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Tarvonen M, Manninen M, Lamminaho P, Jehkonen P, Tuppurainen V, Andersson S. Computer Vision for Identification of Increased Fetal Heart Variability in Cardiotocogram. Neonatology 2024; 121:460-467. [PMID: 38565092 DOI: 10.1159/000538134] [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: 10/13/2023] [Accepted: 02/27/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Increased fetal heart rate variability (IFHRV), defined as fetal heart rate (FHR) baseline amplitude changes of >25 beats per minute with a duration of ≥1 min, is an early sign of intrapartum fetal hypoxia. This study evaluated the level of agreement of machine learning (ML) algorithms-based recognition of IFHRV patterns with expert analysis. METHODS Cardiotocographic recordings and cardiotocograms from 4,988 singleton term childbirths were evaluated independently by two expert obstetricians blinded to the outcomes. Continuous FHR monitoring with computer vision analysis was compared with visual analysis by the expert obstetricians. FHR signals were graphically processed and measured by the computer vision model labeled SALKA. RESULTS In visual analysis, IFHRV pattern occurred in 582 cardiotocograms (11.7%). Compared with visual analysis, SALKA recognized IFHRV patterns with an average Cohen's kappa coefficient of 0.981 (95% CI: 0.972-0.993). The sensitivity of SALKA was 0.981, the positive predictive rate was 0.822 (95% CI: 0.774-0.903), and the false-negative rate was 0.01 (95% CI: 0.00-0.02). The agreement between visual analysis and SALKA in identification of IFHRV was almost perfect (0.993) in cases (N = 146) with neonatal acidemia (i.e., umbilical artery pH <7.10). CONCLUSIONS Computer vision analysis by SALKA is a novel ML technique that, with high sensitivity and specificity, identifies IFHRV features in intrapartum cardiotocograms. SALKA recognizes potential early signs of fetal distress close to those of expert obstetricians, particularly in cases of neonatal acidemia.
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Affiliation(s)
- Mikko Tarvonen
- Department of Gynecology and Obstetrics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Matti Manninen
- School of Engineering, Aalto University, Espoo, Finland
- Department of Geosciences and Geography, University of Helsinki, Espoo, Finland
| | - Petri Lamminaho
- Department of Mathematics and Statistic, University of Jyväskylä, Jyväskylä, Finland
| | - Petri Jehkonen
- Department of Computer, Communication and Information Sciences, Aalto University, Espoo, Finland
| | - Ville Tuppurainen
- Department of Industrial Engineering and Management, LUT University of Technology, Lappeenranta, Finland
- Helsinki University Hospital Area Administration, Helsinki, Finland
| | - Sture Andersson
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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2
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Steyde G, Spairani E, Magenes G, Signorini MG. Fetal heart rate spectral analysis in raw signals and PRSA-derived curve: normal and pathological fetuses discrimination. Med Biol Eng Comput 2024; 62:437-447. [PMID: 37889432 PMCID: PMC10794317 DOI: 10.1007/s11517-023-02953-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023]
Abstract
Cardiotocography (CTG) is the most common technique for electronic fetal monitoring and consists of the simultaneous recording of fetal heart rate (FHR) and uterine contractions. In analogy with the adult case, spectral analysis of the FHR signal can be used to assess the functionality of the autonomic nervous system. To do so, several methods can be employed, each of which has its strengths and limitations. This paper aims at performing a methodological investigation on FHR spectral analysis adopting 4 different spectrum estimators and a novel PRSA-based spectral method. The performances have been evaluated in terms of the ability of the various methods to detect changes in the FHR in two common pregnancy complications: intrauterine growth restriction (IUGR) and gestational diabetes. A balanced dataset containing 2178 recordings distributed between the 32nd and 38th week of gestation was used. The results show that the spectral method derived from the PRSA better differentiates high-risk pregnancies vs. controls compared to the others. Specifically, it more robustly detects an increase in power percentage within the movement frequency band and a decrease in high frequency between pregnancies at high risk in comparison to those at low risk.
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Affiliation(s)
- Giulio Steyde
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milano, Italy.
| | - Edoardo Spairani
- Electrical, Computer and Biomedical Engineering Department, Università di Pavia, 27100, Pavia, Italy
| | - Giovanni Magenes
- Electrical, Computer and Biomedical Engineering Department, Università di Pavia, 27100, Pavia, Italy
| | - Maria G Signorini
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milano, Italy
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3
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Hussain NM, O'Halloran M, McDermott B, Elahi MA. Fetal monitoring technologies for the detection of intrapartum hypoxia - challenges and opportunities. Biomed Phys Eng Express 2024; 10:022002. [PMID: 38118183 DOI: 10.1088/2057-1976/ad17a6] [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: 05/13/2023] [Accepted: 12/20/2023] [Indexed: 12/22/2023]
Abstract
Intrapartum fetal hypoxia is related to long-term morbidity and mortality of the fetus and the mother. Fetal surveillance is extremely important to minimize the adverse outcomes arising from fetal hypoxia during labour. Several methods have been used in current clinical practice to monitor fetal well-being. For instance, biophysical technologies including cardiotocography, ST-analysis adjunct to cardiotocography, and Doppler ultrasound are used for intrapartum fetal monitoring. However, these technologies result in a high false-positive rate and increased obstetric interventions during labour. Alternatively, biochemical-based technologies including fetal scalp blood sampling and fetal pulse oximetry are used to identify metabolic acidosis and oxygen deprivation resulting from fetal hypoxia. These technologies neither improve clinical outcomes nor reduce unnecessary interventions during labour. Also, there is a need to link the physiological changes during fetal hypoxia to fetal monitoring technologies. The objective of this article is to assess the clinical background of fetal hypoxia and to review existing monitoring technologies for the detection and monitoring of fetal hypoxia. A comprehensive review has been made to predict fetal hypoxia using computational and machine-learning algorithms. The detection of more specific biomarkers or new sensing technologies is also reviewed which may help in the enhancement of the reliability of continuous fetal monitoring and may result in the accurate detection of intrapartum fetal hypoxia.
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Affiliation(s)
- Nadia Muhammad Hussain
- Discipline of Electrical & Electronic Engineering, University of Galway, Ireland
- Translational Medical Device Lab, Lambe Institute for Translational Research, University Hospital Galway, Ireland
| | - Martin O'Halloran
- Discipline of Electrical & Electronic Engineering, University of Galway, Ireland
- Translational Medical Device Lab, Lambe Institute for Translational Research, University Hospital Galway, Ireland
| | - Barry McDermott
- Translational Medical Device Lab, Lambe Institute for Translational Research, University Hospital Galway, Ireland
- College of Medicine, Nursing & Health Sciences, University of Galway, Ireland
| | - Muhammad Adnan Elahi
- Discipline of Electrical & Electronic Engineering, University of Galway, Ireland
- Translational Medical Device Lab, Lambe Institute for Translational Research, University Hospital Galway, Ireland
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Nabipour Hosseini ST, Abbasalizadeh F, Abbasalizadeh S, Mousavi S, Amiri P. A comparative study of CTG monitoring one hour before labor in infants born with and without asphyxia. BMC Pregnancy Childbirth 2023; 23:758. [PMID: 37884899 PMCID: PMC10601321 DOI: 10.1186/s12884-023-06040-3] [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: 09/02/2022] [Accepted: 10/01/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND AND AIM Asphyxia is a condition arising when the infant is deprived of oxygen, causing Fetal brain damage or death, which is associated with hypoxia and hypercapnia. Although fetal Cardiotocography (CTG) can show the Fetal health status during labor, some studies have reported cases of fetal asphyxia despite reassuring CTGs. This study hence aimed to compare FHR Monitoring and uterine contractions in the last hour before delivered between two groups of infants born with and without asphyxia. METHODOLOGY The study was conducted on 70 pregnant women who delivered Taleghani and Al-Zahra academic teaching hospitals of Tabriz for labor in 2020-2021. RESULTS The study data showed no significant difference between mothers of infants with and without asphyxia in terms of demographics (p > 0.05). The prevalence of asphyxia was significantly higher only in mothers with the gravidity of 3 and 4 (p = 0.003). In terms of the methods for labor induction, the use of oxytocin was more common among mothers of infants with asphyxia (74.3%) than in those of infants without asphyxia (p = 0.015). The results also revealed a significant difference between infants with and without asphyxia in the Apgar score (first, fifth, and tenth minutes), need for neonatal resuscitation, umbilical cord artery Acidosis (pH, bicarbonate, and BE), and severity of HIE between two groups of infants with asphyxia and without asphyxia (p < 0.0001). The comparison of fetal CTG 0 to 20 min before the delivery indicated that normal variability was observed in 71.4% of infants born with asphyxia, whereas this figure for infants born without asphyxia was 91.4% (p = 0.031). However, the results showed no significant difference between the two groups of infants in any of the tstudied indicators at 20 and 40 min before the labor(p > 0.05). There was a significant difference between the two groups of infants in terms of deceleration at 40 and 60 min before the labor, as it was observed in 53.6% of infants born with asphyxia and only 11.1% of those born without asphyxia. The results also demonstrated a significant difference between the two groups in the type of deceleration (p = 0.025). Pearson and Spearman correlation coefficients showed a significant and direct relationship between interpretation the CTG of the three Perinatologists(p < 0.0001, r > 0.8). CONCLUSION The study results demonstrated a significant difference between infants born with asphyxia and those born without asphyxia in variability at 0 to 20 min before the labor and deceleration at 40 to 60 min before the labor.
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Affiliation(s)
- Seyedeh Tala Nabipour Hosseini
- Women’s Reproductive Health Research Center, Department of Perinatology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Abbasalizadeh
- Women’s Reproductive Health Research Center, Department of Perinatology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shamsi Abbasalizadeh
- Women’s Reproductive Health Research Center, Department of Perinatology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sanaz Mousavi
- Women’s Reproductive Health Research Center, Department of Perinatology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Paria Amiri
- School of Nursing and Midwifery, Tabriz University of Medical Science, Tabriz, Iran
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Lear CA, Ugwumadu A, Bennet L, Gunn AJ. An Update of Our Understanding of Fetal Heart Rate Patterns in Health and Disease. Semin Pediatr Neurol 2023; 47:101072. [PMID: 37919038 DOI: 10.1016/j.spen.2023.101072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 11/04/2023]
Abstract
UNDERSTANDING FETAL HEART RATE PATTERNS THAT MAY PREDICT ANTENATAL AND INTRAPARTUM NEURAL INJURY: Christopher A. Lear, Jenny A. Westgate, Austin Ugwumadu, Jan G. Nijhuis, Peter R. Stone, Antoniya Georgieva, Tomoaki Ikeda, Guido Wassink , Laura Bennet , Alistair J. Gunn Seminars in Pediatric Neurology Volume 28, December 2018, Pages 3-16 Electronic fetal heart rate (FHR) monitoring is widely used to assess fetal well-being throughout pregnancy and labor. Both antenatal and intrapartum FHR monitoring are associated with a high negative predictive value and a very poor positive predictive value. This in part reflects the physiological resilience of the healthy fetus and the remarkable effectiveness of fetal adaptations to even severe challenges. In this way, the majority of "abnormal" FHR patterns in fact reflect a fetus' appropriate adaptive responses to adverse in utero conditions. Understanding the physiology of these adaptations, how they are reflected in the FHR trace and in what conditions they can fail is therefore critical to appreciating both the potential uses and limitations of electronic FHR monitoring.
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Affiliation(s)
- Christopher A Lear
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Austin Ugwumadu
- Department of Obstetrics and Gynaecology, St George's Hospital, St George's University of London, London, UK
| | - Laura Bennet
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.
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Mytinger JR. Reflections and Updates of Contemporary High-Impact Reviews From Seminars in Pediatric Neurology. Semin Pediatr Neurol 2023; 47:101083. [PMID: 37919032 DOI: 10.1016/j.spen.2023.101083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Affiliation(s)
- John R Mytinger
- Director, Infantile Spasms Program, Nationwide Children's Hospital, Associate Professor, The Ohio State University, Columbus, OH.
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7
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Clark AR, Fontinha H, Thompson J, Couper S, Jani D, Mirjalili A, Bennet L, Stone P. Maternal Cardiovascular Responses to Position Change in Pregnancy. BIOLOGY 2023; 12:1268. [PMID: 37759669 PMCID: PMC10525953 DOI: 10.3390/biology12091268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/07/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023]
Abstract
The maternal cardiovascular-circulatory system undergoes profound changes almost from the conception of a pregnancy until the postpartum period to support the maternal adaptions required for pregnancy and lactation. Maintenance of cardiovascular homeostasis requires changes in the cardiovascular autonomic responses. Here, we present a longitudinal study of the maternal cardiovascular autonomic responses to pregnancy and maternal position. Over a normal gestation, in the left lateral position there are significant changes in both time and frequency domain parameters reflecting heart rate variability. We show that cardiovascular autonomic responses to physiological stressors (standing and supine positions in late pregnancy) became significantly different with advancing gestation. In the third trimester, 60% of the subjects had an unstable heart rate response on standing, and these subjects had a significantly reduced sample entropy evident in their heart rate variability data. By 6 weeks, postpartum function returned to near the non-pregnant state, but there were consistent differences in high-frequency power when compared to nulligravid cases. Finally, we review complementary evidence, in particular from magnetic resonance imaging, that provides insights into the maternal and fetal impacts of positioning in pregnancy. This demonstrates a clear relationship between supine position and maternal hemodynamic parameters, which relates to compression of the inferior vena cava (p = 0.05). Together, these studies demonstrate new understanding of the physiology of physiological stressors related to position.
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Affiliation(s)
- Alys R. Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland 1010, New Zealand
| | - Hanna Fontinha
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - John Thompson
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Sophie Couper
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Devanshi Jani
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Ali Mirjalili
- Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Laura Bennet
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Peter Stone
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
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Lear CA, Maeda Y, King VJ, Dhillon SK, Beacom MJ, Gunning MI, Lear BA, Davidson JO, Stone PR, Ikeda T, Gunn AJ, Bennet L. Circadian patterns of heart rate variability in fetal sheep after hypoxia-ischaemia: A biomarker of evolving brain injury. J Physiol 2023. [PMID: 37432936 DOI: 10.1113/jp284560] [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: 02/21/2023] [Accepted: 06/23/2023] [Indexed: 07/13/2023] Open
Abstract
Hypoxia-ischaemia (HI) before birth is a key risk factor for stillbirth and severe neurodevelopmental disability in survivors, including cerebral palsy, although there are no reliable biomarkers to detect at risk fetuses that may have suffered a transient period of severe HI. We investigated time and frequency domain measures of fetal heart rate variability (FHRV) for 3 weeks after HI in preterm fetal sheep at 0.7 gestation (equivalent to preterm humans) until 0.8 gestation (equivalent to term humans). We have previously shown that this is associated with delayed development of severe white and grey matter injury, including cystic white matter injury (WMI) resembling that observed in human preterm infants. HI was associated with suppression of time and frequency domain measures of FHRV and reduced their circadian rhythmicity during the first 3 days of recovery. By contrast, circadian rhythms of multiple measures of FHRV were exaggerated over the final 2 weeks of recovery, mediated by a greater reduction in FHRV during the morning nadir, but no change in the evening peak. These data suggest that the time of day at which FHRV measurements are taken affects their diagnostic utility. We further propose that circadian changes in FHRV may be a low-cost, easily applied biomarker of antenatal HI and evolving brain injury. KEY POINTS: Hypoxia-ischaemia (HI) before birth is a key risk factor for stillbirth and probably for disability in survivors, although there are no reliable biomarkers for antenatal brain injury. In preterm fetal sheep, acute HI that is known to lead to delayed development of severe white and grey matter injury over 3 weeks, was associated with early suppression of multiple time and frequency domain measures of fetal heart rate variability (FHRV) and loss of their circadian rhythms during the first 3 days after HI. Over the final 2 weeks of recovery after HI, exaggerated circadian rhythms of frequency domain FHRV measures were observed. The morning nadirs were lower with no change in the evening peak of FHRV. Circadian changes in FHRV may be a low-cost, easily applied biomarker of antenatal HI and evolving brain injury.
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Affiliation(s)
- Christopher A Lear
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Yoshiki Maeda
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
- The Department of Obstetrics and Gynaecology, Mie University, Mie, Japan
| | - Victoria J King
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Simerdeep K Dhillon
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Michael J Beacom
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Mark I Gunning
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Benjamin A Lear
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Peter R Stone
- The Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
| | - Tomoaki Ikeda
- The Department of Obstetrics and Gynaecology, Mie University, Mie, Japan
| | - Alistair J Gunn
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
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Tolladay J, Lear CA, Bennet L, Gunn AJ, Georgieva A. Prediction of Fetal Blood Pressure during Labour with Deep Learning Techniques. Bioengineering (Basel) 2023; 10:775. [PMID: 37508802 PMCID: PMC10376045 DOI: 10.3390/bioengineering10070775] [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: 05/18/2023] [Revised: 06/16/2023] [Accepted: 06/24/2023] [Indexed: 07/30/2023] Open
Abstract
Our objective is to develop a model for the prediction of minimum fetal blood pressure (FBP) during fetal heart rate (FHR) decelerations. Experimental data from umbilical occlusions in near-term fetal sheep (2698 occlusions from 57 near-term lambs) were used to train a convolutional neural network. This model was then used to estimate FBP for decelerations extracted from the final 90 min of 53,445 human FHR signals collected using cardiotocography. Minimum sheep FBP was predicted with a mean absolute error of 6.7 mmHg (25th, 50th, 75th percentiles of 2.3, 5.2, 9.7 mmHg), mean absolute percentage errors of 17.3% (5.5%, 12.5%, 23.9%) and a coefficient of determination R2=0.36. While the model was unable to clearly predict severe compromise at birth in humans, there is positive evidence that such a model could predict human FBP with further development. The neural network is capable of predicting FBP for many of the sheep decelerations accurately but performed far from satisfactory at identifying FHR segments that correspond to the highest or lowest minimum FBP. These results indicate that with further work and a larger, more variable training dataset, the model could achieve higher accuracy.
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Affiliation(s)
- John Tolladay
- Oxford Labour Monitoring Group, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, OX1 2JD, UK
| | - Christopher A Lear
- The Fetal Physiology and Neuroscience Group, Department of Physiology, University of Auckland, Auckland 1010, New Zealand
| | - Laura Bennet
- The Fetal Physiology and Neuroscience Group, Department of Physiology, University of Auckland, Auckland 1010, New Zealand
| | - Alistair J Gunn
- The Fetal Physiology and Neuroscience Group, Department of Physiology, University of Auckland, Auckland 1010, New Zealand
| | - Antoniya Georgieva
- Oxford Labour Monitoring Group, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, OX1 2JD, UK
- Big Data Institute, Old Road Campus, University of Oxford, Oxford, OX3 7LF, UK
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Lear CA, Beacom MJ, Dhillon SK, Lear BA, Mills OJ, Gunning MI, Westgate JA, Bennet L, Gunn AJ. Dissecting the contributions of the peripheral chemoreflex and myocardial hypoxia to fetal heart rate decelerations in near-term fetal sheep. J Physiol 2023; 601:2017-2041. [PMID: 37017488 DOI: 10.1113/jp284286] [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: 12/19/2022] [Accepted: 03/30/2023] [Indexed: 04/06/2023] Open
Abstract
Brief repeated fetal hypoxaemia during labour can trigger intrapartum decelerations of the fetal heart rate (FHR) via the peripheral chemoreflex or the direct effects of myocardial hypoxia, but the relative contribution of these two mechanisms and how this balance changes with evolving fetal compromise remain unknown. In the present study, chronically instrumented near-term fetal sheep received surgical vagotomy (n = 8) or sham vagotomy (control, n = 11) to disable the peripheral chemoreflex and unmask myocardial hypoxia. One-minute complete umbilical cord occlusions (UCOs) were performed every 2.5 min for 4 h or until arterial pressure fell below 20 mmHg. Hypotension and severe acidaemia developed progressively after 65.7 ± 7.2 UCOs in control fetuses and 49.5 ± 7.8 UCOs after vagotomy. Vagotomy was associated with faster development of metabolic acidaemia and faster impairment of arterial pressure during UCOs without impairing centralization of blood flow or neurophysiological adaptation to UCOs. During the first half of the UCO series, before severe hypotension developed, vagotomy was associated with a marked increase in FHR during UCOs. After the onset of evolving severe hypotension, FHR fell faster in control fetuses during the first 20 s of UCOs, but FHR during the final 40 s of UCOs became progressively more similar between groups, with no difference in the nadir of decelerations. In conclusion, FHR decelerations were initiated and sustained by the peripheral chemoreflex at a time when fetuses were able to maintain arterial pressure. After the onset of evolving hypotension and acidaemia, the peripheral chemoreflex continued to initiate decelerations, but myocardial hypoxia became progressively more important in sustaining and deepening decelerations. KEY POINTS: Brief repeated hypoxaemia during labour can trigger fetal heart rate decelerations by either the peripheral chemoreflex or myocardial hypoxia, but how this balance changes with fetal compromise is unknown. Reflex control of fetal heart rate was disabled by vagotomy to unmask the effects of myocardial hypoxia in chronically instrumented fetal sheep. Fetuses were then subjected to repeated brief hypoxaemia consistent with the rates of uterine contractions during labour. We show that the peripheral chemoreflex controls brief decelerations in their entirety at a time when fetuses were able to maintain normal or increased arterial pressure. The peripheral chemoreflex still initiated decelerations even after the onset of evolving hypotension and acidaemia, but myocardial hypoxia made an increasing contribution to sustain and deepen decelerations.
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Affiliation(s)
- Christopher A Lear
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Michael J Beacom
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Simerdeep K Dhillon
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Benjamin A Lear
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Olivia J Mills
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Mark I Gunning
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Jenny A Westgate
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
- Department of Paediatrics, Starship Children's Hospital, Auckland, New Zealand
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11
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Hubert S, Brodbeck O, David C, Chrusciel J, Kattini A, Sanchez S. Using the CAESARE tool in fetal heart rate analysis. J Gynecol Obstet Hum Reprod 2023; 52:102557. [PMID: 36801462 DOI: 10.1016/j.jogoh.2023.102557] [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: 09/04/2022] [Revised: 02/08/2023] [Accepted: 02/15/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND To evaluate the theoretical impact of the CAESARE decision-making tool (which is based on fetal heart rate) on the rate of cesarean section deliveries and the prevention of metabolic acidosis risk. METHODS We conducted an observational, multicenter, retrospective study of all patients from 2018 to 2020 who had a cesarean section at term due to non-reassuring fetal status (NRFS) during labor. Primary outcome criteria were the rate of cesarean section births observed retrospectively compared to the theoretical rate by the CAESARE tool. Secondary outcome criteria were newborn umbilical pH (vaginal and cesarean delivery). A single-blind analysis was carried out in which two experienced midwives used the tool to decide whether to proceed with vaginal delivery or to seek the advice of an obstetric gynecologist (OB-GYN). The OB-GYN subsequently used the tool to decide between a vaginal or cesarean delivery. RESULTS Our study included 164 patients. The midwives proposed vaginal delivery in 90.2% of cases (of which 60% were without recourse to an OB-GYN). The OB-GYN proposed vaginal delivery for 141 patients (86%) (p<0.01). We found a difference in the umbilical cord arterial pH. The CAESARE tool affected the rapidity of the decision-making process whether to proceed with a cesarean section delivery of newborns with an umbilical cord arterial pH<7.1. The Kappa coefficient was calculated at 0.62. CONCLUSIONS The use of a decision-making tool was shown to reduce the rate of cesarean section births for NRFS while taking the risk of neonatal asphyxiation into account. Future prospective studies to assess whether the tool can reduce the cesarean rate without affecting the outcome of newborns should be conducted.
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Affiliation(s)
- Simon Hubert
- Troyes Hospital: Gynecology and Obstetrics Service, 101 Avenue Anatole France, Troyes 10000, France.
| | - Océane Brodbeck
- Troyes Hospital: Gynecology and Obstetrics Service, 101 Avenue Anatole France, Troyes 10000, France
| | - Claire David
- Troyes Hospital: Gynecology and Obstetrics Service, 101 Avenue Anatole France, Troyes 10000, France
| | - Jan Chrusciel
- Troyes Hospital: Public Health and Performance Hub, Clinical Care Research, 101 Avenue Anatole France, Troyes 10000, France
| | - Amjad Kattini
- Troyes Hospital: Gynecology and Obstetrics Service, 101 Avenue Anatole France, Troyes 10000, France
| | - Stéphane Sanchez
- Troyes Hospital: Public Health and Performance Hub, Clinical Care Research, 101 Avenue Anatole France, Troyes 10000, France
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12
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Marquet M, Blanc J, D'Ercole C, Carcopino X, Bretelle F, Netter A. Does a physiology-based interpretation of cardiotocography allow to dispense with second-line methods? A cross-sectional online survey. J Gynecol Obstet Hum Reprod 2023; 52:102570. [PMID: 36906143 DOI: 10.1016/j.jogoh.2023.102570] [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: 12/13/2022] [Revised: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 03/11/2023]
Abstract
CONTEXT Second line methods are used to help obstetricians to identify abnormalities that reflect fetal acidosis. Since the use of a new technique of cardiotocography (CTG) interpretation based on the pathophysiology of the fetal period, the use of second-line tests has been questioned. OBJECTIVE To evaluate the impact of specific training in CTG physiology-based interpretation on professional attitudes towards the use of second-line methods. METHODS This cross-sectional study included 57 French obstetricians divided into two groups: the trained group (obstetricians who had already participated in a training course in physiology-based interpretation of CTG) and the control group. Ten medical records of patients who had abnormal CTG tracings and underwent fetal blood sampling pH measurement during labour were presented to the participants. They were given three choices: use a second-line method, continue labour without using second-line method, or perform a caesarean section. The main outcome measures was the median number of decisions to use second-line method. RESULTS Forty participants were included in the trained group and 17 in the control group. The median number of recourses to second-line method was significantly inferior for the trained group (4/10 second-line methods) than for the control group (6/10, p=0.040). Regarding the 4 records for which a caesarean section was the real outcome, the median number of decisions of continuing labour was significantly superior in the trained group than in the control group (p=0.032). CONCLUSIONS Participation in a training course in physiology-based interpretation of CTG could be associated with a less frequent use of second-line method at the cost of more frequently continuing labour with the risk compromising fetal and maternal well-being. Additional studies are required to determine whether this change in attitude is safe for the fetal well-being.
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Affiliation(s)
- Manon Marquet
- Department of Gynecology and Obstetrics, AP-HM, Assistance Publique-Hôpitaux de Marseille, Marseille, France; EA 3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, Marseille, France.
| | - Julie Blanc
- Department of Gynecology and Obstetrics, AP-HM, Assistance Publique-Hôpitaux de Marseille, Marseille, France; EA 3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, Marseille, France
| | - Claude D'Ercole
- Department of Gynecology and Obstetrics, AP-HM, Assistance Publique-Hôpitaux de Marseille, Marseille, France; EA 3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, Marseille, France
| | - Xavier Carcopino
- Department of Gynecology and Obstetrics, AP-HM, Assistance Publique-Hôpitaux de Marseille, Marseille, France; Institut Méditerranéen de Biodiversité et d'Écologie Marine et Continentale (IMBE), Aix Marseille University, CNRS, IRD, Avignon University, Marseille, France
| | - Florence Bretelle
- Department of Gynecology and Obstetrics, AP-HM, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Antoine Netter
- Department of Gynecology and Obstetrics, AP-HM, Assistance Publique-Hôpitaux de Marseille, Marseille, France; Institut Méditerranéen de Biodiversité et d'Écologie Marine et Continentale (IMBE), Aix Marseille University, CNRS, IRD, Avignon University, Marseille, France
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13
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Lear CA, Georgieva A, Beacom MJ, Wassink G, Dhillon SK, Lear BA, Mills OJ, Westgate JA, Bennet L, Gunn AJ. Fetal heart rate responses in chronic hypoxaemia with superimposed repeated hypoxaemia consistent with early labour: a controlled study in fetal sheep. BJOG 2023. [PMID: 36808862 DOI: 10.1111/1471-0528.17425] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/30/2023] [Accepted: 02/09/2023] [Indexed: 02/20/2023]
Abstract
OBJECTIVE Deceleration area (DA) and capacity (DC) of the fetal heart rate can help predict risk of intrapartum fetal compromise. However, their predictive value in higher risk pregnancies is unclear. We investigated whether they can predict the onset of hypotension during brief hypoxaemia repeated at a rate consistent with early labour in fetal sheep with pre-existing hypoxaemia. DESIGN Prospective, controlled study. SETTING Laboratory. SAMPLE Chronically instrumented, unanaesthetised near-term fetal sheep. METHODS One-minute complete umbilical cord occlusions (UCOs) were performed every 5 minutes in fetal sheep with baseline pa O2 <17 mmHg (hypoxaemic, n = 8) and >17 mmHg (normoxic, n = 11) for 4 hours or until arterial pressure fell <20 mmHg. MAIN OUTCOME MEASURES DA, DC and arterial pressure. RESULTS Normoxic fetuses showed effective cardiovascular adaptation without hypotension and mild acidaemia (lowest arterial pressure 40.7 ± 2.8 mmHg, pH 7.35 ± 0.03). Hypoxaemic fetuses developed hypotension (lowest arterial pressure 20.8 ± 1.9 mmHg, P < 0.001) and acidaemia (final pH 7.07 ± 0.05). In hypoxaemic fetuses, decelerations showed faster falls in FHR over the first 40 seconds of UCOs but the final deceleration depth was not different to normoxic fetuses. DC was modestly higher in hypoxaemic fetuses during the penultimate (P = 0.04) and final (P = 0.012) 20 minutes of UCOs. DA was not different between groups. CONCLUSION Chronically hypoxaemic fetuses had early onset of cardiovascular compromise during labour-like brief repeated UCOs. DA was unable to identify developing hypotension in this setting, while DC only showed modest differences between groups. These findings highlight that DA and DC thresholds need to be adjusted for antenatal risk factors, potentially limiting their clinical utility.
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Affiliation(s)
- C A Lear
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - A Georgieva
- Nuffield Department of Women's and Reproductive Health, The John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - M J Beacom
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - G Wassink
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - S K Dhillon
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - B A Lear
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - O J Mills
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - J A Westgate
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
| | - L Bennet
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - A J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Starship Children's Hospital, Auckland, New Zealand
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14
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Tarvonen MJ, Lear CA, Andersson S, Gunn AJ, Teramo KA. Increased variability of fetal heart rate during labour: a review of preclinical and clinical studies. BJOG 2022; 129:2070-2081. [PMID: 35596699 PMCID: PMC9796294 DOI: 10.1111/1471-0528.17234] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/02/2022] [Accepted: 05/16/2022] [Indexed: 01/01/2023]
Abstract
Increased fetal heart rate variability (FHRV) in intrapartum cardiotocographic recording has been variably defined and poorly understood, limiting its clinical utility. Both preclinical (animal) and clinical (human) evidence support that increased FHRV is observed in the early stage of intrapartum fetal hypoxaemia but can also be observed in a subset of fetuses during the preterminal stage of repeated hypoxaemia. This review of available evidence provides data and expert opinion on the pathophysiology of increased FHRV, its clinical significance and a stepwise approach regarding the management of this pattern, and propose recommendations for standardisation of related terminology.
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Affiliation(s)
- Mikko J. Tarvonen
- Department of Obstetrics and GynaecologyUniversity of Helsinki, and Helsinki University HospitalHelsinkiFinland
| | - Christopher A. Lear
- Fetal Physiology and Neuroscience GroupDepartment of PhysiologyUniversity of AucklandAucklandNew Zealand
| | - Sture Andersson
- Children’s Hospital, Paediatric Research CentreUniversity of Helsinki, and Helsinki University HospitalHelsinkiFinland
| | - Alistair J. Gunn
- Fetal Physiology and Neuroscience GroupDepartment of PhysiologyUniversity of AucklandAucklandNew Zealand
| | - Kari A. Teramo
- Department of Obstetrics and GynaecologyUniversity of Helsinki, and Helsinki University HospitalHelsinkiFinland
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15
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Schifrin BS, Koos BJ, Cohen WR, Soliman M. Approaches to Preventing Intrapartum Fetal Injury. Front Pediatr 2022; 10:915344. [PMID: 36210941 PMCID: PMC9537758 DOI: 10.3389/fped.2022.915344] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/21/2022] [Indexed: 12/05/2022] Open
Abstract
Electronic fetal monitoring (EFM) was introduced into obstetric practice in 1970 as a test to identify early deterioration of fetal acid-base balance in the expectation that prompt intervention ("rescue") would reduce neonatal morbidity and mortality. Clinical trials using a variety of visual or computer-based classifications and algorithms for intervention have failed repeatedly to demonstrate improved immediate or long-term outcomes with this technique, which has, however, contributed to an increased rate of operative deliveries (deemed "unnecessary"). In this review, we discuss the limitations of current classifications of FHR patterns and management guidelines based on them. We argue that these clinical and computer-based formulations pay too much attention to the detection of systemic fetal acidosis/hypoxia and too little attention not only to the pathophysiology of FHR patterns but to the provenance of fetal neurological injury and to the relationship of intrapartum injury to the condition of the newborn. Although they do not reliably predict fetal acidosis, FHR patterns, properly interpreted in the context of the clinical circumstances, do reliably identify fetal neurological integrity (behavior) and are a biomarker of fetal neurological injury (separate from asphyxia). They provide insight into the mechanisms and trajectory (evolution) of any hypoxic or ischemic threat to the fetus and have particular promise in signaling preventive measures (1) to enhance the outcome, (2) to reduce the frequency of "abnormal" FHR patterns that require urgent intervention, and (3) to inform the decision to provide neuroprotection to the newborn.
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Affiliation(s)
- Barry S. Schifrin
- Department of Obstetrics and Gynecology, Western University of Health Sciences, Pomona, CA, United States
| | - Brian J. Koos
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, Los Angeles, CA, United States
| | - Wayne R. Cohen
- Department of Obstetrics and Gynecology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Mohamed Soliman
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, Los Angeles, CA, United States
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16
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Is It Time to Redefine Fetal Decelerations in Cardiotocography? J Pers Med 2022; 12:jpm12101552. [PMID: 36294689 PMCID: PMC9605652 DOI: 10.3390/jpm12101552] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/13/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022] Open
Abstract
Historically, fetal heart rate (FHR) decelerations were classified into “early”, “late”, and “variable” based on their relationship with uterine contractions. So far, three different putative etiologies were taken for granted. Recently, this belief, passed down through generations of birth attendants, has been questioned by physiologists. This narrative review aimed to assess the evidence on pathophysiology behind intrapartum FHR decelerations. This narrative review is based on information sourced from online peer-reviewed articles databases and recommendations from the major scientific societies in the field of obstetrics. Searches were performed in MEDLINE/PubMed, EMBASE, and Scopus and selection criteria included studies in animals and humans, where the physiology behind FHR decelerations was explored. The greater affinity for oxygen of fetal hemoglobin than the maternal, the unicity of fetal circulation, and the high anaerobic reserve of the myocardium, ensure adequate oxygenation to the fetus, under basal conditions. During acute hypoxic stress the efficiency of these mechanisms are increased because of the peripheral chemoreflex. This reflex, activated at each uterine contraction, is characterized by the simultaneous activation of two neural arms: the parasympathetic arm, which reduces the myocardial consumption of oxygen by decreasing the FHR and the sympathetic component, which promotes an intense peripheric vasoconstriction, thus centralizing the fetal blood volume. This review summarizes the evidence supporting the hypoxic origin of FHR decelerations, therefore archiving the historical belief that FHR decelerations have different etiologies, according to their shape and relationship with uterine contractions. The present review suggests that it is time to welcome the new scientific evidence and to update the CTG classification systems.
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17
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Lovers AAK, Ugwumadu A, Georgieva A. Cardiotocography and Clinical Risk Factors in Early Term Labor: A Retrospective Cohort Study Using Computerized Analysis With Oxford System. Front Pediatr 2022; 10:784439. [PMID: 35372157 PMCID: PMC8966702 DOI: 10.3389/fped.2022.784439] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/14/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The role of cardiotocography (CTG) in fetal risk assessment around the beginning of term labor is controversial. We used routinely collected clinical data in a large tertiary hospital to investigate whether infants with "severe compromise" at birth exhibited fetal heart rate abnormalities in their first-hour CTGs and/or other clinical risks, recorded as per routine care. Materials and Methods Retrospective data from 27,927 parturitions (single UK tertiary site, 2001-2010) were analyzed. Cases were included if the pregnancy was singleton, ≥36 weeks' gestation, cephalic presentation, and if they had routine intrapartum CTG as per clinical care. Cases with congenital abnormalities, planned cesarean section (CS), or CS for reasons other than "presumed fetal compromise" were excluded. We analyzed first-hour intrapartum CTG recordings, using intrapartum Oxford System (OxSys) computer-based algorithms. To reflect the effect of routine clinical care, the data was stratified into three exclusive groups: infants delivered by CS for "presumed fetal compromise" within 2 h of starting the CTG (Emergency CS, n = 113); between 2 and 5 h of starting the CTG (Urgent CS, n = 203); and the rest of deliveries (Others, n = 27,611). First-hour CTG and clinical characteristics were compared between the groups, sub-divided to those with and without severe compromise: a composite outcome of stillbirth, neonatal death, neonatal seizures, encephalopathy, resuscitation followed by ≥48 h in neonatal intensive care unit. Two-sample t-test, X2 test, and Fisher's exact test were used for analysis. Results Compared to babies without severe compromise, those with compromise had significantly higher proportion of cases with baseline fetal heart rate ≥150 bpm; non-reactive trace; reduced long-term and short-term variability; decelerative capacity; and no accelerations in the first-hour CTG across all groups. Prolonged decelerations(≥3 min) were also more common. Thick meconium and small for gestational age were consistently more common in compromised infants across all groups. There was more often thick meconium, maternal fever ≥38 C, sentinel events, and other clinical risk factors in the Emergency CS and Urgent CS compared to the Others group. Conclusion A proportion of infants born with severe compromise had significantly different first-hour CTG features and clinical risk factors.
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Affiliation(s)
- Aimée A. K. Lovers
- Nuffield Department of Women's and Reproductive Health, Big Data Institute, University of Oxford, Oxford, United Kingdom
| | - Austin Ugwumadu
- Department of Obstetrics and Gynaecology, St George's, University of London, London, United Kingdom
| | - Antoniya Georgieva
- Nuffield Department of Women's and Reproductive Health, Big Data Institute, University of Oxford, Oxford, United Kingdom
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18
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Wilson DL, Fung AM, Skrzypek H, Pell G, Barnes M, Howard ME, Walker SP. Maternal sleep behaviours preceding fetal heart rate events on cardiotocography. J Physiol 2022; 600:1791-1806. [DOI: 10.1113/jp282528] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/17/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Danielle L. Wilson
- Institute for Breathing and Sleep, Austin Health Heidelberg Victoria Australia
- Department of Obstetrics and Gynaecology University of Melbourne Parkville Victoria Australia
| | - Alison M. Fung
- Mercy Perinatal Mercy Hospital for Women Heidelberg Victoria Australia
| | - Hannah Skrzypek
- Department of Obstetrics and Gynaecology University of Melbourne Parkville Victoria Australia
- Mercy Perinatal Mercy Hospital for Women Heidelberg Victoria Australia
| | - Gabrielle Pell
- Department of Obstetrics and Gynaecology University of Melbourne Parkville Victoria Australia
| | - Maree Barnes
- Institute for Breathing and Sleep, Austin Health Heidelberg Victoria Australia
- Department of Medicine University of Melbourne Parkville Victoria Australia
| | - Mark E. Howard
- Institute for Breathing and Sleep, Austin Health Heidelberg Victoria Australia
- Department of Medicine University of Melbourne Parkville Victoria Australia
| | - Susan P. Walker
- Department of Obstetrics and Gynaecology University of Melbourne Parkville Victoria Australia
- Mercy Perinatal Mercy Hospital for Women Heidelberg Victoria Australia
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19
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Tournier A, Beacom M, Westgate JA, Bennet L, Garabedian C, Ugwumadu A, Gunn AJ, Lear CA. Physiological control of fetal heart rate variability during labour: Implications and controversies. J Physiol 2021; 600:431-450. [PMID: 34951476 DOI: 10.1113/jp282276] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/25/2021] [Indexed: 11/08/2022] Open
Abstract
The interpretation of fetal heart rate (FHR) patterns is the only available method to continuously monitor fetal wellbeing during labour. One of the most important yet contentious aspects of the FHR pattern is changes in FHR variability (FHRV). Some clinical studies suggest that loss of FHRV during labour is a sign of fetal compromise so this is reflected in practice guidelines. Surprisingly, there is little systematic evidence to support this observation. In this review we methodically dissect the potential pathways controlling FHRV during labour-like hypoxaemia. Before labour, FHRV is controlled by the combined activity of the parasympathetic and sympathetic nervous systems, in part regulated by a complex interplay between fetal sleep state and behaviour. By contrast, preclinical studies using multiple autonomic blockades have now shown that sympathetic neural control of FHRV was potently suppressed between periods of labour-like hypoxaemia, and thus, that the parasympathetic system is the sole neural regulator of FHRV once FHR decelerations are present during labour. We further discuss the pattern of changes in FHRV during progressive fetal compromise and highlight potential biochemical, behavioural and clinical factors that may regulate parasympathetic-mediated FHRV during labour. Further studies are needed to investigate the regulators of parasympathetic activity to better understand the dynamic changes in FHRV and their true utility during labour. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alexane Tournier
- Department of Obstetrics, Universite de Lille, CHU Lille, ULR 2694 - METRICS, Lille, F 59000, France
| | - Michael Beacom
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Jenny A Westgate
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Charles Garabedian
- Department of Obstetrics, Universite de Lille, CHU Lille, ULR 2694 - METRICS, Lille, F 59000, France
| | - Austin Ugwumadu
- Department of Obstetrics and Gynaecology, St George's Hospital, St George's University of London, London, SW17 0RE, UK
| | - Alistair J Gunn
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Christopher A Lear
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
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20
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Tagin MA, Gunn AJ. Neonatal encephalopathy and potential lost opportunities: when the story fits, please cool. Arch Dis Child Fetal Neonatal Ed 2021; 106:458-459. [PMID: 33963006 DOI: 10.1136/archdischild-2021-321696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/20/2021] [Accepted: 04/27/2021] [Indexed: 11/03/2022]
Affiliation(s)
| | - A J Gunn
- Physiology and Paediatrics, University of Auckland, Auckland, New Zealand
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21
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Lear CA, Bennet L, Lear BA, Westgate JA, Gunn AJ. Reply to "Bezold-Jarisch reflex in the near-term fetus during labor: a matter of time". Am J Physiol Regul Integr Comp Physiol 2021; 320:R716-R718. [PMID: 33955788 DOI: 10.1152/ajpregu.00058.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Christopher A Lear
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Benjamin A Lear
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Jenny A Westgate
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
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22
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Wilson E, Dunn L, Beckmann M, Kumar S. Measuring the impact of cardiotocograph decision support software on neonatal outcomes: A propensity score-matched observational study. THE AUSTRALIAN & NEW ZEALAND JOURNAL OF OBSTETRICS & GYNAECOLOGY 2021; 61:876-881. [PMID: 33987831 DOI: 10.1111/ajo.13375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study follows the 2017 UK INFANT Collaborative Group RCT, which compared neonatal outcomes with and without the use of the INFANT cardiotocograph decision support system for over 46 000 patients in labour. The original trial failed to demonstrate a significant improvement to neonatal outcomes; however, the study design was subject to methodological critique. AIMS This Australian retrospective cohort study aimed to report perinatal outcomes before and after the introduction of INFANT decision support software for cardiotocograph use in labour. MATERIALS AND METHODS The study cohort was divided into two equivalent 18-month epochs, before and after the introduction of INFANT-Guardian® CTG decision support system. Propensity score matching analysis was undertaken to balance pre- and post-implementation groups by baseline covariates. The matched cohort included 11 154 public-funded women between November 2016 and 2019, with a singleton live fetus ≥34 + 0 weeks, being induced or in spontaneous labour. The main outcome measures were: a composite measure of serious adverse neonatal outcome comprising of one or more of: admission to intensive care nursery >48 h, Apgar <4 at 5 min, cord arterial pH <7.0, hypoxic ischaemic encephalopathy grade 2 or 3, therapeutic hypothermia, neonatal death. RESULTS The incidence of the composite primary outcome was significantly lower following implementation of INFANT (0.57% vs. 1.00%; OR 0.57, 95%CI 0.37-0.88; P = 0.01). A significant reduction in nursery admission >48 h was also observed (0.05% vs. 0.30%; OR 0.18, 95%CI 0.05-0.60; P = 0.002). CONCLUSIONS INFANT software is associated with a reduction in serious adverse neonatal outcomes, without increasing the rate of operative delivery.
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Affiliation(s)
- Emily Wilson
- Mater Mothers' Hospital, South Brisbane, Queensland, Australia
| | - Liam Dunn
- Mater Research Institute-University of Queensland, South Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Michael Beckmann
- Mater Mothers' Hospital, South Brisbane, Queensland, Australia.,Mater Research Institute-University of Queensland, South Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Sailesh Kumar
- Mater Mothers' Hospital, South Brisbane, Queensland, Australia.,Mater Research Institute-University of Queensland, South Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
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23
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Georgieva A, Lear CA, Westgate JA, Kasai M, Miyagi E, Ikeda T, Gunn AJ, Bennet L. Deceleration area and capacity during labour-like umbilical cord occlusions identify evolving hypotension: a controlled study in fetal sheep. BJOG 2021; 128:1433-1442. [PMID: 33369871 DOI: 10.1111/1471-0528.16638] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Cardiotocography is widely used to assess fetal well-being during labour. The positive predictive value of current clinical algorithms to identify hypoxia-ischaemia is poor. In experimental studies, fetal hypotension is the strongest predictor of hypoxic-ischaemic injury. Cohort studies suggest that deceleration area and deceleration capacity of the fetal heart rate trace correlate with fetal acidaemia, but it is not known whether they are indices of fetal arterial hypotension. DESIGN Prospective, controlled study. SETTING Laboratory. SAMPLE Near-term fetal sheep. METHODS One minute of complete umbilical cord occlusions (UCOs) every 5 minutes (1:5 min, n = 6) or every 2.5 minutes (1:2.5 min, n = 12) for 4 hours or until fetal mean arterial blood pressure fell <20 mmHg. MAIN OUTCOME MEASURES Deceleration area and capacity during the UCO series were related to evolving hypotension. RESULTS The 1:5 min group developed only mild metabolic acidaemia, without hypotension. By contrast, 10/12 fetuses in the 1:2.5-min group progressively developed severe metabolic acidaemia and hypotension, reaching 16.8 ± 0.9 mmHg after 71.2 ± 6.7 UCOs. Deceleration area and capacity remained unchanged throughout the UCO series in the 1:5-min group, but progressively increased in the 1:2.5-min group. The severity of hypotension was closely correlated with both deceleration area (P < 0.001, R2 = 0.66, n = 18) and capacity (P < 0.001, R2 = 0.67, n = 18). Deceleration area and capacity predicted development of hypotension at a median of 103 and 123 minutes before the final occlusion, respectively. CONCLUSIONS Both deceleration area and capacity were strongly associated with developing fetal hypotension, supporting their potential to improve identification of fetuses at risk of hypotension leading to hypoxic-ischaemic injury during labour. TWEETABLE ABSTRACT Deceleration area and capacity of fetal heart rate identify developing hypotension during labour-like hypoxia.
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Affiliation(s)
- A Georgieva
- Nuffield Department of Women's and Reproductive Health, The John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - C A Lear
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - J A Westgate
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - M Kasai
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,The Department of Obstetrics and Gynecology, Yokohama City University, Yokohama, Japan
| | - E Miyagi
- The Department of Obstetrics and Gynecology, Yokohama City University, Yokohama, Japan
| | - T Ikeda
- Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - A J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - L Bennet
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
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24
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Ghesquière L, De Jonckheere J, Storme L, Garabedian C. Measurement of fetal parasympathetic activity during labor: a new pathway for evaluation of fetal well-being? Am J Physiol Regul Integr Comp Physiol 2020; 320:R467-R468. [PMID: 33326344 DOI: 10.1152/ajpregu.00325.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- L Ghesquière
- Public Health Epidemiology and Quality of Care, University of Lille, CHU Lille, Lille, France.,Department of Obstetrics, CHU Lille, Lille, France
| | - J De Jonckheere
- Public Health Epidemiology and Quality of Care, University of Lille, CHU Lille, Lille, France.,CHU Lille, Lille, France
| | - L Storme
- Public Health Epidemiology and Quality of Care, University of Lille, CHU Lille, Lille, France.,Department of Neonatology, CHU Lille, Lille, France
| | - C Garabedian
- Public Health Epidemiology and Quality of Care, University of Lille, CHU Lille, Lille, France.,Department of Obstetrics, CHU Lille, Lille, France
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25
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Zhu LA, Blanc J, Heckenroth H, Peyronel C, Graesslin B, Marcot M, Tardieu S, Bretelle F. Fetal physiology cardiotocography training, a regional evaluation. J Gynecol Obstet Hum Reprod 2020; 50:102039. [PMID: 33316463 DOI: 10.1016/j.jogoh.2020.102039] [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: 10/05/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Cardiotocography (CTG) has its limits in detecting fetal acidosis and intrapartum asphyxia. Our aim was to evaluate a CTG training programme based on fetal physiology in the Mediterranean perinatal network. METHODS Professionals from 41 maternity units of the Mediterranean network were invited to participate in a CTG masterclass based on fetal physiology in March 2019 and October 2019. They were asked to react to three practical cases by a physiological approach before the training course (T0), one month after (T1) and six to seven months after (T2). The mean scores were compared by using a mixed model including lapse of time to evaluation, profession of participants and level of the maternity unit as fixed effects. RESULTS A total of 248 professionals from 32 maternity units finally participated in the organizational audit. By using a mixed model, we found a significant improvement of the mean score at T1=6.44/10 compared to T0=4.97/10 (p<0.0001), and a significant improvement of the mean score obtained at T2=6.17/10 compared to T0 (p<0.0001). T2 scores were not significantly different from T1 scores (p=0.143). DISCUSSION A CTG training programme based on fetal physiology showed a significant improvement in the professionals' interpretation of CTG at short term and stable results at long term. Continuing medical education could help maintain and improve knowledge to ensure neonatal safety.
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Affiliation(s)
- Li-Anne Zhu
- Department of Obstetrics and Gynaecology, Conception Hospital, Assistance Publique des Hôpitaux de Marseille (AP-HM), Aix Marseille Université, Boulevard Baille, 13005, Marseille, France.
| | - Julie Blanc
- Department of Obstetrics and Gynaecology, North Hospital, Assistance Publique des Hôpitaux de Marseille (AP-HM), Aix Marseille Université, Chemin des Bourrely, 13015, Marseille, France; EA 3279, CEReSS, Health Service Research and Quality of Life Centre, Aix-Marseille University, Marseille, France.
| | - Hélène Heckenroth
- Department of Obstetrics and Gynaecology, Conception Hospital, Assistance Publique des Hôpitaux de Marseille (AP-HM), Aix Marseille Université, France.
| | - Caroline Peyronel
- Department of Obstetrics and Gynaecology, La Ciotat Hospital, 70 Boulevard Alphonse de Lamartine, 13600, La Ciotat, France.
| | - Blanche Graesslin
- Clinical Consultant for Neoventa and Midwife, Department of Obstetrics and Gynaecology, Alix de Champagne Maternity, 45 Rue Cognacq Jay, Hôpital Maison Blanche, Reims, France.
| | | | - Sophie Tardieu
- Department of Public Health, Conception Hospital, Assistance Publique des Hôpitaux de Marseille (AP-HM), Aix Marseille Université, Boulevard Baille, 13005, Marseille, France.
| | - Florence Bretelle
- Department of Obstetrics and Gynaecology, Conception Hospital, Assistance Publique des Hôpitaux de Marseille (AP-HM), Aix Marseille Université, Prenatal Diagnosis Timone Conception, IHU, IRD, 13005, Marseille, France; Unité de Recherche sur les Maladies Infectieuses Tropicales et Emergentes, UM63, CNRS, 7278 IRD 198, INSERM 1095, Marseille, France.
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26
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Lear CA, Beacom MJ, Kasai M, Westgate JA, Galinsky R, Magawa S, Miyagi E, Ikeda T, Bennet L, Gunn AJ. Reply to the "Letter to the Editor: Mind the gap: epistemology of heart rate variability". Am J Physiol Regul Integr Comp Physiol 2020; 319:R345-R346. [PMID: 32845174 DOI: 10.1152/ajpregu.00208.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Christopher A Lear
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Michael J Beacom
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Michi Kasai
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynecology, Yokohama City University, Yokohama, Japan
| | - Jenny A Westgate
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Shoichi Magawa
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Etsuko Miyagi
- Department of Obstetrics and Gynecology, Yokohama City University, Yokohama, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Laura Bennet
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
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27
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Lear CA, Westgate JA, Kasai M, Beacom MJ, Maeda Y, Magawa S, Miyagi E, Ikeda T, Bennet L, Gunn AJ. Parasympathetic activity is the key regulator of heart rate variability between decelerations during brief repeated umbilical cord occlusions in fetal sheep. Am J Physiol Regul Integr Comp Physiol 2020; 319:R541-R550. [PMID: 32877241 DOI: 10.1152/ajpregu.00186.2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Fetal heart rate variability (FHRV) is a widely used index of intrapartum well being. Both arms of the autonomic system regulate FHRV under normoxic conditions in the antenatal period. However, autonomic control of FHRV during labor when the fetus is exposed to repeated, brief hypoxemia during uterine contractions is poorly understood. We have previously shown that the sympathetic nervous system (SNS) does not regulate FHRV during labor-like hypoxia. We therefore investigated the hypothesis that the parasympathetic system is the main mediator of intrapartum FHRV. Twenty-six chronically instrumented fetal sheep at 0.85 of gestation received either bilateral cervical vagotomy (n = 7), atropine sulfate (n = 7), or sham treatment (control, n = 12), followed by three 1-min complete umbilical cord occlusions (UCOs) separated by 4-min reperfusion periods. Parasympathetic blockade reduced three measures of FHRV before UCOs (all P < 0.01). Between UCOs, atropine and vagotomy were associated with marked tachycardia (both P < 0.005), suppressed measures of FHRV (all P < 0.01), and abolished FHRV on visual inspection compared with the control group. Tachycardia in the atropine and vagotomy groups resolved over the first 10 min after the final UCO, in association with evidence that the SNS contribution to FHRV progressively returned during this time. Our findings support that SNS control of FHRV is acutely suppressed for at least 4 min after a deep intrapartum deceleration and takes 5-10 min to recover. The parasympathetic system is therefore likely to be the key mediator of FHRV once frequent FHR decelerations are established during labor.
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Affiliation(s)
- Christopher A Lear
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Jenny A Westgate
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Michi Kasai
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynecology, Yokohama City University, Yokohama, Japan
| | - Michael J Beacom
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Yoshiki Maeda
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Shoichi Magawa
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Etsuko Miyagi
- Department of Obstetrics and Gynecology, Yokohama City University, Yokohama, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Laura Bennet
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
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28
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Lear CA, Kasai M, Booth LC, Drury PP, Davidson JO, Maeda Y, Magawa S, Miyagi E, Ikeda T, Westgate JA, Bennet L, Gunn AJ. Peripheral chemoreflex control of fetal heart rate decelerations overwhelms the baroreflex during brief umbilical cord occlusions in fetal sheep. J Physiol 2020; 598:4523-4536. [PMID: 32705685 DOI: 10.1113/jp279573] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 07/13/2020] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS The majority of intrapartum decelerations are widely believed to be mediated by the baroreflex secondary to brief umbilical cord occlusions (UCOs) but this remains unproven. We examined the responses to brief-UCOs in fetal sheep and compared these to a phenylephrine-stimulated baroreflex in a separate cohort. A further cohort was instrumented with near-infrared spectroscopy to measure cerebral oxygenation during UCO. The first 3-4 s of the brief-UCOs were consistent with a baroreflex, and associated with a minor fall in fetal heart rate (FHR). Thereafter, the remainder of the FHR decelerations were highly consistent with the peripheral chemoreflex. The baroreflex is not sufficient to produce deep, rapid decelerations characteristic of variable decelerations and it is therefore likely to be a minor contributor to intrapartum decelerations. ABSTRACT Fetal heart rate (FHR) monitoring is widely used to assess fetal wellbeing during labour, yet the physiology underlying FHR patterns remains incompletely understood. The baroreflex is widely believed to mediate brief intrapartum decelerations, but evidence supporting this theory is lacking. We therefore investigated the physiological changes in near-term fetal sheep during brief repeated umbilical cord occlusions (brief-UCOs, n = 15). We compared this to separate cohorts that underwent a phenylephrine challenge to stimulate the baroreflex (n = 9) or were instrumented with near-infrared spectroscopy and underwent prolonged 15-min complete UCO (prolonged-UCO, n = 9). The first 3-4 s of brief-UCOs were associated with hypertension (P = 0.000), a fall in FHR by 9.7-16.9 bpm (P = 0.002). The FHR/MAP relationship during this time was consistent with that observed during a phenylephrine-induced baroreflex. At 4-5 s, the FHR/MAP relationship began to deviate from the phenylephrine baroreflex curve as FHR fell independently of MAP until its nadir in association with intense peripheral vasoconstriction (P = 0.000). During prolonged-UCO, cerebral oxygenation remained steady until 4 s after the start of prolonged-UCO, and then began to fall (P = 0.000). FHR and cerebral oxygenation then fell in parallel until the FHR nadir. In conclusion, the baroreflex has a minor role in mediating the first 3-4 s of FHR decelerations during complete UCO, but thereafter the peripheral chemoreflex is the dominant mediator. Overall, the baroreflex is neither necessary nor sufficient to produce deep, rapid decelerations characteristic of variable decelerations; it is therefore likely to be a minor contributor to intrapartum decelerations.
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Affiliation(s)
- Christopher A Lear
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Michi Kasai
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynecology, Yokohama City University, Yokohama, Japan
| | - Lindsea C Booth
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Paul P Drury
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Yoshiki Maeda
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Shoichi Magawa
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Etsuko Miyagi
- Department of Obstetrics and Gynecology, Yokohama City University, Yokohama, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Jenny A Westgate
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
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29
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Lear CA, Beacom MJ, Kasai M, Westgate JA, Galinsky R, Magawa S, Miyagi E, Ikeda T, Bennet L, Gunn AJ. Circulating catecholamines partially regulate T-wave morphology but not heart rate variability during repeated umbilical cord occlusions in fetal sheep. Am J Physiol Regul Integr Comp Physiol 2020; 319:R123-R131. [PMID: 32491938 DOI: 10.1152/ajpregu.00026.2020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Fetal heart rate (FHR) variability (FHRV) and ST segment morphology are potential clinical indices of fetal well-being during labor. β-Adrenergic stimulation by circulating catecholamines has been hypothesized to contribute to both FHRV and ST segment morphology during labor, but this has not been tested during brief repeated fetal hypoxemia that is characteristic of labor. Near-term fetal sheep (0.85 gestation) received propranolol (β-adrenergic blockade; n = 10) or saline (n = 7) 30 min before being exposed to three 2-min complete umbilical cord occlusions (UCOs) separated by 3-min reperfusions. T/QRS ratio was calculated throughout UCOs and reperfusion periods, and measures of FHRV (RMSSD, SDNN, and STV) were calculated between UCOs. During the baseline period, before the start of UCOs, propranolol was associated with reduced FHR, SDNN, and STV but did not affect RMSSD or T/QRS ratio. UCOs were associated with rapid FHR decelerations and increased T/QRS ratio; propranolol significantly reduced FHR during UCOs and was associated with a slower rise in T/QRS ratio during the first UCOs, without affecting the maximal rise or T/QRS ratio during the second and third UCO. Between UCOs propranolol reduced FHR and T/QRS ratio but did not affect any measure of FHRV. These data demonstrate that circulating catecholamines do not contribute to FHRV during labor-like hypoxemia. Furthermore, circulating catecholamines did not contribute to the major rise in T/QRS ratio during labor-like hypoxemia but may regulate T/QRS ratio between brief hypoxemia.
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Affiliation(s)
- Christopher A Lear
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Michael J Beacom
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Michi Kasai
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynecology, Yokohama City University, Yokohama, Japan
| | - Jenny A Westgate
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Shoichi Magawa
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Etsuko Miyagi
- Department of Obstetrics and Gynecology, Yokohama City University, Yokohama, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Laura Bennet
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
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30
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Georgieva A, Abry P, Chudáček V, Djurić PM, Frasch MG, Kok R, Lear CA, Lemmens SN, Nunes I, Papageorghiou AT, Quirk GJ, Redman CWG, Schifrin B, Spilka J, Ugwumadu A, Vullings R. Computer-based intrapartum fetal monitoring and beyond: A review of the 2nd Workshop on Signal Processing and Monitoring in Labor (October 2017, Oxford, UK). Acta Obstet Gynecol Scand 2019; 98:1207-1217. [PMID: 31081113 DOI: 10.1111/aogs.13639] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/08/2019] [Indexed: 12/30/2022]
Abstract
The second Signal Processing and Monitoring in Labor workshop gathered researchers who utilize promising new research strategies and initiatives to tackle the challenges of intrapartum fetal monitoring. The workshop included a series of lectures and discussions focusing on: new algorithms and techniques for cardiotocogoraphy (CTG) and electrocardiogram acquisition and analyses; the results of a CTG evaluation challenge comparing state-of-the-art computerized methods and visual interpretation for the detection of arterial cord pH <7.05 at birth; the lack of consensus about the role of intrapartum acidemia in the etiology of fetal brain injury; the differences between methods for CTG analysis "mimicking" expert clinicians and those derived from "data-driven" analyses; a critical review of the results from two randomized controlled trials testing the former in clinical practice; and relevant insights from modern physiology-based studies. We concluded that the automated algorithms performed comparably to each other and to clinical assessment of the CTG. However, the sensitivity and specificity urgently need to be improved (both computerized and visual assessment). Data-driven CTG evaluation requires further work with large multicenter datasets based on well-defined labor outcomes. And before first tests in the clinic, there are important lessons to be learnt from clinical trials that tested automated algorithms mimicking expert CTG interpretation. In addition, transabdominal fetal electrocardiogram monitoring provides reliable CTG traces and variability estimates; and fetal electrocardiogram waveform analysis is subject to promising new research. There is a clear need for close collaboration between computing and clinical experts. We believe that progress will be possible with multidisciplinary collaborative research.
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Affiliation(s)
- Antoniya Georgieva
- Nuffield Department of Women's and Reproductive Health, Big Data Institute, University of Oxford, Oxford, UK
| | - Patrice Abry
- University of Lyon, Ens de Lyon, University Claude Bernard, CNRS, Laboratoire de Physique, Lyon, France
| | - Václav Chudáček
- CIIRC, Czech Technical University in Prague, Prague, Czech Republic
| | - Petar M Djurić
- Electrical and Computer Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Martin G Frasch
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - René Kok
- Nemo Healthcare, Veldhoven, the Netherlands
| | | | | | - Inês Nunes
- Department of Obstetrics and Gynecology, Centro Materno-Infantil do Norte-Centro Hospitalar do Porto, Instituto de Ciências Biomédicas Abel Salazar, Centro de Investigação em Tecnologias e Serviços de Saúde, Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
| | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Gerald J Quirk
- Department of Obstetrics and Gynecology at Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Christopher W G Redman
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | | | - Jiri Spilka
- CIIRC, Czech Technical University in Prague, Prague, Czech Republic
| | - Austin Ugwumadu
- Department of Obstetrics & Gynecology, St. George's University of London, London, UK
| | - Rik Vullings
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
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31
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Zhao Z, Zhang Y, Comert Z, Deng Y. Computer-Aided Diagnosis System of Fetal Hypoxia Incorporating Recurrence Plot With Convolutional Neural Network. Front Physiol 2019; 10:255. [PMID: 30914973 PMCID: PMC6422985 DOI: 10.3389/fphys.2019.00255] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 02/25/2019] [Indexed: 02/05/2023] Open
Abstract
Background: Electronic fetal monitoring (EFM) is widely applied as a routine diagnostic tool by clinicians using fetal heart rate (FHR) signals to prevent fetal hypoxia. However, visual interpretation of the FHR usually leads to significant inter-observer and intra-observer variability, and false positives become the main cause of unnecessary cesarean sections. Goal: The main aim of this study was to ensure a novel, consistent, robust, and effective model for fetal hypoxia detection. Methods: In this work, we proposed a novel computer-aided diagnosis (CAD) system integrated with an advanced deep learning (DL) algorithm. For a 1-dimensional preprocessed FHR signal, the 2-dimensional image was transformed using recurrence plot (RP), which is considered to greatly capture the non-linear characteristics. The ultimate image dataset was enriched by changing several parameters of the RP and was then used to feed the convolutional neural network (CNN). Compared to conventional machine learning (ML) methods, a CNN can self-learn useful features from the input data and does not perform complex manual feature engineering (i.e., feature extraction and selection). Results: Finally, according to the optimization experiment, the CNN model obtained the average performance using optimal configuration across 10-fold: accuracy = 98.69%, sensitivity = 99.29%, specificity = 98.10%, and area under the curve = 98.70%. Conclusion: To the best of our knowledge, this approached achieved better classification performance in predicting fetal hypoxia using FHR signals compared to the other state-of-the-art works. Significance: In summary, the satisfied result proved the effectiveness of our proposed CAD system for assisting obstetricians making objective and accurate medical decisions based on RP and powerful CNN algorithm.
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Affiliation(s)
- Zhidong Zhao
- Hangdian Smart City Research Center of Zhejiang Province, Hangzhou Dianzi University, Hangzhou, China
| | - Yang Zhang
- School of Communication Engineering, Hangzhou Dianzi University, Hangzhou, China
| | - Zafer Comert
- Department of Computer Engineering, Bitlis Eren University, Bitlis, Turkey
| | - Yanjun Deng
- College of Electronics and Information, Hangzhou Dianzi University, Hangzhou, China
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