We sought to define growth parameters of normal fetal heart structures throughout gestation from our database of 2246 normal comprehensive fetal echocardiograms (FECHO). Methods In a retrospective cross sectional study, we evaluated the FECHO results of 2246 normal fetuses. Fetuses had been studied for reasons of family history of congenital heart disease or possible exposure to teratogenic medications, advanced maternal age without karyotyping, suspected abnormalities or difficulty in obtaining complete heart views. None of this group had structural or functional heart disease or arrhythmias. All measurements were performed on a Voluson 730 by one sonographer between 2006 and 2008. Standard cardiovascular diameter measurements were performed on frozen magnified, high resolution images. Valves were measured in long axis at the annulus during diastole with 2 leafets in the image. Systolic and diastolic ventricular measurements were made by follow-the-line methods. These included: ductus venosus size (DV), aorta annulus size (AoV), pulmonary valve annulus size (PV), tricuspid annulus size (TV), mitral annulus size (MV), superior vena cava (SVC) and inferior vena cava (IVC) at the diaphragm sizes, as well as the M-mode measurements including interventricular septum at diastole (IVSD), left ventricular posterior wall dimension at diastole (LVPWD), interventricular septum at systole (IVSS), left ventricular posterior wall dimension at systole (LVPWS) across gestation. Results
Structural cardiac malformations and abnormal cardiac physiology are more prevalent in fetuses of diabetic mothers (FDM). The myocardial performance index is a useful parameter to assess both systolic and diastolic function in fetuses at all gestational ages. We evaluated 102 FDM by comprehensive fetal echocardiography (FECHO) whose mothers were considered well controlled. None of this group had structural heart disease. Cardiovascular function was estimated from CC/TC ratio, left ventricular shortening fraction, tricuspid E and A velocities and E/A ratio, mitral E, A velocities and E/A ratio and Doppler flow patterns in the free loop of the umbilical cord, MCA, ductus arteriosus and ductus venosus (DV) as well as maximal velocities and time velocity integrals into the ascending aorta and main pulmonary artery. The Tei index was calculated as the sum of the isovolumetric contraction time (ICT) and the isovolumetric relaxation time (IRT) divided by the ejection time using the “clicks” method. These parameters were compared to age matched normal fetuses from our data base. From 18 weeks till 34 weeks, there was no difference in any measured parameter between FDM and normal fetuses. After 34 weeks, only the Tei index showed any changes. Abnormal enhanced myocardial performance in FDM is noted after 24 weeks towards term in well controlled diabetic mothers. The Tei index may be the most sensitive method of estimating myocardial performance in fetuses with maternal diabetes. Abnormal enhanced myocardial performance in FDM is noted after 34 weeks towards term in well controlled diabetic mothers. It may be due to myocardial stimulatory response of hypertrophy to hyperglycemia in these fetuses of well controlled mothers as compared to development of asymmetric septal hypertrophy in fetuses of mothers without good metabolic control.
To evaluate the correlation between Doppler profile changes and perinatal outcome in idiopathic IUGR fetuses. A prospective longitudinal study of two hundred and forty one idiopathic IUGR fetuses. Inclusion criteria were idiopathic anatomically normal singleton fetuses, EFW < 10th percentile, increased umbilical artery PI delivered < 32 weeks for non-reassuring cardiotocography or fetal BPS < 4. All fetuses underwent twice weekly Doppler evaluation of umbilical artery, middle cerebral artery and ductus venosus. Neonatal weight and gestational age at delivery were recorded to predict adverse perinatal outcome (RDS, IVH, PVL, NEC, fetal and neonatal death). Data were analysed with stepwise multiple logistic regression. There were 16 stillbirths (6.6%). Among 225 survivors 143 (63.5%) had RDS, 57 (25.3%) IVH, 34 (15.1%) NEC and 12 (5.3%) PVL and 59 (24.5%) neonatal deaths. Stepwise multiple logistic regression analysis revealed that fetal weight was associated with RDS (exp B 0.99—p < 0.001) and neonatal death (exp B 0.99—p < 0.001). Gestational age was a determinant of fetal death (exp B 0.62—p < 0.01). Umbilical artery reversed flow (UA_RF) was associated with IVH (exp B 3.04—p < 0.01) and with NEC (exp B 3.3—p < 0.05) whereas ductus venosus absent or reversed flow (DV_ARF) showed the strongest association with all parameters: RDS (exp B 5.76—p < 0.01), IVH (exp B 4.45—p < 0.01), PVL (exp B 13.86—p < 0.05), NEC (exp B 3.3—p < 0.05), neonatal death (exp B 4.23—p < 0.01) and fetal death (exp B 6.72—p < 0.05). In idiopathic IUGR fetuses delivered < 32 weeks UA-RF is strongly related with IVH and NEC, and DV-ARF with overall adverse perinatal morbidity and mortality. These relationships are independent of gestational age and suggest that randomised trials need to evaluate management that is based on these Doppler findings as triggers for delivery in early onset IUGR presenting < 32 weeks gestation.
Prevalence of spontaneous monochorionic triplet pregnancy is 1 in 7000 pregnancies with a 50–60% incidence of growth restriction. We report a case of 25 year old G1 P0 hospitalized at 24 6/7 weeks for one fetus with selective intrauterine growth restriction (IUGR) with absent or reversed end diastolic flow in the free loop of umbilical artery (FLUA). The estimated growths of the three fetuses were < 10%, 28% and 38%. There was no evidence of structural or functional cardiac abnormalities in any of the fetuses. There was no evidence of twin-twin transfusion syndrome. The patient was managed with bed rest, oxygen by nasal cannula, steroids and followed with daily biophysical profile and non-stress test, weekly Doppler and amniotic fluid evaluations. After eleven days, the IUGR fetus showed improvement in the ductus venosus and middle cerebral artery pulsatility index (PI) while FLUA showed mildly elevated PI. The plan was to prolong delivery of the triplets until after 32 weeks gestation, if possible. The antenatal course remained uneventful while on maternal oxygen therapy. At 32 weeks, the smaller fetus had grown to 37% percentile with all Doppler values within normal limits while on maternal oxygen and the delivery was conducted by scheduled cesarean section. The placental pathology showed a monochorionic placenta with one eccentric and two central insertions of the three vessel umbilical cords. The newborns weighed 1015 grams (g), 1350 g and 1530 g with normal Apgar score at 5 minutes. All of the triplets received continuous positive airway pressure and parenteral support in the newborn period. We conclude that oxygen therapy improved the Doppler flow pattern in the IUGR fetus of this triplet pregnancy and allowed for substantial growth in that fetus, thereby successfully prolonging the delivery date.
Chorioamnionitis (CA) is defined as an infection that can affect amniotic fluid, placenta and uterus. The chorioamnionitis is present in 10-40% of cases of maternal peripartum fever and in 50% of preterm labor. Diagnosis is based on the presence of maternal fever (>38 degrees C) at least 2 of these conditions: maternal leukocytosis (> 15,000 cells/mmc), maternal tachycardia, fetal tachycardia, stained or foul smelling amniotic fluid, uterine tenderness. Obstetric risk factors include nulliparity, presence of stained amniotic fluid, the excessive duration of labor, the presence of pathogens in the genital tract (eg, Gonorrhea, GBS, EC), and the frequency of digital vaginal examinations. In suspicion of CA membranes and placenta are usually sent for histological examination performance, but the diagnosis of CS is not always confirmed by histological or microbiological exams. Early administration of broad-spectrum antibiotic therapy reduces both maternal and neonatal morbidity. The standard treatment by the administration of ampicillin and gentamicin have been shown to be safe and effective. Common maternal complications include bacteremia to septic shock, cesarean section, uterine atony with hemorrhage, pelvic abscess, maternal coagulopathy, thromboembolism and wound infections. The risk of neonatal sepsis, low seizures, low Apgar score at 5 minutes increased in the newborn. Cardiotocographic fetal monitoring should be continued during labor in cases of suspected chorioamnionitis with recourse to caesarean section as soon as signs of severe fetal distress.
Timing longitudinal changes of umbilical artery, middle cerebral artery, umbilical vein, ductus venosus, and amniotic fluid index, up to delivery of IUGR fetuses with abnormal umbilical artery pulsatility index. A group of 145 fetuses with no maternal complications were followed by the time of diagnosis to cesarean delivery performed because of an abnormal biophysical profile or presence of repetitive decelerations. Doppler studies, NST, and biophysical profile, were initially performed every 4 days; they were repeated on a daily basis when the patients were admitted to the Hospital because of a cerebroplacental ratio < 1.0. There were 4 fetal demises and 50 neonatal deaths. Two IUGR groups were identified. Group A (n = 45) included fetuses in whom all Doppler parameters became abnormal and preceded an abnormal biophysical profile or abnormal NST. Group B included fetuses in whom one or more vessels were normal at the time of cesarean delivery. There was no difference in perinatal morbidity and mortality between the two groups. The only parameters that were associated to perinatal morbidity and mortality were umbilical artery reversed flow, ductus venosus absent/reversed flow and birth weight. Umbilical artery reversed flow and absence/reversed flow of the ductus venosus were present 7–8 days before an abnormal biophysical profile or an abnormal fetal heart rate test result. Low birth weight, umbilical artery reversed flow and ductus venosus absent/reversed flow are associated to an increased perinatal morbidity and mortality. Delivering the IUGR fetus in presence of umbilical artery reversed flow or ductus venosus absent/reversed flow in spite of normal biophysical profile and reassuring fetal heart rate, at less than 32 weeks, is probably not wise at the current time.
Gestational diabetes mellitus (GDM) is associated with a wide range of tissue-specific changes depending on the quality of glycemic control of the mothers. Here we tested the hypothesis that GDM is associated with alterations in the human term placenta proteome. For this aim, two different approaches were employed. The placenta homogenates from 20 healthy subjects and those from 20 GDM pregnant women were pooled. The two samples thus obtained were analyzed by matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS) and the proteins detected were tentatively identified by comparison of their molecular weight with the Human Protein Reference Database, restricting the search to the species expressed in the placenta tissue. However this approach led to misleading results: in fact, an in deep analysis of the spectra and tandem mass spectrometry (MS/MS) measurements of the digestion products from the protein detected, unequivocally proved that the species observed are maternal and fetal globins. Consequently, the two pools were analyzed by 1D sodium dodecyl sulphate polyacrylamide gel electrophoresis; the different bands obtained were digested by trypsin and the digestion products were analyzed by MALDI-MS; the protein identification was carried out by comparison of the peptide mass fingerprint with databases. Only modest quantitative differences were observed between the placenta protein profiles of healthy and GDM subjects, indicating that GDM, if well controlled, induces only minor changes in the placental proteome. One example of differently expressed proteins in the placenta homogenate pool from GDM and the controls was the SRRM1 protein, a member of the serine–arginine protein kinase family; for GDM samples, the MALDI spectrum of its digestion products showed the presence of molecular species attributable to glycation and glyco-oxidation processes.
