Effect of corticosteroids on cardiac function in growth-restricted fetuses

Short-Term Effects of Dexamethasone versus Betamethasone on Ultrasonic Measures of Fetal Well-Being: Cohort from a Blinded, Randomized Trial

INTRODUCTION

Maternal corticosteroid administration for anticipated preterm birth is common; however, the corticosteroid effect on fetal ultrasound and cardiotocograph (CTG) remains contested. This study aimed to evaluate short-term ultrasound and CTG impact of (a) dexamethasone versus betamethasone (b) pooled corticosteroid effect.

METHODS

Substudy of blinded randomized trial of dexamethasone versus betamethasone (given <34 weeks). Umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV), and uterine artery Doppler, myocardial performance index (MPI), biophysical profile (BPP), and CTG measured pre-corticosteroid then 1, 2, 4, and 7 days post-corticosteroid.

RESULTS

Of 47 fetuses (39 singleton; 4 dichorionic, diamniotic twins; and 4 monochorionic, diamniotic twins) in the February 2012-2013 period, 24 received dexamethasone and 23 betamethasone at average gestation 29.8 ± 2.9 weeks. Thirteen pregnancies (30%) had pre-corticosteroid fetal concerns (estimated weight <10th centile and/or abnormal UA/MCA Doppler). Few significant differences were seen post-corticosteroid: DV pulsatility index and right MPI initially decreased 15-20%, and average BPP decreased slightly on days 1-2. There were no major differential effects of dexamethasone versus betamethasone.

DISCUSSION/CONCLUSION

No substantive post-corticosteroid effects were seen for most ultrasound/CTG measures in fetuses with heightened preterm birth risk but predominantly normal pre-corticosteroid measures. Clinically, this suggests avoiding overreliance on individual measures for delivery decisions post-corticosteroid; equally, multiple/marked ultrasound changes suggest true pathology and not corticosteroid effect.

Evaluation of right side foetal myocardial performance index in pregestational and gestational diabetes mellitus

The aim of our study is to investigate the myocardial performance index (MPI) of the right side of the foetal heart in pregestational and gestational diabetes mellitus and to compare it with non-diabetic pregnancies. This prospective cross-sectional study was conducted between August 2018 and March 2019 at Kanuni Sultan Suleyman Research and Training Hospital. Women with pregestational or gestational diabetes mellitus at 24-34 weeks of gestation were included in the study and non-diabetic pregnant women were included as the control group. MPI of the right side of the foetal heart were evaluated and compared between the groups. A total of 65 pregestational or gestational diabetic patients and 65 non-diabetic patients were included in the study. Isovolumetric contraction time and isovolumetric relaxation time values were significantly longer in the diabetic group (p < .001). Ejection time values were significantly shorter in the diabetic group (p < .001). MPI values were significantly higher in the diabetic group than the non-diabetic group (p < .001). In conclusion, MPI of the right side of the foetal heart is significantly higher in pregestational and gestational diabetes than in the non-diabetic group.IMPACT STATEMENTWhat is already known on this subject? Gestational diabetes mellitus causes foetal cardiomyopathy and foetal diastolic dysfunction. Myocardial performance index (MPI) is a non-invasive, Doppler-derived myocardial performance assessment that is independent of both heart rate and ventricular anatomy.What do the results of this study add? MPI of the right side of the foetal heart was significantly higher in pregestational and gestational diabetes than in the non-diabetic group. There was no difference in right ventricular MPI between pregestational and gestational groups in diabetic pregnancies, and between insulin using and not insulin using groups.What are the implications of these findings for clinical practice and/or further research? Our study results are promising. MPI of the right side of the foetal heart is significantly higher in pregestational and gestational diabetes than in the non-diabetic group. Prospective cohort studies evaluating serial MPI and evaluating by postpartum foetal echocardiography are needed to evaluate possible adverse effects of diabetes on foetal cardiac functions.

Effects of Antenatal Betamethasone on Fetal Doppler Indices and Short Term Fetal Heart Rate Variation in Early Growth Restricted Fetuses

PURPOSE

 To investigate the effects of the antenatal administration of betamethasone on fetal Doppler and short term fetal heart rate variation (CTG-STV) in early growth restricted (FGR) fetuses.

MATERIALS AND METHODS

 Post hoc analysis of data derived from the TRUFFLE study, a prospective, multicenter, randomized management trial of severe early onset FGR. Repeat Doppler and CTG-STV measurements between the last recording within 48 hours before the first dose of betamethasone (baseline value) and for 10 days after were evaluated. Multilevel analysis was performed to analyze the longitudinal course of the umbilico-cerebral ratio (UC ratio), the ductus venosus pulsatility index (DVPIV) and CTG-STV.

RESULTS

 We included 115 fetuses. A significant increase from baseline in CTG-STV was found on day + 1 (p = 0.019) but no difference thereafter. The DVPIV was not significantly different from baseline in any of the 10 days following the first dose of betamethasone (p = 0.167). Multilevel analysis revealed that, over 10 days, the time elapsed from antenatal administration of betamethasone was significantly associated with a decrease in CTG-STV (p = 0.045) and an increase in the DVPIV (p = 0.001) and UC ratio (p < 0.001).

CONCLUSION

 Although steroid administration in early FGR has a minimal effect on increasing CTG-STV one day afterwards, the effects on Doppler parameters were extremely slight with regression coefficients of small magnitude suggesting no clinical significance, and were most likely related to the deterioration with time in FGR. Hence, arterial and venous Doppler assessment of fetal health remains informative following antenatal steroid administration to accelerate fetal lung maturation.

Drug exposure during pregnancy and fetal cardiac function - a systematic review

Background The aim of this systematic review was to describe the effects of drug exposure during pregnancy on fetal cardiac function. Methods We searched MEDLINE, Embase, Cochrane and SCOPUS for studies assessing fetal cardiac function in drug-exposed human pregnancies. Risk of bias was assessed by the Risk Of Bias In Non-randomized Studies of Interventions (ROBIN-I) tool. Results We included 32 studies on eight different drug groups. They included 51 outcome variables, which were all based on ultrasound techniques primarily assessing systolic function: pulsed wave Doppler, tissue Doppler imaging (TDI), and B- and M-mode. Overall, the risk of bias was moderate. β2 agonists increased the systolic velocity in the ductus arteriosus and the fetal heart rate. β-blockers caused unchanged or decreased systolic velocity of the pulmonary trunk. Corticosteroids increased the velocity in the ductus arteriosus. Furthermore, in growth-restricted fetuses with an increased myocardial performance index (MPI') on the right side, corticosteroids normalized this variable. Nonsteroidal anti-inflammatory drugs (NSAIDs), but not acetylsalicylic acid, increased the flow velocities in the ductus arteriosus, decreased the shortening fraction and increased the end-diastolic ventricular diameters. Metformin and insulin normalized the diastolic strain and global longitudinal strain in diabetic pregnancies. Highly active antiretroviral therapy (HAART) exposure increased the E/A ratio on the right side, prolonged the isovolumic relaxation time (IRT) and ejection time, shortened the isovolumic contraction time (ICT), and decreased left myocardial systolic peak velocities. Chemotherapy did not cause detectable changes. Conclusion Six of the eight drug groups caused detectable changes in fetal cardiac function. However, the evidence was hampered by only a few studies for some drugs.

Sertraline use during pregnancy and effect on fetal cardiac function

Objectives: The objective of this study was to evaluate the fetal cardiac function in human pregnancies exposed to sertraline (a selective serotonin reuptake inhibitor) compared to unexposed pregnancies.Method: We included 44 women in gestational week 25 + 0 days to week 26 + 6 days. Fifteen women used sertraline (50-150 mg per day), and 29 women used no daily medication. We assessed fetal cardiac function by Myocardial Performance Index (MPI), E/A ratios and by tricuspid and mitral annular plane systolic excursion (TAPSE and MAPSE) measured by 2D M-mode and by 4D eSTIC M-mode.Results: There were no differences between the sertraline exposed and the unexposed. The mean difference of MPI was 0.03 (95% CI -0.08-0.03), of tricuspid and mitral E/A ratios 0.00 (95% CI -0.03-0.05) and 0.03 (95% CI -0.07-0.01), respectively. The mean difference of TAPSE, by 2D and eSTIC, was 0.07 mm (95% CI -0.56-0.41) and 0.10 mm (95% CI -0.55-0.34). Mean difference of MAPSE, by 2D and eSTIC was 0.16 mm (95% CI -0.22-0.53) and 0.24 mm (95% CI -0.16-0.65), respectively. Serum levels of sertraline in exposed participants ranged from 33-266, median 92 nmol/L.Conclusions: We found no significant differences in fetal cardiac function, assessed by TAPSE, MAPSE, MPI and E/A ratios, in pregnancies exposed to sertraline compared to the unexposed.

Improvement of cardiac function in fetuses with growth restriction following antenatal betamethasone administration: fact or artifact?

INTRODUCTION

Use of corticosteroids for fetal lung maturation has reduced the perinatal mortality/morbidity from prematurity related complications. There is a paucity of studies evaluating the effect of steroid administration on the fetal circulation and cardiac function in fetal growth restriction (FGR). The aim of the study was to assess changes in fetal Doppler indices and cardiovascular function in pregnancies complicated with FGR after administration of betamethasone.

METHODS

This was a prospective study conducted in a tertiary care research center between July 2017 and May 2018. Pregnant women with FGR between 28 and 36 weeks' gestation, who were scheduled to receive betamethasone (two doses of 12 mg, 24 h apart) were recruited. Fetal cardiovascular function in fetuses FGR was assessed immediately before first dose and once between 6 and 24 h after the second dose of betamethasone by the same operator. Wilcoxon matched-pairs signed-rank test or paired t-tests were used to compare parameters before and after corticosteroid exposure.

RESULTS

Fifty cases with FGR were evaluated before and after administration of betamethasone, at mean gestational age of 34.6 ± 2.0 weeks. Fetal heart rate (148.78 ± 9.10 versus 144.73 ± 9.61, p < .001), left heart myocardial performance index ([MPI], 0.66 ± 0.06 versus 0.55 ± 0.09, p ≤ .001) and right heart MPI (0.65 ± 0.04 versus 0.63 ± 0.04, p .016) showed improvement after steroids. Left heart isovolumic relaxation and contraction indices along with ejection time of both sides showed a small but statistically significant improvement (p < .001), but other fetal cardiac functional and Doppler indices remain unchanged after steroids.

CONCLUSIONS

Fetal heart rate, cardiac MPI, left sided isovolumic indices showed an improvement after betamethasone administration. Follow up studies are needed to ascertain whether these effects persist in the long term and to determine whether these are beneficial to a growth restricted fetuses.

Can fetal left ventricular modified myocardial performance index predict adverse perinatal outcomes in intrahepatic cholestasis of pregnancy?

OBJECTIVE

To investigate fetal left ventricular function using the left ventricular modified myocardial performance index (mod-MPI) and E wave/A wave peak velocity (E/A) ratio, and to explore the success of mod-MPI in the prediction of adverse perinatal outcomes in intrahepatic cholestasis of pregnancy (ICP).

METHODS

Forty-one ICP cases were compared with 41 gestational age-matched healthy controls. Opening and closing clicks of the mitral and aortic valves were used to define the three time periods [ejection time (ET), isovolumetric contraction time (ICT) and isovolumetric relaxation time (IRT)], which were employed in the calculation of mod-MPI [mod-MPI = (ICT + IRT)/ET]. The E/A ratio was calculated as well.

RESULTS

Fetal left ventricular mod-MPI values were significantly higher in the ICP group compared to controls (0.56 ± 0.09 versus 0.37 ± 0.04, p < 0.001), whereas the E/A ratio was lower (0.62 ± 0.11 versus 0.69 ± 0.10, p = 0.011). The optimal cutoff level for mod-MPI in prediction of adverse perinatal outcomes was >0.48 [sensitivity: 81.8%, specificity: 67.6%, area under the curve (AUC): 0.750, 95% CI: 0.613-0.887, p = 0.008].

CONCLUSIONS

Fetuses of ICP cases have significant left ventricular dysfunction. Mod-MPI can be used in the prediction of adverse perinatal outcomes in ICP.