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20180523 Vlemminx Real-time electrohysterography Citation for published version (APA): Vlemminx, M. W. C. (2018). Real-time electrohysterography: a novel technology used on the labour ward. Technische Universiteit Eindhoven. Document status and date: Published: 23/05/2018 Document Version: Publisher’s PDF, also known as Version of Record (includes final page, issue and volume numbers) Please check the document version of this publication: • A submitted manuscript is the version of the article upon submission and before peer-review. There can be important differences between the submitted version and the official published version of record. People interested in the research are advised to contact the author for the final version of the publication, or visit the DOI to the publisher's website. • The final author version and the galley proof are versions of the publication after peer review. • The final published version features the final layout of the paper including the volume, issue and page numbers. Link to publication General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal. If the publication is distributed under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license above, please follow below link for the End User Agreement: www.tue.nl/taverne Take down policy If you believe that this document breaches copyright please contact us at: [email protected] providing details and we will investigate your claim. Download date: 10. Oct. 2021 Real-time electrohysterography: A novel technology used on the labour ward Marion Vlemminx © Marion Vlemminx, Eindhoven, 2018. All rights reserved. No part of this book may be reproduced in any form by any means, without prior permission of the author. A catalogue record is available from the Eindhoven University of Technology Library ISBN: 978-90-386-4485-1 Cover design: evelienjagtman.com Layout: evelienjagtman.com Printing: Ipskamp printing Financial support for the publication of this thesis has been kindly provided by Bridea Medical, Chipsoft, Eindhoven University of Technology, Grafimedics, Máxima Medical Centre and Nemo Healthcare. Real-time electrohysterography: A novel technology used on the labour ward PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Technische Universiteit Eindhoven, op gezag van de rector magnificus prof.dr.ir. F.P.T. Baaijens, voor een commissie aangewezen door het College voor Promoties, in het openbaar te verdedigen op woensdag 23 mei 2018 om 16:00 uur door Maria Wilhelmina Catharina Vlemminx geboren te Middelbeers Dit proefschrift is goedgekeurd door de promotor, en de samenstelling van de promotiecommissie is als volgt: Voorzitter: prof.dr.ir. A.B. Smolders Promotor: prof.dr. S.G. Oei Copromotoren: dr.ir. M.B. van der Hout-van der Jagt dr.ir. C. Rabotti Leden: prof.dr. J.G. Nijhuis (Maastricht Universitair Medisch Centrum) prof.dr. S.A. Scherjon (Universitair Medisch Centrum Groningen) prof.dr. R.M. Aarts prof.dr.ir. J.W.M. Bergmans Het onderzoek dat in dit proefschrift wordt beschreven is uitgevoerd in overeenstemming met de TU/e Gedragscode Wetenschapsbeoefening. SUMMARY Real-time electrohysterography: A novel technology used on the labour ward Uterine activity monitoring is one of the crucial intrapartum measurements for labour surveillance. Unfortunately, conventional uterine monitoring methods have major draw- backs. The intra-uterine pressure catheter (IUPC) can adequately monitor amplitude and frequency of uterine contractions; however it requires ruptured membranes, and it is associated with rare, but severe complications. Nowadays, its non-invasive alternative, external tocodynamometry (TOCO) is most widely used. However, external TOCO meas- urements are affected by a low accuracy and high dependency on proper positioning. Moreover, the sensitivity of TOCO is adversely influenced by maternal obesity which is currently one of the greatest challenges for pregnancy and labour care. Electrohysterography (EHG) is an innovative technology comprising electrodes on the maternal abdomen to measure the underlying uterine biopotentials and, from these, provide an EHG-based tocogram. Recently, several EHG systems have been proposed to provide a tocogram in real-time. This technology is therefore becoming available for daily practice on the labour ward. EHG could enhance external uterine monitoring compared to TOCO due to the less position-sensitiveness by the adhesive contact electrodes, and the improved sensing despite of excessive subcutaneous tissue in obese patients. Addi- tionally, instead of the global variations of intra-uterine pressure measured by IUPC on the one hand, or an average change of the abdominal wall curvature provided by exter- nal TOCO on the other hand, EHG provides more localised measurements. Since these measurements are related to the electrophysiological root cause of uterine contractions, EHG potentially allows for a more detailed diagnostic information. In this PhD-thesis we validated a novel real-time EHG technology and studied the diag- nostic value, advantages and limitations of EHG for uterine monitoring during term labour. In a prospective diagnostic accuracy study, we tested the performance of an EHG system (PUREtrace) which is based on prototypes that have been developed by the Eind- hoven University of Technology in collaboration with the Máxima Medical Centre. During term labour, 52 women were simultaneously exposed to IUPC, TOCO and EHG for two hours. The contractions in each tocogram were automatically detected by a computer-based algorithm. The main outcome parameter was the sensitivity of the external methods (TOCO and EHG) to detect uterine contractions, with IUPC as the method of reference. Furthermore, the EHG sensitivity was compared between obesity groups and correlated to obesity parameters. The results revealed that EHG has a high sensitivity for uterine contraction detection during term labour with IUPC as reference, and the sensitivity of EHG was significantly higher than TOCO. EHG could also enhance external uterine monitoring in obese women as it was significantly less influenced by maternal obesity than TOCO. However, when using EHG in clinics, physicians do need to be aware that EHG detected a higher number of contractions compared to both IUPC and TOCO, possibly due to measuring the origin of contractions instead of its result. Users’ and patients’ preferences were evaluated by customised questionnaires. The patients indicated to prefer EHG over IUPC and TOCO. The placement and presence of EHG electrodes were considered as the least cumbersome, while TOCO was preferred for sensor removal. Our participants reported increased physical discomfort due to the TOCO belt and its frequent need for repositioning. Healthcare professionals instead, reported ambiguous results regarding their preferences for either of the external methods. They advised several technical alterations for EHG such as a wireless and waterproof system with an integrated impedance meter. This thesis further emphasises that uterine activity monitoring deserves a more prom- inent role in obstetric care. In a systematic review, we focused on the special event of uterine rupture. Several uterine activity characteristics, measured by IUPC or TOCO, were associated with uterine rupture: uterine hyperstimulation, decrease in uterine activity, and an increased or reduced baseline tonus. A meta-analysis on uterine hyperstimulation showed an increased risk of uterine rupture in case of hyperstimulation, on the margin of significance. As EHG can provide more details on the uterine activity pattern, it might help to detect these uterine activity characteristics earlier. Besides real-time uterine monitoring during labour, other EHG applications are currently being evaluated, such as the prediction of vaginal birth and the prediction of preterm labour. However, more research is necessary to validate these EHG applications and pre- pare them for daily care. In conclusion, this PhD-thesis shows that EHG is a sensitive method to improve exter- nal uterine monitoring throughout term labour for both non-obese and obese women. Moreover, it provides clinicians an extended overview of EHG characteristics for uterine monitoring during term labour that could be useful for optimal interpretation of EHG traces in clinics. In addition, it aids clinicians in better weighing the advantages and dis- advantages of EHG versus IUPC and TOCO; i.e., the accuracy and invasiveness of IUPC, and the inaccuracy and safety of TOCO. Overall, this thesis supports obstetricians to start using real-time EHG on the labour ward. TABLE OF CONTENTS Chapter 1 General introduction 13 Chapter 2 Electrohysterography: 29 A promising alternative for uterine activity monitoring Nederlands tijdschrift voor geneeskunde. 2015;159(0):A8535 Chapter 3 Clinical use of electrohysterography during term labour: 39 A systematic review on diagnostic value, advantages, and limitations Obstetrical and Gynaecological Survey. Minor revisions.
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