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Mendis L, Palaniswami M, Brownfoot F, Keenan E. Computerised Cardiotocography Analysis for the Automated Detection of Fetal Compromise during Labour: A Review. Bioengineering (Basel) 2023; 10:1007. [PMID: 37760109 PMCID: PMC10525263 DOI: 10.3390/bioengineering10091007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/17/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
The measurement and analysis of fetal heart rate (FHR) and uterine contraction (UC) patterns, known as cardiotocography (CTG), is a key technology for detecting fetal compromise during labour. This technology is commonly used by clinicians to make decisions on the mode of delivery to minimise adverse outcomes. A range of computerised CTG analysis techniques have been proposed to overcome the limitations of manual clinician interpretation. While these automated techniques can potentially improve patient outcomes, their adoption into clinical practice remains limited. This review provides an overview of current FHR and UC monitoring technologies, public and private CTG datasets, pre-processing steps, and classification algorithms used in automated approaches for fetal compromise detection. It aims to highlight challenges inhibiting the translation of automated CTG analysis methods from research to clinical application and provide recommendations to overcome them.
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Affiliation(s)
- Lochana Mendis
- Department of Electrical and Electronic Engineering, The University of Melbourne, Parkville, VIC 3010, Australia; (M.P.); (E.K.)
| | - Marimuthu Palaniswami
- Department of Electrical and Electronic Engineering, The University of Melbourne, Parkville, VIC 3010, Australia; (M.P.); (E.K.)
| | - Fiona Brownfoot
- Obstetric Diagnostics and Therapeutics Group, Department of Obstetrics and Gynaecology, The University of Melbourne, Heidelberg, VIC 3084, Australia;
| | - Emerson Keenan
- Department of Electrical and Electronic Engineering, The University of Melbourne, Parkville, VIC 3010, Australia; (M.P.); (E.K.)
- Obstetric Diagnostics and Therapeutics Group, Department of Obstetrics and Gynaecology, The University of Melbourne, Heidelberg, VIC 3084, Australia;
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Reis‐de‐Carvalho C, Nogueira P, Ayres‐de‐Campos D. Quality of fetal heart rate monitoring with transabdominal fetal ECG during maternal movement in labor: A prospective study. Acta Obstet Gynecol Scand 2022; 101:1269-1275. [PMID: 35959521 PMCID: PMC9812089 DOI: 10.1111/aogs.14434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/10/2022] [Accepted: 07/13/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Transabdominal electrocardiographic (TAfECG) acquisition of fetal heart rate (FHR) signals has recently been introduced into leading commercial cardiotocographic (CTG) monitors. Continuous wireless transmission of signals has raised the possibility of the technology being used during maternal mobilization in labor. This study aims to evaluate signal quality and accuracy of TAfECG acquisition of FHR signals during static and active maternal positions in labor when compared with Doppler signals and with the gold-standard method of fetal scalp electrode (FSE). MATERIAL AND METHODS A total of 76 women with singleton term pregnancies in the active first stage of labor had simultaneously acquired FHR with TAfECG, Doppler, and FSE. Participants were asked to complete a supervised mobilization scheme, comprising five sequential 10-min periods of lying down, standing, sitting, walking, and rocking on the birthing ball. The three FHR signals were compared, defining signal loss as the percentage of signals under 20 bpm or exceeding 250 bpm and accuracy as the difference with FSE values. Computer analysis was used to quantify variability, accelerations, and decelerations. Static labor positions (lying down, standing, and sitting) were compared with active labor positions (walking and rocking on the birthing ball). RESULTS Average signal loss was 5.3% with TAfECG (3.2% in static and 7.4% in active positions) and 15.5% with Doppler (8.3% in static and 30.7% in active positions). Average accuracy was 3.5 bpm with TAfECG (1.9 bpm in static and 5.04 bpm in active positions) and 13.9 bpm with Doppler (3.2 bpm in static and 24.7 bpm in active positions). Average variability was similar with TAfECG and FSE in static positions but significantly higher with TAfECG in active positions (23.6 vs. 13.5 bpm, p < 0.001). CONCLUSIONS In static labor positions, TAfECG provides a low signal loss, similar to that obtained with FSE, and a good signal accuracy, so the technique can be considered reliable when the mother is lying down, standing, or sitting. During maternal movement, TAfECG causes an artificial increase in FHR variability, which can cause false reassurance regarding fetal oxygenation. Doppler signals are unreliable during maternal movements.
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Affiliation(s)
- Catarina Reis‐de‐Carvalho
- Department of Obstetrics and GynecologyMedical School ‐ Santa Maria University HospitalLisbonPortugal
- Medical School ‐ Santa Maria University HospitalLisbonPortugal
| | - Paulo Nogueira
- Medical School ‐ Santa Maria University HospitalLisbonPortugal
- Biomathematics LaboratoryInstitute for Preventive Medicine and Public HealthLisbonPortugal
| | - Diogo Ayres‐de‐Campos
- Department of Obstetrics and GynecologyMedical School ‐ Santa Maria University HospitalLisbonPortugal
- Medical School ‐ Santa Maria University HospitalLisbonPortugal
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Schwartz N, Mhajna M, Moody HL, Zahar Y, Shkolnik K, Reches A, Lowery CL. Novel uterine contraction monitoring to enable remote, self-administered nonstress testing. Am J Obstet Gynecol 2022; 226:554.e1-554.e12. [PMID: 34762863 DOI: 10.1016/j.ajog.2021.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/28/2021] [Accepted: 11/01/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND The serial fetal monitoring recommended for women with high-risk pregnancies places a substantial burden on the patient, often disproportionately affecting underprivileged and rural populations. A telehealth solution that can empower pregnant women to obtain recommended fetal surveillance from the comfort of their own home has the potential to promote health equity and improve outcomes. We have previously validated a novel, wireless pregnancy monitor that can remotely capture fetal and maternal heart rates. However, such a device must also detect uterine contractions if it is to be used to robustly conduct remote nonstress tests. OBJECTIVE This study aimed to describe and validate a novel algorithm that uses biopotential and acoustic signals to noninvasively detect uterine contractions via a wireless pregnancy monitor. STUDY DESIGN A prospective, open-label, 2-center study evaluated simultaneous detection of uterine contractions by the wireless pregnancy monitor and an intrauterine pressure catheter in women carrying singleton pregnancies at ≥32 0/7 weeks' gestation who were in the first stage of labor (ClinicalTrials.gov Identifier: NCT03889405). The study consisted of a training phase and a validation phase. Simultaneous recordings from each device were passively acquired for 30 to 60 minutes. In a subset of the monitoring sessions in the validation phase, tocodynamometry was also deployed. Three maternal-fetal medicine specialists, blinded to the data source, identified and marked contractions in all modalities. The positive agreement and false-positive rates of both the wireless monitor and tocodynamometry were calculated and compared with that of the intrauterine pressure catheter. RESULTS A total of 118 participants were included, 40 in the training phase and 78 in the validation phase (of which 39 of 78 participants were monitored simultaneously by all 3 devices) at a mean gestational age of 38.6 weeks. In the training phase, the positive agreement for the wireless monitor was 88.4% (1440 of 1692 contractions), with a false-positive rate of 15.3% (260/1700). In the validation phase, using the refined and finalized algorithm, the positive agreement for the wireless pregnancy monitor was 84.8% (2722/3210), with a false-positive rate of 24.8% (897/3619). For the subgroup who were monitored only with the wireless monitor and intrauterine pressure catheter, the positive agreement was 89.0% (1191/1338), with a similar false-positive rate of 25.4% (406/1597). For the subgroup monitored by all 3 devices, the positive agreement for the wireless monitor was significantly better than for tocodynamometry (P<.0001), whereas the false-positive rate was significantly higher (P<.0001). Unlike tocodynamometry, whose positive agreement was significantly reduced in the group with obesity compared with the group with normal weight (P=.024), the positive agreement of the wireless monitor did not vary across the body mass index groups. CONCLUSION This novel method to noninvasively monitor uterine activity, via a wireless pregnancy monitoring device designed for self-administration at home, was more accurate than the commonly used tocodynamometry and unaffected by body mass index. Together with the previously reported remote fetal heart rate monitoring capabilities, this added ability to detect uterine contractions has created a complete telehealth solution for remote administration of nonstress tests.
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Faiz Z, Van 't Hof EM, Colenbrander GJ, Lippes R, Bakker PCAM. The quality of intrapartum cardiotocography in preterm labour. J Perinat Med 2022; 50:74-81. [PMID: 34534426 DOI: 10.1515/jpm-2021-0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/19/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study is to determine the quality of the foetal heart rate (FHR) recording, defined as signal loss, during preterm labour below 28 weeks gestational age (GA) and contribute to the discussion if cardiotocography (CTG) is of value for the extreme preterm foetus. METHODS From January 2010 to December 2019 a retrospective study was conducted with data of 95 FHR recordings of singletons born between 24 and 28 weeks GA at the Amsterdam University Medical Centre, location VUmc. FHR tracings had a duration of at least 30 min and were obtained via external ultrasound mode. Data of all recordings were divided in two groups according to gestation (24-26 weeks and 26-28 weeks). Signal loss was analysed. Statistical significance was calculated by non-parametric tests and chi-square tests. The median signal loss and the proportion of cases exceeding the International Federation of Gynaecology and Obstetrics Guidelines (FIGO) threshold of 20% signal loss were calculated. RESULTS One-third of the recordings exceeded the 20% FIGO-criterion for adequate signal quality during the first stage of labour. In the second stage, this was nearly 75%. Similarly, the median signal loss was 13% during the first and 30% during the second stage of labour (p<0.01). CONCLUSIONS The quality of FHR monitoring in the extreme preterm foetus is inadequate in a large proportion of the foetuses, especially during the second stage. FHR monitoring is therefore controversial and should be used with caution.
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Affiliation(s)
- Zohal Faiz
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre Location VUmc, Amsterdam, The Netherlands
| | - Eline M Van 't Hof
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre Location VUmc, Amsterdam, The Netherlands
| | | | - Ralf Lippes
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre Location VUmc, Amsterdam, The Netherlands
| | - Petra C A M Bakker
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre Location VUmc, Amsterdam, The Netherlands
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Fox D, Coddington R, Scarf V, Bisits A, Lainchbury A, Woodworth R, Maude R, Foureur M, Sandall J. Harnessing technology to enable all women mobility in labour and birth: feasibility of implementing beltless non-invasive fetal ECG applying the NASSS framework. Pilot Feasibility Stud 2021; 7:214. [PMID: 34876233 PMCID: PMC8650358 DOI: 10.1186/s40814-021-00953-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 11/26/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND A new wireless and beltless monitoring device utilising fetal and maternal electrocardiography (ECG) and uterine electromyography, known as 'non-invasive fetal ECG' (NIFECG) was registered for clinical use in Australia in 2018. The safety and reliability of NIFECG has been demonstrated in controlled settings for short periods during labour. As far as we are aware, at the time our study commenced, this was globally the first trial of such a device in an authentic clinical setting for the entire duration of a woman's labour. METHODS This study aimed to assess the feasibility of using NIFECG fetal monitoring for women undergoing continuous electronic fetal monitoring during labour and birth. Women were eligible to participate in the study if they were at 36 weeks gestation or greater with a singleton pregnancy, planning to give birth vaginally and with obstetric indications as per local protocol (NSW Health Fetal Heart Rate Monitoring Guideline GL2018_025. 2018) for continuous intrapartum fetal monitoring. Written informed consent was received from participating women in antenatal clinic prior to the onset of labour. This single site clinical feasibility study took place between January and July 2020 at the Royal Hospital for Women in Sydney, Australia. Quantitative and qualitative data were collected to inform the analysis of results using the NASSS (Non-adoption, Abandonment, Scale up, Spread and Sustainability) framework, a validated tool for analysing the implementation of new health technologies into clinical settings. RESULTS Women responded positively about the comfort and freedom of movement afforded by the NIFECG. Midwives reported that when no loss of contact occurred, the device enabled them to focus less on the technology and more on supporting women's physical and emotional needs during labour. Midwives and obstetricians noticed the benefits for women but expressed a need for greater certainty about the reliability of the signal. CONCLUSION The NIFECG device enables freedom of movement and positioning for labouring women and was well received by women and the majority of clinicians. Whilst measurement of the uterine activity was reliable, there was uncertainty for clinicians in relation to loss of contact of the fetal heart rate. If this can be ameliorated the device shows potential to be used as routinely as cardiotocography (CTG) for fetal monitoring. This is the first time the NASSS framework has been used to synthesise the implementation needs of a health technology in the care of women during labour and birth. Our findings contribute new knowledge about the determinants for implementation of a complex technology in a maternity care setting. TRIAL REGISTRATION The Universal Trial Number is reU1111-1228-9845 and the Australian and New Zealand Clinical Trial Registration Number is 12619000293167p. Trial registration occurred on the 20 February, 2019. The trial protocol may be viewed at http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377027.
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Affiliation(s)
- Deborah Fox
- Centre for Midwifery Child and Family Health, University of Technology Sydney, Sydney, Australia.
| | - Rebecca Coddington
- Centre for Midwifery Child and Family Health, University of Technology Sydney, Sydney, Australia
| | - Vanessa Scarf
- Centre for Midwifery Child and Family Health, University of Technology Sydney, Sydney, Australia
| | - Andrew Bisits
- Royal Hospital for Women, NSW Health, Sydney, Australia
| | | | - Rachael Woodworth
- Centre for Midwifery Child and Family Health, University of Technology Sydney, Sydney, Australia
| | - Robyn Maude
- Victoria University of Wellington, Wellington, New Zealand
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Fox D, Coddington R, Scarf V. Wanting to be 'with woman', not with machine: Midwives' experiences of caring for women being continuously monitored in labour. Women Birth 2021; 35:387-393. [PMID: 34556463 DOI: 10.1016/j.wombi.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/12/2021] [Accepted: 09/06/2021] [Indexed: 11/15/2022]
Abstract
PROBLEM Some continuous electronic fetal monitoring (CEFM) devices restrict women's bodily autonomy by limiting their mobility in labour and birth. BACKGROUND Little is known about how midwives perceive the impact of CEFM technologies on their practice. AIM This paper explores the way different fetal monitoring technologies influence the work of midwives. METHODS Wireless and beltless 'non-invasive fetal electrocardiogram' (NIFECG) was trialled on 110 labouring women in an Australian maternity hospital. A focus group pertaining to midwives' experiences of using CTG was conducted prior to the trial. After the trial, midwives were asked about their experiences of using NIFECG. All data were analysed using thematic analysis. FINDINGS Midwives felt that wired CTG creates barriers to physiological processes. Whilst wireless CTG enables greater freedom of movement for women, it requires constant 'fiddling' from midwives, drawing their attention away from the woman. Midwives felt the NIFECG better enabled them to be 'with woman'. DISCUSSION Midwives play a pivotal role in mediating the influence of CEFM on women's experiences in labour. Exploring the way in which different forms of CEFM impact on midwives' practice may assist us to better understand how to prioritise the woman in order to facilitate safe and satisfying birth experiences. CONCLUSION The presence of CEFM technology in the birth space impacts midwives' ways of working and their capacity to be woman-centred. Current CTG technology may impede midwives' capacity to be 'with woman'. Compared to the CTG, the NIFECG has the potential to enable midwives to provide more woman-centred care for those experiencing complex pregnancies.
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Affiliation(s)
- Deborah Fox
- Centre for Midwifery, Child and Family Health, University of Technology Sydney, Australia.
| | - Rebecca Coddington
- Centre for Midwifery, Child and Family Health, University of Technology Sydney, Australia. https://www.twitter.com/Bec_Coddington
| | - Vanessa Scarf
- Centre for Midwifery, Child and Family Health, University of Technology Sydney, Australia. https://www.twitter.com/VScarf
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Detection of Fetal Cardiac Anomaly from Composite Abdominal Electrocardiogram. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2020.102308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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The Noninvasive Fetal Electrocardiogram During Labor: A Review of the Literature. Obstet Gynecol Surv 2021; 75:369-380. [PMID: 32603475 DOI: 10.1097/ogx.0000000000000798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance The introduction of the cardiotocogram (CTG) during labor has not been found to improve neonatal outcome. The search for a more reliable, less invasive, and patient-friendly technique is ongoing. The noninvasive fetal electrocardiogram (NI-fECG) has been proposed as one such alternative. Objectives The aim of this study was to review the literature on the performance of NI-fECG for fetal monitoring during labor. Following the PRISMA guidelines, a systematic search in MEDLINE, EMBASE, and Cochrane Library was performed. Studies involving original research investigating the performance of NI-fECG during labor were included. Animal studies and articles in languages other than English, Dutch, or German were excluded. The QUADAS-2 checklist was used for quality assessment. A descriptive analysis of the results is provided. Results Eight articles were included. Pooled analysis of the results of the separate studies was not possible due to heterogeneity. All studies demonstrate that it is possible to apply NI-fECG during labor. Compared with Doppler ultrasound, NI-fECG performs equal or better in most studies. Conclusions and Relevance NI-fECG for fetal monitoring is a promising noninvasive and patient-friendly technique that provides accurate information. Future studies should focus on signal quality throughout labor, with the aim to further optimize technical development of NI-fECG.
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Lempersz C, Noben L, van Osta G, Wassen MLH, Meershoek BPJ, Bakker P, Jacquemyn Y, Cuerva MJ, Vullings R, Westerhuis MEMH, Oei GS. Intrapartum non-invasive electrophysiological monitoring: A prospective observational study. Acta Obstet Gynecol Scand 2020; 99:1387-1395. [PMID: 32306380 DOI: 10.1111/aogs.13873] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/06/2020] [Accepted: 04/09/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Doppler ultrasound cardiotocography is a non-invasive alternative that, despite its poor specificity, is often first choice for intrapartum monitoring. Doppler ultrasound suffers from signal loss due to fetal movements and is negatively correlated with maternal body mass index (BMI). Reported accuracy of fetal heart rate monitoring by Doppler ultrasound varies between 10.6 and 14.3 bpm and reliability between 62.4% and 73%. The fetal scalp electrode (FSE) is considered the reference standard for fetal monitoring but can only be applied after membranes have ruptured with sufficient cervical dilatation and is sometimes contra-indicated. A non-invasive alternative that overcomes the shortcomings of Doppler ultrasound, providing reliable information on fetal heart rate, could be the answer. Non-invasive fetal electrocardiography (NI-fECG) uses a wireless electrode patch on the maternal abdomen to obtain both fetal and maternal heart rate signals as well as an electrohysterogram. We aimed to validate a wireless NI-fECG device for intrapartum monitoring in term singleton pregnancies, by comparison with the FSE. MATERIAL AND METHODS We performed a multicenter cross-sectional observational study at labor wards of 6 hospitals located in the Netherlands, Belgium, and Spain. Laboring women with a healthy singleton fetus in cephalic presentation and gestational age between 36 and 42 weeks were included. Participants received an abdominal electrode patch and FSE after written informed consent. Accuracy, reliability, and success rate of fetal heart rate readings were determined, using FSE as reference standard. Analysis was performed for the total population and measurement period as well as separated by labor stage and BMI class (≤30 and >30 kg/m2 ). RESULTS We included a total of 125 women. Simultaneous registrations with NI-fECG and FSE were available in 103 women. Overall accuracy is -1.46 bpm and overall reliability 86.84%. Overall success rate of the NI-fECG is around 90% for the total population as well as for both BMI subgroups. Success rate dropped to 63% during second stage of labor, similar results are found when looking at the separate BMI groups. CONCLUSIONS Performance measures of the NI-fECG device are good in the overall group and the separate BMI groups. Compared with Doppler ultrasound performance measures from the literature, NI-fECG is a more accurate alternative. Especially, when women have a higher BMI, NI-fECG performs well, resembling FSE performance measures.
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Affiliation(s)
- Carlijn Lempersz
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands.,Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
| | - Lore Noben
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands.,Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
| | - Gonnie van Osta
- Author! Et al. BV Data analysis and reporting, Hilversum, The Netherlands
| | - Martine L H Wassen
- Department of Obstetrics and Gynecology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Bert P J Meershoek
- Department of Obstetrics and Gynecology, Van Weel-Bethesda Hospital, Dirksland, The Netherlands
| | - Petra Bakker
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Yves Jacquemyn
- Department of Obstetrics and Gynecology, University Hospital Antwerp, Antwerp, Belgium
| | - Marcos Javier Cuerva
- Department of Obstetrics and Gynecology, University Hospital La Paz, Madrid, Spain
| | - Rik Vullings
- Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Michelle E M H Westerhuis
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands.,Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
| | - Guid S Oei
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands.,Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
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Noben L, Westerhuis MEMH, van Laar JOEH, Kok RD, Oei SG, Peters CHL, Vullings R. Feasibility of non-invasive Foetal electrocardiography in a twin pregnancy. BMC Pregnancy Childbirth 2020; 20:215. [PMID: 32293330 PMCID: PMC7161133 DOI: 10.1186/s12884-020-02918-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 04/01/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Twin pregnancy is associated with increased perinatal mortality. Close foetal monitoring is therefore warranted. Doppler Ultrasound cardiotocography is currently the only available method to monitor both individual foetuses. Unfortunately, the performance measures of this method are poor and erroneous monitoring of the same twin with both transducers may occur, leaving the second twin unmonitored. In this study we aimed to determine the feasibility of monitoring both foetuses simultaneously in twin gestation by means of non-invasive foetal electrocardiography (NI-fECG), using an electrode patch on the maternal abdomen. METHODS A NI-fECG recording was performed at 25 + 3 weeks of gestation on a multiparous woman pregnant with dichorionic diamniotic twins. An electrode patch consisting of eight adhesive electrodes was applied on the maternal abdomen, yielding six channels of bipolar electrophysiological measurements. The output was digitized and stored for offline processing. The recorded signals were preprocessed by suppression of high-frequency noise, baseline wander, and powerline interference. Secondly, the maternal ECG was subtracted and segmentation into individual ECG complexes was performed. Finally, ensemble averaging of these individual ECG complexes was performed to suppress interferences. RESULTS Six different recordings were obtained from each of the six recording channels. Depending on the orientation and distance of the fetal heart with respect to each electrode, a distinction could be made between each fetus based on the morphology of the signals. Yielding of the fetal ECGs was performed manually based on the QRS complexes of each fetus. CONCLUSION NI-fECG with multiple electrodes allows for monitoring of the fetal heart rate and ECG of both individual fetuses in twin pregnancies.
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Affiliation(s)
- Lore Noben
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, P.O. Box 7777, 5500, MB, Veldhoven, The Netherlands.
- Eindhoven MedTech Innovation Centre (e/MTIC), P.O. Box 513, 5600, MB, Eindhoven, The Netherlands.
| | - Michelle E M H Westerhuis
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, P.O. Box 7777, 5500, MB, Veldhoven, The Netherlands
- Eindhoven MedTech Innovation Centre (e/MTIC), P.O. Box 513, 5600, MB, Eindhoven, The Netherlands
| | - Judith O E H van Laar
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, P.O. Box 7777, 5500, MB, Veldhoven, The Netherlands
- Eindhoven MedTech Innovation Centre (e/MTIC), P.O. Box 513, 5600, MB, Eindhoven, The Netherlands
| | - René D Kok
- Nemo Healthcare BV, 'MMC Incubator', De Run 4630, 5504, DB, Veldhoven, The Netherlands
| | - S Guid Oei
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, P.O. Box 7777, 5500, MB, Veldhoven, The Netherlands
- Eindhoven MedTech Innovation Centre (e/MTIC), P.O. Box 513, 5600, MB, Eindhoven, The Netherlands
| | - Chris H L Peters
- Department of Clinical Physics, Jeroen Bosch Hospital, P.O. Box 90153, 5200 ME, 's Hertogenbosch, The Netherlands
| | - Rik Vullings
- Eindhoven MedTech Innovation Centre (e/MTIC), P.O. Box 513, 5600, MB, Eindhoven, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, P.O. Box 513, 5600, MB, Eindhoven, The Netherlands
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Hamelmann P, Vullings R, Kolen AF, Bergmans JWM, van Laar JOEH, Tortoli P, Mischi M. Doppler Ultrasound Technology for Fetal Heart Rate Monitoring: A Review. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2020; 67:226-238. [PMID: 31562079 DOI: 10.1109/tuffc.2019.2943626] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Fetal well-being is commonly assessed by monitoring the fetal heart rate (fHR). In clinical practice, the de facto standard technology for fHR monitoring is based on the Doppler ultrasound (US). Continuous monitoring of the fHR before and during labor is performed using a US transducer fixed on the maternal abdomen. The continuous fHR monitoring, together with simultaneous monitoring of the uterine activity, is referred to as cardiotocography (CTG). In contrast, for intermittent measurements of the fHR, a handheld Doppler US transducer is typically used. In this article, the technology of Doppler US for continuous fHR monitoring and intermittent fHR measurements is described, with emphasis on fHR monitoring for CTG. Special attention is dedicated to the measurement environment, which includes the clinical setting in which fHR monitoring is commonly performed. In addition, to understand the signal content of acquired Doppler US signals, the anatomy and physiology of the fetal heart and the surrounding maternal abdomen are described. The challenges encountered in these measurements have led to different technological strategies, which are presented and critically discussed, with a focus on the US transducer geometry, Doppler signal processing, and fHR extraction methods.
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Vullings R, van Laar JOEH. Non-invasive Fetal Electrocardiography for Intrapartum Cardiotocography. Front Pediatr 2020; 8:599049. [PMID: 33363064 PMCID: PMC7755891 DOI: 10.3389/fped.2020.599049] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/19/2020] [Indexed: 11/19/2022] Open
Abstract
Fetal monitoring is important to diagnose complications that can occur during pregnancy. If detected timely, these complications might be resolved before they lead to irreversible damage. Current fetal monitoring mainly relies on cardiotocography, the simultaneous registration of fetal heart rate and uterine activity. Unfortunately, the technology to obtain the cardiotocogram has limitations. In current clinical practice the fetal heart rate is obtained via either an invasive scalp electrode, that poses risks and can only be applied during labor and after rupture of the fetal membranes, or via non-invasive Doppler ultrasound technology that is inaccurate and suffers from loss of signal, in particular in women with high body mass, during motion, or in preterm pregnancies. In this study, transabdominal electrophysiological measurements are exploited to provide fetal heart rate non-invasively and in a more reliable manner than Doppler ultrasound. The performance of the fetal heart rate detection is determined by comparing the fetal heart rate to that obtained with an invasive scalp electrode during intrapartum monitoring. The performance is gauged by comparing it to performances mentioned in literature on Doppler ultrasound and on two commercially-available devices that are also based on transabdominal fetal electrocardiography.
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Affiliation(s)
- Rik Vullings
- Biomedical Diagnostics Lab Eindhoven, Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Nemo Healthcare, Veldhoven, Netherlands
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13
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Martinek R, Kahankova R, Martin B, Nedoma J, Fajkus M. A novel modular fetal ECG STAN and HRV analysis: Towards robust hypoxia detection. Technol Health Care 2019; 27:257-287. [PMID: 30562910 DOI: 10.3233/thc-181375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This paper introduces a comprehensive fetal Electrocardiogram (fECG) Signal Extraction and Analysis Virtual Instrument that integrates various methods for detecting the R-R Intervals (RRIs) as a means to determine the fetal Heart Rate (fHR) and therefore facilitates fetal Heart Rate Variability (HRV) signal analysis. Moreover, it offers the capability to perform advanced morphological fECG signal analysis called ST segment Analysis (STAN) as it seamlessly allows the determination of the T-wave to QRS complex ratio (also called T/QRS) in the fECG signal. The integration of these signal processing and analytical modules could help clinical researchers and practitioners to noninvasively monitor and detect the life threatening hypoxic conditions that may arise in different stages of pregnancy and more importantly during delivery and could therefore lead to the reduction of unnecessary C-sections. In our experiments we used real recordings from a Fetal Scalp Electrode (FSE) as well as maternal abdominal electrodes. This Virtual Instrument (Toolbox) not only serves as a desirable platform for comparing various fECG extraction signal processing methods, it also provides an effective means to perform STAN and HRV signal analysis based on proven ECG morphological as well as Autonomic Nervous System (ANS) indices to detect hypoxic conditions.
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Affiliation(s)
- Radek Martinek
- Department of Cybernetics and Biomedical Engineering, VSB-Technical University of Ostrava, Ostrava 70833, Czech Republic
| | - Radana Kahankova
- Department of Cybernetics and Biomedical Engineering, VSB-Technical University of Ostrava, Ostrava 70833, Czech Republic
| | - Boris Martin
- Polytech Grenoble, Saint-Martin-d'Hres 38400, France
| | - Jan Nedoma
- Department of Telecommunications, VSB-Technical University of Ostrava, Ostrava 70833, Czech Republic
| | - Marcel Fajkus
- Department of Telecommunications, VSB-Technical University of Ostrava, Ostrava 70833, Czech Republic
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14
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Hayes-Gill BR, Martin TRP, Liu C, Cohen WR. Relative accuracy of computerized intrapartum fetal heart rate pattern recognition by ultrasound and abdominal electrocardiogram detection. Acta Obstet Gynecol Scand 2019; 99:413-422. [PMID: 31792930 DOI: 10.1111/aogs.13760] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Noninvasive fetal heart rate monitoring using transabdominal fetal electrocardiographic detection is now commercially available and has been demonstrated to be an effective alternative to traditional Doppler ultrasonographic techniques. Our objective in this study was to compare the results of computerized identification of fetal heart rate patterns generated by ultrasound-based and transabdominal fetal electrocardiogram-based techniques with simultaneously obtained fetal scalp electrode-derived heart rate information. MATERIAL AND METHODS We applied an objective computer-based analysis for recognition of fetal heart rate patterns (Monica Decision Support) to data obtained simultaneously from a direct fetal scalp electrode, Doppler ultrasound, and the abdominal-fetal electrocardiogram techniques. This allowed us to compare over 145 hours of fetal heart rate patterns generated by the external devices with those derived from the scalp electrode in 30 term singleton uncomplicated pregnancies during labor. The direct fetal scalp electrode is considered to be the most accurate and reliable technique used in current clinical practice, and was, therefore, used as the standard for comparison. The program quantified the baseline heart rate, long- and short-term variability. It indicated when an acceleration or deceleration was present and whether it was large or small. RESULTS Ultrasound was associated with significantly greater deviations from the fetal scalp electrode results than the abdominal fetal electrocardiogram technique in recognizing the correct baseline heart rate, its variability, and the presence of small and large accelerations and small decelerations. For large decelerations the two external methods were each not significantly different from the scalp electrode results. CONCLUSIONS Noninvasive fetal heart rate monitoring using maternal abdominal wall electrodes to detect fetal cardiac activity more reliably reproduced the computerized analysis of heart rate patterns derived from a direct fetal scalp electrode than did traditional ultrasound-based monitoring. Abdominal-fetal electrocardiogram should, therefore, be considered a primary option for externally monitored patients.
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Affiliation(s)
- Barrie R Hayes-Gill
- Faculty of Engineering, Department of Electrical and Electronic Engineering, University of Nottingham, Nottingham, UK
| | | | - Chong Liu
- Faculty of Engineering, Department of Electrical and Electronic Engineering, University of Nottingham, Nottingham, UK
| | - Wayne R Cohen
- Department of Obstetrics and Gynecology, University of Arizona College of Medicine, Tucson, AZ, USA
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15
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John RG, Ramachandran KI. Extraction of foetal ECG from abdominal ECG by nonlinear transformation and estimations. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 175:193-204. [PMID: 31104707 DOI: 10.1016/j.cmpb.2019.04.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/13/2019] [Accepted: 04/20/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND OBJECTIVE This paper proposes a simple yet effective method for the extraction of foetal ECG from abdominal ECG which is necessary due to similar spatial and temporal content of mother and foetal ECG. METHODS The proposed algorithm for extraction of foetal ECG (fECG) from abdominal signal uses single channel. Pre-processing of abdominal ECG (abdECG) has been done to eliminate noise and condition the signal. The maternal ECG R-peaks have been detected based on thresholding, first order Gaussian differentiation and zero cross detection on pre-processed signal. Having identified R-peaks and pre-processed signal as base, using Maximum Likelihood Estimation, one beat including QRS complex morphology of maternal ECG (mECG) has been constructed. Extraction of maternal ECG from abdECG is done based on the constructed beat, R-peak locations and its corresponding QRS complex of abdECG. Extracted mECG has been cancelled from abdECG. This results in foetal ECG with residual noise. The noise has been reduced by Polynomial Approximation and Total Variation (PATV) to improve SNR. This approach ensures no loss of partially or completely overlapped fECG signals due to mECG removal. The algorithm is tested on three database namely daISy (DBI), Physiobank challenge 2013 (DBII) and abdominal and direct foetal ECG database (adfecgdb) of Physiobank (DBIII). RESULTS The algorithm detected no false positives or false negatives with certain channel for DBI, DBII and DBIII which shows that the proposed algorithm can achieve good performance. Overall accuracy and sensitivity of the system is 98.53% and 100% for DBI. Best accuracy and sensitivity of 97.77% and 98.63% are obtained for DBII. Best accuracy of 92.41% and sensitivity of 93.8% are obtained for DBIII. Correlation coefficient between actual foetal heart rate (fHR) and estimated fHR of 0.66 for DBII and 0.59 for DBIII is obtained. The method has obtained overall F1 score of 99.25% for DBI, 96.04% for DBII and 94.25% for DBIII. It has obtained a best MSE of fHR and overall MSE of R-R interval which is 10.8bpm2 and 2.2 ms for DBII, 12bpm2 and 2.14 ms for DBIII. CONCLUSION The results for different public databases show that the proposed method is capable of providing good results. The foetal QRS, R-peaks and R-R intervals have also been obtained in this method. Thus, it gives a significant contribution in the required area of research.
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Affiliation(s)
- Rolant Gini John
- Department of Electronics and Communication Engineering, Amrita School of Engineering, Coimbatore, Amrita Vishwa Vidyapeetham, India.
| | - K I Ramachandran
- Center for Computational Engineering & Networking (CEN), Amrita School of Engineering, Coimbatore, Amrita Vishwa Vidyapeetham, India
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16
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Hamelmann P, Mischi M, Kolen AF, van Laar JOEH, Vullings R, Bergmans JWM. Fetal Heart Rate Monitoring Implemented by Dynamic Adaptation of Transmission Power of a Flexible Ultrasound Transducer Array. SENSORS (BASEL, SWITZERLAND) 2019; 19:E1195. [PMID: 30857218 PMCID: PMC6427711 DOI: 10.3390/s19051195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 02/28/2019] [Accepted: 03/04/2019] [Indexed: 11/16/2022]
Abstract
Fetal heart rate (fHR) monitoring using Doppler Ultrasound (US) is a standard method to assess fetal health before and during labor. Typically, an US transducer is positioned on the maternal abdomen and directed towards the fetal heart. Due to fetal movement or displacement of the transducer, the relative fetal heart location (fHL) with respect to the US transducer can change, leading to frequent periods of signal loss. Consequently, frequent repositioning of the US transducer is required, which is a cumbersome task affecting clinical workflow. In this research, a new flexible US transducer array is proposed which allows for measuring the fHR independently of the fHL. In addition, a method for dynamic adaptation of the transmission power of this array is introduced with the aim of reducing the total acoustic dose transmitted to the fetus and the associated power consumption, which is an important requirement for application in an ambulatory setting. The method is evaluated using an in-vitro setup of a beating chicken heart. We demonstrate that the signal quality of the Doppler signal acquired with the proposed method is comparable to that of a standard, clinical US transducer. At the same time, our transducer array is able to measure the fHR for varying fHL while only using 50% of the total transmission power of standard, clinical US transducers.
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Affiliation(s)
- Paul Hamelmann
- Department of Electrical Engineering, Eindhoven University of Technology, 5612 AP Eindhoven, The Netherlands.
| | - Massimo Mischi
- Department of Electrical Engineering, Eindhoven University of Technology, 5612 AP Eindhoven, The Netherlands.
| | | | | | - Rik Vullings
- Department of Electrical Engineering, Eindhoven University of Technology, 5612 AP Eindhoven, The Netherlands.
| | - Jan W M Bergmans
- Department of Electrical Engineering, Eindhoven University of Technology, 5612 AP Eindhoven, The Netherlands.
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17
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Smith V, Arunthavanathan S, Nair A, Ansermet D, da Silva Costa F, Wallace EM. A systematic review of cardiac time intervals utilising non-invasive fetal electrocardiogram in normal fetuses. BMC Pregnancy Childbirth 2018; 18:370. [PMID: 30208861 PMCID: PMC6134593 DOI: 10.1186/s12884-018-2006-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 09/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Non-invasive fetal electrocardiogram (NIFECG) is an evolving technology in fetal surveillance which is attracting increasing research interest. There is however, only limited data outlining the reference ranges for normal cardiac time intervals (CTIs). The objective of our group was to carry out a systematic review to outline normal fetal CTIs using NIFECG. METHODS A systematic review of peer reviewed literature was performed, searching PUBMED,Ovid MEDLINE and EMBASE. The outcomes of interest included fetal CTIs (P wave duration, PR interval, QRS duration and QT interval) and a descriptive summary of relevant studies as well. The outcomes were grouped as early pre-term (≤ 32 weeks), moderate to late pre-term (32-37 weeks) and term (37-41 weeks). RESULTS 8 studies were identified as suitable for inclusion. Reference ranges of CTIs were generated. Both PR interval and QRS duration demonstrated a linear correlation with advancing gestation. Several studies also demonstrated a reduction in signal acquisition between 27 and 32 weeks due to the attenuation by vernix caseosa. In this group, both the P wave and T waves were difficult to detect due to signal strength and interference. CONCLUSION NIFECG demonstrates utility to quantify CTIs in the fetus, particularly at advanced gestations. Larger prospective studies should be directed towards establishing reliable CTIs across various gestations.
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Affiliation(s)
- Vinayak Smith
- Department of Obstetrics and Gynaecology, Monash University, 252 Clayton Road, Melbourne, VIC, 3168, Australia.
- Biorithm Pte Ltd, 81 Ayer Rajah Crescent 03-53, Singapore, 139967, Singapore.
| | - Senthuran Arunthavanathan
- Department of Electrical and Electronic Engineering, University of Melbourne, Parkville Campus, Melbourne, VIC, 3010, Australia
| | - Amrish Nair
- Biorithm Pte Ltd, 81 Ayer Rajah Crescent 03-53, Singapore, 139967, Singapore
| | - Diane Ansermet
- Biorithm Pte Ltd, 81 Ayer Rajah Crescent 03-53, Singapore, 139967, Singapore
| | - Fabricio da Silva Costa
- Department of Obstetrics and Gynaecology, Monash University, 252 Clayton Road, Melbourne, VIC, 3168, Australia
| | - Euan Morrison Wallace
- Department of Obstetrics and Gynaecology, Monash University, 252 Clayton Road, Melbourne, VIC, 3168, Australia
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18
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Odendaal H, Groenewald C, Myers MM, Fifer WP. Maternal heart rate patterns under resting conditions in late pregnancy. ACTA ACUST UNITED AC 2018; 1. [PMID: 31008442 PMCID: PMC6474684 DOI: 10.15761/tr.1000116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Objectives: To describe maternal heart rate patterns observed during antenatal monitoring under resting conditions between the gestational ages of 34 to 38 weeks and to demonstrate its associations with uterine activity. Methods: Each participant had five high quality ECG electrodes attached to her anterior abdominal wall which were connected to the Monica AN24 device to collect raw electrical signals from the maternal and fetal ECG and signals of uterine activity. Proprietary software was then used to download the raw data and extract the maternal and fetal heart rate patterns and uterine activity. Results: Several distinct maternal heart rate patterns were observed. These included unusually high or low levels of variability, tachycardia, bradycardia, regular and irregular periodic changes and sporadic changes where the heart rate suddenly decreased or increased. Some of the fluctuations, especially decelerations of maternal heart rate, seemed to be associated with uterine activity. Conclusion: The clinical implications of these different patterns, for both the mother and fetus, needs to be explored further. There is a need for computerized analyses of the different maternal patterns during different gestational ages to determine its relevance. Synopsis Various maternal heart rate patterns under resting conditions in late pregnancy are described.
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Affiliation(s)
- Hein Odendaal
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Coen Groenewald
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Michael M Myers
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA.,Department of Pediatrics, Columbia University Medical Center, New York, NY, USA.,Division of Developmental Neuroscience, New York State Psychiatric Institute, New York, NY, USA.,Extraordinary Professor, Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - William P Fifer
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA.,Department of Pediatrics, Columbia University Medical Center, New York, NY, USA.,Division of Developmental Neuroscience, New York State Psychiatric Institute, New York, NY, USA.,Extraordinary Professor, Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
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19
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Martinek R, Kahankova R, Jezewski J, Jaros R, Mohylova J, Fajkus M, Nedoma J, Janku P, Nazeran H. Comparative Effectiveness of ICA and PCA in Extraction of Fetal ECG From Abdominal Signals: Toward Non-invasive Fetal Monitoring. Front Physiol 2018; 9:648. [PMID: 29899707 PMCID: PMC5988877 DOI: 10.3389/fphys.2018.00648] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 05/11/2018] [Indexed: 01/15/2023] Open
Abstract
Non-adaptive signal processing methods have been successfully applied to extract fetal electrocardiograms (fECGs) from maternal abdominal electrocardiograms (aECGs); and initial tests to evaluate the efficacy of these methods have been carried out by using synthetic data. Nevertheless, performance evaluation of such methods using real data is a much more challenging task and has neither been fully undertaken nor reported in the literature. Therefore, in this investigation, we aimed to compare the effectiveness of two popular non-adaptive methods (the ICA and PCA) to explore the non-invasive (NI) extraction (separation) of fECGs, also known as NI-fECGs from aECGs. The performance of these well-known methods was enhanced by an adaptive algorithm, compensating amplitude difference and time shift between the estimated components. We used real signals compiled in 12 recordings (real01-real12). Five of the recordings were from the publicly available database (PhysioNet-Abdominal and Direct Fetal Electrocardiogram Database), which included data recorded by multiple abdominal electrodes. Seven more recordings were acquired by measurements performed at the Institute of Medical Technology and Equipment, Zabrze, Poland. Therefore, in total we used 60 min of data (i.e., around 88,000 R waves) for our experiments. This dataset covers different gestational ages, fetal positions, fetal positions, maternal body mass indices (BMI), etc. Such a unique heterogeneous dataset of sufficient length combining continuous Fetal Scalp Electrode (FSE) acquired and abdominal ECG recordings allows for robust testing of the applied ICA and PCA methods. The performance of these signal separation methods was then comprehensively evaluated by comparing the fetal Heart Rate (fHR) values determined from the extracted fECGs with those calculated from the fECG signals recorded directly by means of a reference FSE. Additionally, we tested the possibility of non-invasive ST analysis (NI-STAN) by determining the T/QRS ratio. Our results demonstrated that even though these advanced signal processing methods are suitable for the non-invasive estimation and monitoring of the fHR information from maternal aECG signals, their utility for further morphological analysis of the extracted fECG signals remains questionable and warrants further work.
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Affiliation(s)
- Radek Martinek
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, Ostrava, Czechia
| | - Radana Kahankova
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, Ostrava, Czechia
| | - Janusz Jezewski
- Institute of Medical Technology and Equipment ITAM, Zabrze, Poland
| | - Rene Jaros
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, Ostrava, Czechia
| | - Jitka Mohylova
- Department of General Electrical Engineering, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, Ostrava, Czechia
| | - Marcel Fajkus
- Department of Telecommunications, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, Ostrava, Czechia
| | - Jan Nedoma
- Department of Telecommunications, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, Ostrava, Czechia
| | - Petr Janku
- Department of Obstetrics and Gynecology, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Homer Nazeran
- Department of Electrical and Computer Engineering, University of Texas El Paso, El Paso, TX, United States
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20
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Hamelmann P, Vullings R, Schmitt L, Kolen AF, Mischi M, van Laar JOEH, Bergmans JWM. Improved ultrasound transducer positioning by fetal heart location estimation during Doppler based heart rate measurements. Physiol Meas 2017; 38:1821-1836. [PMID: 28869420 DOI: 10.1088/1361-6579/aa8a1a] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Doppler ultrasound (US) is the most commonly applied method to measure the fetal heart rate (fHR). When the fetal heart is not properly located within the ultrasonic beam, fHR measurements often fail. As a consequence, clinical staff need to reposition the US transducer on the maternal abdomen, which can be a time consuming and tedious task. APPROACH In this article, a method is presented to aid clinicians with the positioning of the US transducer to produce robust fHR measurements. A maximum likelihood estimation (MLE) algorithm is developed, which provides information on fetal heart location using the power of the Doppler signals received in the individual elements of a standard US transducer for fHR recordings. The performance of the algorithm is evaluated with simulations and in vitro experiments performed on a beating-heart setup. MAIN RESULTS Both the experiments and the simulations show that the heart location can be accurately determined with an error of less than 7 mm within the measurement volume of the employed US transducer. SIGNIFICANCE The results show that the developed algorithm can be used to provide accurate feedback on fetal heart location for improved positioning of the US transducer, which may lead to improved measurements of the fHR.
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Affiliation(s)
- Paul Hamelmann
- Department of Electrical Engineering, Eindhoven University of Technology, 5612 AP Eindhoven, Netherlands
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21
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Jezewski J, Wrobel J, Matonia A, Horoba K, Martinek R, Kupka T, Jezewski M. Is Abdominal Fetal Electrocardiography an Alternative to Doppler Ultrasound for FHR Variability Evaluation? Front Physiol 2017; 8:305. [PMID: 28559852 PMCID: PMC5432618 DOI: 10.3389/fphys.2017.00305] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 04/27/2017] [Indexed: 12/02/2022] Open
Abstract
Great expectations are connected with application of indirect fetal electrocardiography (FECG), especially for home telemonitoring of pregnancy. Evaluation of fetal heart rate (FHR) variability, when determined from FECG, uses the same criteria as for FHR signal acquired classically—through ultrasound Doppler method (US). Therefore, the equivalence of those two methods has to be confirmed, both in terms of recognizing classical FHR patterns: baseline, accelerations/decelerations (A/D), long-term variability (LTV), as well as evaluating the FHR variability with beat-to-beat accuracy—short-term variability (STV). The research material consisted of recordings collected from 60 patients in physiological and complicated pregnancy. The FHR signals of at least 30 min duration were acquired dually, using two systems for fetal and maternal monitoring, based on US and FECG methods. Recordings were retrospectively divided into normal (41) and abnormal (19) fetal outcome. The complex process of data synchronization and validation was performed. Obtained low level of the signal loss (4.5% for US and 1.8% for FECG method) enabled to perform both direct comparison of FHR signals, as well as indirect one—by using clinically relevant parameters. Direct comparison showed that there is no measurement bias between the acquisition methods, whereas the mean absolute difference, important for both visual and computer-aided signal analysis, was equal to 1.2 bpm. Such low differences do not affect the visual assessment of the FHR signal. However, in the indirect comparison the inconsistencies of several percent were noted. This mainly affects the acceleration (7.8%) and particularly deceleration (54%) patterns. In the signals acquired using the electrocardiography the obtained STV and LTV indices have shown significant overestimation by 10 and 50% respectively. It also turned out, that ability of clinical parameters to distinguish between normal and abnormal groups do not depend on the acquisition method. The obtained results prove that the abdominal FECG, considered as an alternative to the ultrasound approach, does not change the interpretation of the FHR signal, which was confirmed during both visual assessment and automated analysis.
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Affiliation(s)
- Janusz Jezewski
- Institute of Medical Technology and Equipment ITAMZabrze, Poland
| | - Janusz Wrobel
- Institute of Medical Technology and Equipment ITAMZabrze, Poland
| | - Adam Matonia
- Institute of Medical Technology and Equipment ITAMZabrze, Poland
| | - Krzysztof Horoba
- Institute of Medical Technology and Equipment ITAMZabrze, Poland
| | - Radek Martinek
- Department of Cybernetics and Biomedical Engineering, VSB-Technical University of OstravaOstrava, Czechia
| | - Tomasz Kupka
- Institute of Medical Technology and Equipment ITAMZabrze, Poland
| | - Michal Jezewski
- Institute of Electronics, Silesian University of TechnologyGliwice, Poland
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22
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Hoyer D, Żebrowski J, Cysarz D, Gonçalves H, Pytlik A, Amorim-Costa C, Bernardes J, Ayres-de-Campos D, Witte OW, Schleußner E, Stroux L, Redman C, Georgieva A, Payne S, Clifford G, Signorini MG, Magenes G, Andreotti F, Malberg H, Zaunseder S, Lakhno I, Schneider U. Monitoring fetal maturation-objectives, techniques and indices of autonomic function. Physiol Meas 2017; 38:R61-R88. [PMID: 28186000 PMCID: PMC5628752 DOI: 10.1088/1361-6579/aa5fca] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Monitoring the fetal behavior does not only have implications for acute care but also for identifying developmental disturbances that burden the entire later life. The concept, of 'fetal programming', also known as 'developmental origins of adult disease hypothesis', e.g. applies for cardiovascular, metabolic, hyperkinetic, cognitive disorders. Since the autonomic nervous system is involved in all of those systems, cardiac autonomic control may provide relevant functional diagnostic and prognostic information. The fetal heart rate patterns (HRP) are one of the few functional signals in the prenatal period that relate to autonomic control and, therefore, is predestinated for its evaluation. The development of sensitive markers of fetal maturation and its disturbances requires the consideration of physiological fundamentals, recording technology and HRP parameters of autonomic control. Based on the ESGCO2016 special session on monitoring the fetal maturation we herein report the most recent results on: (i) functional fetal autonomic brain age score (fABAS), Recurrence Quantitative Analysis and Binary Symbolic Dynamics of complex HRP resolve specific maturation periods, (ii) magnetocardiography (MCG) based fABAS was validated for cardiotocography (CTG), (iii) 30 min recordings are sufficient for obtaining episodes of high variability, important for intrauterine growth restriction (IUGR) detection in handheld Doppler, (iv) novel parameters from PRSA to identify Intra IUGR fetuses, (v) evaluation of fetal electrocardiographic (ECG) recordings, (vi) correlation between maternal and fetal HRV is disturbed in pre-eclampsia. The reported novel developments significantly extend the possibilities for the established CTG methodology. Novel HRP indices improve the accuracy of assessment due to their more appropriate consideration of complex autonomic processes across the recording technologies (CTG, handheld Doppler, MCG, ECG). The ultimate objective is their dissemination into routine practice and studies of fetal developmental disturbances with implications for programming of adult diseases.
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Affiliation(s)
- Dirk Hoyer
- Hans Berger Department of Neurology, Biomagnetic Center, Jena University Hospital, Jena 07747, Germany
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23
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Martinek R, Nedoma J, Fajkus M, Kahankova R, Konecny J, Janku P, Kepak S, Bilik P, Nazeran H. A Phonocardiographic-Based Fiber-Optic Sensor and Adaptive Filtering System for Noninvasive Continuous Fetal Heart Rate Monitoring. SENSORS 2017; 17:s17040890. [PMID: 28420215 PMCID: PMC5426540 DOI: 10.3390/s17040890] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 03/28/2017] [Accepted: 04/12/2017] [Indexed: 11/21/2022]
Abstract
This paper focuses on the design, realization, and verification of a novel phonocardiographic- based fiber-optic sensor and adaptive signal processing system for noninvasive continuous fetal heart rate (fHR) monitoring. Our proposed system utilizes two Mach-Zehnder interferometeric sensors. Based on the analysis of real measurement data, we developed a simplified dynamic model for the generation and distribution of heart sounds throughout the human body. Building on this signal model, we then designed, implemented, and verified our adaptive signal processing system by implementing two stochastic gradient-based algorithms: the Least Mean Square Algorithm (LMS), and the Normalized Least Mean Square (NLMS) Algorithm. With this system we were able to extract the fHR information from high quality fetal phonocardiograms (fPCGs), filtered from abdominal maternal phonocardiograms (mPCGs) by performing fPCG signal peak detection. Common signal processing methods such as linear filtering, signal subtraction, and others could not be used for this purpose as fPCG and mPCG signals share overlapping frequency spectra. The performance of the adaptive system was evaluated by using both qualitative (gynecological studies) and quantitative measures such as: Signal-to-Noise Ratio—SNR, Root Mean Square Error—RMSE, Sensitivity—S+, and Positive Predictive Value—PPV.
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Affiliation(s)
- Radek Martinek
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Jan Nedoma
- Department of Telecommunications, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Marcel Fajkus
- Department of Telecommunications, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Radana Kahankova
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Jaromir Konecny
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Petr Janku
- Department of Obstetrics and Gynecology, Masaryk University and University Hospital Brno, Jihlavska 20, 625 00 Brno, Czech Republic.
| | - Stanislav Kepak
- Department of Telecommunications, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Petr Bilik
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Homer Nazeran
- Department of Electrical and Computer Engineering, University of Texas El Paso, 500 W University Ave, El Paso, TX 79968, USA.
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Monitoring Fetal Heart Rate during Labor: A Comparison of Three Methods. J Pregnancy 2017; 2017:8529816. [PMID: 28392944 PMCID: PMC5368359 DOI: 10.1155/2017/8529816] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 02/08/2017] [Accepted: 02/12/2017] [Indexed: 11/17/2022] Open
Abstract
The purpose of the study was to compare the accuracy of a noninvasive fetal heart rate monitor with that of ultrasound, using a fetal scalp electrode as the gold standard, in laboring women of varying body habitus, throughout labor and delivery. Laboring women requiring fetal scalp electrode were monitored simultaneously with the investigational device (noninvasive fetal ECG), ultrasound, and fetal scalp electrode. An algorithm extracted the fetal heart rate from the noninvasive fetal ECG signal. Each noninvasive device recording was compared with fetal scalp electrode with regard to reliability by positive percent agreement and accuracy by root mean squared error. Seventy-one women were included in this analysis. Positive percent agreement was 83.4 ± 15.4% for noninvasive fetal ECG and 62.4 ± 26.7% for ultrasound. The root mean squared error compared with fetal scalp electrode-derived fetal heart rate was 4.8 ± 2.0 bpm for noninvasive fetal ECG and 14.3 ± 8.2 bpm for ultrasound. The superiority of noninvasive fetal ECG was maintained for stages 1 and 2 of labor and increases in body mass index. Compared with fetal scalp electrode-derived fetal heart rate, noninvasive fetal ECG is more accurate and reliable than ultrasound for intrapartum monitoring for stages 1 and 2 of labor and is less affected by increasing maternal body mass index. This confirms the results of other workers in this field.
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van Scheepen JAM, Koster MPH, Vasak B, Redman C, Franx A, Georgieva A. Effect of signal acquisition method on the fetal heart rate analysis with phase rectified signal averaging. Physiol Meas 2016; 37:2245-2259. [DOI: 10.1088/1361-6579/37/12/2245] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Behar J, Andreotti F, Zaunseder S, Oster J, Clifford GD. A practical guide to non-invasive foetal electrocardiogram extraction and analysis. Physiol Meas 2016; 37:R1-R35. [DOI: 10.1088/0967-3334/37/5/r1] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
OBJECTIVES To assess foetal electrocardiographic intervals across gestational age among foetuses with and without congenital heart disease, and to investigate differences between groups. DESIGN A prospective observational cohort study. SETTING Center for Prenatal Pediatrics, Morgan Stanley Children's Hospital of New York-Presbyterian. Population or sample A total of 92 participants with singleton pregnancies, 41 with normal anatomy and 51 with congenital heart disease were included in this study. METHODS Using a maternal abdominal monitor, foetal electrocardiogram was obtained serially from foetuses with and without congenital heart disease at 20-24 weeks (F1), 28-32 weeks (F2), and 34-38 weeks (F3) of gestation. A signal-averaged waveform was calculated, and PR, QRS, and QT intervals were measured. Intervals from controls were compared with gestational age norms. Using Pearson's correlation coefficient, we analysed the relationship between gestational age and foetal electrocardiographic intervals. Intervals from control and congenital heart disease foetuses were compared by Student's t-test. RESULTS PR (r=0.333, p=0.02) and QRS (r=0.248, p=0.05) intervals correlated with gestational age only among controls. QRS intervals in foetuses with congenital heart disease were significantly longer than controls at F1 (63 ± 6 versus 52 ± 5 ms, p<0.001), F2 (61 ± 8 versus 56 ± 7 ms, p=0.02), and F3 (64 ± 10 versus 56 ± 9 ms, p=0.007). CONCLUSIONS PR and QRS intervals lengthen across gestational age among foetuses with normal cardiac anatomy but not in foetuses with congenital heart diseases. As early as 20 weeks of gestation, differences between foetuses with and without congenital heart disease are discernible, with congenital heart disease foetuses demonstrating longer QRS intervals compared with controls.
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Narayan HK, Vignola EF, Fifer WP, Williams IA. Assessment of Cardiac Rate and Rhythm in Fetuses with Arrhythmia via Maternal Abdominal Fetal Electrocardiography. AJP Rep 2015; 5:e176-82. [PMID: 26495180 PMCID: PMC4603866 DOI: 10.1055/s-0035-1558401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 04/30/2015] [Indexed: 10/29/2022] Open
Abstract
Objective This study aims to report our experience using the Monica AN24 (Monica Healthcare Ltd., Nottingham, United Kingdom), a maternal transabdominal fetal electrocardiographic monitor, in a case series of fetuses with arrhythmias. Study Design We recorded fetal electrocardiograms (fECGs) on subjects with fetal arrhythmias diagnosed by fetal echocardiogram. Fetal heart rate and rhythm were determined via manual fECG analysis. Results Overall, 20 fECGs were recorded from a pool of 13 subjects. Fetal heart rate acquisition was determined to be high, medium, and poor quality in 10, 3, and 7 tracings, respectively. High-quality tracings were obtained in 9 of 11 subjects with gestational age < 26 or > 34 weeks. P waves were detectable in five tracings. Conclusion In subjects < 26 or > 34 weeks' gestational age, there was reasonable success in fetal heart rate acquisition. Further study is warranted to determine the potential role of this device in the monitoring of subjects with fetal arrhythmias.
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Affiliation(s)
- Hari K Narayan
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Emilia F Vignola
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - William P Fifer
- Department of Developmental Neuroscience, Columbia University Medical Center, Sackler Institute of Developmental Psychobiology, New York, New York
| | - Ismee A Williams
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Medical Center, New York, New York
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Eggermont M. The Belgian, French and Dutch midwife on trial: A critical case study. Midwifery 2015; 31:547-53. [PMID: 25769187 DOI: 10.1016/j.midw.2015.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 01/12/2015] [Accepted: 02/16/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE to develop juridical recommendations in order to avoid midwifery medical liability when providing intrapartum care. DESIGN case law of the past 40 years concerning midwifery medical negligence when assisting labour/delivery in a hospital was analysed. Databases used were Jura and Judit (Belgium), Legifrance, Juricaf and Dalloz (France) and Recht, Rechtspraak (The Netherlands). A minority of cases were retrieved through contacts with insurance companies (only Belgium), lawyers and courts. SETTING law suits in Belgium, France and The Netherlands. FINDINGS the 100 analysed cases could be categorised into four types. The judicial assessment was focused on three domains of expertise of the midwife. Most cases involved interpreting fetal monitoring (47%), followed by recognising a specific pathology (32%) and responding to a complication (12%). A fourth type of case concerned exceeding the boundaries of the legal competencies of the midwife (9%). KEY CONCLUSIONS not identifying fetal distress through fetal monitoring was the most common cause of midwifery liability (15/47), followed by not recognising the symptoms of a pathology (10/32), particularly placental abruption and uterine rupture. Also an inaccurate response to complications (3/12) and evidently exceeding the professional competencies involved midwifery liability. IMPLICATIONS FOR PRACTICE achieving cardiotocograph interpretation skills is the first and most important recommendation. In pathologic cases, the midwife should immediately refer to an obstetrician, without any hesitation. The third recommendation is working in a team with the obstetrician. If the midwife has reasonable (evidence-based) doubts about the practice of the obstetrician, she should insist on re-assessment with respect to the boundaries of her competencies. The fourth recommendation concerns practising with knowledge of the client׳s/patient׳s medical record and updating the record with performances and observations. Consciously choosing the type of medical intervention in urgent cases of pathology is the final recommendation.
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Affiliation(s)
- Marlies Eggermont
- Ghent University, Artevelde University College of Ghent, Hevelweg 2, 9700 Melden, Belgium.
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Eggermont M. Intrapartum care and substandard care: juridical recommendations to reduce the risk of liability. Arch Gynecol Obstet 2015; 292:87-95. [PMID: 25573796 DOI: 10.1007/s00404-014-3612-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 12/30/2014] [Indexed: 12/26/2022]
Abstract
PURPOSE To develop juridical recommendations to reduce medical liability of the obstetrician, providing intrapartum care. METHODS 107 legal proceedings of the past 40 years from Belgium, France and the Netherlands, involving medical negligence of the obstetrician during intrapartum care, were analyzed in depth. The legal databases used were Jura and Judit (Belgium), Legifrance, Juricaf and Dalloz (France) and Recht, Rechtspraak (the Netherlands). A minority of the cases were retrieved through contacts with insurance companies (Belgium only) and courts. RESULTS The judicial assessment of negligence is focused on four domains of expertise of the obstetrician: 36 % (38/107) recognizing a specific pathology, 33 % (35/107) interpreting fetal monitoring, 19 % (21/107) performing a forceps/vacuum-assisted delivery and 12 % (13/107) managing shoulder dystocia. The highest liability rate of 86 % (30/35) was reflected in the category of interpreting fetal monitoring. CONCLUSION To reduce the liability rate of 66 %, several policy recommendations can be made. Respond to the first symptoms of obstetric complications (particularly placental abruption and uterine rupture). Secondly, respond to disturbing messages of the midwife concerning fetal distress and evaluate every deviation in fetal heart rate monitoring. Education concerning the interpretation of fetal monitoring is a must for every midwife and obstetrician. Use proper methods to monitor the heart rate to optimize the quality of the signal. The third recommendation is to be cautious about opting for a forceps/vacuum-assisted delivery, consider all circumstances. Consider the risk of failed instrumental delivery. And finally in relation to shoulder dystocia, recognize the risk factors by ordering further examinations to purchase a diagnosis.
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Affiliation(s)
- Marlies Eggermont
- Law Faculty, Ghent University (Belgium), Universiteitstraat 4, 9000, Ghent, Belgium,
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Cohen WR, Hayes-Gill B. Influence of maternal body mass index on accuracy and reliability of external fetal monitoring techniques. Acta Obstet Gynecol Scand 2014; 93:590-5. [PMID: 24684703 DOI: 10.1111/aogs.12387] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 03/21/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the performance of external electronic fetal heart rate and uterine contraction monitoring according to maternal body mass index. DESIGN Secondary analysis of prospective equivalence study. SETTING Three US urban teaching hospitals. SAMPLE Seventy-four parturients with a normal term pregnancy. METHODS The parent study assessed performance of two methods of external fetal heart rate monitoring (abdominal fetal electrocardiogram and Doppler ultrasound) and of uterine contraction monitoring (electrohystero-graphy and tocodynamometry) compared with internal monitoring with fetal scalp electrode and intrauterine pressure transducer. Reliability of external techniques was assessed by the success rate and positive percent agreement with internal methods. Bland-Altman analysis determined accuracy. We analyzed data from that study according to maternal body mass index. MAIN OUTCOME MEASURES We assessed the relationship between body mass index and monitor performance with linear regression, using body mass index as the independent variable and measures of reliability and accuracy as dependent variables. RESULTS There was no significant association between maternal body mass index and any measure of reliability or accuracy for abdominal fetal electrocardiogram. By contrast, the overall positive percent agreement for Doppler ultrasound declined (p = 0.042), and the root mean square error from the Bland-Altman analysis increased in the first stage (p = 0.029) with increasing body mass index. Uterine contraction recordings from electrohysterography and tocodynamometry showed no significant deterioration related to maternal body mass index. CONCLUSIONS Accuracy and reliability of fetal heart rate monitoring using abdominal fetal electrocardiogram was unaffected by maternal obesity, whereas performance of ultrasound degraded directly with maternal size. Both electrohysterography and tocodynamometry were unperturbed by obesity.
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Affiliation(s)
- Wayne R Cohen
- Department of Obstetrics and Gynecology, University of Arizona College of Medicine, Tucson, Arizona, USA
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Van Leeuwen P, Werner L, Hilal Z, Schiermeier S, Hatzmann W, Grönemeyer D. Fetal electrocardiographic measurements in the assessment of fetal heart rate variability in the antepartum period. Physiol Meas 2014; 35:441-54. [PMID: 24556971 DOI: 10.1088/0967-3334/35/3/441] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study examines signal availability in fetal electrocardiogram (FECG) beat-to-beat acquisition and the accuracy of fetal heart rate variability (HRV) analysis in the clinical setting using a commercially available FECG monitor. Signal availability was examined in 130 FECG recordings of 0.3-17.5 h duration collected in 63 fetuses (25th-42nd week of gestation) under uncontrolled conditions. Identification of R-peaks demonstrated a signal loss of 30% ± 24% with 3.6 ± 1.7 signal gaps per minute. Median duration of the gaps within a recording was 1.8 ± 0.2 s. Per hour of recording, 1.8 ± 2.1 episodes of 5 min of uninterrupted data were found. Signal availability improved with gestational age and was poorer in women with high body-mass index. Fetal HRV between weeks 36-42 was examined on the basis of 5 min RR-interval episodes obtained under controlled quiet conditions in 55 FECG compared to 46 high quality fetal magnetocardiograms. There were no differences in RR-interval duration, its standard deviation and low frequency power. However, various measures of short-term HRV were significantly higher in the FECG data: root mean square of successive differences (10.0 ± 1.8 versus 6.6 ± 3.0 ms, p < 0.001, high frequency spectral power (24 ± 12 versus 13 ± 13 ms(2), p < 0.001) and approximate entropy (0.86 ± 0.16 versus 0.73 ± 0.24, p = 0.007). We conclude that, in spite of considerable signal loss, FECG recordings can accurately estimate heart rate and its overall variance. However, measures that quantify short-term beat-to-beat HRV will be compromised due to possible recurring inappropriate detection of single R-peaks.
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Affiliation(s)
- Peter Van Leeuwen
- Department of Biomagnetism, Grönemeyer Institute for Microtherapy, University of Witten/Herdecke, Universitätsstr. 142, D-44799 Bochum, Germany
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Sänger N, Louwen F, Reinhard J, Yuan J, Hanker L. Signal quality of non-invasive fetal electrocardiogram in vaginal breech delivery: a case-controlled study. Arch Gynecol Obstet 2013; 288:1017-20. [PMID: 23612929 DOI: 10.1007/s00404-013-2860-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 04/16/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Recently, a non-invasive fetal electrocardiogram monitor has been approved for clinical usage in labour and delivery. To determine the fetal signal quality of vaginal breech deliveries in comparison with a case-controlled cephalic group during labour. STUDY DESIGN This case-control study was carried out at the Department of Obstetrics and Gynecology of the University Hospital Frankfurt between 1st July 2012 and 30th September 2012. A total of seven breech deliveries were evaluated. A case-controlled cephalic group with same gestational age and parity were selected from a previous trial. RESULTS During first stage of labour, vaginal breech and cephalic delivery had no significant different fetal signal success rates (mean 87.8 vs. 85.7 %; p > 0.05). There was a trend of higher fetal signal success rates in the vaginal breech delivery group during second stage of labour (78.4 vs. 55.4 %; p = 0.08). CONCLUSION Similar fetal signal success rates in vaginal breech delivery in comparison to cephalic presentation were demonstrated using the new commercially available non-invasive abdominal fECG device (the Monica AN24(TM)).
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Affiliation(s)
- Nicole Sänger
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Johann Wolfgang Goethe-University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
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Fuchs T, Pomorski M, Grobelak K, Tomiałowicz M, Zimmer M. Comment on the article "accuracy and reliability of fetal heart rate monitoring using maternal abdominal surface electrodes". Acta Obstet Gynecol Scand 2013; 92:992. [PMID: 23607526 DOI: 10.1111/aogs.12154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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