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. 2015 Dec 1:8:39-43.
doi: 10.4137/CMWH.S32825. eCollection 2015.

Prediction of Fetal Hypertrophic Cardiomyopathy in Diabetic Pregnancies Compared with Postnatal Outcome

Sherif F Elmekkawi  1 , Ghada M Mansour  1 , Mohammed S E Elsafty  1 , Alaa S Hassanin  1 , Mohamed Laban  1 , Heba M Elsayed  2
Affiliations

Prediction of Fetal Hypertrophic Cardiomyopathy in Diabetic Pregnancies Compared with Postnatal Outcome

Sherif F Elmekkawi et al. Clin Med Insights Womens Health. .

Abstract

Objective: The aim of this study was to estimate the accuracy of prenatal assessment of interventricular septum (IVS) thickness, right myocardial wall thickness (RMWT), and left myocardial wall thickness (LMWT) by two-dimensional (2D) ultrasound for the prediction of perinatal mortality and postnatal diagnosis of hypertrophic cardiomyopathy (HCM) among diabetic pregnant women.

Subjects and methods: A total of 120 diabetic pregnant women at 35 weeks or more were enrolled in this study from January 1, 2012, to June 30, 2014, at Ain Shams Maternity Hospital, Cairo, Egypt. The 2D ultrasound was done once for all the participants at the time of recruitment; IVS thickness, RMWT, and LMWT were measured. The glycosylated hemoglobin (HbA1c) levels of the participants were recorded. Neonatal assessment including postnatal echocardiography was done after 48 hours. Postnatal results were compared with the prenatal predictive results.

Results: Higher thickness values for IVS, RMW, and LMW were obtained in the uncontrolled diabetic cases (HbA1c > 6.5%) than in the controlled diabetic cases (HbA1c < 6.5%; P < 0.01). Of the included 120 neonates, 10 (8.3%) were stillborn, 99 (82.5%) had a five-minute Apgar score ≥7, and 4 (3.3%) had a five-minute Apgar score ≤3. The four neonates with severe neonatal distress died after admission to neonatal intensive care unit within one week after delivery. Out of 110 live-born neonates, 4 (3.6%) neonates had a low ejection fraction (EF) (<50%) due to HCM; of them 2 (1.8%) died within one week after delivery, while 2 (1.8%) survived. Another two (1.8%) neonates died from severe respiratory distress syndrome. A cutoff value of ≥4.5 mm for prenatal IVS thickness was predictive of neonatal distress due to HCM with a sensitivity of 82%, specificity of 68%, and diagnostic accuracy of 72%. A cutoff value of <1.18 for the ratio of IVS thickness to LMWT had a sensitivity of 82%, specificity of 72%, and diagnostic accuracy of 74% for the prediction of neonatal distress due to HCM. In this study, 8 of the 10 fetuses with intrauterine demise and the 2 neonates who died within one week after delivery due to heart failure had a prenatal IVS thickness of ≥4.5 mm, while 7 of the 10 fetuses with intrauterine demise and the 2 neonates who died postnatal from heart failure had a prenatal IVS thickness to LMWT ratio of ≤1.18.

Conclusion: A prenatal IVS thickness of ≥4.5 mm or an IVS/LMWT ratio of ≤1.18 seems to be predictive of HCM and is associated with almost twofold higher risk of intrauterine fetal death and almost threefold higher risk of possibly relevant perinatal mortality.

Keywords: diabetes mellitus (DM) with pregnancy; echocardiography; hypertrophic cardiomyopathy (HCM); infant of diabetic mother; interventricular septum (IVS) thickness; left myocardial wall thickness (LMWT); two-dimensional ultrasound.

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Figures

Figure 1
Figure 1
ROC curves for estimating the association between prenatal IVS thickness, right and left myocardial thicknesses, and postnatal diagnosis of HCM. Notes: All of those measurements showed significant predictability of HCM, with the prenatal IVS thickness being the most predictable, having the largest area under the curve (AUC). A prenatal IVS thickness ≥4.5 mm was associated with a postnatal diagnosis of HCM at a sensitivity of 82%, a specificity of 68%, a positive predictive value (PPV) of 37%, a negative predictive value (NPV) of 94%, a positive likelihood ratio (LR+) of 2.6, and an overall accuracy of 72%. AUC for prenatal IVS thickness: 0.80, 95% CI (0.66 to 0.93), p < 0.001. AUC for prenatal right myocardial thickness: 0.70, 95% CI (0.57 to 0.84), p = 0.003. AUC for prenatal left myocardial thickness: 0.68, 95% CI (0.53 to 0.82), p = 0.01. AUC, 95% CI: area under the curve and its 95% confidence interval.
Figure 2
Figure 2
ROC curve for estimating the association between prenatal IVS thickness-to-left myocardial thickness (IVS:LMWT) ratio, and postnatal diagnosis of HCM. Notes: A prenatal IVS: LMWT ratio ≤1.18 was associated with a postnatal diagnosis of HCM at a sensitivity of 82%, a specificity of 72%, a PPV of 40%, a NPV of 95%, a LR+ of 3, and an overall accuracy of 74%. AUC: 0.75, 95% CI (0.63 to 0.87), p = 0.003. AUC, 95% CI: area under the curve and its 95% confidence interval.
Figure 3
Figure 3
Fetal interventricular septal thickness 6 mm in a case of uncontrolled pregestational diabetes mellitus with pregnancy by 2D ultrasound.
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