The efficacy of starting postterm antenatal testing at 41 weeks as compared with 42 weeks of gestational age.

Postterm antenatal fetal surveillance has traditionally begun at 42 completed weeks of gestation. However, recent data have shown that a significant percentage of cases of perinatal asphyxia occurs between 40 and 42 weeks of gestation. We compared the perinatal outcome of fetuses with antenatal surveillance beginning at 41 weeks to those starting at 42 weeks of gestation. The study groups consisted of 908 patients who began antenatal testing at 41 weeks and 352 who began testing at 42 weeks. Antenatal testing consisted of twice-weekly amniotic fluid assessments and nonstress tests (including evaluation for late and variable decelerations). Between 41 and 42 weeks, the group whose testing started at 41 weeks had an overall incidence of intrapartum fetal distress of 2.7%, no stillbirths, and no infants with major neonatal morbidity. Patients without antenatal testing who delivered between 41 to 42 weeks did not have a significantly increased incidence of fetal distress (3.3%; p = 0.07). However, this group had a significantly increased incidence of adverse outcomes (p less than 0.05), including three stillbirths and seven cases of major neonatal morbidity. Beyond 42 weeks, the group whose testing started at 41 weeks had a 2.3% overall incidence of fetal distress. This was significantly less (p less than 0.01) than the group whose testing started at 42 weeks (5.6%). Neither of the groups had any stillbirths or infants with major neonatal morbidity. These findings suggest that starting antenatal testing at 41 weeks of gestation may result in decreased postterm perinatal mortality and morbidity as well as a decreased incidence of intrapartum fetal distress.

Early third-trimester ultrasound screening in gestational diabetes to determine the risk of macrosomia and labor dystocia at term.

The purpose of this study was to determine whether an early third-trimester fetal abdominal circumference measurement can be used in patients with gestational diabetes to predict the presence or absence of macrosomia and labor dystocia at term. The predictive accuracy of a 30- to 33-week abdominal circumference measurement was tested, using the ninetieth percentile as the discriminant point. The study consisted of 201 patients with gestational diabetes who maintained weekly fasting glucose levels less than 100 mg/dl and 2-hour postprandial glucose levels less than 120 mg/dl with dietary management alone. The predictive accuracy of a 30- to 33-week fetal abdominal circumference measurement was 96.4% for ruling out macrosomia and 56.3% for predicting macrosomia. Patients with fetal abdominal circumference measurements greater than the ninetieth percentile at 30 to 33 weeks had a significantly increased incidence of cesarean section for failure to progress, shoulder dystocia, and birth trauma, whereas patients with abdominal circumference measurements less than or equal to the ninetieth percentile were at no greater risk than the general population. These results suggest that patients with non-insulin-dependent gestational diabetes with fetal abdominal circumference measurements less than or equal to the ninetieth percentile at 30 to 33 weeks are not at increased risk for macrosomia, cesarean section, or birth trauma at term, as long as their weekly glucose testing remains within normal limits. Efforts to decrease the incidence of macrosomia and its attendant risks should focus on those gestational diabetic patients whose fetal abdominal circumference greater than the ninetieth percentile at 30 to 33 weeks.

Antepartum predictors of fetal distress in postterm pregnancy.

The purpose of this study was to determine the efficacy of combining nonstress testing with ultrasound assessment of amniotic fluid volume for the antenatal evaluation of the postterm fetus. Postterm patients (884) were managed with amniotic fluid assessments and nonstress tests (including evaluation for variable and late decelerations) twice a week. There were no perinatal deaths or major neonatal morbidity. However, the antenatal testing sensitivity, specificity, negative, or positive predictive values were not improved by combining the two tests. Individually, amniotic fluid assessment was just as accurate a predictor of fetal well-being and was a significantly more sensitive test than the nonstress test. In addition, antenatal predictors of fetal distress and intrapartum signs of fetal distress were almost exclusively those reflective of umbilical cord compromise. These findings stress the importance of antenatal screening for signs of umbilical cord compromise as an early indication of potential fetal compromise. Although the results also suggest that amniotic fluid assessment is superior to the nonstress test, they do not conclusively support the use of amniotic fluid assessment as the sole parameter for postterm antenatal surveillance.

The role of antepartum testing in the management of postterm pregnancies with heavy meconium in early labor.

The documented association between heavy meconium in early labor and increased perinatal morbidity and mortality has alerted physicians to the presence of a potential high-risk fetal condition and to the possible need for immediate fetal blood pH determination. The purpose of this study was to determine whether antepartum fetal assessment can predict whether a postterm fetus with heavy meconium in early labor is at low or high risk for an adverse perinatal outcome. Eight hundred thirty-nine postterm patients were followed with antepartum testing, consisting of twice-weekly fetal heart rate (FHR) testing and ultrasonic amniotic fluid volume estimation. Overall, patients with heavy meconium in early labor had a significantly greater frequency of fetal distress. However, when women with heavy meconium in early labor were separated according to their antepartum testing results, those with normal results were found to have no greater risk for fetal distress or perinatal morbidity than women with normal testing and subsequently clear amniotic fluid. These findings suggest that postterm patients with heavy meconium in early labor and normal antepartum testing can be managed in labor in the same manner as low-risk patients without meconium.