Cardiac Measurements of Size and Shape in Fetuses With Absent or Reversed End-Diastolic Velocity of the Umbilical Artery and Perinatal Survival and Severe Growth Restriction Before 34 Weeks' Gestation

Assessment of Atrial Size, Shape, and Contractility in Growth-Restricted and Small-for-Gestational-Age Fetuses

OBJECTIVES

The size, shape, and contractility of the heart's atrial chambers have not been evaluated in fetuses with growth restriction (FGR) or who are small-for-gestational-age (SGA) as defined by the Delphi consensus protocol. This study aimed to examine the atrial chambers using speckle tracking analysis to identify any changes that may be specific for either growth disturbance.

METHODS

Sixty-three fetuses were evaluated with an estimated fetal weight <10th percentile who were classified as FGR or SGA based on the Delphi consensus protocol. The atrial cardiac cycle was defined as end-diastole, end-systole, and end-diastole, equivalent to ventricular end-systole, end-diastole, and end-systole. The atrial size, shape, and contractility were computed from 24 transverse segments and one length measurement identified from speckle tracking analysis of the endocardium at end-diastole and end-systole. The z-score for each atrial measurement was computed using the mean and standard deviation equations from a control group of 200 fetuses. The z-score values were compared between the control and FGR/SGA fetuses as well as between FGR and SGA fetuses using the Kruskal-Wallis test. A P-value of <.05 was considered significant.

RESULTS

Of the 63 fetuses with an estimated fetal weight (EFW) <10th percentile, 60% (38/63) were classified as FGR and 40% (25/63) as SGA. The following abnormal atrial measurements were unique to FGR fetuses: decreased end-diastolic left atrial (LA) area, decreased LA base and mid-chamber end-diastolic width, decreased LA base sphericity index, decreased right atrial (RA) mid-chamber sphericity index, decreased LA ejection volume, and decreased LA emptying volume. The following were unique to the SGA fetuses: Increased RA mid-chamber length, decreased LA fractional area change, decreased RA reservoir strain, decreased RA basal-apical length fractional shortening, and decreased LA base width transverse fractional shortening. The significant difference was an increased LA mid-chamber length in the SGA fetuses.

CONCLUSIONS

Fetuses with an EFW <10th percentile who are classified as either SGA or FGR demonstrate unique abnormalities of atrial size, shape, and contractility, thus allowing the examiner to differentiate between FGR and SGA fetuses.

Maternal oxygen inhalation affects the fetal hemodynamic in low-risk with uncomplicated late pregnancy

BACKGROUND

Maternal oxygen inhalation during labor has not been shown to provide significant benefits to newborns. However, its impact on fetal hemodynamics in late pregnancy remains uncertain.

OBJECTIVE

This study aimed to investigate the association between maternal oxygen inhalation in the late trimester and changes in fetal hemodynamics. Specifically, we assessed the short-term effects of maternal oxygen administration on fetal Doppler parameters and evaluated whether this practice has potential benefits or risks for the fetus.

STUDY DESIGN

These retrospective data were obtained from singleton pregnancies who underwent a after 32+0 weeks prenatal ultrasound examination between January 2022 and December 2022. Participants were categorized into oxygen inhalation and non-oxygen inhalation groups. Oxygen inhalation was administered based on maternal request, primarily due to concerns about hypoxia from prolonged mask use during the COVID-19 pandemic, rather than clinical indication. Our study analysis was performed in August 2023. In oxygen inhalation group, pregnant women received oxygen inhalation with 3 L/min for 30 min by nasal cannula, and before went to department of ultrasound for sonographic assessment within 1 h. The CPR and PPI were predefined as primary outcomes prior to analysis. Each woman was recorded Doppler index and calculated placental pulsatility index (PPI) and cerebroplacental ratio (CPR). Moreover, fetal cardiac function was assessed within pulsed Doppler or M-mode.

MAIN OUTCOME

The primary outcome presented higher PPI, lower CPR, and lower birth weight for the exposure maternal oxygen inhalation group, compare to non-oxygen inhalation group.

RESULTS

A total of 104 singleton pregnancies were included in the final analysis (oxygen inhalation group: n = 48). No significant differences were observed in the resistance indices of the uterine arteries, umbilical arteries, middle cerebral arteries, descending aorta, ductus venosus, or umbilical vein. However, variations were noted in the oxygen inhalation group. Notably, indices with higher sensitivity for predicting adverse outcomes demonstrated significant differences between groups: PPI was higher in the oxygen inhalation group compared to the non-oxygen inhalation group (0.81 ± 0.12 vs. 0.76 ± 0.11, p < .05), while CPR was also lower in the oxygen inhalation group (1.98 ± 0.56 vs. 2.28 ± 0.70, p < .05). Additionally, birth weight was significantly lower in the oxygen inhalation group compared to the non-oxygen inhalation group (2983.78 ± 468.18 g vs. 3178.41 ± 477.59 g, p < .05).

CONCLUSION

Our study found that brief maternal oxygen inhalation in the third trimester was associated with significant changes in fetal hemodynamics, specifically higher PPI and lower CPR. Both of these indices are sensitive markers of unfavorable prenatal outcomes, indicating that maternal oxygen inhalation may adversely affect fetal health. These findings underscore the importance of carefully evaluating the use of oxygen inhalation in pregnant women, especially those in high-risk pregnancies. Additionally, monitoring Doppler indices before and after oxygen administration may help assess fetal well-being and guide clinical decision-making in these situations.

Subclinical myocardial dysfunction among fetal growth restriction neonates: a case-control study

OBJECTIVES

To evaluate cardiac structural and functional changes in neonates with fetal growth restriction (FGR) compared to appropriate-for-gestational-age (AGA) neonates using conventional echocardiography, tissue Doppler imaging (TDI), and speckle tracking echocardiography.

METHOD

This case-control study included 85 FGR neonates and 75 non-FGR, weight adequate for gestational age neonates. Among these, 37 were symmetric FGR and 48 were asymmetric FGR. All the biophysical profiles of these newborns were assessed. An echocardiographic test was performed to evaluate cardiac dimension, Left ventricular ejection fraction (LV EF), Mitral valve Doppler flow velocities, myocardial performance index, tissue annular velocities, and LV global longitudinal strain (GLS).

RESULTS

Although LVEF was found to be within the normal range, mean EF was reduced among neonates with FGR than non-FGR controls (EF: 66.14 ± 3.85% vs 69.46 ± 3.58%; p < 0.001, in FGR and non-FGR, respectively). Furthermore, LV E/E' a measure of LV diastolic function was altered among both types of FGR neonates. Similarly, LV GLS was reduced among FGR neonates (LV GLS: -20.69 ± 2.7% vs -19.06 ± 2.9%; p < 0.001 in non-FGR and FGR, respectively).

CONCLUSION

FGR neonates exhibit significant alterations in cardiac geometry compared to AGA controls. FGR neonates also demonstrated a significant reduction in LV EF, FS, and LV global longitudinal strain, depicting failure to adapt to the increased cardiac workload after birth.

Evaluation of fetal heart size, morphology and function with fetal growth restriction using fetal HQ

BACKGROUND

Fetal growth restriction (FGR) is associated with various perinatal complications. Limited research has focused on the fetal heart in the context of FGR. This study aimed to investigate the application value of fetal heart quantification (HQ) technology in evaluating the size, morphology, and function of the heart in FGR.

METHODS

A total of 31 fetuses diagnosed with FGR in our hospital from April 2022 to May 2024 were included, alongside another 31 normal fetuses matched for gestational age as the control group. Ultrasound Doppler parameters of the middle cerebral artery (MCA), umbilical artery (UA), venous catheter, and fetal HQ parameters were collected for comparative analysis, and perinatal data were followed up.

RESULTS

Fetuses with FGR exhibited significant differences in various parameters of the MCA and UA compared to the control group (P < 0.05). The four-chamber view end-diastolic transverse width, end-diastolic area, left ventricular (LV) end-diastolic area, end-systolic area, end-systolic length, end-diastolic volume, end-systolic volume, and right ventricular (RV) end-systolic area in the FGR group were significantly lower than those in the control group (P < 0.05). In the 24-segment analysis, the LV fractional shortening in the FGR group was greater than in the control group at segments 12 to 14, while the end-diastolic diameter (ED) at segments 5 to 13 of the LV and segments 1 to 14 of the RV were smaller than those in the control group, with statistical significance (P < 0.05). Analysis of each subgroup indicated that fractional shortening (FS) in the early-onset group was significantly greater than in the late-onset group at RV segments 2 to 8. LV-ED at segments 1 to 15 and RV-ED at segments 1 to 16 were significantly smaller in the early-onset group than in the control group, and LV ED segments 20 to 21 were significantly smaller in the early-onset group compared to the late-onset group (P < 0.05). FS in the mild group was significantly larger than in the normal group at LV segments 10 to 16. The severe group exhibited significantly smaller LV segment 2 to 11 ED and the mild group showed smaller RV segments 1 to 13 compared to the control group (P < 0.05).

CONCLUSIONS

Fetal HQ is a promising technique for evaluating the cardiac function, size, and morphology in cases of FGR.

Reference Ranges and Development Patterns of Fetal Myocardial Function Using Speckle Tracking Echocardiography in Healthy Fetuses at 17 to 24 Weeks of Gestation

OBJECTIVE

The purposes of the study were to develop reference ranges and maturation patterns of fetal cardiac function parameters measured by speckle tracking echocardiography (STE) using multiple biometric variables at 17 to 24 weeks' gestation among Thai fetuses and to compare with other previous reports.

STUDY DESIGN

The four-chamber view of the fetal heart in 79 healthy fetuses was suitably analyzed by STE to establish the best-fit regression model. The 95% reference intervals and Z-score equations of fetal cardiac function parameters were computed.

RESULTS

The fractional area change of both ventricles, left ventricular (LV) end-diastolic and end-systolic volumes, LV stroke volume, LV cardiac output (CO), and LV CO per kilogram were all increased according to gestational age (GA) and five fetal biometric measurements. However, the global longitudinal strain, basal-apical length fractional shortening (BAL-FS), BAL annular free wall and septal wall FS, BAL free wall and septal wall annular plane systolic excursions, 24-segment transverse width FS, as well as LV ejection fraction were all independent of GA or other somatic characteristics. There were varying development patterns between fetal right and left ventricles of these cardiac function indices across the gestation period.

CONCLUSION

Our study created Z-score and corresponding centile calculators, 5th and 95th centile reference tables, and corresponding graphs and determined the normal evolution across gestation using multiple somatic growth and age variables between 17 and 24 gestational weeks. These nomograms serve as an essential prerequisite for quantitatively evaluating fetal cardiac contractility and allow for precisely detecting early changes in the fetal heart function.

KEY POINTS

· Most fetal cardiac function measurements were correlated with all the independent variables.. · Fetal ventricular function parameters have their own characteristic maturation changes.. · Racial variability may not occupy an important place for fetal myocardial function during these GA..

Abnormal Shape and Size of the Cardiac Ventricles Are Associated with a Higher Risk of Neonatal Death in Fetuses with Isolated Left Congenital Diaphragmatic Hernia

INTRODUCTION

The objective of this study was to evaluate the association between fetal cardiac deformation analysis (CDA) and cardiac function with severe adverse perinatal outcomes in fetuses with isolated left congenital diaphragmatic hernia (CDH).

METHODS

CDA in each ventricle (contractility, size, and shape), evaluated by speckle tracking and novel FetalHQ software, and markers of cardiac function (E/A ratios, pulmonary and aortic peak systolic velocities, and sigmoid annular valve diameters), were evaluated in fetuses with isolated left CDH. Two evaluations were performed: at referral (CDA and function) and within 3 weeks of delivery (CDA). Severe adverse neonatal outcomes were considered neonatal death (ND) or survival with CDH-associated pulmonary hypertension (CDH-PH). Differences and associations between CDA, cardiac function, and severe adverse outcomes were estimated.

RESULTS

Fifty fetuses were included, and seventeen (34%) had severe adverse neonatal outcomes (11 ND and 6 survivors with CDH-PH). At first evaluation, the prevalence of a small left ventricle was 34% (17/50) with a higher prevalence among neonates presenting severe adverse outcomes (58.8 [10/17] vs. 21.2% [7/33]; p = 0.01; OR, 5.03 [1.4-19.1; p = 0.01]) and among those presenting with neonatal mortality (8/11 [72.7] vs. 9/39 [23.0%]; p = 0.03; OR, 8.9 [1.9-40.7; p = 0.005]). No differences in cardiac function or strain were noted between fetuses with or without severe adverse outcomes. Within 3 weeks of delivery, the prevalence of small left ventricle was higher (19/34; 55.8%) with a more globular shape (reduced transverse/longitudinal ratio). A globular right ventricle was significantly associated with ND or survival with CDH-PH (OR, 14.2 [1.5-138.3]; p = 0.02).

CONCLUSION

Fetuses with isolated CDH at risk of perinatal death or survival with CDH-PH had a higher prevalence of a small left ventricle and abnormal shape of the right ventricle.

Evaluation of the changes in cardiac morphology of fetuses with congenital heart disease using fetalHQ

Objective: To evaluate the changes in cardiac morphology of fetuses with congenital heart disease (CHD) using the fetal heart quantitative technique (fetalHQ).Methods: A total of 20 normal pregnant women (control group) and 20 pregnant women suspected of fetal CHD (case group) were included in this study. The dynamic images of the four-chamber view of the fetal heart were recorded and analyzed using fetalHQ. The global sphericity index (GSI) and 24-segment SI of the two groups were compared. The differences in the left and right ventricular 24-segment SI for each group were investigated.Results: There was no statistically significant difference in the GSI between the two groups (p > 0.05). The difference in the SI values of left ventricular segments 1-2 between the case group and control group was statistically significant (all p < 0.05), while the intergroup difference in SI of left ventricular segments 3-24 was not significant (all p > 0.05). The SI of the 24 segments of the right ventricle showed no significant intergroup difference (all p > 0.05). The difference in the left and right ventricular 24-segment SI in the case group did not reach statistical significance (all p > 0.05). In the control group, the SI values between the left and right ventricles were significantly different in segments 18-24 (all p < 0.05), and no significant difference was found in segments 1-17 (all p > 0.05). There was a statistically significant intergroup difference in the percentage of unusual left ventricular SI, determined based on Z-score (p < 0.05), and the percentage of outliers for the right ventricle between the two groups showed no significant difference (p > 0.05).Conclusion: The fetalHQ is regarded as a straightforward and reliable approach for assessing the cardiac GSI and 24-segment SI of left and right ventricles in fetuses diagnosed with CHD. While CHD may not significantly impact the overall shape of the fetal heart or the geometric shape of the right ventricle, in this study, a notable increase in SI values for the left ventricular 1-2 segments was observed, indicating a more flattened ventricular chamber. Additionally, the morphological distinctions between the left and right ventricles in fetuses with CHD are no longer discernible.

Re: Correspondence on 'Fetal myocardial deformation measured with two-dimensional speckle-tracking echocardiography: longitudinal prospective cohort study of 124 healthy fetuses'

Linked article: This Correspondence comments on van Oostrum et al. Click here to view the article.

Characteristics and outcomes of fetal ventricular aneurysm and diverticulum: combining the use of a new technique, fetal HQ

Objectives

Congenital ventricular aneurysms or diverticulum (VA/VD) are rare cardiac anomalies with lack prenatal evaluation data. The present study aimed to provide the prenatal characteristics and outcomes from a tertiary center and the use of new techniques to evaluate the shape and contractility of these fetuses.

Methods

Ten fetuses were diagnosed with VA or VD, and 30 control fetuses were enrolled. Fetal echocardiography was performed to make the diagnosis. The prenatal echo characteristics and follow-up data were carefully reviewed. The shape and contractility measurements of the four-chamber view (4CV) and both ventricles were measured and computed using fetal fetal heart quantification (HQ).

Results

A total of 10 fetuses were enrolled, including 4 cases of left ventricular diverticulum, 5 cases of left ventricular aneurysm, and 1 case of right ventricular aneurysm (RVA). Four cases chose to terminate the pregnancy. The RVA was associated with a perimembranous ventricular septal defect. Two cases had fetal arrhythmia, and one case had pericardial effusion. After birth, one case underwent surgical resection at five years old. The 4CV global sphericity index (SI) of free-wall located ventricular outpouching (VO) was significantly lower than the apical ones and the control group (p < 0.01). Four of five apical left VOs had significant higher (>95th centile) SI in base segments, and three of four left VOs in the free-wall had significant lower (< 5th centile) SI in the majority of 24 segments. Compared to the control group, the left ventricle (LV) global longitudinal strain, ejection fraction, and fractional area change were significantly decreased (p < 0.01), while the LV cardiac output of the cases was in the normal range. The transverse fraction shortening of the affected segments of ventricles was significantly lower than the other ventricle segments (p < 0.01).

Conclusions

Fetal HQ is a promising technique to evaluate the shape and contractility of congenital ventricular aneurysm and diverticulum.

Cardiac Size, Shape, and Ventricular Contractility in Fetuses at Sea Level With an Estimated Weight Less-than 10th Centile

OBJECTIVES

To investigate cardiac size, shape, and ventricular contractility in fetuses with estimated fetal weight (EFW) <10th centile at sea level (Houston).

METHODS

A prospective ultrasound study examined 37 fetuses with EFW <10th centile at sea level. High-frequency cine clips were used to evaluate the 4-chamber view including end-diastolic measurements and global sphericity index. The size, shape, and contractility of both ventricles were analyzed with speckle tracking methods. Z scores were calculated using the mean ± standard deviation (SD) derived from normal controls. Measurements were abnormal if their Z score values were <-1.65 or >+1.65. The proportion of small fetuses with abnormal parameters was compared to normal reference ranges. Results were compared to a similar published study of small fetuses at higher altitude in Denver.

RESULTS

About one-third of Houston fetuses with EFW <10th centile had enlarged globular shaped 4-chamber hearts with increased right ventricle (RV) area, RV basal-apical length, RV base width, and left ventricle (LV) basal-apical length measurements. Bilateral ventricular hypertrophy was often present. An increased proportion of Houston fetuses had increased ventricular contractility. However, decreased ventricular contractility was more prevalent for higher altitude fetuses.

CONCLUSIONS

Third trimester fetuses at sea level, with an EFW <10th centile, were often associated with enlarged and globular-shaped hearts. They had increased global and longitudinal ventricular contractility as compared to controls. Higher altitude fetuses also had enlarged globular-shaped hearts but with a greater proportion of cases having decreased ventricular contractility as compared to the sea level cohort.

Fetal cardiac geometry and function in pregnancies with well-controlled gestational diabetes mellitus using Fetal HQ

OBJECTIVE

To determine whether abnormal cardiac shape and ventricular global, transverse, and longitudinal contractility are present in fetuses of women with well-controlled GDM.

METHODS

A prospective observational study was performed on 80 fetuses of women with well-controlled GDM and 90 control fetuses. Using Fetal HQ, a new speckle-tracking technique, cardiac shape, global contractility, transverse contractility, and longitudinal contractility were calculated. The number and percentage of fetuses with z score values below 5th or above 95th were computed.

RESULTS

Compared with controls, there were no significant differences in the frequency of cardiac geometric abnormalities in GDM fetuses. Despite good glycemic control, 60.0% of fetuses in the well-controlled GDM group had one or more types of global, longitudinal, and transverse contractility abnormalities of one or both ventricles, but more frequent on the right ventricle (RV, 50%). The most frequent abnormality of the RV occurred in the transverse contractility (35%), followed by abnormalities of global contractility (25%), and longitudinal contractility (21.3%), compared with controls. The left ventricle (LV) analysis demonstrated that the percentage of study fetuses with only transverse contractility abnormality (18.8%) was significantly higher.

CONCLUSIONS

Despite good glycemic control, abnormal ventricular contractility was present in fetuses of women with GDM, but more frequent in the RV. For both the RV and LV, transverse ventricular contractility abnormality were more prevalent than abnormal global and longitudinal contractility. Fetuses of women with GDM should be evaluated for ventricular contractility abnormality and have more follow-ups despite good glycemic control.