Successful magnesium sulfate tocolysis: is "weaning" the drug necessary?

OBJECTIVE

Magnesium sulfate is the most commonly used tocolytic agent for preterm labor. A common clinical practice is to slowly discontinue the drug (wean) after successful tocolysis. Our objective was to determine the necessity of this practice.

STUDY DESIGN

A prospective, randomized clinical trial was performed from June 1993 to July 1996. After successful magnesium sulfate tocolysis, patients with preterm labor were randomized to two groups: stopping the drug abruptly (no weaning) or gradually weaning the drug (approximately 1 gm every 4 hours). Preterm labor was defined as documented cervical change with regular uterine contractions or regular uterine contractions with a cervix of 2 cm and 75% effacement. The primary outcome variable was the necessity to reinstitute magnesium sulfate therapy within 24 hours of discontinuation of successful tocolysis.

RESULTS

One hundred forty-one patients completed the study. No patient in the no-wean group required retocolysis within 24 hours of magnesium discontinuation. However, eight patients in the wean group required retocolysis within 24 hours of magnesium discontinuation (p = 0.01). Significantly more patients in the wean group had retocolysis during pregnancy (3 vs 12, p = 0.03). Patients in the wean group were also in the labor and delivery unit longer and, as would be anticipated, received magnesium sulfate significantly longer. No differences in the neonatal outcomes were noted between the two groups. Seventy-seven percent of the patients in the study were delivered prematurely.

CONCLUSION

This study demonstrated an increased need for retocolysis in the group weaned from magnesium sulfate. We also found that patients in the wean group had an increased labor and delivery time and a longer administration time of magnesium sulfate. Thus weaning magnesium sulfate increases health care cost. The practice of weaning magnesium sulfate does not appear beneficial.

In vitro metabolism of dexamethasone (DEX) in human liver and kidney: the involvement of CYP3A4 and CYP17 (17,20 LYASE) and molecular modelling studies

Dexamethasone (DEX) has previously been shown to be extensively metabolised to 6-hydroxylated and side-chain cleaved metabolites in human liver in vitro. CYP3A4 is responsible for 6alpha- and 6beta-hydroxylation of DEX and CYP17 is thought to mediate side-chain cleavage to generate 9alphafluoro-androsta-1,4-diene-11beta-hydroxy-16alpha-methyl-3,17-dione (9alphaF-A). Although 9alphaF-A has not previously been isolated as a metabolite in its unhydroxylated form in human liver incubations, it is formed as an intermediate metabolite, which is subsequently rapidly hydroxylated to OH-9alphaF-A. A main part of this study has been to conclusively show that DEX undergoes extensive side-chain cleavage to form 9alphaF-A in human kidney fractions, which is in contrast to profiles obtained for DEX metabolism in parallel human liver microsomal incubations where 6-hydroxylation is the predominant pathway. Furthermore, molecular models of CYP3A4 and CYP17 (17,20 lyase) have been used to model the enzyme fits of DEX. From these modelling studies it has been shown that DEX complements both putative enzyme active sites in orientations likely to lead to the formation of the metabolites identified in vitro. We have also been able to rationalise the preferential formation of the 6betaOH-DEX isomer.

Double coupling Edman chemistry for high-sensitivity automated protein sequencing

Capillary electrophoresis with laser-induced fluorescence detection (CE-LIF) is a promising new method for the analysis of protein sequencing products. It gives 10 zmol (1 zmol = 10(-21) mol) limits of detection (3 sigma) for fluorescein thiohydantoin (FTH) amino acids. We have developed a separation for the (FTH)-amino acid products generated from 18 of the 20 coded amino acids. The extremely low volume requirement associated with CE-LIF makes it incompatible with commercial sequencers. For this reason, we have also been developing a miniaturized sequencer that can be more easily coupled to our detection system. Both the CE-LIF system and the miniaturized sequencer are described.

Molecular modelling of mammalian CYP2B isoforms and their interaction with substrates, inhibitors and redox partners

1. The construction of three-dimensional models of CYP2B isozymes from rat (CYP2B1), rabbit (CYP2B4) and man (CYP2B6), based on a multiple sequence alignment with CYP102, a unique eukaryotic-like bacterial P450 (in terms of possessing an NADPH-dependent FAD- and FMN-containing oxidoreductase redox partner) of known crystal structure, is reported. 2. The enzyme models described are shown to be consistent with experimental evidence from site-directed mutagenesis studies, antibody recognition sites and amino acid residues identified as being associated with redox partner interactions, together with the location of a key serine residue (Ser-128) likely to be involved in protein kinaseA-mediated phosphorylation. 3. A substantial number of known substrates and inhibitors of CYP2B isozymes are shown to fit the putative active sites of the enzyme models in agreement with their reported position of metabolism or mode of inhibition respectively. In particular, there is complementarity between the characteristic non-planar geometries of CYP2B substrates and key groups in the enzymes' active sites. 4. Molecular modelling of CYP2B isozymes appears to rationalize a number of the reported findings from quantitative structure-activity relationship investigations on series of CYP2B substrates and inhibitors.

Molecular modelling of cytochrome P4502D6 (CYP2D6) based on an alignment with CYP102: structural studies on specific CYP2D6 substrate metabolism

1. A molecular model of CYP2D6 has been constructed from the bacterial form CYP102 via a homology alignment between the CYP2D subfamily and CYP102 protein sequences. 2. A number of typical CYP2D6 substrates are shown to fit the putative active site of the enzyme, as can the specific inhibitor quinidine. 3. Some of the allelic variants in CYP2D6, which give rise to genetic polymorphisms in 2D6-mediated metabolism, can be rationalized in terms of their position within the active site region. 4. The results of site-directed mutagenesis experiments are consistent with the CYP2D6 model generated from the CYP102 crystal structure. 5. The possibility of an alternative orientation within the active site may explain the CYP2D6-mediated metabolism of relatively large-sized substrates.

Diaminonaphthalenes and related aminocompounds: mutagenicity, CYP1A induction and interaction with the Ah receptor

Using 1- and 2-aminonaphthalene as model substrates, we investigated the effect of insertion of a second amino group on mutagenicity, binding to the cytosolic Ah receptor and CYP1A inducibility, and the effects were compared to those elicited by 3,3'-diaminobenzidine and 1-naphthylethylenediamine. 1,5- and 1,8-diaminonaphthalene were effective inducers of CYP1A activity, more potent than 1-aminonaphthalene. 2,3-Diaminonaphthalene was also an inducer of CYP1A, but the effect was similar to that elicited by 2-aminonaphthalene. In contrast, 3,3'-diaminobenzidine and 1-naphthylethylenediamine did not induce CYP1A activity. All aminonaphthalenes displaced [3H]TCDD from the Ah receptor, whereas 3,3'-diaminobenzidine and 1-naphthylethylenediamine failed to do so. The latter two compounds did not elicit a mutagenic response in the Ames test. Introduction of a second amino group at the 3-position of 2-aminonaphthalene did not modulate its mutagenicity. In the case of the non-mutagenic 1-aminonaphthalene, introduction of a second amino group at position 5 had no effect but when it was incorporated at position 8, mutagenic potential was conferred to the molecule. Computer modelling of the putative active site of CYP1A2 revealed that 1,5-diaminonaphthalene is orientated so that the distance of the second amino group from the iron-oxene is 4.037 A while in the case of 1,8-diaminonaphthalene the distance is shorter, 2.744 A, favouring its activation through N-hydroxylation. Of the compounds studied, 1,8-diaminonaphthalene and, to a lesser extent, 2,3-diaminonaphthalene autoinduced their activation. It is concluded that insertion of a second amino group at the 5- or 8-position of 1-aminonaphthalene may enhance biological activity but in the case of 2-aminonaphthalene insertion of a second amino group at position 3 had no major effect.

Molecular modelling of CYP2E1 enzymes from rat, mouse and man: an explanation for species differences in butadiene metabolism and potential carcinogenicity, and rationalization of CYP2E substrate specificity

Molecular modelling of substrates of cytochrome P4502E1 (CYP2E1) within the putative active site region of CYP2E1 constructed from the CYP102 crystal structure is reported. Structural characteristics of CYP2E1 substrates, such as molecular size, energy levels and polarity, calculated via molecular orbital procedures provide correlations with toxicity and carcinogenicity; and species differences in CYP2E1-mediated metabolism are rationalized in terms of interactions with putative active site amino acid residues, including Thr-437 and Phe-181. In particular, the activation of buta-1,3-diene can be explained by active site modelling with CYP2E1 enzymes sequenced from rat, mouse and man, where there is a non-conservative change T437H between rodent and human isozymes, together with a conservative change I438V between mouse and rat CYP2E1.

Cytochrome P4501A (CYP1A) induction in rat and man by the benzodioxino derivative, fluparoxan

1. Fluparoxan is an alpha 2-adrenoceptor antagonist that has a relatively planar, tricyclic structure and was considered a potential substrate and inducer of cytochrome P4501A (CYP1A) enzymes. 2. Structure-activity analysis indicated some potential for CYP1A interaction, although its greater log P and molecular depth, compared with many CYP1A inducers, suggested fluparoxan would be a weak ligand for the aryl hydrocarbon (Ah) receptor and only a weak inducer. 3. In vitro, fluparoxan showed little affinity for the CYP1A enzymes. The compound was not metabolized by human CYP1A1 or 1A2 heterologously expressed in yeast and its rate of metabolism in rat and human microsomes was unaffected by the addition of the 1A inhibitor alpha-naphthoflavone. Furthermore, Ki's for fluparoxan against EROD activity were > 4000-fold higher than those of alpha-naphthoflavone. 4. In vivo, however, fluparoxan did show some capacity for CYP1A induction. In rat, hepatic EROD activity increased approximately 40-fold with seven once-daily oral doses of fluparoxan (50 mg/kg, solution), and immunoblotting studies confirmed induction of CYP1A2, though not of 1A1. In man, administration of 11 twice-daily oral doses of fluparoxan (8 mg tablet) produced some reduction in plasma levels of orally administered phenacetin and in the ratio of phenacetin AUC/urinary paracetamol, consistent with increased O-deethylation.

New Jersey college students' high-risk behavior: will we meet the health objectives for the year 2000?

The US Centers for Disease Control and Prevention developed the Youth Risk Behavior Survey to measure the health risk behavior of the nation's high school students and to measure progress toward meeting the national health objectives for the year 2000. The survey was adapted for college students and pilot tested in spring 1993 in 18 4-year public and private colleges in New Jersey. In this article, the authors summarize results from this survey regarding unmarried respondents' risk behavior, including sexual behavior, use of alcohol, drugs, and tobacco, and behaviors that may lead to intentional and unintentional injuries. These findings, when compared with the relevant national health objectives, suggest that New Jersey college students will meet the health objectives regarding tobacco and cocaine use but will not meet national targets set for condom and birth control use, alcohol and marijuana use, and seatbelt and bicycle helmet use.

Preterm premature ruptured membranes: a randomized trial of steroids after treatment with antibiotics

OBJECTIVE

To assess the effectiveness of corticosteroids in patients with preterm premature rupture of membranes (PROM) after treatment with a broad-spectrum antibiotic, ampicillin-sulbactam.

METHODS

A randomized clinical trial of corticosteroids in patients with preterm PROM was undertaken after treating these patients for a minimum of 12 hours with ampicillin-sulbactam. No digital vaginal examinations were performed on these patients. Antibiotics were continued for 7 days and the steroids were repeated weekly. No tocolytics were used. The primary outcome measure was the incidence of respiratory distress syndrome (RDS). Secondary outcome measures included latency period and neonatal and maternal infectious morbidity.

RESULTS

Seventy-seven patients were enrolled and data about their pregnancies were analyzed. No statistically significant difference in latency period was noted (14.7 days in the steroid group, 15.8 days in the no-steroid group). Both neonatal and maternal infectious morbidity were similar. A significant reduction in the incidence of RDS (18.4 versus 43.6%, P = .03) were observed in the steroid group.

CONCLUSION

These data suggest that treating preterm PROM patients with a broad-spectrum antibiotic before corticosteroids decreases RDS without apparent adverse sequelae.

Molecular modelling of CYP3A4 from an alignment with CYP102: identification of key interactions between putative active site residues and CYP3A-specific chemicals

1. A structural model of CYP3A4 is reported on the basis of a novel amino acid sequence alignment between the CYP3 family and CYP102, a bacterial P450 of known crystal structure. 2. Construction of the CYP3A4 model from CYP102 is facilitated by the relatively high sequence homology between the two protein (52% homology; 27% identity) with many conservative amino acid changes, yielding a structure of low internal energy. 3. A considerable number of specific substrates, and some specific inhibitors, are shown to occupy the putative CYP3A4 active site via interactions with the same amino acid residues in almost all cases investigated. 4. The CYP3A4 model rationalizes the known positions of metabolism for many substrates of this major human P450 such that the route of metabolism in novel development compounds can be predicted.

COMPACT and molecular structure in toxicity assessment: a prospective evaluation of 30 chemicals currently being tested for rodent carcinogenicity by the NCI/NTP

A new series of 30 miscellaneous National Toxicology Program chemicals has been evaluated prospectively for carcinogenicity and overt toxicity by COMPACT (Computer Optimised Molecular Parametric Analysis for Chemical Toxicity. CYP1A and CYP2E1). Evaluations were also made by Hazardexpert, and for metal ion redox potentials; and these, together with COMPACT, were compared with results from the Ames test for mutagenicity in Salmonella, the micronucleus test, and 90-day subchronic rodent pathology. Seven of the 30 chemicals (nitromethane, chloroprene, xylenesulphonic acid, furfuryl alcohol, anthraquinone, emodin, cinnamaldehyde) were positive for potential carcinogenicity in the COMPACT evaluation; xylenesulphonic acid and furfuryl alcohol were only equivocally positive. Four of the 30 chemicals-scopolamine, D&C Yellow No. 11, citral, cinnamaldehyde-were positive by Hazardexpert; 6 of 30-D&C Yellow No. 11, 1-chloro-2-propanol, anthraquinone, emodin, sodium nitrite, cinnamaldehyde-were positive in the Ames test; 2 of 30-phenolphthalein and emodin-were positive in the in vivo cytogenetics test; and 3 of 30-molybdenum trioxide, gallium arsenide, vanadium pentoxide-were metal compounds with redox potentials of the metal/metal ion indicative of possible carcinogenicity. The overall prediction for carcinogenicity was positive for 12 of 30 chemicals: nitromethane, chloroprene, D&C Yellow No. 11, molybdenum trioxide, 1-chloro-2-propanol, furfuryl alcohol, gallium arsenide, anthraquinone, emodin, sodium nitrite, cinnamaldehyde, vanadium pentoxide). This overall prediction has been made on the basis of the results of the computer tests and from consideration of the information from bacterial mutagenicity, together with likely lipid solubility and pathways of metabolism and elimination.

Molecular modelling of CYP1A subfamily members based on an alignment with CYP102: rationalization of CYP1A substrate specificity in terms of active site amino acid residues

1. Using a novel amino acid sequence alignment, proteins of the CYP1A subfamily have been produced from the CYP102 crystal structure template via residue replacement and energy minimization procedures. 2. Known substrates and inhibitors of CYP1A1 and CYP1A2 are shown to fit their respective active sites via key interactions with complementary amino acid residues. Substrates used in the modelling studies include: caffeine, PhIP, oestradiol, 2,4- and 2,5-diaminotoluenes, Glu-P-1, phenacetin, acetanilide, 7-methoxy and 7-ethoxyresorufins, 11-methyl cyclopenta[a]phenanthren-17-one, 7-ethoxycoumarin, aflatoxin B1, benzo[a]pyrene, benzo[a]pyrene-7,8-diol and 1'-hydroxy 3-methylcholanthrene. 3. A number of aspects relating to CYP1A substrate specificity and metabolism can be explained in terms of the enzyme models, as it is found that key interactions with active site amino acid residues direct CYP1A-mediated metabolism in the known positions.

The metabolism of tamoxifen by human cytochromes P450 is rationalized by molecular modelling of the enzyme-substrate interactions: potential importance to its proposed anti-carcinogenic/carcinogenic actions

A molecular modelling study on the human cytochrome P450-mediated metabolism of tamoxifen is reported. Using three-dimensional models of human P450s constructed from the bacterial crystal structure template, P450bm3 (CYP102), the likely mode of substrate binding is demonstrated, which is consistent with the known positions of metabolism in tamoxifen. In particular, the CYP102-derived structures of CYP3A4, CYP2D6 and CYP2C9 are able to rationalize the routes of tamoxifen metabolism reported in human subjects. The implications for potential toxicity of tamoxifen in man is discussed in the light of these findings.

Preterm delivery from 34 to 37 weeks of gestation: is respiratory distress syndrome a problem?

Our purpose was to evaluate the necessity of using tocolytic agents for preterm labor and the benefit of conservative management for preterm premature rupture of membranes from 34 to 37 weeks' gestation. All patients who had accurate obstetric dates and were delivered between 34 and 37 weeks' gestation with no other medical or obstetric problems were retrospectively evaluated for inclusion in the study. The rates of respiratory distress syndrome and other neonatal outcomes were evaluated. A total of 416 patients met criteria for admission into the study. During the thirty-fourth week of pregnancy the incidence of respiratory distress syndrome was 14.9% (p<0.05). Other neonatal complications were also more frequent in deliveries occurring during the thirty-fourth week of pregnancy than in those occurring in the thirty-fifth or thirty-sixth week. Fetal lung maturity studies should be considered and delivery possibly delayed through the thirty-fourth week of gestation to decrease neonatal morbidity in our population.

Molecular orbital-generated QSARs in a homologous series of alkoxyresorufins and studies of their interactive docking with P450s

1. Molecular and electronic structural parameters have been determined, by molecular orbital (MO) calculations, for a homologous series of 8 alkoxyresorufins (methoxy- to octoxy-). 2. Quantitative structure-activity relationships (QSARs) between these structural parameters and the rates of metabolism of the alkoxyresorufins in hepatic microsomes from the 3-methylcholanthrene (MC)-, and phenobarbital (PB)-pretreated mouse, and the beta-naphthoflavone (beta NF)-pretreated rat have been established. 3. The most significant single relationship is between beta NF-induction of cytochrome P4501 (CYP1A) and the total nucleophilic superdelocalizability (sigma SN) for the eight compounds in the series. 4. For double regressions, the electronic charge on the alkoxy oxygen, Q(O), or alpha-carbon Q(C), is important when combined with the hydrophobic substituent constant (pi). 5. These findings indicate that the rates of metabolism of these alkoxyresorufins are dependent upon their ability to cross cellular membranes, to fit the relevant CYP1A binding site, and on their ability to accept electrons from a donor nucleophilic species. 6. A different set of parameters correlated with CYP2B activity, namely, parameters of overall shape, which indicates that the way in which the alkoxyresorufins fit the CYP2B site, determines their differences in specificity. 7. Computer graphic interactive docking studies of the alkoxyresorufins with their affinity-specific cytochromes P450, namely, methoxy- with CYP1A2; ethoxy- with CYP1A1; pentoxy- with CYP2B1; and benzyloxy- with CYP3A, have also been undertaken to show the specific interactions of the alkoxyresorufins with the binding sites of the individual P450s.

Induction of hepatic CYP1A2 by the oral administration of caffeine to rats: lack of association with the Ah locus

Caffeine was administered to male Wistar albino rats for two weeks at three concentrations, namely 0.1, 0.2 and 0.3%, and hepatic cytochrome P450-dependent mixed-function oxidase determined. Caffeine administration gave rise to a marked, dose-dependent increase in the O-deethylation of ethoxyresorufin and, to a lesser extent, in the O-depentylation of pentoxyresorufin. Erythromycin N-demethylase, p-nitrophenol hydroxylase and lauric acid hydroxylase activities, as well as total cytochrome P450 content were unaffected by this treatment. Immunoblot analysis revealed that caffeine gave rise to a dose-dependent increase in the hepatic CYP1A2, and at the highest dose only, CYP2B apoprotein levels. Apoprotein levels of CYP3A and CYP2E1 were not modulated by the treatment with caffeine at all dose levels studied. Caffeine could not displace [3H]TCDD from the rat hepatic cytosolic Ah receptor. Computer analysis showed that caffeine is essentially a planar molecule with an area/depth ratio 4.8, characteristic of CYP1A substrates/inducers. Molecular modelling revealed that the caffeine molecule could orientate itself within the putative CYP1A2 active site so as to facilitate demethylation of the N-1, N-3 and N-7 positions. However, at physiological pH, the N-9 nitrogen atom is likely to be partially protonated, allowing it to participate in an electrostatic interaction with the negatively-charged glutamate 318-residue, favouring N-3 demethylation, the major pathway of metabolism in both humans and animals. In conclusion caffeine, being essentially planar, is an inducer of CYP1A2 in rat liver.

Species variation in the metabolism of 15,16-dihydro-11-methylcyclopenta[a]phenanthren-17-one to its 3,4-dihydrodiol, the proximate carcinogen

The title compound is a strong carcinogen, similar in potency to benzo[a]pyrene in mouse skin assay. This paper describes a comparison of its in vitro metabolism by hepatic microsomal preparations from mouse, rat, rabbit, hamster, dog, monkey and man. Metabolites were isolated by preparative high pressure liquid chromatography from the ethyl acetate extractable material and their structures tentatively assigned on the basis of their retention times and ultraviolet spectra, when possible by direct comparison with authentic synthetic specimens. Mass spectrometry was then used to confirm these assignments. All these animals produce the same range of metabolites derived exclusively from oxidation at the benzo-ring A, the five-membered ring D, and at the 11-methyl group. However, the amounts of individual metabolites varied substantially. In particular all the animals yielded the proximate carcinogen 3,4-dihydroxy-11-methyl-3,4,15, 16-tetrahydrocyclopenta[a]phenanthren-17-one, from which it is reasoned that all might be susceptible to its carcinogenic action. A rationalization for the observed distribution of the metabolites is proposed on the basis of a molecular model of the active site of cytochrome P450 1A1, the oxidative enzyme involved.

Quantitative structure-activity relationships and COMPACT analysis of a series of food mutagens

Quantitative structure-activity relationships between chemical structure and Ames mutagenicity for a group of 24 food mutagens, including 17 cooked-food heterocyclic amines, have been determined. For the TA98 strain of Salmonella typhimurium (frameshift mutagens) the best correlation of mutagenicity is with molecular diameter (R = 0.91), while for the TA100 strain (base-pair mutations) the best correlation is with delta E, the energy difference between the lowest unoccupied and highest occupied molecular orbitals. High mutagenicity is related to high values of molecular diameter, hence to planarity and to high values of the COMPACT ratio ([area/depth2]/delta E). High mutagenicity is also related to low values of delta E. Consequently, highly mutagenic and potentially carcinogenic food chemicals can readily be identified as substrates of cytochrome P4501 (CYP1) and may therefore be detected by the COMPACT procedure. Highly mutagenic compounds also exhibit high values of dipole moment.

Latency period after preterm premature rupture of membranes: a comparison of ampicillin with and without sulbactam

OBJECTIVE

To compare ampicillin with and without sulbactam with respect to the effect on the latency period after preterm premature rupture of membranes (PROM).

METHODS

Patients with PROM at 25-35 weeks' gestation were offered participation in a randomized blinded trial comparing ampicillin-sulbactam with ampicillin. Evaluations for cervical pathogens were performed on admission and patients were followed-up with daily maternal and fetal evaluation. Maternal and neonatal outcomes were analyzed using indicated techniques.

RESULTS

Fifty-three women were studied, with 25 receiving ampicillin-sulbactam and 28 receiving ampicillin. The ampicillin-sulbactam group had a significantly longer latency period (433 +/- 625 versus 143 +/- 165 hours, P = .03) and significantly fewer neonatal complications (five versus 20, P < .001). Although no neonatal infectious complications were observed in sulbactam-treated cases, there were four cases of neonatal sepsis and two of neonatal pneumonia in the ampicillin group. Also, significantly more neonates in the ampicillin group required prolonged oxygen and ventilatory support. There was no significant difference in maternal morbidity.

CONCLUSIONS

In our population with preterm PROM, a broad-spectrum antibiotic that provides anaerobic coverage appears to extend latency and decrease neonatal morbidity without increasing adverse maternal outcome.