Li Zhuyu, Wang Yan, Cai Jian, Zhao Peizhen, Chen Hanqing, Liu Haiyan, Shen Lixia, Chen Lian, Li Shufang, Zhao Yangyu, Wang Zilian
Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China.
Department of Obstetrics and Gynaecology, Peking University Third Hospital, Beijing 100191, China.
Matern Fetal Med. 2022 Apr 26;4(2):95-102. doi: 10.1097/FM9.0000000000000146. eCollection 2022 Apr.
To evaluate the agreement and reliability of intrapartum nonreasurring cardiotocography (CTG) interpretation and prediction of neonatal acidemia by obstetricians working in different centers.
A retrospective cohort study involving two tertiary hospitals (The First Affiliated Hospital of Sun Yat-sen University and Perking University Third Hospital) was conducted between 30 September 2018 and 1 April 2019. Six obstetricians from two hospitals with three levels of experience (junior, medium, and senior) reviewed 100 nonreassuring fetal heart rate (FHR) tracings from 1 hour before the onset of abnormalities until delivery. Each reviewer determined the FHR pattern, the baseline, variability, and presence of acceleration, deceleration, sinusoidal pattern, and predicted whether neonatal acidemia and abnormal umbilical arterial pH < 7.1 would occur. Inter-observer agreement was assessed using the proportions of agreement (Pa) and the proportion of specific agreement (Pa for each category). Reliability was evaluated with the kappa statistic (k-Light's kappa for n raters) and Gwet's AC1 statistic.
Good inter-observer agreement was found in evaluation of most variables (Pa > 0.5), with the exception of early deceleration (Pa = 0.39, 95% confidence interval (): 0.36,0.43). Reliability was also good among most variables (AC1 > 0.40), except for acceleration, early deceleration, and prediction of neonatal acidemia (AC1 = 0.17, 0.10, and 0.25, respectively). There were no statistically significant differences among the three groups, except in the identification of accelerations (Pa = 0.89, 95% : 0.83,0.95; Pa = 0.50, 95% : 0.41,0.60, and Pa = 0.35, 95% : 0.25,0.43 in junior, medium and senior groups, respectively) and the prediction of neonatal acidemia (Pa = 0.52, 0.52, and 0.62 in junior, medium and senior groups, respectively), where agreement was highest and lowest in the junior-level group, respectively. The accuracy and sensitivity of the prediction for umbilical artery pH < 7.1 were similar among the three groups, but the specificity was higher in the senior groups (93.68% 92.53% 98.85% in junior, medium and senior groups, = 0.015).
Although we found a good inter-observer agreement in the evaluation of the most basic CTG features and FHR category statistically, it was insufficient to meet the clinical requirements for "no objection" interpretation for FHR tracings. Further specialized training is needed for standardized interpretation of intrapartum FHR tracings.
评估不同中心的产科医生对产时无反应型胎心监护（CTG）的解读以及对新生儿酸血症预测的一致性和可靠性。
2018年9月30日至2019年4月1日期间，在两家三级医院（中山大学附属第一医院和北京大学第三医院）进行了一项回顾性队列研究。来自两家医院的6名具有三个经验水平（初级、中级和高级）的产科医生，回顾了100份从异常开始前1小时直至分娩的无反应型胎心率（FHR）描记图。每位评估者确定FHR模式、基线、变异性以及加速、减速、正弦波模式的存在情况，并预测新生儿酸血症以及脐动脉pH值<7.1的异常情况是否会发生。使用一致性比例（Pa）和特定一致性比例（每个类别下的Pa）评估观察者间的一致性。用kappa统计量（n个评估者的Light's kappa）和Gwet's AC1统计量评估可靠性。
在大多数变量的评估中发现观察者间具有良好的一致性（Pa>0.5），早期减速除外（Pa = 0.39，95%置信区间：0.36，0.43）。在大多数变量中可靠性也良好（AC1>0.40），加速、早期减速以及新生儿酸血症预测除外（AC1分别为0.17、0.10和0.25）。三组之间除了在加速的识别方面（初级、中级和高级组的Pa分别为0.89，95%：0.83，0.95；0.50，95%：0.41，0.60；0.35，95%：0.25，0.43）以及新生儿酸血症的预测方面（初级、中级和高级组的Pa分别为0.52、0.52和0.62）存在差异外，无统计学显著差异，其中初级组的一致性分别为最高和最低。三组对脐动脉pH<7.1预测的准确性和敏感性相似，但高级组的特异性更高（初级、中级和高级组分别为93.68%、92.53%和98.85%，P = 0.015）。
虽然我们在统计学上发现观察者间对最基本的CTG特征和FHR类别评估具有良好的一致性，但这不足以满足对FHR描记图“无异议”解读的临床要求。需要进一步进行专业培训以实现产时FHR描记图的标准化解读。
