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Bernardes J. Computerized analysis of cardiotocograms in clinical practice and the SisPorto ® system thirty-two years after: technological, physiopathological and clinical studies. J Perinat Med 2023; 51:145-160. [PMID: 36064191 DOI: 10.1515/jpm-2022-0406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 08/21/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVES The objective of this study is to present the why, what and how about computerized analysis of cardiotocograms (cCTG) and the SisPorto system for cCTG. CONTENT A narrative review about cCTG and the SisPorto system for cCTG is presented. The meta-analysis of randomized controlled trials (RCT) performed so far have evidenced that cCGT compared to traditional CTG analysis may save time spent in hospital for women, in the antepartum period, and is objective with at least equivalent results in maternal and perinatal outcomes, both in the ante and intrapartum periods. The SisPorto system for cCTG closely follows the FIGO guidelines for fetal monitoring. It may be used both in the ante and intrapartum periods, alone or connected to a central monitoring station, with simultaneous monitoring of fetal and maternal signals, not only in singletons but also in twins. It has been assessed in technical, physiopathological and clinical studies, namely in one large multicentric international RCT during labor and two meta-analysis. SUMMARY AND OUTLOOK There is evidence that cCTG may be useful in clinical practice with advantages compared to traditional CTG analysis, although without clear impact on the decrease of preventable maternal and perinatal mortality and morbidity. More studies are warranted, namely on technical improvements and assessment in larger studies in a wider range of clinical settings.
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Affiliation(s)
- João Bernardes
- Head of the Department of Gynecology Obstetrics and Pediatrics, Faculdade de Medicina da Universidade do Porto, Portugal
- Senior Consultant of Centro Hospitalar Universitário de São João, Porto, Portugal
- Senior Researcher of Centro de Investigação em Tecnologias e Sistemas de Saúde (CINTESIS), Porto, Portugal
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Hoyer D, Schmidt A, Pytlik A, Viehöfer L, Gonçalves H, Amorim-Costa C, Bernardes J, Ayres-de-Campos D, Lobmaier SM, Schneider U. Can fetal heart rate variability obtained from cardiotocography provide the same diagnostic value like from electrophysiological interbeat intervals? Physiol Meas 2021; 42:015006. [PMID: 33147578 DOI: 10.1088/1361-6579/abc791] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Fetal heart rate variability (HRV) is widely used for monitoring fetal developmental disturbances. Only expensive fetal magnetocardiography (fMCG) allows the precise recording of the individual fetal heart beat intervals uncovering also highly frequent vagal modulation. In contrast, transabdominal fetal electrocardiography (fECG) suffers from noise overlaying the fetal cardiac signal. Cardiotocography (CTG) is the clinical method of choice, however, based on Doppler ultrasound, improper to resolve single beats concisely. The present work addresses the transferability of established electrophysiological HRV indices to CTG recordings during the fetal maturation period of 20-40 weeks of gestation (WGA). APPROACH We compared (a) HRV indices obtained from fMCG, CTG and fECG of short-term amplitude fluctuations (sAMPs) and long-term amplitude fluctuations (lAMPs) and complexity, and (b) their diagnostic value for identifying maturational age, fetal growth restriction (FGR) and small for gestational age (SGA). We used the functional brain age score (fABAS) and categories of long- and short-term regulation and complexity. MAIN RESULTS Integrating all substudies, we found: (a) indices related to long-term regulation, and with modified meaning and values of short-term regulation and sympathovagal balance (SVB) according to electrophysiological HRV standards can be obtained from CTG. (b) Models using HRV indices calculated from CTG allow the identification of maturational age and discriminate FGR from controls with almost similar precision as electrophysiological means. (c) A modified set of HRV parameters containing short- and long-term regulation and long-term/short-term ratio appeared to be most suitable to describe autonomic developmental state when CTG data is used. SIGNIFICANCE Whereas the predominantly vagally modulated beat-to-beat precise high frequencies of HRV are not assessable from CTG, we identified relevant related HRV indices and categories for CTG recordings with diagnostic potential. They require further evaluation and confirmation with respect to any issues of fetal developmental and perinatal problems in subsequent studies. This methodology significantly extends the measures of established CTG devices. Novelty and significance HRV indices provide predestinated diagnostic markers of autonomic control in fetuses. However, the established CTG does not provide the temporal precision of electrophysiological recordings. Beat-to-beat related, mainly vagally modulated behavior is not exactly represented in CTG. However, a set of CTG-specific HRV indices that are mainly comparable to established electrophysiological HRV parameters obtained by magnetocardiography or electrocardiography provided almost similar predictive value for fetal maturational age and were helpful in characterizing FGR. These results require validation in the monitoring of further fetal developmental disturbances. We recommend a corresponding extension of CTG methodology.
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Affiliation(s)
- Dirk Hoyer
- Biomagnetic Center, Hans Berger Department of Neurology, Jena University Hospital, Jena 07747, Germany. D H and U S equally contributed. Conception, data analysis and writing by D H, U S, A S. Data acquisition (Jena) by A S, A P, L V and others of the Jena research team of fetal autonomic maturation. Data acquisition (Porto) by C A C. Methods for (Porto) data acquisition by J B and D A C. Data acquisition (Munich) by S M L. Scientific discussion and final review of the manuscript by D H, U S, A S, J B, H G, D A C and S M L. Apart D H and U S, the order of the authors follows the appearance of their data sets in the manuscript
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Zizzo AR, Kirkegaard I, Hansen J, Uldbjerg N, Mølgaard H. Fetal Heart Rate Variability Is Affected by Fetal Movements: A Systematic Review. Front Physiol 2020; 11:578898. [PMID: 33101059 PMCID: PMC7554531 DOI: 10.3389/fphys.2020.578898] [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] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/25/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Fetal heart rate variability (FHRV) evaluates the fetal neurological state, which is poorly assessed by conventional prenatal surveillance including cardiotocography (CTG). Accurate FHRV on a beat-to-beat basis, assessed by time domain and spectral domain analyses, has shown promising results in the scope of fetal surveillance. However, accepted standards for these techniques are lacking, and the influence of fetal breathing movements and gross movements may be especially challenging. Thus, current standards for equivalent assessments in adults prescribe rest and controlled respiration. The aim of this review is to clarify the importance of fetal movements on FHRV. Methods: A systematic review in accordance with the PRISMA guidelines based on publications in the EMBASE, the MEDLINE, and the Cochrane Library databases was performed. Studies describing the impact of fetal movements on time domain, spectral domain and entropy analyses in healthy human fetuses were reviewed. Only studies based on fetal electrocardiography or fetal magnetocardiography were included. PROSPERO registration number: CRD42018068806. Results: In total, 14 observational studies were included. Fetal movement detection, signal processing, length, and selection of appropriate time series varied across studies. Despite these divergences, all studies showed an increase in overall FHRV in the moving fetus compared to the resting fetus. Especially short-term, vagal mediated indexes showed an increase during fetal breathing movements including an increase in Root Mean Square of the Successive Differences (RMSSD) and High Frequency power (HF) and a decrease in Low Frequency power/High Frequency power (LF/HF). These findings were present even in analyses restricted to one specific fetal behavioral state defined by Nijhuis. On the other hand, fetal body movements seemed to increase parameters supposed to represent the sympathetic response [LF and Standard Deviation of RR-intervals from normal sinus beats (SDNN)] proportionally more than parameters representing the parasympathetic response (RMSSD, HF). Results regarding entropy analyses were inconclusive. Conclusion: Time domain analyses as well as spectral domain analyses are affected by fetal movements. Fetal movements and especially breathing movements should be considered in these analyses of FHRV.
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Affiliation(s)
- Anne Rahbek Zizzo
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Ida Kirkegaard
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - John Hansen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Henning Mølgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Mathewlynn S, Knutzen L, Impey L. Intrapartum hypoxia and sexual dimorphism in adverse perinatal outcomes. Eur J Obstet Gynecol Reprod Biol 2020; 248:9-13. [PMID: 32182502 DOI: 10.1016/j.ejogrb.2020.03.004] [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: 12/11/2019] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of this study is to evaluate whether markers of intrapartum hypoxia differ according to sex, and if this could explain the increased risk of adverse perinatal outcomes in males. STUDY DESIGN This is a retrospective observational cohort study of non-anomalous, singleton deliveries >36 completed weeks' gestation at a UK teaching hospital over a 4.5 year period. Absent or incomplete cord gas results were excluded and the remaining data were validated according to an established method. The relations between sex and both arterial pH and a composite variable, 'fetal distress' (cases in which operative delivery or caesarean section were undertaken for presumed fetal compromise), were examined using independent samples t-test and Chi-square test. Odds ratios with 95 % confidence intervals were calculated to describe the relation between fetal sex and intermediate-term adverse outcomes. Binary logistic regression was performed to generate odds ratios (with 95 % confidence intervals) adjusted for arterial pH and fetal distress. This was repeated to adjust for labor and induction of labor. RESULTS There were eligible 8758 cases, of which 4655 were male and 4103 female, from a total of 39,148 deliveries during the study period. Neonatal unit admission (OR 1.54, 95 % CI; 1.31-1.80), renal impairment (OR 1.63, 95 % CI; 1.15-2.32), neurological impairment (OR 1.73, 95 % CI; 1.06-2.84) and a composite adverse outcome (OR 1.73, 95 % CI; 1.29-2.33) were all more likely in males, even after adjusting for labor and induction of labor, both of which were more likely males. The mean cord arterial pH of males was lower (7.23 vs 7.24, P = 0.019) although they were not more likely to be acidemic with a pH <7.0 (males 43 (0.92 %) vs females 41 (1.00 %), P = 0.717), and males were also more likely to have fetal distress (834 (17.9 %) vs 588 (14.3 %), P = <0.001). Being male remained associated with adverse outcomes despite adjustment for arterial pH and fetal distress. CONCLUSION Despite a lower mean cord arterial pH and greater incidence of fetal distress in males, intrapartum hypoxia does not account for their worse neonatal outcomes.
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Affiliation(s)
- Sam Mathewlynn
- Fetal Medicine Unit, Women's Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK.
| | - Liv Knutzen
- British Columbia Women's Hospital, 4500 Oak Street, Vancouver, British Columbia, V6H 3N1, Canada
| | - Lawrence Impey
- Fetal Medicine Unit, Women's Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
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Marzbanrad F, Stroux L, Clifford GD. Cardiotocography and beyond: a review of one-dimensional Doppler ultrasound application in fetal monitoring. Physiol Meas 2018; 39:08TR01. [PMID: 30027897 PMCID: PMC6237616 DOI: 10.1088/1361-6579/aad4d1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
One-dimensional Doppler ultrasound (1D-DUS) provides a low-cost and simple method for acquiring a rich signal for use in cardiovascular screening. However, despite the use of 1D-DUS in cardiotocography (CTG) for decades, there are still challenges that limit the effectiveness of its users in reducing fetal and neonatal morbidities and mortalities. This is partly due to the noisy, transient, complex and nonstationary nature of the 1D-DUS signals. Current challenges also include lack of efficient signal quality metrics, insufficient signal processing techniques for extraction of fetal heart rate and other vital parameters with adequate temporal resolution, and lack of appropriate clinical decision support for CTG and Doppler interpretation. Moreover, the almost complete lack of open research in both hardware and software in this field, as well as commercial pressures to market the much more expensive and difficult to use Doppler imaging devices, has hampered innovation. This paper reviews the basics of fetal cardiac function, 1D-DUS signal generation and processing, its application in fetal monitoring and assessment of fetal development and wellbeing. It also provides recommendations for future development of signal processing and modeling approaches, to improve the application of 1D-DUS in fetal monitoring, as well as the need for annotated open databases.
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Affiliation(s)
- Faezeh Marzbanrad
- Department of Electrical and Computer Systems Engineering, Monash University, Clayton, VIC, Australia
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Gonçalves H, Amorim-Costa C, Ayres-de-Campos D, Bernardes J. Evolution of linear and nonlinear fetal heart rate indices throughout pregnancy in appropriate, small for gestational age and preterm fetuses: A cohort study. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2018; 153:191-199. [PMID: 29157452 DOI: 10.1016/j.cmpb.2017.10.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 09/19/2017] [Accepted: 10/12/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND AND OBJECTIVES To assess the evolution of linear and nonlinear fetal heart rate (FHR) analysis throughout pregnancy in appropriate (AGA), small for gestational age (SGA) and preterm (PTB) fetuses. METHODS A prospective cohort study was carried out in 171 singleton pregnancies divided in three groups: AGA (n = 147), SGA (n = 13) fetuses and spontaneous PTB (n = 11). FHR was recorded with an external sensor from the 24th to the 40th week of gestation. Linear time- and frequency-domain and nonlinear FHR indices were computed on 10-min segments. Longitudinal analysis of indices throughout pregnancy was performed with generalized estimating equations, and receiver operating characteristic (ROC) curves were calculated for the prediction of SGA and PTB fetuses. RESULTS Increasing gestational age significantly affected most FHR indices, with a general increase in variability and entropy indices, and a decrease in mean FHR. The PTB group exhibited a significantly lower short-term variation, and no monotonic increase in the sympatho-vagal balance as observed in the AGA group. The SGA group exhibited higher long-term irregularity and lower short-term irregularity than the AGA group throughout gestation. In prediction of SGA and PTB, the largest areas under the ROC curves obtained were 0.76 and 0.78, respectively. CONCLUSIONS Linear and nonlinear FHR analysis provides useful information on the evolution of fetal autonomic nervous and complexity control systems throughout pregnancy, in relation with AGA, SGA and PTB fetuses, which may be helpful in clinical practice.
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Affiliation(s)
- Hernâni Gonçalves
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Portugal.
| | - Célia Amorim-Costa
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Portugal; Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Portugal
| | - Diogo Ayres-de-Campos
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Portugal; Department of Obstetrics and Gynecology, São João Hospital, Porto, Portugal; INEB - Institute of Biomedical Engineering, I3S - Institute for Research and Innovation in Health, University of Porto, Portugal
| | - João Bernardes
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Portugal; Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Portugal; Department of Obstetrics and Gynecology, São João Hospital, Porto, Portugal; Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Portugal
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Gonçalves H, Amorim-Costa C, Ayres-de-Campos D, Bernardes J. Gender-specific evolution of fetal heart rate variability throughout gestation: A study of 8823 cases. Early Hum Dev 2017; 115:38-45. [PMID: 28889037 DOI: 10.1016/j.earlhumdev.2017.09.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 08/29/2017] [Accepted: 09/05/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fetal heart rate (FHR) variability throughout gestation reflects aspects of fetal development, and its analysis has been used for the assessment of fetal well-being. AIM The objective of this study was to provide a gender-specific analysis of the evolution of FHR variability indices throughout gestation, using linear time-domain, spectral and nonlinear FHR indices. STUDY DESIGN A large retrospective study was carried out using antepartum FHR recordings obtained from 4713 male and 4110 female fetuses, with normal pregnancy outcome, between 2004 and 2013, with gestational ages ranging between 25 and 40weeks. OUTCOME MEASURES FHR variability was analysed through linear time-domain methods, as well as using spectral analysis and entropy indices. Evolution of FHR indices throughout gestation was analysed through Spearman correlation coefficient. Comparison between male and female fetuses was performed using nonparametric bootstrap 95% confidence intervals for the median. RESULTS Mean FHR decreased significantly throughout gestation, whereas most variability indices increased. Sympatho-vagal balance measured by spectral analysis exhibited two local maxima at 29-30 and 34-35weeks and decreased afterwards. Entropy indices increased until around the 34th week, slightly decreasing after the 37th week. Female fetuses presented higher mean FHR and entropy from the 34th week afterwards, and lower short-term variability and sympatho-vagal balance in the same period. CONCLUSIONS Spectral and entropy analysis should be considered as a complement to conventional FHR variability analysis, aiming at a better characterization and follow-up of fetal development/maturation throughout gestation. Additionally, gestational age needs to be considered when defining reference ranges for FHR indices in systems of computerized analysis.
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Affiliation(s)
- Hernâni Gonçalves
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Portugal.
| | - Célia Amorim-Costa
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Portugal; Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Portugal; INEB - Institute of Biomedical Engineering, I3S - Institute for Research and Innovation in Health, University of Porto, Portugal
| | - Diogo Ayres-de-Campos
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Portugal; INEB - Institute of Biomedical Engineering, I3S - Institute for Research and Innovation in Health, University of Porto, Portugal; Department of Obstetrics and Gynecology, São João Hospital, Porto, Portugal
| | - João Bernardes
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Portugal; Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Portugal; Department of Obstetrics and Gynecology, São João Hospital, Porto, Portugal; Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Portugal
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Gonçalves H, Fernandes D, Pinto P, Ayres-de-Campos D, Bernardes J. Simultaneous monitoring of maternal and fetal heart rate variability during labor in relation with fetal gender. Dev Psychobiol 2017; 59:832-839. [PMID: 28833043 DOI: 10.1002/dev.21554] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/17/2017] [Indexed: 11/07/2022]
Abstract
Male gender is considered a risk factor for several adverse perinatal outcomes. Fetal gender effect on fetal heart rate (FHR) has been subject of several studies with contradictory results. The importance of maternal heart rate (MHR) monitoring during labor has also been investigated, but less is known about the effect of fetal gender on MHR. The aim of this study is to simultaneously assess maternal and FHR variability during labor in relation with fetal gender. Simultaneous MHR and FHR recordings were obtained from 44 singleton term pregnancies during the last 2 hr of labor (H1, H2 ). Heart rate tracings were analyzed using linear (time- and frequency-domain) and nonlinear indices. Both linear and nonlinear components were considered in assessing FHR and MHR interaction, including cross-sample entropy (cross-SampEn). Mothers carrying male fetuses (n = 22) had significantly higher values for linear indices related with MHR average and variability and sympatho-vagal balance, while the opposite occurred in the high-frequency component and most nonlinear indices. Significant differences in FHR were only observed in H1 with higher entropy values in female fetuses. Assessing the differences between FHR and MHR, statistically significant differences were obtained in most nonlinear indices between genders. A significantly higher cross-SampEn was observed in mothers carrying female fetuses (n = 22), denoting lower synchrony or similarity between MHR and FHR. The variability of MHR and the synchrony/similarity between MHR and FHR vary with respect to fetal gender during labor. These findings suggest that fetal gender needs to be taken into account when simultaneously monitoring MHR and FHR.
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Affiliation(s)
- Hernâni Gonçalves
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Diana Fernandes
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Paula Pinto
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Porto, Portugal
- Hospital Dr Nélio Mendonça, EPE, Funchal, Portugal
| | - Diogo Ayres-de-Campos
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Obstetrics and Gynecology, São João Hospital, Porto, Portugal
- INEB - Institute of Biomedical Engineering; I3S - Institute for Research and Innovation in Health, University of Porto, Porto, Portugal
| | - João Bernardes
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Obstetrics and Gynecology, São João Hospital, Porto, Portugal
- Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Senhora da Hora, Portugal
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Marzbanrad F, Khandoker AH, Kimura Y, Palaniswami M, Clifford GD. Assessment of Fetal Development Using Cardiac Valve Intervals. Front Physiol 2017; 8:313. [PMID: 28567021 PMCID: PMC5434138 DOI: 10.3389/fphys.2017.00313] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 05/01/2017] [Indexed: 11/28/2022] Open
Abstract
An automated method to assess the fetal physiological development is introduced which uses the component intervals between fetal cardiac valve timings and the Q-wave of fetal electrocardiogram (fECG). These intervals were estimated automatically from one-dimensional Doppler Ultrasound and noninvasive fECG. We hypothesize that the fetal growth can be estimated by the cardiac valve intervals. This hypothesis was evaluated by modeling the fetal development using the cardiac intervals and validating against the gold standard gestational age identified by Crown-Rump Length (CRL). Among the intervals, electromechanical delay time, isovolumic contraction time, ventricular filling time and their interactions were selected in a stepwise regression process that used gestational age as the target in a cohort of 57 fetuses. Compared with the gold standard age, the newly proposed regression model resulted in a mean absolute error of 3.8 weeks for all recordings and 2.7 weeks after excluding the low quality recordings. Since Fetal Heart Rate Variability (FHRV) has been proposed in the literature for assessing the fetal development, we compared the performance of gestational age estimation by our new valve-interval based method, vs. FHRV, while assuming the CRL as the gold standard. The valve interval-based method outperformed both the model based on FHRV. Results of evaluation for 30 abnormal cases showed that the new method is less affected by arrhythmias such as tachycardia and bradycardia compared to FHRV, however certain types of heart anomalies cause large errors (more than 10 weeks) with respect to the CRL-based gold standard age. Therefore, discrepancies between the regression based estimation and CRL age estimation could indicate the abnormalities. The cardiac valve intervals have been known to reflect the autonomic function. Therefore the new method potentially provides a novel approach for assessing the development of fetal autonomic nervous system, which may be growth curve independent.
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Affiliation(s)
- Faezeh Marzbanrad
- Department of Electrical and Computer Systems Engineering, Monash UniversityClayton, VIC, Australia
| | - Ahsan H Khandoker
- Electrical and Electronic Engineering Department, University of MelbourneMelbourne, VIC, Australia.,Biomedical Engineering Department, Khalifa University of Science, Technology and ResearchAbu Dhabi, United Arab Emirates
| | | | - Marimuthu Palaniswami
- Electrical and Electronic Engineering Department, University of MelbourneMelbourne, VIC, Australia
| | - Gari D Clifford
- Department of Biomedical Informatics, Emory UniversityAtlanta, GA, United States.,Department of Biomedical Engineering, Georgia Institute of TechnologyAtlanta, GA, United States
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Amorim-Costa C, de Campos DA, Bernardes J. Cardiotocographic parameters in small-for-gestational-age fetuses: How do they vary from normal at different gestational ages? A study of 11687 fetuses from 25 to 40 weeks of pregnancy. J Obstet Gynaecol Res 2017; 43:476-485. [PMID: 28165176 DOI: 10.1111/jog.13235] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 09/16/2016] [Accepted: 10/07/2016] [Indexed: 11/26/2022]
Abstract
AIM The aim of this study was to assess how cardiotocographic (CTG) parameters differ between small-for-gestational-age (SGA) and normal fetuses at different gestational ages. METHODS This was a retrospective cross-sectional study using the first antepartum tracing of singleton pregnancies with no malformations. Fetuses with birthweight ≥10th percentile for gestational age and other normal pregnancy outcome criteria (term birth, normal umbilical artery pH and Apgar scores, no intensive care unit admission) were compared with fetuses with birthweight <10th and <3rd percentiles for gestational age (SGA < p10 and SGA < p3, a subgroup of the latter). Each CTG parameter was compared, by gestational age, using both statistical tests and percentile curves derived from normal outcome cases. Tracings were analyzed with the OmniviewSisPorto® 3.7 system. RESULTS A total of 11 687 tracings (from the same number of fetuses) were analyzed: 9701 normal, 1986 SGA < p10, and 543 SGA < p3. SGA fetuses had lower long- and short-term variability, and number of accelerations, with more pronounced differences between around 28 and 35 weeks. In contrast, baseline was lower in SGA fetuses from 34 weeks onwards. All differences were more pronounced for SGA < p3 fetuses. Similar trends throughout gestation occurred in all groups: decrease in baseline, and increase in long- and short-term variability, and accelerations. CONCLUSIONS This study represents an important step for accurate CTG interpretation in SGA fetuses and, consequently, management of fetal growth restriction (FGR), as it contributes to differentiate between maturational CTG changes that occur physiologically throughout pregnancy, and possible signs of fetal compromise in FGR.
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Affiliation(s)
- Célia Amorim-Costa
- Department of Obstetrics and Gynecology, Medical School, University of Porto, Porto, Portugal.,Institute for Research and Innovation in Health (Instituto de Investigação e Inovação em Saúde - I3S) and Institute of Biomedical Engineering (Instituto de Engenharia Biomédica - INEB), University of Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Porto Medical School, University of Porto, Porto, Portugal
| | - Diogo Ayres de Campos
- Department of Obstetrics and Gynecology, Medical School, University of Porto, Porto, Portugal.,Institute for Research and Innovation in Health (Instituto de Investigação e Inovação em Saúde - I3S) and Institute of Biomedical Engineering (Instituto de Engenharia Biomédica - INEB), University of Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Porto Medical School, University of Porto, Porto, Portugal.,Department of Obstetrics and Gynecology, S. João Hospital, Porto, Portugal
| | - João Bernardes
- Department of Obstetrics and Gynecology, Medical School, University of Porto, Porto, Portugal.,Institute for Research and Innovation in Health (Instituto de Investigação e Inovação em Saúde - I3S) and Institute of Biomedical Engineering (Instituto de Engenharia Biomédica - INEB), University of Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Porto Medical School, University of Porto, Porto, Portugal.,Department of Obstetrics and Gynecology, S. João Hospital, Porto, Portugal.,Department of Obstetrics and Gynecology, Hospital Pedro Hispano, Matosinhos, Portugal
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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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Intrauterine growth restriction: impact on cardiovascular development and function throughout infancy. Pediatr Res 2016; 79:821-30. [PMID: 26866903 DOI: 10.1038/pr.2016.24] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 12/05/2015] [Indexed: 01/08/2023]
Abstract
Intrauterine growth restriction (IUGR) refers to the situation where a fetus does not grow according to its genetic growth potential. One of the main causes of IUGR is uteroplacental vascular insufficiency. Under these circumstances of chronic oxygen and nutrient deprivation, the growth-restricted fetus often displays typical circulatory changes, which in part represent adaptations to the suboptimal intrauterine environment. These fetal adaptations aim to preserve oxygen and nutrient supply to vital organs such as the brain, the heart, and the adrenals. These prenatal circulatory adaptations are thought to lead to an altered development of the cardiovascular system and "program" the fetus for life long cardiovascular morbidities. In this review, we discuss the alterations to cardiovascular structure, function, and control that have been observed in growth-restricted fetuses, neonates, and infants following uteroplacental vascular insufficiency. We also discuss the current knowledge on early life surveillance and interventions to prevent progression into chronic disease.
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Sex-related differences in the development of fetal heart rate dynamics. Early Hum Dev 2016; 93:47-55. [PMID: 26789556 DOI: 10.1016/j.earlhumdev.2015.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/15/2015] [Accepted: 12/18/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite previous efforts to explain the general advantages of female fetuses over males regarding health, sex-related differences in the dynamics or complexity of fetal heart rate (FHR) variability and FHR maturation patterns have not yet been identified. AIM To make linear and nonlinear comparisons of antepartum FHR indices, dynamics, complexity, and reactivity to the non-stress test (NST) and vibroacoustic-stimulation test (VAST) in male and female fetuses. STUDY DESIGN A total of 3835 singleton term deliveries without maternal and fetal complications were divided into female (n=1849) and male (n=1986) groups, and subjected to comparison and analyses. SUBJECTS Linear FHR indices, approximate entropy (ApEn), sample entropy (SampEn), short-term/long-term exponents (α1/α2), correlation dimension (CD), NST and VAST criteria, and modified nonlinear reactive criteria (MNRC) were used to evaluate outcomes. RESULTS ApEn was consistently higher in female fetuses than in male ones. ApEn in female fetuses was maximal at 29-30 gestational weeks, while the increase in ApEn was delayed in male fetuses but more rapid, reaching its peak at 31-32 gestational weeks. In both sexes, CD increased up to term, and α2 rapidly decreased up to 31-32weeks in an analogous manner. The two sexes differed significantly in response to VAST at <31 gestational weeks and there was a structural difference in reactive patterns under MNRC. CONCLUSIONS Female fetuses exhibit greater heart rate dynamics in early gestational periods, suggesting that their cardiovascular system matures earlier than that of males. Male fetuses undergo a compensatory period of rapid change to catch up with females at term.
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DiPietro JA, Costigan KA, Voegtline KM. STUDIES IN FETAL BEHAVIOR: REVISITED, RENEWED, AND REIMAGINED. Monogr Soc Res Child Dev 2015; 80:vii;1-94. [PMID: 26303396 DOI: 10.1111/mono.v80.3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Among the earliest volumes of this monograph series was a report by Lester Sontag and colleagues, of the esteemed Fels Institute, on the heart rate of the human fetus as an expression of the developing nervous system. Here, some 75 years later, we commemorate this work and provide historical and contemporary context on knowledge regarding fetal development, as well as results from our own research. These are based on synchronized monitoring of maternal and fetal parameters assessed between 24 and 36 weeks gestation on 740 maternal-fetal pairs compiled from eight separate longitudinal studies, which commenced in the early 1990s. Data include maternal heart rate, respiratory sinus arrhythmia, and electrodrmal activity and fetal heartrate, motor activity, and their integration. Hierarchical linear modeling of developmental trajectories reveals that the fetus develops in predictable ways consistent with advancing parasympathetic regulation. Findings also include:within-fetus stability (i.e., preservation of rank ordering over time) for heart rate, motor, and coupling measures; a transitional period of decelerating development near 30 weeks gestation; sex differences in fetal heart rate measures but not in most fetal motor activity measures; modest correspondence in fetal neurodevelopment among siblings as compared to unrelated fetuses; and deviations from normative fetal development in fetuses affected by intrauterine growth restriction and other conditions. Maternal parameters also change during this period of gestation and there is evidence that fetal sex and individual variation in fetal neurobehavior influence maternal physio-logical processes and the local intrauterine context. Results are discussed within the framework of neuromaturation, the emergence of individual differences, and the bidirectional nature of the maternal-fetal relationship.We pose a number of open questions for future research. Although the human fetus remains just out of reach, new technologies portend an era of accelerated discovery of the earliest period of development
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REFERENCES. Monogr Soc Res Child Dev 2015. [DOI: 10.1111/mono.12184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fetal behavioral dynamics in cephalic versus breech presentations. Dev Psychobiol 2014; 56:1595-600. [DOI: 10.1002/dev.21242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 06/26/2014] [Indexed: 11/07/2022]
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Almeida R, Gonçalves H, Bernardes J, Rocha AP. Fetal QRS detection and heart rate estimation: a wavelet-based approach. Physiol Meas 2014; 35:1723-35. [DOI: 10.1088/0967-3334/35/8/1723] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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