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Snoep MC, Demir D, Roestenburg AMC, Pajkrt E, van Leeuwen E, Linskens IH, Knobbe I, Clur SA, Rozendaal L, van der Meeren LE, Haak MC. Pregnancy Complications in Fetal Congenital Heart Disease: A Result of Common Early Developmental Pathways Rather Than Fetal Hemodynamics. Prenat Diagn 2025. [PMID: 40420225 DOI: 10.1002/pd.6819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2025] [Revised: 03/28/2025] [Accepted: 05/11/2025] [Indexed: 05/28/2025]
Abstract
OBJECTIVE The aim of this study was to compare placenta-related complications (adverse placental syndrome) between different types of fetal CHD based on cardiac hemodynamics. METHOD All CHD cases diagnosed prenatally by fetal ECHO during 2009-2023 were selected. Exclusion criteria were as follows: multiple pregnancies, pregnancy termination, known genetic aberrations, and extracardiac anomalies. Cases were categorized into 6 groups based on theorized hemodynamic factors. Reference values for fetal growth restriction (FGR), preeclampsia (PE), pregnancy induced hypertension (PIH), and intra uterine fetal demise (IUFD) from the overall Dutch and/or European population were used. RESULTS After exclusion, 1293 cases were available for analysis. The incidence of FGR was 198/1247 (15.9%). There was a significant difference in FGR between the groups of CHD (p = 0.002) though it could not be correlated with aortic flow and oxygenation. There was a high incidence of PE (64/1282, 5.0%), PIH (43/1284, 3.3%), and IUFD (33/1291, 2.6%) in our cohort as compared to reference values. Nonetheless, there were no differences in PE, PIH, and IUFD between the different CHD groups. CONCLUSION A high incidence of adverse placental syndrome was found though this could not be related to fetal hemodynamics. Even in CHDs without hemodynamic changes, a high incidence of these complications was found. This might be a clinical manifestation of early embryological developmental pathways that affect both the placenta and the fetal heart.
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Affiliation(s)
- Maartje C Snoep
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Damla Demir
- Department of Obstetrics and Fetal Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Anouk M C Roestenburg
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Eva Pajkrt
- Department of Obstetrics and Fetal Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Elisabeth van Leeuwen
- Department of Obstetrics and Fetal Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Ingeborg H Linskens
- Department of Obstetrics and Fetal Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Ingmar Knobbe
- Department of Pediatric Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Sally-Ann Clur
- Department of Pediatric Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Lieke Rozendaal
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lotte E van der Meeren
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Pathology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Monique C Haak
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, the Netherlands
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Wang H, Ji X, Han J, Wu J, Hao X, Xie J, Gu X, Sun L, He Y. Four novel types of placental villous trees: Insights from SlowflowHD ultrasound imaging into placental microvascular architecture in congenital heart disease. Int J Gynaecol Obstet 2025. [PMID: 40366308 DOI: 10.1002/ijgo.70215] [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: 01/04/2025] [Revised: 04/18/2025] [Accepted: 04/29/2025] [Indexed: 05/15/2025]
Abstract
OBJECTIVE Placental vascular development is critical for maternal-fetal exchange, and altered fetal cardiovascular physiology in congenital heart disease (CHD) may impact placental circulation. This study aimed to assess whether SlowflowHD imaging technology could qualitatively evaluate alterations in placental vascular structure in CHD. METHODS A cross-sectional study was conducted using SlowflowHD to image placental vasculature in 215 fetuses, normal (n = 106) and CHD (n = 109) including critical CHD (CCHD) (n = 66) and other fetal heart disease (FHD) (n = 43). SlowflowHD provided two-dimensional (2D) and three-dimensional (3D) imaging of placental villous tree structures. Differences in display rates and distribution characteristics of placental villous trees were analyzed between the normal, CCHD, and FHD groups. RESULTS SlowflowHD imaging technology demonstrated high sensitivity in visualizing placental vascular structures, with overall display rates of 95.5%-100%. Primary, secondary, and tertiary villi were visualized with rates of 95.5%-100%, 69.7%-97.7%, and 34.8%-88.7%, respectively. Four distinct placental villous tree types (types 0-3) were identified, exhibiting different distribution characteristics. The composition ratios of these types differed significantly between normal and CCHD fetuses, as well as between CCHD and FHD groups (P < 0.05). CONCLUSION SlowflowHD imaging technology effectively identifies and characterizes placental villous tree structures. Placental villous trees in CCHD fetuses display sparser distribution patterns compared with normal fetuses, highlighting potential implications for maternal-fetal exchange in CHD.
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Affiliation(s)
- Hairui Wang
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xueqin Ji
- Peking University First Hospital Ningxia Women and Children's Hospital, (Ningxia Hui Autonomous Region Maternal and Child Health Hospital), Yinchuan, China
| | - Jiancheng Han
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jian Wu
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Hao
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jiaoyang Xie
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Gu
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lin Sun
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yihua He
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Hedermann G, Hedley PL, Gadsbøll K, Thagaard IN, Krebs L, Karlsen MA, Vedel C, Rode L, Christiansen M, Ekelund CK. Adverse Obstetric Outcomes in Pregnancies With Major Fetal Congenital Heart Defects. JAMA Pediatr 2025; 179:163-170. [PMID: 39680388 PMCID: PMC11791717 DOI: 10.1001/jamapediatrics.2024.5073] [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: 07/22/2024] [Accepted: 09/08/2024] [Indexed: 12/17/2024]
Abstract
Importance Understanding the risk profile of obstetric complications in pregnancies with fetal major congenital heart defects (MCHDs) is crucial for obstetric counseling and care. Objective To investigate the risk of placenta-related adverse obstetric outcomes in pregnancies complicated by fetal MCHDs. Design, Setting, and Participants This cohort study retrieved data from June 1, 2008, to June 1, 2018, from the Danish Fetal Medicine Database, which includes comprehensive data on more than 95% of all pregnancies in Denmark since the database was instituted in 2008. All singleton pregnancies that resulted in a live-born child after 24 weeks' gestation without chromosomal aberrations were included. A systematic search of the literature was performed in PubMed, Embase, and the Cochrane Library from inception to June 1, 2024, to compile existing knowledge and data on adverse obstetric outcomes among MCHD subtypes. Exposure Fetal MCHDs including 1 of 11 subtypes. Main Outcomes and Measures The primary outcome was a composite adverse obstetric outcome defined as preeclampsia, preterm birth, fetal growth restriction, or placental abruption. Secondary outcomes consisted of each adverse obstetric event. Adjusted odds ratios (AORs) were computed using generalized estimating equations adjusted for maternal body mass index, age, smoking, and year of delivery. Meta-analyses were conducted using random-effects models to pool effect sizes for each MCHD subtype and adverse obstetric outcome. Results A total of 534 170 pregnancies were included in the Danish cohort, including 745 with isolated fetal MCHDs (median [IQR] maternal age, 29.0 [26.0-33.0] years) and 533 425 without MCHDs (median [IQR] maternal age, 30.0 [26.0-33.0] years). Pregnancies with fetal MCHDs exhibited a higher rate of adverse obstetric outcomes at 22.8% compared with 9.0% in pregnancies without fetal MCHDs (AOR, 2.96; 95% CI, 2.49-3.53). Preeclampsia (AOR, 1.83; 95% CI, 1.33-2.51), preterm birth at less than 37 weeks (AOR, 3.84; 95% CI, 3.15-4.71), and fetal growth restriction (AOR, 3.25; 95% CI, 2.42-4.38) occurred significantly more frequently in pregnancies with MCHDs. Except for fetal transposition of the great arteries (AOR, 1.19; 95% CI, 0.66-2.15), all MCHD subtypes carried a greater risk of adverse obstetric outcomes. The meta-analysis included 10 additional studies that supported these results. Conclusions and Relevance These findings suggest that nearly 1 in 4 women expecting a child with an MCHD, except transposition of the great arteries, may be at high risk of adverse obstetric outcomes.
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Affiliation(s)
- Gitte Hedermann
- Department for Congenital Disorders, Danish National Biobank and Biomarkers, Statens Serum Institut, Copenhagen, Denmark
- Department of Gynecology, Fertility, and Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Obstetrics and Gynecology, Slagelse Hospital, Slagelse, Denmark
| | - Paula L. Hedley
- Department for Congenital Disorders, Danish National Biobank and Biomarkers, Statens Serum Institut, Copenhagen, Denmark
- Department of Epidemiology, School of Public Health, University of Iowa, Iowa City
| | - Kasper Gadsbøll
- Center for Fetal Medicine and Pregnancy, Department of Gynecology, Fertility, and Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ida N. Thagaard
- Department for Congenital Disorders, Danish National Biobank and Biomarkers, Statens Serum Institut, Copenhagen, Denmark
- Department of Obstetrics and Gynecology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Lone Krebs
- Department of Obstetrics and Gynecology, Copenhagen University Hospital Amager and Hvidovre Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mona Aarenstrup Karlsen
- Department of Gynecology, Fertility, and Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Cathrine Vedel
- Center for Fetal Medicine and Pregnancy, Department of Gynecology, Fertility, and Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Line Rode
- Center for Fetal Medicine and Pregnancy, Department of Gynecology, Fertility, and Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Michael Christiansen
- Department for Congenital Disorders, Danish National Biobank and Biomarkers, Statens Serum Institut, Copenhagen, Denmark
- Department of Epidemiology, School of Public Health, University of Iowa, Iowa City
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte K. Ekelund
- Center for Fetal Medicine and Pregnancy, Department of Gynecology, Fertility, and Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Luke B, Fisher SC, Forestieri NE, Yazdy MM, Betancourt D, Sacha CR, Murugappan G, Cameron K, Baker VL, Purkayastha M, Williams C, Sutcliffe AG, Richard MA, Lupo PJ. Maternal, reproductive and perinatal factors and the risks of birth defects: traditional and emerging factors. Reprod Biomed Online 2024; 50:104781. [PMID: 40273488 DOI: 10.1016/j.rbmo.2024.104781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Revised: 12/02/2024] [Accepted: 12/17/2024] [Indexed: 04/26/2025]
Abstract
RESEARCH QUESTION Does an association exist between maternal, reproductive and perinatal factors, and the risks of major non-chromosomal birth defects? DESIGN This population-based cohort study included 1,126,058 naturally conceived singleton live births (21,644 with and 1,104,414 without a major non-chromosomal defect) who were born between 2004 and 2018 in New York, Texas, Massachusetts and North Carolina. All study children were linked to their respective state birth defect registries to identify major birth defects diagnosed within the first year of life, and to state death records. Children with chromosomal defects were excluded. Genitourinary defects were only evaluated in boys. Placental and bleeding issues included placenta previa, placental abruption, uterine bleeding and other excessive bleeding, and, at delivery, blood transfusion or unplanned hysterectomy. Adjusted odds ratios and 95% confidence intervals were modelled using logistic regression. RESULTS Among major non-chromosomal defects, the highest significant risks were with pre-gestational diabetes (adjusted OR 2.48, 95% CI 2.25 to 2.74), followed by placental or bleeding issues (adjusted OR 1.82, 95% CI 1.66 to 1.99); this pattern was also evident for congenital heart defects, blastogenesis defects, orofacial defects, gastrointestinal defects and musculoskeletal defects. Hypertension (pre-gestational and gestational), prior caesarean delivery, older maternal age and higher body mass index were also significant risk factors. CONCLUSIONS The risk factors most strongly associated with major non-chromosomal birth defects were pre-gestational diabetes and placental or bleeding issues; other significantly increased risks were hypertension (pre-gestational and gestational), prior caesarean delivery, older maternal age and pre-pregnancy body mass index 30 kg/m2 or above.
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Affiliation(s)
- Barbara Luke
- Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, East Lansing, Michigan, USA.; Population, Policy, and Practice Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK..
| | - Sarah C Fisher
- Birth Defects Registry, New York State Department of Health, Albany, New York, USA
| | - Nina E Forestieri
- Birth Defects Monitoring Program, State Center for Health Statistics, North Carolina, USA. Department of Health and Human Services, Raleigh, North Carolina, USA
| | - Mahsa M Yazdy
- Massachusetts Center for Birth Defects Research and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Dayana Betancourt
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Texas Health and Human Services, Austin, Texas, USA
| | - Caitlin R Sacha
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | | | - Katie Cameron
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Valerie L Baker
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mitana Purkayastha
- Population, Policy, and Practice Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Carrie Williams
- Population, Policy, and Practice Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Alastair G Sutcliffe
- Population, Policy, and Practice Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Melissa A Richard
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Philip J Lupo
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA.; Department of Pediatrics, Emory University School of Medicine, Atlanta, USA.; Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, USA
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5
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Prasad J, Van Steenwinckel J, Gunn AJ, Bennet L, Korzeniewski SJ, Gressens P, Dean JM. Chronic Inflammation Offers Hints About Viable Therapeutic Targets for Preeclampsia and Potentially Related Offspring Sequelae. Int J Mol Sci 2024; 25:12999. [PMID: 39684715 PMCID: PMC11640791 DOI: 10.3390/ijms252312999] [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: 08/29/2024] [Revised: 11/22/2024] [Accepted: 11/26/2024] [Indexed: 12/18/2024] Open
Abstract
The combination of hypertension with systemic inflammation during pregnancy is a hallmark of preeclampsia, but both processes also convey dynamic information about its antecedents and correlates (e.g., fetal growth restriction) and potentially related offspring sequelae. Causal inferences are further complicated by the increasingly frequent overlap of preeclampsia, fetal growth restriction, and multiple indicators of acute and chronic inflammation, with decreased gestational length and its correlates (e.g., social vulnerability). This complexity prompted our group to summarize information from mechanistic studies, integrated with key clinical evidence, to discuss the possibility that sustained or intermittent systemic inflammation-related phenomena offer hints about viable therapeutic targets, not only for the prevention of preeclampsia, but also the neurobehavioral and other developmental deficits that appear to be overrepresented in surviving offspring. Importantly, we feel that carefully designed hypothesis-driven observational studies are necessary if we are to translate the mechanistic evidence into child health benefits, namely because multiple pregnancy disorders might contribute to heightened risks of neuroinflammation, arrested brain development, or dysconnectivity in survivors who exhibit developmental problems later in life.
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Affiliation(s)
- Jaya Prasad
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1142, New Zealand; (J.P.); (A.J.G.); (L.B.); (J.M.D.)
| | | | - Alistair J. Gunn
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1142, New Zealand; (J.P.); (A.J.G.); (L.B.); (J.M.D.)
| | - Laura Bennet
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1142, New Zealand; (J.P.); (A.J.G.); (L.B.); (J.M.D.)
| | - Steven J. Korzeniewski
- C.S. Mott Center for Human Growth and Development, Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48202, USA
| | - Pierre Gressens
- Inserm, Neurodiderot, Université de Paris, 75019 Paris, France;
- Centre for the Developing Brain, Division of Imaging Sciences and Department of Biomedical Engineering, King’s College London, King’s Health Partners, St. Thomas’ Hospital, London SE1 7EH, UK
| | - Justin M. Dean
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1142, New Zealand; (J.P.); (A.J.G.); (L.B.); (J.M.D.)
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Lemieux A, Khalilipalandi S, Lauzon-Schnittka J, Taillefer V, Tousignant A, Perreault L, Rego K, Dubois M, Watelle L, Roy LO, Dallaire F. Meta-Analysis of Risk Factors for Congenital Heart Disease: Part 2, Maternal Medication, Reproductive Technologies, and Familial and Fetal Factors. Can J Cardiol 2024; 40:2496-2511. [PMID: 39288833 DOI: 10.1016/j.cjca.2024.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 09/09/2024] [Accepted: 09/11/2024] [Indexed: 09/19/2024] Open
Abstract
BACKGROUND The quantitative effects of congenital heart disease (CHD) risk factors are not fully understood. We conducted a meta-analysis of all CHD risk factors. This report explores maternal medication, assisted reproductive technologies (ART), and familial and fetal factors. METHODS Relevant studies were identified using a search strategy encompassing the concepts of CHD and prenatal risk factors with the following inclusion criteria: (1) peer-reviewed articles, (2) quantifying the effects of CHD risk factors, and (3) between 1989 and 2022. Pooled odds ratios (OR) and 95% confidence intervals (CIs) were calculated using a random effect model. RESULTS There were 131 articles that met the inclusion criteria. Associations were found between CHDs and extracardiac anomalies (OR, 3.41; 95% CI, 1.72-6.77), increased nuchal translucency (OR, 6.87; 95% CI, 2.42-19.53), family history of CHD (OR, 2.90; 95% CI, 2.25-3.75), maternal antidepressants (OR, 1.23; 95% CI, 1.09-1.38), and antihypertensives (OR, 2.07; 95% CI, 1.80-2.38). A positive association was observed between severe CHDs and lithium, but with a very wide CI encompassing the null effect. A positive association was observed between severe CHDs and ARTs (OR, 1.98; 95% CI, 1.30-3.02). The data were insufficient for anomalies of the umbilical cord, anticonvulsants, and retinoid medication. CONCLUSIONS There were strong associations among CHDs and increased nuchal translucency, extracardiac anomalies, and family history of CHD. Effect sizes were modest for maternal medication and ART. Data were scarce and sometimes inconclusive for some risk factors commonly cited as being associated with CHD such as lithium, anomalies of the umbilical cord, anticonvulsants, and retinoid medication.
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Affiliation(s)
- Alyssia Lemieux
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Sara Khalilipalandi
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Jonathan Lauzon-Schnittka
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Valérie Taillefer
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Angélique Tousignant
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Laurence Perreault
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Kevin Rego
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Mélodie Dubois
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Laurence Watelle
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Louis-Olivier Roy
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Frédéric Dallaire
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada.
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7
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Khalilipalandi S, Lemieux A, Lauzon-Schnittka J, Perreault L, Dubois M, Tousignant A, Watelle L, Pratte G, Dallaire F. Systematic Review and Meta-analysis of Prenatal Risk Factors for Congenital Heart Disease: Part 1, Maternal Chronic Diseases and Parental Exposures. Can J Cardiol 2024; 40:2476-2495. [PMID: 38996968 DOI: 10.1016/j.cjca.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 06/14/2024] [Accepted: 07/05/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND There is considerable heterogeneity in studies on prenatal risk factors for congenital heart diseases (CHDs). We performed a meta-analysis of all nongenetic factors of CHDs. This report presents results of factors related to maternal chronic diseases and parental exposures. METHODS A systematic search encompassing concepts of CHD and risk factors was used, using the following inclusion criteria: (1) original peer-reviewed articles, (2) quantifying the effects of risk factors for CHDs, (3) between 1989 and 2022. Pooled odds ratios (ORs) and 95% confidence interval (CI) were calculated using a random-effect model. RESULTS Inclusion criteria were met for 170 studies. There was an association between being overweight or obese and CHDs (OR, 1.26; 95% CI, 1.15-1.37), with a dose-effect relationship. Pregestational diabetes (PGDM) was associated with CHDs (OR, 3.51; 95% CI, 2.86-4.3), without difference between type 1 and type 2 PGDM. The effect size of gestational diabetes was less than that of PGDM (OR, 1.38; 95% CI, 1.18-1.61). There was an association between CHDs and pre-eclampsia (OR, 2.01; 95% CI, 1.32-3.05), paternal smoking (OR, 1.32; 95% CI, 1.03-1.70), and alcohol use (OR, 1.50; 95% CI, 1.08-2.08). A smaller association was found with maternal smoking and advanced maternal age. CONCLUSIONS There exists robust evidence for increased risk of CHD in the presence of obesity, maternal diabetes, maternal smoking, and increased maternal age. The effect sizes were relatively modest, except for PGDM. The robustness of the evidence decreased when CHDs were divided into subgroups or when the analyses were restricted to severe CHDs.
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Affiliation(s)
- Sara Khalilipalandi
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Alyssia Lemieux
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Jonathan Lauzon-Schnittka
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Laurence Perreault
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Mélodie Dubois
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Angélique Tousignant
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Laurence Watelle
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Gabriel Pratte
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Frédéric Dallaire
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada.
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8
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Wang H, Han J, Gu X, Zhang Y, He Y. Visualization of placental villi: Three-dimensional ultrasound imaging shows coral-like placental villous trees. Int J Gynaecol Obstet 2024; 167:1267-1268. [PMID: 38993147 DOI: 10.1002/ijgo.15793] [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: 05/12/2024] [Revised: 06/21/2024] [Accepted: 07/02/2024] [Indexed: 07/13/2024]
Abstract
SynopsisWe introduce a new microflow imaging technique, which can show the blood perfusion and morphological structure of placental villi.
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Affiliation(s)
- Hairui Wang
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jiancheng Han
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Gu
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ye Zhang
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yihua He
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Snoep MC, Nijman M, DeRuiter MC, Bekker MN, Aliasi M, Breur JMPJ, Ten Harkel ADJ, Benders MJNL, van der Meeren LE, Haak MC. Placenta histology related to flow and oxygenation in fetal congenital heart disease. Early Hum Dev 2024; 195:106079. [PMID: 39047634 DOI: 10.1016/j.earlhumdev.2024.106079] [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: 06/03/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Fetuses with congenital heart defects (CHD) show delayed neurodevelopment, fetal growth restriction (FGR) and placenta related complications. The neurodevelopmental delay may be, partly, attributed to placental factors. AIM As both placental development and fetal aortic flow/oxygenation influence neurodevelopment, placentas were compared within fetal CHD groups based on aortic oxygenation and flow, aiming to unravel the true effects in the developmental processes. STUDY DESIGN Placental tissues of pregnancies with fetal CHD and healthy controls were selected from biobanks of two Dutch academic hospitals (LUMC, UMCU). Additionally, biometry and Dopplers were assessed. SUBJECTS CHD cases with reduced oxygenation (RO) towards the fetal brain were compared to cases with reduced flow (RF) in the aortic arch and healthy controls. Genetic abnormalities, termination of pregnancy, fetal demise and/or multiple pregnancies were excluded. OUTCOME MEASURES Histological outcomes were related to fetal Dopplers and biometry. A placenta severity score was used to assess the severity of placental abnormalities per case. RESULTS In CHD, significantly more delayed maturation, maternal vascular malperfusion, fetal hypoxia and higher placenta severity scores (median 14 in RO, 14 in RF, 5 in controls, p < 0.001) were observed. Doppler abnormalities (PI UA > p90, PI MCA < p10, CPR < p10) and FGR were more often found in CHD. There were no differences in placental abnormalities, fetal growth and fetal Dopplers between cases with RO and RF. CONCLUSION Fetal hemodynamics in the ascending aorta could not be related to placenta characteristics. We hypothesize that placental development influences neurodevelopment in excess of hemodynamics 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.
| | - Maaike Nijman
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Pediatric Cardiology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marco C DeRuiter
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mireille N Bekker
- Department of Obstetrics and Fetal Medicine, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Moska Aliasi
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Johannes M P J Breur
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Arend D J Ten Harkel
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Manon J N L Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lotte E van der Meeren
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands; Department of Pathology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Monique C Haak
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, the Netherlands
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10
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Katlaps I, Ronai C, Garg B, Mandelbaum A, Ghafari-Saravi A, Caughey AB, Madriago E. The Ongoing Relationship Between Offspring Congenital Heart Disease and Preeclampsia Across Pregnancies. JACC. ADVANCES 2024; 3:101009. [PMID: 39130014 PMCID: PMC11313037 DOI: 10.1016/j.jacadv.2024.101009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 01/12/2024] [Accepted: 01/30/2024] [Indexed: 08/13/2024]
Abstract
Background Prior literature has described an association between preeclampsia and offspring congenital heart disease (CHD), while suggesting there may be a stronger relationship in individuals with early preeclampsia. Objectives The authors sought to explore the relationship between offspring CHD and preeclampsia among pregnancies in a population-based study. Methods Retrospective cohort study all singleton pregnancies delivered in the state of California 2000 to 2012. We included singleton births with gestational ages of 23 to 42 weeks and excluded pregnancies complicated by pre-existing diabetes or identified fetal chromosomal anomalies. We used multivariable logistic regression to estimate ORs for associations between offspring CHD and preeclampsia. Further subanalyses examined the relationships in deliveries <34 weeks and >34 weeks to analyze if there was a difference according to timing of preeclampsia development. Results Preeclampsia was strongly associated with offspring CHD (aOR: 1.38; 99% CI: 1.29-1.49) in the same pregnancy. Among patients with preeclampsia in the index pregnancy, there was an increased risk of fetal CHD in the subsequent pregnancy (aOR: 1.39; 99% CI: 1.20-1.61). Among patients with offspring CHD in the index pregnancy, there was an increased risk of preeclampsia in the subsequent pregnancy (aOR: 1.39; 99% CI: 1.15-1.68). In all 3 analyses, results remained significant when stratified by <34 weeks and ≥34 weeks. Conclusions Our findings suggest a need for further investigation into the etiology of preeclampsia and its relationship to embryologic development of cardiovascular structures.
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Affiliation(s)
- Isabel Katlaps
- Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Christina Ronai
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bharti Garg
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Ava Mandelbaum
- Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Erin Madriago
- Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
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11
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Aliasi M, Mastenbroek M, Papakosta S, van Geloven N, Haak MC. Birthweight of children with isolated congenital heart disease-A sibling analysis study. Prenat Diagn 2023; 43:639-646. [PMID: 36811197 DOI: 10.1002/pd.6336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/14/2023] [Accepted: 02/14/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE Congenital heart disease (CHD) is associated with decreased birthweight (BW) compared to population-based references. The aim of this study was to compare the BW of isolated CHD cases to their siblings, thus controlling for unknown and unmeasured confounders within the family. METHODS All isolated CHD cases in the Leiden University Medical Center were included (2002-2019). Generalized estimated equation models were constructed to compare BW z scores of CHD neonates with their siblings. Cases were clustered to minor or severe CHD and stratified according to the aortic flow and oxygenation to the brain. RESULTS The overall BW z score of siblings was 0.032 (n = 471). The BW z score was significantly lower in CHD cases (n = 291) compared to their siblings (-0.20, p = 0.005). The results were consistent in the subgroup analysis of severe and minor CHD (BW z score difference -0.20 and -0.10), but did not differ significantly (p = 0.63). Stratified analysis regarding flow and oxygenation showed no BW difference between the groups (p = 0.1). CONCLUSION Isolated CHD cases display a significantly lower BW z score compared to their siblings. As the siblings of these CHD cases show a BW distribution similar to the general population, this suggests that shared environmental and maternal influences between siblings do not explain the difference in BW.
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Affiliation(s)
- Moska Aliasi
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Malou Mastenbroek
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Styliani Papakosta
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Nan van Geloven
- Department of Biomedical Data Sciences, 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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12
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Association between placental DNA methylation and fetal congenital heart disease. Mol Genet Genomics 2023; 298:243-251. [PMID: 36396788 DOI: 10.1007/s00438-022-01944-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 08/11/2022] [Indexed: 11/18/2022]
Abstract
Congenital heart disease (CHD) is a worldwide problem with high morbidity and mortality. Early diagnosis of congenital heart disease is still a challenge in clinical work. In recent years, few studies indicated that placental methylation may be predictors of CHD. More studies are needed to confirm the association between placental methylation and CHD. The aim of this study was to investigate the association between prenatal placental DNA methylation and CHD. Placental tissues were obtained from four fetuses during the second trimester with isolated, non-syndromic congenital heart disease, including three cases with double outlet right ventricle (DORV) and one case with tetralogy of Fallot (TOF), and four unaffected fetuses as controls. The Illumina Infinium Human Methylation 850K BeadChip assay was employed to identify differential methylation sites (DMSs) and differential methylation regions (DMRs). Differential methylation was evaluated by comparing the β-values for individual CpG loci in cases vs. controls. In addition, the function of genes was assessed through KEGG enrichment analysis, Gene Ontology (GO) analysis and KEGG pathway analysis. Compared with the control group, we identified 9625 differential methylation genes on 26,202 DMSs (p < 0.05), of which 6997 were hyper-methylation and 2628 were hypo-methylation. The top 30 terms of GO biological process and KEGG enrichment analysis of DMSs were connected with multiple important pathways of heart development and disease. Ten differentially methylated regions and the genes related to DMRs, such as TLL1, CRABP1, FDFT1, and PCK2, were identified. The deformity caused by the loss of function of these genes is remarkably consistent with the clinical phenotype of our cases. The DNA methylation level of placental tissue is closely associated with fetal congenital heart disease.
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13
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Liu J, Wu Y, Sun H, Liu X, Gu X, Zhao Y, Zhang Y, Han J, He Y. Placental DNA Methylation Abnormalities in Prenatal Conotruncal Heart Defects. Front Genet 2022; 13:878063. [PMID: 35646082 PMCID: PMC9139681 DOI: 10.3389/fgene.2022.878063] [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: 02/17/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aims to characterize the abnormal changes in placental DNA methylation associated with conotruncal heart defects (CTDs) and the level of methylation as epigenetic biomarkers for CTDs detection. Methods: This was a prospective study involving 28 fetuses diagnosed with CTDs in the second trimester at Beijing Anzhen Hospital between September 2020 and June 2021. These cases were classified into four groups based on their subtypes. 12 normal fetuses were used as controls. Placental tissue was obtained after inducing labor in fetuses. To identify differential methylation sites (DMSs) and regions (DMRs) in cases vs. controls, an Infinium Human Methylation 850 k bead chip was used. Differential methylation was assessed by comparing the β-values for individual CpG loci. Based on the p-value (<0.05), the most discriminating CpG sites were identified. The area under the receiver-operating-characteristics curve (AUC) was used to determine the predictive accuracy of CpG loci with significant methylation changes for CTDs. The function of genes was assessed through KEGG enrichment analysis, Gene Ontology (GO) analysis, and KEGG pathway analysis. Results: In comparison to the control group, the DNA methylation of the placental tissue is significantly different in fetuses with CTDs. We identified the most significantly different methylated loci and they demonstrated excellent individual predictive accuracy for CTDs detection with AUC >0.9 in cases compared with controls. HOXD9, CNN1, NOTCH1, and ECE1 were identified as CTDs-detection candidate genes. Conclusion Our study established the abnormal changes in placental methylation associated with CTDs and potential epigenetic biomarkers for CTDs detection.
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Affiliation(s)
- Jingjing Liu
- Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuduo Wu
- Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hairui Sun
- Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaowei Liu
- Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Gu
- Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ying Zhao
- Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ye Zhang
- Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jiancheng Han
- Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yihua He
- Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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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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15
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Zhang S, Qiu X, Wang T, Chen L, Li J, Diao J, Li Y, Qin J, Chen L, Jiang Y. Hypertensive Disorders in Pregnancy Are Associated With Congenital Heart Defects in Offspring: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:842878. [PMID: 35419442 PMCID: PMC8995565 DOI: 10.3389/fcvm.2022.842878] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/03/2022] [Indexed: 11/16/2022] Open
Abstract
Background Although research indicates an association between hypertensive disorders of pregnancy (HDP) and congenital heart defects (CHDs) in offspring, consistency is still lacking. Therefore, we aimed to synthesize the updated published epidemiologic evidence to estimate the association of maternal HDP with the risk of total CHDs and its phenotypes in offspring. Methods A systematic search of Web of Science Database, PubMed, and Embase were searched from inception through April 30, 2021 based on a preprepared protocol, and the reference lists were also manually searched. The combined risk estimates were calculated using either the fixed-effect models or random-effect models. Possible heterogeneity moderators were detected by subgroup, sensitivity analyses, and Galbraith plot. Results Twenty-four studies involving 477,839 CHDs cases among 40,394,699 participants were included in our meta-analysis. Mothers who had HDP exposure were significantly associated with an increased risk of total CHDs compared with non-exposure. When maternal HDP exposure was further subdivided into pre-eclampsia (OR = 1.79, 95% CI: 1.50–2.13), gestational hypertension (OR = 1.16, 95% CI: 1.02–1.31), and chronic hypertension (OR = 1.68, 95% CI: 1.49–1.89), a significantly increased risk of total CHDs were still presented. Furthermore, a statistically significant increased association was found between maternal HDP exposure and most CHD phenotypes. Besides, relevant heterogeneity moderators have been identified by subgroup and sensitivity analyses. Conclusion Our study suggested that maternal HDP exposure may be associated with an increase in the risk of CHDs in offspring. These findings highlight the need for greater surveillance of pregnant women with HDP exposure to allow early prevention that may be good for reducing the risk of CHDs in offspring. Clinical Trial Registration [www.ClinicalTrials.gov], identifier [CRD42021268093].
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Affiliation(s)
- Senmao Zhang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha, China
| | - Xing Qiu
- Xiangya Nursing School of Central South University, Changsha, China
| | - Tingting Wang
- National Health Commission Key Laboratory for Birth Defect Research and Prevention, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, China
| | - Letao Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha, China
| | - Jinqi Li
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha, China
| | - Jingyi Diao
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha, China
| | - Yihuan Li
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha, China
| | - Jiabi Qin
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha, China
| | - Lizhang Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha, China
- *Correspondence: Lizhang Chen,
| | - Yurong Jiang
- Department of Obstetrics, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, China
- Yurong Jiang,
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Ferreira BD, Barros T, Moleiro ML, Guedes-Martins L. Preeclampsia and Fetal Congenital Heart Defects. Curr Cardiol Rev 2022; 18:80-91. [PMID: 35430980 PMCID: PMC9896419 DOI: 10.2174/1573403x18666220415150943] [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: 07/11/2021] [Revised: 12/01/2021] [Accepted: 01/16/2022] [Indexed: 11/22/2022] Open
Abstract
Endothelial dysfunction, impaired implantation and placental insufficiency have been identified as mechanisms behind the development of pre-eclampsia, resulting in angiogenic factors' alteration. Angiogenic imbalance is also associated with congenital heart defects, and this common physiologic pathway may explain the association between them and pre-eclampsia. This review aims to understand the physiology shared by these two entities and whether women with pre-eclampsia have an increased risk of fetal congenital heart defects (or the opposite). The present research has highlighted multiple vasculogenic pathways associated with heart defects and preeclampsia, but also epigenetic and environmental factors, contributing both. It is also known that fetuses with a prenatal diagnosis of congenital heart disease have an increased risk of several comorbidities, including intrauterine growth restriction. Moreover, the impact of pre-eclampsia goes beyond pregnancy as it increases the risk for following pregnancies and for diseases later in life in both offspring and mothers. Given the morbidity and mortality associated with these conditions, it is of foremost importance to understand how they are related and its causative mechanisms. This knowledge may allow earlier diagnosis, an adequate surveillance or even the implementation of preventive strategies.
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Affiliation(s)
| | - Tânia Barros
- Address correspondence to this author at the Instituto de Ciências Biomédicas Abel Salazar, University of Porto, P.O. Box: 4050-313, Porto, Portugal; Tel/Fax: +351917518938; E-mail:
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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: 18] [Impact Index Per Article: 4.5] [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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Izhar R, Ala SH, Husain S, Husain S. Anti-phospholipid antibodies in women presenting with preterm delivery because of preeclampsia or placental insufficiency. J Turk Ger Gynecol Assoc 2021; 22:85-90. [PMID: 33631871 PMCID: PMC8187972 DOI: 10.4274/jtgga.galenos.2021.2020.0143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Objective: To assess the proportion of women presenting with preterm delivery because of preeclampsia or placental insufficiency (PREPI) with anti-phospholipid antibodies (APLA). Material and Methods: This was a prospective cohort study conducted at an obstetrics and gynecology department. Women, aged 20-40 years, with preeclampsia who delivered before 34 weeks were cases while those who delivered before 34 weeks but did not have preeclampsia acted as controls. Both groups had APLA measured at diagnosis and 12-weeks postnatally. Anti-phospholipid antibody syndrome (APS) was diagnosed according to Sapporo’s criteria. Results: The study included 98 cases and 106 controls. Both cases and controls were similar in terms of age, gestational age and parity. The frequency of APS positivity was 17.3% in cases but only 3.8% in controls (p=0.001). Cases were more likely to be of Baloch ethnicity (34.7% vs. 11.3%, p=0.001), have a history of miscarriage (25.5% vs. 13.2%, p=0.026), use aspirin (p<0.001) or low molecular weight heparin (p<0.001), and be obese (p<0.001) than controls. Cases were more likely to have lupus anticoagulant antibodies (82.4% vs. 75%). Conclusion: Our study confirms a high prevalence of APLA in women who have preterm delivery due to PREPI. An opportunity to screen these women should be made, so that proper counselling can be given and future pregnancies can be managed in an appropriate and timely manner.
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Affiliation(s)
- Rubina Izhar
- Department of Obstetrics and Gynecology, Karachi Medical and Dental College, Abbasi Shaheed Hospital, Karachi, Pakistan
| | - Syed Hasan Ala
- Department of Obstetrics and Gynecology, Dow University of Health Sciences, Karachi, Pakistan
| | - Samia Husain
- Department of Obstetrics and Gynecology, Karachi Medical and Dental College, Abbasi Shaheed Hospital, Karachi, Pakistan
| | - Sonia Husain
- Department of Obstetrics and Gynecology, Karachi Medical and Dental College, Abbasi Shaheed Hospital, Karachi, Pakistan
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Wang S, Freud LR, Detterich J, Moon-Grady AJ, Donofrio MT, Jaeggi ET, Szwast AL, Morris SA, Kavanaugh-Mchugh A, Howley LW, van der Velde ME, Cuneo BF, Phoon CK, Tworetzky W, Pruetz JD. Extracardiac Doppler indices predict perinatal mortality in fetuses with Ebstein anomaly and tricuspid valve dysplasia. Prenat Diagn 2021; 41:332-340. [PMID: 33242215 DOI: 10.1002/pd.5873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/22/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Ebstein anomaly and tricuspid valve dysplasia (EA/TVD) carry high perinatal mortality. Past studies have focused on cardiac predictors of mortality; we sought to describe the fetal echo (FE) extracardiac Dopplers in this cohort and determine their association with perinatal mortality. METHOD Fetuses with EA/TVD at 23 centers from 2005-2011 were included for retrospective study. Doppler pattern and velocity of the umbilical artery (UA), umbilical vein (UV), ductus venosus (DV), and middle cerebral artery (MCA) were collected. Bivariate and multivariate analyzes were performed. The primary outcome measure was perinatal mortality, defined as fetal demise or neonatal death. RESULTS Of 190 cases that met eligibility criteria, alterations were seen in 50% of UA, 16% of UV, 48% of DV, and 8% of MCA Doppler indices on the last FE (median 27.4 weeks). Independent predictors of perinatal mortality included abnormal UA Doppler pattern of absence or reversed end diastolic flow (OR 9.7) and UV velocity z score <1 (OR 2.5), in addition to diagnosis <32 weeks (OR 4.2) and tricuspid valve (TV) annulus z score ≥6 (OR 5.3). CONCLUSION Abnormal UA Doppler pattern and decreased UV velocity are independent predictors of perinatal mortality in EA/TVD fetuses and should be used to refine mortality risk and guide perinatal management.
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Affiliation(s)
- Shuo Wang
- Department of Pediatrics, Division of Cardiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Lindsay R Freud
- Department of Pediatrics, Division of Cardiology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jon Detterich
- Department of Pediatrics, Division of Cardiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Anita J Moon-Grady
- Department of Pediatrics, Division of Cardiology, Benioff Children's Hospital, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Mary T Donofrio
- Department of Pediatrics, Division of Cardiology, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Edgar T Jaeggi
- Department of Pediatrics, Division of Cardiology, Hospital for Sick Children, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Anita L Szwast
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Shaine A Morris
- Department of Pediatrics, Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Ann Kavanaugh-Mchugh
- Department of Pediatrics, Division of Cardiology, Monroe Carell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lisa W Howley
- Department of Pediatrics, Division of Cardiology, The Children's Heart Clinic and Children's Minnesota, Minnesota, USA
| | - Mary E van der Velde
- Department of Pediatrics, Division of Cardiology, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Bettina F Cuneo
- Department of Pediatrics, Division of Cardiology, The Children's Heart Clinic and Children's Minnesota, Minnesota, USA
| | - Colin K Phoon
- Department of Pediatrics, Division of Cardiology, Hassenfeld Children's Hospital at NYU Langone, New York University School of Medicine, New York, New York, USA
| | - Wayne Tworetzky
- Department of Pediatrics, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jay D Pruetz
- Department of Pediatrics, Division of Cardiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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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: 2.6] [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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21
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Bahado-Singh R, Vishweswaraiah S, Mishra NK, Guda C, Radhakrishna U. Placental DNA methylation changes in detection of tetralogy of Fallot. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:768-775. [PMID: 30977211 DOI: 10.1002/uog.20292] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/01/2019] [Accepted: 04/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To determine whether the methylation level of cytosine nucleotides in placental DNA can be used to predict tetralogy of Fallot (TOF) and provide insights into the developmental mechanism of this condition. METHODS Tissue sections were obtained from formalin-fixed paraffin-embedded specimens of placental tissue obtained at birth from eight cases with non-chromosomal, non-syndromic TOF and 10 unaffected newborns. The Illumina Infinium HumanMethylation450 BeadChip assay was used to measure cytosine ('CpG' or 'cg') methylation levels at loci throughout the placental genome. Differential methylation was assessed by comparing the β-values (a measure of the extent of cytosine methylation) for individual CpG loci in fetuses with TOF vs in controls. The most discriminating CpG sites were determined based on a preset cut-off of ≥ 2.0-fold change in the methylation level. The predictive accuracy of CpG loci with significant methylation changes for TOF was determined by the area under the receiver-operating-characteristics curve (AUC). A false-discovery-rate (FDR) P-value < 0.05 was used to define a statistically significant difference in the methylation level. Ingenuity Pathway Analysis (IPA) (Qiagen) was used to identify gene pathways that were significantly overexpressed, and thus altered, in TOF cases compared with controls. RESULTS We found a total of 165 significantly differentially methylated CpG loci in TOF cases compared with controls, in 165 separate genes. These biomarkers demonstrated from fair to excellent individual predictive accuracy for TOF detection, with AUCs ≥ 0.75 (FDR P-value < 0.001 for all). The following CpG loci (gene) had the highest predictive accuracy: cg05273049 (ARHGAP22; AUC = 1.00; 95% CI, 1.00-1.00), cg02540011 (CDK5; AUC = 0.96; 95% CI, 0.87-1.00), cg08404201 (TRIM27; AUC = 0.95; 95% CI, 0.84-1.00) and cg00687252 (IER3; AUC = 0.95; 95% CI, 0.84-1.00). IPA revealed over-representation (dysregulation) of 14 gene pathways involved in normal cardiac development, including cardiomyocyte differentiation via bone morphogenetic protein receptors, cardiac hypertrophy signaling and role of nuclear factor of activated T cells in cardiac hypertrophy. Cardiac hypertrophy is an important feature of TOF. CONCLUSIONS Analysis of placental DNA cytosine methylation changes yielded accurate markers for TOF detection and provided mechanistic information on TOF development. Our work appears to confirm the central role of epigenetic changes and of the placenta in the development of TOF. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Bahado-Singh
- Department of Obstetrics and Gynecology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - S Vishweswaraiah
- Department of Obstetrics and Gynecology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - N K Mishra
- Department of Genetics, Cell Biology & Anatomy College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - C Guda
- Department of Genetics, Cell Biology & Anatomy College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - U Radhakrishna
- Department of Obstetrics and Gynecology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
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