Lactate determination in ante- and intrapartum surveillance
Author: Wiberg-Itzel, Eva
Date: 2007-06-01
Location: Södersjukhusets Aula, Sjukhusbacken 10, 6tr
Time: 09.00
Department: Institutionen för klinisk forskning och utbildning, Södersjukhuset / Department of Clinical Science and Education, Södersjukhuset
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thesis.pdf (2.260Mb)
Abstract
Lactate concentration is reported to be high in amniotic fluid (AF).
Prelabour rupture of membranes (PROM) occur in about 20% of all
pregnancies. The condition is associated with fetal and maternal
complications, and might be a marker of imminent delivery. Therefore
among women with suspected prelabour rupture of the membranes (PROM), it
is of great importance to accurately confirm the diagnosis. In our
studies we wanted to assess whether lactate determination in
vaginal/amniotic fluid could be used as a diagnostic test for prelabour
rupture of membranes, and could predict onset of labour in women with
suspected PROM. We selected women with a history of suspect PROM after 34
weeks gestation for determination of lactate concentrations in vaginal
fluid. A lactate concentration > 4.5 mmol/l was found to be the best
cut-off value for a positive ‘Lactest’ and showed a sensitivity of 86%
and specificity 92%.The median time interval between examination and
spontaneous onset of labour among the women with `high´ lactate (> 4.5
mmol/l) were 8.4 hours and for those with `low´ lactate concentration (<
4.5 mmol/l) 54 hours. Among women with `high´ lactate concentration 88%
started in labour within 24 hours, as compared with 21% for those with
`low´ lactate concentration.
Labour dystocia is clinically defined as slow or arrest of progress
during labour and is a common obstetrical problem worldwide. In our study
we looked for an association between high lactate concentration in
amniotic fluid and labour dystocia. We selected women in active labour
attending labour ward, and performed at least two consecutive
measurements of lactate concentration in amniotic fluid during labour.
Among women with spontaneous vaginal deliveries (n=23) the mean lactate
concentration in AF during labour was 8.9 mmol/l and among women with
labour dystocia (n=31) the corresponding value was 10.9 mmol/l (p
<0.001). Of 29 women with a high lactate concentration (>10.1 mmol/l) in
at least two consecutive measures, 86% were delivered
instrumentally/operatively due to dystocia. Using this definition of a
positive test gives a sensitivity of 81% a specificity of 82%, a positive
predictive value of 86%, and a negative predictive value of 76%.
Fetal surveillance during labor is often based on fetal heart rate
monitoring using the cardiotocograph (CTG). A normal CTG is reassuring
for a well oxygenated fetus. However, a non-reassuring trace occurs in up
to 50% of all recordings, but only a small proportion of these fetuses
are at risk of hypoxia. In a multicentre trial we wanted to compare pH
vs. lactate analysis, regarding prevention of acidemia at birth. 2992
women in labour were randomised to pH (n=1,496) or lactate analysis
(n=1,496). Protocol violations were significantly less frequent in women
randomised to lactate compared with women randomised to pH analysis,
11.0% vs. 1.5%. There were no significant differences between the groups
in the rate of metabolic acidemia (RR 0.96) or pH <7.00 (RR 0.88) in cord
artery blood at birth.
We have with this thesis shown the usefulness of determination of lactate
in AF and fetal blood sampling. Lactate in AF can be used in the
diagnosis of suspected PROM, in the prediction of spontaneous onset of
labour for women with suspected PROM, and also in the diagnosis of labour
dystocia. We have shown lactate analysis of fetal scalp blood to be at
least as good as pH analysis in the management of intrapartum fetal
distress.
List of papers:
I. Wiberg-Itzel E, Cnattingius S, Nordstrom L. (2005). "Lactate determination in vaginal fluids: a new method in the diagnosis of prelabour rupture of membranes." BJOG 112(6): 754-8
Pubmed
II. Wiberg-Itzel E, Pettersson H, Cnattingius S, Nordstrom L. (2006). "Abstract Association between lactate in vaginal fluid and time to spontaneous onset of labour for women with suspected prelabour rupture of the membranes." BJOG 113(12): 1426-30
Pubmed
III. Wiberg-Itzel E, Pettersson H, Cnattingius S, Nordstrom L. (1970). "Association between lactate concentration in amniotic fluid and dysfunctional labour." (Submitted)
IV. Wiberg-Itzel E, Lipponer NM, Herbst A, Prebensen D, Hansson A, Bryngelsson A-L, Christoffersson M, Sennström M, Wennerholm U-B, Nordstrom L. (1970). "Fetal scalp blood pH or lactate analysis in the management of intrapartum fetal distress. A randomised controlled trial." (Submitted)
I. Wiberg-Itzel E, Cnattingius S, Nordstrom L. (2005). "Lactate determination in vaginal fluids: a new method in the diagnosis of prelabour rupture of membranes." BJOG 112(6): 754-8
Pubmed
II. Wiberg-Itzel E, Pettersson H, Cnattingius S, Nordstrom L. (2006). "Abstract Association between lactate in vaginal fluid and time to spontaneous onset of labour for women with suspected prelabour rupture of the membranes." BJOG 113(12): 1426-30
Pubmed
III. Wiberg-Itzel E, Pettersson H, Cnattingius S, Nordstrom L. (1970). "Association between lactate concentration in amniotic fluid and dysfunctional labour." (Submitted)
IV. Wiberg-Itzel E, Lipponer NM, Herbst A, Prebensen D, Hansson A, Bryngelsson A-L, Christoffersson M, Sennström M, Wennerholm U-B, Nordstrom L. (1970). "Fetal scalp blood pH or lactate analysis in the management of intrapartum fetal distress. A randomised controlled trial." (Submitted)
Issue date: 2007-05-11
Rights:
Publication year: 2007
ISBN: 978-91-7357-213-2
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