Myocardial hypertrophy and dysfunction in maternal diabetes

Maternal poor glycemic control increases risk of neonatal left ventricular hypertrophy

BACKGROUND

Left ventricular hypertrophy (LVH) is an important complication of infants of diabetic mothers (IDMs). However, the defined factors, such as the influence of glycemic control, insulin administration of diabetic mothers and large for gestational age (LGA) in infants, are largely unknown on the incidence of LVH. Therefore, this study aimed to evaluate the prevalence of maternal and neonatal risk factors associated with LVH in IDMs.

METHODS

This prospective analytic study was conducted at tertiary care hospitals in a 1-year period. Inborn IDMs were enrolled, and ventricular hypertrophy was identified by 2D echocardiography in the first 72 hours after birth.

RESULTS

A total of 160 IDMs met the inclusion criteria, 33 (20.6%) of which had LVH. The incidence of infants with LVH born to mothers with poor glycemic control (fasting blood sugar >95 mg/dL) was significantly elevated than those with good glycemic control (45.5% vs. 14.4%, P<0.001). Twelve IDMs (12/33, 36.5%) of LVH and 17 IDMs (17/127, 13.4%) of non-LVH were LGA. IDMs with LVH, compared those with non-LVH, had significantly increased left ventricular (LV) geometry; IVSd (6.5±0.8 vs. 4.0±0, 7 mm), LV IDd (16.8±3.3 mm vs. 18.4±1.1), left ventricular ejection fraction (LVEF) (68.3±8.5% vs. 62.9±17.5%), left ventricular fraction shortening (LVFS) (35.9±6.6% vs. 32.2±5.5%), LV mass (15.3±11.6 vs. 9.3±2.5 g) and LV mass index (66.2±17.5 vs. 46.6±9.7 g/m2), all with P<0.001. There was significant correlation in LV mass with infants' weight, height and body surface area (BSA) (r=0.408, 0.337 and 0.424, respectively; P<0.001).

CONCLUSIONS

The prevalence of neonatal ventricular hypertrophy in IDMs was 20.6%. Maternal poor glycemic control and LGA status in IDMs were dominant risk factors of LVH.

Novel MYH7 Variant in the Neonate of a Mother with Gestational Diabetes Mellitus Showing Left Ventricular Hypertrophy and Noncompaction

BACKGROUND

Left ventricular hypertrophy (LVH) is a well-recognized cardiac dysfunction in infants of mothers with gestational diabetes mellitus (GDM). Left ventricular noncompaction (LVNC) is a cardiomyopathy that is morphologically characterized by numerous prominent trabeculations and deep intertrabecular recesses on cardiovascular imaging. However, there have been no case reports on neonates of mothers with GDM showing LVH and LVNC.

CASE PRESENTATION

A patient, with LVH of a mother with GDM, was delivered at 36 weeks of gestation. Prominent trabeculations in the LV, suggesting LVNC, instead of LVH, were apparent 1 week after birth. A heterozygous deletion variant in the MYH7 gene (NM_000257.4: c.1090T>C, p.Phe364Leu) was discovered through genetic testing using a cardiomyopathy-associated gene panel in the patient and his father and the older brother who had LVNC. The patient is now 5 years old and does not have major cardiac events, although LVNC persisted. This is the first case of LVH secondary to a mother with GDM and LVNC with a novel variant in the MYH7 gene.

CONCLUSION

Genetic testing should be conducted to obtain an accurate outcome and medical care in a patient with LVH and subsequently prominent hypertrabeculation in the LV.

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.

Impact of overweight and obesity in the fetal cardiac function parameters in the second and third trimesters of pregnancy

OBJECTIVE

To assess the impact of overweight and obesity in the second and third trimesters of pregnancy on fetal cardiac function parameters.

METHODS

We performed a prospective cohort study of 374 singleton pregnant women between 20w0d and 36w6d divided into three groups: 154 controls (body mass index - BMI < 25 kg/m2), 140 overweight (BMI 25-30 kg/m2) and 80 obese (BMI ≥ 30 kg/m2). Fetal left ventricular (LV) modified myocardial performance index (Mod-MPI) was calculated according to the following formula: (isovolumetric contraction time + isovolumetric relaxation time)/ejection time. Spectral tissue Doppler was used to determine LV and right ventricular (RV) myocardial performance index (MPI'), peak myocardial velocity during systole (S'), early diastole (E'), and late diastole (A').

RESULTS

We found significant differences between the groups in maternal age (p < 0.001), maternal weight (p < 0.001), BMI (p < 0.001), number of pregnancies (p < 0.001), parity (p < 0.001), gestational age (p = 0.013), and estimated fetal weight (p = 0.003). Overweight pregnant women had higher LV Mod-MPI (0.046 versus 0.044 seconds, p = 0.009) and LV MPI' (0.50 versus 0.47 seconds, p < 0.001) than the control group. Obese pregnant women had higher RV E' than control (6.82 versus 6.33 cm/sec, p = 0.008) and overweight (6.82 versus 6.46 cm/sec, p = 0.047) groups. There were no differences in 5-min APGAR score < 7, neonatal intensive care unit admission, hypoglycemia and hyperglobulinemia between the groups.

CONCLUSIONS

We observed fetal myocardial dysfunction in overweight and obese pregnant women with higher LV Mod-MPI, LV MPI' and RV E' compared to fetuses from normal weight pregnant women.

Maternal Pre-Existing Diabetes: A Non-Inherited Risk Factor for Congenital Cardiopathies

Congenital heart defects (CHDs) are the most common form of birth defects in humans. They occur in 9 out of 1000 live births and are defined as structural abnormalities of the heart. Understanding CHDs is difficult due to the heterogeneity of the disease and its multifactorial etiology. Advances in genomic sequencing have made it possible to identify the genetic factors involved in CHDs. However, genetic origins have only been found in a minority of CHD cases, suggesting the contribution of non-inherited (environmental) risk factors to the etiology of CHDs. Maternal pregestational diabetes is associated with a three- to five-fold increased risk of congenital cardiopathies, but the underlying molecular mechanisms are incompletely understood. According to current hypotheses, hyperglycemia is the main teratogenic agent in diabetic pregnancies. It is thought to induce cell damage, directly through genetic and epigenetic dysregulations and/or indirectly through production of reactive oxygen species (ROS). The purpose of this review is to summarize key findings on the molecular mechanisms altered in cardiac development during exposure to hyperglycemic conditions in utero. It also presents the various in vivo and in vitro techniques used to experimentally model pregestational diabetes. Finally, new approaches are suggested to broaden our understanding of the subject and develop new prevention strategies.

Fetal echocardiography changes of the right ventricle of well-controlled gestational diabetes mellitus

BACKGROUND

There is few evidence of right ventricular (RV) function in fetuses with gestational diabetes mellitus (GDM). Therefore, the aim of this study was to assess the RV function of fetuses using routine and two-dimensional speckle-tracking echocardiography (2D STE) to determine the effects of well-controlled GDM in the third trimester.

METHODS

We used a Philips Epiq7C ultrasound instrument to obtain RV data sets from 63 subjects from July 2019 to February 2022. We compared the free wall thickness (FWT), fractional area change (FAC), Tei index (TEI), tricuspid annular plane systolic excursion (TAPSE) and free wall longitudinal strain(FWLS)of the RV in mothers with well-controlled GDM and normal gestational age-matched fetuses.

RESULTS

63 third trimester fetuses (32 GDM; 31 healthy controls) met the enrolment criteria. Significant differences in fetal RV were detected between the GDM and control groups for the FAC (36.35 ± 6.19 vs. 41.59 ± 9.11; P = 0.008) and the FWLS (-18.28 ± 4.23 vs. -20.98 ± 5.49; P = 0.021). There was a significant difference among the segmental strains of the base, middle and apex of the RV free wall in the healthy controls (P = 0.003), but in the GDM group, there was no statistical difference (p = 0.076). RV FWLS had a strong correlation with FAC (r = 0.467; P = 0.0002).

CONCLUSIONS

In well-controlled GDM, there was measurable fetal RV hypertrophy and significant systolic function decline, indicating the presence of ventricular remodeling and dysfunction. 2D-STE can evaluate the RV free wall contraction in a more comprehensive way.

A proposed fetal risk scoring system for gestational diabetes to assist in optimising timing of delivery

Background. The pathophysiology of gestational diabetes, which is related to abnormal gluocose tolerance and hyperinsulinaemia, renders standard fetal monitoring models ineffective, insufficient and inappropriate, as these models revolve around detecting and prognosticating on placenta-mediated disease rather than increased metabolic rates due to hyperinsulinaemia, functional hypoxia and ischaemic trophoblastic thresholds. To improve perinatal morbidity and mortality in gestational diabetes, there is therefore a need to introduce new prognostic parameters and scoring systems. Objectives. A proposed risk scoring system has been developed, based on our previous studies, to risk-categorise patients with gestational diabetes in terms of fetal outcome in view of the fact that the pathophysiology of gestational diabetes is not recognised by standard monitoring models, which revolve around placental insufficiency rather than metabolic anomalies.Methods. Patients with diabetes from four case-control studies were combined to form a total sample of 159 cases for validation of the risk scoring system. Univariate logistic regression analysis was used to assess the effect of individual risk factors with proposed cut-offs on adverse pregnancy outcome. The diagnostic accuracy of the total summative score was assessed by computing the area under the receiver operating characteristic (ROC) curve. Results. Four potential parameters were identified to risk-categorise fetuses in a pregnancy complicated by gestational diabetes, i.e. the myocardial performance index (MPI), the E/A ratio (early diastolic filling/late diastolic filling, a marker of diastolic dysfunction), increasing fetal weight (macrosomia), and an increased amniotic fluid index. The total score, obtained by summation of the composite scores for these parameters, ranged from 0 to 11. The total score performed as an excellent predictor of adverse outcome, evidenced by an ROC area under the curve of 0.94. A cut-point of 6 on the score confers a sensitivity of 84.2% and specificity of 90.2% for predicting adverse outcome. Conclusion. To our knowledge, this is the first gestational diabetes scoring system proposed to predict an adverse outcome.

Maternal obesity in pregnancy and children’s cardiac function and structure: A systematic review and meta-analysis of evidence from human studies

The prevalence of obesity is increasing worldwide. Experimental animal studies demonstrate that maternal obesity during pregnancy directly affects cardiac structure and function in their offspring, which could contribute to their increased cardiovascular disease (CVD) risk. Currently, a systematic overview of the available evidence regarding maternal obesity and alterations in cardiac structure and function in human offspring is lacking. We systematically searched the electronic databases Embase, MEDLINE and NARCIS from inception to June 29, 2022 including human studies comparing cardiac structure and function from fetal life onwards in offspring of women with and without obesity. The review protocol was registered with PROSPERO International Prospective Register of Systematic Reviews (identifier: CRD42019125071). Risk of bias was assessed using a modified Newcastle-Ottawa scale. Results were expressed using standardized mean differences (SMD). The search yielded 1589 unique publications, of which thirteen articles were included. Compared to offspring of women without obesity, fetuses of women with obesity had lower left ventricular strain, indicative of reduced systolic function, that persisted in infancy (SMD -2.4, 95% confidence interval (CI) -4.4 standard deviation (SD) to -0.4 SD during fetal life and SMD -1.0, 95% CI -1.6 SD to -0.3 SD in infancy). Furthermore, infants born to women with obesity had a thicker interventricular septum (SMD 0.6 SD, 95% CI 0.0 to 1.2 SD) than children born to women without obesity. In conclusion, cardiac structure and function differs between fetuses and children of women with and without obesity. Some of these differences were present in fetal life, persisted in childhood and are consistent with increased CVD risk. Long-term follow-up research is warranted, as studies in offspring of older age are lacking.

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.

Management of cardiac dysfunction in neonates with pulmonary hypertension and the role of the ductus arteriosus

Pulmonary hypertension in the neonate is associated with cardiopulmonary disturbances and neurodevelopment morbidity. The patent ductus arteriosus is a persistent fetal shunt that can be pathologic vs supportive in the setting of neonatal pulmonary hypertension. Understanding the underlying pathophysiology of pulmonary hypertension and the cardiopulmonary effects of various phenotypes can guide management in this vulnerable population. In this narrative, we will summarize the physiologic principles of pulmonary hypertension, the impact of the patent ductus arteriosus on various phenotypes, and the utility of serial targeted neonatal echocardiography to individualize clinical assessment and management.

Preconception lifestyle intervention in women with obesity and echocardiographic indices of cardiovascular health in their children

BACKGROUND

Improving maternal lifestyle before conception may prevent the adverse effects of maternal obesity on their children's future cardiovascular disease (CVD) risk. In the current study, we examined whether a preconception lifestyle intervention in women with obesity could alter echocardiographic indices of cardiovascular health in their children.

METHODS

Six years after a randomized controlled trial comparing the effects of a 6-month preconception lifestyle intervention in women with obesity and infertility prior to fertility care to prompt fertility care, 315 of the 341 children conceived within 24 months after randomization were eligible for this study. The intervention was aimed at weight loss (≥5% or until BMI < 29 kg/m²). Children underwent echocardiographic assessment of cardiac structure and function, conducted by a single pediatric cardiologist, blinded to group allocation. Results were adjusted for multiple variables including body surface area, age, and sex in linear regression analyses.

RESULTS

Sixty children (32 girls, 53%) were included, mean age 6.5 years (SD 1.09). Twenty-four children (40%) were born to mothers in the intervention group. Children of mothers from the intervention group had a lower end-diastolic interventricular septum thickness (-0.88 Z-score, 95%CI -1.18 to -0.58), a lower left ventricle mass index (-8.56 g/m², 95%CI -13.09 to -4.03), and higher peak systolic and early diastolic annular velocity of the left ventricle (1.43 cm/s 95%CI 0.65 to 2.20 and 2.39 cm/s 95%CI 0.68 to 4.11, respectively) compared to children of mothers from the control group.

CONCLUSIONS

Children of women with obesity, who underwent a preconception lifestyle intervention, had improved cardiac structure and function; a thinner interventricular septum, lower left ventricle mass, and improved systolic and diastolic tissue Doppler velocities. Despite its high attrition rates, our study provides the first experimental human evidence suggesting that preconception lifestyle interventions may present a method of reducing CVD risk in the next generation.

CLINICAL TRIAL REGISTRATION

LIFEstyle study: Netherlands Trial Register: NTR1530 ( https://www.trialregister.nl/trial/1461 ). This follow-up study was approved by the medical ethics committee of the University Medical Centre Groningen (METC code: 2008/284).

Fetal Interventricular Septum Volume Evaluated by Three-Dimensional Ultrasound Using Spatiotemporal Image Correlation and Virtual Organ Computer-Aided Analysis in Fetuses From Pre-Gestational Diabetes Mellitus Pregnant Women

BACKGROUND

To assess the interventricular septum (IVS) volume of fetuses from pre-gestational diabetes mellitus (DM) pregnant women by 3-dimensional ultrasound using spatiotemporal image correlation (STIC) and virtual organ computer-aided analysis (VOCAL) methods.

METHODS

This was a prospective cross-sectional study of 45 fetuses from pre-gestational DM and 45 fetuses from healthy pregnant women (controls). Only singleton pregnancies between 20 and 34 + 6 weeks of gestation were included. The fetal IVS volumes were obtained off-line using STIC and VOCAL methods. To analyze differences among variables, the Student’s t-test and Mann-Whitney U test were used. The correlation among continuous variables was determine using Spearman’s correlation test (r).

RESULTS

The median of fetal IVS volume was significantly higher in pre-gestational DM than in healthy pregnant women (0.3 cm³ vs. 0.2 cm³, p = 0.032). A strong positive correlation was observed between fetal IVS volume and gestational age at the time of ultrasound examination (r = 0.75, R² = 0.48, p < 0.0001) and between fetal IVS volume and estimated fetal weight (r = 0.63, R² = 0.37, p < 0.0001). No significant correlation was noted between fetal IVS volume and glycated hemoglobin levels (r = −0.16, R² = 0.01, p = 0.540) in the pre-gestational DM pregnant women.

CONCLUSIONS

Significant differences were observed in fetal IVS volumes between pre-gestational and healthy mothers, with higher values in the fetuses of pre-gestational DM pregnant women.

Differences in biomarkers of cardiac dysfunction in cord blood between normal pregnancies and pregnancies complicated by maternal diabetes

AIMS

The aim of this study was to compare biomarkers of cardiac dysfunction in cord blood in women with uncomplicated pregnancies and pregnancies complicated by maternal pre-gestational and gestational diabetes and to correlate these findings with fetal echocardiography parameters of cardiac function.

MATERIAL AND METHODS

Fetal echocardiographic assessment was performed longitudinally on 78 fetuses in the normal cohort and 32 in the diabetic cohort by measuring tricuspid annular plane systolic excursion, mitral annular plane systolic excursion, myocardial performance index, interventricular septum (IVS) thickness and left fractional shortening between July 2015 and December 2017. Cord blood samples were obtained at birth and levels of troponin I (TnI), B-type natriuretic peptide (BNP) and the amnio terminal segment of its prohormone measured.

RESULTS

Women with diabetes had significantly higher median body mass index and mean z-scores for BNP. Significant associations were observed between maternal diabetes and obesity and cord-blood BNP z-scores. The effect of diabetes on TnI levels were similar, with mean values higher in women with gestational diabetes compared to normal pregnancies; however, this difference did not reach statistical significance. These biomarker findings correlated with an increased IVS thickness in the diabetic group. No difference was demonstrated in the other cardiac function parameters measured.

CONCLUSION

Biochemical markers of cardiac dysfunction are elevated in infants of diabetic and obese mothers and correlated with increased IVS thickness.

Reference values for left and right ventricular systolic-to-diastolic duration ratio (SDR) found using both spectral and tissue Doppler of fetal heart between 20 and 36+6 weeks of gestation

PURPOSE

To establish reference values for the systolic-to-diastolic duration ratio (SDR) of the left ventricle (LV) using spectral Doppler, as well as for the SDR' of the interventricular septum (SEP), LV, and right ventricles (RV) using tissue Doppler of the fetal heart.

METHOD

This prospective and cross-sectional study evaluated 374 low-risk singleton pregnancies from 20 to 36 + 6 weeks of gestation. The ventricular filling time (FT) was obtained from LV inflow using spectral Doppler. Tissue Doppler was used to assess the FT of each ventricle by placing the cursor at the atrioventricular junction marked by the mitral and tricuspid valves, respectively. SDR was calculated as the sum of the isovolumic contraction time (ICT) and the ejection time (ET) divided by the sum of the isovolumic relaxation time (IRT) and the ventricular FT. We used regression analysis to obtain the best-fit model polynomial equation for the parameters. The concordance correlation coefficient (CCC) was used to assess intra- and inter-observer reproducibility.

RESULTS

SDR and SDR' LV showed a progressive decrease with gestational age (GA); the SDR' RV and SDR' SEP did not show a significant decrease with advancing GA. The SDR LV (r = 0.29, p < 0.0001), SDR' RV (r = 0.21, p < 0.0001), SDR' LV (r = 0.20, p = 0.0001), and SDR' SEP (r = 0.25, p < 0.0001) showed a significant weak positive correlation with fetal heart rate. The inter-observer SDR' SEP measurements demonstrated poor reproducibility (CCC: 0.50), whereas intra-observer SRD LV measurements demonstrated moderate reproducibility (CCC: 0.78).

CONCLUSIONS

Reference values for SDR SEP, LV, and RV using spectral and tissue Doppler of fetal heart were established between 20 and 36+6 weeks of gestation.

Effect of maternal diabetes on fetal heart function on echocardiography: systematic review and meta-analysis

OBJECTIVE

Maternal diabetes in pregnancy is associated with structural anomalies of the fetal heart, as well as hypertrophy and functional impairment. This systematic review and meta-analysis aimed to estimate the effect of maternal diabetes on fetal cardiac function as measured by prenatal echocardiography.

METHODS

We performed a search of the EMBASE, PubMed and The Cochrane Library databases, from inception to 4 July 2019, for studies evaluating fetal cardiac function using echocardiography in pregnancies affected by diabetes compared with uncomplicated pregnancies. Outcome measures were cardiac hypertrophy and diastolic, systolic and overall cardiac function as assessed by various ultrasound parameters. The quality of the studies was assessed using the Newcastle-Ottawa Scale. Data on interventricular septal (IVS) thickness, myocardial performance index (MPI) and E/A ratio were pooled for the meta-analysis using random-effects models. For pregnancies with diabetes, results were reported overall and according to whether diabetes was pregestational (PDM) or gestational (GDM). Results were also stratified according to the trimester in which fetal cardiac assessment was performed.

RESULTS

Thirty-nine studies were included, comprising data for 2276 controls and 1925 women with pregnancy affected by diabetes mellitus (DM). Of these, 1120 had GDM, 671 had PDM and in 134 cases diabetes type was not specified. Fetal cardiac hypertrophy was more prevalent in diabetic pregnancies than in non-diabetic controls in 21/26 studies, and impaired diastolic function was observed in diabetic pregnancies in 22/28 studies. The association between DM and systolic function was inconsistent, with 10/25 studies reporting no difference between cases and controls, although more recent studies measuring cardiac deformation, i.e. strain, did show decreased systolic function in diabetic pregnancies. Of the studies measuring overall fetal cardiac function, the majority (14/21) found significant impairment in diabetic pregnancies. Results were similar when stratified according to GDM or PDM. These effects were already present in the first trimester, but were most profound in the third trimester. Meta-analysis of studies performed in the third trimester showed, compared with controls, increased IVS thickness in both PDM (mean difference, 0.75 mm (95% CI, 0.56-0.94 mm)) and GDM (mean difference, 0.65 mm (95% CI, 0.39-0.91 mm)) pregnancies, decreased E/A ratio in PDM pregnancies (mean difference, -0.09 (95% CI, -0.15 to -0.03)), no difference in E/A ratio in GDM pregnancies (mean difference, -0.01 (95% CI, -0.02 to 0.01)) and no difference in MPI in either PDM (mean difference, 0.04 (95% CI, -0.01 to 0.09)) or GDM (mean difference, 0.03 (95% CI, -0.01 to 0.06)) pregnancies.

CONCLUSIONS

The findings of this review show that maternal diabetes is associated with fetal cardiac hypertrophy, diastolic dysfunction and overall impaired myocardial performance on prenatal ultrasound, irrespective of whether diabetes is pregestational or gestational. Further studies are needed to demonstrate the relationship with long-term outcomes. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Association of Maternal Gestational Weight Gain With Left Ventricle Geometry and Function in Offspring at 4 Years of Age: A Prospective Birth Cohort Study

Background: Maternal gestational weight gain (GWG) may be associated with cardiovascular diseases in the offspring from childhood to adulthood. We aimed to investigate the association between maternal GWG and the left ventricle (LV) geometry and function in the offspring, and explore the influence of the intrauterine environment on early childhood cardiac change. Methods: Data of 981 mother-offspring pairs from the Shanghai Birth Cohort was used. Maternal pre-pregnancy weight and height, weight in the first trimester (≤ 12 weeks), and before delivery were measured. The echocardiography, blood pressure, and anthropometry assessment were evaluated in the offspring at 4 years of age. Results: Interventricular septal thickness during diastole had a significantly positive correlation with total GWG [β = 0.009, (0.001, 0.017)]. In the second and third trimesters, LV mass index [β = 0.149, (0.015,0.282)], interventricular septal thickness in systole [β = 0.027, (0.011,0.043)], and in diastole [β = 0.014, (0.005,0.023)] were positively associated with GWG. The risks of eccentric [OR = 1.115, (1.232, 1.010)] and concentric hypertrophy [OR = 1.133, (1.259,1.018)] increased with the elevation of maternal GWG. Conclusions: This study suggested that the excessive maternal GWG was associated with the thickening of the interventricular septum in the offspring, especially during the second and third trimesters. Excessive GWG in the second and third trimesters was a risk factor for LV eccentric and concentric hypertrophy in the offspring.

Use of vasopressin in neonatal hypertrophic obstructive cardiomyopathy: case series

OBJECTIVE

To determine the effect of vasopressin on arterial blood pressure in infants with neonatal hypertrophic obstructive cardiomyopathy (HOCM).

STUDY DESIGN

Retrospective case study in Neonatal ICU involving six infants; five born to mothers with diabetes mellitus (mean gestational age 37.5 ± 0.9 weeks). Vasopressin infusion was started at a mean dose of 0.3 ± 0.2 mU/kg/min.

RESULT

Initiation of vasopressin was followed by improved mean (p = 0.004), systolic (p = 0.028), and diastolic (p = 0.009) arterial pressure within 2 h. Heart rate (p = 0.025) and oxygen requirement (p = 0.021) also declined after initiation. Serum sodium declined initially and recovered by 72 h (p = 0.017).

CONCLUSION

Although there is limited experience with vasopressin use in neonatal HOCM, our case series suggests it may be beneficial for improving systemic hypotension and stabilization of hemodynamics. The potential for hyponatremia is high, necessitating careful fluid/electrolyte management. A prospective randomized trial is necessary to confirm safety and efficacy of vasopressin treatment in neonatal HOCM.

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.

Fetal Cardiac Function and Ventricular Volumes Determined by Three-Dimensional Ultrasound Using STIC and VOCAL Methods in Fetuses from Pre-gestational Diabetic Women

To assess the fetal cardiac function and ventricular volumes by three-dimensional (3D) ultrasound using spatio-temporal image correlation (STIC) and virtual organ computer-aided analysis (VOCAL) methods in fetuses from pre-gestational diabetic women. This was a prospective and cross-sectional study that evaluated 53 fetuses from pre-gestational diabetic women and 53 fetuses from healthy mothers between 20 and 34 weeks of gestation. Only fetuses with no structural or genetic abnormalities and singleton pregnant women were included in this study. The fetal cardiac volumes were assessed by STIC and VOCAL methods. The ejection fraction, stroke volume, and cardiac output were calculated from these measurements to evaluate fetal cardiac function. The Mann-Whitney U test was performed to compare the two groups. For calculation of intra- and interobserver reproducibility's, we used concordance correlation coefficients. The mean differences in the right atrial volumes between the diabetic and normal groups ranged from 0.05 mL to 0.1 mL (p = 0.917 and 0.355, respectively). The median of left atrium (LA) volume measurement in pre-gestational diabetic group was significantly lower than healthy mothers (LA: 0.62 vs. 0.68 mL; p < 0.001). The fetal right and left ventricular volumes were similar in both groups. No significant differences in ejection fraction, stroke volume and cardiac output were observed (p value range 0.086-0.815). The majority of fetal atrial/ventricular volumes showed good intra- and interobserver reliabilities. Conversely, the majority cardiac function parameters showed poor intra- and interobserver agreements. STIC and VOCAL methods gave reproducible quantitative results for fetal atrial and ventricular volumes. Significant differences in fetal left atrial volumes were observed between the two groups, which be related to LA atrial dysfunction and /or left ventricle (LV) compliance, reflecting earlier stages of cardiac dysfunction.

Role of fetal echocardiography in morphologic and functional assessment of fetal heart in diabetic mothers

Background

Diabetes mellitus (DM) is the commonest medical disorder faced during pregnancy and it includes type I, type II, and gestational diabetes. It may predispose to various complications including fetus malformation, macrosomia, spontaneous abortion, stillbirth, neonatal death, and intrauterine growth retardation. Hypertrophic cardiomyopathy (HCM) is one of the common anomalies depicted with diabetes. Fetal cardiac function analysis might provide important information on the hemodynamic status and cardiac adaptation to different perinatal complications.

Results

The mean septal thickness in the diabetic group was 0.7163 ± 0.1746 cm and 0.4989 ± 0.08068 cm in the control group. The mean myocardial thickness of the right ventricular free wall in the diabetic group was 0.6532 ± 0.13792 cm and 0.4874 ± 0.07482 cm in the control group. The mean myocardial thickness of the left ventricular free wall in the diabetic group was 0.6437 ± 0.13421 cm and 0.4737 ± 0.07573 cm in the control group. The mean value of myocardial performance index (Tie Index) in the diabetic group was 0.6232 ± 0.15606 and 0.4626 ± 0.04357 in the control group.

Conclusion

From our study, we can conclude that prenatal complete echocardiographic study should be mandatory in fetuses of diabetic mothers due to high risk of congenital heart defects and onset of hypertrophic cardiomyopathy with fetal cardiac function impairment in the third trimester.

Early diagnosis of congenital heart defects as well as evidence of hypertrophic cardiomyopathy and fetal cardiac function impairment that occurs in fetuses of maternal diabetes will definitely guide prompt postnatal therapy and care for those neonates.

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.

Cardiac Function in Infants Born to Mothers With Gestational Diabetes - Estimation of Early Diastolic Intraventricular Pressure Differences

Background: This study compared the myocardial performance of infants born to mothers with gestational diabetes mellitus (IGDM) and without GDM (controls) under the new GDM definitions.

Methods and Results: The subjects consisted of 36 IGDM and 39 control infants. GDM diagnosis was based on oral glucose tolerance test during pregnancy or the presence of diabetes prior to the current pregnancy. Between-group infant cardiac function was determined and compared using 2-D speckle tracking analysis, intraventricular pressure difference (IVPD) and IVP gradient (IVPG), using color M-mode Doppler imaging. IVPD and IVPG were higher in IGDM than in the controls, particularly the mid–apical IVPG. The global circumferential strain (GCS) and endocardial GCS were higher in IGDM than in controls. Increased maternal glycated hemoglobin was correlated with reduced transmural and epicardial GCS in the IGDM. Maternal maximum fasting blood sugar had a mild, positive correlation with IVPD and IVPG.

Conclusions: Ventricular sucking force, measured as the IVPD, IVPG, and endocardial GCS, were higher in IGDM than in the controls. A hyperglycemic environment during pregnancy leads to impaired cardiac performance in IGDM, compared with control infants. IGDM might have favorable systolic and diastolic cardiac performance due to cardiac metabolic adaptations occurring before poor glucose control causes impaired cardiac performance.

Reference range of fetal myocardial area by three-dimensional ultrasonography and its applicability in fetuses of pre-gestational diabetic women

Objective To determine the reference range for the myocardial area in healthy fetuses using three-dimensional (3D) ultrasonography and validate these results in fetuses of pregnant women with pre-gestational diabetes mellitus (DM). Methods This cross-sectional retrospective study included 168 healthy pregnant women between gestational weeks 20 and 33+6 days. The myocardial area was measured using spatio-temporal image correlation (STIC) in the four-chamber view. Polynomial regression models were used, and the goodness of fit of the models were evaluated by the coefficient of determination (R2). Intra- and inter-observer reproducibility was determined using the concordance correlation coefficient (CCC). Validation was performed in 30 pregnant women with pre-gestational DM. Results There was a strong correlation (R2=0.71, P<0.0001) between myocardial area and gestational age. There was good intra- and inter-observer reproducibility, with a CCC of 0.86 and 0.83, respectively. However, there was no significant difference in the mean myocardial area between healthy fetuses and fetuses of women with pre-gestational DM (0.11 cm2, P=0.55). Conclusion The reference range was determined for the myocardial area in fetuses, and there was no significant difference in this variable between healthy fetuses and the fetuses of women with pre-gestational DM.

Effect of gestational diabetes and insulin resistance on offspring's myocardial relaxation kinetics at three years of age

PURPOSE

Scientific evidence on the long-term impact of gestational diabetes mellitus (GDM) on offspring's myocardial relaxation is scarce. Studies have linked GDM with transient ventricular hypertrophy in newborns resulting in diastolic dysfunction, but long-term assessment is lacking. The main objective of this study was to evaluate myocardial relaxation in 3-year-old children in relation to the degree of insulin resistance of their mother during pregnancy.

METHODS

We prospectively assessed myocardial relaxation by echocardiography imaging on 106 children at 3 years of age. Subjects were divided into 3 groups [GDM, insulin resistance (IR) and normoglycemic (CTRL)], based on their mother's 75g-OGTT and HOMA-IR results at second trimester screening. We collected information on children adiposity and body size, maternal characteristics and maternal and cord blood measurement of C-peptide and insulin.

RESULTS

The study population comprised 29 children from GDM mothers, 36 children from IR mothers and 41 CTRL children. Compared to the CTRL group, we found that a higher proportion of children in the IR group and the GDM group met the criteria for impaired myocardial relaxation, but this did not reach statistical significance (odds ratio adjusted for heart rate and body surface area of 1.4 [0.2-9.5] and 3.5 [0.6-20.6], respectively).

CONCLUSION

We did not detect an increased risk of impaired myocardial relaxation at three years of age in children exposed in-utero to IR and GDM, compared to children from normoglycemic mothers.

Effect of well-controlled gestational diabetes on left ventricular diastolic dysfunction in neonates

BACKGROUND

There are some evidences supporting the relation between gestational diabetes mellitus (GDM) and diastolic dysfunction. The aim of our study was to investigate the effect of well-controlled GDM on morphological and functional myocardium.

MATERIALS AND METHODS

We designed a prospective cross-sectional study to evaluate left ventricular (LV) diastolic function of 60 neonates born from mothers with well-controlled GDM (case group) on days of 3-5 after birth. The infants of diabetic mothers (IDM) group were divided into two groups: diabetic mothers treated only with diet (class A) and group of mothers on medical therapy by insulin or metformin (class B). Traditional echocardiography and pulsed-wave Doppler (PWD), tissue Doppler imaging (TDI) were performed for all the neonates.

RESULTS

The study group consisted of 60 neonates as males (M) = 32, (0.53%) and females (F) = 28, (0.46%). Using M-mode echocardiography, interventricular septum thickness (IVS), and LV mass were significantly higher in IDM than control group (p = .0001). The PWD showed both a significantly more peak mitral flow at early diastolic wave (E) and an early filling deceleration time (E-DT) (p = .0001). Tissue Doppler echocardiography parameters A' (cm/s) (p = .0001), E' (cm/s) (p = .002), and E'/A' ratio (p = .0001), left ventricular myocardial performance index (LVMPI), and isovolumetric relaxation time (IVRT) were outstandingly different between the two groups (p = .0001, respectively). Evaluating the GDM group mothers of class A and class B, no significant difference was noted in PWD or TDI parameters compared with the healthy ones.

CONCLUSIONS

It seems that neonates of mothers with well-controlled GDM are still at increased risk of cardiac hypertrophy, subclinical diastolic dysfunction, and impaired left ventricular relaxation. This can be interpreted that focusing only on glycemic control is not enough to prevent cardiac dysfunction.

Cardiac function in newborns of obese women and the effect of exercise during pregnancy. A randomized controlled trial

Background

The prevalence of maternal obesity is rising. Pre-pregnancy obesity is associated with later cardiovascular disease in the child and the underlying pathogenesis begins in early life. Therefore, pregnancy and infancy are key periods for potential intervention. The aim of this study was to study the cardiac function in newborns of obese women compared to newborns of normal-weight women, and to determine if exercise intervention during pregnancy could have an effect on cardiac function of newborns to obese women.

Material and methods

Fifty-five pregnant women, 51 obese (BMI ≥ 30 kg/m²) and four overweight (BMI 28–30 kg/m²), were randomized to an exercise training group (n = 27) or a control group (standard maternity care, n = 28). From gestational week 14 until delivery participants in the intervention group were offered supervised training sessions three times weekly. In addition, they were told to exercise at home once weekly. All newborns had an echocardiogram performed 1–3 days and 6–8 weeks after delivery. The results were compared with newborns of normal weight women (n = 20, standard maternity care).

Results

Newborns of obese women had an impaired systolic and diastolic cardiac function with reduced global strain, strain rate, tissue Doppler velocities and a thicker intraventricular septum at birth and after 6–8 weeks after delivery compared to newborns of normal weight women. Exercise had no statistically significant effect on either of the cardiac function parameters. The mean (± standard deviation) adherence to the exercise protocol was 1.3 ± 0.8 sessions per week for supervised training and 0.8 ± 0.7 sessions per week for home-based exercise training.

Conclusions

Newborns of obese women had reduced cardiac function and thicker intraventricular septum compared to newborns of normal weight women. Exercise training during pregnancy had no significant effect, potentially due to a low number of subjects and low adherence to the exercise protocol.

Trial registration

ClinicalTrials.gov NCT01243554.

Behaviour of the Foramen Ovale Flow in Fetuses with Intrauterine Growth Restriction

Background

Foramen ovale (FO) flow may be altered in IUGR. This study was designed to test this hypothesis.

Methods

Forty pregnant women (24–38 weeks) were divided into 3 groups: group I (IUGR), group II (adequate growth and maternal hypertension), and group III (normal controls). Impedance across the FO was assessed by the FO pulsatility index (FOPI): (systolic velocity − presystolic velocity)/mean velocity. Statistical analysis utilized ANOVA, Tukey test, and ROC curves.

Results

Mean FOPI in IUGR fetuses (n = 15) was 3.70 ± 0.99 (3.15–4.26); in the group II (n = 12), it was 2.84 ± 0.69 (2.40–3.28), and in the group III (n = 13), it was 2.77 ± 0.44 (2.50–3.04) (p=0.004). FOPI and UtA RI were correlated (r = 0.375, p=0.017), as well as FOPI and UA RI (r = 0.356, p=0.024) and, inversely, FOPI and MCA RI (r = −0.359, p=0.023).

Conclusions

The FO flow pulsatility index is increased in fetuses with IUGR, probably as a result of impaired left ventricular diastolic function.

Air Pollution and Other Environmental Modulators of Cardiac Function

Cardiovascular disease (CVD) is the leading cause of death in developed regions and a worldwide health concern. Multiple external causes of CVD are well known, including obesity, diabetes, hyperlipidemia, age, and sedentary behavior. Air pollution has been linked with the development of CVD for decades, though the mechanistic characterization remains unknown. In this comprehensive review, we detail the background and epidemiology of the effects of air pollution and other environmental modulators on the heart, including both short- and long-term consequences. Then, we provide the experimental data and current hypotheses of how pollution is able to cause the CVD, and how exposure to pollutants is exacerbated in sensitive states. Published 2017. Compr Physiol 7:1479-1495, 2017.

Subclinical Decrease in Myocardial Function in Asymptomatic Infants of Diabetic Mothers: A Tissue Doppler Study

Infants of diabetic mothers (IDMs) with hypertrophic cardiomyopathy are recognized to have impaired myocardial performance, but less is known about ventricular function in IDMs without hypertrophy. We hypothesized that in asymptomatic newborns with normal two-dimensional echocardiographic evaluations, pulsed wave tissue Doppler imaging (TDI) would suggest a subclinical decrease in the cardiac function of IDMs compared to infants of non-diabetics (nIDMs). This is a retrospective cohort study of asymptomatic neonates ≥36 weeks gestation, at 0-7 days of life, with normal standard echocardiograms. Systolic (S'), early diastolic (E'), and late diastolic (A') TDI velocities were measured at the mitral valve (MV) annulus, basal interventricular septum (IVS), and tricuspid valve (TV) annulus, and averaged from three consecutive cardiac cycles. Demographic, perinatal, and echocardiographic variables were compared between IDM and nIDM groups. Of 631 subjects, 75 IDMs were identified. The mean gestational age of the entire cohort was 39.33 weeks (±1.26), birth weight 3.44 kg (±0.56), and body surface area (BSA) 0.21 m² (±0.02). IDMs had significantly greater birth weight and BSA, lower gestational age, older maternal age, and higher incidence of maternal obesity and hypertension than nIDMs (p < 0.001). On multivariable analysis, IDMs had significantly lower S' (p ≤ 0.03) and E' (p < 0.001) velocities, and higher E/E' ratios (p < 0.001) at the MV, IVS, and TV than nIDMs. In asymptomatic newborn IDMs without cardiac hypertrophy, pulsed wave TDI suggests a subclinical decrease in systolic and diastolic myocardial function compared to nIDMs.

Impact of maternal obesity on fetal programming of cardiovascular disease

The in utero environment is a key determinant of long-term health outcomes; poor maternal metabolic state and placental insufficiency are strongly associated with these long-term health risks. Human epidemiological studies link maternal obesity and offspring cardiovascular disease in later life, but mechanistic studies in animal models are limited. Here, we review the literature pertaining to maternal consequences of obesity during pregnancy and the subsequent impact on fetal cardiovascular development.

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.

The effects of pre-pregnancy obesity on fetal cardiac functions

Obesity is a substantial public health problem with a rapidly increasing prevalence in numerous industrialized nations. The objective of this study was to evaluate the effects of maternal pre-pregnancy obesity on fetal cardiac functions. We studied 55 fetuses of obese mothers and 44 fetuses of healthy mothers at 26-38 weeks of gestation. Cardiac functions were evaluated by M-mode, pulsed-wave, and tissue Doppler echocardiography. The two groups were similar in terms of maternal age, gravidity, parity, gestational age, estimated birth weight, serum lipids, and systolic-diastolic blood pressure. Fetal heart rate, diameters of the aortic and pulmonary valve annulus, aortic and pulmonary peak systolic velocities, ventricular systolic function, and cardiothoracic ratio were similar in the two groups. Pulsed-wave Doppler-derived E/A ratios in the mitral and tricuspid valves were similar in the two groups. The deceleration time of early mitral inflow was prolonged in the fetuses of the obese mothers. In the interventricular septum, left ventricle posterior wall, and right ventricle free wall, the E a and A a were higher, and E a/A a ratios were significantly lower in the study group than in the control group. The E/E a ratio was higher in the obese group than in the control group. The isovolumic relaxation time and the right and left ventricle myocardial performance indices were higher in the fetuses of the obese mothers than in the fetuses of the healthy mothers. We believe that maternal obesity has an important influence on fetal cardiac diastolic functions.

The impact of early nutrition on the ageing trajectory

Epidemiological studies, including those in identical twins, and in individuals in utero during periods of famine have provided robust evidence of strong correlations between low birth-weight and subsequent risk of disease in later life, including type 2 diabetes (T2D), CVD, and metabolic syndrome. These and studies in animal models have suggested that the early environment, especially early nutrition, plays an important role in mediating these associations. The concept of early life programming is therefore widely accepted; however the molecular mechanisms by which early environmental insults can have long-term effects on a cell and consequently the metabolism of an organism in later life, are relatively unclear. So far, these mechanisms include permanent structural changes to the organ caused by suboptimal levels of an important factor during a critical developmental period, changes in gene expression caused by epigenetic modifications (including DNA methylation, histone modification and microRNA) and permanent changes in cellular ageing. Many of the conditions associated with early-life nutrition are also those which have an age-associated aetiology. Recently, a common molecular mechanism in animal models of developmental programming and epidemiological studies has been development of oxidative stress and macromolecule damage, specifically DNA damage and telomere shortening. These are phenotypes common to accelerated cellular ageing. Thus, this review will encompass epidemiological and animal models of developmental programming with specific emphasis on cellular ageing and how these could lead to potential therapeutic interventions and strategies which could combat the burden of common age-associated disease, such as T2D and CVD.

Assessment of fetal cardiac function in mild preeclampsia

This study investigated cardiac function in 65 fetuses of mildly preeclamptic mothers and 55 fetuses of healthy mothers at 26-40 weeks of gestation. Fetuses with intrauterine growth restriction were excluded. Cardiac functions were evaluated by M-mode, pulsed-wave, and tissue Doppler echocardiography. The two groups were similar in terms of maternal age, gravidity, parity, and gestational age. Peak systolic aortic and pulmonary artery velocities were significantly lower in the fetuses of the preeclamptic mothers than in the fetuses of the healthy mothers. The two groups did not differ significantly in terms of shortening fraction or with regard to mitral or tricuspid annular plane systolic excursion. Pulsed-wave Doppler-derived E/A ratios in the mitral and tricuspid valves were similar in the two groups. The deceleration time of early mitral inflow was prolonged in the fetuses of the preeclamptic mothers. The Ea, Aa, and Ea/Aa ratios in the interventricular septum, left ventricle posterior wall, and right ventricle free wall were lower in the preeclampsia group than in the control group. The E/Ea ratio was higher in the preeclampsia group than in the control group. The isovolumic relaxation time and the right and left myocardial performance indices were higher in the fetuses of the preeclamptic mothers than in the fetuses of the healthy mothers. An increased ductus venosus pulsatility index (PI) and a decreased middle cerebral artery (MCA) PI were found in the fetuses of the preeclamptic mothers. All the fetuses were asymptomatic. The results suggest that the increase in fetal cardiac afterload in mild preeclampsia may have caused early subclinical changes in fetal systolic and diastolic cardiac function. In addition, the decrease in MCA-PI may have been caused by redistribution of fetal cardiac output in favor of the left ventricle, secondary to increased placental vascular resistance.

Identification and comparative analyses of myocardial miRNAs involved in the fetal response to maternal obesity

Human and animal studies show that suboptimal intrauterine environments lead to fetal programming, predisposing offspring to disease in later life. Maternal obesity has been shown to program offspring for cardiovascular disease (CVD), diabetes, and obesity. MicroRNAs (miRNAs) are small, noncoding RNA molecules that act as key regulators of numerous cellular processes. Compelling evidence links miRNAs to the control of cardiac development and etiology of cardiac pathology; however, little is known about their role in the fetal cardiac response to maternal obesity. Our aim was to sequence and profile the cardiac miRNAs that are dysregulated in the hearts of baboon fetuses born to high fat/high fructose-diet (HFD) fed mothers for comparison with fetal hearts from mothers eating a regular diet. Eighty miRNAs were differentially expressed. Of those, 55 miRNAs were upregulated and 25 downregulated with HFD. Twenty-two miRNAs were mapped to human; 14 of these miRNAs were previously reported to be dysregulated in experimental or human CVD. We used an Ingenuity Pathway Analysis to integrate miRNA profiling and bioinformatics predictions to determine miRNA-regulated processes and genes potentially involved in fetal programming. We found a correlation between miRNA expression and putative gene targets involved in developmental disorders and CVD. Cellular death, growth, and proliferation were the most affected cellular functions in response to maternal obesity. Thus, the current study reveals significant alterations in cardiac miRNA expression in the fetus of obese baboons. The epigenetic modifications caused by adverse prenatal environment may represent one of the mechanisms underlying fetal programming of CVD.

The programming of cardiac hypertrophy in the offspring by maternal obesity is associated with hyperinsulinemia, AKT, ERK, and mTOR activation

Human and animal studies suggest that suboptimal early nutrition during critical developmental periods impacts long-term health. For example, maternal overnutrition during pregnancy and lactation in mice programs insulin resistance, obesity, and endothelial dysfunction in the offspring. Here we investigated the effects of diet-induced maternal obesity on the offspring cardiac phenotype and explored potential underlying molecular mechanisms. Dams fed the obesogenic diet were heavier (P < 0.01) and fatter (P < 0.0001) than controls throughout pregnancy and lactation. There was no effect of maternal obesity on offspring body weight or body composition up to 8 wk of age. However, maternal obesity resulted in increased offspring cardiac mass (P < 0.05), increased heart-body weight (P < 0.01), heart weight-tibia length (P < 0.05), increased left ventricular free wall thickness and area (P < 0.01 and P < 0.05, respectively), and increased myocyte width (P < 0.001). Consistent with these structural changes, the expression of molecular markers of cardiac hypertrophy were also increased [Nppb(BNP), Myh7-Myh6(βMHC-αMHC) (both P < 0.05) and mir-133a (P < 0.01)]. Offspring were hyperinsulinemic and displayed increased insulin action through AKT (P < 0.01), ERK (P < 0.05), and mammalian target of rapamycin (P < 0.05). p38MAPK phosphorylation was also increased (P < 0.05), suggesting pathological remodeling. Increased Ncf2(p67(phox)) expression (P < 0.05) and impaired manganese superoxide dismutase levels (P < 0.01) suggested oxidative stress, which was consistent with an increase in levels of 4-hydroxy-2-trans-nonenal (a measure of lipid peroxidation). We propose that maternal diet-induced obesity leads to offspring cardiac hypertrophy, which is independent of offspring obesity but is associated with hyperinsulinemia-induced activation of AKT, mammalian target of rapamycin, ERK, and oxidative stress.