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\begin{document}

\title{Association of increased fetal epicardial fat thickness with maternal
pregestational and gestational diabetes}



\author[1]{Baris Sever}%
\author[1]{Burak Bayraktar}%
\author[1]{Duygu Adiyaman}%
\author[1]{Hakan Golbasi}%
\author[1]{Ibrahim Omeroglu}%
\author[1]{Saygin Colak}%
\author[1]{Halil Pala}%
\author[1]{Atalay Ekin}%
\affil[1]{Izmir Il Saglik Mudurlugu Izmir Saglik Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi}%


\vspace{-1em}



  
  \date{May 20, 2024}


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\selectlanguage{english}
\begin{abstract}
\textbf{Objective:} To evaluate the changes of fetal epicardial fat
thickness (EFT) in pregnancies with pregestational (PGDM) and
gestational diabetes mellitus (GDM) and to identify the diagnostic
effectiveness of fetal EFT in differentiating PGDM and GDM from normal
pregnancies. \textbf{Methods:} The study was conducted with pregnant
women who admitted to perinatology department between November 2020 and
September 2022. Patients were analyzed as 3 groups: PGDM (n=161), GDM
(n=171) and control group (n=170). EFT was measured in all three groups
at 29 weeks of gestation. Demographic characteristics and
ultrasonographic findings were recorded and compared. \textbf{Results:}
The mean fetal EFT was significantly higher in PGDM (1.47\selectlanguage{ngerman}±0.083 mm,
p\textless{}0.001) and GDM (1.40±0.082 mm, p\textless{}0.001) groups
compared to control group (1.19±0.049 mm) and was also significantly
higher in PGDM group than GDM group (p\textless{}0.001). Fetal EFT was
significantly positively correlated with maternal age, fasting, 1
\textsuperscript{st} hour, 2 \textsuperscript{nd} hour glucose values,
HbA1c, fetal abdominal circumference and deepest vertical pocket of
amniotic fluid (p\textless{}0.001). Fetal EFT value of 1.3 mm diagnosed
PGDM patients with a sensitivity of 97.3\% and a specificity of 98.2\%.
Fetal EFT value of 1.27 mm diagnosed GDM patients with a sensitivity of
94\% and a specificity of 95\%. \textbf{Conclusions:} Fetal EFT is
greater in pregnancies with diabetes than in normal pregnancies, and
also greater in PGDM than in GDM. In addition, fetal EFT is strongly
correlated with maternal blood glucose levels in diabetic pregnancies.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{Introduction}

The most common metabolic disorder in pregnancy is hyperglycemia
resulting from impaired blood glucose tolerance which is defined as
either pregestational (PGDM) or gestational diabetes mellitus
(GDM)\textsuperscript{1}. Diabetes in pregnancy may cause many adverse
perinatal outcomes including fetal macrosomia, stillbirth, neonatal
hypoglycemia, preeclampsia and birth trauma\textsuperscript{2,3}. The
incidence of diabetes in pregnancy varies~substantially
across~countries, ranging between 0.9\% and 5.7\% for PGDM and 1.8\% and
25.4\% for GDM\textsuperscript{4,5}. Both type 2 PGDM and GDM could be
diagnosed by various screening methods including fasting plasma glucose
(FPG), HbA1c and oral glucose tolerance test (OGTT), but which one of
them is the most successful for the diagnosis is still controversial.

Epicardial fat tissue is located between the visceral pericardium and
myocardium and is usually distributed adjacent to the right
ventricle\textsuperscript{6,7}. Proinflammatory vasoactive peptides,
tumor necrosis factor-\selectlanguage{greek}α, \selectlanguage{english}interleukin-6 and anti-inflammatory substances
(adiponectin, omentin, adrenomedullin) are released from epicardial fat
tissue\textsuperscript{8,9}. Furthermore, epicardial fat tissue
contributes to myocardial energy production\textsuperscript{6}. In
recent years, measurement of epicardial fat thickness (EFT) in adults
has been frequently used to detect insulin
resistance\textsuperscript{10}. It has been shown that there is a
correlation between EFT and cholesterol, adiponectin and diastolic blood
pressure\textsuperscript{11}. Since EFT is not affected by changes in
skin and muscle tissue, it is thought to be more reliable than some
other measurements such as abdominal circumference\textsuperscript{12}.
However, conditions related to EFT are not clearly demonstrated in
antenatal life as in non-pregnant adults. It has been proposed that
increase in maternal EFT in pregnant women might be related to
preeclampsia and vascular complications\textsuperscript{13,14}.

Limited studies in the literature have shown that fetal EFT is higher in
pregnant women with diabetes\textsuperscript{15-18}. However, in these
studies, the comparison of fetal EFT was conducted only in pregnancies
with PGDM or GDM. Due to the methodology of previous studies, it could
not be clarified whether there is a difference for fetal EFT values
between pregnancies with PGDM and GDM. Therefore, the aim of this study
is to identify whether fetal EFT differs in pregnant women with PGDM and
GDM and also to correlate fetal EFT values with demographic parameters
of diabetic pregnancies.

\textbf{Objectives}

To evaluate the changes of fetal epicardial fat thickness (EFT) in
pregnancies with pregestational (PGDM) and gestational diabetes mellitus
(GDM) and to identify the diagnostic effectiveness of fetal EFT in
differentiating PGDM and GDM from normal pregnancies.

\textbf{Methods}

The study was planned as a prospective cohort and performed among
patients who applied to the Perinatology Department of Izmir Tepecik
Training and Research Hospital between November 2020 and September 2022.
A detailed consent form was obtained from all pregnant women
participating in the study. The study was carried out in accordance with
the conditions specified in the Declaration of Helsinki.

The aim of our study was to evaluate and compare the effects of maternal
PGDM and GDM on EFT by ultrasonography. Therefore, we needed a group
with PGDM, a group with GDM and a control group (without PGDM or GDM) to
compare measurements in fetuses of the same gestational age. After the
identification of patients with PGDM at first trimester of pregnancy, we
performed GDM screening in order to determine the GDM and control
groups. All patients without a previous diagnosis of PGDM underwent
75-gr OGTT between 26 and 28 weeks of gestation. In order to compare EFT
measurements at the same gestational week for standardization, all EFT
measurements were performed at 29 weeks of gestation in all pregnant
women who participated in the study. Gestational week was confirmed both
according to the last menstrual period and first trimester ultrasound.
161 patients with PGDM, 171 patients with GDM and 170 patients as a
control group were included in the study. Pregnant women with at least
one high blood glucose level in the 75-gr OGTT and with no~diagnosis of
previous diabetes were considered as GDM (FPG [?] 92 mg/dl,
1\textsuperscript{st} hour glucose [?] 180 mg/dl,
2\textsuperscript{nd}hour glucose [?] 153 mg/dl). OGTT was not performed
to pregnant women with PGDM. Multiple pregnancies, pregnant women with
chromosomal and structural anomalies, insufficient EFT measurements
(inability to obtain a clear measurement due to severe maternal obesity,
unsuitable fetal position, etc.) and comorbidities accompanying
pregnancy (preeclampsia, intrauterine growth retardation, metabolic
disorders, etc.) were not included in the study. A flow chart of our
study population was shown in Figure 1. HbA1c was measured at the
29\textsuperscript{th} weeks of gestation by high-performance liquid
chromatography method supplied by the Bio-Rad Diagnostic Group
(Hercules, CA, USA). The treatment of GDM began with lifestyle
interventions including nutritional counseling, dietary changes, and
daily exercise. Fasting and postprandial self-monitoring of blood
glucose were recommended in pregnancies with GDM to achieve optimal
glucose levels. Glucose targets were FPG \textless{}95 mg/dL and either
1-h postprandial glucose \textless{}140 mg/dL or 2-h postprandial
glucose \textless{}120 mg/dL. If blood glucose targets were not
maintained in more than half of measurements during 1 week assessment,
insulin treatment was initiated. Demographic characteristics (age,
gravida, parity, HbA1C, body mass index (BMI), birthweight), results of
the 75-gr OGTT and ultrasonographic parameters including EFT, biparietal
diameter (BPD), abdominal circumference (AC), femur length (FL) and
deepest vertical pocket of amniotic fluid (DVP) were evaluated.
Macrosomia was defined as a birthweight
\textgreater{}90\textsuperscript{th} percentile corrected for
gestational age and gender. Samsung\selectlanguage{ngerman}® HS 70A4D real time ultrasonography
system (2017, Seoul, Korea) was used for all patients by the same
clinician as described previously\textsuperscript{19}.

Patients whose fetal position was not suitable (the back of the fetus
was close to the probe) and patients who did not have appropriate EFT
measurements due to maternal morbid obesity were not included in the
study. EFT is located along the right ventricular wall. Dimensions of
EFT are highest towards the fetal heart apex and thickness decreases
towards the base of the heart\textsuperscript{20,21}. Thickest area of
epicardial fat was chosen to measure the EFT. In an attempt to
standardize the measurement technique as much as possible, images from
cardiac long axis views of left outflow tract or short axis view of
right outflow tract as close to the level of the aortic valve as
possible were utilized (Figure 2). Measurement should be taken at the
end of diastole and mean thickness of 3 consecutive measurements should
be recorded. Adipose tissue can be easily distinguished from pericardial
effusion as it is more echogenic. Furthermore, pericardial fusion-EFT
distinction can be made with color Doppler\textsuperscript{6}. In
ultrasonographic measurement, calipers should be placed inwardly between
epicardium and myocardium.

Data obtained in the study were analyzed using SPSS (Statistical Package
for Social Sciences) for Windows 25.0 program. While evaluating data,
descriptive statistical methods (number, percentage, min-max values,
mean, standard deviation) were used. The normal distribution of data
depends on skewness and kurtosis values being between ±3. In the
comparison of normally distributed data and quantitative data,
independent t-test was used for difference between two independent
groups, and one-way analysis of variance (ANOVA) was used for comparing
more than two independent groups. Chi-square test was used for
categorical variables. The significance level was accepted as 0.05.
Since OGTT was not performed in patients with PGDM, ANOVA for OGTT
variables was not performed in this group. Independent t-test was used
for these variables. Post Hoc-Bonferroni test was applied to determine
which group make a difference after a statistically significant result
in the comparison of the 3 groups. Correlation test was performed
between EFT and other demographic measurements, and Pearson coefficient
was checked for data with normal distribution.
Receiver-operating-characteristic (ROC) curve analysis was used to
calculate cut-off values in differentiating pregnancies with
pregestational DM and GDM from normal pregnancies according to fetal EFT
value.

\textbf{Results}

A total of 502 patients, including 161 pregnant women with PGDM, 171
pregnant women with GDM and 170 controls, were evaluated. The PGDM group
consisted of 98 (60.8\%) women with Type 1 and 63 (39.2\%) women with
Type 2 DM. Demographic characteristics and ultrasound findings of three
groups were showed in Table 1. Patients in PGDM group were significantly
older than both control and GDM groups (p=0.002) (Table 1). FPG, 1-h and
2-h blood glucose values of patients in GDM group were found to be
significantly higher than control group (p\textless{}0.001). HbA1C
values were significantly higher in both GDM and PDGM groups compared to
control group (p\textless{}0.001). As expected, HbA1c values of patients
with PGDM were significantly higher than those with GDM (p=0.021). Body
mass index was significantly higher in PGDM group compared to control
group (p=0.047). In ultrasound measurements, AC and DVP were found to be
significantly higher in PGDM and GDM groups compared to control group
and also significantly higher in PGDM group compared to GDM group
(p\textless{}0.001).

The mean of EFT measurements were found to be 1.19 ± 0.049 mm, 1.40 ±
0.082 mm and 1.47 ± 0.083 mm for the control, GDM and PGDM groups,
respectively (Table 1). There was a significant difference between all
three groups in terms of EFT (p\textless{}0.001). After~adjusting by
Bonferroni correction, it was observed that the mean EFT of control
group was lower than the mean values of GDM and PGDM groups.
Furthermore, the mean EFT of PGDM group was higher than the mean EFT of
GDM group (p\textless{}0.001). Comparison of the mean values of EFT
using a box plot among three groups were demonstrated in Figure 3a.

Correlation analysis was performed to test the relationship between EFT
and demographic characteristics of patients (Table 2). There was a
statistically significant weak positive correlation between EFT and
maternal age (r=0.184, p\textless{}0.001), FPG (r=0.188, p=0.005) and
DVP (r=0.332, p\textless{}0.001), moderate positive correlation between
EFT and fetal AC (r=0.422, p\textless{}0.001), HbA1C (r=0.559,
p\textless{}0.001) and strong positive correlation between EFT and
1\textsuperscript{st} hour (r=0.650, p\textless{}0.001) and
2\textsuperscript{nd} hour glucose values (r=0.719, p\textless{}0.001).
ROC analysis was performed to identify optimal cut-off points in
differentiating pregnancies with GDM and pregestational DM from normal
pregnancies (Figure 3b,c). The ROC curve of the multivariate logistic
regression model for the diagnosis of GDM demonstrated EFT with other
variables (FPG, 1hPG, 2hPG, HbA1c, AC and DVP) have an AUC of (1.000,
95\% CI 1.000-1.000), which is larger than when using the individual
factors of EFT (0.985, 95\% CI 0.973-0.997), FPG (0.643, 95\% CI
0.565-0.720), 1hPG (0.956, 95\% CI 0.927-0.984), 2hPG (0.976, 95\% CI
0.953-0.999), HbA1c (0.902, 95\% CI 0.861-0.944), AC (0.696, 95\% CI
0.628-0.764) and DVP (0.669, 95\% CI 0.595-0.742). The ROC curve of the
multivariate logistic regression model for the diagnosis of PGDM
demonstrated EFT with other variables (HbA1c, AC and DVP) have an AUC of
(1.000, 95\% CI 1.000-1.000), which is larger than when using the
individual factors of EFT (0.999, 95\% CI 0.998-1.000), HbA1c (0.934,
95\% CI 0.902-0.967), AC (0.858, 95\% CI 0.810-0.906) and DVP (0.814,
95\% CI 0.756-0.873). Using a cut-off level of 1.27 mm, EFT diagnosed
GDM with a sensitivity of 94\% and specificity of 95\% (AUC:0.95 {[}95
CI 0.973-0.997{]}). Furthermore, using a cut-off level of 1.3 mm, EFT
diagnosed PGDM with a sensitivity of 97.3\% and specificity of 98.2\%
(AUC:0.999 {[}95 CI 0.998-1.000{]}). We also performed a ROC curve
analysis for assessing the performance of fetal EFT value in predicting
macrosomia. The AUC was ~0.945 (95\% CI 0.912-0.979) for macrosomia. The
optimal fetal EFT threshold for predicting macrosomia was found as 1.36
mm, with a sensitivity of 93.4\% and specificity of 95.8\%. We did not
calculate inter-observer reproducibility for EFT because all
measurements were obtained by a single clinician. However,
intra-observer analysis demonstrated good repeatability and
reproducibility of EFT. The interclass correlation coefficient of
intra-observer reproducibility for EFT measurement was 0.755 (95 \% CI
0.526-0.984). Intra-observer variability of measurements of EFT was
found to be 0.5 ± 0.4 mm.

\textbf{Discussion}

Diabetes is the most common endocrine disorder during pregnancy.
Fetal-maternal morbidity is significantly reduced if diabetes is
diagnosed and precautions are taken. In this study, we evaluated fetal
EFT, which is a candidate to be a new marker to determine maternal
diabetes status in pregnancy. Unlike other studies in the literature, we
took one step further by separately evaluating fetal EFT in pregnancies
with both PGDM and GDM. Cut off values of EFT for the diagnosis of
diabetes risk were also identified.

It is known that epicardial adipose tissue has important paracrine and
metabolic effects. EFT is closely related to excess fat tissue in the
body. However, the main reason for EFT to be a reliable marker is that
EFT is not affected by changes in subcutaneous and muscle
tissues\textsuperscript{12}. Previous studies in adults revealed that
increase in EFT is an important diabetic marker and may be a determinant
in terms of morbidities that may occur due to
diabetes\textsuperscript{22}. Furthermore, a close relationship was
found between EFT and metabolic syndrome, obesity and insulin
resistance\textsuperscript{8}.

Some recent studies investigated whether use of EFT as a marker in
adults could be beneficial for pregnant women and their fetuses. In the
study by Jackson et al., EFT of fetuses was compared between diabetic
and non-diabetic pregnant women\textsuperscript{16}. They found that
fetal EFT was statistically significantly higher in diabetic pregnant
women (EFT mean=1.43mm). However, in their studies, diabetic pregnancies
were not grouped and evaluated as PGDM and GDM. Similarly, we found that
EFT of fetuses was higher in diabetic pregnant women compared to
non-diabetic pregnancies. Unlike to other studies, we also demonstrated
that fetal EFT was significantly higher in pregnancies with PGDM
compared to those with GDM.

In our study, we found that maternal age and values of HbA1C, AC and DVP
were significantly higher in PGDM and GDM groups. Although maternal age
was not significantly different between GDM and control groups, pregnant
women with PGDM were significantly older than both GDM and control
groups. We've also oberved a statistically significant correlation
between fetal EFT and maternal age. Most of the previous studies did not
explore any significant relationship between fetal EFT and maternal
age\textsuperscript{15,17,18}. Only in the study of Akkurt et al.,
maternal age was found to be greater in diabetic pregnant women as in
our study\textsuperscript{6}. The reason for higher maternal age in
pregnant women with PGDM may be explained by the desire of women with
existing diabetes to postpone their pregnancy to a later age. Another
explanation is that these women with PGDM are more likely suffer from
comorbidities which increase the risk of failure to conceive.

Since diagnosis of PGDM was established at the first trimester of
pregnancy in our study population, OGTT was performed to GDM and control
groups. We found that fetal EFT was significantly positively correlated
with every parameter of OGTT values (fasting, 1\textsuperscript{st} hour
and 2\textsuperscript{nd} hour). Although this correlation was weak for
FPG level, it was strong for 1\textsuperscript{st} hour and
2\textsuperscript{nd} hour glucose levels after OGTT. Similarly, Yavuz
et al. compared and correlated fetal EFT values and blood glucose
measurements obtained during a 75-gr OGTT\textsuperscript{18}. In their
study, fetal EFT had a significantly weak and moderate correlation with
1\textsuperscript{st} hour and 2\textsuperscript{nd} hour glucose level
after controlling for maternal age, gestational age, body mass index and
abdominal circumference. However, when only GDM pregnancies were
included, fetal EFT was positively and moderately related to 2-h glucose
values\textsuperscript{18}. Furthermore, we also explored that there was
a significant and moderate positive correlation between fetal EFT values
and maternal HbA1c levels. Confirming our results, Aydin et al. observed
a strong positive correlation between fetal EFT and maternal HbA1C
values\textsuperscript{17}. In this study, fetal EFT was found to be
significantly associated with adverse perinatal outcomes of diabetes
including macrosomia and polyhydramnios. Fetal EFT was significantly
positively correlated with fetal AC and DVP of amniotic fluid volume.
Akkurt et al. were also demonstrated a higher fetal EFT in pregnancies
with GDM compared to normal pregnancies\textsuperscript{6}. Unlike from
our study, Aydin et al. were determined a positive correlation between
fetal EFT and DVP values instead of AC values\textsuperscript{17}.
However, they compared fetal EFT values only between GDM and control
groups. Among all three groups in our study, HbA1c, AC and DVP values
were significantly higher in PGDM group followed by GDM group. These
findings provide strong evidence that high EFT value is a fetal
reflection of poorly controlled maternal glucose level.

In this study, we investigated the diagnostic value of fetal EFT on
diabetic pregnancies and determined cut-off EFT values for both PGDM and
GDM. Until recently, there are two studies in the literature that
calculate which values of fetal EFT can be used as cut-offs for diabetes
in pregnancy. The first of these was done by Akkurt et al. in
2018\textsuperscript{6}. The recommended equation of the mentioned study
for calculation of EFT in pregnant women with diabetes was EFT = 0.05 x
gestational age + 0.07 (R2 = 0.70). In our study, we did not calculate
the equation related to the gestational week. Instead, we evaluated EFT
of all pregnant women in the same week to ensure standardization.
Another study in the literature was performed by Aydin et al. in
2020\textsuperscript{15}. They conducted a study to determine the
relationship between fetal EFT and weight. Aydin et al. stated that a
cut-off fetal EFT value above 1.38 mm was predictive for diagnosis of
fetuses with large for gestational age with a sensitivity of 94.4\% and
a specificity of 97.6\%\textsuperscript{15}. All patients in that study
were evaluated at 22 weeks of gestation, but diabetic pregnancies were
not grouped as PGDM and GDM. In the present study, cut-off EFT values
for pregnant women with PGDM and GDM were 1.30 mm (sensitivity 97.3\%,
specificity 98.2\%) and 1.27 mm (sensitivity 94\%, specificity 95\%),
respectively. Both EFT cut-off values of our study were found to be
lower than the values calculated by Aydin et al. and Akkurt et
al.\textsuperscript{6,17} We believed that the reason for this
difference is related to patient selection criteria and classification
of study population rather than measurement technique of fetal EFT.

\textbf{Conclusion}

This study revealed that fetal EFT was significantly increased in
diabetic pregnancies with either PGDM or GDM but the increase in fetal
EFT was significantly higher in PGDM compared to GDM. Furthermore, fetal
EFT is strongly correlated with maternal blood glucose levels in
diabetic pregnancies. Therefore, fetal EFT value could be used as a
prognostic marker for PGDM and GDM and also for adverse perinatal
outcomes related to diabetes.

\textbf{Research funding:} None declared.

\textbf{Author contributions:} All authors have accepted responsibility
for the entire content of this manuscript and approved its submission.

\textbf{Disclosure of interest:} The authors report no conflict of
interest.

\textbf{Informed consent:} Informed consent was obtained from all
individuals included in this study.

\textbf{Ethical approval:} The research related to human use complied
with all the relevant national regulations, instutional policies, and in
accordance with the tenets of the Helsinki Declaration, and has been
approved by the authors' Institutional Review Board or equivalent
committee (Izmir Tepecik Training and Research Hospital Ethics
Committee, decision no: 2021/02-50)

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\item
  Yavuz MO, Akkurt S, Yalcin G, et al. Second trimester fetal and
  maternal epicardial fat thickness in gestational diabetic pregnancies.
  Horm Metab Res. 2016;48:595-600.
\item
  Schejbal~V. Epicardial fatty tissue of the right ventricle-morphology,
  morphometry and functional significance. Pneumologie (Stuttgart,
  Germany). 1989; 43:490--499.
\item
  Can MM, Can E, Ozveren O, et al. Epicardial Fat Tissue Thickness in
  Preeclamptic and Normal Pregnancies. ISRN Obstet Gynecol.
  2012;2012:386539.
\item
  Schejbal V. Epicardial fatty tissue of the right ventricle-morphology,
  morphometry and functional significance. Pneumologie. 1989;43:490-499.
\item
  Nasri A, Najafian J, Derakhshandeh SM, et al. Epicardial fat thickness
  and severity of coronary heart disease in patients with diabetes
  mellitus type II. ARYA Atheroscler. 2018;14(1):32-37.
\end{enumerate}\selectlanguage{english}
\begin{longtable}[]{@{}lllllllll@{}}
\toprule
\begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
\textbf{Variables}\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
\textbf{Variables}\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
\textbf{Control} \textbf{(n=170)}\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
\textbf{GDM} \textbf{(n=171)}\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
\textbf{PGDM} \textbf{(n=161)}\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
\textbf{ANOVA} \textbf{p value}\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
\textbf{Post Hoc-Bonferroni test} \textbf{p value}\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
\textbf{Post Hoc-Bonferroni test} \textbf{p value}\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
\textbf{Post Hoc-Bonferroni test} \textbf{p value}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\selectlanguage{ngerman}\textbf{Mean ± SD}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\selectlanguage{ngerman}\textbf{Mean ± SD}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\selectlanguage{ngerman}\textbf{Mean ± SD}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Control vs GDM}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Control vs PGDM}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{GDM vs PGDM}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Age (y)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Age (y)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
27.4\selectlanguage{ngerman}±5.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
28.4\selectlanguage{ngerman}±4.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
30.9\selectlanguage{ngerman}±3.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{0.002}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.415\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{0.011}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{OGTT (fasting) (mg/dl)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{OGTT (fasting) (mg/dl)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
75.4\selectlanguage{ngerman}±5.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
83.3\selectlanguage{ngerman}±10.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{OGTT (1\textsuperscript{st} hour) (mg/dl)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{OGTT (1\textsuperscript{st} hour) (mg/dl)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
158.3\selectlanguage{ngerman}±8.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
188.2\selectlanguage{ngerman}±14.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{OGTT (2\textsuperscript{nd} hour) (mg/dl)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{OGTT (2\textsuperscript{nd} hour) (mg/dl)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
131.4\selectlanguage{ngerman}±13.3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
163.1\selectlanguage{ngerman}±13.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{HbA1c (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{HbA1c (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
4.7\selectlanguage{ngerman}±0.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
6\selectlanguage{ngerman}±1.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
6.3\selectlanguage{ngerman}±0.3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{0.021}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{BMI (kg/m\textsuperscript{2})}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{BMI (kg/m\textsuperscript{2})}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
28.8\selectlanguage{ngerman}±3.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
29.4\selectlanguage{ngerman}±1.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
30.7\selectlanguage{ngerman}±0.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.345\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.974\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{0.047}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.119\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Gravida}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Gravida}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
2.1\selectlanguage{ngerman}±0.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
2.8\selectlanguage{ngerman}±1.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
3\selectlanguage{ngerman}±0.5\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.764\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.541\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.081\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.314\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Parity}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Parity}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
1.1\selectlanguage{ngerman}±0.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
1.5\selectlanguage{ngerman}±1.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
1.6\selectlanguage{ngerman}±1.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.614\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.405\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.097\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.611\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Birthweight (g)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Birthweight (g)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
3516\selectlanguage{ngerman}±451\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
3496\selectlanguage{ngerman}±397\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
3584\selectlanguage{ngerman}±442\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.087\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.265\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.341\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.106\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{BPD (mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{BPD (mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
71.5\selectlanguage{ngerman}±1.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
72.8\selectlanguage{ngerman}±2.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
71.9\selectlanguage{ngerman}±2.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.208\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.461\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.219\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.304\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{HC (mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{HC (mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
263.4\selectlanguage{ngerman}±5.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
267.7\selectlanguage{ngerman}±5.3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
264.4\selectlanguage{ngerman}±6.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.358\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.109\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.271\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.186\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{AC (mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{AC (mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
244.1\selectlanguage{ngerman}±6.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
253.7\selectlanguage{ngerman}±4.5\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
257.7\selectlanguage{ngerman}±5.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{FL (mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{FL (mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
54.7\selectlanguage{ngerman}±1.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
54.3\selectlanguage{ngerman}±5.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
58.5\selectlanguage{ngerman}±5.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.482\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.457\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.387\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.297\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{DVP (mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{DVP (mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
50.7\selectlanguage{ngerman}±4.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
54.3\selectlanguage{ngerman}±5.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
58.5\selectlanguage{ngerman}±5.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Gender (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Male}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
49.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
50.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
48.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.772\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.548\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.427\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.588\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Female}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
50.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
49.3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
51.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{EFT (mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{EFT (mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
1.19\selectlanguage{ngerman}±0.049\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
1.40\selectlanguage{ngerman}±0.082\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
1.47\selectlanguage{ngerman}±0.083\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 1.} Demographic features, laboratory and ultrasound
findings of the three groups (BMI, body mass index; DVP, deepest
vertical pocket; EFT, epicardial fat thickness; FL, femur length; GDM,
gestational diabetes mellitus; OGTT, oral glucose tolerance test; PGDM,
pregestational diabetes mellitus)\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
& \textbf{Epicardial fat thickness} & \textbf{Epicardial fat
thickness}\tabularnewline
\midrule
\endhead
& \textbf{r-value} & \textbf{p-value}\tabularnewline
\textbf{Demographic features} & &\tabularnewline
\textbf{Age} & 0.184\textsuperscript{a} &
\textbf{\textless{}0.001\textsuperscript{a}}\tabularnewline
\textbf{BMI} & 0.101 & 0.066\tabularnewline
\textbf{Gravida} & -0.002 & 0.967\tabularnewline
\textbf{Parity} & 0.020 & 0.712\tabularnewline
\textbf{Birthweight} & 0.742\textsuperscript{d} &
\textbf{\textless{}0.001\textsuperscript{d}}\tabularnewline
\textbf{Laboratory findings} & &\tabularnewline
\textbf{OGTT (fasting)} & 0.188\textsuperscript{a} &
\textbf{0.005\textsuperscript{a}}\tabularnewline
\textbf{OGTT (1-h)} & 0.650\textsuperscript{d} &
\textbf{\textless{}0.001\textsuperscript{d}}\tabularnewline
\textbf{OGTT (2-h)} & 0.719\textsuperscript{d} &
\textbf{\textless{}0.001\textsuperscript{d}}\tabularnewline
\textbf{HbA1c} & 0.559\textsuperscript{c} &
\textbf{\textless{}0.001\textsuperscript{c}}\tabularnewline
\textbf{Ultrasound findings} & &\tabularnewline
\textbf{BPD} & 0.087 & 0.114\tabularnewline
\textbf{HC} & 0.104 & 0.059\tabularnewline
\textbf{AC} & 0.422\textsuperscript{c} &
\textbf{\textless{}0.001\textsuperscript{c}}\tabularnewline
\textbf{FL} & 0.018 & 0.738\tabularnewline
\textbf{DVP} & 0.332\textsuperscript{b} &
\textbf{\textless{}0.001\textsuperscript{b}}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2. Correlation analysis between epicardial fat thickness
and demographic features, laboratory and ultrasound findings
(\textsuperscript{a}very weak positive,
significant;\textsuperscript{b}weak positive,
significant;\textsuperscript{c}moderate positive,
significant;\textsuperscript{d}strong positive, significant.} AC,
abdominal circumference; BMI, body mass index; BPD, biparietal diameter;
DVP, deepest vertical pocket; HC, head circumference; FL, femur length;
OGTT, oral glucose tolerance test).

\textbf{Figure 1.} Flow chart of the study population. IUGR, intra
uterine growth restriction; GDM, gestational diabetes mellitus; PGDM,
pregestational diabetes mellitus; OGTT, oral glucose tolerance test.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 2.} Ultrasonographic image of fetal epicardial fat
tissue. EFT, epicardial fat thickness; RV, right ventricle; LV, left
ventricle; IVS, interventricular septum; Ao, ascending aorta; LA, left
atrium.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 3.} Distribution of EFT values of GDM, PGDM and control
groups \textbf{(a)} . ROC curves constructed with the multivariate
logistic regression model. The AUC of EFT with other variables (FPG,
1hPG, 2hPG, HbA1c, AC and DVP) for the diagnosis of GDM (1.000) is
larger than when using the individual factors of EFT (0.985), FPG
(0.643), 1hPG (0.956), 2hPG (0.976), HbA1c (0.902), AC (0.696) and DVP
(0.669) \textbf{(b)} . The AUC of EFT with other variables (HbA1c, AC
and DVP) for the diagnosis of PGDM (1.000) is larger than when using the
individual factors of EFT (0.999), HbA1c (0.934), AC (0.858) and DVP
(0.814) \textbf{(c)} . 1hPG, 1 hour plasma glucose; 2hPG, 2 hour plasma
glucose; AC, abdominal circumference; DVP, deepest vertical pocket; EFT,
epicardial fat thickness; FPG, fasting plasma glucose; GDM, gestational
diabetes mellitus; PGDM, pregestational diabetes mellitus.

\textbf{Hosted file}

\verb`Figure 1.docx`  available at \url{https://authorea.com/users/572457/articles/617296-association-of-increased-fetal-epicardial-fat-thickness-with-maternal-pregestational-and-gestational-diabetes}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

\end{center}
\end{figure}

\textbf{Hosted file}

\verb`Table 1.docx`  available at \url{https://authorea.com/users/572457/articles/617296-association-of-increased-fetal-epicardial-fat-thickness-with-maternal-pregestational-and-gestational-diabetes}

\textbf{Hosted file}

\verb`Table 2.docx`  available at \url{https://authorea.com/users/572457/articles/617296-association-of-increased-fetal-epicardial-fat-thickness-with-maternal-pregestational-and-gestational-diabetes}

\selectlanguage{english}
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\end{document}

