title: Cardiac output assessment in pregnancy: comparison of two automated monitors with echocardiography.
abstract: OBJECTIVE
  To compare non-invasive hemodynamic measurements obtained in pregnant and postpartum women using two automated cardiac output monitors against those obtained by two-dimensional (2D) transthoracic echocardiography (TTE).
  
  
  METHODS
  This was a cross-comparison study into which we recruited 114 healthy women, either with normal singleton pregnancy (across all three trimesters) or within 72 hours following delivery. Cardiac output estimations were obtained non-invasively using two different monitors, Ultrasound Cardiac Output Monitor (USCOM®, which uses continuous-wave Doppler analysis of transaortic blood flow) and Non-Invasive Cardiac Output Monitor (NICOM®, which uses thoracic bioreactance), and 2D-TTE. The performance of each monitor was assessed relative to that of TTE by calculating bias, precision, 95% limits of agreement and mean percentage difference (MPD). Intraobserver repeatability was assessed for both monitors and interobserver reproducibility was assessed for USCOM, NICOM being operator-independent.
  
  
  RESULTS
  Following exclusions due to poor-quality results of a monitor or TTE, or for medical reasons, our analysis included 98 women (29 in the first trimester, 25 in the second and 21 in the third, and 23 postpartum). For cardiac output estimation, when compared with TTE, USCOM had a bias ranging from 0.4 to 0.9 L/min. The MPD of USCOM was 29% in the third-trimester cohort. NICOM had a bias ranging from -1.0 to 0.6 L/min, with a MPD of 32% in the third-trimester group. There was limited agreement between the cardiac output monitors and TTE in the first and second trimesters, with a MPD of 38% for USCOM in both first and second trimesters, and 71% and 61% for NICOM in first and second trimesters, respectively. For cardiac output estimation using USCOM, we found excellent intraobserver repeatability (intraclass correlation coefficient (ICC), 0.97; 95% CI, 0.95-0.98) and interobserver reproducibility (ICC, 0.90; 95% CI, 0.81-0.94), and the repeatability for NICOM was comparable (ICC, 0.95; 95% CI, 0.93-0.97).
  
  
  CONCLUSIONS
  We found good agreement of both USCOM and NICOM when compared with 2D-TTE, specifically in the third trimester of pregnancy. Both devices had good intraobserver repeatability and either had good interobserver reproducibility or were operator-independent. Future studies should take into account the significant differences in the precise maternal hemodynamic values obtained by these devices, and consider developing device-specific reference ranges in pregnancy and the postpartum period. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
authors.affiliation: Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK.
authors.forename: D
authors.initials: D
authors.lastname: Vinayagam
authors.affiliation: Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK.
authors.forename: O
authors.initials: O
authors.lastname: Patey
authors.affiliation: Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK.
authors.forename: B
authors.initials: B
authors.lastname: Thilaganathan
authors.affiliation: Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK.
authors.forename: A
authors.initials: A
authors.lastname: Khalil
mesh_terms: D002302:Cardiac Output / Q000502:physiology*; D004452:Echocardiography / Q000379:methods*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D008991:Monitoring, Physiologic / Q000295:instrumentation; D015588:Observer Variation; D011247:Pregnancy; D015203:Reproducibility of Results; D013318:Stroke Volume / Q000502:physiology*; D018608:Ultrasonography, Doppler / Q000295:instrumentation*; D016216:Ultrasonography, Prenatal / Q000295:instrumentation; D055815:Young Adult
keywords: NICOM®; USCOM®; cardiac output; echocardiography; hemodynamics; non-invasive