Early origins of adult disease: low birth weight and vascular remodeling.

Cardiovascular diseases (CVD) and diabetes still represent the main cause of mortality and morbidity in the industrialized world. Low birth weight (LBW), caused by intrauterine growth restriction (IUGR), was recently known to be associated with increased rates of CVD and non-insulin dependent diabetes in adult life (Barker's hypothesis). Well-established animal models have shown that environmentally induced IUGR (diet, diabetes, hormone exposure, hypoxia) increases the risk of a variety of diseases later in life with similar phenotypic outcomes in target organs. This suggests that a range of disruptions in fetal and postnatal growth may act through common pathways to regulate the developmental programming and produce a similar adult phenotype. The identification of all involved signaling cascades, underlying the physiopathology of these damages in IUGR fetuses, with their influence on adult health, is still far from satisfactory. The endothelium may be important for long-term remodeling and in the control of elastic properties of the arterial wall. Several clinical and experimental studies showed that IUGR fetuses, neonates, children and adolescents present signs of endothelial dysfunction, valuated by aorta intima media thickness, carotid intima media thickness and stiffness, central pulse wave velocity, brachial artery flow-mediated dilation, laser Doppler skin perfusion and by the measure of arterial blood pressure. In utero identification of high risk fetuses and long-term follow-up are necessary to assess the effects of interventions aimed at preventing pregnancy-induced hypertension, reducing maternal obesity, encouraging a healthy life style and preventing childhood obesity on adult blood pressure and cardiovascular disease in later life.

Timing of delivery and neonatal outcomes for small-for-gestational-age fetuses.

OBJECTIVES: To investigate whether antenatal recognition of small-for-gestational-age (SGA) fetuses with normal maternal and fetal Doppler values delivered after 34 weeks' gestation is associated with changes in the risk of adverse maternal and neonatal outcomes. METHODS: In this retrospective study, we included 313 singleton SGA fetuses and 313 appropriate-for-gestational-age control fetuses born between 34 and 42 weeks' gestation from 2009 to 2012. Small-for-gestational-age fetuses identified before delivery (n = 124), for whom antenatal surveillance was performed until delivery (estimated fetal weight twice weekly and Doppler evaluation of the fetal compartment once weekly), were compared to those not identified at delivery (n = 189). The latter group did not undergo antenatal surveillance for several reasons (women for whom a sonographic evaluation or gynecologic consultation was not performed in the third trimester and incorrect sonographic biometric evaluation in the third trimester). Main outcome measures were mode of delivery, perinatal complications, and neonatal intensive care unit admission. The risk of serious fetal complications was assessed by cross-tabulation analysis adjusted for gestational age and degree of SGA. RESULTS: Prenatally recognized SGA fetuses were smaller and delivered earlier than unrecognized SGA fetuses (P< .05). Fetal acidemia (pH <7.10) was significantly more common in unrecognized SGA fetuses (3.7% versus 0%). Small-for-gestational-age fetuses at or below the 3rd percentile were more commonly recognized prenatally and hospitalized in the neonatal intensive care unit. Unrecognized SGA fetuses also had worse fetal outcomes compared to controls (P< .05). Recognized and unrecognized SGA fetuses were born significantly more frequently by cesarean delivery (P < .05). No significant differences in perinatal outcomes were found between recognized SGA deliveries with or without medical induction. CONCLUSIONS: Antenatal recognition of SGA fetuses delivered after 34 weeks' gestation might improve perinatal outcomes. Medical induction of labor did not modify neonatal outcomes among prenatally recognized SGA fetuses.

Expectant management in type II selective intrauterine growth restriction and abnormal cord insertion in monochorionic twins.

OBJECTIVE: To assess perinatal outcome in type II monochorionic (MC) diamniotic twin pregnancies (DA) affected by selective intrauterine growth restriction (sIUGR) and abnormal cord insertion managed expectantly. METHODS: A prospective longitudinal study from June 2008 and July 2011 on 24 MCDA sIUGR twins. sIUGR was defined as estimated fetal weight below the 10th percentile in one twin and was classified into three groups based on umbilical artery (UA) Doppler diastolic flow (I: presence; II: constantly absent/reverse (AEDF/ARED); III: intermittently absent or reverse). Marginal cord insertion was defined as insertion within 2 cm of the placental disc edge, and velamentous insertion as a cord insertion into the fetal membranes. Expectant management was chosen in these twins, and absent or reverse A wave in the ductus venosus (DV) was a criterion for delivery. Neonatal outcome was available for all twins delivered. Pathological examination and vascular cast of placentas were performed in all cases. RESULTS: Fourteen twin pregnancies were type II sIUGR, and ten presented an abnormal umbilical cord insertion. Median gestational age (GA) at diagnosis of sIUGR was 18 weeks' gestation (range 16-20 weeks), and all sIUGR co-twins showed AEDF of UA at a median gestational age of 20 weeks (range 18-22 weeks). Median gestational age at delivery was 30 weeks (range 28-34 weeks) with a median birth weight of 1285 g (range 307-1725 g). pH at birth and base excess (BE) were normal in all IUGR co-twin (pH>7.10, median BE 5.5); Apgar score at 5 min was >7. Perinatal outcome was favorable in all cases. Placental pathological examination confirmed the marginal insertion of the umbilical cord and the absence of anastomosis between the two portions of umbilical insertion. CONCLUSIONS: This study highlights that expectant management for sIUGR type II twins with or without an abnormal cord insertion should be a valid option to time delivery for these fetuses as shown by the favorable neonatal outcome.