Arch Gynecol Obstet

DOI 10.1007/s00404-015-3819-6

MATERNAL-FETAL MEDICINE

Fetal heart rate patterns of pregnancies with vasa previa

and velamentous cord insertion
Yael Baumfeld1 Gil Gutvirtz1 Iris Shoham1 Eyal Sheiner1,2

Received: 28 September 2014 / Accepted: 13 July 2015

Springer-Verlag Berlin Heidelberg 2015

Abstract
Objective To investigate the fetal heart rate (FHR) patterns in pregnancies complicated with vasa previa and
velamentous cord insertion (VCI).
Methods A retrospective study comparing FHR patterns
in pregnancies and subsequent pregnancies with/without
VCI and in pregnancies with/without vasa previa was
conducted. For each patient, FHR patterns were compared
to the subsequent pregnancy. Deliveries occurred between
the years 1988 and 2012 in a tertiary medical center. FHR
patterns were evaluated according to the ACOG guidelines.
Results During the study period, there were 184 pregnancies with VCI and 37 pregnancies with vasa previa,
undetected during pregnancy. FHR patterns of the VCI
group included more cases of abnormal baseline (7 vs.
2 %, p \ 0.05), out of which 7 % were fetal tachycardia
(vs. 2 %) and 4 % were bradycardia (vs. 1 %). There were
also more cases of abnormal baseline and abnormal variability (7 vs. 2 % and 32 vs. 22 %, respectively, p \ 0.05)
in the VCI group. FHR categories also differed between the
velamentous cord insertion pregnancies and subsequent
ones. VCI pregnancies had more category 2 patterns, not
statistically significant (64 vs. 55 %, p = 0.11). FHR patterns of the vasa previa group included more cases of
abnormal baseline (27 vs. 7 %, p \ 0.05), out of which

& Eyal Sheiner

sheiner@bgu.ac.il
1

Department of Obstetrics and Gynecology, Faculty of Health

Sciences, Soroka University Medical Center, Ben-Gurion
University of the Negev, Beer-Sheva, Israel

Department of Obstetrics and Gynecology, Soroka University

Medical Center, POB 151, Beer Sheva 84101, Israel

18 % were tachycardia and 9 % were bradycardia. Decelerations were recorded in a total of 61 % of the vasa previa
cases (61 vs. 31 %, p = 0.02), most of which were variable
decelerations (48 vs. 17 %). Vasa previa pregnancies had
more category 2 patterns (64 vs. 52 %).
Conclusions Fetal heart rate patterns in pregnancies
complicated with VCI or vasa previa have several nonspecific pathological characteristics; none can be used for
early detection of these conditions.
Keywords Vasa previa
Velamentous insertion

Gestation
Fetal heart rate monitoring

Introduction
Vasa previa is a pathological state defined by the presence
of fetal blood vessels in the membranes covering the
internal cervical os [1]. It is divided into two types: vasa
previa type 1 in which the membranous vessels are associated with velamentous umbilical cord, and type 2 in
which the vessels connect the lobes of a bilobed placenta or
the placenta and a succenturiate lobe [1].
The prevalence of vasa previa is 1 in 2500 deliveries
with risk factors including use of assisted reproductive
technologies [24, 10], placenta previa, bilobed or succenturinate lobe and multiple gestations [49].
Prognosis varies; some of the cases resolve during the
second trimester. More commonly, the vasa previa persists
and is at risk for rupture upon rupture of membranes,
spontaneous or artificial, thus leading to fetal hypotension,
anemia and death due to exsanguination. This can be
reflected by fetal heart rate abnormalities.
There are several ways for the detection of vasa previa,
including transvaginal ultrasound with Doppler, and rare

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Arch Gynecol Obstet

occasions a pulsatile vessel can be palpated in a vaginal

digital examination [1113].
Diagnosis of vasa previa is of utmost importance considering the prognosis. In the absence of prenatal diagnosis,
a clinical diagnosis of vasa previa should be suspected in
the setting of vaginal bleeding that occurs upon rupture of
the membranes and is accompanied with fetal heart rate
abnormalities, particularly a sinusoidal pattern or bradycardia [14, 15, 28].
Velamentous insertion is defined by divergent umbilical
vessels in the placental end of the cord [16]. This pathological finding complicates one percent of all pregnancies;
risk factors include placenta previa and in monochorionic
twin gestations, which can be found in 15 % percent of
pregnancies. However, it is one of the most undiagnosed
conditions in obstetrics [17].
Velamentous insertion has been associated with several
obstetrical complications, ranging from fetal exsanguination due to rupture of vessels with rupture of membranes or
due to kinking and compression of the membranous vessels
leading to a reduction in blood flow, fetal heart rate (FHR)
changes and fetal demise. Other complications include
fetal growth restriction, preterm delivery, congenital
anomalies, fetal distress, low Apgar scores, fetal death, and
retained placenta [18, 26, 27].
Fetal heart rate monitoring is the tool commonly used
for monitoring the wellbeing of the fetus during pregnancy
and labor. The American College of Obstetricians and
Gynecologists (ACOG) published FHR monitoring categories [19]. The categories were divided according to frequency observed. Category 1 was observed in 99 % of
tracings and in 78 % of labor and is considered normal
because it is associated with the absence of fetal acidemia;
category 2 in 84 % of tracings and in 22 % of labor; category 3 in 0.1 % of the tracings and in 0.004 % of labor.
Category 3 is considered abnormal because it is associated
with increased risk of fetal hypoxic acidemia. The interpretation of fetal heart rate monitoring has also been
debated extensively, while fetal heart rate monitoring categories 1 and 3 are relatively straightforward; the interpretation of a category 2 monitor is complex [23].
The study objective was to explore the characteristics of
FHR monitoring during delivery in vasa previa pregnancies
or velamentous insertion compared to subsequent pregnancies of the same patient without cord abnormalities.

Methods

Medical Center (SUMC). SUMC is a 1007 bed tertiary

teaching hospital and the only provider for inpatient care
for population of 700,000 residing in Southern Israel. A
total of 221 patients were included37 women with
vasa previa and 184 with velamentous insertion.
The study population consisted of all women who had
the diagnosis of vasa previa and women with the diagnosis of velamentous cord insertion (VCI). Data were
collected for both patients with either vasa previa (VP)
or VCI. Data from the subsequent pregnancies of the
study population were collected for the same variables
(controls). The database included information on maternal comorbidities, perinatal assessment, maternal and
fetal complications.
Fetal heart rate monitors
The fetal heart rate tracings at time of the delivery were
examined for those pregnancies as well as the subsequent
ones. The monitors were examined for baseline, tachycardia, bradycardia, variability, decelerations and accelerations. They were also divided into the three categories
of fetal heart tracings as defined by the ACOG [18].
FHR monitoring was done continuously throughout the
delivery, interpretation was done by the attending
physician and recorded in the patient file, additional
review and comparison was done by a single observer
one of the authors. The worst monitor patterns were
recorded.
Definitions
The first fetal monitor category was defined by:

Baseline rate: 110160 beats per min

Moderate baseline fetal heart rate (FHR) variability
(amplitude 625 bpm)
No late or variable decelerations
Early decelerations may be present or absent
Accelerations may be present or absent
The third category is defined by:

Absent baseline fetal heart rate variability and (any of

the following):
Recurrent late decelerations
Recurrent variable decelerations
Bradycardia
Or

Study population
A retrospective study was conducted including deliveries between 1988 and 2012 at the Soroka University

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A sinusoidal pattern

The second category includes all the fetal heart rate

patterns that are not classified as class 1 or class 3.

Arch Gynecol Obstet

Data analysis

Vasa previa compared to subsequent pregnancies

The data on continuous variables with normal distribution

were presented as mean SD, and compared between
study groups using Students t test. Continuous variables
without normal distribution and ordinal variables were
presented as median with inter-quartile range (IQ range)
and statistical analysis was done using MannWhitney.
Categorical data were shown in counts and percentages and
the differences were assessed by Chi Square for general
association; Fisher Exact test was used when appropriate.
P value of less than 0.05 was considered statistically significant. The statistical analysis was performed using IBM
SPSS statistics version 20.

Table 1 presents the comparison the vasa previa pregnancies to subsequent pregnancies in the same women (i.e.
non-VP group). The major difference between the VP
group and the non-VP group is the rate of cesarean sections; the rate in the VP group was significantly higher
as compared with subsequent pregnancies (79 vs. 40 %,
p = 0.01).
The VP group had lower Apgar scores compared to the
control group, without a significant difference in the pH
levels. A total of four cases of fetal demise occurred, all of
which were in the VP group; however, this did not reach
statistical significance. Three of which were stillbirths
(antepartum fetal death) and one case of intrapartum fetal
death.

Results
The study population consists of 37 cases of vasa previa
and the control group of subsequent pregnancies and a
second study population of 184 cases of velamentous
insertion and the control group of subsequent pregnancies.
Both of these pathologies were undetected during pregnancy and diagnosed during labor.
Table 1 Baseline
characteristics of vasa previa
pregnancies vs. subsequent
pregnancy

Variables

Fetal heart rate monitoring characteristics

Table 2 presents the fetal heart rate monitor characteristics.
A.

Fetal monitor categoriescategory 2 was more prevalent in the VP group, however, they were not found
statistically significant.

Vasa previa n = 37

No vasa previa n = 37

P value
[0.99

Singleton (%)

36 (97.3)

29 (96.7)

Multiple (%)

1 (2.7)

1 (3.3)

Delivery (%)
Vaginal

6 (20.7)

13 (52.0)

Assisted

0 (0.0)

2 (8.0)

CS

19 (65.5)

7 (28.0)

Elective CS

4 (13.8)

3 (12.0)

CS total

23 (79.3)

10 (40.0)

Vaginal

6 (20.7)

15 (60.0)

7.29 0.06

7.30 0.06

0.01

Neonatal outcomes
pH (mean SD)

0.21

Apgar1
Median, IQ range

9 (1.759)

9 (9)

0.32*

\7

13 (36.1)

2 (6.7)

0.01

C8
Apgar 5

23 (63.9)

28 (93.3)

Median, IQ range

10 (810)

10 (10)

0.32*

\7

8 (22.2)

0 (0.0)

0.01

C8

28 (77.8)

30 (100)

Total

4 (10.8)

0 (0.0)

Stillbirth

3 (8.1)

0 (0.0)

0.24

Intrapartum death

1 (2.7)

0 (0.0)

[0.99

Post-partum death

0 (0.0)

0 (0.0)

Fetal demise (%)

0.12

* Using MannWhitney test for non-parametric variables

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Arch Gynecol Obstet

Table 2 Fetal heart rates
monitor characteristics in vasa
previa pregnancies vs.
subsequent pregnancies

Variables

Vasa previa n = 37

No vasa previa n = 37

P value

1st category

12 (36.4)

14 (48.3)

0.34

2nd category

21 (63.6)

15 (51.7)

Monitor (%)

3rd category

0 (0.0)

0 (0.0)

2nd and 3rd

21 (63.6)

15 (51.7)

0.34

Baseline fetal heart rate (%)

Normal

24 (72.7)

27 (93.1)

Tachycardia

6 (18.2)

1 (3.4)

Bradycardia

3 (9.1)

1 (3.4)

Abnormal baseline

9 (27.3)

2 (6.9)

0.04

Variability (%)
Absent

0 (0.0)

0 (0.0)

Minimal

13 (39.4)

10 (34.5)

Moderate

20 (60.6)

19 (65.5)

Abnormal (absent and minimal)

Normal (moderate and marked)

13 (39.4)
20 (60.6)

10 (34.5)
19 (65.5)

0.69

Absent

16 (48.5)

7 (24.1)

0.05

Present

17 (51.5)

22 (75.9)

Accelerations (%)

Decelerations (%)
Absent

13 (39.4)

20 (69.0)

Early

4 (12.1)

3 (10.3)

Late

0 (0.0)

1 (3.4)

Variable

16 (48.5)

5 (17.2)

Present

20 (60.6)

9 (31.0)

0 (0.0)

0 (0.0)

Sinusoidal pattern (%)

0.02

* Using MannWhitney test for non-parametric variables

B.

C.

D.
E.

Pulse baselinein the VP group there were significantly more cases of fetal tachycardia (18 vs. 3 %) and
fetal bradycardia (9 vs. 3 %). This was statistically
significant (p \ 0.05).
Variabilityabnormal variability (absent and minimal
variability) was found in 39 % of the VP group and
35 % of the non-VP group. These differences were not
statistically significant.
More accelerations were found in the non-VP group
(76 vs. 52 %; p = 0.05).
Decelerations were more common in the VP group (61
vs. 31 %, p = 0.02), mostly variable decelerations.

in the VP group was significantly higher (38 vs. 26 %,

p = 0.02).
The Apgar scores both at the 1st and 5th min were lower
in the VCI group (p = 0.01), no statistically significant
difference was found in neonatal pH. A total of 14 cases of
fetal demise occurred, 11 in the VCI group and 3 in the
non-VCI group (p = 0.001). Four of which were stillbirths
(antepartum fetal death) and one case of intrapartum fetal
death. A total of nine cases of neonatal deaths, six in the
VCI group and three in the non-VCI group.

Fetal heart rate monitoring characteristics

Velamentous cord insertion compared to subsequent
pregnancies

Table 4 presents the FHR monitor characteristics.

A.

Table 3 presents the comparison of the VCI pregnancies to

subsequent pregnancies of the same women (i.e. non-VCI
group). The major difference between the VCI group and
the non-VCI group is the rate of cesarean sections; the rate

123

B.

Fetal monitor categoriescategory 2 was more prevalent in the VCI group, not statistically significant.
Baseline fetal heart ratemore cases of fetal tachycardia (5 vs. 1 %) and fetal bradycardia (3 vs. 1 %)
occurred in the VCI group (p = 0.02).

Arch Gynecol Obstet

Table 3 Baseline
characteristics of velamentous
insertion pregnancies vs.
subsequent pregnancy

Variables

Velamentous insertion n = 184

No velamentous insertion n = 184

P value
\0.001

Singleton (%)

153 (80.1)

183 (99.5)

Multiple (%)

38 (19.9)

1 (0.5)

Vaginal

114 (60.3)

110 (69.6)

Assisted

3 (1.6)

7 (4.4)

CS

60 (31.7)

27 (17.1)

Elective CS

12 (6.3)

14 (8.9)

CS total

72 (38.1)

41 (25.9)

Vaginal

117 (61.9)

117 (74.1)

7.28 0.10

7.30 0.07

0.09

Delivery (%)
0.01

0.02

Neonatal outcomes
pH (mean SD)
Apgar1
Median, IQ range

9 (9)

9 (9)

0.01

\7

29 (14.9)

11 (6.3)

0.01

C8
Apgar 5

165 (85.1)

164 (93.7)

Median, IQ range

10 (10)

10 (10)

0.26*

\7

10 (5.2)

5 (2.9)

0.01

C8

184 (94.8)

170 (97.1)

Total

11 (5.6)

0 (0.0)

Stillbirth

4 (2.1)

0 (0.0)

0.12

Intrapartum death

1 (0.5)

0 (0.0)

[0.99

Post-partum death

6 (3.1)

3 (1.5)

0.50

Fetal demise (%)

0.001

* Using MannWhitney test for non-parametric variables

C.

D.
E.

Variabilityabnormal variability was found in 32 %

of the VCI group and 22 % of the non-VCI group
(p = 0.05).
More accelerations were found in the non-VCI group
(70 vs. 64 %), not statistically significant.
Decelerations were found more often in the VCI group
(57 vs. 54 %, p = 0.65). Most were variable decelerations (47 vs. 39 %, p = 0.02).

Discussion
Vasa previa and VCI are obstetrical pathologies that are
both difficult to diagnose and might have serious implications and complications during labor, including fetal
demise and life threading vaginal bleeding. FHR monitor is
one of the most available and commonly used tools. The
aim of this study was to define the monitor characteristics
of these obstetrical pathologies.
Vasa previa
The main results of our study include several significant differences between the FHR monitors of the VP pregnancies.

The VP group had significantly different FHR monitoring

compared to subsequent pregnancy. These differences included baseline abnormalities and periodic changes (less accelerations and more decelerations). The majority of the fetal
heart rate monitors found in the VP group were categorized as
type 2, whereas the fetal heart rate monitors found in the VP
group were mainly categorized as type 1.
However, no category 3 monitors were observed in
either group. This might be due to a relatively small sample
size or due to quick clinical decision-making, thus not
allowing for the deterioration of the fetal monitor from
category 2 to category 3.
There were significant differences in the neonatal
outcomes both in the Apgar score and fetal demise. The
Apgar scores were also significantly different between
the VP and non-VP groups showing a greater ratio of
Apgar scores under 7 in both the 1st and 5th min
(p = 0.01). There was also a higher prevalence of fetal
demise in the VP group with all four cases of fetal
demise in the VP group. The cases of fetal demise were
mostly stillbirths with only one case of intrapartum
death; this was not statistically significant, possibly due
to the small number of cases.

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Arch Gynecol Obstet

Table 4 Fetal heart rates monitor characteristics in velamentous cord insertion pregnancies vs. subsequent pregnancies
Variables

Velamentous insertion n = 184

No velamentous insertion n = 184

P value

Monitor (%)
1st category

54 (35.3)

70 (44.3)

2nd category

98 (64.1)

87 (55.1)

3rd category

1 (0.7)

1 (0.6)

2nd and 3rd

99 (64.7)

88 (55.7)

0.11

Baseline fetal heart rate (%)

Normal

141 (92.8)

154 (98.1)

Tachycardia

7 (4.6)

2 (1.3)

Bradycardia

4 (2.6)

1 (0.6)

11 (7.2)

3 (1.9)

Abnormal baseline
Variability (%)
Absent

1 (0.7)

0 (0.0)

Minimal

48 (31.6)

35 (22.3)

Moderate

102 (67.1)

121 (77.1)

Marked

1 (0.7)

1 (0.6)

Abnormal (absent and minimal)

49 (32.2)

35 (22.3)

Normal (moderate and marked)

103 (67.8)

122 (77.7)

Absent

55 (36.2)

47 (29.9)

Present

97 (63.8)

110 (70.1)

65 (42.8)

72 (45.9)

7 (4.6)

21 (13.4)

0.02

0.05

Accelerations (%)
0.24

Decelerations (%)
Absent
Early
Late

0.02

8 (5.3)

3 (1.9)

Variable

71 (46.7)

61 (38.9)

Present

85 (57.0)

85 (54.1)

0.65

1 (0.7)

1 (0.6)

1.00

Sinusoidal pattern (%)

* Using MannWhitney test for non-parametric variables

Velamentous cord insertion

More main results of our study include the significant
differences between VCI fetal heart monitors and of subsequent pregnancies included abnormal baseline and variability. Previous studies found that the FHR monitors of the
VCI group had more variable decelerations and less
accelerations [19]. Similarly, we also found more variable
decelerations but the difference was not found statistically
significant.
FHR monitors pathologies have been found in correlation with fetal academia [25], although the clear interpretation of such is complicated [24], particularly category 2
monitors [23]. This is the reason we also analyzed the
neonatal outcomes. Interestingly, the Apgar scores were
significantly lower in the VCI group, both in the first min
and the fifth min scores. The low Apgar scores did not
reflect perinatal mortality or low pH values. The finding of
an increased risk of low Apgar scores and a higher fetal

123

mortality rate is similar to findings in previous findings

[2022].
It should be noted that the rate of cesarean section was
higher both in the VP group and the VCI group compared
to the control, there are several possible explanations. First
of all, as the hypothesis of the study the rate of nonreassuring fetal heart rate is greater in the VP group,
second having that the known complications of VP include
hemorrhage- yet another possible indication is suspected
placental abruption. There were no available data regarding these indications or the rate of previous cesarean
delivery, which could also explain higher rates of cesarean
sections.
The strengths of the study are being a single center for a
large population, having very little lost for follow-up.
However, the weaknesses of the study are that it is a retrospective cohort with a relatively small sample size
probably due to the low incidence of VP and VCI in the
general population.

Arch Gynecol Obstet

In conclusion, it seems that FHR patterns cannot predict

either VP or VCI. FHR monitoring can only raise suspicion
for obstetrical pathologies such as vasa previa and velamentous insertion prior to the development of clear-cut
fetal distress. Further large-scale probably multi-centric
studies should investigate EFM patterns of such
pathologies.
Compliance with ethical standards
Conflict of interest All authors have no conflict of interest to
declare including financial or otherwise.

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