Nancy Searle

Maternal dietary substrates and human fetal biophysical activity. I. The effects of tryptophan and glucose on fetal breathing movements

To study the effects of L-tryptophan and glucose on fetal breathing activity, we examined 40 women with normal term pregnancies, randomly assigned to four equal groups who either continued fasting (group C), received 1 gm of oral tryptophan (group T), received 100 gm of oral glucose (group G), or received both substrates (group T + G). Studies lasted 210 minutes, during which fetal breathing movements were observed with real-time ultrasonography and entered and analyzed for incidence, rate, and variability on a microcomputer. Plasma glucose and tryptophan levels were determined every 30 minutes. The incidence of fetal breathing movements declined in group C and rose significantly in the other groups. Breathing rates were unchanged in groups C and T but rose significantly in groups G and T + G during peak breathing intervals. Breath interval variability did not change significantly in any study group. Maternal administration of tryptophan is associated with an alteration in fetal breathing activity but to a lesser degree than that observed after maternal glucose loading.

Computer-assisted assessment of the fetal biophysical profile

The biophysical profile assesses fetal heart rate, breathing movements, fetal body movements, amniotic fluid volume, and fetal tone. In the past, these data have been scored by an arbitrary, unweighted system. While this approach is useful in detecting major anomalies and oligohydramnios, both static observations, the dynamic variables (fetal heart rate, fetal breathing movements, and fetal body movements) have added little information beyond that of an extended nonstress test alone. We have evaluated an alternative biophysical assessment system, modeled after extended physiologic studies, which not only acquires dynamic fetal variables simultaneously but, with computer assistance, quantifies the biophysical information. With an ADR 4000/L scanner, a Hewlett-Packard 8040 A monitor, and a specially programmed IBM microcomputer, we studied 100 normal term fetuses during 60-minute epochs. Each gestation had normal amniotic fluid volume and fetal tone. Normative values for the dynamic variables, expressed as means +/- SD were: fetal heart rate, 137 +/- 6.3 bpm; incidence of fetal breathing movements, 25.0% +/- 17.3%; rate of fetal breathing movements, 46.0 +/- 9.4 breaths/min; total fetal breathing movements, 823 +/- 61; incidence of fetal body movements, 8.5% +/- 3.9%; accelerations (greater than 15 bpm, 15 seconds), 14.1 +/- 6.3. We conclude that this approach is practicable, respects the biologic cycles of fetal behavior, and provides a basis for population standards and sequential study of the same fetus.

Sequential nonstress testing with use of each fetus as its own control

The sequential nonstress tests of 126 high-risk fetuses were assessed for baseline fetal heart rate, acceleration frequency, amplitude, and duration and the observance of fetal heart rate decelerations. In 108 fetuses (563 tests) with normal perinatal outcomes, no significant trends in these parameters were found. In 18 fetuses (104 tests) with perinatal compromise, 16 had significantly declining acceleration frequencies, 15 had decreasing acceleration duration, four had rising mean baseline rates, and seven, in their last test before delivery, had repetitive late or severe variable decelerations. The last tests of 11 of these 18 fetuses met institutional criteria for reactivity. When the nonstress tests of compromised fetuses were viewed sequentially, acceleration frequency declined by an average of 59% and acceleration duration by an average of 40%. Sequential assessment of the nonstress test, when compared with the use of standard reactivity criteria, improved test sensitivity from 39% to 89% and negative predictive value from 91% to 98%. We conclude that sequential nonstress test assessment in individual fetuses may improve the diagnostic value of this modality and lead to earlier recognition of fetal compromise.

The effects of vibratory acoustic stimulation on baseline fetal heart rate in term pregnancy

Fetal heart rate responses to vibratory acoustic stimulation have been studied in normal and complicated pregnancies. To determine the precise nature of these responses, we studied 50 normal term fetuses with 60 minutes of electronic antepartum fetal heart rate monitoring divided in two 30-minute segments separated by 3 seconds of vibratory acoustic stimulation. All tracings were analyzed by a programmed microcomputer. Comparison of grouped mean 30-minute values before and after vibratory acoustic stimulation showed significant increases in baseline fetal heart rate, fetal heart rate variation, frequency of accelerations exceeding 10 and 15 beats/min, duration of accelerations exceeding 15 beats/min, and frequency of decelerations after vibratory acoustic stimulation. Mean baseline fetal heart rate elevation greater than 10 beats/min occurred within 7.6 +/- 4.4 seconds in 42 of 50 fetuses and lasted for 596 +/- 531 seconds. Reactive tests increased from 35 (70%) to 47 (94%) after vibratory acoustic stimulation. Most healthy term fetuses exhibit fetal heart rate responses after differing in frequency or magnitude from spontaneous fetal heart rate changes. Vibratory acoustic stimulation may be a valid fetal assessment tool but cannot be considered the physiologic equivalent of nonstress testing.

FOETOS in clinical practice: A retrospective analysis of its performance

Abstract The results of the first validation of the prototype expert system FOETOS are presented. FOETOS is designed to assist the obstetrician in the diagnosis of antepartum and intrapartum foetal well-being. To evaluate the performance of this system, 20 delivered patients were selected for retrospective analysis. All patients underwent three antenatal tests (hon-stress test, foetal biophysical profile, and contraction stress test), and their labor data were available. The validation tool utilized was the man-machine performance method. While our results are encouraging, certain aspects of the system require modification to accommodate it to a real clinical environment. With such modifications FOETOS could be developed into a useful tool for the assessment of high risk pregnancies.

The effects of long- and short-term maternal caffeine ingestion on human fetal breathing and body movements in term gestations

The possible effects of long- and short-term maternal ingestion of caffeine during normal human pregnancy on the breathing and body movements of third-trimester fetuses were studied in 14 patients, selected by a dietary questionnaire, and divided into two equal groups: high consumers (greater than 500 mg/day) (group 1) and low consumers (less than 250 mg/day) (group 2). All mothers followed a standard study protocol and underwent overnight fasting; studies began with a 30-minute control period, followed by oral administration of 200 mg caffeine, and a 180-minute subsequent observation period with continued maternal fasting. Blood samples for glucose and caffeine were obtained every 30 minutes and continuous recording of fetal breathing and body movements were entered on a microcomputer for off-line analysis. The two groups were similar for all obstetric outcome features. Plasma glucose levels were similar and constant in both groups whereas caffeine levels increased significantly at 60 minutes after administration; mean plasma caffeine levels were significantly higher in group 1 than in group 2 at all intervals. Fetal breathing rates and body movement incidences were similar in both groups before and after caffeine administration. Fetal breathing movement incidence decreased significantly in group 2 but was sustained at baseline levels in group 1 throughout the study. High long-term ingestion of caffeine during pregnancy is associated with higher maternal plasma caffeine levels and fetal breathing activity when compared with low caffeine ingestion. Short-term administration of 200 mg caffeine does not appear to have a significant physiologic impact on these activities.

Effects of maternal hyperoxia on the biophysical assessment of fetuses with suspected intrauterine growth retardation

Fifty-two third-trimester fetuses with suspected intrauterine growth retardation were studied by means of a computer-assisted biophysical assessment scheme, which used maternal hyperoxia as a diagnostic probe. Biophysical data examined included percentage of time spent in breathing, mean breath rate, and percentage of time spent in body movement during a 90-minute observation: 30-minute baseline, 15-minute hyperoxia, and 45-minute posthyperoxia. Mean baseline movement in fetuses found as neonates to have intrauterine growth retardation (N = 18) was significantly lower than that of normal fetuses (N = 34). Fetal body movements and breathing movements increased significantly after hyperoxia in the intrauterine growth retardation group but not in the normal group. Increases of more than 75% over baseline for fetal breathing and more than 250% over baseline for fetal body movements yielded a sensitivity of 56%, specificity of 94%, positive predicative value of 83%, and negative predicative value of 80%. Maternal hyperoxia during biophysical testing may improve the accuracy of detecting intrauterine growth retardation.

Percent acceleration time: A new method of fetal assessment

The percent acceleration time (PAT) is a fetal heart rate parameter, which may be derived from the nonstress test (NST). It is based on measurement of the duration of individual movement-associated fetal heart rate accelerations (MAFAs), obtained during a nonstress test, and is calculated by the formula: (formula, see text) The authors studied 148 fetuses undergoing four or more serial nonstress tests who were delivered within one week of their last test. Percent acceleration time of fetuses with normal outcomes had a mean value of 15.5 +/- 10.0 (SD)%, correlated well with the frequency and amplitude of movement-associated fetal heart rate accelerations but was independent of gestational age and mean baseline fetal heart rate. No normal fetus had a percent acceleration time of less than 5% on its last nonstress test, while only one abnormal fetus had a percent acceleration time that exceeded the mean percent acceleration time of the normal group. All abnormal fetuses had a significant progressive decline in percent acceleration time (mean: 50.6%). Percent acceleration time values were more sensitive in identifying fetuses with perinatal compromise than were conventional criteria for nonstress test reactivity, and may provide a useful alternative to assessment of fetal status when other quantitative methods are unavailable (continuous ultrasound visualization) or less reliable (maternal perception, tokodynamometry, palpation).

A prospective comparative study of the extended nonstress test and the nipple stimulation contraction stress test

The nonstress test and the nipple stimulation contraction stress test were performed at the Medical College of Georgia and the University of Mississippi Medical Center, with the use of common maternal state protocols, minimum criteria for baseline fetal heart rate reactivity, and follow-up of abnormal test results. At the Medical College of Georgia, 656 patients were studied with nonstress tests used as the primary test, whereas at the University of Mississippi Medical Center, 614 patients were managed with the nipple stimulation contraction stress test used as the primary test. Both populations were comparable in regard to pregnancy complications, gestational age, birth weight, perinatal outcomes, cesarean section rates, and the incidence of positive contraction stress tests. Specificity and positive and negative predictive values were similar for both tests. The extended nonstress test had higher sensitivity but also required significantly longer mean duration of testing. The corrected perinatal mortality rate for a reactive nonstress test or negative nipple stimulation contraction stress test was zero within one week of the last test. We conclude that both tests provide excellent primary methods of fetal surveillance and that the decision to use one test rather than the other should be made on the basis of considerations of cost, convenience, time availability, and the presence of specific test contraindications or pregnancy complications.

The effects of maternal ambulation on the nonstress test

Using a recently developed noninvasive telemetry device (model 8240A, Hewlett-Packard Co., Palo Alto, California), we studied, under controlled conditions, the effects of maternal ambulation on the nonstress test patterns of 100 near-term high-risk pregnancies, randomly divided into two equal groups who underwent three alternating 30-minute periods of ambulation and bed rest, beginning either with ambulation (group 1) or bed rest (group 2). Fetal heart rate data were captured and analyzed by a programmed microcomputer for group mean 30-minute fetal heart rate baseline rates and variability and incidences and dimensions of fetal heart rate accelerations and decelerations. Both groups were similar for the maternal and perinatal data examined. The fetal heart rate parameters analyzed were similar within and between each group during each 30-minute testing segment. No episodes of sustained tachycardia or bradycardia were observed. Although 13 fetuses in each group exhibited variable or late decelerations, the incidence of decelerations was no different during periods of rest or ambulation. Maternal ambulation does not elicit abnormal fetal heart rate responses in most high-risk fetuses and may be an acceptable alternative to conventional nonstress test conditions.