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Kühle H, Cho SKS, Charest-Pekeski AJ, Chow JSM, Lee FT, Aujla T, Saini BS, Lim JM, Darby JRT, Mroczek D, Floh AA, McVey MJ, Morrison JL, Seed M, Sun L, Haller C. Echocardiographic assessment of cardiovascular physiology of preterm miniature piglets supported with a pumped artificial placenta system. Prenat Diagn 2024; 44:888-898. [PMID: 38809178 DOI: 10.1002/pd.6612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/27/2024] [Accepted: 05/12/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVES We evaluated fetal cardiovascular physiology and mode of cardiac failure in premature miniature piglets on a pumped artificial placenta (AP) circuit. METHODS Fetal pigs were cannulated via the umbilical vessels and transitioned to an AP circuit composed of a centrifugal pump and neonatal oxygenator and maintained in a fluid-filled biobag. Echocardiographic studies were conducted to measure ventricular function, umbilical blood flow, and fluid status. In utero scans were used as control data. RESULTS AP fetuses (n = 13; 102±4d gestational age [term 115d]; 616 ± 139 g [g]; survival 46.4 ± 46.8 h) were tachycardic and hypertensive with initially supraphysiologic circuit flows. Increased myocardial wall thickness was observed. Signs of fetal hydrops were present in all piglets. Global longitudinal strain (GLS) measurements increased in the left ventricle (LV) after transition to the circuit. Right ventricle (RV) and LV strain rate decreased early during AP support compared with in utero measurements but recovered toward the end of the experiment. Fetuses supported for >24 h had similar RV GLS to in utero controls and significantly higher GLS compared to piglets surviving only up to 24 h. CONCLUSIONS Fetuses on a pump-supported AP circuit experienced an increase in afterload, and redistribution of blood flow between the AP and systemic circulations, associated with elevated end-diastolic filling pressures. This resulted in heart failure and hydrops. These preterm fetuses were unable to tolerate the hemodynamic changes associated with connection to the current AP circuit. To better mimic the physiology of the native placenta and preserve normal fetal cardiovascular physiology, further optimization of the circuit will be required.
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Affiliation(s)
- Henriette Kühle
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Cardiac and Thoracic Surgery, University Hospital Magdeburg, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Steven K S Cho
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alex J Charest-Pekeski
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jessica S M Chow
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Fu-Tsuen Lee
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tanroop Aujla
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brahmdeep S Saini
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jessie Mei Lim
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Dariusz Mroczek
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Alejandro A Floh
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mark J McVey
- Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Physics, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Janna L Morrison
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Mike Seed
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Liqun Sun
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christoph Haller
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Romanis EC, Adkins V. Artificial placentas, pregnancy loss and loss-sensitive care. JOURNAL OF MEDICAL ETHICS 2024; 50:299-307. [PMID: 37932017 DOI: 10.1136/jme-2023-109412] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/10/2023] [Indexed: 11/08/2023]
Abstract
In this paper, we explore how the prospect of artificial placenta technology (nearing clinical trials in human subjects) should encourage further consideration of the loss experienced by individuals when their pregnancy ends unexpectedly. Discussions of pregnancy loss are intertwined with procreative loss, whereby the gestated entity has died when the pregnancy ends. However, we demonstrate how pregnancy loss can and does exist separate to procreative loss in circumstances where the gestated entity survives the premature ending of the pregnancy. In outlining the value that can be attached to pregnancy beyond fetal-centric narratives, we illustrate how pregnancy loss, separate to procreative loss, can be experienced. This loss has already been recognised among parents who have experienced an unexpected early ending of their pregnancy, resulting in their child being cared for in neonatal intensive care unit. Artificial placentas, however, may exacerbate these feelings and make pregnancy loss (without procreative loss) more visible. We argue that pregnancy is an embodied state in which gestation is facilitated by the body but gestation itself should be recognised as a process-and one that could be separable from pregnancy. In demarcating the two, we explore the different ways in which pregnancy loss can be understood. Our objective in this paper goes beyond contributing to our philosophical understanding of pregnancy towards practical-orientated conclusions regarding the care pathways surrounding the artificial placenta. We make recommendations including the need for counselling and careful consideration of the language used when an artificial placenta is used.
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Affiliation(s)
- Elizabeth Chloe Romanis
- Centre for Ethics and Law in the Life Sciences, Durham Law School, Durham University, Durham, UK
| | - Victoria Adkins
- School of Law and Criminology, University of Greenwich, London, UK
- School of Law and Social Sciences, Royal Holloway University of London, Egham, UK
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3
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van Haren JS, Delbressine FLM, Schoberer M, te Pas AB, van Laar JOEH, Oei SG, van der Hout-van der Jagt MB. Transferring an extremely premature infant to an extra-uterine life support system: a prospective view on the obstetric procedure. Front Pediatr 2024; 12:1360111. [PMID: 38425664 PMCID: PMC10902175 DOI: 10.3389/fped.2024.1360111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/02/2024] [Indexed: 03/02/2024] Open
Abstract
To improve care for extremely premature infants, the development of an extrauterine environment for newborn development is being researched, known as Artificial Placenta and Artificial Womb (APAW) technology. APAW facilitates extended development in a liquid-filled incubator with oxygen and nutrient supply through an oxygenator connected to the umbilical vessels. This setup is intended to provide the optimal environment for further development, allowing further lung maturation by delaying gas exposure to oxygen. This innovative treatment necessitates interventions in obstetric procedures to transfer an infant from the native to an artificial womb, while preventing fetal-to-neonatal transition. In this narrative review we analyze relevant fetal physiology literature, provide an overview of insights from APAW studies, and identify considerations for the obstetric procedure from the native uterus to an APAW system. Lastly, this review provides suggestions to improve sterility, fetal and maternal well-being, and the prevention of neonatal transition.
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Affiliation(s)
- Juliette S. van Haren
- Department of Industrial Design, Eindhoven University of Technology, Eindhoven, Netherlands
- Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
| | | | - Mark Schoberer
- Institute for Applied Medical Engineering and Clinic for Neonatology, University Hospital Aachen, Aachen, Germany
| | - Arjan B. te Pas
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Judith O. E. H. van Laar
- Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - S. Guid Oei
- Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - M. Beatrijs van der Hout-van der Jagt
- Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
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4
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Verrips M, van Haren JS, Oei SG, Moser A, der Hout-van der Jagt MBV. Clinical aspects of umbilical cord cannulation during transfer from the uterus to a liquid-based perinatal life support system for extremely premature infants a qualitative generic study. PLoS One 2023; 18:e0290659. [PMID: 38127930 PMCID: PMC10734990 DOI: 10.1371/journal.pone.0290659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 08/13/2023] [Indexed: 12/23/2023] Open
Abstract
A liquid-based perinatal life support system (PLS) for extremely premature infants (born before 28 week of gestational age) envisions a connection between the infant's native umbilical cord and an artificial placenta system through cannulation. This system mimics a natural mothers' womb to achieve better organ maturations. The objective of this study is to gain insight into the clinical focus points of umbilical cord cannulation and how cannulation should be addressed in extremely premature infants during the transfer from the uterus to an in-utero simulating liquid-based PLS system. We performed an explorative qualitative study. Twelve medical specialists with knowledge of vessel cannulation participated. We collected data through twelve interviews and two focus group discussions. Data were analyzed using inductive content and constant comparison analysis via open and axial coding. Results were derived on the following topics: (1) cannulation technique, (2) cannula fixation, (3) local and systemic anticoagulation, and (4) vasospasm. A side-entry technique is preferred as this may decrease wall damage, stabilizes the vessel better and ensures continuous blood flow. Sutures, especially via an automatic microsurgery instrument, are favored above glue, stents, or balloons as these may be firmer and faster. Medication possibilities for both vasospasm and anticoagulation should function locally since there were uncertainties regarding the systemic effects. According to the findings of this research, the needed umbilical cord cannulation method should include minimal wall damage, improved vascular stability, blood flow maintenance, a strong fixation connection, and local anticoagulation effect.
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Affiliation(s)
- M. Verrips
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, the Netherlands
| | - J. S van Haren
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, the Netherlands
- Faculty of Industrial Design, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - S. G Oei
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, the Netherlands
| | - A Moser
- Department of Family Practice, Maastricht University, Maastricht, the Netherlands
| | - M. B. Van der Hout-van der Jagt
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, the Netherlands
- Faculty of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
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5
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Kukora SK, Mychaliska GB, Weiss EM. Ethical challenges in first-in-human trials of the artificial placenta and artificial womb: not all technologies are created equally, ethically. J Perinatol 2023; 43:1337-1342. [PMID: 37400494 DOI: 10.1038/s41372-023-01713-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 06/07/2023] [Accepted: 06/21/2023] [Indexed: 07/05/2023]
Abstract
Artificial placenta and artificial womb technologies to support extremely premature neonates are advancing toward clinical testing in humans. Currently, no recommendations exist comparing these approaches to guide study design and optimal enrollment eligibility adhering to principles of research ethics. In this paper, we will explore how scientific differences between the artificial placenta and artificial womb approaches create unique ethical challenges to designing first-in-human trials of safety and provide recommendations to guide ethical study design for initial human translation.
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Affiliation(s)
- Stephanie K Kukora
- Division of Neonatology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA.
- Children's Mercy Bioethics Center, Children's Mercy Hospital, Kansas City, MO, USA.
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Elliott Mark Weiss
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
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6
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Usuda H, Watanabe S, T H, Saito M, Sato S, Ikeda H, Kumagai Y, Choolani MC, Kemp MW. Artificial placenta technology: History, potential and perception. Placenta 2023; 141:10-17. [PMID: 37743742 DOI: 10.1016/j.placenta.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/20/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Abstract
As presently conceptualised, the artificial placenta (AP) is an experimental life support platform for extremely preterm infants (i.e. 400-600 g; 21-23+6 weeks of gestation) born at the border of viability. It is based around the oxygenation of the periviable fetus using gas-exchangers connected to the fetal vasculature. In this system, the lung remains fluid-filled and the fetus remains in a quiescent state. The AP has been in development for some sixty years. Over this time, animal experimental models have evolved iteratively from employing external pump-driven systems used to support comparatively mature fetuses (generally goats or sheep) to platforms driven by the fetal heart and used successfully to maintain extremely premature fetuses weighing around 600 g. Simultaneously, sizable advances in neonatal and obstetric care mean that the nature of a potential candidate patient for this therapy, and thus the threshold success level for justifying its adoption, have both changed markedly since this approach was first conceived. Five landmark breakthroughs have occurred over the developmental history of the AP: i) the first human studies reported in the 1950's; ii) foundation animal studies reported in the 1960's; iii) the first extended use of AP technology combined with fetal pulmonary resuscitation reported in the 1990s; iv) the development of AP systems powered by the fetal heart reported in the 2000's; and v) the adaption of this technology to maintain extremely preterm fetuses (i.e. 500-600 g body weight) reported in the 2010's. Using this framework, the present paper will provide a review of the developmental history of this long-running experimental system and up-to-date assessment of the published field today. With the apparent acceleration of AP technology towards clinical application, there has been an increase in the attention paid to the field, along with some inaccurate commentary regarding its potential application and merits. Additionally, this paper will address several misrepresentations regarding the potential application of AP technology that serve to distract from the significant potential of this approach to greatly improve outcomes for extremely preterm infants born at or close to the present border of viability.
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Affiliation(s)
- H Usuda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - S Watanabe
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Hanita T
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - M Saito
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - S Sato
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - H Ikeda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Y Kumagai
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - M C Choolani
- Women and Infants Research Foundation, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - M W Kemp
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia; Women and Infants Research Foundation, King Edward Memorial Hospital, Perth, Western Australia, Australia; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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7
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Usuda H, Ikeda H, Watanabe S, Sato S, Fee EL, Carter SWD, Kumagai Y, Saito Y, Takahashi T, Takahashi Y, Kawamura S, Hanita T, Saito M, Kikuchi A, Choolani MA, Yaegashi N, Kemp MW. Artificial placenta support of extremely preterm ovine fetuses at the border of viability for up to 336 hours with maintenance of systemic circulation but reduced somatic and organ growth. Front Physiol 2023; 14:1219185. [PMID: 37692998 PMCID: PMC10484719 DOI: 10.3389/fphys.2023.1219185] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction: Artificial placenta therapy (APT) is an experimental life support system to improve outcomes for extremely preterm infants (EPI) less than 1,000 g by obviating the need for pulmonary gas exchange. There are presently no long-term survival data for EPI supported with APT. To address this, we aimed to maintain 95d-GA (GA; term-150d) sheep fetuses for up to 2 weeks using our APT system. Methods: Pregnant ewes (n = 6) carrying singleton fetuses underwent surgical delivery at 95d GA. Fetuses were adapted to APT and maintained for up to 2 weeks with constant monitoring of key physiological parameters and extensive time-course blood and urine sampling, and ultrasound assessments. Six age-matched in-utero fetuses served as controls. Data were tested for group differences with ANOVA. Results: Six APT Group fetuses (100%) were adapted to APT successfully. The mean BW at the initiation of APT was 656 ± 42 g. Mean survival was 250 ± 72 h (Max 336 h) with systemic circulation and key physiological parameters maintained mostly within normal ranges. APT fetuses had active movements and urine output constantly exceeded infusion volume over the experiment. At delivery, there were no differences in BW (with edema in three APT group animals), brain weight, or femur length between APT and in-utero Control animals. Organ weights and humerus lengths were significantly reduced in the APT group (p < 0.05). Albumin, IGF-1, and phosphorus were significantly decreased in the APT group (p < 0.05). No cases of positive blood culture were detected. Conclusion: We report the longest use of APT to maintain extremely preterm fetuses to date. Fetal systemic circulation was maintained without infection, but growth was abnormal. This achievement suggests a need to focus not only on cardiovascular stability and health but also on the optimization of fetal growth and organ development. This new challenge will need to be overcome prior to the clinical translation of this technology.
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Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, WA, Australia
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hideyuki Ikeda
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, WA, Australia
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Shimpei Watanabe
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Shinichi Sato
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Erin L. Fee
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, WA, Australia
| | - Sean W. D. Carter
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, WA, Australia
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yusaku Kumagai
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yuya Saito
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Tsukasa Takahashi
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, WA, Australia
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yuki Takahashi
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, WA, Australia
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | | | - Takushi Hanita
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Masatoshi Saito
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, WA, Australia
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Atsuo Kikuchi
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Mahesh A. Choolani
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nobuo Yaegashi
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Matthew W. Kemp
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, WA, Australia
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- School of Veterinary and Life Sciences, Murdoch University, Perth, WA, Australia
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Shah NR, Mychaliska GB. The new frontier in ECLS: Artificial placenta and artificial womb for premature infants. Semin Pediatr Surg 2023; 32:151336. [PMID: 37866171 DOI: 10.1016/j.sempedsurg.2023.151336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Outcomes for extremely low gestational age newborns (ELGANs), defined as <28 weeks estimated gestational age (EGA), remain disproportionately poor. A radical paradigm shift in the treatment of prematurity is to recreate the fetal environment with extracorporeal support and provide an environment for organ maturation using an extracorporeal VV-ECLS artificial placenta (AP) or an AV-ECLS artificial womb (AW). In this article, we will review clinical indications, current approaches in development, ongoing challenges, remaining milestones and ethical considerations prior to clinical translation.
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Affiliation(s)
- Nikhil R Shah
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA.
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9
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Räsänen J. Regulating abortion after ectogestation. JOURNAL OF MEDICAL ETHICS 2023; 49:419-422. [PMID: 35725301 DOI: 10.1136/jme-2022-108174] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/08/2022] [Indexed: 05/24/2023]
Abstract
A few decades from now, it might become possible to gestate fetuses in artificial wombs. Ectogestation as this is called, raises major legal and ethical issues, especially for abortion rights. In countries allowing abortion, regulation often revolves around the viability threshold-the point in fetal development after which the fetus can survive outside the womb. How should viability be understood-and abortion thus regulated-after ectogestation? Should we ban, allow or require the use of artificial wombs as an alternative to standard abortions? Drawing on Cohen, I evaluate three possible positions for the post-ectogestative abortion laws: restrictive, conservative and liberal. While the restrictive position appears untenable, I argue that the liberal and conservative positions can be combined to form a legally and morally coherent basis for post-ectogestative abortion legislation, offering an improvement from the point of both prolife and prochoice positions.
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Affiliation(s)
- Joona Räsänen
- CEPDISC - Centre for the Experimental-Philosophical Study of Discrimination, Department of Political Science, Aarhus University, Aarhus, Denmark
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An Artificial Placenta Experimental System in Sheep: Critical Issues for Successful Transition and Survival up to One Week. Biomedicines 2023; 11:biomedicines11030702. [PMID: 36979681 PMCID: PMC10044909 DOI: 10.3390/biomedicines11030702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
Objective: To describe the development of an artificial placenta (AP) system in sheep with learning curve and main bottlenecks to allow survival up to one week. Methods: A total of 28 fetal sheep were transferred to an AP system at 110–115 days of gestation. The survival goal in the AP system was increased progressively in three consecutive study groups: 1–3 h (n = 8), 4–24 h (n = 10) and 48–168 h (n = 10). Duration of cannulation procedure, technical complications, pH, lactate, extracorporeal circulation (EC) circuit flows, fetal heart rate, and outcomes across experiments were compared. Results: There was a progressive reduction in cannulation complications (75%, 50% and 0%, p = 0.004), improvement in initial pH (7.20 ± 0.06, 7.31 ± 0.04 and 7.33 ± 0.02, p = 0.161), and increment in the rate of experiments reaching survival goal (25%, 70% and 80%, p = 0.045). In the first two groups, cannulation accidents, air bubbles in the extracorporeal circuit, and thrombotic complications were the most common cause of AP system failure. Conclusions: Achieving a reproducible experimental setting for an AP system is extremely challenging, time- and effort-consuming, and requires a highly multidisciplinary team. As a result of the learning curve, we achieved reproducible transition and survival up to 7 days. Extended survival requires improving instrumentation with custom-designed devices.
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Omecinski KS, Frankowski BJ, Federspiel WJ. Design and In Vitro Evaluation of an Artificial Placenta Made From Hollow Fiber Membranes. ASAIO J 2023; 69:e86-e92. [PMID: 36716073 PMCID: PMC9897463 DOI: 10.1097/mat.0000000000001862] [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] [Indexed: 01/31/2023] Open
Abstract
For infants born at the border of viability, care practices and morbimortality rates vary widely between centers. Trends show significant improvement, however, with increasing gestational age and weight. For periviable infants, the goal of critical care is to bridge patients to improved outcomes. Current practice involves ventilator therapy, resulting in chronic lung injuries. Research has turned to artificial uterine environments, where infants are submerged in an artificial amniotic fluid bath and provided respiratory assistance via an artificial placenta. We have developed the Preemie-Ox, a hollow fiber membrane bundle that provides pumpless respiratory support via umbilical cord cannulation. Computational fluid dynamics was used to design an oxygenator that could achieve a carbon dioxide removal rate of 12.2 ml/min, an outlet hemoglobin saturation of 100%, and a resistance of less than 71 mmHg/L/min at a blood flow rate of 165 ml/min. A prototype was utilized to evaluate in-vitro gas exchange, resistance, and plasma-free hemoglobin generation. In-vitro gas exchange was 4% higher than predicted results and no quantifiable plasma-free hemoglobin was produced.
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Affiliation(s)
- Katelin S Omecinski
- From the McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brian J Frankowski
- From the McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William J Federspiel
- From the McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
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12
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Spencer BL, Mychaliska GB. Updates in Neonatal Extracorporeal Membrane Oxygenation and the Artificial Placenta. Clin Perinatol 2022; 49:873-891. [PMID: 36328605 DOI: 10.1016/j.clp.2022.07.002] [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: 01/27/2023]
Abstract
Extracorporeal life support, initially performed in neonates, is now commonly used for both pediatric and adult patients requiring pulmonary and/or cardiac support. Data suggests the clinical feasibility of Extracorporeal Membrane Oxygenation for premature infants (29-33 weeks estimated gestational age [EGA]). For extremely premature infants less than 28 weeks EGA, an artificial placenta has been developed to recreate the fetal environment. This approach is investigational but clinical translation is promising. In this article, we discuss the current state and advances in neonatal and "preemie Extracorporeal Membrane Oxygenation" and the development of an artificial placenta and its potential use in extremely premature infants.
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Affiliation(s)
- Brianna L Spencer
- Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, Fetal Diagnosis and Treatment Center, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, MI, USA.
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13
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Spencer BL, Mychaliska GB. Milestones for clinical translation of the artificial placenta. Semin Fetal Neonatal Med 2022; 27:101408. [PMID: 36437184 DOI: 10.1016/j.siny.2022.101408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Despite significant advances in the treatment of prematurity, premature birth results in significant mortality and morbidity. In particular, extremely low gestational age newborns (ELGANs) defined as <28 weeks estimated gestational age (EGA) suffer from disproportionate mortality and morbidity. A radical paradigm shift in the treatment of prematurity is to recreate fetal physiology using an extracorporeal VV-ECLS artificial placenta (AP) or an AV-ECLS artificial womb (AW). Over the past 15 years, tremendous advances have been made in the laboratory confirming long-term support and organ protection and ongoing development. The major milestones to clinical application are miniaturization, anticoagulation, clinical risk stratification, specialized critical care protocols, a regulatory path and a strategy and platform to translate technology to the bedside. Currently, several groups are addressing the remaining milestones for clinical translation.
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Affiliation(s)
- Brianna L Spencer
- Department of Surgery, University of Michigan, 2101 Taubman Center 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, Fetal Diagnosis and Treatment Center, C.S. Mott Children's Hospital, 1540 E Hospital Dr, Ann Arbor, MI, 48109, USA.
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14
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Segers S, Romanis EC. Ethical, Translational, and Legal Issues Surrounding the Novel Adoption of Ectogestative Technologies. Risk Manag Healthc Policy 2022; 15:2207-2220. [PMID: 36451704 PMCID: PMC9704017 DOI: 10.2147/rmhp.s358553] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/18/2022] [Indexed: 11/08/2023] Open
Abstract
Increasing numbers of research teams are investigating the feasibility of developing artificial amnion and placenta technology (AAPT), commonly referred to as "artificial womb technology". This technology, aimed at supporting ex vivo gestation, has not yet been tested in humans, but it has been stated that we are closer to clinical application than ever before as breakthroughs in animal studies demonstrate good proof of principle. With these proof-of-concept models, further dissemination of AAPT as a research modality is expected. In this review article, we consider the ethical implications of the most imminent anticipated applications for AAPT. We focus specifically on the specific ethical complications regarding the improvements this technology may offer to conventional neonatal intensive care, its potential utility in facilitating prenatal interventions, and some of the broader socio-legal implications such as the debates about abortion access and reproductive and gestational choices. We discuss translational and societal questions when it comes to designing and developing this technology, like commitments to value-sensitive design, along with an examination of the legal and moral status of the entity gestating ex utero, which will be relevant for how it ought to be treated in the context of these various applications. From these perspectives, this review identifies the ethical questions that we believe to be most pressing in the development and potential introduction of AAPT, with due attention to their manifestation as translational and legal issues.
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Affiliation(s)
- Seppe Segers
- Department of Health, Ethics, and Society, Research Institutes GROW and CAPHRI, Maastricht University, Maastricht, the Netherlands
| | - Elizabeth Chloe Romanis
- Edmond & Lily Safra Center for Ethics and Petrie-Flom Center for Health Law Policy, Biotechnology and Bioethics, Harvard University, Cambridge, MA, USA
- Centre for Law and Ethics in the Life Sciences, Durham University, Durham, UK
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15
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Ferreira A. The (Un)Ethical Womb: The Promises and Perils of Artificial Gestation. JOURNAL OF BIOETHICAL INQUIRY 2022; 19:381-394. [PMID: 35403963 DOI: 10.1007/s11673-022-10184-w] [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: 10/21/2020] [Accepted: 10/03/2021] [Indexed: 06/14/2023]
Abstract
The purpose of this article is to reflect on the changes that the implementation of artificial wombs would bring to society, the family, and the concept of motherhood and fatherhood through the lens of two recent books: Helen Sedgwick's The Growing Season and Rebecca Ann Smith's Baby X. Each of the two novels, set in a near future, follows the work of a scientist who develops artificial womb technology. Significantly, both women experience concerns about the technology and its long-term effects that make both of them leave their laboratories and rethink the technology they invented, while considering its many ethical implications. Both novels can be seen as feminist revisionary rewritings of Aldous Huxley's Brave New World, rejecting the vision of rows of mass-produced, anonymous babies in artificial wombs, stressing instead the closeness of the parents to their offspring. They nevertheless critically evaluate not only the many potential benefits for women of ectogenetic technology but also the possible disadvantages and pitfalls.
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16
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Charest-Pekeski AJ, Cho SKS, Aujla T, Sun L, Floh AA, McVey MJ, Sheta A, Estrada M, Crawford-Lean L, Foreman C, Mroczek D, Belik J, Saini BS, Lim JM, Moir OJ, Lee FT, Quinn M, Darby JRT, Seed M, Morrison JL, Haller C. Impact of the Addition of a Centrifugal Pump in a Preterm Miniature Pig Model of the Artificial Placenta. Front Physiol 2022; 13:925772. [PMID: 35941934 PMCID: PMC9356302 DOI: 10.3389/fphys.2022.925772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/22/2022] [Indexed: 11/28/2022] Open
Abstract
The recent demonstration of normal development of preterm sheep in an artificial extrauterine environment has renewed interest in artificial placenta (AP) systems as a potential treatment strategy for extremely preterm human infants. However, the feasibility of translating this technology to the human preterm infant remains unknown. Here we report the support of 13 preterm fetal pigs delivered at 102 ± 4 days (d) gestation, weighing 616 ± 139 g with a circuit consisting of an oxygenator and a centrifugal pump, comparing these results with our previously reported pumpless circuit (n = 12; 98 ± 4 days; 743 ± 350 g). The umbilical vessels were cannulated, and fetuses were supported for 46.4 ± 46.8 h using the pumped AP versus 11 ± 13 h on the pumpless AP circuit. Upon initiation of AP support on the pumped system, we observed supraphysiologic circuit flows, tachycardia, and hypertension, while animals maintained on a pumpless AP circuit exhibited subphysiologic flows. On the pumped AP circuit, there was a progressive decline in umbilical vein (UV) flow and oxygen delivery. We conclude that the addition of a centrifugal pump to the AP circuit improves survival of preterm pigs by augmenting UV flow through the reduction of right ventricular afterload. However, we continued to observe the development of heart failure within a matter of days.
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Affiliation(s)
- Alex J. Charest-Pekeski
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Steven K. S. Cho
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Tanroop Aujla
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Liqun Sun
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Alejandro A. Floh
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mark J. McVey
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Physics, Ryerson University, Toronto, ON, Canada
| | - Ayman Sheta
- Department of Pediatrics, Division of Neonatology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Marvin Estrada
- Lab Animal Services, Peter Gilgan Center for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Lynn Crawford-Lean
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Celeste Foreman
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Dariusz Mroczek
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jaques Belik
- Department of Pediatrics, Division of Neonatology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Brahmdeep S. Saini
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jessie Mei Lim
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Olivia J. Moir
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Fu-Tsuen Lee
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Megan Quinn
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Jack R. T. Darby
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Mike Seed
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Janna L. Morrison
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Christoph Haller
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- *Correspondence: Christoph Haller,
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17
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Ectogenesis, inequality, and coercion: a reproductive justice-informed analysis of the impact of artificial wombs. BIOSOCIETIES 2022. [DOI: 10.1057/s41292-022-00279-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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18
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Usuda H, Carter S, Takahashi T, Newnham JP, Fee EL, Jobe AH, Kemp MW. Perinatal care for the extremely preterm infant. Semin Fetal Neonatal Med 2022; 27:101334. [PMID: 35577715 DOI: 10.1016/j.siny.2022.101334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Being born preterm (prior to 37 weeks of completed gestation) is a leading cause of childhood death up to five years of age, and is responsible for the demise of around one million preterm infants each year. Rates of prematurity, which range from approximately 5 to 18% of births, are increasing in most countries. Babies born extremely preterm (less than 28 weeks' gestation) and in particular, in the periviable (200/7-256/7 weeks) period, are at the highest risk of death, or the development of long-term disabilities. The perinatal care of extremely preterm infants and their mothers raises a number of clinical, technical, and ethical challenges. Focusing on 'micropremmies', or those born in the periviable period, this paper provides an update regarding the aetiology and impacts of periviable preterm birth, advances in the antenatal, intrapartum, and acute post-natal management of these infants, and a review of counselling/support approaches for engaging with the infant's family. It concludes with an overview of emerging technology that may assist in improving outcomes for this at-risk population.
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Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Sean Carter
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore
| | - Tsukasa Takahashi
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - John P Newnham
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Erin L Fee
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Alan H Jobe
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Perinatal Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, University of Cincinnati, Cincinnati, OH, 45229, USA
| | - Matthew W Kemp
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, 6150, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan.
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19
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van der Hout-van der Jagt MB, Verweij EJT, Andriessen P, de Boode WP, Bos AF, Delbressine FLM, Eggink AJ, Erwich JJHM, Feijs LMG, Groenendaal F, Kramer BWW, Lely AT, Loop RFAM, Neukamp F, Onland W, Oudijk MA, te Pas AB, Reiss IKM, Schoberer M, Scholten RR, Spaanderman MEA, van der Ven M, Vermeulen MJ, van de Vosse FN, Oei SG. Interprofessional Consensus Regarding Design Requirements for Liquid-Based Perinatal Life Support (PLS) Technology. Front Pediatr 2022; 9:793531. [PMID: 35127593 PMCID: PMC8809135 DOI: 10.3389/fped.2021.793531] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/14/2021] [Indexed: 12/23/2022] Open
Abstract
Liquid-based perinatal life support (PLS) technology will probably be applied in a first-in-human study within the next decade. Research and development of PLS technology should not only address technical issues, but also consider socio-ethical and legal aspects, its application area, and the corresponding design implications. This paper represents the consensus opinion of a group of healthcare professionals, designers, ethicists, researchers and patient representatives, who have expertise in tertiary obstetric and neonatal care, bio-ethics, experimental perinatal animal models for physiologic research, biomedical modeling, monitoring, and design. The aim of this paper is to provide a framework for research and development of PLS technology. These requirements are considering the possible respective user perspectives, with the aim to co-create a PLS system that facilitates physiological growth and development for extremely preterm born infants.
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Affiliation(s)
- M. Beatrijs van der Hout-van der Jagt
- Department of Obstetrics and Gynecology, Máxima Medical Centre, Veldhoven, Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - E. J. T. Verweij
- Department of Obstetrics and Gynecology, Division of Fetal Therapy, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Peter Andriessen
- Department of Neonatology, Máxima Medical Centre, Veldhoven, Netherlands
- Department of Applied Physics, School of Medical Physics and Engineering Eindhoven, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Willem P. de Boode
- Division of Neonatology, Department of Perinatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, Netherlands
| | - Arend F. Bos
- Department of Neonatology, University Medical Center Groningen, University of Groningen, Beatrix Children's Hospital, Groningen, Netherlands
| | - Frank L. M. Delbressine
- Department of Industrial Design Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Alex J. Eggink
- Department of Obstetrics and Gynecology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Jan Jaap H. M. Erwich
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Loe M. G. Feijs
- Department of Industrial Design Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Utrecht University Medical Center, Utrecht, Netherlands
| | - Boris W. W. Kramer
- Department of Neonatology, Maastricht University Medical Center (MUMC), Maastricht, Netherlands
| | - A. Titia Lely
- Department of Obstetrics and Gynecology, Utrecht University Medical Center, Utrecht, Netherlands
| | - Rachel F. A. M. Loop
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
- Department of Industrial Design Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Franziska Neukamp
- Institute for Applied Medical Engineering and Clinic for Neonatology, University Hospital Aachen, Aachen, Germany
| | - Wes Onland
- Department of Neonatology, Amsterdam UMC, Amsterdam, Netherlands
| | - Martijn A. Oudijk
- Amsterdam Reproduction and Development Research Institute, Department of Obstetrics, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Arjan B. te Pas
- Department of Neonatology, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Irwin K. M. Reiss
- Department of Neonatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Mark Schoberer
- Institute for Applied Medical Engineering and Clinic for Neonatology, University Hospital Aachen, Aachen, Germany
| | - Ralph R. Scholten
- Department of Obstetrics and Gynecology, Radboud Medical Centre, Nijmegen, Netherlands
| | - Marc E. A. Spaanderman
- Department of Obstetrics and Gynecology, Radboud Medical Centre, Nijmegen, Netherlands
- Department of Obstetrics and Gynecology, Maastricht University Medical Center (MUMC), Maastricht, Netherlands
| | - Myrthe van der Ven
- Department of Obstetrics and Gynecology, Máxima Medical Centre, Veldhoven, Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Marijn J. Vermeulen
- Department of Neonatology, Erasmus Medical Centre, Rotterdam, Netherlands
- Care4Neo Foundation, Rotterdam, Netherlands
| | - Frans N. van de Vosse
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - S. Guid Oei
- Department of Obstetrics and Gynecology, Máxima Medical Centre, Veldhoven, Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
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20
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van Willigen BG, van der Hout-van der Jagt MB, Huberts W, van de Vosse FN. A review study of fetal circulatory models to develop a digital twin of a fetus in a perinatal life support system. Front Pediatr 2022; 10:915846. [PMID: 36210952 PMCID: PMC9532745 DOI: 10.3389/fped.2022.915846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Preterm birth is the main cause of neonatal deaths with increasing mortality and morbidity rates with decreasing GA at time of birth. Currently, premature infants are treated in neonatal intensive care units to support further development. However, the organs of, especially, extremely premature infants (born before 28 weeks of GA) are not mature enough to function optimally outside the womb. This is seen as the main cause of the high morbidity and mortality rates in this group. A liquid-filled incubator, a so-called PLS system, could potentially improve these numbers for extremely premature infants, since this system is designed to mimic the environment of the natural womb. To support the development and implementation of such a complex system and to interpret vital signals of the fetus during a PLS system operation, a digital twin is proposed. This mathematical model is connected with a manikin representing the digital and physical twin of the real-life PLS system. Before developing a digital twin of a fetus in a PLS system, its functional and technical requirements are defined and existing mathematical models are evaluated. METHOD AND RESULTS This review summarizes existing 0D and 1D fetal circulatory models that potentially could be (partly) adopted for integration in a digital twin of a fetus in a PLS system based on predefined requirements. The 0D models typically describe hemodynamics and/or oxygen transport during specific events, such as the transition from fetus to neonate. Furthermore, these models can be used to find hemodynamic differences between healthy and pathological physiological states. Rather than giving a global description of an entire cardiovascular system, some studies focus on specific organs or vessels. In order to analyze pressure and flow wave profiles in the cardiovascular system, transmission line or 1D models are used. As for now, these models do not include oxygen transport. CONCLUSION This study shows that none of the models identified in literature meet all the requirements relevant for a digital twin of a fetus in a PLS system. Nevertheless, it does show the potential to develop this digital twin by integrating (parts) of models into a single model.
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Affiliation(s)
- Bettine G van Willigen
- Cardiovascular Biomechanics, Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
| | - M Beatrijs van der Hout-van der Jagt
- Cardiovascular Biomechanics, Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands.,Signal Processing Systems, Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Wouter Huberts
- Cardiovascular Biomechanics, Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Frans N van de Vosse
- Cardiovascular Biomechanics, Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
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21
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Usuda H, Saito M, Ikeda H, Sato S, Kumagai Y, Saito Y, Kawamura S, Hanita T, Sakai H, Kure S, Yaegashi N, Newnham JP, Kemp MW, Watanabe S. Assessment of synthetic red cell therapy for extremely preterm ovine fetuses maintained on an artificial placenta life-support platform. Artif Organs 2021; 46:653-665. [PMID: 34932228 DOI: 10.1111/aor.14155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/29/2021] [Accepted: 12/15/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Artificial placenta therapy (APT) is an experimental care strategy for extremely preterm infants born at 21-24 weeks' gestation. In our previous studies, blood taken from the maternal ewe was used as the basis of priming solutions for the artificial placenta circuit. However, the use of maternal blood as a priming solution is accompanied by several challenges. We explored the use of synthetic red cells (hemoglobin vesicles; HbV) as the basis of a priming solution for APT used to manage extremely early preterm ovine fetuses. METHODS Six ewes with singleton pregnancies at 95 d gestation (term = 150 d) were adapted to APT and maintained with constant monitoring of key vital parameters. The target maintenance period was 72 h in duration. A synthetic red cell solution consisting of HbV, sheep albumin and electrolytes was used as priming solutions for the APT circuit. Fetuses were evaluated on gross appearance, physiological parameters and bleeding after euthanasia. RESULTS Two out of six APT fetuses were successfully maintained for the targeted 72 h experimental period with controllable anemia (>10 g/dl) and methemoglobinemia (<10%) using an infusion of blood transfusion and nitroglycerin delivered >1 h after APT commencement, a sufficient period of time to cross-match blood products and screen for viral agents of concern. CONCLUSIONS Extremely preterm sheep fetuses were maintained for a period of up to 72 h using APT in combination with circuit priming using a synthetic red cell (HbV) preparation. Although significant further refinements are required, these findings demonstrated the potential clinical utility of synthetic blood products in the eventual clinical translation of artificial placenta technology to support extremely preterm infants.
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Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia.,Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Masatoshi Saito
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia.,Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Hideyuki Ikeda
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Shinichi Sato
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yusaku Kumagai
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yuya Saito
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | | | - Takushi Hanita
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Hiromi Sakai
- Department of Chemistry, Nara Medical University, Nara, Japan
| | - Shigeo Kure
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Nobuo Yaegashi
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - John P Newnham
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia.,School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia.,Women and Infants Research Foundation, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Matthew W Kemp
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia.,Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan.,School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia.,Women and Infants Research Foundation, King Edward Memorial Hospital, Perth, Western Australia, Australia.,Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shimpei Watanabe
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
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22
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THE ARTIFICIAL PLACENTA: SCI-FI OR REALITY? REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [DOI: 10.1016/j.rmclc.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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23
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Segers S. The path toward ectogenesis: looking beyond the technical challenges. BMC Med Ethics 2021; 22:59. [PMID: 33985480 PMCID: PMC8120724 DOI: 10.1186/s12910-021-00630-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Breakthroughs in animal studies make the topic of human application of ectogenesis for medical and non-medical purposes more relevant than ever before. While current data do not yet demonstrate a reasonable expectation of clinical benefit soon, several groups are investigating the feasibility of artificial uteri for extracorporeal human gestation. MAIN TEXT This paper offers the first comprehensive and up to date discussion of the most important pros and cons of human ectogenesis in light of clinical application, along with an examination of crucial ethical (and legal) issues that continued research into, and the clinical translation of, ectogenesis gives rise to. The expected benefits include advancing prenatal medicine, improving neonatal intensive care, and providing a novel pathway towards biological parenthood. This comes with important future challenges. Prior to human application, important questions have to be considered concerning translational research, experimental use of human fetuses and appropriate safety testing. Key questions are identified regarding risks to ectogenesis' subjects, and the physical impact on the pregnant person when transfer from the uterus to the artificial womb is required. Critical issues concerning proportionality have to be considered, also in terms of equity of access, relative to the envisaged application of ectogenesis. The advent of ectogenesis also comes with crucial issues surrounding abortion, extended fetal viability and moral status of the fetus. CONCLUSIONS The development of human ectogenesis will have numerous implications for clinical practice. Prior to human testing, close consideration should be given to whether (and how) ectogenesis can be introduced as a continuation of existing neonatal care, with due attention to both safety risks to the fetus and pressures on pregnant persons to undergo experimental and/or invasive procedures. Equally important is the societal debate about the acceptable applications of ectogenesis and how access to these usages should be prioritized. It should be anticipated that clinical availability of ectogenesis, possibly first as a way to save extremely premature fetuses, may spark demand for non-medical purposes, like avoiding physical and social burdens of pregnancy.
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Affiliation(s)
- Seppe Segers
- Department of Philosophy and Moral Sciences, Bioethics Institute Ghent, Ghent University, Blandijnberg 2, 9000, Ghent, Belgium.
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24
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Fallon BP, Mychaliska GB. Development of an artificial placenta for support of premature infants: narrative review of the history, recent milestones, and future innovation. Transl Pediatr 2021; 10:1470-1485. [PMID: 34189106 PMCID: PMC8192990 DOI: 10.21037/tp-20-136] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Over 50 years ago, visionary researchers began work on an extracorporeal artificial placenta to support premature infants. Despite rudimentary technology and incomplete understanding of fetal physiology, these pioneering scientists laid the foundation for future work. The research was episodic, as medical advances improved outcomes of premature infants and extracorporeal life support (ECLS) was introduced for the treatment of term and near-term infants with respiratory or cardiac failure. Despite ongoing medical advances, extremely premature infants continue to suffer a disproportionate burden of mortality and morbidity due to organ immaturity and unintended iatrogenic consequences of medical treatment. With advancing technology and innovative approaches, there has been a resurgence of interest in developing an artificial placenta to further diminish the mortality and morbidity of prematurity. Two related but distinct platforms have emerged to support premature infants by recreating fetal physiology: a system based on arteriovenous (AV) ECLS and one based on veno-venous (VV) ECLS. The AV-ECLS approach utilizes only the umbilical vessels for cannulation. It requires immediate transition of the infant at the time of birth to a fluid-filled artificial womb to prevent umbilical vessel spasm and avoid gas ventilation. In contradistinction, the VV-ECLS approach utilizes the umbilical vein and the internal jugular vein. It would be applied after birth to infants failing maximal medical therapy or preemptively if risk stratified for high mortality and morbidity. Animal studies are promising, demonstrating prolonged support and ongoing organ development in both systems. The milestones for clinical translation are currently being evaluated.
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Affiliation(s)
- Brian P Fallon
- Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
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25
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Darby JRT, Berry MJ, Quinn M, Holman SL, Bradshaw EL, Jesse SM, Haller C, Seed M, Morrison JL. Haemodynamics and cerebral oxygenation of neonatal piglets in the immediate ex utero period supported by mechanical ventilation or ex utero oxygenator. J Physiol 2021; 599:2751-2761. [PMID: 33745149 DOI: 10.1113/jp280803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 03/15/2021] [Indexed: 12/29/2022] Open
Abstract
KEY POINTS The margin of human viability has extended to the extremes of gestational age (<24 weeks) when the lungs are immature and ventilator-induced lung injury is common. Artificial placenta technology aims to extend gestation ex utero in order to allow the lungs additional time to develop prior to entering an air-breathing environment. We compared the haemodynamics and cerebral oxygenation of piglets in the immediate period post-oxygenator (OXY) transition against both paired in utero measures and uniquely against piglets transitioned onto mechanical ventilation (VENT). Post-transition, OXY piglets became hypotensive with reduced carotid blood flow in comparison with both paired in utero measures and VENT piglets. The addition of a pump to the oxygenator circuit may be required to ensure haemodynamic stability in the immediate post-transition period. ABSTRACT Gestational age at birth is a major predictor of wellbeing; the lower the gestational age, the greater the risk of mortality and morbidity. At the margins of human viability (<24 weeks gestation) immature lungs combined with the need for early ventilatory support means lung injury and respiratory morbidity is common. The abrupt haemodynamic changes consequent on birth may also contribute to preterm-associated brain injury, including intraventricular haemorrhage. Artificial placenta technology aims to support oxygenation, haemodynamic stability and ongoing fetal development ex utero until mature enough to safely transition to a true ex utero environment. We aimed to characterize the impact of birth transition onto either an oxygenator circuit or positive pressure ventilation on haemodynamic and cerebral oxygenation of the neonatal piglet. At 112 days gestation (term = 115 days), fetal pigs underwent instrumentation surgery and transitioned onto either an oxygenator (OXY, n = 5) or ventilatory support (VENT, n = 8). Blood pressure (BP), carotid blood flow and cerebral oxygenation in VENT piglets rose from in utero levels to be significantly higher than OXY piglets post-transition. OXY piglet BP, carotid blood flow and carotid oxygen delivery (DO2 ) decreased from in utero levels post-transition; however, cerebral regional oxygen saturation (rSO2 ) was maintained at fetal-like levels. OXY piglets became hypoxaemic and retained CO2 . Whether OXY piglets are able to maintain cerebral rSO2 under these conditions for a prolonged period is yet to be determined. Improvements to OXY piglet oxygenation may lie in maintaining piglet BP at in utero levels and enhancing oxygenator circuit flow.
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Affiliation(s)
- Jack R T Darby
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Mary J Berry
- Centre for Translational Physiology, University of Otago, Wellington, New Zealand.,Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | - Megan Quinn
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Stacey L Holman
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Emma L Bradshaw
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Sarah M Jesse
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Christoph Haller
- Univeristy of Toronto and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mike Seed
- Univeristy of Toronto and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Janna L Morrison
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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26
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Charest‐Pekeski AJ, Sheta A, Taniguchi L, McVey MJ, Floh A, Sun L, Aujla T, Cho SKS, Ren J, Crawford‐Lean L, Foreman C, Lim JM, Saini BS, Estrada M, Lam A, Belik J, Mroczek D, Quinn M, Holman SL, Darby JRT, Seed M, Morrison JL, Haller C. Achieving sustained extrauterine life: Challenges of an artificial placenta in fetal pigs as a model of the preterm human fetus. Physiol Rep 2021; 9:e14742. [PMID: 33650787 PMCID: PMC7923578 DOI: 10.14814/phy2.14742] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 01/12/2021] [Indexed: 11/24/2022] Open
Abstract
Artificial placenta (AP) technology aims to maintain fetal circulation, while promoting the physiologic development of organs. Recent reports of experiments performed in sheep indicate the intrauterine environment can be recreated through the cannulation of umbilical vessels, replacement of the placenta with a low-resistance membrane oxygenator, and incubation of the fetus in fluid. However, it remains to be seen whether animal fetuses similar in size to the extremely preterm human infant that have been proposed as a potential target for this technology can be supported in this way. Preterm Yucatan miniature piglets are similar in size to extremely preterm human infants and share similar umbilical cord anatomy, raising the possibility to serve as a good model to investigate the AP. To characterize fetal cardiovascular physiology, the carotid artery (n = 24) was cannulated in utero and umbilical vein (UV) and umbilical artery were sampled. Fetal UV flow was measured by MRI (n = 16). Piglets were delivered at 98 ± 4 days gestation (term = 115 days), cannulated, and supported on the AP (n = 12) for 684 ± 228 min (range 195-3077 min). UV flow was subphysiologic (p = .002), while heart rate was elevated on the AP compared with in utero controls (p = .0007). We observed an inverse relationship between heart rate and UV flow (r2 = .4527; p < .001) with progressive right ventricular enlargement that was associated with reduced contractility and ultimately hydrops and circulatory collapse. We attribute this to excessive afterload imposed by supraphysiologic circuit resistance and augmented sympathetic activity. We conclude that short-term support of the preterm piglet on the AP is feasible, although we have not been able to attain normal fetal physiology. In the future, we propose to investigate the feasibility of an AP circuit that incorporates a centrifugal pump in our miniature pig model.
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Affiliation(s)
- Alex J. Charest‐Pekeski
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
- Translational MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Ayman Sheta
- Department of PediatricsDivision of NeonatologyThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Luiza Taniguchi
- Division of CardiologyThe Labatt Family Heart CentreThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Mark J. McVey
- Department of Anesthesia and Pain MedicineDepartment of Anesthesiology and Pain MedicineThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
- Department of PhysicsRyerson UniversityTorontoOntarioCanada
| | - Alejandro Floh
- Division of CardiologyThe Labatt Family Heart CentreThe Hospital for Sick ChildrenTorontoOntarioCanada
- Department of Critical Care MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Liqun Sun
- Division of CardiologyThe Labatt Family Heart CentreThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Tanroop Aujla
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
- Translational MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
- Early Origins of Adult Health Research GroupHealth and Biomedical InnovationClinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Steven K. S. Cho
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
- Translational MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
- Early Origins of Adult Health Research GroupHealth and Biomedical InnovationClinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Jiaqi Ren
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
- Translational MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Lynn Crawford‐Lean
- Division of Cardiovascular SurgeryThe Labatt Family Heart CentreThe Hospital for Sick ChildrenUniversity of TorontoTorontoCanada
| | - Celeste Foreman
- Division of Cardiovascular SurgeryThe Labatt Family Heart CentreThe Hospital for Sick ChildrenUniversity of TorontoTorontoCanada
| | - Jessie Mei Lim
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
- Translational MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Brahmdeep S. Saini
- Translational MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
| | - Marvin Estrada
- Lab Animal ServicesResearch InstituteThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Anson Lam
- Lab Animal ServicesResearch InstituteThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Jaques Belik
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
| | - Dariusz Mroczek
- Division of CardiologyThe Labatt Family Heart CentreThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Megan Quinn
- Early Origins of Adult Health Research GroupHealth and Biomedical InnovationClinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Stacey L. Holman
- Early Origins of Adult Health Research GroupHealth and Biomedical InnovationClinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Jack R. T. Darby
- Early Origins of Adult Health Research GroupHealth and Biomedical InnovationClinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Mike Seed
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
- Division of CardiologyThe Labatt Family Heart CentreThe Hospital for Sick ChildrenTorontoOntarioCanada
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
| | - Janna L. Morrison
- Early Origins of Adult Health Research GroupHealth and Biomedical InnovationClinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Christoph Haller
- Division of Cardiovascular SurgeryThe Labatt Family Heart CentreThe Hospital for Sick ChildrenUniversity of TorontoTorontoCanada
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27
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Abstract
The use of extracorporeal life support (ECLS) for the pediatric and neonatal population continues to grow. At the same time, there have been dramatic improvements in the technology and safety of ECLS that have broadened the scope of its application. This article will review the evolving landscape of ECLS, including its expanding indications and shrinking contraindications. It will also describe traditional and hybrid cannulation strategies as well as changes in circuit components such as servo regulation, non-thrombogenic surfaces, and paracorporeal lung-assist devices. Finally, it will outline the modern approach to managing a patient on ECLS, including anticoagulation, sedation, rehabilitation, nutrition, and staffing.
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28
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Advances and Trends in Pediatric Minimally Invasive Surgery. J Clin Med 2020; 9:jcm9123999. [PMID: 33321836 PMCID: PMC7764454 DOI: 10.3390/jcm9123999] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 11/28/2020] [Accepted: 12/03/2020] [Indexed: 12/11/2022] Open
Abstract
As many meta-analyses comparing pediatric minimally invasive to open surgery can be found in the literature, the aim of this review is to summarize the current state of minimally invasive pediatric surgery and specifically focus on the trends and developments which we expect in the upcoming years. Print and electronic databases were systematically searched for specific keywords, and cross-link searches with references found in the literature were added. Full-text articles were obtained, and eligibility criteria were applied independently. Pediatric minimally invasive surgery is a wide field, ranging from minimally invasive fetal surgery over microlaparoscopy in newborns to robotic surgery in adolescents. New techniques and devices, like natural orifice transluminal endoscopic surgery (NOTES), single-incision and endoscopic surgery, as well as the artificial uterus as a backup for surgery in preterm fetuses, all contribute to the development of less invasive procedures for children. In spite of all promising technical developments which will definitely change the way pediatric surgeons will perform minimally invasive procedures in the upcoming years, one must bear in mind that only hard data of prospective randomized controlled and double-blind trials can validate whether these techniques and devices really improve the surgical outcome of our patients.
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29
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Diagnostic Specificity of Cerebral Magnetic Resonance Imaging for Punctate White Matter Lesion Assessment in a Preterm Sheep Fetus Model. Reprod Sci 2020; 28:1175-1184. [PMID: 33237519 DOI: 10.1007/s43032-020-00401-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
Recent studies, using magnetic resonance imaging (MRI) to assess white matter injury in preterm brains, increasingly recognize punctate white matter lesions (PWML) as the primary lesion type. There are some papers showing the relationship between the size and number of PWML and the prognosis of infants. However, the histopathological features are still unknown. In this study, we experimentally induced periventricular leukomalacia (PVL) in a sheep fetus model, aiming to find whether MRI can visualize necrotic foci (small incipient lesions of PVL) as PWML. Three antenatal insults were employed to induce PVL in preterm fetuses at gestational day 101-117: (i) hypoxia under intrauterine inflammation, (ii) restriction of artificial placental blood flow, and (iii) restriction of artificial placental blood flow after exposure to intrauterine inflammation. MRI was performed 3-5 days after the insults, and standard histological studies of the PVL validated its findings. Of the 89 necrotic foci detected in histological samples from nine fetuses with PVL, 78 were visualized as PWML. Four of the lesions detected as abnormal findings on MRI could not be histologically detected as corresponding abnormal findings. The diagnostic sensitivity and positive predictive values of histologic focal necrosis visualized as PWML were 0.92 and 0.95, respectively. The four lesions were excluded from these analyses. These data suggest that MRI can visualize PVL necrotic foci as PWML 3-5 days after the injury induction. PWML can spontaneously become obscure with time after birth, so their accurate diagnosis in the acute phase can prevent overlooking mild PVL.
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30
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Usuda H, Watanabe S, Saito M, Ikeda H, Koshinami S, Sato S, Musk GC, Fee E, Carter S, Kumagai Y, Takahashi T, Takahashi Y, Kawamura S, Hanita T, Kure S, Yaegashi N, Newnham JP, Kemp MW. Successful use of an artificial placenta-based life support system to treat extremely preterm ovine fetuses compromised by intrauterine inflammation. Am J Obstet Gynecol 2020; 223:755.e1-755.e20. [PMID: 32380175 DOI: 10.1016/j.ajog.2020.04.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 04/23/2020] [Accepted: 04/28/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Ex vivo uterine environment therapy is an experimental intensive care strategy for extremely preterm infants born between 21 and 24 weeks of gestation. Gas exchange is performed by membranous oxygenators connected by catheters to the umbilical vessels. The fetus is submerged in a bath of synthetic amniotic fluid. The lungs remain fluid filled, and pulmonary respiration does not occur. Intrauterine inflammation is strongly associated with extremely preterm birth and fetal injury. At present, there are no data that we are aware of to show that artificial placenta-based systems can be used to support extremely preterm fetuses compromised by exposure to intrauterine inflammation. OBJECTIVE To evaluate the ability of our ex vivo uterine environment therapy platform to support extremely preterm ovine fetuses (95-day gestational age; approximately equivalent to 24 weeks of human gestation) exposed to intrauterine inflammation for a period of 120 hours, the following primary endpoints were chosen: (1) maintenance of key physiological variables within normal ranges, (2) absence of infection and inflammation, (3) absence of brain injury, and (4) gross fetal growth and cardiovascular function matching that of age-matched in utero controls. STUDY DESIGN Ten ewes with singleton pregnancies were each given a single intraamniotic injection of 10-mg Escherichia coli lipopolysaccharides under ultrasound guidance 48 hours before undergoing surgical delivery for adaptation to ex vivo uterine environment therapy at 95-day gestation (term=150 days). Fetuses were adapted to ex vivo uterine environment therapy and maintained for 120 hours with constant monitoring of key vital parameters (ex vivo uterine environment group) before being killed at 100-day equivalent gestational age. Umbilical artery blood samples were regularly collected to assess blood gas data, differential counts, biochemical parameters, inflammatory markers, and microbial load to exclude infection. Ultrasound was conducted at 48 hours after intraamniotic lipopolysaccharides (before surgery) to confirm fetal viability and at the conclusion of the experiments (before euthanasia) to evaluate cardiac function. Brain injury was evaluated by gross anatomic and histopathologic investigations. Eight singleton pregnant control animals were similarly exposed to intraamniotic lipopolysaccharides at 93-day gestation and were killed at 100-day gestation to allow comparative postmortem analyses (control group). Biobanked samples from age-matched saline-treated animals served as an additional comparison group. Successful instillation of lipopolysaccharides into the amniotic fluid exposure was confirmed by amniotic fluid analysis at the time of administration and by analyzing cytokine levels in fetal plasma and amniotic fluid. Data were tested for mean differences using analysis of variance. RESULTS Six of 8 lipopolysaccharide control group (75%) and 8 of 10 ex vivo uterine environment group fetuses (80%) successfully completed their protocols. Six of 8 ex vivo uterine environment group fetuses required dexamethasone phosphate treatment to manage profound refractory hypotension. Weight and crown-rump length were reduced in ex vivo uterine environment group fetuses at euthanasia than those in lipopolysaccharide control group fetuses (P<.05). There were no biologically significant differences in cardiac ultrasound measurement, differential leukocyte counts (P>.05), plasma tumor necrosis factor α, monocyte chemoattractant protein-1 concentrations (P>.05), or liver function tests between groups. Daily blood cultures were negative for aerobic and anaerobic growth in all ex vivo uterine environment group animals. No cases of intraventricular hemorrhage were observed. White matter injury was identified in 3 of 6 lipopolysaccharide control group fetuses and 3 of 8 vivo uterine environment group fetuses. CONCLUSION We report the use of an artificial placenta-based system to support extremely preterm lambs compromised by exposure to intrauterine inflammation. Our data highlight key challenges (refractory hypotension, growth restriction, and white matter injury) to be overcome in the development and use of artificial placenta technology for extremely preterm infants. As such challenges seem largely absent from studies based on healthy pregnancies, additional experiments of this nature using clinically relevant model systems are essential for further development of this technology and its eventual clinical application.
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Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan.
| | - Shimpei Watanabe
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Masatoshi Saito
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hideyuki Ikeda
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Shota Koshinami
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Shinichi Sato
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Gabrielle C Musk
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Animal Care Services, The University of Western Australia, Crawley, Western Australia, Australia
| | - Erin Fee
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia
| | - Sean Carter
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia
| | - Yusaku Kumagai
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Tsukasa Takahashi
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yuki Takahashi
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | | | - Takushi Hanita
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Shigeo Kure
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Nobuo Yaegashi
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - John P Newnham
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; School of Veterinary and Life Sciences, Murdoch University, Western Australia, Australia
| | - Matthew W Kemp
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan; School of Veterinary and Life Sciences, Murdoch University, Western Australia, Australia
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31
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De Bie FR, Davey MG, Larson AC, Deprest J, Flake AW. Artificial placenta and womb technology: Past, current, and future challenges towards clinical translation. Prenat Diagn 2020; 41:145-158. [PMID: 32875581 DOI: 10.1002/pd.5821] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/24/2020] [Accepted: 08/29/2020] [Indexed: 01/12/2023]
Abstract
Extreme prematurity remains a major cause of neonatal mortality and severe long-term morbidity. Current neonatal care is associated with significant morbidity due to iatrogenic injury and developmental immaturity of extreme premature infants. A more physiologic approach, replacing placental function and providing a womb-like environment, is the foundational principle of artificial placenta (AP) and womb (AW) technology. The concept has been studied during the past 60 years with limited success. However, recent technological advancements and a greater emphasis on mimicking utero-placental physiology have improved the success of experimental models, bringing the technology closer to clinical translation. Here, we review the rationale for and history of AP and AW technology, discuss the challenges that needed to be overcome, and compare recent successful models. We conclude by outlining some remaining challenges to be addressed on the path towards clinical translation and opportunities for future research.
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Affiliation(s)
- Felix R De Bie
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Marcus G Davey
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Abby C Larson
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jan Deprest
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Alan W Flake
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Musk GC, Usuda H, Kershaw H, Kemp MW, Sharp CR. Maternal-fetal Blood Major Crossmatching in Merino Sheep. Comp Med 2020; 70:355-358. [PMID: 32727639 PMCID: PMC7446640 DOI: 10.30802/aalas-cm-19-000115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
To determine the incidence of ex vivo incompatibility between ovine maternal RBCs and fetal plasma, we performed cross-matching of blood samples from ewes and from lambs delivered by cesarean section. Twenty-one date-mated singleton pregnant Merino ewes were anesthetized for cesarean delivery of the fetus. At the time of delivery, paired maternal and fetal blood samples were collected and subsequently separated for storage as packed red blood cells and fresh frozen plasma. Gel column major cross matching was performed within 2 wk. All fetus-dam crossmatches were major crossmatches, combining fetal (recipient) plasma with dam (donor) RBCs. 172 individual dam-dam cross matches were performed. Two of these tests were incompatible (1.2%). In addition, 19 fetal blood samples collected immediately after cesarean delivery were crossmatched with 21 maternal samples to generate 174 maternal-fetal individual cross matches. No maternal-fetal incompatibility reactions were observed. The results of this study demonstrate that all maternal donors and fetal recipients were compatible. In addition, the incidence of an incompatible crossmatch between adult ewes was 1.2%. These data suggest that lambs may not be born with antibodies against other blood types, but rather may acquire such antibodies at some time during early life. In addition, these data suggest the risk of incompatibility reactions between ewes of a similar breed and from a single farm of origin is very low.
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Affiliation(s)
- Gabrielle C Musk
- Animal Care Services, University of Western Australia, Crawley, Western Australia; Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, Western Australia;,
| | - Haruo Usuda
- Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, Western Australia
| | - Helen Kershaw
- Animal Care Services, University of Western Australia, Crawley, Western Australia
| | - Matthew W Kemp
- Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, Western Australia
| | - Claire R Sharp
- School of Veterinary Medicine, Murdoch University, Murdoch, Western Australia
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Romanis EC, Begović D, Brazier MR, Mullock AK. Reviewing the womb. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106160. [PMID: 32727855 PMCID: PMC8639904 DOI: 10.1136/medethics-2020-106160] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/19/2020] [Accepted: 06/08/2020] [Indexed: 05/20/2023]
Abstract
Throughout most of human history women have been defined by their biological role in reproduction, seen first and foremost as gestators, which has led to the reproductive system being subjected to outside interference. The womb was perceived as dangerous and an object which husbands, doctors and the state had a legitimate interest in controlling. In this article, we consider how notions of conflict surrounding the womb have endured over time. We demonstrate how concerns seemingly generated by the invisibility of reproduction and the inaccessibility of the womb have translated into similar arguments for controlling women, as technology increases the accessibility of the female body and the womb. Developments in reproductive medicine, from in vitro fertilisation (IVF) to surrogacy, have enabled women and men who would otherwise have been childless to become parents. Uterus transplants and 'artificial wombs' could provide additional alternatives to natural gestation. An era of 'womb technology' dawns. Some argue that such technology providing an alternative to 'natural' gestation could be a source of liberation for female persons because reproduction will no longer be something necessarily confined to the female body. 'Womb technology', however, also has the potential to exacerbate the labelling of the female body as a source of danger and an 'imperfect' site of gestation, thus replaying rudimentary and regressive arguments about controlling female behaviour. We argue that pernicious narratives about control, conflict and the womb must be addressed in the face of these technological developments.
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Affiliation(s)
- Elizabeth Chloe Romanis
- Centre for Social Ethics and Policy, Department of Law, University of Manchester, Manchester, UK
| | - Dunja Begović
- Centre for Social Ethics and Policy, Department of Law, University of Manchester, Manchester, UK
| | - Margot R Brazier
- Centre for Social Ethics and Policy, Department of Law, University of Manchester, Manchester, UK
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Usuda H, Watanabe S, Saito M, Sato S, Musk GC, Fee ME, Carter S, Kumagai Y, Takahashi T, Kawamura MS, Hanita T, Kure S, Yaegashi N, Newnham JP, Kemp MW. Successful use of an artificial placenta to support extremely preterm ovine fetuses at the border of viability. Am J Obstet Gynecol 2019; 221:69.e1-69.e17. [PMID: 30853365 DOI: 10.1016/j.ajog.2019.03.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/26/2019] [Accepted: 03/04/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ex vivo uterine environment therapy is an experimental life support platform designed to reduce the risk of morbidity and mortality for extremely preterm infants born at the border of viability (21-24 weeks' gestation). To spare the functionally immature lung, this platform performs gas exchange via a membranous oxygenator connected to the umbilical vessels, and the fetus is submerged in a protective bath of artificial amniotic fluid. We and others have demonstrated the feasibility of extended survival with ex vivo uterine environment therapy therapy in late preterm fetuses; however, there is presently no evidence to show that the use of such a platform can support extremely preterm fetuses, the eventual translational target for therapy of this nature. OBJECTIVE The objective of the study was to use our ex vivo uterine environment therapy platform to support the healthy maintenance of 600-700 g/95 days gestational age (equivalent to 24 weeks of human gestation) sheep fetuses. Primary outcome measures were as follows: (1) maintenance of key physiological variables; (2) absence of infection; (3) absence of brain injury; and (4) growth and cardiovascular function patterns matching that of noninstrumented, age-matched in utero controls. STUDY DESIGN Singleton fetuses from 8 ewes underwent surgical delivery at 95 days' gestation (term, 150 days). Fetuses were adapted to ex vivo uterine environment therapy and maintained for 120 hours with real-time monitoring of key physiological variables. Umbilical artery blood samples were regularly collected to assess blood gas data, differential counts, inflammation, and microbial load to exclude infection. Brain injury was evaluated by gross anatomical and histopathological approaches after euthanasia. Nine pregnant control animals were euthanized at 100 days' gestation to allow comparative postmortem analyses. Data were tested for mean differences with an analysis of variance. RESULTS Seven of 8 ex vivo uterine environment group fetuses (87.5%) completed 120 hours of therapy with key parameters maintained in a normal physiological range. There were no significant intergroup differences (P > .05) in final weight, crown-rump length, and body weight-normalized lung and brain weights at euthanasia compared with controls. There were no biologically significant differences in hematological parameters (total or differential leucocyte counts and plasma concentration of tumor necrosis factor-α and monocyte chemoattractant protein 1) (P > .05). Daily blood cultures were negative for aerobic and anaerobic growth in all ex vivo uterine environment animals. There was no difference in airspace consolidation between control and ex vivo uterine environment animals, and there was no increase in the number of lung cells staining positive for the T-cell marker CD3. There were no increases in interleukin-1, interleukin-6, interleukin-8, tumor necrosis factor-α, and monocyte chemoattractant protein 1 mRNA expression in lung tissues compared with the control group. No cases of intraventricular hemorrhage were observed, and white matter injury was identified in only 1 ex vivo uterine environment fetus. CONCLUSION For several decades, there has been little improvement in outcomes of extremely preterm infants born at the border of viability. In the present study, we report the use of artificial placenta technology to support, for the first time, extremely preterm ovine fetuses (equivalent to 24 weeks of human gestation) in a stable, growth-normal state for 120 hours. With additional refinement, the data generated by this study may inform a treatment option to improve outcomes for extremely preterm infants.
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The artificial womb: What is the next step? J Pediatr Surg 2019; 54:362. [PMID: 30611526 DOI: 10.1016/j.jpedsurg.2018.08.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 08/26/2018] [Indexed: 11/21/2022]
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Ectogenesis as the Dilution of Sex or the End of Females? TECHNO:PHIL – AKTUELLE HERAUSFORDERUNGEN DER TECHNIKPHILOSOPHIE 2019. [DOI: 10.1007/978-3-476-04967-4_6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Romanis EC. Artificial womb technology and the frontiers of human reproduction: conceptual differences and potential implications. JOURNAL OF MEDICAL ETHICS 2018; 44:751-755. [PMID: 30097459 PMCID: PMC6252373 DOI: 10.1136/medethics-2018-104910] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/04/2018] [Accepted: 07/06/2018] [Indexed: 05/20/2023]
Abstract
In 2017, a Philadelphia research team revealed the closest thing to an artificial womb (AW) the world had ever seen. The 'biobag', if as successful as early animal testing suggests, will change the face of neonatal intensive care. At present, premature neonates born earlier than 22 weeks have no hope of survival. For some time, there have been no significant improvements in mortality rates or incidences of long-term complications for preterms at the viability threshold. Artificial womb technology (AWT), that might change these odds, is eagerly anticipated for clinical application. We need to understand whether AWT is an extension of current intensive care or something entirely new. This question is central to determining when and how the biobag should be used on human subjects. This paper examines the science behind AWT and advances two principal claims. First, AWT is conceptually different from conventional intensive care. Identifying why AWT should be understood as distinct demonstrates how it raises different ethico-legal questions. Second, these questions should be formulated without the 'human being growing in the AW' being described with inherently value laden terminology. The 'human being in an AW' is neither a fetus nor a baby, and the ethical tethers associated with these terms could perpetuate misunderstanding and confusion. Thus, the term 'gestateling' should be adopted to refer to this new product of human reproduction: a developing human being gestating ex utero. While this paper does not attempt to solve all the ethical problems associated with AWT, it makes important clarifications that will enable better formulation of relevant ethical questions for future exploration.
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Affiliation(s)
- Elizabeth Chloe Romanis
- Centre for Social Ethics and Policy, School of Law, University of Manchester, Manchester, UK
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Church JT, Coughlin MA, Perkins EM, Hoffman HR, Barks JD, Rabah R, Bentley JK, Hershenson MB, Bartlett RH, Mychaliska GB. The artificial placenta: Continued lung development during extracorporeal support in a preterm lamb model. J Pediatr Surg 2018; 53:1896-1903. [PMID: 29960740 PMCID: PMC6151273 DOI: 10.1016/j.jpedsurg.2018.06.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 05/18/2018] [Accepted: 06/03/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE An artificial placenta (AP) utilizing extracorporeal life support (ECLS) could avoid the harm of mechanical ventilation (MV) while allowing the lungs to develop. METHODS AP lambs (n = 5) were delivered at 118 days gestational age (GA; term = 145 days) and placed on venovenous ECLS (VV-ECLS) with jugular drainage and umbilical vein reinfusion. Lungs remained fluid-filled. After 10 days, lambs were ventilated. MV control lambs were delivered at 118 ("early MV"; n = 5) or 128 days ("late MV"; n = 5), and ventilated. Compliance and oxygenation index (OI) were calculated. After sacrifice, lungs were procured and H&E-stained slides scored for lung injury. Slides were also immunostained for PDGFR-α and α-actin; alveolar development was quantified by the area fraction of alveolar septal tips staining double-positive for both markers. RESULTS Compliance of AP lambs was 2.79 ± 0.81 Cdyn compared to 0.83 ± 0.19 and 3.04 ± 0.99 for early and late MV, respectively. OI in AP lambs was lower than early MV lambs (6.20 ± 2.10 vs. 36.8 ± 16.8) and lung injury lower as well (1.8 ± 1.6 vs. 6.0 ± 1.2). Double-positive area fractions were higher in AP lambs (0.012 ± 0.003) than early (0.003 ± 0.0005) and late (0.004 ± 0.002) MV controls. CONCLUSIONS Lung development continues and lungs are protected from injury during AP support relative to mechanical ventilation. LEVEL OF EVIDENCE n/a (basic/translational science).
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Affiliation(s)
- Joseph T. Church
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine. B560 MSRB II/SPC 5686, 1150 W. Medical Center Dr. Ann Arbor, Michigan, USA
| | - Megan A. Coughlin
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine. B560 MSRB II/SPC 5686, 1150 W. Medical Center Dr. Ann Arbor, Michigan, USA
| | - Elena M. Perkins
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine. B560 MSRB II/SPC 5686, 1150 W. Medical Center Dr. Ann Arbor, Michigan, USA
| | - Hayley R. Hoffman
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine. B560 MSRB II/SPC 5686, 1150 W. Medical Center Dr. Ann Arbor, Michigan, USA
| | - John D. Barks
- Departments of Pediatrics and Communicable Diseases, Michigan Medicine. 1540 E. Medical Center Dr., Ann Arbor, Michigan, USA
| | - Raja Rabah
- Department of Pathology, Michigan Medicine. 1500 E. Medical Center Dr., Ann Arbor, Michigan, USA
| | - John K. Bentley
- Departments of Pediatrics and Communicable Diseases, Michigan Medicine. 1540 E. Medical Center Dr., Ann Arbor, Michigan, USA,Department of Molecular and Integrative Physiology, University of Michigan Medical School, 1301 Catherine St., Ann Arbor, Michigan
| | - Marc B. Hershenson
- Departments of Pediatrics and Communicable Diseases, Michigan Medicine. 1540 E. Medical Center Dr., Ann Arbor, Michigan, USA,Department of Molecular and Integrative Physiology, University of Michigan Medical School, 1301 Catherine St., Ann Arbor, Michigan
| | - Robert H. Bartlett
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine. B560 MSRB II/SPC 5686, 1150 W. Medical Center Dr. Ann Arbor, Michigan, USA
| | - George B. Mychaliska
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine. B560 MSRB II/SPC 5686, 1150 W. Medical Center Dr. Ann Arbor, Michigan, USA,Fetal Diagnosis and Treatment Center, C.S. Mott Children’s Hospital, Michigan Medicine, 1540 E. Medical Center Dr., Ann Arbor, Michigan
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Musk GC, Adams MJ, Usuda H, Kemp MW, Sharp CR. Crossmatching Maternal and Fetal Blood in Sheep. Comp Med 2018; 68:294-297. [PMID: 30037360 DOI: 10.30802/aalas-cm-17-000126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We investigated the incidence of ex vivo incompatibility between ovine maternal RBC and fetal plasma. Time-mated singleton pregnant ewes (n = 8) underwent cesarean delivery of the fetus; at the time of delivery, paired maternal and fetal blood samples were collected and subsequently separated for storage as packed RBC and fresh frozen plasma. Gel column crossmatching was performed 3 to 4 wk later. All fetus-dam crossmatches were considered major crossmatches, combining fetal (recipient) plasma with dam (donor) RBC. The plasma of 8 fetuses was cross-matched with RBC from 5 dams; all autologous controls were negative, and all but one crossmatch (1 of 40, 2.5%) were considered compatible. In addition, the plasma of 3 dams was crossmatched with RBC from 5 dams; all autologous controls were negative; however, significant incompatibility was noted. In total, 4 of 13 (30.8%) dam-dam crossmatches were considered incompatible. The results of this initial study suggest that when a single animal receives multiple blood-product transfusions, the risk of an immunologic transfusion reaction can be reduced by ensuring that the blood products are obtained from a single donor, performing a crossmatch prior to transfusion, and the use of synthetic products to increase the oxygen carrying capacity of fetal blood.
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Affiliation(s)
- Gabrielle C Musk
- Animal Care Services, University of Western Australia, Crawley, Western Australia, Australia.
| | - Murray J Adams
- School of Veterinary and Life Sciences, Murdoch University, Murdoch, Western Australia, Australia
| | - Haruo Usuda
- Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, Western Australia, Australia
| | - Matthew W Kemp
- Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, Western Australia, Australia
| | - Claire R Sharp
- School of Veterinary and Life Sciences, Murdoch University, Murdoch, Western Australia, Australia
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Gleicher N. Expected advances in human fertility treatments and their likely translational consequences. J Transl Med 2018; 16:149. [PMID: 29866181 PMCID: PMC5987489 DOI: 10.1186/s12967-018-1525-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 05/26/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Due to rapid research progress in reproductive biology and reproductive clinical endocrinology, many human infertility treatments are close to potential breakthroughs and translational applications. We here review current barriers, where such breakthroughs will likely come from, what they will entail, and their potential clinical applications. MAIN TEXT The radical nature of change will primarily benefit older women, reduce fertility treatment costs and thereby expand access to treatment. A still widely overlooked prerequisite for implantation and normal pregnancy maintenance is timely development of maternal immunological tolerance toward an implanting paternal semi-allograft, if malfunctioning associated with implantation failure and pregnancy loss, while premature termination of tolerance appears associated with premature labor, pre-eclampsia/eclampsia and gestoses of pregnancy. Common denominators between pregnancy and invasive malignancies have again been attracting attention, suggesting that, like in malignant tumors, degrees of embryo aneuploidy may affect invasiveness and ability to "disarm" the immune system's innate response against implanting embryos. Linking tolerance to implantation, we offer evidence that the so-called "implantation window" is likely immunological rather than hormonally defined. CONCLUSIONS Because many here outlined treatment changes will disproportionally benefit older women, they will exert a pronounced effect on society, as increasing numbers of women at grandparental ages will become mothers.
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Affiliation(s)
- Norbert Gleicher
- The CHR, 21 East 69th Street, New York, NY, 10021, USA.
- The Foundation for Reproductive Medicine, New York, NY, 10021, USA.
- Laboratory for Stem Cell Biology and Molecular Embryology, Rockefeller University, New York, NY, 10065, USA.
- Department of Obstetrics and Gynecology, Vienna Medical School, 1090, Vienna, Austria.
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