Term Fetal Heart Rate Variation in Intrauterine Growth Restriction : development of reference values for a new computational algorithm ( Kurzzeitvariation der fetalen Herzfrequenz in intrauteriner Wachstumsretardierung : Erstellung von Normkurven für (2025)

Outcome in early-onset fetal growth restriction isbest combining computerized fetal heart rate analysis with ductus venosus Doppler: insights from the Trial of Umbilical and Fetal Flow in Europe

American Journal of Obstetrics and Gynecology

BACKGROUND: Early-onset fetal growth restriction represents a particular dilemma in clinical management balancing the risk of iatrogenic prematurity with waiting for the fetus to gain more maturity, while being exposed to the risk of intrauterine death or the sequelae of acidosis. OBJECTIVE: The Trial of Umbilical and Fetal Flow in Europe was a European, multicenter, randomized trial aimed to determine according to which criteria delivery should be triggered in early fetal growth restriction. We present the key findings of the primary and secondary analyses. STUDY DESIGN: Women with fetal abdominal circumference <10th percentile and umbilical pulsatility index >95th percentile between 26-32 weeks were randomized to 1 of 3 monitoring and delivery protocols. These were: fetal heart rate variability based on computerized cardiotocography; and early or late ductus venosus Doppler changes. A safety net based on fetal heart rate abnormalities or umbilical Doppler changes mandated delivery irrespective of randomized group. The primary outcome was normal neurodevelopmental outcome at 2 years. RESULTS: Among 511 women randomized, 362/503 (72%) had associated hypertensive conditions. In all, 463/503 (92%) of fetuses survived and cerebral palsy occurred in 6/ 443 (1%) with known outcome. Among all women there was no difference in outcome based on randomized group; however, of survivors, significantly more fetuses randomized to the late ductus venosus group had a normal outcome (133/144; 95%) than those randomized to computerized cardiotocography alone (111/131; 85%). In 118/310 (38%) of babies delivered <32 weeks, the indication was safety-net criteria: 55/106 (52%) in late ductus venosus, 37/99 (37%) in early ductus venosus, and 26/105 (25%) in computerized cardiotocography groups. Higher middle cerebral artery impedance adjusted for gestation was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02e1.52) and infant survival without neurodevelopmental impairment at 2 years (odds ratio, 1.33; 95% confidence interval, 1.03e1.72) although birthweight and gestational age were more important determinants. CONCLUSION: Perinatal and 2-year outcome was better than expected in all randomized groups. Among survivors, 2-year neurodevelopmental outcome was best in those randomized to delivery based on late ductus venosus changes. Given a high rate of delivery based on the safety-net criteria, deciding delivery based on late ductus venosus changes and abnormal computerized fetal heart rate variability seems prudent. There is no rationale for delivery based on cerebral Doppler changes alone. Of note, most women with early-onset fetal growth restriction develop hypertension.

Objective computerized fetal heart rate analysis

International Journal of Gynecology & Obstetrics, 1998

Objecti¨e: To assess the validity of a computerized methodology for cardiotocogram analysis based on a recently described reproducible visual estimation of the baseline. Methods: Forty-two antepartum and 43 intrapartum Ž . cardiotocograms CTGs acquired by a personal computer were selected. Antepartum tracings were performed in the 48 h that preceded an elective cesarean section, and intrapartum tracings were performed until delivery. FHR baselines were estimated by an expert, according to an objective and reproducible methodology. Using these baselines, automated detection of accelerations and decelerations and estimation of variability was performed by the personal computer. A quantitative adaptation of the FIGO guidelines for fetal monitoring was used to classify tracings. Perinatal outcome was classified according to the Apgar score and umbilical arterial pH. Validity was then Ž . Ž . assessed by the proportions of agreement PA , kappa statistic , sensitivity and specificity, with 95% confidence Ž . intervals 95% CI . Cases showing a disagreement between CTG and perinatal classification were reviewed and an adjustment in baseline definition was tested. Results: The initial overall PA and between CTG and perinatal Ž . Ž . classification were, respectively, 0.79 95% CI: 0.69᎐0.87 and 0.62 95% CI: 0.41᎐0.83 . The overall PA and , after Ž . Ž . baseline adjustment were, respectively, 0.89 95% CI: 0.81᎐0.95 and 0.78 95% CI: 0.58᎐0.98 . Sensitivities and Ž . Ž . specificities ranged between 79% 95% CI: 60᎐92% and 100% 95% CI: 95᎐100% . Conclusions: Good clinical prediction may be possible with an objective methodology for cardiotocogram analysis based on a recently described reproducible baseline estimation. ᮊ 1998 International Federation of Gynecology and Obstetrics

Monitoring of fetuses with intrauterine growth restriction: a longitudinal study

Ultrasound in Obstetrics & Gynecology, 2001

ObjectiveTo describe the time sequence of changes in fetal monitoring variables in intrauterine growth restriction and to correlate these findings with fetal outcome at delivery.To describe the time sequence of changes in fetal monitoring variables in intrauterine growth restriction and to correlate these findings with fetal outcome at delivery.MethodsThis was a prospective longitudinal observational multicenter study on 110 singleton pregnancies with growth-restricted fetuses after 24 weeks of gestation. Short-term variation of fetal heart rate, pulsatility indices of fetal arterial and venous Doppler waveforms and amniotic fluid index were assessed at each monitoring session. The study population was divided into two groups: Group 1 comprised pregnancies with severely premature fetuses, which were delivered ≤ 32 weeks and Group 2 included pregnancies delivered after 32 completed weeks. Logistic regression was used for modeling the probability for abnormality of a variable in relation to the time interval before delivery. Trends over time were analyzed for all variables by multilevel analysis.This was a prospective longitudinal observational multicenter study on 110 singleton pregnancies with growth-restricted fetuses after 24 weeks of gestation. Short-term variation of fetal heart rate, pulsatility indices of fetal arterial and venous Doppler waveforms and amniotic fluid index were assessed at each monitoring session. The study population was divided into two groups: Group 1 comprised pregnancies with severely premature fetuses, which were delivered ≤ 32 weeks and Group 2 included pregnancies delivered after 32 completed weeks. Logistic regression was used for modeling the probability for abnormality of a variable in relation to the time interval before delivery. Trends over time were analyzed for all variables by multilevel analysis.ResultsNinety-three (60 in Group 1 and 33 in Group 2) fetuses had at least three data sets (median, 4; range, 3–27) and had the last measurements taken within 24 h of delivery or intrauterine death. The percentage of abnormal test results and the degree of abnormality were higher in Group 1 compared to Group 2. Amniotic fluid index and umbilical artery pulsatility index were the first variables to become abnormal, followed by the middle cerebral artery, aorta, short-term variation, ductus venosus and inferior vena cava. In Group 1, short-term variation and ductus venosus pulsatility index showed mirror images of each other in their trend over time. Perinatal mortality was significantly higher if both variables were abnormal compared to only one or neither being abnormal (13/33 (39%) vs. 4/60 (7%); P = 0.0002; Fisher's exact test).Ninety-three (60 in Group 1 and 33 in Group 2) fetuses had at least three data sets (median, 4; range, 3–27) and had the last measurements taken within 24 h of delivery or intrauterine death. The percentage of abnormal test results and the degree of abnormality were higher in Group 1 compared to Group 2. Amniotic fluid index and umbilical artery pulsatility index were the first variables to become abnormal, followed by the middle cerebral artery, aorta, short-term variation, ductus venosus and inferior vena cava. In Group 1, short-term variation and ductus venosus pulsatility index showed mirror images of each other in their trend over time. Perinatal mortality was significantly higher if both variables were abnormal compared to only one or neither being abnormal (13/33 (39%) vs. 4/60 (7%); P = 0.0002; Fisher's exact test).ConclusionDuctus venosus pulsatility index and short-term variation of fetal heart rate are important indicators for the optimal timing of delivery before 32 weeks of gestation. Delivery should be considered if one of these parameters becomes persistently abnormal.Copyright © 2001 International Society of Ultrasound in Obstetrics and GynecologyDuctus venosus pulsatility index and short-term variation of fetal heart rate are important indicators for the optimal timing of delivery before 32 weeks of gestation. Delivery should be considered if one of these parameters becomes persistently abnormal.Copyright © 2001 International Society of Ultrasound in Obstetrics and Gynecology

The Normal Fetal Heart Rate Study: Analysis Plan

Nature Precedings, 2007

Recording of fetal heart rate via CTG monitoring has been routinely performed as an important part of antenatal and subpartum care for several decades. The current guidelines of the FIGO (ref 1) recommend a normal range of the fetal heart rate from 110 to 150 bpm. However, there is no agreement in the medical community whether this is the correct range (ref 2). We aim to address this question by computerized analysis (ref 3) of a high quality database (HQDb, ref 4) of about one billion electronically registered fetal heart rate measurements from about 10,000 pregnancies in three medical centres over seven years. In the present paper, we lay out a detailed analysis plan for this evidence-based project in the vein of the validation policy of the Sylvia Lawry Centre for Multiple Sclerosis Research (ref 5) with a split of the database into an exploratory part and a part reserved for validation. We will perform the analysis and the validation after publication of this plan in order to reduce the probability of publishing false positive research findings (ref 6-7).

Computerised analysis of antepartum foetal heart parameters: New reference ranges

Journal of Obstetrics and Gynaecology, 2016

We selected 4012 cCTG records (one trace for each patient) performed in healthy pregnancies from 30th to 42nd gestational week using foetal heart rate (FHR), short-term variability (STV), long-term irregularity (LTI), Delta, approximate entropy (ApEn), spectral components as low frequency (LF), median frequency (MF), high frequency (HF) and LF/(HF þ MF) ratio were analysed. Reference nomograms were created and sensitivity and specificity for the prediction of foetal compromise were calculated which were 90% and 89%, respectively. Changes of cCTG parameters according to gestational week were evaluated: FHR (r ¼ À.65) and LF (r ¼ À.87) showed a statistically significant reduction (p < .05) with gestational age. STV (r ¼ .59), LTI (r ¼ .69), Delta (r ¼ .67), and MF (r ¼ .88) showed a statistically significant increase (p < .05) with gestational age. In contrast, for ApEn (r ¼ À.098), HF (r ¼ .14) and LF/(HF þ MF) ratio (r ¼ À.47) a non-statistically significant change was found (p > .05). The identification of reference ranges for cCTG indexes in according to gestational age could provide a more objective examination of cCTG trace.

Computerised evaluation of fetal heart rate in post-term fetuses: long term variation

BJOG: An International Journal of Obstetrics and Gynaecology, 1998

I K Razvi, S Chua, S Arulkumaran, SS Ratnam. A Comparison between visual estimation and laboratory determination of blood loss during the third stage of labour. Aust N 2 J Obstet Gynuecol 1996; 36: 152-1 54. Steer PJ. The accuracy of catheter-tip pressure transducers for the measurement of intrauterine pressure in labour. Br J Obstet Gynaecoll992; 99: 186-1 89. Chua S, Arulkumaran S, Adaikan G, Ratnam SS. The effect of oxytocins stored at high temperature on postpartum uterine activity. Br J Obstet Gynuecoll993; 100: 813-814. Hendricks CH, Eskes TKAJ3, Saameli K. Uterine contractility at delivery and in the puerperium. Am J Obstet Gynecol 1962; 7: Ulmsten U, Anderson KE. Multichannel intrauterine pressure recording by means of microtransducers.

Cardiotocography and ST analysis for intrapartum fetal monitoring

Acta Obstetricia et Gynecologica Scandinavica, 2012

Fetal heart rate monitoring of short term variation (STV): a methodological observational study

BMC pregnancy and childbirth, 2016

Cardiotocography (CTG) has high sensitivity, but less specificity in detection of fetal hypoxia. There is need for adjunctive methods easy to apply during labor. Low fetal heart rate short term variation (STV) is predictive for hypoxia during the antenatal period. The objectives of our study were to methodologically evaluate monitoring of STV during labor and to compare two different monitors (Sonicaid™ and EDAN™) for antenatal use. A prospective observational study at the obstetric department, Karolinska University hospital, Stockholm (between September 2011 and April 2015). In 100 women of ≥ 36 weeks gestation, STV values were calculated during active labor. In a subset of 20 women we compared STV values between internal and external signal acquisition. Additionally we compared antenatal monitoring with two different monitors in another 20 women. Median STV in 100 fetuses monitored with scalp electrode during labor (EDAN™) was 7.1 msec (range 1.3-25.9) with no difference between e...

Relationship between monitoring parameters and perinatal outcome in severe, early intrauterine growth restriction

Cancer Genetics and Cytogenetics, 2004

ObjectiveTo investigate whether pathological changes in the umbilical artery (UA), ductus venosus (DV) and short-term fetal heart variation are related to perinatal outcome in severe, early intrauterine growth restriction (IUGR).To investigate whether pathological changes in the umbilical artery (UA), ductus venosus (DV) and short-term fetal heart variation are related to perinatal outcome in severe, early intrauterine growth restriction (IUGR).MethodsThis multicenter, prospective, longitudinal, observational study was carried out in the Departments of Fetal Medicine and Obstetrics in Hamburg, Amsterdam, Utrecht and London. In 70 singleton pregnancies with IUGR fetuses, delivered at 26–33 weeks of gestation because of antepartum fetal distress, short-term variation (STV) of fetal heart rate, pulsatility index of the fetal UA (UA PI) and DV pulsatility index for veins (DV PIV) were assessed at least weekly. The final measurement was performed within 24 h of delivery. Standard cut-off levels (2 SD or 3 SD, absent flow or reversed flow) were used and new cut-off levels were calculated by means of receiver–operating characteristics analysis. Adverse outcome was defined as perinatal death, cerebral hemorrhage (≥ Grade II) or bronchopulmonary dysplasia before discharge. The predictive value for adverse outcome was calculated for different cut-off levels of the monitoring parameters, adjusted for gestational age (GA), by multivariate logistic regression analysis. Data were analyzed separately for three different time blocks, namely 8–14, 2–7 and 0–1 days before delivery.This multicenter, prospective, longitudinal, observational study was carried out in the Departments of Fetal Medicine and Obstetrics in Hamburg, Amsterdam, Utrecht and London. In 70 singleton pregnancies with IUGR fetuses, delivered at 26–33 weeks of gestation because of antepartum fetal distress, short-term variation (STV) of fetal heart rate, pulsatility index of the fetal UA (UA PI) and DV pulsatility index for veins (DV PIV) were assessed at least weekly. The final measurement was performed within 24 h of delivery. Standard cut-off levels (2 SD or 3 SD, absent flow or reversed flow) were used and new cut-off levels were calculated by means of receiver–operating characteristics analysis. Adverse outcome was defined as perinatal death, cerebral hemorrhage (≥ Grade II) or bronchopulmonary dysplasia before discharge. The predictive value for adverse outcome was calculated for different cut-off levels of the monitoring parameters, adjusted for gestational age (GA), by multivariate logistic regression analysis. Data were analyzed separately for three different time blocks, namely 8–14, 2–7 and 0–1 days before delivery.ResultsAdverse perinatal outcome occurred in 18/70 (26%) infants. During the last 24 h before delivery DV PIV and UA PI were significantly higher and STV lower in the adverse outcome group, while 2–7 days before delivery only DV PIV was significantly higher. Adverse perinatal outcome could be predicted at 0–1 days before delivery by DV PIV at a cut-off of three multiples of the SD (odds ratio (OR) 11.3; 95% CI 2.3–57) and GA (OR 0.4; 95% CI 0.3–0.8), at 2–7 days by DV PIV at 2 SD (OR 3.0; 95% CI 0.8–12) and GA (OR 0.5; 95% CI 0.3–0.8) and at 8–14 days by DV PIV at 2 SD (OR 3.9; 95% CI 0.8–20) and GA (OR 0.5; 95% CI 0.3–0.8). Other parameters did not contribute to the multivariate model.Adverse perinatal outcome occurred in 18/70 (26%) infants. During the last 24 h before delivery DV PIV and UA PI were significantly higher and STV lower in the adverse outcome group, while 2–7 days before delivery only DV PIV was significantly higher. Adverse perinatal outcome could be predicted at 0–1 days before delivery by DV PIV at a cut-off of three multiples of the SD (odds ratio (OR) 11.3; 95% CI 2.3–57) and GA (OR 0.4; 95% CI 0.3–0.8), at 2–7 days by DV PIV at 2 SD (OR 3.0; 95% CI 0.8–12) and GA (OR 0.5; 95% CI 0.3–0.8) and at 8–14 days by DV PIV at 2 SD (OR 3.9; 95% CI 0.8–20) and GA (OR 0.5; 95% CI 0.3–0.8). Other parameters did not contribute to the multivariate model.ConclusionsDV PIV measurement is the best predictor of perinatal outcome. This measurement may be useful in timing the delivery of early IUGR fetuses and in improving perinatal outcome, even when delivery may be indicated at an earlier GA. However, as GA was also an important factor influencing outcome, with poorer outcome at earlier gestation at delivery, this hypothesis needs to be tested in a multicenter, prospective, randomized trial. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.DV PIV measurement is the best predictor of perinatal outcome. This measurement may be useful in timing the delivery of early IUGR fetuses and in improving perinatal outcome, even when delivery may be indicated at an earlier GA. However, as GA was also an important factor influencing outcome, with poorer outcome at earlier gestation at delivery, this hypothesis needs to be tested in a multicenter, prospective, randomized trial. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

Correlation of Intrapartum Cardiotocographic Changes with Perinatal Outcome, in Cases of Fetal Growth Restriction

International Journal of Current Research and Academic Review, 2016

Fetal Growth Restriction is one of those leading causes of high risk pregnancy, which can result in significant fetal/ perinatal morbidity and mortality if not properly diagnosed and managed. Cardiotocography is a useful and indispesable adjunct to monitor the condition of the endangered foetus. In the proposed study, our focus was to analyse the correlation between the results shown by CTG during intrapartum period and foetal/perinatal outcome in cases of FGR. The present study was conducted in the Department of Obstetrics and Gynecology, S N Medical college, Agra in 2015. Fifty Pateints diagnosed as a case of foetal growth restriction, clinically and by USG with gestation >32 weeks who were in active labour, were included in the study. Intrapartum CTG was performed and findings recorded. Where CTG was non reassuring, Meconium stained liquor was present in 80% cases, cesarean was conducted in 60%, mean birth weight was 1.99kg, mean Apgar scores both at 1 min and 5 min were found to be lower, NICU admissions rate was20% and 8% perinatal deaths all of which occurred with a non ressuring CTG. The perinatal outcome in terms of all above parameters were found to be poor in those cases when CTG was abnormal. On correlating CTG changes with the above parameters, a positive correlation was found which was also statistically significant. Thus Cardiotocography is an effective means for fetal surveillance for pregnancies complicated by fetal growth restriction and an abnormal CTG is an important predictor for poor fetal outcome.