Association of Intrauterine Growth Restriction and Small for Gestational Age Status With Childhood Cognitive Outcomes: A Systematic Review and Meta-analysis

Placental malaria induces a unique methylation profile associated with fetal growth restriction

Fetal growth restriction (FGR) is associated with perinatal death and adverse birth outcomes, as well as long-term complications, including increased childhood morbidity, abnormal neurodevelopment, and cardio-metabolic diseases in adulthood. Placental epigenetic reprogramming associated with FGR may mediate these long-term outcomes. Placental malaria (PM), characterized by sequestration of Plasmodium falciparum-infected erythrocytes in placental intervillous space, is the leading global cause of FGR, but its impact on placental epigenetics is unknown. We hypothesized that placental methylomic profiling would reveal common and distinct mechanistic pathways of non-malarial and PM-associated FGR. We analyzed placentas from a US cohort with no malaria exposure (n = 12) and a cohort from eastern Uganda, a region with a high prevalence of malaria (n = 12). From each site, 8 cases of FGR and 4 healthy controls were analyzed. PM was diagnosed by placental histopathology. We compared the methylation levels of over 850K CpGs of the placentas using Infinium MethylationEPIC v1 microarray. Non-malarial FGR was associated with 65 differentially methylated CpGs (DMCs), whereas PM-FGR was associated with 133 DMCs, compared to their corresponding controls without FGR. One DMC (cg16389901, located in the promoter region of BMP4) was commonly hypomethylated in both groups. We identified 522 DMCs between non-malarial FGR vs. PM-FGR placentas, independent of differing geographic location or cellular composition. Placentas with PM-associated FGR have distinct methylation profiles compared to placentas with non-malarial FGR, suggesting novel epigenetic reprogramming in response to malaria. Larger cohort studies are needed to determine the distinct long-term health outcomes in PM-associated FGR pregnancies.

Small for gestational age children at risk: Identifying placenta-brain axis genes as biomarkers for early prediction of neurodevelopmental delay

AIMS

Small for gestational age (SGA) is a prevalent issue in global public health. The relationship between SGA and neurodevelopmental delay remains a topic of debate and the exploration of potential biomarkers is crucial. The identification of placental-brain axis genes offers novel perspectives for anticipating neurodevelopmental delay.

MAIN METHODS

First, we utilized multiple logistic regression to assess Ages and Stages Questionnaire of China (ASQ-C) scores in children at 6 months, 18 months, and 48 months of age. Next, we analyzed the placental transcriptome data from SGA and appropriate for gestational age (AGA) children in the Ma'anshan Birth Cohort (MABC) and validated it through Real-time quantitative PCR (RT-qPCR). Finally, we combined the experimental data with clinical data to establish a predictive model.

KEY FINDINGS

SGA children were found to have a higher risk of neurodevelopmental delay at 6 months and 18 months of age. Further experimental validation found that decreased RPS27A gene expression was associated with developmental delay in solving-problem and personal-social domain at 6 months of age in SGA children.

SIGNIFICANCE

Our study focused on the neurodevelopmental results of children from three time points, analyzed the mechanism of neurodevelopmental delay in SGA from the perspective of placenta-brain axis, and conducted experimental verification of the selected biomarkers. Therefore, our study has certain novelty and persuasive, providing new insights for early detection of neurodevelopmental delay in children with SGA.

Association and shared biological bases between birth weight and cortical structure

Associations between birth weight and cortical structural phenotypes have been detected; however, the understanding is incomprehensive, and the potential biological bases are not well defined. Leveraging data from genome-wide association studies, we investigated the associations and the shared transcriptomic, proteomic and cellular bases of birth weight and 13 cortical structural phenotypes. Mendelian randomization analyses were performed to examine associations between birth weight and cortical structure. Downstream transcriptome-wide association study (TWAS), proteome-wide association study (PWAS) and summary-based Mendelian randomization (SMR) analyses were utilized to identify the shared cis-regulated gene expressions and proteins. Finally, cell-type expression-specific integration for complex traits (CELLECT) analyses were conducted to explore the enriched cell types. The Mendelian randomization analyses found positive associations between birth weight and global cortical folding index, intrinsic curvature index, local gyrification index, surface area and volume. Downstream transcriptomic-level TWAS and SMR identified three gene expressions both linked to birth weight and at least one cortical structural phenotype (CNNM2, RABGAP1 and CENPW). Parallel PWAS and SMR analyses at the proteomic level identified four proteins linked to both phenotypes (CNNM2, RAB7L1, RAB5B and PPA2), of which CNNM2 was replicated. CELLECT analyses revealed brain cell types enriched in birth weight, including pericytes, inhibitory GABAergic neurons and cerebrovascular cells. These findings support the importance of early life growth to cortical structure, and suggest underlying transcriptomic, proteomic and cellular bases. These results provide intriguing targets for further research into the mechanisms of cortical development.

The impact of gestational age on executive function in infancy and early-to-middle childhood following preterm birth: a systematic review

Lower gestational age (GA) is a risk factor for cognitive and developmental concerns following preterm birth. However, its impact on executive function (EF) is unclear based on conflicting conclusions across the literature. Moreover, as children below 4 years have largely been neglected from previous reviews, the impact of GA on EF within this early developmental period remains unclear. Hence, this systematic review investigated the impact of GA on EF following preterm birth in infancy and early-to-middle childhood. PubMed, Web of Science, and PsycInfo were searched for articles investigating the impact of GA on EF (inhibition, working memory, shifting) in preterm-born (<37 week gestation) and term-born participants aged 0-10 years. Eighteen studies were included. Most of the studies (n = 10) found no significant association between EF and GA. However, several limitations hindered conclusions to be drawn about the strength of this interpretation. Examples include inconsistencies in the theoretical underpinnings and operationalisations of EF, discrepancies in the reporting and measurement of GA, recruitment biases, and a paucity of infant or longitudinal studies available. Consequently, these issues may have contributed to inconsistent or null findings, and they must be addressed in future research to better clarify the impact of GA on EF in preterm-born infants and children.

The effect of Naringin on cognitive function, oxidative stress, cholinergic activity, CREB/BDNF signaling and hippocampal cell damage in offspring rats with utero-placental insufficiency-induced intrauterine growth restriction

Intrauterine growth restriction (IUGR) induced by utero-placental insufficiency (UPI) results in delayed neural development and impaired brain growth. This study investigates the effects of Naringin (Nar) on memory, learning, cholinergic activity, oxidative stress markers, hippocampal CREB/BDNF signal pathway and cell damage in offspring of rats exposed to UPI. Twenty pregnant Wistar rats were randomly assigned to four groups: control, sham surgery, UPI + NS (UPI + normal saline as a vehicle), and UPI + Nar (UPI + Nar at 100 mg/kg/day). UPI was induced by permanently occluding the uterine anterior vessels on embryonic day (ED) 18. Naringin or saline was administered orally from ED15 to ED21. Behavioral assessments of offspring, including working memory, avoidance learning, and anxiety-like behavior, were conducted on a postnatal day (PND) 21. Subsequently, hippocampal acetylcholinesterase (AChE) activity, catalase (CAT), superoxide dismutase (SOD), total antioxidant capacity (TAC), malondialdehyde (MDA), hippocampal transcript level of cyclic AMP response element-binding protein (CREB) and brain derived neurotrophic factor (BDNF) and apoptotic neuron density in the hippocampus were evaluated. Naringin-treated rats demonstrated significant improvements in working and avoidance memory, increases in CAT, SOD, and TAC, CREB, BDNF and reductions in AChE activity, MDA levels, apoptotic neuron density, and anxiety-like behaviors compared to the UPI + NS group (p < 0.05). Naringin mitigates hippocampal cell damage, cognitive impairments, and anxiety by enhancing antioxidant defenses, modulating cholinergic activity and CREB/BDNF signaling in the brains of UPI-exposed offspring.

Cognitive and academic outcomes of large-for-gestational-age babies born at early term: A systematic review and meta-analysis

INTRODUCTION

Early induction of labor (37+0-38+6 gestational weeks) in large-for-gestational-age infants may reduce perinatal risks such as shoulder dystocia, but it may also increase the long-term risks of reduced cognitive abilities. This systematic review aimed to evaluate the cognitive and academic outcomes of large-for-gestational-age children born early term vs full term (combined or independent exposures).

MATERIAL AND METHODS

The protocol was registered in the PROSPERO database under the registration no. CRD42024528626. Five databases were searched from their inception until March 27, 2024, without language restrictions. Studies reporting childhood cognitive or academic outcomes after early term or large-for-gestational-age births were included. Two reviewers independently screened the selected studies. One reviewer extracted the data, and the other double-checked the data. The risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale. In addition to narrative synthesis, meta-analyses were conducted where possible.

RESULTS

Of the 2505 identified articles, no study investigated early-term delivery in large-for-gestational-age babies. Seventy-six studies involving 11 460 016 children investigated the effects of either early-term delivery or large-for-gestational-age. Children born at 37 weeks of gestation (standard mean difference, -0.13; 95% confidence interval, -0.21 to -0.05), but not at 38 weeks (standard mean difference, -0.04; 95% confidence interval, -0.08 to 0.002), had lower cognitive scores than those born at 40 weeks. Large-for-gestational-age children had slightly higher cognitive scores than appropriate-for-gestational-age children (standard mean difference, 0.06; 95% confidence interval, 0.01-0.11). Similar results were obtained using the outcomes of either cognitive impairment or academic performance.

CONCLUSIONS

No study has investigated the combined effect of early-term delivery on cognitive scores in large-for-gestational-age babies. Early-term delivery may have a very small detrimental effect on cognitive scores, whereas being large for gestational age may have a very small benefit. However, evidence from randomized controlled trials or observational studies is required.

Neonatal birthweight prediction using two- and three-dimensional estimated fetal weight among borderline small fetuses

PURPOSE

This study aimed (1) to determine the degree of correlation between 2D and 3D estimated fetal weight (EFW) and neonatal birth weight (BW) among borderline small fetuses and (2) to compare the accuracy and precision of 2D and 3D EFW in BW prediction.

METHODS

A retrospective cohort study evaluated fetuses who had an ultrasound performed between January 2017 and September 2021 at a tertiary maternal center. All singleton pregnancies with 3D EFW within 4 weeks of delivery were included. Fetuses with known structural or genetic abnormalities were excluded. Pearson's correlation coefficients were determined for both 2D and 3D EFW to BW then compared using Williams' test and Fisher r to z transformation, where applicable. Mean percent difference and standard deviation were used to assess the accuracy and precision, respectively, of 2D and 3D EFWs in BW prediction.

RESULTS

Two hundred forty-eight pregnancies were included. Ultrasound studies were performed with a median interval of 2 weeks (IQR 1, 3) between ultrasound and delivery. Both 2D and 3D estimated fetal weights showed a significant correlation with birth weight (r = 0.74 and r = 0.73, respectively), indicating similar accuracy between the two techniques.

CONCLUSION

Two-dimensional and three-dimensional EFWs performed similarly in the prediction of BW in borderline small fetuses.

Long-term neurological outcomes of offspring misdiagnosed with fetal growth restriction

OBJECTIVE

Fetal growth restriction (FGR) is a major determinant of adverse short- and long-term perinatal outcomes. The current definition of FGR (estimated fetal weight measurement < 10th percentile) may lead, at times, to a false diagnosis of fetuses that are eventually born appropriate for gestational age (AGA). Our objective was to investigate the potential association between a misdiagnosis of antepartum fetal growth restriction and long-term neurological outcomes in offspring.

STUDY DESIGN

A population-based cohort analysis was performed including deliveries between the years 1991-2020 in a tertiary medical center. We compared neurological hospitalization during childhood among AGA infants falsely diagnosed as FGR versus AGA infants without a false FGR diagnosis. A Kaplan-Meier survival curve was used to assess cumulative morbidity and a Cox proportional hazards model was employed to control for confounders.

RESULTS

During the study period, 324,620 AGA infants met the inclusion criteria; 3249 of them were falsely classified as FGR. These offspring had higher rates of hospitalizations due to various neurological conditions, as compared to those without an FGR diagnosis (OR 1.431, 95% CI 1.278-1.608; P < 0.001). In addition, cumulative hospitalization incidence was elevated in the FGR group (log-rank P-value < 0.001). When controlling for confounders, a false FGR diagnosis remained independently associated with long-term neurological morbidities (adjusted HR 1.086, 95% CI 1.003-1.177, P = 0.043).

CONCLUSION

Misdiagnosis of FGR in the antepartum period is associated with an increased risk for offspring long-term neurological morbidities.

Neurological outcomes and associated perinatal factors in infants born between 22 and 25 weeks with active care

OBJECTIVES

To elucidate the outcomes of periviable infants receiving active care (AC) and explore perinatal factors associated with neurodevelopmental outcomes.

METHODS

This is a single-center retrospective study on infants born at 22-25 weeks of gestation, all of whom received AC. A developmental quotient (DQ) ≥ 85 at corrected 18 months was judged as normal.

RESULTS

Fifty-seven infants were included in the study. The survival rates at discharge were 83%, 86%, 93%, and 93% at 22, 23, 24, and 25 gestational weeks, respectively. The overall percentage of normal DQ was 26/47 (55%). Acidemia in the arterial blood gas measured within 6 h after birth was identified as a factor significantly associated with subnormal DQ.

CONCLUSIONS

Not only high survival rates, but also favorable neurodevelopmental outcomes may be achieved by AC in periviable infants. Moreover, impaired neurodevelopmental outcomes may be associated with early postnatal acidemia following initial resuscitation.

Evaluation of cord management strategies in intrauterine growth-restricted infants: a systematic review and meta-analysis

Delayed cord clamping (DCC) has been widely adopted in both term and preterm infants to improve neonatal outcomes by increasing blood volume and supporting oxygenation. However, the optimal cord management for intrauterine growth-restricted (IUGR) infants is unclear. To systematically review and meta-analyze the effects of DCC compared to early cord clamping (ECC) in IUGR infants. We followed the PRISMA guidelines for meta-analysis. Six databases were searched for randomized controlled trials (RCTs) and observational studies comparing DCC and ECC in IUGR infants, focusing on neonatal resuscitation measures, hematological parameters, morbidities, and mortality. The Cochrane Collaboration tool and Newcastle-Ottawa scale were used for RCTs and observational studies, respectively. Eight studies with 1531 participants were included, comprising six RCTs and two observational studies. Serum ferritin at 3 months and initial Hb were significantly higher in the DCC group (MD: 36.16 ng/ml [95% CI: 34.09, 38.24]), (MD: 1.64 gm/dl [95%CI: 0.88, 2.4]) respectively. The risk of polycythemia was higher in the DCC group (RR 1.88, 95% CI [1.27, 2.8]), without an increase in the peak total serum bilirubin or the need for exchange transfusion. Conclusion: DCC may be beneficial and safe in IUGR infants, improving hematological parameters without affecting neonatal morbidity and mortality. Further high-quality, large trials are needed to confirm these findings and assess neurodevelopmental impact.

Prevalence, Characteristics, and Adverse Birth Outcomes of Teen Births in West Virginia: A Population-Based Study

STUDY OBJECTIVE

Despite falling teen birth rates in the United States, there is a disproportionate burden of teen births in rural regions. The study aims to investigate the characteristics of teenage mothers and examine the relationships between teen birth and adverse birth outcomes in the rural Appalachian state of West Virginia (WV).

METHODS

Data was obtained from a population-based cohort (Project WATCH) of all singleton live births in WV between May 2018 and April 2023. The primary exposure variable was mothers who gave birth when they were less than 20 years old (teenage births v. adult). Primary outcomes included birthweight, gestational age, NICU admission, 5-minute Apgar score, and breastfeeding status.

RESULTS

Of 86,447 live births, 5310 (6.15%) were birth to teenage mothers. Maternal characteristics of teenage mothers included minority racial groups, lower education, Medicaid, rural residence, and inadequate prenatal care. Teenage births were associated with lower mean birthweight aMD [b = -49.31 g. (-65.37, -33.24)], low birthweight [< 2500 g. vs ≥ 2500 g., aRR = 1.11 (1.0, 1.24)], and small for gestational age [v. appropriate for gestational age, aRR = 1.21 (1.12, 1.30)]. Teenage mothers were less likely to exclusively breastfeed at discharge [aRR, 1.20 (1.11, 1.28)]. Analyses adjusted for maternal race/ethnicity, education, health insurance, smoking, substance use, prenatal care, diabetes, and residence type.

CONCLUSIONS

Teenage births are high in WV and are linked to adverse infant outcomes. These findings may help identify at-risk groups for support and provide policymakers with information to design effective interventions to prevent teenage births and its negative outcomes.

Association between pre-pregnancy maternal stress and small for gestational age: a population-based retrospective cohort study

BACKGROUND

Maternal stress is a potential factor affecting fetal growth, but it is unknown whether it directly affects fetal growth restriction. This study aims to investigate the association between pre-pregnancy maternal stress with small for gestational age (SGA).

METHODS

This study used a population-based retrospective cohort analysis to examine the association between pre-pregnancy maternal stress and SGA in offspring. Data were extracted from the National Preconception Health Care Project (NPHCP), conducted between 2010 and 2012, which encompassed preconception health-related information from 572,989 individuals across various regions in China. Logistic regression models were used to assess the associations between pre-pregnancy maternal stress variables and the risk of SGA. In addition, Synthetic Minority Over-sampling Technique (SMOTE) and Propensity Scores (PS) methods were used to enhance the model's ability to the associations between pre-pregnancy maternal stress and SGA.

RESULTS

Pre-pregnancy maternal stress was significantly associated with an increased the risk of SGA in offspring (OR 1.35, 95% CI 1.20 to 1.51, P < 0.001). Stress related to life and economic factors notably increased the risk of SGA across different socio-economic conditions, whereas stress related to friends did not show a statistically significant association (P > 0.05). Specially, individuals with lower socio-economic status that characterized by below high school education levels (OR = 1.45, 95% CI: 1.23 to 1.70), farmer occupation (OR = 1.33, 95% CI: 1.15 to 1.55, P = 0.002), rural residence (OR = 1.38, 95% CI: 1.22 to 1.56, P < 0.001), and younger age (under 35 years: OR = 1.35, 95% CI: 1.20 to 1.52, P < 0.001) were more susceptible to pre-pregnancy maternal stress, increasing their risk of SGA.

CONCLUSIONS

Pre-pregnancy maternal stress was positively associated with an increased risk of SGA in offspring. Individuals with lower socio-economic status were more likely to experience pre-pregnancy maternal stress related to life and economic factors, which in turn contributed to a higher risk of SGA.

Predicting Adverse Neurodevelopmental Outcomes in Premature Neonates with Intrauterine Growth Restriction Using a Three-Layered Neural Network

Background/Objectives: There is a constant need to improve the prediction of adverse neurodevelopmental outcomes in growth-restricted neonates who were born prematurely. The aim of this retrospective study was to evaluate the predictive performance of a three-layered neural network for the prediction of adverse neurodevelopmental outcomes determined at two years of age by the Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-III) scale in prematurely born infants by affected by intrauterine growth restriction (IUGR). Methods: This observational retrospective study included premature newborns with or without IUGR admitted to a tertiary neonatal intensive care unit from Romania, between January 2018 and December 2022. The patients underwent assessment with the Amiel-Tison scale at discharge, and with the Bailey-3 scale at 3, 6, 12, 18, and 24 months of corrected age. Clinical and paraclinical data were used to construct a three-layered artificial neural network, and its predictive performance was assessed. Results: Our results indicated that this type of neural network exhibited moderate predictive performance in predicting mild forms of cognitive, motor, and language delays. However, the accuracy of predicting moderate and severe neurodevelopmental outcomes varied between moderate and low. Conclusions: Artificial neural networks can be useful tools for the prediction of several neurodevelopmental outcomes, and their predictive performance can be improved by including a large number of clinical and paraclinical parameters.

Association of preterm birth and birth size status with neurodevelopmental and psychiatric disorders in spontaneous births

Preterm birth (PTB) or small birth size are risk factors for certain neurodevelopmental disorders. The magnitude of these associations in spontaneous births, and of associations for combined PTB and birth size status on neurodevelopmental and psychiatric disorders is unexplored. We investigated whether PTB and small/large for gestational age (SGA/LGA), separately or combined, in spontaneous births, are associated with a wide spectrum of neurodevelopmental and psychiatric disorders. In this population-based registry cohort study, all singleton spontaneous births in Finland from 1996 to 2014 were followed until 2018 (n = 819 764). We show that PTB across gestational ages, and SGA, were associated with higher risks for anxiety disorders, intellectual disabilities, specific developmental disorders (SDD), autism spectrum disorders (ASD), attention-deficit/hyperactivity disorders (ADHD) and other emotional and behavioural disorders (F98). Most of these associations were not attributed to familial factors. Larger effect sizes were observed with lower gestational ages. Extremely PTB was associated at highest risks with intellectual disabilities (HR, 10.70 [95%CI, 8.69-13.17]) and SDD (HR, 8.91 [95%CI, 8.18-9.71]). Moreover, very preterm birth combined with SGA was associated with a higher risk for SDD (HR, 7.55 [95%CI, 6.61-8.62]) than that of very preterm or SGA birth alone. Conversely, LGA birth lowered the risk for SDD and other emotional and behavioural disorders among individuals born very preterm. In conclusion, PTB along with SGA is associated with higher risks for SDD than one exposure alone, whereas LGA lowers the risks for SDD and other emotional and behavioural disorders in individuals born spontaneously.

Investigation of newborn blood metabolomics in varying intrauterine growth conditions

OBJECTIVES

This study aimed to investigate changes in the blood metabolic profiles of newborns with varying intrauterine growth conditions. Specifically, we analyzed the levels of amino acids, carnitine, and succinylacetone among full-term newborns, including small for gestational age (SGA), appropriate for gestational age (AGA), and large for gestational age (LGA). We aim to identify differential metabolites and metabolic pathways that may offer insights into clinical interventions.

METHODS

A total of 5106 full-term newborns were included in the study. Blood samples were obtained from all newborns between 3 and 5 days after birth and analyzed using tandem mass spectrometry to detect blood metabolites. Subsequently, we screened for different metabolites and metabolic pathways among the groups using the MetaboAnalystR package (Version 1.0.1) in R software (R-3.6.0).

RESULTS

The levels of blood amino acids and carnitine metabolism differed significantly among newborns with varying intrauterine growth conditions. Full-term SGA newborns exhibited a decrease in multiple amino acids and an increase in multiple carnitines, while full-term LGA newborns showed an increase in multiple amino acids and acylcarnitines.

CONCLUSION

Continuous monitoring of the short-term and long-term growth and metabolic status of full-term SGA and LGA newborns is warranted with individualized dietary and nutritional adjustments to promote healthy growth in a timely manner. The findings of this research contribute to the broader understanding of SGA/LGA and shall inform future research on metabolomics, interventions, and long-term outcomes.

BMI modifies the effect of pregnancy complications on risk of small- or large-for-gestational-age newborns

BACKGROUND

Maternal physical condition (reflected by maternal body mass index (BMI) at delivery) and pregnancy complications influence neonatal health outcomes. High BMI during pregnancy increases various health problems' risks, but studies about the synthesized effect of these factors on fetal growth, are scarce.

METHODS

The retrospective cohort study was conducted in Zhejiang Province, China from 1 January 2019 to 31 December 2021. The associations between complications and small-for-gestational-age (SGA) and large-for-gestational-age (LGA) were measured by the Fine-Gray model and subgroup analysis. Effect modification and interaction analyses were conducted to explore BMI's modification effect and complications' interaction.

RESULTS

Several complications increased the risk for SGA and LGA, some significance varied in different subgroups. There was a positive effect modification of gestational diabetes mellitus (GDM) across BMI strata on LGA (relative excess risk due to interaction (RERI) [95% CI] = 0.57 [0.09,1.04]). Several pairwise complications' interactions were synergistic (e.g., pregestational diabetes and intraamniotic infection for SGA (ratio of ORs [95% CI] = 8.50 [1.74,41.37]), pregestational diabetes and assisted reproductive technology (ART) for LGA (ratio of ORs [95% CI] = 2.71 [1.11,6.62])), one was antagonistic (placental problems and ART for LGA (ratio of ORs [95% CI] = 0.58 [0.35,0.96])).

CONCLUSIONS

High-BMI positively modified the risk of GDM on LGA. Many interactions existed when two specific pregnancy complications occurred simultaneously.

IMPACT

This is the largest retrospective study covering more than 10 pregnancy complications to date in this aspect. High-BMI (BMI > 28 kg/m2) positively modifies the risk of GDM on LGA. Many pregnancy complications influence the risk of SGA and LGA, with several interactions that may create a "syndrome" effect. Pregnant women with different BMIs should consider the additional risks caused by pregnancy complications for their heterogeneous effects on abnormal fetal growth. Measures should be taken to prevent the occurrence of other exposure factors in the "syndrome". This study may aid in developing a new strategy for improving neonatal outcomes.

"Umbilical artery Doppler in severe small for gestational age: Prognostic insights for short and long-term neurodevelopment"

INTRODUCTION

We evaluated the impact of absent end-diastolic flow in the umbilical artery (UA-AEDF) in severe small for gestational age (SGA) cases.

METHODS

This retrospective cohort study focused on fetuses with severe SGA (defined as birth weight ≤2.5 SD). Clinical measurements and neonatal outcomes were compared between the UA-AEDF and non-UA-AEDF groups.

RESULTS

Fifty-four patients were categorized into UA-AEDF (15 patients) and non-UA-AEDF (39 patients) groups. Regarding neonatal short-term prognosis, the UA-AEDF group showed higher rates of respiratory distress syndrome (RDS), late circulatory dysfunction, late metabolic acidosis, and retinopathy of prematurity (ROP) requiring laser treatment than the non-UA-AEDF group. However, within 32 weeks of gestation, the complication rates between the two groups were not significantly different. In the 32 weeks before delivery, the overall developmental quotient (DQ) scores of children in the UA-AEDF group were lower than those in the non-UAAEDF group. Specifically, within the UA-AEDF group, the mean DQ scores at 1.5 years of corrected age was significantly lower prior to 32 weeks of gestation than in the other groups.

DISCUSSION

This study demonstrated that UA-AEDF in severely SGA infants before 32 weeks of gestation may be associated with poor long-term prognosis, comparable to preterm infants. Conversely, in non-UA-AEDF cases, the frequency of poor long-term prognosis, involving DQ, remained consistent before and after 32 weeks of gestation. This study highlights the potential significance of UA-AEDF in predicting neurodevelopmental outcomes in severe SGA infants; thus, incorporating UA Doppler findings into clinical protocols for severe SGA cases is helpful.

Early hypoglycemia is not an independent risk factor for 2-year cognitive impairment in small for gestational age preterm infants of less than 32 weeks

The objective of this study is to evaluate whether early hypoglycemia is an independent risk factor for 2-year cognitive (COG) impairment in small for gestational age (SGA) preterm infants with gestational age (GA) < 32 weeks. We retrospectively reviewed data of 1364 preterm infants with a GA 24+0/7-31+6/7 weeks. Infants were classified based on blood glucose concentrations within the first 6 h of life (HOL) as < or ≥ 40 mg/dL (Glyc < 40[Birth-6HOL] and Glyc ≥ 40[Birth-6HOL], respectively) and subsequently by birth weight z-score as SGA or appropriate for gestational age (AGA). Propensity score matching analyses were conducted for each comparison. Multiple logistic regression was used to evaluate the association of Glyc < 40[Birth-6HOL] with 2-year COG impairment, defined as a Bayley-III score < 85, in SGA infants. Out of the 747 preterm infants who met the inclusion criteria, 173 (23.2%) were classified as Glyc < 40[Birth-6HOL], and 574 (76.8%) as Glyc ≥ 40[Birth-6HOL]. The proportion of SGA infants was significantly higher in Glyc < 40[Birth-6HOL] than in Glyc ≥ 40[Birth-6HOL] (25.4 vs 18.3%, p = 0.039). The incidence of 2-year COG impairment was significantly higher in SGA infants compared to matched AGA counterparts both in Glyc < 40[Birth-6HOL] (+ 20%, p = 0.040) and Glyc ≥ 40[Birth-6HOL] (+ 17%, p = 0.029). Neither in the entire cohort nor in the SGA infants, Glyc < 40[Birth-6HOL] was significantly associated with 2-year COG impairment (aOR: 1.077, p = 0.768; 0.993, p = 0.935; respectively) after the adjustment for GA, sex, Apgar score at 5 min < 7, SGA status, complications of prematurity, duration of mechanical ventilator support > 7 days, cumulative energy intakes from birth to 36 weeks, and maternal university level.

CONCLUSION

 Among SGA preterm infants with GA between 24+0/7 and 31+6/7 weeks/days, hypoglycemia within the first 6 HOL was not an independent risk factor for 2-year COG impairment.

WHAT IS KNOWN

• Hypoglycemia is associated with poor neurodevelopmental outcomes in preterm infants. • Small for gestational age (SGA) preterm infants are more prone to cognitive (COG) impairment compared to AGA counterparts.

WHAT IS NEW

• In a large cohort of preterm infants < 32 weeks, the incidence of hypoglycemia within the first 6 hours of life (HOL) was higher in SGA compared to AGA. • Hypoglycemia within the first 6 HOL was not an independent risk factor for 2-year COG impairment in SGA preterm infants.

GLUT1 exacerbates trophoblast ferroptosis by modulating AMPK/ACC mediated lipid metabolism and promotes gestational diabetes mellitus associated fetal growth restriction

BACKGROUND

Gestational diabetes mellitus (GDM) has been associated with several fetal complications, such as macrosomia and fetal growth restriction (FGR). Infants from GDM associated FGR are at increased risk for adult-onset obesity and associated metabolic disorders. However, the underlying mechanisms of GDM associated FGR remain to be explored.

METHODS

We analyzed placentas from GDM patients with FGR for ferroptosis markers and GLUT1 expression. High glucose conditions were established by adding different concentrations of D-Glucose to the 1640 cell culture medium. RSL3 were used to test ferroptosis sensitivity in trophoblast cells. GLUT1 was inhibited using siRNA or its inhibitor WZB117 to assess its impact on ferroptosis inhibition in HTR8/SVneo cell line. Mechanistic studies explored the effects of GLUT1 on AMPK and ACC phosphorylation, which in turn impacted lipid metabolism and ferroptosis. In mouse models, streptozotocin (STZ)-induced GDM was treated with WZB117 and the ferroptosis inhibitor liproxstatin-1 (Lip-1). Finally, AMPK and ACC phosphorylation levels were evaluated in GDM patient samples.

RESULTS

In this study, placentas from GDM patients with FGR showed signs of ferroptosis and upregulation of GLUT1. In cell models, high glucose conditions sensitized trophoblast cells to ferroptosis and induced GLUT1 expression. Interestingly, GLUT1 inhibition significantly suppressed ferroptosis in trophoblast cells under high glucose conditions. Mechanistically, elevated GLUT1 inhibited AMPK phosphorylation and reduced ACC phosphorylation, thereby promoting lipid synthesis and facilitating ferroptosis. In pregnant mice, STZ-induced hyperglycemia led to FGR, and treatment with either the GLUT1 inhibitor WZB117 or the ferroptosis inhibitor Lip-1 alleviated the FGR phenotype. Moreover, in vivo elevation of GLUT1 increased ferroptosis markers, decreased AMPK/ACC phosphorylation, and resulted in altered lipid metabolism, which likely contributed to the observed phenotype. Finally, placental samples from GDM patients showed reduced AMPK and ACC phosphorylation.

CONCLUSIONS

Our findings suggest a potential role of ferroptosis in GDM associated FGR and indicate that the dysregulated GLUT1-AMPK-ACC axis may be involved in the pathogenesis of GDM associated FGR in clinicals.

Integrated proteomic and transcriptomic landscape of human placenta in small for gestational age infants

Small for gestational age (SGA) infants affected by placental insufficiency are exposed to the risk of stillbirth and long-term complications. Based on RNA-seq and mass spectrometry, we identified dysregulated RNAs and proteins from the comparisons of SGA placental tissues and controls. We revealed two SGA-relevant co-expression modules (SRMs) that also significantly distinguished SGA from controls. Then we performed an integrated analysis of transcriptomic and proteomic profiles to trace their links to SGA as well as their significant correlations. For the core functional molecules we screened, we revealed their potential upstream regulators and validated them experimentally in an independent cohort. Overall, we pointed out insights into different molecular pathways for the pathological mechanisms of SGA and indicated potential target molecules that may be drivers of placental aberrations in the SGA infants.

Associations of fetal and postnatal growth trajectories with child cognition: the GUSTO cohort study

BACKGROUND

Using longitudinal ultrasounds as an improved fetal growth marker, we aimed to investigate if increased postnatal growth following fetal abdominal circumference (AC) growth deceleration is associated with improved child cognition.

METHODS

Among 797 term-born singletons in the Growing Up in Singapore Towards healthy Outcomes (GUSTO) cohort, we derived 2nd-3rd trimester fetal AC growth z-score, fetal AC growth deceleration, standardized height, weight, and body mass index (BMI) growth at early infancy (0-4 months), late infancy (4-15 months), toddlerhood (15-37 months), and early childhood (3-7 years), and investigated their associations with intelligence quotient (IQ) at ages 4.5 years (verbal, non-verbal) and 7 years (non-verbal-block design, matrix reasoning), adjusting for socio-demographic and biological confounders.

RESULTS

Among term-born newborns, 23.3% experienced fetal AC growth deceleration, which was associated with lower non-verbal IQ (4.5 years) [β (95% CI), -4.00 (-7.49, -0.51)]. Higher 0-7 years z-BMI gain was associated with lower non-verbal IQ (block design) (7 years) [-1.33 (-2.51, -0.14)]. Higher late infancy z-BMI gain was associated with higher verbal IQ (4.5 years) [3.36 (0.82,5.90)] but lower non-verbal IQ (matrix reasoning) (7 years) [-2.32 (-4.48, -0.17)]. Among those with fetal AC growth deceleration, higher 0-7 years z-weight gain was associated with lower non-verbal IQ (block design) (7 years) (P-interaction = .049); at z-weight gain of +2 standard deviation score (SDS), those with fetal AC growth deceleration had lower IQ [margins (95% CI), -2.6 (-7.1,1.9)]. On average, children with fetal AC growth deceleration caught up in z-height, z-weight, and z-BMI by 7 years.

CONCLUSION

Fetal AC growth deceleration was associated with lower cognition scores at preschool age. Increased weight or BMI growth from 0-7 years following fetal AC growth deceleration might not be favorable to cognition among generally well-nourished term-born children.

Voting Restrictions and Increased Odds of Adverse Birth Outcomes in the US

BACKGROUND

Disparities persist in adverse birth outcomes - preterm birth and small-for-gestational age (SGA) among racialized populations. Previous studies have indicated that voting restrictions are associated with health outcomes, such as access to health insurance and teenage birth rates. This paper examines whether the association between voting restrictions and adverse birth outcomes varies according to birthing individuals' race/ethnicity.

METHODS

These analyses merged individual-level 2019-2020 Pregnancy Risk Assessment Monitoring System (PRAMS, 8th edition) data with state-level exposure information. The exposure, the Cost of Voting Index (COVI), is a 2020 state-level measure of voting restrictions, and the outcomes were preterm birth and SGA. Multilevel logistic regression, survey-weighted models adjusted for sociodemographic and geographically-based characteristics. Subanalyses examined if the association differed by race (non-Hispanic White, non-Hispanic Black, Hispanic, API, Other).

RESULTS

In the unadjusted model, a standard deviation increase in COVI was associated with increased odds of preterm birth (OR = 1.11, 95% CI = 0.98, 1.25) and SGA (OR = 1.12, 95% CI = 1.02, 1.22). The association for SGA was still significant in the fully adjusted models. Results differed by race/ethnicity with the largest effects among API (OR = 1.20, 95% CI = 0.95, 1.52) for preterm birth and OR = 1.27, 95% CI = 1.01, 1.59) for SGA respectively).

CONCLUSION

Our results suggest structural voting barriers disproportionately increase the odds of adverse birth outcomes, especially for API-birthing individuals. Increasing voting restrictions may amplify existing birth inequities.

Perinatal inflammation, fetal growth restriction, and long-term neurodevelopmental impairment in Bangladesh

BACKGROUND

There are limited data on the impact of perinatal inflammation on child neurodevelopment in low-middle income countries and among growth-restricted infants.

METHODS

Population-based, prospective birth cohort study of 288 infants from July 2016-March 2017 in Sylhet, Bangladesh. Umbilical cord blood was analyzed for interleukin(IL)-1α, IL-1β, IL-6, IL-8, and C-reactive protein(CRP). Child neurodevelopment was assessed at 24 months with Bayley-III Scales of Infant Development. We determined associations between cord blood inflammation and neurodevelopmental outcomes, controlling for potential confounders.

RESULTS

248/288 (86%) live born infants were followed until 24 months, among whom 8.9% were preterm and 45.0% small-for-gestational-age(SGA) at birth. Among all infants, elevated concentrations (>75%) of CRP and IL-6 at birth were associated with increased odds of fine motor delay at 24 months; elevated CRP was also associated with lower receptive communication z-scores. Among SGA infants, elevated IL-1α was associated with cognitive delay, IL-8 with language delay, CRP with lower receptive communication z-scores, and IL-1β with lower expressive communication and motor z-scores.

CONCLUSIONS

In rural Bangladesh, perinatal inflammation was associated with impaired neurodevelopment at 24 months. The associations were strongest among SGA infants and noted across several biomarkers and domains, supporting the neurobiological role of inflammation in adverse fetal development, particularly in the setting of fetal growth restriction.

IMPACT

Cord blood inflammation was associated with fine motor and language delays at 24 months of age in a community-based cohort in rural Bangladesh. 23.4 million infants are born small-for-gestational-age (SGA) globally each year. Among SGA infants, the associations between cord blood inflammation and adverse outcomes were strong and consistent across several biomarkers and neurodevelopmental domains (cognitive, motor, language), supporting the neurobiological impact of inflammation prominent in growth-restricted infants. Prenatal interventions to prevent intrauterine growth restriction are needed in low- and middle-income countries and may also result in long-term benefits on child development.

The correlation between placental growth factor and small for gestational age infants: a matched case-control study

BACKGROUND

At present, research has not found easily accessible, accurate, and safe clinical biomarkers that can effectively predict the occurrence of infants born small for gestational age (SGA). The aim of this study is to explore the predictive role of maternal placental growth factor (PIGF) levels on the occurrence of SGA infants.

METHOD

We conducted a matched case-control study on 226 SGA infants and 226 non-SGA infants born in the Department of Obstetrics, Peking University People's Hospital, from January 2021 to December 2022, with regular monitoring of maternal serum PIGF levels in second trimester during pregnancy. Apply multiple logistic regression analysis and receiver operating characteristic (ROC) curve analysis to determine whether PIGF is an independent influencing factor for the occurrence of SGA in infants, and evaluate whether PIGF can predict the occurrence of SGA in infants.

RESULTS

Multiple logistic regression analysis found that multipara (HR = 0.484, 95% CI = 0.250-0.937, p = 0.031), maternal pre-pregnancy underweight (HR = 4.710, 95% CI = 1.881-11.792, p = 0.001), pre-eclampsia(HR = 2.291, 95% CI = 1.068-4.913, p = 0.033), low levels of PIGF (HR = 26.417, 95% CI = 12.850-54.311, p < 0.001) and oligohydramnios (HR = 4.764, 95% CI = 1.845-12.301, p = 0.001) were independent factors affecting the occurrence of infants born SGA. In addition, ROC curve analysis showed that the area under the curve (AUC) predicted by PIGF level and four other influencing factors for the occurrence of SGA infants were 0.834 and 0.723, respectively. In addition, the combination of PIGF and four other independent influencing factors improved the predictive value (AUC 0.902) for the birth of SGA infants, with enhanced sensitivity and specificity.

CONCLUSION

Low levels of PIGF in second trimester during pregnancy are an independent risk factor for SGA infants. Compared with other indicators, PIGF levels PIGF in second trimester are a better predictor of SGA in infants.

Early Growth and Impacts on Long-Term Neurodevelopment and Human Capital

BACKGROUND

Growth trajectories during the first 1,000 days from conception to 2 years influence human capital, predicting intelligence, skills and health in adults.

SUMMARY

This review describes current evidence on the impacts of adverse pregnancy outcomes such as low birth weight, preterm birth, small for gestational age, and infant nutrition on long-term neurodevelopment and summarizes interventions that have proven to be effective in improving child development and further impact human capital. To date, no globally standardized measurements of child development in low-medium-income countries exist, and comparisons among studies using different developmental scales are challenging. In the perinatal period, birth weight, gestational age at delivery and elevated placental blood flow resistance have been identified as the main risk factors for global neurological delay, poor neurosensory development and cerebral palsy. Although these adverse neurological outcomes have decreased in developed settings, it is still a problem in low-resource populations. Nutritional deficiencies are the main drivers of developmental impairment, notably iron, iodine and folate deficiencies, and environmental stressors during pregnancy such as air pollution, exposure to chemicals, substance abuse, smoking, and maternal/parental psychiatric disorders can affect the developing brain. Interventions aiming to improve maternal macro- and micronutrient status, delayed cord clamping, exclusive breastfeeding and nurturing care have demonstrated to be effective strategies to prevent perinatal complications known to affect child development.

Analysis of Umbilical Artery Hemodynamics in Development of Intrauterine Growth Restriction Using Computational Fluid Dynamics with Doppler Ultrasound

Intrauterine growth restriction (IUGR), the failure of the fetus to achieve his/her growth potential, is a common and complex problem in pregnancy. Clinically, IUGR is usually monitored using Doppler ultrasound of the umbilical artery (UA). The Doppler waveform is generally divided into three typical patterns in IUGR development, from normal blood flow (Normal), to the loss of end diastolic blood flow (LDBF), and even to the reversal of end diastolic blood flow (RDBF). Unfortunately, Doppler ultrasound hardly provides complete UA hemodynamics in detail, while the present in silico computational fluid dynamics (CFD) can provide this with the necessary ultrasound information. In this paper, CFD is employed to simulate the periodic UA blood flow for three typical states of IUGR, which shows comprehensive information on blood flow velocity, pressure, and wall shear stress (WSS). A new finding is the "hysteresis effect" between the UA blood flow velocity and pressure drop in which the former always changes after the latter by 0.1-0.2 times a cardiac cycle due to the unsteady flow. The degree of hysteresis is a promising indicator characterizing the evolution of IUGR. CFD successfully shows the hemodynamic details in different development situations of IUGR, and undoubtedly, its results would also help clinicians to further understand the relationship between the UA blood flow status and fetal growth restriction.

Fetal weight growth trajectories and childhood development: A population-based cohort study

This study aimed to investigate whether fetal growth trajectories (FGTs) could predict early childhood development, indicate intrauterine metabolic changes, and explore potential optimal and suboptimal FGTs. FGTs were developed by using an unsupervised machine-learning approach. Children's neurodevelopment, anthropometry, and respiratory outcomes in the first 6 years of life were assessed at different ages. In a subgroup of participants, we conducted a metabolomics analysis of cord blood to reveal the metabolic features of FGTs. We identified 6 FGTs: early decelerating, early decelerating with late catch-up growth, early accelerating, early accelerating with late medium growth, late decelerating, and late accelerating. The early accelerating with late medium growth pattern might be the optimal FGT due to its associations with better psychomotor development, mental development, intelligence quotient, and lung function and a lower risk of behaviour and respiratory problems. Compared with the optimal FGT, early decelerating and late decelerating FGTs were associated with poor neurodevelopment and lung function, while early accelerating FGT was associated with more severe autistic symptoms, poor lung function, and increased risks of overweight/obesity. Metabolic alterations were enriched in amino acid metabolism for early decelerating and late decelerating FGTs, whereas altered metabolites were enriched in lipid metabolism for early accelerating FGT. These findings suggest that FGTs are predictors of early life development and may indicate intrauterine adaptive metabolism. The discovery of optimal and suboptimal FGTs provides potential clues for the early identification and intervention of fetal origin dysplasia or disease, but further research on related mechanisms is still needed.

Metabolomic signatures associated with fetal growth restriction and small for gestational age: a systematic review

The pathways involved in the pathophysiology of fetal growth restriction (FGR) and small for gestational age (SGA) are incompletely understood. We conduct a systematic review to identify metabolomic signatures in maternal and newborn tissues and body fluids samples associated with FGR/SGA. Here, we report that 825 non-duplicated metabolites were significantly altered across the 48 included studies using 10 different human biological samples, of which only 56 (17 amino acids, 12 acylcarnitines, 11 glycerophosphocholines, six fatty acids, two hydroxy acids, and eight other metabolites) were significantly and consistently up- or down-regulated in more than one study. Three amino acid metabolism-related pathways and one related with lipid metabolism are significantly associated with FGR and/or SGA: biosynthesis of unsaturated fatty acids in umbilical cord blood, and phenylalanine, tyrosine and tryptophan biosynthesis, valine, leucine and isoleucine biosynthesis, and phenylalanine metabolism in newborn dried blood spot. Significantly enriched metabolic pathways were not identified in the remaining biological samples. Whether these metabolites are in the causal pathways or are biomarkers of fetal nutritional deficiency needs to be explored in large, well-phenotyped cohorts.

Prenatal Exposure to Nonpersistent Chemicals and Fetal-to-childhood Growth Trajectories

INTRODUCTION

Prenatal exposure to nonpersistent chemicals, including organophosphate pesticides, phthalates, and bisphenols, is associated with altered fetal and childhood growth. Few studies have examined these associations using longitudinal growth trajectories or considering exposure to chemical mixtures.

METHODS

Among 777 participants from the Generation R Study, we used growth mixture models to identify weight and body mass index trajectories using weight and height measures collected from the prenatal period to age 13. We measured exposure biomarkers for organophosphate pesticides, phthalates, and bisphenols in maternal urine at three timepoints during pregnancy. Multinomial logistic regression was used to estimate associations between averaged exposure biomarker concentrations and growth trajectories. We used quantile g-computation to estimate joint associations with growth trajectories.

RESULTS

Phthalic acid (OR = 1.4; 95% CI = 1.01, 1.9) and bisphenol A (OR = 1.5; 95% CI = 1.0, 2.2) were associated with higher odds of a growth trajectory characterized by smaller prenatal and larger childhood weight relative to a referent trajectory of larger prenatal and average childhood weight. Biomarkers of organophosphate pesticides, individually and jointly, were associated with lower odds of a growth trajectory characterized by average prenatal and lower childhood weight.

CONCLUSIONS

Exposure to phthalates and bisphenol A was positively associated with a weight trajectory characterized by lower prenatal and higher childhood weight, while exposure to organophosphate pesticides was negatively associated with a trajectory of average prenatal and lower childhood weight. This study is consistent with the hypothesis that nonpersistent chemical exposures disrupt growth trajectories from the prenatal period through childhood.

Associations of Maternal Nutritional Status and Supplementation with Fetal, Newborn, and Infant Outcomes in Low-Income and Middle-Income Settings: An Overview of Reviews

BACKGROUND/OBJECTIVES

Despite advances in maternal nutritional knowledge, the effect of maternal diet, micronutrient status and undernutrition, and the effect of maternal supplementation on fetal, neonatal and infant outcomes still have gaps in the literature. This overview of reviews is intended to assess the available information on these issues and identify the main maternal nutritional factors associated with offspring outcomes in low- and middle-income countries as possible targets for public health interventions.

METHODS

The literature search was performed in Medline (PubMed) and Cochrane Library datasets in June 2024. Pre-specified outcomes in offspring were pooled using standard meta-analytical methods.

RESULTS

We found consistent evidence on the impact of maternal undernutrition indicated by low body mass index (BMI), mid-upper arm circumference (MUAC), and stature, but not of individual micronutrient status, on intrauterine-growth retardation, preterm birth, low birth weight, and small for gestational age, with research showing a possible effect of maternal undernutrition in later child nutritional status. Studies on micronutrient supplementation showed possible beneficial effects of iron, vitamin D, and multiple micronutrients on birthweight and/or decreasing small for gestational age, as well as a possible effect of calcium on preterm birth reduction. Interventions showing more consistent beneficial outcomes were balanced protein-energy and lipid base supplements, which demonstrated improved weight in newborns from supplemented mothers and a decreased risk of adverse neonatal outcomes.

CONCLUSIONS

Further research is needed to identify the benefits and risks of maternal individual micronutrient supplementation on neonatal and further child outcomes.

Preeclampsia and Future Implications on Growth and Body Composition in Preterm Infants

BACKGROUND

Preeclampsia is associated with intrauterine growth restriction (IUGR), which can lead to impaired postnatal growth and neurodevelopment in preterm infants. Preeclampsia can also occur without IUGR and its impact on postnatal nutrition, growth, and body composition remains not fully investigated to the best of our knowledge.

METHODS

This study included infants born before 37 weeks of gestation who underwent air displacement plethysmography to measure body composition (fat-free mass [FFM] and fat mass [FM]) at term-equivalent age. We compared infants born to mothers with preeclampsia and IUGR (PE-IUGR group) and preeclampsia without IUGR (PE-non-IUGR group) to those born to mothers without preeclampsia (control group).

RESULTS

In total, 291 infants were enrolled (control: n = 227; PE-non-IUGR: n = 43; PE-IUGR: n = 21). FFM was significantly lower in the PE-IUGR (mean differences -231 g (IQR: (-373, -88); p < 0.001)) and PE-non-IUGR groups (mean differences -260 g (IQR: (-372, -149); p < 0.001)) in comparison to the control group. FM was not significantly different between the three groups.

CONCLUSIONS

This study indicates that infants of preeclamptic mothers, even without IUGR, had significantly lower FFM at term-equivalent age compared to the control group. Further research is necessary to determine if these variations can be modified.

Placental Malaria Induces a Unique Methylation Profile Associated with Fetal Growth Restriction

BACKGROUND

Fetal growth restriction (FGR) is associated with perinatal death and adverse birth outcomes, as well as long-term complications, including increased childhood morbidity, abnormal neurodevelopment, and cardio-metabolic diseases in adulthood. Placental epigenetic reprogramming associated with FGR may mediate these long-term outcomes. Placental malaria (PM), characterized by sequestration of Plasmodium falciparum-infected erythrocytes in placental intervillous space, is the leading global cause of FGR, but its impact on placental epigenetics is unknown. We hypothesized that placental methylomic profiling would reveal common and distinct mechanistic pathways of non-malarial and PM-associated FGR.

RESULTS

We analyzed placentas from a US cohort with no malaria exposure (n = 12) and a cohort from eastern Uganda, a region with a high prevalence of malaria (n = 12). From each site, 8 cases of FGR (defined as birth weight <10%ile for gestational age by Intergrowth-21 standard curves) and 4 healthy controls with normal weight were analyzed. PM was diagnosed by placental histopathology. We compared the methylation levels of over 850K CpGs of the placentas using Infinium MethylationEPIC v1 microarray. Non-malarial FGR was associated with 65 differentially methylated CpGs (DMCs), whereas PM-FGR was associated with 133 DMCs, compared to their corresponding controls without FGR. One DMC (cg16389901, located in the promoter region of BMP4) was commonly hypomethylated in both groups. We identified 522 DMCs between non-malarial FGR vs. PM-FGR placentas, which was independent of differing geographic location or cellular composition.

CONCLUSION

Placentas with PM-associated FGR have distinct methylation profiles as compared to placentas with non-malarial FGR, suggesting novel epigenetic reprogramming in response to malaria. Larger cohort studies are needed to determine the distinct long-term health outcomes in PM-associated FGR pregnancies.

Do serum Delta-Neutrophil Index and Neutrophil-to-Lymphocyte ratio predict fetal growth restriction?

Aim

To investigate the prognostic significance of delta-neutrophil index (DNI) and neutrophil/lymphocyte ratio (NLR) in women with intrauterine growth retardation (IUGR) and normal pregnant women.

Methods

Normal pregnant women who delivered at Health Sciences University Etlik Zübeyde Hanim Women's Health Training and Research Hospital between January 2015 and July 2020 and pregnant women with IUGR were included in the study. 486 pregnant women and 400 normally pregnant women diagnosed with IUGR according to Delphi criteria were included in the analysis. Data available at presentation for delivery or within four weeks before delivery were used for analysis of DNI and other laboratory values in both the patient and control groups.

Results

The mean age of study group was 28.3±4.6 and control group was 27.2±5.6 years. There were significant differences between the study and control groups regarding maternal age, prepregnancy BMI, BMI at delivery and gestational age at admission and delivery, hemoglobin(Hb) levels, hematocrit (Hct) values, WBC values, lymphocyte, monocyte, neutrophile, thrombocyte counts, NLRs, DNI values, between the two groups. The median NLRs were 4.6 (range, 1.54±44.29), the mean DNI value of IUGR was --0.26±3.4 and the mean DNI value of control group was -3.7±5.8 (p<0.001, p<0.001, respectively). The NLR and DNI levels are significantly higher in the IUGR group. The optimal cut-off value for NLR was 3.84, with a sensitivity of 70.6% a specificity of 70.5%, and an area under the receiver operating characteristic curve of 0.780. The optimal cutoff value for DNI was -1.18, with a sensitivity of 53.9%, a specificity of 52%, and an area under the ROC curve of 0.692. The Odds Ratio of the DNI was 1.2, and NLR was 5.7.

Conclusion

Considering its sensitivity and specificity, the NLR value shows that inflammatory events are much more effective in pregnant women with IUGR than we thought.

Interpregnancy interval, air pollution, and the risk of low birth weight: a retrospective study in China

BACKGROUND

Both interpregnancy intervals (IPI) and environmental factors might contribute to low birth weight (LBW). However, the extent to which air pollution influences the effect of IPIs on LBW remains unclear. We aimed to investigate whether IPI and air pollution jointly affect LBW.

METHODS

A retrospective cohort study was designed in this study. The data of birth records was collected from the Jiangsu Maternal Child Information System, covering January 2020 to June 2021 in Nantong city, China. IPI was defined as the duration between the delivery date for last live birth and date of LMP for the subsequent birth. The maternal exposure to ambient air pollutants during pregnancy-including particulate matter (PM) with an aerodynamic diameter of ≤ 2.5 μm (PM2.5), PM10, ozone (O3), nitrogen dioxide (NO2), sulfur dioxide (SO2) and carbon monoxide (CO)-was estimated using a hybrid kriging-LUR-RF model. A novel air pollution score was proposed, assessing combined exposure to five pollutants (excluding CO) by summing their concentrations, weighted by LBW regression coefficients. Multivariate logistic regression models were used to estimate the effects of IPI, air pollution and their interactions on LBW. Relative excess risk due to interaction (RERI), attributable proportion of interaction (AP) and synergy index (S) were utilized to assess the additive interaction.

RESULTS

Among 10, 512 singleton live births, the LBW rate was 3.7%. The IPI-LBW risk curve exhibited an L-shaped pattern. The odds ratios (ORs) for LBW for each interquartile range increase in PM2.5, PM10, O3 and the air pollution score were 1.16 (95% CI: 1.01-1.32), 1.30 (1.06-1.59), 1.22 (1.06-1.41), and 1.32 (1.10-1.60) during the entire pregnancy, respectively. An additive interaction between IPI and PM2.5 was noted during the first trimester. Compared to records with normal IPI and low PM2.5 exposure, those with short IPI and high PM2.5 exposure had the highest risk of LBW (relative risk = 3.53, 95% CI: 1.85-6.49, first trimester).

CONCLUSION

The study demonstrates a synergistic effect of interpregnancy interval and air pollution on LBW, indicating that rational birth spacing and air pollution control can jointly improve LBW outcomes.

Association of birth weight with neuropsychological functioning in early adolescence: A retrospective cohort study

OBJECTIVE

This study aimed to compare the neuropsychological function in early adolescence between children born small for gestational age (SGA) or large for gestational age (LGA) and those born appropriate for gestational age (AGA).

METHODS

This retrospective cohort study utilized data from the Adolescent Brain Cognitive Development study in 2016-18. Children born of singleton pregnancy with complete information of birth weight and delivery week were enrolled. Their neuropsychological functioning were assessed by the brain structural magnetic resonance imaging (MRI), combined with cognitive and behavioral measurements. Linear mixed-effects models and subgroup analyses were performed.

RESULTS

Among 5,922 children aged 9-11, children born SGA and LGA demonstrated similar cognitive and behavioral performances as children born AGA (P > 0.05). In the MRI measurement, brain area and volume were lower among SGA children compared to AGA children (t=-5.626, Cohen's d = 0.448, P < 0.001; t=-6.071, Cohen's d = 0.427, P < 0.001); brain area and volume were higher among LGA children compared to AGA children (t = 8.562, Cohen's d = 0.470, P < 0.001; t = 8.562, Cohen's d = 0.470, P < 0.001). Cortical thickness was of no statistical difference (P > 0.05). These associations were confirmed by sensitivity analyses and propensity score matching.

CONCLUSION

Children born of SGA and LGA status were associated with altered brain area and volume structure in early adolescence.

Neonatal sex and maternal factors associated with small-for-gestational-age neonates: A nationwide population-based study

Background and Aims

Small-for-gestational-age (SGA) newborns have a higher risk of morbidity and mortality. Recognizing the risk factors for SGA helps raise early awareness of the issue and provides valuable insights for both healthcare providers and pregnant women. We aimed to identify determinants of SGA using population-based databases in Taiwan.

Methods

Data were retrieved from the National Health Insurance, Birth Reporting, and Maternal and Child Health databases for this nationwide case-control study. Live births between 20 and 44 weeks of gestation from 2005 to 2014 were enrolled and linked to their mothers to determine maternal conditions during pregnancy. For every SGA newborn, four controls matched by gestational age and birth year were randomly selected. Multivariable logistic regression was used to identify risk factors for SGA, with adjusted odds ratios (aORs) and 95% confidence intervals (CIs) accounting for potential confounders and interaction terms.

Results

A total of 158,405 live SGA births were identified, with 623,584 controls randomly selected. Independent risk factors for SGA included maternal age <20 years (aOR 1.68, 95% CI 1.62, 1.75); female sex in newborns (aOR 1.28, 95% CI 1.27, 1.30); socioeconomic deprivation (aOR 1.29, 95% CI 1.21, 1.38); hypertension (aOR 1.6, 95% CI 1.52, 1.67); kidney disorders (aOR 1.29, 95% CI 1.16, 1.44); thyroid disorders (aOR 1.13, 95% CI 1.09, 1.17); systemic lupus erythematosus (aOR 2.59, 95% CI 2.33, 2.89); antiphospholipid syndrome (aOR 2.08, 95% CI 1.64, 2.64); gestational hypertension (aOR 1.69, 95% CI 1.61, 1.76); pre-eclampsia (aOR 3.12, 95% CI 3.01, 3.25); and antepartum hemorrhage (aOR 1.05, 95% CI 1.03, 1.07) after adjustment for other covariates.

Conclusions

SGA was associated with younger maternal age, female newborns, underlying comorbidities, and obstetric conditions. Gestational hypertension and pre-eclampsia were significant risk factors affecting infants of both sexes and all age groups and could mask the effects of maternal age and infant sex.

Retarded astrogliogenesis in response to hypoxia is facilitated by downregulation of CIRBP

The adverse impacts of chronic hypoxia on maternal and infant health at high altitudes warrant significant attention. However, effective protective measures against the resultant growth restrictions and neurodevelopmental disorders in infants and young children are still lacking. This study investigated the neurodevelopment of mice offspring under hypoxic conditions by exposing pregnant mice to a hypobaric oxygen chamber that simulated the hypobaric hypoxia at an altitude of 4000 m until 28 days after delivery. Our findings suggested that prolonged exposure to hypoxia might result in emotional abnormalities and social disorders in offspring. The significant reduction in astrogliogenesis was a characteristic feature associated with neurodevelopmental disorders induced by hypoxia. Further studies demonstrated that cold-induced RNA-binding protein (CIRBP) was a key transcriptional regulator in astrogliogenesis, which downregulated astrocytic differentiation under hypoxia through its crosstalk with the NFIA. Our study emphasized the crucial role of CIRBP in regulating astrogliogenesis and highlighted its potential as a promising target for therapeutic interventions in neurodevelopmental disorders associated with hypoxia.

Thyroid hormone analogues: Promising therapeutic avenues to improve the neurodevelopmental outcomes of intrauterine growth restriction

Intrauterine growth restriction (IUGR) is a pregnancy complication impairing fetal growth and development. The compromised development is often attributed to disruptions of oxygen and nutrient supply from the placenta, resulting in a number of unfavourable physiological outcomes with impaired brain and organ growth. IUGR is associated with compromised development of both grey and white matter, predisposing the infant to adverse neurodevelopmental outcomes, including long-lasting cognitive and motor difficulties. Cerebral thyroid hormone (TH) signalling, which plays a crucial role in regulating white and grey matter development, is dysregulated in IUGR, potentially contributing to the neurodevelopmental delays associated with this condition. Notably, one of the major TH transporters, monocarboxylate transporter-8 (MCT8), is deficient in the fetal IUGR brain. Currently, no effective treatment to prevent or reverse IUGR exists. Management strategies involve close antenatal monitoring, management of maternal risk factors if present and early delivery if IUGR is found to be severe or worsening in utero. The overall goal is to determine the most appropriate time for delivery, balancing the risks of preterm birth with further fetal compromise due to IUGR. Drug candidates have shown either adverse effects or little to no benefits in this vulnerable population, urging further preclinical and clinical investigation to establish effective therapies. In this review, we discuss the major neuropathology of IUGR driven by uteroplacental insufficiency and the concomitant long-term neurobehavioural impairments in individuals born IUGR. Importantly, we review the existing clinical and preclinical literature on cerebral TH signalling deficits, particularly the impaired expression of MCT8 and their correlation with IUGR. Lastly, we discuss the current evidence on MCT8-independent TH analogues which mimic the brain actions of THs by being metabolised in a similar manner as promising, albeit underappreciated approaches to promote grey and white matter development and improve the neurobehavioural outcomes following IUGR.

Small for gestational age in twin pregnancies and the risk of offspring pediatric neurologic morbidity

OBJECTIVES

Small for gestational age (SGA) singletons are at increased risk for neurodevelopmental abnormalities. Scarce data exist regarding the long-term implications of SGA in twins. We opted to study the association between SGA of one twin and long-term neurologic related morbidity in dichorionic diamniotic twins.

STUDY DESIGN

A population-based retrospective cohort study including consecutive dichorionic diamniotic twins, born between the years 1991 and 2021 at a tertiary medical center was conducted. Total and subtypes of neurologic related pediatric hospitalizations among SGA versus non-SGA twins were compared. A Kaplan-Meier survival curve was used to compare the cumulative neurologic morbidity incidence, and a Cox proportional hazards model was constructed to adjust for confounders.

RESULTS

The study population included 4222 newborns; 180 (4.3%) were SGA. Rate of long-term neurologic related hospitalizations was comparable between the two groups (8.7 vs. 8.0%, p = 0.755; Kaplan-Meier survival curve Log-rank p = 0.652). Using a Cox proportional hazards model, controlling for gender and birth order, no association was found between SGA and the risk for subsequent neurologic pediatric morbidity of the offspring (Adjusted HR = 1.0, 95% CI 0.6-1.8, p = 0.973).

CONCLUSIONS

SGA is not associated with an increased risk for long-term pediatric neurologic morbidity in dichorionic diamniotic twins.

The Impact of Fetal Growth Restriction on Prenatal 2D Ultrasound and Doppler Study of the Fetal Adrenal Gland

Background: Uteroplacental insufficiency in fetuses with growth restriction (FGR) leads to chronic hypoxia and stress, predominantly affecting the adrenal glands. However, the mechanisms of impact remain unclear. Objectives: This study is aimed at comparing the Doppler indices of the adrenal artery and the adrenal gland sizes between FGR and those with normal growth. Materials and Methods: A multicenter, cross-sectional study was conducted from February to December 2023. We compared 34 FGR to 34 with normal growth in terms of inferior adrenal artery (IAA) Doppler indices and adrenal gland volumes. Results: The IAA peak systolic velocity (PSV) in the FGR group was 14.9 ± 2.9 cm/s compared to 13.5 ± 2.0 cm/s in the normal group, with a mean difference of 1.4 cm/s (95% confidence interval [CI]: 0.27-2.65; p value = 0.017). There were no significant differences between groups in terms of IAA pulsatility index (PI), resistance index (RI), or systolic/diastolic (S/D), with p values of 0.438, 0.441, and 0.658, respectively. The volumes of the corrected whole adrenal gland and the corrected neocortex were significantly larger in the FGR group, with p values of 0.031 and 0.020, respectively. Conclusion: Both increased IAA PSV and enlarged volumes of the corrected whole adrenal gland and neocortex were found in fetuses with FGR, suggesting significant adrenal gland adaptation in response to chronic intrauterine stress.

The PRECISE-DYAD Neurodevelopmental substudy protocol: neurodevelopmental risk in children of mothers with pregnancy complications

Background

Over 250 million children are not reaching their developmental potential globally. The impact of prenatal factors and their interplay with postnatal environmental factors on child neurodevelopment, is still unclear-particularly in low- and middle-income settings. This study aims to understand the impact of pregnancy complications as well as environmental, psychosocial, and biological predictors on neurodevelopmental trajectories.

Methods

This is an observational cohort study of female and male children (≈3,950) born to women (≈4,200) with and without pregnancy complications (pregnancy-induced hypertension, foetal growth restriction, and premature birth) previously recruited into PREgnancy Care Integrating Translational Science, Everywhere study with detailed biological data collected in intrapartum and post-partum periods. Children will be assessed at six weeks to 6 months, 11-13 months, 23-25 months and 35-37 months in rural and semi-urban Gambia (Farafenni, Illiasa, and Ngayen Sanjal) and Kenya (Mariakani and Rabai). We will assess children's neurodevelopment using Prechtls General Movement Assessment, the Malawi Development Assessment Tool (primary outcome), Observation of Maternal-Child Interaction, the Neurodevelopmental Disorder Screening Tool, and the Epilepsy Screening tool. Children screening positive will be assessed with Cardiff cards (vision), Modified Checklist for Autism in Toddlers Revised, and Pediatric Quality of Life Inventory Family Impact. We will use multivariate logistic regression analysis to investigate the impact of pregnancy complications on neurodevelopment and conduct structural equation modelling using latent class growth to study trajectories and relationships between biological, environmental, and psychosocial factors on child development.

Conclusions

We aim to provide information regarding the neurodevelopment of infants and children born to women with and without pregnancy complications at multiple time points during the first three years of life in two low-resource African communities. A detailed evaluation of developmental trajectories and their predictors will provide information on the most strategic points of intervention to prevent and reduce the incidence of neurodevelopmental impairments.

Fetal growth after fresh and frozen embryo transfer and natural conception: A population-based register study

OBJECTIVE

To investigate fetal growth trajectories and risks of small and large for gestational age (SGA and LGA), and macrosomia in pregnancies after fresh and frozen embryo transfer (ET), and natural conception (NC).

DESIGN

Longitudinal population-based cohort study.

SETTING

Swedish national registers.

POPULATION

A total of 196 008 singleton pregnancies between 2013 and 2017.

METHODS

Of all singleton pregnancies resulting in live births in the Swedish Pregnancy Register, 10 970 fresh ET, 6520 frozen ET, and 178 518 NC pregnancies with ultrasound data were included. A general least squares model was used to examine the effect of fresh or frozen ET on fetal growth while adjusting for confounders.

MAIN OUTCOME MEASURES

Fetal growth velocity. SGA, LGA and macrosomia.

RESULTS

At 120 days, fetal weights were lower in fresh ET pregnancies compared with NC pregnancies. Thereafter fresh ET as well as FET fetuses had higher fetal weights than NC fetuses, with no differences between themselves until the second trimester. From 210 days, FET fetuses were heavier than fresh ET fetuses, whereas fresh ET fetuses had lower fetal weights than NC fetuses from 245 days. After fresh ET, SGA was more frequent, whereas LGA and macrosomia were less frequent, than after FET.

CONCLUSIONS

This study gives new insights into the differences in fetal growth dynamics between fresh and frozen ET and NC pregnancies. Clinically relevant differences in proportions of SGA, LGA and macrosomia were observed.

Maternal Characteristics and Prevalence of Infants Born Small for Gestational Age

Importance

Being born small for gestational age (SGA) is a risk factor for neonatal mortality and adverse outcomes in the short and long term. The maternal profile in China has substantially changed over the past decade, which may affect the risk of infants born SGA.

Objectives

To analyze the prevalence of infants born SGA from 2012 through 2020 and explore the association of maternal sociodemographic characteristics and other factors with that prevalence.

Design, Setting, and Participants

This cross-sectional study examined data from the National Maternal Near Miss Surveillance System on women who delivered singleton live births at gestational ages of 28 to 42 weeks from January 1, 2012, through December 31, 2020, in China. Statistical analysis was performed from December 2022 to September 2023.

Exposures

Characteristics of delivery (year, region of country, and hospital level), mother (age, educational level, marital status, prenatal visits, parity, preexisting diseases, or prenatal complications), and newborn (birth weight, sex, and gestational age).

Main Outcomes and Measures

Prevalence of infants born SGA stratified by severity and by region of the country, changes in prevalence based on log-linear Poisson regression with robust variance, and association of maternal characteristics with changes in prevalence of infants born SGA between 2012 and 2020 based on the Fairlie nonlinear mean decomposition.

Results

Among 12 643 962 births (6 572 548 [52.0%] male; median gestational age, 39 weeks [IQR, 38-40 weeks]), the overall weighted prevalence of infants born SGA was 6.4%, which decreased from 7.3% in 2012 to 5.3% in 2020, translating to a mean annual decrease rate of 3.9% (95% CI, 3.3%-4.5%). The prevalence of infants born SGA decreased from 2.0% to 1.2% for infants with severe SGA birth weight and from 5.3% to 4.1% for those with mild to moderate SGA birth weight. The mean annual rate of decrease was faster for infants with severe SGA birth weight than for those with mild to moderate SGA birth weight (5.9% [95% CI, 4.6%-7.1%] vs 3.2% [95% CI, 2.6%-3.8%]) and was faster for the less developed western (5.3% [95% CI, 4.4%-6.1%]) and central (3.9% [95% CI, 2.9%-4.8%]) regions compared with the eastern region (2.3% [95% CI, 1.1%-3.4%]). Two-thirds of the observed decrease in the prevalence of infants born SGA could be accounted for by changes in maternal characteristics, such as educational level (relative association, 19.7%), age (relative association, 18.8%), prenatal visits (relative association, 20.4%), and parity (relative association, 19.4%). Conversely, maternal preexisting diseases or prenatal complications counteracted the decrease in the prevalence of infants born SGA (-6.7%).

Conclusions and Relevance

In this cross-sectional study of births in China from 2012 to 2020, maternal characteristics changed and the prevalence of infants born SGA decreased. Future interventions to reduce the risk of infants born SGA should focus on primary prevention.

Implementation of aspirin use during pregnancy in community midwifery-led care in the Netherlands: A pilot survey

INTRODUCTION

Aspirin nowadays is widely used in pregnancy, but implementation among gynecologists took nearly four decades. For a complete insight in the implementation of aspirin, community midwives are to be involved. Community midwives do not have authority to prescribe aspirin and have to refer to a general practitioner or consultant obstetrician for a prescription.

METHODS

The study was an online, national pilot survey about the implementation of aspirin use during pregnancy among independently practicing community midwives consisting of 29 items with five categories: background, advising, prescribing, possible indications, and clinical practice.

RESULTS

Forty-seven community midwives completed the survey between April and May 2021. All respondents had experience on advising aspirin use in pregnancy. History of preterm pre-eclampsia or HELLP syndrome was identified as a risk factor for developing utero-placental complications by 97.9% of the community midwives. Moderate risk factors in women with otherwise low-risk pregnancy were identified by >75% of the participants. Practical issues in prescribing aspirin were experienced by one-third of the respondents. Suggestions were made to obtain authority for community midwives to prescribe aspirin and improve collaboration with consultant obstetricians and general practitioners.

CONCLUSIONS

Community midwives seem to be adequate in identifying risk factors for developing utero-placental complications in women with otherwise low-risk pregnancy. Practical issues for prescribing aspirin occur often. Obtaining authority for community midwives to prescribe aspirin after education should be considered and consulting a consultant obstetrician should become more accessible to overcome the practical issues. Further educating community midwives and general practitioners might improve implementation rates and perinatal outcomes.

Impact on neonatal morbidity of moderate to severe early foetal growth restriction defined by doppler criteria: multicentre study

INTRODUCTION

In recent years, there has been a change in the conceptualization of foetal growth restriction (FGR), which has gone from being defined solely based on weight criteria to being defined and staged based on Doppler criteria. The aim of our study was to evaluate neonatal risk in a cohort of neonates with moderate to severe early-onset FGR defined by Doppler criteria.

POPULATION AND METHODS

We conducted a multicentre prospective cohort study in a cohort of neonates with early-onset foetal growth restriction and abnormal Doppler findings and a control cohort without Doppler abnormalities matched for sex and gestational age.

RESULTS

A total of 105 patients (50 cases, 55 controls) were included. We found a higher frequency of respiratory morbidity in the FGR group, with an increased need of surfactant (30% vs. 27.3%; OR, 5.3 [95% CI, 1.1-26.7]), an increased need for supplemental oxygen (66% vs. 49.1%; OR, 5.6 [95% CI, 1.5-20.5]), and a decreased survival without bronchopulmonary dysplasia (70 vs. 87.3%; OR, 0.16 [95% CI, 0.03-0.99]). Patients with FGR required a longer length of stay and more days of parenteral nutrition and had a higher incidence of haematological abnormalities such as neutropenia and thrombopenia. The lactate level at birth was higher in the severe FGR subgroup (6.12 vs. 2.4 mg/dL; P = .02).

CONCLUSION

The diagnosis of early-onset moderate to severe FGR defined by Doppler criteria carries a greater risk of respiratory, nutritional and haematological morbidity, independently of weight and gestational age. These patients, therefore, should be considered at increased risk compared to constitutionally small for gestational age preterm infants or preterm infants without FGR.

Midline structures and cortical development in late-onset fetal growth restriction according to Doppler status: prospective study

OBJECTIVES

Fetuses with late-onset growth restriction (FGR) have a higher risk of suboptimal neurocognitive performance after birth. Previous studies have reported that impaired brain and cortical development can start in utero. The primary aim of this study was to report midline structure growth and cortical development in fetuses with late-onset FGR according to its severity; the secondary aim was to elucidate whether the severity of FGR, as defined by the presence of abnormal Doppler findings, plays a role in affecting brain growth and maturation.

METHODS

This was a prospective observational study that included fetuses with late-onset FGR (defined according to the Delphi FGR criteria) undergoing neurosonography between 32 and 34 weeks' gestation. Midline structure (corpus callosum (CC) and cerebellar vermis (CV)) length and cortical development, including the depth of the Sylvian (SF), parieto-occipital (POF) and calcarine (CF) fissures, were compared between late-onset FGR, small-for-gestational-age (SGA) and appropriate-for-gestational-age (AGA) fetuses. Subgroup analysis according to the severity of FGR (normal vs abnormal fetal Doppler) was also performed. Univariate analysis was used to analyze the data.

RESULTS

A total of 52 late-onset FGR fetuses with normal Doppler findings, 60 late-onset FGR fetuses with abnormal Doppler findings, 64 SGA fetuses and 100 AGA fetuses were included in the analysis. When comparing AGA controls with SGA fetuses, late-onset FGR fetuses with normal Doppler findings and late-onset FGR fetuses with abnormal Doppler findings, there was a progressive and significant reduction in the absolute values of the following parameters: CC length (median (interquartile range (IQR)), 43.5 (28.9-56.1) mm vs 41.9 (27.8-51.8) mm vs 38.5 (29.1-50.5) mm vs 31.7 (23.8-40.2) mm; K = 26.68; P < 0.0001), SF depth (median (IQR), 14.5 (10.7-16.8) mm vs 12.7 (9.8-15.1) mm vs 11.9 (9.1-13.4) mm vs 8.3 (6.7-10.3) mm; K = 75.82; P < 0.0001), POF depth (median (IQR), 8.6 (6.3-11.1) mm vs 8.1 (5.6-10.4) mm vs 7.8 (6.1-9.3) mm vs 6.6 (4.2-8.0) mm; K = 45.06; P < 0.0001) and CF depth (median (IQR), 9.3 (6.7-11.5) mm vs 8.2 (5.7-10.7) mm vs 7.7 (5.2-9.4) mm vs 6.3 (4.5-7.2) mm; K = 46.14; P < 0.0001). Absolute CV length was significantly higher in AGA fetuses compared with all other groups, although the same progressive pattern was not noted (median (IQR), 24.9 (17.6-29.2) mm vs 21.6 (15.2-26.1) mm vs 19.1 (13.8-25.9) mm vs 21.0 (13.5-25.8) mm; K = 16.72; P = 0.0008). When the neurosonographic variables were corrected for fetal head circumference, a significant difference in the CC length and SF, POF and CF depths, but not CV length, was observed only in late-onset FGR fetuses with abnormal Doppler findings when compared with AGA and SGA fetuses.

CONCLUSIONS

Fetuses with late-onset FGR had shorter CC length and delayed cortical development when compared with AGA fetuses. After controlling for fetal head circumference, these differences remained significant only in late-onset FGR fetuses with abnormal Doppler. These findings support the existence of a link between brain development and impaired placental function. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Maternal Uterine Artery Adenoviral Vascular Endothelial Growth Factor (Ad.VEGF-A165) Gene Therapy Normalises Fetal Brain Growth and Microglial Activation in Nutrient Restricted Pregnant Guinea Pigs

Fetal growth restriction (FGR) is associated with uteroplacental insufficiency, and neurodevelopmental and structural brain deficits in the infant. It is currently untreatable. We hypothesised that treating the maternal uterine artery with vascular endothelial growth factor adenoviral gene therapy (Ad.VEGF-A165) normalises offspring brain weight and prevents brain injury in a guinea pig model of FGR. Pregnant guinea pigs were fed a restricted diet before and after conception and received Ad.VEGF-A165 (1 × 1010 viral particles, n = 18) or vehicle (n = 18), delivered to the external surface of the uterine arteries, in mid-pregnancy. Pregnant, ad libitum-fed controls received vehicle only (n = 10). Offspring brain weight and histological indices of brain injury were assessed at term and 5-months postnatally. At term, maternal nutrient restriction reduced fetal brain weight and increased microglial ramification in all brain regions but did not alter indices of cell death, astrogliosis or myelination. Ad.VEGF-A165 increased brain weight and reduced microglial ramification in fetuses of nutrient restricted dams. In adult offspring, maternal nutrient restriction did not alter brain weight or markers of brain injury, whilst Ad.VEGF-A165 increased microglial ramification and astrogliosis in the hippocampus and thalamus, respectively. Ad.VEGF-A165 did not affect cell death or myelination in the fetal or offspring brain. Ad.VEGF-A165 normalises brain growth and markers of brain injury in guinea pig fetuses exposed to maternal nutrient restriction and may be a potential intervention to improve childhood neurodevelopmental outcomes in pregnancies complicated by FGR.

The Relationship of Preterm and Small for Gestational Age with Child Cognition During School-Age Years

BACKGROUND

Children born preterm and/or small for gestational age (SGA) are at increased risk of poor cognitive outcomes, particularly in low and middle-income countries (LMICs).

OBJECTIVES

This study aimed to examine the cognitive and academic deficits during the school-age years in children born preterm or SGA compared with those in children born term adequate for gestational age (AGA) in rural Vietnam.

METHODS

Children born to women in a preconception micronutrient supplementation trial in Vietnam were classified into 3 groups: preterm AGA (n =138), term SGA (n =169), and term AGA (n = 1134). Cognitive abilities were assessed using the Wechsler Intelligence Scale for Children, measuring 4 domains [verbal comprehension index (VCI), perceptual reasoning index (PRI), working memory index (WMI), and processing speed index (PSI) scores] and full-scale intelligence quotient (FSIQ) at 6-7 and 10-11 y. Academic achievement was assessed with mathematic and language tests. Analysis of variance and multiple regression models were used to analyze differences in cognitive function and academic achievement at 6-7 and 10-11 y by birth phenotypes.

RESULTS

Compared with term AGA children, those born SGA had lower cognitive scores at both 6-7 y (VCI, -2.3; PRI, -3.7; PSI -2.1; and FSIQ, -2.9) and 10-11 y (VCI, -3.7; PRI, -3.5; WMI, -2.7; PSI, -1.9; and FSIQ, -3.9). Children born SGA also had poorer academic achievement with lower language (5.3) and mathematic (2.5) scores. Adjustments for maternal factors and home environment attenuated the associations, but the differences in VCI, PRI, FSIQ, and language at 10-11 y remained significant. There were no differences in cognitive function and academic achievement between children born preterm and AGA.

CONCLUSIONS

Our findings highlight the enduring association of birth phenotype on cognitive functioning and academic achievement during the school years, despite adjustments for maternal education and family environment. Further research is needed to implement effective interventions to improve birth outcomes and optimize child health and development in LMICs. The trial was registered at clinicaltrials.gov as NCT01665378 (URL: https://clinicaltrials.gov/ct2/show/NCT01665378).

Prevalence of autism spectrum disorder diagnosis by birth weight, gestational age, and size for gestational age: a systematic review, meta-analysis, and meta-regression

We aimed to comprehensively pool the prevalence of autism spectrum disorder (ASD) diagnosis by birth weight, gestational age, and size for gestational age. PubMed, EMBASE, Web of Science, Ovid PsycINFO, and Cochrane Library were searched up to December 22, 2021. We pooled data using the random-effects model and quantified heterogeneity using the I2 statistic. Of 66 643 records initially identified, 75 studies were included in the meta-analysis. The pooled prevalence estimates of ASD diagnosis are as follows: very-low-birth weight, 3.1% (912 ASD/66,445 individuals); low-birth weight, 2.3% (5672 ASD/593,927 individuals); normal-birth weight, 0.5% (17,361 ASD/2,378,933 individuals); high-birth weight, 0.6% (4505 ASD/430,699 individuals); very preterm, 2.8% (2113 ASD/128,513 individuals); preterm, 2.1% (19 672 ASD/1 725 244 individuals); term, 0.6% (113,261 ASD/15,297,259 individuals); postterm, 0.6% (9419 ASD/1,138,215 individuals); small-for-gestational-age, 1.9% (6314 ASD/796,550 individuals); appropriate-for-gestational-age, 0.7% (21,026 ASD/5,936,704 individuals); and large-for-gestational-age, 0.6% (2607 ASD/635,666 individuals). Compared with the reference prevalence (those in normal-birth weight, term, and appropriate-for-gestational-age individuals), the prevalence estimates of ASD diagnosis in very-low-birth weight, low-birth weight, very preterm, preterm, and small-for-gestational-age individuals increased significantly, while those in high-birth weight, postterm, and large-for-gestational-age individuals did not change significantly. There were geographical differences in the prevalence estimates. This meta-analysis provided reliable estimates of the prevalence of ASD diagnosis by birth weight, gestational age, and size for gestational age, and suggested that low-birth weight (especially very-low-birth weight), preterm (especially very preterm), and small-for-gestational-age births, rather than high-birth weight, postterm, and large-for-gestational-age births, were associated with increased risk of ASD diagnosis. However, in view of marked between-study heterogeneity in most conditions, unknown effects of certain important confounders associated with ASD due to limited information in original articles, and included studies from a relatively small number of countries, the findings of this study should be interpreted with caution.

Postnatal functional integrity of the brainstem auditory pathway in late preterm infants born of small-for-gestation age: how different from those born of appropriate-for-gestation

It is unclear whether there is any postnatal abnormality in brainstem auditory function in late preterm small-for-gestational-age (SGA) infants. We investigated the functional integrity of the brainstem auditory pathway at 4 months after term in late preterm SGA infants and defined differences from appropriate-for-gestational age (AGA) infants. The maximum length sequence brainstem evoked response (MLS BAER) was recorded and analyzed in 24 SGA (birthweight < 3rd centile) infants and 28 AGA infants (birthweight > 10th centile). All infants were born at 33-36-week gestation without major perinatal and postnatal problems. We found that I-V interval in SGA infants was shorter than in AGA infants at higher click rates and significantly shorter at the highest rate of 910/s. Of the two smaller intervals, I-III interval was significantly shorter in SGA infants than in AGA infants at higher click rates of 455 and 910/s clicks, whereas III-V interval was similar in the two groups. The III-V/I-III interval ratio in SGA infants tended to be greater than in AGA infants at all rates and was significantly greater at 455 and 910/s clicks. The slope of I-III interval-rate functions in SGA infants was moderately smaller than in AGA infants.  Conclusions: The main and fundamental difference between late preterm SGA and AGA infants was a significant shortening in the MLS BAER I-III interval in SGA infants at higher click rates, suggesting moderately faster neural conduction in the caudal brainstem regions. Postnatal neural maturation in the caudal brainstem regions is moderately accelerated in late preterm SGA infants. What is Known: • At 40 weeks of postconceptional age, late preterm SGA infants manifested a mild delay in neural conduction in the auditory brainstem. What is New: • At 56 weeks of postconceptional age, late preterm SGA infants manifested moderately faster neural conduction in the caudal brainstem regions. • Postnatal neural maturation is moderately accelerated in the caudal brainstem regions of late preterm SGA infants.