Roberto Luzietti

Fetal scalp ph and ST analysis of the fetal ECG as an adjunct to cardiotocography to predict fetal acidosis in labor : A multi-center, case controlled study

Abstract Objective: To assess the relationship between scalp pH (FBS) and ST analysis in situations of acidosis with special emphasis on the timing of cardiotocography (CTG), FBS and ST changes during labor. Study design: From a European Union multicenter study on clinical implementation of the STAN methodology, 911 cases were identified where a scalp-pH had been obtained. In 53 cases, marked cord artery acidosis was found (cord artery pH<7.06) and 44 cases showed moderate acidemia at birth (pH 7.06–7.09). Comparisons were made with 97 control cases (pH≥7.20). Results: Of those cases with FHR+ST events recorded within 16 min of delivery, 61% (17/28) had a cord artery pH≥7.20. The corresponding figure for cases where STAN indications occurred for more than 16 min was 19% (13/69) (OR 6.66, 2.53–17.55, P<0.001). Out of the 121 cases with an abnormal CTG, 84 (69%) showed a cord artery pH of <7.10. STAN indicated abnormality in 83% (70 out of 84). The corresponding figure for scalp pH<7.20 was 43% (36/84). In the case of CTG changes at the start of an adequate recording STAN guidelines provided information on developing acidosis in all cases but one (16 out of 17) in the marked acidosis group. STAN guidelines indicated abnormality prior to an abnormal FBS in 14 out of 17 cases. The median duration between STAN indications to intervention and an abnormal FBS was 29 (95% CI 11–74) min. Conclusions: ST analysis, as an adjunct to CTG, identifies adverse fetal conditions during labor similar to that of FBS but on a more consistent basis. The timing of CTG+ST changes relates to the level of acidosis at birth.

European Community Multicentre trial fetal ECG Analysis During labour : the P-R interval

The aim of the European Community Multicentre Trial on Fetal ECG Analysis During Labour was to collect a clinical database of electrocardiograms on which the different patterns of ST waveform and time interval changes, so far identified, could be studied. The aim of this paper was to study the PR-RR relationship and the P wave patterns during normal labour. One thousand three hundred fifty accelerations and 350 decelerations were analysed in 618 labours, all with normal fetal outcome. All ECGs were recorded with the STAN recorder and linked to a PC system for data acquisition and analysis. A positive relationship between P-R and R-R intervals was identified in all reactive fetal heart rate traces. A P-R shortening was identified also with all decelerations of more than 40 bpm from the baseline, resulting in a negative PR-RR relationship. Experimental works have described a P-R shortening concurrent with the maximal R-R lengthening during acutely induced hypoxemia in fetal lambs. In our study normal cord acid-base status indicated that the majority of bradycardia episodes recorded were not related to acute hypoxemia: PR-RR relationship changes seem therefore to indicate an intact physiological fetal heart adaptive response to rapid change in the environment of either hypoxemic or haemodynamic origin. A negative PR-RR relationship by itself seems to be nothing more than an indicator of decelerations during labour and seems unable to discriminate between decelerations of different origin. Finally the P wave was no longer detectable during decelerations of more than 800 msec: in this situation the P-R interval can not be reliably measured.

Multiple True Umbilical Knots: A Silent Risk for Intrauterine Growth Restriction with Anomalous Hemodynamic Pattern

True knots of the umbilical cord can represent a serious complication for the fetus due to the possible alteration in the fetal circulation with consequent intrauterine growth restriction or fetal death. We report a case of 5 true umbilical cord knots associated with severe fetal growth restriction and an abnormal hemodynamic pattern. The Doppler examination showed a hemodynamic pattern characterized by an early alteration in the waveform profile in the fetal venous districts with normal impedance to flow values in both uterine and umbilical arteries. This normal profile of the umbilical arteries remained unchanged until the last stage of hemodynamic decompensation, while the profiles of the uterine arteries remained normal until delivery. This case report suggests that it is important to pay close attention to the evaluation of the fetal cord in situations in which the above described hemodynamic pattern is noted. Although the ultrasound diagnosis of true knots is extremely difficult, the presence of a true knot should always be suspected in the presence of an intrauterine growth restriction fetus when the venous district is altered before the fetal arterial districts after exclusion of other detectable reasons for growth restriction.

Subspecialty in maternal, fetal and perinatal medicine

The European Board and College of Gynaecologists and Obstetricians and the European Association of Perinatal Medicine have been active in the field of quality improvement of specialist training for years. They have formulated guidelines and criteria for this purpose, which are accepted by the representative organizations of medical specialists in the European Union (EU). This work finds its condensation in the European Training Charter for Medical Specialists (1995), which brings together the recommendations on content of postgraduate and continuing medical education in the whole field of specialist medicine. Quality of training is one of the most important factors in the domain of quality of medical care. In the member states of the EU, national professional authorities assess, improve and control specialist training in their countries. For this purpose, feedback is necessary and several feedback instruments should be employed. An important feedback instrument in quality improvement is the visitation of training centres, often coupled with national certification or recertification of trainers and training centres. The need is felt for harmonization and encouragement in the field of visitation of training centres, as national approaches show much variation in the EU presently. This paper presents the general outlines of a European programme for visitation of training centres. The general guidelines for training are also summarized. These are meant as examples and can be adapted to the case at issue. The responsible national authority is recommended to establish programmes for this purpose since these have not been developed yet. These programmes are increasingly required, and they tend to become obligatory as already is the case in several member states of the EU.

The biophysical profile in multiple pregnancy

ABSTRACTThe high risk attributed to multiples calls for close observation during pregnancy. Based on adequate predictions in singletons, it was expected that the biophysical profile (reactive fetal heart rate pattern on non-stress test, presence of fetal breathing and body movements, documentation of normal fetal tone and adequate amount of amniotic fluid) could be used in multiples as well. However, the paucity of studies could not demonstrate an equivalent predictive capacity in multiple pregnancies.