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Wilson RD. Antenatal reproductive screening for pregnant people including preconception: Provides the best reproductive opportunity for informed consent, quality, and safety. Best Pract Res Clin Obstet Gynaecol 2024:102520. [PMID: 38991859 DOI: 10.1016/j.bpobgyn.2024.102520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 05/28/2024] [Accepted: 06/12/2024] [Indexed: 07/13/2024]
Abstract
INTRODUCTION This antenatal screening review will include reproductive screening evidence and approaches for pre-conception and post-conception, using first to third trimester screening opportunities. METHODS Focused antenatal screening peer-reviewed publications were evaluated and summarized. RESULTS Evidenced-based reproductive antenatal screening elements should be offered and discussed, with the pregnancy planning or pregnant person, during Preconception (genetic carrier screening for reproductive partners, personal and family (including reproductive partner) history review for increased genetic and pregnancy morbidity risks); First Trimester (fetal dating with ultrasound; fetal aneuploidy screening plus consideration for expanded fetal morbidity criteria, if appropriate; pregnant person preeclampsia screening; early fetal anatomy screening; early fetal cardiac screening); Second Trimester for standard fetal anatomy screening (18-22 weeks) including cardiac; pregnant person placental and cord pathology screening; pregnant person preterm birth screening with cervical length measurement); Third Trimester (fetal growth surveillance; continued preterm birth risk surveillance). CONCLUSION Antenatal reproductive screening has multiple elements, is complex, is time-consuming, and requires the use of pre- and post-testing counselling for most screening elements. The use of preconception and trimesters 'one to three' requires clear patient understanding and buy-in. Informed consent and knowledge transfer is a main goal for antenatal reproductive screening approaches.
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Affiliation(s)
- R Douglas Wilson
- Emeritus Department of Obstetrics and Gynecology Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Sagar RL, Åström E, Chitty LS, Crowe B, David AL, DeVile C, Forsmark A, Franzen V, Hermeren G, Hill M, Johansson M, Lindemans C, Lindgren P, Nijhuis W, Oepkes D, Rehberg M, Sahlin NE, Sakkers R, Semler O, Sundin M, Walther-Jallow L, Verweij EJTJ, Westgren M, Götherström C. An exploratory open-label multicentre phase I/II trial evaluating the safety and efficacy of postnatal or prenatal and postnatal administration of allogeneic expanded fetal mesenchymal stem cells for the treatment of severe osteogenesis imperfecta in infants and fetuses: the BOOSTB4 trial protocol. BMJ Open 2024; 14:e079767. [PMID: 38834319 PMCID: PMC11163617 DOI: 10.1136/bmjopen-2023-079767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 05/22/2024] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION Severe osteogenesis imperfecta (OI) is a debilitating disease with no cure or sufficiently effective treatment. Mesenchymal stem cells (MSCs) have good safety profile, show promising effects and can form bone. The Boost Brittle Bones Before Birth (BOOSTB4) trial evaluates administration of allogeneic expanded human first trimester fetal liver MSCs (BOOST cells) for OI type 3 or severe type 4. METHODS AND ANALYSIS BOOSTB4 is an exploratory, open-label, multiple dose, phase I/II clinical trial evaluating safety and efficacy of postnatal (n=15) or prenatal and postnatal (n=3, originally n=15) administration of BOOST cells for the treatment of severe OI compared with a combination of historical (1-5/subject) and untreated prospective controls (≤30). Infants<18 months of age (originally<12 months) and singleton pregnant women whose fetus has severe OI with confirmed glycine substitution in COL1A1 or COL1A2 can be included in the trial.Each subject receives four intravenous doses of 3×106/kg BOOST cells at 4 month intervals, with 48 (doses 1-2) or 24 (doses 3-4) hours in-patient follow-up, primary follow-up at 6 and 12 months after the last dose and long-term follow-up yearly until 10 years after the first dose. Prenatal subjects receive the first dose via ultrasound-guided injection into the umbilical vein within the fetal liver (16+0 to 35+6 weeks), and three doses postnatally.The primary outcome measures are safety and tolerability of repeated BOOST cell administration. The secondary outcome measures are number of fractures from baseline to primary and long-term follow-up, growth, change in bone mineral density, clinical OI status and biochemical bone turnover. ETHICS AND DISSEMINATION The trial is approved by Competent Authorities in Sweden, the UK and the Netherlands (postnatal only). Results from the trial will be disseminated via CTIS, ClinicalTrials.gov and in scientific open-access scientific journals. TRIAL REGISTRATION NUMBERS EudraCT 2015-003699-60, EUCT: 2023-504593-38-00, NCT03706482.
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Affiliation(s)
- Rachel L Sagar
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Eva Åström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Lyn S Chitty
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Genetics and Genomics, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Belinda Crowe
- Department of Neurosciences, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Catherine DeVile
- Department of Neurosciences, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Göran Hermeren
- Department of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Melissa Hill
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Genetics and Genomics, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Mats Johansson
- Department of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Caroline Lindemans
- Department of Pediatrics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Peter Lindgren
- Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Wouter Nijhuis
- Department of Orthopedic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Mirko Rehberg
- Department of Pediatrics, University Hospital Cologne, Koln, Nordrhein-Westfalen, Germany
| | - Nils-Eric Sahlin
- Department of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Ralph Sakkers
- Department of Orthopedic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - O Semler
- Department of Pediatrics, University Hospital Cologne, Koln, Nordrhein-Westfalen, Germany
| | - Mikael Sundin
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Section of Pediatic Hematology, Immunology and HCT, Karolinska University Hospital, Stockholm, Sweden
| | - Lilian Walther-Jallow
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - E J T Joanne Verweij
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Magnus Westgren
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Götherström
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Alexe A, Eisele O, Fernandes MFS, Garg A, Kovacs B, Wurst K, Balramsingh-Harry L, Abramova N, Zheteyeva Y, Lewis D. Call to action: Harmonization of pharmacovigilance regulations for post-marketing pregnancy and breastfeeding safety studies. Br J Clin Pharmacol 2024; 90:715-721. [PMID: 37793773 DOI: 10.1111/bcp.15920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 09/17/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023] Open
Abstract
Globally, more than 200 million women become pregnant each year, most of whom receive medications despite limited information on their safe use during pregnancy. The paucity of drug safety data on pregnant and breastfeeding women stems from the routine exclusion of this population from clinical trials due to scientific, ethical, regulatory and legal concerns. Consequently, at the time of initial drug approval, there may be scant safety data to inform the drug benefit-risk balance to the mother, foetus or infant. Although momentum is growing to include this underrepresented population in clinical trials, most information on drug exposure outcomes comes from data collected in the postmarketing setting. Regulatory guidance and legislation on medication use in pregnancy and breastfeeding were reviewed globally by the TransCelerate IGR PV Pregnancy and Breastfeeding Team. The International Conference of Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) standards and Council for International Organizations of Medical Sciences guidelines served as benchmarks for national safety regulations and guidance. The landscape assessment identified a lack of harmonization of global regulations on research in pregnant and breastfeeding women and a lack of specific regulations on this topic in the majority of the territories included in the assessment. This article focuses on the ambiguities and lack of harmonization in global regulations on postmarketing pregnancy and breastfeeding safety studies. There is currently no ICH standard to guide these types of safety studies and, in most regions reviewed, there are no clear regulations or guidance on when and how to conduct them. While a challenging undertaking, greater clarity and harmonization would facilitate more timely completion of postmarketing pregnancy safety studies that would ultimately generate the critical data needed to optimize benefit-risk decisions for women who may conceive, as well as pregnant and breastfeeding women.
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Affiliation(s)
- Amalia Alexe
- Novartis, Lichtstrasse 35, Basel, 4056, Switzerland
| | | | | | - Anju Garg
- Sanofi, Bridgewater, Massachusetts, USA
| | - Birgit Kovacs
- Boehringer Ingelheim Pharmaceuticals, Danbury, Connecticut, USA
| | - Keele Wurst
- GlaxoSmithKline, Raleigh, North Carolina, USA
| | | | | | | | - David Lewis
- Novartis, Lichtstrasse 35, Basel, 4056, Switzerland
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Allegaert K, Salaets T, Wade K, Short MA, Ward R, Singh K, Turner MA, Davis JM, Lewis T. The neonatal adverse event severity scale: current status, a stakeholders' assessment, and future perspectives. Front Pediatr 2024; 11:1340607. [PMID: 38259600 PMCID: PMC10800487 DOI: 10.3389/fped.2023.1340607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
To support informed decisions on drug registration and prescription, clinical trials need tools to assess the efficacy and safety signals related to a given therapeutic intervention. Standardized assessment facilitates reproducibility of results. Furthermore, it enables weighted comparison between different interventions, instrumental to facilitate shared decisions. When focused on adverse events in clinical trials, tools are needed to assess seriousness, causality and severity. As part of such a toolbox, the international Neonatal Consortium (INC) developed a first version of the neonatal adverse event severity scale (NAESS). This version underwent subsequent validation in retro-and prospective trials to assess its applicability and impact on the inter-observer variability. Regulators, sponsors and academic researchers also reported on the use of the NAESS in regulatory documents, trial protocols and study reports. In this paper, we aim to report on the trajectory, current status and impact of the NAESS score, on how stakeholders within INC assess its relevance, and on perspectives to further develop this tool.
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Affiliation(s)
- Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Clinical Pharmacy, Erasmus MC, Rotterdam, Netherlands
| | - Thomas Salaets
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Pediatric Cardiology, University Hospitals, Leuven, Belgium
| | - Kelly Wade
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Mary A. Short
- International Neonatal Consortium, Communications Workgroup, Tucson, AZ, United States
| | - Robert Ward
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Kanwaljit Singh
- International Neonatal Consortium, Critical Path Institute, Tucson, AZ, United States
| | - Mark A. Turner
- Institute of Lifecourse and Medical Sciences, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
- Centre for Women’s Health Research, Liverpool Women’s Hospital, Liverpool, United Kingdom
| | - Jonathan M. Davis
- Department of Pediatrics, Tufts Children’s Hospital, Tufts University School of Medicine, Boston, MA, United States
| | - Tamorah Lewis
- Department of Pediatrics, City School of Medicine, Kansas Children’s Mercy Hospital, University of Missouri Kansas, Kansas City, MO, United States
- Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, Toronto, ON, Canada
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Qaderi S, Javinani A, Blumenfeld YJ, Krispin E, Papanna R, Chervenak FA, Shamshirsaz AA. Mammalian target of rapamycin inhibitors: A new-possible approach for in-utero medication therapy. Prenat Diagn 2024; 44:88-98. [PMID: 38177082 DOI: 10.1002/pd.6492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/04/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
The mammalian/mechanistic target of rapamycin (mTOR) is a protein kinase that plays a crucial role in regulating cellular growth, metabolism, and survival. Although there is no absolute contraindication for the use of mTOR inhibitors during pregnancy, the specific fetal effects remain unknown. Available data from the past 2 decades have examined the use of mTOR inhibitors during pregnancy in patients with solid organ transplantation, showing no clear link to fetal complications or structural abnormalities. Recently, a handful of case reports and series have described transplacental therapy of mTOR inhibitors to control symptomatic and complicated pathologies in the fetus. The effect of these agents includes a significant reduction in lesion size in the fetus and a reduced need for mechanical ventilation in neonates. In this context, we delve into the potential of mTOR inhibitors as in-utero therapy for fetal abnormalities, with a primary focus on lymphatic malformation (LM) and cardiac rhabdomyoma (CR). While preliminary reports underscore the efficacy of mTOR inhibitors for the treatment of fetal CR and fetal brain lesions associated with tuberous sclerosis complex, chylothorax, and LMs, additional investigation and clinical trials are essential to comprehensively assess the safety and efficacy of these medications.
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Affiliation(s)
- Shohra Qaderi
- Maternal Fetal Care Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Javinani
- Maternal Fetal Care Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yair J Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Eyal Krispin
- Maternal Fetal Care Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ramesha Papanna
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at UT Health Houston, Houston, Texas, USA
| | - Frank A Chervenak
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, New York, USA
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Haenen K, Vergote S, Kunpalin Y, De Catte L, Devlieger R, Lewi L, van der Merwe J, Russo F, De Vloo P, Lannoo L, Deprest J. Subsequent fertility, pregnancy, and gynaecological and psychological outcomes after maternal-fetal surgery for open spina bifida: A prospective cohort study. BJOG 2023; 130:1677-1684. [PMID: 37272251 DOI: 10.1111/1471-0528.17557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/07/2023] [Accepted: 05/11/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To determine the medium-term maternal impact of open fetal spina bifida repair. DESIGN Prospective cohort study. SETTING University Hospitals Leuven, Belgium. POPULATION Mothers who had open maternal-fetal spina bifida repair between March 2012 and December 2021. METHODS A patient-reported survey on subsequent fertility, pregnancy, and gynaecological and psychological outcomes. MAIN OUTCOME MEASURES Complications during subsequent pregnancies, and gynaecological and psychological problems. RESULTS Seventy-two out of 100 invited women completed the questionnaire (72%). Despite being advised not to, seven of 13 women attempting to conceive became pregnant within 2 years after fetal surgery and one woman delivered vaginally. Two of the 16 subsequent pregnancies were complicated by an open neural tube defect. One pregnancy was complicated by a placenta accreta and one pregnancy was complicated by a uterine rupture, both with good neonatal outcomes. Nearly half of respondents who did not attempt to conceive reported that this was because of their experience of the index pregnancy and caring for the index child. Three out of four respondents reported medium-term psychological problems, mostly anxiety for the health of the index child, fear for recurrence in subsequent pregnancies and feelings of guilt. CONCLUSIONS Open maternal-fetal surgery for spina bifida did not appear to affect fertility in our cohort. Half of the attempts to conceive took place within 2 years. One uterine rupture and one placenta accreta occurred in 16 subsequent pregnancies. Most respondents reported psychological problems linked to the index pregnancy, which reinforces the need for long-term psychological support.
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Affiliation(s)
- Kobe Haenen
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Simen Vergote
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Yada Kunpalin
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Luc De Catte
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Roland Devlieger
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Liesbeth Lewi
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Johannes van der Merwe
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Francesca Russo
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Philippe De Vloo
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Lore Lannoo
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- University College London Institute for Women's Health, London, UK
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Sagar RL, Walther-Jallow L, Götherström C, Westgren M, David AL. Maternal and fetal safety outcomes after in utero stem cell injection: A systematic review. Prenat Diagn 2023; 43:1622-1637. [PMID: 37975679 DOI: 10.1002/pd.6459] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/14/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To investigate the maternal and fetal safety of In utero stem cell transplantation (IUSCT). METHODS Medline®, Embase and Cochrane library (1967-2023) search for publications reporting IUSCT in humans. Two reviewers independently screened abstracts and full-text papers. RESULTS Sixty six transplantation procedures in 52 fetuses were performed for haemoglobinopathies (n = 14), red cell/bleeding disorders (n = 4), immunodeficiencies (n = 15), storage disorders (n = 7), osteogenesis imperfecta (n = 2) and healthy fetuses (n = 10). The average gestational age was 18.9 weeks; of procedures reporting the injection route, cells were delivered by intraperitoneal (n = 37), intravenous (n = 19), or intracardiac (n = 4) injection or a combination (n = 3); most fetuses received one injection (n = 41). Haematopoietic (n = 40) or mesenchymal (n = 12) stem cells were delivered. The cell dose was inconsistently reported (range 1.8-3.3 × 109 cells total (n = 27); 2.7-5.0 × 109 /kg estimated fetal weight (n = 17)). The acute fetal procedural complication rate was 4.5% (3/66); the acute fetal mortality rate was 3.0% (2/66). Neonatal survival was 69.2% (36/52). Immediate maternal and pregnancy outcomes were reported in only 30.8% (16/52) and 44.2% (23/52) of cases respectively. Four fetal/pregnancy outcomes would also classify as ≥ Grade 2 maternal adverse events. CONCLUSIONS Short-, medium-, and long-term maternal and fetal adverse events should be reported in all IUSCT studies.
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Affiliation(s)
- Rachel L Sagar
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Lilian Walther-Jallow
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, ANA Futura, Huddinge, Sweden
| | - Cecilia Götherström
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, ANA Futura, Huddinge, Sweden
| | - Magnus Westgren
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, ANA Futura, Huddinge, Sweden
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
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Affiliation(s)
- Jan Deprest
- Academic Department Development and Regeneration, Woman and Child and Clinical Department of Obstetrics and Gynaecology, Fetal Medicine Unit, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
| | - Tim Van Mieghem
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
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Vergote S, Van der Stock J, Kunpalin Y, Bredaki E, Maes H, Banh S, De Catte L, Devlieger R, Lewi L, Devroe S, Spencer R, David A, De Vloo P, Van Calenbergh F, Deprest JA. Patient empowerment improves follow-up data collection after fetal surgery for spina bifida: institutional audit. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:565-572. [PMID: 37099513 DOI: 10.1002/uog.26230] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/22/2023] [Accepted: 04/13/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES To define and grade fetal and maternal adverse events following fetal surgery for spina bifida and to report on the impact of engaging patients in collecting follow-up data. METHODS This prospective single-center audit included 100 consecutive patients undergoing fetal surgery for spina bifida between January 2012 and December 2021. In our setting, patients return to their referring unit for further pregnancy care and delivery. On discharge, referring hospitals were requested to return outcome data. For this audit, we prompted patients and referring hospitals to provide data in cases of missing outcomes. Outcomes were categorized as missing, returned spontaneously or returned following additional request, by the patient and/or referring center. Postoperative maternal and fetal complications until delivery were defined and graded according to Maternal and Fetal Adverse Event Terminology (MFAET) and the Clavien-Dindo classification. RESULTS There were no maternal deaths, but severe maternal complications occurred in seven women (anemia in pregnancy, postpartum hemorrhage, pulmonary edema, lung atelectasis, urinary tract obstruction and placental abruption). No cases of uterine rupture were reported. Perinatal death occurred in 3% of fetuses and other severe fetal complications in 15% (perioperative fetal bradycardia/cardiac dysfunction, fistula-related oligohydramnios, chorioamnionitis and preterm prelabor rupture of membranes (PPROM) before 32 weeks). PPROM occurred in 42% of patients and, overall, delivery took place at a median gestational age of 35.3 weeks (interquartile range, 34.0-36.6 weeks). Information provided following additional request, from both centers and patients but mainly from the latter, reduced missing data by 21% for gestational age at delivery, 56% for uterine-scar status at birth and 67% for shunt insertion at 12 months. Compared with the generic Clavien-Dindo classification, the MFAET system ranked complications in a more clinically relevant way. CONCLUSIONS The nature and rate of severe complications following fetal surgery for spina bifida were similar to those reported in other large series. Spontaneous return of outcome data by referring centers was low, yet patient empowerment improved data collection. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Vergote
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - J Van der Stock
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Y Kunpalin
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
| | - E Bredaki
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
| | - H Maes
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - S Banh
- Institute for Women's Health, University College London, London, UK
| | - L De Catte
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - R Devlieger
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - L Lewi
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - S Devroe
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - R Spencer
- Institute for Women's Health, University College London, London, UK
| | - A David
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
| | - P De Vloo
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - F Van Calenbergh
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - J A Deprest
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
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10
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Simon M, Buchanan J, Schimmel J, Brent J, Burkhart K, Wax P, Taylor N, Aldy K. Adverse Events in Pregnant Patients Treated with Coronavirus Disease 2019 Therapeutics. J Med Toxicol 2023; 19:381-388. [PMID: 37581858 PMCID: PMC10522537 DOI: 10.1007/s13181-023-00961-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Pregnant patients are at high risk of maternal and fetal complications from Coronavirus Disease 2019 (COVID-19) infections. The COVID-19 pandemic prompted a surge in the development and repurposing of therapies for the SARS-CoV-2 virus. Evidence is sparse on the efficacy and safety of these therapies in pregnant patients. Our objective was to describe adverse events (AEs) to COVID-19 therapeutics in pregnant patients. METHODS This was a case series of AEs reported to the FDA ACMT COVID-19 ToxIC (FACT) Pharmacovigilance Project between November 23, 2020, and June 28, 2022. FACT is an ongoing toxicosurveillance project at 17 sites to proactively identify and report AEs associated with COVID-19 therapeutics. Abstracted information includes demographics, case narratives, exposure details, clinical information, pregnancy details, treatments, and outcomes. RESULTS Forty-six COVID-19-positive pregnant patients who developed AEs following COVID-19 therapeutics were reported to the FACT Pharmacovigilance Project over 19 months. The most reported medications were remdesivir in 22 patients (47.8%) and casirivimab/imdevimab in 8 patients (17.4%). Four patients (8.7%) had life-threatening clinical manifestation, and 16 patients (34.8%) required intervention to prevent permanent damage. The most common maternal and fetal events were elevated serum alanine aminotransferase (26.1%) and non-reassuring fetal heart patterns (20.0%), respectively. CONCLUSIONS This case series reports AEs of elevated serum alanine aminotransferase, maternal bradycardia, maternal hypothermia, non-reassuring fetal heart patterns, and emergent or unplanned cesarean sections following administration of several COVID-19 therapeutics. This study was not designed to definitely identify causation, and further study is needed to evaluate the causal role of these therapeutics in AEs affecting pregnant COVID-19 patients.
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Affiliation(s)
- Mark Simon
- Rocky Mountain Poison & Drug Safety, Denver Health & Hospital Authority, 1391 Speer Blvd, Unit 600, Denver, CO, 80204, USA.
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA.
| | - Jennie Buchanan
- Rocky Mountain Poison & Drug Safety, Denver Health & Hospital Authority, 1391 Speer Blvd, Unit 600, Denver, CO, 80204, USA
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Jonathan Schimmel
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffrey Brent
- School of Medicine, University of Colorado, CO, Aurora, USA
| | - Keith Burkhart
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Paul Wax
- American College of Medical Toxicology, Phoenix, AZ, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Natalie Taylor
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, CO, USA
| | - Kim Aldy
- American College of Medical Toxicology, Phoenix, AZ, USA
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11
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Vergote S, De Bie FR, Duffy JMN, Bosteels J, Benachi A, Power B, Meijer F, Hedrick HL, Fernandes CJ, Reiss IKM, De Coppi P, Lally KP, Deprest JA. Core outcome set for perinatal interventions for congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:374-382. [PMID: 37099763 DOI: 10.1002/uog.26235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE To develop a core set of prenatal and neonatal outcomes for clinical studies evaluating perinatal interventions for congenital diaphragmatic hernia, using a validated consensus-building method. METHODS An international steering group comprising 13 leading maternal-fetal medicine specialists, neonatologists, pediatric surgeons, patient representatives, researchers and methodologists guided the development of this core outcome set. Potential outcomes were collected through a systematic review of the literature and entered into a two-round online Delphi survey. A call was made for stakeholders with experience of congenital diaphragmatic hernia to review the list and score outcomes based on their perceived relevance. Outcomes that fulfilled the consensus criteria defined a priori were discussed subsequently in online breakout meetings. Results were reviewed in a consensus meeting, during which the core outcome set was defined. Finally, the definitions, measurement methods and aspirational outcomes were defined in online and in-person definition meetings by a selection of 45 stakeholders. RESULTS Overall, 221 stakeholders participated in the Delphi survey and 198 completed both rounds. Fifty outcomes met the consensus criteria and were discussed and rescored by 78 stakeholders in the breakout meetings. During the consensus meeting, 93 stakeholders agreed eventually on eight outcomes, which constituted the core outcome set. Maternal and obstetric outcomes included maternal morbidity related to the intervention and gestational age at delivery. Fetal outcomes included intrauterine demise, interval between intervention and delivery and change in lung size in utero around the time of the intervention. Neonatal outcomes included neonatal mortality, pulmonary hypertension and use of extracorporeal membrane oxygenation. Definitions and measurement methods were formulated by 45 stakeholders, who also added three aspirational outcomes: duration of invasive ventilation, duration of oxygen supplementation and use of pulmonary vasodilators at discharge. CONCLUSIONS We developed with relevant stakeholders a core outcome set for studies evaluating perinatal interventions in congenital diaphragmatic hernia. Its implementation should facilitate the comparison and combination of trial results, enabling future research to better guide clinical practice. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Vergote
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - F R De Bie
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - J M N Duffy
- Department of Women and Children's Health, King's College London, London, UK
| | - J Bosteels
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - A Benachi
- Service de Gynécologie-Obstétrique, Hôpital Antoine-Béclère, AP-HP, Clamart, France
- Centre de Référence Maladies Rares Hernie de Coupole Diaphragmatique, Hôpital Antoine-Béclère, AP-HP, Clamart, France
| | - B Power
- The Congenital Diaphragmatic Hernia Charity (CDH UK), King's Lynn, UK
| | - F Meijer
- PlatformCHD, Arnhem, The Netherlands
| | - H L Hedrick
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - C J Fernandes
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - I K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - P De Coppi
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Specialist Neonatal and Pediatric Surgery, Great Ormond Street Hospital for Children, London, UK
- Stem Cells and Regenerative Medicine Section, Institute of Child Health, University College London, London, UK
| | - K P Lally
- Department of Pediatric Surgery, McGovern Medical School at UTHealth Houston, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - J A Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Women and Children's Health, King's College London, London, UK
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12
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Krispin E, Hessami K, Johnson RM, Krueger AM, Martinez YM, Jackson AL, Southworth AL, Whitehead W, Espinoza J, Nassr AA, Cortes MS, Donepudi R, Belfort MA. Systematic classification and comparison of maternal and obstetrical complications following 2 different methods of fetal surgery for the repair of open neural tube defects. Am J Obstet Gynecol 2023; 229:53.e1-53.e8. [PMID: 36596438 DOI: 10.1016/j.ajog.2022.12.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/11/2022] [Accepted: 12/17/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND In utero repair of open neural tube defects using an open hysterotomy approach (hereafter referred to as "open") has been shown to reduce the need for ventriculoperitoneal shunting and to improve motor outcomes for affected infants. Laparotomy-assisted fetoscopic repair (hereafter referred to as "hybrid") is an alternative approach that may confer similar neurologic benefits while reducing the incidence of hysterotomy-related complications. OBJECTIVE This study aimed to analyze procedure-related maternal and fetal complications of in utero repair using the Clavien-Dindo classification, and to compare the outcomes of the hybrid and open approaches. STUDY DESIGN This was a retrospective cohort study conducted in a single center between September 2011 and July 2021. All patients who met the Management of Myelomeningocele Study criteria and who underwent either hybrid or open fetal surgery were included. Maternal complications were classified using a unique adaptation of the Clavien-Dindo scoring system, allowing the development of a comprehensive complication index score specific to fetal surgery. Primary fetal outcome was defined as gestational age at delivery and summarized according to the World Health Organization definitions of preterm delivery. RESULTS There were 146 fetuses with open neural tube defects who were eligible for, and underwent, in utero repair during the study period. Of these, 102 underwent hybrid fetoscopic repair and 44 underwent open hysterotomy repair. Gestational age at the time of surgery was higher in the hybrid group than in the open group (25.1 vs 24.8 weeks; P=.004). Maternal body mass index was lower in the hybrid than in the open group (25.4 vs 27.1 kg/m2; P=.02). The duration of hybrid fetoscopic surgery was significantly longer in the hybrid than in the open group (250 vs 164 minutes; P<.001). There was a significantly lower Clavien-Dindo Grade III complication rate (4.9% vs 43.2%; P<.001) and a significantly lower overall comprehensive maternal complication index (8.7 vs 22.6; P=.021) in the hybrid group than in the open group. Gestational age at delivery was significantly higher in the hybrid group than in the open group (38.1 vs 35.8 weeks; P<.001), and this finding persisted when gestational age at delivery was analyzed using the World Health Organization definitions of preterm delivery. CONCLUSION Use of our adaptation of the standardized Clavien-Dindo classification to assess the maternal complications associated with in utero open neural tube defect repair provides a new method for objectively assessing different fetal surgical approaches. It also provides a much-needed standardized tool to allow objective comparisons between methods, which can be used when counseling patients. The hybrid open neural tube defect repair was associated with lower rates of maternal adverse events , and later gestational age at delivery compared with the open approach.
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Affiliation(s)
- Eyal Krispin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Kamran Hessami
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Rebecca M Johnson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Angel M Krueger
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Yamely Mendez Martinez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Aimee L Jackson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Annie L Southworth
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - William Whitehead
- Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Jimmy Espinoza
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ahmed A Nassr
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Magdalena Sanz Cortes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Roopali Donepudi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Michael A Belfort
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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13
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Lau MC, Tanaka K, Amoako A, Rudra T. Safety of performing classical versus low transverse caesarean sections in extremely preterm and very preterm births: Maternal and neonatal complications. Aust N Z J Obstet Gynaecol 2023. [PMID: 36789730 DOI: 10.1111/ajo.13652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/22/2023] [Indexed: 02/16/2023]
Abstract
AIMS Improved survivability of extremely preterm infants has led to increased rates of caesarean sections. Short-term maternal and neonatal risks of classical caesarean sections (CCS) in the context of extreme prematurity remain unclear. The aim was to examine maternal and neonatal complications associated with CCSs versus low transverse caesarean sections (LTCS) at extremely preterm (23 0/7-27 6/7 weeks) and very preterm gestational ages (28 0/7-31 6/7 weeks). METHODS A retrospective cohort study was conducted at Royal Brisbane and Womens Hospital, Queensland, Australia between 2016 and 2020. Maternal and neonatal outcomes were examined using univariate and multivariate statistical analysis. RESULTS CCSs (extremely preterm: n = 93; very preterm: n = 83) were associated with higher estimated blood loss than LTCS (extremely preterm: n = 70; very preterm: n = 287) in very preterm births (CCS: 638 ± 410 mL; LTCS: 556 ± 397 mL; P = 0.01). There was no significant difference in composite maternal outcomes between CCS and LTCS for extremely preterm (adjusted odds ratio (aOR): 1.11; 95% confidence interval (CI): 0.58-2.12; P = 0.75) or very preterm births (aOR: 1.08; 95% CI: 0.63-1.94; P = 0.79) after accounting for multiple pregnancy, placenta accreta and non-cephalic fetal presentations. Although CCSs were associated with lower Apgar scores at 1 min post-birth than LTCSs at very preterm gestational ages (CCS: 5.58 ± 2.10; LTCS: 6.25 ± 2.14; P = 0.02), there was no statistical difference in the rates of intraoperative neonatal injuries or composite outcomes when corrected for low birth weight. CONCLUSION Short-term maternal and neonatal outcomes do not significantly differ between CCS and LTCS for extremely preterm or very preterm births.
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Affiliation(s)
- Max C Lau
- Department of Obstetrics and Gynaecology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,The University of Queensland, Brisbane, Queensland, Australia
| | - Keisuke Tanaka
- Department of Obstetrics and Gynaecology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,The University of Queensland, Brisbane, Queensland, Australia
| | - Akwasi Amoako
- Department of Obstetrics and Gynaecology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,The University of Queensland, Brisbane, Queensland, Australia
| | - Thangeswaran Rudra
- Department of Obstetrics and Gynaecology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,The University of Queensland, Brisbane, Queensland, Australia
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14
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Herzeg A, Almeida-Porada G, Charo RA, David AL, Gonzalez-Velez J, Gupta N, Lapteva L, Lianoglou B, Peranteau W, Porada C, Sanders SJ, Sparks TN, Stitelman DH, Struble E, Sumner CJ, MacKenzie TC. Prenatal Somatic Cell Gene Therapies: Charting a Path Toward Clinical Applications (Proceedings of the CERSI-FDA Meeting). J Clin Pharmacol 2022; 62 Suppl 1:S36-S52. [PMID: 36106778 PMCID: PMC9547535 DOI: 10.1002/jcph.2127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/24/2022] [Indexed: 01/19/2023]
Abstract
We are living in a golden age of medicine in which the availability of prenatal diagnosis, fetal therapy, and gene therapy/editing make it theoretically possible to repair almost any defect in the genetic code. Furthermore, the ability to diagnose genetic disorders before birth and the presence of established surgical techniques enable these therapies to be delivered safely to the fetus. Prenatal therapies are generally used in the second or early third trimester for severe, life-threatening disorders for which there is a clear rationale for intervening before birth. While there has been promising work for prenatal gene therapy in preclinical models, the path to a clinical prenatal gene therapy approach is complex. We recently held a conference with the University of California, San Francisco-Stanford Center of Excellence in Regulatory Science and Innovation, researchers, patient advocates, regulatory (members of the Food and Drug Administration), and other stakeholders to review the scientific background and rationale for prenatal somatic cell gene therapy for severe monogenic diseases and initiate a dialogue toward a safe regulatory path for phase 1 clinical trials. This review represents a summary of the considerations and discussions from these conversations.
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Affiliation(s)
- Akos Herzeg
- UCSF Center for Maternal-Fetal PrecisionMedicine, San Francisco, California, USA
- Department of Surgery, University of California, San Francisco, California, USA
- Department of Obstetrics and Gynecology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Graca Almeida-Porada
- Fetal Research and Therapy Program, Wake Forest Institute for Regenerative Medicine, Wake Forest University, Winston Salem, North Carolina, USA
- Wake Forest University, School of Medicine, Winston-Salem, North Carolina, USA
| | - R. Alta Charo
- University of Wisconsin Law School, Madison, Wisconsin, USA
| | - Anna L. David
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London Medical School, London, UK
- National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | - Juan Gonzalez-Velez
- UCSF Center for Maternal-Fetal PrecisionMedicine, San Francisco, California, USA
- Department of Obstetrics and Gynecology, University of California, San Francisco, California, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Brain Tumor Center, University of California San Francisco, San Francisco, California, USA
- Department of Pediatrics and Benioff Children’s Hospital, University of California San Francisco, San Francisco, California, USA
| | - Larissa Lapteva
- Office of Tissues and Advanced Therapies/Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Washington, DC, USA
| | - Billie Lianoglou
- UCSF Center for Maternal-Fetal PrecisionMedicine, San Francisco, California, USA
- Department of Surgery, University of California, San Francisco, California, USA
| | - William Peranteau
- Center for Fetal Research, Division of General, Thoracic, and Fetal Surgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher Porada
- Fetal Research and Therapy Program, Wake Forest Institute for Regenerative Medicine, Wake Forest University, Winston Salem, North Carolina, USA
- Wake Forest University, School of Medicine, Winston-Salem, North Carolina, USA
| | - Stephan J. Sanders
- UCSF Center for Maternal-Fetal PrecisionMedicine, San Francisco, California, USA
- Department of Psychiatry and Behavioral Sciences, UCSF Weill Institute for Neurosciences, University of California, San Francisco, California, USA
- Institute for Human Genetics, University of California, San Francisco, California, USA
- Bakar Computational Health Sciences Institute, University of California, San Francisco, California, USA
| | - Teresa N. Sparks
- UCSF Center for Maternal-Fetal PrecisionMedicine, San Francisco, California, USA
- Department of Obstetrics and Gynecology, University of California, San Francisco, California, USA
| | - David H. Stitelman
- Yale University School of Medicine, Department of Surgery, Division of Pediatric Surgery, New Haven, CT, USA
| | - Evi Struble
- Office of Tissues and Advanced Therapies/Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Washington, DC, USA
| | - Charlotte J. Sumner
- Departments of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tippi C. MacKenzie
- UCSF Center for Maternal-Fetal PrecisionMedicine, San Francisco, California, USA
- Department of Surgery, University of California, San Francisco, California, USA
- Department of Obstetrics and Gynecology, University of California, San Francisco, California, USA
- Department of Pediatrics and Benioff Children’s Hospital, University of California San Francisco, San Francisco, California, USA
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15
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de Coppi P, Loukogeorgakis S, Götherström C, David AL, Almeida-Porada G, Chan JKY, Deprest J, Wong KKY, Tam PKH. Regenerative medicine: prenatal approaches. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:643-653. [PMID: 35963269 PMCID: PMC10664288 DOI: 10.1016/s2352-4642(22)00192-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 05/24/2022] [Accepted: 05/31/2022] [Indexed: 10/15/2022]
Abstract
This two-paper Series focuses on recent advances and applications of regenerative medicine that could benefit paediatric patients. Innovations in genomic, stem-cell, and tissue-based technologies have created progress in disease modelling and new therapies for congenital and incurable paediatric diseases. Prenatal approaches present unique opportunities associated with substantial biotechnical, medical, and ethical obstacles. Maternal plasma fetal DNA analysis is increasingly adopted as a noninvasive prenatal screening or diagnostic test for chromosomal and monogenic disorders. The molecular basis for cell-free DNA detection stimulated the development of circulating tumour DNA testing for adult cancers. In-utero stem-cell, gene, gene-modified cell (and to a lesser extent, tissue-based) therapies have shown early clinical promise in a wide range of paediatric disorders. Fetal cells for postnatal treatment and artificial placenta for ex-utero fetal therapies are new frontiers in this exciting field.
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Affiliation(s)
- Paolo de Coppi
- Stem Cell and Regenerative Medicine Section, Department of Developmental Biology and Cancer Research and Teaching, Great Ormond Street Institute of Child Health, University College London, London, UK; Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Institute of Child Health, University College London, London, UK.
| | - Stavros Loukogeorgakis
- Stem Cell and Regenerative Medicine Section, Department of Developmental Biology and Cancer Research and Teaching, Great Ormond Street Institute of Child Health, University College London, London, UK; Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Cecilia Götherström
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Womens Health, University College London, London, UK
| | - Graça Almeida-Porada
- Wake Forest Institute for Regenerative Medicine, Fetal Research and Therapy Program, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem NC, USA
| | - Jerry K Y Chan
- Academic Clinical Program in Obstetrics and Gynaecology, Duke-NUS Medical School, Singapore; Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
| | - Jan Deprest
- Clinical Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium
| | - Kenneth Kak Yuen Wong
- Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, Special Administrative Region, China
| | - Paul Kwong Hang Tam
- Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, Special Administrative Region, China; Faculty of Medicine, Macau University of Science and Technology, Macau Special Administrative Region, China.
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16
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David AL, Spencer RN. Clinical Assessment of Fetal Well-Being and Fetal Safety Indicators. J Clin Pharmacol 2022; 62 Suppl 1:S67-S78. [PMID: 36106777 PMCID: PMC9544851 DOI: 10.1002/jcph.2126] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/24/2022] [Indexed: 12/03/2022]
Abstract
Delivering safe clinical trials of novel therapeutics is central to enable pregnant women and their babies to access medicines for better outcomes. This review describes clinical monitoring of fetal well‐being and safety. Current pregnancy surveillance includes regular antenatal checks of blood pressure and urine for signs of gestational hypertension. Fetal and placental development is assessed routinely using the first‐trimester “dating” and mid‐trimester “anomaly” ultrasound scans, but the detection of fetal anomalies can continue throughout pregnancy using targeted sonography or magnetic resonance imaging (MRI). Serial sonography can be used to assess fetal size, well‐being, and placental function. Carefully defined reproducible imaging parameters, such as the head circumference (HC), abdominal circumference (AC), and femur length (FL), are combined to calculate an estimate of the fetal weight. Doppler analysis of maternal uterine blood flow predicts placental insufficiency, which is associated with poor fetal growth. Fetal doppler analysis can indicate circulatory decompensation and fetal hypoxia, requiring delivery to be expedited. Novel ways to assess fetal well‐being and placental function using MRI, computerized cardiotocography (CTG), serum circulating fetoplacental proteins, and mRNA may improve the assessment of the safety and efficacy of maternal and fetal interventions. Progress has been made in how to define and grade clinical trial safety in pregnant women, the fetus, and neonate. A new system for improved safety monitoring for clinical trials in pregnancy, Maternal and Fetal Adverse Event Terminology (MFAET), describes 12 maternal and 18 fetal adverse event (AE) definitions and severity grading criteria developed through an international modified Delphi consensus process. This fills a vital gap in maternal and fetal translational medicine research.
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Affiliation(s)
- Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,National Institute for Health and Care Research (NIHR) University College London Hospitals NHS Foundation Trust (UCLH), Biomedical Research Centre, London, UK
| | - Rebecca N Spencer
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,School of Medicine, University of Leeds, Leeds, UK
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17
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Improving Development of Drug Treatments for Pregnant Women and the Fetus. Ther Innov Regul Sci 2022; 56:976-990. [PMID: 35881237 PMCID: PMC9315086 DOI: 10.1007/s43441-022-00433-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/30/2022] [Indexed: 12/12/2022]
Abstract
The exclusion of pregnant populations, women of reproductive age, and the fetus from clinical trials of therapeutics is a major global public health issue. It is also a problem of inequity in medicines development, as pregnancy is a protected characteristic. The current regulatory requirements for drugs in pregnancy are being analyzed by a number of agencies worldwide. There has been considerable investment in developing expertise in pregnancy clinical trials (for the pregnant person and the fetus) such as the Obstetric-Fetal Pharmacology Research Centers funded by the National Institute of Child Health and Human Development. Progress has also been made in how to define and grade clinical trial safety in pregnant women, the fetus, and neonate. Innovative methods to model human pregnancy physiology and pharmacology using computer simulations are also gaining interest. Novel ways to assess fetal well-being and placental function using magnetic resonance imaging, computerized cardiotocography, serum circulating fetoplacental proteins, and mRNA may permit better assessment of the safety and efficacy of interventions in the mother and fetus. The core outcomes in women’s and newborn health initiative is facilitating the consistent reporting of data from pregnancy trials. Electronic medical records integrated with pharmacy services should improve the strength of pharmacoepidemiologic and pharmacovigilance studies. Incentives such as investigational plans and orphan disease designation have been taken up for obstetric, fetal, and neonatal diseases. This review describes the progress that is being made to better understand the extent of the problem and to develop applicable solutions.
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