TY - JOUR
T1 - Combined prenatal and postnatal prediction of early neonatal compromise risk
AU - Eden, Robert D.
AU - Evans, Mark I.
AU - Britt, David W.
AU - Evans, Shara M.
AU - Gallagher, Paula
AU - Schifrin, Barry S.
N1 - Publisher Copyright:
© 2019 Informa UK Limited, trading as Taylor & Francis Group.
PY - 2021
Y1 - 2021
N2 - Objective: Electronic fetal monitoring/cardiotocography (EFM) is nearly ubiquitous, but almost everyone acknowledges there is room for improvement. We have contextualized monitoring by breaking it down into quantifiable components and adding to that, other factors that have not been formally used: i.e. the assessment of uterine contractions, and the presence of maternal, fetal, and obstetrical risk factors. We have created an algorithm, the Fetal Reserve Index (FRI) that significantly improves the detection of at-risk cases. We hypothesized that extending our approach of monitoring to include the immediate newborn period could help us better understand the physiology and pathophysiology of the decrease in fetal reserve during labor and the transition from fetal to neonatal homeostasis, thereby further honing the prediction of outcomes. Such improved and earlier understanding could then potentiate earlier, and more targeted use of neuroprotective attempts during labor treating decreased fetal reserve and improving the fetus’ transition from fetal to neonatal life minimizing risk of neurologic injury. Study design: We have analyzed a 45-year-old research database of closely monitored labors, deliveries, and an additional hour of continuous neonatal surveillance. We applied the FRI prenatally and created a new metric, the INCHON index that combines the last FRI with umbilical cord blood and 4-minute umbilical artery blood parameters to predict later neonatal acid/base balance. Using the last FRI scores, we created 3 neonatal groups. Umbilical cord and catheterized umbilical artery bloods at 4, 8, 16, 32, and 64 minutes were measured for base excess, pH, and PO2. Continuous neonatal heart rate was scored for rate, variability, and reactivity. Results: Neonates commonly do not make a smooth transition from fetal to postnatal physiology. Even in low risk babies, 85% exhibited worsening pH and base excess during the first 4 minutes; 34% of neonates reached levels considered at high risk for metabolic acidosis (≤−12 mmol/L) and neurologic injury. Neonatal heart rate commonly exhibited sustained, significant tachycardia with loss of reactivity and variability. One quarter of all cases would be considered Category III if part of the fetal tracing. Our developed metrics (FRI and INCHON) clearly discriminated and predicted low, medium, and high-risk neonatal physiology. Conclusions: The immediate neonatal period often imposes generally unrecognized risks for the newborn. INCHON improves identification of decreased fetal reserve and babies at risk, thereby permitting earlier intervention during labor (intrauterine resuscitation) or potentially postnatally (brain cooling) to prevent neurologic injury. We believe that perinatal management would be improved by routine, continuous neonatal monitoring–at least until heart rate reactivity is restored. FRI and INCHON can help identify problems much earlier and more accurately than currently and keep fetuses and babies in better metabolic shape.
AB - Objective: Electronic fetal monitoring/cardiotocography (EFM) is nearly ubiquitous, but almost everyone acknowledges there is room for improvement. We have contextualized monitoring by breaking it down into quantifiable components and adding to that, other factors that have not been formally used: i.e. the assessment of uterine contractions, and the presence of maternal, fetal, and obstetrical risk factors. We have created an algorithm, the Fetal Reserve Index (FRI) that significantly improves the detection of at-risk cases. We hypothesized that extending our approach of monitoring to include the immediate newborn period could help us better understand the physiology and pathophysiology of the decrease in fetal reserve during labor and the transition from fetal to neonatal homeostasis, thereby further honing the prediction of outcomes. Such improved and earlier understanding could then potentiate earlier, and more targeted use of neuroprotective attempts during labor treating decreased fetal reserve and improving the fetus’ transition from fetal to neonatal life minimizing risk of neurologic injury. Study design: We have analyzed a 45-year-old research database of closely monitored labors, deliveries, and an additional hour of continuous neonatal surveillance. We applied the FRI prenatally and created a new metric, the INCHON index that combines the last FRI with umbilical cord blood and 4-minute umbilical artery blood parameters to predict later neonatal acid/base balance. Using the last FRI scores, we created 3 neonatal groups. Umbilical cord and catheterized umbilical artery bloods at 4, 8, 16, 32, and 64 minutes were measured for base excess, pH, and PO2. Continuous neonatal heart rate was scored for rate, variability, and reactivity. Results: Neonates commonly do not make a smooth transition from fetal to postnatal physiology. Even in low risk babies, 85% exhibited worsening pH and base excess during the first 4 minutes; 34% of neonates reached levels considered at high risk for metabolic acidosis (≤−12 mmol/L) and neurologic injury. Neonatal heart rate commonly exhibited sustained, significant tachycardia with loss of reactivity and variability. One quarter of all cases would be considered Category III if part of the fetal tracing. Our developed metrics (FRI and INCHON) clearly discriminated and predicted low, medium, and high-risk neonatal physiology. Conclusions: The immediate neonatal period often imposes generally unrecognized risks for the newborn. INCHON improves identification of decreased fetal reserve and babies at risk, thereby permitting earlier intervention during labor (intrauterine resuscitation) or potentially postnatally (brain cooling) to prevent neurologic injury. We believe that perinatal management would be improved by routine, continuous neonatal monitoring–at least until heart rate reactivity is restored. FRI and INCHON can help identify problems much earlier and more accurately than currently and keep fetuses and babies in better metabolic shape.
KW - ACOG category system
KW - Inchon index
KW - base excess
KW - cardiotocography
KW - cerebral palsy
KW - electronic fetal monitoring
KW - fetal reserve index
KW - fetal scalp sampling
KW - metabolic acidosis
KW - neonatal adaptation
KW - neonatal heart rate
KW - pH
UR - http://www.scopus.com/inward/record.url?scp=85076498931&partnerID=8YFLogxK
U2 - 10.1080/14767058.2019.1676714
DO - 10.1080/14767058.2019.1676714
M3 - Article
C2 - 31581872
AN - SCOPUS:85076498931
SN - 1476-7058
VL - 34
SP - 2996
EP - 3007
JO - Journal of Maternal-Fetal and Neonatal Medicine
JF - Journal of Maternal-Fetal and Neonatal Medicine
IS - 18
ER -