Can fetal heart rate variability obtained from cardiotocography provide the same diagnostic value like from electrophysiological interbeat intervals?
Authors: Hoyer Dirk , Schmidt Alexander , Pytlik Adelina , Viehöfer Lukas , Gonçalves Hernâni , Amorim-Costa Célia , Bernardes João , Ayres-de-Campos Diogo , Lobmaier Silvia M , Schneider Uwe 
Published: November 2020

Objective. Fetal heart rate variability (HRV) is widely used for monitoring fetal developmental disturbances. Only expensive fetal magnetocardiography (fMCG) allows the precise recording of the individual fetal heart beat intervals uncovering also highly frequent vagal modulation. In contrast, transabdominal fetal electrocardiography (fECG) suffers from noise overlaying the fetal cardiac signal. Cardiotocography (CTG) is the clinical method of choice, however, based on Doppler ultrasound, improper to resolve single beats concisely. The present work addresses the transferability of established electrophysiological HRV indices to CTG recordings during the fetal maturation period of 20–40 weeks of gestation (WGA). Approach. We compared (a) HRV indices obtained from fMCG, CTG and fECG of short-term amplitude fluctuations (sAMPs) and long-term amplitude fluctuations (lAMPs) and complexity, and (b) their diagnostic value for identifying maturational age, fetal growth restriction (FGR) and small for gestational age (SGA). We used the functional brain age score (fABAS) and categories of long- and short-term regulation and complexity. Main results. Integrating all substudies, we found: (a) indices related to long-term regulation, and with modified meaning and values of short-term regulation and sympathovagal balance (SVB) according to electrophysiological HRV standards can be obtained from CTG. (b) Models using HRV indices calculated from CTG allow the identification of maturational age and discriminate FGR from controls with almost similar precision as electrophysiological means. (c) A modified set of HRV parameters containing short- and long-term regulation and long-term/short-term ratio appeared to be most suitable to describe autonomic developmental state when CTG data is used. Significance. Whereas the predominantly vagally modulated beat-to-beat precise high frequencies of HRV are not assessable from CTG, we identified relevant related HRV indices and categories for CTG recordings with diagnostic potential. They require further evaluation and confirmation with respect to any issues of fetal developmental and perinatal problems in subsequent studies. This methodology significantly extends the measures of established CTG devices.

Novelty and significance HRV indices provide predestinated diagnostic markers of autonomic control in fetuses. However, the established CTG does not provide the temporal precision of electrophysiological recordings.

Beat-to-beat related, mainly vagally modulated behavior is not exactly represented in CTG. However, a set of CTG-specific HRV indices that are mainly comparable to established electrophysiological HRV parameters obtained by magnetocardiography or electrocardiography provided almost similar predictive value for fetal maturational age and were helpful in characterizing FGR.

These results require validation in the monitoring of further fetal developmental disturbances.

We recommend a corresponding extension of CTG methodology.