Pregnancy outcomes of normal versus abnormal cardiotocography in a tertiary centre in Nepal

Background: Pregnancy and childbirth is normal physiological process with great pathological potential. The obstetricians are more concerned with the early recognition of fetal distress during labour and such an adverse outcome should be detected at the earliest point of time by an effective surveillance method. Cardiotocography as a part of biophysical profile has become an established diagnostic tool for fetal surveillance. To compare early perinatal outcome of normal and abnormal cardiotocography in terms of APGAR scores, need for neonatal resuscitation, NICU admission, perinatal death and mode of delivery.Methods: It was a cross-sectional study. 200 nulliparous/multiparous women with singleton pregnancy in cephalic presentation at gestational age 37-42 weeks in latent stage of labor were enrolled in the study and subjected to admission test in left lateral position using fetal monitor. Baseline FHR and contraction pattern were determined for 20 minutes and classification of patients was done into normal, and suspicious or abnormal according to the FIGO guidelines 2015.Results: Low APGAR scores, rate of LSCS, need for neonatal resuscitation, neonatal admission were more in the abnormal cardiotocography group. Cardiotocography in the current study has high sensitivity and high negative predictive value for detecting fetal distress.Conclusions: From the analysis of this study, it would be safe to conclude that an ominous cardiotocography should be managed appropriately without delay and obstetrician should be vigilant in suspicious as well as in normal admission test group for timely intervention for bettering the neonatal outcome

Extraction of digital cardiotocographic signals from digital cardiotocographic images: Robustness of eCTG procedure

none6noA recently developed software application, eCTG, extracts cardiotocographic (CTG) signals from digital CTG images, possibly obtained by scanning paper CTG reports. The aim of this study was to evaluate eCTG robustness across varying image formats, resolution and screw. Using 552 digital CTG signals from the “CTU-UHB Intrapartum Cardiotocography Database” of Physionet, seven sets of digital CTG images were created, differing in format (.TIFF, .PNG and .JPEG), resolution(96 dpi, 300 dpi and 600 dpi) and screw (0.0◦, 0.5◦, and 1.0◦). All created images were submitted to eCTG for CTG signals extraction. Quality of extracted signals was statistically evaluated based 1) on signal morphology, by computation of the correlation coefficient (ρ) and of the mean signal error percent (MSE%), and 2) on signal clinical content, by assessment of 18 standard CTG variables.For all sets of images, ρ was high (ρ ≥ 0.81) and MSE% was small (MSE% ≤ 2%). However, significant changes occurred in median values of four, four and five standard CTG variables in image sets with 96 dpi resolution, 0.5◦ screw and 1.0◦ screw, respectively. In conclusion, for an optimal eCTG performance, digital images should be saved in lossless formats, have a resolution of at least 300 dpi and not be affected by screw.openSbrollini A.; Brini L.; Di Tillo M.; Marcantoni I.; Morettini M.; Burattini L.Sbrollini, A.; Brini, L.; Di Tillo, M.; Marcantoni, I.; Morettini, M.; Burattini, L

Short term fetal heart rate variation in intrauterine growth restriction

Cardiotocography (CTG), the continuous and simultaneous recording of the fetal heart rate (FHR) and the maternal contractions, is a method widely used for the assessment of fetal well-being, predominantly in pregnancies with increased risk of complications. The Oxford system, developed by Dawes and Redman and implemented in the Sonicaid Fetalcare monitor, provides a computerised analysis of the CTG (cCTG) by taking into consideration a number of numerical, computer based parameters, with Short Term Variation (STV), a measure of the micro fluctuations of the FHR, being one of the most significant ones, especially in the monitoring of fetuses with Intrauterine Growth Restriction (IUGR). The Dawes-Redman algorithm calculates the STV by dividing each minute into 16 segments, each one being 3,75 seconds long and including 7-10 fetal heartbeats, or 6-9 pulse intervals (STV16). The average pulse interval in each section is calculated and the STV16 derives from the difference of the average pulse intervals between two sections. This calculated STV16 does not, however, equal the beat-to-beat variation of the FHR. A series of important studies has demonstrated that, when monitoring fetuses with preterm IUGR, STV16 values under 3ms correlate positively with the development of metabolic acidemia and should prompt to delivery. Theoretically, measurement of the pulse interval in much smaller time fractions, so that every heartbeat would be taken into consideration (instead of one every 7-10 heartbeats), would lead to a more accurate approximation of the beat-to-beat variation with significant advantages for the antenatal monitoring of the fetus. The IntelliSpace Perinatal by Philips Medical, which measures the STV by dividing each minute into 240 segments (STV240), attempts to better approximate the beat-to-beat variation of the FHR. An effort in our department to implement the existing cut-off values of the STV16 as reference values for the new STV240 algorithm has resulted in highly abnormal findings, with STV240 values significantly below the cut-off values of the STV16. This observation led to the hypothesis, that the reference values for the STV240 should be different, and, more precisely, lower in comparison to the existing reference values for the STV16. This hypothesis was not only based on clinical observation. The discrepancy noted between the two different algorithms is also logically sound, as it is to be expected that the variation between two subsequent beats will be notably lower as the variation between 7-10 subsequent heartbeats. We therefore conducted a single-center, non-interventional, prospective clinical study in order to develop clinically relevant reference values for the STV240 and to compare the reference values for the STV240 to the ones for the STV16. At the same time, we studied the effects of RDS prophylaxis on STV240 and STV16, in order to verify if the known transient effects of corticosteroids on the STV could also be detected with the new algorithm for the STV240. A total of 228 CTG traces from 94 patients (86 singleton and 8 twin pregnancies) were registered and included in the final statistical analysis for the development of the reference values. The values of the STV240 were significantly lower in comparison to the ones of the STV16. Moreover, not only the mean values but 95% of the values for the STV240 lay beneath the existent cut-off value for the STV16. The STV240 has a relative strong, statistically significant correlation with the STV16 (r=0,646, p<0,001). A medium, although statistically significant correlation (r=0,373, p<0,001) between week of pregnancy and STV240 was documented, whereas the correlation between STV16 and week of pregnancy was negligible. A transient increase of both the STV240 and STV16 was documented in the first 24h after the first intramuscular corticosteroid administration, when compared to the STV240 and STV16 without RDS prophylaxis or at least 72h after. This was followed by a transient decrease of both the STV240 and STV16 between 24h and 72h after the first intramuscular corticosteroid injection. Our results confirmed our hypothesis and allowed us to calculate the reference values for the STV240. Of paramount importance for every clinician using the new algorithm in her or his everyday practice, is to know that the normal values for the STV240 (not only the mean value but also the 95th percentile) lie beneath the, up until now, established cut-off value for the STV16. This stresses the fact that every clinician using cCTG should be, in advance, well aware of the algorithm implemented in his cCTG monitors. Otherwise, there is the threat of unnecessary iatrogenic premature deliveries, with all relevant risks.Cardiotocographie (CTG), die kontinuierliche und gleichzeitige Aufzeichnung der fetalen Herzfrequenz (FHF) und der mütterlichen Kontraktionen, ist eine Methode, die weithin für die Beurteilung des fetalen Wohlbefindens verwendet wird, vorwiegend bei Schwangerschaften mit erhöhtem Komplikationsrisiko. Das von Dawes und Redman entwickelte Oxford-System, welches im Sonicaid Fetalcare Monitor implementiert ist, bietet eine computerisierte Analyse des CTG (cCTG) unter Berücksichtigung einer Reihe von numerischen, computerbasierten Parametern an. Kurzzeitvariation (KZV), eine Maßnahme der Mikrofluktuationen des FHF, ist einer der bedeutendsten computerbasierten Parameter, vor allem bei der Überwachung von Feten mit intrauteriner Wachstumsrestriktion (IUGR). Der Dawes-Redman-Algorithmus berechnet die KZV, indem er jede Minute in 16 Segmente unterteilt, wobei jedes 3,75 Sekunden lang ist und 7-10 fetale Herzschläge oder 6-9 Pulsintervalle (KZV16) enthält. Das mittlere Pulsintervall in jedem Abschnitt wird berechnet und die KZV16 ergibt sich aus der Differenz der mittleren Pulsintervalle zwischen zwei Abschnitten. Diese berechnete KZV16 entspricht jedoch nicht der beat-to-beat-Variation der FHF. Eine Reihe wichtiger Studien hat gezeigt, dass bei der Überwachung von Feten mit früher IUGR KZV-Werte unter 3ms positiv mit der Entwicklung einer metabolischen Azidämie korrelieren und zur Entbindung führen sollten. Theoretisch würde die Messung des Pulsintervalls in viel kleineren Zeitabschnitten, so dass jeder Herzschlag berücksichtigt wäre (statt eines alle 7-10 Herzschläge), zu einer genaueren Annäherung der beat-to-beat-Variation der FHF führen, mit deutlichen Vorteilen für die antepartale Überwachung des Fetus. Das IntelliSpace Perinatal von Philips Medical, das die KZV auswertet, indem es jede Minute in 240 Segmente teilt (KZV240), versucht die beat-to-beat Variation der FHF besser anzunähern. Ein Versuch, in unserer Abteilung, die vorhandenen cut-off-Werte der KZV16 als Referenzwerte für den neuen KZV240-Algorithmus zu implementieren, hat zu sehr auffälligen Befunden geführt, wobei die KZV240-Werte deutlich unter den cut-off- Werten der KZV16 lagen. Diese Beobachtung führte zu der Hypothese, dass die Referenzwerte für die KZV240 im Vergleich zu den vorhandenen Referenzwerten für die KZV16 niedriger sein sollten. Diese Hypothese beruht nicht nur auf der klinischen Beobachtung. Die zwischen den beiden verschiedenen Algorithmen bemerkte Diskrepanz ist auch theoretisch zu erwarten, weil die Variation zwischen zwei nachfolgenden Herzschlägen deutlich geringer als die Variation zwischen 7-10 nachfolgenden Herzschlägen ist. Wir haben daher in unserer Klinik eine nicht interventionelle, prospektive klinische Studie durchgeführt, um klinisch relevante Referenzwerte für die KZV240 zu entwickeln und diese mit denen für die KZV16 zu vergleichen. Gleichzeitig haben wir die Effekte der RDS-Prophylaxe auf KZV240 und KZV16 untersucht, um zu prüfen, ob die bekannten transienten Effekte von Kortikosteroiden auf der KZV auch mit dem neuen Algorithmus für die KZV240 nachgewiesen werden können. Insgesamt wurden 228 CTGs von 94 Patientinnen (86 Einlings- und 8 Zwillings- Schwangerschaften) registriert und in die endgültige statistische Analyse zur Entwicklung der Referenzwerte einbezogen. Die Werte der KZV240 waren im Vergleich zu der KZV16 deutlich niedriger. Darüber hinaus lagen nicht nur die Mittelwerte, sondern 95% der Werte für die KZV240 unter dem vorhandenen cut-off-Wert für die KZV16. Die KZV240 hat eine relativ starke, statistisch signifikante Korrelation mit der KZV16 (r = 0,646, p <0,001). Eine mittlere, obwohl statistisch signifikante Korrelation (r = 0,373, p <0,001) zwischen Schwangerschaftswoche (SSW) und KZV240 wurde dokumentiert, während die Korrelation zwischen KZV16 und SSW vernachlässig war. In den ersten 24h nach der ersten intramuskulären Kortikosteroidgabe wurde eine vorübergehende Zunahme sowohl der KZV240 als auch der KZV16 dokumentiert, im Vergleich zu den KZV240 und KZV16 ohne RDS-Prophylaxe oder mindestens 72h danach. Darauf folgte eine vorübergehende Abnahme sowohl der KZV240 als auch der KZV16 zwischen 24h und 72h nach der ersten intramuskulären Kortikosteroidgabe. Unsere Ergebnisse bestätigten unsere Hypothese und erlaubten uns, die Referenzwerte für die KZV240 zu berechnen. Es ist extrem wichtig für jeden Arzt, der den neuen Algorithmus in seiner alltäglichen Praxis verwendet, zu wissen, dass die Normalwerte für die KZV240 (nicht nur der Mittelwert, sondern auch die 95. Perzentile) unterhalb der bislang etablierten cut-off-Werte für die KZV16 liegen. Dies unterstreicht die Tatsache, dass bei der Interpretation der KZV des cCTGs der verwendete Algorithmus berücksichtigt werden sollte. Ansonsten besteht die Gefahr von unnötigen, iatrogenen, vorzeitigen Entbindungen mit allen damit verbundenen Risiken

Intrapartum cardiotocography patterns observed in suspected clinical and subclinical chorioamnionitis in term fetuses.

AIM: To evaluate the cardiotocography (CTG) features observed in suspected intrapartum chorioamnionitis in term fetuses according to the recently suggested criteria for the pathophysiological interpretation of the fetal heart rate and their correlation with perinatal outcomes. METHODS: Retrospective analysis of nonconsecutive CTG traces. 'CTG chorioamnionitis' was diagnosed either based on a persistent rise in the baseline for the given gestation or on a persistent increase in the baseline fetal heart rate during labor >10% without preceding CTG signs of hypoxia and in the absence of maternal pyrexia. Perinatal outcomes were compared among cases with no sign of chorioamnionitis, in those with only CTG features suspicious for chorioamnionitis and in those who developed clinical chorioamnionitis. RESULTS: Two thousand one hundred and five CTG traces were analyzed. Of these, 356 fulfilled the criteria for "CTG chorioamnionitis". Higher rates of Apgar <7 at 1 and 5 min (21.6% vs 9.0% and 9.8% vs 2.0%, respectively, P < 0.01 for both) and lower umbilical artery pH (7.14 ± 0.11 vs 7.19 ± 0.11, P < 0.01) and an over fivefold higher rate of neonatal intensive care unit admission (16.6% vs 2.9%, P < 0.01) were noted in the 'CTG chorioamnionitis' group. Differences in the incidence of abnormal CTG patterns were noted between cases who eventually had clinical evidence of chorioamnionitis (89/356) and those showing CTG features suspicious for chorioamnionitis in the absence of clinical evidence of chorioamnionitis (267/356). CONCLUSION: Intrapartum CTG features of suspected chorioamnionitis are associated with adverse perinatal outcomes

Comparison of Computerized Cardiotocography Parameters between Male and Female Fetuses

Fetal sex has been identified as an important factor influencing pregnancy outcomes, but its impact on fetal heart rate (FHR) variability in uncomplicated pregnancies is still unclear. The objective of the study was to assess short-term variability (STV) and other computerized cardiotocography (cCTG) parameters in relation to fetal sex during fetal antepartum surveillance. We retrospective compared cCTG parameters of male and female fetuses in uncomplicated singleton pregnancies at term. In addition to univariate analysis, a multivariate analysis was performed taking into account maternal characteristics. A total of 689 cCTG recordings were analyzed: 335 from male fetuses and 354 from female fetuses. Analysis of cCTG results by fetal sex showed no significant difference in percentage of signal loss, number of contractions, movements, accelerations and decelerations, long-term variability (LTV), and STV at both uni-and multivariate analysis. There was a statistically significant difference for baseline FHR at the univariate analysis, which was not confirmed by a multivariate analysis. Our results suggest that fetal sex did not affect cCTG parameters in uncomplicated term singleton pregnancies, and therefore it does not need to be taken into account when interpreting cCTG in physiological conditions

Admission test cardiotocography in labour as a predictor of foetal outcome in high risk pregnancies

Background: Continuous fetal heart monitoring in all pregnant women in labour has gained prominence in obstetric practice in the recent years. The aim of this study was to emphasize on the role of admission cardiotocography (CTG) in labour as a predictor of foetal outcome in high risk pregnancies.Methods: This was a prospective observational study done on 340 high risk patients admitted in labour with a period of gestation of ≥37 weeks. An admission CTG which consists of a 20-minute recording of FHR and uterine contractions was taken and the foetal outcome was correlated with it. The non-parametric Chi-square test was used for statistical calculations and a p valve of <0.05 was considered to designate statistical significance.Results: The admission CTG was reactive in 69.4% of all patients, equivocal in 22.2% and pathological in 8.4% of the 340 recruited patients. A total of 37.5% of the patients were post-dated followed by 20.6% of pregnancy incuded hypertensive patients. The neonatal outcomes in terms of fetal distress, meconium stained liquor, NICU admission were considerably higher in pathological test. The specificity of the test was 53.3%, and the negative predictive was    86.49%.Conclusions: Admission CTG is a simple, useful screening test and serves as a non-invasive tool in forecasting the adverse foetal outcomes in high risk pregnancies

Agreement and accuracy using the FIGO, ACOG and NICE cardiotocography interpretation guidelines.

INTRODUCTION: One of the limitations reported with cardiotocography (CTG) is the modest interobserver agreement observed in tracing interpretation. This study compared agreement, reliability and accuracy of CTG interpretation using the FIGO, ACOG and NICE guidelines. MATERIAL AND METHODS: A total of 151 tracings was evaluated by 27 clinicians from three centers where FIGO, ACOG and NICE guidelines were routinely used. Interobserver agreement was evaluated using the proportions of agreement (PA) and reliability with the kappa (k) statistic. The accuracy of tracings classified as "pathological/category III" was assessed for prediction of newborn acidemia. For all measures, 95% confidence intervals (95%CI) were calculated RESULTS: CTG classifications were more distributed with FIGO (9%, 52%, 39%) and NICE (30%, 33%, 37%) than with ACOG (13%, 81%, 6%). The category with the highest agreement was ACOG category II (PA=0.73 95%CI 0.70-76), and the ones with the lowest agreement were ACOG categories I and III. Reliability was significantly higher with FIGO (k=0.37, 95%CI 0.31-0.43), and NICE (k=0.33, 95%CI 0.28-0.39) than with ACOG (k= 0.15, 95%CI 0.10-0.21), however all represent only slight/fair reliability. FIGO and NICE showed a trend towards higher sensitivities in prediction of newborn acidemia (89% and 97% respectively) than ACOG (32%,), but the latter achieved a significantly higher specificity (95%) CONCLUSIONS: With ACOG guidelines there is high agreement in category II, low reliability, low sensitivity and high specificity in prediction of acidemia. With FIGO and NICE guidelines there is higher reliability, a trend towards higher sensitivity, and lower specificity in prediction of acidemia. This article is protected by copyright. All rights reserved

Role of cardiotocography in high risk pregnancy and its correlation with increase cesarean section rate

Background: FHR monitoring plays the most important role in management of labouring patient when incidence of fetal hypoxia and progressive asphyxia increases. Now a day’s cardiotocography (CTG) become a popular method for monitoring of fetal wellbeing and it is assisting the obstetrician in making the decision on the mode of delivery to improve perinatal outcome. The aim of the study was to assess the effect of cardiotocography on perinatal outcome and its correlation with caesarean section rate.Methods: In this prospective observational study 201 gravid women with high risk pregnancy in first stage of labour were taken. Result was assessed in the form of Apgar score at five minute, NICU admission, perinatal mortality and mode of delivery. Statistical analysis is done by using Chi square test and p&lt;0.05 is considered as statistically significant.Results: Perinatal morbidity in the form of NICU admission is higher in nonreactive group as compare to reactive group (75.7% v/s 22.8%). Cesarean section rate for fetal distress were higher in nonreactive group (87.8%) in comparison to reactive group (20.5%). So this study suggest that there is significant difference in mode of delivery with increasing chances of caesarean section in cases belong to non-reactive traces (p&lt;0.001).Conclusions: Admission test is non-invasive and the best screening test to evaluate the fetal health and to predict the perinatal outcome but it also associated with increase caesarean section rate

Different aspects of electronic fetal monitoring during labor

Background: Cardiotocography (CTG) is a tool to assess fetal well-being during labor and to detect early signs of fetal distress and thereby enable timely interventions to reduce neonatal morbidity and mortality. CTG is associated with shortcomings; poor reliability in interpretation, low specificity with a high proportion of false positive tracings indicating fetal distress when not accurate, no proven effect on rare severe outcomes such as mortality and cerebral palsy, but rather contributing to an increased risk of operative delivery. The aims of this thesis was to determine I) if an extended CTG education could lead to better reliability in interpretation compared to a national standard education, II) if a computerized algorithm could be developed with precision in detecting and quantitating decelerations on CTG, III) if deceleration area was a better predictor of fetal acidemia during labor than deceleration depth and duration, IV) the proportion of fetuses with undetected small for gestational age (SGA) in a low-risk population, comparing women that present with normal CTG at admission to labor (admCTG) to those with abnormal admCTG and to compare neonatal outcomes in the two groups stratified on SGA or non-SGA. Material and methods: The CTG tracings used in paper I-III were extracted from a previous cohort of women in labor, from Karolinska University Hospital, Sweden. All women had undergone fetal blood sampling (FBS) during labor due to suspicious CTG patterns. Six obstetricians from two different hospitals were used as observers in paper I. Inter- and intra-observer reliability using Cohen’s and Fleiss kappa was determined for different parameters assessed on CTG. In paper II two obstetricians visually analyzed CTG tracings with variable decelerations and specified duration, depth and area for each deceleration. The computerized algorithm analyzed and quantified the same CTG traces and was compared to the observers using intra-class correlation and Bland-Altman analysis. In paper III the predictive value of deceleration area, duration, and depth for fetal acidemia, measured as lactate concentration at FBS, was explored using receiver operating characteristics, area under curve (ROC AUC). In paper IV, a register-based study, the risk of SGA in relation to the result of admCTG, normal vs abnormal was assessed in low-risk pregnancies. Neonatal outcomes were also determined by multiple logistic regression analysis. Results: I) The inter- and intra-observer reliability was moderate to excellent at both departments, kappa 0.41-0.93. The department with extended education reached significantly higher interobserver agreement for two of six CTG parameters assessed. II) Computerized assessment of decelerations on CTG compared to visual observers reached excellent intraclass correlation (0.89-0.95) and low bias in Bland-Altman analysis, comparable to that between the two observers. III) The deceleration measures with the best prediction of fetal acidemia was cumulative deceleration area and duration, ROC AUC 0.682 and 0.683 respectively compared to deceleration depth 0.631. IV) The proportion of SGA was two-fold higher among neonates presenting with abnormal admCTG (18.6%) compared to normal admCTG (9.7%). The risk of composite severe adverse neonatal complications was substantially higher in the group with abnormal admCTG/SGA compared to normal admCTG/non-SGA, adjusted odds ratio 23.7 (95% confidence interval 9.8-57.3) Conclusion: Inter- and intra-observer agreement was better than expected at both departments studied and extended education might have an impact on interpretation reliability. A novel computerized algorithm for CTG assessment has high precision in detecting and quantifying decelerations. Cumulative deceleration area and duration are better predictors of fetal acidemia than deceleration depth. In presumed low-risk pregnancies there is a group of undetected SGA fetuses that more often present with abnormal admCTG and are at higher risks of neonatal complications