Cardiac Function in Infants Born to Mothers With Gestational Diabetes - Estimation of Early Diastolic Intraventricular Pressure Differences

Echocardiographic Assessment of Biventricular Mechanics of Fetuses and Infants of Gestational Diabetic Mothers: A Systematic Review and Meta-Analysis

BACKGROUND

Gestational diabetes mellitus (GDM) is the most common complication in pregnancy, representing a serious risk for the mother and fetus. Identifying new biomarkers to ameliorate the screening and improving GDM diagnosis and treatment is crucial. During the last decade, a few studies have used speckle tracking echocardiography (STE) for assessing the myocardial deformation properties of fetuses (FGDM) and infants (IGDM) of GDM women, providing not univocal results. Accordingly, we performed a meta-analysis to examine the overall influence of GDM on left ventricular (LV) and right ventricular (RV) global longitudinal strain (GLS) in both FGDM and IGDM.

METHODS

All echocardiographic studies assessing conventional echoDoppler parameters and biventricular strain indices in FGDM and IGDM vs. infants born to healthy pregnant women, selected from PubMed and EMBASE databases, were included. The studies performed on FGDM and IGDM were separately analyzed. The subtotal and overall standardized mean differences (SMDs) in LV-GLS and RV-GLS in FGDM and IGDM studies were calculated using the random-effect model.

RESULTS

The full texts of 18 studies with 1046 babies (72.5% fetuses) born to GDM women and 1573 babies of women with uncomplicated pregnancy (84.5% fetuses) were analyzed. Compared to controls, FGDM/IGDM were found with a significant reduction in both LV-GLS [average value -18.8% (range -11.6, -24.2%) vs. -21.5% (range -11.8, -28%), p < 0.05)] and RV-GLS [average value -19.7% (range -13.7, -26.6%) vs. -22.4% (range -15.5, -32.6%), p <0.05)]. Large SMDs were obtained for both LV-GLS and RV-GLS studies, with an overall SMD of -0.91 (95%CI -1.23, -0.60, p < 0.001) and -0.82 (95%CI -1.13, -0.51, p < 0.001), respectively. Substantial heterogeneity was detected for both LV-GLS and RV-GLS studies, with an overall I2 statistic value of 92.0% and 89.3%, respectively (both p < 0.001). Egger's test gave a p-value of 0.10 for LV-GLS studies and 0.78 for RV-GLS studies, indicating no publication bias. In the meta-regression analysis, none of the moderators (gestational age, maternal age, maternal body mass index, maternal glycosylated hemoglobin, white ethnicity, GDM criteria, ultrasound system, frame rate, FGDM/IGDM heart rate, and anti-diabetic treatment) were significantly associated with effect modification in both groups of studies (all p > 0.05). The sensitivity analysis supported the robustness of the results.

CONCLUSIONS

GDM is independently associated with biventricular strain impairment in fetuses and infants of gestational diabetic mothers. STE analysis may allow for the early detection of subclinical myocardial dysfunction in FGDM/IGDM.

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.

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).

Implantable Triboelectric Nanogenerators for Self-Powered Cardiovascular Healthcare

Triboelectric nanogenerators (TENGs) have gained significant traction in recent years in the bioengineering community. With the potential for expansive applications for biomedical use, many individuals and research groups have furthered their studies on the topic, in order to gain an understanding of how TENGs can contribute to healthcare. More specifically, there have been a number of recent studies focusing on implantable triboelectric nanogenerators (I-TENGs) toward self-powered cardiac systems healthcare. In this review, the progression of implantable TENGs for self-powered cardiovascular healthcare, including self-powered cardiac monitoring devices, self-powered therapeutic devices, and power sources for cardiac pacemakers, will be systematically reviewed. Long-term expectations of these implantable TENG devices through their biocompatibility and other utilization strategies will also be discussed.

Non-Invasive Myocardial Work Indices in Infants Born to Mothers With Diabetes in Pregnancy

BACKGROUND

This study used echocardiography to investigate non-invasive myocardial work (MCW) indices in infants born to mothers with diabetes mellitus (DM) in pregnancy (gestational DM: GDM), including those diagnosed under novel classification criteria and those with pre-existing DM.

METHODS AND RESULTS

This single-centered, retrospective study included 25 infants born to mothers with GDM (termed "infant with GDM"), which was diagnosed by oral glucose tolerance test results during pregnancy or the presence of diabetes before the current pregnancy. We evaluated the relationship between the infant's MCW, such as global constructive work (GCW), global work index (GWI), global work efficiency (GWE), and global wasted work (GWW), and the mother's GDM maximal HbA1c during pregnancy. HbA1c level in GDM significantly negatively correlated with GWI* (r=-0.565) and GCW* (r=-0.641). In infants with GDM, GWI and GCW were significantly higher with <6.5% HbA1c than in those with >6.5% HbA1c GDM; however, the specific-layer global longitudinal strain analyses did not show any significant differences between the groups. The pressure-strain loop in infants with >6.5% HbA1c in GDM tended to be smaller than in those infants with <6.5% HbA1c GDM.

CONCLUSIONS

The hyperglycemic environment of GDM leads to impaired MCW in the infants. MCW is useful for screening for cardiac illnesses among infants with GDM. Appropriate maternal blood glucose management while maintaining HbA1c <6.5% might be beneficial for the cardiac performance of infants with GDM.

Echocardiographic Evaluation of Cardiac Function in Infants of Mothers with Diabetes

Introduction:

A large number of pregnancies are complicated by diabetes mellitus in the mother which is associated with the risk of various cardiac structural and functional complications in the neonates. A diagnostic tool is needed to detect these dysfunctions early. In contrast to conventional pulsed-wave Doppler, which is influenced by heart rate and the impact of volume changes on transmitral flow, tissue Doppler imaging is the mode of echocardiography that is relatively independent of the loading state. Two-dimensional (2D) speckle-tracking echocardiography-derived strain imaging is a new technology increasingly being used to estimate cardiac systolic and diastolic dysfunction and has superior prognostic value for predicting major adverse cardiac events.

Objective:

The objective of this study was to evaluate cardiac function in neonates of mothers with diabetes on echocardiography and differences in the extent of cardiac dysfunction between neonates of well-controlled and poorly controlled mothers with diabetes.

Methods:

This is a cross-sectional observational study which was done on 152 neonates born to mothers with diabetes (22 overt vs. 130 gestational and 23 well-controlled vs. 129 poorly controlled) and 96 born to nondiabetic mothers. Three modes of echocardiography, i.e. M-mode, Doppler (pulsed wave and tissue), and 2D speckle-tracking echocardiography, were done and cardiac functions were compared among different groups.

Results:

Infants of diabetic mothers (IDMs) had lower ejection fraction on M-mode echocardiography and lower values of global longitudinal strain on 2D speckle-tracking echocardiography along with significantly lower values of mitral and tricuspid E velocity and E/A ratio with higher values of A velocity on pulsed-wave Doppler. Tissue Doppler showed higher left ventricle E/E’ in IDM implying more systolic as well as diastolic dysfunction in IDM as compared to non-IDM. In neonates born to mothers with poorly controlled diabetes, Doppler showed lower values of mitral and tricuspid E/A ratio and left ventricle E’/A’ ratio signifying more diastolic dysfunction as compared to neonates born to mothers having good glycemic control. Similarly, neonates born to mothers with pregestational diabetes had significantly deranged systolic and diastolic functions.

Conclusions:

IDMs have significant cardiac dysfunction on echocardiography which is also related to the degree of glycemic control and onset of diabetes.

Echocardiographic Reference Ranges of Non-Invasive Myocardial Work Indices in Newborns

Background: Myocardial work (MCW), estimated using non-invasive pressure-strain loops, is a novel approach for assessing left ventricular function. MCW offers potential advantages over left ventricular ejection fraction and global longitudinal strain (GLS). This study aimed to establish a reference range for MCW in newborns.

Methods and Results: Overall, 113 healthy newborns (mean [±SD] birth weight 3,120±378 g) were included in the study. After entering peripheral systolic and diastolic blood pressure (BP) values, global constructive work (GCW), global work index (GWI), global work efficiency (GWE), and global wasted work (GWW) were calculated using EchoPAC software (version 204). Considering a mean [±SD] GLS of −16.3±2.8%, the mean [±SD] GWI, GCW, GWW, and GWE was 698.7±147.9 mmHg%, 1,008.5±200.1 mmHg%, 58.1±28.1 mmHg%, and 93.1±2.9%, respectively. All MCW parameters in newborns were lower than those previously reported in children and adults. However, GWI and GCW were more closely correlated with BP and GLS, as in adulthood and children. Estimation of the correlation between MCW and the frame rate index revealed no significant correlations among MCW parameters.

Conclusions: Cardiac function in newborns was evaluated by assessing MCW. With the establishment of reference ranges and normative MCW data for newborns, routine clinical use and rotational mechanics are likely to become increasingly common. Future studies are needed to determine whether MCW is useful in screening for cardiac illness among newborns.

Persistent subclinical myocardial dysfunction among infants of diabetic mothers

INTRODUCTION

Offspring of diabetic mothers have five times higher risk of cardiovascular abnormalities than in normal pregnancies. These cardiac anomalies involve fetal cardiac morphological and functional changes. Here, we investigate subclinical cardiovascular abnormalities, including structural and functional changes among infants of diabetic mothers.

MATERIAL AND METHODS

A prospective cohort study was carried out from March 2017 to September 2020 at a South Indian tertiary care center. One hundred ninety-eight newborns delivered from non-diabetic mothers, well-controlled diabetic mothers (WCDM), and poorly controlled diabetic mothers (PCDM) were studied. Neonates and infantile echocardiographic imaging were performed at the first week of life, at 6-weeks, and 6-months of life. Cardiac structure and function were assessed using 2D, M-mode, Conventional Doppler, and Tissue Doppler imaging.

RESULTS

Out of the total (198) infants, 66 (33.3%) were from the non-diabetic (control) mothers, 60 (30.3%) from the WCDM, and 72 (36.4%) were from the PCDM groups. In both WCDM and PCDM groups, the mean gestational ages at birth were shorter than the control group (37.19 ± 0.82, 36.02 ± 2.15, and 37.91 ± 1.33 weeks respectively). There was a high incidence of neonatal hypoglycemia (p-value <0.001), NICU stay >7 days (p-value <0.018), and persistent fetal transitional cardiac shunt (p-value <0.03) among poorly controlled DM group in comparison to others. Tissue deformation imaging showed a significant reduction in left ventricular global strain and strain rate in the neonatal heart from poorly controlled diabetic mothers. Myocardial wall thickness among neonates of diabetic mothers was higher compared to controls. LV TEI was higher in PCDM groups in comparison with WCDM and control groups; (0.59 ± 0.11, 0.46 ± 0.35, and 0.37 ± 0.12 respectively, p-value =0.01). Similarly, RV TEI was high in the PCDM (0.56 ± 0.09) group compared to the WCDM group (0.33 ± 0.12) and control group (0.28 ± 0.10).

CONCLUSIONS

Infants of diabetic mothers are at higher risk of developing cardiac abnormalities, including structural and functional defects. The highest increase in interventricular septal thickening found in poorly controlled diabetic mothers' neonates will disrupt both ventricles' functions, followed by WCDM and the control group.