From NeoReviews, Strip of the Month: October 2015 Case Review From NeoReviews, Strip of the Month: October 2015

Baseline FHR Baseline FHR Approximate mean FHR rounded to increments of 5 beats/min during a 10 minute segment, excluding accelerations, decelerations, and periods of marked FHR variability. The baseline must be for a minimum of 2 minutes in any 10 minute segment. Normal baseline range is 110-160

Baseline (cont.) Definitions: Tachycardia: The baseline FHR is greater than 160 beats per minute. Bradycardia: The baseline FHR is less than 110 beats per minute.

Variability Fluctuations in the FHR baseline that are irregular in amplitude and frequency, measured from the peak to the trough. Absent- amplitude range is undetectable Minimal- amplitude range is detectable but less than 5 beats/min Moderate- Amplitude range 6-25 beats/min Marked- Amplitude range is greater than 25 beats/min.

FHR Changes Accelerations Visually apparent abrupt increase in the FHR from the baseline. The onset to the peak is less than 30 seconds. Before approximately 32 weeks, an acceleration has a peak of at least 10 beats/min above the bassline and duration of at least 10 seconds. After 32 weeks, an acceleration has a peak of at least 15 beats/min above the baseline and the duration is more than 15 seconds. Prolonged acceleration lasts more than 2 min but less than 10 min If an acceleration is longer than 10 min, it is a baseline change

Decelerations Early Late Variable Prolonged Occurs with a contractions, with a gradual onset (more than 30 seconds to nadir). Generally the nadir occurs at the same time as the peak of the contraction. Late Occurs in association with a contraction with a gradual onset. The Onset, nadir, and recovery occur after the beginning, peak, and end of the contraction. Variable An abrupt (onset to nadir is less than 30 seconds) decrease in the FHR. The decrease is at least 15 beats/min and lasts at least 15 seconds but less than 2 min. Prolonged Decrease in FHR at least 15 beats/min below the baseline, lasting at least 2 min but less than 10.

Three-tier FHR Classification System Category I Normal FHR tracing with all of the following baseline 110-160 FHR variability is moderate Accelerations are present or absent Without late or variable decelerations Early decelerations may be present

Category II Category III Includes all FHR tracings not assigned to Categories I or III Category III FHR tracing includes at least one of the following: Absent variability with late decelerations Absent variability with recurrent variable decelerations Absent variability with bradycardia for at least 10 minutes Sinusoidal pattern for at least 20 minutes

Contractions The number of contractions in a 10-minute window and averaged over 30 min. Normal: 5 or less contractions in 10 minutes Tachysystole: More than 5 contractions in 10 minutes.

Presentation: 41 year-old G2P1 with type 2 diabetes mellitus at 37 5/7 weeks Admitted with early labor and SROM Denies vaginal bleeding Reports feeling frequent fetal movement Significant Hx: Type 2 DM Advanced maternal age Open angle glaucoma Sickle cell trait

Further history Type 2 DM diagnosed 5 years before this pregnancy. Prior medications: Metformin and an ACE Inhibitor. At 8 weeks gestation, transitioned to insulin and the ACE inhibitor was discontinued. Glucose has been well controlled with insulin All 3rd trimester ultrasounds and biophysical profiles have been reassuring.

Progression Admission exam: Blood pressure 126/66 HR 70 Blood glucose 115mg/dL SROM confirmed GBS negaive

Electronic fetal monitoring strip 1. Contractions present? Normal or tachysystole? FHR Baseline? Variability? Accels or Decels? Category? Interpretation: Variability: Moderate Baseline rate: 140 Episodic patterns: none Periodic patterns: none Uterine contractions: every 4 minutes Interpretation: Category 1 Action: continue monitoring labor progression Emily Willner, and Brett C. Young Neoreviews 2015;16:e598-e605 ©2015 by American Academy of Pediatrics

Progression Dilation 3 cm, 75% effaced, and -2 station Insulin drip started

Electronic fetal monitoring strip 2. One hour later… Electronic fetal monitoring strip 2. Electronic fetal monitoring strip 2. Contractions present? Normal or tachysystole? FHR Baseline? Variability? Accels or Decels? Category? Interpretation: Variability: Moderate Baseline rate: 135 Episodic patterns: none Periodic patterns: Variable Decelerations Uterine contractions: Irregular every 1-4 minutes Interpretation: Category II Emily Willner, and Brett C. Young Neoreviews 2015;16:e598-e605 ©2015 by American Academy of Pediatrics

SBAR+R Report Situation Background Assessment Recommendation Read back Nurse calls to MD to evaluate strip: Differential diagnosis: Umbilical cord compression, uteroplacental insufficiency, umbilical cord prolapse Action: Change maternal position, administer IV fluids, SVE to evaluate for umbilical cord prolapse.

Progression Cervical exam: 4 cm, 100 % effaced, and at 0 station Variable decels resolve with position change and IV fluids Epidural placed for pain relief 10 minutes later…

Electronic fetal monitoring strip 3. What are you thinking??? Electronic fetal monitoring strip 3. What are you thinking??? Contractions present? Normal or tachysystole? FHR Baseline? Variability? Accels or Decels? Category? Interpretation: Variability: Moderate Baseline rate: 130 Episodic patterns: Prolonged deceleration Periodic patterns: none Uterine contractions: Irregular every 1-2 minutes Interpretation: Category II Emily Willner, and Brett C. Young Neoreviews 2015;16:e598-e605 ©2015 by American Academy of Pediatrics

SBAR+R Report Situation Background Assessment Recommendation Read back Nurse calls to MD to evaluate strip: Differential diagnosis: Umbilical cord compression, maternal hypotension resulting in uterine hypoperfusion Action: Resuscitative manoeuvres: change maternal position, IV fluids, perform SVE

Progression Dilation 10 cm, 100 % effaced, +2 station. Prolonged decel lasted 9 minutes, despite interventions Decel resolved, and patient began pushing with good effort.

Electronic fetal monitoring strip 4. Variability: Moderate Baseline rate: 110 Episodic pattern: none Periodic pattern: Early and variable decelerations Uterine contractions: every 2 minutes Interpretation: Category II Differential diagnosis: Umbilical cord compression, fetal head compression Action: if delivery is not imminent and the category II tracing continues, the obstetrician may choose to expedite the delivery with forceps or vacuum assisted delivery or proceed with an urgent caesarean delivery. Emily Willner, and Brett C. Young Neoreviews 2015;16:e598-e605 ©2015 by American Academy of Pediatrics

Progression Patient pushed for seven minutes and delivered NICU team in room due to prolonged decel

What are your apgars? 9 9 1 minute : 5 minutes: Color: acrocyanosis Pulse >100 Grimace: good cry Activity: arms and legs flexed with spontaneous movement Resp: more than 50 5 minutes: Color: acrocyanosis Pulse > 100 Grimace: good cry Activity: arms and legs flexed with spontaneous movement Resp: more than 50 9

Outcome Vigorous female at 37 5/7 weeks was delivered by vaginal delivery Wt: 2,615g Uncomplicated neonatal course and was discharged 2 days after birth in stable condition

Discussion 6%-7% of pregnancies are complicated by Diabetes (gestational and Pregestational) Infants of diabetic mothers (IDMs) increased risks: Macrosomia May result in postpartum hemorrhage, cesarean delivery, and extensive perineal damage Shoulder dystocia

Fetal Risks Stillbirth Congenital anomalies Cardiac defects Neural tube defects

Pregestational diabetes increases risks of OB complications: Preeclampsia and other hypertensive disorders of pregnancy Worsening end-organ damage Retinopathy and nephropathy worsen during pregnancy Increased risk of MI Increased risk of diabetic ketoacidosis Placental insufficiency

Neonatal complications Hypoglycemia Respiratory distress Polycythemia Hyperbilirubinemia Increased risk of childhood obesity and development of type 2 diabetes

Risks can be minimized Good control of glucose before and during pregnancy Preconception counseling Ultrasounds monitoring size and fetal well-being “Risks to both the mother and fetus can be minimized by optimization of glucose control before and during pregnancy combined with close monitoring of maternal and fetal well-being. Preconception counseling should include an emphasis on prevention and treatment of end-organ complications of diabetes; avoidance of teratogenic medications, such as angiotensin-converting enzyme inhibitors; and the importance of euglycemia. The rate of fetal congenital anomalies is not significantly increased in the general population when glycosylated hemoglobin levels are within 1% (0.01) of normal (approximately 5%–6%); however, when the glycosylated hemoglobin level is close to 10% (0.10), the rate of congenital anomalies in these pregnancies is 20% to 25%. (2) Short- and long-acting insulin is routinely used for glycemic control. Ultrasonography is used to confirm early pregnancy dating and assess fetal anatomy at 18 to 20 weeks’ gestation. Fetal echocardiography can be considered given the increased risk of congenital cardiac anomalies. Given the increased risk of fetal demise in pregnancies affected by pregestational diabetes, the American College of Obstetricians and Gynecologists supports the use of antenatal fetal surveillance, including fetal movement counting, nonstress testing, and twice-weekly biophysical profile beginning at 32 to 34 weeks’ gestation, with the addition of Doppler velocimetry of the umbilical artery in pregnancies with poor fetal growth. (2)(4)”

References: Strip of the Month: October 2015. Emily Willner and Brett C. Young. NeoReviews 2015;16;e598. DOI: 10.1542/neo.16-10-e598. Retrieved from http://neoreviews.aapublications.org/ by Teriesa Pleyo on May 12, 2016