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Shema N, Weintraub AY, Rotem R, Salem SY. The Correlation Between the Total Decelerations and Accelerations Areas and Cord Blood pH in Women with Low-Risk Pregnancies. Reprod Sci 2024; 31:1401-1407. [PMID: 38253982 DOI: 10.1007/s43032-024-01455-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
Fetal acidosis among low-risk pregnancies is not common; however, identifying those at risk for this complication antenatally is of great interest. We aimed to assess the correlation between the total decelerations area during the last 120 min of fetal monitoring prior to delivery and neonatal acidemia in low-risk pregnancies and whether the total acceleration area has a protective effect in the presence of decelerations. A retrospective cohort study was conducted among women with term low-risk pregnancies. A researcher blinded to fetal outcomes interpreted electronic fetal monitor patterns during the 120 min prior to delivery. The primary outcome was fetal acidemia, defined as umbilical artery pH below 7.10. The correlation between the total decelerations and accelerations areas and cord blood pH was tested using the Spearman correlation coefficient. A total of 109 women were included and of these, six (5.5%) delivered infants with cord blood pH < 7.10. A significant correlation was demonstrated between the total decelerations area and cord blood pH (p = 0.01). No correlation was found between the total accelerations area and cord blood pH. Among low-risk pregnancies, a correlation was found between the total decelerations area but not the total accelerations area during the final 120 min of labor and cord blood pH.
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Affiliation(s)
- Noam Shema
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Center, Beer Sheva, Israel.
- Joyce and Irving Goldman School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
| | - Adi Y Weintraub
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Center, Beer Sheva, Israel
| | - Reut Rotem
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Shimrit Yaniv Salem
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Center, Beer Sheva, Israel
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Rotem R, Theodor E, Hirsch A, Rottenstreich M, Salem SY, Weintraub AY. The Correlation between Fetal Monitor Decelerations Area and Neonatal Cord pH among Preeclamptic parturient: an Automated Approach to a Clinical Challenge. Am J Perinatol 2024; 41:e3133-e3139. [PMID: 37871640 DOI: 10.1055/a-2196-6469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
OBJECTIVE To examine whether a correlation exists between electronic fetal monitoring (EFM) in the final 120 minute prior to delivery and neonatal cord blood pH among parturients with preeclampsia. STUDY DESIGN A retrospective cohort study of parturients with term and near-term preeclampsia who delivered at Soroka University Medical Center between 2013 and 2020 was conducted. EFM tracings, demographical data, and obstetrical outcomes were retrieved from the patients' electronic medical records. Using MATLAB program, area under the curve (AUC) measurements were applied. Correlation was calculated using the Spearman's correlation coefficient. RESULTS EFM of 88 parturients with preeclampsia were assessed. A significant negative correlation was demonstrated between cord blood pH and the decelerations AUC, total decelerations duration, and deceleration depth. No correlation was demonstrated between area over the curve (acceleration) and cord blood pH. In a multivariate linear regression, total deceleration AUC was found independently negatively associated with cord blood pH (beta = -0.264, p = 0.011) controlling for second stage of labor duration and induction of labor. CONCLUSION Among parturients with preeclampsia, EFM indices may assist in the diagnosis of fetal acidemia. Further studies are needed to strengthen and establish the use of electronic EFM in the management of labor and delivery. KEY POINTS · A negative correlation was demonstrated between cord blood pH and the decelerations AUC.. · Total deceleration AUC was found independently negatively associated.. · Among parturients with preeclampsia, EFM indices may assist in the diagnosis of fetal acidemia..
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Affiliation(s)
- Reut Rotem
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ella Theodor
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ayala Hirsch
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Shimrit Y Salem
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Adi Y Weintraub
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Ben M'Barek I, Ben M'Barek B, Jauvion G, Holmström E, Agman A, Merrer J, Ceccaldi PF. Large-scale analysis of interobserver agreement and reliability in cardiotocography interpretation during labor using an online tool. BMC Pregnancy Childbirth 2024; 24:136. [PMID: 38355457 PMCID: PMC10865637 DOI: 10.1186/s12884-024-06322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/05/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND While the effectiveness of cardiotocography in reducing neonatal morbidity is still debated, it remains the primary method for assessing fetal well-being during labor. Evaluating how accurately professionals interpret cardiotocography signals is essential for its effective use. The objective was to evaluate the accuracy of fetal hypoxia prediction by practitioners through the interpretation of cardiotocography signals and clinical variables during labor. MATERIAL AND METHODS We conducted a cross-sectional online survey, involving 120 obstetric healthcare providers from several countries. One hundred cases, including fifty cases of fetal hypoxia, were randomly assigned to participants who were invited to predict the fetal outcome (binary criterion of pH with a threshold of 7.15) based on the cardiotocography signals and clinical variables. After describing the participants, we calculated (with a 95% confidence interval) the success rate, sensitivity and specificity to predict the fetal outcome for the whole population and according to pH ranges, professional groups and number of years of experience. Interobserver agreement and reliability were evaluated using the proportion of agreement and Cohen's kappa respectively. RESULTS The overall ability to predict a pH level below 7.15 yielded a success rate of 0.58 (95% CI 0.56-0.60), a sensitivity of 0.58 (95% CI 0.56-0.60) and a specificity of 0.63 (95% CI 0.61-0.65). No significant difference in the success rates was observed with respect to profession and number of years of experience. The success rate was higher for the cases with a pH level below 7.05 (0.69) and above 7.20 (0.66) compared to those falling between 7.05 and 7.20 (0.48). The proportion of agreement between participants was good (0.82), with an overall kappa coefficient indicating substantial reliability (0.63). CONCLUSIONS The use of an online tool enabled us to collect a large amount of data to analyze how practitioners interpret cardiotocography data during labor. Despite a good level of agreement and reliability among practitioners, the overall accuracy is poor, particularly for cases with a neonatal pH between 7.05 and 7.20. Factors such as profession and experience level do not present notable impact on the accuracy of the annotations. The implementation and use of a computerized cardiotocography analysis software has the potential to enhance the accuracy to detect fetal hypoxia, especially for ambiguous cardiotocography tracings.
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Affiliation(s)
- Imane Ben M'Barek
- Service de Gynécologie Obstétrique, Assistance Publique Hôpitaux de Paris - Hôpital Beaujon, 100 boulevard du Général Leclerc, Clichy La Garenne, France.
- Université Paris Cité, 75006, Paris, France.
- Health Simulation Department, iLumens, Université Paris Cité, Paris, France.
| | | | | | - Emilia Holmström
- Service de Gynécologie Obstétrique, Assistance Publique Hôpitaux de Paris - Hôpital Beaujon, 100 boulevard du Général Leclerc, Clichy La Garenne, France
- Université Paris Cité, 75006, Paris, France
| | - Antoine Agman
- Service de Gynécologie Obstétrique, Assistance Publique Hôpitaux de Paris - Hôpital Beaujon, 100 boulevard du Général Leclerc, Clichy La Garenne, France
| | - Jade Merrer
- AP-HP.Nord-Université Paris Cité, Hôpital Universitaire Robert Debré, Unité d'épidémiologie clinique, 1426, InsermParis, CIC, France
| | - Pierre-François Ceccaldi
- Service de Gynécologie-Obstétrique et Médecine de la reproduction, Hôpital Foch, 40 Rue Worth, 92150, Suresnes, France
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Geva Y, Yaniv Salem S, Geva N, Rotem R, Talmor M, Shema N, Shany E, Weintraub AY. Intrapartum deceleration and acceleration areas are associated with neonatal encephalopathy. Int J Gynaecol Obstet 2022; 161:1061-1068. [PMID: 36572017 DOI: 10.1002/ijgo.14638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 11/08/2022] [Accepted: 12/09/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To investigate whether an association exists between deceleration and acceleration areas on continuous fetal cardiotocography (CTG) and neonatal encephalopathy (NE). METHODS A single center, retrospective case-control study was conducted to compare CTG characteristics of low-risk pregnancies (35 weeks of gestation or more), complicated by moderate to severe NE with two matched controls for every case. Controls were matched by gestational age and cord blood pH. We analyzed the intrapartum CTG recordings by calculation of the deceleration and acceleration areas and the ratio between the two. RESULTS During the period between 2013 and 2019, we identified 95 cases of low-risk pregnancies that were complicated by moderate to severe NE in our center. Thirty-three (34.7%) deliveries were excluded, mostly because of an insufficient duration of the CTG recordings. The remaining 62 cases were matched with 123 controls. We found that NE was significantly associated with an increased total deceleration area, a decreased total acceleration area, and a lower acceleration-to-deceleration ratio. CONCLUSIONS NE was significantly associated with increased total deceleration area, decreased total acceleration area, and a lower acceleration-to-deceleration ratio, independent of cord blood pH. Development of a computerized real-time analysis of fetal heart rate tracings may contribute to making these measurements a more valid clinical tool.
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Affiliation(s)
- Yael Geva
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Shimrit Yaniv Salem
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Neta Geva
- Department of Neonatology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Pediatric Division, Saban Pediatric Medical Center, Soroka University Medical Center, Beer Sheva, Israel
| | - Reut Rotem
- Division of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University Medical School, Jerusalem, Israel
| | - Meital Talmor
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Noam Shema
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Eilon Shany
- Department of Neonatology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Adi Y Weintraub
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
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Jonsson M, Söderling J, Ladfors L, Nordström L, Nilsson M, Algovik M, Norman M, Holzmann M. Implementation of a revised classification for intrapartum fetal heart rate monitoring and association to birth outcome: A national cohort study. Acta Obstet Gynecol Scand 2022; 101:183-192. [PMID: 35092004 DOI: 10.1111/aogs.14296] [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: 07/01/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION A revised intrapartum cardiotocography (CTG) classification was introduced in Sweden in 2017. The aims of the revision were to adapt to the international guideline published in 2015 and to adjust the classification of CTG patterns to current evidence regarding intrapartum fetal physiology. This study aimed to investigate adverse neonatal outcomes before and after implementation of the revised CTG classification. MATERIAL AND METHODS A before-and-after design was used. Cohort I (n = 160 210) included births from June 1, 2014 through May 31, 2016 using the former CTG classification, and cohort II (n = 166 558) included births from June 1, 2018 through May 31, 2020 with the revised classification. Data were collected from the Swedish Pregnancy and Neonatal Registers. The primary outcome was moderate to severe neonatal hypoxic ischemic encephalopathy (HIE 2-3). Secondary outcomes were birth acidemia (umbilical artery pH <7.05 and base excess < -12 mmol/L or pH <7.00), A-criteria for neonatal hypothermia treatment, 5-min Apgar scores <4 and <7, neonatal seizures, meconium aspiration, neonatal mortality and delivery mode. Logistic regression was used (period II vs period I), and results are presented as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs). RESULTS There were no statistically significant differences in HIE 2-3 (aOR 1.27; 95% CI 0.97-1.66), proportion of neonates meeting A-criteria for hypothermia treatment (aOR 0.96; 95% CI 0.89-1.04) or neonatal mortality (aOR 0.68; 95% CI 0.39-1.18) between the cohorts. Birth acidemia (aOR 1.36; 95% CI 1.25-1.48), 5-min Apgar scores <7 (aOR 1.27; 95% CI 1.18-1.36) and <4 (aOR 1.40; 95% CI 1.17-1.66) occurred more often in cohort II. The absolute risk difference for HIE 2-3 was 0.02% (95% CI 0.00-0.04). Operative delivery (vacuum or cesarean) rates were lower in cohort II (aOR 0.82; 95% CI 0.80-0.85 and aOR 0.94; 95% CI 0.91-0.97, respectively). CONCLUSIONS Although not statistically significant, a small increase in the incidence of HIE 2-3 after implementation of the revised CTG classification cannot be excluded. Operative deliveries were fewer but incidences of acidemia and low Apgar scores were higher in the latter cohort. This warrants further in-depth analyses before a full re-evaluation of the revised classification can be made.
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Affiliation(s)
- Maria Jonsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Uppsala University Hospital, Uppsala, Sweden
| | - Jonas Söderling
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Lars Ladfors
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lennart Nordström
- Department Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Mikael Norman
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden.,Swedish Neonatal Quality Register, Stockholm, Sweden
| | - Malin Holzmann
- Department Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
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Electronic intrapartum fetal monitoring: a systematic review of international clinical practice guidelines. AJOG GLOBAL REPORTS 2021; 1:100008. [PMID: 36276305 PMCID: PMC9563206 DOI: 10.1016/j.xagr.2021.100008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Electronic fetal monitoring or fetal assessment using a cardiotocograph is currently the most commonly employed tool for intrapartum surveillance. Furthermore, there are numerous guidelines informing best practice worldwide. OBJECTIVE This systematic review aimed to compare and appraise all available practice guidelines on intrapartum electronic fetal monitoring to describe the similarities and variations in recommendations. STUDY DESIGN A systematic protocol was developed per Preferred Reporting Item for Systematic Review and Meta-Analysis Protocols. A total of 4 independent reviewers were involved with independent searches and quality assessment using the Appraisal of Guidelines for Research and Evaluation Instrument for guideline quality reporting. RESULTS Overall, 7 international practice guidelines were included in this systematic review. Appraisal of Guidelines for Research and Evaluation Instrument showed higher scores for scope and purpose and for clarity of presentation; however, the overall assessment varied between 25% and 89%. When individual characteristics of electronic fetal monitoring or cardiotocograph were compared, all guidelines and guidance were essentially trying to describe the characters similarly, with critical differences described in the full article. CONCLUSION In the context of globalization, a uniform approach for defining terminology, classifying characters and similar interpretation of results is needed for electronic fetal monitoring. Therefore, we should consider a unified, simple, logistically approved, and acceptable guideline, which is probably accepted worldwide.
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Rafi J. Re: Estimation of neonatal outcome artery pH value according to CTG interpretation of the last 60 min before delivery: a retrospective study. Can the outcome pH value be predicted? Arch Gynecol Obstet 2017; 297:547. [PMID: 29242973 DOI: 10.1007/s00404-017-4624-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Junaid Rafi
- Ipswich Hospital NHS Trust, Heath Road, IP4 5PD, Ipswich, UK.
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Response to the Letter to the Editor by Dr. Junaid Rafi. Arch Gynecol Obstet 2017; 297:549-550. [PMID: 29236170 DOI: 10.1007/s00404-017-4622-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Fergus P, Selvaraj M, Chalmers C. Machine learning ensemble modelling to classify caesarean section and vaginal delivery types using Cardiotocography traces. Comput Biol Med 2017; 93:7-16. [PMID: 29248699 DOI: 10.1016/j.compbiomed.2017.12.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 12/06/2017] [Accepted: 12/07/2017] [Indexed: 10/18/2022]
Abstract
Human visual inspection of Cardiotocography traces is used to monitor the foetus during labour and avoid neonatal mortality and morbidity. The problem, however, is that visual interpretation of Cardiotocography traces is subject to high inter and intra observer variability. Incorrect decisions, caused by miss-interpretation, can lead to adverse perinatal outcomes and in severe cases death. This study presents a review of human Cardiotocography trace interpretation and argues that machine learning, used as a decision support system by obstetricians and midwives, may provide an objective measure alongside normal practices. This will help to increase predictive capacity and reduce negative outcomes. A robust methodology is presented for feature set engineering using an open database comprising 552 intrapartum recordings. State-of-the-art in signal processing techniques is applied to raw Cardiotocography foetal heart rate traces to extract 13 features. Those with low discriminative capacity are removed using Recursive Feature Elimination. The dataset is imbalanced with significant differences between the prior probabilities of both normal deliveries and those delivered by caesarean section. This issue is addressed by oversampling the training instances using a synthetic minority oversampling technique to provide a balanced class distribution. Several simple, yet powerful, machine-learning algorithms are trained, using the feature set, and their performance is evaluated with real test data. The results are encouraging using an ensemble classifier comprising Fishers Linear Discriminant Analysis, Random Forest and Support Vector Machine classifiers, with 87% (95% Confidence Interval: 86%, 88%) for Sensitivity, 90% (95% CI: 89%, 91%) for Specificity, and 96% (95% CI: 96%, 97%) for the Area Under the Curve, with a 9% (95% CI: 9%, 10%) Mean Square Error.
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Affiliation(s)
- Paul Fergus
- Liverpool John Moores University, Faculty of Engineering and Technology, Data Science Research Centre, Department of Computer Science, Byron Street, Liverpool, L3 3AF, United Kingdom.
| | - Malarvizhi Selvaraj
- Liverpool John Moores University, Faculty of Engineering and Technology, Data Science Research Centre, Department of Computer Science, Byron Street, Liverpool, L3 3AF, United Kingdom.
| | - Carl Chalmers
- Liverpool John Moores University, Faculty of Engineering and Technology, Data Science Research Centre, Department of Computer Science, Byron Street, Liverpool, L3 3AF, United Kingdom.
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