Morphology of placental lobes and clinical pathophysiology in fetal distress

In order to make a basic study of the etiology, clinical pathophysiology and prevention and management of the fetal distress, an investigation of the placental coefficient, pathomorphology, immunochemistry, and 6 other items were carried out. The placenta lobes of 357 cases with fetal distress were need and a corresponding control was established in each case. The results indicate that the rate of infection of the placenta in fetal distress was 39.5%. The placental coefficient in comparison with the control showed a significant increase (P less than 0.05). Edema of the villi and disease of the villous vascular membrane was prominent. The cytotrophoblast, Hofbauer cell showed cellular compensation proliferation. Estradiol reception (E2R) and progesterone receptor (PgR) were positive mainly in the cyto-trophoblast. The rate of positive finding of Carcinoembryonic Antigen (CEA), AFP and Lysozyme was greater in the fetal distress group in comparison with the control (P less than 0.05). The results indicate that in pregnant women with fetal distress or with risk factors for fetal hypooxygenimia, the administration of anti-infection agents, and improvement of the villus blood circulation as well as giving of anti-amine agents may be beneficial in prevention and management of fetal distress.     

Low placental weight and risk for fetal distress at birth

Abstract Objective: The objective of this study was to assess whether low placental weight is associated with higher risk of emergency delivery (cesarean section and vacuum-assisted delivery). Methods: This was a retrospective cohort study, including 657 normally developed term pregnancies. A strict methodology was used to provide reliable and reproducible placental weight measurement. Fetal heart rate patterns were analyzed according to the guidelines of the Royal College of Obstetricians and Gynecologists. Linear and logistic multiple regression analyses were used to assess risk factors for emergency delivery. Results: Nulliparity, placental weight <10th percentile, and delivery after 40 weeks of gestation remain significantly associated with higher risk of emergency delivery for non-reassuring fetal status in the multivariable model [odds ratio (OR) 5.13, 95% confidence interval (CI) 2.85-9.22, P<0.001; OR 2.46, 95% CI 1.49-4.06, P<0.001; OR 2.23, 95% CI 1.26-4.51, P=0.01, respectively]. In the group of women who had an emergency delivery, 17.3% had a placental weight <10th percentile, which was significantly different to the group of women who delivered normally (9.4%, P≤0.04). If only emergency cesarean sections were analyzed, the percentage of women with placental weight <10th percentile was 37.5% in the cesarean section group compared to 9.8% in women who delivered normally (P≤0.001). Conclusion: This study suggests that, in clinically normally developed term pregnancies, placental weight <10th percentile is associated with an increased risk for emergency delivery during labor. These results warrant further prospective studies for potential use in clinical practice.     

Relationship of placental grade to fetal pulmonary maturity and respiratory distress syndrome

Real-time sonographic placental grading was performed on 215 patients who had amniocentesis for determination of fetal pulmonary maturity between 26 and 42 weeks of gestation. The results of this placental grading were correlated with clinical gestational age and fetal pulmonary maturity, assessed by lecithin-sphingomyelin ratio, phosphatidylglycerol, and the subsequent presence or absence of respiratory distress syndrome. This study showed a statistically significant correlation of placental grade with gestational age, pulmonary maturity, and respiratory distress. Grade 3 placentas were seen in 20% of the cases studied, and in every instance was associated with an absence of subsequent neonatal respiratory distress. Placental grade appeared to be an accurate predictor of fetal pulmonary maturity in the population studied.     

胎儿窘迫的处置

胎儿窘迫可造成围产儿不良结局,因此胎儿窘迫的处置是临床关注的热点。正确识别胎儿窘迫是临床处置的前提,当胎儿窘迫发生时,应进行快捷有效的宫内复苏和针对病因的治疗;终止妊娠的时机和方式是临床决策的重点;胎儿宫内储备状况及对复苏的反应也是影响围产儿结局的重要因素。     

What do placental function tests predict? Observations on placental lactogen levels in growth retardation and fetal distress

Single blood samples were obtained from an unselected population of 527 women between 36 and 40 wk gestation. Serum placental lactogen levels were lower than normal in patients whose infants were growth retarded or developed fetal distress in labor. These associations were independent; the fetal distress group did not contain an excess of subjects with growth retardation. Thus, the results of a biochemical test reflect dynamic aspects of placental function and not simply the overall growth of fetus and placenta.     

The correlation of reduced amniotic fluid volume, placental maturity and morphologic placental changes in placental insufficiency

A reduced quantity of amniotic fluid is diagnosed semiquantitatively in 41 pregnant women in the 38th to 40th week of gestation. In 21 cases, the birth of a mature hypotrophic child below the 10th weight percentile is registered. Sonographically, the placentas of the mature eutrophic children significantly more frequently show a grade III maturity and the placentas of the mature hypotrophic children a grade II maturity. In contrast to the values found in the placentas of eutrophic children and in the placentas with grade III maturity, a significantly decreased villous vascularization is determined in the placentas of hypotrophic children and in placentas with grade II maturity. The area of attachment of the placenta is 301 cm2 for the eutrophic children and 222 cm2 for the hypotrophic children. All findings are discussed and compared with the relevant data of the pertinent literature.     

Studies on the interrelation of fetal heart rate change, placental findings and fetal outcome

The relation between antepartum fetal heart rate (FHR) non stress test (NST), maternal serum estriol, intrapartum FHR change, birth weight, placental findings and Apgar score were studied in 168 normal gestations and 36 high-risk pregnancies including 25 EPH-gestosis cases. The frequency of placental infarcts was higher in severe gestosis than in other high-risk pregnancies and normal gestation. Abnormal NST was more frequent in high-risk pregnancy than normal. Light for date (LFD) infants were more numerous in high-risk pregnancy than normal, and also frequent in the cases of placental infarcts. Particularly in high-risk pregnancy patients with abnormal NST and placental infarcts, 3 out of 5 showed LFD infants. Intrapartum fetal distress was more common in the cases of abnormal NST than normal. The five minute Apgar score was lower in the patients with abnormal NST and in the cases of placental infarcts than normal. The placental infarct ratio was higher in high-risk pregnancies with abnormal NST than normal. The maternal serum estriol level was not changed in cases of high-risk pregnancy, abnormal NST or placental infarcts when compared to normal gestation. The cases of succeeding fetal death, however, showed a low serum estriol level. In conclusion, antepartum abnormal NST suggests severe placental dysfunction caused by its infarcts and the prognosis is poor in patients with high-risk pregnancies, particularly EPH-gestosis. Coping with abnormal antepartum NST is regarded as important in fetal management.     

The relative significance of human placental lactogen in the diagnosis of retarded fetal growth.

The purpose of this prospective study was to determine whether serial maternal venous hPL determinations could identify pregnancies resulting in growth-retarded infants from a selected population at presumed high risk for IUGR. Our results demonstrated that mean hPL levels in IUGR outcome pregnancies were significantly lower than normal after 33 weeks' gestation. Mean hPL was also lower in some pregnancies resulting in normal-weight neonates with abnormally low PI or short CHL, suggesting that these neonates, despite normal birth weight achievement, may represent previously unsuspected.     

The clinical significance of Doppler findings in fetal middle cerebral artery during labor

OBJECTIVES: (1) To investigate fetal intracranial circulation, relative to peripheral blood flow, during labor with abnormal cardiotocographic (CTG) patterns, using three non-invasive methods. (2) To determine the utility of monitoring middle cerebral artery (MCA) Doppler during labor. INTERVENTIONS: Fetuses were assessed using simultaneous CTG, pulse oximetry, and Doppler ultrasonography of both the MCA and umbilical artery (UA) to measure the pulsatility index (PI), resistance index (RI), and flow velocity integral (FVI). STUDY DESIGN: During labor 20 term fetuses with abnormal CTG patterns and oxygen saturation values >30%, and 24 term fetuses with abnormal CTG patterns and oxygen saturation values <30% were studied, and peripartum outcomes were compared. The groups were comparable with regard to maternal age and parity. Results were evaluated using the Student's t-test and Fisher exact test. RESULTS: MCA Doppler showed significantly lower PI and RI, and higher FVI in the presence of reduced oxygen saturation. Differences in fetal outcomes between the two groups correlated with MCA Doppler findings. CONCLUSIONS: In experienced hands, Doppler screening of fetal middle cerebral artery waveforms during labor can be useful in the evaluation of intrapartum hypoxia in complicated pregnancies.     

Malignant placental site trophoblastic tumor associated with placental abruption, fetal distress, and elevated CA-125.

The second pregnancy of 27-year-old woman, gravida 2, para 2 was complicated by a low alpha-fetoprotein and symptoms of chronic placental abruption. She delivered by cesarean section at 35 weeks for fetal distress at which time a biopsy of the uterus revealed a placental site trophoblastic tumor (PSTT). She rapidly developed intraabdominal spread of the neoplasm which did not respond to chemotherapy and she died 10 weeks later. Her CA-125 was elevated to 5360 mu/ml and this decreased after hysterectomy. This patient is reported to highlight a very malignant course of PSTT that was associated with a live-born male infant.     

Acute fetal distress

Three different clinical patterns of acute fetal distress may be observed during labor: an ante-partum hypoxia with a persistent nonreactive and "fixed" fetal heart rate (FHR) on admission to the hospital, a progressive intra-partum asphyxia manifested, as the labor continues, by a substantial rise in baseline heart rate, a loss of variability and repetitive severe variable or late decelerations, and finally, as a result of a catastrophic event, a sudden prolonged FHR deceleration to approximately 60 beats per minute lasting until delivery. However the majority of fetuses with nonreassuring tracings of FHR are neurologically intact, as evidenced by the high false-positive rate of electronic fetal monitoring (EFM). Therefore the diagnosis of fetal distress must be corroborated by complementary methods, such as continuous recording of the fetal electrocardiogram or computed-assisted EFM, fetal pulse oximetry or fetal scalp sampling with immediate determination of blood gases or lactates. Defavorable outcome of an acute fetal distress leading to neonatal encephalopathy or death is best predicted by a persisting low Apgar score (<3) for more than 5 minutes and by a severe metabolic acidosis (umbilical artery pH<7,00 and base-excess>-12mmol/l).     

The fetal response to chronic placental insufficiency

Fetal growth restriction is most commonly caused by failure of the placenta to meet the increasing demands for oxygen and substrate of the developing fetus, resulting in common fetal compensatory responses. Understanding these responses is helpful in developing a management strategy that will optimize pregnancy outcome.