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Marzbanrad F, Stroux L, Clifford GD. Cardiotocography and beyond: a review of one-dimensional Doppler ultrasound application in fetal monitoring. Physiol Meas 2018; 39:08TR01. [PMID: 30027897 PMCID: PMC6237616 DOI: 10.1088/1361-6579/aad4d1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
One-dimensional Doppler ultrasound (1D-DUS) provides a low-cost and simple method for acquiring a rich signal for use in cardiovascular screening. However, despite the use of 1D-DUS in cardiotocography (CTG) for decades, there are still challenges that limit the effectiveness of its users in reducing fetal and neonatal morbidities and mortalities. This is partly due to the noisy, transient, complex and nonstationary nature of the 1D-DUS signals. Current challenges also include lack of efficient signal quality metrics, insufficient signal processing techniques for extraction of fetal heart rate and other vital parameters with adequate temporal resolution, and lack of appropriate clinical decision support for CTG and Doppler interpretation. Moreover, the almost complete lack of open research in both hardware and software in this field, as well as commercial pressures to market the much more expensive and difficult to use Doppler imaging devices, has hampered innovation. This paper reviews the basics of fetal cardiac function, 1D-DUS signal generation and processing, its application in fetal monitoring and assessment of fetal development and wellbeing. It also provides recommendations for future development of signal processing and modeling approaches, to improve the application of 1D-DUS in fetal monitoring, as well as the need for annotated open databases.
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Affiliation(s)
- Faezeh Marzbanrad
- Department of Electrical and Computer Systems Engineering, Monash University, Clayton, VIC, Australia
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Stroux L, Redman CW, Georgieva A, Payne SJ, Clifford GD. Doppler-based fetal heart rate analysis markers for the detection of early intrauterine growth restriction. Acta Obstet Gynecol Scand 2017; 96:1322-1329. [PMID: 28862738 DOI: 10.1111/aogs.13228] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 08/25/2017] [Indexed: 12/27/2022]
Abstract
INTRODUCTION One indicator for fetal risk of mortality is intrauterine growth restriction (IUGR). Whether markers reflecting the impact of growth restriction on the cardiovascular system, computed from a Doppler-derived heart rate signal, would be suitable for its detection antenatally was studied. MATERIAL AND METHODS We used a cardiotocography archive of 1163 IUGR cases and 1163 healthy controls, matched for gestation and gender. We assessed the discriminative power of short-term variability and long-term variability of the fetal heart rate, computed over episodes of high and low variation aiming to separate growth-restricted fetuses from controls. Metrics characterizing the sleep state distribution within a trace were also considered for inclusion into an IUGR detection model. RESULTS Significant differences in the risk markers comparing growth-restricted with healthy fetuses were found. When used in a logistic regression classifier, their performance for identifying IUGR was considerably superior before 34 weeks of gestation. Long-term variability in active sleep was superior to short-term variability [area under the receiver operator curve (AUC) of 72% compared with 71%]. Most predictive was the number of minutes in high variation per hour (AUC of 75%). A multivariate IUGR prediction model improved the AUC to 76%. CONCLUSION We suggest that heart rate variability markers together with surrogate information on sleep states can contribute to the detection of early-onset IUGR.
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Affiliation(s)
- Lisa Stroux
- Institute of Biomedical Engineering, Department of Ethics approval to use this database was givenEngineering Science, University of Oxford, Oxford, UK
| | - Christopher W Redman
- Nuffield Department of Obstetrics & Gynecology, University of Oxford, Oxford, UK
| | - Antoniya Georgieva
- Nuffield Department of Obstetrics & Gynecology, University of Oxford, Oxford, UK
| | - Stephen J Payne
- Institute of Biomedical Engineering, Department of Ethics approval to use this database was givenEngineering Science, University of Oxford, Oxford, UK
| | - Gari D Clifford
- Departments of Biomedical Informatics and Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA, USA
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Kwon JY, Park IY. Fetal heart rate monitoring: from Doppler to computerized analysis. Obstet Gynecol Sci 2016; 59:79-84. [PMID: 27004196 PMCID: PMC4796090 DOI: 10.5468/ogs.2016.59.2.79] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 11/17/2015] [Accepted: 11/17/2015] [Indexed: 11/08/2022] Open
Abstract
The monitoring of fetal heart rate (FHR) status is an important method to check well-being of the baby during labor. Since the electronic FHR monitoring was introduced 40 years ago, it has been expected to be an innovative screening test to detect fetuses who are becoming hypoxic and who may benefit from cesarean delivery or operative vaginal delivery. However, several randomized controlled trials have failed to prove that electronic FHR monitoring had any benefit of reducing the perinatal mortality and morbidity. Also it is now clear that the FHR monitoring had high intra- and interobserver disagreements and increased the rate of cesarean delivery. Despite such limitations, the FHR monitoring is still one of the most important obstetric procedures in clinical practice, and the cardiotocogram is the most-used equipment. To supplement cardiotocogram, new methods of computerized FHR analysis and electrocardiogram have been developed, and several clinical researches have been currently performed. Computerized equipment makes us to analyze beat-to-beat variability and short term heart rate patterns. Furthermore, researches about multiparameters of FHR variability will be ongoing.
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Affiliation(s)
- Ji Young Kwon
- Department of Obstetrics and Gynecology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - In Yang Park
- Department of Obstetrics and Gynecology, The Catholic University of Korea College of Medicine, Seoul, Korea
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Tagliaferri S, Fanelli A, Esposito G, Esposito FG, Magenes G, Signorini MG, Campanile M, Martinelli P. Evaluation of the Acceleration and Deceleration Phase-Rectified Slope to Detect and Improve IUGR Clinical Management. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2015; 2015:236896. [PMID: 26779279 PMCID: PMC4687338 DOI: 10.1155/2015/236896] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 11/16/2015] [Accepted: 11/17/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study used a new method called Acceleration (or Deceleration) Phase-Rectified Slope, APRS (or DPRS) to analyze computerized Cardiotocographic (cCTG) traces in intrauterine growth restriction (IUGR), in order to calculate acceleration- and deceleration-related fluctuations of the fetal heart rate, and to enhance the prediction of neonatal outcome. METHOD Cardiotocograms from a population of 59 healthy and 61 IUGR fetuses from the 30th gestation week matched for gestational age were included. APRS and DPRS analysis was compared to the standard linear and nonlinear cCTG parameters. Statistical analysis was performed through the t-test, ANOVA test, Pearson correlation test and receiver operator characteristic (ROC) curves (p < 0, 05). RESULTS APRS and DPRS showed high performance to discriminate between Healthy and IUGR fetuses, according to gestational week. A linear correlation with the fetal pH at birth was found in IUGR. The area under the ROC curve was 0.865 for APRS and 0.900 for DPRS before the 34th gestation week. CONCLUSIONS APRS and DPRS could be useful in the identification and management of IUGR fetuses and in the prediction of the neonatal outcome, especially before the 34th week of gestation.
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Affiliation(s)
- Salvatore Tagliaferri
- Department of Obstetrical-Gynaecological and Urological Science and Reproductive Medicine, Federico II University, 5 Pansini Street, 80131 Naples, Italy
| | - Andrea Fanelli
- Computational Physiology and Clinical Inference Group, Research Laboratory of Electronics, Massachusetts Institute of Technology, 25 Carleton Street, Cambridge, MA 02139, USA
| | - Giuseppina Esposito
- Department of Obstetrical-Gynaecological and Urological Science and Reproductive Medicine, Federico II University, 5 Pansini Street, 80131 Naples, Italy
| | - Francesca Giovanna Esposito
- Department of Obstetrical-Gynaecological and Urological Science and Reproductive Medicine, Federico II University, 5 Pansini Street, 80131 Naples, Italy
| | - Giovanni Magenes
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, 5 Ferrata Street, 27100 Pavia, Italy
| | - Maria Gabriella Signorini
- Dipartimento di Elettronica, Informazione e Bioingegneria (DEIB), Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133 Milano, Italy
| | - Marta Campanile
- Department of Obstetrical-Gynaecological and Urological Science and Reproductive Medicine, Federico II University, 5 Pansini Street, 80131 Naples, Italy
| | - Pasquale Martinelli
- Department of Obstetrical-Gynaecological and Urological Science and Reproductive Medicine, Federico II University, 5 Pansini Street, 80131 Naples, Italy
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Abstract
AIM OF THE STUDY Analyzing velocimetric (umbilical artery, UA; ductus venosus, DV; middle cerebral artery, MCA) and computerized cardiotocographic (cCTG) (fetal heart rate, FHR; short term variability, STV; approximate entropy, ApEn) parameters in intrauterine growth restriction, IUGR, in order to detect early signs of fetal compromise. POPULATION STUDY: 375 pregnant women assisted from the 28th week of amenorrhea to delivery and monitored through cCTG and Doppler ultrasound investigation. The patients were divided into three groups according to the age of gestation at the time of delivery, before the 34th week, from 34th to 37th week, and after the 37th week. Data were analyzed in relation to the days before delivery and according to the physiology or pathology of velocimetry. Statistical analysis was performed through the t-test, chi-square test, and Pearson correlation test (P < 0.05). Our results evidenced an earlier alteration of UA, DV, and MCA. The analysis between cCTG and velocimetric parameters (the last distinguished into physiological and pathological values) suggests a possible relation between cCTG alterations and Doppler ones. The present study emphasizes the need for an antenatal testing in IUGR fetuses using multiple surveillance modalities to enhance prediction of neonatal outcome.
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Costa MD, Schnettler WT, Amorim-Costa C, Bernardes J, Costa A, Goldberger AL, Ayres-de-Campos D. Complexity-loss in fetal heart rate dynamics during labor as a potential biomarker of acidemia. Early Hum Dev 2014; 90:67-71. [PMID: 24290526 PMCID: PMC4077599 DOI: 10.1016/j.earlhumdev.2013.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 09/13/2013] [Accepted: 10/21/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Continuous fetal heart rate (FHR) monitoring remains central to intrapartum care. However, advances in signal analysis are needed to increase its accuracy in diagnosis of fetal hypoxia. AIMS To determine whether FHR complexity, an index of multiscale variability, is lower among fetuses born with low (≤7.05) versus higher pH values, and whether this measure can potentially be used to help discriminate the two groups. STUDY DESIGN Evaluation of a pre-existing database of sequentially acquired intrapartum FHR signals. SUBJECTS FHR tracings, obtained from a continuous scalp electrocardiogram during labor, were analyzed using the multiscale entropy (MSE) method in 148 singletons divided in two groups according to umbilical artery pH at birth: 141 fetuses with pH>7.05 and 7 with pH≤7.05. A complexity index derived from MSE analysis was calculated for each recording. RESULTS The complexity of FHR signals for the last two hours before delivery was significantly (p<0.004) higher for non-acidemic than for acidemic fetuses. The difference between the two groups remained significant (p<0.003) when FHR data from the last 30min before delivery were excluded. CONCLUSION Complexity of FHR signals, as measured by the MSE method, was significantly lower for acidemic than non-acidemic fetuses. These results are consistent with previous studies showing that decreased nonlinear complexity is a dynamical signature of disrupted physiologic control systems. This analytic approach may have discriminative value in FHR analysis.
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Affiliation(s)
- Madalena D. Costa
- Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA,The Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, USA,Corresponding author at: Beth Israel Deaconess Medical Center (GZ-431), 330 Brookline Ave., Boston, MA 02215, USA. (M.D. Costa)
| | - William T. Schnettler
- Department of Obstetrics and Gynecology, Division of Maternal–Fetal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Célia Amorim-Costa
- Department of Obstetrics and Gynecology, Faculty of Medicine, São João Hospital and Institute of Biomedical Engineering, University of Porto, Porto, Portugal
| | - João Bernardes
- Department of Obstetrics and Gynecology, Faculty of Medicine, São João Hospital and Institute of Biomedical Engineering, University of Porto, Porto, Portugal
| | - Antónia Costa
- Department of Obstetrics and Gynecology, Faculty of Medicine, São João Hospital and Institute of Biomedical Engineering, University of Porto, Porto, Portugal
| | - Ary L. Goldberger
- Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA,The Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, USA
| | - Diogo Ayres-de-Campos
- Department of Obstetrics and Gynecology, Faculty of Medicine, São João Hospital and Institute of Biomedical Engineering, University of Porto, Porto, Portugal
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Decker LM, Moraiti C, Stergiou N, Georgoulis AD. New insights into anterior cruciate ligament deficiency and reconstruction through the assessment of knee kinematic variability in terms of nonlinear dynamics. Knee Surg Sports Traumatol Arthrosc 2011; 19:1620-33. [PMID: 21445594 DOI: 10.1007/s00167-011-1484-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 03/15/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Injuries to the anterior cruciate ligament (ACL) occur frequently, particularly in young adult athletes, and represent the majority of the lesions of knee ligaments. Recent investigations suggest that the assessment of kinematic variability using measures of nonlinear dynamics can provide with important insights with respect to physiological and pathological states. The purpose of the present article was to critically review and synthesize the literature addressing ACL deficiency and reconstruction from a nonlinear dynamics standpoint. METHODS A literature search was carried out in the main medical databases for studies published between 1990 and 2010. RESULTS Seven studies investigated knee kinematic variability in ACL patients. Results provided support for the theory of "optimal movement variability". Practically, loss below optimal variability is associated with a more rigid and very repeatable movement pattern, as observed in the ACL-deficient knee. This is a state of low complexity and high predictability. On the other hand, increase beyond optimal variability is associated with a noisy and irregular movement pattern, as found in the ACL-reconstructed knee, regardless of which type of graft is used. This is a state of low complexity and low predictability. In both cases, the loss of optimal variability and the associated high complexity lead to an incapacity to respond appropriately to the environmental demands, thus providing an explanation for vulnerability to pathological changes following injury. CONCLUSION Subtle fluctuations that appear in knee kinematic patterns provide invaluable insight into the health of the neuromuscular function after ACL rupture and reconstruction. It is thus critical to explore them in longitudinal studies and utilize nonlinear measures as an important component of post-reconstruction medical assessment. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Leslie M Decker
- Nebraska Biomechanics Core Facility, University of Nebraska at Omaha, Omaha, NE 68182-0216, USA
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