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Purpose: Fetal cardiotocography is the most common method to assess fetal well-being during labor. Nevertheless, its predictive ability for acidemia is limited, both in low-risk and high-risk pregnancies (Nelson et al. in N Engl J Med 334: 613–9, 1996; Rinciples P et al. in Health and Human Development Workshop Report on Electronic Fetal Monitoring : Update on Definitions. no. 2007, 510–515, 2008), especially in high-risk pregnancies, such as those complicated by growth restriction. In this study we aim examine the association between deceleration and acceleration areas and other measure of fetal heart rate in intrapartum fetal monitoring and neonatal arterial cord blood pH in pregnancies complicated by growth restriction. Materials and methods: A retrospective cohort study of 100 deliveries complicated by growth restriction, delivered during 2018, was conducted. Known major fetal anomalies, non-vertex presentation and elective cesarean deliveries were excluded. Total deceleration and acceleration areas were calculated as the sum of the areas within the deceleration and acceleration, respectively. Results: In deliveries complicated by growth restriction, cord blood pH is significantly associated with total deceleration area (p = 0.05) and correlates with cumulative duration of the decelerations (Spearman's rank −0.363, p < 0.05), and total acceleration area (−0.358, p < 0.05). By comparing the cord blood pH in deliveries with a total deceleration area that was above and below the median total deceleration area, we demonstrated a significant difference between the categories. Conclusions: Cord blood pH significantly correlates with total deceleration area and other fetal monitoring characteristics in neonates with growth restriction. Future studies using real-time, machine-learning based techniques of fetal heart rate monitoring, may provide population specific threshold values that will support bedside clinical decision making and perhaps achieve better outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: To compare perinatal outcomes between active and routine management in true knot of the umbilical cord (TKUC). Methods: A retrospective study of singletons born beyond 22 6/7 weeks with TKUC. Active management included weekly fetal heart rate monitoring(FHRM) ≥ 30 weeks and labor induction at 36–37 weeks. Outcomes in active and routine management were compared, including composite asphyxia-related adverse outcome, fetal death, labor induction, Cesarean section (CS) or Instrumental delivery due to non-reassuring fetal heart rate (NRFHR), Apgar5 score < 7, cord Ph < 7, neonatal intensive care unit (NICU) admission and more. Results: The Active (n = 59) and Routine (n = 1091) Management groups demonstrated similar rates of composite asphyxia-related adverse outcome (16.9% vs 16.8%, p = 0.97). Active Management resulted in higher rates of labor induction < 37 weeks (22% vs 1.7%, p < 0.001), CS (37.3% vs 19.2%, p = 0.003) and NICU admissions (13.6% vs 3%, p < 0.001). Fetal death occurred exclusively in the Routine Management group (1.8% vs 0%, p = 0.6). Conclusion: Compared with routine management, weekly FHRM and labor induction between 36 and 37 weeks in TKUC do not appear to reduce neonatal asphyxia. In its current form, active management is associated with higher rates of CS, induced prematurity and NICU admissions. Labor induction before 37 weeks should be avoided. [ABSTRACT FROM AUTHOR]

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

Purpose: To explore the contribution of maternal and fetal parameters in predicting the time interval between diagnosis and development of adverse events leading to delivery in singleton pregnancies complicated with fetal microsomia. Methods: Prospective study on singleton pregnancies referred to a tertiary center because of suspicion of fetal smallness in the third trimester. The study cohort included cases with fetal abdominal circumference (AC) ≤ 10th centile or estimated fetal weight ≤ 10th centile or umbilical artery pulsatitlity index ≥ 90th centile. Development of pre-eclampsia, fetal demise, and fetal deterioration diagnosed by fetal Doppler studies or fetal heart rate monitoring and leading to delivery were considered as adverse events. Maternal demographics, obstetric history, blood pressure, serum PLGF, and fetal Doppler studies were explored as predictors of the time interval between the first visit to the clinic and the diagnosis of complications. Results: In 59 women, the median incubation period from presentation to the clinic to an adverse event was 6, 2 weeks, whereas half of the pregnancies (52.5%) did not develop any adverse event. PLGF was the strongest predictor of adverse events. Both PLGF in raw values and PLGF MOM had equally good predictive ability (AUC 0.82 and 0.78 respectively). Optimal cut-off points were 177.7 pg/ml for PLGF raw values (sensitivity 83% and specificity 66.7%) and 0.277 MoM (sensitivity 76% and specificity 86.7%). On multiple Cox regression analysis, maternal systolic blood pressure, PLGF, fetal increased umbilical artery PI, and reduced CP ratio were independently associated with adverse events. Half of the pregnancies with low PLGF and only one in ten with high PLGF were delivered within two weeks after the initial visit. Conclusion: Half of the pregnancies carrying a small fetus in the third trimester will not develop maternal or fetal complications. PLGF is a strong predictor of adverse events that can be used to customize antenatal care. [ABSTRACT FROM AUTHOR]

Previous literature has highlighted the importance of maternal behavior during the prenatal period for the upbringing of healthy adults. During pregnancy, fetal health assessments are mainly carried out non-invasively by monitoring fetal growth and heart rate (HR) or RR interval (RRI). Despite this, research entailing prediction of fHRs from mHRs is scarce mainly due to the difficulty in non-invasive measurements of fetal electrocardiogram (fECG). Also, so far, it is unknown how mHRs are associated with fHR over the short term. In this study, we used two machine learning models, support vector regression (SVR) and random forest (RF), for predicting average fetal RRI (fRRI). The predicted fRRI values were compared with actual fRRI values calculated from non-invasive fECG. fRRI was predicted from 13 maternal features that consisted of age, weight, and non-invasive ECG-derived parameters that included HR variability (HRV) and R wave amplitude variability. 156 records were used for training the models and the results showed that the SVR model outperformed the RF model with a root mean square error (RMSE) of 29 ms and an average error percentage (< 5%). Correlation analysis between predicted and actual fRRI values showed that the Spearman coefficient for the SVR and RF models were 0.31 (P < 0.001) and 0.19 (P < 0.05), respectively. The SVR model was further used to predict fRRI of 14 subjects who were not included in the training. The latter prediction results showed that individual error percentages were (≤ 5%) except in 3 subjects. The results of this study show that maternal factors can be potentially used for the assessment of fetal well-being based on fetal HR or RRI. [ABSTRACT FROM AUTHOR]

This study uses convolutional neural networks (CNNs) and cardiotocography data for the real-time classification of fetal status in the mobile application of a pregnant woman and the computer server of a data expert at the same time (The sensor is connected with the smartphone, which is linked with the web server for the woman and the computer server for the expert). Data came from 5249 (or 4833) cardiotocography traces in Anam Hospital for the mobile application (or the computer server). 150 data cases of 5-minute duration were extracted from each trace with 141,001 final cases for the mobile application and for the computer server alike. The dependent variable was fetal status with two categories (Normal, Abnormal) for the mobile application and three categories (Normal, Middle, Abnormal) for the computer server. The fetal heart rate served as a predictor for the mobile application and the computer server, while uterus contraction for the computer server only. The 1-dimension (or 2-dimension) Resnet CNN was trained for the mobile application (or the computer server) during 800 epochs. The sensitivity, specificity and their harmonic mean of the 1-dimension CNN for the mobile application were 94.9%, 91.2% and 93.0%, respectively. The corresponding statistics of the 2-dimension CNN for the computer server were 98.0%, 99.5% and 98.7%. The average inference time per 1000 images was 6.51 micro-seconds. Deep learning provides an efficient model for the real-time classification of fetal status in the mobile application and the computer server at the same time. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the mechanisms involved in the fetal heart rate (FHR) abnormalities after the epidural analgesia in labor. Methods: A prospective unblinded single-center observational study on 55 term singleton pregnant women with spontaneous labor. All women recruited underwent serial bedside measurements of the main hemodynamic parameters using a non-invasive ultrasound system (USCOM-1A). Total vascular resistances (TVR), heart rate (HR), stroke volume (SV), cardiac output (CO) and arterial blood pressure were measured before epidural administration (T0), after 5 min 5 (T1) from epidural bolus and at the end of the first stage of labor (T2). FHR was continuously recorded through computerized cardiotocography before and after the procedure. Results: The starting CO was significantly higher in a subgroup of women with low TVR than in women with high-TVR group. After the bolus of epidural analgesia in the low-TVR group there was a significant reduction in CO and then increased again at the end of the first stage, in the high-TVR group the CO increased insignificantly after the anesthesia bolus, while it increased significantly in the remaining part of the first stage of labor. On the other hand, CO was inversely correlated with the number of decelerations detected on cCTG in the 1 hour after the epidural bolus while the short-term variation was significantly lower in the group with high-TVR. Conclusion: Maternal hemodynamic status at the onset of labor can make a difference in fetal response to the administration of epidural analgesia. [ABSTRACT FROM AUTHOR]

Purpose: The aim was to investigate if intrapartum monitoring with cardiotocography (CTG) in combination with ST analysis (STAN) results in an improved perinatal outcome. Methods: We performed a two-center randomized trial. 1013 women with term fetuses in cephalic presentation entered the trial. If a CTG showed intermediate or pathological abnormalities, they were offered fetal blood sampling (FBS) and inclusion if the pH value was above 7.25. They were randomized to either CTG + FBS or CTG + STAN. The primary outcome was neonatal metabolic acidosis, defined as umbilical cord arterial blood pH below 7.05, and base excess equal to or below −10. The secondary outcomes included operative vaginal delivery for fetal distress. Results: The rate of metabolic acidosis was 0.8% in the CTG + FBS group and 1.5% in women in the CTG + STAN (P = 0.338). More women in the CTG + STAN group delivered by operative vaginal delivery (25.6% vs 33.5%, P = 0.006). Significantly fewer women in the CTG + STAN group had three to five (28.8% vs 11.0%, P = < 0.001) and six to ten fetal blood samples taken (3.4% vs 0.4%, P = < 0.001). Conclusion: CTG + STAN did not reduce the incidence of neonatal metabolic acidosis compared to CTG + FBS. CTG + STAN was, however, associated with an increased risk of operative vaginal delivery and a reduced use of FBS. If STAN is used for fetal surveillance, we recommend that it is combined with other methods, such as FBS, for confirmation of the need for operative delivery. Clinicaltrials.gov ID: NCT01699646. Date of registration: October 4, 2012 (retrospectively registered). https://clinicaltrials.gov/ct2/show/NCT01699646?id=NCT01699646&draw=2&rank=1 [ABSTRACT FROM AUTHOR]

The survey queried institution-based patient risk stratification, methods and frequency of fetal cardiac surveillance, treatment of varied conduction abnormalities, and post-natal monitoring of anti-Ro/SSA pregnancies. Postnatal data included anatomic diagnosis, associated cardiac anomalies, extracardiac and genetic diagnoses as well as immediate postnatal outcomes. B Background/Hypothesis: b The sensitivity of fetal echocardiography in the prenatal diagnosis of congenital heart defects (CHDs) approaches 90%, yet national prenatal diagnosis rates of CHD are only 30-50%. We collected presenting and delivering gestational age (GA), diagnosis, treatment, time to normal rhythm, type of delivery and postnatal SVA recurrence. [Extracted from the article]

Background: Fetal cardiac magnetic resonance imaging (MRI) requires high spatial and temporal resolution and robustness to random fetal motion to capture the dynamics of the beating fetal heart. Slice-to-volume reconstruction techniques can produce high-resolution isotropic images while compensating for random fetal motion. Objective: The objective of this study was to evaluate image quality for slice-to-volume reconstruction of four-dimensional balanced steady-state free precession (bSSFP) imaging of the fetal heart. Materials and methods: A cohort of 13 women carrying fetuses with congenital heart disease were imaged with real-time bSSFP sequences. Real-time bSSFP sequences were post-processed using a slice-to-volume reconstruction algorithm to produce retrospectively gated 4-D sequences with isotropic spatial resolution. Two radiologists evaluated slice-to-volume reconstruction image quality on a scale from 0 to 4 using 11 categories based on a segmental approach to defining cardiac anatomy and pathology. A score of 0 corresponded to cardiac structures not visualized at all and four corresponded to high quality and distinct appearance of structures. Results: In 11 out of 13 cases, the average radiologist score of image quality across all categories was 3.0 or greater. In the remaining two cases, slice-to-volume reconstruction was not possible due to insufficient image quality in the acquisition. Conclusion: Slice-to-volume reconstruction has the potential to produce isotropic images with high spatial and temporal resolution that can display the anatomy of the fetal heart in arbitrary imaging planes retrospectively. More rapid, motion-robust acquisitions may be necessary to successfully reconstruct the fetal heart in all patients. [ABSTRACT FROM AUTHOR]

Fetal Cardiography is usually performed using in-hospital Cardiotocographic (CTG) devices to assess fetal wellbeing. New technologies may permit home-based, self-administered examinations. We compared the accuracy, clinical interpretability, and user experience of a patient-administered, wireless, fetal heartbeat monitor (HBM) designed for home use, to CTG. Initially, participants had paired HBM and CTG examinations performed in the clinic. Women then used the HBM unsupervised and rated the experience. Sixty-three women had paired clinic-based HBM and CTG recordings, providing 6982 fetal heart rate measures for point-to-point comparison from 126 min of continuous recording. The accuracy of the HBM was excellent, with limits of agreement (95%) for mean fetal heart rate (FHR) between 0.72 and −1.78 beats per minute. The FHR was detected on all occasions and confirmed to be different from the maternal heart rate. Both methods were equally interpretable by Obstetricians, and had similar signal loss ratios. Thirty-four (100%) women successfully detected the FHR and obtained clinically useful cardiographic data using the device at home unsupervised. They achieved the required length of recording required for non-stress test analysis. The monitor ranked in the 96–100th percentile for usability and learnability. The HBM is as accurate as gold-standard CTG, and provides equivalent clinical information enabling use in non-stress test analyses conducted outside of hospitals. It is usable by expectant mothers with minimal training. [ABSTRACT FROM AUTHOR]

Cardiotocography (CTG) applicability to improve fetal outcomes remains controversial. This study aimed to determine the clinically optimal CTG assessment duration using the integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring (iPREFACE score). This single-center, retrospective observational study included 325 normal full-term singleton vaginal deliveries at the Toho University Omori Medical Center, from September 2018 to March 2019. The iPREFACE(10), iPREFACE(30), and iPREFACE(60) scores were calculated at 10, 30, and 60 min immediately before delivery. The primary outcome was fetal acidemia (umbilical artery blood pH < 7.2). The secondary outcome was the correlation between all iPREFACE scores and the umbilical artery blood pH, base excess (BE), and lactate values. Patients without accurate CTG findings or with failure of umbilical artery blood sampling immediately after birth were excluded, leaving 145 patients in the final analysis. Of these, 16, three, and two had umbilical artery blood pH of < 7.2, < 7.1, and < 7.0, respectively. All iPREFACE scores significantly correlated with umbilical artery blood pH, BE, and lactate values. iPREFACE(30) had the highest predictive capacity for fetal acidemia, suggesting that 30 min immediately before delivery may be a useful scoring time in clinical practice. [ABSTRACT FROM AUTHOR]

Breathing and sleep of the fetus and mother show changes over the course of pregnancy. Knowledge of the development of fetal respiration is essential for perinatal medicine. Surfactant is only made available in sufficient quantities from the 35th week of pregnancy. In the case of an earlier premature birth, betamethasone must be administered twice. This medication could make a decisive contribution to a reduction in perinatal mortality and morbidity. Knowledge of fetal sleep enables better fetal monitoring through cardiotocography (CTG). Deep sleep phases resemble a hypoxic state in the CTG. Changes in maternal respiration during labor allow optimal oxygen supply to the fetus. Disorders of maternal breathing e.g. bronchial asthma can be associated with an increased likelihood of a disease from the pregnancy-induced hypertension group. Sleep disorders have so far not played a role in assessing the risk profile of pregnancy. Studies show that obstructive sleep apnea syndrome is associated with an increased risk of a disease from the pregnancy-associated hypertension group and other complications in both the mother and the fetus. In the future, sleep disorders should be diagnosed during pregnancy and included in therapeutic considerations. [ABSTRACT FROM AUTHOR]

Cardiotocography records fetal heart rates and their temporal relationship to uterine contractions. To identify high risk fetuses, obstetricians inspect cardiotocograms (CTGs) by eye. Therefore, CTG traces are often interpreted differently among obstetricians, resulting in inappropriate interventions. However, few studies have focused on quantitative and nonbiased algorithms for CTG evaluation. In this study, we propose a newly constructed deep neural network model (CTG-net) to detect compromised fetal status. CTG-net consists of three convolutional layers that extract temporal patterns and interrelationships between fetal heart rate and uterine contraction signals. We aimed to classify the abnormal group (umbilical artery pH < 7.20 or Apgar score at 1 min < 7) and the normal group from CTG data. We evaluated the performance of the CTG-net with the F1 score and compared it with conventional algorithms, namely, support vector machine and k-means clustering, and another deep neural network model, long short-term memory. CTG-net showed the area under the receiver operating characteristic curve of 0.73 ± 0.04, which was significantly higher than that of long short-term memory. CTG-net, a quantitative and automated diagnostic aid system, enables early intervention for putatively abnormal fetuses, resulting in a reduction in the number of cases of hypoxic injury. [ABSTRACT FROM AUTHOR]

Background: The risk of mortality for the mother and the newborn is aggravated during birth in low- and middle-income countries due to preventable causes, which can be addressed with increased quality of care practices. One such practice is intrapartum fetal heart rate (FHR) monitoring, which is crucial for the early detection of fetal ischemia, but is inadequately monitored in low- and middle-income countries. In India, there is currently a lack of sufficient data on FHR monitoring. Methods: An assessment using facility records, interviews and observation was conducted in seven facilities providing tertiary, secondary or primary level care in aspirational districts of three states. The study sought to investigate the frequency of monitoring, devices used for monitoring and challenges in usage. Results: FHR was not monitored as per standard protocol. Case sheets revealed 70% of labor was monitored at least once. Only 33% of observed cases were monitored every half hour during active labor, and none were monitored every 5 min during the second stage of labor. More time was observed for monitoring with a Doppler compared with a stethoscope, as providers reported fluctuation in readings. Reportedly, low audibility and a perceived need of expertise were associated with using a stethoscope. High case load and the time required for monitoring were reported as challenges in adhering to standard monitoring protocols. Conclusion: The introduction of a standardized device and a short refresher training on the World Health Organization and skilled birth attendant protocols for FHR monitoring will improve usage and compliance. [ABSTRACT FROM AUTHOR]

Intrauterine fetal hypoxia is one of the leading cause of perinatal mortality and morbidity. This can eventually lead to severe neurological damage like cerebral palsy and in extreme cases to fetal demise. It is thus necessary to monitor the fetus during intrapartum and antepartum period. Cardiotocograph (CTG) as a method of assessing the status of the fetus had been in use for last six decades. Nowadays it is the most widely used non-invasive technique for the continuous monitoring of the fetal heart rate (FHR) and the uterine contraction pressure (UCP). Though its introduction limited the birth related problems, the accuracy of interpretation was hindered by quite a few factors. Different guidelines that are provided for the interpretation are based on crisp logic which fails to capture the inherent uncertainty present in the medical diagnosis. Misinterpretations had led to inaccurate diagnosis which resulted in many medico-legal litigations. The vagueness present in the physician's evaluation is best modeled using soft-computing based techniques. In this paper authors used the CTG dataset from UCI Irvine Machine Learning Data Repository which contains 2126 data and each data-point is represented by 37 features. Dimensionality of the feature set was reduced using different automated methods as well as manually by the physicians. The resulting data sets were classified using various machine learning algorithms. Aim of this study is to establish which set of features is best suited to give good insight into the status of the fetus and also determine the most effective machine learning technique for this purpose. The accuracy of the outcomes were measured using statistical methods such as sensitivity, specificity, precision, F-Measure, confusion matrix and kappa value. We obtained an accuracy of 99.91% and kappa measure of 0.997 when the feature set was reduced using MRMR. [ABSTRACT FROM AUTHOR]

Electrohysterogram (EHG) signal is the signal related to action potentials propagating through smooth muscle cells of the uterus (myometrium) to the abdomen of pregnant women which is also known as uterine contraction signal. Cardiotocography (CTG) is the most common method used for monitoring fetal heart rate (FHR) and uterine contractions during pregnancy and labor. This method detects mechanical activity of fetal heart and uterus, however, it provides low accuracy and sensibility and hence more accurate methods are required. The abdominal electrode method of FECG monitoring and Electrohysterography (EHG) are alternative noninvasive method to monitor the FHR and uterine contractions during pregnancy which provides better results compared to CTG. Each information such as the frequency of uterine contractions, length of the contraction and contraction power of uterus, indicates the condition of the uterus which will help the obstetricians to identify the progress of labor. All these above mentioned parameters can be identified from the EHG signal acquired non-invasively by placing the electrodes on the abdomen of the pregnant women. In this work the acquisition of EHG signal as well as analysis of EHG signal in both antepartum condition and labor condition have been carried out and parameters such as number of contractions, contraction duration, amplitude, power of contraction are computed and the quantitative analysis of EHG signals in both above mentioned conditions are performed and it is compared with the simultaneously recorded uterine contraction signal parameters from Cardiotocography (CTG). [ABSTRACT FROM AUTHOR]

Early detection of potential hazards in the fetal physiological state during pregnancy and childbirth is very important. Noninvasive fetal electrocardiogram (FECG) can be extracted from the maternal abdominal signal. However, due to the interference of maternal electrocardiogram and other noises, the task of extraction is challenging. This paper introduces a novel single-lead noninvasive fetal electrocardiogram extraction method based on the technique of clustering and PCA. The method is divided into four steps: (1) pre-preprocessing; (2) fetal QRS complexes and maternal QRS complexes detection based on k-means clustering algorithm with the feature of max-min pairs; (3) FQRS correction step is to improve the performance of step two; (4) template subtraction based on PCA is introduced to extract FECG waveform. To verify the performance of the proposed algorithm, two clinical open-access databases are used to check the performance of FQRS detection. As a result, the method proposed shows the average PPV of 95.35%, Se of 96.23%, and F1-measure of 95.78%. Furthermore, the robustness test is carried out on an artificial database which proves that the algorithm has certain robustness in various noise environments. Therefore, this method is feasible and reliable to detect fetal heart rate and extract FECG. Graphical abstract Early detection of potential hazards in the fetal physiological state during pregnancy and childbirth is very important. Noninvasive fetal electrocardiogram (FECG) can be extracted from maternal abdominal signal. However, due to the interference of maternal electrocardiogram and other noises, the task of extraction is challenging. This paper introduces a novel single-lead noninvasive fetal electrocardiogram extraction method based on the technique of clustering and PCA. The method is divided into four steps: (1) pre-preprocessing; (2) fetal QRS complexes and maternal QRS complexes detection based on k-means clustering algorithm with the feature of max-min pairs; (3) FQRS correction step is to improve the performance of step two; (4) template subtraction based on PCA is introduced to extract FECG waveform. To verify the performance of algorithm, two clinical open-access databases are used to check the performance of FQRS detection. As a result, the method proposed shows the average PPV of 95.35%, Se of 96.23%, and F1-measure of 95.78%. Furthermore, the robustness test is carried out on an artificial database which proves that the algorithm has certain robustness in various noise environments. Therefore, this method is feasible and reliable to detect fetal heart rate and extract FECG. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The objective of this study is to evaluate neonatal outcomes of total anomalous pulmonary venous return (TAPVR) and identify fetal echocardiography findings associated with preoperative pulmonary venous obstruction (PPVO). This retrospective study evaluated TAPVR cases from 2005 to 2014 for preoperative and postoperative outcomes based on prenatal diagnosis, PPVO, and heterotaxy syndrome. Fetal pulmonary and vertical vein Dopplers were analyzed as predictors of PPVO. Of 137 TAPVR cases, 12% were prenatally diagnosed; 60% had PPVO, and 21% had heterotaxy. Of the prenatally diagnosed patients, 63% also had heterotaxy. TAPVR repair was performed in 135 cases and survival to discharge was 82% (112/137). Heterotaxy was the only independent predictor of mortality on multiple regression analysis [OR 5.5 (CI 1.3-16.7), p = 0.02]. PPVO was associated with preoperative acidosis, need for inhaled nitric oxide, and more emergent surgery, but not postoperative mortality. Fetal vertical vein Doppler peak velocity > 0.74 m/s mmHg predicted PPVO (93% sensitivity; 83% specificity) while pulmonary vein Doppler did not. TAPVR has severe neonatal morbidity and mortality with low prenatal diagnosis rates in the absence of heterotaxy. Patients with obstructed TAPVR had greater preoperative morbidity, but only heterotaxy was independently associated with increased postoperative mortality. Vertical vein velocity helped prenatally identify those at risk of PPVO. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the efficacy and safety of intravenous ferric carboxymaltose administration to pregnant women with varying severities of iron deficiency anemia and iron deficiency without anemia.Methods: In this prospective observational study of local obstetric practice, we analyzed data from 863 pregnant women with iron deficiency according to anemia status and severity. All women were treated with intravenous ferric carboxymaltose in pregnancy. Treatment efficacy was assessed by repeat hemoglobin measurements at 3 and 6 week post-infusion and ferritin levels, where available. Safety was assessed by analysis of adverse events, fetal heart rate monitoring, and newborn health outcome data.Results: Ferric carboxymaltose significantly increased hemoglobin in women with mild, moderate, and severe iron deficiency anemia and women with iron deficiency alone at 3 and 6 week post-infusion (p < 0.01 for all). No hemoconcentration occurred in iron-deficient women without anemia. No serious adverse events were recorded, with minor temporary side effects (including local skin irritation, nausea, and headache) occurring in 96 (11%) women. No adverse fetal or neonatal outcomes were observed.Conclusions: Ferric carboxymaltose infusion corrects iron deficiency or various degrees of iron deficiency anemia efficaciously and safely pregnant women, and does not cause hemoconcentration. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to analyze whether the umbilical artery pH value can be estimated throughout CTG assessment 60 min prior to delivery and if the estimated umbilical artery pH value correlates with the actual one. This includes analysis of correlation between CTG trace classification and actual umbilical artery pH value. Intra-and interobserver agreement and the impact of professional experience on visual analysis of fetal heart rate tracing were evaluated.Methods: This was a retrospective study. 300 CTG records of the last 60 min before delivery were picked randomly from the computer database with the following inclusion criteria; singleton pregnancy >37 weeks, no fetal anomalies, vaginal delivery either spontaneous or instrumental-assisted. Five obstetricians and two midwives of different professional experience classified 300 CTG traces according to the FIGO criteria and estimated the postnatal umbilical artery pH.Results: The results showed a significant difference (p < 0.05) in estimated and actual pH value, independent of professional experience. Analysis and correlation of CTG assessment and actual umbilical artery pH value showed significantly (p < 0.05) diverging results. Intra- and interobserver variability was high. Intraobserver variability was significantly higher for the resident (p = 0.001). No significant differences were detected regarding interobserver variability.Conclusion: An estimation of the pH value and consequently of neonatal outcome on the basis of a present CTG seems to be difficult. Therefore, not only CTG training but also clinical experience and the collaboration and consultation within the whole team is important. [ABSTRACT FROM AUTHOR]

Congenital complete atrioventricular block (CCAVB) is a rare condition with an incidence of 1 of 20,000 live births. Hypoplastic left heart syndrome (HLHS) occurs more frequently than CCAVB and occurs in 1 of 5000 live births. HLHS in association with CCAVB is exceedingly rare. In this report, we describe a rare case of HLHS and CCAVB diagnosed in utero. Postnatal diagnosis, management and outcome are presented as well as review of the medical literature. [ABSTRACT FROM AUTHOR]

The monitoring and assessment of the fetus condition are considered to be among the most important obstetric issues to consider during pregnancy and the prenatal period. Monitoring the fetal condition is required to detect the presence of any abnormalities in the oxygen supply to the fetus early in the antenatal or labor period. Early detection can prevent permanent brain damage and death, both of which may arise from suffocation caused by fetal disease, hypoxic-ischemic injury in the neonatal brain, or chronic fetal asphyxia. In this paper, we propose a new signal-fitting method, FitMine, that identifies the fetal condition by analyzing fetal heart rate (FHR) and uterine contraction (UC) signals that are non-invasively measured by cardiotocography (CTG). FitMine is a novel nonlinear dynamic model that reflects the relation between the FHR and UC signals; it combines the chaotic population model and unscented Kalman filter algorithm. The proposed method has several benefits. These are: (a) change-point detection: the proposed method can detect significant pattern variations such as high or low peaks changing suddenly in the FHR and UC signals; (b) parameter-free: it is performed automatically without the requirement for the user to enter input parameters; (c) scalability: FitMine is linearly scalable according to the size of the input data; and (d) applicability: the proposed model can be applied to detect abnormal signs in various domains including electroencephalogram data, epidemic data, temperature data, in addition to CTG recordings. [ABSTRACT FROM AUTHOR]

Timely recognition and appropriate management of high-risk pregnancies, such as intrauterine growth restriction (IUGR), are of paramount importance for every obstetrician. After the initial screening of IUGR fetuses through sonographic fetometry and Doppler, the focus is shifted to the appropriate monitoring and timing of delivery. This can, especially in cases of early IUGR, become a very difficult task. At this point, cardiotocography (CTG) is introduced as a major tool in the day-to-day monitoring of the antenatal well-being of the IUGR fetus. Since the first introduction of CTG up to the nowadays widely spreading implementation of computerised CTG in the clinical practice, there has been great progress in the recording of the fetal heart rate, as well as its interpretation. Focus of this review is to offer an understanding of the evolution of CTG from its early development to modern computerised methods and to provide an insight as to where the future of CTG is leading, especially in the monitoring of IUGR. [ABSTRACT FROM AUTHOR]

Purpose: Fetal scalp blood sampling is considered as a complimentary tool in addition to cardiotocography to assess fetal well-being. This blood sampling is important as the obstetrician has to judge and make decisions regarding the further management of the delivery based on this pH result. The aim of this study was to analyze the correlation between fetal scalp blood pH and the umbilical artery pH after birth. Furthermore, it was investigated whether tocolysis, a performed episiotomy or cord encirclement have an influence on the umbilical artery pH.Methods: This retrospective study over a period of 11 years included all singleton pregnancies without fetal anomalies, which were monitored by fetal scalp blood sampling during labor.Results: 844 out of 1502 deliveries were included for analysis. The analysis demonstrates a good correlation between fetal scalp pH value and outcome pH value. Subgroup analysis with fetal scalp blood pH <7.20 showed a difference in 40 of 82 cases, with an outcome pH value ≥7.20, but this difference was statistically insignificant. Neither did tocolysis, episiotomy or the presence of cord encirclement show an overall effect, nor did they have an impact on the subgroup.Conclusion: Obstetricians must consider that the values of fetal scalp blood are not always reliable and can be false. However, on the basis of CTG and fetal scalp blood pH, decisions are made regarding delivery interventions. Therefore, we would encourage the consideration of taking two samples routinely at every attempt of fetal blood sampling. [ABSTRACT FROM AUTHOR]

Fetal echocardiography is the method of choice to visualize the fetal congenital cardiovascular anomalies. However, there are some disadvantages. Fetal cardiac magnetic resonance imaging (MRI) has the potential to complement ultrasound in detecting congenital cardiovascular anomalies. This pictorial review draws on our experience about fetal cardiac MRI; it describes the four-chamber view on fetal cardiac MRI and important clues on an abnormal four-chamber view to the diagnosis of fetal congenital cardiovascular anomalies. [ABSTRACT FROM AUTHOR]

Fetal heart rate (FHR) monitoring is used routinely in labor, but conventional methods have a limited capacity to detect fetal hypoxia/acidosis. An exploratory study was performed on the simultaneous assessment of maternal heart rate (MHR) and FHR variability, to evaluate their evolution during labor and their capacity to detect newborn acidemia. MHR and FHR were simultaneously recorded in 51 singleton term pregnancies during the last two hours of labor and compared with newborn umbilical artery blood (UAB) pH. Linear/nonlinear indices were computed separately for MHR and FHR. Interaction between MHR and FHR was quantified through the same indices on FHR-MHR and through their correlation and cross-entropy. Univariate and bivariate statistical analysis included nonparametric confidence intervals and statistical tests, receiver operating characteristic curves and linear discriminant analysis. Progression of labor was associated with a significant increase in most MHR and FHR linear indices, whereas entropy indices decreased. FHR alone and in combination with MHR as FHR-MHR evidenced the highest auROC values for prediction of fetal acidemia, with 0.76 and 0.88 for the UAB pH thresholds 7.20 and 7.15, respectively. The inclusion of MHR on bivariate analysis achieved sensitivity and specificity values of nearly 100 and 89.1%, respectively. These results suggest that simultaneous analysis of MHR and FHR may improve the identification of fetal acidemia compared with FHR alone, namely during the last hour of labor. [ABSTRACT FROM AUTHOR]

Objective: To investigate the fetal heart rate (FHR) patterns in pregnancies complicated with vasa previa and velamentous cord insertion (VCI).Methods: A retrospective study comparing FHR patterns in pregnancies and subsequent pregnancies with/without VCI and in pregnancies with/without vasa previa was conducted. For each patient, FHR patterns were compared to the subsequent pregnancy. Deliveries occurred between the years 1988 and 2012 in a tertiary medical center. FHR patterns were evaluated according to the ACOG guidelines.Results: During the study period, there were 184 pregnancies with VCI and 37 pregnancies with vasa previa, undetected during pregnancy. FHR patterns of the VCI group included more cases of abnormal baseline (7 vs. 2 %, p < 0.05), out of which 7 % were fetal tachycardia (vs. 2 %) and 4 % were bradycardia (vs. 1 %). There were also more cases of abnormal baseline and abnormal variability (7 vs. 2 % and 32 vs. 22 %, respectively, p < 0.05) in the VCI group. FHR categories also differed between the velamentous cord insertion pregnancies and subsequent ones. VCI pregnancies had more category 2 patterns, not statistically significant (64 vs. 55 %, p = 0.11). FHR patterns of the vasa previa group included more cases of abnormal baseline (27 vs. 7 %, p < 0.05), out of which 18 % were tachycardia and 9 % were bradycardia. Decelerations were recorded in a total of 61 % of the vasa previa cases (61 vs. 31 %, p = 0.02), most of which were variable decelerations (48 vs. 17 %). Vasa previa pregnancies had more category 2 patterns (64 vs. 52 %).Conclusions: Fetal heart rate patterns in pregnancies complicated with VCI or vasa previa have several non-specific pathological characteristics; none can be used for early detection of these conditions. [ABSTRACT FROM AUTHOR]

The classification and analysis of data is an important issue in today's research. Selecting a suitable set of features makes it possible to classify an enormous quantity of data quickly and efficiently. Feature selection is generally viewed as a problem of feature subset selection, such as combination optimization problems. Evolutionary algorithms using random search methods have proven highly effective in obtaining solutions to problems of optimization in a diversity of applications. In this study, we developed a hybrid evolutionary algorithm based on endocrine-based particle swarm optimization (EPSO) and artificial bee colony (ABC) algorithms in conjunction with a support vector machine (SVM) for the selection of optimal feature subsets for the classification of datasets. The results of experiments using specific UCI medical datasets demonstrate that the accuracy of the proposed hybrid evolutionary algorithm is superior to that of basic PSO, EPSO and ABC algorithms, with regard to classification accuracy using subsets with a reduced number of features. [ABSTRACT FROM AUTHOR]

Cardiac rhythm is an essential component of fetal cardiac evaluation. The Monica AN24 is a fetal heart rate monitor that may provide a quick, inexpensive modality for obtaining a noninvasive fetal electrocardiogram (fECG) in a clinical setting. The fECG device has the ability to acquire fECG signals and allow calculation of fetal cardiac time intervals between 16- and 42-week gestational age (GA). We aimed to demonstrate the feasibility of fECG acquisition in a busy fetal cardiology clinic using the Monica fetal heart rate monitor. This is a prospective observational pilot study of fECG acquired from fetuses referred for fetal echocardiography. Recordings were performed for 5-15 min. Maternal signals were attenuated and fECG averaged. fECG and fetal cardiac time intervals (PR, QRS, RR, and QT) were evaluated by two cardiologists independently and inter-observer reliability was assessed using intraclass coefficient (ICC). Sixty fECGs were collected from 50 mothers (mean GA 28.1 ± 6.1). Adequate signal-averaged waveforms were obtained in 20 studies with 259 cardiac cycles. Waveforms could not be obtained between 26 and 30 weeks. Fetal cardiac time intervals were measured and were reproducible for PR (ICC = 0.89; CI 0.77-0.94), QRS (ICC = 0.79; CI 0.51-0.91), and RR (ICC = 0.77; CI 0.53-0.88). QT ICC was poor due to suboptimal T-wave tracings. Acquisition of fECG and measurement of fetal cardiac time intervals is feasible in a clinical setting between 19- and 42-week GA, though tracings are difficult to obtain, especially between 26 and 30 weeks. There was high reliability in fetal cardiac time intervals measurements, except for QT. The device may be useful for assessing atrioventricular/intraventricular conduction in fetuses from 20 to 26 and >30 weeks. Techniques to improve signal acquisition, namely T-wave amplification, are ongoing. [ABSTRACT FROM AUTHOR]

Purpose: To investigate pregnancy outcome after minor trauma and to identify risk factors at admission that may predict adverse pregnancy outcome. Methods: A retrospective study held between January-2005 and December-2011. Pregnant women at 23 weeks or more, who were admitted due to minor trauma, were included. A standard protocol was applied: physical examination, lab tests and a fetal heart rate monitoring (FHRM) and tocometer for 1 h. In cases of symptomatic women, abnormal FHRM or presence of uterine contractions, the length of monitoring was extended. All women were admitted for 24 h of observation. The primary outcome was a composite adverse outcome that included at least one of the following: placental abruption, preterm birth and birthweight <2,500 g. To investigate pregnancy outcome and identify risk factors that may predict pregnancy outcome, matched (1:2) non-trauma controls were included. Risk factors examined included maternal obstetric variables, complaints at admission, clinical findings, lab test results, FHRM and tocometer findings. Results: A total of 512 women with minor trauma and 1,024 non-trauma controls were included. Composite outcome occurred in 48 (9.4 %) and 131 (12.9 %) of the study and the control groups, respectively ( p = 0.04; OR 0.71; 95 % CI, 0.5-0.99). None of the parameters examined at admission predicted the occurrence of the composite outcome. Conclusion: Pregnant women after minor trauma have a favorable pregnancy outcome. None of the parameters examined at admission were predictive of adverse outcome. Extensive evaluation at admission and observation for 24 h are probably unnecessary following minor trauma, particularly for asymptomatic women. [ABSTRACT FROM AUTHOR]

Purpose: To compare the fetal outcome of preterm breech infants delivered vaginally (VD) or by cesarean section (CS). Methods: A monocentric, retrospective consecutive case series of preterm breech deliveries between 24-37 gestational weeks over 10 years from 1/2000 to 12/2009 was performed in a perinatal care center (Level 1) at the University Clinic of Salzburg, Austria. Data from hospital database were statistically analyzed and compared regarding birth weight, head circumference, parity, transfer rate to neonatal intensive care unit (NICU), arterial and venous cord blood pH and base excess (BE), arterial cord blood pH ≤ 7.10 and BE ≤ −11. Special focus was on fetal outcome of elective CS preterm breech deliveries with a non-urgent medical indication compared to VD. Results: Among 22.115 deliveries, there were 346 live-born preterm singletons and twins in breech presentation (1.56 %), born between 24 + 0 and 37 + 0 gestational weeks. 180 CS and 36 vaginally delivered preterm breech infants were statistically evaluated. On comparing CS vs. VD for premature breech singletons, arterial cord blood pH and BE were lower in the VD group. VD twins had a lower arterial cord blood pH than CS twins. All other parameters were comparable. In preterm breech singletons with non-urgent CS, a statistical analysis was not possible due to small numbers. The VD twin group revealed lower values in birth weight, head circumference, arterial cord blood pH and BE, but no significant difference in venous cord blood pH and BE and transfer rate to NICU. Conclusions: Although general recommendations regarding a superior mode of delivery for improved fetal outcome of preterm breech infants cannot be given, these data do not support a policy of routine CS. [ABSTRACT FROM AUTHOR]

Obesity is a substantial public health problem with a rapidly increasing prevalence in numerous industrialized nations. The objective of this study was to evaluate the effects of maternal pre-pregnancy obesity on fetal cardiac functions. We studied 55 fetuses of obese mothers and 44 fetuses of healthy mothers at 26-38 weeks of gestation. Cardiac functions were evaluated by M-mode, pulsed-wave, and tissue Doppler echocardiography. The two groups were similar in terms of maternal age, gravidity, parity, gestational age, estimated birth weight, serum lipids, and systolic-diastolic blood pressure. Fetal heart rate, diameters of the aortic and pulmonary valve annulus, aortic and pulmonary peak systolic velocities, ventricular systolic function, and cardiothoracic ratio were similar in the two groups. Pulsed-wave Doppler-derived E/ A ratios in the mitral and tricuspid valves were similar in the two groups. The deceleration time of early mitral inflow was prolonged in the fetuses of the obese mothers. In the interventricular septum, left ventricle posterior wall, and right ventricle free wall, the E and A were higher, and E/ A ratios were significantly lower in the study group than in the control group. The E/ E ratio was higher in the obese group than in the control group. The isovolumic relaxation time and the right and left ventricle myocardial performance indices were higher in the fetuses of the obese mothers than in the fetuses of the healthy mothers. We believe that maternal obesity has an important influence on fetal cardiac diastolic functions. [ABSTRACT FROM AUTHOR]

Uncontrolled/untreated maternal hyperthyroidism has been associated with fetal tachycardia. We report a case of right-ventricular (RV) hypertrophy with pericardial effusion related to untreated maternal Graves’ disease. A 33-year-old G4P1021 woman with uncontrolled Graves’ disease presented at 29 weeks gestation with abdominal pain and vaginal bleeding. Fetal echocardiogram showed severe RV hypertrophy and a pericardial effusion. The infant was born prematurely, and initial transthoracic echocardiogram showed severe RV hypertrophy and a small pericardial effusion. The infant had clinical findings consistent with congenital thyrotoxicosis and was treated for this. Follow-up imaging at 4 weeks showed improvement of the cardiac hypertrophy and pericardial effusion. This article describes the presentation of fetal RV hypertrophy with congenital thyrotoxicosis and underscores the importance of screening for this prenatally in mothers with uncontrolled or untreated hyperthyroidism. [ABSTRACT FROM AUTHOR]

Myocardial performance index (MPI), or Tei index, has become a commonly used parameter for the noninvasive, Doppler-derived assessment of global systolic and diastolic performance of the heart in both adults and children. Normal values have been established in adults and children; however, limited data exist in fetal hearts. The aim of this study was to further elucidate normal values of fetal left (LV) and right ventricle (RV) MPI values in second- and third-trimester fetuses and compare these values with other previously published data. This was a retrospective study to measure MPI in healthy fetuses. After Institutional Review Board approval, 2000 fetal echocardiography studies (FES) were acquired during a period of 4 years. Demographic parameters examined included gestational age (GA), maternal age (MA), and indication for fetal echocardiography. Fetuses with congenital heart disease, arrhythmias, or significant noncardiac fetal anomalies were excluded. The following echocardiography parameters were collected: LV ejection time (LVET), mitral valve close-to-open time (MVCO), RVET, tricuspid valve CO (TVCO), and fetal heart rate. For simplicity, LV and RV MPI values were calculated as follows: LV MPI = MVCO − LVET/LVET and RV MPI = TVCO − RVET/RVET. Four hundred twenty FES met the study criteria. LV MPI was evaluated in 230 and 190 FES in the second and third trimester, respectively. Of the 420 FES, 250 (150 in the second trimester and 100 in the third trimester) had all of the measurements required for RV MPI calculation. MA ranged between 16 and 49 years. Indications for FES included diabetes mellitus ( N = 140; 33 %), suspected fetal anomalies on routine obstetrical ultrasound ( N = 80; 20 %), autoimmune disorder ( N = 60; 14 %), family history of CHD ( N = 76; 18 %), medication exposure ( N = 22; 5 %), increase nuchal thickness ( N = 13; 3 %), and other indications ( N = 29; 6 %). Averaged LV and RV MPI values were 0.464 ± 0.08 and 0.466 ± 0.09, respectively. Further analysis based on gestational period showed slightly greater LV and RV MPI values during the third compared with the second trimester, i.e., 0.48 and 0.49, respectively, with no statistically significant difference. There was no significant association of LV and RV MPI with heart rate. To our knowledge, this is the first study to establish normal values of fetal MPI based on a large fetal population from a single tertiary center. LV and RV MPI values were independent of GA and fetal heart rate. MPI is a useful parameter for the assessment of global cardiac function in the fetus and demonstrates good reproducibility with narrow interobserver and intraobserver variability. Its usefulness should be studied in fetal hearts with complex congenital anomalies. [ABSTRACT FROM AUTHOR]

In this study, a new scheme was presented for the prediction of fetal state from fetal heart rate (FHR) and the uterine contraction (UC) signals obtained from cardiotocogram (CTG) recordings. CTG recordings are widely used in pregnancy and provide very valuable information regarding fetal well-being. The information effectively extracted from these recordings can be used to predict pathological state of the fetus and makes an early intervention possible before there is an irreversible damage to the fetus. The proposed scheme is based on adaptive neuro-fuzzy inference systems (ANFIS). Using features extracted from the FHR and UC signals, an ANFIS was trained to predict the normal and the pathological state. The method was tested with clinical data that consist of 1,831 CTG recordings. Out of these 1,831 recordings, 1,655 of them were classified as normal and the remaining 176 were classified as pathological by a consensus of three expert obstetricians. It was demonstrated that the ANFIS-based method was able to classify the normal and the pathologic states with 97.2 and 96.6 % accuracy, respectively. [ABSTRACT FROM AUTHOR]

This study investigated cardiac function in 65 fetuses of mildly preeclamptic mothers and 55 fetuses of healthy mothers at 26-40 weeks of gestation. Fetuses with intrauterine growth restriction were excluded. Cardiac functions were evaluated by M-mode, pulsed-wave, and tissue Doppler echocardiography. The two groups were similar in terms of maternal age, gravidity, parity, and gestational age. Peak systolic aortic and pulmonary artery velocities were significantly lower in the fetuses of the preeclamptic mothers than in the fetuses of the healthy mothers. The two groups did not differ significantly in terms of shortening fraction or with regard to mitral or tricuspid annular plane systolic excursion. Pulsed-wave Doppler-derived E/A ratios in the mitral and tricuspid valves were similar in the two groups. The deceleration time of early mitral inflow was prolonged in the fetuses of the preeclamptic mothers. The Ea, Aa, and Ea/Aa ratios in the interventricular septum, left ventricle posterior wall, and right ventricle free wall were lower in the preeclampsia group than in the control group. The E/Ea ratio was higher in the preeclampsia group than in the control group. The isovolumic relaxation time and the right and left myocardial performance indices were higher in the fetuses of the preeclamptic mothers than in the fetuses of the healthy mothers. An increased ductus venosus pulsatility index (PI) and a decreased middle cerebral artery (MCA) PI were found in the fetuses of the preeclamptic mothers. All the fetuses were asymptomatic. The results suggest that the increase in fetal cardiac afterload in mild preeclampsia may have caused early subclinical changes in fetal systolic and diastolic cardiac function. In addition, the decrease in MCA-PI may have been caused by redistribution of fetal cardiac output in favor of the left ventricle, secondary to increased placental vascular resistance. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the effect that combining multiple ultrasonographic imaging methods has on the proportion of tests with a satisfactory fetal heart assessment at 12-14 weeks of pregnancy using B-mode, color Doppler, and spatiotemporal image correlation software (STIC) via both the abdominal and vaginal routes. This cross-sectional prospective study involved healthy pregnant women at 12-14 weeks of pregnancy with a crown-rump length (CRL) of 84 mm or shorter. The following four cardiac views were assessed: four-chamber, left and right ventricular outflow tract, and aortic arch views. The same examiner sought to identify these four views using B-mode, color Doppler, and STIC via both the vaginal and abdominal routes. The study determined the proportion of cases and the respective 95 % confidence intervals (CIs) in which all four views were identified. The presence of significant differences in comparisons between methods was analyzed using McNemar's test. Although 57 pregnant women at 12-14 weeks of pregnancy agreed to participate in the study, 4 were not included because they presented with a CRL longer than 84 mm. Thus, 53 pregnant women were thoroughly assessed and included in the analysis. The combination of B-mode, color Doppler, and STIC via both the abdominal and vaginal routes enabled the highest proportion of identification of the four views (90.6 %; 95 % CI, 79.8-95.9 %). The lowest proportions were observed when B-mode was used alone via both the vaginal route (30.2 %; 95 % CI, 19.5-43.5 %) and the abdominal route (37.7 %; 95 % CI, 25.9-51.2 %). The abdominal route showed results slightly better than those of the vaginal route with all the methods, but the differences were not statistically significant. In the vast majority of the cases, the fetal hearts were properly assessed at 12-14 weeks of pregnancy when several methods were combined using both the abdominal and vaginal routes. However, only one-third of them would have had adequate heart assessment if the B-mode via either the abdominal or the vaginal route had been used alone. [ABSTRACT FROM AUTHOR]

Objective: To determine the patterns of uterine action potentials in laboring and non-laboring women at term using the non-invasive abdominal electromyography technique. Methods: One hundred pregnant women at term who fulfilled the inclusion criteria were enrolled in the study and equally divided into two groups. Group I consisted of 50 women in active labor, while group II included 50 women not in labor. After enrollment, the cardiotocograph was applied to all women. Abdominal electromyographic recording was started and for every burst of action potential, we measured the amplitude, frequency and duration of action potential. The results were tabulated and statistically analyzed. Results: Both groups were comparable in demographic characteristics. Four patterns of EMG were detected. The amplitude of action potentials was significantly higher in laboring compared to non-laboring women (77.44 ± 11.25 vs 13.71 ± 8.57, P < 0.001). Similar significantly longer durations of electrical bursts were also noted in laboring women (45.94 ± 8.77 vs 7.11 ± 4.68 s, P < 0.001). Specific electromyographic changes were noted in women passing from the non-laboring to laboring state and in women who required oxytocin augmentation during labor. Conclusion: Abdominal electromyography may help to distinguish between women in true active labor from those who are not. It also may help to identify women who will enter into labor within 24-72 h and those who require augmentation of labor. [ABSTRACT FROM AUTHOR]

Purposes: To correlate between umbilical artery cord blood lactate and acid-base status with intrapartum fetal heart rate monitoring, and to measure the reliability of umbilical cord blood lactate for prediction of early neonatal outcome. Methods: Sixty-six participants with intrapartum abnormal fetal heart rate monitoring and 60 participants with normal intrapartum recordings were recruited. The abnormal recordings included late onset, atypical variable and simple variable decelerations. After delivery, the arterial cord blood lactate, pH, actual base excess (ABE), and Apgar score were measured in all participants. Results: There was significant inverse correlation between cord lactate and pH and ABE in all participants (correlation coefficient = −0.7, p < 0.0001). The cord lactate was significantly higher in the late onset and atypical variable decelerations groups compared to control ( p < 0.0001). There was no significant correlation between the Apgar score and blood lactate in all groups; however, the sensitivity and specificity of cord lactate to predict low score at 5 min were higher in comparison to cord pH. Conclusions: Umbilical cord blood lactate is a reliable marker for intrapartum fetal asphyxia compared to cord acid-base status with better prediction for newborns with low Apgar score. [ABSTRACT FROM AUTHOR]

Objective: Primary aim of the study was to identify risk factors for an adverse neonatal outcome in emergency caesarean deliveries (ECD). Secondary, the influence of the decision-to-delivery interval (DDI) on neonatal outcome was evaluated. Methods: Study period of this retrospective investigation was 2001-2011, in which 336 ECD were evaluated. Main outcome measures were risk factors associated with an adverse neonatal outcome (umbilical cord arterial pH < 7.05, umbilical cord arterial base excess (BE) < −12, Apgar score at 5 min <5 and the combination of umbilical cord arterial pH < 7.0, and umbilical cord arterial BE < −12). Secondary, the influence of the DDI on neonatal outcome was assessed. These parameters were tested in univariate and multivariate analyses. Results: Prematurity (<37 + 0 weeks of gestation) and silent cardiotocography (CTG) were identified as the major risk factors for an adverse neonatal outcome. Statistical analyses of the influence of the DDI on umbilical cord arterial pH and BE as well as the Apgar score at 5 min revealed no significant results. Conclusion: Our results emphasize the necessity of attendance in a level-3 department of obstetrics in case of conceivable compromised neonatal conditions. Prematurity and silent CTG were identified as the major risk factors for an adverse neonatal outcome. As long as the DDI is under 20 min, it did not have an impact on neonatal outcome. [ABSTRACT FROM AUTHOR]

Birth asphyxia can result in death or permanent brain damage. To prevent it, the fetal heart rate (FHR) is recorded in labour on a paper strip. In clinical practice, the complicated FHR patterns are assessed by eye, which is error-prone, inconsistent and unreliable. Objective alternatives are needed and thus we investigated the applicability of feed-forward artificial neural networks (ANNs) for FHR analysis. Six FHR features were extracted and combined with six clinical parameters to form a feature space of 12 dimensions. The feature space was reduced to six dimensions by principal component analysis. Subsequently, a network committee of ten ANNs was trained with the data of 124 patients (a balanced set of 62 adverse, coded 1, and 62 normal outcomes, coded 0). The ANN committee was tested on another balanced set of 252 patients obtaining misclassification rate of 36%. Finally, the committee was tested on a large dataset of 7,568 patients (non-balanced). As the committee output continuously increased from 0 to 1, there was a consistent growth of the adverse outcome rate (from 0.26 to 5.3%) and the low umbilical pH rate (from 2.6 to 16.7%.) Based on this correlation between the committee output and the risk of compromise, we concluded that ANNs can be successfully applied to FHR monitoring in labour. However, extensive further work is necessary, for which we outline our plans. To our knowledge, this is the first time that an automated method for FHR diagnostic analysis has been tested on a database of this size. [ABSTRACT FROM AUTHOR]

This case report of a silent cardiotocogram (CTG) registration during general anesthesia in a 33-week-pregnant patient undergoing non-obstetric surgery demonstrates the possibility of misinterpretation whereby typical CTG patterns of fetal reactions to anesthetics can be misinterpreted as fetal hypoxia or even asphyxia. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to assess the fetal heart rate (FHR) signal quality of non-invasive abdominal fetal electrocardiogram (fECG) in comparison to the Doppler ultrasound cardiotocogram (CTG) during the first and second stage of labour. Study design: This was a prospective observational study of non-invasive fECG using five abdominally sited electrodes against the traditional Doppler ultrasound CTG probe on 144 patients. Data were analysed for signal quality before and after outlier removal. Results: Abdominal fECG signal quality was significantly better during the first stage of labour in comparison to Doppler CTG (median fECG reliability of 95.7 % vs. median 87.3 % for Doppler, p < 0.001), whereas during second stage of labour, equivalence was demonstrated ( p > 0.05). For the first and second stage of labour, fECG showed 106/135 (78.5 %) and 46/98 (46.9 %) women having fetal signal loss below 20 %, respectively. Similarly, Doppler ultrasound demonstrated 104/135 (77.0 %) and 51/98 (52.0 %) women having fetal signal loss below 20 % during first and second stage of labour, respectively. Conclusion: The non-invasive abdominal fECG presents an improved FHR signal quality during the first stage of labour and an equivalent signal quality during the second stage. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the clinical significance of intrapartum fetal heart rate (FHR) monitoring in low-risk pregnancies according to guidelines and specific patterns. Methods: An obstetrician, blinded to neonatal outcome, retrospectively reviewed 198 low-risk cases that underwent continuous electronic fetal monitoring (EFM) during the last 2 h before delivery. The tracings were interpreted as normal, suspicious or pathological, according to specific guidelines of EFM and by grouping the different FHR patterns considering baseline, variability, presence of decelerations and bradycardia. The EFM groups and the different FHR-subgroups were associated with neonatal acid base status at birth, as well as the short-term neonatal composite outcome. Comparisons between groups were performed with Kruskal-Wallis test. Differences among categorical variables were evaluated using Fisher's exact test. Significance was set at p < 0.05 level. Results: Significant differences were found for mean pH values in the three EFM groups, with a significant trend from 'normal' [pH 7.25, 95 % confidence interval (CI) 7.28-7.32] to 'pathological' tracings (pH 7.20, 95 % CI 7.17-7.13). Also the rates of adverse composite neonatal outcome were statistically different between the two groups ( p < 0.005). Among the different FHR patterns, tracings with atypical variable decelerations and severe bradycardia were more frequently associated with adverse neonatal composite outcome (11.1 and 26.7 %, respectively). However, statistically significant differences were only observed between the subgroups with normal tracings and bradycardia. Conclusions: In low-risk pregnancies, there is a significant association between neonatal outcome and EFM classification. However, within abnormal tracings, neonatal outcome might differ according to specific FHR pattern. [ABSTRACT FROM AUTHOR]