1. Pregnancy-Specific Stress, Fetoplacental Hemodynamics, and Neonatal Outcomes in SGA Pregnancy: Results from the PORTO Study
Terri Levine, Ruth Grunau, Fiona Alderdice, Fionnuala McAuliffe,
and the PORTO study team

2. Pregnancy-Specific Stress
Fears and concerns about pregnancy
Health of the fetus, labour and delivery
Diet, weight gain, physical symptoms
Bonding with the infant
Changes in relationships with partners, friends, or family
Potentially more sensitive predictor of outcomes than general prenatal stress
Preterm birth, fetal behaviour, infant/child development

3. Fetoplacental Hemodynamics

4. Doppler Ultrasound Non-invasive measurement of hemodynamics
Insonates arteries using a small transducer
High-frequency sound bounces off blood cells passing through arteries
Blood cells reflect this sound beam and change its frequency: Doppler effect

5. Doppler Ultrasound Outcomes
Abnormal UA PI: > 95th centile for GA
Abnormal MCA PI: < 5th centile for GA
Indicates poor placentation, IUGR, poorer childhood developmental outcomes
Fetal brain-sparing, fetal cardiovascular distress, severe fetal hypoxia and acidosis
Absent end diastolic flow (AEDF)
Abnormal CPR: < 1.08 (MCA PI/UA PI)
Increased perinatal and neonatal morbidity and mortality, neurological sequelae, IUGR, prematurity
Caesarean section, fetal distress, NICU admission, neonatal morbidity, stillbirth, poorer developmental outcomes

6. Prenatal Stress and Hemodynamics in Pregnancy: a Systematic Review
Uterine artery (Kent 2002, Maina 2008, Mendelson 2011, Monk 2012, Teixeira 1999, Harville 2008, Helbig 2011 & 2013, Roos 2015, Vythilingum 2010)
Umbilical artery (Caliskan 2009, Harville 2009, Helbig 2011, Maina 2008, Mendelson 2011, Monk 2012)
Fetal MCA and CPR (Roos 2015, Sjostrom 1997, Vythilingum 2010)
Umbilical vein volume blood flow (Helbig 2013)
Limited evidence that prenatal stress is associated with changes in circulation
Necessary improvements: larger sample sizes, repeated assessments, better control for confounders, biomarker collection, measures of pregnancy-specific stress
Levine, T. A., Alderdice, F. A., Grunau, R. E., McAuliffe, F. M. Prenatal stress and hemodynamics in pregnancy: a systematic review. Archives of Women’s Mental Health 2016; 19(5):

7. The PORTO Study
Prospective Observational Trial to Optimise Paediatric Health in IUGR
7 major obstetric hospitals in Ireland and Northern Ireland
1,116 women with SGA pregnancies
Serial ultrasound assessments

8. Eligibility Criteria Singleton pregnancies
Recruited between 24+0 and 36+6 weeks’ gestation
EFW < 10th percentile for gestational age
No major structural or chromosomal abnormalities

9. Prenatal Distress Questionnaire (PDQ)
12-item self-report questionnaire about pregnancy-specific stress
Sample items
‘I am worried about eating healthy foods and a balanced diet for the baby’
‘I am anxious about labour and delivery’
‘I am concerned that having a new baby will alter my relationship with the baby’s father’
Provides overall PDQ score and 3 factor scores
Concerns about birth and the health of the baby
Concerns about physical symptoms and body image
Concerns about relationships and emotions

10. Outcomes Abnormal UA PI, AEDF, Abnormal MCA PI, Abnormal CPR
Prematurity: delivery before 37 weeks’ gestation
Birth weight < 2,500 grams
NICU admission
Composite adverse perinatal outcome
Any IVH, PVL, HIE, NEC, BPD, sepsis, death

11. Statistical Analyses Stress measured at 3 gestational time points:
Binary logistic regression
Confounders included:
smoking, drinking, ethnicity, BMI, mean arterial pressure, socioeconomic status, maternal age, parity
NICU admission models also adjusted for prematurity
Previous miscarriage not associated with pregnancy- specific stress at any time point in this sample
23-28 weeks
29-34 weeks
35-40 weeks
Total Sample
N = 80
N = 203
N = 213
N = 331

12. Abnormal Umbilical Artery PI

13. AEDF

14. Abnormal Middle Cerebral Artery PI

15. Abnormal Cerebroplacental Ratio

16. Prematurity

17. Birthweight < 2,500 g

18. NICU Admission

19. Adverse Perinatal Outcome

20. Conclusions
Explored associations in women with SGA pregnancies among pregnancy-specific stress, fetoplacental hemodynamics, and neonatal outcomes
Increased pregnancy-specific stress was associated with:
Increased odds of abnormal MCA PI, AEDF, prematurity, birth weight < 2,500 g
Decreased odds of abnormal UA PI and NICU admission
No significant associations with abnormal CPR or adverse perinatal outcome

21. Limitations Inconsistent sample sizes at each time point
Stress data not available for full PORTO cohort
Low pregnancy-specific stress reported despite medical risk
Nutrition, physical activity, health behaviours data not collected
Highly stressed or AGA pregnancy groups not included
Risk of type 1 error due to multiple comparisons

22. Strengths
Comprehensive, time-specific exploration of pregnancy-specific stress, Doppler ultrasound parameters, neonatal outcomes
Clinically useful normal/abnormal Doppler ultrasound categories
Large sample sizes
Repeated study design
Both fetoplacental and neonatal outcomes

23. Thank you! Fiona Alderdice Fergal Malone Annette Burke
Fionnuala McAuliffe
Sean Daly
Fiona Cody
Ruth Grunau
Michael Geary
Emma Doolin
Ricardo Segurado
Mairead Kennelly
Azy Khalid
Oliver Perra
Keelin O’Donoghue
Cecelia Mulcahy
Phyl Gargan
Alyson Hunter
Hilda O’Keefe
Elizabeth Tully
John Morrison
Wendy Ooi
Patrick Dicker
Gerard Burke
Edel Varden
Fiona Lynn
Amanda Ali