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This study aimed to evaluate the feasibility and reliability of tricuspid and mitral annular plane systolic excursion measurements (TAPSE and MAPSE) applying M-mode spatiotemporal image correlation (STIC) technology in low-risk pregnancies. An initial retrospective pilot study was carried out to assess repeatability, followed by a larger mixed cross-sectional and prospective longitudinal study, both evaluating low-risk singleton pregnancies between 22+6 and 39+1 weeks. As only annuli capture was necessary, STIC acquisition parameters were set to the minimum volume angle of 15° and acquisition time of 7.5 s. A total of 330 volumes were analysed offline applying STIC M-mode. Acquisition rates were 96.9 % for TAPSE and 93.7 % MAPSE in the pilot study (n=32) and 98.0 % for both in the longitudinal study (n=102). Both study designs revealed good repeatability for both sides of the heart, with higher intraclass correlation coefficients (ICCs) for TAPSE (0.84–0.94) compared to MAPSE (0.80–0.88). Good repeatability was demonstrated for both sides of the heart, more so for TAPSE than MAPSE, with ICCs for TAPSE 0.84–0.91 and MAPSE 0.75–0.76, comparable to prior ICCs for STIC repeatability. Modified STIC acquisition settings specifically tailored for capturing the longitudinal annular displacement may improve STIC TAPSE and MAPSE acquisition rates, optimising image quality for precise measurement and potentially bringing these modalities closer to clinical application. [ABSTRACT FROM AUTHOR]

To investigate the association between birth weight to placental weight (BW/PW) ratio, and echocardiographic left ventricle (LV) morphology at birth, while accounting for other relevant perinatal factors. A prospective cohort study was conducted on neonates at NewYork-Presbyterian Brooklyn Methodist Hospital from 2014 to 2018, categorized by their BW/PW percentile. Missing data were imputed with principal component analysis. Chi-squared and one-way analysis of variance were used to compare BW/PW groups and the best regression model was selected using a genetic and backward stepwise algorithm. We analyzed 827 neonates in three BW/PW groups: small (n=16), normal (n=488), and large (n=323). Placental thickness and smallest diameter were positively correlated with several LV parameters, including inter-ventricular septal thickness during diastole (IVSd) (p=0.002, p<0.001) and systole (IVSs) (p=0.001, p<0.001), LV posterior wall thickness at end of diastole (LVPWd) (p=0.003, p<0.001) and systole (LVPWs) (p<0.001, p<0.001), LV mass (p=0.017, p<0.001), and LV mass/volume (p=0.011, p<0.001). The BW/PW ratio correlated with an increased shortening fraction (estimate=0.29, 95 % CI 0.03–0.55, p=0.027). PW correlated with IVSs (p=0.019), while the longest placental diameter was linked to a decrease in LV internal dimension during diastole (LVIDd) (estimate=−0.07, p=0.039), LV mass (estimate=−0.11, p=0.024), and LV mass/volume (estimate=−0.55, p=0.005). This study found that several placental factors, including the BW/PW ratio, can independently affect LV dimension and morphology, highlighting the importance of fetal growth and placental health in the physiological adaptation of the fetal heart. More research is needed to establish causation and inform newborn prevention strategies. [ABSTRACT FROM AUTHOR]

Right aortic arch (RAA) is a rare anomaly with an incidence of 0.1 % in the adult population and low-risk fetuses. Our aim in this study was to evaluate associated anomalies and conditions according to subtypes. This was a retrospective study examining consecutive pregnancies diagnosed with RAA in our hospital between 2018 and 2022. Fetuses with RAA were divided into three groups, RAA with right-sided ductus arteriosus (RAA-RDA), RAA with left-sided ductus arteriosus (RAA-LDA), and RAA with a double aortic arch (RAA-DAA). A total of 81 fetuses were diagnosed as having RAA during the study period. The rate of cardiac anomalies (82.8 %) in the RAA-RDA group was higher than in the RAA-LDA (17.6 %) and RAA-DAA (22.2 %) groups (p<0.001). No statistically significant difference was found between the groups in terms of maternal age, diagnosis week, pregnancy outcome, extracardiac anomalies, and genetic anomalies. Three (8 %) of 36 fetuses with isolated RAA who resulted in live birth developed symptoms related to the vascular ring, and one (2.7 %) newborn with RAA-DAA underwent surgery. The incidence of cardiac anomalies is high in fetuses with RAA-RDA. Ultrasound examinations should be performed for cardiac anomalies and additional structural anomalies. Vascular ring formation is a rare but important complication due to compression risk to the trachea and esophagus. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the agreement between visual and automatic methods in assessing the adequacy of fetal cardiac views obtained during second trimester ultrasonographic examination. In a prospective observational study frames of the four-chamber view left and right outflow tracts, and three-vessel trachea view were obtained from 120 consecutive singleton low-risk women undergoing second trimester ultrasound at 19–23 weeks of gestation. For each frame, the quality assessment was performed by an expert sonographer and by an artificial intelligence software (Heartassist™). The Cohen's κ coefficient was used to evaluate the agreement rates between both techniques. The number and percentage of images considered adequate visually by the expert or with Heartassist™ were similar with a percentage >87 % for all the cardiac views considered. The Cohen's κ coefficient values were for the four-chamber view 0.827 (95 % CI 0.662–0.992), 0.814 (95 % CI 0.638–0.990) for left ventricle outflow tract, 0.838 (95 % CI 0.683–0.992) and three vessel trachea view 0.866 (95 % CI 0.717–0.999), indicating a good agreement between the two techniques. Heartassist™ allows to obtain the automatic evaluation of fetal cardiac views, reached the same accuracy of expert visual assessment and has the potential to be applied in the evaluation of fetal heart during second trimester ultrasonographic screening of fetal anomalies. [ABSTRACT FROM AUTHOR]

To determine reference curves for fetal aortic and pulmonary valve annulus area by three-dimensional ultrasonography using the spatio-temporal image correlation (STIC) in the rendering mode, and to ascertain its applicability in congenital heart disease (CHD). We performed a retrospective cross-sectional study of 328 normal fetuses and 42 fetuses with CHD between 20 and 33 weeks 6 days of gestation. The outflow plane view of the great vessels was used to measure the areas of the valvar annuli, and the measurements were performed in systole. A linear regression model adjusted according to the determination coefficient (R2) was utilized to construct the reference intervals. The concordance correlation coefficient (CCC) was used to calculate the reproducibility of the mitral and tricuspid valve areas. The mean ± standard deviation (SD) of the aortic and pulmonary valve annulus areas ranged from 6.6 ± 1.2 to 32.9 ± 1.1 mm2 and 10.7 ± 1.3 to 40.3 ± 1.2 mm2, respectively. We observed a linear relationship and strong positive correlation between the area of the aortic and pulmonary valve annuli with r=0.97 and 0.96, respectively. Good intra (CCC=0.99) and interobserver agreement (CCC=0.98) was observed for the measurement of the aortic valve annulus area. A good intra (CCC=0.99) and interobserver (CCC=0.97) agreement was also observed for the measurement of the pulmonary valve annulus area. The mean ± SD of the difference of the areas of the aortic and pulmonary valve annuli between the normal fetuses and those with CHD were −1.801 ± 1.429 mm2 (p=0.208) and −1.033 ± 1.467 mm2 (p<0.0001), respectively. The reference curves for the areas of the aortic and pulmonary valve annuli of fetal hearts were determined, and showed good inter and intraobserver reproducibility. The constructed reference curves showed applicability in different types of CHD. [ABSTRACT FROM AUTHOR]

Maternal urogenital infections during pregnancy are worldwide frequent problem. The aim was to analyze influence of maternal genitourinary infection on fetal cardiac function, pregnancy development and obstetrical outcomes. This was a single-center cohort study on fetuses (average at 28th week) in two groups: with maternal urogenital infections (study group n=49) and control group with no infections (n=59). Parvovirus B19, toxoplasmosis, cytomegalovirus, herpes simplex infections, congenital malformations, fetal growth restriction, chronic maternal diseases, as well as patients with body mass index (BMI) >25 kg/m2 were excluded. We analyzed: maternal age, time of delivery, neonatal birth weight, Apgar scores, average time of hospitalization of newborns after birth and several fetal echocardiographic parameters. The only statistical differences was found for shorter isovolumetric relaxation time (IRT) (40 ± 10 vs. 45 ± 9; p=0.03) and longer ejection time (ET) [ms] for right ventricle (RV) (176 ± 24 vs. 164 ± 18; p=0.01). Thick placenta was observed more frequent in study group than in controls (36.7 vs. 16.9%; p= 0.02). The missing link for explanation of these findings was coincidence with thick placenta. This is probably the first observation suggesting that thick placenta (>5 cm) may affect fetal RV function in normal heart anatomy: prolongation of right ventricular ET and shortening of fetal right ventricular IVRT. [ABSTRACT FROM AUTHOR]

The article discusses the study, which compares fetuses' cardiac structural and functional findings with fetal growth restriction (FGR) and small for gestational age (SGA). The conclusions include the detection of cardiac morphological changes in cases of both SGA and FGR. Findings related to morphological changes on the left side in FGR cases were considered secondary to the volume increase in FGR cases as an indicator of a brain-protective effect.

The article focuses on the study to HDlive Flow Silhouette with spatiotemporal image correlation for assessment of fetal cardiac structures at 12 to 14 + 6 weeks of gestation. It mentions that the feasibility of obtaining fetal five cardiac views using HDlive Flow Silhouette with STIC is good, and this technique provides useful information for evaluating fetal cardiac structures in the late first and early second trimesters of pregnancy.

The subject of our analysis is the influence of umbilical cord collision around the fetal neck on the fetal heart function and cerebral circulation. Our study was carried out on a group of 115 fetuses from single pregnancies with physiological course, during the 15th to 40th week of pregnancy. In our analysis, we examined the following parameters: Tei index for right ventricle, Tei index for left ventricle with Tei index components: isovolumetric contraction time, isovolumetric relaxation time, ejection time and cardiothoracic area ratio, middle cerebral artery peak systolic velocity (PS MCA), middle cerebral artery pulsatility index (PI MCA). Gestational age in our study was: 28+2±34. The study group of patients with fetal umbilical cord around neck group (fUCAN) included 38 fetuses (20 males, 18 females). The control group of patients with no fetal umbilical cord around neck group (NfUCAN) included 77 fetuses (43 males, 34 females). In our study, we found no significant differences in the values obtained: Tei LV in fUCAN: 0.5±0.1 vs. in NfUCAN: 0.5±0.1; p=0.42), Tei RV in fUCAN: 0.5±0.2 vs. in NfUCAN: 0.4±0.1; (p=0.2). Tricuspid valve regurgitation-TR was observed with the following frequency: fUCAN: 7/38, 18% vs. NfUCAN: 13/77, 17%; p=0.8. MCA PS in study fUCAN group was significantly higher than in NfUCAN (40.2±11.5 vs. 32.5±9.5; p=0.003), although other hemodynamic and clinical variables did not differ between the study and control groups. The fetal nuchal umbilical cord collision did not affect the fetal heart function expressed as Tei index, at the time of fetal heart examination (at mean gestational age 29+4 weeks). The fUCAN group presented elevated PS MCA, which was not related to other hemodynamic and clinical variables between the study and control groups. [ABSTRACT FROM AUTHOR]

To report the normal fetal cardiac axis (CA) values at the time of the first trimester screening ultrasound. Standardized images and measurement of the CA were obtained from 100 healthy fetuses between 11+0 and 13+6 weeks of gestation along with the nucal thichkness (NT), Crown–rump length (CRL) and other measurements. We excluded cases with abnormal NT, later diagnosis of abnormalities, and suspected fetal cardiopathy during the pregnancy follow-up. Data analysis was performed after all the patients delivered and cardiopathy was excluded. CA was measurable in all the cases. Higher CRL was associated with a decrease in the CA. The mean ± SD embryonic/fetal CA was 48±5,2°, ranging from 39 to 60°, The 2.5 percentile was defined at 40° and the 97.5 percentile at 59°. The Pearson test resulted in a significant correlation between CA and CRL with a coefficient R of 70% and p-value <0.01. CA tends to decrease at the 11 to 13+6 gestational ages. We defined 2.5 and 97.5% curves for the normal values of CA in our Middle Eastern population. A larger study will be required to differentiate normal and abnormal values for the early detection of heart abnormalities. [ABSTRACT FROM AUTHOR]

To evaluate 24-segment fractional shortening (FS) of the fetal heart using FetalHQ by speckle-tracking regarding reproducibility and the change with advancing gestation. Eighty-one pregnant women at 18–21+6 and 28–31+6 weeks of gestation were studied using FetalHQ with the speckle-tracking technique to calculate 24-segment FS of left and right ventricles. Intra- and inter-class correlation coefficients and intra- and inter-observer agreements of measurements for FS were assessed in each segment. With respect to intra-observer reproducibility, all FS values showed correlations between 0.575 and 0.862 for the left ventricle, with good intra-observer agreements except for left ventricular segments 14–24. Right ventricular FS values showed correlations between 0.334 and 0.685, with good intra-observer agreements. With respect to inter-observer reproducibility, all FS values showed correlations between 0.491 and 0.801 for the left ventricle, with good intra-observer agreements except for left ventricular segments 16–22. Right ventricular FS values showed correlations between 0.375 and 0.575, with good inter-observer agreements. There were significant differences in the mean FS values in the basal segment (segments 1–5) of the left ventricle between 18 and 21+6 and 28–31+6 weeks of gestation (p<0.05), whereas there were significant differences in all mean FS values in the right ventricle between both gestational ages (p<0.05). These results suggest that the reproducibility of the 24-segment FS of the fetal heart using FetalHQ is fair. However, there may be significant differences in FS values with advancing gestational age, especially for the right ventricle. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the effects of nifedipine treatment on fetal hemodynamics and cardiac function during preterm labor. This prospective study assessed several quantitative parameters of fetal cardiac circulation and function, and found no significant changes at 48 h after nifedipine treatment. These findings suggest that tocolytic nifedipine may be safe for fetuses. It supports clinicians to use nifedipine treatment for tocolysis without any cardiac effect on the fetus. Methods: A prospective cohort study was conducted at a tertiary hospital between January 2016 and October 2017. A total of 45 pregnant women who required nifedipine for preterm labor were included in this study. Fetal Doppler ultrasound was performed and fetal systolic and diastolic function was measured prior to, and 48 h after, the first nifedipine treatment. Conventional Doppler parameters were used to evaluate fetal heart function and hemodynamic changes. Tricuspid annular plane systolic excursion, mitral annular plane systolic excursion and the sphericity index were also evaluated to assess changes in fetal cardiac morphology. Results: No significant changes in fetal Doppler parameters were observed following nifedipine tocolysis. There was no significant difference in the fetal cardiac function parameters of both ventricles before vs. after nifedipine treatment. Tricuspid annular plane systolic excursion, mitral annular plane systolic excursion, and sphericity index values were unchanged following nifedipine treatment. Conclusions: Oral administration of nifedipine did not to alter fetal cardiac function or morphology. Fetal cardiac parameters and various Doppler indices were unchanged following nifedipine treatment. Maternal nifedipine treatment does not appear to have any significant effect on fetal cardiac function. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to establish reference ranges for fetal mitral, tricuspid, and interventricular septum annular plane systolic excursions (MAPSE, TAPSE, and SAPSE) in normal pregnant women between 20 and 36 + 6 weeks of gestation. Methods: This prospective and cross-sectional study included 360 low-risk singleton pregnancies between 20 and 36 + 6 weeks of gestation. MAPSE, TAPSE, and SAPSE were measured by M-mode in real time in an apical or basal four-chamber view through placing the cursor at the atrioventricular junction, marked by the valve rings at the tricuspid, mitral, and basal septum, respectively. A regression analysis was done to determine the appropriate polynomial equation model for both measurements and standard deviation (SD) values in relation to gestational age (GA). The intra- and inter-observer reproducibility was evaluated using the concordance correlation coefficient (CCC) and limits of agreement (LoA). Results: There was a significant positive correlation between MAPSE (r=0.705, p<0.0001), TAPSE (r=0.804, p<0.0001), and SAPSE (r=0.690, p<0.0001) and GA. The mean of each parameter ranged as follows: 2.87–5.56 mm, MAPSE; 3.98–8.07 mm, TAPSE; and 2.34–4.21 mm, SAPSE. Poor/moderate intra- and inter-observer reliability (CCC between 0.70 and 0.90) and poor/moderate agreement of all the tested parameters were evaluated (LoA between 10 and 50%). Conclusions: Reference values were established for the fetal MAPSE, TAPSE, and SAPSE between 20 and 36 + 6 weeks of gestation in low-risk pregnant women. These parameters showed poor/moderate reproducibility. [ABSTRACT FROM AUTHOR]

Background: The primary objective of this study was to compare the fetal cardiac performance index (Tei index) between the fetuses of gestational diabetes mellitus (GDM) mothers and non-GDM mothers; and the secondary objective was to compare various other parameters of fetal cardiac function as well as maternal oxidative stress levels between the groups of GDM and non-GDM mothers. Methods: A cross-sectional study was conducted on pregnant women at 24–28 weeks of gestation. All of the participants underwent 100 g, 3-h oral glucose tolerance test (OGTT) as a diagnostic test for GDM and were categorized as non-GDM and GDM group. All participants had fetal echocardiography performed for cardiac function, and then maternal blood samples were collected for biomarker measurements. Results: A total of 80 pregnant women, including 43 in the GDM group and 37 in the non-GDM group, were included in the study. The maternal serum 8-isoprostane (8IsoP), tumor necrosis factor-α (TNF-α) and interleukin (IL)-10 levels were significantly higher in the GDM group than those in the non-GDM group (P: 0.028, P: 0.019 and P: 0.031, respectively). The fetal cardiac function parameters were not significantly different between the two groups. Regardless of the GDM status, the fetuses with high levels of oxidative stress (8Isop ≥1000 pg/mg protein) had a significantly higher rate of impaired shortening fraction (SF) of the left ventricle (P: 0.001). Conclusion: GDM is significantly associated with an increase in the oxidative stress process, and a high level of oxidative stress was significantly associated with left ventricular (LV) function impairment. Though a correlation between GDM and fetal cardiac function impairment was not clearly demonstrated in this study, this study suggests that GDM patients with a high level of oxidative stress should be evaluated for fetal cardiac function. [ABSTRACT FROM AUTHOR]

Objective: To assess the success rates of five fetal cardiac views using HDlive Flow (Silhouette) with spatiotemporal image correlation (STIC) in the second and third trimesters of pregnancy, and to verify the feasibility of obtaining five cardiac views by volumes. Methods: One hundred and eighteen normal fetuses at 18–21 and 28–31 weeks of gestation were studied using HDlive Flow (Silhouette) with STIC to assess the success rates of five fetal cardiac views (frontal, spatial three-vessel, panoramic, posterior, and right lateral views). Target structures in each cardiac view were evaluated. "Good" was assigned when all structures were noted, "Fair" when only one structure was missed, and "Poor" when two and more structures could not been detected. Results: There were no significant differences in success rates of each cardiac view between 18–21 and 28–31 weeks of gestation. The rate of "Good" with a spatial three-vessel view was significantly higher than that with other cardiac views at 18–21 and 28–31 weeks, respectively (P < 0.05). Conclusion: Five cardiac views using HDlive Flow (Silhouette) with STIC may become an adjunctive and useful tool in fetal cardiac examination. [ABSTRACT FROM AUTHOR]

Background: The aim of this systematic review was to describe the effects of drug exposure during pregnancy on fetal cardiac function. Methods: We searched MEDLINE, Embase, Cochrane and SCOPUS for studies assessing fetal cardiac function in drug-exposed human pregnancies. Risk of bias was assessed by the Risk Of Bias In Non-randomized Studies of Interventions (ROBIN-I) tool. Results: We included 32 studies on eight different drug groups. They included 51 outcome variables, which were all based on ultrasound techniques primarily assessing systolic function: pulsed wave Doppler, tissue Doppler imaging (TDI), and B- and M-mode. Overall, the risk of bias was moderate. β2 agonists increased the systolic velocity in the ductus arteriosus and the fetal heart rate. β-blockers caused unchanged or decreased systolic velocity of the pulmonary trunk. Corticosteroids increased the velocity in the ductus arteriosus. Furthermore, in growth-restricted fetuses with an increased myocardial performance index (MPI′) on the right side, corticosteroids normalized this variable. Nonsteroidal anti-inflammatory drugs (NSAIDs), but not acetylsalicylic acid, increased the flow velocities in the ductus arteriosus, decreased the shortening fraction and increased the end-diastolic ventricular diameters. Metformin and insulin normalized the diastolic strain and global longitudinal strain in diabetic pregnancies. Highly active antiretroviral therapy (HAART) exposure increased the E/A ratio on the right side, prolonged the isovolumic relaxation time (IRT) and ejection time, shortened the isovolumic contraction time (ICT), and decreased left myocardial systolic peak velocities. Chemotherapy did not cause detectable changes. Conclusion: Six of the eight drug groups caused detectable changes in fetal cardiac function. However, the evidence was hampered by only a few studies for some drugs. [ABSTRACT FROM AUTHOR]

Background: Ductus venosus spectral waveform has two peaks and two nadirs: S, v, D and a velocities, which are obtained after to some extent of accelerations or decelerations throughout a cardiac cycle. It is aimed to define the actual celeration times and indexes and their relationships with the fetal heart rate (FHR). Methods: The acceleration times and indexes were measured in 357 patients between 11 and 40 weeks of pregnancies with low risk. Results: The FHR has a gradual increasing negative correlation from time for S to time for a with each of the cardiac times of phases according to the statistical analysis (correlations were minus 190, 269, 407 and 541 for S, v, D and a phase times, respectively). The acceleration aS and the deceleration Da have positive correlations with the FHR; however, the deceleration Sv and the acceleration vD do not correlate with the FHR. Conclusion: The deceleration Da time and index are the main components for determining the FHR in fetuses. Therefore, the atrial contraction is the strongest component for determining the FHR in fetuses. [ABSTRACT FROM AUTHOR]

Objective: To analyze the behavior of fetal longitudinal myocardial fibers assessed by speckle tracking (STE) after fetal viability. Methods: A cross-sectional study was performed in 156 women with normal singleton pregnancies from 22 to 31 weeks of gestation. Strain (S) and strain rate (SR) values were measured in both ventricles during the fetal cardiac cycle. The population was divided into five gestational age groups based on 2-week intervals. The correlations of maternal variables with the S and SR variables and intra-observer analysis were performed. Results: There was a significant difference in the S and SR values of the left ventricle (LV) among the gestational age groups (P = 0.007). Significantly higher S and SR values were observed in early age groups demonstrating reductions in LV S and SR values at 26 weeks, followed by stabilization. For the right ventricle (RV), there was no significant difference between gestational age groups. Significant intra-observer agreement was observed for S values of the RV (P = 0.008) and LV (P = 0.0004) and SR values of the RV (P = 0.0001) and LV (P = 0.015). Conclusion: Decreases in the S and SR values of the LV occurred after 26 weeks, followed by stabilization. No significant difference was observed in the S or SR value of the RV among the gestational age groups, and no significant association of any maternal variable evaluated with S and SR values was observed. Significant intra-observer agreement was obtained among the results. [ABSTRACT FROM AUTHOR]

Objective: To evaluate our ability in classifying the fetal heart as normal or abnormal during the 1st trimester scan through fetal cardiac examination and determining the best time for this examination. Methods: This was a prospective study performed on 3240 pregnant women to examine the fetal heart. Four chambers view and ventricular outflow tracts were mainly examined during the scan. We used grayscale and color mapping in the diagnosis. Color Doppler was used if additional information was needed, and all patients were rescanned during the 2nd trimester to confirm or negate our diagnosis. Results: The cardiac findings were normal at both scans in 3108 pregnancies. The same cardiac abnormality was detected at both scans in 79 cases. In 36 cases there was false-positive diagnosis at the early scan; in 20 of these cases, there were mildly abnormal functional findings early in pregnancy with no abnormality found later. In 17 fetuses, there was discordance between the early and later diagnosis due to missed or incorrect diagnoses. The best time to do fetal heart examination during 1st trimester is between 13 and 13 + 6 weeks. Conclusion: A high degree of accuracy in the identification of congenital heart disease (CHD) can be achieved by a 1st trimester fetal echocardiography. [ABSTRACT FROM AUTHOR]

Background: This study aimed to investigate fetal cardiac functions by spectral tissue Doppler imaging (s-TDI) in pregnancies complicated with late-onset fetal growth restriction (LO-FGR) and small-for-gestational age (SGA). Methods: Forty pregnancies complicated with late-onset FGR and 40 pregnancies complicated with SGA between the 34th and 37th weeks of gestation were enrolled in this study. Forty gestational age-matched pregnant women with no obstetrics complication were randomly selected as a control group. Small fetuses were classified as fetal growth restriction or SGA according to estimated fetal weight (EFW), umbilical artery pulsatility index (PI), cerebroplacental ratio (CPR) and uterine artery PI. s-TDI measurements were obtained at the right atrioventricular valve annulus. Results: SGA and LO-FGR fetuses had significantly lower A′ and S′ values, and higher E′/A′ ratio than the control group (P < 0.001). In comparison to controls, significantly prolonged isovolumetric contraction time (ICT′) and isovolumetric relaxation time (IRT′) and, significantly shortened ejection time (ET′) were observed in fetuses with SGA and LO-FGR. Increased myocardial performance index (MPI′) values were also found in fetuses with SGA and LO-FGR compared to controls. Conclusion: The signs of cardiac dysfunction were observed both in fetuses with SGA and LO-FGR. The fetal cardiac function assessment with s-TDI could be a valuable method in the diagnosis of true growth restricted fetuses and in the management of these fetuses. [ABSTRACT FROM AUTHOR]

Background: Altered cardiac geometry affects a proportion of fetuses with growth restriction (FGR). The aim of this study was to explore the hemodynamic factors associated with cardiac remodeling in late FGR. Methods: This was a prospective study of singleton pregnancies complicated by late-onset FGR undergoing assessment of left (LV) and right (RV) ventricular sphericity-index (SI). The study population was divided in two groups according to the presence of cardiac remodelling, defined as LVSI <5th centile. The following outcomes were explored: gestational age at birth, birthweight, caesarean section (CS) for fetal distress, umbilical artery (UA) pH and neonatal admission to special care unit. The differences between the 2 groups in UA pulsatility index (PI), middle cerebral artery (MCA) PI, uterine artery PI, cerebroplacental ratio (CPR) and umbilical vein (UV) flow corrected for fetal abdominal circumference (UVBF/AC) were tested. Results: In total, 212 pregnancies with late FGR were enrolled in the study. An abnormal LV SI was detected in 119 fetuses (56.1%). Late FGR fetuses with cardiac remodeling had a lower birthweight (2390 g vs. 2490; P = 0.04) and umbilical artery pH (7.21 vs. 7.24; P = 0.04) and were more likely to have emergency CS (42.8% vs. 26.9%; P = 0.023) and admission to special care unit (13.4% vs. 4.3%; P = 0.03) compared to those with normal LVSI. No difference in either UA PI (p = 0.904), MCA PI (P = 0.575), CPR (P = 0.607) and mean uterine artery PI (P = 0.756) were present between fetuses with or without an abnormal LV SI. Conversely, UVBF/AC z-score was lower (−1.84 vs. −0.99; P ≤ 0.001) in fetuses with cardiac remodeling and correlated with LV (P ≤ 0.01) and RV SI (P ≤ 0.02). Conclusion: Fetal cardiac remodelling occurs in a significant proportion of pregnancies complicated by late FGR and is affected by a high burden of short-term perinatal compromise. The occurrence of LV SI is independent from fetal arterial Dopplers while it is positively associated with umbilical vein blood flow. [ABSTRACT FROM AUTHOR]

Objective: To determine the reference range for the myocardial area in healthy fetuses using three-dimensional (3D) ultrasonography and validate these results in fetuses of pregnant women with pre-gestational diabetes mellitus (DM). Methods: This cross-sectional retrospective study included 168 healthy pregnant women between gestational weeks 20 and 33 + 6 days. The myocardial area was measured using spatio-temporal image correlation (STIC) in the four-chamber view. Polynomial regression models were used, and the goodness of fit of the models were evaluated by the coefficient of determination (R²). Intra- and inter-observer reproducibility was determined using the concordance correlation coefficient (CCC). Validation was performed in 30 pregnant women with pre-gestational DM. Results: There was a strong correlation (R² = 0.71, P < 0.0001) between myocardial area and gestational age. There was good intra- and inter-observer reproducibility, with a CCC of 0.86 and 0.83, respectively. However, there was no significant difference in the mean myocardial area between healthy fetuses and fetuses of women with pre-gestational DM (0.11 cm², P = 0.55). Conclusion: The reference range was determined for the myocardial area in fetuses, and there was no significant difference in this variable between healthy fetuses and the fetuses of women with pre-gestational DM. [ABSTRACT FROM AUTHOR]

Background: The purpose of our study was to quantify the fetal myocardial function in pregnant women with diabetic diseases (FDM) and in normal controls (FC) using speckle tracking echocardiography (STE). Methods: In this prospective study, the myocardial strain and dyssynchrony were analyzed using STE in a transversal four-chamber view in 180 fetuses (53 FDM, 127 FC) between 19 and 39 weeks of gestation. The measurements of the global and segmental longitudinal strain of both chambers (2C) and of the single left chamber (1C) were executed offline via QLab 10.5 (Philips Medical Systems, Andover, MA, USA). We assessed dyssynchrony as the time difference between peaks in strain in the mid segments of both chambers (interventricular dyssynchrony, 2C_DYS) and of the single left chamber (intraventricular dyssynchrony, 1C_DYS). Results: Measurements were feasible with a high median frame rate of 199 frames/s (1st quartile: 174, 3rd quartile: 199). The global and segmental myocardial longitudinal strain of 2C and 1C were decreased and 2C_DYS and 1C_DYS were increased in pregnancies with diabetes compared to normal controls. Conclusion: Our study demonstrates that fetal hearts affected by maternal diabetes mellitus (DM) show low myocardial strain values and high interventricular dyssynchrony. Two-chamber interventricular dyssynchrony has the potential to become a diagnostic marker for DM. [ABSTRACT FROM AUTHOR]

Background: Tricuspid regurgitation (TR) is a common sonographic finding during the fetal life. It has been reported in 7% of normal fetuses. It may be associated with aneuploidy and with both cardiac and extracardiac defects. Objectives: In this study, we have looked at the characteristics of fetuses with and without TR at 11+0 to 13+6 weeks' gestation. Groups were compared with respect to the following variables: prevalence of chromosomal defects; other markers of aneuploidy; fetal cardiac; and extracardiac anomalies. Methods: The study group included women, who underwent an ultrasound examination at 11 13+6 weeks' gestation between 2009 and 2012. The inclusion criteria were singleton pregnancies with crown-rump length measurements of 45-84 mm where the pregnancy outcome was known. Results: Some 1075 patients met our inclusion criteria including 979 fetuses without TR and 96 with TR. There were 72 cases of aneuploidy diagnosed (6.7%). Isolated TR was found in 53 euploid fetuses (5.2%). All of the TR(+) aneuploid fetuses (n=40) had additional ultrasound markers present. Extracardiac anatomy showed a higher prevalence of abnormalities in the group of TR positives (12.5%) vs. TR negatives (1.6%). Abnormal cardiac findings were more frequent in the TR-positive group independently of chromosomal status and were found in 18.8% of fetuses with TR and in 1.9% with a normal tricuspid flow. Conclusions: TR in combination with other markers is the strongest predictor for aneuploidy. TR, as an isolated parameter, is a poor screening tool both for all and for each individual chromosomal abnormality and congenital cardiac defects. [ABSTRACT FROM AUTHOR]

Objective: To compare fetal heart rate (FHR) signals acquired simultaneously by an external ultrasound probe and a scalp electrode during the second stage of labor. Methods: This was a prospective observational study in a labor ward of a tertiary care university hospital. The population was women in labor with uneventful singleton pregnancies at term. Simultaneous external and internal FHR monitoring was performed in 67 consecutively recruited women during the second stage of labor. Cases were subsequently excluded if the trace length was under 40 min, cesarean birth occurred, or the interval between trace-end and birth exceeded 5 min, leaving a total of 33 traces for analysis. The last 40-60 min of these traces were analyzed by a computer system (Omniview-SisPorto® 3.5; Speculum®, Lisbon, Portugal) to quantify cardiotocographic parameters. Paired sample t-test and Bland-Altman limits of agreement (LoA) were used for statistical analysis, setting significance at 0.05. The main outcome measures were signal loss, FHR baseline, periodic events, and percentage of periodic events coinciding with contractions. Results: A higher signal loss was observed with external monitoring [10% vs. 4%; P<0.001, LoA=(-6, 18)]. No differences were found in mean FHR baseline [129 bpm vs. 130 bpm, P=0.245, LoA=(-15, 12)], but more accelerations [12 vs. 8, P<0.001, LoA=(-5, 13)] and less decelerations [8 vs. 10, P<0.001, LoA=(-8, 4)] were detected with external monitoring. With this method there were also more accelerations (66% vs. 55%, P=0.036) and less decelerations (68% vs. 81%, P=0.017) coinciding with contractions. Conclusions: External FHR monitoring during the second stage of labor results in higher signal loss, increased number of accelerations, and decreased number of decelerations when compared with internal monitoring. [ABSTRACT FROM AUTHOR]

Despite its recognized limitations, fetal heart rate monitoring is a mainstay of intrapartum care. Although the basic technology in standard electronic fetal monitors has changed little in recent decades, clinical behavior in response to heart rate monitoring has changed considerably. In addition to clearly defined nomenclature and clinical guidelines, there is an increased awareness that environmental and human factors can impair clinical judgment, resulting in delayed intervention and, consequently, birth-related injury. This review examines three essential steps that affect clinical outcome: (1) signal acquisition, (2) associations with physiological outcome, and (3) clinical intervention. Only the third step is directly responsible for changing clinical outcome. However, timely initiation of interventions is dependent upon the second step, which is dependent upon the first step. Thus, deficiencies at each step tend to accumulate and contribute to the worsening of overall clinical outcome. This review article summarizes advances occurring at each step. The synergy and convergence of innovations in engineering, mathematics, and behavioral science shows considerable promise in intrapartum fetal surveillance. [ABSTRACT FROM AUTHOR]

Objective: Tissue-tracking echocardiography (TTE) is a method for quantitative assessment of myocardial contraction and relaxation. The purpose of this study was to assess the feasibility of TTE in fetuses and investigate fetal myocardial properties in normal pregnancies. Methods: Two hundred thirty pregnant women participated in the study. Fetal four-chamber-view cineloops were saved for off-line analysis. Reference values for the global longitudinal peak velocity (V), strain (S), strain rate (SR), and displacement (D) in the fetal heart were established using data from 62 right ventricles (RV) and 68 left ventricles (LV). Furthermore, the change of the motion (V and D) and deformation (S and SR) in the course of the pregnancy was analyzed. Intraobserver variability was assessed in a total of 137 cases. The remaining 93 cases were excluded, as there was no tracking possible. Results: Normal fetuses exhibit a statistically significant increase in all motion parameters in both ventricles with increasing gestational age (GA). In contrast, the deformation parameters with advancing GA decrease. RV has a higher diastolic V and SR than LV. Conclusions: The increase in motion is attributable to fetal cardiac growth, whereas the decrease in deformation para\xadmeters indicates an intrauterine adaptation mechanism. RV appears to have a different relaxation pattern than LV. This study establishes a base for further utilization of TTE in fetal medicine and emphasizes a distinct diastolic difference between RV and LV function. [ABSTRACT FROM AUTHOR]

Objectives: To examine if the fetal main pulmonary artery diastolic forward flows (MPADFs) are detected consistently, if the waves from fetal MPADFs coincide with those from atrial contractions, and the reproducibility of the cardiac cycle measurements using this technique. Methods: Two examiners performed a fetal pulsed Doppler echocardiography of the four chamber (4CV), ductal arch (DA) and short axis (SA) views on 44 women with singleton pregnancies. Time intervals between atrial contraction peaks and those between MPADF peaks were compared. Atrioventricular (AV) and ventriculoatrial (VA) intervals were measured from MPADF waves in DA and SA views and compared between observers. Intraclass correlation coefficients (ICCs) were calculated as a measure of inter-observer reproducibility. Results: In all observations, MPADFs were demonstrated. The mean time intervals between atrial contraction peaks from 4CV and those between MPADF peaks from DA and SA views were not significantly different. The mean AV and VA intervals were not significantly different between observers. Comparison of measurements of two observers had substantial agreements. Conclusions: Our data show that MPADFs can be found consistently and coincide with atrial contractions. As cardiac cycle measurements can be done with considerable reproducibility, this technique may be useful in assessing fetal cardiac cycle. [ABSTRACT FROM AUTHOR]

Objective: Our objective was to determine the obstetrical risk for spontaneous focal intestinal perforation (FIP) in very low birth weight (VLBW) infants. Methods: Eight mothers delivered infants who underwent laparotomy for FIP between 2001 and 2006 in our hospital. A retrospective case-control study of the eight case mothers and 32 control mothers was conducted. Clinical findings were retrospectively analyzed. Results: There were significant differences in the frequency of oligohydramnios (P<0.01) and velamentous cord insertion (P<0.05) between cases and controls. The 1-min Apgar score was significantly lower in the FIP group than in the control group (P<0.05). Moreover, primigravidity was significantly associated with a risk of FIP. Conclusions: The etiology of FIP may be related to changes in the blood circulation, such as fetal hypoxic-ischemic episodes or disturbance in the umbilical blood flow, during the antepartum and/or intrapartum periods. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether National Institute of Child Health and Human Health and Development (NICHD) fetal heart rate categories were predictive of neonatal survival in periviable pregnancies. Methods: We reviewed the charts of 57 infants delivered at 23 and 24 weeks' gestation. Fetal heart rate tracings were evaluated following the NICHD 2008 criteria, using the acceleration height of 10 bpm and duration of 10 s. Multiple logistic regression analyses were performed using survival, fetal morbidities, and cord pH <7.1 as dependent variables. Independent variables included fetal heart rate category, mode of delivery, resuscitation, and histological chorioamnionitis. Outcomes of infants delivered at 23 and 24 weeks were also compared. Results: In 23-week pregnancies, fetal heart rate category 2 was associated with improved short-term survival compared to category 3 (OR 1.3, 95% CI 0.11-15.7). Cesarean delivery and histological chorioamnionitis were not predictive of survival [(OR 0.5, 95% CI 0.04-7.1, and OR 0.4, 95% CI 0.02-6.85), respectively]. Long-term survival for infants born at 23 and 24 weeks was 8% and 56%, respectively. Conclusions: The NICHD fetal heart rate category during labor may be associated with survival for infants born at 23 and 24 weeks of gestation. Cesarean delivery was not associated with improved survival. [ABSTRACT FROM AUTHOR]

Aims: To determine the loss of fetal heart rate (FHR) baseline variability by frequency analysis. Methods: The FHR tracings of 12 normal fetuses and others with various conditions, as well as flat FHR tracings of a late deceleration (LD) and anencephaly recorded with Doppler fetal monitors, were scanned and processed using fast Fourier transform (FFT) analysis. The ratio of the area under the low frequency spectrum divided by the area under the whole spectrum (La/Ta) and the peak power spectrum density (PPSD) were determined. Results: Long-term variability (LTV) measures >10 bpm revealed significantly more La/Ta and PPSD than LTV <10 bpm in normal FHR tracings. The La/Ta and PPSD were >15% and 60 bpm2/Hz, respectively, in representative values of normal FHR cases and in those of fetal respiration, hiccupps and non-reactive FHR, whereas those of the flat baseline of LD and anencephaly were <15% and 60 bpm2/Hz. Conclusion: Loss of baseline variability is diagnosed when the La/Ta ratio and PPSD are <15% and 60 bpm2/Hz, respectively, based on the FFT frequency analysis of the FHR baseline. [ABSTRACT FROM AUTHOR]

Aims: To compare between computer analysis of intrapartum cardiotocography (CTG) features by the Omniview-SisPorto® 3.5 and a consensus of clinicians. Methods: Agreement study using 50 consecutively acquired tracings (206 h of signals) with >60 min duration, <10% signal loss and recorded in labor at term by internal fetal heart rate (FHR) monitoring. Tracings were divided into 10-min segments and independently analyzed by three experienced clinicians, in order to estimate the FHR baseline and identify periodic events. A consensus was reached using a three round Delphi procedure. Results were compared with the analysis provided by the Omniview-SisPorto® 3.5 system. Results: For baseline estimation, agreement between the computer and the consensus was high [intraclass correlation coefficient (ICC)=0.85; 95% confidence interval (CI) 0.46–0.93], with a mean difference of 3.7 bpm (limits of agreement –4.4–11.9 bpm), and 99% of differences under 15 bpm. A concordant identification was observed in 71% of accelerations (95% CI: 69%–73%), 68% of decelerations (95% CI: 66%–70%), and 87% of uterine contractions (95% CI: 85%–89%). Conclusions: A high agreement was observed between the Omniview-SisPorto® 3.5 and a consensus of clinicians in evaluation of intrapartum CTG baseline, accelerations, decelerations and uterine contractions. [ABSTRACT FROM AUTHOR]

Objective: To examine differences in intrapartum fetal heart rate (FHR) patterns among cases with various cord abnormalities. Methods: Vertex singleton cases with nuchal cord (226 cases), velamentous (12 cases), marginal cord insertion (53 cases) or hyper-coiled cord (39 cases) and without them (466) that were delivered at our hospital were examined. The relationship between cord abnormalities and intrapartum FHR patterns were retrospectively investigated. Deceleration patterns were analyzed for the presence of variable, early, late and prolonged decelerations. The frequencies of each FHR pattern per uterine contraction were assessed during 30 uterine contractions at the end of the first stage and throughout the entire second stage of labor. Results: In the first stage of labor, frequencies of variable decelerations were 34.5±23.8% and 27.3±25.5% in cases with velamentous insertion and hyper-coiled cord, respectively. These were significantly higher than in controls (11.7±17.3%, P<0.0001). In the second stage of labor, however, frequencies of each deceleration were not different among various cord abnormalities. Conclusion: Fetal heart rate tracing from the first stage of labor is indicated in cases with the prenatal diagnosis of velamentous insertion or hyper-coiling of the cord. [ABSTRACT FROM AUTHOR]

Aim: To assess linear and complex heart rate dynamics in relation to fetal gender in normal and acidemic fetuses during the minutes preceding delivery. Methods: Linear and non-linear fetal heart rate indices, namely mean FHR, long-term irregularity index, short-term variability, low and high frequency spectral indices, approximate and sample entropy, were assessed in 36 female and 30 male fetuses, adjusted for gestational age and weight, during the minutes preceding delivery. Analysis was performed in the initial and final minutes of each tracing in fetuses with umbilical artery blood pH at delivery ≥7.20, 7.11–7.19 and ≤7.10. Results: Progression of labor was associated with a significant decrease in non-linear indices and an increase in almost all linear indices, both in female and male fetuses, but changes were more marked in female fetuses. Non-acidemic females showed higher mean FHR in the final minutes of labor, compared with males. Acidemic females had higher linear indices when compared to similar male fetuses. Conclusions: During the minutes preceding delivery, female fetuses express higher linear indices than male fetuses, suggesting greater activation of the autonomic nervous system, while maintaining similar complexity indices, which suggests different reaction and adaptation capabilities to stress and distress. [ABSTRACT FROM AUTHOR]

Aim: To summarize the currently available knowledge on (1) the methods to monitor uterine activity (UA); (2) the units to quantify UA; and (3) to assess the importance of abnormal contraction patterns on the condition of the fetus. The need for correct assessment and interpretation of the uterine contraction curve to improve fetal outcome will be emphasized. Study results: Correct assessment of the uterine contraction curve is an essential part of the cardiotocogram and should be obtained by the best method available; i.e., internal tocography (IT). IT provides objective information on quantization of UA and has the ability to obtain a good quality trace in an obese, restless patient. Accurate information on UA is essential because elevated UA during the first and second stage of labor can increase the risk of adverse fetal outcome. The relaxation time appears to be an important contraction parameter to maintain fetal well-being during labor. Almost all abnormal contraction patterns are characterized by shortening of the relaxation time and can lead to severe asphyxia. Duration, amplitude and frequency of contractions are of importance as well. The mean active pressure unit is the means to quantify UA since it incorporates these three contraction parameters. Conclusion: Proper application of UA monitoring by means of the internal method and adequate reading and interpretation of the uterine contraction curve is a prerequisite for high quality electronic fetal heart rate monitoring. [ABSTRACT FROM AUTHOR]

Aims: We studied how linear and nonlinear heart rate dynamics differ between normal fetuses (n=135) and uncomplicated small-for-gestational age (SGA) fetuses (n=65), aged 32–40 weeks' gestation. Methods: We analyzed each fetal heart rate time series for 20 min. We quantified the complexity (nonlinear dynamics) of each fetal heart rate (FHR) time series by approximate entropy (ApEn) and correlation dimension (CD). The linear dynamics were analyzed by canonical correlation analysis (CCA). Results: The ApEn and CD of the uncomplicated SGA fetuses were significantly lower than that of the normal fetuses in all three gestational periods (32–34, 35–37, 38–40 weeks). Canonical correlation ensemble in SGA fetuses is slightly higher than normal ones in all three gestational periods, especially at 35–37 weeks. Conclusions: Irregularity and complexity of the heart rate dynamics of SGA fetuses are lower than that of normal ones. Also, canonical ensemble in SGA fetuses is higher than in normal ones, suggesting that the FHR control system has multiple complex interactions. Along with the clear difference between the two groups' non-linear chaotic dynamics in FHR patterns, we clarified the hidden subtle differences in linearity (e.g., canonical ensemble). The decrease in non-linear dynamics may contribute to the increase in linear dynamics. The present statistical methodology can be readily and routinely utilized in obstetrics and gynecologic fields. [ABSTRACT FROM AUTHOR]

Objective: To compare the impact of electronic fetal monitoring (EFM) alone vs. EFM with additional fetal blood sampling (FBS) in vaginal deliveries complicated by pathologic fetal heart rate (FHR). Methods: All deliveries in Hesse between 1990 and 2000 were evaluated for participation in this study. Inclusion criteria comprised (1) pathologic fetal heart rate, (2) singleton pregnancy, (3) cephalic presentation, (4) vaginal delivery, and (5) gestational age at delivery of more than 35 weeks' gestation. In order to analyze the meaning of additional risk factors at birth for the effectiveness of FBS two subgroups were selected depending on the presence of additional risk factors at birth. To examine the impact of FBS in deliveries with pathologic FHR on the mode of delivery and on neonatal outcome, univariate regression analysis was performed and odds ratios (OR) and their corresponding 95% confindence intervals (95% CI) were calculated. Results: The study population comprised 49,560 deliveries, among deliveries complicated by pathologic FHR, 26% underwent FBS. Deliveries with pathologic FHR and controlled by FBS, with no additional antepartum risk factors, were associated with an increase in spontaneous births OR 1.41 (95% CI 1.27–1.58), and in the presence of additional risk factors OR 1.24 (1.19–1.30). Short-term neonatal outcome parameters were characterized by a lower frequency of severe fetal acidosis (umbilical artery pH <7.0) OR 0.55 (0.42–0.72), and Apgar score <5 after 5 min, OR 0.71 (0.55–0.90). Conclusion: In vaginal deliveries with pathologic FHR the use of FBS as an additional means of intrapartum fetal surveillance is associated with less vaginal operative deliveries, and with an improved short-term neonatal outcome. [ABSTRACT FROM AUTHOR]

Objective: To test the efficacy of a recently introduced ultrasonic scanning plane (three vessel and trachea view -3VTV- plus color flow mapping -3VTVC) on a low-risk population for detection of congenital heart disease (CHD).Patients and setting: Antenatal clinic dealing with local low-risk population. All antenatal patients having a second trimester scan in a 1 year period. All patients had a 3VT plus 3VTC views added to routine four chamber view. Postnatal examinations were performed according to standard hospital protocol.Results: 2847 patients were examined. The plane was achievable in all 23 fetuses with CHD detected, three false negative (aortic coarctation) and two false positive. Sensitivity of the examination was 88.5%, as high as more sophisticated and difficult targeted cardiac scanning. The extra time necessary to perform the test was minimal.Conclusion: 3VTV and 3VTCV were satisfactory used as imaging planes in a busy antenatal clinic in a low-risk population. They could be easily added to the four chamber view as routine screening for CHD and increase the detection rate to 90%. [ABSTRACT FROM AUTHOR]