14 research outputs found
Uterine myoelectrical activity as biomarker of successful induction with Dinoprostone: Influence of parity
[EN] The prolonged latent phase of Induction of Labour (IOL) is associated with increased risks of maternal mortality and morbidity. Electrohysterography (EHG) has outperformed traditional clinical measures monitoring labour progress. Although parity is agreed to be of particular relevance to the success of IOL, no previous EHG¿related studies have been found in the literature. We thus aimed to identify EHG¿biomarkers to predict IOL success (active phase of labour in¿¿¿24¿h) and determine the influence of the myoelectrical response on the parity of this group. Statistically significant and sustained differences between the successful and failed groups were found from 150¿min in amplitude and non¿linear parameters, especially in Spectral Entropy and in their progression rates. In the nulliparous¿parous comparison, parous women showed statistically significantly higher amplitude progression rate. These biomarkers would therefore be useful for early detection of the risk of induction failure and would help to develop more robust and generalizable IOL success¿prediction systems.This work was supported by the Spanish Ministry of Economy and Competitiveness and the European Regional Development Fund (MCIU/AEI/FEDER, UE RTI2018-094449-A-I00-AR
and PID2021-124038OB-I00).
Funding for open access charge: CRUE-Universitat Politècnica de ValènciaDiaz-Martinez, A.; Monfort-Ortiz, R.; Ye Lin, Y.; Garcia-Casado, J.; Nieto-Tous, M.; Nieto Del-Amor, F.; Diago-Almela, VJ.... (2023). Uterine myoelectrical activity as biomarker of successful induction with Dinoprostone: Influence of parity. Biocybernetics and Biomedical Engineering (Online). 43(1):142-156. https://doi.org/10.1016/j.bbe.2022.12.00414215643
Caracterización y utilidad de la electromiografía uterina en diferentes escenarios obstétricos: partos inducidos y estimación de presión intrauterina
[ES] La monitorización de la frecuencia cardíaca fetal y de la actividad uterina es una práctica clínica habitual para obtener información del estado del feto durante el embarazo y el parto. Para la monitorización de la dinámica uterina tradicionalmente se han empleado técnicas como la tocodinamometría (TOCO) y la medida de la presión intrauterina mediante catéter. Sin embargo, ambas técnicas presentan limitaciones que hacen que se requiera la búsqueda de otras alternativas. En este sentido para solventar los problemas relacionados con estas técnicas se plantea el registro de la señal electrohisterográfica (EHG) como una alternativa para monitorizar de forma precisa y no invasiva la actividad mioeléctrica uterina. La técnica ha sido ampliamente estudiada en diferentes condiciones obstétricas como es el caso de la predicción del parto prematuro y en la detección de contracciones de parto; y unos pocos en la predicción del éxito de la inducción del parto y en la estimación de la presión intrauterina. A pesar de que el registro EHG ha demostrado que aporta información relevante sobre las propiedades bioeléctricas del útero, existen pocos estudios sobre la respuesta mioeléctrica uterina a los medicamentos empleados en la inducción del parto que puedan servir como herramienta de ayuda en la predicción del resultado de la inducción del parto. En la presente tesis se abordó este problema mediante dos objetivos generales: 1) caracterizar la respuesta electrofisiológica uterina a los fármacos de inducción del parto a partir de registros EHG y 2) desarrollar y valorar sistemas de ayuda al diagnóstico para predecir el éxito de inducción del parto. Los resultados del primer objetivo revelaron una diferente evolución de los parámetros EHG entre los grupos de éxito y fracaso, revelando que podría ser útil para una predicción de inducción exitosa en las primeras etapas de la inducción, especialmente cuando se usa misoprostol. Para el segundo objetivo se diseñaron sistemas predictores del éxito de la inducción del parto mediante técnicas de machine learning valorando su capacidad predictora. Los resultados mostraron que el EHG puede usarse potencialmente para predecir la inducción exitosa del parto y supera al uso de las características obstétricas tradicionales. El uso clínico del sistema de predicción propuesto ayudaría a mejorar el bienestar materno-fetal y optimizar los recursos hospitalarios.
Por otra parte, en la presente tesis también se abordó el registro EHG como una técnica no invasiva para la estimación de la presión intrauterina. Diversos estudios han intentado estimar la señal IUP a partir de parámetros extraídos de la señal EHG. A pesar de estos esfuerzos, existen limitaciones no abordadas específicamente en dichos estudios como es el caso de la gran variabilidad entre pacientes. Por ello, se propuso mejorar la estimación de presión uterina reportada en la literatura mediante un enfoque de interés clínico y abordando la problemática de la variabilidad entre pacientes. Se diseñaron modelos para la estimación de IUP, utilizando diferentes tipos de criterios de optimización y se desarrollaron modelos individuales (mono-paciente) y globales (con el conjunto de pacientes). Finalmente, se abordó el problema de la variabilidad entre sujetos mediante el desarrollo de algoritmos adaptativos para mejorar la exactitud de las estimaciones de IUP derivadas de los modelos globales. Los modelos adaptativos desarrollados superaron los modelos globales, proporcionando un mejor balance para estimar la señal continua de IUP, el tono y la máxima presión. Los modelos de estimación de IUP basados en EHG propuestos en la presente tesis permiten una monitorización no invasiva de la actividad uterina más precisa y, por lo tanto, una mejor evaluación del progreso del parto y del bienestar materno y fetal.[EN] Monitoring fetal heart rate and uterine activity is a common clinical practice to obtain information on the status of the fetus during pregnancy and delivery. Techniques such as tocodynamometry (TOCO) and measurement of intrauterine pressure using a catheter have traditionally been used to monitor uterine dynamics. However, both techniques have limitations that require the search for other alternatives. In this sense, to solve the problems related to these techniques, the recording of the electrohysterographic signal (EHG) is proposed as an alternative to monitor uterine myoelectrical activity accurately and noninvasively. The technique has been extensively studied in different obstetric conditions, such as the prediction of preterm labor and the detection of labor contractions; and a few in predicting the success of labor induction and in estimating intrauterine pressure. Despite the fact that the EHG record has been shown to provide relevant information on the bioelectric properties of the uterus, there are few studies on the uterine myoelectrical response to the medications used to induce labor that can serve as a tool to help predict the outcome of induction of labor. In the present thesis, this problem was addressed through two general objectives: 1) to characterize the uterine electrophysiological response to labor induction drugs from EHG records and 2) to develop and assess diagnostic aid systems to predict the success of induction of labor. The results of the first objective revealed a different evolution of the EHG parameters between the success and failure groups, revealing that it could be useful for a successful induction prediction in the early stages of induction, especially when misoprostol is used. For the second objective, predictive systems for the success of labor induction were designed using machine learning techniques, evaluating its predictive capacity. The results showed that EHG can potentially be used to predict successful induction of labor and outperforms the use of traditional obstetric features. The clinical use of the proposed prediction system would help improve maternal-fetal well-being and optimize hospital resources.
On the other hand, in this thesis, EHG recording was also addressed as a non-invasive technique for estimating intrauterine pressure. Various studies have attempted to estimate the IUP signal from parameters extracted from the EHG signal. Despite these efforts, there are limitations not specifically addressed in these studies, such as the great variability between patients. Therefore, it was proposed to improve the estimation of uterine pressure reported in the literature using an approach of clinical interest and addressing the problem of variability between patients. Models were designed for the estimation of IUP, using different types of optimization criteria, and individual (single-patient) and global models (with the set of patients) were developed. Finally, the problem of variability between subjects was addressed through the development of adaptive algorithms to improve the accuracy of IUP estimates derived from global models. The adaptive models developed outperformed the global models, providing better balance to estimate continuous IUP signal, tonus, and maximum pressure. The EHG-based IUP estimation models proposed in this thesis allow more precise non-invasive monitoring of uterine activity and, therefore, a better evaluation of labor progress and maternal and fetal well-being[CA] La monitorització de la freqüència cardíaca fetal i de l'activitat uterina és una pràctica clínica habitual per a obtindre informació de l'estat del fetus durant l'embaràs i el part. Per a la monitorització de la dinàmica uterina tradicionalment s'han empleat tècniques com la tocodinamometría (TOQUE) i la mesura de la pressió intrauterina per mitjà de catèter. No obstant això, ambdós tècniques presenten limitacions que fan que es requerisca la busca d'altres alternatives. En este sentit per a resoldre els problemes relacionats amb estes tècniques es planteja el registre del senyal electrohisterográfica (EHG) com una alternativa per a monitoritzar de forma precisa i no invasiva l'activitat mioeléctrica uterina. La tècnica ha sigut àmpliament estudiada en diferents condicions obstétricas com és el cas de la predicció del part prematur i en la detecció de contraccions de part; i uns pocs en la predicció de l'èxit de la inducció del part i en l'estimació de la pressió intrauterina. A pesar que el registre EHG ha demostrat que aporta informació rellevant sobre les propietats bioeléctricas de l'úter, hi ha pocs estudis sobre la resposta mioeléctrica uterina als medicaments empleats en la inducció del part que puguen servir com a ferramenta d'ajuda en la predicció del resultat de la inducció del part. En la present tesi es va abordar este problema per mitjà de dos objectius generals: 1) caracteritzar la resposta electrofisiològica uterina als fàrmacs d'inducció del part a partir de registres EHG i 2) desenrotllar i valorar sistemes d'ajuda al diagnòstic per a predir l'èxit d'inducció del part. Els resultats del primer objectiu van revelar una diferent evolució dels paràmetres EHG entre els grups d'èxit i fracàs, revelant que podria ser útil per a una predicció d'inducció exitosa en les primeres etapes de la inducció, especialment quan s'usa misoprostol. Per al segon objectiu es van dissenyar sistemes predictors de l'èxit de la inducció del part per mitjà de tècniques de machine learning valorant la seua capacitat predictora. Els resultats van mostrar que l'EHG pot usar-se potencialment per a predir la inducció exitosa del part i supera a l'ús de les característiques obstétricas tradicionals. L'ús clínic del sistema de predicció proposat ajudaria a millorar el benestar matern-fetal i optimitzar els recursos hospitalaris. D'altra banda, en la present tesi també es va abordar el registre EHG com una tècnica no invasiva per a l'estimació de la pressió intrauterina. Diversos estudis han intentat estimar el senyal IUP a partir de paràmetres extrets del senyal EHG. A pesar d'estos esforços, hi ha limitacions no abordades específicament en els dits estudis com és el cas de la gran variabilitat entre pacients. Per això, es va proposar millorar l'estimació de pressió uterina reportada en la literatura per mitjà d'un enfocament d'interés clínic i abordant la problemàtica de la variabilitat entre pacients. Es van dissenyar models per a l'estimació d'IUP, utilitzant diferents tipus de criteris d'optimització i es van desenrotllar models individuals (mona-pacient) i globals (amb el conjunt de pacients). Finalment, es va abordar el problema de la variabilitat entre subjectes per mitjà del desenrotllament d'algoritmes adaptatius per a millorar l'exactitud de les estimacions d'IUP derivades dels models globals. Els models adaptatius desenrotllats van superar els models globals, proporcionant un millor balanç per a estimar el senyal continu d'IUP, el to i la màxima pressió. Els models d'estimació d'IUP basats en EHG proposats en la present tesi permeten una monitorització no invasiva de l'activitat uterina més precisa i, per tant, una millor avaluació del progrés del part i del benestar matern i fetal.Benalcazar Parra, CA. (2020). Caracterización y utilidad de la electromiografía uterina en diferentes escenarios obstétricos: partos inducidos y estimación de presión intrauterina [Tesis doctoral no publicada]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/149403TESI
A Comparative Study of Vaginal Labor and Caesarean Section Postpartum Uterine Myoelectrical Activity
[EN] Postpartum hemorrhage (PPH) is one of the major causes of maternal mortality and morbidity worldwide, with uterine atony being the most common origin. Currently there are no obstetrical techniques available for monitoring postpartum uterine dynamics, as tocodynamometry is not able to detect weak uterine contractions. In this study, we explored the feasibility of monitoring postpartum uterine activity by non-invasive electrohysterography (EHG), which has been proven to outperform tocodynamometry in detecting uterine contractions during pregnancy. A comparison was made of the temporal, spectral, and non-linear parameters of postpartum EHG characteristics of vaginal deliveries and elective cesareans. In the vaginal delivery group, EHG obtained a significantly higher amplitude and lower kurtosis of the Hilbert envelope, and spectral content was shifted toward higher frequencies than in the cesarean group. In the non-linear parameters, higher values were found for the fractal dimension and lower values for Lempel-Ziv, sample entropy and spectral entropy in vaginal deliveries suggesting that the postpartum EHG signal is extremely non-linear but more regular and predictable than in a cesarean. The results obtained indicate that postpartum EHG recording could be a helpful tool for earlier detection of uterine atony and contribute to better management of prophylactic uterotonic treatment for PPH prevention.This work was supported by the Spanish Ministry of Economy and Competitiveness, the European Regional Development Fund (MCIU/AEI/FEDER, UE RTI2018-094449-A-I00-AR) and the Generalitat Valenciana (GV/2018/104 and AICO/2019/220).Díaz-Martínez, MDA.; Mas-Cabo, J.; Prats-Boluda, G.; Garcia-Casado, J.; Cardona-Urrego, K.; Monfort-Ortiz, R.; Lopez-Corral, A.... (2020). A Comparative Study of Vaginal Labor and Caesarean Section Postpartum Uterine Myoelectrical Activity. 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Computational and Mathematical Methods in Medicine, 2014, 1-11. doi:10.1155/2014/470786Alberola-Rubio, J., Garcia-Casado, J., Prats-Boluda, G., Ye-Lin, Y., Desantes, D., Valero, J., & Perales, A. (2017). Prediction of labor onset type: Spontaneous vs induced; role of electrohysterography? Computer Methods and Programs in Biomedicine, 144, 127-133. doi:10.1016/j.cmpb.2017.03.018Maner, W. L., MacKay, L. B., Saade, G. R., & Garfield, R. E. (2006). Characterization of abdominally acquired uterine electrical signals in humans, using a non-linear analytic method. Medical & Biological Engineering & Computing, 44(1-2), 117-123. doi:10.1007/s11517-005-0011-3Marchini, G., Lagercrantz, H., Winberg, J., & Uvnäs-Moberg, K. (1988). Fetal and maternal plasma levels of gastrin, somatostatin and oxytocin after vaginal delivery and elective cesarean section. Early Human Development, 18(1), 73-79. doi:10.1016/0378-3782(88)90044-8Pickering, K., Gallos, I. D., Williams, H., Price, M. J., Merriel, A., Lissauer, D., … Roberts, T. E. (2018). Uterotonic Drugs for the Prevention of Postpartum Haemorrhage: A Cost-Effectiveness Analysis. PharmacoEconomics - Open, 3(2), 163-176. doi:10.1007/s41669-018-0108-xMorfaw, F., Fundoh, M., Pisoh, C., Ayaba, B., Mbuagbaw, L., Anderson, L. N., & Thabane, L. (2019). Misoprostol as an adjunct to oxytocin can reduce postpartum-haemorrhage: a propensity score–matched retrospective chart review in Bamenda-Cameroon, 2015–2016. BMC Pregnancy and Childbirth, 19(1). doi:10.1186/s12884-019-2407-3Grotegut, C. A., Paglia, M. J., Johnson, L. N. C., Thames, B., & James, A. H. (2011). Oxytocin exposure during labor among women with postpartum hemorrhage secondary to uterine atony. American Journal of Obstetrics and Gynecology, 204(1), 56.e1-56.e6. doi:10.1016/j.ajog.2010.08.023Shen, Y., Oda, T., Tamura, N., Kohmura‐Kobayashi, Y., Furuta‐Isomura, N., Yaguchi, C., … Kanayama, N. (2019). 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Low dose vaginal misoprostol vs vaginal dinoprostone insert for induction of labor beyond 41st week: a randomized trial
Introduction: The aim of this study was to compare the efficacy and safety of a low‐dose protocol of vaginal misoprostol and vaginal dinoprostone insert for induction of labor in women with post‐term pregnancies. Material and methods: We designed a prospective, randomized, open‐labeled trial with evaluators blinded to the end‐point, including women of at least 41 weeks of gestational age with uncomplicated singleton pregnancies and a Bishop score <6. They were randomized into dinoprostone or misoprostol groups in a 1:1 ratio. Baseline maternal data and perinatal outcomes were recorded for statistical analysis. Successful vaginal delivery within 24 hours was the primary outcome variable. A P value <0.05 was considered statistically significant. This study was registered in ClinicalTrials.gov (number NTC03744364). Results: We included 198 women for analysis (99 women in each group). Vaginal birth rate within 24 hours did not differ between groups (49.5% vs 42.4%; P = 0.412). When the Bishop score was <4, dinoprostone insert showed a higher probability of vaginal delivery within 12 hours (17.8% vs 4%; P = 0.012). In the dinoprostone group, removal of the insert was more likely to be due to an adverse event (5.1% vs 14.1%; P = 0.051) and an abnormal fetal heart rate pattern during active labor (44.4% vs 58.6%; P = 0.047). Both groups were similar in neonatal outcomes including Apgar score, umbilical cord pH and neonatal intensive care unit admission. Conclusions: Low‐dose vaginal misoprostol and vaginal dinoprostone insert seem to be equally effective and safe for induction of labor in pregnant women with a gestational age beyond 41 weeks
Maduración pre-inducción de parto. Comparación entre dinoprostona y misoprostol con objetivación de dinámica uterina mediante electrohisterografía: Un enfoque pragmático
La inducción del parto y la maduración cervical son temas de gran interés dentro de la obstetricia, llegando a alcanzar el 30% del total de nacimientos. Además, su inadecuada indicación conlleva una iatrogenia considerable respecto a los resultados neonatales, el aumento de la tasa de cesáreas y los costes. Si bien disponemos de muchos métodos con una efectividad y seguridad contrastada, la investigación en busca del método óptimo para la maduración cervical en cuellos uterinos desfavorables continúa en marcha. Actualmente las prostaglandinas Dinoprostona y Misoprostol son los agentes maduradores de primera elección en nuestro medio. Entre los diferentes estudios publicados, existe heterogeneidad en las dosificaciones, por ejemplo, la dosis óptima y el intervalo de tiempo del misoprostol por vía vaginal no son del todo conocidos. El uso de dosis en dichos estudios es variable, existiendo pocos en lo que se comparan dosis similares a las que se comercializan en el mercado como la de 25 mcg para el misoprostol y de 10 mg para la dinoprostona. En los estudios en los que se ha visto una mayor eficacia del misoprostol, no se ha llegado a justificar la causa exacta de la misma, siendo la más aceptada la producción de una mayor dinámica uterina. La tocografía externa es la técnica más utilizada en la actualidad para determinar la dinámica uterina. Este método no proporciona información muy fiable ya que depende en gran medida del juicio subjetivo del examinador. Como alternativa, para el control de la dinámica uterina se ha propuesto la medición de la actividad mioeléctrica del útero en la superficie abdominal conocido como electrohisterografía (EHG). La literatura ha establecido que la señal de EHG puede proporcionar información fiable y objetiva sobre las contracciones. Por ello podremos objetivar mayor cantidad de parámetros de la dinámica y no solo la frecuencia que nos permitían los tocógrafos convencionales, es decir confirmar si realmente existe una mayor intensidad contráctil si se usa misoprostol en comparación con la dinoprostona. Pocos estudios se centran en la respuesta de la actividad mioeléctrica uterina a los fármacos de inducción del parto, por ello, sigue sin estar claro si los parámetros de la señal de EHG experimentan cambios a través de la inducción del trabajo de parto por parte de las prostaglandinas y si estos parámetros también podrían usarse para desarrollar herramientas para predecir la inducción exitosa en las primeras horas del proceso de inducción. Nuestra hipótesis se centra en el estudio del proceso de maduración cervical y la actividad contráctil uterina en respuesta a la administración de prostaglandinas. Por una parte, presentamos la hipótesis de que al realizar el análisis comparativo entre el misoprostol y la dinoprostona vía vaginal, ambos fármacos presentarían un perfil de eficacia y seguridad similar. Por otra, planteamos la hipótesis de que la dinoprostona y el misoprostol administrados en los embarazos en vías de prolongación, proporcionarían diferentes respuestas en términos de actividad uterina. Podremos evaluar la respuesta electrofisiológica, analizando los parámetros de EHG en las madres embarazadas tratadas con dinoprostona y misoprostol. Esto último con la intención de explorar la posibilidad de predecir el éxito de la inducción a partir de la respuesta electrofisiológica en las primeras horas de la maduración cervical. Nuestro objetivo fue comparar la respuesta de la actividad uterina a la administración de misoprostol (25 mcg) y dinoprostona (10 mg) para la maduración cervical en gestantes con cuellos uterinos desfavorables durante las primeras 4 h en respuesta a los medicamentos de inducción del parto. Además de evaluar la eficacia y seguridad materno-fetal asociada a la administración de cada uno de los fármacos. Un total de 500 pacientes fueron reclutados. Se definieron dos cohortes: misoprostol (comprimidos vaginales de 25 mcg; 251 mujeres) y dinoprostona (dispositivo vaginal de 10 mg; 249 mujeres). La cohorte de misoprostol se asoció con un tiempo más corto para alcanzar periodo activo de parto y parto vaginal y con un mayor porcentaje de parto vaginal en menos de 24 h en las madres con una puntuación cervical muy desfavorable (Índice de Bishop entre 0 y 3). Respecto al análisis con EHG, un conjunto de parámetros temporales, espectrales y de complejidad se calcularon a partir de las ráfagas de EHG. Al analizar las diferencias entre las mujeres que lograron la fase activa del parto y aquellas que no (inducciones exitosas y fallidas), en cuanto a las inducciones exitosas con misoprostol, se obtuvieron incrementos con respecto al período basal para la amplitud de EHG, frecuencia media, índice de actividad uterina (AUI) y Teager, después de 60 minutos de la administración del fármaco. En el caso de las inducciones exitosas con dinoprostona, la duración, amplitud, número de contracciones y AUI presentaron incrementos con respecto al período basal después de 120 minutos. Además, Teager mostró diferencias estadísticamente significativas y sostenidas entre inducciones exitosas y fallidas para el grupo de misoprostol, pero no en el de dinoprostona, probablemente debido a la farmacocinética más lenta de este medicamento. Estos resultados revelaron que EHG podría ser útil para la predicción exitosa de inducción en las primeras etapas de la inducción del parto, especialmente cuando se usa misoprostol. En conclusión, no hay diferencias entre misoprostol y dinoprostona respecto a su perfil de seguridad, que es favorable. El misoprostol vaginal acorta el tiempo hasta parto vaginal en 3 horas en comparación con la dinoprostona vaginal, además favorece el parto vaginal en menos de 24 horas en pacientes con condiciones cervicales muy desfavorables. Al comparar con EHG las inducciones exitosas de las fallidas, con el Misoprostol se distingue la evolución de los parámetros contráctiles a partir del minuto 60-90, mientras que la evolución de la dinoprostona es similar entre el éxito y el fracaso de inducción. Podría ser posible usar los parámetros de EHG para propósitos de predicción y sugieren que podrían proporcionar información valiosa sobre el estado mioeléctrico del útero durante la inducción del parto.Induction of labor and cervical ripening are topics of great interest within obstetrics, reaching 30% of all births. In addition, its inadequate indication leads to a considerable iatrogenia regarding the neonatal results, the increase in the cesarean rate and costs. Although we have many methods with proven effectiveness and safety, research into the optimal method for cervical ripening in unfavorable cervix is ongoing. Currently the prostaglandins Dinoprostone and Misoprostol are the ripening agents of first choice in our environment. Among the different studies published, there is heterogeneity in the dosages, for example, the optimal dose and time interval of vaginal misoprostol are not completely known. The use of doses in these studies is variable, there being few in which doses similar to those marketed in the market are compared, such as 25 mcg for misoprostol and 10 mg for dinoprostone. In studies that have seen a greater efficacy of misoprostol, the exact cause of it has not been justified, the most accepted being the production of greater uterine dynamics. External tocography is the most commonly used technique to determine uterine dynamics. This method does not provide very reliable information since it depends to a large extent on the subjective judgment of the examiner. As an alternative, for the control of uterine dynamics, the measurement of the myoelectric activity of the uterus on the abdominal surface known as electrohysterography (EHG) has been proposed. The literature has established that the EHG signal can provide reliable and objective information about contractions. Therefore, we can objectify more parameters of the dynamics and not only the frequency that conventional tohographs allowed, that is, confirm if there really is a greater contractile intensity if misoprostol is used in comparison with dinoprostone. Few studies focus on the response of uterine myoelectric activity to induction of labor drugs, therefore, it remains unclear if the parameters of the EHG signal undergo changes through the induction of labor with prostaglandins and whether these parameters could also be used to develop tools to predict successful induction in the early hours of the induction process. Our hypothesis focuses on the study of cervical maturation process and uterine contractile activity in response to the administration of prostaglandins. On the one hand, we present the hypothesis that when performing the comparative analysis between vaginal misoprostol and vaginal dinoprostone, both drugs would present a similar efficacy and safety profile. On the other hand, we hypothesized that dinoprostone and misoprostol administered during prolonged pregnancy would provide different responses in terms of uterine activity. We can evaluate the electrophysiological response, analyzing the parameters of EHG in pregnant mothers treated with dinoprostone and misoprostol. The latter with the intention of exploring the possibility of predicting the success of induction from the electrophysiological response in the first hours of cervical ripening. Our objective was to compare the response of uterine activity to the administration of misoprostol (25 mcg) and dinoprostone (10 mg) for cervical ripening in pregnant women with unfavorable cervix during the first 4 h in response to induction of labor. In addition to assess the maternal-fetal efficacy and safety associated with the administration of each of the drugs. A total of 500 patients were recruited. Two cohorts were defined: misoprostol (25 mcg vaginal tablets, 251 women) and dinoprostone (10 mg vaginal device, 249 women). The misoprostol cohort was associated with a shorter time to reach the active period of vaginal delivery and delivery and with a higher percentage of vaginal delivery in less than 24 h in mothers with a very unfavorable cervical score (Bishop Index between 0 and 3). Regarding the analysis with EHG, a set of temporal, spectral and complexity parameters were calculated from the EHG bursts. When analyzing the differences between women who achieved the active phase of delivery and those who did not (successful and failed inductions), in successful inductions with misoprostol, increases were obtained with respect to the baseline period for the EHG amplitude, mean frequency, uterine activity index (AUI) and Teager, after 60 minutes of drug administration. In the case of successful inductions with dinoprostone, the duration, amplitude, number of contractions and UAI showed increases with respect to the baseline period after 120 minutes. In addition, Teager showed statistically significant and sustained differences between successful and failed inductions for the misoprostol group, but not for dinoprostone, probably due to the slower pharmacokinetics of this medication. These results revealed that EHG could be useful for the successful prediction of induction in the early stages of induction of labor, especially when misoprostol is used. In conclusion, there is no difference between misoprostol and dinoprostone with respect to its safety profile, which is favorable. The vaginal misoprostol shortens the time to vaginal delivery in 3 hours compared to the vaginal dinoprostone, also favors vaginal delivery in less than 24 hours in patients with very unfavorable cervical conditions. When comparing successful inductions of failed ones with EHG, with the Misoprostol the evolution of the contractile parameters is distinguished from the 60-90 minute, while the evolution of dinoprostone is similar between success and failure of induction. It may be possible to use the EHG parameters for prediction purposes and suggest that they could provide valuable information about the myoelectric status of the uterus during induction of labor
New electrohysterogram-based estimators of intrauterine pressure signal, tonus and contraction peak for non-invasive labor monitoring
[EN] Background: Uterine activity monitoring is an essential part of managing the progress of pregnancy
and labor. Although intrauterine pressure (IUP) is the only reliable method of estimating uterine
mechanical activity, it is highly invasive. Since there is a direct relationship between the electrical and
mechanical activity of uterine cells, surface electrohysterography (EHG) has become a noninvasive
monitoring alternative. The Teager energy (TE) operator of the EHG signal has been used for IUP
continuous pressure estimation, although its accuracy could be improved. We aimed to develop new
optimized IUP estimation models for clinical application. Approach: We first considered enhancing
the optimal estimation of IUP clinical features (maximum pressure and tonus) rather than
optimizing the signal only (continuous pressure). An adaptive algorithm was also developed to deal
with inter-patient variability. For each optimizing signal feature (continuous pressure, maximum
pressure and tonus), individual (single patient), global (full database) and adaptive models were
built to estimate the recorded IUP signal. The results were evaluated by computing the root mean
square errors (RMSe): continuous pressure error (CPe), maximum pressure error (MPe) and
tonus error (TOe). Main results: The continuous pressure global model yielded IUP estimates with
Cpe = 14.61mm Hg, MPe = 29.17mm Hg and Toe = 7.8mm Hg. The adaptive models significantly
reduced errors to CPe = 11.88, MPe = 16.02 and Toe = 5.61mm Hg. The EHG-based IUP estimates
outperformed those from traditional tocographic recordings, which had significantly higher errors
(CPe = 21.93, MPe = 26.97, and TOe = 13.96). Significance: Our results show that adaptive models
yield better IUP estimates than the traditional approaches and provide the best balance of the
different errors computed for a better assessment of the labor progress and maternal and fetal wellbeing.This research project was supported by the Spanish Ministry of Economy and Competitiveness, the European Regional Development Fund (DPI2015-68397-R), and by the projects UPV_ FE-2018-C03 and GV/2018/104.Benalcazar-Parra, C.; Garcia-Casado, J.; Ye Lin, Y.; Alberola-Rubio, J.; López-Corral, A.; Perales Marin, AJ.; Prats-Boluda, G. (2019). New electrohysterogram-based estimators of intrauterine pressure signal, tonus and contraction peak for non-invasive labor monitoring. Physiological Measurement. 40(8):1-12. https://doi.org/10.1088/1361-6579/ab37dbS11240
Prediction of Labor Induction Success from the Uterine Electrohysterogram
[EN] Pharmacological agents are often used to induce labor. Failed inductions are associated with unnecessarily long waits and greater maternal-fetal risks, as well as higher costs. No reliable models are currently able to predict the induction outcome from common obstetric data (area under the ROC curve (AUC) between 0.6 and 0.7). The aim of this study was to design an early success-predictor system by extracting temporal, spectral, and complexity parameters from the uterine electromyogram (electrohysterogram (EHG)). Different types of feature sets were used to design and train artificial neural networks: Set_1: obstetrical features, Set_2: EHG features, and Set_3: EHG+obstetrical features. Predictor systems were built to classify three scenarios: (1) induced women who reached active phase of labor (APL) vs. women who did not achieve APL (non-APL), (2) APL and vaginal delivery vs. APL and cesarean section delivery, and (3) vaginal vs. cesarean delivery. For Scenario 3, we also proposed 2-step predictor systems consisting of the cascading predictor systems from Scenarios 1 and 2. EHG features outperformed traditional obstetrical features in all the scenarios. Little improvement was obtained by combining them (Set_3). The results show that the EHG can potentially be used to predict successful labor induction and outperforms the traditional obstetric features. Clinical use of this prediction system would help to improve maternal-fetal well-being and optimize hospital resources.This work received financial support from the Spanish Ministry of Economy and Competitiveness, the European Regional Development Fund (DPI2015-68397-R and RTI2018-094449-A-I00), Universitat Politècnica de València VLC/Campus (UPV-FE-2018-B02), Generalitat Valenciana (GV/2018/104), and Bial S.A.Benalcazar-Parra, C.; Ye Lin, Y.; Garcia-Casado, J.; Monfort-Ortiz, R.; Alberola Rubio, J.; Perales Marin, AJ.; Prats-Boluda, G. (2019). 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A comparison of various linear and non-linear signal processing techniques to separate uterine EMG records of term and pre-term delivery groups. Medical & Biological Engineering & Computing, 46(9), 911-922. doi:10.1007/s11517-008-0350-yTerrien, J., Marque, C., Gondry, J., Steingrimsdottir, T., & Karlsson, B. (2010). Uterine electromyogram database and processing function interface: An open standard analysis platform for electrohysterogram signals. Computers in Biology and Medicine, 40(2), 223-230. doi:10.1016/j.compbiomed.2009.11.019Hassan, M., Terrien, J., Marque, C., & Karlsson, B. (2011). Comparison between approximate entropy, correntropy and time reversibility: Application to uterine electromyogram signals. Medical Engineering & Physics, 33(8), 980-986. doi:10.1016/j.medengphy.2011.03.010Lemancewicz, A., Borowska, M., Kuć, P., Jasińska, E., Laudański, P., Laudański, T., & Oczeretko, E. (2016). 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Comparison of labour induction with misoprostol and dinoprostone and characterization of uterine response based on electrohysterogram
[EN] Objective: The objective of this study is to compare the uterine activity response between women administered dinoprostone (prostaglandin E2) and misoprostol (prostaglandin E1) for induction of labour (IOL) by analysing not only the traditional obstetric data but also the parameters extracted from uterine electrohysterogram (EHG).
Methods: Two cohorts were defined: misoprostol (25-mg vaginal tablets; 251 women) and dinoprostone cohort (10 mg vaginal inserts; 249 women). All the mothers were induced by a medical indication of a Bishop Score < ¿ 6.
Results: The misoprostol cohort was associated with a shorter time to achieve active labour (p ¿ .017) and vaginal delivery (p ¿ .009) and with a higher percentage of vaginal delivery in less than 24 h in mothers with a very unfavourable cervix score (risk ratio (RR): 1.41, IC95% 1.17¿1.69, p ¿ .002). Successful inductions with misoprostol showed EHG parameter values significantly higher than basal state for amplitude and pseudo Montevideo units (PMU) 60¿ after drug administration, while spectral parameters significantly increased after 150¿. This response was not observed in failed inductions. In the successful dinoprostone group, the duration and number of contractions increased significantly after 120¿, PMU did so after 180¿, and no significant differences were found for spectral parameters, possibly due to the slower pharmacokinetics of this drug.
Conclusion: Successful inductions of labour by misoprostol are associated with earlier effective contractions than in labours induced by dinoprostone.This work was partially supported by the Spanish Ministry of Economy and Competitiveness and the European Regional Development Fund under grant [DPI2015-68397-R] and by the company Bial SA.Benalcazar-Parra, C.; Monfort-Orti, R.; Ye Lin, Y.; Prats-Boluda, G.; Alberola Rubio, J.; Perales Marín, AJ.; Garcia-Casado, J. (2019). Comparison of labour induction with misoprostol and dinoprostone and characterization of uterine response based on electrohysterogram. The Journal of Maternal-Fetal & Neonatal Medicine. 32(10):1586-1594. https://doi.org/10.1080/14767058.2017.1410791S15861594321
Electrohysterography in the diagnosis of preterm birth: a review
This is an author-created, un-copyedited versíon of an article published in Physiological Measurement. IOP Publishing Ltd is not responsíble for any errors or omissíons in this versíon of the manuscript or any versíon derived from it. The Versíon of Record is available online at http://doi.org/10.1088/1361-6579/aaad56.[EN] Preterm birth (PTB) is one of the most common and serious complications in pregnancy. About 15 million preterm neonates are born every year, with ratios of 10-15% of total births. In industrialized countries, preterm delivery is responsible for 70% of mortality and 75% of morbidity in the neonatal period. Diagnostic means for its timely risk assessment are lacking and the underlying physiological mechanisms are unclear. Surface recording of the uterine myoelectrical activity (electrohysterogram, EHG) has emerged as a better uterine dynamics monitoring technique than traditional surface pressure recordings and provides information on the condition of uterine muscle in different obstetrical scenarios with emphasis on predicting preterm deliveries. Objective: A comprehensive review of the literature was performed on studies related to the use of the electrohysterogram in the PTB context. Approach: This review presents and discusses the results according to the different types of parameter (temporal and spectral, non-linear and bivariate) used for EHG characterization. Main results: Electrohysterogram analysis reveals that the uterine electrophysiological changes that precede spontaneous preterm labor are associated with contractions of more intensity, higher frequency content, faster and more organized propagated activity and stronger coupling of different uterine areas. Temporal, spectral, non-linear and bivariate EHG analyses therefore provide useful and complementary information. Classificatory techniques of different types and varying complexity have been developed to diagnose PTB. The information derived from these different types of EHG parameters, either individually or in combination, is able to provide more accurate predictions of PTB than current clinical methods. However, in order to extend EHG to clinical applications, the recording set-up should be simplified, be less intrusive and more robust-and signal analysis should be automated without requiring much supervision and yield physiologically interpretable results. Significance: This review provides a general background to PTB and describes how EHG can be used to better understand its underlying physiological mechanisms and improve its prediction. The findings will help future research workers to decide the most appropriate EHG features to be used in their analyses and facilitate future clinical EHG applications in order to improve PTB prediction.This work was supported by the Spanish Ministry of Economy and Competitiveness and the European Regional Development Fund under grant DPI2015-68397-R.Garcia-Casado, J.; Ye Lin, Y.; Prats-Boluda, G.; Mas-Cabo, J.; Alberola Rubio, J.; Perales Marin, AJ. (2018). Electrohysterography in the diagnosis of preterm birth: a review. Physiological Measurement. 39(2). https://doi.org/10.1088/1361-6579/aaad56S39
Diseño y desarrollo de un sistema predictor del éxito de inducción de parto en base a registros electrohisterográficos
[ES] La inducción del parto es una práctica habitual en obstetricia que asciende al 20% de todos los
nacimientos y se indica cuando los beneficios de finalizar la gestación para la salud de la madre y del
feto son mayores que los de permitir que el embarazo continúe. Sin embargo, la inducción se asocia
con un aumento de complicaciones en comparación con el trabajo de parto de inicio espontáneo.
Uno de los aspectos claves en el inicio y gestión de la inducción del parto es que hay una gran
incertidumbre en la predicción de su éxito o si se requerirá una cesárea. La disposición de una
herramienta que permita predecir el éxito de inducción permitirá a los obstetras diseñar una
estrategia de gestión personalizada para cada paciente.
En la literatura se ha demostrado que las condiciones cervicales antes de la administración del
fármaco, las características de la madre y del feto son factores que influyen sobre el éxito de
inducción. Sin embargo, no se dispone de un modelo matemático fiable para predecir el éxito de
inducción. En este sentido, conocer el estado electrofisiológico del útero y su grado de “madurez”-
excitabilidad y propagabilidad de las células musculares uterinas-es clave para predecir la respuesta a
los fármacos empleados en la inducción. El registro de la actividad eléctrica uterina en superficie
(electrohisterograma, EHG) ha demostrado ser uno de los marcadores biofísicos prometedores no
sólo de la dinámica uterina sino también del estado electrofisiológico del útero. Por tanto, el objetivo
de este trabajo es el diseño y desarrollo de un sistema predictor del éxito de inducción del parto en
base a los registros de EHG y datos obstétricos.
Para ello, se ha utilizado 94 registros de EHG adquiridos en mujeres inducidas con misoprostol o
dinoprostona, siendo estos dos los fármacos comúnmente empleado para la inducción del parto.
Cada sesión de registro implica la adquisición de 30 minutos antes de la administración del fármaco y
las primeras 4 horas después de la misma. Se han calculado un total de 23 de parámetros
temporales, espectrales y no lineales para la caracterización de los EHG-bursts (actividad mioeléctrica
asociada a las contracciones uterinas) presentes en bloques de cada 30 minutos. El análisis de la
evolución temporal durante las primeras 4 horas indica que las características de EHG cambian
significativamente respecto a la actividad basal a partir del minuto 120 independientemente del
fármaco empleado para la inducción. En base a estos resultados, se ha utilizado las características de
EHG de la actividad basal (antes de la administración del fármaco), minuto 120, 150 y 180 y 210 para
el diseño del sistema predictor del éxito de inducción. Para ello, se ha utilizado el algoritmo
optimización por enjambre de partículas (PSO) para la selección de las características relevantes, la
técnica de ADASYN para solventar el problema de desbalanceo del tamaño muestral del grupo éxito y
fracaso de inducción, y las técnicas de redes neuronales para desarrollar el sistema predictor del
éxito de inducción. El clasificador diseñado presenta una exactitud del 84 y 76% para la predicción
del éxito de inducción desde el punto de vista farmacológico (si alcanza el periodo activo de parto o
no) y clínica (parto vaginal o cesárea). Para mejora la precisión de este último se ha propuesto un
clasificador anillado que permite predecir en una primera fase si una mujer alcanzará el periodo
activo de parto o no, y discriminar los partos vaginales de los partos por cesárea en una segunda fase
para aquellas mujeres que alcanzan el periodo activo de parto. Los resultados experimentales
muestran que el clasificador anillado permite obtener una exactitud del 93% para distinguir los
partos vaginales de los partos por cesárea. Estos resultados sugieren que el EHG podría ser utilizado
iii
para el diseño de sistema predictor del éxito de inducción, constituyéndose así una herramienta de
gran ayuda para la toma de decisión de los obstetras en la inducción del parto.[CA] La inducció del part és una pràctica habitual en obstetrícia que ascendeix al 20% de tots els
naixements i s'indica quan els beneficis de finalitzar la gestació per a la salut de la mare i del fetus
són majors que els de permetre que l'embaràs continue. No obstant això, la inducció s'associa amb
un augment de complicacions en comparació del treball de part d'inici espontani. Un dels aspectes
claus en l'inici i gestió de la inducció del part és que hi ha una gran incertesa en la predicció del seu
èxit o si es requerirà una cesària. La disposició d'una eina que permeta predir l'èxit d'inducció
permetrà als obstetres dissenyar una estratègia de gestió personalitzada per a cada pacient.
En la literatura s'ha demostrat que les condicions cervicals abans de l'administració del fàrmac i les
característiques de la mare i del fetus són factors que influeixen sobre l'èxit d'inducció. No obstant
això, no es disposa d'un model matemàtic fiable per a predir l'èxit d'inducció. En aquest sentit,
conèixer l'estat electrofisiològic de l'úter i el seu grau de maduresa -excitabilitat i propagabilitat de
les cèl·lules musculars uterines- és clau per a predir la resposta als fàrmacs emprats en la inducció. El
registre de l'activitat elèctrica uterina en superfície (electrohisterograma, EHG) ha demostrat ser un
dels marcadors biofísics prometedors no solament de la dinàmica uterina sinó també de l'estat
electrofisiològic de l'úter. Per tant, l'objectiu d'aquest treball és el disseny i desenvolupament d'un
sistema predictor de l'èxit d'inducció del part sobre la base dels registres d'EHG i dades obstètrics.
Per a això, s'ha utilitzat 94 registres d'EHG adquirits en dones induïdes amb misoprostol o
dinoprostona, sent aquests dos els fàrmacs comunment emprat per a la inducció del part. Cada
sessió de registre implica l'adquisició de 30 minuts abans de l'administració del fàrmac i de les
primeres 4 hores després de la mateixa. S'han calculat un total de 23 paràmetres temporals,
espectrals i no lineals per a la caracterització dels EHG-burst (activitat mioeléctrica associada a les
contraccions uterines) presents en blocs de 30 minuts. L'anàlisi de l'evolució temporal durant les
primeres 4 hores indica que les característiques d'EHG canvien significativament respecte a l'activitat
basal a partir del minut 120 independentment del fàrmac emprat per a la inducció. Sobre la base
d'aquests resultats, s'ha utilitzat les característiques d'EHG de l'activitat basal (abans de
l'administració del fàrmac), minut 120, 150, 180 i 210 per al disseny del sistema predictor de l'èxit
d'inducció. Per a açò, s'ha utilitzat l'algoritme d'optimització per eixam de partícules (PSO) per a la
selecció de les característiques rellevants, la tècnica d'ADASYN per a solucionar el problema del
desbalanceig del grups d'èxit i de fracàs d'inducció, i xarxes neuronals per a desenvolupar el sistema
predictor de l'èxit d'inducció. El classificador dissenyat presenta una exactitud del 84 i 76% per a la
predicció de l'èxit d'inducció des del punt de vista farmacològic (si arriba al període actiu de part o
no) i clínica (part vaginal o cesària). Per a millora la precisió d'aquest últim s'ha proposat un
classificador anellat que permet predir en una primera fase si una dona arribarà el període actiu de
part o no, i discriminar els parts vaginals dels parts per cesària en una segona fase per a aquelles
dones que arriben el període actiu de part. Els resultats experimentals mostren que el classificador
anellat permet obtenir una exactitud del 93% per a distingir els parts vaginals dels parts per cesària.
Aquests resultats suggereixen que l'EHG podria ser utilitzat per al disseny de sistema predictor de
l'èxit d'inducció, constituint-se així una eina de gran ajuda per a la presa de decisió dels obstetres en
la inducció del part.[EN] Labor induction is a common practice in obstetrics that raises to the 20% of the births and that is
indicated when further benefits from finalizing gestation for both the mother and the fetus are
obtained rather than letting the pregnancy continue. However, labor induction is associated with
more complications in comparison with spontaneous labor. One of the key point in the labor
induction’s beginning and ending is that there is a great uncertainty about if it will succeed or if a csection
will be required. The providing of a tool that enables physician to predict the induction
success will let them design a tailored asset management strategy.
It has been proved in literature that cervix state before the drug administration and the mother’s and
fetus characteristics are factor that impacts on the induction success. Nevertheless, we lack from a
reliable mathematical model that predicts it. In this sense, knowing the electrophysiological state of
the uterus and it’s “maturity” -the muscular uterine cells excitability and propagability grade- is a key
point for predicting labor induction drugs response. The uterine electric activity register on the
surface (electrohysterogram, EHG) has been proved to be one of the most promising biomarkers not
just of the uterine dynamics but also electrophysiologic uterus state. Therefore, the goal of this paper
is the design and development of a labor induction prediction system based on EHG registers and
obstetrics data.
For this purpose, 94 EHG registers have been used which have been obtained from women who have
been induced with misoprostol or dinoprostone, the two most common used labor induction drugs.
Each recording session has taken 30 minutes before drug administration and the first 4 hours after it.
23 temporal, spectral and non-lineal parameters have been calculated for EHG-burst characterization
-myoelectric activity associated with uterine contractions- located in 30 minutes signal blocks. The
temporal evolution analysis during the first 4 hours indicates that EHG characteristics suffers a
significant change after 120 minutes regarding basal activity independently of the drug used. Based
on these results, EHG parameters used have been calculated from basal activity -before drug
administration-, and the activity after 120, 150, 180 and 210 minutes for the labor induction
predictive system design. For this purpose, Particle Swarm Optimization has been used for selecting
the most relevant characteristics, ADASYN has been used for balancing both success and failure
inductions classes and artificial neural network have been used for developing the labor induction
predictor. The designed classifier achieves an 84 and 76% for labor success prediction from the
pharmacological (whether if the patient reaches the active labor period) and clinical (whether if labor
is vaginal or c-section) point of view. For improving the latter precision, a nested classifier has been
developed that predicts at first whether if a woman will achieve the active labor period or not and in
a second phase whether if the women (those who had reached the active labor period) delivery will
be a vaginal one or if a c-section will be needed. Experimental results show that the nested classifier
gives us a 93% accuracy in distinguishing between vaginal delivery and c-section delivery. These
results suggest that EHG could be used for the design of a labor induction success predictor,
constituting a helpful tool for clinician’s decision-making in labor induction.Felipe Machancoses, AD. (2018). Diseño y desarrollo de un sistema predictor del éxito de inducción de parto en base a registros electrohisterográficos. http://hdl.handle.net/10251/10661