Marta Campanile

Quantitative Assessment of Fetal Well-Being Through CTG Recordings: A New Parameter Based on Phase-Rectified Signal Average

Since the 1980s, cardiotocography (CTG) has been the most diffused technique to monitor fetal well-being during pregnancy. CTG consists of the simultaneous recording of fetal heart rate (FHR) signal and uterine contractions and its interpretation is usually performed through visual inspection by trained obstetric personnel. To reduce inter- and intraobserver variabilities and to improve the efficacy of prenatal diagnosis, new quantitative parameters, extracted from the CTG digitized signals, have been proposed as additional tools in the clinical diagnosis process. In this paper, a new parameter computed on FHR time series and based on the phase-rectified signal average curve (PRSA) is introduced. It is defined as acceleration phase-rectified slope (APRS) or deceleration phase-rectified slope (DPRS) depending on the slope sign of the PRSA curve. The new PRSA parameter was applied to FHR time series of 61 healthy and 61 intrauterine growth restricted (IUGR) fetuses during CTG nonstress tests. Performance of APRS and DPRS was compared with 1) the results provided by other parameters extracted from the PRSA curve itself but already existing in the literature, and 2) other clinical indices provided by computerized cardiotocographic systems. APRS and DPRS indices performed better than any other parameter in this study in the distinction between healthy and IUGR fetuses. Our results suggest this new index might reliably contribute to the quality of early fetal diagnosis.

Regional and international prenatal telemedicine network for computerized antepartum cardiotocography.

The objective of this work was to review the activity of TOCOMAT, a system for antepartum cardiotocographic telemonitoring. Nine peripheral units recorded the traces, transmitted them via modem to the University operation center, where the computerized analysis was performed, and received the medical report within a few minutes, via fax or e-mail. Traces were classified as reassuring, nonreassuring, or pathological. The parameters of computerized analysis were grouped together for each week of gestation. The perinatal outcome was also evaluated. In 5 years, 5830 traces were analyzed: 4372 (75%) from 1344 high-risk patients and 1458 (25%) from 529 patients at apparent low risk. The system allowed the identification of high-risk patients (32.8% with nonreassuring traces and 7.1% with pathologic traces) and lowrisk patients (16.3% with nonreassuring traces and 4.3% with pathologic traces) that required further evaluation. The neonatal outcome was good overall. At each week of pregnancy, the mean values of computerized parameters resulted in normal ranges. The TOCOMAT system allowed a decentralization of prenatal surveillance and improved the patients quality of life and the level of prenatal care.

Multiparameter analysis of heart rate variability signal for the investigation of high risk fetuses

The purpose of this study is to evaluate the information content provided by the fluximetry information and the analysis of fetal heart rate (FHR) signals, obtained from cardiotocographic recordings, during prenatal monitoring, in a high risk population. The parameters assessed on FHR signals are divided in: (i) time domain parameters (ii) frequency domain parameters, and (iii) the complexity parameters: Approximate Entropy (ApEn), Sample Entropy (SampEn), Multiscale Entropy (MSE), the Lempel Ziv Complexity (LZC) and the Detrended Fluctuation Analysis (DFA). The fetuses were classified as fetal growth restricted (FGR). The results have shown that the FGR fetuses preterm delivered have produced a markedly reduced heart rate variability in respect with those fetuses which were characterized by an alteration in the fluximetric indices. The normal range in cord blood sampling analysis excludes the prolonged hypoxia as a causing factor. Finally, it seems that the residual cardiovascular response in FGR fetuses could be correlated to an alteration in the flow of the main vessels.

Fetal Vibroacoustic Stimulation in Computerized Cardiotocographic Analysis: The Role of Short-Term Variability and Approximate Entropy

The aim of this study was to evaluate the impact of vibroacoustic stimulation (VAS) on computerized cardiotocography short-term variability (STV) and approximate entropy (ApEn) in both low- and high-risk pregnancies. VAS was performed on 121 high- and 95 low-risk pregnancies after 10 minutes of continuous quiet, while their FHR parameters were monitored and recorded by cCTG analysis. Fetal heart rate was recorded using a computer-assisted equipment. Baseline FHR, accelerations, decelerations, STV, long-term irregularity (LTI), ApEn, and fetal movements (FMs) were calculated for defined observational periods before VAS and after 10 minutes. Data were also investigated in relationship with the perinatal outcome. In each group of patients, FHR after VAS remained almost unmodified. Fetal movements significantly increased after VAS in both groups. Results show that only in the high-risk pregnancies, the increase of STV and the decrease of ApEn after VAS were significantly associated with favorable perinatal outcomes.

Conventional and computerized antepartum telecardiotocography. Experienced and inexperienced observers versus computerized analysis.

The study assessed the agreement in cardiotocogram interpretation between the 2CTG computerized system and experienced and inexperienced observers involved in a telecardiotocography project called ‘TOCOMAT’. Both observers and computer analyzed FHR baseline, FHR variability, and number of large accelerations and of decelerations. The k coefficient was calculated for the statistical analysis. The interobserver agreement about the evaluation of the FHR baseline and of the large accelerations was good; it was poor about the assessment of the FHR variability and the decelerations. Similar results were obtained for the agreement among observers and computer. The use of a computerized system provides exact values for most CTG parameters; the experts, however, should rely both on clinical features and on the computerized interpretation, to make decisions about management.

Prenatal Telemedicine: A New System for Conventional and Computerized Telecardiotocography and Tele-Ultrasonography

Andrea Di Lieto1, Marta Campanile2, Marianna De Falco3, Ilma Floriana Carbone4, Giovanni Magenes5, Maria Gabriella Signorini6 and Donatella Di Lieto7 1Full Professor of Obstetrics and Gynaecology Director of Prenatal Unit Responsible of Project of Telecardiotocography in Campania Region Responsible of European Project Conventional and Computerized Telecardiotocography Medical School University Federico II of Naples 2Specialist in Obstetrics and Gynaecology University High Professional Physician Operation Center of Conventional and Computerized Telecardiotocography Medical School University Federico II of Naples 3Specialist in Obstetrics and GynaecologyPhD in Reproduction, Growth and Human Development Head Physician University Hospital Federico II of Naples 4MD. Resident in Obstetrics and Gynaecology Research fellow at Medical School University Federico II of Naples 5Full Professor Director of Department of Informatics and Systems – Medical School University of Pavia 6 Associate Professor Department of BioengineeringPolytechnic of Milan 7 Lawyer Specialist in Legal Professions Law of New Technologies and Communications Italy

Atrial Natriuretic Peptide and the Renin Angiotensin Aldosterone System in Normontensive and Hypertensive Pregnancy

Sixty four patients (51 pregnant and 13 non-pregnant women), were investigated for atrial natriuretic peptide (ANP) levels, plasma volume, plasma renin activity and aldosterone.Twenty three women had a normal pregnancy, eighteen experienced a hypertensive one, while ten women were in pre-eclamptic conditions.ANP levels were significantly increased, whether in normotensive or in hypertensive pregnancies, probably because of a counterbalancing effect of this peptide on sodium and water deposits. Plasma volume, plasma renin activity and aldosterone showed different courses.

Influence of goserelin depot therapy on epidermal growth factor receptor expression in pelvic endometriosis

We have studied epidermal growth factor (EGF) receptor expression in endometrium and in endometriotic implants, testing a group of 36 women before and after a 4-month gonadotropin-releasing hormone (GnRH) analog (GnRH-a) goserelin depot treatment. Each woman underwent laparoscopy twice. At the initial laparoscopy, before starting treatment, the disease was staged according to the American Fertility Society (AFS) classification and biopsies of endometriotic implants were undertaken. The follow-up laparoscopy was performed within 5 weeks of the last GnRH-a administration. Biopsies were taken from areas of previously noted disease, both visually persistent and visually free of disease. At the time of each laparoscopy, photographs of all areas of disease were taken. Specimens of eutopic endometrium were collected from each patient at the time of laparoscopy by a Novak curette. Endometrial and endometriotic samples were processed for immunohistochemical detection of EGF receptor, using anti-EGF receptor monoclonal antibody Ab-3. After treatment, the marked improvement of AFS score was associated with a dramatic reduction of EGF receptor immunostaining, but the exact meaning of this finding is still not completely understood. The dramatic reduction of EGF receptor expression in eutopic and ectopic endometrium samples after treatment is not obviously related to the hypoestrogenism induced by the drug. It has been suggested that steroid hormones and EGF play a role in regulation of EGF receptor expression, so that drugs such as goserelin depot could act directly at local peripheral level influencing the EGF receptor expression via the production of its ligand.

IUGR management: new perspectives.

Aim of the Study. Analyzing velocimetric (umbilical artery, UA; ductus venosus, DV; middle cerebral artery, MCA) and computerized cardiotocographic (cCTG) (fetal heart rate, FHR; short term variability, STV; approximate entropy, ApEn) parameters in intrauterine growth restriction, IUGR, in order to detect early signs of fetal compromise. Population Study. 375 pregnant women assisted from the 28th week of amenorrhea to delivery and monitored through cCTG and Doppler ultrasound investigation. The patients were divided into three groups according to the age of gestation at the time of delivery, before the 34th week, from 34th to 37th week, and after the 37th week. Data were analyzed in relation to the days before delivery and according to the physiology or pathology of velocimetry. Statistical analysis was performed through the t-test, chi-square test, and Pearson correlation test (P < 0.05). Our results evidenced an earlier alteration of UA, DV, and MCA. The analysis between cCTG and velocimetric parameters (the last distinguished into physiological and pathological values) suggests a possible relation between cCTG alterations and Doppler ones. The present study emphasizes the need for an antenatal testing in IUGR fetuses using multiple surveillance modalities to enhance prediction of neonatal outcome.

Desogestrel versus gestodene in oral contraceptives: influence on the clinical and histomorphological features of benign breast disease

Forty-four female volunteers asking for oral contraception, affected by symptomatic benign breast disease (BBD) were evaluated to compare the effects on mastalgia and breast nodularity of two different low dose oral contraceptives (OCs), containing 20 micrograms [corrected] ethinylestradiol + 150 micrograms desogestrel (EE+D) and 30 micrograms ethinylestradiol + 75 micrograms gestodene (EE+G), respectively. Physical examination, bilateral thermography, X-ray and/or ultrasonography of breast, and needle and screw-needle biopsies of mammary tissue were performed in all patients before OCs administration and after six cycles of treatment. OCs administration caused an overall improvement of mastalgia in 53%. Breast nodularity improved only in 8% of patients in both groups. Epithelial tissue modifications in mammary biopsies were observed, with involutive and/or secretory histomorphological and ultrastructural changes, frequently coexisting in different areas of the same breast.