Effectiveness of intrapartum fetal surveillance to improve maternal and neonatal outcomes: a systematic review and network meta-analysis

BACKGROUND:Cesarean delivery is the most common surgical procedure worldwide. Intrapartum fetal surveillance is routinely offered to improve neonatal outcomes, but the effects of different methods on the risk of emergency cesarean deliveries remains uncertain. We conducted a systematic review and network meta-analysis to evaluate the effectiveness of different types of fetal surveillance.METHODS:We searched MEDLINE, Embase and CENTRAL until June 1, 2020, for randomized trials evaluating any intrapartum fetal surveillance method. We performed a network meta-analysis within a frequentist framework. We assessed the quality and network inconsistency of trials. We reported primarily on intrapartum emergency cesarean deliveries and other secondary maternal and neonatal outcomes using risk ratios (RRs) and 95% confidence intervals (CIs).RESULTS:We included 33 trials (118 863 patients) evaluating intermittent auscultation with Pinard stethoscope/handheld Doppler (IA), cardiotocography (CTG), computerized cardiotocography (cCTG), CTG with fetal scalp lactate (CTG-lactate), CTG with fetal scalp pH analysis (CTG-FBS), CTG with fetal pulse oximetry (FPO-CTG), CTG with fetal heart electrocardiogram (CTG-STAN) and their combinations. Intermittent auscultation reduced the risk of emergency cesarean deliveries compared with other types of surveillance (IA v. CTG: RR 0.83, 95% CI 0.72–0.97; IA v. CTG-FBS: RR 0.71, 95% CI 0.63–0.80; IA v.CTG-lactate: RR 0.77, 95% CI 0.64–0.92; IA v. FPO-CTG: RR 0.75, 95% CI 0.65–0.87; IA v.FPO-CTG-FBS: RR 0.81, 95% CI 0.67–0.99; cCTG-FBS v. IA: RR 1.21, 95% CI 1.04–1.42), except STAN-CTG-FBS (RR 1.17, 95% CI 0.98–1.40). There was a similar reduction observed for emergency cesarean deliveries for fetal distress. None of the evaluated methods was associated with a reduced risk of neonatal acidemia, neonatal unit admissions, Apgar scores or perinatal death.INTERPRETATION:Compared with other types of fetal surveillance, intermittent auscultation seems to reduce emergency cesarean deliveries in labour without increasing adverse neonatal and maternal outcomes.

Cesarean delivery is the most common surgical procedure worldwide, performed to expedite delivery and avoid neonatal complications. Fetal surveillance is routinely offered to patients in labour to reduce the risk of adverse neonatal outcomes, as well as the risk of unnecessary emergency cesarean deliveries and other maternal interventions. Fetal surveillance aims to detect intrapartum hypoxia from acute or subacute adverse events in labour requiring medical intervention and to reduce the risk of serious complications such as neonatal cerebral palsy, hypoxic–ischemic encephalopathy or stillbirth.Monitoring the fetal heart rate to detect intrapartum hypoxia using simple surveillance techniques, such as the Pinard stethoscope, has been practised for decades.¹ Over the last 50 years, several newer surveillance methods have been evaluated, with varied uptake in practice.² Cardiotocography (CTG) remains the most common surveillance method used in high-risk pregnancies.³ However, given its limited accuracy, many researchers have evaluated its use in combination with other surveillance methods, such as fetal heart electrocardiogram (STAN), fetal scalp pH analysis (FBS) or fetal pulse oximetry (FPO), and with computer-aided decision models (cCTG) to improve its diagnostic value.^4–6 Despite extensive investment in clinical research, the overall effectiveness of such methods in improving maternal and neonatal outcomes remains debatable as stillbirth rates have plateaued worldwide, while cesarean delivery rates continue to rise.^7,8Existing meta-analyses evaluating different intrapartum fetal surveillance methods remain limited to head-to-head comparisons of monitoring techniques, without a comprehensive assessment of their effectiveness in improving maternal and neonatal pregnancy outcomes.^4,9–13 We conducted a systematic review of randomized trials and a network meta-analysis to evaluate the effectiveness of all available fetal surveillance methods in improving maternal and neonatal outcomes.     

Bumetanide Enhances Phenobarbital Efficacy in a Rat Model of Hypoxic Neonatal Seizures

Neonatal seizures can be refractory to conventional anticonvulsants, and this may in part be due to a developmental increase in expression of the neuronal Na⁺-K⁺-2 Cl⁻ cotransporter, NKCC1, and consequent paradoxical excitatory actions of GABA_A receptors in the perinatal period. The most common cause of neonatal seizures is hypoxic encephalopathy, and here we show in an established model of neonatal hypoxia-induced seizures that the NKCC1 inhibitor, bumetanide, in combination with phenobarbital is significantly more effective than phenobarbital alone. A sensitive mass spectrometry assay revealed that bumetanide concentrations in serum and brain were dose-dependent, and the expression of NKCC1 protein transiently increased in cortex and hippocampus after hypoxic seizures. Importantly, the low doses of phenobarbital and bumetanide used in the study did not increase constitutive apoptosis, alone or in combination. Perforated patch clamp recordings from ex vivo hippocampal slices removed following seizures revealed that phenobarbital and bumetanide largely reversed seizure-induced changes in E_GABA. Taken together, these data provide preclinical support for clinical trials of bumetanide in human neonates at risk for hypoxic encephalopathy and seizures.     

Biochemical alterations in neonatal hypoxic ischaemic brain damage

Asphyxiated (n = 39) and control (n = 23) were elected for the study. Free radical-mediated lipid peroxidation, prostaglandin E₂ and vitamin E levels were studied and the degree of hypoxic ischaemic encephalopathy was determined in each case. In the hypoxic group the concentration of prostaglandin E₂ activity (P < 0.05) and malondialdehyde levels (P < 0.01) were significantly higher when compared to that of controls. The high vitamin E concentrations in the asphyxiated infants supports the role of oxygen free radicals in hypoxic ischaemic encephalopathy of newborns.     

Risk factors for neonatal encephalopathy in Kathmandu, Nepal, a developing country: unmatched case-control study

This unmatched case-control study determined the risk factors for neonatal encephalopathy among term infants in Kathmandu, Nepal. Study participants included 131 infants with neonatal encephalopathy born between January 1995 and July 1996, and 635 unmatched infants systematically recruited over 12 months. The prevalence of neonatal encephalopathy was 6.1% per 1000 live births, of which 63% were infants with moderate encephalopathy. Antepartum risk factors included multiple births (odds ratio, OR = 22), primiparity (OR = 2.0), and nonattendance for antenatal care (OR = 2.1). Intrapartum risk factors were particulate meconium (OR = 18), noncephalic presentation (OR = 3.4), prolonged rupture of membranes (OR = 3.8), and other complications. In addition, induction of labor with oxytocin was associated with encephalopathy in 12 of 41 deliveries (OR = 5.7). Overall, 78 affected infants (60%) compared with 36 controls (6%) either had evidence of intrapartum compromise or were born after an intrapartum difficulty likely to result in fetal compromise. Moreover, maternal hemoglobin concentration 8.0 g/dl (OR = 2.5) and thyroid stimulating hormone 5 ml U/l (OR = 2.1) were associated with encephalopathy. Intrapartum risk factors remain important for neonatal encephalopathy in developing countries. There is some evidence of a protective effect from antenatal care. The use of oxytocin in low-income countries where intrapartum monitoring is suboptimal presents a major risk to the fetus. Further studies are required to explore the association between maternal deficiency states and neonatal encephalopathy.     

Effets immédiats du dimenhydrinate sur la contraction utérine e le rythme cardiaque foetal durant le travail.

The effects of intravenous administration of 100 mg of dimenhydrinate (Gravol) were studied in 20 patients during active spontaneous labour. The uterine activity and the fetal heart rate were monitored by an invasive technique. After administration of the medication the uterine activity increases significantly, and in 20% of the cases decelerations in the fetal heart rate of the hypoxic type occurred. Because of its unpredictable effects, this drug should be used with care during labour.     

血清心肌酶谱及cTnI对新生儿缺氧缺血性脑病的诊断价值

目的:研究血清心肌酶谱及心肌肌钙蛋白I(c Tn I)对新生儿缺氧缺血性脑病的诊断价值。方法:选取2012年11月到2014年11月我院收治的新生儿缺氧缺血性脑病患儿70例(研究组),另选同期健康新生儿70例(对照组),采用生化仪检测入选者血清心肌酶谱,应用化学发光法检测血清c Tn I,比较两组血清心肌酶谱和c Tn I水平。结果:研究组肌酸激酶(CK)、天门冬氨酸氨基转移酶(AST)、肌酸激酶同工酶(CK-MB)、a-羟丁酸脱氢酶(HBDH)、乳酸脱氢酶(LDH)均显著高于对照组,两组比较差异具有统计学意义(P0.05);研究组c Tn I水平显著高于对照组,两组比较差异具有统计学意义(P0.05);CK-MB检测灵敏度最高,c Tn I检测的特异性最高。结论:血清心肌酶谱及c Tn I对新生儿缺氧缺血性脑病具有重要的诊断价值,为临床治疗提供一定依据。     

脑苷肌肽对新生儿缺氧缺血性脑病的临床疗效及安全性评价

目的:探究脑苷肌肽对新生儿缺氧缺血性脑病的临床疗效及安全性。方法:收集我院收治的缺氧缺血性脑病患儿61例,根据治疗方法不同分为实验组与对照组,实验组31例采用脑苷肌肽治疗,对照组30例采用胞二磷胆碱治疗。观察并比较两组患儿的治疗效果及不良反应情况。结果:治疗后,两组患儿惊厥、嗜睡以及过度兴奋等神经症状均逐渐消失,且实验组明显早于对照组,差异具有统计学意义(P0.05);与治疗前相比,两组治疗后行为能力、肌张力、原始反应以及意识状态水平均明显升高,且治疗10-14天后,实验组新生儿行为学评分显著高于对照组,差异具有统计学意义(P0.05);两组不良反应比较,差异无统计学意义(P0.05)。结论:脑苷肌肽治疗新生儿缺氧缺血性脑病可有效减轻缺血所致的神经功能障碍,加速神经损伤恢复,临床疗效显著,且安全性较高。     

Treatment Trials for Neonatal Seizures: The Effect of Design on Sample Size

Neonatal seizures are common in the neonatal intensive care unit. Clinicians treat these seizures with several anti-epileptic drugs (AEDs) to reduce seizures in a neonate. Current AEDs exhibit sub-optimal efficacy and several randomized control trials (RCT) of novel AEDs are planned. The aim of this study was to measure the influence of trial design on the required sample size of a RCT. We used seizure time courses from 41 term neonates with hypoxic ischaemic encephalopathy to build seizure treatment trial simulations. We used five outcome measures, three AED protocols, eight treatment delays from seizure onset (T_d) and four levels of trial AED efficacy to simulate different RCTs. We performed power calculations for each RCT design and analysed the resultant sample size. We also assessed the rate of false positives, or placebo effect, in typical uncontrolled studies. We found that the false positive rate ranged from 5 to 85% of patients depending on RCT design. For controlled trials, the choice of outcome measure had the largest effect on sample size with median differences of 30.7 fold (IQR: 13.7–40.0) across a range of AED protocols, T_d and trial AED efficacy (p<0.001). RCTs that compared the trial AED with positive controls required sample sizes with a median fold increase of 3.2 (IQR: 1.9–11.9; p<0.001). Delays in AED administration from seizure onset also increased the required sample size 2.1 fold (IQR: 1.7–2.9; p<0.001). Subgroup analysis showed that RCTs in neonates treated with hypothermia required a median fold increase in sample size of 2.6 (IQR: 2.4–3.0) compared to trials in normothermic neonates (p<0.001). These results show that RCT design has a profound influence on the required sample size. Trials that use a control group, appropriate outcome measure, and control for differences in T_d between groups in analysis will be valid and minimise sample size.     

Randomised controlled trial of cardiotocography versus Doppler auscultation of fetal heart at admission in labour in low risk obstetric population

ObjectiveTo compare the effect of admission cardiotocography and Doppler auscultation of the fetal heart on neonatal outcome and levels of obstetric intervention in a low risk obstetric population.DesignRandomised controlled trial.SettingObstetric unit of teaching hospitalParticipantsPregnant women who had no obstetric complications that warranted continuous monitoring of fetal heart rate in labour.InterventionWomen were randomised to receive either cardiotocography or Doppler auscultation of the fetal heart when they were admitted in spontaneous uncomplicated labour.ResultsThere were no significant differences in the incidence of metabolic acidosis or any other measure of neonatal outcome among women who remained at low risk when they were admitted in labour. However, compared with women who received Doppler auscultation, women who had admission cardiotocography were significantly more likely to have continuous fetal heart rate monitoring in labour (odds ratio 1.49, 95% confidence interval 1.26 to 1.76), augmentation of labour (1.26, 1.02 to 1.56), epidural analgesia (1.33, 1.10 to 1.61), and operative delivery (1.36, 1.12 to 1.65).ConclusionsCompared with Doppler auscultation of the fetal heart, admission cardiotocography does not benefit neonatal outcome in low risk women. Its use results in increased obstetric intervention, including operative delivery.

What is already known on this topic

The admission cardiotocogram is a short recording of the fetal heart rate immediately after admission to the labour wardOpinion varies about its value in identifying a potentially compromised fetusIn low risk women, the incidence of intrapartum fetal compromise is low

What this study adds

Compared with Doppler auscultation of the fetal heart, admission cardiotocography has no benefit on neonatal outcome in low risk womenAdmission cardiotocography results in increased obstetric intervention, including operative delivery     

弥散加权成像及1H磁共振波谱在新生儿缺氧缺血性脑病中的诊断价值

目的:探讨弥散加权成像、1H磁共振波谱诊断新生儿缺氧缺血性脑病的应用价值。方法:以本院收治的缺氧缺血性脑病新生儿37例为研究组,另选择健康新生儿40例作为对照组,两组新生儿均接受弥散加权成像及1H磁共振波谱检查,观察研究组新生儿普通MRI与弥散加权成像检查结果,对比研究组和对照组新生儿的脑代谢化合物相对浓度。结果:与普通MRI检出率相比,研究组患儿的弥散加权成像信号明显升高,差异存在统计学意义(P0.05)。研究组NAA/Cr比值低于对照组,Cho/Cr、MI/Cr、Glu-Gln/Cr、Lac/Cr比值高于对照组,差异存在统计学意义(P0.05)。结论:临床上诊断新生儿缺氧缺血性脑病时,弥散加权成像与1H磁共振波谱的联合应用可提升诊断准确率,通过对代谢物浓度的分析有利于评价缺氧缺血导致脑组织损害的严重程度。     

Intracardiac iron distribution in newborn guinea pigs following isolated and combined fetal hypoxemia and fetal iron deficiency

Myocardial iron deficiency complicates chronic intrauterine hypoxemia during diabetic pregnancies. To understand the effect of both conditions during fetal life on intracardiac iron prioritization, we measured heart myoglobin, cytochrome c, and elemental iron concentrations in six iron-deficient, hypoxic, five iron-sufficient, hypoxic, six iron-deficient, normoxic, and six iron-sufficient, normoxic newborn guinea pigs. The iron-deficient, hypoxic group had lower heart iron (p = 0.03) but higher myoglobin concentration (p < 0.0001) when compared with the iron-sufficient, normoxic group. The percentage of iron incorporated into myoglobin was higher than control in the iron-deficient, hypoxic group (23.2+/-7.2% vs. 5.2+/-0.8%; p < 0.001) and increased as total heart iron decreased (r = 0.97; p < 0.001). In contrast, heart cytochrome c concentration was lower than control in the iron-deficient, hypoxic group (p = 0.01), with equal percentages of heart iron incorporated into cytochrome c. This intracellular prioritization of myocardial iron to myoglobin and away from cytochrome c following combined fetal hypoxemia and iron deficiency may represent an adaptive mechanism to preserve myocardial tissue oxygenation, although at the expense of oxidative phosphorylative capability.     

彩色多普勒超声用于评估妊娠高血压缺氧程度的临床价值

目的:探讨彩色多普勒超声用于评估妊娠高血压缺氧程度的临床价值。方法:将我院自2017年6月至2019年6月收治的妊娠高血压患者106例作为研究组及同期产检正常孕妇103例作为对照组,采用彩色多普勒超声检查仪监测两组孕妇的子宫动脉血流动力学情况,并分析新生儿的缺氧程度。结果:研究组孕妇脐血流搏动指数(pulsatility index,PI)、脐血流阻力指数(resistance index,RI)和脐动脉血流收缩期/舒张期(S/D)水平均明显高于对照组(P0.05),舒张早期切迹发生率为47.17%,亦明显高于对照组8.74%(P0.05)。研究组孕妇平均孕周、新生儿体重和体重指数均明显少于对照组(P0.05),其早产率为19.81%、剖宫产率为64.15%、胎儿窘迫发生率为15.09%,均明显高于对照组(5.83%、19.42%、4.85%,P0.05)。研究组中切迹组孕周、新生儿体重均明显小于非切迹组(P0.05)。研究组羊水异常发生率为16.00%,早产率为40.00%,新生儿窒息率为14.00%,胎儿窘迫发生率为26.00%,均明显高于对照组(5.36%、1.79%、1.79%、5.38%,P0.05)。结论:采用彩色多普勒超声仪检测孕妇子宫动脉血流频谱可作为了解子宫-胎盘-胎儿循环的检查方式,评估妊娠并发症的发生风险,监测胎儿宫内生长发育。     

Developmental changes in heart and muscle phosphofructokinase isozymes

Phosphofructokinase isozymes of fetal, neonatal, and adult rat heart and skeletal muscle were characterized by DEAE-cellulose chromatography, agarose gel electrophoresis, and immunodiffusion with specific antisera. The results of these studies indicate that in skeletal muscle and heart the levels of the major liver phosphofructokinase isozyme (PFK-L2) and the muscle phosphofructokinase isozyme (PFK-M) are dependent on the developmental status of the rat. For example, PFK-L2 and PFK-M are present in fetal and early neonatal skeletal muscle; whereas in adult skeletal muscle, only PFK-M is detectable. By DEAE- cellulose chromatography, PFK-L2 activity was estimated to be 2.4 units/g (41% of total phosphofructokinase activity) in fetal muscle, very low and not resolved from PFK-M in 7-day neonatal muscle, and not detectable in adult muscle. Further, PFK-M activity was found to be 3.4 units/g (59% of total phosphofructokinase activity), 10 units/g, and 31.6 units/g in fetal, 7-day neonatal, and adult skeletal muscle, respectively. The developmental changes of heart phosphofructokinase isozymes differ considerably from that of the skeletal muscle phosphofructokinase isozymes. In fetal heart, PFK-L2 is the major phosphofructokinase isozyme (5.6 units/g), constituting 67% of total phosphofructokinase activity. Further, in fetal heart another phosphofructokinase isozyme (33% of total phosphofructokinase activity) was found by DEAE-cellulose chromatography which is different from PFK-M and PFK-L2. In 7-day neonatal and adult heart, PFK-M and PFK-L2 are the only detectable phosphofructokinase isozymes. Varying from 5.6 units/g (44% of total) in 7-day neonatal to 5.9 units/g (40% of total) in adult heart, PFK-L2 activity remains fairly constant. Also, PFK-M is very low in fetal heart but increases within 1 week postpartum to 5.5 units/g (50% of total activity) and to 8.9 units/g (60% of total activity) in adult heart.     

M-mode ultrasonic assessment of equine fetal heart rate

Embryonic heart rate was studied during 87 examinations in 56 mares on Days 25 to 174 post ovulation. Real-time B-mode using a stopwatch and M-mode ultrasonography were compared. For analyses of heart rates, data were grouped into weeks or months. For the stopwatch and M-mode techniques, respectively, heart rates averaged 123 and 133 beats per minute during Month 1, peaked during Month 3 at 172 or 196 beats, then gradually decreased over the duration of the study to 126 and 130 beats during Month 6. There was a significant increase in heart rate from Months 1 to 2 and Months 2 to 3 and a significant decrease from Months 3 to 4 and Months 5 to 6 for both techniques. There was a tendency for a difference (P<0.08) between techniques during Month 1 and a significant difference between techniques for each of Months 2 and 3. The lower heart rate values for the stopwatch technique during Months 1, 2 and 3 may have reflected the difficulties associated with maintaining the transducer field on the fetal heart continuously for an adequate period of time (Months 1 and 2) and difficulty counting fast enough to keep up with the fetal heart (Months 2 and 3). When data were grouped weekly, the largest increase in fetal heart rate occurred between Weeks 4 and 5.     

Hormonal factors in the control of heart rate in normoxaemic and hypoxaemic fetal, neonatal and adult sheep

The relationship of plasma levels of adrenaline, noradrenaline, arginine vasopressin (AVP) and plasma renin activity (PRA) to heart rate were studied in normoxaemic and hypoxaemic fetal, neonatal and adult sheep. The mean heart rate response of fetuses at the end of a 30 minute period of 10% oxygen delivery to the maternal ewe was tachycardia. However bradycardia, usually of a transient nature, was observed in 9 of the 12 fetuses (P less than 0.05). Multiple regression analysis was used to determine the contribution of blood gas, blood pressure and plasma hormone levels to the variance in heart rate in the perinatal sheep. 22% of the variance in fetal heart rate was provided by PRA and age from conception (P less than 0.001). Tachycardia was the invariable heart rate response of the neonates and adults to hypoxaemia. 61% of the variance in neonatal heart rate was contributed by PaO2, PaCO2, AVP, PRA and systolic blood pressure (SBP, P less than 0.001). PaO2 and plasma levels of adrenaline were significantly related to adult heart rate (P less than 0.001). Those fetuses which developed bradycardia had lower PaO2 but higher AVP and PRA during hypoxaemia than those which did not develop bradycardia. The major determinant of the area of the fetal bradycardia response was found, by multiple regression analysis, to be plasma adrenaline concentration (P less than 0.05). Thus different hormonal factors may play a role in the regulation of heart rate in normoxaemic and hypoxaemic fetal, neonatal and adult sheep.     

Continuous Fetal Heart Rate Monitoring and Tocodynamometry in Routine Obstetrical Care,Fetal Stress and Non-Stress Testing,and Labor Induction in the Chimpanzee (Pan troglodytes)

The use of continuous fetal heart rate (FHR) and uterine pressure monitoring in the chimpanzee (Pan troglodytes) by external Doppler transducer and tocodynamometer is described in 1) the routine obstetrical assessment of fetal well-being, 2) oxytocin challenge (stress) testing (OCT) and non-stress testing (NST) for the diagnosis of in utero fetal distress, and 3) induction of labor by intravenous oxytocin infusion, by surgical rupture of the chorio-amniotic membranes (amniotomy), or by a combination of these techniques, as an alternative to Caesarean section for clinical, managemental, or experimental purposes. FHR traces were analyzed during a total of 57 term pregnancies for three basic characteristics: baseline rate, variability, and periodic pattern. Results indicated that continuous FHR monitoring in the chimpanzee can provide a valuable tool for fetal assessment and management of labor in any attempt to reduce the unacceptably high annual incidence of perinatal and neonatal infant mortality reported in the U.S.     

Midwife managed delivery unit: a randomised controlled comparison with consultant led care.

OBJECTIVE--To examine whether intrapartum care and delivery of low risk women in a midwife managed delivery unit differs from that in a consultant led labour ward. DESIGN--Pragmatic randomised controlled trial. Subjects were randomised in a 2:1 ratio between the midwives unit and the labour ward. SETTING--Aberdeen Maternity Hospital, Grampian. SUBJECTS--2844 low risk women, as defined by existing booking criteria for general practitioner units in Grampian. 1900 women were randomised to the midwives unit and 944 to the labour ward. MAIN OUTCOME MEASURES--Maternal and perinatal morbidity. RESULTS--Of the women randomised to the midwives unit, 647 (34%) were transferred to the labour ward antepartum, 303 (16%) were transferred intrapartum, and 80 (4%) were lost to follow up. 870 women (46%) were delivered in the midwives unit. Primigravid women (255/596, 43%) were significantly more likely to be transferred intrapartum than multi-gravid women (48/577, 8%). Significant differences between the midwives unit and labour ward were found in monitoring, fetal distress, analgesia, mobility, and use of episiotomy. There were no significant differences in mode of delivery or fetal outcome. CONCLUSIONS--Midwife managed intrapartum care for low risk women results in more mobility and less intervention with no increase in neonatal morbidity. However, the high rate of transfer shows that antenatal criteria are unable to determine who will remain at low risk throughout pregnancy and labour.     

Cardiac ultrasonography in structural abnormalities and arrhythmias. Recognition and treatment.

Fetal cardiac ultrasonography has become an important tool in the evaluation of fetuses at risk for cardiac anomalies. It can both guide prenatal treatment and assist the management and timing of delivery. We recommend that a fetal echocardiogram be done when there is a family history of congenital heart disease; maternal disease that may affect the fetus; a history of maternal drug use, either therapeutic or illegal; evidence of other fetal abnormalities; or evidence of fetal hydrops. The optimal timing of evaluation is 18 to 22 weeks'' gestation. An entire range of structural cardiac defects can be visualized prenatally, including atrioventricular septal defect, ventricular septal defect, cardiomyopathy, ventricular outlet obstruction, and complex cardiac defects. The outcome for a fetus with a recognized abnormality is unfavourable, with less than 50% surviving the neonatal period. Fetal cardiac arrhythmias are also a common occurrence, 15% in the series described here. Premature atrial or ventricular contractions are most commonly seen and usually require no treatment. Supraventricular tachycardia can result in hydrops and require in utero treatment to prevent fetal demise. Complete heart block, particularly in association with structural heart disease, has a poor prognosis for fetal survival.     

Estimation of gestational age in Egyptian native goats by ultrasonographic fetometry

The main aim of the present study was to estimate the gestational age of Egyptian goats by B-mode ultrasound measurement of embryonic or fetal parts throughout pregnancy. Trans-rectal (TR) ultrasonography (7 MHz) was carried out on 15 pregnant Egyptian does at Day 10 post mating on alternate days until Day 25 and then once at 3-5-day intervals until Day 50. Trans-abdominal (TA) ultrasonography (3.5-5 MHz) was carried out on the same animals from Days 25 to 130 at 3-5-day intervals. After imaging the embryo or the fetus, the following parameters were measured: length of the embryo or fetus (CRL), heart rate (FHR), biparital diameter (BPD), trunk diameter (TD), placentome size (PS), umbilical cord diameter (UCD) and femur length (FL). The average of days at which the embryonic vesicle was first determined by TR and TA ultrasonography was 16.98+/-1.97 and 27.87+/-3.48, respectively. The embryo proper with a beating heart was first determined by TR and TA ultrasonography at an average of 22.36+/-2.66 and 30.36+/-4.75 days, respectively. All the fetal measures were significantly (P<0.0001) correlated with the gestational age. With the exception of fetal heart rate (R(2)=0.551), all the measured fetal structures were highly correlated (R(2)> or =90) with the gestational age. In conclusion, the age of embryo or fetus in Egyptian does can be estimated by ultrasound measuring the crown rump length, biparital diameter, trunk diameter, placentome size, umbilical cord diameter and femur length.