Fetal cardiovascular parameters for the

prediction of postnatal cardiovascular risk

in intrauterine growth-restriction?

Fàtima Crispi, Monica Cruz-Lemini, Brenda Valenzuela-Alcaraz, Francesc Figueras, Olga Gómez, Marta Sitges, Bart Bijnens, Eduard Gratacós

Department of Maternal-Fetal Medicine, Hospital Clinic; Fetal Medicine Research Center, IDIBAPS; Barcelona, Spain

ICREA, Universitat Pompeu Fabra, Barcelona, Spain

Cardiology Department, Thorax Clinic Institute, Hospital Clinic,, Barcelona, Spain

17th International Conference on Prenatal Diagnosis and Therapy

Lisbon, June 2013

No disclosure

fcrispi@clinic.ub.es

www.medicinafetalbarcelona.org

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IUGR Fetus Low BW Child CV

Disease Adult

Myocardial infartion

Hypertension

Diabetes/Obesity

introduction

Fetal life Early life Old age Childhood Maturity

IMPACT OF

ENVIRONMENT

OPPORTUNITY

FOR

CORRECTION

How do we choose who to follow up into

childhood?

Barker BMJ 1995, Hecher Circulation 1995, Crispi AJOG 2008, Crispi Circulation 2010 © w

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Fetus

Myocardial Performance Index

M-mode

Tissue Doppler

6mo Child 5yr Child

Blood Pressure

Tissue Doppler

Sphericity Index

Cruz-Lemini UOG 2013.

Comas, AJOG 2010.

Comas, AJOG 2011.

Crispi, AJOG 2008.

Cruz-Martínez, UOG 2011.

Crispi, Circulation 2010.

IUGR defined as EFW/birthweight <10th centile

Control

n=100

IUGR

n=100

Conventional Doppler

Fetal

Echocardiography

Control

n=100

IUGR

n=100

Blood Pressure

Aortic IMT

Logistic Regression CV RISK

To evaluate whether fetal echocardiography has a value for the

prediction of postnatal cardiovascular outcome in IUGR

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Controls

n= 100

IUGR

n= 100 p

Fetal Parameters

Umbilical artery PI (z-score) 0.1 ± 0.6 0.7 ± 1.4 <0.001

Mean uterine artery PI (z-score) -0.7 ± 1.3 0.7 ± 1.9 0.002

Cerebroplacental ratio (z-score) 0.1 ± 1.3 -0.9 ± 1.6 <0.001

Delivery Data

Gestational age at delivery

(weeks) 39.9 ± 1.2 37.3 ± 3.5 <0.001

Birthweight centile 45 ± 23 3 ± 3 <0.001

Child Demographics

Corrected age at scan (months) 6.5 ± 0.7 6.5 ± 0.7 0.916

Height (cm) 68 ± 2 65 ± 3 <0.001

Weight (g) 7819 ± 767 6892 ± 956 <0.001

Body mass index (kg/m2) 16.9 ± 1.6 16.3 ± 1.8 0.051

PI, pulsatility index; IUGR, intrauterine growth restriction.

Doppler measurements expressed in z-scores, mean ± SD. Differences estimated by Student’s t test.

results Descriptive Data

IUGR: 25% abnormal

postnatal CV outcome (BP >p95 + aIMT >p75)

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OR p

Standard criteria

Gestational age at delivery 1.2 (1.0 – 1.4) 0.055

Birthweight centile 1.2 (0.9 – 1.4) 0.134

Mean uterine artery PI 1.4 (0.9 – 1.9) 0.052

Umbilical artery PI 1.8 (1.2 – 2.6) 0.003

Cerebroplacental ratio 2.2 (1.4 – 3.5) 0.001

Ductus venosus PI 2.0 (1.2 – 3.4) 0.007

Aortic isthmus PI 1.0 (0.9 – 1.1) 0.079

Fetal echocardiographic parameters

Right ejection fraction 0.9 (0.9 – 1.1) 0.918

Isovolumetric relaxation time 2.1 (1.2 – 3.7) 0.008

TAPSE 11.4 (3.6 – 35.7) <0.001

Tricuspid S’ 7.5 (1.4 – 50) 0.041

Right sphericity index 9.2 (4.3 – 19.9) <0.001

Right ventricular wall (adjusted) 4.8 (2.7 – 8.5) <0.001

PI, pulsatility index; TAPSE, tricuspid annular plane systolic excursion;

S’, peak systolic velocity. Right wall adjusted by cardiac transverse diameter

results

Univariate Regressions Outcome: MBP>p95 + aIMT>p95

25%

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Outcome: MBP>p95 + aIMT>p95

25% results

Conventional parameters: poor prediction of postnatal CV risk

GA at delivery AUC: 0.51 (95% CI 0.42 – 0.60, p=0.070)

Birthweight centile AUC: 0.60 (95% CI 0.51 – 0.68, p=0.066)

Umbilical artery PI AUC: 0.67 (95% CI 0.59 – 0.75, p=0.070)

GA at delivery

BW Centile

Umbilical artery PI

0 20 40 60 80 100

100

80

60

40

20

0

100-Specificity

Se

nsitiv

ity

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OR p

Standard criteria

Gestational age at delivery 1.2 (1.0 – 1.4) 0.055

Birthweight centile 1.2 (0.9 – 1.4) 0.134

Mean uterine artery PI 1.4 (0.9 – 1.9) 0.052

Umbilical artery PI 1.8 (1.2 – 2.6) 0.003

Cerebroplacental ratio 2.2 (1.4 – 3.5) 0.001

Ductus venosus PI 2.0 (1.2 – 3.4) 0.007

Aortic isthmus PI 1.0 (0.9 – 1.1) 0.079

Fetal echocardiographic parameters

Right ejection fraction 0.9 (0.9 – 1.1) 0.918

Isovolumetric relaxation time 2.1 (1.2 – 3.7) 0.008

TAPSE 11.4 (3.6 – 35.7) <0.001

Tricuspid S’ 7.5 (1.4 – 50) 0.041

Right sphericity index 9.2 (4.3 – 19.9) <0.001

Right ventricular wall (adjusted) 4.8 (2.7 – 8.5) <0.001

PI, pulsatility index; TAPSE, tricuspid annular plane systolic excursion;

S’, peak systolic velocity. Right wall adjusted by cardiac transverse diameter

results

Univariate Regressions Outcome: MBP>p95 + aIMT>p95

25%

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Fetal Echocardiographic Parameters

results

Outcome: MBP>p95 + aIMT>p95

25%

sphericity index

OR 5.6 (2.6-12.2)

OR 2.4 (1.4-3.9)

isovolumic relaxation time

aorta

E A

TAPSE

OR 10.2 (4.2-36)

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Composite CV Score AUC: 0.87 (95% CI 0.79 – 0.93, p<0.001)

Sensitivity 90%, Specificity 77%

Gestational Age at Birth AUC: 0.50

(95% CI 0.41 – 0.59, p=0.071)

Birthweight AUC: 0.59

(95% CI 0.50 – 0.68, p=0.066)

Umbilical Artery AUC: 0.67

(95% CI 0.59 – 0.76, p=0.070) 0 20 40 60 80 100

100

80

60

40

20

0

100-Specificity

Se

nsitiv

ity

results

Cardiovascular Score: TAPSE + CPR + RSI + IRT

Outcome: MBP>p95 + aIMT>p95

n = 25%

1.907 + (TAPSEz*-0.589) + (CPRz*-0.286) + (RSI*-1.938) + (IRTz*0.342)

≥ 0.1253

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conclusions

• Fetal echocardiographic parameters help identifying a high-risk

group within the IUGR fetuses, which could be targeted for

early screening of blood pressure, as well as for promoting

healthy diet and physical exercise.

• Larger studies are warranted to assess clinical utility of

algorithms based on fetal echocardiography to select IUGR

cases with higher cardiovascular risk later in life.

THANK YOU

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