Prenatal Growth in Fetuses with Isolated Cyanotic and Non-Cyanotic Congenital Heart Defects

Abstract

Background: Fetal growth may vary significantly in different congenital heart defects (CHDs). Objectives: To investigate prenatal growth of CHD fetuses and its correlation with classifications based upon expected oxygen delivery to the fetal brain or structural findings. Methods: Seventy-nine euploid fetuses with isolated CHD were recruited prospectively and categorized by the expected oxygen supply to the brain (low, intermediate, and high) or by the expected arterial mixing considering two categories (cyanotic or non-cyanotic). Biometry and Doppler were recorded, and Z-scores (Zs) calculated. Growth changes at different time points were analyzed and compared with 150 controls. Results: A total of 664 exams were performed on 229 fetuses. Median head circumference (HC) Zs were lower in all CHD fetuses from the second trimester onwards and in cyanotic CHD fetuses from the first onwards, with associated smaller abdominal circum-ference (AC) in the third trimester (first-trimester biparietal diameter Zs cyanotic: -1.3 [-2.36; -0.98], non-cyanotic -0.72 [-1.25; -0.6], p = 0.044, second-trimester HC Zs cyanotic: -1.47 [-2.3; -0.84]; non-cyanotic -0.45 [-0.83; -0.02], p < 0.0001; AC Zs cyanotic 0.0 [-0.44; 0.86]; non-cyanotic 0.65 [0.31; 1], p = 0.0006). Birth-weight centiles were smaller in CHDs (particularly in cyanotic) with no differences between categories of brain oxygen delivery. Conclusions: Fetuses with cyanotic CHD have fetal growth restriction, impaired head growth, yet normal posterior fossa dimensions and fetal-placental Doppler.

Fetal brain issues in congenital heart disease

“…However, the onset of reduced volumetric brain growth is not limited to the third trimester as many studies have also found reductions in fetal head biometry beginning in the second trimester in both major and minor CHD (28)(29)(30)(31)(32), though more prominent in fetuses with single ventricle physiology (SVP), HLHS, TOF, and TGA. More compellingly, fetuses with CHD, especially cyanotic subtypes, have demonstrated abnormal fetal head biometry in the first trimester (33) and as early as 11-14 GW in fetuses with left heart hypoplasia (34), suggesting a potential genetic contribution towards abnormal brain development in CHD.…”

Adverse perinatal outcome and placental abnormalities in pregnancies with major fetal congenital heart defects: A retrospective case‐control study

“…6,7 Moreover, fetuses with CHD (especially within the cyanotic group) present abnormal pattern of prenatal growth with lower birthweight and head size. 8 Signs of placental dysfunction are already evident in the first trimester of pregnancy with lower serum levels of pregnancy-associated plasma protein A (PAPP-A) and placental growth factor (PlGF) in CHD pregnancies as compared to controls. 1 Such placental impairment might be associated with underperfusion resulting in an increase in the uterine artery pulsatility index (UtA-PI) in mid-pregnancy in CHD pregnancies.…”

“…Abnormal placental cord insertion is more common in placentas from pregnancies with fetal CHD 6,7 . Moreover, fetuses with CHD (especially within the cyanotic group) present abnormal pattern of prenatal growth with lower birthweight and head size 8 …”

Editorial for “3D Volumetric MRI Detects Early Alterations of the Brain Growth in Fetuses with Congenital Heart Disease”

“…2 Reduced cerebral oxygen and nutrient delivery, particularly inadequate glucose supply in CHD fetuses, are responsible for impaired brain development during fetal life, and even the most contemporary publications stress this in the third trimester of pregnancy, 3 while it has been well established on ultrasound (US) that fetuses with CHD have a smaller head circumference (HC) and biparietal diameter from the second trimester of pregnancy onward and, recently, that those with cyanotic CHD have smaller HC from the first trimester, as early as 11-14 gestational weeks (GW), compared to age-matched controls. 4 Magnetic resonance imaging (MRI), obviously, provides more detailed insight into the brain structure and volume than US; however, it is more affected by fetal motion. MRI allows for fetal brain segmentation and measurement of structures' volumes, and three-dimensional (3D) volumetry is performed mostly in the third trimester, preferably near the end of pregnancy, when the fetus is least mobile and the segmentation is easiest to carry out.…”

“…Reduced cerebral oxygen and nutrient delivery, particularly inadequate glucose supply in CHD fetuses, are responsible for impaired brain development during fetal life, and even the most contemporary publications stress this in the third trimester of pregnancy, 3 while it has been well established on ultrasound (US) that fetuses with CHD have a smaller head circumference (HC) and biparietal diameter from the second trimester of pregnancy onward and, recently, that those with cyanotic CHD have smaller HC from the first trimester, as early as 11–14 gestational weeks (GW), compared to age‐matched controls 4 …”