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Dalkalitsis A, Zikopoulos A, Katrachouras A, Samara I, Gkrozou F. Non-Cardiogenic Pulmonary Edema Due to Administration of Atosiban. Cureus 2023; 15:e36799. [PMID: 37123811 PMCID: PMC10134783 DOI: 10.7759/cureus.36799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 03/30/2023] Open
Abstract
We report the case of a pregnant woman, treated with atosiban for premature labor, who developed non-cardiogenic pulmonary edema. She corresponded initially to oxygen supplementation and furosemide administration to induce diuresis but the onset of preterm contractions combined with aggravation of respiratory failure led the patient to a cesarean section, and subsequently to the intensive care unit where she remained intubated for 24 hours. In this case report, we emphasize the importance of distinguishing between two types of pulmonary edema: cardiogenic and non-cardiogenic. The instant separation between these two categories, most of the time with transthoracic echocardiography while the patient is on early support of ventilation, increases the optimum outcome for the patient.
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2
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Do obstetric units adhere to the evidence-based national guideline? A Germany-wide survey on the current practice of initial tocolysis. Eur J Obstet Gynecol Reprod Biol 2022; 270:133-138. [DOI: 10.1016/j.ejogrb.2022.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/02/2022] [Accepted: 01/06/2022] [Indexed: 12/22/2022]
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3
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Liu WY, Zhang JR, Xu XM, Ye TY. Toxic epidermal necrolysis induced by ritodrine in pregnancy: A case report. World J Clin Cases 2022; 10:1381-1387. [PMID: 35211573 PMCID: PMC8855204 DOI: 10.12998/wjcc.v10.i4.1381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/21/2021] [Accepted: 12/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Preterm birth accounts for about 12% of all pregnancies worldwide and is the leading cause of neonatal morbidity and mortality. In order to avoid premature birth and prolong gestational age, tocolytics are the first and the best choice. Ritodrine is the most commonly used tocolytic medication. However, side effects such as pulmonary edema, hypokalemia, and hyperglycemia are known. Here we report a rare but serious side effect–toxic epidermal necrolysis (TEN)–caused by ritodrine.
CASE SUMMARY A woman (31 years, gravida 4, para 2) was hospitalized because of premature contractions at 27 + 6 wk of gestation. A skin rash with pruritus appeared at 32 + 3 wk of gestation after administration of ritodrine, indomethacin, and dexamethasone, and it spread throughout the whole body in 3 d, particularly the four limbs. After 11 d’ treatment, she was diagnosed with TEN. An emergency cesarean section was performed immediately to deliver the baby and intensive symptomatic treatment was promptly commenced after delivery. She recovered from the severe condition without any sequelae except for slight pigmentation after symptomatic treatment.
CONCLUSION When a skin rash appears during the administration of ritodrine, we are supposed to consider the risk of TEN.
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Affiliation(s)
- Wen-Yu Liu
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201600, China
| | - Jia-Rong Zhang
- Department of Obstetrics and Gynecology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xian-Ming Xu
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201600, China
| | - Tian-Yi Ye
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201600, China
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4
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Yart L, Frieden M, Konig S, Cohen M, Martinez de Tejada B. Dual effect of nifedipine on pregnant human myometrium contractility: Implication of TRPC1. J Cell Physiol 2022; 237:1980-1991. [PMID: 34988986 PMCID: PMC9306527 DOI: 10.1002/jcp.30666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 11/19/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022]
Abstract
Nifedipine, an L‐type voltage‐gated Ca2+ channel (L‐VGCC) blocker, is one of the most used tocolytics to treat preterm labor. In clinical practice, nifedipine efficiently decreases uterine contractions, but its efficacy is limited over time, and repeated or maintained nifedipine‐based tocolysis appears to be ineffective in preventing preterm birth. We aimed to understand why nifedipine has short‐lasting efficiency for the inhibition of uterine contractions. We used ex vivo term pregnant human myometrial strips treated with cumulative doses of nifedipine. We observed that nifedipine inhibited spontaneous myometrial contractions in tissues with high and regular spontaneous contractions. By contrast, nifedipine appeared to increase contractions in tissues with low and/or irregular spontaneous contractions. To investigate the molecular mechanisms activated by nifedipine in myometrial cells, we used the pregnant human myometrial cell line PHM1‐41 that does not express L‐VGCC. The in vitro measurement of intracellular Ca2+ showed that high doses of nifedipine induced an important intracellular Ca2+ entry in myometrial cells. The inhibition or downregulation of the genes encoding for store‐operated Ca2+ entry channels from the Orai and transient receptor potential‐canonical (TRPC) families in PHM1‐41 cells highlighted the implication of TRPC1 in nifedipine‐induced Ca2+ entry. In addition, the use of 2‐APB in combination with nifedipine on human myometrial strips tends to confirm that the pro‐contractile effect induced by nifedipine on myometrial tissues may involve the activation of TRPC channels.
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Affiliation(s)
- Lucile Yart
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals and University of Geneva Faculty of Medicine, Geneva, Switzerland.,Translational Research Center in Oncohaematology, University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Maud Frieden
- Department of Cell Physiology and Metabolism, University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Stéphane Konig
- Department of Cell Physiology and Metabolism, University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Marie Cohen
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals and University of Geneva Faculty of Medicine, Geneva, Switzerland.,Translational Research Center in Oncohaematology, University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Begoña Martinez de Tejada
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals and University of Geneva Faculty of Medicine, Geneva, Switzerland
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Effects of Solvents, Emulsions, Cosolvents, and Complexions on Ex Vivo Mouse Myometrial Contractility. Reprod Sci 2021; 29:586-595. [PMID: 33852137 PMCID: PMC8782813 DOI: 10.1007/s43032-021-00576-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/02/2021] [Indexed: 11/27/2022]
Abstract
A great need exists to develop tocolytic and uterotonic drugs that combat poor, labor-related maternal and fetal outcomes. A widely utilized method to assess novel compounds for their tocolytic and uterotonic efficacy is the isometric organ bath contractility assay. Unfortunately, water-insoluble compounds can be difficult to test using the physiological, buffer-based, organ bath assay. Common methods for overcoming solubility issues include solvent variation, cosolvency, surfactant or complexion use, and emulsification. However, these options for drug delivery or formulation can impact tissue function. Therefore, the goal of this study was to evaluate the ability of common solvents, surfactants, cosolvents, and emulsions to adequately solubilize compounds in the organ bath assay without affecting mouse myometrial contractility. We found that acetone, acetonitrile, and ethanol had the least effect, while dimethylacetamide, ethyl acetate, and isopropanol displayed the greatest inhibition of myometrial contractility based on area under the contractile curve analyses. The minimum concentration of surfactants, cosolvents, and human serum albumin required to solubilize nifedipine, a current tocolytic drug, resulted in extensive bubbling in the organ bath assay, precluding their use. Finally, we report that an oil-in-water base emulsion containing no drug has no statistical effect beyond the control (water), while the drug emulsion yielded the same potency and efficacy as the freely solubilized drug.
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Morgan AS, Waheed S, Gajree S, Marlow N, David AL. Maternal and infant morbidity following birth before 27 weeks of gestation: a single centre study. Sci Rep 2021; 11:288. [PMID: 33431902 PMCID: PMC7801674 DOI: 10.1038/s41598-020-79445-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/30/2020] [Indexed: 11/09/2022] Open
Abstract
Delivery at extreme preterm gestational ages (GA) [Formula: see text] weeks is challenging with limited evidence often focused only on neonatal outcomes. We reviewed management and short term maternal, fetal and neonatal outcomes of births for 132 women (22 + 0 to 26 + 6 weeks' GA) with a live fetus at admission to hospital and in labour or at planned emergency Caesarean section: 103 singleton and 29 (53 live fetuses) twin gestations. Thirty women (23%) had pre-existing medical problems, 110 (83%) had antenatal complications; only 17 (13%) women experienced neither. Major maternal labour and delivery complications affected 35 women (27%). 151 fetuses (97%) were exposed to antenatal steroids, 24 (15%) to tocolysis and 70 (45%) to magnesium sulphate. Delivery complications affected 11 fetuses, with 12 labour or delivery room deaths; survival to discharge was 75% (117/156), increasing with GA: 25% (1/4), 75% (18/24), 69% (29/42), 73% (33/45) and 88% (36/41) at 22, 23, 24, 25 and 26 weeks GA respectively (p = 0.024). No statistically important impact was seen from twin status, maternal illness or obstetric management. Even in a specialist perinatal unit antenatal and postnatal maternal complications are common in extreme preterm births, emphasising the need to include maternal as well as neonatal outcomes.
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Affiliation(s)
- Andrei S Morgan
- Research Department of Neonatology, Elizabeth Garrett Anderson Institute for Women's Health, University College London, 2nd floor, Medical School Building, 74 Huntley Street, London, WC1E 6AU, UK.,INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, 75020, Paris, France.,SAMU 93-SMUR Pédiatrique, CHI André Gregoire, Groupe Hospitalier Universitaire Paris Seine-Saint-Denis, Assistance Publique des Hôpitaux de Paris, Montreuil, France.,Women's Health Division, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - Saadia Waheed
- Women's Health Division, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - Shivani Gajree
- Women's Health Division, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - Neil Marlow
- Research Department of Neonatology, Elizabeth Garrett Anderson Institute for Women's Health, University College London, 2nd floor, Medical School Building, 74 Huntley Street, London, WC1E 6AU, UK.,Women's Health Division, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK.,NIHR University College London Hospitals BRC, Maple House, 149 Tottenham Court Road, London, W1T 7DN, UK
| | - Anna L David
- Women's Health Division, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK. .,NIHR University College London Hospitals BRC, Maple House, 149 Tottenham Court Road, London, W1T 7DN, UK. .,Research Department of Maternal Fetal Medicine, Institute for Women's Health, University College London, 2nd floor, Medical School Building, 74 Huntley Street, London, WC1E 6AU, UK.
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7
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Ali AA, Sayed AK, El Sherif L, Loutfi GO, Ahmed AMM, Mohamed HB, Anwar AT, Taha AS, Yahia RM, Elgebaly A, Abdel-Daim MM. Systematic review and meta-analysis of randomized controlled trials of atosiban versus nifedipine for inhibition of preterm labor. Int J Gynaecol Obstet 2019; 145:139-148. [PMID: 30784056 DOI: 10.1002/ijgo.12793] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 11/11/2018] [Accepted: 02/19/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Two tocolytic drugs-atosiban and nifedipine-are currently used for first-line treatment of preterm labor (PTL). OBJECTIVE To compare the efficacy and safety of atosiban with nifedipine for PTL treatment. SEARCH STRATEGY In May 2017, we searched PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Clinical Trials with search terms including "nifedipine", "atosiban", and "preterm labor". SELECTION CRITERIA Randomized controlled trials of women with PTL. DATA COLLECTION AND ANALYSIS Data were extracted for study design, patient characteristics, risk of bias domains, and study outcomes. A random-effects model was used to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs). RESULTS We included seven studies that enrolled 992 patients. There was no significant difference between atosiban and nifedipine for pregnancy prolongation of 48 hours or more regarding efficacy (RR 1.06, 95% CI 0.92-1.22; P=0.440) or effectiveness (0.93, 0.84-1.03; P=0.177). Pregnancy prolongation for 7 days or more also did not differ between groups for efficacy (RR 1.04, 95% CI 0.89-1.21; P=0.656) or effectiveness (0.91, 0.79-1.05; P=0.177). Atosiban-however-was associated with fewer maternal side-effects than nifedipine. CONCLUSION Atosiban resulted in fewer maternal side-effects than nifedipine, with no difference in pregnancy prolongation. PROSPERO registration: CRD42018090223.
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Affiliation(s)
- Aya Ashraf Ali
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Ahmed Kamal Sayed
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Loalo'a El Sherif
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Gihan Ossam Loutfi
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Abdullah Mahmoud Mohamed Ahmed
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Hajer Bassem Mohamed
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Ahmad Tareq Anwar
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Abdullah Salah Taha
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Reem Mohamed Yahia
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Ahmed Elgebaly
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt.,Medical Research Education and Practice Association (MREP), Cairo, Egypt
| | - Mohamed M Abdel-Daim
- Pharmacology Department, Faculty of Veterinary Medicine, Suez Canal University, Ismailia, Egypt
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8
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Rath W, Kehl S. Acute Tocolysis - a Critical Analysis of Evidence-Based Data. Geburtshilfe Frauenheilkd 2018; 78:1245-1255. [PMID: 30655648 PMCID: PMC6294642 DOI: 10.1055/a-0717-5329] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/24/2018] [Accepted: 08/26/2018] [Indexed: 11/23/2022] Open
Abstract
Tocolysis is among the most common obstetric measures. The objective is to prolong the pregnancy by at least 48 hours to complete foetal lung maturation and for the in-utero transfer of the pregnant woman to a perinatal centre. The indication for tocolysis is regular, premature contractions (≥ 4/20 min) and a dynamic shortening of the cervical length/cervical opening between 22 + 0 to 33 + 6 weeks of pregnancy. In this connection, the cervical length measured on ultrasound and the determination of biomarkers in the cervicovaginal secretions can be important decision-making aids. Beta sympathomimetics should no longer be used due to the high rate of severe maternal adverse effects. Given controversial data, magnesium sulphate is no longer recommended for tocolysis in current guidelines. Atosiban is as effective for prolonging pregnancy as beta sympathomimetics and nifedipine, has the lowest rate of maternal adverse effects, but also the highest drug costs. Nifedipine and indomethacin are recommended in international guidelines for acute tocolysis, however there are indications of increased neonatal morbidity following indomethacin. Current problems are, above all, the lack of randomised, controlled comparative and placebo-controlled studies, the data which are controversial to some extent, and the insufficient evidence of tocolytics to significantly improve the neonatal outcome.
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Affiliation(s)
- Werner Rath
- Medizinische Fakultät Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
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9
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Ostadal B, Parizek A, Ostadalova I, Kolar F. Cardiotoxicity of β-mimetic catecholamines during ontogenetic development - possible risks of antenatal therapy. Can J Physiol Pharmacol 2018; 96:639-646. [PMID: 29633627 DOI: 10.1139/cjpp-2017-0774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Catecholamines are involved in the regulation of a wide variety of vital functions. The β-adrenergic receptor (β-AR) - adenylyl cyclase system has been identified early in embryogenesis before the heart has received adrenergic innervation. The structure of β-receptors in the immature myocardium is similar to that in adults; there are, however, significant quantitative developmental changes in the inotropic and chronotropic responsiveness. Information on the toxic effect of the β-AR agonists in the immature heart is surprisingly scarce, even though these agents are used in clinical practice both during pregnancy and in early postnatal development. Large doses of β-AR agonists induce malformations of the cardiovascular system; the type of change depends upon the time at which the β-AR agonist was administered during embryogenesis. During postnatal ontogeny, the cardiotoxicity of β-AR agonists increased from birth to adulthood. It seems likely that despite interspecies differences, developmental changes in the cardiac sensitivity to β-AR agonists may exist in all mammals, depending on the degree of maturation of the system involved in β-adrenergic signaling. All the existing data draw attention to the possible harmful consequences of the clinical use of β-AR agonists during early phases of cardiac development. Late effects of the early disturbances of the cardiac muscle cannot be excluded.
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Affiliation(s)
- B Ostadal
- a Institute of Physiology, Czech Academy of Sciences, Videnska 1083, 14220 Prague 4, Czech Republic
| | - A Parizek
- b Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Charles University and General Faculty Hospital, Prague, Czech Republic
| | - I Ostadalova
- a Institute of Physiology, Czech Academy of Sciences, Videnska 1083, 14220 Prague 4, Czech Republic
| | - F Kolar
- a Institute of Physiology, Czech Academy of Sciences, Videnska 1083, 14220 Prague 4, Czech Republic
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Altay MA, Görker I, Aslanova R, Bozatlı L, Turan N, Kaplan PB. Association between Beta-Sympathomimetic Tocolysis and Risk of Autistic Spectrum Disorders, Behavioural and Developmental Outcome in Toddlers. Open Access Maced J Med Sci 2017; 5:730-735. [PMID: 29104681 PMCID: PMC5661710 DOI: 10.3889/oamjms.2017.153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 11/05/2022] Open
Abstract
AIM To investigate whether maternal intravenous beta-mimetic tocolytic therapy increases the risk of autistic spectrum disorders (ASD) and poorer behavioural and developmental outcomes. METHOD Our study is a prospective case-control study among 90 children between 1.5 and three years old. Cases (n = 46) were toddlers with betamimetic tocolytic exposure; control group toddlers (n = 44) were tocolytic untreated. Treated and untreated groups were also divided into subgroups: term and preterm delivered. The gestational age of tocolytic treatment start, the dose and duration of exposure in hours were obtained from obstetric medical records. The Brief Infant-Toddler Social and Emotional Assessment (BITSEA), the Modified Checklist for Autism in Toddlers (M-CHAT) and the Denver Developmental Screening Test (DDST) tests were applied for evaluation of social, emotional problems, autism and developmental disorders. RESULTS Term and preterm born toddlers treated tocolytically in utero didn't demonstrate a higher risk of autistic disorders or poorer behavioural and developmental results than controls. In the preterm group, the earliest start of tocolytic treatment was correlated with toddlers lower score of the Competencies Scale (p = 0.009) and a higher score of the Problems Scale (p = 0.048). Also, we concluded that preterm membrane rupture was associated with higher ASD risk in the untreated group (p = 0.043). CONCLUSION Exposure to betamimetics during pregnancy was not associated with an increased risk of autism, behavioural and developmental disorders.
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Affiliation(s)
- Mengühan Araz Altay
- Department of Child and Adolescent Psychiatry, Edirne Sultan 1. Murat State Hospital, Edirne, Turkey
| | - Işık Görker
- Department of Child and Adolescent Psychiatry, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Rakhshanda Aslanova
- Department of Obstetrics and Gynecology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Leyla Bozatlı
- Department of Child and Adolescent Psychiatry, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Nesrin Turan
- Department of Biostatistics and Medical Informatics, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Petek Balkanlı Kaplan
- Department of Obstetrics and Gynecology, Trakya University Faculty of Medicine, Edirne, Turkey
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11
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Mischi M, Chen C, Ignatenko T, de Lau H, Ding B, Oei SGG, Rabotti C. Dedicated Entropy Measures for Early Assessment of Pregnancy Progression From Single-Channel Electrohysterography. IEEE Trans Biomed Eng 2017; 65:875-884. [PMID: 28692959 DOI: 10.1109/tbme.2017.2723933] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Preterm birth is a large-scale clinical problem involving over 10% of infants. Diagnostic means for timely risk assessment are lacking and the underlying physiological mechanisms unclear. To improve the evaluation of pregnancy before term, we introduce dedicated entropy measures derived from a single-channel electrohysterogram (EHG). METHODS The estimation of approximate entropy (ApEn) and sample entropy (SampEn) is adjusted to monitor variations in the regularity of single-channel EHG recordings, reflecting myoelectrical changes due to pregnancy progression. In particular, modifications in the tolerance metrics are introduced for improving robustness to EHG amplitude fluctuations. An extensive database of 58 EHG recordings with 4 monopolar channels in women presenting with preterm contractions was manually annotated and used for validation. The methods were tested for their ability to recognize the onset of labor and the risk of preterm birth. Comparison with the best single-channel methods according to the literature was performed. RESULTS The reference methods were outperformed. SampEn and ApEn produced the best prediction of delivery, although only one channel showed a significant difference () between labor and nonlabor. The modified ApEn produced the best prediction of preterm delivery, showing statistical significance () in three channels. These results were also confirmed by the area under the receiver operating characteristic curve and fivefold cross validation. CONCLUSION The use of dedicated entropy estimators improves the diagnostic value of EHG analysis earlier in pregnancy. SIGNIFICANCE Our results suggest that changes in the EHG might manifest early in pregnancy, providing relevant prognostic opportunities for pregnancy monitoring by a practical single-channel solution.
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12
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Abstract
A broad definition of preconditioning is "the preparation for a subsequent action." Mounting evidence demonstrates that novel remote preconditioning paradigms, in which protective stimuli experienced locally can capacitate systemic tolerance and enhanced cell viability upon exposure to ensuing cellular insults, have been largely successful in the field of cardiovascular ischemia/reperfusion injury. To ensure successful protective preconditioning, some models (including the uterus) have been demonstrated to activate the unfolded protein response (UPR), which is a cellular stress response controlled at the level of the endoplasmic reticulum. However, in the context of remote preconditioning, activation of these intracellular molecular pathways must result in the extracellular transmission of adaptive signals to remote targets. In our recently published manuscript, we have described the activation of the UPR in the pregnant uterine myocyte to be associated with increased uterine myocyte quiescence and normal gestational length. We hypothesize that ubiquitous uterine gestational stresses experienced in every pregnancy, which have been demonstrated in other systems to activate the UPR, may induce a robust paracrine dissemination of a uterine secretome, for example, glucose-regulated protein 78, with preconditioning-like properties. Furthermore, we speculate that the gestational stress-induced uterine secretome acts to promote both local and systemic tolerance to the ensuing gestational insults, allowing for the maintenance of uterine quiescence. In this context, preterm labor may be the result of a pregnant uterus experiencing a stress it cannot accommodate or when it is unable to host an appropriate UPR resulting in insufficient preconditioning and a diminished local and systemic capacity to tolerate pregnancy-dependent increases in normal gestational stress. This is highly attractive from a clinical viewpoint as we ultimately aim to identify local and systemic adaptations that may serve as preconditioning stimuli for use as a strategy to restore appropriate preconditioning profiles to prolong uterine quiescence in pregnancy.
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Affiliation(s)
- Judith Ingles
- 1 Department of Physiology, Wayne State University Perinatal Initiative, School of Medicine, Wayne State University, Detroit, MI, USA.,2 Department of Obstetrics and Gynecology, Wayne State University Perinatal Initiative, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Chandrashekara N Kyathanahalli
- 1 Department of Physiology, Wayne State University Perinatal Initiative, School of Medicine, Wayne State University, Detroit, MI, USA.,2 Department of Obstetrics and Gynecology, Wayne State University Perinatal Initiative, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Pancharatnam Jeyasuria
- 1 Department of Physiology, Wayne State University Perinatal Initiative, School of Medicine, Wayne State University, Detroit, MI, USA.,2 Department of Obstetrics and Gynecology, Wayne State University Perinatal Initiative, School of Medicine, Wayne State University, Detroit, MI, USA.,3 Perinatal Research Initiative Wayne State University School of Medicine, Wane State University, Detroit, MI, USA
| | - Jennifer C Condon
- 1 Department of Physiology, Wayne State University Perinatal Initiative, School of Medicine, Wayne State University, Detroit, MI, USA.,2 Department of Obstetrics and Gynecology, Wayne State University Perinatal Initiative, School of Medicine, Wayne State University, Detroit, MI, USA.,3 Perinatal Research Initiative Wayne State University School of Medicine, Wane State University, Detroit, MI, USA
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13
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Needham K, Fadia M, Dahlstrom JE, Harrington K, Shadbolt B, Robson SJ. Significance of mast cell distribution in placental tissue and membranes in spontaneous preterm birth. J Inflamm Res 2016; 9:141-5. [PMID: 27468246 PMCID: PMC4944924 DOI: 10.2147/jir.s80722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Preterm birth is a common cause of adverse neonatal and childhood outcomes, in both the short and long term. Preterm labor is commonly associated with inflammation at the maternal–fetal interface. There is some indirect evidence that mast cells (MCs) might represent a link between hormonal influences and local reactions leading to the onset of labor. Patients and methods The placentas and membranes of 51 uncomplicated spontaneous term births were compared to those from 50 spontaneous preterm births. Immunohistochemical staining for MC tryptase was undertaken allowing MC concentration, location, and degranulation status to be determined. Regression modeling was used to compare results. Results There were no significant differences in the demographic characteristics of the two cohorts. There were significantly more MCs in the decidua for term births than preterm births (P=0.03). The presence of histological chorioamnionitis did not affect MC concentrations. Conclusion Despite evidence suggesting a possible role for MCs in spontaneous preterm birth, this study found that the concentration of decidual MCs was in fact significantly lower in preterm compared to term birth.
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Affiliation(s)
- Kate Needham
- Department of Obstetrics and Gynaecology, Centenary Hospital for Women and Children, Canberra Hospital, Garran, ACT, Australia
| | - Mitali Fadia
- Department of Anatomical Pathology, ACT Pathology, Canberra Hospital, Garran, ACT, Australia; ANU Medical School, Australian National University, Canberra, ACT, Australia
| | - Jane E Dahlstrom
- Department of Anatomical Pathology, ACT Pathology, Canberra Hospital, Garran, ACT, Australia; ANU Medical School, Australian National University, Canberra, ACT, Australia
| | - Kirsti Harrington
- Department of Anatomical Pathology, ACT Pathology, Canberra Hospital, Garran, ACT, Australia; ANU Medical School, Australian National University, Canberra, ACT, Australia
| | - Bruce Shadbolt
- Department of Epidemiology and Population Health, Canberra Hospital, Garran, ACT, Australia
| | - Stephen J Robson
- Department of Obstetrics and Gynaecology, Centenary Hospital for Women and Children, Canberra Hospital, Garran, ACT, Australia; ANU Medical School, Australian National University, Canberra, ACT, Australia; John James Medical Centre, Deakin, ACT, Australia
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Kawanishi Y, Saijo Y, Yoshioka E, Nakagi Y, Yoshida T, Miyamoto T, Sengoku K, Ito Y, Miyashita C, Araki A, Kishi R. The Association between Prenatal Yoga and the Administration of Ritodrine Hydrochloride during Pregnancy: An Adjunct Study of the Japan Environment and Children's Study. PLoS One 2016; 11:e0158155. [PMID: 27348869 PMCID: PMC4922558 DOI: 10.1371/journal.pone.0158155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 06/10/2016] [Indexed: 11/22/2022] Open
Abstract
Introduction While the beneficial effects of prenatal yoga have been reported in recent years, little is known about its effectiveness in pregnant Japanese women. Despite several adverse effects, ritodrine hydrochloride is frequently prescribed to suppress preterm labor in Japan, and its usage may therefore indicate cases of preterm labor. This study aimed to clarify the association between prenatal yoga and ritodrine hydrochloride use during pregnancy. Methods An observational study was conducted as an adjunct study by the Hokkaido unit of the Japan Environment and Children’s Study. Information on prenatal yoga practice was collected using a self-questionnaire between March 21, 2012, and July 7, 2015, targeting women who had recently delivered. Ritodrine hydrochloride use was identified from medical records. A total of 2,692 women were analyzed using logistic regression models that adjusted for possible confounders. Results There were 567 (21.1%) women who practiced prenatal yoga, which was associated with a lower risk of ritodrine hydrochloride use (adjusted odds ratio [OR] 0.77; 95% CI 0.61–0.98). This was especially evident in women with a total practice duration that exceeded 900 minutes throughout their pregnancy (adjusted OR 0.54; 95% CI 0.38–0.76). A sensitivity analysis that excluded patients with threatened abortion during the study period produced similar results. Conclusions Prenatal yoga was associated with a lower risk of ritodrine hydrochloride use, particularly in women with more than 900 minutes of practice time over the course of their pregnancy. Prenatal yoga may be a beneficial option for pregnant women in the selection of alternative therapies.
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Affiliation(s)
- Yasuyuki Kawanishi
- Department of Health Science, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
- * E-mail:
| | - Yasuaki Saijo
- Department of Health Science, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Eiji Yoshioka
- Department of Health Science, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yoshihiko Nakagi
- Department of Health Science, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Takahiko Yoshida
- Department of Health Science, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Toshinobu Miyamoto
- Department of Obstetrics and Gynecology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Kazuo Sengoku
- Department of Obstetrics and Gynecology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yoshiya Ito
- Faculty of Nursing, Japanese Red Cross Hokkaido College of Nursing, Kitami, Hokkaido, Japan
| | - Chihiro Miyashita
- Center for Environmental and Health Sciences, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Atsuko Araki
- Center for Environmental and Health Sciences, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Reiko Kishi
- Center for Environmental and Health Sciences, Hokkaido University, Sapporo, Hokkaido, Japan
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Lamont CD, Jørgensen JS, Lamont RF. The safety of tocolytics used for the inhibition of preterm labour. Expert Opin Drug Saf 2016; 15:1163-73. [DOI: 10.1080/14740338.2016.1187128] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Callum D. Lamont
- Department of Medical Education, Lincoln County Hospital, Lincoln, UK
| | - Jan Stener Jørgensen
- Department of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, Research Unit of Gynaecology and Obstetrics, University of Southern Denmark, Odense, Denmark
- Centre for Innovative Medical Technology, Odense University Hospital, Odense, Denmark
| | - Ronald F. Lamont
- Department of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, Research Unit of Gynaecology and Obstetrics, University of Southern Denmark, Odense, Denmark
- Division of Surgery, University College London, Northwick Park Institute for Medical Research Campus, London, UK
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16
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Sharp GC, Hutchinson JL, Hibbert N, Freeman TC, Saunders PTK, Norman JE. Transcription Analysis of the Myometrium of Labouring and Non-Labouring Women. PLoS One 2016; 11:e0155413. [PMID: 27176052 PMCID: PMC4866706 DOI: 10.1371/journal.pone.0155413] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 04/28/2016] [Indexed: 11/18/2022] Open
Abstract
An incomplete understanding of the molecular mechanisms that initiate normal human labour at term seriously hampers the development of effective ways to predict, prevent and treat disorders such as preterm labour. Appropriate analysis of large microarray experiments that compare gene expression in non-labouring and labouring gestational tissues is necessary to help bridge these gaps in our knowledge. In this work, gene expression in 48 (22 labouring, 26 non-labouring) lower-segment myometrial samples collected at Caesarean section were analysed using Illumina HT-12 v4.0 BeadChips. Normalised data were compared between labouring and non-labouring groups using traditional statistical methods and a novel network graph approach. We sought technical validation with quantitative real-time PCR, and biological replication through inverse variance-weighted meta-analysis with published microarray data. We have extended the list of genes suggested to be associated with labour: Compared to non-labouring samples, labouring samples showed apparent higher expression at 960 probes (949 genes) and apparent lower expression at 801 probes (789 genes) (absolute fold change ≥1.2, rank product percentage of false positive value (RP-PFP) <0.05). Although half of the women in the labouring group had received pharmaceutical treatment to induce or augment labour, sensitivity analysis suggested that this did not confound our results. In agreement with previous studies, functional analysis suggested that labour was characterised by an increase in the expression of inflammatory genes and network analysis suggested a strong neutrophil signature. Our analysis also suggested that labour is characterised by a decrease in the expression of muscle-specific processes, which has not been explicitly discussed previously. We validated these findings through the first formal meta-analysis of raw data from previous experiments and we hypothesise that this represents a change in the composition of myometrial tissue at labour. Further work will be necessary to reveal whether these results are solely due to leukocyte infiltration into the myometrium as a mechanism initiating labour, or in addition whether they also represent gene changes in the myocytes themselves. We have made all our data available at www.ebi.ac.uk/arrayexpress/ (accession number E-MTAB-3136) to facilitate progression of this work.
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Affiliation(s)
- Gemma C. Sharp
- Tommy’s Centre for Maternal and Fetal Health and Medical Research Council (MRC) Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
- * E-mail:
| | - James L. Hutchinson
- Tommy’s Centre for Maternal and Fetal Health and Medical Research Council (MRC) Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Nanette Hibbert
- Tommy’s Centre for Maternal and Fetal Health and Medical Research Council (MRC) Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Tom C. Freeman
- Systems Immunology Group, Division of Genetics and Genomics, The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, United Kingdom
| | - Philippa T. K. Saunders
- Tommy’s Centre for Maternal and Fetal Health and Medical Research Council (MRC) Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Jane E. Norman
- Tommy’s Centre for Maternal and Fetal Health and Medical Research Council (MRC) Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
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Miyazaki C, Moreno Garcia R, Moreno RG, Ota E, Swa T, Oladapo OT, Mori R. Tocolysis for inhibiting preterm birth in extremely preterm birth, multiple gestations and in growth-restricted fetuses: a systematic review and meta-analysis. Reprod Health 2016; 13:4. [PMID: 26762152 PMCID: PMC4712490 DOI: 10.1186/s12978-015-0115-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 12/31/2015] [Indexed: 11/21/2022] Open
Abstract
This systematic review was to identify available evidence on the effectiveness of tocolysis in inhibiting preterm delivery for women with threatened extremely preterm birth, multiple gestations, and growth-restricted babies, and their infants' outcomes. A comprehensive search using MEDLINE, Embase, the Cochrane Library, CINAHL, POPLINE and the WHO Global Health Library databases was conducted on 14 February 2014. For selection criteria, randomized controlled trials and non-randomized studies that compared tocolysis treatment to placebo or no treatment were considered. Selection of eligible studies, critical appraisal of the included studies, data collection, meta-analyses, and assessment of evidence quality were performed in accordance with the Cochrane Collaboration's guidance and validated assessment criteria. The search identified seven studies for extremely preterm birth, in which three were randomized controlled trials (RCTs) and four were non-randomized studies (non-RCTs). There were no eligible studies identified for women with multiple pregnancy and growth-restricted fetuses. Meta-analyses indicated no significant difference was found for the relative effectiveness of tocolytics versus placebo for prolonging pregnancy in women with extremely preterm birth (RR 1.04, 95% CI 0.83 to 1.31) or reducing the rate of perinatal deaths (RR 2.22, 95% CI 0.26 to 19.24). In summary, there is no evidence to draw conclusions on the effectiveness of tocolytic therapy for women with threatened extremely preterm birth, multiple gestations, and growth-restricted babies.
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Affiliation(s)
- Celine Miyazaki
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.
| | - Ralf Moreno Garcia
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.
| | | | - Erika Ota
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.
| | - Toshiyuki Swa
- Graduate School of Human Sciences, Osaka University, Osaka, Japan.
| | - Olufemi T Oladapo
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
| | - Rintaro Mori
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.
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Abstract
OBJECTIVE To compare adipokinins between women experiencing preterm labor (PTL) and prior preterm deliveries (PTD). STUDY DESIGN In this prospective observational cohort, 110 women with a singleton <35 weeks at increased risk of PTD were studied. Serum leptin, adiponectin, and resistin were obtained at three times (23-34 weeks, 35-36 weeks, at delivery) and analyzed via enzyme-linked immunosorbent assay. The adipokinins were compared across time and between PTL (n = 59) and prior PTD (n = 51) groups using generalized estimated equation models. RESULTS There were no differences in leptin, adiponectin, or resistin levels over the three times between the PTL and PTD groups. There was a trend toward higher leptin levels (p = 0.06 unadjusted analysis, p = 0.09 adjusted analysis) at 23-34 weeks. When stratified by body mass index (BMI), there were differences in leptin (p < 0.001 for BMI < 30; p = 0.77 for BMI ≥ 30) and adiponectin (p = 0.04 for BMI < 30; p = 0.09 for BMI ≥ 30), but not in resistin over the three times between the PTL and prior PTD groups. CONCLUSION There were no significant differences in adipokinins in women with PTL and a prior PTD. The trends toward higher leptin levels at 23-34 weeks in women with PTL may represent a compensatory response and require further evaluation in the study of treatments for PTL.
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Affiliation(s)
- Michelle A Kominiarek
- a Department of Obstetrics and Gynecology , Division of Maternal-Fetal Medicine, University of Illinois at Chicago , Chicago , IL , USA
| | - Cecilia T Gambala
- b Division of Maternal-Fetal Medicine , Department of Obstetrics and Gynecology, Tulane University , New Orleans , LA , USA , and
| | - Monique Sutherland
- a Department of Obstetrics and Gynecology , Division of Maternal-Fetal Medicine, University of Illinois at Chicago , Chicago , IL , USA
| | - Krista Varady
- c College of Applied Health Sciences, Department of Kinesiology and Nutrition, University of Illinois at Chicago , Chicago , IL , USA
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19
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Differing In Vitro Potencies of Tocolytics and Progesterone in Myometrium From Singleton and Twin Pregnancies. Reprod Sci 2015; 23:98-111. [DOI: 10.1177/1933719115597788] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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20
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Thornton S, Miller H, Valenzuela G, Snidow J, Stier B, Fossler MJ, Montague TH, Powell M, Beach KJ. Treatment of spontaneous preterm labour with retosiban: a phase 2 proof-of-concept study. Br J Clin Pharmacol 2015; 80:740-9. [PMID: 25819462 DOI: 10.1111/bcp.12646] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 03/19/2015] [Accepted: 03/22/2015] [Indexed: 11/29/2022] Open
Abstract
AIM The aim was to investigate the efficacy and safety of intravenous retosiban in women with spontaneous preterm labour. METHODS This was a randomized, double-blind, placebo-controlled, phase 2 trial. Retosiban was administered intravenously for 48 h to women in spontaneous preterm labour between 30(0/7) and 35(6/7) weeks' gestation with an uncomplicated singleton pregnancy in an in-patient obstetric unit. Outcome measures were uterine quiescence (primary endpoint), days to delivery, preterm delivery and safety. RESULTS Uterine quiescence was achieved in 62% of women who received retosiban (n = 30) compared with 41% who received placebo (n = 34). The relative risk (RR) was 1.53 (95% credible interval [CrI] 0.98, 2.48; NS). Retosiban resulted in a significant increase in time to delivery compared with placebo (mean difference 8.2 days, 95% CrI 2.7, 13.74). This difference was consistent across all gestational ages. The proportion of preterm births in the retosiban and placebo groups was 18.7% (95% CrI 7.4%, 33.7%) and 47.2% (95% CrI 31.4%, 63.4%), respectively. The RR of preterm birth in women treated with retosiban was 0.38 (95% CrI 0.15, 0.81). There were no deliveries within 7 days in the retosiban group, but there were six (17.6%) births in the placebo group. The maternal, fetal and neonatal adverse events were comparable in the retosiban and placebo groups. CONCLUSIONS Intravenous administration of retosiban in women with spontaneous preterm labour was associated with a greater than 1 week increase in time to delivery compared with placebo, a significant reduction in preterm deliveries, a non-significant increase in uterine quiescence and a favourable safety profile.
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Affiliation(s)
| | - Hugh Miller
- Watching Over Mothers and Babies Foundation, Tucson, AZ, USA
| | | | - Jerry Snidow
- GlaxoSmithKline, Research Triangle Park, NC, USA
| | | | | | | | - Marcy Powell
- GlaxoSmithKline, Research Triangle Park, NC, USA
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21
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Hadzi Lega M, Daneva Markova A, Stefanovic M, Tanturovski M. Interleukin 6 and fetal fibronectin as a predictors of preterm delivery in symptomatic patients. Bosn J Basic Med Sci 2015; 15:51-6. [PMID: 25725144 DOI: 10.17305/bjbms.2015.1.93] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 10/05/2014] [Accepted: 10/05/2014] [Indexed: 11/16/2022] Open
Abstract
Preterm delivery is the leading cause of neonatal mortality and morbidity. The rate of preterm births has been estimated to be about 15 million, which accounts for 11.1% of all live births worldwide. The purpose of this study was to evaluate the cervico-vaginal (CVF) cytokine IL-6 and fetal fibronectin (fFN) status as predictors of preterm delivery in patients with symptoms of preterm labor. Patients with symptoms suggestive of preterm labor were recruited from September 2013 to March 2014. Vaginal swabs were taken for fetal fibronectin test (fFN) and CVF IL-6. Antibiotics, steroids and tocolytics were administered, where appropriate. The outcome was measured by the occurrence of preterm delivery within 14 days from the day of hospital admission. Cut-off value of 1305 pg/mL for the concentration of IL-6 in the CVF was the best predictor of preterm delivery, with the sensitivity of 69.4% and specificity of 68.2%. Patients with positive fFN test had the OR of 6.429 (95%CI 1.991-20.758) to deliver prematurely. The multivariate analysis of combined fFN and CVF IL-6 tests resulted in risk of 86.7% to deliver prematurely, if both tests were positive. The combination of both tests performed better than the individual tests and decreased the false positive rate, which in turn reduced the chances for inappropriate patient treatment, bringing down the costs.
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Affiliation(s)
- Marija Hadzi Lega
- Clinic of Obstetrics and Gynecology, Medical Faculty, Ss. Cyril and Methodius University, Skopje, Macedonia.
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Lee CM, Yang SH, Lee SP, Hwang BC, Kim SY. Clinical factors affecting the timing of delivery in twin pregnancies. Obstet Gynecol Sci 2014; 57:436-41. [PMID: 25469330 PMCID: PMC4245335 DOI: 10.5468/ogs.2014.57.6.436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 07/05/2014] [Accepted: 07/12/2014] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To investigate clinical factors affecting the timing of delivery in twin pregnancies in order to minimize perinatal complications. METHODS A retrospective study involved 163 twin pregnancies delivered from January 2006 to September 2011 at Gachon University Gil Medical Center. These cases were divided into three groups based on the delivery timing: less than 32 weeks' gestation (group A), between 32 and 35+6 weeks' gestation (group B), and over 36 weeks' gestation (group C). Clinical factors including maternal age, parity, presence of premature uterine contraction, presence of premature rupture of membrane, white blood cell, high sensitive C-reactive protein level, cervical dilatation, maternal complication, chorionicity, twin specific complication, and perinatal complication were analyzed for each group. RESULTS In group B, the timing of delivery was postponed for 14 days or more from the time of admission, and there were fewer numbers of babies with low Apgar score at birth compared with other groups. The frequency of uterine contraction (P<0.001), presence of premature rupture of membranes (P=0.017), dilatation of cervix (P<0.001), increased white blood cell and high sensitive C-reactive protein levels (P=0.002, P<0.001) were important clinical factors during decision making process of delivery timing in twin pregnancies. Twin specific fetal conditions, such as twin-twin transfusion syndrome and discordant growth (over 25% or more) were shown more frequently in group A. However, there were no significant statistical differences among three groups (P=0.06, P=0.14). CONCLUSION Proper management for preventing premature contraction and inflammation can be essential in twin pregnancies until 32 weeks' gestation, and may decrease maternal and perinatal complications.
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Affiliation(s)
- Chae Min Lee
- Department of Obstetrics and Gynecology, Gachon University Gil Hospital, Gachon University Graduate School of Medicine, Incheon, Korea
| | - Sun Hye Yang
- Department of Obstetrics and Gynecology, Gachon University Gil Hospital, Gachon University Graduate School of Medicine, Incheon, Korea
| | - Sun Pyo Lee
- Department of Obstetrics and Gynecology, Gachon University Gil Hospital, Gachon University Graduate School of Medicine, Incheon, Korea
| | - Byung Chul Hwang
- Department of Obstetrics and Gynecology, Gachon University Gil Hospital, Gachon University Graduate School of Medicine, Incheon, Korea
| | - Suk Young Kim
- Department of Obstetrics and Gynecology, Gachon University Gil Hospital, Gachon University Graduate School of Medicine, Incheon, Korea
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Boğa Pekmezekmek A, Binokay US, Seçilmiş MA, Kumcu E, Şimşek E, Akillioğlu K, Sertdemir Y, Özaykan B. Evaluating the Teratogenicity of Ritodrine and Nifedipine using a Frog Embryo Teratogenesis assay (FETAX). Drug Chem Toxicol 2014; 38:254-65. [DOI: 10.3109/01480545.2014.947423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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McCubbin K, Moore S, MacDonald R, Vaillancourt C. Medical Transfer of Patients in Preterm Labor: Treatments and Tocolytics. PREHOSP EMERG CARE 2014; 19:103-109. [PMID: 25153368 DOI: 10.3109/10903127.2014.942475] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract Objective. To examine the epidemiology, effectiveness, and safety of tocolytics, and the variation in use of standard treatments and predictive testing for women in preterm labor (PTL) transported to tertiary care. Methods. This was a health record review of consecutive PTL patients (<38 weeks gestation) transported to a tertiary care facility by Ontario's air and land critical care transport service between January 1, 2006 and January 1, 2011. The primary outcome was the effectiveness of tocolytics in decreasing the frequency of contractions and incidence of delivery. Secondary outcomes included the type of tocolytics used, adverse events (defined a priori), use of standard treatments (corticosteroid, antibiotic), and use of predictive tests (cervical length measurement, fetal fibronectin). We report descriptive statistics and relative risk of contractions decreasing with tocolytics with 95% confidence intervals. Results. Of the 510 transports reviewed, 488 met all inclusion criteria with the following characteristics: mean age 26.1 years, mean gestational age 31.2 weeks, mean transport time 80 minutes, 61.0% multiparous, 13.3% twins, mean initial dilatation 1.8 cm, contraction <8 min apart 67.7%, and 66.8% from Northern Ontario. Tocolytics were used in 206 (42.2%), with nonsteroidal anti-inflammatory drugs and nitroglycerine being used most frequently. Eleven (2.3%) patients delivered during transport, 4 (36.4%) of which received tocolytics with relative risk (RR) 0.8 (95%CI 0-2.0), and number needed to treat (NNT) 165 (31.5-299.3). Among the 311 (63.7%) patients for which change in contractions was documented, 140 (45%) received tocolytics and of these patients, contractions decreased in 94 (67%), with an RR 0.6 (95%CI 0.3-0.9) and NNT 4.6 (3.1-6.2). Adverse events were documented in 67 (14%) patients (most commonly tachycardia 5.8%). Steroids were appropriately used in 268 (54.9%) patients and antibiotics were appropriately used in 286 (58.6%) patients. Predictive testing was performed in only 19 (3.9%) patients. Conclusions. Tocolytics were associated with decreased contraction frequency in more than two-thirds of those treated. However, nearly half those who did not receive the treatment also had decreased contractions, and the effect did not reach statistical significance. Variation in the type of tocolytic drug used suggests a need for clinical practice guidelines for tocolytic use during transport of PTL patients.
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Haram K, Mortensen JHS, Morrison JC. Tocolysis for acute preterm labor: does anything work. J Matern Fetal Neonatal Med 2014; 28:371-8. [DOI: 10.3109/14767058.2014.918095] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Danti L, Zonca M, Barbetti L, Lojacono A, Marini S, Cappello N, Bianchi U, Benedetto C. Prophylactic oral nifedipine to reduce preterm delivery: a randomized controlled trial in women at high risk. Acta Obstet Gynecol Scand 2014; 93:802-8. [PMID: 24773243 DOI: 10.1111/aogs.12405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 04/17/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To establish the efficacy of prophylactic nifedipine vs. placebo in reducing spontaneous preterm delivery in asymptomatic women at high risk for preterm delivery. DESIGN Prospective multicentric randomized double-blind study. SETTING Tertiary care centre, University Hospitals of Brescia and Torino, Italy. POPULATION Eighty-seven singleton pregnancies without uterine contractions and ultrasonographic cervical length of ≤25 mm at 24-32 weeks, at risk for preterm delivery, with longitudinal follow up in our Preterm Prevention Clinic. METHODS Selection was done on the basis of ultrasonographic cervical length; 43 women were randomized to receive placebo and 44 to receive nifedipine. MAIN OUTCOME MEASURES Primary end point: spontaneous preterm delivery <37 weeks in nifedipine vs. placebo. SECONDARY OUTCOMES delivery <32 weeks, maternal side effects, neonatal complications, admissions to the Neonatal Intensive Care Unit and randomization/delivery time in nifedipine vs. placebo. RESULTS There was no trend towards a lower risk of spontaneous preterm delivery, neither at <37 weeks of nifedipine vs. placebo (11.4% vs. 19.0%; p = 0.320), or <32 weeks (2.3% vs. 2.4%; p = 0.973). Nifedipine reduced spontaneous preterm delivery <37 weeks (p = 0.015) in the multiparous women by stratified analysis for parity. SECONDARY OUTCOMES between the groups did not differ except for a higher percentage of maternal side-effects in the nifedipine group (31.8%) vs. placebo (11.9%) (p < 0.05). Subgroup analysis showed a borderline (p = 0.047) lower percentage of spontaneous preterm delivery in women with a ultrasonographic cervical length of <20 mm in the nifedipine group. CONCLUSIONS Prophylactic nifedipine in asymptomatic women at high risk for preterm delivery had a positive effect on the rate of spontaneous preterm delivery <37 weeks in multiparous women.
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Affiliation(s)
- Luana Danti
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
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Flenady V, Reinebrant HE, Liley HG, Tambimuttu EG, Papatsonis DNM. Oxytocin receptor antagonists for inhibiting preterm labour. Cochrane Database Syst Rev 2014; 2014:CD004452. [PMID: 24903678 PMCID: PMC11086629 DOI: 10.1002/14651858.cd004452.pub3] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Preterm birth, defined as birth between 20 and 36 completed weeks, is a major contributor to perinatal morbidity and mortality globally. Oxytocin receptor antagonists (ORA), such as atosiban, have been specially developed for the treatment of preterm labour. ORA have been proposed as effective tocolytic agents for women in preterm labour to prolong pregnancy with fewer side effects than other tocolytic agents. OBJECTIVES To assess the effects on maternal, fetal and neonatal outcomes of tocolysis with ORA for women with preterm labour compared with placebo or any other tocolytic agent. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 December 2013). SELECTION CRITERIA We included all randomised controlled trials (published and unpublished) of ORA for tocolysis of labour between 20 and 36 completed weeks' gestation. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated methodological quality and extracted trial data. When required, we sought additional data from trial authors. Results are presented as risk ratio (RR) for categorical and mean difference (MD) for continuous data with the 95% confidence intervals (CI). Where appropriate, the number needed to treat for benefit (NNTB) and the number needed to treat for harm (NNTH) were calculated. MAIN RESULTS This review update includes eight additional studies (790 women), giving a total of 14 studies involving 2485 women.Four studies (854 women) compared ORA (three used atosiban and one barusiban) with placebo. Three studies were considered at low risk of bias in general (blinded allocation to treatment and intervention), the fourth study did not adequately blind the intervention. No difference was shown in birth less than 48 hours after trial entry (average RR 1.05, 95% CI 0.15 to 7.43; random-effects, (two studies, 152 women), perinatal mortality (RR 2.25, 95% CI 0.79 to 6.38; two studies, 729 infants), or major neonatal morbidity. ORA (atosiban) resulted in a small reduction in birthweight (MD -138.86 g, 95% CI -250.53 to -27.18; two studies with 676 infants). In one study, atosiban resulted in an increase in extremely preterm birth (before 28 weeks' gestation) (RR 3.11, 95% CI 1.02 to 9.51; NNTH 31, 95% CI 8 to 3188) and infant deaths (up to 12 months) (RR 6.13, 95% CI 1.38 to 27.13; NNTH 28, 95% CI 6 to 377). However, this finding may be confounded due to randomisation of more women with pregnancy less than 26 weeks' gestation to atosiban. ORA also resulted in an increase in maternal adverse drug reactions requiring cessation of treatment in comparison with placebo (RR 4.02, 95% CI 2.05 to 7.85; NNTH 12, 95% CI 5 to 33). No differences were shown in preterm birth less than 37 weeks' gestation or any other adverse neonatal outcomes. No differences were evident by type of ORA, although data were limited.Eight studies (1402 women) compared ORA (atosiban only) with betamimetics; four were considered of low risk of bias (blinded allocation to treatment and to intervention). No statistically significant difference was shown in birth less than 48 hours after trial entry (RR 0.89, 95% CI 0.66 to 1.22; eight studies with 1389 women), very preterm birth (RR 1.70, 95% CI 0.89 to 3.23; one study with 145 women), extremely preterm birth (RR 0.84, 95% CI 0.37 to 1.92; one study with 244 women) or perinatal mortality (RR 0.55, 95% CI 0.21 to 1.48; three studies with 816 infants). One study (80 women), of unclear methodological quality, showed an increase in the interval between trial entry and birth (MD 22.90 days, 95% CI 18.03 to 27.77). No difference was shown in any reported measures of major neonatal morbidity (although numbers were small). ORA (atosiban) resulted in less maternal adverse effects requiring cessation of treatment (RR 0.05, 95% CI 0.02 to 0.11; NNTB 6, 95% CI 6 to 6; five studies with 1161 women).Two studies including (225 women) compared ORA (atosiban) with calcium channel blockers (CCB) (nifedipine only). The studies were considered as having high risk of bias as neither study blinded the intervention and in one study it was not known if allocation was blinded. No difference was shown in birth less than 48 hours after trial entry (average RR 1.09, 95% CI 0.44 to 2.73, random-effects; two studies, 225 women) and extremely preterm birth (RR 2.14, 95% CI 0.20 to 23.11; one study, 145 women). No data were available for the outcome of perinatal mortality. One small trial (145 women), which did not employ blinding of the intervention, showed an increase in the number of preterm births (before 37 weeks' gestation) (RR 1.56, 95% CI 1.13 to 2.14; NNTH 5, 95% CI 3 to 19), a lower gestational age at birth (MD -1.20 weeks, 95% CI -2.15 to -0.25) and an increase in admission to neonatal intensive care unit (RR 1.70, 95% CI 1.17 to 2.47; NNTH 5, 95% CI 3 to 20). ORA (atosiban) resulted in less maternal adverse effects (RR 0.38, 95% CI 0.21 to 0.68; NNTB 6, 95% CI 5 to 12; two studies, 225 women) but not maternal adverse effects requiring cessation of treatment (RR 0.36, 95% CI 0.01 to 8.62; one study, 145 women). No longer-term outcome data were included. AUTHORS' CONCLUSIONS This review did not demonstrate superiority of ORA (largely atosiban) as a tocolytic agent compared with placebo, betamimetics or CCB (largely nifedipine) in terms of pregnancy prolongation or neonatal outcomes, although ORA was associated with less maternal adverse effects than treatment with the CCB or betamimetics. The finding of an increase in infant deaths and more births before completion of 28 weeks of gestation in one placebo-controlled study warrants caution. However, the number of women enrolled at very low gestations was small. Due to limitations of small numbers studied and methodological quality, further well-designed randomised controlled trials are needed. Further comparisons of ORA versus CCB (which has a better side-effect profile than betamimetics) are needed. Consideration of further placebo-controlled studies seems warranted. Future studies of tocolytic agents should measure all important short- and long-term outcomes for women and infants, and costs.
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Affiliation(s)
- Vicki Flenady
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)Translating Research Into Practice (TRIP) CentreLevel 2 Aubigny Place, Mater Health ServicesAnnerley Road, WoolloongabbaBrisbaneQueenslandAustralia4102
| | - Hanna E Reinebrant
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)Translating Research Into Practice (TRIP) CentreLevel 2 Aubigny Place, Mater Health ServicesAnnerley Road, WoolloongabbaBrisbaneQueenslandAustralia4102
| | - Helen G Liley
- Mater Mothers’ Hospital, Mater Research, The University of QueenslandSouth BrisbaneAustralia
| | - Eashan G Tambimuttu
- Royal Brisbane and Women's HospitalDepartment of Gynaecology Oncology/Obstetrics and GynaecologyButterfield Street, HerstonBrisbaneQueenslandAustralia4006
| | - Dimitri NM Papatsonis
- Amphia Hospital BredaDepartment of Obstetrics and GynaecologyLangendijk 75BredaNetherlands4819 EV
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Abstracts of the XXIV European Congress of Perinatal Medicine, June 4-7, 2014, Florence, Italy. J Matern Fetal Neonatal Med 2014; 27 Suppl 1:1-437. [PMID: 24893668 DOI: 10.3109/14767058.2014.924236] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Saleh SS, Al-Ramahi MQ, Al Kazaleh FA. Atosiban and nifedipine in the suppression of pre-term labour: a comparative study. J OBSTET GYNAECOL 2014; 33:43-5. [PMID: 23259877 DOI: 10.3109/01443615.2012.721822] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This is a retrospective study comparing the efficacy and safety of atosiban and nifedipine in the suppression of pre-term labour. A total of 75 patients were included in this study; 34 received atosiban and 41 received nifedipine. There were no statistically significant differences in the baseline characteristics for both groups. A total of 68.3% of women in the atosiban group remained undelivered at 7 days or more, compared with 64.7% in the nifedipine group, which was not statistically significant. Average birth weight, admission to the neonatal intensive care unit and mode of delivery were similar in both groups. However, the gestational age at delivery was significantly higher in the nifedipine group. We concluded that atosiban and nifedipine are effective in delaying delivery for 7 days or more in women presenting with pre-term labour. They have the same efficacy and associated minor side-effects. However, flushing, palpitation and hypotension were significantly higher in the nifedipine group.
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Affiliation(s)
- S S Saleh
- Department of Obstetrics and Gynaecology, Jordan University Hospital, Amman, Jordan.
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Tocolysis for preterm labor: Expert opinion. Arch Gynecol Obstet 2014; 289:903-9. [DOI: 10.1007/s00404-013-3137-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 12/13/2013] [Indexed: 10/25/2022]
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Boots AB, Sanchez-Ramos L, Bowers DM, Kaunitz AM, Zamora J, Schlattmann P. The short-term prediction of preterm birth: a systematic review and diagnostic metaanalysis. Am J Obstet Gynecol 2014; 210:54.e1-54.e10. [PMID: 24021995 DOI: 10.1016/j.ajog.2013.09.004] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 08/08/2013] [Accepted: 09/06/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the diagnostic accuracy of fetal fibronectin (fFN), fetal breathing movements (FBM), and cervical length (CL) for the short-term prediction of preterm birth in symptomatic patients. STUDY DESIGN Diagnostic metaanalysis using bivariate methods. RESULTS Pooled sensitivities for fFN, FBM, and CL for delivery within 48 hours of testing were 0.62 (95% confidence interval [CI], 0.43-0.78), 0.75 (95% CI, 0.57-0.87) and 0.77 (95% CI, 0.54-0.90), respectively. Pooled specificities for fFN, FBM, and CL for delivery within 48 hours were 0.81 (95% CI, 0.74-0.86), 0.93 (95% CI, 0.75-0.98) and 0.88 (95% CI, 0.84-0.91). Pooled sensitivities for fFN, FBM, and CL for delivery within 7 days were 0.75 (95% CI, 0.69-0.80), 0.67 (95% CI, 0.43-0.84), and 0.74 (95% CI, 0.58-0.85). Pooled specificities for fFN, FBM, and CL for delivery within 7 days were 0.79 (95% CI, 0.76-0.83), 0.98 (95% CI, 0.83-1.00) and 0.89 (95% CI, 0.85-0.92). Based on a pretest probability of 10% for delivery within 48 hours, posttest probabilities (positive and negative) were 27% and 5% for fFN, 54% and 3% for fFN, and 42% and 3% for CL. For a pretest probability of 20% for delivery within 7 days, posttest probabilities (positive and negative) were 48% and 7% for fFN, 89% and 8% for FBM, and 63% and 7% for CL. CONCLUSION In symptomatic patients, for fFN, absence of FBM, and CL have diagnostic use as predictors of delivery within 48 hours and within 7 days of testing. Absence of FBM appears to be the best test for predicting preterm birth.
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Papatsonis DNM, Flenady V, Liley HG. Maintenance therapy with oxytocin antagonists for inhibiting preterm birth after threatened preterm labour. Cochrane Database Syst Rev 2013:CD005938. [PMID: 24122673 DOI: 10.1002/14651858.cd005938.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In some women, an episode of preterm labour settles and does not result in immediate preterm birth. Subsequent treatment with tocolytic agents such as oxytocin receptor antagonists may then have the potential to prevent the recurrence of preterm labour, prolonging gestation, and preventing the adverse consequences of prematurity for the infant. OBJECTIVES To assess the effects of maintenance therapy with oxytocin antagonists administered by any route after an episode of preterm labour in order to delay or prevent preterm birth. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2013), sought ongoing and unpublished trials by contacting experts in the field and searched the reference lists of relevant articles. SELECTION CRITERIA Randomised controlled trials comparing oxytocin antagonists with any alternative tocolytic agent, placebo or no treatment, used for maintenance therapy after an episode of preterm labour. DATA COLLECTION AND ANALYSIS We used the standard methods of The Cochrane Collaboration and the Cochrane Pregnancy and Childbirth Group. Two review authors independently undertook evaluation of methodological quality and extracted trial data. MAIN RESULTS This review includes one trial of 513 women. When compared with placebo, atosiban did not reduce preterm birth before 37 weeks (risk ratio (RR) 0.89; 95% confidence intervals (CI) 0.71 to 1.12), 32 weeks (RR 0.85; 95% CI 0.47 to 1.55), or 28 weeks (RR 0.75; 95% CI 0.28 to 2.01). No difference was shown in neonatal morbidity, or perinatal mortality. AUTHORS' CONCLUSIONS There is insufficient evidence to support the use of oxytocin receptor antagonists to inhibit preterm birth after a period of threatened or actual preterm labour. Any future trials using oxytocin antagonists or other drugs as maintenance therapy for preventing preterm birth should examine a variety of important infant outcome measures, including reduction of neonatal morbidity and mortality, and long-term infant follow-up. Future research should also focus on the pathophysiological pathways that precede preterm labour.
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Affiliation(s)
- Dimitri N M Papatsonis
- Department of Obstetrics and Gynaecology, Amphia Hospital Breda, Langendijk 75, Breda, Netherlands, 4819 EV
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Rosenbaum ST, Larsen T, Joergensen JC, Bouchelouche PN. Relaxant effect of a novel calcium-activated potassium channel modulator on human myometrial spontaneous contractility in vitro. Acta Physiol (Oxf) 2012; 205:247-54. [PMID: 22099068 DOI: 10.1111/j.1748-1716.2011.02384.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To investigate the effect of 4,5-dichloro-1,3-diethyl-1,3-dihydro-benzoimidazol-2-one (NS4591), a novel SK/IK channels positive modulator, on human myometrial activity. METHODS Organ bath studies were performed on myometrial preparations obtained from women undergoing elective caesarean section at term (N = 11) or hysterectomy (N = 11). NS4591 was added cumulatively in the concentration range of 0.3-30 μm. In separate experiments, the effects of pre-incubation of muscle preparation with the SK or IK channel blockers apamin (1 μm) and TRAM34 (10 μm) on the outcomes of NS4591 were evaluated. Simultaneous vehicle controls were performed for all experiments. The effects of drugs were studied on spontaneous contractions. RESULTS NS4591 exerted an inhibitory effect on myometrial contractions in muscle strips from non-pregnant and pregnant women. The contractility in non-pregnant and pregnant myometrium was reduced to the following values respectively: amplitude 20.65 ± 7.38% (P < 0.001) and 42.85 ± 11.04% (P < 0.05) and area under the curve 11.72 ± 7.39% (P < 0.001) and 34.84 ± 10.50% (P < 0.001) and are reflective of 30 μm NS4591 compared to vehicle control. In non-pregnant tissue, apamin partially reduced the inhibitory effects of NS4591, but we observed relaxation mediated by NS4591 despite pre-incubation with TRAM34. In contrast, in pregnant tissue, neither apamin nor TRAM34 could reverse the relaxatory effects of NS4591. CONCLUSION Our findings imply that SK/IK channels are present and functional in myometrium from pregnant and non-pregnant women. The SK/IK channel-positive modulator NS4591 exerts relaxation of human myometrium in vitro, and this may have implications for the clinical management of preterm labour.
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Affiliation(s)
- S T Rosenbaum
- Department of Gynecology and Obstetrics, Holbaek Hospital, Holbaek, Denmark.
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Abstract
The incidence of twin gestation has increased significantly over the past 30 years. One of the most significant public health implications of this trend is the increased incidence of preterm birth (PTB). Efforts to improve neonatal outcomes must address the rate of PTB, particularly among multiple gestations, which contribute a disproportionate share to the burden of PTB and neonatal morbidity. There is evidence that sonographic cervical length assessment and fetal fibronectin testing can identify twin pregnancies at risk for PTB, but, to date, there are no proven interventions for prevention of PTB in this population. Perhaps the most promising is vaginal progesterone, which has been shown to reduce the risk of PTB in a cohort of women that included twin gestations. However, the study lacked statistical power to definitively answer this question. Identification of an appropriate treatment for twin gestations recognized to be at increased risk for prematurity will help to decrease overall rate of PTB, a significant public health problem in the United States.
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Affiliation(s)
- Sara G Brubaker
- Division of Maternal Fetal Medicine, Columbia University Medical Center, New York, NY 10032, USA.
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The underestimation of immaturity in late preterm infants. Arch Gynecol Obstet 2012; 286:619-26. [PMID: 22562386 DOI: 10.1007/s00404-012-2366-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 04/23/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Late preterm infants with gestational ages between 34 0/7 and 36 6/7 weeks are known to be at higher risk of mortality and morbidity than term newborns. This study aims to investigate the nature and frequency of neonatological complications in the late preterm population resulting in neonatal intensive care unit admissions as well as to draw obstetrical conclusions from the results. METHODS Neonatological outcomes of 893 consecutively born late preterm infants were evaluated and classified by the frequency of occurrence in relation to potential maternal or fetal risk factors. RESULTS Out of 893 late preterm infants, 528 (59.1 %) required intensive neonatal care. The incidence of apnea and bradycardia, the occurrence of feeding difficulties and the requirement of continuous positive airway pressure (CPAP) were inversely proportional to gestational age (p < 0.001). Gestational diabetes of the mother was more frequently associated with hypoglycemia (p < 0.001), but showed a reduced risk of hypothermia (p < 0.001). Small for gestational age neonates had a significantly lower rate of respiratory disorders (p < 0.001), but were more often affected by feeding difficulties (p < 0.01). Normal vaginal delivery had a significant advantage with regard to the necessity of CPAP (p < 0.01) and the occurrence of feeding difficulties (p < 0.05). Infants born by cesarean section were at higher risk of hypoglycemia (p < 0.001), but at lower risk of hyperbilirubinemia (p < 0.001). CONCLUSIONS The high risk of a problematic neonatological outcome in late preterms requires fundamental reconsideration. All efforts to prolong a pregnancy should be made beyond the 34th week of gestation.
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Rydhstroem H, Heraib F. Gestational Duration, and Fetal and Infant Mortality for Twins vs Singletons. ACTA ACUST UNITED AC 2012. [DOI: 10.1375/twin.4.4.227] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractThe aim of this research was to study fetal and infant mortality in Sweden between 1973 and 1996 in twins vs singletons in relation to gestational duration. Analysis was of fetal and infant mortality based on the number of pregnancies at risk as the denominator rather than the number of deliveries each week. The analysis was based on information stored at the Medical Birth Registry (MBR), the National Board of Health and Welfare, Stockholm. The MBR keeps records on virtually all pregnancies (> 99%) regarding delivery and neonatal information, and for infant mortality up to 1 year of age. During the study period, 2,206,738 singleton and 52,658 twin births were registered. Risk evaluation was made as odds ratio (OR) with a 95% confidence interval. The material was stratified according to parity, maternal age, year of delivery, and delivery unit. Results showed the OR for twin births before 34 weeks gestation was 6 to 8-fold increased compared with singletons. The OR for fetal mortality was increased in all gestational weeks, and like-sexed twins had a consistently poorer prognosis compared to unlike-sexed. Between 1989–96, unlike-sexed twins had a fetal mortality approaching that of singletons. In conclusion, real progress in reduction of infant mortality in twins may be impossible until the high incidence of preterm births can be decreased. Hypothetically, about 100 twin labors would have to be induced to avoid one fetal death in like-sexed twin pregnancies.
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Abstract
The pathophysiology leading to preterm labor is not well understood and often multifactorial; initiating factors include intrauterine infection, inflammation, ischemia, overdistension, and hemorrhage. Given these different potential causes, directing therapy for preterm labor has been difficult and suboptimal. To date, no single drug has been identified as successful in treating all of the underlying mechanisms leading to preterm labor. In addition, the methodology of many of the tocolytic studies is limited by lack of sufficient patient numbers, lack of comparison with a placebo, and inconsistent use of glucocorticoids. The limitations in these individual studies make it difficult to evaluate the efficacy of a single tocolytic by meta-analysis. Despite these limitations, the goals for tocolysis for preterm labor are clear: To complete a course of glucocorticoids and secure the appropriate level of neonatal care for the fetus in the event of preterm delivery. The literature demonstrates that many tocolytic agents inhibit uterine contractility. The decision as to which tocolytic agent should be used as first-line therapy for a patient is based on multiple factors, including gestational age, the patient’s medical history, common and severe side effects, and a patient’s response to therapy. In a patient at less than 32 weeks gestation, indomethacin may be a reasonable first choice based on its efficacy, ease of administration, and minimal side effects. Concurrent administration of magnesium for neuroprotection may be given. At 32 to 34 weeks, nifedipine may be a reasonable first choice because it does not carry the fetal risks of indomethacin at these later gestational ages, is easy to administer, and has limited side effects relative to beta-mimetics. In an effort to review a commonly faced obstetrical complication, this article has provided a summary of the most commonly used tocolytics, their mechanisms of action, side effects, and clinical data regarding their efficacy.
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MESH Headings
- Calcium Channel Blockers/therapeutic use
- Drug Administration Schedule
- Female
- Gestational Age
- Humans
- Indomethacin/therapeutic use
- Infant, Newborn
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/epidemiology
- Infant, Premature, Diseases/prevention & control
- Magnesium Compounds/therapeutic use
- Nifedipine/therapeutic use
- Obstetric Labor, Premature/drug therapy
- Obstetric Labor, Premature/epidemiology
- Obstetric Labor, Premature/prevention & control
- Pregnancy
- Pregnancy, High-Risk
- Tocolysis/methods
- Tocolytic Agents/administration & dosage
- Tocolytic Agents/therapeutic use
- United States/epidemiology
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Affiliation(s)
- Adi Abramovici
- Division of Maternal-Fetal Medicine, University of Alabama, Birmingham, 619 19th Street South 176F 10270C, Birmingham, AL 35249-7333, USA.
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Kaya T, Karadas B, Altun A, Sarac İ, Bagcivan I. Effects and selectivity of CL 316243, beta-3-adrenoceptor agonist, in term-pregnant rat myometrium. Gynecol Obstet Invest 2011; 73:63-9. [PMID: 22189156 DOI: 10.1159/000332393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 08/17/2011] [Indexed: 01/09/2023]
Abstract
BACKGROUND/AIMS Recent evidence supports a predominant role of β(3)-adrenoceptors at the end of pregnancy in myometrium. This study was designed to characterize the pharmacology of the selective β(3)-adrenoceptor agonist CL 316243 on oxytocin-induced myometrial contractions and the levels of cAMP and cGMP of myometrial strips isolated from term-pregnant rats. METHODS Myometrial strips were obtained from term-pregnant Wistar albino rats (n = 10), mounted in organ baths and tested for changes in isometric tension in response to CL 316243 (10(-10)-10(-5) M) on oxytocin-induced myometrial contractions. Effects of CL 316243 on cAMP and cGMP levels in isolated myometrial strips (n = 8) were evaluated by radioimmunoassay kits. We evaluated the effect of increasing concentrations of CL 316243 on myometrial contractions and on contractions of myometrial smooth muscle pretreated with metoprolol, ICI 118.551 and SR 59230A (β(1)-, β(2)-, β(3)-adrenoceptor antagonists, respectively, 10(-6) M). RESULTS The inhibition of the amplitude of oxytocin-induced contractions by CL 316243 were antagonized with SR 59230A (10(-6) M), but they were not changed by metoprolol (10(-6) M) or ICI 118.551 (10(-6) M). CL 316243 increased cAMP levels compared to the control group. CL 316243 increased cGMP levels, in the CL 316243 group more than in the control group, but this increase is less significant than cAMP levels. CONCLUSION These results demonstrate that the inhibition of rat myometrial contractions with CL 316243 is mediated by β(3)-adrenoceptor subtype and increased cAMP and cGMP levels.
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Affiliation(s)
- Tijen Kaya
- Department of Pharmacology, Cumhuriyet University School of Medicine, Sivas, Turkey.
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Smart DE, Princivalle MB. Improving RDS treatment with current drugs. J Matern Fetal Neonatal Med 2011; 25:1209-11. [DOI: 10.3109/14767058.2011.634456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kenyon AP, Peebles D. Myth: tocolysis for prevention of preterm birth has a major role in modern obstetrics. Semin Fetal Neonatal Med 2011; 16:242-6. [PMID: 21641289 DOI: 10.1016/j.siny.2011.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Tocolytics are widely used to reduce uterine activity in the context of preterm labour. Growing evidence that bacterial colonization of fetal membranes and amniotic fluid triggers an inflammatory response in mother and fetus and leads to preterm labour and long term neurological and respiratory complications in the neonate also raises questions about the desirability of prolonging pregnancy in this context. Combined with recent meta-analyses that fail to demonstrate improvements in neonatal outcome with tocolytic use, and a poor maternal/fetal side-effect profile, the case for continued use of these drugs needs to be questioned.
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Affiliation(s)
- A P Kenyon
- Institute for Women's Health, University College London, UK
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On benzofuroindole analogues as smooth muscle relaxants. J Biomed Biotechnol 2011; 2011:389056. [PMID: 21941431 PMCID: PMC3177241 DOI: 10.1155/2011/389056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 07/14/2011] [Indexed: 11/18/2022] Open
Abstract
At least two laboratories have independently reported the synthesis of benzofuroindole compounds having potential therapeutic implications in many disease states including those that involve smooth muscle hyperactivity. Through a series of in vitro screenings, they demonstrated the efficacy (and selectivity) of these compounds to potentiate large conductance calcium- (Ca2+-) activated K+ (BKCa) channels, by far, the most characterized of all Ca2+-dependent K+ channels. Interestingly, promising benzofuroindole derivatives such as compound 7 (10H-benzo[4,5]furo[3,2-b]indole) and compound 22 (4-chloro-7-trifluoromethyl-10H-benzo[4,5]furo[3,2-b]indole-1-carboxylic acid) both exhibited high bladder (versus aorta) selectivity, making them attractive alternative treatments for bladder overactivity. In recent reports, compound 22 (LDD175 or TBIC) also showed inhibition of ileum and uterine contractions, indicating multiple target tissues, which is not surprising as BKCa channels are ubiquitously expressed in the animal and human tissues. In this paper, the authors discuss the value of benzofuroindole compounds and the challenges that need to be overcome if they were considered as smooth muscle relaxants.
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Hall NR. What agent should be used to prevent recurrent preterm birth: 17-P or natural progesterone? Obstet Gynecol Clin North Am 2011; 38:235-46, ix-x. [PMID: 21575799 DOI: 10.1016/j.ogc.2011.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Preterm birth has increased over the last decade. In 2006, 12.5% of all births in the United States occurred at fewer than 37 weeks gestation. This is associated with significant health care costs as well as related neonatal morbidity and mortality. In 2003, costs related to care for infants with preterm-birth or low-birth weight exceeded 11 billion dollars. This article reviews the literature on 17 alpha-hydroxyprogesterone caproate (17-P) and natural progesterone and concludes that 17-P is indicated for prevention of preterm birth in women with a documented history of a preterm birth before 37 weeks.
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Affiliation(s)
- Nicole Ruddock Hall
- Division of Maternal Fetal Medicine, Department of Obstetrics/Gynecology, University of Texas Health Science Center, Houston, TX 77026, USA.
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McCallum LA, Pierce SL, England SK, Greenwood IA, Tribe RM. The contribution of Kv7 channels to pregnant mouse and human myometrial contractility. J Cell Mol Med 2011; 15:577-86. [PMID: 20132415 PMCID: PMC3922379 DOI: 10.1111/j.1582-4934.2010.01021.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Premature birth accounts for approximately 75% of neonatal mortality and morbidity in the developed world. Despite this, methods for identifying and treating women at risk of preterm labour are limited and many women still present in preterm labour requiring tocolytic therapy to suppress uterine contractility. The aim of this study was to assess the utility of Kv7 channel activators as potential uterine smooth muscle (myometrium) relaxants in tissues from pregnant mice and women. Myometrium was obtained from early and late pregnant mice and from lipopolysaccharide (LPS)-injected mice (day 15 of gestation; model of infection in pregnancy). Human myometrium was obtained at the time of Caesarean section from women at term (38–41 weeks). RT-PCR/qRT-PCR detected KCNQ and KCNE expression in mouse and human myometrium. In mice, there was a global suppression of all KCNQ isoforms, except KCNQ3, in early pregnancy (n= 6, P < 0.001 versus late pregnant); expression subsequently increased in late pregnancy (n= 6). KCNE isoforms were also gestationally regulated (P < 0.05). KCNQ and KCNE isoform expression was slightly down-regulated in myometrium from LPS-treated-mice versus controls (P < 0.05, n= 3–4). XE991 (10 μM, Kv7 inhibitor) significantly increased spontaneous myometrial contractions in vitro in both human and mouse myometrial tissues (P < 0.05) and retigabine/flupirtine (20 μM, Kv7 channel activators) caused profound myometrial relaxation (P < 0.05). In summary, Kv7 activators suppressed myometrial contraction and KCNQ gene expression was sustained throughout gestation, particularly at term. Consequently, activation of the encoded channels represents a novel mechanism for treatment of preterm labour.
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Affiliation(s)
- Laura A McCallum
- Maternal and Fetal Research Unit, Division of Reproduction and Endocrinology, King's College London, St Thomas' Hospital Campus, London, UK
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Campbell S. Universal cervical-length screening and vaginal progesterone prevents early preterm births, reduces neonatal morbidity and is cost saving: doing nothing is no longer an option. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:1-9. [PMID: 21713990 DOI: 10.1002/uog.9073] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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46
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Kordić-Bojinović J, Oreščanin-Dušić Z, Slavić M, Radojičić R, Spasić M, Milovanović SR, Blagojević D. Effect of indometacin pretreatment on protamine sulfate-mediated relaxation of the isolated rat uterus: the role of the antioxidative defense system. Pharmacol Rep 2011; 63:1019-28. [DOI: 10.1016/s1734-1140(11)70618-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Revised: 03/03/2011] [Indexed: 10/25/2022]
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Lucovnik M, Kuon RJ, Chambliss LR, Maner WL, Shi SQ, Shi L, Balducci J, Garfield RE. Progestin treatment for the prevention of preterm birth. Acta Obstet Gynecol Scand 2011; 90:1057-69. [PMID: 21564026 DOI: 10.1111/j.1600-0412.2011.01178.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Progestin supplementation appears to be a promising approach to both preventing initiation of preterm labor and treating it once it is already established, given the role of progesterone in maintaining pregnancy, as well as support from basic and clinical research. Progesterone and 17α-hydroxyprogesterone acetate slow the process of cervical ripening, and this is the rationale for prophylactic long-term progestin supplementation mostly studied so far. However, progesterone (but not 17α-hydroxyprogesterone acetate) also inhibits myometrial activity even after the cervix has already ripened. Moreover, these effects depend greatly on the vehicle used and the route of administration. Understanding different mechanisms of action, as well as the importance of progestin formulation, vehicle and route of administration, is the key to finding the optimal progestin treatment for prevention of preterm birth.
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Affiliation(s)
- Miha Lucovnik
- Department of Obstetrics and Gynecology, St Joseph's Hospital and Medical Center, 445 North 5th Street, Phoenix, AZ 85004, USA
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Orth TA, Shi SQ, Williamson K, Shi L, Chambliss L, Coonrod DV, Balducci J, Garfield RE. Additive Inhibitory Effects of Progesterone and Sodium Nitroprusside on Uterine Contractility During Pregnancy. Reprod Sci 2011; 18:868-75. [DOI: 10.1177/1933719111398141] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Teresa A. Orth
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Obstetrics and Gynecology Department, Maricopa Medical Center, Phoenix, AZ, USA
| | - Shao-Qing Shi
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Kelli Williamson
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Leili Shi
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Linda Chambliss
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Dean V. Coonrod
- Obstetrics and Gynecology Department, Maricopa Medical Center, Phoenix, AZ, USA
| | - James Balducci
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Robert E. Garfield
- Obstetrics and Gynecology Department, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
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Chawanpaiboon S, Pimol K, Sirisomboon R. Comparison of success rate of nifedipine, progesterone, and bed rest for inhibiting uterine contraction in threatened preterm labor. J Obstet Gynaecol Res 2011; 37:787-91. [DOI: 10.1111/j.1447-0756.2010.01434.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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50
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Demirci O, Ünal A, Demirci E, Sözen H, Akdemir Y, Boybek E, Ertekin A. Sonographic measurement of cervical length and risk of preterm delivery. J Obstet Gynaecol Res 2011; 37:809-14. [DOI: 10.1111/j.1447-0756.2010.01440.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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