Cardiomyopathy and cardiomegaly in stillborn infants of diabetic mothers

Maternal Hemoglobin A1c in the Third-Trimester May Underestimate Maternal Hyperglycemia and Its Impact on Offspring in Perinatal Demise Associated With Gestational Diabetes Mellitus: An Autopsy Case Series

INTRODUCTION

Gestational diabetes mellitus (GDM) is a common metabolic disorder linked to adverse pregnancy outcomes. Recent research indicates that HbA1c is reliable in detecting maternal glycemia during the first trimester but may underestimate glucose intolerance in the late second to third trimesters. Therefore, it is reasonable to hypothesize that mothers with GDM, despite apparently normal HbA1c levels in the third trimester, may give birth to infants displaying characteristic features often seen in infants of diabetic mothers with suboptimal glycemic control. This study aimed to describe a case series of autopsy cases involving stillborn or deceased neonates delivered in the third trimester to mothers diagnosed with GDM and having normal HbA1c levels at or around the time of delivery. The primary focus was on identifying and documenting the characteristic features commonly associated with "infants of diabetic mothers" with suboptimal glycemic control in this series of cases.

MATERIALS AND METHODS

We conducted a retrospective review of autopsy reports from our institution spanning 7.5 years. The study included cases that met the following criteria: (1) stillborn or infants who died in the early neonatal period, delivered in the third trimester; (2) mothers diagnosed with GDM; (3) normal maternal HbA1c levels of ≤6.1% at or around the time of delivery; (4) birthweight or femoral length exceeding the 90th percentile for gestational age; and (5) absence of genetic aberrations. We also examined these cases for other characteristic features associated with "infants of diabetic mothers."

RESULTS

Ten autopsy cases met our inclusion criteria, including 9 stillbirths and 1 neonatal death. Gestational age at delivery ranged from 32 to 39 weeks (mean: 35.7 weeks). Femoral length exceeded the 90th percentile in all cases, and 6 cases had birthweights above the 90th percentile. Puffy facies were observed in 6 cases. Among the 9 cases with complete autopsies including internal examination, 6 exhibited excess adipose tissue, 4 had cardiomegaly, and 3 showed pancreatic islet hyperplasia. Hypoxic-ischemic encephalopathy was detected in 7 cases. No structural abnormalities were noted.

DISCUSSION

Our findings demonstrated that fetuses and neonates born to mothers with apparently normal HbA1c levels in the third trimester could still display characteristic features commonly observed in infants of diabetic mothers with poor glycemic control, also known as "infants of diabetic mothers." This study underscores the potential of third-trimester maternal HbA1c measurements to underestimate maternal glycemia and its consequential impact on fetal development, as well as the subsequent manifestation of features of "infants of diabetic mothers."

A convolutional attention mapping deep neural network for classification and localization of cardiomegaly on chest X-rays

Building a reliable and precise model for disease classification and identifying abnormal sites can provide physicians assistance in their decision-making process. Deep learning based image analysis is a promising technique for enriching the decision making process, and accordingly strengthening patient care. This work presents a convolutional attention mapping deep learning model, Cardio-XAttentionNet, to classify and localize cardiomegaly effectively. We revisit the global average pooling (GAP) system and add a weighting term to develop a light and effective Attention Mapping Mechanism (AMM). The model enables the classification of cardiomegaly from chest X-rays through image-level classification and pixel-level localization only from image-level labels. We leverage some of the advanced ConvNet architectures as a backbone-model of the proposed attention mapping network to build Cardio-XAttentionNet. The proposed model is trained on ChestX-Ray14, which is a publicly accessible chest X-ray dataset. The best single model achieves an overall precision, recall, F-1 measure and area under curve (AUC) scores of 0.87, 0.85, 0.86 and 0.89, respectively, for the classification of the cardiomegaly. The results also demonstrate that the Cardio-XAttentionNet model well captures the cardiomegaly class information at image-level as well as localization at pixel-level on chest x-rays. A comparative analysis between the proposed AMM and existing GAP based models shows that the proposed model achieves a state-of-the-art performance on this dataset for cardiomegaly detection using a single model.

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

AIMS

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

RESULTS

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

CONCLUSIONS

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

A rare case of fetal cardiac hypertrophy developing into acute circulatory insufficiency and fetal compromise in type 1 diabetic pregnancy

Fetal cardiac hypertrophy (CH) in pregnant women with diabetes is believed to be a benign condition. We encountered a rare case of fetal CH in a pregnant woman with type 1 diabetes, which developed into severe fetal circulatory insufficiency and acidemia. Fetal echocardiography at 37-week gestation showed cardiomegaly with a ventricular hypertrophy. Cardiac function was impaired, and pulsed Doppler findings indicated circulatory failure. The patient was diagnosed with fetal compromise due to fetal CH, and a large for gestational age boy was delivered by an urgent cesarean section. Despite myocardial hyperplasia and left ventricular outflow tract stenosis, the neonate was hemodynamically stabilized by fluid resuscitation alone. Although the neonatal course was favorable, we speculated that the neonate was on the verge of death because he was already acidemic at birth. Therefore, comprehensive fetal echocardiography should be performed in pregnant women with diabetes, and clinicians should not miss the optimal timing of delivery.

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

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

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

Background

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

Results

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

Conclusion

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

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

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

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

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

AIMS/HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS/INTERPRETATION

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

Assessment of the Protective Role of Prenatal Zinc versus Insulin Supplementation on Fetal Cardiac Damage Induced by Maternal Diabetes in Rat Using Caspase-3 and KI67 Immunohistochemical Stains

Maternal diabetes mellitus (DM) affects early organogenesis. Metabolic disorders of DM are associated with a depleted zinc status. This study evaluated the effect of maternal DM on cardiac development of rat fetuses and protective roles of prenatal zinc versus insulin supplementation. Pregnant rats were divided into 4 groups ((I) control, (II) STZ-induced DM, (III) STZ-induced DM treated with Zn, and (IV) STZ induced DM treated with insulin), all sacrificed on GD 20. Fetal heart weight of diabetic rats showed significant decrease compared to controls (P < 0.05). H&E stained section of controls had normal appearance of the myocardium, compared to diabetics that showed myocardial disarray with characteristic degenerative changes. Sections of zinc treated group showed restored architecture of normal myofibrils with minimal degenerative changes, while those of insulin treated group show partial restoration of the normal architecture of cardiomyocytes with focal improvement of cardiac tissue. Caspase-3 immunostained slides showed positive cytoplasmic immunoreactivity in diabetic group. But KI67 immunostained slides revealed negative nuclear immunoreaction in diabetics. We observed that gestational diabetes was associated with increased risk of fetal myocardial damage that might be caused by increased apoptotic level. Treating diabetic pregnant subjects with zinc and insulin was associated with improvement in myocardial integrity.

Heart rate variability in neonates of type 1 diabetic pregnancy

BACKGROUND

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

AIMS

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

STUDY DESIGN AND SUBJECTS

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Stillbirth in the pregnancy complicated by diabetes

Pregestational diabetes currently complicates 4% of pregnancies, while gestational diabetes complicates approximately 8% of pregnancies. Increased risk of stillbirth in diabetic pregnancies has been a well-known and recognized complication for decades. While stillbirth rates for diabetic pregnancies have decreased due to screening, treatment, and antenatal surveillance of these patients, about 4% of all stillbirths remain attributable to diabetes, and diabetic pregnancies continue to be at increased risk for perinatal mortality. The purpose of this article is to review the literature on the epidemiology, pathophysiology, and prevention, as well as future research, of diabetes-associated perinatal mortality.

Elevated neonatal insulin-like growth factor I is associated with fetal hypertrophic cardiomyopathy in diabetic women

OBJECTIVE

We sought to determine if fetal hypertrophic cardiomyopathy (HCM) or cardiac dysfunction is associated with elevated maternal or neonatal insulin-like growth factor (IGF)-I levels in women with diabetes.

STUDY DESIGN

In a prospective cohort study, fetal echocardiogram findings at 36 weeks' gestation in women with pregestational diabetes mellitus were compared to those in women without diabetes mellitus. HCM was defined as septal or free wall thickness ≥5 mm and cardiac dysfunction as a modified myocardial performance index ≥0.43. Cord serum IGF-I levels at delivery were measured with enzyme-linked immunosorbent assay. Neonates with abnormal fetal echocardiogram were followed up until resolution or 6 months of life.

RESULTS

In all, 75 participants completed fetal echocardiography (55 diabetics and 20 controls). In the diabetic group, 33 of 55 (60%) had abnormal fetal echocardiograms with cardiac dysfunction in 21 of 55 (38.2%) and HCM in 8 of 55 (14.5%) and both in 4 of 55 (7.3%). At 6 months of age, 1 of 12 (8%) had persistent HCM. None in the comparison group had abnormal findings. There were no significant clinical differences in those diabetic women with normal vs abnormal fetal echocardiograms. However, among diabetic women, mean neonatal IGF-I was significantly higher in fetuses with HCM (80 ± 16 ng/mL) as compared to those without HCM (61 ± 18 ng/mL), (P < .001).

CONCLUSION

Elevated neonatal IGF-I appears to be associated with fetal HCM in fetuses of diabetic women.

Stillbirth: the heart of the matter

We evaluated 2,083 cases within the Wisconsin Stillbirth Service Program (WiSSP) that had autopsy reports or ultrasound data relevant to the heart. Of these, 167/1,782 (9.4%) stillbirths after 20 weeks and 11/301 (3.7%) miscarriages <20 weeks had congenital heart disease (CHD). Cases were classified by type of heart defect and whether it related to cause of death. Among cardiac anomalies that contributed significantly to fetal death, 125/151 (83%) were associated with underlying conditions or syndromes, nearly half of which were chromosomal. The most common forms of CHD in stillborns were severe cyanotic lesions (3%), then ventricular (2.6%) and atrial (1.9%) septal defects. Compared to livebirths, this represents a shift toward more severe cardiac lesions, although all comparable categories, including non-lethal conditions such as atrial septal defect, are more common in stillbirths. Clinical cardiomyopathy was identified as cause of death in 1.2% of stillborns. Cardiomegaly, occurring in 26.7% of all cases and 76.7% of infants born to diabetic mothers, may represent undiagnosed cardiomyopathy and/or may decrease fetal tolerance of hypoxia. In contrast, 78.5% of Turner syndrome infants, all <32 weeks, had small hearts. More attention to cardiac findings can lead to increased understanding of stillbirth causes. Based on our findings, we recommend chromosome studies on all stillbirths and close attention to the heart during second trimester ultrasounds, with chromosome studies offered if CHD is found. Consideration of heart size can result in prenatal identification of infants at risk for stillbirth, particularly large hearts in fetuses of diabetic mothers in the third trimester, which may identify fetal cardiomyopathy before it becomes life-threatening.

Cardiomyopathy in offspring of pregestational diabetic mouse pregnancy

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Two novel mutations identified in familial cases with Donohue syndrome

Donohue syndrome (DS) is a rare and lethal autosomal recessive disease caused by mutations in the insulin receptor (INSR) gene, manifesting marked insulin resistance, severe growth retardation, hypertrichosis, and characteristic dysmorphic features. We report the clinical, molecular, and biochemical characterization of three new patients with DS, and address genotype–phenotype issues playing a role in the pathophysiology of DS. A female infant born to first-degree cousins Muslim Arab parents and two brothers born to first-degree cousins Druze parents presented classical features of DS with hypertrophic cardiomyopathy and died in infancy. Each patient was found homozygous for one missense mutation within the extracellular domain of the INSR gene. Western blot analysis identified the proreceptor of INSR, but not its mature subunits alpha and beta. Of 95 healthy Muslims, no heterozygous was found and of 52 healthy Druze from the same village, one was heterozygous. This study presents two novel familial mutations in the alpha subunit of the INSR which appear to impair post-translational processing of the INSR, resulting loss of its function. Both mutations cause DS with hypertrophic cardiomyopathy and early death. Identification of the causative mutation enables prevention of this devastating disease.

The association of cardiac ventricular hypertrophy with congenital hyperinsulinism

OBJECTIVE

Ventricular hypertrophy (VH) has been observed in children with congenital hyperinsulinism (CHI), a condition of hypoglycaemia characterised by dysregulated insulin secretion, but the prevalence is not known.

PATIENTS AND METHODS

Cardiac assessment was performed in children (n=49) with CHI at diagnosis and follow-up. Two dimensional and Doppler echocardiography studies were used to assess cardiac structures, while M-mode study was used to measure left ventricular (LV) dimensions, subsequently converted to Z scores. Where possible, LV hypertrophy was confirmed by LV mass index (g/m(2.7)) >95th centile.

RESULTS

Cardiac structural lesions were found in 14 (28%) children. At initial echocardiography, VH was present in 31 (65%) children with median (range) LV posterior wall dimension in diastole Z scores of +1.6 (-2.4 to +5.8) and interventricular septal wall dimension in end diastole Z scores of +1.9 (-1.7 to +17.2). At follow-up echocardiography, performed after an interval of 178 (45-390) days, VH persisted in 16 (33%) children. In regression analysis, the presence of VH (odds ratio (95% confidence intervals) 1.1 (1.0-1.2), P=0.04) at initial echocardiography was correlated with maximum glucose requirement at diagnosis, indicating that severity of CHI at presentation may play a role in the pathogenesis of VH.

CONCLUSIONS

A significant proportion of children with CHI have cardiac structural lesions. A majority also have VH, which may be associated with the severity of CHI at diagnosis. VH may persist in some children, which requires careful long-term cardiac review.

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

BACKGROUND

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

AIMS

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

STUDY DESIGN

This is a prospective study.

SUBJECTS

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Maternal and fetal cocaine- and amphetamine-regulated transcript in diabetic and non-diabetic pregnancy

Cocaine- and amphetamine-regulated transcript (CART) is a leptin-regulated anorectic neuropeptide. Increased levels of leptin in cord blood of diabetic mothers have previously been described. The aim of this study was to quantify maternal and fetal serum CART levels in type 1 diabetes mellitus (T1DM, n = 10) and non-diabetic pregnancy (n = 10). Matched maternal serum samples (n = 20) were obtained at 36-weeks gestation and cord samples from the umbilical vein at delivery (n = 20), CART was quantified using a competitive enzyme immunoassay. Statistical analysis was performed using Spearmans correlation and t test. There was no difference in maternal CART levels at 36-weeks gestation between T1DM (mean = 331.13 pg/ml, Standard Error of the Mean (SEM) = 114.54) and non-diabetic pregnancy (mean = 195.01 pg/ml SEM = 29.37) (p = 0.106). Fetal CART levels in the umbilical vein were similar in T1DM (mean = 199.27 pg/ml, SEM = 39.81) and non-diabetic pregnancy (mean = 149.76 pg/ml, SEM = 26.08) (p = 0.143). Maternal serum CART levels measured at 36-weeks gestation correlated with maternal BMI at booking (Spearmans ρ = 0.332) (p = 0.001) irrespective of diabetes. Serum CART can be detected in both diabetic and non-diabetic human pregnancy and may play an important role in body mass regulation in pregnancy.

Clinical associations with a placental diagnosis of delayed villous maturation: a retrospective study

Delayed villous maturation (DVM) is a spectrum of placental disease characterized by decreased tertiary villus formation, reduced vasculosyncytial membrane formation, and, in its more severe forms, increased large bullous villi. In some series it has been associated with an increased risk of stillbirth in the late third trimester, but overall there are few data on its significance. The aim of this study was to assess perinatal factors associated with, and the clinical significance of, the finding of DVM on placental histology. This was a retrospective study investigating all pregnancies with DVM diagnosed on placental histology in a tertiary level unit between December 2001 and August 2006. Over a 6-year period, 2915 placentas were triaged for histopathological assessment, representing 6.1% of all 48 054 deliveries in this time period. One hundred ninety (6.3%) of these selected cases showed DVM. Fifteen placentas from infants with less than 34 completed weeks of gestation were excluded, leaving 175 for further analysis. When compared with controls matched for gestation and delivering within the same time period (n  =  175), DVM was significantly associated with pregestational diabetes (8% vs 2.8%, P < .05; relative risk 2.8 [95% confidence interval 1.03-7.6]), gestational diabetes (8.6% vs 3.4%, P < 0.05; relative risk 2.5 [95% confidence interval 0.99-6.3]), and prenatal or intrapartum intrauterine death (8.6% vs 0%, P < 0.05). Delayed villous maturation is associated with both gestational and pregestational diabetes mellitus and with perinatal death.

Foetal and neonatal complications in gestational diabetes: perinatal mortality, congenital malformations, macrosomia, shoulder dystocia, birth injuries, neonatal complications

OBJECTIVE

To evaluate the risks of perinatal complications in infants born to mothers with treated or untreated gestational diabetes mellitus (GDM).

METHODS

A search of the PubMed database was performed and recommendations from NICE and the French National Authority for Health were consulted.

RESULTS

Untreated moderate or severe GDM increases the risk of foetal and neonatal complications (EL1). The risk of malformations slightly increases in newborns of mothers with GDM compared to the general population (EL2). This risk is probably associated with the presence of undiagnosed type 2 diabetes among patients with GDM (EL2). There is a linear relationship between maternal blood glucose levels and an increased birth weight (EL2). Treatment for GDM reduces the incidence of macrosomia (EL1). Although the risk of cardiomyopathy in cases of GDM cannot be accurately estimated based on the available data, severe clinical forms are rare. The risks of neonatal asphyxia and perinatal mortality are no higher in infants born to women with GDM (EL2). Birth injuries and brachial plexus injuries are rare, and no more likely to occur in cases of untreated GDM. It is difficult to assess the risk of respiratory distress, regardless of its cause. It is not possible to establish a link between GDM and neonatal respiratory problems due to insufficient data. Although the risk of neonatal hypoglycaemia is difficult to determine due to the variable definitions reported in the literature, the incidence of hypoglycaemia requiring intravenous therapy is low (EL1). The risks of hypocalcaemia (EL4) and hyperbilirubinemia (EL1) are similar to the general population.

CONCLUSION

Serious perinatal complications specifically associated with GDM are rare. Macrosomia has been demonstrated to be the predominant adverse outcome in cases of GDM. It is the main factor linked to reported cases of complications in GDM. Maternal obesity is an additional risk factor for complications, regardless of diabetes status.

Echocardiographic findings of congenital cardiopathies among fetuses of diabetic pregnant women and their relationship with plasma fructosamine levels

OBJECTIVE

To study the occurrence of congenital cardiopathies at echocardiography (CCE) in fetuses whose mothers had preexisting diabetes mellitus (PGDM) and to study the potential of using fructosamine level as a late marker (beyond the first trimester) for CCE.

METHODS

A register study covering 91 pregnant women that underwent routine fetal echocardiography ordered due to PGDM. The first dosage of plasma fructosamine found in 65 medical records was analyzed during prenatal care (20.4 ± 8.0 weeks of gestation). The presence or absence of structural or functional CCE was associated with fructosamine levels by logistic regression. We assessed the effect modification odds ratio by maternal age and insulin usage.

RESULTS

Thirty-four fetuses (52.3% of 65 fetuses) presented CCE. Twenty of them had functional CCE and 14 presented structural CCE. The mean maternal plasma fructosamine level was higher among pregnant women whose fetuses presented CCE than in those whose fetuses did not (2.86 ± 0.73 mmol/l, 2.22 ± 0.54 mmol/l, respectively, p < 0.0001). Crude OR for CCE and abnormal plasma fructosamine (>2.68 mmol/l) was 9.6 (2.8-33.7, 95% CI, p < 0.0001). Adjusted OR by maternal age and insulin usage was 10.9 (2.7-45.2, 95% CI p < 0.0001).

CONCLUSIONS

An abnormal plasma fructosamine level increases the chances of CCE occurring among referral pregnant women with PGDM.

Obstetric problems in diabetic pregnancy - The role of fetal hypoxia

Perinatal mortality has not decreased over the last two decades in pregestational diabetic pregnancies. Stillbirth rate is 4-6 times and neonatal mortality 2-4 times higher in diabetic than in non-diabetic pregnancies despite modern electronic fetal surveillance methods. Majority of late stillbirths are "unexplained", many of which are presumably caused by fetal hypoxia. Both experimental and clinical studies have shown that fetal hyperglycaemia and hyperinsulinaemia can independently cause fetal hypoxia, which ultimately can lead to fetal death. Poor glycaemic control is associated with perinatal complications. Sharp increases in amniotic fluid erythropoietin levels indicate fetal hypoxia in diabetic pregnancy. Fetal erythropoietin concentrations correlate directly with maternal HbA(1c) levels. It is therefore important to maintain near-normal glycaemic level throughout pregnancy. Measurement of amniotic fluid erythropoietin level is a new way to detect fetal hypoxia antenatally. Sufficiently large controlled studies are needed before definitive answer of the clinical utility of amniotic fluid erythropoietin measurements in diabetic pregnancies can be determined.

Teenage pregnancy in type 1 diabetes mellitus

Younger maternal age at delivery has been linked to adverse reproductive outcomes. Pregnancy complicated by type 1 diabetes mellitus (T1DM) is also associated with adverse pregnancy outcomes. Optimising diabetic glycaemic control prior to pregnancy is known to reduce the rate of congenital abnormalities and improve pregnancy outcomes. Teenage pregnancies are not usually planned and little data exist on teenage pregnancy complicated by T1DM. We sought to identify the glycemic control achieved in teenage pregnancy with T1DM and to clarify if there is an associated increase in adverse pregnancy outcomes compared to those seen in older women with T1DM. We compared outcomes in 18 teenagers (TG) with 582 older women with T1DM (CON) from 1995-2007. TG booked to the combined diabetes-obstetrical service at a median gestational age of 11 weeks (range 6-22) compared to 7 weeks in CON (range 4-40, p < 0.02). Glycaemic was worse in TG compared to CON at 13, 26 and 35 weeks gestation, despite higher insulin doses. First trimester miscarriage rate did not differ between groups. Major congenital anomaly rate was 6.2% (1/16) compared to 3.2% in CON. This preliminary study has demonstrated that pregnant teenage women with T1DM book later to specialised care and have worse glycaemic control in pregnancy compared to older women with T1DM. This group also appear to be more insulin resistant than older women in early pregnancy. Our data would suggest that teenagers with type 1 diabetes mellitus may constitute a high-risk group for adverse pregnancy outcomes.

Troponin T and pro-B-type natriuretic Peptide in fetuses of type 1 diabetic mothers

OBJECTIVE

Cardiomyopathy is noted in up to 40% of infants of diabetic mothers, and the exact mechanisms are unknown. The aim of this study was to determine whether fetal serum markers of cardiac function differ between normal and type 1 diabetic pregnancies and to examine the relationship between these markers and fetal cardiac structure and function.

RESEARCH DESIGN AND METHODS

This was a prospective observational study of 45 type 1 diabetic pregnancies and 39 normal pregnancies. All participants had concentrations of fetal pro-B-type natriuretic peptide (proBNP) and troponin-T (TnT) measured at the time of delivery. All patients with type 1 diabetes had Doppler evaluation of the umbilical artery, middle cerebral artery, and ductus venosus in the third trimester, and a subset (n = 21) had detailed fetal echocardiograms performed in each trimester.

RESULTS

Fetal proBNP and TnT concentrations were higher in the diabetic cohort than in the normal cohort (P < 0.05). ProBNP correlated positively with interventricular septum thickness (P < 0.05) but not with cardiac function indexes in the third trimester. In patients with poor glycemic control, there was a significant positive correlation (P < 0.05) between fetal TnT and the third trimester umbilical artery pulsatility index. There were also increased levels of fetal TnT in infants with poor perinatal outcome (P < 0.05).

CONCLUSIONS

Biochemical markers of cardiac dysfunction are elevated in infants of diabetic mothers, especially those with cardiomyopathy or poor perinatal outcome. Hyperglycemia in early pregnancy may affect myocardial and placental development, thus contributing to the susceptibility to hypoxia seen in these infants.

Fetal cardiac effects of maternal hyperglycemia during pregnancy

Maternal diabetes mellitus is associated with increased teratogenesis, which can occur in pregestational type 1 and type 2 diabetes. Cardiac defects and with neural tube defects are the most common malformations observed in fetuses of pregestational diabetic mothers. The exact mechanism by which diabetes exerts its teratogenic effects and induces embryonic malformations is unclear. Whereas the sequelae of maternal pregestational diabetes, such as modulating insulin levels, altered fat levels, and increased reactive oxygen species, may play a role in fetal damage during diabetic pregnancy, hyperglycemia is thought to be the primary teratogen, causing particularly adverse effects on cardiovascular development. Fetal cardiac defects are associated with raised maternal glycosylated hemoglobin levels and are up to five times more likely in infants of mothers with pregestational diabetes compared with those without diabetes. The resulting anomalies are varied and include transposition of the great arteries, mitral and pulmonary atresia, double outlet of the right ventricle, tetralogy of Fallot, and fetal cardiomyopathy.A wide variety of rodent models have been used to study diabetic teratogenesis. Both genetic and chemically induced models of type 1 and 2 diabetes have been used to examine the effects of hyperglycemia on fetal development. Factors such as genetic background as well as confounding variables such as obesity appear to influence the severity of fetal abnormalities in mice. In this review, we will summarize recent data on fetal cardiac effects from human pregestational diabetic mothers, as well as the most relevant findings in rodent models of diabetic cardiac teratogenesis.

Effect of pregestational diabetes mellitus on fetal cardiac function and structure

OBJECTIVE

Fetuses of diabetic pregnancy experience cardiomyopathy, the intracardiac cause of which is understood poorly. The aim of this study was to assess the interrelation between cardiac functional and structural changes in fetuses of mothers with pregestational diabetes mellitus.

STUDY DESIGN

Twenty-six mothers with pregestational diabetes mellitus were recruited prospectively to have a fetal echocardiogram at 13, 20, and 36 weeks of gestation to assess cardiac function and structure. For comparison, 30 healthy control subjects were recruited at each gestational age.

RESULTS

In the first trimester, there was evidence of poorer fetal cardiac diastolic function among the diabetic cohort (lower left early/atrial ratio, longer isovolumetric relaxation time and higher left myocardial performance index; P < .05). In the third trimester, the fetal interventricular septum and the right ventricular free wall were thicker in the diabetic cohort (P < .05).

CONCLUSION

In fetuses of pregestational diabetic pregnancy, sonographic evidence of altered cardiac function is evident before ultrasound evidence of cardiac structural changes. This suggests that altered cardiac function may precede cardiac structural changes in fetuses of pregestational diabetic pregnancy.