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Preeclampsia and fetal heart rate decelerations
Correspondence
Volume 153 ~umber I
5. McNeil BJ, Keeler E, Adelstein SJ. Primer on certain elements of medical decision-making. N Engl J Med 1975;293:211-5. 6. Carson JL, Eisenberg JM, Shaw LM, et al. Diagnostic accuracy of four assays of prostatic acid phosphatase. Comparison using receiver operating characteristic curve analysis. JAMA 1985;253:665-9.
Preeclampsia and fetal heart rate decelerations To the Editors: The article by John Bourgeois et al., entitled "The significance of fetal heart rate decelerations during nonstress testing" (AM J OBSTET Gvr-:ECOL 1984; 150:213), suggests that nonstress tests showing deceleration of this type in term pregnancy should be viewed with alarm and that such fetuses should be delivered. It was added that, in preterm pregnancy with a nonreactive nonstress test such decelerations may also be valid grounds for delivery, although some discrimination is possible when the nonstress test is reactive. We would like to comment on the management of two of the reported cases. In patient No. 3, Table IB, the indication for testing was preeclampsia, and the nonstress test was performed at 41 weeks of gestation. According to the data, the nonstress test was nonreactive and the contraction stress test was negative. The patient presented 48 hours later with fetal death. We think that preeclampsia itself at 41 weeks' gestation could be the reason for the intrauterine fetal death. According to Pritchard and MacDonald, 1 in cases with preeclampsia it may be illadvised to wait, since the sequelae of the disease itself may kill the fetus. Few obstetricians would opt for expectant management in cases of preeclampsia after 40 weeks' gestation. The fetal heart rate deceleration in these circumstances is secondary to fetal jeopardy. Patient No. 4, Table IB, was diagnosed as having severe preeclampsia with intrauterine growth retardation. The nonstress test performed was nonreactive, and the contraction stress test was interpreted as being negative, although recurrent variable decelerations and decreased beat-to-beat variability were noted. Based on the data, we think that there were enough signs of fetal compromise for delivery to be considered, even without information on the fetal heart rate. This case shows once again that the fetal heart rate deceleration is simply one more sign of fetal distress in a very compromised maternal fetal condition. It is misleading to analyze the significance of prolonged deceleration in the above two unfortunate cases. Furthermore, it would not be recommended to reach a final conclusion on this basis. It is our opinion that patients in whom the initial nonstress test was performed because of specific indication should be managed according to the protocols applied to that condition and not according to such sporadic findings on antepartum monitoring. 2 · " Otherwise, this finding might always be interpreted as an ominous sign and delivery considered in every case, regardless of the
115
other well-known antepartum fetal heart rate testing schemes or biophysical profile score. Such an approach may lead to many undue terminations of pregnancy. On the other hand, we agree with the authors that the incidence of fetal distress during labor is significantly higher in patients showing previous sporadic fetal heart rate deceleration than in otherwise normal pregnancies. 2 Therefore, these patients should be monitored carefully during labor. However, in the absence of other complications, there 1s no need for elective termination of pregnancy. M. Mazor, M.D. ]. R. Leiberman, M.D. Z.]. Hagay, M.D. V. Insler, M.D. Division of Obstetrics and Gynecology Soroka University Hospital Faculty of Health Sciences Ben-Gurion University of the Negev Beer-Sheva, Israel REFERENCES I. Pritchard .J A, MacDonald PC. Williams' Obstetrics. 16th ed, New York: Appleton-Century-Crofts, 1980:682-3. 2. Hagay ZJ, Mazor M, Leiberman.JR, Katz M, Insler V. The significance of single sporadic deceleration during a nonstress test. Eur .J Obstet Gynec Reprod Biol 1983; 15: 165. 3. Mazor M, Hagay Z.J, Leiberman.JR, Katz M, Insler V. Significance of fetal deceleration during antepartum heart rate testing [Letter]. AM .J 0BSTET GY!'>ECOL 1985; 151: 146.
Reply To the Editors: We wish to address what appear to be two serious misinterpretations of our findings and conclusions in this report. First, as represented in our discussions, we feel that the finding of deceleration in this circumstance is not to be interpreted without regard to findings on a nonstress test. As noted, we feel pregnancies that are premature can be continued and monitored closely when the finding of deceleration coincides with a reactive nonstress test. We do nevertheless maintain that decelerations of this nature may be of ominous significance in compromised pregnancies and feel that it is exactly the point that such deceleration "is simply one more sign of fetal distress." We in no way suggested, nor do we now, that final action be based solely on the deceleration and regardless of other fetal assessment techniques. Furthermore, we feel that it is precisely in situations leading to fetal distress that the accurate interpretation of the finding of fetal heart rate decelerations is most imperative. In fact, had the significance of such a finding been known at the time, the cases cited would have been managed differently. Heretofore, a negative contraction stress test in the presence of a nonreactive nonstress test would have been accepted as indicative of immediate fetal well-being. We certainly agree with Mazor et al. that the finding
Volume 153 ~umber I
5. McNeil BJ, Keeler E, Adelstein SJ. Primer on certain elements of medical decision-making. N Engl J Med 1975;293:211-5. 6. Carson JL, Eisenberg JM, Shaw LM, et al. Diagnostic accuracy of four assays of prostatic acid phosphatase. Comparison using receiver operating characteristic curve analysis. JAMA 1985;253:665-9.
Preeclampsia and fetal heart rate decelerations To the Editors: The article by John Bourgeois et al., entitled "The significance of fetal heart rate decelerations during nonstress testing" (AM J OBSTET Gvr-:ECOL 1984; 150:213), suggests that nonstress tests showing deceleration of this type in term pregnancy should be viewed with alarm and that such fetuses should be delivered. It was added that, in preterm pregnancy with a nonreactive nonstress test such decelerations may also be valid grounds for delivery, although some discrimination is possible when the nonstress test is reactive. We would like to comment on the management of two of the reported cases. In patient No. 3, Table IB, the indication for testing was preeclampsia, and the nonstress test was performed at 41 weeks of gestation. According to the data, the nonstress test was nonreactive and the contraction stress test was negative. The patient presented 48 hours later with fetal death. We think that preeclampsia itself at 41 weeks' gestation could be the reason for the intrauterine fetal death. According to Pritchard and MacDonald, 1 in cases with preeclampsia it may be illadvised to wait, since the sequelae of the disease itself may kill the fetus. Few obstetricians would opt for expectant management in cases of preeclampsia after 40 weeks' gestation. The fetal heart rate deceleration in these circumstances is secondary to fetal jeopardy. Patient No. 4, Table IB, was diagnosed as having severe preeclampsia with intrauterine growth retardation. The nonstress test performed was nonreactive, and the contraction stress test was interpreted as being negative, although recurrent variable decelerations and decreased beat-to-beat variability were noted. Based on the data, we think that there were enough signs of fetal compromise for delivery to be considered, even without information on the fetal heart rate. This case shows once again that the fetal heart rate deceleration is simply one more sign of fetal distress in a very compromised maternal fetal condition. It is misleading to analyze the significance of prolonged deceleration in the above two unfortunate cases. Furthermore, it would not be recommended to reach a final conclusion on this basis. It is our opinion that patients in whom the initial nonstress test was performed because of specific indication should be managed according to the protocols applied to that condition and not according to such sporadic findings on antepartum monitoring. 2 · " Otherwise, this finding might always be interpreted as an ominous sign and delivery considered in every case, regardless of the
115
other well-known antepartum fetal heart rate testing schemes or biophysical profile score. Such an approach may lead to many undue terminations of pregnancy. On the other hand, we agree with the authors that the incidence of fetal distress during labor is significantly higher in patients showing previous sporadic fetal heart rate deceleration than in otherwise normal pregnancies. 2 Therefore, these patients should be monitored carefully during labor. However, in the absence of other complications, there 1s no need for elective termination of pregnancy. M. Mazor, M.D. ]. R. Leiberman, M.D. Z.]. Hagay, M.D. V. Insler, M.D. Division of Obstetrics and Gynecology Soroka University Hospital Faculty of Health Sciences Ben-Gurion University of the Negev Beer-Sheva, Israel REFERENCES I. Pritchard .J A, MacDonald PC. Williams' Obstetrics. 16th ed, New York: Appleton-Century-Crofts, 1980:682-3. 2. Hagay ZJ, Mazor M, Leiberman.JR, Katz M, Insler V. The significance of single sporadic deceleration during a nonstress test. Eur .J Obstet Gynec Reprod Biol 1983; 15: 165. 3. Mazor M, Hagay Z.J, Leiberman.JR, Katz M, Insler V. Significance of fetal deceleration during antepartum heart rate testing [Letter]. AM .J 0BSTET GY!'>ECOL 1985; 151: 146.
Reply To the Editors: We wish to address what appear to be two serious misinterpretations of our findings and conclusions in this report. First, as represented in our discussions, we feel that the finding of deceleration in this circumstance is not to be interpreted without regard to findings on a nonstress test. As noted, we feel pregnancies that are premature can be continued and monitored closely when the finding of deceleration coincides with a reactive nonstress test. We do nevertheless maintain that decelerations of this nature may be of ominous significance in compromised pregnancies and feel that it is exactly the point that such deceleration "is simply one more sign of fetal distress." We in no way suggested, nor do we now, that final action be based solely on the deceleration and regardless of other fetal assessment techniques. Furthermore, we feel that it is precisely in situations leading to fetal distress that the accurate interpretation of the finding of fetal heart rate decelerations is most imperative. In fact, had the significance of such a finding been known at the time, the cases cited would have been managed differently. Heretofore, a negative contraction stress test in the presence of a nonreactive nonstress test would have been accepted as indicative of immediate fetal well-being. We certainly agree with Mazor et al. that the finding