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Alur P, Holla I, Hussain N. Impact of sex, race, and social determinants of health on neonatal outcomes. Front Pediatr 2024; 12:1377195. [PMID: 38655274 PMCID: PMC11035752 DOI: 10.3389/fped.2024.1377195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/22/2024] [Indexed: 04/26/2024] Open
Abstract
Despite the global improvements in neonatal outcomes, mortality and morbidity rates among preterm infants are still unacceptably high. Therefore, it is crucial to thoroughly analyze the factors that affect these outcomes, including sex, race, and social determinants of health. By comprehending the influence of these factors, we can work towards reducing their impact and enhancing the quality of neonatal care. This review will summarize the available evidence on sex differences, racial differences, and social determinants of health related to neonates. This review will discuss sex differences in neonatal outcomes in part I and racial differences with social determinants of health in part II. Research has shown that sex differences begin to manifest in the early part of the pregnancy. Hence, we will explore this topic under two main categories: (1) Antenatal and (2) Postnatal sex differences. We will also discuss long-term outcome differences wherever the evidence is available. Multiple factors determine health outcomes during pregnancy and the newborn period. Apart from the genetic, biological, and sex-based differences that influence fetal and neonatal outcomes, racial and social factors influence the health and well-being of developing humans. Race categorizes humans based on shared physical or social qualities into groups generally considered distinct within a given society. Social determinants of health (SDOH) are the non-medical factors that influence health outcomes. These factors can include a person's living conditions, access to healthy food, education, employment status, income level, and social support. Understanding these factors is essential in developing strategies to improve overall health outcomes in communities.
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Affiliation(s)
- Pradeep Alur
- Penn State College of Medicine, Hampden Medical Center, Enola, PA, United States
| | - Ira Holla
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, United States
| | - Naveed Hussain
- Department of Pediatrics, Connecticut Children’s, Hartford, CT, United States
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Brown RE, Noah AI, Hill AV, Taylor BD. Fetal Sexual Dimorphism and Preeclampsia Among Twin Pregnancies. Hypertension 2024; 81:614-619. [PMID: 38152884 PMCID: PMC10922256 DOI: 10.1161/hypertensionaha.123.22380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/13/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND In singleton pregnancies, fetal sexual dimorphism has been observed in hypertensive disorders of pregnancy, particularly preeclampsia, a morbid syndrome that increases the risk of adult-onset cardiovascular disease for mothers and their offspring. However, few studies have explored the effect of fetal sex on hypertensive disorders of pregnancy among twin pregnancies. METHODS We conducted a retrospective cohort study of 1032 twin pregnancies between 2011 and 2022 using data from a perinatal database that recruits participants from 3 hospitals in Houston, TX. We categorized pregnancies based on fetal sex pairings into female/female, male/male, and female/male. Pregnancies with female/female pairs were used as our reference group. Our primary outcomes included gestational hypertension, preeclampsia, superimposed preeclampsia, and preeclampsia subtyped by gestational age of delivery. A modified Poisson regression model with robust error variance was used to calculate the relative risk and 95% CI for the association between fetal sex pairs and hypertensive disorders of pregnancy. RESULTS Adjusted models of female/male pairs were associated with preterm preeclampsia (relative risk, 2.01 [95% CI, 1.15-3.53]) relative to those with female/female pairs. No associations with other hypertensive disorders of pregnancy were observed among pregnancies with male/male pairs compared with those with female/female fetal sex pairs. CONCLUSIONS We found some evidence of sexual dimorphism for preterm preeclampsia among female/male twin pairs. Additional research is needed to understand what biological mechanisms could explain these findings.
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Affiliation(s)
- Rebekah E. Brown
- Department of Obstetrics and Gynecology, Division of Basic Science and Translational Research, University of Texas Medical Branch, Galveston, TX, USA
| | - Akaninyene I. Noah
- Department of Obstetrics and Gynecology, Division of Basic Science and Translational Research, University of Texas Medical Branch, Galveston, TX, USA
| | - Ashley V. Hill
- Department of Epidemiology, School of Public Health, University of Pittsburgh, USA
| | - Brandie DePaoli Taylor
- Department of Obstetrics and Gynecology, Division of Basic Science and Translational Research, University of Texas Medical Branch, Galveston, TX, USA
- Department of Population Health and Health Disparities, University of Texas Medical Branch, Galveston, TX, USA
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Croen LA, Ames JL, Qian Y, Alexeeff S, Ashwood P, Gunderson EP, Wu YW, Boghossian AS, Yolken R, Van de Water J, Weiss LA. Inflammatory Conditions During Pregnancy and Risk of Autism and Other Neurodevelopmental Disorders. BIOLOGICAL PSYCHIATRY GLOBAL OPEN SCIENCE 2024; 4:39-50. [PMID: 38045769 PMCID: PMC10689278 DOI: 10.1016/j.bpsgos.2023.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 09/20/2023] [Accepted: 09/25/2023] [Indexed: 12/05/2023] Open
Abstract
Background Maternal inflammation can result from immune dysregulation and metabolic perturbations during pregnancy. Whether conditions associated with inflammation during pregnancy increase the likelihood of autism spectrum disorder (ASD) or other neurodevelopmental disorders (DDs) is not well understood. Methods We conducted a case-control study among children born in California from 2011 to 2016 to investigate maternal immune-mediated and cardiometabolic conditions during pregnancy and risk of ASD (n = 311) and DDs (n = 1291) compared with children from the general population (n = 967). Data on maternal conditions and covariates were retrieved from electronic health records. Maternal genetic data were used to assess a causal relationship. Results Using multivariable logistic regression, we found that mothers with asthma were more likely to deliver infants later diagnosed with ASD (odds ratio [OR] = 1.62, 95% CI: 1.15-2.29) or DDs (OR = 1.30, 95% CI: 1.02-1.64). Maternal obesity was also associated with child ASD (OR = 1.51, 95% CI: 1.07-2.13). Mothers with both asthma and extreme obesity had the greatest odds of delivering an infant later diagnosed with ASD (OR = 16.9, 95% CI: 5.13-55.71). These increased ASD odds were observed among female children only. Polygenic risk scores for obesity, asthma, and their combination showed no association with ASD risk. Mendelian randomization did not support a causal relationship between maternal conditions and ASD. Conclusions Inflammatory conditions during pregnancy are associated with risk for neurodevelopmental disorders in children. These risks do not seem to be due to shared genetic risk; rather, inflammatory conditions may share nongenetic risk factors with neurodevelopmental disorders. Children whose mothers have both asthma and obesity during pregnancy may benefit from earlier screening and intervention.
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Affiliation(s)
- Lisa A. Croen
- Division of Research, Kaiser Permanente Northern California, Oakland, California
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Jennifer L. Ames
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Yinge Qian
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Stacey Alexeeff
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Paul Ashwood
- Department of Medical Microbiology and Immunology and the MIND Institute, University of California, Davis, Davis, California
| | - Erica P. Gunderson
- Division of Research, Kaiser Permanente Northern California, Oakland, California
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Yvonne W. Wu
- Departments of Neurology and Pediatrics, University of California San Francisco, San Francisco, California
| | - Andrew S. Boghossian
- Institute for Human Genetics, Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California
| | - Robert Yolken
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Judy Van de Water
- Division of Rheumatology/Allergy/Clinical Immunology, Department of Internal Medicine, University of California at Davis, Davis, California
| | - Lauren A. Weiss
- Institute for Human Genetics, Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California
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Brown RE, Noah AI, Hill AV, DePaoli Taylor B. Fetal sexual dimorphism and preeclampsia among twin pregnancies. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.10.23298403. [PMID: 37986979 PMCID: PMC10659481 DOI: 10.1101/2023.11.10.23298403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Background In singleton pregnancies, fetal sexual dimorphism has been observed in hypertensive disorders of pregnancy (HDP), particularly preeclampsia, a morbid syndrome that increases risk of adult onset cardiovascular disease for mothers and their offspring. However, few studies have explored the effect of fetal sex on HDP among twin pregnancies. Methods We conducted a retrospective cohort study of 1,032 twin pregnancies between 2011 - 2022 using data from a perinatal database that recruits participants from three hospitals in Houston, TX. We categorized pregnancies based on fetal sex pairings into female/female, male/male, and female/male. Pregnancies with a female/female fetal sex were used as our reference group. Our primary outcomes included gestational hypertension, preeclampsia, superimposed preeclampsia, and preeclampsia subtyped by gestational age of delivery. A modified Poisson regression model with robust error variance was used to calculate the relative risk (RR) and 95% confidence interval (CI) for the association between fetal sex pairs and HDP. Results Adjusted models of female/male fetal sex pairs were associated with preterm preeclampsia (RR 2.01, 95% CI 1.15-3.53) relative to those with female/female fetuses. No associations with other HDP were observed among pregnancies with male/male fetal sex compared to those with female/female fetal sex pairs. Conclusions We found some evidence of sexual dimorphism for preterm preeclampsia among female/male twin pairs. Additional research is needed to understand what biological mechanisms could explain these findings.
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Affiliation(s)
- Rebekah E. Brown
- Department of Obstetrics and Gynecology, Division of Basic Science and Translational Research, University of Texas Medical Branch, Galveston, TX, USA
| | - Akaninyene I. Noah
- Department of Obstetrics and Gynecology, Division of Basic Science and Translational Research, University of Texas Medical Branch, Galveston, TX, USA
| | - Ashley V. Hill
- Department of Epidemiology, School of Public Health, University of Pittsburgh, USA
| | - Brandie DePaoli Taylor
- Department of Obstetrics and Gynecology, Division of Basic Science and Translational Research, University of Texas Medical Branch, Galveston, TX, USA
- Department of Population Health and Health Disparities, University of Texas Medical Branch, Galveston, TX, USA
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Mabry S, Wilson EN, Bradshaw JL, Gardner JJ, Fadeyibi O, Vera E, Osikoya O, Cushen SC, Karamichos D, Goulopoulou S, Cunningham RL. Sex and age differences in social and cognitive function in offspring exposed to late gestational hypoxia. Biol Sex Differ 2023; 14:81. [PMID: 37951901 PMCID: PMC10640736 DOI: 10.1186/s13293-023-00557-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 10/09/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Gestational sleep apnea is a hypoxic sleep disorder that affects 8-26% of pregnancies and increases the risk for central nervous system dysfunction in offspring. Specifically, there are sex differences in the sensitivity of the fetal hippocampus to hypoxic insults, and hippocampal impairments are associated with social dysfunction, repetitive behaviors, anxiety, and cognitive impairment. Yet, it is unclear whether gestational sleep apnea impacts these hippocampal-associated functions and if sex and age modify these effects. To examine the relationship between gestational sleep apnea and hippocampal-associated behaviors, we used chronic intermittent hypoxia (CIH) to model late gestational sleep apnea in pregnant rats. We hypothesized that late gestational CIH would produce sex- and age-specific social, anxiety-like, repetitive, and cognitive impairments in offspring. METHODS Timed pregnant Long-Evans rats were exposed to CIH or room air normoxia from GD 15-19. Behavioral testing of offspring occurred during either puberty or young adulthood. To examine gestational hypoxia-induced behavioral phenotypes, we quantified hippocampal-associated behaviors (social function, repetitive behaviors, anxiety-like behaviors, and spatial memory and learning), hippocampal neuronal activity (glutamatergic NMDA receptors, dopamine transporter, monoamine oxidase-A, early growth response protein 1, and doublecortin), and circulating hormones in offspring. RESULTS Late gestational CIH induced sex- and age-specific differences in social, repetitive, and memory functions in offspring. In female pubertal offspring, CIH impaired social function, increased repetitive behaviors, and elevated circulating corticosterone levels but did not impact memory. In contrast, CIH transiently induced spatial memory dysfunction in pubertal male offspring but did not impact social or repetitive functions. Long-term effects of gestational CIH on social behaviors were only observed in female offspring, wherein CIH induced social disengagement and suppression of circulating corticosterone levels in young adulthood. No effects of gestational CIH were observed in anxiety-like behaviors, hippocampal neuronal activity, or circulating testosterone and estradiol levels, regardless of sex or age of offspring. CONCLUSIONS Our results indicate that hypoxia-associated pregnancy complications during late gestation can increase the risk for behavioral and physiological outcomes in offspring, such as social dysfunction, repetitive behaviors, and cognitive impairment, that are dependent on sex and age.
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Affiliation(s)
- Steve Mabry
- Department of Pharmaceutical Sciences, School of Pharmacy, University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA
| | - E Nicole Wilson
- Department of Pharmaceutical Sciences, School of Pharmacy, University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA
| | - Jessica L Bradshaw
- Department of Pharmaceutical Sciences, School of Pharmacy, University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA
| | - Jennifer J Gardner
- Department of Pharmaceutical Sciences, School of Pharmacy, University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX, 76107, USA
| | - Oluwadarasimi Fadeyibi
- Department of Pharmaceutical Sciences, School of Pharmacy, University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA
| | - Edward Vera
- Department of Pharmaceutical Sciences, School of Pharmacy, University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, TX, 76107, USA
| | - Oluwatobiloba Osikoya
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX, 76107, USA
| | - Spencer C Cushen
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX, 76107, USA
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, TX, 76107, USA
| | - Dimitrios Karamichos
- Department of Pharmaceutical Sciences, School of Pharmacy, University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA
- North Texas Eye Research Institute, University of North Texas Health Science Center, 3430 Camp Bowie Blvd, Fort Worth, TX, 76107, USA
- Department of Pharmacology and Neuroscience, University of North Texas Health Science, Fort Worth, TX, 76107, USA
| | - Styliani Goulopoulou
- Departments of Basic Sciences, Gynecology and Obstetrics, Lawrence D. Longo, MD Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, CA, 92350, USA
| | - Rebecca L Cunningham
- Department of Pharmaceutical Sciences, School of Pharmacy, University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA.
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Mirzakhani H, Weiss ST. Fetal sex and risk of preeclampsia: Dose maternal race matter? J Matern Fetal Neonatal Med 2022; 35:3379-3387. [PMID: 32924669 PMCID: PMC7954987 DOI: 10.1080/14767058.2020.1818221] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/21/2020] [Accepted: 08/30/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To examine whether maternal race could affect the relationship between fetal sex and preeclampsia. MATERIAL AND METHODS This study was a cohort analysis using prospectively collected data from pregnant women who participated in the Vitamin Antenatal Asthma Reduction Trial (VDAART). Preeclampsia was the secondary outcome of VDAART. We examined the association of fetal sex with preeclampsia and its potential interaction with maternal race in 813 pregnant women (8% with preeclampsia) in logistic regression models with adjustment for preterm birth (<37 weeks of gestation), maternal age, education, and body mass index at enrollment and clinical center. We further conducted a race stratified analysis and also examined whether any observed association was dependent on the gestational age at delivery and prematurity. RESULTS In an analysis of all races combined, preeclampsia was not more common among pregnant women with a male fetus compared to those with a female fetus (odds ratio [OR] = 1.3, 95% CI = 0.81, 2.24). There was an interaction between African American race and fetal sex in association with preeclampsia after adjustment for preterm delivery and other potential confounders (p = .014). In race stratified analyses, we observed higher odds of preeclampsia among African American pregnant women who carried male fetuses after adjustment for preterm delivery and other potential confounders (adjusted OR = 2.4, 95% CI = 1.12, 5.60). CONCLUSION We observed fetal sexual dimorphic differences in the occurrence of preeclampsia in African American women, but not in Whites. Information on fetal sex may ultimately improve the prediction of pre-eclampsia in African American mothers, who might be at higher risk for this adverse condition in pregnancy.
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Affiliation(s)
- Hooman Mirzakhani
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott T. Weiss
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Partners Center for Personalized Medicine, Partners Health Care, Boston, MA, USA
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Association between fetal sex and pregnancy outcomes among women with twin pregnancies: a multicenter cross-sectional study. Arch Gynecol Obstet 2022; 307:1397-1405. [PMID: 35624168 DOI: 10.1007/s00404-022-06623-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 05/07/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To examine the frequency and to what extent fetal sex is associated with pregnancy outcomes among twin pregnancies, stratified by chorionicity. METHODS This registry-based multicenter cross-sectional study was conducted using the Japan Society of Obstetrics and Gynecology perinatal database between 2007 and 2016. The sample population was restricted to women with twin pregnancies. The main pregnancy-related outcomes included preterm birth, very preterm birth, extremely preterm birth, preeclampsia, twin-to-twin transfusion syndrome (TTTS), and selective intrauterine growth restriction (s-IUGR). Birth weight, small for gestational age (SGA), and fetal death were also investigated. RESULTS The primary analysis was performed based on 37,953 women, including 23,804 women with dichorionic diamniotic (DD) twins and 14,149 women with monochorionic diamniotic (MD) twins. Women with male/male DD twins had a significantly higher risk of preterm birth (adjusted risk ratio [aRR]: 1.07, 95% confidence interval [CI]: 1.03-1.10) and a lower risk of preeclampsia (aRR: 0.74, 95% CI: 0.62-0.88) than women with female/female DD twins. Women with male/male MD twins also had a significantly higher risk of preterm birth (aRR: 1.06, 95% CI: 1.04-1.09) than women with female/female MD twins. Risks of preeclampsia, TTTS, and s-IUGR did not differ by sex among MD pregnancies. Male SGA risk was significantly higher among male/male twins than among male/female DD twins. Among MD twins, risks of SGA and fetal death were significantly higher in male/male fetuses. CONCLUSIONS This study demonstrated significant associations between fetal sex and several pregnancy outcomes in twin pregnancies, some of which differed by chorionicity.
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Miremberg H, Ganer Herman H, Bustan M, Weiner E, Schreiber L, Bar J, Kovo M. Placental vascular lesions differ between male and female fetuses in early-onset preeclampsia. Arch Gynecol Obstet 2021; 306:717-722. [DOI: 10.1007/s00404-021-06328-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 11/05/2021] [Indexed: 01/04/2023]
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Male Disadvantage in Oxidative Stress-Associated Complications of Prematurity: A Systematic Review, Meta-Analysis and Meta-Regression. Antioxidants (Basel) 2021; 10:antiox10091490. [PMID: 34573122 PMCID: PMC8465696 DOI: 10.3390/antiox10091490] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/14/2021] [Indexed: 11/17/2022] Open
Abstract
A widely accepted concept is that boys are more susceptible than girls to oxidative stress-related complications of prematurity, including bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), and periventricular leukomalacia (PVL). We aimed to quantify the effect size of this male disadvantage by performing a systematic review and meta-analysis of cohort studies exploring the association between sex and complications of prematurity. Risk ratios (RRs) and 95% CIs were calculated by a random-effects model. Of 1365 potentially relevant studies, 41 met the inclusion criteria (625,680 infants). Male sex was associated with decreased risk of hypertensive disorders of pregnancy, fetal distress, and C-section, but increased risk of low Apgar score, intubation at birth, respiratory distress, surfactant use, pneumothorax, postnatal steroids, late onset sepsis, any NEC, NEC > stage 1 (RR 1.12, CI 1.06–1.18), any IVH, severe IVH (RR 1.28, CI 1.22–1.34), severe IVH or PVL, any BPD, moderate/severe BPD (RR 1.23, CI 1.18–1.27), severe ROP (RR 1.14, CI 1.07–1.22), and mortality (RR 1.23, CI 1.16–1.30). In conclusion, preterm boys have higher clinical instability and greater need for invasive interventions than preterm girls. This leads to a male disadvantage in mortality and short-term complications of prematurity.
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Inkster AM, Fernández-Boyano I, Robinson WP. Sex Differences Are Here to Stay: Relevance to Prenatal Care. J Clin Med 2021; 10:3000. [PMID: 34279482 PMCID: PMC8268816 DOI: 10.3390/jcm10133000] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 07/02/2021] [Indexed: 12/27/2022] Open
Abstract
Sex differences exist in the incidence and presentation of many pregnancy complications, including but not limited to pregnancy loss, spontaneous preterm birth, and fetal growth restriction. Sex differences arise very early in development due to differential gene expression from the X and Y chromosomes, and later may also be influenced by the action of gonadal steroid hormones. Though offspring sex is not considered in most prenatal diagnostic or therapeutic strategies currently in use, it may be beneficial to consider sex differences and the associated mechanisms underlying pregnancy complications. This review will cover (i) the prevalence and presentation of sex differences that occur in perinatal complications, particularly with a focus on the placenta; (ii) possible mechanisms underlying the development of sex differences in placental function and pregnancy phenotypes; and (iii) knowledge gaps that should be addressed in the development of diagnostic or risk prediction tools for such complications, with an emphasis on those for which it would be important to consider sex.
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Affiliation(s)
- Amy M. Inkster
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada; (A.M.I.); (I.F.-B.)
- Department of Medical Genetics, University of British Columbia, Vancouver, BC V6H 3N1, Canada
| | - Icíar Fernández-Boyano
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada; (A.M.I.); (I.F.-B.)
- Department of Medical Genetics, University of British Columbia, Vancouver, BC V6H 3N1, Canada
| | - Wendy P. Robinson
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada; (A.M.I.); (I.F.-B.)
- Department of Medical Genetics, University of British Columbia, Vancouver, BC V6H 3N1, Canada
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Hypoxia-Induced Alpha-Globin Expression in Syncytiotrophoblasts Mimics the Pattern Observed in Preeclamptic Placentas. Int J Mol Sci 2021; 22:ijms22073357. [PMID: 33806017 PMCID: PMC8036899 DOI: 10.3390/ijms22073357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 12/16/2022] Open
Abstract
Preeclampsia (PE) is a pregnancy disorder associated with placental dysfunction and elevated fetal hemoglobin (HbF). Early in pregnancy the placenta harbors hematopoietic stem and progenitor cells (HSPCs) and is an extramedullary source of erythropoiesis. However, globin expression is not unique to erythroid cells and can be triggered by hypoxia. To investigate the role of the placenta in increasing globin levels previously reported in PE, flow cytometry, histological and immunostaining and in situ analyses were used on placenta samples and ex vivo explant cultures. Our results indicated that in PE pregnancies, placental HSPC homing and erythropoiesis were not affected. Non-erythroid alpha-globin mRNA and protein, but not gamma-globin, were detected in syncytiotrophoblasts and stroma of PE placenta samples. Similarly, alpha-globin protein and mRNA were upregulated in normal placenta explants cultured in hypoxia. The upregulation was independent of HIF1 and NRF2, the two main candidates of globin transcription in non-erythroid cells. Our study is the first to demonstrate alpha-globin mRNA expression in syncytiotrophoblasts in PE, induced by hypoxia. However, gamma-globin was only expressed in erythrocytes. We conclude that alpha-globin, but not HbF, is expressed in placental syncytiotrophoblasts in PE and may contribute to the pathology of the disease.
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Differences in pregnancy complications and outcomes by fetal gender among Japanese women: a multicenter cross-sectional study. Sci Rep 2020; 10:18810. [PMID: 33139809 PMCID: PMC7606487 DOI: 10.1038/s41598-020-75969-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 10/22/2020] [Indexed: 11/09/2022] Open
Abstract
The association between fetal gender and rare pregnancy complications has not been extensively investigated, and no studies have examined this association in Japanese women. Thus, we used a large Japanese birth registry database to investigate the extent to which fetal gender affects various pregnancy outcomes. We analyzed 1,098,268 women with a singleton delivery with no congenital anomaly at 22 weeks or later between 2007 and 2015. Women carrying a male fetus had a significantly higher risk of placental abruption (adjusted risk ratio [aRR] 1.15, 95% confidence interval (CI) 1.10–1.20)], preterm delivery (aRR 1.20, 95% CI 1.19–1.22), instrumental delivery (aRR 1.27, 95% CI 1.26–1.29), and cesarean delivery (aRR 1.01, 95% CI 1.00–1.02). In contrast, they had a significantly lower risk of preeclampsia (aRR 0.92, 95% CI 0.89–0.94), placenta accreta (aRR 0.90, 95% CI 0.85–0.96), atonic hemorrhage (aRR 0.95, 95% CI 0.93–0.96), and maternal blood transfusion (aRR 0.95, 95% CI 0.92–0.99). Our findings demonstrate a significant association between fetal gender and various pregnancy complications and delivery outcomes among Japanese women.
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Zhang M, Michos ED, Wang G, Wang X, Mueller NT. Associations of Cord Blood Vitamin D and Preeclampsia With Offspring Blood Pressure in Childhood and Adolescence. JAMA Netw Open 2020; 3:e2019046. [PMID: 33017029 PMCID: PMC7536588 DOI: 10.1001/jamanetworkopen.2020.19046] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Maternal preeclampsia may be one of the early risk factors for childhood and adolescence elevated blood pressure (BP). It is unknown whether the intergenerational association between maternal preeclampsia and offspring BP differs by cord blood vitamin D levels. OBJECTIVE To assess the associations between maternal preeclampsia and offspring systolic BP (SBP) across childhood and adolescence and to test whether these associations vary by cord blood 25-hydroxyvitamin D [25(OH)D] concentrations (a biomarker of in utero vitamin D status). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study analyzed 6669 SBP observations from 754 mother-child pairs from the Boston Birth Cohort, who were enrolled from December 1998 to June 2009. Data were analyzed from October 2019 to March 2020. EXPOSURES Physician-diagnosed maternal preeclampsia. Plasma 25(OH)D concentrations measured in cord blood samples collected at delivery. MAIN OUTCOMES AND MEASURES Repeated SBP measures between 3 and 18 years of age. The SBP percentile was calculated based on the 2017 American Academy of Pediatrics hypertension guidelines. Mean difference in SBP percentile in children born to mothers with vs without preeclampsia was compared across different cord blood 25(OH)D levels. RESULTS There were 6669 SBP observations from the 754 children; 50.0% were female and 18.6% were born preterm. Of the 754 mothers, 62.2% were Black and 10.5% had preeclampsia. Median cord blood 25(OH)D was 12.2 (interquartile range, 7.9-17.2) ng/mL. Maternal preeclampsia was associated with 5.34 (95% CI, 1.37-9.30) percentile higher SBP after adjusting for confounders. This association varied by quartiles of cord blood 25(OH)D concentrations: the differences in SBP percentile comparing children born to mothers with vs without preeclampsia were 10.56 (95% CI, 2.54-18.56) for quartile 1 (lowest), 7.36 (95% CI, -0.17 to 14.88) for quartile 2, 4.94 (95% CI, -3.07 to 12.96) for quartile 3, and -1.87 (95% CI, -9.71 to 5.96) for quartile 4 (highest). When cord blood 25(OH)D was analyzed continuously, children born to mothers with preeclampsia had 3.47 (95% CI, 0.77-6.18) percentile lower SBP per 5 ng/mL 25(OH)D increment. These associations did not differ by child sex or developmental stages. CONCLUSIONS AND RELEVANCE In this study of a US high-risk birth cohort, maternal preeclampsia was associated with higher offspring SBP from early childhood to adolescence. These associations were attenuated by higher cord blood 25(OH)D levels in a dose-response fashion. Additional studies, including clinical trials, are warranted.
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Affiliation(s)
- Mingyu Zhang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Erin D. Michos
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Guoying Wang
- Center on the Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Xiaobin Wang
- Center on the Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Division of General Pediatrics & Adolescent Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Noel T. Mueller
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
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14
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Differences in Placental Imprinted Gene Expression across Preeclamptic and Non-Preeclamptic Pregnancies. Genes (Basel) 2020; 11:genes11101146. [PMID: 33003346 PMCID: PMC7601230 DOI: 10.3390/genes11101146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 11/16/2022] Open
Abstract
Preeclampsia is a multi-systemic syndrome that presents in approximately 5% of pregnancies worldwide and is associated with a range of subsequent postpartum and postnatal outcomes, including fetal growth restriction. As the placenta plays a critical role in the development of preeclampsia, surveying genomic features of the placenta, including expression of imprinted genes, may reveal molecular markers that can further refine subtypes to aid targeted disease management. In this study, we conducted a comprehensive survey of placental imprinted gene expression across early and late onset preeclampsia cases and preterm and term normotensive controls. Placentas were collected at delivery from women recruited at the Magee-Womens Hospital prenatal clinics, and expression levels were profiled across 109 imprinted genes. We observed downregulation of placental Mesoderm-specific transcript (MEST) and Necdin (NDN) gene expression levels (false discovery rate (FDR) < 0.05) among early onset preeclampsia cases compared to preterm controls. No differences in placental imprinted gene expression were observed between late onset preeclampsia cases and term controls. While few studies have linked NDN to pregnancy complications, reductions in MEST expression levels, as observed in our study, are consistently reported in the literature in relation to various pregnancy complications, including fetal growth restriction, suggesting a potential role for placental MEST expression as a biosensor of an adverse in utero environment.
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15
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Yuan N, Sun J, Li Z, Chai S, Zhang X, Ji L. Relationship between anti-thyroid peroxidase antibody positivity and pregnancy-related and fetal outcomes in Euthyroid women: a single-center cohort study. BMC Pregnancy Childbirth 2020; 20:491. [PMID: 32847542 PMCID: PMC7449005 DOI: 10.1186/s12884-020-03176-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/14/2020] [Indexed: 12/16/2022] Open
Abstract
Background Thyroid autoimmunity (TAI) and subclinical hypothyroidism (SCH) have been associated with poor pregnancy and fetal outcomes. However, whether euthyroid women with anti-thyroid peroxidase antibody (TPOAb) positivity have a higher risk of poor pregnancy and fetal outcomes is debatable. Therefore, this study aimed to investigate the association between TPOAb positivity and pregnancy-related and fetal outcomes in euthyroid women. Methods In total, 938 pregnant women participated in this prospective cohort study. The euthyroid group included 837 pregnant women and the TPOAb-positive group included 101 euthyroid pregnant women. Serum TPOAb, thyroglobulin antibody (TGAb), thyroid-stimulating hormone (TSH), and free thyroxine (FT4) levels were assessed. Pregnancy and fetal outcomes included gestational diabetes mellitus, spontaneous abortion, premature rupture of membranes, hypertensive disorders of pregnancy, preterm birth, fetal distress, low birth weight, fetal macrosomia, and small for gestational age infant. Results Logistic regression analysis showed TPOAb positivity was not associated with an increased risk of poor pregnancy or fetal outcomes in euthyroid women. However, TPOAb-positive euthyroid women pregnant with a female fetus were independently associated with preterm births (OR: 4.511, 95% CI: 1.075–18.926) after adjustment for potential confounding factors. Conclusions TPOAb positivity was not found to be associated with poor pregnancy-related or fetal outcomes in euthyroid women. However, in euthyroid women with a female fetus, TPOAb positivity was strongly associated with preterm births. The risk of preterm birth in the euthyroid women with TPOAb positivity should be emphasized in clinical practice. Trial registration ClinicalTrials.gov Identifier: NCT02966405. Registered on October 24th 2016 - Retrospectively registered.
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Affiliation(s)
- Ning Yuan
- Department of Endocrinology, Peking University People's Hospital, Beijing, 100044, China
| | - Jianbin Sun
- Department of Endocrinology, Peking University International Hospital, Beijing, 102206, China
| | - Zhi Li
- Department of gynaecology and obstetrics, Peking University International Hospital, Beijing, 102206, China
| | - Sanbao Chai
- Department of Endocrinology, Peking University International Hospital, Beijing, 102206, China
| | - Xiaomei Zhang
- Department of Endocrinology, Peking University International Hospital, Beijing, 102206, China.
| | - Linong Ji
- Department of Endocrinology, Peking University People's Hospital, Beijing, 100044, China.
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16
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Fetal HLA-G mediated immune tolerance and interferon response in preeclampsia. EBioMedicine 2020; 59:102872. [PMID: 32680723 PMCID: PMC7502669 DOI: 10.1016/j.ebiom.2020.102872] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/17/2020] [Accepted: 06/18/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Fetal immune tolerance is crucial for pregnancy success. We studied the link between preeclampsia, a severe pregnancy disorder with uncertain pathogenesis, and fetal human leukocyte antigen G (HLA-G) and other genes regulating maternal immune responses. METHODS We assessed sex ratios and regulatory HLA-G haplotypes in population cohorts and series of preeclampsia and stillbirth. We studied placental mRNA expression of 136 genes by sequencing and HLA-G and interferon alpha (IFNα) protein expression by immunohistochemistry. FINDINGS We found underrepresentation of males in preeclamptic births, especially those delivered preterm or small for gestational age. Balancing selection at HLA-G associated with the sex ratio, stillbirth, and preeclampsia. We observed downregulation of HLA-G, its receptors, and many other tolerogenic genes, and marked upregulation of IFNA1 in preeclamptic placentas. INTERPRETATION These findings indicate that an evolutionary trade-off between immune tolerance and protection against infections at the maternal-fetal interface promotes genetic diversity in fetal HLA-G, thereby affecting survival, preeclampsia, and sex ratio. We highlight IFNA1 as a potential mediator of preeclampsia and a target for therapeutic trials. FUNDING Finnish Medical Foundation, Päivikki and Sakari Sohlberg Foundation, Karolinska Institutet Research Foundation, Scandinavia-Japan Sasakawa Foundation, Japan Eye Bank Association, Astellas Foundation for Research on Metabolic Disorders, Japan Society for the Promotion of Science, Knut and Alice Wallenberg Foundation, Swedish Research Council, Medical Society Liv och Hälsa, Sigrid Jusélius Foundation, Helsinki University Hospital and University of Helsinki, Jane and Aatos Erkko Foundation, Academy of Finland, Finska Läkaresällskapet, Novo Nordisk Foundation, Finnish Foundation for Pediatric Research, and Emil Aaltonen Foundation.
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17
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Ibrahim ZM, Kishk EA, Elzamlout MS, Elshahat AM, Taha OT. Fetal gender, serum human chorionic gonadotropin, and testosterone in women with preeclampsia. Hypertens Pregnancy 2020; 39:302-307. [PMID: 32406308 DOI: 10.1080/10641955.2020.1765174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Evaluation of the association between fetal gender, serum beta-human chorionic gonadotropin, and serum testosterone, and preeclampsia. METHODS Case-control study conducted at the Obstetrics and Gynecology Department. 120 patients divided into study group (patients with preeclampsia subdivided into mild and severe) and control group (normotensive women). INTERVENTIONS Fetal gender was determined. Serum testosterone and HCG levels were estimated at 32 weeks or at the time of diagnosis of preeclampsia (study group) or recruitment (control group). RESULTS Positive association between the male gender of the fetus and preeclampsia. Increased HCG and Testosterone were associated with developing preeclampsia. CONCLUSION The mechanism of preeclampsia could be androgen-mediated. There is a significant correlation between serum HCG and testosterone and preeclampsia.
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Affiliation(s)
- Zakia M Ibrahim
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University , Ismailia, Egypt
| | - Eman A Kishk
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University , Ismailia, Egypt
| | - Mahmoud S Elzamlout
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University , Ismailia, Egypt
| | - Amal M Elshahat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University , Ismailia, Egypt
| | - Omima T Taha
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University , Ismailia, Egypt
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18
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Broere-Brown ZA, Adank MC, Benschop L, Tielemans M, Muka T, Gonçalves R, Bramer WM, Schoufour JD, Voortman T, Steegers EAP, Franco OH, Schalekamp-Timmermans S. Fetal sex and maternal pregnancy outcomes: a systematic review and meta-analysis. Biol Sex Differ 2020; 11:26. [PMID: 32393396 PMCID: PMC7216628 DOI: 10.1186/s13293-020-00299-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 04/08/2020] [Indexed: 12/15/2022] Open
Abstract
Background Since the placenta also has a sex, fetal sex–specific differences in the occurrence of placenta-mediated complications could exist. Objective To determine the association of fetal sex with multiple maternal pregnancy complications. Search strategy Six electronic databases Ovid MEDLINE, EMBASE, Cochrane Central, Web-of-Science, PubMed, and Google Scholar were systematically searched to identify eligible studies. Reference lists of the included studies and contact with experts were also used for identification of studies. Selection criteria Observational studies that assessed fetal sex and the presence of maternal pregnancy complications within singleton pregnancies. Data collection and analyses Data were extracted by 2 independent reviewers using a predesigned data collection form. Main results From 6522 original references, 74 studies were selected, including over 12,5 million women. Male fetal sex was associated with term pre-eclampsia (pooled OR 1.07 [95%CI 1.06 to 1.09]) and gestational diabetes (pooled OR 1.04 [1.02 to 1.07]). All other pregnancy complications (i.e., gestational hypertension, total pre-eclampsia, eclampsia, placental abruption, and post-partum hemorrhage) tended to be associated with male fetal sex, except for preterm pre-eclampsia, which was more associated with female fetal sex. Overall quality of the included studies was good. Between-study heterogeneity was high due to differences in study population and outcome definition. Conclusion This meta-analysis suggests that the occurrence of pregnancy complications differ according to fetal sex with a higher cardiovascular and metabolic load for the mother in the presence of a male fetus. Funding None.
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Affiliation(s)
- Zoe A Broere-Brown
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, the Netherlands.,Generation R Study Group, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Maria C Adank
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, the Netherlands.,Generation R Study Group, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Laura Benschop
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, the Netherlands.,Generation R Study Group, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Myrte Tielemans
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands.,Department Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Taulant Muka
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands.,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Romy Gonçalves
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, the Netherlands.,Generation R Study Group, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Wichor M Bramer
- Medical Library, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Josje D Schoufour
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands.,Hogeschool van Amsterdam (HvA), Amsterdam, the Netherlands
| | - Trudy Voortman
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Eric A P Steegers
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands.,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Sarah Schalekamp-Timmermans
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, the Netherlands. .,Generation R Study Group, Erasmus Medical Center, Rotterdam, the Netherlands.
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19
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Rosenfeld CS. The placenta-brain-axis. J Neurosci Res 2020; 99:271-283. [PMID: 32108381 DOI: 10.1002/jnr.24603] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/25/2020] [Accepted: 02/12/2020] [Indexed: 12/18/2022]
Abstract
All mammalian species depend on the placenta, a transient organ, for exchange of gases, nutrients, and waste between the mother and conceptus. Besides serving as a conduit for such exchanges, the placenta produces hormones and other factors that influence maternal physiology and fetal development. To meet all of these adaptations, the placenta has evolved to become the most structurally diverse organ within all mammalian taxa. However, commonalities exist as to how placental responses promote survival against in utero threats and can alter the trajectory of fetal development, in particular the brain. Increasing evidence suggests that reactions of the placenta to various in utero stressors may lead to long-standing health outcomes, otherwise considered developmental origin of health and disease effects. Besides transferring nutrients and gases, the placenta produces neurotransmitters, including serotonin, dopamine, norepinephrine/epinephrine, that may circulate and influence brain development. Neurobehavioral disorders, such as autism spectrum disorders, likely trace their origins back to placental disturbances. This intimate relationship between the placenta and brain has led to coinage of the term, the placenta-brain-axis. This axis will be the focus herein, including how conceptus sex might influence it, and technologies employed to parse out the effects of placental-specific transcript expression changes on later neurobehavioral disorders. Ultimately, the placenta might provide a historical record of in utero threats the fetus confronted and a roadmap to understand how placenta responses to such encounters impacts the placental-brain-axis. Improved early diagnostic and preventative approaches may thereby be designed to mitigate such placental disruptions.
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Affiliation(s)
- Cheryl S Rosenfeld
- Biomedical Sciences, University of Missouri, Columbia, MO, USA.,Bond Life Sciences Center, University of Missouri, Columbia, MO, USA.,MU Informatics Institute, University of Missouri, Columbia, MO, USA.,Thompson Center for Autism and Neurobehavioral Disorders, University of Missouri, Columbia, MO, USA.,Genetics Area Program, University of Missouri, Columbia, MO, USA
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20
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Voskamp BJ, Peelen MJCS, Ravelli ACJ, van der Lee R, Mol BWJ, Pajkrt E, Ganzevoort W, Kazemier BM. Association between fetal sex, birthweight percentile and adverse pregnancy outcome. Acta Obstet Gynecol Scand 2019; 99:48-58. [PMID: 31424085 PMCID: PMC6973256 DOI: 10.1111/aogs.13709] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 08/09/2019] [Indexed: 01/05/2023]
Abstract
Introduction The objective was to evaluate the association between fetal sex and adverse pregnancy outcome, while correcting for fetal growth and gestational age at delivery. Material and methods Data from the Netherlands Perinatal Registry (1999‐2010) were used. The study population comprised all white European women with a singleton delivery between 25+0 and 42+6 weeks of gestation. Fetuses with structural or chromosomal abnormalities were excluded. Outcomes were antepartum death, intrapartum/neonatal death (from onset of labor until 28 days after birth), perinatal death (antepartum death or intrapartum/neonatal death), a composite of neonatal morbidity (including infant respiratory distress syndrome, sepsis, necrotizing enterocolitis, meconium aspiration, persistent pulmonary hypertension of the newborn, periventricular leukomalacia, Apgar score <7 at 5 minutes, and intracranial hemorrhage) and a composite adverse neonatal outcome (perinatal death or neonatal morbidity). Outcomes were expressed stratified by birthweight percentile (<p10 [small for gestation], p10‐90 [normal weight], >p90 [large for gestation]) and gestational age at delivery (25+0‐27+6, 28+0‐31+6, 32+0‐36+6, 37+0‐42+6 weeks). The association between fetal sex and outcome was assessed using the fetus at risk approach. Results We studied 1 742 831 pregnant women. We found no increased risk of antepartum, intrapartum/neonatal and perinatal death in normal weight and large‐for‐gestation males born after 28+0 weeks compared with females. We found an increased risk of antepartum death among small‐for‐gestation males born after 28+0 weeks (relative risk [RR] 1.16‐1.40). All males born after 32+0 weeks of gestation suffered more neonatal morbidity than females regardless of birthweight percentile (RR 1.07‐1.34). Infant respiratory distress syndrome, sepsis, persistent pulmonary hypertension of the newborn, Apgar score <7 at 5 minutes, and intracranial hemorrhage all occurred more often in males than in females. Conclusions Small‐for‐gestation males have an increased risk of antepartum death and all males born after 32+0 weeks of gestation have an increased risk of neonatal morbidity compared with females. In contrast to findings in previous studies we found no increased risk of antepartum, intrapartum/neonatal or perinatal death in normal weight and large‐for‐gestation males born after 28+0 weeks.
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Affiliation(s)
- Bart Jan Voskamp
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Myrthe J C S Peelen
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Anita C J Ravelli
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Robin van der Lee
- Department of Pediatrics and Neonatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ben W J Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia
| | - Eva Pajkrt
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Brenda M Kazemier
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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21
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Reckelhoff JF, LaMarca B, Garovic VD, Alexander BT. Human Umbilical Venous Endothelial Cells: Early Predictors of Cardiovascular Risk in Offspring? Hypertension 2019; 74:32-34. [PMID: 31154902 DOI: 10.1161/hypertensionaha.119.12652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Jane F Reckelhoff
- From the Departments of Cell and Molecular Biology (J.F.R.), University of Mississippi Medical Center Jackson, MS.,Mississippi Center of Excellence in Perinatal Research (J.F.R., B.L., V.G., B.T.A.)
| | - Babbette LaMarca
- Pharmacology and Toxicology (B.L.), University of Mississippi Medical Center Jackson, MS.,Mississippi Center of Excellence in Perinatal Research (J.F.R., B.L., V.G., B.T.A.)
| | - Vesna D Garovic
- Mississippi Center of Excellence in Perinatal Research (J.F.R., B.L., V.G., B.T.A.).,Departments of Internal Medicine (V.G.), Mayo Clinic, Rochester, MN.,Hypertension and Nephrology (V.G.), Mayo Clinic, Rochester, MN
| | - Barbara T Alexander
- Physiology and Biophysics (B.T.A.), University of Mississippi Medical Center Jackson, MS.,Mississippi Center of Excellence in Perinatal Research (J.F.R., B.L., V.G., B.T.A.)
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22
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Preeclampsia is Associated with Sex-Specific Transcriptional and Proteomic Changes in Fetal Erythroid Cells. Int J Mol Sci 2019; 20:ijms20082038. [PMID: 31027199 PMCID: PMC6514549 DOI: 10.3390/ijms20082038] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/12/2019] [Accepted: 04/17/2019] [Indexed: 12/11/2022] Open
Abstract
Preeclampsia (PE) has been associated with placental dysfunction, resulting in fetal hypoxia, accelerated erythropoiesis, and increased erythroblast count in the umbilical cord blood (UCB). Although the detailed effects remain unknown, placental dysfunction can also cause inflammation, nutritional, and oxidative stress in the fetus that can affect erythropoiesis. Here, we compared the expression of surface adhesion molecules and the erythroid differentiation capacity of UCB hematopoietic stem/progenitor cells (HSPCs), UCB erythroid profiles along with the transcriptome and proteome of these cells between male and female fetuses from PE and normotensive pregnancies. While no significant differences were observed in UCB HSPC migration/homing and in vitro erythroid colony differentiation, the UCB HSPC transcriptome and the proteomic profile of the in vitro differentiated erythroid cells differed between PE vs. normotensive samples. Accordingly, despite the absence of significant differences in the UCB erythroid populations in male or female fetuses from PE or normotensive pregnancies, transcriptional changes were observed during erythropoiesis, particularly affecting male fetuses. Pathway analysis suggested deregulation in the mammalian target of rapamycin complex 1/AMP-activated protein kinase (mTORC1/AMPK) signaling pathways controlling cell cycle, differentiation, and protein synthesis. These results associate PE with transcriptional and proteomic changes in fetal HSPCs and erythroid cells that may underlie the higher erythroblast count in the UCB in PE.
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23
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Lumbers ER, Delforce SJ, Arthurs AL, Pringle KG. Causes and Consequences of the Dysregulated Maternal Renin-Angiotensin System in Preeclampsia. Front Endocrinol (Lausanne) 2019; 10:563. [PMID: 31551925 PMCID: PMC6746881 DOI: 10.3389/fendo.2019.00563] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 08/02/2019] [Indexed: 12/11/2022] Open
Abstract
A healthy pregnancy outcome depends on the activation of the renin-angiotensin-aldosterone system (RAAS) as a regulated, integrated response to the growing demands of the conceptus. Both the circulating RAAS and the intrarenal renin-angiotensin system (iRAS) play major roles in cardiovascular function and fluid and electrolyte homeostasis. The circulating RAAS becomes dysfunctional in preeclampsia and we propose that dysregulation of the iRAS plays a role in development of the clinical syndrome known as preeclampsia. Experimental studies in animals have shown that placental renin, when released into the maternal circulation, can cause hypertension. We postulate that abnormal placental development is associated with over-secretion of renin and other RAS proteins/angiotensin (Ang) peptides by the placenta/decidua into the maternal circulation. We hypothesise that this is because of increased shedding of exosomes and other placental particles into the maternal circulation that not only contain RAS proteins and peptides but also microRNAs (miRNAs) that target RAS mRNAs, and Ang II type 1 receptor autoantibodies (AT1R-AAs), that are agonists for, and have the same actions as, Ang II. As a result, there is both suppression of the circulating RAAS that is responsible for maintaining maternal homeostasis and activation of the iRAS. Together with altered vascular reactivity to Ang peptides, the iRAS causes hypertension, renal damage and secondary changes in the neurohumoral control of the maternal circulation and fluid and electrolyte balance, which contribute to the pathophysiology of preeclampsia.
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Affiliation(s)
- Eugenie R. Lumbers
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle upon Tyne, NSW, Australia
- Priority Research Centre for Reproductive Sciences, University of Newcastle, Newcastle upon Tyne, NSW, Australia
- Pregnancy and Reproduction Program, Hunter Medical Research Institute, Newcastle upon Tyne, NSW, Australia
- *Correspondence: Eugenie R. Lumbers
| | - Sarah J. Delforce
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle upon Tyne, NSW, Australia
- Priority Research Centre for Reproductive Sciences, University of Newcastle, Newcastle upon Tyne, NSW, Australia
- Pregnancy and Reproduction Program, Hunter Medical Research Institute, Newcastle upon Tyne, NSW, Australia
| | - Anya L. Arthurs
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, SA, Australia
| | - Kirsty G. Pringle
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle upon Tyne, NSW, Australia
- Priority Research Centre for Reproductive Sciences, University of Newcastle, Newcastle upon Tyne, NSW, Australia
- Pregnancy and Reproduction Program, Hunter Medical Research Institute, Newcastle upon Tyne, NSW, Australia
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Gong S, Sovio U, Aye IL, Gaccioli F, Dopierala J, Johnson MD, Wood AM, Cook E, Jenkins BJ, Koulman A, Casero RA, Constância M, Charnock-Jones DS, Smith GC. Placental polyamine metabolism differs by fetal sex, fetal growth restriction, and preeclampsia. JCI Insight 2018; 3:120723. [PMID: 29997303 PMCID: PMC6124516 DOI: 10.1172/jci.insight.120723] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/31/2018] [Indexed: 02/02/2023] Open
Abstract
Preeclampsia and fetal growth restriction (FGR) are major causes of the more than 5 million perinatal and infant deaths occurring globally each year, and both are associated with placental dysfunction. The risk of perinatal and infant death is greater in males, but the mechanisms are unclear. We studied data and biological samples from the Pregnancy Outcome Prediction (POP) study, a prospective cohort study that followed 4,212 women having first pregnancies from their dating ultrasound scan through delivery. We tested the hypothesis that fetal sex would be associated with altered placental function using multiomic and targeted analyses. We found that spermine synthase (SMS) escapes X-chromosome inactivation (XCI) in the placenta and is expressed at lower levels in male primary trophoblast cells, and male cells were more sensitive to polyamine depletion. The spermine metabolite N1,N12-diacetylspermine (DiAcSpm) was higher in the female placenta and in the serum of women pregnant with a female fetus. Higher maternal serum levels of DiAcSpm increased the risk of preeclampsia but decreased the risk of FGR. To our knowledge, DiAcSpm is the first maternal biomarker to demonstrate opposite associations with preeclampsia and FGR, and this is the first evidence to implicate polyamine metabolism in sex-related differences in placentally related complications of human pregnancy.
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Affiliation(s)
- Sungsam Gong
- Department of Obstetrics and Gynaecology, NIHR Cambridge Comprehensive Biomedical Research Centre
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, NIHR Cambridge Comprehensive Biomedical Research Centre,,Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience
| | - Irving L.M.H. Aye
- Department of Obstetrics and Gynaecology, NIHR Cambridge Comprehensive Biomedical Research Centre,,Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience
| | - Francesca Gaccioli
- Department of Obstetrics and Gynaecology, NIHR Cambridge Comprehensive Biomedical Research Centre,,Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience
| | - Justyna Dopierala
- Department of Obstetrics and Gynaecology, NIHR Cambridge Comprehensive Biomedical Research Centre,,Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience
| | - Michelle D. Johnson
- Department of Obstetrics and Gynaecology, NIHR Cambridge Comprehensive Biomedical Research Centre,,Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience
| | | | - Emma Cook
- Department of Obstetrics and Gynaecology, NIHR Cambridge Comprehensive Biomedical Research Centre
| | - Benjamin J. Jenkins
- NIHR BRC Core Metabolomics and Lipidomics Laboratory, University of Cambridge, Cambridge, United Kingdom
| | - Albert Koulman
- NIHR BRC Core Metabolomics and Lipidomics Laboratory, University of Cambridge, Cambridge, United Kingdom
| | - Robert A. Casero
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Miguel Constância
- Department of Obstetrics and Gynaecology, NIHR Cambridge Comprehensive Biomedical Research Centre,,Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience,,University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, United Kingdom
| | - D. Stephen Charnock-Jones
- Department of Obstetrics and Gynaecology, NIHR Cambridge Comprehensive Biomedical Research Centre,,Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience
| | - Gordon C.S. Smith
- Department of Obstetrics and Gynaecology, NIHR Cambridge Comprehensive Biomedical Research Centre,,Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience
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The impact of female fetal sex on preeclampsia and the maternal immune milieu. Pregnancy Hypertens 2018; 12:53-57. [PMID: 29674199 DOI: 10.1016/j.preghy.2018.02.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 02/20/2018] [Accepted: 02/23/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Small studies suggest that fetal sex alters maternal inflammation. We examined the association between fetal sex, preeclampsia and circulating maternal immune markers. METHODS This was a secondary data analysis within a nested case-control study of 216 preeclamptic women and 432 randomly selected normotensive controls from the Collaborative Perinatal Project. All women had singleton, primiparous pregnancies without chronic health conditions. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for associations between female fetal sex and preeclampsia. Outcomes included preeclampsia, preterm preeclampsia (<37 and <34 weeks), and normotensive preterm birth <37 weeks. Associations between female fetal sex and immune markers [interleukin (IL)-6, IL4, IL5, IL12, IL10, IL8, IL1-beta, interferon (IFN)-gamma, tumor necrosis factor (TNF)-beta, and transforming growth factor-beta] were examined using a statistical method developed for large proportions of censored biomarker data. Models were adjusted for maternal age, race, body mass index, and smoking. RESULTS Women with early preterm preeclampsia (<34 weeks) had higher odds of having a female fetus (ORadj. 3.2, 95% CI 1.1-9.6) and women with normotensive preterm birth had lower odds (ORadj. 0.5, 95% CI 0.3-0.9). Female fetal sex was associated with lower first trimester pro-inflammatory IFNγ and IL-12 but higher second trimester pro-inflammatory IL1β and TNFβ, anti-inflammatory IL4r, and regulatory cytokines IL5 and IL10. Female fetal sex was associated with higher postpartum IL10 in preeclamptic women only. CONCLUSIONS We identified sexual dimorphism in maternal inflammation. Longitudinal studies are needed to determine if fetal sex impacts the maternal immune milieu across pregnancy.
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Korzeniewski SJ, Allred EN, Joseph RM, Heeren T, Kuban KC, O’Shea TM, Leviton A. Neurodevelopment at Age 10 Years of Children Born <28 Weeks With Fetal Growth Restriction. Pediatrics 2017; 140:peds.2017-0697. [PMID: 29030525 PMCID: PMC5654396 DOI: 10.1542/peds.2017-0697] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We sought to evaluate the relationships between fetal growth restriction (FGR) (both severe and less severe) and assessments of cognitive, academic, and adaptive behavior brain function at age 10 years. METHODS At age 10 years, the Extremely Low Gestational Age Newborns Cohort Study assessed the cognitive function, academic achievement, social-communicative function, psychiatric symptoms, and overall quality of life of 889 children born before 28 weeks' gestation. A pediatric epileptologist also interviewed parents as part of a seizure evaluation. The 52 children whose birth weight z scores were <-2 were classified as having severe FGR, and the 113 whose birth weight z scores were between -2 and -1 were considered to have less severe FGR. RESULTS The more severe the growth restriction in utero, the lower the level of function on multiple cognitive and academic achievement assessments performed at age 10 years. Growth-restricted children were also more likely than their extremely preterm peers to have social awareness impairments, autistic mannerisms, autism spectrum diagnoses, difficulty with semantics and speech coherence, and diminished social and psychosocial functioning. They also more frequently had phobias, obsessions, and compulsions (according to teacher, but not parent, report). CONCLUSIONS Among children born extremely preterm, those with severe FGR appear to be at increased risk of multiple cognitive and behavioral dysfunctions at age 10 years, raising the possibility that whatever adversely affected their intrauterine growth also adversely affected multiple domains of cognitive and neurobehavioral development.
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Affiliation(s)
- Steven J. Korzeniewski
- Department of Obstetrics and Gynecology, School of Medicine, Wayne State University, Detroit, Michigan;,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan
| | - Elizabeth N. Allred
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Neurology, Harvard Medical School, Harvard University, Boston, Massachusetts
| | | | - Tim Heeren
- Department of Biostatistics, School of Public Health
| | - Karl C.K. Kuban
- Boston University, Boston, Massachusetts;,Departments of Pediatrics, Boston Medical Center, Boston, Massachusetts; and
| | - T. Michael O’Shea
- Department of Pediatrics, Wake Forest University, Winston-Salem, North Carolina
| | - Alan Leviton
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Neurology, Harvard Medical School, Harvard University, Boston, Massachusetts
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Masoumi Z, Familari M, Källén K, Ranstam J, Olofsson P, Hansson SR. Fetal hemoglobin in umbilical cord blood in preeclamptic and normotensive pregnancies: A cross-sectional comparative study. PLoS One 2017; 12:e0176697. [PMID: 28453539 PMCID: PMC5409527 DOI: 10.1371/journal.pone.0176697] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/14/2017] [Indexed: 12/14/2022] Open
Abstract
Preeclampsia (PE) is associated with increased fetal hemoglobin (HbF) in the maternal circulation but its source is unknown. To investigate whether excessive HbF is produced in the placenta or the fetus, the concentration of HbF (cHbF) in the arterial and venous umbilical cord blood (UCB) was compared in 15825 normotensive and 444 PE pregnancies. The effect of fetal gender on cHbF was also evaluated in both groups. Arterial and venous UCB sampled immediately after birth at 36-42 weeks of gestation were analyzed for total Hb concentration (ctHb) (g/L) and HbF% using a Radiometer blood gas analyzer. Non-parametric tests were used for statistical comparison and P values < 0.05 were considered significant. Our results indicated higher cHbF in venous compared to arterial UCB in both normotensive (118.90 vs 117.30) and PE (126.75 vs 120.12) groups. In PE compared to normotensive pregnancies, a significant increase was observed in arterial and venous ctHb (171.00 vs 166.00 and 168.00 vs 163.00, respectively) while cHbF was only significantly increased in venous UCB (126.75 vs 118.90). The pattern was similar in both genders. These results indicate a substantial placental contribution to HbF levels in UCB, which increases in PE and is independent of fetal gender, suggesting the elevated cHbF evident in PE results from placental dysfunction.
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Affiliation(s)
- Zahra Masoumi
- Department of Clinical Sciences Lund, Division of Obstetrics and Gynecology, Lund University, Lund, Sweden
| | - Mary Familari
- School of Biosciences, University of Melbourne, Parkville, Australia
| | - Karin Källén
- Center for Reproductive Epidemiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Jonas Ranstam
- Department of Clinical Sciences Lund, Division of Orthopedics, Faculty of Medicine, Lund University, Lund, Sweden
| | - Per Olofsson
- Department of Clinical Sciences Malmö, Division of Obstetrics and Gynecology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Stefan R. Hansson
- Department of Clinical Sciences Lund, Division of Obstetrics and Gynecology, Lund University, Lund, Sweden
- Department of Clinical Sciences Malmö, Division of Obstetrics and Gynecology, Lund University, Skåne University Hospital, Malmö, Sweden
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