Transitional hemodynamics in infants of diabetic mothers by targeted neonatal echocardiography, electrocardiography and peripheral flow study

Abstract

Objective: Metabolic alterations of intrauterine environment in diabetes mellitus (DM) lead to fetal cardiac dysfunctions that can persist after birth. The aim of the study was to assess the cardiovascular adaptation in infants born to diabetic mothers (IDM) with different degrees of glycometabolic control, in relation to revised guidelines for diagnosis of DM and quality improvements in neonatal care. Materials and methods: An observational case-control study was conducted on IDM with gestational, type 1 and type 2 DM. Relevant maternal and neonatal anamnestic, clinical and laboratory data were analyzed. Electrocardiographic and echocardiographic analyses, including structural and systo-diastolic evaluation, were performed. Results: In 68 IDM enrolled, we observed a lower incidence of negative perinatal outcome than expected. Comparing to non-IDM, they presented larger fetal shunts, higher pulmonary pressures, early and atrial wave velocities. At 72 hours, kinesis and heart rate variability remained low. Cerebral blood flow velocities were higher. The most serious impairment of transition was in pregestational IDM. Conclusion: Maternal DM impaired neonatal transitional hemodynamics also in asymptomatic IDM with good glycometabolic control. These results confirm the need for an early cardiologic and cerebrovascular evaluation, to identify IDM with delayed maturation at risk of worse longterm metabolic, cardiovascular, and neurodevelopmental outcome. ARTICLE HISTORY

Effect of maternal diabetes on fetal heart function on echocardiography: systematic review and meta‐analysis

“…These adverse outcomes have been observed in studies reporting even smaller differences between diabetic pregnancies and controls than we found in our meta-analysis of IVS thickness and E/A ratio. Impaired cardiac function can persist during the first days postpartum and may be accompanied by impaired transitional hemodynamics 15,48,[74][75][76][77] 28 Chu (2012) 31 Dervisoglu (2018) 32 Fouda (2013) 34 Garcia-Flores (2011) 36 Garg (2014) 38 Moghadam (2019) 47 Wang (2015) 56 Wang (2016) 55 Wong 2007 32 Fouda (2013) 34 Gandhi (1995) 35 Gonzalez (2014) 39 Jaeggi (2001) 41 Russell (2008) 50 Tsyvian (1998) 52 Weber (1991) 58 Weber (1994) 57 Gandhi (1995) 35 Jaeggi (2001) 41 Macklon (1998) 45 Russell (2008) 50 Weber (1991) 58 Weber 1994 Total (95% CI) Heterogeneity: Tau 2 = 0.07; Chi 2 = 74.29, df = 14 (P < 0.00001); I 2 = 81% Test for overall effect: Z = 6.32 (P < 0.00001) Test for subgroup differences: Chi 2 = 13.94, df = 1 (P = 0.0002), I 2 = 92.8%…”

“…These adverse outcomes have been observed in studies reporting even smaller differences between diabetic pregnancies and controls than we found in our meta-analysis of IVS thickness and E/A ratio. Impaired cardiac function can persist during the first days postpartum and may be accompanied by impaired transitional hemodynamics 15,48,[74][75][76][77] 32 Fouda (2013) 34 Gandhi (1995) 35 Gonzalez (2014) 39 Jaeggi (2001) 41 Russell (2008) 50 Tsyvian (1998) 52 Weber (1991) 58 Weber (1994) 57 2. Gandhi (1995) 35 Jaeggi (2001) 41 Macklon (1998) 45 Russell (2008) 50 Weber (1991) 58 Weber (1994) 57 Subtotal (95% CI) Subtotal (95% CI) Heterogeneity: Tau 2 = 0.02; Chi 2 = 16.97, df = 5 (P = 0.005); I 2 = 71% Test for overall effect: Z = 3.19 (P = 0.001) Heterogeneity: Tau 2 = 0.04; Chi 2 = 18.17, df = 8 (P = 0.02); I 2 = 56% Test for overall effect: Z = 7.66 (P < 0.00001) Subtotal (95% CI) Heterogeneity: Tau 2 = 0.01; Chi 2 = 2.30, df = 1 (P = 0.13); I 2 = 56% Test for overall effect: Z = 0.25 (P = 0.80) Total (95% CI) Heterogeneity: Tau 2 = 0.07; Chi 2 = 74.29, df = 14 (P < 0.00001); I 2 = 81% Test for overall effect: Z = 6.32 (P < 0.00001) Test for subgroup differences: Chi 2 = 13.94, df = 1 (P = 0.0002), I 2 = 92.8% Third trimester Subtotal (95% CI) Heterogeneity: Tau 2 = 0.16; Chi 2 = 123.70, df = 9 (P < 0.00001); I 2 = 93% Test for overall effect: Z = 4.84 (P < 0.00001) Total (95% CI) Heterogeneity: Tau 2 = 0.26; Chi 2 = 274.19, df = 11 (P < 0.00001); I 2 = 96% Test for overall effect: Z = 3.53 (P = 0.0004) Test for subgroup differences: Chi 2 = 16.52, df = 1 (P < 0.0001), I 2 = 93.9% 12.8% 10.6% Atiq (2017) 27 Wong (2007) 60 Dervisoglu (2018) 32 Fouda (2013) 34 Jaeggi (2001) 41 Russell (2008) 50 Sanhal (2017) 51 Tsyvian (1998) 52 Weiner (1999 6.6% 7.2% 6.5% 6.8% 7.5% 0.03 (-0.02 to 0.08) -0.01 (-0.03 to 0.01) -0.17 (-0.22 to -0.12) 0.04 (0.00 to 0.08) -0.03 (-0.04 to -0.02) Rizzo (1991) 49...…”

“…Impaired fetal cardiac function is associated with adverse pregnancy outcome and neonatal morbidity 12,13 . Moreover, although cardiac hypertrophy usually resolves spontaneously postpartum, there is growing concern that in-utero and early-life cardiac dysfunction may persist, and may potentially have long-lasting effects, predisposing to future cardiovascular disease 9,14,15 .…”

Cardiac changes in infants of diabetic mothers

“…Changes in the cardiovascular system are the most important changes when the foetal bypass shunts close, and blood normally circulates[ 35 ]. Metabolic alterations of the intrauterine environment in gestational diabetes cause foetal cardiac dysfunctions that can persist after birth and impair neonatal transitional haemodynamics even in asymptomatic neonates[ 36 ]. They have a prolonged isometric contraction phase of right ventricle (RV) with elevated RV pre-ejection period (RVPEP)/RV ejection time (RVET) ratio (RVPEP/ RVET Ratio).…”

Assessment of fetal cardiac diastolic function of gestational diabetes mellitus using dual-gate Doppler

“…[ 36 ] which may persist and potentially has short- and long-term consequences to the offspring health. [ 37 – 41 ]…”