Evaluation and treatment of fetal arrhythmias

In a series of 31 cases referred for the evaluation of fetal arrhythmia, it was possible to identify the rhythm disturbance correctly using M-mode echocardiography. Cross-sectional echocardiography delineated structural abnormality where it occurred in association with an arrhythmia. Fifteen cases had premature atrial or ventricular contractions occurring in structurally normal hearts. These were not associated with perinatal mortality or morbidity in our series. Nine cases had complete heart block, three of which had structural cardiac anomalies. Seven cases were of atrial tachycardia, six were treated prenatally, one was delivered prematurely. Correct identification of an arrhythmia and appropriate prenatal therapy where indicated, was found to prevent unnecessary operative or premature deliveries.     

Diagnosis of Tetralogy of Fallot and Its Variants in the Late First and Early Second Trimester: Details of Initial Assessment and Comparison with Later Fetal Diagnosis

Objective: We sought to evaluate the completeness of echocardiographic diagnosis of fetal tetralogy of Fallot (fTOF) at 12–17 weeks gestation, and compare assessment and clinical outcomes to diagnoses made at >17 weeks gestation. Methods: We identified all fTOF diagnoses made in our experience from 2003 to 2008. Referral indication, anatomic detail by echocardiography and pregnancy outcomes were compared between fetuses diagnosed at ≤17 weeks (Group I) and >17 weeks gestation (Group II). A 10‐point scoring tool was applied retrospectively to the echocardiograms at initial diagnosis (1 point each was ascribed to visualization of right ventricular outflow obstruction, pulmonary valve, pulmonary arteries including dimensions, pulmonary arterial flow, systemic and pulmonary venous anatomy, atrioventricular valves, ductus arteriosus, ductus flow, aortic arch morphology, sidedness and flow). Results: There were 10 pregnancies in Group I (12–17 weeks) and 25 in Group II (mean gestation at diagnosis 23.5 ± 5.7). The most common reason for referral was extracardiac pathology in Group I (80%) and suspected fetal heart disease on obstetric ultrasound in Group II (64%). Transabdominal imaging was adequate in about half of Group I studies. Mean anatomic diagnosis score in Group I was 6.1(range 2.5–9) and Group II was 8.4 (range 6.5–10). Elective pregnancy termination occurred in 80% in Group I and 33% in Group II. Conclusions: fTOF can be diagnosed in first and early second trimesters with detailed anatomic assessment possible in most. Referral indication and pregnancy outcome differ considerably between early and later prenatal diagnosis of fTOF.     

Prenatal detection of critical cardiac outflow tract anomalies remains suboptimal despite revised obstetrical imaging guidelines

Background: Fetal echocardiography can accurately diagnose critical congenital heart disease prenatally, but relies on referrals from abnormalities identified on routine obstetrical ultrasounds. Critical congenital heart disease that is frequently missed due to inadequate outflow tract imaging includes anomalies such as truncus arteriosus, double outlet right ventricle, transposition of the great arteries, tetralogy of Fallot, pulmonary stenosis, and aortic stenosis.
Objective: This study evaluated the prenatal detection rate of critical outflow tract anomalies in a single urban pediatric hospital before and after “AIUM Practice Guideline for the Performance of Obstetric Ultrasound Examinations,” which incorporated outflow tract imaging.
Design: Infants with outflow tract anomalies who required cardiac catheterization and/or surgical procedure(s) in the first 3 months of life were retrospectively identified. This study evaluated two time periods; pre‐guidelines from June 2010 to May 2013 and post‐guidelines from January 2015 to June 2016. June 2013‐December 2014 was excluded as a theoretical period necessary for obstetrical practices to implement the revised guidelines.
Results: Overall, prenatal diagnosis occurred in 55% of infants with critical outflow tract anomalies; of the three most common defects, prenatal diagnosis occurred in 53% of D‐transposition of the great arteries, 63% of tetralogy of Fallot, and 80% of double outlet right ventricle patients. Pre‐guidelines, prenatal diagnosis occurred in 52% (52 of 102) infants with critical outflow tract anomalies requiring early cardiac intervention. Post‐guidelines, prenatal diagnosis occurred in 61% (33 of 54) infants, not significantly different than the prenatal detection rate pre‐guidelines (P = .31).
Conclusions: Despite revised obstetrical guidelines highlighting the importance of outflow tract imaging, referrals and prenatal diagnosis of these types of critical congenital heart disease remain low. Education of obstetrical sonographers and practitioners who perform fetal anatomic screening is vital to increase referrals and prenatal detection of critical outflow tract anomalies.     

Isozyme patterns in erythrocytes from human fetuses

Starch gel electrophoretic patterns of 26 enzymes (corresponding to 36 gene loci) were examined in hemolysates of erythrocytes from 11 first-trimester and midtrimester human fetuses (65-138 gestation days). The zymograms of 16 enzymes were identical in fetal and control adult red cells. Six enzymes (enolase, guanylate kinase, lactate dehydrogenase, nucleoside Phosphorylase, phosphofructokinase, hexokinase) showed differences in the staining intensity of certain isozyme zones as compared with the controls. Also, the fetal red cell zymograms, in contrast to those of adults, contained the mitochondrial forms of isocitric dehydrogenase and glutamic oxaloacetic transaminase as well as more definite zones of phosphoglucomutase-3. Finally, some of the isozymes of uridine diphosphate kinase in the fetal cells had slightly retarded mobility. These observed differences between fetal and adult red cells could reflect the expression of a different program of protein synthesis in red cells of the fetuses or the epigenetic modifications of isozymes in immature red cells.     

Introduction: From fetal echocardiography to fetal cardiology: A journey of over half a century

In this Special Issue of the Journal, 8 review articles that represent the new developments and applications of fetal echocardiography and fetal cardiology for diagnosis, prognosis, and treatment of fetal cardiovascular disease are included. The goal was to provide an updated review of the evidence for the current and emerging use of fetal echocardiography and cardiac magnetic resonance, improved diagnosis of challenging congenital heart disease, new tools for evaluation of fetal systolic and diastolic function, better prognosis and risk stratification of newborns with congenital heart diseases, and new and promising therapies for fetuses with cardiovascular disease.     

A case report of prenatal diagnosis of fetal alloimmune thrombocytopenia: A CARE-compliant article

Rationale:Fetal alloimmune thrombocytopenia (FAIT) is a serious life-threatening disease caused by platelet-antigen incompatibility between the mother and fetus. FAIT can lead to fetal thrombocytopenia, intracranial hemorrhage (ICH), fetal death and severe neurological disorders after birth. Noninvasive prenatal diagnosis technology has not been widely used in China, and thus few cases of FAIT can be diagnosed prenatally. In this study, we report a case of prenatal diagnosis and treatment of FAIT.Patient concerns:A 29-year-old female was admitted at 32 weeks’ gestational age (GA). Fetal ultrasound at 32 weeks’ GA showed a hemorrhagic focus area in the left lateral ventricle and the sign of severe fetal anemia. Hence, fetal umbilical cord puncture was ordered to identify the etiology.Diagnoses:The fetal cord blood test revealed a normal hemoglobin level but severe fetal thrombocytopenia (platelet count, 23 × 10⁹/L). Antibodies of human platelet antigens and human leukocyte antigens between mother and fetus were positive, and thus the diagnosis of FAIT was confirmed.Interventions:The patient refused intravenous immunoglobulin (IVIG) therapy owing to financial consideration. She was treated with dexamethasone acetate tablets (Xianju Company, China) 0.75 mg twice a day until delivery and cesarean section was performed at 34 weeks’ GA. The newborn received postnatal anti-platelet antibody treatment.Outcomes:The platelet count of the newborn progressively decreased until the third day after birth and it increased to normal level after postnatal treatment. The neonatal cerebral ultrasound showed the area of hemorrhage was in the process of absorption. During the postnatal one-year follow-up, the neonate showed normal developmental milestones and had no abnormal signs of neurological symptoms.Lessons:For FAIT, the fetal umbilical cord puncture can be carried out by skilled fetal medical teams. Dexamethasone acetate tablets can be an alternative choice for patients from underdeveloped areas.     

Fetal haemoglobin levels and haematological characteristics of compound heterozygotes for haemoglobin S and deletional hereditary persistence of fetal haemoglobin

Compound heterozygotes for sickle haemoglobin (HbS) and hereditary persistence of fetal haemoglobin (HPFH) have high fetal haemoglobin (HbF) levels but few, if any, sickle cell disease‐related complications. We studied 30 cases of HbS‐HPFH (types 1 and 2), confirmed by molecular analysis, and report the haematological features and change in HbF levels over time. These results were compared to those of patients with sickle cell anaemia or HbS‐β⁰ thalassaemia, including a subgroup of patients carrying the XmnI polymorphism, known to be associated with elevated HbF. Among the HbS‐HPFH patients, HbF level was 50–90% during infancy and declined steeply within the first few years of life, stabilizing between ages 3 and 5 years, at approximately 30%. Mean HbF of individuals age 5 or older was 31 ± 3%, average haemoglobin concentration was 130 ± 10 g/l and average mean corpuscular volume (MCV) was 75 ± 4 fl. Univariate and multivariate regression analyses significantly associated HbF with age, haemoglobin concentration, and MCV (P < 0·001). There was a strong inverse association between HbF and age (r = ?0·9, P < 0·001). Despite having a much higher HbF level, patients with HbS‐HPFH have a similar age‐related pattern of HbF decline and associations as patients with sickle cell anaemia or HbS‐β⁰ thalassaemia.     

Differential Diagnosis of Cardiac Malposition by Fetal Echocardiography

To explore the method and operating skill of fetal echocardiography in diagnosing cardiac malposition.Methods 91 consecutive fetuses were studied （control： 50 cases, cardiac malposition ： 41 cases） between 2003 and 2008. The position of fetal heart was evaluated according to the fetal posture and the visceral situs by fetal routine scan- ning. The detailed echocardiography should be performed in the differential diagnosis of cardiac lesions when the heart was found to be abnormal position. Results In the control group, all fetuses were levocardia. 39 cases of cardiac mal- positions were detected by fetal echocardiography, included 25 fetuses with dextrocardia, 6 mesocard, 5 with levover- sion of heart, 3 common heart of conjoined twins and 2 extrathorax heart. Two of dextroversion were missed by fetal routine scanning, but found by autopsy or operation after birth. Conclusions When the abnormal visceral situs was found by fetal routine scanning , there is exceedingly high incidence of cardiac malpositions. Proficiently operating skill of fetal echocardiography is helpful to detect abnormal fetal cardiac position. （ S Chin J Cardiol2009 ; 10 （1） ： 23 -25）     

4D fetal echocardiography—An update

With the introduction of the electronic 4‐dimensional and spatial‐temporal image Correlation (e‐STIC), it is now possible to obtain large volume datasets of the fetal heart that are virtually free of artifact. This allows the examiner to use a number of imaging modalities when recording the volumes that include two‐dimensional real time, power and color Doppler, and B‐flow images. Once the volumes are obtained, manipulation of the volume dataset allows the examiner to recreate views of the fetal heart that enable examination of cardiac anatomy. The value of this technology is that a volume of the fetal heart can be obtained, irrespective of the position of the fetus in utero, and manipulated to render images for interpretation and diagnosis. This article presents a summary of the various imaging techniques and provides clinical examples of its application used for prenatal diagnosis of congenital heart defects and abnormal cardiac function.     

进口与国产胎牛血清影响气道原代成纤维细胞生长的对比研究

目的：对比进口与国产胎牛血清(FBS)对气道原代成纤维细胞生长的影响。方法成功培养新西兰兔和 SD 大鼠原代气道成纤维细胞后,将细胞分为4组：A 组：大鼠气道原代成纤维细胞采用含20%进口 FBS 的高糖 DMEM 培养组,B 组：大鼠气道原代成纤维细胞采用含20%国产 FBS 的高糖DMEM 培养组,C 组：兔气道原代成纤维细胞采用含20%进口 FBS 的高糖 DMEM 培养组,D 组：兔气道原代成纤维细胞采用含20%国产 FBS 的高糖 DMEM 培养组。分别采用进口 FBS(Gibco 公司)、国产FBS(杭州四季青公司)进行培养原代气道成纤维细胞。倒置显微镜观察,细胞爬片后 HE 染色,MTS 法描绘生长曲线,流式细胞仪测量细胞周期,判定不同 FBS 培养气道原代细胞的效果差异。结果①采用进口 FBS 和国产 FBS 均能成功培养新西兰兔和 SD 大鼠原代气道成纤维细胞。②采用国产 FBS 培养原代气道成纤维细胞,效果略低于进口 FBS,但10代以内细胞生长良好,对实验无明显影响。结论国产FBS 可以替代进口 FBS 培养实验动物原代气道成纤维细胞,降低实验成本预算,产生一定经济效益。     

Role of prenatal echocardiography in the study of hypertrophic cardiomyopathy in the fetus

The increased incidence of hypertrophic cardiomyopathy in children of diabetic mothers has already been demonstrated, but its prenatal diagnosis has not yet been extensively studied. The purpose of this prospective study was to evaluate the frequency, severity, and echocardiographic features of fetal hypertrophic cardiomyopathy in a population with several indications for prenatal echocardiography. From March 1987 to April 1991, 283 fetuses were submitted to comprehensive prenatal echocardiography, including M-mode measurements, cross-sectional imaging, Doppler studies, and color flow mapping. One hundred seventy-six were pregnancies complicated by previous or gestational diabetes. The diagnosis of disproportionate septal hypertrophy was made in 39 fetuses (mean septal thickness 7.12 +/- 1.6 mm), at a mean gestational age of 32 weeks. Diabetes mellitus was present in 36 of these pregnancies (92.3%). In four cases, nonimmune hydrops was detected. A systolic anterior motion of the mitral valve was present in three fetuses, but only one showed a gradient across the left ventricular outflow tract. Postnatal echocardiographic examination in 27 babies did not show false positivity. In ten cases, spontaneous regression of the septal hypertrophy was shown. There were three neonatal deaths, unrelated to the myocardial disease. We concluded that transient hypertrophic cardiomyopathy is a frequent entity, especially when associated with diabetes during gestation, being a potential cause for nonimmune hydrops. Fetal echocardiography is the method of choice for its prenatal diagnosis and should always be indicated in diabetic mothers.     

Human fetal lung changes associated with maternal smoking during pregnancy

Pulmonary impairment in the offspring of smoking mothers is well documented by epidemiologic studies. The morphologic bases for the functional impairment are largely unexplored. We studied 17 infant lungs obtained at autopsy, ten from smoking (group 1) and seven from nonsmoking (group 2) mothers, by light (LM), transmission (TEM), and scanning electron microscopy (SEM). By LM, the alveolar mean linear intercept was similar in both groups; the total lung volume and alveolar surface area increased with the increase in gestational age in all lungs studied. By SEM, the sizes of the neuroepithelial bodies (NEB) were larger in group 1 than in group 2. By SEM and TEM, ciliated cells were increased, but the amount of dense core granules was decreased, in the NEB of the smoking group. Maternal smoking during pregnancy appears to alter the size and cellular composition of fetal NEB. The detailed mechanisms of the alteration in NEB and their implications are unclear from this study and needed further clarification.