Effect of maternal diabetes on fetal heart function on echocardiography: systematic review and meta-analysis

Association Between Sphericity and Ventricular Function in Fetus of Diabetic Mother: A Longitudinal Study from Fetal to Neonatal Period

The impact of maternal diabetes on the fetal heart is complex and not fully understood. The study aimed to investigate how different types and stages of maternal diabetes affect fetal heart function and ventricular remodeling during prenatal and postnatal periods. The study included 45 pregnant women with diabetes and 15 with uncomplicated pregnancies. Fetal echocardiograms were performed between 28 and 32 weeks of gestation using different techniques to assess cardiac function. Measurements of ventricular transverse and longitudinal diameters, as well as the sphericity index, were determined. Postnatal follow-up echocardiograms were also performed. The diabetic pregnant group was divided into three subgroups: 15 with GDM and 30 with PGD, including 15 wellcontrolled and 15 uncontrolled cases. The E and E/A ratio values for the mitral and tricuspid valves were significantly lower in fetuses and neonates affected by diabetes compared to the healthy group. The Tei-Doppler index for the left ventricle was significantly higher in pregnancies affected by diabetes, affecting both fetuses and neonates. The right ventricle exhibited significant differences in all groups of diabetic pregnancies in fetuses and postnatally in cases of pregestational diabetes. The sphericity index differed significantly in all fetal diabetic groups and in neonates compared to controls, except for the LV in the GDM cohort. Postnatally, the sphericity index of the RV increased compared to fetal values, while the LV sphericity index remained unchanged. Maternal diabetes mellitus affects fetal cardiac function and structure, which may continue into the early days of life.

Prenatal Diagnosis of Ductal Constriction in Normal Heart Anatomy-Are There Any Neonatal Consequences?

Background/Objectives: The main goal of this study was to determine whether ductal constriction in the third trimester of a pregnancy during fetal echocardiography examination has an impact on the neonatal clinical condition during the first days after birth. Methods: A retrospective study was based on 348 newborns who were examined during their fetal life in the third trimester of a pregnancy in our fetal cardiology center. They were divided into two groups: the study group (n = 49): neonates with "normal heart anatomy" (NHA), assessed by fetal echocardiography (ECHO) examination and prenatally diagnosed ductal constriction (NHA-DC); and the control group (n = 299): NHA neonates without DC (NHA-NDC). Results: Prenatally, DC was associated with other functional abnormalities, such as myocardial hypertrophy, cardiomegaly, tricuspid regurgitation, pericardial effusion and abnormal flow through foramen ovale. Neonates with prenatally diagnosed DC in 43% of cases presented with elevated neonatal bilirubin levels requiring phototherapy treatment (p < 0.006). In the study group 27% of neonates showed signs of breathing difficulties in the first hours of life (p < 0.001). Neonates with a prenatal diagnosis of DC were hospitalized longer than neonates with a normal heart study (NHS) (p < 0.001). Conclusions: Neonates with a prenatal diagnosis of ductal constriction are prone to having transient respiratory problems (up to 27%) and mild neonatal hyperbilirubinemia (in presented series up to 43%). Gestational diabetes can be associated with ductal constriction.

Endothelial-to-mesenchymal transition in the fetoplacental macrovasculature and microvasculature in pregnancies complicated by gestational diabetes

Gestational diabetes mellitus (GDM) is linked to altered fetal development and an increased risk of offspring developing cardiometabolic diseases in adulthood. The mechanisms responsible are unclear; however, GDM is associated with altered fetoplacental vascularisation, fibrosis and endothelial dysfunction. In non-pregnant individuals with diabetes, similar vascular changes are attributed to disruptions in endothelial-to-mesenchymal transition (EndMT), a key process where endothelial cells adopt a mesenchymal phenotype. Here, we assess whether alterations in the fetoplacental macro- and microvasculature are attributed to EndMT, using human umbilical vein endothelial cells (HUVECs) and human term placental tissue, respectively. Transforming growth factor (TGF)-β2 and interleukin (IL)-1β induced morphological and molecular changes consistent with EndMT in both GDM and non-GDM HUVECs. The ability of TGF-β2 and IL-1β to alter expression of known EndMT regulators, VWF, TGFBR1, IL1B and IL1R1, was diminished in GDM HUVECs; however, all other hallmarks of EndMT were similar. In placental villous tissue, Slug and Snail, two key transcriptional regulators of EndMT, were detected in the villous stroma, suggesting that EndMT probably occurs in the placental microvasculature. We observed a reduction in endothelial marker genes PECAM1, VWF and CDH5 in GDM placentas, suggesting reduced placental vascularisation. This was accompanied by a reduction in EndMT regulators SNAI2, TGB2, TGFB3 and TGFBR2; however, there was no change in mesenchymal markers or other EndMT regulators. This suggests that there may be some alterations in EndMT in GDM but this probably does not fully explain the endothelial dysfunction and altered vascularisation that occurs in the fetoplacental vasculature in pregnancies complicated by GDM. KEY POINTS: Gestational diabetes mellitus (GDM) has been linked to altered placental vascularisation, fibrosis and endothelial dysfunction. Disruptions in endothelial-to-mesenchymal transition (EndMT), a process where endothelial cells adopt a mesenchymal phenotype, has been linked to vascular complications in diabetes, but EndMT in GDM has not been investigated. Transforming growth factor (TGF)-β2 and interleukin (IL)-1β induced morphological and molecular changes consistent with EndMT in GDM and non-GDM human umbilical vein endothelial cells (HUVECs). Although the expression of EndMT mediators, VWF, TGFBR1, IL1B, and IL1R1, was diminished in GDM HUVECs, other EndMT hallmarks were similar. Transcriptional regulators of EndMT, Slug and Snail, were detected in the human term placenta. Despite a reduction in endothelial markers, PECAM1, VWF and CDH5, as well as SNAI2, TGFB2/3 and TGFBR2 in GDM placenta, there was no change in mesenchymal or other EndMT markers. This suggests that, although there may be some changes to EndMT in GDM, the vascular dysfunction is probably not explained fully by alterations in EndMT.

Assessment of left ventricular systolic function using pressure-strain loops in offspring of women with gestational diabetes mellitus: a prospective cohort study

Background

Gestational diabetes mellitus (GDM) increases the risk of cardiovascular abnormalities in offspring. The objective of this study is to assess changes in left ventricular myocardial work using the left ventricular pressure-strain loop (LVPSL) method in neonates born to mothers with GDM. The aim of the research is to examine early impairments in neonatal left ventricular systolic function and to investigate whether these impairments persist over time.

Methods

In a prospective cohort study, we enrolled 61 neonates born to mothers with GDM and 30 healthy neonates born to mothers without pregnancy complications between August 2021 and March 2023 using a random method. The GDM group was further subdivided based on maternal hemoglobin A1c (HbA1c) levels into those with HbA1c ≤6.5% and those with HbA1c >6.5%. Echocardiographic assessments and left ventricular myocardial work parameters were measured and compared across the three groups using one-way analysis of variance (ANOVA) with multiple comparisons conducted using the Least Significant Difference t (LSD-T) test and multiple correction using the Bonferroni method in terms of data of normal distribution and homoscedasticity. Non-normally distributed data were presented as median (first quartile, third quartile) [M (Q1, Q3)] and compared using the Kruskal-Wallis H test. The correlation between myocardial work parameters in neonates born to mothers with GDM and the maternal HbA1c levels was also analyzed using Pearson correlation analysis or Spearman's rank correlation.

Results

The enrolled 61 neonates born to women with GDM comprised 34 male and 27 female neonates, with a gestational age (GA) of 38.9±1.7 weeks. The control group 30 healthy neonates comprised 17 males and 13 females, with a GA of 39.1±1.8 weeks. Neonates in the HbA1c ≤6.5% and HbA1c >6.5% groups demonstrated increased interventricular septal thickness (IVSD) (P<0.05) compared to the control group. However, no significant differences in IVSD were observed among the groups after a 12-month follow-up (P>0.05). At birth and during the 12-month follow-up, global longitudinal strain (GLS), global work index (GWI), and global constructive work (GCW) values were lower in both HbA1c groups compared to the control group, with the HbA1c >6.5% group revealing significantly reduced GLS, GWI, and GCW (P<0.05). Neonatal GLS exhibited a positive correlation with maternal HbA1c, whereas GWI and GCW revealed negative correlations (r=0.683, r=-0.709, r=-0.688, P<0.001).

Conclusions

The LVPSL method can examine early impairments in left ventricular systolic function in neonates born to mothers with GDM. More severe impairments are associated with poorer glycemic control during pregnancy, as indicated by higher maternal HbA1c levels. These functional impairments persist in the offspring 12 months postpartum.

Association between gestational diabetes mellitus and offspring health: a two-sample mendelian randomization study

BACKGROUND

Gestational diabetes mellitus (GDM) constitutes a significant contributor to maternal and fetal morbidity, which is observed to be associated with future risks of offspring health. Nevertheless, it is essential to acknowledge that observational findings may be susceptible to residual confounding and bias.

METHODS

To investigate the association of GDM with offspring health, a genome-wide genetic association study employing Mendelian Randomization (MR) is conducted between May 31 and November 30, 2023. The inverse-variance-weighted (IVW) is utilized in the primary analysis stage. The study data of the majority patients are European ancestry, which are sourced from the IEU open genome-wide association study project.

RESULTS

Genetically predicted GDM is associated with an increased risk of various short- and long-term health problem in offspring. For fetal and neonatal conditions, GDM is linked to an elevated risk of preterm delivery [ odd ratio (OR) = 1.150, false discovery rate (FDR)-adjusted PIVW = 0.009] and placental disorders (OR = 2.143, FDR-adjusted PIVW = 0.028). In respiratory diseases, it is associated with a higher likelihood of influenza (OR = 1.175, FDR-adjusted PIVW = 0.008), bacterial pneumonia (OR = 1.141, FDR-adjusted PIVW = 0.008), congenital malformations of the respiratory system (OR = 1.673, FDR-adjusted PIVW = 0.033), influenza with pneumonia (OR = 1.078, FDR-adjusted PIVW = 0.008), and need for non-invasive ventilation (OR = 1.265, FDR-adjusted PIVW = 0.028). In terms of neurodevelopmental and psychiatric outcomes, GDM is linked to a higher risk of cerebral palsy (OR = 1.721, FDR-adjusted PIVW = 0.008). For urinary conditions, GDM increases the risk of acute tubulo-interstitial nephritis (OR = 1.098, FDR-adjusted PIVW = 0.008). No association is identified between genetically predicted GDM and major digestive diseases, such as gastroesophageal reflux, or cardiovascular conditions in offspring.

CONCLUSIONS

The findings of this study provide genetic evidence supporting an association between GDM and higher risk of offspring diseases. This supports classification of GDM as risk factors for short- and long-term offspring health.

Predictive Value of Maternal HbA1c Levels for Fetal Hypertrophic Cardiomyopathy in Pregestational Diabetic Pregnancies

(1) Background: This study investigated the utility of first-visit HbA1c levels as a predictor of fetal hypertrophic cardiomyopathy (FHCM) in women with pregestational diabetes mellitus (PGDM). (2) Methods: A retrospective observational cohort study was conducted among all pregnant women with PGDM between 2012 and 2019. (3) Results: Of 329 participants, 5.8% had fetuses diagnosed with FHCM. These women exhibited significantly higher pregestational HbA1c (8.2% vs. 7.3%, p = 0.003) and higher first-visit HbA1c (7.6% vs. 6.9%, p = 0.001) and were less likely to have planned their pregnancies (p = 0.035). Fetuses with FHCM demonstrated a higher incidence of macrosomia (63.2% vs. 17.7%, p < 0.001; OR 9.20, 95% CI 3.31-25.58). Receiver-operating characteristic (ROC) analysis indicated an adequate predictive capacity for FHCM using first-visit HbA1c (AUC 0.75). An HbA1c threshold of 7.15% provided the best discriminative power, encompassing 38.9% of the cohort. (4) Conclusions: These findings underscore the value of assessing first-visit HbA1c levels for predicting FHCM in women with PGDM. The significant association between glycemic status and FHCM highlights the importance of optimizing glycemic control before and during pregnancy. Establishing optimal HbA1c cutoffs enables effective risk stratification and supports targeted clinical interventions.

Fetal cardiac function in pregnancy affected by congenital heart disease: protocol for a multicentre prospective cohort study

BACKGROUND

Congenital heart disease (CHD) is the most common fetal malformation, and it can result first in cardiac remodeling and dysfunction and later in cardiac failure and hydrops. A limited number of studies have evaluated cardiac function in fetuses affected by CHD. Functional parameters could potentially identify fetuses at risk of cardiac failure before its development. However, these techniques have not translated from research to clinical settings, due to a lack of standardization and poor repeatability. We seek to evaluate whether application of automated techniques to a cohort with fetal pathology could overcome these factors.

METHODS

A multicenter cohort study will be carried out in eight teaching hospitals across Europe, Australia, and Middle East. Based on a previous observed standard deviation, a total sample of 381 pregnancies is required to achieve 80% power to detect a difference of 0.03 in mean myocardial performance index (MPI) with a two-sided type I error rate of 5%. After adjustments allowing for patient exclusions or incomplete datasets, a total of 330 healthy singleton pregnancies and 165 diagnosed with CHD will be recruited. Two fetal cardiac function evaluations at 19 + 6-28 + 6 and 32 + 6-36 + 6 weeks will be offered assessing automated pulsed wave doppler (PWD) MPI, spatio-temporal image correlation (STIC) annular and septal plane excursion (TAPSE, MAPSE and SAPSE), alongside cardiac morphometric and Doppler evaluations of flow across the valves. A secondary nested case-control study will evaluate fetuses with hydrops compared to those without. Differences in functional parameters between cases and controls and over time will be assessed using generalized linear mixed models. Logistic regression will estimate the association between cardiac parameters and hydrops' incidence.

DISCUSSION

This study will provide evidence as to whether automated functional parameters could be significantly different in pregnancy affected by CHD versus healthy pregnancies. The primary objective is to compare automated PWD-MPI and STIC TAPSE, MAPSE and SAPSE in fetuses affected by CHD versus healthy. The secondary objective is to estimate whether these automated parameters could improve the predictive value of the classical cardiovascular profile score in case of hydrops.

TRIAL REGISTRATION

The study protocol has been registered in the ClinicalTrials.gov Protocol Registration System, identification number NCT05698277.

Quantitative analysis of fetal cardiac structure and function in gestational diabetes mellitus using fetal HQ technology

BACKGROUND

Gestational diabetes mellitus (GDM) can contribute to changes in fetal cardiac structure and function, with potential implications for long-term cardiovascular health. This study focuses on assessing these cardiac adaptations in fetuses from GDM pregnancies by using the innovative Fetal Heart Quantification (Fetal HQ) technology to provide a detailed evaluation of structural and functional parameters.

METHODS

A prospective study was conducted from March 2023 to October 2024 at Xiangyang No.1 People's Hospital, involving 382 pregnant women in their second and third trimesters, including 167 with GDM and 215 healthy controls. Fetal cardiac assessments were performed using Fetal HQ, which allows for direct measurement of cardiac deformation and function. Key parameters such as left ventricular (LV) and right ventricular (RV) dimensions, global longitudinal strain (GLS), and fractional area change (FAC) were analyzed. Maternal clinical data, including blood glucose levels and body mass index (BMI), were also collected. Statistical analyses were performed to compare the cardiac parameters between the two groups.

RESULTS

Significant differences were observed in fetal cardiac dimensions, with the GDM group exhibiting larger LV end-diastolic area (2.04 ± 0.73 cm2 vs. 1.81 ± 0.69 cm2, p = 0.002) and lower RV GLS (-20.1 ± 5.3 % vs. -22.6 ± 4.6 %, p = 0.000). Other functional parameters, including LV GLS and FAC, did not show significant differences between groups. Correlation analysis revealed a significant positive relationship between maternal HbA1c levels and RV FAC (r = 0.348, p = 0.036), indicating that maternal glycemic control may influence fetal cardiac function.

CONCLUSIONS

The findings suggest that GDM is associated with altered fetal cardiac morphology, particularly in the left ventricle, and impaired right ventricular function, as evidenced by reduced GLS. These results highlight the potential impact of maternal hyperglycemia on fetal cardiac development and underscore the importance of monitoring fetal cardiac health in pregnancies complicated by GDM. The use of Fetal HQ technology provides a valuable tool for early detection of cardiac dysfunction in this high-risk population.

Practical Evaluation of the Fetal Cardiac Function

The fetal heart adapts dynamically to nutrient and oxygen needs from all fetal organs. These continuous changes make it difficult to define normal/abnormal cardiac function based only on the evaluation of a few cycles. Many signs of fetal cardiac dysfunction have been suggested; however, very few can stand as true manifestations of cardiac deterioration, and none has emerged as a single reliable marker of cardiac dysfunction. It is the combination of abnormal findings that provides a more accurate assessment of the status of the fetal heart function.

Is It Diabetes or Just Macrosomia? Fetal Myocardial Performance Index in Large-for-Gestational Age Fetuses

Our aim in this study was to investigate whether there is an association between large-for-gestational age (LGA) fetuses and myocardial performance index (MPI). This is a cross-sectional study conducted from July 2022 to July 2023. Prospectively gathered data from 65 LGA cases and 65 age and gestational-age (GA)-matched controls were analyzed. Presence of polyhydramnios and diabetes were recorded in the study group. Fetal left ventricular mod-MPI, peak systolic velocity (PSV) of E and A waves, umbilical and middle cerebral artery (MCA) pulsatility indexes (PI) were sonographically measured. Association between these sonographic measures and LGA fetuses were sought. The LGA group had 33 diabetic cases (22 GDM and 11 PGDM). The LGA group had greater mod-MPI (0.51 vs. 0.45, p = 0.0048). The LGA group also had prolonged isovolumetric contraction time (ICT), compared to controls (37 ms vs. 33 ms, p = 0.008). ICT was longer in LGA fetuses with non-diabetic mothers (38 ms vs. 33 ms, p = 0.009). LGA fetuses with polyhydramnios but without diabetic mothers had also longer ICT (39 ms vs. 33 ms, p = 0.002). Mod-MPI was similar in controls and LGA without diabetes/LGA with polyhydramnios but without diabetes subgroups. Our results indicate that fetal mod-MPI values are higher in LGA fetuses and ICT is prolonged among LGA fetuses irrespective of presence of maternal diabetes.

Prospective evaluation of ultrasonographic fetal cardiac morphometry and functions in the third trimester of pregnancies with gestational diabetes mellitus

OBJECTIVE

This study aimed to compare cardiac morphological and functional changes in fetuses of patients with diet-regulated gestational diabetes mellitus (GDM-A1), insulin-regulated GDM (GDM-A2), and a control group.

METHOD

A prospective cohort study included pregnant women aged 18-40 years with singleton pregnancies. Fetal biometric, cardiac morphological, and functional measurements were recorded using Z-scores at 34-37 weeks of gestation.

RESULTS

The study included 87 patients. Both right and left ventricular wall thicknesses were significantly different between the three groups (p < 0.001 and p < 0.001, respectively). Z-scores of the mitral valve, left and right EDD were significantly lower in GDM-A1 and GDM-A2 groups compared to the control group (p < 0.001, p < 0.001, p = 0.002, respectively). Right and left ventricular areas were decreased only in GDM-A2 group compared to the control group (p = 0.003 and p = 0.001, respectively). MPI and IVRT values were also significantly higher in the same groups (p = 0.016, p < 0.001, respectively).

CONCLUSION

Gestational diabetes increased IVS and ventricular wall thicknesses in both right and left ventricles, irrespective of whether it was controlled by diet or insulin. Cardiac functional changes were observed in the GDM-A2 group.

Infants of diabetic mothers: epidemiology, pathophysiology, fetal heartassessment, structural and functional heart consequences: A narrative review

Infants of diabetic mothers are neonates born to a woman who had periodic hyperglycaemia during pregnancy. Consequently, infants of diabetic mothers are at higher risks of illness besides morbidity and mortality due to teratogenic effects on the fetal cardiovascular system, causing most frequent CHDs. The primary purpose of this review is to present, on this topic, a better-comprehended review covering pertinent material and data to be informed of severe risks to a newborn's cardiac system and function. These conditions can affect maternal, fetal, neonatal, and future adult health. Further research should be addressed towards the early detection of diabetes, its magnitude, and management. Immediate interventions should be proposed to lessen the diabetes burden and its adversative effects during the prenatal period.

Feasibility of automated measurement of fetal right ventricular modified myocardial performance index with development of reference values and clinical application

To establish normal reference ranges for fetal right ventricular modified myocardial performance index (RV Mod-MPI) using automatic synchronization of the RV inflow and outflow images (MPI+TM). Additionally, we aimed to clinically apply RV Mod-MPI to investigate its changes in fetal right congenital diaphragmatic hernia (CDH) compared to normal fetuses. This prospective study included uncomplicated singleton pregnancies between 16 and 38 weeks of gestational age. Cases with any maternal or fetal complications that developed during the enrollment period were excluded. Two experienced operators measured the RV Mod-MPI using the automated and manual methods. The intraclass correlation coefficients (ICC) were calculated for intra- and inter-operator reproducibility. The mean differences between the manual and automated measurements were also compared. The RV Mod-MPI was then compared between the right CDH fetuses and normal fetuses. Seventy normal fetuses were analyzed for the feasibility of an automated system, and 364 examinations from 272 fetuses were analyzed for developing the normal references. The automated system showed significantly higher intra- and inter-operator reproducibility of Mod-MPI than those of manual measurements (ICC = 0.962 vs. 0.913 and 0.961 vs. 0.889, respectively). The mean difference in Mod-MPI between the manual and automated method was 0.0002 ± 0.0586 with a 95% confidence interval of -0.0095-0.0099. The Mod-MPI and isovolumetric relaxation time increased throughout the gestational weeks. The isovolumetric contraction time increased until 24 weeks of gestation and then slightly decreased afterwards, and the ejection time also increased until 31 weeks of gestation and then decreased. There was no significant difference in the Mod-MPI between right CDH and normal fetuses. The automated system showed high inter- and intra-operator reproducibility. Furthermore, the normal reference values of Mod-MPI for each gestational age were established. Our results suggest that the automated system might be clinically feasible for evaluating fetal cardiac function.

Folic Acid and Selected Risk Factors for Fetal Heart Defects-Preliminary Study Results

BACKGROUND

The available data on the relationship between diet/folic acid and congenital heart disease (CHD) are not consistent. This study aimed to investigate the relationship between the intake and supplementation of folic acid and other selected factors in mothers and the risk of congenital heart defects in fetuses.

METHODS

A case-control study was conducted. The study group included pregnant women with fetuses from singleton pregnancies with prenatally diagnosed heart defects in the fetus (n = 79) and pregnant women whose course of pregnancy was normal with no heart defects or other developmental anomalies diagnosed in the fetus (n = 121). The patients were diagnosed at a reference center in Poland. The women completed a lifestyle questionnaire and FFQ and precisely described their use of dietary supplements. A univariate logistic regression model was used to evaluate the association between folic acid and selected risk factors and CHD. The association was significant and included such risk factors such as nutritional status, medications taken, smoking, and alcohol consumption. Additionally, the time of starting folic acid supplementation turned out to be statistically significant. The reference period of supplementation was the period before pregnancy.

RESULTS

Lack of supplementation increases the risk of heart defects in children by more than four times compared to supplementation before pregnancy (OR = 4.19; p = 0.0117), whereas supplementation beyond the eighth week of gestation increases the risk almost threefold (OR = 2.90; p = 0.0474). The presence of congenital defects in the family is also an important factor.

CONCLUSIONS

A history of congenital heart defects or other defects, lack of periconceptional folic acid supplementation, and lack of dietary supplementation before pregnancy were associated with congenital heart defects in the fetus. Place of residence, parents' education, lifestyle habits such as smoking and alcohol consumption, nutritional status before pregnancy, and mother's diseases did not show a significant relationship with congenital heart defects in the children. There is an urgent need to develop preventive strategies and conduct extensive public education.

Role of Ductus Venosus Doppler Sonography for the Prediction of Perinatal Outcome in Term Pregnancies Complicated by Gestational Diabetes Mellitus

PURPOSE

Ductus venosus (DV) Doppler velocimetry reflects fetal cardiac function. Gestational diabetes mellitus (GDM) is assumed to impair cardiac function due to fetal hyperglycemia. The purpose of this study was to assess the ability of DV Doppler to predict an adverse perinatal outcome (APO) in term pregnancies with GDM.

METHODS

This is a retrospective cohort study including GDM pregnancies of singleton, non-anomalous fetuses without any signs of placental dysfunction. All GDM women who primarily had a vaginal delivery attempt and in which DV Doppler was examined from 37+0 weeks on were included. Receiver operating characteristic curve (ROC) analyses were performed to assess the predictive value of DV pulsatility index (DV-PI) regarding a composite APO (CAPO). Furthermore, a subgroup analysis was performed regarding the presence of a large-for-gestational-age (LGA) newborn.

RESULTS

A total of n=89 cases were included. Overall, CAPO occurred in 26 out of 89 cases (29.2%). All DV Doppler examinations showed a positive A wave. DV-PI was>95th percentile in 8 out of 89 cases (9%). Overall, ROC analysis showed no significant association of DV-PI with CAPO (AUC=0.523, p=0.735). However, regarding individual APO parameters, ROC analysis showed a significant association of DV-PI with 5th-min AGPAR (AUC=0.960, p=0.027), which was not confirmed after exclusion of LGA cases.

CONCLUSION

In GDM pregnancies at term, DV Doppler sonography seems to have no benefit for APO prediction.

Up-regulation of BRD4 contributes to gestational diabetes mellitus-induced cardiac hypertrophy in offspring by promoting mitochondria dysfunction in sex-independent manner

Gestational diabetes mellitus (GDM) is associated with cardiovascular disease in postnatal life. The current study tested the hypothesis that GDM caused the cardiac hypertrophy in fetal (ED18.5), postnatal day 7 (PD7), postnatal day 21 (PD21) and postnatal day 90 (PD90) offspring by upregulation of BRD4 and mitochondrial dysfunction. Pregnant mice were divided into control and GDM groups. Hearts were isolated from ED18.5, PD7, PD21 and PD90. GDM increased the body weight (BW) and heart weight (HW) in ED18.5 and PD7, but not PD21 and PD90 offspring. However, HW/BW ratio was increased in all ages of GDM offspring compared to control group. Electron microscopy showed disorganized myofibrils, mitochondrial swelling, vacuolization, and cristae disorder in GDM offspring. GDM resulted in myocardial hypertrophy in offspring, which persisted from fetus to adult in a sex-independent manner. Echocardiography analysis revealed that GDM caused diastolic dysfunction, but had no effect on systolic function. Meanwhile, myocardial BRD4 was significantly upregulated in GDM offspring and BRD4 inhibition by JQ1 alleviated GDM-induced myocardial hypertrophy in offspring. Co-immunoprecipitation showed that BRD4 interacted with DRP1 and there was an increase of BRD4 and DRP1 interaction in GDM offspring. Furthermore, GDM caused the accumulation of damaged mitochondria in hearts from all ages of offspring, including mitochondrial fusion fission imbalance (upregulation of DRP1, and downregulation of MFN1, MFN2 and OPA1) and myocardial mitochondrial ROS accumulation, which was reversed by JQ1. These results suggested that the upregulation of BRD4 is involved in GDM-induced myocardial hypertrophy in the offspring through promoting mitochondrial damage in a gender-independent manner.

Diabetes in pregnancy and offspring cardiac function: a systematic review and meta-analysis

Introduction

Diabetes in pregnancy is associated with impaired offspring cardiac function. The objective of this systematic review was to determine the effect of diabetes in pregnancy on cardiac function in the offspring measured by echocardiography.

Methods

PubMed, Embase, Cochrane CENTRAL and Web of Science databases were searched from 1992 to June 27, 2023. Studies reporting offspring (age < 18 years) cardiac function by echocardiography compared between any type of diabetes in pregnancy and healthy control pregnancies were included. Study selection, quality assessment and risk of bias was independently performed by two reviewers. Meta-analyses was performed where possible.

Results

Thirty-one observational studies were included 1,679 cases and 2,694 controls. In the first week of life (23 studies, n = 2,663), intraventricular septum diastolic diameter (hypertrophy) was increased, while myocardial performance index (global function) and LV E/A-ratio (diastolic function) were decreased. No difference was found for left ventricular ejection fraction (systolic function). At 1-6 months (4 studies, n = 454) studies found hypertrophy, and decreased global function, but no difference in systolic or diastolic function. At 1-8 years (7 studies, n = 1,609) no difference was found. The available data did not allow for sub-analysis based on the type of diabetes, treatment, or glycemic control.

Conclusions

Diabetes in pregnancy is associated with cardiac hypertrophy and impaired global cardiac function in infants up to six months old. The few studies reporting on older children found no difference in the parameters investigated. Longitudinal studies employing more advanced echocardiographic measures or MRI are needed to evaluate consequences for long-term cardiac health.

Systematic Review Registration

https://www.crd.york.ac.uk/, identifier (CRD42022312471).

Fetal Strain and Strain Rate Measured with Speckle Tracking Echocardiography in Maternal Diabetes: Systematic Review

INTRODUCTION

The aim of this systematic review and meta-analysis was to evaluate fetal cardiac function in fetuses of mothers with diabetes compared to those of mothers without diabetes using 2D-STE.

METHODS

Embase, MEDLINE, and CENTRAL were searched for observational studies on 2D-STE fetal left and right ventricular global longitudinal strain and strain rate that included singleton, non-anomalous pregnancies complicated by pregestational or gestational diabetes mellitus compared to uncomplicated pregnancies. The strain values were pooled per 4 weeks of gestation for meta-analysis using random-effects models.

RESULTS

Fifteen studies met the criteria, including 990 fetuses of diabetic mothers and 1,645 control fetuses. The study design was cross-sectional in fourteen studies and longitudinal in one study. Gestational age, type of diabetes, ultrasound device, and 2D-STE software varied between the studies. Glycemic control and type of treatment were often lacking. In fetuses of diabetic mothers versus healthy mothers, left ventricular strain was significantly decreased (7 studies), increased (1 study), or not significantly different (7 studies). Right ventricular strain was decreased (7 studies), increased (1 study), or not different (2 studies). Left ventricular strain rate was decreased (3 studies), increased (1 study), or not different (2 studies). Right ventricular strain rate was increased (1 study) or not different (2 studies).

CONCLUSION

Fetuses of mothers with diabetes show evidence of systolic dysfunction, which is more visible in the right ventricle. Contradictory results are probably due to suboptimal study designs and variation in gestational age, diabetes severity, image acquisition, and software. Large prospective longitudinal studies are needed to assess fetal myocardial function with 2D-STE in pregestational diabetes mellitus type 1 and 2 and gestational diabetes mellitus pregnancies. The influence of glycemic control, BMI, and treatment should be evaluated.

Maternal Cardiac Function in Pregnancies with Metabolic Disorders

The obesity epidemic is growing and poses significant risks to pregnancy. Metabolic impairment can be associated with short- and long-term maternal and perinatal morbidity and mortality. The cardiovascular implications are known in those with metabolic disorder outside of pregnancy; however, little is known of the cardiac function in pregnancies complicated by obesity. Maternal cardiac adaptation plays a vital role in normal pregnancy and is known to be involved in the pathophysiology of adverse pregnancy outcomes. Bariatric surgery is the most successful treatment for sustainable weight loss and pre-pregnancy bariatric surgery can drastically change the maternal metabolic profile and pregnancy outcomes. In this review, we discuss the available evidence on maternal cardiac function in pregnancies affected by obesity and its associated consequences of gestational diabetes and hypertension (chronic and hypertensive disorders in pregnancy), as well as pregnancies following bariatric surgery.

Fetal left and right ventricular strain parameters using speckle tracking in congenital heart diseases

Assessment of fetal ventricular function is mostly subjective, and currently, for the objective assessment left ventricular shortening fraction is obtained. However, this by itself is not very reliable. Hence, more tools that can provide an objective assessment are needed to increase the confidence of functional assessment. Speckle tracking imaging can provide one such tool. In this study we sought to establish the normative value of global longitudinal and circumferential strain for our fetal patients and for two major forms of congenital heart diseases, namely atrioventricular canal defects (AVC) and uncorrected dextro-transposition of the great arteries (dTGA) to act as a benchmark. The study was completed via a single center retrospective analysis on 72 fetal echocardiograms (26 normal, 15 dTGA, and 31 AVC). Tomtec Arena™ echocardiography analysis software was used for analysis. In normal fetuses, mean left ventricular (LV) global longitudinal strain (GLS) was - 22.6% (95% CI -24, -21.1) and mean right ventricular (RV) GLS was - 22.1% (95% CI -23.6, -20.6). In AVC patients LV GLS was-26.6% (95% CI -28,-25.3) and mean RV GLS was - 26.5% (95% CI -27.9,-25.2). In dTGA patients LV GLS was - 22.9% (95% CI of -24.8, -21) and RV GLS was - 21.3% (95% CI was - 23.4, -20.8). There was good intra-rater reliability though poor to fair inter-rater reliability. Notwithstanding its current limitations, strain imaging can provide useful information that can increase confidence of cardiac functional assessment in fetal patients. However, to be reliable across the board, further automation and standardization is required.

Glucose control during pregnancy in patients with type 1 diabetes correlates with fetal hemodynamics: a prospective longitudinal study

BACKGROUND

Maternal diabetes adversely affects fetal cardiovascular system development. Previous studies have reported that the fetuses of mothers with diabetes exhibit both structural and functional changes; nevertheless, prior studies have not examined the association between glucose control and fetal cardiac morphology and performance. Thus, the objective was to determine the association between fetal cardiac morphology and function and maternal glucose control in type 1 diabetes and to compare the differences in measured cardiac parameters between the fetuses of mothers with diabetes and healthy controls.

METHODS

In this prospective, longitudinal case-control study - including 62 pregnant women with type 1 diabetes mellitus and 30 healthy pregnant women - fetal cardiac assessment using B-mode, M-mode, and spectral pulsed-wave Doppler was performed in the second and third trimesters. In women with T1DM, glycated hemoglobin and data obtained from glucose sensors - including the percentage of time in, below, and above the range (TIR, TBR, and TAR, respectively), and coefficient of variation (CV) - were analyzed across three time periods: the last menstrual period to 13 (V1), 14-22 (V2), and 23-32 weeks (V3) of gestation. Fetal cardiac indices were compared between groups, and the correlation between glucose control and fetal cardiac indices was assessed.

RESULTS

At 28-32 weeks, the fetuses of women with T1DM exhibited increased left ventricular end-diastolic length, relative interventricular septum thickness, right ventricular cardiac output, and pulmonary valve peak systolic velocity compared with healthy controls. At 18-22 weeks, pulmonary and aortic valve diameters, left and right ventricular stroke volumes, and left cardiac output inversely correlated with the CV and glycated hemoglobin levels at V1 and V2. Furthermore, at 28-32 weeks, pulmonary and aortic valve diameters, left ventricular stroke volume, cardiac output, and right/left atrioventricular valve ratio inversely correlated with the TBR at V1, V2, and V3. Moreover, diastolic functional parameters correlated with the TAR and glycated hemoglobin levels, particularly after the first trimester.

CONCLUSION

In women with T1DM, maternal hyperglycemia during pregnancy correlates with fetal diastolic function, whereas glucose variability and hypoglycemia inversely correlate with fetal left ventricular systolic function in the second and third trimesters.

Novel MYH7 Variant in the Neonate of a Mother with Gestational Diabetes Mellitus Showing Left Ventricular Hypertrophy and Noncompaction

BACKGROUND

Left ventricular hypertrophy (LVH) is a well-recognized cardiac dysfunction in infants of mothers with gestational diabetes mellitus (GDM). Left ventricular noncompaction (LVNC) is a cardiomyopathy that is morphologically characterized by numerous prominent trabeculations and deep intertrabecular recesses on cardiovascular imaging. However, there have been no case reports on neonates of mothers with GDM showing LVH and LVNC.

CASE PRESENTATION

A patient, with LVH of a mother with GDM, was delivered at 36 weeks of gestation. Prominent trabeculations in the LV, suggesting LVNC, instead of LVH, were apparent 1 week after birth. A heterozygous deletion variant in the MYH7 gene (NM_000257.4: c.1090T>C, p.Phe364Leu) was discovered through genetic testing using a cardiomyopathy-associated gene panel in the patient and his father and the older brother who had LVNC. The patient is now 5 years old and does not have major cardiac events, although LVNC persisted. This is the first case of LVH secondary to a mother with GDM and LVNC with a novel variant in the MYH7 gene.

CONCLUSION

Genetic testing should be conducted to obtain an accurate outcome and medical care in a patient with LVH and subsequently prominent hypertrabeculation in the LV.

ATP5me alleviates high glucose-induced myocardial cell injury

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with adverse myocardial remodeling and impaired cardiac function of fetus. Nevertheless, specific molecular mechanisms underlying type 1 GDM-induced fetal myocardial injury remain unknown. Therefore, this study proposes to identify possible molecular mechanisms using RNA-seq.

METHODS

A rat type 1 GDM model was developed using streptozotocin (STZ) (25 and 50 mg/kg), and weight and glucose tolerance of maternal and offspring were evaluated. Changes in markers of myocardial injury and oxidative stress identified by ELISA and biochemical kits in offspring hearts. Identification of differentially expressed mRNAs (DE-mRNAs) associated with myocardial injury in type 1 GDM offspring using RNA-seq. Proliferation, apoptosis, and oxidative stress were assessed in high glucose-induced H9C2 cells after exogenously modulating ATP Synthase Membrane Subunit E (ATP5me).

RESULTS

Maternal weight, glucose and glucose tolerance, and fetal weight and heart weight were reduced in the type 1 GDM model, especially in 50 mg/kg STZ-induced. Increased of creatine kinase-MB (CK-MB), cardiac troponin T (cTnT), hypersensitive C-reactive protein (hs-CRP), reactive oxygen species (ROS) and malondialdehyde (MDA) and decreased of superoxide dismutase (SOD) were observed in type 1 GDM offspring hearts. type 1 GDM offspring hearts exhibited disorganized cardiomyocytes with enlarged gaps, broken myocardial fibers, erythrocyte accumulation and inflammatory infiltration. RNA-seq identified 462 DE-mRNAs in type 1 GDM offspring hearts, which mainly regulate immunity, redox reactions, and cellular communication. Atp5me was under-expressed in type 1 GDM offspring hearts, and high glucose decreased Atp5me expression in H9C2 cells. Overexpressing Atp5me alleviated high glucose-induced decrease in proliferation, mitochondrial membrane potential, BCL2 and SOD, and increase in apoptosis, MDA, ROS, c-Caspase-3, and BAX in H9C2 cells.

CONCLUSION

This study first demonstrated that ATP5me attenuated type 1 GDM-induced fetal myocardial injury. This provides a possible molecular mechanism for the treatment of type 1 GDM-induced fetal myocardial injury.

The evaluation of fetal interventricular septum with M-mode and spectral tissue Doppler imaging in gestational diabetes mellitus: a case-control study

OBJECTIVES

To demonstrate possible functional changes in the frequently affected fetal interventricular septum (IVS) with spectral tissue Doppler imaging (TDI) and M-mode imaging to compare gestational diabetes mellitus (GDM) and control groups.

METHODS

A total of 63 pregnant women with GDM, 30 on diet (A1 GDM) and 33 on treated with insulin (A2 GDM), and 63 healthy pregnant women randomly selected and matched to the case group in the control group were included.

RESULTS

The GDM fetuses had significantly thickened IVS, increased early diastole (E'), atrial contraction (A'), systole (S'), higher myocardial performance index (MPI'), prolonged isovolumetric relaxation time (IVRT'), shortened ejection time (ET'), and decreased septal annular plane systolic excursion (SAPSE) than the controls. The A2 GDM group fetuses had significantly thickened IVS, increased S' and shortened ET' than the A1 GDM group. In the GDM group, we found a significantly positive low correlation between glycated hemoglobin levels and maternal serum fasting glucose and one-hour postprandial glucose with fetal IVS thickness. We demonstrated a significantly negative low correlation between maternal serum one-hour postprandial glucose, glycated hemoglobin levels, and gestational weight gain with fetal IVS ET'.

CONCLUSIONS

Fetal IVS diastolic and systolic functions were altered in the GDM group compared to controls, and systolic functions were altered in A2 GDM compared to A1 GDM. This may alert clinicians to possible cardiovascular diseases in the postnatal life, and early preventive strategies and long-term lifestyle changes may provide protection in fetuses with GDM.

Impact of overweight and obesity in the fetal cardiac function parameters in the second and third trimesters of pregnancy

OBJECTIVE

To assess the impact of overweight and obesity in the second and third trimesters of pregnancy on fetal cardiac function parameters.

METHODS

We performed a prospective cohort study of 374 singleton pregnant women between 20w0d and 36w6d divided into three groups: 154 controls (body mass index - BMI < 25 kg/m2), 140 overweight (BMI 25-30 kg/m2) and 80 obese (BMI ≥ 30 kg/m2). Fetal left ventricular (LV) modified myocardial performance index (Mod-MPI) was calculated according to the following formula: (isovolumetric contraction time + isovolumetric relaxation time)/ejection time. Spectral tissue Doppler was used to determine LV and right ventricular (RV) myocardial performance index (MPI'), peak myocardial velocity during systole (S'), early diastole (E'), and late diastole (A').

RESULTS

We found significant differences between the groups in maternal age (p < 0.001), maternal weight (p < 0.001), BMI (p < 0.001), number of pregnancies (p < 0.001), parity (p < 0.001), gestational age (p = 0.013), and estimated fetal weight (p = 0.003). Overweight pregnant women had higher LV Mod-MPI (0.046 versus 0.044 seconds, p = 0.009) and LV MPI' (0.50 versus 0.47 seconds, p < 0.001) than the control group. Obese pregnant women had higher RV E' than control (6.82 versus 6.33 cm/sec, p = 0.008) and overweight (6.82 versus 6.46 cm/sec, p = 0.047) groups. There were no differences in 5-min APGAR score < 7, neonatal intensive care unit admission, hypoglycemia and hyperglobulinemia between the groups.

CONCLUSIONS

We observed fetal myocardial dysfunction in overweight and obese pregnant women with higher LV Mod-MPI, LV MPI' and RV E' compared to fetuses from normal weight pregnant women.

Prenatal arsenite exposure alters maternal cardiac remodeling during late pregnancy

Exposure to inorganic arsenic through drinking water is widespread and has been linked to many chronic diseases, including cardiovascular disease. Arsenic exposure has been shown to alter hypertrophic signaling in the adult heart, as well as in utero offspring development. However, the effect of arsenic on maternal cardiac remodeling during pregnancy has not been studied. As such, there is a need to understand how environmental exposure contributes to adverse pregnancy-related cardiovascular events. This study seeks to understand the impact of trivalent inorganic arsenic exposure during gestation on maternal cardiac remodeling in late pregnancy, as well as offspring outcomes. C57BL/6 J mice were exposed to 0 (control), 100 or 1000 μg/L sodium arsenite (NaAsO2) beginning at embryonic day (E) 2.5 and continuing through E17.5. Maternal heart function and size were assessed via transthoracic echocardiography, gravimetric measurement, and histology. Transcript levels of hypertrophic markers were probed via qRT-PCR and confirmed by western blot. Offspring outcomes were assessed through echocardiography and gravimetric measurement. We found that maternal heart size was smaller and transcript levels of Esr1 (estrogen receptor alpha), Pgrmc1 (progesterone receptor membrane component 1) and Pgrmc2 (progesterone receptor membrane component 2) reduced during late pregnancy with exposure to 1000 μg/L iAs vs. non-exposed pregnant controls. Both 100 and 1000 μg/L iAs also reduced transcription of Nppa (atrial natriuretic peptide). Akt protein expression was also significantly reduced after 1000 μg/L iAs exposure in the maternal heart with no change in activating phosphorylation. This significant abrogation of maternal cardiac hypertrophy suggests that arsenic exposure during pregnancy can potentially contribute to cardiovascular disease. Taken together, our findings further underscore the importance of reducing arsenic exposure during pregnancy and indicate that more research is needed to assess the impact of arsenic and other environmental exposures on the maternal heart and adverse pregnancy events.

Changes in the shape and function of the fetal heart of pre- and gestational diabetes mothers

BACKGROUND

Hyperglycemia during pregnancy can affect fetal heart in many ways, including causing cardiac malformation, leading to hypertrophic cardiomyopathy and cardiac dysfunction. Echocardiographic evaluation can assist identify alterations in heart structure, morphology and function, enabling prompt monitoring and management. However, according to earlier research, the cardiac alterations are modest in hyperglycemic mothers' fetuses, and might not be detectable using conventional methods and it is also unclear whether these changes are related to the metabolism of mothers. Fetal Heart Quantification (Fetal HQ) can assess ventricular geometry and function more sensitively and thoroughly, and identify sub-clinical cardiac dysfunction. The purpose of this study was to evaluate fetal heart by Fetal HQ in fetuses of hyperglycemic mothers who either had pre-gestational or gestational diabetes and to correlate them with maternal metabolic indices.

METHODS

The fetuses of 25 gestational age-matched control mothers, 48 women with gestational diabetes mellitus (GDM), and 11 women with diabetes mellitus (DM) were included in the prospective case-control research. Using fetal echocardiography and speckle tracking echocardiography (STE), the heart of the fetus was evaluated. Differences in the groups' anthropometric, metabolic, and cardiac parameters were examined. It was assessed whether maternal features, prenatal glucose, lipids, and maternal hemoglobin A1c (HbA1c) correlated with fetal cardiac parameters.

RESULTS

The LV EDV and ESV were significantly higher in the GDM group as compared to the DM group (p < 0.05). The GSI% was significantly lower in the GDM group compared with the control (p < 0.05). The LV SV and CO of the GDM group were both significantly higher compared with the DM group (p < 0.05). There was a significant decrease in RV FS for segments 1-7 in GDM fetuses compared to the control (p < 0.05) and for segments 5-10 compared to DM (p < 0.05). Fetal cardiac morphology and function indices correlate with maternal pregestational weight, BMI, early pregnancy fast glucose, lipids, and glycemic control levels.

CONCLUSIONS

Fetuses exposed to gestational diabetes have altered heart morphology and function that is linked to maternal metabolic parameters, which presents a special indication for performing geometry and function cardiac assessment. Fetal HQ can be employed to evaluate the fetal cardiac shape and function in fetuses exposed to gestational diabetes.

Acute Intake of Fructose Increases Arterial Pressure in Humans: A Meta-Analysis and Systematic Review

Hypertension is a major cardiac risk factor. Higher blood pressures are becoming more prevalent due to changing dietary habits. Here, we evaluated the impact on blood pressure in human subjects after acutely ingesting fructose using meta-analysis. A total of 89 studies were collected from four different electronic databases from 1 January 2008 to 1 August 2023. Of these studies, 10 were selected that fulfilled all the criteria for this meta-analysis. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), and blood glucose level were analyzed using the Cohen's d analysis or standardized mean difference at a confidence interval (CI) of 95%. The SBP, DBP, and MAP showed medium effect size; HR and glucose level displayed small effect size. The standardized mean difference of normal diet groups and fructose diet groups showed a significant increase in SBP (p = 0.04, REM = 2.30), and DBP (p = 0.03, REM = 1.48) with heterogeneity of 57% and 62%, respectively. Acute fructose ingestion contributes to an increase in arterial pressure in humans. The different parameters of arterial pressure in humans correlated with each other. These findings support further rigorous investigation, retrospective of necessity, into the effect of chronic dietary of fructose in humans in order to better understand the impact on long term arterial pressure.

Association of increased fetal epicardial fat thickness with maternal pregestational and gestational diabetes

OBJECTIVE

To evaluate the changes of fetal epicardial fat thickness (EFT) in pregnancies with pregestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM) and to identify the diagnostic effectiveness of fetal EFT in differentiating PGDM and GDM from normal pregnancies.

METHODS

The study was conducted with pregnant women who admitted to perinatology department between October 2020 and August 2021. Patients were grouped as PGDM (n = 110), GDM (n = 110), and control (n = 110) for comparison of fetal EFT. EFT was measured in all three groups at 29 weeks of gestation. Demographic characteristics and ultrasonographic findings were recorded and compared.

RESULTS

The mean fetal EFT was significantly higher in PGDM (1.47 ± 0.083 mm, p < .001) and GDM (1.40 ± 0.082 mm, p < .001) groups compared to control group (1.19 ± 0.049 mm) and was also significantly higher in PGDM group than GDM group (p < .001). Fetal EFT was significantly positively correlated with maternal age, fasting, 1st hour, 2nd hour glucose values, HbA1c, fetal abdominal circumference, and deepest vertical pocket of amniotic fluid (p < .001). Fetal EFT value of 1.3 mm diagnosed PGDM patients with a sensitivity of 97.3% and a specificity of 98.2%. Fetal EFT value of 1.27 mm diagnosed GDM patients with a sensitivity of 94% and a specificity of 95%.

CONCLUSIONS

Fetal EFT is greater in pregnancies with diabetes than in normal pregnancies, and also greater in PGDM than in GDM. In addition, fetal EFT is strongly correlated with maternal blood glucose levels in diabetic pregnancies.

Fetal echocardiography changes of the right ventricle of well-controlled gestational diabetes mellitus

BACKGROUND

There is few evidence of right ventricular (RV) function in fetuses with gestational diabetes mellitus (GDM). Therefore, the aim of this study was to assess the RV function of fetuses using routine and two-dimensional speckle-tracking echocardiography (2D STE) to determine the effects of well-controlled GDM in the third trimester.

METHODS

We used a Philips Epiq7C ultrasound instrument to obtain RV data sets from 63 subjects from July 2019 to February 2022. We compared the free wall thickness (FWT), fractional area change (FAC), Tei index (TEI), tricuspid annular plane systolic excursion (TAPSE) and free wall longitudinal strain(FWLS)of the RV in mothers with well-controlled GDM and normal gestational age-matched fetuses.

RESULTS

63 third trimester fetuses (32 GDM; 31 healthy controls) met the enrolment criteria. Significant differences in fetal RV were detected between the GDM and control groups for the FAC (36.35 ± 6.19 vs. 41.59 ± 9.11; P = 0.008) and the FWLS (-18.28 ± 4.23 vs. -20.98 ± 5.49; P = 0.021). There was a significant difference among the segmental strains of the base, middle and apex of the RV free wall in the healthy controls (P = 0.003), but in the GDM group, there was no statistical difference (p = 0.076). RV FWLS had a strong correlation with FAC (r = 0.467; P = 0.0002).

CONCLUSIONS

In well-controlled GDM, there was measurable fetal RV hypertrophy and significant systolic function decline, indicating the presence of ventricular remodeling and dysfunction. 2D-STE can evaluate the RV free wall contraction in a more comprehensive way.

Prenatal Arsenite Exposure Alters Maternal Cardiac Remodeling During Late Pregnancy

Exposure to inorganic arsenic through drinking water is widespread and has been linked to many chronic diseases, including cardiovascular disease. Arsenic exposure has been shown to alter hypertrophic signaling in the adult heart, as well as in-utero offspring development. However, the effect of arsenic on maternal cardiac remodeling during pregnancy has not been studied. As such, there is a need to understand how environmental exposure contributes to adverse pregnancy-related cardiovascular events. This study seeks to understand the impact of trivalent inorganic arsenic exposure during gestation on maternal cardiac remodeling in late pregnancy, as well as offspring outcomes. C57BL/6J mice were exposed to 0 (control), 100 or 1000 µg/L sodium arsenite (NaAsO 2 ) beginning at embryonic day (E) 2.5 and continuing through E17.5. Maternal heart function and size were assessed via transthoracic echocardiography, gravimetric measurement, and histology. Transcript levels of hypertrophic markers were probed via qRT-PCR and confirmed by western blot. Offspring outcomes were assessed through echocardiography and gravimetric measurement. We found that exposure to 1000 µg/L iAs abrogated normal physiologic growth of the maternal heart during late pregnancy and reduced transcript levels of estrogen receptor alpha (ERα), progesterone receptor membrane component 1 (Pgrmc1) and progesterone receptor membrane component 2 (Pgrmc2). Both 100 and 1000 µg/L iAs also reduced transcription of protein kinase B (Akt) and atrial natriuretic peptide (ANP). Akt protein expression was also significantly reduced after 1000 µg/L iAs exposure in the maternal heart with no change in activating phosphorylation. This significant abrogation of maternal cardiac hypertrophy suggests that arsenic exposure during pregnancy can potentially contribute to cardiovascular disease. Taken together, our findings further underscore the importance of reducing arsenic exposure during pregnancy and indicate that more research is needed to assess the impact of arsenic and other environmental exposures on the maternal heart and adverse pregnancy events.

Maternal diabetes increases FOXO1 activation during embryonic cardiac development

Maternal diabetes is known to affect heart development, inducing the programming of cardiac alterations in the offspring's adult life. Previous studies in the heart of adult offspring have shown increased activation of FOXO1 (a transcription factor involved in a wide variety of cellular functions such as apoptosis, cellular proliferation, reactive oxygen species detoxification, and antioxidant and pro-inflammatory processes) and of target genes related to inflammatory and fibrotic processes. In this work, we aimed to evaluate the effects of maternal diabetes on FOXO1 activation as well as on the expression of target genes relevant to the formation of the cardiovascular system during organogenesis (day 12 of gestation). The embryonic heart from diabetic rats showed increased active FOXO1 levels, reduced protein levels of mTOR (a nutrient sensor regulating cell growth, proliferation and metabolism) and reduced mTORC2-SGK1 pathway, which phosphorylates FOXO1. These alterations were related to increases in the levels of 4-hydroxynonenal (an oxidative stress marker) and increased mRNA levels of inducible nitric oxide synthase, angiopoietin-2 and matrix metalloproteinase-2 (MMP2) (all FOXO1 target genes relevant for cardiac development). Results also showed increased extracellular and intracellular immunolocalization of MMP2 in the myocardium and its projection into the lumen of the cavity (trabeculations) together with decreased immunostaining of connexin 43, a protein relevant for cardiac function that is target of MMP2. In conclusion, increases in active FOXO1 induced by maternal diabetes initiate early during embryonic heart development and are related to increases in markers of oxidative stress and of proinflammatory cardiac development, as well to an altered expression of proteolytic enzymes that regulate connexin 43. These alterations may lead to an altered programming of cardiovascular development in the embryonic heart of diabetic rats.

Evaluation of fetal myocardial performance index in gestational diabetes mellitus

This study aimed to compare fetal myocardial performance index (MPI) between fetuses of pregnant women with gestational diabetes mellitus (GDM) and healthy controls and to evaluate the relationship between MPI and maternal glucose levels. This was a prospective study of 90 pregnant women, including 50 pregnancies with GDM (27 pregnancies with insulin-regulated GDM and 23 pregnancies with diet-regulated GDM) and 40 healthy controls. Isovolumetric contraction time (ICT) + isovolumetric relaxation time (IRT)/ejection time (ET) were used to calculate the MPI (MPI = [ICT + IRT]/ET). Fetal MPI, PR interval, E/A ratio, maternal plasma glucose levels on the day of MPI measurement, and neonatal outcomes were compared. The fetal left-MPI was significantly higher in the GDM group than healthy controls (0.43 ± 0.04 vs. 0.40 ± 0.06, p = 0.007). The best cut-off level for MPI was >0.41 to predict adverse perinatal outcomes (sensitivity: 70%, specificity: 68%, area under the curve: 0.715, 95% confidence interval: 0.5143-0.8205, p < 0.001). The fetal MPI values showed no correlation with maternal plasma fasting, postprandial glucose, and hemoglobin A1c (HbA1c) levels. Reduced E/A ratio, higher neonatal intensive care unit admissions, and the need for cesarean delivery were detected in the GDM group. Fetal MPI is impaired in women with GDM, and the need for insulin therapy is associated with higher MPI values and adverse neonatal outcomes. Fetal MPI can help detect fetuses with potential adverse outcome risks, owing to impaired fetal cardiac function.

Impaired myocardial deformation persists at 2 years in offspring of mothers with diabetes mellitus

BACKGROUND

A diabetic intrauterine environment has been proposed as a potential etiological mechanism for in utero programming of cardiac disease, and is associated with impaired fetal cardiac function. We aimed to assess cardiac function in offspring of mothers with diabetes mellitus (ODM) and determine whether fetal cardiac abnormalities persist during follow-up.

METHODS

Longitudinal observational study to evaluate and compare myocardial function in 40 ODM to age-matched control offspring (CO). Myocardial deformation was measured using speckle-tracking echocardiography (STE).

RESULTS

Significant differences were detected in global longitudinal strain (-20.9 ± 3.1 vs. -23.6 ± 2.2%; p = 0.001), global circumferential strain (-24.4 ± 3.9 vs. -26.9 ± 2.7%; p = 0.017), average radial strain (29.0 ± 9.8 vs. 37.1 ± 7.2%; p = 0.003), average longitudinal systolic strain rate (-1.24 ± 0.25/s vs. -1.47 ± 0.30/s; p = 0.011) and average circumferential systolic strain rate (-1.56 ± 0.37/s vs. -1.84 ± 0.37/s; p = 0.013) in comparison to CO up to 2 years of follow-up. Minimal differences were observed within ODM over the 2-year period.

CONCLUSION

Impaired cardiac function in ODM persists during 2 years follow-up. Functional cardiac assessment might therefore be useful to detect these unfavorable changes, independent of screening for congenital heart disease or hypertrophic cardiomyopathy in this population.

IMPACT

We demonstrate persistence of subclinical myocardial deformation abnormalities in offspring of mothers with diabetes mellitus from fetal life to early childhood years. These results extend the cellular observations in basic and translational research of developmental programming into the clinical realm. Persistence of subclinical myocardial deformation abnormalities may shed light on the known incidence of early cardiovascular disease in offspring of mother with diabetes. Cardiac myocardial strain assessment can be useful to detect these abnormalities, independent of screening for congenital heart disease or hypertrophic cardiomyopathy in this population.

The Impact of Pregnancy on Diabetic Retinopathy: A Single-Site Study of Clinical Risk Factors

INTRODUCTION

This study aimed to provide information on modifiable and non-modifiable risk factors for the progression and development of diabetic retinopathy (DR) and diabetic macular edema (DME). This retrospective chart review case-control study was designed to provide perspective on clinical variables.

METHODS

Single-center study analysis was completed with chart review, identifying 50 patients (100 eyes) ultimately included in the final analysis. Included patients were women with type 1 or 2 diabetes that entered prenatal care and had a delivery from January 2010 to December 2022. The primary outcome measure was clinical variables between progression and no progression groups. Data were analyzed via χ2 analysis and independent samples t test when appropriate. Significantly different variables were further analyzed by binary logistic regression.

RESULTS

The DR progression group had significantly higher prepregnancy HbA1c levels (9.9) when compared to the no progression group (8.5, p value 0.028). DR progression group also had higher rates (51.9%) of full-term births. The DME progression group had significantly higher rates of type 2 diabetics (100%) compared to the no progression group (30.9%, p value 0.029). Hypertension treatment before (81.8%; p value 0.008) pregnancy was also more common in the DME progression group. Intravitreal injections were more common in patients with visual acuity deterioration (26.7%, p value 0.046). The average number of fetal complications was significantly higher in the visual acuity non-worsening group (1.1) compared to the progression group (0.5, p value 0.04). These variables were not statistically significant after entry into multivariate analysis.

DISCUSSION

Severity and treatment of retinopathy before pregnancy, type of diabetes, and blood pressure control are all significant factors affecting the progression and development of severe ocular complications in pregnancy.

Intrahepatic cholestasis of pregnancy and fetal cardiac dysfunction: a systematic review and meta-analysis

OBJECTIVE

Intrahepatic cholestasis of pregnancy is associated with adverse perinatal outcomes. Fetal cardiac dysfunction may be 1 part of the pathophysiology of pregnancies complicated by intrahepatic cholestasis of pregnancy. This systematic review and meta-analysis aimed to evaluate the association between intrahepatic cholestasis of pregnancy and fetal cardiac dysfunction.

DATA SOURCES

Systematic searches were performed on the databases of Medline, Embase, and Cochrane Library (up to March 2, 2023) for studies evaluating fetal cardiac function in pregnancies complicated by intrahepatic cholestasis of pregnancy in addition to the reference lists of included studies.

STUDY ELIGIBILITY CRITERIA

Studies were eligible for inclusion if they assessed the fetal cardiac function by fetal echocardiography in women with intrahepatic cholestasis of pregnancy (mild or severe) and compared with fetuses of healthy pregnant women. The studies published in English were included.

METHODS

The quality of the retrieved studies was assessed using the Newcastle-Ottawa Scale. Data on fetal myocardial performance index, E wave/A wave peak velocities ratio, and PR interval were pooled for the meta-analysis using random-effects models. The results were presented as weighted mean differences and 95% confidence intervals. This meta-analysis was registered with the International Prospective Register of Systematic Reviews (registration number: CRD42022334801).

RESULTS

A total of 14 studies were included in this qualitative analysis. Of note, 10 studies that reported data on fetal myocardial performance index, E wave/A wave peak velocities ratio, and PR interval were included in the quantitative analysis and showed a significant association between intrahepatic cholestasis of pregnancy and fetal cardiac dysfunction. Significantly higher fetal left ventricular myocardial performance index values (weighted mean difference, 0.10; 95% confidence interval, 0.04-0.16) and longer fetal PR intervals (weighted mean difference, 10.10 ms; 95% confidence interval, 7.34-12.86) were revealed in pregnancies complicated by intrahepatic cholestasis of pregnancy. Compared with the situation in pregnancies complicated by mild intrahepatic cholestasis of pregnancy, PR intervals were even longer in pregnancies complicated by severe intrahepatic cholestasis of pregnancy (weighted mean difference, 5.98 ms; 95% confidence interval, 0.20-11.77). There was no significant difference in fetal E wave/A wave peak velocities ratio between the group with intrahepatic cholestasis of pregnancy and the healthy pregnant group (weighted mean difference, 0.01; 95% confidence interval, -0.03 to 0.05).

CONCLUSION

Our findings supported the idea that intrahepatic cholestasis of pregnancy is associated with overall impaired fetal myocardial performance and impaired fetal cardiac conduction system. However, current evidence about the association between fetal cardiac dysfunction and intrahepatic cholestasis of pregnancy-induced stillbirth is lacking. Further studies are needed to reveal the relationship between fetal cardiac dysfunction and adverse perinatal outcomes in pregnancies complicated by intrahepatic cholestasis of pregnancy.

Associations Among Physical Activity, Adiposity, and Insulin Resistance in Children Exposed In Utero to Maternal Obesity With and Without Gestational Diabetes

PURPOSE

Investigate whether obesity risk and current weight status are independently associated with physical activity (PA) and whether PA is associated with adiposity and insulin resistance (homeostatic model assessment of insulin resistance) among children with high versus low obesity risk based on in utero exposure to maternal overweight/obesity with gestational diabetes mellitus (GDM; high risk) or without GDM (overweight/obesity; high risk) or maternal normal weight without GDM (low risk).

METHOD

Secondary analysis of data from children born to women with overweight/obesity and GDM, overweight/obesity without GDM, or normal weight without GDM. PA was assessed with accelerometry, percentage of body fat derived from anthropometrics, and homeostatic model assessment of insulin resistance calculated from glucose and insulin.

RESULTS

Among 4- to 10-year-old children (N = 163), analyses of covariance showed that children with a current BMI ≥85th percentile had less vigorous PA than those with BMI <85th percentile, but in utero exposure was not an independent predictor of PA. In linear regression modeling, moderate to vigorous PA was inversely associated with percentage of body fat and homeostatic model assessment of insulin resistance independent of age, Tanner stage, and accelerometer wear time, with stronger associations in high-risk groups.

CONCLUSIONS

Children's PA is related to current weight status but not underlying risk for obesity but may be especially important to reduce obesity and insulin resistance in high-risk children.

ER stress and lipid imbalance drive embryonic cardiomyopathy in a human heart organoid model of pregestational diabetes

Congenital heart defects constitute the most common birth defect in humans, affecting approximately 1% of all live births. The incidence of congenital heart defects is exacerbated by maternal conditions, such as diabetes during the first trimester. Our ability to mechanistically understand these disorders is severely limited by the lack of human models and the inaccessibility to human tissue at relevant stages. Here, we used an advanced human heart organoid model that recapitulates complex aspects of heart development during the first trimester to model the effects of pregestational diabetes in the human embryonic heart. We observed that heart organoids in diabetic conditions develop pathophysiological hallmarks like those previously reported in mouse and human studies, including ROS-mediated stress and cardiomyocyte hypertrophy, among others. Single cell RNA-seq revealed cardiac cell type specific-dysfunction affecting epicardial and cardiomyocyte populations, and suggested alterations in endoplasmic reticulum function and very long chain fatty acid lipid metabolism. Confocal imaging and LC-MS lipidomics confirmed our observations and showed that dyslipidemia was mediated by fatty acid desaturase 2 (FADS2) mRNA decay dependent on IRE1-RIDD signaling. We also found that the effects of pregestational diabetes could be reversed to a significant extent using drug interventions targeting either IRE1 or restoring healthy lipid levels within organoids, opening the door to new preventative and therapeutic strategies in humans.

The effect of maternal pregestational diabetes on fetal autonomic nervous system

Heart rate variability assessment of neonates of pregestational diabetic mothers have shown alterations in the autonomic nervous system (ANS). The objective was to study the effect of maternal pregestational diabetes on ANS at the fetal stage by combining cardiac and movement parameters using a non-invasive fetal magnetocardiography (fMCG) technique. This is an observational study with 40 participants where fetuses from a group of 9 Type 1, 19 Type 2 diabetic, and 12 non-diabetic pregnant women were included. Time and frequency domain fetal heart rate variability (fHRV) and coupling of movement and heart rate acceleration parameters related to fetal ANS were analyzed. Group differences were investigated using analysis of covariance to adjust for gestational age (GA). When compared to non-diabetics, the Type 1 diabetics had a 65% increase in average ratio of very low-frequency (VLF) to low-frequency (LF) bands and 63% average decrease in coupling index after adjusting for GA. Comparing Type 2 diabetics to non-diabetics, there was an average decrease in the VLF (50%) and LF bands (63%). Diabetics with poor glycemic control had a higher average VLF/LF (49%) than diabetics with good glycemic control. No significant changes at p < 0.05 were observed in high-frequency (HF) frequency domain parameters or their ratios, or in the time domain. Fetuses of pregestational diabetic mothers exhibited some differences in fHRV frequency domain and heart rate-movement coupling when compared to non-diabetics but the effect of fHRV related to fetal ANS and sympathovagal balance were not as conclusive as observed in the neonates of pregestational diabetic mothers.

Is There Any Correlation Between QT Dispersion and Echocardiographic Indices in Term Neonates with and Without Maternal Gestational Diabetes Mellitus?

Background: Gestational diabetes mellitus (GDM) can cause diastolic dysfunction and asymmetric ventricular septal hypertrophy in infants of gestational diabetic mothers (IGDMs). Ventricular thickness can affect QT interval and other QT parameters. Objectives: This study aimed to evaluate and compare the duration of QT, corrected QT (QTc), QT dispersion (QTD), and echocardiographic indices in two groups of neonates of mothers with and without GDM. Methods: In this case-control study, 76 term neonates were enrolled. The case group (n = 38) included IGDM, and the control group (n = 38) included neonates born to healthy mothers. The QT, QTD, and QTc were calculated based on electrocardiographic results. Ejection fraction (EF), interventricular septal thickness at the end of diastole (IVSTD), left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), and left ventricular posterior wall thickness (LVPWT) were evaluated by performing echocardiography, and the two groups were compared regarding them. Data were analyzed using SPSS version 21. Results: In this study, neonates' mean age and weight were 4.18 ± 1.3 days and 3418.16 ± 549.24 grams, respectively. As for the gender of neonates, 68.4% in the case group and 47.4% in the control group were female. The two groups had no significant difference regarding age, weight, and sex (P > 0.05). Minimum QTc (QTc min) was significantly higher in the case group (P = 0.046). Considerably lower EF and higher IVSTD were found in the case group (P = 0.011 and P = 0.05 respectively). In univariate analysis, echocardiographic parameters were not the predictors of QTD (P > 0.05); in multivariate analysis, however, QTD was significantly correlated with LVEDD (P = 0.001) and LVESD (P = 0.015). Conclusions: A higher proportion of septal hypertrophy was detected in IGDMs compared to infants of the healthy mothers without any correlation with ECG indices. This involvement was accompanied by relatively decreased EF verified by echocardiography. Most ECG findings, including QTD values, had no linear relationship with echocardiographic parameters except for LVEDD and LVESD.

Third Trimester Myocardial Performance Index in Fetuses from Women with Hyperglycemia in Pregnancy: A Systematic Review and Meta-Analysis

INTRODUCTION

 The myocardial performance index (MPI) has been proposed to evaluate cardiac dysfunction in newborns from diabetic mothers. Although MPI is routinely assessed in newborns, its role in the evaluation of fetuses from women with hyperglycemia in pregnancy (HIP) is still under evaluation. We aimed to evaluate the differences in third trimester fetal MPI in pregnant women with hyperglycemia compared to healthy controls.

MATERIALS AND METHODS

 Seven electronic databases were searched for all studies assessing women with HIP who underwent evaluation of fetal left MPI during pregnancy compared to a control group. The summary measures were reported as mean differences (MD) in the mean fetal left MPI between women with HIP and healthy controls, with a 95 % confidence interval (CI). A post hoc subgroup analysis based on the type of HIP - pregestational diabetes, GDM, or gestational impaired glucose tolerance (GIGT) - was performed as an additional analysis.

RESULTS

 14 studies assessing 1326 fetuses (580 from women with HIP and 746 from controls) were included. Women with HIP had a significantly higher mean left fetal MPI compared to controls (MD 0.08; 95 %CI: 0.05 to 0.11; p < 0.00 001). Subgroup analysis according to the type of HIP concurred with the overall analysis for women with DM (MD 0.07; 95 %CI: 0.01 to 0.13; p = 0.02) and for women with GDM (MD 0.012; 95 %CI: 0.07 to 0.17; p < 0.00 001) but not for women with GIGT (MD -0.01, 95 % CI -0.28 to 0.27; p = 0.96).

CONCLUSION

 Fetal left MPI is increased in pregnancies with HIP appearing as a potential marker of cardiac dysfunction.

Feto-placental endothelial dysfunction in Gestational Diabetes Mellitus under dietary or insulin therapy

OBJECTIVE

Gestational diabetes mellitus (GDM) is a serious complication in pregnancy. Despite controlling the plasma glucose levels with dietary intervention (GDM-D) or insulin therapy (GDM-I), children born of diabetic mothers suffer more long-term complications from childhood to early adulthood. Placental circulation and nutrient exchange play a vital role in fetal development. Additionally, placental endothelial function is an indicator of vascular health, and plays an important role in maintaining placental circulation for nutrient exchange. This study was conducted to assess changes in fetal endothelial dysfunction in GDM under different interventions during pregnancy.

METHODS

The primary human umbilical vein endothelial cells (HUVECs) were obtained from normal pregnant women (n = 11), GDM-D (n = 14), and GDM-I (n = 12) patients. LC-MS/MS was used to identify differentially expressed proteins in primary HUVECs among the three groups, after which Bioinformatics analysis was performed. Glucose uptake, ATP level, apoptosis, and differentially expressed proteins were assessed to investigate changes in energy metabolism.

RESULTS

A total of 8174 quantifiable proteins were detected, and 142 differentially expressed proteins were identified after comparing patients with GDM-D/GDM-I and healthy controls. Of the 142, 64 proteins were upregulated while 77 were downregulated. Bioinformatics analysis revealed that the differentially expressed proteins were involved in multiple biological processes and signaling pathways related to cellular processes, biological regulation, and metabolic processes. According to the results from KEGG analysis, there were changes in the PI3K/AKT signaling pathway after comparing the three groups. In addition, there was a decrease in glucose uptake in the GDM-I (P < 0.01) group. In GDM-I, there was a significant decrease in the levels of glucose transporter 1 (GLUT1) and glucose transporter 3 (GLUT3). Moreover, glucose uptake was significantly decreased in GDM-I, although in GDM-D, there was only a decrease in the levels of GLUT1. ATP levels decreased in GDM-I (P < 0.05) and apoptosis occurred in both the GDM-D and GDM-I groups. Compared to the normal controls, the levels of phosphate AKT and phosphate AMPK over total AKT and AMPK were reduced in the GDM-I group.

CONCLUSION

In summary, endothelial dysfunction occurred in pregnancies with GDM even though the plasma glucose levels were controlled, and this dysfunction might be related to the degree of glucose tolerance. The energy dysfunction might be related to the regulation of the AKT/AMPK/mTOR signaling pathway.

The impact of maternal diabetes on birth to placental weight ratio and umbilical cord oxygen values with implications for fetal-placental development

INTRODUCTION

We determined the impact of gestational diabetes (GDM) and pre-existing diabetes (DM) on birth/placental weight and cord oxygen values with implications for placental efficiency and fetal-placental growth and development.

METHODS

A hospital database was used to obtain birth/placental weight, cord PO₂ and other information on patients delivering between Jan 1, 1990 and Jun 15, 2011 with GA >34 weeks (N = 69,854). Oxygen saturation was calculated from the cord PO₂ and pH data, while fetal O₂ extraction was calculated from the oxygen saturation data. The effect of diabetic status on birth/placental weight and cord oxygen values was examined adjusting for covariates.

RESULTS

Birth/placental weights were stepwise decreased in GDM and DM compared to non-diabetics with placentas disproportionally larger indicating decreasing placental efficiency. Umbilical vein oxygen was marginally increased in GDM but decreased in DM attributed to the previously reported hyper-vascularization in diabetic placentas with absorbing surface area of capillaries initially increased, but then constrained by increasing distance from maternal blood within the intervillous space. Umbilical artery oxygen was unchanged in GDM and DM, with fetal O₂ extraction decreased in DM indicating that fetal O₂ delivery must be increased relative to O₂ consumption and likely due to increased umbilical blood flow.

DISCUSSION

Increased villous density/hyper-vascularization in GDM and DM with placentas disproportionately larger and umbilical blood flow increased, are postulated to normalize umbilical artery oxygen despite increased birth weights and growth-related O₂ consumption. These findings have implications for mechanisms signaling fetal-placental growth and development in diabetic pregnancies and differ from that reported with maternal obesity.

Infantile hypertrophic pyloric stenosis: maternal diabetes and perinatal exposure to non-macrolide antibiotics

OBJECTIVE

Infant exposure to macrolide antibiotics is a risk factor for infantile hypertrophic pyloric stenosis (IHPS). The aim of the study was to establish whether perinatal exposure to non-macrolide antibiotics was a risk factor for IHPS.

STUDY DESIGN

A retrospective matched case-control study was performed using a database including all children born at Soroka University Medical Centre between 2006 and 2018. Cases and controls were compared using Student T-test and multiple logistic regression.

RESULT

Of 189 461 children in the database, 63 infants were diagnosed with IHPS and underwent pyloromyotomy. There was no association between non-macrolide antibiotic exposure and IHPS. Maternal diabetes (DM) had an adjusted odds ratio for infants developing IHPS of 4.53 (p = 0.004).

CONCLUSION

The lack of association between exposure to non-macrolide antibiotics and IHPS suggests a quality unique to macrolides. An association between DM and IHPS may suggest elevated levels of IGF-1 have a role.

Incidence of Fetal Myocardial Hypertrophy in Mother with Diabetes Mellitus by Using Cardio-Spatiotemporal Image Correlation (STIC) M-Mode

Objective

The aim was to demonstrate the prevalence of fetal myocardial hypertrophy (FMH) in diabetes mellitus (DM) pregnant women using spatio-temporal image correlation (STIC) M-mode.

Material and Methods

This prospective descriptive study was conducted at Bhumibol Adulyadej Hospital (BAH) Royal Thai Air Force between April and December 2022. Participants were singleton DM pregnant women with gestational age (GA) between 18 and 40 weeks who had antenatal care and delivery at BAH. DM screening was randomized blood sugar obtained from all participants. All participants underwent fetal heart exams by four-dimension ultrasound with STIC M-mode.

Results

One hundred and forty-five participants were recruited and classified as pregestational (PDM) and gestational DM (GDM) at 31 and 114 cases, respectively. The mean age of participants was 31.7 years old. Fasting blood sugar (FBS) of PDM was significantly higher than GDM (105.1 vs 87.0 mg%). GDMA2 had more elevated FBS than GDMA1 (p < 0.001). PDM had significantly greater FBS and two-hour postprandial blood sugar (2hr-PP) than GDM (105.1/87.0 and 151.5/117.9 mg%, respectively). FBS and 2hr-PP of GDMA2 were more than GDMA1 with statistical significance. Good glycemic control of GDM was significantly better than PDM. GDMA1 had better glycemic control than GDMA2 with statistical significance. Four-fifth (115/145) of participants had FMH. FMH and estimated fetal weight among PDM and GDM were comparable. Both good and poor glycemic control had similar FMH. Neonatal outcomes of FMH or non-FMH infants were similar.

Conclusion

The prevalence of FMH in diabetic pregnant women was 79.3%. Glycemic control had no correlation to FMH.

Evaluation of Fetal Cardiac Function in Maternal Gestational Diabetes Mellitus by Speckle-Tracking Echocardiography

OBJECTIVES

Gestational diabetes mellitus (GDM) is the most common metabolic disease that occurs during pregnancy and may result in fetal cardiac dysfunction. Our study aimed to assess the cardiac function in fetuses of mothers with GDM by a quantitative analysis software based on speckle-tracking echocardiography.

METHODS

Forty-nine fetuses exposed to GDM and 50 normal fetuses were enrolled, and fetal echocardiography were performed and analyzed in this prospective cross-sectional study. We compared cardiac systolic function between the two groups using fetal cardiac quantitative analysis software.

RESULTS

In the GDM group, left ventricular (24 ± 4 versus 28 ± 4, P < .001) and right ventricular global longitudinal strain (23 ± 4 versus 26 ± 4, P = .002) and right ventricular free wall strain (26 ± 6 versus 29 ± 5, P = .006) were significantly lower compared with the control group, whereas there was no significant difference in global spherical index (1.2 ± 0.1 versus 1.2 ± 0.1, P = .425). Additionally, 24-segment transverse fraction shortening of the right ventricle was more impaired than the left, and the segments with reduced fraction shortening were mainly located in the mid and apical sections of the right ventricle, and midsection of the left ventricle.

CONCLUSION

Fetuses exposed to GDM may have cardiac dysfunction before the onset of cardiac morphologic abnormalities, and the right ventricle is more vulnerable than the left during fetal development.

Gestational Diabetes Mellitus and Antenatal Corticosteroid Therapy-A Narrative Review of Fetal and Neonatal Outcomes

BACKGROUND

There, we review the pathogenesis of gestational diabetes mellitus (GDM), its influence on fetal physiology, and neonatal outcomes, as well as the usage of antenatal corticosteroid therapy (ACST) in pregnancies complicated by GDM.

METHODS

MEDLINE and PubMed search was performed for the years 1990-2022, using a combination of keywords on such topics. According to the aim of the investigation, appropriate articles were identified and included in this narrative review.

RESULTS

GDM is a multifactorial disease related to unwanted pregnancy course and outcomes. Although GDM has an influence on the fetal cardiovascular and nervous system, especially in preterm neonates, the usage of ACST in pregnancy must be considered taking into account maternal and fetal characteristics.

CONCLUSIONS

GDM has no influence on neonatal outcomes after ACST introduction. The ACST usage must be personalized and considered according to its gestational age-specific effects on the developing fetus.

Left atrial shortening fraction to predict fetal cardiac abnormalities and dysfunction in gestational diabetes mellitus

Objective

To evaluate the diagnostic efficiency of left atrial shortening fraction (LASF) in the detection of fetal cardiac abnormalities and dysfunction in patients with gestational diabetes mellitus (GDM).

Methods

In this study, we enrolled 256 pregnant women and divided them into GDM group (n = 156) and control group (n = 100). Fetal echocardiography was performed at 24-28 weeks of gestation to measure the LASF and interventricular septum (IVS) thickness. Based on IVS thickness, the GDM group was subdivided into the septal hypertrophy group (GDM I, n = 62) and non-septal hypertrophy group (GDM II, n = 94). LASF and IVS thickness were compared between the GDM and control groups and between GDM I and GDM II groups. Receiver operating characteristic (ROC) analysis was performed to determine the diagnostic accuracy of LASF in predicting septal hypertrophy.

Results

The GDM group had a larger IVS thickness (P < 0.05) but a lower LASF level (P < 0.001) than those of the control group. GDM I group had significantly lower LASF level than that in the GDM II group (P < 0.001). At 38.41% as the cutoff value, the LASF can predict septal hypertrophy with diagnostic sensitivity and specificity of 96.7% and 65.2%, respectively.

Conclusion

Fetal GDM are more likely to induce septal hypertrophy and ventricular dysfunction. LASF is a good indicator of septal hypertrophy or early diastolic dysfunction without septal hypertrophy.

Maternal obesity in pregnancy and children's cardiac function and structure: A systematic review and meta-analysis of evidence from human studies

The prevalence of obesity is increasing worldwide. Experimental animal studies demonstrate that maternal obesity during pregnancy directly affects cardiac structure and function in their offspring, which could contribute to their increased cardiovascular disease (CVD) risk. Currently, a systematic overview of the available evidence regarding maternal obesity and alterations in cardiac structure and function in human offspring is lacking. We systematically searched the electronic databases Embase, MEDLINE and NARCIS from inception to June 29, 2022 including human studies comparing cardiac structure and function from fetal life onwards in offspring of women with and without obesity. The review protocol was registered with PROSPERO International Prospective Register of Systematic Reviews (identifier: CRD42019125071). Risk of bias was assessed using a modified Newcastle-Ottawa scale. Results were expressed using standardized mean differences (SMD). The search yielded 1589 unique publications, of which thirteen articles were included. Compared to offspring of women without obesity, fetuses of women with obesity had lower left ventricular strain, indicative of reduced systolic function, that persisted in infancy (SMD -2.4, 95% confidence interval (CI) -4.4 standard deviation (SD) to -0.4 SD during fetal life and SMD -1.0, 95% CI -1.6 SD to -0.3 SD in infancy). Furthermore, infants born to women with obesity had a thicker interventricular septum (SMD 0.6 SD, 95% CI 0.0 to 1.2 SD) than children born to women without obesity. In conclusion, cardiac structure and function differs between fetuses and children of women with and without obesity. Some of these differences were present in fetal life, persisted in childhood and are consistent with increased CVD risk. Long-term follow-up research is warranted, as studies in offspring of older age are lacking.

Evaluation of Fetal Cardiac Geometry and Contractility in Gestational Diabetes Mellitus by Two-Dimensional Speckle-Tracking Technology

Background: The most commonly known cardiac effect of gestational diabetes mellitus (GD) in the fetus is hypertrophic cardiomyopathy, but recent studies show that it is preceded by subclinical cardiac dysfunction. This study aimed to assess the effect of GD on fetal cardiac geometry and contractility by two-dimensional speckle-tracking technology. Methods: We performed a prospective observational study that included 33 pregnant patients with GD and 30 healthy individuals. For all fetuses, a four-chamber 3 s cine-loop was recorded and analyzed with Fetal Heart Quantification (FetalHQ®), a novel proprietary speckle-tracking software. The following cardiac indices were calculated: global sphericity index (GSI), global longitudinal strain (GLS), fractional area change (FAC), and 24-segment end-diastolic diameter (EDD), fractional shortening (FS), and sphericity index (SI) for both ventricles. Demographic and cardiac differences between the two groups were analyzed, as well as intra-rater and inter-rater reliability. Results: There were significant changes in right ventricular FAC and FS for segments 4−24 in fetuses exposed to GD (−1 SD, p < 0.05). No significant differences were detected for GSI, GLS, EDD, or SI for either ventricle. Conclusions: Fetuses exposed to GD present impaired right ventricular contractility, especially in the mid and apical segments.