Fetal echocardiographic screening of diabetic pregnancies for congenital heart disease

Loss of glycogen synthase kinase 3 isoforms during murine oocyte growth induces offspring cardiac dysfunction

Glycogen synthase kinase-3 (GSK3) is a constitutively active serine threonine kinase with 1) two isoforms (GSK3A and GSK3B) that have unique and overlapping functions, 2) multiple molecular intracellular mechanisms that involve phosphorylation of diverse substrates, and 3) implications in pathogenesis of many diseases. Insulin causes phosphorylation and inactivation of GSK3 and mammalian oocytes have a functional insulin-signaling pathway whereby prolonged elevated insulin during follicle/oocyte development causes GSK3 hyperphosphorylation, reduced GSK3 activity, and altered oocyte chromatin remodeling. Periconceptional diabetes and chronic hyperinsulinemia are associated with congenital malformations and onset of adult diseases of cardiovascular origin. Objectives were to produce transgenic mice with individual or concomitant loss of GSK3A and/or GSK3B and investigate the in vivo role of oocyte GSK3 on fertility, fetal development, and offspring health. Wild-type males bred to females with individual or concomitant loss of oocyte GSK3 isoforms did not have reduced fertility. However, concomitant loss of GSK3A and GSK3B in the oocyte significantly increased neonatal death rate due to congestive heart failure secondary to ventricular hyperplasia. Individual loss of oocyte GSK3A or GSK3B did not induce this lethal phenotype. In conclusion, absence of oocyte GSK3 in the periconceptional period does not alter fertility yet causes offspring cardiac hyperplasia, cardiovascular defects, and significant neonatal death. These results support a developmental mechanism by which periconceptional hyperinsulinemia associated with maternal metabolic syndrome, obesity, and/or diabetes can act on the oocyte and affect offspring cardiovascular development, function, and congenital heart malformation.

Predictors of postnatal complications and congenital cardiac diseases in infants of mothers with pregestational and gestational diabetes

AIM

In this study, we aimed to evaluate the postnatal problems of infants of mothers with pregestational and gestational diabetes and the clinical properties of infants who were found to have congenital cardiac disease.

MATERIAL AND METHODS

We retrospectively examined the records of 337 newborns who were followed up with a diagnosis of infant of diabetic mother between January 2010 and January 2012 in our Neonatology Unit. The demographic data of the diabetic mothers and their babies, the postnatal problems of the babies of diabetic mothers and congenital heart diseases found on transthoracic echocardiography were examined.

RESULTS

The patients were classified as group A, B and C in accordance with the recommendations of The American Congress of Obstetricians and Gynecologists (ACOG) according to the type of diabetes. The most common postnatal problems included hyperbilirubinemia, respiratory distress, hypoglycemia and hypocalcemia. The rate of congenital heart disease was found be 17.3% in group A, 50% in group B and 9% in group C. No correlation was found between congenital heart disease and gender, multiple pregnancy, diabetes type, diet treatment, use of oral antidiabetic drugs and drug usage. A positive significant correlation was found between congenital heart disease and genetic disease, murmur, cyanosis and presence of gestational hypertension. It was shown that use of insulin, genetic disease and presence of gestational diabetes increased the risk of congenital heart disease.

CONCLUSIONS

In our study, the overall incidence of congenital heart disease was found to be 24% in infants of diabetic mothers. It should be kept in mind that it is important to investigate the infants of mothers with pregestational and gestational diabetes in terms of the risk of congenital heart disease.

Hemoglobin A1c in pregestational diabetic gravidas and the risk of congenital heart disease in the fetus

This study aimed to determine whether poor glycemic control in early pregnancy is associated with an increased risk of congenital heart disease (CHD) for infants of women with preexisting diabetes. A retrospective review examined two tertiary care centers of diabetic pregnancies that recorded early hemoglobin A1c (HbA1c) values (<20 weeks). The incidence of prenatally diagnosed CHD was calculated and stratified by HbA1c level. Poor glycemic control was defined as an HbA1c level of 8.5 % or higher. Fetal echocardiography was used to identify fetuses that resulted in infants with suspected CHD. Neonatal echocardiograms and pathology reports were reviewed for confirmation of the diagnosis. Of 535 patients, 30 (5.6 %) delivered an infant with confirmed CHD. Among the patients with poor glycemic control, 8.3 % (n = 17) delivered an infant with CHD, whereas 3.9 % (n = 13) of those with an HbA1c level lower than 8.5 % delivered an infant with CHD (p = 0.03). Poor glycemic control in early pregnancy is associated with an increased risk of CHD in offspring. The incidence of CHD in patients with adequate glycemic control still is sufficiently high to justify routine fetal echocardiography for all gravidas with preexisting diabetes regardless of HbA1c level.

Congenital heart disease in pregnancies complicated by maternal diabetes mellitus. An international clinical collaboration, literature review, and meta-analysis

PURPOSE

Investigation of the incidence and distribution of congenital structural cardiac malformations among the offspring of mothers with diabetes type 1 and of the influence of periconceptional glycemic control.

METHODS

Multicenter retrospective clinical study, literature review, and meta-analysis. The incidence and pattern of congenital heart disease in the own study population and in the literature on the offspring of type 1 diabetic mothers were compared with the incidence and spectrum of the various cardiovascular defects in the offspring of nondiabetic mothers as registered by EUROCAT Northern Netherlands. Medical records were, in addition, reviewed for HbA(1c) during the 1st trimester.

RESULTS

The distribution of congenital heart anomalies in the own diabetic study population was in accordance with the distribution encountered in the literature. This distribution differed considerably from that in the nondiabetic population. Approximately half the cardiovascular defects were conotruncal anomalies. The authors' study demonstrated a remarkable increase in the likelihood of visceral heterotaxia and variants of single ventricle among these patients. As expected, elevated HbA(1c) values during the 1st trimester were associated with offspring fetal cardiovascular defects.

CONCLUSION

This study shows an increased likelihood of specific heart anomalies, namely transposition of the great arteries, persistent truncus arteriosus, visceral heterotaxia and single ventricle, among offspring of diabetic mothers. This suggests a profound teratogenic effect at a very early stage in cardiogenesis. The study emphasizes the frequency with which the offspring of diabetes-complicated pregnancies suffer from complex forms of congenital heart disease. Pregnancies with poor 1st-trimester glycemic control are more prone to the presence of fetal heart disease.

Indications for fetal echocardiography high referral, low yield?

An excellent imaging tool in the prenatal diagnosis and ongoing evaluation of congenital heart defects, fetal echocardiography is indicated in a selected population at increased risk compared with the general population. For certain "soft markers" of fetal congenital heart defects, ambiguity in the indications for fetal echo may result in a high referral rate, but low yield of congenital heart disease. Here, we critically examine 4 conditions, 2 maternal and 2 fetal: maternal gestational diabetes, advanced maternal age, isolated echogenic focus, and single umbilical artery. This critical review reveals that more prospective population-based studies with higher power and minimal bias need to be performed to establish the absolute risk of congenital heart defects in a selected population compared with that of the general population. Nonetheless, our analysis indicates that the absolute risk of congenital heart defects associated with each of these markers is low.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader should be able to define which patients should be referred for fetal echocardiography based on known risks, distinguish between relative and absolute risks for fetal congenital heart disease, and summarize fetal anomaly risks for women with altered glucose metabolism.

Reducing the cost of detection of congenital heart disease in fetuses of women with pregestational diabetes mellitus

OBJECTIVE

To provide a cost minimization analysis to support a paradigm shift in the use of comprehensive ultrasound and echocardiography in the prenatal diagnosis of congenital heart disease (CHD) in fetuses of women with diabetes mellitus (DM).

METHODS

In this retrospective cohort study, the diabetic clinic service database of the University of California San Diego was searched from January 2001 to June 2004 for pregnant women with Type I or II DM and HbA1c >6.3%. Subjects underwent comprehensive ultrasound examination (with four-chamber views and outflow tracts) and fetal echocardiography according to a standard protocol. Newborns were examined for cardiac defects and underwent postnatal echocardiography as indicated. The cost of screening was evaluated.

RESULTS

Of 115 neonates and two terminations of pregnancy there were 20 (17%) cases of CHD. Six of these CHD were major and all six were detected prenatally by both ultrasound and echocardiography. Three additional clinically insignificant cases of CHD were identified by fetal echocardiography. Eleven cases of CHD were identified by postnatal echocardiography only, all of which were clinically insignificant lesions. The prenatal detection rate of major CHD was 100% (6/6) for both ultrasound and echocardiography. The sensitivites of ultrasound (30% (95% CI, 13-54%)) and echocardiography (45% (95% CI, 24-68%)) were similar (P = 0.32). A cost minimization analysis was done using the published Medicaid (California) system's relative value unit and conversion factors. Accordingly, our current protocol costs $6503.43 per case of major CHD detected. If echocardiography had been performed only as indicated and postnatal echocardiography had been performed on all neonates, the cost would have been $7056.83 per case of major CHD detected. Alternatively, combined targeted ultrasound with indicated prenatal and postnatal echocardiography would have been associated with a cost of $4996.05 per case of major CHD detected.

CONCLUSION

Detection of major CHD was excellent with both comprehensive prenatal ultrasound and echocardiography. Echocardiography added little to the prenatal diagnosis of CHD if the comprehensive ultrasound examination was normal. The highest cost-benefit ratio and most efficacious protocol for screening based on our data would be comprehensive ultrasound with prenatal and postnatal echocardiography only as indicated. Further prospective studies are warranted.

Increased periconceptual maternal glycated haemoglobin in diabetic mothers reduces fetal long axis cardiac function

OBJECTIVE

To compare ventricular long axis function in fetuses of diabetic mothers (FDM) with contemporaneously studied normal controls (N) and to assess the effect of pre-pregnancy diabetic control on these measurements.

DESIGN

Long axis function was compared in 41 FDM and 159 N fetuses in a cross sectional observational study.

SETTING

Fetal medicine unit.

METHODS AND RESULTS

Echocardiography confirmed structural normality. Pulsed wave valvar Doppler velocimetry, lengthening and shortening myocardial velocities, and amplitude of ventricular long axis movement were recorded at the base of the left and right ventricular free walls and septum. Periconceptual diabetic control was assessed by haemoglobin A1c (HbA1c) in early pregnancy. Doppler and myocardial velocities were negatively related and myocardial thickness was positively related with HbA1c. In both cohorts all variables except mitral and tricuspid late filling (A wave) velocities were dependent on gestational age. FDM gestational age related values were higher for most variables and robust analysis of covariance showed significantly different maturation patterns in mitral valve E:A ratio (p = 0.036) and pulmonary velocity (p = 0.04), late lengthening myocardial velocities (left p = 0.016 and right p = 0.066), left myocardial shortening velocities (p = 0.008), and left free wall (p = 0.03) and septal (p = 0.04) amplitude of motion. FDM septal thickness was significantly increased throughout gestation (p < 0.0001).

CONCLUSION

Periconceptual diabetic control influences fetal cardiac performance and myocardial hypertrophy but, unlike the pathophysiology of adult ventricular hypertrophy, is accompanied by functional adaptation. It is unlikely to explain the increased rate of late stillbirth observed in diabetic pregnancies.

Congenital heart disease in infants of diabetic mothers: echocardiographic study

Our objective was to study neonates born to insulin-dependent diabetes mellitus (IDDM) mothers to detect the spectrum of congenital heart disease (CHD). Between July 2000 and June 2001, a prospective study of 100 consecutive infants of diabetic mothers (IDMs) at King Khalid University Hospital in Riyadh was undertaken. Family and maternal history, physical examination with special attention to the cardiovascular system, and echocardiography were performed. A total of 100 consecutive IDMs examined. The most common echocardiographic findings were patent ductus arteriosus (PDA; 70%), patent foramen ovale (68%), atrial septal defect (5%), small muscular ventricular septal defect (4%), mitral valve prolapse (2%), and pulmonary stenosis (1%). Hypertrophic cardiomyopathy (HCMP) was observed in 38% of cases, mainly hypertrophy of the interventricular septum. Severe forms of CHD encountered were D-transposition of great arteries, tetralogy of Fallot, and hypoplastic left heart syndrome (1% each). Isolated aortic stenosis and coarctation of aorta were not encountered in this series. Overall incidence of congenital heart disease was 15% after excluding PDA and HCMP. Maternal IDDM is a significant risk factor for CHD. Careful evaluation and early diagnosis of CHD in this high-risk group are highly indicated. There is a need for development of prenatal screening programs for CHD in our population.

Cardiovascular malformations in infants of diabetic mothers

OBJECTIVE

To compare the prevalence at live birth and the spectrum of cardiovascular malformations in infants born to diabetic mothers with pre-existing diabetes with that in infants of non-diabetic mothers.

DESIGN

Prospective study of all live births in the resident population of one health region, with recording of details of the outcome of all pregnancies of women with pre-existing diabetes and of all live born babies with cardiovascular malformations.

RESULTS

In the six years 1995-2000 there were 192 618 live births in the study population. Cardiovascular malformations were confirmed in 22 of 609 (3.6%) babies with diabetic mothers and in 1417 of 192 009 (0.74%) babies with non-diabetic mothers. The odds ratio for a cardiovascular malformation with maternal diabetes was 5.0 (95% confidence interval 3.3 to 7.8). Combination of these results with previous reports and comparison with the spectrum of cardiovascular malformations in infants of non-diabetic mothers shows a greater than threefold excess of transposition of the great arteries, truncus arteriosus, and tricuspid atresia.

CONCLUSIONS

Pre-existing maternal diabetes is associated with a fivefold increase in risk of cardiovascular malformations. Transposition of the great arteries, truncus arteriosus, and tricuspid atresia are overrepresented to produce a substantial excess of these malformations.

Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease

BACKGROUND

Pregnant women with heart disease (HD) are at increased risk for cardiac (CV) complications. However, the frequency of neonatal (NE) complications in pregnant women with HD relative to pregnant women without HD has not been examined.

METHODS AND RESULTS

Pregnant women with HD were prospectively monitored during 302 pregnancies. The frequency of NE and CV complications was compared with those in a control group without HD during 572 pregnancies. The frequency of NE complications was higher in the HD group (18% versus 7%; HD versus controls). The NE complication rate was lowest in pregnancies of women age 20 to 35 years who did not smoke during pregnancy, did not receive anticoagulants, and had no obstetric risk factors: 4% in control patients, 5% in HD patients with no cardiac risk factors for NE complications (left heart obstruction, poor functional class, or cyanosis), and 7% in HD patients with > or =1 such risk factor. In contrast, the event rate in pregnancies of controls age <20 or >35 years who had obstetric risk factors or multiple gestation or who smoked was 11%. In the HD group, women age <20 or >35 years who had obstetric risk factors or multiple gestation, who smoked, or who received anticoagulants experienced an even higher NE complication rate (27% with no cardiac risks for NE events and 33% in the presence of >or =1 cardiac risk factors). The frequency of CV complications was higher in the HD group (17% versus 0%; HD versus controls).

CONCLUSION

Pregnant women with HD are at increased risk for both NE and CV complications. The risk for NE adverse events in pregnant women with HD is highest in those with both obstetric and cardiac risk factors for NE complications.

Routine ultrasound screening in diabetic pregnancies

OBJECTIVES

To assess the detection rate of congenital fetal malformations and specific problems related to routine ultrasound screening in women with pre-existing diabetes.

METHODS

A retrospective study was carried out to assess the performance of routine ultrasound screening in women with pre-existing diabetes (Types 1 and 2) within a tertiary institution. The incidence, type and risk factors for congenital fetal malformations were determined. The detection rate of fetal anomalies for diabetic women was compared with that for the low-risk population. Factors affecting these detection rates were evaluated.

RESULTS

During the study period, 12 169 low-risk pregnant women and 130 women with pre-existing diabetes had routine ultrasound screening performed within the institution. A total of 10 major anomalies (7.7%) and three minor anomalies (2.3%) were present in the fetuses of the diabetic women. Central nervous system and cardiovascular system anomalies accounted for 60% of the major anomalies. Periconceptional hemoglobin A1c of more than 9% was associated with a high prevalence of major anomalies (143/1000). Women who had fetuses with major anomalies had a significantly higher incidence of obesity (78% vs. 37%; P < 0.05). Ultrasound examination of these diabetic pregnancies showed high incidences of suboptimal image quality (37%), incomplete examinations, and repeat examinations (17%). Compared to the 'low-risk' non-diabetic population from the same institution, the relative risk for a major congenital anomaly among the diabetic women was 5.9-fold higher (95% confidence interval, 2.9-11.9). The detection rate for major fetal anomalies was significantly lower for diabetic women (30% vs. 73%; P < 0.01), and the mean body mass index for the diabetic group was significantly higher (29 vs. 23 kg/m2; P < 0.001).

CONCLUSION

The incidence of congenital anomalies is higher in diabetic pregnancies. Unfortunately, the detection rate for fetal anomalies by antenatal ultrasound scan was significantly worse than that for the low-risk population. This is likely to be related to the maternal body habitus and unsatisfactory examinations. Methods to overcome these difficulties are discussed.

Maternal issues affecting the fetus

Maternal disorders and exposures that affect fetal cardiac structure and function are reviewed, emphasizing fetal echocardiographic diagnosis and monitoring, and approaches for in utero therapy. Maternal diabetes, hyperthyroidism, lupus erythematosis, epilepsy, congenital heart disease, infections, and drug exposures are considered.

Advances in echocardiographic diagnostic modalities for the pediatrician

Two-dimensional Doppler echocardiography has become the primary diagnostic tool in the assessment of infants and children with congenital and acquired heart disease. Over the past 10 years, specialized echocardiographic techniques have also become critical components in the evaluation and treatment of these patients. Using fetal echocardiography enables us to image the heart early in gestation and have begun to understand those lesions that can develop and progress in utero. Transesophageal echocardiography has allowed you to image the patient with congenital heart disease during repair in the operating room and in the cardiac catheterization laboratory so that adequacy of the repair can be assess and any residual lesions addressed immediately. Both of these specialized techniques are discussed in detail, with a brief overview at the three-dimensional future of echocardiography in the pediatric patient.