Development, Validation, and Diagnostic Accuracy of the Fetal Lack of Responsiveness Scale for Diagnosis of Severe Perinatal Hypoxia.

Background: There are limitations to predicting perinatal asphyxia, as current tools rely almost entirely on fetal cardiotocography (CTG). The fetal lack of responsiveness scale (FLORS) is a new diagnostic alternative based on the physiological phenomena associated with fetal hypoxia. Objectives: The objective of this study was to develop, validate, and assess the diagnostic accuracy of the FLORS for predicting severe perinatal hypoxia (SPH). Study Design: A two-phase retrospective observational cross-sectional analytical study was conducted. Phase 1 involved the formulation and retrospective validation of the FLORS. A total of 366 fetal CTG records were evaluated twice by seven readers. Phase 2 was a collaborative, retrospective, multicenter diagnostic test study that included 37 SPH and 366 non-SPH cases. Results: Phase 1: A numeric, physiology-based scale was developed and refined based on expert opinions. The median time to apply the scale per reading was 38 s. Cronbach's alpha, which is a reliability measure, was significant (p = 0.784). The kappa index for test-retest agreement was moderate to reasonable, with a median value of 0.642. For interobserver agreement, the kappa index per variable was as follows: baseline, 0.669; accelerations, 0.658; variability, 0.467; late/variable decelerations, 0.638; slow response decelerations, 0.617; and trend to change, 0.423. Phase 2, including 37 SPH and 366 non-SPH cases, showed a sensitivity of 62.2% and specificity of 75.4% for the 2-point score, whereas the 3-point score had a sensitivity of 35.1% and specificity of 89.9%. The area under the curve (AUC) was significant at 0.73 (CI 0.645-0.818). Conclusions: FLORS demonstrated significant internal consistency and observer agreement, with a promising sensitivity-specificity balance and significant AUC. Further research is needed to assess its impact on perinatal hypoxia and cesarean delivery.

International expert consensus statement on physiological interpretation of cardiotocograph (CTG): First revision (2024).

The first international consensus guideline on physiological interpretation of cardiotocograph (CTG) produced by 44 CTG experts from 14 countries was published in 2018. This guideline ensured a paradigm shift from classifying CTG by arbitrarily grouping certain features of the fetal heart rate into different "categories", and then, randomly combining them to arrive at an overall classification of CTG traces into "Normal, Suspicious and Pathological" (or Category I, II and III) to a classification which is based on the understanding of fetal pathophysiology. The guideline recommended the recognition of different types of fetal hypoxia, and the determination of features of fetal compensatory responses as well as decompensation to ongoing hypoxic stress on the CTG trace. Since its first publication in 2018, there have been several scientific publications relating physiological interpretation of CTG, especially relating to features indicative of autonomic instability due to hypoxic stress (i.e., the ZigZag pattern), and of fetal inflammation. Moreover, emerging evidence has suggested improvement in maternal and perinatal outcomes in maternity units which had implemented physiological interpretation of CTG. Therefore, the guideline on Physiological Interpretation of CTG has been revised to incorporate new scientific evidence, and the interpretation table has been expanded to include features of chorioamnionitis and relative utero-placental insufficiency of labour (RUPI-L).

Emerging Paradigms in Fetal Heart Rate Monitoring: Evaluating the Efficacy and Application of Innovative Textile-Based Wearables.

This comprehensive review offers a thorough examination of fetal heart rate (fHR) monitoring methods, which are an essential component of prenatal care for assessing fetal health and identifying possible problems early on. It examines the clinical uses, accuracy, and limitations of both modern and traditional monitoring techniques, such as electrocardiography (ECG), ballistocardiography (BCG), phonocardiography (PCG), and cardiotocography (CTG), in a variety of obstetric scenarios. A particular focus is on the most recent developments in textile-based wearables for fHR monitoring. These innovative devices mark a substantial advancement in the field and are noteworthy for their continuous data collection capability and ergonomic design. The review delves into the obstacles that arise when incorporating these wearables into clinical practice. These challenges include problems with signal quality, user compliance, and data interpretation. Additionally, it looks at how these technologies could improve fetal health surveillance by providing expectant mothers with more individualized and non-intrusive options, which could change the prenatal monitoring landscape.

Testing an artificial intelligence algorithm to predict fetal heartbeat of vitrified-warmed blastocysts from a single image: predictive ability in different settings.

STUDY QUESTION: Could an artificial intelligence (AI) algorithm predict fetal heartbeat from images of vitrified-warmed embryos? SUMMARY ANSWER: Applying AI to vitrified-warmed blastocysts may help predict which ones will result in implantation failure early enough to thaw another. WHAT IS KNOWN ALREADY: The application of AI in the field of embryology has already proven effective in assessing the quality of fresh embryos. Therefore, it could also be useful to predict the outcome of frozen embryo transfers, some of which do not recover their pre-vitrification volume, collapse, or degenerate after warming without prior evidence. STUDY DESIGN, SIZE, DURATION: This retrospective cohort study included 1109 embryos from 792 patients. Of these, 568 were vitrified blastocysts cultured in time-lapse systems in the period between warming and transfer, from February 2022 to July 2023. The other 541 were fresh-transferred blastocysts serving as controls. PARTICIPANTS/MATERIALS, SETTING, METHODS: Four types of time-lapse images were collected: last frame of development of 541 fresh-transferred blastocysts (FTi), last frame of 467 blastocysts to be vitrified (PVi), first frame post-warming of 568 vitrified embryos (PW1i), and last frame post-warming of 568 vitrified embryos (PW2i). After providing the images to the AI algorithm, the returned scores were compared with the conventional morphology and fetal heartbeat outcomes of the transferred embryos (n = 1098). The contribution of the AI score to fetal heartbeat was analyzed by multivariate logistic regression in different patient populations, and the predictive ability of the models was measured by calculating the area under the receiver-operating characteristic curve (ROC-AUC). MAIN RESULTS AND THE ROLE OF CHANCE: Fetal heartbeat rate was related to AI score from FTi (P < 0.001), PW1i (P < 0.05), and PW2i (P < 0.001) images. The contribution of AI score to fetal heartbeat was significant in the oocyte donation program for PW2i (odds ratio (OR)=1.13; 95% CI [1.04-1.23]; P < 0.01), and in cycles with autologous oocytes for PW1i (OR = 1.18; 95% CI [1.01-1.38]; P < 0.05) and PW2i (OR = 1.15; 95% CI [1.02-1.30]; P < 0.05), but was not significantly associated with fetal heartbeat in genetically analyzed embryos. AI scores from the four groups of images varied according to morphological category (P < 0.001). The PW2i score differed in collapsed, non-re-expanded, or non-viable embryos compared to normal/viable embryos (P < 0.001). The predictability of the AI score was optimal at a post-warming incubation time of 3.3-4 h (AUC = 0.673). LIMITATIONS, REASONS FOR CAUTION: The algorithm was designed to assess fresh embryos prior to vitrification, but not thawed ones, so this study should be considered an external trial. WIDER IMPLICATIONS OF THE FINDINGS: The application of predictive software in the management of frozen embryo transfers may be a useful tool for embryologists, reducing the cancellation rates of cycles in which the blastocyst does not recover from vitrification. Specifically, the algorithm tested in this research could be used to evaluate thawed embryos both in clinics with time-lapse systems and in those with conventional incubators only, as just a single photo is required. STUDY FUNDING/COMPETING INTERESTS: This study was supported by the Regional Ministry of Innovation, Universities, Science and Digital Society of the Valencian Community (CIACIF/2021/019) and by Instituto de Salud Carlos III (PI21/00283), and co-funded by European Union (ERDF, 'A way to make Europe'). M.M. received personal fees in the last 5 years as honoraria for lectures from Merck, Vitrolife, MSD, Ferring, AIVF, Theramex, Gedeon Richter, Genea Biomedx, and Life Whisperer. There are no other competing interests. TRIAL REGISTRATION NUMBER: N/A.

Analysis of CTG patterns in cases with metabolic acidosis at birth with and without neonatal neurological alterations.

OBJECTIVE: To determine cardiotocographic patterns in newborns with metabolic acidosis, based on clinical signs of neurological alteration (NA) and the need for hypothermic treatment. METHODS: All term newborns with metabolic acidosis in a single center from 2016 to 2020 were included in the study. Three segments of intrapartum CTG (cardiotocography) were considered (first 30 min of active labor, 90 to 30 min before birth, and last 30 min before delivery) and a longitudinal analysis of CTG pattern was performed according to the 2015 FIGO classification. RESULTS: Three hundred and twenty-four neonates with metabolic acidosis diagnosed at birth were divided into three groups: the first group included all neonates with any clinical sign of neurological alteration, requiring hypothermia according to the recommendation of the Italian Society of Neonatology (group TNA-Treated neurological Alteration, n = 17), the second encompassed neonates with any clinical sign of neurological alteration not requiring hypothermia (group NTNA-Not Treated neurological Alteration, n = 83), and the third enclosed all neonates without any sign of clinical neurological involvement (group NoNA-No neurological Alteration, n = 224). The most frequent alterations of CTG in TNA group were late decelerations, reduced variability, bradycardia, and tachysystole. Unexpectedly, from the longitudinal analysis of the CTG, 49% of all cases with metabolic acidosis never showed a pathological CTG with normal trace at the beginning of labor followed by normal or suspicious trace in the final part of labor, the same as in TNA and NTNA groups (10 and 39%, respectively). CONCLUSIONS: CTG has limited specificity in identifying cases of acidosis at birth, even in babies who will develop NA.

Performance of five cardiotocography classification templates in labor: a cohort study.

OBJECTIVE: New guidelines for the interpretation of cardiotocography (CTG) have been presented by FIGO in 2015 (FIGO-15) and by NICE in 2017 (NICE-17) and 2022 (NICE-22) In Sweden, a previous template from 2009 (SWE-09) was replaced in 2017 (SWE-17).The objective of the study was to compare these five different templates for CTG classification regarding sensitivity, specificity, positive and negative predictive values in identifying neonates with acidemia at birth (cord artery pH <7.10). METHODS: This is a historical cohort study including singleton births in Lund November 2015-February 2016, after spontaneous or induced labor at ≥34 completed gestational weeks with validated umbilical cord acid-base samples.Characteristics of cardiotocographic traces during the last hour before birth were reviewed by two independent assessors blinded to outcome. Each template was then used to classify the CTG as normal, suspicious, or pathological. Traces for which classification differed between the two assessors for any of the templates were assessed by a third assessor. The classification by majority (at least 2 of 3) was used for analyses.Main outcome measures were the sensitivity, specificity, and positive and negative predictive values for each template to identify neonates with cord artery pH <7.10 by the classification pathological. In a secondary analysis, these outcome measures were calculated for the classifications suspicious + pathological together. RESULTS: SWE-09 and NICE-22 had significantly higher sensitivity (both 92%; 95% CI 79-98%) than NICE-17 (68%; 51-82%), FIGO-15 (42%; 26-59%) and SWE-17 (39%; 24-57%) to identify neonates with acidemia by the classification pathological. Specificity was significantly higher for SWE-17 (91%; 88-93%), FIGO-15 (90%; 88-93%) and NICE-17 (78%; 74-81%) than for NICE-22 (63%; 59-67%) and SWE-09 (62%; 58-66%). The positive predictive value of a pathological pattern ranged between 15% (SWE-09 and NICE-22) and 24% (FIGO-15), and negative predictive values between 95% (SWE-17) and 99% (SWE-09 and NICE-22). Combining suspicious and pathological patterns increased the sensitivity and decreased the specificity for all templates. CONCLUSIONS: Current CTG interpretation templates either have low sensitivity to identify fetal acidemia or low specificity. Among current guidelines, NICE 2022 had the highest sensitivity to identify neonates with acidemia and is considered the safest current classification system. Efforts to further improve diagnostic precision are warranted.

Relative uteroplacental insufficiency of labor.

Relative uteroplacental insufficiency of labor (RUPI-L) is a clinical condition that refers to alterations in the fetal oxygen "demand-supply" equation caused by the onset of regular uterine activity. The term RUPI-L indicates a condition of "relative" uteroplacental insufficiency which is relative to a specific stressful circumstance, such as the onset of regular uterine activity. RUPI-L may be more prevalent in fetuses in which the ratio between the fetal oxygen supply and demand is already slightly reduced, such as in cases of subclinical placental insufficiency, post-term pregnancies, gestational diabetes, and other similar conditions. Prior to the onset of regular uterine activity, fetuses with a RUPI-L may present with normal features on the cardiotocography. However, with the onset of uterine contractions, these fetuses start to manifest abnormal fetal heart rate patterns which reflect the attempt to maintain adequate perfusion to essential central organs during episodes of transient reduction in oxygenation. If labor is allowed to continue without an appropriate intervention, progressively more frequent, and stronger uterine contractions may result in a rapid deterioration of the fetal oxygenation leading to hypoxia and acidosis. In this Commentary, we introduce the term relative uteroplacental insufficiency of labor and highlight the pathophysiology, as well as the common features observed in the fetal heart rate tracing and clinical implications.

Rapid detection of fetal compromise using input length invariant deep learning on fetal heart rate signals.

Standard clinical practice to assess fetal well-being during labour utilises monitoring of the fetal heart rate (FHR) using cardiotocography. However, visual evaluation of FHR signals can result in subjective interpretations leading to inter and intra-observer disagreement. Therefore, recent studies have proposed deep-learning-based methods to interpret FHR signals and detect fetal compromise. These methods have typically focused on evaluating fixed-length FHR segments at the conclusion of labour, leaving little time for clinicians to intervene. In this study, we propose a novel FHR evaluation method using an input length invariant deep learning model (FHR-LINet) to progressively evaluate FHR as labour progresses and achieve rapid detection of fetal compromise. Using our FHR-LINet model, we obtained approximately 25% reduction in the time taken to detect fetal compromise compared to the state-of-the-art multimodal convolutional neural network while achieving 27.5%, 45.0%, 56.5% and 65.0% mean true positive rate at 5%, 10%, 15% and 20% false positive rate respectively. A diagnostic system based on our approach could potentially enable earlier intervention for fetal compromise and improve clinical outcomes.

Elicitation of fetal ECG from abdominal recordings using Blind Source Separation techniques and Robust Set Membership Affine Projection algorithm for signal quality enhancement.

BACKGROUND: The utilization of non-invasive techniques for fetal cardiac health surveillance is pivotal in evaluating fetal well-being throughout the gestational period. This process requires clean and interpretable fetal Electrocardiogram (fECG) signals. METHOD: The proposed work is the novel framework for the elicitation of fECG signals from abdominal ECG (aECG) recordings of the pregnant mother. The comprehensive approach encompasses pre-processing of the raw ECG signal, Blind Source Separation techniques (BSS), Decomposition techniques like Empirical Mode Decomposition (EMD), and its variants like Ensemble Empirical Mode Decomposition (EEMD), and Complete Ensemble Empirical Mode Decomposition with Additive Noise (CEEMDAN). The Robust Set Membership Affine Projection (RSMAP) Algorithm is deployed for the enhancement of the obtained fECG signal. RESULT: The results show significant improvements in the elicited fECG signal with a maximum Signal Noise Ratio (SNR) of 31.72 dB and correlation coefficient = 0.899, Maximum Heart Rate(MHR) obtained in the range of 108-142 bpm for all the records of abdominal ECG signals. The statistical test gave a p-value of 0.21 accepting the null hypothesis. The Abdominal and Direct Fetal Electrocardiogram Database (ABDFECGDB) from PhysioNet has been used for this analysis. CONCLUSION: The proposed framework demonstrates a robust and effective method for the elicitation and enhancement of fECG signals from the abdominal recordings.

Effect of dural puncture epidural block technique on fetal heart rate variability during labor analgesia.

PURPOSE: To explore the effect of dural puncture epidural (DPE) block technique on fetal heart rate variability (HRV) during labor analgesia. METHODS: Sixty full-term primiparas who were in our hospital from April 2021 to October 2021 were selected and randomized into epidural analgesia (CEA) and dural puncture epidural analgesia (DPEA) groups (n = 30). After a successful epidural puncture, routine epidural catheter (EC) was performed in CEA group, and spinal anesthesia needle (as an EC) was used to puncture the dura mater to subarachnoid space in DPE group. Anesthetics were injected through EC. The time when the temperature sensation plane reached T10 (W1) and visual analog pain score (VAS), baseline heart rate score, amplitude variation score, cycle variation score, acceleration score, deceleration score, and total score of the first contraction after W1 were recorded. Apgar scores at 1 min, 5 min, and 10 min of neonates after delivery were recorded. RESULTS: The onset time of anesthesia in CEA group was significantly longer than that in DPEA group (p < .05). However, there are no significant differences in W1, VAS, baseline heart rate score, amplitude variation score, cycle variation score, acceleration score, deceleration score, and total score of the first contraction after W1 between the two groups (p > .05). Moreover, the Apgar scores at 1 min, 5 min and 10 min of neonates after delivery were not notably different between the two groups (p > .05). CONCLUSION: Compared with CEA, DPE block technique in labor analgesia relieves maternal pain without adverse effects on fetal HRV and newborns.

How pregnant women with diabetes experience telemonitoring of the fetal heart rate - An interview study.

OBJECTIVES: The use of telemonitoring in healthcare is generally increasing. Women with complicated pregnancies are using telemonitoring as an alternative to conventional management, encompassing hospitalization or frequent outpatient clinic visits. However, there is sparse evidence on how pregnant women experience monitoring of their unborn babies at home. Women might feel uncomfortable with this responsibility, and moreover they might miss face-to-face contact with healthcare personnel. STUDY DESIGN: The study setting was a Danish hospital with a tertiary obstetric unit attending approximately 3400 births annually. A qualitative study design with interview as method included 11 pregnant women with type 1 diabetes or Gestational Diabetes Mellitus. This design was used to investigate how pregnant women with complicated pregnancies experienced telemonitoring of the fetus. Reflexive thematic analysis was used to analyze the pregnant women's experiences of telemonitoring. RESULTS: Women with type 1 diabetes or Gestational Diabetes Mellitus found the advantages of telemonitoring to outweigh the disadvantages. They experienced telemonitoring as time-saving and that telemonitoring decreased the level of stress. Moreover, telemonitoring supports positive collaboration with healthcare professionals. The women also experienced a lack of coordination of consultations between different departments at the hospital and challenges with timing, feedback, and technical issues. Moreover, the women requested an opportunity to discuss family formation and emotions. CONCLUSIONS: Pregnant women with type 1 diabetes or Gestational Diabetes Mellitus benefit from the use of telemonitoring. To further improve the implementation and use of telemonitoring clinical implications, consider how timing and coordination of care, technical equipment, and feedback mechanisms could be improved.

Effect of Direct and Mediated through Maternal Organism Activation of the Catecholaminergic System on Heart Rate Parameters in Rat Fetuses.

We performed a comparative analysis of direct and mediated through the maternal organism effects of elevated catecholamine concentration on changes in the cardiac activity parameters in female rats and their fetuses on gestation days 18 and 20 under in vivo conditions. Administration of L-DOPA, a precursor of catecholaminergic transmitters, did not cause chronotropic effects in fetuses. Analysis of HR variability showed that in fetuses, irrespective of the administration route, there was an increase in nervous influences while the leading role of humoral-metabolic factors in the regulation of HR was preserved. In females receiving L-DOPA injection on day 18 of gestation, a decrease in humoral-metabolic and an increase in nerve effects were observed; in rats injected with L-DOPA on day 20 of gestation, an increase in sympathetic influences was found. Administration of L-DOPA to fetuses provoked a slight increase in the power of all components of the heart rhythm periodogram spectrum in females on day 18 of gestation and their decrease on day 20. Changes in the parameters of HR variability in females can confirm the hypothesis that in the "mother-fetus" system, the heart rhythm in the mother can be affected by both maternal and fetal influences presumably through the humoral-metabolic regulation.

Risk Factors Are Not Very Risky Once a Normal Embryonic Heart Rate is Seen in Early Pregnancy.

OBJECTIVES: To assess first-trimester prognosis when an early pregnancy sonogram demonstrates a normal embryonic heart rate and to determine how a number of risk factors affect prognosis. METHODS: Our study population consisted of 6597 first-trimester scans with gestational age (GA) ≤ 7.0 weeks (all with crown-rump length [CRL] <10 mm), normal embryonic heart, and known first-trimester outcome. We recorded GA; CRL; heart rate; first-trimester outcome; maternal age; presence, absence, and size of subchorionic hematoma; presence or absence of vaginal bleeding; and presence, absence, and size of uterine fibroids. We assessed first-trimester outcome in the study population and subsets based on the above data. RESULTS: First-trimester outcome was successful in 6030 of the 6597 cases (91.4%). The prognosis was somewhat worse with each of the following risk factors: maternal age ≥35 years, large subchorionic hematoma, and large or multiple uterine fibroids (P < .02, chi-squared or Cochran's test for trend, for all of these items). The rate of successful outcome was in the range of 83-88% with each of these risk factors and 93.8% in the absence of any of these factors. CONCLUSIONS: The presence of a normal embryonic heart rate on an early first-trimester sonogram is a reassuring finding, indicating a likelihood of good first-trimester outcome of at least 83% even in the presence of risk factors, and of over 90% in the absence of such factors.

Transcutaneous Discrimination of Fetal Heart Rate from Maternal Heart Rate: A Fetal Oximetry Proof-of-Concept.

Intrapartum care uses electronic fetal heart rate monitoring (EFHRM) for over 50 years to indirectly assess fetal oxygenation. However, this approach has been associated with an increase in cesarean delivery rates and limited improvements in neonatal hypoxic outcome. To address these shortcomings, a novel transabdominal fetal pulse oximeter (TFO) is being developed to provide an objective measurement of fetal oxygenation. Previous studies have evaluated the performance of TFO on pregnant ewe. Building on the animal model, this study aims to determine whether TFO can successfully capture human fetal heart rate (FHR) signals during non-stress testing (NST) as a proof-of-concept. Eight ongoing pregnancies meeting specific inclusion criteria (18-40 years old, singleton, and at least 36 weeks' gestation) were enrolled with consent. Each study session was 15 to 20 min long. Reference maternal heart rate (MHR) and FHR were obtained using finger pulse oximetry and cardiotocography for subsequent comparison. The overall root-mean-square error was 9.7BPM for FHR and 4.4 for MHR, while the overall mean-absolute error was 7.6BPM for FHR and 1.8 for MHR. Bland-Altman analysis displayed a mean bias ± standard deviation between TFO and reference of -3.9 ± 8.9BPM, with limits of agreement ranging from -21.4 to 13.6 BPM. Both maternal and fetal heart rate measurements obtained from TFO exhibited a p-value < 0.001, showing significant correlation with the reference. This proof-of-concept study successfully demonstrates that TFO can accurately differentiate maternal and fetal heart signals in human subjects. This achievement marks the initial step towards enabling fetal oxygen saturation measurement in humans using TFO.

Short-term variation of the fetal heart rate as a marker of intraamniotic infection in pregnancies with preterm prelabor rupture of membranes: a historical cohort study.

INTRODUCTION: Intraamniotic infection (IAI) and subsequent early-onset neonatal sepsis (EONS) are among the main complications associated with preterm prelabor rupture of membranes (PPROM). Currently used diagnostic tools have been shown to have poor diagnostic performance for IAI. This study aimed to investigate whether the exposure to IAI before delivery is associated with short-term variation of the fetal heart rate in pregnancies with PPROM. METHODS: Observational cohort study of 678 pregnancies with PPROM, delivering between 24 + 0 and 33 + 6 gestational weeks from 2012 to 2019 in five labor units in Stockholm County, Sweden. Electronic medical records were examined to obtain background and exposure data. For the exposure IAI, we used the later diagnosis of EONS in the offspring as a proxy. EONS is strongly associated to IAI and was considered a better proxy for IAI than the histological diagnosis of acute chorioamnionitis, since acute chorioamnionitis can be observed in the absence of both positive microbiology and biochemical markers for inflammation. Cardiotocography traces were analyzed by a computerized algorithm for short-term variation of the fetal heart rate, which was the main outcome measure. RESULTS: Twenty-seven pregnancies were categorized as having an IAI, based on the proxy diagnosis of EONS after birth. Fetuses exposed to IAI had significantly lower short-term variation values in the last cardiotocography trace before birth than fetuses who were not exposed (5.25 vs 6.62 ms; unadjusted difference: -1.37, p = 0.009). After adjustment for smoking and diabetes, this difference remained significant. IAI with a later positive blood culture in the neonate (n = 12) showed an even larger absolute difference in STV (-1.65; p = 0.034), with a relative decrease of 23.5%. CONCLUSION: In pregnancies with PPROM, fetuses exposed to IAI with EONS as a proxy have lower short-term variation of the fetal heart rate than fetuses who are not exposed. Short-term variation might be useful as adjunct surveillance in pregnancies with PPROM.

Multicentric intelligent cardiotocography signal interpretation using deep semi-supervised domain adaptation via minimax entropy and domain invariance.

BACKGROUND AND OBJECTIVE: Obstetricians use Cardiotocography (CTG), which is the continuous recording of fetal heart rate and uterine contraction, to assess fetal health status. Deep learning models for intelligent fetal monitoring trained on extensively labeled and identically distributed CTG records have achieved excellent performance. However, creation of these training sets requires excessive time and specialist labor for the collection and annotation of CTG signals. Previous research has demonstrated that multicenter studies can improve model performance. However, models trained on cross-domain data may not generalize well to target domains due to variance in distribution among datasets. Hence, this paper conducted a multicenter study with Deep Semi-Supervised Domain Adaptation (DSSDA) for intelligent interpretation of antenatal CTG signals. This approach helps to align cross-domain distribution and transfer knowledge from a label-rich source domain to a label-scarce target domain. METHODS: We proposed a DSSDA framework that integrated Minimax Entropy and Domain Invariance (DSSDA-MMEDI) to reduce inter-domain gaps and thus achieve domain invariance. The networks were developed using GoogLeNet to extract features from CTG signals, with fully connected, softmax layers for classification. We designed a Dynamic Gradient-driven strategy based on Mutual Information (DGMI) to unify the losses from Minimax Entropy (MME), Domain Invariance (DI), and supervised cross-entropy during iterative learning. RESULTS: We validated our DSSDA model on two datasets collected from collaborating healthcare institutions and mobile terminals as the source and target domains, which contained 16,355 and 3,351 CTG signals, respectively. Compared to the results achieved with deep learning networks without DSSDA, DSSDA-MMEDI significantly improved sensitivity and F1-score by over 6%. DSSDA-MMEDI also outperformed other state-of-the-art DSSDA approaches for CTG signal interpretation. Ablation studies were performed to determine the unique contribution of each component in our DSSDA mechanism. CONCLUSIONS: The proposed DSSDA-MMEDI is feasible and effective for alignment of cross-domain data and automated interpretation of multicentric antenatal CTG signals with minimal annotation cost.

Mapping Early Brain-Body Interactions: Associations of Fetal Heart Rate Variation with Newborn Brainstem, Hypothalamic, and Dorsal Anterior Cingulate Cortex Functional Connectivity.

The autonomic nervous system (ANS) regulates the body's physiology, including cardiovascular function. As the ANS develops during the second to third trimester, fetal heart rate variability (HRV) increases while fetal heart rate (HR) decreases. In this way, fetal HR and HRV provide an index of fetal ANS development and future neurobehavioral regulation. Fetal HR and HRV have been associated with child language ability and psychomotor development behavior in toddlerhood. However, their associations with postbirth autonomic brain systems, such as the brainstem, hypothalamus, and dorsal anterior cingulate cortex (dACC), have yet to be investigated even though brain pathways involved in autonomic regulation are well established in older individuals. We assessed whether fetal HR and HRV were associated with the brainstem, hypothalamic, and dACC functional connectivity in newborns. Data were obtained from 60 pregnant individuals (ages 14-42) at 24-27 and 34-37 weeks of gestation using a fetal actocardiograph to generate fetal HR and HRV. During natural sleep, their infants (38 males and 22 females) underwent a fMRI scan between 40 and 46 weeks of postmenstrual age. Our findings relate fetal heart indices to brainstem, hypothalamic, and dACC connectivity and reveal connections with widespread brain regions that may support behavioral and emotional regulation. We demonstrated the basic physiologic association between fetal HR indices and lower- and higher-order brain regions involved in regulatory processes. This work provides the foundation for future behavioral or physiological regulation research in fetuses and infants.

Increased risk of preterm birth due to heat exposure during pregnancy: Exploring the mechanism of fetal physiology.

BACKGROUND: Heat exposure during pregnancy can increase the risk of preterm birth (PTB) through a range of potential mechanisms including pregnancy complications, hormone secretion and infections. However, current research mainly focuses on the effect of heat exposure on pathophysiological pathways of pregnant women, but ignore that maternal heat exposure can also cause physiological changes to the fetus, which will affect the risk of PTB. OBJECTIVE: In this study, we aimed to explore the mediating role of fetal heart rate (FHR) in the relationship between maternal heat exposure and PTB incidence. METHODS: We assigned heat exposure to a multi-center birth cohort in China during 2015-2018, which included all 162,407 singleton live births with several times FHR measurements during the second and third trimesters. We examined the associations between heat exposure, FHR and PTB in the entire pregnancy, each trimester and the last gestational month. The inverse odds ratio-weighted approach applied to the Cox regression was used to identify the mediation effect of heat exposure on PTB and its clinical subtypes via FHR. FINDINGS: Exposure to heat significantly increased the risk of PTB during the third trimester and the entire pregnancy, hazard ratios and 95 % CIs were 1.266 (1.161, 1.379) and 1.328 (1.218, 1.447). Heat exposure during the third trimester and entire pregnancy increased FHR in the third trimester by 0.24 bpm and 0.14 bpm. The proportion of heat exposure mediated by FHR elevation on PTB and its subtype ranged from 3.68 % to 24.06 %, with the significant mediation effect found for both medically indicated PTB and spontaneous PTB. CONCLUSIONS: This study suggests that heat exposure during pregnancy has an important impact on fetal health, and FHR, as a surrogate marker of fetal physiology, may mediate the increased risk of PTB caused by extreme heat. Monitoring and managing physiological changes in the fetus would constitute a promising avenue to reduce adverse birth outcomes associated with maternal heat exposure.

Implementation barriers and facilitators of Moyo foetal heart rate monitor during labour in public hospitals in Nepal.

BACKGROUND: Globally, every year, approximately 1 million foetal deaths take place during the intrapartum period, fetal heart monitoring (FHRM) and timely intervention can reduce these deaths. OBJECTIVE: This study evaluates the implementation barriers and facilitators of a device, Moyo for FHRM. METHODS: The study adopted a qualitative study design in four hospitals in Nepal where Moyo was implemented for HRM. The study participants were labour room nurses and convenience sampling was used to select them. A total of 20 interviews were done to reach the data saturation. The interview transcripts were translated to English, and qualitative content analysis using deductive approach was applied. RESULTS: Using the deductive approach, the data were organised into three categories i) changes in practice of FHRM, ii) barriers to implementing Moyo and iii) facilitators of implementing Moyo. Moyo improved adherence to intermittent FHRM as the device could handle higher caseloads compared to the previous devices. The implementation of Moyo was hindered by difficulty to organise training ondevice during non-working hours, technical issue of the device, nurse mistrust towards the device and previous experience of poor implementation to similar innovations. Facilitators for implementation included effective training on how to use Moyo, improvement in intrapartum foetal monitoring and improvement in staff morale, ease of using the device, Plan Do Study Act (PDSA) meetings to improve use of Moyo and supportive leadership. CONCLUSION: The change in FHRM practice suggests that the implementation of innovative solution such as Moyo was successful with adequate facilitation, supportive staff attitude and leadership.

Main findings: Before the Moyo implementation, foetal heart rate monitoring was sub-optimal in the hospitals, which changed after introduction of the device, as it helped early display of foetal heart rate in the monitor and supported communication with women during the labour and delivery.Added knowledge: Implementation of Moyo in low-resource setting requires an interdisciplinary approach with continuous support to health care providers on how to correctly read Moyo, maintenance of device and management of false reading.Global health impact for policy and action: The global efforts to accelerate reduce preventable intrapartum related neonatal death requires contextual understanding of clinical context for effective implementation of Moyo.