The association between undetected small-for-gestational age and abnormal admission cardiotocography: A registry-based study.

OBJECTIVE: To assess the association between undetected small-for-gestational age (SGA) fetuses and abnormal admission cardiotocography (admCTG) in a low-risk population. DESIGN: An observational study. SETTING: Four hospitals in Stockholm-Gotland, Sweden. SAMPLE: A cohort of 127 461 deliveries between 1 February 2012 and 15 June 2020. METHODS: This cohort was linked to the Swedish Neonatal Quality Register. Pregnancies were designated as high or low risk at the time of admission to the labour ward according to pre-defined risk measures. SGA was defined as a birthweight at or below the tenth centile and at or below the third centile for gestational age. MAIN OUTCOME MEASURES: The main outcome was the proportion of undetected SGA by admCTG (normal or abnormal). The secondary outcome was a composite severe adverse neonatal outcome for fetuses born less than 6 hours after admission (Apgar score <4 at 5 minutes, hypoxic-ischaemic encephalopathy grade of 2-3, neonatal seizures and neonatal death). RESULTS: The rate of abnormal admCTG was 4.9%. The proportion of SGA at or below the tenth centile was higher in the abnormal admCTG group than in the normal admCTG group, 18.6% versus 9.7% (odds ratio 2.1, 95% CI 1.9-2.3). Abnormal admCTG and SGA (≤10th) was associated with a more than 20-fold increased risk of an adverse outcome compared with normal admCTG and non-SGA (adjusted odds ratio 23.7, 95% CI 9.8-57.3). The latter had a risk of 1/2000 of an adverse outcome. CONCLUSIONS: In this low-risk population, undetected SGA fetuses were more prone to having abnormal admCTG and had a substantially higher risk of severe adverse neonatal outcomes.

Variable deceleration features and intrapartum fetal acidemia - The role of deceleration area.

OBJECTIVE: In recent years deceleration area has received increasing attention as a potential predictor of intrapartum fetal hypoxia. In several studies, the area has been manually esteemed as triangular in shape, which might introduce bias. In addition, the commonly used outcome acidemia in umbilical artery is affected by mode of delivery. We wanted to investigate the association between the variable deceleration features area, duration, depth and cumulative deceleration area (30 and 60 min) and intrapartum fetal acidemia measured as lactate concentration at fetal scalp blood sampling (FBS) in immediate connection to the decelerations. STUDY DESIGN: In the source population of 1070 labors at Karolinska University Hospital, Sweden, with FBS performed on indication, we found 507 fetuses with predominantly variable decelerations as the indication for FBS. We examined the last 60- and 30-minutes of fetal monitoring preceding the FBS with focus on deceleration area, duration and depth. The contours of the decelerations were outlined manually but the area was calculated with a computer software program. We assessed area, duration and depth both as mean values per deceleration and as cumulative values during the time period of interest. We analyzed Pearson correlations and area under receiver operating characteristics curves (AUC). We also performed an adjusted analysis, with baseline frequency, variability, and accelerations as covariates. RESULTS: Deceleration area and duration were the best predictors of intrapartum fetal acidemia (fetal lactate concentration >4.8 mmol/L measured with Lactate Pro™) with AUCs of 0.671 (0.682) and 0.678 (0.683) for cumulative measures during 30 (60) minutes prior to FBS, compared to deceleration depth with AUC of 0.632 (0.631). Corresponding Pearson correlations in 30-min (60-min) groups were 0.329 (0.335) and 0.358 (0.354) for deceleration area and duration and 0.212 (0.204) for deceleration depth. Using 250 beats cumulative cut-off for deceleration area during last 30 min, 71% vs. 43% were acidemic and non-acidemic, odds ratio = 3.2 (95% CI 1.7-6.1). CONCLUSIONS: Deceleration area and duration were better predictors of intrapartum fetal acidemia than deceleration depth. Cumulative deceleration area >250 beats during 30 min was associated with three-fold higher odds of intrapartum acidemia compared to <250 beats.

Validation of a computerized algorithm to quantify fetal heart rate deceleration area.

INTRODUCTION: Reliability in visual cardiotocography interpretation is unsatisfying, which has led to the development of computerized cardiotocography. Computerized analysis is well established for antenatal fetal surveillance but has yet not performed sufficiently during labor. We aimed to investigate the capacity of a new computerized algorithm compared with visual assessment in identifying intrapartum fetal heart rate baseline and decelerations. MATERIAL AND METHODS: In all, 312 intrapartum cardiotocography tracings with variable decelerations were analyzed by the computerized algorithm and visually examined by two observers, blinded to each other and the computer analysis. The width, depth and area of each deceleration was measured. Four cases (>100 variable decelerations) were subjected to in-depth detailed analysis. The outcome measures were bias in seconds (width), beats per minute (depth), and beats (area) between computer and observers using Bland-Altman analysis. Interobserver reliability was determined by calculating intraclass correlation and Spearman rank analysis. RESULTS: The analysis (312 cases) showed excellent intraclass correlation (0.89-0.95) and very strong Spearman correlation (0.82-0.91). The detailed analysis of >100 decelerations in four cases revealed low bias between the computer and the two observers; width 1.4 and 1.4 seconds, depth 5.1 and 0.7 beats per minute, and area 0.1 and -1.7 beats. This was comparable to the bias between the two observers: 0.3 seconds (width), 4.4 beats per minute (depth) and 1.7 beats (area). The intraclass correlation was excellent (0.90-.98). CONCLUSION: A novel computerized algorithm for intrapartum cardiotocography analysis is as accurate as gold standard visual assessment, with high correlation and low bias.

Reliability in cardiotocography interpretation - impact of extended on-site education in addition to web-based learning: an observational study.

INTRODUCTION: Previous studies have shown poor reproducibility in cardiotocography (CTG) interpretation. Studies evaluating the Swedish web-based CTG-education program have not proven to increase accurate CTG assessments. The aim of this study was to evaluate whether an extended education can improve inter- and intra-observer reliability in CTG interpretation. MATERIAL AND METHODS: Six obstetricians from two different departments interpreted 106 CTG tracings on two occasions. Both departments used a Swedish national web-based CTG education and test for training. One department had, in addition, an extended education program consisting of on-site lectures and oral examinations. Inter- and intra-observer agreements were calculated by simple or weighted kappa (κ) values for the five parameters assessed on CTG. RESULTS: In both departments inter-observer and intra-observer κ showed moderate to excellent agreement (ranges for κ 0.41-0.76 and 0.65-0.93, respectively). Obstetricians at the department with extended CTG education had better inter-observer reliability for variability and accelerations. This was also the case for intra-observer reliability with the addition of baseline frequency. Both inter- and intra-observer agreement increased from moderate to substantial in both departments when decelerations were dichotomized into harmless (including early and simple variable decelerations) or hypoxic (including late, severe variable, prolonged and combined decelerations) (κ 0.63-0.78) compared with the current sub-classification of decelerations (κ 0.42-0.65). CONCLUSIONS: Agreement in CTG interpretation was better than expected in both departments, especially when divided into harmless/hypoxic changes. Combination of different learning methods (web-based, on-site lectures and case discussion) might result in a better CTG interpretation agreement compared with web-based learning solely.

Low density lipoprotein receptor-related protein-2/megalin is expressed in oligodendrocytes in the mouse spinal cord white matter.

Lipoprotein receptor-related protein-2 (LRP2)/megalin is a member of the low density lipoprotein receptor (LDLR) family, and is essential in absorptive epithelia for endocytosis of lipoproteins, low molecular weight proteins, cholesterol and vitamins, as well as in cellular signaling. Previous studies have shown megalin expression in ependymal cells and choroid plexus. We have investigated megalin expression in the spinal cord of postnatal mice with immunohistochemistry and immunoblot. Antibodies recognizing either the cytoplasmic tail (MM6) or the extracellular domain (E11) of megalin labeled oligodendrocytes in the spinal cord white matter, in parallel with myelination. MM6 antibodies, predominantly labeled the nuclei, whereas E11 antibodies labeled the cytoplasm of these cells. MM6 antibodies labeled also nuclei of oligodendrocytes cultured from embryonic mouse spinal cord. Immunoblots of spinal cord showed intact megalin, as well as its carboxyterminal fragment, the part remaining after shedding of the extracellular domain of megalin. Megalin-immunoreactive oligodendrocytes also expressed presenilin 1, an enzyme responsible for gamma-secretase mediated endodomain cleavage. These findings show that spinal cord oligodendrocytes are phenotypically different from those in the brain, and indicate that megalin translocates signals from the cell membrane to the nucleus of oligodendrocytes during the formation and maintenance of myelin of long spinal cord pathways.