Alvaro Sepúlveda-Martínez

Objective: To establish and assess the reproducibility of standardized echocardiographic nomenclature and the protocol for comprehensive evaluation of fetal aortic morphology. Methods: This was a prospective cohort study of fetuses with a normal three‐vessel branching pattern of the aortic arch, evaluated from 18–40 weeks' gestation at a single center between January 2024 and November 2024. Alongside standard two‐dimensional views, four‐dimensional spatiotemporal image correlation cardiac volumes were acquired to establish the correspondence between the longitudinal aortic‐arch view and the three‐vessel‐and‐trachea (3VT) view. A comprehensive nomenclature, based on clear anatomical landmarks, and stringent measurement protocol were defined for fetal aortic dimensions and angles measured in the left ventricular outflow tract (LVOT), the longitudinal aortic‐arch and the 3VT echocardiographic views. Measurements were performed independently by two observers, with a repeat analysis by a single observer, to assess intra‐ and interobserver reproducibility, respectively, using intraclass correlation coefficients (ICCs). Results: A total of 45 singleton fetuses with normal three‐vessel branching were randomly selected to comprise the study population. Parameters measured in the LVOT view demonstrated good‐to‐excellent intra‐ and interobserver reproducibility (ICC > 0.8), with excellent reproducibility observed for the sinotubular junction and mid‐ascending aorta diameters (except the interobserver reproducibility for mid‐ascending aorta diameter (ICC, 0.883 (95% CI, 0.739–0.945)), which was good). Good‐to‐excellent intra‐ and interobserver reproducibility (ICC, 0.8–0.9) was also demonstrated for longitudinal aortic‐arch diameters and distances between supra‐aortic vessels, whereas the ascending‐to‐descending aorta angle showed moderate intra‐ and interobserver reproducibility (ICC, 0.652 (95% CI, 0.435–0.798) and 0.593 (95% CI, 0.199–0.776), respectively). In the 3VT view, the standardized aortic diameters and the 3VT angle had good‐to‐excellent intraobserver reproducibility (ICC, 0.75–0.9). There was also good agreement between the aortic isthmus diameter in the longitudinal aortic‐arch view and the 3VT view (ICC, 0.870 (95% CI, 0.458–0.995); P < 0.001). No significant differences or systematic bias were found between observers. Conclusion: A standardized echocardiographic protocol with uniform nomenclature and anatomical landmarks would enable reliable and reproducible fetal aortic morphometry across multiple echocardiographic views, and would be a significant step towards harmonizing fetal aorta imaging, enabling meaningful comparisons across studies and promoting collaborative research. © 2026 International Society of Ultrasound in Obstetrics and Gynecology.

Objective: The aim of this study was to evaluate the impact on perinatal outcomes related to placental insufficiency with the application of the new 2017 ACC/AHA guidelines to a group of chronic hypertensive pregnancies during their first-trimester assessment.Study design: This retrospective cohort study included pregnancies with preconceptional hypertension and known perinatal outcomes. In the first trimester, a combined screening for preterm preeclampsia (p-PE) was performed, including blood pressure (BP), mean uterine artery Doppler, and maternal characteristics. Patients were divided, according to the 2017 ACC/AHA consensus, into the following groups: elevated or less, Stage 1, and Stage 2. For adverse perinatal outcome assessment, univariate and multivariate regression analyses were performed, considering the “elevated or less” group as a reference. Odds ratios (OR) were compared with linear trend analysis. The main outcomes measured were preterm PE and FGR < 3^rd percentile.Results: Of the 130 included patients, 59 (45.4%) were classified as elevated or less, 47 (36.2%) as Stage 1, and 24 (18.4%) as Stage 2. p-PE showed a significant increase according to BP range [7% (OR = 1.0), 19.6% (OR = 3.2), and 21.7% (OR = 3.7)]; trend p = 0.02, for elevated or less, Stage 1, and Stage 2, respectively. There was a non-significant increased trend of FGR < 3^rd percentile according to the BP stage. The best multivariate predictive model for p-PE included a previous PE background (OR = 15) and mean arterial pressure in mmHg (OR = 1.1).Conclusion: The use of the 2017 ACC/AHA consensus in pregnancies with chronic hypertension identifies an intermediate risk group for placental-mediated diseases.

Aim: To analyze the presence of fetal myocardial dysfunction in intrahepatic cholestasis of pregnancy (ICP) at diagnosis.Methods: This prospective cohort study included 49 pregnant participants with ICP at diagnosis and 49 nonaffected controls from a single public hospital. ICP was diagnosed based on clinical symptoms after excluding other causes of pruritus and presence of autoimmune diseases. Total bile acids were not obtained in this cohort. ICP pregnancies were assessed with a functional echocardiography at diagnosis including PR‐interval, isovolumetric contraction time (ICT), ejection time (ET), and isovolumetric relaxation time (IRT) for electrical, systolic, and diastolic function, respectively. Controls were assessed at recruitment. Perinatal outcomes were obtained from delivery books. The main outcome was the presence of PR‐interval prolongation or first‐degree fetal heart block, and echographic signs of diastolic and systolic dysfunction.Results: Compared to controls, ICP were above upper limit in conjugated bilirubin (2.0% vs. 20.4%; p = 0.008), aspartate aminotransferase (2.0% vs. 24.5%; p = 0.002), and alanine aminotransferase (4.1% vs. 28.6%; p = 0.002). ICP was associated with a higher PR‐interval (130 ± 12 ms vs. 121 ± 6 ms; p < 0.0001) with five first‐degree fetal heart blocks. IRT was significantly higher in ICP (42 ± 6 ms vs. 37 ± 5 ms; p = 0.0001), with no differences in ICT and ET. PR‐interval trend was only positively correlated with IRT in ICP pregnancies (p = 0.04 and p = 0.34, in ICP and controls, respectively).Conclusions: Our study demonstrates that fetuses affected by maternal ICP are associated with electrical and diastolic myocardial dysfunction. More studies focused on antenatal and postnatal functional echocardiography are necessary to validate our results and consider these markers in the clinical management of ICP pregnancies.

Fetal growth restriction is one of the most common obstetric complications, affecting 7-10% of all pregnancies. Affected fetuses are exposed to an adverse environment in utero during a critical time of development and may face long-term health consequences such as increased cardiovascular risk in adulthood. Growth restricted fetuses develop remodeled hearts with signs of systolic and diastolic dysfunction. Cardiac adaptations are more evident in early severe cases, but also present in late onset fetal growth restriction. Cardiovascular remodeling persists into postnatal life, from the neonatal period to adolescence, encompassing an increased susceptibility to adult disease. In this review, we summarize the current evidence on cardiovascular programming associated to fetal growth restriction, its postnatal consequences and potential strategies to reduce their cardiovascular risk.

The alteration of the uterocervical angle (UCA) has been proposed to play an important role in spontaneous preterm birth (sPTB). The aim of this systematic review and meta-analysis was to evaluate the evidence on the UCA predictive role in sPTB. In this study, PubMed, Web of Science, Scopus, and Google scholar were systematically searched from inception up to June 2020. Inter-study heterogeneity was also assessed using Cochrane’s Q test and the I² statistic. Afterward, the random-effects model was used to pool the weighted mean differences (WMDs) and the corresponding 95% confidence intervals (CIs). Eleven articles that reported second-trimester UCA of 5,061 pregnancies were included in this study. Our meta-analysis results indicate that a wider UCA significantly increases the risk of sPTB in following cases: all pregnancies (WMD = 15.25, 95% CI: 11.78–18.72, p < 0.001; I² = 75.9%, p < 0.001), singleton (WMD = 14.43, 95% CI: 8.79–20.06, p < 0.001; I² = 82.4%, p < 0.001), and twin pregnancies (WMD = 15.14, 95% CI: 13.42–16.87, p < 0.001; I² = 0.0%, p = 0.464). A wider ultrasound-measured UCA in the second trimester seems to be associated with the increased risk of sPTB in both singleton and twin pregnancies, which reinforces the clinical evidence that UCA has the potential to be used as a predictive marker of sPTB.

Introduction: Both echocardiography and CMR imaging are used to quantify longitudinal function. Inter‐method variability for mitral (MAPSE) and tricuspid (TAPSE) annular plane systolic excursion, and variability between directly measured MAPSE and TAPSE and as based on atrioventricular plane displacement (AVPD) analysis by CMR, are, however, not known. This study, therefore, assessed inter‐method variability and variability between annular plane systolic excursion and AVPD‐based values in a healthy adult population.Methods: Echocardiography and CMR were performed in 111 adults (35 [32–38] years). Method comparisons were assessed with Deming regression, Bland–Altman analysis and coefficient of variation. Observer reproducibility was assessed by the concordance correlation coefficient.Results: Echocardiography and semi‐automatic CMR agreed on MAPSE (17 ± 2 mm vs. 17 ± 2 mm, p = 0.1) and TAPSE (25 ± 3 mm vs. 25 ± 3 mm, p = 0.5), correlated highly between methods (fitted‐slope 1.22 [95% CI 1.07–1.38] and 1.12 [95% CI 0.95–1.29]) and showed low bias (0.42 [95% CI − 2.05 to 2.88] and − 0.18 [95% CI − 4.78 to 4.43]). Intra‐/inter‐observer reproducibility was high for both methods for both MAPSE (echocardiography 0.96/0.86; CMR 0.87/0.85) and TAPSE (echocardiography 0.96/0.95; CMR 0.97/0.96). MAPSE (16 ± 2 mm vs. 17 ± 2 mm; p < 0.001) and TAPSE (24 ± 3 vs. 25 ± 3 mm; p < 0.001) based on AVPD were similar but statistically different compared with semi‐automatic CMR.Conclusions: Echocardiography and semi‐automatic CMR have low variability and provide similar values for MAPSE and TAPSE and are thus interchangeable for follow‐up studies. Lateral values based on tracked data from AVPD analysis are not clinically significantly different and could be used as a representation of annular displacement.

Objective: To construct nomograms for fetal cardiac, ventricular and atrial relative size and geometry parameters from 18 to 41 weeks' gestation using a low‐risk population of singleton pregnancies.Methods: This was a prospective cohort study of 602 low‐risk singleton pregnancies undergoing comprehensive fetal echocardiography, from 18 to 41 weeks of gestation, to assess fetal cardiac, atrial and ventricular relative size and sphericity, ventricular dominance, wall asymmetry and relative wall thickness. Intra‐ and interobserver measurement reproducibility was evaluated using intraclass correlation coefficients (ICC). In order to construct reference ranges across pregnancy, parametric regressions were tested to model each measurement against gestational age and estimated fetal weight. The measurements evaluated were: cardiothoracic ratio; atrial‐to‐heart area ratios; ventricular‐to‐heart area ratios; cardiac, ventricular and atrial sphericity indices; right‐to‐left basal and midventricular ratios; septal‐to‐free wall thickness ratios; and relative wall thickness.Results: Fetal cardiac, ventricular and atrial morphometry for assessing relative size and geometry could be successfully performed in > 95% of the population, with moderate‐to‐excellent interobserver reproducibility (ICC, 0.623–0.907) and good‐to‐excellent intraobserver reproducibility (ICC, 0.787–0.938). Cardiothoracic ratio and ventricular right‐to‐left ratio showed a modest increase throughout gestation. Atrial‐to‐heart and ventricular‐to‐heart area ratios, atrial sphericity indices and septal‐to‐free wall thickness ratios were constant with gestational age. Left and right ventricular basal sphericity indices showed a tendency to decrease at the end of gestation, while left and right midventricular sphericity indices tended to decrease in the second trimester. The cardiac sphericity index and left and right relative wall thickness showed a modest decrease with gestational age. Nomograms across gestation were constructed for all echocardiographic parameters described.Conclusions: The assessment of cardiac, ventricular and atrial relative size and geometry is feasible and reproducible in the fetus. We provide standardized reference ranges for these parameters throughout gestation, enabling the accurate assessment of cardiac remodeling patterns during fetal life. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

Objectives: Fetal cardiac function can be evaluated using a variety of parameters. Among these, cardiac cycle time‐related parameters, such as filling time fraction (FTF) and ejection time fraction (ETF), are promising but rarely studied. We aimed to report the feasibility and reproducibility of fetal FTF and ETF measurements using pulsed‐wave Doppler, to provide reference ranges for fetal FTF and ETF, after evaluating their relationship with heart rate (HR), gestational age (GA) and estimated fetal weight (EFW), and to evaluate their potential clinical utility in selected fetal conditions.Methods: This study included a low‐risk prospective cohort of singleton pregnancies and a high‐risk population of fetuses with severe twin–twin transfusion syndrome (TTTS), aortic stenosis (AoS) or aortic coarctation (CoA), from 18 to 41 weeks' gestation. Left ventricular (LV) and right ventricular inflow and outflow pulsed‐wave Doppler signals were analyzed, using valve clicks as landmarks. FTF was calculated as: (filling time/cycle time) × 100. ETF was calculated as: (ejection time/cycle time) × 100. Intraclass correlation coefficients (ICC) were used to evaluate the intra‐ and interobserver reproducibility of FTF and ETF measurements in low‐risk fetuses. The relationships of FTF and ETF with HR, GA and EFW were evaluated using multivariate regression analysis. Reference ranges for FTF and ETF were then constructed using the low‐risk population. Z‐scores of FTF and ETF in the high‐risk fetuses were calculated and analyzed.Results: In total, 602 low‐risk singleton pregnancies and 54 high‐risk fetuses (nine pairs of monochorionic twins with severe TTTS, 16 fetuses with AoS and 20 fetuses with CoA) were included. Adequate Doppler traces for FTF and ETF could be obtained in 95% of low‐risk cases. Intraobserver reproducibility was good to excellent (ICC, 0.831–0.905) and interobserver reproducibility was good (ICC, 0.801–0.837) for measurements of all timing parameters analyzed. Multivariate analysis of FTF and ETF in relation to HR, GA and EFW in low‐risk fetuses identified HR as the only variable predictive of FTF, while ETF was dependent on both HR and GA. FTF increased with decreasing HR in low‐risk fetuses, while ETF showed the opposite behavior, decreasing with decreasing HR. Most recipient twins with severe TTTS showed reduced FTF and preserved ETF. AoS was associated with decreased FTF and increased ETF in the LV, with seemingly different patterns associated with univentricular vs biventricular postnatal outcome. The majority of fetuses with CoA had FTF and ETF within the normal range in both ventricles.Conclusions: Measurement of FTF and ETF using pulsed‐wave Doppler is feasible and reproducible in the fetus. The presented reference ranges account for associations of FTF with HR and of ETF with HR and GA. These time fractions are potentially useful for clinical monitoring of cardiac function in severe TTTS, AoS and other fetal conditions overloading the heart. © 2020 International Society of Ultrasound in Obstetrics and Gynecology