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Placental Function Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1066 Placental Function An Epidemiological and Magnetic Resonance Study SARA SOHLBERG ACTA UNIVERSITATIS UPSALIENSIS ISSN 1651-6206 ISBN 978-91-554-9142-0 UPPSALA urn:nbn:se:uu:diva-239294 2015 Dissertation presented at Uppsala University to be publicly examined in Auditorium Minus, Gustavianum, Akademigatan 3, Uppsala, Friday, 27 February 2015 at 09:00 for the degree of Doctor of Philosophy (Faculty of Medicine). The examination will be conducted in Swedish. Faculty examiner: Professor Karel Marsal (Lunds universitet). Abstract Sohlberg, S. 2015. Placental Function. An Epidemiological and Magnetic Resonance Study. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1066. 72 pp. Uppsala: Acta Universitatis Upsaliensis. ISBN 978-91-554-9142-0. Placental function is central for normal pregnancy and in many of the major pregnancy disorders. We used magnetic resonance imaging techniques to investigate placental function in normal pregnancy, in early and late preeclampsia and in intrauterine growth restriction. We also investigated maternal body mass index and height, as risk factors for preeclampsia. A high body mass index and a short maternal stature increase the risk of preeclampsia, of all severities. The association seems especially strong between short stature and early preeclampsia, and a high body mass index and late preeclampsia. (Study I) Using diffusion-weighted magnetic resonance imaging, we found that the placental perfusion fraction decreases with increasing gestational age in normal pregnancy. Also, the placental perfusion fraction is smaller in early preeclampsia, and larger in late preeclampsia, compared with normal pregnancies. That these differences are in opposite directions, suggests that there are differences in the underlying pathophysiology of early and late preeclampsia. (Study II) Using magnetic resonance spectroscopy, we found that the phosphodiester spectral intensity fraction and the phosphodiester/phosphomonoester spectral intensity ratio increases with increasing gestational age. Also, we found that the phosphodiester spectral intensity fraction and the phosphodiester/phosphomonoester spectral intensity ratio are higher in early preeclampsia, compared with early normal pregnancy. These findings indicate increased apoptosis with increasing gestational age in normal pregnancy, and increased apoptosis in early preeclampsia. (Study III) The placental perfusion fraction is smaller in intrauterine growth restriction than in normal pregnancy. Fetal growth, Doppler blood flow in maternal and fetal vessels, infant birth weight and plasma markers of placental function are all correlated to the placental perfusion fraction. The placental perfusion fraction examination seems therefore to offer a fast, direct estimate of the degree of placental dysfunction. (Study IV) In conclusion: Our findings in studies I-III all support the hypothesis of partly different pathophysiology between early and late preeclampsia, and suggest a strong link between early preeclampsia and placental dysfunction. Study IV shows that the placental perfusion fraction has potential to contribute to the clinical assessment of placental dysfunction. Keywords: body height, body mass index, early preeclampsia, late preeclampsia, magnetic resonance imaging, placenta, perfusion, IVIM, risk factors, energy metabolism, magnetic resonance spectroscopy, 31P-MRS Sara Sohlberg, Department of Women's and Children's Health, Akademiska sjukhuset, Uppsala University, SE-75185 Uppsala, Sweden. © Sara Sohlberg 2015 ISSN 1651-6206 ISBN 978-91-554-9142-0 urn:nbn:se:uu:diva-239294 (http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-239294) “Our greatest glory is not in never falling, but in rising every time we fall.” – Oliver Goldsmith In memory of Else and Erik Hammerlund List of Papers This thesis is based on the following papers, which are referred to in the text by their Roman numerals. I Sohlberg S, Stephansson O, Cnattingius S, Wikström AK. Maternal body mass index, height, and risks of preeclampsia. Am J Hypertension, 2012 Jan; 25(1):120-5. II Sohlberg S, Mulic-Lutvica A, Lindgren P, Ortiz-Nieto F, Wikström AK, Wikström J. Placental perfusion in normal pregnancy and early and late preeclampsia: a magnetic reso- nance imaging study. Placenta, 2014 May; 35(3):202-6. III Sohlberg S, Wikström AK, Olovsson M, Lindgren P, Axels- son O, Mulic-Lutvica A, Weis J, Wikström J. In vivo 31PMR spectroscopy in normal pregnancy, early and late preeclamp- sia: a study of placental metabolism. Placenta, 2014 Mar; 35(5):318-23. IV Sohlberg S, Mulic-Lutvica A, Olovsson M, Weis J, Axelsson O, Wikström J, Wikström AK. MRI estimated placental perfu- sion in fetal growth assessment. Ultrasound in Obstetrics and Gynecology, in press (Acceptance letter Jan. 7, 2015). Reprints were made with permission from the respective publishers. Cover illustration: The Miraculous Journey, by Damien Hirst Photographer: Penny Yi Wang Reprint made with permission from the photographer and The Museum of Islamic Art, Qatar Contents Introduction ................................................................................................... 11 Preeclampsia ............................................................................................. 11 Definition of preeclampsia .................................................................. 11 Pathophysiology of preeclampsia ........................................................ 12 The clinical syndrome of preeclampsia ............................................... 16 Intrauterine growth restriction .................................................................. 17 Pathophysiology of IUGR ................................................................... 17 Antenatal management of IUGR ......................................................... 18 Methods to estimate optimal time of delivery ..................................... 19 Circulatory markers of placental function ................................................ 19 Magnetic resonance .................................................................................. 20 Basic principles of magnetic resonance ............................................... 20 Safety aspects of magnetic resonance in pregnancy ............................ 21 Perfusion estimation using DWI and the IVIM method ...................... 21 Magnetic resonance spectroscopy ....................................................... 21 Aims .............................................................................................................. 23 Material and Methods ................................................................................... 24 Study populations and study designs ........................................................ 24 Study I .................................................................................................. 24 Studies II-IV ........................................................................................ 24 Studies II-III ........................................................................................ 24 Study IV ............................................................................................... 25 Methods .................................................................................................... 26 Study I .................................................................................................. 26 Studies II-IV ........................................................................................ 26 Studies II and IV .................................................................................. 26 Study III ............................................................................................... 27 Study IV ............................................................................................... 29 Statistical analysis .................................................................................... 29 Study I .................................................................................................. 29 Studies II-III ........................................................................................ 30 Study IV ............................................................................................... 30 Results ........................................................................................................... 32 Study I: Maternal BMI, height and risks of different types of preeclampsia ............................................................................................. 32 Study II: Placental perfusion in normal pregnancy, and in early and late preeclampsia ...................................................................................... 33 Study III: Placental metabolism in normal pregnancy, and in early and late preeclampsia ............................................................................... 36 Study IV: Placental perfusion in fetal growth assessment ....................... 37 Discussion ..................................................................................................... 40 Study I ...................................................................................................... 40 Study II ..................................................................................................... 41 Study III ..................................................................................................
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