Prediction of Fetal Hypertrophic Cardiomyopathy in Diabetic Pregnancies Compared with Postnatal Outcome

Abstract

OBJECTIVEThe aim of this study was to estimate the accuracy of prenatal assessment of interventricular septum (IVS) thickness, right myocardial wall thickness (RMWT), and left myocardial wall thickness (LMWT) by two-dimensional (2D) ultrasound for the prediction of perinatal mortality and postnatal diagnosis of hypertrophic cardiomyopathy (HCM) among diabetic pregnant women.SUBJECTS AND METHODSA total of 120 diabetic pregnant women at 35 weeks or more were enrolled in this study from January 1, 2012, to June 30, 2014, at Ain Shams Maternity Hospital, Cairo, Egypt. The 2D ultrasound was done once for all the participants at the time of recruitment; IVS thickness, RMWT, and LMWT were measured. The glycosylated hemoglobin (HbA1c) levels of the participants were recorded. Neonatal assessment including postnatal echocardiography was done after 48 hours. Postnatal results were compared with the prenatal predictive results.RESULTSHigher thickness values for IVS, RMW, and LMW were obtained in the uncontrolled diabetic cases (HbA1c > 6.5%) than in the controlled diabetic cases (HbA1c < 6.5%; P < 0.01). Of the included 120 neonates, 10 (8.3%) were stillborn, 99 (82.5%) had a five-minute Apgar score ≥7, and 4 (3.3%) had a five-minute Apgar score ≤3. The four neonates with severe neonatal distress died after admission to neonatal intensive care unit within one week after delivery. Out of 110 live-born neonates, 4 (3.6%) neonates had a low ejection fraction (EF) (<50%) due to HCM; of them 2 (1.8%) died within one week after delivery, while 2 (1.8%) survived. Another two (1.8%) neonates died from severe respiratory distress syndrome. A cutoff value of ≥4.5 mm for prenatal IVS thickness was predictive of neonatal distress due to HCM with a sensitivity of 82%, specificity of 68%, and diagnostic accuracy of 72%. A cutoff value of <1.18 for the ratio of IVS thickness to LMWT had a sensitivity of 82%, specificity of 72%, and diagnostic accuracy of 74% for the prediction of neonatal distress due to HCM. In this study, 8 of the 10 fetuses with intrauterine demise and the 2 neonates who died within one week after delivery due to heart failure had a prenatal IVS thickness of ≥4.5 mm, while 7 of the 10 fetuses with intrauterine demise and the 2 neonates who died postnatal from heart failure had a prenatal IVS thickness to LMWT ratio of ≤1.18.CONCLUSIONA prenatal IVS thickness of ≥4.5 mm or an IVS/LMWT ratio of ≤1.18 seems to be predictive of HCM and is associated with almost twofold higher risk of intrauterine fetal death and almost threefold higher risk of possibly relevant perinatal mortality.

The emerging role of metformin in gestational diabetes mellitus

“…The infants of mothers with early undetected diabetes are at an increased risk of congenital heart defects, including (most commonly) ventricular septal defect, atrial septal defect and transposition of the great arteries …”

Diyabetik Anne Bebeğinde Görülen Kardiyovasküler Komplikasyonlar

“…Risk, genel popülasyona göre 3-5 kat artmıştır. Diyabetik anne bebeklerinin yaklaşık %3-6'sında doğumsal kalp anomalileri ortaya çıkmaktadır 20 . Yapılan bir çalışmada 609 DAB'dan 22'sinde (%3,6) kardiyovasküler malformasyon olduğu tespit edilmiştir 11 .…”

“…Sol ventrikülün yanında sağ ventrikülde etkilenebilir. En önemli hipertrofi, insülin reseptörlerinin fazla sayıda olmasından dolayı interventriküler septumda meydana gelir 20 .…”

“…Sol ventrikül çıkım yolunda, Doppler ile ölçülen pik akım hızı 30 mmHg ve daha fazla ise HKMP'nin obstrüktif olduğu söylenebilir 25 . Prenatal dönemde yapılan fetal EKO incelemesinde, interventriküler septum kalınlığının 4.5 mm ve üzerinde, interventriküler septumun sol ventrikül miyokard duvar kalınlığına oranının 1.18'in altında olmasının, postnatal dönemde önemli HKMP gelişiminin bir göstergesi olabileceği bildirilmiştir 20 . Diyabetik anne bebeğinde hipoglisemi olması, ASH görülme riskini artırmaktadır 32 .…”

CARDIOVASCULAR MORBIDITY OF INFANTS OF DIABETIC MOTHERS AND ITS ASSOCIATION WITH MATERNAL GLYCAEMIC CONTROL ACCORDING TO HbA1c

“…[22,23] A positive correlation between HbA1c levels and septal thickness measurements is reported. [24] The symptomatic infants (5 to 10 percent) typically recover after two to three weeks of supportive care and propranolol, but the echocardiographic findings take 6 to 12 months to resolve.…”