Feasibility of ventricular volumetry by cardiovascular MRI to assess cardiac function in the fetal sheep

KEY POINTS

The application of fetal cardiovascular magnetic resonance imaging (CMR) to assess fetal cardiovascular physiology and cardiac function through the quantification of ventricular volumes has previously been investigated, but the approach has not yet been fully validated. Ventricular output measurements calculated from heart rate and stroke volumes (SV) of the right and left ventricles measured by ventricular volumetry (VV) exhibited a high level of agreement with phase-contrast (PC) blood flow measurements in the main pulmonary artery and ascending aorta, respectively. Ejection fraction of the right ventricle, which is lower than that of the left ventricle in postnatal subjects, was similar to the left ventricular ejection fraction in the fetus; probably due to the different loading conditions present in the fetal circulation. This study provides evidence to support the reliability of VV in the sheep fetus, providing evidence for its use in animal models of human diseases affecting the fetal circulation.

ABSTRACT

The application of ventricular volumetry (VV) by cardiovascular magnetic resonance imaging (CMR) in the fetus remains challenging due to the small size of the fetal heart and high heart rate. The reliability of this technique in utero has not yet been established. The aim of this study was to assess the feasibility and reliability of VV in a fetal sheep model of human pregnancy. Right and left ventricular outputs by stroke volume (SV) measured using VV were compared with 2D phase-contrast (PC) CMR measurements of blood flow in the main pulmonary artery (MPA) and ascending aorta (AAo). At 124-140 days (d) gestation, singleton bearing Merino ewes underwent CMR under general anaesthesia using fetal femoral artery catheters, implanted at 109-117d, to trigger cine steady state free precession acquisitions of ventricular short-axis stacks. The short-axis cine stacks were segmented at end-systole and end-diastole, yielding right and left ventricular SV, ejection fraction, and cardiac outputs (SV × heart rate). PC cine acquisitions of MPA and AAo were analysed to measure blood flow, which served as comparators for the right and left cardiac outputs by VV. There was good correlation and agreement between VV and PC measures of ventricular outputs with no significant bias (r²  = 0.926; P < 0.0001; Bias = -4.7 ± 10.5 ml min^-1  kg^-1 ; 95% limits of agreement: -15.9 to 25.2 ml min^-1  kg^-1 ). This study validates fetal VV by CMR in a large animal model of human pregnancy and provides preliminary reference values of fetal sheep right and left ventricles in late gestation.

Thyroid Deficiency Before Birth Alters the Adipose Transcriptome to Promote Overgrowth of White Adipose Tissue and Impair Thermogenic Capacity

Background: Development of adipose tissue before birth is essential for energy storage and thermoregulation in the neonate and for cardiometabolic health in later life. Thyroid hormones are important regulators of growth and maturation in fetal tissues. Offspring hypothyroid in utero are poorly adapted to regulate body temperature at birth and are at risk of becoming obese and insulin resistant in childhood. The mechanisms by which thyroid hormones regulate the growth and development of adipose tissue in the fetus, however, are unclear. Methods: This study examined the structure, transcriptome, and protein expression of perirenal adipose tissue (PAT) in a fetal sheep model of thyroid hormone deficiency during late gestation. Proportions of unilocular (UL) (white) and multilocular (ML) (brown) adipocytes, and UL adipocyte size, were assessed by histological and stereological techniques. Changes to the adipose transcriptome were investigated by RNA sequencing and bioinformatic analysis, and proteins of interest were quantified by Western blotting. Results: Hypothyroidism in utero resulted in elevated plasma insulin and leptin concentrations and overgrowth of PAT in the fetus, specifically due to hyperplasia and hypertrophy of UL adipocytes with no change in ML adipocyte mass. RNA sequencing and genomic analyses showed that thyroid deficiency affected 34% of the genes identified in fetal adipose tissue. Enriched Kyoto Encyclopedia of Genes and Genomes (KEGG) and Gene Ontology (GO) pathways were associated with adipogenic, metabolic, and thermoregulatory processes, insulin resistance, and a range of endocrine and adipocytokine signaling pathways. Adipose protein levels of signaling molecules, including phosphorylated S6-kinase (pS6K), glucose transporter isoform 4 (GLUT4), and peroxisome proliferator-activated receptor γ (PPARγ), were increased by fetal hypothyroidism. Fetal thyroid deficiency decreased uncoupling protein 1 (UCP1) protein and mRNA content, and UCP1 thermogenic capacity without any change in ML adipocyte mass. Conclusions: Growth and development of adipose tissue before birth is sensitive to thyroid hormone status in utero. Changes to the adipose transcriptome and phenotype observed in the hypothyroid fetus may have consequences for neonatal survival and the risk of obesity and metabolic dysfunction in later life.

Repolarization Predictors of Fetal Long QT Syndrome

Background

Diagnosis of fetal long QT syndrome (LQTS) using fetal magnetocardiography (fMCG) is straightforward in cases of overt QTc prolongation accompanied by LQTS rhythms; however, cases of isolated QTc prolongation can be challenging.

Objective

The purpose of this study was to characterize repolarization in normal and phenotype-positive LQTS fetuses with the goal of using additional parameters of repolarization to improve the accuracy of fMCG diagnosis of LQTS.

Methods

fMCG recordings were taken from 37 phenotype-positive fetuses with confirmed LQTS and 132 normal controls. The normal fetuses were grouped into those with T and U waves and those with only T waves. We compared the repolarization characteristics of normal fetuses with only T waves with those of LQTS fetuses. We also compared the repolarization characteristics of normal fetuses with T and U waves with those of LQTS fetuses with 2-component T waves.

Results

Late-peaking T waves were strongly associated with LQTS (35/37 [95%]). No normal fetuses showed both QTc prolongation (QTc >500 ms) and a late-peaking T wave. U waves were seen in 11 normal fetuses (8%) and resulted in waveforms that often mimicked those of the 19 LQTS fetuses with 2-component T waves. However, in normal fetuses the polarities of the T and U waves were the same, whereas in LQTS fetuses with 2-component T waves the polarities of the components usually were opposite.

Conclusion

A late-peaking T wave in association with QTc prolongation is a distinctive, reliable indicator of fetal LQTS. U waves confound assessment of QTc; however, normal U waves usually can be distinguished from LQTS T waves based on polarity.

Prenatal nicotine exposure affects cardiovascular function and growth of the developing fetus

AIM

Effects of nicotine on fetal hemodynamics are not well known, especially in the first trimester fetus. We investigated the acute and chronic effects of nicotine on hemodynamics in pregnant mice and their fetuses using ultrasound. Postnatal health status including growth and hemodynamics was also examined.

METHODS

To investigate the acute effects of nicotine on fetal hemodynamics, we injected nicotine 0.2 mg/kg subcutaneously into pregnant mice on gestational days (GD) 9.5, 11.5 and 13.5 and compared with saline-injected group. To determine the chronic effects of nicotine on fetal hemodynamics, we administered nicotine in drinking water (0.1 mg/mL) to pregnant mice from GD 6.5 until they gave birth and compared hemodynamics with water-administered mice.

RESULTS

Regarding the acute effects of nicotine, we found no intergroup difference in maternal hemodynamics; however, fetal blood flow through the dorsal aorta, carotid artery and umbilical artery tended to decrease, particularly on GD 11.5. Regarding the chronic effects of nicotine, we observed no intergroup difference in maternal body weight changes and hemodynamics; however, blood flow to all fetal organs tended to be lower in the nicotine water group than in the water group with significant difference on GD 13.5. The offspring of the nicotine water group had significantly low birth weights and continued to have low body weight until 9 weeks of age. In addition, these offspring developed postnatal cardiac hypertrophy.

CONCLUSION

Nicotine adversely affects fetal hemodynamics acutely and chronically in early pregnancy, potentially leading to fetal tissue hypoxia, intrauterine growth restriction and adverse postnatal health effects.

Maternal Zika Virus (ZIKV) Infection following Vaginal Inoculation with ZIKV-Infected Semen in Timed-Pregnant Olive Baboons

Zika virus (ZIKV) infection is now firmly linked to congenital Zika syndrome (CZS), including fetal microcephaly. While Aedes species of mosquito are the primary vector for ZIKV, sexual transmission of ZIKV is a significant route of infection. ZIKV has been documented in human, mouse, and nonhuman primate (NHP) semen. It is critical to establish NHP models of the vertical transfer of ZIKV that recapitulate human pathogenesis. We hypothesized that vaginal deposition of ZIKV-infected baboon semen would lead to maternal infection and vertical transfer in the olive baboon (Papio anubis). Epidemiological studies suggest an increased rate of CZS in the Americas compared to the original link to CZS in French Polynesia; therefore, we also compared the French Polynesian (FP) ZIKV isolate to the Puerto Rican (PR) isolate. Timed-pregnant baboons (n = 6) were inoculated via vaginal deposition of baboon semen containing 10⁶ focus-forming units (FFU) of ZIKV (n = 3 for FP isolate H/PF/2013; n = 3 for PR isolate PRVABC59) at midgestation (86 to 95 days of gestation [dG]; term, 183 dG) on day 0 (all dams) and then at 7-day intervals through 3 weeks. Maternal blood, saliva, and cervicovaginal wash (CVW) samples were obtained. Animals were euthanized at 28 days (n = 5) or 39 days (n = 1) after the initial inoculation, and maternal/fetal tissues were collected. Viremia was achieved in 3/3 FP ZIKV-infected dams and 2/3 PR ZIKV-infected dams. ZIKV RNA was detected in CVW samples of 5/6 dams. ZIKV RNA was detected in lymph nodes but not the ovaries, uterus, cervix, or vagina in FP isolate-infected dams. ZIKV RNA was detected in lymph nodes (3/3), uterus (2/3), and vagina (2/3) in PR isolate-infected dams. Placenta, amniotic fluid, and fetal tissues were ZIKV RNA negative in the FP isolate-infected dams, whereas 2/3 PR isolate-infected dam placentas were ZIKV RNA positive. We conclude that ZIKV-infected semen is a means of ZIKV transmission during pregnancy in primates. The PR isolate appeared more capable of widespread dissemination to tissues, including reproductive tissues and placenta, than the FP isolate.IMPORTANCE Zika virus remains a worldwide health threat, with outbreaks still occurring in the Americas. While mosquitos are the primary vector for the spread of the virus, sexual transmission of Zika virus is also a significant means of infection, especially in terms of passage from an infected to an uninfected partner. While sexual transmission has been documented in humans, and male-to-female transmission has been reported in mice, ours is the first study in nonhuman primates to demonstrate infection via vaginal deposition of Zika virus-infected semen. The latter is important since a recent publication indicated that human semen inhibited, in a laboratory setting, Zika virus infection of reproductive tissues. We also found that compared to the French Polynesian isolate, the Puerto Rican Zika virus isolate led to greater spread throughout the body, particularly in reproductive tissues. The American isolates of Zika virus appear to have acquired mutations that increase their efficacy.

Intrapartum non-invasive electrophysiological monitoring: A prospective observational study

INTRODUCTION

Doppler ultrasound cardiotocography is a non-invasive alternative that, despite its poor specificity, is often first choice for intrapartum monitoring. Doppler ultrasound suffers from signal loss due to fetal movements and is negatively correlated with maternal body mass index (BMI). Reported accuracy of fetal heart rate monitoring by Doppler ultrasound varies between 10.6 and 14.3 bpm and reliability between 62.4% and 73%. The fetal scalp electrode (FSE) is considered the reference standard for fetal monitoring but can only be applied after membranes have ruptured with sufficient cervical dilatation and is sometimes contra-indicated. A non-invasive alternative that overcomes the shortcomings of Doppler ultrasound, providing reliable information on fetal heart rate, could be the answer. Non-invasive fetal electrocardiography (NI-fECG) uses a wireless electrode patch on the maternal abdomen to obtain both fetal and maternal heart rate signals as well as an electrohysterogram. We aimed to validate a wireless NI-fECG device for intrapartum monitoring in term singleton pregnancies, by comparison with the FSE.

MATERIAL AND METHODS

We performed a multicenter cross-sectional observational study at labor wards of 6 hospitals located in the Netherlands, Belgium, and Spain. Laboring women with a healthy singleton fetus in cephalic presentation and gestational age between 36 and 42 weeks were included. Participants received an abdominal electrode patch and FSE after written informed consent. Accuracy, reliability, and success rate of fetal heart rate readings were determined, using FSE as reference standard. Analysis was performed for the total population and measurement period as well as separated by labor stage and BMI class (≤30 and >30 kg/m² ).

RESULTS

We included a total of 125 women. Simultaneous registrations with NI-fECG and FSE were available in 103 women. Overall accuracy is -1.46 bpm and overall reliability 86.84%. Overall success rate of the NI-fECG is around 90% for the total population as well as for both BMI subgroups. Success rate dropped to 63% during second stage of labor, similar results are found when looking at the separate BMI groups.

CONCLUSIONS

Performance measures of the NI-fECG device are good in the overall group and the separate BMI groups. Compared with Doppler ultrasound performance measures from the literature, NI-fECG is a more accurate alternative. Especially, when women have a higher BMI, NI-fECG performs well, resembling FSE performance measures.

Pakistan Developmental Origins of Health and Disease (DOHaD) Society: addressing the 'DO' component of DOHaD

Adverse intrauterine environment could serve as an important stimulus for postnatal altered health status and for increased susceptibility to long-term non-communicable diseases (NCDs). The notion is now recognized as the Developmental Origins of Health and Disease (DOHaD), which was first proposed by Sir David Barker. Since then, several scientific disciplines have strived to measure the magnitude of the early fetal programming and later risk of diseases. Pakistan, with striking figures of morbidity and mortality from NCDs, is currently tackling with double burden of diseases and requires planned efforts to counteract the threat of NCDs. Considering the growing needs and available evidences, Pakistan DOHaD Society was officially instigated in September 2016. The Society aims to explicitly address the association of life in utero with future health and disease and to endorse early screening and interventions to reduce the burden of NCDs, mental health issues and learning disorders along the life course. It has shown significant progress toward investigating the influence of adverse in utero environment such as diabetes, maternal under-nutrition and pre-eclampsia on fetal programming under two major research lines, that is, cardiovascular and cerebrovascular programming. The Society has been successful in disseminating its research findings through several esteemed international scientific conferences. Pakistan DOHaD Society encourages scientific community for collaborative research aimed at improving the quality of life during early childhood, adolescence and adulthood through provision of appropriate pre-pregnancy and antenatal interventions targeted to address at-risk in utero conditions.

The Subplate Layers: The Superficial and Deep Subplate Can be Discriminated on 3 Tesla Human Fetal Postmortem MRI

The subplate (SP) is a transient structure of the human fetal brain that becomes the most prominent layer of the developing pallium during the late second trimester. It is important in the formation of thalamocortical and cortico-cortical connections. The SP is vulnerable in perinatal brain injury and may play a role in complex neurodevelopmental disorders, such as schizophrenia and autism. Nine postmortem fetal human brains (19-24 GW) were imaged on a 3 Tesla MR scanner and the T2-w images in the frontal and temporal lobes were compared, in each case, with the histological slices of the same brain. The brains were confirmed to be without any brain pathology. The purpose of this study was to demonstrate that the superficial SP (sSP) and deep SP (dSP) can be discriminated on postmortem MR images. More specifically, we aimed to clarify that the observable, thin, hyperintense layer below the cortical plate in the upper SP portion on T2-weighted MR images has an anatomical correspondence to the histologically established sSP. Therefore, the distinction between the sSP and dSP layers, using clinically available MR imaging methodology, is possible in postmortem MRI and can help in the imaging interpretation of the fetal cerebral layers.

Neonatal incubator or artificial womb? Distinguishing ectogestation and ectogenesis using the metaphysics of pregnancy

A 2017 Nature report was widely touted as hailing the arrival of the artificial womb. But the scientists involved claim their technology is merely an improvement in neonatal care. This raises an under-considered question: what differentiates neonatal incubation from artificial womb technology? Considering the nature of gestation-or metaphysics of pregnancy-(a) identifies more profound differences between fetuses and neonates/babies than their location (in or outside the maternal body) alone: fetuses and neonates have different physiological and physical characteristics; (b) characterizes birth as a physiological, mereological and topological transformation as well as a (morally relevant) change of location; and (c) delivers a clear distinction between neonatal incubation and ectogestation: the former supports neonatal physiology; the latter preserves fetal physiology. This allows a detailed conceptual classification of ectogenetive and ectogestative technologies according to which the 2017 system is not just improved neonatal incubation, but genuine ectogestation. But it is not an artificial womb, which is a term that is better put to rest. The analysis reveals that any ethical discussion involving ectogestation must always involve considerations of possible risks to the mother as well as her autonomy and rights. It also adds a third and potentially important dimension to debates in reproductive ethics: the physiological transition from fetus/gestateling to baby/neonate.

Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know

Coronavirus disease 2019 is an emerging disease with a rapid increase in cases and deaths since its first identification in Wuhan, China, in December 2019. Limited data are available about coronavirus disease 2019 during pregnancy; however, information on illnesses associated with other highly pathogenic coronaviruses (ie, severe acute respiratory syndrome and the Middle East respiratory syndrome) might provide insights into coronavirus disease 2019's effects during pregnancy. Coronaviruses cause illness ranging in severity from the common cold to severe respiratory illness and death. Currently the primary epidemiologic risk factors for coronavirus disease 2019 include travel from mainland China (especially Hubei Province) or close contact with infected individuals within 14 days of symptom onset. Data suggest an incubation period of ∼5 days (range, 2-14 days). Average age of hospitalized patients has been 49-56 years, with a third to half with an underlying illness. Children have been rarely reported. Men were more frequent among hospitalized cases (54-73%). Frequent manifestations include fever, cough, myalgia, headache, and diarrhea. Abnormal testing includes abnormalities on chest radiographic imaging, lymphopenia, leukopenia, and thrombocytopenia. Initial reports suggest that acute respiratory distress syndrome develops in 17-29% of hospitalized patients. Overall case fatality rate appears to be ∼1%; however, early data may overestimate this rate. In 2 reports describing 18 pregnancies with coronavirus disease 2019, all were infected in the third trimester, and clinical findings were similar to those in nonpregnant adults. Fetal distress and preterm delivery were seen in some cases. All but 2 pregnancies were cesarean deliveries and no evidence of in utero transmission was seen. Data on severe acute respiratory syndrome and Middle East respiratory syndrome in pregnancy are sparse. For severe acute respiratory syndrome, the largest series of 12 pregnancies had a case-fatality rate of 25%. Complications included acute respiratory distress syndrome in 4, disseminated intravascular coagulopathy in 3, renal failure in 3, secondary bacterial pneumonia in 2, and sepsis in 2 patients. Mechanical ventilation was 3 times more likely among pregnant compared with nonpregnant women. Among 7 first-trimester infections, 4 ended in spontaneous abortion. Four of 5 women with severe acute respiratory syndrome after 24 weeks' gestation delivered preterm. For Middle East respiratory syndrome, there were 13 case reports in pregnant women, of which 2 were asymptomatic, identified as part of a contact investigation; 3 patients (23%) died. Two pregnancies ended in fetal demise and 2 were born preterm. No evidence of in utero transmission was seen in severe acute respiratory syndrome or Middle East respiratory syndrome. Currently no coronavirus-specific treatments have been approved by the US Food and Drug Administration. Because coronavirus disease 2019 might increase the risk for pregnancy complications, management should optimally be in a health care facility with close maternal and fetal monitoring. Principles of management of coronavirus disease 2019 in pregnancy include early isolation, aggressive infection control procedures, oxygen therapy, avoidance of fluid overload, consideration of empiric antibiotics (secondary to bacterial infection risk), laboratory testing for the virus and coinfection, fetal and uterine contraction monitoring, early mechanical ventilation for progressive respiratory failure, individualized delivery planning, and a team-based approach with multispecialty consultations. Information on coronavirus disease 2019 is increasing rapidly. Clinicians should continue to follow the Centers for Disease Control and Prevention website to stay up to date with the latest information (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html).

Assessing vascular characteristics of the fetal descending aorta: A feasibility study

Research describing fetal arterial structure and function is lacking within the literature. This study's purpose was to measure intima-media thickness (IMT), compliance and distensibility of 24- to 25-week fetuses' abdominal aortas using conventional ultrasonography from 16 diabetic (DM) and 25 non-diabetic mothers (NDM). We found no significant differences in fetal abdominal aorta IMT (P = .68), diameter distensibility (P = .22), or cross-sectional distensibility (P = .23). However, both fetal abdominal aortic diameter compliance (P = .03) and cross-sectional compliance (P = .005) were greater in DM than in NDM (P = .005). This study demonstrates that it is possible and potentially useful to measure fetal abdominal aorta biometrics and biomechanical characteristics.

Bovine aortic arch: Prevalence in human fetuses

OBJECTIVE

"Bovine aortic arch" is the second most common variant of aortic arch branching, in which only two branches originate directly from the aorta. The prevalence of this condition has been reported in different studies to be around 6% in human fetuses and 11-27% in the adult population. In this study, we describe the prevalence of bovine aortic arch in fetuses, and assess the prevalence of concomitant fetal anomalies.

METHODS

A retrospective analysis of 417 fetuses between 15-40 weeks of gestation. Data regarding branching of the fetal aortic arch and other fetal anomalies were collected by fetal echocardiography and/or fetal ultrasonography.

RESULTS

A bovine arch was found in 20/413 fetuses (4.8%, 95CI 3.1-7.3%), of whom 14/310 (4.5%) had no fetal anomalies, and 6/77 (7.8%) exhibited minor changes (P = .241). None of the 26 fetuses with major anomalies had a bovine arch.

CONCLUSION

Fetuses in this study had a lower prevalence of bovine aortic arch than that previously reported in adults, most probably due to differences in the population examined. This study was underpowered to determine that bovine arch is a common anatomic variant, and is not associated with fetal anomalies.

Plasma Formate Is Greater in Fetal and Neonatal Rats Compared with Their Mothers

BACKGROUND

Formate can be incorporated into 10-formyl-tetrahydrofolate (10-formyl-THF), which is a substrate for purine synthesis, and after further reduction of the one-carbon group, may be used as a substrate for thymidylate synthesis and for homocysteine remethylation.

OBJECTIVE

We examined plasma formate concentrations and the expression of genes involved in the production and utilization of formate in fetal and neonatal rats and in pregnant and virgin female rats.

METHODS

In 1 experiment, plasma formate was measured by GC-MS in rats aged 1-56 d. In a second experiment, virgin female (adult) rats, 19-d pregnant rats (P) and their male and female fetuses (F), and 3-d-old (N) and 7-d-old (J) offspring had plasma and amniotic fluid analyzed for formate by GC-MS, mRNA abundance in liver and placenta by qPCR, and several plasma amino acids by HPLC.

RESULTS

The plasma formate concentration was significantly higher in fetuses at embryonic day 19 than in the mothers. It was also significantly higher in neonatal rats but slowly returned to adult concentrations by ∼3 wk. The abundance of mitochondrial monofunctional 10-formyl-tetrahydrofolate synthetase (Mthfd1l) mRNA was significantly higher in placenta (PP) and F liver than in liver of N or J. Expression of mitochondrial bifunctional NAD-dependent methylene-tetrahydrofolate dehydrogenase/methenyl-tetrahydrofolate cyclohydrolase (Mthfd2) was significantly enriched in PP and liver of P, intermediate in F liver, and much lower in liver of N and J, relative to PP. Serine hydroxymethyltransferase 2 (Shmt2), methylenetetrahydrofolate dehydrogenase 1 (Mthfd1), and glycine decarboxylase protein of the glycine cleavage system (Gldc) mRNA expression was significantly lower in PP compared with other groups. Cytoplasmic NAD(P)-dependent 10-formyl-tetrahydrofolate dehydrogenase (Aldh1/1) and mitochondrial NAD(P)-dependent 10-formyl-tetrahydrofolate dehydrogenase (Aldh1/2) , genes responsible for the catabolism of 10-formylTHF, were very weakly expressed in PP, low in livers of F and N, and reached the significantly higher adult levels in J. Serine, glycine, and methionine concentrations in plasma of F were significantly higher than in plasma of P.

CONCLUSIONS

Formate metabolism is highly active in fetuses and in placenta of pregnant rats.

A Broad Spectrum Chemokine Inhibitor Prevents Preterm Labor but Not Microbial Invasion of the Amniotic Cavity or Neonatal Morbidity in a Non-human Primate Model

Leukocyte activation within the chorioamniotic membranes is strongly associated with inflammation and preterm labor (PTL). We hypothesized that prophylaxis with a broad-spectrum chemokine inhibitor (BSCI) would downregulate the inflammatory microenvironment induced by Group B Streptococcus (GBS, Streptococcus agalactiae) to suppress PTL and microbial invasion of the amniotic cavity (MIAC). To correlate BSCI administration with PTL and MIAC, we used a unique chronically catheterized non-human primate model of Group B Streptococcus (GBS)-induced PTL. In the early third trimester (128–138 days gestation; ~29–32 weeks human pregnancy), animals received choriodecidual inoculations of either: (1) saline (N = 6), (2) GBS, 1–5 × 10⁸ colony forming units (CFU)/ml; N = 5), or (3) pre-treatment and daily infusions of a BSCI (10 mg/kg intravenous and intra-amniotic) with GBS (1–5 × 10⁸ CFU/ml; N = 4). We measured amniotic cavity pressure (uterine contraction strength) and sampled amniotic fluid (AF) and maternal blood serially and cord blood at delivery. Cesarean section was performed 3 days post-inoculation or earlier for PTL. Data analysis used Fisher's exact test, Wilcoxon rank sum and one-way ANOVA with Bonferroni correction. Saline inoculation did not induce PTL or infectious sequelae. In contrast, GBS inoculation typically induced PTL (4/5, 80%), MIAC and fetal bacteremia (3/5; 60%). Remarkably, PTL did not occur in the BSCI+GBS group (0/4, 0%; p = 0.02 vs. GBS), despite MIAC and fetal bacteremia in all cases (4/4; 100%). Compared to the GBS group, BSCI prophylaxis was associated with significantly lower cytokine levels including lower IL-8 in amniotic fluid (p = 0.03), TNF-α in fetal plasma (p < 0.05), IFN-α and IL-7 in the fetal lung (p = 0.02) and IL-18, IL-2, and IL-7 in the fetal brain (p = 0.03). Neutrophilic chorioamnionitis was common in the BSCI and GBS groups, but was more severe in the BSCI+GBS group with greater myeloperoxidase staining (granulocyte marker) in the amnion and chorion (p < 0.05 vs. GBS). Collectively, these observations indicate that blocking the chemokine response to infection powerfully suppressed uterine contractility, PTL and the cytokine response, but did not prevent MIAC and fetal pneumonia. Development of PTL immunotherapies should occur in tandem with evaluation for AF microbes and consideration for antibiotic therapy.

Prenatal diagnosis of fetal aortopulmonary window by two- and four-dimensional echocardiography with spatiotemporal image correlation

BACKGROUND

Aortopulmonary window (APW) is a rare congenital heart disease which challenges most screening sonographers. The current study aims to summarize the two-dimensional (2D) and four-dimensional (4D) sonographic features in the fetal diagnosis.

METHODS

Ten cases of fetal APW were retrospectively reviewed, including 6 and 4 fetuses with distal and proximal defects, respectively. In addition, 40 normal fetuses with similar gestational age were also enrolled. The angle (α) between the pulmonary artery and aorta, and the length (D) of the ductus/pulmonary artery before its convergence with aorta were measured and compared between the normal and APW fetuses, respectively. Cardiac volumes of APW fetuses were acquired with spatial temporal image correlation (STIC) technique and post-analyzed to obtain 4D rendered images.

RESULTS

The D and the α were smaller and greater in distal APW fetuses than those in the normal fetuses, respectively (both P < .01), while no difference presented between the proximal APW fetuses and the normal fetuses. The ductus was absent for all distal APW fetuses, while it was normal for proximal APW fetuses. In 9 of 10 fetuses (90%), the 4D rendered image could be successfully obtained, which clearly showed the abnormal blood communication between the two great arteries in space.

CONCLUSION

It is essential to scan around the three-vessel view and three-vessel trachea view to identify fetal APW using grayscale and color Doppler echocardiography. Distal APW is always with an increasing angulation between aorta and the pulmonary artery, and without the presence of normal ductus. 4D STIC technique may provide additional spatial relationships of the great arteries and thus help the diagnosis and consultation.

Right aortic arch, bilateral ductus arteriosus, and anomalous origin of left pulmonary artery from innominate artery in a fetus with normal intracardiac anatomy

Right aortic arch (RAA) with right ductus arteriosus (RDA) is one of the least frequently diagnosed cardiac abnormalities prenatally. We describe here a case of RAA, bilateral ductus arteriosus (BDA), and anomalous origin of left pulmonary artery from innominate artery in a fetus with normal intracardiac anatomy.

Pregnancy after valproate withdrawal-Fetal malformations and seizure control

OBJECTIVE

To assess the outcomes in women with epilepsy in relation to fetal malformation and epileptic seizure control during pregnancy when valproate (VPA) intake was ceased, or the drug's dose was reduced before pregnancy.

METHODS

Statistical analysis of data collected in the Australian Pregnancy Register between 1999 and 2018 concerning 580 pregnancies previously treated with VPA, with the VPA dose reduced or the drug withdrawn prior to pregnancy in 158 cases.

RESULTS

Although the available data have limitations, fetal malformation rates in the pregnancies studied were lower in the VPA changed pregnancies (4.5%) than in the VPA unchanged comparator pregnancies (10.9%, hazard ratio [HR] 0.412, 95% confidence interval [CI] 0.190-0.892), and were only 2.7% where VPA intake was ceased before pregnancy (HR 0.262, 95% CI 0.083-0.826). Seizure-affected pregnancies were more frequent in the VPA changed pregnancies than in the VPA unchanged ones (46.2% vs 30.8%, HR 1.500, 95% CI 1.203-1.870). Convulsive seizure-affected pregnancies also were increased, but the difference was not statistically significant.

SIGNIFICANCE

Prepregnancy reduction in VPA dosage reduced the hazard of fetal malformations, whereas ceasing intake of the drug decreased the hazard to one similar to that which applies in the general population, but at a cost of decreased control of epileptic seizures during the pregnancies studied. Further investigations are needed to see whether such findings apply more widely in women with epilepsy.

The Relationship of Nutritional Energy and Macronutrient Intake with Pregnancy Outcomes in Czech Pregnant Women

Maternal nutrition and metabolism play important roles for the well-being of both mother and fetus during pregnancy. This longitudinal study brings an original evaluation of the relationship between the nutritional energy and macronutrients intake (NEMI) and pregnancy outcomes and an assessment of the changes in such intake over the previous ten years. Sixty-five healthy Czech pregnant women were examined in three pregnancy periods (1st: 17th-27th; 2nd: 28th-35th; 3rd: 36th-38th gestational weeks). Results of 7-day dietary records were analyzed using NutriDan software. Energy intake decreased from 30.0 kcal/kg to 25.0 kcal/kg during pregnancy. The data also showed a decrease in macronutrients intake (p < 0.0001) with the advancing stage of pregnancy. Positive correlations were demonstrated between NEMI and birth weight (r = 0.410, p < 0.001). In the second pregnancy period, NEMI (excluding carbohydrates) positively associated with neonatal birth length (p < 0.01) and negatively with duration of birth (p < 0.05). An increased NEMI in the last period of pregnancy shortened the length of pregnancy.

Terbutaline-induced neonatal ventricular tachycardia: A case report and review of literature

Neonatal ventricular tachycardia (VT) is an extremely rare condition. We present a 35-week-old gestation neonate who developed tachycardia following maternal exposure to terbutaline. Upon transfer to our neonatal intensive care unit, an electrocardiogram (ECG) was obtained which was consistent with VT. The arrhythmia did not respond to vagal maneuvers or adenosine but resolved following cardioversion demonstrated on postcoversion ECG. At outpatient follow-up, the infant had no further episodes of arrhythmia. To the best of our knowledge, this represents the first case describing terbutaline-induced fetal or neonatal VT.

Consumption of a Branched-Chain Amino Acid (BCAA) during Days 2-10 of Pregnancy Causes Abnormal Fetal and Placental Growth: Implications for BCAA Supplementation in Humans

A relatively large branched-chain amino acid (BCAA) supplement, consumed for more than 10 days, appears to be especially effective at alleviating muscle damage and soreness during intense human training. However, perturbations in amino acid and protein consumption could have unwanted transgenerational effects on male and female reproduction. This paper hypothesizes that isoleucine consumption by female mice from days 2 to 10 of pregnancy will alter fetal and placental growth later in gestation. Mice that had received 118 mM isoleucine in their drinking water delivered pups on day 19 of pregnancy that were 9% larger than normal, whereas the reverse was true for pups born on day 20. Moreover, the inverse correlation between birth weight and litter size was lost in mice that previously consumed excess isoleucine. Similarly, the normal correlations between fetal and placental weights were lost by day 18 of pregnancy in mice that had consumed excess isoleucine. Mice that consumed excess isoleucine had placentas smaller than, and fetuses larger than normal on day 18 of pregnancy, but the reverse was true on day 15. Other unintended and unexpected effects of BCAA consumption should be studied more thoroughly due to the increasing use of BCAAs to alleviate muscle damage and soreness in athletes.

Evaluation of the development of the posterior fossa in normal Chinese fetuses by using magnetic resonance imaging

The posterior fossa is an important brain structure containing the cerebellum, cerebral ventricle, and cistern. Early evaluation of the cerebellar structure and function may be valuable for early detection of fetal deformities. At present, no normal value for the fetal posterior fossa has been established yet. This study is aimed to investigate the development of the posterior fossa in normal Chinese fetuses by using magnetic resonance imaging (MRI).Pregnant women who need MRI scan were enrolled in our Hospital between January 2012 and December 2014. The fetal supero-inferior diameter (SID), anterio-posterior diameter (APD), cerebellar vermis area, cerebellar width (CW), cerebellar volume (CV), superior cerebellar cistern width, and cerebellomedullary cistern width were measured using MRI. Pearson's correlation analysis was used to detect the relationship between those parameters and gestational age. A regression analysis was performed for all parameters.A total of 92 participants were retrospectively enrolled finally. The results indicated SID, APD, cerebellar vermis area, CW, and CV were positively associated with gestational age, while no significant correlation was found between the superior cerebellar cistern width and cerebellomedullary cistern width and gestational age. Each equation was established.Our study demonstrated that MRI has the advantages over ultrasound imaging for prenatal evaluation of the fetal posterior fossa with multiple views. Normal value of the posterior fossa of Chinese fetuses was established in this study.

The relationship between hope and resilience with promoting maternal attachment to the fetus during pregnancy

INTRODUCTION

Maternal attachment to the fetus is an emotional bond and the unique relationship of the pregnant woman to the fetus. Attachment is an important predictor of mental health. One of the psychological factors affecting mental health is resilience and hope. The purpose of this study was to determine the relationship between hope and resilience with promoting maternal attachment to the fetus during pregnancy.

METHODS

This is a descriptive correlational study performed on 386 pregnant women referred to community health centers in Isfahan-Iran. The research instruments were standard questionnaires of Hope Snyder, Conor and Davidson Resilience, and maternal attachment to the fetus of Cranley. Data were analyzed using descriptive statistics and Pearson's correlation test.

RESULTS

The results showed that there is no significant relationship between the overall score of maternal attachment to the fetus and the total score of hope (P = 0.73). The overall score of maternal attachment to the fetus was positively and significantly correlated with hope subscales, including thinking (P = 0.004) and path (P = 0.047). The overall score of maternal attachment to the fetus was positively and significantly correlated with the overall score of resilience (P = 0.03). There was a correlation between the dimensions of maternal attachment to the fetus, including interaction with the fetus (P = 0.003) and self-sacrifice (P = 0.015). Maternal role acceptance (P = 0.001) was positively and significantly correlated with hope thinking subscale. Self-sacrifice (P = 0.027) and differentiation between self and fetus (P = 0.035) were positively and positively correlated with hope path subscales. Self-sacrifice (P = 0.03) and attribution to fetus (P = 0.001) had a significant positive relationship with resilience.

CONCLUSION

The results of this study showed that hope and resiliency are positively and significantly associated with maternal attachment to the fetus during pregnancy. Hope and resiliency are positively and significantly associated with maternal attachment to the fetus, thus increasing the expectation of pregnant mothers to increase their attachment to their fetus. As a result, they are paying more attention to prenatal care, which can guarantee the health of their mothers and their babies.

Serum Microelements in Early Pregnancy and their Risk of Large-for-Gestational Age Birth Weight

Excessive birth weight has serious perinatal consequences, and it “programs” long-term health. Mother’s nutritional status can be an important element in fetal “programming”; microelements such as selenium (Se), zinc (Zn), copper (Cu), and iron (Fe) are involved in many metabolic processes. However, there are no studies assessing the relationship of the microelements in the peri-conceptual period with the risk of excessive birth weight. We performed a nested case control study of serum microelements’ levels in the 10–14th week of pregnancy and assessed the risk of large-for-gestational age (LGA) newborns using the data from a prospective cohort of pregnant women recruited in 2015–2016 in Poznań, Poland. Mothers delivering LGA newborns (n = 66) were examined with matched mothers delivering appropriate-for-gestational age (AGA) newborns (n = 264). Microelements’ levels were quantified using mass spectrometry. The odds ratios of LGA (and 95% confidence intervals) were calculated by multivariate logistic regression. In the whole group, women with the lowest quartile of Se had a 3 times higher LGA risk compared with women in the highest Se quartile (AOR = 3.00; p = 0.013). Importantly, the result was sustained in the subgroup of women with the normal pre-pregnancy BMI (AOR = 4.79; p = 0.033) and in women with a male fetus (AOR = 6.28; p = 0.004), but it was not sustained in women with a female fetus. There were no statistical associations between Zn, Cu, and Fe levels and LGA. Our study provides some preliminary evidence for the relationships between lower serum Se levels in early pregnancy and a higher risk of large-for-gestational age birth weight. Appropriate Se intake in the periconceptual period may be important for optimal fetal growth.