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vitamin D. Specifically, they can alter the corresponding abnormal epigenetic modification status and
[49]
improve the adverse programming effects caused by prenatal stress . Advantageous effects have been
obtained by modifying the diet and physical exercise, and performing interventions on the gut microbiome,
as abovementioned. Furthermore, it has estimated, across gestation, that genetic and environmental
[50]
influences vary during the various sensitive periods of pregnancy . Accordingly, environmental factors
have stronger influence on fetal growth at early end of first trimester, but are overtaken by genetic influences
in late gestation. In addition, the fetal growth can be used as an optimal tool for measuring and estimating
the effects.

Meticulous studies are indispensable to improve our knowledge in this field and the development of
appropriate treatments, such as prenatal or postnatal supplementations. This might facilitate the reduction
of the incidence and prevalence of this disease in new generations. Currently, such preventive measures
are limited. However, it is well established until now that some surgical treatments, including both balloon
pulmonary angioplasty (BPA) and pulmonary endarterectomy (PEA), can improve long-term survival,
clinical status and hemodynamics in patients affected by this pathology. BPA is preferentially used for
inoperable chronic thromboembolic pulmonary hypertension (CTEPH) or residual PH after PEA. PEA is,
indeed, performed for operable CTEPH. Recent systematic reviews suggest their efficacy and safety [51,52] .

DECLARATIONS
Authors’ contributions
The author contributed solely to the article.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
The author declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2018.

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