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Cardiovascular and Cerebrovascular Implications of Growth Restriction: Mechanisms and Potential Treatments

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Cardiovascular and Cerebrovascular Implications of Growth Restriction: Mechanisms and Potential Treatments International Journal of Molecular Sciences Review Cardiovascular and Cerebrovascular Implications of Growth Restriction: Mechanisms and Potential Treatments Charmaine R. Rock 1,2,†, Tegan A. White 1,2,†, Beth R. Piscopo 1,2, Amy E. Sutherland 1 , Suzanne L. Miller 1,2, Emily J. Camm 1,2,‡ and Beth J. Allison 1,2,*,‡ 1 The Ritchie Centre, Hudson Institute of Medical Research, Clayton 3168, Australia; [email protected] (C.R.R.); [email protected] (T.A.W.); [email protected] (B.R.P.); [email protected] (A.E.S.); [email protected] (S.L.M.); [email protected] (E.J.C.) 2 Department of Obstetrics and Gynaecology, Monash University, Clayton 3168, Australia * Correspondence: [email protected] † First authors contributed equally. ‡ Last authors contributed equally. Abstract: Fetal growth restriction (FGR) is a common complication of pregnancy, resulting in a fetus that fails to reach its genetically determined growth potential. Whilst the fetal cardiovascular response to acute hypoxia is well established, the fetal defence to chronic hypoxia is not well understood due to experiment constraints. Growth restriction results primarily from reduced oxygen and nutrient supply to the developing fetus, resulting in chronic hypoxia. The fetus adapts to chronic hypoxia by redistributing cardiac output via brain sparing in an attempt to preserve function in the developing Citation: Rock, C.R.; White, T.A.; brain. This review highlights the impact of brain sparing on the developing fetal cardiovascular Piscopo, B.R.; Sutherland, A.E.; Miller, and cerebrovascular systems, as well as emerging long-term effects in offspring that were growth S.L.; Camm, E.J.; Allison, B.J. restricted at birth. Here, we explore the pathogenesis associated with brain sparing within the Cardiovascular and Cerebrovascular cerebrovascular system. An increased understanding of the mechanistic pathways will be critical Implications of Growth Restriction: to preventing neuropathological outcomes, including motor dysfunction such as cerebral palsy, or Mechanisms and Potential behaviour dysfunctions including autism and attention-deficit/hyperactivity disorder (ADHD). Treatments. Int. J. Mol. Sci. 2021, 22, 7555. https://doi.org/10.3390/ Keywords: fetal growth restriction; brain sparing; cardiovascular; cerebrovascular; developmental ijms22147555 programming; brain injury Academic Editors: David Ferguson and Janna Morrison Received: 4 May 2021 1. Introduction Accepted: 8 July 2021 Suboptimal in utero growth is now well understood to have long-lasting physiological Published: 14 July 2021 implications for the developing fetus and the subsequent newborn and adult. This narrative review will focus on the impacts of fetal growth restriction (FGR) on the cardiovascular Publisher’s Note: MDPI stays neutral and cerebrovascular system. One of the earliest physiological responses the fetus has to with regard to jurisdictional claims in hypoxic stress is brain sparing. Brain sparing is an innate response that aims to preserve the published maps and institutional affil- development of vital organs, including the brain. Despite the nomenclature, brain sparing iations. does not save the brain, and our group, amongst others, have shown subsequent brain [1], cardiovascular [2], and renal [3,4] injury. Indeed, it is likely that many of the mechanisms enacted throughout brain sparing, including chronic mal-activation of the autonomic nervous system and endocrine systems, contribute to the developmental programming Copyright: © 2021 by the authors. of disease. This review examines the mechanisms underpinning the cardiovascular and Licensee MDPI, Basel, Switzerland. cerebrovascular dysfunction associated with fetal growth restriction and brain sparing This article is an open access article (Figure1). distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). Int. J. Mol. Sci. 2021, 22, 7555. https://doi.org/10.3390/ijms22147555 https://www.mdpi.com/journal/ijms Int. J. Mol. Sci. 2021, 22, 7555 2 of 14 Int. J. Mol. Sci. 2021, 22, 7555 2 of 15 FigureFigure 1. Brain1. Brain sparing sparing and and consequences consequences forfor thethe offspring. The The fetus fetus responds responds to to hypoxia hypoxia via via afferent afferent signals signals (red (red arrow) arrow) byby redistributing redistributing blood blood flow flow to to essential essential vascular vascular beds beds (via (via efferent efferent output, output, green green arrows),arrows), aa processprocess known as brain spar- sparing. Vagaling. control Vagal control (purple (purple arrow) arrow) decreases decreases heart heart rate. rate. This This leads lead tos a to number a number of consequencesof consequences in in the the fetus, fetus, particularly particularly inin the cardiovascularthe cardiovascular and cerebrovascular and cerebrovascular systems. systems. Abbrev: Abbrev: autism au spectrumtism spectrum disorder, disorder, ASD; attentionASD; attention deficit disorderdeficit disorder (ADHD). (ADHD). 2. Fetal Growth Restriction 2. Fetal Growth Restriction FGR is a common complication of pregnancy where the fetus fails to reach its ge- FGR is a common complication of pregnancy where the fetus fails to reach its genet- netically determined growth potential [5]. Depending on the specific definition of FGR, ically determined growth potential [5]. Depending on the specific definition of FGR, the the incidence is up to 9% of pregnancies in high-income countries, and as high as 30% in incidence is up to 9% of pregnancies in high-income countries, and as high as 30% in low- low-income countries, with up to 30 million cases of FGR being diagnosed worldwide income countries, with up to 30 million cases of FGR being diagnosed worldwide annu- annually [6,7]. A consensus definition for FGR was reached in 2016 to include biometric ally [6,7]. A consensus definition for FGR was reached in 2016 to include biometric measuresmeasures ofof poorpoor growthgrowth and functional parameters parameters of of placental placental dysfunction dysfunction [8] [and8] and is is summarisedsummarised inin TableTable1 1.. PriorPrior toto thisthis definition,definition, FGR FGR and and small small for for gestational gestational age age (SGA) (SGA) werewere virtually virtually used used interchangeably. interchangeably. SGA SGA refers refers to to infants infants that that are are born born with with a birthweight a birth- lessweight than less the than 10th the percentile 10th percentile for their for gestational their gestational age likely age likely due todue being to being genetically genetically small, whilesmall, an while infant an definedinfant defined as FGR as indicatesFGR indicates pathological pathological changes changes during during pregnancy pregnancy that contributethat contribute to suboptimal to suboptimal growth. growth. FGR FGR is linked is linked to a myriadto a myriad of adverse of adverse impacts impacts including in- perinatalcluding perinatal mortality, mortality, preterm preterm birth [9 ]birth as well [9] as well pathology as pathology in the offspringin the offspring which which persists throughoutpersists throughout childhood childhood development developm andent further and further into adulthood into adulthood [10]. [10]. There are a range of fetal, maternal and placental factors that cause FGR. However, the most common cause is placental insufficiency, characterised by suboptimal placental function and abnormalities in placental blood flow, resulting in compromised oxygen and nutrient transfer to the fetus [11]. Optimal placental function and uteroplacental blood flow are essential for the maintenance of an adequate supply of oxygen and nutrients to support fetal development and growth. Any impairment in this supply can result in fetal hypoglycaemia and hypoxaemia [12]. Our understanding of FGR had been obtained from both human and pre-clinical animal models. The benefits and limitations of pre-clinical animal models of FGR have previously been reviewed [13]. Int. J. Mol. Sci. 2021, 22, 7555 3 of 14 Table 1. Consensus definition of early and late onset FGR. Early FGR Late FGR Gestation <32 weeks >32 weeks Congenital anomalies absent absent <3rd percentile or absent Estimated fetal weight or end-diastolic flow in the <3rd percentile abdominal circumference umbilical artery OR OR 2 out of <10th percentile or crossing > Estimated fetal weight or <10th percentile 2 quartiles on growth abdominal circumference percentiles Uterine artery pulsatility index >95th percentile Umbilical artery pulsatility >95th percentile >95th percentile index Cerebroplacental ratio <5th percentile 3. Fetal Cardiovascular Response to Acute Hypoxia The fetal cardiovascular system detects acute hypoxaemia and responds by redis- tributing its cardiac output towards essential vascular beds, such as the brain, heart and adrenal glands, at the expense of non-essential vascular beds (i.e., liver, skeletal muscle). This response is commonly referred to as brain sparing [9,13,14] and is the fetus’ attempt to minimise energy use [13]. Chemoreceptors located in the carotid body at the carotid artery’s bifurcation detect hypoxaemia, increasing sympathetic output to peripheral blood vessels via the fetal brain stem [14,15]. This increase in sympathetic output results in vasoconstriction in peripheral blood vessels [16]. Peripheral vasoconstriction initially occurs due to autonomic stimuli and is main- tained by neutrally-induced
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