\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[T2A]{fontenc}
\usepackage[polish,ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Assessment Of Fetal Cardiac Functions In Pregnant Women W\selectlanguage{polish}ı\selectlanguage{english}th Asthma\selectlanguage{english}}



\author[1]{Bergen LALELI KOC}%
\author[1]{Deniz Oluklu}%
\author[1]{Derya Uyan Hendem}%
\author[1]{Dilek Menekse Beser}%
\author[1]{Berchan Besimoglu}%
\author[1]{Atakan Tanacan}%
\author[1]{Doğa Öcal}%
\author[1]{Dilek Sahin}%
\affil[1]{Ankara Sehir Hastanesi}%


\vspace{-1em}



  
  \date{May 19, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Aim:This study aims to investigate the effects of maternal asthma on
fetal cardiac functions. Methods:The study was planned with 30 pregnant
women who presented to a tertiary health center and were diagnosed with
asthma and 60 healthy controls with similar gestational ages. The fetal
echocardiographic assessment was assessed between 33 and 35 weeks of
gestation with pulsed-wave Doppler (PW), M-mode, and tissue Doppler
imaging (TDI). Fetal cardiac functions were compared between maternal
asthma and control group. Cardiac functions were assessed according to
the duration of maternal asthma diagnosis, as well. Results:Early
diastolic function parameters, tricuspid E wave (p=0.001), and tricuspid
E/A ratio (P=0.005) were significantly lower in the group with maternal
asthma. TAPSE and MAPSE values were statistically lower in the study
group than in the control group; p=0.010 and p=0.012, respectively.
Parameters assessed with TDI (E', A', S', E/E', and MPI' of tricuspid
valves) and global cardiac function parameters assessed with pulsed-wave
Doppler like myocardial performance index (MPI) and left cardiac output
(LCO) were similar between groups (p\textgreater{} 0.05). Although, MPI
did not change between groups, and the isovolumetric relaxation time
(IVRT) value was prolonged in maternal asthma cases (p=0.025).
Conclusion:We found that maternal asthma disease causes alteration in
fetal diastolic and early systolic cardiac functions, but the global
fetal cardiac function does not change. Diastolic heart function values
also varied with the duration of maternal asthma. Prospective studies
are needed to compare fetal cardiac functions with additional patient
groups according to disease severity and type of medical treatment.%
\end{abstract}%



\sloppy


\textbf{Title}

Assessment Of Fetal Cardiac Functions In Pregnant Women W\selectlanguage{polish}ı\selectlanguage{english}th Asthma

\textbf{Short Title}

Fetal cardiac functions in maternal asthma

\textbf{Author information}

Author 1,

Bergen Laleli Koc, Department of Obstetrics and Gynecology, Division of
Perinatology, Turkish Ministry of Health Ankara Bilkent City Hospital,
Ankara, Turkey. E-mail: bergen.laleli@gmail.com . ORCID ID:
0000-0001-8029-7489

Author 2,

Deniz Oluklu, Department of Obstetrics and Gynecology, Division of
Perinatology, Turkish Ministry of Health Ankara Bilkent City Hospital,
Ankara, Turkey. E-mail: denizoluklu9@gmail.com . ORCID ID:
0000-0002-9050-2041

Author 3,

Derya Uyan Hendem, Department of Obstetrics and Gynecology, Division of
Perinatology, Turkish Ministry of Health Ankara Bilkent City Hospital,
Ankara, Turkey. E-mail: drderyauyan@gmail.com . ORCID ID:
0000-0003-1866-7295

Author 4,

Dilek Menekse Beser, Department of Obstetrics and Gynecology, Division
of Perinatology, Turkish Ministry of Health Ankara Bilkent City
Hospital, Ankara, Turkey. E-mail: dilekmbeser@gmail.com . ORCID ID:
0000-0002-7022-0610

Author 5,

Berchan Besimoglu, Department of Obstetrics and Gynecology, Division of
Perinatology, Turkish Ministry of Health Ankara Bilkent City Hospital,
Ankara, Turkey. E-mail: berhan\_besimoglu@yahoo.com . ORCID ID:
0000-0003-0376-2513

Author 6,

Atakan Tanacan, Department of Obstetrics and Gynecology, Division of
Perinatology, Turkish Ministry of Health Ankara Bilkent City Hospital,
Ankara, Turkey. E-mail: atakantanacan@yahoo.com . ORCID ID:
0000-0001-8209-8248

Author 7,

Fatma Doga Ocal, Department of Obstetrics and Gynecology, Division of
Perinatology, Turkish Ministry of Health Ankara Bilkent City Hospital,
Ankara, Turkey. E-mail: eadoga@yahoo.com . ORCID ID: 0000-0003-4727-7982

Author 8,

Dilek Sahin, Department of Obstetrics and Gynecology, Division of
Perinatology, Ankara Bilkent City Hospital, Turkish Ministry of Health,
University of Health Sciences, Ankara, Turkey. E-mail:
dilekuygur@gmail.com . ORCID ID: 0000-0001-8567-9048

Corresponding author: Bergen Laleli Koc

Mailing address: Department of Obstetrics and Gynecology, Division of
Perinatology, Turkish Ministry of Health Ankara Bilkent City Hospital,
Ankara, Turkey.

E-mail: bergen.laleli@gmail.com

Phone number: +905079320818\textbf{AbstractAim:} This study aims to
investigate the effects of maternal asthma on fetal cardiac
functions.\textbf{Methods:} The study was planned with 30 pregnant women
who presented to a tertiary health center and were diagnosed with asthma
and 60 healthy controls with similar gestational ages. The fetal
echocardiographic assessment was assessed between 33 and 35 weeks of
gestation with pulsed-wave Doppler (PW), M-mode, and tissue Doppler
imaging (TDI). Fetal cardiac functions were compared between maternal
asthma and the control group. Cardiac functions were assessed according
to the duration of maternal asthma diagnosis, as well.\textbf{Results:}
Early diastolic function parameters, tricuspid E wave (p=0.001), and
tricuspid E/A ratio (P=0.005) were significantly lower in the group with
maternal asthma. TAPSE and MAPSE values were statistically lower in the
study group than in the control group; p=0.010 and p=0.012,
respectively. Parameters assessed with TDI (E', A', S', E/E', and MPI'
of tricuspid valves) and global cardiac function parameters assessed
with pulsed-wave Doppler like myocardial performance index (MPI) and
left cardiac output (LCO) were similar between groups (p\textgreater{}
0.05). Although, MPI did not change between groups, and the
isovolumetric relaxation time (IVRT) value was prolonged in maternal
asthma cases (p=0.025).\textbf{Conclusion:} We found that maternal
asthma disease causes alteration in fetal diastolic and early systolic
cardiac functions, but the global fetal cardiac function does not
change. Diastolic heart function values also varied with the duration of
maternal asthma. Prospective studies are needed to compare fetal cardiac
functions with additional patient groups according to disease severity
and type of medical treatment.\textbf{Keywords:} fetal echocardiography,
asthma, pregnancy, fetal cardiac function.

\textbf{Introduction}

Asthma is a multifactorial, immune-mediated inflammatory disease. The
pathophysiology of the disease is reversible lower airway constriction
due to intermittent smooth muscle constriction in response to
environmental allergens, infections, and irritants \textsuperscript{1}.
Asthma is a common chronic inflammatory disease in pregnancy and has
become one of the most common public health problems worldwide. In
general, asthma is thought to worsen with pregnancy in one-third of
patients, improve in one-third, and have no significant change in the
remaining patients. However, recent multiple case-control studies show
that the percentage of asthma patients who worsen during pregnancy,
18.8\%, is lower than previous data and is related to disease
severity\textsuperscript{2}.

The diaphragm rises by 4-5 cm, and the subcostal angle increases by 50\%
with pregnancy. As a result, total lung volume and functional residual
capacity decreased by 5\% and 20\%, respectively. Increased body weight
also contributes to dyspnea during pregnancy. Progesterone is a
stimulant of respiratory dynamics that can increase the sensitivity of
the respiratory center to carbon dioxide, while estrogen increases the
sensitivity of progesterone receptors in the respiratory system and is
jointly involved in altering respiratory function \textsuperscript{2}.
Studies have shown that maternal asthma increases the risk of
complications, including small for gestational age, low birth weight,
congenital malformations, preterm birth, gestational hypertension and
preeclampsia, diabetes, and perinatal mortality in fetuses and mothers.
The cesarean section rate is higher in patients with severe or
uncontrolled asthma during pregnancy than in the healthy pregnant
population due to adverse perinatal outcomes \textsuperscript{3}.

Mediators of human basophil cells interact with environmental factors,
allergens, and irritants. These mediators are associated with oxidative
stress in the cord blood of newborns of mothers with atopic
asthma\textsuperscript{4}. Chronic fetal infections and hypoxia are
examples of adverse conditions that impair cardiac myogenesis during
complicated pregnancy and increase the lifetime risk of heart
disease\textsuperscript{5}. In one study, neutrophil-triggered
inflammation of the placenta was found to lead to inadequate placental
development and a lack of barrier function. As a result, maternally
derived inflammatory monocytes from the placenta may migrate into the
embryonic heart and alter the structure of cardiac tissue and the normal
composition of resident cardiac macrophages \textsuperscript{6}.

The circulatory physiology of the fetus is different from that of the
newborn. The right ventricle provides greater cardiac output from the
second half of pregnancy until delivery \textsuperscript{7}. Assessment
of cardiac function by fetal echocardiography allows earlier detection
of changes in cardiac morphology and may help predict perinatal and
long-term cardiovascular outcomes. We hypothesized that chronic
inflammation in pregnant women with asthma might affect fetal cardiac
function. This study aimed to assess fetal cardiac function in pregnant
women with asthma compared with a healthy group.

\textbf{Methods Study Population}This study was performed on 90 fetuses
without cardiac abnormalities, including 30 fetuses of mothers with
asthma and 60 fetuses of the uncomplicated healthy pregnant population.
thirty pregnant women with asthma who visited the perinatology
outpatient department of Ankara City Hospital in Ankara from May 2022 to
October 2022 were included in the study. Fetal examinations were
performed between 33 and 35 weeks of gestation. The study protocol was
approved by the Medical Research Ethics Department of Ankara City
Hospital and was conducted according to the guidelines of the
Declaration of Helsinki. (E2-22-2392). Written informed consent was
obtained from the study participants. Pregnant women diagnosed with
preeclampsia, diabetes mellitus, and other chronic maternal and
pregnancy-related diseases, multiple pregnancies, fetal growth
restriction, fetal structural or chromosomal abnormalities, premature
rupture of membranes, and taking medications other than antiasthmatic
drugs were excluded from the study. Other exclusion criteria included
maternal tobacco use and signs of fetal infection. Healthy pregnant
women in a similar gestational week range were randomly selected as a
control group. Maternal information, sociodemographic characteristics,
and obstetric history were recorded. The year of asthma diagnosis and
medication of the patients were recorded. Based on risk and
exacerbation, asthma is classified as intermittent, mild persistent,
moderate persistent, and severe persistent \textsuperscript{8}. Our
study included only patients receiving combination drugs such as inhaled
corticosteroids and long-acting B2 agonists. Well-controlled asthma
patients were included in the study according to the ACOG
guideline\textsuperscript{9}. All patients were asymptomatic at the time
of the study. Asthma controls were intermittent throughout pregnancy,
and no attack was observed.\textbf{Measurements}All ultrasound
examinations were performed with the Voluson E8 ultrasound system (GE
Medical System, Milwaukee, WI, USA) with a convex 2-5-MHz ultrasound
transducer. All ultrasound examinations were performed by a perinatology
fellow BLK and checked by FD\selectlanguage{ngerman}Ö who is an associate professor and has
almost ten years of experience in maternal-fetal medicine. First, the
fetus was anatomically examined with 2DUS, the biophysical profile of
all fetuses showed fetal well-being, and the estimated fetal weights
were appropriate for gestational age. Standard fetoplacental Doppler
indices were performed, including the determination of the pulsation
index for the umbilical artery and middle cerebral artery. The fetal
echocardiographic assessment was performed with two-dimensional (2D)
imaging, M-mode imaging, pulsed-wave Doppler (PW), and tissue Doppler
imaging (TDI). Doppler parameters were assessed in the absence of fetal
motion. The angle of insonation was less than 20 degrees from the
direction of blood flow, and measurements were made on at least three
consecutive waveforms. These parameters were collected prospectively at
33 to 35 weeks gestation. Recorded perinatal outcomes included
gestational age at delivery, body mass index (BMI), mode of delivery,
birth weight, and APGAR scores. Mitral and tricuspid valve early
diastole (E) and atrial contraction (A) were measured with PW Doppler by
placing the cursor directly under the tricuspid and mitral valve
leaflets in the apical four-chamber view. The E/A ratio was calculated
\textsuperscript{10}. Tissue Doppler was examined at the tricuspid
annuli in the apical or basal four-chamber view in spectral Doppler
mode. Peak velocities of the tricuspid valve in early diastole (E'),
atrial contraction (A'), and systole (S') were measured with an
insonation angle of less than 30 degrees without angular correction by
placing the cursor on the lateral side of the tricuspid valve, adjusting
the sample volume by 2-4 mm with TDI. Tricuspid velocity parameters were
recorded in the same cardiac cycle\textsuperscript{11}. The three most
distinct waveforms and valve click with a fetal heart rate in the normal
range (120-160 beats/min) were measured, and the values were averaged.
E/E' indices were calculated for the tricuspid valve. After obtaining a
clear image of the mitral and aortic valves in the five-chamber view of
the heart, the sample volume was placed on the medial wall of the
ascending aorta containing the aortic and mitral flows. Valvular clicks
were used as cues for the calculation of each period. Myocardial
performance index (MPI) was calculated from the waveform obtained
(isovolumetric contraction time (IVCT) + isovolumetric relaxation time
(IVRT)/ejection time (ET))\textsuperscript{12}.

Sample volumes were placed in the basal part of the right ventricular
wall (tricuspid annulus). All velocities were measured during the same
cardiac cycle, and no angular correction was applied. To calculate the
right MPI' with TDI, the following time periods were examined:
isovolumetric contraction time (IVCT'), ejection time (ET'), and
isovolumetric relaxation time (IVRT'). MPI' was calculated as (IVCT' +
IVRT') / ET' \textsuperscript{11}. Measurements of mitral annular plane
systolic excursion (MAPSE) and tricuspid annular plane systolic
excursion (TAPSE) were performed on the free walls in the four-chamber
view with apical or basal position of the fetal heart with M-mode
imaging. The cursor was placed vertically at the atrioventricular
junction, and measurements were performed. The maximum amplitude motion
was considered as the magnitude of displacement between the end-systolic
and end-diastolic regions and was measured in
millimeters\textsuperscript{13}.

Statistical analysis IBM SPSS version 25 software (IBM Corp. Released
2017. IBM SPSS Statistics for Windows, version 25.0. Armonk, NY: IBM
Corp.) was used for statistical analyses. The sample size was calculated
using G Power software (version 3.1 Franz Foul, Kiel University). It was
determined that at least 30 participants had to be included to achieve a
mean effect size of 0.50 and 95\% power at a significance level of
\textless{} 0.05 \textsuperscript{14}. Control cases were planned as 60
participants as well. The Kolmogorov-Smirnov test was used whether the
variables were normally distributed or not. Because the variables were
normally distributed, descriptive analyses were reported as mean and
standard deviation. A percentile calculation was performed for asthma
duration. The top quartile (75th percentile) over twelve years of asthma
duration was determined. Comparison of nonnormally distributed
quantitative data (asthma duration) between two independent groups was
performed using the Mann-Whitney U test, and the data were expressed as
the median (interquartile range). Student's t-test was used to compare
the measured values of two independent groups, and Pearson's test was
used for correlation coefficients. P value below 0.05 was accepted as
statistically significant.

\textbf{Results}

The clinical characteristics and perinatal outcomes of the study groups
are shown in Table 1. Gestational age (p=0.104) and BMI (p=0.145) were
similar between groups. Maternal age (p=0.042), gravidity (p=0.010), and
parity (p=0.017) were higher in the maternal asthma group than in the
control group. APGAR scores at 1st and 5th minutes, birth weight, and
gestational age at birth did not differ between groups.

Table 1. Clinical features and perinatal outcomes between the groups\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Asthma (N:30) Mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Control (N:60) Mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
P value \textsuperscript{a}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Gestational age at examination\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
34.06 \selectlanguage{ngerman}± 0.90\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
34.35 \selectlanguage{ngerman}± 0.76\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.104\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Maternal age\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
29.23 \selectlanguage{ngerman}± 4.84\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
27.13 \selectlanguage{ngerman}± 4.38\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.042*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Gravida\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2.70 \selectlanguage{ngerman}± 1.95\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.85 \selectlanguage{ngerman}± 1.13\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.010*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Parity\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.23 \selectlanguage{ngerman}± 1.05\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.65 \selectlanguage{ngerman}± 0.39\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.017*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
BMI\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
25.84 \selectlanguage{ngerman}± 2.67\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
25.06 \selectlanguage{ngerman}± 2.17\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.145\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Gestational age at birth\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
38.50 \selectlanguage{ngerman}± 1.04\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
37.96 \selectlanguage{ngerman}± 1.60\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.097\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Birth weight\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3257 \selectlanguage{ngerman}± 524\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3123 \selectlanguage{ngerman}± 367\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.161\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
APGAR score 1 min\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
7.23 \selectlanguage{ngerman}± 0.72\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
7.35 \selectlanguage{ngerman}± 0.73\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.477\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
APGAR score 5 min\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
8.63 \selectlanguage{ngerman}± 0.66\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
8.61 \selectlanguage{ngerman}± 0.64\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.909\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textsuperscript{a} Independent Sample-t test was used to compare the
values of two independent groups. * values show statistical significance
at the p\textless{}0.05 level.\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textsuperscript{a} Independent Sample-t test was used to compare the
values of two independent groups. * values show statistical significance
at the p\textless{}0.05 level.\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textsuperscript{a} Independent Sample-t test was used to compare the
values of two independent groups. * values show statistical significance
at the p\textless{}0.05 level.\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textsuperscript{a} Independent Sample-t test was used to compare the
values of two independent groups. * values show statistical significance
at the p\textless{}0.05 level.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

A comparison of the fetal Doppler indices and cardiac function
measurements of maternal asthma and control groups is shown in Table 2.
Doppler indices did not differ between groups. The Tricuspid E wave
velocity and tricuspid E/A ratio measured by pulse wave were
statistically different between groups. (p=0.001) and (p=0.005),
respectively. These parameters were lower in the case group. Left
ventricular IVRT was statistically different between groups (p=0.025)
and was longer in the asthma group, 45.06\selectlanguage{ngerman}±8.47 ms (mean±SD), than in the
control group, 40.98±7.76 ms (mean±SD). When the M-mode technique was
used, the mean values of the TAPSE (p=0.010) and MAPSE (p=0.012)
measurements were statistically different between the groups. The mean
value of TAPSE was 8.17±1.32 mm and the mean value of MAPSE was
6.97±1.39 mm in the case group, and these values were significantly
lower in the asthma group than in the control group.

Table 2. Comparison of Doppler indices and fetal cardiac function
measurements between the groups.\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Asthma (N:30) Mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Control (N:60) Mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
P value\textsuperscript{a}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Doppler Indices\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Umb. A S/D\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2.60 \selectlanguage{ngerman}± 0.40\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2.46 \selectlanguage{ngerman}± 0.33\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.161\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Umb. A PI\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.97 \selectlanguage{ngerman}± 0.18\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.89 \selectlanguage{ngerman}± 0.18\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.083\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
MCA PI\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.80 \selectlanguage{ngerman}± 0.36\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.64 \selectlanguage{ngerman}± 0.45\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.104\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Cardiac Function\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
PW Doppler\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Tricuspid E (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
37.30 \selectlanguage{ngerman}± 5.52\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
40.73 \selectlanguage{ngerman}± 4.06\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.001*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Tricuspid A (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
58.56 \selectlanguage{ngerman}± 4.55\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
58.92 \selectlanguage{ngerman}± 5.46\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.758\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Tricuspid E/A ratio\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.63 \selectlanguage{ngerman}± 0.09\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.69 \selectlanguage{ngerman}± 0.07\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.005*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Mitral E (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
34.81 \selectlanguage{ngerman}± 6.27\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
33.84 \selectlanguage{ngerman}± 7.41\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.540\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Mitral A (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
47.52 \selectlanguage{ngerman}± 7.98\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
49.97 \selectlanguage{ngerman}± 10.19\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.253\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Mitral E/A ratio\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.73 \selectlanguage{ngerman}± 0.09\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.68 \selectlanguage{ngerman}± 0.13\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.091\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
LV IVCT (ms)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
36.30 \selectlanguage{ngerman}± 6.65\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
34.13 \selectlanguage{ngerman}± 6.00\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.123\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
LV ET (ms)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
164.13 \selectlanguage{ngerman}± 20.95\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
160.41 \selectlanguage{ngerman}± 16.25\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.357\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
LV IVRT (ms)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
45.06 \selectlanguage{ngerman}± 8.47\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
40.98 \selectlanguage{ngerman}± 7.76\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.025*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
LV MPI\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.50 \selectlanguage{ngerman}± 0.09\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.47 \selectlanguage{ngerman}± 0.08\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.093\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
LCO\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
340 \selectlanguage{ngerman}± 109\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
378 \selectlanguage{ngerman}± 104\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.111\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Tricuspid E/E' ratio\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5.04 \selectlanguage{ngerman}± 1.92\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5.00 \selectlanguage{ngerman}± 0.90\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.901\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
TDI\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Tricuspid E' (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8.07 \selectlanguage{ngerman}± 2.02\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8.33 \selectlanguage{ngerman}± 1.35\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.465\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Tricuspid A' (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
13.31 \selectlanguage{ngerman}± 3.11\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
13.27 \selectlanguage{ngerman}± 1.98\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.942\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Tricuspid E'/A' ratio\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.61 \selectlanguage{ngerman}± 0.09\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.63 \selectlanguage{ngerman}± 0.08\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.257\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Tricuspid S' (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
11.53 \selectlanguage{ngerman}± 7.82\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9.77 \selectlanguage{ngerman}± 2.20\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.109\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
RV IVCT' (ms)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
41.46 \selectlanguage{ngerman}± 9.26\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
40.60 \selectlanguage{ngerman}± 9.95\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.694\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
RV ET' (ms)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
159.33 \selectlanguage{ngerman}± 17.10\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
155.30 \selectlanguage{ngerman}± 17.44\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.302\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
RV IVRT' (ms)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
47.23 \selectlanguage{ngerman}± 12.13\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
44.50 \selectlanguage{ngerman}± 8.40\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.217\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
RV MPI'\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.55 \selectlanguage{ngerman}± 0.11\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.54 \selectlanguage{ngerman}± 0.07\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.429\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
M-Mode\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
TAPSE (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8.17 \selectlanguage{ngerman}± 1.32\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8.86 \selectlanguage{ngerman}± 1.09\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.010*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
MAPSE (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6.97 \selectlanguage{ngerman}± 1.39\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
7.64 \selectlanguage{ngerman}± 1.03\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.012*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textsuperscript{a} Independent Sample-t test was used to compare the
values of two independent groups. * values show statistical significance
at the p\textless{}0.05 level.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textsuperscript{a} Independent Sample-t test was used to compare the
values of two independent groups. * values show statistical significance
at the p\textless{}0.05 level.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textsuperscript{a} Independent Sample-t test was used to compare the
values of two independent groups. * values show statistical significance
at the p\textless{}0.05 level.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textsuperscript{a} Independent Sample-t test was used to compare the
values of two independent groups. * values show statistical significance
at the p\textless{}0.05 level.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textsuperscript{a} Independent Sample-t test was used to compare the
values of two independent groups. * values show statistical significance
at the p\textless{}0.05 level.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textsuperscript{a} Independent Sample-t test was used to compare the
values of two independent groups. * values show statistical significance
at the p\textless{}0.05 level.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

A comparison of fetal cardiac functions as a function of asthma duration
is shown in Table 3. We found that 12 years or more maternal asthma
duration represented the top quartile of asthma duration. The asthma
duration of 8 pregnant women with asthma was twelve years or more. The
parameters of diastolic dysfunction such as mitral E wave velocity
(p=0.031), mitral A wave velocity (p=0.013), tricuspid E wave velocity
(p=0.034), and tricuspid A wave velocity (p=0.020) were significantly
different between the pregnant women with asthma duration of 12 years
and more compared to pregnant women with asthma of less than 12 years.

Table 3. Comparison of fetal cardiac functions according to asthma
duration\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Asthma\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Duration \textless{}12 years N:22\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Duration [?]12 years N:8\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
P value\textsuperscript{b}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Global Function\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LV MPI\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.51 (0.47-0.56)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.46 (0.39-0.57)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.372\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
RV MPI'\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.58 (0.51-0.66)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.51 (0.48-0.57)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.100\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LCO\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
320 (251-389)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
341 (297-370)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.851\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Systolic Function\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LV IVCT (ms)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
38 (33-40)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
34 (28-41)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.383\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LV ET (ms)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
165 (153-177)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
164 (159-168)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.622\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
RV IVCT' (ms)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
40 (33-47)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
41 (37-47)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.759\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
RV ET' (ms)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
160 (142-173)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
165 (154-175)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.302\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Tricuspid S' (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
8.67 (6.69-10.04)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17.20 (7.91-19.78)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.083\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
TAPSE (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7.73 (7.03-9.48)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
8.15 (7.35-9.15)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.870\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
MAPSE (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6.81 (6.20-7.45)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6.69 (5.85-8.62)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.907\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Diastolic Function\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LV IVRT (ms)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
45 (40-50)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
36 (34-49)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.063\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
RV IVRT'\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
50 (42-58)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
43 (40-47)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.260\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Mitral E (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
32.1 (28.9-38.5)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
41.3(35.1-43.9)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.031*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Mitral A (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
45.4 (40.0-48.1)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
53.0 (48.5-61.7)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.013*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Mitral E/A ratio\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.75 (0.68-0.81)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.71 (0.65-0.76)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.399\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Tricuspid E (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
36.8 (35.0-43.6)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
35.3 (32.5-36.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.034*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Tricuspid A (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
60.8 (56.0-62.9)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
56.7 (51.9-58.5)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.020*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Tricuspid E/A ratio\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.65 (0.57-0.72)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.63 (0.56-0.69)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.606\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Tricuspid E' (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
8.1 (6.6-9.1)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9.2 (7.1-10.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.223\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Tricuspid A' (cm/sec)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
11.7 (10.3-14.9)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
15.3 (12.7-16.9)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.087\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Tricuspid E'/A' ratio\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.64 (0.56-0.71)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.58 (0.51-0.65)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.214\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Tricuspid E/E' ratio\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5.05 (4.01-6.00)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.73 (3.10-5.17)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.159\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textsuperscript{b}Mann Whitney U test was used to compare the
measurement values of two independent groups. Values were presented
Median (IQR). * values show statistical significance at the
p\textless{}0.05 level.\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textsuperscript{b}Mann Whitney U test was used to compare the
measurement values of two independent groups. Values were presented
Median (IQR). * values show statistical significance at the
p\textless{}0.05 level.\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textsuperscript{b}Mann Whitney U test was used to compare the
measurement values of two independent groups. Values were presented
Median (IQR). * values show statistical significance at the
p\textless{}0.05 level.\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textsuperscript{b}Mann Whitney U test was used to compare the
measurement values of two independent groups. Values were presented
Median (IQR). * values show statistical significance at the
p\textless{}0.05 level.\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textsuperscript{b}Mann Whitney U test was used to compare the
measurement values of two independent groups. Values were presented
Median (IQR). * values show statistical significance at the
p\textless{}0.05 level.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

The correlation between the duration of maternal asthma and fetal
cardiac functions is shown in Table 4. A positive correlation was found
between mitral E wave velocity, A wave velocity, and duration of
maternal asthma. A negative correlation was found for the tricuspid A
wave velocity with maternal asthma duration.

Table 4. Correlation of maternal asthma duration and fetal cardiac
functions\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
Asthma duration & Tricuspid A wave & Mitral E wave & Mitral A
wave\tabularnewline
R value\textsuperscript{c} & -0.406 & 0.511 & 0.556\tabularnewline
P value\textsuperscript{c} & 0.026* & 0.004* & 0.001*\tabularnewline
\textsuperscript{c} Pearson Correlation test was used to determine the
correlation between maternal asthma duration and fetal cardiac
functions. * values show statistical significance at the
p\textless{}0.05 level. & \textsuperscript{c} Pearson Correlation test
was used to determine the correlation between maternal asthma duration
and fetal cardiac functions. * values show statistical significance at
the p\textless{}0.05 level. & \textsuperscript{c} Pearson Correlation
test was used to determine the correlation between maternal asthma
duration and fetal cardiac functions. * values show statistical
significance at the p\textless{}0.05 level. & \textsuperscript{c}
Pearson Correlation test was used to determine the correlation between
maternal asthma duration and fetal cardiac functions. * values show
statistical significance at the p\textless{}0.05 level.\tabularnewline
\bottomrule
\end{longtable}

\textbf{Discussion}

In our study, we aimed to investigate whether or not the inflammatory
process associated with maternal asthma affects fetal cardiac functions.
Fetal cardiac function measurements from pregnant women with asthma in
the asymptomatic period of the disease and with uncomplicated
pregnancies were compared with those from healthy pregnancies. Fetal
right and left ventricular functions were studied using different
ultrasound techniques such as pulse wave Doppler, spectral TDI, and
M-mode. Using the pulse wave Doppler technique, we found that the
tricuspid E wave velocity and tricuspid E/A ratio were lower in the
fetuses of mothers with asthma compared with the control group. This
finding showed us that an early diastolic change began in the fetuses of
pregnant women with asthma. While MPI and LCO parameters, which are
indicators of global cardiac function, did not change, it was observed
that the left ventricular IVRT value, which is one of the MPI
parameters, was prolonged in the asthma group, which is another marker
of diastolic change in the heart. In the study performed with the M-mode
technique, we found significantly lower MAPSE and TAPSE values in
fetuses of pregnant women with asthma. A significant difference was
found between an asthma diagnosis duration of 12 years or more and a
duration of less than 12 years in both atrioventricular valves E and A
wave velocities. We found that the duration of maternal asthma was
negatively correlated with the tricuspid A wave velocity and positively
correlated with the mitral E wave velocity and A wave velocity. In adult
cardiac dysfunction cases, diastolic functions are affected in the early
phase and systolic functions in the later phase. The E/A ratio reflects
the ventricular inflow pattern, and this ratio is used to assess
diastolic function or ventricular relaxation. Parameters such as annular
displacement or velocities, which indicate longitudinal function, are
typically impaired in the very early stages of fetal cardiac dysfunction
compared with radial function parameters such as ejection fraction and
cardiac output. Similarly, diastolic parameters such as IVRT are the
first to be altered to reflect impaired relaxation\textsuperscript{15}.
The E/A ratio partly reflects cardiac preload, whereas the outflow tract
reflects cardiac afterload and is often considered together. MPI is an
early and reliable marker that indicates global myocardial function
\textsuperscript{16} and provides data on different periods during the
systolic phase of the cardiac cycle. IVRT is the most important
parameter of MPI affected in complicated pregnancies. In general,
impaired ventricular dysfunction is associated with higher MPI values,
which is due to the prolongation of IVRT. Increased IVRT is associated
with decreased ET. IVCT is the most stable parameter of MPI
\textsuperscript{10}. Reduced E/A ratios and increased MPI values in
IUGR fetuses have been demonstrated in the
literature\textsuperscript{17-19}. Interestingly, some studies found
higher left ventricular MPI values and higher E/A ratios in fetuses with
PPROM with microbial invasion of the amniotic cavity and with signs of
fetal inflammatory response syndrome \textsuperscript{20, 21}. In
another study investigating fetal heart functions in maternal familial
Mediterranean fever (FMF) associated with chronic inflammation, it was
found that fetal diastolic functions might be altered in fetuses of
mothers with FMF. As the duration of maternal FMF increases, systolic
functions may also change \textsuperscript{14}. In our study, we found
that MPI and LCO parameters did not change, but E wave and E/A ratio
values were lower in the asthma group. We also found a prolongation of
IVRT in the asthma group. TDI is a method of estimating early
preclinical cardiac dysfunction by measuring the velocity of myocardial
movement. Comas et al. suggested that TDI may be a more sensitive method
than conventional echocardiographic techniques for assessing fetal
cardiac dysfunction\textsuperscript{11}. TDI also allows measurement of
MPI similar to pulsed Doppler. The E/E' ratio, the ratio of early
tricuspid annular velocity (E') to early peak filling velocity of the
tricuspid valve (E), is one of the echocardiographic parameters of
diastolic function in the prenatal period \textsuperscript{7}. Some
studies have investigated fetal cardiac functional changes in fetuses
with IUGR using the s-TDI technique \textsuperscript{18, 22}. Our study
did not find any difference between the groups in the parameters
examined by the TDI method.

The M-mode method can be used to assess the longitudinal motion of the
heart. This approach is best suited for the examination of the right
ventricle. Longitudinal cardiac function, which is driven by
longitudinal myocardial fibers, is considered the first function to be
affected in the presence of hypoxia. In a study, it was found that all
annular parameters indicative of subclinical cardiac dysfunction
decreased significantly in the IUGR group. In this study, it was found
that M-mode examination showed the same performance as a classifier
compared with TDI examination, especially in the tricuspid
annulus\textsuperscript{23}. In our study, we found that MAPSE and TAPSE
levels were decreased in the maternal asthma group compared with the
control group. However, asthma duration did not affect MAPSE and TAPSE
scores.

\textbf{Limitations}

One of the major limitations of our study is that the sample group is
small and it is a single-center study. In addition, inflammatory markers
in maternal blood and cord blood were not studied. The results were not
confirmed by echocardiography at postnatal follow-up of the newborns,
which is another limitation of our study. There are insufficient data in
the literature on the fetal cardiac effects of inhaled corticosteroid
use. No subgroup analysis was performed according to the severity of
maternal asthma and the type of medical treatment.\textbf{Conclusion}To
our knowledge, this is the first study to examine fetal cardiac function
in pregnant women with asthma. We found that maternal asthma affects
fetal diastolic and early systolic cardiac functions, but global fetal
cardiac functions do not change. Diastolic heart functions may be
affected by the duration of maternal asthma. We believe that fetal
echocardiographic assessment plays an important role in maternal
systemic and inflammatory diseases. Further studies are needed to
compare fetal cardiac function parameters in relation to disease
severity and type of medical treatment with additional patient groups.

\textbf{Acknowledgments}

The authors want to acknowledge health professionals working in Ankara
City Hospital Perinatology Department.

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest.

\textbf{Funding}

There is no funding in this study.

\textbf{References}

1. Patel, S. J.; Teach, S. J., Asthma. \emph{Pediatr Rev}
\textbf{2019,}\emph{40} (11), 549-567.

2. Wang, H.; Li, N.; Huang, H., Asthma in Pregnancy: Pathophysiology,
Diagnosis, Whole-Course Management, and Medication Safety. \emph{Can
Respir J} \textbf{2020,} \emph{2020} , 9046842.

3. Murphy, V. E.; Schatz, M., Asthma in pregnancy: a hit for
two.\emph{Eur Respir Rev} \textbf{2014,} \emph{23} (131), 64-8.

4. Ling, Y.; Yin-Shi, G.; Hong-Wei, S.; Yan, Z.; Qiang, L.; Ye, T.;
Ying, X., Oxidative stress status in umbilical cord blood from neonates
born to mothers with atopic asthma. \emph{J Matern Fetal Neonatal
Med}\textbf{2014,} \emph{27} (2), 192-6.

5. Frasch, M. G.; Giussani, D. A., Impact of Chronic Fetal Hypoxia and
Inflammation on Cardiac Pacemaker Cell Development.
\emph{Cells}\textbf{2020,} \emph{9} (3).

6. Ward, E. J.; Bert, S.; Fanti, S.; Malone, K. M.; Maughan, R. T.;
Gkantsinikoudi, C.; Prin, F.; Volpato, L. K.; Piovezan, A. P.; Graham,
G. J.; Dufton, N. P.; Perretti, M.; Marelli-Berg, F. M.; Nadkarni, S.,
Placental Inflammation Leads to Abnormal Embryonic Heart
Development.\emph{Circulation} \textbf{2022} .

7. Nakata, M.; Sakuma, J.; Takano, M.; Nagasaki, S., Assessment of fetal
cardiac function with echocardiography. \emph{J Obstet Gynaecol
Res}\textbf{2020,} \emph{46} (1), 31-38.

8. NAEPP expert panel report. Managing asthma during pregnancy:
recommendations for pharmacologic treatment-2004 update. \emph{J Allergy
Clin Immunol} \textbf{2005,} \emph{115} (1), 34-46.

9. Dombrowski, M. P.; Schatz, M., ACOG practice bulletin: clinical
management guidelines for obstetrician-gynecologists number 90, February
2008: asthma in pregnancy. \emph{Obstet Gynecol}
\textbf{2008,}\emph{111} (2 Pt 1), 457-64.

10. Hernandez-Andrade, E.; Benavides-Serralde, J. A.; Cruz-Martinez, R.;
Welsh, A.; Mancilla-Ramirez, J., Evaluation of conventional Doppler
fetal cardiac function parameters: E/A ratios, outflow tracts, and
myocardial performance index. \emph{Fetal Diagn Ther}
\textbf{2012,}\emph{32} (1-2), 22-9.

11. Comas, M.; Crispi, F.; G\selectlanguage{ngerman}ómez, O.; Puerto, B.; Figueras, F.;
Gratacós, E., Gestational age- and estimated fetal weight-adjusted
reference ranges for myocardial tissue Doppler indices at 24-41 weeks'
gestation. \emph{Ultrasound Obstet Gynecol} \textbf{2011,} \emph{37}(1),
57-64.

12. Peixoto, A. B.; Bravo-Valenzuela, N. J.; Rocha, L. A.; Araujo
Júnior, E., Spectral Doppler, tissue Doppler, and speckle-tracking
echocardiography for the evaluation of fetal cardiac function: an
update. \emph{Radiol Bras} \textbf{2021,} \emph{54} (2), 99-106.

13. Herling, L.; Johnson, J.; Ferm-Widlund, K.; Zamprakou, A.; Westgren,
M.; Acharya, G., Automated quantitative evaluation of fetal
atrioventricular annular plane systolic excursion. \emph{Ultrasound
Obstet Gynecol} \textbf{2021,} \emph{58} (6), 853-863.

14. Oluklu, D.; Kara, O.; Turgut, E.; Goncu Ayhan, S.; Yildirim, M.;
Sahin, D., Evaluation of fetal cardiac morphology and functions in
pregnant women with familial Mediterranean fever.\emph{Echocardiography}
\textbf{2022,} \emph{39} (4), 606-611.

15. Crispi, F.; Valenzuela-Alcaraz, B.; Cruz-Lemini, M.; Gratacós, E.,
Ultrasound assessment of fetal cardiac function. \emph{Australas J
Ultrasound Med} \textbf{2013,} \emph{16} (4), 158-167.

16. Öcal, D. F.; Yakut, K.; Öztürk, F. H.; Öztürk, M.; O\selectlanguage{polish}ğ\selectlanguage{english}uz, Y.;
Alt\selectlanguage{polish}ı\selectlanguage{english}nbo\selectlanguage{polish}ğ\selectlanguage{english}a, O.; \selectlanguage{ngerman}Çelen, \selectlanguage{polish}Ş., \selectlanguage{english}Utility of the modified myocardial performance
index in growth-restricted fetuses.
\emph{Echocardiography}\textbf{2019,} \emph{36} (10), 1895-1900.

17. Severi, F. M.; Rizzo, G.; Bocchi, C.; D'Antona, D.; Verzuri, M. S.;
Arduini, D., Intrauterine growth retardation and fetal cardiac
function.\emph{Fetal Diagn Ther} \textbf{2000,} \emph{15} (1), 8-19.

18. P\selectlanguage{ngerman}érez-Cruz, M.; Cruz-Lemini, M.; Fernández, M. T.; Parra, J. A.;
Bartrons, J.; Gómez-Roig, M. D.; Crispi, F.; Gratacós, E., Fetal cardiac
function in late-onset intrauterine growth restriction vs
small-for-gestational age, as defined by estimated fetal weight,
cerebroplacental ratio and uterine artery Doppler. \emph{Ultrasound
Obstet Gynecol} \textbf{2015,} \emph{46} (4), 465-71.

19. Oluklu, D.; Menekse Beser, D.; Uyan Hendem, D.; Y\selectlanguage{polish}ı\selectlanguage{english}ld\selectlanguage{polish}ı\selectlanguage{english}r\selectlanguage{polish}ı\selectlanguage{english}m, M.; Lalel\selectlanguage{polish}ı
\selectlanguage{english}Koc, B.; Tanacan, A.; Sahin, D., Assessment of fetal cardiac morphology
and functional changes in early-onset and late-onset fetal growth
restriction. \emph{Int J Gynaecol Obstet} \textbf{2022} .

20. Letti M\selectlanguage{ngerman}üller, A. L.; Barrios Pde, M.; Kliemann, L. M.; Valério, E.
G.; Gasnier, R.; Magalhães, J. A., Tei index to assess fetal cardiac
performance in fetuses at risk for fetal inflammatory response
syndrome.\emph{Ultrasound Obstet Gynecol} \textbf{2010,} \emph{36} (1),
26-31.

21. Romero, R.; Espinoza, J.; Gonçalves, L. F.; Gomez, R.; Medina, L.;
Silva, M.; Chaiworapongsa, T.; Yoon, B. H.; Ghezzi, F.; Lee, W.;
Treadwell, M.; Berry, S. M.; Maymon, E.; Mazor, M.; DeVore, G., Fetal
cardiac dysfunction in preterm premature rupture of membranes. \emph{J
Matern Fetal Neonatal Med} \textbf{2004,} \emph{16} (3), 146-57.

22. Kaya, B.; Tayyar, A.; Açar, D. K.; Kaya, S., Comparison of fetal
cardiac functions between small-for-gestational age fetuses and
late-onset growth-restricted fetuses. \emph{J Perinat Med}\textbf{2019,}
\emph{47} (8), 879-884.

23. Cruz-Lemini, M.; Crispi, F.; Valenzuela-Alcaraz, B.; Figueras, F.;
Sitges, M.; Gómez, O.; Bijnens, B.; Gratacós, E., Value of annular
M-mode displacement vs tissue Doppler velocities to assess cardiac
function in intrauterine growth restriction. \emph{Ultrasound Obstet
Gynecol} \textbf{2013,} \emph{42} (2), 175-81.

\selectlanguage{english}
\FloatBarrier
\end{document}

