A prospective observational study comparing cardiac function of small for gestational age with appropriate for gestational age babies using serial echocardiographic studies

Understanding changes in echocardiographic parameters at different ages following fetal growth restriction: a systematic review and meta-analysis

Fetal growth restriction (FGR) increases cardiovascular risk by cardiac remodeling and programming. This systematic review and meta-analysis across species examines the use of echocardiography in FGR offspring at different ages. PubMed and Embase.com were searched for animal and human studies reporting on echocardiographic parameters in placental insufficiency-induced FGR offspring. We included six animal and 49 human studies. Although unable to perform a meta-analysis of animal studies because of insufficient number of studies per individual outcome, all studies showed left ventricular dysfunction. Our meta-analyses of human studies revealed a reduced left ventricular mass, interventricular septum thickness, mitral annular peak velocity, and mitral lateral early diastolic velocity at neonatal age. No echocardiographic differences during childhood were observed, although the small age range and number of studies limited these analyses. Only two studies at adult age were performed. Meta-regression on other influential factors was not possible due to underreporting. The few studies on myocardial strain analysis showed small changes in global longitudinal strain in FGR offspring. The quality of the human studies was considered low and the risk of bias in animal studies was mostly unclear. Echocardiography may offer a noninvasive tool to detect early signs of cardiovascular predisposition following FGR. Clinical implementation yet faces multiple challenges including identification of the most optimal timing and the exact relation to long-term cardiovascular function in which echocardiography alone might be limited to reflect a child's vascular status. Future research should focus on myocardial strain analysis and the combination of other (non)imaging techniques for an improved risk estimation.NEW & NOTEWORTHY Our meta-analysis revealed echocardiographic differences between fetal growth-restricted and control offspring in humans during the neonatal period: a reduced left ventricular mass and interventricular septum thickness, reduced mitral annular peak velocity, and mitral lateral early diastolic velocity. We were unable to pool echocardiographic parameters in animal studies and human adults because of an insufficient number of studies per individual outcome. The few studies on myocardial strain analysis showed small preclinical changes in FGR offspring.

Second-trimester cardiovascular biometries in growth-restricted fetuses; a multicenter cohort study

BACKGROUND

Intrauterine growth restriction is associated with an increased risk of cardiovascular changes neonatally. However, the underlying pathways are poorly understood, and it is not clear whether the dysfunction is already present in the fetus.

OBJECTIVE

This study aimed to investigate fetal cardiac dimensions assessed from images at the second trimester anatomy scan from fetuses classified postnatally as small for gestational age and intrauterine growth restricted and compare them with appropriate for gestational age fetuses.

STUDY DESIGN

This was a substudy from The Copenhagen Baby Heart Study, a prospective, multicenter cohort study including fetuses from the second trimester of pregnancy in Copenhagen from April 2016 to October 2018. The mothers were recruited at the second trimester anatomy scan that included extended cardiovascular image documentation followed by consecutively measured heart biometries by 2 investigators blinded for the pregnancy outcome. The fetuses were classified postnatally as small for gestational age and intrauterine growth restricted according to the International Society of Ultrasound in Obstetrics and Gynecology 2020 guidelines using birthweight and with a retrospective assessment of Doppler flow. The mean differences in the cardiovascular biometries were adjusted for gestational age at the time of the second trimester scan and the abdominal circumference. The z-scores were calculated, and the comparisons were Bonferroni corrected (significance level of P<.005). Receiver operating characteristic curves were computed after performing backward regression on several maternal characteristics and biomarkers.

RESULTS

We included 8278 fetuses, with 625 (7.6%) of them being small for gestational age and 289 (3.5%) being intrauterine growth restricted. Both small for gestational age and intrauterine growth restricted fetuses had smaller heart biometries, including the diameter at the location of the aortic valve (P<.005), the ascending aorta in the 3-vessel view (P<.005), and at the location of the pulmonary valve (P<.005). The intrauterine growth restricted group had significantly smaller hearts with respect to length and width (P<.005) and smaller right and left ventricles (P<.005). After adjusting for the abdominal circumference, the differences in the aortic valve and the pulmonary valve remained significant in the intrauterine growth restricted group. Achievement of an optimal receiver operating characteristic curve included the following parameters: head circumference, abdominal circumference, femur length, gestational age, pregnancy associated plasma protein-A multiples of median, nullipara, spontaneous conception, smoking, body mass index <18.5, heart width, and pulmonary valve with an area under the curve of 0.91 (0.88-0.93) for intrauterine growth restricted cases.

CONCLUSION

Intrauterine growth restricted fetuses had smaller prenatal cardiovascular biometries, even when adjusting for abdominal circumference. Our findings support that growth restriction is already associated with altered cardiac growth at an early stage of pregnancy. The heart biometries alone did perform well as a screening test, but combined with other factors, it increased the sensitivity and specificity for intrauterine growth restriction.

Myocardial performance index in term appropriate and small for gestational age neonates - a cross sectional study

BACKGROUND

It is known that small for gestational age (SGA) babies may be at an increased risk of cardiovascular diseases during adulthood. There is paucity of literature regarding comparative cardiac functions of SGA and appropriate for gestational age (AGA) babies in neonatal period. The present study was conceived to compare the cardiac function of term small and appropriate for gestational age (AGA) babies through a relatively novel echocardiographic index in early neonatal period.

OBJECTIVES

To compare values of myocardial performance index (MPI) index (MPI = IVCT + IVRT/ET) at 48-72 hours of age among AGA and SGA babies.

METHODS

Morphological and anthropometric assessment of serially born term babies was done at time of birth to recruit hundred each of AGA and SGA babies. Tissue Doppler Imaging (TDI) was done between 48-72 hours for each enrolled baby to assess both right and left ventricle MPI in each group.

RESULTS

Mean±SD values for right ventricular MPI in AGA and SGA groups were 0.268 + 0.007 and 0.30 + 0.026 respectively (p < 0.001). Mean±SD values for left ventricular MPI in AGA and SGA groups were 0.25 + 0.012 and 0.30 + 0.017 respectively (p < 0.001). There was significant negative correlation between MPI values for either ventricles and the birth weight (spearmen's rho of -0.66) (p < 0.001). Mean±SD values for LVET in AGA and SGA group were 0.304 + 0.026 and 0.266 + 0.032 respectively (p < 0.001).

CONCLUSION

MPI had a higher absolute value in the SGA babies as compared to AGA babies. These observations point towards suboptimal cardiac performance among SGA babies as compared to AGA babies on the basis of myocardial performance index.