Carlos Benito

Effects of Narcotic and Non-Narcotic Continuous Epidural Anesthesia on Intrapartum Fetal Heart Rate Tracings as Measured by Computer Analysis

OBJECTIVE To evaluate the effect of narcotic and non-narcotic continuous epidural anesthesia on intrapartum fetal heart rate (FHR) tracings as measured by computer analysis. METHODS We studied 37 women with uncomplicated pregnancies at term with reactive FHR tracings. The women were randomized to receive epidural anesthesia with either bupivicaine with fentanyl or bupivicaine alone. One-hour FHR tracings were obtained before epidural anesthesia. Thirty minutes after the initial bolus of the epidural a repeat computer analysis of 60-minute FHR tracing was obtained. Median values are reported for FHR parameters with statistical analysis performed by the Mann-Whitney U and Wilcoxon signed rank tests where appropriate. A power calculation was performed using a power of 90% to determine a required sample size of 28 patients. Statistical significance was set at P < .05. RESULTS In early first stage of labor, there was no significant difference in pre- and postepidural anesthesia FHR baseline, accelerations of 10 and 15 beats per minute, episodes of high and low variation, and short- and long-term variation when using either narcotic or non-narcotic anesthetic agents. CONCLUSIONS Thus, the clinician can consider the use of narcotic as well as non-narcotic continuous epidural anesthesia in the dosages used in our study with its attendant advantages without fear of obscuring the fetal heart rate tracing.

Antenatal Prediction of Fetal pH in Growth Restricted Fetuses Using Computer Analysis of the Fetal Heart Rate

We tested the accuracy of a mathematical model based on computer analysis of the fetal heart rate tracing in predicting umbilical artery pH at birth. In a previous report based on data on 38 growth-restricted fetuses, the second-order polynomial regression equation, umbilical artery pH = 7.28 + 0.002 (duration of episodes of low variation in minutes) + 0.00009 (duration of episodes of low variation in minutes), was retrospectively found to be the best model for the prediction of umbilical artery pH at birth. In the present study, this formula was prospectively tested in 29 growth restricted fetuses between 26 and 37 weeks of gestation from pregnancies with abnormal uterine and/or umbilical artery Doppler velocimetry. Computer analysis of the fetal heart rate tracing of 1 hour duration was performed within 1.5-6 hours of cesarean birth prior to the onset of labor. Umbilical artery cord blood was collected at birth with pH determined within 5 minutes of collection. Acidemia was defined as umbilical artery pH < 7.20, preacidemia pH 7.20-7.25 and nonacidemia pH > 7.25. Then, the data on all 67 growth-restricted fetuses were pooled to generate a new formula that was retrospectively assessed against the entire group. Values are reported as median (range). In the 29 prospectively evaluated cases, there was no statistical difference between the predicted and actual umbilical artery pH at birth [7.28 (7.1-7.29) vs. 7.28 (7.18-7.37), P = 0.57]. The median difference between the paired predicted and actual umbilical artery pH values was -0.001 (-0.10-0.08). The difference between the predicted and actual umbilical artery pH was zero and within +/- 0.04 in 17% (5/29) and 76% (22/29) of the cases, respectively. When the data on the 67 growth-restricted fetuses were pooled together the formula did not change. There was no difference between the predicted and actual umbilical artery pH at birth when the formula was applied to all 67 growth-restricted fetuses [7.28 (7.08-7.29) vs. 7.27 (6.97-7.37), P = 0.41]. The median difference between the paired predicted and actual pH values was -0.001 (-0.12-0.12). The difference between the predicted and actual umbilical artery pH was zero and within +/- 0.04 in 15% (10/67) and 74% (49/67) of the cases, respectively. The accuracy of the formula in correctly categorizing the umbilical artery pH at birth was: acidemia 67% (8/12), preacidemia 28% (8/29) and nonacidemia 80% (37/46), P < 0.0001. A mathematical formula using the computer analysis index of duration of episodes of low variation reliably predicted umbilical artery pH at birth. This type of noninvasive monitoring may allow for the antepartum estimation and continuous tracking of fetal pH.

The clinical significance of absence of end-diastolic velocities of the umbilical artery detected in the severely preterm fetus

Objective: To determine whether there is a gestational age cutoff at the time of diagnosis of AEDV of the umbilical artery Doppler waveform that is associated with nearly zero perinatal survival. Methods: Over an 8-year period we identified and compared the outcomes of pregnancies in which AEDV of the umbilical artery Doppler waveform was detected between 19–24 and 25–28 weeks of gestation. All fetuses had normal structure and karyotypes. Small for gestational age (SGA) was defined as less than the 10th percentile for gestational age based on Brenner’s curve. Values are reported in median (range). Results: There were no survivors among the 27 cases identified at 19–24 weeks of gestation: 5 terminations for severe-SGA fetus (birth weight 336 [130–430] grams), 3 terminations for severe preeclampsia and SGA fetus, 12 fetal deaths, 7 neonatal deaths, and 10 cases (46%) of pregnancy-induced hypertension/preeclampsia (PIH/PE). All 8 cases detected at 25–28 weeks of gestation resulted in neonatal survival at discharge (P <0.0001), and there were 2 cases (25%) of PIH/PE (P = 0.54). Conclusion: In this study, AEDV of the umbilical artery Doppler waveform identified at less than 25 weeks of gestation is associated with a 100% perinatal mortality rate and a high rate of PIH/PE. This information should be incorporated into the counseling and management of women in this clinical setting.

The relationship of Ureaplasma urealyticum cervical colonization and preterm delivery in high-risk pregnancies

Objective: To determine whether cervical colonization with Ureaplasma urealyticum is associated with preterm delivery in a high-risk clinic population. Methods: Patients from the high-risk clinic at Saint Peter’s University Hospital from December 1997 to June 1999 with history of preterm delivery (PTD), preterm labor, second- trimester loss, or fetal demise served as the study population. Cervical cultures for Ureaplasma (UR) were obtained at the first prenatal visit, and patients were divided into groups based on results. Patients with positive UR served as the study group and were compared with noncolonized patients. All patients with positive cultures were treated. Age, gravidity, parity, number of prenatal visits, gestational age (GA) at first visit, weight gain, drug use, smoking, antibiotic therapy, use of aspirin, use of aspirin and heparin, cerclage, and GA at delivery were the variables collected. The outcome variable was PTD, which was defined as delivery between 24 and 37 weeks of gestation. Significance was set as P less than 0.05. Results: A total of 100 patients met the inclusion criteria. Positive cultures were found in 69% (69/100) of the patients. UR cervical colonization was not significantly associated with PTD. There were no significant differences between groups for the maternal variables studied. Conclusion: In this high-risk clinic population, antibiotic therapy for UR cervical colonization at the first prenatal care visit did not reduce the risk for preterm delivery.

Anticardiolipin antibodies in first- and second-trimester pregnancy loss

Abstract Objective: To determine whether a difference exists in the prevalence of anticardiolipin antibodies in patients with a history of recurrent first- versus second-trimester pregnancy loss. Methods: Patients presenting to the Pregnancy Loss Evaluation Service (PLES) from June 1994 to December 1999 were tested for the presence of anticardiolipin IgG, IgM, and IgA antibodies. Levels were measured by a single reference laboratory test. Patients were eligible for the service if they had experienced recurrent first-trimester losses (RFTLs) or at least one second-trimester loss (STL). Comparisons based on the presence of the anticardiolipin antibody were made between patients with RFTL versus STL. Significance was set at P less than 0.05. Results: Anticardiolipin antibody levels were obtained in 93% (243/261) of patients during PLES evaluations. There were 132 patients with RFTL and 129 patients with a STL. 1st-trimester loss 2nd-trimester loss P value Anticardiolipin IgG 6.1% (8/130) 4.4% (5/113) 0.49 Anticardiolipin IgM 7.1% (9/126) 1.7% (2/115) 0.08 Anticardiolipin IgA 2.2% (2/88) 0% (0/78) 0.18 Conclusion: Although the prevalence of anticardiolipin antibodies is greater in patients with first-trimester losses, testing is justified in both first-trimester and second-trimester loss evaluations.

Perinatal outcomes of a multidisciplinary pregnancy loss evaluation service

Abstract Objective: To determine the outcomes of patients presenting to a multidisciplinary pregnancy loss evaluation service. Methods: Patients presenting to the Pregnancy Loss Evaluation Service (PLES) from July 1994 to December 1998 were evaluated. Criteria for the PLES include three first-trimester losses (FTL) or any second-trimester (STL), third-trimester (TTL), or term pregnancy loss (TL). Each patient was discussed in a multidisciplinary setting that included a maternal–fetal medicine specialist, geneticist, perinatal pathologist, reproductive endocrinologist, and rheumatologist. The variables studied were FTL, STL, TTL, TL, term pregnancy (TP), gestational age at delivery, preterm delivery (PTD), and ongoing pregnancy. Preterm delivery was defined as delivery at less than 36 weeks of gestation. Results: The PLES evaluated 215 patients, and data were available for 70% (151/215). Pregnancies occurred in 76% (114/151) of patients and were not achieved in 24% (37/151). Fourteen ongoing pregnancies were not included. Term Pregnancy Preterm Delivery Loss Rate FTL (n = 48) 75% (36/48) 2% (1/48) 23% (11/48) STL (n = 42) 69% (29/42) 5% (2/42) 26% (11/42) TTL (n = 1) 100% (1/1) 0% 0% TL (n = 9) 88% (8/9) 11% (1/9) 0% Total (n = 100) 74% (74/100) 4% (4/100) 22% (22/100) Conclusion: Patients who have experienced pregnancy loss can have good outcomes (> 75%) when thorough evaluations and medical interventions are performed in a multidisciplinary setting.

Elective cerclage versus cervical sonography in the management of women with prior midtrimester loss

Abstract Objective: To compare the outcome of women with a history of midtrimester loss (MTL) when managed with elective cerclage (EC) versus serial cervical sonography (CS). Methods: Over a 7-year period, we identified 199 women with a prior MTL carrying singleton gestations. We compared pregnancy outcomes between 114 women managed with serial CS between 15 and 24 weeks of gestation and 85 women who received EC. In the group who were followed with serial CS, a rescue cerclage or restricted physical activity as the only treatment was considered when the cervical length shortened to 2.0 cm or less. Values were reported as median (range). Results: Results are reported in the following table. Elective cerclage (N = 85) Cervical sonography (N = 114) Cerclage rate 100% 35% Gestational age (GA) at delivery (weeks) 37 (23–41) 38 (18–42) GA less than 37 weeks 44.1% 25.4% ( P = 0.009) GA less than 33 weeks 21.0% 17.5% Preoperative cervical length — 0.88 (0.0–2.0) Conclusion: Women with prior midtrimester loss managed with serial cervical sonography have equal or better perinatal outcomes with lower utilization of cerclage than those treated with elective cerclage.