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Jaques LA, Stermer PRR, de Oliveira AKB, Marães VRFDS, Jácomo RH, Alves AT, Cunha KDC, da Silva ML. Autonomic modulation of heart rate during physical activity in pregnant women: A systematic review of literature. Pacing Clin Electrophysiol 2024; 47:802-814. [PMID: 38577940 DOI: 10.1111/pace.14976] [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: 12/18/2023] [Revised: 03/05/2024] [Accepted: 03/16/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND There are important physiological changes in the heart rate autonomic modulation in pregnant women and these changes may affect the way their bodies respond to exercise stimulus. The objective of this review is to verify the physical exercise influence on autonomic modulation of heart rate in pregnant women. METHODS This study is a Systematic Review. The electronic databases used to search for the studies were Cochrane Library, MEDLINE via PUBMED, Regional Health Portal and EMBASE. Experimental studies that evaluated heart-rate variability in pregnant women practicing physical exercises were included. And articles that addressed only fetal heart-rate variability, case reports, congress abstracts, clinical trial protocols without results, preprints, and gray literature were excluded. There were no language or publication year restrictions. The descriptors used in the Search were Cardiac Chronotropism, Sympathetic Nervous System, Pregnancy, and Physical Exercise. For statistical analysis, the fixed effect model was used. RESULTS A total of 3106 articles were found, and 12 studies were included, which 5 were nonrandomized clinical trials, 4 were randomized clinical trials, and 3 were cross-sectional studies. Three hundred and four pregnant women were included in the studies. The application of physical exercise was varied, but in general they used aerobic exercises and with increased variability of the heart rate and reflex on the autonomic modulation of heart rate. CONCLUSION Most studies demonstrate benefits heart rate in pregnant women, but limited research makes it hard to compare specific types of exercise and larger studies are needed to identify the best exercise.
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Affiliation(s)
- Lucas Alves Jaques
- Center of Biological and Health Sciences, State University of Pará, Marabá, Pará State, Brazil
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Widatalla N, Alkhodari M, Koide K, Yoshida C, Kasahara Y, Saito M, Kimura Y, Habib Khandoker A. Prediction of fetal RR intervals from maternal factors using machine learning models. Sci Rep 2023; 13:19765. [PMID: 37957257 PMCID: PMC10643643 DOI: 10.1038/s41598-023-46920-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/07/2023] [Indexed: 11/15/2023] Open
Abstract
Previous literature has highlighted the importance of maternal behavior during the prenatal period for the upbringing of healthy adults. During pregnancy, fetal health assessments are mainly carried out non-invasively by monitoring fetal growth and heart rate (HR) or RR interval (RRI). Despite this, research entailing prediction of fHRs from mHRs is scarce mainly due to the difficulty in non-invasive measurements of fetal electrocardiogram (fECG). Also, so far, it is unknown how mHRs are associated with fHR over the short term. In this study, we used two machine learning models, support vector regression (SVR) and random forest (RF), for predicting average fetal RRI (fRRI). The predicted fRRI values were compared with actual fRRI values calculated from non-invasive fECG. fRRI was predicted from 13 maternal features that consisted of age, weight, and non-invasive ECG-derived parameters that included HR variability (HRV) and R wave amplitude variability. 156 records were used for training the models and the results showed that the SVR model outperformed the RF model with a root mean square error (RMSE) of 29 ms and an average error percentage (< 5%). Correlation analysis between predicted and actual fRRI values showed that the Spearman coefficient for the SVR and RF models were 0.31 (P < 0.001) and 0.19 (P < 0.05), respectively. The SVR model was further used to predict fRRI of 14 subjects who were not included in the training. The latter prediction results showed that individual error percentages were (≤ 5%) except in 3 subjects. The results of this study show that maternal factors can be potentially used for the assessment of fetal well-being based on fetal HR or RRI.
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Affiliation(s)
- Namareq Widatalla
- Khalifa University, Abu Dhabi, UAE.
- Next Generation Biological Information Technology, Tohoku University Graduate School of Biomedical Engineering, Sendai, Japan.
| | - Mohanad Alkhodari
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center, Khalifa University, Abu Dhabi, UAE
- Radcliffe Department of Medicine, Cardiovascular Clinical Research Facility, University of Oxford, Oxford, UK
| | - Kunihiro Koide
- Department of Maternal and Fetal Therapeutics, Tohoku University Graduate School of Medicine, Sendai, Japan
- Advanced Interdisciplinary Biomedical Engineering, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Chihiro Yoshida
- Department of Maternal and Fetal Therapeutics, Tohoku University Graduate School of Medicine, Sendai, Japan
- Advanced Interdisciplinary Biomedical Engineering, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshiyuki Kasahara
- Next Generation Biological Information Technology, Tohoku University Graduate School of Biomedical Engineering, Sendai, Japan
- Department of Maternal and Fetal Therapeutics, Tohoku University Graduate School of Medicine, Sendai, Japan
- Advanced Interdisciplinary Biomedical Engineering, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Maternal and Child Health Care Medical Science, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masatoshi Saito
- Next Generation Biological Information Technology, Tohoku University Graduate School of Biomedical Engineering, Sendai, Japan
- Department of Maternal and Fetal Therapeutics, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Maternal and Child Health Care Medical Science, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshitaka Kimura
- Next Generation Biological Information Technology, Tohoku University Graduate School of Biomedical Engineering, Sendai, Japan
- Department of Maternal and Fetal Therapeutics, Tohoku University Graduate School of Medicine, Sendai, Japan
- Advanced Interdisciplinary Biomedical Engineering, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ahsan Habib Khandoker
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center, Khalifa University, Abu Dhabi, UAE
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Nichting TJ, Bester M, Joshi R, Mischi M, van der Ven M, van der Woude DAA, Oei SG, van Laar JOEH, Vullings R. Evidence and clinical relevance of maternal-fetal cardiac coupling: A scoping review. PLoS One 2023; 18:e0287245. [PMID: 37437012 DOI: 10.1371/journal.pone.0287245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 06/01/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Researchers have long suspected a mutual interaction between maternal and fetal heart rhythms, referred to as maternal-fetal cardiac coupling (MFCC). While several studies have been published on this phenomenon, they vary in terms of methodologies, populations assessed, and definitions of coupling. Moreover, a clear discussion of the potential clinical implications is often lacking. Subsequently, we perform a scoping review to map the current state of the research in this field and, by doing so, form a foundation for future clinically oriented research on this topic. METHODS A literature search was performed in PubMed, Embase, and Cochrane. Filters were only set for language (English, Dutch, and German literature were included) and not for year of publication. After screening for the title and the abstract, a full-text evaluation of eligibility followed. All studies on MFCC were included which described coupling between heart rate measurements in both the mother and fetus, regardless of the coupling method used, gestational age, or the maternal or fetal health condition. RESULTS 23 studies remained after a systematic evaluation of 6,672 studies. Of these, 21 studies found at least occasional instances of MFCC. Methods used to capture MFCC are synchrograms and corresponding phase coherence indices, cross-correlation, joint symbolic dynamics, transfer entropy, bivariate phase rectified signal averaging, and deep coherence. Physiological pathways regulating MFCC are suggested to exist either via the autonomic nervous system or due to the vibroacoustic effect, though neither of these suggested pathways has been verified. The strength and direction of MFCC are found to change with gestational age and with the rate of maternal breathing, while also being further altered in fetuses with cardiac abnormalities and during labor. CONCLUSION From the synthesis of the available literature on MFCC presented in this scoping review, it seems evident that MFCC does indeed exist and may have clinical relevance in tracking fetal well-being and development during pregnancy.
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Affiliation(s)
- Thomas J Nichting
- Department of Gynaecology and Obstetrics, Veldhoven, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven MedTech Innovation Centre, Eindhoven, The Netherlands
| | - Maretha Bester
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven MedTech Innovation Centre, Eindhoven, The Netherlands
- Department of Patient Care and Monitoring, Philips Research, Eindhoven, The Netherlands
| | - Rohan Joshi
- Department of Patient Care and Monitoring, Philips Research, Eindhoven, The Netherlands
| | - Massimo Mischi
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven MedTech Innovation Centre, Eindhoven, The Netherlands
| | - Myrthe van der Ven
- Department of Gynaecology and Obstetrics, Veldhoven, The Netherlands
- Eindhoven MedTech Innovation Centre, Eindhoven, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Daisy A A van der Woude
- Department of Gynaecology and Obstetrics, Veldhoven, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven MedTech Innovation Centre, Eindhoven, The Netherlands
| | - S Guid Oei
- Department of Gynaecology and Obstetrics, Veldhoven, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven MedTech Innovation Centre, Eindhoven, The Netherlands
| | - Judith O E H van Laar
- Department of Gynaecology and Obstetrics, Veldhoven, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven MedTech Innovation Centre, Eindhoven, The Netherlands
| | - Rik Vullings
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven MedTech Innovation Centre, Eindhoven, The Netherlands
- Nemo Healthcare, Veldhoven, The Netherlands
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Widatalla N, Khandoker A, Alkhodari M, Koide K, Yoshida C, Kasahara Y, Kimura Y, Saito M. Similarities between maternal and fetal RR interval tachograms and their association with fetal development. Front Physiol 2022; 13:964755. [PMID: 36479345 PMCID: PMC9721082 DOI: 10.3389/fphys.2022.964755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/02/2022] [Indexed: 12/26/2023] Open
Abstract
An association between maternal and fetal heart rate (HR) has been reported but, so far, little is known about its physiological implication and importance relative to fetal development. Associations between both HRs were investigated previously by performing beat-by-beat coupling analysis and correlation analysis between average maternal and fetal HRs. However, studies reporting on the presence of similarities between maternal and fetal HRs or RR intervals (RRIs) over the short term (e.g., 5-min) at different gestational ages (GAs) are scarce. Here, we demonstrate the presence of similarities in the variations exhibited by maternal and fetal RRl tachograms (RRITs). To quantify the same similarities, a cross-correlation (CC) analysis between resampled maternal and fetal RRITs was conducted; RRITs were obtained from non-invasive electrocardiogram (ECG). The degree of similarity between maternal and fetal RRITs (bmfRRITs) was quantified by calculating four CC coefficients. CC analysis was performed for a total of 330 segments (two 5-min segments from 158 subjects and one 5-min from 14 subjects). To investigate the association of the similarity bmfRRITs with fetal development, the linear correlation between the calculated CC coefficients and GA was calculated. The results from the latter analysis showed that similarities bmfRRITs are common occurrences, they can be negative or positive, and they increase with GA suggesting the presence of a regulation that is associated with proper fetal development. To get an insight into the physiological mechanisms involved in the similarity bmfRRITs, the association of the same similarity with maternal and fetal HR variability (HRV) was investigated by comparing the means of two groups in which one of them had higher CC values compared to the other. The two groups were created by using the data from the 158 subjects where fetal RRI (fRRI) calculation from two 5-min ECG segments was feasible. The results of the comparison showed that the maternal very low frequency (VLF) HRV parameter is potentially associated with the similarity bmfRRITs implying that maternal hormones could be linked to the regulations involved in the similarity bmfRRITs. Our findings in this study reinforce the role of the maternal intrauterine environment on fetal development.
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Affiliation(s)
- Namareq Widatalla
- Graduate School of Biomedical Engineering, Tohoku University, Sendai, Japan
| | - Ahsan Khandoker
- Healthcare Engineering Innovation Center, Department of Biomedical Engineering, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Mohanad Alkhodari
- Healthcare Engineering Innovation Center, Department of Biomedical Engineering, Khalifa University, Abu Dhabi, United Arab Emirates
- Cardiovascular Clinical Research Facility, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Kunihiro Koide
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Chihiro Yoshida
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshiyuki Kasahara
- Graduate School of Biomedical Engineering, Tohoku University, Sendai, Japan
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshitaka Kimura
- Graduate School of Biomedical Engineering, Tohoku University, Sendai, Japan
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masatoshi Saito
- Graduate School of Biomedical Engineering, Tohoku University, Sendai, Japan
- Tohoku University Graduate School of Medicine, Sendai, Japan
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Alkhodari M, Widatalla N, Wahbah M, Al Sakaji R, Funamoto K, Krishnan A, Kimura Y, Khandoker AH. Deep learning identifies cardiac coupling between mother and fetus during gestation. Front Cardiovasc Med 2022; 9:926965. [PMID: 35966548 PMCID: PMC9372367 DOI: 10.3389/fcvm.2022.926965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/29/2022] [Indexed: 11/18/2022] Open
Abstract
In the last two decades, stillbirth has caused around 2 million fetal deaths worldwide. Although current ultrasound tools are reliably used for the assessment of fetal growth during pregnancy, it still raises safety issues on the fetus, requires skilled providers, and has economic concerns in less developed countries. Here, we propose deep coherence, a novel artificial intelligence (AI) approach that relies on 1 min non-invasive electrocardiography (ECG) to explain the association between maternal and fetal heartbeats during pregnancy. We validated the performance of this approach using a trained deep learning tool on a total of 941 one minute maternal-fetal R-peaks segments collected from 172 pregnant women (20–40 weeks). The high accuracy achieved by the tool (90%) in identifying coupling scenarios demonstrated the potential of using AI as a monitoring tool for frequent evaluation of fetal development. The interpretability of deep learning was significant in explaining synchronization mechanisms between the maternal and fetal heartbeats. This study could potentially pave the way toward the integration of automated deep learning tools in clinical practice to provide timely and continuous fetal monitoring while reducing triage, side-effects, and costs associated with current clinical devices.
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Affiliation(s)
- Mohanad Alkhodari
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center, Khalifa University, Abu Dhabi, United Arab Emirates
- *Correspondence: Mohanad Alkhodari
| | - Namareq Widatalla
- Graduate School of Biomedical Engineering, Tohoku University, Sendai, Japan
| | - Maisam Wahbah
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Raghad Al Sakaji
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Kiyoe Funamoto
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Anita Krishnan
- Division of Cardiology, Children's National Hospital, Washington, DC, United States
| | - Yoshitaka Kimura
- Department of Maternal and Child Health Care Medical Science, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ahsan H. Khandoker
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center, Khalifa University, Abu Dhabi, United Arab Emirates
- Ahsan H. Khandoker
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Khandoker AH, Wahbah M, Yoshida C, Kasahara Y, Funamoto K, Niizeki K, Kimura Y. Investigating the effect of cholinergic and adrenergic blocking agents on maternal-fetal heart rates and their interactions in mice fetuses. Biol Open 2022; 11:274473. [PMID: 35188546 PMCID: PMC9019529 DOI: 10.1242/bio.058999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 02/15/2022] [Indexed: 11/20/2022] Open
Abstract
This study examines the role of autonomic control of maternal and fetal heart rate variability (MHRV and FHRV) and their heartbeats phase coupling prevalence (CPheartbeat) in mice. The subjects are divided into three groups: control with saline, cholinergic blockade with atropine, and β-adrenergic blockade with propranolol. Electrocardiogram signals of 27 anesthetized pregnant mice and 48 fetuses were measured for 20 min (drugs were administered after 10 min). For the coupling analysis, different maternal heartbeats were considered for one fetal beat. Results show that saline infusion did not produce any significant changes in MHRV and FHRV, as well as CPheartbeat. Atropine increased maternal HR (MHR) and decreased MHRV significantly without any considerable effect on fetal HR (FHR) and FHRV. Propranolol infusion did not produce any significant changes in MHR and MHRV, but significantly decreased FHR and increased FHRV. Moreover, atropine had led to a decrease in CPheartbeat when considering two and three maternal beats, and an increase for four beats; while propranolol resulted in a decrease for two heartbeats, but an increase for four and five beats. The proposed approach is useful for assessing the impact of maternal autonomic modulation activity on fetal distress and obstetric complications prevalent in pregnant mothers. Summary: Autonomic development of fetal mice is analyzed through electrocardiography. Saline infusion does not alter maternal and fetal heart rate variation and coupling significantly. Atropine increases maternal heart rate, while propranolol lowers fetal heart rate.
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Affiliation(s)
- Ahsan H Khandoker
- Health Engineering Innovation Center (HEIC), Department of Biomedical Engineering, Khalifa University, Abu Dhabi 127788, United Arab Emirates
| | - Maisam Wahbah
- Health Engineering Innovation Center (HEIC), Department of Biomedical Engineering, Khalifa University, Abu Dhabi 127788, United Arab Emirates
| | - Chihiro Yoshida
- Graduate School of Medicine, Tohoku University, Sendai, Japan
| | | | - Kiyoe Funamoto
- Health Engineering Innovation Center (HEIC), Department of Biomedical Engineering, Khalifa University, Abu Dhabi 127788, United Arab Emirates
| | - Kyuichi Niizeki
- Graduate School of Bio-System Engineering, Yamagata University, Yamagata, Japan
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da Silva DF, Mohammad S, Hutchinson KA, Adamo KB. Determination of minimal recording period to assess resting heart rate variability during pregnancy. Appl Physiol Nutr Metab 2020; 45:431-436. [DOI: 10.1139/apnm-2019-0351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Traditionally, resting heart rate variability (rHRV) is measured for 10 min using the last 5 min for analyses (e.g., criterion period). It is unknown whether the measurement period can be shortened in pregnant women as there are currently no established standards. We aimed to compare shorter time segments (e.g., from the 1st to 10th minutes) of the parasympathetic index natural logarithm transformation of root mean square of successive R–R differences (Ln rMSSD) with the criterion period in pregnant and nonpregnant women. Twelve pregnant (age: 30.8 ± 3.4 years; gestational age: 20.1 ± 5.0 weeks) and 15 nonpregnant women (age: 29.8 ± 4.0 years) were included. rHRV was measured using a portable heart rate monitor for 10 min while sitting. Ln rMSSD difference/agreement between shorter time segments and criterion period was analyzed. The result observed between the 4th–5th minutes was the shortest time segment not different from/highly agreed with the criterion period in pregnant women (difference [95% confidence interval (CI)]: −0.10 [−0.22 to 0.02]/bias ± 1.96 × SD: −0.06 [−0.38 to 0.25]). In nonpregnant women, the 2nd–3rd-minute segment was the shortest with similar results (difference [95% CI]: −0.04 [−0.15 to 0.07]/bias ± 1.96 × SD: −0.03 [−0.39 to 0.32]). The Ln rMSSD was found to be stable from the 5th–10th minutes and the 3rd–10th minutes in pregnant and nonpregnant women, respectively. A shortened rHRV assessment can increase its applicability in clinical/exercise-training settings. Novelty Ln rMSSD can be measured for 5 min in pregnant women, with the last 1-min segment analyzed. The last 1-min segment from 3 min can be used for rHRV measurement in nonpregnant women. The shortened rHRV assessment can facilitate its applicability in clinical/exercise-training settings.
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Affiliation(s)
- Danilo Fernandes da Silva
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1L 6N5, Canada
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1L 6N5, Canada
| | - Shuhiba Mohammad
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1L 6N5, Canada
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1L 6N5, Canada
| | - Kelly Ann Hutchinson
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1L 6N5, Canada
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1L 6N5, Canada
| | - Kristi Bree Adamo
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1L 6N5, Canada
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Alangari HM, Kimura Y, Khandoker AH. Preliminary Evaluation of Fetal Congenital Heart Defects Changes on Fetal-Maternal Heart Rate Coupling Strength. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2019; 2018:251-254. [PMID: 30440385 DOI: 10.1109/embc.2018.8512272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Monitoring fetal heart rate in an important aspect in evaluating fetal well being. Maternal-fetal interaction has shown evolution during fetal maturation. In this work, we studied maternal-fetal heart rate synchronization in early and late gestation fetuses. We also evaluated variations in the synchronization due to congenital heart defect (CHD). Maternal-fetal heart rate synchronization for 22 early gestation (Age < 32 weeks), $late gestation (Age >32 weeks) and 7 CHD fetuses (5 of them with gestational age < 32 weeks). The synchronization ratio between the mother and the fetus was more localized at certain fetus heart rate in the early gestation group while it was spreading over more fetal heart rate for the late group. For example, for maternal primary cycle of 3 beat- to-beat (m=3), the synchronization ratio of 5 fetus beats (n=5) contributed 60±30% of the whole coupling ratios for the early group while it contributed 30°30% for the late group (p< 0.01). On the other hand, the coupling ratio of m:n=3:7 contributed 4±17% of the early group and 13±24% for the late group (p< 0.05). The standard deviation of the phase coherence index $(\lambda_{-\mathrm{S}\mathrm{D}})$ for both the late and the CHD groups were significantly higher than the early group at different values. For example, $\lambda -\mathrm{S}\mathrm{D} was 0.006\pm 0.004$ for the early group while it was 0.009±0.008 for the late group (p< 0.01) and 0.01± 0.002 for the CHD group (p< 0.01) for m=3. The variation between the early and late normal groups might indicate a healthy development of the autonomic nervous system while the higher variation in the CHD group could be a good marker for impairment of the cardiac autonomic activity. Further coupling analysis with more abnormal cases is needed to verify these findings.
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Hoyer D, Schmidt A, Gustafson KM, Lobmaier SM, Lakhno I, van Leeuwen P, Cysarz D, Preisl H, Schneider U. Heart rate variability categories of fluctuation amplitude and complexity: diagnostic markers of fetal development and its disturbances. Physiol Meas 2019; 40:064002. [PMID: 31071684 DOI: 10.1088/1361-6579/ab205f] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE In fetal diagnosis the myriad and diversity of heart rate variability (HRV) indices prevents a comparable routine evaluation of disturbances in fetal development and well-being. The work aims at the extraction of a small set of HRV key indices that could help to establish a universal, overarching tool to screen for any disturbance. APPROACH HRV indices were organized in categories of short-term (prefix s) and long-term (prefix l) amplitude fluctuations (AMP), complexity (COMP), and patterns (PATTERN) and common representatives for each category were extracted. This procedure was done with respect to the diagnostic value in the evaluation of the maturation age throughout the second and complete third trimester of pregnancy as well as to potential differences associated with maternal life-style factors (physical exercise, smoking), nutrient intervention (docosahexaenoic acid (DHA) supplementation), and complications of pregnancy (gestational diabetes mellitus (GDM), intra-uterine growth restriction (IUGR)). MAIN RESULTS We found a comprehensive minimal set that includes [lAMP: short term variation (STV), initially introduced in cardiotocography, sAMP: heart rate increase across one interbeat interval of phase rectified averaged signal - acceleration capacity (ACst1), lCOMP: scale 4 multi-scale entropy (MSE4), PATTERN: skewness] for the maturation age prediction, and partly overlapping [lAMP: STV, sAMP: ACst1, sCOMP: Lempel Ziv complexity (LZC)] for the discrimination of the deviations. SIGNIFICANCE The minimal set of category-based HRV representatives allows for a screening of fetal development and well-being. These results are an important step towards a universal and comparable diagnostic tool for the early identification of developmental disturbances. Novelty & Significance Fetal development and its disturbances have been reported to be associated with a multiplicity of HRV indices. Furthermore, these HRV indices change with maturation. We propose the abstraction of HRV categories defined by short- and long-term fluctuation amplitude, complexity, and pattern indices that cover all relevant aspects of maturational age, behavioral influences and a series of pathological disturbances. The study data are provided by multiple centers. Our approach is an important step towards the goal of a standardized diagnostic tool for early identification of fetal developmental disturbances with respect to the reduction of serious complications in the later life.
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Affiliation(s)
- Dirk Hoyer
- Hans Berger Department of Neurology, Biomagnetic Center, Jena University Hospital, Jena 07747, Germany
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Khandoker AH, Schulz S, Al-Angari HM, Voss A, Kimura Y. Alterations in Maternal-Fetal Heart Rate Coupling Strength and Directions in Abnormal Fetuses. Front Physiol 2019; 10:482. [PMID: 31105586 PMCID: PMC6498890 DOI: 10.3389/fphys.2019.00482] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 04/08/2019] [Indexed: 11/24/2022] Open
Abstract
Because fetal gas exchange takes place via the maternal placenta, there has been growing interests in investigating the patterns and directions of maternal-fetal cardiac coupling to better understand the mechanisms of placental gas transfer. We recently reported the evidence of short-term maternal–fetal cardiac couplings in normal fetuses by using Normalized Short Time Partial Directed Coherence (NSTPDC) technique. Our results have shown weakening of coupling from fetal heart rate to maternal heart rate as the fetal development progresses while the influence from maternal to fetal heart rate coupling behaves oppositely as it shows increasing coupling strength that reaches its maximum at mid gestation. The aim of this study is to test if maternal-fetal coupling patterns change in various types of abnormal cases of pregnancies. We applied NSTPDC on simultaneously recorded fetal and maternal beat-by-beat heart rates collected from fetal and maternal ECG signals of 66 normal and 19 abnormal pregnancies. NSTPDC fetal-to-maternal coupling analyses revealed significant differences between the normal and abnormal cases (normal: normalized factor (NF) = −0.21 ± 0.85, fetus-to-mother coupling area (A_fBBI→ mBBI) = 0.44 ± 0.13, mother-to-fetus coupling area (A_mBBI→ fBBI) = 0.46 ± 0.12; abnormal: NF = −1.66 ± 0.77, A_fBBI→ mBBI = 0.08 ± 0.12, A_mBBI→ fBBI = 0.66 ± 0.24; p < 0.01). In conclusion, maternal-fetal cardiac coupling strength and direction and their associations with regulatory mechanisms (patterns) of developing autonomic nervous system function could be novel clinical markers of healthy prenatal development and its deviation. However, further research is required on larger samples of abnormal cases.
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Affiliation(s)
- Ahsan H Khandoker
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Steffen Schulz
- Institute of Innovative Health Technologies IGHT, Ernst-Abbe-Hochschule, Jena, Germany
| | - Haitham M Al-Angari
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Andreas Voss
- Institute of Innovative Health Technologies IGHT, Ernst-Abbe-Hochschule, Jena, Germany
| | - Yoshitaka Kimura
- Institute of International Advanced Interdisciplinary Research, Tohoku University School of Medicine, Sendai, Japan.,Department of Gynecology and Obstetrics, Tohoku University Hospital, Sendai, Japan
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11
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Lin C, Yeh CH, Wang CY, Shi W, Serafico BMF, Wang CH, Juan CH, Vincent Young HW, Lin YJ, Yeh HM, Lo MT. Robust Fetal Heart Beat Detection via R-Peak Intervals Distribution. IEEE Trans Biomed Eng 2019; 66:3310-3319. [PMID: 30869605 DOI: 10.1109/tbme.2019.2904014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Monitoring fetal heart rate during pregnancy is essential to assist clinicians in making more timely decisions. Non-invasive monitoring of fetal heart activities using abdominal ECGs is useful for diagnosis of heart defects. However, the extracted fetal ECGs are usually too weak to be robustly detected. Thus, it is a necessity to enhance fetal R-peak since their peaks may be hidden within the signal due to the immaturity of the fetal cardiovascular system. Therefore, to improve the detection of the fetal heartbeat, a novel fetal R-peak enhancement technique was proposed to statistically generate the weighting mask according to the distribution of the neighboring temporal intervals between each pair of peaks. Two sets of simulations were designed to validate the reliability of the method: challenges with different levels of (1) noise contamination and (2) R-peak interval changing rate. The simulation results showed that the weighting mask improved the accuracy of the R-peak detection rate by 25% and decreased the false alarm rate by 20% with white noise contamination, and ensured high R-peak detection rate (>80%), especially with mild noise contamination (noise amplitude ratio <1.5 and noise rate per minute <25%). For the simulations with continuous R-peak intervals changing, the masking process can still effectively eliminate noise contamination especially when the amplitude of the sinusoidal fetal R-R intervals is lower than 50 ms. For the real fetus ECGs, the detection rate was increased by 3.498%, whereas the false alarm rate was decreased by 3.933%. Next, we implemented the fetal R-peak enhancement technique to investigate fractal regulation and multiscale entropy of the real fetal heartbeat intervals. Both scaling exponent (∼0.6 to ∼1 in scale 4-15) and entropy measure (scale 6-10) increased with gestational ages (22-40 weeks). The results confirmed fractal slope and complexity of fetal heartbeat intervals can reflect the maturation of fetus organism.
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12
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Yoon H, Choi SH, Kim SK, Kwon HB, Oh SM, Choi JW, Lee YJ, Jeong DU, Park KS. Human Heart Rhythms Synchronize While Co-sleeping. Front Physiol 2019; 10:190. [PMID: 30914965 PMCID: PMC6421336 DOI: 10.3389/fphys.2019.00190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 02/14/2019] [Indexed: 11/13/2022] Open
Abstract
Human physiological systems have a major role in maintenance of internal stability. Previous studies have found that these systems are regulated by various types of interactions associated with physiological homeostasis. However, whether there is any interaction between these systems in different individuals is not well-understood. The aim of this research was to determine whether or not there is any interaction between the physiological systems of independent individuals in an environment where they are connected with one another. We investigated the heart rhythms of co-sleeping individuals and found evidence that in co-sleepers, not only do independent heart rhythms appear in the same relative phase for prolonged periods, but also that their occurrence has a bidirectional causal relationship. Under controlled experimental conditions, this finding may be attributed to weak cardiac vibration delivered from one individual to the other via a mechanical bed connection. Our experimental approach could help in understanding how sharing behaviors or social relationships between individuals are associated with interactions of physiological systems.
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Affiliation(s)
- Heenam Yoon
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, South Korea
| | - Sang Ho Choi
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, South Korea
| | - Sang Kyong Kim
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, South Korea
| | - Hyun Bin Kwon
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, South Korea
| | - Seong Min Oh
- Department of Neuropsychiatry and Center for Sleep and Chronobiology, Seoul National University Hospital, Seoul, South Korea
| | - Jae-Won Choi
- Department of Neuropsychiatry, Eulji University School of Medicine, Eulji General Hospital, Seoul, South Korea
| | - Yu Jin Lee
- Department of Neuropsychiatry and Center for Sleep and Chronobiology, Seoul National University Hospital, Seoul, South Korea
| | - Do-Un Jeong
- Department of Neuropsychiatry and Center for Sleep and Chronobiology, Seoul National University Hospital, Seoul, South Korea
| | - Kwang Suk Park
- Department of Biomedical Engineering, College of Medicine, Seoul National University, Seoul, South Korea
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13
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Popescu EA, Gustafson KM. Prospective advances in fetal biomagnetometry - Challenges remain. Clin Neurophysiol 2018; 129:503-504. [PMID: 29325857 DOI: 10.1016/j.clinph.2017.11.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 11/28/2017] [Indexed: 10/18/2022]
Affiliation(s)
- E A Popescu
- Hoglund Brain Imaging Center, Kansas City, KS 66160, USA
| | - K M Gustafson
- Hoglund Brain Imaging Center, Kansas City, KS 66160, USA; Department of Neurology, University of Kansas Medical Center, Kansas City, KS 66160, USA.
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14
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Dietz P, Watson ED, Sattler MC, Ruf W, Titze S, van Poppel M. The influence of physical activity during pregnancy on maternal, fetal or infant heart rate variability: a systematic review. BMC Pregnancy Childbirth 2016; 16:326. [PMID: 27784276 PMCID: PMC5081933 DOI: 10.1186/s12884-016-1121-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 10/21/2016] [Indexed: 12/03/2022] Open
Abstract
Background Physical activity (PA) during pregnancy has been shown to be associated with several positive effects for mother, fetus, and offspring. Heart rate variability (HRV) is a noninvasive and surrogate marker to determine fetal overall health and the development of fetal autonomic nervous system. In addition, it has been shown to be significantly influenced by maternal behavior. However, the influence of maternal PA on HRV has not yet been systematically reviewed. Therefore, the aim of this systematic review was to assess the influence of regular maternal PA on maternal, fetal or infant HRV. Methods A systematic literature search following a priori formulated criteria of studies that examined the influence of regular maternal PA (assessed for a minimum period of 6 weeks) on maternal, fetal or infant HRV was performed in the databases Pubmed and SPORTDiscus. Quality of each study was assessed using the standardized Quality Assessment Tool for Quantitative Studies (QATQS). Results Nine articles were included into the present systematic review: two intervention studies, one prospective longitudinal study, and six post-hoc analysis of subsets of the longitudinal study. Of these articles four referred to maternal HRV, five to fetal HRV, and one to infant HRV. The overall global rating for the standardized quality assessment of the articles was moderate to weak. The articles regarding the influence of maternal PA on maternal HRV indicated contrary results. Five of five articles regarding the influence of maternal PA on fetal HRV showed increases of fetal HRV on most parameters depending on maternal PA. The article referring to infant HRV (measured one month postnatal) showed an increased HRV. Conclusions Based on the current evidence available, our overall conclusion is that the hypothesis that maternal PA influences maternal HRV cannot be supported, but there is a trend that maternal PA might increase fetal and infant HRV (clinical conclusion). Therefore, we recommend that further, high quality studies addressing the influence of maternal PA on HRV should be performed (methodological conclusion).
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Affiliation(s)
- Pavel Dietz
- Department of Physical Activity and Public Health, Institute of Sports Science, University of Graz, Mozartgasse 14, Graz, 8010, Austria.
| | - Estelle D Watson
- Centre for Exercise Science and Sports Medicine, School of Therapeutic Sciences, Faculty of Health Sciences, University of Witwatersrand, Private Bag 3, Johannesburg, 2050, South Africa
| | - Matteo C Sattler
- Department of Physical Activity and Public Health, Institute of Sports Science, University of Graz, Mozartgasse 14, Graz, 8010, Austria
| | - Wolfgang Ruf
- Department of Physical Activity and Public Health, Institute of Sports Science, University of Graz, Mozartgasse 14, Graz, 8010, Austria
| | - Sylvia Titze
- Department of Physical Activity and Public Health, Institute of Sports Science, University of Graz, Mozartgasse 14, Graz, 8010, Austria
| | - Mireille van Poppel
- Department of Physical Activity and Public Health, Institute of Sports Science, University of Graz, Mozartgasse 14, Graz, 8010, Austria.,Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Centre, Van der Boechorststraat 7, Amsterdam, 1081 BT, The Netherlands
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15
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16
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Khandoker AH, Marzbanrad F, Voss A, Schulz S, Kimura Y, Endo M, Palaniswami M. Analysis of maternal–fetal heart rate coupling directions with partial directed coherence. Biomed Signal Process Control 2016. [DOI: 10.1016/j.bspc.2016.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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17
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Abstract
Although the physiology of the heart and vascular system has not changed, there are many things we have learned and are still learning today. Research related to heart adaptations during pregnancy has been performed since the 1930s. Since the mid-1950s, researchers began to look at changes in the maternal cardiovascular system during exercise while pregnant. Research related to exercise during pregnancy and offspring heart development began and has continued since the 1970s. We will review the normal female cardiovascular system adaptations to pregnancy in general. Additionally, topics related to maternal cardiac adaptations to pregnancy during acute exercise, as well as the chronic conditioning response from exercise training will be explored. Since physical activity during pregnancy influences fetal development, the fetal cardiac development will be discussed in regards to acute and chronic maternal exercise. Similarly, the influence of various types of maternal exercise on acute and chronic fetal heart responses will be described. Briefly, the topics related to how and if there is maternal-fetal synchrony will be explained. Lastly, the developmental changes of the fetal cardiovascular system that persist after birth will be explored. Overall, the article will discuss maternal cardiac physiology related to changes with normal pregnancy, and exercise during pregnancy, as well as fetal cardiac physiology related to changes with normal development, and exercise during pregnancy as well as developmental changes in offspring after birth.
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Affiliation(s)
- Linda May
- Assistant Professor, Foundational Sciences and Research, East Carolina University, Greenville, NC
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18
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Marzbanrad F, Kimura Y, Palaniswami M, Khandoker AH. Quantifying the Interactions between Maternal and Fetal Heart Rates by Transfer Entropy. PLoS One 2015; 10:e0145672. [PMID: 26701122 PMCID: PMC4689348 DOI: 10.1371/journal.pone.0145672] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 12/06/2015] [Indexed: 11/18/2022] Open
Abstract
Evidence of the short term relationship between maternal and fetal heart rates has been found in previous studies. However there is still limited knowledge about underlying mechanisms and patterns of the coupling throughout gestation. In this study, Transfer Entropy (TE) was used to quantify directed interactions between maternal and fetal heart rates at various time delays and gestational ages. Experimental results using maternal and fetal electrocardiograms showed significant coupling for 63 out of 65 fetuses, by statistically validating against surrogate pairs. Analysis of TE showed a decrease in transfer of information from fetus to the mother with gestational age, alongside the maturation of the fetus. On the other hand, maternal to fetal TE was significantly greater in mid (26-31 weeks) and late (32-41 weeks) gestation compared to early (16-25 weeks) gestation (Mann Whitney Wilcoxon (MWW) p<0.05). TE further increased from mid to late, for the fetuses with RMSSD of fetal heart rate being larger than 4 msec in the late gestation. This difference was not observed for the fetuses with smaller RMSSD, which could be associated with the quiet sleep state. Delay in the information transfer from mother to fetus significantly decreased (p = 0.03) from mid to late gestation, implying a decrease in fetal response time. These changes occur concomitant with the maturation of the fetal sensory and autonomic nervous systems with advancing gestational age. The effect of maternal respiratory rate derived from maternal ECG was also investigated and no significant relationship was found between breathing rate and TE at any lag. In conclusion, the application of TE with delays revealed detailed information on the fetal-maternal heart rate coupling strength and latency throughout gestation, which could provide novel clinical markers of fetal development and well-being.
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Affiliation(s)
- Faezeh Marzbanrad
- Electrical and Electronic Engineering Department, University of Melbourne, Melbourne, VIC 3010, Australia
| | | | - Marimuthu Palaniswami
- Electrical and Electronic Engineering Department, University of Melbourne, Melbourne, VIC 3010, Australia
| | - Ahsan H. Khandoker
- Electrical and Electronic Engineering Department, University of Melbourne, Melbourne, VIC 3010, Australia
- Biomedical Engineering Department, Khalifa University of Science, Technology and Research, Abu Dhabi, UAE
- * E-mail:
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19
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May LE, Knowlton J, Hanson J, Suminski R, Paynter C, Fang X, Gustafson KM. Effects of Exercise During Pregnancy on Maternal Heart Rate and Heart Rate Variability. PM R 2015; 8:611-7. [PMID: 26603201 DOI: 10.1016/j.pmrj.2015.11.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pregnancy is associated with an increased sympathetic state, which can be exacerbated by gestational conditions. Research has shown that exercise during pregnancy lowers heart rate (HR) and can attenuate the symptoms of gestational conditions associated with increased sympathetic control. However, changes in maternal heart autonomic function in response to exercise have not been reported across multiple time points during pregnancy. This analysis is designed to address this gap. OBJECTIVE To determine if exercise throughout gestation improves maternal cardiac autonomic nervous system functioning, as evidenced by decreased HR and increased heart rate variability (HRV) indices. DESIGN Case control study. SETTING Academic medical institution. PARTICIPANTS A total of 56 women with healthy, singleton, low-risk pregnancies. METHODS Participants were asked to complete 3 resting 18-minute HRV recordings at 28, 32, and 36 weeks' gestation, along with a physical activity questionnaire. MAIN OUTCOME MEASURES HRV indices were calculated for time (R peak to R peak interval standard deviation and root mean squared of successive differences) and frequency (very low, low, and high frequency) domain measures. The differences between groups were compared for HRV indices at 28, 32, and 36 weeks. RESULTS Resting HR was significantly lower in the exercise group at 28 weeks (P < .01) compared with the control group. The exercise group had significantly (P < .05) increased measures of resting HRV time domain measures at 28, 32, and 36 weeks' gestation compared with the control group. Resting HRV power was significantly increased (P < .05) in all frequency domain measures at 32 weeks in the exercise group relative to the control group. No differences occurred in sympathovagal balance (low frequency/high frequency ratio) between groups. CONCLUSION Exercise throughout pregnancy can significantly improve cardiac autonomic control. More research is needed to determine if this adaptation to exercise may reduce the risk of adverse outcomes associated with gestational conditions with poor autonomic control, such as diabetes, hypertension, pre-eclampsia, and excessive weight gain.
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Affiliation(s)
- Linda E May
- Foundational Sciences and Research, East Carolina University, 1851 MacGregor Downs Rd, MS 701, #3144, Greenville, NC 27834(∗).
| | - Jennifer Knowlton
- Department of Physical Medicine and Rehabilitation, East Carolina University, Greenville, NC(†)
| | - Jessica Hanson
- Department of Physical Medicine and Rehabilitation, East Carolina University, Greenville, NC(‡)
| | - Richard Suminski
- Department of Physiology, Kansas City University of Medicine and Biosciences, Kansas City, MO(¶)
| | - Christopher Paynter
- Department of Physiology, Kansas City University of Medicine and Biosciences, Kansas City, MO(§)
| | - Xiangming Fang
- Department of Biostatistics, East Carolina University, Greenville, NC(∗∗)
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