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.

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.