Fetal Heart Rate Accelerations and the Risk of Cerebral Lesions and Poor Neurodevelopmental Outcome in Very Low Birthweight Neonates

ABSTRACT

The risk of intraventricular hemorrhage and periventricular leukomalacia correlates with fetal brain immaturity. Given that the appearance of fetal heart rate (FHR) accelerations is associated with brain maturation, we tested the hypothesis that neonatal cerebral lesions and developmental delay in very low birthweight newborns are associated with absent reactivity of the FHR tracing prior to delivery. We analyzed the FHR tracing of 97 fetuses with birthweight < 1200 g who underwent head ultrasound at day 3 and Bayley Scales of Infant Development testing at age 1 year. We used multivariate analysis to adjust for confounding variables. We found that the absence of two FHR accelerations of 10 beats per minute (bpm) for 10 seconds twice in a 20-minute window 1 hour before delivery was associated with intraventricular hemorrhage and/or periventricular leukomalacia (p < 0.01) and a significant risk for mental and psychomotor delays by Bayley testing (p < 0.001). The absence of accelerations of 15 bpm for 15 seconds was not associated with these abnormalities. The absence of FHR accelerations before delivery suggests a greater risk for cerebral injury and developmental delay in the very premature neonate.

KEYWORDS

Fetal heart rate - intraventricular hemorrhage - periventricular leukomalacia - Bayley Scales of Infant Development

REFERENCES

• 1 Volpe J J. Brain injury in the premature infant: overview of clinical aspects, neuropathology, and pathogenesis.  Semin Pediatr Neurol. 1998;  5 135-151
• 2 Papile L A, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm.  J Pediatr. 1978;  92 529-534
• 3 Philip A G, Allan W C, Tito A M, Wheeler L R. Intraventricular hemorrhage in preterm infants: declining incidence in the 1980s.  Pediatrics. 1989;  84 797-801
• 4 Vohr B R, Wright L L, Dusick A M et al.. Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993-1994.  Pediatrics. 2000;  105 1216-1226
• 5 Vohr B, Ment L R. Intraventricular hemorrhage in the preterm infant.  Early Hum Dev. 1996;  44 1-16
• 6 Cooke R W. Factors associated with periventricular haemorrhage in very low birthweight infants.  Arch Dis Child. 1981;  56 425-431
• 7 National Institute of Child Health and Human Development (NICHD) Research Planning Workshop . Electronic fetal heart rate monitoring: research guidelines for interpretation.  Am J Obstet Gynecol. 1997;  177 1385-1390
• 8 Van Leeuwen P, Lange S, Bettermann H, Gronemeyer D, Hatzmann W. Fetal heart rate varibility and complexity in the course of pregnancy.  Early Hum Dev. 1999;  54 259-269
• 9 Guinn D A, Kimberlin D F, Wigton T R, Socol M L, Frederiksen M C. Fetal heart rate characteristics at 25 to 28 weeks' gestation.  Am J Perinatol. 1998;  15 507-510
• 10 Bishop E H. Fetal acceleration test.  Am J Obstet Gynecol. 1981;  141 905-909
• 11 Druzin M L, Fox A, Kogut E, Carlson C. The relationship of the nonstress test to gestational age.  Am J Obstet Gynecol. 1985;  153 386-389
• 12 Pillai M, James D. The development of fetal heart rate patterns during normal pregnancy.  Obstet Gynecol. 1990;  76 812-816
• 13 De Vries L S, Van Haastert I L, Rademaker K J, Koopman C, Groenendaal F. Ultrasound abnormalities preceding cerebral palsy in high-risk preterm infants.  J Pediatr. 2004;  144 815-820
• 14 Bayley N. Bayley Scales of Infant Development II. San Antonio, TX; The Psychological Corp. 1993
• 15 Garite T J, Rumney P J, Briggs G G et al.. A randomized, placebo-controlled trial of betamethasone for the prevention of respiratory distress syndrome at 24 to 28 weeks' gestation.  Am J Obstet Gynecol. 1992;  166 646-651
• 16 Maher J E, Cliver S P, Goldenberg R L, Davis R O, Copper R L. The effect of corticosteroid therapy in the very premature infant. March of Dimes Multicenter Study Group.  Am J Obstet Gynecol. 1994;  170 869-873
• 17 Chen B, Basil J B, Schefft G L, Cole F S, Sadovsky Y. Antenatal steroids and intraventricular hemorrhage after premature rupture of membranes at 24-28 weeks' gestation.  Am J Perinatol. 1997;  14 171-176
• 18 Canterino J C, Verma U, Visintainer P F, Elimian A, Klein S A, Tejani N. Antenatal steroids and neonatal periventricular leukomalacia.  Obstet Gynecol. 2001;  97 135-139
• 19 Baud O, Foix-L'Helias L, Kaminski M et al.. Antenatal glucocorticoid treatment and cystic periventricular leukomalacia in very premature infants.  N Engl J Med. 1999;  341 1190-1196
• 20 Rotmensch S, Lev S, Kovo M et al.. Effect of betamethasone administration on fetal heart rate tracing: a blinded longitudinal study.  Fetal Diagn Ther. 2005;  20 371-376
• 21 Koenen S V, Mulder E J, Wijnberger L D, Visser G H. Transient loss of the diurnal rhythms of fetal movements, heart rate, and its variation after maternal betamethasone administration.  Pediatr Res. 2005;  57 662-666
• 22 Subtil D, Tiberghien P, Devos P et al.. Immediate and delayed effects of antenatal corticosteroids on fetal heart rate: a randomized trial that compares betamethasone acetate and phosphate, betamethasone phosphate, and dexamethasone.  Am J Obstet Gynecol. 2003;  188 524-531
• 23 Yoon B H, Park C W, Chaiworapongsa T. Intrauterine infection and the development of cerebral palsy.  BJOG. 2003;  110(suppl 20) 124-127
• 24 Garnier Y, Coumans A B, Jensen A, Hasaart T H, Berger R. Infection-related perinatal brain injury: the pathogenic role of impaired fetal cardiovascular control.  J Soc Gynecol Investig. 2003;  10 450-459
• 25 Nelson K B, Ellenberg J H. Antecedents of cerebral palsy. Multivariate analysis of risk.  N Engl J Med. 1986;  315 81-86
• 26 Crowther C A, Hiller J E, Doyle L W, Haslam R R. Effect of magnesium sulfate given for neuroprotection before preterm birth: a randomized controlled trial.  JAMA. 2003;  290 2669-2676
• 27 Grether J K, Hoogstrate J, Walsh-Greene E, Nelson K B. Magnesium sulfate for tocolysis and risk of spastic cerebral palsy in premature children born to women without preeclampsia.  Am J Obstet Gynecol. 2000;  183 717-725
• 28 Althaus J E, Petersen S M, Fox H E, Holcroft C J, Graham E M. Can electronic fetal monitoring identify preterm neonates with cerebral white matter injury?.  Obstet Gynecol. 2005;  105 458-465
• 29 Burrus D R, O'Shea Jr T M, Veille J C, Mueller-Heubach E. The predictive value of intrapartum fetal heart rate abnormalities in the extremely premature infant.  Am J Obstet Gynecol. 1994;  171 1128-1132
• 30 Zanini B, Paul R H, Huey J R. Intrapartum fetal heart rate: correlation with scalp pH in the preterm fetus.  Am J Obstet Gynecol. 1980;  136 43-47
• 31 Tejani N, Rebold B, Tuck S, Ditroia D, Sutro W, Verma U. Obstetric factors in the causation of early periventricular-intraventricular hemorrhage.  Obstet Gynecol. 1984;  64 510-515
• 32 Bowes Jr W A, Gabre S G, Bowes C. Fetal heart rate monitoring in premature infants weighing 1,500 grams or less.  Am J Obstet Gynecol. 1980;  137 791-796
• 33 Strauss A, Kirz D, Modanlou H D, Freeman R K. Perinatal events and intraventricular/subependymal hemorrhage in the very low-birth weight infant.  Am J Obstet Gynecol. 1985;  151 1022-1027
• 34 Hashimoto K, Hasegawa H, Kida Y, Takeuchi Y. Correlation between neuroimaging and neurological outcome in periventricular leukomalacia: diagnostic criteria.  Pediatr Int. 2001;  43 240-245