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Avena-Zampieri CL, Dassios T, Milan A, Santos R, Kyriakopoulou V, Cromb D, Hall M, Egloff A, McGovern M, Uus A, Hutter J, Payette K, Rutherford M, Greenough A, Story L. Correlation of fetal lung area with MRI derived pulmonary volume. Early Hum Dev 2024; 194:106047. [PMID: 38851106 DOI: 10.1016/j.earlhumdev.2024.106047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Neonatal chest-Xray (CXR)s are commonly performed as a first line investigation for the evaluation of respiratory complications. Although lung area derived from CXRs correlates well with functional assessments of the neonatal lung, it is not currently utilised in clinical practice, partly due to the lack of reference ranges for CXR-derived lung area in healthy neonates. Advanced MR techniques now enable direct evaluation of both fetal pulmonary volume and area. This study therefore aims to generate reference ranges for pulmonary volume and area in uncomplicated pregnancies, evaluate the correlation between prenatal pulmonary volume and area, as well as to assess the agreement between antenatal MRI-derived and neonatal CXR-derived pulmonary area in a cohort of fetuses that delivered shortly after the antenatal MRI investigation. METHODS Fetal MRI datasets were retrospectively analysed from uncomplicated term pregnancies and a preterm cohort that delivered within 72 h of the fetal MRI. All examinations included T2 weighted single-shot turbo spin echo images in multiple planes. In-house pipelines were applied to correct for fetal motion using deformable slice-to-volume reconstruction. An MRI-derived lung area was manually segmented from the average intensity projection (AIP) images generated. Postnatal lung area in the preterm cohort was measured from neonatal CXRs within 24 h of delivery. Pearson correlation coefficient was used to correlate MRI-derived lung volume and area. A two-way absolute agreement was performed between the MRI-derived AIP lung area and CXR-derived lung area. RESULTS Datasets from 180 controls and 10 preterm fetuses were suitable for analysis. Mean gestational age at MRI was 28.6 ± 4.2 weeks for controls and 28.7 ± 2.7 weeks for preterm neonates. MRI-derived lung area correlated strongly with lung volumes (p < 0.001). MRI-derived lung area had good agreement with the neonatal CXR-derived lung area in the preterm cohort [both lungs = 0.982]. CONCLUSION MRI-derived pulmonary area correlates well with absolute pulmonary volume and there is good correlation between MRI-derived pulmonary area and postnatal CXR-derived lung area when delivery occurs within a few days of the MRI examination. This may indicate that fetal MRI derived lung area may prove to be useful reference ranges for pulmonary areas derived from CXRs obtained in the perinatal period.
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Affiliation(s)
- Carla L Avena-Zampieri
- Department of Women and Children's Health King's College London, United Kingdom; Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom.
| | - Theodore Dassios
- Department of Women and Children's Health King's College London, United Kingdom
| | - Anna Milan
- Neonatal Unit, Guy's and St Thomas' NHS Foundation Trust, United Kingdom
| | - Rui Santos
- Children's Radiology Department, Evelina London Children's Hospital, Guy's and St Thomas NHS Foundation Trust, United Kingdom
| | - Vanessa Kyriakopoulou
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom; Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom
| | - Daniel Cromb
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom
| | - Megan Hall
- Department of Women and Children's Health King's College London, United Kingdom; Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom
| | - Alexia Egloff
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom; Fetal Medicine Unit, Guy's and St Thomas' NHS Foundation Trust, United Kingdom
| | - Matthew McGovern
- Neonatal Unit, Guy's and St Thomas' NHS Foundation Trust, United Kingdom
| | - Alena Uus
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom; Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom
| | - Jana Hutter
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom
| | - Kelly Payette
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom; Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom
| | - Mary Rutherford
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom
| | - Anne Greenough
- Department of Women and Children's Health King's College London, United Kingdom
| | - Lisa Story
- Department of Women and Children's Health King's College London, United Kingdom; Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom; Fetal Medicine Unit, Guy's and St Thomas' NHS Foundation Trust, United Kingdom
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DeVore GR, Polanco B, Lee W, Fowlkes JB, Peek EE, Putra M, Hobbins JC. Maternal rest improves growth in small-for-gestational-age fetuses (<10th percentile). Am J Obstet Gynecol 2024:S0002-9378(24)00530-1. [PMID: 38842845 DOI: 10.1016/j.ajog.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/20/2024] [Accepted: 04/22/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Optimal management of fetuses diagnosed as small for gestational age based on an estimated fetal weight of <10th percentile represents a major clinical problem. The standard approach is to increase fetal surveillance with serial biometry and antepartum testing to assess fetal well-being and timing of delivery. Observational studies have indicated that maternal rest in the left lateral position improves maternal cardiac output and uterine blood flow. However, maternal bed rest has not been recommended based on the results of a randomized clinical trial that showed that maternal rest does not improve fetal growth in small-for-gestational-age fetuses. This study was conducted to revisit this question. OBJECTIVE This study aimed to determine whether maternal bed rest was associated with an increase in the fetal biometric parameters that reflect growth after the diagnosis of a small-for-gestational-age fetus. STUDY DESIGN A retrospective study was conducted on fetuses who were diagnosed as small for gestational age because of an estimated fetal weight of <10th percentile for gestational age. The mothers were asked to rest in the left lateral recumbent position. Fetal biometry was performed 2 weeks after the diagnosis. All fetuses before entry into the study had a previous ultrasound that demonstrated an estimated fetal weight of >10th percentile. To assess the response to bed rest, the change in fetal biometric parameters (estimated fetal weight, head circumference, abdominal circumference, and femur length) after the recommendation of bed rest was computed for 2 periods: (1) before the diagnosis of a weight of <10th percentile vs at the time of diagnosis of a weight of <10th percentile and (2) at the time of diagnosis of a weight of <10th percentile vs 2 weeks after maternal bed rest. For repeated measures, proportions were compared using the McNemar test, and percentile values were compared using the Bonferroni Multiple Comparison Test. A P value of <.05 was considered significant. To describe changes in the estimated fetal weight without bed rest, 2 control groups in which the mothers were not placed on bed rest after the diagnosis of a small-for-gestational-age fetus were included. RESULTS A total of 265 fetuses were observed before and after maternal bed rest. The following were observed in this study: (1) after 2 weeks of maternal rest, 199 of 265 fetuses (75%) had a fetal weight of >10th percentile; (2) the median fetal weight percentile increased from 6.8 (interquartile range, 4.4-8.4) to 18.0 (interquartile range, 9.5-29.5) after 2 weeks of bed rest; (3) similar trends were noted for the head circumference, abdominal circumference, and femur length. In the groups of patients who were not asked to be on bed rest, a reassignment to a weight of >10th percentile at a follow-up examination only occurred in 7 of 37 patients (19%) in the Texas-Michigan group and 13 of 111 patients (12%) in the Colorado group compared with the bed rest group (199/265 [75%]) (P<.001). CONCLUSION Patients who were prescribed 2 weeks of bed rest after the diagnosis of a fetal weight of <10th percentile had an increase in weight of >10th percentile in 199 of 265 fetuses (75%). This increase in fetal weight was significantly higher than that in the 2 control groups in which bed rest was not prescribed. This observation suggests that bed rest improves fetal growth in a subset of patients.
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Affiliation(s)
- Greggory R DeVore
- Fetal Diagnostic Centers, Pasadena, Tarzana, and Lancaster, CA; Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI.
| | - Bardo Polanco
- Fetal Diagnostic Centers, Pasadena, Tarzana, and Lancaster, CA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Jeffrey Brian Fowlkes
- Departments of Radiology and Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Emma E Peek
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
| | - Manesha Putra
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
| | - John C Hobbins
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
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Avena-Zampieri CL, Hutter J, Uus A, Deprez M, Payette K, Hall M, Bafadhel M, Russell REK, Milan A, Rutherford M, Shennan A, Greenough A, Story L. Functional MRI assessment of the lungs in fetuses that deliver very Preterm: An MRI pilot study. Eur J Obstet Gynecol Reprod Biol 2024; 293:106-114. [PMID: 38141484 PMCID: PMC10929943 DOI: 10.1016/j.ejogrb.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/11/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVES To compare mean pulmonary T2* values and pulmonary volumes in fetuses that subsequently spontaneously delivered before 32 weeks with a control cohort with comparable gestational ages and to assess the value of mean pulmonary T2* as a predictor of preterm birth < 32 weeks' gestation. METHODS MRI datasets scanned at similar gestational ages were selected from fetuses who spontaneously delivered < 32 weeks of gestation and a control group who subsequently delivered at term with no complications. All women underwent a fetal MRI on a 3 T MRI imaging system. Sequences included T2-weighted single shot fast spin echo and T2* sequences, using gradient echo single shot echo planar sequencing of the fetal thorax. Motion correction was performed using slice-to-volume reconstruction and T2* maps generated using in-house pipelines. Lungs were manually segmented and volumes and mean T2* values calculated for both lungs combined and left and right lung separately. Linear regression was used to compare values between the preterm and control cohorts accounting for the effects of gestation. Receiver operating curves were generated for mean T2* values and pulmonary volume as predictors of preterm birth < 32 weeks' gestation. RESULTS Datasets from twenty-eight preterm and 74 control fetuses were suitable for analysis. MRI images were taken at similar fetal gestational ages (preterm cohort (mean ± SD) 24.9 ± 3.3 and control cohort (mean ± SD) 26.5 ± 3.0). Mean gestational age at delivery was 26.4 ± 3.3 for the preterm group and 39.9 ± 1.3 for the control group. Mean pulmonary T2* values remained constant with increasing gestational age while pulmonary volumes increased. Both T2* and pulmonary volumes were lower in the preterm group than in the control group for all parameters (both combined, left, and right lung (p < 0.001 in all cases). Adjusted for gestational age, pulmonary volumes and mean T2* values were good predictors of premature delivery in fetuses < 32 weeks (area under the curve of 0.828 and 0.754 respectively). CONCLUSION These findings indicate that mean pulmonary T2* values and volumes were lower in fetuses that subsequently delivered very preterm. This may suggest potentially altered oxygenation and indicate that pulmonary morbidity associated with prematurity has an antenatal antecedent. Future work should explore these results correlating antenatal findings with long term pulmonary outcomes.
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Affiliation(s)
- Carla L Avena-Zampieri
- Department of Women and Children's Health King's College London, United Kingdom; Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom.
| | - Jana Hutter
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom
| | - Alena Uus
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom; Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom
| | - Maria Deprez
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom; Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom
| | - Kelly Payette
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom; Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom
| | - Megan Hall
- Department of Women and Children's Health King's College London, United Kingdom; Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom; Fetal Medicine Unit, Guy's and St Thomas' NHS Foundation Trust, United Kingdom
| | - Mona Bafadhel
- King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Richard E K Russell
- King's Centre for Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Anna Milan
- Neonatal Unit, Guy's and St Thomas' NHS Foundation Trust, United Kingdom
| | - Mary Rutherford
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom
| | - Andrew Shennan
- Department of Women and Children's Health King's College London, United Kingdom
| | - Anne Greenough
- Department of Women and Children's Health King's College London, United Kingdom
| | - Lisa Story
- Department of Women and Children's Health King's College London, United Kingdom; Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom; Fetal Medicine Unit, Guy's and St Thomas' NHS Foundation Trust, United Kingdom
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Saini BS, Ducas R, Darby JRT, Marini D, Sun L, Macgowan CK, Windrim R, Kingdom JC, Wald RM, Morrison JL, Seed M. Feasibility of MRI assessment of maternal-fetal oxygen transport and consumption relative to maternal position in healthy late gestational pregnancies. J Physiol 2023; 601:5413-5436. [PMID: 37906114 DOI: 10.1113/jp285097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/16/2023] [Indexed: 11/02/2023] Open
Abstract
Late gestational supine positioning reduces maternal cardiac output due to inferior vena caval (IVC) compression, despite increased collateral venous return. However, little is known about the impact of maternal position on oxygen (O2 ) delivery and consumption of the gravid uterus, fetus, placenta and lower limbs. We studied the effects of maternal positioning on these parameters in 20 healthy pregnant subjects at 36 ± 2 weeks using magnetic resonance imaging (MRI); a follow-up MRI was performed 6-months postpartum (n = 16/20). MRI techniques included phase-contrast and T1/T2 relaxometry for blood flow and oximetry imaging, respectively. O2 transport was measured in the following vessels (bilateral where appropriate): maternal abdominal descending aorta (DAoabdo ), IVC, ovarian, paraspinal veins (PSV), uterine artery (UtA) and external iliacs, and umbilical. Maternal cardiac output was measured by summing DAothoracic and superior vena cava flows. Supine mothers (n = 6) had lower cardiac output and O2 delivery in the DAoabdo , UtA and external iliac arteries, and higher PSV flow than those in either the left (n = 8) or right (n = 6) lateral positions during MRI. However, O2 consumption in the gravid uterus, fetus, placenta and lower limbs was unaffected by maternal positioning. The ratio of IVC/PSV flow decreased in supine mothers while ovarian venous flow and O2 saturation were unaltered, suggesting a major route of pelvic venous return unaffected by maternal position. Placental-fetal O2 transport and consumption were similar between left and right lateral maternal positions. In comparison to non-pregnant findings, DAoabdo and UtA O2 delivery and pelvic O2 consumption increased, while lower-limb consumption remained constant , despite reduced external iliac artery O2 delivery in late gestation. KEY POINTS: Though sleeping supine during the third trimester is associated with an increased risk of antepartum stillbirth, the underlying biological mechanisms are not fully understood. Maternal cardiac output and uteroplacental flow are reduced in supine mothers due to inferior vena caval compression from the weight of the gravid uterus. This MRI study provides a comprehensive circulatory assessment, demonstrating reduced maternal cardiac output and O2 delivery (uteroplacental, lower body) in supine compared to lateral positioning; however, O2 consumption (gravid uterus, fetus, placenta, lower limbs) was preserved. Unlike other mammalian species, the ovarian veins conduct substantial venous return from the human pregnant uterus that is unaffected by maternal positioning. Lumbar paraspinal venous flow increased in supine mothers. These observations may have important considerations during major pelvic surgery in pregnancy (i.e. placenta percreta). Future studies should address the importance of maternal positioning as a potential tool to deliver improved perinatal outcomes in pregnancies with compromised uteroplacental O2 delivery.
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Affiliation(s)
- Brahmdeep S Saini
- Heart Centre, Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robin Ducas
- Department of Internal Medicine, Section of Cardiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Davide Marini
- Heart Centre, Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Liqun Sun
- Heart Centre, Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christopher K Macgowan
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Biophysics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rory Windrim
- Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Division, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John C Kingdom
- Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Division, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rachel M Wald
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Janna L Morrison
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mike Seed
- Heart Centre, Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Herrera CL, Wang Y, Udayakumar D, Xi Y, Do QN, Lewis MA, Owen DM, Fei B, Spong CY, Twickler DM, Madhuranthakam AJ. Longitudinal assessment of placental perfusion in normal and hypertensive pregnancies using pseudo-continuous arterial spin-labeled MRI: preliminary experience. Eur Radiol 2023; 33:9223-9232. [PMID: 37466705 PMCID: PMC10796849 DOI: 10.1007/s00330-023-09945-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 05/05/2023] [Accepted: 05/17/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVES To evaluate longitudinal placental perfusion using pseudo-continuous arterial spin-labeled (pCASL) MRI in normal pregnancies and in pregnancies affected by chronic hypertension (cHTN), who are at the greatest risk for placental-mediated disease conditions. METHODS Eighteen normal and 23 pregnant subjects with cHTN requiring antihypertensive therapy were scanned at 3 T using free-breathing pCASL-MRI at 16-20 and 24-28 weeks of gestational age. RESULTS Mean placental perfusion was 103.1 ± 48.0 and 71.4 ± 18.3 mL/100 g/min at 16-20 and 24-28 weeks respectively in normal pregnancies and 79.4 ± 27.4 and 74.9 ± 26.6 mL/100 g/min in cHTN pregnancies. There was a significant decrease in perfusion between the first and second scans in normal pregnancies (p = 0.004), which was not observed in cHTN pregnancies (p = 0.36). The mean perfusion was not statistically different between normal and cHTN pregnancies at both scans, but the absolute change in perfusion per week was statistically different between these groups (p = 0.044). Furthermore, placental perfusion was significantly lower at both time points (p = 0.027 and 0.044 respectively) in the four pregnant subjects with cHTN who went on to have infants that were small for gestational age (52.7 ± 20.4 and 50.4 ± 20.9 mL/100 g/min) versus those who did not (85 ± 25.6 and 80.0 ± 25.1 mL/100 g/min). CONCLUSION pCASL-MRI enables longitudinal assessment of placental perfusion in pregnant subjects. Placental perfusion in the second trimester declined in normal pregnancies whereas it remained unchanged in cHTN pregnancies, consistent with alterations due to vascular disease pathology. Perfusion was significantly lower in those with small for gestational age infants, indicating that pCASL-MRI-measured perfusion may be an effective imaging biomarker for placental insufficiency. CLINICAL RELEVANCE STATEMENT pCASL-MRI enables longitudinal assessment of placental perfusion without administering exogenous contrast agent and can identify placental insufficiency in pregnant subjects with chronic hypertension that can lead to earlier interventions. KEY POINTS • Arterial spin-labeled (ASL) magnetic resonance imaging (MRI) enables longitudinal assessment of placental perfusion without administering exogenous contrast agent. • ASL-MRI-measured placental perfusion decreased significantly between 16-20 week and 24-28 week gestational age in normal pregnancies, while it remained relatively constant in hypertensive pregnancies, attributed to vascular disease pathology. • ASL-MRI-measured placental perfusion was significantly lower in subjects with hypertension who had a small for gestational age infant at 16-20-week gestation, indicating perfusion as an effective biomarker of placental insufficiency.
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Affiliation(s)
- Christina L Herrera
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Yiming Wang
- Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9061, USA
| | - Durga Udayakumar
- Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9061, USA
- Advanced Imaging Research Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Yin Xi
- Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9061, USA
- Department of Clinical Science, UT Southwestern Medical Center, Dallas, TX, USA
| | - Quyen N Do
- Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9061, USA
| | - Matthew A Lewis
- Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9061, USA
| | - David M Owen
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Baowei Fei
- Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9061, USA
- Advanced Imaging Research Center, UT Southwestern Medical Center, Dallas, TX, USA
- Department of Bioengineering, University of Texas at Dallas, Richardson, TX, USA
| | - Catherine Y Spong
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Diane M Twickler
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
- Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9061, USA
| | - Ananth J Madhuranthakam
- Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9061, USA.
- Advanced Imaging Research Center, UT Southwestern Medical Center, Dallas, TX, USA.
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Clark AR, Fontinha H, Thompson J, Couper S, Jani D, Mirjalili A, Bennet L, Stone P. Maternal Cardiovascular Responses to Position Change in Pregnancy. BIOLOGY 2023; 12:1268. [PMID: 37759669 PMCID: PMC10525953 DOI: 10.3390/biology12091268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/07/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023]
Abstract
The maternal cardiovascular-circulatory system undergoes profound changes almost from the conception of a pregnancy until the postpartum period to support the maternal adaptions required for pregnancy and lactation. Maintenance of cardiovascular homeostasis requires changes in the cardiovascular autonomic responses. Here, we present a longitudinal study of the maternal cardiovascular autonomic responses to pregnancy and maternal position. Over a normal gestation, in the left lateral position there are significant changes in both time and frequency domain parameters reflecting heart rate variability. We show that cardiovascular autonomic responses to physiological stressors (standing and supine positions in late pregnancy) became significantly different with advancing gestation. In the third trimester, 60% of the subjects had an unstable heart rate response on standing, and these subjects had a significantly reduced sample entropy evident in their heart rate variability data. By 6 weeks, postpartum function returned to near the non-pregnant state, but there were consistent differences in high-frequency power when compared to nulligravid cases. Finally, we review complementary evidence, in particular from magnetic resonance imaging, that provides insights into the maternal and fetal impacts of positioning in pregnancy. This demonstrates a clear relationship between supine position and maternal hemodynamic parameters, which relates to compression of the inferior vena cava (p = 0.05). Together, these studies demonstrate new understanding of the physiology of physiological stressors related to position.
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Affiliation(s)
- Alys R. Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland 1010, New Zealand
| | - Hanna Fontinha
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - John Thompson
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Sophie Couper
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Devanshi Jani
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Ali Mirjalili
- Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Laura Bennet
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Peter Stone
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
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Avena-Zampieri CL, Hutter J, Deprez M, Payette K, Hall M, Uus A, Nanda S, Milan A, Seed PT, Rutherford M, Greenough A, Story L. Assessment of normal pulmonary development using functional magnetic resonance imaging techniques. Am J Obstet Gynecol MFM 2023; 5:100935. [PMID: 36933803 PMCID: PMC10711505 DOI: 10.1016/j.ajogmf.2023.100935] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND The mainstay of assessment of the fetal lungs in clinical practice is via evaluation of pulmonary size, primarily using 2D ultrasound and more recently with anatomical magnetic resonance imaging. The emergence of advanced magnetic resonance techniques such as T2* relaxometry in combination with the latest motion correction post-processing tools now facilitates assessment of the metabolic activity or perfusion of fetal pulmonary tissue in vivo. OBJECTIVE This study aimed to characterize normal pulmonary development using T2* relaxometry, accounting for fetal motion across gestation. METHODS Datasets from women with uncomplicated pregnancies that delivered at term, were analyzed. All subjects had undergone T2-weighted imaging and T2* relaxometry on a Phillips 3T magnetic resonance imaging system antenatally. T2* relaxometry of the fetal thorax was performed using a gradient echo single-shot echo planar imaging sequence. Following correction for fetal motion using slice-to-volume reconstruction, T2* maps were generated using in-house pipelines. Lungs were manually segmented and mean T2* values calculated for the right and left lungs individually, and for both lungs combined. Lung volumes were generated from the segmented images, and the right and left lungs, as well as both lungs combined were assessed. RESULTS Eighty-seven datasets were suitable for analysis. The mean gestation at scan was 29.9±4.3 weeks (range: 20.6-38.3) and mean gestation at delivery was 40±1.2 weeks (range: 37.1-42.4). Mean T2* values of the lungs increased over gestation for right and left lungs individually and for both lungs assessed together (P=.003; P=.04; P=.003, respectively). Right, left, and total lung volumes were also strongly correlated with increasing gestational age (P<.001 in all cases). CONCLUSION This large study assessed developing lungs using T2* imaging across a wide gestational age range. Mean T2* values increased with gestational age, which may reflect increasing perfusion and metabolic requirements and alterations in tissue composition as gestation advances. In the future, evaluation of findings in fetuses with conditions known to be associated with pulmonary morbidity may lead to enhanced prognostication antenatally, consequently improving counseling and perinatal care planning.
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Affiliation(s)
- Carla L Avena-Zampieri
- Department of Women and Children's Health, King's College London, London, United Kingdom (XX Avena-Zampieri, XX Hall, XX Seed, XX Greenough, and XX Story); Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom (Ms Avena-Zampieri, Dr Hutter, Mr Deprez, Ms Payette, Dr Hall, Ms Uus, Prof Rutherford, and Dr Story).
| | - Jana Hutter
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom (Ms Avena-Zampieri, Dr Hutter, Mr Deprez, Ms Payette, Dr Hall, Ms Uus, Prof Rutherford, and Dr Story)
| | - Maria Deprez
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom (Ms Avena-Zampieri, Dr Hutter, Mr Deprez, Ms Payette, Dr Hall, Ms Uus, Prof Rutherford, and Dr Story); Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom (Ms Deprez, Ms Payette, and Ms Uus)
| | - Kelly Payette
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom (Ms Avena-Zampieri, Dr Hutter, Mr Deprez, Ms Payette, Dr Hall, Ms Uus, Prof Rutherford, and Dr Story); Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom (Ms Deprez, Ms Payette, and Ms Uus)
| | - Megan Hall
- Department of Women and Children's Health, King's College London, London, United Kingdom (XX Avena-Zampieri, XX Hall, XX Seed, XX Greenough, and XX Story); Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom (Ms Avena-Zampieri, Dr Hutter, Mr Deprez, Ms Payette, Dr Hall, Ms Uus, Prof Rutherford, and Dr Story); Fetal Medicine Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (Dr Hall, Dr Nanda, and Dr Story)
| | - Alena Uus
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom (Ms Avena-Zampieri, Dr Hutter, Mr Deprez, Ms Payette, Dr Hall, Ms Uus, Prof Rutherford, and Dr Story); Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom (Ms Deprez, Ms Payette, and Ms Uus)
| | - Surabhi Nanda
- Fetal Medicine Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (Dr Hall, Dr Nanda, and Dr Story)
| | - Anna Milan
- Neonatal Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (Dr Milan)
| | - Paul T Seed
- Department of Women and Children's Health, King's College London, London, United Kingdom (XX Avena-Zampieri, XX Hall, XX Seed, XX Greenough, and XX Story)
| | - Mary Rutherford
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom (Ms Avena-Zampieri, Dr Hutter, Mr Deprez, Ms Payette, Dr Hall, Ms Uus, Prof Rutherford, and Dr Story)
| | - Anne Greenough
- Department of Women and Children's Health, King's College London, London, United Kingdom (XX Avena-Zampieri, XX Hall, XX Seed, XX Greenough, and XX Story); Neonatal Unit, King's College Hospital, London, United Kingdom (Prof Greenough); National Institute for Health and Care Research Biomedical Research Centre based at Guy's & St Thomas NHS Foundation Trusts and King's College London, London, United Kingdom (Prof Greenough)
| | - Lisa Story
- Department of Women and Children's Health, King's College London, London, United Kingdom (XX Avena-Zampieri, XX Hall, XX Seed, XX Greenough, and XX Story); Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom (Ms Avena-Zampieri, Dr Hutter, Mr Deprez, Ms Payette, Dr Hall, Ms Uus, Prof Rutherford, and Dr Story); Fetal Medicine Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (Dr Hall, Dr Nanda, and Dr Story)
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8
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Prayer D, Malinger G, De Catte L, De Keersmaecker B, Gonçalves LF, Kasprian G, Laifer-Narin S, Lee W, Millischer AE, Platt L, Prayer F, Pugash D, Salomon LJ, Sanz Cortes M, Stuhr F, Timor-Tritsch IE, Tutschek B, Twickler D, Raine-Fenning N. ISUOG Practice Guidelines (updated): performance of fetal magnetic resonance imaging. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:278-287. [PMID: 36722431 PMCID: PMC10107509 DOI: 10.1002/uog.26129] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 05/03/2023]
Affiliation(s)
- D Prayer
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - G Malinger
- Division of Ultrasound in Obstetrics & Gynecology, Lis Maternity Hospital, Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - L De Catte
- Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - B De Keersmaecker
- Department of Obstetrics & Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - L F Gonçalves
- Fetal Imaging, William Beaumont Hospital, Royal Oak and Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - G Kasprian
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - S Laifer-Narin
- Division of Ultrasound and Fetal MRI, Columbia University Medical Center - New York Presbyterian Hospital, New York, NY, USA
| | - W Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Pavilion for Women, Houston, TX, USA
| | - A-E Millischer
- Radiodiagnostics Department, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - L Platt
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, Los Angeles, CA, USA
| | - F Prayer
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - D Pugash
- Department of Radiology, University of British Columbia, Vancouver, Canada; Department of Obstetrics and Gynecology, BC Women's Hospital, Vancouver, Canada
| | - L J Salomon
- Department of Obstetrics, Hôpital Necker-Enfants Malades, Assistance Publique-Hopitaux de Paris, Université Paris Descartes, Paris, France
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Pavilion for Women, Houston, TX, USA
| | - F Stuhr
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - I E Timor-Tritsch
- Division of Obstetrical & Gynecological Ultrasound, NYU Grossmann School of Medicine, New York, NY, USA
| | - B Tutschek
- Department of Obstetrics & Gynecology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Prenatal Zurich, Zürich, Switzerland
| | - D Twickler
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - N Raine-Fenning
- Department of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK; Nurture Fertility, The Fertility Partnership, Nottingham, UK
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9
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Mikail N, Rossi A, Bengs S, Haider A, Stähli BE, Portmann A, Imperiale A, Treyer V, Meisel A, Pazhenkottil AP, Messerli M, Regitz-Zagrosek V, Kaufmann PA, Buechel RR, Gebhard C. Imaging of heart disease in women: review and case presentation. Eur J Nucl Med Mol Imaging 2022; 50:130-159. [PMID: 35974185 PMCID: PMC9668806 DOI: 10.1007/s00259-022-05914-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/12/2022] [Indexed: 11/04/2022]
Abstract
Cardiovascular diseases (CVD) remain the leading cause of mortality worldwide. Although major diagnostic and therapeutic advances have significantly improved the prognosis of patients with CVD in the past decades, these advances have less benefited women than age-matched men. Noninvasive cardiac imaging plays a key role in the diagnosis of CVD. Despite shared imaging features and strategies between both sexes, there are critical sex disparities that warrant careful consideration, related to the selection of the most suited imaging techniques, to technical limitations, and to specific diseases that are overrepresented in the female population. Taking these sex disparities into consideration holds promise to improve management and alleviate the burden of CVD in women. In this review, we summarize the specific features of cardiac imaging in four of the most common presentations of CVD in the female population including coronary artery disease, heart failure, pregnancy complications, and heart disease in oncology, thereby highlighting contemporary strengths and limitations. We further propose diagnostic algorithms tailored to women that might help in selecting the most appropriate imaging modality.
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Affiliation(s)
- Nidaa Mikail
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Ahmed Haider
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Barbara E Stähli
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Angela Portmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Alessio Imperiale
- Nuclear Medicine and Molecular Imaging - Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, Strasbourg, France
- Molecular Imaging - DRHIM, IPHC, UMR 7178, CNRS/Unistra, Strasbourg, France
| | - Valerie Treyer
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Alexander Meisel
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Vera Regitz-Zagrosek
- Charité, Universitätsmedizin, Berlin, Berlin, Germany
- University of Zurich, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Cathérine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland.
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.
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10
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Mayuga KA, Fedorowski A, Ricci F, Gopinathannair R, Dukes JW, Gibbons C, Hanna P, Sorajja D, Chung M, Benditt D, Sheldon R, Ayache MB, AbouAssi H, Shivkumar K, Grubb BP, Hamdan MH, Stavrakis S, Singh T, Goldberger JJ, Muldowney JAS, Belham M, Kem DC, Akin C, Bruce BK, Zahka NE, Fu Q, Van Iterson EH, Raj SR, Fouad-Tarazi F, Goldstein DS, Stewart J, Olshansky B. Sinus Tachycardia: a Multidisciplinary Expert Focused Review. Circ Arrhythm Electrophysiol 2022; 15:e007960. [PMID: 36074973 PMCID: PMC9523592 DOI: 10.1161/circep.121.007960] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.
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Affiliation(s)
- Kenneth A. Mayuga
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Artur Fedorowski
- Karolinska Institutet & Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University of Chieti-Pescara, Chieti Scalo, Italy
| | | | | | | | | | | | - Mina Chung
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Phoenix, AZ
| | - David Benditt
- University of Minnesota Medical School, Minneapolis, MN
| | | | - Mirna B. Ayache
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Hiba AbouAssi
- Division of Endocrinology, Metabolism, and Nutrition, Duke University Medical Center, Durham, NC
| | | | | | | | | | - Tamanna Singh
- Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | | | - James A. S. Muldowney
- Vanderbilt University Medical Center &Tennessee Valley Healthcare System, Nashville Campus, Department of Veterans Affairs, Nashville, TN
| | - Mark Belham
- Cambridge University Hospitals NHS FT, Cambridge, UK
| | - David C. Kem
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Cem Akin
- University of Michigan, Ann Arbor, MI
| | | | - Nicole E. Zahka
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Qi Fu
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas & University of Texas Southwestern Medical Center, Dallas, TX
| | - Erik H. Van Iterson
- Section of Preventive Cardiology & Rehabilitation, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic Cleveland, OH
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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11
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Pallas JD. Management of gestational supraventricular tachycardia with a 'modified' modified Valsalva manoeuvre. Int Emerg Nurs 2022; 64:101201. [PMID: 36027702 DOI: 10.1016/j.ienj.2022.101201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/02/2022] [Accepted: 07/09/2022] [Indexed: 11/05/2022]
Abstract
A 36 year old woman with chest pain and palpitations at 34 weeks gestation (gravidity 2, parity 1) presented to the emergency department where she was found to be in supraventricular tachycardia (SVT). This patient had an earlier episode of SVT during the same pregnancy that was managed with intravenous adenosine. During both presentations a REVERT trial style 'modified' Valsalva manoeuvre (including supine positioning with passive leg raise) was attempted without success. Acknowledging the potential for vena caval compression in pregnant patients while in the Trendelenburg position, the same manoeuvre was attempted with the novel additional of 45 degree left pelvic tilt. This 'modified' modified Valsalva was successful in restoring sinus rhythm, suggesting this technique may warrant further investigation as a viable treatment for pregnant patients with hemodynamically stable SVT.
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Affiliation(s)
- Jeremy D Pallas
- Master of Nursing, John Hunter Emergency Department, Australia.
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12
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Ho A, Chappell LC, Story L, Al-Adnani M, Egloff A, Routledge E, Rutherford M, Hutter J. Visual assessment of the placenta in antenatal magnetic resonance imaging across gestation in normal and compromised pregnancies: Observations from a large cohort study. Placenta 2022; 117:29-38. [PMID: 34768166 PMCID: PMC8761363 DOI: 10.1016/j.placenta.2021.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 09/12/2021] [Accepted: 10/06/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Visual assessment of the placenta in antenatal magnetic resonance imaging is important to confirm healthy appearances or to identify pathology complicating fetal anomaly or maternal disease. METHODS We assessed the placenta in a large cohort of 228 women with low and high risk pregnancies across gestation. All women gave written informed consent and were imaged using either a 3T Philips Achieva or 1.5T Philips Ingenia scanner. Images were acquired with a T2-weighted single shot turbo spin echo sequence of the whole uterus (thereby including placenta) for anatomical information. RESULTS A structured approach to visual assessment of the placenta on T2-weighted imaging has been provided including determination of key anatomical landmarks to aid orientation, placental shape, signal intensity, lobularity and granularity. Transient factors affecting imaging are shown including the effect of fetal movement, gross fetal motion and contractions. Placental appearances across gestation in low risk pregnancies are shown and compared to pregnancies complicated by preeclampsia and chronic hypertension. The utility of other magnetic resonance techniques (T2* mapping as an indirect marker for quantifying oxygenation) and histological assessment alongside visual assessment of placental T2-weighted imaging are demonstrated. DISCUSSION A systematic approach with qualitative descriptors for placental visual assessment using T2-weighted imaging allows confirmation of normal placental development and can detect placental abnormalities in pregnancy complications. T2-weighted imaging can be visually assessed alongside functional imaging (such as T2* maps) in order to further probe the visual characteristics seen.
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Affiliation(s)
- Alison Ho
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, United Kingdom
| | - Lucy C. Chappell
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, United Kingdom
| | - Lisa Story
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, United Kingdom
| | - Mudher Al-Adnani
- Department of Cellular Pathology, Guy’s and St Thomas’ Hospital, London, United Kingdom
| | - Alexia Egloff
- Centre for the Developing Brain, King’s College London, London, United Kingdom
| | - Emma Routledge
- Centre for the Developing Brain, King’s College London, London, United Kingdom
| | - Mary Rutherford
- Centre for the Developing Brain, King’s College London, London, United Kingdom
| | - Jana Hutter
- Centre for the Developing Brain, King’s College London, London, United Kingdom,Biomedical Engineering Department, King’s College London, London, United Kingdom
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13
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Ducas R, Saini BS, Yamamura K, Bhagra C, Marini D, Silversides CK, Roche SL, Colman JM, Kingdom JC, Sermer M, Hanneman K, Seed M, Wald RM. Maternal and Fetal Hemodynamic Adaptations to Pregnancy and Clinical Outcomes in Maternal Cardiac Disease. Can J Cardiol 2021; 37:1942-1950. [PMID: 34224828 DOI: 10.1016/j.cjca.2021.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/04/2021] [Accepted: 06/12/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although insufficient maternal cardiac output (CO) has been implicated in poor outcomes in mothers with heart disease (HD), maternal-fetal interactions remain incompletely understood. We sought to quantify maternal-fetal hemodynamics using magnetic resonance imaging (MRI) and explore their relationships with adverse events. METHODS Pregnant women with moderate or severe HD (n=22; age 32±5 years) were compared with healthy controls (n=21; 34±3 years). An MRI was performed during the third trimester at peak output (maternal-fetal) and six-months postpartum with return of maternal hemodynamics to baseline (reference). Phase-contrast MRI was used for flow quantification and was combined with T1/T2 relaxometry for derivation of fetal oxygen delivery/consumption. RESULTS Third trimester CO and cardiac index (CI) measurements were similar in HD and control groups (CO 7.2±1.5 versus 7.3±1.6 L/min, p=0.79; CI 4.0±0.7 versus 4.3±0.7 L/min/m2, p=0.28). However, the magnitude of CO/CI increase (Δ, peak-pregnancy-reference) in the HD group exceeded controls (CO 46±24% versus 27±16%, p=0.007; CI 51±28% versus 28±17%, p=0.005). Fetal growth and oxygen delivery/consumption were similar between groups. Adverse cardiovascular outcomes (non-mutually exclusive) in 6 HD women included arrhythmia (n=4), heart failure (n=2) and hypertensive disorder of pregnancy (n=1); fetal prematurity was observed in 2 of these women. The odds of a maternal cardiovascular event were inversely associated with peak CI (OR 0.10 [95% confidence interval 0.001-0.86], p=0.04) and ΔCI (0.02 [0.001-0.71], p=0.03). CONCLUSIONS Maternal-fetal hemodynamics can be well-characterized in pregnancy using MRI. Impaired adaptation to pregnancy in women with HD appears to be associated with development of adverse outcomes of pregnancy. BRIEF SUMMARY Maternal and placental-fetal vascular flows in women with heart disease (HD) were measured using magnetic resonance imaging. Adaptive peak pregnancy cardiac output and cardiac index (CI) were formidable in the majority of mothers. Placental-fetal hemodynamics were maintained and neonatal outcomes were favourable. Women with adverse cardiovascular events in pregnancy had insufficient augmentation of CI antenatally. Understanding hemodynamic responses of HD mothers in pregnancy may help physicians counsel women pre-conceptually and further optimize management antenatally.
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Affiliation(s)
- Robin Ducas
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada
| | - Brahmdeep S Saini
- Division of Cardiology, Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kenichiro Yamamura
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada
| | - Catriona Bhagra
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada
| | - Davide Marini
- Division of Cardiology, Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada; Department of Diagnostic Imaging, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada
| | - Candice K Silversides
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynaecology, Mount Sinai Hospital; University of Toronto, Toronto, Ontario, Canada
| | - S Lucy Roche
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada
| | - Jack M Colman
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynaecology, Mount Sinai Hospital; University of Toronto, Toronto, Ontario, Canada
| | - John C Kingdom
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital; University of Toronto, Toronto, Ontario, Canada
| | - Mathew Sermer
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital; University of Toronto, Toronto, Ontario, Canada
| | - Kate Hanneman
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada; Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Mike Seed
- Division of Cardiology, Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Diagnostic Imaging, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada
| | - Rachel M Wald
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynaecology, Mount Sinai Hospital; University of Toronto, Toronto, Ontario, Canada; Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
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