ANTEPARTUM SURVEILLANCE IN DIABETIC PREGNANCIES - PREDICTORS OF FETALDISTRESS IN LABOR

OBJECTIVE: Our purpose was to evaluate an antepartum testing program b ased on twice-weekly nonstress testing and amniotic fluid evaluation i n pregnancies complicated by diabetes mellitus and to weight the test components in the prediction of fetal distress requiring cesarean deli very. STUDY DESIGN: During the 4-year period of 1987 through 1990, 213 4 women with pregnancies complicated by diabetes underwent antepartum testing. Of these 1501 women (class A(1), n = 505; A(2)-diet, n = 305; A(2)-insulin, n = 580; B-1 n = 71; C to D, n = 29; R to F, n = Il)wer e delivered within 4 days of their last test. Categoric analysis of da ta was performed according to diabetic class, fetal heart rate results , and the presence of decreased, normal, or increased amniotic fluid a ssessment. A univariate logistical regression was first conducted with cesarean delivery for fetal distress as outcome variable by use of th e following variables: fetal weight and sex, diabetic class, gestation al age at delivery, presence of additional indications for antepartum testing, largest vertical pocket, amniotic fluid index (summation of t he four quadrants of the largest vertical pocket), nonstress test reac tivity (two accelerations of greater than or equal to 15 beats/min of 15 seconds' duration), presence of decelerations (greater than or equa l to 15 beats/min for 15 seconds) during the nonstress test, and the i nteractions of the nonstress test with deceleration, largest vertical pocket, and amniotic fluid index. Multivariate analysis was then appli ed to predict the best model. RESULTS: No stillbirths occurred within 4 days of the last antepartum test. However, the corrected stillbirth rate of the entire tested population was 1.4 per 1000. Eighty-five wom en required cesarean delivery for fetal distress. The factors most pre dictive of cesarean delivery for fetal distress (p < 0.05, odds ratio and 95% confidence interval) were a deceleration (3.60, 2.14 to 6.06), nonreactive nonstress test (2.68, 1.60 to 4.49), and the interaction of both a nonreactive nonstress test and decelerations (5.63, 2.67 to 11.9). Amniotic fluid assessment by largest vertical pocket or amnioti c fluid index were not statistically significant. The multivariate ana lysis selected the interaction of nonstress test and deceleration as t he best significant predictor for cesarean delivery for fetal distress . CONCLUSION: An antepartum fetal surveillance program using twice-wee kly nonstress test and fluid index assessment in pregnancies complicat ed by diabetes was successful in preventing stillbirth, The absence of fetal heart rate reactivity and the presence of decelerations were pr edictive of the diagnosis of fetal distress in labor requiring cesarea n delivery, Ultrasonographic assessment of amniotic fluid volume was n ot a significant predictor of fetal distress in labor in the diabetic pregnancy.