Fetal myocardial performance index in the late third trimester for the prediction of intrapartum cardiotocographic abnormalities

Fetal myocardial performance index in the late third trimester for the prediction of intrapartum cardiotocographic abnormalities | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL Echocardiography This is a preprint and has not been peer reviewed. Data may be preliminary. 26 July 2025 V1 Latest version Share on Fetal myocardial performance index in the late third trimester for the prediction of intrapartum cardiotocographic abnormalities Authors : Sikolia Wanyonyi 0000-0001-6160-8720 [email protected] and Ingrid Gichere Authors Info & Affiliations https://doi.org/10.22541/au.175354418.84531762/v1 Published Echocardiography Version of record Peer review timeline 1501 views 934 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective We sought to determine whether fetal MPI performed in the late third trimester could be a predictor for the risk of intrapartum cardiotocographic (CTG) abnormalities. Methods A prospective observational study including women presenting for fetal growth ultrasound from 32 weeks. Three consecutive measurements of the left ventricular myocardial performance index were obtained and averaged. The patients’ intrapartum CTG events were later observed. Results A total of 299 women were analyzed. The fetal MPI across the population were 0.41, 0.50 and 0.63, representing 10 th , 50 th and 90 th centiles respectively. A one-way ANOVA did not show a significant difference in MPI values across intrapartum findings for normal, suspicious, and pathological CTGs ( (F (3, 298) = 0.417, p = 0.57) . There was no difference in mean fetal MPI for those women who had pre-eclampsia (0.36; 95% CI (-0.04- 0.05 p= 0.76), gestational diabetes (t (57.31) = -0.34, p = 0.73) and fetal growth restriction (0.49; 95% CI (-0.02-0.06); p = 0.56) compared to the low-risk women. Furthermore, MPI had a modest sensitivity (62.5%) and specificity (50.9%) with a positive and negative predictive value of 31.3% and 79.2% respectively for detecting abnormal intrapartum CTG. The discriminatory ability of MPI for abnormal CTG was also poor (AUC=0.53), besides having minimal diagnostic value (positive likelihood ratio of 1.27 and negative predictive value of 0.74%). No association was found between fetal MPI and adverse neonatal outcomes Conclusion Fetal myocardial performance index obtained in the late third trimester during the growth scan is not a good predictor for abnormal intrapartum fetal heart patterns. Fetal myocardial performance index in the late third trimester for the prediction of intrapartum cardiotocographic abnormalities Running title: Association of myocardial performance and intrapartum cardiotocogram jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf Authors Sikolia Z. Wanyonyi* Aga Khan University, Nairobi, Kenya Ingrid Gichere jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf Aga Khan University, Nairobi, Kenya *Corresponding author: [email protected] ; Tel: +254703124803 Manuscript words: 3520 Figures: 8 Tables: 1 Objective We sought to determine whether fetal MPI performed in the late third trimester could be a predictor for the risk of intrapartum cardiotocographic (CTG) abnormalities. Methods A prospective observational study including women presenting for fetal growth ultrasound from 32 weeks. Three consecutive measurements of the left ventricular myocardial performance index were obtained and averaged. The patients’ intrapartum CTG events were later observed. Results A total of 299 women were analyzed. The fetal MPI across the population were 0.41, 0.50 and 0.63, representing 10 th , 50 th and 90 th centiles respectively. A one-way ANOVA did not show a significant difference in MPI values across intrapartum findings for normal, suspicious, and pathological CTGs ( (F (3, 298) = 0.417, p = 0.57) . There was no difference in mean fetal MPI for those women who had pre-eclampsia (0.36; 95% CI (-0.04- 0.05 p= 0.76), gestational diabetes (t (57.31) = -0.34, p = 0.73) and fetal growth restriction (0.49; 95% CI (-0.02-0.06); p = 0.56) compared to the low-risk women. Furthermore, MPI had a modest sensitivity (62.5%) and specificity (50.9%) with a positive and negative predictive value of 31.3% and 79.2% respectively for detecting abnormal intrapartum CTG. The discriminatory ability of MPI for abnormal CTG was also poor (AUC=0.53), besides having minimal diagnostic value (positive likelihood ratio of 1.27 and negative predictive value of 0.74%). No association was found between fetal MPI and adverse neonatal outcomes Conclusion Fetal myocardial performance index obtained in the late third trimester during the growth scan is not a good predictor for abnormal intrapartum fetal heart patterns. What is already known about the topic? Myocardial performance index is higher in fetuses with fetal growth restriction, obstetric cholestasis, gestational diabetes mellitus and is associated with adverse perinatal outcomes Myocardial hypoxia could lead to abnormal intrapartum fetal heart rate patterns on cardiotocogram What does this study add? There is no correlation between a high myocardial performance index and intrapartum cardiotocographic abnormalities. Introduction Besides its role in the determination of structural integrity of the heart, fetal echocardiography is increasingly being used to assess physiological cardiac function 1-3 . One such cardiac parameter used to evaluate fetal cardiac function is the myocardial performance index (MPI). This numeric value, obtained by using cardiac time intervals, can be captured for each ventricle separately and used to determine primary myocardial systolic dysfunction independent of the heart rate, blood pressure or ventricular geometry 4-6 . While it has been widely used in adult population for the assessment of myocardial performance for cases of myocardial infarction, cardiomyopathy and amyloidosis to predict clinical outcomes and in pediatric patients to evaluate myocardial function in patients undergoing anthracycline treatment 5-8 ; its clinical use in fetal medicine remains sporadic with varying results 9-11 . Consequently, there is no consensus on the utility of fetal myocardial performance index in routine clinical practice. We opined that poor myocardial perfusion because of fetal hypoxia could lead to poor cardiac contractility with consequent fetal death or severe ischemic encephalopathy. These changes should therefore be seen on cardiotocograph (CTG) manifesting either as unprovoked, late or recurrent variable decelerations and/or reduced short-term variation 12,13 . It is known that the ability of the fetus to withstand hypoxic events is dependent on pre-existing conditions and the severity of the insult. However, there are fetuses with no apparent risk factors who still have unfavorable outcomes after exposure to these insults, such as uterine contraction, while some with underlying risk factors apparently tolerate the insults well without any manifestations of cardiac rhythm abnormalities on the intrapartum CTGs 12 . We, therefore, hypothesized that the ability of a fetus to withstand hypoxic events during labour may depend on the functional ability of the fetal heart which the a priori MPI could determine. Consequently, those fetuses with an already high MPI would be more vulnerable to abnormal cardiac rhythms in labour compared to those with a normal MPI, regardless of the underlying risk profile. We hoped that this information would help us determine those fetuses that may benefits from continuous electronic fetal monitoring despite their low risk profile to present adverse perinatal outcomes. To achieve this, we sought to determine whether fetal myocardial performance index in the third trimester could be used to predict the risk of intrapartum cardiotocographic (CTG) abnormalities. METHODS Study Design : A prospective observational study Study population: Pregnant women presenting for fetal growth ultrasound in the third trimester. Eligibility criteria: We enrolled all women attending for fetal growth scan after 32 weeks of gestation. We excluded those with known fetal congenital anomalies, multiple gestation, and those who were recommended immediate delivery after the ultrasound session for other indications. jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf Sample size We estimated that 214 women would be needed, assuming a higher proportion (0.6) of fetuses with a high MPI will exhibit abnormal CTG features with type 1 error of 0.05, power of 80% and a 2- sided significance level of 0.05. jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf Recruitment All women who presented for the fetal growth scan after 32 weeks’ gestation were invited to participate in the study, provided they met the eligibility criteria. Every consecutive eligible woman was recruited until the appropriate sample size was obtained. Measurement of the MPI All measurements for the MPI were undertaken on the General Electric Voluson ultrasound machines at the Aga Khan University Hospital, Nairobi, Fetal Medicine Unit. All measurements were undertaken by one operator who was skilled in the fetal echocardiography. The measurements were stored and recorded but were not available to the attending physician since this is not a routinely acquired measurement and is not currently used in clinical practice. The subsequent management of the patient was not altered by this measurement, and the women continued with their care as prescribed by the obstetrician. Upon presenting in labour, the admission CTG was assessed for any abnormalities as per the unit protocol and any abnormal CTG patterns in labour were documented. Women eligible for continuous electronic fetal monitoring were managed as per the unit protocols. The patient charts were later accessed to capture the intrapartum events Echocardiographic technique for obtaining left ventricular MPI Considering lack of consensus on the most appropriate MPI technique to use in the fetus, the left ventricular MPI was chosen. This is because it easy to obtain, with a good reproducibility, moreover, it has been shown to be comparable the right MPI 4,14 . jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf Technique for obtaining left ventricular MPI A two-dimensional fetal echocardiography was performed using a General Electric Voluson E10. The images were frozen, and measurements obtained using the inbuilt software for TEI index. A gated pulsed Doppler sample volume (5mm) was placed in the left ventricle at the junction of the anterior leaflet of the mitral valve and the LV outflow tract in an apical five-chamber view and normal LV filling and emptying noted (Figure 1). The following time intervals were measured: from the end of the A-wave to the onset of the aortic pulsed Doppler tracing; isovolumetric contraction time(ICT), from the onset to the end of the aortic pulsed Doppler tracing; ejection time(ET) and from the end of the ejection time to the onset of the E-wave; isovolumetric relaxation time (IRT) (Figure 1). A sweep speed of 75-100mm/sec was used, and three successive measurements were obtained and averaged. Primary outcome measures Abnormal CTG (suspicious or pathological) Secondary outcomes measures Admission to Neonatal Intensive care Unit (NICU) Ethical Consideration Ethical approval was sought from the Institutional Scientific, Ethics and Research Committee (ISERC) Ref: 2022/ISERC-100 (V2) and the study was approved by the National Commission for Science Technology and Innovation (NACOSTI); Licence No: NACOSTI/P/23/28100. Written informed consent was obtained from all women enrolled in the study and all data were anonymized and deidentified. Data management and analysis Data were captured from the data collection forms and transferred to an Excel spreadsheet, cleaned and analyzed using R-Programming Language for Data Sciences. Baseline characteristics were presented using appropriate measurement of spread and variations. An analysis of variance (ANOVA)- test was used to determine correlation between MPI and CTG abnormalities, and the Student T-test was used to determine the association between MPI and fetal weight, preeclampsia and gestational hypertension. RESULTS A total of 304 women were recruited during the study period, of which 5 declined to participate, leaving 299 women available for the ultrasound scan. The flow of the participants is shown in figure 2 Most of the women, 205 (68.5%), were multiparous. The characteristics of the study participants with intrapartum outcomes are presented in Table 1. The median duration from the time of acquiring the ultrasound measurements to the initial CTG was 3.6 weeks (interquartile range 5.6-9.2 weeks). The distribution of the left ventricular function (LVFT), which was used to determine the fetal myocardial performance is shown in figure 3 with values of 0.41, 0.50 and 0.63 representing the 10 th , 50 th and 90 th centiles, respectively. We therefore defined high MPI as any value above 0.63 (90th centile). We compared the left ventricular MPI for those participants who had intrapartum CTG. The data exploration (Figure 4) showed that low MPI was more common in fetuses with suspicious and pathological CTG patterns. To determine whether the mean Myocardial Performance Index (MPI) values differed across intrapartum CTG findings groups (Normal, Suspicious, and Pathological), we conducted a one-way ANOVA, which showed no statistically significant difference (F (3, 299) = 0.417, p = 0.57). Furthermore, MPI had a modest sensitivity (62.5%) and specificity (50.9%) with a positive and negative predictive value of 31.3% and 79.2% respectively for detecting abnormal intrapartum CTG. The discriminatory ability of MPI for abnormal CTG was also poor (Area Under the Curve=0.53), besides having minimal diagnostic value (positive likelihood ratio of 1.27 and negative predictive value of 0.74%), even when a lower cut off value of 0.50 was used (Figure 5). We compared the MPI between appropriate for gestational age (AGA) and fetal growth-restricted (FGR) fetuses using an independent t-test. The results indicated no statistically significant difference in mean MPI values between the two groups 0.49 95% CI ( -0.02-0.06; p = 0.56). (Figure 6) There was no statistically significant difference in mean MPI in pregnancies without pre-eclampsia and those with pre-eclampsia (0.36, 95% CI (-0.04- 0.05; p= 0.76)). (Figure 7) We then compared LVFT between pregnancies with and without diabetes and found no significant difference (t (57.31) = -0.34, p = 0.73). However, we observed a statistically significant difference in LVFT between pregnancies with and without any other condition (t (45.16) = 2.67, p = 0.01), suggesting that the any other condition may significantly influence LVFT. Any other condition was a composite measurement for other medical conditions that the women had other than those mentioned above e.g. thyroid disease, cholestasis, thrombocytopenia, renal disease and skin conditions There were 16 babies (6.7%) who were admitted in the neonatal intensive unit (NICU), but no cases of stillbirth or neonatal deaths in our cohort. There was also no difference in fetal MPI in those babies who were admitted to NICU compared to those who were not (figure 8). We assessed intra-observer variability for repeated measurements of isovolumetric contraction time (ICT), ejection time (ET), and isovolumetric relaxation time (IRT) using the intraclass correlation coefficient (ICC). The ICC for ICT was (F (301, 604) = 6.04, p < 0.001), the ICC for ET was (F (301, 604) = 7.81, p < 0.001) and. the ICC for IRT was (F (301, 604) = 7.02, p < 0.001). Discussion In this observational study, there was no correlation found between high fetal MPI obtained in the late third trimester (defined as a value above the 90 th centile) and intrapartum CTG abnormalities. Furthermore MPI had a poor discriminatory ability and sensitivity for prediciting abnormal intrapartum CTG findings. We had postulated that those fetuses with a high myocardial performance were more likely to have some degree of compromise and would therefore exhibit abnormal heart patterns during labour. The purpose was to determine if third-trimester MPI obtained during fetal growth assessment could be used as a triage tool for those women who may need continuous electronic fetal monitoring in labour. However, contrary to these assumptions, there was a higher tendency (though not statistically significant) for fetuses with a lower MPI to have abnormal CTG patterns. Similar findings were reported in a smaller study by Gimovsky et a l 15 who observed higher MPI in those fetuses that had accelerations, which presumably should be an indication of a healthy fetus. It is known that regular uterine contractions cause mechanical compression of the fetal head and umbilical cord, which could eventually lead to hypoxic stress to the fetus. This results in myocardial hypoperfusion which could then affect contractility of the fetal heart. These changes are ultimately manifested on the intrapartum CTG 16. We expected that those fetuses with high MPI would be more venerable to these effects. However, the absence of significant changes in CTG for the fetuses with a high MPI, indicates that intrapartum CTG patterns are more than just a reflection of fetal myocardial hypoxia but an interplay of various other fetal and maternal factors. Interestingly, several studies have shown that MPI is higher in fetuses with fetal growth restriction, obstetric cholestasis, gestational diabetes mellitus and overall adverse perinatal outcomes 17-25 . Even though our study was not sufficiently powered for these outcomes, the sub-analysis did not demonstrate an association of fetal MPI with either fetal growth restriction, gestational diabetes, gestational hypertension or adverse perinatal outcomes as determined by admission to NICU. Similarly, Henry et al 26 did not find any clinical utility of fetal MPI in triage for either FGR or small for gestational age SGA fetus. However, we found a tendency for a higher MPI in fetuses of women, who had ‘other medical conditions’, but since this was a composite variable consisting of several conditions, it would be difficult to single out which conditions influenced this trend. Our study was well powered and with an adequate sample size which was achieved despite an attrition rate of 20%. We used a standardized technique for measuring the MPI, and there was good intraoperator variability and reproducibility. Since this was not a trial, we do anticipate inherent limitations associated with observational studies. We also acknowledge that we did not use absolute cut-off values for MPI as described by some authors who have attempted to define the gestational specific reference charts 27-31 . These are yet to be universally validated and adopted for clinical use. However, we used MPI centiles to define high and low MPI, as we considered this approach to be more pragmatic. Conclusion Fetal myocardial performance index obtained in the late third trimester during the growth scan is not a good predictor for abnormal intrapartum fetal heart patterns and therefore has limited utility in triaging women who may require continuous intrapartum electronic fetal monitoring. There is still uncertainty on its use in supplementing the management decisions in other conditions that may compromise fetal wellbeing, thus a need for continued research on its use in routine obstetric care. Authors’ Contribution Statement Sikolia Z. Wanyonyi: Conceptualization and design of study, image acquisition, data analysis and synthesis and writing the initial and final manuscript Ingrid Gichere: Initial conceptualization and design of the study, writing of the initial and final manuscript Acknowledgment We would like to thank Ms. Moreen Oundo for the recruitment and follow-up of study participants and for keeping all the data secure, Dr Morris Ogero who assisted with the data analysis and all the women who volunteered to participate in this study Data Availability jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions Ethical Approval Statement Ethical approval was sought from the Aga Khan University, Nairobi; Institutional Scientific, Ethics and Research Committee (ISERC) Ref: 2022/ISERC-100 (V2); Date: 03/04/2023 and the study was approved by the National Commission for Science Technology and Innovation (NACOSTI), Kenya; License No: NACOSTI/P/23/28100; Date 23/07/2023 Patient Consent statement Written informed consent was obtained from all women enrolled in the study and all data were anonymized and deidentified. All women recruited in this study were above the legal age for consent. Funding Sources None Conflict of interest The authors declare no conflict of interest References 1. van Splunder IP, Wladimiroff JW. Cardiac functional changes in the human fetus in the late first and early second trimesters. Ultrasound Obstet Gynecol 1996; 7: 411–415. 2. Kleinman CS, Donnerstein RL. 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Ultrasound Obstet Gynecol 2013; 42: 59 jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf Figure legends Figure 1: Left ventricular myocardial performance index measurements Figure 2: Flow of participants in the study Figure 3: Left ventricular function (myocardial performance index) across gestation age Figure 4. Myocardial performance index and intrapartum CTG findings Figure 5: Receiver operating curve for MPI and intrapartum CTG findings Figure 6: Myocardial performance index according to the fetal weight Figure 7: Myocardial performance index in patients with pre-eclampsia Figure 8: Myocardial performance index and admission to NICU Supplementary Material File (figure 2.docx) Download 38.32 KB File (revised table 1 echo.docx) Download 15.67 KB Information & Authors Information Version history V1 Version 1 26 July 2025 Peer review timeline Published Echocardiography Version of Record 18 Sep 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Echocardiography Keywords cardiotocogram fetal echocardiogram myocardial performance index Authors Affiliations Sikolia Wanyonyi 0000-0001-6160-8720 [email protected] The Aga Khan University Hospital Nairobi View all articles by this author Ingrid Gichere The Aga Khan University Hospital Nairobi View all articles by this author Metrics & Citations Metrics Article Usage 1501 views 934 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Sikolia Wanyonyi, Ingrid Gichere. Fetal myocardial performance index in the late third trimester for the prediction of intrapartum cardiotocographic abnormalities. Authorea . 26 July 2025. DOI: https://doi.org/10.22541/au.175354418.84531762/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. 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