Peripartum events associated with severe neurologic morbidity and mortality among acidemic neonates.

PURPOSE: To identify peripartum events that may predict the development of short-term neurologic morbidity and mortality among acidemic neonates. METHODS: Retrospective case-control study conducted at a single-teaching hospital on data from January 2010 to December 2015. The study cohort group included all acidemic neonates (cord artery pH ≤ 7.1) born at ≥ 34 weeks. Primary outcome was a composite including any of the following: neonatal encephalopathy, convulsions, intra-ventricular hemorrhage, or neonatal death. The study cohort was divided to the cases group, i.e., acidemic neonates who had any component of the primary outcome, and a control group, i.e., acidemic neonates who did not experience any component of the primary outcome. RESULTS: Of all 24,311 neonates born ≥ 34 weeks during the study period, 568 (2.3%) had a cord artery pH ≤ 7.1 and composed the cohort study group. Twenty-one (3.7%) neonates composed the cases group. Multivariate logistic regression analysis revealed that cases were significantly more likely to have experienced placental abruption (OR 18.78; 95% CI 5.57-63.26), born ≤ 2500 g (OR 13.58; 95% CI 3.70-49.90), have meconium (OR 3.80; 95% CI 1.20-11.98) and cord entanglement (OR 5.99; 95% CI 1.79-20.06). The probability for developing the composite outcome rose from 3.7% with isolated acidemia to 97% among neonates who had all these peripartum events combined with intrapartum fetal heart rate tracing category 2 or 3. CONCLUSION: Neonatal acidemia carries a favorable outcome in the vast majority of cases. In association with particular antenatal and intrapartum events, the short-term outcome may be unfavorable.

[Fetal scalp pH during labor: Which threshold for intervention?] / pH au scalp pendant le travail : quel seuil décisionnel pour intervenir ?

OBJECTIVE: In case of abnormal fetal heart rate, there is no consensus on the decision threshold pH scalp leading to a rapid birth. The objective of this study was to compare neonatal issues and cesarean rate in two maternity using different decision thresholds of scalp pH. MATERIAL AND METHODS: A comparative retrospective study conducted in two level III maternity units between January 2013 and May 2014, one maternity unit used a decision threshold of 7.20 (maternity unit 7,20), and the other one a threshold of 7.25 (maternity unit 7,25). An adverse neonatal outcome was defined by a composite endpoint of neonatal morbidity. The risk of cesarean was assessed using a multivariate analysis. RESULTS: One hundred and four patients were included in the maternity unit 7,20 and 163 patients in the maternity 7,25. Adverse neonatal outcome was similar in both maternities (25% vs. 30,1%; P=0.4). The average pH at birth was similar in both maternities, as well as the Apgar score at 5minutes and neonatal transfer rates. However, BE<-12 was more frequent in maternity using 7,20 scalp pH threshold (7% vs. 0%; P<0.01). The cesarean rate was higher in maternity 7,25 (adjusted OR=2.23 95% CI [1.17-4.25]). CONCLUSION: It seems that a decisional threshold fixed to 7,20 could be used reasonably. It could allow to reduce cesarean rate. Other studies are, however, needed to confirm that such threshold of 7,20 does not increase the risk of severe acidosis.

Is trial of labor harmful in breech delivery? A cohort comparison for breech and vertex presentations.

INTRODUCTION: Planned vaginal delivery in breech presentation is accompanied by an excess neonatal risk that has, however, rarely been compared to that of delivery in vertex presentation. Because of the severity of complications that can occur in long-term follow-up, the risk of asphyxia is of particular concern. MATERIAL AND METHODS: To assess immediate neonatal status after a planned vaginal delivery of fetuses in breech compared with vertex presentation, we planned a retrospective hospital cohort study of singleton term deliveries from 2000 to 2011. The indicators used to assess neonatal status were: 5-min Apgar score<7, acidosis, both moderate (pH<7.15) and severe (pH<7.0), asphyxia (pH<7.0 and base deficit≥12.0mmol/L), transfer to the neonatal intensive care unit (NICU), and in-hospital neonatal death. RESULTS: Compared with 43,595 trials of vaginal delivery in vertex presentation at term during the 12-year study period (93.8% of all vertex presentations), the 665 breech deliveries for which planned vaginal delivery was planned (43.2% of all breech presentations) had a quadrupled risk of severe acidosis (ORa 4.3 [2.2-7.5]), but no increase in the risk of asphyxia (ORa 0.7 [0.1-3.0]), NICU transfer (ORa 0.8 [0.4-1.3]) or in-hospital death (ORa 1.3 [0.1-6.0]). Moreover, compared with the 876 planned cesareans, the risk of severe acidosis in the 665 trials of vaginal delivery in breech presentation was four times higher (OR 4.3 [2.3-4.7]), but we observed no increase in neither asphyxia nor other risks studied. CONCLUSION: In our hospital, planned vaginal delivery is safe for breech presentations because it is associated with an increase of severe acidosis but not asphyxia.

Asphyxia in the Newborn: Evaluating the Accuracy of ICD Coding, Clinical Diagnosis and Reimbursement: Observational Study at a Swiss Tertiary Care Center on Routinely Collected Health Data from 2012-2015.

BACKGROUND: The ICD-10 categories of the diagnosis "perinatal asphyxia" are defined by clinical signs and a 1-minute Apgar score value. However, the modern conception is more complex and considers metabolic values related to the clinical state. A lack of consistency between the former clinical and the latter encoded diagnosis poses questions over the validity of the data. Our aim was to establish a refined classification which is able to distinctly separate cases according to clinical criteria and financial resource consumption. The hypothesis of the study is that outdated ICD-10 definitions result in differences between the encoded diagnosis asphyxia and the medical diagnosis referring to the clinical context. METHODS: Routinely collected health data (encoding and financial data) of the University Hospital of Bern were used. The study population was chosen by selected ICD codes, the encoded and the clinical diagnosis were analyzed and each case was reevaluated. The new method categorizes the diagnoses of perinatal asphyxia into the following groups: mild, moderate and severe asphyxia, metabolic acidosis and normal clinical findings. The differences of total costs per case were determined by using one-way analysis of variance. RESULTS: The study population included 622 cases (P20 "intrauterine hypoxia" 399, P21 "birth asphyxia" 233). By applying the new method, the diagnosis asphyxia could be ruled out with a high probability in 47% of cases and the variance of case related costs (one-way ANOVA: F (5, 616) = 55.84, p < 0.001, multiple R-squared = 0.312, p < 0.001) could be best explained. The classification of the severity of asphyxia could clearly be linked to the complexity of cases. CONCLUSION: The refined coding method provides clearly defined diagnoses groups and has the strongest effect on the distribution of costs. It improves the diagnosis accuracy of perinatal asphyxia concerning clinical practice, research and reimbursement.

Inborn errors of ketone body utilization.

Succinyl-CoA:3-ketoacid CoA transferase (SCOT) deficiency and mitochondrial acetoacetyl-CoA thiolase (beta-ketothiolase or T2) deficiency are classified as autosomal recessive disorders of ketone body utilization characterized by intermittent ketoacidosis. Patients with mutations retaining no residual activity on analysis of expression of mutant cDNA are designated as severe genotype, and patients with at least one mutation retaining significant residual activity, as mild genotype. Permanent ketosis is a pathognomonic characteristic of SCOT-deficient patients with severe genotype. Patients with mild genotype, however, may not have permanent ketosis, although they may develop severe ketoacidotic episodes similar to patients with severe genotype. Permanent ketosis has not been reported in T2 deficiency. In T2-deficient patients with severe genotype, biochemical diagnosis is done on urinary organic acid analysis and blood acylcarnitine analysis to observe characteristic findings during both ketoacidosis and non-episodic conditions. In Japan, however, it was found that T2-deficient patients with mild genotype are common, and typical profiles were not identified on these analyses. Based on a clinical study of ketone body utilization disorders both in Japan and worldwide, we have developed guidelines for disease diagnosis and treatment. These diseases are treatable by avoiding fasting and by providing early infusion of glucose, which enable the patients to grow without sequelae.

Mechanism of reduction of newborn metabolic acidemia following application of a rule-based 5-category color-coded fetal heart rate management framework.

UNLABELLED: Abstracts Objective: We have reported a 7-fold reduction in newborn umbilical arterial (UA) metabolic acidemia after adoption of a rule-based 5-category color-coded fetal heart rate (FHR) management framework. We sought evidence for the relationship being causal by detailed analysis of FHR characteristics and acid-base status before and after training. METHODS: Rates of UA pH and base excess (BE) were determined over a 5-year period in a single Japanese hospital, serving mainly low-risk patients, with 3907 deliveries. We compared results in the 2 years before and after a 6-month training period in the FHR management system. We used a previously published classification schema, which was linked to management guidelines. RESULTS: After the training period, there was an increase in the percentage of normal patterns (23%), and a decrease in variable decelerations (14%), late decelerations (8%) and prolonged decelerations (12%) in the last 60 min of labor compared to the pre-training period. There was also a significant reduction in mean UA pH and BE in the groups with decelerations after introduction of the FHR management framework. CONCLUSIONS: The adoption of this FHR management system was associated with a reduction of decelerations and metabolic acidemia, without a change in cesarean or vacuum delivery rates. These results suggest that the obstetrical providers were able to better select for intervention those patients destined to develop more severe acidemia, demonstrating a possible causal relationship between the management system and reduced decelerations and metabolic acidemia.

Suboptimal care and metabolic acidemia is associated with neonatal encephalopathy but not with neonatal seizures alone: a population-based clinical audit.

OBJECTIVE: To determine the incidence of moderate to severe neonatal encephalopathy (NE) and neonatal seizures without encephalopathy, and the association with metabolic acidemia. Secondly, to investigate the occurrence of suboptimal intrapartum care and its impact on neonatal outcome. DESIGN: Clinical audit. SETTING: Two university hospitals in Sweden. POPULATION: Neonates ≥34 weeks with moderate or severe NE and neonatal seizures alone, i.e. without encephalopathy, from a population of 71 189 births, where umbilical blood gases were routinely analyzed. METHODS: Neonates were categorized depending on the presence of metabolic acidemia at birth by umbilical artery pH < 7.00, base deficit ≥12 mmol/L. Records were audited for suboptimal care and a decision was made on whether management was assessed to have impacted neonatal outcome. MAIN OUTCOME MEASURES: Encephalopathy and seizures alone. RESULTS: We identified 80 neonates with NE and 30 with seizures alone, of which 48 (60%) and none, respectively, had metabolic acidemia. Suboptimal care could be assessed in 77 and occurred in 28 (36%) NE cases and in one neonate with seizures alone (p < 0.001). In 47 NE cases with metabolic acidemia, suboptimal care occurred in 22 (47%) vs. 6/30 (20%) without metabolic acidemia (p = 0.02). Suboptimal care had an impact on outcome in 18/77 (23%) NE cases but in no cases with seizures alone. CONCLUSION: Suboptimal care was commonly seen with NE, particularly in neonates with metabolic acidemia, and also affected neonatal outcome. No such associations were found in neonates with seizures alone.

Intrapartum fetal heart rate monitoring: evaluation of a standardized system of interpretation for prediction of metabolic acidosis at delivery and neonatal neurological morbidity.

OBJECTIVE: To assess the ability of the intrapartum fetal heart rate interpretation system developed in 2008 by the National Institute of Child Health and Human Development (NICHD) to predict fetal metabolic acidosis at delivery and neonatal neurological morbidity. METHODS: We analyzed the intrapartum fetal heart rate tracings of 314 singleton fetuses at ≥ 37 weeks using the NICHD three-tier system of interpretation: Category I (normal), Category II (indeterminate) and Category III (abnormal). Category II was further divided into Category IIA, with moderate fetal heart rate variability or accelerations, and Category IIB, with minimal/absent fetal heart rate variability and no accelerations. The presence and duration of the different patterns were compared with several clinical neonatal outcomes and with umbilical artery acid-base balance at birth. RESULTS: The mean values of pH and base excess decreased proportionally as tracings worsened (p < 0.001). The duration of at least 30 min for Category III tracings was highly predictive of a pH <7.00 and a base excess ≤-12 mmol/L. The same was true for the duration of Category IIB tracings that lasted for at least 50 min. CONCLUSIONS: Our study demonstrates that the interpretation of fetal heart rate tracings based on a strictly standardized system is closely associated with umbilical artery acid-base status at delivery.

[Prospective study of the relationship between heart rate fetal anomalies, pH umbilical cord at birth and Apgar]. / Etude prospective de la relation entre anomalie du rythme cardiaque fœtale, pH ombilical et Apgar à la naissance

BACKGROUND: The search for an acute fetal distress during labor remains one of the objectives of obstetrical surveillance. AIM: To find a relationship between different aspects of fetal heart rate (FHR) occurring during labor, Apgar score at first minute and the pH blood at birth. METHODS: A prospective study which involved 170 single-fetal pregnancies to term. RESULTS: In our population, by comparing the APGAR score in the first minute and umbilical pH, it was found that only 25.7% of newborns with Apgar at 1st minute less than 7 had an umbilical arterial pH <7.15. Thus in our study, the Apgar score did not predict umbilical acidosis and the difference was significant (p = 0.02). In the same population, by comparing the analysis of FCR and umbilical PH, we found that fetal bradycardia was associated with pH umbilical lowest with an average of 7008 and the difference was significant (p = 0.008). Other types of ERCF were also significantly associated with neonatal acidosis. CONCLUSION: Recording fetal heart rate is a limited review to assess the exact condition of the fetus. It has a good negative predictive value but there is little specific consideration. Combination with other techniques to better assess the fetal state.

Brain injury patterns in hypoglycemia in neonatal encephalopathy.

BACKGROUND AND PURPOSE: Low glucose values are often seen in term infants with NE, including HIE, yet the contribution of hypoglycemia to the pattern of neurologic injury remains unclear. We hypothesized that MR features of neonatal hypoglycemia could be detected, superimposed on the predominant HIE injury pattern. MATERIALS AND METHODS: Term neonates (n = 179) with NE were prospectively imaged with day-3 MR studies and had glucose data available for review. The predominant imaging pattern of HIE was recorded as watershed, basal ganglia, total, focal-multifocal, or no injury. Radiologic hypoglycemia was diagnosed on the basis of selective edema in the posterior white matter, pulvinar, and anterior medial thalamic nuclei. Clinical charts were reviewed for evidence of NE, HIE, and hypoglycemia (<46 mg/dL). RESULTS: The predominant pattern of HIE injury imaged included 17 watershed, 25 basal ganglia, 10 total, 42 focal-multifocal, and 85 cases of no injury. A radiologic diagnosis of hypoglycemia was made in 34 cases. Compared with laboratory-confirmed hypoglycemia, MR findings had a positive predictive value of 82% and negative predictive value of 78%. Sixty (34%) neonates had clinical hypoglycemia before MR imaging. Adjusting for 5-minute Apgar scores and umbilical artery pH with logistic regression, clinical hypoglycemia was associated with a 17.6-fold higher odds of MR imaging identification (P < .001). Selective posterior white matter and pulvinar edema were most predictive of clinical hypoglycemia, and no injury (36%) or a watershed (32%) pattern of injury was seen more often in severe hypoglycemia. CONCLUSIONS: In term infants with NE and hypoglycemia, specific imaging features for both hypoglycemia and hypoxia-ischemia can be identified.

Acidemia at birth in the vigorous infant as a trigger incident to assess intrapartum care with regard to CTG patterns.

OBJECTIVE: To evaluate if acidemia in vigorous infants is a useful variable in the assessment of intrapartum care with regard to cardiotocographic (CTG) patterns during the second stage. METHODS: Cases (n = 241) were infants with an umbilical artery pH < 7.05, controls (n = 482) were infants with pH ≥ 7.05. Apgar score was ≥ 7 at 5 min in both groups. CTGs during the last two hours of labor were assessed and neonatal outcomes compared. A sub-analysis of cases with metabolic acidemia: pH < 7.00 and base deficit ≥ 12 mmol/L and acidemia: 7.00 < pH < 7.05 was performed. RESULTS: 63% of cases had a pathological CTG versus 26% of controls (p < 0.001). Patterns with severe variable decelerations had a significantly longer duration in cases. Metabolic acidemia was significantly associated with severe variable decelerations and decreased variability. Infants to cases were admitted to neonatal care in 19% versus 2% of controls (p < 0.001). With metabolic acidemia, 32% were admitted. CONCLUSION: An umbilical artery pH < 7.05 at birth of vigorous infants may be a useful variable for quality control of intrapartum management with regard to the assessment of second-stage CTGs. Differences in duration of pathological patterns indicate passiveness in academic cases.

Added value of umbilical vein flow as a predictor of perinatal outcome in term small-for-gestational-age fetuses.

OBJECTIVE: To compare umbilical vein (UV) flow with standard Doppler parameters in prediction of adverse perinatal outcome in late-onset small-for-gestational age (SGA) fetuses. METHODS: Umbilical, uterine and middle cerebral arteries, and UV blood flow were evaluated by Doppler before delivery in a cohort of 193 term SGA fetuses. The value of the Doppler parameters to predict risk of emergency delivery for non-reassuring fetal status and neonatal metabolic acidosis was analyzed. RESULTS: Fifty-three (27%) fetuses had non-reassuring fetal status requiring emergency delivery, whereas 21 (11%) newborns developed neonatal metabolic acidosis. Multivariable analysis showed that significant contributions to prediction of emergency delivery for non-reassuring fetal status and neonatal metabolic acidosis were provided by middle cerebral artery (MCA) pulsatility index (PI) and UV blood flow normalized by fetal weight. Decision tree analysis defined three groups with increasing risk of need for emergency delivery for non-reassuring fetal status: MCA-PI > 1.46 (risk 15.6%); MCA-PI ≤ 1.46 and UV blood flow > 68 mL/min/kg (risk 25%); and MCA-PI ≤ 1.46 and UV flow ≤ 68 mL/min/kg (risk 53.1%); and two groups with different risks of neonatal metabolic acidosis: UV flow > 68 mL/min/kg or UV flow ≤ 68 mL/min/kg and MCA-PI > 1.23 (risk ≤ 10%); and UV flow ≤ 68 mL/min/kg and MCA-PI ≤ 1.23 (risk 39.1%). CONCLUSION: The evaluation of UV blood flow with spectral brain Doppler allows better identification of SGA fetuses with late-onset intrauterine growth restriction at risk of adverse perinatal outcome.

The clinical interpretation and significance of electronic fetal heart rate patterns 2 h before delivery: an institutional observational study.

PURPOSE: To evaluate the clinical significance of intrapartum fetal heart rate (FHR) monitoring in low-risk pregnancies according to guidelines and specific patterns. METHODS: An obstetrician, blinded to neonatal outcome, retrospectively reviewed 198 low-risk cases that underwent continuous electronic fetal monitoring (EFM) during the last 2 h before delivery. The tracings were interpreted as normal, suspicious or pathological, according to specific guidelines of EFM and by grouping the different FHR patterns considering baseline, variability, presence of decelerations and bradycardia. The EFM groups and the different FHR-subgroups were associated with neonatal acid base status at birth, as well as the short-term neonatal composite outcome. Comparisons between groups were performed with Kruskal-Wallis test. Differences among categorical variables were evaluated using Fisher's exact test. Significance was set at p < 0.05 level. RESULTS: Significant differences were found for mean pH values in the three EFM groups, with a significant trend from "normal" [pH 7.25, 95 % confidence interval (CI) 7.28-7.32] to "pathological" tracings (pH 7.20, 95 % CI 7.17-7.13). Also the rates of adverse composite neonatal outcome were statistically different between the two groups (p < 0.005). Among the different FHR patterns, tracings with atypical variable decelerations and severe bradycardia were more frequently associated with adverse neonatal composite outcome (11.1 and 26.7 %, respectively). However, statistically significant differences were only observed between the subgroups with normal tracings and bradycardia. CONCLUSIONS: In low-risk pregnancies, there is a significant association between neonatal outcome and EFM classification. However, within abnormal tracings, neonatal outcome might differ according to specific FHR pattern.

[Targeted temperature management in critical care : current 2011 recommendations]. / Gezieltes Temperaturmanagement auf der Intensivstation : Aktuelle Empfehlungen 2011.

Since October 2011 new guidelines exist for temperature management in critical care. According to the guidelines the term targeted temperature management (TTM) should replace the term therapeutic hypothermia. There is now a strong recommendation for TTM using 32-34°C as the preferred treatment for out-of-hospital adult cardiac arrest with a first registered electrocardiography rhythm of ventricular fibrillation or pulseless ventricular tachycardia and still unconscious after restoration of spontaneous circulation. A TTM of 32.5-35.5°C is also recommended for the treatment of term newborns who sustain asphyxia and exhibit acidosis and/or encephalopathy.

High uterine contraction rates in births with normal and abnormal umbilical artery gases.

OBJECTIVE: To determine if the incidence of high contraction (HC) rates and associated decelerations were different in term births with metabolic acidemia (MA) compared to those with normal gases (N) over the last 4 h of labor. METHODS: MA included 316 babies with cord base deficits (BD) over 12 mmol/L N - 3,320 babies with BD under 8 mmol/L. HC rates were defined as >5/10 min. RESULTS: One or more episodes of HC occurred in 43.7% of MA and 36.6% of N. (p = 0.015) In both groups the HC rates rose from about 1 in 30 patients at the beginning to 1 in 7 to 9 patients at the end. MA showed a different transition of the deceleration response over time. At the beginning the average ratio of decelerations to uterine contractions was similar in both groups but over the final 140 min MA showed a consistently higher ratio. CONCLUSIONS: Although HC rates were more frequent in the MA, it was not uncommon in N. On average MA showed more decelerations at every level of contractions and had a persistently higher level of decelerations per contraction for more than 2 h before birth.

Variable decelerations: do size and shape matter?

OBJECTIVE: To determine the ability of variable decelerations and 8 subtypes, defined by size and shape, to discriminate tracings between babies with normal umbilical artery gases (N) and those with metabolic acidemia (MA). METHODS: Tracings from the last 4 hours from N-3320 babies with base deficit levels under 8 mmol/L, and from MA-316 babies with base deficits over 12 mmol/L were analyzed using computerized pattern recognition. We created receiver operating characteristic curves and area under the curves (AUCs) for each deceleration subtype. RESULTS: Only 3 subtypes showed significant discrimination: those with a prolonged duration (AUC 0.6109 P < 0.0001), loss of internal variability (AUC 0.5694 P < 0.0001) or with "sixties" criteria (AUC 0.5997 P < 0.0001). A variable deceleration met the sixties criteria if two or more of the following were present: depth was 60 bpm or more, lowest value was 60 or less, duration was 60 seconds or longer. All other subtypes were no better than chance. CONCLUSIONS: Finer gradation within the middle category of electronic fetal monitoring classification is needed because most tracings, including those from babies with MA, will be located in the Category II. This analysis identifies which variable decelerations have a significant association with MA and which do not.

Specific change in spectral power of fetal heart rate variability related to fetal acidemia during labor: comparison between preterm and term fetuses.

BACKGROUND: Spectral analysis of fetal heart rate (FHR) variability is a useful method to assess fetal condition. There have been several studies involving the change in spectral power related to fetal acidemia, but the results have been inconsistent. AIMS: To determine the change in spectral power related to fetal umbilical arterial pH at birth, dividing cases into preterm (31-36 weeks) and term (≥37 weeks) gestations. STUDY DESIGN: Case-control study. The 514 cases of deliveries were divided into a low-pH group (an umbilical arterial pH <7.2) and a control group (pH≥7.2). SUBJECTS: FHR recorded on cardiotocography during the last 2h of labor. OUTCOME MEASURES: The spectral powers in various bands of FHR variability. RESULTS: In preterm fetuses, the total, low (LF), and movement (MF) frequency spectral powers and LF/HF ratio were significantly lower in the low-pH group than the control group (all P<0.05). In contrast, in term fetuses, the total frequency, LF, and MF powers were significantly higher in the low-pH group than the control group (all P<0.05). The area under the receiver operating characteristic of LF power to detect a low pH at birth was 0.794 in preterm fetuses and 0.595 in term fetuses. The specificity was 86.8% and 93.3% in preterm and term fetuses, respectively. CONCLUSIONS: The changes in spectral power responding to a low pH are different between term and preterm fetuses. Spectral analysis of FHR variability may be useful fetal monitoring for early detection of fetal acidemia.

Target decision to delivery intervals for emergency caesarean section based on neonatal outcomes and three year follow-up.

OBJECTIVE: To investigate current target decision to delivery intervals (DDIs) for 'emergency' caesarean section. STUDY DESIGN: Prospective observational cohort study in a teaching hospital providing district and tertiary maternity services delivering 6000 babies per annum. RESULTS: 68% Category 1 deliveries were achieved within 30min and 66% Category 2 within 75min (26% for antepartum Category 2 deliveries). Category 1 deliveries were quicker using general rather than regional anaesthesia (21 vs. 29min, odds ratio [OR] for delivery <30min 4.2, 95%CI 1.3-14.2). 8% Category 1 and 4% Category 2 neonates were acidotic or asphyxiated. The risk of acidosis was not reduced by delivery within 30min for Category 1 (OR 0.56; 0.11-2.81), or within 75min for Category 2 (OR 2.72; 0.6-25.1). Three babies were registered with developmental impairment by three years of age; none were Category 1 deliveries. CONCLUSIONS: Our data suggest that clinical triage is effective, with the more compromised fetus delivered more rapidly using general anaesthesia. For Category 1 deliveries a 30min target DDI is appropriate, although those born after longer DDI did not show developmental impairment. For Category 2 caesarean sections performed for acute fetal distress or concerns, failed instrumental delivery, failure to progress or placental bleeding, a 75min DDI may be an appropriate target but did not protect against acidosis, asphyxia or developmental impairment. Longer DDIs did not result in unfavourable outcomes for other Category 2 indications.

Outcome of severe intrapartum acidemia diagnosed with fetal scalp blood sampling.

AIM: To analyze short-term neonatal outcome and the sampling to delivery interval in cases with severe intrapartum acidemia diagnosed with fetal scalp blood sampling (FBS). METHODS: This is a secondary analysis of data from a trial of 2992 women, who were, when indicated, randomized to either lactate or pH analyses by FBS. Median and 95(th) centile values for lactate analyses were 2.9 mmol/L and 6.6 mmol/L, respectively. Corresponding pH values were 7.30 and 7.17. We defined severe intrapartum acidemia as lactate >6.6 mmol/L or pH <7.17. Outcome measures were cord artery pH <7.00, Apgar <7 at 5 min, hypoxic ischemic encephalopathy and time interval from FBS to delivery. RESULTS: Severe intrapartum acidemia was present in 85/1355 (6.3%) cases with lactate analyses and in 69/1008 (6.8%) cases with pH analyses. Cord artery pH <7.00 occurred in 12/154 (7.8%), Apgar <7 at 5 min in 16/154 (10.4%) and hypoxic ischemic encephalopathy in 4/154 (2.6%) of the cases. There were no differences in outcomes between the two groups. However, delivery was expedited more rapidly in the pH management group (median 16 vs. 21 min; P=0.01). CONCLUSION: Severe neonatal morbidity occurred in 10% or less in this high-risk group. FBS is an early marker of intrapartum hypoxia and can be used to prevent severe birth acidemia. Lactate might be an earlier marker than pH in the hypoxic process.

Neonatal brain imaging and the identification of metabolic acidemia and hypoxic-ischemic encephalopathy.

OBJECTIVE: To determine the precision with which intrapartum metabolic acidemia and hypoxic-ischemic encephalopathy (HIE) in term and near-term infants can be identified by neonatal brain imaging. STUDY DESIGN: This is a case-control study whose inclusion criteria were neonates born at > or =34 weeks gestation with a cord gas at delivery, suspected neurological abnormalities, and computed tomography (CT) or magnetic resonance (MR) imaging of the brain. Neonates with chromosomal and major congenital malformations were excluded. Brain imaging for neonates with and without metabolic acidemia (pH < 7.0 and base deficit > 12 mM) at birth and HIE were retrospectively reviewed by a neuroradiologist blinded to their clinical course and compared. RESULTS: There were 54 neonates admitted to the NICU at a single university hospital between 1992 and 2006 that met these inclusion criteria of which 27 had metabolic acidemia at birth. There were 16 diagnosed clinically as having HIE at the time of neonatal discharge, 13 from the acidemic group and 3 from the nonacidemic group. Radiological signs of basal ganglia injury were significantly more common in neonates with metabolic acidemia (29.6%, 3.7%, p = 0.02) and HIE (37.5%, 7.9%, p = 0.01). Logistic regression corrected for gestational age showed that radiological signs of basal ganglia injury could identify the presence of HIE with area under the ROC curve of 0.71, sensitivity 37.5%, specificity 92.1%, positive predictive value 66.7%, and negative predictive value of 77.8%. CONCLUSION: Radiological signs of basal ganglia injury on early neonatal imaging are associated with metabolic acidemia and HIE, but is not precise enough to serve as a gold standard in the identification of these conditions.