Even more egregious was to print it in such a way as to make
it look like an article vetted by the peer-review process and not
clearly formatted to appear as an advertisement. This decision
has less to do with the validity of the science than the integrity
of the peer-review process. That said, however, I stand by the
decision further in that the evidence presented would probably
not be sufficient at this point to result in a recommendation of
acceptance by qualified reviewers, but that is speculation.
The irony is that you have certainly been able to get your
point across through the letter I am responding to, which, by
the way, we have chosen not to edit or censure. f
Thomas J. Garite, MD
Editor-in-Chief
© 2010 Published by Mosby, Inc. doi: 10.1016/j.ajog.2009.11.009
Graded classification of fetal heart rate tracings: association
with neonatal metabolic acidosis and neurologic morbidity
TO THE EDITORS: The recent article by Elliot et al
1
present-
ing the association of neonatal metabolic acidosis and neuro-
logic morbidity and the 5-color FHR classification of Parer and
Ikeda
2
deserves comment.
To understand the evolution of FHR patterns in association
with adverse outcome, it would be important to know the cat-
egory (normalcy) of each fetus both at the beginning of the
labor as well as just before delivery. This would likely enable the
authors to separate groups A (acidosis and encephalopathy)
and I (acidosis only) according to problems arising during la-
bor, during delivery, or previously. For this article, the analysis
begins only 3 hours before delivery, without distinction of
whether this time includes the first stage of labor or not. The
authors present cumulative time (in 2-minute windows) in
each color zone, although these brief times may not be consec-
utive or physiologically relevant. The average cumulative time
in the red zone is brief (5.2– 6.3 minutes), irrespective of out-
come group. This suggests either rapid response to these pat-
terns or, alternatively, that these patterns change rapidly. As the
authors acknowledge, the timing and benefit of intervention, if
any, is not included. The positive association between adverse
outcomes beginning with the “blue and above” zone suggests a
continuum of deterioration and a penalty for delay. It seems
likely that the pattern of deterioration is probably as important
as the cumulative duration at any color. Does the deteriorating
fetus go sequentially from green to orange/red or can it jump
colors? Can red or orange go to green and vice versa? And how
rapidly?
About 25% of the encephalopathic group (A) had Apgars
above 3 at 1 minute and above 6 at 5 minutes (Table 2), features
that do not comport with “essential criteria” for assigning en-
cephalopathy to the events of labor.
3
Almost half (48.4%) of
group A does not progress beyond the yellow zone, suggesting
an unusually high false-negative (false-normal) rate. The study
might profit from using low Apgar scores rather than base ex-
cess as the point of stratification. Low Apgar scores may have
worse neurologic outcomes with “normal” pHs rather than
“low” pHs.
4
Finally, failure to recognize a benign pattern as the
maternal heart rate may help to explain abnormal outcomes
with apparently benign patterns.
5
f
Barry S. Schifrin, MD
Kaiser Permanente-Los Angeles Medical Center
9018 Balboa Blvd. #595
Northridge, CA 91325
REFERENCES
1. Elliott C, Warrick PA, Graham E, Hamilton EF. Graded classification of
fetal heart rate tracings: association with neonatal metabolic acidosis and
neurologic morbidity. Am J Obstet Gynecol 2010;202:258.e1-8.
2. Parer JT, Ikeda T. A framework for standardized management of intra-
partum fetal heart rate patterns. Am J Obstet Gynecol 2007;197:26.e1-6.
3. American College of Obstetricians and Gynecologists. Neonatal en-
cephalopathy and cerebral palsy: defining the pathogenesis and patho-
physiology. Washington, DC: ACOG; 2003.
4. Dennis J, Johnson A, Mutch L, Yudkin P, Johnson P. Acid-base status
at birth and neurodevelopmental outcome at four and one-half years.
Am J Obstet Gynecol 1989;161:213-20.
5. Neilson DR Jr, Freeman RK, Mangan S. Signal ambiguity resulting in
unexpected outcome with external fetal heart rate monitoring. Am J Ob-
stet Gynecol 2008;198:717-24.
© 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2009.11.017
REPLY
One article or brief response cannot adequately address all the
pertinent comments raised in this thoughtful letter.
We agree that it would be ideal to know the timing of injury
(or, conversely, the “normalcy” of the infant) to separately an-
alyze the infants with problems arising before or during labor.
This was not possible, as we had no continuous measure of
either fetal acidemia or neurologic status. Indeed, the unavail-
ability of such techniques today is why we can only infer, not
prove, the condition of the fetus, especially at times remote
from birth. For this reason, we confined the analysis to a rela-
tively short period, the last 3 hours, recognizing that all infants
were probably not always in a state that we could only measure
after birth. Neonatal magnetic resonance imaging or postmor-
tem examinations have been used to determine what propor-
tions of infants with hypoxic ischemic encephalopathy have
isolated acute vs acute superimposed on chronic changes.
Cowan et al
1
examined 245 term infants exhibiting similar cord
gases and neonatal encephalopathy and found that more than
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