2008

Confidential Enquiry into Maternal and Child Death (CEMACH)

Cemach.org.uk

Obesity in Pregnancy has been selected as CEMACH's principal project with a maternal health focus for 2008-2011

Substantial evidence that obesity in pregnancy contributes to increased morbidity and mortality for mother and baby.

30% of mothers who had a stillbirth or neonatal death were obese

Obese women spend an average of 4.83 more days in hospital and increased levels of complications in pregnancy and interventions in labour represent a 5 fold increase in cost of antental care.

2007

Monitoring Contractions in Obese Parturients: Electrohysterography Compared With Traditional Monitoring.

American College of Obstetricians and Gynecologists 2007 May;109(5):1136-40

Tammy Y. Euliano, MD, Minh Tam Nguyen, MS, Dorothee Marossero, MS, and Rodney K. Edwards, MD, MS

To compare electrohysterogram derived contractions with both tocodynamometry and intrauterine pressure monitor in obese laboring women.

25 subjects median BMI 39.6

Tocodynamometry identified 248 contractions compared with 336 by electrohysterography, whereas intrauterine pressure catheter monitoring identified 319 contractions compared with 342 by electrohystergraphy.

In obese women in this study, the electrohysterogram –derived contraction pattern correlated better with the intrauterine pressure catheter than tocodynamometry.

Electrohysterography may provide another noninvasive means of monitoring labor, particularly for those women in whom tocodynamometry is adequate.

2007

Monitoring Contractions in Obese Parturients: Electrohysterography Compared With Traditional Monitoring.

American College of Obstetricians and Gynecologists 2007 May;109(5):1136-40

Tammy Y. Euliano, MD, Minh Tam Nguyen, MS, Dorothee Marossero, MS, and Rodney K. Edwards, MD, MS

To compare electrohysterogram derived contractions with both tocodynamometry and intrauterine pressure monitor in obese laboring women.

25 subjects median BMI 39.6

Tocodynamometry identified 248 contractions compared with 336 by electrohysterography, whereas intrauterine pressure catheter monitoring identified 319 contractions compared with 342 by electrohystergraphy.

In obese women in this study, the electrohysterogram –derived contraction pattern correlated better with the intrauterine pressure catheter than tocodynamometry.

Electrohysterography may provide another noninvasive means of monitoring labor, particularly for those women in whom tocodynamometry is adequate.

1982

Diurnal and other cyclic variations in human fetal heart rate near term

Am J Obstet Gynecol. 1982 Mar 1;142(5):535-44

Visser GH, Goodman JD, Levine DH, Dawes GS.

In 10 healthy women near term, fetal heart rate, as monitored from an abdominal electrocardiogram and its variation were analyzed over 24 hours. During the daytime, this was combined with real-time scanning for fetal breathing and movements. There was an episodic change in high and low pulse (R-R) interval variation with a mean cycle length of 92 minutes. The changes in cycle length were large; around midnight, episodes of high variation lasted up to 6 hours.

Episodes of high variation coincided with greater fetal movement (measured only in daytime). Neither low nor high episodes were consistently related to fetal breathing. Both fetal heart rate and its variability showed a diurnal variation, by 11% and 50%, respectively; these were not statistically related. There was a particularly large change in pulse interval variation with peak values around midnight; concomitantly, there was a diurnal variation in the incidence of accelerations of defined size.

1994

Transient reduction in fetal activity and heart rate variation after maternal betamethasone administration.

Early Hum Dev. 1994 Jan; 36(1):49-60

Mulder EJ, Derks JB, Zonneveld MF, Bruinse HW, Visser GH.

We studied the short-term effects of maternal betamethasone administration on fetal well-being by recording of fetal movement and heart rate patterns. In 13 women at high risk of preterm delivery (26-32 weeks), eighty 1-h recordings were made of fetal body and breathing movements and fetal heart rate (FHR) and its variation during 5 consecutive days.

Betamethasone was administered in two doses 24 h apart after a control recording had been made. After two doses of betamethasone, fetal body and breathing movements and FHR variation were considerably reduced (P < 0.01), but returned to normal after treatment was discontinued. FHR variation was transiently below the lower normal range in 46% of the cases.

We conclude that maternal betamethasone administration results in a considerable reduction in fetal movements and FHR variation which may erroneously be interpreted as deterioration of the fetal condition. Knowledge of these transient changes is of significant clinical importance as it may prevent iatrogenic delivery because of suspected fetal distress. The observed effects are possibly mediated by centrally located glucocorticoid receptors.

1990

Changes in antepartum heart rate patterns with progressive deterioration of the fetal condition.

Int J Biomed Comput. 1990 May;25(4):239-46

Visser GH, Bekedam DJ, Ribbert LS

In this paper changes in antepartum fetal heart rate (FHR) patterns are described, that occur with progressive deterioration of the fetal condition.

A possible rank ordering is presented in which changes in FHR pattern, body movements and blood flow velocity wave form patterns occur with progressive deterioration of the fetal condition.

It is concluded that in small-for-date fetuses changes in heart rate and movement patterns are rather late signs of impairment, coinciding with fetal hypoxaemia.

In general, heart rate variation falls below the norm at the same time as decelerations occur; there are, however, large inter-fetal differences.

The advantages of a numerical analysis of FHR patterns include identification of fetuses with low FHR variation, precision of the actual fetal condition and (at early gestation) longitudinal follow-up of fetuses with abnormal heart rate patterns.

2004

Maternal self-administered fetal heart rate monitoring and transmission from home in high-risk pregnancies

Int J Gynaecol Obstet. 2004 Jan;84(1):33-9

Kerner R, Yogev Y, Belkin A, Ben-Haroush A, Zeevi B, Hod M

Objectives: To evaluate the feasibility of high-risk pregnancy surveillance by patient-directed fetal heart rate monitoring and transmission, and to assess patient satisfaction with this technology.

Methods: Thirty-six women with high-risk pregnancies performed daily non-stress tests at home and transmitted the data to our perinatal care center by telephone. Questionnaire on quality of life and anxiety state before and after the study.

Results: There were no significant immediate adverse maternal or neonatal outcomes as a result of the monitoring. Three were hospitalised for further monitoring.

Conclusions: Daily home FHR monitoring in high-risk patients is safe and feasible at all gestational ages, based on this initial pilot evaluation. It is easily and reliably performed and accepted by patients with a high level of satisfaction.

2003

Telemedicine for antenatal surveillance of high-risk pregnancies with ambulatory and home fetal heart rate monitoring-an update

J.Perinat.Med. 31 (2003) 195-200

Moshe Hod; Ram Kerner

Aim of this review was to assess the current data on the application of this new technology with regard to feasibility, access to care, maternal and neonatal outcome, patient and physician satisfaction, and cost-effectiveness.

The availability of the monitoring device at home adds flexibility and management time, and enables more frequent surveillance at no extra cost.

Horio et al. found that 96% of their patients who tried NST screening at home wanted to use the monitor again in their next pregnancy.

Telemonitoring does not seem to be associated with an excess rate of neonatal or maternal adverse effects, though more evidence is needed before it can be adopted for routine use. There is high potential for cost savings.

2007

Twenty-four-hour CTG monitoring: comparison of normal pregnancies of 25-30 weeks of gestation versus 36-42 weeks of gestation

Arch Gyneocol Obstetrics (2007) 275:451-460

Maritta Kuhnert, Lars Hellmeyer, Werner Stein, Stephan Schmidt

Goal of the study: if a continuous 24-hour CTG allows an earlier detection of beginning hypoxia in case of normal pregnancy of 36-42 week compared to pregnancies of 25-30 weeks of gestation.

Subjects: 21 mothers in each group had 24 hour CTG’s by means of telemetry (Hewlett-Packard)‏ Comparison of the results of both groups was done to look for early signs of pathological findings concerning reduced fetal well-being and a potential day and night rhythm.

Conclusion: Twenty four hour CTG is a good screening method to detect early onset of hypoxia in case of second and third trimester pregnancies and a big help to detect a fetus at risk earlier. In future computerised CTG-systems should be proved in this connection be compared with our study.

2008

Association between Obesity during Pregnancy and Increased Use of Health Care

N Eng J Med 2008; 358:1444-53

Susan Y Chu, Ph.D.,M.S.P.H, Donald J.Bachman, et al

Study using 13,442 pregnancies among women 18 years age or older at the time of conception that resulted in live or stillbirths.

Assessed associations between measures of use of health care services and body-mass index.

Finding may reflect the fact that clinicians will monitor fetal growth and development more closely in women with high-risk conditions, but because measuring growth clinically in very obese or extremely obese women is more difficult, more frequent tests may be needed.

In conclusion, we found that maternal BMI higher than normal is associated with greater use of heath care services

2006

ABC of Obesity, Obesity and Reproduction

BMJ Dec 2006;333:1159-1162

Ramsay JE, Greer I, Sattar N.

Potential problems in monitoring obese mothers, external electronic fetal monitoring can be problematic, women have reduced awareness of fetal movements, Large cuffs required to measure blood pressure.

Obesity can raise management costs of pregnancy, Increased risk of admission to hospital for complications such as pre-eclampsia

Increased use of ultrasonography and operator time for difficult anomaly scans andfetal assessment

2006

The growing trends in maternal obesity

Royal College of Obstetricians and Gynaecology Oct 2006 Vol 113; No 10

Editor –in-chief of BJOG Philip Steer

Philip Steer in this article says ‘Maternal obesity needs to be recognised as a serious and growing health problem. The RCOG is so concerned it has convened a special study group to debate the topic, discuss idea’s on how to manage the situation and find possible solutions’

Obesity during pregnancy is a risk factor for adverse pregnancy outcomes. This is a major concern in the west, where 28% of pregnant women are overweight and 11% are obese. In the UK population 33% of women are currently overweight (BMI>25) and 23% are obese (BMI>30), a total of 56% over the recommended BMI