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Pereira S, Bakker P, Zaima A, Ghi T, Kessler J, Timonen S, Vayssière C, Löser K, Holmberg K, Jacquemyn Y, Chandraharan E, Wertheim D, Olofsson P. Is the fetus fit for labor? Introducing fast-and-frugal trees (FFTrees) to simplify triage of women for STAN monitoring: An interobserver agreement comparison with traditional classification. Acta Obstet Gynecol Scand 2024; 103:68-76. [PMID: 37890863 PMCID: PMC10755137 DOI: 10.1111/aogs.14680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 08/20/2023] [Accepted: 09/03/2023] [Indexed: 10/29/2023]
Abstract
INTRODUCTION It is a shortcoming of traditional cardiotocography (CTG) classification table formats that CTG traces are frequently classified differently by different users, resulting in poor interobserver agreements. A fast-and-frugal tree (FFTree) flow chart may help provide better concordance because it is straightforward and has clearly structured binary questions with understandable "yes" or "no" responses. The initial triage to determine whether a fetus is suitable for labor when utilizing fetal ECG ST analysis (STAN) is very important, since a fetus with restricted capacity to respond to hypoxic stress may not generate STAN events and therefore may become falsely negative. This study aimed to compare physiology-focused FFTree CTG interpretation with FIGO classification for assessing the suitability for STAN monitoring. MATERIAL AND METHODS A retrospective study of 36 CTG traces with a high proportion of adverse outcomes (17/36) selected from a European multicenter study database. Eight experienced European obstetricians evaluated the initial 40 minutes of the CTG recordings and judged whether STAN was a suitable fetal surveillance method and whether intervention was indicated. The experts rated the CTGs using the FFTree and FIGO classifications at least 6 weeks apart. Interobserver agreements were calculated using proportions of agreement and Fleiss' kappa (κ). RESULTS The proportions of agreement for "not suitable for STAN" were for FIGO 47% (95% confidence interval [CI] 42%-52%) and for FFTree 60% (95% CI 56-64), ie a significant difference; the corresponding figures for "yes, suitable" were 74% (95% CI 71-77) and 70% (95% CI 67-74). For "intervention needed" the figures were 52% (95% CI 47-56) vs 58% (95% CI 54-62) and for "expectant management" 74% (95% CI 71-77) vs 72% (95% CI 69-75). Fleiss' κ agreement on "suitability for STAN" was 0.50 (95% CI 0.44-0.56) for the FIGO classification and 0.57 (95% CI 0.51-0.63) for the FFTree classification; the corresponding figures for "intervention or expectancy" were 0.53 (95% CI 0.47-0.59) and 0.57 (95% CI 0.51-0.63). CONCLUSIONS The proportion of agreement among expert obstetricians using the FFTree physiological approach was significantly higher compared with the traditional FIGO classification system in rejecting cases not suitable for STAN monitoring. That might be of importance to avoid false negative STAN recordings. Other agreement figures were similar. It remains to be shown whether the FFTree simplicity will benefit less experienced users and how it will work in real-world clinical scenarios.
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Affiliation(s)
- Susana Pereira
- Fetal Medicine Unit, The Royal London Hospital, Barts Health NHS TrustLondonUK
| | - Petra Bakker
- Department of Obstetrics and GynecologyAmsterdam UMCAmsterdamThe Netherlands
| | - Ahmed Zaima
- Department of Obstetrics and GynaecologyKingston Hospital NHS Foundation TrustLondonUK
| | - Tullio Ghi
- Department of Medicine and SurgeryUniversity of ParmaParmaItaly
| | - Jörg Kessler
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, and Department of Clinical ScienceUniversity of BergenBergenNorway
| | - Susanna Timonen
- Department of Obstetrics and GynecologyTurku University HospitalTurkuFinland
| | - Christoph Vayssière
- Department of Obstetrics and Gynecology, Paule de Viguier HospitalToulouse III UniversityToulouseFrance
| | - Katrin Löser
- Department of Obstetrics and GynecologySouth Jutland Hospital Aabenraa CampusAabenraaDenmark
| | - Kaisa Holmberg
- Department of Obstetrics and GynecologyTurku University HospitalTurkuFinland
| | - Yves Jacquemyn
- Department of Obstetrics and GynecologyAntwerp University Hospital, Edegem, and Global Health Institute, Antwerp UniversityAntwerpBelgium
| | | | - David Wertheim
- School of Computing and Information Systems, Faculty of Science, Engineering and Computing, Kingston UniversityLondonUK
| | - Per Olofsson
- Institution of Clinical Sciences Malmö, Lund UniversityMalmöSweden
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Ekengård F, Cardell M, Herbst A. Sporadic accelerations during labor strongly indicate normal pH, whereas periodic accelerations do not: a case-control study. J Matern Fetal Neonatal Med 2023; 36:2157717. [PMID: 36521850 DOI: 10.1080/14767058.2022.2157717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE To determine the association between the occurrence of sporadic and periodic fetal heart rate accelerations during labor and acidemia at birth. MATERIALS AND METHODS This is a case-control study of fetal heart rate patterns from 364 neonates with acidemia at birth (cord blood pH <7.05 at vaginal birth, or pH <7.10 at birth after first stage cesarean delivery) and 731 controls with pH ≥7.15. The last 30-60 min of the cardiotocographic traces before birth from the neonates born with acidemia and from the corresponding stage in labor for the controls were scrutinized. Odds ratios (OR) with 95% confidence interval for acidemia at birth were determined. RESULTS During the first stage, ≥2 sporadic accelerations were present in 16% of cases and 78% of controls; OR for acidemia (compared to 0-1 accelerations) 0.05 (0.02-0.10). In the second stage, the corresponding rates were 13% and 60%, OR 0.09 (0.06-0.14). Isolated periodic accelerations were infrequent. A weak negative association between ≥2 periodic accelerations and acidemia (compared with 0-1 accelerations) was found in the second stage, OR 0.51 (0.30-0.86), but was not significant in the first stage, OR 0.24 (0.04-1.4). Even among fetuses with normal fetal heart rate variability (5-25 beats per minute) the occurrence of less than two sporadic accelerations was associated with an increased risk of acidemia, OR 10.3 (7.2-14.8). CONCLUSIONS Sporadic accelerations indicate a very low probability of acidosis but are absent in 40% of fetuses with normal pH during a 30-60 min second-stage recording.
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Affiliation(s)
- Frida Ekengård
- Department of Obstetrics and Gynecology, Skåne University Hospital, Institution of Clinical Sciences Lund University, Lund, Sweden
| | - Monika Cardell
- Department of Obstetrics and Gynecology, Skåne University Hospital, Institution of Clinical Sciences Lund University, Lund, Sweden
| | - Andreas Herbst
- Department of Obstetrics and Gynecology, Skåne University Hospital, Institution of Clinical Sciences Lund University, Lund, Sweden
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Ekengård F, Cardell M, Herbst A. CTG interpretation templates affect residents' decision making. Eur J Obstet Gynecol Reprod Biol 2023; 285:148-152. [PMID: 37120910 DOI: 10.1016/j.ejogrb.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/14/2023] [Accepted: 04/24/2023] [Indexed: 05/02/2023]
Abstract
OBJECTIVE To study whether a revision of CTG guidelines and educational program influenced the perceived need for intervention by residents in obstetrics and gynecology. A secondary aim was to study the sensitivity and specificity of the classification pathological after classification by residents using two different guidelines in identifying neonates with acidemia. STUDY DESIGN Cardiotocograms, CTGs, from 223 neonates with acidemia at birth (cord blood pH < 7.05 at vaginal birth or second stage cesarean, or pH < 7.10 at first stage cesarean) were included, as well as 223 CTGs from neonates with cord blood pH ≥ 7.15. Two separate groups of residents, who each were educated in and had clinical experience only from either of the two different guidelines, SWE09 and SWE17, classified the patterns according to the at the time current template and judged whether the patterns indicated an intervention. Sensitivity, specificity, and agreement were calculated. RESULTS Residents using SWE09 found indication to intervene in a higher proportion of neonates with acidemia (84.8%) than residents using SWE17 (75.8%; p = 0.002), as well as in cases without acidemia (29.6% vs 22.4%; p = 0.038). Among residents using SWE09 the perceived need for intervention had a sensitivity of 85% and a specificity of 70% to identify acidemia. With SWE17 the corresponding rates were 76% and 78%. The sensitivity to identify neonates with acidemia by classification pathological was 91% with SWE09 and 72% with SWE17. The specificity was 53% and 76% respectively. The agreement rate between perception of indication to intervene and classification pathological using the SWE09 was κ 0.73, moderate, and with the SWE17 κ 0.77, moderate. The agreement on subjective perception of necessity to intervene between users of the two templates was weak to moderate, κ 0.60, and on classification pathological weak, κ 0.47. CONCLUSION The perceived need for intervention by residents interpreting CTGs was significantly affected by the guidelines in use. The difference in decisions were less pronounced than the difference in classification. The sensitivity for both perceived need for intervention and for classification pathological to identify acidosis was higher with SWE09, and the specificity higher with SWE17, when assessed by the two comparable groups of residents.
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Affiliation(s)
- Frida Ekengård
- Department of Obstetrics and Gynecology Skåne University Hospital, Institution of Clinical Sciences Lund, Lund University, Sweden; Study Conducted in Malmö and Lund, Sweden.
| | - Monika Cardell
- Department of Obstetrics and Gynecology Skåne University Hospital, Institution of Clinical Sciences Lund, Lund University, Sweden; Study Conducted in Malmö and Lund, Sweden
| | - Andreas Herbst
- Department of Obstetrics and Gynecology Skåne University Hospital, Institution of Clinical Sciences Lund, Lund University, Sweden; Study Conducted in Malmö and Lund, Sweden
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Abdul Halim SF, Zakaria Z, Pusppanathan J, Mohd Noor A, Norali AN, Fazalul Rahiman MH, Mohd Muji SZ, Abdul Rahim R, Engku-Husna EI, Ali Hassan MK, Aziz Safar MJ, Salleh AF, Mat Som MH. A Review on Magnetic Induction Spectroscopy Potential for Fetal Acidosis Examination. SENSORS 2022; 22:s22041334. [PMID: 35214235 PMCID: PMC8963069 DOI: 10.3390/s22041334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/24/2021] [Accepted: 01/07/2022] [Indexed: 02/06/2023]
Abstract
Fetal acidosis is one of the main concerns during labor. Currently, fetal blood sampling (FBS) has become the most accurate measurement of acidosis detection. However, it is invasive and does not provide a real time measurement due to laboratory procedures. Delays in diagnosis of acidosis have caused serious injury to the fetus, especially for the brain and the heart. This paper reviews the new technique in diagnosis of acidosis non-invasively. Magnetic Induction Spectroscopy (MIS) has been proposed to be a new device for acidosis detection in recent years. This paper explains the basic principle of MIS and outlines the design specifications and design considerations for a MIS pH probe. It is expected that readers will gain a basic understanding of the development of a MIS pH probe from this review.
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Affiliation(s)
- Siti Fatimah Abdul Halim
- Biomedical Electronic Engineering, Faculty of Electronic Engineering Technology, Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia; (S.F.A.H.); (A.M.N.); (A.N.N.); (A.F.S.); (M.H.M.S.)
| | - Zulkarnay Zakaria
- Biomedical Electronic Engineering, Faculty of Electronic Engineering Technology, Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia; (S.F.A.H.); (A.M.N.); (A.N.N.); (A.F.S.); (M.H.M.S.)
- Medical Device & Life Sciences Cluster, Sports Engineering Research Centre (SERC), Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia; (M.K.A.H.); (M.J.A.S.)
- Correspondence:
| | - Jaysuman Pusppanathan
- Sport Innovation & Technology Centre (SiTC), Institute of Human Centered Engineering (iHumen), Universiti Teknologi Malaysia, Skudai 81310, Johor, Malaysia;
| | - Anas Mohd Noor
- Biomedical Electronic Engineering, Faculty of Electronic Engineering Technology, Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia; (S.F.A.H.); (A.M.N.); (A.N.N.); (A.F.S.); (M.H.M.S.)
- Medical Device & Life Sciences Cluster, Sports Engineering Research Centre (SERC), Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia; (M.K.A.H.); (M.J.A.S.)
| | - Ahmad Nasrul Norali
- Biomedical Electronic Engineering, Faculty of Electronic Engineering Technology, Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia; (S.F.A.H.); (A.M.N.); (A.N.N.); (A.F.S.); (M.H.M.S.)
- Medical Device & Life Sciences Cluster, Sports Engineering Research Centre (SERC), Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia; (M.K.A.H.); (M.J.A.S.)
| | | | - Siti Zarina Mohd Muji
- Department of Electronic Engineering, Faculty of Electrical and Electronic Engineering, Universiti Tun Hussein Onn Malaysia, Parit Raja, Batu Pahat 86400, Johor, Malaysia;
| | - Ruzairi Abdul Rahim
- School of Electrical Engineering, Faculty of Engineering, Universiti Teknologi Malaysia, Skudai 81310, Johor, Malaysia;
| | - Engku Ismail Engku-Husna
- Department of Obstetrics and Gynaecology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
| | - Muhamad Khairul Ali Hassan
- Medical Device & Life Sciences Cluster, Sports Engineering Research Centre (SERC), Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia; (M.K.A.H.); (M.J.A.S.)
- Faculty of Electrical Engineering Technology, Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia;
| | - Muhammad Juhairi Aziz Safar
- Medical Device & Life Sciences Cluster, Sports Engineering Research Centre (SERC), Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia; (M.K.A.H.); (M.J.A.S.)
- Faculty of Electrical Engineering Technology, Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia;
| | - Ahmad Faizal Salleh
- Biomedical Electronic Engineering, Faculty of Electronic Engineering Technology, Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia; (S.F.A.H.); (A.M.N.); (A.N.N.); (A.F.S.); (M.H.M.S.)
- Medical Device & Life Sciences Cluster, Sports Engineering Research Centre (SERC), Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia; (M.K.A.H.); (M.J.A.S.)
| | - Mohd Hanafi Mat Som
- Biomedical Electronic Engineering, Faculty of Electronic Engineering Technology, Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia; (S.F.A.H.); (A.M.N.); (A.N.N.); (A.F.S.); (M.H.M.S.)
- Medical Device & Life Sciences Cluster, Sports Engineering Research Centre (SERC), Universiti Malaysia Perlis, Arau 02600, Perlis, Malaysia; (M.K.A.H.); (M.J.A.S.)
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Costa-Santos C, Bernardes J. A letter to the editor regarding the article "Impaired validity of the new FIGO and Swedish CTG classification templates to identify fetal acidosis in the first stage of labor". J Matern Fetal Neonatal Med 2021; 35:7071-7072. [PMID: 34167413 DOI: 10.1080/14767058.2021.1941854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Cristina Costa-Santos
- Department of Community Medicine, Information and Health Decision Sciences-MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research-CINTESIS, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Bernardes
- Center for Health Technology and Services Research-CINTESIS, Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of University of Porto, Porto, Portugal.,Centro Hospitalar Universitário de S. João, Alameda Hernâni Monteiro, Porto, Portugal
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Ekengård F, Cardell M, Herbst A. Reply to letter to the editor entitled 'Low sensitivity of the new FIGO classification system for electronic fetal monitoring to identify fetal acidosis in the second stage of labor?'. Eur J Obstet Gynecol Reprod Biol 2021; 258:465. [PMID: 33536148 DOI: 10.1016/j.ejogrb.2021.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Frida Ekengård
- Department of Obstetrics and Gynecology, Skåne University Hospital, Institution of Clinical Sciences, Lund University, Lund, Sweden.
| | - Monika Cardell
- Department of Obstetrics and Gynecology, Skåne University Hospital, Institution of Clinical Sciences, Lund University, Lund, Sweden
| | - Andreas Herbst
- Department of Obstetrics and Gynecology, Skåne University Hospital, Institution of Clinical Sciences, Lund University, Lund, Sweden
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