Clinician Identification of Birth Asphyxia Using Intrapartum Cardiotocography Among Neonates With and Without Encephalopathy in New Zealand
Clinician Identification of Birth Asphyxia Using Intrapartum Cardiotocography Among Neonates With and Without Encephalopathy in New Zealand
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DOI：
10.1001/jamanetworkopen.2019.21363
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发表时间：
2020-02-19
影响因子：
13.8
通讯作者：
Sadler, Lynn
中科院分区：
文献类型：
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作者：
Farquhar, Cynthia M.;Armstrong, Sarah;Sadler, Lynn
重要性尽管产前保健的改善和剖宫产率的增加，出生窒息导致新生儿脑病（NE）继续导致新生儿死亡和长期的神经发育障碍。产程描记术（CTG）已在分娩中使用了几十年，以检测应激胎儿，从而加快分娩并避免NE。目的探讨经验丰富的临床医生是否能够发现和应对出生前倒数第二个小时的异常读数从CTG的中重度NE，但没有急性围产期事件的婴儿。设计，设置和参与者本病例对照研究包括10个执业产科医生和助产士在新西兰的妇产科医院。对围产期结局不知情的参与者被要求评估35名NE新生儿和出生缺氧证据（即病例）以及105名无NE或出生缺氧的新生儿（即对照组）的CTG描记，所有这些新生儿均出生于2010年至2011年。数据分析于2017年5月至12月进行。暴露为每名婴儿提供了简短的临床详细信息和出生前倒数第二个小时起的1小时CTG描记。临床医生评估了CTG描记并推荐了一个计划。主要结果和测量报告了评估者内和评估者间对CTG结果和行动计划的一致性，以及评估导致立即行动（即胎儿血样或立即分娩）的异常CTG读数的敏感性（即检测NE）和特异性（即排除无NE）。结果共有35名婴儿（平均[SD]胎龄，40 [1.4]周; 16 [45.7%]剖宫产）被指定为病例，105名婴儿（平均[SD]胎龄，39.4 [1.2]周; 22 [21.0%]剖宫产）被指定为对照。没有婴儿有先天性畸形。所有评估者检测异常CTG结果和建议立即采取行动的平均（范围）灵敏度分别为75%（63%-91%）和41%（23%-57%），平均（范围）特异性分别为67%（53%-77%）和87%（65%-99%）。敏感性分析仅包括评估者间一致率≥ 80%的评估者，与主要分析的差异仅≤ 6%（检测的平均[范围]灵敏度为76% [63%-91%];行动计划的灵敏度为36% [25%-49%];检测的特异性为71% [53%-77%];行动计划的特异性，93% [88%-99%]）。结论和相关性有经验的临床医生检测到3 4名婴儿谁随后被诊断为NE。建议对超过40%的NE婴儿采取加速分娩的措施。这些结果表明，CTG并不能识别出所有有NE风险的婴儿，并且有必要进一步投资于分娩中胎儿监测的新方法。这种情况-一项对照研究调查了在新西兰患有中度至重度新生儿脑病但无急性围产期事件的婴儿中，经验丰富的临床医生是否能在出生前倒数第二个小时从心电图中检测到异常读数。临床医生在患有中度至重度新生儿脑病但无急性围产期事件的婴儿中，在出生前倒数第二个小时检测并处理异常心电图读数？结果在35例新生儿脑病和105例没有，有经验的产科医生和助产士的病例对照研究中，能够检测到3的4个新生儿谁随后被诊断为脑病使用心电图。建议对超过40%的脑病婴儿立即采取行动。这项研究的结果表明，需要进一步投资于产时胎儿监测的新方法。
Importance Despite improvements in antenatal care and increasing cesarean delivery rates, birth asphyxia leading to neonatal encephalopathy (NE) continues to contribute to neonatal death and long-term neurodevelopmental disability. Cardiotocography (CTG) has been used in labor for several decades to detect a stressed fetus so that delivery can be expedited and NE avoided. Objective To investigate whether experienced clinicians can detect and respond to abnormal readings from CTGs during the penultimate hour before birth in infants with moderate to severe NE but no acute peripartum event. Design, Setting, and Participants This case-control study included 10 practicing obstetricians and midwives at maternity hospitals in New Zealand. Participants, who were masked to the perinatal outcome, were asked to assess CTG tracings from 35 neonates with NE and evidence of birth hypoxia (ie, cases) and 105 neonates without NE or birth hypoxia (ie, controls), all of whom were born in 2010 to 2011. Data analysis was conducted from May to December 2017. Exposures Brief clinical details and 1 hour of CTG tracings from the penultimate hour before birth were provided for each baby. Clinicians assessed the CTG tracings and recommended a plan. Main Outcomes and Measures Intra-assessor and interassessor agreement on CTG findings and action plans as well as sensitivity (ie, detection of NE) and specificity (ie, ruling out those without NE) for the assessment of abnormal CTG readings leading to immediate action (ie, fetal blood sample or immediate delivery) were reported. Results A total of 35 infants (mean [SD] gestational age, 40 [1.4] weeks; 16 [45.7%] cesarean deliveries) were designated cases, and 105 infants (mean [SD] gestational age, 39.4 [1.2] weeks; 22 [21.0%] cesarean deliveries) were designated controls. No infants had congenital anomalies. The mean (range) sensitivity for detection of abnormal CTG results and for recommending immediate action for all assessors was 75% (63%-91%) and 41% (23%-57%), respectively, with a mean (range) specificity of 67% (53%-77%) and 87% (65%-99%), respectively. A sensitivity analysis including only assessors with 80% or more interassessor agreement only differed from the main analysis by 6% or less (mean [range] sensitivity for detection, 76% [63%-91%]; sensitivity for action plan, 36% [25%-49%]; specificity for detection, 71% [53%-77%]; and specificity for action plan, 93% [88%-99%]). Conclusions and Relevance Experienced clinicians detected 3 of 4 infants who were subsequently diagnosed with NE. Action to expedite delivery was recommended for more than 40% of infants with NE. These results indicate that CTG does not identify all infants at risk of NE, and that there is a need for further investment in new approaches to fetal surveillance in labor.This case-control study investigates whether experienced clinicians can detect abnormal readings from cardiotocography during the penultimate hour before birth among infants in New Zealand with moderate to severe neonatal encephalopathy but no acute peripartum event.Question Can experienced clinicians detect and manage abnormal cardiotocograph readings during the penultimate hour before birth among infants with moderate to severe neonatal encephalopathy but no acute peripartum event? Findings In this case-control study of 35 infants with neonatal encephalopathy and 105 without, experienced obstetricians and midwives were able to detect 3 of 4 neonates who were subsequently diagnosed with encephalopathy using cardiotocography. Immediate action was recommended for more than 40% of infants with encephalopathy. Meaning The findings of this study indicate that further investment in new approaches to intrapartum fetal surveillance is needed.