Fetal growth restriction induced by chronic placental insufficiency has long-term effects on the retina but not the optic nerve.

PURPOSE: Reduced birth weight is associated with an increased risk of visual impairments. This study was undertaken to determine whether prenatal exposure to a chronic compromise sufficient to cause fetal growth restriction (FGR) results in long-term alterations to the retina and optic nerve. METHODS: FGR was induced by umbilicoplacental embolization (UPE) in two cohorts of pregnant ewes from (1) 120 days of gestation (dg) until 140 dg and (2) 120 dg until term ( approximately 147 dg). Control fetuses were not subjected to UPE. The structure and neurochemistry of the retina and number and structure of ganglion cell axons were assessed in near-term (140 dg) and adult animals (2.3 years). RESULTS: In near-term FGR fetuses compared with control fetuses there were significant reductions (P < 0.05) in the outer plexiform layer (OPL), the photoreceptor inner and outer segment layers, the inner nuclear layer (INL) in the central retina and the outer nuclear layer (ONL) in the peripheral retina, and the diameter of ganglion cell axons in the optic nerve, with a proportional reduction in the thickness of myelin sheaths. In FGR animals compared with the control at 2.3 years, there were significant reductions (P < 0.05) in the total thickness of the retina, the thickness of the photoreceptor outer segment layer and the INL and the number of tyrosine hydroxylase-immunoreactive (TH-IR) dopaminergic amacrine cells. Axonal diameter and myelin sheath thickness in the optic nerve were not different (P > 0.05) between groups. CONCLUSIONS: Chronic placental insufficiency in late gestation results in long-lasting effects on specific retinal components, including photoreceptor outer segments and TH-IR amacrine cells. Other alterations observed at term, including reductions in growth and myelination of optic nerve axons, do not persist, suggesting delayed rather than permanently compromised development. Alterations persisting into adulthood could affect visual function.

Suboptimal neurodevelopment in very preterm infants is related to fetal cardiovascular compromise in placental insufficiency.

OBJECTIVE: The purpose of this study was to determine the relationship between fetal cardiovascular hemodynamics and neurodevelopmental outcome in infants born before 32 gestational weeks with placental insufficiency. STUDY DESIGN: Seventeen fetuses that underwent Doppler ultrasonography within 24 hours before delivery were included in this prospective cross-sectional study. Placental histology was examined. Multiple inflammatory markers and vascular endothelial growth factor (VEGF) and its receptor were analyzed from umbilical cord serum. Neurodevelopmental outcome was assessed by Griffiths scales at 1 year of corrected age. RESULTS: Infants with suboptimal outcome (n = 7) had higher umbilical artery, ductus venosus, and inferior vena cava pulsatility index values (P < .05) and lower weight-indexed cardiac outputs (P < .05) than infants with normal outcome (n = 10). Placental histology and serum revealed no inflammation. VEGF values were similar among all infants. CONCLUSION: In placental insufficiency with delivery before 32 gestational weeks, suboptimal neurodevelopment was related to decreased fetal weight-indexed cardiac output and increased systemic venous pressure.

Cysteinylation of maternal plasma albumin and its association with intrauterine growth restriction.

OBJECTIVES: We investigated cysteinylation of maternal plasma albumin in an observational study of intrauterine growth restriction (IUGR). High-risk pregnancies and uteroplacental insufficiency (UPI) have been associated with elevated levels of homocysteine, and, in oxidizing environments, homocysteine is converted to cysteine, resulting in cysteinylation of proteins. METHODS: The study population included pregnancies with IUGR (n = 12) and uncomplicated pregnancies as controls (n = 8). In all cases, cysteinylation of maternal plasma albumin was measured in a blinded fashion using liquid chromatography coupled with electrospray ionization mass spectrometry. RESULTS: Markedly elevated maternal plasma levels of cysteinylated albumin were detected in pregnancies with IUGR (44.7 +/- 14.8% of total albumin) compared to those in normal pregnancies (20.9 +/- 6.1%). As a result, native albumin decreased from 52.5 +/- 6.5% of total albumin in normal pregnancies to 30.1 +/- 13.3% in IUGR pregnancies. CONCLUSIONS: We hypothesize that sustained oxidative stress present in UPI is reflected by high levels of maternal cysteinylated albumin and may be a factor in the etiology of IUGR. Results of this preliminary study suggest that measurement of maternal plasma cysteinylated albumin may be useful for monitoring pregnancies associated with UPI and for detection of IUGR.

Effects of exposure to chronic placental insufficiency on the postnatal brain and retina in sheep.

Chronic placental insufficiency (CPI) has the potential to affect fetal brain development and to cause brain injury. Our aim was to determine the effects of exposure to CPI during late gestation on brain and retinal structure and brain neurotrophin expression 8 weeks after birth. Six fetal sheep were exposed to CPI, induced by umbilico-placental embolization, from 120 days of gestation until term (approximately 147 days) such that fetal arterial oxygen saturation (SaO2) was reduced by approximately 50%. Nine untreated animals served as controls. During CPI, fetal arterial PO2, SaO2, pH, and growth were reduced (p < 0.05); these animals remained small at 8 weeks after birth. Structural abnormalities were present in the brains and retinae of all CPI-exposed lambs. There was a reduction in retinal width and in the number of retinal tyrosine hydroxylase-immunoreactive dopaminergic amacrine cells (p < 0.05). In the dorsal hippocampus the combined width of strata oriens and pyramidale was significantly reduced (p < 0.05). In the cerebellum there was a significant reduction (p = 0.05) in cerebellar cross-sectional area, most notably in the inner granule cell layer, and a reduction (p < 0.05) in immunoreactivity for the cytoskeletal protein neurofilament-200 in the white matter. Gliosis was present in either the cerebral white matter or cerebellum in all animals and degeneration was seen around blood vessels in 4/6 umbilico-placental embolization animals. There were reductions in brain-derived neurotrophic factor immunoreactivity in the hippocampus (p < 0.05) and tyrosine kinase B immunoreactivity in the cerebellum (p < 0.05). This study shows that late gestational CPI affects morphology and neurotrophin expression of the postnatal brain. These alterations in the brain can apparently persist from fetal life or become established after birth; some changes that were present in the fetus at term did not persist into postnatal life.

Alteration of homocysteine catabolism in pre-eclampsia, HELLP syndrome and placental insufficiency.

Hyperhomocysteinemia is a risk factor in obstetrical complications such as pre-eclampsia, 'hemolysis, elevated liver enzymes, low platelet' (HELLP)-syndrome and placental insufficiency. The aim of our study was to investigate the alterations of homocysteine catabolism in these patients in relation to serum B-vitamins and renal function. Maternal fasting serum from pre-eclampsia (n=24), HELLP (n=20) and placental insufficiency (n=25) patients at the time of diagnosis and pregnant controls (n=34) was analyzed for homocysteine and its metabolites cystathionine and methylmalonic acid, the vitamins B6, B12 and folate, renal and additional parameters. Cystathionine, a parameter of homocysteine catabolism, was significantly increased in pre-eclampsia and HELLP compared with controls and placental insufficiency patients (mean concentrations: 343, 324, 248, 227 nmol/l; p=0.001). Homocysteine, folic acid, vitamin B6 and methylmalonic acid, however, did not differ significantly between groups. The main determinants of cystathionine are cystatin C and vitamin B6, whereas the main determinants of homocysteine are folate and uric acid. The strongest dependency of cystathionine on vitamin B6 was observed in pre-eclampsia and HELLP patients. The results suggest that the vitamin B6-dependent trans-sulfuration pathway is activated in pre-eclampsia and HELLP syndrome, probably by oxidative stress. Therefore, the demand for vitamin B6 is increased in these patients. Furthermore, renal dysfunction and low vitamin B6 levels contribute to the increase of cystathionine in pre-eclampsia and HELLP patients.

An animal model of chronic placental insufficiency: relevance to neurodevelopmental disorders including schizophrenia.

Evidence now suggests that compromised prenatal brain development may increase the risk for the manifestation of neurological disorders such as schizophrenia. We present a guinea-pig model which mimics a condition of human pregnancy, namely, chronic placental insufficiency. Previously we reported that at term there are changes in the brains of these offspring which are relevant to changes in patients with schizophrenia. The aim of this study was to examine whether deficits in brain structure persist to adolescence and young adulthood (8-12 weeks) and have implications for behavioral function. Reduced uteroplacental blood flow was induced via unilateral ligation of the uterine artery at mid-gestation. The brain was examined in control and prenatally compromised (PC) animals 8 weeks after birth using morphometric and immunohistochemical markers. In a separate cohort of animals, prepulse inhibition (PPI) of the acoustic startle response was assessed at 4, 8 and 12 weeks of age. Brain neurochemistry was examined by determining the concentrations of dopamine and its metabolite, dihydroxyphenylacetic acid (DOPAC), at 12 weeks using high performance liquid chromatography. In PC animals compared with controls there was a reduction in brain weight, persistent enlargement of the lateral ventricles, a reduction in the volume of the basal ganglia and septal region and no evidence of gliosis. No differences were observed in concentration of catecholamines in any brain region examined. At 12, but not 4 or 8, weeks of age, PPI was reduced in PC animals compared with controls. The findings of reduced brain weight, ventriculomegaly, reduced basal ganglia volume and absence of astrogliosis in the PC guinea-pig brain at adolescence parallel some of the changes observed in patients with schizophrenia. The impairment of PPI is comparable to sensorimotor gating deficits observed in patients with schizophrenia. These results indicate that adverse prenatal conditions lead to long-term alterations in brain structure and function which resemble alterations seen in patients with schizophrenia and therefore support the early neurodevelopmental hypothesis of schizophrenia.

Cardiovascular and renal disease in the adolescent guinea pig after chronic placental insufficiency.

OBJECTIVE: The aim of this study was to determine the long-term effects of chronic placental insufficiency on the metabolic state and organ structure in the fetal and adolescent guinea pig. STUDY DESIGN: The maternal uterine artery was ligated at day 28-30 to reduce placental function and restrict fetal growth. Whole body and tissue weights and plasma metabolites were determined at 60 days of gestation and 8 weeks of age; tissue structure was determined at the latter age in restricted and control offspring. RESULTS: Fetal growth restriction increased fibrosis in the heart and kidneys (P < .05), increased aortic wall thickening (P < .01), reduced the number of glomeruli in the kidneys (P < .05), and increased the plasma urea and chloride in adolescent offspring. CONCLUSION: This study demonstrates that diseases in the heart, aorta, and kidneys that result from an adverse prenatal environment are evident at adolescence and may contribute to subsequent adult disease.

Restricted fetal growth and adverse maternal psychosocial and socioeconomic conditions as risk factors for suicidal behaviour of offspring: a cohort study.

BACKGROUND: Until now, sparse and contradictory results about an association between adverse neonatal, obstetric, and maternal conditions and heightened suicide risk in adolescents have been reported. The aims of this study were to investigate the relations between fetal growth, obstetric complications, and the mother's psychosocial and socioeconomic situation and the risk in early adulthood of suicide and attempted suicide in the offspring. METHODS: Obstetric, neonatal, and maternal risk factors for suicide and attempted suicide in 713370 young adults, born in Sweden between 1973 and 1980, who were followed-up until Dec 31, 1999, were examined by data linkage between Swedish registers. Univariate and multivariate hazard ratios, derived from proportional-hazard models, were estimated. FINDINGS: Significantly raised risk of attempted suicide was reported for individuals of short birth length, adjusted for gestational age (hazard ratio 1.29, 95% CI 1.18-1.41, p<0.0001); born fourth or more in birth order (1.79, 1.62-1.97, p<0.0001); born to mothers with a low educational level (1.36, 1.27-1.46, p<0.0001) (attributable proportion 10.3%); and those who, at time of delivery, had mothers aged 19 years or younger (2.09, 1.89-2.32, p<0.0001). Significant predictors of suicide were low birthweight, adjusted for gestational age (2.23, 1.43-3.46, p<0.0001), and teenage motherhood (2.30, 1.64-3.22, p<0.0001). INTERPRETATION: Multiparity and low maternal education predicted suicide attempt, whereas restricted fetal growth and teenage motherhood were associated with both suicide completion and attempt in offspring.

Pathophysiology of fetal growth restriction: implications for diagnosis and surveillance.

UNLABELLED: Normal fetal growth depends on the genetically predetermined growth potential and is modulated by fetal, placental, maternal, and external factors. Fetuses with intrauterine growth restriction (IUGR) are at high risk for poor short- and long-term outcome. Although there are many underlying etiologies, IUGR resulting from placental insufficiency is most relevant clinically because outcome could be altered by appropriate diagnosis and timely delivery. A diagnostic approach that aims to separate IUGR resulting from placental disease from constitutionally small fetuses and those with other underlying etiologies (e.g., aneuploidy, viral infection, nonaneuploid syndromes) needs to integrate multiple imaging modalities. In placental-based IUGR, cardiovascular and behavioral responses are interrelated with the disease severity. Ultrasound assessment of fetal anatomy, amniotic fluid volume, and growth is complementary to the Doppler investigation of fetoplacental blood flow dynamics. A diagnostic approach to IUGR combining these modalities is presented in this review. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to describe the development of the placental interface, to outline the mechanisms of placental insufficiency, and to list the manifestations of placental insufficiency and the tests that can be used to diagnose fetal growth restriction.

[Corrective action of the microwave electromagnetic field on progeny development in rats with impared uteroplacental circulation]. / Eksperimental'noe issledovanie korrigirueshchego deistviia élektromagnitnykh polei detsimetrovogo diapazona voln na razvitie potomstva krys pri narushenii matochno-platsentarnogo krovoobrashcheniia.

The experiment on 71 non-inbred white pregnant rats, 316 fetuses and placentas, 323 first progeny in experimental chronic impairment of uteroplacental circulation in females with pregnancy in the ploid period has found that decimetric waves (DW) in a weak heat dose (40 mW/cm2) prevents hypotrophy and disorders of fetal and placental development. Also, DW accelerate formation of motorsensory reflexes in the progeny in an early neonatal period and normalize their behavioral reactions at a mature age. The findings may serve experimental-theoretical grounds for application of weak heat DW radiation in obstetric practice in various general and regional hemocirculation.

Chronic placental insufficiency affects retinal development in the guinea pig.

PURPOSE: Very low birth weight (VLBW) and fetal growth restriction are associated with increased risks of long-term visual impairments, including alterations to contrast sensitivity, a parameter mediated in part by dopaminergic amacrine cells. This study was conducted to determine whether chronic placental insufficiency (CPI), sufficient to cause growth restriction, results in neurochemical alterations to retinal interneurons, specifically amacrine and horizontal cell populations near term. METHODS: CPI was induced just before midgestation (term approximately 67 days of gestation, dg) in guinea pigs through unilateral ligation of the uterine artery. Growth-restricted (GR, n = 32) and control (n = 29) fetuses were euthanized at 60 dg and retinas prepared for analysis of amacrine cell populations by using antibodies to calbindin, calretinin, cholineacetyltransferase (ChAT), gamma-amino-butyric acid (GABA), dopamine beta-hydroxylase (D beta H), tyrosine hydroxylase (TH, dopaminergic), and NADPH-diaphorase histochemistry (nitrergic). Calbindin immunoreactivity (IR) was also used to identify horizontal cells. HPLC was used to assess concentrations of catecholamines and Western blot analysis to detect total TH levels. RESULTS: In GR compared with control fetuses the total number of TH-IR amacrine (P < 0.02) and calbindin-IR horizontal (P < 0.05) cells was reduced; however, there were no differences in the number of the ChAT, calbindin, calretinin, GABAergic, or nitrergic amacrine cell populations. HPLC revealed a reduction in the concentration of dopamine (P < 0.05) and noradrenaline (P < 0.05), and Western blot analysis revealed a reduction in TH in the retinas of GR compared with control fetuses (P < 0.05). CONCLUSIONS: CPI results in alterations to specific populations of retinal neurons. Such effects could contribute to visual impairments reported for VLBW children.

Brain development during fetal life: influences of the intra-uterine environment.

The intrauterine environment can significantly affect fetal brain development. Here we review our recent findings using animal models that mimic adverse intrauterine conditions which could exist during human pregnancy. We have focused on effects of both acute and chronic hypoxic and inflammatory insults. Relatively brief periods of hypoxemic compromise can have significant effects on the fetal brain causing neuronal loss and cerebral white matter damage. Subtle brain injury can occur, for example to a particular class of neuron, and this can have a significant effect on the function of a specific system. Chronic mild placental insufficiency can result in long term deficits in neuronal connectivity affecting function postnatally as demonstrated in the auditory and visual systems. Repeated acute exposure to an inflammatory agent results in diffuse subcortical white matter damage and in some cases periventricular necrosis. We have demonstrated that the timing and severity of these prenatal insults are determinants of the outcomes, in terms of the severity of the damage and the regions of the brain affected.

Fetal growth restriction due to placental disease.

Normal fetal growth depends on the genetically predetermined growth potential and its modulation by the health of the fetus, placenta and the mother. Fetuses that are small because of intrauterine growth restriction (IUGR) are at higher risk for poor perinatal and long-term outcome than those who are appropriately grown. Of the many potential underlying processes that may result in IUGR, placental disease is clinically the most relevant. Fetal cardiovascular and behavioral responses to placental insufficiency and the metabolic status are interrelated. The concurrent evaluation of fetal biometry, amniotic fluid volume, heart rate patterns, arterial and venous Doppler, and biophysical variables therefore allow the most comprehensive fetal evaluation in IUGR. In the absence of successful intrauterine therapy, the timing of delivery is perhaps the most critical aspect of the antenatal management. A discussion of the fetal responses to placental insufficiency and a management protocol that accounts for multiple Doppler and biophysical parameters as well as gestational age is provided in this review.

Decreased endothelium-dependent NO-cGMP vascular relaxation and hypertension in growth-restricted rats on a high-salt diet.

Low birth weight caused by placental insufficiency increases the risk of hypertension in young adults, particularly while ingesting a high-salt diet; however, the vascular mechanisms involved are unclear. We tested whether intrauterine fetal growth restriction results in salt-sensitive offspring that exhibit impaired endothelium-dependent relaxation, enhanced vascular contraction, and hypertension during high-salt diet feeding. Male offspring of control pregnant rats and pregnant rats with reduced uterine perfusion pressure (intrauterine growth restricted [IUGR]) were fed either a normal-sodium (NS, 1%) or a high-sodium (HS, 8%) diet. Body weight was less in IUGR/NS and IUGR/HS than in NS and HS rats. Arterial pressure was greater in IUGR/NS (144+/-4 mm|Hg) than in NS (131+/-3 mm|Hg) rats and far greater in IUGR/HS (171+/-12 mm|Hg) than in HS (129+/-2 mm|Hg) rats. In isolated, endothelium-intact aortic strips, phenylephrine (Phe, 10(-5) mol/L) caused an increase in active stress that was greater in IUGR/NS (13.9+/-0.9 N/m2) than in NS (8.5+/-0.6 N/m2) animals and far greater in IUGR/HS (18.2+/-1.2 N/m2) than in HS (9.4+/-0.8x10(4) N/m2) rats. Acetylcholine caused relaxation of the Phe-mediated contraction and induced vascular nitrite/nitrate production that was less in IUGR/NS than in NS animals and far less in IUGR/HS than in HS rats. N(G)-nitro-L-arginine methyl ester, which inhibits nitric oxide (NO) synthase, or ODQ, which inhibits cGMP production in smooth muscle, inhibited acetylcholine relaxations and enhanced Phe contractions in NS and HS rats but not in IUGR/NS or IUGR/HS rats. Endothelium removal enhanced Phe-induced stress in NS and HS rats but not in IUGR/NS or IUGR/HS rats. Thus, endothelium-dependent relaxation via the NO-cGMP pathway is inhibited in systemic vessels of IUGR rats, particularly during intake of an HS diet. This might explain the increased vasoconstriction and arterial pressure in low-birth-weight offspring during ingestion of an HS diet.

Fetal consequences of chronic substrate deprivation.

The aim of this paper is to review the mechanisms by which animal and human fetuses survive prolonged periods of substrate deprivation in utero. Two reasons why such information is important for those who care for growth-restricted fetuses and neonates are as follows. (1) Understanding the physiology is central to designing appropriate tests for determining fetal well-being. For instance, most currently available techniques for monitoring fetal well-being are actually better designed to detect acute than chronic fetal hypoxaemia. (2) There is increasing interest in the medium- and long-term consequences of fetal growth restriction on cardiovascular, neurological and lung function. As an example, the reasons why chronic oxygen deprivation may influence cerebral structure and function are discussed.

Management of fetal growth restriction.

When fetuses are growth restricted as a result of inadequate placental function, there is an increased risk of poor perinatal outcome compared with fetuses where small dimensions are constitutional and associated with normal placental function. The management of reduced fetal size should therefore focus on the identification of the fetus at risk due to placental dysfunction, and longitudinal assessment to reduce the morbidity and mortality associated with this pathology by ideal timing of delivery. The aim of this review is to rationalize the best way to assess fetuses affected in this way and how to improve their outcome by appropriately timed intervention.

Maternal constraint of fetal growth and its consequences.

The major non-genetic factor determining the size of the fetus at term is maternal constraint. This term refers to a set of poorly defined processes by which maternal and uteroplacental factors act to limit the growth of the fetus, presumably by limiting nutrient availability and/or the metabolic-hormonal drive to grow. Maternal constraint can be divided into supply-limited constraint (e.g. maternal size) and demand-driven constraint (e.g. twinning). Maternal constraint acts in all pregnancies, but is greater in some situations, particularly those involving young maternal age, small maternal size, nulliparous and multiple pregnancies. Maternal constraint is an important physiological cause of the variation in birth size, but is not without longer-term consequences. There is increasing evidence that maternal constraint is an important factor in determining the increased risk of adult diseases in those who have poor fetal growth due to pathophysiological factors. The evidence is reviewed and placed in the context of discussing the evolutionary significance of maternal constraint. The role of predictive adaptive responses as the basis of programming, and the effects of maternal constraint on these responses are discussed. Changing demography means that maternal constraint must increasingly be considered as a significant factor in determining the pattern of disease.

Thyroid function tests in preterm infants born to preeclamptic mothers with placental insufficiency.

OBJECTIVE: Since preeclampsia causes placental insufficiency, it can be hypothesized that it decreases placental passage of thyroxine (T4) from mother to infant and thus may deepen the transient hypothyroxinemia seen in preterm infants after birth. The aim of this study was to compare thyroid function tests of preterm infants born to preeclamptic mothers with placental insufficiency with preterm infants born to mothers without placental insufficiency. METHODS: Thirty-one preterm infants born to preeclamptic mothers with placental insufficiency were included in the study (group I) and 31 preterm infants born to mothers without placental insufficiency were included as the control group (group II). Thyroid hormone levels were assayed from blood samples obtained from the women before birth and thereafter from the infants at delivery (cord) and on the 1st, 3rd, 7th, and 21st days of life. RESULTS: Cord blood triiodothyronine (T3), free T3 (FT3) and free thyroxine (FT4) levels in group I were lower than in group II, whereas thyrotropin (TSH) and thyroxine binding globulin (TBG) levels were higher. No statistical difference in hormone levels studied at postnatal 1st, 3rd, 7th, and 21st day was found between the two groups. CONCLUSION: Low levels of thyroid hormones and high level of TSH in cord blood in premature infants born to preeclamptic mothers with placental insufficiency suggest intrauterine hypothyroidism. Increase in TSH and thyroid hormone concentrations after birth reveal that the hypothalamic-pituitary-thyroid axis is intact.