Follow-up of children born with an umbilical arterial blood pH <7

doi:10.1016/0002-9378(95)90423-9

American Journal of Obstetrics and Gynecology

Volume 173, Issue 6, December 1995, Pages 1758-1764

https://doi.org/10.1016/0002-9378(95)90423-9 Get rights and content

Abstract

OBJECTIVE: We performed neurodevelopmental assessment in children born with an umbilical artery pH <7.

STUDY DESIGN: All infants born with an umbilical artery pH <7 from a 19-month period were retrieved from the obstetric database. Obstetric, neonatal, and pediatric records were reviewed. At an age of 1 to 3 years, children were visited at home for semi-structured questioning of the mother and a Denver Developmental Screening Test of the child.

RESULTS: During the study period 1614 umbilical artery pH measurements were entered in the database. Thirty (1.9%) were <7. From this group 23 infants were admitted to the neonatal intensive care unit, and 8 of them required intubation. Twenty-eight children survived the neonatal period. Three children experienced an episode of mild hypertonia. One child had a mild motor developmental delay.

CONCLUSION: Babies born with an umbilical artery pH <7 are at great risk to experience considerable short-term mobidity. Those who leave the neonatal intensive care unit without major problems have good outcomes, and pessimism in counseling their parents is unwarranted.

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Cited by (54)

Maternal levels of care during pregnancy influence labor and delivery outcomes - present practices and future priorities
2024, Seminars in Fetal and Neonatal Medicine
Neonatal encephalopathy (NE) is a diagnosis that is usually unexpected. Though there are many risk factors for the condition and multiple theories as to its genesis, the majority of cases cannot be predicted prior to the occurrence of the clinical syndrome. Indeed, it is common for a pregnant person to have multiple risk factors and a completely healthy child. Conversely, people with seemingly no risk factors may go on to have a profoundly affected child. In this synopsis we review risk factors, potential mechanisms for encephalopathy, the complicated issue of choosing which morbidity to take on and how the maternal level of care may influence outcomes. The reader should be able to better understand the limitations of current testing and the profound levels of maternal intervention that have been undertaken to prevent or mitigate the rare, but devastating occurrence of NE. Further, we suggest candidate future approaches to prevent the occurrence, and decrease the severity of NE. Any future improvements in the NE syndrome cannot be achieved via obstetric intervention and management alone or conversely, by improvements in treatments offered post-birth. Multidisciplinary approaches that encompass prepregnancy health, pregnancy care, intrapartum management and postpartum care will be necessary.
Reference percentiles for paired arterial and venous umbilical cord blood gases: An indirect nonparametric approach
2019, Clinical Biochemistry
Citation Excerpt :
The study shows that percentiles from female and male neonates are close, supporting the use of common reference intervals. Many reference values have been proposed for arterial pH (pHa) from UCBG, with low limits ranging from 7.03 [33,34] to 7.18 [35,36], and high limits ranging from ~7.36 [1,37] to 7.43 [38,39], regardless of selection criteria. In accordance, our 2.5th percentile pHa at 7.14 is within the expected ranges, keeping in mind that the probability of intrapartum hypoxia-related neonatal encephalopathy increases for a pHa <7.0, but decreases progressively up to 7.20, the pHa threshold for which this likelihood is admitted as null [40].
Reference intervals for arterial and venous umbilical cord blood gas (UCBG) parameters are scarce, are mainly focused on pH, pO2, pCO2 and base deficit, and are usually assessed using parametric tests, despite a generally skewed data distribution. Here, the purpose is to determine reference percentiles for nine parameters of concomitant arterial and venous UCBG (CAV-UCBG) from neonates at birth, using nonparametric tests.
Results of CAV-UCBG, assayed over a 4.5-year period, were extracted from a hospital laboratory database for pH, pCO2, pO2, oxygen saturation, concentration of total oxygen, total carbon dioxide, hydrogen carbonate, total haemoglobin, and acid-base excess. Exclusion criteria were: a venous–arterial pH difference <0.02, an arterial–venous pCO2 <0.7 kPa, and a venous pCO2 <2.9 kPa. Nonparametric bivariate kernel density estimations were used for the selection of plots within the 95% percentile surface of the pCO2-to-pH relationship (NBKDE-95P). Outliers from skewed data were removed using an adjusted-Tukey method, and percentiles were calculated according to the CLSI EP28-A3 nonparametric method.
Overall, 31% (5033/16164) of CAV-UCBG were discarded using the three exclusion criteria. Then, 6% (670/11131) of CAV-UCBG were excluded from the NBKDE-95P, and 0.1 to 3.5% outliers were subsequently removed. Depending on the parameter, the 2.5th and 97.5th percentiles from the whole group were similar or slightly narrower compared to reference intervals from other studies, while those from female and male neonates did not differ substantially.
Using an indirect nonparametric approach, this study proposes new percentiles for parameters from concomitant arterial and venous umbilical cord blood gases.
Severe neonatal acidosis: Comparison and analysis of obstetrical practices in two French perinatal centers
2014, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
Comparer les facteurs prédictifs d’acidose néonatale sévère à terme – définie par un pH artériel au cordon inférieur à 7,00 – et analyser les pratiques obstétricales associées, dans deux maternités françaises de type différent.
Étude observationnelle sur six ans (de 2003 à 2008), portant sur tous les nouveau-nés ayant un pH artériel au cordon inférieur à 7,00, dans les maternités du CHU de Poitiers (type III) et du CHU Saint-Antoine à Paris (type II), dans lesquelles la réalisation d’un pH au cordon est systématique pour toute naissance depuis plus de dix ans. Pour chaque cas ont été relevés les caractéristiques maternelles, les antécédents médicaux et obstétricaux, le déroulement de la grossesse, du travail et modalités de l’accouchement ainsi que l’état des enfants à la naissance.
Sur les 23 508 naissances qui ont eu lieu au cours de la période d’étude sur les deux sites, 177 nouveau-nés à terme avaient un pH artériel inférieur à 7,00. Le taux était comparable pour les deux sites de Poitiers et de Saint-Antoine (0,92 % et 0,77 % respectivement). Certains facteurs de risque étaient similaires dans les deux établissements chez les fœtus en acidose sévère : âge maternel, taux d’utérus cicatriciels, fréquence des liquides méconiaux. Des différences importantes de pratiques obstétricales ont été relevées entre les deux maternités : le taux de césariennes (programmées et réalisées en cours de travail) et des extractions instrumentales était plus élevé à Saint-Antoine qu’à Poitiers, tandis que le taux de déclenchements du travail était plus important à Poitiers.
La survenue d’une acidose profonde est associée à de nombreux facteurs liés aux caractéristiques des patientes, aux modalités du travail et aux pratiques obstétricales. Nous n’avons pas observé de lien direct entre le taux de césariennes et le taux d’acidose néonatale profonde.
To identify and compare risk factors for severe neonatal acidosis, defined by an umbilical artery pH inferior to 7.00, and clinical practices in two different perinatal centers.
In a retrospective study, from 2003 to 2008, in two university perinatal centers (Poitiers and Saint-Antoine in Paris) on all term pregnancies complicated by severe neonatal acidosis (umbilical artery pH < 7.00), we elected to compare the following risk factors: maternal characteristics, medical and obstetrical histories, progress of pregnancy, labour and delivery as well as the neonatal status.
Among 23,508 births, 177 term newborns had severe neonatal acidosis. The rate was similar for both perinatals centers of Poitiers and Saint-Antoine (0.92% and 0.77% respectively). Factors associated with severe neonatal acidosis were similar in both centers: maternal age, thick meconium, prior cesarean section. There were differences in obstetrical pratices between the two centers: there were more caesarean sections and assisted vaginal deliveries in Paris and more inductions of labour in Poitiers.
Severe neonatal acidosis is associated with the geographical origin, the progress of labour and the mode of delivery. It seems that severe neonatal acidosis is unrelated to caesarian delivery.
Cerebral palsy and perinatal asphyxia (I- Diagnosis)
2010, Gynecologie Obstetrique et Fertilite
L’infirmité motrice d’origine cérébrale (IMOC) est une perturbation du développement de la motricité et de la posture limitant l’activité, que l’on attribue à des lésions non évolutives du cerveau survenues pendant la période fœtale ou néonatale. Les troubles moteurs sont souvent associés à des troubles sensitifs, sensoriels, cognitifs et comportementaux, voire à une épilepsie. Dans les pays développés, l’incidence de l’IMOC est restée stable au cours des 30 dernières années, malgré la généralisation du monitorage fœtal et une multiplication par 5 à 6 du taux de césarienne. Chez l’enfant né à terme, l’IMOC peut être rattachée à une asphyxie en cas d’acidose métabolique grave au sang du cordon (pH < 7,00 et déficit en base > 12 mmol/L), suivie d’une encéphalopathie néonatale modérée ou sévère ayant débuté dans les 24 premières heures de vie et compliquée, plus tard, d’un handicap neurologique, où prédominent la quadriparésie et la dyskinésie/dystonie. Pour dater le moment de l’épisode asphyxique au cours du travail, les principaux éléments sont l’existence de complications aiguës pendant l’accouchement et la présence d’anomalies du rythme cardiaque fœtal, aiguës ou progressives, survenant après un tracé d’admission normal ou encore la nécessité d’une réanimation néonatale intensive, l’existence d’une défaillance multiviscérale dans les 72 premières heures et surtout l’imagerie cérébrale précoce, notamment par résonance magnétique nucléaire (IRM), avec des lésions aiguës, non focalisées. L’IRM montre, d’une part, des lésions des noyaux gris centraux, des thalami et des bras postérieurs des capsules internes en cas d’asphyxie aiguë sub-totale, avec une épargne relative du cortex, survenues à l’occasion d’un événement sentinelle s’exprimant par une bradycardie fœtale sans récupération ; d’autre part, des atteintes cortico-sous-corticales prédominant dans des zones plus faiblement vascularisées, avec une épargne relative de la substance grise centrale, en cas d’asphyxie prolongée et partielle, révélée par une tachycardie fœtale progressive sur un fond de ralentissements tardifs et variables atypiques du rythme cardiaque fœtal, avec perte de la réactivité et de la fluctuation. La prolongation de chacun des deux types d’asphyxie se solde par des lésions plus globales de l’ensemble du cerveau. Pour pouvoir éliminer toutes les autres causes possible d’IMOC, qu’elles soient infectieuses, malformatives, génétiques, métaboliques ou vasculaires (hémorragies ou thromboses), il faut disposer au minimum d’une IRM cérébrale performante et d’un examen histologique attentif du placenta.
Cerebral palsy (CP) is a group of disorders of the development of movement and posture, causing activity limitations, that are attributed to nonprogressing disturbances that occurred in the developing fetal or infant brain. The motor abnormalies are often accompagnied by disturbances of sensation, perception, cognition, behavior and/or by a seizure disorder. The prevalence of CP has not decreased in developed countries over the past 30 years, despite the widespread use of electronic fetal heart rate monitoring and a 5- to 6-fold increase in the cesarean delivery rate. In the term newborn, CP may be attributed to perinatal asphyxia in case of metabolic acidosis in the cord blood (pH < 7,00 and base deficit > 12 mmol/L), followed by a moderate or severe neonatal encephalopathy within 24 hours and a further neurological impairement characterized by spastic quadriplegia and dyskinesia/dystonia. Dating the time of fetal asphyxia during delivery is possible when there are acute catastrophic complications during labor and unexpected acute or progressive fetal heart rate anomalies after a normal admission test, when there is a need for intensive neonatal resuscitation, a multi-organ failure within 72 hours of birth and visualization of acute non focal cerebral abnormalities, mainly by early magnetic resonance imaging (MRI). MRI sequences show either a brain-damaged pattern of the central basal ganglia, thalami and posterior limbs of internal capsules with relative cortical sparing, in acute, near-total asphyxial insults manifested by a continuous bradycardia or a pattern of cortical injury in the watershed zones and relative sparing of the central grey matter, in prolonged partial asphyxia, manifested by late or atypical variable decelerations with progressive fetal tachycardia, loss of reactivity and absent fluctuation. Prolongation of either type of asphyxial insult results in more global brain damage. In order to differentiate a CP occurring after perinatal asphyxia from other neurological sequelae in relation with infection, hemorrhage, stroke, malformations, genetic or metabolic diseases, it is essential that a definitive information from the brain by MRI and an extensive histological examination of the placenta are at disposal.
A systematic review of the role of intrapartum hypoxia-ischemia in the causation of neonatal encephalopathy
2008, American Journal of Obstetrics and Gynecology
Citation Excerpt :
For neonates with cord pH < 7.0 cardiopulmonary resuscitation and epinephrine intervention in the delivery room for persistent bradycardia identified those at greatest risk for short-term adverse outcome, and it was concluded that therapeutic strategies to preserve brain function in severe fetal acidemia should focus on such infants.15 A review of the obstetric, neonatal, and pediatric records for all infants born with a pH < 7.0 over a 19-month period in Leiden found that 2 of 21 (9.5%) infants died in the neonatal period, but when the survivors were evaluated at 1-3 years, they had normal results on the Denver Developmental Screening Test.16 They concluded that the umbilical arterial pH at birth is not predictive of serious developmental delay unless accompanied by clinical evidence of HIE.
The object of this review was to determine the incidence, morbidity, and mortality of an umbilical arterial pH < 7.0; the incidence of hypoxic-ischemic encephalopathy; and the proportion of cerebral palsy associated with intrapartum hypoxia-ischemia in nonanomalous term infants. A systematic review of the English language literature on the association between intrapartum hypoxia-ischemia and neonatal encephalopathy was conducted by using Pubmed and Embase. For nonanomalous term infants, the incidence of an umbilical arterial pH < 7.0 at birth is 3.7 of 1000, of which 51 of 297 (17.2%) survived with neonatal neurologic morbidity, 45 of 276 (16.3%) had seizures, and 24 of 407 (5.9%) died during the neonatal period. The incidence of neonatal neurologic morbidity and mortality for term infants born with cord pH < 7.0 was 23.1%. The incidence of hypoxic-ischemic encephalopathy is 2.5 of 1000 live births. The proportion of cerebral palsy associated with intrapartum hypoxia-ischemia is 14.5%. The vast majority of cases of cerebral palsy in nonanomalous term infants are not associated with intrapartum hypoxia-ischemia.
Intrapartum fetal heart rate monitoring
2005, International Congress Series
The risk of fetal hypoxia during labour and delivery is far higher than in a similar period in the third trimester of pregnancy. Especially during the second stage of labour the fetus has an increased risk of suffering from hypoxia/asphyxia/acidosis. Particularly the development of neonatal seizures in the first 1–2 days following birth is an unfavourable sign for functioning in later life. Absence of accelerations and minimal or absent variability are prominent signs in infants who develop acidosis, followed by seizures in the neonatal period.
A number of societies have provided guidelines on who, when and how to monitor the condition of the fetus during the process of labour and delivery. The choice mostly is between intermittent auscultation and electronic FHR monitoring. In some guidelines, electronic FHR monitoring is not a required standard, even for high-risk patients. Nevertheless few practitioners or hospitals have removed cardiotocographs from their labour and delivery units. The recommendation to leave the choice between intermittent auscultation and electronic FHR monitoring to the labouring woman and her attending clinician is based on the conclusions from meta-analyses summarizing outcomes and interventions in randomized controlled trials. Most randomized controlled trials (RCTs) were performed during the 1970s and 1980s. They comprise a mixture of low- and high-risk patients, and preterm and term labours. The studies lack information on how electronic FHR monitoring was performed. Allocation to either intermittent auscultation or electronic FHR monitoring has been variable. The outcome parameters varied likewise. Nearly all RCTs would not fulfil current standards for the quality of a randomised controlled trial.
It is a general belief that the FHR tracings obtained with the external mode of FHR monitoring are of a quality comparable to the internal mode. Rupture of the membranes is considered unnecessary to generate a good quality trace. These opinions leading to false trust and the neglect of obtaining good quality traces are not supported by data from our own hospital. In singletons and especially in twins, internal FHR monitoring provides far better data than the external mode.

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Follow-up of children born with an umbilical arterial blood pH <7

Abstract

Eur J Obstet Gynecol Reprod Biol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Early Hum Dev

Am J Obstet Gynecol

Am J Obstet Gynecol

Microblutuntersuchungen am Feten: Klinischer Einsatz und erste Ergebnisse

Z Geburtshilfe Gynaekol

Clinical aspects of fetal acid-base balance during labor

Response of fetal acid-base balance to duration of second stage of labour

Int J Gynaecol Obstet