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Nijman M, van der Meeren LE, Nikkels PGJ, Stegeman R, Breur JMPJ, Jansen NJG, ter Heide H, Steenhuis TJ, de Heus R, Bekker MN, Claessens NHP, Benders MJNL. Placental Pathology Contributes to Impaired Volumetric Brain Development in Neonates With Congenital Heart Disease. J Am Heart Assoc 2024; 13:e033189. [PMID: 38420785 PMCID: PMC10944035 DOI: 10.1161/jaha.123.033189] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/01/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND Neonates with congenital heart disease are at risk for impaired brain development in utero, predisposing children to postnatal brain injury and adverse long-term neurodevelopmental outcomes. Given the vital role of the placenta in fetal growth, we assessed the incidence of placental pathology in fetal congenital heart disease and explored its association with total and regional brain volumes, gyrification, and brain injury after birth. METHODS AND RESULTS Placentas from 96 term singleton pregnancies with severe fetal congenital heart disease were prospectively analyzed for macroscopic and microscopic pathology. We applied a placental pathology severity score to relate placental abnormalities to neurological outcome. Postnatal, presurgical magnetic resonance imaging was used to analyze brain volumes, gyrification, and brain injuries. Placental analyses revealed the following abnormalities: maternal vascular malperfusion lesions in 46%, nucleated red blood cells in 37%, chronic inflammatory lesions in 35%, delayed maturation in 30%, and placental weight below the 10th percentile in 28%. Severity of placental pathology was negatively correlated with cortical gray matter, deep gray matter, brainstem, cerebellar, and total brain volumes (r=-0.25 to -0.31, all P<0.05). When correcting for postmenstrual age at magnetic resonance imaging in linear regression, this association remained significant for cortical gray matter, cerebellar, and total brain volume (adjusted R2=0.25-0.47, all P<0.05). CONCLUSIONS Placental pathology occurs frequently in neonates with severe congenital heart disease and may contribute to impaired brain development, indicated by the association between placental pathology severity and reductions in postnatal cortical, cerebellar, and total brain volumes.
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Affiliation(s)
- Maaike Nijman
- Department of NeonatologyWilhelmina Children’s Hospital, University Medical Center UtrechtUtrechtthe Netherlands
- Department of Pediatric CardiologyWilhelmina Children’s Hospital, University Medical Center UtrechtUtrechtthe Netherlands
| | - Lotte E. van der Meeren
- Department of PathologyErasmus Medical Center RotterdamRotterdamthe Netherlands
- Department of PathologyLeiden University Medical CenterLeidenthe Netherlands
| | - Peter G. J. Nikkels
- Department of PathologyUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Raymond Stegeman
- Department of NeonatologyWilhelmina Children’s Hospital, University Medical Center UtrechtUtrechtthe Netherlands
- Department of Pediatric CardiologyWilhelmina Children’s Hospital, University Medical Center UtrechtUtrechtthe Netherlands
- Department of PediatricsBeatrix Children’s Hospital, University Medical Center GroningenGroningenthe Netherlands
| | - Johannes M. P. J. Breur
- Department of Pediatric CardiologyWilhelmina Children’s Hospital, University Medical Center UtrechtUtrechtthe Netherlands
| | - Nicolaas J. G. Jansen
- Department of PediatricsBeatrix Children’s Hospital, University Medical Center GroningenGroningenthe Netherlands
| | - Henriette ter Heide
- Department of Pediatric CardiologyWilhelmina Children’s Hospital, University Medical Center UtrechtUtrechtthe Netherlands
| | - Trinette J. Steenhuis
- Department of Pediatric CardiologyWilhelmina Children’s Hospital, University Medical Center UtrechtUtrechtthe Netherlands
| | - Roel de Heus
- Department of Obstetrics and GynecologyUniversity Medical Center UtrechtUtrechtthe Netherlands
- Department of Obstetrics and GynecologySt. Antonius HospitalUtrechtthe Netherlands
| | - Mireille N. Bekker
- Department of Obstetrics and GynecologyUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Nathalie H. P. Claessens
- Department of NeonatologyWilhelmina Children’s Hospital, University Medical Center UtrechtUtrechtthe Netherlands
- Department of PediatricsWilhelmina Children’s Hospital, University Medical Center UtrechtUtrechtthe Netherlands
| | - Manon J. N. L. Benders
- Department of NeonatologyWilhelmina Children’s Hospital, University Medical Center UtrechtUtrechtthe Netherlands
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Cromb D, Slator P, Hall M, Price A, Alexander D, Counsell S, Hutter J. Advanced magnetic resonance imaging detects altered placental development in pregnancies affected by congenital heart disease. RESEARCH SQUARE 2024:rs.3.rs-3873412. [PMID: 38343847 PMCID: PMC10854304 DOI: 10.21203/rs.3.rs-3873412/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Congenital heart disease (CHD) is the most common congenital malformation and is associated with adverse neurodevelopmental outcomes. The placenta is crucial for healthy fetal development and placental development is altered in pregnancy when the fetus has CHD. This study utilized advanced combined diffusion-relaxation MRI and a data-driven analysis technique to test the hypothesis that placental microstructure and perfusion are altered in CHD-affected pregnancies. 48 participants (36 controls, 12 CHD) underwent 67 MRI scans (50 control, 17 CHD). Significant differences in the weighting of two independent placental and uterine-wall tissue components were identified between the CHD and control groups (both pFDR<0.001), with changes most evident after 30 weeks gestation. A Significant trend over gestation in weighting for a third independent tissue component was also observed in the CHD cohort (R = 0.50, pFDR=0.04), but not in controls. These findings add to existing evidence that placental development is altered in CHD. The results may reflect alterations in placental perfusion or the changes in fetal-placental flow, villous structure and maturation that occur in CHD. Further research is needed to validate and better understand these findings and to understand the relationship between placental development, CHD, and its neurodevelopmental implications.
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Rakha S, Mohamed AA, Yussif SM. Placental Histopathologic Findings in the Setting of Prenatally Diagnosed Major Congenital Heart Disease. Fetal Pediatr Pathol 2023; 42:922-935. [PMID: 37817745 DOI: 10.1080/15513815.2023.2266489] [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: 03/03/2023] [Accepted: 09/26/2023] [Indexed: 10/12/2023]
Abstract
Objectives: Studies suggest an association between placenta and congenital heart disease (CHD). We evaluated placental pathologies associated with major CHD. Methods: A prospective study included fetuses with major CHD, identified by fetal echocardiography. Fetal Doppler of umbilical artery (UA), middle cerebral artery (MCA), and placental histopathology were assessed. Outcome was measured by mortality at one month of age. Results: 21 cases were analyzed. Hypoplastic left heart syndrome was the commonest lesion (23.8%). Significant differences were detected among categories regarding MCA systolic/diastolic (S/D) ratio & pulsatility index (p = 0.023; 0.036), respectively. Placental histopathologies were demonstrated in 18(85.7%), predominately involved fetal malperfusion lesions 16/21(76.2%), especially chorangiosis (33.3%). No significant association was detected between placental histopathological abnormalities and Doppler parameter, diagnostic category, or mortality. Conclusion: The high prevalence of abnormal placental histopathological findings in major fetal CHD provides additional evidence of placental-cardiac interlinkage. No association was detected between abnormal placental histopathology and fetal Doppler measurements or neonatal outcome of CHD.
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Affiliation(s)
- Shaimaa Rakha
- Pediatric Cardiology Unit, Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Alhussein Ahmed Mohamed
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Shaimaa M Yussif
- Department of Pathology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Josowitz R, Linn R, Rychik J. The Placenta in Congenital Heart Disease: Form, Function and Outcomes. Neoreviews 2023; 24:e569-e582. [PMID: 37653088 DOI: 10.1542/neo.24-9-e569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
The maternal-fetal environment, controlled and modulated by the placenta, plays a critical role in the development and well-being of the fetus, with long-term impact through programming of lifelong health. The fetal cardiovascular system and placenta emerge at the same time embryologically, and thus placental form and function are altered in the presence of congenital heart disease (CHD). In this review, we report on what is known about the placenta from a structural and functional perspective when there is CHD. We describe the various unique pathologic findings as well as the diagnostic imaging tools used to characterize placental function in utero. With growing interest in the placenta, a standardized approach to characterizing placental pathology has emerged. Furthermore, application of ultrasonography techniques and magnetic resonance imaging now allow for insights into placental blood flow and functionality in vivo. An improved understanding of the intriguing relationship between the placenta and the fetal cardiovascular system will provide opportunities to develop novel ways to optimize outcomes. Once better understood, therapeutic modulation of placental function offered during the vulnerable period of fetal plasticity may be one of the most impactful ways to alter the course of CHD and its complications.
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Affiliation(s)
- Rebecca Josowitz
- Division of Cardiology, Fetal Heart Program, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rebecca Linn
- Division of Anatomic Pathology, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA
| | - Jack Rychik
- Division of Cardiology, Fetal Heart Program, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA
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Miles KG, Liu J, Tseng SY, DeFranco EA, Divanovic AA, Jones HN, Ollberding NJ, Cnota JF. Neonatal Depression Is Associated With 1-Year Mortality in Critical Congenital Heart Disease. J Am Heart Assoc 2023; 12:e028774. [PMID: 37260029 PMCID: PMC10381992 DOI: 10.1161/jaha.122.028774] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/03/2023] [Indexed: 06/02/2023]
Abstract
Background Low 5-minute Apgar scores (AS) are predictive of term and preterm neonatal mortality but have not been well studied in the critical congenital heart disease (CCHD) population. We analyzed US national vital statistics data to evaluate the association between neonatal depression (AS 0-3) and 1-year mortality in CCHD. Methods and Results We performed a retrospective cohort study using 2014 to 2018 Centers for Disease Control and Prevention cohort-linked birth certificate and infant death records. Five-minute AS were categorized as ≤3, 4 to 6, or ≥7. We calculated birth rates and associated mortality rates by AS group in infants with and without CCHD. Multivariable logistic regression analyzed neonatal, maternal, and pregnancy-related risk factors for neonatal depression and 1-year mortality. Of 11 642 neonates with CCHD (0.06% of all births), the 5.8% with AS 0 to 3 accounted for 23.3% of all 1-year CCHD mortality, with 69.9% of deaths occurring within 1 month of life. Gestational age at birth, growth restriction, extracardiac defects, race, and low maternal education were associated with an increased odds of AS 0 to 3 in neonates with CCHD relative to those with AS 7 to 10 on multivariable analysis. AS 0 to 3 was associated with 1-year CCHD mortality after adjusting for these factors, prenatal care, and delivery location (adjusted odds ratio, 14.57 [95% CI, 11.73-18.10]). Conclusions The AS is a routine clinical measure providing important prognostic information in CCHD. These findings suggest that prenatal and perinatal factors, beyond those included in current risk stratification tools, are important for CCHD outcomes. Multidisciplinary collaboration to understand the pathophysiology underlying neonatal depression may help identify interventions to improve CCHD mortality rates.
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Affiliation(s)
| | - James Liu
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyUniversity of CincinnatiCincinnatiOH
| | | | - Emily A. DeFranco
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyUniversity of CincinnatiCincinnatiOH
| | | | - Helen N. Jones
- Department of Physiology and AgingUniversity of FloridaGainesvilleFL
| | - Nicholas J. Ollberding
- Division of Biostatistics and EpidemiologyCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - James F. Cnota
- The Heart InstituteCincinnati Children’s HospitalCincinnatiOH
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Pijpers AGH, de Beaufort CMC, Maat SC, Broers CJM, Straver B, van Heurn E, Gorter RR, Derikx JPM. Additional Anomalies in Children with Gastroschisis and Omphalocele: A Retrospective Cohort Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:688. [PMID: 37189937 PMCID: PMC10137210 DOI: 10.3390/children10040688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/31/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Congenital abdominal wall defects might be associated with other anomalies, such as atresia in gastroschisis and cardiac anomalies in omphalocele patients. However, in the current literature, an overview of these additional anomalies and potential patient-specific risk factors is missing. Therefore, we aimed to assess the prevalence of associated anomalies and their patient-specific risk factors in patients with gastroschisis and omphalocele. METHODS A mono-center retrospective cohort study between 1997 and 2023 was performed. Outcomes were the presence of any additional anomalies. Risk factors were analyzed via logistic regression analysis. RESULTS In total, 122 patients were included, of whom 82 (67.2%) had gastroschisis, and 40 (32.8%) had omphalocele. Additional anomalies were identified in 26 gastroschisis patients (31.7%) and in 27 omphalocele patients (67.5%). In patients with gastroschisis, intestinal anomalies were most identified (n = 13, 15.9%), whereas, in patients with omphalocele, cardiac anomalies were most identified (n = 15, 37.5%). Logistic regression showed that cardiac anomalies were associated with complex gastroschisis (OR: 8.5; CI-95%: 1.4-49.5). CONCLUSIONS In patients with gastroschisis and omphalocele, intestinal and cardiac anomalies were most identified, respectively. Cardiac anomalies were found to be a risk factor for patients with complex gastroschisis. Therefore, regardless of the type of gastroschisis and/or omphalocele, postnatal cardiac screening remains important.
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Affiliation(s)
- Adinda G. H. Pijpers
- Department of Pediatric Surgery, Emma Children’s Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology and Metabolism Research Institute, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, 1105 AZ Amsterdam, The Netherlands
| | - Cunera M. C. de Beaufort
- Department of Pediatric Surgery, Emma Children’s Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology and Metabolism Research Institute, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, 1105 AZ Amsterdam, The Netherlands
| | - Sanne C. Maat
- Department of Pediatric Surgery, Emma Children’s Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology and Metabolism Research Institute, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, 1105 AZ Amsterdam, The Netherlands
| | - Chantal J. M. Broers
- Department of Pediatrics, Emma Children’s Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Bart Straver
- Department of Pediatric Cardiology, Emma Children’s Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Ernest van Heurn
- Department of Pediatric Surgery, Emma Children’s Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology and Metabolism Research Institute, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, 1105 AZ Amsterdam, The Netherlands
| | - Ramon R. Gorter
- Department of Pediatric Surgery, Emma Children’s Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology and Metabolism Research Institute, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, 1105 AZ Amsterdam, The Netherlands
| | - Joep P. M. Derikx
- Department of Pediatric Surgery, Emma Children’s Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology and Metabolism Research Institute, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, 1105 AZ Amsterdam, The Netherlands
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Associations between Maternal Risk Factors and Intrinsic Placental and Fetal Brain Functional Properties in Congenital Heart Disease. Int J Mol Sci 2022; 23:ijms232315178. [PMID: 36499505 PMCID: PMC9738149 DOI: 10.3390/ijms232315178] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/15/2022] [Accepted: 11/24/2022] [Indexed: 12/11/2022] Open
Abstract
The relationship between maternal risk factors (MRFs) (particularly pre-gravid obesity, diabetes, and hypertension) and congenital heart disease (CHD) to placental and fetal brain outcomes is poorly understood. Here, we tested the hypothesis that MRF and CHD would be associated with reduced intrinsic placental and fetal brain function using a novel non-invasive technique. Pregnant participants with and without MRF and fetal CHD were prospectively recruited and underwent feto-placental MRI. Using intrinsic properties of blood oxygen level dependent imaging (BOLD) we quantified spatiotemporal variance of placenta and fetal brain. MRFs and CHD were correlated with functional characteristics of the placenta and fetal brain. Co-morbid MRF (hypertension, diabetes, and obesity) reduced spatiotemporal functional variance of placenta and fetal brain (p < 0.05). CHD predicted reduced fetal brain temporal variance compared to non-CHD (p < 0.05). The presence of both MRF and CHD was associated with reduced intrinsic pBOLD temporal variance (p = 0.047). There were no significant interactions of MRFs and CHD status on either temporal or spatial variance of intrinsic brain BOLD. MRF and CHD reduced functional characteristic of placenta and brain in fetuses. MRF modification and management during pregnancy may have the potential to not only provide additional risk stratification but may also improve neurodevelopmental outcomes.
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