Jeroen H. Becker

Effects on (neuro)developmental and behavioral outcome at 2 years of age of induced labor compared with expectant management in intrauterine growth-restricted infants: long-term outcomes of the DIGITAT trial

OBJECTIVE We sought to study long-term (neuro)developmental and behavioral outcome of pregnancies complicated by intrauterine growth restriction at term in relation to induction of labor or an expectant management. STUDY DESIGN Parents of 2-year-old children included in the Disproportionate Intrauterine Growth Intervention Trial at Term (DIGITAT) answered the Ages and Stages Questionnaire (ASQ) and Child Behavior Checklist (CBCL). RESULTS We approached 582 (89.5%) of 650 parents. The response rate was 50%. Of these children, 27% had an abnormal score on the ASQ and 13% on the CBCL. Results of the ASQ and the CBCL for the 2 policies were comparable. Low birthweight, positive Morbidity Assessment Index score, and admission to intermediate care increased the risk of an abnormal outcome of the ASQ. This effect was not seen for the CBCL. CONCLUSION In women with intrauterine growth restriction at term, neither a policy of induction of labor nor expectant management affect developmental and behavioral outcome when compared to expectant management.

ST Analysis of the Fetal Electrocardiogram in Intrapartum Fetal Monitoring: A Meta-Analysis.

OBJECTIVE: To compare the effects of ST-waveform analysis in combination with cardiotocography with conventional cardiotocography for intrapartum fetal monitoring. DATA SOURCES: We searched MEDLINE, Embase, and PubMed for randomized controlled trials (RCTs) evaluating ST-waveform analysis for intrapartum fetal monitoring. METHODS OF STUDY SELECTION: We identified RCTs that compared ST-waveform analysis and conventional cardiotocography for intrapartum fetal monitoring of singleton pregnancies in cephalic presentation beyond 34 weeks of gestation and evaluating at least one of the following: metabolic acidosis, umbilical cord pH less than 7.15, umbilical cord pH less than 7.10, umbilical cord pH less than 7.05, umbilical cord pH less than 7.00, Apgar scores less than 7 at 5 minutes, admittance to the neonatal intensive care unit, need for intubation, presence of hypoxic ischemic encephalopathy, perinatal death, operative delivery, and number of fetal blood samplings. TABULATION, INTEGRATION, AND RESULTS: Five RCTs, which included 15,352 patients, met the selection criteria. Random-effects models were used to estimate the combined relative risks (RRs) of ST analysis compared with conventional cardiotocography. Compared with conventional cardiotocography, ST analysis showed a nonsignificant reduction in metabolic acidosis (RR 0.72, 95% confidence interval 0.43–1.19, number needed to treat [NNT] 357). ST analysis significantly reduced the incidence of additional fetal blood sampling (RR 0.59, 95% confidence interval 0.44–0.79, NNT 11), operative vaginal deliveries (RR 0.88, 95% confidence interval 0.80–0.97, NNT 64), and total operative deliveries (RR 0.94, 95% confidence interval 0.89–0.99, NNT 64). For other outcomes, no differences in effect were seen between ST analysis and conventional cardiotocography, or data were not suitable for meta-analysis. CONCLUSION: The additional use of ST analysis for intrapartum monitoring reduced the incidence of operative vaginal deliveries and the need for fetal blood sampling but did not reduce the incidence of metabolic acidosis at birth.

Cerebrospinal fluid leakage, an uncommon complication of fetal blood sampling: a case report and review of the literature.

In a recently published randomized clinical trial on intrapartum fetal monitoring, fetal blood samples were obtained in 879 women. One serious complication of fetal blood sampling (FBS) was reported, a case in which physical examination of the neonate after delivery revealed clear fluid loss from the incision site. Four layers of the scalp appeared to be incised. The subarachnoid space was closed with 2 sutures, and antibiotics were started due to the risk of meningitis. The patient was discharged in good clinical condition. In this article, the case is presented and the literature reviewed. We found 12 articles reporting 37 cases of a complication due to FBS, none concerning leakage of cerebrospinal fluid. In conclusion, complications of FBS are rare but can be serious. Excessive fetal bleeding is most frequently reported and often associated with an underlying coagulopathy in the neonate. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this educational activity, the obstetrician/gynecologist should be better able to assess the chance of possible complications due to fetal blood sampling; select fetuses at risk for complications due to fetal blood sampling; and evaluate certain technical precautions when performing this procedure.

Identification of cases with adverse neonatal outcome monitored by cardiotocography versus ST analysis: secondary analysis of a randomized trial

Objective. To evaluate whether correct adherence to clinical guidelines might have led to prevention of cases with adverse neonatal outcome. Design. Secondary analysis of cases with adverse outcome in a multicenter randomized clinical trial. Setting. Nine Dutch hospitals. Population. Pregnant women with a term singleton fetus in cephalic position. Methods. Data were obtained from a randomized trial that compared monitoring by STAN® (index group) with cardiotocography (control group). In both trial arms, three observers independently assessed the fetal surveillance results in all cases with adverse neonatal outcome, to determine whether an indication for intervention was present, based on current clinical guidelines. Main outcome measures. Adverse neonatal outcome cases fulfilled one or more of the following criteria: (i) metabolic acidosis in umbilical cord artery (pH < 7.05 and base deficit in extracellular fluid >12 mmol/L); (ii) umbilical cord artery pH < 7.00; (iii) perinatal death; and/or (iv) signs of moderate or severe hypoxic ischemic encephalopathy. Results. We studied 5681 women, of whom 61 (1.1%) had an adverse outcome (26 index; 35 control). In these women, the number of performed operative deliveries for fetal distress was 18 (69.2%) and 16 (45.7%), respectively. Reassessment of all 61 cases showed that there was a fetal indication to intervene in 23 (88.5%) and 19 (57.6%) cases, respectively. In 13 (50.0%) vs. 11 (33.3%) cases, respectively, this indication occurred more than 20 min before the time of delivery, meaning that these adverse outcomes could possibly have been prevented. Conclusions. In our trial, more strict adherence to clinical guidelines could have led to additional identification and prevention of adverse outcome.

Fetal blood sampling in addition to intrapartum ST-analysis of the fetal electrocardiogram: evaluation of the recommendations in the Dutch STAN® trial

Please cite this paper as: Becker J, Westerhuis M, Sterrenburg K, van den Akker E, van Beek E, Bolte A, van Dessel T, Drogtrop A, van Geijn H, Graziosi G, van Lith J, Mol B, Moons K, Nijhuis J, Oei S, Oosterbaan H, Porath M, Rijnders R, Schuitemaker N, Wijnberger L, Willekes C, Visser G, Kwee A. Fetal blood sampling in addition to intrapartum ST‐analysis of the fetal electrocardiogram: evaluation of the recommendations in the Dutch STAN® trial. BJOG 2011; DOI: 10.1111/j.1471‐0528.2011.03027.x.

Predictive value of the baseline T-QRS ratio of the fetal electrocardiogram in intrapartum fetal monitoring: a prospective cohort study

Objective. To evaluate the added value of the baseline T/QRS ratio to other known risk factors in predicting adverse outcome and interventions for suspected fetal distress. Design. Prospective cohort study. Setting. Three academic and six non‐academic teaching hospitals in the Netherlands. Population. Laboring women with a high‐risk cephalic singleton pregnancy beyond 36 weeks of gestation. Methods. We obtained STAN® recordings (ST‐analysis, Neoventa, Sweden) from two previous studies. Three patient groups were defined: cases with adverse outcome, cases with emergency delivery because of suspected fetal distress without adverse outcome, and a reference group of uncomplicated cases. Baseline T/QRS ratios among the adverse outcome and intervention for suspected fetal distress cases were compared to those of the uncomplicated cases. The ability of baseline T/QRS to predict adverse outcome and suspected fetal distress was determined using a multivariable logistic model. Main outcome measures. The added value of the baseline T/QRS to other known risk factors in the prediction of adverse outcome and interventions for suspected fetal distress. Results. From 3462 recordings, 2459 were available for analysis. Median baseline T/QRS for uncomplicated cases, adverse outcome and interventions for suspected fetal distress were 0.12 (range 0.00–0.52), 0.12 (0.00–0.42) and 0.13 (0.00–0.39), respectively. There was no statistical difference between these groups. Multivariable analysis showed no added value of baseline T/QRS in the prediction of either adverse outcome or interventions for suspected fetal distress. Conclusion. Baseline T/QRS has no added value in the prediction of adverse neonatal outcome or interventions for suspected fetal distress.

The added predictive value of biphasic events in ST analysis of the fetal electrocardiogram for intrapartum fetal monitoring

To study the predictive value of biphasic ST‐events for interventions for suspected fetal distress and adverse neonatal outcome, when using ST‐analysis of the fetal electrocardiogram (FECG) for intrapartum fetal monitoring.

Intrapartum epidural analgesia and ST analysis of the fetal electrocardiogram.

Objective. To evaluate the influence of intrapartum epidural analgesia on the occurrence of ST events of the fetal ECG. Design. Nested case–control study. Setting. Single‐centre academic hospital in the Netherlands. Population. Laboring women with a high‐risk singleton pregnancy in cephalic position beyond 36weeks of gestation. Methods. Data of 72 women who received epidural analgesia using bupivacaine combined with sufentanil and 72 control women were collected and analyzed. The moment of epidural infusion was defined as t0. In the control group, t0 was defined by matching dilatation in centimeters. STAN® registrations from one hour before until two hours after t0 were classified, and the numbers and types of ST events were recorded and judged according to the STAN® clinical guidelines. T/QRS ratios were collected from one hour before t0 until two hours after t0, and differences were compared between the two groups. Main Outcome Measures. Numbers and types of ST events and mean T/QRS ratios before and after t0. Results. There were no significant differences between cases and control women regarding the numbers of ST events, types of ST events and whether they were significant (intervention advised) or not. Correction for outliers (three cases and three control women) did not change the results. Differences of T/QRS ratios before and after t0 were comparable between cases and control women. Conclusions. Epidural analgesia has no effect on the numbers or types of ST events when using ST analysis of the fetal ECG.

Is intrapartum fever associated with ST-waveform changes of the fetal electrocardiogram? A retrospective cohort study

Please cite this paper as: Becker J, van Rijswijk J, Versteijnen B, Evers A, van den Akker E, van Beek E, Bolte A, Rijnders R, Mol B, Moons K, Porath M, Drogtrop A, Schuitemaker N, Willekes C, Westerhuis M, Visser G, Kwee A. Is intrapartum fever associated with ST‐waveform changes of the fetal electrocardiogram? A retrospective cohort study. BJOG 2012;119:1410–1416.