*4.1. Participants*

The study included prospectively collected cohort of Caucasian children born within 2007–2014 descending from pregnancies with GH (*n* = 54), PE (*n* = 133), FGR (*n* = 34), and children after normal course of gestation (*n* = 88) that were chosen on the basis of equal age. An in-person visit was conducted 3–11 years after the pregnancy ended. Of the 133 PE pregnancies, 27 were diagnosed with mild PE and 106 had symptoms of severe PE. In 49 PE pregnancies gestation was terminated before 34 weeks (early PE) and 84 children were delivered after 34 weeks (late PE). PE occurred mainly in normotensive patients (128 cases), or exceptionally was superimposed on prior hypertension (5 cases). Thirteen FGR fetuses required delivery <32 weeks (early FGR) and 21 cases were delivered >32 weeks (late FGR). Oligohydramnios and/or anhydramnios were present in 20 FGR fetuses and 19 PE cases.

Arterial Doppler examination showed an abnormal pulsatility index (PI) in the umbilical artery (PI > 95th percentile) in 9 PE and 20 FGR cases and in the middle cerebral artery (PI < 5th percentile) in 7 PE and 8 FGR cases. The cerebro-placental ratio (CPR) was 5th percentile in 15 PE and 21 FGR cases. The umbilical artery Doppler showed absent and/or zero diastolic flow in 2 PE and 4 FGR cases. The mean PI in the uterine artery >95th percentile was identified in 10 PE and 7 FGR pregnancies with the presence of unilateral or bilateral diastolic notch in 12 PE and 6 FGR cases. Ductus venosus examination revealed an absence of flow during atrial contraction (a wave) (deep a wave) in 1 FGR pregnancy. In addition, abnormal PI of ductus venosus (>1) was detected in 3 PE and/or FGR pregnancies.

The clinical characteristics of children descending from normal and complicated pregnancies are presented in Table 3.

Normal pregnancies were defined as those without medical, obstetrical, or surgical complications at the time of the study and who subsequently delivered full term, singleton healthy infants weighing >2500 g after 37 completed weeks of gestation.

Gestational hypertension usually develops after 20 weeks of gestation and is defined as high blood pressure (>140/90 mmHg) without the sign of proteinuria. On the other hand, preeclampsia is characterized as hypertension (blood pressure > 140/90 mmHg in two determinations 4 h apart) associated with proteinuria (>300 mg/24 h) that appears after the twentieth week of gestation [129].

Severe preeclampsia is defined by the presence of one or more of the following findings: 1) a systolic blood pressure over 160 mmHg or a diastolic blood pressure over 110 mmHg, 2) proteinuria (>5 g of protein in a 24-h sample), 3) very low urine output (<500 mL in 24 h), 4) signs of pulmonary oedema or cyanosis, 5) impairment of liver function, 6) signs of severe headache, visual disturbances, 7) pain in the epigastric area or right upper quadrant, 8) thrombocytopenia, and 9) the presence of severe FGR [129].

FGR fetuses are defined as those with the estimated fetal weight (EFW) < 3rd percentile or <10th percentile for the evaluated gestational age after the adjustments for the appropriate population standards of the Czech Republic (the Hadlock formula, Astraia Software GmbH). Early onset FGR was diagnosed when the EFW was less than the third percentile or absent and/or zero diastolic flow was present in the umbilical artery. In addition, early onset FGR was classified when fetal weight below the threshold of the 10th percentile was associated with an abnormal pulsatility index in the umbilical artery (>95th percentile) or an abnormal pulsatility index in the uterine artery (>95th percentile). Late onset FGR was determined by only one parameter (EWF below the third percentile) or by the combination of 2 parameters: EFW below the tenth percentile and the cerebro–placental ratio (CPR) below the fifth percentile. CPR is expressed as a ratio between the middle cerebral artery and the umbilical artery pulsatility indexes [130–132].


**Table 3.** Characteristics of cases and controls.



The presence of absent and/or zero end-diastolic flow (AEDF) in the umbilical artery in mid to late pregnancy usually occurs as a result of placental insufficiency. Increased resistance (the mean PI > 95th percentile) in the uterine artery with or without the presence of unilateral or bilateral diastolic notch identifies pregnancies with a risk of placental failure. Centralization of the fetal circulation manifests itself in redistribution of the circulation in the brain, liver and heart at the expense of the flow reduction in the periphery and represents a protective reaction of the fetus against hypoxia [133,134]. Absence or reversal of flow during atrial contraction (a wave) (deep a wave in the ductus venosus) indicates failure of fetal circulatory compensation to supply well oxygenated blood to vital organ. The pulsatility index of DV more than 1 between the second trimester and term indicates of DV dilatation and poor outcome in severe fetal growth retardation.

Patients demonstrating other pregnancy-related complications such as premature rupture of membranes, in utero infections, fetal anomalies or chromosomal abnormalities, and fetal demise in utero or stillbirth were not involved in the study.

Written informed consent was provided for all participants included in the study. The study was approved by the Ethics Committee of the Institute for the Care of the Mother and Child, Prague, Czech Republic (grant no. AZV 16-27761A, Long-term monitoring of complex cardiovascular profile in the mother, fetus and offspring descending from pregnancy-related complications, date of approval: 28 May 2015) and by the Ethics Committee of the Third Faculty of Medicine, Prague, Czech Republic (grant no. AZV 16-27761A, Long-term monitoring of complex cardiovascular profile in the mother, fetus and offspring descending from pregnancy-related complications, date of approval: 27 March 2014).
