Antônio Piccoli

Myocardial tissue Doppler assessment of diastolic function in the growth-restricted fetus

Myocardial tissue Doppler (MTD) is a technique for the measurement of myocardial velocities in systole and diastole. This study evaluates the use of MTD in the assessment of cardiac diastolic function in fetuses with intrauterine growth restriction (IUGR) with placental insufficiency and in appropriate‐for‐gestational age (AGA) fetuses with hypertensive mothers.

Myocardial hypertrophy and dysfunction in maternal diabetes.

Diabetes in pregnancy, both pre-gestational and gestational, is a frequent cause of fetal myocardial hypertrophy, partly due to fetal hyperinsulinism. In fetal life, cardiac function may be impaired, especially during diastole, as a result of decreased left ventricular distensibility and altered left atrial dynamics secondary to myocardial hypertrophy. In neonates, the hypertrophy is a transient disorder, with spontaneous regression of the increased myocardial thickness during the first months of life. Nevertheless, cardiac hypertrophy may be associated with neonatal cardiomegaly and respiratory distress secondary to poor left ventricular compliance. The development of a number of new echocardiographic parameters discussed in this article, and primarily based on the pathophysiological consequences of myocardial hypertrophy, highlight an area of research priority: the assessment of diastolic function in fetuses of diabetic mothers with (and without) myocardial hypertrophy. A score for grading the severity of fetal diastolic dysfunction in these fetuses is proposed.

Alternative parameters for echocardiographic assessment of fetal diastolic function

Alternative methods to assess ventricular diastolic function in the fetus are proposed. Fetal myocardial hypertrophy in maternal diabetes was used as a model of decreased left ventricular compliance (LVC), and fetal respiratory movements as a model of increased LVC. Comparison of three groups of fetuses showed that, in 10 fetuses of diabetic mothers (FDM) with septal hypertrophy (SH), the mean excursion index of the septum primum (EISP) (ratio between the linear excursion of the flap valve and the left atrial diameter) was 0.36 +/- 0.09, in 8 FDM without SH it was 0.51 +/- 0.09 (P=0.001), and in the 8 normal control fetuses (NCF) it was 0.49 +/- 0.12 (P=0.003). In another study, 28 fetuses in apnea had a mean EISP of 0.39 +/- 0.05 which increased to 0.57 +/- 0.07 during respiration (P<0.001). These two studies showed that the mobility of the septum primum was reduced when LVC was decreased and was increased when LVC was enhanced. Mean pulmonary vein pulsatility was higher in 14 FDM (1.83 +/- 1.21) than in 26 NCF (1.02 +/- 0.31; P=0.02). In the same fetuses, mean left atrial shortening was decreased (0.40 +/- 0.11) in relation to NCF (0.51 +/- 0.09; P=0.011). These results suggest that FDM may have a higher preload than normal controls, probably as a result of increased myocardial mass and LV hypertrophy. Prenatal assessment of LV diastolic function by fetal echocardiography should include analysis of septum primum mobility, pulmonary vein pulsatility, and left atrial shortening.

New insights on fetal ductal constriction: role of maternal ingestion of polyphenol-rich foods

Fetal ductus arteriosus constriction is a clinical disorder that occurs as a result of inhibition of the prostaglandin synthesis pathway, and has long been associated to maternal intake of nonsteroidal anitiinflammatory drugs in late pregnancy. As a consequence of an increased right ventricular pressure, with tricuspid regurgitation and heart failure, there is a risk for the development of neonatal pulmonary artery hypertension. This artcile reviews the basic knowledge of the mechanisms involved in this important disorder. Clinical and experimental evidence that maternal consumption of polyphenol-rich substances, such as herbal teas, orange and grape juice, chocolate, and others, may interfere with fetal ductus arteriosus dynamics are discussed. Preventive measures to avoid fetal ductal constriction in the third trimester of pregnancy are discussed, including the possible need to change maternal dietary orientation, aiming to limit ingestion of foods with high concentrations of polyphenol-rich substances.

Pulsatilidade venosa pulmonar em fetos de mães diabéticas: estudo doppler-ecocardiográfico pré-natal

OBJECTIVE To verify the hypothesis that the pulmonary vein pulsatility index is higher in fetuses of diabetic mothers than it is in normal fetuses of nondiabetic mothers. METHODS Twenty-four fetuses of mothers with either gestational or previous diabetes (cases), and 25 normal fetuses of mothers without systemic disease (control) were examined. Fetuses were examined through prenatal Doppler and color flow mapping. The pulmonary vein pulsatility index was obtained by placing the pulsed Doppler sample volume over the right superior pulmonary vein and applying the formula (systolic velocity - presystolic velocity)/mean velocity. RESULTS The mean gestational age of the study fetuses was 30.3 2.7 weeks, and gestational age of the controls was 29 3.3 weeks, with no significant difference in gestational age between groups (p=0.14). Fetuses of diabetic mothers had a mean pulmonary vein pulsatility index of 1.6 1, and those of the control group had an index of 0.86 0.27. CONCLUSION Fetuses of diabetic mothers had pulmonary vein pulsatility indexes (parameter easily obtained through Doppler echocardiography that may be related to fetal diastolic function) higher than those in fetuses of mothers with normal glycemia.

Development and validation of a food frequency questionnaire for consumption of polyphenol‐rich foods in pregnant women

Previous studies have shown that maternal consumption of polyphenol-rich foods after the third trimester of pregnancy may interfere with the anatomical and functional activity of the fetal heart as, to our knowledge, there are no validated instruments to quantify total polyphenols in pregnant women. The aim of this study was evaluate the reproducibility and validity of a food frequency questionnaire (FFQ), with 52 items, to assess the intake of polyphenol-rich foods in pregnant women in Brazil. This cross-sectional study included 120 pregnant women who participated in nutritional interviews in two moments. The intake of polyphenols estimated by the developed FFQ was compared with the average of two 24-h recalls (24HR), with the average intake measured by a 3-day food diary (D3days) and with the urinary excretion of total polyphenols. The triangular method was applied to calculate Pearsons correlation coefficients, intraclass correlation and Bland-Altman plots for the FFQ, using an independent biochemical marker, in addition to classification by quarters of consumption. The questionnaires were log transformed, adjusted for body mass index and gestational age. The adjustment for energy was applied only of 24HR and D3days. Analysis of the reproducibility between the FFQ showed a very high correlation (r = 0.72; P < 0.05). A low but significant association was observed between the FFQ and urinary excretion (0.23; P = 0.01). The association between the dietary survey methods was moderate to very high (r = 0.36 to r = 0.72; P < 0.001). In conclusion, this questionnaire showed reproducibility and validity for the quantification of consumption of total polyphenols in pregnant women.

Left atrial shortening fraction in fetuses with and without myocardial hypertrophy in diabetic pregnancies

To test the hypothesis that, in diabetic pregnancies, left atrial shortening fraction (LASF) is decreased in fetuses with myocardial hypertrophy, compared to those without hypertrophy and to fetuses of non‐diabetic mothers.

Fluxo no ducto venoso e hipertrofia miocárdica em fetos de mães diabéticas

OBJECTIVE To test the hypothesis that the pulsatility index of ductus venosus (PIDV) is greater in the fetuses of diabetic mothers (FDM) with myocardial hypertrophy (MH) than in the FDM with no MH and in the control fetuses of nondiabetic mothers (FNDM). Comparing the results with mitral and tricuspid diastolic peak flows. METHODS The cross-sectional study included fetuses with gestational ages ranging from 20 weeks to term, divided into the following 3 groups: 56 FDM with MH (group I), 36 FDM with no MH (group II), and 53 FNDM (group III, control). The Doppler echocardiogram assessed the PIDV through the ratio (systolic velocity - presystolic velocity)/mean velocity. The mitral and tricuspid E and A waves were also assessed. RESULTS The mean PIDV in groups I, II, and III were 1.13 +/- 0.64, 0.84 +/- 0.38, and 0.61 +/- 0.17, respectively. Using ANOVA and the Tukey test, a statistically significant difference was found in the 3 groups (P = 0.015 between groups I and II; P < 0.001 between groups I and III; and P = 0.017 between groups II and III). The mean mitral E wave was significantly greater in group I (0.39 +/- 0.12 m/s) than in groups II (0.32 +/- 0.08 m/s) (P = 0.024) and III (0.32 +/- 0.08 m/s) (P = 0.023). The mean tricuspid E wave was also greater in group I (0.43 +/- 0.1 m/s) than in group III (0.35 +/- 0.10 m/s) (P = 0.031). CONCLUSION The PIDV is significantly greater in FDM with MH than in FDM with no MH and in FNDM. Because the PIDV may represent modifications in ventricular compliance, this index may be a more sensitive parameter for assessing fetal diastolic function.

Fetal ductal constriction caused by maternal ingestion of green tea in late pregnancy: an experimental study

The aim of this study was to test the hypothesis that experimental maternal intake of green tea in late pregnancy causes fetal ductus arteriosus constriction, probably because of prostaglandin inhibition.

OC97: Ductal flow dynamics and right ventricular size are influenced by maternal ingestion of polyphenol‐rich common beverages in normal pregnancies

Objectives: We have already demonstrated that maternal consumption of beverages with high polyphenol compounds causes fetal ductal constriction, as a result of COX-2 and prostaglandin inhibition. This study tested the hypothesis that in normal pregnancies maternal ingestion of polyphenol-rich common beverages (MIPRB) interferes with fetal ductal flow velocities and with the size of the right ventricle. Methods: A prospective analysis of 140 third-trimester fetuses from normal mothers was carried out, determining systolic and diastolic ductal flow velocities (DFV) and right to left ventricular dimension ratio. Mean gestational age was 28.4 ± 3.1 weeks (range, 23–38 weeks). A questionnaire was applied about MIPRB during pregnancy (herbal teas, mate tea and grape derivatives). Results: The group of 100 fetuses whose mothers declared to have used herbal teas or grape juice derivatives showed higher mean systolic (0.96 ± 0.23 m/s) and diastolic (0.17 ± 0.05 m/s) DFV, as well as higher mean RV/LV ratio (1.23 ± 0.23) than the group of 40 fetuses whose mothers had not utilized these substances (mean systolic velocity: 0.61 ± 0.18 m/s, P 0.85 m/s (P 0.15 m/s (P 1.1 (P < 0.001, relative risk = 27.6; 95% CI, 3.96–192.01), independently of gestational age. Conclusions: Ductal flow velocities are higher and right ventricular to left ventricular dimension ratios are larger in fetuses exposed to maternal ingestion of polyphenol-rich substances than in those not exposed. It seems clear that the ductal flow response to consumption of polyphenols during pregnancy is not a categorical parameter, but rather a continuous dose-dependent variable.