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1.
Obstet Gynecol ; 135(2): 453-462, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31923063

RESUMO

OBJECTIVE: To assess the association of fetal movement counting with perinatal mortality. DATA SOURCES: Electronic databases (ie, MEDLINE, ClinicalTrials.gov, ScienceDirect, the Cochrane Library at the CENTRAL Register of Controlled Trials) were searched from inception until May 2019. Search terms used were: "fetal movement," "fetal movement counting," "fetal kick counting," "stillbirth," "fetal demise," "fetal mortality," and "perinatal death." METHODS OF STUDY SELECTION: We included all randomized controlled trials comparing perinatal mortality in those women randomized to receive instructions for fetal movement counting compared with a control group of women without such instruction. TABULATION, INTEGRATION AND RESULTS: The primary outcome was perinatal mortality. Five of 1,290 identified articles were included, with 468,601 fetuses. Definitions of decreased fetal movement varied. In four of five studies, women in the intervention group were asked to contact their health care providers if they perceived decreased fetal movement; the fifth study did not provide details. Reported reduction in fetal movement usually resulted in electronic fetal monitoring and ultrasound assessment of fetal well-being. There was no difference in the incidence of perinatal outcome between groups. The incidence of perinatal death was 0.54% (1,252/229,943) in the fetal movement counting group and 0.59% (944/159,755) in the control group (relative risk [RR] 0.92, 95% CI 0.85-1.00). There were no statistical differences for other perinatal outcomes as stillbirths, neonatal deaths, birth weight less than 10th percentile, reported decreased fetal movement, 5-minute Apgar score less than 7, neonatal intensive care unit admission or perinatal morbidity. There were weak but significant increases in preterm delivery (7.6% vs 7.1%; RR 1.07, 95% CI 1.05-1.10), induction of labor (36.6% vs 31.6%; RR 1.15, 95% CI 1.09-1.22), and cesarean delivery (28.2% vs 25.3%; RR 1.11, 95% CI 1.10-1.12). CONCLUSION: Instructing pregnant women on fetal movement counting compared with no instruction is not associated with a clear improvement in pregnancy outcomes. There are weak associations with some secondary outcomes such as preterm delivery, induction of labor, and cesarean delivery. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42019123264.


Assuntos
Cardiotocografia/métodos , Movimento Fetal , Trabalho de Parto , Mortalidade Perinatal , Feminino , Humanos , Recém-Nascido , Gravidez , Resultado da Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo
2.
Int J Gynaecol Obstet ; 148(2): 145-156, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31646629

RESUMO

BACKGROUND: Using Doppler to improve detection of intrapartum fetal heart rate (FHR) abnormalities coupled with appropriate, timely intrapartum care in low- and middle-income countries (LMIC) can save lives. OBJECTIVE: To review studies using Doppler to improve detection of intrapartum FHR abnormalities and intrapartum care quality in LMIC health facilities. SEARCH STRATEGY: PubMed, Web of Science, Embase, Global Health, and Scopus were searched from inception to October 2018 by combining terms for Doppler, perinatal outcomes, and FHR monitoring. SELECTION CRITERIA: Selected studies compared Doppler and Pinard stethoscope for detecting/monitoring intrapartum FHR, or described provider and maternal preferences for FHR monitoring in LMIC settings. DATA COLLECTION AND ANALYSIS: Two team members independently screened and collected data. Risk of bias was assessed by Cochrane EPOC criteria. RESULTS: Eleven studies from eight countries were included. Doppler was superior at detecting abnormal intrapartum FHR as compared with Pinard stethoscope, but was not associated with improved perinatal outcomes. Using Doppler on admission helped to accurately measure perinatal deaths occurring after facility admission. CONCLUSION: Studies and program learning are needed to translate improved detection of FHR abnormalities to improved case management in LMICs. Doppler should be used to calculate a facility indicator of intrapartum care quality. PROSPERO registration: CRD42019121924.


Assuntos
Cardiotocografia/métodos , Cardiopatias Congênitas/diagnóstico por imagem , Frequência Cardíaca Fetal/fisiologia , Ultrassonografia Doppler , Países em Desenvolvimento , Feminino , Saúde Global , Humanos , Recém-Nascido , Mortalidade Perinatal , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Ultrassonografia Pré-Natal
3.
Arch Gynecol Obstet ; 301(1): 137-142, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31883047

RESUMO

PURPOSE: Phase-rectified signal averaging method (PRSA) represents an analysis method which applied on fetal cardiotocography (CTG) allows the quantification of the speed of fetal heart rate changes. By calculating the average deceleration capacity (ADC) an assessment of the fetal autonomic nervous system (ANS) is possible. The objective of this study was to test its ability to predict perinatal acidosis. METHODS: A case-control study was performed at a University Hospital in Munich. All intrapartum CTG heart rate tracings saved during a 7-year period were considered for analysis. All neonates born with an umbilical arterial blood pH ≤ 7.10 were considered as cases. Controls were defined as healthy fetuses born with a pH ≥ 7.25. The main matching criteria were gestational age at delivery, parity, birth mode, and birth weight percentile. Exclusion criteria were a planned caesarean section, fetal malformations, and multiple pregnancies. ADC and STV were then calculated during the last 60, the last 45, and the last 30 min intervals prior to delivery. RESULTS: Of all stored birth CTG recordings, 227 cases met the inclusion criteria and were studied. ADC was significantly higher in fetuses born with acidemia (4.85 bpm ± 3.0) compared to controls (3.36 bpm ± 2.2). The area under ROC curve was 0.659 (95% CI 0.608-0.710) for ADC and 0.566 (0.512-0.620) for STV (p = 0.013). CONCLUSIONS: This study confirms that the assessment of ADC using PRSA represents a good additional tool for the prediction of acute fetal acidosis during delivery.


Assuntos
Acidose/sangue , Cardiotocografia/métodos , Sangue Fetal/química , Doenças Fetais/diagnóstico , Estudos de Casos e Controles , Feminino , Sangue Fetal/citologia , Doenças Fetais/sangue , Frequência Cardíaca Fetal/fisiologia , Humanos , Masculino , Gravidez
4.
Curationis ; 42(1): e1-e7, 2019 Nov 27.
Artigo em Inglês | MEDLINE | ID: mdl-31793307

RESUMO

BACKGROUND: The primary purpose of cardiotocography is to detect early signs of intrapartum hypoxia and improve foetal outcomes. Intrapartum hypoxia remains the major cause of perinatal deaths during monitored labours. This is attributed to the midwives' lack of knowledge and skills in the foetal implementation and interpretation of cardiotocographs. OBJECTIVES: This study aimed to establish midwives' knowledge and interpretive skills of cardiotocography. METHOD: The study employed a quantitative research approach with an explorative, descriptive, cross-sectional design. A total of 226 purposively selected participants were asked to complete a self-administered, structured questionnaire, of which 125 responded by completing the questionnaire. The study was conducted in labour wards in KwaZulu-Natal public hospitals in 2014. Data analysis was performed by means of descriptive and inferential statistics using analysis of variance. RESULTS: The findings revealed that the midwives in KwaZulu-Natal public hospitals were found to be clinically lacking in knowledge of cardiotocography. CONCLUSION: The limited cardiotocographic knowledge of the midwives in KwaZulu-Natal public hospitals was possibly because of a lack of in-service training, as more than half of the participants (70%) indicated a need for this.


Assuntos
Cardiotocografia/métodos , Competência Clínica/normas , Enfermeiras Obstétricas/normas , Adulto , Cardiotocografia/estatística & dados numéricos , Competência Clínica/estatística & dados numéricos , Estudos Transversais , Avaliação Educacional/métodos , Feminino , Humanos , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Monitorização Fisiológica/normas , Enfermeiras Obstétricas/estatística & dados numéricos , África do Sul , Inquéritos e Questionários
5.
BMC Pregnancy Childbirth ; 19(1): 501, 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31842798

RESUMO

BACKGROUND: Maternal heart rate artefact is a signal processing error whereby the fetal heart rate is masked by the maternal pulse, potentially leading to danger by failure to recognize an abnormal fetal heart rate or a pre-existing fetal death. Maternal heart rate artefact may be exacerbated by autocorrelation algorithms in modern fetal monitors due to smooth transitions between maternal and fetal heart rates rather than breaks in the tracing. In response, manufacturers of cardiotocography monitors recommend verifying fetal life prior to monitoring and have developed safeguards including signal ambiguity detection technologies to simultaneously and continuously monitor the maternal and fetal heart rates. However, these safeguards are not emphasized in current cardiotocography clinical practice guidelines, potentially leading to a patient safety gap. METHODS: The United States Food and Drug Administration Manufacturer and User Facility Device Experience database was reviewed for records with event type "Death" for the time period March 31, 2009 to March 31, 2019, in combination with search terms selected to capture all cases reported involving cardiotocography devices. Records were reviewed to determine whether maternal heart rate artefact was probable and/or whether the report contained a recommendation from the device manufacturer regarding maternal heart rate artefact. RESULTS: Forty-seven cases of perinatal mortality were identified with probable maternal heart rate artefact including 14 with antepartum fetal death prior to initiation of cardiotocography, 14 with intrapartum fetal death or neonatal death after initiation of cardiotocography, and 19 where the temporal relationship between initiation of cardiotocography and death cannot be definitively established from the report. In 29 cases, there was a recommendation from the manufacturer regarding diagnosis and/or management of maternal heart rate artefact. CONCLUSIONS: This case series indicates a recurring problem with undetected maternal heart rate artefact leading to perinatal mortality and, in cases of pre-existing fetal death, healthcare provider confusion. In response, manufacturers frequently recommend safeguards which are found in their device's instructions for use but not in major intrapartum cardiotocography guidelines. Cardiotocography guidelines should be updated to include the latest safeguards against the risks of maternal heart rate artefact. An additional file summarizing key points for clinicians is included.


Assuntos
Artefatos , Cardiotocografia/mortalidade , Morte Perinatal/etiologia , Mortalidade Perinatal , Cardiotocografia/métodos , Feminino , Frequência Cardíaca Fetal , Humanos , Recém-Nascido , Gravidez , Processamento de Sinais Assistido por Computador , Estados Unidos/epidemiologia , United States Food and Drug Administration
7.
BJOG ; 126 Suppl 4: 21-26, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31257695

RESUMO

OBJECTIVE: To study the changes in the rates of perinatal mortality, birth asphyxia, and caesarean sections in relation to interventions implemented over the past 18 years, in a tertiary centre in South India. DESIGN: Retrospective study. SETTING: Labour and maternity unit of a tertiary centre in South India. POPULATION OR SAMPLE: Women who gave birth between 2000 and 2018. METHODS: Information from perinatal audits, chart reviews, and data retrieved from the electronic database were used. Interventions implemented during this time period were audits and training, obstetric re-organisation, and minor changes in staffing and infrastructure. MAIN OUTCOME MEASURES: Main outcome measures were perinatal mortality rate, birth asphyxia rate, and caesarean section rate. RESULTS: Perinatal mortality rate decreased from 44 per 1000 births in 2000 to 16.4 per 1000 births in 2018 (P < 0.001). The rates of babies born with birth asphyxia requiring admission to the neonatal unit decreased from 24 per 1000 births in 2001 to 0.7 per 1000 births in 2018 (P < 0.00001). The overall caesarean section rate was maintained close to 30%. CONCLUSION: In a large tertiary hospital in South India, with 14 000 deliveries per year, a policy of rigorous audits of stillbirths and birth asphyxia, electronic fetal monitoring, and the introduction of standardised criteria for trial of scar, reduced the perinatal mortality and the rate of babies born with birth asphyxia over the past 18 years, without an increase in the caesarean section rate. TWEETABLE ABSTRACT: Rigorous perinatal audits with training in fetal cardiotocography, decreased birth asphyxia, without a major increase in caesarean rates.


Assuntos
Asfixia Neonatal/epidemiologia , Cesárea/estatística & dados numéricos , Mortalidade Perinatal , Cuidado Pré-Natal/normas , Centros de Atenção Terciária/estatística & dados numéricos , Adulto , Asfixia Neonatal/prevenção & controle , Cardiotocografia/métodos , Feminino , Humanos , Índia/epidemiologia , Recém-Nascido , Período Periparto , Gravidez , Cuidado Pré-Natal/métodos , Estudos Retrospectivos
8.
Brain Behav ; 9(8): e01345, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31254448

RESUMO

INTRODUCTION: Some studies suggest that maternal touch of the abdomen produces an increase in the number of movements of the fetus. However, the influence of maternal touch of the abdomen on fetal cardiotocography patterns has not been studied. METHODS: This nonrandomized, before-after clinical trial that assessed fetal cardiotocography patterns during maternal touch of the abdomen in 28 low-risk pregnant women. RESULTS: Baseline fetal heart rate, accelerations, decelerations, and variability did not change with maternal touch of the abdomen, but fetal movements increased (p = 0.044). CONCLUSION: Fetal movements increases during maternal touch of the abdomen.


Assuntos
Cardiotocografia/métodos , Movimento Fetal/fisiologia , Frequência Cardíaca Fetal/fisiologia , Abdome , Adulto , Família , Feminino , Humanos , Gravidez , Tato/fisiologia , Percepção do Tato/fisiologia
9.
Artif Intell Med ; 96: 33-44, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31164209

RESUMO

The combination of machine vision and soft computing approaches in the clinical decisions, using training data, can improve medical decisions and treatments. The cardiotocography (CTG) monitoring and uterine activity (UA) provides useful information about the condition of the fetus and the cesarean or natural delivery. The visual assessment by the pathologists takes a lot of time and may be incompatible. Therefore, creating a computer intelligent method to assess fetal wellbeing before the mother labour is very important. In this study, many diverse approaches are suggested for predicting fetal state classes based on artificial intelligence. The various topologies of multi-layer architecture of a sub-adaptive neuro fuzzy inference system (MLA-ANFIS) using multiple input features, neural networks (NN), deep stacked sparse auto-encoders (DSSAEs), and deep-ANFIS models are implemented on a CTG data set. Experimental results contributing to DSSAE are more accurate than other suggested techniques to predict fetal state. The proposed method achieved a sensitivity of 99.716, specificity of 97.500 and geometric mean of 98.602 with accuracy of 99.503.


Assuntos
Cardiotocografia/métodos , Aprendizado Profundo , Inteligência Artificial , Feminino , Lógica Fuzzy , Humanos , Redes Neurais de Computação , Gravidez , Contração Uterina/fisiologia
10.
Acta Obstet Gynecol Scand ; 98(11): 1450-1454, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31148156

RESUMO

INTRODUCTION: The objective of this study was to examine the outcomes and interventions in pregnant women presenting with a perception of reduced fetal movements (RFM), and to determine if repeated episodes of RFM increase the risk of adverse outcomes. MATERIAL AND METHODS: This was a retrospective cohort study conducted in six NHS hospitals within the Thames Valley network region, UK and one neighboring hospital, an area with approximately 31 000 births annually. All women with a primary presentation of perceived RFM after 24 completed weeks of gestation during the month of October 2016 were included in the study. Prospective records in all units were examined and individual case-notes were reviewed. Pregnancy and neonatal outcomes and their relation with recurrent presentations with RFM were examined using relative risks with 95% CI. The main outcome measures are described. Neonatal outcomes measured were perinatal mortality, neonatal unit admission, abnormal cardiotocography at presentation, a composite severe morbidity outcome of Apgar <7 at 5 minutes or arterial pH <7.0 or encephalopathy, and birthweight. Pregnancy outcomes measured were induction of labor, cesarean section, admission and ultrasound usage rates. RESULTS: In all, 591 women presented with RFM during the month; using annual hospital birth figures, the incidence of RFM was estimated at 22.6% (range 14.9%-32.5%). More than 1 presentation of RFM occurred in 273 (46.2%). All 3 deaths (0.5%) were at the first presentation. More than 1 presentation was associated with higher induction rates (56.0% vs 31.9%), but no increase in any adverse outcomes including small-for-gestational-age. CONCLUSIONS: Reduced fetal movements, and recurrent episodes, are common, and lead to considerable resource usage and obstetric intervention. We found no evidence to suggest that recurrent episodes increase pregnancy risk.


Assuntos
Retardo do Crescimento Fetal/diagnóstico por imagem , Movimento Fetal/fisiologia , Recém-Nascido Pequeno para a Idade Gestacional , Resultado da Gravidez , Natimorto , Ultrassonografia Pré-Natal , Adulto , Cardiotocografia/métodos , Estudos de Coortes , Feminino , Idade Gestacional , Humanos , Gravidez , Estudos Retrospectivos , Medição de Risco , Reino Unido
11.
Biomed Tech (Berl) ; 64(6): 669-675, 2019 Dec 18.
Artigo em Inglês | MEDLINE | ID: mdl-31199757

RESUMO

A new technique for electronic fetal monitoring (EFM) using an efficient structure of neural networks based on the Legendre series is presented in this paper. Such a structure is achieved by training a Legendre series-based neural network (LNN) to classify the different fetal states based on recorded cardiotocographic (CTG) data sets given by others. These data sets consist of measurements of fetal heart rate (FHR) and uterine contraction (UC). The applied LNN utilizes a Legendre series expansion for the input vectors and, hence, has the capability to produce explicit equations describing multi-input multi-output systems. Simulations of the proposed technique in EFM demonstrate its high efficiency. Training the LNN requires a few number of iterations (5-10 epochs). The applied technique makes the classification of the fetal state available through equations combining the trained LNN weights and the current measured CTG record. A comparison of performance between the proposed LNN and other popular neural network techniques such as the Volterra neural network (VNN) in EFM is provided. The comparison shows that, the LNN outperforms the VNN in case of less computational requirements and fast convergence with a lower mean square error.


Assuntos
Cardiotocografia/métodos , Frequência Cardíaca Fetal/fisiologia , Feminino , Humanos , Redes Neurais de Computação , Gravidez
12.
Arch Gynecol Obstet ; 300(1): 7-14, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31053949

RESUMO

OBJECTIVES: To determine the degree of inter-rater reliability (IRR) between human and artificial intelligence (AI) interpretation of fetal heart rate tracings (FHR), and to determine whether AI-assisted electronic fetal monitoring interpretation improves neonatal outcomes amongst laboring women. DATA SOURCES: We searched Medline, EMBASE, Google Scholar, Scopus, ISI Web of Science and Cochrane database search, as well as PubMed ( www.pubmed.gov ) and RCT registry ( www.clinicaltrials.gov ) until the end of October 2018 to conduct a systematic review and meta-analysis comparing visual and AI interpretation of EFM in labor. Similarly, we sought out all studies evaluating the IRR between AI and expert interpretation of EFM. TABULATION, INTEGRATION AND RESULTS: Weighed mean Cohen's Kappa was calculated to assess the global IRR. Risk of bias was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. We used relative risks (RR) and a random effects (RE) model to calculate weighted estimates. Statistical homogeneity was checked by the χ2 test and I2 using Review Manager 5.3.5 (The Cochrane Collaboration, 2014.) We obtained 201 records, of which 9 met inclusion criteria. Three RCT's were used to compare the neonatal outcomes and 6 cohort studies were used to establish the degree of IRR between both approaches of EFM evaluation. With regards to the neonatal outcomes, a total of 55,064 patients were included in the analysis. Relative to the use of clinical (visual) evaluation of the FHR, the use of AI did not change the incidence rates of neonatal acidosis, cord pH below < 7.20, 5-min APGAR scores < 7, mode of delivery, NICU admission, neonatal seizures, or perinatal death. With regards to the degrees of inter-rater reliability, a weighed mean Cohen's Kappa of 0.49 [0.32-0.66] indicates moderate agreement between expert observers and computerized systems. CONCLUSION: The use of AI and computer analysis for the interpretation of EFM during labor does not improve neonatal outcomes. Inter-rater reliability between experts and computer systems is moderate at best. Future studies should aim at further elucidating these findings.


Assuntos
Inteligência Artificial/normas , Cardiotocografia/métodos , Frequência Cardíaca Fetal/fisiologia , Feminino , Humanos , Recém-Nascido , Gravidez
13.
J Obstet Gynaecol Res ; 45(7): 1343-1351, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31099119

RESUMO

AIM: The early-onset intrauterine growth restriction (IUGR) is associated with severe placental insufficiency and Doppler abnormalities. The late-onset IUGR is associated with mild placental insufficiency and normal Doppler velocimetry. The computerized cardiotocographic (cCTG) monitoring is used to evaluate the fetal well-being in pregnancies complicated by IUGR. Our aim was to investigate the cardiotocographic characteristics of IUGR fetuses and to identify every cCTG difference between Healthy and IUGR fetuses. METHODS: Four hundred thirty pregnant women were enrolled starting from the 28th week of gestation until the time of delivery: 200 healthy and 230 IUGR fetuses. Fetal heart rate (FHR) baseline (FHR), short-term variability (STV), long-term irregularity (LTI), delta, interval index (II), approximate entropy (ApEn), high frequency (HF), low frequency (LF), movement frequency (MF), LF/(HF + MF) ratio (LF/(HF + MF)) and number of decelerations were examined. Newborn baby data were also collected. RESULTS: The parameters of short- and medium-term variability discriminate between IUGR and healthy fetuses before 36 weeks including FHR, STV, LTI and delta discriminate between each subgroup of IUGR were compared to each one of the other two (P < 0.05). CONCLUSION: cCTG is a useful tool for the evaluation of chronic hypoxemia, which causes a delay in the maturation of all components of the autonomic and central nervous system. However, cCTG requires integration with fetal ultrasound and Doppler vessels evaluation to improve the ability to predict the neonatal outcome.


Assuntos
Cardiotocografia/estatística & dados numéricos , Retardo do Crescimento Fetal/diagnóstico por imagem , Retardo do Crescimento Fetal/fisiopatologia , Frequência Cardíaca Fetal , Hipóxia/diagnóstico por imagem , Adulto , Cardiotocografia/métodos , Feminino , Idade Gestacional , Humanos , Hipóxia/embriologia , Hipóxia/fisiopatologia , Recém-Nascido , Gravidez , Resultado da Gravidez , Ultrassonografia Doppler/métodos , Ultrassonografia Doppler/estatística & dados numéricos , Ultrassonografia Pré-Natal/métodos , Ultrassonografia Pré-Natal/estatística & dados numéricos
14.
Medicine (Baltimore) ; 98(18): e15472, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31045828

RESUMO

INTRODUCTION: Placental abruption (PA) is a serious complication of pregnancy, associated with significant perinatal complications, including intrauterine fetal demise (IUFD). Continuous electronic fetal monitoring (EFM) has been widely applied in China in recent decades. Exploration of potentially PA-specific patterns of EFM contributes to early detection of PA occurrence. PATIENT CONCERNS AND DIAGNOSIS: A 33-year-old woman (gravida 3, para 1) was referred to our hospital at 33 weeks gestation due to non-reassuring fetal heart rate (FHR) pattern, and suffered sudden onset of severe PA and subsequent intrauterine fetal demise. INTERVENTIONS: We analyzed the characteristics of her non-stress tests (NSTs) 1 day and 10 min before the detection of PA, aiming to explore potentially PA-specific patterns of EFM and provide reference for early detection of asymptomatic PA occurrence in obstetric practice. OUTCOMES: Unfavored characteristics of FHR patterns before PA onset are analyzed. CONCLUSION: For those who sense decreased fetal movements (DFMs), a NST and a biophysical profile (BPP) are recommended for exclusion of potential adverse maternal and fetal complications.


Assuntos
Descolamento Prematuro da Placenta/fisiopatologia , Cardiotocografia/métodos , Morte Fetal/etiologia , Adulto , Feminino , Idade Gestacional , Frequência Cardíaca Fetal , Humanos , Gravidez
15.
Acta Obstet Gynecol Scand ; 98(9): 1207-1217, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31081113

RESUMO

The second Signal Processing and Monitoring in Labor workshop gathered researchers who utilize promising new research strategies and initiatives to tackle the challenges of intrapartum fetal monitoring. The workshop included a series of lectures and discussions focusing on: new algorithms and techniques for cardiotocogoraphy (CTG) and electrocardiogram acquisition and analyses; the results of a CTG evaluation challenge comparing state-of-the-art computerized methods and visual interpretation for the detection of arterial cord pH <7.05 at birth; the lack of consensus about the role of intrapartum acidemia in the etiology of fetal brain injury; the differences between methods for CTG analysis "mimicking" expert clinicians and those derived from "data-driven" analyses; a critical review of the results from two randomized controlled trials testing the former in clinical practice; and relevant insights from modern physiology-based studies. We concluded that the automated algorithms performed comparably to each other and to clinical assessment of the CTG. However, the sensitivity and specificity urgently need to be improved (both computerized and visual assessment). Data-driven CTG evaluation requires further work with large multicenter datasets based on well-defined labor outcomes. And before first tests in the clinic, there are important lessons to be learnt from clinical trials that tested automated algorithms mimicking expert CTG interpretation. In addition, transabdominal fetal electrocardiogram monitoring provides reliable CTG traces and variability estimates; and fetal electrocardiogram waveform analysis is subject to promising new research. There is a clear need for close collaboration between computing and clinical experts. We believe that progress will be possible with multidisciplinary collaborative research.


Assuntos
Algoritmos , Monitorização Fetal/métodos , Acidose/diagnóstico , Cardiotocografia/métodos , Eletrocardiografia/métodos , Feminino , Humanos , Gravidez , Diagnóstico Pré-Natal , Processamento de Sinais Assistido por Computador , Reino Unido
16.
Am J Obstet Gynecol ; 221(6): 577-601.e11, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-30980794

RESUMO

BACKGROUND: In the past century, some areas of obstetric including intrapartum care have been slow to benefit from the dramatic advances in technology and medical care. Although fetal heart rate monitoring (cardiotocography) became available a half century ago, its interpretation often differs between institutions and countries, its diagnostic accuracy needs improvement, and a technology to help reduce the unnecessary obstetric interventions that have accompanied the cardiotocography is urgently needed. STUDY DESIGN: During the second half of the 20th century, key findings in animal experiments captured the close relationship between myocardial glycogenolysis, myocardial workload, and ST changes, thus demonstrating that ST waveform analysis of the fetal electrocardiogram can provide information on oxygenation of the fetal myocardium and establishing the physiological basis for the use of electrocardiogram in intrapartum fetal surveillance. RESULTS: Six randomized controlled trials, 10 meta-analyses, and more than 20 observational studies have evaluated the technology developed based on this principle. Nonetheless, despite this intensive assessment, differences in study protocols, inclusion criteria, enrollment rates, clinical guidelines, use of fetal blood sampling, and definitions of key outcome parameters, as well as inconsistencies in randomized controlled trial data handling and statistical methodology, have made this voluminous evidence difficult to interpret. Enormous resources spent on randomized controlled trials have failed to guarantee the generalizability of their results to other settings or their ability to reflect everyday clinical practice. CONCLUSION: The latest meta-analysis used revised data from primary randomized controlled trials and data from the largest randomized controlled trials from the United States to demonstrate a significant reduction of metabolic acidosis rates by 36% (odds ratio, 0.64; 95% confidence interval, 0.46-0.88) and operative vaginal delivery rates by 8% (relative risk, 0.92; 95% confidence interval, 0.86-0.99), compared with cardiotocography alone.


Assuntos
Cardiotocografia/métodos , Eletrocardiografia/métodos , Animais , Feminino , Frequência Cardíaca Fetal/fisiologia , Humanos , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto
17.
Lancet ; 393(10181): 1619-1627, 2019 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-30910324

RESUMO

BACKGROUND: Two-dimensional (2D) ultrasound echocardiography is the primary technique used to diagnose congenital heart disease before birth. There is, however, a longstanding need for a reliable form of secondary imaging, particularly in cases when more detailed three-dimensional (3D) vascular imaging is required, or when ultrasound windows are of poor diagnostic quality. Fetal MRI, which is well established for other organ systems, is highly susceptible to fetal movement, particularly for 3D imaging. The objective of this study was to investigate the combination of prenatal MRI with novel, motion-corrected 3D image registration software, as an adjunct to fetal echocardiography in the diagnosis of congenital heart disease. METHODS: Pregnant women carrying a fetus with known or suspected congenital heart disease were recruited via a tertiary fetal cardiology unit. After initial validation experiments to assess the general reliability of the approach, MRI data were acquired in 85 consecutive fetuses, as overlapping stacks of 2D images. These images were then processed with a bespoke open-source reconstruction algorithm to produce a super-resolution 3D volume of the fetal thorax. These datasets were assessed with measurement comparison with paired 2D ultrasound, structured anatomical assessment of the 2D and 3D data, and contemporaneous, archived clinical fetal MRI reports, which were compared with postnatal findings after delivery. FINDINGS: Between Oct 8, 2015, and June 30, 2017, 101 patients were referred for MRI, of whom 85 were eligible and had fetal MRI. The mean gestational age at the time of MRI was 32 weeks (range 24-36). High-resolution (0·50-0·75 mm isotropic) 3D datasets of the fetal thorax were generated in all 85 cases. Vascular measurements showed good overall agreement with 2D echocardiography in 51 cases with paired data (intra-class correlation coefficient 0·78, 95% CI 0·68-0·84), with fetal vascular structures more effectively visualised with 3D MRI than with uncorrected 2D MRI (657 [97%] of 680 anatomical areas identified vs 358 [53%] of 680 areas; p<0·0001). When a structure of interest was visualised in both 2D and 3D data (n=358), observers gave a higher diagnostic quality score for 3D data in 321 (90%) of cases, with 37 (10%) scores tied with 2D data, and no lower scores than for 2D data (Wilcoxon signed rank test p<0·0001). Additional anatomical features were described in ten cases, of which all were confirmed postnatally. INTERPRETATION: Standard fetal MRI with open-source image processing software is a reliable method of generating high-resolution 3D imaging of the fetal vasculature. The 3D volumes produced show good spatial agreement with ultrasound, and significantly improved visualisation and diagnostic quality compared with source 2D MRI data. This freely available combination requires minimal infrastructure, and provides safe, powerful, and highly complementary imaging of the fetal cardiovascular system. FUNDING: Wellcome Trust/EPSRC Centre for Medical Engineering, National Institute for Health Research.


Assuntos
Cardiotocografia/métodos , Coração Fetal/diagnóstico por imagem , Processamento de Imagem Assistida por Computador/métodos , Imageamento Tridimensional/métodos , Imagem por Ressonância Magnética , Feminino , Coração Fetal/patologia , Idade Gestacional , Cardiopatias Congênitas/diagnóstico , Humanos , Gravidez , Estudos Prospectivos , Ultrassonografia Pré-Natal
18.
Ultrasound Obstet Gynecol ; 54(6): 786-790, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30868659

RESUMO

OBJECTIVE: To examine the effect of hypoxemia on fetal heart rate (FHR) variability, using an instrumented pregnant sheep model. METHODS: In this prospective study, 19 pregnant sheep were instrumented under general anesthesia, at a mean gestational age of 127 days. After a 5-day recovery period, hypoxemia was induced by attaching the mother to a rebreathing circuit. Hypoxemia was sustained for 120 min, following which it was reversed until maternal and fetal partial pressure of oxygen (pO2 ) returned to baseline. FHR recordings at baseline, after 30 and 120 min of hypoxemia and at recovery were analyzed to calculate short-term variation (STV) in 16 epochs of 3.75 s, every minute. Phase-rectified signal averaging (window length (L) = 10, time (T) = 2 and scale (S) = 2) was used to calculate FHR acceleration (AC) and deceleration (DC) capacities. RESULTS: At baseline, mean ± SD fetal pO2 was 2.90 ± 0.38 kPa. Acute hypoxemia was associated with a significant reduction in mean pO2 at 30 (1.62 ± 0.37 kPa) and 120 (1.51 ± 0.16 kPa) min. Mean ± SD fetal pO2 at recovery was 2.86 ± 0.32 kPa. At baseline, median STV, AC and DC were 1.307 (interquartile range (IQR), 0.515-2.508) ms, 1.295 (IQR, 0.990-2.685) beats per minute (bpm) and 1.197 (IQR, 0.850-1.836) bpm, respectively. At 30 min of hypoxemia, the values were 1.323 (IQR, 0.753-2.744) ms, 1.696 (IQR, 1.310-3.013) bpm and 1.584 (IQR, 1.217-4.132) bpm, respectively. At 120 min of hypoxemia, they were 1.760 (IQR, 0.928-4.656) ms, 3.098 (IQR, 1.530-5.163) bpm and 3.054 (IQR, 1.508-4.522) bpm, respectively. At recovery, they changed to 0.962 (IQR, 0.703-1.154) ms, 1.228 (IQR, 1.071-2.234) bpm and 1.086 (IQR, 0.873-1.568) bpm, respectively. Hypoxemia for 30 and 120 min was associated with a significant increase in DC compared to baseline (P = 0.014 and 0.017, respectively). The changes in STV and AC were not significant. CONCLUSION: Acute hypoxemia is associated with a significant increase in the DC of FHR in a fetal sheep model. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.


Assuntos
Cardiotocografia/métodos , Feto/irrigação sanguínea , Frequência Cardíaca Fetal/fisiologia , Hipóxia/fisiopatologia , Consumo de Oxigênio/fisiologia , Animais , Gasometria/métodos , Desaceleração , Feminino , Feto/fisiopatologia , Feto/cirurgia , Idade Gestacional , Hipóxia/complicações , Modelos Animais , Pressão Parcial , Gravidez , Estudos Prospectivos , Ovinos
19.
Am J Obstet Gynecol ; 221(1): 63.e1-63.e13, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30826340

RESUMO

BACKGROUND: Although the evidence regarding the benefit of using ST waveform analysis of the fetal electrocardiogram is conflicting, ST waveform analysis is considered as adjunct to identify fetuses at risk for asphyxia in our center. Most randomized controlled trials and meta-analyses have not shown a significant decrease in umbilical metabolic acidosis, while some observational studies have shown a gradual decrease of this outcome over a longer period of time. Observational studies can give more insight into the effect of implementation of the ST technology in daily clinical practice. OBJECTIVE: To evaluate the change in frequency of perinatal intervention and adverse neonatal outcome after the implementation of ST waveform analysis of the fetal electrocardiogram from 2000 to 2013. STUDY DESIGN: This retrospective longitudinal study was conducted in a tertiary referral center. A total of 19,664 medium- and high-risk singleton pregnancies with fetuses in cephalic presentation, a gestational age of ≥36 weeks, and the intention to deliver vaginally were included. ST waveform analysis of the fetal electrocardiogram was implemented in the year 2000 and by 2010 all deliveries were monitored using this technology. Data were collected on the following perinatal outcomes: fetal blood sampling, mode of delivery, umbilical cord blood gases, Apgar scores, neonatal encephalopathy, and perinatal death. Longitudinal trend analysis was used to detect changes over time in all deliveries monitored by cardiotocography either alone or in adjunct to ST waveform analysis of the fetal electrocardiogram. Logistic regression was used to correct for possible confounders. RESULTS: The umbilical artery metabolic acidosis rate declined from 2.5% (average rate of 2000 + 2001 + 2002) to 0.4% (average of 2011 + 2012 + 2013) (P < .001), which represents an 84% decrease. This decrease largely occurred between 2006 and 2008, during the Dutch randomized trial on fetal electrocardiogram ST waveform analysis. At this time, approximately 20% of deliveries were monitored using this method. Furthermore, there were significant reductions in fetal blood sampling rate (P < .001). Overall cesarean and vaginal instrumental deliveries decreased significantly (P < .001), but not for fetal distress. There were no changes in the Apgar scores. The incidence of neonatal encephalopathy was significantly lower in the second part of the study (odds ratio 0.39, 95% confidence interval 0.17-0.89). CONCLUSION: There was an 84% decrease in the incidence of umbilical artery metabolic acidosis in all deliveries between 2000 and 2013. The neonatal encephalopathy rate, fetal blood sampling rate, and the total number of cesarean and vaginal instrumental deliveries also decreased.


Assuntos
Acidose/epidemiologia , Cardiotocografia/métodos , Eletrocardiografia/métodos , Hipóxia Fetal/epidemiologia , Adulto , Índice de Apgar , Gasometria , Cesárea/estatística & dados numéricos , Parto Obstétrico , Extração Obstétrica/estatística & dados numéricos , Feminino , Sangue Fetal/química , Idade Gestacional , Humanos , Incidência , Modelos Logísticos , Estudos Longitudinais , Países Baixos , Gravidez , Gravidez de Alto Risco , Estudos Retrospectivos , Medição de Risco , Artérias Umbilicais
20.
Reprod Sci ; 26(6): 858-863, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30832536

RESUMO

OBJECTIVE: Electronic fetal monitoring (EFM) has been used extensively for almost 50 years but performs poorly in predicting and preventing adverse neonatal outcome. In recent years, the current "enhanced" classification of patterns (category I-III system [CAT]) were introduced into routine practice without corroborative studies, which has resulted in even EFM experts lamenting its value. Since abnormalities of arterial cord blood parameters correlate reasonably well with risk of fetal injury, here we compare the statistical performance of EFM using the current CAT system with the Fetal Reserve Index (FRI) for predicting derangements in base excess (BE), pH, and pO2 in arterial cord blood. METHODS: We utilized a research database of labor data, including umbilical cord blood measurements to assess patients by both worst CAT and last FRI classifications. We compared these approaches for their ability to predict BE, pH, and pO2 in cord blood. RESULTS: The FRI showed a clear correlation with cord blood BE and pH with BE being more highly correlated than pH. The CAT was much less predictive than FRI (P < .05). The CAT II cases had FRI scores across the spectrum of severity of FRI designations and as such provide little clinical discrimination. The PO2 was not discriminatory, in part, because of neonatal interventions. CONCLUSIONS: The Fetal Reserve Index (FRI) provides superior performance over CAT classification of FHR patterns in predicting the BE and pH in umbilical cord blood. Furthermore, the CAT system fails to satisfy multiple fundamental principles required for successful screening programs. Limitations of CAT are further compounded by assumptions about physiology that are not consistent with clinical observations.


Assuntos
Cardiotocografia/métodos , Cardiotocografia/estatística & dados numéricos , Sangue Fetal/química , Resultado da Gravidez , Dióxido de Carbono/sangue , Reações Falso-Positivas , Feminino , Doenças Fetais/sangue , Humanos , Concentração de Íons de Hidrogênio , Recém-Nascido , Oxigênio/sangue , Gravidez , Cuidado Pré-Natal , Estudos Retrospectivos , Sensibilidade e Especificidade
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