Currently, epidemiological and experimental data indicate that exposures during prenatal and perinatal life may have lifelong consequences for the risk of developing obesity and metabolic and cardiovascular diseases. In this context, observations of the offspring of mothers with gestational diabetes as well as studies of children with low birth weight were most influential. This paper illustrates the current knowledge about perinatal programming of obesity and associated diseases and discusses possible etiopathogenic mechanisms, focussing on epidemiological and animal studies of the consequences of exposure to maternal diabetes and pre-/neonatal undernutrition. The resultant far-reaching potential for primary prevention of chronic diseases as well as the paradigmatic character of these hypotheses and observations for the general understanding of health and disease are highlighted.
'Fetal programming' describes the association of alterations of the intrauterine fetal environment and the subsequent development of cardiovascular, metabolic and endocrine disorders in adult life. It is now commonly accepted that beside these so-called lifestyle disorders hypertensive disorders in pregnancy have also an intrauterine determination. It is commonly agreed that women born with low birth weight do have an elevated risk for the development of hyper-tensive pregnancy disorders, which is pronounced especially in those women born with low birth weight, who become obese in later life. Until now the exact pathophysiological mechanisms remain elusive: beside placental mechanisms intrauterine alterations in kidney development and insulin resistance seem to be major key factors. The pathophysiological similarities and risks of hypertensive pregnancy disorders (especially preeclampsia) and these 'lifestyle disorders' - both are also considered to be mutual risk factors for the development of the other disorder - suggest the possibility of a general impairment of the maternal cardiovascular system by intrauterine factors.
Multiples run various risks. While for triplets and higher-grade multiples caesarean section is the first-line mode of delivery, the method is still under discussion in the case of twins. Evidence-based data in favour of a general elective caesarean section are lacking but prospective randomized study results on this subject are expected. The organization of the clinic is essential for the safety of twins during vaginal delivery. The prerequisites for the vaginal delivery of twins and its management under various conditions are discussed in light of the literature.
A close surveillance of fetal growth in multiple pregnancies is mandatory for the prevention and/or reduction of neonatal morbidity and mortality. Multiples have the same genetically determined growth potential as singletons. However, this growth potential is restricted by the functional capacity of the placenta and uterus. Multiples show a specific growth pattern compared to singletons. Nevertheless, for clinical surveillance, the 10th percentile of singleton growth charts may be used, because significant differences, which may define normally grown multiples as small for gestational age or growth restricted, can only be detected at higher gestational ages, when most of the multiples may have already been delivered. At higher gestational ages, obstetricians should take into account the specific growth pattern for multiples. In multiples with growth discordance, it is necessary to consider or exclude the various causes, and if necessary the clinical follow-up has to be intensified.
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