The quality of intrapartum cardiotocography in preterm labour.

OBJECTIVES: The aim of this study is to determine the quality of the foetal heart rate (FHR) recording, defined as signal loss, during preterm labour below 28 weeks gestational age (GA) and contribute to the discussion if cardiotocography (CTG) is of value for the extreme preterm foetus. METHODS: From January 2010 to December 2019 a retrospective study was conducted with data of 95 FHR recordings of singletons born between 24 and 28 weeks GA at the Amsterdam University Medical Centre, location VUmc. FHR tracings had a duration of at least 30 min and were obtained via external ultrasound mode. Data of all recordings were divided in two groups according to gestation (24-26 weeks and 26-28 weeks). Signal loss was analysed. Statistical significance was calculated by non-parametric tests and chi-square tests. The median signal loss and the proportion of cases exceeding the International Federation of Gynaecology and Obstetrics Guidelines (FIGO) threshold of 20% signal loss were calculated. RESULTS: One-third of the recordings exceeded the 20% FIGO-criterion for adequate signal quality during the first stage of labour. In the second stage, this was nearly 75%. Similarly, the median signal loss was 13% during the first and 30% during the second stage of labour (p<0.01). CONCLUSIONS: The quality of FHR monitoring in the extreme preterm foetus is inadequate in a large proportion of the foetuses, especially during the second stage. FHR monitoring is therefore controversial and should be used with caution.

Care Pathway for Foetal Joint Contractures, Foetal Akinesia Deformation Sequence, and Arthrogryposis Multiplex Congenita.

INTRODUCTION: The majority of arthrogryposis multiplex congenita (AMC) and lethal forms of AMC such as foetal akinesia deformation sequence (FADS) cases are missed prenatally. We have demonstrated the additional value of foetal motor assessment and evaluation in a multidisciplinary team for the period 2007-2016. An applied care pathway was developed for foetuses presenting with joint contracture(s) in one anatomic region (e.g., talipes equinovarus [TEV]), more than one body part with non-progressive contractures and motility (AMC) and with deterioration over time (FADS). METHODS: The multidisciplinary team of Amsterdam University Medical Centre Expertise Centre FADS and AMC developed the care pathway. Additional tools are provided including a motor assessment by ultrasound examination and a post-mortem assessment form. RESULTS: An eight-step care pathway is presented with a proposed timing for prenatal sonographic examination, genetic examinations, multidisciplinary meetings, prenatal and postnatal counselling of the parents by a specialist also treating after birth, and the follow-up of prenatal and postnatal findings with counselling for future pregnancies. DISCUSSION/CONCLUSION: The scheduled serial structural and motor sonograpahic assessment together with follow-up examinations and genetic analysis should be tailored per prenatal centre per available resources. The multidisciplinary care pathway may pave the way to increase the detection rate and diagnosis of isolated contracture(s), TEV with underlying genetic causes, and the rare phenotypes AMC/FADS and prompt treatment after birth within expertise teams.

Association between infection and fever in terminations of pregnancy using misoprostol: a retrospective cohort study.

BACKGROUND: Fever is a well-known side effect of misoprostol, but clinically difficult to distinguish from an intra uterine infection. The aim of this study was to determine the incidence of fever in terminations of pregnancy (TOP) using misoprostol and to evaluate fever as indication of intra uterine infection. METHODS: A retrospective cohort study was performed. Consecutive second trimester TOP with misoprostol between January 2008 and October 2012 were selected. We included 403 cases and determined the incidence of fever. To examine intra uterine infection as plausible cause of fever, pathological examination reports of placentas were reviewed for signs of infections. RESULTS: The incidence of fever was 42%. Logistic regression showed a dose dependent association between dosage misoprostol and degree of fever (OR 1.86; 95% CI: 1.3-2.7). There was no association between fever and epidural analgesia. Fever has a sensitivity of 55% and a specificity of 58% as a marker of intra uterine infection. The positive predictive value of fever for an intra uterine infection is 4% and the negative predictive value is 98%. CONCLUSION: Administration of misoprostol for the indication TOP is strongly associated with fever during labor. Fever is a poor predictor of intra uterine infection in the context of TOP.

Antidepressants during pregnancy and postpartum hemorrhage: a systematic review.

The use of antidepressants in pregnancy is increasing. Concerns have risen about the use of antidepressants during pregnancy and the risk of postpartum hemorrhage (PPH). The aim of this systematic review is to summarize evidence on the association between use of antidepressants during pregnancy and the risk of PPH. An Embase and Pubmed search was conducted. English and Dutch language studies reporting original data regarding bleeding after delivery associated with exposure to antidepressants during pregnancy were selected. Quality appraisal was conducted using the Newcastle Ottawa Scale (NOS). Out of 81 citations, 4 studies were included. Based on the NOS, 3 were considered of good quality and 1 was considered of satisfactory quality. Two studies reported an increased incidence of PPH in women who used antidepressants during pregnancy. The other two studies identified no overall increased risk of PPH among pregnant women exposed to antidepressants. The existing evidence remains inconclusive whether use of antidepressants during pregnancy is associated with an increased risk of postpartum hemorrhage. If there is such an association the absolute increased risk will be low and the clinical relevance needs to be further examined.

Misidentification of maternal for fetal heart rate patterns after delivery of the first twin.

BACKGROUND: The 2nd born in twin delivery is at higher risk of fetal asphyxia. We tested the hypothesis that inadequate, fetal heart rate (FHR) monitoring has contributed to an inadvertent outcome. STUDY DESIGN: A database was reviewed consisting of 41 twin deliveries with a pH in the umbilical artery of the 2nd twin below 7.05. Cardiotocograms were examined for possible signs of a maternal instead of a fetal origin of the heart rate pattern. RESULTS: In four of the reviewed cases, a good outcome had been anticipated by the attending physician based on the cardiotocogram, whereas the 2nd twin was born with low Apgar scores and a low pH of the umbilical artery. In retrospect it was concluded that the recorded heart rate pattern was of maternal origin. In all four cases the heart rate tracings had characteristics typical for a maternal origin. CONCLUSION: Misidentifying the maternal for the fetal heart rate increases the risk that a compromised fetal condition is missed. This occurrence may contribute to the increased incidence of fetal asphyxia in 2nd twins.

The quality of intrapartum uterine activity monitoring.

AIMS: To determine the quality of intrapartum uterine activity (UA) monitoring in daily practice during the first and second stage of labor. The total duration of inadequate UA monitoring is quantified in relation to the technique applied: external or internal. METHODS: One hundred and ninety-two UA recordings, collected from 1 April 2006 untill 1 October 2006 from consecutive deliveries at the Vrije Universiteit Medical Center in Amsterdam, were analyzed. Included recordings were from singleton, spontaneous, vaginal deliveries. The last two hours of the first stage and the complete second stage had to be monitored. Internal and external UA recordings were judged by their quality: adequate, a recognizable and reliable UA pattern during the complete registration, or inadequate. Recordings labeled as inadequate were divided into two groups: absence of UA recording (non recognizable) or inadequate calibration (unreliable). Statistical analyses were performed with the Mann-Whitney U-test and the Wilcoxon signed ranks test. RESULTS: The percentages of adequate UA recordings in the first stage of labor were much higher for the internal than the external mode. Only 2% of the external recordings were of good quality vs. 40% of the internal recordings. In the second stage, percentages of adequate UA recordings were nearly equal, approximately 30%. Inadequate external registrations were characterized by almost 30% of the time absent UA monitoring, whereas with inadequate internal registrations the primary problem was correct calibration. CONCLUSION: Intrapartum UA monitoring in daily practice via the direct mode provides a more recognizable UA trace.

Uterine activity: implications for the condition of the fetus.

AIM: The aim of this review is to provide more insight in the fetal mechanisms as a response to uterine contractions and to emphasize the importance of correct assessment of uterine activity (UA) patterns during labor. STUDY RESULTS: UA causes a decreased flow through the uterine artery. In the healthy uncompromised fetus, this will not cause fetal acidemia. The fetus has developed certain protection mechanisms to survive labor; (1) During a contraction, fetal preload increases and enables the fetus to maintain a constant blood flow through the umbilical artery and (2) UA increases the blood flow in the fetal middle cerebral artery, i.e., a brain sparing effect. The shortcoming of those protection mechanisms in the compromised fetus and in case of excessive UA increases the risk of adverse fetal outcome. The brain sparing effect will become more pronounced to compensate for the decreased umbilical artery blood flow and fetal oxygen saturation. Maintenance of normal UA, especially a sufficiently long relaxation time, is essential so that the supply of well oxygenated maternal blood to the intervillous space will be restored and the fetal cerebral oxygen saturation can remain stable. CONCLUSION: Adequate UA monitoring is a prerequisite for proper reading and interpretation of cardiotocograms. It alarms in cases of excessive UA and can help to prevent fetal acidemia. Uterine contraction monitoring deserves full attention in daily obstetric practice.

Uterine activity monitoring during labor.

AIM: To summarize the currently available knowledge on (1) the methods to monitor uterine activity (UA); (2) the units to quantify UA; and (3) to assess the importance of abnormal contraction patterns on the condition of the fetus. The need for correct assessment and interpretation of the uterine contraction curve to improve fetal outcome will be emphasized. STUDY RESULTS: Correct assessment of the uterine contraction curve is an essential part of the cardiotocogram and should be obtained by the best method available; i.e., internal tocography (IT). IT provides objective information on quantization of UA and has the ability to obtain a good quality trace in an obese, restless patient. Accurate information on UA is essential because elevated UA during the first and second stage of labor can increase the risk of adverse fetal outcome. The relaxation time appears to be an important contraction parameter to maintain fetal well-being during labor. Almost all abnormal contraction patterns are characterized by shortening of the relaxation time and can lead to severe asphyxia. Duration, amplitude and frequency of contractions are of importance as well. The mean active pressure unit is the means to quantify UA since it incorporates these three contraction parameters. CONCLUSION: Proper application of UA monitoring by means of the internal method and adequate reading and interpretation of the uterine contraction curve is a prerequisite for high quality electronic fetal heart rate monitoring.