Disclosures UCSF June 2014 I have no financial disclosures - PowerPoint PPT Presentation

Disclosures UCSF June 2014 � I have no financial disclosures LEADING THE QUEST FOR HEALTH  � No off label use of drugs TACHYSYSTOLE… Kimberly D. Gregory MD, MPH Vice Chair Women’s Healthcare Quality & Performance Improvement Cedars Sinai Medical Center, Dept Ob/Gyn Professor, David Geffen School of Medicine & UCLA School of Public Health KD Gregory 5/2014 Objectives What is tachysystole? � At the completion of this lecture, participants will be able to … � 2008 NICHD Workshop Report on Electronic Fetal Monitoring — Describe (and be able to recognize) the different types of — Macones et al; Obstet Gynecol 2008; 112:661-6 tachysystole � A full description of EFM tracing requires a qualitative and quantitative description of — Describe the maternal and neonatal clinical implications of tachysystole 1. Uterine Contractions — Describe various treatment options for tachysystole 2. Baseline fetal heart rate (FHR) — Describe components of QI program to “cease and desist” 3. Baseline FHR variability � No more “pitting through it” 4. Presence of accelerations � No more “pit to distress” 5. Periodic or episodic decelerations 6. Changes or trends of FHR patterns over time KD Gregory 5/2014 KD Gregory 5/2014 1

What is Tachysystole? What is tachysystole? � 2008 NICHD Workshop Report on Electronic Fetal Monitoring � 2008 NICHD Workshop Report on Electronic Fetal Monitoring — Macones et al; Obstet Gynecol 2008; 112:661-6 — Macones et al; Obstet Gynecol 2008; 112:661-6; — ACOG Practice Bulletin, Obstet Gynecol 2009; 114:192-202 � Uterine Contractions � Uterine Contractions — Number of contractions present in 10 minute window, averaged over 30 minutes — “the terms hyperstimulation and hypercontractility are not defined and should be abandoned” — NORMAL: <5 contractions in 10 min window — TACHYSYSTOLE:>5 contractions in 10 minutes — “other factors such as duration, intensity, and relaxation � TS can be spontaneous or associated with stimulated labor time between contractions are equally important in clinical � TS no decelerations vs TS + decelerations practice” KD Gregory 5/2014 KD Gregory 5/2014 What is Tachysystole? What does Tachysystole look like? � Kunz et al JOGNN, 2013;42:12-18 — NICHD, ACOG, SMFM, AWHONN � Tachysystole is identified when one or more criteria are present (30 min increments) 1. More than 5 contractions in a 10 min window, averaged over 30 min 2. A series of single contractions lasting 2 min or more 3. Contractions of normal duration occurring within one minute of each other (ACOG 2003, Simpson & Creehan 2008) 4. Insufficient return of uterine resting tone between contractions via palpation or intrauterine amniotic pressure above 25 mmHg between contractions via IUPC (Simpson & Creehan) TS, no FHR changes TS + FHR changes � Gregory take home point: TS is… TOO MANY CONTRACTIONS!!! Google images, uterine hyperstimulation KD Gregory 5/2014 KD Gregory 5/2014 2

What does Tachysystole look like? Why Should We be Concerned About Tachysystole? TS + FHR changes Google images, uterine hyperstimulation www.birthinjury.org KD Gregory 5/2014 KD Gregory 5/2014 Why Should We be Concerned About Tachysystole? What’s the Evidence? Is it Much Ado about Nothing? � During contraction, myometrial pressure � NICHD 2008 Research Recommendations exceeds the arterial pressure —“…studies include work that evaluates � Uterine blood flow stops, oxygen exchange stops contraction frequency, strength, and duration — If UC >30 mmHg spiral arteries on FHR and clinical outcomes.” are compressed — Labor mean uterine pressure 85- 90mmHg, higher with pushing � Duration, strength of contraction determines length of time spiral arteries are compressed — Too long, too strong can cause www.birthinjury.org fetal hypoxemia KD Gregory 5/2014 KD Gregory 5/2014 3

What’s the Evidence? Is it Much Ado about Nothing? What’s the Evidence? Is it Much Ado about Nothing? � Bakker et al, AJOG 2007; 196:313.e1-313.e6 � Bakker et al, AJOG 2007; 196:313.e1-313.e6 � Elevated uterine activity increases the risk of fetal acidosis Characteristic First stage Second stage at birth (<7.11 vs >7.12) (<7.11 vs >7.12) � Amsterdam, June 1993-July 2004 Shorter avg relax time (sec) 51 vs 63 36 vs 47 � N=2886 (all cases with IUPC); tracings analyzed via computer Longer contraction duration (sec) 2216 vs 2053 1465 vs 1268 and 2 independent reviewers for each 10 min window for last Contraction amplitude (mmHg) 1383 vs 1178 1477 vs 1219 hour of first stage and all second stage Contraction surface (mmHg x sec) 479 vs 418 442 vs 370 Montevideo units 261 vs 236 442 vs 402 � Evaluated: relaxation time, duration, amplitude, surface, Mv units, active planimeter units, and contraction frequency Contraction frequency/10 min 5.0 vs 4.8 5.5 vs 5.2 � Routinely collected blood gases; acidosis defined as pH< 7.11 Conclude: increased uterine activity is significantly associated with higher incidence of umbilical artery pH <7.11 KD Gregory 5/2014 KD Gregory 5/2014 What’s the Evidence? Is it Much Ado about Nothing? What’s the Evidence? Is it Much Ado about Nothing? � Simpson & James AJOG 2008; 199:34.e1-34.e5 Simpson & James AJOG 2008; 199:34.e1-34.e5 � Effects of oxytocin-induced uterine hyperstimulation 60 during labor on fetal oxygen status and fetal heart rate patterns 50 20% decrease � Retrospective study, 56 women with hyperstimulation >30 min 40 defined as <6 or >=6 UC in 10 min 29% decrease FSpO2 UC <5/10 min � Evaluated fetal oxygen saturation and FHR patterns 30 UC=5/10 min UC>=6/10 min 20 As contraction frequency increased, effect of 10 fetal oxygen saturation is more pronounced 0 Prior 5 min 10 min 15 min 20 min 25 min 30 min KD Gregory 5/2014 KD Gregory 5/2014 4

What’s the Evidence? Is it Much Ado about Nothing? What’s the Evidence? Is it Much Ado about Nothing? � Simpson & James AJOG 2008; 199:34.e1-34.e5 � Stewart et al, AJOG 2012; 207:290.e1-6. FSpO2 & Normal UC =5 UC >= 6 UC p � Defining uterine tachysystole: how much is too much? FHR <5/10 min /10 min /10 min � Prospective cohort study, 584 women undergoing induction of N=158 N=102 N=56 labor with oral misoprostol (100ug) FSpO2 No change 20% dec 29% dec <0.001 � Tachysystole >=6 UC in 10 min during first four hours of Oxytocin mean mU 6.08 9.64 12.03 <0.001 induction Absent variability (%) 0 1.9 3.6 0.011 Minimal variability (%) 7.6 10.8 16.1 0.011 � Uterine hypertonus—contraction > 120 sec 77.5 62.5 Accelerations (%) 86.0 <0.001 � Evaluated infant condition at birth Variables (%) 17.7 29.4 25.0 0.451 — Composite measure: 5 min Apgar<3, pH<7.1, intubation in Late decelerations (%) 8.9 15.7 26.8 0.032 DR, neonatal seizures, NICU admission or death Prolonged decels (%) 0 3.9 3.6 0.085 21.6 37.5 Recurrent decels (%) 9.5 0.002 KD Gregory 5/2014 KD Gregory 5/2014 What’s the Evidence? Is it Much Ado about Nothing? What’s the Evidence? Is it Much Ado about Nothing? � Stewart et al, AJOG 2012; 207:290.e1-6. � Kunz et al JOGNN 2013;42:12-18 � Tachysystole during first four hours of misoprostol induction � Incidence of Uterine Tachysystole in Women Induced with � 253 (43%) women had at least one 10 min window with >6 UC Oxytocin first 4 hours � Retrospective study, 55 women undergoing induction of labor � 129 (22%) met criteria averaged over 30 min with oxytocin � 89 (15%) uterine hypertonus � Tachysystole >5 UC in 10 min averaged over 30 min — Stratified into <4, 5, 6, >7 UC or hypertonus—no difference � Series of single contractions 2 min or more in fetal composite measure � UC’s within one min of each other — FHR decelerations were associated with increased number � Insufficient return to baseline (palpation or IUPC >25 mmHg of contractions and hypertonus between contractions � Limitation—elapsed time; conclude self-limited episodes remote from delivery are not harmful KD Gregory 5/2014 KD Gregory 5/2014 5