Handling non-reactive NSTs in a remote setting

How are non-reactive NSTs handled in a remote setting?

Nuvo’s purpose is to provide clinicians and patients with the best possible monitoring options, conveniently accessed from wherever the patient is located. While we do offer customer and technical support, we do not provide clinical interpretation of INVU readings or dispense medical advice (See Legal Disclaimer below).

While INVU does not endorse or recommend a specific clinical approach to the management of non-reactive tracings, we reference the ACOG Practice Bulletin on Antepartum Surveillance in case this might be helpful1 . This bulletin discusses the high false-positive rates for antenatal fetal testing, as well as some of the strategies that can be taken for a non-reactive test. These may include prolonging the monitoring for 40 minutes or longer, use of vibroacoustic stimulation, repeating the test or using another test (e.g. biophysical profile). If the clinical situation warrants it, delivery might be considered as well.

The goal of monitoring via INVU is to remotely supply a monitoring tracing that is similar to the tracing obtained from in-office fetal monitoring machines. Clinical management of these tracings is at the discretion of the provider. However, one notable advantage of remote monitoring via INVU is that if the provider feels like prolonged monitoring is warranted - for example, to give more time to achieve reactivity or to gain additional reassurance after a non-recurrent deceleration - the home monitoring session can be extended beyond the typical 40 minutes without the patient needing to come into the office and without burdening the office staff.

As the primary advantage of pregnancy monitoring via INVU is that the patient does not need to be in a medical facility, we recognize that this may prompt questions related to the ability to react or respond to various findings on the tracing. However, to our knowledge, there is no standard or guideline that requires patients to live within a certain distance of a medical facility. In fact, more than 50% of US counties do not even have an obstetric provider, making it quite common for clinical questions to arise when patients are not near a medical facility. In addition, there are an increasing number of clinical measures being routinely obtained at home. Therefore, although the new-found capability of remote fetal monitoring with INVU is a more significant innovation in prenatal care, the issue of a provider seeing remote data that may require action is already highly prevalent in-home blood pressure monitoring approaches which are commonly used in prenatal care.

It is also important for both providers and patients to have the appropriate expectations regarding the goals of fetal monitoring. As pointed out in the ACOG Bulletin referenced above, the antenatal surveillance “tests generally do not predict stillbirths related to acute changes in maternal-fetal status, such as those that occur with abruptio placentae or an umbilical cord accident.” If, despite all attempts, reactivity is not achieved, an in-person visit to a medical office or hospital may be recommended. In addition, we recommend that if a situation arises where the clinician is recommending an in-person evaluation, Nuvo Group USA, Inc. 252 Nassau Street Princeton, NJ 08542 T: +1 800 554 9041 www.nuvocares.com communication with the patient via a telephone call would likely be the most expeditious and allow for proper patient counseling.

One of our provider partners, an experienced maternal-fetal medicine specialist, sums up the perspective in this quote: "The primary benefit of INVU fetal monitoring is the ability to perform on a flexible schedule remotely thus freeing up valuable time for other patients that require in-person visits. The approach to the remote NST is no different from an inperson model requiring direct oversight by someone capable of interpreting the tracing and making acute and sometimes critical management decisions. Although rare, there may be an occasion where a tracing is non-reassuring requiring an immediate intervention and my response would be identical whether the patient was in the office or at the remote location. The advantage of the convenience and flexibility of monitoring for both the patient and clinician far outweighs the possibility of a rare emergent tracing enough to make it a practical concern".

Is there a difference between escalating a non-reactive NST remotely vs. in the clinic?

In general, our goal at Nuvo is to enable patients and providers to obtain pregnancy monitoring data remotely. While the general management of a non-reactive NST should follow the same general approach whether obtained in the office or at home, we recognize that remote monitoring may alter the decision-making that a provider may use when considering various options for managing a tracing.

Per the ACOG Practice Bulletin on Antepartum Fetal Surveillance, “because antepartum fetal surveillance tests have high false-positive rates and low positive predictive values, abnormal test results are usually followed by another test or delivery based on consideration of test results, maternal and fetal condition, and gestational age.”

One observation we have made in our discussions with providers is that, in a busy office setting, the staff often truncates the monitoring session at 20 or 30 minutes to aid in the patient flow and refers patients for a biophysical profile if the NST was not yet reactive. This may lead to an even higher rate of false-positive NSTs and use of more resources. Thus, one potential advantage for remote monitoring is that it may be easier for the clinical staff to prolong the monitoring session to 40 minutes, or even greater, to maximize the chance of obtaining a reactive NST.

However, if the clinician ultimately determines that the NST is non-reactive, then the clinical management should mimic the general approach they would take if the NST were obtained in the office. With remote monitoring, this could mean, prolonging the monitoring session beyond the typical 40 minutes, repeating an at-home NST later in the day, or escalating to an in-person assessment, which may include a BPP. However, the interpretation and clinical management of each monitoring session remains the responsibility of the clinician and should be individualized based on the patient’s case.

Of note, the ACOG Bulletin also clarifies that “acute, catastrophic changes in fetal status, such as those that can occur with placental abruption or an umbilical cord accident, are generally not predicted by tests of fetal well-being.” Thus, the goal of testing is not to predict such acute events. Thus, conducting NSTs remotely still allows for clinical assessment of fetal well-being, with options for escalation of care if indicated. Overall, the introduction of remote monitoring to a provider’s care protocol allows for easy, frequent collection of data insights while increasing flexibility for both providers and patients and improving patient access to high quality antenatal care.

LEGAL DISCLAIMER

No information contained within this FAQ document should be relied upon as professional medical advice, nor shall any information be construed as the practice of medicine or providing medical /advice services by Nuvo. Nuvo does not provide medical advice, diagnosis or treatment, but provisions INVU as a remote patient monitoring device. The information provided in this FAQ document is intended solely as general educational materials even if the information is presented by a licensed medical professional, is not intended to be used for any diagnostic purposes, and is not a substitute for professional medical advice. Readers of this FAQ document should always seek the advice of a physician or other qualified healthcare provider who is familiar with their state of health concerning questions regarding a medical condition, and before starting, stopping or modifying any treatment or medication. Never delay obtaining medical advice or disregard medical advice because of something you have or have not read within this FAQ document. Nuvo makes no warranties or representations as to the accuracy of the information provided within this FAQ document and assumes no responsibility for any consequences relating directly or indirectly to any action or inaction that is taken based upon such information. Readers assume the entire risk of loss in relying upon the information contained within this FAQ document, and should contact their physicians immediately if their health conditions change, and if a Reader requires urgent care, should contact their local emergency services immediately. Neither Nuvo nor its content providers assume any liability or responsibility for damage or injury to you arising from any use of the information, ideas or instructions contained within this FAQ document.

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