Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-76fb5796d-wq484 Total loading time: 0 Render date: 2024-04-27T04:49:12.363Z Has data issue: false hasContentIssue false

Chapter 18 - Fetal Cardiac Function in Fetal Growth Restriction

from Section 5 - Characteristics of Fetal Growth Restriction

Published online by Cambridge University Press:  23 July 2018

Christoph Lees ,
Gerard H. A. Visser  and
Kurt Hecher
By
Fàtima Crispi  and
Eduard Gratacós
Christoph Lees
Affiliation:
Imperial College London
Gerard H. A. Visser
Affiliation:
Universiteit Utrecht, The Netherlands
Kurt Hecher
Affiliation:
University Medical Centre, Hamburg
Get access

Summary

A summary is not available for this content so a preview has been provided. Please use the Get access link above for information on how to access this content.
Image of the first page of this content. For PDF version, please use the ‘Save PDF’ preceeding this image.'
Type
Chapter
Information
Placental-Fetal Growth Restriction , pp. 164 - 177
Publisher: Cambridge University Press
Print publication year: 2018

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Barker, DJ, Osmond, C, Golding, J, Kuh, D, Wadsworth, ME. Growth in utero, blood pressure in childhood and adult life, and mortality from cardiovascular disease. BMJ 1989 Mar 4;298(6673):564–7.CrossRefGoogle ScholarPubMed
Tintu, A, Rouwet, E, Verlohren, S, Brinkmann, J, Ahmad, S, Crispi, F, Van Bilsen, M, Carmeliet, P, Staff, AC, Tjwa, M, Cetin, I, Gratacós, E, Hernandez-Andrade, E, Hofstra, L, Jacobs, M, Lamers, WH, Morano, I, Safak, E, Ahmed, A, le Noble, F. Hypoxia induces dilated cardiomyopathy in the chick embryo: Mechanism, intervention, and long-term consequences. PLoS One 2009;4:e5155.Google Scholar
Gluckman, PD. Developmental origins of disease paradigm: A mechanistic and evolutionary perspective. Pediatr Res 2004;56:311–17.Google Scholar
Palinski, W, Napoli, C. Impaired fetal growth, cardiovascular disease, and the need to move on. Circulation 2008;117:341–3.CrossRefGoogle ScholarPubMed
Phillips, D. Insulin resistance as a programmed response to fetal undernutrition. Diabetologia 1996;39:1119–22.Google Scholar
Gluckman, PD, Hanson, MA, Cooper, C, Thornburg, KL. Effect of in utero and early-life conditions on adult health. N Engl J Med 2008;359:61–73.CrossRefGoogle ScholarPubMed
Committee on Practice Bulletins Gynecology, American College of Obstetricians and Gynecologists. Intrauterine growth restriction. Clinical management guidelines for obstetrician-gynecologists. Int J Gynecol Obstet 2001;72:85–96.CrossRefGoogle Scholar
Figueras, F, Gratacós, E. Update on the diagnosis and classification of fetal growth restriction and proposal of a stage-based management protocol. Fetal Diagn Ther 2014;36:86–98.CrossRefGoogle ScholarPubMed
Alberry, M, Soothill, P. Management of fetal growth restriction. Arch Dis Child Fetal Neonatal Ed 2007;92:62–7.CrossRefGoogle ScholarPubMed
Baschat, AA, Cosmi, E, Bilardo, CM, Wolf, H, Berg, C, Rigano, S, Germer, U, Moyano, D, Turan, S, Hartung Jm Bhide, A, Muller, T, Bower, S, Nicolaides, KH, Thilaganathan, B, Gembruch, U, Ferrazzi, E, Hecher, K, Galan, H, Harman, CR. Predictors of neonatal outcome in early-onset placental dysfunction. Obstet Gynecol 2007;109:253–61.CrossRefGoogle ScholarPubMed
Crispi, F, Gratacós, E. Fetal cardiac function: Technical considerations and potential research and clinical applications. Fetal Diagn Ther 2012;32(1–2):47–64.Google Scholar
Crispi, F, Hernandez-Andrade, E, Pelsers, MM, Plasencia, W, Benavides-Serralde, JA, Eixarch, E, et al. Cardiac dysfunction and cell damage across clinical stages of severity in growth-restricted fetuses. Am J Obstet Gynecol 2008 Sep;199(3):254 e1–8.Google Scholar
Comas, M, Crispi, F, Cruz-Martinez, R, Martinez, JM, Figueras, F, Gratacós, E. Usefulness of myocardial tissue Doppler vs conventional echocardiography in the evaluation of cardiac dysfunction in early-onset intrauterine growth restriction. Am J Obstet Gynecol 2010;203:45.e1–45.e7.Google Scholar
Cruz-Lemini, M Crispi, F, Valenzuela-Alcaraz, B, Figueras, F, Gómez, O, Sitges, M, Bijnens, B, Gratacós, E. A fetal cardiovascular score to predict infant hypertension and arterial remodeling in intrauterine growth restriction. Am J Obstet Gynecol 2014 Jun;210(6):552.e1–552.e22.CrossRefGoogle ScholarPubMed
Crispi, F, Bijnens, B, Figueras, F, Bartrons, J, Eixarch, E, Le Noble, F, Ahmed, A, Gratacós, E. Fetal growth restriction results in remodeled and less efficient hearts in children. Circulation 2010 Jun 8;121(22):2427–36.CrossRefGoogle ScholarPubMed
Demicheva, E, Crispi, F. Long-term follow-up of intrauterine growth restriction: Cardiovascular disorders. Fetal Diagn Ther 2014;36(2):143–53.CrossRefGoogle ScholarPubMed
Baschat, AA. Neurodevelopment following fetal growth restriction and its relationship with antepartum parameters of placental dysfunction. Ultrasound Obstet Gynecol 2011;37:501–14.CrossRefGoogle ScholarPubMed
Crispi, F, Figueras, F, Cruz-Lemini, M, Bartrons, J, Bijnens, B, Gratacos, E. Cardiovascular programming in children born small for gestational age and relationship with prenatal signs of severity. Am J Obstet Gynecol 2012;207:121.e1–e9.Google Scholar
Parra-Saavedra, M, Crovetto, F, Triunfo, S, Savchev, S, Peguero, A, Nadal, A, Parra, G, Gratacos, E, Figueras, F. Placental findings in late-onset SGA births without Doppler signs of placental insufficiency. Placenta 2013 Dec;34(12):1136–41.Google Scholar
Guyton, AC. HJ. Textbook of Medical Physiology. 12 edn. Philadelphia, PA: Elsevier Saunder 2011.Google Scholar
Bijnens, B, Cikes, M, Butakoff, C, Sitges, M, Crispi, F. Myocardial motion and deformation: What does it tell us and how does it relate to function? Fetal Diagn Ther 2012;32(1–2):5–16.CrossRefGoogle ScholarPubMed
Bijnens, BH, Cikes, M, Claus, P, Sutherland, GR. Velocity and deformation imaging for the assessment of myocardial dysfunction. Eur J Echocardiogr 2009 Mar;10(2):216–26.Google ScholarPubMed
Huhta, JC. Guidelines for the evaluation of heart failure in the fetus with or without hydrops. Pediatr Cardiol 2004 May–Jun;25(3):274–86.CrossRefGoogle ScholarPubMed
Rychik, J, Tian, Z, Bebbington, M, Xu, F, McCann, M, Mann, S, et al. The twin-twin transfusion syndrome: Spectrum of cardiovascular abnormality and development of a cardiovascular score to assess severity of disease. Am J Obstet Gynecol 2007 Oct;197(4):392 e1–8.CrossRefGoogle ScholarPubMed
Opie, LH, Commerford, PJ, Gersh, BJ, MA. P. Controversies in ventricular remodelling. Lancet 2006;367:356–67.Google Scholar
Jessup, M AW, Casey, DE, Feldman, AM, Francis, GS, Ganiats, TG, Konstam, MA, Mancini, DM, Rahko, PS, Silver, MA, Stevenson, LW, Yancy, CW. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: Developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009;14(119):1977–2016.Google Scholar
Kiserud, T, Acharya, G. The fetal circulation. Prenat Diagn 2004 Dec 30;24(13):1049–59.CrossRefGoogle ScholarPubMed
Comas, M, Crispi, F. Assessment of fetal cardiac function using tissue Doppler techniques. Fetal Diagn Ther 2012;32(1–2):30–8.Google Scholar
Germanakis, I, Gardiner, H. Assessment of fetal myocardial deformation using speckle tracking techniques. Fetal Diagn Ther 2012;32(1–2):39–46.CrossRefGoogle ScholarPubMed
Godfrey, ME, Messing, B, Valsky, DV, Cohen, SM, Yagel, S. Fetal cardiac function: M-mode and 4D spatiotemporal image correlation. Fetal Diagn Ther 2012;32(1–2):17–21.Google Scholar
Hernandez-Andrade, E, Benavides-Serralde, JA, Cruz-Martinez, R, Welsh, A, Mancilla-Ramirez, J. Evaluation of conventional Doppler fetal cardiac function parameters: E/A ratios, outflow tracts, and myocardial performance index. Fetal Diagn Ther 2012;32(1–2):22–9.Google Scholar
Lee, W, Allan, L, Carvalho, JS, Chaoui, R, Copel, J, Devore, G, Hecher, K, Munoz, H, Nelson, T, Paladini, D, Yagel, S. ISUOG consensus statement: What constitutes a fetal echocardiogram? Ultrasound Obstet Gynecol 2008;32:239–42.Google Scholar
Kasper, DL, Braunwald, E, Fauci, A, et al: Harrison’s Principles of Internal Medicine. 16 edn. New York: McGraw-Hill, 2005, p. 1346.Google Scholar
Timmerman, E, Clur, SA, Pajkrt, E, Bilardo, CM. First-trimester measurement of the ductus venosus pulsatility index and the prediction of congenital heart defects. Ultrasound Obstet Gynecol 2010;36:668–75.Google ScholarPubMed
Cruz-Martinez, R, Figueras, F, Bennasar, M, Garcia-Posadas, R, Crispi, F, Hernandez-Andrade, E, et al. Normal reference ranges from 11 to 41 weeks’ gestation of fetal left modified myocardial performance index by conventional Doppler with the use of stringent criteria for delimitation of the time periods. Fetal Diagn Ther 2011:32(1–2):79–86.Google Scholar
Tei, C, Nishimura, RA, Seward, JB, Tajik, AJ. Noninvasive Doppler-derived myocardial performance index: Correlation with simultaneous measurements of cardiac catheterization measurements. J Am Soc Echocardiogr 1997;10:169–78.CrossRefGoogle ScholarPubMed
Yagel, S, Silverman, NH, Gembruch, U: Fetal Cardiology: Embryology, Genetics, Physiology, Echocardiographic Evaluation, Diagnosis and Perinatal Management of Cardiac Diseases. 2 edn. New York: Informa Healthcare USA, 2009.Google Scholar
Gardiner, HM, Pasquini, L, Wolfenden, J, Barlow, A, Li, W, Kulinskaya, E, et al. Myocardial tissue Doppler and long axis function in the fetal heart. Int J Cardiol 2006 Oct 26;113(1):39–47.Google Scholar
Carvalho, JS, O’Sullivan, C, Shinebourne, EA, Henein, MY. Right and left ventricular long-axis function in the fetus using angular M-mode. Ultrasound Obstet Gynecol 2001 Dec;18(6):619–22.Google Scholar
Trambaiolo, P, Tonti, G, Salustri, A, Fedele, F, Sutherland, G. New insights into regional systolic and diastolic left ventricular function with tissue Doppler echocardiography: From qualitative analysis to a quantitative approach. J Am Soc Echocardiogr 2001 Feb;14(2):85–96.Google Scholar
Yu, CM, Sanderson, JE, Marwick, TH, Oh, JK. Tissue Doppler imaging: A new prognosticator for cardiovascular diseases. J Am Coll Cardiol 2007 May 15;49(19):1903–14.CrossRefGoogle ScholarPubMed
Crispi, F, Sepulveda-Swatson, E, Cruz-Lemini, M, Rojas-Benavente, J, Garcia-Posada, R, Dominguez, JM, et al. Feasibility and reproducibility of a standard protocol for 2D speckle tracking and tissue Doppler-based strain and strain rate analysis of the fetal heart. Fetal Diagn Ther 2012;32(1–2):96–108.CrossRefGoogle ScholarPubMed
Van Mieghem, T, DeKoninck, P, Steenhaut, P, Deprest, J. Methods for prenatal assessment of fetal cardiac function. Prenat Diagn 2009;29:1193–203.CrossRefGoogle ScholarPubMed
Hecher, K, Campbell, S, Doyle, P, Harrington, K, Nicolaides, K. Assessment of fetal compromise by Doppler ultrasound investigation of the fetal circulation: Arterial, intracardiac, and venous blood flow velocity studies. Circulation 1995;91:129–38.Google Scholar
Cruz-Lemini, M, Bijnens, B, Valenzuela-Alcaraz, B, Sitges, M, Figueras, F, Crispi, F, Gratacós, E. Cardiac remodeling in utero in early- and late-onset intrauterine growth restriction. Ultrasound Obstet Gynecol 2012:40 (Issue S1):14.Google Scholar
Cruz-Lemini, M, Crispi, F, Valenzuela-Alcaraz, B, Figueras, F, Sitges, M, Gomez, O, et al. Value of annular M-mode displacement versus tissue Doppler velocities to assess cardiac function in intrauterine growth restriction. Ultrasound Obstet Gynecol 2013 Aug;42(2):175–81.Google Scholar
Bilardo, CM, Wolf, H, Stigter, RH, Ville, Y, Baez, E, Visser, CHA, Hecher, K. Relationship between monitoring parameters and perinatal outcome in severe, early intrauterine growth restriction. Ultrasound Obstet Gynecol 2004;23:119–25.CrossRefGoogle ScholarPubMed
Makikallio, K, Vuolteenaho, O, Jouppila, P, Rasanen, J. Ultrasonographic and biochemical markers of human fetal cardiac dysfunction in placental insufficiency. Circulation 2002;105:2058–63.CrossRefGoogle ScholarPubMed
Niewiadomska-Jarosik, K, Lipecka-Kidawska, E, Kowalska-Koprek, U, et al. Assessment of cardiac function in fetuses with intrauterine growth retardation using the Tei index. Med Wieku Rozwoj 2005;9:153–60.Google Scholar
Larsen, LU, Petersen, OB, Sloth, E, Uldbjerg, N. Color Doppler myocardial imaging demonstrates reduced diastolic tissue velocity in growth retarded fetuses with flow redistribution. Eur J Obstet Gynecol Reprod Biol 2011 Apr;155(2):140–5.CrossRefGoogle ScholarPubMed
Crispi, F, Bijnens, B, Sepulveda-Swatson, E, Cruz-Lemini, M, Rojas-Benavente, J, Gonzalez-Tendero, A, Garcia-Posada, R, Rodriguez-Lopez, M, Demicheva, E, Sitges, M, Gratacós, E. Postsystolic shortening by myocardial deformation imaging as a sign of cardiac adaptation to pressure overload in fetal growth restriction. Circ Cardiovasc Imaging 2014 Sep;7(5):781–7.CrossRefGoogle ScholarPubMed
Comas, M, Crispi, F, Cruz-Martinez, R, Figueras, F, Gratacos, E. Tissue Doppler echocardiographic markers of cardiac dysfunction in small-for-gestational age fetuses. Am J Obstet Gynecol 2011 Jul;205(1):57.e1–6.CrossRefGoogle ScholarPubMed
Cruz-Martinez, R, Figueras, F, Hernandez-Andrade, E, Oros, D, Gratacos, E. Changes in myocardial performance index and aortic isthmus and ductus venosus Doppler in term, small-for-gestational age fetuses with normal umbilical artery pulsatility index. Ultrasound Obstet Gynecol 2011;38(4):400–5.Google Scholar
Pérez-Cruz, M, Crispi, F, Fernández, M, Parra, J, Gómez Roig, M, Gratacós, E. Fetal cardiac function in late IUGR versus SGA defined by estimated fetal weight, cerebro-placental ratio and uterine artery Doppler. Ultrasound Obstet Gynecol 2014:44 (Issue S1): 19.Google Scholar
Chaiworapongsa, T, Espinoza, J, Yoshimatsu, J, et al. Subclinical myocardial injury in small-for-gestational-age neonates. J Matern Fetal Neonatal Med 2002;11:385–90.CrossRefGoogle ScholarPubMed
Crispi, F, Gonzalez-Tendero, A, Zhang, C, Balicevic, V, Cardenas, R, Loncaric, S, Bonnin, A, Gratacós, E, Bijnens, B. Cardiac fiber orientation and coronary changes in a rabbit model of IUGR using X-ray phase-contrast synchrotron radiation-based micro-CT. Ultrasound Obstet Gynecol 2014; 44 (Issue S1): 133.Google Scholar
Gonzalez-Tendero, A, Torre, I, Garcia-Canadilla, P, Crispi, F, García-García, F, Dopazo, J, Bijnens, B, Gratacós, E. Intrauterine growth restriction is associated with cardiac ultrastructural and gene expression changes related to the energetic metabolism in a rabbit model. Am J Physiol Heart Circ Physiol 2013 Dec;305(12):H1752–60.CrossRefGoogle Scholar
Iruretagoyena, JY, Torre, I, Amat-Roldan, I, Psilodimitrakopoulos, S, Crispi, F, Garcia-Canadilla, P, Gonzalez-Tendero, A, Nadal, A, Eixarch, E, Loza-Alvarez, P, Artigas, D, Gratacos, E. Ultrastructural analysis of myocardiocyte sarcomeric changes in relation with cardiac dysfunction in human fetuses with intrauterine growth restriction. Am J Obstet Gynecol 2011;204:S34.Google Scholar
Skilton, MK, Evans, N, Griffiths, KA, Harmer, JA, Celermajer, D. Aortic wall thickness in newborns with intrauterine restriction. Lancet 2005;23:1484–6.Google Scholar
Stergiotou, I, Crispi, F, Valenzuela-Alcaraz, B, Cruz-Lemini, M, Bijnens, B, Gratacos, E. Aortic and carotid intima-media thickness in term small-for-gestational-age newborns and relationship with prenatal signs of severity. Ultrasound Obstet Gynecol 2014 Jun;43(6):625–31.Google Scholar
Cosmi, E, Visentin, S, Fanelli, T, Mautone, AJ, Zanardo, V. Aortic intima media thickness in fetuses and children with intrauterine growth restriction. Obstet Gynecol 2009 Nov;114(5):1109–14.CrossRefGoogle ScholarPubMed
Martin, H, Hu, J, Gennser, G, Norman, M. Impaired endothelial function and increased carotid stiffness in 9-year-old children with low birthweight. Circulation 2000;102:2739–44.CrossRefGoogle ScholarPubMed
Bjarnegård, N, Morsing, E, Cinthio, M, Länne, T, Brodszki, J. Cardiovascular function in adulthood following intrauterine growth restriction with abnormal fetal blood flow. Ultrasound Obstet Gynecol 2013 Feb;41(2):177–84.Google Scholar
Berenson, GS. Childhood risk factors predict adult risk associated with subclinical cardiovascular disease. The Bogalusa Heart Study. Am J Cardiol 2002;90:3L–7L.Google Scholar
Girsen, A, Ala-Kopsala, M, Makikallio, K, Vuolteenaho, O, Rasanen, J. Cardiovascular hemodynamics and umbilical artery N-terminal peptide of proB-type natriuretic peptide in human fetuses with growth restriction. Ultrasound Obstet Gynecol 2007;29:296–303.Google Scholar
Baschat, AA. Ductus venosus Doppler for fetal surveillance in high-risk pregnancies. Clin Obstet Gynecol 2010 Dec;53(4):858–68.Google Scholar
Cruz-Lemini, M, Crispi, F, Van Mieghem, T, Pedraza, D, Cruz-Martinez, R, Acosta-Rojas, R, et al. Risk of perinatal death in early-onset intrauterine growth restriction according to gestational age and cardiovascular Doppler indices: A multicenter study. Fetal Diagn Ther 2012;32(1–2):116–22.CrossRefGoogle ScholarPubMed
Hernandez-Andrade, E, Crispi, F, Benavides-Serralde, JA, Plasencia, W, Diesel, HF, Eixarch, E, Acosta-Rojas, R, Figueras, F, Nicolaides, K, Gratacós, E. Contribution of the myocardial performance index and aortic isthmus blood flow index to predicting mortality in preterm growth-restricted fetuses. Ultrasound Obstet Gynecol 2009 Oct;34(4):430–6.Google Scholar
Williams, CL, Hayman, LL, Daniels, SR, Robinson, TN, Steinberger, J, Paridon, S, Bazzarre, T. Cardiovascular health in childhood: A statement for health professionals from the Committee on Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of the Council on Cardiovascular Disease in the Young, American Heart Association. Circulation 2002;106:143–60.Google Scholar
Skilton, MR, Mikkilä, V, Würtz, P, Ala-Korpela, M, Sim, KA, Soininen, P, Kangas, AJ, Viikari, JS, Juonala, M, Laitinen, T, Lehtimäki, T, Taittonen, L, Kähönen, M, Celermajer, DS, Raitakari, OT. Fetal growth, omega-3 (ω-3) fatty acids, and progression of subclinical atherosclerosis: preventing fetal origins of disease? The Cardiovascular Risk in Young Finns Study. Am J Clin Nutr 2013;97:58–65.CrossRefGoogle ScholarPubMed
Skilton, MR, Ayer, JG, Harmer, JA, Webb, K, Leeder, SR, Marks, GB, Celermajer, DS. Impaired fetal growth and arterial wall thickening. A randomized trial of omega-3 supplementation. Pediatrics 2012;129:e698.Google Scholar
Rodriguez-Lopez, M, Osorio, L, Acosta, R, Cruz-Lemini, M, Figueras, J, Figueras, F, Gratacós, E, Crispi, F. Effect of postnatal diet on reverting cardiovascular remodelling in intrauterine growth restriction. Ultrasound Obstet Gynecol 2014; 44 (Issue S1): 120.Google Scholar
Mancia, G, Fagard, R, Narkiewicz, K, Redón, J, Zanchetti, A, Böhm, M, Christiaens, T, Cifkova, R, De Backer, G, Dominiczak, A, Galderisi, M, Grobbee, DE, Jaarsma, T, Kirchhof, P, Kjeldsen, SE, Laurent, S, Manolis, AJ, Nilsson, PM, Ruilope, LM, Schmieder, RE, Sirnes, PA, Sleight, P, Viigimaa, M, Waeber, B, Zannad, F; Task Force Members. 2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013;31:1281–357.Google Scholar
Kavey, RE, Allada, V, Daniels, SR, Hayman, LL, McCrindle, BW, Newburger, JW, Parekh, RS, Steinberger, J. Cardiovascular risk reduction in high-risk pediatric patients: A scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: Endorsed by the American Academy of Pediatrics. Circulation 2006;114:2710–38.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×