start of GnRHa and stopping versus continuation of GnRHa at the start of stimulation. AUTHORS' CONCLUSIONS: The pregnancy rate was found to be higher when GnRHa was used in a long protocol as compared to a short or ultrashort protocol. There was no evidence of a difference in live birth rate, but this outcome was only reported by three studies. There was no evidence of a difference in the outcomes amongst various long protocols; nor that stopping or reducing GnRHa at the start of stimulation was associated with a reduced pregnancy rate. For all comparison, except a long versus short protocol, there was a lack of power.

Office hysteroscopy: current trends and potential applications: a critical review.

Office hysteroscopy is an excellent method of identifying and treating intracavitary uterine lesions. It has become easy to learn and perform; as an aid of modern technological applications, it is safe, accurate, provides immediate results under direct visualisation, and offers the additional benefit of histological confirmation and the discomfort of patients is minimal. We applied an extended literature search to explore the special features and details of the technique itself, as it evolved since it first appeared 30 years back. Our initial goal was to examine potential changes/improvements of the modality, in terms of the instrumentation used and the technique itself, the indications of use, its incorporation in daily practice, and patients' and clinicians' acceptability.

In vitro maturation in sub fertile women with polycystic ovarian syndrome undergoing assisted reproduction.

BACKGROUND: Polycystic ovarian syndrome (PCOS) occurs in 4% to 7% of all women of reproductive age and 20% of women presenting with sub-fertility. A significant proportion of these women will ultimately need assisted reproductive techniques (ART). In women with PCOS, the supra-physiological doses of gonadotrophins used for controlled ovarian hyperstimulation (COH) often result in an exaggerated ovarian response characterised by the development of a large cohort of follicles of uneven quality, retrieval of immature oocytes, and increased risk of ovarian hyperstimulation syndrome. A potentially useful intervention for women with PCOS-related infertility involves earlier retrieval of immature oocytes followed by in vitro maturation (IVM). OBJECTIVES: To compare live birth rates per woman following in vitro maturation (IVM) with conventional in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) for women with PCOS undergoing ART. SEARCH STRATEGY: We searched the Menstrual Disorders and Subfertility Group Specialised Register of controlled trials for any relevant trials from the title, abstract, or keyword sections. Following a search of electronic databases (MEDLINE in all languages) using Ovid software we also performed a manual search of the references of all retrieved articles, sought unpublished papers and abstracts submitted to international conferences, and contacted experts. In addition, we searched the National Institute of Clinical Excellence fertility assessment and treatment guidelines (NICE 2004) and handsearched reference lists of relevant systematic reviews and randomised trials. SELECTION CRITERIA: All randomised trials on the intention to perform IVM before IVF or ICSI and conventional IVF or ICSI for sub-fertile women with PCOS. DATA COLLECTION AND ANALYSIS: We identified no studies that met the inclusion criteria. MAIN RESULTS: There were no trials suitable for inclusion in the review. AUTHORS' CONCLUSIONS: There are no randomised controlled trials upon which to base any practice recommendations regarding IVM before IVF or ICSI for women with PCOS. There is an urgent need for randomised trials in this field.

Unexplained infertility: does it really exist? Does it matter?

Unexplained infertility (UI) refers to a diagnosis made in couples in whom standard investigations including semen analysis, tests of ovulation and tubal patency are normal. It has been suggested that the term UI is unsustainable, as conditions such as endometriosis, tubal infertility, premature ovarian ageing and immunological infertility tend to be misdiagnosed as UI. In this debate, we present the view that, although scientifically unsatisfying, the diagnosis of UI is sustainable from a clinical and practical perspective. Given our present treatment options, further investigations leading to a more 'accurate' diagnosis is unlikely to change our management in these cases. Scientific curiosity must take second place to a more pragmatic approach, which takes into account the clinical and financial costs of making a more 'accurate' diagnosis.

Fetal pulse oximetry and wavelet analysis of the fetal heart rate in the evaluation of abnormal cardiotocography tracings.

AIM: Previous studies indicate that the addition of wavelet analysis of the fetal pulse oximetry tracings (FSPO2) and fetal heart rate (FHR) variability to cardiotocography (CTG), for intrapartum fetal monitoring, provides useful information on the fetal response to hypoxia. We applied the new procedure in non-reassuring CTG patterns, in which cesarean section was performed, and tested its accuracy in the diagnosis of the intrapartum fetal compromise. METHODS: At the 'Aretaieion' University Hospital labor ward, 318 women with term fetuses in the cephalic presentation entered the trial during labor. They all were monitored with external CTG and fetal pulse oximetry. In the cases that cesarean section was applied, because of abnormal CTG tracings, we applied a method based on the multiresolution wavelet analysis and a self-organized map neural network on the first and second stage of labor. The main outcome parameter was the rate of cord metabolic acidosis at birth (pH < 7.05). Secondary outcomes included Apgar scores at 5 min, fetal transmission to neonatal intensive care unit (NICU) and neonatal encephalopathy. RESULTS: Fifty out of 318 cases delivered operatively because of abnormal CTG patterns (rate 15.72%). In 30 cases, cord pH was >7.05, while in 11 Apgar scores at 5 min were <7, while none of those neonates were transferred to NICU. In the rest 20 cases cord pH was <7.05; in all of these cases Apgar scores at 5 min were <7, while four neonates were transferred to NICU. In one of them, neonatal encephalopathy was diagnosed. After the offline application of wavelet analysis and neural networks to the pulse oximetry and FHR variability readings of the 50 cases, statistics calculated that the system showed a sensitivity of 85% and a specificity of 93%, while false negative and false positive rates were 15% and 7%, respectively. CONCLUSION: Computerized FHR and FSPO2 monitoring shows an excellent efficacy and reliability in interpreting non-reassuring FHR recordings.