Morphologic development of the first-trimester utero-placental vasculature is positively associated with embryonic and fetal growth: the Rotterdam Periconception Cohort

STUDY QUESTION

Is morphologic development of the first-trimester utero-placental vasculature associated with embryonic growth and development, fetal growth, and birth weight percentiles?

SUMMARY ANSWER

Using the utero-placental vascular skeleton (uPVS) as a new imaging marker, this study reveals morphologic development of the first-trimester utero-placental vasculature is positively associated with embryonic growth and development, fetal growth, and birth weight percentiles.

WHAT IS KNOWN ALREADY

First-trimester development of the utero-placental vasculature is associated with placental function, which subsequently impacts embryonic and fetal ability to reach their full growth potential. The attribution of morphologic variations in the utero-placental vascular development, including the vascular structure and branching density, on prenatal growth remains unknown.

STUDY DESIGN, SIZE, DURATION

This study was conducted in the VIRTUAL Placental study, a subcohort of 214 ongoing pregnancies, embedded in the prospective observational Rotterdam Periconception Cohort (Predict study). Women were included before 10 weeks gestational age (GA) at a tertiary referral hospital in The Netherlands between January 2017 and March 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We obtained three-dimensional power Doppler volumes of the gestational sac including the embryo and the placenta at 7, 9, and 11 weeks of gestation. Virtual Reality-based segmentation and a recently developed skeletonization algorithm were applied to the power Doppler volumes to generate the uPVS and to measure utero-placental vascular volume (uPVV). Absolute vascular morphology was quantified by assigning a morphologic characteristic to each voxel in the uPVS (i.e. end-, bifurcation-crossing-, or vessel point). Additionally, total vascular length (mm) was calculated. The ratios of the uPVS characteristics to the uPVV were calculated to determine the density of vascular branching. Embryonic growth was estimated by crown-rump length and embryonic volume. Embryonic development was estimated by Carnegie stages. Fetal growth was measured by estimated fetal weight in the second and third trimester and birth weight percentiles. Linear mixed models were used to estimate trajectories of longitudinal measurements. Linear regression analysis with adjustments for confounders was used to evaluate associations between trajectories of the uPVS and prenatal growth. Groups were stratified for conception method (natural/IVF-ICSI conceptions), fetal sex (male/female), and the occurrence of placenta-related complications (yes/no).

MAIN RESULTS AND THE ROLE OF CHANCE

Increased absolute vascular morphologic development, estimated by positive random intercepts of the uPVS characteristics, is associated with increased embryonic growth, reflected by crown-rump length (endpoints β = 0.017, 95% CI [0.009; 0.025], bifurcation points β = 0.012, 95% CI [0.006; 0.018], crossing points β = 0.017, 95% CI [0.008; 0.025], vessel points β = 0.01, 95% CI [0.002; 0.008], and total vascular length β = 0.007, 95% CI [0.003; 0.010], and similarly with embryonic volume and Carnegie stage, all P-values ≤ 0.01. Density of vascular branching was negatively associated with estimated fetal weight in the third trimester (endpoints: uPVV β = -94.972, 95% CI [-185.245; -3.698], bifurcation points: uPVV β = -192.601 95% CI [-360.532; -24.670]) and birth weight percentiles (endpoints: uPVV β = -20.727, 95% CI [-32.771; -8.683], bifurcation points: uPVV β -51.097 95% CI [-72.257; -29.937], and crossing points: uPVV β = -48.604 95% CI [-74.246; -22.961])), all P-values < 0.05. After stratification, the associations were observed in natural conceptions specifically.

LIMITATION, REASONS FOR CAUTION

Although the results of this prospective observational study clearly demonstrate associations between first-trimester utero-placental vascular morphologic development and prenatal growth, further research is required before we can draw firm conclusions about a causal relationship.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings support the hypothesis that morphologic variations in utero-placental vascular development play a role in the vascular mechanisms involved in embryonic and fetal growth and development. Application of the uPVS could benefit our understanding of the pathophysiology underlying placenta-related complications. Future research should focus on the clinical applicability of the uPVS as an imaging marker for the early detection of fetal growth restriction.

STUDY FUNDING/COMPETING INTEREST(S)

This research was funded by the Department of Obstetrics and Gynecology of the Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. There are no conflicts of interest.

TRIAL REGISTRATION NUMBER

Registered at the Dutch Trial Register (NTR6854).

First-trimester maternal renin-angiotensin-aldosterone system activation and the association with maternal telomere length after natural and IVF/ICSI conceived pregnancies: the Rotterdam periconception cohort

OBJECTIVE

To study associations between the first-trimester maternal determinants of renin-angiotensin-aldosterone system (RAAS) activation and telomere length (TL) in pregnancies conceived natural and after IVF/ICSI.

METHODS

In 145 pregnancies of the Rotterdam Periconception cohort renin, prorenin and aldosterone concentrations were measured in maternal blood at 9 weeks gestational age (GA). TL was measured by qPCR at 20 weeks GA.

RESULTS

A significantly negative correlation was found between renin and TL, which was attenuated for prorenin but not observed for aldosterone. Maternal TL was significantly shorter in pregnancies conceived after in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) compared to natural pregnancies.

CONCLUSION

The negative association between first-trimester maternal renin and maternal TL, and the shorter maternal TL in women after IVF/ICSI treatment compared to natural pregnancies, substantiates the role of excessive RAAS activation.

Embryonic morphological development is delayed in pregnancies ending in a spontaneous miscarriage

STUDY QUESTION

Is there a difference in embryonic morphological development between ongoing pregnancies and live pregnancies ending in a miscarriage?

SUMMARY ANSWER

Embryonic morphological development, assessed by the Carnegie stages, is delayed in live pregnancies ending in a miscarriage compared to ongoing pregnancies.

WHAT IS KNOWN ALREADY

Pregnancies ending in a miscarriage tend to have smaller embryos and slower heart rates.

STUDY DESIGN, SIZE, DURATION

Between 2010 and 2018, 644 women with singleton pregnancies, in the periconception period, were enrolled in a prospective cohort study with follow up until 1 year after delivery. A miscarriage was registered as a non-viable pregnancy before 22 weeks gestational age, defined by an absent heartbeat by ultrasound for a previously reported live pregnancy.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Pregnant women with live singleton pregnancies were included and serial three-dimensional transvaginal ultrasound scans were performed. Embryonic morphological development was assessed by the Carnegie developmental stages and evaluated using virtual reality techniques. The embryonic morphology was compared to clinically used growth parameters (i.e. crown-rump length (CRL) and embryonic volume (EV)). Linear mixed models were used to evaluate the association between miscarriage and the Carnegie stages. Logistic regression with generalized estimating equations was used to calculate the odds of a miscarriage after a delay in Carnegie stages. Adjustments were made for potential confounders or covariates and include age, parity, and smoking status.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 611 ongoing pregnancies and 33 pregnancies ending in a miscarriage were included between 7 + 0 and 10 + 3 weeks gestational age, resulting in 1127 assigned Carnegie stages for evaluation. Compared to an ongoing pregnancy, a pregnancy ending in a miscarriage is associated with a lower Carnegie stage (βCarnegie = -0.824, 95% CI -1.190; -0.458, P < 0.001). A live embryo of a pregnancy ending in a miscarriage will reach the final Carnegie stage with a delay of 4.0 days compared to an ongoing pregnancy. A pregnancy ending in a miscarriage is associated with a smaller CRL (βCRL = -0.120, 95% CI -0.240; -0.001, P = 0.049) and EV (βEV = -0.060, 95% CI -0.112; -0.007, P = 0.027). The delay in Carnegie stage increases the odds of a miscarriage by 1.5% per delayed Carnegie stage (ORCarnegie = 1.015, 95% CI 1.002; 1.028, P = 0.028).

LIMITATIONS, REASONS FOR CAUTION

We included a relatively small number of pregnancies ending in a miscarriage from a study population that is recruited from a tertiary referral centre. Furthermore, results of genetic testing on the products of the miscarriages or information on the karyotype of the parents were not available.

WIDER IMPLICATIONS OF THE FINDINGS

Embryonic morphological development, assessed by the Carnegie stages, is delayed in live pregnancies ending in a miscarriage. In the future, embryonic morphology may be used to estimate the likelihood of a pregnancy continuing to the delivery of a healthy baby. This is of crucial importance for all women but in particular for those at risk of a recurrent pregnancy loss. As part of supportive care, both women and their partners may benefit from information on the prospective outcome of the pregnancy and the timely identification of a miscarriage.

STUDY FUNDING/COMPETING INTEREST(S)

The work was funded by the Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. The authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

OUP accepted manuscript

STUDY QUESTION

Is periconceptional maternal smoking associated with embryonic morphological development in ongoing pregnancies?

SUMMARY ANSWER

Smoking during the periconceptional period is associated with a delayed embryonic morphological development which is not fully recuperated beyond the first trimester of pregnancy.

WHAT IS KNOWN ALREADY

Smoking during pregnancy decreases prenatal growth, increasing the risk of preterm birth, small for gestational age (GA) and childhood obesity.

STUDY DESIGN, SIZE, DURATION

Between 2010 and 2018, 689 women with ongoing singleton pregnancies were periconceptionally enrolled in a prospective cohort study with follow-up until 1 year after delivery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Between 7 + 0 and 10 + 3 weeks, GA serial three-dimensional transvaginal ultrasound scans were performed. Embryonic morphological development as assessed by the Carnegie developmental stages was evaluated using Virtual Reality techniques. In the absence of fetal morphology classification methods beyond the embryonic period, fetal ultrasound measurements at around 20 weeks’ GA, and birth weight were used to assess fetal growth. Linear mixed models were used to evaluate the association between smoking and the Carnegie stages. Regarding first-trimester morphological development, we additionally stratified our findings for mode of conception. Multiple linear regression models were used to study the association between smoking, fetal growth and birth weight. To investigate to which extent delayed embryonic morphological development mediated the effect of smoking, contemporary mediation analysis was used. Adjustments were made for potential confounders and other covariates.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 689 singleton ongoing pregnancies were included and 1210 Carnegie stages were determined. Maternal periconceptional smoking represented by the number of cigarettes/day was associated with a slight non-significant delay of the Carnegie stages (β_{cigarettes/day} = −0.058, 95% CI −0.122; 0.007, P = 0.080). Smoking of ≥10 cigarettes/day showed the strongest association (β_{≥10 cigarettes/day} = −0.352, 95% CI −0.648; −0.057, P = 0.019), as reflected by a 0.9-day delay in reaching the final Carnegie stage. Stratification for mode of conception showed a stronger negative association between the number of cigarettes/day in the IVF/ICSI group (β_{cigarettes/day} = −0.126, 95% CI −0.200; −0.051, P = 0.001) compared to naturally conceived pregnancies (β_{cigarettes/day} = 0.009, 95% CI −0.093; 0.111, P = 0.867). In the IVF/ICSI group, periconceptional smoking of ≥10 cigarettes/day was associated with in a 1.6 day delay in reaching the final Carnegie stage (β_{≥10 cigarettes/day} = −0.510, 95% CI −0.834; −0.186, P = 0.002). In the second trimester, periconceptional smoking was associated with a smaller femur length (β_{cigarettes/day} = −0.077, 95% CI −0.147; −0.008, P = 0.029) and a larger head circumference (β_{1–9 cigarettes/day} = 0.290, 95% CI 0.065; 0.514, P = 0.012). Smoking was associated with a lower birth weight, with a dose-response effect (β_{cigarettes/day} = −0.150, 95% CI −0.233; −0.068, P < 0.001). Furthermore, using the unadjusted model, 40–60% of the association between smoking and fetal ultrasound parameters and 6.3% of the association between smoking and birth weight can be explained by a delayed embryonic morphology.

LIMITATIONS, REASONS FOR CAUTION

The study population was recruited from a tertiary referral center. Smoking habits were explored using self-reported questionnaires and checked for consistency by trained researchers.

WIDER IMPLICATIONS OF THE FINDINGS

This study shows that the association of periconceptional maternal smoking and human morphological development can already be detected early in the first trimester of pregnancy using embryonic morphology as outcome. One of the key messages of this study is that the delay, or dysregulation, in embryonic morphology is associated with allometric growth reflected by smaller fetal measurements at 20 weeks gestation and lower weight at birth. The delay in embryonic morphology, measured in early pregnancy, cannot be recuperated during the pregnancy. The results of this study emphasize the importance of smoking intervention programs prior to conception. More research is warranted to assess the association between periconceptional smoking cessation and embryonic development.

STUDY FUNDING/COMPETING INTEREST(S)

The work was funded by the Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. The authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

First-trimester maternal haemodynamic adaptation to pregnancy and placental, embryonic and fetal development: the prospective observational Rotterdam Periconception cohort

Objective

To investigate whether first‐trimester maternal haemodynamic adaptation impacts placental, embryonic and fetal development as well as birth outcomes in pregnancies with and without placenta‐related complications.

Design

Prospective observational cohort.

Setting

A Dutch tertiary hospital.

Population

Two hundred and fourteen ongoing pregnancies.

Methods

At 7, 9 and 11 weeks of gestation, we assessed maternal haemodynamic adaptation (mean arterial blood pressure [MAP], uterine artery [UtA] blood flow) and placental development (placental volume [PV], uteroplacental vascular volume [uPVV]) using three‐dimensional power Doppler ultrasound volumes, and embryonic development (crown–rump length, embryonic volume). At 22 and 32 weeks of gestation, fetal development was assessed by estimated fetal weight. Birth outcomes (birthweight, placental weight) were extracted from medical records. Linear mixed modelling and linear regression analyses were applied.

Main outcome measures

Birthweight centile and placental weight.

Results

In placenta‐related complications (n= 55, 25.7%), reduced haemodynamic adaptation, i.e. higher UtA pulsatility index (PI) and resistance index (RI) trajectories, was associated with smaller increase in PV (β = −0.559, 95% CI −0.841 to −0.278, P< 0.001; β = −0.579, 95% CI −0.878 to −0.280, P< 0.001) and uPVV trajectories (UtA PI: β = −0.301, 95% CI −0.578 to −0.023, P= 0.034). At birth, reduced haemodynamic adaptation was associated with lower placental weight (UtA PI: β = −0.502, 95% CI −0.922 to −0.082, P= 0.022; UtA RI: β = −0.435, 95% CI −0.839 to −0.032, P= 0.036). In pregnancies without placenta‐related complications, higher MAP trajectories were positively associated with birthweight centile (β = 0.398, 95% CI 0.049–0.748, P= 0.025).

Conclusions

Reduced first‐trimester maternal haemodynamic adaptation impacts both placental size and vascularisation and birthweight centile, in particular in pregnancies with placenta‐related complications.

Tweetable abstract

Reduced first‐trimester maternal haemodynamic adaptation to pregnancy impairs early placental development.

First-trimester utero-placental (vascular) development and embryonic and fetal growth: The Rotterdam periconception cohort

INTRODUCTION

Impaired placental development is a major cause of fetal growth restriction (FGR) and early detection will therefore improve antenatal care and birth outcomes. Here we aim to investigate serial first-trimester ultrasound markers of utero-placental (vascular) development in association with embryonic and fetal growth.

METHODS

In a prospective cohort, we periconceptionally included 214 pregnant women. Three-dimensional power Doppler ultrasonography at 7, 9 and 11 weeks gestational age (GA) was used to measure placental volumes (PV) and basal plate surface area by Virtual Organ Computer-aided AnaLysis™, and utero-placental vascular volume (uPVV), crown-rump length (CRL) and embryonic volume (EV) by a V-scope volume rendering application. Estimated fetal weight (EFW) was measured by ultrasound at 22 and 32 weeks GA and birth weight percentile (BW) was recorded. Linear mixed models and regression analyses were applied and appropriately adjusted. All analyses were stratified for fetal sex.

RESULTS

PV trajectories were positively associated with CRL (β_adj = 0.416, 95%CI:0.255; 0.576, p < 0.001), EV (β_adj = 0.220, 95%CI:0.058; 0.381, p = 0.008) and EFW (β_adj = 0.182, 95%CI:0.012; 0.352, p = 0.037). uPVV trajectories were positively associated with CRL (β_adj = 0.203, 95%CI 0.021; 0.384, p = 0.029). In girls, PV trajectories were positively associated with CRL (p < 0.001), EV (p = 0.018), EFW (p = 0.026), and uPVV trajectories were positively associated with BW (p = 0.040). In boys, positive associations were shown between PV trajectories and CRL (p = 0.002), and between uPVV trajectories and CRL (p = 0.046).

DISCUSSION

First-trimester utero-placental (vascular) development is associated with embryonic and fetal growth, with fetal sex specific modifications. This underlines the opportunity to monitor first-trimester placental development and supports the associations with embryonic and fetal growth.

First trimester anomaly scan using virtual reality (VR FETUS study): study protocol for a randomized clinical trial

Background

In recent years it has become clear that fetal anomalies can already be detected at the end of the first trimester of pregnancy by two-dimensional (2D) ultrasound. This is why increasingly in developed countries the first trimester anomaly scan is being offered as part of standard care. We have developed a Virtual Reality (VR) approach to improve the diagnostic abilities of 2D ultrasound. Three-dimensional (3D) ultrasound datasets are used in VR assessment, enabling real depth perception and unique interaction. The aim of this study is to investigate whether first trimester 3D VR ultrasound is of additional value in terms of diagnostic accuracy for the detection of fetal anomalies. Health-related quality of life, cost-effectiveness and also the perspective of both patient and ultrasonographer on the 3D VR modality will be studied.

Methods

Women in the first trimester of a high risk pregnancy for a fetus with a congenital anomaly are eligible for inclusion. This is a randomized controlled trial with two intervention arms. The control group receives ‘care as usual’: a second trimester 2D advanced ultrasound examination. The intervention group will undergo an additional first trimester 2D and 3D VR ultrasound examination. Following each examination participants will fill in validated questionnaires evaluating their quality of life and healthcare related expenses. Participants’ and ultrasonographers’ perspectives on the 3D VR ultrasound will be surveyed. The primary outcome will be the detection of fetal anomalies. The additional first trimester 3D VR ultrasound examination will be compared to ‘care as usual’. Neonatal or histopathological examinations are considered the gold standard for the detection of congenital anomalies. To reach statistical significance and 80% power with a detection rate of 65% for second trimester ultrasound examination and 70% for the combined detection of first trimester 3D VR and second trimester ultrasound examination, a sample size of 2800 participants is needed.

Discussion

First trimester 3D VR detection of fetal anomalies may improve patients’ quality of life through reassurance or earlier identification of malformations. Results of this study will provide policymakers and healthcare professionals with the highest level of evidence for cost-effectiveness of first trimester ultrasound using a 3D VR approach.

Trial registration

Dutch Trial Registration number NTR6309, date of registration 26 January 2017.

Trochanteric Fixation Nail® with Helical Blade Compared with Femoral Neck Screw for Operative Treatment of Intertrochanteric Femoral Fractures

Purpose

This study was performed to compare outcomes of the Trochanteric Fixation Nail (TFN®) with a helical blade versus TFN® with a femoral neck screw for the treatment of intertrochanteric femoral fractures.

Materials and Methods

A single center, retrospective cohort study. Patients (>18 years of age) with an intertrochanteric femoral fracture, who were operated on between January 1, 2012 and December 31, 2016 were included. Primary and secondary outcome measures were cut-out rate and intervention variables, respectively. Data from X-ray examinations and patient medical files were collected and analyzed. The chi-square test or Student's t-test were used for statistical analysis.

Results

A total of 631 patients were surgically treated for an intertrochanteric femoral fracture. Of this group, 239 patients (37.9%) were treated with a TFN® with helical blade and 392 patients (62.1%) with a TFN® with femoral neck screw. There were no statistically significant differences between the baseline characteristics of both groups. A total of 17 (2.7%) cut-outs were recorded, with no statistically significant difference between the two groups (P=0.19). Additionally, there were no statistically significant differences in the secondary outcome measures between the two groups.

Conclusion

There are no statistically significant differences in primary and secondary outcomes following treatment of intertrochanteric femur fracture with the TFN® helical blade or TFN® femoral neck screw. These findings suggest that the choice of collum implant for the surgical treatment of intertrochanteric femur fractures cannot be made based on the surgical outcomes of the two implants evaluated here.

Prenatal cerebellar growth trajectories and the impact of periconceptional maternal and fetal factors

STUDY QUESTION

CAN WE assess human prenatal cerebellar growth from the first until the third trimester of pregnancy and create growth trajectories to investigate associations with periconceptional maternal and fetal characteristics?

SUMMARY ANSWER

Prenatal growth trajectories of the human cerebellum between 9 and 32 weeks gestational age (GA) were created using three-dimensional ultrasound (3D-US) and show negative associations with pre-pregnancy and early first trimester BMI calculated from self-reported and standardized measured weight and height, respectively.

WHAT IS KNOWN ALREADY

The cerebellum is essential for normal neurodevelopment and abnormal cerebellar development has been associated with neurodevelopmental impairments and psychiatric diseases. Cerebellar development is particularly susceptible to exposures during the prenatal period, including maternal folate status, smoking habit and alcohol consumption.

STUDY DESIGN, SIZE, DURATION

From 2013 until 2015, we included 182 singleton pregnancies during the first trimester as a subgroup in a prospective periconception cohort with follow-up until birth. For the statistical analyses, we selected 166 pregnancies ending in live born infants without congenital malformations.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We measured transcerebellar diameter (TCD) at 9, 11, 22, 26 and 32 weeks GA on ultrasound scans. Growth rates were calculated and growth trajectories of the cerebellum were created. Linear mixed models were used to estimate associations between cerebellar growth and maternal age, parity, mode of conception, geographic origin, pre-pregnancy and first trimester BMI, periconceptional smoking, alcohol consumption, timing of folic acid supplement initiation and fetal gender.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 166 pregnancies provided 652 (87%) ultrasound images eligible for TCD measurements. Cerebellar growth rates increased with advancing GA being 0.1691 mm/day in the first trimester, 0.2336 mm/day in the second trimester and 0.2702 mm/day in the third trimester. Pre-pregnancy BMI, calculated from self-reported body weight and height, was significantly associated with decreased cerebellar growth trajectories (β = -0.0331 mm, 95% CI = -0.0638; -0.0024, P = 0.035). A similar association was found between cerebellar growth trajectories and first trimester BMI, calculated from standardized measurements of body weight and height (β = -0.0325, 95% CI = -0.0642; -0.0008, P = 0.045, respectively).

LIMITATIONS, REASONS FOR CAUTION

As the study population largely consisted of tertiary hospital patients, external validity should be studied in the general population. Whether small differences in prenatal cerebellar growth due to a higher pre-pregnancy and first trimester BMI have consequences for neurodevelopmental outcome needs further investigation.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings further substantiate previous evidence for the detrimental impact of a higher maternal BMI on neurodevelopmental health of offspring in later life.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Department of Obstetrics and Gynecology, Erasmus MC University Medical Centre and Sophia Children's Hospital Fund, Rotterdam, The Netherlands (SSWO grant number 644). No competing interests are declared.

Periconceptional maternal one-carbon biomarkers are associated with embryonic development according to the Carnegie stages

STUDY QUESTION

Is periconceptional maternal one-carbon (I-C) metabolism associated with embryonic morphological development in non-malformed ongoing pregnancies?

SUMMARY ANSWER

Serum vitamin B12, red blood cell (RBC) folate and plasma total homocysteine (tHcy) are associated with embryonic development according to the Carnegie stages.

WHAT IS KNOWN ALREADY

Derangements in maternal I-C metabolism affect reproductive and pregnancy outcomes, as well as future health of the offspring.

STUDY DESIGN, SIZE, DURATION

Between 2010 and 2014, women with singleton ongoing pregnancies were enrolled in a prospective periconceptional cohort study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 234 pregnancies, including 138 spontaneous or IUI pregnancies with strict pregnancy dating and 96 pregnancies derived from IVF, ICSI or cryopreserved embryo transfer (IVF/ICSI pregnancies), underwent longitudinal transvaginal three-dimensional ultrasound (3D US) scans from 6+0 up to 10+2 weeks of gestation. Carnegie stages were defined using internal and external morphologic criteria in a virtual reality system. Maternal venous blood samples were collected at enrollment for serum vitamin B12, RBC folate and plasma tHcy assessment. Associations between biomarker concentrations and longitudinal Carnegie stages were investigated using linear mixed models.

MAIN RESULTS AND THE ROLE OF CHANCE

We performed a median of three 3D US scans per pregnancy (range 1-5) resulting in 600 good quality data sets for the Carnegie stage annotation (80.5%). Vitamin B12 was positively associated with embryonic development in the total study population (β = 0.001 (95% CI: 0.000; 0.002), P < 0.05) and in the subgroup of strictly dated spontaneous pregnancies (β = 0.002 (95% CI: 0.001; 0.003), P < 0.05). Low vitamin B12 concentrations (-2SD, 73.4 pmol/l) were associated with delayed embryonic development by 1.4 days (95% CI: 1.3-1.4) compared with high concentrations (+2SD, 563.1 pmol/l). RBC folate was positively associated with Carnegie stages only in IVF/ICSI pregnancies (β = 0.001 (95% CI: 0.0005; 0.0015), P < 0.05). In this group, low RBC folate concentrations (-2SD, 875.4 nmol/l) were associated with a 1.8-day delay (95% CI: 1.7-1.8) in development compared with high concentrations (+2SD, 2119.9 nmol/l). tHcy was negatively associated with embryonic development in the total study population (β = -0.08 (95% CI: -0.14; -0.02), P < 0.01), as well as in the IVF/ICSI subgroup (β = -0.08 (95% CI: -0.15; -0.01), P < 0.05). High tHcy concentrations (+2SD, 10.4 µmol/l) were associated with a delay of 1.6 days (95% CI: 1.5-1.7) in embryonic development compared with low concentrations (-2SD, 3.0 µmol/l).

LIMITATIONS, REASONS FOR CAUTION

The study was performed in a tertiary care center, resulting in high rates of folic acid supplement use and comorbidity that may reduce the external validity of our findings.

WIDER IMPLICATIONS OF THE FINDINGS

In periconceptional care, maternal I-C biomarkers should be taken into account as predictors of embryonic morphological development. Combining embryonic size measurements with morphological assessment could better define normal embryonic development.

STUDY FUNDING/COMPETING INTEREST(S)

The work was funded by the Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. RPMST is CSO of the startup company Slimmere Zorg and CEO of eHealth Care Solutions. The authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

Not applicable.

Periconceptional maternal 'high fish and olive oil, low meat' dietary pattern is associated with increased embryonic growth: The Rotterdam Periconceptional Cohort (Predict) Study

OBJECTIVE

To investigate the association between periconceptional maternal dietary pattern and first-trimester embryonic growth.

METHODS

This was a prospective cohort study of 228 women with a singleton ongoing pregnancy, of which 135 were strictly dated spontaneous pregnancies and 93 were pregnancies achieved after in-vitro fertilization or intracytoplasmatic sperm injection (IVF/ICSI). All women underwent serial transvaginal three-dimensional ultrasound (3D-US) examinations from 6 + 0 to 13 + 0 weeks' gestation. Crown-rump length (CRL) and embryonic volume (EV) measurements were performed using a virtual reality system. Information on periconceptional maternal dietary intake was collected via food frequency questionnaires. Principal component analysis was performed to identify dietary patterns. Associations between dietary patterns and CRL and EV trajectories were investigated using linear mixed models adjusted for potential confounders.

RESULTS

A median of five (range, one to seven) 3D-US scans per pregnancy were performed. Of 1162 datasets, quality was sufficient to perform CRL measurements in 991 (85.3%) and EV measurements in 899 (77.4%). A dietary pattern comprising high intake of fish and olive oil and a very low intake of meat was identified as beneficial for embryonic growth. In strictly dated spontaneous pregnancies, strong adherence to the 'high fish and olive oil, low meat' dietary pattern was associated with a 1.9 mm (95% CI, 0.1-3.63 mm) increase in CRL (+14.6%) at 7 weeks and a 3.4 mm (95% CI, 0.2-7.81 mm) increase (+6.9%) at 11 weeks, whereas EV increased by 0.06 cm³ (95% CI, 0.01-0.13 cm³ ) (+20.4%) at 7 weeks and 1.43 cm³ (95% CI, 0.99-1.87 cm³ ) (+14.4%) at 11 weeks. No significant association was observed in the total study population or in the IVF/ICSI subgroup.

CONCLUSION

Periconceptional maternal adherence to a high fish and olive oil, low meat dietary pattern is positively associated with embryonic growth in spontaneously conceived pregnancies. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

New imaging markers for preconceptional and first-trimester utero-placental vascularization

INTRODUCTION

The availability of imaging makers of early placental circulation development is limited. This study aims to develop a feasible and reliable method to assess preconceptional and early first-trimester utero-placental vascular volumes using three-dimensional power Doppler (3D PD) ultrasound on two different Virtual Reality (VR) systems.

METHODS

3D PD ultrasound images of the uterine and placental vasculature were obtained in 35 women, either preconceptionally (n = 5), or during pregnancy at 7 (n = 10), 9 (n = 10) or 11 (n = 10) weeks of gestation. Preconceptional uterine vascular volume (UVV), first-trimester placental vascular volume (PVV) and embryonic vascular volume (EVV) were measured by two observers on two VR systems, i.e., a Barco I-Space and VR desktop. Intra- and inter-observer agreement and intersystem agreement were assessed by intra-class correlation coefficients (ICC) and absolute and relative differences.

RESULTS

Uterine-, embryonic- and placental vascular volume measurements showed good to excellent intra- and inter-observer agreement and inter-system reproducibility with most ICC above 0.80 and relative differences of less than 20% preconceptionally and almost throughout the entire gestational age range. Inter-observer agreement of PVV at 11 weeks gestation was suboptimal (ICC 0.69, relative difference 50.1%).

DISCUSSION

Preconceptional and first-trimester 3D PD ultrasound utero-placental and embryonic vascular volume measurements using VR are feasible and reliable. Longitudinal cohort studies with repeated measurements are needed to further validate this and assess their value as new imaging markers for placental vascular development and ultimately for the prediction of placenta-related pregnancy complications.

Foetal fractional thigh volume: an early 3D ultrasound marker of neonatal adiposity

BACKGROUND

The predisposition for obesity is suggested to originate in the prenatal period. Prenatal markers are needed to identify foetuses at risk for neonatal adiposity, as early marker of childhood obesity.

OBJECTIVE

The aim of this study is to assess the association between foetal fractional thigh volume (TVol) and neonatal percentage fat mass from mid-gestation onward.

METHODS

In this perinatal cohort study, singleton pregnancies with term born infants were included. Foetal TVol was measured on three-dimensional ultrasound scans (3D US) obtained at 22, 26 and 32 weeks of gestation. Neonatal body composition measurement (percentage body fat (%BF)) was planned between 42⁺⁰ and 42⁺⁶ -week postmenstrual age. Cross-sectional and longitudinal linear regression analyses were performed.

RESULTS

Seventy-nine mother-child pairs were included. Median (interquartile range) TVol increased from 7.6 (7.1; 8.5) cm³ at 22 weeks to 36.5 (33.8; 40.9) cm³ at 32 weeks. Median neonatal %BF was 14.3% (11.7; 17.0). TVol at 22 weeks (β = -1.58, 95% CI -2.45; -0.70, explained variance 31%) was negatively associated with %BF, but no associations were found at 26 and 32 weeks of gestation. TVol growth between 22 and 32 weeks of gestation (explained variance 18%) was also statistically significantly negatively associated with %BF.

CONCLUSIONS

Foetal TVol is a promising 3D US marker for prediction of neonatal adiposity from mid-gestation onward.

New Ultrasound Measurements to Bridge the Gap between Prenatal and Neonatal Brain Growth Assessment

BACKGROUND AND PURPOSE

Most ultrasound markers for monitoring brain growth can only be used in either the prenatal or the postnatal period. We investigated whether corpus callosum length and corpus callosum-fastigium length could be used as markers for both prenatal and postnatal brain growth.

MATERIALS AND METHODS

A 3D ultrasound study embedded in the prospective Rotterdam Periconception Cohort was performed at 22, 26 and 32 weeks' gestational age in fetuses with fetal growth restriction, congenital heart defects, and controls. Postnatally, cranial ultrasound was performed at 42 weeks' postmenstrual age. First, reliability was evaluated. Second, associations between prenatal and postnatal corpus callosum and corpus callosum-fastigium length were investigated. Third, we created reference curves and compared corpus callosum and corpus callosum-fastigium length growth trajectories of controls with growth trajectories of fetuses with fetal growth retardation and congenital heart defects.

RESULTS

We included 199 fetuses; 22 with fetal growth retardation, 20 with congenital heart defects, and 157 controls. Reliability of both measurements was excellent (intraclass correlation coefficient ≥ 0.97). Corpus callosum growth trajectories were significantly decreased in fetuses with fetal growth restriction and congenital heart defects (β = -2.295; 95% CI, -3.320-1.270; P < .01; β = -1.267; 95% CI, -0.972-0.562; P < .01, respectively) compared with growth trajectories of controls. Corpus callosum-fastigium growth trajectories were decreased in fetuses with fetal growth restriction (β = -1.295; 95% CI, -2.595-0.003; P = .05).

CONCLUSIONS

Corpus callosum and corpus callosum-fastigium length may serve as reliable markers for monitoring brain growth from the prenatal into the postnatal period. The clinical applicability of these markers was established by the significantly different corpus callosum and corpus callosum-fastigium growth trajectories in fetuses at risk for abnormal brain growth compared with those of controls.

A New Ultrasound Marker for Bedside Monitoring of Preterm Brain Growth

BACKGROUND AND PURPOSE

Preterm neonates are at risk for neurodevelopmental impairment, but reliable, bedside-available markers to monitor preterm brain growth during hospital stay are still lacking. The aim of this study was to assess the feasibility of corpus callosum-fastigium length as a new cranial sonography marker for monitoring of preterm brain growth.

MATERIALS AND METHODS

In this longitudinal prospective cohort study, cranial ultrasound was planned on the day of birth, days 1, 2, 3, and 7 of life; and then weekly until discharge in preterm infants born before 29 weeks of gestational age. Reproducibility and associations between clinical variables and corpus callosum-fastigium growth trajectories were studied.

RESULTS

A series of 1-8 cranial ultrasounds was performed in 140 infants (median gestational age at birth, 27(+2) weeks (interquartile range, 26(+1) to 28(+1); 57.9% male infants). Corpus callosum-fastigium measurements showed good-to-excellent agreement for inter- and intraobserver reproducibility (intraclass correlation coefficient >0.89). Growth charts for preterm infants between 24 and 32 weeks of gestation were developed. Male sex and birth weight SD score were positively associated with corpus callosum-fastigium growth rate.

CONCLUSIONS

Corpus callosum-fastigium length measurement is a new reproducible marker applicable for bedside monitoring of preterm brain growth during neonatal intensive care stay.

Ductal carcinoma in situ diagnosed by breast needle biopsy: Predictors of invasion in the excision specimen

BACKGROUND

A substantial proportion of women with a pre-operative diagnosis of pure ductal carcinoma in situ (DCIS) has a final diagnosis of invasive breast cancer (IBC) after surgical excision and, consequently, a potential indication for lymph node staging. The aim of our study was to identify novel predictors of invasion in patients with a needle-biopsy diagnosis of DCIS that would help us to select patients that may benefit from a sentinel node biopsy (SNB).

PATIENTS AND METHODS

We included 153 patients with a needle-biopsy diagnosis of DCIS between 2000 and 2014, which was followed by surgical excision. Several pre-operative clinical, radiological and pathological features were assessed and correlated with the presence of invasion in the excision specimen. Features that were significantly associated with upstaging in the univariable analysis were combined to calculate upstaging risks.

RESULTS

Overall, 22% (34/155) of the patients were upstaged to IBC. The following risk factors were significantly associated with upstaging: palpability, age ≤40 years, mammographic mass lesion, moderate to severe periductal inflammation and periductal loss of decorin expression. The upstaging-risk correlated with the number of risk factors present: e.g. 9% for patients without risk factors, 29% for patients with 1 risk factor, 37% for patients with 2 risk factors and 54% for patients with ≥3 risk factors.

CONCLUSION

The identified risk factors may be helpful to predict the upstaging-risk for patients with a needle-biopsy diagnosis of pure DCIS, which facilitates the performance of a selective SNB for high-risk patients and avoid this procedure in low-risk patients.

Growth trajectories of the human embryonic head and periconceptional maternal conditions

STUDY QUESTION

Can growth trajectories of the human embryonic head be created using 3D ultrasound (3D-US) and virtual reality (VR) technology, and be associated with second trimester fetal head size and periconceptional maternal conditions?

SUMMARY ANSWER

Serial first trimester head circumference (HC) and head volume (HV) measurements were used to create reliable growth trajectories of the embryonic head, which were significantly associated with fetal head size and periconceptional maternal smoking, age and ITALIC! in vitro fertilization (IVF)/intra-cytoplasmic sperm injection (ICSI) treatment.

WHAT IS KNOWN ALREADY

Fetal growth is influenced by periconceptional maternal conditions.

STUDY DESIGN, SIZE, DURATION

We selected 149 singleton pregnancies with a live born non-malformed fetus from the Rotterdam periconception cohort.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Bi-parietal diameter and occipital frontal diameter to calculate HC, HV and crown-rump length (CRL) were measured weekly between 9 + 0 and 12 + 6 weeks gestational age (GA) using 3D-US and VR. Fetal HC was obtained from second trimester structural anomaly scans. Growth trajectories of the embryonic head were created with general additive models and linear mixed models were used to estimate associations with maternal periconceptional conditions as a function of GA and CRL, respectively.

MAIN RESULTS

A total of 303 3D-US images of 149 pregnancies were eligible for embryonic head measurements (intra-class correlation coefficients >0.99). Associations were found between embryonic HC and fetal HC ( ITALIC! ρ = 0.617, ITALIC! P < 0.001) and between embryonic HV and fetal HC ( ITALIC! ρ = 0.660, ITALIC! P < 0.001) in ITALIC! Z-scores. Maternal periconceptional smoking was associated with decreased, and maternal age and IVF/ICSI treatment with increased growth trajectories of the embryonic head measured by HC and HV (All ITALIC! P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

The consequences of the small effect sizes for neurodevelopmental outcome need further investigation. As the study population consists largely of tertiary hospital patients, external validity should be studied in the general population.

WIDER IMPLICATIONS OF THE FINDINGS

Assessment of growth trajectories of the embryonic head may be of benefit in future early antenatal care.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by the Department of Obstetrics and Gynaecology, Erasmus MC University Medical Centre and Sophia Foundation for Medical Research, Rotterdam, The Netherlands (SSWO grant number 644). No competing interests are declared.

The influence of IVF/ICSI treatment on human embryonic growth trajectories

STUDY QUESTION

Is in vitro fertilization treatment with or without intracytoplasmatic sperm injection (IVF/ICSI) associated with changes in first and second trimester embryonic and fetal growth trajectories and birthweight in singleton pregnancies?

SUMMARY ANSWER

Embryonic and fetal growth trajectories and birthweight are not significantly different between pregnancies conceived with IVF/ICSI treatment and spontaneously conceived pregnancies with reliable pregnancy dating.

WHAT IS KNOWN ALREADY

IVF/ICSI treatment has been associated with increased risks of preterm birth, fetal growth restriction and low birthweight. Decreased first-trimester crown-rump length (CRL) in the general population has been inversely associated with the same adverse pregnancy outcomes.

STUDY DESIGN, SIZE, DURATION

In a prospective periconception birth cohort study conducted in a tertiary centre, 146 singleton pregnancies with reliable pregnancy dating and nonmalformed live borns were investigated, comprised of 88 spontaneous and 58 IVF/ICSI pregnancies.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Serial 3D ultrasound scans were performed from 6 to 12 weeks of gestation. As estimates of embryonic growth, CRL and embryonic volume (EV) were measured using the I-Space virtual reality system. General characteristics were obtained from self-administered questionnaires at enrolment. Fetal growth parameters at 20 weeks and birthweight were obtained from medical records. To assess associations between IVF/ICSI and embryonic growth trajectories, estimated fetal weight and birthweight, stepwise linear mixed model analyses and linear regression analyses were performed using square root transformed CRL and fourth root transformed EV.

MAIN RESULTS AND THE ROLE OF CHANCE

In 146 pregnancies, 934 ultrasound scans were performed of which 849 (90.9%) CRLs and 549 (58.8%) EVs could be measured. Embryonic growth trajectories were comparable between IVF/ICSI pregnancies and spontaneously conceived pregnancies (CRL: βIVF/ICSI = 0.10√mm; P = 0.10; EV: βIVF/ICSI = 0.03(4)√cm³; P = 0.13). Estimated fetal weight and birthweight were also comparable between both groups (βIVF/ICSI = 6 g; P = 0.36 and βIVF/ICSI = 80 g; P = 0.24, respectively).

LIMITATIONS, REASONS FOR CAUTION

Variations in embryonic growth trajectories of spontaneously conceived pregnancies with reliable pregnancy dating may partially be a result of less precise pregnancy dating and differences in endometrium receptivity compared with IVF/ICSI pregnancies.

WIDER IMPLICATIONS OF THE FINDINGS

The absence of a significant difference in embryonic and fetal growth trajectories suggests safety of IVF/ICSI treatment with regard to early embryonic growth. However, further research is warranted to ascertain the influence of IVF/ICSI treatments in a larger study population, and to estimate the impact of the underlying causes of the subfertility and other periconceptional exposures on human embryonic and fetal growth trajectories.

FUNDING STATEMENT

This study was supported by the Department of Obstetrics and Gynaecology of the Erasmus MC, University Medical Centre.

CONFLICT OF INTEREST

No competing interests are declared.

Determinants of number-specific recall error of last menstrual period: a retrospective cohort study

OBJECTIVE

To assess the digit preference for last menstrual period (LMP) dates, associated determinants and impact on obstetric outcome.

DESIGN

Retrospective cohort study.

SETTING

University medical centre (the Netherlands).

POPULATION

Cohort of 24 665 LMP records and a subgroup of 4630 cases with known crown-rump length (CRL) measurement, and obstetric outcome.

METHODS

Digit preference was determined by comparing the observed to expected counts of each day. Associated determinants were identified by multivariate regression analysis. Differences in obstetric outcome between LMP and CRL dating were analysed.

MAIN OUTCOME MEASURES

(Non)deprived neighbourhood, cycle irregularity, certainty of LMP date, maternal age, smoking, body mass index, parity and ultrasound investigator. Preterm and post-term delivery.

RESULTS

LMP digit preference for the first [odds ratio (OR), 1.28; 95% confidence interval (95% CI), 1.20-1.36], fifth (OR, 1.10; 95% CI, 1.03-1.17), 10th (OR, 1.17; 95% CI, 1.09-1.25), 15th (OR, 1.31; 95% CI, 1.23-1.40), 20th (OR, 1.22; 95% CI, 1.15-1.30) and 25th (OR, 1.08; 95% CI, 1.01-1.15) days of the month occurred more often than expected. Digit preference occurred more frequently in women living in a deprived neighbourhood (OR, 1.21; 95% CI, 1.06-1.39), with uncertain LMP (OR, 2.03; 95% CI, 1.63-2.52) or irregular cycle (OR, 1.24; 95% CI, 1.06-1.44). More post-term (≥42 weeks) deliveries (OR, 1.27; 95% CI, 1.05-1.54) were observed in LMP dating. This effect was larger in women with a digit preference (OR, 1.56; 95% CI, 1.03-2.37).

CONCLUSIONS

LMP digit preference occurs more often in women living in deprived neighbourhoods, with uncertain LMP or an irregular cycle. LMP-dated pregnancies are associated with more post-term pregnancies.

Early first-trimester trophoblast volume in pregnancies that result in live birth or miscarriage

OBJECTIVES

To assess the validity of trophoblast volume measurements on three-dimensional ultrasound (3D-US) with Virtual Organ Computer-aided AnaLysis (VOCAL(TM) ), to create reference values between 6 and 12 weeks of gestation and to compare trophoblast volume between pregnancies ending in miscarriage and those resulting in live birth.

METHODS

In a prospective periconceptional cohort, we performed weekly 3D-US in 112 singleton pregnancies resulting in a non-malformed live birth and in 56 ending in miscarriage. Scans were performed between 6 and 12 weeks. Trophoblast volumes were calculated by subtracting the gestational sac volume from the volume of the total pregnancy. The interobserver and intraobserver agreement of measurements were determined to assess validity. Reference values were created for trophoblast volume in relation to crown-rump length and gestational age.

RESULTS

A total of 722 3D-US examinations were available for offline VOCAL measurements, but measurements could be performed in only 53% of these due to non-targeted scanning and incomplete framing. Interobserver and intraobserver agreement for trophoblast volume measurements were excellent, with intraclass correlation coefficients > 0.97. Trophoblast volumes of pregnancies ending in miscarriage were significantly smaller (P < 0.01) than were those of pregnancies that resulted in live birth. Trophoblast growth in pregnancies ending in miscarriage was also reduced compared with that in pregnancies that resulted in live birth.

CONCLUSION

VOCAL is a valid technique for measuring trophoblast volume during the early first trimester of pregnancy. Pregnancies ending in miscarriage have smaller trophoblast volumes as well as reduced trophoblast growth compared with those that result in live birth.

Periconception maternal characteristics and embryonic growth trajectories: the Rotterdam Predict study

STUDY QUESTION

Are maternal characteristics and lifestyle factors associated with human embryonic growth trajectories?

SUMMARY ANSWER

Periconception maternal age is associated with increased, and smoking and alcohol use with decreased embryonic growth trajectories, estimated with crown-rump length (CRL) measurements.

WHAT IS KNOWN ALREADY

Fetal weight is associated with health and disease in later life. Maternal characteristics and lifestyle factors affect fetal growth in the second and third trimesters of pregnancy and at birth; however, little is known about the association of these characteristics with first trimester embryonic growth.

STUDY DESIGN, SIZE, DURATION

In a tertiary centre, pregnant women were recruited and enrolled in a prospective periconception cohort study before 8 weeks of gestation. We selected 87 spontaneously conceived singleton pregnancies of women recruited in 2009 and 2010 that ended in non-malformed live births.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We performed weekly three-dimensional ultrasound scans from enrolment up to 13 weeks of gestation. At enrolment, a questionnaire was completed. Embryonic CRL measurements were performed using the V-Scope software in the BARCO I-Space. Associations between maternal characteristics and embryonic growth were assessed using square root transformed CRL as response in linear mixed model analyses, adjusted for potential confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

Four hundred and ninety-six scans from 87 pregnancies were included. In the multivariable analysis, maternal age was positively associated with first trimester CRL (difference per maternal year of age 0.024√mm (95% confidence interval (CI) 0.009, 0.040), P = 0.001). At 6 and 12 weeks of gestation, the CRL of an embryo from a 40-year-old mother was estimated 2.0 mm (61%) and 7.2 mm (14%) larger, respectively, compared with an embryo from a 20-year-old mother. Smoking of 10 or more cigarettes per day was negatively associated with CRL (difference -0.211√mm (95% CI -0.416, -0.006), P = 0.04), with embryos that were 0.9 mm (18.7%) and 3.1 mm (5.5%) smaller at 6 and 12 weeks, respectively, compared with non-smokers. Periconception alcohol use was negatively associated with CRL growth rate (difference -0.0025√mm (95% CI -0.0047, -0.0003)/day gestational age, P = 0.022), with embryos that were 0.2 mm (3%) and 1.1 mm (2%) smaller at 6 and 12 weeks, respectively, compared with non-alcohol users. Parity, BMI and moment of initiation of folic acid use were not significantly associated with embryonic CRL.

LIMITATIONS, REASONS FOR CAUTION

Due to the selection of pregnancies in a tertiary centre and the small number of pregnancies, the external validity of the results has to be confirmed using larger sample sizes and other population-based periconception cohort studies.

WIDER IMPLICATIONS OF THE FINDINGS

The association of maternal age and smoking with embryonic growth is in line with previous literature, whereas the association between embryonic growth and alcohol use is a new finding. However, concerning exposure to alcohol, the effect estimate was small and it is questionable whether this is of clinical value. More research is warranted to unravel underlying mechanisms and to assess the implications for preconception and early pregnancy care, such as the development and implementation of effective lifestyle interventions.

STUDY FUNDING/COMPETING INTEREST(S)

The work was funded by the Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. The authors declare no conflicts of interest.

Interaction of a 17q12 variant with both fetal and infant smoke exposure in the development of childhood asthma-like symptoms

BACKGROUND

Gene variants on chromosome 17q12-21 are associated with an increased risk of childhood-onset asthma, a risk known to be modified by environmental tobacco smoke (ETS).

OBJECTIVES

To assess whether the association of rs2305480 on chromosome 17q12 in the GSDML gene with asthma-like symptoms in the first 4 years of life is modified by smoke exposure during fetal and early postnatal life.

METHODS

We used data from two independent prospective cohort studies from fetal life onwards in the Netherlands. We genotyped rs2305480 and assessed maternal smoking during pregnancy and ETS exposure at the age of 2. Asthma-like symptoms, defined as any reported wheezing, shortness of breath or dry nocturnal cough, were reported by parents when the children were 1, 2, 3, and 4 years. Analyses were based on a total group of 4461 Caucasian children.

RESULTS

The G risk-allele of rs2305480 was associated with asthma-like symptoms [overall odds ratio 1.17 (1.11, 1.24), 2.66E-9]. The effect of rs2305480 on asthma-like symptoms was stronger among children who were exposed to smoke during fetal life (P-interaction = 0.04). Smoke exposure in early postnatal life was also associated with an increased effect of the 17q12 single nucleotide polymorphism (SNP) on asthma-like symptoms (P-interaction = 5.06E-4). These associations were consistent in both cohorts.

CONCLUSION

A 17q12 variant, rs2305480, was associated with asthma-like symptoms in preschool children, and this association was modified by smoke exposure already during fetal life, and in infancy. Further investigation regarding SNPs in linkage disequilibrium with rs2305480 in relation to pathophysiological pathways is needed.

Duration and exclusiveness of breastfeeding and childhood asthma-related symptoms

The aim of our study was to examine the associations of breastfeeding duration and exclusiveness with the risks of asthma-related symptoms in preschool children, and to explore whether these associations are explained by atopic or infectious mechanisms. This study was embedded in a population-based prospective cohort study of 5,368 children. Information on breastfeeding duration, exclusiveness and asthma-related symptoms, including wheezing, shortness of breath, dry cough and persistent phlegm, was obtained by questionnaires. Compared with children who were breastfed for 6 months, those who were never breastfed had overall increased risks of wheezing, shortness of breath, dry cough and persistent phlegm during the first 4 yrs (OR 1.44 (95% CI 1.24-1.66), 1.26 (1.07-1.48), 1.25 (1.08-1.44) and 1.57 (1.29-1.91), respectively). Similar associations were observed for exclusive breastfeeding. The strongest associations per symptom per year were observed for wheezing at 1 and 2 yrs. Additionally adjusted analyses showed that the associations of breastfeeding with asthma-related symptoms were not explained by eczema but partly by lower respiratory tract infections. Shorter duration and nonexclusivity of breastfeeding were associated with increased risks of asthma-related symptoms in preschool children. These associations seemed, at least partly, to be explained by infectious, but not by atopic, mechanisms.

Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open label randomised controlled trial

OBJECTIVE

To assess the effectiveness of supervised exercise therapy compared with usual care with respect to recovery, pain, and function in patients with patellofemoral pain syndrome.

DESIGN

Open label randomised controlled trial.

SETTING

General practice and sport physician practice.

PARTICIPANTS

Patients with a new episode of patellofemoral pain syndrome recruited by their general practitioner or sport physician.

INTERVENTIONS

The intervention group received a standardised exercise programme for 6 weeks tailored to individual performance and supervised by a physical therapist, and were instructed to practise the tailored exercises at home for 3 months. The control group were assigned usual care, which comprised a "wait and see" approach of rest during periods of pain and refraining from pain provoking activities. Both the intervention group and the control group received written information about patellofemoral pain syndrome and general instructions for home exercises.

MAIN OUTCOME MEASURES

The primary outcomes were self reported recovery (7 point Likert scale), pain at rest and pain on activity (0-10 point numerical rating scale), and function (0-100 point Kujala patellofemoral score) at 3 months and 12 months follow-up.

RESULTS

A total of 131 participants were included in the study: 65 in the intervention group and 66 in the control group. After 3 months, the intervention group showed better outcomes than the control group with regard to pain at rest (adjusted difference -1.07, 95% confidence interval -1.92 to -0.22; effect size 0.47), pain on activity (-1.00, -1.91 to -0.08; 0.45), and function (4.92, 0.14 to 9.72; 0.34). At 12 months, the intervention group continued to show better outcomes than the control group with regard to pain (adjusted difference in pain at rest -1.29, -2.16 to -0.42; effect size 0.56; pain on activity -1.19, -2.22 to -0.16; effect size 0.54), but not function (4.52, -0.73 to 9.76). A higher proportion of patients in the exercise group than in the control group reported recovery (41.9% v 35.0% at 3 months and 62.1% v 50.8% at 12 months), although the differences in self reported recovery between the two groups were not statistically significant. Predefined subgroup analyses revealed that patients recruited by sport physicians (n=30) did not benefit from the intervention, whereas those recruited by general practitioners (n=101) showed significant and clinically relevant differences in pain and function in favour of the intervention group.

CONCLUSION

Supervised exercise therapy resulted in less pain and better function at short term and long term follow-up compared with usual care in patients with patellofemoral pain syndrome in general practice. Exercise therapy did not produce a significant difference in the rate of self reported recovery.

TRIAL REGISTRATION

ISRCTN83938749.

Effect of glucosamine sulphate on joint space narrowing, pain and function in patients with hip osteoarthritis; subgroup analyses of a randomized controlled trial

OBJECTIVE

Recently we reported that glucosamine sulphate (GS) did not have an effect on the symptoms and progression of primary care patients with hip osteoarthritis (OA). The aim of this present study was to investigate whether there are subgroups of patients with hip OA for whom GS might be an effective therapy.

METHOD

We randomized 222 patients with hip OA that met one of the American College of Rheumatology criteria to either 1500 mg of oral GS or placebo once daily for 2 years. Subgroup analyses were predefined for radiographic severity (Kellgren & Lawrence (KL)=1 vs >or=2) and for type of OA (localised vs generalised). Additional exploratory subgroup analyses focused on groups based on pain level, pain medication use, baseline joint space width (JSW), and concomitant knee OA at baseline. Primary outcome measures were Western Ontario MacMaster Universities (WOMAC) pain and function scores over 24 months, and joint space narrowing (JSN) after 24 months.

RESULTS

In the predefined subgroups based on radiographic severity and type of OA, the outcomes WOMAC pain, function and JSN were similar for the GS and placebo group.

CONCLUSION

GS was not significantly better than placebo in reducing symptoms and progression of hip OA in subgroups of patients.