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Cromb D, Steinweg J, Aviles Verdera J, van Poppel MPM, Bonthrone AF, Lloyd DFA, Pushparajah K, Simpson J, Razavi R, Rutherford M, Counsell SJ, Hutter J. T2*-Relaxometry MRI to Assess Third Trimester Placental and Fetal Brain Oxygenation and Placental Characteristics in Healthy Fetuses and Fetuses With Congenital Heart Disease. J Magn Reson Imaging 2024. [PMID: 38994701 DOI: 10.1002/jmri.29498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND Congenital heart disease (CHD) has been linked to impaired placental and fetal brain development. Assessing the placenta and fetal brain in parallel may help further our understanding of the relationship between development of these organs. HYPOTHESIS 1) Placental and fetal brain oxygenation are correlated, 2) oxygenation in these organs is reduced in CHD compared to healthy controls, and 3) placental structure is altered in CHD. STUDY TYPE Retrospective case-control. POPULATION Fifty-one human fetuses with CHD (32 male; median [IQR] gestational age [GA] = 32.0 [30.9-32.9] weeks) and 30 from uncomplicated pregnancies with normal birth outcomes (18 male; median [IQR] GA = 34.5 [31.9-36.7] weeks). FIELD STRENGTH/SEQUENCE 1.5 T single-shot multi-echo-gradient-echo echo-planar imaging. ASSESSMENT Masking was performed using an automated nnUnet model. Mean brain and placental T2* and quantitative measures of placental texture, volume, and morphology were calculated. STATISTICAL TESTS Spearman's correlation coefficient for determining the association between brain and placental T2*, and between brain and placental characteristics with GA. P-values for comparing brain T2*, placenta T2*, and placental characteristics between groups derived from ANOVA. Significance level P < 0.05. RESULTS There was a significant positive association between placental and fetal brain T2* (⍴ = 0.46). Placental and fetal brain T2* showed a significant negative correlation with GA (placental T2* ⍴ = -0.65; fetal brain T2* ⍴ = -0.32). Both placental and fetal brain T2* values were significantly reduced in CHD, after adjusting for GA (placental T2*: control = 97 [±24] msec, CHD = 83 [±23] msec; brain T2*: control = 218 [±26] msec, CHD = 202 [±25] msec). Placental texture and morphology were also significantly altered in CHD (Texture: control = 0.84 [0.83-0.87], CHD = 0.80 [0.78-0.84]; Morphology: control = 9.9 [±2.2], CHD = 10.8 [±2.0]). For all fetuses, there was a significant positive association between placental T2* and placental texture (⍴ = 0.46). CONCLUSION Placental and fetal brain T2* values are associated in healthy fetuses and those with CHD. Placental and fetal brain oxygenation are reduced in CHD. Placental appearance is significantly altered in CHD and shows associations with placental oxygenation, suggesting altered placental development and function may be related. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 3.
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Affiliation(s)
- Daniel Cromb
- Centre for the Developing Brain, School of Biomedical and Engineering Sciences, King's College London, London, UK
| | - Johannes Steinweg
- Department of Cardiovascular Imaging, School of Biomedical Engineering & Imaging Science, King's College London, London, UK
| | - Jordina Aviles Verdera
- Centre for the Developing Brain, School of Biomedical and Engineering Sciences, King's College London, London, UK
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Milou P M van Poppel
- Department of Cardiovascular Imaging, School of Biomedical Engineering & Imaging Science, King's College London, London, UK
| | - Alexandra F Bonthrone
- Centre for the Developing Brain, School of Biomedical and Engineering Sciences, King's College London, London, UK
| | - David F A Lloyd
- Centre for the Developing Brain, School of Biomedical and Engineering Sciences, King's College London, London, UK
- Department of Cardiovascular Imaging, School of Biomedical Engineering & Imaging Science, King's College London, London, UK
| | - Kuberan Pushparajah
- Department of Cardiovascular Imaging, School of Biomedical Engineering & Imaging Science, King's College London, London, UK
| | - John Simpson
- Department of Cardiovascular Imaging, School of Biomedical Engineering & Imaging Science, King's College London, London, UK
| | - Reza Razavi
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Mary Rutherford
- Centre for the Developing Brain, School of Biomedical and Engineering Sciences, King's College London, London, UK
- MRC Centre for Neurodevelopmental Disorders, King's College London, London, UK
| | - Serena J Counsell
- Centre for the Developing Brain, School of Biomedical and Engineering Sciences, King's College London, London, UK
| | - Jana Hutter
- Centre for the Developing Brain, School of Biomedical and Engineering Sciences, King's College London, London, UK
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Smart Imaging Lab, Radiological Institute, University Hospital Erlangen, Erlangen, Germany
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2
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Cromb D, Slator PJ, Hall M, Price A, Alexander DC, Counsell SJ, Hutter J. Advanced magnetic resonance imaging detects altered placental development in pregnancies affected by congenital heart disease. Sci Rep 2024; 14:12357. [PMID: 38811636 PMCID: PMC11136986 DOI: 10.1038/s41598-024-63087-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/24/2024] [Indexed: 05/31/2024] Open
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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Affiliation(s)
- Daniel Cromb
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK
- Centre for Medical Engineering, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Paddy J Slator
- Centre for Medical Image Computing, Department of Computer Science, University College London, London, UK
- School of Computer Science and Informatics, Cardiff University, Cardiff, UK
- Cardiff University Brain Research Imaging Centre, School of Psychology, Cardiff University, Cardiff, UK
| | - Megan Hall
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK
| | - Anthony Price
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK
- Centre for Medical Engineering, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Daniel C Alexander
- Centre for Medical Image Computing, Department of Computer Science, University College London, London, UK
| | - Serena J Counsell
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK.
- Centre for Medical Engineering, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
| | - Jana Hutter
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK
- Centre for Medical Engineering, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Smart Imaging Lab, Radiological Institute, University Hospital Erlangen, Erlangen, Germany
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3
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Gaynor JW, Moldenhauer JS, Zullo EE, Burnham NB, Gerdes M, Bernbaum JC, D’Agostino JA, Linn RL, Klepczynski B, Randazzo I, Gionet G, Choi GH, Karaj A, Russell WW, Zackai EH, Johnson MP, Gebb JS, Soni S, DeBari SE, Szwast AL, Ahrens-Nicklas RC, Drivas TG, Jacobwitz M, Licht DJ, Vossough A, Nicolson SC, Spray TL, Rychik J, Putt ME. Progesterone for Neurodevelopment in Fetuses With Congenital Heart Defects: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2412291. [PMID: 38805228 PMCID: PMC11134212 DOI: 10.1001/jamanetworkopen.2024.12291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/08/2024] [Indexed: 05/29/2024] Open
Abstract
Importance Neurodevelopmental outcomes for children with congenital heart defects (CHD) have improved minimally over the past 20 years. Objectives To assess the feasibility and tolerability of maternal progesterone therapy as well as the magnitude of the effect on neurodevelopment for fetuses with CHD. Design, Setting, and Participants This double-blinded individually randomized parallel-group clinical trial of vaginal natural progesterone therapy vs placebo in participants carrying fetuses with CHD was conducted between July 2014 and November 2021 at a quaternary care children's hospital. Participants included maternal-fetal dyads where the fetus had CHD identified before 28 weeks' gestational age and was likely to need surgery with cardiopulmonary bypass in the neonatal period. Exclusion criteria included a major genetic or extracardiac anomaly other than 22q11 deletion syndrome and known contraindication to progesterone. Statistical analysis was performed June 2022 to April 2024. Intervention Participants were 1:1 block-randomized to vaginal progesterone or placebo by diagnosis: hypoplastic left heart syndrome (HLHS), transposition of the great arteries (TGA), and other CHD diagnoses. Treatment was administered twice daily between 28 and up to 39 weeks' gestational age. Main Outcomes and Measures The primary outcome was the motor score of the Bayley Scales of Infant and Toddler Development-III; secondary outcomes included language and cognitive scales. Exploratory prespecified subgroups included cardiac diagnosis, fetal sex, genetic profile, and maternal fetal environment. Results The 102 enrolled fetuses primarily had HLHS (n = 52 [50.9%]) and TGA (n = 38 [37.3%]), were more frequently male (n = 67 [65.7%]), and without genetic anomalies (n = 61 [59.8%]). The mean motor score differed by 2.5 units (90% CI, -1.9 to 6.9 units; P = .34) for progesterone compared with placebo, a value not statistically different from 0. Exploratory subgroup analyses suggested treatment heterogeneity for the motor score for cardiac diagnosis (P for interaction = .03) and fetal sex (P for interaction = .04), but not genetic profile (P for interaction = .16) or maternal-fetal environment (P for interaction = .70). Conclusions and Relevance In this randomized clinical trial of maternal progesterone therapy, the overall effect was not statistically different from 0. Subgroup analyses suggest heterogeneity of the response to progesterone among CHD diagnosis and fetal sex. Trial Registration ClinicalTrials.gov Identifier: NCT02133573.
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Affiliation(s)
- J. William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Julie S. Moldenhauer
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Erin E. Zullo
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nancy B. Burnham
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Marsha Gerdes
- Department of Psychology, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Judy C. Bernbaum
- Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jo Ann D’Agostino
- Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rebecca L. Linn
- Division of Anatomic Pathology, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brenna Klepczynski
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Isabel Randazzo
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Gabrielle Gionet
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Grace H. Choi
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Antoneta Karaj
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - William W. Russell
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Elaine H. Zackai
- Division of Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mark P. Johnson
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Juliana S. Gebb
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Shelly Soni
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Suzanne E. DeBari
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Anita L. Szwast
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca C. Ahrens-Nicklas
- Division of Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Theodore G. Drivas
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Marin Jacobwitz
- Division of Neurology, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Daniel J. Licht
- Division of Neurology, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Arastoo Vossough
- Division of Radiology, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Susan C. Nicolson
- Division of Cardiac Anesthesia, Department of Anesthesia and Critical Medicine, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Thomas L. Spray
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jack Rychik
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary E. Putt
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Ortinau CM, Newburger JW. Placenta-Heart-Brain Connection in Congenital Heart Disease. J Am Heart Assoc 2024; 13:e033875. [PMID: 38420776 PMCID: PMC10944051 DOI: 10.1161/jaha.124.033875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Cynthia M. Ortinau
- Department of PediatricsWashington University in St. LouisSt. LouisMOUSA
| | - Jane W. Newburger
- Department of CardiologyBoston Children’s HospitalBostonMAUSA
- Department of PediatricsHarvard Medical SchoolBostonMAUSA
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5
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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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7
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Andersen KN, Yao S, White BR, Jacobwitz M, Breimann J, Jahnavi J, Schmidt A, Baker WB, Ko TS, Gaynor JW, Vossough A, Xiao R, Licht DJ, Shih EK. Cerebral microhemorrhages in children with congenital heart disease: Prevalence, risk factors, and impact on neurodevelopmental outcomes. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.05.23299539. [PMID: 38105980 PMCID: PMC10723520 DOI: 10.1101/2023.12.05.23299539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Background Infants with complex congenital heart disease (CHD) require life-saving corrective/palliative heart surgery in the first weeks of life. These infants are at risk for brain injury and poor neurodevelopmental outcomes. Cerebral microhemorrhages (CMH) are frequently seen after neonatal bypass heart surgery, but it remains unknown if CMH are a benign finding or constitute injury. Herein, we investigate the risk factors for developing CMH and their clinical significance. Methods 192 infants with CHD undergoing corrective cardiac surgery with cardiopulmonary bypass (CPB) at a single institution were prospectively evaluated with pre-(n = 183) and/or postoperative (n = 162) brain magnetic resonance imaging (MRI). CMH severity was scored based on total number of microhemorrhages. Antenatal, perioperative, and postoperative candidate risk factors for CMH and neurodevelopmental (ND) outcomes were analyzed. Eighteen-month neurodevelopmental outcomes were assessed using the Bayley-III Scales of Infants and Toddler Development in a subset of patients (n = 82). Linear regression was used to analyze associations between risk factors or ND outcomes and presence/number of CMH. Results The most common CHD subtypes were hypoplastic left heart syndrome (HLHS) (37%) and transposition of the great arteries (TGA) (33%). Forty-two infants (23%) had CMH present on MRI before surgery and 137 infants (85%) post-surgery. No parameters evaluated were significant risk factors for preoperative CMH. In multivariate analysis, cardiopulmonary bypass (CPB) duration (p < 0.0001), use of extracorporeal membrane oxygenation (ECMO) support (p < 0.0005), postoperative seizure(s) (p < 0.03), and lower birth weight (p < 0.03) were associated with new or worsened CMH postoperatively. Higher CMH number was associated with lower scores on motor (p < 0.03) testing at 18 months. Conclusion CMH is a common imaging finding in infants with CHD with increased prevalence and severity after CPB and adverse impact on neurodevelopmental outcomes starting at a young age. Longer duration of CPB and need for postoperative ECMO were the most significant risk factors for developing CMH. However, presence of CMH on preoperative scans indicates non-surgical risk factors that are yet to be identified. Neuroprotective strategies to mitigate risk factors for CMH may improve neurodevelopmental outcomes in this vulnerable population.
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Phillips K, Callaghan B, Rajagopalan V, Akram F, Newburger JW, Kasparian NA. Neuroimaging and Neurodevelopmental Outcomes Among Individuals With Complex Congenital Heart Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:2225-2245. [PMID: 38030353 DOI: 10.1016/j.jacc.2023.09.824] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/13/2023] [Indexed: 12/01/2023]
Abstract
Although neuroimaging advances have deepened our understanding of brain health in individuals with congenital heart disease (CHD), it is less clear how neuroimaging findings relate to neurodevelopmental and mental health outcomes across the lifespan. We systematically synthesized and critically evaluated evidence on associations between neuroimaging and neurodevelopmental, neurocognitive, psychiatric, or behavioral outcomes among individuals with transposition of great arteries or single-ventricle CHD (Protocol CRD42021229617). Six databases were searched and 45 papers from 25 unique studies were identified. Structural brain injury was generally linked to poorer neurodevelopment in infancy. Brain volumes and microstructural and functional brain changes appear linked to neurocognitive outcomes, including deficits in attention, learning, memory, and executive function in children and adolescents. Fetal neuroimaging studies were limited. Four papers investigated psychiatric outcomes; none found associations with neuroimaging. Multicenter, longitudinal studies incorporating functional neuroimaging and mental health outcomes are much-needed to inform early neuroprotective and therapeutic strategies in CHD.
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Affiliation(s)
- Katelyn Phillips
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Bridget Callaghan
- Department of Psychology, University of California Los Angeles, Los Angeles, California, USA
| | - Vidya Rajagopalan
- Department of Radiology, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Farah Akram
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Nadine A Kasparian
- Heart and Mind Wellbeing Center, Heart Institute and the Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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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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10
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Gallagher K, Aruma JFC, Oji-Mmuo CN, Pauli JM, Curtin WM, Goldstein JA, Stuckey HL, Gernand AD. Placental pathology reports: A qualitative study in a US university hospital setting on perceived clinical utility and areas for improvement. PLoS One 2023; 18:e0286294. [PMID: 37289756 PMCID: PMC10249791 DOI: 10.1371/journal.pone.0286294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 05/12/2023] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVE To explore how placental pathology is currently used by clinicians and what placental information would be most useful in the immediate hours after delivery. STUDY DESIGN We used a qualitative study design to conduct in-depth, semi-structured interviews with obstetric and neonatal clinicians who provide delivery or postpartum care at an academic medical center in the US (n = 19). Interviews were transcribed and analyzed using descriptive content analysis. RESULTS Clinicians valued placental pathology information yet cited multiple barriers that prevent the consistent use of pathology. Four main themes were identified. First, the placenta is sent to pathology for consistent reasons, however, the pathology report is accessed by clinicians inconsistently due to key barriers: difficult to find in the electronic medical record, understand, and get quickly. Second, clinicians value placental pathology for explanatory capability as well as for contributions to current and future care, particularly when there is fetal growth restriction, stillbirth, or antibiotic use. Third, a rapid placental exam (specifically including placental weight, infection, infarction, and overall assessment) would be helpful in providing clinical care. Fourth, placental pathology reports that connect clinically relevant findings (similar to radiology) and that are written with plain, standardized language and that non-pathologists can more readily understand are preferred. CONCLUSION Placental pathology is important to clinicians that care for mothers and newborns (particularly those that are critically ill) after birth, yet many problems stand in the way of its usefulness. Hospital administrators, perinatal pathologists, and clinicians should work together to improve access to and contents of reports. Support for new methods to provide quick placenta information is warranted.
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Affiliation(s)
- Kelly Gallagher
- Ross and Carol Nese College of Nursing, The Pennsylvania State University, University Park, Pennsylvania, United States of America
| | - Jane-Frances C. Aruma
- College of Medicine, Pennsylvania State University College of Medicine University Park Campus, Hershey, Pennsylvania, United States of America
| | - Christiana N. Oji-Mmuo
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Penn State University College of Medicine, Hershey, Pennsylvania, United States of America
| | - Jaimey M. Pauli
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Penn State University College of Medicine, Hershey, Pennsylvania, United States of America
| | - William M. Curtin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Penn State University College of Medicine, Hershey, Pennsylvania, United States of America
- Division of Maternal-Fetal Medicine, Department of Pathology and Laboratory Medicine, Penn State University College of Medicine, Hershey, Pennsylvania, United States of America
| | - Jeffery A. Goldstein
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Heather L. Stuckey
- Department of Medicine, Penn State University College of Medicine, Hershey, Pennsylvania, United States of America
| | - Alison D. Gernand
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, Pennsylvania, United States of America
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11
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Desmond A, Imany-Shakibai H, Wong D, Kwan L, Satou G, Sklansky M, Afshar Y. Prenatal Congenital Heart Disease and Placental Phenotypes: Preserved Neonatal Weight Despite Small Placentas. JACC. ADVANCES 2023; 2:100383. [PMID: 38938228 PMCID: PMC11198356 DOI: 10.1016/j.jacadv.2023.100383] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 03/03/2023] [Accepted: 03/31/2023] [Indexed: 06/29/2024]
Abstract
Background Congenital heart disease (CHD) affects 8 in 1,000 live births with significant postnatal implications including growth failure, neurodevelopmental delay, and mortality. The placenta develops concomitantly with the fetal heart. High rates of placental pathology and discordant growth in pregnancies affected by CHD highlight the significance of the fetal-placental-cardiac axis. Objectives This study aimed to characterize the relationship between neonatal birthweight (BW), head circumference, placental weight (PW), and placental pathology in pregnancies affected by CHD. PW:BW provides a surrogate to assess placental efficiency, or nutrient exchange and delivery by the placenta, across CHD phenotypes. Methods Retrospective cohort of 139 live-born singletons with postnatally confirmed CHD with placental pathology. Placental examination, infant BW, head circumference, and CHD categories (septal defects, right-sided defects, left-sided defects, conotruncal anomalies, and others) were included. Chi-square, Fisher's exact, or Kruskall-Wallis tests and multinomial logistic regressions, as appropriate. Results Median birthweight and head circumference percentile was 33 and 35, respectively. Placental pathology was documented in 37% of cases. PW to BW ratios were <10th percentile for 78% and <3rd percentile for 54% of the cohort, with no difference between CHD categories (P = 0.39 and P = 0.56, respectively). Conclusions Infants with CHD have preserved BW and head circumferences in the setting of small placentas and increased prevalence of placental pathology, suggesting placental efficiency. Detection of abnormal placental growth could add prenatal diagnostic value. Placental and neonatal discordant growth may allude to a vascular anomaly predisposing fetuses to developing CHD. Further studies are needed to explore fetal nutrient delivery and utilization efficiency.
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Affiliation(s)
- Angela Desmond
- Division of Neonatology, Department of Pediatrics, University of California-Los Angeles, Los Angeles, California, USA
- David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Helia Imany-Shakibai
- David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Deanna Wong
- David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California-Los Angeles, Los Angeles, California, USA
| | - Lorna Kwan
- Department of Urology, University of California-Los Angeles, Los Angeles, California, USA
| | - Gary Satou
- David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA
- Division of Pediatric Cardiology, Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Mark Sklansky
- David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA
- Division of Pediatric Cardiology, Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Yalda Afshar
- David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California-Los Angeles, Los Angeles, California, USA
- Molecular Biology Institute, University of California-Los Angeles, Los Angeles, California, USA
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12
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Moon-Grady AJ. Why Would a Cardiologist Be Interested in the Placenta? JACC. ADVANCES 2023; 2:100403. [PMID: 38938231 PMCID: PMC11198137 DOI: 10.1016/j.jacadv.2023.100403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Anita J. Moon-Grady
- Division of Cardiology, Department of Pediatrics, University of California-San Francisco, San Francisco, California, USA
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13
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Moray AA, Robertson CMT, Bond GY, Abeysekera JB, Mohammadian P, Dinu IA, Atallah J, Switzer HN, Hornberger LK. Third Trimester Umbilical Arterial Pulsatility Index is Associated with Neurodevelopmental Outcomes at 2-Years in Major Congenital Heart Disease. Pediatr Cardiol 2023; 44:816-825. [PMID: 36905431 DOI: 10.1007/s00246-022-03062-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/21/2022] [Indexed: 03/12/2023]
Abstract
Major congenital heart disease (CHD) is associated with impaired neurodevelopment (ND), partly from prenatal insults. In this study we explore associations between 2nd and 3rd trimester umbilical (UA) and middle cerebral artery (MCA) pulsatility index (PI = systolic-diastolic velocities/mean velocity) in fetuses with major CHD and 2-year ND and growth outcomes. Eligible patients included those with a prenatal diagnosis of CHD from 2007 to 2017 without a genetic syndrome who underwent previously defined cardiac surgeries and 2-year biometric and ND assessments in our program. UA and MCA-PI Z-scores at fetal echocardiography were examined for relationships with 2-year Bayley Scales of Infant and Toddler Development and biometric Z-scores. Data from 147 children was analyzed. Second and 3rd trimester fetal echocardiograms were performed at 22.4 ± 3.7 and 34.7 ± 2.9 weeks (mean ± SD), respectively. Multivariable regression analysis showed an inverse relationship between 3rd trimester UA-PI for all CHD and cognitive - 1.98 (- 3.37, - 0.59), motor - 2.57 (- 4.15, - 0.99), and language - 1.67 (- 3.3, - 0.03) (effect size and 95th confidence interval) ND domains (p < 0.05), with the strongest relationships in the single ventricle and hypoplastic left heart syndrome subgroups. No association was found for 2nd trimester UA-PI or any trimester MCA-PI and ND or between UA or MCA-PI and 2-year growth parameters. Increased 3rd trimester UA-PI, reflecting an altered late gestation fetoplacental circulation, relates to worse 2-year ND in all domains.
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Affiliation(s)
- Amol A Moray
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Pediatric Cardiology, Stollery Children's Hospital 4C2, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Charlene M T Robertson
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, Glenrose Rehabilitation Hospital, University of Alberta, Edmonton, AB, Canada
| | - Gwen Y Bond
- Department of Pediatrics, Glenrose Rehabilitation Hospital, University of Alberta, Edmonton, AB, Canada
| | - Jayani B Abeysekera
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Pediatric Cardiology, Stollery Children's Hospital 4C2, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Parsa Mohammadian
- Institute of Biostatistics and Registry Research, Bradenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Irina A Dinu
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Joseph Atallah
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Pediatric Cardiology, Stollery Children's Hospital 4C2, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Heather N Switzer
- Wascana Children's Program, Saskatchewan Health Authority, Regina, SK, Canada
| | - Lisa K Hornberger
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, AB, Canada. .,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada. .,Women's & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada. .,Pediatric Cardiology, Stollery Children's Hospital 4C2, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada.
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14
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O'Hare CB, Mangin-Heimos KS, Gu H, Edmunds M, Bebbington M, Lee CK, He M, Ortinau CM. Placental delayed villous maturation is associated with fetal congenital heart disease. Am J Obstet Gynecol 2023; 228:231.e1-231.e11. [PMID: 35985515 PMCID: PMC10436378 DOI: 10.1016/j.ajog.2022.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/31/2022] [Accepted: 08/07/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND The placenta is crucial for the overall development and lifelong health of the fetus. Abnormal placental development and function occur in pregnancies with fetal congenital heart disease. However, studies that use standardized diagnostic criteria and incorporate control populations are lacking. This limits the generalizability of current research and the ability to determine the specific placental abnormalities associated with congenital heart disease. OBJECTIVE This study applied consensus statement guidelines (known as the Amsterdam criteria) for placental pathology interpretation to compare the frequency and pattern of abnormalities in pregnancies with fetal congenital heart disease to demographically matched control pregnancies and evaluate for differences in placental abnormalities by cardiac physiology. STUDY DESIGN A single-center retrospective cohort study was conducted from January 2013 to June 2019. Infants with a prenatal diagnosis of moderate-severe congenital heart disease who were born at ≥37 weeks of gestation were included. A control group born at ≥37 weeks of gestation but without fetal congenital heart disease or other major pregnancy complications was matched to the congenital heart disease group on maternal race and ethnicity and infant sex. Using the Amsterdam criteria, placental pathology findings were categorized as delayed villous maturation, maternal vascular malperfusion, fetal vascular malperfusion, and inflammatory lesions. The frequency of placental abnormalities was compared between groups, and logistic regression was performed to evaluate the association of clinical and sociodemographic factors with delayed villous maturation, maternal vascular malperfusion, and fetal vascular malperfusion. RESULTS There were 194 pregnancies with fetal congenital heart disease and 105 controls included, of whom 83% in the congenital heart disease group and 82% in the control group were of non-Hispanic White race and ethnicity. Compared with controls, pregnancies with fetal congenital heart disease had higher rates of delayed villous maturation (6% vs 19%; P<.001) and maternal vascular malperfusion (19% vs 34%; P=.007) but not fetal vascular malperfusion (6% vs 10%; P=.23). Infants with congenital heart disease with 2-ventricle anatomy displayed the highest odds of delayed villous maturation compared with controls (odds ratio, 5.5; 95% confidence interval, 2.2-15.7; P<.01). Maternal vascular malperfusion was 2.2 times higher (P=.02) for infants with 2-ventricle anatomy and 2.9 times higher (P=.02) for infants with single-ventricle physiology with pulmonic obstruction. Within the congenital heart disease group, delayed villous maturation was associated with higher maternal body mass index, polyhydramnios, larger infant birth head circumference, and infant respiratory support in the delivery room, whereas maternal vascular malperfusion was associated with oligohydramnios. In multivariable models adjusting for cardiac diagnosis, associations of delayed villous maturation persisted for infant birth head circumference (odds ratio, 1.2; 95% confidence interval, 1.0-1.5; P=.02) and infant respiratory support in the delivery room (odds ratio, 3.0; 95% confidence interval, 1.3-6.5; P=.007). CONCLUSION Pregnancies with fetal congenital heart disease displayed higher rates of delayed villous maturation and maternal vascular malperfusion than controls, suggesting that placental maldevelopment may relate to maternal factors. Future investigations are needed to determine the association of these abnormalities with postnatal infant outcomes.
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Affiliation(s)
- Clare B O'Hare
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO.
| | - Kathryn S Mangin-Heimos
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Hongjie Gu
- Division of Biostatistics, Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Michael Bebbington
- Department of Women's Health, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Caroline K Lee
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Mai He
- Department of Anatomic and Molecular Pathology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Cynthia M Ortinau
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO
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15
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Workalemahu T, Dalton S, Allshouse A, Carey AZ, Page JM, Blue NR, Thorsten V, Goldenberg RL, Pinar H, Reddy UM, Silver RM. Copy number variants and placental abnormalities in stillborn fetuses: A secondary analysis of the Stillbirth Collaborative Research Network study. BJOG 2022; 129:2125-2131. [PMID: 35876766 PMCID: PMC9643668 DOI: 10.1111/1471-0528.17269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/19/2022] [Accepted: 05/28/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine the association of fetal/placental DNA copy number variants (CNVs) with pathologic placental lesions (PPLs) in pregnancies complicated by stillbirth. DESIGN A secondary analysis of stillbirth cases in the Stillbirth Collaborative Research Network case-control study. SETTING Multicenter, 59 hospitals in five geographical regions in the USA. POPULATION 387 stillbirth cases (2006-2008). METHODS Using standard definitions, PPLs were categorised by type including maternal vascular, fetal vascular, inflammatory and immune/idiopathic lesions. Single-nucleotide polymorphism array detected CNVs of at least 500 kb. CNVs were classified into two groups: normal, defined as no CNV >500 kb or benign CNVs, and abnormal, defined as pathogenic or variants of unknown clinical significance. MAIN OUTCOME MEASURES The proportions of abnormal CNVs and normal CNVs compared between stillbirth cases with and without PPLs using the Wald Chi-square test. RESULTS Of 387 stillborn fetuses, 327 (84.5%) had maternal vascular PPLs and 60 (15.6%) had abnormal CNVs. Maternal vascular PPLs were more common in stillborn fetuses with abnormal CNVs than in those with normal CNVs (81.7% versus 64.2%; P = 0.008). The proportions of fetal vascular, maternal/fetal inflammatory and immune/idiopathic PPLs were similar among stillborn fetuses with abnormal CNVs and those with normal CNVs. Pathogenic CNVs in stillborn fetuses with maternal vascular PPLs spanned several known genes. CONCLUSIONS Abnormal placental/fetal CNVs were associated with maternal vascular PPLs in stillbirth cases. The findings may provide insight into the mechanisms of specific genetic abnormalities associated with placental dysfunction and stillbirth.
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Affiliation(s)
| | | | | | | | - Jessica M. Page
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Salt Lake City, UT
| | | | - Vanessa Thorsten
- Columbia University Medical Center, New York, NY
- RTI International, Research Triangle Park, NC
| | | | - Halit Pinar
- Division of Perinatal Pathology, Brown University School of Medicine, Providence, RI
| | - Uma M. Reddy
- Obstetrics, Gynecology & Reproductive Sciences, Yale University, New Haven, CT
| | - Robert M. Silver
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Salt Lake City, UT
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16
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deRegnier RA. Disparities in Neurodevelopmental Services Between Children with Congenital Heart Disease and Children Born Very Preterm. J Pediatr 2022; 250:9-10. [PMID: 35944712 DOI: 10.1016/j.jpeds.2022.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 07/29/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Raye-Ann deRegnier
- Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
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17
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In infants with congenital heart disease autonomic dysfunction is associated with pre-operative brain injury. Pediatr Res 2022; 91:1723-1729. [PMID: 34963700 PMCID: PMC9237187 DOI: 10.1038/s41390-021-01931-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Brain injury is a serious and common complication of critical congenital heart disease (CHD). Impaired autonomic development (assessed by heart rate variability (HRV)) is associated with brain injury in other high-risk neonatal populations. OBJECTIVE To determine whether impaired early neonatal HRV is associated with pre-operative brain injury in CHD. METHODS In infants with critical CHD, we evaluated HRV during the first 24 h of cardiac ICU (CICU) admission using time-domain (RMS 1, RMS 2, and alpha 1) and frequency-domain metrics (LF, nLF, HF, nHF). Pre-operative brain magnetic resonance imaging (MRI) was scored for injury using an established system. Spearman's correlation coefficient was used to determine the association between HRV and pre-operative brain injury. RESULTS We enrolled 34 infants with median birth gestational age of 38.8 weeks (IQR 38.1-39.1). Median postnatal age at pre-operative brain MRI was 2 days (IQR 1-3 days). Thirteen infants had MRI evidence of brain injury. RMS 1 and RMS 2 were inversely correlated with pre-operative brain injury. CONCLUSIONS Time-domain metrics of autonomic function measured within the first 24 h of admission to the CICU are associated with pre-operative brain injury, and may perform better than frequency-domain metrics under non-stationary conditions such as critical illness. IMPACT Autonomic dysfunction, measured by heart rate variability (HRV), in early transition is associated with pre-operative brain injury in neonates with critical congenital heart disease. These data extend our earlier findings by providing further evidence for (i) autonomic dysfunction in infants with CHD, and (ii) an association between autonomic dysfunction and brain injury in critically ill neonates. These data support the notion that further investigation of HRV as a biomarker for brain injury risk is warranted in infants with critical CHD.
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18
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Sadhwani A, Wypij D, Rofeberg V, Gholipour A, Mittleman M, Rohde J, Velasco-Annis C, Calderon J, Friedman KG, Tworetzky W, Grant PE, Soul JS, Warfield SK, Newburger JW, Ortinau CM, Rollins CK. Fetal Brain Volume Predicts Neurodevelopment in Congenital Heart Disease. Circulation 2022; 145:1108-1119. [PMID: 35143287 PMCID: PMC9007882 DOI: 10.1161/circulationaha.121.056305] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Neurodevelopmental impairment is common in children with congenital heart disease (CHD), but postnatal variables explain only 30% of the variance in outcomes. To explore whether the antecedents for neurodevelopmental disabilities might begin in utero, we analyzed whether fetal brain volume predicted subsequent neurodevelopmental outcome in children with CHD. METHODS Fetuses with isolated CHD and sociodemographically comparable healthy control fetuses underwent fetal brain magnetic resonance imaging and 2-year neurodevelopmental evaluation with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) and the Adaptive Behavior Assessment System, Third Edition (ABAS-3). Hierarchical regression evaluated potential predictors of Bayley-III and ABAS-3 outcomes in the CHD group, including fetal total brain volume adjusted for gestational age and sex, sociodemographic characteristics, birth measures, and medical history. RESULTS The CHD group (n=52) had lower Bayley-III cognitive, language, and motor scores than the control group (n=26), but fetal brain volumes were similar. Within the CHD group, larger fetal total brain volume correlated with higher Bayley-III cognitive, language, and motor scores and ABAS-3 adaptive functioning scores (r=0.32-0.47; all P<0.05), but this was not noted in the control group. Fetal brain volume predicted 10% to 21% of the variance in neurodevelopmental outcome measures in univariate analyses. Multivariable models that also included social class and postnatal factors explained 18% to 45% of the variance in outcome, depending on developmental domain. Moreover, in final multivariable models, fetal brain volume was the most consistent predictor of neurodevelopmental outcome across domains. CONCLUSIONS Small fetal brain volume is a strong independent predictor of 2-year neurodevelopmental outcomes and may be an important imaging biomarker of future neurodevelopmental risk in CHD. Future studies are needed to support this hypothesis. Our findings support inclusion of fetal brain volume in risk stratification models and as a possible outcome in fetal neuroprotective intervention studies.
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Affiliation(s)
- Anjali Sadhwani
- Department of Psychiatry, Boston Children’s Hospital, Boston, MA
- Department of Psychiatry, Harvard Medical School, Boston, MA
| | - David Wypij
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
| | - Ali Gholipour
- Department of Radiology, Boston Children’s Hospital, Boston, MA
- Department of Radiology, Harvard Medical School, Boston, MA
| | | | - Julia Rohde
- Department of Neurology, Boston Children’s Hospital, Boston, MA
| | | | - Johanna Calderon
- Department of Psychiatry, Boston Children’s Hospital, Boston, MA
- Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Kevin G. Friedman
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - P. Ellen Grant
- Department of Radiology, Boston Children’s Hospital, Boston, MA
- Department of Radiology, Harvard Medical School, Boston, MA
| | - Janet S. Soul
- Department of Neurology, Boston Children’s Hospital, Boston, MA
- Department of Neurology, Harvard Medical School, Boston, MA
| | | | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Caitlin K. Rollins
- Department of Neurology, Boston Children’s Hospital, Boston, MA
- Department of Neurology, Harvard Medical School, Boston, MA
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19
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Parekh SA, Cox SM, Barkovich AJ, Chau V, Steurer MA, Xu D, Miller SP, McQuillen PS, Peyvandi S. The Effect of Size and Asymmetry at Birth on Brain Injury and Neurodevelopmental Outcomes in Congenital Heart Disease. Pediatr Cardiol 2022; 43:868-877. [PMID: 34853878 PMCID: PMC9005428 DOI: 10.1007/s00246-021-02798-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 11/24/2021] [Indexed: 11/10/2022]
Abstract
Poor and asymmetric fetal growth have been associated with neonatal brain injury (BI) and worse neurodevelopmental outcomes (NDO) in the growth-restricted population due to placental insufficiency. We tested the hypothesis that postnatal markers of fetal growth (birthweight (BW), head circumference (HC), and head to body symmetry) are associated with preoperative white matter injury (WMI) and NDO in infants with single ventricle physiology (SVP) and d-transposition of great arteries (TGA). 173 term newborns (106 TGA; 67 SVP) at two sites had pre-operative brain MRI to assess for WMI and measures of microstructural brain development. NDO was assessed at 30 months with the Bayley Scale of Infant Development-II (n = 69). We tested the association between growth parameters at birth with the primary outcome of WMI on the pre-operative brain MRI. Secondary outcomes included measures of NDO. Newborns with TGA were more likely to have growth asymmetry with smaller heads relative to weight while SVP newborns were symmetrically small. There was no association between BW, HC or asymmetry and WMI on preoperative brain MRI or with measures of microstructural brain development. Similarly, growth parameters at birth were not associated with NDO at 30 months. In a multivariable model only cardiac lesion and site were associated with NDO. Unlike other high-risk infant populations, postnatal markers of fetal growth including head to body asymmetry that is common in TGA is not associated with brain injury or NDO. Lesion type appears to play a more important role in NDO in CHD.
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Affiliation(s)
- Shalin A Parekh
- Division of Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, Mission Hall Box 0544, 550 16th Street, 5th Floor, San Francisco, CA, 94158, USA
| | - Stephany M Cox
- Division of Developmental Pediatrics and Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, USA
| | - A James Barkovich
- Department of Radiology, University of California, San Francisco, USA
| | - Vann Chau
- Department of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Martina A Steurer
- Division of Critical Care, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, USA
| | - Duan Xu
- Department of Radiology, University of California, San Francisco, USA
| | - Steven P Miller
- Department of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Patrick S McQuillen
- Division of Critical Care, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, USA
| | - Shabnam Peyvandi
- Division of Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, Mission Hall Box 0544, 550 16th Street, 5th Floor, San Francisco, CA, 94158, USA.
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20
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Aliasi M, Snoep MC, van Geloven N, Haak MC. Birthweight and isolated congenital heart defects - A systematic review and meta-analysis. BJOG 2022; 129:1805-1816. [PMID: 35352871 PMCID: PMC9542320 DOI: 10.1111/1471-0528.17164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/28/2021] [Accepted: 01/22/2022] [Indexed: 11/30/2022]
Abstract
Background Birthweight (BW) is an important prognostic factor in newborns with congenital heart defects (CHD). Objectives To give an overview of the literature on BW z‐score in children with isolated CHD. Search strategy A systematic search was performed on isolated CHD and BW in PubMed, Embase, Web of Science, COCHRANE Library and Emcare. Selection criteria Neonates with isolated CHD were included if a BW percentile, BW z‐score or % small‐or‐gestational age (SGA) was reported. Data collection and analysis BW z‐score and percentage SGA were pooled with random‐effect meta‐analysis. Quality and risk of bias were assessed using the modified Newcastle Ottawa Scale. Main results Twenty‐three articles (27 893 cases) were included. BW z‐scores were retrieved from 11 articles, resulting in a pooled z‐score of −0.20 (95% CI −0.50 to 0.11). The overall pooled prevalence of SGA <10th percentile was 16.0% (95% CI 11.4–20.5; 14 studies). Subgroup analysis of major CHD showed similar results (BW z‐score −0.23 and percentage SGA 16.2%). Conclusions Overall BW in isolated CHD is within range of normality but impaired, with a 1.6‐fold higher risk of SGA, irrespective of the type of CHD (major CHD vs all CHD combined). Our findings underline the association between CHD and BW. The use of BW z‐scores provides insight into growth of all fetuses with CHD. Tweetable abstract Infants with a congenital heart defect (CHD) have a lower birthweight z‐score and a higher incidence of small‐for‐gestational age (<10th percentile). This was encountered both in the major CHD‐group as well as in all‐CHD combined group analysis. Future research on the association between birthweight and CHD should include all types of CHDs (including mild cardiac defects) and placental‐related disease, such as pre‐eclampsia. We advocate the use of international standardised fetal growth and birthweight charts in CHD research. Infants with a congenital heart defect (CHD) have a lower birthweight z‐score and a higher incidence of small‐for‐gestational age (<10th percentile). This was encountered both in the major CHD‐group as well as in all‐CHD combined group analysis. Future research on the association between birthweight and CHD should include all types of CHDs (including mild cardiac defects) and placental‐related disease, such as pre‐eclampsia. We advocate the use of international standardised fetal growth and birthweight charts in CHD research.
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Affiliation(s)
- Moska Aliasi
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Maartje C Snoep
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Nan van Geloven
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - Monique C Haak
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Centre, Leiden, The Netherlands
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21
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Leon RL, Kalvacherla V, Andrews MM, Thomas JM, Mir IN, Chalak LF. Placental pathologic lesions associated with stroke in term neonates. Front Endocrinol (Lausanne) 2022; 13:920680. [PMID: 36157451 PMCID: PMC9492924 DOI: 10.3389/fendo.2022.920680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/17/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To determine the birth prevalence of perinatal stroke in term born infants at our high-volume delivery center and assess the frequency of both gross and histologic placental pathologies associated with perinatal stroke using the Amsterdam Placental Workshop Group Consensus Statement guidelines and definitions. STUDY DESIGN A single-center retrospective cohort study spanning 2010-2020. RESULTS There were 129,759 live births at Parkland Hospital during the study period and a total of 18 term born infants leading to a birth prevalence of 1 in 6,829 infants. Perinatal risk factors were found in all but one patient, and 74% presented with seizures. Pathologic placental examination was available in 56% of the cohort and only one patient had normal placental examination. Acute histologic chorioamnionitis was described in five placentas (50%) and an additional two had isolated umbilical and/or chorionic plate vasculitis with or without funisitis compared to a rate of 28% with acute inflammation in a Control group. Chronic inflammation in the form of villitis of unknown etiology was described in three of the acutely inflamed placentas and was high-grade in each of those while none of the placentas from our Control group showed evidence of any chronic lesion. CONCLUSION Both acute and chronic placental inflammation are common in perinatal stroke; placental examination should be considered an essential component to the diagnostic workup.
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Affiliation(s)
- Rachel L. Leon
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
- *Correspondence: Rachel L. Leon,
| | | | | | - Jennifer M. Thomas
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Imran N. Mir
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lina F. Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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22
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Snoep MC, Aliasi M, van der Meeren LE, Jongbloed MRM, DeRuiter MC, Haak MC. Placenta morphology and biomarkers in pregnancies with congenital heart disease - A systematic review. Placenta 2021; 112:189-196. [PMID: 34388551 DOI: 10.1016/j.placenta.2021.07.297] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/16/2021] [Accepted: 07/27/2021] [Indexed: 01/29/2023]
Abstract
Impaired placentation is an important contributing factor to intra-uterine growth restriction and pre-eclampsia in fetuses with congenital heart defects (CHD). These pregnancy complications occur more frequently in pregnancies with fetal CHD. One of the most important factors influencing the life of children with CHD is neurodevelopmental delay, which seems to start already in utero. Delayed neurodevelopment in utero may be correlated or even (partly) explained by impaired placentation in CHD cases. This systematic review provides an overview of published literature on placental development in pregnancies with fetal CHD. A systematic search was performed and the Newcastle-Ottawa scale was used to access data quality. Primary outcomes were placenta size and weight, vascular and villous architecture, immunohistochemistry, angiogenic biomarkers and/or placental gene expression. A total of 1161 articles were reviewed and 21 studies were included. Studies including CHD with a genetic disorder or syndrome and/or multiple pregnancies were excluded. Lower placental weight and elevated rates of abnormal umbilical cord insertions were found in CHD. Cases with CHD more frequently showed microscopic placental abnormalities (i.e. abnormal villous maturation and increased maternal vascular malperfusion lesions), reduced levels of angiogenic biomarkers and increased levels of anti-angiogenic biomarkers in maternal serum and umbilical cord blood. Altered gene expression involved in placental development and fetal growth were found in maternal serum and CHD placentas. In conclusion, abnormal placentation is found in CHD. More extensive studies are needed to elucidate the contribution of impaired placentation to delayed neurodevelopment in CHD cases.
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Affiliation(s)
- Maartje C Snoep
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, the Netherlands.
| | - Moska Aliasi
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Monique R M Jongbloed
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marco C DeRuiter
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands
| | - Monique C Haak
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, the Netherlands
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23
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Hogan WJ, Moon-Grady AJ, Zhao Y, Cresalia NM, Nawaytou H, Quezada E, Brook M, McQuillen P, Peyvandi S. Fetal cerebrovascular response to maternal hyperoxygenation in congenital heart disease: effect of cardiac physiology. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:769-775. [PMID: 32202689 PMCID: PMC7673795 DOI: 10.1002/uog.22024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/23/2020] [Accepted: 03/13/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Fetal cerebrovascular resistance is influenced by several factors in the setting of intact autoregulation to allow for normal cerebral blood flow and oxygenation. Maternal hyperoxygenation (MH) allows for acute alterations in fetal physiology and can be a tool to test cerebrovascular reactivity in late-gestation fetuses. In this study, we utilized MH to evaluate cerebrovascular reactivity in fetuses with specific congenital heart disease (CHD). METHODS This was a cross-sectional study of fetuses with complex CHD compared to controls without CHD. CHD cases were grouped according to physiology into: left-sided obstructive lesion (LSOL), right-sided obstructive lesion (RSOL) or dextro-transposition of the great arteries (d-TGA). Subjects underwent MH testing during the third-trimester fetal echocardiogram. The pulsatility index (PI) was calculated for the fetal middle cerebral artery (MCA), umbilical artery (UA) and branch pulmonary artery (PA). The change in PI from baseline to during MH was compared between each CHD group and controls. RESULTS Sixty pregnant women were enrolled (CHD, n = 43; control, n = 17). In the CHD group, there were 27 fetuses with LSOL, seven with RSOL and nine with d-TGA. Mean gestational age was 33.9 (95% CI, 33.6-34.2) weeks. At baseline, MCA-PI Z-score was lowest in the LSOL group (-1.8 (95% CI, -2.4 to -1.2)) compared with the control group (-0.8 (95% CI, -1.3 to -0.3)) (P = 0.01). In response to MH, MCA-PI Z-score increased significantly in the control and d-TGA groups but did not change significantly in the LSOL and RSOL groups. The change in MCA-PI Z-score was significantly higher in the control group than in the LSOL group (0.9 (95% CI, 0.42-1.4) vs 0.12 (95% CI, -0.21 to 0.45); P = 0.03). This difference was more pronounced in the LSOL subgroup with retrograde aortic arch flow. Branch PA-PI decreased significantly in response to MH in all groups, with no difference in the change from baseline to MH between the groups, while UA-PI was unchanged during MH compared with at baseline. CONCLUSIONS The fetal cerebrovascular response to MH varies based on the underlying CHD diagnosis, suggesting that cardiovascular physiology may influence the autoregulatory capacity of the fetal brain. Further studies are needed to determine the clinical implications of these findings on long-term neurodevelopment in these at-risk children. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- W J Hogan
- Division of Pediatric Cardiology, Department of Pediatrics, The University of California San Francisco, San Francisco, CA, USA
| | - A J Moon-Grady
- Division of Pediatric Cardiology, Department of Pediatrics, The University of California San Francisco, San Francisco, CA, USA
| | - Y Zhao
- Division of Pediatric Cardiology, Department of Pediatrics, The University of California San Francisco, San Francisco, CA, USA
| | - N M Cresalia
- Division of Pediatric Cardiology, Department of Pediatrics, The University of California San Francisco, San Francisco, CA, USA
| | - H Nawaytou
- Division of Pediatric Cardiology, Department of Pediatrics, The University of California San Francisco, San Francisco, CA, USA
| | - E Quezada
- Division of Pediatric Cardiology, Department of Pediatrics, The University of California San Francisco, San Francisco, CA, USA
| | - M Brook
- Division of Pediatric Cardiology, Department of Pediatrics, The University of California San Francisco, San Francisco, CA, USA
| | - P McQuillen
- Division of Critical Care, Department of Pediatrics, The University of California San Francisco, San Francisco, CA, USA
| | - S Peyvandi
- Division of Pediatric Cardiology, Department of Pediatrics, The University of California San Francisco, San Francisco, CA, USA
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24
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Abstract
Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.
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25
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Steinweg JK, Hui GTY, Pietsch M, Ho A, van Poppel MP, Lloyd D, Colford K, Simpson JM, Razavi R, Pushparajah K, Rutherford M, Hutter J. T2* placental MRI in pregnancies complicated with fetal congenital heart disease. Placenta 2021; 108:23-31. [PMID: 33798991 DOI: 10.1016/j.placenta.2021.02.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/05/2021] [Accepted: 02/25/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Congenital heart disease (CHD) is one of the most important and common group of congenital malformations in humans. Concurrent development and close functional links between the fetal heart and placenta emphasise the importance of understanding placental function and its influence in pregnancy outcomes. The aim of this study was to evaluate placental oxygenation by relaxometry (T2*) to assess differences in placental phenotype and function in CHD. METHODS In this prospective cross-sectional observational study, 69 women with a fetus affected with CHD and 37 controls, whole placental T2* was acquired using a 1.5-Tesla MRI scanner. Gaussian Process Regression was used to assess differences in placental phenotype in CHD cohorts compared to our controls. RESULTS Placental T2* maps demonstrated significant differences in CHD compared to controls at equivalent gestational age. Mean T2* values over the entire placental volume were lowest compared to predicted normal in right sided obstructive lesions (RSOL) (Z-Score 2.30). This cohort also showed highest lacunarity indices (Z-score -1.7), as a marker of lobule size. Distribution patterns of T2* values over the entire placental volume were positively skewed in RSOL (Z-score -4.69) and suspected, not confirmed coarctation of the aorta (CoA-) (Z-score -3.83). Deviations were also reflected in positive kurtosis in RSOL (Z-score -3.47) and CoA- (Z-score -2.86). CONCLUSION Placental structure and function appear to deviate from normal development in pregnancies with fetal CHD. Specific patterns of altered placental function assessed by T2* deliver crucial complementary information to antenatal assessments in the presence of fetal CHD.
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Affiliation(s)
- Johannes K Steinweg
- Department of Cardiovascular Imaging, School of Biomedical Engineering & Imaging Science, King's College London, London, United Kingdom.
| | - Grace Tin Yan Hui
- Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Maximilian Pietsch
- Centre for the Developing Brain, King's College London, London, United Kingdom; Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Science, King's College London, London, United Kingdom
| | - Alison Ho
- Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Milou Pm van Poppel
- Department of Cardiovascular Imaging, School of Biomedical Engineering & Imaging Science, King's College London, London, United Kingdom
| | - David Lloyd
- Department of Cardiovascular Imaging, School of Biomedical Engineering & Imaging Science, King's College London, London, United Kingdom; Department of Congenital Heart Disease, Evelina Children's Hospital, London, United Kingdom
| | - Kathleen Colford
- Centre for the Developing Brain, King's College London, London, United Kingdom
| | - John M Simpson
- Department of Cardiovascular Imaging, School of Biomedical Engineering & Imaging Science, King's College London, London, United Kingdom; Department of Congenital Heart Disease, Evelina Children's Hospital, London, United Kingdom
| | - Reza Razavi
- Department of Cardiovascular Imaging, School of Biomedical Engineering & Imaging Science, King's College London, London, United Kingdom; Department of Congenital Heart Disease, Evelina Children's Hospital, London, United Kingdom
| | - Kuberan Pushparajah
- Department of Cardiovascular Imaging, School of Biomedical Engineering & Imaging Science, King's College London, London, United Kingdom; Department of Congenital Heart Disease, Evelina Children's Hospital, London, United Kingdom
| | - Mary Rutherford
- Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Jana Hutter
- Centre for the Developing Brain, King's College London, London, United Kingdom; Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Science, King's College London, London, United Kingdom
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26
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Placental origins of neonatal diseases: toward a precision medicine approach. Pediatr Res 2021; 89:377-383. [PMID: 33288874 DOI: 10.1038/s41390-020-01293-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/05/2020] [Accepted: 10/20/2020] [Indexed: 01/30/2023]
Abstract
The placenta is the single most reliable source for precise information on intrauterine environment, as well as maternal and fetal health. It mediates the physiology of two distinct yet highly interconnected individuals. The pathology that develops in the placenta, and the adaptations the placenta undergoes to mitigate this pathology, may influence the later life health of the mother and baby. Pathological placental examination provides a unique opportunity to explore and understand the intrauterine environment, as well as providing a record of events that may be associated with adverse pregnancy outcomes. A number of placental lesions have been described in association with various neonatal morbidities. The purpose of this review is to summarize the evidence for the association of placental pathologic lesions with neurodevelopmental outcomes infants with specific neonatal morbidities, including (1) neonatal encephalopathy, (2) bronchopulmonary dysplasia, (3) congenital heart diseases, and (4) autism spectrum disorders. For each of these disease processes, we will also propose specific research priorities in future studies. We conclude with a hospital-specific protocol for triaging which placentas should receive histological evaluation as a fundamental first step for the field of neuroplacentology to guide precision-based therapeutic approaches in the affected newborns. IMPACT: The purpose of this review is to summarize the evidence for placental origins of neonatal diseases. We propose specific research priorities in the field of neuroplacentology in future studies. We also present a targeted hospital-based approach for triaging which placentas should receive histological evaluation.
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27
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Scher MS. "The First Thousand Days" Define a Fetal/Neonatal Neurology Program. Front Pediatr 2021; 9:683138. [PMID: 34408995 PMCID: PMC8365757 DOI: 10.3389/fped.2021.683138] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/27/2021] [Indexed: 01/11/2023] Open
Abstract
Gene-environment interactions begin at conception to influence maternal/placental/fetal triads, neonates, and children with short- and long-term effects on brain development. Life-long developmental neuroplasticity more likely results during critical/sensitive periods of brain maturation over these first 1,000 days. A fetal/neonatal program (FNNP) applying this perspective better identifies trimester-specific mechanisms affecting the maternal/placental/fetal (MPF) triad, expressed as brain malformations and destructive lesions. Maladaptive MPF triad interactions impair progenitor neuronal/glial populations within transient embryonic/fetal brain structures by processes such as maternal immune activation. Destructive fetal brain lesions later in pregnancy result from ischemic placental syndromes associated with the great obstetrical syndromes. Trimester-specific MPF triad diseases may negatively impact labor and delivery outcomes. Neonatal neurocritical care addresses the symptomatic minority who express the great neonatal neurological syndromes: encephalopathy, seizures, stroke, and encephalopathy of prematurity. The asymptomatic majority present with neurologic disorders before 2 years of age without prior detection. The developmental principle of ontogenetic adaptation helps guide the diagnostic process during the first 1,000 days to identify more phenotypes using systems-biology analyses. This strategy will foster innovative interdisciplinary diagnostic/therapeutic pathways, educational curricula, and research agenda among multiple FNNP. Effective early-life diagnostic/therapeutic programs will help reduce neurologic disease burden across the lifespan and successive generations.
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Affiliation(s)
- Mark S Scher
- Division of Pediatric Neurology, Department of Pediatrics, Fetal/Neonatal Neurology Program, Emeritus Scholar Tenured Full Professor in Pediatrics and Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, United States
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28
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Peyvandi S, Xu D, Wang Y, Hogan W, Moon-Grady A, Barkovich AJ, Glenn O, McQuillen P, Liu J. Fetal Cerebral Oxygenation Is Impaired in Congenital Heart Disease and Shows Variable Response to Maternal Hyperoxia. J Am Heart Assoc 2020; 10:e018777. [PMID: 33345557 PMCID: PMC7955474 DOI: 10.1161/jaha.120.018777] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Impairments in fetal oxygen delivery have been implicated in brain dysmaturation seen in congenital heart disease (CHD), suggesting a role for in utero transplacental oxygen therapy. We applied a novel imaging tool to quantify fetal cerebral oxygenation by measuring T2* decay. We compared T2* in fetuses with CHD with controls with a focus on cardiovascular physiologies (transposition or left‐sided obstruction) and described the effect of brief administration of maternal hyperoxia on T2* decay. Methods and Results This is a prospective study performed on pregnant mothers with a prenatal diagnosis of CHD compared with controls in the third trimester. Participants underwent a fetal brain magnetic resonance imaging scan including a T2* sequence before and after maternal hyperoxia. Comparisons were made between control and CHD fetuses including subgroup analyses by cardiac physiology. Forty‐four mothers (CHD=24, control=20) participated. Fetuses with CHD had lower total brain volume (238.2 mm3, 95% CI, 224.6–251.9) compared with controls (262.4 mm3, 95% CI, 245.0–279.8, P=0.04). T2* decay time was faster in CHD compared with controls (beta=−14.4, 95% CI, −23.3 to −5.6, P=0.002). The magnitude of change in T2* with maternal hyperoxia was higher in fetuses with transposition compared with controls (increase of 8.4 ms, 95% CI, 0.5–14.3, P=0.01), though between‐subject variability was noted. Conclusions Cerebral tissue oxygenation is lower in fetuses with complex CHD. There was variability in the response to maternal hyperoxia by CHD subgroup that can be tested in future larger studies. Cardiovascular physiology is critical when designing neuroprotective clinical trials in the fetus with CHD.
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Affiliation(s)
- Shabnam Peyvandi
- Department of Pediatrics Division of Cardiology University of California San Francisco San Francisco CA.,Department of Epidemiology and Biostatistics University of California San Francisco San Francisco CA
| | - Duan Xu
- Department of Radiology and Biomedical Imaging University of California San Francisco San Francisco CA
| | - Yan Wang
- Department of Radiology and Biomedical Imaging University of California San Francisco San Francisco CA
| | - Whitnee Hogan
- Department of Pediatrics Division of Cardiology University of California San Francisco San Francisco CA
| | - Anita Moon-Grady
- Department of Pediatrics Division of Cardiology University of California San Francisco San Francisco CA
| | - A James Barkovich
- Department of Radiology and Biomedical Imaging University of California San Francisco San Francisco CA
| | - Orit Glenn
- Department of Radiology and Biomedical Imaging University of California San Francisco San Francisco CA
| | - Patrick McQuillen
- Department of Pediatrics, Division of Critical Care University of California San Francisco San Francisco CA
| | - Jing Liu
- Department of Radiology and Biomedical Imaging University of California San Francisco San Francisco CA
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29
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Ng IHX, Bonthrone AF, Kelly CJ, Cordero-Grande L, Hughes EJ, Price AN, Hutter J, Victor S, Schuh A, Rueckert D, Hajnal JV, Simpson J, Edwards AD, Rutherford MA, Batalle D, Counsell SJ. Investigating altered brain development in infants with congenital heart disease using tensor-based morphometry. Sci Rep 2020; 10:14909. [PMID: 32913193 PMCID: PMC7483731 DOI: 10.1038/s41598-020-72009-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022] Open
Abstract
Magnetic resonance (MR) imaging studies have demonstrated reduced global and regional brain volumes in infants with congenital heart disease (CHD). This study aimed to provide a more detailed evaluation of altered structural brain development in newborn infants with CHD compared to healthy controls using tensor-based morphometry (TBM). We compared brain development in 64 infants with CHD to 192 age- and sex-matched healthy controls. T2-weighted MR images obtained prior to surgery were analysed to compare voxel-wise differences in structure across the whole brain between groups. Cerebral oxygen delivery (CDO2) was measured in infants with CHD (n = 49) using phase contrast MR imaging and the relationship between CDO2 and voxel-wise brain structure was assessed using TBM. After correcting for global scaling differences, clusters of significant volume reduction in infants with CHD were demonstrated bilaterally within the basal ganglia, thalami, corpus callosum, occipital, temporal, parietal and frontal lobes, and right hippocampus (p < 0.025 after family-wise error correction). Clusters of significant volume expansion in infants with CHD were identified in cerebrospinal fluid spaces (p < 0.025). After correcting for global brain size, there was no significant association between voxel-wise brain structure and CDO2. This study localizes abnormal brain development in infants with CHD, identifying areas of particular vulnerability.
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Affiliation(s)
- Isabel H X Ng
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK
| | - Alexandra F Bonthrone
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK
| | - Christopher J Kelly
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK
| | - Lucilio Cordero-Grande
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK.,Biomedical Image Technologies, ETSI Telecomunicación, Universidad Politécnica de Madrid and CIBER-BBN, Madrid, Spain
| | - Emer J Hughes
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK
| | - Anthony N Price
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK
| | - Jana Hutter
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK
| | - Suresh Victor
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK
| | - Andreas Schuh
- Biomedical Image Analysis Group, Department of Computing, Imperial College London, London, UK
| | - Daniel Rueckert
- Biomedical Image Analysis Group, Department of Computing, Imperial College London, London, UK
| | - Joseph V Hajnal
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK.,Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - John Simpson
- Paediatric Cardiology Department, Evelina London Children's Hospital, St Thomas' Hospital, London, UK
| | - A David Edwards
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK
| | - Mary A Rutherford
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK
| | - Dafnis Batalle
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK.,Department of Forensic and Neurodevelopmental Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Serena J Counsell
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, SE1 7EH, UK.
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Link D, Many A, Ben Sira L, Tarrasch R, Bak S, Kidron D, Gordon Z, Yagel S, Harel S, Ben Bashat D. Placental vascular tree characterization based on ex-vivo MRI with a potential application for placental insufficiency assessment. Placenta 2020; 101:252-260. [PMID: 32933767 DOI: 10.1016/j.placenta.2020.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Understanding regarding the whole placental vascular network structure is limited. Our aim was to quantitatively characterize the human placental vascular tree ex-vivo using high-resolution MRI. METHODS 34 normal placentas were rinsed and injected with a solution of gelatin and contrast agent through the umbilical vessels. A sample of six placentas taken from pregnancies with intrauterine-growth-restriction (IUGR) was used to demonstrate the potential application to cases with placental insufficiency. Structural ex-vivo MR scans of the placenta were performed using high resolution T1 weighted images. A semi-automatic method was developed to segment and characterize the placental vascular architecture: placental volume and cord insertion location; number of bifurcations, generations and vessels diameters. RESULTS Different vascular patterns were found in placentas with central versus marginal cord-insertion. Based on the placental volume and number of bifurcations we were able to predict birth weight. Furthermore, preliminary results on IUGR sample demonstrated the potential of this method to differentiate between small newborns with suspected IUGR from small normal newborns who reached their full growth potential. Results obtained using the automatic method were validated against manual values demonstrating no significant differences or bias. Histopathology supported the imaging findings. DISCUSSION This is the first study to quantitatively characterize the human placental vascular architecture using high resolution ex-vivo MRI. Different patterns of vascular architecture may be related to different functioning of the placenta and affect fetal development. This method is simple, relatively fast, provides detailed information of the placental vascular architecture, and may have important clinical applications.
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Affiliation(s)
- Daphna Link
- Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Many
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Liat Ben Sira
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Division of Pediatric Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ricardo Tarrasch
- Jaime and Joan Constantiner School of Education, Tel Aviv University, Tel Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Stella Bak
- Division of Pathology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Debora Kidron
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Pathology, Meir Medical Center, Kfar Saba, Israel
| | - Zoya Gordon
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Medical Engineering Afeka, Tel Aviv Academic College of Engineering, Tel Aviv, Israel
| | - Simcha Yagel
- Obstretrics and Gynecology Division, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Shaul Harel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Pediatric Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Dafna Ben Bashat
- Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel.
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Giorgione V, Fesslova V, Boveri S, Candiani M, Khalil A, Cavoretto P. Adverse perinatal outcome and placental abnormalities in pregnancies with major fetal congenital heart defects: A retrospective case-control study. Prenat Diagn 2020; 40:1390-1397. [PMID: 32557693 DOI: 10.1002/pd.5770] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/09/2020] [Accepted: 06/16/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The placental development has been shown to be compromised in pregnancies affected by fetal congenital heart defects (CHD). This study aimed to investigate the frequency of complications related to utero-placental insufficiency in pregnancies with and without major CHD. METHOD This retrospective case-control study was conducted at a Fetal Echocardiography Center in Milan. The following outcomes were compared between the two groups: preeclampsia (PE), small for gestational age (SGA), placental disorders and preterm birth (PTB). The logistic regression analysis was adjusted for maternal age, parity, co-morbidities and mode of conception. RESULTS The CHD group (n = 480) showed significantly increased incidence of PE (2.9% vs 0.9%; aOR, 6.50; 95% CI, 1.39-30.41; P = .017) as compared to the control group (n = 456). Placental disorders occurred more frequently in the CHD than in controls, but the increased risk showed only a borderline significance (4.5% vs 3.3%; aOR, 2.56; 95% CI, 0.99-1.02; P = .046). There was a significantly higher risk of SGA in CHD than in controls (8.7% vs 3.9%; aOR, 3.37; 95% CI, 1.51-7.51; P = .003). PTB occurred in 65/477 (13.6%) cases and in 39/447 (8.7%) controls (P = .022) (aOR, 2.17; 95% CI, 1.24-3.81; P = .007). CONCLUSION Major CHD are significantly associated with the risk of PE, SGA and PTB.
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Affiliation(s)
- Veronica Giorgione
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy.,Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Vlasta Fesslova
- Center of Fetal Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Sara Boveri
- Scientific Directorate, IRCCS Policlinico San Donato, Milan, Italy
| | - Massimo Candiani
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Asma Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Paolo Cavoretto
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
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Abeysekera JB, Gyenes DL, Atallah J, Robertson CMT, Bond GY, Rebeyka IM, Moez EK, Dinu IA, Switzer HN, Hornberger LK. Fetal Umbilical Arterial Pulsatility Correlates With 2-Year Growth and Neurodevelopmental Outcomes in Congenital Heart Disease. Can J Cardiol 2020; 37:425-432. [PMID: 32653583 DOI: 10.1016/j.cjca.2020.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Children with congenital heart disease (CHD) are at risk of adverse long-term neurodevelopmental outcomes, believed to be, in part, secondary to prenatal insults. Placental pathology and altered fetal middle cerebral arterial (MCA) flow suggestive of brain sparing have been documented in fetal CHD. In the present study we investigated the relationship between MCA and umbilical arterial (UA) flow patterns in fetal transposition of the great arteries (d-TGA) and hypoplastic left heart syndrome (HLHS) and growth and 2-year neurodevelopmental outcomes. METHODS We included children with d-TGA and HLHS who had third-trimester fetal echocardiograms between 2004 and 2014, at which time umbilical artery (UA) and MCA pulsatility indices (PIs) were measured, and who underwent 2-year growth and neurodevelopmental assessments. RESULTS We identified 24 children with d-TGA and 36 with HLHS. Mean age at fetal echocardiography was 33.8 ± 3.5 weeks. At 2-year follow-up, head circumference z score (standard deviation [SD]) was -0.09 (1.07) and 0.17 (1.7) for the d-TGA and HLHS groups, respectively. Bayley III mean (SD) cognitive, language, and motor scores were 97.7 (10.8), 94.7 (13.4), and 98.6 (8.6) for the d-TGA group and 90.3 (13.9), 87.2 (17.5), and 85.3 (16.2) for the HLHS group. On multivariate linear regression analysis, UA-PI was associated (effect sizes [95% CI]) with length (-1.45 [-2.7, -0.17], P = 0.027), weight (-1.46 [-2.6 to -0.30], P = 0.015) and cognitive scores (-14.86 [-29.95 to 0.23], P = 0.05) at 2 years of age. MCA PI showed no statistically significant correlation. CONCLUSIONS In fetal d-TGA and HLHS, a higher UA-PI in the third trimester, suggestive of placental insufficiency-but not MCA-PI-is associated with worse 2-year growth and neurodevelopment.
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Affiliation(s)
- Jayani B Abeysekera
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Dora L Gyenes
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph Atallah
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Charlene M T Robertson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Glenrose Rehabilitation Hospital, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Gwen Y Bond
- Glenrose Rehabilitation Hospital, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ivan M Rebeyka
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | | | - Irina A Dinu
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | | | - Lisa K Hornberger
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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Kuhn V, Yerebakan C. Brain and Congenital Heart Disease-Together in Good Times and Bad. Semin Thorac Cardiovasc Surg 2020; 32:945-946. [PMID: 32610195 DOI: 10.1053/j.semtcvs.2020.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Viktoria Kuhn
- Department of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Can Yerebakan
- Department of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.
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Ortinau CM, Shimony JS. The Congenital Heart Disease Brain: Prenatal Considerations for Perioperative Neurocritical Care. Pediatr Neurol 2020; 108:23-30. [PMID: 32107137 PMCID: PMC7306416 DOI: 10.1016/j.pediatrneurol.2020.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 12/21/2019] [Accepted: 01/05/2020] [Indexed: 12/17/2022]
Abstract
Altered brain development has been highlighted as an important contributor to adverse neurodevelopmental outcomes in children with congenital heart disease. Abnormalities begin prenatally and include micro- and macrostructural disturbances that lead to an altered trajectory of brain growth throughout gestation. Recent progress in fetal imaging has improved understanding of the neurobiological mechanisms and risk factors for impaired fetal brain development. The impact of the prenatal environment on postnatal neurological care has also gained increased focus. This review summarizes current data on the timing and pattern of altered prenatal brain development in congenital heart disease, the potential mechanisms of these abnormalities, and the association with perioperative neurological complications.
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Affiliation(s)
- Cynthia M Ortinau
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri.
| | - Joshua S Shimony
- Mallinkrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
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35
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Placental vascular tree characterization based on ex-vivo MRI with a potential application for placental insufficiency assessment. Placenta 2020; 96:34-43. [PMID: 32560856 DOI: 10.1016/j.placenta.2020.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/13/2020] [Accepted: 05/04/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Understanding regarding the whole placental vascular network structure is limited. Our aim was to quantitatively characterize the human placental vascular tree ex-vivo using high-resolution MRI. METHODS 34 normal placentas were rinsed and injected with a solution of gelatin and contrast agent through the umbilical vessels. A sample of six placentas taken from pregnancies with intrauterine-growth-restriction (IUGR) was used to demonstrate the potential application to cases with placental insufficiency. Structural ex-vivo MR scans of the placenta were performed using high resolution T1 weighted images. A semi-automatic method was developed to segment and characterize the placental vascular architecture: placental volume and cord insertion location, number of bifurcations, generations and vessels diameters. RESULTS Different vascular patterns were found in placentas with central versus marginal cord-insertion. Based on the placental volume and number of bifurcations we were able to predict birth weight. Furthermore, preliminary results on IUGR sample demonstrated the potential of this method to differentiate between small newborns with suspected IUGR from small normal newborns who reached their full growth potential. Results obtained using the automatic method were validated against manual values demonstrating no significant differences or bias. Histopathology supported the imaging findings. DISCUSSION This is the first study to quantitatively characterize the human placental vascular architecture using high resolution ex-vivo MRI. Different patterns of vascular architecture may be related to different functioning of the placenta and affect fetal development. This method is simple, relatively fast, provides detailed information of the placental vascular architecture, and may have important clinical applications.
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36
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Miremberg H, Gindes L, Schreiber L, Raucher Sternfeld A, Bar J, Kovo M. The association between severe fetal congenital heart defects and placental vascular malperfusion lesions. Prenat Diagn 2019; 39:962-967. [PMID: 31254468 DOI: 10.1002/pd.5515] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/23/2019] [Accepted: 06/24/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Studies have shown an association between infant with congenital heart defects (CHD) and the risk of preeclampsia. We aimed to characterize placental histopathology from pregnancies who underwent termination of pregnancy (TOP) because of severe CHD. METHODS This was a case control study. The medical files of all TOPs due to fetal congenital malformations were reviewed. Cases with CHD included hypoplastic left heart, transposition of great arteries, AV canal, tetralogy of Fallot, double outlet RV, and coractation of aorta. The controls included TOPs due to congenital central nervous system defects (CNS group) that were matched in a 1:1 ratio, by gestational age and maternal age. Placental lesions were classified to maternal and fetal vascular malperfusion (MVM and FVM) and inflammatory lesions. RESULTS Higher rates of any MVM or FVM lesion were observed in placentas from the CHD group (n = 32) as compared with the CNS group (n = 32), 40.6% versus 12.5% respectively, p = .02. As compared with the CNS group, the CHD group had more abnormal coiling of umbilical cord (p = .01). CONCLUSION Placental vascular malperfusion lesions are more common in pregnancies complicated with CHD as compared with CNS malformations. These findings support the hypothesis of similar etiopathogenetic factors, contributing to the development of preeclampsia and CHD.
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Affiliation(s)
- Hadas Miremberg
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Holon, Israel
| | - Liat Gindes
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Holon, Israel
| | - Letizia Schreiber
- Department of Pathology, The Edith Wolfson Medical Center, Holon, Israel
| | | | - Jacob Bar
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Holon, Israel
| | - Michal Kovo
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Holon, Israel
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