OBJETIVOS: Comparar resultados perinatais entre gemelares, com dopplervelocimetria da artéria umbilical (AU) com fluxo diastólico presente (FDP), discordantes (GD) e concordantes (GC) em relação ao peso estimado fetal (PEF) e de acordo com a corionicidade. MÉTODOS: Estudo retrospectivo, caso-controle, desenvolvido na Clínica Obstétrica HCFMUSP entre janeiro 2005 e dezembro 2015. Para cada GD, foram selecionados 2 controles de GC, pareados pela idade gestacional do parto (IG) e corionicidade. Critérios de inclusão: discordância PEF >= 20%, Doppler da artéria umbilical (AU) com fluxo diastólico presente, ausência de malformação ou cromossomopatias, diamniótica, fetos vivos na primeira avaliação, ausência de complicações da monocorionicidade, parto na instituição. Resultados perinatais considerados: peso no nascimento, IG no parto, internação na unidade de terapia intensiva (UTI) neonatal, tempo de internação na UTI, suporte ventilatório (VM), hemorragia periventricular (HIPV), hipoglicemia (HG), icterícia (Ic), enterocolite necrosante (EN), sepse (Sp), óbito perinatal. Foram comparados os resultados perinatais dos fetos maiores e menores entre os grupos GD e GC. O resultado perinatal do feto menore foi comparado de acordo com a presença ou ausência de restrição de crescimento fetal (RCF). RESULTADOS: Selecionados 14 GD e 28 GC monocoriônicos (MC), e 38 GD e 76 GC dicoriônicos (DC). Fetos menores MC GD apresentaram maior TI (30,60 ± 20,19 vs 10,68 ± 11,64 dias, P<0,001), maior frequência de Ic (78,6% vs 28,6%; P=0,003; RC=9,17) e Sp (21,4% vs 0%; P=0,032; RC=23,42) em comparação com fetos menores GC. Nos DC, fetos menores GD apresentaram maior frequência de Sp (10,5% vs 1,3%; P=0,042; RC=8,82), HG (15,8% vs 3,9%; P=0,003; RC=4,56), EN (5,3% vs 0%; P=0,044; RC=20,63) e Ic (57,9% vs 28,9%, P=0,003; RC=3,38) comparado com fetos menores GC. Dentre os fetos menores MC, 10 (71,4%) tem RCF e dentre os DC menores, 21 (55,3%). Os gemelares menores sem RCF apresentaram frequência de morbidade neonatal similar entre os GD e GC, exceto pelo menor peso no nascimento do feto GD DC (2167,35 vs 2339,68g, P=0,026). CONCLUSÃO: Na presença do Doppler AU com FDP, o feto menor GD apresenta maior frequência de morbidades perinatais comparado aos fetos menores GC, independentemente da corionicidade. A presença da RCF, e não apenas a discordância de peso entre os fetos, parece ser responsável pela piora dos parâmetros de morbidade neonatal dentre os fetos GD / OBJECTIVE: The aim of this study was to compare the perinatal outcome between fetal weight discordance (FwD) with fetal weight concordant (FwC) twins, with umbilical artery (UA) Doppler with positive end-diastolic flow, according to chorionicity. METHODS: This was a retrospective case-control study of twin pregnancy over an 11-year period in a tertiary referral center. For each FwD, it was selected 2 controls of FwC matched for gestational age at delivery and chorionicity. The inclusion criteria were: estimated fetal weight (EFW) discordance >= 20%, UA Doppler with positive end-diastolic flow, absence of fetal malformation or chromosomal abnormalities, known chorionicity, diamniotic pregnancies, both fetuses alive at the first assessment, absence of monochorionic (MC) complications, delivery in our institution. The perinatal outcomes considered were: birth weigh (BW), length of hospital stay (LOS), admission to the neonatal intensive care unit (NICU), length of NICU stay, need for ventilator support, intraventricular hemorrhage (IVH), hypoglycemia (Hp), jaundice (JD), necrotizing enterocolitis (NE), sepsis (SP), intrauterine and neonatal death. Perinatal outcome of the smaller and larger twin comparisons between FwD with FwC were analyzed according to chorionicity. In addition, perinatal outcome from smaller twin was compared between FwD with FwC with and without fetal growth restriction (FGR). RESULTS: A total of 14 pregnancies with FwD and 28 with FwC of MC twin and 38 pregnancies with FwD and 76 with FwC of dichorionic (DC) twin were selected. According to chorionicity, in MC FwD group, the smaller twin presented presented longer LOS (30.60 ± 20.19 vs 10.68 ± 11.64 days, P < 0.001), higher frequency of SP (21.4% vs 0%; P=0.032; OR=23.42) and JD (78.6% vs 28.6%; P=0.003; OR=9.17) compared to smaller FwC twin; whereas in DC FwD group, smaller twin presented higher frequency of SP (10.5% vs 1.3%; P=0.042; OR=8.82), Hp (15.8% vs 3.9%; P=0.003; OR=4.56), NE (5.3% vs 0%; P=0.044; RC=20.63) and JD (57.9% vs 28.9%, P=0.003; OR=3.38) compared to smaller FwC twin. FGR in the smaller MC twin was observed in 71.4% (n=10) and in the smaller DC twin, 55.3% (n=21). Twin pregnancies without FGR had similar frequency of neonatal morbidity in discordant and concordant groups, excepted for the lower BW in FwD DC twins (2167.35 vs 2339.68g, P=0.026). CONCLUSION: Regardless chorionicity, perinatal morbidity is increased in the smaller discordant twin with UA Doppler with positive end-diastolic flow, compared to concordant smaller twin. Probably the FGR is responsible to complicate the perinatal outcome of smaller discordant twin

Introdução: A restrição de crescimento fetal (RCF) é a condição na qual o peso fetal encontra-se abaixo do percentil 10 para a idade gestacional. Essa condição caracteriza a gestação como de alto risco e constitui causa de morbidade e mortalidade perinatal. Além de fatores biológicos fetais, maternos e placentários, a RCF é influenciada por fatores psicossociais como depressão e estresse. Esse estudo tem como objetivo comparar gestantes com suspeita de RCF e gestantes sem intercorrências clínicas em relação à depressão, estresse, apoio social e autoestima. Método: Estudo transversal realizado com 79 gestantes com suspeita de RCF, atendidas no Ambulatório de Baixo Peso Fetal da Clínica Obstétrica do HC-FMUSP e 92 gestantes do Pré-Natal de baixo risco, com fetos de crescimento normal. O PRIME-MD foi utilizado para avaliar depressão e a PPP para avaliação de estresse, apoio social e autoestima. Análise quantitativa foi realizada por meio do teste t ou teste não paramétrico de Mann-Whitney e para comparação de mais de dois grupos foi considerado o teste não paramétrico de Kruskal-Wallis. O teste de Dunn com correção dos valores p foi utilizado para comparações 2 a 2. Os testes qui-quadrado de Pearson ou teste exato de Fisher foram utilizados para análise das variáveis qualitativas. Resultados: Neste estudo, as gestantes com suspeita de RCF apresentaram média de idade de 25,89(DP=6,11), média de idade gestacional de 33,33(DP=3,36) e média de números de gestação de 1,92(DP=1,22). As gestantes sem intercorrências clínicas apresentaram médias 27,27(DP=5,90), 32,55(DP=4,01) e 1,83(DP=0,93), respectivamente. Constatou-se diagnóstico de depressão entre 17,7% das gestantes com suspeita de RCF e 16,3% das gestantes sem intercorrências clínicas. Quanto ao estresse, apoio do companheiro, apoio de outras pessoas e autoestima, entre as gestantes com suspeita de RCF, foram constatados os escores médios de 18,27(DP=5,50), 55,15(DP=13,76), 53,77(DP=13,27) e 32,70(DP=4,60). Já entre as gestantes sem intercorrências clínicas, os escores médios foram 19,72(DP=5,16), 55,70(DP=11,37), 51,33(DP=13,26) e 34,22(DP=4,85), respectivamente. Na associação entre os grupos com suspeita de RCF e depressão(RCF+D) e com suspeita RCF sem depressão(RCF-D) foi verificada significância estatística entre estresse (p < 0,01) e autoestima (p < 0,01). Entre os grupos sem intercorrências e com depressão(BR+D) e sem intercorrências e sem depressão(BR-D) foi verificada significância estatística entre estresse (p=0,04) e autoestima (p < 0,01). Entre os grupos RCF+D e BR-D foi constatada significância estatística entre autoestima (p < 0,01). Entre os grupos BR+D e RCF-D foi encontrada significância estatística entre autoestima (p=0,03). Não foram verificadas diferenças estatísticas quanto ao estresse entre os grupos RCF+D e BR+D, RCF-D e BR-D, e BR-D e RCF+D e quanto à autoestima entre os grupos RCF+D e BR+D, e RCF-D e BR-D. Nenhum dos grupos estudados apresentou diferença estatística quanto aos escores de apoio do companheiro e de outras pessoas. Conclusão: Neste estudo, a presença de depressão durante a gestação mostrou-se associada à maior escore de estresse e menor escore de autoestima, tanto entre gestantes com suspeita de RCF como entre aquelas sem intercorrências clínicas / Evaluation of depression, stress, social support and self-esteem in pregnant woman with suspected fetal growth restriction [Dissertation]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2017. Introduction: Fetal Growth Restriction (FGR) is the condition in which fetal weight is below the 10th percentile for gestational age. This condition characterizes a high-risk pregnancy and is an important cause of perinatal morbidity and mortality. In addition to biological fetal, maternal and placental factors, the FGR is influenced by psychosocial factors such as depression and stress. This study aims to compare pregnant woman with suspected FGR and pregnant woman without clinical intercurrences in relation to depression, stress, social support and self-esteem. Methods: Cross-sectional study with 79 pregnant women with suspected FGR, met at the Low Fetal Weight Clinic of the PRIME-MD was used to evaluate depression and PPP for stress assessment, social support and self-esteem. Quantitative analysis was performed using the t-test or non-parametric Mann-Whitney test and for comparison of more than two groups was considered the nonparametric Kruskal-Wallis test. The Dunn test, with corrected p values, was used for 2 on 2 comparisons. The Pearson\'s chi-square tests or Fisher\'s exact tests were used for qualitative data analysis. Results: In the present study, pregnant women with a suspicion of FGR had a mean age of 25.89 (SD=6.11), mean gestational age of 33.33 weeks (SD=3.36 weeks) and average gestation numbers of 1.92 (SD=1.22). The pregnant woman without clinical intercurrences presented averages 27,27 (SD=5.90), 32.55 (SD=4.01) and 1.83 (SD=0.93), respectively. A diagnosis of depression was found among 17.7% of pregnant women with suspected FGR and 16.3% of pregnant women without clinical intercurrences. As for stress, peer support, support from other people and self-esteem was found among pregnant women with suspected FGR mean scores of 18.27 (SD=5.50), 55.15 (SD=13.76), 53.77 (SD=13.27) and 32.70 (SD=4.60). Among the pregnant women without clinical intercurrences, the mean scores were 19.72 (SD=5.16), 55.70 (SD=11.37), 51.33 (SD = 13.26) and 34.22 (SD = 4.85), respectively. The statistical significance of stress (p < 0.01) and self-esteem (p < 0.01) were found in the association between the groups with suspected FGR and depression (RCF+D) and with suspected FGR without depression (RCF-D). Among the groups without intercurrences and with depression (BR+D) and without intercurrences and without depression (BR-D), statistical significance was observed between stress (p=0.04) and self-esteem (p < 0.01). Among the RCF+D and BR-D groups, statistical significance was found between self-esteem (p < 0.01). Among the BR + D and RCF-D groups, statistical significance was found between self-esteem (p=0.03). Statistical differences were not found for stress among the RCF+D and BR+D, RCF-D and BR-D, and BR-D and RCF+D groups, and for self-esteem between the RCF+D and BR+D groups, And RCF-D and BR-D. None of the groups studied presented statistical difference regarding the support scores of the companion and the support of other people. Conclusions: In this study, the presence of depression during pregnancy was associated with a higher stress score and lower self-esteem score both among pregnant women with FGR suspicion and among pregnant women without clinical intercurrences

LEITE, F. Influência da restrição de crescimento intra-uterino na idade da menarca: estudo da coorte de nascidos vivos de Ribeirão Preto de 1978/9. 2008. 85 p. Dissertação (Mestrado) apresentada à Faculdade de Medicina de Ribeirão Preto/USP. A idade da menarca é um marco da puberdade e, quando antecipada, parece estar associada a um maior risco de desenvolvimento de câncer de mama, síndrome metabólica e obesidade. É possível que alterações no ambiente intrauterino, como a restrição de crescimento do feto, levem a interferências no sistema hipotálamo-hipófise-gonadal resultando em alterações na idade da menarca. Em vista da controvérsia dos fatores que influenciam na idade da menarca, este estudo testou a hipótese da associação entre restrição de crescimento intra-uterino (baixo peso ao nascer, pequeno para idade gestacional, restrição intra-uterina de Kramer) e antecipação da idade da menarca. Em uma sub-amostra foi testada a possível interação entre a restrição de crescimento intra-uterino e o índice de massa corpórea. Para esse estudo foram utilizadas informações coletadas nos seguimentos de 1987/9 e 2004/5 de 1056 meninas nascidas em Ribeirão Preto, provenientes do estudo de coorte dos nascidos vivos em Ribeirão Preto de 1978/9. Menarca antecipada foi definida como primeiro sangramento vaginal ocorrido antes dos 12 anos de idade. Análise univariada foi seguida de análise bivariada e multivariada por meio de modelo generalizado empregando distribuição de Poisson para estimativa de riscos relativos e erro padrão por meio de método robusto. Os fatores de confusão controlados foram idade, escolaridade e situação conjugal da mãe, número de irmãos, comprimento ao nascer, prematuridade e índice de massa corpórea (apenas para a subamostra). Em média, a menarca ocorreu aos 12,3 anos (DP=1,5). A ocorrência de menarca antecipada foi de 27,7% (n= 293) para a coorte inteira e de 29,1% (n= 172) na sub-amostra. Foi encontrada associação negativa entre restrição de crescimento intra-uterino, seja representado por baixo peso ao nascer (Risco Relativo, RR= 0,47; Intervalo de Confiança de 95%, IC95%: 0,26-0,84), pequeno para idade gestacional (RR = 0,57;IC95%:0,37-0,89) ou restrição de Kramer (RR= 0,65; IC95%:0,47-0,92), com a antecipação da idade da menarca. Os resultados foram semelhantes na análise da sub-amostra, porém sem significância estatística. Quando o índice de massa corpórea foi considerado na análise da sub-amostra, não houve modificação dos resultados. Desta forma, este estudo demonstrou associação negativa entre restrição de crescimento intra-uterino e antecipação da idade da menarca, ou seja, a restrição de crescimento foi fator de proteção da menarca antecipada. / LEITE, F. Influence of intrauterine growth restriction on the age of menarche: the cohort study of live births of Ribeirao Preto in 1978/9. 2008. 85 p. Dissertation (Master) submitted to the Faculty of Medicine of Ribeirao Preto/USP. This study tested the hypothesis of association between intrauterine growth restriction and early age of menarche. For this study, follow-up data (n = 1056) from the population based livebirth cohort study of Ribeirao Preto of 19789 were analyzed. Early menarche was defined as having the first menstrual event before 12 years-old and intrauterine growth restriction was defined by three measurements: low birthweight (< 2500grs), small for gestational age (< 10% Williams growth curve) and fetal growth ratio (< 0.85 mean weight for gestational age). Relative risks were estimated by generalized estimation equations (Poisson distribution) with robust method for estimation of standard errors. Analyzes were adjusted for maternal age, education and marital status, number of siblings, birth length and preterm. Body mass index was tested as intervenient or interaction factor in a subsample of the cohort examined at 9 yrs-old. The mean age of menarche was 12.3 years (Standard Deviation = 1.5). Early menarche was observed for 27.7% for the entire cohort and 29.1% for the sub-sample. Negative association was observed between intrauterine growth restriction and early menarche. The adjusted relative risks and respective confidence intervals (95% CI) for low birth weight, small for gestational age and fetal growth ratio were respectively: 0.47 (95% CI: 0.26-0.84), 0.57 (95% CI: 0,37-0,89), and 0.65 (95%CI: 0,47-0, 92). No evidence that body mass index was an intermediate or interaction factor was observed. Thus, this study showed a negative association between intrauterine growth restriction and anticipation of age of menarche.

Introdução: A restrição de crescimento fetal (RCF) é a condição na qual o peso fetal encontra-se abaixo do percentil 10 para a idade gestacional. Essa condição caracteriza a gestação como de alto risco e constitui causa de morbidade e mortalidade perinatal. Além de fatores biológicos fetais, maternos e placentários, a RCF é influenciada por fatores psicossociais como depressão e estresse. Esse estudo tem como objetivo comparar gestantes com suspeita de RCF e gestantes sem intercorrências clínicas em relação à depressão, estresse, apoio social e autoestima. Método: Estudo transversal realizado com 79 gestantes com suspeita de RCF, atendidas no Ambulatório de Baixo Peso Fetal da Clínica Obstétrica do HC-FMUSP e 92 gestantes do Pré-Natal de baixo risco, com fetos de crescimento normal. O PRIME-MD foi utilizado para avaliar depressão e a PPP para avaliação de estresse, apoio social e autoestima. Análise quantitativa foi realizada por meio do teste t ou teste não paramétrico de Mann-Whitney e para comparação de mais de dois grupos foi considerado o teste não paramétrico de Kruskal-Wallis. O teste de Dunn com correção dos valores p foi utilizado para comparações 2 a 2. Os testes qui-quadrado de Pearson ou teste exato de Fisher foram utilizados para análise das variáveis qualitativas. Resultados: Neste estudo, as gestantes com suspeita de RCF apresentaram média de idade de 25,89(DP=6,11), média de idade gestacional de 33,33(DP=3,36) e média de números de gestação de 1,92(DP=1,22). As gestantes sem intercorrências clínicas apresentaram médias 27,27(DP=5,90), 32,55(DP=4,01) e 1,83(DP=0,93), respectivamente. Constatou-se diagnóstico de depressão entre 17,7% das gestantes com suspeita de RCF e 16,3% das gestantes sem intercorrências clínicas. Quanto ao estresse, apoio do companheiro, apoio de outras pessoas e autoestima, entre as gestantes com suspeita de RCF, foram constatados os escores médios de 18,27(DP=5,50), 55,15(DP=13,76), 53,77(DP=13,27) e 32,70(DP=4,60). Já entre as gestantes sem intercorrências clínicas, os escores médios foram 19,72(DP=5,16), 55,70(DP=11,37), 51,33(DP=13,26) e 34,22(DP=4,85), respectivamente. Na associação entre os grupos com suspeita de RCF e depressão(RCF+D) e com suspeita RCF sem depressão(RCF-D) foi verificada significância estatística entre estresse (p < 0,01) e autoestima (p < 0,01). Entre os grupos sem intercorrências e com depressão(BR+D) e sem intercorrências e sem depressão(BR-D) foi verificada significância estatística entre estresse (p=0,04) e autoestima (p < 0,01). Entre os grupos RCF+D e BR-D foi constatada significância estatística entre autoestima (p < 0,01). Entre os grupos BR+D e RCF-D foi encontrada significância estatística entre autoestima (p=0,03). Não foram verificadas diferenças estatísticas quanto ao estresse entre os grupos RCF+D e BR+D, RCF-D e BR-D, e BR-D e RCF+D e quanto à autoestima entre os grupos RCF+D e BR+D, e RCF-D e BR-D. Nenhum dos grupos estudados apresentou diferença estatística quanto aos escores de apoio do companheiro e de outras pessoas. Conclusão: Neste estudo, a presença de depressão durante a gestação mostrou-se associada à maior escore de estresse e menor escore de autoestima, tanto entre gestantes com suspeita de RCF como entre aquelas sem intercorrências clínicas / Evaluation of depression, stress, social support and self-esteem in pregnant woman with suspected fetal growth restriction [Dissertation]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2017. Introduction: Fetal Growth Restriction (FGR) is the condition in which fetal weight is below the 10th percentile for gestational age. This condition characterizes a high-risk pregnancy and is an important cause of perinatal morbidity and mortality. In addition to biological fetal, maternal and placental factors, the FGR is influenced by psychosocial factors such as depression and stress. This study aims to compare pregnant woman with suspected FGR and pregnant woman without clinical intercurrences in relation to depression, stress, social support and self-esteem. Methods: Cross-sectional study with 79 pregnant women with suspected FGR, met at the Low Fetal Weight Clinic of the PRIME-MD was used to evaluate depression and PPP for stress assessment, social support and self-esteem. Quantitative analysis was performed using the t-test or non-parametric Mann-Whitney test and for comparison of more than two groups was considered the nonparametric Kruskal-Wallis test. The Dunn test, with corrected p values, was used for 2 on 2 comparisons. The Pearson\'s chi-square tests or Fisher\'s exact tests were used for qualitative data analysis. Results: In the present study, pregnant women with a suspicion of FGR had a mean age of 25.89 (SD=6.11), mean gestational age of 33.33 weeks (SD=3.36 weeks) and average gestation numbers of 1.92 (SD=1.22). The pregnant woman without clinical intercurrences presented averages 27,27 (SD=5.90), 32.55 (SD=4.01) and 1.83 (SD=0.93), respectively. A diagnosis of depression was found among 17.7% of pregnant women with suspected FGR and 16.3% of pregnant women without clinical intercurrences. As for stress, peer support, support from other people and self-esteem was found among pregnant women with suspected FGR mean scores of 18.27 (SD=5.50), 55.15 (SD=13.76), 53.77 (SD=13.27) and 32.70 (SD=4.60). Among the pregnant women without clinical intercurrences, the mean scores were 19.72 (SD=5.16), 55.70 (SD=11.37), 51.33 (SD = 13.26) and 34.22 (SD = 4.85), respectively. The statistical significance of stress (p < 0.01) and self-esteem (p < 0.01) were found in the association between the groups with suspected FGR and depression (RCF+D) and with suspected FGR without depression (RCF-D). Among the groups without intercurrences and with depression (BR+D) and without intercurrences and without depression (BR-D), statistical significance was observed between stress (p=0.04) and self-esteem (p < 0.01). Among the RCF+D and BR-D groups, statistical significance was found between self-esteem (p < 0.01). Among the BR + D and RCF-D groups, statistical significance was found between self-esteem (p=0.03). Statistical differences were not found for stress among the RCF+D and BR+D, RCF-D and BR-D, and BR-D and RCF+D groups, and for self-esteem between the RCF+D and BR+D groups, And RCF-D and BR-D. None of the groups studied presented statistical difference regarding the support scores of the companion and the support of other people. Conclusions: In this study, the presence of depression during pregnancy was associated with a higher stress score and lower self-esteem score both among pregnant women with FGR suspicion and among pregnant women without clinical intercurrences

The geometry of an organ’s vascular system determines the blood flow distribution to tissues for exchange of gas and nutrients by determining its vascular resistance. The importance of vascular geometry is evident in the placenta, where insufficient fetoplacental vascularity elevates vascular resistance thereby impairing perfusion, leading to one of the most common and severe pregnancy complications, intrauterine growth restriction (IUGR). The mouse is becoming a widely used model for human placental development due to the increasing availability of mouse models thought to have a placental defect. Vascular geometry can now be imaged and quantified using micro-computed tomography (micro-CT) and results used to estimate resistance to blood flow. This thesis first describes the implementation of contrast agent perfusion and micro-CT imaging of the mouse fetoplacental vasculature throughout late gestation. Application of a vascular segmentation technique is then described and evaluated for quantification of the arterial fetoplacental tree. Normal fetoplacental vascular development in late gestation is described for two common mouse strains, CD1 and C57Bl6 (B6). In B6 placentas, both late gestational capillary growth and thinning of the interhaemal membrane were blunted relative to CD1. Analysis of CD1 and B6 tree geometry revealed a constant number of arterial segments throughout late gestation in both strains but expansion of arterial diameters in B6 only, resulting in decreased B6 arterial resistance and shear stress in late gestation. Strain dependence shows the importance of genetics in fetoplacental vascular development. Quantification of the arterial tree in a mouse model of maternal pre-pregnancy exposure to chemicals commonly found in cigarettes revealed an increase in vascular tortuousity and a reduced number of arteriole sized vessels. This led to an increase in vascular resistance and a predicted decrease in blood flow, which could contribute to the observed reduction in fetal weights. In future studies, the methods described herein can be used in phenotyping numerous mouse models which currently are suspected to have a placental vascular defect.

The geometry of an organ’s vascular system determines the blood flow distribution to tissues for exchange of gas and nutrients by determining its vascular resistance. The importance of vascular geometry is evident in the placenta, where insufficient fetoplacental vascularity elevates vascular resistance thereby impairing perfusion, leading to one of the most common and severe pregnancy complications, intrauterine growth restriction (IUGR). The mouse is becoming a widely used model for human placental development due to the increasing availability of mouse models thought to have a placental defect. Vascular geometry can now be imaged and quantified using micro-computed tomography (micro-CT) and results used to estimate resistance to blood flow. This thesis first describes the implementation of contrast agent perfusion and micro-CT imaging of the mouse fetoplacental vasculature throughout late gestation. Application of a vascular segmentation technique is then described and evaluated for quantification of the arterial fetoplacental tree. Normal fetoplacental vascular development in late gestation is described for two common mouse strains, CD1 and C57Bl6 (B6). In B6 placentas, both late gestational capillary growth and thinning of the interhaemal membrane were blunted relative to CD1. Analysis of CD1 and B6 tree geometry revealed a constant number of arterial segments throughout late gestation in both strains but expansion of arterial diameters in B6 only, resulting in decreased B6 arterial resistance and shear stress in late gestation. Strain dependence shows the importance of genetics in fetoplacental vascular development. Quantification of the arterial tree in a mouse model of maternal pre-pregnancy exposure to chemicals commonly found in cigarettes revealed an increase in vascular tortuousity and a reduced number of arteriole sized vessels. This led to an increase in vascular resistance and a predicted decrease in blood flow, which could contribute to the observed reduction in fetal weights. In future studies, the methods described herein can be used in phenotyping numerous mouse models which currently are suspected to have a placental vascular defect.

Altered DNA methylation may lead to suboptimal fetal programming, increasing the risk of adverse pregnancy outcomes such as small for gestational age (SGA); however, few studies have examined the associations between DNA methylation, prenatal exposures, and fetal outcomes. Cross-sectional data from a larger, ongoing study were used to assess the impact of prenatal smoking on gene specific methylation of umbilical cord blood derived DNA and to investigate the association between gene-specific methylation and risk of SGA. The association between gene-specific DNA methylation and birthweight was also assessed. Maternal and infant covariates were abstracted from medical records, cigarette smoke exposure was determined by measuring cotinine in umbilical cord blood plasma, and the Illumina Infinium Methylation27 assay was used to assess CpG site specific methylation. Methylation was represented by a beta value ranging from 0 to 1. Gene-level methylation was calculated by averaging the methylation levels over the CpG sites interrogated in that gene. Logistic regression was used to generate adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between SGA and methylation of CYP1A1, HIF1A, GSTT1, and GSTM1 and the association between cotinine level and hypermethylation of CYP1A1, HIF1A, GSTT1, and GSTM1. DNA was considered hypermethylated if the beta value was greater than or equal to the 75th percentile. Univariate and multivariable linear regression were used to examine the association between birthweight and methylation of the IGF1 and IGF2 gene. The analyses included 90 singleton births. A 0.10 unit increase in methylation of GSTT1 increased the risk of SGA almost 3-fold (OR=2.69, 95%CI=1.34, 5.43). A 5ng/ml increase in cotinine level increased the risk of hypermethylation of GSTT1 (OR=1.18, 95%CI=1.02, 1.37). Birthweight did not appear to be impacted by methylation of IGF2 (β=0.07, 95%CI=-2.91, 3.05), but a one standard deviation increase in methylation of IGF1 was associated with a 3.63% decrease in birthweight (95%CI= -6.49, -0.78). No differences in DNA methylation by prenatal vitamin intake were detected. These findings suggest that DNA methylation plays a critical role in fetal growth and may mediate the risk of SGA and low birthweight.

Σκοπός: Να αξιολογηθεί ο λόγος αγόρια/κορίτσια (sex ratio) στα παιδιά καπνιστριών και μη καπνιστριών μητέρων, σε σχέση με τη σειρά γέννησης των παιδιών (τόκος). Να αξιολογηθεί το αποτέλεσμα του καπνίσματος της μητέρας κατά την εγκυμοσύνη στην εμβρυική ανάπτυξη σε σχέση με τον τόκο την ηλικία και τον αριθμό των τσιγάρων που κάπνιζαν οι μητέρες ανά ημέρα κατά την εγκυμοσύνη και το φύλο των παιδιών. Σχεδιασμός: Προοπτική μελέτη. Τόπος: Πανεπιστημιακό Γενικό Νοσοκομείο Πατρών. Αντικείμενο: Μελετήθηκαν 2.108 τελοιόμηνα νεογνά που γεννήθηκαν από το 1993 έως και το 2002, 665 νεογνά καπνιστριών μητέρων και 1.443 νεογνά μη καπνιστριών μητέρων. Αποτελέσματα: Ο λόγος αγόρια/κορίτσια στο σύνολο των νεογνών που μελετήθηκε ήταν 1,09. Η υπεροχή των αγοριών στα παιδιά των καπνιστριών και μη καπνιστριών μητέρων ήταν 1,26 και 1,03 αντίστοιχα. Στα παιδιά των καπνιστριών μητέρων που ήταν τόκων 1, 2 και ≥3 ήταν 1,47, 1,35 και 0,92 αντίστοιχα, ενώ στα παιδιά των μη καπνιστριών μητέρων ήταν 1,04, 1,00 και 1,03 αντίστοιχα. Η στατιστική ανάλυση παλινδρόμησης έδειξε ότι η πιθανότητα για γέννηση αγοριού από καπνίστριες μητέρες ήταν σημαντικά μεγαλύτερη στις πρωτότοκες παρά στους τόκους ≥3, ανεξάρτητα από την ηλικία της μητέρας. Αντίστροφα, η σειρά γέννησης των παιδιών δεν επηρέασε τον λόγο αγόρια/κορίτσια στις μη καπνίστριες μητέρες. Αυξανομένου του τόκου στα νεογνά των μη καπνιστριών μητέρων παρατηρήθηκε μια σταδιακή αύξηση της ανάπτυξης ενώ στα νεογνά μη καπνιστριών μητέρων παρατηρήθηκε μια σταδιακή μείωση της ανάπτυξης. Αυτό το αποτέλεσμα ήταν περισσότερο εμφανές στα αγόρια. Ένα σημαντικά αρρνητικό αποτέλεσμα στην αύξηση παρατηρήθηκε από την στην συσχέτιση του καπνίσματος με τον τόκο (p=0,0013) και, με το φύλο και τον τόκο (p=0,001). Υπήρχε μια σημαντική αρρνητική συσχέτιση ανάμεσα στον αριθμό των τσιγάρων που καπνίζονταν ανά ημέρα και της αύξησης η δύναμη της οποίας αυξανόταν με την αύξηση του τόκου, κυρίως στα αγόρια. Συμπεράσματα: Οι πρωτότοκες μητέρες που κάπνιζαν κατά την εγκυμοσύνη γέννησαν σημαντικά περισσότερα αγόρια απ’ ότι κορίτσια, ενώ μητέρες με τόκους ≥3 γέννησαν περισσότερα κορίτσια. Δευτερότοκες γυναίκες που κάπνιζαν λιγότερα από 10 τσιγάρα την ημέρα γέννησαν σημαντικά περισσότερα αγόρια, αλλά ο λόγος αγόρια/κορίτσια ελαττώθηκε όταν κάπνιζαν ≥10 τσιγάρα την ημέρα. Το κάπνισμα της μητέρας κατά την κύηση προκαλεί καθυστέρηση στην εμβρυική αύξηση, κυρίως στα αγόρια, ένα αποτέλεσμα που ενισχύεται με τον τόκο αλλά είναι ανεξάρτητο από την ηλικία της μητέρας. / Objective: To assess the sex ratio in offspring of smoking and nonsmoking mothers in relationship to the parity. To examine the effect of maternal smoking during pregnancy on fetal growth in relationship to maternal parity, age and number of cigarettes smoked/day, and offspring’s gender. Design: Prospective study. Setting: University hospital. Subjects: Were studied 2018 term singleton neonates born form 1993 to 2002, 665 from smoking and 1443 from nonsmoking mothers. Main outcome measures: Secondary sex ratio in regard to maternal periconseptual smoking and parity. Results: The male preponderance in the offspring of smoking and nonsmoking mothers was 0.558 and 0.506, respectively (p=0.031). In the smoking women parity 1, 2 and 3 it was 0.596, 0.574 and 0.462, respectively, whereas in the nonsmoking it was 0.511, 0.500 and 0.508, respectively (p=0.02, 0.04 and 0.64, respectively). Logistic regression analysis showed that the possibility for a boy to be delivered by mothers who smoked was significantly greater in primiparous than in party ≥3, independently of the maternal age. Conversely, parity did not affect the sax ratio in the offspring of the nonsmoking mothers. With increasing parity, in the neonates of nonsmoking mothers there was a gradual increase of growth, whereas in neonates of smoking mothers there was a gradual decrease of growth. This effect was more pronounced in males. A significant negative main effect on growth resulted from the interaction of smoking with parity (p=0,013), and with gender and parity (p=0,001). There was a significant negative correlation between number of cigarettes smoked per day and growth, the strength of which increased with parity, mainly in males. Conclusions: Among women who smoked in the periconceptual period, significantly more male than female offspring are born from primiparous, whereas parity >3 give birth to more female offspring; women parity 2 give birth to significantly more male, but the sex ratio declines when they smoked ≥10 cigarettes/day. Maternal smoking during pregnancy causes a delay in getal growth, which is greater in male offspring, an effect that is enhanced with parity but is independent of maternal age.

Vielfältige Studien haben bereits Zusammenhänge zwischen niedrigem Geburtsgewicht und der Entwicklung von Adipositas und eines metabolischen Syndroms im späteren Lebensalter dargestellt. Umfangreiche Daten liegen vor allem für frühgeborene Neonaten vor. Ziel dieser Arbeit ist deshalb die Bewertung perinataler Parameter und der frühen Entwicklung reifer SGA – Neugeborener. Für die vorliegende prospektive Studie wurden 50 Neugeborene mit einem Geburtsgewicht < 10. Perzentile und 50 eutrophe Neugeborene erfasst. Bei allen Kindern wurden anamnestische Befunde zum Schwangerschaftsverlauf, die Biometrie der Eltern sowie Daten zur Geburt und zum stationären Verlauf erfasst. Mit Hilfe eines standardisierten Fragebogens an die niedergelassenen Kinderärzte erfolgte die Nachbeobachtung der Kinder hinsichtlich der Gewichts–, Längen– und Kopfumfangsentwicklung sowie der Ernährung bis zur 15. Lebenswoche. Die Ergebnisse der Studie zeigen, dass nur 13% der SGA – Kinder ein genetisch vermindertes Wachstumspotential haben. Demnach liegt bei der Mehrzahl der SGA – Geborenen ein pathologischer Mechanismus zugrunde. Während der Schwangerschaft waren in der SGA – Gruppe häufiger uterine Perfusionsstörungen bei einem erhöhten Auftreten von Präeklampsien oder Nikotinabusus darstellbar. Die SGA – Kinder wurden häufiger per sectionem geboren und zeigten zu einem erhöhten Anteil Dysmaturitätszeichen als Ausdruck einer intrauterinen Stress– oder Mangelsituation. Aufgrund der perinatalen Risiken sollte die Geburt dieser Kinder in einem Perinatalzentrum erfolgen. In der SGA – Gruppe bestand eine signifikante Korrelation zwischen Gestationsalter und Geburtsgewicht, deshalb ist eine individuelle Abwägung des Geburtszeitpunktes zur Nutzung des noch vorhandenen intrauterinen Wachstumspotentials erforderlich. Kinder der SGA – Gruppe bedurften häufiger einer intensivmedizinischen Betreuung und hatten einen längeren stationären Aufenthalt als Kinder der Vergleichsgruppe; Säurebasenstatus, APGAR – Werte und Blutdruck unterschieden sich nicht. Während des stationären Aufenthaltes wurden die SGA – Neonaten vermehrt zugefüttert und zeigten eine geringere postnatale Gewichtsabnahme. Nach der Entlassung kam es, bezogen auf die Körperlänge, zu einer stärkeren und rascheren Gewichtszunahme bei SGA – Kindern, während die Längendifferenz zunächst bestehen blieb. Ein frühes Aufholwachstum, welches sich in dieser Studie isoliert auf das Gewicht bezieht, ist hinsichtlich späterer metabolischer Störungen als möglicher Risikofaktor zu werten.

Le dépistage et le diagnostic de l’insuffisance placentaire (IP), qu’il s’agisse du retard de croissance intra-utérin (RCIU) ou de la prééclampsie (PE), sont des enjeux majeurs de santé publique. En pratique clinique, les propriétés mécaniques du placenta ne sont pas explorées, pourtant des modifications de son architecture tissulaire pourraient engendrer des variations d’élasticité. Parmi les méthodes d’élastographie ultrasonore (US), l’élastographie transitoire paraît adaptée pour une telle application. Cette technique consiste à calculer la vitesse de l’onde de cisaillement (Cs) générée par une vibration externe se propageant dans le milieu considéré. Les valeurs d’élasticité obtenues à partir des méthodes US actuelles ne sont calculées qu’à une fréquence unique. Une modification structurelle du tissu pouvant correspondre à une loi de puissance particulière de la dispersion fréquentielle de Cs, nous avons évalué l’intérêt d’une approche multifréquentielle pour distinguer l’élasticité des placentas normaux et celle de placentas présentant des signes d’IP au troisième trimestre de la grossesse. Nous avons développé un dispositif préliminaire en onde plane (pour l’exploration ex vivo) permettant de valider le principe de la méthode proposée, puis un dispositif d’élastographie transitoire 2D (exploration ex vivo et in vivo). Les données sont ajustées au moyen d’un modèle rhéologique fractionnaire dans lequel le comportement en fréquence est modélisé par une loi de puissance (exposant n du modèle). Nous avons montré que les placentas RCIU présentent des valeurs de Cs et n inférieures à celles des placentas normaux ou des PE. Cette diminution de n pourrait s’expliquer par les lésions anatomopathologiques du RCIU et la diminution de Cs est cohérente avec l’étude d’un modèle murin de RCIU par ligature utérine. Enfin, l’analyse de la dispersion fréquentielle est faisable chez la femme enceinte. La valeur ajoutée de la méthode développée devrait désormais être testée lors d’une large étude clinique. / Screening and diagnosis of placental insufficiency (PI), whether intrauterine growth restriction (IUGR) or preeclampsia (PE) are major public health issues. In clinical practice, the mechanical properties of the placenta are not explored; however changes in its tissue architecture could cause variations in elasticity. Among the ultrasound (US) elastography methods, transient elastography seemed suitable for such an application. This technique consists in calculating the shear wave speed (Cs) generated by an external vibration propagating in the medium under consideration. Elasticity values obtained from current US methods are calculated at a single frequency. As a structural modification of the tissue may correspond to a particular power law of frequency dispersion of Cs, we evaluated the interest of a multifrequency approach to distinguish the elasticity of healthy placentas and that of placentas with PI signs in the third trimester of pregnancy. We have developed a preliminary plane wave device (for ex vivo exploration) to validate the principle of the proposed method, and then a 2D transient elastography device (ex vivo and in vivo exploration). The data is adjusted using a fractional rheological model where the frequency behavior is modeled by a power law (exponent n of the model). We have shown that IUGR placentas have Cs and n values lower than those of healthy placentas or PE. This decrease in the n value could be explained by histopathological lesions of IUGR. As for the decrease of Cs in cases of IUGR, this result is consistent with the study of an IUGR rat model by uterine ligation. Finally, the frequency dispersion analysis is feasible in pregnant women. The added value of this method should now be tested in a large clinical study.