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Pathophysiology of variable and late decelerations

J. de Haan/ C . B . Martin/ J . L . H . Evers, H.W. Jongsma

I Introduction
The classification of the fetal heart rate patterns
developed around 1960 lack still a clear and definitive
pathophysiological base. The names given to the several
decelerations suggest however that the pathophysiological
pathways along which they arise are completely clarified.
Therefore we directed our research the last years to
this subject. This paper is restricted to the presentation
of some data concerning the Simulation of variable and late
decelerations in chronically instrumented sheep preparations.
Acute changes in the fetal heart rate pattern can in
general and theoretically be caused by
1. direct hemodynamic changes
2. activitation of the fetal autonomic System by
chemoreceptor mediated hypoxaemia and or direct
fetal adrenal release of catecholamines.
3. direct myocardial depression.
Correct Interpretation of changes in the fetal heart rate
pattern and estimation of the fetal condition requires knowledge
about the activity of each of the three factors mentioned.

II Variable decelerations
Variable decelerations are thought to be due to obstruction
of the umbilical circulation ( 4 ) . Simulation of variable dece-
lerations was performed by placing a special device around
the umbilical cord directly over and fixed to the fetal abdomen
( 3 ) . The device consists of two separated compartments with
inflatable balloons which can be inflated separately or simulta-
neously. Placing both umbilical arteries in one compartment
and the umbilical veins in the other compartment, or one artery
and one vein in each of the compartments each possible impair-
ment of the umbilical flow can be simulated. Following recovery
from anesthesia and surgical procedures the vessels were
occluded during 30 seconds. Fetal femoral artery blood samples
were taken five minutes before and five minutes following the
occlusion äs well äs at the end of the 30 seconds lasting
- occlusion period, With this method a total number of 197
different types of umbilical cord clampings were performed.
Moreover an additional number of 42 clampings were performed
during pharmocological blockäde of the different parts of the
autonomic nervous System.
The fetal arterial pO2 before and at the end of the occlusion
period shows a significant difference in all instances.
Occlusion of both umbilical arteries results in an
immediate rise of th.e systolic and diastolic pressure reaching
a certain steady state and followed in some occlusions by a
second rise especially expressed in the diastolic pressure after
a variable time, however still within the 30 seconds lasting
occlusion period ( f i g . l ) .
The fetal heart frequency decreases immediately within one
or two heart beats to a certain level, followed by a further
decrease simultaneously with the second rise in blood pressure
if present.
In case of occlusion of both umbilical veins a certain delay

0300-5577/81/0091-0002 $ 2.00
Copyright by Walter de Gruyter & Co.
8

MEflN PRESSURE SH7805


1000-
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= 800 -
Σ

^ 600 -
ο
400
-flfl ->
200 _J 1 L.

Ο
MIN

MIN
Fig. l Fetal systolic pressure before, during and following
a 30 seconds lasting occlusion of the umbilical arteries
(upper graph) and umbilical veins (lower graph). The
occlusion period is indicated by the vertical bars.

is present between the Start of the occlusion and the first


cardiovascular reactions. The increase in systolic and diastolic
blood pressure is initially preceded by a 3-5 seconds lasting
decrease ( f i g . l ) . The blood pressure reaches finally the same
level compared to the arterial clampings. Also during venous
occlusions a second step increase in the fetal arterial· blood
pressure might be observed. It lasts almost ten heart beats before
a decrease in the fetal heart frequency is observed in case of
venous occlusions. Sometimes a small increase precedes the following
decrease.
Total occlusion of the umbilical cord mimics almost compl·etel·y
the arterial occlusion regarding the reaction in the fetal blood
pressure and heart frequency ( f i g . 2 ) .
The reaction in systolic and diastolic blood pressure after
cholinergic blockade were in all types of occlusion completely
comparable to the occlusions in fetal lambs with an intact autonomic
nervous System, including the second step rise in blood pressure.
systolic pressure aorta
change

50- T T complete occ. umb. cord.


AA complete occ umb. arteries
V V complete occ umb. veins

40-

30-

10-

0-

-10

30sec occlusion

Fig. 2 Percentual change in fetal systolic pressure during


30 seconds lasting clampings of the total umbilical cord
(TT) r the umbilical arteries (AA) or the umbilical veins (W)
In 11 out of 19 experiments the fetal heart frequency did not
change, regardless of the kind of occlusion during cholinergic
blockade (fig. 3) . In six experiments a small decirease in fetal
heart frequency was observed and in two experiments an increase
in heart frequency was observed in occlusions during cholinergic
blockade.
In case of alpha-adrenergic blockade arterial pressure initially
increased follpwed by a decrease to values equal to or even below
the pressure values before the occlusion (fig. 4 ) . The fetal heart
frequency decreased in all types of occlusion during alpha-adrenergic
blockade.
The first direct increase in arterial blood pressure following
occlusion of the umbilical vessels must be due to the strong increase
10

FETflL R R - I N T E R V f l L SH6912
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500

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FETRL RR-INTERVflL SH6913


1500-

1000- -
o

500 -
V -. B -
'-T*^
.. 1 , . ,. , . 1 . ,

MIN

Fig. 3 Fetal R-R interval before, during and following a thirty ||1
seconds lasting occlusion of the total umbilical cord before \
(TT, upper graph) and after cholinergic blockade (T*. '
lower graph). ;

DIflSTOLIC PRESSURE SH6922


1000

^ 750

-| 500
o
250

0 -i 1 1 1

0
MIN

Fig. 4 Diastolic pressure before, during and following a' 30 seconds


lasting occlusion of the total umbilical cord during
fetal alpha-adrenergic blockade. The occlusion is indicated
by two vertical bars.
11

of the peripheral resistance by occluding the input of the placental


circulation.
The baroreceptor reflex mediates the decrease in fetal heart
frequency which can be concluded from occlusions during cholinergic
blockade.
The second increase in blood pressure must probably be due to
peripheral vasoconstriction in the course of redistribution of blood
flow, caused by the decrease in partial oxygen pressure, since the
fetal arterial partial oxygen pressure decreases with 20-40 percent
during the occlusion. This possible mechanism is also underlined by
the fact that the second arterial pressure increase is not present
at all in the occlusions during alpha-adrenergic blockade.
The initial decrease in arterial pressure following venous
occlusions must be caused by an initial decreased filling of the fetal
heart due to trapping of a certain amount of blood in the placental
circulation untill arterial pressure is maintained in the rest of the
circulation. If the placental circulation would be a rigid System
the reaction in the pressure Parameters following an occlusion
would be the same in case of compression of the umbilical arteries
or the umbilical veins. Since differences s shown are present,
the umbilical placental circulation must have a certain compliance
which is underlined by flow measurements in one umbilical artery
during occlusion of the umbilical veins.

pH 742 pH
IS b
fetal arterial 1OO η
3.1 kPa
Oa 5.7 kPa
VV30*
f^-J . ^
pressure ...

(mm Hg)
50- ! ; ? ι
25- ^P' p5^>^4^ ^^^^ ·· ·- '
: ' · . . . ' . .i '-.''. Ί
fetat heart 20O Ί
frequency
(txpm)

.
FECG
... 1. « . . . < . , . . . . . , . . « ^.

flow umbilical ΘΟΟ


artery eoo
60
(ml/min) °
40O
200
O
«vw 63-76 : gest age 110 days
28hrs postop.
time(min)

Fig. 5 Fetal arterial pressure, heart frequency, electrocardiogram


and umbilical artery blood flow before, during and after a
thirty seconds lasting occlusion of both umbilical veins.
A positive mean arterial blood flow is present during the
first seconds of the occlusion.
12

During several seconds following the Start of the occlusion


of the umbilical veins, a positive decreasing mean flbw can be
measured in the umbilical artery ( f i g . 5 ) . This lasts probably
untill the System is completely filled and arterial pressure
Starts to rise and fetal heart frequency Starts to decrease.
The degree of hypoxaemia reached in these experiments
is certainly deep enough to elicit fetal adrenal catecholamine j
release ( 1 , 5 ) . Since we did not measure the fetal catecholamine |
levels and or the velocity of fetal adrenal catecholamine j
relaese, it remains unclear to what extent this mechanism act '
upon these experiments.
Changes in fetal blood pressure and heart frequency and especially
in the fetal pre-ejection time periöd, stronlgy süggest that
this mechanism is active ( 2 ) .
It is unlikely that the brief exposure to low p02 values
in these experiments interferes with myocardial cpntractility.
III Late decelerations
Late decelerations are thoüght to be due to temporary
insufficient fetal oxygen supply caused by a compromised maternal
fetal exchange System.
Simulation of late decelerations was performed by placing
an inflatable occluder around the common internal iliac artery.
This vessel is the main uterine blood supply in the pregnant ewe.
The effect of uterine contractions was simulated by periodic
occlusion of this vessel for periods of from 30-60 seconds and
was repeated at an interval of 2 , 5 minutes from the beginiiing
of one occlusion to the Start of the following compression.
To increase the degree of hypoxaemia in some experiments, the
vessel was left partially occluded between the total occlusions.
The experiments were performed under chronic conditions 2-9 days
following surgeiy.
Since the effect of uterine contractions is reducing maternal
placental blood flow and thus reducing oxygen delivery to the
fetus, this method, causing late decelerations also, is with
great certainty equivalent in its pathophysiologic mechanism to
spontaneous occurring late decelerations .
At regulär intervals fetal blood samples were taken.s The
role of reflex mechanisms in the cardiovascular changes caused
by the occlusions was studied by blocking parts of the autonomic
nervous System pharmacologically.
Periodic occlusion of the common internal iliac artery
results during the first occlusions either in a fetal heart
frequency deceleration or an acceleration. From the fourth
occlusion onwards almost always a deceleration is present ( f i g . 6 ) .
The time relationship between the increase in fetal blood pressure
and decrease in fetal heart frequency varied. In some instances
the heart frequency started to decrease several seconds before
the onset of blood pressure increase. In non acidemic fetuses
the highest blood pressure and the lowest fetal heart rate
occurred generally during the same time periöd.
With progressing fetal acidosis a complementary fetal tachycardia
occurred and the amount of deceleration was less, whereas the
pattern of progressive hypertension disappeared. Below a fetal
arterial pH of 7.10 a decrease in blood pressure accompanied the
fetal heart rate deceleration ( f i g . 7 ) .
13

pH 7.36
pO2 23 kPa
pC02 52 KPa
B£ -2.6 mmol/l
fetal arterial 100 i
pressure
(mm Hg)

fetal heart
frequency
(b.p.m)
250
1
lüiJ:1-ii---iiiij^^^
•^i^s^**·^*^^
50
:'. ·': ".\'·:\ ' ' i ; : ; h ; : ' : h ! ; ' i i ! ; ; M ; : M l i ^ i i I
intra uterine 0 *
pressure '.
(mm Hg)
25-

4 i H ! i J i i - , r :;.;.i Li.inj-i.yq:·.!:-;.;
,",^. ..
• i i' ·- - · i » > .. 4- i-l ' i 4 4
.|-i~t
? < j ji : ..LH
. ..rfV'rt-'U
i..|4|4
flow uterine 6OO ·
, .J.-.4.. ,. r < r Tt r
•tvid
artery
(ml/min)

FECG

ewe 92-78 gest. age:l29 days


days postop. periodic totai ocdusion
tlme(min)

Fig. 6 Periodic total occlusion of the common internal iliac artery,


The figures below the uterine blood flow tracing indicate
the number of occlusion.
Alpha-adrenergic blockade with phentolamine prevented
the progressive hypertensive response of the fetus to the
periodic Interruption of the uterine blood flow. Some cardiac
slowing could be present however in occlusions during
alpha-adrenergic blockade ( f i g . 8 ) .
During cholinergic blockade with atropine/ periodic
accelerations occurred in response to the occlusions in case of
non acidemic fetuses. These accelerations could be eliminated
by beta-adrenergic blockade with propranolol, but not with an
alpha-adrenergic blocking agenti
Administration of atröpine to the already acidotic fetus
resulted in an increase in the base line fetal heart rate, but
no change in the amount of the deceleration occurred ( f i g . 9 ) .
The beat to beat variability o£ the baseline fetal heart
rate äs judged visually persisted and disappeared very lately
in case of severe fetal acidemia.
The observations just described suggest several reflex
pathways in producing late decelerations ( f i g . 1 0 ) . The dominant
reflex is the chemoreceptpr mediated reflex vasoconstriction,
producing an increase in blood pressure and in turn baro-reflex
induced cardiac slowing. Direct Stimulation by hypoxaemia of
the cardiodecelerator reflex is probably also possible since
the onset of the deceleration can precede the' increase in
blood pressure. Moreover cardiac slowing is present in occlusions
during alpha-adrenergic blockade.
pH? 7.14
pO2 1.5 KPa
pC02 6.3 kPa
BE -m mmot/l
fetal artenal 1OO
pressure
(mm Hg)
50

fetal heart 250 η .. μ .Μ. J ' L .:,..., Η«4~1,; 4-Η ·ί ·ΐ


frequency
(b.pm) 15

50-

i|/M-Tj::i.{1^n;;i;i--4 f r r ^ii^rrtm! Γ;Τ


intra uterine
pressure
0 ~\ Uu iiiiiairS
(mm Hg)
25J

flow uterine 600


artery
(ml/min)

FECG

ewe 92-78 ^: gest. age: 129days


6doys postop. ; continuing partial occlusion, periodic total occluston
time (min)

Fig. 7 Continuing partial occlusion with periodic total occlusion


of the common internal iliac artery. The figures below the
uterine blood flow tracing indicate the number of
occlusion. In this acidotic fetus arterial blood pressure
decreases during the fetal heart rate decelerations.
pH 7.35
Pp2 1.4 kPa
pC02 ai kPa
BE -O7 mmol/l
fetal arterial lOO-i
pressure '
(mm Hg) ^

-:i ;~r; i Π-ί^Ι^"1^^^

:
intra uterine
pressure
(mm Hg)
0
2Q
7mm ':'^
flow uterine 5OO -
artery I
(ml/min) QJ

FECG

gest age 128 days


periodic total occlusion g>adrenerglc blocKade
time (min)

Fig. 8 Periodic total occlusion of the common internal iliac artery


after blocking the fetal alpha-adrenergic System.
15

pH 6.96
pO^ 1.6 kPa
pCO, 7.Θ KPa
ΘΕ 19.7mmot/l
fetal arteriat 1OO
pressure
(mm Hg)

fetal heart SOO


frequency
(b.pm) 3QQ

10O'·

intra uterine 0
pressure
(mm Hg)

flow uterine 6OO


artery
(ml/min)

FEC6

ewe 92 -78 gest. oge : 129 days


contlnutng portiol occtuslon. perWic total occlusion

Fig. 9 Continuing partial occlusion with periodic total occlusion


of the common internal iliac artery before and following
fetal cholinergic blockade in case of a severe distressed
fetus.
hypoxaemia

chemoreceptor

sympathetic
itii center

4-
vasoconstriction
- L blockade

—/3 blockade

blood pressure j

l
baro receptor

I
vagal center
\
atropine-
*
fetal heart rate
Fig. 10 Possible pathways producing periodic changes in the fetal
heart rate pattern due to hypoxaemia - hypoxia.
16

An adrenergic cardioaccelerator component is also, present äs


demonstrated from the accelerations in occlusions during
cholinergic blockade and from the accelerations during the very
first occlusions in the experiment. This accelerations could be
blocked by propranolol.
The last pathway is the direct hypoxic depression of the
fetal myocardium under conditions of severe fetal acidosis äs
shown from the experiments under cholinergic blockade and severe
fetal acidosis. The exact point at which reflex mechanisms in
producing late decelerations are replaced by direct hypoxic
depression is however not determined. Therefore more experiments
has to be performed, although this transierit point seems to lie
somewhere around a pH of 7 . 2 5 . This point is probably different
in each fetus dependent also on the previous oxygen content,
cardiac glycogen Stores and blood glucose levels.
Although results obtained in animal experiments cän never
be transposed completely on human fetuses, with these data
several phenomena in human fetal heart rate patterns can be
understood better.

REFERENCES

1. Comline, R . S . , Silver, I . A . , Silver, M. :


Factors responsible for the Stimulation of the adrenal
medulla during asphyxia in the fetal lamb.
J. Physiol. 178 : 211, 1965.
2. Evers, J . L . H . : The cardiac pre-ejection period during
prenatal life. Studies in stressed and unstressed fetal }
lambs. Thesis, Catholic University, Nijmegen 1978. ;|
3. de Haan, J . , Jongsma, H . W . , Crevels, A . J . , Arts, T . H . M . :
The cardiovascular ef f ects f ollowing compression of the
umbilical veins and or arteries in chronic sheep preparation.
In : Abstracts of free Communications. 5th European Congress
of Perinatal Medicine p. 50, nr 79. Almqvist and Wiksell
Intern. Stockholm 1976.
4. Hon, E . H . : An atlas of fetal heart rate patternsl
Harty Press Inc., New Haven 1968.
5. Jones, C . T . , Robinson, R . D . : Plasma catecholamines in foetal
and adult sheep. J. Physiol. 248 : 15, 1975
6. Martin, C . B . , de Haan, J . , van der Wildt, B . , Jongsma, H . W . ,
Dieleman, A . , Arts, T . H . M . :
Mechanisms of late decelerations in the fetal heart rate;
A study with autonomic blocking agents in fetal lambs (in press).

P r o f . D r . J . d e Haan
Rijksuniversiteit Limburg
Zieke'nhuis St.Annadal
Dept.Obstet..* Gynec.
Maastricht/Netherlands