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Alda MG, Holberton J, MacDonald TM, Charlton JK. Small for gestational age at preterm birth identifies adverse neonatal outcomes more reliably than antenatal suspicion of fetal growth restriction. J Matern Fetal Neonatal Med 2023; 36:2279017. [PMID: 37981759 DOI: 10.1080/14767058.2023.2279017] [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: 06/05/2023] [Accepted: 10/30/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Fetal growth restriction (FGR) is an important reason for premature delivery and a leading cause of perinatal morbidity and mortality. We aimed to evaluate whether classification as small for gestational age (SGA; <10th centile) at birth or antenatal suspicion of FGR was more strongly associated with neonatal morbidity and mortality in preterm infants. METHODS A retrospective audit of infants born between 24 + 0 and 32 + 6 weeks of gestation from 2012-2019 and admitted to the Neonatal Unit at Mercy Hospital for Women (MHW). Infants were categorized according to whether FGR was listed as an antenatal complication in the medical records and whether they were SGA (<10th centile on Fenton chart) or appropriate for gestational age (AGA) at birth, and comparisons for neonatal outcomes were made. RESULTS 371/2126 preterm infants (17.5%) had antenatal suspicion of FGR, and 166 (7.8%) were SGA at birth. No differences in any neonatal outcomes were found between infants with or without suspected FGR, except decreased intraventricular hemorrhage (IVH) in the FGR group. SGA classification was associated with increased rates of all morbidities other than IVH, including bronchopulmonary dysplasia, retinopathy of prematurity, and necrotizing enterocolitis, compared with the AGA group. Death was significantly higher in the SGA group (7.2%) compared with the AGA group (3.5%). CONCLUSION SGA by Fenton chart more reliably identified neonates at risk of adverse neonatal outcomes than antenatal suspicion of FGR, suggesting it is a reasonable clinical proxy. This most likely reflects the much lower tenth centile weight cutoffs on the Fenton charts compared to in-utero charts used antenatally to diagnose FGR based on ultrasound estimated fetal weight. SGA classification by Fenton approximately equates to <3rd centile on in-utero charts at our institution, therefore identifying the most severe FGR cases.
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Affiliation(s)
- Maria G Alda
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Department of Paediatrics, Mercy Hospital for Women, Melbourne, Australia
| | - James Holberton
- Department of Paediatrics, Mercy Hospital for Women, Melbourne, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Teresa M MacDonald
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | - Julia K Charlton
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Division of Neonatology, BC Women's Hospital, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
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2
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Meler E, Mazarico E, Peguero A, Gonzalez A, Martinez J, Boada D, Vellvé K, Arca G, Gómez-Roig MD, Gratacós E, Figueras F. Death and severe morbidity in isolated periviable small-for-gestational-age fetuses. BJOG 2023; 130:485-493. [PMID: 35437890 DOI: 10.1111/1471-0528.17181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aims to predict perinatal death or severe sequelae in isolated small-for-gestational-age fetuses, diagnosed at a periviable gestational age, based on ultrasound and Doppler parameters at diagnosis. DESIGN Observational study. SETTING A tertiary perinatal centre. POPULATION A cohort of singleton non-malformed fetuses suspected to be small for gestational age (estimated fetal weight, EFW, <10th centile) diagnosed at 22.0-25.6 weeks of gestation. The following parameters were recorded at diagnosis: severe smallness (<3rd centile); absent or reversed end-diastolic velocity in umbilical artery; abnormal middle cerebral artery Doppler; abnormal cerebroplacental ratio; abnormal uterine artery Doppler; and absent or reversed end-diastolic velocity in the ductus venosus. METHODS Logistic regression analysis. MAIN OUTCOME MEASURES Predictive performance of EFW and Doppler parameters for short-term adverse outcome of perinatal morbimortality and composite serious adverse outcomes (death, neurological impairment or severe bronchopulmonary dysplasia). RESULTS A total of 155 pregnancies were included. There were 13 (8.4%) intrauterine and 11 (7.7%) neonatal deaths. A short-term adverse perinatal outcome occurred in 40 (25.8%) pregnancies. There were 31 (20%) cases of serious adverse outcomes. For the prediction of serious adverse outcomes, the combination of absent or reversed end-diastolic velocity in the umbilical artery and impaired middle cerebral artery detected by Doppler evaluation achieved a detection rate of 87%, with a false-positive rate of 14% (accuracy 86%). CONCLUSION In periviable isolated small-for-gestational-age fetuses, a Doppler evaluation of the umbilical and fetal brain circulation can accurately predict short-term adverse perinatal complications and serious adverse outcomes.
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Affiliation(s)
- Eva Meler
- Barcelona Centre for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS (Institut D'Investigacions Biomediques August Pi i Sunyer), University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Edurne Mazarico
- Barcelona Centre for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), University of Barcelona and Institut de Recerca Sant Joan de Déu (IR-SJD), Barcelona, Spain.,Maternal and Child Health Development Network, RETICS (Redes Temáticas de Investigación Cooperativa en Salud), Research Institute Carlos III, Spanish Ministry of Economy and Competitiveness, Madrid, Spain
| | - Anna Peguero
- Barcelona Centre for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS (Institut D'Investigacions Biomediques August Pi i Sunyer), University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Alba Gonzalez
- Barcelona Centre for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), University of Barcelona and Institut de Recerca Sant Joan de Déu (IR-SJD), Barcelona, Spain
| | - Judit Martinez
- Barcelona Centre for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS (Institut D'Investigacions Biomediques August Pi i Sunyer), University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - David Boada
- Barcelona Centre for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS (Institut D'Investigacions Biomediques August Pi i Sunyer), University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Killian Vellvé
- Barcelona Centre for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS (Institut D'Investigacions Biomediques August Pi i Sunyer), University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Gemma Arca
- Department of Neonatology, Hospital Clinic, IDIBAPS (Institut D'Investigacions Biomediques August Pi i Sunyer), Barcelona, Spain.,NeNE Foundation, Madrid, Spain
| | - Maria Dolores Gómez-Roig
- Barcelona Centre for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), University of Barcelona and Institut de Recerca Sant Joan de Déu (IR-SJD), Barcelona, Spain.,Maternal and Child Health Development Network, RETICS (Redes Temáticas de Investigación Cooperativa en Salud), Research Institute Carlos III, Spanish Ministry of Economy and Competitiveness, Madrid, Spain
| | - Eduard Gratacós
- Barcelona Centre for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS (Institut D'Investigacions Biomediques August Pi i Sunyer), University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Francesc Figueras
- Barcelona Centre for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS (Institut D'Investigacions Biomediques August Pi i Sunyer), University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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3
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Parekh SA, Cox SM, Barkovich AJ, Chau V, Steurer MA, Xu D, Miller SP, McQuillen PS, Peyvandi S. The Effect of Size and Asymmetry at Birth on Brain Injury and Neurodevelopmental Outcomes in Congenital Heart Disease. Pediatr Cardiol 2022; 43:868-877. [PMID: 34853878 PMCID: PMC9005428 DOI: 10.1007/s00246-021-02798-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 11/24/2021] [Indexed: 11/10/2022]
Abstract
Poor and asymmetric fetal growth have been associated with neonatal brain injury (BI) and worse neurodevelopmental outcomes (NDO) in the growth-restricted population due to placental insufficiency. We tested the hypothesis that postnatal markers of fetal growth (birthweight (BW), head circumference (HC), and head to body symmetry) are associated with preoperative white matter injury (WMI) and NDO in infants with single ventricle physiology (SVP) and d-transposition of great arteries (TGA). 173 term newborns (106 TGA; 67 SVP) at two sites had pre-operative brain MRI to assess for WMI and measures of microstructural brain development. NDO was assessed at 30 months with the Bayley Scale of Infant Development-II (n = 69). We tested the association between growth parameters at birth with the primary outcome of WMI on the pre-operative brain MRI. Secondary outcomes included measures of NDO. Newborns with TGA were more likely to have growth asymmetry with smaller heads relative to weight while SVP newborns were symmetrically small. There was no association between BW, HC or asymmetry and WMI on preoperative brain MRI or with measures of microstructural brain development. Similarly, growth parameters at birth were not associated with NDO at 30 months. In a multivariable model only cardiac lesion and site were associated with NDO. Unlike other high-risk infant populations, postnatal markers of fetal growth including head to body asymmetry that is common in TGA is not associated with brain injury or NDO. Lesion type appears to play a more important role in NDO in CHD.
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Affiliation(s)
- Shalin A Parekh
- Division of Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, Mission Hall Box 0544, 550 16th Street, 5th Floor, San Francisco, CA, 94158, USA
| | - Stephany M Cox
- Division of Developmental Pediatrics and Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, USA
| | - A James Barkovich
- Department of Radiology, University of California, San Francisco, USA
| | - Vann Chau
- Department of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Martina A Steurer
- Division of Critical Care, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, USA
| | - Duan Xu
- Department of Radiology, University of California, San Francisco, USA
| | - Steven P Miller
- Department of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Patrick S McQuillen
- Division of Critical Care, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, USA
| | - Shabnam Peyvandi
- Division of Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, Mission Hall Box 0544, 550 16th Street, 5th Floor, San Francisco, CA, 94158, USA.
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4
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Sutherland AE, Yawno T, Castillo-Melendez M, Allison BJ, Malhotra A, Polglase GR, Cooper LJ, Jenkin G, Miller SL. Does Antenatal Betamethasone Alter White Matter Brain Development in Growth Restricted Fetal Sheep? Front Cell Neurosci 2020; 14:100. [PMID: 32425758 PMCID: PMC7203345 DOI: 10.3389/fncel.2020.00100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/01/2020] [Indexed: 11/13/2022] Open
Abstract
Fetal growth restriction (FGR) is a common complication of pregnancy often associated with neurological impairments. Currently, there is no treatment for FGR, hence it is likely these babies will be delivered prematurely, thus being exposed to antenatal glucocorticoids. While there is no doubt that antenatal glucocorticoids reduce neonatal mortality and morbidities, their effects on the fetal brain, particularly in FGR babies, are less well recognized. We investigated the effects of both short- and long-term exposure to antenatal betamethasone treatment in both FGR and appropriately grown fetal sheep brains. Surgery was performed on pregnant Border-Leicester Merino crossbred ewes at 105-110 days gestation (term ~150 days) to induce FGR by single umbilical artery ligation (SUAL) or sham surgery. Ewes were then treated with a clinical dose of betamethasone (11.4 mg intramuscularly) or saline at 113 and 114 days gestation. Animals were euthanized at 115 days (48 h following the initial betamethasone administration) or 125 days (10 days following the initial dose of betamethasone) and fetal brains collected for analysis. FGR fetuses were significantly smaller than controls (115 days: 1.68 ± 0.11 kg vs. 1.99 ± 0.11 kg, 125 days: 2.70 ± 0.15 kg vs. 3.31 ± 0.20 kg, P < 0.001) and betamethasone treatment reduced body weight in both control (115 days: 1.64 ± 0.10 kg, 125 days: 2.53 ± 0.10 kg) and FGR fetuses (115 days: 1.41 ± 0.10 kg, 125 days: 2.16 ± 0.17 kg, P < 0.001). Brain: body weight ratios were significantly increased with FGR (P < 0.001) and betamethasone treatment (P = 0.002). Within the fetal brain, FGR reduced CNPase-positive myelin staining in the subcortical white matter (SCWM; P = 0.01) and corpus callosum (CC; P = 0.01), increased GFAP staining in the SCWM (P = 0.02) and reduced the number of Olig2 cells in the periventricular white matter (PVWM; P = 0.04). Betamethasone treatment significantly increased CNPase staining in the external capsule (EC; P = 0.02), reduced GFAP staining in the CC (P = 0.03) and increased Olig2 staining in the SCWM (P = 0.04). Here we show that FGR has progressive adverse effects on the fetal brain, particularly within the white matter. Betamethasone exacerbated growth restriction in the FGR offspring, but betamethasone did not worsen white matter brain injury.
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Affiliation(s)
- Amy E Sutherland
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Tamara Yawno
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Margie Castillo-Melendez
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Beth J Allison
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Atul Malhotra
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia.,Department of Paediatrics, Monash University, Clayton, VIC, Australia
| | - Graeme R Polglase
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Leo J Cooper
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Graham Jenkin
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Suzanne L Miller
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
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5
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Zanno AE, Romer MA, Fox L, Golden T, Jaeckle-Santos L, Simmons RA, Grinspan JB. Reducing Th2 inflammation through neutralizing IL-4 antibody rescues myelination in IUGR rat brain. J Neurodev Disord 2019; 11:34. [PMID: 31839002 PMCID: PMC6913005 DOI: 10.1186/s11689-019-9297-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 11/11/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Intrauterine growth restriction (IUGR) is a common complication of pregnancy and is associated with significant neurological deficits in infants, including white matter damage. Previous work using an animal model of IUGR has demonstrated that IUGR rats exhibit neurobehavioral deficits and developmental delays in oligodendrocyte maturation and myelination, but the mechanisms which cause this delay are unknown. Inflammation may be an important etiological factor in IUGR and has been recognized as playing a fundamental role in the pathogenesis of myelin disorders, including cerebral palsy. METHODS To create the model, the uterine arteries of pregnant rats were ligated at embryonic day 15. Rats delivered spontaneously. Cytokine and chemokine expression was evaluated at one prenatal and three postnatal time points, and myelin protein expression and oligodendrocyte cell numbers were evaluated by several methods at postnatal day 14. IL-4 was identified as a potential inhibitor of myelination, and rat pups were injected with IL-4 function blocking antibody from postnatal days 1-5 and myelination was assessed. RESULTS Here, we show a novel mechanism of white matter injury. IUGR induces an exaggerated Th2 response in the developing rat brain, including upregulation of several Th2 cytokines. Of these, IL-4 is significantly increased during the period corresponding to robust developmental myelination. We show that neutralizing IL-4 antibody therapy given in the newborn period ameliorates inflammation and restores myelin protein expression and oligodendrocyte cell number in the IUGR brain to control levels, demonstrating a novel role for Th2 responses and IL-4 in IUGR and white matter injury. In addition, IL-4 directly affects oligodendrocytes in vitro decreasing differentiation. CONCLUSIONS In this study, we have identified inflammation as a factor in the decrease in myelin seen in an animal model of IUGR. IL-4, an inflammatory protein often thought to be protective in the adult, is specifically increased, and treatment of these animals to prevent this increase ameliorates white matter damage. Our results suggest that the immune system plays a role in IUGR that is different in the perinatal period than in the adult and preventing this exaggerated Th2 response may be a potential therapeutic target.
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Affiliation(s)
- Allison E. Zanno
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
| | - Micah A. Romer
- Department of Neurology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 516D Abramson Center, 3615 Civic Center Blvd, Philadelphia, PA 19104 USA
| | - Lauren Fox
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
| | - Thea Golden
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
| | - Lane Jaeckle-Santos
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
| | - Rebecca A. Simmons
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
| | - Judith B. Grinspan
- Department of Neurology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 516D Abramson Center, 3615 Civic Center Blvd, Philadelphia, PA 19104 USA
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6
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Melatonin as a master regulator of cell death and inflammation: molecular mechanisms and clinical implications for newborn care. Cell Death Dis 2019; 10:317. [PMID: 30962427 PMCID: PMC6453953 DOI: 10.1038/s41419-019-1556-7] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 03/19/2019] [Indexed: 12/11/2022]
Abstract
Melatonin, more commonly known as the sleep hormone, is mainly secreted by the pineal gland in dark conditions and regulates the circadian rhythm of the organism. Its intrinsic properties, including high cell permeability, the ability to easily cross both the blood–brain and placenta barriers, and its role as an endogenous reservoir of free radical scavengers (with indirect extra activities), confer it beneficial uses as an adjuvant in the biomedical field. Melatonin can exert its effects by acting through specific cellular receptors on the plasma membrane, similar to other hormones, or through receptor-independent mechanisms that involve complex molecular cross talk with other players. There is increasing evidence regarding the extraordinary beneficial effects of melatonin, also via exogenous administration. Here, we summarize molecular pathways in which melatonin is considered a master regulator, with attention to cell death and inflammation mechanisms from basic, translational and clinical points of view in the context of newborn care.
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7
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Goetzinger KR, Cahill AG, Odibo L, Macones GA, Odibo AO. Three-Dimensional Power Doppler Evaluation of Cerebral Vascular Blood Flow: A Novel Tool in the Assessment of Fetal Growth Restriction. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:139-147. [PMID: 28708246 DOI: 10.1002/jum.14323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 03/29/2017] [Accepted: 04/02/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To determine whether fetuses with fetal growth restriction (FGR) are more likely to have abnormal cerebral vascular flow patterns compared to fetuses who are appropriate for gestational age (AGA) when quantified by using 3-dimensional (3D) power Doppler ultrasound. METHODS We conducted a prospective cohort study of singleton gestations presenting for growth ultrasound examination between 24 and 36 weeks' gestation. Patients with FGR (estimated fetal weight < 10th percentile) were enrolled and matched 1:1 for gestational age (±7 days) with AGA fetuses. A standardized 3D power Doppler image of the middle cerebral artery territory was obtained from each patient. The vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) were calculated by the Virtual Organ computer-aided analysis technique (GE Healthcare, Milwaukee, WI). These indices were compared between FGR and AGA fetuses and correlated with 2-dimensional Doppler parameters. Neonatal outcomes were also compared with respect to the 3D parameters. RESULTS Of 306 patients, there were 151 cases of FGR. There was no difference in the VI (6.0 versus 5.7; P = .65) or VFI (2.0 versus 1.8; P = .31) between the groups; however, the FI was significantly higher in FGR fetuses compared to AGA controls (33.9 versus 32.3; P = .009). There was a weak, but significant, negative correlation between the FI and both the middle cerebral artery pulsatility index (r = -0.34; P < .001) and cerebroplacental ratio (r = -0.29; P < .001). Within the FGR group, there was no difference in any of the 3D vascular indices with regard to neonatal outcomes. CONCLUSIONS Three-dimensional power Doppler measurement of cerebral blood flow, but not the vascularization pattern, is significantly altered in FGR. This measurement may play a future role in distinguishing pathologic FGR from constitutionally small growth.
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Affiliation(s)
- Katherine R Goetzinger
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland, Baltimore, Maryland, USA
| | - Alison G Cahill
- Department of Obstetrics and Gynecology, Washington University, St Louis, Missouri, USA
| | - Linda Odibo
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, USA
| | - George A Macones
- Department of Obstetrics and Gynecology, Washington University, St Louis, Missouri, USA
| | - Anthony O Odibo
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, USA
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Sehgal A, Crispi F, Skilton MR, de Boode WP. Clinician performed ultrasound in fetal growth restriction: fetal, neonatal and pediatric aspects. J Perinatol 2017; 37:1251-1258. [PMID: 28837134 DOI: 10.1038/jp.2017.119] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/02/2017] [Accepted: 06/26/2017] [Indexed: 11/09/2022]
Abstract
Fetal growth restriction (FGR) affects 7-10% pregnancies. Conventional and tissue Doppler imaging has noted cardiac compromise during fetal and early neonatal periods in this cohort. In this article, we discuss the use of salient ultrasound parameters across age groups. During fetal life, certain feto-placental sonographic parameters have been linked to adverse perinatal outcomes and are predictive of later life hypertension. During the early postnatal period altered morphometry (hypertrophied and globular hearts) with sub-clinical impairment of cardiac function has been noted in both term and preterm infants with FGR. Vascular imaging has noted thickened and stiffer arteries in association with significantly elevated blood pressure. Similar findings in the pediatric age groups indicate persistence of these alterations, and have formed the basis of intervention studies. Assessment methodology and clinical relevance of these parameters, especially in designing and monitoring of intervention strategies is discussed. Frontline care givers (obstetricians and neonatologists) are increasingly using point of care ultrasound to discern these manifestations of FGR during the sub-clinical phase.
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Affiliation(s)
- A Sehgal
- Neonatologist, Monash Newborn, Monash Children's Hospital, Monash University, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - F Crispi
- BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Boden Institute, IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - M R Skilton
- The Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders, The University of Sydney, Camperdown, NSW, Australia
| | - W-P de Boode
- Department of Neonatology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
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9
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Lee YA. White Matter Injury of Prematurity: Its Mechanisms and Clinical Features. J Pathol Transl Med 2017; 51:449-455. [PMID: 28797157 PMCID: PMC5611534 DOI: 10.4132/jptm.2017.07.25] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/19/2017] [Accepted: 07/25/2017] [Indexed: 11/17/2022] Open
Abstract
A developing central nervous system is vulnerable to various insults such as infection and ischemia. While increased understanding of the dynamic nature of brain development allows a deeper insight into the pathophysiology of perinatal brain injury, the precise nature of specific fetal and neonatal brain injuries and their short- and long-term clinical consequences need special attention and further elucidation. The current review will describe the pathophysiological aspects and clinical significance of white matter injury of prematurity, a main form of perinatal brain injury in premature newborns, with a particular emphasis on its potential antenatal components.
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Affiliation(s)
- Young Ah Lee
- Division of Pediatric Neurology, Department of Pediatrics, Beaumont Hospital, Oakland University School of Medicine, Royal Oak, MI, USA
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10
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Detection and assessment of brain injury in the growth-restricted fetus and neonate. Pediatr Res 2017; 82:184-193. [PMID: 28234891 DOI: 10.1038/pr.2017.37] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/14/2017] [Indexed: 11/08/2022]
Abstract
Fetal growth restriction (FGR) is a common complication of pregnancy and, in severe cases, is associated with elevated rates of perinatal mortality, neonatal morbidity, and poor neurodevelopmental outcomes. The leading cause of FGR is placental insufficiency, with the placenta failing to adequately meet the increasing oxygen and nutritional needs of the growing fetus with advancing gestation. The resultant chronic fetal hypoxia induces a decrease in fetal growth, and a redistribution of blood flow preferentially to the brain. However, this adaptation does not ensure normal brain development. Early detection of brain injury in FGR, allowing for the prediction of short- and long-term neurodevelopmental consequences, remains a significant challenge. Furthermore, in FGR infants the detection and diagnosis of neuropathology is complicated by preterm birth, the etiological heterogeneity of FGR, timing of onset of growth restriction, its severity, and coexisting complications. In this review, we examine existing and emerging diagnostic tools from human and preclinical studies for the detection and assessment of brain injury in FGR fetuses and neonates. Increased detection rates, and early detection of brain injury associated with FGR, will offer opportunities for developing and assessing interventions to improve long-term outcomes.
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Groom KM, McCowan LM, Stone PR, Chamley LC, McLintock C. Enoxaparin for the prevention of preeclampsia and intrauterine growth restriction in women with a prior history - an open-label randomised trial (the EPPI trial): study protocol. BMC Pregnancy Childbirth 2016; 16:367. [PMID: 27876004 PMCID: PMC5120461 DOI: 10.1186/s12884-016-1162-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/15/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Preeclampsia and intrauterine fetal growth restriction (IUGR) are two of the most common causes of maternal and perinatal morbidity and mortality. Current methods of predicting those at most risk of these conditions remain relatively poor, and in clinical practice past obstetric history remains the most commonly used tool. Aspirin and, in women at risk of preeclampsia only, calcium have been demonstrated to have a modest effect on risk reduction. Several observational studies and randomised trials suggest that low molecular weight heparin (LMWH) therapy may confer some benefit. METHODS/DESIGN This is a multicentre open label randomised controlled trial to determine the effect of the LMWH, enoxaparin, on the prevention of recurrence of preeclampsia and/or IUGR in women at high risk due to their past obstetric history in addition to standard high risk care for all participants. INCLUSION CRITERIA A singleton pregnancy >6+0 and <16+0 weeks gestation with most recent prior pregnancy with duration >12 weeks having; (1) preeclampsia delivered <36+0 weeks, (2) Small for gestational age (SGA) infant <10th customised birthweight centile delivered <36+0 weeks or, (3) SGA infant ≤3rd customised birthweight centile delivered at any gestation. Randomisation is stratified for maternal thrombophilia status and women are randomly assigned to 'standard high risk care' or 'standard high risk care' plus enoxaparin 40 mg from recruitment until 36+0 weeks or delivery, whichever occurs sooner. Standard high risk care includes the use of aspirin 100 mg daily and calcium 1000-1500 mg daily (unless only had previous SGA with no preeclampsia). The primary outcome is preeclampsia and/or SGA <5th customised birthweight centile. Analysis will be by intention to treat. DISCUSSION The EPPI trial has more focussed and clinically relevant inclusion criteria than other randomised trials with a more restricted composite primary outcome. The inclusion of standard use of aspirin (and calcium) for all participants will help to ensure that any differences observed in outcome are likely to be related to enoxaparin use. These data will make a significant contribution to future meta-analyses and systematic reviews on the use of LMWH for the prevention of placental mediated conditions. TRIAL REGISTRATION ACTRN12609000699268 Australian New Zealand Clinical Trials Registry. Date registered 13/Aug/2009 (prospective registration).
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Affiliation(s)
- K. M. Groom
- Department of Obstetrics and Gynaecology, Faculty of Medical Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
- National Women’s Health, Auckland City Hospital, Private Bag 92024, Auckland, New Zealand
| | - L. M. McCowan
- Department of Obstetrics and Gynaecology, Faculty of Medical Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
- National Women’s Health, Auckland City Hospital, Private Bag 92024, Auckland, New Zealand
| | - P. R. Stone
- Department of Obstetrics and Gynaecology, Faculty of Medical Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - L. C. Chamley
- Department of Obstetrics and Gynaecology, Faculty of Medical Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - C. McLintock
- National Women’s Health, Auckland City Hospital, Private Bag 92024, Auckland, New Zealand
| | - the EPPI trial Study Group
- Department of Obstetrics and Gynaecology, Faculty of Medical Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
- National Women’s Health, Auckland City Hospital, Private Bag 92024, Auckland, New Zealand
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Perinatal outcome and cardiac dysfunction in preterm growth-restricted neonates in relation to placental impairment severity. An Pediatr (Barc) 2016. [DOI: 10.1016/j.anpede.2015.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Malhotra A, Yahya Z, Sasi A, Jenkin G, Ditchfield M, Polglase GR, Miller SL. Does fetal growth restriction lead to increased brain injury as detected by neonatal cranial ultrasound in premature infants? J Paediatr Child Health 2015; 51:1103-8. [PMID: 25939374 DOI: 10.1111/jpc.12910] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2015] [Indexed: 01/21/2023]
Abstract
AIM Intra-uterine growth restriction (IUGR) is an important cause for prematurity as well as a significant risk factor for neurodevelopmental deficits. In this study, we aimed to examine the association between IUGR and early brain injury on neonatal cranial ultrasound in preterm infants. METHODS This retrospective cohort study examined the relationship between IUGR and neonatal cranial ultrasound findings in preterm infants <32 weeks gestation with IUGR, compared with gestation and year of birth-matched appropriately grown infants, in a tertiary level neonatal unit. Primary outcome was incidence and severity of intraventricular haemorrhage (IVH), periventricular leucomalacia (PVL) and hydrocephalus detected by cranial ultrasound in the neonatal period. RESULTS A total of 153 IUGR and 306 non-IUGR preterm infants <32 weeks were included. The rates of IVH (21.6% vs. 23.9%), severe IVH (3.9% vs. 4.6%), PVL (8.4% vs. 9.4%), cystic PVL (2.6% vs. 0%) and hydrocephalus (0.7% vs. 0.3%) were similar in the two groups. Composite outcome of death and severe brain injury (severe IVH, cystic PVL and hydrocephalus) was greater (20.2% vs. 9.1%, P = 0.001) in IUGR infants. CONCLUSION IUGR did not lead to increased neonatal brain injury on cranial ultrasound but was associated with increased mortality. Advanced neonatal neuroimaging techniques may be necessary to estimate risk and to provide prognostic information of adverse neurological outcomes in this vulnerable population.
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Affiliation(s)
- Atul Malhotra
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia.,The Ritchie Centre, MIMR-PHI Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Zamir Yahya
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Arun Sasi
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Graham Jenkin
- The Ritchie Centre, MIMR-PHI Institute, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Michael Ditchfield
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia.,Diagnostic Imaging, Monash Health, Melbourne, Victoria, Australia
| | - Graeme R Polglase
- The Ritchie Centre, MIMR-PHI Institute, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Suzanne L Miller
- The Ritchie Centre, MIMR-PHI Institute, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
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Cruz-Martinez R, Tenorio V, Padilla N, Crispi F, Figueras F, Gratacos E. Risk of ultrasound-detected neonatal brain abnormalities in intrauterine growth-restricted fetuses born between 28 and 34 weeks' gestation: relationship with gestational age at birth and fetal Doppler parameters. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:452-459. [PMID: 26053732 DOI: 10.1002/uog.14920] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 05/26/2015] [Accepted: 05/31/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To estimate the value of gestational age at birth and fetal Doppler parameters in predicting the risk of neonatal cranial abnormalities in intrauterine growth-restricted (IUGR) fetuses born between 28 and 34 weeks' gestation. METHODS Fetal Doppler parameters including umbilical artery (UA), middle cerebral artery (MCA), aortic isthmus, ductus venosus and myocardial performance index were evaluated in a cohort of 90 IUGR fetuses with abnormal UA Doppler delivered between 28 and 34 weeks' gestation and in 90 control fetuses matched for gestational age. The value of gestational age at birth and fetal Doppler parameters in predicting the risk of ultrasound-detected cranial abnormalities (CUA), including intraventricular hemorrhage, periventricular leukomalacia and basal ganglia lesions, was analyzed. RESULTS Overall, IUGR fetuses showed a significantly higher incidence of CUA than did control fetuses (40.0% vs 12.2%, respectively; P < 0.001). Within the IUGR group, all predictive variables were associated individually with the risk of CUA, but fetal Doppler parameters rather than gestational age at birth were identified as the best predictor. MCA Doppler distinguished two groups with different degrees of risk of CUA (48.5% vs 13.6%, respectively; P < 0.01). In the subgroup with MCA vasodilation, presence of aortic isthmus retrograde net blood flow, compared to antegrade flow, allowed identification of a subgroup of cases with the highest risk of CUA (66.7% vs 38.6%, respectively; P < 0.05). CONCLUSION Evaluation of fetal Doppler parameters, rather than gestational age at birth, allows identification of IUGR preterm fetuses at risk of neonatal brain abnormalities.
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Affiliation(s)
- R Cruz-Martinez
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- Fetal Medicine and Surgery Research Unit, Children's and Women's Specialty Hospital of Queretaro and Unidad de Investigación en Neurodesarrollo 'Dr. Augusto Fernández Guardiola', Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM) Campus Juriquilla, Queretaro, Mexico
| | - V Tenorio
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - N Padilla
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - F Crispi
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - F Figueras
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - E Gratacos
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Candel Pau J, Perapoch López J, Castillo Salinas F, Sánchez Garcia O, Pérez Hoyos S, Llurba Olivé E. Neurodevelopment in preterm infants with and without placenta-related intrauterine growth restriction and its relation to perinatal and postnatal factors. J Matern Fetal Neonatal Med 2015; 29:2268-74. [DOI: 10.3109/14767058.2015.1081893] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Candel Pau J, Castillo Salinas F, Perapoch López J, Carrascosa Lezcano A, Sánchez García O, Llurba Olivé E. [Perinatal outcome and cardiac dysfunction in preterm growth-restricted neonates in relation to placental impairment severity]. An Pediatr (Barc) 2015; 85:170-180. [PMID: 25982472 DOI: 10.1016/j.anpedi.2015.03.014] [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: 02/04/2015] [Revised: 03/25/2015] [Accepted: 03/27/2015] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Intrauterine growth restriction (IUGR) and prematurity have been associated with increased perinatal morbidity and mortality and also with cardiovascular foetal programming. However, there are few studies on the impact of placenta-related IUGR on perinatal outcomes and cardiovascular biomarkers in pre-term infants. OBJECTIVES To determine differences in neonatal morbidity, mortality and cord blood biomarkers of cardiovascular dysfunction between pre-term placenta-related IUGR and non-IUGR new-borns, and to analyse their relationship with the severity of IUGR according to foetal Doppler evaluation. MATERIAL AND METHODS Prospective cohort study: pre-term infants with placenta-related IUGR and matched pre-term infants without IUGR. A Doppler scan was performed, and placenta-IUGR was classified according to severity. Comparative analysis of perinatal outcomes, neonatal morbidity and mortality, and cord blood levels of biomarkers of cardiovascular dysfunction was performed. RESULTS IUGR new-borns present lower weight, length, head circumference, and Apgar score at birth, as well as increased neonatal and cardiovascular dysfunction biomarker levels, compared with pre-term new-borns without IUGR. These differences increase with the severity of IUGR determined by prenatal umbilical artery Doppler scan. CONCLUSIONS Placenta-related-IUGR pre-term infants, irrespective of gestational age, present increased neonatal morbidity and mortality that is significantly proportional to the severity of IUGR. Placental impairment and severity also determine levels of cardiovascular dysfunction biomarkers at birth.
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Affiliation(s)
- Júlia Candel Pau
- Fundación Institut de Recerca de la Vall d'Hebron (VHIR), Barcelona, España.
| | - Félix Castillo Salinas
- Servicio de Neonatología, Hospital Universitario Vall d'Hebron, Barcelona, España; Universidad Autónoma de Barcelona, Barcelona, España
| | - Josep Perapoch López
- Servicio de Neonatología, Hospital Universitario Vall d'Hebron, Barcelona, España; Red de Salud Materno Infantil y del Desarrollo (RED SAMID), Barcelona, España
| | - Antonio Carrascosa Lezcano
- Servicio de Pediatría y Endocrinología Pediátrica, Hospital Universitario Vall d'Hebron, Barcelona, España; Universidad Autónoma de Barcelona, Barcelona, España; CIBERER, Barcelona, España
| | - Olga Sánchez García
- Fundación Institut de Recerca de la Vall d'Hebron (VHIR), Barcelona, España; Red de Salud Materno Infantil y del Desarrollo (RED SAMID), Barcelona, España
| | - Elisa Llurba Olivé
- Servicio de Obstetricia y Ginecología, Hospital Universitario Vall d'Hebron, Barcelona, España; Red de Salud Materno Infantil y del Desarrollo (RED SAMID), Barcelona, España; Universidad Autónoma de Barcelona, Barcelona, España
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Ballardini E, Tarocco A, Baldan A, Antoniazzi E, Garani G, Borgna-Pignatti C. Universal cranial ultrasound screening in preterm infants with gestational age 33-36 weeks. A retrospective analysis of 724 newborns. Pediatr Neurol 2014; 51:790-4. [PMID: 25456299 DOI: 10.1016/j.pediatrneurol.2014.08.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 08/05/2014] [Accepted: 08/23/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cranial ultrasonography is a useful tool to detect intracranial lesions in premature neonates at risk. Our primary aim was to determine the number of patients with abnormal cranial ultrasonography. Secondary aims were to evaluate the usefulness of universal cranial ultrasonography screening in moderately preterm infants. METHODS All infants born from 2007 to 2012 at the University Hospital of Ferrara (Italy), with gestational age of 33-36 weeks, were included in the study. Cranial ultrasonography findings were retrospectively classified into nonsignificant and significant. RESULTS All the 724 babies born were screened. Intracranial lesions were in 13% of neonates (3.7% at 36 weeks to 27.1% at 33 weeks of gestational age). Babies born at 33-34 weeks of gestational age were four times more likely to have an abnormal cranial ultrasonography than those at 35-36 weeks. Statistical analysis revealed no association between cranial ultrasonography abnormalities and being small for gestational age or mode of delivery. A significant association was present between the presence of head circumference less than the third percentile, the need for ventilation or surfactant, low Apgar index at fifth minute, and neurological abnormalities. The presence of at least one considered risk factor increases the probability of cranial ultrasonography abnormalities twice in infants born at 33-34 weeks and 15 times in born at 35-36 weeks. CONCLUSIONS A considerable number of infants born between 33 and 36 weeks have cranial ultrasonography abnormalities. We suggest that screening should be performed or at least that a uniform protocol should be developed for the early detection of all significant cranial ultrasonography abnormalities.
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Affiliation(s)
- Elisa Ballardini
- Neonatal Intensive Care Unit, Department of Reproduction and Growth, University Hospital of Ferrara, Ferrara, Italy.
| | - Anna Tarocco
- Paediatric Unit, Department of Medical Sciences, University Hospital of Ferrara, Ferrara, Italy
| | - Alessandro Baldan
- Paediatric Unit, Department of Medical Sciences, University Hospital of Ferrara, Ferrara, Italy
| | - Elisa Antoniazzi
- Paediatric Unit, Department of Medical Sciences, University Hospital of Ferrara, Ferrara, Italy
| | - Giampaolo Garani
- Neonatal Intensive Care Unit, Department of Reproduction and Growth, University Hospital of Ferrara, Ferrara, Italy
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Kittler PM, Brooks PJ, Rossi V, Karmel BZ, Gardner JM, Flory MJ. Neonatal Intensive-Care Unit Graduates Show Persistent Difficulties in an Intra-Dimensional Shift Card Sort. JOURNAL OF COGNITION AND DEVELOPMENT 2013; 14:633-650. [PMID: 24683313 DOI: 10.1080/15248372.2012.698433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Neonatal intensive-care unit (NICU) graduates, a group at risk for attention problems and ADHD, performed an intra-dimensional shift card sort at 34, 42, 51, and 60 months to assess executive function and to examine effects of individual risk factors. In the 'silly' game, children sorted cards (airplanes and dogs) so they were not the same as targets. In the 'same' game they did the opposite. Performance on the 'silly' game was poor, especially when it was presented first. Success in following 'silly' game rules improved with age, and was significantly linked to maternal education and birth weight for gestational age, a measure of intrauterine stress. Degree of CNS injury differentiated children who completed the task from children who did not, and also affected the need to repeat instructions in the 'same' game. These results confirm an increased likelihood of impairments in executive function during preschool years in NICU graduates.
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Affiliation(s)
- Phyllis M Kittler
- New York State Institute for Basic Research in Developmental Disabilities
| | - Patricia J Brooks
- College of Staten Island and the Graduate Center of City University of New York
| | - Vanessa Rossi
- New York State Institute for Basic Research in Developmental Disabilities
| | - Bernard Z Karmel
- New York State Institute for Basic Research in Developmental Disabilities and Richmond University Medical Center
| | - Judith M Gardner
- New York State Institute for Basic Research in Developmental Disabilities and Richmond University Medical Center
| | - Michael J Flory
- New York State Institute for Basic Research in Developmental Disabilities and Richmond University Medical Center
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Cerebral blood flow studies in the diagnosis and management of intrauterine growth restriction. Curr Opin Obstet Gynecol 2013; 25:138-44. [DOI: 10.1097/gco.0b013e32835e0e9c] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Scher MS. Normal and abnormal cerebrovascular development. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:1021-42. [DOI: 10.1016/b978-0-444-52910-7.00021-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Hernandez-Andrade E, Serralde JAB, Cruz-Martinez R. Can anomalies of fetal brain circulation be useful in the management of growth restricted fetuses? Prenat Diagn 2012; 32:103-12. [PMID: 22418951 DOI: 10.1002/pd.2913] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Assessment of the fetal cerebral circulation provides important information on the hemodynamic changes associated with chronic hypoxia and intrauterine growth restriction. Despite the incorporation of new US parameters, the landmark for the fetal brain hemodynamic evaluation is still the middle cerebral artery. However, new vascular territories, such as the anterior and posterior cerebral arteries, might provide additional information on the onset of the brain sparing effect. The fractional moving blood volume estimation and three-dimensional power Doppler ultrasound indices are new techniques that seem to be promising in identifying cases at earlier stages of vascular deterioration; still, they are not available for clinical application and more information is needed on the reproducibility and advantages of three-dimensional power Doppler ultrasound blood flow indices. In the past, the brain sparing effect was considered as a protective mechanism; however, recent information challenges this concept. There is growing evidence of an association between brain sparing effect and increased risk of abnormal neurodevelopment after birth. Even in mild late-onset intrauterine growth restriction affected fetuses with normal umbilical artery blood flow, increased cerebral blood perfusion can be associated with a substantial risk of abnormal neuroadaptation and neurodevelopment during childhood.
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Affiliation(s)
- Edgar Hernandez-Andrade
- Maternal Fetal Medicine Department, National Institute of Perinatology, Mexico City, Mexico.
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Intracerebral lipopolysaccharide induces neuroinflammatory change and augmented brain injury in growth-restricted neonatal rats. Pediatr Res 2012; 71:645-52. [PMID: 22337231 PMCID: PMC3601589 DOI: 10.1038/pr.2012.26] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Intrauterine growth restriction (IUGR) alters fetal development and is associated with neurodevelopmental abnormalities. We hypothesized that growth restriction from reduced intrauterine perfusion would predispose neonatal rats to subsequent inflammatory brain injury. METHODS In this study, IUGR was achieved by induced placental insufficiency in pregnant rats at 14 days of gestation. IUGR offspring and sham-operated control pups were subsequently injected with intracerebral lipopolysaccharide (LPS) as a model of periventricular leukomalacia (PVL). RESULTS LPS similarly elevates proinflammatory cytokines in the brains of both IUGR and control rat pups. However, the chemokines cytokine-induced neutrophil chemoattractant-1 (CINC-1) and macrophage chemoattractant protein-1 (MCP-1), as well as microglia activation, were significantly higher in LPS-treated IUGR rat pups as compared with LPS-treated controls. In addition to the unique brain inflammatory response, IUGR rat pups demonstrated increased brain damage with an increased number of apoptotic cells, larger lateral ventricular size, and more severe impairment of myelination. DISCUSSION This study provides evidence that placental insufficiency may sensitize the innate immune system in the immature brain and reveals a possible link between brain inflammation and injury.
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Abstract
OBJECTIVES We used magnetic resonance imaging (MRI) to perform volumetry of foetuses with and without growth restriction, and identify deviations in organ growth. STUDY DESIGN 20 growth restricted and 19 normal foetuses were scanned once during pregnancy at gestational age 20.53-36.57 weeks. MRI scans were performed on a 1.5T system using ssFSE sequences. Manual segmentation of whole body, brain, heart, lung, liver, thymus and kidney volume was performed. Data on the severity of foetal growth restriction and pregnancy outcome was collected. RESULTS There was a significant reduction in foetal whole body volume and volume of all internal organs except the brain in growth restricted foetuses. A brain:liver ratio above 3.0 was associated with a 3.3 fold increase in risk of perinatal mortality (95% CI=1.68-6.47). CONCLUSION MRI provides an accurate assessment of foetal organ growth. It may have a role to play in monitoring disease severity and the effect of future interventions.
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Scher MS. Developmental origins of cerebrovascular disease II: considering gene-environment interactions when developing neuroprotective strategies. J Child Neurol 2012; 27:238-50. [PMID: 22180566 DOI: 10.1177/0883073811417715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The second part of this review of the developmental origins of cerebrovascular disease discusses prenatal gene-environment interactions concerning maternal, placental, and fetal conditions that culminate in specific injuries such as perinatal stroke, as well as complications of intrauterine growth restriction and congenital heart disease. A greater understanding of gene-environment influences on cerebrovascular health and disease in early life will contribute to the successful development of neuroprotective strategies throughout the lifespan.
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Affiliation(s)
- Mark S Scher
- School of Medicine, Case Western Reserve University, and Division of Pediatric Neurology, Fetal/Neonatal Neurology Program, Rainbow Babies and Children's Hospital, Case Medical Center, University Hospitals of Cleveland, OH, USA.
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Cruz-Martinez R, Figueras F, Benavides-Serralde A, Crispi F, Hernandez-Andrade E, Gratacos E. Sequence of changes in myocardial performance index in relation to aortic isthmus and ductus venosus Doppler in fetuses with early-onset intrauterine growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:179-184. [PMID: 21154784 DOI: 10.1002/uog.8903] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/22/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To explore the sequence of changes in myocardial performance index (MPI) and aortic isthmus (AoI) and ductus venosus (DV) flow in fetuses with early-onset intrauterine growth restriction (IUGR). METHODS MPI and AoI and DV pulsatility indices (PI) were evaluated every 1-7 days in a cohort of IUGR fetuses with abnormal umbilical artery Doppler PI (> 95(th) percentile) delivered before 34 weeks' gestation. The longitudinal changes were analyzed in the last 30 days before delivery by multilevel and survival analysis. RESULTS A total of 430 scans were performed on 115 IUGR fetuses. MPI, AoI-PI and DV-PI showed increases with the progression of fetal deterioration throughout the follow-up study period, but the rates of progression were different. On average, MPI, AoI-PI and DV-PI crossed the 95(th) percentile at 26 days, 12 days and 5 days before delivery, respectively. At the last examination before delivery, the proportion of increased MPI (70.4%) was significantly higher than that of abnormal AoI-PI (55.7%; P < 0.01) and DV-PI (47.8%; P < 0.01). CONCLUSION In early-onset IUGR, MPI and AoI and DV Doppler indices all increase but at different rates, which could provide the basis for further research on their use for improving in-utero monitoring and prediction of long-term outcome.
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Affiliation(s)
- R Cruz-Martinez
- Department of Maternal-Fetal Medicine, ICGON, Hospital Clinic-IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Padilla N, Falcón C, Sanz-Cortés M, Figueras F, Bargallo N, Crispi F, Eixarch E, Arranz A, Botet F, Gratacós E. Differential effects of intrauterine growth restriction on brain structure and development in preterm infants: A magnetic resonance imaging study. Brain Res 2011; 1382:98-108. [DOI: 10.1016/j.brainres.2011.01.032] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 01/10/2011] [Accepted: 01/11/2011] [Indexed: 11/16/2022]
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Damodaram M, Story L, Eixarch E, Patel A, McGuinness A, Allsop J, Wyatt-Ashmead J, Kumar S, Rutherford M. Placental MRI in intrauterine fetal growth restriction. Placenta 2010; 31:491-8. [PMID: 20347139 DOI: 10.1016/j.placenta.2010.03.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Revised: 02/11/2010] [Accepted: 03/01/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Our objectives were to determine if MR imaging of the placenta could demonstrate a specific placental phenotype in small for gestational age fetuses with increasing severity of fetal growth restriction, and if MRI findings at the time of scan could be used to predict fetal or neonatal mortality. METHOD We included singleton growth restricted fetuses with increasing severity of fetal growth restriction secondary to placental insufficiency. 20 growth restricted fetuses and 28 normal fetuses were scanned once during pregnancy at varying gestations. MRI scans were performed on a 1.5T system using ssFSE sequences through the uterus. Data was collected on the severity of fetal growth restriction and pregnancy outcome, including clinical neonatal details, perinatal mortality, and birthweight and centile. Placental volume, maximal placental thickness, the placental thickness to volume ratio, the placenta to amniotic fluid signal intensity ratio, and the presence of abnormal signal intensity consistent with placental pathology were noted. In a subset of patients, histopathological diagnosis was compared with the MRI appearance of the placenta. RESULTS There was a significant increase in the placental volume affected by pathology in growth restricted fetuses (p < 0.001). The placental appearance was also thickened and globular, with an increase in the placental thickness to volume ratio (p < 0.001). Although placental volume increased with increasing gestation, it remained reduced in the growth restricted fetuses (p = 0.003). There was a significant correlation between the severity of fetal growth restriction and the placental volume affected by pathology, the placental thickness to volume ratio, and the placental volume. ROC analysis showed that fetal or neonatal death was predicted by the percentage of abnormal signal intensity consistent with placental pathology (p = 0.002). The presence of a thickened, globular placenta and a maximal placental thickness to volume ratio above the 95% confidence limit for gestation was significantly associated with an increased incidence of fetal or neonatal mortality (relative risk = 1.615, p = 0.001 and relative risk = 7, p < 0.001). CONCLUSIONS The MRI appearance of the placenta provides an indication of the severity and underlying disease process in fetal growth restriction. In units where MRI imaging of the growth restricted fetus occurs, we suggest that the assessment of the placenta should also occur as it may contribute to management decisions in cases at the threshold of viability. It may have a role to play in monitoring disease severity, and the effect of future interventions designed to improve placental function.
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Affiliation(s)
- M Damodaram
- Imperial College London, Hammersmith Campus, London, UK.
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Melatonin promotes oligodendroglial maturation of injured white matter in neonatal rats. PLoS One 2009; 4:e7128. [PMID: 19771167 PMCID: PMC2742165 DOI: 10.1371/journal.pone.0007128] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2009] [Accepted: 09/01/2009] [Indexed: 02/01/2023] Open
Abstract
Objective To investigate the effects of melatonin treatment in a rat model of white matter damage (WMD) in the developing brain. Additionally, we aim to delineate the cellular mechanisms of melatonin effect on the oligodendroglial cell lineage. Methods A unilateral ligation of the uterine artery in pregnant rat at the embryonic day 17 induces fetal hypoxia and subsequent growth restriction (GR) in neonatal pups. GR and control pups received a daily intra-peritoneal injection of melatonin from birth to post-natal day (P) 3. Results Melatonin administration was associated with a dramatic decrease in microglial activation and astroglial reaction compared to untreated GR pups. At P14, melatonin prevented white matter myelination defects with an increased number of mature oligodendrocytes (APC-immunoreactive) in treated GR pups. Conversely, melatonin was not found to be associated with an increased density of total oligodendrocytes (Olig2-immunoreactive), suggesting that melatonin is able to promote oligodendrocyte maturation but not proliferation. These effects appear to be melatonin-receptor dependent and were reproduced in vitro. Interpretation These data suggest that melatonin has a strong protective effect on developing damaged white matter through decreased microglial activation and oligodendroglial maturation leading to a normalization of the myelination process. Consequently, melatonin should be a considered as an effective neuroprotective candidate not only in perinatal brain damage but also in inflammatory and demyelinating diseases observed in adults.
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Benavides-Serralde A, Hernández-Andrade E, Fernández-Delgado J, Plasencia W, Scheier M, Crispi F, Figueras F, Nicolaides KH, Gratacós E. Three-dimensional sonographic calculation of the volume of intracranial structures in growth-restricted and appropriate-for-gestational age fetuses. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 33:530-537. [PMID: 19326370 DOI: 10.1002/uog.6343] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES To evaluate the feasibility and reproducibility of volume segmentation of fetal intracranial structures using three-dimensional (3D) ultrasound imaging, and to estimate differences in the volume of intracranial structures between intrauterine growth-restricted (IUGR) and appropriate-for-gestational age (AGA) fetuses. METHODS Total intracranial, frontal, thalamic and cerebellar volumes were measured using 3D ultrasound imaging and Virtual Organ Computer-aided AnaLysis (VOCAL) in 39 IUGR and 39 AGA fetuses matched for gestational age, at 28-34 weeks of gestation. Volumes of, and ratios between, structures were estimated, and differences between IUGR and AGA fetuses were calculated. Volume measurements were performed by two observers, and interobserver and intraobserver intraclass correlation coefficients (ICCs) were calculated for each structure. RESULTS Volumes were satisfactorily obtained in all fetuses. All net volumes except those for the thalamus (P = 0.23) were significantly smaller (P = 0.001) in IUGR fetuses. After adjusting volumes for biparietal diameter the frontal volume was significantly smaller (P = 0.02) and the thalamic volume significantly greater (P = 0.03) in IUGR fetuses than in AGA fetuses. Significant intergroup differences in the ratios between structures were found only in those involving the frontal region. Interobserver ICCs were as follows: total intracranial 0.97 (95% CI, 0.92-0.98), cerebellar 0.69 (95% CI, 0.44-0.75), frontal 0.66 (95% CI, 0.42-0.79) and thalamic 0.54 (95% CI, 0.37-0.72). CONCLUSIONS IUGR fetuses show differences in the volume of intracranial structures compared with AGA fetuses, with the largest difference found in the frontal region. These differences might be explained by in-utero processes of neural reorganization induced by chronic hypoxia.
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Affiliation(s)
- A Benavides-Serralde
- Fetal and Perinatal Medicine Research Group, Department of Maternal-Fetal Medicine, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Schober ME, McKnight RA, Yu X, Callaway CW, Ke X, Lane RH. Intrauterine growth restriction due to uteroplacental insufficiency decreased white matter and altered NMDAR subunit composition in juvenile rat hippocampi. Am J Physiol Regul Integr Comp Physiol 2009; 296:R681-92. [DOI: 10.1152/ajpregu.90396.2008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Uteroplacental insufficiency (UPI), the major cause of intrauterine growth restriction (IUGR) in developed nations, predisposes to learning impairment. The underlying mechanism is unknown. Neuronal N-methyl-d-aspartate receptors (NMDARs) are critical for synaptogenesis and learning throughout life. We hypothesized that UPI-induced IUGR alters rat hippocampal NMDAR NR2A/NR2B subunit ratio and/or NR1 mRNA isoform expression and synaptic density at day 21 (P21). To test this hypothesis, IUGR was induced by bilateral uterine artery ligation of the late-gestation Sprague-Dawley dam. At P21, hippocampal NMDAR subunit mRNA and protein were measured, as were levels of synaptophysin. Neuronal, synaptic, and glial density in CA1, CA3, and dentate gyrus (DG) was assessed by immunofluorescence. IUGR increased NR1 mRNA isoform NR1-3a and 1-3b expression in both sexes. In P21 males, IUGR increased protein levels of NR1 C2′ and decreased NR1 C2, NR2A, and the NR2A-to-NR2B ratio, whereas in females, IUGR increased NR2B protein. In males, IUGR was associated with decreased myelin basic protein-to-neuronal nuclei ratio in CA1, CA3, and DG. We conclude that IUGR has sex-specific effects and that neither neuronal loss nor decreased synaptic density appears to account for the changes in NMDAR subunits. Rather, it is possible that synaptic NMDAR subunit composition is altered. Our results suggest that apparent recovery in the IUGR hippocampus may be associated with synaptic hyperexcitability. We speculate that the NMDAR plays an important role in IUGR-associated cognitive impairment.
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