Correlation of Cardiotocography with Intraoperative findings and neonatal outcome in caesarean section for non-reassuring fetal status

Aims: To demonstrate the correlation of cardiotocography with intraoperative findings and neonatal outcome undergoing emergency cesarean section for non-reassuring fetal status. Methods: It is a hospital based cross sectional study at maternity ward of Shree Birendra Hospital in Kathmandu with non-reassuring CTG who underwent cesarean section in a period of one year. Their CTG were correlated with their intraoperative findings and neonatal outcome such as meconium stained liquor, nuchal cord, Apgar score at birth, NICU admission, perinatal mortality and stillbirth. Results: Fifty four patients were recruited. Most common operative finding was meconium stained liquor (35.2%); and cardiotocographic abnormality was variable Deceleration (37%). Variable deceleration and late deceleration had significant correlation with meconium stain liquor and nuchal cord. Apgar score ≤ 7 at 5 minute was 7.4%. NICU admission was 13% with common abnormality as late Deceleration. Conclusion: CTG pattern of variable and late deceleration had correlated with the meconium stained liquor and nuchal cord only. There was no relation with neonatal outcome in terms of Apgar score and admission rate.

Cerebral Palsy is 25 or More of Hypoxia Index and No Cerebral Palsy is 24 or Less of Index in Fetal Monitoring

Fetal outcome was ominous if fetal heart rate (FHR) was late deceleration (LD) in the past, while 3 connected typical LDs were normal, and repeated LDs for 50 min were heavy fetal brain damage. Also, LD is defined as LD when it is repeated for 15 minutes. As the fetus is damaged by repeated hypoxic decelerations followed by cerebral palsy, but not by its late appearing in LD, novel fetal hypoxia index (HI) is the sum of all deceleration durations (min) divided by the lowest FHR (bpm) and multiplied by 100 in fetal monitoring. The hypoxia index was 25 or more in all of 6 cerebral palsy cases, while it was 24 or less in all 16 cases of no cerebral palsy. As error probability is almost zero in the chi2 test of hypoxia index, no cerebral palsy is decided when the hypoxia index is 24 or less, while it is cerebral palsy, if hypoxia index is 25 or more. The hypoxia index is adopted to all FHR decelerations and bradycardia, as hypoxia index does not evaluate the late appearing of deceleration, instead of past subjective deceleration pattern diagnosis in fetal monitoring.

Cerebral Palsy is 25 or More of Hypoxia Index and No Cerebral Palsy is 24 or Less of Index in Fetal Monitoring

Fetal outcome was ominous if fetal heart rate (FHR) was late deceleration (LD) in the past, while 3 connected typical LDs were normal, and repeated LDs for 50 min were heavy fetal brain damage. Also, LD is defined as LD when it is repeated for 15 minutes. As the fetus is damaged by repeated hypoxic decelerations followed by cerebral palsy, but not by its late appearing in LD, novel fetal hypoxia index (HI) is the sum of all deceleration durations (min) divided by the lowest FHR (bpm) and multiplied by 100 in fetal monitoring. The hypoxia index was 25 or more in all of 6 cerebral palsy cases, while it was 24 or less in all 16 cases of no cerebral palsy. As error probability is almost zero in the chi2 test of hypoxia index, no cerebral palsy is decided when the hypoxia index is 24 or less, while it is cerebral palsy, if hypoxia index is 25 or more. The hypoxia index is adopted to all FHR decelerations and bradycardia, as hypoxia index does not evaluate the late appearing of deceleration, instead of past subjective deceleration pattern diagnosis in fetal monitoring.

Nuchal cord: from dread towards confident management

Background: This study was aimed at observing the outcomes of pregnancies with sonographically detected nuchal cord or cord around the neck at term. Early studies on nuchal cord showed many maternal and neonatal complications. But several recent studies have suggested that maternal and neonatal complications do not increase with nuchal cord at delivery. This ambiguity increases anxiety in treating obstetricians and relatives of pregnant women, thus leading to unnecessary caesarean sections. This study is intended to observe the maternal and neonatal outcomes of 300 pregnant women with sonographically detected nuchal cord at term.Methods: Prospective observational study where 300 term pregnant women with sonographically detected nuchal cord were observed through delivery at Shri Venkata Sai Medical College, Mahabubnagar, Telangana, during October 2016 to April 2018.Results: In this study 80.6% women had normal vaginal delivery, 8.3% had LSCS, 11% had instrumental deliveries. 54% had loose nuchal cord, 46% had tight loop of cord.60% had normal CTG, 8% had variable deceleration, 2% late deceleration. Neonatal morbidity was 9.6% and zero neonatal mortality.Conclusions: The study concluded that the presence of nuchal cord does not adversely affect the mother and the neonate. Presence of nuchal cord per se is not an indication for LSCS. Effect of nuchal cord on neonate is only transient. These women can be allowed for vaginal delivery with routine labour room protocols. Routine sonographycal detection of nuchal cord is not required and if it is reported, it should not dictate obstetric management.

Study of Oligohydramnios and its perinatal outcome

Background: Importance of amniotic fluid volume as an indicator of fetal status is being appreciated relatively recently. Around 3% to 8% of pregnant women are presenting with low amniotic fluid at any point of pregnancy. The present study was undertaken to study the outcome of pregnancies with Oligohydramnios [(amniotic fluid index) AFI≤5cm] at or beyond 34 weeks.Methods: This study consists of 50 cases of antenatal patients with oligohydramnios (AFI≤5) at or beyond 34 weeks of gestation compared with age and gestation matched 50 normal liquor (AFI≥5 and ≤25). The outcome measures recorded were labor, gestational age at delivery, amniotic fluid index (AFI), mode of delivery, indication for cesarean section or instrumental delivery, APGAR score and birth weight.Results: In the present study, AFI was significantly decreased in cases (3.74±1.2) compared (12.54±2.5) with controls. Variable deceleration was noted in 14 (28%) and late deceleration in 5 (10%) cases. In control group, 2 (4%) had late deceleration. In cases induced labor is in 14 (28%), spontaneous labor 36 (72%). In cases, term normal vaginal delivery was in 15 (30%), PVD in 6 (12%), LSCS in 28 (56%) and instrumental vaginal delivery in 1 (2%). In controls, full term normal vaginal delivery was in 41 (82%), PVD in 5 (10%), LSCS in 4 (8%). APGAR score <7 at 1 minute was in 19 (38%) and at 5 minutes was in 5 (10%) in cases. Birth weight is reduced in cases. IUGR was reported in 9 (18%) in cases.Conclusions: Pregnancies with Oligohydramnios (AFI≤5) is associated with increased rate of non-reactive NST. Routine induction of labor for Oligohydramnios is not recommended. It is preferable to allow patients to go into spontaneous labor with continuous FHR monitoring. Antepartum diagnosis of Oligohydramnios warrants close fetal surveillance.

Prevention of Cerebral Palsy with Novel Hypoxia Index Composed of Fetal Heart Rate Deceleration

Fetal brain damage develops after the loss of FHR variability followed by infantile cerebral palsy due to severe hypoxia in frequently repeated fetal heart rate (FHR) decelerations (transient bradycardia) or prolonged fetal bradycardia, where novel hypxia index is 25 or more, and it is prevented if the hpoxia index is 24 or less. The hypoxia index (HI) is the sum of FHR deceleration durations (min) divided by the lowest FHR (bpm), and multiplied by 100 (Figure 1). The HI is calculated by visual measurement, while it is also suitably calculated by computerized FHR monitoring. Cerebral palsy is prevented when HI is 24 or less with almost zero error probability in the delivery. The cases whose HI was 25 or more will develop cerebral palsy, thus, it can receive early cerebral palsy trearments in neonatal stage. As late deceleration disappeared when the parturient woman changed her posture to lateral one from supine, a parturient woman is recommended to have lateral posture, when they notice the appearance of FHR deceleration during the delivery to disappear deceleration to prevent the increase of HI value. As the HI is adopted not only late deceleration, but also all decelerations and continuous bradycardia, fetal diagnosis will change to objective numeric FHR analysis from the monitoring with vague subjective FHR pattern classification.

Solidification Chronology of the Metal Matrix and a Study of Conditions for Micropore Formation in Cast Irons Using EPMA and FTA

Microsegregation is intimately coupled with solidification, the development of microstructure, and involved in the formation of various casting defects. This paper demonstrates how the local composition of the metal matrix of graphitic cast irons, measured using quantitative electron microprobe analysis, can be used to determine its solidification chronology. The method is applied in combination with Fourier thermal analysis to investigate the formation of micropores in cast irons with varying proportions of compacted and spheroidal graphite produced by remelting. The results indicate that micropores formed at mass fractions of solid between 0.77 and 0.91, which corresponded to a stage of solidification when the temperature decline of the castings was large and increasing. In 4 out of the 5 castings, pores appear to have formed soon after the rate of solidification and heat dissipation had reached their maximum and were decreasing. While the freezing point depression due to build-up of microsegregation and the transition from compacted to spheroidal type growth of the eutectic both influencing solidification kinetics and the temperature evolution of the casting, the results did not indicate a clear relation to the observed late deceleration of solidification.