Intraoperative Findings, Placental Assessment And Neonatal Outcome In Emergent Cesarean Deliveries For Non-Reassuring Fetal Heart Rate

Eran Weiner1, Jacob Bar1, Nataly Fainstein1, Letizia Schreiber2, Michal Kovo1

Depts. of Obstet. & Gyn1 and Pathology2, the E. Wolfson Medical Center, Holon, and Sackler Faculty of Medicine, Tel Aviv University, Israel
Objective: To correlate between intra-operative findings, placental histopathology and neonatal outcome in emergent cesarean deliveries (ECD) for non-reassuring fetal heart rate (NRFHR).

Study Design: Data on ECD for NRFHR were reviewed for labor, documented intraoperative findings, neonatal outcome and placental histopathology reports. Results were compared between those with and without intraoperative findings. Placental lesions were classified to those related to maternal underperfusion, fetal thrombo-occlusive disease, and maternal (MIR) and fetal (FIR) inflammatory responses. Neonatal outcome consisted of Apgar score, pH<7.0, and evidence of RDS, NEC, sepsis, phototherapy, transfusion, ventilation, seizures, death.
Results: Intraoperative findings were observed in 49.5% of 543 women and included: cord entanglements in 77%, placental abruptions in 25.5%%, true knots in 6.6%, short cord in 6.3%, uterine rupture & dehiscence in 1.5 %, and cord prolapse in 1.5% (more than one cause was possible). Placental lesions were more common in those without intraoperative findings as compared to those with intraoperative findings: placental lesions related to maternal under-perfusion, vascular lesions , 9.1% vs. 4.1%, p=0.024, and villous changes, 39.2% vs. 30.7%, p=0.047, lesions consistent with fetal thrombo-occlusive disease, 13.6% vs. 7.4%, p=0.024, and inflammatory lesions, MIR and FIR, p=0.033, p=0.001, respectively. By using multivariate logistic regression analysis, adverse neonatal outcome was found to be dependent on maternal age, gestational age, preeclampsia placental weight <10th %, and MIR.
Conclusion: NRFHR necessitating ECD may originate from different underlying mechanisms. In about half, the insult is probably acute and can be identified intraoperatively. In the remaining half, underlying placental compromise may be involved.