JOURNAL OF EVIDENCE BASED MEDICINE AND HEALTHCARE

Table of Contents

2018 Month : September Volume : 5 Issue : 37 Page : 2665-2668

EVALUATION OF DIFFERENT MODES OF DIAGNOSIS OF FOETAL DISTRESS AND EARLY PERINATAL OUTCOME IN A TERTIARY CARE CENTRE, SOUTH KERALA

Kitty Elizabeth Mammen1, Heera Shenoy T2

1. Assistant Professor, Department of Obstetrics and Gynaecology, Travancore Medical College, Mylapore, Kollam, Kerala.
2. Assistant Professor, Department of Obstetrics and Gynaecology, Travancore Medical College, Mylapore, Kollam, Kerala.

Corresponding Author:
Dr. Kitty Elizabeth Mammen,
Assistant Professor,
Department of Obstetrics and Gynaecology,
Travancore Medical College,
Mylapore, Kollam, Kerala.
E-mail: drkittyemammen@yahoo.com
DOI: 10.18410/jebmh/2018/547

ABSTRACT
BACKGROUND
The most common indication of caesarean section has been foetal distress for the past few decades. Foetal distress indicates foetal hypoxia and acidosis during intrauterine life.
The objective of this study was to correlate the diagnosis of foetal distress by different modes with perinatal outcome.

MATERIALS AND METHODS
Retrospective analysis of case records was carried out between January 2014 to March 2016 in the Department of Obstetrics and Gynaecology and Neonatal Intensive Care Unit, Travancore Medical College Hospital, a tertiary health care facility in South Kerala, of 112 antenatal cases who were diagnosed to have Foetal distress and undergone Caesarean section.

RESULTS
In our study, 88 (78.6%) were nulliparous and 64 (57.1%) were between the age group 18-25 years. The mode of diagnosis of foetal distress was 74.1% with one parameter and the method most commonly employed to diagnose was the external cardiotocography (45 cases). Predictivity value of the parameters used to identify the foetuses at jeopardy was found to be more sensitive when used in combination. 19 babies (17.0%) had a 5-minute Apgar score <7 and required immediate resuscitation. 5 Babies had a 1-minute Apgar score <4, while there were 3 cases of severe birth asphyxia (Apgar score <4 at 5 minutes) who died. The neonatal outcome was poorer in cases with associated complicating factors.

CONCLUSION
The clinical diagnosis of foetal distress is accurate in about a third of the cases and it has led to an unnecessary caesarean section in the remaining two thirds and do not correlate well with early perinatal outcome. The correlation was however better in cases with two parameters used together, mainly meconium stained liquor and abnormal foetal heart rate pattern. On the contrary, lack of adverse outcome could reflect that our unit makes decisions at a time before clinically significant foetal compromise occurs. The use of other modalities like foetal ECG as an adjunct to cardiotocography may help in improving the predictive value of foetal monitoring. Antepartum and Intrapartum risk factors have shown to significantly increase the risk of emergency caesarean section due to non-reassuring foetal status.

KEYWORDS
Foetal Distress, Cardiotocography, Caesarean Section, Perinatal Outcome, APGAR Score.

How to cite this article

Mammen KE, Heera Shenoy T. Evaluation of different modes of diagnosis of foetal distress and early perinatal outcome in a tertiary care centre, South Kerala. J. Evid. Based Med. Healthc. 2018; 5(37), 2665-2668. DOI: 10.18410/jebmh/2018/547

BACKGROUND

Foetal distress may be defined as a physiological state in which there is a metabolic acidosis secondary to hypoxia. It is brought about by factors that causes umbilical cord compression or impaired gaseous exchange between placenta and maternal circulation or foetal sepsis, which could be alone or in combination.

Clinically, usually it is characterized by Abnormal Foetal heart rate and rhythm or passage of meconium into the amniotic fluid or decreased foetal movements. The most common indicator of intrapartum caesarean section is Foetal distress for the past few decades.1,2 The diagnosis of Foetal distress made on the basis of these modes has led to a high rate of caesarean deliveries without the foetuses being adversely affected. Hence there is a need to assess the efficacy of different modes of diagnosis of foetal distress especially electronic foetal monitoring. Keeping this issue into consideration, this study was undertaken to analyse the correlation between caesarean section for foetal distress and early perinatal outcome.

 

Aims and Objectives

  1. The primary outcome measures assessed were the different modes of diagnosis of foetal distress such as Abnormal foetal heart rate pattern in cardiotocography, Meconium stained liquor, Decreased foetal movements perception and Abnormal Doppler indices in USG. And the best mode of diagnosis among these, in predicting early perinatal outcome.
  2. The secondary outcome measures evaluated the associated obstetric risk factors contributing to foetal distress.

 

MATERIALS AND METHODS

We conducted a retrospective case review of 112 women who underwent caesarean section for foetal distress in the department of obstetrics and gynaecology and neonatal intensive care unit in a Tertiary care centre. The study was approved by the institutional ethics committee. As it was a retrospective study, consent from the participants was waived, but confidentiality was maintained. Details of antenatal cases were collected from the medical records department and also from the maternal register maintained in labour room and neonatal register maintained in neonatal intensive care unit and was entered in a pre-structured Performa. Data was then entered in MS excel and analysed by SPSS version 20. Women who underwent vaginal delivery, or instrumental delivery and Twins and Triplet pregnancies were excluded from the study.

 

RESULTS

 

Variables

n = 112

Percentage

Age

18-25

64

57.1

26-30

38

33.9

>30

10

8.9

Total

112

100

Social Status

Rural

64

57.1

Urban

48

42.9

Total

112

100

Parity

Primigravida

88

78.6

Gravida 2

20

17.9

Multigravida

4

3.6

Total

112

100

Period of Gestation

26-30 wks.

29

25.9

31-35 wks.

33

29.4

36-40 wks.

50

44.7

Total

112

100

Table 1. Sociodemographic Profile of Patient

Figure 1. Obstetric Risk Factors

Causing Foetal Distress

Comorbidities

n = 112

Percentage

No Comorbidities

16

14.3

Hypertensive Disease

26

23.2

IUGR

20

17.9

Oligohydramnios

18

16.0

GDM/Overt DM

13

11.6

APH-AP/PP

3

2.7

Anaemia

5

4.5

Uterine Anomaly

1

0.9

Thrombophilia

1

0.9

PROM

9

8.0

Total

112

100

Table 2. Comorbidities

 

 

Variables

(n=112)

Percentage

Apgar Score at 1 Minute

0-4

5

4.5

4-7

24

21.4

>7

83

74.1

Total

112

100

Apgar Score at 5 Minutes

0-4

3

2.7

4-7

16

14.3

>7

93

83.0

Total

112

100

Birth Weight

<1 Kg.

4

3.6

1-2 Kg

17

15.2

2-3 Kg.

54

48.2

3-4 Kg.

37

33.0

Total

112

100

Admission In NICU

Yes

112

100.0

No

0

0

Total

112

100

Ventilator Use

Yes

8

7.1

No

104

92.9

Total

112

100

CPAP Use

Yes

16

14.3

No

96

85.7

Total

112

100

Neonatal Deaths

Yes

3

2.7

No

109

97.3

Total

112

100

Table 4. Perinatal Outcome of the Study Group

 

DISCUSSION

Continuous electronic foetal monitoring is probably the most common form of intrapartum foetal assessment used currently.3,4 It is widely accepted method of foetal monitoring during labour. When electronic foetal monitoring by cardiotocography was introduced 30 years ago, the aim was to identify foetuses affected by hypoxia better. It is presumed to be superior method for foetal hypoxia as it detects the subtle changes in foetal heart rate which can be missed on intermittent auscultation by stethoscope. However, the main risk of wide spread application of continuous monitoring has been the observed risk of caesarean delivery noted in retrospective and prospective studies.5,6 Various studies7,8,9 implicate that abnormal foetal heart rate in cardiotocography is inconsistent, is at times inaccurate and may fail to predict early perinatal outcome.

Impey et al10 found 32 % traces as abnormal. In our study 54.2% cases had abnormal foetal heart rate. Despite significant number of neonatal admissions with non-reassuring foetal heart rate, there was no significant rise in perinatal mortality (2.7%). The majority (74.1%) of the babies who were delivered with Apgar score at 1 minute of more than 7 despite the diagnosis of foetal distress in this study is higher. This implies that the clinical diagnosis of foetal distress, using only the foetal heart rate measurement, as reported in our study, is causing a lot of unnecessary caesarean sections.

But in this Medico legal era ‘play safe’ attitude was also adopted by us and resulted in high incidence of caesarean sections for non-reassuring foetal heart rate. To improve this situation, the concept of detecting foetal acidosis using foetal scalp blood sampling appeared attractive, but practical difficulties in carrying it out have restricted its use. These limitations of foetal heart monitoring and foetal blood sampling have led to the introduction of electrocardiogram (ECG) recently. Various randomized controlled trials11,12,13,14 showed that addition of ST analysis to conventional cardiotocography improved the specificity of intrapartum monitoring and thereby reducing the rate of operative deliveries for foetal distress. Vayssiere et al15 in 2007 reported that, in a population with abnormal foetal heart rate, ST segment analysis sensitivity is moderate (almost 40 %) for predicting PH – 7.15 and better (almost 60%) for severe acidosis, PH <7.05. Therefore, we strongly feel that Foetal ECG system needs to be introduced in addition to conventional cardiotocography wherever possible to reduce the rate of unnecessary caesarean sections.

Similarly, lack of significant association between fresh meconium stained liquor and foetal distress in this study is supported by the previous report by Wong and his co-authors.16,17,18 However, this is contrary to the report from the case-control study by Desai et al in which there was a strong association between meconium stained liquor and foetal distress. In view of this controversy, the diagnosis of foetal distress using history of passage of meconium is not yet conclusive.

The present study also showed that in 29 cases (25.9%), foetal distress was detected using 2 parameters, among which meconium stained liquor along with foetal heart rate abnormality was detected in 18 cases. The results obtained in this study agreed with those who consider intrapartum passage of meconium and abnormal foetal heart rate pattern, to signify clinical foetal distress that carries bad prognostic outcome. These two parameters should still be used to indicate foetal distress which requires immediate institution of supportive therapy and immediate delivery. Hence diagnosis of foetal distress should be made with great care and should not be based on a single parameter thus eliminating the risk of overdoing caesarean for jeopardized foetus.

A number of Obstetrical and Medical problems during pregnancy may subject the foetus to chronic distress, unless monitored carefully, these cases are more likely to develop hypoxia during labour, as labour itself is considered a process of repetitive hypoxic events. Very strict intrapartum foetal monitoring of such cases is required to decrease the risk of further foetal compromise. Chaudhari et al19 reported majority of cases belonged to PIH (12%), and in our study also majority (23.2%) belonged to PIH, followed by IUGR (17.9%) and Oligohydramnios (16.0%). These antepartum and intrapartum risk factors have been associated with incidence of meconium stained liquor, foetal distress, low Apgar score, admission to NICU, birth asphyxia and caesarean section for foetal distress.

In the present study, after birth, at 1 minute, the Apgar score was <7 in 29 (25.9%) cases which improved at 5 minutes and at 5 minutes the resulting Apgar score of <7 was found only in 19 (17%). Overall 112 neonates were admitted to NICU for foetal distress (Respiratory distress, Neonatal depression, Meconium aspiration, Observation), out of which 8(7.1%) required Ventilatory support and 16(14.3%) were on CPAP.

 

CONCLUSION

The clinical diagnosis of foetal distress is accurate in about a third of the cases. However, it has led to unnecessary caesarean sections in the remaining two thirds of the parturients and does not correlate well with early perinatal outcome. The correlation was however better in cases with two parameters used together to indicate foetal distress, mainly meconium stained liquor and abnormal foetal heart rate pattern which requires immediate institution of supportive therapy and immediate delivery. On the contrary, lack of adverse outcome could reflect that our unit makes decisions at a time before clinically significant foetal compromise occurs. The use of other modalities like foetal ECG as an adjunct to cardiotocography may help in improving the predictive value of foetal monitoring.

Antepartum and intrapartum risk factors have shown to significantly increase the risk of emergency caesarean section due to non-reassuring foetal status. Early detection of the above risk factors is required for timely institution of appropriate intervention in order to result in improved maternal and neonatal outcome.

 

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