#456 - [Journal Club] - 🫀 From The Heart - Why Does a Sicker Mom Sometimes Mean a Stronger Neonatal Heart?

In this small prospective pilot study, Adrianne and Nim explore a domain rarely discussed on rounds, how a mother's cardiovascular function in preeclampsia shapes her newborn's circulatory transition. Using maternal echo and neonatal electrical cardiometry across 13 mother-baby dyads, the authors found an inverse relationship: the worse the mother's cardiac function, the higher the neonate's cardiac output, though vascular tone barely budged. It's a compelling hypothesis about placental strain and fetal adaptation. But Nim pushes back hard on the methodology, pairing this paper with a companion study showing electrical cardiometry consistently overestimates cardiac output in neonates, and questioning why daily echoes were performed on these babies but the results never reported.

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Linking maternal and neonatal circulation in preeclampsia. Piani F, Annesi L, Degli Esposti D, Vincenzi S, De Crescenzo S, Della Gatta AN, Simonazzi G, Corvaglia L, Martini S.Am J Physiol Heart Circ Physiol. 2026 Mar 1;330(3):H708-H716. doi: 10.1152/ajpheart.00945.2025. Epub 2026 Jan 12.PMID: 41525138 Free article.

Transcript

Nim Goldshtrom (00:00.000)
So the next one I wanted to talk about is called "Linking Maternal and Neonatal Circulation in Preeclampsia," which I thought was interesting because it's a kind of novel domain for me, where you're looking at both the moms and the babies. First author is Piani, second author Annesi.

Adrianne Rahde Bischoff (00:31.510)
Great.

Adrianne Rahde Bischoff (00:34.516)
Senior author is Martini, and this paper was published now in 2026 in the American Journal of Physiology-Heart and Circulatory Physiology. So this was a prospective observational pilot study that enrolled 13 mother-and-baby dyads affected by early-onset preeclampsia. And what they did that was kind of unique,

at least from my perspective, was that they looked at maternal cardiovascular function using echo within three weeks before delivery, and then neonatal cardiovascular adaptation in the first 72 hours postpartum using electrical cardiometry. So, in terms of summary — I'm not going to go into the methodology in too much detail — key findings: they found an inverse association between maternal systolic function and neonatal cardiac output.

Meaning that the worse the cardiac output, ejection fraction, and tissue Doppler velocities in the mom, the higher the neonatal cardiac output. And that held even after adjusting for PDA and inotropic support. They reported minimal neonatal vascular adaptation. Even though maternal ejection fraction was positively associated with neonatal systemic vascular resistance in some adjusted models,

this effect actually weakened after PDA adjustment. The other finding was that neonates appeared to compensate for maternal hemodynamic impairment primarily by increasing cardiac output, but not really by altering vascular tone, which I think is interesting — not necessarily surprising, but interesting. So this is, to some extent, the first study to quantify maternal and neonatal hemodynamic coupling in early-onset preeclampsia.

So some of the things they did well: obviously this was a very novel study with a clinically meaningful question. It addresses a high-impact and underexplored area, where maternal cardiovascular adaptation directly influences neonatal hemodynamic transition — which has major implications we absolutely do not talk about these days for individualized neonatal care, and will just make our lives even more complicated if, besides looking at the baby, we also have to think about

Adrianne Rahde Bischoff (02:56.940)
the mom — besides what we typically do in a very broad stroke, like whether they have chorioamnionitis, diabetes, preeclampsia, and so on. They also used more robust physiologic measurements — they did maternal echo, which is essentially the gold standard for non-invasively assessing cardiac function, and then electrical cardiometry, which provides continuous, non-invasive neonatal data.

Nim Goldshtrom (03:50.240)
Yeah, so here's what I want to ask you, as our resident echo expert. In reading the methods section, it seems the methodology for the maternal echo was pretty standard — they performed LV (left ventricular) function and output assessments. I'll talk about electrical cardiometry in a second, but they did say they performed transthoracic echo in the babies, in the methods section, during those 72 hours, which is really interesting.

Nim Goldshtrom (03:54.656)
And I wanted to make sure I was reading that correctly a few times, because I kind of wonder why they would say that and only report the non-invasive data. Because if you do an echo on a baby — and this is where I need your expertise — how hard is it to get, you know, LV and RV output and ejection fraction in preterm infants, with either method? Honestly speaking, what's your experience?

Adrianne Rahde Bischoff (04:07.500)
It's not hard once you're trained, but it's not standard, right? And it's not standard to obtain quantitative measurements — specifically of output — in the cardiology world. We know it's feasible to train people, and we are part, here in Iowa, of the Echo Core Lab for a pivotal PDA trial, meaning we provided training for echo labs

Nim Goldshtrom (04:30.180)
That's standard, okay.

Nim Goldshtrom (04:33.784)
Sure, sure.

Adrianne Rahde Bischoff (04:48.994)
throughout the country as part of this multicenter study, to help obtain the measurements we use in our PDA severity score. As part of our PDA score, it does include measurements of left ventricular output and right ventricular output. So we know it's feasible — people can do it once they're trained. There's still technique

finessing that we provide feedback on, even to this day, as we're about 75% through enrollment. But it has gotten a lot better, and it is feasible — it's just not routinely acquired. So I'm not sure why that wasn't reported.

Nim Goldshtrom (05:21.400)
Sure.

Nim Goldshtrom (05:24.780)
This is great perspective, because on page seven, in the middle, they clearly say concomitant daily echocardiographic assessments were performed to assess neonatal cardiac function and ductal status. So I have to wonder — they did the echoes, they put on the electrical cardiometry monitor, and they only reported the electrical cardiometry data, which is interesting to me. So my second question for you — I go down to the end of the table, I think it's Table 1.

Adrianne Rahde Bischoff (05:48.900)
Ha, ha, ha.

Adrianne Rahde Bischoff (05:49.345)
Yeah.

Nim Goldshtrom (05:53.760)
And I look at some of the numbers there for cardiac output, stroke volume, SVR (systemic vascular resistance) — that cardiac output, 280 mL per kilogram per minute — is that what you'd expect for preterm infants? Is that — and in which direction is that? Too low? Too high? What are you seeing there?

Adrianne Rahde Bischoff (06:10.300)
Absolutely not.

Adrianne Rahde Bischoff (06:11.966)
It's definitely higher than what I'm used to. I will say, if the baby has a PDA that is hemodynamically significant, it's not completely out of the realm — but even then, in the first 72 hours of life, that's still higher than what I typically see. Most often, preterm infants — obviously it depends on gestational age, but most often preterm infants with a hemodynamically significant PDA are not able to mount

Nim Goldshtrom (06:20.150)
Yeah, correct.

Nim Goldshtrom (06:21.688)
Correct, correct — which a lot of these kids had, I think, from the reporting, yeah.

Adrianne Rahde Bischoff (06:41.440)
a much higher pre-ductal cardiac output. What happens is they end up with a lower post-ductal cardiac output, but they don't have such a high pre-ductal cardiac output. But we do know that's method-based — when we look at studies comparing non-invasive cardiac output measures with echo, we know they're discrepant. The value I find, at least to this day, is in using non-invasive methods as a trend —

Nim Goldshtrom (07:02.600)
Correct.

Adrianne Rahde Bischoff (07:10.198)
Right. If you have a baseline and it goes up or down, you can use it that way — not as an absolute value, which is kind of what they were reporting here.

Nim Goldshtrom (07:17.050)
Mm-hmm, correct.

Nim Goldshtrom (07:18.924)
So I'm so glad we're having this discussion, and I'm glad we picked this article, because it walks through the whole cascade of what I was hoping would be a teaching point, and I hope the audience appreciates it. I really hope the premise of this paper ends up being true — that preeclamptic mothers, with placentas under strain, show some kind of adaptive mechanism in the baby, and that this can help us understand certain maladaptive mechanisms — that when a

preterm baby comes out after being exposed to preeclampsia, seeing those expected changes in cardiac output and SVR may actually help us — if we're seeing those kids being either hypotensive or having high blood pressure, similar to what we see with HIE (hypoxic-ischemic encephalopathy) populations who have RV (right ventricular) failure or LV (left ventricular) dysfunction — that would totally make sense. However, based on everything you've just described in the study, this is not the study to establish that. So, my biases and problems with this —

on the Incubator site, we're going to also post these articles alongside another article which, in my opinion, describes exactly the problem here. So Anup Katheria and his group recently published a great paper called "Multimodal Approach to IVH (intraventricular hemorrhage) Using Echocardiography, NIRS (near-infrared spectroscopy), and Electrical Cardiometry in Preterm Infants." And the reason I mention it is that they highlight a problem this paper perfectly exhibits: electrical cardiometry is a great technology — it uses electrical impedance, the same as the telemetry leads we put on kids to get heart rate,

and then a proprietary technology, using equations that take the EKG signal and break it apart to give you the stroke volume under each QRS complex, essentially, with some adjustment for control variables, to give you an estimate of cardiac output. However, in data looking at infants, neonates, small children, and adults, the group with the worst confidence intervals and the most extreme bias and limits of agreement is neonates.

And the Katheria study perfectly summarizes that — the most modern study — showing that the values from electrical cardiometry, compared to LV and RV output by transthoracic echo and neonatal echocardiography, were much lower than electrical cardiometry's numbers. Electrical cardiometry often overestimates cardiac output, particularly in the neonatal population. So I was very suspicious when they said they performed echoes every single day on these kids

Nim Goldshtrom (09:43.320)
for function and ductal status, and then only wanted to report the electrical cardiometry data. And the value was so high, as you expertly told us, that there's something fishy here. It still might be true, and I hope it is, but this is not the study for that right now, in its current conception, without a more gold-standard comparison. There are reasonable limits of agreement for electrical cardiometry in neonates — it gets worse as cardiac output gets higher, but electrical cardiometry will consistently overestimate in the neonate. So

if you use it, use it as a trend marker, just like NIRS. NIRS is not a perfect point estimate, but it's a great trend marker. I personally haven't found that electrical cardiometry is a perfect trend marker either — maybe we're just not using it in the right populations. But this is why I wanted to discuss this article: a great concept, a great idea, not executed the way I'd think is best, statistically and methodologically. So it's wonderful to go through, and I hope the audience appreciates the nuances there.

Sounds good, all right. Have you guys ever used electrical cardiometry at all, tested it, studied it?

Nim Goldshtrom (11:01.388)
Yeah, yeah.

Adrianne Rahde Bischoff (11:13.408)
Only in research settings. We talk about some scenarios where we wonder if it would be helpful — in the preterm baby, for example, in the transitional period, we screen all our babies to look for a hemodynamically significant duct that we do treat pretty early on. But there are many babies where, by the time we do the screening echo, they still haven't quite transitioned — they have kind of a transitional physiology, still a bidirectional shunt, and we'll scan them again the next day, but sometimes we wonder — is this duct going to become an issue within six hours, within twelve hours, when we're not scanning? And perhaps if we had that trend of pre-ductal cardiac output, it would be a trigger to say, well, this baby's probably already transitioning — maybe we should do the echo sooner rather than later, or start therapy sooner rather than later. But it's all speculative — we don't actually use it in routine practice.

Nim Goldshtrom (11:47.200)
Same here. I did an early study several years ago, trying it on the congenital heart disease group after surgery — same problem. A lot of overshoot, not a lot of variance. So we use, again, NIRS — especially renal NIRS — as our early-warning indicator, because it just moved... it moved, but not to the same degree that renal NIRS does, in terms of being a good early-warning predictor. So I hope either technology gets better, or the ability to combine them gets better, but yeah — echo is still the gold standard.