Gestational diabetes alters the fetal heart rate variability during an oral glucose tolerance test: a fetal magnetocardiography study

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.

Maternal Weight Gain during Pregnancy and the Developing Autonomic Nervous System-Possible Impact of GDM

OBJECTIVE

The intrauterine environment is known to affect the offspring's long-term risk for obesity and diabetes. Previous data show that maternal metabolism and gestational weight gain (GWG) are associated with fetal autonomic nervous system (ANS) function, which can be assessed with heart rate variability (HRV). We investigated whether this association is also present in 2-year-old children and addressed the impact of gestational diabetes (GDM).

RESEARCH DESIGN AND METHODS

We examined the 2-year-old offspring of mothers who had undergone a 5-point, 75 g oral glucose tolerance test during pregnancy. To assess HRV, a 10-minute ECG was recorded, and time domain and frequency domain parameters were analyzed. Body composition was assessed using bioelectrical impedance testing.

RESULTS

We examined 67 children (33 girls, 34 boys), 30 of whom were born to mothers with treated GDM and normoglycemic pregnancies (NGT), respectively. No differences were found between the groups with regard to birth weight, weight at the age of 2 years, and body fat content. We observed that GWG was associated with heart rate and HRV, indicating that children of mothers with low GWG had a lower parasympathetic tone. This association was detected in NGT-exposed-but not in GDM-exposed-children. HR and HRV correlated with body fat and fat-free mass in children from normoglycemic pregnancies only.

CONCLUSION

We found that the impact of maternal GWG on offspring ANS function was missing in the presence of treated GDM. The balance of the ANS was related to offspring body composition in children from NGT pregnancies only. Our results suggest that maternal weight gain during pregnancy has a critical impact on the developing ANS, which might be disturbed in the presence of GDM.

The German Gestational Diabetes Study (PREG), a prospective multicentre cohort study: rationale, methodology and design

INTRODUCTION

Even well-treated gestational diabetes mellitus (GDM) might still have impact on long-term health of the mother and her offspring, although this relationship has not yet been conclusively studied. Using in-depth phenotyping of the mother and her offspring, we aim to elucidate the relationship of maternal hyperglycaemia during pregnancy and adequate treatment, and its impact on the long-term health of both mother and child.

METHODS

The multicentre PREG study, a prospective cohort study, is designed to metabolically and phenotypically characterise women with a 75-g five-point oral glucose tolerance test (OGTT) during, and repeatedly after pregnancy. Outcome measures are maternal glycaemia during OGTTs, birth outcome and the health and growth development of the offspring. The children of the study participants are followed up until adulthood with developmental tests and metabolic and epigenetic phenotyping in the PREG Offspring study. A total of 800 women (600 with GDM, 200 controls) will be recruited.

ETHICS AND DISSEMINATION

The study protocol has been approved by all local ethics committees. Results will be disseminated via conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

The PREG study and the PREG Offspring study are registered with Clinical Trials (ClinicalTrials.gov identifiers: NCT04270578, NCT04722900).

Digital Resilience Biomarkers for Personalized Health Maintenance and Disease Prevention

Health maintenance and disease prevention strategies become increasingly prioritized with increasing health and economic burden of chronic, lifestyle-related diseases. A key element in these strategies is the empowerment of individuals to control their health. Self-measurement plays an essential role in achieving such empowerment. Digital measurements have the advantage of being measured non-invasively, passively, continuously, and in a real-world context. An important question is whether such measurement can sensitively measure subtle disbalances in the progression toward disease, as well as the subtle effects of, for example, nutritional improvement. The concept of resilience biomarkers, defined as the dynamic evaluation of the biological response to an external challenge, has been identified as a viable strategy to measure these subtle effects. In this review, we explore the potential of integrating this concept with digital physiological measurements to come to digital resilience biomarkers. Additionally, we discuss the potential of wearable, non-invasive, and continuous measurement of molecular biomarkers. These types of innovative measurements may, in the future, also serve as a digital resilience biomarker to provide even more insight into the personal biological dynamics of an individual. Altogether, digital resilience biomarkers are envisioned to allow for the measurement of subtle effects of health maintenance and disease prevention strategies in a real-world context and thereby give personalized feedback to improve health.

Associations of cord metabolome and biochemical parameters with the neonatal deaths of cloned pigs

Neonatal cloned pigs generated via somatic cell nuclear transfer (SCNT) have high incidences of malformation and mortality. The mechanisms underlying the massive loss of cloned pig neonates remain unclear. We compared the cord serum metabolic profiles and biochemical indexes of SCNT-derived piglets that died within 4 days (SCNT-DW4), SCNT-derived piglets that survived over 4 days (SCNT-SO4) and artificial insemination (AI)-generated piglets that survived over 4 days (AI-SO4) to investigate the associations of serum metabolomics and biochemical indexes in umbilical cord (UC) sera at delivery with the neonatal loss of cloned pigs. Results showed that compared with SCNT-SO4 and AI-SO4 piglets, SCNT-DW4 piglets had lower birth weight, placental indexes, placental vascularization scores, UC scores, vitality scores, serum glucose and levels but higher creatinine, urea nitrogen and uric acid levels in cord sera. Metabolomics analysis revealed alterations in lipid, glucose and purine metabolism in the cord sera of SCNT-DW4 piglets. These results indicated that the disturbance of the cord serum metabolome might be associated with the low birth weight and malformations of cloned neonates. These effects were likely the consequences of the impaired placental morphology and function of SCNT-derived piglets. This study provides helpful information regarding the potential mechanisms responsible for the neonatal death of cloned pigs and also offers an important basis for the design of effective strategies to improve the survival rate of these animals.

Cardiac changes in infants of diabetic mothers

Diabetes mellitus (DM) is a systemic chronic metabolic disorder characterized by increased insulin resistance and/or β- cell defects. It affects all ages from the foetal life, neonates, childhood to late adulthood. Gestational diabetes is a critical risk factor for congenital heart diseases (CHDs). Moreover, the risk increases with low maternal education, high body mass index at conception, undiagnosed pre-gestational diabetes, inadequate antenatal care, improper diabetes control, and maternal smoking during pregnancy. Maternal DM significantly affects the foetal heart and foetal–placental circulation in both structure and function. Cardiac defects, myocardial hypertrophy are three times more prevalent in infants of diabetic mothers (IDMs). Antenatal evaluation of the cardiac function and structures can be performed with foetal electrocardiography and echocardiography. Postnatal cardiac evaluation can be performed with natal and postnatal electrocardiography and echocardiography, detection of early atherosclerotic changes by measuring aortic intima-media thickness, and retinal vascular changes by retinal photography. Ameliorating the effects of diabetes during pregnancy on the offspring depends mainly on pregestational and gestational diabetes prevention. However, other measures to reduce the risk, such as using medications, nutritional supplements, or probiotics, still need more research. This review discusses the mechanism of foetal sequels and the risk factors that increase the prevalence of CHDs in gestational DM, the various cardiac outcomes of gestational DM on the foetus and offspring, cardiac evaluation of foetuses and IDMs, and how to alleviate the consequences of gestational DM on the offspring.

The Relationship between Gestational Diabetes Metabolic Control and Fetal Autonomic Regulation, Movement and Birth Weight

(1) Background: Maternal metabolic control in gestational diabetes is suggested to influence fetal autonomic control and movement activity, which may have fetal outcome implications. We aimed to analyze the relationship between maternal metabolic control, fetal autonomic heart rate regulation, activity and birth weight. (2) Methods: Prospective noninterventional longitudinal cohort monitoring study accompanying 19 patients with specialist clinical care for gestational diabetes. Monthly fetal magnetocardiography with electro-physiologically-based beat-to-beat heart rate recording for analysis of heart rate variability (HRV) and the ‘fetal movement index’ (FMI) was performed. Data were compared to 167 healthy pregnant women retrieved from our pre-existing study database. (3) Results: Fetal vagal tone was increased with gestational diabetes compared to controls, whereas sympathetic tone and FMI did not differ. Within the diabetic population, sympathetic activation was associated with higher maternal blood-glucose levels. Maternal blood-glucose levels correlated positively with birth weight z scores. FMI showed no correlation with birth weight but attenuated the positive correlation between maternal blood-glucose levels and birth weight. (4) Conclusion: Fetal autonomic control is altered by gestational diabetes and maternal blood-glucose level, even if metabolic adjustment and outcome is comparable to healthy controls.

Higher maternal weight is related to poorer fetal autonomic function

Maternal obesity is an established risk factor for poor infant neurodevelopmental outcomes; however, the link between maternal weight and fetal development in utero is unknown. We investigated whether maternal obesity negatively influences fetal autonomic nervous system (ANS) development. Fetal heart rate variability (HRV) is an index of the ANS that is associated with neurodevelopmental outcomes in the infant. Maternal-fetal magnetocardiograms were recorded using a fetal biomagnetometer at 36 weeks (n = 46). Fetal HRV was represented by the standard deviation of sinus beat-to-beat intervals (SDNN). Maternal weight was measured at enrollment (12-20 weeks) and 36 weeks. The relationships between fetal HRV and maternal weight at both time points were modeled using adjusted ordinary least squares regression models. Higher maternal weight at enrollment and 36 weeks were associated with lower fetal HRV, an indicator of poorer ANS development. Further study is needed to better understand how maternal obesity influences fetal autonomic development and long-term neurodevelopmental outcomes.

Association of first trimester fetal heart rate and nuchal translucency with preterm birth

OBJECTIVE

To evaluate whether first trimester fetal heart rate (FHR) and nuchal translucency (NT) associate with preterm birth (PTB).

METHODS

This was a comparative case-control study of 518 normal pregnancies with no history of PTB, of which 272 delivered at term (TB) and 246 progressed to spontaneous PTB prior to 37, 34, 32, and 28 weeks. Fetal heart rate (FHR) and NT values at the first-trimester scan were compared by means of univariable (Mann-Whitney) and multivariable logistic regression analysis considering hourglass membranes (HM) as the most severe PTB subgroup. Finally, severity trends for both parameters were investigated using correlations with gestational age (GA) at delivery and Kruskal-Walls tests.

RESULTS

Regardless of GA at delivery, pregnancies affected with PTB showed higher FHR and thicker NT at the first trimester scan. The association was confirmed by the multivariable analysis and the severity trends, which paired the highest FHR and NT values with the most severe cases of PTB (p < .001) (p < .0001).

CONCLUSION

Fetuses with subsequent late, early and very early PTB show higher values of NT and FHR at the first-trimester scan.

Nutritional and developmental programming effects of insulin

The discovery of insulin in 1921 was a major breakthrough in medicine and for therapy in patients with diabetes. The dramatic rise in the prevalence of overweight and obesity has been tightly linked to an increased prevalence of gestational diabetes mellitus (GDM), which poses major health concerns. Babies born to GDM mothers are more likely to develop obesity, type 2 diabetes and cardiovascular disease later in life. Evidence accumulated during the past two decades has revealed that high levels insulin, such as those observed during GDM, can have a widespread effect on the development and function of a variety of organs. This review summarises our current knowledge on the role of insulin in the placenta, cardiovascular system and brain during critical periods of development, as well as how it can contribute to lifelong metabolic regulation. We also discuss possible intervention strategies to ameliorate and hopefully reverse the developmental defects associated with obesity and GDM.

Evaluation of fetal cardiac function in pregnancies with well-controlled gestational diabetes

OBJECTIVE

To evaluate fetal ventricular diastolic function in pregnancies of women with gestational diabetes (GD), to determine whether minimal anomalies of glucose metabolism may influence fetal cardiac function.

STUDY DESIGN

Fetal ventricular filling time was measured by transabdominal ultrasound in singleton pregnancies between 34 and 37 weeks of gestation. We used a measurement which consists in the ratio between the diastolic time and the whole cardiac cycle time.

RESULTS

The study included 35 women with a GD and 217 non-diabetic. Right ventricular filling time (RVFT) was significantly lower in the GD group (mean of RVFT = 39.2 ± 4.4 vs 43.6 ± 4.6; p  <  0.01). Likewise, left ventricular filling time (LVFT) was shorter in the GD group compared to the non-GD group, though the difference was not significant (mean of LVFT = 43.6 ± 4.6 vs 44.6 ± 5.5; p  = 0.33).

CONCLUSIONS

Fetal right cardiac function is altered also in pregnancies where gestational diabetes is well controlled.

Exposures influencing the developing central autonomic nervous system

Autonomic nervous system function is critical for transition from in-utero to ex-utero life and is associated with neurodevelopmental and neuropsychiatric outcomes later in life. Adverse prenatal and neonatal conditions and exposures can impair or alter ANS development and, as a result, may also impact long-term neurodevelopmental outcomes. The objective of this article is to provide a broad overview of the impact of factors that are known to influence autonomic development during the fetal and early neonatal period, including maternal mood and stress during and after pregnancy, fetal growth restriction, congenital heart disease, toxic exposures, and preterm birth. We touch briefly on the typical development of the ANS, then delve into both in-utero and ex-utero maternal and fetal factors that may impact developmental trajectory of the ANS and, thus, have implications in transition and in long-term developmental outcomes. While many types of exposures and conditions have been shown to impact development of the autonomic nervous system, there is still much to be learned about the mechanisms underlying these influences. In the future, more advanced neuromonitoring tools will be required to better understand autonomic development and its influence on long-term neurodevelopmental and neuropsychological function, especially during the fetal period.

Fetal Heart Rate Variability Is Affected by Fetal Movements: A Systematic Review

Introduction: Fetal heart rate variability (FHRV) evaluates the fetal neurological state, which is poorly assessed by conventional prenatal surveillance including cardiotocography (CTG). Accurate FHRV on a beat-to-beat basis, assessed by time domain and spectral domain analyses, has shown promising results in the scope of fetal surveillance. However, accepted standards for these techniques are lacking, and the influence of fetal breathing movements and gross movements may be especially challenging. Thus, current standards for equivalent assessments in adults prescribe rest and controlled respiration. The aim of this review is to clarify the importance of fetal movements on FHRV. Methods: A systematic review in accordance with the PRISMA guidelines based on publications in the EMBASE, the MEDLINE, and the Cochrane Library databases was performed. Studies describing the impact of fetal movements on time domain, spectral domain and entropy analyses in healthy human fetuses were reviewed. Only studies based on fetal electrocardiography or fetal magnetocardiography were included. PROSPERO registration number: CRD42018068806. Results: In total, 14 observational studies were included. Fetal movement detection, signal processing, length, and selection of appropriate time series varied across studies. Despite these divergences, all studies showed an increase in overall FHRV in the moving fetus compared to the resting fetus. Especially short-term, vagal mediated indexes showed an increase during fetal breathing movements including an increase in Root Mean Square of the Successive Differences (RMSSD) and High Frequency power (HF) and a decrease in Low Frequency power/High Frequency power (LF/HF). These findings were present even in analyses restricted to one specific fetal behavioral state defined by Nijhuis. On the other hand, fetal body movements seemed to increase parameters supposed to represent the sympathetic response [LF and Standard Deviation of RR-intervals from normal sinus beats (SDNN)] proportionally more than parameters representing the parasympathetic response (RMSSD, HF). Results regarding entropy analyses were inconclusive. Conclusion: Time domain analyses as well as spectral domain analyses are affected by fetal movements. Fetal movements and especially breathing movements should be considered in these analyses of FHRV.

Studying the Effect of Maternal Pregestational Diabetes on Fetal Neurodevelopment Using Magnetoencephalography

Background. Developmental origin of health and disease states that an adverse intrauterine environment can lead to different diseases in later life. In this study, we aimed to explore the effect of maternal pregestational diabetes on the fetal brain activity using magnetoencephalography (MEG). Methods. Forty participants were included in an observational study with 9 type 1 and 19 type 2 diabetic pregnant women compared with data from 12 nondiabetic participants. Spontaneous fetal MEG signals were recorded and power spectral density was computed in 4 standard frequency bands. Group differences were investigated using analysis of covariance. Results. Our results showed that type 1 group was significantly different (P < .05) from the reference group for 3 of the 4 brain activity frequency bands, while in type 2 group, 2 bands exhibited this trend. When dichotomized based on the maternal glycemic control, significant differences in all bands were observed between the poor-control and reference groups. Conclusion. The fetal background brain activity parameters appear to be altered in diabetic pregnancy in comparison with the reference low-risk group. The study showed that maternal pregestational diabetes could potentially influence in utero neurodevelopment.

Development of Brain Networks In Utero: Relevance for Common Neural Disorders

Magnetic resonance imaging, histological, and gene analysis approaches in living and nonliving human fetuses and in prematurely born neonates have provided insight into the staged processes of prenatal brain development. Increased understanding of micro- and macroscale brain network development before birth has spurred interest in understanding the relevance of prenatal brain development to common neurological diseases. Questions abound as to the sensitivity of the intrauterine brain to environmental programming, to windows of plasticity, and to the prenatal origin of disorders of childhood that involve disruptions in large-scale network connectivity. Much of the available literature on human prenatal neural development comes from cross-sectional or case studies that are not able to resolve the longitudinal consequences of individual variation in brain development before birth. This review will 1) detail specific methodologies for studying the human prenatal brain, 2) summarize large-scale human prenatal neural network development, integrating findings from across a variety of experimental approaches, 3) explore the plasticity of the early developing brain as well as potential sex differences in prenatal susceptibility, and 4) evaluate opportunities to link specific prenatal brain developmental processes to the forms of aberrant neural connectivity that underlie common neurological disorders of childhood.

Central nervous pathways of insulin action in the control of metabolism and food intake

Insulin acts on the CNS to modulate behaviour and systemic metabolism. Disturbances in brain insulin action represent a possible link between metabolic and cognitive health. Current findings from human research suggest that boosting central insulin action in the brain modulates peripheral metabolism, enhancing whole-body insulin sensitivity and suppressing endogenous glucose production. Moreover, central insulin action curbs food intake by reducing the salience of highly palatable food cues and increasing cognitive control. Animal models show that the mesocorticolimbic circuitry is finely tuned in response to insulin, driven mainly by the dopamine system. These mechanisms are impaired in people with obesity, which might increase their risk of developing type 2 diabetes and associated diseases. Overall, current findings highlight the role of insulin action in the brain and its consequences on peripheral metabolism and cognition. Hence, improving central insulin action could represent a therapeutic option for people at an increased risk of developing metabolic and cognitive diseases.

Spotlight on the fetus: how physical activity during pregnancy influences fetal health: a narrative review

Before and during pregnancy, women often aim to improve their lifestyle so as to provide a healthier environment for their developing child. It remains unresolved, however, as to whether physical activity (PA) during pregnancy poses a possible risk or whether it might even have beneficial effects on the developing child. There is increasing evidence that PA during pregnancy is indeed beneficial to maternal physiological and psychological health and that it is generally not detrimental to the fetal cardiovascular system and neuronal function in the developing child. This also led to international recommendations for PAs during pregnancy. In the current review, we aimed to comprehensively assess the evidence of beneficial and harmful effects of maternal PA, including high-performance sports, on fetal development. The different mental and body-based relaxation techniques presented here are frequently performed during pregnancy. We found a considerable number of studies addressing these issues. In general, neither low key, moderate maternal PA nor relaxation techniques were observed to have a harmful effect on the developing child. However, we identified some forms of PA which could have at least a transient unfavourable effect. Notably, the literature currently available does not provide enough evidence to enable us to make a general conclusive statement on this subject. This is due to the lack of longitudinal studies on the metabolic and cognitive effects of regular PA during pregnancy and the wide diversity of methods used. In particular, the kind of PA investigated in each study differed from study to study.

Maternal Weight, Weight Gain, and Metabolism are Associated with Changes in Fetal Heart Rate and Variability

OBJECTIVE

Prepregnancy obesity and extensive weight gain can lead to diseases in the offspring later in life. The aim of this study was to evaluate the effect of anthropometric and metabolic factors on the fetal autonomic nervous system (ANS) in uncomplicated pregnancies.

METHODS

A total of 184 pregnant women in the second or third trimester were included, and for 104 women, maternal insulin sensitivity (ISI) was determined. Fetal heart rate (HR) and heart rate variability (HRV) were determined by magnetic recording. Associations of maternal prepregnancy BMI, weight gain, and ISI with fetal HR and HRV were evaluated by ANCOVA, partial correlation, and mediation analysis.

RESULTS

HR was increased and HRV decreased in fetuses of mothers with overweight or obesity in comparison to normal-weight mothers. Fetal HR was negatively correlated with maternal weight gain. Maternal prepregnancy BMI was positively correlated with fetal high frequency and was negatively correlated with low frequency and low/high frequency ratio. Maternal ISI showed a negative correlation with fetal HR.

CONCLUSIONS

The results show that the fetal ANS is sensitive to alterations of prepregnancy BMI, weight changes, and glucose metabolism. These findings highlight the importance of the intrauterine environment on the developing ANS and the possible programming of obesity.

Heart rate variability categories of fluctuation amplitude and complexity: diagnostic markers of fetal development and its disturbances

OBJECTIVE

In fetal diagnosis the myriad and diversity of heart rate variability (HRV) indices prevents a comparable routine evaluation of disturbances in fetal development and well-being. The work aims at the extraction of a small set of HRV key indices that could help to establish a universal, overarching tool to screen for any disturbance.

APPROACH

HRV indices were organized in categories of short-term (prefix s) and long-term (prefix l) amplitude fluctuations (AMP), complexity (COMP), and patterns (PATTERN) and common representatives for each category were extracted. This procedure was done with respect to the diagnostic value in the evaluation of the maturation age throughout the second and complete third trimester of pregnancy as well as to potential differences associated with maternal life-style factors (physical exercise, smoking), nutrient intervention (docosahexaenoic acid (DHA) supplementation), and complications of pregnancy (gestational diabetes mellitus (GDM), intra-uterine growth restriction (IUGR)).

MAIN RESULTS

We found a comprehensive minimal set that includes [lAMP: short term variation (STV), initially introduced in cardiotocography, sAMP: heart rate increase across one interbeat interval of phase rectified averaged signal - acceleration capacity (ACst1), lCOMP: scale 4 multi-scale entropy (MSE4), PATTERN: skewness] for the maturation age prediction, and partly overlapping [lAMP: STV, sAMP: ACst1, sCOMP: Lempel Ziv complexity (LZC)] for the discrimination of the deviations.

SIGNIFICANCE

The minimal set of category-based HRV representatives allows for a screening of fetal development and well-being. These results are an important step towards a universal and comparable diagnostic tool for the early identification of developmental disturbances. Novelty & Significance Fetal development and its disturbances have been reported to be associated with a multiplicity of HRV indices. Furthermore, these HRV indices change with maturation. We propose the abstraction of HRV categories defined by short- and long-term fluctuation amplitude, complexity, and pattern indices that cover all relevant aspects of maturational age, behavioral influences and a series of pathological disturbances. The study data are provided by multiple centers. Our approach is an important step towards the goal of a standardized diagnostic tool for early identification of fetal developmental disturbances with respect to the reduction of serious complications in the later life.

Fully Automated R-peak Detection Algorithm (FLORA) for fetal magnetoencephalographic data

BACKGROUND AND OBJECTIVE

Fetal magnetoencephalography (fMEG) is a method for recording fetal brain signals, fetal and maternal heart activity simultaneously. The identification of the R-peaks of the heartbeats forms the basis for later heart rate (HR) and heart rate variability (HRV) analysis. The current procedure for the evaluation of fetal magnetocardiograms (fMCG) is either semi-automated evaluation using template matching (SATM) or Hilbert transformation algorithm (HTA). However, none of the methods available at present works reliable for all datasets.

METHODS

Our aim was to develop a unitary, responsive and fully automated R-peak detection algorithm (FLORA) that combines and enhances both of the methods used up to now.

RESULTS

The evaluation of all methods on 55 datasets verifies that FLORA outperforms both of these methods as well as a combination of the two, which applies in particular to data of fetuses at earlier gestational age.

CONCLUSION

The combined analysis shows that FLORA is capable of providing good, stable and reproducible results without manual intervention.

The Impact of Maternal Eating Disorders on Dietary Intake and Eating Patterns during Pregnancy: A Systematic Review

Maternal nutrition in pregnancy has a key influence on optimum fetal health. Eating disorders (EDs) during pregnancy may have detrimental effects on fetal growth and the child’s early development. There is limited knowledge concerning the eating behavior, dietary intake and derived nutritional biomarkers as well as the nutrient supplementation in women with EDs during pregnancy. We performed a systematic review according to the PRISMA statement to synthesize current evidence in this field. Of N = 1203 hits, 13 full-texts were included in the qualitative synthesis. While women with current Binge Eating Disorder (BED) showed higher energy and fat intakes during pregnancy, women with a lifetime Anorexia Nervosa (AN), Bulimia Nervosa (BN) or both (AN + BN) had similar patterns of nutrient intake and dietary supplement use as healthy women. There is evidence, that women with a history of EDs have a sufficient diet quality and are more likely to be vegetarian. Dieting and bingeing improved substantially with pregnancy. The highlighted differences in the consumption of coffee/caffeine and artificially sweetened beverages as well as the elevated prevalence of iron deficiency anemia in women with a past or active ED during pregnancy might have an important impact on fetal development.

The Critical Role of the Central Autonomic Nervous System in Fetal-Neonatal Transition

The objective of this article is to understand the complex role of the central autonomic nervous system in normal and complicated fetal-neonatal transition and how autonomic nervous system dysfunction can lead to brain injury. The central autonomic nervous system supports coordinated fetal transitional cardiovascular, respiratory, and endocrine responses to provide safe transition of the fetus at delivery. Fetal and maternal medical and environmental exposures can disrupt normal maturation of the autonomic nervous system in utero, cause dysfunction, and complicate fetal-neonatal transition. Brain injury may both be caused by autonomic nervous system failure and contribute directly to autonomic nervous system dysfunction in the fetus and newborn. The central autonomic nervous system has multiple roles in supporting transition of the fetus. Future studies should aim to improve real-time monitoring of fetal autonomic nervous system function and in supporting typical autonomic nervous system development even under complicated conditions.

Exosomes: Outlook for Future Cell-Free Cardiovascular Disease Therapy

Cardiovascular diseases are the number one cause of death globally with an estimated 7.4 million people dying from coronary heart disease. Studies have been conducted to identify the therapeutic utility of exosomes in many diseases, including cardiovascular diseases. It has been demonstrated that exosomes are immune modulators, can be used to treat cardiac ischemic injury, pulmonary hypertension and many other diseases, including cancers. Exosomes can be used as a biomarker for disease and cell-free drug delivery system for targeting the cells. Many studies suggest that exosomes can be used as a cell-free vaccine for many diseases. In this chapter, we explore the possibility of future therapeutic potential of exosomes in various cardiovascular diseases.

Family History of Diabetes Is Associated With Delayed Fetal Postprandial Brain Activity

Introduction: We have previously shown that fetuses of mothers with gestational diabetes mellitus (GDM) and insulin resistance exhibit a prolongation of fetal auditory event-related brain responses (fAER) compared to fetuses of normal glucose tolerant women during an oral glucose tolerance test (oGTT). This implies that maternal metabolism may program the developing fetal brain. We now asked whether a family history of type 2 diabetes without metabolic programing also impacts fetal brain activity. We therefore investigated brain activity in fetuses of normal glucose tolerant mothers with and without family history of type 2 diabetes (FHD+ and FHD-). Methods: A 75 g oGTT was performed in healthy pregnant women. Plasma glucose and insulin levels were measured after 0, 60, and 120 min. Each blood draw was preceded by fetal magnetoencephalographic (fMEG) recordings of fAER. From a group of 167 participants, a subsample of 52 metabolically healthy women, 37 with a negative, and 15 with a positive FHD (at least one first- or second-degree relative) was carefully selected based on the following inclusion criteria: inconspicuous pregnancy, no GDM, BMI 18.5-30 kg/m², no preterm birth and at least two fMEG with detectable fetal responses during oGTT. Results: An ANOVA showed a significant interaction between fMEG measurement time during the oGTT and FHD on fAER latency [F ₍₂₎ = 4.163, p = 0.018]. Fetuses of mothers with FHD+ had a prolonged fAER (273 ± 113 ms) compared to fetuses of mothers with FHD- (219 ± 69 ms) at 60 min during the oGTT [F ₍₁₎ = 4.902, p = 0.032]. There were no significant differences in age, BMI before pregnancy, weight gain during pregnancy and gestational age between the groups. Maternal glucose levels and insulin sensitivity were also not significantly different. Discussion: In addition to the previously shown influence of maternal metabolism on fetal brain activity, maternal family history of diabetes (FHD) is also linked to fetal postprandial brain activity. This indicates that genetic and/or epigenetic factors modulate the postprandial brain response of the developing fetus.

Chorioamnionitis following preterm premature rupture of membranes and fetal heart rate variability

Introduction

The objective of this study was to identify prenatal markers of histological chorioamnionitis (HC) during pPROM using fetal computerized cardiotocography (cCTG).

Materials and methods

Retrospective review of medical records from pregnant women referred for pPROM between 26 and 34 weeks, in whom placental histology was available, in a tertiary level obstetric service over a 5-year period. Fetal heart rate variability was assessed using cCTG. Patients were included if they were monitored at least six times in the 72 hours preceding delivery. Clinical and biological cCTG parameters during the pPROM latency period were compared between cases with or without HC.

Results

In total, 222 pPROM cases were observed, but cCTG data was available in only 23 of these cases (10 with and 13 without HC) after exclusion of co-morbidities which may potentially perturb fetal heart rate variability measures. Groups were comparable for maternal age, parity, gestational age at pPROM, pPROM duration and neonatal characteristics (p>0.1). Baseline fetal heart rate was higher in the HC group [median 147.3 bpm IQR (144.2–149.2) vs. 141.3 bpm (137.1–145.4) in no HC group; p = 0.02]. The number of low variation episodes [6.4, (3.5–15.3) vs. 2.3 (1–5.2); p = 0.04] was also higher in the HC group, whereas short term variations were lower in the HC group [7.1 ms (6–7.4) vs. 8.1 ms (7.4–9); p = 0.01] within 72 hours before delivery. Differences were especially discriminant within 24 hours before delivery, with less short-term variation [5 ms (3.7–5.9) vs. 7.8 ms (5.4–8.7); p = 0.007] and high variation episodes [3.9 (4.9–3.2) vs. 0.8 (1.5–0.2); p < 0.001] in the HC group.

Conclusion

These results show differences in fetal heart rate variability, suggesting that cCTG could be used clinically to diagnoses chorioamnionitis during the pPROM latency period.

Non-Invasive Fetal Monitoring: A Maternal Surface ECG Electrode Placement-Based Novel Approach for Optimization of Adaptive Filter Control Parameters Using the LMS and RLS Algorithms

This paper is focused on the design, implementation and verification of a novel method for the optimization of the control parameters (such as step size μ and filter order N) of LMS and RLS adaptive filters used for noninvasive fetal monitoring. The optimization algorithm is driven by considering the ECG electrode positions on the maternal body surface in improving the performance of these adaptive filters. The main criterion for optimal parameter selection was the Signal-to-Noise Ratio (SNR). We conducted experiments using signals supplied by the latest version of our LabVIEW-Based Multi-Channel Non-Invasive Abdominal Maternal-Fetal Electrocardiogram Signal Generator, which provides the flexibility and capability of modeling the principal distribution of maternal/fetal ECGs in the human body. Our novel algorithm enabled us to find the optimal settings of the adaptive filters based on maternal surface ECG electrode placements. The experimental results further confirmed the theoretical assumption that the optimal settings of these adaptive filters are dependent on the ECG electrode positions on the maternal body, and therefore, we were able to achieve far better results than without the use of optimization. These improvements in turn could lead to a more accurate detection of fetal hypoxia. Consequently, our approach could offer the potential to be used in clinical practice to establish recommendations for standard electrode placement and find the optimal adaptive filter settings for extracting high quality fetal ECG signals for further processing. Ultimately, diagnostic-grade fetal ECG signals would ensure the reliable detection of fetal hypoxia.