The latest medical research on Radiology

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Screening for trisomies at 11-13 weeks' gestation: use of PAPP-A, PlGF or both.

Ultrasound in Obstetrics and Gynecology

Serum pregnancy associated plasma protein-A (PAPP-A) and placental growth factor (PlGF) at 11-13 weeks' gestation are reduced in pregnancies with fetal trisomies and in those that subsequently develop preeclampsia (PE). In screening for trisomies the established biochemical marker is PAPP-A, whereas in screening for PE the preferred marker is PLGF. The objective of this study is to examine the impact of replacing PAPP-A with PlGF in first-trimester screening for trisomies 21, 18 and 13 by maternal age, fetal nuchal translucency thickness (NT) and free β-human chorionic gonadotropin (hCG).

This is a prospective screening study in singleton pregnancies for trisomies 21, 18 and 13 by a combination of maternal age, fetal NT and serum PAPP-A and free β-hCG at 11-13 weeks' gestation in which we also measured PlGF. Multiple of the median (MoM) values were calculated for PAPP-A, free β-hCG and PlGF. The data set was randomly split into training and test data sets of roughly equal size and the parameters for PlGF obtained from the training data set were used in risk calculation for the test data set. Standardized detection rates were computed by obtaining the likelihood ratios for biochemistry and fetal NT for trisomy 21, trisomy 18 and trisomy 13 pregnancies in the sample and then applying these to each year of maternal age from 12 to 50 to estimate the age-specific detection rates. These were then weighted according to the maternal age distributions of trisomy 21, trisomy 18 and trisomy 13 pregnancies in England and Wales in 2018. Similarly, standardized false positive rates (FPR) were computed by obtaining the likelihood ratios for biochemistry and NT, as appropriate, in normal pregnancies in the sample and then applying these to each year of maternal age from 12 to 50 to estimate the age-specific FPRs. A modelling approach was used to assess the performance of screening according to gestational age at biochemical testing.

The study population of 71,266 pregnancies, included 70,858 (99.4%) with normal fetal karyotype or birth of a phenotypically normal neonate and 263 with trisomy 21, 109 with trisomy 18 and 36 with trisomy 13. There are five main findings of this study. First, the performance of screening for trisomies by the first-trimester combined test or the combined test whereby PAPP-A is replaced by PLGF is substantially better at 11 than at 13 weeks' gestation; for example, the detection rates of trisomy 21 by the combined test were 94%, 90% and 84%, at 5% FPR, when testing was carried out at 11, 12 and 13 weeks and the respective values in screening by a test whereby PAPP-A is replaced by PLGF were 90%, 87% and 86%. Second, in trisomy 21 pregnancies the deviation of median MoM PAPP-A from normal decreases with increasing gestational age, whereas the deviation in PLGF does not change with gestational age. Third, the performance of screening for trisomy 21 during the 11th and 12th gestational week is superior if screening includes PAPP-A rather than PlGF, whereas during the 13th week the performance is slightly higher with the use of PlGF over PAPP-A. Fourth, in our population with mean gestational age at testing of 12.7 weeks screening by maternal age, fetal NT, serum free β-hCG and serum PAPP-A predicted 88%, 96% and 97% of fetal trisomies 21, 18 and 13, respectively, at FPR of 5%; the respective values in screening by a test whereby PAPP-A is replaced by PLGF were 85%, 96% and 96%. Fifth, addition of serum PlGF does not improve the prediction of trisomies provided by maternal age, fetal NT and serum free β-hCG and PAPP-A.

In first trimester screening for trisomies the preferred biochemical marker is PAPP-A rather than PlGF, especially when biochemical testing is carried out during the 11th week of gestation or earlier. However, if PlGF was to be used rather than PAPP-A the same detection rate can be achieved but at a higher FPR. This may be an acceptable compromise to minimize cost and achieve effective screening for both trisomies and PE. This article is protected by copyright. All rights reserved.

Ultrasound diagnosis of endometrial cancer by subjective pattern recognition in women with postmenopausal bleeding: a prospective inter-rater agreement and reliability study.

Ultrasound in Obstetrics and Gynecology

The objective of our study was to assess the inter-rater agreement and reliability of using subjective pattern recognition to diagnose endometrial cancer on ultrasound in women with postmenopausal bleeding.

This was a prospective cross-sectional study at a gynaecological rapid access clinic, between Oct 2016 - Dec 2017, where consecutive women with postmenopausal bleeding and endometrial thickness of ≥4.5mm on transvaginal ultrasound scan were included. We excluded women on hormone replacement therapy, tamoxifen or with a history of primary gynaecological malignancy. Two raters independently performed ultrasound examinations, blinded to each other's findings, and classified women into having uniformly thickened endometrium, benign polyp or endometrial cancer, by subjective pattern recognition. Inter-rater reliability of the ultrasound diagnoses was assessed by using Cohen's kappa statistics. All women subsequently underwent either outpatient endometrial biopsy, hysteroscopy or hysterectomy.

Forty women were included in the study with a median age of 61 (IQR 57-69) and a median endometrial thickness of 11.0mm (IQR 6.2-20.3). Final histological analysis confirmed 16 (40%) women with endometrial cancer, 16 (40%) endometrial polyps, 4 (10%) atrophic endometrium, 3 (7%) proliferative endometrium and 1 (3%) endometrial hyperplasia. Inter-rater agreement for the ultrasound diagnoses of uniformly thickened endometrium, polyp and cancer, were 14/16 (87.5%), 22/30 (73.3%) and 28/34 (82.4%), respectively; the inter-rater reliability was good (κ = 0.69, 95% C.I. 0.49-0.88). When the ultrasound diagnoses were combined as either cancer or no cancer, the inter-rater agreement was 85% and the inter-rater reliability was also good (κ = 0.78, 95% C.I. 0.61-0.95). Rater A correctly identified 14/16 cancers and Rater B identified 15/16. Endometrial cancers were misdiagnosed as benign polyps on ultrasound in two women by Rater A, and in one woman by Rater B. The overall accuracies of Rater A and Rater B in differentiating between benign endometrial pathologies and malignancy were 90% and 85%, respectively.

Our results showed good inter-rater reliability of subjective pattern recognition in diagnosing uniformly thickened endometrium, polyp and cancer on ultrasound in women with postmenopausal bleeding. Our findings should facilitate wider use of subjective pattern recognition in routine clinical practice. This article is protected by copyright. All rights reserved.

Fetal aortic valvuloplasty may rescue fetuses with critical aortic stenosis and hydrops.

Ultrasound in Obstetrics and Gynecology

Critical aortic stenosis (CAS) with a restrictive interatrial septum may lead to fetal congestive heart failure and hydrops, usually leading to fetal demise if left untreated. The aim of this study was to assess the effects of fetal aortic valvuloplasty on hemodynamics and outcome in these patients.

A retrospective review for fetuses with CAS and signs of hydrops undergoing fetal aortic valvuloplasty (FAV) in our center since 2000 was performed. Echocardiograms and patient's charts were analysed for ventricular and valvular dimensions as well as for outcome.

Since 2000, hydrops was present in 15 fetuses with CAS at the time of FAV. All but one had at least 1 technical successful procedure. There were no procedure related deaths, but 3 intrauterine deaths. Twelve patients were live born. Two patients died within 24 hours after birth due to persistent hydrops. Ventricular function improved and hydrops resolved in 71% of the fetuses within 3-4 weeks after a technical successful intervention. A biventricular outcome was achieved in 50% of successfully treated patients.

Fetuses with CAS and hydrops can be successfully treated with FAV. It has the potential to restore a sufficient fetal cardiac output, which may lead to resolution of hydrops. Surviving patients seem to be good candidates for a biventricular outcome. This article is protected by copyright. All rights reserved.

Optimal gestational age at delivery for congenital diaphragmatic hernia.

Ultrasound in Obstetrics and Gynecology

To evaluate the neonatal morbidity and mortality of babies with isolated congenital diaphragmatic hernia (CDH) according to gestational age at delivery.

We conducted a retrospective study in the University Hospitals of Antoine Béclère-Bicêtre and Leuven between January 1, 2010 and December 31, 2018. Isolated left-sided CDH cases were included. The Kaplan-Meier method was used to calculate cumulative survival at 28 days according to gestational age at delivery. The association between gestational age at delivery, as a continuous variable, and survival at 28 days was modeled using a fractional polynomial. Adjustment for position of the liver, management center, and mode of delivery was performed. The association was studied according to the severity of the CDH, defined by the o/e LHR, categorized in three classes: below 25%, between 25 and 45%, above 45%.

We included 213 fetuses with isolated left-sided CDH, with a median gestational age at delivery of 38+2 WG [IQR: 37+0 -39+6 ]. Survival rates at 28 days and 6 months were 66.7% (142/213) and 64.3% (137/213), respectively. Kaplan-Meier curves showed higher survival up to 28 days for babies born between 37+0 and 39+0 WG than for those born after 39+0 WG (log-rank test, p<.001). In the subgroup of moderate forms, the survival rates at 28 days and 6 months were significantly higher for newborns delivered between 37+0 and 39+0 WG, compared to newborns delivered after 39+0 WG: 81.5% vs 61.5% (p=0.03). In this subgroup, 28-day survival significantly increased with advancing gestational age at birth until 38-39 WG (p=0.005) and significantly decreased from 39 WG.

Delivery between 37+0 and 39+0 WG is associated with a higher survival rate at 28 days of life for moderate forms independently of intrathoracic liver, management center, and mode of delivery. This article is protected by copyright. All rights reserved.

New device permitting non-invasive reversal of fetoscopic tracheal occlusion: ex-vivo and in-vivo study.

Ultrasound in Obstetrics and Gynecology

One of the drawbacks of fetoscopic endoluminal tracheal occlusion for congenital diaphragmatic hernia is the need for a second invasive intervention to reestablish airway patency. The "Smart-TO" (Strasbourg University-BSMTI, France) is a new balloon for endoluminal tracheal occlusion, which spontaneously deflates when placed in a strong magnetic field, therefore overcoming the need of a second procedure. The safety and efficacy of this device has not been demonstrated. This study investigates the reversibility, local side effects, and occlusiveness of the Smart-TO both in a simulated in-utero environment as well as in the fetal lamb model.

First, reversibility was tested in a high-fidelity simulator. Following videoscopic tracheoscopic balloon insertion, the mannequin was placed within a 1L water-filled balloon to mimic the amniotic cavity. This was held by an operator in front of the abdomen in different fetal and maternal positions to mimic the most common clinical scenarios. Following exposure to the magnetic field generated by a 1.5T magnetic resonance (MR) machine, deflation was assessed by tracheoscopy. In case of failed deflation, the mannequin was reinserted into a water-filled balloon for additional MR exposure, up to maximum three times. Secondly, reversibility, occlusiveness, and local effects were tested in-vivo in fetal lambs. Tracheal occlusion was performed in fetal lambs on gestational day (GD) 95 (term=145), either with the balloon currently clinically used (Goldbal2, Balt, Montmorency, France) (n=5) or the Smart-TO balloon (n=5). On GD116, the presence of the balloon was assessed by tracheoscopy. Deflation was performed by puncture (Goldbal2) or by MR exposure (Smart-TO). Six unoccluded lambs served as controls. Following euthanasia, the lung-to-body-weight-ratio, lung morphometry, and tracheal circumference were assessed. Local tracheal changes were measured using a hierarchical histologic scoring system.

Ex-vivo, balloon deflation occurred after a single MR exposure in 100% of cases in standing position with the mannequin at 95 (n=32), 55 (n=8), and 125 (n=8) cm height. The deflation rate at first exposure was 100% when lying on a stretcher (n=8). Three out of eight balloons (37.5%) failed to deflate at first exposure when sitting in a wheelchair. Of these, two balloons deflated after a second exposure. One balloon remained inflated after a third exposure. In-vivo, all Smart-TO balloons deflated successfully. The LBWR was significantly higher than controls and comparable for the two balloon types. There were no differences in lung morphometry and tracheal circumference. Tracheal histology showed minimal changes for both balloons.

The Smart-TO balloon was effectively deflated by exposure of the fetus in different positions to a 1.5T-MR system. There was only one failure, i.e., when the mother was sitting in a wheelchair. In healthy fetal lambs, the balloon is as occlusive as the clinical standard Goldbal2 system and has only limited local side effects. This article is protected by copyright. All rights reserved.

Competing risks model for prediction of small-for-gestational-age neonates from maternal characteristics and medical history.

Ultrasound in Obstetrics and Gynecology

The established method of identifying a group of women at high-risk of delivering SGA neonates, requiring increased surveillance, is use of risk scoring systems based on maternal demographic characteristics and medical history. Although this approach is relatively simple to perform, it does not provide patient-specific risks and has an uncertain performance of predicting SGA. Another approach to predict delivery of SGA neonates is to use logistic regression models that combine maternal factors with first-trimester biomarkers. These models provide patient-specific risks for different pre-specified cut-offs of birth weight percentile and gestational age at delivery.

First, to develop a competing risks model for prediction of SGA based on maternal demographic characteristics and medical history in which gestational age at the time of delivery (GA) and birth weight z - scores (Z) are treated as a continuous variables. Second to compare the predictive performance of the new model for SGA neonates to that of previous methods.

This was a prospective observational study in 124,443 women with singleton pregnancies undergoing routine ultrasound examination at 11+0 - 13+6 weeks' gestation. The dataset was randomly divided into a training and a test dataset. The training dataset was used to develop a model for the joint distribution of GA and Z from variables of maternal characteristics and medical history. This patient specific joint Gaussian distribution of GA and Z allows risk calculation for SGA defined in terms of different birth weight percentiles and gestational age. The new model was then validated in the test dataset to assess performance of screening and we compared its' predictive performance to that of logistic regression models for different SGA definitions.

In the new model the joint Gaussian distribution of GA and Z is shifted to lower GA and Z values, resulting in an increased risk for SGA, by lower maternal weight and height, Black, East Asian, South Asian and Mixed racial origin, medical history of chronic hypertension, diabetes mellitus and systemic lupus erythematosus or antiphospholipid syndrome, conception by in vitro fertilization or ovulation induction and smoking. For parous women variables from the last pregnancy that increased the risk for SGA were history of preeclampsia or stillbirth, decreasing birth weight z-score and decreasing gestational age at delivery of the last pregnancy and inter-pregnancy interval <0.5 years. In the test dataset, at a screen positive rate of 10%, the new model predicted 30.1%, 32.1%, 32.2% and 37.8% of cases of SGA neonates with birth weight <10th percentile delivered at <42, <37, <34 and <30 weeks' gestation, respectively, which were similar or higher to the respective values achieved by a series of logistic regression models. The calibration study demonstrated good agreement between the predicted risks and the observed incidence of SGA in both the training and test datasets.

A new competing risks model, based on maternal characteristics and medical history, provides estimation of patient-specific risks for SGA in which GA and Z are treated as a continuous variables. Such estimation of the a priori risk for SGA is an essential first step in the use of Bayes theorem to combine maternal factors with biomarkers for the continuing development of more effective methods of screening for SGA. This article is protected by copyright. All rights reserved.

Frontal lobe growth is impaired in fetuses with congenital heart disease.

Ultrasound in Obstetrics and Gynecology

The primary objective of this study is to assess whether foetuses with congenital heart disease (CHD) have smaller frontal brain areas than normal controls. Secondary objective is to evaluate whether there is any difference among CHD with different haemodynamics.

Retrospective cross-sectional study, including 421 normal foetuses and 101 fetuses with isolated CHD. The study group was subdivided according to the CHD haemodynamics into the following subcategories: 1) Hypoplastic left heart syndrome (HLHS) and other forms of functionally univentricular heart defects; 2) Transposition of the Great Arteries; 3) conotruncal defects and other CHDs with large shunts; 4) right ventricular outflow tract obstruction, without a hypoplastic right ventricle; 5) left outflow tract obstruction; 6) others. The transventricular axial view of the fetal head was used as reference view, on which the Frontal Antero-Posterior Diameter (FAPD) and the Occipito-Frontal Diameter (OFD) were measured, assuming the former as representative of the frontal lobes' area. The FAPD/OFD ratio was then calculated (FAPD/OFD*100). These two variables (FAPD and FAPD/OFD Ratio) were then evaluated in the study and control group. Statistics included Kruskal-Wallis and Mann-Whitney U tests for two groups' comparison. Adjustment for gestational age both via multiple linear regression model and by using the a posteriori matching based on the propensity score was also employed.

In normal foetuses, FAPD showed a linear positive correlation with gestational age. In foetuses with CHD, the FAPD was shorter than in normal foetuses at all gestational ages, with the difference increasing after 30 gestational weeks. The FAPD/OFD Ratio was significantly lower in foetuses with CHD than in normal foetuses (p < 0.0001) at all gestational ages, with no differences among the various CHD categories, which all showed lower FAPD/OFD Ratios than normals (p < 0.0001).

Fetuses with CHD show a shorter FAPD and a lower FAPD/OFD than normal foetuses. This impaired growth of the frontal area of the brain seems to occur in all types of CHD, regardless of their haemodynamics. This article is protected by copyright. All rights reserved.

Perinatal outcome of monochorionic diamniotic twins complicated by selective intrauterine growth restriction according to the umbilical artery Doppler flow pattern: a single-center study using a strict fetal surveillance protocol.

Ultrasound in Obstetrics and Gynecology

To determine the perinatal outcome of monochorionic diamniotic (MCDA) twins complicated by selective intrauterine growth restriction (sIUGR) according to the umbilical artery (UA) Doppler flow pattern of the IUGR twin.

A retrospective cohort study of all MCDA twin pregnancies diagnosed with sIUGR and managed at a single tertiary referral center between the years 2012-2018. Cases were classified according to the UA Doppler flow pattern of the IUGR twin: Type I (positive end-diastolic flow), Type II (persistently absent/reversed end-diastolic flow) or Type III (intermittently absent/reversed end-diastolic flow). Patients with sIUGR Type II or III were hospitalized at 26-28 weeks of gestation for increased fetal surveillance. Perinatal outcomes and immediate and long-term neurodevelopmental outcomes were stratified according to the UA Doppler flow pattern at the final examination. Intact survival rate was defined as the number of infants surviving without neurological impairment, divided by the total number of fetuses. A composite adverse outcome, defined as any mortality, the presence of severe brain lesions on postnatal transcranial ultrasound or severe neurological morbidity, was also assessed.

Of 88 MCDA twin pregnancies included in the study, 28 underwent selective termination by cord occlusion using radiofrequency ablation, resulting in a perinatal survival rate of 89.3% and a median gestational age (GA) at delivery of 33.8 (IQR 28.8-38.2) weeks. Expectant management was employed in 60 cases. In 26 (43.3%) cases, the classification according to the UA Doppler flow pattern had changed during gestation, resulting in 26 (43%) cases of Type I, 22 (36%) cases of Type II and 12 (20%) cases of Type III at the final examination. The perinatal survival rate of both twins with sIUGR Type I, II and III at the final examination was 100%, 82% and 75%, respectively (P=0.04). 2 cases of double fetal death and one case of single fetal death occurred 1-4 weeks after the Doppler pattern had changed from Type I or Type II to Type III. The median GA at delivery was 34.8 (IQR 33.1-35.7) weeks in Type I, 30.3 (IQR 28.6-32.1) weeks in Type II and 32 (IQR 31.3-32.6) weeks in Type III (P<0.01). The total intact survival rate was 100% for Type I, 77.3% for Type II and 75% for Type III (P<0.001). Multivariate analysis demonstrated that early gestational age at onset of disease [odds ratio 0.83 (95% CI 0.69-0.99); P=0.04] and the presence of type II or III vs type I at final examination [odds ratio13.16 (95% CI 1.53-113.32) ;P=0.02] were associated with preterm birth < 32 weeks. Early gestational age at onset of disease was also associated with the composite adverse outcome [0.60 (95% CI 0.36-0.99); P=0.04].

The classification system of MCDA twins complicated by sIUGR according to the UA Doppler flow pattern of the IUGR twin at final examination is correlated with perinatal outcome. Importantly, the UA Doppler flow pattern can change during gestation, which has an impact on the risk of fetal death. Nevertheless, under strict fetal surveillance, the perinatal outcome of these pregnancies is favorable. This article is protected by copyright. All rights reserved.

Fetal cerebral Doppler changes and outcome in late preterm fetal growth restriction: prospective cohort study.

Ultrasound in Obstetrics and Gynecology

To explore the association between fetal umbilical and middle cerebral artery (MCA) Doppler abnormalities and outcome in late preterm pregnancies at risk of fetal growth restriction.

This was a prospective cohort study of singleton pregnancies at risk of fetal growth restriction at 32 + 0 to 36 + 6 weeks of gestation, enrolled in 33 European centers between 2017 and 2018, in which umbilical and fetal MCA Doppler velocimetry was performed. Pregnancies were considered at risk of fetal growth restriction if they had estimated fetal weight and/or abdominal circumference (AC) < 10th centile, abnormal arterial Doppler and/or a fall in AC growth velocity of more than 40 centile points from the 20-week scan. Composite adverse outcome comprised both adverse immediate birth outcome and major neonatal morbidity. Using a range of cut-off values, the association of MCA pulsatility index and umbilicocerebral ratio (UCR) with composite adverse outcome was explored.

The study population comprised 856 women. There were two (0.2%) intrauterine deaths. Median gestational age at delivery was 38 (interquartile range (IQR), 37-39) weeks and birth weight was 2478 (IQR, 2140-2790) g. Compared with infants with normal outcome, those with composite adverse outcome (n = 93; 11%) were delivered at an earlier gestational age (36 vs 38 weeks) and had a lower birth weight (1900 vs 2540 g). The first Doppler observation of MCA pulsatility index < 5th centile and UCR Z-score above gestational-age-specific thresholds (1.5 at 32-33 weeks and 1.0 at 34-36 weeks) had the highest relative risks (RR) for composite adverse outcome (RR 2.2 (95% CI, 1.5-3.2) and RR 2.0 (95% CI, 1.4-3.0), respectively). After adjustment for confounders, the association between UCR Z-score and composite adverse outcome remained significant, although gestational age at delivery and birth-weight Z-score had a higher predictive importance.

In this prospective multicenter study, fetal cerebral Doppler abnormalities were found to be associated with adverse outcome in late preterm singleton pregnancies at risk of fetal growth restriction. Whether cerebral redistribution is a marker describing the severity of fetal growth restriction or an independent risk factor for adverse outcome remains unclear, and whether it is useful for clinical management can be answered only in a randomized trial. This article is protected by copyright. All rights reserved.

The earlier the better or the later the better: optimal timing of fetal reduction from twins to singleton.

Ultrasound in Obstetrics and Gynecology

The aim of this study was to compare pregnancy complications, obstetric and neonatal outcomes of twin pregnancies that were reduced to singletons at early versus later gestational age.

From January 2005 through February 2017, 248 dichorionic diamniotic twin pregnancies underwent reduction to singleton in a single tertiary referral center. Fetal reductions performed at 11-14 weeks' gestation were mainly done at the patient's request or as a result of a complicated medical or obstetric history (early reduction, n=172). Selective reduction performed at 15-23 weeks were for structural or genetic anomalies (late reduction, n=76). Main outcome measures compared between early and late reductions included rates of pregnancy complications, pregnancy loss, preterm delivery and neonatal outcomes.

Although the gestational age at delivery was not significantly different between early and late reduction of twins (39, IQR 38-40 weeks vs. 38, IQR 36-40 weeks, respectively, P=0.2), the rates of preterm delivery were significantly higher in late reduction before 37 weeks (28.0% vs. 14.0%, p=0.004), 34 weeks (12.0% vs. 1.8%, p=0.001) and 32 weeks' gestation (8.0% vs. 1.8%, p=0.012). Regression analysis revealed that late reduction of twins was an independent risk factor for preterm delivery, after adjustment for maternal age, parity, BMI and the location of the reduced sac. There was no significant difference in the rate of pregnancy loss before 24 weeks (0.6% in early reduction vs. 1.3% in late reduction, p=0.52) and no cases of intrauterine fetal death after 24 weeks were documented. There was no significant difference in the prevalence of gestational diabetes, hypertensive disorders of pregnancy, preterm premature rupture of membranes and intra-uterine growth restriction. The rates of respiratory distress syndrome, exposure to mechanical ventilation and composite neonatal morbidity were higher in the late reduction group (RDS: 6.7% vs. 0%, p=0.002, mechanical ventilation: 6.7% vs. 0.6%, p=0.01, composite morbidity: 10.7% vs. 2.9%, p=0.025). Other neonatal outcomes were comparable between the groups.

Second trimester reduction of twins is associated with an increased rate of prematurity and adverse neonatal outcomes compared with late first trimester reduction, without increasing the procedure-related complications. Technological advances in earlier sonographic diagnosis and more frequent use of CVS have allowed earlier detection of fetal anatomic and chromosomal abnormalities. Therefore, efforts should be made to complete early fetal assessment to allow reduction during the first trimester. This article is protected by copyright. All rights reserved.

Introduction to artificial intelligence in ultrasound imaging in obstetrics and gynecology.

Ultrasound in Obstetrics and Gynecology

Artificial intelligence (AI) uses data and algorithms to aim to draw conclusions as good as humans (or even better). AI is already a part of our da...

Maternal cardiac function in gestational diabetes mellitus at 35-36 weeks' gestation and after six months postpartum.

Ultrasound in Obstetrics and Gynecology

Women with gestational diabetes mellitus (GDM) are at increased risk for adverse cardiovascular outcome later in life. However, it is uncertain whether this increased risk is due to cardiovascular changes occurring during pregnancy and persisting thereafter or to an adverse underlying cardiovascular risk factor profile. Few studies have reported that GDM is associated with reduced systolic and diastolic left ventricular function in pregnancy however it remains unknown whether these changes persist after delivery. The objective of this study is to compare maternal cardiac function and structure in women with GDM and those with uncomplicated pregnancy at 35-36 weeks' gestation and about six months after delivery.

This is a longitudinal study where women with GDM and those with uncomplicated pregnancy had detailed cardiovascular assessment at 35-36 weeks' gestation and repeat examination around six months after delivery. In all women, left ventricular systolic and diastolic indices were measured and left ventricular mass indexed for body surface area was calculated. Cardiac output and peripheral vascular resistance were also calculated using echocardiography. Linear mixed model analysis accounting for differences in maternal characteristics was carried out to compare findings in cardiovascular function between the GDM group and controls and within each group at 35-36 weeks' gestation and at six months after delivery.

We studied 73 women with GDM and 73 controls with uncomplicated pregnancies. At 35-36 weeks' gestation, women with GDM, compared to controls, had higher E/e' ratio and lower E/A ratio and global longitudinal systolic function; there were no significant differences between the groups in ejection fraction and myocardial performance index. Left ventricular mass indexed for body surface area was also increased in GDM women. There were no significant differences between the groups in cardiac output and peripheral vascular resistance. At one year after delivery, cardiac functional indices improved for both the GDM patients and controls, but in the GDM group, compared to controls, there was a lower degree of improvement in E/A ratio and global longitudinal systolic function.

In the third trimester, GDM patients have subtle differences in diastolic and systolic left ventricular function compared to controls and despite improvement after delivery, these changes persist for at least six months. Long term follow up therefore is needed to assess whether GDM women are at risk for an accelerated decline in their cardiac function and if so whether this trend can be reversed or delayed by optimal cardiovascular risk factor modification. This article is protected by copyright. All rights reserved.