Potential Impact of a Pregnant Woman's Microbiota on the Development of Fetal Heart Defects: A Review of the Literature.

Developments in medicine and biology in recent decades have led to a significant increase in our knowledge of the complex interactions between the microbiota and human health. In the context of perinatal medicine and neonatology, particular attention is being paid to the potential impact of the maternal microbiota on fetal development. Among the many aspects of this relationship, the question of the impact of dysbiosis on the development of fetal heart defects is an important one. In this article, we present an analysis of recent research and scientific evidence on the relationship between a pregnant woman's microbiota and the development of fetal heart defects. We also discuss potential intervention strategies, including the role of probiotics and diet in optimising the maternal microbiota.

Prenatal Echo-Sonographic Parameters in Fetuses Wrapped with the Umbilical Cord in the Third Trimester of Pregnancy.

This study constitutes a description of prenatal echo-sonographic parameters in fetuses wrapped with the umbilical cord in the third trimester of pregnancy and demonstrates the practical importance of the umbilical cord collision. Echocardiographic examinations were performed within 6 months, and a group of patients in the third trimester with a mean age of 28.1 ± 0.79 weeks of gestation (p = 0.075) was distinguished. The group included 46 fetuses from single pregnancies with the umbilical cord around the fetal neck and 70 fetuses without the umbilical cord around the fetal neck. The course of the umbilical cord coiling around the fetal neck was recorded by color Doppler. We also conducted a follow-up with the newborns. In the study group, there was an elevated peak systolic velocity of the umbilical artery (UMB PSV) at a level of 44.17 cm/s vs. 38.90 cm/s in the control group (p = 0.004), and caesarean sections were significantly more frequent (54.5% vs. 31.4%). The persistence of the nuchal cord during delivery was observed in 37% of newborns in the study group, while the occurrence of umbilical wrapping during delivery was found in 18.6% of newborns in the control group (p = 0.027). In the studied cases, caesarean sections were 2.62 times more frequent (OR = 2.62), whereas nuchal cords during delivery were 2.57 times more often observed (OR = 2.57). Fetal umbilical cord wrapping in the third trimester of pregnancy does not have a significant hemodynamic impact; however, the UMB PSV might be slightly elevated in this group, and the frequency of umbilical cord collision during delivery and the need to perform a caesarean section at term seem to be more common.

Impact of Prenatal and Postnatal Diagnosis on Parents: Psychosocial and Economic Aspects Related to Congenital Heart Defects in Children.

Congenital heart defects (CHD) are defects detected both prenatally and after birth. They are the most common congenital defects. Despite advances in diagnosis and treatment, CHD remain an important cause of morbidity and mortality in newborns, which has a great impact on economic aspects. It is crucial to provide a holistic approach to the care of children with CHD, including regular cardiac check-ups, appropriate drug treatment, surgical or cardiac interventions as needed, rehabilitation, psychological support, and education for patients and their families. Parents experience a variety of psychological problems. This article summarizes the influence of CHD in the psychological and economic areas.

Fetal Third-Trimester Functional Cardiovascular Abnormalities and Neonatal Elevated Bilirubin Level.

BACKGROUND: The aim of the study was to analyze the neonatal outcomes of fetuses with diagnosed functional cardiovascular abnormalities, also considering the connection with neonatal hyperbilirubinemia. MATERIALS AND METHODS: It was an observational study of 100 neonates who had fetal echocardiography examinations in the third trimester (mean gestational age during the last echocardiography was 34 ± 3 weeks and mean birth weight was 3550 g). There were two groups: A: normal heart anatomy + no functional anomalies; group B: normal heart anatomy + functional abnormalities. Hyperbilirubinemia was defined as a bilirubin level of >10 mg%. RESULTS: In group A, there were 72 cases and only 5 cases despite having normal heart anatomy and normal heart study that presented additional problems. In group B (28 cases), the prenatal functional findings included tricuspid regurgitation (TR) (15 cases, 53%), pericardial effusion (4 cases, 14%), myocardial hypertrophy (4 cases, 14%), cardiomegaly (2 cases, 7%), abnormal bidirectional blood flow across the foramen ovale (3 cases, 11%), aneurysm of atrial septum (2 case, 7%), abnormal E/A ratio for mitral and tricuspid valve (1 case, 3%), bright spot (3 case, 11%), abnormal Doppler flow in ductus arteriosus compared to aortic arch (difference >60 cm/s) (1 case, 3%), supraventricular tachycardia (SVT) (1 case), and mitral regurgitation (1 case, 3%). In group A (n = 72 cases), bilirubin levels of >10 mg/dL were observed in 8% of newborns. In group B (n = 28), bilirubin levels of > 10 m/dL were observed in 46% of cases and TR was present in group B in 53% of cases (15/28 cases). The difference between group A and B in terms of elevated bilirubin levels was statistically significant (p < 0.001). CONCLUSIONS: In the case of fetal normal heart anatomy and normal heart study, a good neonatal outcome may be expected. When fetal cardiovascular functional abnormalities in normal heart anatomy are detected, with special attention paid to tricuspid valve regurgitation, a neonatal elevated bilirubin level (mean 11 mg/dL, range 10-15 mg/dL) may be expected.

Fetal Cardiac Hemodynamic and Sonographic Anomalies in Maternal COVID-19 Infection Depending on Vaccination Status-Polish Multicenter Cohort Study.

Most obstetrical studies have focused on maternal response to the SARS-CoV-2 virus but much less is known about the effect of COVID-19 on fetal physiology. We aimed to evaluate the effect of the maternal SARS-CoV-2 infection on the fetal homeostasis with the use of detailed ultrasonography and echocardiography and consideration of the effect of vaccination. This was a multi-center study of fetuses who had prenatal detailed ultrasound and echocardiographic examinations performed by fetal cardiology specialists. The subjects were divided based on the COVID vaccination status (vaccinated women who did not have COVID-group V, unvaccinated women who had COVID-group UV, and unvaccinated women who did not have COVID-control group). We evaluated the ultrasound and echocardiography results obtained. The study group included 237 gravidas from four prenatal cardiology centers. In the group of fetuses with normal heart anatomy, normal cardiovascular function had 147 (81%) fetuses and functional cardiovascular anomalies were present in 35 (19%) cases. Functional cardiovascular anomalies were present in 11 (16%) fetuses in the V group, 19 (47%) fetuses in the UV group and 5 (8%) fetuses in the control group (p < 0.01). There were 56 (24%) fetuses with extracardiac anomalies. Extracardiac anomalies were present in 20 (22%) fetuses in the V group, 22 (45%) fetuses of the UV group and in 14 (14%) fetuses in the control group (p < 0.01). Our study has proved that maternal COVID-19 infection can affect the fetal physiology and mild cardiac and extracardiac markers detected by fetal ultrasonography and echocardiography. Moreover, maternal vaccination results in lower occurrence of these findings in fetuses.

The Predictive Value of the CSA Index in the Prenatal Diagnosis of Aortic Coarctation in Ultrasound Examination Performed during the Second Trimester.

BACKGROUND: Aortic coarctation (CoA) is the fourth most common congenital heart defect (8-10%) which occurs at a frequency of about 20-60/100,000 births. Only 22.3% of all cases appears to be diagnosed during the second trimester of pregnancy. Since the detection of prenatal aortic coarctations is very low, every effort should be made to change this situation. According to the authors of this study, the CSAi (carotid to subclavian artery index) could serve as a reliable indicator. MATERIAL AND METHODS: Ninety-six fetuses from healthy, single, pregnancies, with good ultrasound visualization between 18 and 27.5 weeks of gestation, and twenty-three fetuses suspected of aortic coarctation (postnatally confirmed) were included in this study. Our first aim was to compare the current most common method of prenatal CoA diagnosis based on the measurement of the aortic z-score in the aortic isthmus using the method suggested by us-CSAi. RESULTS: Logistic regression coefficients for z-score and CSAi were analyzed as predictors of coarctation occurrence. It appears that 39.4% of coarctation occurrence can be predicted on the basis of the z-score, and 93.5% on the basis of the CSAi. The cut-off value for CSAi in the study group was 0.81 (sensitivity: 95.7%, specificity 99%). Based on the ROC curve analysis, the cut-off value for the carotid to subclavian distance (mm) was determined; the risk of coarctation increased above this value. Based on the Gini index (0.867), this value was set at 2.55 (sensitivity 82.6%, specificity 93.7%). CONCLUSIONS: CSAi measurement is currently the most sensitive method for aortic coarctation detection. For the purpose of our study, this method was applied in diagnostics in the second trimester of pregnancy. This method is easy, reproducible and should be widely introduced into everyday echocardiographic diagnostics of coarctation to minimize the risk of error.

Prenatal echocardiography in Trisomy 18 - the key to diagnosis and further management in the second half of pregnancy.

OBJECTIVES: Trisomy 18 is an autosomal chromosomal disorder, which is associated with numerous ranges of congenital anomalies. Purpose of this largest study in Poland was to analyze diagnosis and follow-up of fetuses with the prenatal diagnosis of Trisomy 18 in our tertiary center. MATERIAL AND METHODS: The study was conducted in a tertiary center for fetal cardiology. The inclusion criteria comprised fetuses with karyotype of Trisomy 18. Data on number of delivery, number of pregnancy, cardiac and extracardiac diseases, type and date of childbirth, sex, birth date, Apgar score, survival time and autopsy were analyzed. RESULTS: There were 41 fetuses with diagnosis confirmed by amniocentesis: 34 were females, 7 males. CHD was detected prenatally in 73% cases at mean gestational age of 26 weeks. The most common CHD was AV-canal (13 cases, 43%) and VSD (13 cases, 43%). In 1999-2010 the average time to detect a heart defect was 29 weeks, in 2011-2021 it was 23 weeks (p < 0.01, U-Mann-Whitney). IUGR was diagnosed in the 3rd trimester in 29 cases (70%), polyhydramnion in 21 cases (51%). CONCLUSIONS: Congenital heart defects in female fetuses with intrauterine growth restriction in 3rd trimester with polyhydramnios and in subsequent pregnancy, regardless of maternal age, were typical prenatal findings for Trisomy 18. Heart defects with incomplete septum such as AVC or VSD (which nowadays can be detected in the 1st half of the pregnancy) were the most common anomaly in Edwards Syndrome. These heart defects did not require intervention in the early neonatal period.

The Presence of a Single Nuchal Cord in the Third Trimester May Not Affect Tei Index in LGA Fetuses.

(1) Background: The aim of this study was to assess the RV (right ventricle) and LV (left ventricle) Tei index in large for gestational age (LGA) fetuses with a single 360-degree umbilical coil of the umbilical cord around the fetal neck identified by ultrasound in the third trimester of gestation. (2) Methods: The RV and LV Tei index for the cardiac function were measured in 297 singleton pregnancies, and we identified 25 LGA fetuses. There were 48% of LGA fetuses with a nuchal umbilical cord-LGA/NC-larger for gestational age fetuses with a nuchal cord. NC was detected with a color Doppler during a transverse scan of the fetal neck, when the umbilical cord formed a U shape. All fetuses had normal anatomy and normal uterine, placental, umbilical, intracardiac and cerebral Doppler waveforms values for their gestational age. (3) Results: The RV Tei index was significantly higher in the LGA subgroup vs. AGA (0.6 ± 0.2 vs. 0.50 ± 0.2; p value = 0.01), but in LGA fetuses with a single coil of the nuchal cord, there were not any significant changes in the Tei indexes. (4) Conclusions: The Tei index might not be impacted by the presence of the nuchal cord in LGA fetuses.

Functional assessment of atrial wall excursion and foramen ovale flap tracings in 3rd trimester as predictor of short-term hemodynamic stability in congenital heart defects fetuses.

OBJECTIVES: Right atrium and left atrium of the fetal heart play a fundamental role in fetal heart circulatory physiology. METHODS: Excursion of fetal atria walls and tracings of foramen ovale (FO) flap movement were analyzed by M-mode echocardiography by new FO index to determine fetal and neonatal outcome in the first week and month of life in various congenital heart defects. The study group was divided into 3 subgroups: group A: neonates stable after birth (all on I.V. prostaglandin infusion) for at least 7 days, group B: neonates unstable after birth (despite I.V. prostaglandin infusion) requiring catheterization procedure or early cardiac surgery <6th day of life and group C: fetuses with in utero demise. RESULTS: The average values of FO index: group A - 32, group B - 20, group C - 12.Schaffe test showed statistical difference of FO index between group A and B (p=0.029) and group A and C (p=0.001), but no difference between group B and C (p=0.24) The FO index of stability was determined by ROC curve analysis. Cut-off point distinguishing between postnatal stability and postnatal instability + in utero demise constituted FO index=25 (specificity 82%; sensitivity 90%). CONCLUSIONS: Prenatal features of atrial M-mode echocardiography shortly before birth might be helpful to predict the short term prognosis of fetal hemodynamic stability or instability shortly after birth regardless of the type of congenital heart defects (CHD).

Maternal urogenital infection and fetal heart functional assessment - what is the missing link?

OBJECTIVES: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Longitudinal Surveillance of Fetal Heart Failure Using Speckle Tracking Analysis.

Long-term monitoring of a fetus with heart failure is an undeniable challenge for prenatal cardiology. Echocardiography is constrained by many fetal and maternal factors, and it is difficult to maintain the reproducibility of the measured and analyzed parameters. In our study, we presented the possibilities of using modern speckle tracking technology in combination with standard echocardiography parameters that may be insufficient or less sensitive in the context of monitoring life-threatening fetal conditions. Our analysis shows the superiority of the parameters used to assess fetal cardiac architecture, such as the GSI Global sphericity Index, and fetal cardiac function, such as the FAC fractional area change and the EF ejection fraction, which temporal change may indicate a worsening condition of the fetus with heart failure. The significant increase in the parameters of fetal heart size in speckle tracking allows for an improved echocardiographic diagnosis and monitoring of the fetus with heart failure and the prognostic conclusions about the clinical condition after birth. Significant decreases in FAC for the left and right ventricles and EF for the left ventricle may indicate an unfavourable prognosis for the monitored fetus due to heart failure.

Fetal echocardiography and early neonatal balloon valvuloplasty improved overall survival in prenatally detected aortic stenosis over 25 years of tertiary center experience.

PURPOSE: This article aimed to present the factors determining survival and prognosis in fetuses and newborns with critical prenatal aortic stenosis (AS) and to present 26 years of tertiary center experience. METHODS: Study included 87 fetuses with critical AS requiring surgical intervention during neonatal period. All results were expressed as means ± SD, in numbers and percentages. The statistically significant results were those with p < 0.05. RESULTS: An increase in the number of cases of AS was observed in our center along with a decrease in gestational age of our patients during the first echocardiographic exam. The survival rate of newborns was considerably higher when born in due time (p < 0.05) with body weight > 2500 g (p < 0.05). Balloon valvuloplasty performed in the first days after birth occurred to be an optimal solution in these cases. CONCLUSIONS: Fetal echocardiography and special perinatal care with transplacental maternal pharmacotherapy in selected cases and an early neonatal aortic balloon valvuloplasty have shown improvement in survival rate. The most dangerous for the newborn with AS was the first week of postnatal life. It is vital to refer the fetuses with AS to the reference centers which offer the possibility of invasive cardiac intervention on the first day after birth, and it might be an optimal solution.

Fetal kidney measurement - additional biometric parameter for accurate gestational age assessment.

OBJECTIVES: Ultrasound examination - recommended in the prenatal period - allows for an assessment of fetal anatomy and well-being and for monitoring its growth trend. Determining gestational age is important in monitoring the developing fetus. Research is increasingly being conducted in search of further biometric components that may improve ultrasound techniques in terms of predicting the gestational age. It should be noted that a fairly large number of publications focus on the accessibility of fetal kidneys to diagnostic imaging during routine ultrasound examination. The reported study was an attempt to answer the question whether fetal kidney dimensions correlated with gestational age. The obtained results are presented as fetal kidney normograms for particular weeks of gestation. MATERIAL AND METHODS: The study covered by dissertation was conducted among patients hospitalized at the Provincial Specialist Hospital in Zgierz, Department of Gynecology, Obstetrics and Endoscopic Therapy, in the period from 1st April 2019 to 30th November 2019. The study group included patients in a single pregnancy. The control group was not included in the study. The ultrasound examinations, which are the basis of the study, were carried out using the PHILIPS Affiniti 70 ultrasound device, with a frequency of 3.5 MHz transabdominal transducer. All data were subjected to statistical analysis using the Statistica 13.1 program. CONCLUSIONS: Kidney dimensions strongly correlated with gestational age. Fetal kidney growth was a linear process in normal pregnancy. Fetal kidney measurements can provide additional biometric parameters for accurate gestational age assessment.

Longitudinal functional assessment of atrial M-mode in dextro- transposition of the great arteries fetus may help to predict the necessity for urgent neonatal Rashkind procedure.

Six fetal echocardiographic examinations were analyzed and presented with special emphasis on atrial M-mode in one case of fetal isolated dextro- transposition of the great arteries. The only significant changes were seen based on analysis of the new index of foramen ovale (FO) flap movement. Emergency Rashkind procedure on the first day of postnatal life was predicted based on fetal atrial M-mode.

Functional assessment of atrial M-mode in 3rd trimester in the context of postnatal balloon atrial septostomy in fetuses with simple dextro-transposition of the great arteries.

OBJECTIVE: This study aimed to identify new functional echocardiographic features of fetal foramen ovale (FO) to predict the need of urgent balloon atrial septostomy (BAS) in neonates with simple dextro-transposition of the great arteries (d-TGA). METHOD: Single-center prospective study of fetuses, who had prenatal echocardiographic examination <30 days before delivery and fetal diagnosis of simple d-TGA. The subjects were divided according to the need of BAS within the first 24 h after neonatal birth and before arterial switch operation. We analyzed following parameters: FO diameter, pulmonary venous maximal velocity, new FO flap tracings index analyzed by M-mode echocardiography. RESULTS: Out of 130 fetuses, 12 patients were included. Cutoff value of FO index provided maximum sensitivity (100%) and negative predictive value (100%) and cutoff value of FO index multiplied by FO diameter provided maximum specificity (100%) and positive predictive value (100%) in fetuses with fetal d-TGA in predicting need of urgent BAS. CONCLUSION: FO index could potentially be used to predict postnatal haemodynamic stability in fetuses with simple d-TGA. FO index multiplied by FO diameter could potentially be used to predict prenatally the need of urgent BAS following the birth.

Ebstein's anomaly: epidemiological analysis and presentation of different prenatal management.

OBJECTIVES: To present the crucial role of echocardiographic examination in perinatal care and analyze influence of prenatal treatment for neonatal outcome. Furthermore, the attempt to answer the question if there was any relationship between the occurrence of fetal Ebstein's anomaly and environmental risk factors in polish population. METHODS: Forty-five prenatal diagnoses of Ebstein's anomaly were compiled over the 21-year period (1998‒2018) form our single unit. The analysis included the assessment of maternal parameters (age, past obstetric history, and place of residence) and fetal parameters (sex, gestational age, anatomy, the fetal cardiovascular condition assessed by the CVPS, associated extracardiac anomalies or malformations, prenatal treatment, delivery and follow-up). RESULTS: The average age of gravida was 29.5 years (± 5.2 years) and gravidae <35 years of age accounted for 80% . There were 43 singleton pregnancies and 2 cases of multiple pregnancy. Ebstein's anomaly was mostly (averagely) diagnosed at 28th week of gestation. Forty-three fetuses had normal karyotypes and two had trisomy 21. Cardiomegaly was present in 91% (41) of fetuses. The average heart area to chest area ratio was 0.56 (± 0.12). In 21 cases, there was only fetal monitoring - echocardiographic examinations and postnatal mortality was 44.4%. In 5 cases, transplacental digoxin treatment was administered and mortality was: 40%. In another 5 cases, only steroid therapy was applied and postnatal mortality was 100%. Steroids and transplacental digoxin treatment were administered in 11 cases and mortality was 63.6%. In 3 last cases transplacental digoxin treatment, steroids and maternal hyperoxygenation therapy were given and mortality was 0%. Cesarean section rate was 49%. Moreover, due to Ebstein's anomaly regional peak of occurrence benzopyrene was deliberated as environmental risk factor. CONCLUSIONS: Fetal Ebstein's anomaly occurred in our population in healthy young women, expecting their first child and malformation was not related to fetus gender, nor to maternal health condition. Our data can be a new signal for the development of novel treatment strategies in therapy in fetuses with Ebstein's anomaly.

Normal ranges of fetal heart rate values for healthy fetuses in Poland, as determined by ultrasound between weeks 18 and 29 of gestation.

BACKGROUND: Fetal heart rate (FHR) is commonly used to assess fetal well-being. AIMS: The aim was to establish normal ranges of FHR during pregnancy by umbilical artery (UMB-A) Doppler analysis in a healthy Polish population. METHODS: The study was conducted in a tertiary center for fetal cardiology. Data on gestational age (GA), FHR measured on UMB-A, cardiac problems, and extracardiac problems were collected. All fetuses underwent echocardiographic examination. The inclusion criteria comprised normal fetal biometry and biophysical profile, labels of "normal heart anatomy and normal heart function", "no extracardiac malformations", and no "extracardiac anomalies". RESULTS: Based on the data from 258 healthy fetuses, a scatter graph with regression line giving a prognosis of normal values for FHR during pregnancy was prepared (95% confidence interval). The regression equation for FHR, as function of GA in weeks, was found to be: FHR (beats/minute) = 149 - GA according to biometry (weeks) × 0.22; (r = -0.1032; P = 0.098); FHR (beats/minute) = 148 - GA according to the last menstrual period (weeks) × 0.16; (r = -0.0722; P = 0.253). The 5th, 50th, 95th percentiles, mean and standard deviation of FHR between weeks 18 and 29 of gestation were calculated. CONCLUSIONS: We present the normal ranges for FHR measured on UMB-A for weeks 18 to 29 of gestation in healthy fetuses with normal heart function and anatomy. The obtained values may be of value to departments of obstetrics and should be considered important elements of the basic fetal ultrasound report.