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O'Shea TM, Downey LC, Kuban KKC. Extreme prematurity and attention deficit: epidemiology and prevention. Front Hum Neurosci 2013; 7:578. [PMID: 24065904 PMCID: PMC3776954 DOI: 10.3389/fnhum.2013.00578] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 08/28/2013] [Indexed: 01/01/2023] Open
Affiliation(s)
- T. Michael O'Shea
- Division of Neonatology, Department of Pediatrics, Wake Forest School of Medicine, Winston-SalemNC, USA
| | - L. Corbin Downey
- Division of Neonatology, Department of Pediatrics, Wake Forest School of Medicine, Winston-SalemNC, USA
| | - Karl K. C. Kuban
- Division of Pediatric Neurology, Department of Pediatrics, Boston UniversityBoston, MA, USA
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Repeat antenatal steroid exposure and later blood pressure, arterial stiffness, and metabolic profile. J Pediatr 2013; 163:711-6. [PMID: 23651768 DOI: 10.1016/j.jpeds.2013.03.074] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 02/20/2013] [Accepted: 03/26/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the relationship between repeat courses of antenatal corticosteroids (ACS) and risk factors for cardiovascular disease in adolescents and young adults. STUDY DESIGN We assessed body mass index, blood pressure, arterial stiffness, blood lipids, and insulin resistance (IR) in a Swedish population-based cohort (n = 100) at a median age of 18 (range 14-26) years. Fifty-eight subjects (36 males) had been exposed to 2-9 weekly courses of antenatal betamethasone and 42 (23 males) were unexposed subjects matched for age, sex, and gestational age (GA). RESULTS There were no significant differences between the groups regarding body mass index, systolic or diastolic blood pressures, arterial stiffness measured by augmentation index, blood lipids, IR, or morning cortisol levels either in simple regression or in multivariable models. However, more subjects with elevated augmentation index had been exposed to repeat courses of ACS (n = 7) compared with unexposed subjects (n =1, P = .06), and glucose, insulin, and IR correlated inversely to GA at start of ACS (P < .01). CONCLUSIONS Repeat courses of ACS did not correlate to adverse cardiovascular risk profile in adolescence and young adulthood, but long-standing effects on the arterial tree and glucose metabolism, the latter dependent on GA at ACS exposure, cannot be excluded. These observations have clinical implications for the ongoing discussion on short-term benefits and long-term safety of repeat ACS treatment.
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Boesveld M, Heida KY, Oudijk MA, Brouwers HAA, Koenen SV, Kwee A. Evaluation of antenatal corticosteroid prescribing patterns among 984 women at risk for preterm delivery. J Matern Fetal Neonatal Med 2013; 27:516-9. [DOI: 10.3109/14767058.2013.821975] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Stålnacke J, Diaz Heijtz R, Norberg H, Norman M, Smedler AC, Forssberg H. Cognitive outcome in adolescents and young adults after repeat courses of antenatal corticosteroids. J Pediatr 2013; 163:441-6. [PMID: 23485033 DOI: 10.1016/j.jpeds.2013.01.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 12/03/2012] [Accepted: 01/14/2013] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To investigate whether repeat courses of antenatal corticosteroids have long-term effects on cognitive and psychological functioning. STUDY DESIGN In a prospective cohort study, 58 adolescents and young adults (36 males) who had been exposed to 2-9 weekly courses of betamethasone in utero were assessed with neuropsychological tests and behavior self-reports. Unexposed subjects (n = 44, 25 males) matched for age, sex, and gestational age at birth served as a comparison group. In addition, individuals exposed in utero to a single course (n = 25, 14 males) were included for dose-response analysis. Group differences were investigated using multilevel linear modeling. RESULTS Mean scores obtained in 2 measures of attention and speed were significantly lower in subjects exposed to 2 or more antenatal corticosteroids courses (Symbol Search, P = .009; Digit Span Forward, P = .02), but these were not dose-dependent. Exposure to repeat courses of antenatal corticosteroids was not associated with general deficits in higher cognitive functions, self-reported attention, adaptability, or overall psychological function. CONCLUSIONS Although this study indicates that repeat exposure to antenatal corticosteroids may have an impact on aspects of executive functioning, it does not provide support for the prevailing concern that such fetal exposure will have a major adverse impact on cognitive functions and psychological health later in life.
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Luyckx VA, Bertram JF, Brenner BM, Fall C, Hoy WE, Ozanne SE, Vikse BE. Effect of fetal and child health on kidney development and long-term risk of hypertension and kidney disease. Lancet 2013; 382:273-83. [PMID: 23727166 DOI: 10.1016/s0140-6736(13)60311-6] [Citation(s) in RCA: 365] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Developmental programming of non-communicable diseases is now an established paradigm. With respect to hypertension and chronic kidney disease, adverse events experienced in utero can affect development of the fetal kidney and reduce final nephron number. Low birthweight and prematurity are the most consistent clinical surrogates for a low nephron number and are associated with increased risk of hypertension, proteinuria, and kidney disease in later life. Rapid weight gain in childhood or adolescence further compounds these risks. Low birthweight, prematurity, and rapid childhood weight gain should alert clinicians to an individual's lifelong risk of hypertension and kidney disease, prompting education to minimise additional risk factors and ensuring follow-up. Birthweight and prematurity are affected substantially by maternal nutrition and health during pregnancy. Optimisation of maternal health and early childhood nutrition could, therefore, attenuate this programming cycle and reduce the global burden of hypertension and kidney disease in the future.
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Affiliation(s)
- Valerie A Luyckx
- Division of Nephrology, University of Alberta, Edmonton, AB, Canada.
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Crowther CA, Harding JE, Middleton PF, Andersen CC, Ashwood P, Robinson JS. Australasian randomised trial to evaluate the role of maternal intramuscular dexamethasone versus betamethasone prior to preterm birth to increase survival free of childhood neurosensory disability (A*STEROID): study protocol. BMC Pregnancy Childbirth 2013; 13:104. [PMID: 23642125 PMCID: PMC3655914 DOI: 10.1186/1471-2393-13-104] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 04/16/2013] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Both dexamethasone and betamethasone, given to women at risk of preterm birth, substantially improve short-term neonatal health, increase the chance of the baby being discharged home alive, and reduce childhood neurosensory disability, remaining safe into adulthood. However, it is unclear which corticosteroid is of greater benefit to mother and child.This study aims to determine whether giving dexamethasone to women at risk of preterm birth at less than 34 weeks' gestation increases the chance of their children surviving free of neurosensory disability at two years' corrected age, compared with betamethasone. METHODS/DESIGN Design randomised, multicentre, placebo controlled trial.Inclusion criteria women at risk of preterm birth at less than 34 weeks' gestation with a singleton or twin pregnancy and no contraindications to the use of antenatal corticosteroids and who give informed consent.Trial entry & randomisation at telephone randomisation eligible women will be randomly allocated to either the dexamethasone group or the betamethasone group, allocated a study number and corresponding treatment pack.Study groups women in the dexamethasone group will be administered two syringes of 12 mg dexamethasone (dexamethasone sodium phosphate) and women in the betamethasone group will be administered two syringes of 11.4 mg betamethasone (Celestone Chronodose). Both study groups consist of intramuscular treatments 24 hours apart.Primary study outcome death or any neurosensory disability measured in children at two years' corrected age.Sample size a sample size of 1449 children is required to detect either a decrease in death or any neurosensory disability from 27.0% to 20.1% with dexamethasone compared with betamethasone, or an increase from 27.0% to 34.5% (two-sided alpha 0.05, 80% power, 5% loss to follow up, design effect 1.2). DISCUSSION This study will provide high-level evidence of direct relevance for clinical practice. If one drug clearly results in significantly fewer deaths and fewer disabled children then it should be used consistently in women at risk of preterm birth and would be of great importance to women at risk of preterm birth, their children, health services and communities. TRIAL REGISTRATION TRIAL REGISTRATION NUMBER ACTRN12608000631303.
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Affiliation(s)
- Caroline A Crowther
- Australian Research Centre for Health of Women and Babies (ARCH), The Robinson Institute, Discipline of Obstetrics and Gynaecology, Women’s & Children’s Hospital, The University of Adelaide, 72 King William Road, North Adelaide, South Australia, 5006, Australia
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Philippa F Middleton
- Australian Research Centre for Health of Women and Babies (ARCH), The Robinson Institute, Discipline of Obstetrics and Gynaecology, Women’s & Children’s Hospital, The University of Adelaide, 72 King William Road, North Adelaide, South Australia, 5006, Australia
| | - Chad C Andersen
- Department of Perinatal Medicine, Women’s and Children’s Hospital, Adelaide, Australia
| | - Pat Ashwood
- Australian Research Centre for Health of Women and Babies (ARCH), The Robinson Institute, Discipline of Obstetrics and Gynaecology, Women’s & Children’s Hospital, The University of Adelaide, 72 King William Road, North Adelaide, South Australia, 5006, Australia
| | - Jeffrey S Robinson
- Australian Research Centre for Health of Women and Babies (ARCH), The Robinson Institute, Discipline of Obstetrics and Gynaecology, Women’s & Children’s Hospital, The University of Adelaide, 72 King William Road, North Adelaide, South Australia, 5006, Australia
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Crowther CA, Middleton PF, Wilkinson D, Ashwood P, Haslam R. Magnesium sulphate at 30 to 34 weeks' gestational age: neuroprotection trial (MAGENTA)--study protocol. BMC Pregnancy Childbirth 2013; 13:91. [PMID: 23570677 PMCID: PMC3636106 DOI: 10.1186/1471-2393-13-91] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 03/28/2013] [Indexed: 05/27/2023] Open
Abstract
Background Magnesium sulphate is currently recommended for neuroprotection of preterm infants for women at risk of preterm birth at less than 30 weeks’ gestation, based on high quality evidence of benefit. However there remains uncertainty as to whether these benefits apply at higher gestational ages. The aim of this randomised controlled trial is to assess whether giving magnesium sulphate compared with placebo to women immediately prior to preterm birth between 30 and 34 weeks’ gestation reduces the risk of death or cerebral palsy in their children at two years’ corrected age. Methods/design Design: Randomised, multicentre, placebo controlled trial. Inclusion criteria: Women, giving informed consent, at risk of preterm birth between 30 to 34 weeks’ gestation, where birth is planned or definitely expected within 24 hours, with a singleton or twin pregnancy and no contraindications to the use of magnesium sulphate. Trial entry & randomisation: Eligible women will be randomly allocated to receive either magnesium sulphate or placebo. Treatment groups: Women in the magnesium sulphate group will be administered 50 ml of a 100 ml infusion bag containing 8 g magnesium sulphate heptahydrate [16 mmol magnesium ions]. Women in the placebo group will be administered 50 ml of a 100 ml infusion bag containing isotonic sodium chloride solution (0.9%). Both treatments will be administered through a dedicated IV infusion line over 30 minutes. Primary study outcome: Death or cerebral palsy measured in children at two years’ corrected age. Sample size: 1676 children are required to detect a decrease in the combined outcome of death or cerebral palsy, from 9.6% with placebo to 5.4% with magnesium sulphate (two-sided alpha 0.05, 80% power, 5% loss to follow up, design effect 1.2). Discussion Given the magnitude of the protective effect in the systematic review, the ongoing uncertainty about benefits at later gestational ages, the serious health and cost consequences of cerebral palsy for the child, family and society, a trial of magnesium sulphate for women at risk of preterm birth between 30 to 34 weeks’ gestation is both important and relevant for clinical practice globally. Trial registration Australian New Zealand Clinical Trials Registry - ACTRN12611000491965
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Affiliation(s)
- Caroline A Crowther
- Australian Research Centre for Health of Women and Babies (ARCH), The Robinson Institute, The University of Adelaide, Adelaide, Australia.
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Slotkin TA, Card J, Infante A, Seidler FJ. Prenatal dexamethasone augments the sex-selective developmental neurotoxicity of chlorpyrifos: implications for vulnerability after pharmacotherapy for preterm labor. Neurotoxicol Teratol 2013; 37:1-12. [PMID: 23416428 DOI: 10.1016/j.ntt.2013.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 01/28/2013] [Accepted: 02/02/2013] [Indexed: 01/01/2023]
Abstract
Glucocorticoids are routinely given in preterm labor and are also elevated by maternal stress; organophosphate exposures are virtually ubiquitous, so coexposures to these two agents are pervasive. We administered dexamethasone to pregnant rats on gestational days 17-19 at a standard therapeutic dose (0.2mg/kg); offspring were then given chlorpyrifos on postnatal days 1-4, at a dose (1mg/kg) that produces barely-detectable (<10%) inhibition of brain cholinesterase activity. We evaluated indices for acetylcholine (ACh) synaptic function throughout adolescence, young adulthood and later adulthood, in brain regions possessing the majority of ACh projections and cell bodies; we measured nicotinic ACh receptor binding, hemicholinium-3 binding to the presynaptic choline transporter and choline acetyltransferase activity, all known targets for the adverse developmental effects of dexamethasone and chlorpyrifos given individually. Dexamethasone did not enhance the systemic toxicity of chlorpyrifos, as evidenced by weight gain and measurements of cholinesterase inhibition during chlorpyrifos treatment. Nevertheless, it enhanced the loss of presynaptic ACh function selectively in females, who ordinarily show sparing of organophosphate developmental neurotoxicity relative to males. Females receiving the combined treatment showed decrements in choline transporter binding and choline acetyltransferase activity that were unique (not found with either treatment alone), as well as additive decrements in nicotinic receptor binding. On the other hand, males given dexamethasone showed no augmentation of the effects of chlorpyrifos. Our findings indicate that prior dexamethasone exposure could create a subpopulation that is especially vulnerable to the adverse effects of organophosphates or other developmental neurotoxicants.
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Affiliation(s)
- Theodore A Slotkin
- Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, NC 27710, USA.
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Purdy IB, Smith L, Wiley D, Badr L. A psychoneuroimmunologic examination of cumulative perinatal steroid exposures and preterm infant behavioral follow-up. Biol Res Nurs 2013; 15:86-95. [PMID: 21900308 PMCID: PMC4171102 DOI: 10.1177/1099800411420134] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE This study's aim was to explore relationships between preterm infant behavioral outcomes and maternal/infant glucocorticoid (dexamethasone [DEX]) treatments using a psychoneuroimmunologic approach. Research questions were (a) do relationships exist between infant cumulative perinatal steroid (PNS) exposure and child behavioral problems? and (b) do maternal/infant characteristics (e.g., immune markers and biophysiologic stressors) influence these relationships? METHODS The convenience sample comprised 45 mother-child dyads in which the children (mean age 8 years ± 2.3) had been born at a mean postconceptional age of 28 weeks (± 4.2). We used the Child Behavior Checklist (CBCL) to assess behavior, the Clinical Risk Index for Babies (CRIB) to score stress at birth, and retrospective record review to identify additional perinatal factors (PNS dosage, sepsis, and maternal and infant complete blood counts near delivery). RESULTS Children were dichotomized into high (> 0.2 mg/kg; n = 20) versus low-no (≤0.2 mg/kg; n = 25) PNS exposure groups. Significant relationships existed between CBCL Total Problems score and sepsis, PNS exposure, timing of initial PNS, and infant length percentile at discharge. Competence problems were significantly associated with PNS, neonatal intensive care unit (NICU) infant length percentile, CRIB score, sepsis, retinopathy of prematurity, hearing deficit, and immunity markers (i.e., maternal lymphocyte percentage and infant band/seg ratio). Children in the higher PNS group exhibited more behavioral problems (e.g., withdrawn, attention, conduct, social, and rule breaking problems), but there were no significant differences. The findings are reassuring regarding long-term effects of this PNS dose on preterm infant behavioral outcomes.
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Affiliation(s)
- Isabell B Purdy
- Department of Pediatrics, Neonatology, David Geffen School of Medicine at University of California, Los Angeles, 90096, USA.
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ERIKSSON LENA, HAGLUND BENGT, EWALD UWE, ODLIND VIVECA, KIELER HELLE. Health consequences of prophylactic exposure to antenatal corticosteroids among children born late preterm or term. Acta Obstet Gynecol Scand 2012; 91:1415-21. [DOI: 10.1111/aogs.12014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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111
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Teune MJ, van Wassenaer AG, Malin GL, Asztalos E, Alfirevic Z, Mol BWJ, Opmeer BC. Long-term child follow-up after large obstetric randomised controlled trials for the evaluation of perinatal interventions: a systematic review of the literature. BJOG 2012; 120:15-22. [PMID: 23078194 DOI: 10.1111/j.1471-0528.2012.03465.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although the hope is that many perinatal interventions are performed with an ultimate aim to improve the long-term health and development of the child, long-term outcome is rarely used as a primary end-point in perinatal randomised controlled trials (RCTs). OBJECTIVE To evaluate how often and with which tools long-term follow-up is performed after large obstetric RCTs. SEARCH STRATEGY We searched the Cochrane Library for Cochrane reviews published by the Cochrane Pregnancy and Childbirth Group for reviews on interventions that aimed to improve neonatal outcome. Selection criteria Reviews on perinatal interventions that were not performed to improve the condition of the neonate were excluded. We limited our review to RCTs with more than 350 participating women. For each included study, we checked in Web of Science as to whether the researchers had reported on follow-up in subsequent publications. DATA COLLECTION AND ANALYSIS Relevant information was extracted from these RCTs by two reviewers using a predefined data collection sheet. All information was analysed using SPSS 17.0 (SPSS Inc., Chicago, IL, USA). MAIN RESULTS We studied 212 reviews including 1837 RCTs on perinatal interventions, 249 (14%) of which included 350 participants. Only 40 of 249 RCTs (16%) followed the children after discharge from the hospital to evaluate the effect of a specific perinatal intervention. The number of RCTs with long-term follow-up remained stable, with 10 of 67 RCTs (15%) reporting follow-up before 1990, 17 of 115 (15%) between 1990 and 2000, and 13 of 67 (19%) after 2000 (P = 0.68). CONCLUSIONS Only a small minority of large perinatal RCTs report the long-term follow-up of the child. Future obstetric RCTs should consider performing long-term follow-up at the start of the trial.
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Affiliation(s)
- M J Teune
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, the Netherlands.
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Lee SM, Romero R, Park JW, Kim SM, Park CW, Korzeniewski SJ, Chaiworapongsa T, Yoon BH. The clinical significance of a positive Amnisure test in women with preterm labor and intact membranes. J Matern Fetal Neonatal Med 2012; 25:1690-8. [PMID: 22280400 PMCID: PMC3422421 DOI: 10.3109/14767058.2012.657279] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study was conducted to examine the frequency and clinical significance of a positive Amnisure test in patients with preterm labor and intact membranes by sterile speculum exam. STUDY DESIGN A retrospective cohort study was performed including 90 patients with preterm labor and intact membranes who underwent Amnisure tests prior to amniocentesis (< 72 h); most patients (n=64) also underwent fetal fibronectin (fFN) tests. Amniotic fluid (AF) was cultured for aerobic/anaerobic bacteria and genital mycoplasmas and assayed for matrix metalloproteinase-8. RESULTS (1) the prevalence of a positive Amnisure test was 19% (17/90); (2) patients with a positive Amnisure test had significantly higher rates of adverse pregnancy and neonatal outcomes (e.g., impending preterm delivery, intra-amniotic infection/inflammation, and neonatal morbidity) than those with a negative Amnisure test; (3) a positive test was associated with significantly increased risk of intra-amniotic infection and/or inflammation, delivery within 7, 14, or 28 days and spontaneous preterm birth (< 35 weeks) among patients with a negative fFN test. CONCLUSIONS A positive Amnisure test in patients with preterm labor and intact membranes is a risk factor for adverse pregnancy outcome, particularly in patients with a negative fFN test. A positive Amnisure test in patients without symptoms or signs of ROM should not be taken as an indicator that membranes have ruptured.
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Affiliation(s)
- Seung Mi Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD and Detroit, MI, USA
| | - Jeong Woo Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Sun Min Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Chan-Wook Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Steven J. Korzeniewski
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Bo Hyun Yoon
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
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Bae YSC, Van Voorhees AS, Hsu S, Korman NJ, Lebwohl MG, Young M, Bebo B, Kimball AB. Review of treatment options for psoriasis in pregnant or lactating women: From the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol 2012; 67:459-77. [DOI: 10.1016/j.jaad.2011.07.039] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 07/27/2011] [Accepted: 07/29/2011] [Indexed: 02/08/2023]
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Repeated courses of antenatal corticosteroids have adverse effects on aspects of brain development in naturally delivered baboon infants. Pediatr Res 2012; 71:661-7. [PMID: 22436975 PMCID: PMC3582393 DOI: 10.1038/pr.2012.18] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Repeated courses of antenatal steroids in women at risk of preterm delivery have beneficial effects on lung maturation, but concern exists about the effects on brain development. We aimed to determine whether repeated courses of corticosteroids increased the risk of neuropathology as compared with single courses or no treatment. METHODS Single-course animals received a 6-mg dose of steroids at 123 and 124 d of gestation (dg; term, 185 dg; n = 6). Repeated-course animals received additional doses at 137 and 138 dg (n = 7). Controls received no steroids (n = 5). Baboons delivered naturally at term and necropsy was performed. Brains were assessed histologically for parameters of development and neuropathology. RESULTS Body weights did not differ between the groups (P > 0.05); neither did brain/body weight ratio. Density of glial fibrillary acidic protein (GFAP)-immunoreactive (IR) astrocytes in white matter (WM) was increased in the single- (P < 0.05) and repeated-course (P < 0.01) groups as compared with controls. Density of myelin basic protein (MBP)-IR oligodendrocytes was reduced in the repeated-course animals as compared with both the control and single-course groups (P < 0.05); oligodendrocyte transcription factor 2 (Olig2)-IR showed no difference between groups. DISCUSSION Repeated courses of antenatal corticosteroids have effects on myelination in the developing nonhuman primate brain, which should be taken into account when determining a dosing regimen.
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Jayasekera BAP, Bacon AD, Whitfield PC. Management of glioblastoma multiforme in pregnancy. J Neurosurg 2012; 116:1187-94. [DOI: 10.3171/2012.2.jns112077] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Glioblastoma multiforme presenting during pregnancy presents unique challenges to the clinician. In planning treatment, potential benefits to the mother must be balanced against the risks to the fetus. In addition, evidence relating to timing of surgery and the use of radiotherapy and chemotherapy in pregnancy is limited. Management of peritumoral edema and seizures in pregnancy is also complicated by the potential for drug-related teratogenic effects and adverse neonatal outcomes on the fetus. The general anesthetic used for surgery must factor obstetric and neurosurgical considerations.
In this review article, the authors seek to examine the role, safety, and timing of therapies for glioblastoma in the context of pregnancy. This covers the use of radiotherapy and chemotherapy, timing of surgery, postoperative care, anesthetic considerations, and use of anticonvulsant medications and steroids. The authors hope that this will provide a framework for clinicians treating pregnant patients with glioblastomas.
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Affiliation(s)
| | - Andrew D. Bacon
- 2Department of Neurosurgery, Frenchay Hospital, Bristol; and
| | - Peter C. Whitfield
- 3Southwest Neurosurgical Centre, Derriford Hospital, Plymouth, United Kingdom
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Surbek D, Drack G, Irion O, Nelle M, Huang D, Hoesli I. Antenatal corticosteroids for fetal lung maturation in threatened preterm delivery: indications and administration. Arch Gynecol Obstet 2012; 286:277-81. [DOI: 10.1007/s00404-012-2339-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 04/13/2012] [Indexed: 11/29/2022]
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Abstract
OBJECTIVE To estimate the effect of multiple courses of antenatal corticosteroids on neonatal size, controlling for gestational age at birth and other confounders, and to determine whether there was a dose-response relationship between number of courses of antenatal corticosteroids and neonatal size. METHODS This is a secondary analysis of the Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study, a double-blind randomized controlled trial of single compared with multiple courses of antenatal corticosteroids in women at risk for preterm birth and in which fetuses administered multiple courses of antenatal corticosteroids weighed less, were shorter, and had smaller head circumferences at birth. All women (n=1,858) and children (n=2,304) enrolled in the Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study were included in the current analysis. Multiple linear regression analyses were undertaken. RESULTS Compared with placebo, neonates in the antenatal corticosteroids group were born earlier (estimated difference and confidence interval [CI]: -0.428 weeks, CI -0.10264 to -0.75336; P=.01). Controlling for gestational age at birth and confounding factors, multiple courses of antenatal corticosteroids were associated with a decrease in birth weight (-33.50 g, CI -66.27120 to -0.72880; P=.045), length (-0.339 cm, CI -0.6212 to -0.05676]; P=.019), and head circumference (-0.296 cm, -0.45672 to -0.13528; P<.001). For each additional course of antenatal corticosteroids, there was a trend toward an incremental decrease in birth weight, length, and head circumference. CONCLUSION Fetuses exposed to multiple courses of antenatal corticosteroids were smaller at birth. The reduction in size was partially attributed to being born at an earlier gestational age but also was attributed to decreased fetal growth. Finally, a dose-response relationship exists between the number of corticosteroid courses and a decrease in fetal growth. The long-term effect of these findings is unknown. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT00187382. LEVEL OF EVIDENCE II.
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Antenatal corticosteroids: a risk factor for the development of chronic disease. J Nutr Metab 2012; 2012:930591. [PMID: 22523677 PMCID: PMC3317130 DOI: 10.1155/2012/930591] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Revised: 12/30/2011] [Accepted: 12/31/2011] [Indexed: 01/21/2023] Open
Abstract
Preterm birth remains a major health issue worldwide. Since the 1990s, women at risk for preterm birth received a single course of exogenous antenatal corticosteroids (ACSs) to facilitate fetal lung maturity. More recently, repeated or multiple courses of ACS have been supported to provide continued fetal maturity support for women with continued risk of preterm birth. However, exogenous ACS reduces birth weight which, in turn, is associated with adverse adult outcomes such as coronary heart disease, stroke, hypertension, and type 2 diabetes. The long-term effects of ACS exposure on HPA axis activity and neurological function are well documented in animal studies, and it appears that ACS, regardless of dose exposure, is capable of affecting fetal HPA axis development causing permanent changes in the HPA axis that persists through life and is manifested by chronic illness and behavioral changes. The challenge in human studies is to demonstrate whether an intervention such as ACS administration in pregnancy contributes to developmental programming and how this is manifested in later life.
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Obstetric interventions beneficial to prematurely delivering newborn babies: antenatal corticostetroids, progesterone, magnesium sulfate. Clin Perinatol 2012; 39:33-45. [PMID: 22341535 DOI: 10.1016/j.clp.2011.12.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Although improvements in neonatal care have continued to result in reduced mortality and morbidity of prematurely delivering newborns for decades, the results of a myriad of obstetric efforts and interventions have failed to reduce the overall rate of prematurity or prolong pregnancy at any gestational age. A few new developments or refinements of established interventions give increased hope for an improved obstetric contribution to the problem of prematurity. These include a better understanding of how best to use antenatal corticosteroids, and the newer options of magnesium sulfate to ameliorate or avoid cerebral palsy associated with prematurity and maternal progesterone administration to selected at-risk populations to decrease the likelihood of premature delivery.
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McKinlay CJ, Crowther CA, Middleton P, Harding JE. Repeat antenatal glucocorticoids for women at risk of preterm birth: a Cochrane Systematic Review. Am J Obstet Gynecol 2012; 206:187-94. [PMID: 21982021 DOI: 10.1016/j.ajog.2011.07.042] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 07/13/2011] [Accepted: 07/25/2011] [Indexed: 11/25/2022]
Abstract
Administration of antenatal glucocorticoids to women at risk of preterm birth has major benefits for infants but the use of repeat dose(s) is controversial. We performed a systematic review of randomized trials, using standard Cochrane methodology, to assess the effectiveness and safety of 1 or more repeat doses given to women at risk of preterm birth 7 or more days after an initial course. Ten trials were included involving over 4730 women and 5700 infants. Treatment with repeat dose(s) compared with no repeat treatment reduced the risk of respiratory distress syndrome (risk ratio, 0.83; 95% confidence interval, 0.75-0.91) and serious neonatal morbidity (risk ratio, 0.84; 95% confidence interval, 0.75-0.94). At 2- to 3-year follow-up (4 trials, 4170 children), there was no evidence of either significant benefit or harm. Repeat doses of glucocorticoids should be considered in women at risk of preterm birth 7 or more days after an initial course, in view of the neonatal benefits.
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Abstract
Asthma is a chronic inflammatory airway disease that is commonly seen in the emergency department (ED). This article provides an evidence-based review of diagnosis and management of asthma. Early recognition of asthma exacerbations and initiation of treatment are essential. Treatment is dictated by the severity of the exacerbation. Treatment involves bronchodilators and corticosteroids. Other treatment modalities including magnesium, heliox, and noninvasive ventilator support are discussed. Safe disposition from the ED can be considered after stabilization of the exacerbation, response to treatment and attaining peak flow measures.
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Carlo WA, McDonald SA, Fanaroff AA, Vohr BR, Stoll BJ, Ehrenkranz RA, Andrews WW, Wallace D, Das A, Bell EF, Walsh MC, Laptook AR, Shankaran S, Poindexter BB, Hale EC, Newman NS, Davis AS, Schibler K, Kennedy KA, Sánchez PJ, Van Meurs KP, Goldberg RN, Watterberg KL, Faix RG, Frantz ID, Higgins RD. Association of antenatal corticosteroids with mortality and neurodevelopmental outcomes among infants born at 22 to 25 weeks' gestation. JAMA 2011; 306:2348-58. [PMID: 22147379 PMCID: PMC3565238 DOI: 10.1001/jama.2011.1752] [Citation(s) in RCA: 244] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Current guidelines, initially published in 1995, recommend antenatal corticosteroids for mothers with preterm labor from 24 to 34 weeks' gestational age, but not before 24 weeks due to lack of data. However, many infants born before 24 weeks' gestation are provided intensive care. OBJECTIVE To determine if use of antenatal corticosteroids is associated with improvement in major outcomes for infants born at 22 and 23 weeks' gestation. DESIGN, SETTING, AND PARTICIPANTS Cohort study of data collected prospectively on inborn infants with a birth weight between 401 g and 1000 g (N = 10,541) born at 22 to 25 weeks' gestation between January 1, 1993, and December 31, 2009, at 23 academic perinatal centers in the United States. Certified examiners unaware of exposure to antenatal corticosteroids performed follow-up examinations on 4924 (86.5%) of the infants born between 1993 and 2008 who survived to 18 to 22 months. Logistic regression models generated adjusted odds ratios (AORs), controlling for maternal and neonatal variables. MAIN OUTCOME MEASURES Mortality and neurodevelopmental impairment at 18 to 22 months' corrected age. RESULTS Death or neurodevelopmental impairment at 18 to 22 months was significantly lower for infants who had been exposed to antenatal corticosteroids and were born at 23 weeks' gestation (83.4% with exposure to antenatal corticosteroids vs 90.5% without exposure; AOR, 0.58 [95% CI, 0.42-0.80]), at 24 weeks' gestation (68.4% with exposure to antenatal corticosteroids vs 80.3% without exposure; AOR, 0.62 [95% CI, 0.49-0.78]), and at 25 weeks' gestation (52.7% with exposure to antenatal corticosteroids vs 67.9% without exposure; AOR, 0.61 [95% CI, 0.50-0.74]) but not in those infants born at 22 weeks' gestation (90.2% with exposure to antenatal corticosteroids vs 93.1% without exposure; AOR, 0.80 [95% CI, 0.29-2.21]). If the mothers had received antenatal corticosteroids, the following events occurred significantly less in infants born at 23, 24, and 25 weeks' gestation: death by 18 to 22 months; hospital death; death, intraventricular hemorrhage, or periventricular leukomalacia; and death or necrotizing enterocolitis. For infants born at 22 weeks' gestation, the only outcome that occurred significantly less was death or necrotizing enterocolitis (73.5% with exposure to antenatal corticosteroids vs 84.5% without exposure; AOR, 0.54 [95% CI, 0.30-0.97]). CONCLUSION Among infants born at 23 to 25 weeks' gestation, antenatal exposure to corticosteroids compared with nonexposure was associated with a lower rate of death or neurodevelopmental impairment at 18 to 22 months.
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Affiliation(s)
- Waldemar A Carlo
- Department of Pediatrics, University of Alabama, 9380 Women and Infants Center, 1700 Sixth Ave S, Birmingham, AL 35249, USA.
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Damsted SK, Born AP, Paulson OB, Uldall P. Exogenous glucocorticoids and adverse cerebral effects in children. Eur J Paediatr Neurol 2011; 15:465-77. [PMID: 21632268 DOI: 10.1016/j.ejpn.2011.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Revised: 04/15/2011] [Accepted: 05/06/2011] [Indexed: 10/18/2022]
Abstract
Glucocorticoids are commonly used in treatment of paediatric diseases, but evidence of associated adverse cerebral effects is accumulating. The various pharmacokinetic profiles of the exogenous glucocorticoids and the changes in pharmacodynamics during childhood, result in different exposure of nervous tissue to exogenous glucocorticoids. Glucocorticoids activate two types of intracellular receptors, the mineralocorticoid receptor and the glucocorticoid receptor. The two receptors differ in cerebral distribution, affinity and effects. Exogenous glucocorticoids favor activation of the glucocorticoid receptor, which is associated with unfavorable cellular outcomes. Prenatal treatment with glucocorticoids can compromise brain growth and is associated with periventricular leukomalacia, attentions deficits and poorer cognitive performance. In the neonatal period exposure to glucocorticoids reduces neurogenesis and cerebral volume, impairs memory and increases the incidence of cerebral palsy. Cerebral effects of glucocorticoids in later childhood have been less thoroughly studied, but apparent brain atrophy, reduced size of limbic structures and neuropsychiatric symptoms have been reported. Glucocortioids affect several cellular structures and functions, which may explain the observed adverse effects. Glucocorticoids can impair neuronal glucose uptake, decrease excitability, cause atrophy of dendrites, compromise development of myelin-producing oligodendrocytes and disturb important cellular structures involved in axonal transport, long-term potentiation and neuronal plasticity. Significant maturation of the brain continues throughout childhood and we hypothesize that exposure to exogenous glucocorticoids during preschool and school age causes adverse cerebral effects. It is our opinion that studies of associations between exposure to glucocorticoids during childhood and impaired neurodevelopment are highly relevant.
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Affiliation(s)
- Sara K Damsted
- Department of Paediatrics, Copenhagen University Hospital, Rigshospitalet, Juliane Marie Center, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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124
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Riley CA, Boozer K, King TL. Antenatal corticosteroids at the beginning of the 21st century. J Midwifery Womens Health 2011; 56:591-7. [PMID: 22060219 DOI: 10.1111/j.1542-2011.2011.00119.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Corticosteroids administered to women in preterm labor are the standard of care for reducing neonatal morbidity and mortality associated with prematurity. These agents promote lung development and reduce the incidence of neonatal intraventricular hemorrhage. Several studies have investigated the method by which fetal lung fluid is cleared after birth. This exploration resulted in the elucidation of the Starling equation or the hypothesis that fluid filtration through capillary membranes is dependent on the balance between the pressure blood places on the capillary membranes and the osmotic pressure of the membranes. The clinical observation that a neonate experiences a vaginal squeeze during a vaginal birth may be important, but it can account for only a small percentage of the lung fluid absorbed. Perhaps more importantly, amiloride-sensitive sodium transport channels (ENaCs) have emerged as key factors in the movement of alveolar fluid from the lung into the vascular system. Several potential clinical applications have been developed from this new knowledge about the physiology of lung fluid clearance at birth. Neonates born late preterm or at term by elective cesarean before the onset of labor are more likely to develop respiratory distress than those born vaginally. Based on the mechanism of action of antenatal corticosteroids, these drugs may be beneficial in the clearance of fetal lung fluid in this population. This article reviews how fetal lung fluid is cleared; the pharmacologic effects of corticosteroids on the fetus; and the risks, benefits, and controversies associated with corticosteroid use.
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Affiliation(s)
- Cheryl A Riley
- Neonatal Nurse Practitioner Program, Baylor University, TX, USA
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125
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Church MW, Adams BR, Anumba JI, Jackson DA, Kruger ML, Jen KLC. Repeated antenatal corticosteroid treatments adversely affect neural transmission time and auditory thresholds in laboratory rats. Neurotoxicol Teratol 2011; 34:196-205. [PMID: 21963399 DOI: 10.1016/j.ntt.2011.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 09/14/2011] [Accepted: 09/15/2011] [Indexed: 12/12/2022]
Abstract
Antenatal corticosteroid (AC) treatment is given to pregnant women at risk for preterm birth to reduce infant morbidity and mortality by enhancing lung and brain maturation. However, there is no accepted regimen on how frequently AC treatments should be given and some studies found that repeated AC treatments can cause growth retardation and brain damage. Our goal was to assess the dose-dependent effects of repeated AC treatment and estimate the critical number of AC courses to cause harmful effects on the auditory brainstem response (ABR), a sensitive measure of brain development, neural transmission and hearing loss. We hypothesized that repeated AC treatment would have harmful effects on the offspring's ABRs and growth only if more than 3 AC treatment courses were given. To test this hypothesis, pregnant Wistar rats were given either a high regimen of AC (HAC), a moderate regimen (MAC), a low regimen (LAC), or saline (SAL). An untreated control (CON) group was also used. Simulating the clinical condition, the HAC dams received 0.2mg/kg Betamethasone (IM) twice daily for 6 days during gestation days (GD) 17-22. The MAC dams received 3 days of AC treatment followed by 3 days of saline treatment on GD 17-19 and GD 20-22, respectively. The LAC dams received 1 day of AC treatment followed by 5 days of saline treatment on GD 17 and GD 18-22, respectively. The SAL dams received 6 days of saline treatment from GD 17 to 22 (twice daily, isovolumetric to the HAC injections, IM). The offspring were ABR-tested on postnatal day 24. Results indicated that the ABR's P4 latencies (neural transmission time) were significantly prolonged (worse) in the HAC pups and that ABR's thresholds were significantly elevated (worse) in the HAC and MAC pups when compared to the CON pups. The HAC and MAC pups were also growth retarded and had higher postnatal mortality than the CON pups. The SAL and LAC pups showed little or no adverse effects. In conclusion, repeated AC treatment had harmful effects on the rat offspring's ABRs, postnatal growth and survival. The prolonged ABR latencies reflect slowed neural transmission times along the auditory nerve and brainstem auditory pathway. The elevated ABR thresholds reflect hearing deficits. We concluded that repeated AC treatment can have harmful neurological, sensory and developmental effects on the rat offspring. These effects should be considered when weighing the benefits and risks of repeated AC treatment and when monitoring and managing the prenatally exposed child for possible adverse effects.
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Affiliation(s)
- M W Church
- Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI 48201, USA.
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126
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Abstract
There is no controversy that women at risk of preterm delivery before 32 to 34 weeks' gestational age should be treated with antenatal steroids. Three recent meta-analyses by the Cochrane Collaboration on the benefits of antenatal steroids, the choice of steroid and dosing, and repeat doses of corticosteroids comprehensively summarize the available clinical information to about 2007. However, there are many unanswered questions about which steroid and dose to use and about their use in selected populations. This review focuses on those areas of uncertainty.
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Affiliation(s)
- Ronald Wapner
- Department of Obstetrics and Gynecology, Columbia University Medical Center
| | - Alan H. Jobe
- Cincinnati Children’s Hospital Medical Center, Division of Pulmonary Biology, The University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, TEL: (513) 636-8563, FAX: (513) 636-8691
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127
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Autret-Leca É, Cissoko H, Jonville-Béra AP. Risque néonatal des médicaments pris à la fin de la grossesse. Therapie 2011; 66:431-6. [DOI: 10.2515/therapie/2011057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 06/20/2011] [Indexed: 11/20/2022]
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128
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Ganzevoort W, Sibai BM. Temporising versus interventionist management (preterm and at term). Best Pract Res Clin Obstet Gynaecol 2011; 25:463-76. [DOI: 10.1016/j.bpobgyn.2011.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Accepted: 01/13/2011] [Indexed: 10/18/2022]
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129
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Crowther CA, McKinlay CJD, Middleton P, Harding JE. Repeat doses of prenatal corticosteroids for women at risk of preterm birth for improving neonatal health outcomes. Cochrane Database Syst Rev 2011:CD003935. [PMID: 21678343 PMCID: PMC4170912 DOI: 10.1002/14651858.cd003935.pub3] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND It has been unclear whether repeat dose(s) of prenatal corticosteroids are beneficial. OBJECTIVES To assess the effectiveness and safety of repeat dose(s) of prenatal corticosteroids. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011), searched reference lists of retrieved studies and contacted authors for further data. SELECTION CRITERIA Randomised controlled trials of women who had already received a single course of corticosteroids seven or more days previously and considered still at risk of preterm birth. DATA COLLECTION AND ANALYSIS We assessed trial quality and extracted data independently. MAIN RESULTS We included 10 trials (more than 4730 women and 5650 babies) with low to moderate risk of bias. Treatment of women who remain at risk of preterm birth seven or more days after an initial course of prenatal corticosteroids with repeat dose(s), compared with no repeat corticosteroid treatment, reduced the risk of their infants experiencing the primary outcomes respiratory distress syndrome (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.75 to 0.91, eight trials, 3206 infants, numbers needed to treat (NNT) 17, 95% CI 11 to 32) and serious infant outcome (RR 0.84, 95% CI 0.75 to 0.94, seven trials, 5094 infants, NNT 30, 95% CI 19 to 79).Treatment with repeat dose(s) of corticosteroid was associated with a reduction in mean birthweight (mean difference (MD) -75.79 g, 95% CI -117.63 to -33.96, nine trials, 5626 infants). However, outcomes that adjusted birthweight for gestational age (birthweight Z scores, birthweight multiples of the median and small-for-gestational age) did not differ between treatment groups.At early childhood follow-up no statistically significant differences were seen for infants exposed to repeat prenatal corticosteroids compared with unexposed infants for the primary outcomes (total deaths; survival free of any disability or major disability; disability; or serious outcome) or in the secondary outcome growth assessments. AUTHORS' CONCLUSIONS The short-term benefits for babies of less respiratory distress and fewer serious health problems in the first few weeks after birth support the use of repeat dose(s) of prenatal corticosteroids for women still at risk of preterm birth seven days or more after an initial course. These benefits were associated with a small reduction in size at birth. The current available evidence reassuringly shows no significant harm in early childhood, although no benefit.Further research is needed on the long-term benefits and risks for the woman and baby. Individual patient data meta-analysis may clarify how to maximise benefit and minimise harm.
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Affiliation(s)
- Caroline A Crowther
- ARCH: Australian Research Centre for Health of Women and Babies, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, Australia
| | | | - Philippa Middleton
- ARCH: Australian Research Centre for Health of Women and Babies, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, Australia
| | - Jane E Harding
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
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130
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Davidson JO, Quaedackers JSLT, George SA, Gunn AJ, Bennet L. Maternal dexamethasone and EEG hyperactivity in preterm fetal sheep. J Physiol 2011; 589:3823-35. [PMID: 21646408 DOI: 10.1113/jphysiol.2011.212043] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Maternal treatment with synthetic corticosteroids such as dexamethasone (DEX)significantly reduces neonatal morbidity and mortality, but its effects on the fetal brain remain unclear. In this study we evaluated the effects of DEX on EEG activity in preterm fetal sheep. Ewes at 103 days gestation received two intramuscular injections of DEX (12 mg, n = 8) or saline vehicle (n = 7) 24 h apart. Fetal EEG activity was recorded from 6 h before until 120 h after the first injection (DEX-1). DEX-1 was associated with a marked transient rise in total EEG power, maximal at 12 h (P < 0.001), with a relative increase in delta and reduced theta, alpha and beta activity, resolving by 24 h. Continuous EEG records showed a shift to larger but less frequent transient waveforms (P < 0.001). Unexpectedly, evolving epileptiform activity, consistent with electrographic and clinical seizures, developed from 178 ± 44 min after DEX-1.Similar but smaller changes were seen after the second injection. Following the injections, total power returned to control values, but the proportion of alpha activity progressively increased vs. controls (P < 0.001), with reduced interburst interval duration and number (P < 0.001). No histological neural injury or microglial activation was seen. In summary, exposure to maternal dexamethasone was associated with dramatic, evolving low-frequency hyperactivity on fetal cortical EEG recordings, followed by sustained changes consistent with maturation of fetal sleep architecture. We postulate that these effects may contribute to improved neonatal outcomes.
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Affiliation(s)
- Joanne O Davidson
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand
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131
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PELTONIEMI OUTIM, KARI MANNELI, HALLMAN MIKKO. Repeated antenatal corticosteroid treatment: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2011; 90:719-27. [DOI: 10.1111/j.1600-0412.2011.01132.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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132
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Amant F, Deckers S, Van Calsteren K, Loibl S, Halaska M, Brepoels L, Beijnen J, Cardoso F, Gentilini O, Lagae L, Mir O, Neven P, Ottevanger N, Pans S, Peccatori F, Rouzier R, Senn HJ, Struikmans H, Christiaens MR, Cameron D, Du Bois A. Breast cancer in pregnancy: recommendations of an international consensus meeting. Eur J Cancer 2011; 46:3158-68. [PMID: 20932740 DOI: 10.1016/j.ejca.2010.09.010] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 09/03/2010] [Indexed: 01/09/2023]
Abstract
PURPOSE To provide guidance for clinicians about the diagnosis, staging and treatment of breast cancer occurring during an otherwise uncomplicated pregnancy. METHODS An international expert Panel convened to address a series of questions identified by a literature review and personal experience. Issues relating to the diagnosis and management of breast cancer after delivery were outside the scope. RESULTS There is a paucity of large and/or randomized studies. Based on cohort studies, case series and case reports, the recommendations represent the best available evidence, albeit of a lower grade than is optimal. RECOMMENDATIONS In most circumstances, serious consideration should be given to the option of treating breast cancer whilst continuing with the pregnancy. Each woman should ideally be referred to a centre with sufficient expertise, given a clear explanation of treatment options. Most diagnostic and staging examinations can be performed adequately and safely during pregnancy. Treatment should however be adapted to the clinical presentation and the trimester of the pregnancy: surgery can be performed during all trimesters of pregnancy; radiotherapy can be considered during the first and second trimester but should be postponed during the third trimester; and standard chemotherapies can be used during the second and third trimester. Since neonatal morbidity mainly appears to be related to prematurity, delivery should not be induced before 37 weeks, if at all possible. CONCLUSIONS The treatment of breast cancer in pregnancy should be executed by experienced specialists in a multidisciplinary setting and should adhere as closely as possible to standard protocols.
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Affiliation(s)
- Frédéric Amant
- Multidisciplinary Breast Center, Leuven Cancer Institute, UZ Gasthuisberg, Katholieke Universiteit Leuven, Belgium.
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133
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Coutant R. Hormones et comportement Les traitements hormonaux, quels effets sur le comportement ? Arch Pediatr 2011. [DOI: 10.1016/s0929-693x(11)70964-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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134
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Abstract
The perinatal period is particularly sensitive to a variety of insults during which stress-regulating systems can be permanently altered and psychopathologies ensue. The programming of physiological, endocrinological, and behavioral functions by perinatal adversities is mediated by altered levels of glucocorticoids or the hypothalamic-pituitary-adrenal axis activity in either the mother or offspring. In this article, I review the integrated data from human studies and from animal models that suggest the programming effects of perinatal glucocorticoids exposure. Finally, the concept of developmental origins of psychiatric disorders is discussed.
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Affiliation(s)
- Li-Tung Huang
- Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
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135
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Velíšek L. Prenatal corticosteroid exposure alters early developmental seizures and behavior. Epilepsy Res 2011; 95:9-19. [PMID: 21429712 DOI: 10.1016/j.eplepsyres.2011.01.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 01/24/2011] [Accepted: 01/26/2011] [Indexed: 10/18/2022]
Abstract
In humans, corticosteroids are often administered prenatally to improve lung development in preterm neonates. Studies in exposed children as well as in children, whose mothers experienced significant stress during pregnancy indicate behavioral problems and possible increased occurrence of epileptic spasms. This study investigated whether prenatal corticosteroid exposure alters early postnatal seizure susceptibility and behaviors. On gestational day 15, pregnant rats were injected i.p. with hydrocortisone (2×10mg/kg), betamethasone (2×0.4mg/kg) or vehicle. On postnatal day (P)15, seizures were induced by flurothyl or kainic acid (3.5 or 5.0mg/kg). Horizontal bar holding was determined prior to seizures and again on P17. Performance in the elevated plus maze was assessed on P20-22. Prenatal exposure to betamethasone decreased postnatal susceptibility to flurothyl-induced clonic seizures but not to kainic acid-induced seizures. Prenatal hydrocortisone decreased postnatal weight but did not affect seizure susceptibility. Hydrocortisone alone did not affect performance in behavioral tests except for improving horizontal bar holding on P17. A combination of prenatal hydrocortisone and postnatal seizures resulted in increased anxiety. Prenatal exposure to mineralocorticoid receptor blocker canrenoic acid did not attenuate, but surprisingly amplified the effects of hydrocortisone on body weight and significantly worsened horizontal bar performance. Thus, prenatal exposure to excess corticosteroids alters postnatal seizure susceptibility and behaviors. Specific effects may depend on corticosteroid species.
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Affiliation(s)
- Libor Velíšek
- Department of Cell Biology & Anatomy, Department of Pediatrics, New York Medical College, 15 Dana Rd., Valhalla, NY, USA. Libor
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136
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Norberg H, Stålnacke J, Diaz Heijtz R, Smedler AC, Nyman M, Forssberg H, Norman M. Antenatal corticosteroids for preterm birth: dose-dependent reduction in birthweight, length and head circumference. Acta Paediatr 2011; 100:364-9. [PMID: 21054513 DOI: 10.1111/j.1651-2227.2010.02074.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM This study was undertaken to evaluate the effects of repeated courses of antenatal corticosteroids (ACS) on foetal growth. METHODS We studied 94 infants exposed to 2-9 courses of ACS. Mean gestational age (GA) at first exposure was 29 and at birth 34 weeks. Exposure data were retrieved from case record files. Information on potential confounders was collected from the Swedish Medical Birth Registry. Standard deviation scores (SDS) for birthweight (BW), birthlength (BL) and head circumference (HC) were calculated and considered as outcomes. RESULTS GA at start of ACS did not affect outcome. BW-SDS, BL-SDS and HC-SDS were -0.21, -0.19 and +0.25 in infants exposed to two courses, compared to -1.01, -1.04 and -0.23 in infants exposed to ≥ 4 courses of ACS (p = 0.04-0.07). In multiple regression analyses, ≥ 4 courses were associated with lower BW-SDS, BL-SDS and HC-SDS (p = 0.007-0.04) compared to SDS after 2-3 courses. The effects from ≥ 4 courses on BW and BL were comparable to reduction in birth size seen in twins and on HC to that observed after maternal smoking. CONCLUSIONS Multiple courses of ACS are associated with a dose-dependent decline in foetal growth, which may affect later development and health.
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Affiliation(s)
- Hanna Norberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
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Barnett CP, Chitayat D, Bradley TJ, Wang Y, Hinek A. Dexamethasone normalizes aberrant elastic fiber production and collagen 1 secretion by Loeys-Dietz syndrome fibroblasts: a possible treatment? Eur J Hum Genet 2011; 19:624-33. [PMID: 21267002 DOI: 10.1038/ejhg.2010.259] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized by facial dysmorphism, cleft palate, dilation of the aortic arch, blood vessel tortuosity and a high risk of aortic dissection. It is caused by mutations in the transforming growth factor β-receptor 1 and 2 (TGFβ-R1 and TGFβ-R2) genes. Fibroblasts derived from 12 Loeys-Dietz syndrome patients, six with TGFB-R1 mutations and six with TGFB-R2 mutations, were analyzed using RT-PCR, biochemical assays, immunohistochemistry and electron microscopy for production of elastin, fibrillin 1, fibulin 1 and fibulin 4 and deposition of collagen type I. All LDS fibroblasts with TGFβ-R1 mutations demonstrated decreased expression of elastin and fibulin 1 genes and impaired deposition of elastic fibers. In contrast, fibroblasts with TGFβ-R2 mutations consistently demonstrated intracellular accumulation of collagen type I in the presence of otherwise normal elastic fiber production. Treatment of the cell cultures with dexamethasone induced remarkable upregulation in the expression of tropoelastin, fibulin 1- and fibulin 4-encoding mRNAs, leading to normalization of elastic fiber production in fibroblasts with TGFβ-R1 mutations. Treatment with dexamethasone also corrected the abnormal secretion of collagen type I from fibroblasts with TGFβ-R2 gene mutations. As the organogenesis-relevant elastic fiber production occurs exclusively in late fetal and early neonatal life, these findings may have implications for treatment in early life. Further studies are required to determine if dexamethasone treatment of fetuses prenatally diagnosed with LDS would prevent or alleviate the connective tissue and vascular defects seen in this syndrome.
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Affiliation(s)
- Christopher P Barnett
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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138
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Abstract
Because they might not be efficient in reducing neonatal morbidities associated with preterm birth after 7 days of exposure, antenatal corticosteroids have been systematically repeated every week or every 2 weeks in the late 90's. Evaluation of these strategies by randomized trials demonstrated, for the neonates exposed to multiple courses, short-term neonatal benefits, mainly pulmonary, but also alterations of fetal growth and potential impairments in neurodevelopmental outcomes, without benefits at 2 years of age. This is the reason why systematic repetitive doses of antenatal corticosteroids have been stopped and has emerged the concept of rescue course in which betamethasone is given only when delivery has again become likely. It can be concluded from the only two randomized trials having evaluated this strategy that antenatal corticosteroids rescue courses might be beneficial in reducing acute pulmonary morbidity, without noticeable effects on fetal growth. Scientific data suggesting the efficacy and innocuousness of antenatal corticosteroids rescue courses in the early neonatal period are now available, however, they should be further confirmed by new randomized trials and follow up studies before this strategy can be recommended for a daily clinical practice.
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Affiliation(s)
- T Schmitz
- AP-HP, Hôpital Robert Debré, Service de Gynécologie Obstétrique, Paris, France.
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139
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Asztalos EV, Murphy KE, Hannah ME, Willan AR, Matthews SG, Ohlsson A, Kelly EN, Saigal S, Ross S, Delisle MF, Amankwah K, Guselle P, Gafni A, Lee SK, Armson BA, Sananes R, Tomat L. Multiple courses of antenatal corticosteroids for preterm birth study: 2-year outcomes. Pediatrics 2010; 126:e1045-55. [PMID: 20956409 DOI: 10.1542/peds.2010-0857] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine the effects of repeated courses of prenatal corticosteroid therapy versus placebo on death or neurologic impairment among the children enrolled in the Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study, at 18 to 24 months of age. METHODS A total of 2305 infants were eligible for follow-up evaluation; 2104 infants (1069 in the prenatal corticosteroid therapy group and 1035 in the placebo group) were monitored. The primary outcome was death or neurologic impairment, defined as either cerebral palsy or cognitive delay, at 18 to 24 months of age. The secondary outcomes were measurements of growth (height, weight, and head circumference). RESULTS Children exposed to multiple courses of prenatal corticosteroid therapy had similar rates of death or neurologic impairment, compared with children exposed to placebo (148 children [13.8%] vs 142 children [13.7%]; odds ratio: 1.001[95% confidence interval: 0.75-1.30]; P = .95). They had a mean weight of 11.94 kg, compared with 12.14 kg in the placebo group (P = .04), a mean height of 85.51 cm, compared with 85.46 cm (P = .87), and a mean head circumference of 48.18 cm, compared with 48.25 cm (P = .45). CONCLUSIONS Multiple courses of prenatal corticosteroid therapy, given every 14 days, did not increase or decrease the risk of death or neurologic impairment at 18 to 24 months of age, compared with a single course of prenatal corticosteroid therapy. Continued follow-up monitoring of these children is necessary to assess neurobehavioral function, school performance, and possible susceptibility to disease.
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Affiliation(s)
- Elizabeth V Asztalos
- Department of Newborn and Developmental Paediatrics, Centre for Mother, Infant, and Child Research, Sunnybrook Health Sciences Centre, M4-233 2075 Bayview Ave Toronto, Ontario, M4N 3M5, Canada.
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140
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Church MW, Wapner RJ, Mele LM, Johnson F, Dudley DJ, Spong CY, Peaceman AM, Moawad AH, O’Sullivan MJ, Miodovnik M. Repeated courses of antenatal corticosteroids: are there effects on the infant's auditory brainstem responses? Neurotoxicol Teratol 2010; 32:605-10. [PMID: 20553856 PMCID: PMC2955992 DOI: 10.1016/j.ntt.2010.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 05/04/2010] [Accepted: 05/20/2010] [Indexed: 11/17/2022]
Abstract
Our objective was to assess the effects of repeated antenatal corticosteroid treatments on the neonatal auditory brainstem response (ABR), a sensitive measure of neonatal brain maturity and auditory function. To achieve this, we performed and blindly evaluated neonatal ABRs on a subset of infants delivering within a multicenter randomized placebo-controlled clinical trial comparing single versus repeated courses of antenatal corticosteroid treatments for women at 23-31 weeks gestation who remained at increased risk for preterm birth. The women were randomly assigned to either the single or the repeated antenatal corticosteroid treatment group. Women in the repeated antenatal corticosteroid group received weekly antenatal corticosteroid treatments until 34 weeks gestation or until they reached a study-determined limited number of courses, whereas women in the single antenatal corticosteroid group received an initial course of corticosteroid followed by weekly placebo injections. We performed ABR testing on their infants prior to discharge. The latencies of waves I, III and V and the peak-to-trough amplitudes of waves I and V were compared between those in the single (n=27) and repeated antenatal corticosteroid treatment (n=24) groups. The majority of repeated antenatal corticosteroid infants (20 of 24) were exposed to ≥ 4 antenatal corticosteroid treatments. Even though gestational age was similar between our subset of single and repeated antenatal corticosteroid treatment groups, infant birth weight and length and head circumference were significantly smaller in the repeated antenatal corticosteroid group (p <0.05). Despite these differences in birth sizes, there were no significant group differences in the ABR wave latencies or amplitudes. We concluded that our repeated antenatal corticosteroid treatments, in comparison to a single treatment, did not significantly benefit or harm the neonatal ABR despite significant effects on birth size.
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Affiliation(s)
- Michael W. Church
- Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Ronald J. Wapner
- Obstetrics & Gynecology, Drexel University College of Medicine, Philadelphia, PA 19103, USA
| | - Lisa M. Mele
- The George Washington University Biostatistics Center, Rockville, MD 20852, USA
| | - Francee Johnson
- Obstetrics & Gynecology, Ohio State University, Columbus, OH 43210, USA
| | - Donald J. Dudley
- Obstetrics & Gynecology, University of Utah, Salt Lake City, UT 84132, USA
| | - Catherine Y. Spong
- National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Alan M. Peaceman
- Obstetrics & Gynecology, Northwestern University, Chicago, IL 60611, USA
| | - Atef H. Moawad
- Obstetrics & Gynecology, University of Chicago, Chicago, IL 60637, USA
| | | | - Menachem Miodovnik
- Obstetrics & Gynecology, University of Cincinnati, Cincinnati, OH 45267, USA
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141
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Reynolds RM. Corticosteroid-mediated programming and the pathogenesis of obesity and diabetes. J Steroid Biochem Mol Biol 2010; 122:3-9. [PMID: 20117209 DOI: 10.1016/j.jsbmb.2010.01.009] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Revised: 12/21/2009] [Accepted: 01/20/2010] [Indexed: 01/23/2023]
Abstract
Epidemiological studies have shown that low birthweight is associated with increased risk of development of diabetes and obesity in later life. Over-exposure of the developing fetus to glucocorticoids is one of the major hypotheses that has been proposed to explain this association. In animal models, a range of manipulations that increase fetal glucocorticoid load, 'programme' permanent changes in glucose and insulin metabolism and adiposity. This may be mediated by alterations in regulation of the hypothalamic-pituitary-adrenal (HPA) axis. In humans, low birthweight is associated with increased circulating glucocorticoid levels, and an increased cortisol response to physiological and psychosocial stressors, in child- and adulthood. This activation of the HPA axis is also associated with increased risk of development of diabetes and obesity in later life.
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Affiliation(s)
- Rebecca M Reynolds
- Endocrinology Unit, Centre for Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, United Kingdom.
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142
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McEvoy C, Schilling D, Peters D, Tillotson C, Spitale P, Wallen L, Segel S, Bowling S, Gravett M, Durand M. Respiratory compliance in preterm infants after a single rescue course of antenatal steroids: a randomized controlled trial. Am J Obstet Gynecol 2010; 202:544.e1-9. [PMID: 20227053 DOI: 10.1016/j.ajog.2010.01.038] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Revised: 01/15/2010] [Accepted: 01/15/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To compare respiratory compliance and functional residual capacity in infants randomized to a rescue course of antenatal steroids vs placebo. STUDY DESIGN Randomized, double-blinded trial. Pregnant women > or =14 days after initial antenatal steroids were randomized to rescue antenatal steroids or placebo. The primary outcomes were measurements of respiratory compliance and functional residual capacity. This study is registered with clinicaltrials.gov (NCT00669383). RESULTS Forty-four mothers (56 infants) received rescue antenatal steroids and 41 mothers (57 infants) received placebo. There was no significant difference in birthweight, or head circumference. Infants in the rescue group had an increased respiratory compliance (1.21 vs 1.01 mL/cm H(2)O/kg; adjusted 95% confidence interval, 0.01-0.49; P = .0433) compared with placebo. 13% in the rescue vs 29% in the placebo group required > or =30% oxygen (P < .05). Patients delivered at < or =34 weeks had greater pulmonary benefits. CONCLUSION Infants randomized to rescue antenatal steroids have a significantly increased respiratory compliance compared with placebo.
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Affiliation(s)
- Cindy McEvoy
- Division of Neonatology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA.
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143
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Bevilacqua E, Brunelli R, Anceschi MM. Review and meta-analysis: Benefits and risks of multiple courses of antenatal corticosteroids. J Matern Fetal Neonatal Med 2010. [DOI: 10.3109/14767050903165222] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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144
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McKendry AA, Palliser HK, Yates DM, Walker DW, Hirst JJ. The effect of betamethasone treatment on neuroactive steroid synthesis in a foetal Guinea pig model of growth restriction. J Neuroendocrinol 2010; 22:166-74. [PMID: 20041984 DOI: 10.1111/j.1365-2826.2009.01949.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There are ongoing concerns that antenatal corticosteroids, which are administered to women at high risk of delivering preterm to reduce the incidence of respiratory distress syndrome, have adverse effects on foetal brain development and subsequent effects on behaviour and learning, when administered as repeated courses. The present study aimed to examine whether repeated betamethasone treatment alters the expression of the key-rate limiting enzyme, 5alpha-reductase, in the synthetic pathway of the potent neuroactive steroid allopregnanolone in the brain and placenta and whether this effect is potentiated in growth restricted foetuses. To investigate this, pregnant guinea pigs carrying either control (sham surgery) or growth-restricted foetuses were treated with vehicle or betamethasone (1 mg/kg/day) for 4 days prior to sacrifice (65d). Placental insufficiency was induced by the ablation of uterine artery branches supplying each placenta at mid gestation, resulting in foetal growth restriction characterised by 'brain sparing'. Real-time reverse transcriptase polymerase chain reaction was used to determine relative 5alpha-reductase type 1 and 2 mRNA expression in the placenta and brain. Immunohistochemistry was used to examine the glial fibrillary acidic protein (GFAP) expression in the subcortical white matter, CA1 and dentate regions of the hippocampus. 5alpha-reductase type 2 mRNA expression in the brain was markedly reduced by betamethasone treatment in male foetuses compared to vehicle-treated controls but not in female foetuses. In addition, 5alpha-reductase type 1 expression in the brain was increased by growth restriction and/or betamethasone treatment in female foetuses but expression in males foetuses did not increase. 5alpha-reductase type 2 expression in the placenta was markedly reduced by betamethasone treatment compared to vehicle-treated control. Intrauterine growth restriction and betamethasone treatment reduced GFAP expression in the CA1 region of the hippocampus in the brains of male but not female foetuses. These data indicate that betamethasone treatment suppresses placental expression and has sexually dimorphic effects on expression of neuroactive steroid synthetic enzymes in the brain. These actions may lead to adverse effects on the developing brain, particularly in male foetuses, such as the observed effects on GFAP expression.
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Affiliation(s)
- A A McKendry
- Mothers & Babies Research Centre and School of Biomedical Sciences, University of Newcastle, Newcastle, NSW, Australia.
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145
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Dunn E, Kapoor A, Leen J, Matthews SG. Prenatal synthetic glucocorticoid exposure alters hypothalamic-pituitary-adrenal regulation and pregnancy outcomes in mature female guinea pigs. J Physiol 2010; 588:887-99. [PMID: 20064858 DOI: 10.1113/jphysiol.2009.182139] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Preterm delivery occurs in approximately 10% of all pregnancies. Prenatal exposure to synthetic glucocorticoids (sGCs) reduces the incidence of respiratory distress syndrome (RDS) in these babies. Therefore, administration of multiple courses of sGCs became common practice. Animal and human studies have demonstrated that multiple courses of sGCs can have long-term effects. While the majority of animal studies have been undertaken in male offspring, it is emerging that there are profound sex differences in the consequences of prenatal sGC exposure. To our knowledge, no studies have determined the effects of prenatal sGC exposure on hypothalamic-pituitary-adrenal (HPA) axis function in female offspring while accounting for reproductive cycle status, or determined if there are effects on pregnancy parameters. Pregnant guinea pigs were administered three courses of betamethasone (Beta), dexamethasone (Dex) or vehicle on gestational days 40/41, 50/51 and 60/61. In adulthood (age range: postnatal days 126-165), basal and activated HPA axis function were assessed at various stages of the reproductive cycle. The female offspring were then mated and underwent an undisturbed pregnancy. Females were killed in the luteal phase of the reproductive cycle following litter weaning, and molecular analysis undertaken. In the luteal phase, Beta-exposed females exhibited significantly lower basal salivary cortisol levels (P < 0.05). Dex-exposed females also exhibited significantly lower basal salivary cortisol levels during the luteal phase (P < 0.05), but increased basal salivary cortisol levels during the ostrous phase (P < 0.01). The Beta-exposed females exhibited increased glucocorticoid receptor (GR) mRNA expression in the CA1/2 region of the hippocampus (P < 0.05) and MC2R mRNA in the adrenal cortex (P < 0.05). The Dex-exposed animals exhibited higher hippocampal GR and mineralocorticoid receptor (MR) mRNA levels (P < 0.05). Beta-exposed females showed reduced fecundity (P < 0.05). In Dex-exposed females there was a lower male to female sex ratio. In conclusion, prenatal sGC exposure affects HPA axis activity, in a cycle-dependent manner, and long-term reproductive success. The clinical implications of the findings on endocrine function and pregnancy in females are profound and further follow-up is warranted in human cohorts. Furthermore, we have shown there are considerable difference in phenotypes between the Beta- and Dex-exposed females and the specific endocrine and maternal outcome is contingent on the specific sGCs administered during pregnancy.
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Affiliation(s)
- Elizabeth Dunn
- Department of Physiology, Faculty of Medicine, University of Toronto, Medical Sciences Building, Toronto, Ontario, Canada
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146
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Braun T, Li S, Sloboda DM, Li W, Audette MC, Moss TJM, Matthews SG, Polglase G, Nitsos I, Newnham JP, Challis JRG. Effects of maternal dexamethasone treatment in early pregnancy on pituitary-adrenal axis in fetal sheep. Endocrinology 2009; 150:5466-77. [PMID: 19846612 DOI: 10.1210/en.2009-0086] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fetal exposure to elevated levels of bioactive glucocorticoids early in gestation, as in suspected cases of congenital adrenal hyperplasia, may result in adverse neurological events. Fetal hypothalamic-pituitary-adrenal development and function may be involved. We investigated immediate and long-term effects of maternal dexamethasone (DEX) administration early in pregnancy on fetal growth and pituitary-adrenal activity in sheep. Pregnant ewes carrying singleton fetuses (total n = 119) were randomized to control (2 ml saline/ewe) or DEX-treated groups (im injections of 0.14 mg/kg ewe weight . 12 h) at 40-41 d gestation (dG). At 50, 100, 125, and 140 dG, fetal plasma and tissues were collected. DEX-exposed fetuses were lighter than controls at 100 dG (P < 0.05) but not at any other times. Fetal plasma ACTH levels and pituitary POMC and PC-1 mRNA levels were similar between groups. Fetal plasma cortisol levels were significantly reduced after DEX exposure in both male and female fetuses at 50 dG (P < 0.05), were similar at 100 and 125 dG, but were significantly higher than controls at 140 dG. At 140 dG, there was increased adrenal P450C(17) and 3beta-HSD mRNA in female fetuses and reduced expression of ACTH-R mRNA in males. Fetal hepatic CBG mRNA levels mimicked plasma cortisol patterns. DEX exposure reduced CBG only in males at 50 dG (P < 0.05). Placental mRNA levels of 11beta-HSD2 were increased after DEX in males (P < 0.05). Therefore, in sheep, early DEX may alter the developmental trajectory of the fetal hypothalamic-pituitary-adrenal axis, directly increasing fetal adrenal activation but not anterior pituitary function. In females, this effect may be attributed, in part, to increased fetal adrenal steroidogenic activity.
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Affiliation(s)
- Thorsten Braun
- Department of Physiology and Obstetrics and Gynecology, University of Toronto, Toronto, Ontario M5S 1A8, Canada
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147
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Grivell R, Dodd J, Robinson J. The prevention and treatment of intrauterine growth restriction. Best Pract Res Clin Obstet Gynaecol 2009; 23:795-807. [DOI: 10.1016/j.bpobgyn.2009.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Revised: 04/25/2009] [Accepted: 06/06/2009] [Indexed: 10/20/2022]
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148
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Verhaeghe J, van Bree R, Van Herck E. Oxidative stress after antenatal betamethasone: acute downregulation of glutathione peroxidase-3. Early Hum Dev 2009; 85:767-71. [PMID: 19926412 DOI: 10.1016/j.earlhumdev.2009.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Revised: 10/13/2009] [Accepted: 10/30/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND Human and experimental data show that antenatal exposure to glucocorticoids (GC) temporarily reduces fetal well-being and impairs the fetal response to hypoxemia. AIMS We tested the hypothesis that antenatal betamethasone provokes transient oxidative stress, which may be triggered directly by the GC or indirectly by metabolic signals such as increased glucose and free fatty acid (FFA) concentrations. STUDY DESIGN Prospective (single center, 18 months) cohort study in newborns <34 weeks gestational age at birth. METHODS We studied 105 newborns and measured oxidative damage to lipids [malondialdehyde (MDA)] and proteins (protein carbonyls), as well as glutathione peroxidase-3 (GPx3), an important antioxidant enzyme, in umbilical vein (UV) plasma. In addition, we measured umbilical artery and UV blood gases, and metabolic indices (plasma glucose, FFA and insulin) in UV. RESULTS MDA but not protein carbonyl concentrations was inversely related to time elapsed since the first or last betamethasone administration (p=0.006); MDA remained elevated by 69-96% for at least 72 h after the last betamethasone. By contrast, GPx3 concentrations were repressed in newborns who received betamethasone < or =24h before birth. GPx3 and MDA concentrations were correlated (r=-0.38, p<0.001). Labor, GA, sex, size at birth, blood gases or metabolic indices did not explain the effects of betamethasone on MDA and GPx3. CONCLUSIONS Antenatal GC elicit a rapid suppression of the GPx3 antioxidant defense system which may contribute to a longer-lasting but also transient rise in lipid oxidative damage.
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Affiliation(s)
- Johan Verhaeghe
- Department of Obstetrics and Gynecology, Health Campus Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
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149
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Vento M, Aguar M, Escobar J, Arduini A, Escrig R, Brugada M, Izquierdo I, Asensi MA, Sastre J, Saenz P, Gimeno A. Antenatal steroids and antioxidant enzyme activity in preterm infants: influence of gender and timing. Antioxid Redox Signal 2009; 11:2945-55. [PMID: 19645572 DOI: 10.1089/ars.2009.2671] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Antenatal steroids have improved the survival of preterm infants; however, the mechanism of action is not fully understood. We aimed to establish an association between antenatal steroids and antioxidant activity and postnatal oxidative stress. In a prospective cohort study, extremely preterm neonates receiving antenatal steroids (CORT) or not (NOCORT) were enrolled. An association between antenatal steroids and activities of antioxidant enzymes and glutathione cycle enzymes in cord blood was found. In addition, reduced oxidative stress (GSH/GSSG ratio, CORT vs. NOCORT, 35.68 + or - 12.20 vs. 28.38 + or - 9.92; p < 0.01) and, decreased oxidation of proteins (ortho-tyrosine/phenylalanine ratio, CORT vs. NOCORT, 8.66 + or - 2.45 vs. 12.55 + or - 4.41; p < 0.01) and DNA (8oxodG/2dG ratio, CORT vs. NOCORT, 6.73 + or - 2.18 vs. 9.53 + or - 3.83; p < 0.01) also was found. Antenatal steroids were associated with reduced oxygen supplementation, mechanical ventilation, and conditions such as bronchopulmonary dysplasia, intra-periventricular hemorrhage, or retinopathy of prematurity. The maximal effectiveness was when steroids were administered 2-4 days before delivery. Female preterm infants had less oxidative stress and increased antioxidant activity and better clinical outcomes than did male infants, independent of receiving or not antenatal steroids. Antenatal steroids are accompanied by a reduction in postnatal oxidative-stress-derived conditions and increased antioxidant enzyme activity. Both these effects seem to be influenced by specific timing and female gender.
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Affiliation(s)
- Máximo Vento
- Division of Neonatology, University Hospital La Fe, Valencia, Spain
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150
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Affiliation(s)
- Olli M Pitkänen
- Division of Paediatric Cardiology, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland.
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