1
|
Umapathy A, Clark A, Sehgal A, Karanam V, Rajaraman G, Kalionis B, Jones H, James J, Murthi P. Molecular regulators of defective placental and cardiovascular development in fetal growth restriction. Clin Sci (Lond) 2024; 138:761-775. [PMID: 38904187 PMCID: PMC11193155 DOI: 10.1042/cs20220428] [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: 12/29/2023] [Revised: 05/12/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024]
Abstract
Placental insufficiency is one of the major causes of fetal growth restriction (FGR), a significant pregnancy disorder in which the fetus fails to achieve its full growth potential in utero. As well as the acute consequences of being born too small, affected offspring are at increased risk of cardiovascular disease, diabetes and other chronic diseases in later life. The placenta and heart develop concurrently, therefore placental maldevelopment and function in FGR may have profound effect on the growth and differentiation of many organ systems, including the heart. Hence, understanding the key molecular players that are synergistically linked in the development of the placenta and heart is critical. This review highlights the key growth factors, angiogenic molecules and transcription factors that are common causes of defective placental and cardiovascular development.
Collapse
Affiliation(s)
- Anandita Umapathy
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Alys Clark
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
- Auckland Bioengineering Institute, Bioengineering Institute, New Zealand
| | - Arvind Sehgal
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia and Monash Newborn, Monash Children’s Hospital, Melbourne, VIC, Australia
| | - Vijaya Karanam
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Royal Women’s Hospital, Victoria, Australia
| | - Gayathri Rajaraman
- First year college, Victoria University, St Albans, Victoria 3021, Australia
| | - Bill Kalionis
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Royal Women’s Hospital, Victoria, Australia
- Department of Maternal Fetal Medicine, Pregnancy Research Centre, Royal Women’s Hospital, Victoria, Australia
| | - Helen N. Jones
- Department of Physiology and Aging, University of Florida College of Medicine, Gainesville, FL, U.S.A
- Center for Research in Perinatal Outcomes, University of Florida College of Medicine, Gainesville, FL, U.S.A
| | - Jo James
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
- Auckland Bioengineering Institute, Bioengineering Institute, New Zealand
| | - Padma Murthi
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Royal Women’s Hospital, Victoria, Australia
- Department of Maternal Fetal Medicine, Pregnancy Research Centre, Royal Women’s Hospital, Victoria, Australia
- Department of Pharmacology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
2
|
DeVore GR, Polanco B, Lee W, Fowlkes JB, Peek EE, Putra M, Hobbins JC. Maternal rest improves growth in small-for-gestational-age fetuses (<10th percentile). Am J Obstet Gynecol 2024:S0002-9378(24)00530-1. [PMID: 38842845 DOI: 10.1016/j.ajog.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/20/2024] [Accepted: 04/22/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Optimal management of fetuses diagnosed as small for gestational age based on an estimated fetal weight of <10th percentile represents a major clinical problem. The standard approach is to increase fetal surveillance with serial biometry and antepartum testing to assess fetal well-being and timing of delivery. Observational studies have indicated that maternal rest in the left lateral position improves maternal cardiac output and uterine blood flow. However, maternal bed rest has not been recommended based on the results of a randomized clinical trial that showed that maternal rest does not improve fetal growth in small-for-gestational-age fetuses. This study was conducted to revisit this question. OBJECTIVE This study aimed to determine whether maternal bed rest was associated with an increase in the fetal biometric parameters that reflect growth after the diagnosis of a small-for-gestational-age fetus. STUDY DESIGN A retrospective study was conducted on fetuses who were diagnosed as small for gestational age because of an estimated fetal weight of <10th percentile for gestational age. The mothers were asked to rest in the left lateral recumbent position. Fetal biometry was performed 2 weeks after the diagnosis. All fetuses before entry into the study had a previous ultrasound that demonstrated an estimated fetal weight of >10th percentile. To assess the response to bed rest, the change in fetal biometric parameters (estimated fetal weight, head circumference, abdominal circumference, and femur length) after the recommendation of bed rest was computed for 2 periods: (1) before the diagnosis of a weight of <10th percentile vs at the time of diagnosis of a weight of <10th percentile and (2) at the time of diagnosis of a weight of <10th percentile vs 2 weeks after maternal bed rest. For repeated measures, proportions were compared using the McNemar test, and percentile values were compared using the Kruskal-Wallis test. A P value of <.05 was considered significant. To describe changes in the estimated fetal weight without bed rest, 2 control groups in which the mothers were not placed on bed rest after the diagnosis of a small-for-gestational-age fetus were included. RESULTS A total of 265 fetuses were observed before and after maternal bed rest. The following were observed in this study: (1) after 2 weeks of maternal rest, 199 of 265 fetuses (75%) had a fetal weight of >10th percentile; (2) the median fetal weight percentile increased from 6.8 (interquartile range, 4.4-8.4) to 18.0 (interquartile range, 9.5-29.5) after 2 weeks of bed rest; (3) similar trends were noted for the head circumference, abdominal circumference, and femur length. In the groups of patients who were not asked to be on bed rest, a reassignment to a weight of >10th percentile at a follow-up examination only occurred in 7 of 37 patients (19%) in the Texas-Michigan group and 13 of 111 patients (12%) in the Colorado group compared with the bed rest group (199/265 [75%]) (P<.001). CONCLUSION Patients who were prescribed 2 weeks of bed rest after the diagnosis of a fetal weight of <10th percentile had an increase in weight of >10th percentile in 199 of 265 fetuses (75%). This increase in fetal weight was significantly higher than that in the 2 control groups in which bed rest was not prescribed. This observation suggests that bed rest improves fetal growth in a subset of patients.
Collapse
Affiliation(s)
- Greggory R DeVore
- Fetal Diagnostic Centers, Pasadena, Tarzana, and Lancaster, CA; Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI.
| | - Bardo Polanco
- Fetal Diagnostic Centers, Pasadena, Tarzana, and Lancaster, CA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Jeffrey Brian Fowlkes
- Departments of Radiology and Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Emma E Peek
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
| | - Manesha Putra
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
| | - John C Hobbins
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
| |
Collapse
|
3
|
Dixit S, Dixit NA, Rawat A, Bajpai A, Alelyani M, Sabah ZU, Raghuwanshi S. Color Doppler ultrasound in high-low risk pregnancies and its relationship to fetal outcomes: a cross-sectional study. Front Pediatr 2024; 11:1221766. [PMID: 38444769 PMCID: PMC10912586 DOI: 10.3389/fped.2023.1221766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 12/26/2023] [Indexed: 03/07/2024] Open
Abstract
Objective To calculate the multivessel color Doppler indices in high-risk and low-risk pregnancies and relate these to fetal outcomes. Methods The investigation involved 60 patients who were pregnant. The patients were separated into groups according to assessment of low and high risk. The patients underwent color Doppler ultrasonography to detect the maternal and fetal blood vessels, and the measured Doppler indices were then analyzed for any association with fetal outcomes. Results The gestational stages (in weeks) of the participants at the respective times of investigation and delivery were 32.06 ± 2.98 and 36.2 ± 1.78 in the low-risk group and 29.21 ± 1.95 and 29.83 ± 1.86 in the high-risk group. The pulsatility index (PI), resistive index (RI), and systolic/diastolic ratio (SD) decreased with gestation length in the low-risk group, whereas in the high-risk group, these values increased in the uterine and umbilical arteries. With increased gestational stage, MCA-PSV (peak systolic velocity) in the middle cerebral artery (MCA) increased, while PI decreased. Pulsatile and reversal flow of the uterine vein, the vein of Galen, and the umbilical vein were noted in high-risk pregnancies, and these negatively affected the fetal outcome. The fetal venous parameters were more specific and sensitive for predicting an unfavorable fetal outcome than the arterial factors, with a greater negative predictive value. Conclusion The results of our study indicate that abnormal Doppler indices of the blood vessels in high-risk pregnant patients will result in adverse clinical outcomes. Therefore, the patients can be monitored and managed accordingly using Doppler ultrasonography.
Collapse
Affiliation(s)
- Snehil Dixit
- Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
| | - Nitin Arun Dixit
- Department of Radiodiagnosis, King George Medical University, Lucknow, India
| | - Anil Rawat
- Department of Radiodiagnosis, King George Medical University, Lucknow, India
| | - Akanksha Bajpai
- Department of Radiodiagnosis, Career Institute of Medical Sciences, Lucknow, India
| | - Magbool Alelyani
- Department of Radiological Sciences, College of Applied Medical Science, King Khalid University, Abha, Saudi Arabia
| | - Zia Ul Sabah
- Department of Medicine, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | | |
Collapse
|
4
|
Prins LI, van de Meent M, Kooiman J, Pels A, Gordijn SJ, Lely T, Ganzevoort W. Practice variation in timing of antenatal corticosteroid administration in early-onset fetal growth restriction: A secondary analysis of the Dutch STRIDER study. Acta Obstet Gynecol Scand 2024; 103:77-84. [PMID: 37904620 PMCID: PMC10755118 DOI: 10.1111/aogs.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/21/2023] [Accepted: 09/12/2023] [Indexed: 11/01/2023]
Abstract
INTRODUCTION In early-onset fetal growth restriction the fetus fails to thrive in utero due to unmet fetal metabolic demands. This condition is linked to perinatal mortality and severe neonatal morbidity. Maternal administration of corticosteroids in high-risk pregnancies for preterm birth at a gestational age between 24 and 34 weeks has been shown to reduce perinatal mortality and morbidity. Practice variation exists in the timing of the administration of corticosteroids based on umbilical artery monitoring findings in early-onset fetal growth restriction. The aim of this study was to examine differences in neonatal outcomes when comparing different corticosteroid timing strategies. MATERIAL AND METHODS This was a post-hoc analysis of the Dutch STRIDER trial. We examined neonatal outcomes when comparing institutional strategies of early (umbilical artery pulsatility index >95th centile) and late (umbilical artery shows absent or reversed end-diastolic flow) administration of corticosteroids. The primary outcomes were neonatal mortality and a composite of neonatal mortality and neonatal morbidity, defined as bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis or retinopathy of prematurity. We also analyzed predictors for adverse neonatal outcomes, including gestational age at delivery, birthweight, maternal hypertensive disorders, and time interval between corticosteroids and birth. RESULTS A total of 120 patients matched our inclusion criteria. In 69 (57.5%) the early strategy was applied and in 51 (42.5%) patients the late strategy. Median gestational age at delivery was 28 4/7 (± 3, 3/7) weeks. Median birthweight was 708 (± 304) g. Composite primary outcome was found in 57 (47.5%) neonates. No significant differences were observed in the primary outcome between the two strategies (neonatal mortality adjusted odds ratio [OR] 1.22, 95% CI 0.44-3.38; composite primary outcome adjusted OR 1.05, 95% CI 0.42-2.64). Only gestational age at delivery was a significant predictor for improved neonatal outcome (adjusted OR 0.91, 95% CI 0.86-0.96). CONCLUSIONS No significant differences in neonatal outcomes were observed when comparing early and late strategy of antenatal corticosteroid administration on neonatal outcomes in pregnancies complicated by early-onset fetal growth restriction. We found no apparent risk contribution of interval between corticosteroid administration and delivery in multivariate analysis. Gestational age at delivery was found to be an important predictor of neonatal outcome.
Collapse
Affiliation(s)
- Leah I. Prins
- Department of Obstetrics and GynecologyAmsterdam University Medical Centers, University of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development Research InstituteAmsterdamThe Netherlands
| | - Mette van de Meent
- Department of Obstetrics and GynecologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Judith Kooiman
- Department of Obstetrics and GynecologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Anouk Pels
- Department of Obstetrics and GynecologyAmsterdam University Medical Centers, University of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development Research InstituteAmsterdamThe Netherlands
| | - Sanne J. Gordijn
- Department of Obstetrics and GynecologyUniversity Medical Center GroningenGroningenThe Netherlands
| | - Titia Lely
- Department of Obstetrics and GynecologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and GynecologyAmsterdam University Medical Centers, University of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development Research InstituteAmsterdamThe Netherlands
| |
Collapse
|
5
|
Lu J, Li H, Zheng X, Liu Y, Zhao P. Small RNA sequencing analysis of exosomes derived from umbilical plasma in IUGR lambs. Commun Biol 2023; 6:943. [PMID: 37714996 PMCID: PMC10504244 DOI: 10.1038/s42003-023-05276-1] [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: 04/15/2023] [Accepted: 08/23/2023] [Indexed: 09/17/2023] Open
Abstract
During the summer, pregnant ewes experience heat stress, leading to the occurrence of IUGR lambs. This study aims to explore the biomarkers of exosomal miRNAs derived from umbilical plasma in both IUGR and normal Hu lambs. We establish a heat-stressed Hu sheep model during mid-late gestation and selected IUGR and normal lambs for analysis. Exosomes from umbilical plasma were separated and small RNA sequencing is used to identify differentially expressed miRNAs. Next, we utilize MiRanda to predict the target genes of the differentially expressed miRNAs. To further understand the biological significance of these miRNAs, we conduct GO and KEGG pathway enrichment analysis for their target genes. The study's findings indicate that oar-miR-411a-5p is significantly downregulated in exosomes derived from umbilical plasma of IUGR lambs, while oar-miR-200c is significantly upregulated in the HS-IUGR group (P < 0.05). Furthermore, GO and KEGG enrichment analysis demonstrate that the target genes are involved in the Wnt, TGF-beta, and Rap1 signaling pathways. miRNAs found in exosomes have the potential to be utilized as biomarkers for both the diagnosis and treatment of IUGR fetuses.
Collapse
Affiliation(s)
- Jiawei Lu
- College of Animal Science and Technology, Nanjing Agricultural University, 210095, Nanjing, China
| | - Huixia Li
- College of Animal Science and Technology, Nanjing Agricultural University, 210095, Nanjing, China.
| | - Xiaomin Zheng
- Research Institute for Reproductive Medicine and Genetic Diseases, Wuxi Maternity and Child Health Hospital, Wuxi, 214002, Jiangsu, China.
| | - Yuan Liu
- College of Animal Science and Technology, Nanjing Agricultural University, 210095, Nanjing, China
| | - Peng Zhao
- College of Animal Science and Technology, Nanjing Agricultural University, 210095, Nanjing, China
| |
Collapse
|
6
|
Jonker D, Melly B, Brink LT, Odendaal HJ, Stein DJ, Donald KA. Associations between prenatal alcohol and tobacco exposure on Doppler flow velocity waveforms in pregnancy: a South African study. BMC Pregnancy Childbirth 2023; 23:601. [PMID: 37612623 PMCID: PMC10464169 DOI: 10.1186/s12884-023-05881-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 07/27/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND The negative impact of prenatal alcohol and tobacco exposure (PAE and PTE) on fetal development and birth outcomes are well described, yet pathophysiologic mechanisms are less clear. Our aim was to investigate (1) the associations between quantity, frequency and timing (QFT) of PAE and PTE with blood flow velocities in arteries of the fetal-placental-maternal circulation and (2) the extent to which combined effect of QFT of PAE and/or PTE and Doppler flow velocity waveforms (FWV) predict infant birth weight. METHODS The Safe Passage Study is a cohort based in urban Cape Town, South Africa. Recruitment occurred between 2007 and 2015. Information on QFT of PAE and PTE was collected prospectively at up to 4 occasions during pregnancy using a modified Timeline Follow-Back approach. Ultrasound examinations consisted of Doppler flow velocity waveforms of the uterine, umbilical (UA) and fetal middle cerebral arteries for the pulsatility index (PI) at 20-24 and 34-38 weeks. Exclusion criteria included: twin pregnancies, stillbirths, participants exposed to other drugs. The sample was divided into three groups (controls, PAE and PTE) and included 1396 maternal-fetal-dyads assessed during the second trimester; 1398 assessed during the third trimester. RESULTS PTE was associated with higher UA PI values in second and third trimesters (p < 0.001), compared to the PAE and control group. The total amount of cigarettes smoked during pregnancy was positively correlated with UA PI values (r = 0.087, p < 0.001). There was a positive correlation between cigarettes smoked per day in trimester one (r = 0.091, p < 0.01), and trimester two (r = 0.075, p < 0.01) and UA PI (in trimester two), as well as cigarettes smoked per day in trimester two (r = 0.058, p < 0.05) and trimester three (r = 0.069, p < 0.05) and the UA PI in trimester three. Generalized additive models indicated that PAE in trimester two, PTE in trimester one and Doppler FWV in trimester three were significant predictors of birth weight in this sample. CONCLUSION In our study, PTE in trimesters two and three resulted in increased vascular resistance of the placenta. These findings highlight nuance in associations between PAE, PTE and blood flow velocities in arteries of the fetal-placental-maternal circulation and birth weight, suggesting that quantity and timing are important factors in these relationships.
Collapse
Affiliation(s)
- Deborah Jonker
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
| | - Brigitte Melly
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Lucy T Brink
- Department of Obstetrics and Gynaecology, Stellenbosch University, Parow, South Africa
| | - Hein J Odendaal
- Department of Obstetrics and Gynaecology, Stellenbosch University, Parow, South Africa
| | - Dan J Stein
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- Unit on Risk and Resilience in Mental Disorders, South African Medical Research Council (SAMRC), Cape Town, South Africa
| | - Kirsten A Donald
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
7
|
Hoffman MK, Clifton RG, Biggio JR, Saade GR, Ugwu LG, Longo M, Bousleiman SZ, Clark K, Grobman WA, Frey HA, Chauhan SP, Dugoff L, Manuck TA, Chien EK, Rouse DJ, Simhan HN, Esplin MS, Macones GA. Cervical Pessary for Prevention of Preterm Birth in Individuals With a Short Cervix: The TOPS Randomized Clinical Trial. JAMA 2023; 330:340-348. [PMID: 37490086 PMCID: PMC10369212 DOI: 10.1001/jama.2023.10812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/01/2023] [Indexed: 07/26/2023]
Abstract
Importance A short cervix as assessed by transvaginal ultrasound is an established risk factor for preterm birth. Study findings for a cervical pessary to prevent preterm delivery in singleton pregnancies with transvaginal ultrasound evidence of a short cervix have been conflicting. Objective To determine if cervical pessary placement decreases the risk of preterm birth or fetal death prior to 37 weeks among individuals with a short cervix. Design, Setting, and Participants We performed a multicenter, randomized, unmasked trial comparing a cervical pessary vs usual care from February 2017 through November 5, 2021, at 12 centers in the US. Study participants were nonlaboring individuals with a singleton pregnancy and a transvaginal ultrasound cervical length of 20 mm or less at gestations of 16 weeks 0 days through 23 weeks 6 days. Individuals with a prior spontaneous preterm birth were excluded. Interventions Participants were randomized 1:1 to receive either a cervical pessary placed by a trained clinician (n = 280) or usual care (n = 264). Use of vaginal progesterone was at the discretion of treating clinicians. Main Outcome and Measures The primary outcome was delivery or fetal death prior to 37 weeks. Results A total of 544 participants (64%) of a planned sample size of 850 were enrolled in the study (mean age, 29.5 years [SD, 6 years]). Following the third interim analysis, study recruitment was stopped due to concern for fetal or neonatal/infant death as well as for futility. Baseline characteristics were balanced between participants randomized to pessary and those randomized to usual care; 98.9% received vaginal progesterone. In an as-randomized analysis, the primary outcome occurred in 127 participants (45.5%) randomized to pessary and 127 (45.6%) randomized to usual care (relative risk, 1.00; 95% CI, 0.83-1.20). Fetal or neonatal/infant death occurred in 13.3% of those randomized to receive a pessary and in 6.8% of those randomized to receive usual care (relative risk, 1.94; 95% CI, 1.13-3.32). Conclusions and Relevance Cervical pessary in nonlaboring individuals with a singleton gestation and with a cervical length of 20 mm or less did not decrease the risk of preterm birth and was associated with a higher rate of fetal or neonatal/infant mortality. Trial Registration ClinicalTrials.gov Identifier: NCT02901626.
Collapse
Affiliation(s)
- Matthew K. Hoffman
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | | | | | | | - Lynda G. Ugwu
- George Washington University Biostatistics Center, Washington, DC
| | - Monica Longo
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Sabine Z. Bousleiman
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Kelly Clark
- University of North Carolina at Chapel Hill, Chapel Hill
| | | | | | - Suneet P. Chauhan
- University of Texas Health Science at Houston–Children’s Memorial Hermann Hospital, Houston
| | | | | | - Edward K. Chien
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | | | | | - M. Sean Esplin
- University of Utah Health Sciences Center, Salt Lake City
| | | |
Collapse
|
8
|
Baadsgaard K, Hansen DN, Peters DA, Frøkjær JB, Sinding M, Sørensen A. T2* weighted fetal MRI and the correlation with placental dysfunction. Placenta 2023; 131:90-97. [PMID: 36565490 DOI: 10.1016/j.placenta.2022.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/29/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Transverse relaxation time (T2*) is related to tissue oxygenation and morphology. We aimed to describe T2* weighted MRI in selected fetal organs in normal pregnancies, and to investigate the correlation between fetal organ T2* and placental T2*, birthweight (BW) deviation, and redistribution of fetal blood flow. METHODS T2*-weighted MRI was performed in 126 singleton pregnancies between 23+6- and 41+3-weeks' gestation. The T2* value was obtained from the placenta and fetal organs (brain, lungs, heart, liver, kidneys, and spleen). In normal BW pregnancies (BW > 10th centile), the correlation between the T2* value and gestational age (GA) at MRI was estimated by linear regression. The correlation between fetal organ Z-score and BW group was demonstrated by boxplots and investigated by analysis of variance (ANOVA) for each organ. RESULTS In normal BW pregnancies fetal organ T2* was negatively correlated with GA. We found a significant correlation between BW group and fetal organ T2* z-score in the fetal heart, kidney, lung and spleen. A positive linear correlation was demonstrated between fetal organ T2* and outcomes related to placental function such as BW deviation and placenta T2* in all investigated fetal organs except for the fetal liver. In the fetal heart, kidneys, and spleen the T2* value showed a significant correlation with fetal redistribution of blood flow (Middle cerebral artery Pulsatility Index) before delivery. DISCUSSION Fetal T2* is correlated with BW, placental function, and redistribution of fetal blood flow, suggesting that fetal organ T2* reflects fetal oxygenation and morphological changes related to placental dysfunction.
Collapse
Affiliation(s)
- Kirstine Baadsgaard
- Department of Clinical Medicine Aalborg University, Søndre Skovvej 15, 9000, Aalborg, Denmark; Department of Obstetrics and Gynecology, Aalborg University Hospital, Reberbansgade 15, 9000, Aalborg, Denmark.
| | - Ditte N Hansen
- Department of Clinical Medicine Aalborg University, Søndre Skovvej 15, 9000, Aalborg, Denmark; Department of Obstetrics and Gynecology, Aalborg University Hospital, Reberbansgade 15, 9000, Aalborg, Denmark
| | - David A Peters
- Department of Clinical Engineering, Central Denmark Region, Universitetsbyen 25, 8000, Aarhus C, Denmark
| | - Jens B Frøkjær
- Department of Clinical Medicine Aalborg University, Søndre Skovvej 15, 9000, Aalborg, Denmark; Department of Radiology, Aalborg University Hospital, Reberbansgade 15, 9000, Aalborg, Denmark
| | - Marianne Sinding
- Department of Clinical Medicine Aalborg University, Søndre Skovvej 15, 9000, Aalborg, Denmark; Department of Obstetrics and Gynecology, Aalborg University Hospital, Reberbansgade 15, 9000, Aalborg, Denmark
| | - Anne Sørensen
- Department of Clinical Medicine Aalborg University, Søndre Skovvej 15, 9000, Aalborg, Denmark; Department of Obstetrics and Gynecology, Aalborg University Hospital, Reberbansgade 15, 9000, Aalborg, Denmark
| |
Collapse
|
9
|
Liu J, Sun W, Liu C, Na Q. Umbilical Cord Blood-Derived Exosomes in Maternal-Fetal Disease: a Review. Reprod Sci 2023; 30:54-61. [PMID: 35157260 DOI: 10.1007/s43032-022-00879-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
The nutrients and other factors transported by umbilical cord blood, which is vital for fetal survival, play crucial roles in fetal development. There are various communication modes between the fetal-placental system and the maternal-placental system, and these communication modes are all mediated by umbilical cord blood. During the process of umbilical cord blood transportation, the changes of some nutrients and factors may play a key role in fetal development. Exosomes, which are members of the extracellular vesicle family, are present in the umbilical cord blood and play roles in information transmission as a result of their efficient cellular communication activity. The study of umbilical cord blood-derived exosomes provides a new approach for research on the etiology of maternal-fetal diseases and they may be useful for the development of intrauterine treatments. This review summarizes specific functions and research directions regarding umbilical cord blood-derived exosomes, and their potential associations with pregnancy complications.
Collapse
Affiliation(s)
- Jingyi Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Wei Sun
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Caixia Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Quan Na
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.
| |
Collapse
|
10
|
Zabel RR, Favaro RR, Groten T, Brownbill P, Jones S. Ex vivo perfusion of the human placenta to investigate pregnancy pathologies. Placenta 2022; 130:1-8. [DOI: 10.1016/j.placenta.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/26/2022] [Accepted: 10/08/2022] [Indexed: 11/07/2022]
|
11
|
Voggel J, Fink G, Zelck M, Wohlfarth M, Post JM, Bindila L, Rauh M, Amann K, Alejandre Alcázar MA, Dötsch J, Nüsken KD, Nüsken E. Elevated n-3/n-6 PUFA ratio in early life diet reverses adverse intrauterine kidney programming in female rats. J Lipid Res 2022; 63:100283. [PMID: 36152882 PMCID: PMC9619183 DOI: 10.1016/j.jlr.2022.100283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/30/2022] [Accepted: 09/11/2022] [Indexed: 11/27/2022] Open
Abstract
Intrauterine growth restriction (IUGR) predisposes to chronic kidney disease via activation of proinflammatory pathways, and omega-3 PUFAs (n-3 PUFAs) have anti-inflammatory properties. In female rats, we investigated 1) how an elevated dietary n-3/n-6 PUFA ratio (1:1) during postnatal kidney development modifies kidney phospholipid (PL) and arachidonic acid (AA) metabolite content and 2) whether the diet counteracts adverse molecular protein signatures expected in IUGR kidneys. IUGR was induced by bilateral uterine vessel ligation or intrauterine stress through sham operation 3.5 days before term. Control (C) offspring were born after uncompromised pregnancy. On postnatal (P) days P2–P39, rats were fed control (n-3/n-6 PUFA ratio 1:20) or n-3 PUFA intervention diet (N3PUFA; ratio 1:1). Plasma parameters (P33), kidney cortex lipidomics and proteomics, as well as histology (P39) were studied. We found that the intervention diet tripled PL-DHA content (PC 40:6; P < 0.01) and lowered both PL-AA content (PC 38:4 and lyso-phosphatidylcholine 20:4; P < 0.05) and AA metabolites (HETEs, dihydroxyeicosatrienoic acids, and epoxyeicosatrienoic acids) to 25% in all offspring groups. After ligation, our network analysis of differentially expressed proteins identified an adverse molecular signature indicating inflammation and hypercoagulability. N3PUFA diet reversed 61 protein alterations (P < 0.05), thus mitigating adverse IUGR signatures. In conclusion, an elevated n-3/n-6 PUFA ratio in early diet strongly reduces proinflammatory PLs and mediators while increasing DHA-containing PLs regardless of prior intrauterine conditions. Counteracting a proinflammatory hypercoagulable protein signature in young adult IUGR individuals through early diet intervention may be a feasible strategy to prevent developmentally programmed kidney damage in later life.
Collapse
Affiliation(s)
- Jenny Voggel
- Clinic and Polyclinic for Pediatric and Adolescent Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Gregor Fink
- Clinic and Polyclinic for Pediatric and Adolescent Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Magdalena Zelck
- Clinic and Polyclinic for Pediatric and Adolescent Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Maria Wohlfarth
- Clinic and Polyclinic for Pediatric and Adolescent Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Julia M Post
- Clinical Lipidomics Unit, Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Laura Bindila
- Clinical Lipidomics Unit, Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Manfred Rauh
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Kerstin Amann
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen, Erlangen, Germany
| | - Miguel A Alejandre Alcázar
- Clinic and Polyclinic for Pediatric and Adolescent Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany; Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany; Institute for Lung Health, University of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Gießen, Germany
| | - Jörg Dötsch
- Clinic and Polyclinic for Pediatric and Adolescent Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Kai-Dietrich Nüsken
- Clinic and Polyclinic for Pediatric and Adolescent Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Eva Nüsken
- Clinic and Polyclinic for Pediatric and Adolescent Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany.
| |
Collapse
|
12
|
Voggel J, Mohr J, Nüsken KD, Dötsch J, Nüsken E, Alejandre Alcazar MA. Translational insights into mechanisms and preventive strategies after renal injury in neonates. Semin Fetal Neonatal Med 2022; 27:101245. [PMID: 33994314 DOI: 10.1016/j.siny.2021.101245] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Adverse perinatal circumstances can cause acute kidney injury (AKI) and contribute to chronic kidney disease (CKD). Accumulating evidence indicate that a wide spectrum of perinatal conditions interferes with normal kidney development and ultimately leads to aberrant kidney structure and function later in life. The present review addresses the lack of mechanistic knowledge with regard to perinatal origins of CKD and provides a comprehensive overview of pre- and peri-natal insults, including genetic predisposition, suboptimal nutritional supply, obesity and maternal metabolic disorders as well as placental insufficiency leading to intrauterine growth restriction (IUGR), prematurity, infections, inflammatory processes, and the need for life-saving treatments (e.g. oxygen supplementation, mechanical ventilation, medications) in neonates. Finally, we discuss future preventive, therapeutic, and regenerative directions. In summary, this review highlights the perinatal vulnerability of the kidney and the early origins of increased susceptibility toward AKI and CKD during postnatal life. Promotion of kidney health and prevention of disease require the understanding of perinatal injury in order to optimize perinatal micro- and macro-environments and enable normal kidney development.
Collapse
Affiliation(s)
- Jenny Voggel
- University of Cologne, Faculty of Medicine, University Hospital Cologne, Department of Pediatric and Adolescent Medicine, Germany; University of Cologne, Faculty of Medicine, University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Germany
| | - Jasmine Mohr
- University of Cologne, Faculty of Medicine, University Hospital Cologne, Translational Experimental Pediatrics - Experimental Pulmonology, Department of Pediatric and Adolescent Medicine, Germany; University of Cologne, Faculty of Medicine, University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Germany
| | - Kai-Dietrich Nüsken
- University of Cologne, Faculty of Medicine, University Hospital Cologne, Department of Pediatric and Adolescent Medicine, Germany
| | - Jörg Dötsch
- University of Cologne, Faculty of Medicine, University Hospital Cologne, Department of Pediatric and Adolescent Medicine, Germany
| | - Eva Nüsken
- University of Cologne, Faculty of Medicine, University Hospital Cologne, Department of Pediatric and Adolescent Medicine, Germany
| | - Miguel A Alejandre Alcazar
- University of Cologne, Faculty of Medicine, University Hospital Cologne, Translational Experimental Pediatrics - Experimental Pulmonology, Department of Pediatric and Adolescent Medicine, Germany; University of Cologne, Faculty of Medicine, University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Germany; Excellence Cluster on Stress Responses in Aging-associated Diseases (CECAD), University of Cologne, Faculty of Medicine, University Hospital Cologne Cologne, Germany; Institute for Lung Health, University of Giessen and Marburg Lung Centre (UGMLC), Member of the German Centre for Lung Research (DZL), Gießen, Germany.
| |
Collapse
|
13
|
Yuliana ME, Huang ZH, Chou HC, Chen CM. Effects of uteroplacental insufficiency on growth-restricted rats with altered lung development: A metabolomic analysis. Front Pediatr 2022; 10:952313. [PMID: 36160795 PMCID: PMC9492919 DOI: 10.3389/fped.2022.952313] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Intrauterine growth restriction (IUGR) is among the most challenging problems in antenatal care. Several factors implicated in the pathophysiology of IUGR have been identified. We aimed to investigate the effect of UPI on lung development by identifying metabolic changes during the first seven days of postnatal life. MATERIALS AND METHODS On gestation day 17, four time-dated pregnant Sprague Dawley rats were randomized to a IUGR group or a control group, which underwent an IUGR protocol comprising bilateral uterine vessel ligation and sham surgery, respectively. On gestation day 22, 39 control and 26 IUGR pups were naturally delivered. The rat pups were randomly selected from the control and IUGR group on postnatal day 7. The pups' lungs were excised for histological, Western blot, and metabolomic analyses. Liquid chromatography mass spectrometry was performed for metabolomic analyses. RESULTS UPI induced IUGR, as evidenced by the IUGR rat pups having a significantly lower average body weight than the control rat pups on postnatal day 7. The control rats exhibited healthy endothelial cell healthy and vascular development, and the IUGR rats had a significantly lower average radial alveolar count than the control rats. The mean birth weight of the 26 IUGR rats (5.89 ± 0.74 g) was significantly lower than that of the 39 control rats (6.36 ± 0.55 g; p < 0.01). UPI decreased the levels of platelet-derived growth factor-A (PDGF-A) and PDGF-B in the IUGR newborn rats. One-way analysis of variance revealed 345 features in the pathway, 14 of which were significant. Regarding major differential metabolites, 10 of the 65 metabolites examined differed significantly between the groups (p < 0.05). Metabolite pathway enrichment analysis revealed significant between-group differences in the metabolism of glutathione, arginine-proline, thiamine, taurine-hypotaurine, pantothenate, alanine-aspartate-glutamate, cysteine-methionine, glycine-serine-threonine, glycerophospholipid, and purine as well as in the biosynthesis of aminoacyl-tRNA, pantothenate, and CoA. CONCLUSIONS UPI alters lung development and metabolomics in growth-restricted newborn rats. Our findings may elucidate new metabolic mechanisms underlying IUGR-induced altered lung development and serve as a reference for the development of prevention and treatment strategies for IUGR-induced altered lung development.
Collapse
Affiliation(s)
- Merryl Esther Yuliana
- International PhD Program in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Faculty of Medicine, Christian University of Indonesia, Jakarta, Indonesia
| | - Zheng-Hao Huang
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Chu Chou
- Department of Anatomy and Cell Biology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chung-Ming Chen
- International PhD Program in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Pediatrics, Taipei Medical University Hospital, Taipei, Taiwan
| |
Collapse
|
14
|
Korkalainen N, Ilvesmäki T, Parkkola R, Perhomaa M, Mäkikallio K. Brain volumes and white matter microstructure in 8- to 10-year-old children born with fetal growth restriction. Pediatr Radiol 2022; 52:2388-2400. [PMID: 35460034 PMCID: PMC9616762 DOI: 10.1007/s00247-022-05372-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 03/05/2022] [Accepted: 03/29/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Fetal growth restriction caused by placental insufficiency is associated with increased risk of poor neurodevelopment, even in the absence of specific perinatal brain injury. Placental insufficiency leads to chronic hypoxaemia that may alter cerebral tissue organisation and maturation. OBJECTIVE The aim of this study was to assess the effects fetal growth restriction and fetal haemodynamic abnormalities have on brain volumes and white matter microstructure at early school age. MATERIALS AND METHODS This study examined 32 children born with fetal growth restriction at 24 to 40 gestational weeks, and 27 gestational age-matched children, who were appropriate for gestational age. All children underwent magnetic resonance imaging (MRI) at the age of 8-10 years. Cerebral volumes were analysed, and tract-based spatial statistics and atlas-based analysis of white matter were performed on 17 children born with fetal growth restriction and 14 children with birth weight appropriate for gestational age. RESULTS Children born with fetal growth restriction demonstrated smaller total intracranial volumes compared to children with normal fetal growth, whereas no significant differences in grey or white matter volumes were detected. On atlas-based analysis of white matter, children born with fetal growth restriction demonstrated higher mean and radial diffusivity values in large white matter tracts when compared to children with normal fetal growth. CONCLUSION Children ages 8-10 years old born with fetal growth restriction demonstrated significant changes in white matter microstructure compared to children who were appropriate for gestational age, even though no differences in grey and white matter volumes were detected. Poor fetal growth may impact white matter maturation and lead to neurodevelopmental impairment later in life.
Collapse
Affiliation(s)
- Noora Korkalainen
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Oulu University Hospital, Aapistie 5 A, 5000, FI-90014, Oulu, PL, Finland. .,University of Oulu, Oulu, Finland.
| | - Tero Ilvesmäki
- Department of Radiology, Turku University Hospital, Turku, Finland ,Department of Radiology, University of Turku, Turku, Finland
| | - Riitta Parkkola
- Department of Radiology, Turku University Hospital, Turku, Finland ,Department of Radiology, University of Turku, Turku, Finland
| | - Marja Perhomaa
- Department of Radiology, Oulu University Hospital, Oulu, Finland
| | - Kaarin Mäkikallio
- Department of Radiology, University of Turku, Turku, Finland ,Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland
| |
Collapse
|
15
|
Oke SL, Hardy DB. The Role of Cellular Stress in Intrauterine Growth Restriction and Postnatal Dysmetabolism. Int J Mol Sci 2021; 22:6986. [PMID: 34209700 PMCID: PMC8268884 DOI: 10.3390/ijms22136986] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/24/2021] [Accepted: 06/24/2021] [Indexed: 12/18/2022] Open
Abstract
Disruption of the in utero environment can have dire consequences on fetal growth and development. Intrauterine growth restriction (IUGR) is a pathological condition by which the fetus deviates from its expected growth trajectory, resulting in low birth weight and impaired organ function. The developmental origins of health and disease (DOHaD) postulates that IUGR has lifelong consequences on offspring well-being, as human studies have established an inverse relationship between birth weight and long-term metabolic health. While these trends are apparent in epidemiological data, animal studies have been essential in defining the molecular mechanisms that contribute to this relationship. One such mechanism is cellular stress, a prominent underlying cause of the metabolic syndrome. As such, this review considers the role of oxidative stress, mitochondrial dysfunction, endoplasmic reticulum (ER) stress, and inflammation in the pathogenesis of metabolic disease in IUGR offspring. In addition, we summarize how uncontrolled cellular stress can lead to programmed cell death within the metabolic organs of IUGR offspring.
Collapse
Affiliation(s)
- Shelby L. Oke
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond Street, London, ON N6A 5C1, Canada;
- The Children’s Health Research Institute, The Lawson Health Research Institute, London, ON N6A 5C1, Canada
| | - Daniel B. Hardy
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond Street, London, ON N6A 5C1, Canada;
- The Children’s Health Research Institute, The Lawson Health Research Institute, London, ON N6A 5C1, Canada
- Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, The University of Western Ontario, 1151 Richmond Street, London, ON N6A 5C1, Canada
| |
Collapse
|
16
|
Melamed N, Baschat A, Yinon Y, Athanasiadis A, Mecacci F, Figueras F, Berghella V, Nazareth A, Tahlak M, McIntyre HD, Da Silva Costa F, Kihara AB, Hadar E, McAuliffe F, Hanson M, Ma RC, Gooden R, Sheiner E, Kapur A, Divakar H, Ayres-de-Campos D, Hiersch L, Poon LC, Kingdom J, Romero R, Hod M. FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction. Int J Gynaecol Obstet 2021; 152 Suppl 1:3-57. [PMID: 33740264 PMCID: PMC8252743 DOI: 10.1002/ijgo.13522] [Citation(s) in RCA: 175] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations.
The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR.
This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.
Collapse
Affiliation(s)
- Nir Melamed
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Ahmet Baschat
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA
| | - Yoav Yinon
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Federico Mecacci
- Maternal Fetal Medicine Unit, Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Francesc Figueras
- Maternal-Fetal Medicine Department, Barcelona Clinic Hospital, University of Barcelona, Barcelona, Spain
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Amala Nazareth
- Jumeira Prime Healthcare Group, Emirates Medical Association, Dubai, United Arab Emirates
| | - Muna Tahlak
- Latifa Hospital for Women and Children, Dubai Health Authority, Emirates Medical Association, Mohammad Bin Rashid University for Medical Sciences, Dubai, United Arab Emirates
| | - H David McIntyre
- Mater Research, The University of Queensland, Brisbane, Qld, Australia
| | - Fabrício Da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Anne B Kihara
- African Federation of Obstetricians and Gynaecologists, Khartoum, Sudan
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Fionnuala McAuliffe
- UCD Perinatal Research Centre, School of Medicine, National Maternity Hospital, University College Dublin, Dublin, Ireland
| | - Mark Hanson
- Institute of Developmental Sciences, University Hospital Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University of Southampton, Southampton, UK
| | - Ronald C Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China.,Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Rachel Gooden
- FIGO (International Federation of Gynecology and Obstetrics), London, UK
| | - Eyal Sheiner
- Soroka University Medical Center, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Anil Kapur
- World Diabetes Foundation, Bagsvaerd, Denmark
| | | | | | - Liran Hiersch
- Sourasky Medical Center and Sackler Faculty of Medicine, Lis Maternity Hospital, Tel Aviv University, Tel Aviv, Israel
| | - Liona C Poon
- Department of Obstetrics and Gynecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - John Kingdom
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, USA
| | - Moshe Hod
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| |
Collapse
|
17
|
Saghian R, Cahill L, Rahman A, Steinman J, Stortz G, Kingdom J, Macgowan C, Sled J. Interpretation of wave reflections in the umbilical arterial segment of the feto-placental circulation: computational modeling of the feto-placental arterial tree. IEEE Trans Biomed Eng 2021; 68:3647-3658. [PMID: 34010124 DOI: 10.1109/tbme.2021.3082064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Placental vascular abnormalities are associated with a host of pregnancy complications including placenta mediated fetal growth restriction (FGR). Umbilical arterial (UA) Doppler ultrasound velocity waveforms are widely used in the diagnosis of underlying placental vascular abnormalities in pregnancies with suspected FGR, which greatly help prevent stillbirth via ongoing fetal monitoring and timely delivery. However, the sensitivity of UA Doppler diagnosis diminishes late in gestation. Our goal was to present a generalized wave decomposition method to compute forward and reflected components from UA waveforms. A detailed anatomical based model was also developed to explain observed UA flow waveform and to explore how vascular properties affect the shape of flow wave components. Using pregnant mice and high frequency ultrasound microscopy, we obtained in utero Doppler and M- mode ultrasound measurements in 15 fetuses UA. Following ultrasound, the placentas were collected and perfused with contrast agent to obtain high-resolution 3D images of the feto-placental arteries. Model results indicate the significant role of terminal load impedance (capillary and/or veins) in creating positive or negative reflected waveforms. A negative reflected waveform is obtained when terminal impedance increases. This is consistent with the elongated and non-branching terminal villi that are proposed cause the highly abnormal UA waveforms found in early-onset FGR. The significance of these findings for the diagnostic utility of UA Doppler in human pregnancy is that the identification and measurement of wave reflections may aid in discriminating between healthy and abnormal placental vasculature in pregnancies with suspected late-onset FGR.
Collapse
|
18
|
The application of in utero magnetic resonance imaging in the study of the metabolic and cardiovascular consequences of the developmental origins of health and disease. J Dev Orig Health Dis 2020; 12:193-202. [PMID: 33308364 PMCID: PMC8162788 DOI: 10.1017/s2040174420001154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Observing fetal development in utero is vital to further the understanding of later-life diseases. Magnetic resonance imaging (MRI) offers a tool for obtaining a wealth of information about fetal growth, development, and programming not previously available using other methods. This review provides an overview of MRI techniques used to investigate the metabolic and cardiovascular consequences of the developmental origins of health and disease (DOHaD) hypothesis. These methods add to the understanding of the developing fetus by examining fetal growth and organ development, adipose tissue and body composition, fetal oximetry, placental microstructure, diffusion, perfusion, flow, and metabolism. MRI assessment of fetal growth, organ development, metabolism, and the amount of fetal adipose tissue could give early indicators of abnormal fetal development. Noninvasive fetal oximetry can accurately measure placental and fetal oxygenation, which improves current knowledge on placental function. Additionally, measuring deficiencies in the placenta’s transport of nutrients and oxygen is critical for optimizing treatment. Overall, the detailed structural and functional information provided by MRI is valuable in guiding future investigations of DOHaD.
Collapse
|
19
|
Altered molecular signatures during kidney development after intrauterine growth restriction of different origins. J Mol Med (Berl) 2020; 98:395-407. [PMID: 32008055 PMCID: PMC7080693 DOI: 10.1007/s00109-020-01875-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 12/16/2019] [Accepted: 01/07/2020] [Indexed: 12/17/2022]
Abstract
Abstract This study was performed to identify transcriptional alterations in male intrauterine growth restricted (IUGR) rats during and at the end of nephrogenesis in order to generate hypotheses which molecular mechanisms contribute to adverse kidney programming. IUGR was induced by low protein (LP) diet throughout pregnancy, bilateral uterine vessel ligation (LIG), or intrauterine stress (IUS) by sham operation. Offspring of unimpaired dams served as controls. Significant acute kidney damage was ruled out by negative results for proteins indicative of ER-stress, autophagy, apoptosis, or infiltration with macrophages. Renal gene expression was examined by transcriptome microarrays, demonstrating 53 (LP, n = 12; LIG, n = 32; IUS, n = 9) and 134 (LP, n = 10; LIG, n = 41; IUS, n = 83) differentially expressed transcripts on postnatal days (PND) 1 and 7, respectively. Reduced Pilra (all IUGR groups, PND 7), Nupr1 (LP and LIG, PND 7), and Kap (LIG, PND 1) as well as increased Ccl20, S100a8/a9 (LIG, PND 1), Ifna4, and Ltb4r2 (IUS, PND 7) indicated that inflammation-related molecular dysregulation could be a “common” feature after IUGR of different origins. Network analyses of transcripts and predicted upstream regulators hinted at proinflammatory adaptions mainly in LIG (arachidonic acid-binding, neutrophil aggregation, toll-like-receptor, NF-kappa B, and TNF signaling) and dysregulation of AMPK and PPAR signaling in LP pups. The latter may increase susceptibility towards obesity-associated kidney damage. Western blots of the most prominent predicted upstream regulators confirmed significant dysregulation of RICTOR in LP (PND 7) and LIG pups (PND 1), suggesting that mTOR-related processes could further modulate kidney programming in these groups of IUGR pups. Key messages Inflammation-related transcripts are dysregulated in neonatal IUGR rat kidneys. Upstream analyses indicate renal metabolic dysregulation after low protein diet. RICTOR is dysregulated after low protein diet and uterine vessel ligation.
Electronic supplementary material The online version of this article (10.1007/s00109-020-01875-1) contains supplementary material, which is available to authorized users.
Collapse
|
20
|
Δ9-tetrahydrocannabinol exposure during rat pregnancy leads to symmetrical fetal growth restriction and labyrinth-specific vascular defects in the placenta. Sci Rep 2020; 10:544. [PMID: 31953475 PMCID: PMC6969028 DOI: 10.1038/s41598-019-57318-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/20/2019] [Indexed: 02/08/2023] Open
Abstract
1 in 5 women report cannabis use during pregnancy, with nausea cited as their primary motivation. Studies show that (-)-△9-tetrahydrocannabinol (Δ9-THC), the major psychoactive ingredient in cannabis, causes fetal growth restriction, though the mechanisms are not well understood. Given the critical role of the placenta to transfer oxygen and nutrients from mother, to the fetus, any compromise in the development of fetal-placental circulation significantly affects maternal-fetal exchange and thereby, fetal growth. The goal of this study was to examine, in rats, the impact of maternal Δ9-THC exposure on fetal development, neonatal outcomes, and placental development. Dams received a daily intraperitoneal injection (i.p.) of vehicle control or Δ9-THC (3 mg/kg) from embryonic (E)6.5 through 22. Dams were allowed to deliver normally to measure pregnancy and neonatal outcomes, with a subset sacrificed at E19.5 for placenta assessment via immunohistochemistry and qPCR. Gestational Δ9-THC exposure resulted in pups born with symmetrical fetal growth restriction, with catch up growth by post-natal day (PND)21. During pregnancy there were no changes to maternal food intake, maternal weight gain, litter size, or gestational length. E19.5 placentas from Δ9-THC-exposed pregnancies exhibited a phenotype characterized by increased labyrinth area, reduced Epcam expression (marker of labyrinth trophoblast progenitors), altered maternal blood space, decreased fetal capillary area and an increased recruitment of pericytes with greater collagen deposition, when compared to vehicle controls. Further, at E19.5 labyrinth trophoblast had reduced glucose transporter 1 (GLUT1) and glucocorticoid receptor (GR) expression in response to Δ9-THC exposure. In conclusion, maternal exposure to Δ9-THC effectively compromised fetal growth, which may be a result of the adversely affected labyrinth zone development. These findings implicate GLUT1 as a Δ9-THC target and provide a potential mechanism for the fetal growth restriction observed in women who use cannabis during pregnancy.
Collapse
|
21
|
Lane SL, Dodson RB, Doyle AS, Park H, Rathi H, Matarrazo CJ, Moore LG, Lorca RA, Wolfson GH, Julian CG. Pharmacological activation of peroxisome proliferator-activated receptor γ (PPAR-γ) protects against hypoxia-associated fetal growth restriction. FASEB J 2019; 33:8999-9007. [PMID: 31039323 PMCID: PMC6662983 DOI: 10.1096/fj.201900214r] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/08/2019] [Indexed: 12/11/2022]
Abstract
The hypoxia of high-altitude (HA) residence increases the risk of intrauterine growth restriction (IUGR) and preeclampsia 3-fold, augmenting perinatal morbidity and mortality and the risk for childhood and adult disease. Currently, no effective therapies exist to prevent these vascular disorders of pregnancy. The peroxisome proliferator-activated receptor γ (PPAR-γ) is an important regulator of uteroplacental vascular development and function and has been implicated in the pathogenesis of IUGR and preeclampsia. Here, we used a model of HA pregnancy in mice to determine whether hypoxia-induced fetal growth restriction reduces placental PPAR-γ protein expression and placental vascularization and, if so, to evaluate the effectiveness of the selective PPAR-γ agonist pioglitazone (PIO) for preventing hypoxia-induced IUGR. Hypoxia resulted in asymmetric IUGR, placental insufficiency, and reduced placental PPAR-γ expression; PIO prevented approximately half of the fetal growth restriction and attenuated placental insufficiency. PIO did not affect fetal growth under normoxia. Although PIO was beneficial for fetal growth, PIO treatment reduced placental vascular density of the labrynthine zone in normoxic and hypoxic (Hx) conditions, and mean vascular area was reduced in the Hx group. Our results suggest that pharmacological PPAR-γ activation is a potential strategy for preventing IUGR in pregnancies complicated by hypoxia, although further studies are needed to identify its likely metabolic or vascular mechanisms.-Lane, S. L., Dodson, R. B., Doyle, A. S., Park, H., Rathi, H., Matarrazo, C. J., Moore, L. G., Lorca, R. A., Wolfson, G. H., Julian, C. G. Pharmacological activation of peroxisome proliferator-activated receptor γ (PPAR-γ) protects against hypoxia-associated fetal growth restriction.
Collapse
Affiliation(s)
- Sydney L. Lane
- Integrated Physiology Program, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - R. Blair Dodson
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Alexandrea S. Doyle
- Department of Integrative Biology, University of Colorado Denver, Denver, Colorado, USA
| | - Haemin Park
- Colorado Undergraduate Research in Environmental Health Sciences, University of Colorado Denver, Denver, Colorado, USA
| | - Hinal Rathi
- Department of Integrative Biology, University of Colorado Denver, Denver, Colorado, USA
| | | | - Lorna G. Moore
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ramón A. Lorca
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Gabriel H. Wolfson
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; and
| | - Colleen G. Julian
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; and
| |
Collapse
|
22
|
Vascular changes in fetal growth restriction: clinical relevance and future therapeutics. J Perinatol 2019; 39:366-374. [PMID: 30518801 DOI: 10.1038/s41372-018-0287-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/13/2018] [Accepted: 09/17/2018] [Indexed: 01/08/2023]
Abstract
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.
Collapse
|
23
|
Simões RV, Cabañas ME, Loreiro C, Illa M, Crispi F, Gratacós E. Assessment of prenatal cerebral and cardiac metabolic changes in a rabbit model of fetal growth restriction based on 13C-labelled substrate infusions and ex vivo multinuclear HRMAS. PLoS One 2018; 13:e0208784. [PMID: 30589837 PMCID: PMC6307735 DOI: 10.1371/journal.pone.0208784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 11/25/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND We have used a previously reported rabbit model of fetal growth restriction (FGR), reproducing perinatal neurodevelopmental and cardiovascular impairments, to investigate the main relative changes in cerebral and cardiac metabolism of term FGR fetuses during nutrient infusion. METHODS FGR was induced in 9 pregnant New Zealand rabbits at 25 days of gestation: one horn used as FGR, by partial ligation of uteroplacental vessels, and the contralateral as control (appropriate for gestation age, AGA). At 30 days of gestation, fasted mothers under anesthesia were infused i.v. with 1-13C-glucose (4 mothers), 2-13C-acetate (3 mothers), or not infused (2 mothers). Fetal brain and heart samples were quickly harvested and frozen down. Brain cortex and heart apex regions from 30 fetuses were studied ex vivo by HRMAS at 4°C, acquiring multinuclear 1D and 2D spectra. The data were processed, quantified by peak deconvolution or integration, and normalized to sample weight. RESULTS Most of the total 13C-labeling reaching the fetal brains/hearts (80-90%) was incorporated to alanine and lactate (cytosol), and to the glutamine-glutamate pool (mitochondria). Acetate-derived lactate (Lac C2C3) had a slower turnover in FGR brains (~ -20%). In FGR hearts, mitochondrial turnover of acetate-derived glutamine (Gln C4) was slower (-23%) and there was a stronger accumulation of phospholipid breakdown products (glycerophosphoethanolamine and glycerophosphocholine, +50%), resembling the profile of non-infused control hearts. CONCLUSIONS Our results indicate specific functional changes in cerebral and cardiac metabolism of FGR fetuses under nutrient infusion, suggesting glial impairment and restricted mitochondrial metabolism concomitant with slower cell membrane turnover in cardiomyocytes, respectively. These prenatal metabolic changes underlie neurodevelopmental and cardiovascular problems observed in this FGR model and in clinical patients, paving the way for future studies aimed at evaluating metabolic function postnatally and in response to stress and/or treatment.
Collapse
Affiliation(s)
- Rui V. Simões
- Fetal i+d Fetal Medicine Reseach Center, BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), ICGON, IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, SPAIN
- * E-mail:
| | - Miquel E. Cabañas
- Servei de Resonància Magnètica Nuclear, Universitat Autònoma de Barcelona (UAB), SPAIN
| | - Carla Loreiro
- Fetal i+d Fetal Medicine Reseach Center, BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), ICGON, IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, SPAIN
| | - Miriam Illa
- Fetal i+d Fetal Medicine Reseach Center, BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), ICGON, IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, SPAIN
| | - Fatima Crispi
- Fetal i+d Fetal Medicine Reseach Center, BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), ICGON, IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, SPAIN
| | - Eduard Gratacós
- Fetal i+d Fetal Medicine Reseach Center, BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), ICGON, IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, SPAIN
| |
Collapse
|
24
|
Senra JC, Carvalho MA, Rodrigues AS, Krebs VLJ, Gibelli MABC, Francisco RPV, Bernardes LS. An unfavorable intrauterine environment may determine renal functional capacity in adulthood: a meta-analysis. Clinics (Sao Paulo) 2018; 73:e401. [PMID: 30365822 PMCID: PMC6172979 DOI: 10.6061/clinics/2018/e401] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 04/02/2018] [Indexed: 11/18/2022] Open
Abstract
Since studies show that an unfavorable environment during intrauterine development predisposes individuals to several diseases in adulthood, our objective is to assess the relation between fetal growth restriction and chronic renal disease in adults. We searched four different electronic databases through November 2017: CENTRAL, EMBASE, LILACS and MEDLINE. We selected studies with longitudinal or transversal designs associating kidney function in adulthood with low birth weight. Two reviewers evaluated the inclusion criteria and the risk of bias and extracted data from the included papers. Thirteen studies were selected for the systematic review and meta-analysis. We observed increased risks of presenting end-stage renal disease (risk ratio 1.31, 95% confidence interval: 1.17, 1.47), a lower glomerular filtration rate (ml/min) (mean difference 7.14; 95% confidence interval: -12.12, -2.16), microalbuminuria (risk ratio 1.40; 95% confidence interval: 1.28, 1.52) and a small increase in the albumin/creatinine ratio (mean difference 0.46; 95% confidence interval: 0.03, 0.90) in the low birth weight patients, compared with control group. These findings suggest that low birth weight is associated with renal dysfunction in adults.
Collapse
Affiliation(s)
- Janaína Campos Senra
- Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Mariana Azevedo Carvalho
- Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Agatha Sacramento Rodrigues
- Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Vera Lúcia Jornada Krebs
- Unidade Neonatal, Departamento de Pediatria Faculdade de Medicina FMUSP, Universidade de Sao Paulo Sao Paulo, SP, BR
| | | | | | - Lisandra Stein Bernardes
- Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| |
Collapse
|
25
|
Wang M, Mercer JS, Padbury JF. Delayed Cord Clamping in Infants with Suspected Intrauterine Growth Restriction. J Pediatr 2018; 201:264-268. [PMID: 29954605 DOI: 10.1016/j.jpeds.2018.05.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/25/2018] [Accepted: 05/16/2018] [Indexed: 12/14/2022]
Abstract
UNLABELLED We evaluated a subset of infants with suspected intrauterine growth restriction or birth weights small for gestational age enrolled in a study of delayed cord clamping for preterm infants. Compared with immediate clamping, delayed cord clamping was associated with no apparent harm and less suspected necrotizing enterocolitis. TRIAL REGISTRATION ClinicalTrials.gov: NCT00818220 and NCT01426698.
Collapse
Affiliation(s)
- Meijia Wang
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI
| | - Judith S Mercer
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI; College of Nursing, University of Rhode Island, Kingston, RI; Department of Pediatrics, Alpert School of Medicine, Brown University, Providence, RI
| | - James F Padbury
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI; Department of Pediatrics, Alpert School of Medicine, Brown University, Providence, RI
| |
Collapse
|
26
|
Yadav BK, Krishnamurthy U, Buch S, Jella P, Hernandez-Andrade E, Yeo L, Korzeniewski SJ, Trifan A, Hassan SS, Haacke EM, Romero R, Neelavalli J. Imaging putative foetal cerebral blood oxygenation using susceptibility weighted imaging (SWI). Eur Radiol 2018; 28:1884-1890. [PMID: 29247352 PMCID: PMC5884705 DOI: 10.1007/s00330-017-5160-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 10/03/2017] [Accepted: 10/27/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the magnetic susceptibility, ∆χ v , as a surrogate marker of venous blood oxygen saturation, S v O 2, in second- and third-trimester normal human foetuses. METHODS Thirty-six pregnant women, having a mean gestational age (GA) of 31 2/7 weeks, underwent magnetic resonance imaging (MRI). Susceptibility-weighted imaging (SWI) data from the foetal brain were acquired. ∆χ v of the superior sagittal sinus (SSS) was quantified using MR susceptometry from the intra-vascular phase measurements. Assuming the magnetic property of foetal blood, ∆χ do , is the same as that of adult blood, S v O 2 was derived from the measured Δχ v . The variation of ∆χ v and S v O 2, as a function of GA, was statistically evaluated. RESULTS The mean ∆χ v in the SSS in the second-trimester (n = 8) and third-trimester foetuses (n = 28) was found to be 0.34± 0.06 ppm and 0.49 ±0.05 ppm, respectively. Correspondingly, the derived S v O 2 values were 69.4% ±3.27% and 62.6% ±3.25%. Although not statistically significant, an increasing trend (p = 0.08) in Δχ v and a decreasing trend (p = 0.22) in S v O 2 with respect to advancing gestation was observed. CONCLUSION We report cerebral venous blood magnetic susceptibility and putative oxygen saturation in healthy human foetuses. Cerebral oxygen saturation in healthy human foetuses, despite a slight decreasing trend, does not change significantly with advancing gestation. KEY POINTS • Cerebral venous magnetic susceptibility and oxygenation in human foetuses can be quantified. • Cerebral venous oxygenation was not different between second- and third-trimester foetuses. • Foetal cerebral venous oxygenation does not change significantly with advancing gestation.
Collapse
Affiliation(s)
- Brijesh Kumar Yadav
- Department of Radiology, Wayne State University School of Medicine, 4201 St. Antoine, Detroit, MI, 48201, USA
- Department of Biomedical Engineering, Wayne State University College of Engineering, Detroit, MI, USA
| | - Uday Krishnamurthy
- Department of Radiology, Wayne State University School of Medicine, 4201 St. Antoine, Detroit, MI, 48201, USA
- Department of Biomedical Engineering, Wayne State University College of Engineering, Detroit, MI, USA
| | - Sagar Buch
- The MRI Institute for Biomedical Research, Waterloo, ON, Canada
| | - Pavan Jella
- Department of Radiology, Wayne State University School of Medicine, 4201 St. Antoine, Detroit, MI, 48201, USA
| | - Edgar Hernandez-Andrade
- Perinatology Research Branch, NICHD/NIH/DHHS, Hutzel Women's Hospital, 3990 John R, 4 Brush, Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Lami Yeo
- Perinatology Research Branch, NICHD/NIH/DHHS, Hutzel Women's Hospital, 3990 John R, 4 Brush, Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Steven J Korzeniewski
- Perinatology Research Branch, NICHD/NIH/DHHS, Hutzel Women's Hospital, 3990 John R, 4 Brush, Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
| | - Anabela Trifan
- Department of Radiology, Wayne State University School of Medicine, 4201 St. Antoine, Detroit, MI, 48201, USA
| | - Sonia S Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Hutzel Women's Hospital, 3990 John R, 4 Brush, Detroit, MI, 48201, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - E Mark Haacke
- Department of Radiology, Wayne State University School of Medicine, 4201 St. Antoine, Detroit, MI, 48201, USA
- Department of Biomedical Engineering, Wayne State University College of Engineering, Detroit, MI, USA
- The MRI Institute for Biomedical Research, Waterloo, ON, Canada
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Hutzel Women's Hospital, 3990 John R, 4 Brush, Detroit, MI, 48201, USA.
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA.
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA.
| | - Jaladhar Neelavalli
- Department of Radiology, Wayne State University School of Medicine, 4201 St. Antoine, Detroit, MI, 48201, USA.
| |
Collapse
|
27
|
Padmanabhan S, Lee VW, Mclean M, Athayde N, Lanzarone V, Khoshnow Q, Peek MJ, Cheung NW. The Association of Falling Insulin Requirements With Maternal Biomarkers and Placental Dysfunction: A Prospective Study of Women With Preexisting Diabetes in Pregnancy. Diabetes Care 2017; 40:1323-1330. [PMID: 28798085 DOI: 10.2337/dc17-0391] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/09/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the association of falling insulin requirements (FIR) among women with preexisting diabetes with adverse obstetric outcomes and maternal biomarkers longitudinally in pregnancy. RESEARCH DESIGN AND METHODS A multicenter prospective cohort study of 158 women (41 with type 1 diabetes and 117 with type 2 diabetes) was conducted. Women with FIR of ≥15% from the peak total daily dose after 20 weeks' gestation were considered case subjects (n = 32). The primary outcome was a composite of clinical markers of placental dysfunction (preeclampsia, small for gestational age [≤5th centile], stillbirth, premature delivery [<30 weeks], and placental abruption). Maternal circulating angiogenic markers (placental growth factor [PlGF] and soluble fms-like tyrosine kinase 1 [sFlt-1]), placental hormones (human placental lactogen, progesterone, and tumor necrosis factor-α), HbA1c, and creatinine were studied serially during pregnancy. RESULTS FIR ≥15% were associated with an increased risk of the composite primary outcome (odds ratio [OR] 4.38 [95% CI 1.9-10.3]; P < 0.001), preeclampsia (OR 6.76 [95% CI 2.7-16.7]; P < 0.001), and was more common among women with type 1 diabetes (36.6 vs. 14.5%; P = 0.002). Creatinine was modestly elevated among women with FIR ≥15%; however, there was no difference in HbA1c. The ratio of sFlt-1 to PlGF was significantly higher among women with FIR at 25, 30, and 36 weeks, with differences maintained in the subgroup that developed preeclampsia. There was no difference in placental hormones between the groups. CONCLUSIONS This is the first prospective study to associate FIR with altered expression of placental antiangiogenic factors and preeclampsia. FIR are an important clinical sign, among women with preexisting diabetes, that should alert the clinician to investigate underlying placental dysfunction.
Collapse
Affiliation(s)
- Suja Padmanabhan
- Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia .,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Vincent W Lee
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mark Mclean
- Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,Diabetes and Endocrinology, Blacktown Hospital, Sydney, New South Wales, Australia.,Western Sydney University, Sydney, New South Wales, Australia
| | - Neil Athayde
- Obstetric Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Valeria Lanzarone
- Obstetric Medicine, Nepean Hospital, Sydney, New South Wales, Australia
| | - Qemer Khoshnow
- Obstetric Medicine, Nepean Hospital, Sydney, New South Wales, Australia
| | - Michael J Peek
- College of Medicine, Biology and Environment, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - N Wah Cheung
- Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
28
|
Baumfeld Y, Herskovitz R, Niv ZB, Mastrolia SA, Weintraub AY. Placenta associated pregnancy complications in pregnancies complicated with placenta previa. Taiwan J Obstet Gynecol 2017; 56:331-335. [DOI: 10.1016/j.tjog.2017.04.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2016] [Indexed: 11/16/2022] Open
|
29
|
Simões RV, Muñoz-Moreno E, Cruz-Lemini M, Eixarch E, Bargalló N, Sanz-Cortés M, Gratacós E. Brain metabolite alterations in infants born preterm with intrauterine growth restriction: association with structural changes and neurodevelopmental outcome. Am J Obstet Gynecol 2017; 216:62.e1-62.e14. [PMID: 27667762 DOI: 10.1016/j.ajog.2016.09.089] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 08/02/2016] [Accepted: 09/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Intrauterine growth restriction and premature birth represent 2 independent problems that may occur simultaneously and contribute to impaired neurodevelopment. OBJECTIVE The objective of the study was to assess changes in the frontal lobe metabolic profiles of 1 year old intrauterine growth restriction infants born prematurely and adequate-for-gestational-age controls, both premature and term adequate for gestational age and their association with brain structural and biophysical parameters and neurodevelopmental outcome at 2 years. STUDY DESIGN A total of 26 prematurely born intrauterine growth restriction infants (birthweight <10th centile for gestational age), 22 prematurely born but adequate for gestational age controls, and 26 term adequate-for-gestational-age infants underwent brain magnetic resonance imaging and magnetic resonance spectroscopy at 1 year of age during natural sleep, on a 3 Tesla scanner. All brain T1-weighted and diffusion-weighted images were acquired along with short echo time single-voxel proton spectra from the frontal lobe. Magnetic resonance imaging/magnetic resonance spectroscopy data were processed to derive structural, biophysical, and metabolic information, respectively. Neurodevelopment was evaluated at 2 years of age using the Bayley Scales 3rd edition, assessing cognitive, language, motor, socioemotional, and adaptive behavior. RESULTS Prematurely born intrauterine growth restriction infants had slightly smaller brain volumes and increased frontal lobe white matter mean diffusivity compared with both prematurely born but adequate for gestational age and term adequate for gestational age controls. Frontal lobe N-acetylaspartate levels were significantly lower in prematurely born intrauterine growth restriction than in prematurely born but adequate for gestational age infants but increased in prematurely born but adequate for gestational age compared with term adequate-for-gestational-age infants. The prematurely born intrauterine growth restriction group also showed slightly lower choline compounds, borderline decrements of estimated glutathione levels, and increased myoinositol to choline ratios, compared with prematurely born but adequate for gestational age controls. These specific metabolite changes were locally correlated to lower gray matter content and increased mean diffusivity and reduced white matter fraction and fractional anisotropy. Prematurely born intrauterine growth restriction infants also showed a tendency for poorer neurodevelopmental outcome at 2 years, associated with lower levels of frontal lobe N-acetylaspartate at 1 year within the preterm subset. CONCLUSIONS Preterm intrauterine growth restriction infants showed altered brain metabolite profiles during a critical stage of brain maturation, which correlate with brain structural and biophysical parameters and neurodevelopmental outcome. Our results suggest altered neurodevelopmental trajectories in preterm intrauterine growth restriction and adequate-for-gestational-age infants, compared with term adequate-for-gestational-age infants, which require further characterization.
Collapse
|
30
|
Altered cardiovascular function at birth in growth-restricted preterm lambs. Pediatr Res 2016; 80:538-46. [PMID: 27356081 DOI: 10.1038/pr.2016.104] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 03/01/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cardiovascular dysfunction at birth may underlie poor outcomes after fetal growth restriction (FGR) in neonates. We compared the cardiovascular transition between FGR and appropriately grown (AG) preterm lambs and examined possible mechanisms underlying any cardiovascular dysfunction in FGR lambs. METHODS FGR was induced in ewes bearing twins at 0.7 gestation; the twin was used as an internal control (AG). At 0.8 gestation, lambs were delivered and either euthanized with their arteries isolated for in vitro wire myography, or ventilated for 2 h. At 60 min, inhaled nitric oxide (iNO) was administered in a subgroup for 30 min. Molecular assessment of the nitric oxide (NO) pathway within lung tissue was conducted. RESULTS FGR lambs had lower left ventricular output and cerebral blood flow (CBF) and higher systemic vascular resistance compared with AG lambs. INO administration to FGR lambs rapidly improved cardiovascular and systemic hemodynamics but resulted in decreased CBF in AG lambs. Isolated arteries from FGR lambs showed impaired sensitivity to NO donors, but enhanced vasodilation to Sildenafil and Sodium nitroprusside, and altered expression of components of the NO pathway. CONCLUSION Cardiovascular dysfunction at birth may underlie the increased morbidity and mortality observed in preterm FGR newborns. Impaired NO signaling likely underlies the abnormal vascular reactivity.
Collapse
|
31
|
Barry JS, Rozance PJ, Brown LD, Anthony RV, Thornburg KL, Hay WW. Increased fetal myocardial sensitivity to insulin-stimulated glucose metabolism during ovine fetal growth restriction. Exp Biol Med (Maywood) 2016; 241:839-47. [PMID: 26873920 PMCID: PMC4950398 DOI: 10.1177/1535370216632621] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 01/21/2016] [Indexed: 01/18/2023] Open
Abstract
Unlike other visceral organs, myocardial weight is maintained in relation to fetal body weight in intrauterine growth restriction (IUGR) fetal sheep despite hypoinsulinemia and global nutrient restriction. We designed experiments in fetal sheep with placental insufficiency and restricted growth to determine basal and insulin-stimulated myocardial glucose and oxygen metabolism and test the hypothesis that myocardial insulin sensitivity would be increased in the IUGR heart. IUGR was induced by maternal hyperthermia during gestation. Control (C) and IUGR fetal myocardial metabolism were measured at baseline and under acute hyperinsulinemic/euglycemic clamp conditions at 128-132 days gestation using fluorescent microspheres to determine myocardial blood flow. Fetal body and heart weights were reduced by 33% (P = 0.008) and 30% (P = 0.027), respectively. Heart weight to body weight ratios were not different. Basal left ventricular (LV) myocardial blood flow per gram of LV tissue was maintained in IUGR fetuses compared to controls. Insulin increased LV myocardial blood flow by ∼38% (P < 0.01), but insulin-stimulated LV myocardial blood flow in IUGR fetuses was 73% greater than controls. Similar to previous reports testing acute hypoxia, LV blood flow was inversely related to arterial oxygen concentration (r(2 )= 0.71) in both control and IUGR animals. Basal LV myocardial glucose delivery and uptake rates were not different between IUGR and control fetuses. Insulin increased LV myocardial glucose delivery (by 40%) and uptake (by 78%) (P < 0.01), but to a greater extent in the IUGR fetuses compared to controls. During basal and hyperinsulinemic-euglycemic clamp conditions LV myocardial oxygen delivery, oxygen uptake, and oxygen extraction efficiency were not different between groups. These novel results demonstrate that the fetal heart exposed to nutrient and oxygen deprivation from placental insufficiency appears to maintain myocardial energy supply in the IUGR condition via increased glucose uptake and metabolic response to insulin, which support myocardial function and growth.
Collapse
Affiliation(s)
- James S Barry
- Perinatal Research Center, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Paul J Rozance
- Perinatal Research Center, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Laura D Brown
- Perinatal Research Center, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Russell V Anthony
- Department of Biomedical Sciences, Colorado State University, Ft. Collins, CO 80503, USA
| | - Kent L Thornburg
- Center for Developmental Health, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR 97239, USA
| | - William W Hay
- Perinatal Research Center, University of Colorado School of Medicine, Aurora, CO 80045, USA
| |
Collapse
|
32
|
Sørensen A, Sinding M, Peters DA, Petersen A, Frøkjær JB, Christiansen OB, Uldbjerg N. Placental oxygen transport estimated by the hyperoxic placental BOLD MRI response. Physiol Rep 2015; 3:3/10/e12582. [PMID: 26471757 PMCID: PMC4632952 DOI: 10.14814/phy2.12582] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Estimating placental oxygen transport capacity is highly desirable, as impaired placental function is associated with fetal growth restriction (FGR) and poor neonatal outcome. In clinical obstetrics, a noninvasive method to estimate the placental oxygen transport is not available, and the current methods focus on fetal well-being rather than on direct assessment of placental function. In this article, we aim to estimate the placental oxygen transport using the hyperoxic placental blood oxygen level-dependent (BOLD) magnetic resonance imaging (MRI) response. In 21 normal pregnancies and in four cases of severe early onset FGR, placental BOLD MRI was performed in a 1.5 Tesla MRI system (TR:8000 msec, TE:50 msec, Flip angle:90). Placental histological examination was performed in the FGR cases. In normal pregnancies, the average hyperoxic placental BOLD response was 12.6 ± 5.4% (mean ± SD). In the FGR cases, the hyperoxic BOLD response was abnormal only in cases with histological signs of maternal hypoperfusion of the placenta. The hyperoxic placental BOLD response is mainly derived from an increase in the saturation of maternal venous blood. In the normal placenta, the pO2 of the umbilical vein is closely related to the pO2 of the uterine vein. Therefore, the hyperoxic placental BOLD response may reflect the placental oxygen supply to the fetus. In early onset FGR, the placental oxygen transport is reduced mainly because of the maternal hypoperfusion, and in these cases the placental BOLD response might be altered. Thus, the placental BOLD MRI might provide direct noninvasive assessment of placental oxygen transport.
Collapse
Affiliation(s)
- Anne Sørensen
- Obstetrics and Gýnecology, Aalborg University Hospital, Aalborg, Denmark
| | - Marianne Sinding
- Obstetrics and Gýnecology, Aalborg University Hospital, Aalborg, Denmark
| | - David A Peters
- Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jens B Frøkjær
- Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Ole B Christiansen
- Obstetrics and Gýnecology, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Uldbjerg
- Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
33
|
Deter RL, Lee W, Sangi-Haghpeykar H, Tarca AL, Li J, Yeo L, Romero R. Personalized third-trimester fetal growth evaluation: comparisons of individualized growth assessment, percentile line and conditional probability methods. J Matern Fetal Neonatal Med 2015; 29:177-85. [PMID: 25491881 DOI: 10.3109/14767058.2014.995083] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To compare third-trimester size trajectory prediction errors (average transformed percent deviations) for three individualized fetal growth assessment methods. METHODS This study utilized longitudinal measurements of nine directly measured size parameters in 118 fetuses with normal neonatal growth outcomes. Expected value (EV) function coefficients and variance components were obtained using two-level random coefficient modeling. Growth models (IGA) or EV coefficients and variance components (PLM and CPM) were used to calculate predicted values at ∼400 third-trimester time points. Percent deviations (%Dev) calculated at these time points using all three methods were expressed as percentages of IGA MA-specific reference ranges [transformed percent deviations (T%Dev)]. Third-trimester T%Dev values were averaged (aT%Dev) for each parameter. Mean ± standard deviation's for sets of aT%Dev values derived from each method (IGA, PLM and CPM) were calculated and compared. RESULTS Mean aT%Dev values for nine parameters were: (i) IGA: -4.3 to 5.2% (9/9 not different from zero); (ii) PLM: -32.7 to 25.6% (4/9 not different from zero) and (iii) CPM: -20.4 to 17.4% (5/9 not different from zero). Seven of nine systematic deviations from zero were statistically significant when IGA values were compared to either PLM or CPM values. Variabilities were smaller for IGA when compared to those for PLM or CPM, with (i) 5/9 being statistically significant (IGA versus PLM), (ii) 2/9 being statistically significant (IGA versus CPM) and (iii) 5/9 being statistically significant (PLM versus CPM). CONCLUSIONS Significant differences in the agreement between predicted third-trimester size parameters and their measured values were found for the three methods tested. With most parameters, IGA gave smaller mean aT%Dev values and smaller variabilities. The CPM method was better than the PLM approach for most but not all parameters. These results suggest that third-trimester size trajectories are best characterized by IGA in fetuses with normal growth outcomes.
Collapse
Affiliation(s)
- Russell L Deter
- a Department of Obstetrics and Gynecology , Baylor College of Medicine , Houston , TX , USA
| | - Wesley Lee
- a Department of Obstetrics and Gynecology , Baylor College of Medicine , Houston , TX , USA .,b Department of Obstetrics and Gynecology , Oakland University William Beaumont School of Medicine , Rochester , MI , USA .,c Perinatology Research Branch, NICHD/NIH/DHHS , Detroit , MI , USA
| | - Haleh Sangi-Haghpeykar
- a Department of Obstetrics and Gynecology , Baylor College of Medicine , Houston , TX , USA
| | - Adi L Tarca
- c Perinatology Research Branch, NICHD/NIH/DHHS , Detroit , MI , USA
| | - Jia Li
- d Department of Electrical and Computer Engineering , Oakland University , Rochester , MI , USA
| | - Lami Yeo
- c Perinatology Research Branch, NICHD/NIH/DHHS , Detroit , MI , USA .,e Department of Obstetrics and Gynecology , Wayne State University/Hutzel Hospital , Detroit , MI , USA
| | - Roberto Romero
- c Perinatology Research Branch, NICHD/NIH/DHHS , Detroit , MI , USA .,f Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , MI , USA , and.,g Department of Epidemiology and Biostatistics , Michigan State University , East Lansing , MI , USA
| |
Collapse
|
34
|
Stepan H, Kuse-Föhl S, Klockenbusch W, Rath W, Schauf B, Walther T, Schlembach D. Diagnosis and Treatment of Hypertensive Pregnancy Disorders. Guideline of DGGG (S1-Level, AWMF Registry No. 015/018, December 2013). Geburtshilfe Frauenheilkd 2015; 75:900-914. [PMID: 28435172 PMCID: PMC5396549 DOI: 10.1055/s-0035-1557924] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Hypertensive pregnancy disorders contribute significantly to perinatal as well as maternal morbidity and mortality worldwide. Also in Germany these diseases are a major course for hospitalization during pregnancy, iatrogenic preterm birth and long-term cardiovascular morbidity. Methods: This S1-guideline is the work of an interdisciplinary group of experts from a range of different professions who were commissioned by DGGG to carry out a systematic literature search of positioning injuries. Members of the participating scientific societies develop a consensus in an informal procedure. Afterwards the directorate of the scientific society approves the consensus. Recommendations: This guideline summarizes the state-of-art for classification, risk stratification, diagnostic, treatment of hypertensive pregnancy disorders.
Collapse
Affiliation(s)
- H. Stepan
- Abteilung für Geburtsmedizin, Universitätsklinikum Leipzig,
Leipzig
| | - S. Kuse-Föhl
- Abteilung für Geburtsmedizin, Universitätsklinikum Leipzig,
Leipzig
| | - W. Klockenbusch
- Universitätsklinikum Münster, Klinik und Poliklinik für Frauenheilkunde und
Geburtshilfe, Abt. für Geburtshilfe, Münster
| | - W. Rath
- Frauenklinik für Gynäkologie und Geburtshilfe, Universitätsklinikum RWTH
Aachen, Aachen
| | - B. Schauf
- Frauenklinik Sozialstiftung Bamberg, Bamberg
| | - T. Walther
- Department of Pharmacology and Therapeutics, University College Cork, Cork,
Ireland
| | - D. Schlembach
- Klinik für Geburtsmedizin, Vivantes Klinikum Neukölln, Berlin
| |
Collapse
|
35
|
Krishnamurthy U, Szalai G, Shen Y, Xu Z, Yadav BK, Tarca AL, Chaiworapongsa T, Hernandez-Andrade E, Than NG, Haacke EM, Romero R, Neelavalli J. Longitudinal Changes in Placental Magnetic Resonance Imaging Relaxation Parameter in Murine Pregnancy: Compartmental Analysis. Gynecol Obstet Invest 2015; 81:193-201. [PMID: 26336923 PMCID: PMC4769121 DOI: 10.1159/000431223] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 05/06/2015] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To quantify gestation-dependent longitudinal changes in the magnetic resonance transverse relaxation time (T2) parameter of the major constituent regions of the mouse placenta and to evaluate their relative contributions to changes in overall placental T2. METHODS Timed-pregnant CD-1 mice underwent magnetic resonance imaging at 7.0 T field strength, on gestational day 13 (GD13), GD15 and GD17. T2 of the placenta and its constituent high and low blood perfusion regions were quantified. A linear mixed-effects model was used to fit the T2 across gestation, and the significance of coefficients was tested. RESULTS A decrease in the T2 values of the placenta and its constituent regions was observed across gestation. The temporal change in T2 was estimated to be -1.85 ms/GD (p < 0.0001) for the placenta, -1.00 ms/GD (p < 0.001) for the high-perfusion zones (HPZs) and -1.66 ms/GD (p < 0.0001) for the low-perfusion zones (LPZs). CONCLUSION T2 of the constituent zones of the murine placenta decreases with advancing gestation. While the T2 of the LPZ is smaller than that of the HPZ, there is no difference in their decrease rate relative to that of the whole placenta (p = 0.24). The results suggest an increased role of constituent volume fractions in affecting overall gestation-dependent placental T2 decrease in mice.
Collapse
Affiliation(s)
- Uday Krishnamurthy
- Department of Radiology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Biomedical Engineering, Wayne State University College of Engineering, Detroit, Michigan, USA
| | - Gabor Szalai
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Yimin Shen
- Department of Radiology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Zhonghui Xu
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Brijesh Kumar Yadav
- Department of Radiology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Biomedical Engineering, Wayne State University College of Engineering, Detroit, Michigan, USA
| | - Adi Laurentiu Tarca
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Computer Science, Wayne State University, Detroit, Michigan, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Edgar Hernandez-Andrade
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Nandor Gabor Than
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Ewart Mark Haacke
- Department of Radiology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Biomedical Engineering, Wayne State University College of Engineering, Detroit, Michigan, USA
| | | | - D Med Sci
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
| | - Jaladhar Neelavalli
- Department of Radiology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Biomedical Engineering, Wayne State University College of Engineering, Detroit, Michigan, USA
| |
Collapse
|
36
|
Callec R, Lamy C, Perdriolle-Galet E, Patte C, Heude B, Morel O. Impact on obstetric outcome of third-trimester screening for small-for-gestational-age fetuses. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:216-220. [PMID: 25487165 DOI: 10.1002/uog.14755] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 11/26/2014] [Accepted: 12/04/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To evaluate the performance of screening for small-for-gestational-age (SGA) fetuses by ultrasound biometry at 30-35 weeks' gestation, and to determine the impact of screening on obstetric and neonatal outcomes. METHODS For this prospective cohort study, pregnant women were recruited from two French university maternity centers between 2003 and 2006. Performance measures of third-trimester biometry for the prediction of SGA, defined as estimated fetal weight < 10(th) centile, were analyzed. Obstetric outcomes and neonatal health status were compared, first, between SGA neonates diagnosed correctly at ultrasound examination (true positive (TP); n = 45) and SGA neonates that went undiagnosed (false negative (FN); n = 110) and, second, between non-SGA neonates identified as normal at ultrasound examination (true negative (TN); n = 1641) and non-SGA neonates diagnosed incorrectly as SGA (false positive (FP); n = 101). RESULTS In the prediction of SGA, third-trimester ultrasound had a sensitivity of 29.0% (95% CI, 22.5-36.6%) and specificity of 94.2% (95% CI, 93.0-95.2%). Positive and negative predictive values were 30.8% (95% CI, 23.9-38.7%) and 93.7% (95% CI, 92.5-94.8%), respectively. One hundred and ten SGA neonates went undiagnosed at ultrasound. Compared to the TN neonates considered as of normal weight at ultrasound, planned preterm delivery (before 37 weeks) and elective Cesarean section for a fetal growth indication were 2.4 (P = 0.01) and 2.85 (P = 0.003) times more likely to occur, respectively, in the FP group of non-SGA neonates, diagnosed incorrectly as SGA during the antenatal period. There was no statistically significant difference in 5-min Apgar score < 7, cord blood pH at birth < 7.15 and need for neonatal resuscitation between the two subgroups (TN vs FP and TP vs FN). CONCLUSIONS The performance of third-trimester ultrasound screening for SGA seems poor, as it misses the diagnosis of a large number of SGA neonates. The consequences of routine screening for SGA in a low-risk population may lead to unnecessary planned preterm deliveries and elective Cesarean sections in FP pregnancies, without improved neonatal outcome in the FN pregnancies.
Collapse
Affiliation(s)
- R Callec
- Obstetrics and Fetal Medicine Unit, Centre Hospitalier Universitaire, Nancy, France
- Université de Lorraine, Nancy, France
- INSERM, U947, Nancy, France
| | - C Lamy
- Obstetrics and Fetal Medicine Unit, Centre Hospitalier Universitaire, Nancy, France
| | - E Perdriolle-Galet
- Obstetrics and Fetal Medicine Unit, Centre Hospitalier Universitaire, Nancy, France
- Université de Lorraine, Nancy, France
- INSERM, U947, Nancy, France
| | - C Patte
- Obstetrics and Fetal Medicine Unit, Centre Hospitalier Universitaire, Nancy, France
| | - B Heude
- Centre for Research in Epidemiology and Population Health (CESP), INSERM, Villejuif, France
- Université Paris Sud, Villejuif, France
| | - O Morel
- Obstetrics and Fetal Medicine Unit, Centre Hospitalier Universitaire, Nancy, France
- Université de Lorraine, Nancy, France
- INSERM, U947, Nancy, France
| |
Collapse
|
37
|
Simões RV, Muñoz-Moreno E, Carbajo RJ, González-Tendero A, Illa M, Sanz-Cortés M, Pineda-Lucena A, Gratacós E. In Vivo Detection of Perinatal Brain Metabolite Changes in a Rabbit Model of Intrauterine Growth Restriction (IUGR). PLoS One 2015. [PMID: 26208165 PMCID: PMC4514800 DOI: 10.1371/journal.pone.0131310] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Intrauterine growth restriction (IUGR) is a risk factor for abnormal neurodevelopment. We studied a rabbit model of IUGR by magnetic resonance imaging (MRI) and spectroscopy (MRS), to assess in vivo brain structural and metabolic consequences, and identify potential metabolic biomarkers for clinical translation. Methods IUGR was induced in 3 pregnant rabbits at gestational day 25, by 40–50% uteroplacental vessel ligation in one horn; the contralateral horn was used as control. Fetuses were delivered at day 30 and weighted. A total of 6 controls and 5 IUGR pups underwent T2-w MRI and localized proton MRS within the first 8 hours of life, at 7T. Changes in brain tissue volumes and respective contributions to each MRS voxel were estimated by semi-automated registration of MRI images with a digital atlas of the rabbit brain. MRS data were used for: (i) absolute metabolite quantifications, using linear fitting; (ii) local temperature estimations, based on the water chemical shift; and (iii) classification, using spectral pattern analysis. Results Lower birth weight was associated with (i) smaller brain sizes, (ii) slightly lower brain temperatures, and (iii) differential metabolite profile changes in specific regions of the brain parenchyma. Specifically, we found estimated lower levels of aspartate and N-acetylaspartate (NAA) in the cerebral cortex and hippocampus (suggesting neuronal impairment), and higher glycine levels in the striatum (possible marker of brain injury). Our results also suggest that the metabolic changes in cortical regions are more prevalent than those detected in hippocampus and striatum. Conclusions IUGR was associated with brain metabolic changes in vivo, which correlate well with the neurostructural changes and neurodevelopment problems described in IUGR. Metabolic parameters could constitute non invasive biomarkers for the diagnosis and abnormal neurodevelopment of perinatal origin.
Collapse
Affiliation(s)
- Rui V. Simões
- BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Emma Muñoz-Moreno
- BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Rodrigo J. Carbajo
- Structural Biochemistry Laboratory, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Anna González-Tendero
- BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Miriam Illa
- BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Magdalena Sanz-Cortés
- BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Antonio Pineda-Lucena
- Structural Biochemistry Laboratory, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Eduard Gratacós
- BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal i+D Fetal Medicine Research Center, IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- * E-mail:
| |
Collapse
|
38
|
Jones S, Bischof H, Lang I, Desoye G, Greenwood SL, Johnstone ED, Wareing M, Sibley CP, Brownbill P. Dysregulated flow-mediated vasodilatation in the human placenta in fetal growth restriction. J Physiol 2015; 593:3077-92. [PMID: 25920377 PMCID: PMC4532528 DOI: 10.1113/jp270495] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 04/22/2015] [Indexed: 11/14/2022] Open
Abstract
Increased vascular resistance and reduced fetoplacental blood flow are putative aetiologies in the pathogenesis of fetal growth restriction (FGR); however, the regulating sites and mechanisms remain unclear. We hypothesised that placental vessels dictate fetoplacental resistance and in FGR exhibit endothelial dysfunction and reduced flow-mediated vasodilatation (FMVD). Resistance was measured in normal pregnancies (n = 10) and FGR (n = 10) both in vivo by umbilical artery Doppler velocimetry and ex vivo by dual placental perfusion. Ex vivo FMVD is the reduction in fetal-side inflow hydrostatic pressure (FIHP) following increased flow rate. Results demonstrated a significant correlation between vascular resistance measured in vivo and ex vivo in normal pregnancy, but not in FGR. In perfused FGR placentas, vascular resistance was significantly elevated compared to normal placentas (58 ± 7.7 mmHg and 36.8 ± 4.5 mmHg, respectively; 8 ml min−1; means ± SEM; P < 0.0001) and FMVD was severely reduced (3.9 ± 1.3% and 9.1 ± 1.2%, respectively). In normal pregnancies only, the highest level of ex vivo FMVD was associated with the lowest in vivo resistance. Inhibition of NO synthesis during perfusion (100 μm l-NNA) moderately elevated FIHP in the normal group, but substantially in the FGR group. Human placenta artery endothelial cells from FGR groups exhibited increased shear stress-induced NO generation, iNOS expression and eNOS expression compared with normal groups. In conclusion, fetoplacental resistance is determined by placental vessels, and is increased in FGR. The latter also exhibit reduced FMVD, but with a partial compensatory increased NO generation capacity. The data support our hypothesis, which highlights the importance of FMVD regulation in normal and dysfunctional placentation.
Collapse
Affiliation(s)
- Sarah Jones
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Helen Bischof
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Ingrid Lang
- Institute of Cell Biology, Histology and Embryology, Medical University of Graz, Graz, Austria
| | - Gernot Desoye
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Sue L Greenwood
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Edward D Johnstone
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Mark Wareing
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Colin P Sibley
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Paul Brownbill
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| |
Collapse
|
39
|
Yoshida A, Umehara N, Sasahara J, Ozawa K, Ichizuka K, Tanaka K, Tanemoto T, Ishikawa H, Murakoshi T, Kiyoshi K, Oba MS, Ishii K, Sago H. Prenatal risk stratification of severe small-for-gestational-age infants: a Japanese multicenter study. J Matern Fetal Neonatal Med 2015; 29:1353-7. [DOI: 10.3109/14767058.2015.1049147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
40
|
AbdelMaboud NM, Elsaid HH. Role of venous Doppler evaluation of intrauterine growth retardation. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2015. [DOI: 10.1016/j.ejrnm.2014.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
41
|
Kiseli M, Caglar GS, Gursoy AY, Ozdemir ED, Ozdemir H, Seker RT, Demirtas S. Maternal and fetal blood levels of S100 and ischaemia modified albumin in term intrauterine growth restricted fetuses with abnormal umbilical artery Doppler values. J OBSTET GYNAECOL 2014; 35:368-71. [DOI: 10.3109/01443615.2014.968105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
42
|
Padmanabhan S, McLean M, Cheung NW. Falling insulin requirements are associated with adverse obstetric outcomes in women with preexisting diabetes. Diabetes Care 2014; 37:2685-92. [PMID: 25071078 DOI: 10.2337/dc14-0506] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the clinical significance of falling insulin requirements in women with preexisting or overt diabetes in pregnancy. RESEARCH DESIGN AND METHODS A retrospective review of 139 pregnancies was conducted in women, with preexisting diabetes, delivering between January 2010 and January 2013. Women with falling insulin requirements of 15% or more from the peak total daily dose in late pregnancy were considered case subjects (n = 35). The primary outcome consisted of a composite of clinical markers of placental dysfunction, including preeclampsia, small for gestational age (SGA, ≤5th percentile for gestational age), stillbirth (>20 weeks), and premature delivery (≤30 weeks). RESULTS A total of 25.2% of women had >15% fall in insulin requirements with nulliparity as the only predictor at baseline (odds ratio [OR] 2.5 [95% CI 1.1-5.7], P = 0.03). Falling insulin requirements were associated with an increased risk of preeclampsia (OR 3.5 [1.1-10.7], P < 0.05) and the composite of clinical markers of placental dysfunction (4.4 [1.73-11.26], P = 0.002). Although falling insulin requirements were associated with higher rates of SGA (3.4 [1.0-11.3], P = 0.048), they were not associated with other adverse neonatal outcomes. However, there was a higher incidence of neonatal intensive care unit admission (15.5 [3.1-77.6], P = 0.001) and earlier delivery in this group (median 37.7 weeks [IQR 34.3-38.4] vs. 38.3 weeks [37.4-38.9], P = 0.014). CONCLUSIONS Falling insulin requirements, in women with preexisting diabetes, are associated with an increased risk of complications related to placental dysfunction. Further prospective studies are needed to guide clinical management.
Collapse
Affiliation(s)
- Suja Padmanabhan
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, New South Wales, Australia School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Mark McLean
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, New South Wales, Australia Department of Diabetes and Endocrinology, Blacktown Hospital, Blacktown, New South Wales, Australia School of Medicine, University of Western Sydney, Sydney, New South Wales, Australia
| | - N Wah Cheung
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, New South Wales, Australia School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
43
|
Deter RL, Lee W, Sangi-Haghpeykar H, Tarca AL, Yeo L, Romero R. A modified prenatal growth assessment score for the evaluation of fetal growth in the third trimester using single and composite biometric parameters. J Matern Fetal Neonatal Med 2014; 28:745-54. [PMID: 24993892 DOI: 10.3109/14767058.2014.934218] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To define modified Prenatal Growth Assessment Scores (mPGAS) for single and composite biometric parameters and determine their reference ranges in normal fetuses. METHODS Nine anatomical parameters (ap) were measured and the weight estimated (EWTa, EWTb) in a longitudinal study of 119 fetuses with normal neonatal growth outcomes. Expected third trimester size trajectories, obtained from second trimester Rossavik size models, were used in calculating Percent Deviations (% Dev's) and their age-specific reference ranges in each fetus. The components of individual % Dev's values outside their reference ranges, designated +iapPGAS, -iapPGAS, were averaged to give +apPGAS and -apPGAS values for the 3rd trimester. The +iapPGAS and -iapPGAS values for different combinations of ap (c1a (HC, AC, FDL, ThC, EWTa), c1b (HC, AC, FDL, ThC, EWTb), c2 (ThC, ArmC, AVol, TVol), c3 (HC, AC, FDL, EWTa)) were then averaged to give +icPGAS and -icPGAS values at different time points or at the end of the third trimester (+cPGAS, -cPGAS). Values for iapPGAS, ic1bPGAS, and ic2PGAS were compared to their respective apPGAS or cPGAS reference ranges. RESULTS All mPGAS values had one 95% range boundary at 0.0%. Upper boundaries of 1D +apPGAS values ranged from 0.0% (HC) to +0.49% (ThC) and were +0.06%, +2.3% and +1.8% for EWT, AVol and TVol, respectively. Comparable values for -apPGAS were 0.0% (BPD, FDL, HDL), to -0.58% (ArmC), -0.13% (EWT), -0.8% (AVol), and 0.0% (TVol). The +cPGAS, 95% reference range upper boundaries varied from +0.36% (c1b) to +0.89% (c2). Comparable values for -cPGAS lower boundaries were -0.17% (c1b) to -0.43% (c2). CONCLUSIONS The original PGAS concept has now been extended to individual biometric parameters and their combinations. With the standards provided, mPGAS values can now be tested to see if detection of different types of third trimester growth problems is improved.
Collapse
Affiliation(s)
- Russell L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine , Houston, TX , USA
| | | | | | | | | | | |
Collapse
|
44
|
Kovo M, Schreiber L, Elyashiv O, Ben-Haroush A, Abraham G, Bar J. Pregnancy Outcome and Placental Findings in Pregnancies Complicated by Fetal Growth Restriction With and Without Preeclampsia. Reprod Sci 2014; 22:316-21. [DOI: 10.1177/1933719114542024] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Michal Kovo
- Department of Obstetrics & Gynecology, Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Letizia Schreiber
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pathology, Edith Wolfson Medical Center, Holon, Israel
| | - Osnat Elyashiv
- Department of Obstetrics & Gynecology, Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Ben-Haroush
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Obstetrics & Gynecology, Rabin Medical Center, Petah-Tikva
| | - Golan Abraham
- Department of Obstetrics & Gynecology, Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob Bar
- Department of Obstetrics & Gynecology, Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
45
|
Herrera EA, Krause B, Ebensperger G, Reyes RV, Casanello P, Parra-Cordero M, Llanos AJ. The placental pursuit for an adequate oxidant balance between the mother and the fetus. Front Pharmacol 2014; 5:149. [PMID: 25009498 PMCID: PMC4068002 DOI: 10.3389/fphar.2014.00149] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 06/06/2014] [Indexed: 11/13/2022] Open
Abstract
The placenta is the exchange organ that regulates metabolic processes between the mother and her developing fetus. The adequate function of this organ is clearly vital for a physiologic gestational process and a healthy baby as final outcome. The umbilico-placental vasculature has the capacity to respond to variations in the materno-fetal milieu. Depending on the intensity and the extensity of the insult, these responses may be immediate-, mediate-, and long-lasting, deriving in potential morphostructural and functional changes later in life. These adjustments usually compensate the initial insults, but occasionally may switch to long-lasting remodeling and dysfunctional processes, arising maladaptation. One of the most challenging conditions in modern perinatology is hypoxia and oxidative stress during development, both disorders occurring in high-altitude and in low-altitude placental insufficiency. Hypoxia and oxidative stress may induce endothelial dysfunction and thus, reduction in the perfusion of the placenta and restriction in the fetal growth and development. This Review will focus on placental responses to hypoxic conditions, usually related with high-altitude and placental insufficiency, deriving in oxidative stress and vascular disorders, altering fetal and maternal health. Although day-to-day clinical practice, basic and clinical research are clearly providing evidence of the severe impact of oxygen deficiency and oxidative stress establishment during pregnancy, further research on umbilical and placental vascular function under these conditions is badly needed to clarify the myriad of questions still unsettled.
Collapse
Affiliation(s)
- Emilio A Herrera
- Laboratorio de Función y Reactividad Vascular, Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile Santiago, Chile ; International Center for Andean Studies, Universidad de Chile Santiago, Chile
| | - Bernardo Krause
- División de Obstetricia y Ginecología, Facultad de Medicina, Pontificia Universidad Católica de Chile Santiago, Chile
| | - German Ebensperger
- Laboratorio de Función y Reactividad Vascular, Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile Santiago, Chile
| | - Roberto V Reyes
- Laboratorio de Función y Reactividad Vascular, Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile Santiago, Chile
| | - Paola Casanello
- División de Obstetricia y Ginecología, Facultad de Medicina, Pontificia Universidad Católica de Chile Santiago, Chile ; División de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile Santiago, Chile
| | - Mauro Parra-Cordero
- Unidad Materno-Fetal, Hospital Clínico Universidad de Chile, Universidad de Chile Santiago, Chile
| | - Anibal J Llanos
- Laboratorio de Función y Reactividad Vascular, Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile Santiago, Chile ; International Center for Andean Studies, Universidad de Chile Santiago, Chile
| |
Collapse
|
46
|
Seravalli V, Block-Abraham DM, Turan OM, Doyle LE, Blitzer MG, Baschat AA. Second-trimester prediction of delivery of a small-for-gestational-age neonate: integrating sequential Doppler information, fetal biometry, and maternal characteristics. Prenat Diagn 2014; 34:1037-43. [PMID: 24864018 DOI: 10.1002/pd.4418] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 05/19/2014] [Accepted: 05/19/2014] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the predictive accuracy of second-trimester ultrasound parameters, maternal characteristics, and sequential Doppler changes between first and second trimesters for the prediction of small-for-gestational-age (SGA) infants (birth weight < 10th percentile). METHODS We conducted a prospective study of singleton pregnancies enrolled in the first trimester with subsequent second-trimester follow-up. Maternal characteristics, uterine artery (UtA) pulsatility index (PI), fetal biometry, and umbilical artery (UA)-PI were ascertained. UtA and UA-PI change from first to second trimester was calculated (ΔUtA-PI and ΔUA-PI). These parameters were tested for their ability to predict delivery of an SGA infant. RESULTS Among 1982 women, 172 delivered an SGA neonate. African-American ethnicity, nulliparity, tobacco use, and low abdominal circumference (AC) z-score were independent predictors of SGA. No difference was found in the magnitude of ΔUtA-PI and ΔUA-PI between SGA and no-SGA. Receiver-operating characteristics curve analysis yielded an area under the curve of 0.700 for AC z-score. The combination of low AC and bilateral notching had high specificity (99%) but low sensitivity (7%) for SGA prediction. CONCLUSIONS A small second-trimester fetal AC is a specific marker for SGA when found with bilateral UtA notching. Only a small proportion is predicted by the factors studied, suggesting a small contributory role or later evolution of SGA.
Collapse
Affiliation(s)
- Viola Seravalli
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | | | | | | |
Collapse
|
47
|
Stergiotou I, Crispi F, Valenzuela-Alcaraz B, Cruz-Lemini M, Bijnens B, Gratacos E. Aortic and carotid intima-media thickness in term small-for-gestational-age newborns and relationship with prenatal signs of severity. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:625-631. [PMID: 24272754 DOI: 10.1002/uog.13245] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 09/30/2013] [Accepted: 10/23/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To assess carotid and aortic intima-media thickness (IMT) in term small-for-gestational-age (SGA) newborns with and without prenatal signs of severity. METHODS This prospective study comprised 67 cases diagnosed prenatally and 134 normally grown newborns. Cases were subclassified into SGA with no signs of severity and those with signs of severity, defined as a birth weight below the 3(rd) percentile or abnormal uterine artery Doppler or cerebroplacental ratio. Blood pressure and vascular IMT were evaluated. RESULTS SGA newborns showed a non-significant trend for higher values of blood pressure. IMT values were significantly increased in SGA newborns, with and without signs of severity, compared with controls. The magnitude of the increase was higher in SGA newborns with signs of severity. CONCLUSIONS Vascular IMT was increased in SGA newborns, irrespective of the presence or absence of prenatal signs of severity. This finding challenges the notion of 'constitutionally small' SGA, and supports the premise that the majority of SGA newborns have true growth restriction and suffer fetal cardiovascular programming.
Collapse
Affiliation(s)
- I Stergiotou
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Barcelona, Spain; IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | | | | | | | | | | |
Collapse
|
48
|
Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Pregnancy Hypertens 2014; 4:105-45. [PMID: 26104418 DOI: 10.1016/j.preghy.2014.01.003] [Citation(s) in RCA: 245] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 01/17/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation and treatment of the hypertensive disorders of pregnancy (HDP). EVIDENCE The literature reviewed included the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines from 2008 and their reference lists, and an update from 2006. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT) and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2006 and March 2012. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care and GRADE.
Collapse
Affiliation(s)
| | - Anouk Pels
- Academic Medical Centre, Amsterdam, The Netherlands
| | | | | | | | | |
Collapse
|
49
|
Mikovic Z, Mandic V, Parovic V, Bogavac M, Simin N. Erythropoietin in amniotic fluid as a potential marker in distinction between growth restricted and constitutionally small fetuses. J Matern Fetal Neonatal Med 2013; 27:1134-7. [PMID: 24144060 DOI: 10.3109/14767058.2013.851184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine if there is any difference in amniotic fluid erythropoietin (EPO) concentration between fetuses small for gestational age (SGA) and appropriate for gestational age (AGA), and between the constitutionally small (CSF) and growth-restricted (GRF) fetuses. METHODS EPO concentrations in the amniotic fluid samples were determined by EpoELISA test in 38 pregnancies with SGA and 15 pregnancies with AGA fetuses. In the SGA group we measured Ponderal index (PI) and skin-fold thickness (SFT). If PI and/or SFT were below 10th percentile the neonate was GRF. If both PI and SFT were above 10th percentile the neonate was CSF. RESULTS Higher levels of EPO were detected in the SGA in comparison to the AGA fetuses (p < 0.01). EPO concentration was higher in GRF compared to CSF (p < 0.05). The EPO cut-off level between SGA and AGA was 6.81 IU/L (sensitivity 92.3%; specificity 73.3%), and between GRF and CSF was 9.8 IU/L (sensitivity 81%; specificity 80%). CONCLUSION The preliminary results of this study suggest that amniotic fluid erythropoietin concentration is elevated in growth-restricted fetuses and could potentially be used for distinction between growth restricted and constitutionally small fetuses. Confirmation of these results on a larger group of pregnant women is needed.
Collapse
Affiliation(s)
- Zeljko Mikovic
- Department of High-risk Pregnancies, University Clinic for Gynecology and Obstetrics "Narodni front", Medical School, University of Belgrade , Belgrade , Serbia
| | | | | | | | | |
Collapse
|
50
|
Skråstad RB, Eik-Nes SH, Sviggum O, Johansen OJ, Salvesen KÅ, Romundstad PR, Blaas HGK. A randomized controlled trial of third-trimester routine ultrasound in a non-selected population. Acta Obstet Gynecol Scand 2013; 92:1353-60. [DOI: 10.1111/aogs.12249] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 08/21/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Ragnhild B. Skråstad
- Faculty of Medicine; Department of Laboratory Medicine Children's and Women's Health; Norwegian University of Science and Technology; Trondheim Norway
- Department of Obstetrics and Gynecology; National Center for Fetal Medicine; St Olav's Hospital; Trondheim University Hospital; Trondheim Norway
| | - Sturla H. Eik-Nes
- Faculty of Medicine; Department of Laboratory Medicine Children's and Women's Health; Norwegian University of Science and Technology; Trondheim Norway
- Department of Obstetrics and Gynecology; National Center for Fetal Medicine; St Olav's Hospital; Trondheim University Hospital; Trondheim Norway
| | | | - Ole J. Johansen
- Department of Pediatrics; St Olav's Hospital; Trondheim University Hospital; Trondheim Norway
| | - Kjell Å. Salvesen
- Faculty of Medicine; Department of Laboratory Medicine Children's and Women's Health; Norwegian University of Science and Technology; Trondheim Norway
- Department of Obstetrics and Gynecology; National Center for Fetal Medicine; St Olav's Hospital; Trondheim University Hospital; Trondheim Norway
| | - Pål R. Romundstad
- Department of Public Health and General Practice; Norwegian University of Science and Technology (NTNU); Trondheim Norway
| | - Harm-Gerd K. Blaas
- Faculty of Medicine; Department of Laboratory Medicine Children's and Women's Health; Norwegian University of Science and Technology; Trondheim Norway
- Department of Obstetrics and Gynecology; National Center for Fetal Medicine; St Olav's Hospital; Trondheim University Hospital; Trondheim Norway
| |
Collapse
|