Effect of pregestational diabetes mellitus on fetal cardiac function and structure

The evaluation of fetal interventricular septum with M-mode and spectral tissue Doppler imaging in gestational diabetes mellitus: a case-control study

OBJECTIVES

To demonstrate possible functional changes in the frequently affected fetal interventricular septum (IVS) with spectral tissue Doppler imaging (TDI) and M-mode imaging to compare gestational diabetes mellitus (GDM) and control groups.

METHODS

A total of 63 pregnant women with GDM, 30 on diet (A1 GDM) and 33 on treated with insulin (A2 GDM), and 63 healthy pregnant women randomly selected and matched to the case group in the control group were included.

RESULTS

The GDM fetuses had significantly thickened IVS, increased early diastole (E'), atrial contraction (A'), systole (S'), higher myocardial performance index (MPI'), prolonged isovolumetric relaxation time (IVRT'), shortened ejection time (ET'), and decreased septal annular plane systolic excursion (SAPSE) than the controls. The A2 GDM group fetuses had significantly thickened IVS, increased S' and shortened ET' than the A1 GDM group. In the GDM group, we found a significantly positive low correlation between glycated hemoglobin levels and maternal serum fasting glucose and one-hour postprandial glucose with fetal IVS thickness. We demonstrated a significantly negative low correlation between maternal serum one-hour postprandial glucose, glycated hemoglobin levels, and gestational weight gain with fetal IVS ET'.

CONCLUSIONS

Fetal IVS diastolic and systolic functions were altered in the GDM group compared to controls, and systolic functions were altered in A2 GDM compared to A1 GDM. This may alert clinicians to possible cardiovascular diseases in the postnatal life, and early preventive strategies and long-term lifestyle changes may provide protection in fetuses with GDM.

The Influence of Maternal Condition on Fetal Cardiac Function during the Second Trimester

OBJECTIVE

Maternal health has a direct, profound and lasting effect on the formation and development of the fetal cardiovascular system. The aim of this research was to find whether maternal age, BMI hypertension (GH) or gestational diabetic mellitus (GDM) would affect fetal cardiac function in the second trimester.

METHOD

329 mothers who had a fetal echocardiogram examination at the International Peace Maternity & Child Health Hospital of China Welfare Institute, Shanghai, China, from 1 January 2020 to 30 April 2020 were enrolled at the gestational age of 21 to 26 weeks (mean 22.78 ± 1.13 weeks). Single-factor analysis and multi-factor line regression analysis were used to find the contribution values of each factor to fetal cardiac function.

RESULTS

at the second trimester, maternal age had a minor influence on the fetal left ventricle diastolic function. Higher maternal BMI could cause a decrease in the fetal diastolic function of both the left and right ventricle and the systolic function of the left ventricle. Maternal hypertension and gestational diabetic mellitus had a profound influence on both the left and right fetal heart ventricles of both systolic and diastolic function.

CONCLUSION

maternal condition will have a profound influence on fetal cardiac function as early as the second trimester.

The effect of maternal pregestational diabetes on fetal autonomic nervous system

Heart rate variability assessment of neonates of pregestational diabetic mothers have shown alterations in the autonomic nervous system (ANS). The objective was to study the effect of maternal pregestational diabetes on ANS at the fetal stage by combining cardiac and movement parameters using a non-invasive fetal magnetocardiography (fMCG) technique. This is an observational study with 40 participants where fetuses from a group of 9 Type 1, 19 Type 2 diabetic, and 12 non-diabetic pregnant women were included. Time and frequency domain fetal heart rate variability (fHRV) and coupling of movement and heart rate acceleration parameters related to fetal ANS were analyzed. Group differences were investigated using analysis of covariance to adjust for gestational age (GA). When compared to non-diabetics, the Type 1 diabetics had a 65% increase in average ratio of very low-frequency (VLF) to low-frequency (LF) bands and 63% average decrease in coupling index after adjusting for GA. Comparing Type 2 diabetics to non-diabetics, there was an average decrease in the VLF (50%) and LF bands (63%). Diabetics with poor glycemic control had a higher average VLF/LF (49%) than diabetics with good glycemic control. No significant changes at p < 0.05 were observed in high-frequency (HF) frequency domain parameters or their ratios, or in the time domain. Fetuses of pregestational diabetic mothers exhibited some differences in fHRV frequency domain and heart rate-movement coupling when compared to non-diabetics but the effect of fHRV related to fetal ANS and sympathovagal balance were not as conclusive as observed in the neonates of pregestational diabetic mothers.

Poor Correlation between Fetal Tissue Doppler Imaging and Pulsed Wave Myocardial Performance Indices

INTRODUCTION

Both tissue Doppler imaging (TDI) and pulsed wave Doppler (PWD) Myocardial Performance Indices (MPIs) have been proposed as tools for functional fetal cardiology. We wished to determine if there was any correlation between TDI-MPI and PWD-MPI.

METHODS

A cohort of uncomplicated women with morphologically normal singleton fetuses between 22 and 39 weeks of gestation was recruited. A single sonologist acquired Doppler waveforms for evaluation of both left and right TDI-MPI and PWD-MPI. The PWD-MPI values were calculated using a previously published algorithm and the TDI-MPI time intervals were measured manually by a single operator.

RESULTS

Achievability and repeatability were high for both modalities. TDI produced significantly lower right MPI values yet significantly higher left MPI values, potentially reflecting their evaluation of physiologically different events, blood flow versus myocardial contraction.

CONCLUSION

This study demonstrates that MPIs measured from PWD and TDI have a weak correlation and cannot be used interchangeably, even with the exclusion of suboptimal TDI-MPI scans from the analysis. Given the lack of correlation between the two methods, the high variation in TDI waveform, and the lack of unified approach to TDI analysis, we feel further research is needed before adoption of this technique.

Measuring the Area of the Interventricular Septum in the 4-Chamber View: A New Technique to Evaluate the Fetus at Risk for Septal Hypertrophy

OBJECTIVES

One of the problems for the clinician who desires to measure the interventricular septum (IVS) in a high-risk fetus is to know where to make the measurement. The purpose of this study was to use speckle-tracking analysis to measure the IVS area, 24-segment widths, and length at end-diastole (ED) and end-systole (ES) in normal fetuses.

METHODS

From the 4-chamber view, speckle-tracking analysis was performed at ED and ES on the IVS in 200 normal fetuses. The following were computed and regressed against gestational age (GA) and fetal biometric (FB) measurements: area, length, and the 24-segment transverse widths from the apex to the crux. The 24-segment width/length ratio was also measured. The speckle-tracking measurements of the ED area and length were compared using a point-to-point measurement tool available on all ultrasound machines.

RESULTS

The ED and ES areas, lengths, and 24-segment widths increased with GA and FB. The ED and ES areas were virtually identical. The 24-segment width/length ratio decreased from the apex to the crux of the septum. There was no significant difference in the measurement of the ED area and the length between speckle-tracking and the point-to-point measurements.

CONCLUSIONS

Measurement of the area and length of the IVS are simple to obtain and provide a new diagnostic tool to evaluate the fetus at risk for IVS hypertrophy which may be observed in fetuses of mothers with pregestational and gestational diabetes.

Pregestational Diabetes and Congenital Heart Defects

Studies have consistently shown a significant increase in the risk of congenital heart defects in the offspring of diabetic mothers compared with those of nondiabetic pregnancies. Evidence points that all types of pregestational diabetes have the capacity of generating cardiac malformations in a more accentuated manner than in gestational diabetes, and there seems to be an increased risk for all congenital heart defects phenotypes in the presence of maternal diabetes. Currently, the application of some therapies is under study in an attempt to reduce the risks inherent to diabetic pregnancies; however, it has not yet been possible to fully prove their effectiveness. The present review aims to better understand the mechanisms that govern the association between pregestational diabetes and congenital heart defects and how maternal diabetes interferes with fetal cardiac development, as there is still a long way to go in the investigation of this complex process.

Pregestational diabetes alters cardiac structure and function of neonatal rats through developmental plasticity

Pregestational diabetes (PGDM) leads to developmental impairment, especially cardiac dysfunction, in their offspring. The hyperglycemic microenvironment inside the uterus alters the cardiac plasticity characterized by electrical and structural remodeling of the heart. The altered expression of several transcription factors due to hyperglycemia during fetal development might be responsible for molecular defects and phenotypic changes in the heart. The molecular mechanism of the developmental defects in the heart due to PGDM remains unclear. To understand the molecular defects in the 2-days old neonatal rats, streptozotocin-induced diabetic female rats were bred with healthy male rats. We collected 2-day-old hearts from the neonates and identified the molecular basis for phenotypic changes. Neonates from diabetic mothers showed altered electrocardiography and echocardiography parameters. Transcriptomic profiling of the RNA-seq data revealed that several altered genes were associated with heart development, myocardial fibrosis, cardiac conduction, and cell proliferation. Histopathology data showed the presence of focal cardiac fibrosis and increased cell proliferation in neonates from diabetic mothers. Thus, our results provide a comprehensive map of the cellular events and molecular pathways perturbed in the neonatal heart during PGDM. All of the molecular and structural changes lead to developmental plasticity in neonatal rat hearts and develop cardiac anomalies in their early life.

Comprehensive assessment of biventricular myocardial function by two-dimensional speckle tracking echocardiography in infants of gestational diabetic mothers

AIMS

No previous research provided a complete biventricular and multidirectional left ventricular (LV) functional assessment by two-dimensional (2D) speckle tracking echocardiography (STE) in infants of gestational diabetic mothers (IGDM) METHODS: A total of 30 consecutive IGDM and 30 infants of healthy mothers were examined between March 2021 and July 2021. Both groups of infants underwent evaluation by neonatologist and 2D transthoracic echocardiography (TTE) implemented with 2D-STE quantification of LV-global longitudinal strain (GLS), LV-global circumferential strain (GCS), LV-global radial strain (GRS) and right ventricular (RV)-GLS, within 3 days of life and at 40 days after birth. Predictors of persistent subclinical myocardial dysfunction, defined as a LVGLS less negative than -20% at 40-day follow-up, in IGDM population, were determined.

RESULTS

At 2.2 ± 1.3 days after birth, LV-GLS (- 17.2 ± 1.9 vs. - 23.9 ± 3.8%), LV-GCS (- 17.9 ± 2.7 vs. - 27.3 ± 3.4%), LV-GRS (25.6 ± 3.4 vs. 35.8 ± 3.6%) and RV-GLS (- 17.6 ± 3.6 vs. - 22.6 ± 3.8%) were significantly impaired in IGDM than controls (all p < 0.001). At 36.8 ± 5.2 days of life, LV-GLS was still impaired (less negative than -20%) in 26.6% of IGDM. Maternal third trimester body mass index (BMI) (OR 1.89, 95%CI 1.05-3.39) and third trimester glycosylated hemoglobin (HbA1C) (OR 1.59, 95%CI 1.08-2.19) were independently associated with persistent LV-GLS impairment in IGDM. Maternal BMI ≥ 30 Kg/m2 and HbA1C ≥ 38 mmol/mol showed the maximum of sensitivity and specificity for predicting persistent subclinical myocardial dysfunction in IGDM at 40 days of life.

CONCLUSIONS

IGDM have diffuse pattern of myocardial dysfunction during perinatal period. This dysfunction may be persistent up to 40 days of life in infants of GDM women with obesity and uncontrolled diabetes.

Fetal echocardiographic parameters in pregnancies complicated by diabetes: a case control study

Background

At present, the prevalence of pregestational diabetes is 2.2% with an overall prevalence of hyperglycaemia in pregnancy of about 16.2%. Fetuses of diabetic mothers are at risk of functional cardiac abnormalities without structural cardiac anomalies especially in the third trimester. The main aim of this study was to assess the association of diabetes with different fetal echocardiographic parameters.

Methods

A case control study comprising a total of 120 pregnant women (60 cases and 60 controls). The cases group included fetuses of mothers known to have pre-gestational type 2 diabetes (DM group) while the control group included fetuses of euglycaemic healthy pregnant women. They were examined twice at 23–24 weeks' gestation (visit 1) and followed up at 27–28 weeks’ gestation (visit 2). The Modified Myocardial Performance Index (Mod MPI) was obtained in all fetuses. Also, M-mode echocardiography was used to measure the interventricular septum thickness at diastole in a transverse four chamber view.

Results

There was a significant increase in Iso-volumetric contraction time (ICT) (45.4 ms ± 8.9), Iso-volumetric relaxation time (IRT) (54.7 ms ± 11.22), Interventricular septal thickness (IVST) (4.08 mm ± 0.8), aortic acceleration time (AAT) (54.16 ms ± 12.77) and MPI (0.64 ± 0.09) in the diabetic group compared to the normal control group ICT (38.5 ms ± 9.59), IRT (46.13 ms ± 10.29), IVST (3.17 mm ± 0.6), AAT (49.73 ms ± 10.68) and MPI (0.5 ± 0.1) (all P values were < 0.001).

When comparing parameters assessed at both visits among diabetic patients, there was a significant increase in IVST in the second visit (4.74 ± 0.78 mm) compared to the first visit (4.08 ± 0.8 mm) (P value < 0.05).

The incidence of hypertrophic cardiomyopathy (HCM) was significantly higher in diabetic patients than in the control group. This is was observed in both first and second visit (33.4% and 56.7%) (P value < 0.001).

Conclusions

Fetuses of diabetic pregnant females show a significant increase in MPI, decrease in E\A ratio and HCM. These alterations in cardiac functions and structure were found to be continuous throughout the period of time between the two visits.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04969-5.

Evaluation of the selected parameters of the fetal diastolic functions in normally grown or macrosomic fetuses of gestational diabetic mothers with poor glycaemic control

OBJECTIVE

This study aimed to investigate whether the third trimester fetal cardiac diastolic function measured by selected conventional Doppler indices is affected in appropriate-for-gestational-age or macrosomic fetuses of gestational diabetic mothers with poor glycaemic control.

METHODS

This cross-sectional study included 93 pregnant women divided into two groups. Group 1 included 45 appropriate-for-gestational-age or macrosomic fetuses from gestational diabetic mothers with poor glycaemic control (study group). Group 2 included 48 appropriate-for-gestational-age fetuses from gestational age-matched healthy mothers (control group). Functional fetal cardiac parameters and fetoplacental Doppler parameters were measured. Data were compared between the two groups.

RESULTS

Maternal characteristics did not differ significantly between the study and the control group. There were no significant differences in the early and late velocity, early/late velocity ratio of both mitral and tricuspid valves, the fetal pulmonary vein pulsatility index, and the ductus venosus pulsatility index between the study and the control group. Moreover, the rate of abnormal Doppler findings in pulmonary vein (pulmonary vein pulsatility index >95th centile), ductus venosus (ductus venosus pulsatility index >95th centile), and peripheral vessels (umbilical artery pulsatility index >95th centile, middle cerebral artery pulsatility index <5th centile, cerebra-placental index >95th centile) were comparable in both groups.

CONCLUSIONS

The third trimester fetal diastolic functions measured by selected conventional Doppler techniques do not seem to be altered in appropriate-for-gestational-age or macrosomic fetuses of gestational diabetic mothers who have poor glycaemic control.

Fetal Cardiac Function: Myocardial Performance Index

The Myocardial Performance Index (MPI) or Tei index, presented by Tei in 1995, is the ratio of the sum of the duration of the isovolumetric contraction time (ICT) and isovolumetric relaxation time (IRT) to the duration of the ejection time (ET). The Modified Myocardial Performance Index (Mod-MPI), proposed in 2005, is considered a reliable and useful tool in the study of fetal heart function in several conditions, such as growth restriction, twin-twin transfusion syndrome, maternal diabetes, preeclampsia, intrahepatic cholestasis of pregnancy, and adverse perinatal outcomes. Nevertheless, clinical translation is currently limited by poorly standardised methodology as variations in the technique, machine settings, caliper placement, and specific training required can result in significantly different MPI values. This review aims to provide a survey of the relevant literature on MPI, present a strict methodology and technical considerations, and propose future research.

Third Trimester Myocardial Performance Index in Fetuses from Women with Hyperglycemia in Pregnancy: A Systematic Review and Meta-Analysis

INTRODUCTION

 The myocardial performance index (MPI) has been proposed to evaluate cardiac dysfunction in newborns from diabetic mothers. Although MPI is routinely assessed in newborns, its role in the evaluation of fetuses from women with hyperglycemia in pregnancy (HIP) is still under evaluation. We aimed to evaluate the differences in third trimester fetal MPI in pregnant women with hyperglycemia compared to healthy controls.

MATERIALS AND METHODS

 Seven electronic databases were searched for all studies assessing women with HIP who underwent evaluation of fetal left MPI during pregnancy compared to a control group. The summary measures were reported as mean differences (MD) in the mean fetal left MPI between women with HIP and healthy controls, with a 95 % confidence interval (CI). A post hoc subgroup analysis based on the type of HIP - pregestational diabetes, GDM, or gestational impaired glucose tolerance (GIGT) - was performed as an additional analysis.

RESULTS

 14 studies assessing 1326 fetuses (580 from women with HIP and 746 from controls) were included. Women with HIP had a significantly higher mean left fetal MPI compared to controls (MD 0.08; 95 %CI: 0.05 to 0.11; p < 0.00 001). Subgroup analysis according to the type of HIP concurred with the overall analysis for women with DM (MD 0.07; 95 %CI: 0.01 to 0.13; p = 0.02) and for women with GDM (MD 0.012; 95 %CI: 0.07 to 0.17; p < 0.00 001) but not for women with GIGT (MD -0.01, 95 % CI -0.28 to 0.27; p = 0.96).

CONCLUSION

 Fetal left MPI is increased in pregnancies with HIP appearing as a potential marker of cardiac dysfunction.

Evaluation of fetal cardiac functions in the setting of maternal diabetes: Application of the global spherical index, global strain and fractional area change by the speckle tracking technique

OBJECTIVE

To evaluate ventricular contractility and profile heart deformations in fetuses of hyperglycemic mothers using the Speckle tracking imaging (STI). The fractional area change (FAC), global longitudinal strain (GLS) and global sphericity index (GSI) of the 4-chamber view (4-CV) were computed.

STUDY DESIGN

Dynamic 4-CV images of 60 fetuses exposed to maternal diabetes (MD) and 60 controls were retrospectively collected between 19 and 37 weeks of gestation. Speckle-tracking analysis was used to compute and compare GSI, GLS and FAC of the right ventricle (RV) and the left ventricle (LV) between the groups. By definition, GSI was the ratio of the epicardial basal-apical length in end-diastole (BAL) to the overall transverse length of RV and LV in end-diastole (TL). The FAC was calculated by dividing the difference between end-diastolic area and end-systolic area by the end-diastolic area. Similarly, the GLS of the RV and LV was obtained by dividing the difference between the endocardial length in end-systole and endocardial length in end-diastole to the endocardial length in end-diastole. Data for conventional echocardiographic parameters, standard biological measurements of fetus and maternal baseline characteristics were also recorded and compared between the groups. Linear regression analysis was performed to assess the association between age, BMI and the inter-ventricular septum thickness (IVST).

RESULTS

Gestational age at the time of examination did not differ significantly between the control and gestational diabetes group (p = 0.74). In fetuses exposed to MD, the thickness of the IVS was higher while the FAC of RV, GLS of RV and the GSI were all significantly lower. The FAC and global strain of LV generally decreased with progress in gestation but the difference between the two groups was not statistically significant. Conventional echocardiography in fetuses exposed to MD revealed a lower mitral E/A ratio and a larger myocardial performance index (MPI) of the RV and LV. Although the annular plane systolic excursion (MAPSE), tricuspid annular plane systolic excursion (TAPSE) and septal annular plane systolic excursion (SAPSE) were also lower in this group, the difference was not statistically significant compared to fetuses of the control group. No regression relationship between age, BMI and IVST were noticed in any group.

CONCLUSION

This study found that diastolic dysfunction among fetuses of gestational diabetic mothers is accompanied by global cardiac deformation and functional decrease of the RV in systole in the second and third trimester. The GSI, global strain and FAC acquired by SRI can be used as convenient and reliable quantitative parameters in the assessment of cardiac function in fetuses exposed to gestational diabetes.

The effect of nuchal umbilical cord on fetal cardiac and cerebral circulation-cross-sectional study

OBJECTIVES

The subject of our analysis is the influence of umbilical cord collision around the fetal neck on the fetal heart function and cerebral circulation.

METHODS

Our study was carried out on a group of 115 fetuses from single pregnancies with physiological course, during the 15th to 40th week of pregnancy. In our analysis, we examined the following parameters: Tei index for right ventricle, Tei index for left ventricle with Tei index components: isovolumetric contraction time, isovolumetric relaxation time, ejection time and cardiothoracic area ratio, middle cerebral artery peak systolic velocity (PS MCA), middle cerebral artery pulsatility index (PI MCA). Gestational age in our study was: 28+2±34. The study group of patients with fetal umbilical cord around neck group (fUCAN) included 38 fetuses (20 males, 18 females). The control group of patients with no fetal umbilical cord around neck group (NfUCAN) included 77 fetuses (43 males, 34 females).

RESULTS

In our study, we found no significant differences in the values obtained: Tei LV in fUCAN: 0.5±0.1 vs. in NfUCAN: 0.5±0.1; p=0.42), Tei RV in fUCAN: 0.5±0.2 vs. in NfUCAN: 0.4±0.1; (p=0.2). Tricuspid valve regurgitation-TR was observed with the following frequency: fUCAN: 7/38, 18% vs. NfUCAN: 13/77, 17%; p=0.8. MCA PS in study fUCAN group was significantly higher than in NfUCAN (40.2±11.5 vs. 32.5±9.5; p=0.003), although other hemodynamic and clinical variables did not differ between the study and control groups.

CONCLUSIONS

The fetal nuchal umbilical cord collision did not affect the fetal heart function expressed as Tei index, at the time of fetal heart examination (at mean gestational age 29+4 weeks). The fUCAN group presented elevated PS MCA, which was not related to other hemodynamic and clinical variables between the study and control groups.

Ultrasound evaluation of the fetal fat tissue, heart, liver and umbilical cord measurements in pregnancies complicated by gestational and type 1 diabetes mellitus: potential application in the fetal birth-weight estimation and prediction of the fetal macrosomia

BACKGROUND

The aim of the study was to evaluate the ultrasound-derived measurements of the fetal soft-tissue, heart, liver and umbilical cord in pregnancies complicated by gestational (GDM) and type 1 diabetes mellitus (T1DM), and further to assess their applicability in the estimation of the fetal birth-weight and prediction of fetal macrosomia.

METHODS

Measurements were obtained from diet-controlled GDM (GDMG1) (n = 40), insulin-controlled GDM (GDMG2) (n = 40), T1DM (n = 24) and healthy control (n = 40) patients. The following parameters were selected for analysis: fetal sub-scapular fat mass (SSFM), abdominal fat mass (AFM), mid-thigh fat/lean mass (MTFM/MTLM) and inter-ventricular septum (IVS) thicknesses, heart and thorax circumference and area (HeC/HeA; ThC/ThA), liver length (LL), umbilical cord/vein/arteries circumference and area (UmC/UmA; UvC/UvA; UaC/UaA) together with total umbilical vessels (UveA) and Wharton's jelly area (WjA). Regression models were created in order to assess the contribution of selected parameters to fetal birth-weight (FBW) and risk of fetal macrosomia.

RESULTS

Measurements of the fetal SSFM, AFM, MTFM, MTFM/MTLM ratio, HeC, HeA, IVS, LL, UmC, UmA, UaC, UaA, UveA and WjA were significantly increased among patients with GDMG2/T1DM as compared to GDMG1 and/or control groups (p < .05). The regression analysis revealed that maternal height as well as fetal biparietal diameter, abdominal circumference (AC), AFM and LL measurements were independent predictors of the FBW (p < .05). In addition, increase in the fetal AFM, AC and femur length (FL) was associated with a significant risk of fetal macrosomia occurrence (p < .05). The equation developed for the FBW estimation [FBW(g) = - 2254,942 + 17,204 * FL (mm) + 105,531 * AC (cm) + 131,347 * AFM (mm)] provided significantly lower mean absolute percent error than standard formula in the sub-group of women with T1DM (5.7% vs 9.4%, p < .05). Moreover, new equation including AC, FL and AFM parameters yielded sensitivity of 93.8%, specificity 77.7%, positive predictive value 54.5% and negative predictive value of 97.8% in the prediction of fetal macrosomia.

CONCLUSIONS

Ultrasound measurements of the fetal soft tissue, heart, liver and umbilical cord are significantly increased among women with GDM treated with insulin and T1DM. In addition to standard biometric measurements, parameters, such as AFM, may find application in the management of diabetes-complicated pregnancies.

Longitudinal assessment of ventricular strain, tricuspid and mitral annular plane systolic excursion (TAPSE and MAPSE) in fetuses from pregnancies complicated by diabetes mellitus

OBJECTIVES

To evaluate fetal cardiac function using myocardial deformation analyses, tricuspid annular plane systolic excursion (TAPSE), mitral annular plane systolic excursion (MAPSE) and diastolic function parameters in pregnancies complicated by maternal diabetes mellitus.

METHODS

Myocardial deformation using velocity vector imaging (VVI), TAPSE, MAPSE and diastolic function was measured in 126 women with uncomplicated singleton pregnancies and 50 women with diabetes mellitus. Women underwent ultrasound scans every four weeks from recruitment (18-28 weeks gestational age) until delivery.

RESULTS

Left ventricle strain and strain rate, right ventricle strain and strain rate, TAPSE, MAPSE and diastolic parameters were not different between the diabetic cohort and controls throughout gestation. We did not find any significant correlation between the fetal cardiac function parameters with parity or smoking status. There was however a significant difference in strain and strain rate values in the left ventricle, but not the right ventricle in women with BMI >30 kg/m², and reduced TAPSE values in this same group. Fetuses in the diabetes group had thicker interventricular septum (IVS) throughout gestation.

CONCLUSION

Myocardial deformation of the fetal left ventricle, as measured by VVI, and TAPSE were reduced in fetuses of mothers in association with maternal obesity but not in women with diabetes mellitus. No significant differences in the fetal cardiac function parameters measured were different between the two groups, except for IVS thickness.

Normal reference ranges for fetal cardiac function: Assessed by modified Doppler myocardial performance index (Mod MPI) in the Egyptian population

AIM

To develop gestational age-based reference ranges for the modified Doppler myocardial performance index (Mod MPI) and to examine the maternal characteristics that affect this measurement.

METHODS

This was a cross-sectional study, comprised of 1021 healthy pregnancies between 20+0 to 35+6 weeks' gestation. They were all undergoing ultrasound examination in Cairo Fetal Medicine Unit (CAIFM) in Cairo University, Egypt from 1st April 2017 till 1st April 2019. Mod MPI was obtained used method described by Friedman et al. (2003). Median and SD models were fitted between Mod MPI and gestational age. The distributions of Mod MPI Z-scores were examined in relation to maternal characteristics RESULTS: The normal Mod MPI in second and third trimester (20 + 1 to 35 + 6 weeks' gestation) was 0.408 ± 0.08. Mod MPI was not affected by maternal age, body mass index (BMI) or parity (p value 0.5, 0.6 and 0.2 respectively).

CONCLUSION

This study established normal reference ranges for Mod MPI according to gestational age and generated a graph with 5th,10th, 90th and 95th centiles. Maternal characteristics as age, BMI or parity do not affect value of Mod MPI.

Fetal Cardiac Functional Abnormalities Assessed by Echocardiography in Mothers Suffering Gestational Diabetes Mellitus: A Systematic Review and Meta-analysis

Abnormal cardiovascular changes especially hypertrophic cardiomyopathy is potentially expected in the fetuses of the diabetic pregnancy women. However, there is still little consensus on quantitative cardiac abnormalities in infants with diabetic mothers. The present study comprehensively analyzed the studies on functional changes in heart in infants of diabetic mothers with a greater focus on occurrence of hypertrophic cardiomyopathy. All comparative studies evaluating and comparing quantitatively the changes in cardiac parameters using echocardiography in fetuses with and without diabetic mothers were eligible for assessment. The included studies were identified through electronically reviewing the manuscripts databases of MEDLINE, EMBASE, Web of knowledge, and Google Scholar from inception to May 2020. The meta-analysis included 11 comparative with overall 849 fetuses for gestational diabetic mothers and 1247 for healthy mothers. Assessing cardiac diameters by fetal echocardiography showed significantly lower mitral E/A ratio, lower tricuspid E/A ratio, higher interventricular septal thickness, higher myocardial performance index, higher isovolumic relaxation time, and higher isovolumic contraction time in fetuses of gestational diabetes mellitus group as compared to healthy group adjusting for gestational diabetes mellitus. The presence of gestational diabetes mellitus can potentially affect the fetal cardiac parameters especially as hypertrophic cardiomyopathy leading both cardiac systolic and diastolic dysfunction.

Stillbirth in women with diabetes: a retrospective analysis of fetal autopsy reports

Introduction: Diabetes in pregnancy is associated with an increased rate of stillbirth. There are a wide variety of factors that have been implicated including placental insufficiency, hypoxia, hyperinsulinemia and impaired cardiac function. Furthermore, there is evidence that diabetic pregnancies have an increased rate of fetal cardiomyopathy as compared to non-diabetic pregnancies. Prior studies have indicated that this association can also be an etiology for diabetic stillbirth. The purpose of this study was to determine if diabetic pregnancies have an increased risk of fetal cardiomyopathy identified on fetal autopsy as compared to non-diabetic women with a stillbirth in a cohort of pregnancies that had evaluation with a fetal autopsy.Materials and methods: Retrospective cohort study of women with a stillbirth who consented to fetal autopsy at an academic medical center from 2011 to 2017. Stillbirth was defined as an intrauterine fetal demise at ≥20 weeks' gestation. Women with diabetes defined as pre-gestational diabetes type 1, pre-gestational diabetes type 2, and gestational diabetes were compared to women without diabetes. Primary outcome was fetal cardiomyopathy. Other etiologies for stillbirth were also evaluated and classified according to the Stillbirth Collaborative Research Network (SCRN) initial causes of fetal death. Fisher exact test, χ2 test, and Mann Whitney U tests were performed as appropriate, with p < .05 considered significant. Generalized linear models were performed for fetal organ weights controlling for gestational age of delivery, maternal chronic hypertension, delivery body mass index, and birthweight.Results: A total of 78 women elected to have fetal autopsy examinations during the study period. Of these, 75 had complete information available for review. A total of 60 women did not have diabetes and 15 women had diabetes. Of pregnancies complicated by diabetes, 11 had insulin dependent diabetes and 4 had non-insulin dependent diabetes. Fetal cardiomyopathy was diagnosed on autopsy for 7 (46.7%) of pregnancies with diabetes and 2 (3.3% of pregnancies without diabetes (RR 14.00 [95% CI 3.23-60.65], p < .001). These associations were still significant even when analyzing only those pregnancies without fetal congenital heart disease (7 [46.7%] diabetic pregnancies with cardiomyopathy versus 1 [2.0%] nondiabetic pregnancy with cardiomyopathy, RR 23.80 [95% CI 3.17-178.46], p < .001). There was no difference between diabetic and non-diabetic pregnancies in regards to other causes for stillbirth. Stillbirths in pregnancies with diabetes also had larger fetal heart, liver, and adrenal weights on fetal autopsy.Conclusion: Women with diabetes have 14 times the risk of fetal cardiomyopathy identified at fetal autopsy as compared to women without diabetes. As the prediction and prevention of diabetic stillbirth is limited, information on potential causes of stillbirth may help future research identify those pregnancies at the greatest risk for adverse outcome.

Impact of type I and type II maternal diabetes mellitus on fetal cardiac function assessment parameters using spectral and tissue Doppler

The aim of this study was to evaluate the impact of pregestational diabetes mellitus (DM) on fetal cardiac function two-dimensional parameters using spectral and tissue Doppler. Pregnant women between 20 and 36 + 6 weeks gestation were divided into three groups: controls, type I DM, and type II DM. The right ventricle (RV) and left ventricle (LV) annular velocity peaks were measured using spectral (E, A) and tissue (E', A', S') Doppler. The myocardial performance index was calculated as (isovolumetric contraction time [ICT] + isovolumetric relaxation time [IRT])/ejection time using tissue (MPI') and the spectral Doppler (MPI). A general linear model, with fetal heart rate as a covariant, was used to evaluate the effect of DM on the fetal heart function assessment parameters. To assess the association of type I and II DM with adverse perinatal outcomes, Fisher's exact test was used. A receiver operating characteristic curve was used to determine the best cutoff for fetal cardiac function assessment parameters to identify the neonatal composite outcomes. The sample comprised 179 pregnant women. DM had significant effect on RV and LV A peak velocities (p = 0.026 and p = 0.011, respectively). LV ICT (p < 0.001) and LV MPI (p < 0.001) were significantly affected by maternal DM. Fetuses from pregnant women with type II DM showed significantly higher LV MPI (0.492 vs. 0.459, p = 0.006) and RV S' (7.2 vs. 6.44 cm/s, p = 0.024) than controls. Fetuses from type I DM pregnant women showed increase in cardiac parameters that evaluated the LV and RV diastolic function (LV IRT' p < 0.001 and RV MPI' p = 0.044). Type I and II DM were associated with adverse perinatal outcomes: neonatal intensive care unit stay (p < 0.0001), macrosomia (p < 0.0001), hyperbilirubinemia (p < 0.0001), and hypoglycemia (p < 0.0001). The LV MPI' showed significant but moderate sensitivity in identifying the composite neonatal outcomes (AUC: 0.709, 95% CI 0.629-0.780, p < 0.001). Tissue Doppler and MPI parameters can be useful to detect subclinical cardiac dysfunction in the fetal heart of pregestational DM pregnant women.

Use of the modified myocardial performance index for evaluating fetal cardiac functions in pregestational diabetic pregnancy babies

The aim of this study is assessment of importance of use of the modified myocardial performance index (Mod-MPI) for the evaluation of foetal cardiac function in foetuses of women with pregestational diabetes mellitus (PDM). In this study, data of 30 pregnant patients aged 18-45 years diagnosed with PDM and 30 pregnant women aged 18-45 years with normal pregnancy and their babies were evaluated. Foetal echocardiographic and doppler measurements, foetal biometric measurements, umbilical artery and ductus venosus pulsatility indexes were measured in both PDM and control groups. The Mod-MPI was significantly higher in foetuses of PDM women. Many influences especially cardiac and postpartum complications are observed in infants of PDM women. The Mod-MPI is a simple and useful method for assessing foetal ventricular function. Our study has shown that PDM is associated with foetal ventricular dysfunction.Impact statementWhat is already known on this subject? Although MPI is frequently used in routine clinical assessment of neonates, it is not used adequately in foetuses. Many influences especially cardiac and postpartum complications are observed in infants of PDM women. However, there are few studies focussed specifically on the assessment of foetal cardiac function in PDM.What do the results of this study add? MPI, which shows both diastolic and systolic functions is independent of ventricular anatomy and foetal heart rate, was found significantly higher in diabetic mother foetuses, can be said to be a valuable parameter in evaluating foetal cardiac functions globally.What are the implications of these findings for clinical practice and/or further research? Our study has shown that foetuses PDM are associated with foetal ventricular dysfunction. For this MPI measurement can be routinely performed at foetal cardiac measurements in foetuses of PDM mothers.

Utility of the modified myocardial performance index in growth-restricted fetuses

OBJECTIVES

The modified myocardial performance index (Mod-MPI) can be used to assess myocardial function. Fetal growth restriction can affect fetal myocardial function, thereby altering the Mod-MPI. The results of previous studies on the utility of the Mod-MPI in growth-restricted fetuses are conflicting. The aim of this study was to calculate the left modified-MPI in growth-restricted fetuses and to compare the results with those of healthy fetuses.

METHODS

This was a prospective cross-sectional case-control study. In total, 40 women with growth-restricted fetuses and 40 women with fetuses of normal weight (controls) at 29-39 gestational weeks were enrolled in the study. An experienced obstetrician calculated the Mod-MPI for each fetus. Women with systemic diseases or fetuses with chromosomal/structural abnormalities were excluded from the study. The results of Mod-MPI measurements of the two groups were compared.

RESULTS

The mean single deepest vertical pocket (SDVP) of amniotic fluid, estimated fetal weight (EFW), and isovolumetric relaxation time (IRT) was significantly lower in the fetal growth restriction (FGR) group as compared with these parameters in the control group (P < .05). The uterine artery (UtA) pulsatility index (PI) was significantly higher in the FGR group as compared with that in the control group (P < .05). There were six cases of absent end-diastolic flow (AED) in the FGR group. There were no statistically significant between-group differences in the Mod-MPI, isovolumetric contraction time (ICT), and ejection time (ET) (P > .05). There was also no statistically significant correlation between the Mod-MPI in the fetuses with AED and the control group for Mod-MPI (P > .05).

CONCLUSION

The utility of the Mod-MPI in FGR remains unclear. Future studies with larger populations are needed to determine the utility of the Mod-MPI as a predictor of cardiac compromise in FGR.

Say NO to ROS: Their Roles in Embryonic Heart Development and Pathogenesis of Congenital Heart Defects in Maternal Diabetes

Congenital heart defects (CHDs) are the most prevalent and serious birth defect, occurring in 1% of all live births. Pregestational maternal diabetes is a known risk factor for the development of CHDs, elevating the risk in the child by more than four-fold. As the prevalence of diabetes rapidly rises among women of childbearing age, there is a need to investigate the mechanisms and potential preventative strategies for these defects. In experimental animal models of pregestational diabetes induced-CHDs, upwards of 50% of offspring display congenital malformations of the heart, including septal, valvular, and outflow tract defects. Specifically, the imbalance of nitric oxide (NO) and reactive oxygen species (ROS) signaling is a major driver of the development of CHDs in offspring of mice with pregestational diabetes. NO from endothelial nitric oxide synthase (eNOS) is crucial to cardiogenesis, regulating various cellular and molecular processes. In fact, deficiency in eNOS results in CHDs and coronary artery malformation. Embryonic hearts from diabetic dams exhibit eNOS uncoupling and oxidative stress. Maternal treatment with sapropterin, a cofactor of eNOS, and antioxidants such as N-acetylcysteine, vitamin E, and glutathione as well as maternal exercise have been shown to improve eNOS function, reduce oxidative stress, and lower the incidence CHDs in the offspring of mice with pregestational diabetes. This review summarizes recent data on pregestational diabetes-induced CHDs, and offers insights into the important roles of NO and ROS in embryonic heart development and pathogenesis of CHDs in maternal diabetes.

Maternal arterial stiffness and fetal cardiovascular physiology in diabetic pregnancy

OBJECTIVES

In mothers with pregestational or gestational diabetes, abnormal arterial stiffness (stiffer arteries) has been reported. The impact of abnormal maternal arterial stiffness on placental and fetal cardiovascular physiology is unknown. The purpose of this study was to determine the impact of maternal diabetes on maternal arterial stiffness and the association with fetal cardiovascular physiology as measured by fetal echocardiography.

METHODS

Between December 2013 and January 2017 a prospective study was conducted on diabetic (but otherwise healthy) and non-diabetic, healthy pregnant mothers aged 18-40 years at 20-28 weeks' gestation who had a normal fetal cardiac echocardiogram and obstetric ultrasound. Clinical data were collected by means of a patient questionnaire and measurement of blood pressure, height, weight, arterial augmentation index (AIx) and placental and fetal cardiovascular parameters were collected by fetal echocardiography. Descriptive statistics were calculated. Comparisons were made using parametric and non-parametric tests between controls and diabetic mothers.

RESULTS

Twenty-three healthy pregnant controls and 43 diabetic pregnant women (22 with pregestational and 21 with gestational diabetes) were included in the study. Maternal AIx was higher in those with diabetes than in healthy controls (12.4 ± 10.6% vs 4.6 ± 7.9%; P = 0.003). Fetal aortic valve (AoV) velocity time integral (VTI) was higher in fetuses whose mothers had diabetes than in those with non-diabetic mothers (7.7 ± 1.9 cm vs 6.3 ± 3.0 cm; P = 0.022). Left ventricular (LV) myocardial performance index (MPI) was lower in diabetic pregnancies than in controls (0.40 ± 0.09 vs 0.46 ± 0.11; P = 0.021). Umbilical artery (UA) resistance index (RI) was lower in diabetic pregnancies with glycated hemoglobin (HbA1c) levels ≥ 6.5% than in those with HbA1c levels < 6.5% (0.69 ± 0.06, n = 15 vs 0.76 ± 0.08, n = 21; P = 0.009) but not at higher HbA1C cut-offs. No correlation between AIx and AoV-VTI, LV-MPI or UA-RI was found.

CONCLUSIONS

Arterial stiffness is higher in pregnant women with diabetes than in controls. Fetuses of diabetic mothers show altered cardiovascular parameters, with higher AoV-VTI and lower LV-MPI, which are markers of myocardial function. Placental function assessed by UA-RI was normal despite differences between groups. Arterial stiffness did not correlate with placental or fetal cardiovascular variables. Instead, the findings are likely to represent a shared response to the environment of abnormal glucose metabolism. The clinical significance of these findings is yet to be determined. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Fetal Cardiac Function in Maternal Diabetes: A Conventional and Speckle-Tracking Echocardiographic Study

BACKGROUND

Intrauterine exposure to a diabetic environment is associated with adverse fetal myocardial remodeling. The aim of this study was to assess the biventricular systolic and diastolic function of fetuses exposed to maternal diabetes (MD) compared with control subjects, using a comprehensive cardiac functional assessment and exploring the role of speckle-tracking to assess myocardial deformation. The authors hypothesized that fetuses exposed to MD present signs of biventricular dysfunction, which can be detected by deformation analysis.

METHODS

A cross-sectional study was conducted in 129 fetuses with structurally normal hearts, including 76 fetuses of mothers with diabetes and 53 of mothers without diabetes. Maternal baseline characteristics, standard fetoplacental Doppler indices, and conventional echocardiographic and myocardial deformation parameters were prospectively collected at 30 to 33 weeks of gestation.

RESULTS

Fetuses of mothers with diabetes had a significantly thicker interventricular septum compared with control subjects (median, 4.25 mm [interquartile range (IQR), 3.87-4.50 mm] vs 3.67 mm [IQR, 3.40-3.93 mm), P < .001), but no effect modification was demonstrated on myocardial deformation analysis. No significant differences were found in conventional systolic and diastolic functional parameters for the left ventricle and right ventricle, except for lower left ventricular cardiac output in the MD group (median, 320 mL/min [IQR, 269-377 mL/min] vs 365 mL/min [IQR, 311-422 mL/min], P < .05]. Deformation analysis demonstrated a significantly lower early diastolic strain rate (SRe) and late diastolic strain rate (SRa) for both ventricles in the MD group (left ventricle: SRe 1.85 ± 0.72 vs 2.26 ± 0.68 sec^-1, SRa 1.50 ± 0.52 vs 1.78 ± 0.57 sec^-1; right ventricle: SRe 1.57 ± 0.73 vs 1.97 ± 0.73 sec^-1, SRa 2 ± 0.77 vs 1.68 ± 0.79 sec^-1; P < .05), suggesting biventricular diastolic impairment. Additionally, the right ventricle presented a lower global longitudinal strain in the study group (-13.67 ± 4.18% vs -15.52 ± 3.86%, P < .05). Multivariate analysis revealed that maternal age is an independent predictor of left and right ventricular global longitudinal strain (P < .05), with a significant effect only in MD after group stratification.

CONCLUSIONS

Fetuses of mothers with diabetes present signs of biventricular diastolic dysfunction and right ventricular systolic dysfunction by deformation analysis in the third trimester of pregnancy. They may represent a special indication group for functional cardiac assessment, independently of septal hypertrophy. Two-dimensional speckle-tracking could offer an additional benefit over conventional echocardiography to detect subclinical unfavorable changes in myocardial function in this population.

Markers of maternal and infant metabolism are associated with ventricular dysfunction in infants of obese women with type 2 diabetes

BackgroundTo test the hypothesis that infants born to obese women with pre-gestational type 2 diabetes mellitus (IBDMs) have ventricular dysfunction at 1 month that is associated with markers of maternal lipid and glucose metabolism.MethodsIn a prospective observational study of IBDMs (OB+DM, n=25), echocardiographic measures of septal, left (LV) and right ventricular (RV) function, and structure were compared at 1 month of age with those in infants born to OB mothers without DM (OB, n=24) and to infants born to non-OB mothers without DM (Lean, n=23). Basal maternal lipid and glucose kinetics and maternal plasma and infant (cord) plasma were collected for hormone and cytokine analyses.ResultsRV, LV, and septal strain measures were lower in the OB+DM infants compared with those in other groups, without evidence of septal hypertrophy. Maternal hepatic insulin sensitivity, maternal plasma free-fatty-acid concentration, and cord plasma insulin and leptin most strongly predicted decreased septal strain in OB+DM infants.ConclusionIBDMs have reduced septal function at 1 month in the absence of septal hypertrophy, which is associated with altered maternal and infant lipid and glucose metabolism. These findings suggest that maternal obesity and DM may have a prolonged impact on the cardiovascular health of their offspring, despite the resolution of cardiac hypertrophy.

Prospective longitudinal assessment of the fetal left modified Myocardial Performance Index

INTRODUCTION

The fetal left modified Myocardial Performance Index (Mod-myocardial performance index (MPI)) is a measure of systolic versus diastolic time intervals obtained from a single cardiac cycle with ultrasound. It is a measure of global ventricular function and has been investigated for potential utility in fetal conditions associated with cardiac dysfunction.

OBJECTIVES

The objective of this study is to compare values from a precisely replicated fetal left Mod-MPI technique to published reference ranges.

METHODS

Three hundred and sixty-five nulliparae prospectively underwent fetal left Mod-MPI measurement at 27⁺⁰-29⁺⁰ and 35⁺⁰-37⁺⁰ weeks' gestation. Measurements from pregnancies complicated by gestational diabetes mellitus, preeclampsia, or a small-for-gestational-age (<10th centile) infant were excluded. Mod-MPI values were compared with three published references created using similar measurement techniques.

RESULTS

Compared with one selected reference, at 29⁺⁰ and 35⁺⁰-37⁺⁰ weeks' gestation, 90-100% of our values fell within the 5th-95th percentile range as expected. Thus, this reference range was validated for our population in late pregnancy. However, the expected level of concordance was not seen at 27⁺⁰-28⁺⁶ weeks'. The other two references to which we compared our Mod-MPI values demonstrated poor concordance, especially at 27⁺⁰-29⁺⁰ weeks'. Pearson interobserver correlation was also improved at 35⁺⁰-37⁺⁰ weeks' at 0.434, compared with 0.083 at 27⁺⁰-29⁺⁰ weeks' gestation.

CONCLUSIONS

Concordance and interobserver variability between our cohort and similar populations were both improved at 35⁺⁰-37⁺⁰ weeks' compared with 27⁺⁰-29⁺⁰ weeks' gestation. Overall, variable Mod-MPI reproducibility across gestations limits clinical application, especially earlier in pregnancy. Manual Mod-MPI measurement should be considered most reliable in late pregnancy until automated MPI measurement is possible.

Risks of asphyxia-related neonatal complications in offspring of mothers with type 1 or type 2 diabetes: the impact of maternal overweight and obesity

AIMS/HYPOTHESIS

We aimed to compare the risks of severe asphyxia-related neonatal complications in the offspring of mothers with type 1 or type 2 diabetes, and to assess the impact of maternal overweight/obesity on these risks.

METHODS

This was a population-based study of 1,343,751 live-born singleton infants in Sweden between 1997 and 2011, including 5941 and 711 infants of mothers with type 1 and type 2 diabetes, respectively. ORs with 95% CIs were calculated for low Apgar score (0-6) at 5 min after birth, hypoxic ischaemic encephalopathy and neonatal seizures.

RESULTS

The rates of a low Apgar score were 0.9%, 2.6% and 2.1% in the offspring of mothers without diabetes or with type 1 or type 2 diabetes, respectively. After controlling for maternal confounders (including BMI), the risk of a low Apgar score increased in the offspring of mothers with type 1 diabetes (OR 2.67, 95% CI 2.23, 3.20) but not in the offspring of mothers with type 2 diabetes (OR 1.25, 95% CI 0.66, 2.35). The ORs of hypoxic ischaemic encephalopathy or neonatal seizures were increased in the offspring of mothers with type 1 diabetes (OR 3.41, 95% CI 2.58, 4.49) and type 2 diabetes (OR 2.54, 95% CI 1.13, 5.69). Maternal overweight/obesity was a risk factor for asphyxia-related neonatal complications and low Apgar scores in the offspring of mothers with type 1 diabetes and mothers without diabetes.

CONCLUSIONS/INTERPRETATION

The risks of a low Apgar score and severe asphyxia-related neonatal complications are increased in the offspring of mothers with type 1 or type 2 diabetes. Maternal overweight/obesity is an important contributing factor.

Assessment of Cardiac Function in Fetuses of Gestational Diabetic Mothers During the Second Trimester

Fetuses of diabetic mothers may have structural or functional cardiac abnormalities which increase morbidity and mortality. Isolated functional abnormalities have been identified in the third trimester. The aim of the present study was to assess fetal cardiac function (systolic, diastolic, and global myocardial performance) in the second trimester in mothers with gestational diabetes, and also to relate cardiac function with glycemic control. Mothers with gestational diabetes mellitus referred for fetal cardiac evaluation in the second trimester (between 19 and 24 weeks) from March 2015 to February 2016 were enrolled as case subjects in this study. Non-diabetic mothers who had a fetal echocardiogram done between 19 and 24 weeks for other indications were enrolled as controls. Functional cardiac variables showed a statistically significant difference in isovolumetric relaxation and contraction times and the myocardial performance index and mitral E/A ratios in the gestational diabetic group (p = 0.003). Mitral annular plane systolic excursion was significantly less in the diabetic group (p = 0.01). The only functional cardiac variable found abnormal in mothers with poor glycemic control was the prolonged isovolumetric relaxation time. Functional cardiac abnormalities can be detected in the second trimester in fetuses of gestational diabetic mothers and timely intervention can improve postnatal outcomes.

Fetal myocardial deformation in maternal diabetes mellitus and obesity

OBJECTIVE

Experimental evidence suggests that changes in the fetal myocardium result from intrauterine effects of maternal diabetes mellitus and obesity. The aim of this study was to assess fetal cardiac function using two-dimensional speckle-tracking echocardiography to determine the effects of maternal diabetes and obesity on the fetal myocardium.

METHODS

Comparative cross-sectional evaluation of myocardial function in fetuses of mothers with diabetes mellitus (FDM) or obesity (FO) and normal gestational age-matched control fetuses (FC) was performed using two-dimensional speckle-tracking echocardiography at two centers.

RESULTS

In total, 178 fetuses (82 FDM, 26 FO and 70 FC) met the enrolment criteria. Mean gestational age at assessment was similar among groups: 25.3 ± 5.1 weeks for FDM, 25.0 ± 4.6 weeks for FO and 25.1 ± 4.9 weeks for FC. Mean maternal body mass index was significantly higher in FDM and FO groups compared with the FC group. Statistically significant differences in fetal cardiac function were detected between FDM and FC for global longitudinal strain (mean ± SD, -21.4 ± 6.5% vs -27.0 ± 5.2%; P < 0.001), global circumferential strain (mean ± SD, -22.6 ± 6.5% vs -26.2 ± 6.8%; P = 0.002), average longitudinal systolic strain rate (median, -1.4 (interquartile range (IQR), -1.7 to -1.1)/s vs -1.6 (IQR, -2.0 to -1.4)/s; P = 0.001) and average circumferential systolic strain rate (median, -1.4 (IQR, -1.9 to -1.1)/s vs -1.6 (IQR, -2.1 to -1.3)/s; P = 0.006). Cases of non-obese FDM also had abnormal strain parameters compared with FC. Global longitudinal strain (mean ± SD, -21.1 ± 7.5%) and average circumferential systolic strain rate (median, -1.3 (IQR, -1.8 to -1.1)/s) were significantly lower in FO compared with FC.

CONCLUSIONS

Unfavorable changes occur in the fetal myocardium in response to both maternal diabetes mellitus and obesity. The long-term prognostic implications of these changes require further study. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Evaluation of an automated fetal myocardial performance index

OBJECTIVE

To compare automated measurements of the fetal left myocardial performance index (MPI) with manual measurements for absolute value, repeatability and waveform acceptability.

METHODS

This was a multicenter international online study using images from uncomplicated, morphologically normal singleton pregnancies (16-38 weeks' gestation). Single Doppler ultrasound cardiac cycle images of 25 cases were selected, triplicated and randomized (n = 75). Six senior observers, unaware of the repetition of images, manually calculated MPI for each waveform and the results were compared with automation. Intraobserver repeatability and interobserver reproducibility were assessed using intraclass correlation coefficients (ICCs) and 95% CI. The agreement between each observer's manual MPI measurements and corresponding automated measurements was evaluated using Bland-Altman plots and ICCs with 95% CI. The degree of variation between experts in the classification of fetal MPI waveform quality was assessed using individual cardiac cycle left MPI images previously classified by two authors as 'optimal', 'suboptimal' or 'unacceptable', with 30 images selected for each quality group. Ten images in each category were duplicated and the resulting 120 images were randomized and then classified online by five observers. The kappa statistic (κ) was used to demonstrate interobserver and intraobserver agreement and agreement of classifications by the five observers.

RESULTS

The automated measurement software returned the same value for any given image, resulting in an ICC of 1.00. Manual measurements had intraobserver repeatability ICC values ranging from 0.69 to 0.97, and the interobserver reproducibility ICC was 0.78. Comparison of automated vs manual MPI absolute measurements for each observer gave ICCs ranging from 0.77 to 0.96. Interobserver image quality classification agreement gave k = 0.69 (P < 0.001), and the intraobserver agreement was variable (κ ranging from 0.40 to 0.81).

CONCLUSIONS

Automated fetal MPI provides superior repeatability and reproducibility to manual methodology. Additionally, experts vary significantly when classifying suitability of fetal MPI waveforms. Automated MPI may facilitate clinical translation by removing human subjectivity. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Heart rate variability in neonates of type 1 diabetic pregnancy

BACKGROUND

Cardiomyopathy is a common finding in offspring of pre-gestational type 1 diabetic pregnancy. Echocardiographic and biochemical evidence of fetal cardiac dysfunction have also been reported. Studies suggest that offspring of diabetic mothers (ODM) undergo a fetal programming effect due to the hyperglycaemic intrauterine milieu which increases their risk of cardiovascular morbidity in adult life. Decreased neonatal heart rate variability (HRV) has been described in association with in-utero growth restriction, prematurity, sudden infant death syndrome and congenital heart disease. The effect of in-utero exposure to hyperglycaemia in diabetic pregnancy on neonatal HRV is unknown.

AIMS

Our aim was to determine if neonatal HRV differs between normal and diabetic pregnancy.

STUDY DESIGN AND SUBJECTS

This was a prospective observational study of 38 patients with pregestational type 1 diabetes and 26 controls. HRV assessment was performed using Powerlab (ADI Instruments Ltd).

OUTCOME MEASURES

Heart rate variability assessment and cord blood sampling for pH and glucose were performed for all neonates. Maternal glycaemic control was assessed via measurement of glycosylated haemoglobin in each trimester in the diabetic cohort.

RESULTS

Neonates of diabetic mothers had evidence of altered heart rate variability, with increased low frequency to high frequency ratio (LF: HF), suggestive of a shift towards sympathetic predominance (p<0.05). This altered HRV was significantly related to fetal acidaemia, cord blood glucose values and maternal glycaemic control during pregnancy (p<0.05).

CONCLUSION

Neonates of pregestational diabetic pregnancy have altered HRV which is related to maternal hyperglycaemia, fetal acidaemia and fetal glycaemia. Exposure of the developing heart to fluctuations in maternal glycaemia with subsequent alterations in HRV may explain why infants of diabetic mothers are at greater risk of cardiovascular disease in later life.

The Fetal Modified Myocardial Performance Index: Is Automation the Future?

The fetal modified myocardial performance index (Mod-MPI) is a noninvasive, pulsed-wave Doppler-derived measure of global myocardial function. This review assesses the progress in technical refinements of its measurement and the potential for automation to be the crucial next step. The Mod-MPI is a ratio of isovolumetric to ejection time cardiac time intervals, and the potential for the left ventricular Mod-MPI as a tool to clinically assess fetal cardiac function is well-established. However, there are wide variations in published reference ranges, as (1) a standardised method of selecting cardiac time intervals used in Mod-MPI calculation has not been established; (2) cardiac time interval measurement currently requires manual, inherently subjective placement of callipers on Doppler ultrasound waveforms; and (3) ultrasound machine settings and ultrasound system type have been found to affect Mod-MPI measurement. Collectively these factors create potential for significant inter- and intraobserver measurement variability. Automated measurement of the Mod-MPI may be the next key development which propels the Mod-MPI into routine clinical use. A novel automated system of Mod-MPI measurement is briefly presented and its implications for the future of the Mod-MPI in fetal cardiology are discussed.

The (Pulsed-Wave) Doppler Fetal Myocardial Performance Index: Technical Challenges, Clinical Applications and Future Research

Functional cardiovascular assessment is becoming an increasingly important tool in the study of fetal pathology. The myocardial performance index (MPI) is a parameter measuring global myocardial function. Since its introduction, several studies have proposed methods to improve its reproducibility and have constructed normative reference ranges. Fetal heart evaluation using the MPI is technically challenging, requiring specific training and expertise, and a consensus has yet to be reached on the method of delineating the time periods used to calculate the index. Despite these limitations, it has been shown to be a useful and highly sensitive parameter of dysfunction in a number of fetal pathologies. Further research is warranted into the effect of pathology on MPI, parameters of unilateral cardiac strain that utilise MPI, and automation of the MPI to encourage incorporation of the MPI as a useful tool in clinical practice.

The effect of pregestational diabetes on fetal heart function

Pregestational diabetes affects nearly 2% of all pregnancies. Moreover, Type 2 diabetes in child-bearing women is on the rise because of the childhood obesity epidemic. Pregestational diabetes can affect the fetal heart in several ways. First, the risk of fetal congenital heart disease is markedly increased; second, fetal hypertrophic cardiomyopathy may occur even with good glycemic control; third, studies have shown impaired function of the hearts of some infants and fetuses of diabetic pregnancies, which can occur with and without septal hypertrophy. Small-for-gestational-age infants of diabetic mothers may have diminished cardiovascular health in the long term. This review mainly discusses methods to detect fetal diabetic cardiomyopathy prenatally. The focus is on the noninvasive diagnostic markers that can serve as an outcome measure for future therapeutic trials, which are still lacking. There is some experimental research on treatment strategies to prevent fetal heart disease in diabetic pregnancies but little clinical data.

Prolonged QT dispersion in the infants of diabetic mothers

Myocardial hypertrophy and cardiac dysfunction frequently occur in newborns of diabetic mothers. The authors hypothesized that wall hypertrophy or disproportionate left ventricular wall thickness in newborns of diabetic mothers may affect both QT and QTc dispersion. This study aimed to assess whether left ventricular hypertrophy affects the QT variables of infants born to diabetic mothers. This prospective cross-sectional study was conducted with 47 consecutively selected neonates of gestational diabetic mothers and 30 healthy neonates born to healthy mothers. All the subjects were evaluated during the neonatal period. Electrocardiography with echocardiography was performed for the patients and the control subjects. The newborns of the diabetic mothers were classified according to septal thickness as group 1 (16 newborns with septal hypertrophy) or group 2 (31 newborns without septal hypertrophy). The study group consisted of three cohorts: groups 1, 2, and 3 (control group). Both QT and QTc dispersion were computed from a randomly selected beat as well as from an average beat derived from 12 beats included in a 10-s electrocardiography. A total of 16 infants (34%) had a septal thickness of 6 mm or greater. The left ventricular end-systolic diameter in group 1 was smaller (p = 0.0029) than in groups 2 and 3 (p = 0.003). The interventricular septal thickness at end diastole (IVSTd) and the left ventricular posterior wall thickness at end diastole in group 1 were higher than in of groups 2 and 3. The QT and QTc dispersion intervals were longer in group 1 than in groups 2 and 3 (p < 0.001), and a highly significant positive correlation was detected between IVSTd and QT dispersion (r = 0.514, p = 0.042). Elevated QT and QTc dispersions may be risk factors for the development of arrhythmias in newborns of diabetic mothers. These patients may critically need systematic cardiac screening.

Modified myocardial performance index is not affected in fetuses with an isolated echogenic focus in the left ventricle

OBJECTIVES

We prospectively investigated the efficacy of modified myocardial performance index (mod-MPI) in the assessment of cardiac functions in fetuses with and without an isolated hyperechogenic focus (IHF) in the left ventricle and compared with conventional fetal echocardiography.

METHODS

The study group consisted of 50 fetuses with only an IHF in the left ventricle, without any other cardiac or extracardiac anomalies; 50 fetuses without IHF served as controls. All fetal echocardiographic studies were performed between 20th and 24th weeks of gestation. Left ventricular functions were evaluated with both conventional echocardiographic methods (peak velocity of the aortic valve, mitral E/A ratio, fractional shortening) and mod-MPI.

RESULTS

There was no statistically significant difference between the groups in terms of maternal age, BMI or gestational age at the time of examination (p > 0.05 for all). No statistically significant differences were found between the findings of conventional echocardiographic measurements and left ventricular mod-MPI between the study and control groups (p > 0.05 for all).

CONCLUSION

Fetal left ventricular mod-MPI is not affected by the presence of an IHF in the fetal left ventricle between 20th and 24th gestational weeks and thus it does not need to be assessed in this situation.

Cardiomyopathy in offspring of pregestational diabetic mouse pregnancy

PURPOSE

To investigate cardiomyopathy in offspring in a mouse model of pregestational type 1 diabetic pregnancy.

METHODS

Pregestational diabetes was induced with STZ administration in female C57BL6/J mice that were subsequently mated with healthy C57BL6/J males. Offspring were sacrificed at embryonic day 18.5 and 6-week adolescent and 12-week adult stages. The size and number of cardiomyocyte nuclei and also the extent of collagen deposition within the hearts of diabetic and control offspring were assessed following cardiac tissue staining with either haematoxylin and eosin or Picrosirius red and subsequently quantified using automated digital image analysis.

RESULTS

Offspring from diabetic mice at embryonic day 18.5 had a significantly higher number of cardiomyocyte nuclei present compared to controls. These nuclei were also significantly smaller than controls. Collagen deposition was shown to be significantly increased in the hearts of diabetic offspring at the same age. No significant differences were found between the groups at 6 and 12 weeks.

CONCLUSIONS

Our results from offspring of type 1 diabetic mice show increased myocardial collagen deposition in late gestation and have increased myocardial nuclear counts (hyperplasia) as opposed to increased myocardial nuclear size (hypertrophy) in late gestation. These changes normalize postpartum after removal from the maternal intrauterine environment.

A maternal diet rich in fish oil may improve cardiac Akt-related signaling in the offspring of diabetic mother rats

OBJECTIVE

Newborns of diabetic mothers have abnormal circulatory organs, so in this study, we explore insulin signaling in the newborn rat heart.

METHODS

Pregnant rats were divided into streptozotocin-induced diabetic groups (DM) and control groups (CM). Rats were fed lard (21% fat), fish oil (21% fat), or a control diet (7% fat). To examine changes in insulin signaling in the hearts of infants of diabetic mothers (IDM) in relation to diet, we isolated the hearts from the IDM and control infants and determined the phosphorylation levels of Akt308, Akt473, p38, c-jun-NH2-terminal protein kinase (JNK), and extracellular signal-regulated protein kinase (ERK), and the expression levels of phosphoinositide-dependent protein kainase1 (PDK1) and mammalian target of rapamycin (mTOR).

RESULTS

The mean blood glucose levels in the DM group and their infants were significantly higher than those in the CM group (P < 0.05) and their infants (P < 0.05), but the mean blood glucose levels of all infants was normal on postnatal d 4. Phosphorylation levels of Akt (Thr 308) (P < 0.05) and Akt (Ser 473) and the expression levels of PDK1 and mTOR were lower in infants of diabetic mothers (IDM) than in control infants. The phosphorylation level of Akt (Ser 473) and the expression level of mTOR increased in IDM fed the fish oil diet compared with those fed the lard diet (P < 0.05).

CONCLUSION

A maternal diet rich in fish oil improves cardiac Akt-related signaling in the offspring of diabetic rats.

Maternal hyperglycemia leads to fetal cardiac hyperplasia and dysfunction in a rat model

Accelerated fetal myocardial growth with altered cardiac function is a well-documented complication of human diabetic pregnancy, but its pathophysiology is still largely unknown. Our aim was to explore the mechanisms of fetal cardiac remodeling and cardiovascular hemodynamics in a rat model of maternal pregestational streptozotocin-induced hyperglycemia. The hyperglycemic group comprised 107 fetuses (10 dams) and the control group 219 fetuses (20 dams). Fetal cardiac function was assessed serially by Doppler ultrasonography. Fetal cardiac to thoracic area ratio, newborn heart weight, myocardial cell proliferative and apoptotic activities, and cardiac gene expression patterns were determined. Maternal hyperglycemia was associated with increased cardiac size, proliferative, apoptotic and mitotic activities, upregulation of genes encoding A- and B-type natriuretic peptides, myosin heavy chain types 2 and 3, uncoupling proteins 2 and 3, and the angiogenetic tumor necrosis factor receptor superfamily member 12A. The genes encoding Kv channel-interacting protein 2, a regulator of electrical cardiac phenotype, and the insulin-regulated glucose transporter 4 were downregulated. The heart rate was lower in fetuses of hyperglycemic dams. At 13-14 gestational days, 98% of fetuses of hyperglycemic dams had holosystolic atrioventricular valve regurgitation and decreased outflow mean velocity, indicating diminished cardiac output. Maternal hyperglycemia may lead to accelerated fetal myocardial growth by cardiomyocyte hyperplasia. In fetuses of hyperglycemic dams, expression of key genes that control and regulate cardiomyocyte electrophysiological properties, contractility, and metabolism are altered and may lead to major functional and clinical implications on the fetal heart.

Clinical and ultrasound features of placental maturation in pre-gestational diabetic pregnancy

BACKGROUND

Pre-gestational diabetes (PGDM) is a significant cause of neonatal morbidity and mortality. Delayed villous maturation (DVM) is a placental diagnosis with increased risk of perinatal mortality.

AIMS

This study aimed to prospectively look at the incidence of DVM in a PGDM population compared to non-diabetic controls. Additionally, we analysed antenatal ultrasound and clinical markers for DVM in the diabetic population.

STUDY DESIGN

This is a prospective study.

SUBJECTS

Placentae of women with non-diabetic and PGDM pregnancies underwent detailed blinded histo-pathological examination.

OUTCOME MEASURES

Clinical data, including birth weight, peri-natal outcome, and, in PGDM group, glycaemic control and ultrasound findings, were obtained.

RESULTS

77 non-diabetic women and 74 PGDM women consented to the study. The incidence of DVM in the PGDM group was higher than in the non-diabetic group (21/74 (28.4%) vs. 11/77 (14.3%) p=0.02; RR 1.98). In the PGDM group clinical and ultrasound markers were compared between the DVM group (n=21) and the non-DVM group (n=53). There was no difference in perinatal outcome nor glycaemic control between these two groups.

CONCLUSION

DVM, a placental finding with an increased risk of perinatal mortality, is increased in PGDM population compared to non-diabetic controls. No association was found with maternal glycaemic control. The presence of placental DVM was not associated with antenatal ultrasound parameters nor clinical perinatal outcome.

Cardiac troponin I levels and its relation to echocardiographic findings in infants of diabetic mothers

BACKGROUND

Cardiomyopathy is noted in up to 40% of infants of diabetic mothers, and the exact mechanisms responsible for it are unknown. The aim of this study was to compare between infants of diabetic mothers (IDM) and infants of non- diabetic mothers (INDM) as regards cardiac troponin I (cTnI) levels (as a marker of cardiac dysfunction) and to examine the relationship between this marker and neonatal echocardiographic changes (cardiac structure and function).

METHODS

A prospective, comparative study included eighty full term neonates during the first three days of life, during the period from April 2008 to June 2011. They were divided into 2 groups, group I: included 40 infants of diabetic mothers (IDMs)and group II: included 40 infants of non diabetic healthy mothers as a control group.

RESULTS

37.5% of the IDMs were large for gestational age and demonstrated a significantly lower blood glucose level than the control group (34.6 ± 11.3mg/dl Vs 77.2 ± 19.8 mg/dl respectively) , respiratory distress and cyanosis were the presenting signs in 67.5% of IDMs. Cardiac TnI on the second day of life increased significantly in infants of diabetic mothers in comparison to INDM (p < 0.006) . IDMs had a significant increase in left atrial thickness ( 11.5 ± 1.8mm in IDM Vs 10.5 ± 0.9mm in INDM P < 0.002*) and a significant increase in septal thickness (5.0 ± 1.2mm in IDM Vs 4.0 ± 0.5mm in INDM P < 0.001*). CTnI correlated positively with interventricular septum thickness (P-value = 0.002*). Cardiac TnI was significantly increased in IDMs with respiratory distress (P -value < 0.05).

CONCLUSIONS

This study demonstrated a highly significant positive correlation between cTnI level on the second day of life and the left ventricular end diastolic diameter (LVED) and interventricular septum diameter (IVSD). Cardiac troponin I (cTnI) is a useful biochemical marker for monitoring myocardial injury in infants of diabetic mothers. An elevated cTnI concentration in infants of diabetic mothers with respiratory distress was a good predictor for hypertrophic cardiomyopathy and/or left ventricular dysfunction.