Ultrasonographic evaluation of Caval Aortic Index in gestational and pregestational diabetes: a predictor of perinatal outcomes?

Year 2025, Volume: 8 Issue: 2, 254 - 261, 21.03.2025

Gülşan Karabay , Zeynep Şeyhanlı , Ahmet Arif Filiz , Betül Tokgöz Çakır , Gizem Aktemur , Sadun Sucu , Nazan Vanlı Tonyalı , Umut Karabay , Şevki Çelen , Zehra Vural Yılmaz

Abstract

Aims: Diabetes mellitus (DM), including gestational (GDM) and pregestational diabetes (pre-GDM), adversely affects maternal and fetal outcomes due to hyperglycemia and vascular changes. The Caval Aortic Index, a non-invasive measure of blood volume, could provide insights into these complications. In our study, we aimed to determine the functional changes in inferior vena cava (IVC) and aorta (Ao) diameters as well as the importance of caval aortic index in predicting perinatal outcomes in diabetic pregnant women.
Methods: This prospective case-control study included 120 DM patients and 100 controls. DM patients were divided into pre-GDM, diet-regulated GDM, and insulin-regulated GDM groups. Ultrasound measurements of inferior vena cava and aortic diameters were performed, alongside Doppler evaluations. Statistical analyses were conducted to assess the association of these parameters with adverse perinatal outcomes.
Results: Although the IVC and aortic diameters of the pregnant women with DM were higher compared to the control group and a statistically significant difference (p<0.001) was found between the groups, the Caval-Aortic Index was similar between the groups. Adverse outcomes (APGAR 5 min <7, need for mechanical ventilation, need for continued positive airway pressure, respiratory distress syndrome, transient tachypnea of the newborn and neonatal intensive care unit admission and neonatal low cord blood pH) were higher in DM groups but showed no direct correlation with IVC or aortic parameters. IVC diameter was the most predictive parameter in DM patients and the cut-off was >3.81 mm (AUC: 0.674).
Conclusion: Ultrasonographic IVC and aortic diameters reflect vascular adaptations in diabetic pregnancies but lack predictive value for adverse outcomes. While the Caval Aortic Index provides limited prognostic utility, integrating these measurements into comprehensive models may enhance perinatal risk assessment.

Keywords

Gestational diabetes, pregestational diabetes, Caval Aortic Index, perinatal outcomes, ultrasonography, vascular adaptations

Ethical Statement

The Ankara Etlik City Hospital’s Ethics Committee gave its permission to the study protocol (approval number: AESH-EK1-2023-621). The Declaration of Helsinki’s guidelines were followed in the conduct of this study.

Gestasyonel ve pregestasyonel diyabette Caval Aort İndeksinin ultrasonografik değerlendirmesi: perinatal sonuçları öngörebilir mi?

Abstract

Amaç: Diabetes mellitus (DM), gebelik diyabeti (GDM) ve gebelik öncesi diyabeti (pre-GDM) içermekle beraber hiperglisemi ve vasküler değişiklikler nedeniyle maternal ve fetal sonuçları olumsuz etkileyebilir. Kaval aortik indeks, dolaşımdaki kan hacmini değerlendiren non-invaziv bir parametre olup, bu komplikasyonlar ile ilişkilendirilebilir. Biz de çalışmamızda diyabetli gebelerde inferior vena kava (IVC) ve aort (Ao) çaplarındaki fonksiyonel değişikliklerin yanı sıra kaval aort indeksinin perinatal sonuçları tahmin etmedeki önemini belirlemeyi amaçladık.
Yöntemler: Bu prospektif vaka-kontrol çalışmasına 120 DM olan gebe ve 100 sağlıklı kontrol gebesi dahil edilmiştir. DM olan gebeler; pre-GDM, diyetle düzenlenen ve insülinle düzenlenen GDM olarak üç gruba ayrılmıştır. Ultrasonografi ile inferior vena kava ve aort çapları ölçülmüş ve Doppler değerlendirmeleri yapılmıştır. Bu parametrelerin olumsuz perinatal sonuçlarla ilişkisi istatistiksel analizlerle değerlendirilmiştir.
Bulgular: DM olan gebelerin IVC ve aort çapları, kontrol grubuna kıyasla daha yüksek olup gruplar arasında istatistiksel olarak anlamlı fark (p<0.001) saptanmasına rağmen kaval aortik indeks gruplar arasında benzerdi. Olumsuz perinatal sonuçlar (APGAR 5. dakika <7, mekanik ventilasyon ihtiyacı, sürekli pozitif hava yolu basıncı ihtiyacı, solunum sıkıntısı sendromu, yenidoğanın geçici taşipnesi, yenidoğan yoğun bakım ünitesine yatış ve yenidoğanda düşük kordon kanı pH'ı) DM gruplarında daha yüksek bulunmasına rağmen, bu sonuçlar ile IVC veya aort çapı parametreleri arasında doğrudan bir korelasyon saptanmamıştır. DM olan gebelerde IVC çapı en anlamlı prediktif parametre olarak belirlenmiş ve >3.81 mm kesim noktası ile AUC: 0.674 olarak hesaplanmıştır.
Sonuç: Ultrasonografik IVC ve aort çapları, diyabetik gebeliklerde vasküler adaptasyonları yansıtabilir ancak olumsuz perinatal sonuçları öngörmede sınırlı değere sahiptir. Kaval aortik indeksin prognostik değeri düşük olmakla birlikte, bu ölçümlerin kapsamlı risk değerlendirme modellerine entegre edilmesi, perinatal risk öngörüsünü artırabilir.

Keywords

Gebelik diyabeti, gebelik öncesi diyabet, kaval aort indeks, perinatal sonuçlar, ultrasonografi, vasküler adaptasyonlar

References

• American Diabetes Association. 2. classification and diagnosis of diabetes: standards of medical care in diabetes-2019. Diabetes Care. 2019;42(Suppl 1):S13-S28. doi:10.2337/dc19-S002
• American College of Obstetricians and Gynecologists’ committee on practice bulletins-obstetrics. ACOG practice bulletin no. 201: pregestational diabetes mellitus. Obstet Gynecol. 2018;132(6):e228-e248. doi:10.1097/AOG.0000000000002960
• ACOG Practice Bulletin No. 190: Gestational Diabetes...: Obstetrics & Gynecology. Accessed December 27, 2024. https://journals.lww.com/greenjournal/abstract/2018/02000/acog_practice_bulletin_no__190__gestational.37.aspx
• Duygulu D, Mutlu Sütcüoğlu B, Turgut E, Özdemir H, Karçaaltıncaba D. Prospective evaluation of ultrasonographic fetal cardiac morphometry and functions in the third trimester of pregnancies with gestational diabetes mellitus. J Clin Ultrasound. 2024;52(9):1265-1272. doi:10.1002/jcu.23776
• Mitanchez D, Yzydorczyk C, Siddeek B, Boubred F, Benahmed M, Simeoni U. The offspring of the diabetic mother-short- and long-term implications. Best Pract Res Clin Obstet Gynaecol. 2015;29(2):256-269. doi:10.1016/j.bpobgyn.2014.08.004
• Rubarth LB. Infants of diabetic mothers. Neonatal Netw NN. 2013;32(6): 416-418. doi:10.1891/0730-0832.32.6.416
• Bayraktar B, Balıkoğlu M, Kanmaz AG. Pregnancy outcomes of women with hypoglycemia in the oral glucose tolerance test. J Gynecol Obstet Hum Reprod. 2020;49(4):101703. doi:10.1016/j.jogoh.2020.101703
• Bayraktar B, Balıkoğlu M, Bayraktar MG, Kanmaz AG. Number of relationships between abnormal values in oral glucose tolerance test and adverse pregnancy outcome. Indian J Med Spec. 2021;12(4):211-215. doi:10.4103/injms.injms_29_21
• Plows JF, Stanley JL, Baker PN, Reynolds CM, Vickers MH. The pathophysiology of gestational diabetes mellitus. Int J Mol Sci. 2018; 19(11):3342. doi:10.3390/ijms19113342
• Di Cianni G, Miccoli R, Volpe L, Lencioni C, Del Prato S. Intermediate metabolism in normal pregnancy and in gestational diabetes. Diabetes Metab Res Rev. 2003;19(4):259-270. doi:10.1002/dmrr.390
• Chen ZY, Mao SF, Guo LH, Qin J, Yang LX, Liu Y. Effect of maternal pregestational diabetes mellitus on congenital heart diseases. World J Pediatr WJP. 2023;19(4):303-314. doi:10.1007/s12519-022-00582-w
• Codazzi AC, Ippolito R, Novara C, Tondina E, Cerbo RM, Tzialla C. Hypertrophic cardiomyopathy in infant newborns of diabetic mother: a heterogeneous condition, the importance of anamnesis, physical examination and follow-up. Ital J Pediatr. 2021;47(1):197. doi:10.1186/s13052-021-01145-x
• Denizli R, Tanaçan A, Sakcak B, et al. Evaluation of the Caval Aortic Index in fetal growth restriction: a case-control study in a tertiary center. Int J Gynecol Obstet. 2023;163(1):186-193. doi:10.1002/ijgo.14808
• Durajska K, Januszkiewicz E, Szmygel Ł, Kosiak W. Inferior vena cava/aorta diameter index in the assessment of the body fluid status-a comparative study of measurements performed by experienced and inexperienced examiners in a group of young adults. J Ultrason. 2014; 14(58):273-279. doi:10.15557/JoU.2014.0027
• Miller JB, Sen A, Strote SR, et al. Inferior vena cava assessment in the bedside diagnosis of acute heart failure. Am J Emerg Med. 2012;30(5):778-783. doi:10.1016/j.ajem.2011.04.008
• Bhide A, Acharya G, Baschat A, et al. ISUOG Practice Guidelines (updated): use of Doppler velocimetry in obstetrics. Ultrasound Obstet Gynecol J Int Soc Ultrasound Obstet Gynecol. 2021;58(2):331-339. doi: 10.1002/uog.23698
• Tsakiridis I, Mamopoulos A, Athanasiadis A, Kourtis A, Dagklis T. Management of pregestational diabetes mellitus: a comparison of guidelines. J Matern Fetal Neonatal Med. 2022;35(3):423-432. doi:10.1080/14767058.2020.1719481
• Tonge HM, Struyk PC, Custers P, Wladimiroff JW. Vascular dynamics in the descending aorta of the human fetus in normal late pregnancy. Early Hum Dev. 1983;9(1):21-26. doi:10.1016/0378-3782(83)90098-1
• Szpinda M, Szpinda A, Woźniak A, Mila-Kierzenkowska C, Kosiński A, Grzybiak M. Quantitative anatomy of the growing abdominal aorta in human fetuses: an anatomical, digital and statistical study. Med Sci Monit Int Med J Exp Clin Res. 2012;18(10):BR419-426. doi:10.12659/msm.883483
• Skilton MR, Evans N, Griffiths KA, Harmer JA, Celermajer DS. Aortic wall thickness in newborns with intrauterine growth restriction. Lancet. 2005;365(9469):1484-1486. doi:10.1016/S0140-6736(05)66419-7
• Cosmi E, Visentin S, Fanelli T, Mautone AJ, Zanardo V. Aortic intima media thickness in fetuses and children with intrauterine growth restriction. Obstet Gynecol. 2009;114(5):1109-1114. doi:10.1097/AOG. 0b013e3181bb23d3
• Rizzo G, Arduini D, Romanini C. Inferior vena cava flow velocity waveforms in appropriate- and small-for-gestational-age fetuses. Am J Obstet Gynecol. 1992;166(4):1271-1280. doi:10.1016/s0002-9378(11)90621-8
• Uzun Çilingir I, Sayın C, Sutcu H, İnan C, Erzincan S, Varol F. Evaluation of inferior and superior vena cava and the vena cava ratio in growth restricted fetuses. J Ultrasound Med. 2023;42(11):2653-2659. doi: 10.1002/jum.16300
• Bilgin S, Topal FE, Yamanoğlu A, et al. Effect of changes in intravascular volume on inferior vena cava and aorta diameters and the Caval Aorta Index in healthy volunteers. J Ultrasound Med. 2020;39(2):231-238. doi: 10.1002/jum.15093
• Ornoy A, Becker M, Weinstein-Fudim L, Ergaz Z. Diabetes during pregnancy: a maternal disease complicating the course of pregnancy with long-term deleterious effects on the offspring. a clinical review. Int J Mol Sci. 2021;22(6):2965. doi:10.3390/ijms22062965
• Perkovic-Kepeci S, Cirkovic A, Milic N, et al. Doppler indices of the uterine, umbilical and fetal middle cerebral artery in diabetic versus non-diabetic pregnancy: systematic review and meta-analysis. Med Kaunas Lith. 2023;59(8):1502. doi:10.3390/medicina59081502
• Rane BM, Malau-Aduli BS, Alele F, O’Brien C. Prognostic accuracy of antenatal doppler ultrasound measures in predicting adverse perinatal outcomes for pregnancies complicated by diabetes: a systematic review. AJOG Glob Rep. 2023;3(3):100241. doi:10.1016/j.xagr.2023.100241
• Leung WC, Lam H, Lee CP, Lao TT. Doppler study of the umbilical and fetal middle cerebral arteries in women with gestational diabetes mellitus. Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol. 2004;24(5):534-537. doi:10.1002/uog.1730