Advertisement

Z-Score Reference Ranges for Fetal Heart Functional Measurements in a Large Brazilian Pregnant Women Sample

  • Luciane Alves Rocha
  • Liliam Cristine Rolo
  • Luciano Marcondes Machado Nardozza
  • Gabriele Tonni
  • Edward Araujo Júnior
Original Article
  • 14 Downloads

Abstract

The objective of this study was to determine the reference values for fetal heart functional measurements at 24 and 34 weeks of gestation and to develop Z-score equations for all measurements. A single-center, prospective, cross-sectional study with normal fetuses between 24 and 34 weeks of gestation was performed. All pregnant women underwent a comprehensive fetal Doppler echocardiogram with anatomical and functional analysis. Measurements of left and right cardiac output, combined cardiac output, mitral and tricuspid valve flow, inferior vena cava flow, and pulmonary vein flow were performed. The Shapiro–Wilk test and histogram evaluation were performed on all variables. Linear regression was used to assess the relationships between measurements and gestational age. A total of 612 pregnant women with singleton and normal fetuses were included. We assessed the reference values and percentiles of cardiac function as a function of gestational age. The variables that were not normally distributed were subjected to logarithmic or square root transformation. Eleven Z-score equations were developed, with equations for left and right ventricle output and combined cardiac output that were dependent on gestational age and with other equations that were independent of gestational age. The present study produced a large database, allowing the demonstration of reference values and percentiles as well as the development of Z-score equations to facilitate the echocardiographic evaluation of fetal heart function.

Keywords

Fetal heart Two-dimensional echocardiography Cardiac function Reference values 

Notes

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Donofrio MTC, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A et al (2014) Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association. Circulation 129:2183–2242CrossRefGoogle Scholar
  2. 2.
    Hernandez-Andrade E, Benavides-Serralde JA, Cruz-Martinez R, Welsh A, Mancilla-Ramirez J (2012) Evaluation of conventional Doppler fetal cardiac function parameters: E/A ratios, outflow tracts, and myocardial performance index. Fetal Diagn Ther 32:22–29CrossRefGoogle Scholar
  3. 3.
    Godfrey ME, Messing B, Cohen SM, Valsky DV, Yagel S (2012) Functional assessment of the fetal heart: a review. Ultrasound Obstet Gynecol 39:131–144CrossRefGoogle Scholar
  4. 4.
    Miranda JO, Cerqueira RJ, Ramalho C, Areias JC, Henriques-Coelho T (2018) Fetal cardiac function in maternal diabetes: a conventional and speckle-tracking echocardiographic study. J Am Soc Echocardiogr 31:333–341CrossRefGoogle Scholar
  5. 5.
    Rudolph AM (2009) Congenital diseases of the heart: clinical physyological considerations, 3th edn. Wiley-Blackwell, HobokenCrossRefGoogle Scholar
  6. 6.
    Daubeney PE, Blackstone EH, Weintraub RG, Slavik Z, Scanlon J, Webber SA (1999) Relationship of the dimension of cardiac structures to body size: an echocardiographic study in normal infants and children. Cardiol Young 9:402–410CrossRefGoogle Scholar
  7. 7.
    Rimoldi HJA, Lev M (1963) A note on the concept of normality and abnormality in quantitation of pathologic findings in congenital heart disease. Pediatr Clin North Am 10:589–591CrossRefGoogle Scholar
  8. 8.
    Olivieri L, Arling B, Friberg M, Sable C (2009) Coronary artery Z score regression equations and calculators derived from a large heterogeneous population of children undergoing echocardiography. J Am Soc Echocardiogr 22:159–164CrossRefGoogle Scholar
  9. 9.
    Pettersen MD, Du W, Skeens ME, Humes RA (2008) Regression equations for calculation of Z scores of cardiac structures in a large cohort of healthy infants, children, and adolescents: an echocardiographic study. J Am Soc Echocardiogr 21:922–934CrossRefGoogle Scholar
  10. 10.
    Dallaire F, Bigras JL, Prsa M, Dahdah N (2014) Bias related to body mass index in pediatric echocardiographic Z scores. Pediatr Cardiol 36:667–676CrossRefGoogle Scholar
  11. 11.
    Devore GR (2005) The use of Z-scores in the analysis of fetal cardiac dimensions. Ultrasound Obstet Gynecol 26:596–598CrossRefGoogle Scholar
  12. 12.
    Schneider CS, McCrindle BW, Carvalho JS, Hornberger LK, McCArthy KP, Daubeney PE (2005) Development of Z-scores for fetal cardiac dimensions from Echocardiography. Ultrasound Obstet Gynecol 26:599–605CrossRefGoogle Scholar
  13. 13.
    Pasquini L, Mellander M, Seale A, Matsui H, Roughton M, Ho SY et al (2007) Z–scores of the fetal aortic isthmus and duct: an aid to assessing arch hipoplasia. Ultrassound Obstet Gynecol 29:628–633CrossRefGoogle Scholar
  14. 14.
    Gagnon C, Bigras JL, Fouron JC, Dallaire F (2016) Reference values and Z scores for pulsed-wave Doppler and M-mode measurements in fetal echocardiography. J Am Soc Echocardiogr 29:448–460CrossRefGoogle Scholar
  15. 15.
    Vimpeli T, Huhtala H, Wilsgaard T, Acharya G (2009) Fetal cardiac output and its distribution to the placenta at 11–20 weeks of gestation. Ultrasound Obstet Gynecol 33:265–271CrossRefGoogle Scholar
  16. 16.
    Axt-Fliedner R, Wiegank U, Fetsch C, Friedrich M, Krapp M, Georg T et al (2004) Reference values of fetal ductus venosus, inferior vena cava and hepatic vein blood flow velocities and waveform indices during the second and third trimester of pregnancy. Arch Gynecol Obstet 270:46–55CrossRefGoogle Scholar
  17. 17.
    Luewan S, Srisupundit K, Tongprasert F, Tongsong T (2012) Normal reference ranges of inferior vena cava doppler indices from 14 to 40 weeks of gestation. J Clin Ultrasound 40:214–218CrossRefGoogle Scholar
  18. 18.
    Talbert DG, Johnson P (2000) The pulmonary vein Doppler flow velocity waveform: feature analysis by comparison of in vivo pressures and flows with those in a computerized fetal physiological model. Ultrasound Obstet Gynecol 16:457–467CrossRefGoogle Scholar
  19. 19.
    Altman DG, Chitty LS (1994) Charts of fetal size: 1. Methodology. Br J Obstet Gynecol 101:29–34CrossRefGoogle Scholar
  20. 20.
    Koo TK, Li MY (2016) A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 15:155–163CrossRefGoogle Scholar
  21. 21.
    Tutschek B, Schmidt KG (2011) Techniques for assessing cardiac output and fetal cardiac function. Semin Fetal Neonatal Med 16:13–21CrossRefGoogle Scholar
  22. 22.
    Axt-Fliedner R, Graupner O, Kawecki A, Degenhardt J, Herrmann J, Tenzer A et al (2015) Evaluation of right ventricular function in fetuses with hypoplastic left heart syndrome using tissue Doppler techniques. Ultrasound Obstet Gynecol 45:670–677CrossRefGoogle Scholar
  23. 23.
    Bahlmann F, Gallinat R, Schmidt-Fittschen M, Al Naimi A, Reinhard I, Willruth A (2016) Fetal pulmonary venous blood flow velocities in a normal population and new calculated reference values. Prenat Diagn 36:1033–1040CrossRefGoogle Scholar
  24. 24.
    Zielinsky P, Piccoli A, Gus E, Manica JL, Satler F, Nicoloso LH et al (2003) Dynamics of the pulmonary venous flow in the fetus and its association with vascular diameter. Circulation 108:2377–2380CrossRefGoogle Scholar
  25. 25.
    Rajagopalan B, Friend JA, Stallard T, Lee GD (1979) Blood flow in pulmonar veins: I. Studies in dog and man. Cardiovasc Res 13:667–676CrossRefGoogle Scholar
  26. 26.
    Rajagopalan B, Friend JA, Stallard T, Lee GD (1979) Blood flow in pulmonar veins: II. The influence of events transmitted from the right and left sides of the heart. Cardiovasc Res 13:677–683CrossRefGoogle Scholar
  27. 27.
    Rajagopalan B, Bertram CD, Stallard T, Lee GD (1979) Blood flow in the pulmonary veins: III. Simultaneous measurements of their dimensions, intravascular pressure and flow. Cardiovasc Res 13:684–692CrossRefGoogle Scholar
  28. 28.
    Brezinka C, Laudy JA, Ursem NT, Hop WC, Wladimiroff JW (1999) Fetal pulmonary venous flow into the left atrium relative to diastolic and systolic cardiac time intervals. Ultrasound Obstet Gynecol 13:191–195CrossRefGoogle Scholar
  29. 29.
    Kiserud T, Eik-Nes SH, Blaas H-G, Hellevik LR (1992) Foramen ovale: an ultrasonographic study of its relation to the inverter vena cava, ductus venosus and hepatic veins. Ultrasound Obstet Gynecol 2:389–396CrossRefGoogle Scholar
  30. 30.
    Mori A, Uchida N, Ishiguro Y, Atsuko T, Kanako M, Mikio M (2007) Evaluation of cardiac function of the fetus by inferior vena cava diameter pulse waveform. Am Heart J 154:789–794CrossRefGoogle Scholar
  31. 31.
    Reed KL, Appleton CP, Anderson CF, Shenker L, Sahn DJ (1990) Doppler studies in vena cava flows in human fetuses. Insights into normal and abnormal cardiac physiology. Circulation 81:498–505CrossRefGoogle Scholar
  32. 32.
    Ghawi H, Gendi S, Mallula K, Zghouzi M, Faza N, Awad S (2013) Fetal left and right ventricle myocardial performance index: defining normal values for the second and third trimesters—single tertiary center experience. Pediatr Cardiol 34:1808–1815CrossRefGoogle Scholar
  33. 33.
    Van Mieghem T, Gucciardo L, Lewi P, Lewi L, Van Schoubroeck D, Devlieger R et al (2009) Validation of the fetal myocardial performance index in the second and third trimesters of gestation. Ultrasound Obstet Gynecol 33:58–63CrossRefGoogle Scholar
  34. 34.
    Tsutsumi T, Ishii M, Eto G, Hota M, Kato H (1999) Serial evaluation for myocardial performance in fetuses and neonates using a new Doppler index. Pediatr Int 41:722–727CrossRefGoogle Scholar
  35. 35.
    Luewan S, Tongprasert F, Srisupundit K, Traisrisilp K, Tongsong T (2014) Reference ranges of myocardial performance index from 12 to 40 weeks of gestation. Arch Gynecol Obstet 290:859–865CrossRefGoogle Scholar
  36. 36.
    Friedman D, Buyon J, Kim M, Glickstein JS (2003) Fetal cardiac function assessed by Doppler myocardial performance index (Tei index). Ultrasound Obstet Gynecol 21:33–36CrossRefGoogle Scholar
  37. 37.
    Meriki N, Welsh AW (2012) Development of Australian reference ranges for the left fetal modified myocardial performance index and the influence of caliper location on time interval measurement. Fetal Diagn Ther 32:87–95CrossRefGoogle Scholar
  38. 38.
    Rozmus-Warcholinska W, Wloch A, Acharya G, Cnota W, Czuba B, Sodowski K et al (2010) Reference values for variables of fetal cardiocirculatory dynamics at 11–14 weeks of gestation. Ultrasound Obstet Gynecol 35:540–547CrossRefGoogle Scholar
  39. 39.
    Gallarreta FM, Martins WP, Nastri CO, Mauad Filho F, Nicolau LG, Barra DA et al (2011) Evaluation of ductus venosus and inferior vena cava by using multiple Doppler ultrasound parameters in healthy fetuses. Arch Gynecol Obstet 283:959–963CrossRefGoogle Scholar
  40. 40.
    Eidem BW, Edwards JM, Cetta F (2001) Quantitative assessment of fetal ventricular function: establishing normal values of the myocardial performance index in the fetus. Echocardiography 18:9–13CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Obstetrics, Paulista School of MedicineFederal University of São Paulo (EPM-UNIFESP)São PauloBrazil
  2. 2.Prenatal Diagnostic Service, Department of Obstetrics and GynecologyIstituto di Ricerca a Carattere Clinico Scientifico (IRCCS), AUSL Reggio EmiliaReggio EmiliaItaly

Personalised recommendations