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Hristova MD, Krishnan T, Rossi CA, Nouza J, White A, Peebles DM, Sebire NJ, Zachary IC, David AL, Vaughan OR. Maternal Uterine Artery Adenoviral Vascular Endothelial Growth Factor (Ad.VEGF-A 165) Gene Therapy Normalises Fetal Brain Growth and Microglial Activation in Nutrient Restricted Pregnant Guinea Pigs. Reprod Sci 2024; 31:2199-2208. [PMID: 38907125 PMCID: PMC11289362 DOI: 10.1007/s43032-024-01604-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/22/2024] [Indexed: 06/23/2024]
Abstract
Fetal growth restriction (FGR) is associated with uteroplacental insufficiency, and neurodevelopmental and structural brain deficits in the infant. It is currently untreatable. We hypothesised that treating the maternal uterine artery with vascular endothelial growth factor adenoviral gene therapy (Ad.VEGF-A165) normalises offspring brain weight and prevents brain injury in a guinea pig model of FGR. Pregnant guinea pigs were fed a restricted diet before and after conception and received Ad.VEGF-A165 (1 × 1010 viral particles, n = 18) or vehicle (n = 18), delivered to the external surface of the uterine arteries, in mid-pregnancy. Pregnant, ad libitum-fed controls received vehicle only (n = 10). Offspring brain weight and histological indices of brain injury were assessed at term and 5-months postnatally. At term, maternal nutrient restriction reduced fetal brain weight and increased microglial ramification in all brain regions but did not alter indices of cell death, astrogliosis or myelination. Ad.VEGF-A165 increased brain weight and reduced microglial ramification in fetuses of nutrient restricted dams. In adult offspring, maternal nutrient restriction did not alter brain weight or markers of brain injury, whilst Ad.VEGF-A165 increased microglial ramification and astrogliosis in the hippocampus and thalamus, respectively. Ad.VEGF-A165 did not affect cell death or myelination in the fetal or offspring brain. Ad.VEGF-A165 normalises brain growth and markers of brain injury in guinea pig fetuses exposed to maternal nutrient restriction and may be a potential intervention to improve childhood neurodevelopmental outcomes in pregnancies complicated by FGR.
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Affiliation(s)
- M D Hristova
- Elizabeth Garrett Anderson Institute for Women's Health, 86-96 Chenies Mews, University College London, London, WC1E 6HX, UK
| | - T Krishnan
- Elizabeth Garrett Anderson Institute for Women's Health, 86-96 Chenies Mews, University College London, London, WC1E 6HX, UK
| | - C A Rossi
- Elizabeth Garrett Anderson Institute for Women's Health, 86-96 Chenies Mews, University College London, London, WC1E 6HX, UK
| | - J Nouza
- Elizabeth Garrett Anderson Institute for Women's Health, 86-96 Chenies Mews, University College London, London, WC1E 6HX, UK
| | - A White
- Biological Services Unit, Royal Veterinary College, London, UK
| | - D M Peebles
- Elizabeth Garrett Anderson Institute for Women's Health, 86-96 Chenies Mews, University College London, London, WC1E 6HX, UK
| | - N J Sebire
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - I C Zachary
- Centre for Cardiovascular Biology and Medicine, Division of Medicine, University College London, London, UK
| | - A L David
- Elizabeth Garrett Anderson Institute for Women's Health, 86-96 Chenies Mews, University College London, London, WC1E 6HX, UK
| | - O R Vaughan
- Elizabeth Garrett Anderson Institute for Women's Health, 86-96 Chenies Mews, University College London, London, WC1E 6HX, UK.
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2
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Nair S, Ormazabal V, Carrion F, Handberg A, McIntyre H, Salomon C. Extracellular vesicle-mediated targeting strategies for long-term health benefits in gestational diabetes. Clin Sci (Lond) 2023; 137:1311-1332. [PMID: 37650554 PMCID: PMC10472199 DOI: 10.1042/cs20220150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/23/2023] [Accepted: 08/09/2023] [Indexed: 09/01/2023]
Abstract
Extracellular vesicles (EVs) are critical mediators of cell communication, playing important roles in regulating molecular cross-talk between different metabolic tissues and influencing insulin sensitivity in both healthy and gestational diabetes mellitus (GDM) pregnancies. The ability of EVs to transfer molecular cargo between cells imbues them with potential as therapeutic agents. During pregnancy, the placenta assumes a vital role in metabolic regulation, with multiple mechanisms of placenta-mediated EV cross-talk serving as central components in GDM pathophysiology. This review focuses on the role of the placenta in the pathophysiology of GDM and explores the possibilities and prospects of targeting the placenta to address insulin resistance and placental dysfunction in GDM. Additionally, we propose the use of EVs as a novel method for targeted therapeutics in treating the dysfunctional placenta. The primary aim of this review is to comprehend the current status of EV targeting approaches and assess the potential application of these strategies in placental therapeutics, thereby delivering molecular cargo and improving maternal and fetal outcomes in GDM. We propose that EVs have the potential to revolutionize GDM management, offering hope for enhanced maternal-fetal health outcomes and more effective treatments.
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Affiliation(s)
- Soumyalekshmi Nair
- Translational Extracellular Vesicle in Obstetrics and Gynae-Oncology Group, UQ Centre for Clinical Research, Royal Brisbane and Women's Hospital, Faculty of Medicine, The University of Queensland, Australia
| | - Valeska Ormazabal
- Department of Pharmacology, Faculty of Biological Sciences, University of Concepcion, Concepción, Chile
| | - Flavio Carrion
- Departamento de Investigación, Postgrado y Educación Continua (DIPEC), Facultad de Ciencias de la Salud, Universidad del Alba, Santiago, Chile
| | - Aase Handberg
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | - H David McIntyre
- Mater Research, Faculty of Medicine, University of Queensland, Mater Health, South Brisbane, Australia
| | - Carlos Salomon
- Translational Extracellular Vesicle in Obstetrics and Gynae-Oncology Group, UQ Centre for Clinical Research, Royal Brisbane and Women's Hospital, Faculty of Medicine, The University of Queensland, Australia
- Departamento de Investigación, Postgrado y Educación Continua (DIPEC), Facultad de Ciencias de la Salud, Universidad del Alba, Santiago, Chile
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3
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Swingle KL, Safford HC, Geisler HC, Hamilton AG, Thatte AS, Billingsley MM, Joseph RA, Mrksich K, Padilla MS, Ghalsasi AA, Alameh MG, Weissman D, Mitchell MJ. Ionizable Lipid Nanoparticles for In Vivo mRNA Delivery to the Placenta during Pregnancy. J Am Chem Soc 2023; 145:4691-4706. [PMID: 36789893 PMCID: PMC9992266 DOI: 10.1021/jacs.2c12893] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Ionizable lipid nanoparticles (LNPs) are the most clinically advanced nonviral platform for mRNA delivery. While they have been explored for applications including vaccines and gene editing, LNPs have not been investigated for placental insufficiency during pregnancy. Placental insufficiency is caused by inadequate blood flow in the placenta, which results in increased maternal blood pressure and restricted fetal growth. Therefore, improving vasodilation in the placenta can benefit both maternal and fetal health. Here, we engineered ionizable LNPs for mRNA delivery to the placenta with applications in mediating placental vasodilation. We designed a library of ionizable lipids to formulate LNPs for mRNA delivery to placental cells and identified a lead LNP that enables in vivo mRNA delivery to trophoblasts, endothelial cells, and immune cells in the placenta. Delivery of this top LNP formulation encapsulated with VEGF-A mRNA engendered placental vasodilation, demonstrating the potential of mRNA LNPs for protein replacement therapy during pregnancy to treat placental disorders.
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Affiliation(s)
- Kelsey L Swingle
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Hannah C Safford
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Hannah C Geisler
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Alex G Hamilton
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Ajay S Thatte
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Margaret M Billingsley
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Ryann A Joseph
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Kaitlin Mrksich
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Marshall S Padilla
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Aditi A Ghalsasi
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Mohamad-Gabriel Alameh
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States.,Penn Institute for RNA Innovation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Drew Weissman
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States.,Penn Institute for RNA Innovation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Michael J Mitchell
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States.,Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States.,Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States.,Institute for Regenerative Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States.,Penn Institute for RNA Innovation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
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4
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Davenport BN, Wilson RL, Jones HN. Interventions for placental insufficiency and fetal growth restriction. Placenta 2022; 125:4-9. [PMID: 35414477 PMCID: PMC10947607 DOI: 10.1016/j.placenta.2022.03.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/09/2022] [Accepted: 03/28/2022] [Indexed: 01/16/2023]
Abstract
Pregnancy complications adversely impact both mother and/or fetus throughout the lifespan. Fetal growth restriction (FGR) occurs when a fetus fails to reach their intrauterine potential for growth, it is the second highest leading cause of infant mortality, and leads to increased risk of developing non-communicable diseases in later life due 'fetal programming'. Abnormal placental development, growth and/or function underlies approximately 75% of FGR cases and there is currently no treatment save delivery, often prematurely. We previously demonstrated in a murine model of FGR that nanoparticle mediated, intra-placental human IGF-1 gene therapy maintains normal fetal growth. Multiple models of FGR currently exist reflecting the etiologies of human FGR and have been used by us and others to investigate the development of in utero therapeutics as discussed here. In addition to the in vivo models discussed herein, utilizing human models including in vitro (Choriocarcinoma cell lines and primary trophoblasts) and ex vivo (term villous fragments and placenta cotyledon perfusion) we have demonstrated robust nanoparticle uptake, transgene expression, nutrient transporter regulation without transfer to the fetus. For translational gene therapy application in the human placenta, there are multiple avenues that require investigation including syncytial uptake from the maternal circulation, transgene expression, functionality and longevity of treatment, impact of treatment on the mother and developing fetus. The potential impact of treating the placenta during gestation is high, wide-ranging across pregnancy complications, and may offer reduced risk of developing associated cardio-metabolic diseases in later life impacting at both an individual and societal level.
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Affiliation(s)
- Baylea N Davenport
- Center for Research in Perinatal Outcomes, University of Florida College of Medicine, United States
| | - Rebecca L Wilson
- Center for Research in Perinatal Outcomes, University of Florida College of Medicine, United States
| | - Helen N Jones
- Center for Research in Perinatal Outcomes, University of Florida College of Medicine, United States.
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Chevillard PM, Batailler M, Piégu B, Estienne A, Blache MC, Dubois JP, Pillon D, Vaudin P, Dupont J, Just N, Migaud M. Seasonal vascular plasticity in the mediobasal hypothalamus of the adult ewe. Histochem Cell Biol 2022; 157:581-593. [PMID: 35118552 DOI: 10.1007/s00418-022-02079-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 12/16/2022]
Abstract
Sheep, like most seasonal mammals, exhibit a cyclic adaptive reproductive physiology that allows ewes to give birth to their progeny during the spring when environmental conditions are favorable to their survival. This process relies on the detection of day length (or photoperiod) and is associated with profound changes in cellular plasticity and gene expression in the hypothalamic-pituitary-gonadal axis, mechanisms that are suggested to participate in the seasonal adaptation of neuroendocrine circuits. Recently, pituitary vascular growth has been proposed as a seasonally regulated process in which the vascular endothelial growth factor A (VEGFA), a well-known angiogenic cytokine, is suspected to play a crucial role. However, whether this mechanism is restricted to the pituitary gland or also occurs in the mediobasal hypothalamus (MBH), a crucial contributor to the control of the reproductive function, remains unexplored. Using newly developed image analysis tools, we showed that the arcuate nucleus (ARH) of the MBH exhibits an enhanced vascular density during the long photoperiod or non-breeding season, associated with higher expression of VEGFA. In the median eminence (ME), a structure connecting the MBH to the pituitary gland, higher VEGFA, kinase insert domain receptor (KDR/VEGFR2) and plasmalemma vesicle-associated protein (PLVAP) gene expressions were detected during the long photoperiod. We also found that VEGFA and its receptor, VEGFR2, are expressed by neurons and tanycytes in both the ARH and ME. Altogether, these data show variations in the MBH vasculature according to seasons potentially through a VEGFA-dependent pathway, paving the way for future studies aiming to decipher the role of these changes in the hypothalamic control of seasonal reproduction.
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Affiliation(s)
- Pierre-Marie Chevillard
- Physiologie de la Reproduction et des Comportements PRC Centre INRAE Val de Loire, CNRS, IFCE, INRAE, Université de Tours, 37380, Nouzilly, France
| | - Martine Batailler
- Physiologie de la Reproduction et des Comportements PRC Centre INRAE Val de Loire, CNRS, IFCE, INRAE, Université de Tours, 37380, Nouzilly, France
| | - Benoît Piégu
- Physiologie de la Reproduction et des Comportements PRC Centre INRAE Val de Loire, CNRS, IFCE, INRAE, Université de Tours, 37380, Nouzilly, France
| | - Anthony Estienne
- Physiologie de la Reproduction et des Comportements PRC Centre INRAE Val de Loire, CNRS, IFCE, INRAE, Université de Tours, 37380, Nouzilly, France
| | - Marie-Claire Blache
- Physiologie de la Reproduction et des Comportements PRC Centre INRAE Val de Loire, CNRS, IFCE, INRAE, Université de Tours, 37380, Nouzilly, France
| | - Jean-Philippe Dubois
- Physiologie de la Reproduction et des Comportements PRC Centre INRAE Val de Loire, CNRS, IFCE, INRAE, Université de Tours, 37380, Nouzilly, France
| | - Delphine Pillon
- Physiologie de la Reproduction et des Comportements PRC Centre INRAE Val de Loire, CNRS, IFCE, INRAE, Université de Tours, 37380, Nouzilly, France
| | - Pascal Vaudin
- Physiologie de la Reproduction et des Comportements PRC Centre INRAE Val de Loire, CNRS, IFCE, INRAE, Université de Tours, 37380, Nouzilly, France
| | - Joëlle Dupont
- Physiologie de la Reproduction et des Comportements PRC Centre INRAE Val de Loire, CNRS, IFCE, INRAE, Université de Tours, 37380, Nouzilly, France
| | - Nathalie Just
- Physiologie de la Reproduction et des Comportements PRC Centre INRAE Val de Loire, CNRS, IFCE, INRAE, Université de Tours, 37380, Nouzilly, France
| | - Martine Migaud
- Physiologie de la Reproduction et des Comportements PRC Centre INRAE Val de Loire, CNRS, IFCE, INRAE, Université de Tours, 37380, Nouzilly, France.
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6
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Pepe GJ, Albrecht ED. Novel Technologies for Target Delivery of Therapeutics to the Placenta during Pregnancy: A Review. Genes (Basel) 2021; 12:1255. [PMID: 34440429 PMCID: PMC8392549 DOI: 10.3390/genes12081255] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
Uterine spiral artery remodeling is essential for placental perfusion and fetal growth and, when impaired, results in placental ischemia and pregnancy complications, e.g., fetal growth restriction, preeclampsia, premature birth. Despite the high incidence of adverse pregnancies, current treatment options are limited. Accordingly, research has shifted to the development of gene therapy technologies that provide targeted delivery of "payloads" to the placenta while limiting maternal and fetal exposure. This review describes the current strategies, including placental targeting peptide-bound liposomes, nanoparticle or adenovirus constructs decorated with specific peptide sequences and placental gene promoters delivered via maternal IV injection, directly into the placenta or the uterine artery, as well as noninvasive site-selective targeting of regulating genes conjugated with microbubbles via contrast-enhanced ultrasound. The review also provides a perspective on the effectiveness of these technologies in various animal models and their practicability and potential use for targeted placental delivery of therapeutics and genes in adverse human pregnancies affected by placental dysfunction.
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Affiliation(s)
- Gerald J. Pepe
- Department of Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA 23507, USA;
| | - Eugene D. Albrecht
- Departments of Obstetrics/Gynecology/Reproductive Sciences and Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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7
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Hu X, Zhang L. Uteroplacental Circulation in Normal Pregnancy and Preeclampsia: Functional Adaptation and Maladaptation. Int J Mol Sci 2021; 22:8622. [PMID: 34445328 PMCID: PMC8395300 DOI: 10.3390/ijms22168622] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/04/2021] [Accepted: 08/09/2021] [Indexed: 02/07/2023] Open
Abstract
Uteroplacental blood flow increases as pregnancy advances. Adequate supply of nutrients and oxygen carried by uteroplacental blood flow is essential for the well-being of the mother and growth/development of the fetus. The uteroplacental hemodynamic change is accomplished primarily through uterine vascular adaptation, involving hormonal regulation of myogenic tone, vasoreactivity, release of vasoactive factors and others, in addition to the remodeling of spiral arteries. In preeclampsia, hormonal and angiogenic imbalance, proinflammatory cytokines and autoantibodies cause dysfunction of both endothelium and vascular smooth muscle cells of the uteroplacental vasculature. Consequently, the vascular dysfunction leads to increased vascular resistance and reduced blood flow in the uteroplacental circulation. In this article, the (mal)adaptation of uteroplacental vascular function in normal pregnancy and preeclampsia and underlying mechanisms are reviewed.
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Affiliation(s)
- Xiangqun Hu
- Lawrence D. Longo, MD Center for Perinatal Biology, Department of Basic Sciences, School of Medicine, Loma Linda University, Loma Linda, CA 92350, USA
| | - Lubo Zhang
- Lawrence D. Longo, MD Center for Perinatal Biology, Department of Basic Sciences, School of Medicine, Loma Linda University, Loma Linda, CA 92350, USA
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8
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Yang W, Li Q, Duncan JW, Bakrania BA, Bradshaw JL, Granger JP, Rana S, Spradley FT. Luteolin-induced vasorelaxation in uterine arteries from normal pregnant rats. Pregnancy Hypertens 2020; 23:11-17. [PMID: 33161224 DOI: 10.1016/j.preghy.2020.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The flavonoid, luteolin, promotes vasorelaxation in various arteries through endothelial-dependent and independent mechanisms. Although there is growing interest in the vasoactive effects of flavonoids on maternal vascular function during pregnancy, it is unknown whether luteolin elicits vasorelaxation in the uterine circulation. We tested the hypothesis that luteolin induces vasorelaxation via endothelial-dependent mechanisms in uterine arteries from normal pregnant rats during late gestation. METHODS Uterine arteries and aortas were isolated from Sprague-Dawley rats at gestational day 19 and prepared for wire myography. RESULTS The potency of luteolin-induced vasorelaxation was examined between uterine arteries and the aortas. By 50 µM of luteolin, there was complete relaxation (100.5 ± 5.2%) in uterine arteries as compared to aortas (27.5 ± 10.0%). Even the highest concentration of 100 µM luteolin produced less than half relaxation (43.6 ± 8.6%) in aortas compared to uterine arteries. We then explored if luteolin-induced vasorelaxation in uterine arteries from pregnant rats was mediated by endothelial-dependent vasorelaxation pathways, including nitric oxide synthase (NOS), cyclooxygenase (COX), or potassium (K+) channels. Blocking these pathways with N(G)-Nitro-l-arginine methyl ester hydrochloride (L-NAME), indomethacin, or tetraethylammonium (TEA)/high potassium chloride (KCl), respectively, did not alter luteolin responses in uterine arteries from pregnant rats. These findings suggested that endothelial factors may not mediate luteolin-induced vasorelaxation in uterine arteries during pregnancy. Indeed, experiments where the endothelium was removed did not alter luteolin-induced vasorelaxation in uterine arteries during pregnancy. CONCLUSIONS Luteolin directly promotes vasorelaxation in the medial smooth muscle layer of uterine arteries during normal pregnancy.
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Affiliation(s)
- Weiwei Yang
- School of Biosciences, Weifang Medical University, Weifang 261053, China; Department of Physiology and Biophysics, The University of Mississippi Medical Center, Jackson, MS 39216, United States
| | - Qinghua Li
- School of Public Health and Management, Weifang Medical University, Weifang 261053, China; Department of Physiology and Biophysics, The University of Mississippi Medical Center, Jackson, MS 39216, United States
| | - Jeremy W Duncan
- Department of Physiology and Biophysics, The University of Mississippi Medical Center, Jackson, MS 39216, United States
| | - Bhavisha A Bakrania
- Department of Physiology and Biophysics, The University of Mississippi Medical Center, Jackson, MS 39216, United States
| | - Jessica L Bradshaw
- Department of Physiology and Biophysics, The University of Mississippi Medical Center, Jackson, MS 39216, United States
| | - Joey P Granger
- Department of Physiology and Biophysics, The University of Mississippi Medical Center, Jackson, MS 39216, United States
| | - Sarosh Rana
- Department of Obstetrics and Gynecology, The University of Chicago, Chicago, IL 60637, United States.
| | - Frank T Spradley
- Department of Physiology and Biophysics, The University of Mississippi Medical Center, Jackson, MS 39216, United States; Department of Surgery, The University of Mississippi Medical Center, Jackson, MS 39216, United States
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Rossi C, Lees M, Mehta V, Heikura T, Martin J, Zachary I, Spencer R, Peebles DM, Shaw R, Karhinen M, Yla-Herttuala S, David AL. Comparison of Efficiency and Function of Vascular Endothelial Growth Factor Adenovirus Vectors in Endothelial Cells for Gene Therapy of Placental Insufficiency. Hum Gene Ther 2020; 31:1190-1202. [PMID: 32988220 PMCID: PMC7698978 DOI: 10.1089/hum.2020.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 06/25/2020] [Indexed: 12/13/2022] Open
Abstract
Severe fetal growth restriction (FGR) affects 1:500 pregnancies, is untreatable and causes serious neonatal morbidity and death. Reduced uterine blood flow (UBF) and lack of bioavailable VEGF due to placental insufficiency is a major cause. Transduction of uterine arteries in normal or FGR sheep and guinea pigs using an adenovirus (Ad) encoding VEGF isoforms A (Ad.VEGF-A165) and a FLAG-tagged pre-processed short form D (DΔNΔC, Ad.VEGF-DΔNΔC-FLAG) increases endothelial nitric oxide expression, enhances relaxation and reduces constriction of the uterine arteries and their branches. UBF and angiogenesis are increased long term, improving fetal growth in utero. For clinical trial development we compared Ad.VEGF vector transduction efficiency and function in endothelial cells (ECs) derived from different species. We aimed to compare the transduction efficiency and function of the pre-clinical study Ad. constructs (Ad.VEGF-A165, Ad.VEGF-DΔNΔC-FLAG) with the intended clinical trial construct (Ad.VEGF-DΔNΔC) where the FLAG tag is removed. We infected ECs from human umbilical vein, pregnant sheep uterine artery, pregnant guinea pig aorta and non-pregnant rabbit aorta, with increasing multiplicity of infection (MOI) for 24 or 48 hours of three Ad.VEGF vectors, compared to control Ad. containing the LacZ gene (Ad.LacZ). VEGF supernatant expression was analysed by ELISA. Functional assessment used tube formation assay and Erk-Akt phosphorylation by ELISA. VEGF expression was higher after Ad.VEGF-DΔNΔC-FLAG and Ad.VEGF-DΔNΔC transduction compared to Ad.VEGF-A165 in all EC types (*p < 0.001). Tube formation was higher in ECs transduced with Ad.VEGF-DΔNΔC in all species compared to other constructs (***p < 0.001, *p < 0.05 with rabbit aortic ECs). Phospho-Erk and phospho-Akt assays displayed no differences between the three vector constructs, whose effect was, as in other experiments, higher than Ad.LacZ (***p < 0.001). In conclusion, we observed high transduction efficiency and functional effects of Ad.VEGF-DΔNΔC vector with comparability in major pathway activation to constructs used in pre-clinical studies, supporting its use in a clinical trial.
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Affiliation(s)
- Carlo Rossi
- Elizabeth Garrett Anderson Institute for Women's Health
- Centre for Cardiovascular Biology and Medicine; University College London, London, United Kingdom
| | - Mark Lees
- Elizabeth Garrett Anderson Institute for Women's Health
- Centre for Cardiovascular Biology and Medicine; University College London, London, United Kingdom
| | - Vedanta Mehta
- Centre for Cardiovascular Biology and Medicine; University College London, London, United Kingdom
| | - Tommi Heikura
- A.I.Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - John Martin
- Centre for Cardiovascular Biology and Medicine; University College London, London, United Kingdom
| | - Ian Zachary
- Centre for Cardiovascular Biology and Medicine; University College London, London, United Kingdom
| | | | | | | | | | - Seppo Yla-Herttuala
- A.I.Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
- Heart Center and Gene Therapy Unit, Kuopio University Hospital, Kuopio, Finland
| | - Anna L. David
- Elizabeth Garrett Anderson Institute for Women's Health
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10
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Ganguly E, Hula N, Spaans F, Cooke CLM, Davidge ST. Placenta-targeted treatment strategies: An opportunity to impact fetal development and improve offspring health later in life. Pharmacol Res 2020; 157:104836. [PMID: 32344051 DOI: 10.1016/j.phrs.2020.104836] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/26/2020] [Accepted: 04/13/2020] [Indexed: 01/06/2023]
Abstract
The Developmental Origins of Health and Disease (DOHaD) theory states that a sub-optimal prenatal and early postnatal environment during development leads to an increased risk of long-term development of adult chronic diseases. Developmental programming of disease has the potential to greatly impact the health of our population. Therefore, research has focused on the development of primary treatment strategies and/or therapeutic interventions for individuals who are at increased risk, with the objective to reverse or prevent later life onset of chronic disease in the offspring born from complicated pregnancies. Many studies have focused on systemic treatments and/or interventions in complicated pregnancies to improve offspring outcomes. However, there are limitations to systemic maternal/prenatal treatments, as most of the treatments are able to cross the placenta and have potential adverse off-target effects on the developing fetus. The placenta serves as the primary interface between mother and fetus, and placental dysfunction in complicated pregnancies has been associated with impaired fetal development and negative impact on offspring health. Therefore, recent research has focused on treatment strategies that specifically target the placenta to improve placental function and prevent passage of prenatal therapeutics and/or treatments into the fetal circulation, thus avoiding any potential adverse off-target effects on the fetus. This article reviews the currently available knowledge on treatment strategies and/or therapeutics that specifically target the placenta with the goal of improving pregnancy outcomes with a focus on long-term health of the offspring born of complicated pregnancies.
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Affiliation(s)
- Esha Ganguly
- Department of Physiology, University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynaecology, University of Alberta, Edmonton, Canada; Women and Children's Health Research Institute, University of Alberta, Edmonton, Canada
| | - Nataliia Hula
- Department of Physiology, University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynaecology, University of Alberta, Edmonton, Canada; Women and Children's Health Research Institute, University of Alberta, Edmonton, Canada
| | - Floor Spaans
- Department of Obstetrics and Gynaecology, University of Alberta, Edmonton, Canada; Women and Children's Health Research Institute, University of Alberta, Edmonton, Canada
| | - Christy-Lynn M Cooke
- Department of Obstetrics and Gynaecology, University of Alberta, Edmonton, Canada; Women and Children's Health Research Institute, University of Alberta, Edmonton, Canada
| | - Sandra T Davidge
- Department of Physiology, University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynaecology, University of Alberta, Edmonton, Canada; Women and Children's Health Research Institute, University of Alberta, Edmonton, Canada.
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11
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Placental Origins of Preeclampsia: Potential Therapeutic Targets. Curr Med Sci 2019; 39:190-195. [PMID: 31016509 DOI: 10.1007/s11596-019-2018-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 02/24/2019] [Indexed: 02/06/2023]
Abstract
Preeclampsia (PE) remains a leading cause of maternal and perinatal morbidity and mortality in obstetrics worldwide. No effective treatments to reduce its incidence and severity in clinical practice are currently available. A variety of hypotheses have been generated aiming to explain the origins of PE, notably being the genetic predispositions and placental dysfunction. As regard to placental dysfunction, much progress has been made in basic research and several potential therapeutic targets have been identified. This review will discuss in detail the potential therapeutic targets in PE models including uteroplacental blood flow, oxidative stress, vasoactive factors and inflammation/immune response, and introduce the evolving technologies for placental research nowadays.
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12
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Spencer R, Rossi C, Lees M, Peebles D, Brocklehurst P, Martin J, Hansson SR, Hecher K, Marsal K, Figueras F, Gratacos E, David AL. Achieving orphan designation for placental insufficiency: annual incidence estimations in Europe. BJOG 2019; 126:1157-1167. [DOI: 10.1111/1471-0528.15590] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2018] [Indexed: 01/17/2023]
Affiliation(s)
- R Spencer
- Institute for Women's Health University College London London UK
| | - C Rossi
- Institute for Women's Health University College London London UK
| | - M Lees
- Institute for Women's Health University College London and Magnus Life Science London UK
| | - D Peebles
- Institute for Women's Health University College London London UK
| | - P Brocklehurst
- Birmingham Clinical Trials Unit University of Birmingham Birmingham UK
| | - J Martin
- Centre for Cardiovascular Biology and Medicine University College London London UK
| | - SR Hansson
- Department of Obstetrics and Gynecology Institute of Clinical Sciences Skane University Hospital Lund University Lund Sweden
| | - K Hecher
- Department of Obstetrics and Fetal Medicine University Medical Centre Hamburg‐Eppendorf Hamburg Germany
| | - K Marsal
- Department of Obstetrics and Gynecology Institute of Clinical Sciences Skane University Hospital Lund University Lund Sweden
| | - F Figueras
- BCNatal Hospital Clinic and Hospital Sant Joan de Deu CIBERER and IDIBAPS University of Barcelona Barcelona Spain
| | - E Gratacos
- BCNatal Hospital Clinic and Hospital Sant Joan de Deu CIBERER and IDIBAPS University of Barcelona Barcelona Spain
| | - AL David
- Institute for Women's Health University College London London UK
- NIHR University College London Hospitals Biomedical Research Centre London UK
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13
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Malhotra A, Allison BJ, Castillo-Melendez M, Jenkin G, Polglase GR, Miller SL. Neonatal Morbidities of Fetal Growth Restriction: Pathophysiology and Impact. Front Endocrinol (Lausanne) 2019; 10:55. [PMID: 30792696 PMCID: PMC6374308 DOI: 10.3389/fendo.2019.00055] [Citation(s) in RCA: 203] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/22/2019] [Indexed: 12/11/2022] Open
Abstract
Being born small lays the foundation for short-term and long-term implications for life. Intrauterine or fetal growth restriction describes the pregnancy complication of pathological reduced fetal growth, leading to significant perinatal mortality and morbidity, and subsequent long-term deficits. Placental insufficiency is the principal cause of FGR, which in turn underlies a chronic undersupply of oxygen and nutrients to the fetus. The neonatal morbidities associated with FGR depend on the timing of onset of placental dysfunction and growth restriction, its severity, and the gestation at birth of the infant. In this review, we explore the pathophysiological mechanisms involved in the development of major neonatal morbidities in FGR, and their impact on the health of the infant. Fetal cardiovascular adaptation and altered organ development during gestation are principal contributors to postnatal consequences of FGR. Clinical presentation, diagnostic tools and management strategies of neonatal morbidities are presented. We also present information on the current status of targeted therapies. A better understanding of neonatal morbidities associated with FGR will enable early neonatal detection, monitoring and management of potential adverse outcomes in the newborn period and beyond.
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Affiliation(s)
- Atul Malhotra
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- *Correspondence: Atul Malhotra
| | - Beth J. Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Margie Castillo-Melendez
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Graeme R. Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Suzanne L. Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
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14
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Vaughan OR, Rossi CA, Ginsberg Y, White A, Hristova M, Sebire NJ, Martin J, Zachary IC, Peebles DM, David AL. Perinatal and long-term effects of maternal uterine artery adenoviral VEGF-A165 gene therapy in the growth-restricted guinea pig fetus. Am J Physiol Regul Integr Comp Physiol 2018; 315:R344-R353. [PMID: 29847165 DOI: 10.1152/ajpregu.00210.2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Uterine artery application of adenoviral vascular endothelial growth factor A165 (Ad.VEGF-A165) gene therapy increases uterine blood flow and fetal growth in experimental animals with fetal growth restriction (FGR). Whether Ad.VEGF-A165 reduces lifelong cardiovascular disease risk imposed by FGR remains unknown. Here, pregnant guinea pigs fed 70% normal food intake to induce FGR received Ad.VEGF-A165 (1×1010 viral particles, n = 15) or vehicle ( n = 10), delivered to the external surface of the uterine arteries, in midpregnancy. Ad libitum-fed controls received vehicle only ( n = 14). Litter size, gestation length, and perinatal mortality were similar in control, untreated FGR, and FGR+Ad.VEGF-A165 animals. When compared with controls, birth weight was lower in male but higher in female pups following maternal nutrient restriction, whereas both male and female FGR+Ad.VEGF-A165 pups were heavier than untreated FGR pups ( P < 0.05, ANOVA). Postnatal weight gain was 10-20% greater in female FGR+Ad.VEGF-A165 than in untreated FGR pups, depending on age, although neither group differed from controls. Maternal nutrient restriction reduced heart weight in adult female offspring irrespective of Ad.VEGF-A165 treatment but did not alter ventricular wall thickness. In males, postnatal weight gain and heart morphology were not affected by maternal treatment. Neither systolic, diastolic, mean arterial pressure, adrenal weight, nor basal or challenged plasma cortisol were affected by maternal undernutrition or Ad.VEGF-A165 in either sex. Therefore, increased fetal growth conferred by maternal uterine artery Ad.VEGF-A165 is sustained postnatally in FGR female guinea pigs. In this study, we did not find evidence for an effect of maternal nutrient restriction or Ad.VEGF-A165 therapy on adult offspring blood pressure.
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Affiliation(s)
- O R Vaughan
- Department of Maternal and Fetal Medicine, Institute for Women's Health, University College London , London , United Kingdom
| | - C A Rossi
- Department of Maternal and Fetal Medicine, Institute for Women's Health, University College London , London , United Kingdom
| | - Y Ginsberg
- Department of Maternal and Fetal Medicine, Institute for Women's Health, University College London , London , United Kingdom
| | - A White
- Department of Maternal and Fetal Medicine, Institute for Women's Health, University College London , London , United Kingdom
| | - M Hristova
- Department of Maternal and Fetal Medicine, Institute for Women's Health, University College London , London , United Kingdom
| | - N J Sebire
- Department of Maternal and Fetal Medicine, Institute for Women's Health, University College London , London , United Kingdom
| | - J Martin
- Department of Maternal and Fetal Medicine, Institute for Women's Health, University College London , London , United Kingdom
| | - I C Zachary
- Department of Maternal and Fetal Medicine, Institute for Women's Health, University College London , London , United Kingdom
| | - D M Peebles
- Department of Maternal and Fetal Medicine, Institute for Women's Health, University College London , London , United Kingdom
| | - A L David
- Department of Maternal and Fetal Medicine, Institute for Women's Health, University College London , London , United Kingdom
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15
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Abstract
Fetal growth restriction (FGR) continues to be a leading cause of preventable stillbirth and poor neurodevelopmental outcomes in offspring, and furthermore is strongly associated with the obstetrical complications of iatrogenic preterm birth and pre-eclampsia. The terms small for gestational age (SGA) and FGR have, for too long, been considered equivalent and therefore used interchangeably. However, the delivery of improved clinical outcomes requires that clinicians effectively distinguish fetuses that are pathologically growth-restricted from those that are constitutively small. A greater understanding of the multifactorial pathogenesis of both early- and late-onset FGR, especially the role of underlying placental pathologies, may offer insight into targeted treatment strategies that preserve placental function. The new maternal blood biomarker placenta growth factor offers much potential in this context. This review highlights new approaches to effective screening for FGR based on a comprehensive review of: etiology, diagnosis, antenatal surveillance and management. Recent advances in novel imaging methods provide the basis for stepwise multi-parametric testing that may deliver cost-effective screening within existing antenatal care systems.
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16
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Desforges M, Rogue A, Pearson N, Rossi C, Olearo E, Forster R, Lees M, Sebire NJ, Greenwood SL, Sibley CP, David AL, Brownbill P. In Vitro Human Placental Studies to Support Adenovirus-Mediated VEGF-D ΔNΔC Maternal Gene Therapy for the Treatment of Severe Early-Onset Fetal Growth Restriction. HUM GENE THER CL DEV 2018; 29:10-23. [PMID: 29228803 DOI: 10.1089/humc.2017.090] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Severe fetal growth restriction (FGR) affects 1 in 500 pregnancies, is untreatable, and causes serious neonatal morbidity and death. Reduced uterine blood flow (UBF) is one cause. Transduction of uterine arteries in normal and FGR animal models using an adenovirus (Ad) encoding VEGF isoforms increases UBF and improves fetal growth in utero. Understanding potential adverse consequences of this therapy before first-in-woman clinical application is essential. The aims of this study were to determine whether Ad.VEGF-DΔNΔC (1) transfers across the human placental barrier and (2) affects human placental morphology, permeability and primary indicators of placental function, and trophoblast integrity. Villous explants from normal term human placentas were treated with Ad.VEGF-DΔNΔC (5 × 107-10 virus particles [vp]/mL), or virus formulation buffer (FB). Villous structural integrity (hematoxylin and eosin staining) and tissue accessibility (LacZ immunostaining) were determined. Markers of endocrine function (human chorionic gonadotropin [hCG] secretion) and cell death (lactate dehydrogenase [LDH] release) were assayed. Lobules from normal and FGR pregnancies underwent ex vivo dual perfusion with exposure to 5 × 1010 vp/mL Ad.VEGF-DΔNΔC or FB. Perfusion resistance, para-cellular permeability, hCG, alkaline phosphatase, and LDH release were measured. Ad.VEGF-DΔNΔC transfer across the placental barrier was assessed by quantitative polymerase chain reaction in DNA extracted from fetal-side venous perfusate, and by immunohistochemistry in fixed tissue. Villous explant structural integrity and hCG secretion was maintained at all Ad.VEGF-DΔNΔC doses. Ad.VEGF-DΔNΔC perfusion revealed no effect on placental permeability, fetoplacental vascular resistance, hCG secretion, or alkaline phosphatase release, but there was a minor elevation in maternal-side LDH release. Viral vector tissue access in both explant and perfused models was minimal, and the vector was rarely detected in the fetal venous perfusate and at low titer. Ad.VEGF-DΔNΔC did not markedly affect human placental integrity and function in vitro. There was limited tissue access and transfer of vector across the placental barrier. Except for a minor elevation in LDH release, these test data did not reveal any toxic effects of Ad.VEGF-DΔNΔC on the human placenta.
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Affiliation(s)
- Michelle Desforges
- 1 Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester , Manchester, United Kingdom .,2 St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust , Manchester Academic Health Science Centre, Manchester, United Kingdom
| | | | - Nick Pearson
- 4 Pharmaceutical Sciences, pRED, F Hoffmann-La Roche , Basel, Switzerland
| | - Carlo Rossi
- 5 Magnus Growth , London, United Kingdom .,6 Institute for Women's Health, University College London (UCL) , London, United Kingdom
| | - Elena Olearo
- 6 Institute for Women's Health, University College London (UCL) , London, United Kingdom
| | | | - Mark Lees
- 5 Magnus Growth , London, United Kingdom
| | - Neil J Sebire
- 7 Institute of Child Health, University College London (UCL) , London, United Kingdom
| | - Susan L Greenwood
- 1 Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester , Manchester, United Kingdom .,2 St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust , Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Colin P Sibley
- 1 Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester , Manchester, United Kingdom .,2 St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust , Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Anna L David
- 6 Institute for Women's Health, University College London (UCL) , London, United Kingdom
| | - Paul Brownbill
- 1 Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester , Manchester, United Kingdom .,2 St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust , Manchester Academic Health Science Centre, Manchester, United Kingdom
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17
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Nawathe A, David AL. Prophylaxis and treatment of foetal growth restriction. Best Pract Res Clin Obstet Gynaecol 2018; 49:66-78. [PMID: 29656983 DOI: 10.1016/j.bpobgyn.2018.02.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 02/13/2018] [Accepted: 02/15/2018] [Indexed: 02/07/2023]
Abstract
Foetal growth restriction (FGR) and associated placental pathologies such as pre-eclampsia and stillbirth arise in early pregnancy when inadequate remodelling of maternal spiral arteries leads to persistent high-resistance low-flow uteroplacental circulation. Current interventions concentrate on targeting the placental ischaemia-reperfusion injury and oxidative stress associated with an imbalance in angiogenic/anti-angiogenic factors. Recent meta-analyses confirm that aspirin modestly reduces the risk for small-for-gestational-age pregnancy in high-risk women. A dose of ≥100 mg starting by 16 weeks of gestation is recommended. In vitro and in vivo studies suggest that low-molecular-weight heparin may prevent FGR; further research is needed to confirm efficacy. Once FGR is diagnosed, no treatment will improve foetal growth. Potential FGR therapies such as phosphodiesterase type-5 inhibitors or maternal VEGF gene therapy aim to improve poor placentation and/or uterine blood flow. Melatonin, creatine and N-acetyl cysteine have potential as novel neuroprotective and cardioprotective agents in FGR.
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Affiliation(s)
- Aamod Nawathe
- Fetal Medicine Unit, University College London NHS Foundation Trust, 235 Euston Road, NW1 2BU, UK.
| | - Anna L David
- Research Department of Maternal Fetal Medicine, Institute for Women's Health, University College London, 86-96 Chenies Mews, London, WC1E 6HX, UK; NIHR University College London Hospitals Biomedical Research Centre, Research & Development, Maple House 1st Floor, 149 Tottenham Court Road, London, W1T 7DN, UK.
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18
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Groom KM, David AL. The role of aspirin, heparin, and other interventions in the prevention and treatment of fetal growth restriction. Am J Obstet Gynecol 2018; 218:S829-S840. [PMID: 29229321 DOI: 10.1016/j.ajog.2017.11.565] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 10/20/2017] [Accepted: 11/08/2017] [Indexed: 11/24/2022]
Abstract
Fetal growth restriction and related placental pathologies such as preeclampsia, stillbirth, and placental abruption are believed to arise in early pregnancy when inadequate remodeling of the maternal spiral arteries leads to persistent high-resistance and low-flow uteroplacental circulation. The consequent placental ischaemia, reperfusion injury, and oxidative stress are associated with an imbalance in angiogenic/antiangiogenic factors. Many interventions have centered on the prevention and/or treatment of preeclampsia with results pertaining to fetal growth restriction and small-for-gestational-age pregnancy often included as secondary outcomes because of the common pathophysiology. This renders the study findings less reliable for determining clinical significance. For the prevention of fetal growth restriction, a recent large-study level meta-analysis and individual patient data meta-analysis confirm that aspirin modestly reduces small-for-gestational-age pregnancy in women at high risk (relative risk, 0.90, 95% confidence interval, 0.81-1.00) and that a dose of ≥100 mg should be recommended and to start at or before 16 weeks of gestation. These findings support national clinical practice guidelines. In vitro and in vivo studies suggest that low-molecular-weight heparin may prevent fetal growth restriction; however, evidence from randomized control trials is inconsistent. A meta-analysis of multicenter trial data does not demonstrate any positive preventative effect of low-molecular-weight heparin on a primary composite outcome of placenta-mediated complications including fetal growth restriction (18% vs 18%; absolute risk difference, 0.6%; 95% confidence interval, 10.4-9.2); use of low-molecular-weight heparin for the prevention of fetal growth restriction should remain in the research setting. There are even fewer treatment options once fetal growth restriction is diagnosed. At present the only management option if the risk of hypoxia, acidosis, and intrauterine death is high is iatrogenic preterm birth, with the use of peripartum maternal administration of magnesium sulphate for neuroprotection and corticosteroids for fetal lung maturity, to prevent adverse neonatal outcomes. The pipeline of potential therapies use different strategies, many aiming to increase fetal growth by improving poor placentation and uterine blood flow. Phosphodiesterase type 5 inhibitors that potentiate nitric oxide availability such as sildenafil citrate have been extensively researched both in preclinical and clinical studies; results from the Sildenafil Therapy In Dismal Prognosis Early-Onset Intrauterine Growth Restriction consortium of randomized control clinical trials are keenly awaited. Targeting the uteroplacental circulation with novel therapeutics is another approach, the most advanced being maternal vascular endothelial growth factor gene therapy, which is being translated into the clinic via the doEs Vascular endothelial growth factor gene therapy safEly impRove outcome in seveRe Early-onset fetal growth reSTriction consortium. Other targeting approaches include nanoparticles and microRNAs to deliver drugs locally to the uterine arterial endothelium or trophoblast. In vitro and in vivo studies and animal models have demonstrated effects of nitric oxide donors, dietary nitrate, hydrogen sulphide donors, statins, and proton pump inhibitors on maternal blood pressure, uteroplacental resistance indices, and angiogenic/antiangiogenic factors. Data from human pregnancies and, in particular, pregnancies with fetal growth restriction remain very limited. Early research into melatonin, creatine, and N-acetyl cysteine supplementation in pregnancy suggests they may have potential as neuro- and cardioprotective agents in fetal growth restriction.
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19
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Logue OC, Mahdi F, Chapman H, George EM, Bidwell GL. A Maternally Sequestered, Biopolymer-Stabilized Vascular Endothelial Growth Factor (VEGF) Chimera for Treatment of Preeclampsia. J Am Heart Assoc 2017; 6:e007216. [PMID: 29629873 PMCID: PMC5779036 DOI: 10.1161/jaha.117.007216] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 10/30/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Preeclampsia is a hypertensive syndrome that complicates 3% to 5% of pregnancies in the United States. Preeclampsia originates from an improperly vascularized and ischemic placenta that releases factors that drive systemic pathophysiology. One of these factors, soluble fms-like tyrosine kinase-1, is believed to sequester vascular endothelial growth factor (VEGF), leading to systemic endothelial dysfunction and hypertension. With the goal of targeting soluble fms-like tyrosine kinase-1 while simultaneously preventing fetal exposure to VEGF, we fused VEGF to elastin-like polypeptide, a biopolymer carrier that does not cross the placental barrier (ELP-VEGF). METHODS AND RESULTS ELP-VEGF restored in vitro endothelial cell tube formation in the presence of plasma from placental ischemic rats. Long-term administered ELP-VEGF in pregnant rats accumulated in maternal kidneys, aorta, liver, and placenta, but the protein was undetectable in the pups when administered at therapeutic doses in dams. Long-term administration of ELP-VEGF in a placental ischemia rat model achieved dose-dependent attenuation of hypertension, with blood pressure equal to sham controls at a dose of 5 mg/kg per day. ELP-VEGF infusion increased total plasma soluble fms-like tyrosine kinase-1 levels but dramatically reduced free plasma soluble fms-like tyrosine kinase-1 and induced urinary excretion of nitrate/nitrite, indicating enhanced renal nitric oxide signaling. ELP-VEGF at up to 5 mg/kg per day had no deleterious effect on maternal or fetal body weight. However, dose-dependent adverse events were observed, including ascites production and neovascular tissue encapsulation around the minipump. CONCLUSIONS ELP-VEGF has the potential to treat the preeclampsia maternal syndrome, but careful dosing and optimization of the delivery route are necessary.
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Affiliation(s)
- Omar C Logue
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS
| | - Fakhri Mahdi
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS
| | - Heather Chapman
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS
| | - Eric M George
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS
- Department of Biochemistry, University of Mississippi Medical Center, Jackson, MS
| | - Gene L Bidwell
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS
- Department of Biochemistry, University of Mississippi Medical Center, Jackson, MS
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20
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Krishnan T, David AL. Placenta-directed gene therapy for fetal growth restriction. Semin Fetal Neonatal Med 2017; 22:415-422. [PMID: 28522033 DOI: 10.1016/j.siny.2017.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Fetal growth restriction (FGR) is a serious pregnancy complication affecting ∼8% of all pregnancies. There is no treatment to increase fetal growth in the uterus. Gene therapy presents a promising treatment strategy for FGR, with the use of adenoviral vectors encoding for proteins such as vascular endothelial growth factor (VEGF) and insulin-like growth factor demonstrating improvements in fetal growth, placental function, and neonatal outcome in preclinical studies. Safety assessments suggest no adverse risk to the mother or fetus for VEGF maternal gene therapy; a clinical trial is in development. This review assesses research into placenta-directed gene therapy for FGR, investigating the use of transgenes and vectors, their route of administration in obstetrics, and the steps that will be needed to take this treatment modality into the clinic.
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Affiliation(s)
- Tara Krishnan
- UCL Institute for Women's Health, University College London, London, United Kingdom.
| | - Anna L David
- Head of Research Department of Maternal Fetal Medicine at the Institute for Women's Health, University College London, United Kingdom
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21
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David AL. Maternal uterine artery VEGF gene therapy for treatment of intrauterine growth restriction. Placenta 2017; 59 Suppl 1:S44-S50. [DOI: 10.1016/j.placenta.2017.09.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/18/2017] [Accepted: 09/25/2017] [Indexed: 11/24/2022]
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22
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Boehmer BH, Limesand SW, Rozance PJ. The impact of IUGR on pancreatic islet development and β-cell function. J Endocrinol 2017; 235:R63-R76. [PMID: 28808079 PMCID: PMC5808569 DOI: 10.1530/joe-17-0076] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 08/10/2017] [Indexed: 12/14/2022]
Abstract
Placental insufficiency is a primary cause of intrauterine growth restriction (IUGR). IUGR increases the risk of developing type 2 diabetes mellitus (T2DM) throughout life, which indicates that insults from placental insufficiency impair β-cell development during the perinatal period because β-cells have a central role in the regulation of glucose tolerance. The severely IUGR fetal pancreas is characterized by smaller islets, less β-cells, and lower insulin secretion. Because of the important associations among impaired islet growth, β-cell dysfunction, impaired fetal growth, and the propensity for T2DM, significant progress has been made in understanding the pathophysiology of IUGR and programing events in the fetal endocrine pancreas. Animal models of IUGR replicate many of the observations in severe cases of human IUGR and allow us to refine our understanding of the pathophysiology of developmental and functional defects in islet from IUGR fetuses. Almost all models demonstrate a phenotype of progressive loss of β-cell mass and impaired β-cell function. This review will first provide evidence of impaired human islet development and β-cell function associated with IUGR and the impact on glucose homeostasis including the development of glucose intolerance and diabetes in adulthood. We then discuss evidence for the mechanisms regulating β-cell mass and insulin secretion in the IUGR fetus, including the role of hypoxia, catecholamines, nutrients, growth factors, and pancreatic vascularity. We focus on recent evidence from experimental interventions in established models of IUGR to understand better the pathophysiological mechanisms linking placental insufficiency with impaired islet development and β-cell function.
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Affiliation(s)
- Brit H Boehmer
- Department of PediatricsPerinatal Research Center, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sean W Limesand
- School of Animal and Comparative Biomedical SciencesUniversity of Arizona, Tucson, Arizona, USA
| | - Paul J Rozance
- Department of PediatricsPerinatal Research Center, University of Colorado School of Medicine, Aurora, Colorado, USA
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23
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Abstract
Placental dysfunction underlies major obstetric diseases such as pre-eclampsia and fetal growth restriction (FGR). Whilst there has been a little progress in prophylaxis, there are still no treatments for placental dysfunction in normal obstetric practice. However, a combination of increasingly well-described in vitro systems for studying the human placenta, together with the availability of more appropriate animal models of pre-eclampsia and FGR, has facilitated a recent surge in work aimed at repurposing drugs and therapies, developed for other conditions, as treatments for placental dysfunction. This review: (1) highlights potential candidate drug targets in the placenta - effectors of improved uteroplacental blood flow, anti-oxidants, heme oxygenase induction, inhibition of HIF, induction of cholesterol synthesis pathways, increasing insulin-like growth factor II availability; (2) proposes an experimental pathway for taking a potential drug or treatment for placental dysfunction from concept through to early phase clinical trials, utilizing techniques for studying the human placenta in vitro and small animal models, particularly the mouse, for in vivo studies; (3) describes the data underpinning sildenafil citrate and adenovirus expressing vascular endothelial growth as potential treatments for placental dysfunction and summarizes recent research on other potential treatments. The importance of sharing information from such studies even when no effect is found, or there is an adverse outcome, is highlighted. Finally, the use of adenoviral vectors or nanoparticle carriers coated with homing peptides to selectively target drugs to the placenta is highlighted: such delivery systems could improve efficacy and reduce the side effects of treating the dysfunctional placenta.
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Affiliation(s)
- Colin P Sibley
- Maternal and Fetal Health Research CentreDivision of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- St Mary's HospitalCentral Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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25
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Kellie FJ. Vasodilators for treating intrauterine growth restriction. Hippokratia 2017. [DOI: 10.1002/14651858.cd011978.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Frances J Kellie
- The University of Liverpool; Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health; First Floor, Liverpool Women's NHS Foundation Trust Crown Street Liverpool UK L8 7SS
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James JL, Chamley LW, Clark AR. Feeding Your Baby In Utero: How the Uteroplacental Circulation Impacts Pregnancy. Physiology (Bethesda) 2017; 32:234-245. [DOI: 10.1152/physiol.00033.2016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/20/2016] [Accepted: 12/22/2016] [Indexed: 11/22/2022] Open
Abstract
The utero-placental circulation links the maternal and fetal circulations during pregnancy, ensuring adequate gas and nutrient exchange, and consequently fetal growth. However, our understanding of this circulatory system remains incomplete. Here, we discuss how the utero-placental circulation is established, how it changes dynamically during pregnancy, and how this may impact on pregnancy success, highlighting how we may address knowledge gaps through advances in imaging and computational modeling approaches.
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Affiliation(s)
- Joanna L. James
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand; and
| | - Lawrence W. Chamley
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand; and
| | - Alys R. Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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Sulistyowati S, Bachnas MA, Anggraini ND, Yuliantara EE, Prabowo W, Anggraini NWP, Pramono MBA, Dachlan EG, Andonotopo W. Recombinant vascular endothelial growth factor 121 injection for the prevention of fetal growth restriction in a preeclampsia mouse model. J Perinat Med 2017; 45:245-251. [PMID: 27996960 DOI: 10.1515/jpm-2016-0149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 10/27/2016] [Indexed: 11/15/2022]
Abstract
AIM To discover the potential role of recombinant VEGF121 (rVEGF121) injection for the prevention of fetal growth restriction in a preeclampsia (PE) mouse model (Mus musculus). SUBJECTS AND METHODS This is an experimental study of 30 pregnant mice that were randomly divided into three groups: normal, PE, and PE with rVEGF121 injection. The PE mouse model was created by injecting anti Qa-2 10 ng iv, which is deleterious to Qa-2 expression (homologous to HLA-G), from the first to the fourth day of gestation. PE was validated by measuring serum levels of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor(PIGF) and also by kidney histopathology. Recombinant VEGF121 was given on the ninth day until the 11th day of pregnancy; mice were terminated on the 16th day. Fetal weights were acquired with a Denver analytical balance. Serum levels of sFlt-1 and PlGF were measured using enzyme-linked immunosorbent assay (ELISA). The data were statistically analyzed via analysis of variance (ANOVA). RESULTS On average, fetal birth weight was 0.7150 g in the normal group, 0.4936 g in the PE group, and 0.6768 g in the PE with rVEGF121 injection group. ANOVA showed significant growth restriction in the PE group (P=0.006), confirming the use of anti Qa-2 as a suitable PE model. Kidney histopathology results, sFlt-1 levels, and PlGF levels also demonstrated that anti Qa-2 consistently conferred hallmarks of PE in mice. Vascular endothelial growth factor (VEGF) injection prevented fetal growth restriction; comparable fetal weights were observed between the PE model with VEGF treatment and the normal group (P=0.610) but differed from the untreated PE group (P=0.021). CONCLUSIONS Injection of rVEGF121 has the potential to prevent fetal growth restriction in a newly proposed PE mouse model.
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Spencer R, Ambler G, Brodszki J, Diemert A, Figueras F, Gratacós E, Hansson SR, Hecher K, Huertas-Ceballos A, Marlow N, Marsál K, Morsing E, Peebles D, Rossi C, Sebire NJ, Timms JF, David AL. EVERREST prospective study: a 6-year prospective study to define the clinical and biological characteristics of pregnancies affected by severe early onset fetal growth restriction. BMC Pregnancy Childbirth 2017. [PMID: 28114884 DOI: 10.1186/s12884‐017‐1226‐7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fetal growth restriction (FGR) is a serious obstetric condition for which there is currently no treatment. The EVERREST Prospective Study has been designed to characterise the natural history of pregnancies affected by severe early onset FGR and establish a well phenotyped bio-bank. The findings will provide up-to-date information for clinicians and patients and inform the design and conduct of the EVERREST Clinical Trial: a phase I/IIa trial to assess the safety and efficacy of maternal vascular endothelial growth factor (VEGF) gene therapy in severe early onset FGR. Data and samples from the EVERREST Prospective Study will be used to identify ultrasound and/or biochemical markers of prognosis in pregnancies with an estimated fetal weight (EFW) <3rd centile between 20+0 and 26+6 weeks of gestation. METHODS This is a 6 year European multicentre prospective cohort study, recruiting women with a singleton pregnancy where the EFW is <3rd centile for gestational age and <600 g at 20+0 to 26+6 weeks of gestation. Detailed data are collected on: maternal history; antenatal, peripartum, and postnatal maternal complications; health economic impact; psychological impact; neonatal condition, progress and complications; and infant growth and neurodevelopment to 2 years of corrected age in surviving infants. Standardised longitudinal ultrasound measurements are performed, including: fetal biometry; uterine artery, umbilical artery, middle cerebral artery, and ductus venosus Doppler velocimetry; and uterine artery and umbilical vein volume blood flow. Samples of maternal blood and urine, amniotic fluid (if amniocentesis performed), placenta, umbilical cord blood, and placental bed (if caesarean delivery performed) are collected for bio-banking. An initial analysis of maternal blood samples at enrolment is planned to identify biochemical markers that are predictors for fetal or neonatal death. DISCUSSION The findings of the EVERREST Prospective Study will support the development of a novel therapy for severe early onset FGR by describing in detail the natural history of the disease and by identifying women whose pregnancies have the poorest outcomes, in whom a therapy might be most advantageous. The findings will also enable better counselling of couples with affected pregnancies, and provide a valuable resource for future research into the causes of FGR. TRIAL REGISTRATION NCT02097667 registered 31st October 2013.
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Affiliation(s)
- Rebecca Spencer
- Institute for Women's Health, University College London, London, UK. .,Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK.
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Jana Brodszki
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Anke Diemert
- Obstetrics and Fetal Medicine Unit, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Francesc Figueras
- BCNatal, Hospital Clinic and Hospital Sant Joan de Deu, University of Barcelona, CIBERER and IDIBAPS, Barcelona, Spain
| | - Eduard Gratacós
- BCNatal, Hospital Clinic and Hospital Sant Joan de Deu, University of Barcelona, CIBERER and IDIBAPS, Barcelona, Spain
| | - Stefan R Hansson
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Kurt Hecher
- Obstetrics and Fetal Medicine Unit, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Neil Marlow
- Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Karel Marsál
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Eva Morsing
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Donald Peebles
- Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | | | - Neil J Sebire
- Paediatric and Developmental Pathology, Great Ormond Street Hospital, London, UK
| | - John F Timms
- Institute for Women's Health, University College London, London, UK
| | - Anna L David
- Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK
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Spencer R, Ambler G, Brodszki J, Diemert A, Figueras F, Gratacós E, Hansson SR, Hecher K, Huertas-Ceballos A, Marlow N, Marsál K, Morsing E, Peebles D, Rossi C, Sebire NJ, Timms JF, David AL. EVERREST prospective study: a 6-year prospective study to define the clinical and biological characteristics of pregnancies affected by severe early onset fetal growth restriction. BMC Pregnancy Childbirth 2017; 17:43. [PMID: 28114884 PMCID: PMC5259830 DOI: 10.1186/s12884-017-1226-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 01/14/2017] [Indexed: 11/10/2022] Open
Abstract
Background Fetal growth restriction (FGR) is a serious obstetric condition for which there is currently no treatment. The EVERREST Prospective Study has been designed to characterise the natural history of pregnancies affected by severe early onset FGR and establish a well phenotyped bio-bank. The findings will provide up-to-date information for clinicians and patients and inform the design and conduct of the EVERREST Clinical Trial: a phase I/IIa trial to assess the safety and efficacy of maternal vascular endothelial growth factor (VEGF) gene therapy in severe early onset FGR. Data and samples from the EVERREST Prospective Study will be used to identify ultrasound and/or biochemical markers of prognosis in pregnancies with an estimated fetal weight (EFW) <3rd centile between 20+0 and 26+6 weeks of gestation. Methods This is a 6 year European multicentre prospective cohort study, recruiting women with a singleton pregnancy where the EFW is <3rd centile for gestational age and <600 g at 20+0 to 26+6 weeks of gestation. Detailed data are collected on: maternal history; antenatal, peripartum, and postnatal maternal complications; health economic impact; psychological impact; neonatal condition, progress and complications; and infant growth and neurodevelopment to 2 years of corrected age in surviving infants. Standardised longitudinal ultrasound measurements are performed, including: fetal biometry; uterine artery, umbilical artery, middle cerebral artery, and ductus venosus Doppler velocimetry; and uterine artery and umbilical vein volume blood flow. Samples of maternal blood and urine, amniotic fluid (if amniocentesis performed), placenta, umbilical cord blood, and placental bed (if caesarean delivery performed) are collected for bio-banking. An initial analysis of maternal blood samples at enrolment is planned to identify biochemical markers that are predictors for fetal or neonatal death. Discussion The findings of the EVERREST Prospective Study will support the development of a novel therapy for severe early onset FGR by describing in detail the natural history of the disease and by identifying women whose pregnancies have the poorest outcomes, in whom a therapy might be most advantageous. The findings will also enable better counselling of couples with affected pregnancies, and provide a valuable resource for future research into the causes of FGR. Trial registration NCT02097667 registered 31st October 2013. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1226-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rebecca Spencer
- Institute for Women's Health, University College London, London, UK. .,Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK.
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Jana Brodszki
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Anke Diemert
- Obstetrics and Fetal Medicine Unit, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Francesc Figueras
- BCNatal, Hospital Clinic and Hospital Sant Joan de Deu, University of Barcelona, CIBERER and IDIBAPS, Barcelona, Spain
| | - Eduard Gratacós
- BCNatal, Hospital Clinic and Hospital Sant Joan de Deu, University of Barcelona, CIBERER and IDIBAPS, Barcelona, Spain
| | - Stefan R Hansson
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Kurt Hecher
- Obstetrics and Fetal Medicine Unit, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Neil Marlow
- Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Karel Marsál
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Eva Morsing
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Donald Peebles
- Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | | | - Neil J Sebire
- Paediatric and Developmental Pathology, Great Ormond Street Hospital, London, UK
| | - John F Timms
- Institute for Women's Health, University College London, London, UK
| | - Anna L David
- Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK
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30
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Dall’Asta A, Brunelli V, Prefumo F, Frusca T, Lees CC. Early onset fetal growth restriction. Matern Health Neonatol Perinatol 2017; 3:2. [PMID: 28116113 PMCID: PMC5241928 DOI: 10.1186/s40748-016-0041-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/27/2016] [Indexed: 01/01/2023] Open
Abstract
Fetal growth restriction (FGR) diagnosed before 32 weeks is identified by fetal smallness associated with Doppler abnormalities and is associated with significant perinatal morbidity and mortality and maternal complications. Recent studies have provided new insights into pathophysiology, management options and postnatal outcomes of FGR. In this paper we review the available evidence regarding diagnosis, management and prognosis of fetuses diagnosed with FGR before 32 weeks of gestation.
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Affiliation(s)
- Andrea Dall’Asta
- Centre for Fetal Care, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS United Kingdom
- Department of Obstetrics & Gynecology, University of Parma, Parma, Italy
| | - Valentina Brunelli
- Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Unit, University of Brescia, Brescia, Italy
| | - Federico Prefumo
- Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Unit, University of Brescia, Brescia, Italy
| | - Tiziana Frusca
- Department of Obstetrics & Gynecology, University of Parma, Parma, Italy
| | - Christoph C Lees
- Centre for Fetal Care, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Department of Development and Regeneration, KU Leuven, Belgium
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31
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Swanson AM, Rossi CA, Ofir K, Mehta V, Boyd M, Barker H, Ledwozyw A, Vaughan O, Martin J, Zachary I, Sebire N, Peebles DM, David AL. Maternal Therapy with Ad.VEGF-A 165 Increases Fetal Weight at Term in a Guinea-Pig Model of Fetal Growth Restriction. Hum Gene Ther 2016; 27:997-1007. [PMID: 27530140 DOI: 10.1089/hum.2016.046] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In a model of growth-restricted sheep pregnancy, it was previously demonstrated that transient uterine artery VEGF overexpression can improve fetal growth. This approach was tested in guinea-pig pregnancies, where placental physiology is more similar to humans. Fetal growth restriction (FGR) was attained through peri-conceptual nutrient restriction in virgin guinea pigs. Ad.VEGF-A165 or Ad.LacZ (1 × 1010vp) was applied at mid-gestation via laparotomy, delivered externally to the uterine circulation with thermosensitive gel. At short-term (3-8 days post surgery) or at term gestation, pups were weighed, and tissues were sampled for vector spread analysis, VEGF expression, and its downstream effects. Fetal weight at term was increased (88.01 ± 13.36 g; n = 26) in Ad.VEGF-A165-treated animals compared with Ad.LacZ-treated animals (85.52 ± 13.00 g; n = 19; p = 0.028). The brain, liver, and lung weight and crown rump length were significantly larger in short-term analyses, as well as VEGF expression in transduced tissues. At term, molecular analyses confirmed the presence of VEGF transgene in target tissues but not in fetal samples. Tissue histology analysis and blood biochemistry/hematological examination were comparable with controls. Uterine artery relaxation in Ad.VEGF-A165-treated dams was higher compared with Ad.LacZ-treated dams. Maternal uterine artery Ad.VEGF-A165 increases fetal growth velocity and term fetal weight in growth-restricted guinea-pig pregnancy.
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Affiliation(s)
- Anna M Swanson
- 1 Prenatal Cell and Gene Therapy Group, Institute for Women's Health , UCL, London, United Kingdom
| | - Carlo A Rossi
- 1 Prenatal Cell and Gene Therapy Group, Institute for Women's Health , UCL, London, United Kingdom
| | - Keren Ofir
- 1 Prenatal Cell and Gene Therapy Group, Institute for Women's Health , UCL, London, United Kingdom
| | - Vedanta Mehta
- 2 Centre for Cardiovascular Biology and Medicine , UCL, London, United Kingdom
| | - Michael Boyd
- 3 Biological Services Unit, Royal Veterinary College, London, United Kingdom
| | - Hannah Barker
- 3 Biological Services Unit, Royal Veterinary College, London, United Kingdom
| | - Agata Ledwozyw
- 1 Prenatal Cell and Gene Therapy Group, Institute for Women's Health , UCL, London, United Kingdom
| | - Owen Vaughan
- 1 Prenatal Cell and Gene Therapy Group, Institute for Women's Health , UCL, London, United Kingdom
| | - John Martin
- 2 Centre for Cardiovascular Biology and Medicine , UCL, London, United Kingdom
| | - Ian Zachary
- 2 Centre for Cardiovascular Biology and Medicine , UCL, London, United Kingdom
| | - Neil Sebire
- 4 Department of Paediatric Pathology, Institute of Child Health , UCL, London, United Kingdom
| | - Donald M Peebles
- 1 Prenatal Cell and Gene Therapy Group, Institute for Women's Health , UCL, London, United Kingdom
| | - Anna L David
- 1 Prenatal Cell and Gene Therapy Group, Institute for Women's Health , UCL, London, United Kingdom
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32
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Ilekis JV, Tsilou E, Fisher S, Abrahams VM, Soares MJ, Cross JC, Zamudio S, Illsley NP, Myatt L, Colvis C, Costantine MM, Haas DM, Sadovsky Y, Weiner C, Rytting E, Bidwell G. Placental origins of adverse pregnancy outcomes: potential molecular targets: an Executive Workshop Summary of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Am J Obstet Gynecol 2016; 215:S1-S46. [PMID: 26972897 DOI: 10.1016/j.ajog.2016.03.001] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 02/11/2016] [Accepted: 03/01/2016] [Indexed: 12/26/2022]
Abstract
Although much progress is being made in understanding the molecular pathways in the placenta that are involved in the pathophysiology of pregnancy-related disorders, a significant gap exists in the utilization of this information for the development of new drug therapies to improve pregnancy outcome. On March 5-6, 2015, the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health sponsored a 2-day workshop titled Placental Origins of Adverse Pregnancy Outcomes: Potential Molecular Targets to begin to address this gap. Particular emphasis was given to the identification of important molecular pathways that could serve as drug targets and the advantages and disadvantages of targeting these particular pathways. This article is a summary of the proceedings of that workshop. A broad number of topics were covered that ranged from basic placental biology to clinical trials. This included research in the basic biology of placentation, such as trophoblast migration and spiral artery remodeling, and trophoblast sensing and response to infectious and noninfectious agents. Research findings in these areas will be critical for the formulation of the development of future treatments and the development of therapies for the prevention of a number of pregnancy disorders of placental origin that include preeclampsia, fetal growth restriction, and uterine inflammation. Research was also presented that summarized ongoing clinical efforts in the United States and in Europe that has tested novel interventions for preeclampsia and fetal growth restriction, including agents such as oral arginine supplementation, sildenafil, pravastatin, gene therapy with virally delivered vascular endothelial growth factor, and oxygen supplementation therapy. Strategies were also proposed to improve fetal growth by the enhancement of nutrient transport to the fetus by modulation of their placental transporters and the targeting of placental mitochondrial dysfunction and oxidative stress to improve placental health. The roles of microRNAs and placental-derived exosomes, as well as messenger RNAs, were also discussed in the context of their use for diagnostics and as drug targets. The workshop discussed the aspect of safety and pharmacokinetic profiles of potential existing and new therapeutics that will need to be determined, especially in the context of the unique pharmacokinetic properties of pregnancy and the hurdles and pitfalls of the translation of research findings into practice. The workshop also discussed novel methods of drug delivery and targeting during pregnancy with the use of macromolecular carriers, such as nanoparticles and biopolymers, to minimize placental drug transfer and hence fetal drug exposure. In closing, a major theme that developed from the workshop was that the scientific community must change their thinking of the pregnant woman and her fetus as a vulnerable patient population for which drug development should be avoided, but rather be thought of as a deprived population in need of more effective therapeutic interventions.
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Affiliation(s)
- John V Ilekis
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Department of Health and Human Services, Bethesda, MD.
| | - Ekaterini Tsilou
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Department of Health and Human Services, Bethesda, MD.
| | - Susan Fisher
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Vikki M Abrahams
- Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine; New Haven, CT
| | - Michael J Soares
- Institute of Reproductive Health and Regenerative Medicine and Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS
| | - James C Cross
- Comparative Biology and Experimental Medicine, University of Calgary Health Sciences Centre, Calgary, Alberta, Canada
| | - Stacy Zamudio
- Department of Obstetrics and Gynecology, Hackensack University Medical Center, Hackensack, NJ
| | - Nicholas P Illsley
- Department of Obstetrics and Gynecology, Hackensack University Medical Center, Hackensack, NJ
| | - Leslie Myatt
- Center for Pregnancy and Newborn Research, University of Texas Health Science Center, San Antonio, TX
| | - Christine Colvis
- Therapeutics Discovery Program, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD
| | - Maged M Costantine
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - David M Haas
- Department of Obstetrics and Gynecology Indiana University, Indianapolis, IN
| | | | - Carl Weiner
- University of Kansas Medical Center, Kansas City, KS
| | - Erik Rytting
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Gene Bidwell
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS
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Carr DJ, Wallace JM, Aitken RP, Milne JS, Martin JF, Zachary IC, Peebles DM, David AL. Peri- and Postnatal Effects of Prenatal Adenoviral VEGF Gene Therapy in Growth-Restricted Sheep. Biol Reprod 2016; 94:142. [PMID: 27103444 DOI: 10.1095/biolreprod.115.133744] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 03/16/2016] [Indexed: 11/01/2022] Open
Abstract
Uterine artery (UtA) adenovirus (Ad) vector-mediated overexpression of vascular endothelial growth factor (VEGF) enhances uterine blood flow in normal sheep pregnancy and increases fetal growth in the overnourished adolescent sheep model of fetal growth restriction (FGR). Herein, we examined its impact on gestation length, neonatal survival, early postnatal growth and metabolism. Singleton-bearing ewes were evenly allocated to receive Ad.VEGF-A165 (5 × 10(10) particles/ml, 10 ml, n = 17) or saline (10 ml, n = 16) injected into each UtA at laparotomy (0.6 gestation). Fetal growth was serially monitored (blind) by ultrasound until delivery. Lambs were weighed and blood was sampled weekly and a glucose tolerance test performed (68-day postnatal age). Hepatic DNA/RNA was extracted at necropsy (83-day postnatal age) to examine methylation status of eight somatotropic axis genes. IGF1 mRNA and protein expression were measured by RT-PCR and radioimmunoassay, respectively. All pregnancies remained viable following Ad.VEGF-A165 treatment. Fetal abdominal circumference and renal volume were greater in the Ad.VEGF-A165 group compared with the saline group at 21/28 days (P ≤ 0.04) postinjection. At delivery, gestation length (P = 0.07), lamb birthweight (P = 0.08), umbilical girth (P = 0.06), and plasma glucose (P = 0.09) tended to be greater in Ad.VEGF-A165-treated lambs. Levels of neonatal intervention required to ensure survival was equivalent between groups. Absolute postnatal growth rate (P = 0.02), insulin area under the curve (P = 0.04) and carcass weight at necropsy (P = 0.04) were increased by Ad.VEGF-A165 treatment. There was no impact on markers of insulin sensitivity or methylation/expression of key genes involved in somatic growth. Ad.VEGF-A165 gene therapy increased fetal growth in a sheep FGR model, and lambs continued to thrive during the neonatal and early postnatal period.
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Affiliation(s)
- David J Carr
- Prenatal Cell and Gene Therapy Group, University College London Institute for Women's Health, University College London, London, United Kingdom Rowett Institute of Nutrition and Health, University of Aberdeen, Bucksburn, Aberdeen, United Kingdom
| | - Jacqueline M Wallace
- Rowett Institute of Nutrition and Health, University of Aberdeen, Bucksburn, Aberdeen, United Kingdom
| | - Raymond P Aitken
- Rowett Institute of Nutrition and Health, University of Aberdeen, Bucksburn, Aberdeen, United Kingdom
| | - John S Milne
- Rowett Institute of Nutrition and Health, University of Aberdeen, Bucksburn, Aberdeen, United Kingdom
| | - John F Martin
- Centre of Cardiovascular Biology and Medicine, University College London, London, United Kingdom
| | - Ian C Zachary
- Centre of Cardiovascular Biology and Medicine, University College London, London, United Kingdom
| | - Donald M Peebles
- Prenatal Cell and Gene Therapy Group, University College London Institute for Women's Health, University College London, London, United Kingdom National Institute for Health Research University College London Hospitals Biomedical Research Centre, Maple House, London, United Kingdom
| | - Anna L David
- Prenatal Cell and Gene Therapy Group, University College London Institute for Women's Health, University College London, London, United Kingdom National Institute for Health Research University College London Hospitals Biomedical Research Centre, Maple House, London, United Kingdom
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34
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Sheppard M, Spencer RN, Ashcroft R, David AL. Ethics and social acceptability of a proposed clinical trial using maternal gene therapy to treat severe early-onset fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:484-491. [PMID: 26968870 DOI: 10.1002/uog.15880] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 01/20/2016] [Accepted: 01/29/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To evaluate the ethical and social acceptability of a proposed clinical trial using maternal uterine artery vascular endothelial growth factor (VEGF) gene therapy to treat severe early-onset fetal growth restriction (FGR) in pregnant women. METHODS We conducted a literature review on the ethics and legality of experimental treatments in pregnant women, in particular advanced therapeutics. Issues that were identified from the literature helped develop interview guides for semistructured, qualitative interviews, carried out in four European countries, with 34 key stakeholders (disability groups, professional bodies and patient support groups) and 24 women/couples who had experienced a pregnancy affected by severe early-onset FGR. RESULTS The literature review identified two main questions: 'is it ethical to give a pregnant woman a potentially risky treatment from which she does not benefit directly?' and 'is it ethical to treat a condition of the unborn child, who may then be born with a serious disability when, without treatment, they would have died?'. The review concluded that there were no ethical or legal objections to the intervention, or to a trial of this intervention. Overall, respondents viewed the proposed trial in positive terms. Women were generally interested in participating in clinical trials that conferred a potential benefit to their unborn child. The risk of disability of the premature child was a concern, but not considered a major stumbling block for maternal VEGF gene therapy. CONCLUSIONS This study did not identify any fundamental or insurmountable objections to a trial of maternal gene therapy for severe early-onset FGR. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Sheppard
- School of Law, Queen Mary University of London, London, UK
| | - R N Spencer
- Institute for Women's Health, University College London, London, UK
| | - R Ashcroft
- School of Law, Queen Mary University of London, London, UK
| | - A L David
- Institute for Women's Health, University College London, London, UK
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Mehta V, Ofir K, Swanson A, Kloczko E, Boyd M, Barker H, Avdic-Belltheus A, Martin J, Zachary I, Peebles D, David AL. Gene Targeting to the Uteroplacental Circulation of Pregnant Guinea Pigs. Reprod Sci 2016; 23:1087-95. [PMID: 26865541 DOI: 10.1177/1933719116630411] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Our study aimed to target adenoviral gene therapy to the uteroplacental circulation of pregnant guinea pigs in order to develop a novel therapy for fetal growth restriction. Four methods of delivery of an adenovirus encoding β-galactosidase (Ad.LacZ) were evaluated: intravascular injection using phosphate-buffered saline (PBS) into (1) uterine artery (UtA) or (2) internal iliac artery or external administration in (3) PBS or (4) pluronic F-127 gel (Sigma Aldrich). Postmortem examination was performed 4 to 7 days after gene transfer. Tissue transduction was assessed by X-gal histochemistry and enzyme-linked immunosorbent assay. External vascular application of the adenovirus vector in combination with pluronic gel had 91.7% success rate in terms of administration (85% maternal survival) and gave the best results for maternal/fetal survival and local transduction efficiency without any spread to maternal or fetal tissues. This study suggests an optimal method of gene delivery to the UtAs of a small rodent for preclinical studies.
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Affiliation(s)
- Vedanta Mehta
- Institute for Women's Health, University College London, London, United Kingdom Centre for Cardiovascular Biology and Medicine, University College London, London, United Kingdom
| | - Keren Ofir
- Institute for Women's Health, University College London, London, United Kingdom
| | - Anna Swanson
- Institute for Women's Health, University College London, London, United Kingdom
| | - Ewa Kloczko
- Institute for Women's Health, University College London, London, United Kingdom
| | - Michael Boyd
- BSU, Royal Veterinary College, London, United Kingdom
| | - Hannah Barker
- BSU, Royal Veterinary College, London, United Kingdom
| | | | - John Martin
- Centre for Cardiovascular Biology and Medicine, University College London, London, United Kingdom
| | - Ian Zachary
- Centre for Cardiovascular Biology and Medicine, University College London, London, United Kingdom
| | - Donald Peebles
- Institute for Women's Health, University College London, London, United Kingdom
| | - Anna L David
- Institute for Women's Health, University College London, London, United Kingdom
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Zhou K, Ma Y, Brogan MS. Chronic and non-healing wounds: The story of vascular endothelial growth factor. Med Hypotheses 2015; 85:399-404. [PMID: 26138626 DOI: 10.1016/j.mehy.2015.06.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 06/01/2015] [Accepted: 06/19/2015] [Indexed: 12/24/2022]
Abstract
The pathophysiology of the chronicity and non-healing status of wounds remains unknown. This paper presents the following hypothesis: abnormal patterns of vascular endothelial growth factor receptors (VEGFRs) are the culprits of wound chronicity and non-healing. More specifically, for patients with poor circulation, the decreased VEGFR-2 level is the cause of poor wound healing; for patients with non-compromised circulation, for example, patients with concurrent chronic wounds and active autoimmune diseases, the increased VEGFR-1 level is related to the non-healing status of wounds. The hypothesis is supported by the following facts. VEGFR-1 is the main contributor for inflammation and VEGFR-2 facilitates angiogenesis; soluble VEGFR-1 (sVEGFR-1) inactivates both VEGFR-1 and VEGFR-2. Patients with auto-immune disease have abnormally increased VEGFR-1 and decreased sVEGFR. Wounds in patients with active autoimmune diseases have poor response to electric stimulation which facilitates chronic wound healing in patients without active autoimmune diseases via increasing vascular endothelial growth factor (VEGF) secretion. Patients with chronic wounds (including diabetic foot ulcers and venous leg ulcers) but no active autoimmune diseases have decreased VEGFR-2 levels. We thus believe that abnormal patterns of VEGFRs are the culprits of wound chronicity and non-healing. For wounds with compromised circulation, VEGFR-2 decrease contributes to its chronicity; whereas for wounds with non-compromised circulation, VEGFR-1 increase is the leading cause of the non-healing status of chronic wounds. Treatments and research in wound care should be tailored to target these changes based on circulation status of wounds. Complete elucidation of changes of VEGFRs in chronic and non-healing wounds will enhance our understandings in tissue healing and thus better our selection of appropriate treatments for chronic and non-healing wounds.
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Affiliation(s)
- Kehua Zhou
- Department of Health Care Studies, Daemen College, Amherst, NY 14226, USA; Daemen College Physical Therapy Wound Care Clinic, Daemen College, Amherst, NY 14226, USA.
| | - Yan Ma
- Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Internal Medicine and Sleep Center, Eye Hospital, China Academy of Chinese Medical Science, Beijing, China.
| | - Michael S Brogan
- Department of Physical Therapy, Daemen College, Amherst, NY 14226, USA.
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From Pre-Clinical Studies to Clinical Trials: Generation of Novel Therapies for Pregnancy Complications. Int J Mol Sci 2015; 16:12907-24. [PMID: 26062129 PMCID: PMC4490478 DOI: 10.3390/ijms160612907] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 05/26/2015] [Accepted: 05/28/2015] [Indexed: 02/07/2023] Open
Abstract
Complications of pregnancy represent a significant disease burden, with both immediate and lasting consequences for mother and baby. Two key pregnancy complications, fetal growth restriction (FGR) and preeclampsia (PE), together affect around 10%–15% of all pregnancies worldwide. Despite this high incidence, there are currently no therapies available to treat these pregnancy disorders. Early delivery remains the only intervention to reduce the risk of severe maternal complications and/or stillbirth of the baby; however early delivery itself is associated with increased risk of neonatal mortality and morbidity. As such, there is a pressing need to develop new and effective treatments that can prevent or treat FGR and PE. Animal models have been essential in identifying and screening potential new therapies in this field. In this review, we address recent progress that has been made in developing therapeutic strategies for pregnancy disorders, some of which are now entering clinical trials.
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Swanson A, David A. Animal models of fetal growth restriction: Considerations for translational medicine. Placenta 2015; 36:623-30. [DOI: 10.1016/j.placenta.2015.03.003] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 03/03/2015] [Accepted: 03/04/2015] [Indexed: 11/26/2022]
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Spencer RN, Carr DJ, David AL. Treatment of poor placentation and the prevention of associated adverse outcomes--what does the future hold? Prenat Diagn 2014; 34:677-84. [PMID: 24799349 PMCID: PMC4265258 DOI: 10.1002/pd.4401] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 04/29/2014] [Accepted: 04/29/2014] [Indexed: 12/14/2022]
Abstract
Poor placentation, which manifests as pre-eclampsia and fetal growth restriction, is a major pregnancy complication. The underlying cause is a deficiency in normal trophoblast invasion of the spiral arteries, associated with placental inflammation, oxidative stress, and an antiangiogenic state. Peripartum therapies, such as prenatal maternal corticosteroids and magnesium sulphate, can prevent some of the adverse neonatal outcomes, but there is currently no treatment for poor placentation itself. Instead, management relies on identifying the consequences of poor placentation in the mother and fetus, with iatrogenic preterm delivery to minimise mortality and morbidity. Several promising therapies are currently under development to treat poor placentation, to improve fetal growth, and to prevent adverse neonatal outcomes. Interventions such as maternal nitric oxide donors, sildenafil citrate, vascular endothelial growth factor gene therapy, hydrogen sulphide donors, and statins address the underlying pathology, while maternal melatonin administration may provide fetal neuroprotection. In the future, these may provide a range of synergistic therapies for pre-eclampsia and fetal growth restriction, depending on the severity and gestation of onset.
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Affiliation(s)
- RN Spencer
- Institute for Women's Health, University College LondonLondon, UK
| | - DJ Carr
- Institute for Women's Health, University College LondonLondon, UK
| | - AL David
- Institute for Women's Health, University College LondonLondon, UK
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Mehta V, Abi-Nader KN, Shangaris P, Shaw SWS, Filippi E, Benjamin E, Boyd M, Peebles DM, Martin J, Zachary I, David AL. Local over-expression of VEGF-DΔNΔC in the uterine arteries of pregnant sheep results in long-term changes in uterine artery contractility and angiogenesis. PLoS One 2014; 9:e100021. [PMID: 24977408 PMCID: PMC4076190 DOI: 10.1371/journal.pone.0100021] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 05/22/2014] [Indexed: 12/23/2022] Open
Abstract
Background The normal development of the uteroplacental circulation in pregnancy depends on angiogenic and vasodilatory factors such as vascular endothelial growth factor (VEGF). Reduced uterine artery blood flow (UABF) is a common cause of fetal growth restriction; abnormalities in angiogenic factors are implicated. Previously we showed that adenovirus (Ad)-mediated VEGF-A165 expression in the pregnant sheep uterine artery (UtA) increased nitric oxide synthase (NOS) expression, altered vascular reactivity and increased UABF. VEGF-D is a VEGF family member that promotes angiogenesis and vasodilatation but, in contrast to VEGF-A, does not increase vascular permeability. Here we examined the effect of Ad.VEGF-DΔNΔC vector encoding a fully processed form of VEGF-D, on the uteroplacental circulation. Methods UtA transit-time flow probes and carotid artery catheters were implanted in mid-gestation pregnant sheep (n = 5) to measure baseline UABF and maternal haemodynamics respectively. 7–14 days later, after injection of Ad.VEGF-DΔNΔC vector (5×1011 particles) into one UtA and an Ad vector encoding β-galactosidase (Ad.LacZ) contralaterally, UABF was measured daily until scheduled post-mortem examination at term. UtAs were assessed for vascular reactivity, NOS expression and endothelial cell proliferation; NOS expression was studied in ex vivo transduced UtA endothelial cells (UAECs). Results At 4 weeks post-injection, Ad.VEGF-DΔNΔC treated UtAs showed significantly lesser vasoconstriction (Emax144.0 v/s 184.2, p = 0.002). There was a tendency to higher UABF in Ad.VEGF-DΔNΔC compared to Ad.LacZ transduced UtAs (50.58% v/s 26.94%, p = 0.152). There was no significant effect on maternal haemodynamics. An increased number of proliferating endothelial cells and adventitial blood vessels were observed in immunohistochemistry. Ad.VEGF-DΔNΔC expression in cultured UAECs upregulated eNOS and iNOS expression. Conclusions Local over-expression of VEGF-DΔNΔC in the UtAs of pregnant mid-gestation sheep reduced vasoconstriction, promoted endothelial cell proliferation and showed a trend towards increased UABF. Studies in cultured UAECs indicate that VEGF-DΔNΔC may act in part through upregulation of eNOS and iNOS.
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Affiliation(s)
- Vedanta Mehta
- Institute for Women's Health, UCL, London, United Kingdom
- Centre for Cardiovascular Biology and Medicine, Division of Medicine, Rayne Building, UCL, London, United Kingdom
- * E-mail:
| | | | | | | | - Elisa Filippi
- Institute for Women's Health, UCL, London, United Kingdom
| | | | - Michael Boyd
- BSU, Royal Veterinary College, Camden, London, United Kingdom
| | | | - John Martin
- Centre for Cardiovascular Biology and Medicine, Division of Medicine, Rayne Building, UCL, London, United Kingdom
| | - Ian Zachary
- Centre for Cardiovascular Biology and Medicine, Division of Medicine, Rayne Building, UCL, London, United Kingdom
| | - Anna L. David
- Institute for Women's Health, UCL, London, United Kingdom
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Carr DJ, Wallace JM, Aitken RP, Milne JS, Mehta V, Martin JF, Zachary IC, Peebles DM, David AL. Uteroplacental adenovirus vascular endothelial growth factor gene therapy increases fetal growth velocity in growth-restricted sheep pregnancies. Hum Gene Ther 2014; 25:375-84. [PMID: 24593228 DOI: 10.1089/hum.2013.214] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Fetal growth restriction (FGR) occurs in ∼8% of pregnancies and is a major cause of perinatal mortality and morbidity. There is no effective treatment. FGR is characterized by reduced uterine blood flow (UBF). In normal sheep pregnancies, local uterine artery (UtA) adenovirus (Ad)-mediated overexpression of vascular endothelial growth factor (VEGF) increases UBF. Herein we evaluated Ad.VEGF therapy in the overnourished adolescent ewe, an experimental paradigm in which reduced UBF from midgestation correlates with reduced lamb birthweight near term. Singleton pregnancies were established using embryo transfer in adolescent ewes subsequently offered a high intake (n=45) or control intake (n=12) of a complete diet to generate FGR or normal fetoplacental growth, respectively. High-intake ewes were randomized midgestation to receive bilateral UtA injections of 5×10¹¹ particles Ad.VEGF-A165 (n=18), control vector Ad.LacZ (n=14), or control saline (n=13). Fetal growth/well-being were evaluated using serial ultrasound. UBF was monitored using indwelling flowprobes until necropsy at 0.9 gestation. Vasorelaxation, neovascularization within the perivascular adventitia, and placental mRNA expression of angiogenic factors/receptors were examined using organ bath analysis, anti-vWF immunohistochemistry, and qRT-PCR, respectively. Ad.VEGF significantly increased ultrasonographic fetal growth velocity at 3-4 weeks postinjection (p=0.016-0.047). At 0.9 gestation fewer fetuses were markedly growth-restricted (birthweight >2SD below contemporaneous control-intake mean) after Ad.VEGF therapy. There was also evidence of mitigated fetal brain sparing (lower biparietal diameter-to-abdominal circumference and brain-to-liver weight ratios). No effects were observed on UBF or neovascularization; however, Ad.VEGF-transduced vessels demonstrated strikingly enhanced vasorelaxation. Placental efficiency (fetal-to-placental weight ratio) and FLT1/KDR mRNA expression were increased in the maternal but not fetal placental compartments, suggesting downstream effects on placental function. Ad.VEGF gene therapy improves fetal growth in a sheep model of FGR, although the precise mechanism of action remains unclear.
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Affiliation(s)
- David J Carr
- 1 UCL Institute for Women's Health, University College London , London WC1E 6HX, United Kingdom
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Abi-Nader KN, Rodeck CH, David AL. Prenatal gene therapy for the early treatment of genetic disorders. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.4.1.25] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
Prenatal gene therapy aims to deliver genes to cells and tissues early in prenatal life, allowing correction of a genetic defect, before irreparable tissue damage has occurred. In contrast to postnatal gene therapy, prenatal application may target genes to a large population of stem cells, and the smaller fetal size allows a higher vector to target cell ratio to be achieved. Early gestation delivery may allow the development of immune tolerance to the transgenic protein, which would facilitate postnatal repeat vector administration if needed. Moreover, early delivery would avoid anti-vector immune responses which are often acquired in postnatal life. The NIH Recombinant DNA Advisory Committee considered that a candidate disease for prenatal gene therapy should pose serious morbidity and mortality risks to the fetus or neonate, and not have any effective postnatal treatment. Prenatal gene therapy would therefore be appropriate for life-threatening disorders, in which prenatal gene delivery maintains a clear advantage over cell transplantation or postnatal gene therapy. If deemed safer and more efficacious, prenatal gene therapy may be applicable for nonlethal conditions if adult gene transfer is unlikely to be of benefit. Many candidate diseases will be inherited congenital disorders such as thalassaemia or lysosomal storage disorders. However, obstetric conditions such as fetal growth restriction may also be treated using a targeted gene therapy approach. In each disease, the condition must be diagnosed prenatally, either via antenatal screening and prenatal diagnosis, for example, in the case of hemophilias, or by ultrasound assessment of the fetus, for example, congenital diaphragmatic hernia. In this chapter, we describe some examples of the candidate diseases and discuss how a prenatal gene therapy approach might work.
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Affiliation(s)
- Anna L David
- Prenatal Cell and Gene Therapy Group, EGA Institute for Women's Health, University College London, London, UK.
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Mehta V, Abi-Nader KN, Carr D, Wallace J, Coutelle C, Waddington SN, Peebles D, David AL. Monitoring for potential adverse effects of prenatal gene therapy: use of large animal models with relevance to human application. METHODS IN MOLECULAR BIOLOGY (CLIFTON, N.J.) 2012; 891:291-328. [PMID: 22648778 DOI: 10.1007/978-1-61779-873-3_14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Safety is an absolute prerequisite for introducing any new therapy, and the need to monitor the consequences of administration of both vector and transgene to the fetus is particularly important. The unique features of fetal development that make it an attractive target for gene therapy, such as its immature immune system and rapidly dividing populations of stem cells, also mean that small perturbations in pregnancy can have significant short- and long-term consequences. Certain features of the viral vectors used, the product of the delivered gene, and sometimes the invasive techniques necessary to deliver the construct to the fetus in utero have the potential to do harm. An important goal of prenatal gene therapy research is to develop clinically relevant techniques that could be applied to cure or ameliorate human disease in utero on large animal models such as sheep or nonhuman primates. Equally important is the use of these models to monitor for potential adverse effects of such interventions. These large animal models provide good representation of individual patient-based investigations. However, analyses that require defined genetic backgrounds, high throughput, defined variability and statistical analyses, e.g. for initial studies on teratogenic and oncogenic effects, are best performed on larger groups of small animals, in particular mice. This chapter gives an overview of the potential adverse effects in relation to prenatal gene therapy and describes the techniques that can be used experimentally in a large animal model to monitor the potential adverse consequences of prenatal gene therapy, with relevance to clinical application. The sheep model is particularly useful to allow serial monitoring of fetal growth and well-being after delivery of prenatal gene therapy. It is also amenable to serially sampling using minimally invasive and clinically relevant techniques such as ultrasound-guided blood sampling. For more invasive long-term monitoring, we describe telemetric techniques to measure the haemodynamics of the mother or fetus, for example, that interferes minimally with normal animal behaviour. Implanted catheters can also be used for serial fetal blood sampling during gestation. Finally, we describe methods to monitor events around birth and long-term neonatal follow-up that are important when considering human translation of this therapy.
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Affiliation(s)
- Vedanta Mehta
- Prenatal Cell and Gene Therapy Group, EGA Institute for Women's Health, University College London, London, UK
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Abstract
This introductory chapter provides a short review of the ideas and practical approaches that have led to the present and perceived future development of prenatal gene therapy. It summarizes the advantages and the potential adverse effects of this novel preventive and therapeutic approach to the management of prenatal diseases. It also provides guidance to the range of conditions to which prenatal gene therapy may be applied and to the technical approaches, vectors, and societal/ethical considerations for this newly emerging field of Fetal Medicine.
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Abstract
Over the first decade of this new millennium gene therapy has demonstrated clear clinical benefits in several diseases for which conventional medicine offers no treatment. Clinical trials of gene therapy for single gene disorders have recruited predominantly young patients since older subjects may have suffered irrevocablepathological changes or may not be available because the disease is lethal relatively early in life. The concept of fetal gene therapy is an extension of this principle in that diseases in which irreversible changes occur at or beforebirth can be prevented by gene supplementation or repair in the fetus or associated maternal tissues. This article ccnsiders the enthusiasm and skepticism held for fetal gene therapy and its potential for clinical application. It coversa spectrum of candidate diseases for fetal gene therapy including Pompe disease, Gaucher disease, thalassemia, congenital protein C deficiency and cystic fibrosis. It outlines successful and not-so-successful examples of fetal gene therapy in animal models. Finally the application and potential of fetal gene transfer as a fundamental research tool for developmental biology and generation of somatic transgenic animals is surveyed.
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Long-term increase in uterine blood flow is achieved by local overexpression of VEGF-A165 in the uterine arteries of pregnant sheep. Gene Ther 2011; 19:925-35. [DOI: 10.1038/gt.2011.158] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Langlois A, Bietiger W, Seyfritz E, Maillard E, Vivot K, Peronet C, Meyer N, Kessler L, Jeandidier N, Pinget M, Sigrist S. Improvement of Rat Islet Viability during Transplantation: Validation of Pharmacological Approach to Induce VEGF Overexpression. Cell Transplant 2011; 20:1333-42. [DOI: 10.3727/096368910x557182] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Delayed and insufficient revascularization during islet transplantation deprives islets of oxygen and nutrients, resulting in graft failure. Vascular endothelial growth factor (VEGF) could play a critical role in islet revascularization. We aimed to develop pharmacological strategies for VEGF overexpression in pancreatic islets using the iron chelator deferoxamine (DFO), thus avoiding obstacles or safety risks associated with gene therapy. Rat pancreatic islets were infected in vivo using an adenovirus (ADE) encoding human VEGF gene (4.108 pfu/pancreas) or were incubated in the presence of DFO (10 μmol/L). In vitro viability, functionality, and the secretion of VEGF were evaluated in islets 1 and 3 days after treatment. Infected islets or islets incubated with DFO were transplanted into the liver of syngenic diabetic rats and the graft efficiency was estimated in vivo by measuring body weight, glycemia, C-peptide secretion, and animal survival over a period of 2 months. DFO induced transient VEGF overexpression over 3 days, whereas infection with ADE resulted in prolonged VEGF overexpression lasting 14 days; however, this was toxic and decreased islet viability and functionality. The in vivo study showed a decrease in rat deaths after the transplantation of islets treated with DFO or ADE compared with the sham and control group. ADE treatment improved body weight and C-peptide levels. Gene therapy and DFO improved metabolic control in diabetic rats after transplantation, but this effect was limited in the presence of DFO. The pharmacological approach is an interesting strategy for improving graft efficiency during transplantation, but this approach needs to be improved with drugs that are more specific.
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Affiliation(s)
- A. Langlois
- Centre européen d'étude du Diabète, Strasbourg, France
| | - W. Bietiger
- Centre européen d'étude du Diabète, Strasbourg, France
| | - E. Seyfritz
- Centre européen d'étude du Diabète, Strasbourg, France
| | - E. Maillard
- Centre européen d'étude du Diabète, Strasbourg, France
| | - K. Vivot
- Centre européen d'étude du Diabète, Strasbourg, France
| | - C. Peronet
- Centre européen d'étude du Diabète, Strasbourg, France
| | - N. Meyer
- Faculté de Médecine de Strasbourg, Laboratoire de Biostatistique, Strasbourg, France
| | - L. Kessler
- Service d'endocrinologie, de diabète et des maladies métaboliques, Médicale B Hopital civil, Strasbourg cedex, France
- Université de Strasbourg (UdS), Strasbourg cedex, France
| | - N. Jeandidier
- Service d'endocrinologie, de diabète et des maladies métaboliques, Médicale B Hopital civil, Strasbourg cedex, France
- Université de Strasbourg (UdS), Strasbourg cedex, France
| | - M. Pinget
- Centre européen d'étude du Diabète, Strasbourg, France
- Service d'endocrinologie, de diabète et des maladies métaboliques, Médicale B Hopital civil, Strasbourg cedex, France
- Université de Strasbourg (UdS), Strasbourg cedex, France
| | - S. Sigrist
- Centre européen d'étude du Diabète, Strasbourg, France
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Abstract
In primates, adequate growth of the fetus depends on the development of the uteroplacental unit. On the fetal side, this is achieved by the creation of the vascular network of the placenta. On the maternal side, the transformation of the spiral arteries into saccular nonreactive vessels by the trophoblast provides high blood flow to the intervillous space. Apart from the changes in the uterine arteries, the mother expands her plasma volume – at the expense of stimulating the renin-angiotensin-aldosterone system – and her cardiac output. In the maintaining of normotension in the face of an increased cardiac output and plasma volume, the renin-angiotensin-aldosterone system requires an enhanced vasodilator synthesis. Finally, in the late stages of pregnancy, a normal endothelial function is required to provide an ample margin to the activation provoked by deportation of syncytiotrophoblast fragments/factors to the maternal circulation. These four adaptative processes require various interrelated vasodilator systems. Deficient adaptations cause isolated or proteinuric arterial hypertension, intrauterine growth restriction, preterm delivery, and stillbirths, among others. Moreover, a normal or a defective adaptation to pregnancy influences maternal cardiovascular health in later life, as evidenced by various studies, most of them epidemiological; thus, pregnancy is now considered a stress test to the maternal cardiovascular system. Because of this, women planning to become pregnant should be screened for clinical and biochemical cardiovascular risks. Inversely, women presenting with hypertension in pregnancy should be thoroughly studied to detect and correct cardiovascular risks. The incorporation of the predictive value of a hypertensive pregnancy should help reduce cardiovascular disease in women.
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Affiliation(s)
- Gloria Valdés
- Centro de Investigaciones Médicas y Departamento Nefrología, Escuela Medicina, Pontificia Universidad Católica, Santiago, Chile
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Mehta V, Abi Nader K, Waddington S, David AL. Organ targeted prenatal gene therapy--how far are we? Prenat Diagn 2011; 31:720-34. [PMID: 21618255 DOI: 10.1002/pd.2787] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Revised: 04/14/2011] [Accepted: 04/17/2011] [Indexed: 12/14/2022]
Abstract
Prenatal gene therapy aims to deliver genes to cells and tissues early in prenatal life, allowing correction of a genetic defect, before long-term tissue damage has occurred. In contrast to postnatal gene therapy, prenatal application can target genes to a large population of dividing stem cells, and the smaller fetal size allows a higher vector-to-target cell ratio to be achieved. Early-gestation delivery may allow the development of immune tolerance to the transgenic protein which would facilitate postnatal repeat vector administration if needed. Targeting particular organs will depend on manipulating the vector to achieve selective tropism and on choosing the most appropriate gestational age and injection method for fetal delivery. Intra-amniotic injection reaches the skin, and other organs that are bathed in the fluid however since gene transfer to the lung and gut is usually poor more direct injection methods will be needed. Delivery to the liver and blood can be achieved by systemic delivery via the umbilical vein or peritoneal cavity. Gene transfer to the central nervous system in the fetus is difficult but newer vectors are available that transduce neuronal tissue even after systemic delivery.
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Affiliation(s)
- Vedanta Mehta
- Prenatal Cell and Gene Therapy Group, Institute for Women's Health, University College London, London, UK
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