Assessment of fetal myocardial performance in severe early onset pre-eclampsia (EO-PET) with and without intrauterine growth restriction across deteriorating stages of placental vascular resistance and links to adverse outcomes

Multi-Organ Phenotypes of Offspring Born Following Hypertensive Disorders of Pregnancy: A Systematic Review

BACKGROUND

Hypertensive pregnancies are associated with an increased risk of cardiovascular and neurological diseases in the offspring during later life. However, less is known about the potential impact on multi-organ phenotypes in offspring before disease symptoms occur. The objective of this systematic review was to determine the associations of fetal exposure to maternal hypertensive pregnancy with multi-organ phenotypes across developmental stages.

METHODS AND RESULTS

Ovid MEDLINE, EMBASE, CENTRAL (Cochrane Central Register of Controlled Trials), WoS, Scopus, CINAHL, and ClinicalTrials.gov were systematically searched until February 2024. Records were independently screened by 2 authors. Studies reporting on the structure or function of the heart, blood vessels, brain, liver, and kidneys in offspring of hypertensive pregnancies compared with a normotensive control population were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. Extracted data were presented using harvest plots. Seventy-three studies including 7091 offspring of hypertensive pregnancies and 42 164 controls were identified that met the inclusion criteria. Thirty-two studies were investigations in fetuses, 24 in neonates and infants, 12 in children, 2 in adolescents, and 3 in adults. Offspring of hypertensive pregnancies had structural and functional changes in the heart compared with controls in some studies across developmental stages. Offspring of hypertensive pregnancies also had smaller occipital and parietal vessels, higher aortic intima-media thickness, and lower retinal arteriolar-to-venular ratio. Some conflicting evidence existed for other phenotypical alterations.

CONCLUSIONS

There is still inconsistent evidence of multi-organ structural and functional differences in offspring of hypertensive pregnancies. The evidence base could therefore be further strengthened through well-designed and conducted prospective studies.

REGISTRATION INFORMATION

www.crd.york.ac.uk. Unique Identifier: CRD42023387550.

Effect of abnormal placentation on fetal heart function and neonatal outcomes

OBJECTIVE

This study aimed to investigate the fetal modified (mod)-myocardial performance index (MPI) for fetal cardiac function in placenta percreta (PPC) pregnancies with placenta previa (PP) and assess neonatal outcomes.

MATERIALS AND METHODS

This study included 104 pregnant women: 52 with PPC and 52 as the control group. Mod-MPI measurements and neonatal outcomes were evaluated in all cases.

RESULTS

The PPC group had a significantly lower left ejection time (p = 0.044) and significantly higher mod-MPI (p = 0.001) than the control group. The optimal mod-MPI predictive cut-off value at the neonatal intensive care unit (NICU) admission in the PPC group was 0.53 with 53.8% specificity and 88.5% sensitivity (p = 0.019). The optimal mod-MPI predictive cut-off value at the 5th APGAR score below 7 in the PPC group was 0.55 with a specificity of 67.7% and a sensitivity of 76.2% (p = 0.016).

CONCLUSION

Fetal MPI was higher in pregnant women with PPC compared to the control group. Among the PPC cases, those with MPI above a certain predictive level showed more frequent NICU admissions and lower APGAR scores.

Myocardial Function in Offspring Aged 5 to 8 Years of Pregnancy Complicated by Severe Preeclampsia Measured by Two-Dimensional Speckle-Tracking Echocardiography

Objective: This study aimed to quantitatively assess myocardial strain in preterm children aged 5 to 8 years of pregnancy complicated by severe preeclampsia (PE) by two-dimensional (2D) speckle tracking echocardiography.

Method: A cohort study of 23 preterm children delivered by severe PE pregnant women from 2010 to 2012 in the First Affiliated Hospital of Soochow University was carried out. 23 preterm children from uneventful pregnancies in the same period served as controls. Myocardial functions including left ventricular longitudinal strain, radial strain, circumferential strain, and right ventricular longitudinal strain were evaluated by conventional Doppler, tissue Doppler imaging, and 2D speckle-tracking echocardiography (2D STE). All examinations were performed by an experienced ultrasonographer using the VIVID E9 (GE Healthcare) machine, according to standard techniques.

Results: Children aged 5–8 years delivered from severe PE presented less weight (24.41 vs. 20.89 kg, P < 0.05), shorter height (124.1 vs 115.6 cm, P < 0.05) and faster heart rates (84 vs. 93 bpm, P < 0.05) compared to offspring of normotensive women. There were no significant differences in global left ventricular longitudinal strain, radial strain, circumferential strain, and right ventricular longitudinal strain between the children in the experimental group and the control group (P > 0.05).

Conclusion: Exposure to the intrauterine environment of severe PE during the fetal period did not have a significant impact on cardiac structure in premature children at 5–8 years old, but they had a higher resting heart rate which may be associated with cardiovascular disease in the long run.

Progress of Pathogenesis in Pediatric Multifocal Atrial Tachycardia

Multifocal atrial tachycardia (MAT) is defined as irregular P-P, R-R, and P-R intervals, isoelectric baseline between P waves, and ventricular rate over 100 beats/min. Although the prognosis of pediatric MAT in most patients is favorable, adverse outcomes of MAT have been reported, such as cardiogenic death (3%), respiratory failure (6%), or persistent arrhythmia (7%), due to delayed diagnosis and poorly controlled MAT. Previous studies demonstrated that pediatric MAT is associated with multiple enhanced automatic lesions located in the atrium or abnormal automaticity of a single lesion located in the pulmonary veins via multiple pathways to trigger electrical activity. Recent studies indicated that pediatric MAT is associated with the formation of a re-entry loop, abnormal automaticity, and triggering activity. The occurrence of pediatric MAT is affected by gestational disease, congenital heart disease, post-cardiac surgery, pulmonary hypertension, and infectious diseases, which promote MAT via inflammation, redistribution of the autonomic nervous system, and abnormal ion channels. However, the pathogenesis of MAT needs to be explored. This review is aimed to summarize and analyze the pathogenesis in pediatric MAT.

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.

Fetal and Neonatal Modified Myocardial Performance Indices in Preeclamptic versus Normotensive Pregnancies: A Prospective Cohort Study

Objective

To compare fetal and neonatal cardiac functions in terms of global, systolic, and diastolic function between the preeclampsia and normotensive blood pressure of pregnancies.

Methods

A prospective cohort study was conducted at a university hospital in Northeast Thailand. Twenty-nine pregnancies diagnosed as preeclampsia with or without severe features were compared with 29 normotensive pregnancies. Global cardiac, systolic, and diastolic function were assessed at prenatal and postnatal periods, by a professionally trained obstetrician and pediatric cardiologist, respectively.

Results

The fetal left modified myocardium performance index (Mod-MPI) in preeclampsia and normotensive blood pressure were 0.60±0.08 and 0.59±0.08 (p-value=0.341), respectively, while fetal right Mod-MPI were 0.57±0.16 and 0.54±0.21 (p-value=0.861), respectively. There were no statistically significant differences in terms of fetal isovolumic contraction time (ICT), isovolumic relaxation time (IRT), ejection time (ET), aortic peak systolic velocity (Ao PSV), pulmonary artery peak systolic velocity (PA PSV), mitral valve (MV) E:A ratio, or tricuspid valve (TV) E:A ratios between the two groups. Neonatal mitral valve E peak systolic velocity (MV-E PV) in preeclamptic and normotensive blood pressure groups were significantly different at 51.1±8.02 cm/s and 43.56±5.21cm/s (p-value=0.036), respectively, whereas neonatal left Mod-MPI, mitral valve A peak systolic velocity (MV-A PV), MV E:A ratio, and Ao PSV were not significantly different (p-value=0.436, 0.119, 0.379, and 0.709), respectively.

Conclusion

Neonatal MV-E PV of the preeclampsia group was significantly higher than the normotensive blood pressure group, while there were no statistically significant differences in terms of global cardiac and diastolic functions during the fetal period between two groups.

Fetal Myocardial Performance Index in the Third Trimester of Pregnancy: Feasibility and Reproducibility of Conventional Spectral Doppler versus Spectral Tissue Doppler Technique

OBJECTIVE

This study aims to compare completion rates and reproducibility of myocardial performance index (MPI) using conventional spectral Doppler versus tissue Doppler in an unselected high-risk third trimester population.

STUDY DESIGN

This was a prospective cross-sectional study of high-risk pregnancies at ≥28 + 0 weeks' gestation. Conventional spectral and tissue Doppler MPI of the left ventricle (LV) and right ventricle (RV) was attempted on all patients.

RESULTS

Seventy-nine pregnancies were evaluated. LV tissue Doppler MPI was completed more frequently than LV conventional spectral Doppler MPI (63/79, 79.7% vs. 45/79, 55.7%), p-value <0.01. RV tissue Doppler MPI was completed more frequently than RV conventional spectral Doppler MPI (68/79, 86% vs. 42/79, 53.2%), p-value <0.01. In obese subjects (n = 50) LV tissue Doppler MPI was completed more frequently than LV conventional spectral Doppler MPI (37/50, 74% vs. 26/50, 52%), p-value <0.01. RV tissue Doppler MPI was completed more frequently than RV conventional spectral Doppler MPI (40/50, 80% vs. 25/50, 50%), p-value <0.01. intraclass correlation coefficient for all modalities ranged between 0.73 and 0.93, except for LV conventional spectral Doppler intraobserver variability which was 0.22.

CONCLUSION

Tissue Doppler had statistically higher completion rates than conventional spectral Doppler, including the obese subgroup, with evidence of strong reproducibility in the third trimester.

Effect of Early-Onset Preeclampsia on Offspring's Blood Pressure during the First Month of Life

OBJECTIVE

To explore the effect of early-onset preeclampsia on the blood pressure of offspring during the first month of life.

STUDY DESIGN

This prospective case-control study included 106 neonates of mothers with early-onset preeclampsia (developing at <34 weeks of gestation) and 106 infants of normotensive mothers, matched 1-to-1 for sex and gestational age. Serial blood pressure measurements were obtained on admission, daily for the first postnatal week, and then weekly up to the fourth week of life.

RESULTS

There were no differences in blood pressure values on admission and the first day of life between cases and controls. Conversely, infants exposed to preeclampsia had significantly higher systolic (SBP), diastolic (DBP), and mean blood pressure (MBP) on the subsequent days up to the fourth postnatal week (P <.001-.033). Multiple regression analyses with adjustment for sex, gestational age, antenatal corticosteroid use, and maternal antihypertensive medication use confirmed the foregoing findings (P <.001-.048). Repeated-measures ANOVA also identified preeclampsia as a significant determinant of trends in SBP, DBP, and MBP during the first month of life (F = 16.2, P < .001; F = 16.4, P < .001; and F = 17.7, P < .001, respectively).

CONCLUSIONS

Infants of mothers with early-onset preeclampsia have elevated blood pressure values throughout the neonatal period compared with infants born to normotensive mothers.

Evaluation of Hemodynamic Changes in Fetuses With Isolated Mild-to-Moderate Ventriculomegaly by Transabdominal Ultrasound

OBJECTIVES

To investigate fetal hemodynamic alterations using transabdominal ultrasound in fetuses with isolated mild-to-moderate ventriculomegaly (VM).

METHODS

Fetuses diagnosed with isolated mild-to-moderate VM by transabdominal ultrasound were evaluated for hemodynamic changes, including changes in fetal cardiac function, the umbilical artery, the ductus venosus, and the middle cerebral artery. The fetuses with isolated mild-to-moderate VM were divided into 2 groups, namely, before 32 weeks' gestation (20 weeks-31 weeks 6 days) and after 32 weeks' gestation (32-38 weeks), and matched to corresponding healthy control fetuses.

RESULTS

The 53 fetuses with VM before 32 weeks had a longer mean isovolumetric relaxation time (IRT; mean ± SD, 42.9 ± 6.8 versus 40.4 ± 5.0 milliseconds; P < .05) and an apparently higher modified myocardial performance index 0.46 ± 0.06 versus 0.43 ± 0.05; P < .01) than the healthy control fetuses. The 43 fetuses with VM after 32 weeks had a significantly longer mean IRT (45.5 ± 6.7 versus 40.9 ± 7.2 milliseconds; P < .01) and a lower UA pulsatility index (0.81 ± 0.13 versus 0.89 ± 0.11; P < .01). The optimal cutoff levels for the IRT in the prediction of adverse perinatal outcomes were 40 and 43 milliseconds before and after 32 weeks, respectively (sensitivity, 100% versus 100%; specificity, 40.4% versus 50.0%; area under the curve, 0.601 versus 0.748; 95% confidence interval, 0.457-0.733 versus 0.590-0.869; P = .291 versus .005).

CONCLUSIONS

Some fetuses with isolated mild-to-moderate VM may have impaired cardiac function, characterized by a higher modified myocardial performance index or longer IRT. This finding might be useful for improving fetal surveillance.

Melhoria da qualidade do cuidado à hipertensão gestacional em terapia intensiva

Objetivo: avaliar o efeito de um ciclo de melhoria da qualidade na implementação de práticas baseadas em evidências no tratamento de mulheres com doenças hipertensivas gestacionais admitidas em Unidade de Terapia Intensiva Materna (UTIM).Métodos: estudo quase-experimental, sem grupo de controle, realizado numa UTIM de um hospital universitário que seguiu as etapas de um ciclo de melhoria da qualidade. Avaliaram-se nove critérios de processo em todas as mulheres admitidas com diagnóstico de doenças hipertensivas gestacionais nos períodos anterior (n = 50) e posterior à intervenção (n = 50) em 2015. Estimou-se a conformidade com intervalo de confiança de 95 %, as não conformidades com gráficos de Pareto e a significância da melhoria com teste do valor Z unilateral (α = 5 %).Resultados: o nível de qualidade inicial foi alto em seis dos nove critérios (amplitude: 94-100 %), as práticas com menor adesão foram a “manutenção de sulfato de magnésio” (54 %), “solicitação de ultrassom fetal” (72 %) e “restrição hídrica intravenosa” (78 %). Houve melhoria absoluta em cinco dos nove critérios (amplitude: 2-16 %), que foi significativa para a solicitação de ultrassom fetal (melhoria absoluta: 16 %; p = 0,023) e para o total de critérios (4 %; p = 0,01).Conclusão: a intervenção de melhoria da qualidade proposta aumentou a adesão às recomendações baseadas em evidência para o tratamento de pacientes com doenças hipertensivas gestacionais admitidas em uma UTIM.

Fetal cardiac remodeling and dysfunction is associated with both preeclampsia and fetal growth restriction

BACKGROUND

Preeclampsia and fetal growth restriction share some pathophysiologic features and are both associated with placental insufficiency. Fetal cardiac remodeling has been described extensively in fetal growth restriction, whereas little is known about preeclampsia with a normally grown fetus.

OBJECTIVE

To describe fetal cardiac structure and function in pregnancies complicated by preeclampsia and/or fetal growth restriction as compared with uncomplicated pregnancies.

STUDY DESIGN

This was a prospective, observational study including pregnancies complicated by normotensive fetal growth restriction (n=36), preeclampsia with a normally grown fetus (n=35), preeclampsia with fetal growth restriction (preeclampsia with a normally grown fetus-fetal growth restriction, n=42), and 111 uncomplicated pregnancies matched by gestational age at ultrasound. Fetal echocardiography was performed at diagnosis for cases and recruitment for uncomplicated pregnancies. Cord blood concentrations of B-type natriuretic peptide and troponin I were measured at delivery. Univariate and multiple regression analysis were conducted.

RESULTS

Pregnancies complicated by preeclampsia and/or fetal growth restriction showed similar patterns of fetal cardiac remodeling with larger hearts (cardiothoracic ratio, median [interquartile range]: uncomplicated pregnancies 0.27 [0.23-0.29], fetal growth restriction 0.31 [0.26-0.34], preeclampsia with a normally grown fetus 0.31 [0.29-0.33), and preeclampsia with fetal growth restriction 0.28 [0.26-0.33]; P<.001) and more spherical right ventricles (right ventricular sphericity index: uncomplicated pregnancies 1.42 [1.25-1.72], fetal growth restriction 1.29 [1.22-1.72], preeclampsia with a normally grown fetus 1.30 [1.33-1.51], and preeclampsia with fetal growth restriction 1.35 [1.27-1.46]; P=.04) and hypertrophic ventricles (relative wall thickness: uncomplicated pregnancies 0.55 [0.48-0.61], fetal growth restriction 0.67 [0.58-0.8], preeclampsia with a normally grown fetus 0.68 [0.61-0.76], and preeclampsia with fetal growth restriction 0.66 [0.58-0.77]; P<.001). Signs of myocardial dysfunction also were observed, with increased myocardial performance index (uncomplicated pregnancies 0.78 z scores [0.32-1.41], fetal growth restriction 1.48 [0.97-2.08], preeclampsia with a normally grown fetus 1.15 [0.75-2.17], and preeclampsia with fetal growth restriction 0.45 [0.54-1.94]; P<.001) and greater cord blood B-type natriuretic peptide (uncomplicated pregnancies 14.2 [8.4-30.9] pg/mL, fetal growth restriction 20.8 [13.1-33.5] pg/mL, preeclampsia with a normally grown fetus 31.8 [16.4-45.8] pg/mL and preeclampsia with fetal growth restriction 37.9 [15.7-105.4] pg/mL; P<.001) and troponin I as compared with uncomplicated pregnancies.

CONCLUSION

Fetuses of preeclamptic mothers, independently of their growth patterns, presented cardiovascular remodeling and dysfunction in a similar fashion to what has been previously described for fetal growth restriction. Future research is warranted to better elucidate the mechanism(s) underlying fetal cardiac adaptation in these conditions.

Assessment of Fetal Myocardial Performance Index in Women with Placenta Previa

Background

This study investigated whether fetuses of placenta previa pregnancies have cardiac dysfunction by use of a modified myocardial performance index (Mod-MPI).

Material/Methods

A prospective cross-sectional study was conducted including 178 fetuses at 28–40 weeks of gestation. Eighty-nine fetuses of mothers with placenta previa and without pregnancy complications were recruited (placenta previa group) and matched with 89 fetuses of mothers with normal pregnancies (control group). Fetal cardiac function parameters and perinatal outcomes as well as the Mod-MPI were compared between the 2 groups.

Results

The median Mod-MPI was significantly increased in fetuses of mothers with placenta previa compared with controls (0.47±0.05 vs. 0.45±0.05; P<0.01). Among fetuses of mothers with or without placenta previa, the Mod-MPI was significantly higher in the incomplete placenta previa group compared with the complete placenta previa group and control group (P<0.01). An increased Mod-MPI in placenta previa pregnancies was independently associated with fetal cord pH <7.2 (odds ratio, 4.8; 95% confidence interval, 0.98–23.54; P=0.003).

Conclusions

There is impairment of fetal cardiac function in pregnancies with placenta previa. An increased MPI was independently associated with adverse perinatal outcomes to some extent in the placenta previa pregnancies.

Determination of the fetal myocardial performance index in women with gestational impaired glucose tolerance and to assess whether this parameter is a possible prognostic indicator of adverse fetal outcome

AIM

The aim of this study was to investigate if the myocardial performance index (MPI) is altered in fetuses in women with gestational impaired glucose tolerance (GIGT), controlled on diet and whether this parameter is also predictive of adverse outcome in this group, as in poorly controlled gestational diabetes.

METHODS

In a prospective cross-sectional study, 32 women with GIGT on diet in the 3rd trimester were recruited and matched with 32 women with normal pregnancies (control group). Using Doppler echocardiography, the MPI was calculated. Placental resistance Doppler markers in both groups were also determined. An abnormal outcome was defined as any of the following: stillbirth, neonatal death, neonatal intensive care unit (NICU) admissions, tachypnea with pulmonary oedema, neonatal cord pH <7.15, five minute Apgar score <7, and cardiomyopathy.

RESULTS

The cases had a significantly higher median MPI compared to controls, p value <.0001. There were eight abnormal outcomes recorded in the 32 fetuses in the study group, corresponding to an adverse outcome rate of 25%. Fetuses with an adverse outcome had significantly higher MPI measurements compared to the GIGT fetuses with normal outcome. The MPI served as an excellent predictor of adverse outcome in the GIGT fetuses, with a total area under the ROC curve of 0.96. An MPI z-score greater than 4.0 conferred a sensitivity of 100% and specificity of 80%. No abnormal outcomes were noted in the control group.

CONCLUSIONS

The MPI is impaired in fetuses in GIGT women, with fetuses with an adverse outcome having significantly higher MPI measurements compared to the fetuses with normal outcome in the GIGT group. MPI has the potential to improve fetal surveillance in gestational diabetes.