Characterization of uterine activity by electrohysterography

A growing number of pregnancies is complicated by miscarriage, preterm delivery, and birth defects, with consequent health problems later in life. It is therefore increasingly important to monitor the health status of mother and fetus, so as to permit timely medical intervention when acute health risks are detected. For timely recognition of complications, quantitative assessment of uterine activity can be fundamental during both pregnancy and delivery. During pregnancy, timely prediction of preterm delivery can improve the effectiveness of the required treatments. Unfortunately, the prognostic techniques employed in current obstetrical practice, namely, uterine contraction measurements using an elastic belt (external tocography), cervical change evaluation, and the use of biomarkers like fetal fibronectin, have been demonstrated to be inaccurate for the prediction of preterm delivery. In the last stage of pregnancy and during labor, contractions are routinely and constantly monitored. Especially when complications occur, e.g., when labor shows poor progress, quantitative assessment of uterine activity can guide the physician to choose a uterine contraction induction or augmentation, a cesarean section, or other therapies. Furthermore, monitoring the fetal heart response to the uterine activity (cardiotography) is widely used as a screening test for timely recognition of fetal distress (e.g. asphyxia). However, in current obstetrical practice, accurate quantitative assessment of the uterine contractions can be provided only invasively and during labor. The current golden standard for contraction monitoring, which is based on the direct internal uterine pressure (IUP) measurement by an intrauterine catheter, can be risky and its use is generally limited to very complicated deliveries. The contractile element of the uterus is the myometrium, which is composed of smooth muscle cells. Uterine contractions are caused by electrical activity in the form of action potentials (AP) that propagate through the myometrium cells. Electrohysterography is the measurement of the uterine electrical activity and can be performedby electrodes placed on the abdomen. Electrohysterographic (EHG) measurements are inexpensive and noninvasive. Moreover, it has been demonstrated that the noninvasively recorded EHG signal is representative of those APs that, by propagating from cell to cell, are the root cause of a uterine contraction. Therefore, in view of the limitation of current obstetrical practice, significant benefits could be expected from the introduction of EHG signal analysis for routine contraction monitoring. Previous studies highlighted the potential prognostic and diagnostic value of EHG signal analysis, but did not investigate the possibility of accurately estimating the IUP from noninvasive EHG recordings. Moreover, important issues like the effect of the tissues interposed between the uterus and the skin (volume conductor) on EHG recordings have not been studied. Besides, EHG signal interpretation has been typically based on single-channel measurements, while the use of multiple electrodes conveys additional information (e.g., distribution and dynamics of the electrical activation) that can possibly be predictive of delivery. In this thesis, we focus on the analysis of the EHG signal as an alternative to existing techniques for predicting preterm delivery and monitoring uterine contractions during both pregnancy and delivery. The main goal of this work is to contribute to the technical basis which is required for the introduction of electrohysterography in everyday clinical practice. A major part of this thesis investigates the possibility of using electrohysterography to replace invasive IUP measurements. A novel method for IUP estimation from EHG recordings is developed in the first part of this thesis. The estimates provided by the method are compared to the IUP invasively recorded on women during delivery and result in a root mean squared error (RMSE) with respect to the reference invasive IUP recording as low as 5 mmHg, which is comparable to the accuracy of the invasive golden standard. Another important objective of this thesis work is to contribute to the introduction of novel techniques for timely prediction of preterm delivery. As the spreading of electrical activity at the myometrium is the root cause of coordinated and effective contractions, i.e., contractions that are capable of pushing the fetus down into the birth canal ultimately leading to delivery, a multichannel analysis of the spatial propagation properties of the EHG signal could provide a fundamental contribution for predicting delivery. A thorough study of the EHG signal propagation properties is therefore carried out in this work. Parameters related to the EHG that are potentially predictive of delivery, such as the uterine area where the contraction originates (pacemaker area) or the distribution and dynamics of the EHG propagation vector, can be derived from the delay by which the signal is detected at multiple locations over the whole abdomen. To analyze the propagation of EHG signals on a large scale (cm), a method is designed for calculating the detection delay among the EHG signals recorded by by electrodes placed on the abdomen. Electrohysterographic (EHG) measurements are inexpensive and noninvasive. Moreover, it has been demonstrated that the noninvasively recorded EHG signal is representative of those APs that, by propagating from cell to cell, are the root cause of a uterine contraction. Therefore, in view of the limitation of current obstetrical practice, significant benefits could be expected from the introduction of EHG signal analysis for routine contraction monitoring. Previous studies highlighted the potential prognostic and diagnostic value of EHG signal analysis, but did not investigate the possibility of accurately estimating the IUP from noninvasive EHG recordings. Moreover, important issues like the effect of the tissues interposed between the uterus and the skin (volume conductor) on EHG recordings have not been studied. Besides, EHG signal interpretation has been typically based on single-channel measurements, while the use of multiple electrodes conveys additional information (e.g., distribution and dynamics of the electrical activation) that can possibly be predictive of delivery. In this thesis, we focus on the analysis of the EHG signal as an alternative to existing techniques for predicting preterm delivery and monitoring uterine contractions during both pregnancy and delivery. The main goal of this work is to contribute to the technical basis which is required for the introduction of electrohysterography in everyday clinical practice. A major part of this thesis investigates the possibility of using electrohysterography to replace invasive IUP measurements. A novel method for IUP estimation from EHG recordings is developed in the first part of this thesis. The estimates provided by the method are compared to the IUP invasively recorded on women during delivery and result in a root mean squared error (RMSE) with respect to the reference invasive IUP recording as low as 5 mmHg, which is comparable to the accuracy of the invasive golden standard. Another important objective of this thesis work is to contribute to the introduction of novel techniques for timely prediction of preterm delivery. As the spreading of electrical activity at the myometrium is the root cause of coordinated and effective contractions, i.e., contractions that are capable of pushing the fetus down into the birth canal ultimately leading to delivery, a multichannel analysis of the spatial propagation properties of the EHG signal could provide a fundamental contribution for predicting delivery. A thorough study of the EHG signal propagation properties is therefore carried out in this work. Parameters related to the EHG that are potentially predictive of delivery, such as the uterine area where the contraction originates (pacemaker area) or the distribution and dynamics of the EHG propagation vector, can be derived from the delay by which the signal is detected at multiple locations over the whole abdomen. To analyze the propagation of EHG signals on a large scale (cm), a method is designed for calculating the detection delay among the EHG signals recorded by multiple electrodes. Relative to existing interelectrode delay estimators, this method improves the accuracy of the delay estimates for interelectrode distances larger than 5-10 cm. The use of a large interelectrode distance aims at the assessment of the EHG propagation properties through the whole uterine muscle using a limited number of sensors. The method estimates values of velocity within the physiological range and highlights the upper part of the uterus as the most frequent (65%) pacemaker area during labor. Besides, our study suggests that more insight is needed on the effect that tissues interposed between uterus and skin (volume conductor) have on the EHG signal. With the aim of improving the current interpretation and measurement accuracy of EHG parameters with potential clinical relevance, such as the conduction velocity (CV), a volume conductor model for the EHG signal is introduced and validated. The intracellular AP at the myometrium is analytically modeled in the spatial domain by a 2-parameter exponential in the form of a Gamma variate function. The unknown atomical parameters of the volume conductor model are the thicknesses of the biological tissues interposed between the uterus and the abdominal surface. These model parameters can be measured by echography for validation. The EHG signal is recorded by an electrode matrix on women with contractions. In order to increase the spatial resolution of the EHG measurements and reduce the geometrical and electrical differences among the tissues below the recording locations, electrodes with a reduced surface and smaller interelectrode distance are needed relative to the previous studies on electrohysterography. The EHG signal is recorded, for the first time, by a 64-channel (8×8) high-density electrode grid, comprising 1 mm diameter electrodes with 4 mm interelectrode distance. The model parameters are estimated in the spatial frequency domain from the recorded EHG signal by a least mean square method. The model is validated by comparing the thickness of the biological tissues recorded by echography to the values estimated using the mathematical model. The agreement between the two measures (RMSE = 1 mm and correlation coefficient, R = 0.94) suggests the model to be representative of the underlying physiology. In the last part of this dissertation, the analysis of the EHG signal propagation focuses on the CV estimation of single APs. As on a large scale this parameter cannot be accurately derived, the propagation analysis is here carried out on a small scale (mm). Also for this analysis, the EHG signal is therefore recorded by a 3×3 cm2 high-density electrode grid containing 64 electrodes (8×8). A new method based on maximum likelihood estimation is then applied in two spatial dimensions to provide an accurate estimate of amplitude and direction of the AP CV. Simulation results prove the proposed method to be more robust to noise than the standard techniques used for other electrophysiological signals, leading to over 56% improvement of the RMS CV estimate accuracy. Furthermore, values of CV between 2 cm/s and 12 cm/s, which are in agreement with invasive and in-vitro measurements described in the literature, are obtained from real measurements on ten women in labor. In conclusion, this research provides a quantitative characterization of uterine contractions by EHG signal analysis. Based on an extensive validation, this thesis indicates that uterine contractions can be accurately monitored noninvasively by dedicated analysis of the EHG signal. Furthermore, our results open the way to new clinical studies and applications aimed at improving the understanding of the electrophysiological mechanisms leading to labor, possibly reducing the incidence of preterm delivery and improving the perinatal outcome

Feasibility of transabdominal electrohysterography for analysis of uterine activity in nonpregnant women

Purpose: Uterine activity plays a key role in reproduction, and altered patterns of uterine contractility have been associated with important physiopathological conditions, such as subfertility, dysmenorrhea, and endometriosis. However, there is currently no method to objectively quantify uterine contractility outside pregnancy without interfering with the spontaneous contraction pattern. Transabdominal electrohysterography has great potential as a clinical tool to characterize noninvasively uterine activity, but results of this technique in nonpregnant women are poorly documented. The purpose of this study is to investigate the feasibility of transabdominal electrohysterography in nonpregnant women. Methods: Longitudinal measurements were performed on 22 healthy women in 4 representative phases of the menstrual cycle. Twelve electrohysterogram-based indicators previously validated in pregnancy have been estimated and compared in the 4 phases of the cycle. Using the Tukey honest significance test, significant differences were defined for P values below .05. Results: Half of the selected electrohysterogram-based indicators showed significant differences between menses and at least 1 of the other 3 phases, that is the luteal phase. Conclusion: Our results suggest transabdominal electrohysterography to be feasible for analysis of uterine activity in nonpregnant women. Due to the lack of a golden standard, this feasibility study is indirectly validated based on physiological observations. However, these promising results motivate further research aiming at evaluating electrohysterography as a method to improve understanding and management of dysfunctions (possibly) related to altered uterine contractility, such as infertility, endometriosis, and dysmenorrhea

Electrohysterographic volume conductor modeling

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Electrohysterographic conduction velocity estimation

Monitoring and analysis of the fetal-heart and the uterine-muscle activity, referred to as electrohysterogram (EHG), is essential to permit timely treatment during pregnancy. While remarkable progress is reported for monitoring of the fetal cardiac activity, the EHG measurement and interpretation remains challenging, and limited knowledge is available on the underlying physiological processes. In particular, little attention has been paid to the analysis of the EHG propagation, whose characteristics might indicate the presence of coordinated uterine contractions leading to intrauterine pressure increase. Therefore, this study focuses for the first time on the noninvasive estimation of the conduction velocity of EHG action potentials by means of multichannel EHG recording and surface high-density electrodes. A maximum likelihood algorithm, initially proposed for skeletal-muscle electromyography, is modified for the required EHG analysis. The use of clustering and weighting is introduced to deal with poor signal similarity between different channels. The presented methods were evaluated by specific simulations, proving the combination of weighting and clustering to be the most accurate method. A preliminary EHG measurement during labor confirmed the feasibility of the method. An extensive clinical validation will however be necessary to optimize the method and assess the relevance of the EHG conduction velocity for pregnancy monitoring

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A wireless body measurement system to study fatigue in multiple sclerosis

Fatigue is reported as the most common symptom by patients with multiple sclerosis (MS). The physiological and functional parameters related to fatigue in MS patients are currently not well established. A new wearable wireless body measurement system, named Fatigue Monitoring System (FAMOS), was developed to study fatigue in MS. It can continuously measure electrocardiogram, body-skin temperature, electromyogram and motions of feet. The goal of this study is to test the ability of distinguishing fatigued MS patients from healthy subjects by the use of FAMOS. This paper presents the realization of the measurement system including the design of both hardware and dedicated signal processing algorithms. Twenty-six participants including 17 MS patients with fatigue and 9 sex- and age-matched healthy controls were included in the study for continuous 24 h monitoring. The preliminary results show significant differences between fatigued MS patients and healthy controls. In conclusion, the FAMOS enables continuous data acquisition and estimation of multiple physiological and functional parameters. It provides a new, flexible and objective approach to study fatigue in MS, which can distinguish between fatigued MS patients and healthy controls. The usability and reliability of the FAMOS should however be further improved and validated through larger clinical trials

Nifedipine-Induced Changes in the Electrohysterogram of Preterm Contractions: Feasibility in Clinical Practice

Objective. Evaluating changes in the power spectral density (PSD) peak frequency of the electrohysterogram (EHG) caused by nifedipine in women with preterm contractions. Methods. Calculation of the PSD peak frequency in EHG contraction bursts at different times of nifedipine treatment in women in gestational age 24 to 32 weeks with contractions. Results. A significant (P < .05) decrease of PSD peak frequency between EHG signals measured before and 15 minutes after administration of nifedipine. A significant (P < .05) decrease in PSD peak frequency comparing signals recorded within 24 hours after administration of nifedipine to signals 1 day after tocolytic treatment. A higher average PSD peak frequency for patients delivering within 1 week than that for patients delivering after 1 week from nifedipine treatment (P > .05). Conclusions. EHG signal analysis has great potential for quantitative monitoring of uterine contractions. Treatment with nifedipine leads to a shift to lower PSD peak frequency in the EHG signal

Comparison of electrohysterogram signal measured by surface electrodes with different designs: A computational study with dipole band and abdomen models

Non-invasive measurement of uterine activity using electrohysterogram (EHG) surface electrodes has been attempted to monitor uterine contraction. This study aimed to computationally compare the performance of acquiring EHG signals using monopolar electrode and three types of Laplacian concentric ring electrodes (bipolar, quasi-bipolar and tri-polar). With the implementation of dipole band model and abdomen model, the performances of four electrodes in terms of the local sensitivity were quantifed by potential attenuation. Furthermore, the efects of fat and muscle thickness on potential attenuation were evaluated using the bipolar and tri-polar electrodes with diferent radius. The results showed that all the four types of electrodes detected the simulated EHG signals with consistency. That the bipolar and tri-polar electrodes had greater attenuations than the others, and the shorter distance between the origin and location of dipole band at 20dB attenuation, indicating that they had relatively better local sensitivity. In addition, ANOVA analysis showed that, for all the electrodes with diferent outer ring radius, the efects of fat and muscle on potential attenuation were signifcant (all p<0.01). It is therefore concluded that the bipolar and tri-polar electrodes had higher local sensitivity than the others, indicating that they can be applied to detect EHG efectively

Blind source separation for clutter and noise suppression in ultrasound imaging:review for different applications

Blind source separation (BSS) refers to a number of signal processing techniques that decompose a signal into several 'source' signals. In recent years, BSS is increasingly employed for the suppression of clutter and noise in ultrasonic imaging. In particular, its ability to separate sources based on measures of independence rather than their temporal or spatial frequency content makes BSS a powerful filtering tool for data in which the desired and undesired signals overlap in the spectral domain. The purpose of this work was to review the existing BSS methods and their potential in ultrasound imaging. Furthermore, we tested and compared the effectiveness of these techniques in the field of contrast-ultrasound super-resolution, contrast quantification, and speckle tracking. For all applications, this was done in silico, in vitro, and in vivo. We found that the critical step in BSS filtering is the identification of components containing the desired signal and highlighted the value of a priori domain knowledge to define effective criteria for signal component selection