Placental pathology in fetal growth restriction

Utility of placental biomarkers and fetoplacental Dopplers in predicting likely placental pathology in early and late fetal growth restriction - A prospective study

INTRODUCTION

The aim of this study was to evaluate the association between placental abnormalities, placental biomarkers, and fetoplacental Dopplers in a cohort of pregnancies complicated by fetal growth restriction (FGR). We also ascertained the risk of perinatal mortality, severe neurological morbidity, and severe non-neurological morbidity by type of placental abnormality.

METHODS

This was a prospective cohort study. Multivariable logistic regression was used to evaluate the effect of early vs. late FGR, placental biomarkers and fetoplacental Dopplers on Maternal Vascular Malperfusion (MVM) which was the commonest placental abnormality identified.

RESULTS

There were 161 (53.5 %) early FGR and 140 (46.5 %) late FGR cases. MVM abnormalities were present in 154 (51.2 %), VUE in 45 (14.6 %), FVM in 16 (5.3 %), DVM in 14 (4.7 %) and CHI in 4 (1.3 %) cases. The odds of MVM were higher in early compared to late FGR cohort (OR 1.89, 95%CI 1.14, 3.14, p = 0.01). Low maternal PlGF levels <100 ng/L (OR 2.34, 95%CI 1.27,4.31, p = 0.01), high sFlt-1 level (OR 2.13, 95%CI 1.35, 3.36, p = 0.001) or elevated sFlt-1/PlGF ratio (OR 3.48, 95%CI 1.36, 8.91, p = 0.01) were all associated with MVM. Increased UA PI > 95th centile (OR 2.91, 95%CI 1.71, 4.95, p=<0.001) and mean UtA PI z-score (OR 1.74, 95%CI 1.15, 2.64, p = 0.01) were associated with higher odds of MVM. Rates of severe non-neurological morbidity were highest in the MVM, FVM, and CHI cohorts (44.8 %, 50 %, and 50 % respectively).

CONCLUSION

MVM was the commonest placental abnormality in FGR, particularly in early-onset disease. Low maternal PlGF levels, high sFlt-1 levels, elevated sFlt-1/PlGF ratio, and abnormal fetoplacental Dopplers were also significantly associated with MVM. MVM, FVM, and CHI abnormalities were associated with lower median birthweight, higher rates of preterm birth, operative birth for non-reassuring fetal status, and severe neonatal non-neurological morbidity.

Covid-19 during Pregnancy - Histopathological Lesions of the Placenta

INTRODUCTION

Pregnant women and their offspring represented a vulnerable patient collective during the Covid-19 pandemic. Beyond the direct effect of SARS-CoV-2 via vertical transmission, an indirect impact on the fetus can occur through placental lesions deteriorating placental villous function. We performed a histopathological analysis of placentas of parturients with SARS-CoV-2 compared to healthy controls.

METHODS AND MATERIALS

Between February 2022 and July 2022 we conducted a prospective case-control study analyzing placental specimens of parturients with SARS-CoV-2 infection compared to specimens of placentas of healthy controls. Patient history, Covid-19-specific symptoms, and obstetric outcomes were recorded. Statistical analysis was performed.

RESULTS

During the observation period 71 patients were included with a gestational age 37 1/7-41 5/7 weeks. Thirty-six patients presented with SARS-CoV-2 infection. The control group consisted of 35 patients and showed no placental abnormalities. Among SARS-CoV-2-positive parturients, 66.7% of placentas of the case group showed histopathological abnormalities classified as vascular or inflammatory abnormalities. 22.2% of placentas showed acute ischemic infarction areas. 8.3% of placentas showed subchorionic layered thrombi. There was one case of severe acute subchorionitis. SARS-CoV-2 increased the risk of placental lesions significantly (OR 3.000, CI 1.890-4.762, p=0.0001). Placental lesions had no significant impact on perinatal acidosis (OR 0.455, CI 0.044-4.667, p=0.498) or number of cesarean sections (OR 2.314, CI 0.717-7.473, p=0.156).

CONCLUSION

SARS-CoV-2 infection during labor and delivery increased the risk of adverse outcomes. Histopathological analysis indicated that the placenta as a maternal-fetal interface was affected by SARS-CoV-2, leading to systemic vasculopathy and inflammation.

Systemic Oxidative Stress in Severe Early-Onset Fetal Growth Restriction Associates with Concomitant Pre-Eclampsia, Not with Severity of Fetal Growth Restriction

BACKGROUND

Placental insufficiency is an important mechanism underlying early-onset fetal growth restriction (eoFGR). Reduced placental function causes impaired metabolic and gaseous exchange. This unfavorable placental environment is among other processes characterized by increased oxidative stress. Systemic free thiols (FT) are known for their reactive oxygen species scavenging capacity, and higher plasma levels of FT are associated with a better outcome in a multitude of ischemic and inflammatory diseases. We aimed to investigate the relationships between systemic FT levels and maternal and perinatal clinical characteristics and outcomes.

STUDY DESIGN

In a post hoc analysis of the Dutch Strider study, a cohort of women with eoFGR, we investigated the association between the maternal redox status (FT) levels at study inclusion, placental biomarkers, and maternal and neonatal outcomes in 108 patients.

RESULTS

FT were significantly lower in pregnancies complicated with eoFGR with concurrent maternal hypertensive disorders (pregnancy-induced hypertension; ρ = -0.281 p = 0.004, pre-eclampsia; ρ = -0.505 p = 0.000). In addition, lower FT levels were significantly associated with higher systolic (ρ = -0.348 p = 0.001) and diastolic blood pressure (ρ = -0.266 p = 0.014), but not with the severity of eoFGR. FT levels were inversely associated with sFlt (ρ = -0.366, p < 0.001). A strong relation between systemic FT levels and PlGF levels was observed in women with pre-eclampsia at delivery (ρ = 0.452, p = 0.002), which was not found in women without hypertensive disorders (ρ = 0.008, p = 0.958).

CONCLUSIONS

In women with pregnancies complicated with eoFGR, FT levels reflect the severity of maternal disease related to the underlying placental insufficiency rather than the severity of the placental dysfunction as reflected in eoFGR or perinatal outcomes.

Does fetal growth restriction induce neuropathology within the developing brainstem?

Fetal growth restriction (FGR) is a complex obstetric issue describing a fetus that does not reach its genetic growth potential. The primary cause of FGR is placental dysfunction resulting in chronic fetal hypoxaemia, which in turn causes altered neurological, cardiovascular and respiratory development, some of which may be pathophysiological, particularly for neonatal life. The brainstem is the critical site of cardiovascular, respiratory and autonomic control, but there is little information describing how chronic hypoxaemia and the resulting FGR may affect brainstem neurodevelopment. This review provides an overview of the brainstem-specific consequences of acute and chronic hypoxia, and what is known in FGR. In addition, we discuss how brainstem structural alterations may impair functional control of the cardiovascular and respiratory systems. Finally, we highlight the clinical and translational findings of the potential roles of the brainstem in maintaining cardiorespiratory adaptation in the transition from fetal to neonatal life under normal conditions and in response to the pathological environment that arises during development in growth-restricted infants. This review emphasises the crucial role that the brainstem plays in mediating cardiovascular and respiratory responses during fetal and neonatal life. We assess whether chronic fetal hypoxaemia might alter structure and function of the brainstem, but this also serves to highlight knowledge gaps regarding FGR and brainstem development.

Placental Pathology and Its Associations With Clinical Signs in Different Subtypes of Fetal Growth Restriction

OBJECTIVE

We evaluated placental alterations in different subtypes of fetal growth restriction (FGR) to determine any clinical associations.

METHODS

FGR placentas classified according to the Amsterdam criteria were correlated with clinical findings. Percentage of intact terminal villi and villous capillarization ratio were calculated in each specimen. Correlations of placental histopathology and perinatal outcomes were studied. 61 FGR cases were studied.

RESULTS

Early-onset-FGR was more often associated with preeclampsia and recurrence than late-onset-FGR; placentas from early-onset-FGR often had diffuse maternal (or fetal) vascular malperfusion and villitis of unknown etiology. Decreased percentage of intact terminal villi was associated with pathologic CTG. Decreased villous capillarization was associated with early-onset-FGR and birth weight below the second percentile. Avascular villi and infarction were more common when femoral length/abdominal circumference ratio was >0.26, and perinatal outcome was poor in this group.

CONCLUSION

In early-onset-FGR and preeclamptic FGR, altered vascularization of villi may have a key role in pathogenesis, and recurrent FGR is associated with villitis of unknown etiology. There is an association between femoral length/abdominal circumference ratio >0.26 and histopathological alterations of placenta in FGR pregnancies. There are no significant differences in the percentage of intact terminal villi between different FGR subtypes by onset or recurrency.

Investigation on birth weight outcomes in schistosomiasis and praziquantel research: a correspondence

Infection with Schistosoma sp. during pregnancy can cause low birth weight of the newborn. To allow a better differentiation between newborns with low birth weight and those with normal weight, the terms of intrauterine growth restriction (IUGR), small for gestational age (SGA) or fetal growth restriction (FGR) should be used. FGR describes the relationship between birth weight and gestational age and is defined as the incapability of a fetus to achieve expected growth with birth weight below the 10th percentile for gestational age. Additional investigations of the proportion of newborns with FGR should obtain more certainty about the effect of praziquantel and schistosomiasis on fetal growth.

Hepatic and Skeletal Muscle Autophagy Marker Levels in Rat Models of Prenatal and Postnatal Protein Restriction

Fetal growth restriction (FGR) leads to adult-onset metabolic syndrome. Intrauterine and early postnatal caloric restriction ameliorates the risk in animal models. To understand the underlying mechanism, we compared autophagic marker levels between offspring with FGR and those with prenatal and early postnatal protein restriction (IPPR). We postulated that FGR would impair, whereas IPPR would help regulate, autophagy in neonatal rats. This study involved control (Con), FGR offspring (Pre), and IPPR offspring groups (Pre + Post); n = 5/group. We assessed the abundance of autophagy markers in the liver and skeletal muscles. At birth, the Pre group pups had lower levels of some autophagy-related proteins, with increased p62 expression and a low microtubule-associated protein light chain beta (LC3-II:LC3-I) ratio. This finding suggests a lower hepatic autophagy flux in FGR offspring than the Con group. The hepatic levels of autophagy proteins were considerably decreased in the Pre and Pre + Post groups at 21 days of age compared to the Con group, but the LC3-II:LC3-I ratio was higher in the Pre + Post group than in the Con and Pre groups. The muscle levels of beclin-1, LC3-II, and p62 were lower in the Pre group pups, with no difference in the LC3-II:LC3-I ratio among the groups. An imbalance in the nutritional environment is associated with downstream autophagic flux, thus suggesting that FGR offspring will have impaired autophagic flux, and that post-natal nutrition restriction might help reduce this risk.

Machine learning-based placental clusters and their associations with adverse pregnancy outcomes

BACKGROUND

Placental abnormalities have been described in clinical convenience samples, with predominately adverse outcomes. Few studies have described placental patterns in unselected samples.

OBJECTIVE

We aimed to investigate associations between co-occurring placental features and adverse pregnancy outcomes in a prospective cohort of singletons.

METHODS

Data were from the Safe Passage study (U.S. and South Africa, 2007-2015). Before 24 weeks' gestation, participants were randomly invited to donate placental tissue at delivery for blinded, standardised pathological examination. We used hierarchical clustering to construct statistically derived groups using 60 placental features. We estimated associations between the placental clusters and select adverse pregnancy outcomes, expressed as unadjusted and adjusted risk ratios (RRs) and robust 95% confidence intervals (CI).

RESULTS

We selected a 7-cluster model. After collapsing 2 clusters to form the reference group, we labelled the resulting 6 analytic clusters according to the overarching category of their most predominant feature(s): severe maternal vascular malperfusion (n = 117), fetal vascular malperfusion (n = 222), other vascular malperfusion (n = 516), inflammation 1 (n = 269), inflammation 2 (n = 175), and normal (n = 706). Risks for all outcomes were elevated in the severe maternal vascular malperfusion cluster. For instance, in unadjusted analyses, this cluster had 12 times the risk of stillbirth (RR 12.07, 95% CI 4.20, 34.68) and an almost doubling in the risk of preterm delivery (RR 1.93, 95% CI 1.27, 2.93) compared with the normal cluster. Small infant size was more common among the abnormal clusters, with the highest unadjusted RRs observed in the fetal vascular malperfusion cluster (small for gestational age birth RR 2.99, 95% CI 2.24, 3.98, head circumference <10th percentile RR 2.86, 95% CI 1.60, 5.12). Upon adjustment for known risk factors, most RRs attenuated but remained >1.

CONCLUSION

Our study adds to the growing body of epidemiologic research, finding adverse pregnancy outcomes may occur through etiologic mechanisms involving co-occurring placental abnormalities.

Intrauterine Growth Restriction-Prediction and Peripartum Data on Hospital Care

Background and Objectives: We aimed to prospectively obtain data on pregnancies complicated with intrauterine growth restriction (IUGR) in the Prenatal Diagnosis Unit of the Emergency County Hospital of Craiova. We collected the demographic data of mothers, the prenatal ultrasound (US) features, the intrapartum data, and the immediate postnatal data of newborns. We aimed to assess the detection rates of IUGR fetuses (the performance of the US in estimating the actual neonatal birth weight), to describe the prenatal care pattern in our unit, and to establish predictors for the number of total hospitalization days needed postnatally. Materials and Methods: Data were collected from cases diagnosed with IUGR undergoing prenatal care in our hospital. We compared the percentile of estimated fetal weight (EFW) using the Hadlock 4 technique with the percentile of weight at birth. We retrospectively performed a regression analysis to correlate the variables predicting the number of hospitalization days. Results: Data on 111 women were processed during the period of 1 September 2019-1 September 2022. We confirmed the significant differences in US features between early- (Eo) and late-onset (Lo) IUGR cases. The detection rates were higher if the EFW was lower, and Eo-IUGR was associated with a higher number of US scans. We obtained a mathematical formula for estimating the total number of hospitalization days needed postnatally. Conclusion: Early- and late-onset IUGR have different US features prenatally and different postnatal outcomes. If the US EFW percentile is lower, a prenatal diagnosis is more likely to be made, and a closer follow-up is offered in our hospital. The total number of hospitalization days may be predicted using intrapartum and immediate postnatal data in both groups, having the potential to optimize the final financial costs and to organize the neonatal department efficiently.

Impact of Co-Occurrence of Obesity and SARS-CoV-2 Infection during Pregnancy on Placental Pathologies and Adverse Birth Outcomes: A Systematic Review and Narrative Synthesis

Obesity is a risk factor for severe COVID-19 disease during pregnancy. We hypothesized that the co-occurrence of high maternal body mass index (BMI) and gestational SARS-CoV-2 infection are detrimental to fetoplacental development. We conducted a systematic review following PRISMA/SWiM guidelines and 13 studies were eligible. In the case series studies (n = 7), the most frequent placental lesions reported in SARS-CoV-2(+) pregnancies with high maternal BMI were chronic inflammation (71.4%, 5/7 studies), fetal vascular malperfusion (FVM) (71.4%, 5/7 studies), maternal vascular malperfusion (MVM) (85.7%, 6/7 studies) and fibrinoids (100%, 7/7 studies). In the cohort studies (n = 4), three studies reported higher rates of chronic inflammation, MVM, FVM and fibrinoids in SARS-CoV-2(+) pregnancies with high maternal BMI (72%, n = 107/149; mean BMI of 30 kg/m2) compared to SARS-CoV-2(−) pregnancies with high BMI (7.4%, n = 10/135). In the fourth cohort study, common lesions observed in placentae from SARS-CoV-2(+) pregnancies with high BMI (n = 187 pregnancies; mean BMI of 30 kg/m2) were chronic inflammation (99%, 186/187), MVM (40%, n = 74/187) and FVM (26%, n = 48/187). BMI and SARS-CoV-2 infection had no effect on birth anthropometry. SARS-CoV-2 infection during pregnancy associates with increased prevalence of placental pathologies, and high BMI in these pregnancies could further affect fetoplacental trajectories.

Multimodal fusion model for classifying placenta ultrasound imaging in pregnancies with hypertension disorders

BACKGROUND

A multimodal fusion model was proposed to assist the traditional visual diagnosis in evaluating the placental features of hypertension disorders of pregnancy (HDP).

OBJECTIVE

The aim of this study was to analyse and compare the placental features between normal and HDP pregnancies and propose a multimodal fusion deep learning model for differentiating and characterizing the placental features from HDP to normal pregnancy.

METHODS

This observational prospective study included 654 pregnant women, including 75 with HDPs. Grayscale ultrasound images (GSIs) and Microflow images (MFIs) of the placentas were collected from all patients during routine obstetric examinations. On the basis of intelligent extraction and features fusion, after quantities of training and optimization, the classification model named GMNet (the intelligent network based on GSIs and MFIs) was introduced for differentiating the placental features of normal and HDP pregnancies. The distributions of placental features extracted by the deep convolutional neural networks (DCNNs) were visualized by Uniform Manifold Approximation and Projection for Dimension Reduction (UMAP). Metrics including sensitivity, specificity, accuracy, and the area under the curve (AUC) were used to score the model. Finally, placental tissue samples were randomly selected for microscopic analyses to prove the interpretability and effectiveness of the GMNet model.

RESULTS

Compared with the Normal group in ultrasonic images, the light spots were rougher and the parts with focal cystic or hypoechogenic lesions were increased in the HDP groups. The overall diagnostic performance of the GMNet model depending on the region of interest (ROI) was excellent (AUC: 97%), with a sensitivity of 90.0%, a specificity of 93.5%, and an accuracy of 93.1%. The fusion features of GSIs and MFIs in the placenta showed a higher discriminative power than single-mode features (fusion features vs GSI features vs MFI features, 97.0% vs 91.2% vs 94.8%). Furthermore, according to the microscopic analysis, unevenly distributed villi, increased syncyte nodules and aggregated intervillous cellulose deposition were particularly frequent in the HDP cases.

CONCLUSIONS

The GMNet model could sensitively identify abnormal changes in the placental microstructure in pregnancies with HDP.

Effects of Salvia miltiorrhiza active compounds on placenta-mediated pregnancy complications

Placenta-mediated pregnancy complications (PMPCs), including preeclampsia (PE), fetal growth restriction (FGR), and recurrent spontaneous abortion (RSA), occur in approximately 5% of pregnancies and are caused by abnormal placenta development. The development of effective therapies for PMPCs is still challenging due to the complicated pathogenesis, such as disrupted vascular homeostasis and subsequent abnormal placentation. Synthetic drugs have been recommended for treating PMPCs; however, they tend to cause adverse reactions in the mother and fetus. Salvia miltiorrhiza (S. miltiorrhiza) has potential effects on PMPCs owing to its advantages in treating cardiovascular disorders. S. miltiorrhiza and its active compounds could attenuate the symptoms of PMPCs through anticoagulation, vasodilation, antioxidation, and endothelial protection. Thus, in this review, we summarize the literature and provide comprehensive insights on S. miltiorrhiza and its phytochemical constituents, pharmacological activities, and on PMPCs, which would be valuable to explore promising drugs.

Morphological and histopathological changes in placentas of pregnancies with intrauterine growth restriction

Aim: The definition of fetal growth restriction (FGR) refers to the incapability of a fetus to achieve the appropriate estimated growth, with expected fetal weight below the 10^th percentile calculated for its gestational age. Placental factors and hypoxemia are considered to be essential elements with influence on intrauterine growth restriction (IUGR) and fetal death. The purpose of the present study was to investigate the macroscopic and microscopic pathological findings regarding the placentas in pregnancies complicated by influence on IUGR. Patients, Materials and Methods: Our study included 42 third-trimester pregnant patients admitted to the Cuza Vodă Hospital of Obstetrics and Gynecology, Iaşi, Romania, in the last three years. Soon after delivery, the 42 placentas were collected and analyzed; 32 placentas came from cases previously diagnosed with influence on IUGR and were included in our study group. Ten other placentas included in the control group were selected from uncomplicated pregnancies. Standard Hematoxylin–Eosin (HE) staining method, as well as Periodic Acid–Schiff (PAS) staining, and immunohistochemical techniques for cluster of differentiation 31 (CD31) and collagen IV were used in order to highlight the morphological features of the studied placentas. Results: Our study revealed that reduced placental dimensions and eccentric umbilical cord insertion are correlated with the birthweight of the fetuses with IUGR (p<0.05). The most common histological finding in our study group was placental infarction later correlated with IUGR, but a certain causality could not be demonstrated, as this finding was also present in normal pregnancies. Other histopathological findings were also present in the influence on IUGR group, such as fibrin deposits, diffuse calcification, chronic villitis, avascular chronical villi, with no significant statistical correlations. CD31 was strongly immunoexpressed in the villous endothelial cells. Collagen IV presented a strong immunoreaction in the basement membrane and mesenchyme of the placental villi. Conclusions: Our study revealed a correlation between the dimensions of the diameters and volume of the maternal placenta and the presence of influence on IUGR. Moreover, it confirms the available data suggesting that the place of insertion of the umbilical cord is correlated with the weight of the fetus. Further studies with extended panel antibodies are needed in order to determine and complete the role of these morphological changes in the development of influence on IUGR.

The thrifty phenotype hypothesis: The association between ultrasound and Doppler studies in fetal growth restriction and the development of adult disease

Barker pioneered the idea that the epidemic of coronary heart disease in Western countries in the 20th century, which paradoxically coincided with improved standards of living and nutrition, has its origin in fetal life. Indeed, there is substantial evidence associating low birthweight because of fetal growth restriction with an increased risk of vascular disease in later adult life. These conclusions led to the second part of the Barker hypothesis, the thrifty phenotype, in which adaptation to undernutrition in fetal life leads to permanent metabolic and endocrine changes. Such changes are beneficial if the undernutrition persists after birth but may predispose the individual to obesity and impaired glucose tolerance if conditions improve. The hypothesis assumes that a poor nutrient supply during a critical period of in utero life may "program" a permanent structural or functional change in the fetus, thereby altering the distribution of cell types, gene expression, or both. The fetus, in response to placental undernutrition and to maintain sufficient vascular supply to the brain, decreases resistance to blood flow in the middle cerebral artery. Simultaneously, because of the limited blood supply to the fetus, the arterial redistribution process is accompanied by increased resistance to flow to other fetal vital organs, such as the heart, kidneys, liver, and pancreas. It may explain why individuals exposed to ischemic changes in utero develop dyslipidemia, lower nephron number, and impaired glucose tolerance, all factors contributing to metabolic syndrome later in life. Nevertheless, support for the hypotheses comes mainly from studies in rodents and retrospective epidemiologic studies. This review focused on ultrasound and Doppler studies of human fetal growth restriction in several fetal organs: the placenta, fetal circulation, brain, heart, kidneys, adrenal glands, liver, and pancreas. Support for the hypothesis was provided by animal studies involving conditions that create fetuses with growth restriction with effects on various fetal organs and by human studies that correlate impaired fetal circulation with the in utero development and function of fetal organs.

Passively inhaled tobacco smoke - pregnancy and neonatal outcomes in correlation with placental histopathology

INTRODUCTION

We aimed to investigate the effect of maternal passive smoking (MPS) during pregnancy-on placental pathology and pregnancy outcomes.

METHODS

A prospective case-control study. We recruited low-risk laboring women at 37+0-41 + 0 weeks between 9/2019-7/2020. MPS was defined as exposure to in-house spouse tobacco smoking of >20 cigarettes/day in the absence of maternal active-smoking. In attempt to "purify" the effect of MPS on placental pathology-we excluded cases with preeclampsia, diabetes, suspected fetal growth restriction (FGR), preterm labor, and illicit drug use. Maternal characteristics, pregnancy outcomes, and placental pathology were compared between the MPS group and a control group matched for gestational age, maternal age, and delivery date. Placental lesions were classified according to the "Amsterdam" criteria. The study was powered to detect a 33% difference in placental malperfusion lesions. Multivariable regression was performed to identify independent associations with placental malperfusion lesions.

RESULTS

In labor, the MPS group (n = 115) had higher rates of meconium stained amniotic fluid (MSAF, p < 0.001) and non-reassuring fetal heart-rate (NRFHR,p = 0.006), compared to controls (n = 115). Neonates in the MPS group had higher rates of undiagnosed FGR (p = 0.01) and NICU admissions (p = 0.004). The MPS group had higher rates of placental-hypoplasia (p = 0.02) and fetal vascular malperfusion (FVM) lesions (p = 0.04). In regression analysis MPS was associated with FVM lesions independent of background confounders (aOR = 1.24 95% CI 1.10-2.65).

DISCUSSION

In otherwise low-risk pregnancies, MPS was associated with higher rates of MSAF, NRFHR, undiagnosed FGR, and NICU admissions, probably mediated via placental FVM. These worrisome findings mandate patient counseling and further investigation in larger population-based studies.

Metabolomics in Prenatal Medicine: A Review

Pregnancy is a complicated and insidious state with various aspects to consider, including the well-being of the mother and child. Developing better non-invasive tests that cover a broader range of disorders with lower false-positive rates is a fundamental necessity in the prenatal medicine field, and, in this sense, the application of metabolomics could be extremely useful. Metabolomics measures and analyses the products of cellular biochemistry. As a biomarker discovery tool, the integrated holistic approach of metabolomics can yield new diagnostic or therapeutic approaches. In this review, we identify and summarize prenatal metabolomics studies and identify themes and controversies. We conducted a comprehensive search of PubMed and Google Scholar for all publications through January 2020 using combinations of the following keywords: nuclear magnetic resonance, mass spectrometry, metabolic profiling, prenatal diagnosis, pregnancy, chromosomal or aneuploidy, pre-eclampsia, fetal growth restriction, pre-term labor, and congenital defect. Metabolite detection with high throughput systems aided by advanced bioinformatics and network analysis allowed for the identification of new potential prenatal biomarkers and therapeutic targets. We took into consideration the scientific papers issued between the years 2000-2020, thus observing that the larger number of them were mainly published in the last 10 years. Initial small metabolomics studies in perinatology suggest that previously unidentified biochemical pathways and predictive biomarkers may be clinically useful. Although the scientific community is considering metabolomics with increasing attention for the study of prenatal medicine as well, more in-depth studies would be useful in order to advance toward the clinic world as the obtained results appear to be still preliminary. Employing metabolomics approaches to understand fetal and perinatal pathophysiology requires further research with larger sample sizes and rigorous testing of pilot studies using various omics and traditional hypothesis-driven experimental approaches.

Fetal growth restriction in a cohort of migrants in Germany

Background

Migrant women may have an increased risk of adverse birth outcomes. This study analyses the occurrence of low birth weight, preterm birth and intrauterine growth restriction / fetal growth restriction (IUGR/FGR) in pregnant migrants.

Method

Cross-sectional study of 82 mother-child pairs of pregnant migrants attending medical care in Germany.

Results

The Median age was 27 years, 49% of patients were of oriental-asian ethnicity and median year of migration was 2015. At least one previous pregnancy was reported in 76% of patients, in 40% the delivery mode was caesarian section. Median gestational age was 39.7 weeks. Preterm birth occurred in 6.1% of pregnancies. Median gestational age for preterm birth was 32.3 weeks. Low birth weight (< 2500 g) occurred in 6.1%. Birth weights below the 10th percentile of birth weight for gestational age were observed in 8.5% of the total cohort.

Conclusions

Compared to German data no increased occurrence of low birth weight, preterm birth or IUGR/FGR was found. We note that the rate of caesarian section births was higher than in the general population for reasons yet to be identified. The authors propose stratification according to migration status for the national documentation of birth outcomes in Germany.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03620-z.

Formulating a Meaningful and Comprehensive Placental Phenotypic Classification

INTRODUCTION

While many placental lesions have been identified and defined, the significance of multiple overlapping lesions has not been addressed. The purpose of our analysis was to evaluate overlapping patterns of placental pathology and determine meaningful phenotypes associated with adverse birth outcomes.

METHODS

Placental pathology reports were obtained from a single hospital between 2009 and 2018. Placental lesions were grouped into four major categories: acute inflammation (AI), chronic inflammation (CI), maternal vascular malperfusion (MVM), and fetal vascular malperfusion (FVM). Within each category, lesions were classified as not present, low grade or high grade. Combinations of pathologies were evaluated in relation to preterm birth (<37 weeks) and small for gestational age (SGA) infant (birthweight <10th percentile).

RESULTS

During the study period, 19,027 placentas were reviewed by pathologists. Results from interaction models indicate that MVM and MVM in combination with CI and/or FVM are associated with the greatest odds of SGA infant and PTB. When incorporating grade, we identified 21 phenotype groups, each with characteristic associations with the SGA infant and patterns of PTB.

DISCUSSION

We have developed a comprehensive and meaningful placental phenotype that incorporates severity and multiplicity of placental lesions. We have also developed a web application to facilitate phenotype determination (https://placentaexpression.shinyapps.io/phenotype).

The effect of concomitant histologic chorioamnionitis in pregnancies complicated by fetal growth restriction

INTRODUCTION

We aimed to investigate the effect of placental histologic chorioamnionitis (HC) on neonatal outcomes in pregnancies complicated by fetal growth restriction (FGR).

METHODS

- The computerized medical files of all pregnancies diagnosed with FGR (birthweight <10th percentile) at 24-42 weeks of gestation between 2008 and 2019 were reviewed. Maternal and neonatal outcomes were compared between FGR with and without evidence of placental HC. Placental lesions were classified according to "Amsterdam" criteria. Composite adverse neonatal outcome-included any of the following complications: neurological morbidity, neonatal respiratory assistance, RDS, NEC, sepsis, blood transfusion, phototherapy, hypoglycemia, or neonatal death. Composite severe adverse neonatal outcome included any of the following complications - neurological morbidity, blood transfusion, NEC, sepsis, RDS, neonatal death.

RESULTS

- Compared to FGR without HC (n = 446), FGR with HC (n = 57) was characterized by more advanced gestational age at delivery 39.2 (38.3-39.9) vs. 38.2 (36.9-39.2), weeks respectively, p < 0.001), higher rate of nulliparity (73.7% vs. 45.1%, p < 0.001), less vascular lesions of MVM (1.8% vs.11.2%, p = 0.02), higher rate of Apgar scores at 5 min <7 (10.5% vs. 2%, p = 0.004), increased neonatal death (7.0% vs. 0.9%, p = 0.007), higher rates of both composite adverse neonatal outcome (31.1% vs. 17.3% p = 0.02), and composite severe adverse neonatal outcome (16.3% vs. 8.2% p = 0.04). By multivariate regression analysis HC was found to be independently associated with composite adverse neonatal outcome (aOR = 1.21, 95% CI 1.08-2.38) and with severe composite adverse neonatal outcome (aOR = 1.39, 95% CI 1.16-3.76).

CONCLUSIONS

Pregnancies complicated by FGR with concomitant HC were associated with higher rates of adverse neonatal outcomes.

Vanishing Twins Conceived Through Fresh In Vitro Fertilization: Obstetric Outcomes and Placental Pathology

OBJECTIVE

To characterize the obstetric outcomes and placental pathology in live births arising from vanishing twin pregnancies compared with nonreduced in vitro fertilization (IVF) pregnancies.

METHODS

This is a retrospective cohort study of live births resulting from fresh embryo transfers after IVF cycles with autologous oocytes from 2004 through 2017 at a large academic fertility center. Clinical information and pathology reports were reviewed. Placental diagnoses were coded using established nosology by expert placental pathologists. Analysis of variance, Kruskal-Wallis, Pearson's χ, and Fisher exact tests were used, as appropriate, to compare pathology categories between pregnancy outcomes. Mixed effects logistic regression models were generated to reveal the association between pregnancy outcome and placenta pathology, controlling for pregnancies arising in the same woman and various suspected confounders.

RESULTS

Of 905 fresh autologous IVF cycles with placental pathology available for review, we identified 73 vanishing twin pregnancies (8.1%), 556 singleton pregnancies (61.4%), and 276 twin pregnancies (30.5%). Vanishing twin syndrome was not associated with preterm delivery, route of delivery, growth restriction or other obstetric outcomes as compared with IVF singleton pregnancies. However, vanishing twin syndrome pregnancies showed distinctive placental pathologies including an increased rate of small placentas (less than the 10th percentile by weight), with more anatomical abnormalities than IVF singleton pregnancies (odds ratio 1.73, 95% CI 0.94-3.19; adjusted odds ratio 2.15, 95% CI 1.08-4.28). The frequency of placental vascular and inflammatory pathologies associated with IVF vanishing twin syndrome pregnancies were similar to that of IVF singleton pregnancies. Loss of a twin after 8 weeks of gestation was not associated with greater risks of placental pathologies.

CONCLUSION

In vitro fertilization pregnancies affected by vanishing twin syndrome did not have significant differences in obstetric or perinatal outcomes as compared with twin or singleton gestations. However, early twin loss was potentially associated with differences in placental development associated with a higher rate of small placentas and other anatomic pathologies.

Does macroscopic estimation of the extent of placental abruption correlate with pregnancy outcomes?

INTRODUCTION

We aimed to study the correlation between the extent of placental abruption (PA), as grossly estimated immediately after delivery, and pregnancy outcomes, in correlation with placental histopathology.

MATERIALS AND METHODS

Pregnancy and placental reports of all pregnancies complicated by PA (clinically diagnosed) between 11/2008-12/2018 were reviewed. We compared maternal background, pregnancy outcomes, and placental histopathology between cases of PA divided into three groups according to the extent of abruption: Group 1-<30 %, Group 2-30-49 %, and Group 3->50 % of placental surface. Placental lesions were classified according to the current "Amsterdam" criteria. The primary outcome was defined as a composite of severe neonatal morbidity and included ≥ 1 of the following complications: seizures, intraventricular hemorrhage, hypoxic-ischemic encephalopathy, periventricular leukomalacia, blood transfusion, necrotizing enterocolitis, intrauterine fetal demise, or neonatal death.

RESULTS

A total of 260 PA cases were included: 111 (42.7 %) in Group 1, 94 (36.2 %) in Group 2, and 55 (21.1 %) in Group 3. The rate of the primary outcome (7.2 % vs. 11.7 % vs. 27.3 %, p = 0.02) was associated with the degree of PA as well as maternal heavy smoking (p = 0.04), DIC (p = 0.03), umbilical artery Ph <7.1 (p = 0.02), 5-minute Apgar scores <7 (p = 0.03), NICU admissions, placental maternal vascular malperfusion lesions (p = 0.04), and neonatal weights <5th percentile (0.04). In multivariable analysis severe adverse neonatal outcome was independently associated with the percentage of PA (aOR = 1.4, 95 % CI = 1.3-3.9).

CONCLUSION

The extent of placental abruption, as estimated by the examiner, correlated with DIC and severe neonatal outcomes and may serve as an early alarming sign in deliveries complicated by PA.

Altered Levels of Decidual Immune Cell Subsets in Fetal Growth Restriction, Stillbirth, and Placental Pathology

Immune cells are critically involved in placental development and functioning, and inadequate regulation of the maternal immune system is associated with placental pathology and pregnancy complications. This study aimed to explore numbers of decidual immune cells in pregnancies complicated with fetal growth restriction (FGR) and stillbirth (SB), and in placentas with histopathological lesions: maternal vascular malperfusion (MVM), fetal vascular malperfusion (FVM), delayed villous maturation (DVM), chorioamnionitis (CA), and villitis of unknown etiology (VUE). Placental tissue from FGR (n = 250), SB (n = 64), and healthy pregnancies (n = 42) was included. Histopathological lesions were classified according to criteria developed by the Amsterdam Placental Workshop Group. Tissue slides were stained for CD68 (macrophages), CD206 (M2-like macrophages), CD3 (T cells), FOXP3 [regulatory T (Treg) cells], and CD56 [natural killer (NK) cells]. Cell numbers were analyzed in the decidua basalis using computerized morphometry. The Mann-Whitney U-test and Kruskal Wallis test with the Dunn's as post-hoc test were used for statistical analysis. Numbers of CD68⁺ macrophages were higher in FGR compared to healthy pregnancies (p < 0.001), accompanied by lower CD206⁺/CD68⁺ ratios (p < 0.01). In addition, in FGR higher numbers of FOXP3⁺ Treg cells were seen (p < 0.01) with elevated FOXP3⁺/CD3⁺ ratios (p < 0.01). Similarly, in SB elevated FOXP3⁺ Treg cells were found (p < 0.05) with a higher FOXP3+/CD3+ ratio (p < 0.01). Furthermore, a trend toward higher numbers of CD68⁺ macrophages was found (p < 0.1) in SB. Numbers of CD3⁺ and FOXP3⁺ cells were higher in placentas with VUE compared to placentas without lesions (p < 0.01 and p < 0.001), accompanied by higher FOXP3⁺/CD3⁺ ratios (p < 0.01). Elevated numbers of macrophages with a lower M2/total macrophage ratio in FGR suggest a role for a macrophage surplus in its pathogenesis and could specifically indicate involvement of inflammatory macrophages. Higher numbers of FOXP3⁺ Treg cells with higher Treg/total T cell ratios in VUE may be associated with impaired maternal-fetal tolerance and a compensatory response of Treg cells. The abundant presence of placental lesions in the FGR and SB cohorts might explain the increase of Treg/total T cell ratios in these groups. More functionality studies of the observed altered immune cell subsets are needed.

Effect of prenatal nutritional intervention on foetal growth restriction: a real-world study in Shenzhen, China

Objective: Fetal growth restriction (FGR) is the primary cause of infant morbidity and mortality. Although nutritional intervention is generally used to cure FGR, its effects on early- and late-onset FGR have not been reported. This study aimed to resolve this issue in a real-world setting.Study design: We collected the data of pregnant women whose fetuses were diagnosed with FGR and subsequently born at Nanshan Women and Children's Care Hospital in Shenzhen, China. We conducted a MANOVA and series of Cox regression analyses to evaluate the effects of a prenatal nutritional intervention on early and late FGR after adjusting for potential confounders.Results: Our results demonstrated that the average birth weights in the four sub-intervention groups were 50.36-160.05 g higher than those in the nonintervention group. These differences were insignificant with respect to early-onset FGR. In late-onset FGR, however, the interventions led to birth weight increases of 164.95-244.45 g greater than those in the nonintervention group, and these differences were significant. During early-onset FGR, four different nutritional interventions reduced the incidence of small-for-gestational age by 8.00-13.76% relative to the incidence in the nonintervention group, while in late-onset FGR, the incidence decreased by 11.37-17.39%.Conclusions: Our results based on a real-world setting reaffirmed that a prenatal nutritional intervention could improve the birth outcomes in cases of FGR and further suggested a better effectiveness on late-onset FGR.

Maternal use of selective serotonin reuptake inhibitors (SSRI) during pregnancy-neonatal outcomes in correlation with placental histopathology

OBJECTIVE

We investigated the association between prenatal selective serotonin reuptake inhibitors (SSRI) exposure and pregnancy-outcomes with correlation to placental-histopathology.

STUDY DESIGN

Included were pregnancies with maternal SSRI use throughout pregnancy (SSRI-group) and the control group was matched with pregnancies unexposed to SSRI. Placental lesions were classified according to the "Amsterdam" criteria. Adverse neonatal outcome was defined as ≥1 early neonatal-complications.

RESULTS

SSRI group had lower birthweights (p < 0.001), higher rates of meconium (p = 0.009), NICU admissions (p < 0.001), and adverse neonatal-outcome (p < 0.001). SSRI placentas had lower birthweight-to-placental-weight ratio (p = 0.02) and higher rates of fetal vascular malperfusion (FVM) lesions (p = 0.03). Using multivariable analyses: GA < 37 weeks (aOR = 2.1, 95%CI 1.7-4.6) and SSRI (aOR = 1.7, 95%CI 1.3-3.9) were independently associated with adverse neonatal outcome while GA < 37 weeks (aOR = 1.6, 95%CI 1.2-3.4), SSRI (aOR = 1.3, 95%CI 1.1-2.6), and smoking (aOR = 1.2, 95%CI 1.1-4.0) were independently associated with FVM lesions.

CONCLUSION

SSRI use during pregnancy was independently associated with adverse neonatal outcome and placental FVM.

MORPHOLOGICAL FINDINGS IN INTRAUTERINE GROWTH RESTRICTION (IUGR) PLACENTAS VERSUS NORMAL PLACENTAS IN PREGNANT WOMEN OF DISTRICT RAWALPINDI, PAKISTAN

Background: Intrauterine growth restriction (IUGR) is a principal cause of fetal and neonatal morbidity and mortality. The placenta, as a vector for maternal-fetal nutrient and oxygen exchange has major influence on birthweight. The objectives of this study were to compare the placental weight (grams), number of syncytial knots and number of blood vessels in villi of IUGR placentas versus normal placentas. Materials & Methods: This cross-sectional study was carried out at Rai Medical College, Sargodha, Pakistan in collaboration with Zainab Memorial Hospital, Rawalpindi, Pakistan from December 2016 to November 2018. Study group included 45 IUGR placentas and control group included 25 normal placentas. Placental weight in grams, number of syncytial knots and number of blood vessels in villi of placentas were three research variables. These were described by mean, minimum, maximum, range and standard deviation for each group separately and were compared between the two groups through independent-samples t-test. Results: Descriptively the mean placental weight in grams in IUGR group (423.35±64.13g) was lower than control group placentas (535.92±44.57g). The number of syncytial knots in IUGR group placentas (22.04±5.21) was more than control group placentas (13.84±4.41). The number of blood vessels in IUGR placentas was lower than control group placentas. All three null hypothesis for research variables between the two groups were rejected (p=

Placental pathology in pregnancies complicated by fetal growth restriction: recurrence vs. new onset

OBJECTIVE

In an attempt to shed new light on the pathogenesis of fetal growth restriction (FGR), we aimed to study pregnancy characteristics, neonatal outcomes, and placental histopathological lesions of FGR pregnancies in two different subgroups: when developed after appropriate for gestational age (AGA) pregnancy and when developed after previous pregnancy with FGR.

STUDY DESIGN

Pregnancy and placental reports of all singleton pregnancies complicated by FGR (defined as actual birthweight below the 10th percentile according to local birthweight nomograms) between 2008 and 2018 were reviewed. Included were only cases with previous delivery. Maternal background, neonatal outcomes, and placental histopathology were compared between FGR that occurred after FGR (recurrent FGR group) and FGR that occurred after an AGA pregnancy (FGR after AGA group). Placental lesions were classified according to the current "Amsterdam" criteria. Continuous variables were compared using the Student's t test or the Mann-Whitney test as appropriate. Categorical variables were compared using Chi-square or Fisher's exact test as appropriate.

RESULTS

A total of 334 FGR cases with a previous delivery were included in the study. Of them, 111 cases constituted the recurrent FGR group and 223 constituted the FGR after AGA group. The recurrent FGR group was characterized by higher rates of maternal diabetes during pregnancy and hypertensive diseases (9% versus 2.7%, p = 0.01 and 19.8% versus 11.6%, p = 0.04). The FGR after AGA group was characterized by a higher rate of fetal vascular malperfusion (FVM) lesions (29.6% versus 18.0%, p = 0.02), and by lower mean birthweight (1842 ± 424.9 versus 1977.4 ± 412.2, p = 0.005), as compared to the recurrent FGR group.

CONCLUSION

Recurrent FGR was associated with maternal background morbidities during pregnancy which represents a chronic repeated insult, while "new" FGR cases (those followed an AGA pregnancy) were characterized by a higher rate of FVM lesions and lower birthweight which probably represent an "accident" in placentation. These findings may suggest that different mechanisms of placental dysfunction exist in the two subgroups of FGR.

Placental changes in diabetic pregnancies and the contribution of hypertension

Objective: To evaluate placental abnormalities in pregnancies affected by diabetes compared to unaffected pregnancies from a single academic center.Methods: This is a retrospective cohort study of women with singleton gestations delivered at the University of Arkansas for Medical Sciences from 2007 to 2016. Pathologic examination of placentas from pregestational and gestational diabetic pregnancies were compared to placentas from patients without diabetes using 12 histologic elements. Maternal and neonatal outcomes were extracted from the medical record and compared between groups. Findings were adjusted for hypertensive disorders of pregnancy. Placental lesions were also correlated with diabetic control.Results: Pathology reports of 590 placentas along with corresponding medical records were reviewed. The diabetic group (N = 484) consisted of 188 patients with pregestational diabetes and 296 patients with gestational diabetes. The nondiabetic group consisted of 106 patients. The diabetic group was older, had a higher average BMI, and more hypertensive disorders (p < .0001). Out of the 12 histologic elements investigated, accelerated villous maturation (aOR = 8.45, 95%CI (1.13-62.95)) and increased placental weight (aOR = 3.131, 95% CI (1.558-6.293)) were noted to be significantly increased in placentas from diabetic pregnancies after controlling for hypertension. Intervillous thrombi were not significantly increased in pregnancies affected by diabetes. Neonates of the diabetic group were more likely to be large for gestational age (p < .0001) and had a higher rate of preterm delivery (p < .0001).Conclusions: Accelerated villous maturation was found to be more frequent in pregnancies complicated by pregestational diabetes, even after controlling for hypertension. In pregnancies complicated by gestational diabetes, the placental findings were not significant after controlling for hypertension. In contrast with prior studies, there was no increase in thrombotic lesions of the placenta in patients with diabetes.

Trophoblast lineage-specific differentiation and associated alterations in preeclampsia and fetal growth restriction

The human placenta is a poorly-understood organ, but one that is critical for proper development and growth of the fetus in-utero. The epithelial cell type that contributes to primary placental functions is called "trophoblast," including two main subtypes, villous and extravillous trophoblast. Cytotrophoblast and syncytiotrophoblast comprise the villous compartment and contribute to gas and nutrient exchange, while extravillous trophoblast invade and remodel the uterine wall and vessels, in order to supply maternal blood to the growing fetus. Abnormal differentiation of trophoblast contributes to placental dysfunction and is associated with complications of pregnancy, including preeclampsia (PE) and fetal growth restriction (FGR). This review describes what is known about the cellular organization of the placenta during both normal development and in the setting of PE/FGR. It also explains known trophoblast lineage-specific markers and pathways regulating their differentiation, and how these are altered in the setting of PE/FGR, focusing on studies which have used human placental tissues. Finally, it also highlights remaining questions and needed resources to advance this field.

Evaluation of placental vascularization in thrombophilia and intrauterine growth restriction (IUGR)

The placenta is an essential organ in the proper development of pregnancy, and it can present a lot of structural and vascular lesions that can affect fetal development. One of the pathologies associated with pregnancy, which can change the placental structure is thrombophilia (TPh), and this can be correlated with an intrauterine growth restriction (IUGR) of the fetus. Maternal clinical aspects (age, weight) can be correlated with fetal ones (weight, gender), but also with the structural and vascular aspect of the placenta. The placental structure associated with TPh and IUGR shows macroscopic changes, such as fibrin deposition, calcifications and placental infarctions, but microscopic lesions are best highlighted by classical staining techniques: Hematoxylin–Eosin (HE), Masson’s trichrome (MT) and Periodic Acid–Schiff (PAS)–Hematoxylin, but also by immunohistochemistry technique with the help of anti-cluster of differentiation 34 (CD34) antibody that could make it possible to quantify vascular density depending on the pathology. Microscopic changes were massive infarcts caused by vascular ischemia, intravenous and extravillous fibrin deposits, calcifications, and vascular thrombosis. All these clinical, morphological and morphopathological data are interconnected and may vary in the presence of TPh and IUGR.

Distinctive patterns of placental lesions in pre-eclampsia vs small-for-gestational age and their association with fetoplacental Doppler

OBJECTIVES

To describe placental histopathological findings in a large cohort of pregnancies complicated by pre-eclampsia (PE) and/or small-for-gestational age (SGA), and to investigate their association with fetoplacental Doppler parameters.

METHODS

This was a prospective observational study of normotensive pregnancies with SGA (defined as birth weight < 10^th centile) (n = 184), PE pregnancies with a normally grown fetus (n = 102), pregnancies with both PE and SGA (n = 120) and uncomplicated pregnancies (n = 202). Uterine (UtA), umbilical (UA) and fetal middle cerebral (MCA) artery pulsatility indices (PI) were assessed. The cerebroplacental ratio (CPR) was calculated by dividing MCA-PI by UA-PI. Doppler parameters were considered abnormal when UtA-PI or UA-PI was > 95^th centile or MCA-PI or CPR was < 5^th centile. Placental lesions were categorized as vascular (maternal or fetal side), immunoinflammatory or other, according to the 2014 Amsterdam Placental Workshop Group Consensus Statement. Comparison between the study groups was performed using univariate and multiple regression analysis, and logistic regression was used to determine the relationship between abnormal Doppler parameters and placental lesions.

RESULTS

Maternal-side vascular lesions were significantly more common in PE pregnancies with SGA than in the other groups (PE + SGA, 73% vs PE, 46% vs SGA, 38% vs controls, 31%; P = 0.01) and included mainly two types of lesion: developmental (PE + SGA, 13% vs PE, 5% vs SGA, 3% vs controls, 1.5%; P < 0.001) and malperfusion (PE + SGA, 70% vs PE, 39% vs SGA, 32% vs controls, 25%; P = 0.001). In contrast, the incidence of fetal-side developmental lesions was significantly higher in normotensive SGA pregnancies than in controls and PE pregnancies (PE + SGA, 0% vs PE, 3% vs SGA, 8% vs controls, 2%; P = 0.001). All cases displayed a lower prevalence of infectious lesions than did controls, with the highest prevalence of immune lesions observed in pregnancies with both PE and SGA (PE + SGA, 18% vs PE, 8% vs SGA, 10% vs controls, 9%; P = 0.001). All fetoplacental Doppler parameters evaluated were associated with maternal-side vascular lesions, mainly malperfusion (mean UtA-PI: odds ratio (OR), 2.45 (95% CI, 1.51-3.97); UA-PI: OR, 2.05 (95% CI, 1.02-4.47); MCA-PI: OR, 2.75 (95% CI, 1.40-5.42); CPR: OR, 1.75 (95% CI, 1.04-2.95)). This association was evident mainly in the normotensive SGA group, being non-significant in controls or PE pregnancies without SGA. No significant associations were observed between fetoplacental Doppler parameters and other placental lesions in any of the study groups.

CONCLUSIONS

PE and SGA are associated with different patterns of placental histopathological lesions in accordance with the clinical manifestation of the placental disorder (maternal vs fetal). Fetoplacental Doppler findings show an association with placental malperfusion lesions on the maternal side, supporting the use of abnormal Doppler as a surrogate for placental insufficiency. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Recurrent intrauterine growth restriction: characteristic placental histopathological features and association with prenatal vascular Doppler

PURPOSE

Intrauterine growth restriction (IUGR) is a leading cause of perinatal morbidity and mortality, carrying a 20% recurrence rate. The placental disease is a cardinal factor among IUGR underlying processes. This study describes placental histopathological features (HPf) characteristic of recurrent IUGR (rIUGR) and assesses association with antenatal Doppler studies.

METHODS

We conducted a retrospective case-control study, between the years 2005-2016, evaluating 34 placentae of 17 women with rIUGR, and 59 placentae of a gestational age-matched control. Doppler studies within a week prior to delivery were analyzed for the rIUGR group.

RESULTS

Placental HPf characteristic of rIUGR is maternal and fetal vascular malperfusion lesions; maternal accelerated villous maturation and villous infarcts, repetitive feature rate 88.8% (95% CI 37.2-97), and fetal chorionic plate/stem villous thrombi, repetitive feature rate 66.6% (95% CI 30-90.3). Among women with abnormal Doppler, 83.3% had a placenta HPf of maternal vascular malperfusion lesions and 66.7% presented with a hypertensive disorder.

CONCLUSIONS

Women with rIUGR are a unique group of patients characterized by repetitive placental HPf of both maternal and fetal vascular malperfusion lesions. Specifically, maternal vascular malperfusion lesions are associated with abnormal Doppler findings. In conclusion, characteristic placental HPf may serve as predictors of future IUGR recurrence, thus offering early recognition of pregnancies that require "high-risk" antenatal care.

Placental elasticity assessment by point shear wave elastography in pregnancies with intrauterine growth restriction

Background Placental elasticity varies in different diseases. Our objective was to evaluate placental elasticity using point shear wave elastography (pSWE) in pregnancies with intrauterine growth restriction (IUGR). Methods A total of 66 pregnant women with IUGR and 81 healthy pregnant women were enrolled. Placental elasticity was measured using the transabdominal pSWE method. Ten measurements were made, and the mean was accepted as the mean placental elasticity value in each case. The results for IUGR pregnancies and controls were compared. Results The mean pSWE values were significantly higher in pregnancies with IUGR, which means that women with IUGR have stiffer placentas (P < 0.001). Furthermore, the pSWE values were significantly and positively correlated with Doppler indices and adverse perinatal outcomes. Conclusion The pregnancies with IUGR had stiffer placentas than the healthy controls. The utilization of pSWE for placental elasticity may be useful in the diagnosis and management of IUGR as a supplement to the existing ultrasonography methods.

Perspective: L-arginine and L-citrulline Supplementation in Pregnancy: A Potential Strategy to Improve Birth Outcomes in Low-Resource Settings

The available data support the hypothesis that L-arginine or L-citrulline supplementation would be suitable for implementation in resource-constrained settings and will enhance placental vascular development and improve birth outcomes. In resource-constrained settings, the rates of adverse birth outcomes, including fetal growth restriction, preterm birth, and low birth weight, are disproportionately high. Complications resulting from preterm birth are now the leading cause of mortality in children <5 y of age worldwide. Despite the global health burden of adverse birth outcomes, few effective interventions are currently available and new strategies are urgently needed, especially for low-resource settings. L-arginine is a nutritionally essential amino acid in pregnancy and an immediate precursor of nitric oxide. During pregnancy, placental and embryonic growth increases the demand for L-arginine, which can exceed endogenous synthesis of L-arginine from L-citrulline, necessitating increased dietary intake. In many low-resource settings, dietary intake of L-arginine in pregnancy is inadequate owing to widespread protein malnutrition and depletion of endogenous L-arginine due to maternal infections, in particular malaria. Here we examine the role of the L-arginine-nitric oxide biosynthetic pathway in pregnancy including placental vascular development and fetal growth. We review the evidence for the relations between altered L-arginine bioavailability and pregnancy outcomes, and strategies for arginine supplementation in pregnancy. Existing studies of L-arginine supplementation in pregnancy in high-resource settings have shown improved maternal and fetal hemodynamics, prevention of pre-eclampsia, and improved birth outcomes including higher birth weight and longer gestation. Arginine supplementation studies now need to be extended to pregnant women in low-resource settings, especially those at risk of malaria.

The Impact of Infection in Pregnancy on Placental Vascular Development and Adverse Birth Outcomes

Healthy fetal development is dependent on nutrient and oxygen transfer via the placenta. Optimal growth and function of placental vasculature is therefore essential to support in utero development. Vasculogenesis, the de novo formation of blood vessels, and angiogenesis, the branching and remodeling of existing vasculature, mediate the development and maturation of placental villi, which form the materno-fetal interface. Several lines of evidence indicate that systemic maternal infection and consequent inflammation can disrupt placental vasculogenesis and angiogenesis. The resulting alterations in placental hemodynamics impact fetal growth and contribute to poor birth outcomes including preterm delivery, small-for-gestational age (SGA), stillbirth, and low birth weight (LBW). Furthermore, pathways involved in maternal immune activation and placental vascularization parallel those involved in normal fetal development, notably neurovascular development. Therefore, immune-mediated disruption of angiogenic pathways at the materno-fetal interface may also have long-term neurological consequences for offspring. Here, we review current literature evaluating the influence of maternal infection and immune activation at the materno-fetal interface and the subsequent impact on placental vascular function and birth outcome. Immunomodulatory pathways, including chemokines and cytokines released in response to maternal infection, interact closely with the principal pathways regulating placental vascular development, including the angiopoietin-Tie-2, vascular endothelial growth factor (VEGF), and placental growth factor (PlGF) pathways. A detailed mechanistic understanding of how maternal infections impact placental and fetal development is critical to the design of effective interventions to promote placental growth and function and thereby reduce adverse birth outcomes.

Pregnancy outcome in mothers over the age of 35

PURPOSE OF REVIEW

The proportion of pregnancies occurring in women of at least 35 years of age has increased from 6.2% in 1980 to 22.3% of births in 2016. This review summarizes recent epidemiological and basic scientific studies investigating the association between older maternal age and adverse pregnancy outcome(s), and clinical studies which investigate the effects of intervention to reduce adverse events.

RECENT FINDINGS

Women of at least 35 years of age have increased risk of maternal and foetal complications in pregnancy including: stillbirth, a small for gestational age baby, preterm birth, preeclampsia and maternal death. These risks increase with increasing age. The reasons for this increased risk are incompletely understood, but likely involve ageing of the maternal cardiovascular and endocrine systems which impacts upon placental function. Intervention, by induction of labour (IOL) at 39-week gestation does not increase operative deliveries or short-term adverse maternal and neonatal outcomes and would reduce perinatal mortality.

SUMMARY

The additional risks of pregnancy should be discussed with women of at least 35 years of age; additional foetal surveillance may be required in the antenatal period. The benefits and risks of IOL at 39-week gestation should be discussed with women at least 35 years of age.

Placental Chorionic Cyst Fluid Has Prothrombotic Properties and Differs From Amniotic Fluid

INTRODUCTION

Chorionic cysts of the chorion laeve, fetal chorionic plate, septum, and free membranes have been associated with placental hypoxia, but they have no clear clinical significance. Although immunohistochemistry has identified fibronectin and collagen IV in cyst fluid, the contents have yet to be fully characterized.

METHODS

Placental chorionic cysts (N = 10) were sampled by fluid extraction and hemotoxylin and eosin-stained sections. Amniotic fluid samples (N = 8) were obtained from pregnant women who had cytogenetic evaluation. The content of the cysts was tested for thrombogenicity using thromboelastography. The cyst content was tested by Luminex multiplex and ELISA assays and for known prothrombotic and proinflammatory factors.

RESULTS

We identified cysts, especially those in the chorionic plate, adjacent to intervillous thrombi with apparent cyst rupture. Thromboelastography revealed a significantly shorter R time compared to whole blood control samples. Concentration of creatinine, α-fetoprotein, and surfactant D in the cyst fluid differed significantly from amniotic fluid. Cyst fluids had a significantly higher expression of all prothrombotic and some proinflammatory factors.

DISCUSSION

Our data provide the first evidence that chorionic cyst fluid is prothrombotic and different from amniotic fluid. The association of ruptured cysts with adjacent thrombi and the prothrombotic properties of cyst fluid suggest a causal relationship; however, further studies are needed.

Prenatal exposure to fine particulate matter, maternal hemoglobin concentration, and fetal growth during early pregnancy: associations and mediation effects analysis

BACKGROUND

Fetal essential organ development is completed during early pregnancy which is important for fetal and postnatal health. However, the effect of exposure to PM_2.5 on fetal growth during early pregnancy is less studied and the related mechanisms are largely unknown.

METHODS

We conducted a birth cohort study of 1945 pregnant women with measurement of the fetal crown to rump length (CRL) by ultrasound between the gestational age of 11 and 14 weeks. We estimated residential exposures of PM_2.5 from the date of LMP to the date of ultrasound examination using a spatial-temporal land use regression model. Maternal hemoglobin concentration was examined by maternal blood samples during the same gestational period or ±1 week of the ultrasound examination. The associations of exposure to PM_2.5 with maternal hemoglobin concentration, and exposure to PM_2.5 with fetal CRL during early pregnancy were estimated by multiple linear regression models. The mediation effect of maternal hemoglobin concentration on the association between exposure to PM_2.5 and fetal CRL was explored by a casual mediation analysis.

RESULTS

One IQR increment of prenatal exposure to PM_2.5 was associated with a 0.929 g/L (95% CI: 0.068, 1.789) increase in maternal hemoglobin concentration, and associated with a -0.082 cm (95% CI: 0.139, -0.025) decrease in fetal CRL. One g/L increment of maternal hemoglobin concentration was associated a -0.011 cm (95% CI: 0.014, -0.008) decrease in fetal CRL. The mediation analysis indicated that 12.1% of the total effect of prenatal exposure to PM_2.5 on reducing fetal CRL was mediated by increased maternal hemoglobin concentration.

CONCLUSION

Exposure to PM_2.5 was associated with reduced fetal growth during early pregnancy and elevated maternal hemoglobin concentration mediated this association.

Placental Histology After Minor Trauma in Pregnancy: A Pilot Study

OBJECTIVE

Trauma in pregnancy may cause placental abruption. Consequences of moderate placental injury on neurodevelopment are unknown. The aim was to evaluate placental histology after maternal trauma.

METHODS

A prospective study was conducted at 2 tertiary medical centers in the Netherlands. Placentas from women exposed to maternal trauma ≥ 20 weeks' gestational age were histologically examined. Neurological follow-up of the infants was performed at 1 year of age by means of Alberta Infant Motor Scale. Histological findings were compared to placentas from pregnancies without trauma.

PRINCIPAL RESULTS

Thirteen placentas were investigated in the trauma group. The control group consisted of 15 placentas. Placental pathology was seen more often in the trauma cases (11 of the 13) than in the controls (6 of the 15), P = .024. Neurological follow-up was normal.

CONCLUSIONS

In this small population, majority of the placentas showed pathology after minor trauma in pregnancy without consequences for neurodevelopment at 1 year.

Associations Between the Features of Gross Placental Morphology and Birthweight

The placenta plays a critical role in regulating fetal growth. Recent studies suggest that there may be sex-specific differences in placental development. The purpose of our study was to evaluate the associations between birthweight and placental morphology in models adjusted for covariates and to assess sex-specific differences in these associations. We analyzed data from the Stillbirth Collaborative Research Network's population-based case-control study conducted between 2006 and 2008, which recruited cases of stillbirth and population-based controls in 5 states. Our analysis was restricted to singleton live births with a placental examination (n = 1229). Characteristics of placental morphology evaluated include thickness, surface area, difference in diameters, shape, and umbilical cord insertion site. We used linear regression to model birthweight as a function of placental morphology and covariates. Surface area had the greatest association with birthweight; a reduction in surface area of 83 cm2, which reflects the interquartile range, is associated with a 260.2-g reduction in birthweight (95% confidence interval, -299.9 to -220.6), after adjustment for other features of placental morphology and covariates. Reduced placental thickness was also associated with lower birthweight. These associations did not differ between males and females. Our results suggest that reduced placental thickness and surface area are independently associated with lower birthweight and that these relationships are not related to sex.

Pregnancy outcomes in correlation with placental histopathology in subsequent pregnancies complicated by fetal growth restriction

OBJECTIVE

In attempt to shed new light on the etiopathogenesis of fetal growth restriction (FGR) we aimed to compare pregnancy outcomes and placental histopathology in cases of first vs. subsequent FGR occurrence.

STUDY DESIGN

Pregnancy and placental reports of FGR pregnancies (defined by birth weight <10th percentile), born between 2008 and 2018 were reviewed. Included only cases with recurrent FGR, in two consecutive pregnancies, thus each subject served as her own control in two FGRs consecutive pregnancies. Neonatal outcome and placental histopathology were compared between the first FGR delivery (first FGR group) and the subsequent FGR delivery (subsequent FGR group). Composite adverse neonatal outcome was defined as one or more early neonatal complications.

RESULTS

Included in the study a total of 96 cases with recurrence of FGR pregnancies. Placentas from the first FGR group were characterized by higher rate of maternal vascular malperfusion (MVM) lesions as compared with the subsequent FGR group (71.8% versus 55.2%, respectively, p = 0 .02). Adverse neonatal outcome was more prevalent in the first FGR group as compared to the recurrent FGR group (41.6% versus 25%, respectively, p = 0.02). After controlling for confounders, using multivariate regression analysis, placental MVM lesions (aOR = 1.36, 95% CI = 1.12-1.45) and composite adverse neonatal outcome (aOR = 1.18 95% CI = 1.09-1.55) were found to be independently associated with the first FGR group.

CONCLUSION

First event of FGR is associated with a higher rate of placental MVM lesions and adverse neonatal outcome as compared to FGR in subsequent pregnancies.

Mitochondrial implications in human pregnancies with intrauterine growth restriction and associated cardiac remodelling

Intrauterine growth restriction (IUGR) is an obstetric complication characterised by placental insufficiency and secondary cardiovascular remodelling that can lead to cardiomyopathy in adulthood. Despite its aetiology and potential therapeutics are poorly understood, bioenergetic deficits have been demonstrated in adverse foetal and cardiac development. We aimed to evaluate the role of mitochondria in human pregnancies with IUGR. In a single‐site, cross‐sectional and observational study, we included placenta and maternal peripheral and neonatal cord blood mononuclear cells (PBMC and CBMC) from 14 IUGR and 22 control pregnancies. The following mitochondrial measurements were assessed: enzymatic activities of mitochondrial respiratory chain (MRC) complexes I, II, IV, I + III and II + III, oxygen consumption (cell and complex I‐stimulated respiration), mitochondrial content (citrate synthase [CS] activity and mitochondrial DNA copy number), total ATP levels and lipid peroxidation. Sirtuin3 expression was evaluated as a potential regulator of bioenergetic imbalance. Intrauterine growth restriction placental tissue showed a significant decrease of MRC CI enzymatic activity (P < 0.05) and CI‐stimulated oxygen consumption (P < 0.05) accompanied by a significant increase of Sirtuin3/β‐actin protein levels (P < 0.05). Maternal PBMC and neonatal CBMC from IUGR patients presented a not significant decrease in oxygen consumption (cell and CI‐stimulated respiration) and MRC enzymatic activities (CII and CIV). Moreover, CS activity was significantly reduced in IUGR new‐borns (P < 0.05). Total ATP levels and lipid peroxidation were preserved in all the studied tissues. Altered mitochondrial function of IUGR is especially present at placental and neonatal level, conveying potential targets to modulate obstetric outcome through dietary interventions aimed to regulate Sirtuin3 function.

Vascular changes in fetal growth restriction: clinical relevance and future therapeutics

Fetal growth restriction (FGR) affects about 5-10% pregnancies and is associated with poorer outcomes in the perinatal period. Additionally, long standing epidemiological data support its association with chronic diseases such as hypertension and diabetes. Cardiac and vascular adaptations in response to chronic hypoxemia due to utero-placental insufficiency are hallmarks of fetal adaptations. Investigators have attempted to identify these changes in the placenta at the microscopic and molecular level. The ex vivo dual perfusion model of the placenta enables the study of placental haemodynamics in growth-restricted pregnancies. Persistent arterial abnormalities (thickness and stiffness) noted on vascular ultrasound during fetal life through to the young-adult age group for those affected by FGR, seem to be a plausible link between in utero events and chronic circulatory diseases. Using these, this review reflects current thought on vascular maladaptive changes in the FGR cohorts and the role in investigating current and future therapeutics.

More Maternal Vascular Malperfusion and Chorioamnionitis in Placentas After Expectant Management vs. Immediate Delivery in Fetal Growth Restriction at (Near) Term: A Further Analysis of the DIGITAT Trial

Objective: Management of late fetal growth restriction (FGR) is limited to adequate fetal monitoring and optimal timing of delivery. The Disproportionate Intrauterine Growth Intervention Trial At Term (DIGITAT) trial compared induction of labor with expectant management in pregnancies at (near) term complicated by suspected FGR. Findings of the DIGITAT trial were that expectant monitoring prolonged pregnancy for 10 days and increased birth weight with only 130 grams. This resulted in more infants born below the 2.3rd percentile compared to induction of labor, respectively, 12.5% in induction of labor and 30.6% in expectant monitoring group. The main placental lesions associated with FGR are maternal vascular malperfusion, fetal vascular malperfusion, and villitis of unknown etiology. We investigated whether placentas of pregnancies complicated with FGR in the expectant monitoring group reveal more and more severe pathology due to pregnancy prolongation. Material and methods: The DIGITAT trial was a multicenter, randomized controlled trial with suspected FGR beyond 36 + 0 weeks. We now analyzed all available cases (n = 191) for placental pathology. The macroscopic details were collected and histological slides were recorded and classified by a single perinatal pathologist, blinded for pregnancy details and outcome. The different placental lesions were scored based on the latest international criteria for placental lesions as defined in the Amsterdam Placental Workshop Group Consensus Statement. Results: The presence of maternal vascular malperfusion and chorioamnionitis were higher in the expectant management group (p < 0.05 and p < 0.01, respectively). No differences in placental weight and maturation of the placenta between the induction of labor and the expectant management group were seen. Fetal vascular malperfusion, villitis of unknown etiology and nucleated red blood cell count did not differ between the groups. Conclusion: Expectant management of late FGR is associated with increased maternal vascular malperfusion and chorioamnionitis. This may have implications for fetal and neonatal outcome, such as programming in the developing child influencing health outcomes later in life.

Evaluation of Placental Perfusion Based on Intravoxel Incoherent Motion Diffusion Weighted Imaging (IVIM-DWI) and Its Predictive Value for Late-Onset Fetal Growth Restriction

Objective The aim of this study was to investigate placental blood perfusion in middle and late pregnancy and explore its predictive value for fetal growth restriction (FGR).

Methods All pregnant women included in the study were examined using placental intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI). Three IVIM parameters (D, f, D*) were obtained for each pregnant woman and analyzed using Image J software. Perfusion fraction f is a radiological marker of placental perfusion. The pulsatility index (PI) of the uterine artery is used to indirectly evaluate placental function.

Results f-values were significantly lower in the late-onset FGR group compared to the normal late pregnancy group (19.07 vs. 27.78%). In addition, uterine artery PI values were markedly increased in the late-onset FGR group compared to the normal late pregnancy group (1.96 vs. 1.03), and neonatal weight was significantly lower in the late-onset FGR group (2.75 vs. 3.18 kg). There was a significant positive correlation between f-value, uterine artery PI and neonatal weight (r = 0.968, p < 0.01; r = 0.959, p < 0.01). There was a significant negative correlation between f-value and age of gestation (r = − 0.534, p < 0.01).

Conclusion Perfusion fraction f was strongly correlated with uterine artery blood flow resistance as measured by color Doppler and had a certain predictive value for late-onset FGR.

Defining early vs late fetal growth restriction by placental pathology

INTRODUCTION

Although early and late fetal growth restriction have been suggested to be distinct entities, the optimal gestational age cut-off that differentiates the two conditions is currently unclear and has been arbitrarily set in previous studies between 32 and 37 weeks. We aimed to use placental pathology findings to determine that optimal gestational age cut-off between early and late fetal growth restriction.

MATERIAL AND METHODS

A retrospective cohort study of all women with singleton gestation who gave birth to a neonate diagnosed as small-for-gestational age (small-for-gestational age, defined as birthweight <10th percentile for gestational age) at a tertiary referral center between January 2001 and December 2015, and for whom placental pathology was available. Placental abnormalities were classified into lesions associated with maternal vascular malperfusion (MVM), fetal vascular malperfusion, placental hemorrhage and chronic villitis. Placental findings were analyzed as a function of gestational age at birth. The analysis was repeated in the subgroups of women without hypertensive complications of pregnancy (to reflect changes associated with isolated small-for-gestational age) and of neonates with severe small-for-gestational age (defined as birthweight <5th percentile), which are more likely to represent true fetal growth restriction.

RESULTS

A total of 895 women met the inclusion criteria. The only histological finding that changed with gestational age was MVM pathology, which decreased in frequency with increasing gestational age. We identified a considerable drop in the rate of MVM lesions at 33 weeks of gestation. The rate of MVM pathology in placentas of infants born before 33^0/7  weeks was significantly higher than that observed in placentas of infants born at 33^0/7  weeks or longer: 71.6% vs 27.4%, P < 0.001 for ≥2 MVM lesions, and 35.5% vs 3.5%, P < 0.001 for ≥3 MVM lesions. These findings persisted in the subgroups of women without hypertensive complications of pregnancy (n = 662) and of neonates with severe small-for-gestational age (n = 464).

CONCLUSIONS

Using placental pathology as a direct measure of the mechanisms underlying fetal growth restriction, the optimal gestational age at birth cut-off which differentiates early from late fetal growth restriction appears to be 33^0/7  weeks.

Placenta microstructure and microcirculation imaging with diffusion MRI

PURPOSE

To assess which microstructural models best explain the diffusion-weighted MRI signal in the human placenta.

METHODS

The placentas of nine healthy pregnant subjects were scanned with a multishell, multidirectional diffusion protocol at 3T. A range of multicompartment biophysical models were fit to the data, and ranked using the Bayesian information criterion.

RESULTS

Anisotropic extensions to the intravoxel incoherent motion model, which consider the effect of coherent orientation in both microvascular structure and tissue microstructure, consistently had the lowest Bayesian information criterion values. Model parameter maps and model selection results were consistent with the physiology of the placenta and surrounding tissue.

CONCLUSION

Anisotropic intravoxel incoherent motion models explain the placental diffusion signal better than apparent diffusion coefficient, intravoxel incoherent motion, and diffusion tensor models, in information theoretic terms, when using this protocol. Future work will aim to determine if model-derived parameters are sensitive to placental pathologies associated with disorders, such as fetal growth restriction and early-onset pre-eclampsia. Magn Reson Med 80:756-766, 2018. © 2017 The Authors Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

MRI features of the placenta in fetuses with and without CNS abnormalities

AIM

To investigate if magnetic resonance imaging (MRI) features of the placenta are different in fetuses with and without central nervous system (CNS) abnormalities.

MATERIAL AND METHODS

Institutional research ethics board approval was obtained. Fetal MRI of 97 singleton pregnancies were analysed retrospectively (19-25 weeks gestation), 65 with CNS morphological abnormalities and 32 controls. Placental T2 signal intensity, placental and fetal volumes, placental-to-fetal volume ratio, and placental apparent diffusion coefficient (ADC) values were assessed. Measurements were compared with the presence or absence of CNS fetal abnormalities using the Mann-Whitney test. Separate slopes models and intercept models were used to check for significant differences in the slopes and intercepts, respectively, among the groups.

RESULTS

Placental ADC values were significantly lower in placentas of fetuses with CNS abnormalities compared to controls (p=0.04). Placental T2 signal intensity, fetal and placental volumes did not differ between the two groups. The rate of increase in fetal-to-placental volume ratio with gestational age (GA) was greater among the controls.

CONCLUSION

The presence of fetal CNS abnormalities is associated with reduced ADC values of the placenta. Moreover, placentas of fetuses with CNS abnormalities show a less rapid increase in fetal to placental volume ratio with GA. Therefore, ADC mapping, as well as different growth kinetics of the placenta relative to the fetus, may potentially serve as early markers of pathological neurodevelopment.

Estrogen-related receptor γ regulates expression of 17β-hydroxysteroid dehydrogenase type 1 in fetal growth restriction

INTRODUCTION

Estrogen-related receptor γ (ERRγ) and 17β-hydroxysteroid dehydrogenase type 1 (HSD17B1) have important roles in cell invasion and in the proliferation of many types of cancer cells. However, it remains unknown whether ERRγ and HSD17B1 contribute to abnormal placental structure and dysfunction which characterize fetal growth restriction (FGR). Therefore, the aim of this study was to investigate the expression profiles of ERRγ and HSD17B1 in placenta tissues affected by FGR and to examine a possible molecular mechanism by which ERRγ is able to regulate HSD17B1 during development of FGR.

METHODS

Placenta tissues were collected from women affected by FGR (n = 28) and from women with appropriately gestational age (AGA) (n = 30). Relative mRNA and protein levels of ERRγ and HSD17B1 in both groups were assessed by quantitative real-time PCR, immunohistochemistry, and Western blot analyses. The effect of ERRγ on trophoblast function and its associated mechanistic details were studied in the trophoblast cell line, HTR-8/SVneo, which was transfected with small interfering RNA (siRNA) targeting ERRγ.

RESULTS

Both mRNA and protein levels of ERRγ and HSD17B1 were significantly lower in FGR placentae (P < 0.05). When ERRγ expression was knocked down in HTR-8/SVneo cells with siRNA, invasion and proliferation were inhibited. In addition, HSD17B1 expression was significantly decreased. In dual luciferase reporter assays, ERRγ stimulated transcription of HSD17B1 by targeting the ERRγ response element within its 5'-flanking promoter region.

DISCUSSION

Aberrant ERRγ expression may contribute to the pathogenesis of FGR by regulating the transcriptional activity of HSD17B1.