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Kurt I, Kulhan M, AlAshqar A, Borahay MA. Uterine Collagen Cross-Linking: Biology, Role in Disorders, and Therapeutic Implications. Reprod Sci 2024; 31:645-660. [PMID: 37907804 DOI: 10.1007/s43032-023-01386-7] [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: 06/22/2023] [Accepted: 10/13/2023] [Indexed: 11/02/2023]
Abstract
Collagen is an essential constituent of the uterine extracellular matrix that provides biomechanical strength, resilience, structural integrity, and the tensile properties necessary for the normal functioning of the uterus. Cross-linking is a fundamental step in collagen biosynthesis and is critical for its normal biophysical properties. This step occurs enzymatically via lysyl oxidase (LOX) or non-enzymatically with the production of advanced glycation end-products (AGEs). Cross-links found in uterine tissue include the reducible dehydro-dihydroxylysinonorleucine (deH-DHLNL), dehydro-hydroxylysinonorleucine (deH-HLNL), and histidinohydroxymerodesmosine (HHMD); and the non-reducible pyridinoline (PYD), deoxy-pyridinoline (DPD); and a trace of pentosidine (PEN). Collagen cross-links are instrumental for uterine tissue integrity and the continuation of a healthy pregnancy. Decreased cervical cross-link density is observed in preterm birth, whereas increased tissue stiffness caused by increased cross-link density is a pathogenic feature of uterine fibroids. AGEs disrupt embryo development, decidualization, implantation, and trophoblast invasion. Uterine collagen cross-linking regulators include steroid hormones, such as progesterone and estrogen, prostaglandins, proteoglycans, metalloproteinases, lysyl oxidases, nitric oxide, nicotine, and vitamin D. Thus, uterine collagen cross-linking presents an opportunity to design therapeutic targets and warrants further investigation in common uterine disorders, such as uterine fibroids, cervical insufficiency, preterm birth, dystocia, endometriosis, and adenomyosis.
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Affiliation(s)
- Irem Kurt
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
- Selcuk University Faculty of Medicine, 42000, Konya, Turkey
| | - Mehmet Kulhan
- Department of Gynecology and Obstetrics, Selcuk University Faculty of Medicine, 42000, Konya, Turkey
| | - Abdelrahman AlAshqar
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Mostafa A Borahay
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.
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2
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Shynlova O, Nadeem L, Lye S. Progesterone control of myometrial contractility. J Steroid Biochem Mol Biol 2023; 234:106397. [PMID: 37683774 DOI: 10.1016/j.jsbmb.2023.106397] [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: 06/08/2023] [Revised: 08/01/2023] [Accepted: 09/04/2023] [Indexed: 09/10/2023]
Abstract
During pregnancy, the primary function of the uterus is to be quiescent and not contract, which allows the growing fetus to develop and mature. A uterine muscle layer, myometrium, is composed of smooth muscle cells (SMCs). Before the onset of labor contractions, the uterine SMCs experience a complex biochemical and molecular transformation involving the expression of contraction-associated proteins. Labor is initiated when genes in SMCs are activated in response to a combination of hormonal, inflammatory and mechanical signals. In this review, we provide an overview of molecular mechanisms regulating the process of parturition in humans, focusing on the hormonal control of the myometrium, particularly the steroid hormone progesterone. The primary reason for discussing the regulation of myometrial contractility by progesterone is the importance of the clinical problem of preterm birth. It is thought that the hormonal mechanisms regulating premature uterine contractions represent an untimely triggering of the normal events occurring during term parturition. Yet, our knowledge of the complex and redundant hormonal pathways controlling uterine contractile activity leading to delivery of the neonate remains incomplete. Finally, we introduce recent animal studies using a novel class of drugs, Selective Progesterone Receptor Modulators, targeting progesterone signaling to prevent premature myometrial contractions.
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Affiliation(s)
- Oksana Shynlova
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto M5G 1X5, Canada; Department of Physiology, University of Toronto, M5S 1A1, Canada; Department of Obstetrics & Gynecology, University of Toronto, M5S 1A1, Canada.
| | - Lubna Nadeem
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto M5G 1X5, Canada
| | - Stephen Lye
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto M5G 1X5, Canada; Department of Physiology, University of Toronto, M5S 1A1, Canada; Department of Obstetrics & Gynecology, University of Toronto, M5S 1A1, Canada
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3
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Tripathy S, Nallasamy S, Mahendroo M. Progesterone and its receptor signaling in cervical remodeling: Mechanisms of physiological actions and therapeutic implications. J Steroid Biochem Mol Biol 2022; 223:106137. [PMID: 35690241 PMCID: PMC9509468 DOI: 10.1016/j.jsbmb.2022.106137] [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: 11/05/2021] [Revised: 05/26/2022] [Accepted: 06/06/2022] [Indexed: 10/18/2022]
Abstract
The remodeling of the cervix from a closed rigid structure to one that can open sufficiently for passage of a term infant is achieved by a complex series of molecular events that in large part are regulated by the steroid hormones progesterone and estrogen. Among hormonal influences, progesterone exerts a dominant role for most of pregnancy to initiate a loss of tissue strength yet maintain competence in a phase termed softening. Equally important are the molecular events that abrogate progesterone function in late pregnancy to allow a loss of tissue competence and strength during cervical ripening and dilation. In this review, we focus on current understanding by which progesterone receptor signaling for the majority of pregnancy followed by a loss/shift in progesterone receptor action at the end of pregnancy, collectively ensure cervical remodeling as necessary for successful parturition.
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Affiliation(s)
- Sudeshna Tripathy
- Division of Basic Research, Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; Cecil H. and Ida Green Center for Reproductive Biology Sciences, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Shanmugasundaram Nallasamy
- Division of Basic Research, Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; Cecil H. and Ida Green Center for Reproductive Biology Sciences, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Mala Mahendroo
- Division of Basic Research, Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; Cecil H. and Ida Green Center for Reproductive Biology Sciences, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
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4
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Shynlova O, Nadeem L, Dorogin A, Mesiano S, Lye SJ. The selective progesterone receptor modulator-promegestone-delays term parturition and prevents systemic inflammation-mediated preterm birth in mice. Am J Obstet Gynecol 2022; 226:249.e1-249.e21. [PMID: 34418351 DOI: 10.1016/j.ajog.2021.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Progesterone, acting via its nuclear receptors called progesterone receptors, promotes myometrial relaxation during pregnancy, and suspension of this activity triggers labor. We previously found that 20α-hydroxysteroid dehydrogenase causes a local withdrawal of progesterone in the term and preterm myometrium by converting the progesterone into an inactive form before it accesses the progesterone receptors. OBJECTIVE We hypothesized that a selective progesterone receptor modulator called promegestone, which is not metabolized by 20α-hydroxysteroid dehydrogenase, would sustain progesterone receptor signaling and prevent/delay term labor and preterm labor in mice. STUDY DESIGN In the term labor mouse model, promegestone (0.2 mg/dam) or a vehicle were administered subcutaneously in timed-pregnant CD-1 mice at gestational days 15, 16, and 17 (term gestational days, 19.5). In the inflammation preterm labor model, pregnant mice received promegestone or a vehicle on gestational days 15, 16, and 17, which was 24 hours before, immediately before, and 24 hours after systemic bacterial endotoxin (50 μg intraperitoneal; lipopolysaccharide group) or vehicle (saline) administration. The maternal and fetal tissues were collected on gestational day 16 6 hours after lipopolysaccharide±promegestone injection and at term gestational day 18.75. The protein levels of 10 cytokines were measured by multiplex immunoassay in maternal plasma and amniotic fluid. Myometrial, decidual, and placental messenger RNA levels of multiple cytokines and procontractile proteins were evaluated by real-time polymerase chain reaction and confirmed by immunoblotting. RESULTS Promegestone prevented term labor and maintained mice pregnancy postterm >24 hours. The litter size and fetal weights were not different from the controls. Promegestone prevented systemic bacterial-endotoxin-induced preterm labor in 100% of the mice, blocked uterine contractions, significantly inhibited all systemic inflammation-induced myometrial cytokines, and partially inhibited decidual and placental inflammation. Promegestone did not prevent bacterial-endotoxin-induced fetal toxicity. CONCLUSION Promegestone a selective progesterone receptor modulator that binds progesterone receptors with high affinity and is not metabolized by 20α-hydroxysteroid dehydrogenase could completely suppress term parturition and systemic bacterial-endotoxin-induced preterm birth in mice. We suggest that such selective progesterone receptor modulators may represent a potential therapeutic approach to the prevention of preterm labor in women at high risk of preterm birth.
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Affiliation(s)
- Oksana Shynlova
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada.
| | - Lubna Nadeem
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anna Dorogin
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sam Mesiano
- Department of Reproductive Biology, Case Western Reserve University, Cleveland, OH
| | - Stephen J Lye
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
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5
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Nuclear Receptors in Pregnancy and Outcomes: Clinical Perspective. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1390:3-19. [DOI: 10.1007/978-3-031-11836-4_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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6
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Zierden HC, Ortiz JI, DeLong K, Yu J, Li G, Dimitrion P, Bensouda S, Laney V, Bailey A, Anders NM, Scardina M, Mahendroo M, Mesiano S, Burd I, Wagner G, Hanes J, Ensign LM. Enhanced drug delivery to the reproductive tract using nanomedicine reveals therapeutic options for prevention of preterm birth. Sci Transl Med 2021; 13:13/576/eabc6245. [PMID: 33441428 DOI: 10.1126/scitranslmed.abc6245] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 10/13/2020] [Indexed: 12/12/2022]
Abstract
Inflammation contributes to nearly 4 million global premature births annually. Here, we used a mouse model of intrauterine inflammation to test clinically used formulations, as well as engineered nanoformulations, for the prevention of preterm birth (PTB). We observed that neither systemic 17a-hydroxyprogesterone caproate (Makena) nor vaginal progesterone gel (Crinone) was sufficient to prevent inflammation-induced PTB, consistent with recent clinical trial failures. However, we found that vaginal delivery of mucoinert nanosuspensions of histone deacetylase (HDAC) inhibitors, in some cases with the addition of progesterone, prevented PTB and resulted in delivery of live pups exhibiting neurotypical development. In human myometrial cells in vitro, the P4/HDAC inhibitor combination both inhibited cell contractility and promoted the anti-inflammatory action of P4 by increasing progesterone receptor B stability. Here, we demonstrate the use of vaginally delivered drugs to prevent intrauterine inflammation-induced PTB resulting in the birth of live offspring in a preclinical animal model.
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Affiliation(s)
- Hannah C Zierden
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.,Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Jairo I Ortiz
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.,Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Kevin DeLong
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.,Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Jingqi Yu
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Gaoshan Li
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.,Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Peter Dimitrion
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Sabrine Bensouda
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Victoria Laney
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.,Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Anna Bailey
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Nicole M Anders
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Morgan Scardina
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Mala Mahendroo
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Sam Mesiano
- Department of Reproductive Biology, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Irina Burd
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Gunter Wagner
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT 06520, USA
| | - Justin Hanes
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.,Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Laura M Ensign
- Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA. .,Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD 21287, USA
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7
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Next generation strategies for preventing preterm birth. Adv Drug Deliv Rev 2021; 174:190-209. [PMID: 33895215 DOI: 10.1016/j.addr.2021.04.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 12/22/2022]
Abstract
Preterm birth (PTB) is defined as delivery before 37 weeks of gestation. Globally, 15 million infants are born prematurely, putting these children at an increased risk of mortality and lifelong health challenges. Currently in the U.S., there is only one FDA approved therapy for the prevention of preterm birth. Makena is an intramuscular progestin injection given to women who have experienced a premature delivery in the past. Recently, however, Makena failed a confirmatory trial, resulting the Center for Drug Evaluation and Research's (CDER) recommendation for the FDA to withdrawal Makena's approval. This recommendation would leave clinicians with no therapeutic options for preventing PTB. Here, we outline recent interdisciplinary efforts involving physicians, pharmacologists, biologists, chemists, and engineers to understand risk factors associated with PTB, to define mechanisms that contribute to PTB, and to develop next generation therapies for preventing PTB. These advances have the potential to better identify women at risk for PTB, prevent the onset of premature labor, and, ultimately, save infant lives.
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8
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Coler BS, Shynlova O, Boros-Rausch A, Lye S, McCartney S, Leimert KB, Xu W, Chemtob S, Olson D, Li M, Huebner E, Curtin A, Kachikis A, Savitsky L, Paul JW, Smith R, Adams Waldorf KM. Landscape of Preterm Birth Therapeutics and a Path Forward. J Clin Med 2021; 10:2912. [PMID: 34209869 PMCID: PMC8268657 DOI: 10.3390/jcm10132912] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 12/24/2022] Open
Abstract
Preterm birth (PTB) remains the leading cause of infant morbidity and mortality. Despite 50 years of research, therapeutic options are limited and many lack clear efficacy. Tocolytic agents are drugs that briefly delay PTB, typically to allow antenatal corticosteroid administration for accelerating fetal lung maturity or to transfer patients to high-level care facilities. Globally, there is an unmet need for better tocolytic agents, particularly in low- and middle-income countries. Although most tocolytics, such as betamimetics and indomethacin, suppress downstream mediators of the parturition pathway, newer therapeutics are being designed to selectively target inflammatory checkpoints with the goal of providing broader and more effective tocolysis. However, the relatively small market for new PTB therapeutics and formidable regulatory hurdles have led to minimal pharmaceutical interest and a stagnant drug pipeline. In this review, we present the current landscape of PTB therapeutics, assessing the history of drug development, mechanisms of action, adverse effects, and the updated literature on drug efficacy. We also review the regulatory hurdles and other obstacles impairing novel tocolytic development. Ultimately, we present possible steps to expedite drug development and meet the growing need for effective preterm birth therapeutics.
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Affiliation(s)
- Brahm Seymour Coler
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Oksana Shynlova
- Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada; (O.S.); (A.B.-R.); (S.L.)
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada
| | - Adam Boros-Rausch
- Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada; (O.S.); (A.B.-R.); (S.L.)
| | - Stephen Lye
- Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada; (O.S.); (A.B.-R.); (S.L.)
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada
| | - Stephen McCartney
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Kelycia B. Leimert
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB T6G 2R7, Canada; (K.B.L.); (W.X.); (D.O.)
| | - Wendy Xu
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB T6G 2R7, Canada; (K.B.L.); (W.X.); (D.O.)
| | - Sylvain Chemtob
- Departments of Pediatrics, Université de Montréal, Montréal, QC H3T 1J4, Canada;
| | - David Olson
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB T6G 2R7, Canada; (K.B.L.); (W.X.); (D.O.)
- Departments of Pediatrics and Physiology, University of Alberta, Edmonton, AB T6G 2S2, Canada
| | - Miranda Li
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
- Department of Biological Sciencies, Columbia University, New York, NY 10027, USA
| | - Emily Huebner
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Anna Curtin
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Alisa Kachikis
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Leah Savitsky
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Jonathan W. Paul
- Mothers and Babies Research Centre, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia; (J.W.P.); (R.S.)
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
| | - Roger Smith
- Mothers and Babies Research Centre, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia; (J.W.P.); (R.S.)
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
- John Hunter Hospital, New Lambton Heights, NSW 2305, Australia
| | - Kristina M. Adams Waldorf
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
- Department of Global Health, University of Washington, Seattle, WA 98195, USA
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9
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Zierden HC, Josyula A, Shapiro RL, Hsueh H, Hanes J, Ensign LM. Avoiding a Sticky Situation: Bypassing the Mucus Barrier for Improved Local Drug Delivery. Trends Mol Med 2021; 27:436-450. [PMID: 33414070 PMCID: PMC8087626 DOI: 10.1016/j.molmed.2020.12.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/24/2020] [Accepted: 12/01/2020] [Indexed: 02/06/2023]
Abstract
The efficacy of drugs administered by traditional routes is limited by numerous biological barriers that preclude reaching the intended site of action. Further, full body systemic exposure leads to dose-limiting, off-target side effects. Topical formulations may provide more efficacious drug and nucleic acid delivery for diseases and conditions affecting mucosal tissues, but the mucus protecting our epithelial surfaces is a formidable barrier. Here, we describe recent advances in mucus-penetrating approaches for drug and nucleic acid delivery to the ocular surface, the female reproductive tract, the gastrointestinal tract, and the airways.
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Affiliation(s)
- Hannah C. Zierden
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231,Department of Chemical & Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218
| | - Aditya Josyula
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231,Department of Chemical & Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218
| | - Rachel L. Shapiro
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231,Department of Chemical & Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218
| | - Henry Hsueh
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231,Department of Chemical & Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218
| | - Justin Hanes
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231,Department of Chemical & Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218,Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287,Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, 21218,Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287,The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD 21287,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287
| | - Laura M. Ensign
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21231,Department of Chemical & Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218,Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287,Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, 21218,Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287,The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD 21287,Departments Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287,Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD 21287,Correspondence: (L.M. Ensign)
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10
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Kuon RJ, Berger R, Rath W. 17-Hydroxyprogesterone Caproate for the Prevention of Recurrent Preterm Birth - A Systematic Review and Meta-analysis Taking into Account the PROLONG Trial. Geburtshilfe Frauenheilkd 2021; 81:61-69. [PMID: 33487666 PMCID: PMC7815338 DOI: 10.1055/a-1295-0752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/18/2020] [Indexed: 10/26/2022] Open
Abstract
Background Prior spontaneous preterm birth is a strong risk factor for the recurrence of spontaneous preterm birth in a subsequent pregnancy and has been evaluated in prevention studies using progesterone (natural progesterone administered orally or vaginally, and 17-hydroxyprogesterone caproate [17-OHPC]) as a selection criterion. Based on the findings of a randomized, placebo-controlled study, 17-OHPC was approved for use in 2011 by the Food and Drug Administration in the USA for the prevention of recurrent preterm birth. The approval was granted with qualification that a subsequent confirmatory study would need to be carried out, the results of which have just been published (PROLONG trial). Method A systematic literature search for the period from 1970 to April 2020 using the search terms "preterm birth" and "17-OHPC" or "progesterone" was carried out. Only randomized, placebo-controlled studies of women with singleton pregnancies who received 17-OHPC to prevent recurrent preterm birth were included in the subsequent meta-analysis. The relative risk and associated 95% confidence intervals were calculated. The heterogeneity between studies was evaluated with I 2 statistics. Results In addition to the original study used for the approval and the PROLONG trial, only one other study was found which met the inclusion criteria (total number of patients: 2221). With considerable heterogeneity between the studies, particularly with respect to the risk factors for preterm birth, the comparison between 17-OHPC and placebo showed no significant reduction in preterm birth rates before 37, 35 and 32 weeks of gestation and no significant differences with regard to the prevalence of miscarriage before 20 weeks of gestation or fetal deaths (antepartum or intrapartum) after 20 weeks of gestation and neonatal morbidity. Conclusion Based on the currently available data, 17-OHPC cannot be recommended for the prevention of recurrent preterm birth. Further randomized, placebo-controlled studies with clearly defined, comparable risk factors are required to identify the group of pregnant women which could benefit from the use of 17-OHPC to prevent preterm birth.
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Affiliation(s)
- Ruben-J Kuon
- Universitätsklinikum Heidelberg, Abteilung für Gynäkologische Endokrinologie und Fertilitätsstörungen, Frauenklinik, Heidelberg, Germany
| | | | - Werner Rath
- Medizinische Fakultät Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Marinello W, Feng L, Allen TK. Progestins Inhibit Interleukin-1β-Induced Matrix Metalloproteinase 1 and Interleukin 8 Expression via the Glucocorticoid Receptor in Primary Human Amnion Mesenchymal Cells. Front Physiol 2020; 11:900. [PMID: 32792990 PMCID: PMC7394241 DOI: 10.3389/fphys.2020.00900] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/06/2020] [Indexed: 12/18/2022] Open
Abstract
Preterm premature rupture of membranes is a leading cause of preterm births. Cytokine induced matrix metalloproteinase1 and interleukin 8 production from amnion mesenchymal cells may contribute to fetal membrane weakening and rupture. Progestins inhibit inflammation induced fetal membrane weakening but their effect on the inflammatory response of amnion mesenchymal cells is unknown. This study was designed to determine the role of progesterone receptor membrane component 1 and the glucocorticoid receptor in mediating the effects of progestins on interleukin-1β induced matrix metalloproteinase 1 and interleukin-8 expression in human amnion mesenchymal cells. Primary amnion mesenchymal cells harvested from human fetal membranes were passaged once and treated with vehicle, progesterone or medroxyprogesterone acetate at 10-6 M for 1 h followed by stimulation with interleukin-1β at 1 ng/ml for 24 h. Medroxyprogesterone acetate but not progesterone inhibited interleukin-1β-induced interlukin-8 and matrix metalloproteinase 1 mRNA expression. In subsequent dose response studies, medroxyprogesterone acetate, but not progesterone, at doses of 10-6-10-8 M inhibited interleukin-1β induced interleukin-8 and matrix metalloproteinase 1 mRNA expression. We further demonstrated that inhibition of glucocorticoid receptor expression, but not progesterone receptor membrane component 1 knockdown with small interfering RNA transfection, resulted in a reversal in medroxyprogesterone acetate's (10-7 M) inhibition of interleukin-1β- induced matrix metalloproteinase 1 mRNA expression and interleukin-8 mRNA expression and protein expression. Our findings demonstrate that medroxyprogesterone acetate exerts its anti-inflammatory effect primarily through the glucocorticoid receptor in human amnion mesenchymal cells. Modulation of glucocorticoid receptor signaling pathways maybe a useful therapeutic strategy for preventing inflammation induced fetal membrane weakening leading to preterm premature rupture of membranes.
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Affiliation(s)
- William Marinello
- Department of Anesthesiology, Duke University Hospital, Durham, NC, United States
| | - Liping Feng
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, NC, United States
| | - Terrence K. Allen
- Department of Anesthesiology, Duke University Hospital, Durham, NC, United States
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12
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Kashanian M, KaramiAbd T, Sheikhansari N, AminiMoghaddam S, Jangjoo S. Efficacy of daily rectal micronized progesterone for prevention of preterm delivery: a randomized clinical trial. J Matern Fetal Neonatal Med 2020; 35:122-128. [PMID: 31937160 DOI: 10.1080/14767058.2020.1712709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Preterm delivery is the leading cause of neonatal morbidity and mortality and its prevention is always under serious concern.Objective: The aim of the present study was to determine the efficacy of rectal progesterone as a maintenance tocolytic after arresting preterm labor, for increasing the duration of pregnancy, and postponing preterm birth.Method: The study was performed as a double blind randomized clinical trial on women with preterm labor in whom contractions have been stopped. The eligible women were randomly divided into two groups. In the intervention group (progesterone group), progesterone was administered rectally as a dose of 200 mg daily until 36+6 weeks or spontaneous delivery before that time, whichever came first; and in the placebo group, placebo was administered in a similar manner. Primary outcomes were number of deliveries before 37 weeks of gestation and time to delivery interval in two groups. Secondary outcomes were neonatal Apgar score and weight, and need for NICU admission.Results: 160 women finished the study (80 women in each group). The women of the two groups did not have significant difference according to the baseline characteristics. Frequency of preterm labor (earlier than 37 weeks) and mean gestational age at the time of delivery did not show significant difference in two groups. Also, neonatal outcome including Apgar score, birth weight, NICU admission and neonatal complications were not different between the two groups. The pregnancy length was longer in progesterone group (28.84 ± 3.36 VS 21.19 ± 4.62 days), [p = .001, CI 95%: 3.71-4.83]. The time-to-event (delivery) analysis showed a hazard ratio of 1.02 (95% CI 0.36-2.77).Conclusion: Rectal progesterone at a daily dose of 200 mg as a maintenance tocolytic agent, cannot lower the frequency of preterm delivery but was suggested to prolong pregnancy length.
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Affiliation(s)
- Maryam Kashanian
- Akbarabadi Teaching Hospital, Department of Obstetrics and Gynecology, Iran University of Medical Sciences, Tehran, Iran
| | - Tayyebeh KaramiAbd
- Akbarabadi Teaching Hospital, Department of Obstetrics and Gynecology, Iran University of Medical Sciences, Tehran, Iran
| | | | - Soheila AminiMoghaddam
- Akbarabadi Teaching Hospital, Department of Obstetrics and Gynecology, Iran University of Medical Sciences, Tehran, Iran
| | - Solmaz Jangjoo
- Akbarabadi Teaching Hospital, Department of Obstetrics and Gynecology, Iran University of Medical Sciences, Tehran, Iran
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13
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Zierden HC, Ortiz Ortiz JI, Dimitrion P, Laney V, Bensouda S, Anders NM, Scardina M, Hoang T, Ronnett BM, Hanes J, Burd I, Mahendroo M, Ensign LM. Characterization of an Adapted Murine Model of Intrauterine Inflammation-Induced Preterm Birth. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 190:295-305. [PMID: 31837289 DOI: 10.1016/j.ajpath.2019.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/11/2019] [Accepted: 10/03/2019] [Indexed: 11/17/2022]
Abstract
Preterm birth (PTB) affects nearly 15 million infants each year. Of these PTBs, >25% are a result of inflammation or infection. Animal models have improved our understanding of the mechanisms leading to PTB. Prior work has described induction of intrauterine inflammation in mice with a single injection of lipopolysaccharide (LPS). Herein, we have improved the reproducibility and potency of LPS in the model using two injections distal to the cervix. An in vivo imaging system revealed more uniform distribution of Evans Blue Dye using a double distal injection (DDI) approach compared with a single proximal injection (SPI). Endotoxin concentrations in vaginal lavage fluid from SPI dams were significantly higher than from DDI dams. At equivalent LPS doses, DDI consistently induced more PTB than SPI, and DDI showed a linear dose-response, whereas SPI did not. Gene expression in myometrial tissue revealed increased levels of inflammatory markers in dams that received LPS DDI compared with LPS SPI. The SPI group showed more significant overexpression in cervical remodeling genes, likely due to the leakage of LPS from the uterine horns through the cervix. The more reliable PTB induction and uniform uterine exposure provided by this new model will be useful for further studying fetal outcomes and potential therapeutics for the prevention of inflammation-induced PTB.
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Affiliation(s)
- Hannah C Zierden
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Jairo I Ortiz Ortiz
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter Dimitrion
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Victoria Laney
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Sabrine Bensouda
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nicole M Anders
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Morgan Scardina
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thuy Hoang
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brigitte M Ronnett
- Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Justin Hanes
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, Maryland; Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Irina Burd
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Integrated Research Center for Fetal Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Mala Mahendroo
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Laura M Ensign
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, Maryland; Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Integrated Research Center for Fetal Medicine, Johns Hopkins University, Baltimore, Maryland.
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14
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Kuon RJ, Voß P, Rath W. Progesterone for the Prevention of Preterm Birth - an Update of Evidence-Based Indications. Geburtshilfe Frauenheilkd 2019; 79:844-853. [PMID: 31423019 PMCID: PMC6690740 DOI: 10.1055/a-0854-6472] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 02/05/2019] [Accepted: 02/10/2019] [Indexed: 02/06/2023] Open
Abstract
The prevention and treatment of preterm birth remains one of the biggest challenges in obstetrics. Worldwide, 11% of all children are born prematurely with far-reaching consequences for the children concerned, their families and the health system. Experimental studies suggest that progesterone inhibits uterine contractions, stabilises the cervix and has immunomodulatory effects. Recent years have seen the publication of numerous clinical trials using progestogens for the prevention of preterm birth. As a result of different inclusion criteria and the use of different progestogens and their methods of administration, it is difficult to draw comparisons between these studies. A critical evaluation of the available studies was therefore carried out on the basis of a search of the literature (1956 to 09/2018). Taking into account the most recent randomised, controlled studies, the following evidence-based recommendations emerge: In asymptomatic women with singleton pregnancies and a short cervical length on ultrasound of ≤ 25 mm before 24 weeks of gestation (WG), daily administration of vaginal progesterone (200 mg capsule or 90 mg gel) up until 36 + 6 WG leads to a significant reduction in the preterm birth rate and an improvement in neonatal outcome. The latest data also suggest positive effects of treatment with progesterone in cases of twin pregnancies with a short cervical length on ultrasound of ≤ 25 mm before 24 WG. The study data for the administration of progesterone in women with singleton pregnancies with a previous preterm birth have become much more heterogeneous, however. It is not possible to make a general recommendation for this indication at present, and decisions must therefore be made on a case-by-case basis. Even if progesterone use is considered to be safe in terms of possible long-term consequences, exposure should be avoided where it is not indicated. Careful patient selection is crucial for the success of treatment.
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Affiliation(s)
- Ruben-J. Kuon
- Universitätsklinikum Heidelberg, Abteilung für Gynäkologische Endokrinologie und Fertilitätsstörungen, Frauenklinik, Heidelberg, Germany
| | - Pauline Voß
- Universitätsklinikum Heidelberg, Abteilung für Gynäkologische Endokrinologie und Fertilitätsstörungen, Frauenklinik, Heidelberg, Germany
| | - Werner Rath
- Medizinische Fakultät Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
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15
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Rath W, Kuon RJ. Progesterone - Effective for Tocolysis and Maintenance Treatment After Arrested Preterm Labour?: Critical Analysis of the Evidence. Geburtshilfe Frauenheilkd 2019; 79:834-843. [PMID: 31423018 PMCID: PMC6690738 DOI: 10.1055/a-0829-3992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/05/2019] [Accepted: 01/07/2019] [Indexed: 12/19/2022] Open
Abstract
Numerous experimental studies indicate that natural progesterone, through various mechanisms, exerts an inhibitory effect on uterine contractility and sensitises the myometrium for tocolytics. It was therefore appropriate to investigate the possible benefits of oral/vaginal progesterone and the synthetic progesterone derivative 17-α-hydroxyprogesterone caproate, applied intramuscularly, in clinical studies on primary tocolysis, additively to established tocolytics ("adjunctive tocolysis") and as maintenance treatment after successful tocolysis in cases of threatened preterm birth. Three studies with a small number of cases do not yield any sufficient evidence for recommending progesterone/17-α-hydroxyprogesterone caproate as primary tocolysis in women with preterm labour. There is also no evidence that progesterone or 17-α-hydroxyprogesterone caproate combined with commonly used tocolytics leads to a prolongation of pregnancy and a significant decrease in the rate of preterm birth. The data on the use of progesterone as maintenance treatment is controversial. While randomised, controlled studies with low quality showed promising results, studies with high quality did not reveal any significant differences with regard to the rate of preterm birth < 37 weeks of gestation, the latency period until delivery and in the neonatal outcome between progesterone/17-α-hydroxyprogesterone caproate and placebo or no treatment. Significant differences in the methodology, the inclusion and outcome criteria, the mode of application and the dosages of the substances as well as the inadequate statistical power as a result of low numbers of cases make interpretation and comparability of the studies difficult. Therefore, well-designed randomised, placebo-controlled, double-blind studies with uniform primary outcome criteria are needed in order to clarify whether progesterone and via which route of administration and at which dosage is of clinical benefit for patients with manifest preterm contractions and as maintenance treatment after arrested preterm labour.
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Affiliation(s)
- Werner Rath
- Medizinische Fakultät Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ruben-J Kuon
- Universitätsklinikum Heidelberg, Abteilung für Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Germany
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16
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Development of a mucoinert progesterone nanosuspension for safer and more effective prevention of preterm birth. J Control Release 2019; 295:74-86. [PMID: 30597245 PMCID: PMC6398330 DOI: 10.1016/j.jconrel.2018.12.046] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/19/2018] [Accepted: 12/27/2018] [Indexed: 02/03/2023]
Abstract
Preterm birth (PTB) is a significant global problem, but few therapeutic options exist. Vaginal progesterone supplementation has been demonstrated to reduce PTB rates in women with a sonographic short cervix, yet there has been little investigation into the most effective dose or delivery form. Further, vaginal products like progesterone gel often contain excipients that cause local toxicity, irritation, and leakage. Here, we describe the development and characterization of a mucoinert vaginal progesterone nanosuspension formulation for improved drug delivery to the female reproductive tract. We compare the pharmacokinetics and pharmacodynamics to the clinical comparator progesterone gel in pregnant mice and demonstrate increased vaginal absorption and biodistribution via the uterine first-pass effect. Importantly, the unique plasma progesterone double peak observed in humans, reflecting recirculation from the uterus, was also observed in pregnant mice with vaginal dosing. We adapted a mouse model of progesterone withdrawal that was previously believed to be incompatible with testing the efficacy of exogenous progestins, and are first to demonstrate efficacy in preventing preterm birth with vaginal progesterone in this model. Further, improved vaginal progesterone delivery by the nanosuspension led to increased efficacy in PTB prevention. Additionally, we identified histological and transcriptional evidence of cervical and uterine toxicity with a single vaginal administration of the clinical gel that are absent after dosing with the mucoinert nanosuspension formulation. We demonstrate that a progesterone formulation that is designed for improved vaginal progesterone absorption and vaginal biocompatibility could be more effective for PTB prevention.
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17
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Amro B, Almahdi S. Outcome of pregnancy among women with threatened miscarriage in Latifa Hospital-Dubai. HAMDAN MEDICAL JOURNAL 2019. [DOI: 10.4103/hmj.hmj_77_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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18
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In an in-vitro model using human fetal membranes, 17-α hydroxyprogesterone caproate is not an optimal progestogen for inhibition of fetal membrane weakening. Am J Obstet Gynecol 2017; 217:695.e1-695.e14. [PMID: 29031893 DOI: 10.1016/j.ajog.2017.10.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/25/2017] [Accepted: 10/02/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The progestogen 17-α hydroxyprogesterone caproate (17-OHPC) is 1 of only 2 agents recommended for clinical use in the prevention of spontaneous preterm delivery, and studies of its efficacy have been conflicting. We have developed an in-vitro model to study the fetal membrane weakening process that leads to rupture in preterm premature rupture of the fetal membranes (pPROM). Inflammation/infection associated with tumor necrosis factor-α (TNF-α) induction and decidual bleeding/abruption associated thrombin release are leading causes of preterm premature rupture of the fetal membranes. Both agents (TNF-α and thrombin) cause fetal membrane weakening in the model system. Furthermore, granulocyte-macrophage colony-stimulating factor (GM-CSF) is a critical intermediate for both TNF-α and thrombin-induced fetal membrane weakening. In a previous report, we demonstrated that 3 progestogens, progesterone, 17-alpha hydroxyprogesterone (17-OHP), and medroxyprogesterone acetate (MPA), each inhibit both TNF-α- and thrombin-induced fetal membrane weakening at 2 distinct points of the fetal membrane weakening pathway. Each block both the production of and the downstream action of the critical intermediate granulocyte-macrophage colony-stimulating factor. OBJECTIVE The objective of the study was to characterize the inhibitory effects of 17-OHPC on TNF-α- and thrombin-induced fetal membrane weakening in vitro. STUDY DESIGN Full-thickness human fetal membrane fragments from uncomplicated term repeat cesarean deliveries were mounted in 2.5 cm Transwell inserts and cultured with/without 17-alpha hydroxyprogesterone caproate (10-9 to 10-7 M). After 24 hours, medium (supernatant) was removed and replaced with/without the addition of tumor necrosis factor-alpha (20 ng/mL) or thrombin (10 U/mL) or granulocyte-macrophage colony-stimulating factor (200 ng/mL). After 48 hours of culture, medium from the maternal side compartment of the model was assayed for granulocyte-macrophage colony-stimulating factor and the fetal membrane fragments were rupture strength tested. RESULTS Tumor necrosis factor-alpha and thrombin both weakened fetal membranes (43% and 62%, respectively) and increased granulocyte-macrophage colony-stimulating factor levels (3.7- and 5.9-fold, respectively). Pretreatment with 17-alpha hydroxyprogesterone caproate inhibited both tumor necrosis factor-alpha- and thrombin-induced fetal membrane weakening and concomitantly inhibited the induced increase in granulocyte-macrophage colony-stimulating factor in a concentration-dependent manner. However, contrary to our prior reports regarding progesterone and other progestogens, 17-alpha hydroxyprogesterone caproate did not also inhibit granulocyte-macrophage colony-stimulating factor-induced fetal membrane weakening. CONCLUSION 17-Alpha hydroxyprogesterone caproate blocks tumor necrosis factor-alpha- and thrombin-induced fetal membrane weakening by inhibiting the production of granulocyte-macrophage colony-stimulating factor. However, 17-alpha hydroxyprogesterone caproate did not also inhibit granulocyte-macrophage colony-stimulating factor-induced weakening. We speculate that progestogens other than 17-alpha hydroxyprogesterone caproate may be more efficacious in preventing preterm premature rupture of the fetal membranes-related spontaneous preterm birth.
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Yellon SM. Contributions to the dynamics of cervix remodeling prior to term and preterm birth. Biol Reprod 2017; 96:13-23. [PMID: 28395330 PMCID: PMC5803764 DOI: 10.1095/biolreprod.116.142844] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 11/01/2016] [Accepted: 11/28/2016] [Indexed: 01/05/2023] Open
Abstract
Major clinical challenges for obstetricians and neonatologists result from early cervix remodeling and preterm birth. Complications related to cervix remodeling or delivery account for significant morbidity in newborns and peripartum mothers. Understanding morphology and structure of the cervix in pregnant women is limited mostly to the period soon before and after birth. However, evidence in rodent models supports a working hypothesis that a convergence of factors promotes a physiological inflammatory process that degrades the extracellular collagen matrix and enhances biomechanical distensibility of the cervix well before the uterus develops the contractile capabilities for labor. Contributing factors to this remodeling process include innervation, mechanical stretch, hypoxia, and proinflammatory mediators. Importantly, the softening and shift to ripening occurs while progesterone is near peak concentrations in circulation across species. Since progesterone is required to maintain pregnancy, the premise of this review is that loss of responsiveness to progesterone constitutes a common final mechanism for remodeling the mammalian cervix in preparation for birth at term. Various inputs are suggested to promote signaling between stromal cells and resident macrophages to drive proinflammatory processes that advance the soft cervix into ripening. With infection, pathophysiological processes may prematurely drive components of this remodeling mechanism and lead to preterm birth. Identification of critical molecules and pathways from studies in various rodent models hold promise for novel endpoints to assess risk and provide innovative approaches to treat preterm birth or promote the progress of ripening at term.
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Affiliation(s)
- Steven M. Yellon
- Longo Center for Perinatal Biology, Departments of Basic Sciences Division of Physiology and Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA 92350, USA
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20
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Qian X, Jiang Y, Liu L, Shi SQ, Garfield RE, Liu H. Changes in ectocervical surface area in women throughout pregnancy compared to non-pregnant and postpartum states. J Matern Fetal Neonatal Med 2016; 29:3677-81. [PMID: 26864001 DOI: 10.3109/14767058.2016.1140739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The objective of this study is to estimate changes in the surface area of the ectocervix (CA) in women during pregnancy and compare this to postpartum and non-pregnant states. METHODS CA was evaluated in 210 normal nulliparous women divided into groups from early to late gestation, 40 postpartum women, and 25 non-pregnant women. CA in cm(2) was estimated from analysis of images taken with an endoscope of the cervical face and an mm scale. An mm scale was also used to determine fornix length and fornix area computed. RESULTS The face, fornix, and total areas of the CA of non-pregnant and postpartum groups are significantly smaller (p < 0.001) than these areas in groups during pregnancy. Generally, the CA of the face, fornix, and total area are also less in early pregnancy compared with late gestation (p < 0.01 to <0.001). Total CA correlates with gestational age (r = 0.196, p < 0.004). CONCLUSIONS (1) During pregnancy, CA slowly and progressively increases to >75% area compared with CA of non-pregnant patients and then reverts back to low CA postpartum. (2) Increases in CA during pregnancy occur in both the face and fornix areas. (3) Increases in CA reflect enlargement in cervical volume and remodeling during pregnancy.
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Affiliation(s)
- Xueya Qian
- a Preterm Birth Prevention and Treatment Unit, Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou , China and.,b Department of Obstetrics , First Affiliated Hospital of Jinan University , Guangzhou , China
| | - Yanmin Jiang
- a Preterm Birth Prevention and Treatment Unit, Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou , China and
| | - Lei Liu
- a Preterm Birth Prevention and Treatment Unit, Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou , China and
| | - Shao-Qing Shi
- a Preterm Birth Prevention and Treatment Unit, Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou , China and
| | - Robert E Garfield
- a Preterm Birth Prevention and Treatment Unit, Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou , China and
| | - Huishu Liu
- a Preterm Birth Prevention and Treatment Unit, Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou , China and
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Furcron AE, Romero R, Plazyo O, Unkel R, Xu Y, Hassan SS, Chaemsaithong P, Mahajan A, Gomez-Lopez N. Vaginal progesterone, but not 17α-hydroxyprogesterone caproate, has antiinflammatory effects at the murine maternal-fetal interface. Am J Obstet Gynecol 2015; 213:846.e1-846.e19. [PMID: 26264823 DOI: 10.1016/j.ajog.2015.08.010] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 06/25/2015] [Accepted: 08/04/2015] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Progestogen (vaginal progesterone or 17-alpha-hydroxyprogesterone caproate [17OHP-C]) administration to patients at risk for preterm delivery is widely used for the prevention of preterm birth (PTB). The mechanisms by which these agents prevent PTB are poorly understood. Progestogens have immunomodulatory functions; therefore, we investigated the local effects of vaginal progesterone and 17OHP-C on adaptive and innate immune cells implicated in the process of parturition. STUDY DESIGN Pregnant C57BL/6 mice received vaginal progesterone (1 mg per 200 μL, n = 10) or Replens (control, 200 μL, n = 10) from 13 to 17 days postcoitum (dpc) or were subcutaneously injected with 17OHP-C (2 mg per 100 μL, n = 10) or castor oil (control, 100 μL, n = 10) on 13, 15, and 17 dpc. Decidual and myometrial leukocytes were isolated prior to term delivery (18.5 dpc) for immunophenotyping by flow cytometry. Cervical tissue samples were collected to determine matrix metalloproteinase (MMP)-9 activity by in situ zymography and visualization of collagen content by Masson's trichrome staining. Plasma concentrations of progesterone, estradiol, and cytokines (interferon [IFN]γ, interleukin (IL)-1β, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12p70, keratinocyte-activated chemokine/growth-related oncogene, and tumor necrosis factor-α) were quantified by enzyme-linked immunosorbent assays. Pregnant mice pretreated with vaginal progesterone or Replens were injected with 10 μg of an endotoxin on 16.5 dpc (n = 10 each) and monitored via infrared camera until delivery to determine the effect of vaginal progesterone on the rate of PTB. RESULTS The following results were found: (1) vaginal progesterone, but not 17OHP-C, increased the proportion of decidual CD4+ regulatory T cells; (2) vaginal progesterone, but not 17OHP-C, decreased the proportion of decidual CD8+CD25+Foxp3+ T cells and macrophages; (3) vaginal progesterone did not result in M1→M2 macrophage polarization but reduced the proportion of myometrial IFNγ+ neutrophils and cervical active MMP-9-positive neutrophils and monocytes; (4) 17OHP-C did not reduce the proportion of myometrial IFNγ+ neutrophils; however, it increased the abundance of cervical active MMP-9-positive neutrophils and monocytes; (5) vaginal progesterone immune effects were associated with reduced systemic concentrations of IL-1β but not with alterations in progesterone or estradiol concentrations; and (6) vaginal progesterone pretreatment protected against endotoxin-induced PTB (effect size 50%, P = 0.011). CONCLUSION Vaginal progesterone, but not 17OHP-C, has local antiinflammatory effects at the maternal-fetal interface and the cervix and protects against endotoxin-induced PTB.
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Ackerman WE, Summerfield TL, Mesiano S, Schatz F, Lockwood CJ, Kniss DA. Agonist-Dependent Downregulation of Progesterone Receptors in Human Cervical Stromal Fibroblasts. Reprod Sci 2015; 23:112-23. [PMID: 26243545 DOI: 10.1177/1933719115597787] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Progesterone (P(4)) maintains uterine quiescence during the majority of pregnancy, whereas diminished progesterone receptor (PR) expression and/or activity (ie, functional P(4) withdrawal) promotes parturition. To investigate the regulation of PR expression in cervical stroma, fibroblasts from premenopausal hysterectomy specimens were prepared. Greater than 99% of the cultures were vimentin positive (mesenchymal cell marker) with only occasional cytokeratin-8 positivity (epithelial cell marker) and no evidence of CD31-positive (endothelial cell marker) cells. Cells were immunolabeled with antibodies directed against PRs (PR-A and PR-B), estrogen receptor α (ER-α), and glucocorticoid receptor-α/β (GR-α/β). All cells were uniformly immunopositive for ER-α and GR-α/β but did not express PRs. Incubation of cells with 10(-8) mol/L 17β-estradiol induced a time-dependent increase in PR-A and PR-B messenger RNAs (mRNAs) by quantitative real-time polymerase chain reactions and proteins by immunoblotting and immunofluorescence. Incubation of cervical fibroblasts with PR ligands (medroxyprogesterone acetate or Org-2058) downregulated PR-A and PR-B levels. Coincubation of cells with PR ligands plus RU-486, a PR antagonist, partially abrogated agonist-induced receptor downregulation. Dexamethasone, a pure glucocorticoid, had no inhibitory effect on PR expression. These results indicate that progestins and estrogens regulate PR expression in cervical fibroblasts. We postulate that hormonal regulation of PR expression in the cervical stroma may contribute to functional P(4) withdrawal in preparation for parturition.
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Affiliation(s)
- William E Ackerman
- Division of Maternal-Fetal Medicine and Laboratory of Perinatal Research, Department of Obstetrics and Gynecology, The Ohio State University, College of Medicine and Wexner Medical Center, Columbus, OH, USA
| | - Taryn L Summerfield
- Division of Maternal-Fetal Medicine and Laboratory of Perinatal Research, Department of Obstetrics and Gynecology, The Ohio State University, College of Medicine and Wexner Medical Center, Columbus, OH, USA
| | - Sam Mesiano
- Department of Obstetrics, Gynecology and Reproductive Sciences, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - Frederick Schatz
- Division of Maternal-Fetal Medicine and Laboratory of Perinatal Research, Department of Obstetrics and Gynecology, The Ohio State University, College of Medicine and Wexner Medical Center, Columbus, OH, USA Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Charles J Lockwood
- Division of Maternal-Fetal Medicine and Laboratory of Perinatal Research, Department of Obstetrics and Gynecology, The Ohio State University, College of Medicine and Wexner Medical Center, Columbus, OH, USA Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Douglas A Kniss
- Division of Maternal-Fetal Medicine and Laboratory of Perinatal Research, Department of Obstetrics and Gynecology, The Ohio State University, College of Medicine and Wexner Medical Center, Columbus, OH, USA Department of Biomedical Engineering, College of Engineering, The Ohio State University, Columbus, OH, USA
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Winer N, Bretelle F, Senat MV, Bohec C, Deruelle P, Perrotin F, Connan L, Vayssière C, Langer B, Capelle M, Azimi S, Porcher R, Rozenberg P. 17 alpha-hydroxyprogesterone caproate does not prolong pregnancy or reduce the rate of preterm birth in women at high risk for preterm delivery and a short cervix: a randomized controlled trial. Am J Obstet Gynecol 2015; 212:485.e1-485.e10. [PMID: 25448515 DOI: 10.1016/j.ajog.2014.10.1097] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 09/26/2014] [Accepted: 10/28/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate the efficacy of 17 alpha-hydroxyprogesterone caproate (17OHP-C) in prolonging gestation in patients with a short cervix and other risk factors for preterm delivery, such as previous preterm birth, cervical surgery, uterine anomalies, or prenatal diethylstilbestrol (DES) exposure. STUDY DESIGN This open-label, multicenter, randomized controlled trial included asymptomatic singleton pregnancies from 20(+0) through 31(+6) weeks of gestation with a cervical length less than 25 mm and a history of preterm delivery or cervical surgery or uterine malformation or prenatal DES exposure. Randomization assigned them to receive (or not) 500 mg of intramuscular 17OHP-C weekly until 36 weeks. The primary outcome was time from randomization to delivery. RESULTS After enrolling 105 patients, an interim analysis demonstrated the lack of efficacy of 17OHP-C in prolonging pregnancy. The study was discontinued because of futility. The groups were similar for maternal age, body mass index, parity, gestational age at inclusion, history of uterine anomalies, DES syndrome, previous preterm delivery or midtrimester abortion, and cervical length at randomization. The enrollment-to-delivery interval did not differ between patients allocated to 17OHP-C (n = 51) and those allocated to the control group (n = 54) (median [interquartile range] time to delivery: 77 [54-103] and 74 [52-99] days, respectively). The rate of preterm delivery less than 37 (45% vs 44%, P > .99), less than 34 (24% vs 30%, P = .51), or less than 32 (14% vs 20%, P = .44) weeks was similar in patients allocated to 17OHP-C and those in the control group. CONCLUSION 17OHP-C did not prolong pregnancy in women with singleton gestations, a sonographic short cervix, and other risk factors of preterm delivery (prior history, uterine malformations, cervical surgery, or prenatal DES exposure).
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Affiliation(s)
- Norbert Winer
- Department of Obstetrics and Gynecology, Hôpital Mère-Enfant, Nantes, France
| | - Florence Bretelle
- Department of Obstetrics and Gynecology, Hôpital Nord, Marseille, France
| | - Marie-Victoire Senat
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Hôpital Antoine Béclère, Université Paris Sud, Faculté de Médecine Paris XI, Paris, France
| | - Caroline Bohec
- Department of Obstetrics and Gynecology, Hôpital Morvan, Brest, France
| | - Philippe Deruelle
- Department of Obstetrics and Gynecology, Hôpital Jeanne de Flandre, Lille, France
| | - Frank Perrotin
- Department of Obstetrics and Gynecology, Hôpital Bretonneau, Tours, France
| | - Laure Connan
- Department of Obstetrics and Gynecology, Hôpital Paul de Viguier, Toulouse, France
| | - Christophe Vayssière
- Department of Obstetrics and Gynecology, Centre Médico-Chirurgical Obstetrical, Schiltigheim, France
| | - Bruno Langer
- Department of Obstetrics and Gynecology, Hôpital Hautepierre, Strasbourg, France
| | - Marianne Capelle
- Department of Obstetrics and Gynecology, Hôpital de La Conception, Marseille, France
| | - Shohreh Azimi
- Department of Clinical Research, Ile-de-France, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Raphael Porcher
- Department of Biostatistics, Hôpital Saint-Louis, Paris Diderot University, and Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Patrick Rozenberg
- Department of Obstetrics and Gynecology, Hôpital Poissy-Saint Germain, Versailles-Saint Quentin University, Versailles, France.
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Miller NR, Dolinsky BM, Napolitano PG. Micronized progesterone reduces vasoconstriction in the placenta. J Matern Fetal Neonatal Med 2014; 28:1581-4. [DOI: 10.3109/14767058.2014.961008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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25
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Luo D, Yu H, Garfield RE, Shi SQ, Towe B. Treatment with focused ultrasound waves softens the rat cervix during pregnancy. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:2107-2112. [PMID: 24972500 DOI: 10.1016/j.ultrasmedbio.2014.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 02/07/2014] [Accepted: 02/20/2014] [Indexed: 06/03/2023]
Abstract
Application of focused ultrasound stimulation (FUS) to the rat cervix during pregnancy has significant physiologic effects. One-millisecond-long pulses of 680-kHz ultrasound with a repetition frequency of 25 Hz, at ISPTA (spatial-peak, temporal-average intensity) of 1, 2 and 4W/cm(2), were applied to the rat abdomen over the cervix. FUS produced a significant change in cervical elasticity known as softening, which is part of the ripening process, comparable to the degree seen just before delivery. Timed-pregnant Sprague-Dawley rats (n = 40) were used. During gestation, the FUS system was applied to the cervix for variable times up to 1 h. Daily measurements of cervix light-induced florescence were made to estimate changes in softening. In addition, cervical stretch estimates of softening were made of isolated cervices of control and FUS-treated rats to measure distensiblity. The ultrasound power with ISPPA (spatial-peak, pulse-average intensity) of 40 W/cm(2) was considered tolerable; the U.S. Food and Drug Administration regulatory limit is 190 W/cm(2) for both the body periphery and the fetus. This is the first report of alterations induced by ultrasound in the connective tissue of the cervix and suggests the therapeutic application of ultrasound for the facilitation of labor and delivery.
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Affiliation(s)
- Daishen Luo
- Harrington Biomedical Engineering, School of Biological Health Systems Engineering, Arizona State University, Tempe, Arizona, USA
| | - Heng Yu
- Harrington Biomedical Engineering, School of Biological Health Systems Engineering, Arizona State University, Tempe, Arizona, USA
| | - Robert E Garfield
- Department of Obstetrics and Gynecology, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Shao-Qing Shi
- Department of Obstetrics and Gynecology, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Bruce Towe
- Harrington Biomedical Engineering, School of Biological Health Systems Engineering, Arizona State University, Tempe, Arizona, USA.
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House M, Tadesse-Telila S, Norwitz ER, Socrate S, Kaplan DL. Inhibitory effect of progesterone on cervical tissue formation in a three-dimensional culture system with human cervical fibroblasts. Biol Reprod 2014; 90:18. [PMID: 24285720 DOI: 10.1095/biolreprod.113.112540] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Progesterone supplementation is recommended to prevent preterm birth in women with a short cervix, but the mechanism is unclear. We hypothesize that progesterone acts by altering the composition of the cervical extracellular matrix (ECM). We tested this hypothesis using human cervical fibroblasts in both two-dimensional (2D) and three-dimensional (3D) cultures. For 2D culture, cells were seeded in 6-well plates and cultured with media supplemented with estradiol (10(-8) M), progesterone (10(-7) or 10(-6) M), and vehicle. For 3D culture, the cells were cultured on a porous silk protein scaffold system. Progesterone and estrogen receptors were documented by immunohistochemistry and Western blot analysis. In both 2D and 3D cultures, decreased collagen synthesis was seen with increased progesterone concentration. Three-dimensional cultures could be maintained significantly longer than 2D cultures, and the morphology of 3D cultures appeared similar to native cervical tissue. Thus, further studies were performed in 3D culture. To determine the effect of progesterone concentration, the 3D scaffolds were cultured with estradiol (10(-8) M) and five conditions: vehicle; 10(-9), 10(-8), or 10(-7) M progesterone; or 10(-7) M progesterone plus 10(-6) M mifepristone. The highest progesterone concentration correlated with the least amount of collagen synthesis. Collagen synthesis progressively increased as progesterone concentration decreased. This effect was partially antagonized by mifepristone, suggesting the mechanism is mediated by the progesterone receptor. This hormonally responsive 3D culture system supports the hypothesis that progesterone has a direct effect on remodeling cervical ECM during pregnancy. The 3D culture system could be useful for studying the mechanism of progesterone effects on the cervix.
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Affiliation(s)
- Michael House
- Division of Maternal Fetal Medicine, Tufts Medical Center, Boston, Massachusetts
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27
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Yang J, Shi SQ, Shi L, Liu H, Fang D, Garfield RE. Nicotine treatment prolongs gestation and inhibits cervical ripening in pregnant rats. Am J Obstet Gynecol 2014; 210:76.e1-7. [PMID: 24036401 DOI: 10.1016/j.ajog.2013.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 07/02/2013] [Accepted: 09/09/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aims of this study were to examine the effects of nicotine treatment on the length of gestation, on fetal outcome, on cervical ripening, and on uterine contractility during pregnancy in rats. STUDY DESIGN Pregnant rats were treated with various concentrations of nicotine (0.25, 0.5, 1, 2 mg/kg/d, subcutaneously). Delivery times and fetal weights were obtained. Cervical collagen cross-links were assessed in vivo by collagen light-induced fluorescence (LIF), and cervical resistance to stretch was measured by in vitro extensibility tests. RESULTS Delivery time is significantly (P = .002) prolonged after high-dose nicotine treatments. There are no significant changes in pup weights and placenta weights after nicotine treatments. Cervical collagen LIF and extensibility progressively decrease throughout pregnancy in control rats. Nicotine-treated rats showed significant (P < .001) cervical resistance to stretch and higher LIF compared with the control rats. Nicotine treatment in vitro had little effect on uterine contractility. CONCLUSION Nicotine exposure during pregnancy prolongs gestation and inhibits cervical ripening, possibly by suppression of a cholinergic antiinflammatory response.
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28
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Romero R, Stanczyk FZ. Progesterone is not the same as 17α-hydroxyprogesterone caproate: implications for obstetrical practice. Am J Obstet Gynecol 2013; 208:421-6. [PMID: 23643669 DOI: 10.1016/j.ajog.2013.04.027] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 04/22/2013] [Indexed: 11/29/2022]
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Conde-Agudelo A, Romero R, Nicolaides K, Chaiworapongsa T, O'Brien JM, Cetingoz E, da Fonseca E, Creasy G, Soma-Pillay P, Fusey S, Cam C, Alfirevic Z, Hassan SS. Vaginal progesterone vs. cervical cerclage for the prevention of preterm birth in women with a sonographic short cervix, previous preterm birth, and singleton gestation: a systematic review and indirect comparison metaanalysis. Am J Obstet Gynecol 2013; 208:42.e1-42.e18. [PMID: 23157855 PMCID: PMC3529767 DOI: 10.1016/j.ajog.2012.10.877] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 10/12/2012] [Accepted: 10/17/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE No randomized controlled trial has compared vaginal progesterone and cervical cerclage directly for the prevention of preterm birth in women with a sonographic short cervix in the mid trimester, singleton gestation, and previous spontaneous preterm birth. We performed an indirect comparison of vaginal progesterone vs cerclage using placebo/no cerclage as the common comparator. STUDY DESIGN Adjusted indirect metaanalysis of randomized controlled trials. RESULTS Four studies that evaluated vaginal progesterone vs placebo (158 patients) and 5 studies that evaluated cerclage vs no cerclage (504 patients) were included. Both interventions were associated with a statistically significant reduction in the risk of preterm birth at <32 weeks of gestation and composite perinatal morbidity and mortality compared with placebo/no cerclage. Adjusted indirect metaanalyses did not show statistically significant differences between vaginal progesterone and cerclage in the reduction of preterm birth or adverse perinatal outcomes. CONCLUSION Based on state-of-the-art methods for indirect comparisons, either vaginal progesterone or cerclage are equally efficacious in the prevention of preterm birth in women with a sonographic short cervix in the mid trimester, singleton gestation, and previous preterm birth. Selection of the optimal treatment needs to consider adverse events, cost and patient/clinician preferences.
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Feltovich H, Hall TJ, Berghella V. Beyond cervical length: emerging technologies for assessing the pregnant cervix. Am J Obstet Gynecol 2012; 207:345-54. [PMID: 22717270 DOI: 10.1016/j.ajog.2012.05.015] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 05/02/2012] [Accepted: 05/21/2012] [Indexed: 12/12/2022]
Abstract
Spontaneous preterm birth is a heterogeneous phenotype. A multitude of pathophysiologic pathways culminate in the final common denominator of cervical softening, shortening, and dilation that leads to preterm birth. A precise description of specific microstructural changes to the cervix is imperative if we are to identify the causative upstream molecular processes and resultant biomechanical events that are associated with each unique pathway. Currently, however, we have no reliable clinical tools for quantitative and objective evaluation, which likely contributes to the reason the singleton spontaneous preterm birth rate has not changed appreciably in >100 years. Fortunately, promising techniques to evaluate tissue hydration, collagen structure, and/or tissue elasticity are emerging. These will add to the body of knowledge about the cervix and facilitate the coordination of molecular studies and ultimately lead to novel approaches to preterm birth prediction and, finally, prevention.
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Gupta S, Roman AS. 17-α hydroxyprogesterone caproate for the prevention of preterm birth. ACTA ACUST UNITED AC 2012; 8:21-30. [PMID: 22171770 DOI: 10.2217/whe.11.78] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
17 α hydroxyprogesterone caproate is a synthetic form of the natural progestin 17-α hydroxyprogesterone that is US FDA approved for the prevention of recurrent spontaneous preterm birth in women with a history of a prior singleton preterm birth. For women with a history of a prior spontaneous preterm birth between 20 weeks and 36 weeks and 6 days of gestation, the use of 17-α hydroxyprogesterone caproate has been shown to reduce the risk of recurrent preterm birth by more than 30%. This medication is the only drug currently FDA approved for the prevention of preterm birth, and it is the first drug the FDA has approved for use exclusively during pregnancy in approximately 15 years.
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Affiliation(s)
- Simi Gupta
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, NYU School of Medicine, New York, NY 10016, USA
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Baumbach J, Shi SQ, Shi L, Balducci J, Coonrod DV, Garfield RE. Inhibition of uterine contractility with various tocolytics with and without progesterone: in vitro studies. Am J Obstet Gynecol 2012; 206:254.e1-5. [PMID: 22244470 DOI: 10.1016/j.ajog.2011.12.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 11/14/2011] [Accepted: 12/12/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Various tocolytics are used to suppress uterine contractility in patients in preterm labor. Progesterone (P4) is used in patients at high risk for preterm delivery. In this study, we evaluated the effects of various tocolytics with and without P4 to examine effects on uterine contractility. STUDY DESIGN Uterine tissues (n = 280) from women undergoing cesarean at term were exposed in vitro to various agents (vehicle, magnesium sulfate [MgSO(4)], nifedipine, indomethacin, or pinacidil-all with and without P4). Contractility was measured before and after addition of the various agents. RESULTS P4 alone at 10(-5) mol/L concentration has little effect to inhibit contractility (P ≥ .05). MgSO(4) (2-8 × 10(-3) mol/L) inhibits uterine contractility (P < .05) but there is no change when combined with P4 (P > .05). Nifedipine (10(-8) mol/L) and indomethacin (10(-5) mol/L) inhibit contractions alone (P < .05) and to a greater extent when combined with P4 (P < .05). P4 significantly (P < .05) reduced the effects of pinacidil (10(-6.5) mol/L). CONCLUSION Combinations of P4 with nifedipine or indomethacin, but not MgSO(4), might be used to effectively suppress preterm labor.
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Affiliation(s)
- Jennifer Baumbach
- Department of Obstetrics and Gynecology, and Women's Health, Maricopa Integrated Health System, Phoenix, AZ 85008, USA.
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Garfield R, Shi L, Shi SQ. Use of progesterone and progestin analogs for inhibition of preterm birth and other uterine contractility disorders. Facts Views Vis Obgyn 2012; 4:237-44. [PMID: 24753915 PMCID: PMC3987481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
In this paper we focus on preterm birth as a uterine contractility disorder caused by hypercontractility of the -myometrium. We describe changes in uterine function during term and preterm labor and delivery. We also examine the usefulness of measurement of uterine electromyographic (EMG) activity, noninvasively monitored from the -abdominal surface of pregnant patients. The use of progesterone treatment for preterm birth is discussed and we conclude that present therapies with progesterone could be improved by changing the route of administration. -Finally we show the results of recent studies that show that progesterone injections completely inhibit uterine EMG activity when given several days to hours before normal delivery. These studies illustrate how progesterone suppresses labor at term or preterm, probably through repression of genes which control excitability and conduction of electrical activity. However, direct profusion of soluble progesterone into the uterine cavity has little immediate inhibitory action and this may demonstrate that progesterone has no direct, nongenomic effects, at least in the rat model used. Further studies are required to determine the effects of progesterone on human uterine EMG activity and whether progesterone treatments will prevent preterm birth.
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Kuon RJ, Garfield R. Actions of progestins for the inhibition of cervical ripening and uterine contractions to prevent preterm birth. Facts Views Vis Obgyn 2012; 4:110-9. [PMID: 24753898 PMCID: PMC3987504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The importance of progesterone (P4) for maintenance of pregnancy, its role in cervical ripening and uterine contractions is at least partly established and therefore, not surprisingly, the basis for the concept to use P4 as a treatment for preterm birth. Due to the complexity of the condition of preterm birth there are still questions concerning the optimal population that might benefit, timing of treatment, dosage, vehicle and route of administration. Recently vaginal P4 and intramuscular 17-alpha-hydroxyprogesterone caproate (17P) have been used to prevent preterm birth in patients with a high risk for early delivery. The aim of this study was to assess cervical changes throughout pregnancy in rats and the timing of term and preterm delivery after various progestin treatments given by different routes and vehicles in hope of identifying better treatment regimens. This paper presents results that suggest that there are better routes of treatment than the vaginal route (e.g. topical), that the vehicle used in many of the clinical studies (Replens®) is not appropriate due to a low release of the steroid and consequently low uptake of P4, and that inhibition of birth is primarily due to inhibition of uterine contractility that can be achieved by supplementation of P4 but not with 17P.
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Affiliation(s)
- R.-J. Kuon
- Department of Obstetrics and Gynecology, University of Heidelberg, 69115 Heidelberg, Germany
| | - R.E. Garfield
- Department of Obstetrics and Gynecology, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona 85013, USA.
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Progesterone interactions with the cervix: translational implications for term and preterm birth. Infect Dis Obstet Gynecol 2011; 2011:353297. [PMID: 22114461 PMCID: PMC3206389 DOI: 10.1155/2011/353297] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 08/29/2011] [Indexed: 01/04/2023] Open
Abstract
The uterine cervix plays a vital role in maintaining pregnancy and an equally important role in allowing parturition to occur. Progesterone, either endogenously produced or supplied exogenously, supports the function of the cervix in sustaining intrauterine pregnancy, and the withdrawal of progesterone, either through natural processes or pharmacologic intervention, leads to delivery which underscores the importance of the progesterone's biological activities manifest in normal gestation and pregnancy that ends prematurely. Research crossing many scientific disciplines has demonstrated that progesterone is a pleotropic compound that affects the cervix through cytoplasmic and membrane receptors with profound effects on cellular and molecular functions that influence inflammatory cascades and extracellular matrix, both of which have consequences for parturition. Beyond the local cell and molecular biology of progesterone, it has systemic effects of relevance to pregnancy as well. This paper examines the biology of the cervix from its gross to cellular structure and biological activities of its cell and molecular processes that may be affected by progesterone. The implications of these processes for preterm birth are explored, and direction of current research is in relation to translational medicine implications for diagnostic, prognostic, and therapeutic approaches to threatened preterm birth.
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Abstract
17 α-hydroxyprogesterone caproate is a synthetic progestin of which there is now a US FDA-approved formulation available for intramuscular administration (Makena™) to reduce the risk of preterm birth. Intramuscular 17 α-hydroxyprogesterone caproate (identical in formulation and manufacturing process to Makena™, thus hereafter referred to as Makena™) 250 mg once weekly, initiated at 16-20 weeks' gestation, was effective in reducing the risk of preterm birth in women with a singleton pregnancy at high risk of delivering preterm in a large, well designed, placebo-controlled trial (n = 463 randomized). Rates of delivery before 37 (primary endpoint), 35, or 32 weeks' gestation were significantly lower with Makena™ than with placebo, corresponding to relative risk reductions of 34%, 33%, and 42%, respectively. The benefit of the drug in reducing the risk of preterm birth was observed when deliveries were spontaneous (but not when indicated because of complications) and regardless of maternal race. In addition, there was a significantly lower rate of several adverse fetal/neonatal outcomes among infants of women who received Makena™ than among infants of placebo recipients, including necrotizing enterocolitis, need for supplemental oxygen, birth weight of <2500 g, and intraventricular hemorrhage. Makena™ was generally well tolerated in pregnant women in this trial. Moreover, fetal exposure to the drug appeared to be safe according to a 2- to 5-year follow-up of the study, with no evidence of a detrimental effect of the drug on child neurodevelopment and a low overall incidence (≈2%) of reproductive or genital abnormalities that was not significantly different from placebo.
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Affiliation(s)
- Emma D Deeks
- Adis, a Wolters Kluwer Business, Auckland, New Zealand.
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Kuon RJ, Shi SQ, Maul H, Sohn C, Balducci J, Shi L, Garfield RE. A novel optical method to assess cervical changes during pregnancy and use to evaluate the effects of progestins on term and preterm labor. Am J Obstet Gynecol 2011; 205:82.e15-20. [PMID: 21497789 DOI: 10.1016/j.ajog.2011.02.048] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2010] [Revised: 02/08/2011] [Accepted: 02/14/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether optical methods can estimate cervix function during pregnancy and whether progestins modify this process. STUDY DESIGN Photos of the external cervix of timed-pregnant rats were taken every other day from day 13 until postpartum day 5 after daily treatments with vehicle (controls) or progestin treatments (progesterone, subcutaneously or vaginally; 17-alpha-hydroxyprogesterone caproate [17P] and RU-486 subcutaneously, once on day 16). The surface area of the cervix was estimated from photos. RESULTS The surface area of cervix increases throughout pregnancy and reverses after delivery in controls. In the progesterone subcutaneously or 17P subcutaneously groups, increases in surface area are lower (17P group until day 19 only; P < .05). Vaginal progesterone does not prevent surface area increases. Only the progesterone subcutaneously blocked delivery. RU-486 increases the surface area of the cervix (P < .05) during preterm delivery. CONCLUSION An optical method is useful for quantitative assessment of the cervix and evaluation of agents that modify cervical function.
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Affiliation(s)
- Ruben J Kuon
- Department of Obstetrics and Gynecology of the St. Joseph's Hospital and Medical Center, Phoenix, AZ 85004, USA
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Calleja-Agius J, Muttukrishna S, Pizzey AR, Jauniaux E. Pro- and antiinflammatory cytokines in threatened miscarriages. Am J Obstet Gynecol 2011; 205:83.e8-16. [PMID: 21514552 DOI: 10.1016/j.ajog.2011.02.051] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Revised: 01/25/2011] [Accepted: 02/14/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate circulating and intracellular levels of Th1 and Th2 cytokines in women with threatened miscarriage (TM) and subsequent outcome. STUDY DESIGN Plasma levels of tumor necrosis factor (TNF)-receptors 1 and 2, TNFα, interferon gamma (IFNγ), and interleukins (IL) -6 and -10 were measured by flow cytometric bead assays in 80 women with TM: 53 women with normal outcome and 27 women who miscarried. Fluorescent antibody labeling was also performed on whole blood in a subgroup of 27 women of TM: 16 women with normal outcome and 11 women who miscarried. RESULTS Monocyte expression of TNFα and circulating levels of TNFα, IFNγ, IL-10, IL-6, and TNF-R1 were significantly lower, whereas circulating levels of TNFα/IL-10, IFNγ/IL-10, and TNFα/IL-6 ratios were significantly higher, in women with TM who subsequently miscarried, compared with the women with normal outcome. CONCLUSION An increased Th1 type of immune response, which was similar to that observed in preterm delivery, was found in TM cases that were complicated by a subsequent miscarriage.
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Lucovnik M, Kuon RJ, Chambliss LR, Maner WL, Shi SQ, Shi L, Balducci J, Garfield RE. Progestin treatment for the prevention of preterm birth. Acta Obstet Gynecol Scand 2011; 90:1057-69. [PMID: 21564026 DOI: 10.1111/j.1600-0412.2011.01178.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Progestin supplementation appears to be a promising approach to both preventing initiation of preterm labor and treating it once it is already established, given the role of progesterone in maintaining pregnancy, as well as support from basic and clinical research. Progesterone and 17α-hydroxyprogesterone acetate slow the process of cervical ripening, and this is the rationale for prophylactic long-term progestin supplementation mostly studied so far. However, progesterone (but not 17α-hydroxyprogesterone acetate) also inhibits myometrial activity even after the cervix has already ripened. Moreover, these effects depend greatly on the vehicle used and the route of administration. Understanding different mechanisms of action, as well as the importance of progestin formulation, vehicle and route of administration, is the key to finding the optimal progestin treatment for prevention of preterm birth.
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Affiliation(s)
- Miha Lucovnik
- Department of Obstetrics and Gynecology, St Joseph's Hospital and Medical Center, 445 North 5th Street, Phoenix, AZ 85004, USA
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40
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Orth TA, Shi SQ, Williamson K, Shi L, Chambliss L, Coonrod DV, Balducci J, Garfield RE. Additive Inhibitory Effects of Progesterone and Sodium Nitroprusside on Uterine Contractility During Pregnancy. Reprod Sci 2011; 18:868-75. [DOI: 10.1177/1933719111398141] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Teresa A. Orth
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Obstetrics and Gynecology Department, Maricopa Medical Center, Phoenix, AZ, USA
| | - Shao-Qing Shi
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Kelli Williamson
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Leili Shi
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Linda Chambliss
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Dean V. Coonrod
- Obstetrics and Gynecology Department, Maricopa Medical Center, Phoenix, AZ, USA
| | - James Balducci
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Robert E. Garfield
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
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41
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Norwitz ER, Caughey AB. Progesterone supplementation and the prevention of preterm birth. REVIEWS IN OBSTETRICS & GYNECOLOGY 2011; 4:60-72. [PMID: 22102929 PMCID: PMC3218546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Preterm birth is currently the most important problem in maternal-child health in the United States and possibly throughout the world. It complicates one in eight US deliveries, and accounts for over 85% of all perinatal morbidity and mortality. Although survival of preterm infants has increased steadily over the past four decades-due in large part to the use of antenatal corticosteroids, improvements in neonatal resuscitation, and the introduction of neonatal intensive care units-efforts to prevent preterm birth have been largely unsuccessful. On February 3, 2011, the US Food and Drug Administration (FDA) approved the use of progesterone supplementation (hydroxyprogesterone caproate) during pregnancy to reduce the risk of recurrent preterm birth in women with a history of at least one prior spontaneous preterm delivery. This is the first time that the FDA has approved a medication for the prevention of preterm birth, and represents the first approval of a drug specifically for use in pregnancy in almost 15 years. This article reviews the evidence behind the use of progesterone for the prevention of preterm birth, and provides guidelines for the use of progesterone supplementation in clinical practice. A number of areas of ongoing controversy are addressed, including the optimal formulation and route of administration, the safety of progesterone supplementation in pregnancy, and its proposed mode of action.
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Clyde LA, Lechuga TJ, Ebner CA, Burns AE, Kirby MA, Yellon SM. Transection of the pelvic or vagus nerve forestalls ripening of the cervix and delays birth in rats. Biol Reprod 2010; 84:587-94. [PMID: 21106964 DOI: 10.1095/biolreprod.110.086207] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Innervation of the cervix is important for normal timing of birth because transection of the pelvic nerve forestalls birth and causes dystocia. To discover whether transection of the parasympathetic innervation of the cervix affects cervical ripening in the process of parturition was the objective of the present study. Rats on Day 16 of pregnancy had the pelvic nerve (PnX) or the vagus nerve (VnX) or both pathways (PnX+VnX) transected, sham-operated (Sham) or nonpregnant rats served as controls. Sections of fixed peripartum cervix were stained for collagen or processed by immunohistochemistry to identify macrophages and nerve fibers. All Sham controls delivered by the morning of Day 22 postbreeding, while births were delayed in more than 75% of neurectomized rats by more than 12 h. Dystocia was evident in more than 25% of the PnX and PnX+VnX rats. Moreover, on prepartum Day 21, serum progesterone was increased severalfold in neurectomized versus Sham rats. Assessments of cell nuclei counts indicated that the cervix of neurectomized rats and Sham controls had become equally hypertrophied compared to the unripe cervix in nonpregnant rats. Collagen content and structure were reduced in the cervix of all pregnant rats, whether neurectomized or Shams, versus that in nonpregnant rats. Stereological analysis of cervix sections found reduced numbers of resident macrophages in prepartum PnX and PnX+VnX rats on Day 21 postbreeding, as well as in VnX rats on Day 22 postbreeding compared to that in Sham controls. Finally, nerve transections blocked the prepartum increase in innervation that occurred in Sham rats on Day 21 postbreeding. These findings indicate that parasympathetic innervation of the cervix mediates local inflammatory processes, withdrawal of progesterone in circulation, and the normal timing of birth. Therefore, pelvic and vagal nerves regulate macrophage immigration and nerve fiber density but may not be involved in final remodeling of the extracellular matrix in the prepartum cervix. These findings support the contention that immigration of immune cells and enhanced innervation are involved in processes that remodel the cervix and time parturition.
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Affiliation(s)
- Lindsey A Clyde
- Department of Physiology, Pathology, and Human Anatomy, Loma Linda University School of Medicine, Loma Linda, CA, USA
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