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Timonen S, Holmberg K. The importance of the learning process in ST analysis interpretation and its impact in improving clinical and neonatal outcomes. Am J Obstet Gynecol 2018; 218:620.e1-620.e7. [PMID: 29577914 DOI: 10.1016/j.ajog.2018.03.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/06/2018] [Accepted: 03/16/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Intrapartum fetal heart rate monitoring was introduced with the goal to reduce fetal hypoxia and deaths. However, continuous fetal heart rate monitoring has been shown to have a high sensitivity but also a high false-positive rate. To improve specificity, adjunctive technologies have been developed to identify fetuses at risk for intrapartum asphyxia. Intensive research on the value of ST-segment analysis of the fetal electrocardiogram as an adjunct to standard electronic fetal monitoring in lowering the rates of fetal metabolic acidosis and operative deliveries has been ongoing. The conflicting results in randomized and observational studies may partly be due to differences in study design. OBJECTIVE This study aims to determine the significance of the learning process for the introduction of ST analysis into clinical practice and its impact on initial and subsequent obstetric outcomes. STUDY DESIGN This was a prospective observational study with the primary objective to evaluate the importance of the learning period on the rates of metabolic acidosis and operative deliveries after the implementation of ST analysis. The study was conducted at the Turku University Hospital, Turku, Finland, with 3400-4200 annual deliveries. The whole study population consisted of all 42,146 deliveries during the study period 2001 through 2011. The ST analysis usage rate was 18%. The data were collected prospectively from labors monitored with ST analysis as an adjunct to conventional intrapartum fetal heart rate monitoring. Primary endpoints were the rates of metabolic acidosis (cord artery pH <7.05 and an extracellular fluid compartment base deficit >12.0 mmol/L), fetal scalp blood sampling, and operative deliveries. Comparisons of these outcomes were made between the initiation period (the first 2 years) and the subsequent usage period (the next 9 years). RESULTS In the whole study population the prevalence of cord pH <7.05 decreased from 1.5-0.81% (relative risk, 0.54; 95% confidence interval, 0.43-0.67), the rate of cesarean deliveries from 17.2-14.1% (relative risk, 0.82; 95% confidence interval, 0.89-0.97), and the rate of fetal scalp blood sampling from 1.75-0.82% (relative risk, 0.47; 95% confidence interval, 0.38-0.58) when the 2 study periods were compared. In the ST analysis group, the frequency of cord metabolic acidosis rate was reduced from 1.0-0.25% (relative risk, 0.33; 95% confidence interval, 0.15-0.72). CONCLUSION We provide evidence that the results improve over time and there is a learning curve in the introduction of the ST analysis method. This was demonstrated by the lower rates of metabolic acidosis and operative deliveries after the initial implementation period.
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Andriessen P, Zwanenburg A, van Laar JOEH, Vullings R, Hermans BJM, Niemarkt HJ, Jellema RK, Ophelders DRMG, Wolfs TGAM, Kramer BW, Delhaas T. ST waveform analysis for monitoring hypoxic distress in fetal sheep after prolonged umbilical cord occlusion. PLoS One 2018; 13:e0195978. [PMID: 29659625 PMCID: PMC5901956 DOI: 10.1371/journal.pone.0195978] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 04/03/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The inconclusive clinical results for ST-waveform analysis (STAN) in detecting fetal hypoxemia may be caused by the signal processing of the STAN-device itself. We assessed the performance of a clinical STAN device in signal processing and in detecting hypoxemia in a fetal sheep model exposed to prolonged umbilical cord occlusion (UCO). METHODS Eight fetal lambs were exposed to 25 minutes of UCO. ECG recordings were analyzed during a baseline period and during UCO. STAN-event rates and timing of episodic T/QRS rise, baseline T/QRS rise and the occurrence of biphasic ST-waveforms, as well as signal loss, were assessed. RESULTS During baseline conditions of normoxemia, a median of 40 (IQR, 25-70) STAN-events per minute were detected, compared to 10 (IQR, 2-22) during UCO. During UCO STAN-events were detected in five subjects within 10 minutes and in six subjects after 18 minutes, respectively. Two subjects did not generate any STAN-event during UCO. Biphasic ST event rate was reduced during UCO (median 0, IQR 0-5), compared to baseline (median 32, IQR, 6-55). ST-waveforms could not be assessed in 62% of the recording time during UCO, despite a good quality of the ECG signal. CONCLUSIONS The STAN device showed limitations in detecting hypoxemia in fetal sheep after prolonged UCO. The STAN device produced high false positive event rates during baseline and did not detect T/QRS changes adequately after prolonged fetal hypoxemia. During 14% of baseline and 62% of the UCO period, the STAN-device could not process the ECG signal, despite its good quality. Resolving these issues may improve the clinical performance of the STAN device.
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Affiliation(s)
- Peter Andriessen
- Department of Pediatrics, Máxima Medical Centre, Veldhoven, the Netherlands
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Alex Zwanenburg
- Department of Biomedical Engineering, Maastricht University, Maastricht, the Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | | | - Rik Vullings
- Signal Processing Systems group, Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Ben J. M. Hermans
- Department of Biomedical Engineering, Maastricht University, Maastricht, the Netherlands
| | | | - Reint K. Jellema
- Department of Pediatrics, Máxima Medical Centre, Veldhoven, the Netherlands
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Daan R. M. G. Ophelders
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, the Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Tim G. A. M. Wolfs
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, the Netherlands
- Department of Biomedical Engineering, Maastricht University, Maastricht, the Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Boris W. Kramer
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, the Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, Maastricht University, Maastricht, the Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
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Comparison of ECG-based physiological markers for hypoxia in a preterm ovine model. Pediatr Res 2016; 79:907-15. [PMID: 26866904 DOI: 10.1038/pr.2016.21] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 11/24/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Current methods for assessing perinatal hypoxic conditions did not improve infant outcomes. Various waveform-based and interval-based ECG markers have been suggested, but not directly compared. We compare performance of ECG markers in a standardized ovine model for fetal hypoxia. METHODS Sixty-nine fetal sheep of 0.7 gestation had ECG recorded 4 h before, during, and 4 h after a 25-min period of umbilical cord occlusion (UCO), leading to severe hypoxia. Various ECG markers were calculated, among which were heart rate (HR), HR-corrected ventricular depolarization/repolarization interval (QTc), and ST-segment analysis (STAN) episodic and baseline rise markers, analogue to clinical STAN device alarms. Performance of interval- and waveform-based ECG markers was assessed by correlating predicted and actual hypoxic/normoxic state. RESULTS Of the markers studied, HR and QTc demonstrated high sensitivity (≥86%), specificity (≥96%), and positive predictive value (PPV) (≥86%) and detected hypoxia in ≥90% of fetuses at 4 min after UCO. In contrast, STAN episodic and baseline rise markers displayed low sensitivity (≤20%) and could not detect severe fetal hypoxia in 65 and 28% of the animals, respectively. CONCLUSION Interval-based HR and QTc markers could assess the presence of severe hypoxia. Waveform-based STAN episodic and baseline rise markers were ineffective as markers for hypoxia.
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Racz S, Hantosi E, Marton S, Toth K, Ruzsa D, Halvax L, Bodis J, Farkas B. Impact of maternal obesity on the fetal electrocardiogram during labor. J Matern Fetal Neonatal Med 2016; 29:3712-6. [PMID: 26788979 DOI: 10.3109/14767058.2016.1141887] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Maternal obesity affects one in every five women giving birth worldwide. This condition is associated with adverse perinatal outcomes, as well as increased morbidity and mortality for mother and offspring. METHODS We carried out a prospective study at the University of Pecs Medical Center, Pecs, Hungary, between 1 January 2013 and 1 January 2014. We enrolled 60 obese (body mass index >30 kg/m(2)) low-risk pregnant women and 108 age-, ethnicity-, and parity-matched nonobese pregnant control subjects. The ST segment of the fetal electrocardiogram was assessed by STAN® monitoring. Neonatal outcomes and cord gas analysis of the umbilical vessels were evaluated after birth. RESULTS No infant with definitive metabolic acidosis was delivered in either group. We observed 32 and 106 ST events in the obese and control group, respectively, but this difference was not statistically significant. To date, none of the infants delivered as part of this study have demonstrated developmental insufficiency. CONCLUSIONS Obesity might not influence the fetal electrocardiogram during labor as an independent risk factor for adverse pregnancy outcomes. Studies with larger cohort sizes are needed to confirm our findings.
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Affiliation(s)
- Sandor Racz
- a Department of Obstetrics and Gynecology , University of Pecs Clinical Center , Pecs , Hungary
| | - Eszter Hantosi
- a Department of Obstetrics and Gynecology , University of Pecs Clinical Center , Pecs , Hungary
| | - Sandor Marton
- b Department of Anesthesiology and Intensive Therapy , University of Pecs Clinical Center , Pecs , Hungary , and
| | - Krisztina Toth
- b Department of Anesthesiology and Intensive Therapy , University of Pecs Clinical Center , Pecs , Hungary , and
| | - Diana Ruzsa
- c Heart Institute, University of Pecs Clinical Center , Pecs , Hungary
| | - Laszlo Halvax
- a Department of Obstetrics and Gynecology , University of Pecs Clinical Center , Pecs , Hungary
| | - Jozsef Bodis
- a Department of Obstetrics and Gynecology , University of Pecs Clinical Center , Pecs , Hungary
| | - Balint Farkas
- a Department of Obstetrics and Gynecology , University of Pecs Clinical Center , Pecs , Hungary
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Yli BM, Källen K, Khoury J, Stray-Pedersen B, Amer-Wåhlin I. Intrapartum cardiotocography (CTG) and ST-analysis of labor in diabetic patients. J Perinat Med 2011; 39:457-65. [PMID: 21604995 DOI: 10.1515/jpm.2011.046] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIM To determine the prevalence and types of intrapartum cardiotocography (CTG) patterns and investigate their relationship to moderate acidemia in term fetuses of diabetic mothers. Also, to assess if the combination of fetal electrocardiogram (FECG) and those CTG patterns strengthens the association with moderate acidemia. MATERIAL AND METHODS The material for this study is obtained from the Swedish randomized control trial and the European Union ST-analysis trial. We developed an analytical model for CTG patterns based on the progress in CTG changes, in a longitudinal periodic manner. The model was then combined with information regarding changes in ST interval that indicate threatening asphyxia, and the findings were analyzed to determine correlation with the presence of moderate acidemia at birth. RESULTS This study involved data of 413 diabetic mothers. A preterminal CTG was more common in the diabetes mellitus (DM) group (6/70, 8.6%) than in the gestational diabetes (GD) group (3/307, 1.0%; P=0.003). For diabetic mothers (i.e., DM+GD) with a normal CTG at the start of monitoring, the presence of FECG data indicating asphyxia significantly increased the likelihood of an umbilical artery pH<7.15 at birth [odds ratio (OR)=3.65, 95% confidence interval (CI)=1.33-10.05]. Among labors where the CTG was non-reassuring at the start of monitoring, no significant association was found between pH<7.15 and indication to intervene according to FECG information (OR=1.51, 95% CI=0.33-7.0). CONCLUSIONS A preterminal CTG is more common in the fetuses of DM than GD mothers during labor. When CTG was normal at the start of recording, the addition of FECG information gave a significant add on information to predict moderate acidemia.
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Affiliation(s)
- Branka M Yli
- Women and Children's Division, Oslo University Hospital Rikshospitalet and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
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