Amnon Hadar

Clinical significance of fetal heart rate tracings during the second stage of labor

Objective To examine the significance of abnormal fetal heart rate (FHR) patterns during the second stage of labor in terms of pregnancy outcome. Methods A prospective observational study comparing women who had abnormal FHR patterns during the second stage of labor with women who demonstrated normal FHR patterns. Results Abnormal second-stage FHR patterns were found in 420 tracings (75%), whereas 140 tracings (25%) were normal. In a multivariable analysis, nulliparity (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.5, 4.2), cord problems (OR 1.8; 95% CI 1.03, 3.3), and male sex (OR 1.5; 95% CI 1.01, 2.2) were independent factors affecting the occurrence of abnormal second-stage FHR patterns. Patients with abnormal tracings had significantly higher rates of operative delivery compared with patients with normal tracings. The newborns from the case group had significantly higher percentages of Apgar scores lower than 7 at 1 minute, arterial pH lower than 7.2, and base deficit of 12 mmol/L or higher, and six were admitted to the intensive care unit (ICU). A multiple logistic regression model found second-stage late decelerations, bradycardia less than 70 beats per minute, and the presence of abnormal FHR patterns during the first stage of labor to be independently associated with fetal acidosis (determined by pH less than 7.2 and base deficit greater than 12 mmol/L). Conclusion Late decelerations, bradycardia less than 70 beats per minute, and abnormal FHR patterns during the first stage of labor might jeopardize fetal well-being, and expedited delivery should be considered.

Incidence, obstetric risk factors and pregnancy outcome of preterm placental abruption: a retrospective analysis

Objective: To determine obstetric risk factors for the occurrence of preterm placental abruption and to investigate its subsequent perinatal outcome. Study design: A retrospective comparison of all singleton preterm deliveries complicated with placental abruption, between the years 1990-1998, to all singleton preterm deliveries without placental abruption, in the Soroka University Medical Center. Results: Placental abruption complicated 300 (5.1%) of all preterm deliveries (n = 5934). A back-step multivariable analysis found the following factors to be independently correlated with the occurrence of preterm placental abruption: grandmultiparity (more than five deliveries), early gestational age, severe pregnancy-induced hypertension, previous second-trimester bleeding and non-vertex presentation. These pregnancies had a significantly lower rate of preterm premature rupture of membranes than preterm pregnancies without placental abruption. Pregnancies complicated with preterm placental abruption had significantly higher rates of cord prolapse, non-reassuring fetal heart rate patterns, congenital malformations, Cesarean deliveries, perinatal mortality, Apgar scores lower than 7 at 5 min, postpartum anemia and delayed discharge from the hospital than did preterm deliveries without placental abruption. In order to assess whether the increased risk for perinatal mortality was due to the placental abruption, or due to its significant association with other risk factors, a multivariable analysis was constructed with perinatal mortality as the outcome variable. Placental abruption (OR 3.0, 95% CI 2.1-4.1) as well as cord prolapse, previous perinatal death, low birth weight and congenital malformations were found to be independent risk factors for perinatal mortality. Conclusion: Preterm placental abruption is an unpredictable severe complication associated with significant perinatal morbidity and mortality. Factors found to be independently associated with placental abruption were grandmultiparity, severe pregnancy-induced hypertension, malpresentation, earlier gestational age and a history of second-trimester vaginal bleeding.

The effect of meconium on perinatal outcome: a prospective analysis

Objective: To evaluate the effect of meconium-stained amniotic fluid (AF) on perinatal outcome. Methods: A prospective observational study was performed, comparing perinatal outcome of parturients with thick and thin meconium-stained AF to those with clear AF. Results: The rate of meconium-stained AF was 18.1% (106/586). Of those, 78 (13.3%) patients had thin and 28 (4.8%) had thick meconium-stained AF. The rate of oligohydramnios was significantly higher among pregnancies complicated with thick meconium-stained AF (OR 7.2, 95% CI 2.1-24.1; p = 0.002). A significant linear association, using the Mantel-Haenszel test for linearity, was found between the thickness of the meconium and abnormal fetal heart rate patterns during the first and second stages of labor, low Apgar scores at 1 min and the risk for Cesarean section. A statistically significantly higher risk for neonatal intensive care unit admission was observed among patients with thick meconium as compared to those with clear AF (OR 11.4, 95% CI 2.0-59.3; p = 0.006), even after adjustment for oligohydramnios and abnormal fetal heart rate patterns. Conclusions: Thick, and not thin, meconium-stained AF, was associated with an increased risk for perinatal complications during labor and delivery. Therefore, thick meconium-stained AF should be considered a marker for possible fetal compromise, and lead to careful evaluation of fetal well-being.

Effect of Ob/Gyn Residents’ Fatigue and Training Level on the Accuracy of Fetal Weight Estimation

Objective: To determine the effect of Ob/Gyn residents’ fatigue and training level on the accuracy of their clinical and ultrasonographical estimation of fetal weight (EFW). Methods: In this study, clinical and ultrasonographical EFWs were performed by various residents. Actual birth weight, gravidity, parity, gestational age, body mass index, presence or absence of diabetes and hypertensive diseases, presentation and amniotic fluid index were recorded. All EFWs were divided into 3 groups according to the hour they were performed. All residents were divided into 4 groups according to their training level. The accuracy of EFW as compared with actual birth weight was then analyzed according to the shift and to the residents’ seniority by using the ANOVA test. Multivariate analysis was performed to evaluate the factors that significantly and independently affected the weight evaluation. Results: Statistically significant differences were found between the clinical EFW and the birth weight among the working shifts for birth weights of 2,500 g and more (p = 0.032 and p = 0.035). For clinical EFW, night shifts were the most inaccurate (9.27, 8.05 and 9.78% of error for day, evening and night shift, respectively; p = 0.03). The accuracy of ultrasonographical EFW was not affected by the residents’ fatigue level. The residents’ training level did not alter the accuracy of either clinical or sonographical EFW. The accuracy of clinical EFW was affected independently by the work shift (p = 0.01), whereas no factor was found to independently effect the accuracy of ultrasonographic EFW. Conclusions: Ob/Gyn residents’ fatigue affects the accuracy of clinical but not ultrasonographical EFWs. Residents’ training level does not alter either the clinical or sonographical EFW.

Intercellular adhesion molecule-1 concentration, in utero, decreases after antibiotic treatment

A parturient suffering from preterm premature rupture of membranes at 29-weeks of gestation was hospitalized and staphylococcus was detected in her amniotic fluid. After treatment with antibiotics she delivered a healthy neonate three weeks later. ICAM-1 levels decreased by 20 fold correlating with elimination of the bacteria and prolongation of the pregnancy.

Amniotic fluid intercellular adhesion molecule-1 (ICAM -1) concentrations : A marker for impending intraamniotic infection with Ureaplasma and preterm delivery

CONCENTRATIONS : A MARKER FOR IMPENDING INTRAAMNIOTIC INFECTION WITH UREAPLASMA AND PRETERM DELIVERY SHULAMITH HOROWITZ, AMNON HADAR, NOA SHANI-SHREM, MOSHE MAZOR, Soroka University Medical Center, Microbiology and Immunology, National Center for Micoplasma, Israel, Beer Sheva, Israel, Soroka University Medical Center, Obstetrics and Gynecology, Beer-Sheva, Israel, Soroka University Medical Center, Obstetrics and Gynecology, Soroka University Medical Center, Beer Sheva, Israel OBJECTIVE: To determine the amniotic fluid ICAM-1 concentrations in women with preterm labor (PTL), according to the presence or absence of intraamniotic (IAI) infection. STUDY DESIGN: Amniotic fluid was obtained by amniocentesis from 132 women with PTL and the samples were examined for ICAM-1 concentrations and for intraamniotic infection with Ureaplasmas and other, less frequent, bacteria. Sixty eight women (51.5%) had preterm delivery (PTD) and 64 women had term deliveries. The statistical significance of the categorical variables was analyzed by c test, or Fisher’s exact test, when appropriate. Odds ratios (95% confidence intervals) were calculated. RESULTS: In the PTD group, 46% (31/68) had IAI with Ureaplasmas, compared to 20% (13/64) in the term delivery group (OR = 3.29, 95% CI 1.47.5; P= .002). The value of ICAM-1 used as the diagnostic cutoff was 1300 ng/ ml [as calculated from a Receiver Operating Characteristic (ROC) curve]. In women with PTD with IAI, 26% (8/31) had ICAM-1 levels above 1300ng/mL whereas none (0/37) in the PTD group without IAI attained this diagnostic level ( P= .001). In parturients with term delivery, there was no significant difference between those with or without IAI, (15% [2/13] had ICAM-1 >1300 ng/mL, compared with 3.9% [2/51], respectively [OR = 4.45, 95% CI 0.4-51.7; P = .13]). CONCLUSION: Amniotic fluid ICAM-1 concentrations exceeding 1300ng/mL might be used as a marker for IAI with Ureaplasma in patients with PTL.