The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20

Association between fetal myocardial

performance index and fetal heart rate
monitoring: a prospective observational cohort
study

Alexis C. Gimovsky, Brianne Whitney, Dennis Wood & Stuart Weiner

To cite this article: Alexis C. Gimovsky, Brianne Whitney, Dennis Wood & Stuart Weiner (2017):
Association between fetal myocardial performance index and fetal heart rate monitoring: a
prospective observational cohort study, The Journal of Maternal-Fetal & Neonatal Medicine, DOI:
10.1080/14767058.2017.1399119

To link to this article: http://dx.doi.org/10.1080/14767058.2017.1399119

Published online: 13 Nov 2017.

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 THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE, 2017
https://doi.org/10.1080/14767058.2017.1399119

ORIGINAL ARTICLE

Association between fetal myocardial performance index and fetal heart rate
monitoring: a prospective observational cohort study
Alexis C. Gimovskya , Brianne Whitneyb, Dennis Woodc and Stuart Weinerc
a
Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, the George Washington University School of
Medicine and Health Sciences, Washington, DC, USA; bDepartment of Obstetrics and Gynecology, Sidney Kimmel Medical College at
Thomas Jefferson University, Philadelphia, PA, USA; cDepartment of Obstetrics and Gynecology, Division of Maternal Fetal Medicine,
Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA

ABSTRACT ARTICLE HISTORY

Objective: To evaluate whether the left myocardial performance index (MPI) changes in associ- Received 11 September 2017
ation with the fetal heart rate (FHR) tracing during labor. Revised 16 October 2017
Study design: Women with term, singleton pregnancies, in labor were recruited to this pro- Accepted 27 October 2017
Downloaded by [University of Glasgow] at 17:11 15 November 2017

spective cohort study. Primary outcome: difference in left MPI between Category of fetal heart
rate tracings. Secondary outcomes: differences in left MPI by FHR characteristics. Participants KEYWORDS
underwent ultrasound examination, during which fetal MPI was measured. Myocardial Performance
Results: Twenty-four laboring patients were recruited. There were 13 patients with Category I Index; Tei Index; fetal
FHR, 11 patients with Category II FHR, and 0 patients with Category III FHR. Demographics were echocardiography; labor;
similar between the groups. MPI was not significantly different between fetuses with Category I ultrasound; fetal heart rate
or Category II FHR (0.67 versus 0.65, p ¼ .385). MPI was significantly higher in fetuses with accel- category
erations versus those without (0.71 versus 0.59, p ¼ .045). MPI was not significantly different for
fetuses with or without decelerations (0.65 versus 0.68, p ¼ .350), between deceleration type
(0.50 versus 0.64 versus, 0.75, p ¼ .421), or between variability type (0.56 versus 0.68, p ¼ .113).
Conclusions: MPI of fetuses in term, laboring patients did not vary with differing FHR character-
istics except for the presence or absence of accelerations.

Introduction normal term labor [14]. In some circumstances, labor

Myocardial performance index (MPI) is a Doppler-
derived tool that evaluates global myocardial perform-
ance. This tool was originally described by Tei in 1995
to assess cardiac changes between normal hearts and
severe dilated cardiomyopathy [1]. The MPI is depend-
ent on myocardial function, systemic arterial and ven-
ous pressure, diastolic function, contractility, and atrial
function [2,3]. Additionally, it is not affected by ven-
tricular size or heart rate [1,4]. During the last decade,
it has been evaluated for use in understanding global
cardiac function in fetuses with twin to twin transfu-
sion syndrome, preterm premature rupture of mem-
branes, fetal anemia, diabetes, fetal arrhythmia, and
intrauterine growth restriction (IUGR) [2,5–13]. Many of
these studies have found significant increases to MPI
in these fetuses [7,12,13].
MPI has previously been evaluated during normal
term labor to establish attainability and normative val-
ues [14]. MPI was both able to be measured during
labor and also was found to remain unchanged by
can be a stressful milieu for a fetus. During labor, the
fetal heart rate is monitored continuously to evaluate
fetal well-being by screening for signs of fetal decom-
pensation from hypoxemia, or acidosis. Fetal hypox-
emia may affect fetal cardiovascular status, as
manifested by progressive loss of beat-to-beat variabil-
ity and heart rate decelerations, especially variable or
late decelerations and may also cause fetal tachycar-
dia. The MPI changes mostly with isovolumetric con-
traction time; fetal hypoxemia may increase the
isovolumetric contraction time relative to ejection
time.
The earliest mention of Fetal Heart Rate (FHR) moni-
toring was reported by Marsac in 1650 [15]. In 1893,
Von Winckel suggested that a FHR greater than 160
beats per minute (bpm) or less than 100 bpm was
indicative of “fetal distress” [16]. In the early twentieth
century intrapartum FHR monitoring by intermittent
auscultation became standard practice. During the late
1940s and 1950s, physicians attempted to improve on
intermittent auscultation by implementing continuous

CONTACT Alexis C. Gimovsky agimovsky@mfa.gwu.edu 2150 Pennsylvania Ave, 6A, Washington, DC 8–8995, USA
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
 2 A. C. GIMOVSKY ET AL.
intrapartum FHR monitoring. This became standard
clinical practice in the early 1970s in the United States.
The practice of continuous FHR monitoring was
thought to be impartial; proving early detection of
fetal hypoxemia preceding permanent fetal neurologic
damage [17,18]. During the 1980–2000s, clinicians
described FHR’s directly, by baseline, variability, pres-
ence or absence of accelerations and decelerations
and made clinical decisions without formal definitions
of exactly what was considered a sign of hypoxemia.
In order to formalize nomenclature, in 2008, the
Eunice Kennedy Shriver National Institute of Child
Health and Human Development partnered with the
American College of Obstetricians and Gynecologists
(ACOG) and the Society for Maternal Fetal Medicine to
sponsor a workshop focused on electronic FHR moni-
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toring with the purposes of “(1) to review and update
the definitions for FHR pattern categorization from the
prior workshop; (2) to assess existing classification sys-
tems for interpreting specific FHR patterns and make
recommendations about a system for use in the USA;
and (3) to make recommendations for research prior-
ities for EFM” [19]. In 2010, ACOG introduced a follow
up practice bulletin on “Management of Intrapartum
FHR tracings”. In this document, management strat-
egies are based on FHR Category [20].
These categories were created in order to aid pro-
viders in clinical decision making during labor in
regards to risk of potential fetal hypoxemia. Category I
is strongly prognostic of normal fetal acid–base status,
Category II is considered to be indeterminate and
Category III signifies abnormal fetal acid–base status
[19]. It is possible that the physiological changes that
cause differences in fetal heart rate patterns may also
be apparent as a difference in fetal MPI. We hypothe-
size that the underlying pathophysiology of differences
in fetal heart rate tracing patterns have an effect on
global cardiac function and therefore may be corre-
lated to the MPI and that MPI may be a useful adjunct
to Fetal Heart Rate (FHR) tracing interpretation. The
objective of this study was to evaluate whether the
left myocardial performance index (MPI) changes in
association with categories of FHR tracings.
Materials and methods
Women with term, singleton pregnancies in labor
were recruited to this pilot prospective cohort study at
a single academic medical center. This study was
approved by the Thomas Jefferson University
Institutional Review Board and written informed con-
sent was obtained from all participants. Because this
was a pilot study, the sample size was obtained by
convenience.
Women included in this study were those with
singleton pregnancies, undergoing continuous fetal
heart tracings and were in labor between 36 and 41
weeks gestation. Labor was defined as contractions with
cervical change. Exclusion criteria were women with car-
diac abnormalities in the fetus, other known major fetal
anomalies, multiple gestations, intrauterine growth
restriction, noncephalic presentation, received narcotic
analgesia within 2 hours, currently on supplemental oxy-
gen, and scheduled delivery via cesarean section.
Pregnancy outcomes were collected after delivery.
Demographic data for the participants including
age, gravity, parity, ethnicity, BMI, and gestational age
were recorded. Gestational age was determined by last
menstrual period with confirmation by first or second
trimester ultrasound.
Patients were recruited upon presentation to labor
and delivery. An ultrasound was then performed on
each participant. One single provider, a fellow in
Maternal Fetal Medicine, performed all ultrasound
exams with the Zonare machine (SmartCart Diagnostic
Ultrasound System, Mountain View, CA) and a transab-
dominal curvilinear transducer (C6-2 transducer). The
ultrasound provider was trained by a certified fetal
echocardiogram sonographer. The participants were
assessed in the supine position with a left lateral tilt.
An apical four-chamber view of the fetal heart was
found and pulsed Doppler was used to obtain a wave-
form to obtain the MPI using a single Doppler gate
over the mitral and aortic valve leaflets as described in
previous studies [14,21]. The time intervals measured
from the Doppler waveform included the isovolumetric
contraction time (ICT), defined as the time from the
closure of the mitral valve until the opening of the
aortic valve, the isovolumetric relaxation time (IRT),
defined as the time from closure of the aortic valve
closure until opening of the mitral valve, and ejection
time (ET), from the opening of the aortic valve to the
closing of the aortic valve. Measurements were
obtained using valve “clicks”. These measurements
were taken three times but only one time during a
patient’s labor course. These measurements were then
used to calculate the left MPI from the formula
MPI ¼ (ICT þ IRT)/ET. Figure 1 represents both sche-
matic and real time acquisition of fetal MPI. The mean
MPI over the three attained values was used for ana-
lysis. MPI measurements were used only if within 5
beats per minute of each other to limit beat-to-beat
variability. We chose to only report left MPI in this
study since we have published previously on MPI in
labor and found no clinically significant difference
 THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 3

(a) Schematic representation (b)

Real time image acquisition

F
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Figure 1. Myocardial Performance Index [27]. IVCT: intraventricular contraction time; IVRT: intraventricular relaxation time; LVET:
left ventricular ejection time; LVOT TEI: left ventricular outflow tract Tei Index; LV TEI: left ventricular Tei Index.

between right and left MPI [14]. One single researcher Table 1. Demographics.
evaluated the Doppler waveforms to make measure- Category I FHR Category II FHR
Demographic (n ¼ 13) (n ¼ 11) p value
ments. MPI values during labor have been published
Age, years 30.2 ± 5.9 28.2 ± 5.4 .39
previously by our group [14]. Gravidity 4.5 ± 3.7 3.6 ± 1.7 .74
At the time of the ultrasound FHR characteristics Parity 1.7 ± 1.4 1.2 ± 1.0 .32
BMI at delivery 33.6 ± 5.8 34.8 ± 6.8 .64
were recorded. FHR Categories were recorded as Gestational age, weeks 39.9 ± 1.0 39.9 ± 1.0 .88
defined by ACOG Practice Bulletin 106 [19]. After deliv- Race
African American 6 (46.2) 7 (63.6) .54
ery, perinatal outcomes were collected including mode Caucasian 3 (23.1) 2 (16.2)
of delivery, Apgar score, neonatal intensive care unit Hispanic 3 (23.1) 1 (9.1)
Asian 0 (0) 1 (9.1)
(NICU) admission, birth weight, and umbilical cord pH. Other 1 (7.7) 0 (0)
The patient’s care during labor and delivery was Data are reported in mean ± standard deviation or n (%).
then as per provider preference. The providers and BMI: Body mass index; FHR: fetal heart rate.
labor and delivery staff were blinded to the results of
the ultrasound assessment and of the MPI calculation.
The primary outcome was the difference in left MPI Board and all patients underwent informed consent.
between Category I and Category II FHR. Secondary All were able to have their MPI measured. There
outcomes were the differences in left MPI between were 13 patients with Category I, 11 patients with
other fetal heart rate characteristics. This included the Category II, and zero patients with Category III FHR.
presence or absence of accelerations, presence or Demographics were similar between patients with
absence of decelerations, presence of deceleration by Category I or II FHR in terms of age, gravidity, parity,
type (early, variable or late), and by class of variability body mass index, gestational age or race (Table 1).
(absent, minimal, moderate or marked). Left MPI was not significantly different between
Statistical analysis was performed using SPSS ver- fetuses with Category I or Category II FHR (0.67 versus
sion 23.0 software (IBM, Armonk, NY). X2, Student’s 0.65, p ¼ .385) (Figure 2). The left MPI was not signifi-
t-test, and analysis of variance tests were used to cantly different for fetuses with or without any type of
analyze the data. A p value of .05 was considered stat- deceleration (0.65 versus 0.68, p ¼ .350), between decel-
istically significant. eration type (0.50 versus 0.64 versus 0.75, p ¼ .421), or
between different classes of variability (0.56 versus
0.68, p ¼ .113) (Figure 2). MPI was significantly higher in
Results
fetuses with accelerations on their FHR versus those
From March 2014 through May 2015, 24 laboring without (0.71 versus 0.59, p ¼ .045) (Figure 2).
patients were recruited. This study was approved by Delivery outcomes were not statistically significantly
the Thomas Jefferson University Institutional Review different between groups (Table 2).
 4 A. C. GIMOVSKY ET AL.
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Figure 2. Average Left myocardial performance index (MPI) for FHR Characteristics. Accels: accelerations; Decels: decelerations;
FHR: fetal heart rate; L MPI: left myocardial performance index.

Table 2. Maternal and neonatal outcomes. dysfunction in human fetuses resulting in fetal acid–-
Category I FHR Category II FHR base status deterioration during labor. MPI was eval-
Demographic (n ¼ 13) (n ¼ 11) p value uated during labor to investigate whether it could be
Delivery type .23
NSVD 10 (76.9) 11 (100)
used as a possible surrogate marker for this acute
OVD 1 (7.7) 0 (0) deterioration.
CD 2 (15.4) 0 (0) Interestingly, this study found no difference seen
min Apgar <7 (5) 1 (7.7) 1 (10.0) .85
NICU admission 2 (15.4) 4 (40) .18 between Category I and Category II fetal heart trac-
Birth weight (grams) 3275 ± 411.5 3111 ± 291.5 .30 ing in regard to MPI. One possible explanation is
Cord Ph 7.26 (0.1) 7.29 (0.0) .34
that, as others have suggested, FHR Category I versus
Data are reported in mean ± standard deviation or n (%).
NSVD: normal spontaneous vaginal delivery; OVD: operative vaginal deliv- II does not adequately differentiate fetuses at risk of
ery; CD: cesarean delivery; NICU: Neonatal Intensive Care Unit; FHR: fetal fetal acid–base decompensation. This may be due to
heart rate.
the interpretation of Category II as “indeterminate” of
fetal status, but usually no evidence of compromise
Discussion
at birth and thus, MPI would be expected to be
This study of laboring women suggests that fetal MPI unchanged between Category I and II FHR [20,22]. An
is not different between Category I and II FHR. additional explanation can be that MPI is not a suit-
Additionally, MPI did not differ between fetal heart able marker to evaluate this physiology due to our
tracing characteristics including with or without decel- small sample size. In addition to the findings of
erations, between deceleration type and across classes equivalent MPI between FHR categories, it is perhaps
of variability. MPI was elevated in fetal heart rate trac- even stronger evidence that MPI does not differ with
ings with the presence of accelerations. FHR characteristics because it also was unchanged
It has been previously reported that the fetal car- across the FHR characteristics as single entities, i.e.
diovascular system including MPI is impacted by fetal the presence or absence of decelerations, type of
conditions such as intrauterine growth restriction deceleration and variability there was no difference
(IUGR), diabetes, twin to twin transfusion syndrome seen in the MPI.
and other disorders [9,12,13]. These conditions are MPI was seen to increase with FHR accelerations.
chronic insults that lead to changes over time in the One explanation of this could be that prolonged peri-
fetal myocardium from various suggested etiologies ods of tachycardia cause a shorter ET; subsequently
such as ventricular remodeling secondary to increased increasing the MPI.
afterload and chronic hypervolemia in twin to twin There are several strengths of this study. This was a
transfusion syndrome. Currently, fetal status during prospectively designed study with no similar studies in
labor is evaluated using FHR Categories. Little is the literature on this subject. Additionally, there was
known about specific acute cardiac function or no loss to follow up and there were no protocol

changes during the study. Lastly, only one provider
performed the ultrasound examinations, thus, increas-
ing the internal validity.
One potential limitation to this study was the small
number of women who were included. Figure 2
appears to show an increasing association between
MPI and deceleration type, with late decelerations hav-
ing the highest MPI value. Based on the data in the
Figure, we performed a post-hoc power analysis and
calculated that for 80% power to detect an association
to be statistically significantly different between decel-
eration types we would need a total of 147 patients
(52 with late decelerations, 52 with variable decelera-
tions, and 33 with early decelerations).
Additionally, there is potential for selection bias in
this study as patients were chosen from a sample of
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convenience. Another limitation is that there were no
patients included with Category III FHR. This is likely
because clinically, when a patient develops a Category
III FHR, they are emergently delivered, with no time to
undergo an ultrasound evaluation.
The average value of the MPI that we measured
during labor was somewhat higher than values
obtained in the literature in the third trimester
[23–26]. One reason could be due to our small sample
size. Another hypothesis is related to the pathophysi-
ology of labor. Labor is a more stressful environment
on cardiac physiology than outside of labor. Previous
studies show increased MPI associated with diabetes
in pregnancy, congenital heart disease, IUGR and twin
to twin transfusion syndrome; which similarly repre-
sent demanding fetal conditions. Additionally, some
studies correlate increased MPI with perinatal morbid-
ity and mortality, low 5 minutes Apgar, neonatal acide-
mia, and cardiomyopathy [6]. The setting of labor
could be shifting the global cardiac physiology in a
similar fashion.
Measurement of the fetal MPI during labor may not
be useful in evaluation of fetal acid–base status in
Category I versus Category II FHR. However, it may be
useful to evaluate fetal MPI and its relationship to fetal
acid–base status outside the context of the FHR
Categories or characteristics of FHR. Answering this
question could possibly illustrate the usefulness of MPI
as a tool to evaluate fetal status in labor [25].
Disclosure statement
The authors report no conflicts of interest.
ORCID
Alexis C. Gimovsky http://orcid.org/0000-0002-9358-8995
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 5
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