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The need of a third trimester screening

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Impact on fetal programming

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Fatima Crispi, Eduard Gratacos
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Maternal-Fetal Medicine Department and Research Center


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Hospital Clinic - University of Barcelona


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www.medicinafetalbarcelona.org
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©
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FIRST TRIMESTER ?

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screening of major

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pregnancy complications
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Down’s structural preeclampsia prematurity


syndrome malformations IUGR
screening for PE/IUGR

11-14 wks early late

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PE/IUGR PE/IUGR

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COMBINED 1T SCREENING

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milder disease
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heterogeneity
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highly predictive for limited for (+/- placental disease)


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EARLY PE/IUGR LATE PE/IUGR


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DR 60-90% DR 20-60%
(PFR 10%) (FPR 10%)

Crispi UOG 2007, Poon Hypertens 209, Scazzochio AJOG 2013, Crovetto UOG 2013
prediction of PE & IUGR
EARLY-ONSET LATE-ONSET

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IMPORTANCE OF LATE PE/IUGR

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4-8 %

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PREECLAMPSIA

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1%
high prevalence

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PREECLAMPSIA + IUGR

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maternal
1% serious complications
cause of stillbirth in IUGR
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4-8 %
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fetal programming
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20 25 30 35 40
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www.fetalmedicinebarcelona.org/
Late-onset IUGR (>34w + normal UA Doppler)

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adverse perinatal outcome in 376 consecutive cases

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Figueras 2011
Biological programming and age

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IMPACT OF
ENVIRONMENT
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epigenetics
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Fetus Child Young Mature Old


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FETAL
PROGRAMMING
1986 Barker (MRC Unit, Southampton, UK):
Coronary heart disease mortality rates

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FETAL CARDIOVASCULAR PROGRAMMING

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PRIMARY

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intrauterine CARDIOVASCULAR

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growth PROGRAMMING cardiovascular

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restriction disease in

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fetal cardiac adulthood

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dysfunction hypertension

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coronary disease

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stroke

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obesity

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diabetes
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impact of mild
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late IUGR / SGA


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Barker BMJ 1986, Barker BMJ 1995 , Hecher Circulation 1995, Crispi AJOG 2008, Crispi Circulation 2010, Cruz FDT 2011, Crispi AJOG 2012
Exposure
Prematurity Infection

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Fetal growth restriction Genetics

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Neurocognitive disorders/Learning disabilities

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Overall ≥10%

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Estimated 2/3 of prenatal origin

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Non-specific disorders
5-8%

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Attention Deficit Hyperactivity
in Autism Spectrum Disorder
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Disorder 0.5-1%
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2-5%
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120
* * *
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100
w Bayley Score

impact of mild 80
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late IUGR / SGA 60


Satchev, 2012
©

40
Figueras 2006-2011
Baschat 2009, 2011
20 Vohr 2004
Geva 2002-2011
Marsal 00-06
cognitive language motor socio-emot adaptive Visser 01-11
behavior
fetal programming

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placental

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coronary disease

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disease
hypertension
prematurity

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obesity
infection

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diabetes
IVF

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atention disorders
twins
autism spectrum

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IMPACT OF

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ENVIRONMENT

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OPPORTUNITY
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FOR
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CORRECTION
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Fetus Child Young Mature Old


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4P medicine

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•Predictive
•Preventive

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•Personalized

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•Participatory
IDENTIFICATION OF RISK

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INDIVIDUAL

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BIOMARKERS

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INTERVENTION

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in
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WINDOW OF
ed

OPPORTUNITY
w BIRTH
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Fetus Child
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Functional / structural
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Problem evident
organ remodeling
screening for late PE

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32-34w

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PE

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THIRD TRIMESTER APPROACH

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maternal OR UtA Doppler OR biomarkers

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Detection Rates (for FPR 10%)


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Lai et al. Fetal Diagn Ther 2013


LATE PE
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(BP, UtA Doppler, sEng)


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Chaiworapongsa et al. AJOG 2013


(PlGF, sFlt-1, sEng) 70-75 %

www.medicinafetalbarcelona.org/
screening for late IUGR
IMPROVING DETECTION: THE DEFINITION OF “RESTRICTION”

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screening for late IUGR
IMPROVING DETECTION: THE DEFINITION OF “RESTRICTION”

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Birthweight inverse relation with perinatal outcome AND brain-cardiac remodelling

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INTEGRATED 3T SCREENING FOR LATE-PREGNANCY COMPLICATIONS


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Late-PE, Late-IUGR, Stillbirth

Mula 2012
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4P (fetal) medicine
INTEGRATED THIRD TRIMESTER

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SCREENING FOR THE PREDICTION OF

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PERINATAL AND LONG-TERM OUTCOME

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IDENTIFICATION OF RISK

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INDIVIDUAL

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BIOMARKERS

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INTERVENTION

in
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WINDOW OF
ed

OPPORTUNITY
wBIRTH
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Fetus Child
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©

Functional / structural
Problem evident
organ remodeling
thank you
fcrispi@clinic.ub.es gratacos@clinic.ub.es
g
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towards integrated third trimester

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screening in pregnancy

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thank you
©

fcrispi@clinic.ub.es
gratacos@clinic.ub.es

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