Biophysical profile in the treatment of intrauterine growth-restricted fetuses who weigh <1000 g.

OBJECTIVE: The aim of this study was to determine the biophysical profile (BPP) usefulness in the prediction of cord pH, base excess, and guidance regarding the timing of delivery in preterm intrauterine growth-restricted (IUGR) fetuses. STUDY DESIGN: A BPP was performed daily in 48 IUGR fetuses and was considered abnormal when it was 2/10 on 1 single occasion or 4/10 on 2 consecutive occasions 2 hours apart. RESULTS: The median gestational age and fetal weight for the total population was 27.6 weeks and 632 g, respectively. In 13 fetuses with a BPP of 6, there were 3 deaths, and 7 fetuses were acidemic. In 27 fetuses with a BPP of 8, there were 3 deaths, and 12 fetuses were acidemic. CONCLUSION: BPP alone is not a reliable test in the treatment of preterm IUGR fetuses, because of high false-positive and -negative results. The common notion of a good BPP providing reassurance for at least 24 hours is not applicable in severely preterm IUGR fetuses who weigh <1000 g.

Ductus venosus S-wave/isovolumetric A-wave (SIA) index and A-wave reversed flow in severely premature growth-restricted fetuses.

OBJECTIVE: Ductus venosus (DV) Doppler waveforms show 2 periods of decreased velocity during iso-volumetric relaxation (isovolumetric relaxation velocity [IRV]) and atrial contraction (A wave or end-diastolic velocity [EDV]). In intrauterine growth-restricted (IUGR) fetuses, both may become abnormal. The hypothesis for this study was that in severely premature IUGR fetuses, Doppler assessment of both the IRV and EDV allows a more accurate prediction of fetal outcome than absent/reversed end-diastolic flow (A/REDF) alone. METHODS: Ductus venosus Doppler waveforms were serially studied in 49 severely premature IUGR fetuses from diagnosis until death or delivery. The DV waveforms were assessed for peak systolic velocity (PSV), IRV, and EDV and qualitatively for forward end-diastolic flow or A/REDF. The S-wave/isovolumetric A-wave (SIA) index [PSV/(IRV + EDV)] for each fetus was compared to fetal/neonatal outcomes. RESULTS: There were 8 cases of fetal death (FD), 9 cases of neonatal death (ND), and 32 cases of neonatal survival (NS). A receiver operating characteristic (ROC) curve for the SIA index in all cases showed that values less than -1.25 correlated with FD and those greater than -1.25 correlated with live birth, with 100% sensitivity and 100% specificity. A second ROC curve of live births showed that values less than 2.07 correlated with NS and those greater than 2.07 correlated with ND with 67% sensitivity and 94% specificity. Ductus venosus A/REDF correlated with FD, ND, and NS with sensitivity values of 88%, 78%, and 32%, respectively. Of the 32 NSs, 11 (34%) had A/REDF with a median of 11 days before delivery. CONCLUSIONS: The SIA index is a novel Doppler parameter for assessment of severely premature IUGR fetuses that allows a much more accurate prediction of fetal outcome compared to A/REDF alone.

Kidney-specific expression of GFP by in-utero delivery of pseudotyped adeno-associated virus 9.

Gene therapy targeting of kidneys has been largely unsuccessful. Recently, a recombinant adeno-associated virus (rAAV) vector was used to target adult mouse kidneys. Our hypothesis is that a pseudotyped rAAV 2/9 vector can produce fetal kidney-specific expression of the green fluorescent protein (GFP) gene following maternal tail vein injection of pregnant mice. Pregnant mice were treated with rAAV2/9 vectors with either the ubiquitous cytomegalovirus promoter or the minimal NPHS1 promoter to drive kidney-specific expression of GFP. Kidneys from dams and pups were analyzed for vector DNA, gene expression, and protein. Vector DNA was identified in kidney tissue out to 12 weeks at low but stable levels, with levels higher in dams than that in pups. Robust GFP expression was identified in the kidneys of both dams and pups treated with the cytomegalovirus (CMV)-enhanced green fluorescent protein (eGFP) vector. When treated with the NPHS1-eGFP vector, dams and pups showed expression of GFP only in kidneys, localized to the glomeruli. An 80-fold increase in GFP mRNA expression in dams and a nearly 12-fold increase in pups was found out to 12 weeks of life. Selective targeting of the fetal kidney with a gene therapy vector was achieved by utilizing the pseudotyped rAAV 2/9 vector containing the NPHS1 promoter.

Activation of ß-catenin signaling in MLO-Y4 osteocytic cells versus 2T3 osteoblastic cells by fluid flow shear stress and PGE2: Implications for the study of mechanosensation in bone.

The osteocyte is hypothesized to be the mechanosensory cell in bone. However, osteoblastic cell models have been most commonly used to investigate mechanisms of mechanosensation in bone. Therefore, we sought to determine if differences might exist between osteocytic and osteoblastic cell models relative to the activation of ß-catenin signaling in MLO-Y4 osteocytic, 2T3 osteoblastic and primary neonatal calvarial cells (NCCs) in response to pulsatile fluid flow shear stress (PFFSS). ß-catenin nuclear translocation was observed in the MLO-Y4 cells at 2 and 16 dynes/cm(2) PFFSS, but only at 16 dynes/cm(2) in the 2T3 or NCC cultures. The MLO-Y4 cells released high amounts of PGE(2) into the media at all levels of PFFSS (2-24 dynes/cm(2)) and we observed a biphasic pattern relative to the level of PFFSS. In contrast PGE(2) release by 2T3 cells was only detected during 16 and 24 dynes/cm(2) PFFSS starting at >1h and never reached the levels produced by the MLO-Y4 cells. Exogenously added PGE(2) was able to induce ß-catenin nuclear translocation in all cells suggesting that the differences between the cell lines observed for ß-catenin nuclear translocation were associated with the differences in PGE(2) production. To investigate a possible mechanism for the differences in PGE(2) release by the MLO-Y4 and 2T3 cells we examined the regulation of Ptgs2 (Cox-2) gene expression by PFFSS. 2T3 cell Ptgs2 mRNA levels at both 0 and 24h after 2h of PFFSS showed biphasic increases with peaks at 4 and 24 dynes/cm(2) and 24-hour levels were higher than zero-hour levels. MLO-Y4 cell Ptgs2 expression was similarly biphasic; however at 24-hour post-flow Ptgs2 mRNA levels were lower. Our data suggest significant differences in the sensitivity and kinetics of the response mechanisms of the 2T3 and neonatal calvarial osteoblastic versus MLO-Y4 osteocytic cells to PFFSS. Furthermore our data support a role for PGE(2) in mediating the activation of ß-catenin signaling in response to the fluid flow shear stress.

The transitional phase of ductus venosus reversed flow in severely premature IUGR fetuses.

The guiding hypothesis for this work is that in severe intrauterine growth-restricted (IUGR) fetuses, the time from ductus venosus (DV) reversed flow (RF) appearance to intrauterine fetal demise (IUFD) or nonreassuring fetal testing is variable. As such, there must be a transitional phase between the presence of end-diastolic forward flow (FF) and absent or reversed end-diastolic flow (A/REDF). Ductus venosus Doppler was serially studied in 19 IUGR fetuses (estimated fetal weight < 10th percentile and umbilical artery pulsatility index > 95th percentile) from diagnosis until demise or delivery occurring for nonreassuring fetal testing. Ductus venosus waveforms were assessed qualitatively: forward flow versus absent or reversed flow in diastole. Two sets of at least 30 consecutive ductus venosus waveforms were obtained at each examination. If the waveforms differed between the two sets, they were defined as alternating. Cord arterial pH and base excess (BE) were obtained at birth. In 14 cases, DVRF occurred intermittently between periods of FF during the same clinical visit. Intermittent DVRF was present from 2 to 57 days (median, 13 days) and became continuous from 1 to 23 days (median, 7 days) before the occurrence of delivery for nonreassuring fetal testing or fetal demise. One fetus had an abnormal arterial pH (< 7.0) and one had an abnormal BE (< -12). These data show that (1) there is a transitional phase in which DV alternates FF and A/RF before RF becomes persistent; (2) the time from the appearance of DVRF to delivery or IUFD is variable, and (3) not all very preterm IUGR fetuses with continuous DVRF are acidemic. Because of these findings, the decision of delivery regarding early severe IUGR fetuses should be individualized, and the DVRF Doppler information has to be integrated with other antenatal fetal parameters.