A Hypothesis for Self-Organization and Symmetry Reduction in the Synchronization of Organ-Level Contractions in the Human Uterus during Labor

Uterine slow wave: directionality and changes with imminent delivery

OBJECTIVE

The slow wave (SW) of the electrohysterogram (EHG) may contain relevant information on the electrophysiological condition of the uterus throughout pregnancy and labor. Our aim was to assess differences in the SW as regards the imminence of labor and the directionality of uterine myoelectrical activity.

APPROACH

The SW of the EHG was extracted from the signals of the Icelandic 16-electrode EHG database in the bandwidth [5, 30] mHz and its power, spectral content, complexity and synchronization between the horizontal (X) and vertical (Y) directions were characterized by the root mean square (RMS), dominant frequency (domF), sample entropy (SampEn) and maximum cross-correlation (CCmax) of the signals, respectively. Significant differences between parameters at time-to-delivery (TTD) ≤7 vs. >7 days and between the horizontal vs. vertical directions were assessed.

MAIN RESULTS

The SW power significantly increased in both directions as labor approached (TTD≤7d vs. >7d (mean±SD): x= 0.12±0.10 vs. 0.08±0.06mV; y= 0.12±0.09 vs. 0.08±0.05mV), as well as the dominant frequency in the horizontal direction (= 9.1±1.3 vs. 8.5±1.2mHz) and the synchronization between both directions (= 0.44±0.16 vs. 0.36±0.14). Furthermore, its complexity decreased in the vertical direction (= 6.13·10-2±8.7·10-3 vs. 6.50·10-2±8.3·10-3), suggesting a higher cell-to-cell electrical coupling. Whereas there were no differences between the SW features in both directions in the general population, statistically significant differences were obtained between them in individuals in many cases.

SIGNIFICANCE

Our results suggest that the SW of the EHG is related to bioelectrical events in the uterus and could provide objective information to clinicians in challenging obstetric scenarios.

A Novel, Cardiac-Derived Algorithm for Uterine Activity Monitoring in a Wearable Remote Device

Background: Uterine activity (UA) monitoring is an essential element of pregnancy management. The gold-standard intrauterine pressure catheter (IUPC) is invasive and requires ruptured membranes, while the standard-of-care, external tocodynamometry (TOCO)’s accuracy is hampered by obesity, maternal movements, and belt positioning. There is an urgent need to develop telehealth tools enabling patients to remotely access care. Here, we describe and demonstrate a novel algorithm enabling remote, non-invasive detection and monitoring of UA by analyzing the modulation of the maternal electrocardiographic and phonocardiographic signals. The algorithm was designed and implemented as part of a wireless, FDA-cleared device designed for remote pregnancy monitoring. Two separate prospective, comparative, open-label, multi-center studies were conducted to test this algorithm.

Methods: In the intrapartum study, 41 laboring women were simultaneously monitored with IUPC and the remote pregnancy monitoring device. Ten patients were also monitored with TOCO. In the antepartum study, 147 pregnant women were simultaneously monitored with TOCO and the remote pregnancy monitoring device.

Results: In the intrapartum study, the remote pregnancy monitoring device and TOCO had sensitivities of 89.8 and 38.5%, respectively, and false discovery rates (FDRs) of 8.6 and 1.9%, respectively. In the antepartum study, a direct comparison of the remote pregnancy monitoring device to TOCO yielded a sensitivity of 94% and FDR of 31.1%. This high FDR is likely related to the low sensitivity of TOCO.

Conclusion: UA monitoring via the new algorithm embedded in the remote pregnancy monitoring device is accurate and reliable and more precise than TOCO standard of care. Together with the previously reported remote fetal heart rate monitoring capabilities, this novel method for UA detection expands the remote pregnancy monitoring device’s capabilities to include surveillance, such as non-stress tests, greatly benefiting women and providers seeking telehealth solutions for pregnancy care.

Novel uterine contraction monitoring to enable remote, self-administered nonstress testing

BACKGROUND

The serial fetal monitoring recommended for women with high-risk pregnancies places a substantial burden on the patient, often disproportionately affecting underprivileged and rural populations. A telehealth solution that can empower pregnant women to obtain recommended fetal surveillance from the comfort of their own home has the potential to promote health equity and improve outcomes. We have previously validated a novel, wireless pregnancy monitor that can remotely capture fetal and maternal heart rates. However, such a device must also detect uterine contractions if it is to be used to robustly conduct remote nonstress tests.

OBJECTIVE

This study aimed to describe and validate a novel algorithm that uses biopotential and acoustic signals to noninvasively detect uterine contractions via a wireless pregnancy monitor.

STUDY DESIGN

A prospective, open-label, 2-center study evaluated simultaneous detection of uterine contractions by the wireless pregnancy monitor and an intrauterine pressure catheter in women carrying singleton pregnancies at ≥32 0/7 weeks' gestation who were in the first stage of labor (ClinicalTrials.gov Identifier: NCT03889405). The study consisted of a training phase and a validation phase. Simultaneous recordings from each device were passively acquired for 30 to 60 minutes. In a subset of the monitoring sessions in the validation phase, tocodynamometry was also deployed. Three maternal-fetal medicine specialists, blinded to the data source, identified and marked contractions in all modalities. The positive agreement and false-positive rates of both the wireless monitor and tocodynamometry were calculated and compared with that of the intrauterine pressure catheter.

RESULTS

A total of 118 participants were included, 40 in the training phase and 78 in the validation phase (of which 39 of 78 participants were monitored simultaneously by all 3 devices) at a mean gestational age of 38.6 weeks. In the training phase, the positive agreement for the wireless monitor was 88.4% (1440 of 1692 contractions), with a false-positive rate of 15.3% (260/1700). In the validation phase, using the refined and finalized algorithm, the positive agreement for the wireless pregnancy monitor was 84.8% (2722/3210), with a false-positive rate of 24.8% (897/3619). For the subgroup who were monitored only with the wireless monitor and intrauterine pressure catheter, the positive agreement was 89.0% (1191/1338), with a similar false-positive rate of 25.4% (406/1597). For the subgroup monitored by all 3 devices, the positive agreement for the wireless monitor was significantly better than for tocodynamometry (P<.0001), whereas the false-positive rate was significantly higher (P<.0001). Unlike tocodynamometry, whose positive agreement was significantly reduced in the group with obesity compared with the group with normal weight (P=.024), the positive agreement of the wireless monitor did not vary across the body mass index groups.

CONCLUSION

This novel method to noninvasively monitor uterine activity, via a wireless pregnancy monitoring device designed for self-administration at home, was more accurate than the commonly used tocodynamometry and unaffected by body mass index. Together with the previously reported remote fetal heart rate monitoring capabilities, this added ability to detect uterine contractions has created a complete telehealth solution for remote administration of nonstress tests.

Mechanotransduction mechanisms for coordinating uterine contractions in human labor

This review presents evolving concepts of how the human uterus contracts in pregnancy, with emphasis on the mechanisms of long-distance signaling. Action potential propagation has historically been assumed to be the sole mechanism for signaling and tissue recruitment over both short and long distances. However, data in animals and humans indicate that a single action potential does not travel distances greater than a few centimeters. To address this enigma, a long-distance signaling mechanism based on hydraulic signaling and mechanotransduction is developed. By combining this mechanism for long-distance signaling with the action potential propagation mechanism for signaling over short distances, a comprehensive dual mechanism model (or 'dual model') of uterine function is formulated. Mechanotransduction is an accepted phenomenon of myometrium, but the dual model identifies mechanotransduction as relevant to normal labor. For hydraulic signaling, a local contraction slightly increases intrauterine pressure, which globally increases wall tension. Increased wall tension then mechanically induces additional local contractions that further raise pressure. This leads to robust, positive feedback recruitment that explains the emergence of consistently strong contractions of human labor. Three key components of the dual model - rapid long-distance signaling, mechanical triggering, and electrical activity - converge with the concept of mechanically sensitive electrogenic pacemakers distributed throughout the wall. The dual model retains excitation-contraction coupling and action potential propagation for signaling over short distances (<10cm) and hence is an extension of the action potential model rather than a replacement.