1
|
Cheung KW, Bonet M, Frank KA, Oladapo OT, Hofmeyr GJ. Clinical algorithms for management of fetal heart rate abnormalities during labour. BJOG 2024; 131 Suppl 2:102-111. [PMID: 35415966 DOI: 10.1111/1471-0528.16731] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To construct algorithms with a sequential decision analysis pathway for monitoring of the fetal heart rate and managing fetal heart rate bradycardia, late decelerations and tachycardia during labour. POPULATION Low-risk pregnant women in labour with singleton cephalic term pregnancies. SETTING Institutional births in low- and middle-income countries. SEARCH STRATEGY We sought relevant published clinical algorithms, guidelines and randomised trials/reviews by searching the Cochrane Library, PubMed and Google on the terms: "fetal AND heart AND rate AND algorithm AND (labour OR intrapartum)", up to March 2020. CASE SCENARIOS The two scenarios included were fetal heart rate bradycardia or late decelerations (potentially related to uterine rupture, placental abruption, cord prolapse, maternal hypotension, uterine hyperstimulation or unexplained) and fetal heart rate tachycardia (potentially related to maternal hyperthermia, infection, dehydration or unexplained). The algorithms provide pathways for definition, assessment, diagnosis, interventions to correct the abnormalities and ongoing monitoring leading to mode of birth, and linking to other algorithms in the series. CONCLUSIONS The algorithms provide a framework for monitoring and managing fetal heart rate bradycardia, late decelerations and tachycardia during labour. We emphasise the inherent diagnostic inaccuracy of fetal heart rate monitoring, the tendency to over-diagnose fetal compromise, the need to consider fetal heart rate information in the context of other clinical features and the need to engage in informed, shared, family-centred decision-making. We note the need for further research on methods of fetal assessment during labour including clinical fetal arousal testing and the rapid biophysical profile test. TWEETABLE ABSTRACT Decision analysis algorithms for fetal bradycardia, late decelerations and tachycardia highlight diagnostic limitations.
Collapse
Affiliation(s)
- K W Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong City, Hong Kong SAR, China
| | - M Bonet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - K A Frank
- Department of Obstetrics and Gynaecology, University of the Witwatersrand, Johannesburg, South Africa
- University of Kwa-Zulu Natal, Pietermaritzburg, South Africa
| | - O T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - G J Hofmeyr
- Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana
- Effective Care Research Unit, University of the Witwatersrand and Water Sisulu University, Mthatha, South Africa
| |
Collapse
|
2
|
Shahshahan Z, Zarean E, Jahanfar S, Hedayat P. Comparison of Histological Chorioamnionitis in Pre-Term Delivery with and without Pre-Term Rupture of Membrane. Adv Biomed Res 2024; 13:33. [PMID: 39234438 PMCID: PMC11373726 DOI: 10.4103/abr.abr_300_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 05/17/2023] [Accepted: 05/20/2023] [Indexed: 09/06/2024] Open
Abstract
Background Histological chorioamnionitis (HCA) is a histologic response to intra-uterine inflammation that is usually confirmed by pathology examination after pre-term delivery and characterized by acute granulocyte infiltration into the fetal-maternal or fetal tissues. This study aimed to compare the HCA in pre-term delivery with and without pre-term rupture of membrane for assessment of its role on early neonatal outcomes and fetal heart rate patterns. Materials and Methods This case-control study was conducted on placenta, chorionamnion, and cord of 100 cases with and without pre-term rupture of membrane between 28 0/7 and 36 6/7 weeks delivered between March 2018 and February 2021. The kind of delivery, gestational age, neonatal intensive care unit admission, a 5 min Apgar score <7, and fetal heart rate patterns in two groups with and without HCA were assessed. Results The odds ratio (OR) for HCA was adjusted for fetal heart rate patterns, gestational age, and delivery mode (vaginal delivery or cesarean section). Vaginal delivery, gestational age, neonatal intensive care unit admission, and a 5 min Apgar score <7 were associated with HCA [OR: 2.4, 95% confidence interval (CI): 1.2-9.5, P < 0.05; OR: 0.8, 95% CI: 0.5-1.1, P < 0.05; OR: 1.1, 95% CI: 0.6-2.1, P < 0.05; and OR: 0.9, 95% CI: 0.7-1.3, P < 0.05), respectively. However, there were no specific fetal heart rate patterns associated with HCA. Conclusion Placental histology examination in pre-term infants with low Apgar scores may be useful to investigate the association between neonatal complications in pre-term delivery and asymptomatic chorioamnionitis.
Collapse
Affiliation(s)
- Zahra Shahshahan
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medicine, Isfahan, Iran
| | - Elahe Zarean
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medicine, Isfahan, Iran
| | - Samaneh Jahanfar
- Department of Obstetrics and Gynecology, Al-Zahra Hospital, Isfahan, Iran
| | - Pegah Hedayat
- Department of Pathology, School of Medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
3
|
Beaves M, Zoanetti N, Wallace EM, Palmer KR. Immediate and longer-term impacts of fetal surveillance education on workforce knowledge and cognitive skills. MEDEDPUBLISH 2023; 13:38. [PMID: 38779369 PMCID: PMC11109546 DOI: 10.12688/mep.19656.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 05/25/2024] Open
Abstract
Background: Following the development of the Royal Australian College of Obstetricians and Gynaecologists Intrapartum Fetal Surveillance Guideline in 2003, an education program was developed to support guideline implementation and clinical practice. It was intended that improved clinician knowledge, particularly of cardiotocography, would reduce rates of intrapartum fetal morbidity and mortality. The program contains a multiple-choice assessment, designed to assess fetal surveillance knowledge and the application of that knowledge. We used the results of this assessment over time to evaluate the impact of the education program on clinicians' fetal surveillance knowledge and interpretive skills, in the immediate and longer-term. Methods: We undertook a retrospective analysis of the assessment results for all participants in the Fetal Surveillance Education Program, between 2004 and 2018. Classical Test Theory and Rasch Item Response Theory analysis were used to evaluate the statistical reliability and quality of the assessment, and the measurement invariance or stability of the assessments over time. Clinicians' assessment scores were then reviewed by craft group and previous exposure to the program. Results: The results from 64,430, broadly similar assessments, showed that participation in the education program was associated with an immediate improvement in clinician performance in the assessment. Performance improvement was sustained for up to 18 months following participation in the program and recurrent participation was associated with progressive improvements. These trends were observed for all craft groups (consultant obstetricians, doctors in training, general practitioners, midwives, student midwives). Conclusions: These findings suggest that the Fetal Surveillance Education Program has improved clinician knowledge and the associated cognitive skills over time. The stable difficulty of the assessment tool means any improvement in clinician's results, with ongoing exposure to the program, can be reliably assessed and demonstrated. Importantly this holds true for all craft groups involved in intrapartum care and the interpretation of cardiotocography.
Collapse
Affiliation(s)
- Mark Beaves
- Royal Australian and New Zealand College of Obstetricians and Gynaecologists, MELBOURNE, Victoria, 3004, Australia
- Dept of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, 3800, Australia
| | - Nathan Zoanetti
- Research, Australian Council for Educational Research, Camberwell, Victoria, 3124, Australia
| | - Euan M Wallace
- Dept of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, 3800, Australia
- Victorian Government, Department of Health, MELBOURNE, Victoria, 3000, Australia
| | - Kirsten R Palmer
- Dept of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, 3800, Australia
- Obstetrics and Gynaecology, Monash Health, Clayton, Victoria, 3168, Australia
| |
Collapse
|
4
|
Ghesquière L, Moreeuw M, Drumez E, Gilbert M, Hanssens S, Védé M, Garabedian C. [Is it possible to safely reduce the use of in utero pH in the delivery room? Analysis of practices]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:270-274. [PMID: 36931599 DOI: 10.1016/j.gofs.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/04/2023] [Accepted: 03/08/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To evaluate our clinical practices since the implementation of different tools to reduce the use of pH in utero (pHiu) in the delivery room. METHODS A single-centre retrospective study was conducted in our university maternity hospital of Lille from October 2016 to March 2021. All patients in labour with a vaginal delivery agreement, a fetus in cephalic presentation and no contraindication to perform a pHiu were included. Since 2019, team training in fetal heart rate interpretation and a change in birth room practices with the introduction of fetal scalp pacing have been implemented to reduce the use of pH in utero. In order to evaluate the impact on clinical practices, the rate of pHiu, the number of pHiu performed per patient, the rates of instrumental deliveries, caesarean sections and pH at birth below 7.0 were studied and compared over time. RESULTS In total, 1515 patients had one or more pHiu during our study period, i.e. 7.3% (1515/20,562). The rate of pHiu decreased significantly from 2016 to 2021: in 2016, 12.1% (142/1171) of our sample had a pHiu during their labour, compared to 3.4% (33/963) in 2021. pH < 7.0 remained stable, ranging from 1.6 to 2.2%. Similarly, the rates of instrumental deliveries and caesarean sections remained stable, ranging from 17.7% to 21% and from 9.8% to 11.6%, respectively. CONCLUSION Improved knowledge of fetal physiology, awareness of teams of the limits of pHiu and introduction of fetal scalp stimulation have led to a decrease in the number of pHiu, without an increase in the rates of neonatal acidosis, instrumental deliveries and caesarean sections.
Collapse
Affiliation(s)
- Louise Ghesquière
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France; ULR 2694 - METRICS : évaluation des technologies de santé et des pratiques médicales, CHU de Lille, University of Lille, 59000 Lille, France.
| | - Marine Moreeuw
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Elodie Drumez
- ULR 2694 - METRICS : évaluation des technologies de santé et des pratiques médicales, CHU de Lille, University of Lille, 59000 Lille, France; Department of Biostatistics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Mélissa Gilbert
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Sandy Hanssens
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Morgane Védé
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Charles Garabedian
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France; ULR 2694 - METRICS : évaluation des technologies de santé et des pratiques médicales, CHU de Lille, University of Lille, 59000 Lille, France
| |
Collapse
|
5
|
Cavoretto PI, Seidenari A, Farina A. Hazard and cumulative incidence of umbilical cord metabolic acidemia at birth in fetuses experiencing the second stage of labor and pathologic intrapartum fetal heart rate requiring expedited delivery. Arch Gynecol Obstet 2023; 307:1225-1232. [PMID: 35596749 PMCID: PMC10023766 DOI: 10.1007/s00404-022-06594-1] [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: 03/16/2022] [Accepted: 04/25/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE The aim of the study was to determine the cause-specific hazard (CSH) and the cumulative incidence function (CIF) for umbilical cord metabolic acidemia at birth (MA; pH < 7.0 and/or BE [Formula: see text] - 12 mmol/L) at delivery in patients experiencing the 2nd stage of labor (2STG), stratified for both FIGO-2015 pathologic intrapartum cardiotocography requiring expedited delivery (CTG_RED) and duration of 2nd stage of labor. METHODS 3459 pregnancies experiencing the 2nd stage of labor and delivering at the Division of Obstetrics and Prenatal Medicine, IRCCS Sant'Orsola-Malpighi Hospital, Bologna (Italy), were identified between 2018 and 2019. Survival analysis was used to assess CSH and CIF for MA, stratified for FIGO-2015 pathologic CTG and relevant covariates. RESULTS FIGO-2015 pathological CTG with expedited operative delivery or urgent cesarean section within 10 or 20 min from diagnosis, respectively occurred in 282/3459 (8.20%). The rate of MA at delivery was 3.32% (115/3459). The spline of CSH for MA showed a direct correlation with the duration of 2STG always presenting higher values and greater slope in the presence of pathologic CTG, with plateau between 60 and 120 min and rapid increase after 120 min. The CIF at 180 min in the 2STG was 2.67% for nonpathological and 10.63% for pathological CTG_RED. Nulliparity, pathological CTG, and meconium-stained amniotic fluid resulted significant predictors of MA in our multivariable model. CONCLUSION The risk for MA increases moderately across the 2STG with nonpathological CTG and quadruples with pathological CTG_RED. Adjustment for other predictors of MA including meconium-stained amniotic fluid and nulliparity reveals a significant hazard increase for MA associated with pathologic CTG_RED.
Collapse
Affiliation(s)
- Paolo Ivo Cavoretto
- Gynecology and Obstetrics Department, IRCCS San Raffaele Hospital, University Vita-Salute, Milan, Italy
| | - Anna Seidenari
- Division of Obstetrics and Prenatal Medicine, Department of Medicine and Surgery (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy, University of Bologna, Via Massarenti 13, 40138, Bologna, Italy
| | - Antonio Farina
- Division of Obstetrics and Prenatal Medicine, Department of Medicine and Surgery (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy, University of Bologna, Via Massarenti 13, 40138, Bologna, Italy.
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Baauw L, Rosman AN, van den Akker TH. Lessons learned in cases of late preterm mortality in the Netherlands: Results from nationwide perinatal audits, a mixed method study. Eur J Obstet Gynecol Reprod Biol X 2023; 17:100179. [PMID: 36824398 PMCID: PMC9941355 DOI: 10.1016/j.eurox.2023.100179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Objective Assess improvable care factors in late preterm mortality, defined as death of a child during labour or in the first 28 days thereafter between 32 + 0 and 36 + 6 weeks gestation, in the Netherlands. Design Perinatal audit has been coordinated and supported at the national level, with selection of nationwide audit themes, and audit sessions are performed at the local level across the country as multidisciplinary meetings with primary and secondary level health care professionals, organised in local perinatal cooperation units. In 2017-2019, late preterm mortality was such a theme. We compiled and systematically categorised all improvable care factors formulated during local audit meetings in a national perinatal audit database. Results In total, 27 cases were discussed in local perinatal audits and analysed locally and at the national level. Altogether, 52 improvable care factors were identified. Most identified improvable care factors concerned inadequate foetal monitoring by cardiotocography during labour, factors related to care organisation, particularly unclarity around local assigning of responsibilities and work procedures, and poor communication between involved health care professionals especially in transfer of care. Conclusion Several critical improvable care factors were identified through nationwide perinatal audit of late preterm deaths in the Netherlands.
Collapse
Affiliation(s)
- Ludovic Baauw
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Ageeth N. Rosman
- Department of Healthcare Studies, Center of Innovations of Care, Rotterdam University of Applied Sciences, Rochussenstraat 180, 3015 EK Rotterdam, the Netherlands,Perined, Mercatorlaan 1200, 3528 BK Utrecht, the Netherlands,Corresponding author at: Department of Healthcare Studies, Center of Innovations of Care, Rotterdam University of Applied Sciences, Rochussenstraat 180, 3015 EK Rotterdam, the Netherlands.
| | - Thomas H. van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands,Athena Institute, VU University, Amsterdam, the Netherlands
| |
Collapse
|
8
|
Ugwumadu A, Arulkumaran S. A second look at intrapartum fetal surveillance and future directions. J Perinat Med 2023; 51:135-144. [PMID: 36054840 DOI: 10.1515/jpm-2022-0292] [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: 06/19/2022] [Accepted: 07/25/2022] [Indexed: 01/17/2023]
Abstract
Intrapartum fetal surveillance aims to predict significant fetal hypoxia and institute timely intervention to avoid fetal injury, and do so without unnecessary operative delivery of fetuses at no risk of intrapartum hypoxia. However, the configuration and application of current clinical guidelines inadvertently undermine these aims because of persistent failure to incorporate increased understanding of fetal cardiovascular physiology and adaptations to oxygen deprivation, advances in signal acquisition/processing, and related technologies. Consequently, the field on intrapartum fetal surveillance is stuck in rudimentary counts of the fetal R-R intervals and visual assessment of very common, but nonspecific fetal heart decelerations and fetal heart rate variability. The present authors argue that the time has come to move away from classifications of static morphological appearances of FHR decelerations, which do not assist the thinking clinician in understanding how the fetus defends itself and compensates for intrapartum hypoxic ischaemic insults or the patterns that suggest progressive loss of compensation. We also reappraise some of the controversial aspects of intrapartum fetal surveillance in modern obstetric practice, the current state of flux in training and certification, and contemplate the future of the field particularly in the context of the emerging role of artificial intelligence.
Collapse
Affiliation(s)
- Austin Ugwumadu
- Department of Obstetrics & Gynaecology, St George's, University of London, London SW17 0RE, UK
| | - Sabaratnam Arulkumaran
- Department of Obstetrics & Gynaecology, St George's, University of London, London SW17 0RE, UK
| |
Collapse
|
9
|
Murphy DJ, Devane D, Molloy E, Shahabuddin Y. Fetal scalp stimulation for assessing fetal well-being during labour. Cochrane Database Syst Rev 2023; 1:CD013808. [PMID: 36625680 PMCID: PMC9831024 DOI: 10.1002/14651858.cd013808.pub2] [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] [Indexed: 01/11/2023]
Abstract
BACKGROUND Continuous fetal heart rate monitoring by cardiotocography (CTG) is used in labour for women with complicated pregnancies. Fetal heart rate abnormalities are common and may result in the decision to expedite delivery by caesarean section. Fetal scalp stimulation (FSS) is a second-line test of fetal well-being that may provide reassurance that the labour can continue. OBJECTIVES To evaluate methods of FSS as second-line tests of intrapartum fetal well-being in cases of non-reassuring CTG. FSS and CTG were compared to CTG alone, and to CTG with fetal blood sampling (FBS). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, the WHO ICTRP and conference proceedings), ClinicalTrials.gov (18 October 2022), and reference lists of retrieved studies. SELECTION CRITERIA Eligible studies were randomised controlled trials (RCTs) that compared any form of FSS to assess fetal well-being in labour. Quasi-RCTs, cluster-RCTs and studies published in abstract form were also eligible for inclusion, but none were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS Two trials, involving 377 women, met the inclusion criteria for this review. Both trials were conducted in hospital settings and included women with singleton, term (37+0 weeks or more) pregnancies, a cephalic presentation, and abnormal CTG. Follow-up was until hospital discharge after the birth. A pilot trial of 50 women in a high-income country (Ireland) compared CTG and digital fetal scalp stimulation (dFSS) with CTG and fetal blood sampling (FBS). A single-centre trial of 327 women in a lower middle-income country (India) compared CTG and manual fetal stimulation (abdominal or vaginal scalp stimulation) with CTG alone. The two included studies were at moderate or unclear risk of bias. Both trials provided clear information on allocation concealment but it was not possible to blind participants or health professionals in relation to the intervention. Although objective outcome measures were reported, outcome assessment was not blinded or blinding was unclear. dFSS and CTG versus FBS and CTG There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. The risk of caesarean section (CS) may be lower with dFSS compared to FBS (risk ratio (RR) 0.38, 95% confidence interval (CI) 0.16 to 0.92; 1 pilot trial, 50 women; very low-certainty evidence) but the evidence is very uncertain. There were no cases of neonatal encephalopathy reported. The evidence was also very uncertain between dFSS and FBS for assisted vaginal birth (RR 1.44, 95% CI 0.76 to 2.75; very low-certainty evidence) and for the spontaneous vaginal birth rate (RR 2.33, 95% CI 0.68 to 8.01, very low-certainty evidence). Maternal acceptability of the procedures was not reported. FSS and CTG versus CTG alone Manual stimulation of the fetus was performed either abdominally (92/164) or vaginally (72/164). There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. There may be little differences in the risk of CS on comparing manual fetal stimulation and CTG with CTG alone (RR 0.83, 95% CI 0.59 to 1.18; 1 trial, 327 women; very low-certainty evidence), but again the evidence was very uncertain. There were no cases of neonatal encephalopathy reported. There may be no differences in the risk of assisted vaginal birth (RR 1.43, 95% CI 0.78 to 2.60; very low-certainty evidence) or in the rates of spontaneous vaginal birth (RR 1.01, 95% CI 0.85 to 1.21, very low-certainty evidence), but again the evidence is very uncertain. Maternal acceptability of abdominal stimulation/FSS was not reported although 13 women withdrew consent after randomisation due to concerns about fetal well-being. AUTHORS' CONCLUSIONS There is very low-certainty evidence available which makes it unclear whether stimulating the fetal scalp is a safe and effective way to confirm fetal well-being in labour. Evidence was downgraded based on limitations in study design and imprecision. Further high-quality studies of adequate sample size are required to evaluate this research question. In order to be generalisable, these trials should be conducted in different settings, including broad clinical criteria at both preterm and term gestational ages, and standardising the method of stimulation. There is an ongoing study (FIRSST) that will be incorporated into this review in a subsequent update.
Collapse
Affiliation(s)
- Deirdre J Murphy
- Department of Obstetrics and Gynaecology Trinity College, University of Dublin, Dublin, Ireland
| | - Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Eleanor Molloy
- Department of Paediatrics, Trinity College Dublin, Dublin, Ireland
| | - Yulia Shahabuddin
- Department of Obstetrics and Gynaecology Trinity College, University of Dublin, Dublin, Ireland
| |
Collapse
|
10
|
Descourvieres L, Ghesquiere L, Drumez E, Martin C, Sauvage A, Subtil D, Houfflin‐Debarge V, Garabedian C. Types of intrapartum hypoxia in the newborn at term with metabolic acidemia: A retrospective study. Acta Obstet Gynecol Scand 2022; 101:1276-1281. [PMID: 36004701 PMCID: PMC9812112 DOI: 10.1111/aogs.14436] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION In the most recent recommendations of the International Federation of Gynecology and Obstetrics (FIGO), a chapter was dedicated to the physiological approach and to the description of fetal mechanisms developed to respond to hypoxia. Our objective was to classify the type of hypoxia in the case of metabolic acidemia and to describe the order of appearance of fetal heart rate abnormalities in cases of gradually evolving hypoxia. MATERIAL AND METHODS 132 neonates born between 2018 and 2020 with acidemia were included. We excluded preterm birth, fetuses with congenital anomaly and twin pregnancies. Intrapartum cardiotocography traces were assigned to one of these four types of labor hypoxia: acute, subacute, gradually evolving and chronic hypoxia. For gradually evolving hypoxia, fetal heart rate abnormalities were described according to the FIGO classification. RESULTS 36 cardiotocography traces (27.3%) were classified as acute hypoxia, 14 (10.6%) as subacute hypoxia, and 3 (3.2%) as chronic hypoxia; gradually evolving hypoxia occurred in 62 cases (47%). In 77.4% of cases of gradually evolving hypoxia, deceleration was the first anomaly to appear, with loss of variability and bradycardia appearing later. Increased fetal heart rate was observed immediately after late deceleration in 46.8% of cases and was followed by a loss of variability or saltatory rhythm in 37.1% of cases. CONCLUSIONS In cases of metabolic acidemia at term, the most frequent situation observed was gradually evolving hypoxia, with an initial occurrence of decelerations. The sequence of fetal heart rate modifications was variable.
Collapse
Affiliation(s)
| | | | - Elodie Drumez
- Department of Biostatistics, EA2694 Public Health: Epidemiology and Quality of CareUniversity of Lille, University Hospital Center (CHU) LilleLilleFrance
| | - Claire Martin
- Department of Biostatistics, EA2694 Public Health: Epidemiology and Quality of CareUniversity of Lille, University Hospital Center (CHU) LilleLilleFrance
| | - Audrey Sauvage
- Obstetrics CenterJeanne de Flandre Hospital, CHRU LilleLilleFrance
| | - Damien Subtil
- Obstetrics Center, EA 4489 – Perinatal Environment and HealthJeanne de Flandre Hospital, CHRU Lille, University LilleLilleFrance
| | | | | |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Xodo S, Londero AP. Is It Time to Redefine Fetal Decelerations in Cardiotocography? J Pers Med 2022; 12:1552. [PMID: 36294689 PMCID: PMC9605652 DOI: 10.3390/jpm12101552] [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] [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.
Collapse
Affiliation(s)
- Serena Xodo
- Department of Gynecology and Obstetrics, School of Medicine of Udine, 33100 Udine, Italy
| | - Ambrogio P. Londero
- Academic Unit of Obstetrics and Gynaecology, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, 16132 Genova, Italy
| |
Collapse
|
14
|
Ghesquière L, Ternynck C, Sharma D, Hamoud Y, Vanspranghels R, Storme L, Houfflin-Debarge V, De Jonckheere J, Garabedian C. Heart rate markers for prediction of fetal acidosis in an experimental study on fetal sheep. Sci Rep 2022; 12:10615. [PMID: 35739219 PMCID: PMC9226053 DOI: 10.1038/s41598-022-14727-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 06/10/2022] [Indexed: 11/09/2022] Open
Abstract
To overcome the difficulties in interpreting fetal heart rate (FHR), several tools based on the autonomic nervous system and heart rate variability (HRV) have been developed. The objective of this study was to use FHR and HRV parameters for the prediction of fetal hypoxia. It was an experimental study in the instrumented fetal sheep. Repeated umbilical cord occlusions were performed to achieve severe acidosis. Hemodynamic parameters, ECG, and blood gases were analyzed. The variables used were heart rate baseline, HRV analysis (RMSSD, SDNN, LF, HF, HFnu, Fetal Stress Index (FSI), …), and morphological analysis of decelerations. The gold standard used to classify hypoxia was the fetal arterial pH (pH < 7.10). Different multivariable statistical methods (logistic regression and decision trees) were applied for the detection of acidosis. 21 lambs were instrumented. A total of 130 pairs of FHR/fetal pH analysis were obtained of which 29 in the acidosis group and 101 in the non-acidosis group. After logistic regression model with bootstrap resampling and stepwise backward selection, only one variable was selected, FSI. The AUC of FSI alone in this model was 0.81 with a sensitivity of 0.66, specificity of 0.88, PPV of 0.61, and NPV of 0.90 considering a threshold of 68. Decision trees with CHAID and CART algorithms showed a sensitivity of 0.48 and 0.59, respectively, and a specificity of 0.94 for both. All employed methods identified HRV variables as the most predictive of acidosis. The primary variables selected automatically were those from the HRV. Supporting the use of FHRV measures for the screening of fetal acidosis during labour is interesting.
Collapse
Affiliation(s)
- Louise Ghesquière
- Univ. Lille, CHU Lille, ULR 2694-METRICS-Evaluation des technologies de santé et des pratiques médicales, 59000, Lille, France.
- Department of Obstetrics, CHU Lille, 59000, Lille, France.
- Department of Obstetrics, CHU Lille, Avenue Eugène Avinée, 59037, Lille Cedex, France.
| | - C Ternynck
- Univ. Lille, CHU Lille, ULR 2694-METRICS-Evaluation des technologies de santé et des pratiques médicales, 59000, Lille, France
- Department of Biostatistics, CHU Lille, 59000, Lille, France
| | - D Sharma
- Univ. Lille, CHU Lille, ULR 2694-METRICS-Evaluation des technologies de santé et des pratiques médicales, 59000, Lille, France
- Department of Pediatric Surgery, CHU Lille, 59000, Lille, France
| | - Y Hamoud
- Univ. Lille, CHU Lille, ULR 2694-METRICS-Evaluation des technologies de santé et des pratiques médicales, 59000, Lille, France
- Department of Obstetrics, CHU Lille, 59000, Lille, France
| | - R Vanspranghels
- Univ. Lille, CHU Lille, ULR 2694-METRICS-Evaluation des technologies de santé et des pratiques médicales, 59000, Lille, France
- Department of Obstetrics, CHU Lille, 59000, Lille, France
| | - L Storme
- Univ. Lille, CHU Lille, ULR 2694-METRICS-Evaluation des technologies de santé et des pratiques médicales, 59000, Lille, France
- Department of Neonatology, CHU Lille, 59000, Lille, France
| | - V Houfflin-Debarge
- Univ. Lille, CHU Lille, ULR 2694-METRICS-Evaluation des technologies de santé et des pratiques médicales, 59000, Lille, France
- Department of Obstetrics, CHU Lille, 59000, Lille, France
| | - J De Jonckheere
- Univ. Lille, CHU Lille, ULR 2694-METRICS-Evaluation des technologies de santé et des pratiques médicales, 59000, Lille, France
- CHU Lille, CIC-IT 1403, 59000, Lille, France
| | - C Garabedian
- Univ. Lille, CHU Lille, ULR 2694-METRICS-Evaluation des technologies de santé et des pratiques médicales, 59000, Lille, France
- Department of Obstetrics, CHU Lille, 59000, Lille, France
| |
Collapse
|
15
|
Seidenari A, Cavoretto PI, Carbone IF, Germano C, Iurlaro E, Gaeta G, Cetera GE, Amodeo S, Morano D, Masturzo B, Di Martino DD, Giambanco L, Candiani M, Farina A. The cumulative incidence of neonatal metabolic acidemia after terminal bradycardia in the 2nd stage of labor: a survival-based model. Arch Gynecol Obstet 2022; 307:1407-1414. [PMID: 35635618 DOI: 10.1007/s00404-022-06619-9] [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: 02/27/2022] [Accepted: 05/07/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of the study was to estimate by a survival analysis model the hazard function (HF) for neonatal metabolic acidemia (MA) throughout the 2nd stage of labor (2STG) at the time of occurrence of a terminal bradycardia ≥ 10 min requiring expedited delivery, and the cumulative incidence function (CIF) for MA according with the duration of bradycardia stratified in 10-12 min and > 12 min. METHODS Singleton pregnancies experiencing terminal fetal bradycardia requiring expedited delivery in the 2STG at 38 + 0-41 + 3 weeks and delivering in the year 2019, were identified. The presence of MA (pH < 7 and/or BE ≤ - 12 mmol/L) was determined based on the acid-base status in the umbilical artery cord blood. Survival analysis was used to assess the hazard function (HF) and the cumulative incidence function (CIF) for MA occurring after terminal fetal bradycardia, at the 2STG. RESULTS Out of a non-consecutive population of 12,331 pregnancies, there were 52 cases that fit the inclusion criteria. Twenty-four (46.2%) of those develop MA. Abnormal quantitative pH values and the HF for MA correlated with the duration of 2STG at the time of bradycardia onset, but not with bradycardia duration. After 60 min of duration of 2STG, the HF (or instantaneous rate of failure) increased dramatically (from 1.2 to 20 about at 120 min). At paired duration of 2STG, a higher CIF was observed for the terminal bradycardia > 12 min. CONCLUSION Forty-six percent of term fetuses with terminal bradycardia had MA at birth. Despite the low sensitivity and a non-significant association with quantitative pH values, the duration of terminal bradycardia in the 2STG is associated with a higher CIF for MA.
Collapse
Affiliation(s)
- Anna Seidenari
- Division of Obstetrics and Prenatal Medicine, Department of Medicine and Surgery (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
| | - Paolo Ivo Cavoretto
- Gynecology and Obstetrics Department, IRCCS San Raffaele Hospital, University Vita-Salute, Milan, Italy
| | - Ilma Floriana Carbone
- Unit of Obstetrics, Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Mangiagalli Center, Milan, Italy
| | - Chiara Germano
- Department of Surgical Sciences, Sant'Anna Hospital, University of Turin, Turin, Italy
| | - Enrico Iurlaro
- Unit of Obstetrics, Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Mangiagalli Center, Milan, Italy
| | - Gerarda Gaeta
- Gynecology and Obstetrics Department, IRCCS San Raffaele Hospital, University Vita-Salute, Milan, Italy
| | - Giulia Emily Cetera
- Unit of Obstetrics, Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Mangiagalli Center, Milan, Italy
| | - Silvia Amodeo
- Department of Obstetrics and Gynecology, S. Antonio Abate Hospital, Trapani, Italy
| | - Danila Morano
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, University of Ferrara, Cona, Ferrara, Italy.
| | - Bianca Masturzo
- Department of Surgical Sciences, Sant'Anna Hospital, University of Turin, Turin, Italy
| | - Daniela Denis Di Martino
- Unit of Obstetrics, Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Mangiagalli Center, Milan, Italy
| | - Laura Giambanco
- Department of Obstetrics and Gynecology, S. Antonio Abate Hospital, Trapani, Italy
| | - Massimo Candiani
- Gynecology and Obstetrics Department, IRCCS San Raffaele Hospital, University Vita-Salute, Milan, Italy
| | - Antonio Farina
- Division of Obstetrics and Prenatal Medicine, Department of Medicine and Surgery (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Pereira S, Patel R, Zaima A, Tvarozkova K, Chisholm P, Kappelou O, Evanson J, Chandraharan E, Wertheim D, Shah DK. Physiological CTG categorization in types of hypoxia compared with MRI and neurodevelopmental outcome in infants with HIE. J Matern Fetal Neonatal Med 2022; 35:9675-9683. [PMID: 35282752 DOI: 10.1080/14767058.2022.2050366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Commonly used methods of CTG classification do not reliably predict neonatal hypoxic-ischemic encephalopathy (HIE). OBJECTIVE To examine whether a relationship exists between the types of hypoxia as identified on the cardiotocograph using novel physiology-based CTG classification and patterns of injury on neonatal cerebral MRI and later neurodevelopmental outcomes. STUDY DESIGN A retrospective study of term-born infants admitted to four neonatal units with HIE as part of a brain injury biomarkers study between January 2014 and December 2015. Intrapartum CTG traces were analyzed by two obstetricians trained in physiological CTG classification, blind to neonatal outcomes. Neonatal cerebral MR images were assessed independently by a neuroradiologist and an expert neonatologist. CTG traces were classified into types of hypoxia and allocated to groups; (1) chronic hypoxia or antepartum injury; (2) gradually evolving or subacute hypoxia; and (3) acute hypoxia. RESULTS Of 106 infants recruited to the study, records were available for 58 cases. Of these, CTGs were available for 37. All 37 had abnormal CTGs. Twenty-four infants, all of whom had received therapeutic hypothermia had cerebral MRI. Fourteen of the 24 (58%) infants had abnormal MRI. In group 1 (chronic hypoxia/antenatal injury), total brain injury was most predominant (4/6 infants). Group 2 (gradually evolving/subacute hypoxia) was associated with peripheral brain injury (5/5 infants). Group 3 (acute hypoxia) was associated with basal-ganglia thalamic injury pattern (3/3 infants). Later neurodevelopmental outcomes were available for 35 cases. Infants suspected to have a pre-labor injury on CTG (group 1) had a higher proportion of adverse neurodevelopmental outcomes (4/10, 40%) compared to groups 2 and 3 (4/25, 16%). CONCLUSION Using this novel physiology-based CTG classification, we demonstrate an association between types of hypoxia observed on the CTG and MRI patterns of hypoxic brain injury. Infants with CTG trace suggestive of chronic hypoxia or other antenatal injuries were overrepresented in this cohort and were also more likely to have a poor neurodevelopmental outcome.
Collapse
Affiliation(s)
- Susana Pereira
- Kingston Hospital NHS Foundation Trust, Kingston upon Thames, UK
| | - Ryan Patel
- Centre for Neuroscience & Trauma, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ahmed Zaima
- Kingston Hospital NHS Foundation Trust, Kingston upon Thames, UK
| | | | | | - Olga Kappelou
- Homerton University Hospital, NHS Foundation Trust, London, UK
| | - Jane Evanson
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Edwin Chandraharan
- Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Nether Mayne, Basildon, UK.,Global Academy of Medical Education and Training, London, UK
| | - David Wertheim
- Faculty of Science, Engineering and Computing, School of Computer Science and Mathematics, Kingston University, Kingston upon Thames, UK
| | - Divyen K Shah
- Centre for Neuroscience & Trauma, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Royal London Hospital, Barts Health NHS Trust, London, UK
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
Yagur Y, Weitzner O, Biron-Shental T, Hornik-Lurie T, Bookstein Peretz S, Tzur Y, Shechter Maor G. Can we improve our ability to interpret category II fetal heart rate tracings using additional clinical parameters? J Perinat Med 2021; 49:1089-1095. [PMID: 34109773 DOI: 10.1515/jpm-2020-0592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 05/12/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study examined predictive factors, in addition to Category II Fetal Herat Rate (FHR) monitoring that might imply fetal acidosis and risk of asphyxia. METHODS This retrospective cohort study compared three groups of patients with Category II FHR monitoring indicating need for imminent delivery. Groups were divided based on fetal cord blood pH: pH≤7.0, 7.0<pH<7.2 and pH≥7.2. Demographics, medical history, delivery data and early neonatal outcomes were reviewed. RESULTS The cohort included 417 women. Nine (2.2%) had cord pH≤7.0, 105 (25.2%) pH 7.0 to 7.2 and 303 (72.6%) ad pH≥7.2. Background characteristics, pregnancy follow-up and intrauterine fetal evaluation prior to delivery were similar in all groups. As expected, more patients in the low pH group had cesarean section (55.6%), than vaginal delivery or vacuum extraction (p=0.02). Five-minute Apgar scores were similar in all groups. CONCLUSIONS This retrospective study did not detect a specific parameter that could help predict the prognosis of fetal acidosis and risk of asphyxia. As we only included patients with a Category II tracing that was worrisome enough to lead to imminent delivery, it is reasonable to believe that this is due to patient selection, meaning that when the Category II FHR results in decision for prompt delivery, there is no added value in additional clinical characteristics. The evaluation should be expanded to all patients with Category II tracing for better interpretation tools for Category II FHR monitors, as well as a larger study population.
Collapse
Affiliation(s)
- Yael Yagur
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omer Weitzner
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Biron-Shental
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Yehuda Tzur
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Shechter Maor
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Meir Medical Center Institute for Research, Kfar Saba, Israel
| |
Collapse
|
20
|
Identification of the Fetus at Risk for Metabolic Acidemia Using Continuous Fetal Heart Rate Monitoring. Clin Obstet Gynecol 2021; 63:616-624. [PMID: 32516155 DOI: 10.1097/grf.0000000000000546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The fetal heart rate can be used to assess the current metabolic state of the fetus and predict the risk of the evolution of metabolic acidemia through the course of labor. In this chapter, we will present the pathophysiology of the development of fetal acidemia and provide an organized approach to identifying the risk of worsening acidemia using changes noted in the fetal heart rate pattern to allow for interventions that might alter this course.
Collapse
|
21
|
The Golden Hours of Fetal Heart Rate Monitoring: Systematic Approach to the Critical Times of Labor and Delivery. Clin Obstet Gynecol 2021; 63:668-677. [PMID: 32516156 DOI: 10.1097/grf.0000000000000545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The first hour after admission and the last hour before delivery are critical times for identifying and preventing hypoxic-ischemic encephalopathy. These are times of transition that require coordinated steps to identify fetuses at risk, institute effective plans for fetal heart rate monitoring, and to establish situational awareness. Interpretation and intervention based on fetal heart rate monitoring is an important part of the care provided during these crucial times. We present checklists for the first and last hour of labor for use on labor and delivery to help standardize and optimize the approach to care during these times.
Collapse
|
22
|
Recher M, Prevost ALD, Sharma D, De Jonckheere J, Garabedian C, Storme L. Roles of parasympathetic outflow and sympathetic outflow in the cardiovascular response to brief umbilical cord occlusion in fetal sheep. PLoS One 2021; 16:e0254155. [PMID: 34228770 PMCID: PMC8259953 DOI: 10.1371/journal.pone.0254155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/21/2021] [Indexed: 01/08/2023] Open
Abstract
Fetal heart rate (FHR) deceleration is the most common change seen during labor. The role of the autonomic nervous system in regulating the fetal cardiovascular response during multiple uterine contractions has been well-established. However, the mechanism underlying the hemodynamic response remains unclear and the specific reflex that mediates the cardiovascular modifications is still controversial. This study aimed to determine the role of the sympathetic and parasympathetic systems on fetal hemodynamics in complete cord occlusion. Chronically instrumented fetal sheep were randomized to receive an intravenous injection of atropine 2.5 mg (n = 8), propranolol 5 mg (n = 7), atropine and propranolol (n = 7), or a control protocol (n = 9), followed by three episodes of 1-minute umbilical cord occlusion repeated every 5 minutes. Cord compression induces a rapid decrease in the FHR and a rapid increase in MAP. The decrease in FHR is caused by an increase in parasympathetic activity, (atropine and atropine-propranolol abolish the FHR response to the occlusion). The change in FHR during occlusion was not modified by propranolol injection, showing no effect of sympathetic tone. The increase in MAP during occlusion was similar in the four protocols. After releasing occlusion, the FHR was still lower than that at baseline due to a sustained parasympathetic tone. Suppression of the parasympathetic output to the cardiovascular system unmasks an increase in the FHR above baseline values. The lower FHR with the propranolol protocol further supports an increase in myocardial β-adrenoceptor stimulation after cord release. The increase in MAP after cord release was similar in the four protocols, except after the early stage of interocclusion period in atropine protocol. Four minutes after cord release, the FHR returned to baseline irrespective of the drugs that were infused, thereby showing recovery of ANS control. Blood gases (pH, PaCO2, PaO2) and plasma lactate concentrations was similar between the four protocols at the end of three applications of UCO. Complete cord compression-induced deceleration is likely due to acute activation of parasympathetic output. β-adrenoceptor activity is involved in the increase in FHR after cord release. Understanding the reflexes involved in FHR deceleration may help us understand the mechanisms underlying fetal autonomic adaptation during cord occlusion.
Collapse
Affiliation(s)
- Morgan Recher
- Univ. Lille, ULR 2694 – METRICS: Evaluation des technologies de santé et des pratiques médicales, Lille, France
- Department of Pediatric Intensive Care Unit, CHU Lille, Jeanne de Flandre Hospital, Lille, France
| | - Arthur Lauriot Dit Prevost
- Univ. Lille, ULR 2694 – METRICS: Evaluation des technologies de santé et des pratiques médicales, Lille, France
- Department of Pediatric Surgery, CHU Lille, Jeanne de Flandre Hospital, Lille, France
| | - Dyuti Sharma
- Univ. Lille, ULR 2694 – METRICS: Evaluation des technologies de santé et des pratiques médicales, Lille, France
- Department of Pediatric Surgery, CHU Lille, Jeanne de Flandre Hospital, Lille, France
| | - Julien De Jonckheere
- Univ. Lille, ULR 2694 – METRICS: Evaluation des technologies de santé et des pratiques médicales, Lille, France
- CHU Lille, Centre d’Innovation Technologique, Lille, France
| | - Charles Garabedian
- Univ. Lille, ULR 2694 – METRICS: Evaluation des technologies de santé et des pratiques médicales, Lille, France
- Department of Obstetrics, CHU Lille, Jeanne de Flandre Hospital, Lille, France
| | - Laurent Storme
- Univ. Lille, ULR 2694 – METRICS: Evaluation des technologies de santé et des pratiques médicales, Lille, France
- Department of Neonatology, CHU Lille, Jeanne de Flandre Hospital, Lille, France
| |
Collapse
|
23
|
Pereira S, Lau K, Modestini C, Wertheim D, Chandraharan E. Absence of fetal heart rate cycling on the intrapartum cardiotocograph (CTG) is associated with intrapartum pyrexia and lower Apgar scores. J Matern Fetal Neonatal Med 2021; 35:7980-7985. [PMID: 34157928 DOI: 10.1080/14767058.2021.1940130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cycling consists of alternating periods of reduced and normal fetal heart variability, reflecting changes in fetal behavioral states. Occurrence of active and quiet sleep cycles is considered to be a hallmark of fetal autonomic nervous system integrity, demonstrating healthy interaction between the parasympathetic and sympathetic nervous systems. Cycling is an overlooked feature in most international cardiotocography (CTG) guidelines. The authors tested the hypothesis that fetuses showing no cycling in the intrapartum period have poorer outcomes. AIM To investigate whether the absence of cycling at the commencement of intrapartum fetal monitoring is associated with poorer neonatal outcomes (umbilical arterial cord pH, Apgar scores and neonatal unit admission). METHODS Analysis of a database of sequentially acquired intrapartum CTG traces from a single center. Only cases of singleton pregnancies over 36 weeks gestation in cephalic presentation with recorded umbilical artery cord pH were considered. Neonatal outcomes were assessed based on umbilical cord artery pH, Apgar ≤7 at 5 min and unexpected admission to the neonatal unit. Intrapartum pyrexia, presence of meconium-stained amniotic fluid and mode of delivery were also recorded. RESULTS A total of 684 cases were analyzed. Absence of cycling from the beginning of the intrapartum CTG recording was noted in 5% of cases. Cases with no cycling were more likely to have maternal pyrexia (≥37.8 °C) (p = .006) and Apgars ≤7 at 5 min (p = .04). There was an association between increasing baseline fetal heart rate and the proportion of cases with no cycling. There was no significant difference between the two groups with regard to the mode of delivery or umbilical cord arterial pH <7.05 (p = .53). CONCLUSION Absence of cycling is associated with intrapartum maternal pyrexia and fetuses with the absence of cycling are more likely to have poorer perinatal outcomes measured by Apgar ≤ 7 at 5 min, despite no association with fetal acidosis. Results from this research were presented at the XXVI European Congress of Perinatal Medicine in September 2018.
Collapse
Affiliation(s)
| | | | | | - David Wertheim
- Faculty of Science, Engineering and Computing, Kingston University, Surrey, UK
| | | |
Collapse
|
24
|
Gilbert M, Ghesquiere L, Drumez E, Subtil D, Fague V, Berveiller P, Garabedian C. How to reduce fetal scalp blood sampling? A retrospective study evaluating the diagnostic value of scalp stimulation to predict fetal wellbeing assessed by scalp blood sampling. Eur J Obstet Gynecol Reprod Biol 2021; 263:153-158. [PMID: 34216939 DOI: 10.1016/j.ejogrb.2021.05.032] [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: 02/15/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The Fetal Blood Sample (FBS) is used as an indicator of fetal acidosis during labor. Its place is discussed through the lack of randomized trials, as well as the limitations related to the technical procedure. An alternative could be the Fetal Scalp Stimulation (FSS). AIM Our objective was to describe the FSS diagnostic value to predict fetal wellbeing defined from FBS. METHODS The FSS consisted in a digital scalp stimulation for 15 s. Test was negative when an acceleration and/or a normal variability were elicited in the 2 min following. FSS was performed before each FBS which was classified as normal when pH was > 7.25. The diagnostic value was assessed by sensibility, specificity, positive and negative predictive values. FINDINGS 148 women were included in our center from February to December 2019. Of the 191 FBS procedures, when accelerations were elicited sensibility was 58,3 (36.8-77.1), specificity was 67,5 (59.3-75), positive predictive value was 20,9 (12.5-32.9) and negative predictive value was 91.7 % (95 %CI, 85-95.5). DISCUSSION FBS is considered as the gold standard in our study which could be discussed as it is abandoned in some countries because of its questioned reliability and the lack of controlled randomized trials. CONCLUSION This study suggests that FSS could be an interesting alternative adjunctive test to perform in the first instance as it seems to be reliable, non-invasive and easy to perform in order to limit FBS only to absence of acceleration after FSS.
Collapse
Affiliation(s)
- M Gilbert
- CHU Lille, Department of Obstetrics, F-59000, Lille, France.
| | - L Ghesquiere
- CHU Lille, Department of Obstetrics, F-59000, Lille, France; Univ. Lille, ULR 2694 METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, F-59000, Lille, France
| | - E Drumez
- Univ. Lille, ULR 2694 METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, F-59000, Lille, France; CHU Lille, Department of Biostatistics, F-59000, Lille, France
| | - D Subtil
- CHU Lille, Department of Obstetrics, F-59000, Lille, France; Univ. Lille, ULR 2694 METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, F-59000, Lille, France
| | - V Fague
- CH Valenciennes, Department of Obstetrics, F-59300, Valenciennes, France
| | - P Berveiller
- CH Poissy, Department of Obstetrics, F-78300, Poissy, France
| | - C Garabedian
- CHU Lille, Department of Obstetrics, F-59000, Lille, France; Univ. Lille, ULR 2694 METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, F-59000, Lille, France
| |
Collapse
|
25
|
Maeda Y, Lear CA, Beacom MJ, Davidson JO, Zhou KQ, Gunning M, Ikeda T, Gunn AJ, Bennet L. Transient effects of forebrain ischemia on fetal heart rate variability in fetal sheep. Am J Physiol Regul Integr Comp Physiol 2021; 320:R916-R924. [PMID: 33881362 DOI: 10.1152/ajpregu.00032.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Fetal heart rate variability (FHRV) is a key index of antenatal and intrapartum fetal well-being. FHRV is well established to be mediated by both arms of the autonomic nervous system, but it remains unknown whether higher centers in the forebrain contribute to FHRV. We tested the hypothesis that selective forebrain ischemia would impair the generation of FHRV. Sixteen chronically instrumented near-term fetal sheep were subjected to either forebrain ischemia induced by bilateral carotid occlusion or sham-ischemia for 30 min. Time, frequency, and nonlinear measures of FHRV were assessed during and for seven days after ischemia. Ischemia was associated with profound suppression of electroencephalographic (EEG) power, which remained suppressed throughout the recovery period (P < 0.001). During the first 5 min of ischemia, multiple time and frequency domain measures were increased (all P < 0.05) before returning back to sham levels. A delayed increase in sample entropy was observed during ischemia (P < 0.05). For the first 3 h after ischemia, there was moderate suppression of two measures of FHRV (very-low frequency power and the standard deviation of RR-intervals, both P < 0.05) and increased sample entropy (P < 0.05). Thereafter, all measures of FHRV returned to control levels. In conclusion, profound forebrain ischemia sufficient to lead to severe neural injury had only transient effect on multiple measures of FHRV. These findings suggest that the forebrain makes a limited contribution to FHRV. FHRV therefore primarily originates in the hindbrain and is unlikely to provide meaningful information on forebrain neurodevelopment or metabolism.
Collapse
Affiliation(s)
- Yoshiki Maeda
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,The Department of Obstetrics and Gynaecology, Mie University, Mie, Japan
| | - 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
| | - Joanne O Davidson
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Kelly Q Zhou
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Mark Gunning
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Tomoaki Ikeda
- The Department of Obstetrics and Gynaecology, Mie University, Mie, Japan
| | - Alistair J Gunn
- 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
| |
Collapse
|
26
|
Tarvonen M, Hovi P, Sainio S, Vuorela P, Andersson S, Teramo K. Factors associated with intrapartum ZigZag pattern of fetal heart rate: A retrospective one-year cohort study of 5150 singleton childbirths. Eur J Obstet Gynecol Reprod Biol 2020; 258:118-125. [PMID: 33421808 DOI: 10.1016/j.ejogrb.2020.12.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/11/2020] [Accepted: 12/28/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Recent studies suggest that intrapartum ZigZag pattern of fetal heart rate (FHR) is significantly associated with cord blood acidaemia and neonatal complications. For the clinical significance of this pattern, it is mandatory that ZigZag episodes in cardiotocographic (CTG) recording are correctly identified. The aim of the present study was to examine maternal, fetal and delivery-related factors that could explain the occurrence of ZigZag pattern of FHR during the last 2 h of labour in a large obstetric cohort. STUDY DESIGN CTG recordings from 5150 singleton childbirths at ≥33 weeks of gestation during one year were evaluated retrospectively and blinded to pregnancy and neonatal outcomes in a university hospital in Helsinki, Finland. All women in the cohort were in the active phase of labour with regular uterine contractions. ZigZag FHR pattern was defined as FHR baseline amplitude changes of >25 bpm with a duration of 2-30 min. The following maternal, fetal and labour/delivery-related variables were determined: maternal age, obesity (prepregnancy BMI ≥ 30.0 kg/m2), parity, preeclampsia, maternal fever ≥38.0 °C, smoking, gestational age at delivery, fetal sex, birth weight z-score, mode of delivery, and type of onset of labour. RESULTS ZigZag pattern occurred in 582/5150 (11.3 %) cases, and only in childbirths after 37 weeks of gestation. Fetal male gender (OR 3.29; 95 % CI 2.70-4.02), nulliparous pregnancy (OR 2.60; 95 % CI 2.15-3.15) and post-term gestational age (≥42 weeks) (OR 1.92; 95 % CI 1.47-2.48) were independently associated with the occurrence of ZigZag pattern. Among the three significant risk factors, clustering of two or three factors was associated with an increase of the ZigZag pattern occurrence risk to 5.0-16.4-fold (95 % CI 3.16-31.60). CONCLUSIONS ZigZag pattern occurred in term pregnancies after 37 weeks of gestation only. Fetal male gender, nulliparity and post-term pregnancy are significantly associated with ZigZag FHR pattern during the last two hours of labour. Identification of maternal, fetal and delivery-related variables are imperative in order to interpret correctly the findings of CTG and to prevent adverse neonatal outcome.
Collapse
Affiliation(s)
- Mikko Tarvonen
- Department of Obstetrics and Gynaecology, University of Helsinki, and Helsinki University Hospital, Finland.
| | - Petteri Hovi
- National Institute for Health and Welfare (THL), Helsinki, Finland; Children's Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Finland
| | - Susanna Sainio
- Finnish Red Cross Blood Transfusion Service, Helsinki, Finland
| | - Piia Vuorela
- Health and Social Welfare Department, City of Vantaa, Finland
| | - Sture Andersson
- Children's Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Finland
| | - Kari Teramo
- Department of Obstetrics and Gynaecology, University of Helsinki, and Helsinki University Hospital, Finland
| |
Collapse
|
27
|
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
| |
Collapse
|
28
|
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.
Collapse
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.
| |
Collapse
|
29
|
Sholapurkar SL. The proposed "physiological CTG interpretation" - true to its claims or "Anti"-physiological with serious safety issues? J Matern Fetal Neonatal Med 2020; 35:4240-4242. [PMID: 33487085 DOI: 10.1080/14767058.2020.1849099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
30
|
Fuentealba P, Illanes A, Ortmeier F. Cardiotocograph Data Classification Improvement by Using Empirical Mode Decomposition .. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:5646-5649. [PMID: 31947134 DOI: 10.1109/embc.2019.8856673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This work proposes to study the fetal heart rate (FHR) signal based on information about its dynamics as a signal resulting from the modulation by the autonomic nervous system. The analysis is performed using the complete ensemble empirical mode decomposition with adaptive noise (CEEMDAN) technique. The main idea is to extract a set of signal features based on that technique and also conventional time-domain features proposed in the literature in order to study their performance by using a support vector machine (SVM) as a classifier. As a hypothesis, we postulate that by including CEEMDAN based features, the classification performance should improve compared with the performance achieved by conventional features. The proposed method has been evaluated using real FHR data extracted from the open access CTU-UHB database. Results show that the classification performance improved from 67, 6% using only conventional features, to 71, 7% by incorporating CEEMDAN based features.
Collapse
|
31
|
Feng G, Quirk JG, Djurić PM. DISCOVERING CAUSALITIES FROM CARDIOTOCOGRAPHY SIGNALS USING IMPROVED CONVERGENT CROSS MAPPING WITH GAUSSIAN PROCESSES. PROCEEDINGS OF THE ... IEEE INTERNATIONAL CONFERENCE ON ACOUSTICS, SPEECH, AND SIGNAL PROCESSING. ICASSP (CONFERENCE) 2020; 2020:1309-1313. [PMID: 33551683 DOI: 10.1109/icassp40776.2020.9053462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Convergent cross mapping (CCM) is designed for causal discovery in coupled time series, where Granger causality may not be applicable because of a separability assumption. However, CCM is not robust to observation noise which limits its applicability on signals that are known to be noisy. Moreover, the parameters for state space reconstruction need to be selected using grid search methods. In this paper, we propose a novel improved version of CCM using Gaussian processes for discovery of causality from noisy time series. Specifically, we adopt the concept of CCM and carry out the key steps using Gaussian processes within a non-parametric Bayesian probabilistic framework in a principled manner. The proposed approach is first validated on simulated data, and then used for understanding the interaction between fetal heart rate and uterine activity in the last two hours before delivery and of interest in obstetrics. Our results indicate that uterine activity affects the fetal heart rate, which agrees with recent clinical studies.
Collapse
Affiliation(s)
- Guanchao Feng
- Department of Electrical and Computer Engineering, Stony Brook University
| | - J Gerald Quirk
- Department of Obstetrics/Gynecology, Stony Brook University Hospital
| | - Petar M Djurić
- Department of Electrical and Computer Engineering, Stony Brook University
| |
Collapse
|
32
|
Locatelli A, Lambicchi L, Incerti M, Bonati F, Ferdico M, Malguzzi S, Torcasio F, Calzi P, Varisco T, Paterlini G. Is perinatal asphyxia predictable? BMC Pregnancy Childbirth 2020; 20:186. [PMID: 32228514 PMCID: PMC7106720 DOI: 10.1186/s12884-020-02876-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 03/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of our study was to evaluate the association between perinatal asphyxia and hypoxic-ischemic encephalopathy (HIE) with the presence of ante and intrapartum risk factors and/or abnormal fetal heart rate (FHR) findings, in order to improve maternal and neonatal management. METHODS We did a prospective observational cohort study from a network of four hospitals (one Hub center with neonatal intensive care unit and three level I Spoke centers) between 2014 and 2016. Neonates of gestational age ≥ 35 weeks, birthweight ≥1800 g, without lethal malformations were included if diagnosed with perinatal asphyxia, defined as pH ≤7.0 or Base Excess (BE) ≤ - 12 mMol/L in Umbical Artery (UA) or within 1 h, 10 min Apgar < 5, or need for resuscitation > 10 min. FHR monitoring was classified in three categories according to the American College of Obstetricians and Gynecologists (ACOG). Pregnancies were divided into four classes: 1) low risk; 2) antepartum risk; 3) intrapartum risk; 4) and both ante and intrapartum risk. In the first six hours of life asphyxiated neonates were evaluated using the Thomson score (TS): if TS ≥ 5 neonates were transferred to Hub for further assessment; if TS ≥ 7 hypothermia was indicated. RESULTS Perinatal asphyxia occurred in 21.5‰ cases (321/14,896) and HIE in 1.1‰ (16/14,896). The total study population was composed of 281 asphyxiated neonates: 68/5152 (1.3%) born at Hub and 213/9744 (2.2%) at Spokes (p < 0.001, OR 0.59, 95% CI 0.45-0.79). 32/213 (15%) neonates were transferred from Spokes to Hub. Overall, 12/281 were treated with hypothermia. HIE occurred in 16/281 (5.7%) neonates: four grade I, eight grade II and four grade III. Incidence of HIE was not different between Hub and Spokes. Pregnancies resulting in asphyxiated neonates were classified as class 1) 1.1%, 2) 52.3%, 3) 3.2%, and 4) 43.4%. Sentinel events occurred in 23.5% of the cases and FHR was category II or III in 50.5% of the cases. 40.2% cases of asphyxia and 18.8% cases of HIE were not preceded by sentinel events or abnormal FHR. CONCLUSIONS We identified at least one risk factor associated with all cases of HIE and with most cases of perinatal asphyxia. In absence of risk factors, the probability of developing perinatal asphyxia resulted extremely low. FHR monitoring alone is not a reliable tool for detecting the probability of eventual asphyxia.
Collapse
Affiliation(s)
- Anna Locatelli
- Department of Obstetrics and Gynecology, ASST Vimercate, Carate B.za Hospital, University of Milano-Bicocca, Monza, Italy.
| | - Laura Lambicchi
- Department of Obstetrics and Gynecology, Fondazione MBBM, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Maddalena Incerti
- Department of Obstetrics and Gynecology, Fondazione MBBM, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Francesca Bonati
- Department of Obstetrics and Gynecology, ASST Vimercate, Carate B.za Hospital, University of Milano-Bicocca, Monza, Italy
| | - Massimo Ferdico
- Department of Obstetrics and Gynecology, ASST Vimercate, Vimercate Hospital, Vimercate, Italy
| | - Silvia Malguzzi
- Neonatal Intensive Care Unit, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Ferruccio Torcasio
- Department of Pediatrics, ASST Vimercate, Carate B.za Hospital, Vimercate, Italy
| | - Patrizia Calzi
- Department of Pediatrics, ASST Vimercate, Vimercate Hospital, Vimercate, Italy
| | - Tiziana Varisco
- Department of Pediatrics, ASST Monza, Desio Hospital, Desio, Italy
| | - Giuseppe Paterlini
- Neonatal Intensive Care Unit, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| |
Collapse
|
33
|
Independent Analysis of Decelerations and Resting Periods through CEEMDAN and Spectral-Based Feature Extraction Improves Cardiotocographic Assessment. APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app9245421] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Fetal monitoring is commonly based on the joint recording of the fetal heart rate (FHR) and uterine contraction signals obtained with a cardiotocograph (CTG). Unfortunately, CTG analysis is difficult, and the interpretation problems are mainly associated with the analysis of FHR decelerations. From that perspective, several approaches have been proposed to improve its analysis; however, the results obtained are not satisfactory enough for their implementation in clinical practice. Current clinical research indicates that a correct CTG assessment requires a good understanding of the fetal compensatory mechanisms. In previous works, we have shown that the complete ensemble empirical mode decomposition with adaptive noise, in combination with time-varying autoregressive modeling, may be useful for the analysis of those characteristics. In this work, based on this methodology, we propose to analyze the FHR deceleration episodes separately. The main hypothesis is that the proposed feature extraction strategy applied separately to the complete signal, deceleration episodes, and resting periods (between contractions), improves the CTG classification performance compared with the analysis of only the complete signal. Results reveal that by considering the complete signal, the classification performance achieved 81.7% quality. Then, including information extracted from resting periods, it improved to 83.2%.
Collapse
|
34
|
Toomey PC, Oppenheimer L. Prediction of Hypoxic Acidemia in Last 2 Hours of Labour in Low-Risk Women. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1564-1570. [PMID: 30885507 DOI: 10.1016/j.jogc.2018.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Prediction of hypoxic acidemia in neonates using cardiotocogram (CTG) features continues to be challenging. The objective of this study was to explore the association between contraction frequency and fetal heart rate characteristics with hypoxic acidemia in low-risk women in labour. METHODS Cases were singleton, vertex, in labour with umbilical artery pH ≤7.05. Controls were the next consecutive birth with pH ≥7.15, matched for gestational age, maternal age, and parity. Obstetrical complications and maternal comorbidities were excluded. CTG features were tabulated for the last 2 hours of labour. "Cut-off points" above which acidemia is more likely were calculated for significant variables (Canadian Task Force Classification II-2). RESULTS A total of 190 case-control pairs were included. Among cases we observed greater marked variability, tachycardia, variable and late decelerations, and fewer accelerations and early decelerations. A conditional logistic regression model included tachycardia, accelerations, total decelerations, and contractions. Tachycardia and total decelerations (variable, late) were significant. Tachycardia was most specific in predicting neonatal acidemia, whereas total (variable, late) decelerations were most sensitive. Late decelerations alone and total (variable, late) decelerations were similarly predictive for detecting neonatal acidemia using receiver-operating characteristic analysis; tachycardia was least discriminatory. Acidemic neonates were more likely to have CTGs with ≥11 late decelerations, ≥15 total decelerations (variable, late), and at least 80 minutes of tachycardia in the last 2 hours of labour. CONCLUSION Tachycardia, late decelerations, and total (variable, late) decelerations were associated with acidosis in our population. Identifying "cut-off" points for the frequency of significant CTG features should be explored as a potential screening tool for neonatal acidemia.
Collapse
Affiliation(s)
- Patricia C Toomey
- Department of Obstetrics and Gynecology, Winchester District Memorial Hospital, Winchester, ON.
| | | |
Collapse
|
35
|
Boudet S, Houzé de l'Aulnoit A, Demailly R, Peyrodie L, Beuscart R, Houzé de l'Aulnoit D. Fetal heart rate baseline computation with a weighted median filter. Comput Biol Med 2019; 114:103468. [PMID: 31577964 DOI: 10.1016/j.compbiomed.2019.103468] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 09/14/2019] [Accepted: 09/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Automated fetal heart rate (FHR) analysis removes inter- and intra-expert variability, and is a promising solution for reducing the occurrence of fetal acidosis and the implementation of unnecessary medical procedures. The first steps in automated FHR analysis are determination of the baseline, and detection of accelerations and decelerations (A/D). We describe a new method in which a weighted median filter baseline (WMFB) is computed and A/Ds are then detected. METHOD The filter weightings are based on the prior probability that the sampled FHR is in the baseline state or in an A/D state. This probability is computed by estimating the signal's stability at low frequencies and by progressively trimming the signal. Using a competition dataset of 90 previously annotated FHR recordings, we evaluated the WMFB method and 11 recently published literature methods against the ground truth of an expert consensus. The level of agreement between the WMFB method and the expert consensus was estimated by calculating several indices (primarily the morphological analysis discordance index, MADI). The agreement indices were then compared with the values for eleven other methods. We also compared the level of method-expert agreement with the level of interrater agreement. RESULTS For the WMFB method, the MADI indicated a disagreement of 4.02% vs. the consensus; this value is significantly lower (p<10-13) than that calculated for the best of the 11 literature methods (7.27%, for Lu and Wei's empirical mode decomposition method). The level of inter-expert agreement (according to the MADI) and the level of WMFB-expert agreement did not differ significantly (p=0.22). CONCLUSION The WMFB method reproduced the expert consensus analysis better than 11 other methods. No differences in performance between the WMFB method and individual experts were observed. The method Matlab source code is available under General Public Licence at http://utsb.univ-catholille.fr/fhr-wmfb.
Collapse
Affiliation(s)
- Samuel Boudet
- Univ Nord de France, UCLille, Faculté de Médecine et Maïeutique, Biomedical Signal Processing Unit (UTSB), F-59800, Lille, France.
| | - Agathe Houzé de l'Aulnoit
- Univ Nord de France, UCLille, Faculté de Médecine et Maïeutique, Biomedical Signal Processing Unit (UTSB), F-59800, Lille, France; Lille Catholic Hospital, Obstetrics Department, F-59020, Lille, France
| | - Romain Demailly
- Univ Nord de France, UCLille, Faculté de Médecine et Maïeutique, Biomedical Signal Processing Unit (UTSB), F-59800, Lille, France; Lille Catholic Hospital, Obstetrics Department, F-59020, Lille, France
| | - Laurent Peyrodie
- Yncréa École des hautes études d'ingénieur, Biomedical Signal Processing Unit (UTSB), 59800, Lille, France; I3MTO EA 4708 Orléans, France
| | - Régis Beuscart
- Univ Nord de France, CHU Lille, UDSL EA2694, F-59000, Lille, France
| | - Denis Houzé de l'Aulnoit
- Univ Nord de France, UCLille, Faculté de Médecine et Maïeutique, Biomedical Signal Processing Unit (UTSB), F-59800, Lille, France; Lille Catholic Hospital, Obstetrics Department, F-59020, Lille, France
| |
Collapse
|
36
|
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.
Collapse
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
| |
Collapse
|
37
|
Feng G, Quirk JG, Djurić PM. INFERENCE ABOUT CAUSALITY FROM CARDIOTOCOGRAPHY SIGNALS USING GAUSSIAN PROCESSES. PROCEEDINGS OF THE ... IEEE INTERNATIONAL CONFERENCE ON ACOUSTICS, SPEECH, AND SIGNAL PROCESSING. ICASSP (CONFERENCE) 2019; 2019:2852-2856. [PMID: 32158361 DOI: 10.1109/icassp.2019.8683052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In this paper, we propose a novel and simple method for discovery of Granger causality from noisy time series using Gaussian processes. More specifically, we adopt the concept of Granger causality, but instead of using autoregressive models for establishing it, we work with Gaussian processes. We show that information about the Granger causality is encoded in the hyper-parameters of the used Gaussian processes. The proposed approach is first validated on simulated data, and then used for understanding the interaction between fetal heart rate and uterine activity in the last two hours before delivery and of interest in obstetrics. Our results indicate that uterine activity affects fetal heart rate, which agrees with recent clinical studies.
Collapse
Affiliation(s)
- Guanchao Feng
- Department of Electrical and Computer Engineering, Stony Brook University
| | - J Gerald Quirk
- Department of Obstetrics/Gynecology, Stony Brook University Hospital
| | - Petar M Djurić
- Department of Electrical and Computer Engineering, Stony Brook University
| |
Collapse
|
38
|
Fratelli N, Mazzoni G, Maggi C, Gerosa V, Lojacono A, Prefumo F. Cerebroplacental ratio before induction of labour in normally grown fetuses at term and intrapartum fetal compromise. Eur J Obstet Gynecol Reprod Biol 2018; 227:78-80. [PMID: 29880419 DOI: 10.1016/j.ejogrb.2018.05.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 05/25/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Nicola Fratelli
- Department of Obstetrics and Gynaecology, University of Brescia, Spedali Civili di Brescia, Brescia, Italy
| | - Giorgia Mazzoni
- Department of Obstetrics and Gynaecology, University of Brescia, Spedali Civili di Brescia, Brescia, Italy
| | - Claudia Maggi
- Department of Obstetrics and Gynaecology, University of Brescia, Spedali Civili di Brescia, Brescia, Italy
| | - Vera Gerosa
- Department of Obstetrics and Gynaecology, University of Brescia, Spedali Civili di Brescia, Brescia, Italy
| | - Andrea Lojacono
- Department of Obstetrics and Gynaecology, University of Brescia, Spedali Civili di Brescia, Brescia, Italy
| | - Federico Prefumo
- Department of Obstetrics and Gynaecology, University of Brescia, Spedali Civili di Brescia, Brescia, Italy.
| |
Collapse
|
39
|
Rosenberg KR, Trevathan WR. Evolutionary perspectives on cesarean section. EVOLUTION MEDICINE AND PUBLIC HEALTH 2018. [DOI: 10.1093/emph/eoy006] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Karen R Rosenberg
- Department of Anthropology, University of Delaware, Newark, DE 19716, USA
| | - Wenda R Trevathan
- Department of Anthropology, New Mexico State University, Las Cruces, NM 80003, USA
| |
Collapse
|
40
|
Sholapurkar SL. Obstetrics at Decisive Crossroads Regarding Pattern-Recognition of Fetal Heart Rate Decelerations: Scientific Principles and Lessons From Memetics. J Clin Med Res 2018; 10:302-308. [PMID: 29511418 PMCID: PMC5827914 DOI: 10.14740/jocmr3307e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 12/20/2017] [Indexed: 12/05/2022] Open
Abstract
The survival of cardiotocography (CTG) as a tool for intrapartum fetal monitoring seems threatened somewhat unjustifiably and unwittingly despite the absence of better alternatives. Fetal heart rate (FHR) decelerations are center-stage (most important) in the interpretation of CTG with maximum impact on three-tier classification. The pattern-discrimination of FHR decelerations is inexorably linked to their nomenclature. Unscientific or flawed nomenclature of decelerations can explain the dysfunctional CTG interpretation leading to errors in detection of acidemic fetuses. There are three contrasting concepts about categorization of FHR decelerations: 1) all rapid decelerations (the vast majority) should be grouped as “variable” because they are predominantly due to cord-compression, 2) all decelerations are due to chemoreflex from fetal hypoxemia hence their timing is not important, and 3) FHR decelerations should be categorized into “early/late/variable” based primarily on their time relationship to contractions. These theoretical concepts are like memes (ideas/beliefs). Lessons from “memetics” are that the most popular, attractive or established beliefs may not necessarily be true, scientific, beneficial or even without harm. Decelerations coincident with contractions with trough corresponding to the peak of contractions cannot be explained by cord-compression or increasing hypoxia (from compromised uteroplacental perfusion, cord-compression or even cerebral hypoperfusion/anoxia purportedly conceivable from head-compression). Decelerations due to hypoxemia would be associated with delayed recovery of decelerations (lag phase). It is a scientific imperative to cast away disproven/falsified theories. Practices based on unscientific theories lead to patient harm. Clinicians should urgently adopt the categorization of FHR decelerations based primarily of the time relationship to contractions as originally proposed by Hon and Caldeyro-Barcia. This analytical review shows it to be underpinned by most robust physiological and scientific hypotheses unlike the other categorizations associated with untruthful hypotheses, irreconcilable fallacies and contradictions. Without truthful framework and meaningful pattern-recognition of FHR decelerations, the CTG will not fulfil its true potential.
Collapse
Affiliation(s)
- Shashikant L Sholapurkar
- Department of Obstetrics and Gynaecology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, UK.
| |
Collapse
|
41
|
Fergus P, Hussain A, Al-Jumeily D, Huang DS, Bouguila N. Classification of caesarean section and normal vaginal deliveries using foetal heart rate signals and advanced machine learning algorithms. Biomed Eng Online 2017; 16:89. [PMID: 28679415 PMCID: PMC5498914 DOI: 10.1186/s12938-017-0378-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 06/26/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Visual inspection of cardiotocography traces by obstetricians and midwives is the gold standard for monitoring the wellbeing of the foetus during antenatal care. However, inter- and intra-observer variability is high with only a 30% positive predictive value for the classification of pathological outcomes. This has a significant negative impact on the perinatal foetus and often results in cardio-pulmonary arrest, brain and vital organ damage, cerebral palsy, hearing, visual and cognitive defects and in severe cases, death. This paper shows that using machine learning and foetal heart rate signals provides direct information about the foetal state and helps to filter the subjective opinions of medical practitioners when used as a decision support tool. The primary aim is to provide a proof-of-concept that demonstrates how machine learning can be used to objectively determine when medical intervention, such as caesarean section, is required and help avoid preventable perinatal deaths. METHODS This is evidenced using an open dataset that comprises 506 controls (normal virginal deliveries) and 46 cases (caesarean due to pH ≤ 7.20-acidosis, n = 18; pH > 7.20 and pH < 7.25-foetal deterioration, n = 4; or clinical decision without evidence of pathological outcome measures, n = 24). Several machine-learning algorithms are trained, and validated, using binary classifier performance measures. RESULTS The findings show that deep learning classification achieves sensitivity = 94%, specificity = 91%, Area under the curve = 99%, F-score = 100%, and mean square error = 1%. CONCLUSIONS The results demonstrate that machine learning significantly improves the efficiency for the detection of caesarean section and normal vaginal deliveries using foetal heart rate signals compared with obstetrician and midwife predictions and systems reported in previous studies.
Collapse
Affiliation(s)
- Paul Fergus
- Applied Computing Research Group, Department of Computer Science, Faculty of Engineering and Technology, Liverpool John Moors University, Byron Street, Liverpool, L3 3AF, UK.
| | - Abir Hussain
- Applied Computing Research Group, Department of Computer Science, Faculty of Engineering and Technology, Liverpool John Moors University, Byron Street, Liverpool, L3 3AF, UK
| | - Dhiya Al-Jumeily
- Applied Computing Research Group, Department of Computer Science, Faculty of Engineering and Technology, Liverpool John Moors University, Byron Street, Liverpool, L3 3AF, UK
| | - De-Shuang Huang
- Institute of Machine Learning and Systems Biology, Tongji University, No. 4800 Caoan Road, Shanghai, 201804, China
| | - Nizar Bouguila
- Concordia Institute for Information Systems Engineering, Concorida University, 1455 de Maisonneuve Blvd West, EV7.632, Montreal, QC, HJ3G 2W1, Canada
| |
Collapse
|
42
|
Pruksanusak N, Thongphanang P, Chainarong N, Suntharasaj T, Kor-Anantakul O, Suwanrath C, Petpichetchian C. Agreement of three interpretation systems of intrapartum foetal heart rate monitoring by different levels of physicians. J OBSTET GYNAECOL 2017; 37:996-999. [PMID: 28599582 DOI: 10.1080/01443615.2017.1312314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A prospective study was conducted in centre in Southern Thailand, to evaluate agreement in EFM interpretation among various physicians in order to find out the most practical system for daily use. We found strong agreement of very normal FHR tracings among the FIGO, NICHD 3-tier and 5-tier systems. The NICHD 3-tier was more compatible with the FIGO system than 5-tier system. Overall inter-observer agreement was moderate for the NICHD 3-tier system while inter-observer agreement of 5-tier system was fair also the intra-observer agreement was higher in the NICHD 3-tier system. So the 3-tier systems are more suitable than the 5-tier system in general obstetric practice. Impact statement What is already known on this subject: The 3-tier and 5-tier systems were widely used in general obstetrics practice. What the results of this study add: The inter- and intra-observer agreement of NICHD 3-tier system was higher than the 5-tier system. What the implications are of these findings for clinical practice and/or further research: The 3-tier systems were more suitable than the 5-tier systems in general obstetrics practice.
Collapse
Affiliation(s)
- Ninlapa Pruksanusak
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
| | - Putthaporn Thongphanang
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
| | - Natthicha Chainarong
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
| | - Thitima Suntharasaj
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
| | - Ounjai Kor-Anantakul
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
| | - Chitkasaem Suwanrath
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
| | - Chusana Petpichetchian
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Prince of Songkla University , Songkhla , Thailand
| |
Collapse
|
43
|
Tahir Mahmood U, O’Gorman C, Marchocki Z, O’Brien Y, Murphy DJ. Fetal scalp stimulation (FSS) versus fetal blood sampling (FBS) for women with abnormal fetal heart rate monitoring in labor: a prospective cohort study. J Matern Fetal Neonatal Med 2017; 31:1742-1747. [DOI: 10.1080/14767058.2017.1326900] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Uzma Tahir Mahmood
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin, Ireland
| | - Catherine O’Gorman
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin, Ireland
| | - Zibi Marchocki
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin, Ireland
| | - Yvonne O’Brien
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin, Ireland
| | - Deirdre J. Murphy
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin, Ireland
| |
Collapse
|
44
|
Berazategui JP, Aguilar A, Escobedo M, Dannaway D, Guinsburg R, de Almeida MFB, Saker F, Fernández A, Albornoz G, Valera M, Amado D, Puig G, Althabe F, Szyld E. Risk factors for advanced resuscitation in term and near-term infants: a case-control study. Arch Dis Child Fetal Neonatal Ed 2017; 102:F44-F50. [PMID: 27269195 DOI: 10.1136/archdischild-2015-309525] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 05/09/2016] [Accepted: 05/10/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE (1) To determine which antepartum and/or intrapartum factors are associated with the need for advanced neonatal resuscitation (ANR) at birth in infants with gestational age (GA) ≥34 weeks. (2) To develop a risk score for the need for ANR in neonates with GA ≥34 weeks. DESIGN Prospective multicentre, case-control study. In total, 16 centres participated in this study: 10 in Argentina, 1 in Chile, 3 in Brazil and 2 in the USA. RESULTS A case-control study conducted from December 2011 to April 2013. Of a total of 61 593 births, 58 429 were reported as an GA ≥34 weeks, and of these, only 219 (0.37%) received ANR. After excluding 23 cases, 196 cases and 784 consecutive birth controls were included in the analysis. The final model was generated with three antepartum and seven intrapartum factors, which correctly classified 88.9% of the observations. The area under the receiver operating characteristic (AROC) performed to evaluate discrimination was 0.88, 95% CI 0.62 to 0.91. The AROC performed for external validity testing of the model in the validation sample was 0.87 with 95% CI 0.58 to 0.92. CONCLUSIONS We identified 10 risk factors significantly associated with the need for ANR in newborns ≥34 weeks. We developed a validated risk score that allows the identification of newborns at higher risk of need for ANR. Using this tool, the presence of specialised personnel in the delivery room may be designated more appropriately.
Collapse
Affiliation(s)
- Juan Pablo Berazategui
- Fundación para la Salud Materno Infantil, Buenos Aires, Argentina.,Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina.,Hospital Universitario Austral, Pilar, Buenos Aires, Argentina.,Hospital Juan A Fernández, Buenos Aires, Argentina
| | - Adriana Aguilar
- Fundación para la Salud Materno Infantil, Buenos Aires, Argentina
| | | | | | - Ruth Guinsburg
- Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brasil
| | | | | | - Ariel Fernández
- Fundación para la Salud Materno Infantil, Buenos Aires, Argentina.,Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
| | | | | | | | | | - Fernando Althabe
- Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
| | - Edgardo Szyld
- Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina.,University of Oklahoma, Oklahoma, USA.,Icahn School of Medicine at Mt. Sinai, USA.,Universidad Abierta Interamericana, Buenos Aires, Argentina
| | | |
Collapse
|
45
|
Sholapurkar SL. Re: Time to optimise and enforce training in interpretation of intrapartum cardiotocograph: Time is not ripe for imposing pass/fail licensing examination in cardiotocography interpretation in UK. BJOG 2016; 124:168-169. [PMID: 28009118 DOI: 10.1111/1471-0528.14402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2016] [Indexed: 11/29/2022]
|
46
|
Ugwumadu A. Author's reply re: Time to optimise and enforce training in interpretation of intrapartum cardiotocograph. BJOG 2016; 124:169-170. [PMID: 28009125 DOI: 10.1111/1471-0528.14405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Austin Ugwumadu
- Department of Obstetrics & Gynaecology, St George's, University of London, London, UK
| |
Collapse
|
47
|
Martí Gamboa S, Lapresta Moros M, Pascual Mancho J, Lapresta Moros C, Castán Mateo S. Deceleration area and fetal acidemia. J Matern Fetal Neonatal Med 2016; 30:2578-2584. [DOI: 10.1080/14767058.2016.1256993] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
48
|
Sholapurkar SL. International consensus on intrapartum cardiotocography should be underpinned by sound scientific foundation. J Matern Fetal Neonatal Med 2016; 30:2340-2341. [PMID: 27756167 DOI: 10.1080/14767058.2016.1247801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Shashikant L Sholapurkar
- a Department of Obstetrics and Gynaecology , Royal United Hospital Bath NHS Foundation Trust , Bath , UK
| |
Collapse
|
49
|
Johnston JC, Wester K, Sartwelle TP. Neurological Fallacies Leading to Malpractice: A Case Studies Approach. Neurol Clin 2016; 34:747-73. [PMID: 27445252 DOI: 10.1016/j.ncl.2016.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A young woman presents with an intracranial arachnoid cyst. Another is diagnosed with migraine headache. An elderly man awakens with a stroke. And a baby delivered vaginally after 2 hours of questionable electronic fetal monitoring patterns grows up to have cerebral palsy. These seemingly disparate cases share a common underlying theme: medical myths. Myths that may lead not only to misdiagnosis and treatment harms but to seemingly never-ending medical malpractice lawsuits, potentially culminating in a settlement or judgment against an unsuspecting neurologist. This article provides a case studies approach exposing the fallacies and highlighting proper management of these common neurologic presentations.
Collapse
Affiliation(s)
- James C Johnston
- Legal Medicine Consultants, 1150 N Loop 1604 West, Suite 108-625, San Antonio, TX 78248, USA.
| | - Knut Wester
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen 5021, Norway
| | | |
Collapse
|
50
|
Lear CA, Galinsky R, Wassink G, Yamaguchi K, Davidson JO, Westgate JA, Bennet L, Gunn AJ. The myths and physiology surrounding intrapartum decelerations: the critical role of the peripheral chemoreflex. J Physiol 2016; 594:4711-25. [PMID: 27328617 DOI: 10.1113/jp271205] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 02/17/2016] [Indexed: 11/08/2022] Open
Abstract
A distinctive pattern of recurrent rapid falls in fetal heart rate, called decelerations, are commonly associated with uterine contractions during labour. These brief decelerations are mediated by vagal activation. The reflex triggering this vagal response has been variably attributed to a mechanoreceptor response to fetal head compression, to baroreflex activation following increased blood pressure during umbilical cord compression, and/or a Bezold-Jarisch reflex response to reduced venous return from the placenta. Although these complex explanations are still widespread today, there is no consistent evidence that they are common during labour. Instead, the only mechanism that has been systematically investigated, proven to be reliably active during labour and, crucially, capable of producing rapid decelerations is the peripheral chemoreflex. The peripheral chemoreflex is triggered by transient periods of asphyxia that are a normal phenomenon associated with all uterine contractions. This should not cause concern as the healthy fetus has a remarkable ability to adapt to these repeated but short periods of asphyxia. This means that the healthy fetus is typically not at risk of hypotension and injury during uncomplicated labour even during repeated brief decelerations. The physiologically incorrect theories surrounding decelerations that ignore the natural occurrence of repeated asphyxia probably gained widespread support to help explain why many babies are born healthy despite repeated decelerations during labour. We propose that a unified and physiological understanding of intrapartum decelerations that accepts the true nature of labour is critical to improve interpretation of intrapartum fetal heart rate patterns.
Collapse
Affiliation(s)
- Christopher A Lear
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Robert Galinsky
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Guido Wassink
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Kyohei Yamaguchi
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynaecology, Mie University Graduate School of Medicine, Mie, Japan
| | - Joanne O Davidson
- 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.,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.,Starship Children's Hospital, Auckland, New Zealand
| |
Collapse
|