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SecretsofPretermFetalHeartRateTracing:ClinicalRecommendationsforInterpretationandManagement

RebeccaCypher,MSN,PNNPChiefNursingOfficer,Perigen

Disclosure

IntheinterestoffulldisclosureIwishtocommunicatethatIhaveaprofessionalrelationshipwith

PeriGen:ChiefNursingOfficerProfessionalEducationCenter:Educator

Co-author:Mosby’sPocketGuide:“FetalMonitoring:AMultidisciplinaryApproach” monetaryroyalties

MonitoringthePretermFetusEFMimplementedtoestablishfetalwellbeing◦ Physiologicdifferencesdependentonfetaldevelopmentstage◦ Responseand/ortolerancetooxygenationpathwaydisruptions◦ Differfromthoseoftermfetus

Limitedinterpretationresearch(<26weeks)◦ PresumedmaturationofANS◦Developmentoffetalcardio-regulatorymechanismat~30weeks◦ Fetalbehaviorandmaternalexposureliteratureevolving

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ViabilityNecessitatesFHRMonitoring…..Lowerlimitsforviability◦ SophisticatedNICUcareleadingtoimprovedsurvivalrates

PretermFMoftenhampersabilitytocollectuninterrupteddata◦ Inconsistenthighqualitytracings

CurrentequipmentunabletopreciselydetermineFHRtiming◦ Employsheartrateaveragingtechniques◦ AntepartumFSEnotpractical

20 –21 +6 22 -22+6 23–23 +6 24 – 24+6 25– 25+6

Assess for NRP N/R Consider Consider Yes YesSteroids N/R N/R Consider Yes Yes

Tocolysis for steroids N/R N/R Consider Yes Yes

Neuroprotection N/R N/R Consider Yes Yes

Antibiotics for PPROM latency

Consider Consider Consider Yes Yes

Intrapartum antibiotics for Group B Strep

N/R N/R Consider Yes Yes

Csection for fetal reasons N/R N/R Consider Consider Yes

Periviable birth: Obstetric Care Consensus No.4. ACOG. Obstet Gyneol 2016; 127:e157-69

“Continuous electronicfetalmonitoringisnotseparatelyconsideredasaninterventionbecauseinmostcasesitsusewillbelinkedtoplansregardingcesareandeliveryforfetalindications.Evenifcesareandeliveryforfetalindicationsisnotplannedifarrangementshavebeenmadeforresuscitationofapotentiallyviablelivebornneonate,electronicfetalmonitoringmaybeconsideredifitisbelievedthatintrauterineresuscitationwillaffectthenewborn’soutcome”

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HowShouldWeMonitor?ContinuousEFM?◦ Someconsiderthistobestandardinpatientswhoareexpectantlymanaged◦Nodatatosupportthis

Liability?◦ Potentialifwrittenordernotcarriedout

TheProblemwithContinuousEFMRetrospectivecohortstudy

Purpose:EvaluatethecompletenessoftherecordduringcontinuousEFM◦ NopreviousdatatosupportcontinuousEFMandliabilityissueifnotcarriedout

PPROMpatientsbeingmanagedexpectantly◦ 47patients◦ 24-34weeksgestation◦ Singletons

Exclusioncriteria◦ Labor,chorioamnionitisorFHRabnormalities

LiY,Gonik B.Continuousfetalheartratemonitoringinpatientswithpretermprematureruptureofmembranesundergoingexpectantmanagement.TheJournalofMaternal-Fetal&NeonatalMedicine.2009Jan1;22(7):589-92.

ResultsDurationofmonitoring◦ 321– 2272minutes(mean970minutes)

28.3%oftracingsdidnotshowlegiblerecordings◦ 85%ofuninterpretabledatalasted<10minutes◦ 15%ofuninterpretabledatalasted10-80minutes

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ResultsSignificantportionofthetracingwasnotrecordedasordered◦ 28%◦Nodifferenceinfirst/secondhalfofshift◦ Nodifferenceindayshiftversusnightshift

LowerEGAandincreasedBMIcorrelatedtoproportionofabsenttracing◦ Average294/7weeks(242/7weeks)◦ AverageBMI=31.4(58.1)

Conclusion

“Weproposethatuntilsuchtimethatevidencebasedmedicinejustifiestheuseofcontinuousexternalfetalheartratemonitoring,alternativeapproachesshouldbeinvestigatedandapplied.”

Physiology:ExtrinsicandIntrinsicFactorsEXTRINSIC:“OUTSIDE”INFLUENCE

Maternalanduteroplacentalcharacteristicsaffectbloodflow◦Maternalimpact◦Uteroplacentalimpact◦ Umbilicalcirculation◦ Amnioticfluidfeatures

INTRINSIC:“INSIDE”INFLUENCE

MaintainsfetalhomeostasisFetalcirculation◦ Autonomicnervoussystem◦ Parasympathetic◦ Vagus Nerve/MedullaOblongata◦ Sympathetic◦Nervefibersofmyocardium

◦Baroreceptors/Chemoreceptors◦ Hormonalresponses

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PhysiologicExtrinsicInfluenceMaternalinfluences◦ Positioning:compressiononinferiorvenacava◦ ⬇ Venousreturn◦ ⬇ Bloodflowtouterus

◦ Contractions:⬇ uterinebloodflow◦ CompensatoryhypotensionPlacentalinfluences◦ Amountofsurfaceareaformaternal-fetal02exchange◦ Composition:damagedcotyledons,smoking,vesselconstriction

PhysiologicExtrinsicInfluenceUmbilicalCord◦ Structuraldefects◦ Knots,2vesselcord

◦ Mechanicalfunction◦ Partialorcompletecompression

AmnioticFluid◦ ⬇ Placentalfunctionleadsto⬇ fetalkidneyperfusion◦ Shuntsbloodawayfromkidneys

Cignini, P., Laganà, A.S., Retto, A. and Vitale, S.G., 2016. Knotting on heaven’s door: 3D color Doppler ultrasound imaging of a true cord knot. Archives of Gynecology and Obstetrics, pp.1-2.

PhysiologicIntrinsicInfluenceIntrinsicinfluences◦Designedtointeractandensureadequateoxygenationtovitalorgans

AutonomicNervousSystem:◦ ParasympatheticandSympathetic◦ Respondstofetaloxygenationstatusandfetalbloodpressure

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PhysiologicIntrinsicInfluence◦ParasympatheticNervousSystem:“Pokey”◦ InfluencesFHRvariability◦ PNSactivity⬆withgestationalage◦ Tone⬆andFHRbaseline⬇withadvancinggestationalage◦ SympatheticNervousSystem:“Speedy”◦ StimulationincreasesFHRandmaybepromotedbyhypoxemia◦ FHRBL⬇whenblocked◦ SNSactivity⬇withadvancinggestationalage

PhysiologicIntrinsicInfluenceChemoreceptors◦RespondtochangesinfetalO2,CO2andpHlevels◦MildincreasesinCO2ordecreasesin02resultinfetalBP/FHRchanges◦Severeenoughwillcausebradycardia

Baroreceptors◦StretchreceptorsrespondtochangesinfetalBP◦Locatedinaorticarchandcarotidarteries◦IncreasesinBPdecreaseFHRresultinginBPdecrease◦DecreasesinBPstimulatesanincreaseinFHR

PhysiologicalInfluencesHormonal(epinephrine,norepinephrine,vasopressin)◦ RespondtostressorswhichimpactFHR◦ Stresscausedby⬇ PO2&pH(hypoxemiaand/orhypovolemia)◦ Epinephrine/norepinephrine arereleased◦ FHR⬆ andbloodisshuntedtobrain/heart

◦ Vasopressin isreleased◦ Impactsfetalkidneys intravascularvolumeandperipheralresistance◦ ⬆ fetalBP

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OxygenationPathwayPathway Etiology TreatmentLungs Respiratory

depressionOxygen

Heart Regionalanesthesia TreatwithRx,fluids

Vasculature Hypovolemia Fluids,positionchange

Uterus Tachysystole Decreasestimulants

Placenta Abruption DeliveryUmbilicalCord Compression Amnioinfusion

Miller,L.A.,Miller,D.A.andCypher,R.L.,2016.Mosby'spocketguidetofetalmonitoring:amultidisciplinaryapproach.ElsevierHealthSciences

FetalHeartRateBaselineMeanFHRroundedtoincrementsof5bpmduringa10minutewindowExcludes◦ Periodicorepisodicchanges◦MarkedFHRvariability(>25bpm)Minimumof2minutesofidentifiablebaseline◦ Canbedeterminedbetweencontractions◦DoesnotneedtocontiguousNormal110-160bpm

IsthereaninverserelationshipbetweenEGAandFHRbaseline?

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DevelopmentofFHRPatternsDuringNormalPregnancy

43lowriskwomenin2nd/3rd trimesterSynchronizedrecordingsin4weekintervals◦ EFMfor90-100minutes◦ 9amand6pm◦Ultrasound◦ Fetaleye/mouthingmovement,limb/bodymovement,fetalbreathing

Pillai, M., & James, D. (1990). The development of fetal heart rate patterns during normal pregnancy. Obstetrics & Gynecology, 76(5), 812-816.

Results:BaselineRateNegativecorrelationwithgestationalageMeanfallinbaseline:16weeksto“term”◦ 24bpm◦ 1bpmperweekofgestationalage

Rateoffallgreatestbetween16-20weeks◦ Lessmarkedinlasttrimester◦ Establishmentofrest/activitycycles

DevelopmentofFHRPatternsDuringNormalPregnancyNulliparouswomenat13weeks(7)and20-22weeks(10)Real-timeultrasound◦Observationsat0800,1300,and2200◦60minutes=13weeks◦120minutes=20-22weeks◦24hoursofFHR20-22weeks

De Vries JI, Visser GH, Mulder EJ, Prechtl HF. Diurnal and other variations in fetal movement and heart rate patterns at 20–22 weeks. Early human development. 1987 Nov 1;15(6):333-48.

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Results:DiurnalVariationsDIURNAL

13weeks◦ Novariations

20-22weeks◦ “Significant”changes◦ Movementandbreathing◦ Highestinevening◦ Breathingrelatedtomaternalmeals◦ Lowestafter3rd meal

Results:HeartRatePatterns(20-22weeks)

Decels morefrequentthanaccelsDecelerations◦25-40ms (10-15bpm)◦162/163tracings◦Exceeding40ms◦ 147/163tracing

Accelerations◦25-40ms◦115/163tracings◦Exceeding40ms◦47/163tracings

Variability

FluctuationsinFHRBLthatareirregularinamplitudeandfrequency

Quantifiedas amplitudeofpeakandtrough◦ Inbpm

Excludes◦ Periodicorepisodicchanges

Determinedin10-minutewindow

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FetalHeartRateVariability92singletonsTwosubgroups◦ 24+1to32+0weeks◦ 32+1to41+6weeks

Magnetocardiogramsessions◦MeasurementofmagneticfieldsproducedbyFHRelectricalactivity

Schneider,U.,etal."Fetalheartratevariabilityrevealsdifferentialdynamicsintheintrauterinedevelopmentofthesympatheticandparasympatheticbranchesoftheautonomicnervoussystem."Physiologicalmeasurement30.2(2009):215.

ResultsInverserelationshipwithgestationalageFHRPatternI◦FHRwith“smalloscillationbandwidth”<5bpm◦24+1to32+0gestationsFHRPatternII◦FHRwithoscillations>5bpm◦>32+1to41+6gestations

AccelerationVisuallyapparentabruptincreaseinFHRPeak≥15bpmfrombaselineandlasting≥15secondsPretermgestation (32weeks)◦Peak≥10bpmfrombaselineandlasting≥10seconds

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Acceleration65lowriskwomenbetween64minutetracingsmadebetween0900-1300hours◦15patients:5-10tracingsbetween18-41weeks◦50patients:1-4tracingsbetween18-41weeksMovementrecordedbynurseandpatient◦Handheldsensorwithresponseintervalsof5seconds

Visser GH, Dawes GS, Redman CW. Numerical analysis of the normal human antenatal fetal heart rate. BJOG: An International Journal of Obstetrics & Gynaecology. 1981 Aug 1;88(8):792-802.

Results:IncidenceofAccels,FMandEGAWeeks

GestationPatients Accelsover40ms

10-15bpmMean#ofAccels

Meannumberofmovements/accels

18-22 8 0 023-26 5 2(40%) 0.8 6227-28 13 9(30%) 2.9 4329-30 15 10(66%) 3.9 3831-32 21 19(95%) 5.4 4033-34 28 25(89%) 8.7 3935-36 38 38(100%) 14.5 4337-38 43 43(100%) 14.9 6139-40 22 21(95%) 16.0 5041 3 3(100%) 25.7 57

DecelerationsMostfrequentbetween20-30weeksAbsenceofuterinecontractionsFetalmovementReflectionofdevelopingcardioregulatorymechanismsandCNSmaturity

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AccelerationsandDecelerationsLowriskpatients◦ 20-22weeks(10patients)◦ 28-30weeks(10patients)

Fetalmonitoring◦Daysessionslasting1-2hoursinquietroom◦ 1-2hoursafterameal◦ Semi-fowlerswithlateraltilt

Sorokin, Y., et al. "The association between fetal heart rate patterns and fetal movements in pregnancies between 20 and 30 weeks' gestation." Am J Obstet Gynecol143.3 (1982): 243-249.

FHRChanges

EGA Minutes monitored

Accels Decels Accels/Decels

20-22 weeks 964 1.3 % 97.1% 1.6%

28-30 weeks 1012 35.8% 33.9% 30.3%

FHRChangeswithFetalMovementEGA Accels Decels Accels/Decels

20-22 weeks 62.5% 62.8% 40%

28-30 weeks 94.6% 60.3% 90.6%

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FHRPatternsat20to24weeksgestationStudyaim:◦ DescribeearlypatternsofFHRrecordedbytransabdominalfetalelectrocardiogram

281recordings◦ Successrateoftherecordingswas95.4

Results◦ 20–24-weekfetusdemonstratesFHRpatternswithmoreaccelerationsanddecelerations◦Higherbaselinevariability

Hofmeyr,F.,etal."Fetalheartratepatternsat20to24weeksgestationasrecordedbyfetalelectrocardiography."TheJournalofMaternal-Fetal&NeonatalMedicine 27.7(2014):714-718.

APFT

24-28weeks:50%ofNSTsarenotreactive(Bishop,1981)

28-32weeks:15%ofNSTsarenotreactive(Macones,2008;Lavin,1984;Druzin,1985)

Variabledecelerationsarefoundin~50%ofNSTs(Meis,1986)

WhatisNormal?StudyAim◦ Establishnormalpatterndevelopmentandrelationshiptoactivityandbehavior

43lowrisksingletonpregnanciesin2nd and3rd trimester◦ 22primips and21multips

Fetalmonitoringin4weekintervalsandrealtimeultrasound◦ Biophysicalcharacteristics

Recordingsdonebetween9amand6pmfor90-100minutes

Definitions◦ Accelerations:15x15◦ Decelerations:⬇ FHRatleast15bpmbelowbaselinelasting10seconds

◦ “Averagevariability”

Pillai M,James D:Thedevelopmentoffetalheartratepatternsduringnormalpregnancy.Obstet Gynecol 76:812,1990b

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FetusesWithAtLeastOne15x15AccelerationResults◦ Totalnumberofrecordings:267◦ Totalhoursofrecording:401.1

EarliestEGAforaccel withFM◦ 17weeks

Conclusion◦ Before30weeks10x10ismoreappropriate

Pillai M,James D:Thedevelopmentoffetalheartratepatternsduringnormalpregnancy.Obstet Gynecol 76:812,1990b

10 x 10 Accel

• CousinsLMetal.Nonstresstestingat</=32.0weeks’gestation:arandomizedtrialcomparingdifferentassessmentcriteria.AmJObstet Gynecol 2012;207:311.

• Glantz JC,Bertoia N.Pretermnonstress testing:10-beatcomparedwith15-beatcriteria.Obstet Gynecol 2011;118:87–93.

RCTcomparingcriteriaObjective◦ Compareoutcomesat<32weeksusing10x10and15x15criteria

143singletonhighriskpatients◦NST20minutes◦Nonreactive:VASfollowedby20moreminutes;notreactiveBPP

Conclusion◦ TimetoachievereactiveNST4minutesshorterin10x10group◦Noadverseoutcomesineithergroup

CousinsLMetal.Nonstresstestingat</=32.0weeks’gestation:arandomizedtrialcomparingdifferentassessmentcriteria.AmJObstet Gynecol 2012;207:311.

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“Considering the low incidence of adverse events after outpatient NST at 32 weeks’ gestation, the authors suggest that it would be difficult to test this question in a prospective randomized study with anything other than a very large multicenter trial. A power analysis (alpha, .05; beta, 80%) indicated a total sample size of 8856 would be needed to find a difference in 5-minute Apgar scores of 7 or a total sample size of 7528 to detect a difference in neonatal intensive care unit admissions.”

PretermNSTObjective◦ Evaluateperinataloutcome<32weeksbetween10x10and15x15

RetrospectivereviewSingletonpregnanciesbetween23-32weekanddeliveredbefore34weeks751NSTsreviewedon488women(mostlyinpatient)ResultsAfteradjustmentforEGA/BW,therewasNOassociationbetweenNSTcriterionandoutcomesexceptbetweennonreactivity andperinataldeath

Glantz JC,Bertoia N.Pretermnonstress testing:10-beatcomparedwith15-beatcriteria.Obstet Gynecol 2011;118:87–93

Iftheperinataldeathrateinthe10x10groupisestimatedtobe10%,anadequatelypoweredstudywouldrequire2000patientsineacharmtodemonstratea25%differenceinperinataldeath)Iftheperinataldeathinthe10x10groupisestimatedtobe1%,morethan21,000patientswouldbeneededineachgrouptodemonstratea25%differenceD.A.Miller,MD

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FHMandMedicationsinthePretermFetusMagnesiumsulfate◦ Decreasesvariability◦ Decreasesaccelerationamplitude

Corticosteroids◦ Decreasesvariability◦ Decreasesbiophysicalcharacteristics

Progesterone◦Nonereported

Betasympathomimetics◦ Tachycardia◦Motherandfetus

Prostaglandininhibitors◦ Nonereported◦ Constrictionofductusarteriosis

Calciumchannelblockers◦ Nonereported

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MagnesiumSulfate

Neuroprotectionpriortopretermbirth◦ Neuroprotectiveintent◦ Reducevascularinstability,lessenhypoxicdamage,andprotectagainstcytokineoraminoaciddamage

◦ Pre-deliverymagnesium(<32weeks)◦ Reducesseverityandriskofcerebralpalsy

Study Dose Duration

Crowther 4gramloadfollowed

by1gram/hour

Upto24hours

Rouse 6gramloadfollowed

by2grams/hr

Upto12hours;treatmentresumeswhendeliveryis

imminent

EffectofMagnesiumSulfateonFHRParameters:ASystematicReviewStudyObjective◦ Examinepotentialeffectsonante/intrapartumEFM

Systematicreview◦ 18RCTs,observationalstudies,casestudies◦ FHRBL,variabilityandacceleration-decelerationpatterns

Nensi, Alysha, et al. "Effect of magnesium sulfate on fetal heart rate parameters: a systematic review." Journal of Obstetrics and Gynaecology Canada 36.12 (2014): 1055-1064.

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ResultsStatisticallysignificantdecreaseinFHR◦Upto15bpm◦Allremainedinnormalrange110-160bpm

DecreaseinFHRvariabilityDecreaseinaccelerationnumberand/orfrequency◦ Nomorethan5- 10bpm

EffectsofMagnesiumSulfateOnCerebralBloodFlow

38patients◦ Singletons/twins(24-31weeksEGA)◦ 18MagnesiumSulfate(Rouseprotocol)◦ 10Placebo

Middlecerebralarterymeasurements◦ Beforemedicationadministration◦ 1,2,3,and4hourintervals

Twickler, Diane M., et al. "Effects of magnesium sulfate on preterm fetal cerebral blood flow using Doppler analysis: a randomized controlled trial." Obstetrics & Gynecology115.1 (2010): 21-25.

ResultsDecreaseinFHRbaseline(dopplerwaveforms)◦ 8-10bpm

Nosignificantdifference◦ Peaksystolicvelocity◦ Vesseldiameter◦ Volumeflow

Conclusion◦Nosignificanteffectsonfetalcerebralbloodflow

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TheEffectofMagnesiumSulfateOnFHRParameters

34patients>30weeksEGA(nonlaboring)800kcalmealRandomized◦MagnesiumSulfate(6gramloadand2gram/hr)◦ Placebo

Onehourmonitoringsessions◦ Baseline,1hourand3hoursofinfusion

Hallak,Mordechai,etal."Theeffectofmagnesiumsulfateonfetalheartrateparameters:arandomized,placebo-controlledtrial." AJOG 181.5(1999):1122-1127.

ResultsFHR Group 0hour 1hour 3hour

Baseline Placebo 134.4± 6.3 134.4±7.1 134.6±7.1

MagSulfate 136.6± 6.4 135.1± 6.6 132.3± 7.6

Variability Placebo 2.75± 0.33 2.81± 0.30 2.71± 0.52

MagSulfate 2.82± 0.29 2.84± 0.28 2.67± 0.36

Accels Placebo 10.2± 8.3 10.3± 8.2 10.4± 6.9

MagSulfate 11.1± 6.2 10.3± 8.2 7.4± 4.1

CorticosteroidsforFetalMaturationSingle course ◦Risk of PTD within 7 days◦ 23/24 to 34 weeks◦Later EGA’s

Betamethasone◦ 12 mg q24h x2

Dexamethasone◦ 6 mg q12 x 4 doses

Treatment <24h has some benefitNo additional benefit to “accelerated dosing” (q week)◦Giving doses at shorter intervals

Rescue dose◦ Initial treatment >2 weeks prior◦Likely to deliver w/in 1 week & <34 wks◦Single course

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BetamethasoneAdministration

31womenwhohadreceived2dosesforPTL◦Gestationalage:26-32weeks

DailyEFMfor5successivedays(0-4)◦ 30-60minutes

Ultrasound(Days0,2and4)◦ Fetalbodymovement,breathing,eyemovements

Derks, Jan B., Eduard JH Mulder, and Gerard HA Visser. "The effects of maternal betamethasone administration on the fetus." BJOG: An International Journal of

Obstetrics & Gynaecology 102.1 (1995): 40-46.

ResultsFHRvariabilitybelownormalrangeforEGA◦ 1/3cases

Bodymovement◦ Reducedby50%onDay2

Breathingmovement◦ AbsentonDay2

Eyemovements:unchanged

Day4:returntonormalstate

Considerabledecreaseinbiophysicalcharacteristics◦ Excepteyemovement

Transientreductioninmovementsandactivity

?Glucocorticoidreceptormediatedprocess

CorticosteroidsandBPP/DopplerIndices

35singletonpregnancies◦28-34weeks◦BetamethasoneBiophysicalprofileanddopplers◦Pre-steroid◦24,48,72,96and120hoursafter1stdose

Deren, Özgür, et al. "The effect of steroids on the biophysical profile and Doppler indices of umbilical and middle cerebral arteries in healthy preterm fetuses." European Journal of Obstetrics & Gynecology and Reproductive Biology 99.1 (2001): 72-76.

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ResultsReducedbiophysicalcharacteristics◦Movement,fetalbreathing&reactivity

Amnioticfluidindexunchanged◦Notvolume

FetaltoneunchangedUmbilicalartery&middlecerebralartery

SpecificBiophysicalScoresPresteroid:1024hours:848hours:6(maximumpeakofsteroid)72hours:896hours:10120hours:10

PretermFetalHeartRateAssessmentsRate

Variability

PeriodicandEpisodicChanges

UterineActivity

PatternEvolution

AssociatedClinicalFindings

Urgency

Communication

UseofHealthInformationTechnologyAdapted from Fox, Kilpatrick, King & Parer, (2000)

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“Theremustbeabalancebetweenknowledge,expertskills,clinicalintuitionandthebenefitsoftechnology.Theperceptionthattechnologywilltakeoverclinicalresponsibilities,suchasFHRinterpretation,leavingalldatatobeinterpreted,documentedandmanagedbyartificialintelligenceisnotonlyincorrectbutillogical.“

R.Cypher,MSN,PNNPAugust2016

http://perigen.com/ld-resource-library/perinatal-nursing-technology/

AssessmentandDocumentationForPretermGestationsNomentionineitherdocumentexceptforactiveandsecondstagelabor

HighRiskAntepartumCare

AWHONN,2010

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Birth is the sudden opening of a window, through which you look out upon a stupendous prospect. For what has happened? A miracle. You have exchanged nothing for the possibility of everything.

William MacNeile Dixon, 1866 - 1946

ThankYou!rlcjumper@aol.com