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N. 5/2000
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Andrea Di Lieto
CURRICULUM
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Prenatal Care is the Science that, by right
means, protects the unborn child yet before conception, assures the
harmonious embryonic and fetal development, avoids any delivery risk. The prevention of many fetal syndromes
(eclampsia, pregnancy haemorrhages, prolonged pregnancy, important cardiopathies,
hemopathies, etc.) is mostly based on a proper pregnant's care either under
social and sanitary regards. It's notorious that perinatal mortality or
diseases caused by C.N.S. lesions that can be recognised in a long time are
chiefly the result of serious care deficit during pregnancy and delivery. The purpose of
the modern Perinatal Care is to know always better and more deeper the
intrauterine fetal assessment also by fetal behaviour study, with all the
ontological, clinical and therapeutic consequences of this prospective. In the
prevention of perinatal mortality and morbility, an important forward step
has been obtained with risk-pregnancies monitoring by fetal ultrasonographic
biometry, maternalfetal Doppler velocimetry and by antepartum and intrapartum
cardiotocography. With the new fetal semeiotic it's possible to confirm fetal
well-being or to diagnose fetal distress that require a timely obstetrical
intervention; so it will be likely to reduce perinatal mortality that in
South Italy is still higher than in North Italy, improving pregnant and
stillborn life-style and rationalizing the Sanitary Costs for maternal and
neonatal care. Cardiotocography
is the continuous recording by biomedical set of fetal heart activity,
uterine contractions and fetal active movements. Cardiotocographic recording
is among more used methods to diagnose antepartum fetal distress. Van Geijn
affirms that the stillness that the obstetricians draw from a
cardiotocographic tracing of a normal fetal heart activity has made
Cardiotocography an important technique to monitor fetal assessment during
pregnancy and delivery. Prenatal
Telemedicine is a new biomedical science that born from simultaneous use of
electromedical sets - the cardiotocographs and a remote monitoring central -
informatics technologies and telecommunication systems directed to prenatal
care. The main targets
are to give medical specialized competences also to pregnant women that cannot
directly arrive, for logistic reason or in emergency conditions, at specific
Prenatal Care sanitary Service; so it came possible not take away the
patients from their family life and leave them, until it is possible, in a
domiciliary recovery “protected” by technological innovations. The achievement
state of our Prenatal Telemedicine Project has been showed during the
television program “Check-up” (RAI 1, March 3, 2000) by a real-time link with
the Prenatal Care Operative Unit, of which I have the head physician
responsibility, at the Department of Obstetrical-Gynecological and Urological
Science and Reproductive Medicine, University of Naples “Federico II”, Italy. The project,
first in Italy, approved by a funds of University of Naples “Federico II” and
Campania Scientific Researches Assessorship and carried out with the
cooperation of Marcello Bracale, Professor of Bio-Engineering, regards the
“Telematic simultaneous analysis, aimed at the elaboration, the comparison,
the management and the registration of cardiotocographic's traces transmitted
from regional, interregional, national and international fetal-maternal units
for prenatal pathologies early diagnosis”. Staring from the
logistic needs and the offered partnerships, they have been identified some
maternal-fetal peripheral Units equipped with electromedical technologies
necessary to the project realization, that are cardiotocographs provided with
modem card with electronic sheet with bar code for optic pen, enable to make
a cardiotocographic trace (in periphery) and to transmit it by telefax (to
the Operative Hearing Centre). Peripheral units
taking part in the project at the beginning are Capri' s Hospital, Consulting
Rooms of Ischia and Procida, Nola' s and Polla' s Hospitals; those units will
be equipped with cardiotocographs to control fetal condition in patients with
risk-pregnancies. At first we chose fetal-maternal assistence units from
which could be difficult to transfer risk-pregnancy patients to a
High-Specialized Department of Obstetrics and Gynecology; in this way we'll
also avoid taking away these pregnant women from their family-life until it
is possible. Moreover,
“Cardarelli” and “Loreto Mare” Hospitals, some Advisory bureau of Naples,
Civilian Hospitals of Caserta and Capua, Lecce's and Potenza's Hospitals,
declared their availability to take part in the project. The Hearing
Operative Centre of the University Department is equipped with an advanced
electromedical set: the signal is received, displayed, analysed, memorized,
managed and field on optic disk through the advanced software of the
“Obstetric Trace Vue” system. Furthermore, for a better understanding of the
cardiotocographic patterns by computerized analysis, there is the 2CTG system
which can collect, manage and save all transmitted data in a database,
including clinical information about the patients, for any future use or
statistical treatment. The conventional visual reading of the
cardiotocographic trace is burdened with a considerable intra- and
inter-observer variability. So, it should be
integrated with numeric online analysis of fetal heart rate and basal
variability, and with calculation of fetal behavioural states, short-term
variability and base line (defined as the mean fetal heart rate in absence of
fetal movements and uterine contractions). An exact definition of the base
line is necessary to identify both acceleration and deceleration and to
quantify statistical indices. The Hearing
Operative Centre is also provided with a fax to send the medical report to
the peripheral unit. It's important
emphasize that a software for a good management of a Hearing Operative Centre
must be able to clean the received signal (with particular reference to the
analogical system' s adulterations), to memorize and retrieve data quickly
and efficiently. The Hearing
Operative Centre staff includes medical and technical members. They provide
for a multidisciplinary service (one or more speciality), alternating at the
moment from 9.00 a.m. to 2.00 p.m. (24/24 hours in the future), sending the
medical reports in real or differed time and teleassisting the users. The members of
the staff are: medical doctors specialized in the scientific disciplines
object of the Prenatal Telemedicine Service, taking turns to provide the
service hours adequately; managing personnel, able to collaborate with the
physicians in any sphere of service activity like medical reporting and
teleconsulting; technical personnel experienced in medical informatics, in
management of electromedical sets and new hardware systems, and able to
warrant continuously the efficiency of hardware and software system. In the future, Prenatal
Telemedicine could be put in practice through a large telematic and satellite
nets, with peripheral instruments set in consulting-rooms and hospitals of
decentralized areas, ships, airplanes, motor-and hydro-ambulances. Moreover, the
Hearing Operative Centre could be joined with the Emergency Regional Number,
118, so to can carry out programmed or urgent hospitalisation after
domiciliary or ambulatory controls. It need for a
balanced growth of Prenatal Telemedicine, like in many other disciplines, to
overcome resistances of some specialized physicians who are afraid to loose
their own professional individuality. An obstetric specialist, for example,
can fear a patient will not ask anymore for his service after a domiciliary
or ambulatory cardiotocographic trace sent to the Hearing Operative Centre.
However, the Hearing Operative Centre attends to patients in peripheral areas
with special problems which cannot be resolved by a single specialized
physician; for the rest, his professional competence remains necessary for
the global clinical patient management. The importance of Prenatal
Telemedicine can be farther understood if we think about emergency cases in
peripheral areas, islands, mountains, ships and plain, where it's not
possible for pregnant women to consult a specialized physician. So, the initial
distrusts are being lower, also because some specialists are realizing they
can take part in telemedicine centres. Our Hearing
Operative Centre (www.telemedicinaprenatale.org) will be a netincubation
for new regional or inter-regional Hearing Centres and will contribute
sufficiently also to the permanent training and modernization of medical and
technical staff. Therefore, it
will be offered a teleteaching service, which forms part of principal targets
of a modern Medicine School. Prenatal telemedicine will improve life quality
of pregnant women and unborn children also by the diffusion of specialized
telediagnosis and teleconsultation. Primario
di Medicina dell’etą prenatale Universitą
Degli Studi di Napoli “Federico II” |
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