A Pragmatic Approach to Fetal Monitoring via Cardiotocography Using Feature Elimination and Hyperparameter Optimization.

Cardiotocography (CTG) is used to assess the health of the fetus during birth or antenatally in the third trimester. It concurrently detects the maternal uterine contractions (UC) and fetal heart rate (FHR). Fetal distress, which may require therapeutic intervention, can be diagnosed using baseline FHR and its reaction to uterine contractions. Using CTG, a pragmatic machine learning strategy based on feature reduction and hyperparameter optimization was suggested in this study to classify the various fetal states (Normal, Suspect, Pathological). An application of this strategy can be a decision support tool to manage pregnancies. On a public dataset of 2126 CTG recordings, the model was assessed using various standard CTG dataset specific and relevant classifiers. The classifiers' accuracy was improved by the proposed method. The model accuracy was increased to 97.20% while using Random Forest (best classifier). Practically speaking, the model was able to correctly predict 100% of all pathological cases and 98.8% of all normal cases in the dataset. The proposed model was also implemented on another public CTG dataset having 552 CTG signals, resulting in a 97.34% accuracy. If integrated with telemedicine, this proposed model could also be used for long-distance "stay at home" fetal monitoring in high-risk pregnancies.

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.

Is it time to end the use of base deficit for fetal well-being assessment?

Authors have expressed reservations regarding the use of base deficit measured in umbilical artery blood samples to assess fetal well-being during the course of labor and to predict neonatal neurologic morbidity. Despite its integration into clinical practice for more than 50 years, obstetricians and maternal-fetal medicine specialists may not realize that this marker has significant limitations in accurately identifying neonatal metabolic acidosis as a proxy for fetal well-being. In brief, there are 2 large families of base deficit, namely whole blood and extracellular fluid. Both rely on equations that use normal adult acid-base characteristics (pH 7.40 and partial CO2 pressure of 40 mm Hg) that overlook the specificity of the normal in utero acid-base status of pH 7.27 and partial CO2 pressure of 54 mm Hg. In addition, it ignores the unique characteristic of the in utero fetal response to acute hypoxia. The dependence on placental circulation for CO2 elimination may lead to extremely high values (up to 130 to 150 mm Hg) during hypoxic events, a phenomenon that is absent in adults with acute metabolic acidosis who can hyperventilate. The dispute over if to include a correction for high partial CO2 pressure in the bicarbonate estimation, as presented in the Great Trans-Atlantic Debates, remains unresolved. The key constants computed for adult acid-base physiology in the current base deficit algorithms, without accounting for the impact of high partial CO2 pressure or other fetal characteristics of buffering capacity (eg, differences in body water content composition, plasma protein, and hemoglobin attributes), may lead to an overestimation of metabolic acidosis, especially in newborns who are experiencing hypercarbia during the early stages of the hypoxic response. These unrecognized limitations impact the base deficit results and may mislead clinicians on fetal well-being assessments when discussing the management of fetal heart rate monitoring and neonatal outcomes. Based on our arguments, we believe that it is prudent to consider an alternative to base deficit for drawing conclusions regarding fetal well-being during the course of birth management. We propose a marker specifically related to the newborn acid-base physiology--the neonatal eucapnic pH correction. This marker can be added to arterial cord blood gas analysis, and we have described how to interpret it as a marker of neonatal metabolic acidosis.

Duration of biophysical profile in periviable and very preterm low-risk pregnancies.

BACKGROUND: In recent years, perinatal viability has shifted from 24 to 22 weeks of gestation at many institutions after improvements in survival in neonates delivered at the limit of viability. Monitoring these fetuses is essential because antenatal interventions with resuscitation efforts are available for patients at risk of delivery at the limit of viability. However, fetal monitoring using biophysical profiles has not been extensively studied in very preterm pregnancies, particularly in the periviable period (20 weeks 0 days to 23 weeks 6 days). OBJECTIVE: This study aimed to (1) investigate whether the completion of biophysical profiles within 30 minutes is feasible in very preterm pregnancies, and (2) determine the average observation time required to achieve a score of 8 out of 8 in very preterm pregnancies from 20 weeks 0 days to 31 weeks 6 days. STUDY DESIGN: This study prospectively evaluated biophysical scores in singleton pregnancies undergoing routine ultrasonography at or near viability from 20 weeks 0 days to 23 weeks 6 days (periviable or group I), 24 weeks 0 days to 27 weeks 6 days (group II), and 28 weeks 0 days to 31 weeks 6 days (group III). The results and duration of biophysical profiles were compared with those of a control group (32 weeks 0 days to 35 weeks 6 days) undergoing indicated fetal surveillance. Biophysical profiles were performed for all studied pregnancies until a score of 8 out of 8 was obtained. When >1 biophysical profile was obtained during pregnancy, each was analyzed individually. Pregnancies with fetal anomalies or obstetrical/medical indications for fetal well-being surveillance were excluded. Analysis of variance and post hoc Tukey tests were used for comparisons. RESULTS: Data were collected for 123 participants, yielding 79, 75, and 72 studies for groups I, II, and III, respectively. The control group included 42 patients, yielding 140 studies. At 30 minutes, 80% (63/79) of the studies in the periviable group had a score of 8 out of 8, as opposed to 100% (140/140) in the control group (P<.001). The mean±standard deviation time in minutes to achieve a biophysical score of 8 out of 8 was 23.3±10.1 in the periviable group, as opposed to 9.4±6.5 in controls (P<.001). Extending the study to +2 standard deviations (43.6 minutes) in the periviable group resulted in 97% (77/79) of the scans scoring 8 out of 8 in the absence of adverse outcomes. In the other groups, a biophysical score of 8 out of 8 within 30 minutes was obtained in 97% (73/75) and 100% (72/72) in groups II and III, respectively; the mean±standard deviation times were 17.1±8.4 minutes (group II) and 13.1±7.3 minutes (group III). No adverse outcomes developed during the study participation in groups I to III. CONCLUSION: Biophysical scores of 8 out of 8 can be successfully achieved in low-risk periviable pregnancies (20 weeks 0 days to 23 weeks 6 days) within an observation time longer than the standard 30-minute duration. The time required to reach a score of 8 out of 8 decreases as gestation progresses. We suggest adjusting the observation time for biophysical profile completion according to the gestational age.

A Fetal Well-Being Diagnostic Method Based on Cardiotocographic Morphological Pattern Utilizing Autoencoder and Recursive Feature Elimination.

Cardiotocography (CTG), which measures the fetal heart rate (FHR) and maternal uterine contractions (UC) simultaneously, is used for monitoring fetal well-being during delivery or antenatally at the third trimester. Baseline FHR and its response to uterine contractions can be used to diagnose fetal distress, which may necessitate therapeutic intervention. In this study, a machine learning model based on feature extraction (autoencoder), feature selection (recursive feature elimination), and Bayesian optimization, was proposed to diagnose and classify the different conditions of fetuses (Normal, Suspect, Pathologic) along with the CTG morphological patterns. The model was evaluated on a publicly available CTG dataset. This research also addressed the imbalance nature of the CTG dataset. The proposed model has a potential application as a decision support tool to manage pregnancies. The proposed model resulted in good performance analysis metrics. Using this model with Random Forest resulted in a model accuracy of 96.62% for fetal status classification and 94.96% for CTG morphological pattern classification. In rational terms, the model was able to accurately predict 98% Suspect cases and 98.6% Pathologic cases in the dataset. The combination of predicting and classifying fetal status as well as the CTG morphological patterns shows potential in monitoring high-risk pregnancies.

Utilizing Amniotic Fluid Metabolomics to Monitor Fetal Well-Being: A Narrative Review of the Literature.

Fetal and perinatal periods are critical phases for long-term development. Early diagnosis of maternal complications is challenging due to the great complexity of these conditions. In recent years, amniotic fluid has risen in a prominent position in the latest efforts to describe and characterize prenatal development. Amniotic fluid may provide real-time information on fetal development and metabolism throughout pregnancy as substances from the placenta, fetal skin, lungs, gastric fluid, and urine are transferred between the mother and the fetus. Applying metabolomics to monitor fetal well-being, in such a context, could help in the understanding, diagnosis, and treatment of these conditions and is a promising area of research. This review shines a spotlight on recent amniotic fluid metabolomics studies and their methods as an interesting tool for the assessment of many conditions and the identification of biomarkers. Platforms in use, such as proton nuclear magnetic resonance (1H NMR) and ultra-high-performance liquid chromatography (UHPLC), have different merits, and a combinatorial approach could be valuable. Metabolomics may also be used in the quest for habitual diet-induced metabolic signals in amniotic fluid. Finally, analysis of amniotic fluid can provide information on exposure to exogenous substances by detecting the exact levels of metabolites carried to the fetus and associated metabolic effects.

Fetal and maternal Doppler adaptation to maternal exercise during pregnancy: a randomized controlled trial.

BACKGROUND: Regular and supervised exercise during pregnancy is worldwide recommended due to its proven benefits, but, during exercise, maternal blood flow is redirected from the viscera to the muscles and how fetal wellbeing may be affected by this redistribution is still not well known. OBJECTIVE: To analyze the longitudinal effect of a supervised moderate physical exercise program during pregnancy on uteroplacental and fetal Doppler parameters. METHODS: This is a planned secondary analysis of an randomized controlled trial (RCT), performed at Hospital Universitario de Torrejón, Madrid, Spain, including 124 women randomized from 12+0 to 15+6 weeks of gestation to exercise vs. control group. Fetal umbilical artery (UA), middle cerebral artery, and uterine artery pulsatility index (PI), were longitudinally collected by Doppler ultrasound assessment throughout gestation, and derived cerebroplacental ratio (normalized by z-score), and maternal mean PI in the uterine arteries (normalized by multiplies of the median). Obstetric appointments were scheduled at 12 (baseline, 12+0 to 13+5), 20 (19+0 to 24+2), 28 (26+3 to 31+3) and 35 weeks (32+6 to 38+6) of gestation. Generalized estimating equations were adjusted to assess longitudinal changes in the Doppler measurements according to the randomization group. RESULTS: No significant differences in the fetal or maternal Doppler measurements were found at any of the different checkup time points studied. The only variable that consistently affected the Doppler standardized values was gestational age at the time of assessment. The evolution of the UA PI z-score during the pregnancy was different in the two study groups, with a higher z-score in the exercise group at 20 weeks and a subsequent decrease until delivery while in the control group it remained stable at around zero. CONCLUSIONS: A regular supervised moderate exercise program during pregnancy does not deteriorate fetal or maternal ultrasound Doppler parameters along the pregnancy, suggesting that the fetal well-being is not compromised by the exercise intervention. Fetal UA PI z-score decreases during pregnancy to lower levels in the exercise group compared with the control group.

Effect of Ramadan Fasting in Turkey Upon Fetal Well-being and Perinatal Outcomes During the Last-Trimester of Pregnancy.

Ramadan, a one-month period in which eating and drinking are prohibited from sunrise to sunset, is considered sacred by Muslims. According to Islamic rules, fasting is obligatory for adults and healthy people, but patients and travelers are exempted from this rule. It is not clear whether pregnant women can fast during Ramadan. This cross-sectional case-control study included low-risk pregnant women at 32-37 weeks of gestation in Turkey. We examined healthy women in the last period of their pregnancy and found similar perinatal outcomes between the fasting and nonfasting participants. In the evaluation of fetal well-being, a decrease in the number of accelerations in the non-stress test (NST) and the need to repeat the test were found to be statistically significantly higher in fasting pregnant women. We consider that this may prolong the evaluation period and increase unnecessary hospitalizations due to nonreactive NST results. More randomized controlled trials are needed to conclude that fasting during pregnancy is safe.

Reference ranges of uterine artery pulsatility index from first to third trimester based on serial Doppler measurements: longitudinal cohort study.

OBJECTIVE: To provide gestational-age (GA)-specific reference ranges for mean uterine artery (UtA) pulsatility index (PI) based on longitudinal data assessment throughout pregnancy. METHODS: This was a prospective longitudinal cohort study of singleton low-risk pregnancies with adequate health and nutritional status at the time of enrolment and without fetal anomaly, receiving prenatal care between January 2018 and July 2021 at the Maternal Fetal Medicine Unit of IRCCS San Raffaele Scientific Institute, Milan, Italy. Women were recruited at ≤ 12 + 6 weeks' gestation and underwent serial standardized ultrasound monitoring, including UtA-PI measurement, by experienced certified operators until delivery. Association of UtA-PI with GA was modeled with fractional polynomial regression. Equations for mean ± SD of the estimated curves were calculated, as well as GA-specific reference charts of centiles for UtA-PI from 10 + 0 to 39 + 0 gestational weeks. RESULTS: We included 476 healthy, low-risk pregnant women and a total of 2045 ultrasound scans (median, 4 (range, 3-9) per patient) were available for analysis. Mean UtA-PI was 1.84 ± 0.55, 1.07 ± 0.38 and 0.78 ± 0.23 in the first, second and third trimesters of pregnancy, respectively. Goodness-of-fit assessment revealed that second-degree smoothing was the most accurate fractional polynomial for describing the course of UtA-PI throughout gestation; therefore, it was modeled in a multilevel framework for the construction of UtA-PI curves. We observed a rapid and substantial decrease in mean UtA-PI before 16 weeks, with subsequent smoother decrement of the slope and more stable values from 20 until 39 weeks. The 3rd , 5th , 10th , 25th , 50th , 75th , 90th , 95th and 97th centiles according to GA for UtA-PI are provided, as well as equations to allow calculation of any value as a centile. CONCLUSIONS: UtA-PI shows a progressive non-linear decrease throughout pregnancy. The new reference ranges for GA-specific mean UtA-PI constructed using rigorous methodology may have a better performance compared with previous models for screening for placenta-associated diseases in the early stages of pregnancy and for evaluating the potential risk for pregnancy-induced hypertension and/or small-for-gestational age later in pregnancy. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prediction of fetal death in monochorionic twin pregnancies complicated by Type-III selective fetal growth restriction.

OBJECTIVE: Monochorionic diamniotic twin pregnancies complicated by Type-III selective fetal growth restriction (sFGR) are at high risk of fetal death. The aim of this study was to identify predictors of fetal death in these pregnancies. METHODS: This was an international multicenter retrospective cohort study. Type-III sFGR was defined as fetal estimated fetal weight (EFW) of one twin below the 10th percentile and intertwin EFW discordance of ≥ 25% in combination with intermittent absent or reversed end-diastolic flow in the umbilical artery of the smaller fetus. Predictors of fetal death were recorded longitudinally throughout gestation and assessed in univariable and multivariable logistic regression models. The classification and regression trees (CART) method was used to construct a prediction model of fetal death using significant predictors derived from the univariable analysis. RESULTS: A total of 308 twin pregnancies (616 fetuses) were included in the analysis. In 273 (88.6%) pregnancies, both twins were liveborn, whereas 35 pregnancies had single (n = 19 (6.2%)) or double (n = 16 (5.2%)) fetal death. On univariable analysis, earlier gestational age at diagnosis of Type-III sFGR, oligohydramnios in the smaller twin and deterioration in umbilical artery Doppler flow were associated with an increased risk of fetal death, as was larger fetal EFW discordance, particularly between 24 and 32 weeks' gestation. None of the parameters identified on univariable analysis maintained statistical significance on multivariable analysis. The CART model allowed us to identify three risk groups: a low-risk group (6.8% risk of fetal death), in which umbilical artery Doppler did not deteriorate; an intermediate-risk group (16.3% risk of fetal death), in which umbilical artery Doppler deteriorated but the diagnosis of sFGR was made at or after 16 + 5 weeks' gestation; and a high-risk group (58.3% risk of fetal death), in which umbilical artery Doppler deteriorated and gestational age at diagnosis was < 16 + 5 weeks' gestation. CONCLUSIONS: Type-III sFGR is associated with a high risk of fetal death. A prediction algorithm can help to identify the highest-risk group, which is characterized by Doppler deterioration and early referral. Further studies should investigate the potential benefit of fetal surveillance and intervention in this cohort. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Manual fetal stimulation during intrapartum fetal surveillance: a randomized controlled trial.

BACKGROUND: Manual fetal stimulation, either by mechanical manipulation or by stimulation of the fetal scalp, is known to evoke a fetal heart response in a normal fetus. OBJECTIVE: This study aimed to assess the clinical effectiveness of manual fetal stimulation in the assessment of fetal well-being during labor vs no stimulation among women with a singleton pregnancy and to investigate the maternal and neonatal outcomes in the 2 groups. STUDY DESIGN: This was a randomized controlled trial conducted in the department of obstetrics and gynecology at a tertiary care teaching hospital between 2014 and 2016. The inclusion criteria included women with a singleton pregnancy at ≥37 weeks of gestation with cephalic presentation in labor having one of the following abnormalities on fetal heart tracing: fetal heart rate of <110 bpm or >160 bpm, variable decelerations, late decelerations, and minimal or absent beat-to-beat variability. The exclusion criteria included women requiring immediate cesarean delivery, conditions that would preclude a vaginal delivery, and intrauterine fetal demise or a major fetal congenital abnormality. The women were followed up in labor and randomized to either the manual stimulation group or the no stimulation group when one of the cardiotocography abnormalities were present. In the manual stimulation group, the fetus was stimulated abdominally by holding the head in the palm of 1 hand when the cervical dilatation was <3 cm or vaginally by pinching the scalp of the fetus when the cervical dilatation was ≥3 cm. After delivery, a cord blood sample was collected and pH estimated. Mother and baby were followed up until discharge, and mode of delivery, cord blood pH at birth, Apgar scores at 1 minute and 5 minutes, neonatal intensive care unit admissions, and duration of stay were the outcomes studied. Data were entered and compiled as frequency and percentage for categorical variables. For continuous variables, data were calculated using mean and standard deviation. The chi-square test was used for assessing the association between the intervention and fetal and maternal outcomes. RESULTS: A total of 327 women were included in the trial, of whom 164 were in the manual fetal stimulation group (group 1) and 163 were in the "no stimulation" group (group 2). The cesarean delivery rates were 25.61% in group 1 and 30.67% in group 2 (P=.308). The mean cord blood pH levels at birth were 7.267±0.027 in group 1 and 7.265±0.024 in group 2 (P=.479), and the Apgar scores at 1 minute and 5 minutes (P=.169 and P=.423, respectively, between the 2 groups) were not found to be statistically different among the 2 groups. CONCLUSION: There was no considerable change in fetomaternal outcomes with manual fetal stimulation in women having nonreassuring cardiotocographic changes in labor.

Relationship between Thyroid Status during the First Trimester of Pregnancy and Neonatal Well-Being.

Iodine is an essential micronutrient for the synthesis of thyroid hormones. The proper functioning of the thyroid axis is essential for the normal development of the nervous system, especially in the first trimester of gestation. The aim of the present study was to analyze the perinatal outcomes, anthropometry, and APGAR test scores of newborns and to relate them to maternal thyroid status. A total of 190 newborns participated in the study. No correlation was found between thyroid stimulating hormone (TSH) and maternal ioduria values in the first trimester of gestation with the weight or length of the newborn, or the APGAR score at one minute after birth. However, we found significant differences between the APGAR scores of children whose mothers had an iodine sufficiency level in the first trimester compared to the children of mothers with iodine deficiency. Similarly, the APGAR scores of children whose mothers had a TSH > 4 have significantly better APGAR scores than the children of mothers with a TSH < 4. Likewise, we found significant differences between the measurements of the newborns depending on whether their mothers smoked. The children of mothers who took iodine supplements or iodized salt obtained the highest APGAR score at one and five minutes after birth. It is essential to focus on recommending adequate consumption of iodine supplements and iodized salt prior to gestation and at least during the first trimester to achieve better fetal well-being.

Midwives' experiences of using the Mindfetalness method when talking with pregnant women about fetal movements.

BACKGROUND: Information given to pregnant women about fetal movements is important in maternity care and decreased fetal movements is associated with fetal growth restriction and stillbirth. The fetal movement pattern is different for every fetus and women perceive different types of movements. Mindfetalness is a self-assessment method for a woman to use to become familiar with her unborn baby's fetal movement pattern. AIM: We aimed to explore midwives' perceptions about informing pregnant women about fetal movements and their experiences of working with Mindfetalness in their daily work. METHODS: A web-questionnaire was distributed to midwives who participated in a randomized controlled trial evaluating Mindfetalness, a method for the observation of fetal movements. In total, 67 maternity clinics in Stockholm, Sweden, were randomized to Mindfetalness or routine care. Of the 144 midwives working in maternity clinics randomized to Mindfetalness, 80% answered the questionnaire. FINDINGS: The midwives thought that the leaflet about Mindfetalness was supportive in their work when informing women about fetal movements and the majority wanted to continue to distribute the leaflet when the trial ended. The midwives also expressed that the study increased their own knowledge about fetal movements. Women embraced the information about Mindfetalness positively and appreciated the written material. The midwives thought that talking about fetal movements in maternity care is an important but challenging task. CONCLUSION: Mindfetalness is a useful tool to use in maternity clinics when informing pregnant women about fetal movements. The written information was appreciated by both pregnant women and midwives.

Evaluation of cord blood creatine kinase (CK), cardiac troponin T (cTnT), N-terminal-pro-B-type natriuretic peptide (NT-proBNP), and s100B levels in nonreassuring foetal heart rate.

AIM: To evaluate the possible associations between creatine kinase (CK), cardiac troponin T (cTnT), N-terminal-pro-B-type natriuretic peptide (NT-proBNP), and s100B levels in umbilical cord blood and nonstress test results, cord-blood gas analyses and Apgar scores. MATERIAL AND METHODS: A total of 93 cesarean section deliveries after 34 + 0/7 gestational week (GW) were evaluated. The study (n = 50) and control (n = 43) groups consisted of type III and type I nonstress test (NST) according to the 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring. The serum levels of ProBNP II, S100-B, CK-MB, and cTnT were measured in cord blood and were evaluated according to the NST results, cord-blood gas analyses (pH and base-excess values) and 1- and 5-minute Apgar scores. Exclusion criteria for both groups included congenital abnormalities, multiple pregnancy, chorioamnionitis, oligohydramnios, polyhydramnios, intrauterine growth retardation (IUGR), and placental abruption. RESULTS: Mean age, weight, height, gestational age, and birth weight were comparable in type I and III NST groups. 1- and 5- minute Apgar, umbilical artery and vein pH values, and base deficiency were significantly lower in type III NST group compared to the type I NST group. The serum 100B (1616 ± 119 versus 533 ± 95 ng/L, p < .001), CK-MB (28.67 ± 21.17 versus 14.20 ± 11.26 ng/L, p < .001), cTnT (657 ± 396 versus 230 ± 132 ng/L, p < .001) and proBNP (1727 ± 379 versus 1069 ± 721 ng/L, p < .001) levels were significantly elevated in the NST type III compared to the NST type I group. The serum 100B, CK-MB, cTnT and proBNP levels were significantly elevated in the cord pH < 7.00 (n = 10) compared to pH = 7.00-7.15 group (n = 18). The serum 100B and proBNP were significantly elevated in the cord pH = 7.00-7.15 compared to the pH > 7.15 group (n = 65), whereas serum cTnT and proBNP levels were comparable in the latter two groups. In the study group, S100B, cTnT, and proBNP had negative correlations with 1- and 5-minute Apgar scores. All of the four markers showed negative correlations with A. umbilicalis pH and base excess. CONCLUSIONS: Mean S100B, CK-MB, cTnT, and NT-proBNP were significantly higher in the study group compared to the control group. The serum 100B, CK-MB, cTnT, and proBNP levels were significantly elevated in the cord pH < 7.00 compared to pH = 7.00-7.15 group. The serum 100B and proBNP were significantly elevated in the cord pH = 7.00-7.15 compared to the pH > 7.15 group.

Improving the Information Availability and Accessibility of Antenatal Measurements to Ensure Safe Delivery: A Research-Based Policy Recommendation to Reduce Neonatal Mortality in Indonesia.

PURPOSE: Assessing the risks and preventable causes of maternal and neonatal mortality requires the availability of good-quality antenatal information. In Indonesia, however, access to reliable information on pregnancy-related results remains challenging. This research has proposed a research-based policy recommendation to improve availability and accessibility to vital information on antenatal examinations. PATIENTS AND METHODS: Descriptive statistics were used to characterize midwives' capabilities in routinely gathering and recording antenatal information during pregnancy. The investigation was carried out among 19 midwives in South Kalimantan, Indonesia, from April 2016 to October 2017. Antenatal data on 4946 women (retrospective study) and 381 women (prospective study) have been accessed through a scientific and technical training program. RESULTS: To date, lack of timely access to antenatal information has hampered the process of reducing neonatal mortality in Indonesia. The post-training statistical analysis showed that the training has significantly improved midwives' scientific knowledge and technical abilities in providing more reliable data on antenatal measurements. CONCLUSION: Consistent scientific and technical training among midwives is required to update their knowledge and skills, particularly those relating to documenting the results of antenatal examinations at different stages of pregnancy and using that information to assess potential risks and identify necessary interventions. This should also be followed by routine monitoring on the quality of collected antenatal data. This can be one of the enabling actions to achieve the 2030 Sustainable Development Goals target in reducing neonatal mortality in Indonesia.

International gestational age-specific centiles for umbilical artery Doppler indices: a longitudinal prospective cohort study of the INTERGROWTH-21st Project.

BACKGROUND: Reference values for umbilical artery Doppler indices are used clinically to assess fetal well-being. However, many studies that have produced reference charts have important methodologic limitations, and these result in significant heterogeneity of reported reference ranges. OBJECTIVES: To produce international gestational age-specific centiles for umbilical artery Doppler indices based on longitudinal data and the same rigorous methodology used in the original Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project. STUDY DESIGN: In Phase II of the INTERGROWTH-21st Project (the INTERBIO-21st Study), we prospectively continued enrolling pregnant women according to the same protocol from 3 of the original populations in Pelotas (Brazil), Nairobi (Kenya), and Oxford (United Kingdom) that had participated in the Fetal Growth Longitudinal Study. Women with a singleton pregnancy were recruited at <14 weeks' gestation, confirmed by ultrasound measurement of crown-rump length, and then underwent standardized ultrasound every 5±1 weeks until delivery. From 22 weeks of gestation umbilical artery indices (pulsatility index, resistance index, and systolic/diastolic ratio) were measured in a blinded fashion, using identical equipment and a rigorously standardized protocol. Newborn size at birth was assessed using the international INTERGROWTH-21st Standards, and infants had detailed assessment of growth, nutrition, morbidity, and motor development at 1 and 2 years of age. The appropriateness of pooling data from the 3 study sites was assessed using variance component analysis and standardized site differences. Umbilical artery indices were modeled as functions of the gestational age using an exponential, normal distribution with second-degree fractional polynomial smoothing; goodness of fit for the overall models was assessed. RESULTS: Of the women enrolled at the 3 sites, 1629 were eligible for this study; 431 (27%) met the entry criteria for the construction of normative centiles, similar to the proportion seen in the original fetal growth longitudinal study. They contributed a total of 1243 Doppler measures to the analysis; 74% had 3 measures or more. The healthy low-risk status of the population was confirmed by the low rates of preterm birth (4.9%) and preeclampsia (0.7%). There were no neonatal deaths and satisfactory growth, health, and motor development of the infants at 1 and 2 years of age were documented. Only a very small proportion (2.8%-6.5%) of the variance of Doppler indices was due to between-site differences; in addition, standardized site difference estimates were marginally outside this threshold in only 1 of 27 comparisons, and this supported the decision to pool data from the 3 study sites. All 3 Doppler indices decreased with advancing gestational age. The 3rd, 5th 10th, 50th, 90th, 95th, and 97th centiles according to gestational age for each of the 3 indices are provided, as well as equations to allow calculation of any value as a centile and z scores. The mean pulsatility index according to gestational age = 1.02944 + 77.7456*(gestational age)-2 - 0.000004455*gestational age3. CONCLUSION: We present here international gestational age-specific normative centiles for umbilical artery Doppler indices produced by studying healthy, low-risk pregnant women living in environments with minimal constraints on fetal growth. The centiles complement the existing INTERGROWTH-21st Standards for assessment of fetal well-being.

The use of actograph in the assessment of fetal well-being.

Purpose: Third trimester maternal perception of fetal movements is often used to assess fetal well-being. However, its true clinical value is unknown, primarily because of the variability in subjective quantification. The actograph, a technology available on most cardiotocograph machines, quantifies movements, but has never previously been investigated in relation to fetal health and existing monitoring devices. The objective of this study was to quantify actograph output in healthy third trimester pregnancies and investigate this in relation to other methods of assessing fetal well-being.Methods: Forty-two women between 24 and 34 weeks of gestation underwent ultrasound scan followed by a computerized cardiotocograph (CTG). Post capture analysis of the actograph recording was performed and expressed as a percentage of activity over time. The actograph output results were analyzed in relation to Doppler, ultrasound and CTG findings expressed as z-score normalized for gestation.Results: There was a significant association between actograph output recording and estimated fetal weight Z-score (R = 0.546, p ≤ .005). This activity was not related to estimated fetal weight. Increased actograph activity was negatively correlated with umbilical artery pulsatility index Z-score (R = -0.306, p = .049) and middle cerebral artery pulsatility index Z-score (R = -0.390, p = .011).Conclusion: Fetal movements assessed by the actograph are associated both with fetal size in relation to gestation and fetoplacental Doppler parameters. It is not the case that larger babies move more, however, as the relationship with actograph output related only to estimated fetal weight z-score. These findings suggest a plausible link between the frequency of fetal movements and established markers of fetal health.RATIONALEThe objective of this study was to quantify actograph output in healthy third trimester pregnancies and investigate this in relation to other methods of assessing fetal well-being. This is a widely available method of assessing fetal movements objectively, which has been shown to be an important marker of fetal health. This research is novel in the fact that actograph has never been truly investigated in relation to fetal well-being, despite being available on most cardiotocograph (CTG) machines.Our results show that fetal movements assessed by the actograph are associated both with fetal size in relation to gestation and fetoplacental Doppler parameters. If this proves to be true, smaller babies that move less maybe at particular perinatal risk.

ACR Appropriateness Criteria® Growth Disturbances-Risk of Fetal Growth Restriction.

Fetal growth restriction, or an estimated fetal weight of less than the 10th percentile, is associated with adverse perinatal outcome. Optimizing management for obtaining the most favorable outcome for mother and fetus is largely based on detailed ultrasound findings. Identifying and performing those ultrasound procedures that are most associated with adverse outcome is necessary for proper patient management. Transabdominal ultrasound is the mainstay of initial management and assessment of fetal growth. For those fetuses that are identified as small for gestational age, assessment of fetal well-being with biophysical profile and Doppler velocimetry provide vital information for differentiating those fetuses that may be compromised and may require delivery and those that are well compensated. Delivery of the pregnancy is primarily based upon the gestational age of the pregnancy and the ultrasound findings. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Diagnóstico de madurez pulmonar fetal por velocimetria doppler / Diagnosis of fetal pulmonary maturity by doppler flow assessment

Objetivo: Establecer la relación entre la edad gestacional y la velocidad máxima del ductus arterioso (VmxDA), y determinar si es posible predecir la madurez pulmonar fetal con flujometría Doppler de la VmxDA. Diseño del estudio: Se realizó un estudio de cohortes, prospectivo, con muestreo no probabilístico donde se tomó como población a pacientes sanos que cumplan los criterios de inclusión. Se valoró la velocidad máxima del ductus arterioso. Se estimaron los valores paramétricos y se evaluó el coeficiente regresión y correlación, sensibilidad y especificidad, con la edad gestacional. Se utilizó un intervalo de confianza del 95%, se obtuvo las diferentes velocidades máximas del ductus arterioso según edad gestacional, y su respectivo error estándar junto con sus desviaciones estándar y se correlacionaron con la edad gestacional, para determinar la posibilidad de predecir la madurez pulmonar por flujometría Doppler. Resultados: Se evaluó un total de 824 pacientes donde se evidenció un aumento de la velocidad máxima del ductus arterioso a medida que avanza la edad gestacional. Se encontró dos puntos de inflexión en la curva de la VmxDA a las 28 semanas y a las 35 semanas. Se obtuvo un coeficiente de correlación de 0.97 con un nivel de probabilidad menor de 0.0001. Los valores de sensibilidad y especificidad para predecir madurez pulmonar fueron de 83.9% y 100% para 95 cm/s y 91.5% y 100% para 98 cm/s, con un VPP del 0.709 y un VPN del 1.0. La variabilidad interobservador fue menor de 5%para la VmxDA. Conclusiones: Existe una relación directa entre la edad gestacional y la velocidad máxima del ductus arterioso, pudiendo ser utilizado como un buen predictor de madurez pulmonar fetal.

Objective: To establish the relationship between the gestational age and the maximum velocity of the ductus arteriosus (VmxDA), and to determine if it is possible to predict the fetal lung maturity with Doppler flow assessment of the VmxDA. Study design: A prospective, cohort study was conducted with non-probabilistic sampling where healthy patients who met the inclusion criteria were taken as a population. The maximum velocity of the ductus arteriosus was evaluated. Parametric values were estimated and the coefficient of regression and correlation, sensitivity and specificity was evaluated with gestational age. A 95% confidence interval was used, the different maximum ductus arteriosus velocities were obtained according to gestational age, and their respective standard error along with their standard deviations and they were correlated with gestational age, to determine the possibility of predicting lung maturity by flow assessment of the VmxDA. Results: 824 patients were evaluated where it was evidenced an increase in the maximum velocity of the ductus arteriosus was observed as gestational age progressed. Two inflection points were found in the VmxDA curve at 28 weeks and at 35 weeks. A correlation coefficient of 0.97 was obtained with a probability level of less than 0.0001. The values of sensitivity and specificity to predict lung maturity were 83.9% and 100% for 95 cm / s and 91.5% and 100% for 98 cm / s, with a PPV of 0.709 and a NPV of 1.0. The interobserver variability was less than 5% for the VmxDA. Conclusions: There is a direct relationship between gestational age and the maximum velocity of the ductus arteriosus, which can be used as a good predictor of fetal lung maturity