Maternal obesity affects fetal myocardial function as early as in the first trimester.

OBJECTIVE: To investigate cardiac function from 14 weeks' gestation in fetuses of obese pregnant women (FOW). Animal studies have shown that maternal obesity induces fibrosis in fetal myocardium. We hypothesized that fetal cardiac function would be impaired among FOW. METHODS: A case-control study with longitudinal follow-up was performed at Trondheim University Hospital, Norway. In total, 80 pregnant women were included and the final population comprised 52 obese and 24 of normal weight (mean body mass index before pregnancy, 34.8 ± 4.1 vs 21.0 ± 2.2 kg/m(2) ; P < 0.001). The main outcome measures were global strain rate (GSR) and strain by tissue Doppler imaging, tissue Doppler velocities (TDVs) and interventricular septal thickness assessed by fetal echocardiography at gestational ages of 14, 20 and 32 weeks. RESULTS: In FOW, fetal left ventricle (LV) and right ventricle (RV) GSR and strain were significantly lower than in fetuses of normal-weight pregnant women: LV GSR was 33.3% lower at 14 weeks, 22.4% lower at 20 weeks and 22.8% lower at 32 weeks of gestation (P < 0.001) with no difference in fetal heart rate. Systolic and late diastolic TDVs for LV were significantly lower from 20 weeks' gestation and remained lower throughout pregnancy. Fetal interventricular septum was 26.6% (P < 0.001) thicker in late pregnancy in FOW compared with normal-weight pregnancies. CONCLUSIONS: At 14 weeks of gestation, we detected fetal myocardial dysfunction with reduced LV and RV GSR and strain in FOW compared with fetuses of women with normal weight. Our finding is alarming considering the high prevalence of obesity and may partly explain the predisposition of offspring to cardiovascular disease later in life.

Esophageal obstruction-prenatal detection rate and outcome.

OBJECTIVE: Prenatal diagnosis of esophageal obstruction is believed to improve the outcome for the affected newborn. However, the prenatal detection rate is only 10-40%, the diagnosis is usually not made before the third trimester and the false-positive rate has been high. This study investigated the prenatal detection rate and time of prenatal diagnosis at our center and its influence on outcome. In addition, incidence, detection rate and accuracy of the diagnosis in a large non-selected population were determined. METHODS: All cases diagnosed pre- or postnatally with esophageal obstruction and examined prenatally by ultrasound at the National Center for Fetal Medicine in Norway during 1987-2004 were evaluated. RESULTS: Of 48 cases with esophageal obstruction, 21 (44%) were diagnosed prenatally (median, 32 + 0 weeks). All 21 had a small or empty stomach, 20/21 (95%) had polyhydramnios and 9/21 (43%) had a visible esophageal pouch. Associated anomalies were present in 38/48 cases (79%). The karyotype was abnormal in 11/48 cases (23%). Ten (21%) pregnancies with lethal fetal conditions were terminated. Two fetuses died in utero. Ten infants with associated anomalies died within 3 months after birth. The 26/48 (54%) survivors included 16/21 cases with a prenatal diagnosis of esophageal obstruction and 9/10 cases with isolated esophageal obstruction. CONCLUSIONS: The clinical signs of polyhydramnios were the most important factors for prenatal detection of esophageal obstruction. Consequently, the time of diagnosis was late and the detection rate was low (44%). An increased awareness of the possibility of esophageal obstruction, leading to targeted examinations whenever the suspicion is raised during pregnancy, might improve the prenatal detection rate and thereby provide a possibility to improve the outcome. Of the cases with isolated esophageal obstruction, 90% survived, irrespective of prenatal diagnosis.

Imperforate anus: A relatively common anomaly rarely diagnosed prenatally.

OBJECTIVE: Despite the relatively common occurrence of imperforate anus, prenatal diagnosis is rarely reported. In this study, we investigated the presence and diagnosis of imperforate anus along with strategies for improving prenatal diagnosis of the condition. PATIENTS AND METHODS: Fetuses and infants with imperforate anus who had been examined prenatally by ultrasound at the National Center for Fetal Medicine (NCFM) from 1987 to 2004, were evaluated. RESULTS: Of 69 cases with imperforate anus, only 11 (15.9%) were diagnosed prenatally, at a median gestation of 18 + 4 (range, 15 + 6 to 35 + 6) weeks. In all 11, dilatations of the rectum or lower part of the bowel were seen. Additional anomalies, most of them diagnosed prenatally, were present in 59/69 (85.5%) of the cases. The most frequent additional anomalies were urogenital (53.6%). The karyotype was abnormal in nine cases (13.0%). A retrospective evaluation of available videotapes of 22 cases of imperforate anus that were not diagnosed prenatally revealed that it was possible to suspect the diagnosis in 11/22 (50%) cases. Sixteen infants were born with imperforate anus without prenatal diagnosis of any abnormality. In total, 31/69 (44.9%) cases were terminated, two (2.9%) died in utero and 12 (17.4%) died postnatally. Twenty-four (34.8%) infants survived, including all 10 with isolated imperforate anus and seven of eight cases with only one additional anomaly. CONCLUSIONS: The prenatal detection rate of imperforate anus was only 15.9%. Imperforate anus is often associated with other anomalies; in this study, 85.5% had additional anomalies. Prenatal diagnosis makes prenatal counseling possible and facilitates optimized postnatal care. We believe that the prenatal detection rate of imperforate anus could be improved. Examiners should intensify their search for typical findings of imperforate anus especially when other anomalies that frequently accompany this condition are present.

Characteristics and outcome of 90 cases of fetal omphalocele.

OBJECTIVE: The aim of this study was to describe the outcome of a case series of fetuses with omphalocele. METHODS: Ninety fetuses with omphalocele at the National Center for Fetal Medicine (NCFM) between January 1985 and January 2004 were followed from the time of prenatal diagnosis. Follow-up times ranged from 6 months to 17 years. Omphaloceles were subdivided into epigastric, central and hypogastric types based on their location on the abdominal wall. RESULTS: There were 58 central and 32 epigastric omphaloceles. Abnormal karyotype was found in 40/58 (69%) of the central and in 4/32 (12.5%) of the epigastric omphaloceles. Trisomy 18 was the most frequent abnormality associated with omphalocele. Among the fetuses with normal karyotype, 89% of the central and 71% of the epigastric cases had other anomalies. 38 (66%) of the fetuses with central omphalocele were terminated and 12 (21%) died during pregnancy or after delivery. 11 (34%) of the fetuses with epigastric omphalocele were terminated and eight (25%) died during pregnancy or after delivery. Of the 90 cases followed from the time of diagnosis there were 21 (23%) survivals. Of eight survivals with central omphalocele, only two were considered healthy while six had other anomalies and/or substantially impaired development. Of 13 survivals with epigastric omphalocele, six were considered healthy and seven had other anomalies and/or substantial impairment. CONCLUSIONS: Fetal central and epigastric omphaloceles may be different entities: central omphaloceles are more strongly associated with abnormal karyotype (69%) than are epigastric omphaloceles (12.5%). The outcome of fetuses with omphalocele is poor irrespective of the type of omphalocele, with only eight of the 90 (9%) being alive and healthy at present. The results emphasize the importance of identifying both those fetuses with a potentially good prognosis and favorable outcome and those which are likely to have a fatal outcome.

Surveillance and outcome of fetuses with gastroschisis.

OBJECTIVES: Infants with gastroschisis have a high survival rate. However, the rate (10-15%) of intrauterine fetal death (IUFD) is considerable, and the association with fetal distress is well known. The aim of this study was to describe the outcome of fetuses with a prenatal diagnosis of gastroschisis. The impact of correct prenatal diagnosis, surveillance and signs of complicating risk factors were evaluated. METHODS: All fetuses with prenatally diagnosed gastroschisis at the National Center for Fetal Medicine from January 1988 to August 2002 were registered and prospectively evaluated with regular ultrasound examinations. From 34-36 completed gestational weeks the fetuses were monitored daily to every second day with cardiotocography (CTG). RESULTS: Gastroschisis was diagnosed in 64 fetuses at a mean gestational age of 19 + 2 weeks. All had normal karyotype. Associated anomalies were found in four cases (6.3%). Three pregnancies (4.7%) were terminated, all for reasons other than gastroschisis. One fetus (1.6%) died in utero. Thirteen fetuses (22%) had abnormal CTG leading to subsequent Cesarean sections. Mean gestational age at delivery was 36 + 1 weeks. Mean birth weight was 2586 g. Thirteen infants (22%) were small for gestational age (SGA). In 15 cases (25%) meconium-stained amniotic fluid was found; 14 of these had abnormal CTG and/or were SGA. Small bowel atresia was found in four infants (6.7%). Four infants died postnatally at the age of 0-9 months. CONCLUSIONS: CTG surveillance of fetuses with gastroschisis may improve the outcome through detection of fetal distress thereby reducing the risk of IUFD. Other clinical situations of importance that are associated with gastroschisis are described and discussed.

Fetal duodenal obstructions: increased risk of prenatal sudden death.

OBJECTIVES: The aim of this study was to describe the outcome of fetuses with duodenal obstruction diagnosed prenatally and to compare the outcome with the results of studies of newborns. METHODS: All fetuses with a prenatal diagnosis of duodenal obstruction were registered and evaluated prospectively from January 1985 to December 2000. RESULTS: Duodenal obstruction was found in 29 fetuses at a mean gestational age of 29+2 weeks. Polyhydramnios was found in 24 cases (83%). Six fetuses (21%) had trisomy 21. Associated anomalies, including trisomy 21, were found in 18 cases (62%). Four fetuses with normal karyotype died in utero at 31-35 gestational weeks. Two of them had associated anomalies, but the anomalies could not explain the prenatal deaths and the deaths occurred suddenly and unexpectedly. Three infants died postnatally; all three had associated anomalies. Four infants with normal karyotype had neurological impairment suggesting that they might have had intrauterine asphyxia. CONCLUSIONS: The present study indicates that duodenal obstruction is a more serious condition than previously believed, with an increased risk of prenatal asphyxia and death, even when the karyotype is normal and no associated anomalies are present. We consider the possibility that it could be caused by bradycardia/asystole following vagal overactivity due to distension of the upper gastrointestinal tract.

Central arterial hemodynamics in small-for-gestational-age fetuses before and during maternal hyperoxygenation: a Doppler velocimetric study with particular attention to the aortic isthmus.

OBJECTIVE: Hemodynamic changes indicating a normalization of fetal blood flow redistribution during maternal oxygen administration have been suggested to be of positive prognostic value in growth-restricted fetuses. The aortic isthmus has been suggested as a site for early detection of blood flow redistribution as well as for verification of a response to maternal hyperoxygenation. The present study was performed to investigate whether this concept could be confirmed in a study involving fetuses assumed to have only a moderate disturbance in fetoplacental hemodynamics. DESIGN AND SUBJECTS: Twenty-five singleton fetuses with an estimated weight less than -2 SD below the gestational age-related mean and without any malformation or chromosomal aberration were studied between 27 and 38 (median 34) weeks of gestation. METHODS: Velocity waveforms from the mitral valve, aortic valve, middle cerebral artery, aortic isthmus and umbilical artery were recorded before and during maternal breathing of 100% oxygen. RESULTS: Nine fetuses demonstrated absent or reversed end-diastolic velocity (ARED) in the aortic isthmus while forward flow was present in the umbilical artery. The cerebral artery pulsatility index (PI) increased with oxygen administration and there was a decrease in the aortic isthmus PI. Variables obtained from the other recording sites did not change with maternal hyperoxygenation. CONCLUSIONS: ARED in the aortic isthmus appears to be an early sign of blood flow redistribution in this group of fetuses. Maternal oxygenation results in velocity waveform changes that suggest an increase of cerebral vascular resistance and a redistribution of blood from the brain to the vascular beds supplied by the descending aorta. The aortic isthmus is a suitable site to verify this response.