The fetal recoil test

The fetal recoil test Thomas H. Strong, Jr., MD," Denise L. Jordan, RN,b and David W. Marden, DOc Phoenix, Arizona, and Pomona, California A reassuring fetal recoil test had positive and negative predictive values of 98% and 8%, respectively, for a reactive nonstress test (sensitivity 89%, specificity 33%). Among 21 of 30 subjects in whom recoil was present immediately before delivery, none had umbilical arterial pH values $7.20 versus 5 of 9 (56%) with non reassuring recoil (p = 0.005). We concluded that a reassuring fetal recoil test is a reliable marker for fetal well-being. (AM J OasTET GVNECOL 1992;167:1382-3.)

Key words: Fetal acoustic stimulation, fetal recoil, fetal monitoring

The fetal startle response after fetal acoustic stimulation consists of a short-term increase in body movements ("recoil") followed by an acceleration in the fetal heart rate (FHR). Whereas the FHR acceleration produced by fetal acoustic stimulation is a reassuring finding,l little attention has been given to fetal recoil as a marker that is independent of the FHR response. The purpose of this study was to assess the ability of fetal recoil alone to identifY the intact fetus.

Material and methods The fetal recoil test, an antepartum assessment technique developed by the authors, was performed on fetuses ~ 36 weeks' gestation during 100 consecutive nonstress tests (NSTs) at Good Samaritan Regional Medical Center in Phoenix, Arizona. A reassuring fetal recoil test was defined as a palpable fetal startle response occurring during the delivery of a 1- to 3-second vibroacoustic stimulus (Western Electric model 5C electrolarynx). All 100 tests were administered by one investigator and all NSTs were interpreted by another (blinded) observer. Next, 30 women at ~ 30 weeks' gestation underwent the recoil test within 5 minutes of cesarean delivery. Umbilical arterial pH values were then compared with the results of the recoil test.

Results Among the 100 NSTs, 97 were reactive and 88 exhibited reassuring fetal recoil tests (positive predictive value 98%, negative predictive value 8%, sensitivity 89%, specificity 33%). A reassuring recoil test was also associated with an FHR acceleration of ~ 15 beats/min

From Phoenix Perinatal Associates, the Division of Maternal-Fetal Medicine, a and the Perinatal Evaluation Center, b Good Samaritan Regional Medical Center, and the College of Osteopathic Medicine of the Pacific.' Received for publication March 10, 1992; revised May 19, 1992; accepted May 27, 1992. Reprints not available. 6/1/39611

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for ~ 15 seconds within 60 seconds of stimulation (positive predictive value 90%, negative predictive value 21 %, sensitivity 88%, specificity 25%). Among the 30 undergoing the recoil test immediately before cesarean section, 21 (70%) had reassuring test results (Table I). The positive and negative predictive values of a reassuring recoil test result for an umbilical arterial pH ~ 7.20 were 100% and 56%, respectively (sensitivity 84%, specificity 100%).

Comment Fetal acoustic stimulation offers the advantage of rapid availability of results, noninvasiveness, and reliability but requires concomitant monitoring of the FHR. Therefore the fetal acoustic stimulation test is limited to settings where electricity, monitoring equipment, and personnel with the appropriate expertise are available. The fetal recoil test has utility because it assesses a component of the fetal startle response that is easy to detect. Therefore the test may add a dimension to fetal surveillance that was previously unavailable with simple auscultation of the FHR. For instance, its use during labor or routine prenatal visits may provide greater reassurance of well-being than simple FHR auscultation alone. The recoil test may also have benefit in assessing the third-trimester fetus during "in the field" emergencies or maternal transports. No attempt was made to evaluate the recoil test as a long-term (i.e., 7-day) predictor of fetal well-being. Pending further studies, a reassuring fetal recoil test should be viewed as a marker for fetal well-being in the short-term setting only. As with all antepartum tests of fetal well-being, the recoil test has high sensitivity but low specificity. In the event that fetal acoustic stimulation fails to evoke a reassuring fetal recoil, other modalities should be called on to clarify the clinical picture. The fetal recoil test may be less reliable among the obese and those with multiple gestations or polyhydramnios. 2 These limitations notwithstanding, the fetal

Fetal recoil

Volume 167 Number 5

Table I. Fetal recoil and umbilical arterial pH values Recoil present

Recoil absent (n = 9)

Significance

7.29 ± 0.05

7.27 ± 0.16 5 (56%)

P=

(n = 21)

pH (mean ± SD) pH <7.20 (No. and %)

o

NS 0.005*

NS, Not significant.

*Fisher's exact test.

recoil test appears to be a reliable technique for assessing fetal well-being that can be applied more widely than the NST or biophysical profile. As such, its utility may lie in its availability.

tic stimulation with acid-base determinations. AM J OBSTET GYNECOL 1986;155:726-8. 2. Richards DS, Abrams RM, Gerhardt KJ, McCann ME. Effects of vibration frequency and tissue thickness on intrauterine sound levels in sheep. AM J OBSTET GYNECOL 1991; 165:438-42.

REFERENCES J. Smith Cv, Nguyen HN, Phelan JP, Paul RH. Intrapartum assessment of fetal well-being: a comparison of fetal acous-

Recurrent squamous carcinoma of the vulva A. Stephen Tilmans, MD," Gregory P. Sutton, MD,b Katherine Y. Look, MD,b Frederick B. Stehman, MD,b Clarence E. Ehrlich, MD,b and Ned B. Hornback, MD" Indianapolis, Indiana OBJECTIVE: This study reviews experience at Indiana University with recurrent squamous carcinoma of the vulva over an 18-year period from 1971 to 1989. The pattern of recurrence, time interval to recurrence, and efficacy of salvage therapy are evaluated in the context of the primary tumor. STUDY DESIGN: This is a retrospective study of 40 patients, 21 of whom underwent primary therapy for invasive squamous carcinoma of the vulva at Indiana University. RESULTS: Vulvar recurrences were observed in 17 patients (43%), the groin was involved in 12 (30%), whereas pelvic and distant recurrences were observed in 2 (5%) and 9 (22.5%) patients, respectively. Salvage surgery and/or radiotherapy were successful in 25 patients (62.5%) alive from 1 to 144 months (median 8 months) from secondary therapy. Survival after retreatment varied significantly by site of recurrence (p = 0.002), tumor grade (p == 0.009), and interval to recurrence (p < 0.001). Best outcomes were in patients with initial stage I or " disease (International Federation of Gynecology and Obstetrics), grade 1 tumors, local failure, and interval to relapse of > 16 months' duration. Two of 12 patients with groin recurrences were salvaged with surgery and radiotherapy. CONCLUSION: Long-term follow-up of patients with vulvar cancer and careful restaging at the time of recurrence are mandatory. Although local and nodal recurrences may be controlled with surgery and/or radiotherapy, regional recurrences are usually fatal. (AM J OSSTET GVNECOL 1992;167:1383-9.)

Key words: Vulvar cancer, recurrence

From the Department of Radiation Oncology" and the Section of Gynecology Oncology, Department of Obstetrics and Gynecology," Indiana University Medical Center. Received for publication September 26, 1991; revised March 27, 1992; accepted April 21, 1992. Reprint requests: G.P. Sutton. MD, Section of Obstetrics and Gynecology, Indiana Universit,v Medical Center. 926 W. Michigan St., Indianapolis, IN 46202-5274.

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Radical vulvectomy with bilateral inguinal lymphadenectomy has been the accepted primary management for squamous carcinoma of the vulva. I Conservative resection rather than more extensive procedures has been recently advocated for some subsets of patients.2 Many have attempted to define reliable prognostic variables that allow a more limited resection."" 1383