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Medicina 2018Hypoxic-ischemic encephalopathy is a clearly recognizable clinical syndrome of in term newborns due to fetal asphyxia at birth. The incidence is 1.5 (95% CI 1.3 to 1.7)... (Review)
Review
Hypoxic-ischemic encephalopathy is a clearly recognizable clinical syndrome of in term newborns due to fetal asphyxia at birth. The incidence is 1.5 (95% CI 1.3 to 1.7) but it ranges from 1-8 and 25 out of every 1000 born in developed and developing countries, respectively. The most frequent causes are detachment of the placenta, prolapse of the umbilical cord and uterine rupture. The diagnostic criteria include partial or total incapacity for the newborn to cry and breath at birth even when stimulated, requiring assisted ventilation in the delivery room, Apgar < 5 in 5 and 10 minutes, acidemia (pH ≤ 7 and / or bases deficit ≥ 12 mmol/l), alterations of the conscience and the reflexes of Moro, grasping and suction, muscular stretching and muscle tone. The clinical forms are mild, moderate and severe. In the mild forms, the recovery is total in three days without, or with minimal, neurodevelopmental alterations. The moderate and severe forms cause permanent neurological deficits and neurodevelopmental alterations (48%) or death (27%). The regular or amplitude integrated EEG and the magnetic and spectroscopic magnetic resonance imaging performed between 24 and 96 hours and 7 and 21 days after birth, respectively, have a high diagnostic and prognostic value. Induced hypothermia (33.5° C for 72 hours) is recommended before 6 hours old. The result is a decrease in mortality (from 35% to 27%) and morbidity (from 48% to 27%).
Topics: Asphyxia Neonatorum; Humans; Hypothermia, Induced; Hypoxia-Ischemia, Brain; Incidence; Infant, Newborn; Severity of Illness Index
PubMed: 30199363
DOI: No ID Found -
Obstetrics and Gynecology Mar 2020Umbilical cord abnormalities are commonly cited as a cause of stillbirth, but details regarding these stillbirths are rare. Our objective was to characterize stillbirths...
OBJECTIVE
Umbilical cord abnormalities are commonly cited as a cause of stillbirth, but details regarding these stillbirths are rare. Our objective was to characterize stillbirths associated with umbilical cord abnormalities using rigorous criteria and to examine associated risk factors.
METHODS
The Stillbirth Collaborative Research Network conducted a case-control study of stillbirth and live births from 2006 to 2008. We analyzed stillbirths that underwent complete fetal and placental evaluations and cause of death analysis using the INCODE (Initial Causes of Fetal Death) classification system. Umbilical cord abnormality was defined as cord entrapment (defined as nuchal, body, shoulder cord accompanied by evidence of cord occlusion on pathologic examination); knots, torsions, or strictures with thrombi, or other obstruction by pathologic examination; cord prolapse; vasa previa; and compromised fetal microcirculation, which is defined as a histopathologic finding that represents objective evidence of vascular obstruction and can be used to indirectly confirm umbilical cord abnormalities when suspected as a cause for stillbirth. We compared demographic and clinical factors between women with stillbirths associated with umbilical cord abnormalities and those associated with other causes, as well as with live births. Secondarily, we analyzed the subset of pregnancies with a low umbilical cord index.
RESULTS
Of 496 stillbirths with complete cause of death analysis by INCODE, 94 (19%, 95% CI 16-23%) were associated with umbilical cord abnormality. Forty-five (48%) had compromised fetal microcirculation, 27 (29%) had cord entrapment, 26 (27%) knots, torsions, or stricture, and five (5%) had cord prolapse. No cases of vasa previa occurred. With few exceptions, maternal characteristics were similar between umbilical cord abnormality stillbirths and non-umbilical cord abnormality stillbirths and between umbilical cord abnormality stillbirths and live births, including among a subanalysis of those with hypo-coiled umbilical cords.
CONCLUSION
Umbilical cord abnormalities are an important risk factor for stillbirth, accounting for 19% of cases, even when using rigorous criteria. Few specific maternal and clinical characteristics were associated with risk.
Topics: Adult; Case-Control Studies; Female; Humans; Pregnancy; Stillbirth; Umbilical Cord; United States; Young Adult
PubMed: 32028503
DOI: 10.1097/AOG.0000000000003676 -
American Journal of Obstetrics and... Oct 2021Umbilical cord prolapse is an unpredictable obstetrical emergency with an incidence ranging from 1 to 6 per 1000 pregnancies. It is associated with high perinatal... (Review)
Review
Umbilical cord prolapse is an unpredictable obstetrical emergency with an incidence ranging from 1 to 6 per 1000 pregnancies. It is associated with high perinatal mortality, ranging from 23% to 27% in low-income countries to 6% to 10% in high-income countries. In this review, we specifically addressed 3 issues. First, its definition is not consistent in the current literature, and "occult cord prolapse" is a misnomer because the cord is still above the cervix. We proposed that cord prolapse, cord presentation, and compound cord presentation should be classified according to the positional relationship among the cord, the fetal presenting part, and the cervix. All of them may occur with either ruptured or intact membranes. The fetal risk is highest in cord prolapse, followed by cord presentation, and lastly by compound cord presentation, which replaces the misnomer "occult cord prolapse." Second, the mainstay of treatment of cord prolapse is urgent delivery, which means cesarean delivery in most cases, unless vaginal delivery is imminent. The urgency depends on the fetal heart rate pattern, which can be bradycardia, recurrent decelerations, or normal. It is most urgent in cases with bradycardia, because a recent study showed that cord arterial pH declines significantly with the bradycardia-to-delivery interval at a rate of 0.009 per minute (95% confident interval, 0.0003-0.0180), and this may indicate an irreversible pathology such as vasospasm or persistent cord compression. However, cord arterial pH does not correlate with either deceleration-to-delivery interval or decision-to-delivery interval, indicating that intermittent cord compression causing decelerations is reversible and less risk. Third, while cesarean delivery is being arranged, different maneuvers should be adopted to relieve cord compression by elevating the fetal presenting part and to prevent further cord prolapse beyond the vagina. A recent study showed that the knee-chest position provides the greatest elevation effect, followed by filling of the maternal urinary bladder with 500 mL of fluid, and then the Trendelenburg position (15°) and other maneuvers. However, each maneuver has its own advantages and limitations; thus, they should be applied wisely and with great caution, depending on the actual clinical situation. Therefore, we have proposed an algorithm to guide this acute management.
Topics: Bradycardia; Cesarean Section; Delivery, Obstetric; Disease Management; Female; Fetal Blood; Head-Down Tilt; Heart Rate, Fetal; Humans; Hydrogen-Ion Concentration; Labor Presentation; Obstetric Labor Complications; Patient Positioning; Pregnancy; Prolapse; Time Factors; Tocolysis; Umbilical Cord
PubMed: 34181893
DOI: 10.1016/j.ajog.2021.06.077 -
American Journal of Obstetrics and... Jun 2023Any acute and profound reduction in fetal oxygenation increases the risk of anaerobic metabolism in the fetal myocardium and, hence, the risk of lactic acidosis. On the... (Review)
Review
Any acute and profound reduction in fetal oxygenation increases the risk of anaerobic metabolism in the fetal myocardium and, hence, the risk of lactic acidosis. On the contrary, in a gradually evolving hypoxic stress, there is sufficient time to mount a catecholamine-mediated increase in the fetal heart rate to increase the cardiac output and redistribute oxygenated blood to maintain an aerobic metabolism in the fetal central organs. When the hypoxic stress is sudden, profound, and sustained, it is not possible to continue to maintain central organ perfusion by peripheral vasoconstriction and centralization. In case of acute deprivation of oxygen, the immediate chemoreflex response via the vagus nerve helps reduce fetal myocardial workload by a sudden drop of the baseline fetal heart rate. If this drop in the fetal heart rate continues for >2 minutes (American College of Obstetricians and Gynecologists' guideline) or 3 minutes (National Institute for Health and Care Excellence or physiological guideline), it is termed a prolonged deceleration, which occurs because of myocardial hypoxia, after the initial chemoreflex. The revised International Federation of Gynecology and Obstetrics guideline (2015) considers the prolonged deceleration to be a "pathologic" feature after 5 minutes. Acute intrapartum accidents (placental abruption, umbilical cord prolapse, and uterine rupture) should be excluded immediately, and if they are present, an urgent birth should be accomplished. If a reversible cause is found (maternal hypotension, uterine hypertonus or hyperstimulation, and sustained umbilical cord compression), immediate conservative measures (also called intrauterine fetal resuscitation) should be undertaken to reverse the underlying cause. In reversible causes of acute hypoxia, if the fetal heart rate variability is normal before the onset of deceleration, and normal within the first 3 minutes of the prolonged deceleration, then there is an increased likelihood of recovery of the fetal heart rate to its antecedent baseline within 9 minutes with the reversal of the underlying cause of acute and profound reduction in fetal oxygenation. The continuation of the prolonged deceleration for >10 minutes is termed "terminal bradycardia," and this increases the risk of hypoxic-ischemic injury to the deep gray matter of the brain (the thalami and the basal ganglia), predisposing to dyskinetic cerebral palsy. Therefore, any acute fetal hypoxia, which manifests as a prolonged deceleration on the fetal heart rate tracing, should be considered an intrapartum emergency requiring an immediate intervention to optimize perinatal outcome. In uterine hypertonus or hyperstimulation, if the prolonged deceleration persists despite stopping the uterotonic agent, then acute tocolysis is recommended to rapidly restore fetal oxygenation. Regular clinical audit of the management of acute hypoxia, including the "the onset of bradycardia to delivery interval," may help identify organizational and system issues, which may contribute to poor perinatal outcomes.
Topics: Pregnancy; Female; Humans; Bradycardia; Heart Rate, Fetal; Deceleration; Placenta; Fetal Hypoxia
PubMed: 37270260
DOI: 10.1016/j.ajog.2022.05.014 -
The Cochrane Database of Systematic... Jan 2017Prelabour rupture of membranes (PROM) at term is managed expectantly or by planned early birth. It is not clear if waiting for birth to occur spontaneously is better... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Prelabour rupture of membranes (PROM) at term is managed expectantly or by planned early birth. It is not clear if waiting for birth to occur spontaneously is better than intervening, e.g. by inducing labour.
OBJECTIVES
The objective of this review is to assess the effects of planned early birth (immediate intervention or intervention within 24 hours) when compared with expectant management (no planned intervention within 24 hours) for women with term PROM on maternal, fetal and neonatal outcomes.
SEARCH METHODS
We searched Cochrane Pregnancy and Childbirth's Trials Register (9 September 2016) and reference lists of retrieved studies.
SELECTION CRITERIA
Randomised or quasi-randomised controlled trials of planned early birth compared with expectant management (either in hospital or at home) in women with PROM at 37 weeks' gestation or later.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trials for inclusion, extracted the data, and assessed risk of bias of the included studies. Data were checked for accuracy.
MAIN RESULTS
Twenty-three trials involving 8615 women and their babies were included in the update of this review. Ten trials assessed intravenous oxytocin; 12 trials assessed prostaglandins (six trials in the form of vaginal prostaglandin E2 and six as oral, sublingual or vaginal misoprostol); and one trial each assessed Caulophyllum and acupuncture. Overall, three trials were judged to be at low risk of bias, while the other 20 were at unclear or high risk of bias.Primary outcomes: women who had planned early birth were at a reduced risk of maternal infectious morbidity (chorioamnionitis and/or endometritis) than women who had expectant management following term prelabour rupture of membranes (average risk ratio (RR) 0.49; 95% confidence interval (CI) 0.33 to 0.72; eight trials, 6864 women; Tau² = 0.19; I² = 72%; low-quality evidence), and their neonates were less likely to have definite or probable early-onset neonatal sepsis (RR 0.73; 95% CI 0.58 to 0.92; 16 trials, 7314 infants;low-quality evidence). No clear differences between the planned early birth and expectant management groups were seen for the risk of caesarean section (average RR 0.84; 95% CI 0.69 to 1.04; 23 trials, 8576 women; Tau² = 0.10; I² = 55%; low-quality evidence); serious maternal morbidity or mortality (no events; three trials; 425 women; very low-quality evidence); definite early-onset neonatal sepsis (RR 0.57; 95% CI 0.24 to 1.33; six trials, 1303 infants; very low-quality evidence); or perinatal mortality (RR 0.47; 95% CI 0.13 to 1.66; eight trials, 6392 infants; moderate-quality evidence).
SECONDARY OUTCOMES
women who had a planned early birth were at a reduced risk of chorioamnionitis (average RR 0.55; 95% CI 0.37 to 0.82; eight trials, 6874 women; Tau² = 0.19; I² = 73%), and postpartum septicaemia (RR 0.26; 95% CI 0.07 to 0.96; three trials, 263 women), and their neonates were less likely to receive antibiotics (average RR 0.61; 95% CI 0.44 to 0.84; 10 trials, 6427 infants; Tau² = 0.06; I² = 32%). Women in the planned early birth group were more likely to have their labour induced (average RR 3.41; 95% CI 2.87 to 4.06; 12 trials, 6945 women; Tau² = 0.05; I² = 71%), had a shorter time from rupture of membranes to birth (mean difference (MD) -10.10 hours; 95% CI -12.15 to -8.06; nine trials, 1484 women; Tau² = 5.81; I² = 60%), and their neonates had lower birthweights (MD -79.25 g; 95% CI -124.96 to -33.55; five trials, 1043 infants). Women who had a planned early birth had a shorter length of hospitalisation (MD -0.79 days; 95% CI -1.20 to -0.38; two trials, 748 women; Tau² = 0.05; I² = 59%), and their neonates were less likely to be admitted to the neonatal special or intensive care unit (RR 0.75; 95% CI 0.66 to 0.85; eight trials, 6179 infants), and had a shorter duration of hospital (-11.00 hours; 95% CI -21.96 to -0.04; one trial, 182 infants) or special or intensive care unit stay (RR 0.72; 95% CI 0.61 to 0.85; four trials, 5691 infants). Women in the planned early birth group had more positive experiences compared with women in the expectant management group.No clear differences between groups were observed for endometritis; postpartum pyrexia; postpartum antibiotic usage; caesarean for fetal distress; operative vaginal birth; uterine rupture; epidural analgesia; postpartum haemorrhage; adverse effects; cord prolapse; stillbirth; neonatal mortality; pneumonia; Apgar score less than seven at five minutes; use of mechanical ventilation; or abnormality on cerebral ultrasound (no events).None of the trials reported on breastfeeding; postnatal depression; gestational age at birth; meningitis; respiratory distress syndrome; necrotising enterocolitis; neonatal encephalopathy; or disability at childhood follow-up.In subgroup analyses, there were no clear patterns of differential effects for method of induction, parity, use of maternal antibiotic prophylaxis, or digital vaginal examination. Results of the sensitivity analyses based on trial quality were consistent with those of the main analysis, except for definite or probable early-onset neonatal sepsis where no clear difference was observed.
AUTHORS' CONCLUSIONS
There is low quality evidence to suggest that planned early birth (with induction methods such as oxytocin or prostaglandins) reduces the risk of maternal infectious morbidity compared with expectant management for PROM at 37 weeks' gestation or later, without an apparent increased risk of caesarean section. Evidence was mainly downgraded due to the majority of studies contributing data having some serious design limitations, and for most outcomes estimates were imprecise.Although the 23 included trials in this review involved a large number of women and babies, the quality of the trials and evidence was not high overall, and there was limited reporting for a number of important outcomes. Thus further evidence assessing the benefits or harms of planned early birth compared with expectant management, considering maternal, fetal, neonatal and longer-term childhood outcomes, and the use of health services, would be valuable. Any future trials should be adequately designed and powered to evaluate the effects on short- and long-term outcomes. Standardisation of outcomes and their definitions, including for the assessment of maternal and neonatal infection, would be beneficial.
Topics: Cesarean Section; Female; Fetal Membranes, Premature Rupture; Humans; Labor, Induced; Misoprostol; Obstetric Labor Complications; Oxytocics; Oxytocin; Pregnancy; Pregnancy Outcome; Prostaglandins; Randomized Controlled Trials as Topic; Term Birth; Time Factors; Watchful Waiting
PubMed: 28050900
DOI: 10.1002/14651858.CD005302.pub3 -
Placenta Feb 2018With the improvement of prenatal diagnoses of foetuses, the prevalence of stillbirth due to foetal anomaly after mid-gestation decreased, whereas that of stillbirth... (Review)
Review
With the improvement of prenatal diagnoses of foetuses, the prevalence of stillbirth due to foetal anomaly after mid-gestation decreased, whereas that of stillbirth associated with umbilical cord factors tended to increase. Prenatal detection of umbilical cord abnormalities and appropriate management during the antenatal period and delivery based on the ultrasound diagnosis will improve the perinatal morbidity and mortality rates. In the present review, the strategy to reduce the incidence of foetal compromise due to umbilical cord problems is discussed considering the current knowledge regarding the physiological and pathological aspects of umbilical cord abnormalities.
Topics: Delivery, Obstetric; Female; Humans; Pregnancy; Ultrasonography, Prenatal; Umbilical Cord
PubMed: 29405969
DOI: 10.1016/j.placenta.2017.12.003 -
Obstetrical & Gynecological Survey Aug 2020Umbilical cord prolapse is a rare occurrence and is a life-threatening emergency for the fetus. These events are unpredictable and unpreventable. Umbilical cord prolapse... (Review)
Review
IMPORTANCE
Umbilical cord prolapse is a rare occurrence and is a life-threatening emergency for the fetus. These events are unpredictable and unpreventable. Umbilical cord prolapse requires swift diagnosis and management for optimal outcome.
OBJECTIVE
The aim of this review is to describe the incidence, risk factor, pathophysiology, diagnosis, and management of this rare but potentially life-threatening event.
EVIDENCE ACQUISITION
A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched.
RESULTS
There were 200 articles identified, with 53 being the basis of review. Multiple risk factors for a umbilical cord prolapse have been suggested including fetal malpresentation or abnormal lie, prematurity, multifetal gestation, and polyhydramnios. The diagnosis is largely made by examination and found after rupture of membranes, and most often, examination is prompted by fetal heart rate decelerations. The management of umbilical cord prolapse is expedited delivery; however, there are rare specific scenarios in which immediate delivery is not possible and efforts should be made to relieve cord compression.
CONCLUSIONS
Rapid identification of an umbilical cord prolapse facilitates management and increases likelihood of an optimal outcome. The management is an expedited delivery with efforts to relieve cord compression until delivery can be achieved.
RELEVANCE
Umbilical cord prolapse is a rare but a life-threatening obstetrical emergency.
Topics: Female; Humans; Incidence; Pregnancy; Pregnancy Complications; Prolapse; Risk Factors; Umbilical Cord
PubMed: 32856717
DOI: 10.1097/OGX.0000000000000818