Association of placental perfusion, as assessed by magnetic resonance imaging and uterine artery Doppler ultrasound, and its relationship to pregnancy outcome

Heat Stress and Placental Abruption: A Space-Time Stratified Case-Crossover Study

OBJECTIVE

To examine whether heat stress, measured by wet bulb globe temperature (WBGT), a comprehensive heat stress index is associated with placental abruption within 7 days.

DESIGN

A space-time-stratified case-crossover design.

SETTING

All 11 regions in Japan during the warm season (June-September) from 2011 to 2020.

POPULATION

6947 cases of placental abruption were registered in the Japan Perinatal Registry Network database.

METHODS

Quasi-Poisson regression with distributed lag linear models assessed the association between heat stress, defined as daily maximum WBGT exceeding the 95th percentile of the regional distribution during the warm season, and daily placental abruption cases over a lag period of 0-7 days. Stratified analyses examined gestational week (preterm vs. term), hypertensive disorders of pregnancy (HDP), and small for gestational age (SGA).

MAIN OUTCOME MEASURES

Clinical diagnosed placental abruption.

RESULTS

Heat stress was associated with an increased risk of placental abruption on lag 1 (relative risk [RR]: 1.23, 95% confidence interval [CI]: 1.11-1.39) and lower risk on lag 2 (RR: 0.84, 95% CI: 0.74-0.95), with negligible cumulative risk over lag 0-7 due to counterbalancing effects. Similar patterns were observed in preterm and term pregnancies. Individuals with HDP showed a higher risk on lag 1 (RR: 1.57, 95% CI: 1.31-1.88), as did those with SGA infants (RR: 1.47, 95% CI: 1.26-1.73).

CONCLUSIONS

Heat stress during pregnancy may increase the risk of placental abruption on the day after exposure, potentially advancing cases that might have occurred later, particularly in individuals with HDP or SGA infants.

Quantitative evaluation of placental microvascular blood flow and microstructure in fetal growth restriction with IVIM MRI

BACKGROUND

Intravoxel incoherent motion (IVIM) MRI uses diffusion-weighted (DW) MRI acquisitions to evaluate the microvascular and cellular environments of tissue. Due to these properties, IVIM has been increasingly utilized to evaluate abnormal placentation.

OBJECTIVE

Our primary objective was to compare IVIM parameters in the placenta of patients with fetal growth restriction and appropriate for gestational age controls across gestational ages. Our secondary aim was to quantify IVIM parameters in fetal versus maternal placental aspects to evaluate microvascular and parenchymal differences.

MATERIALS AND METHODS

With IRB approval, pregnant individuals with a diagnosis of fetal growth restriction (n=24) and controls (n=22) were retrospectively analyzed. DW-MRI data were collected at 1.5 T with nine b-values (range, 0 s/mm2 to 1,000 s/mm2). Data were processed by one non-blinded reader to obtain mean perfusion fraction (f), pseudo-diffusion coefficient (D*), their product fD*, and diffusion coefficient (D) in maternal and fetal aspects of the placenta, defined by bisecting the thickness of the placenta. Repeated measures of two-way ANOVAs were used to compare IVIM parameters in fetal and maternal placental aspects between participant groups. Correlations between IVIM parameters and gestational age were also evaluated in both groups.

RESULTS

The average gestational age at MRI was 27±4 weeks for both groups. The percentile estimated fetal weight was 5.4±5.9% for the fetal growth restriction group and 42.8±28.5% for controls (P<0.001). The parameters D* and fD*, related to microvascular blood flow and tissue perfusion, were significantly lower in participants with fetal growth restriction compared to controls (D*, 40.5 vs. 52.4×10-3 mm2/s, P=0.043; fD*, 14.7 vs. 21.0×10-3 mm2/s, P=0.019). No other differences were observed, nor associations between gestational age and IVIM parameters in either group.

CONCLUSION

Our results suggest reduced microvascular flow in placentas of patients with fetal growth restriction compared to controls.

Doppler Evaluation of Uterine Blood Flow in Patients with Unexplained Recurrent Pregnancy Loss

Objective

This study aimed to analyze uterine artery and spiral artery hemodynamics in patients with unexplained recurrent pregnancy loss (URPL) with varying pregnancy outcomes.

Methods

174 pregnant women with URPL and 144 pregnant women without adverse pregnancy histories were enrolled in this retrospective study. Based on pregnancy outcomes, these patients were divided into two groups: normal pregnancy outcomes (URPL-N, n=138) and adverse pregnancy outcomes (URPL-A, n=36). Control group participants were categorized into normal pregnancy outcomes (CON-N, n=129) and adverse pregnancy outcomes (CON-A, n=15). We compared uterine artery and spiral artery hemodynamics during different stages of gestation and the predictive value of these parameters for pregnancy outcomes.

Results

URPL-N group had fewer pregnancy losses and lower BMI compared to URPL-A group (P< 0.05). Spiral artery hemodynamics in URPL-N and CON-N groups were lower than those in URPL-A and CON-A groups during the mid-luteal phase, 11-13 weeks, 15-17 weeks, and 19-21 weeks of gestation, respectively. Uterine artery hemodynamics ((Pulsatility index (mPI), resistive index (mRI), and systolic-to-diastolic ratio (mS/D)) in the mid-luteal period were lower in URPL-N group than URPL-A group. Similarly, in CON-N group were lower than CON-A group. The URPL-A and CON-A groups had higher uterine artery and spiral artery hemodynamics when compared to the URPL-N and CON-N groups. Spiral artery hemodynamics exhibited larger areas under the ROC curve compared to uterine artery parameters.

Conclusion

Abnormal hemodynamics in these arteries may contribute to URPL and adverse pregnancy outcomes. Spiral artery hemodynamics are more reliable predictors of pregnancy outcomes than uterine artery parameters.

Effect of Mediterranean diet or mindfulness-based stress reduction during pregnancy on placental volume and perfusion: A subanalysis of the IMPACT BCN randomized clinical trial

INTRODUCTION

The IMPACT BCN trial-a parallel-group randomized clinical trial where 1221 pregnant women at high risk for small-for-gestational age (SGA) newborns were randomly allocated at 19- to 23-week gestation into three groups: Mediterranean diet, Mindfulness-based Stress reduction or non-intervention-has demonstrated a positive effect of Mediterranean diet and Stress reduction in the prevention of SGA. However, the mechanism of action of these interventions remains still unclear. The aim of this study is to investigate the effect of Mediterranean diet and Stress reduction on placental volume and perfusion.

MATERIAL AND METHODS

Participants in the Mediterranean diet group received monthly individual and group educational sessions, and free provision of extra-virgin olive oil and walnuts. Women in the Stress reduction group underwent an 8-week Stress reduction program adapted for pregnancy, consisting of weekly 2.5-h and one full-day sessions. Non-intervention group was based on usual care. Placental volume and perfusion were assessed in a subgroup of randomly selected women (n = 165) using magnetic resonance (MR) at 36-week gestation. Small placental volume was defined as MR estimated volume <10th centile. Perfusion was assessed by intravoxel incoherent motion.

RESULTS

While mean MR placental volume was similar among the study groups, both interventions were associated with a lower prevalence of small placental volume (3.9% Mediterranean diet and 5% stress reduction vs. 17% non-intervention; p = 0.03 and p = 0.04, respectively). Logistic regression showed that small placental volume was significantly associated with higher risk of SGA in both study groups (OR 7.48 [1.99-28.09] in Mediterranean diet and 20.44 [5.13-81.4] in Stress reduction). Mediation analysis showed that the effect of Mediterranean diet on SGA can be decomposed by a direct effect and an indirect effect (56.6%) mediated by a small placental volume. Similarly, the effect of Stress reduction on SGA is partially mediated (45.3%) by a small placental volume. Results on placental intravoxel incoherent motion perfusion fraction and diffusion coefficient were similar among the study groups.

CONCLUSIONS

Structured interventions during pregnancy based on Mediterranean diet or Stress reduction are associated with a lower proportion of small placentas, which is consistent with the previously observed beneficial effects of these interventions on fetal growth.

Magnetic resonance imaging of placental intralobule structure and function in a preclinical nonhuman primate model†

Although the central role of adequate blood flow and oxygen delivery is known, the lack of optimized imaging modalities to study placental structure has impeded our understanding of its vascular function. Magnetic resonance imaging is increasingly being applied in this field, but gaps in knowledge remain, and further methodological developments are needed. In particular, the ability to distinguish maternal from fetal placental perfusion and the understanding of how individual placental lobules are functioning are lacking. The potential clinical benefits of developing noninvasive tools for the in vivo assessment of blood flow and oxygenation, two key determinants of placental function, are tremendous. Here, we summarize a number of structural and functional magnetic resonance imaging techniques that have been developed and applied in animal models and studies of human pregnancy over the past decade. We discuss the potential applications and limitations of these approaches. Their combination provides a novel source of contrast to allow analysis of placental structure and function at the level of the lobule. We outline the physiological mechanisms of placental T2 and T2* decay and devise a model of how tissue composition affects the observed relaxation properties. We apply this modeling to longitudinal magnetic resonance imaging data obtained from a preclinical pregnant nonhuman primate model to provide initial proof-of-concept data for this methodology, which quantifies oxygen transfer and placental structure across and between lobules. This method has the potential to improve our understanding and clinical management of placental insufficiency once validation in a larger nonhuman primate cohort is complete.

Diffusion-derived vessel density (DDVD) computed from a simple diffusion MRI protocol as a biomarker of placental blood circulation in patients with placenta accreta spectrum disorders: A proof-of-concept study

OBJECTIVES

Increasing trend of PAS (placenta accreta spectrum disorders) incidence is a major health concern as PAS is associated with high maternal morbidity and mortality during cesarean section. Prenatal identification of PAS is crucial for delivery planning and patients management. This study aims to explore whether diffusion-derived vessel density (DDVD) computed from a simple diffusion MRI protocol differs in PAS from normal placenta.

METHODS

We enrolled 86 patients with PAS disorders and 40 pregnant women without PAS disorders. Each patient underwent intravoxel incoherent motion (IVIM) MRI sequence with 11 b-values. Placenta diffusion-derived vessel density (DDVD-b0b50) was the signal difference between b = 0 and b = 50 s/mm2 images. DDVD(b0b50) A/N was calculated as [accreta lesion DDVD(b0b50)]/ [normal placenta DDVD(b0b50)]. The correlation between DDVD and gestational age was explored using Spearman rank correlation. Differences of DDVD(b0b50) A/N in patients with normal placentas and with PAS, and in patients with different subtypes of PAS were explored.

RESULTS

DDVD was negatively correlated with gestational age (p = 0.023, r = -0.359) in patients with normal placentas. DDVD(b0b50) A/N was significantly higher in patients with PAS (median:1.16, mean: 1.261) than normal placenta (median:1.02, mean: 1.032, p < 0.001) and especially higher in patients with placenta increta (median:1.14, mean: 1.278) and percreta (median: 1.20, mean: 1.396, p < 0.001).

CONCLUSION

As a higher DDVD indicates higher physiological volume of micro-vessels in PAS, this study suggests DDVD can be a potential biomarker to evaluate the placenta perfusion.

Long-Term Neurologic Consequences following Fetal Growth Restriction: The Impact on Brain Reserve

BACKGROUND

Fetal growth restriction (FGR) corresponds to the fetus's inability to achieve an adequate weight gain based on genetic potential and gestational age. It is an important cause of morbidity and mortality.

SUMMARY

In this review, we address the challenges of diagnosis and classification of FGR. We review how chronic fetal hypoxia impacts brain development. We describe recent advances on placental and fetal brain imaging using magnetic resonance imaging and how they offer new noninvasive means to study growth restriction in humans. We go on to review the impact of FGR on brain integrity in the neonatal period, later childhood, and adulthood and review available therapies.

KEY MESSAGES

FGR consequences are not limited to the perinatal period. We hypothesize that impaired brain reserve, as defined by structure and size, may predict some concerning epidemiological data of impaired cognitive outcomes and dementia with aging in this group of patients.

BACKGROUND

Fetal growth restriction (FGR) corresponds to the fetus's inability to achieve an adequate weight gain based on genetic potential and gestational age. It is an important cause of morbidity and mortality.

SUMMARY

In this review, we address the challenges of diagnosis and classification of FGR. We review how chronic fetal hypoxia impacts brain development. We describe recent advances on placental and fetal brain imaging using magnetic resonance imaging and how they offer new noninvasive means to study growth restriction in humans. We go on to review the impact of FGR on brain integrity in the neonatal period, later childhood, and adulthood and review available therapies.

KEY MESSAGES

FGR consequences are not limited to the perinatal period. We hypothesize that impaired brain reserve, as defined by structure and size, may predict some concerning epidemiological data of impaired cognitive outcomes and dementia with aging in this group of patients.

Velocity-selective arterial spin labeling perfusion measurements in 2nd trimester human placenta with varying BMI

INTRODUCTION

Proper placental development is crucial to fetal health but is challenging to functionally assess non-invasively and is thus poorly characterized in populations. Body mass index (BMI) has been linked with adverse outcomes, but the causative mechanism is uncertain. Velocity-selective arterial spin labeling (VS-ASL) MRI provides a method to non-invasively measure placental perfusion with robustness to confounding transit time delays. In this study, we report on the measurement of perfusion in the human placenta in early pregnancy using velocity-selective arterial spin labeling (VS-ASL) MRI, comparing non-obese and obese participants.

METHODS

Participants (N = 97) undergoing routine prenatal care were recruited and imaged with structural and VS-ASL perfusion MRI at 15 and 21 weeks gestation. Resulting perfusion images were analyzed with respect to obesity based on BMI, gestational age, and the presence of adverse outcomes.

RESULTS

At 15 weeks gestation BMI was not associated with placental perfusion or perfusion heterogeneity. However, at 21 weeks gestation BMI was associated with higher placental perfusion (p < 0.01) and a decrease in perfusion heterogeneity (p < 0.05). In alignment with past studies, perfusion values were also higher at 21 weeks compared to 15 weeks gestation. In a small cohort of participants with adverse outcomes, at 21 weeks lower perfusion was observed compared to participants with uncomplicated pregnancies.

DISCUSSION

These results suggest low placental perfusion in the early second trimester may not be the culpable factor driving associations of obesity with adverse outcomes.

Two-Compartment Perfusion MR IVIM Model to Investigate Normal and Pathological Placental Tissue

BACKGROUND

Perfusion and diffusion coexist in the placenta and can be altered by pathologies. The two-perfusion model, where f1 and, f2 are the perfusion-fraction of the fastest and slowest perfusion compartment, respectively, and D is the diffusion coefficient, may help differentiate between normal and impaired placentas.

PURPOSE

Investigate the potential of the two-perfusion IVIM model in differentiating between normal and abnormal placentas.

STUDY-TYPE

Retrospective, case-control.

POPULATION

43 normal pregnancy, 9 fetal-growth-restriction (FGR), 6 small-for-gestational-age (SGA), 4 accreta, 1 increta and 2 percreta placentas.

FIELD STRENGTH/SEQUENCE

Diffusion-weighted-echo planar imaging sequence at 1.5 T.

ASSESSMENT

Voxel-wise signal-correction and fitting-controls were used to avoid overfitting obtaining that two-perfusion model fitted the observed data better than the IVIM model (Akaike weight: 0.94). The two-perfusion parametric-maps were quantified from ROIs in the fetal and maternal placenta and in the accretion zone of accreta placentas. The diffusion coefficient D was evaluated using a b ≥ 200 sec/mm2 -mono-exponential decay fit. IVIM metrics were quantified to fix f1  + f2  = fIVIM .

STATISTICAL-TESTS

ANOVA with Dunn-Sidák's post-hoc correction and Cohen's d test were used to compare parameters between groups. Spearman's coefficient was evaluated to study the correlation between variables. A P-value<0.05 indicated a statistically significant difference.

RESULTS

There was a significant difference in f1 between FGR and SGA, and significant differences in f2 and fIVIM between normal and FGR. The percreta + increta group showed the highest f1 values (Cohen's d = -2.66). The f2 between normal and percreta + increta groups showed Cohen's d = 1.12. Conversely, fIVIM had a small effective size (Cohen's d = 0.32). In the accretion zone, a significant correlation was found between f2 and GA (ρ = 0.90) whereas a significant negative correlation was found between fIVIM and D (ρ = -0.37 in fetal and ρ = -0.56 in maternal side) and f2 and D (ρ = -0.38 in fetal and ρ = -0.51 in maternal side) in normal placentas.

CONCLUSION

The two-perfusion model provides complementary information to IVIM parameters that may be useful in identifying placenta impairment.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY STAGE: 1.

Risk factors and glycaemic control in small-for-gestational-age infants born to mothers with gestational diabetes mellitus: a case-control study using propensity score matching based on a large population

BACKGROUND

Small for gestational age (SGA) poses a significant concern for newborns, being linked to neonatal complications and potential metabolic disorders in adulthood, especially when born to mothers with gestational diabetes mellitus (GDM), elevating their risk of complications and mortality. However, the pregnancy risk factors and glycaemic control associated with SGA infants born to mothers with GDM remain unclear.

AIM

To identify the pregnancy risk factors and glycaemic control associated with SGA infants born to mothers with GDM.

METHOD

This case-control study was conducted among 1910 women with GDM in China. Data were collected by the integrated electronic medical record system. Using 1:4 propensity score matching analysis, we adjusted for gestational age as confounder. Univariate and multivariate analyses were performed to identify risk factors.

RESULTS

Risk factors for SGA born to mothers with GDM included a history of low birth weight, gestational hypertension, oligohydramnios, short maternal height, underweight pre-pregnancy body mass index and inadequate weight growth. While SGA was protected by weakly positive ketonuria levels in the first trimester, multiparous, anaemia and previous uterine scar were protective factors for SGA. Moreover, 2-hour postprandial glucose and haemoglobin A1c in the second trimester, as well as the 0-hour and 2-hour 75 g oral glucose tolerance test (OGTT) were linked to risk of SGA.

CONCLUSIONS

SGA infants are the result of multifactorial interactions among GDM pregnant women. Notably, glycaemic control levels were associated with SGA. There is a need for enhanced perinatal monitoring and antenatal care to reduce SGA.

Diffusion-sensitized magnetic resonance imaging highlights placental microstructural damage in patients with previous SARS-CoV-2 pregnancy infection

INTRODUCTION

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been a major global health problem since December 2019. This work aimed to investigate whether pregnant women's mild and moderate SARS-CoV-2 infection was associated with microstructural and vascular changes in the placenta observable in vivo by Intravoxel Incoherent Motion (IVIM) at different gestational ages (GA).

METHODS

This was a retrospective, nested case-control of pregnant women during the SARS-CoV-2 pandemic (COVID-19 group, n = 14) compared to pre-pandemic healthy controls (n = 19). MRI IVIM protocol at 1.5T was constituted of diffusion-weighted (DW) images with TR/TE = 3100/76 ms and 10 b-values (0,10,30,50,75,100,200,400,700,1000s/mm2). Differences between IVIM parameters D (diffusion), and f (fractional perfusion) quantified in the two groups were evaluated using the ANOVA test with Bonferroni correction and linear correlation between IVIM metrics and GA, COVID-19 duration, the delay time between a positive SARS-CoV-2 test and MRI examination (delay-time exam+) was studied by Pearson-test.

RESULTS

D was significantly higher in the COVID-19 placentas compared to that of the age-matched healthy group (p < 0.04 in fetal and p < 0.007 in maternal site). No significant difference between f values was found in the two groups suggesting no-specific microstructural damage with no perfusion alteration (potentially quantified by f) in mild/moderate SARS-Cov-2 placentas. A significant negative correlation was found between D and GA in the COVID-19 placentas whereas no significant correlation was found in the control placentas reflecting a possible accelerated senescence process due to COVID-19.

DISCUSSION

We report impaired microstructural placental development during pregnancy and the absence of perfusion-IVIM parameter changes that may indicate no perfusion changing through microvessels and microvilli in the placentas of pregnancies with mild/moderate SARS-Cov-2 after reaching negativity.

Non-invasive mapping of human placenta microenvironments throughout pregnancy with diffusion-relaxation MRI

INTRODUCTION

In-vivo measurements of placental structure and function have the potential to improve prediction, diagnosis, and treatment planning for a wide range of pregnancy complications, such as fetal growth restriction and pre-eclampsia, and hence inform clinical decision making, ultimately improving patient outcomes. MRI is emerging as a technique with increased sensitivity to placental structure and function compared to the current clinical standard, ultrasound.

METHODS

We demonstrate and evaluate a combined diffusion-relaxation MRI acquisition and analysis pipeline on a sizable cohort of 78 normal pregnancies with gestational ages ranging from 15 + 5 to 38 + 4 weeks. Our acquisition comprises a combined T2*-diffusion MRI acquisition sequence - which is simultaneously sensitive to oxygenation, microstructure and microcirculation. We analyse our scans with a data-driven unsupervised machine learning technique, InSpect, that parsimoniously identifies distinct components in the data.

RESULTS

We identify and map seven potential placental microenvironments and reveal detailed insights into multiple microstructural and microcirculatory features of the placenta, and assess their trends across gestation.

DISCUSSION

By demonstrating direct observation of micro-scale placental structure and function, and revealing clear trends across pregnancy, our work contributes towards the development of robust imaging biomarkers for pregnancy complications and the ultimate goal of a normative model of placental development.

Effect of Parity on Placental Histopathology Features in Singleton Live Births Following IVF

The aim of this study was to evaluate the effect of parity (primipara vs multipara) on the histopathology of the placenta in singleton live births following in vitro fertilization. We conducted a retrospective cohort study evaluating data of all IVF resulted live births from one university affiliated hospital during 2009-2017. All patients had the placenta sent for pathological evaluation. Exclusion criteria were history of miscarriage or elective termination of pregnancy, abnormal uterine cavity findings, previous uterine surgery, in vitro maturation cycles, gestational carrier cycles, oocyte recipient cycles, preimplantation genetic diagnosis cycles, and multiple pregnancies. The outcomes measured included anatomical, inflammation, vascular malperfusion, and villous maturation placental features. A multivariate analysis was conducted to adjust the results for factors potentially associated with placental pathology features. A total of 395 live births were included in the final analysis and were allocated to the study groups according to parity: primipara (n = 273) and multipara (n = 122). After adjustment for potential confounding factors, multiparity was found to be significantly associated with delayed villous maturation (OR 4.9; 95% CI 1.2-19.8) and primiparity was significantly associated with maternal vascular malperfusion (OR 0.6; 95% CI 0.3-0.8). We showed that parity has an impact on placental histopathological changes which in turn may affect perinatal outcome.

Developments in functional imaging of the placenta

The placenta is both the literal and metaphorical black box of pregnancy. Measurement of the function of the placenta has the potential to enhance our understanding of this enigmatic organ and serve to support obstetric decision making. Advanced imaging techniques are key to support these measurements. This review summarises emerging imaging technology being used to measure the function of the placenta and new developments in the computational analysis of these data. We address three important examples where functional imaging is supporting our understanding of these conditions: fetal growth restriction, placenta accreta, and twin-twin transfusion syndrome.

Low-Field Combined Diffusion-Relaxation MRI for Mapping Placenta Structure and Function

Purpose

Demonstrating quantitative multi-parametric mapping in the placenta with combined T 2 ∗ -diffusion MRI at low-field (0.55T).

Methods

We present 57 placental MRI scans performed on a commercially available 0.55T scanner. We acquired the images using a combined T 2 ∗ -diffusion technique scan that simultaneously acquires multiple diffusion preparations and echo times. We processed the data to produce quantitative T 2 ∗ and diffusivity maps using a combined T 2 ∗ -ADC model. We compared the derived quantitative parameters across gestation in healthy controls and a cohort of clinical cases.

Results

Quantitative parameter maps closely resemble those from previous experiments at higher field strength, with similar trends in T 2 ∗ and ADC against gestational age observed.

Conclusion

Combined T 2 ∗ -diffusion placental MRI is reliably achievable at 0.55T. The advantages of lower field strength - such as cost, ease of deployment, increased accessibility and patient comfort due to the wider bore, and increased T 2 ∗ for larger dynamic ranges - can support the widespread roll out of placental MRI as an adjunct to ultrasound during pregnancy.

Update on state-of-the-art for arterial spin labeling (ASL) human perfusion imaging outside of the brain

This review article provides an overview of developments for arterial spin labeling (ASL) perfusion imaging in the body (i.e., outside of the brain). It is part of a series of review/recommendation papers from the International Society for Magnetic Resonance in Medicine (ISMRM) Perfusion Study Group. In this review, we focus on specific challenges and developments tailored for ASL in a variety of body locations. After presenting common challenges, organ-specific reviews of challenges and developments are presented, including kidneys, lungs, heart (myocardium), placenta, eye (retina), liver, pancreas, and muscle, which are regions that have seen the most developments outside of the brain. Summaries and recommendations of acquisition parameters (when appropriate) are provided for each organ. We then explore the possibilities for wider adoption of body ASL based on large standardization efforts, as well as the potential opportunities based on recent advances in high/low-field systems and machine-learning. This review seeks to provide an overview of the current state-of-the-art of ASL for applications in the body, highlighting ongoing challenges and solutions that aim to enable more widespread use of the technique in clinical practice.

Multi-modal MRI reveals changes in placental function following preterm premature rupture of membranes

PURPOSE

Preterm premature rupture of membranes complicates up to 40% of premature deliveries. Fetal infection may occur in the absence of maternal symptoms, delaying diagnosis and increasing morbidity and mortality. A noninvasive antenatal assessment of early signs of placental inflammation is therefore urgently required.

METHODS

Sixteen women with preterm premature rupture of membranes < 34 weeks gestation and 60 women with uncomplicated pregnancies were prospectively recruited. A modified diffusion-weighted spin-echo single shot EPI sequence with a diffusion preparation acquiring 264 unique parameter combinations in < 9 min was obtained on a clinical 3 Tesla MRI scanner. The data was fitted to a 2-compartment T 2 * $$ {\mathrm{T}}_2^{\ast } $$ -intravoxel incoherent motion model comprising fast and slowly circulating fluid pools to obtain quantitative information on perfusion, density, and tissue composition. Z values were calculated, and correlation with time from between the rupture of membranes and the scan, gestational age at delivery, and time between scan and delivery assessed.

RESULTS

Placental T 2 * $$ {\mathrm{T}}_2^{\ast } $$ was significantly reduced in preterm premature rupture of membranes, and the 2-compartmental model demonstrated that this decline is mainly linked to the perfusion component observed in the placental parenchyma. Multi-modal MRI measurement of placental function is linked to gestational age at delivery and time from membrane rupture.

CONCLUSION

More complex models and data acquisition can potentially improve fitting of the underlying etiology of preterm birth compared with individual single-contrast models and contribute to additional insights in the future. This will need validation in larger cohorts. A multi-modal MRI acquisition between rupture of the membranes and delivery can be used to measure placental function and is linked to gestational age at delivery.

Differences in placental oxygenation and perfusion status between fetal growth-restricted and small-for-gestational-age pregnancies: a functional magnetic resonance imaging study

OBJECTIVE

Functional magnetic resonance imaging (MRI) can assess oxygenation and perfusion status in the placenta. We aimed to explore the differences in functional parameters between pregnancies complicated by fetal growth restriction (FGR) and small-for-gestational-age (SGA).

METHODS

This was a prospective study. A pregnancy complicated by SGA was defined by prenatal ultrasonic estimated fetal weight (EFW) and a final birthweight < the 10th percentile. A pregnancy complicated by FGR was defined as a more severe subtype (ultrasonic EFW < the 3rd percentile or abnormal Doppler results). All pregnant women underwent T2* and intravoxel incoherent motion (IVIM) scans using a 3.0-T MRI scanner. Functional parameters in the control, SGA, and FGR groups, namely, the T2* Z score, apparent diffusion coefficient (ADC), diffusion coefficient (D), pseudodiffusion coefficient (D*), and perfusion fraction (f), were calculated and compared.

RESULTS

In total, 30 pregnancies complicated by SGA, 24 pregnancies complicated by FGR, and 28 control pregnancies were included in the final analysis. Oxygenation status, as assessed by the T2* Z score, was significantly lower in pregnancies complicated by FGR than in pregnancies complicated by SGA (p < 0.001). However, diffusion and perfusion parameters, including the ADC, D, D*, and f, were similar between pregnancies complicated by SGA and FGR (p > 0.05 for all). Compared to the control pregnancies, all the parameters were significantly decreased in the SGA and FGR groups, except for the D* value. The T2* Z score, ADC, and D values were negatively correlated with birthweight.

CONCLUSION

Although both pregnancies complicated by SGA and FGR were associated with significantly lower oxygenation and perfusion than normal control pregnancies, placental hypoxia seemed to be more predominant in pregnancies complicated by FGR than in pregnancies complicated by SGA.

KEY POINTS

• Pregnancy complicated by FGR was associated with a more severe type of hypoxia than pregnancy complicated by SGA. • The diffusion and perfusion parameters of pregnancies complicated by SGA and FGR were similar. • SGA may represent another growth disorder that is not entirely healthy.

Placental perfusion using intravoxel incoherent motion MRI combined with Doppler findings in differentiating between very low birth weight infants and small for gestational age infants

INTRODUCTION

Abnormalities in placental morphology and function can lead to small for gestational age infants (SGA) and very low birth weight infants (VLBWI). In this study, we explored the value of intravoxel incoherent motion (IVIM) histogram parameters, MRI morphological parameters, and Doppler findings of the placenta in differentiating between VLBWI and SGA.

METHODS

Thirty-three pregnant women who were diagnosed with SGA and met the inclusion criteria were enrolled in this retrospective study and divided into two groups: 22 with non-VLBWI and 11 with VLBWI. The IVIM histogram parameters (perfusion fraction (f), true diffusion coefficient (D), and pseudo-diffusion coefficient (D*)), MRI morphological parameters, and Doppler findings were compared between groups. The diagnostic efficiency was compared by receiver operating characteristic (ROC) curve analysis.

RESULTS

The D_mean, D_90th, D*_90th, f_max, and placental area of the VLBWI group were significantly lower than those of the non-VLBWI group (p < 0.05). The values of umbilical artery pulsatility index, resistance index (RI), and peak systolic velocity/end-diastolic velocity were significantly higher in the VLBWI group than in the non-VLBWI group (p < 0.05). D_90th, placental area, and umbilical artery RI had the highest areas under the curve (AUCs) of the ROC curves, at 0.787, 0.785, and 0.762, respectively. A combined predictive model (D_90th, placental area, and umbilical artery RI) improved the performance in differentiating between VLBWI and SGA compared with the single model (AUC = 0.942).

DISCUSSION

IVIM histogram (D_90th) and MRI morphological (placental area) parameters and a Doppler finding (umbilical artery RI) may be sensitive indicators for differentiating between VLBWI and SGA.

Placental location and obstetrical-neonatal outcomes: A retrospective study

OBJECTIVE

To explore the potential association of lateral placentation with pregnancy outcome.

METHODS

The database of a tertiary medical center was searched for women who gave birth to a singleton neonate from 2012 to 2020 for whom placental location was documented during antepartum sonographic examination. Clinical data were compared between patients with a central (anterior/posterior/fundal) or lateral placenta using standard statistics. The primary outcome measure was neonatal birthweight, and secondary outcome measures were pregnancy complications and mode of delivery.

RESULTS

The cohort included 12 306 women: 11 608 (94%) with a central placenta and 698 (5.6%) with a lateral placenta. The lateral placenta group had higher rates (P < 0.05) of prior and current cesarean delivery, assisted delivery, and preterm birth. On multivariate regression analyses, placental location (adjusted odds ratio [aOR], 1.36; 95% confidence interval [CI], 1.11-1.66) and maternal age (aOR, 1.02; 95% CI, 1.01-1.03) were associated with risk of preterm birth. Lateral placenta (aOR, 1.22; 95% CI, 1.02-1.47), maternal age (aOR, 1.07; 95% CI, 1.06-1.08), parity (aOR, 0.32; 95% CI, 0.28-0.35), and prior cesarean delivery (aOR, 12.00; 95% CI, 10.60-13.60) were associated with risk of current cesarean delivery.

CONCLUSION

The findings suggest that lateral placentation may pose a risk of preterm birth and cesarean delivery compared with central placentation.

Monoexponential, biexponential and diffusion kurtosis MR imaging models: quantitative biomarkers in the diagnosis of placenta accreta spectrum disorders

BACKGROUND

To investigate the diagnostic value of monoexponential, biexponential, and diffusion kurtosis MR imaging (MRI) in differentiating placenta accreta spectrum (PAS) disorders.

METHODS

A total of 65 patients with PAS disorders and 27 patients with normal placentas undergoing conventional DWI, IVIM, and DKI were retrospectively reviewed. The mean, minimum, and maximum parameters including the apparent diffusion coefficient (ADC) and exponential ADC (eADC) from standard DWI, diffusion kurtosis (MK), and mean diffusion coefficient (MD) from DKI and pure diffusion coefficient (D), pseudo-diffusion coefficient (D*), and perfusion fraction (f) from IVIM were measured from the volumetric analysis and compared between patients with PAS disorders and patients with normal placentas. Univariate and multivariated logistic regression analyses were used to evaluate the value of the above parameters for differentiating PAS disorders. Receiver operating characteristics (ROC) curve analyses were used to evaluate the diagnostic efficiency of different diffusion parameters for predicting PAS disorders.

RESULTS

Multivariate analysis demonstrated that only D mean and D max differed significantly among all the studied parameters for differentiating PAS disorders when comparisons between accreta lesions in patients with PAS (AP) and whole placentas in patients with normal placentas (WP-normal) were performed (all p < 0.05). For discriminating PAS disorders, a combined use of these two parameters yielded an AUC of 0.93 with sensitivity, specificity, and accuracy of 83.08, 88.89, and 83.70%, respectively.

CONCLUSION

The diagnostic performance of the parameters from accreta lesions was better than that of the whole placenta. D mean and D max were associated with PAS disorders.

Human placental microperfusion and microstructural assessment by intra-voxel incoherent motion MRI for discriminating intrauterine growth restriction: a pilot study

OBJECTIVES

To evaluate the potential of Intravoxel Incoherent Motion (IVIM) Imaging in the quantification of placental micro-perfusion and microstructural features to identify and discriminate different forms of intrauterine growth restriction (IUGR) and normal fetuses pregnancies.

METHODS

Small for gestational age SGA (n = 8), fetal growth restriction FGR (n = 10), and normal (n = 49) pregnancies were included in the study. Placental Magnetic Resonance Imaging (MRI) was performed at 1.5 T using a diffusion-weighted sequence with 10 b-values. IVIM fractional perfusion (fp), diffusion (D), and pseudodiffusion (D*) were evaluated on the fetal and maternal placental sides. Correlations between IVIM parameters, Gestational Age (GA), Birth Weight (BW), and the presence or absence of prenatal fetoplacental Doppler abnormalities at the US were investigated in SGA, FGR, and normal placentae.

RESULTS

fp and D* of the placental fetal side discriminate between SGA and FGR (p = .021; p = .036, respectively), showing lower values in FGR. SGA showed an intermediate perfusion pattern in terms of fp and D* compared to FGR and normal controls. In the intrauterine growth restriction group (SGA + FGR), a significant positive correlation was found between fp and BW (p < .002) in the fetal placenta and a significant negative correlation was found between D and GA in both the fetal (p < .0009) and maternal (p < .006) placentas.

CONCLUSIONS

Perfusion IVIM parameters fp and D* may be useful to discriminate different micro-vascularization patterns in IUGR being helpful to detect microvascular subtle impairment even in fetuses without any sign of US Doppler impairment in utero. Moreover, fp may predict fetuses' body weight in intrauterine growth restriction pregnancies. The diffusion IVIM parameter D may reflect more rapid microstructural rearrangement of the placenta due to aging processes in the IUGR group than in normal controls.

Use of intravoxel incoherent motion MRI to assess placental perfusion in normal and Fetal Growth Restricted pregnancies on their third trimester

INTRODUCTION

Intravoxel Incoherent Motion (IVIM) MRI is a non-invasive, in vivo techniques which can assess placental perfusion quantitatively, and be useful for evaluating placental microcirculation. Our primary aim was to investigate whether fetal growth restriction (FGR) pregnancies have different placental perfusion and diffusion compared with normal pregnancies using IVIM. A secondary aim was to investigate correlations between placental IVIM parameters and gestational age in normal pregnancy.

METHODS

This study population included 17 FGR pregnancies and 36 normal pregnancies between 28 + 3 to 38 + 0 weeks. All women underwent a MRI examination including an IVIM sequence with 9 b-values on a 3.0 T MRI system. The standard diffusion coefficeint (D), pseudodiffusion (D*) and perfusion fraction (f) were calculated.

RESULTS

Placental f was significantly lower in the FGR group than that in the normal group (33.96 ± 2.62(%) vs 38.48 ± 5.31(%), p = 0.002). Placental D and D* in two groups showed no statistical significance (P > 0.05). Placental f moderately increased with increasing gestational age in normal pregnancies (r = 0.411, p = 0.013), and there existed a negative correlation between D values and gestational age (r = -0.390, p = 0.019).

DISCUSSION

The f values are able to distinguish FGR from normal pregnancies. It can be uses as a feasible index to evaluate placenta perfusion. Gestational age-associated changes in placental IVIM parameters likely reveal trajectories of microvascular perfusion fraction and diffusion characteristics in the normal developing placenta.

Placental functional assessment and its relationship to adverse pregnancy outcome: comparison of intravoxel incoherent motion (IVIM) MRI, T2-relaxation time, and umbilical artery Doppler ultrasound

BACKGROUND

Early identification of placental insufficiency can lead to appropriate treatment selections and can improve neonates' outcomes. Possible contributions of magnetic resonance imaging (MRI) have been suggested.

PURPOSE

To evaluate the prognostic capabilities of placental intravoxel incoherent motion (IVIM) parameters and T2-relaxation time, and their correlation with fetal growth and adverse outcomes, comparing umbilical artery (UmA) pulsatility index (PI).

MATERIAL AND METHODS

A total of 68 singleton pregnancies at 24-40 weeks of gestation underwent placental MRI and were reviewed retrospectively. UmA-PI was measured using Doppler ultrasound by obstetricians. IVIM parameters (Dfast, Dslow, and f) were calculated with a Bayesian model fitting. First, the associations between gestational age (GA) with placental IVIM parameters, T2-relaxation time, and placental thickness (PT) were evaluated. Second, IVIM parameters, T2 value (Z-score), PT (Z-score), and UmA-PI (Z-score) were compared between ( 1) those delivering small for gestational age (SGA) and appropriate for gestational age (AGA) neonates, ( 2) emergency cesarean section (ECS), and non-ECS, and ( 3) preterm birth and full-term birth.

RESULTS

Low birth weight was observed in 15/68 cases (22%). GA was significantly associated only with T2-relaxation time and PT. SGA was significantly associated with T2 value (Z-score), f, and UmA-PI (Z-score). In the ECS groups, T2 value (Z-score), f, and Dfast were significantly lower than those in non-ECS groups. All IVIM parameters and T2 values (Z-score) showed significantly lower scores in the preterm birth group.

CONCLUSION

Placental f and T2 value (Z-score) had significant associations with low birth weight and clinical adverse outcomes and could be potential imaging biomarkers of placental insufficiency.

Ex-Vivo MRI of the Normal Human Placenta: Structural-Functional Interplay and the Association With Birth Weight

BACKGROUND

Advanced magnetic resonance imaging (MRI) methods are increasingly being used to assess the human placenta. Yet, the structure-function interplay in normal placentas and their associations with pregnancy risks are not fully understood.

PURPOSE

To characterize the normal human placental structure (volume and umbilical cord centricity index (CI)) and function (perfusion) ex-vivo using MRI, to assess their association with birth weight (BW), and identify imaging-markers for placentas at risk for dysfunction.

STUDY TYPE

Prospective.

POPULATION

Twenty normal term ex-vivo placentas.

FIELD STRENGTH/SEQUENCE

3 T/ T₁ and T₂ weighted (T₁ W, T₂ W) turbo spin-echo, three-dimensional susceptibility-weighted image, and time-resolved angiography with interleaved stochastic trajectories (TWIST), during passage of a contrast agent using MRI compatible perfusion system that mimics placental flow.

ASSESSMENT

Placental volume and CI were manually extracted from the T₁ W images by a fetal-placental MRI scientist (D.L., 7 years of experience). Perfusion maps including bolus arrival-time and full-width at half maximum were calculated from the TWIST data. Mean values, entropy, and asymmetries were calculated from each perfusion map, relating to both the whole placenta and volumes of interest (VOIs) within the umbilical cord and its daughter blood vessels.

STATISTICAL TESTS

Pearson correlations with correction for multiple comparisons using false discovery rate were performed between structural and functional parameters, and with BW, with P < 0.05 considered significant.

RESULTS

All placentas were successfully perfused and scanned. Significant correlations were found between whole placenta and VOIs perfusion parameters (mean R = 0.76 ± 0.06, range = 0.67-0.89), which were also significantly correlated with CI (mean R = 0.72 ± 0.05, range = 0.65-0.79). BW was correlated with placental volume (R = 0.62), but not with CI (P = 0.40). BW was also correlated with local perfusion asymmetry (R = -0.71).

DATA CONCLUSION

Results demonstrate a gradient of placental function, associated with CI and suggest several ex-vivo imaging-markers that might indicate an increased risk for placental dysfunction.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: Stage 1.

Dynamic contrast enhanced magnetic resonance imaging: A review of its application in the assessment of placental function

It is important to develop a better understanding of placental insufficiency given its role in common maternofetal complications such as preeclampsia and fetal growth restriction. Functional magnetic resonance imaging offers unprecedented techniques for exploring the placenta under both normal and pathological physiological conditions. Dynamic contrast-enhanced magnetic resonance imaging (DCE MRI) is an established and very robust method to investigate the microcirculatory parameters of an organ and more specifically its perfusion. It is currently a gold standard in the physiological and circulatory evaluation of an organ. Its application to the human placenta could enable to access many microcirculatory parameters relevant to the placental function such as organ blood flow, fractional blood volume, and permeability surface area, by the acquisition of serial images, before, during, and after administration of an intravenous contrast agent. Widely used in animal models with gadolinium-based contrast agents, its application to the human placenta could be possible if the safety of contrast agents in pregnancy is established or they are confirmed to not cross the placenta.

On the use of multicompartment models of diffusion and relaxation for placental imaging

Multi-compartment models of diffusion and relaxation are ubiquitous in magnetic resonance research especially applied to neuroimaging applications. These models are increasingly making their way into the world of placental imaging. This review provides a framework for their motivation and implementation and describes some of the outstanding questions that need to be answered before they can be routinely adopted.

Multiscale and multimodal imaging of utero-placental anatomy and function in pregnancy

Placental structures at the nano-, micro-, and macro scale each play important roles in contributing to its function. As such, quantifying the dynamic way in which placental structure evolves during pregnancy is critical to both clinical diagnosis of pregnancy disorders, and mechanistic understanding of their pathophysiology. Imaging the placenta, both exvivo and invivo, can provide a wealth of structural and/or functional information. This review outlines how imaging across modalities and spatial scales can ultimately come together to improve our understanding of normal and pathological pregnancies. We discuss how imaging technologies are evolving to provide new insights into placental physiology across disciplines, and how advanced computational algorithms can be used alongside state-of-the-art imaging to obtain a holistic view of placental structure and its associated functions to improve our understanding of placental function in health and disease.

Comparative study of placental T2* and intravoxel incoherent motion in the prediction of fetal growth restriction

INTRODUCTION

Both transverse relaxation time (T2*) and intravoxel incoherent motion (IVIM) on magnetic resonance imaging (MRI) are promising for discriminating fetal growth restriction (FGR). We aimed to compare the utility of these two parameters and their combination in the same cohort.

METHODS

Twenty-seven FGR and 24 control pregnancies after 28 weeks of gestation in which both T2* and IVIM scans were performed on a 3.0 T MRI were recruited. We compared the T2* Z-score, perfusion fraction (f), diffusion coefficient (D) and pseudodiffusion coefficient (D*) between groups. Binary logistic regression analysis and areas under the curve (AUCs) with receiver operating characteristic (ROC) curve were used to evaluate the diagnostic efficacy of these parameters and their combination.

RESULTS

Compared with normal pregnancies, T2* Z-score (0.036 ± 0.95 vs. -2.479 ± 1.56, p < 0.001), f (0.2753 ± 0.035 vs. 0.3304 ± 0.035, p < 0.001), D* (48279.82 ± 7497.36 μm2/s vs. 56167.92 ± 8549.87 μm2/s, p = 0.001) and D (1664.32 ± 288.53 μm2/s vs. 1887.15 ± 204.08 μm2/s, p = 0.002) were significantly decreased in FGR pregnancies. However, only AUC(T2* Z-score) (0.903) and AUC(f) (0.873) were good predictors of FGR. The AUC(T2* Z-score-IVIM) (0.937), calculated with the combination of T2* Z-score and f, was similar to AUC(T2* Z-score) and ACU(f).

DISCUSSION

Both T2* and f were effective in discriminating FGR. However, the combination of the two parameters did not further improve diagnostic efficacy. We suggest that T2* might be more suitable for evaluating placental dysfunction, as it is fast to obtain and easy to measure.

Data-Driven multi-Contrast spectral microstructure imaging with InSpect: INtegrated SPECTral component estimation and mapping

•

Unsupervised learning technique for spectroscopic analysis of quantitative MRI.

•

Shares information across voxels to improve estimation of multi-dimensional or single-dimensional spectra.

•

Spectral maps are dramatically improved compared to existing approaches.

•

Can potentially identify and map tissue environments; in placental diffusion-relaxometry MRI we demonstrate that it identifies components that correspond to distinct tissue types.

We introduce and demonstrate an unsupervised machine learning technique for spectroscopic analysis of quantitative MRI experiments. Our algorithm supports estimation of one-dimensional spectra from single-contrast data, and multidimensional correlation spectra from simultaneous multi-contrast data. These spectrum-based approaches allow model-free investigation of tissue properties, but require regularised inversion of a Laplace transform or Fredholm integral, which is an ill-posed calculation. Here we present a method that addresses this limitation in a data-driven way. The algorithm simultaneously estimates a canonical basis of spectral components and voxelwise maps of their weightings, thereby pooling information across whole images to regularise the ill-posed problem. We show in simulations that our algorithm substantially outperforms current voxelwise spectral approaches. We demonstrate the method on multi-contrast diffusion-relaxometry placental MRI scans, revealing anatomically-relevant sub-structures, and identifying dysfunctional placentas. Our algorithm vastly reduces the data required to reliably estimate spectra, opening up the possibility of quantitative MRI spectroscopy in a wide range of new applications. Our InSpect code is available at github.com/paddyslator/inspect.

Parity and the risks of adverse birth outcomes: a retrospective study among Chinese

Background

Nulliparity is considered to be a risk factor of preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA). With the new two-child policy launched in 2016, more Chinese women have delivered their 2nd baby. Yet few studies have assessed the impact of parity on adverse birth outcomes in China. This study aimed to examine the association between parity and risks of PTB, LBW and SGA in a Chinese population. The combined effects of maternal age and parity on adverse birth outcomes were also assessed.

Methods

This retrospective study included all non-malformed live births born during January 1, 2014 and December 31, 2018 in Chengdu, China. A total of 746,410 eligible live singletons with complete information were included in the analysis. Parity was classified into nulliparity (i.e. has never delivered a newborn before) and multiparity (i.e. has delivered at least one newborn before). Log-binomial regression analyses were applied to evaluate the association between parity and PTB, LBW and SGA. We further divided maternal age into different groups (< 25 years, 25–29 years, 30–34 years and ≥ 35 years) to assess the combined effects of maternal age and parity on adverse birth outcomes.

Results

Multiparity was associated with reduced risks of PTB (aRR = 0.91, 95% CI: 0.89–0.93), LBW (aRR = 0.74, 95% CI: 0.72–0.77) and SGA (aRR = 0.67, 95% CI: 0.66–0.69) compared with nulliparity. In each age group, we observed that multiparity was associated with lower risks of adverse birth outcomes. Compared to nulliparous women aged between 25 and 29 years, women aged ≥35 years had greater risks of PTB and LBW, regardless of their parity status. In contrast, multiparous women aged ≥35 years (aRR = 0.73, 95% CI: 0.70–0.77) and those aged < 25 years (aRR = 0.88, 95% CI: 0.84–0.93) were at lower risk of SGA compared with nulliparous women aged between 25 and 29 years.

Conclusion

Multiparity was associated with lower risks of all adverse birth outcomes. Special attention should be paid to nulliparous mothers and those with advanced age during antenatal care, in order to reduce the risks of adverse birth outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03718-4.

The effects of maternal position, in late gestation pregnancy, on placental blood flow and oxygenation: an MRI study

KEY POINTS

Maternal supine sleep position in late pregnancy is associated with an increased risk of stillbirth. Maternal supine position in late pregnancy reduces maternal cardiac output and uterine blood flow. Using MRI, this study shows that compared to the left lateral position, maternal supine position in late pregnancy is associated with reduced utero-placental blood flow and oxygen transfer across the placenta with an average 6.2% reduction in oxygen delivery to the fetus and an average 11% reduction in fetal umbilical venous blood flow.

ABSTRACT

Maternal sleep position in late gestation is associated with an increased risk of stillbirth, though the pathophysiological reasons for this are unclear. Studies using magnetic resonance imaging (MRI) have shown that compared with lateral positions, lying supine causes a reduction in cardiac output, reduced abdominal aortic blood flow and reduced vena caval flow which is only partially compensated for by increased flow in the azygos venous system. Using functional MRI techniques, including an acquisition termed diffusion-relaxation combined imaging of the placenta (DECIDE), which combines diffusion weighted imaging and T2 relaxometry, blood flow and oxygen transfer were estimated in the maternal, fetal and placental compartments when subjects were scanned both supine and in left lateral positions. In late gestation pregnancy, lying supine caused a 23.7% (P < 0.0001) reduction in total internal iliac arterial blood flow to the uterus. In addition, lying in the supine position caused a 6.2% (P = 0.038) reduction in oxygen movement across the placenta. The reductions in oxygen transfer to the fetus, termed delivery flux, of 11.2% (P = 0.0597) and in fetal oxygen saturation of 4.4% (P = 0.0793) did not reach statistical significance. It is concluded that even in healthy late gestation pregnancy, maternal position significantly affects oxygen transfer across the placenta and may in part provide an explanation for late stillbirth in vulnerable fetuses.

The application of in utero magnetic resonance imaging in the study of the metabolic and cardiovascular consequences of the developmental origins of health and disease

Observing fetal development in utero is vital to further the understanding of later-life diseases. Magnetic resonance imaging (MRI) offers a tool for obtaining a wealth of information about fetal growth, development, and programming not previously available using other methods. This review provides an overview of MRI techniques used to investigate the metabolic and cardiovascular consequences of the developmental origins of health and disease (DOHaD) hypothesis. These methods add to the understanding of the developing fetus by examining fetal growth and organ development, adipose tissue and body composition, fetal oximetry, placental microstructure, diffusion, perfusion, flow, and metabolism. MRI assessment of fetal growth, organ development, metabolism, and the amount of fetal adipose tissue could give early indicators of abnormal fetal development. Noninvasive fetal oximetry can accurately measure placental and fetal oxygenation, which improves current knowledge on placental function. Additionally, measuring deficiencies in the placenta’s transport of nutrients and oxygen is critical for optimizing treatment. Overall, the detailed structural and functional information provided by MRI is valuable in guiding future investigations of DOHaD.

Functional diagnosis of placenta accreta by intravoxel incoherent motion model diffusion-weighted imaging

OBJECTIVES

To investigate the diagnostic value of intravoxel incoherent motion (IVIM) DWI for placenta accreta by comparing diffusion and perfusion characteristics of placentas with accreta lesions (APs) with those of normal placentas (NPs).

METHODS

Twenty-five pregnant women with AP and 24 with NP underwent 3-T magnetic resonance examinations with IVIM-DWI. The perfusion percentage (f), pseudo-diffusion coefficient (D*), and diffusion coefficient (D) values were calculated from different ROIs: the entire-plane of the AP (AP-ROI) and NP (NP-ROI) and the implanted (IR-ROI) and non-implanted region (NIR-ROI) of the AP. The AP-ROIs and NP-ROIs were compared using covariance analysis; the IR-ROIs and NIR-ROIs were compared using the Wilcoxon signed-rank test. ROC curves were produced to evaluate the parameters for predicting placenta accreta.

RESULTS

The f and D* values for the AP-ROIs ([45.0 ± 7.63]%, [11.64 ± 2.15]mm²/s) were significantly higher than those for the NP-ROIs ([31.85 ± 5.96]%, [9.04 ± 3.13]mm²/s) (both p < 0.05); the IR-ROIs (54.8%, 14.03 mm²/s) were also significantly higher than the NIR-ROIs (37.4%, 11.4 mm²/s) (both p < 0.05). No significant differences were found between the D values of the AP-ROIs and NP-ROIs (p > 0.05) or of the IR-ROIs and NIR-ROIs (p > 0.05). The areas under the curve for f and D* of the ROC curves were 0.93 and 0.79, respectively.

CONCLUSIONS

These results suggest that the IVIM parameters f and D* can be used to quantitatively evaluate the higher perfusion of AP when compared with NP. Furthermore, IVIM may be a useful functional diagnostic technique to predict placenta accreta.

KEY POINTS

• Intravoxel incoherent motion (IVIM) may be a useful diagnostic technique to quantitatively estimate the perfusion of the placenta. • The perfusion percentage (f) and pseudo-diffusion coefficient (D*) values differed significantly between placentas with accreta lesions and normal placentas. • ROC curves showed that perfusion percentage (f) and pseudo-diffusion coefficient (D*) values could accurately predict placenta accreta.

Magnetic resonance imaging measurement of placental perfusion and oxygen saturation in early-onset fetal growth restriction

OBJECTIVE

We hypothesised that a multi-compartment magnetic resonance imaging (MRI) technique that is sensitive to fetal blood oxygenation would identify changes in placental blood volume and fetal blood oxygenation in pregnancies complicated by early-onset fetal growth restriction (FGR).

DESIGN

Case-control study.

SETTING

London, UK.

POPULATION

Women with uncomplicated pregnancies (estimated fetal weight [EFW] >10th centile for gestational age [GA] and normal maternal and fetal Doppler ultrasound, n = 12) or early-onset FGR (EFW <3rd centile with or without abnormal Doppler ultrasound <32 weeks GA, n = 12) were studied.

METHODS

All women underwent MRI examination. Using a multi-compartment MRI technique, we quantified fetal and maternal blood volume and feto-placental blood oxygenation.

MAIN OUTCOME MEASURES

Disease severity was stratified according to Doppler pulsatility index and the relationship to the MRI parameters was investigated, including the influence of GA at scan.

RESULTS

The FGR group (mean GA 27⁺⁵  weeks, range 24⁺² to 33⁺⁶  weeks) had a significantly lower EFW compared with the control group (mean GA 29⁺¹  weeks; -705 g, 95% CI -353 to -1057 g). MRI-derived feto-placental oxygen saturation was higher in controls compared with FGR (75 ± 9.6% versus 56 ± 16.2%, P = 0.02, 95% CI 7.8-30.3%). Feto-placental oxygen saturation estimation correlated strongly with GA at scan in controls (r = -0.83).

CONCLUSION

Using a novel multimodal MRI protocol we demonstrated reduced feto-placental blood oxygen saturation in pregnancies complicated by early-onset FGR. The degree of abnormality correlated with disease severity defined by ultrasound Doppler findings. Gestational age-dependent changes in oxygen saturation were also present in normal pregnancies.

TWEETABLE ABSTRACT

MRI reveals differences in feto-placental oxygen saturation between normal and FGR pregnancy that is associated with disease severity.

Probing the ballistic microcirculation in placenta using flow-compensated and non-compensated intravoxel incoherent motion imaging

PURPOSE

Intravoxel incoherent motion (IVIM) imaging is widely used to evaluate microcirculatory flow, which consists of diffusive and ballistic flow components. We proposed a joint use of flow-compensated (FC) and non-compensated (NC) diffusion gradients to probe the fraction and velocity of ballistic flow in the placenta.

METHODS

Forty pregnant women were included in this study and scanned on a 1.5T clinical scanner. FC and NC diffusion MRI (dMRI) sequences were achieved using a pair of identical or mirrored bipolar gradients. A joint FC-NC model was established to estimate the fraction (f_b ) and velocity (v_b ) of the ballistic flow. Conventional IVIM parameters (f, D, and D*) were obtained from the FC and NC data, separately. The v_b and f·D*, as placental flow velocity measurements, were correlated with the umbilical-artery Doppler ultrasound indices and gestational ages.

RESULTS

The ballistic flow component can be observed from the difference between the FC and NC dMRI signal decay curves. v_b fitted from the FC-NC model showed strong correlations with umbilical-artery impedance indices, the systolic-to-diastolic (SD) ratio and pulsatility index (PI), with correlation coefficients of 0.65 and 0.62. The f·D* estimated from the NC data positively correlated with SD and PI, while the FC-based f·D* values showed weak negative correlations. Significant gestational-age dependence was also found in the flow velocity measurements.

CONCLUSION

Our results demonstrated the feasibility of using FC and NC dMRI to noninvasively measure ballistic flow velocity in the placenta, which may be used as a new marker to evaluate placenta microcirculation.

The haemodynamics of the human placenta in utero

We have used magnetic resonance imaging (MRI) to provide important new insights into the function of the human placenta in utero. We have measured slow net flow and high net oxygenation in the placenta in vivo, which are consistent with efficient delivery of oxygen from mother to fetus. Our experimental evidence substantiates previous hypotheses on the effects of spiral artery remodelling in utero and also indicates rapid venous drainage from the placenta, which is important because this outflow has been largely neglected in the past. Furthermore, beyond Braxton Hicks contractions, which involve the entire uterus, we have identified a new physiological phenomenon, the ‘utero-placental pump’, by which the placenta and underlying uterine wall contract independently of the rest of the uterus, expelling maternal blood from the intervillous space.

MRI provides important new insights into the function of the human placenta, revealing slow net flow and high, uniform oxygenation in healthy pregnancies, detecting changes that will lead to compromised oxygen delivery to the fetus in preeclampsia, and identifying a new physiological phenomenon, the ‘utero-placental pump’.

Exploring in vivo placental microstructure in healthy and growth-restricted pregnancies through diffusion-weighted magnetic resonance imaging

INTRODUCTION

Gross and microstructural changes in placental development can influence placental function and adversely impact fetal growth and well-being; however, there is a paucity of invivo tools available to reliably interrogate in vivo placental microstructural development. The objective of this study is to characterize invivo placental microstructural diffusion and perfusion in healthy and growth-restricted pregnancies (FGR) using non-invasive diffusion-weighted imaging (DWI).

METHODS

We prospectively enrolled healthy pregnant women and women whose pregnancies were complicated by FGR. Each woman underwent DWI-MRI between 18 and 40 weeks gestation. Placental measures of small (D) and large (D*) scale diffusion and perfusion (f) were estimated using the intra-voxel incoherent motion (IVIM) model.

RESULTS

We studied 137 pregnant women (101 healthy; 36 FGR). D and D* are increased in late-onset FGR, and the placental perfusion fraction, f, is decreased (p < 0.05 for all).

DISCUSSION

Placental DWI revealed microstructural alterations of the invivo placenta in FGR, particularly in late-onset FGR. Early and reliable identification of placental pathology in vivo may better guide future interventions.

Feasibility of image registration and fusion for evaluation of structure and perfusion of the entire second trimester placenta by three-dimensional power Doppler ultrasound

BACKGROUND

Placental perfusion can be evaluated by 3D power Doppler ultrasound (3D PD-US), particularly using the validated tool 3D Fractional Moving Blood Volume (3D-FMBV); however regional variability and size limitations beyond the first trimester mean that multiple 3D PD-US volumes are required to evaluate the whole organ.

PURPOSE

We assessed the feasibility of manual offline stitching of second trimester 3D PD-US volumes of the placenta to assess whole organ perfusion using 3D-FMBV.

MATERIALS AND METHODS

This was a single-centre, prospective, observational cohort study of 36 normal second trimester singleton pregnancies with anterior placentas. 3D PD-US placental volumes were manually segmented offline and stitched together by rigid registration using manually selected, pair-wise coordinates. Data acquisition and offline volume segmentation and stitching were triplicated by a single observer with Dice similarity coefficient (DSC) and Hausdorff distance used to assess consistency. Intraclass correlation coefficient (ICC) was used to assess intra-observer repeatability of 3D-FMBV and placental volume.

RESULTS

Acquisition and stitching success were 94% and 88%, respectively. Median time for acquisition, segmentation and stitching were 13 min, 40 min and 95 min, respectively. Median intra-observer DSCs were 0.94 and 0.88, and Hausdorff distances were 11.85 mm and 36.6 mm, for segmentations and stitching, respectively.

CONCLUSION

3D-ultrasound volume stitching of the placenta is technically feasible. Intra-observer repeatability was good to excellent for all measured parameters. This work demonstrates technical feasibility; further studies may provide the basis of an in-vivo assessment tool to measure the placenta in mid-to late pregnancy.

Systematic evaluation of velocity-selective arterial spin labeling settings for placental perfusion measurement

Purpose

Placental function is key for successful human pregnancies. Perfusion may be a sensitive marker for the in vivo assessment of placental function. Arterial spin labeling (ASL) MRI enables noninvasive measurement of tissue perfusion and it was recently suggested that ASL with velocity‐selective (VS) labeling could be advantageous in the placenta. We systematically evaluated essential VS‐ASL sequence parameters to determine optimal settings for efficient placental perfusion measurements.

Methods

Eleven pregnant women were scanned at 3T using VS‐ASL with 2D multislice echo planar imaging (EPI)‐readout. One reference VS‐ASL scan was acquired in all subjects; within subgroups the following parameters were systematically varied: cutoff velocity, velocity encoding direction, and inflow time. Visual evaluation and region of interest analyses were performed to compare perfusion signal differences between acquisitions.

Results

In all subjects, a perfusion pattern with clear hyperintense focal regions was observed. Perfusion signal decreased with inflow time and cutoff velocity. Subject‐specific dependence on velocity encoding direction was observed. High temporal signal‐to‐noise ratios with high contrast on the perfusion images between the hyperintense regions and placental tissue were seen at ~1.6 cm/s cutoff velocity and ~1000 ms inflow time. Evaluation of measurements at multiple inflow times revealed differences in blood flow dynamics between placental regions.

Conclusion

Placental perfusion measurements are feasible at 3T using VS‐ASL with 2D multislice EPI‐readout. A clear dependence of perfusion signal on VS labeling parameters and inflow time was demonstrated. Whereas multiple parameter combinations may advance the interpretation of placental circulation dynamics, this study provides a basis to select an effective set of parameters for the observation of placenta perfusion natural history and its potential pathological changes.

Placental diffusion-weighted MRI in normal pregnancies and those complicated by placental dysfunction due to vascular malperfusion

INTRODUCTION

Our aim was to assess placental function by diffusion-weighted magnetic resonance imaging (MRI) using intravoxel incoherent motion (IVIM) analysis in uncomplicated pregnancies and pregnancies complicated by placental dysfunction.

METHODS

31 normal pregnancies and 9 pregnancies complicated by placental dysfunction (birthweight ≤ -2SD and histological signs of placental vascular malperfusion) were retrieved from our placental MRI research database. MRI was performed at gestational weeks 20.1-40.6 in a 1.5 T system using 10 b-values (0-1000 s/mm²). Regions of interest were drawn covering the entire placenta in five transverse slices. Diffusion coefficient (D), pseudodiffusion coefficient (D*) and perfusion fraction (f) were estimated by IVIM analysis.

RESULTS

In normal pregnancies, placental f decreased linearly with gestational age (r = -0.522, p = 0.002) being 26.2% at week 20 and 18.8% at week 40. D and D* were 1.57 ± 0.03 and 31.7 ± 3.1 mm²/s (mean ± SD), respectively, and they were not correlated with gestational age. In complicated pregnancies, f was significantly reduced (mean Z-score = -1.16; p = 0.02) when compared to the group of normal pregnancies, whereas D and D* did not differ significantly between groups. Subgroup analysis demonstrated that f was predominantly reduced in dysfunctional placentas characterized by fetal vascular malperfusion (mean Z-score = -2.11, p < 0.001) rather than maternal vascular malperfusion (mean Z-score = -0.40, p = 0.42). In addition, f was negatively correlated with uterine artery pulsatility index (r = -0.396, p = 0.01).

DISCUSSION

Among parameters obtained by the IVIM analysis, only f revealed significant differences between the normal and the dysfunctional placentas. Subgroup analysis suggests that placental f may be able to discriminate non-invasively between different histological types of vascular malperfusion.

Diffusion-weighted imaging of placenta in intrauterine growth restriction with worsening Doppler US findings

PURPOSE

We aimed to compare the placental diffusion difference between intrauterine growth restriction (IUGR) patients with worsening Doppler ultrasonography (US) findings and control group with normal Doppler US findings by using diffusion-weighted imaging (DWI).

METHODS

We performed a prospective study to compare the placental diffusion difference in 63 patients (gestational week, 28-34 weeks), including 50 IUGR patients (mean gestational week, 30 weeks 3 days ±16.2 days) with worsening Doppler US findings and 13 patients with normal Doppler US findings (mean gestational week, 29 weeks 4 days ±12.3 days) by using DWI (b value, 0-1000 s/mm2). We classified IUGR patients into three groups according to the reference values of the umbilical artery pulsatility index (PI) chart. Placenta apparent diffusion coefficient (ADC) calculations were performed by freehand drawn regions-of-interest (ROIs) (min, 8.04 cm2; max, 200 cm2).

RESULTS

Placental ADC values in IUGR patients (mean, 1.624±0.181 ×10-³ mm²/s; range, 1.35-1.96 ×10-3 mm2/s) were significantly reduced compared with the control group (mean, 1.827±0.191 ×10-³ mm²/s; range, 1.35-2.84 ×10-3 mm2/s) (P = 0.001). For adjusted ROI area calculation, ADC values were significantly lower in groups 3, 2 and 1, respectively, compared with the control group (P < 0.05); and there was no significant difference between groups 1 and 2 (P > 0.05). Preeclampsia significantly reduced the placental diffusion compared with patients without preeclampsia (P = 0.003). Gestational aging did not significantly affect ADC values in control patients (r=0.08, P = 0.561). The sensitivity, specificity, negative and positive predictive values of ADC to detect IUGR were 72%, 84.6%, 44%, and 94.7% with a cutoff value of 1.727 ×10-3 mm2/s, respectively.

CONCLUSION

The diagnostic estimation of placental ADC values to predict the severity of IUGR is comparable to that of umbilical artery PI. Considering that at the very early onset of IUGR, placental diffusion diminishes, ADC as a marker for IUGR in lieu of umbilical artery PI has the potential to determine the threshold for decreased placental diffusion. Therefore, DWI should be added to routine fetal MRI to show diffusion changes in placenta.

In Utero Diffusion MRI: Challenges, Advances, and Applications

In utero diffusion magnetic resonance imaging (MRI) provides unique opportunities to noninvasively study the microstructure of tissue during fetal development. A wide range of developmental processes, such as the growth of white matter tracts in the brain, the maturation of placental villous trees, or the fibers in the fetal heart remain to be studied and understood in detail. Advances in fetal interventions and surgery furthermore increase the need for ever more precise antenatal diagnosis from fetal MRI. However, the specific properties of the in utero environment, such as fetal and maternal motion, increased field-of-view, tissue interfaces and safety considerations, are significant challenges for most MRI techniques, and particularly for diffusion. Recent years have seen major improvements, driven by the development of bespoke techniques adapted to these specific challenges in both acquisition and processing. Fetal diffusion MRI, an emerging research tool, is now adding valuable novel information for both research and clinical questions. This paper will highlight specific challenges, outline strategies to target them, and discuss two main applications: fetal brain connectomics and placental maturation.

Placental MRI and its application to fetal intervention

OBJECTIVE

Magnetic resonance imaging (MRI) of placental invasion has been part of clinical practice for many years. The possibility of being better able to assess placental vascularization and function using MRI has multiple potential applications. This review summarises up-to-date research on placental function using different MRI modalities.

METHOD

We discuss how combinations of these MRI techniques have much to contribute to fetal conditions amenable for therapy such as singletons at high risk for fetal growth restriction (FGR) and monochorionic twin pregnancies for planning surgery and counselling for selective growth restriction and transfusion conditions.

RESULTS

The whole placenta can easily be visualized on MRI, with a clear boundary against the amniotic fluid, and a less clear placental-uterine boundary. Contrasts such as diffusion weighted imaging, relaxometry, blood oxygenation level dependent MRI and flow and metabolite measurement by dynamic contrast enhanced MRI, arterial spin labeling, or spectroscopic techniques are contributing to our wider understanding of placental function.

CONCLUSION

The future of placental MRI is exciting, with the increasing availability of multiple contrasts and new models that will boost the capability of MRI to measure oxygen saturation and placental exchange, enabling examination of placental function in complicated pregnancies.

Improved fetal blood oxygenation and placental estimated measurements of diffusion-weighted MRI using data-driven Bayesian modeling

PURPOSE

Motion correction in placental DW-MRI is challenging due to maternal breathing motion, maternal movements, and rapid intensity changes. Parameter estimates are usually obtained using least-squares methods for voxel-wise fitting; however, they typically give noisy estimates due to low signal-to-noise ratio. We introduce a model-driven registration (MDR) technique which incorporates a placenta-specific signal model into the registration process, and we present a Bayesian approach for Diffusion-rElaxation Combined Imaging for Detailed placental Evaluation model to obtain individual and population trends in estimated parameters.

METHODS

MDR exploits the fact that a placenta signal model is available and thus we incorporate it into the registration to generate a series of target images. The proposed registration method is compared to a pre-existing method used for DCE-MRI data making use of principal components analysis. The Bayesian shrinkage prior (BSP) method has no user-defined parameters and therefore measures of parameter variation in a region of interest are determined by the data alone. The MDR method and the Bayesian approach were evaluated on 10 control 4D DW-MRI singleton placental data.

RESULTS

MDR method improves the alignment of placenta data compared to the pre-existing method. It also shows a further reduction of the residual error between the data and the fit. BSP approach showed higher precision leading to more clearly apparent spatial features in the parameter maps. Placental fetal oxygen saturation (FO₂ ) showed a negative linear correlation with gestational age.

CONCLUSIONS

The proposed pipeline provides a robust framework for registering DW-MRI data and analyzing longitudinal changes of placental function.

Perfusion and apparent oxygenation in the human placenta (PERFOX)

PURPOSE

To study placental function-both perfusion and an oxygenation surrogate ( T 2 * )-simultaneously and quantitatively in-vivo.

METHODS

Fifteen pregnant women were scanned on a 3T MR scanner. For perfusion measurements, a velocity selective arterial spin labeling preparation module was placed before a multi-echo gradient echo EPI readout to integrate T 2 * and perfusion measurements in 1 joint perfusion-oxygenation (PERFOX) acquisition. Joint motion correction and quantification were performed to evaluate changes in T 2 * and perfusion over GA.

RESULTS

The optimized integrated PERFOX protocol and post-processing allowed successful visualization and quantification of perfusion and T 2 * in all subjects. Areas of high T 2 * and high perfusion appear to correspond to placental sub-units and show a systematic offset in location along the maternal-fetal axis. The areas of highest perfusion are consistently closer to the maternal basal plate and the areas of highest T 2 * closer to the fetal chorionic plate. Quantitative results show a strong negative correlation of gestational age with T 2 * and weak negative correlation with perfusion.

CONCLUSIONS

A strength of the joint sequence is that it provides truly simultaneous and co-registered estimates of local T 2 * and perfusion, however, to achieve this, the time per slice is prolonged compared to a perfusion only scan which can potentially limit coverage. The achieved interlocking can be particularly useful when quantifying transient physiological effects such as uterine contractions. PERFOX opens a new avenue to elucidate the relationship between maternal supply and oxygen uptake, both of which are central to placental function and dysfunction.

The effect of maternal hyperoxygenation on placental perfusion in normal and Fetal Growth Restricted pregnancies using Intravoxel Incoherent Motion

PURPOSE

To evaluate the effect of maternal hyperoxygenation on placental perfusion in normal and Fetal Growth Restricted (FGR) pregnancies using Intravoxel Incoherent Motion (IVIM).

METHODS

Ten FGR pregnancies and twenty-five normal pregnancies underwent IVIM examinations before and after maternal hyperoxygenation (95% O₂, 5% CO₂) using a 1.5T MR scanner. The IVIM parameters (f_p, D_t, D_p) were determined for the placentas of both groups. The IVIM parameters within and between groups and their correlations with Doppler findings were statistically analyzed. ROC analysis was performed to evaluate the diagnostic power of IVIM derived parameters.

RESULTS

Before maternal hyperoxygenation, the perfusion fraction f_p was significantly lower in the FGR group than that in the normal group (22.88±10.29 (%) vs. 36.28±9.70 (%), p = 0.000). After maternal hyperoxygenation, f_p decreased significantly in the normal group (36.28±9.70 (%) vs. 29.93±10.25 (%), p = 0.032), whereas it remained relatively stable in the FGR group (22.88±10.29 (%) vs. 24.38±13.67 (%), p = 0.508). An increase of D_t was found only for the normal group and D_p did not changed significantly after maternal hyperoxygenation. There existed a negative correlation between f_ppre and umbilical artery pulsatility index (PI) (r = -0.385, p < 0.05) as well as D_tpost and PI (r = -0.574, p < 0.01). The f_ppre displayed a best diagnostic power of all parameters with the area under curve (AUC) of 0.912.

CONCLUSION

The perfusion fraction, f_p, is able to distinguish FGR from normal pregnancies by its value pre and by its change (or lack thereof) post maternal hyperoxygenation. IVIM may potentially help improve the diagnosis of placenta function as it relates to disease.