Search

Beat-to-beat variability has been suggested as a sensitive indication of fetal well-being. The suggestion originates from case reports of observed decrease in variability preceding clinical signs of fetal asphyxia and fetal death. Against this background a study was performed to evaluate possible changes in heart rate variability in relation to changes in fetal oxygenation. Chloralose-anesthetized sheep were used. Short-term hypoxia was produced without acidosis. The FECGs were recorded on magnetic tape and later analysed by scrutinizing each QRS complex prior to the trigger of a rate meter. The differential index (DI) described by Yeh and co-workers was chosen because it is easily computed and reflects the variability of coefficient of variation for two successive R-R intervals. In contrast to the generally held view of a progressive diminution of variability during the development of asphyxia, the variability was found to increase parallel with a decrease in fetal arterial PO2 determined on blood samples withdrawn at intervals and ranging between 26 and 10 mmHg. The correlation between variability and PO2 in the range below 8-10 mmHg is still to be determined. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Kro G, Yli B, Rasmussen S, Norèn H, Amer-Wåhlin I, Didrik Saugstad O, Stray-Pedersen B, Rosén K. A new tool for the validation of umbilical cord acid-base data. BJOG 2010;117:1544-1552. Objective To identify the distribution of carbon dioxide tension (pCO2) relative to pH in validated umbilical cord acid-base data. Design Observational study. Setting European hospital labour wards. Population Data for 36 432 term newborns were obtained from three sources: two trials of fetal monitoring with electrocardiography (ECG; the Swedish randomised controlled trial and the European Union Fetal ECG trial) and data from Mölndal Hospital. Methods From the total study population, cases with missing values or obvious typing errors were excluded. The remaining data were validated based on specified criteria. Percentiles of arterial pCO2 by pH were calculated using multilevel regression modelling. Main outcome measures Umbilical cord pH, pCO2 and base deficit. Results Acid-base values were considered invalid in one out of seven cases. Percentiles for arterial pCO2 corresponding to specified values of arterial pH were developed from the validated data of 26 690 cases. Conclusions Percentiles for arterial pCO2 for a specified arterial pH can be used as a tool to identify cases with erroneously low pCO2 values, and thus avoid an incorrect interpretation of the newborn's acid-base status. [ABSTRACT FROM AUTHOR]

Objective: To identify the distribution of carbon dioxide tension (pCO(2) ) relative to pH in validated umbilical cord acid-base data., Design: Observational study., Setting: European hospital labour wards., Population: Data for 36,432 term newborns were obtained from three sources: two trials of fetal monitoring with electrocardiography (ECG; the Swedish randomised controlled trial and the European Union Fetal ECG trial) and data from Mölndal Hospital., Methods: From the total study population, cases with missing values or obvious typing errors were excluded. The remaining data were validated based on specified criteria. Percentiles of arterial pCO(2) by pH were calculated using multilevel regression modelling., Main Outcome Measures: Umbilical cord pH, pCO(2) and base deficit., Results: Acid-base values were considered invalid in one out of seven cases. Percentiles for arterial pCO(2) corresponding to specified values of arterial pH were developed from the validated data of 26, 690 cases., Conclusions: Percentiles for arterial pCO(2) for a specified arterial pH can be used as a tool to identify cases with erroneously low pCO(2) values, and thus avoid an incorrect interpretation of the newborn's acid-base status., (© 2010 The Authors Journal compilation © RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology.)

Objective: To find whether low-to-high frequency (LF/HF) ratio of fetal heart rate (FHR) variability changes in relation to a significant ST-event during delivery, and if the change is predictive of metabolic acidosis of the newborn., Design: A case-control study., Setting: Data from a multicentre project., Subjects: Acidotic and control fetuses with abnormal cardiotocography together with a ST-event in fetal electrocardiogram (ECG)., Methods: We studied intrapartum FHR variability with spectral analysis from 34 fetuses with a significant ST-event in the fetal ECG. LF/HF ratio of FHR variability was measured within a period of 1 hour before and 1 hour after a significant ST-event. Sensitivity and specificity of the change in LF/HF ratio of FHR variability in prediction of metabolic acidosis (pH < or = 7.05 and base deficit value > 12.0 mmol/l) of the newborn were described by means of the receiver operating characteristic curve., Main Outcome Measures: Change in LF/HF ratio of FHR in relation to a significant ST-event., Results: We found that a relative change in LF/HF ratio greater than 30% in relation to a significant ST-event predicted cord arterial metabolic acidosis with a sensitivity of 89% (95% CI 68-100%) and specificity of 80% (95% CI 64-96%)., Conclusions: Relative changes in LF/HF ratio of FHR variability in relation to a significant ST-event are more pronounced in fetuses born with metabolic acidosis.

A two stage intervention study was carried out to establish the degree to which a newly developed, electrostatic air cleaning (EAC) system can improve indoor air quality (IAQ) by reducing the number of airborne fine particles. The IAQ and how employees in a city centre office (49 m2) perceived it, was monitored from May until November 1998. The number of fine particles, PM3 (0.3-3.0 microm); number of coarse particles, PM7 (3.0-7.0 microm); number of small positive and negative air ions; relative humidity and temperature were recorded in and out of doors. To assess the employees' perception of any changes in their work environment, a questionnaire was completed. Number of particles, relative humidity and temperature were also recorded in a nearby office, equipped with an identical air processor, where no interventions were made. The results from the first intervention (Stage 1), comparing number of airborne particles outdoors to indoors, gave a 19% reduction for PM3 and a 67% reduction for PM7 (P < 0.001). The reduction in PM3 was inconsistent and not statistically significant (P = 0.3). The reduction in PM7 from outdoors and the removal of PM7 created indoors was achieved by optimizing the existing air moving equipment. The results from the second intervention (Stage 2--with EAC units installed) comparing indoor to outdoor values, gave a further reduction in PM3 of 21% (P < 0.001) and a further 3% reduction for PM7 (P > 0.05). Therefore, at the end of Stage 2, the total reductions in particles from outdoors to indoors were 40% for PM3 and 70% for PM7 (P < 0.001). The Stage 2 results strongly suggest that electrostatic forces, created by the EAC unit(s) improved the removal of PM3, with no further significant improvement in the reduction of PM7. The questionnaire indicated an improvement in the IAQ, as perceived by the employees. The results suggest that the EAC system is effective in reducing PM3 and thereby improving IAQ in an urban office.

To conduct a controlled trial to test the ability of a newly developed electrostatic air cleaning technology (EAC) to improve Indoor Air Quality (IAQ) as defined by levels of airborne particles and to investigate the potential to reduce non-attendance rates due to illness among children in two Swedish day care centres. The EAC technology was shown to significantly reduce the indoor particulate load for very fine particles caused by outdoor air pollution by 78% and to reduce the number of fine particles produced indoors by 45%. To test the hypothesis, non-attendance was followed in two centres during 3 years. The EAC technology was in operation during year 2. Non-attendance rates among children in the larger day-care centre decreased by 55%, equalling those levels noted in family-based day care. It is speculated that the air cleaning effect may be due to alterations in electrostatic forces operating within the room enabling fine particulate matter to more easily become and stay airborne. The EAC technology is cost-efficient and might be a way forward to improve IAQ.

This report form part of the European Community Multi-Center Trial "Fetal ECG Analysis during Labor". Aim of this prospective trial was to identify changes in the fetal ECG waveform with cases of verified fetal hypoxia. In this paper we also report on the use of a newly developed automatic system for identification of ST waveform changes (ST Log). All ECG were recorded with the STAN recorder (Neoventa Medical AB, Gothenburg, Sweden). The ECG information was not displayed during labor in order not to influence the clinical management. This report includes data from 320 cases and include six cases of fetal intrapartum hypoxia. Twenty seven cases showed changes in ST waveform. All five cases with the most marked ST change (a rise in T/QRS of > 0.10 units and lasting more then 10 minutes) had signs of ongoing intrapartum hypoxia. Six out of six cases with evidence of intrapartum asphyxia, showed ST changes. On the basis of our multi-center trial it appears that the combined analysis of CTG and ST waveform changes provides an accurate way to identify adverse events during labor. The work is continuing with a new STAN recorder developed by Neoventa Medical in Göteborg and currently being tested in a Swedish randomized, controlled multi-center trial.

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.

Intrapartum fetal surveillance is still under debate, despite 30 years of clinical experience and numerous clinical trials. Waveform analysis of the fetal electrocardiogram has emerged not as an alternative to cardiotochography but as a support tool to allow more accurate interpretation of intrapartum events. During hypoxia, the healthy fetus is utilizing a series of defense mechanisms. Among these, the increase in sympathetic activity, with an increase in circulating adrenaline, activates the myocardium with an increase in workload (the product of cardiac output, myocardium contractility and blood pressure). If there is an imbalance between myocardial oxygen supply and consumption, determined by the workload, then anaerobic metabolism, with a breakdown of myocardial glycogen stores starts and high T waves emerges. ST depression with negative T waves has recently been observed during hypoxia experiments in experimentally growth retarded guinea pigs whilst their normally grown littermates showed ST elevation. These findings have stimulated the development of a dedicated fetal ECG monitor - STAN - incorporating both standard CTG and ST waveform analysis. The STAN concept has now been taken through the process of recognized validation including several prospective studies and a large randomized trial in Plymouth of 2400 high risk, term deliveries. The T/QRS ratio is only one parameter to be used - equally important is to identify the occurrence of ST depression with biphasic negative T waves and to interrelate the CTG and the ST waveform as outlined in the clinical guidelines (table I). This table contains the clinical experience gained over many years and has formed the basis for the first randomized controlled trial comparing ST waveform + CTG with CTG only. Obviously, when the T/QRS ratio is used as the only component of such a scheme, confusion emerges. The analysis should also contain cases with significant intrapartum hypoxia. Recent findings indicate that only when cord artery pH falls below 7.0 and when there is substantial metabolic acidemia is there a significant risk of intrapartum asphyxia. Metabolic acidemia should be estimated from base deficit in the extracellular fluid and the combination of cord artery and vein data should allow for a more accurate assessment of intrapartum events, including the assessment of the duration of hypoxia. The Plymouth trial has tested the hypothesis that the combination of ST wave form and CTG analysis compared with CTG analysis only would reduce operative interventions for fetal distress without placing the fetus at a risk.(ABSTRACT TRUNCATED AT 400 WORDS)

The PR and RR intervals and T wave amplitude of the fetal lamb electrocardiogram were studied during acute hypoxemia produced by reduction of the maternal placental blood flow. Five chronically-instrumented fetal lambs (124 to 143 days of gestation) were subjected to acute hypoxemia (observations = 13) through complete occlusion of the maternal aorta for 60 s. The fetuses responded to the occlusion with a fall in oxygen tension (2.18 +/- 0.12 kPa to 1.11 +/- 0.14 kPa, SEM, P < 0.001) and oxygen saturation (48 +/- 4% to 19 +/- 4%, P < 0.001). Modest changes of pH (7.37 +/- 0.05 to 7.35 +/- 0.01, p), carbon dioxide tension (5.79 +/- 0.15 kPa to 6.17 +/- 0.14 kPa, P < 0.001) and plasma lactate concentration (2.1 +/- 0.6 mmol/l to 2.2 +/- 0.6 mmol/l, ns) occurred. The PR interval showed a triphasic pattern following occlusion. Initially, and simultaneously with the onset of the RR interval lengthening, a prolongation of the PR interval occurred (P < 0.01) with a peak value after 41 +/- 3 s after occlusion. Following this transient prolongation, the PR interval shortened concurrently with a maximum lengthening of the RR interval (P < 0.001) 2 +/- 3 s after the end of the occlusion. A maximum PR shortening (P < 0.001) occurred 27 +/- 5 s after occlusion followed by a prolongation of the PR interval (P < 0.001) with a peak value 203 +/- 21 s after release of the occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)

After unilateral uterine artery ligation in midpregnancy twelve guinea-pig does were anesthetized at 63 days of gestation. The ST waveform of the fetal electrocardiogram and the short term heart rate variability were studied during normoxia and in response to acute hypoxia in growth retarded fetuses (n = 12, mean +/- SEM, 58.5 +/- 3.9 g) and their normal sized littermates (n = 12, 94.3 +/- 3.5 g). Hypoxia was induced by letting the doe breathe a low-oxygen gas mixture. After 10 min of hypoxia fetal blood was sampled by decapitation and blood gases, acid-base status and catecholamine concentrations were analyzed. The does responded to decrease in inspired oxygen concentration with changes in oxygen tension (13.8 +/- 0.8 to 4.3 +/- 0.2 kPa) and oxygen saturation (99.9 +/- 0.1% to 70.5 +/- 1.8%). Fetal blood gases and plasma catecholamine concentrations did not differ between the groups. In the growth retarded group standard bicarbonate was significantly lower compared to controls. The T/QRS ratio (the quotient between T wave height and QRS peak to peak amplitude) was normal and similar in both groups prior to the hypoxic period. In response to hypoxia T/QRS ratio increased in the normal sized group and T/QRS was correlated to carbon dioxide tension, oxygen saturation, pH, lactate, standard bicarbonate concentration, standard base excess and plasma noradrenaline concentration, respectively. The growth retarded fetuses presented a completely different pattern where 7 out of 12 fetuses showed a biphasic ST waveform during hypoxia with depression and downward sloping of the ST segment and negative T wave.(ABSTRACT TRUNCATED AT 250 WORDS)

The aim of this experimental ultrasound study on six fetal lambs was to evaluate how blood flow variables and vessel diameters of the descending aorta and the common carotid artery change during fetal asphyxia in the acute preparation. When acute asphyxia was induced by obstructing the maternal aortic blood flow all fetuses reacted with significant decrease in the aortic diameter and blood flow. In the common carotid artery vessel diameter and the blood flow increased significantly. The results support the theory of a brain sparing effect during fetal distress with significant changes of blood vessel diameters occurring in opposite directions in the aorta and the common carotid artery, thereby contributing to the centralisation of circulation.