[Show abstract][Hide abstract] ABSTRACT: Abstract Objective: Intrauterine growth restriction (IUGR) and prenatal exposure to oxidative stress are thought to lead to increased risks of cardiovascular disease later in life. The objective of the present study was to document whether cord blood oxidative stress biomarkers vary with the severity of IUGR and of vascular disease in the twin pregnancy model in which both foetuses share the same maternal environment. Methods: This prospective cohort study involved dichorionic twin pairs, with one co- twin with IUGR. Oxidative stress biomarkers were measured in venous cord blood samples from each neonate of 32 twin pairs, and compared, according to severity of IUGR (IUGR <5th percentile), Doppler anomalies of the umbilical artery and early onset IUGR (in the second trimester) of the growth restricted twin. Results: Oxidized Low-Density Lipoproteins (oxLDL) and Malondialdehyde (MDA) concentrations were increased proportionally in cases of severe IUGR. OxLDL concentrations were also increased in cases of IUGR with Doppler anomaly. Conclusion: Our data indicate that severe IUGR, is related to a derangement in redox balance, illustrated by increased venous cord blood oxydative stress biomarkers concentrations. Severe IUGR and IUGR with abnormal Doppler can be translated into conditions with intense oxidative stress.
Full-text · Article · Aug 2014 · Journal of Maternal-Fetal and Neonatal Medicine
[Show abstract][Hide abstract] ABSTRACT: Congestive fetal heart failure, defined as inability of the heart to deliver adequate blood flow to organs such as the brain, liver, and kidneys, is a common final outcome of many intrauterine disease states that may lead to fetal demise. Advances in fetal medicine during the past 3 decades now provide the diagnostic tools to detect and also treat conditions that may lead to fetal heart failure. Fetal echocardiographic findings depend on severity of diastolic and systolic dysfunction of both ventricles. At an advanced stage, findings include cardiomegaly; valvar regurgitation; venous congestion; fetal edema and effusions; oligohydramnios; and preferential shunting of blood flow to the brain, heart, and adrenals in the distressed fetus. A useful diagnostic tool to quantify severity of heart failure is the cardiovascular profile score, which is a composite score based on 5 different echocardiographic parameters. To predict outcomes, the score should be interpreted in the context of the underlying disease, as different causes of intrauterine heart failure may have highly variable outcomes. Low fetal cardiac output may result from a myocardial disease (cardiomyopathy, myocarditis, ischemia), abnormal loading conditions (arterial hypertension, obstructive structural heart disease, atrioventricular malformations, twin-to-twin transfusion), arrhythmia, or external cardiac compression (pleural and/or pericardial effusions, cardiac tumours). Treatment options are available for several of these conditions.
No preview · Article · May 2013 · The Canadian journal of cardiology
[Show abstract][Hide abstract] ABSTRACT: We describe a fetus at 36 weeks with long QT syndrome presenting with variable types of atrioventricular blocks, ventricular premature beats, and torsades de pointes. All these diagnoses were made with the superior vena cava-aorta Doppler approach and confirmed with postnatal electrocardiography.
No preview · Article · Jul 2012 · American journal of obstetrics and gynecology
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to evaluate whether changes of uterine arteries and aortic isthmus Doppler blood flow recordings could enhance the prediction of necrotizing enterocolitis.
Doppler characteristics of the uterine artery, umbilical and middle cerebral arteries, ductus venosus, and aortic isthmus were reviewed in 123 growth-restricted fetuses who were then divided into 2 groups: with and without necrotizing enterocolitis.
Twelve of 123 newborn infants (9%) expressed necrotizing enterocolitis. This group showed significant association between necrotizing enterocolitis and bilateral notching on the uterine artery (83.3% vs 29.7%; P < .001), uterine artery mean resistance index (83.3% vs 36.9%; P < .002), aortic isthmus diastolic blood flow velocity integrals (Z score: -7.32 vs -3.99; P = .028), and absent or negative "a" wave on the ductus venosus (17% vs 1.8%; P = .021). With the use of logistic regression, uterine bilateral notching could predict necrotizing enterocolitis with a sensitivity of 83.3% and a specificity of 70.3%.
More than any other variable, uterine bilateral notching should be recognized as a strong risk factor for necrotizing enterocolitis.
No preview · Article · Nov 2011 · American journal of obstetrics and gynecology
[Show abstract][Hide abstract] ABSTRACT: Pregnancy is associated with significant cardiac adaptations. The regulatory mechanisms involved in functional cardiac adaptations during pregnancy are still largely unknown. In pathologic conditions, mineralocorticoids have been shown to mediate structural as well as functional remodelling of the heart. However, their role in cardiac physiological conditions is not completely understood. Here, we examined cardiac cell metabolic remodelling in the late stages of rat pregnancy, as well as mineralocorticoid involvement in this regulation.
We have applied rapid video imaging, echocardiography, patch clamp technique, confocal microscopy, and time-resolved fluorescence spectroscopy.
Our results revealed that cardiac cells undergo metabolic remodelling in pregnancy. Inhibition of mineralocorticoid receptors during pregnancy elicited functional alterations in cardiac cells: blood levels of energy substrates, particularly lactate, were decreased. As a consequence, the cardiomyocyte contractile response to these substrates was blunted, without modifications of L-type calcium current density. Interestingly, this response was associated with changes in the mitochondrial metabolic state, which correlated with modifications of bound reduced nicotinamide adenine dinucleotide (phosphate) NAD(P)H levels. We also noted that mineralocorticoid receptor inhibition prevented pregnancy-induced decrease in transient outward potassium current.
This study demonstrates that in pregnancy, mineralocorticoids contribute to functional adaptations of cardiac myocytes. By regulating energy substrate levels, in particular lactate, in the plasma and metabolic state in the cells, mineralocorticoids affect the contractility responsiveness to these substrates. In the future, understanding cardiac adaptations during pregnancy will help us to comprehend their pathophysiological alterations.
No preview · Article · Sep 2011 · The Canadian journal of cardiology
[Show abstract][Hide abstract] ABSTRACT: We verified whether oxidative stress indices (oxidized low-density lipoproteins and malondialdehyde) and inflammatory biomarkers (circulating C-reactive protein, interleukin-6, tumour necrosis factor-α, serum amyloid A and soluble intercellular vascular cell adhesion molecule) are increased in the umbilical vein of placental insufficiency induced intra-uterine growth restricted neonates.
The prospective cohort study, involving 3 tertiary care centers, consists of 200 consecutively recruited pregnant women carrying twins. We chose the twin pregnancy model because both fetuses share the same maternal environment, thereby avoiding potential confounding factors when comparing oxidative stress and inflammation biomarkers. We analysed only twin pairs with one with intra-uterine growth restriction (N=38) defined as fetal growth<10th percentile with abnormal Doppler of the umbilical artery. Blood samples were taken at birth from the umbilical vein. Intra-pair comparisons on the biomarkers were performed using the Student paired t-test.
We observed increased cord blood levels of oxidized low-density lipoproteins, (2.394 ± .412 vs 1.296 ± .204, p=.003) but not of malondialdehyde in growth restricted neonates when compared to their normal counterparts. Although indices of inflammation tended to be increased in cord blood from growth restricted newborns, the difference did not reach statistical significance.
In the twin model, intra-uterine growth restriction is associated with low-density lipoprotein oxidation without apparent dysregulation of inflammation biomarkers.
Increased oxidized low-density lipoproteins are observed in growth restricted twins compared to their co-twins with normal growth at birth.
No preview · Article · Feb 2011 · European journal of obstetrics, gynecology, and reproductive biology
[Show abstract][Hide abstract] ABSTRACT: The objective of the study was to evaluate the reliability of the 2 most commonly used ultrasonographic approaches for monitoring fetal atrioventricular conduction time (AVCT): (1) superior vena cava/ascending aorta (SVC/AA), and (2) left ventricular inflow/outflow tract (LVI/O) Doppler recordings.
Echographic studies from fetuses followed up for first-degree atrioventricular block (AVB-1) between 1998 and 2008 were reviewed. The ability to identify atrial contractions in the same fetuses by the SVC/AA and LVI/O approaches was analyzed.
Sixty-six studies of 13 fetuses with AVB-1 were available. Atrial contractions were visible in all SVC/AA studies. With the LVI/O approach, atrial contractions could not be identified in 26 studies (39%). AVCT delay was significantly greater in the nonidentifiable compared with the identifiable atrial contraction group (P < .001). Differences in heart rate and gestational age were not significant.
The LVI/O is unsuitable for prenatal screening of conduction system anomalies.
Full-text · Article · Apr 2010 · American journal of obstetrics and gynecology
[Show abstract][Hide abstract] ABSTRACT: Cardiac rhabdomyomas are benign cardiac tumours with few cardiac complications, but with a known association to tuberous sclerosis that affects the neurologic outcome of the patients. We have analysed the long-term cardiac and neurological outcomes of patients with cardiac rhabdomyomas in order to allow comprehensive prenatal counselling, basing our findings on the records of all patients seen prenatally and postnatally with an echocardiographic diagnosis of cardiac rhabdomyoma encountered from August, 1982, to September, 2007. We analysed factors such as the number and the location of the tumours to establish their association with a diagnosis of tuberous sclerosis, predicting the cardiac and neurologic outcomes for the patients.Cardiac complications include arrhythmias, obstruction of the ventricular outflow tracts, and secondary cardiogenic shock. Arrhythmias were encountered most often during the neonatal period, with supraventricular tachycardia being the commonest rhythm disturbance identified. No specific dimension or location of the cardiac rhabdomyomas predicted the disturbances of rhythm.The importance of the diagnosis of tuberous sclerosis is exemplified by the neurodevelopmental complications, with four-fifths of the patients showing epilepsy, and two-thirds having delayed development. The presence of multiple cardiac tumours suggested a higher risk of being affected by tuberous sclerosis. The tumours generally regress after birth, and cardiac-related problems are rare after the perinatal period. Tuberous sclerosis and the associated neurodevelopmental complications dominate the clinical picture, and should form an important aspect of the prenatal counselling of parents.
Full-text · Article · Feb 2010 · Cardiology in the Young
[Show abstract][Hide abstract] ABSTRACT: To evaluate the cardiovascular impact of fetal anemia.
We reviewed 53 echo-Doppler studies from 24 fetuses with anemia due to alloimmunization.
There was no difference between the severe and nonsevere anemia for heart rate, cardiothoracic ratio, and contractility. There was an increased left ventricular dimension, peak velocities of the middle cerebral artery (MCA) and a decreased pulsatility index of the umbilical artery (UAPI) in the severe group. The combination of MCA and UAPI had a high sensitivity (86%), specificity (91%), positive (80%) and negative (94%) predictive value as well as positive predictive likelihood ratio (9.6) to detect severe anemia.
Standard echocardiograhic parameters are not useful to correlate anemia. The combination of MCA and UAPI improves the accuracy to detect severe anemia.
No preview · Article · Sep 2008 · Fetal Diagnosis and Therapy
[Show abstract][Hide abstract] ABSTRACT: The systemic pressor response to bolus injections of Angiotensin I (A-I) into the pulmonary artery (PA) and the aortic root (Ao) was compared in 11 children during routine left and right heart catheterization; five had a left-to-right shunt and 6 had no hemodynamic abnorm'alities. An additional 4 children with normal hemodynamics were tested with Angiotensin I1,(A-II). Systemic pressor peaks to PA injections of A-I were slightly higher than those resulting from Ao injections. A study of the time course of the pressor responses showed that the intervals from the injection to onset of response, and from injection to half peak, were significantly prolonged after injection of A-I into the aorta, as compared with injections of A-I1 by the same route. Such a difference was not observed when A-I and A-I1 were given into the PA. These results indicate that conversion occurs to a considerable degree in the peripheral circulation, with a delay that is most probably due to the process of activation. When this peripheral conversion is maximal, the systemic pressor response assay is unable to detect pulmonary conversion solely on the basis of the height of pressor peaks, because the responses are equal after PA and Ao injections. PA injections of Angiotensin I and I1 had no effect on pulmonary artery pressure. It is concluded that: (1) pulmonary conversion occurs in all children with and without shunt; (2) peripheral (systemic) conversion occurs to a considerable degree and can account for most of the overall conversion of Angiotensin I, so that the role of the lung in the renin-angiotensin system seems unlikely.
No preview · Article · Jan 2008 · Acta Paediatrica
[Show abstract][Hide abstract] ABSTRACT: The new physiological concept: because of the parallel disposition of the fetal ventricles and of their respective arterial outlet, the flow through the aortic isthmus represents the only arterial shunt in the fetal circulation. The low resistance of the placental circulation explains the forward systolic and diastolic flows normally observed through the isthmus. Clinical implications: (1) assessment of individual performances of each ventricle : left ventricle causes forward flow while the right ventricle has a retrograde influence; (2) any changes of flow and/or resistances affecting one of the two fetal arterial systems organized in parallel should influence the flow pattern within the isthmus. Examples : peripheral arterio-venous fistula, increase in placental vascular resistance leading to intra-uterine growth restriction, etc. Conclusion: doppler flow recordings in the fetal aortic isthmus: (1) provides information on the global condition of the fetal cardiocirculatory system; (2) is a good indicator of fetal individual ventricular performance; (3) allows assessment of hemodynamic consequences of abnormalities of the peripheral circulatory systems.
Preview · Article · Dec 2007 · Medecine sciences: M/S
[Show abstract][Hide abstract] ABSTRACT: Pulmonary valve stenosis or atresia with intact ventricular septum represents a spectrum of severity. This study aimed to identify ultrasound markers of biventricular versus non-biventricular outcome. The fetal echocardiograms of 41 fetuses diagnosed with pulmonary stenosis or atresia and right ventricular (RV)/left ventricular (LV) length ratios >0.4 from 17 to 31 weeks of gestation were reviewed. Of 27 live-born patients with intention to treat, 8 had non-biventricular outcomes and 19 had biventricular circulation. At the time of diagnosis, poor RV function, flow reversal in the arterial duct, the degree of tricuspid valve (TV) regurgitation, and inferior vena cava Doppler flow pattern did not differ between the 2 outcome groups. However, RV sinusoids, the RV/LV length ratio, the TV/mitral valve ratio, and TV inflow duration were significantly different. Cut-off values derived from receiver-operating characteristic curves yielding the best sensitivity and specificity for a non-biventricular outcome were TV/mitral valve ratio <0.7, RV/LV length ratio <0.6, TV inflow duration <31.5% of cardiac cycle length, and the presence of RV sinusoids. If 3 of these 4 criteria were fulfilled, this predicted a non-biventricular outcome with sensitivity of 100% and specificity of 75%. In conclusion, in fetuses < or =31 weeks of gestation with pulmonary stenosis or atresia and intact ventricular septum, progression to a non-biventricular outcome can be predicted by a 4-criterion scoring system. The criteria may be useful in selecting fetuses for prenatal catheter intervention to prevent progressive RV hypoplasia.
No preview · Article · Mar 2007 · The American Journal of Cardiology
[Show abstract][Hide abstract] ABSTRACT: Complete fetal heart block (HB) and endocardial fibroelastosis (EFE) are known to be associated with maternal anti-Ro and anti-La antibodies. Complete fetal HB is irreversible.
We sought to (1) assess the value of the superior vena cava/ascending aorta Doppler approach in the early detection of abnormal delay in the fetal atrioventricular (AV) time of conduction, before appearance of complete fetal HB; and (2) report the effect of prenatal steroid therapy on EFE, HB, or both.
The clinical history, echocardiographic, and Doppler investigations of 3 fetuses and children born to mothers positive for anti-Ro and anti-La antibodies are reported. Two fetuses presented with EFE either isolated (29 weeks) or associated with AV block (25 weeks). In this last case, the superior vena cava/ascending aorta approach allowed the identification of a Luciani-Wenckebach phenomenon. In a third fetus, 2:1 AV block was noted at 23 weeks of gestation. Dexamethasone (4 mg/day) was administered to all 3 patients. Complete regression of the EFE and conduction abnormalities was documented in all cases.
Early prenatal detection of abnormal delay in fetal AV time conduction is possible with the Doppler superior vena cava/ascending aorta approach. Steroid therapy can cure fetal EFE and AV conduction delays associated with maternal anti-Ro and anti-La antibodies.
No preview · Article · May 2005 · Journal of the American Society of Echocardiography
[Show abstract][Hide abstract] ABSTRACT: We evaluated the consequence of different types of fetal arrhythmia in the development of neonatal cholestasis. The charts of 38 children born at St. Justine Hospital between 1993 and 2001 with sustained and hemodynamically significant fetal arrhythmias were studied: 19 with supraventricular tachycardia, 14 with atrial flutter, and 5 with atrio-ventricular (AV) block. Six of these 38 children presented with cholestasis. The average duration of arrhythmia was 15.7 days in the noncholestatic group, compared with 40.3 days in the cholestatic group ( P <.05). The three infants with supraventricular tachycardia who developed cholestasis survived and resolved their cholestasis, whereas 2 of 3 infants with AV block died. No infant with atrial flutter developed cholestasis. We conclude that newborns who developed tachyarrhythmia during their fetal life can show transient neonatal cholestasis. In patients with AV block, severe and irreversible liver failure could be observed. In addition, extensive collapse of the stroma and the absence of hepatocytes (foie vide) also were observed in a patient with anti-Ro antibodies.
No preview · Article · Mar 2005 · Journal of Pediatrics
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to evaluate the association between an abnormal aortic isthmus blood flow index and postnatal neurodevelopmental outcome in fetuses with placental circulatory insufficiency. STUDY DESIGN Forty-eight children who were born between 1991 and 1999 were included in this study on the basis of abnormal umbilical artery Doppler velocimetry. Prenatal isthmus blood flow index was obtained by dividing the sum of the systolic and diastolic Doppler blood flow velocity integrals by the systolic blood flow integrals. Neurodevelopmental outcome between 2 and 5 years was classified as optimal, when neurologic assessment and developmental quotient were within normal limits and as nonoptimal when abnormal neurologic findings and/or a nonoptimal developmental quotient was present. Neurodevelopmental outcome was analyzed in relation to isthmus flow index and pulsatility indices in the umbilical artery.
The mean gestational age at delivery was 33.0 +/- 2 weeks. Nonoptimal neurodevelopmental outcome was found in 60.4% of the children (29/48). An inverse correlation was found between the isthmus blood flow index and postnatal neurodevelopmental outcome. All 13 children with an isthmus blood flow index of <0.5 were in the nonoptimal group. All 19 children with an optimal outcome had an isthmus blood flow index of >0.5, but this was also the case for 16 other children with nonoptimal neurodevelopmental outcome. An isthmus blood flow index cut-off value of 0.70 was associated with the highest overall positive and negative predictive values. The pulsatility index in the umbilical artery did not provide any significant contribution in the explanation of the outcome.
The isthmic blood flow index can help to identify a subgroup of fetuses with placental circulatory insufficiency that might benefit from early delivery.
Full-text · Article · Feb 2005 · American Journal of Obstetrics and Gynecology
[Show abstract][Hide abstract] ABSTRACT: We intend to review our experience with the investigation and management of foetal arrhythmia on the basis of superior vena cava/ascending aorta (SVC/AA) Doppler flow velocity recordings. Irregular rhythms n = 307. Premature atrial and ventricular contractions were easily identified and generally self-limited in time. Sustained bradycardia n = 19. Four had sinus bradycardia, six presented with blocked atrial bigeminism, three showed 2:1, and five had a complete atrio-ventricular (AV) block. Another foetus that presented with first-degree AV block developed a Luciani-Wenckebach phenomenon 1 week later. These different types of bradycardia were all identified on SVC/AA Doppler recordings. Tachyarrhythmia n = 30. Five types of tachyarrhythmia were observed: Type I: Short ventriculo-atrial (VA) tachycardia (VA < AV), n = 11. Ten foetuses of this group presented a distinctive Doppler flow velocity pattern characterised by 1:1 AV conduction and a tall atrial wave ('a' wave) superimposed on the aortic ejection wave. They were considered to have re-entrant tachycardia through a fast-conducting AV accessory pathway; all 10 responded to digoxin therapy. The eleventh foetus with short VA tachycardia had atrial ectopic tachycardia with AV node dysfunction; he was treated successfully with sotalol. Type II: Long VA tachycardia (VA > AV): n = 8. In seven cases, an 'a' wave of normal amplitude with normal AV time interval could be clearly identified in front of the aortic ejection wave: one foetus in this group was considered to be in sinus tachycardia based on the variability of its heart rate; in another, sudden onset of tachycardia triggered by extrasystoles led to the possibility of permanent junctional reciprocating tachycardia (PJRT). The five other foetuses had atrial ectopic tachycardia. The last foetus presented with AV and VA intervals of the same duration and a heart rate of 210 beats/min; he did not respond either to digoxin or to sotalol, and was found after birth to have PJRT. The drug of first choice in this group was sotalol. Type III: Simultaneous onset of atrial and ventricular contractions: n = 3. These foetuses were classified as junctional ectopic tachycardia. Two responded to amiodarone. The other foetus converted spontaneously to sinus rhythm. Type IV: Flutter: n = 7. All presented with 2:1 AV relationship except one who had a variable block. Digoxin was prescribed as a first choice associated with sotalol in three cases. Conversion to sinus rhythm was documented in all; however, one hydropic foetus with advanced cardiomyopathy died one day after birth. Type V: Ventricular tachycardia: n = 1. This 30-week foetus presented alternance of AV dissociation (atrial rate: 130, ventricular rate: 170 beats/min) and atrial capture (ventricular rate of 138 beats/min). The arrhythmia responded well to propanol, and no recurrence was recorded after birth. Precise prenatal identification of arrhythmia type can be achieved with the SVC/AA Doppler approach. Such information allows for a better management and a rational choice of appropriate anti-arrhythmic drug.
No preview · Article · Dec 2004 · Prenatal Diagnosis