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Franke N, Wouldes TA, Brown GTL, Ward K, Rogers J, Harding JE. Perspectives of adult offspring of participants recruited to a randomised trial in pregnancy: a qualitative study. Arch Dis Child 2024; 109:209-214. [PMID: 38041673 DOI: 10.1136/archdischild-2023-326017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/06/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Routinely assessed outcomes in paediatric health studies may not reflect families' priorities. Increasing our understanding of childhood experiences of research participation may contribute to improving the quality of consent and better align study aims with the concerns of relevant communities. OBJECTIVE To explore young adults' views on their participation in medical research during their childhood, specifically around the acceptability of consent and their priorities regarding health, development and well-being as potential trial outcomes. METHODS A qualitative descriptive 20-year follow-up study of a medical trial which aimed to improve outcomes after preterm birth. Semistructured dialogue transcripts were analysed using inductive thematic analysis. SETTING AND PARTICIPANTS Seventeen young adults whose parents consented to their participation in a clinical trial when they were fetuses, and in follow-up studies as preschoolers and school-age children. RESULTS Overall, participants expressed comfort with their parents consenting to medical research on their behalf. However, autonomous child assent may not be attainable due to children's susceptibility to suggestions. Participants generally expressed satisfaction with the outcomes investigated in the follow-up studies, although some suggested other outcomes of interest such as mental health and learning disabilities. CONCLUSIONS Current consent procedures were deemed acceptable as parents hold responsibility for making decisions on behalf of their children, and their commitment to their child's well-being ensures that they make appropriate choices. The outcomes assessed in this trial and health and developmental outcomes in the follow-up assessments aligned well with outcomes of interest to the young adult participants.
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Affiliation(s)
- Nike Franke
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Trecia Ann Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | | | - Kim Ward
- Liggins Institute, The University of Auckland, Auckland, New Zealand
- School of Nursing, The University of Auckland, Auckland, New Zealand
| | - Jenny Rogers
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
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Kitahara G, Higashisaka K, Nakamoto Y, Yamamoto R, Okuno W, Serizawa M, Sakahashi Y, Tsujino H, Haga Y, Tsutsumi Y. Valproic acid elevates HIF-1α-mediated CGB expression and suppresses glucose uptake in BeWo cells. J Toxicol Sci 2024; 49:69-77. [PMID: 38296531 DOI: 10.2131/jts.49.69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Placental dysfunction can disrupt pregnancy. However, few studies have assessed the effects of chemical-induced toxicity on placental function. Here, we examined the effects of valproic acid (VPA) as a model chemical on production of hormones and on glucose uptake in human choriocarcinoma cell line BeWo. Cells were treated with forskolin to differentiate into syncytiotrophoblasts, which were then treated with VPA for 72 hr. Real-time RT-PCR analysis showed that VPA significantly increased the mRNA expression of chorionic gonadotropin β (CGB), a hormone that is produced by the placenta in the first trimester of pregnancy, relative to that in the forskolin-only group. It also suppressed the increase in intracellular glucose uptake and GLUT1 level observed in the forskolin-only group. RNA-seq analysis and pathway database analysis revealed that VPA consistently decreased the level of HIF-1α protein and expression of its downstream target genes HK2 and ADM in the hypoxia pathway. Cobalt chloride, a HIF-1α inducer, inhibited CGB upregulation in VPA-treated cells and rescued VPA-induced suppression of glucose uptake and GLUT1 level. Thus, HIF-1α-mediated elevation of CGB expression and suppression of glucose uptake by VPA is a novel mechanism of placental dysfunction.
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Affiliation(s)
- Go Kitahara
- Graduate School of Pharmaceutical Sciences, Osaka University
| | - Kazuma Higashisaka
- Graduate School of Pharmaceutical Sciences, Osaka University
- Institute for Advanced Co-Creation Studies, Osaka University
| | - Yurina Nakamoto
- Graduate School of Pharmaceutical Sciences, Osaka University
| | - Rena Yamamoto
- Graduate School of Pharmaceutical Sciences, Osaka University
| | - Wakako Okuno
- Graduate School of Pharmaceutical Sciences, Osaka University
| | - Momoe Serizawa
- Graduate School of Pharmaceutical Sciences, Osaka University
| | - Yuji Sakahashi
- Graduate School of Pharmaceutical Sciences, Osaka University
| | - Hirofumi Tsujino
- Graduate School of Pharmaceutical Sciences, Osaka University
- The Museum of Osaka University
| | - Yuya Haga
- Graduate School of Pharmaceutical Sciences, Osaka University
| | - Yasuo Tsutsumi
- Graduate School of Pharmaceutical Sciences, Osaka University
- Global Center for Medical Engineering and Informatics, Osaka University
- Institute for Open and Transdisciplinary Research Initiatives, Osaka University
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Guerini C, Goffinet F, Marchand-Martin L, Delorme P, Pierrat V, Ancel PY, Schmitz T. Timing of antenatal corticosteroids and survival without neurologic disabilities at 5½ years in children born before 35 weeks of gestation. Am J Obstet Gynecol 2023; 229:675.e1-675.e18. [PMID: 37394223 DOI: 10.1016/j.ajog.2023.06.047] [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: 02/04/2023] [Revised: 06/21/2023] [Accepted: 06/27/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND The efficacy of antenatal corticosteroids for neonatal preterm complications wanes beyond 7 days after treatment. The neurodevelopmental effects of longer treatment-to-birth intervals have not been adequately evaluated. OBJECTIVE This study aimed to assess the impact of antenatal corticosteroid timing on survival without moderate or severe neurologic disabilities at 5½ years. STUDY DESIGN This was a secondary analysis of the EPIPAGE-2 study, a national population-based cohort (France) that recruited neonates in 2011 and followed them up at 5½ years (results first reported in 2021). Participants were children born alive between 24+0 and 34+6 weeks, with a complete corticosteroid course, delivery >48 hours after the first injection, and neither limitation of care decided before birth nor severe congenital malformation. The study included 2613 children, 2427 of whom were alive at 5½ years; 71.9% (1739/2427) had a neurologic assessment at this age; 1537 had a clinical examination (complete for 1532), and 202 were assessed with a postal questionnaire. Exposure was defined as the interval between the first injection of the last antenatal corticosteroid course and delivery in days, studied in 2 categories (days 3-7 and after day 7), in 4 categories (days 3-7, 8-14, 15-21, and after day 21), and continuously in days. The main outcome was survival at 5½ years without moderate/severe neurologic disabilities, defined as moderate/severe cerebral palsy, or unilateral or bilateral blindness or deafness, or Full-Scale Intelligence Quotient 2 standard deviations below the mean. A multivariate analysis with a generalized estimated equation logistic regression model assessed the statistical association between the main outcomes and the interval from the first corticosteroid injection of the last course to birth. Multivariate analyses were adjusted for potential confounders, defined with a directed acyclic graph: gestational age in days, number of corticosteroid courses, multiple pregnancy, and cause of prematurity in 5 categories. Because neurologic follow-up was complete in only 63.2% of cases (1532/2427), the analyses used imputed data. RESULTS Among 2613 children, 186 died between birth and 5½ years. Overall survival was 96.6% (95% confidence interval, 95.9-97.0), and survival without moderate or severe neurologic disabilities was 86.0% (95% confidence interval, 84.7-87.0). Survival without moderate or severe neurologic disabilities was lower after day 7 (85.0%) than during the interval from day 3 to day 7 (87.0%) (adjusted odds ratio, 0.70; 95% confidence interval, 0.54-0.89). CONCLUSION The association of a >7-day interval between antenatal corticosteroid administration and birth with a lower rate of survival without moderate or severe neurologic disabilities among children aged 5½ years emphasizes the importance of better targeting women at risk of preterm delivery to optimize the timing and thus benefits of treatment.
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Affiliation(s)
- Claire Guerini
- Université Paris Cité, Centre of Research in Epidemiology and Statistics, Obstetrical Perinatal and Pediatric Epidemiology Research Team, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Institut National de la Sante et de la Recherche Medicale, Institut National de la Recherche Agronomique, Paris, France; Maternité Port-Royal, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France.
| | - François Goffinet
- Université Paris Cité, Centre of Research in Epidemiology and Statistics, Obstetrical Perinatal and Pediatric Epidemiology Research Team, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Institut National de la Sante et de la Recherche Medicale, Institut National de la Recherche Agronomique, Paris, France; Maternité Port-Royal, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Laetitia Marchand-Martin
- Université Paris Cité, Centre of Research in Epidemiology and Statistics, Obstetrical Perinatal and Pediatric Epidemiology Research Team, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Institut National de la Sante et de la Recherche Medicale, Institut National de la Recherche Agronomique, Paris, France
| | - Pierre Delorme
- Université Paris Cité, Centre of Research in Epidemiology and Statistics, Obstetrical Perinatal and Pediatric Epidemiology Research Team, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Institut National de la Sante et de la Recherche Medicale, Institut National de la Recherche Agronomique, Paris, France; Hôpital Trousseau, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Véronique Pierrat
- Université Paris Cité, Centre of Research in Epidemiology and Statistics, Obstetrical Perinatal and Pediatric Epidemiology Research Team, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Institut National de la Sante et de la Recherche Medicale, Institut National de la Recherche Agronomique, Paris, France; Department of Neonatology, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Pierre-Yves Ancel
- Université Paris Cité, Centre of Research in Epidemiology and Statistics, Obstetrical Perinatal and Pediatric Epidemiology Research Team, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Institut National de la Sante et de la Recherche Medicale, Institut National de la Recherche Agronomique, Paris, France; Center for Clinical Investigation P1419, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Thomas Schmitz
- Université Paris Cité, Centre of Research in Epidemiology and Statistics, Obstetrical Perinatal and Pediatric Epidemiology Research Team, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Institut National de la Sante et de la Recherche Medicale, Institut National de la Recherche Agronomique, Paris, France; Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, Université de Paris Cité, Paris, France
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Favero D, Lapuchesky LS, Poggio F, Nardin S, Perachino M, Arecco L, Scavone G, Ottonello S, Latocca MM, Borea R, Puglisi S, Cosso M, Fozza A, Spinaci S, Lambertini M. Choosing the appropriate pharmacotherapy for breast cancer during pregnancy: what needs to be considered? Expert Opin Pharmacother 2023; 24:1975-1984. [PMID: 38179613 DOI: 10.1080/14656566.2023.2293167] [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: 09/03/2023] [Accepted: 12/06/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Breast cancer is the most commonly diagnosed malignancy during pregnancy. Breast cancer during pregnancy is a challenging clinical condition requiring proper and timely multidisciplinary management. AREAS COVERED This review focuses on the management of breast cancer during pregnancy with a focus about the current state-of-the-art on the feasibility and safety of pharmacotherapy approaches in this setting. EXPERT OPINION Multidisciplinary care is key for a proper diagnostic-therapeutic management of breast cancer during pregnancy. Engaging patients and their caregivers in the decision-making process is essential and psychological support should be provided. The treatment of patients with breast cancer during pregnancy should follow the same recommendations as those for breast cancer in young women outside pregnancy but taking into account the gestational age at the time of treatment.Anthracycline-, cyclophosphamide-, and taxane-based regimens can be safely administered during the second and third trimesters with standard protocols, preferring weekly regimens whenever possible. Endocrine therapy, immune checkpoint inhibitors, and targeted agents are contraindicated throughout pregnancy, also due to the very limited data available to guide their administration in this setting. During treatment, careful fetal growth monitoring is mandatory, and even after delivery proper health monitoring for the children exposed in utero to chemotherapy should be continued.
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Affiliation(s)
- Diletta Favero
- Department of Internal Medicine and Medical Specialties (Di.M.I.), School of Medicine, University of Genova, Genoa, Italy
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Laura Sabina Lapuchesky
- Department of Medical Oncology, Instituto Alexander Fleming, University of Buenos Aires, Buenos Aires, Argentina
| | - Francesca Poggio
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Simone Nardin
- Department of Internal Medicine and Medical Specialties (Di.M.I.), School of Medicine, University of Genova, Genoa, Italy
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Marta Perachino
- Department of Internal Medicine and Medical Specialties (Di.M.I.), School of Medicine, University of Genova, Genoa, Italy
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Luca Arecco
- Department of Internal Medicine and Medical Specialties (Di.M.I.), School of Medicine, University of Genova, Genoa, Italy
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Graziana Scavone
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Silvia Ottonello
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Maria Maddalena Latocca
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Roberto Borea
- Department of Internal Medicine and Medical Specialties (Di.M.I.), School of Medicine, University of Genova, Genoa, Italy
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Silvia Puglisi
- Department of Internal Medicine and Medical Specialties (Di.M.I.), School of Medicine, University of Genova, Genoa, Italy
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Maurizio Cosso
- Department of Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alessandra Fozza
- Department of Radiotherapy, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Stefano Spinaci
- Division of Breast Surgery, Ospedale Villa Scassi, Genoa, Italy
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (Di.M.I.), School of Medicine, University of Genova, Genoa, Italy
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Crowther CA, Ashwood P, Middleton PF, McPhee A, Tran T, Harding JE. Prenatal Intravenous Magnesium at 30-34 Weeks' Gestation and Neurodevelopmental Outcomes in Offspring: The MAGENTA Randomized Clinical Trial. JAMA 2023; 330:603-614. [PMID: 37581672 PMCID: PMC10427942 DOI: 10.1001/jama.2023.12357] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/16/2023] [Indexed: 08/16/2023]
Abstract
Importance Intravenous magnesium sulfate administered to pregnant individuals before birth at less than 30 weeks' gestation reduces the risk of death and cerebral palsy in their children. The effects at later gestational ages are unclear. Objective To determine whether administration of magnesium sulfate at 30 to 34 weeks' gestation reduces death or cerebral palsy at 2 years. Design, Setting, and Participants This randomized clinical trial enrolled pregnant individuals expected to deliver at 30 to 34 weeks' gestation and was conducted at 24 Australian and New Zealand hospitals between January 2012 and April 2018. Intervention Intravenous magnesium sulfate (4 g) was compared with placebo. Main Outcomes and Measures The primary outcome was death (stillbirth, death of a live-born infant before hospital discharge, or death after hospital discharge before 2 years' corrected age) or cerebral palsy (loss of motor function and abnormalities of muscle tone and power assessed by a pediatrician) at 2 years' corrected age. There were 36 secondary outcomes that assessed the health of the pregnant individual, infant, and child. Results Of the 1433 pregnant individuals enrolled (mean age, 30.6 [SD, 6.6] years; 46 [3.2%] self-identified as Aboriginal or Torres Strait Islander, 237 [16.5%] as Asian, 82 [5.7%] as Māori, 61 [4.3%] as Pacific, and 966 [67.4%] as White) and their 1679 infants, 1365 (81%) offspring (691 in the magnesium group and 674 in the placebo group) were included in the primary outcome analysis. Death or cerebral palsy at 2 years' corrected age was not significantly different between the magnesium and placebo groups (3.3% [23 of 691 children] vs 2.7% [18 of 674 children], respectively; risk difference, 0.61% [95% CI, -1.27% to 2.50%]; adjusted relative risk [RR], 1.19 [95% CI, 0.65 to 2.18]). Components of the primary outcome did not differ between groups. Neonates in the magnesium group were less likely to have respiratory distress syndrome vs the placebo group (34% [294 of 858] vs 41% [334 of 821], respectively; adjusted RR, 0.85 [95% CI, 0.76 to 0.95]) and chronic lung disease (5.6% [48 of 858] vs 8.2% [67 of 821]; adjusted RR, 0.69 [95% CI, 0.48 to 0.99]) during the birth hospitalization. No serious adverse events occurred; however, adverse events were more likely in pregnant individuals who received magnesium vs placebo (77% [531 of 690] vs 20% [136 of 667], respectively; adjusted RR, 3.76 [95% CI, 3.22 to 4.39]). Fewer pregnant individuals in the magnesium group had a cesarean delivery vs the placebo group (56% [406 of 729] vs 61% [427 of 704], respectively; adjusted RR, 0.91 [95% CI, 0.84 to 0.99]), although more in the magnesium group had a major postpartum hemorrhage (3.4% [25 of 729] vs 1.7% [12 of 704] in the placebo group; adjusted RR, 1.98 [95% CI, 1.01 to 3.91]). Conclusions and Relevance Administration of intravenous magnesium sulfate prior to preterm birth at 30 to 34 weeks' gestation did not improve child survival free of cerebral palsy at 2 years, although the study had limited power to detect small between-group differences. Trial Registration anzctr.org.au Identifier: ACTRN12611000491965.
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Affiliation(s)
- Caroline A. Crowther
- Liggins Institute, University of Auckland, Auckland, New Zealand
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Pat Ashwood
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Philippa F. Middleton
- School of Medicine, University of Adelaide, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide
| | - Andrew McPhee
- South Australian Health and Medical Research Institute, Adelaide
- Department of Neonatal Medicine, Women’s and Children’s Hospital, Adelaide, Australia
| | - Thach Tran
- School of Biomedical Engineering, University of Technology Sydney, Sydney, Australia
| | - Jane E. Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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Navalón P, Campos-Berga L, Buesa J, Lizarán M, Ghosn F, Almansa B, Moreno-Giménez A, Vento M, Diago V, García-Blanco A. Rescue doses of antenatal corticosteroids, children's neurodevelopment, and salivary cortisol after a threatened preterm labor: a 30-month follow-up study. Am J Obstet Gynecol MFM 2023; 5:100918. [PMID: 36882125 DOI: 10.1016/j.ajogmf.2023.100918] [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: 11/28/2022] [Revised: 02/21/2023] [Accepted: 03/01/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Antenatal corticosteroids reduce neonatal complications when administered to women at risk for preterm birth. Moreover, antenatal corticosteroid rescue doses are recommended for women who remain at risk after the initial course. However, there is controversy about the most appropriate frequency and the exact timing of administering additional antenatal corticosteroid doses because there are potential long-term negative effects on infants' neurodevelopment and physiological stress functioning. OBJECTIVE This study aimed to (1) to assess the long-term neurodevelopmental effects of receiving antenatal corticosteroid rescue doses in comparison with receiving only the initial course; (2) to measure the cortisol levels of infants of mothers who received antenatal corticosteroid rescue doses; (3) to examine a potential dose-response effect of the number of antenatal corticosteroid rescue doses on children's neurodevelopment and salivary cortisol. STUDY DESIGN This study followed 110 mother-infant pairs who underwent a spontaneous episode of threatened preterm labor until the children were 30 months old, regardless of their gestational age at birth. Among the participants, 61 received only the initial course of corticosteroids (no rescue dose group), and 49 participants required at least one rescue dose of corticosteroids (rescue doses group). The follow-up was carried out at 3 different times, namely at threatened preterm labor diagnosis (T1), when the children were 6 months of age (T2), and when the children were 30 months of corrected age for prematurity (T3). Neurodevelopment was assessed using the Ages & Stages Questionnaires, Third Edition. Saliva samples were collected for cortisol level determination. RESULTS First, the rescue doses group showed lower problem-solving skills at 30 months of age than the no rescue doses group. Second, the rescue doses group demonstrated higher salivary cortisol levels at 30 months of age. Third, a dose-response effect was found that indicated that the more rescue doses the rescue doses group received, the lower the problem-solving skills and the higher the salivary cortisol levels at 30 months of age. CONCLUSION Our findings reinforce the hypothesis that additional antenatal corticosteroid doses provided after the initial course may have long-term effects on the neurodevelopment and glucocorticoid metabolism of the offspring. In this regard, the results raise concerns about the negative effects of repeated doses of antenatal corticosteroids in addition to a full course. Further studies are necessary to confirm this hypothesis to help physicians reassess the standard antenatal corticosteroid treatment regimens.
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Affiliation(s)
- Pablo Navalón
- Neonatal Research Group, La Fe Health Research Institute, Valencia, Spain (Drs Navalón, Campos-Berga, and Buesa, Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez, and Drs Vento and García-Blanco); Division of Psychiatry and Clinical Psychology, La Fe University and Polytechnic Hospital, Valencia, Spain (Drs Navalón, Campos-Berga, Buesa, and García-Blanco)
| | - Laura Campos-Berga
- Neonatal Research Group, La Fe Health Research Institute, Valencia, Spain (Drs Navalón, Campos-Berga, and Buesa, Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez, and Drs Vento and García-Blanco); Division of Psychiatry and Clinical Psychology, La Fe University and Polytechnic Hospital, Valencia, Spain (Drs Navalón, Campos-Berga, Buesa, and García-Blanco)
| | - Julia Buesa
- Neonatal Research Group, La Fe Health Research Institute, Valencia, Spain (Drs Navalón, Campos-Berga, and Buesa, Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez, and Drs Vento and García-Blanco); Division of Psychiatry and Clinical Psychology, La Fe University and Polytechnic Hospital, Valencia, Spain (Drs Navalón, Campos-Berga, Buesa, and García-Blanco)
| | - Marta Lizarán
- Neonatal Research Group, La Fe Health Research Institute, Valencia, Spain (Drs Navalón, Campos-Berga, and Buesa, Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez, and Drs Vento and García-Blanco); Department of Personality, Evaluation, and Psychological Treatments, Faculty of Psychology, University of Valencia, Valencia, Spain (Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez and Dr García-Blanco)
| | - Farah Ghosn
- Neonatal Research Group, La Fe Health Research Institute, Valencia, Spain (Drs Navalón, Campos-Berga, and Buesa, Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez, and Drs Vento and García-Blanco); Department of Personality, Evaluation, and Psychological Treatments, Faculty of Psychology, University of Valencia, Valencia, Spain (Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez and Dr García-Blanco)
| | - Belén Almansa
- Neonatal Research Group, La Fe Health Research Institute, Valencia, Spain (Drs Navalón, Campos-Berga, and Buesa, Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez, and Drs Vento and García-Blanco); Department of Personality, Evaluation, and Psychological Treatments, Faculty of Psychology, University of Valencia, Valencia, Spain (Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez and Dr García-Blanco)
| | - Alba Moreno-Giménez
- Neonatal Research Group, La Fe Health Research Institute, Valencia, Spain (Drs Navalón, Campos-Berga, and Buesa, Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez, and Drs Vento and García-Blanco); Department of Personality, Evaluation, and Psychological Treatments, Faculty of Psychology, University of Valencia, Valencia, Spain (Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez and Dr García-Blanco)
| | - Máximo Vento
- Neonatal Research Group, La Fe Health Research Institute, Valencia, Spain (Drs Navalón, Campos-Berga, and Buesa, Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez, and Drs Vento and García-Blanco); Division of Neonatology, La Fe University and Polytechnic Hospital, Valencia, Spain (Dr Vento)
| | - Vicente Diago
- Division of Obstetrics and Gynecology, La Fe University and Polytechnic Hospital, Valencia, Spain (Dr Diago)
| | - Ana García-Blanco
- Neonatal Research Group, La Fe Health Research Institute, Valencia, Spain (Drs Navalón, Campos-Berga, and Buesa, Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez, and Drs Vento and García-Blanco); Division of Psychiatry and Clinical Psychology, La Fe University and Polytechnic Hospital, Valencia, Spain (Drs Navalón, Campos-Berga, Buesa, and García-Blanco); Department of Personality, Evaluation, and Psychological Treatments, Faculty of Psychology, University of Valencia, Valencia, Spain (Mses Lizarán, Ghosn, Almansa, and Moreno-Giménez and Dr García-Blanco).
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Liauw J, Foggin H, Socha P, Crane J, Joseph KS, Burrows J, Lacaze-Masmonteil T, Jain V, Boutin A, Hutcheon J. Technical Update No. 439: Antenatal Corticosteroids at Late Preterm Gestation. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:445-457.e2. [PMID: 36572248 DOI: 10.1016/j.jogc.2022.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To update recommendations for administration of antenatal corticosteroids in the late preterm period. TARGET POPULATION Pregnant individuals at risk of preterm birth from 340 to 366 weeks gestation. OPTIONS Administration or non-administration of a single course of antenatal corticosteroids at 340 to 366 weeks gestation. OUTCOMES Neonatal morbidity (respiratory distress, hypoglycemia), long-term neurodevelopment, and other long-term outcomes (growth, cardiac/metabolic, respiratory). BENEFITS, HARMS, AND COSTS Administration of antenatal corticosteroids from 340 to 366 weeks gestation decreases the risk of neonatal respiratory distress but increases the risk of neonatal hypoglycemia. The long-term impacts of antenatal corticosteroid administration from 340 to 366 weeks gestation are uncertain. EVIDENCE For evidence on the neonatal effects of antenatal corticosteroid administration at late preterm gestation, we summarized evidence from the 2020 Cochrane review of antenatal corticosteroids and combined this with evidence from published randomized trials identified by searching Ovid MEDLINE from January 1, 2020, to May 11, 2022. Given the absence of direct evidence on the impact of late preterm antenatal corticosteroid administration on neurodevelopmental outcomes, we summarized evidence on the impact of antenatal corticosteroids across gestational ages on neurodevelopmental outcomes using the following sources: (1) the 2020 Cochrane review; and (2) evidence obtained by searching Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to January 5, 2022. We did not apply date or language restrictions. Given the absence of direct evidence on the impact of late preterm antenatal corticosteroid administration on other long-term outcomes, we summarized evidence on the impact of antenatal corticosteroids across gestational ages on other long-term outcomes by combining findings from the 2020 Cochrane review with evidence obtained by searching Ovid MEDLINE for observational studies related to long-term cardiometabolic, respiratory, and growth effects of antenatal corticosteroids from inception to October 22, 2021. We reviewed reference lists of included studies and relevant systematic reviews for additional references. See Appendix A for search terms and summaries. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix B (Tables B1 for definitions and B2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE Maternity care providers, including midwives, family physicians, and obstetricians. SUMMARY STATEMENTS RECOMMENDATIONS.
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Mise à jour technique no 439 : Corticothérapie prénatale en période de prématurité tardive. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 45:458-472.e2. [PMID: 36572247 DOI: 10.1016/j.jogc.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Chawanpaiboon S, Pooliam J, Chuchotiros M. A case-control study on the effects of incomplete, one, and more than one dexamethasone course on acute respiratory problems in preterm neonates born between 28 0 and 36 6 weeks of gestation. BMC Pregnancy Childbirth 2022; 22:880. [PMID: 36443697 PMCID: PMC9703789 DOI: 10.1186/s12884-022-05209-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/11/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To compare the effects of an incomplete course and more than 1 course of dexamethasone, relative to a control of a single complete course, on foetal respiratory problems and other adverse outcomes of preterm birth. METHODS This was a retrospective chart review of 1800 women with preterm delivery. Data were collected on newborns whose mothers administered 1 full course of dexamethasone (916/1800; 50.9%), a partial course (716/1800; 39.8%) and more than 1 course (168/1800; 9.3%). Demographic data and adverse maternal and neonatal outcomes were recorded. RESULTS Preterm singleton newborns whose mothers received several steroid hormone courses were significantly more likely to have adverse outcomes than newborns of mothers given 1 course. The negative outcomes were the need for positive pressure ventilation ([aOR] 1.831; 95% CI, (1.185,2.829); P = 0.019), ventilator support ([aOR] 1.843; 95% CI, (1.187,2.861); P = 0.011), and phototherapy ([aOR] 1.997; 95% CI, (1.378,2.895); P < 0.001), transient tachypnoea of the newborn ([aOR] 1.801; 95% CI, (1.261,2.571); P = 0.002), intraventricular haemorrhage ([aOR] 2.215; 95% CI, (1.159, 4.233); P = 0.027), sepsis ([aOR] 1.737; 95% CI, (1.086, 2.777); P = 0.007), and admission to neonatal intensive care ([aOR] 1.822; 95% CI, (1.275,2.604); P = 0.001). In the group of very preterm infants, newborns of mothers administered an incomplete course had developed respiratory distress syndrome (RDS) ([aOR] 3.177; 95% CI, (1.485, 6.795); P = 0.006) and used ventilatory support ([aOR] 3.565; 95% CI, (1.912, 6.650); P < 0.001) more than those of mothers receiving a single course. CONCLUSIONS Preterm singleton newborns whose mothers were given multiple courses of dexamethasone had an increased incidence of RDS and other adverse outcomes than those of mothers receiving a full course. However, very preterm newborns whose mothers were administered 1 full dexamethasone course had a significantly lower incidence of RDS than those whose mothers were given partial courses.
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Affiliation(s)
- Saifon Chawanpaiboon
- grid.10223.320000 0004 1937 0490Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynaecology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700 Thailand
| | - Julaporn Pooliam
- grid.10223.320000 0004 1937 0490Clinical Epidemiological Unit, Office for Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700 Thailand
| | - Monsak Chuchotiros
- grid.10223.320000 0004 1937 0490Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynaecology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700 Thailand
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Tao S, Du J, Chi X, Zhu Y, Wang X, Meng Q, Ling X, Diao F, Song C, Jiang Y, Lv H, Lu Q, Qin R, Huang L, Xu X, Liu C, Ding Y, Jiang T, Ma H, Xia Y, Liu J, Lin Y, Jin G, Hu Z. Associations between antenatal corticosteroid exposure and neurodevelopment in infants. Am J Obstet Gynecol 2022; 227:759.e1-759.e15. [PMID: 35667419 DOI: 10.1016/j.ajog.2022.05.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/21/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND It has been well recognized that antenatal administration of dexamethasone to pregnant women at risk of preterm delivery may markedly accelerate fetal maturation and reduce the risk of adverse perinatal outcomes in their preterm infants, particularly for births before 34 weeks of gestation. Since 2015, antenatal corticosteroid administration has been extended beyond 34 weeks of gestation by clinical guidelines, as it might have beneficial effects on fetal maturation and perinatal outcomes. However, concerns regarding the potential influence of antenatal corticosteroid treatment on offspring neurodevelopment have been raised. OBJECTIVE This study aimed to investigate whether maternal antenatal corticosteroid administration was associated with neurodevelopment in infants at 1 year of age. STUDY DESIGN In this prospective and longitudinal birth cohort study, women were followed up throughout gestation, and their infants underwent a Bayley Scales of Infant and Toddler Development, Third Edition, screening test at 1 year of age between December 2018 and September 2020. Finally, 1609 pregnant women and 1759 infants were included in the current study. Using a generalized linear mixed model, we examined the association between antenatal corticosteroid exposure and infant neurodevelopment in cognitive, receptive communication, expressive communication, fine motor, and gross motor functions. RESULTS Of the 1759 infants eligible for this study, 1453 (82.6%) were singletons. A total of 710 infants were exposed to antenatal corticosteroids, among whom 415 were dexamethasone exposed and 483 were prednisone exposed. Dexamethasone was prescribed most often in late pregnancy, whereas prednisone was often used before 8 weeks of gestation among women who conceived through assisted reproductive technology. Compared with those who had no exposure, antenatal corticosteroid exposure was associated with an increased risk of infants being noncompetent in the cognitive development domain after adjusting for conventional risk factors (adjusted risk ratio, 1.53; 95% confidence interval, 1.08-2.18; P=.017). For medication-specific exposure, those exposed vs not exposed to antenatal dexamethasone were 1.62-fold (95% confidence interval, 1.10-2.38; P=.014) more likely to be noncompetent in the cognitive development domain at 1 year. The association did not vary markedly between preterm and term infants, singletons and twins, or assisted reproductive technology-conceived and spontaneously conceived infants (all P>.05 for heterogeneity). In contrast, a null association was observed for the risk of being noncompetent in any domain of neurodevelopment with antenatal prednisone exposure at early pregnancy. CONCLUSION Here, antenatal corticosteroid, particularly dexamethasone exposure, was markedly associated with an increased risk of infants being noncompetent in the cognitive development domain at 1 year of age. These findings may provide new information when weighing the benefits and potential risks of maternal antenatal corticosteroid administration.
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Affiliation(s)
- Shiyao Tao
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jiangbo Du
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China; State Key Laboratory of Reproductive Medicine (Suzhou Centre), Nanjing Medical University Affiliated Suzhou Hospital, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Xia Chi
- Department of Child Health Care, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu, China
| | - Yeyi Zhu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Xiaoyan Wang
- Department of Obstetrics, Nanjing Medical University Affiliated Suzhou Hospital, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Qingxia Meng
- State Key Laboratory of Reproductive Medicine (Suzhou Centre), Nanjing Medical University Affiliated Suzhou Hospital, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China; Reproductive Genetic Center, Nanjing Medical University Affiliated Suzhou Hospital, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Xiufeng Ling
- Department of Reproduction, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu, China
| | - Feiyang Diao
- Clinical Center of Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ci Song
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yangqian Jiang
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hong Lv
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China; State Key Laboratory of Reproductive Medicine (Suzhou Centre), Nanjing Medical University Affiliated Suzhou Hospital, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Qun Lu
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Rui Qin
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lei Huang
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xin Xu
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Cong Liu
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yuqing Ding
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Tao Jiang
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hongxia Ma
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China; State Key Laboratory of Reproductive Medicine (Suzhou Centre), Nanjing Medical University Affiliated Suzhou Hospital, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Yankai Xia
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; Key Laboratory of Modern Toxicology of Ministry of Education, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jiayin Liu
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; State Key Laboratory of Reproductive Medicine (Suzhou Centre), Nanjing Medical University Affiliated Suzhou Hospital, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China; Clinical Center of Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yuan Lin
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; State Key Laboratory of Reproductive Medicine (Suzhou Centre), Nanjing Medical University Affiliated Suzhou Hospital, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China; Department of Maternal, Child, and Adolescent Health, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Guangfu Jin
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China; State Key Laboratory of Reproductive Medicine (Suzhou Centre), Nanjing Medical University Affiliated Suzhou Hospital, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Zhibin Hu
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China; State Key Laboratory of Reproductive Medicine (Suzhou Centre), Nanjing Medical University Affiliated Suzhou Hospital, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, China.
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Schmitz T, Doret-Dion M, Sentilhes L, Parant O, Claris O, Renesme L, Abbal J, Girault A, Torchin H, Houllier M, Le Saché N, Vivanti AJ, De Luca D, Winer N, Flamant C, Thuillier C, Boileau P, Blanc J, Brevaut V, Bouet PE, Gascoin G, Beucher G, Datin-Dorriere V, Bounan S, Bolot P, Poncelet C, Alberti C, Ursino M, Aupiais C, Baud O. Neonatal outcomes for women at risk of preterm delivery given half dose versus full dose of antenatal betamethasone: a randomised, multicentre, double-blind, placebo-controlled, non-inferiority trial. Lancet 2022; 400:592-604. [PMID: 35988568 DOI: 10.1016/s0140-6736(22)01535-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 07/10/2022] [Accepted: 08/04/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Antenatal betamethasone is recommended before preterm delivery to accelerate fetal lung maturation. However, reports of growth and neurodevelopmental dose-related side-effects suggest that the current dose (12 mg plus 12 mg, 24 h apart) might be too high. We therefore investigated whether a half dose would be non-inferior to the current full dose for preventing respiratory distress syndrome. METHODS We designed a randomised, multicentre, double-blind, placebo-controlled, non-inferiority trial in 37 level 3 referral perinatal centres in France. Eligible participants were pregnant women aged 18 years or older with a singleton fetus at risk of preterm delivery and already treated with the first injection of antenatal betamethasone (11·4 mg) before 32 weeks' gestation. We used a computer-generated code producing permuted blocks of varying sizes to randomly assign (1:1) women to receive either a placebo (half-dose group) or a second 11·4 mg betamethasone injection (full-dose group) 24 h later. Randomisation was stratified by gestational age (before or after 28 weeks). Participants, clinicians, and study staff were masked to the treatment allocation. The primary outcome was the need for exogenous intratracheal surfactant within 48 h after birth. Non-inferiority would be shown if the higher limit of the 95% CI for the between-group difference between the half-dose and full-dose groups in the primary endpoint was less than 4 percentage points (corresponding to a maximum relative risk of 1·20). Four interim analyses monitoring the primary and the secondary safety outcomes were done during the study period, using a sequential data analysis method that provided futility and non-inferiority stopping rules and checked for type I and II errors. Interim analyses were done in the intention-to-treat population. This trial was registered with ClinicalTrials.gov, NCT02897076. FINDINGS Between Jan 2, 2017, and Oct 9, 2019, 3244 women were randomly assigned to the half-dose (n=1620 [49·9%]) or the full-dose group (n=1624 [50·1%]); 48 women withdrew consent, 30 fetuses were stillborn, 16 neonates were lost to follow-up, and 9 neonates died before evaluation, so that 3141 neonates remained for analysis. In the intention-to-treat analysis, the primary outcome occurred in 313 (20·0%) of 1567 neonates in the half-dose group and 276 (17·5%) of 1574 neonates in the full-dose group (risk difference 2·4%, 95% CI -0·3 to 5·2); thus non-inferiority was not shown. The per-protocol analysis also did not show non-inferiority (risk difference 2·2%, 95% CI -0·6 to 5·1). No between-group differences appeared in the rates of neonatal death, grade 3-4 intraventricular haemorrhage, stage ≥2 necrotising enterocolitis, severe retinopathy of prematurity, or bronchopulmonary dysplasia. INTERPRETATION Because non-inferiority of the half-dose compared with the full-dose regimen was not shown, our results do not support practice changes towards antenatal betamethasone dose reduction. FUNDING French Ministry of Health.
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Affiliation(s)
- Thomas Schmitz
- Department of Obstetrics and Gynaecology, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Université Paris Cité, Centre for Research in Epidemiology and Statistics, INSERM U1153, INRA, Paris, France.
| | - Muriel Doret-Dion
- Department of Obstetrics and Gynaecology, Hospital Femme-Mère-Enfant, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Lyon, France
| | - Loic Sentilhes
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Bordeaux, France
| | - Olivier Parant
- Department of Obstetrics and Gynaecology, Toulouse University Hospital, Toulouse, France
| | - Olivier Claris
- Department of Neonatology, Hospital Femme-Mère-Enfant, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Lyon, France
| | - Laurent Renesme
- Department of Neonatology, Bordeaux University Hospital, Bordeaux, France
| | - Julie Abbal
- Department of Neonatology, Toulouse University Hospital, Toulouse, France
| | - Aude Girault
- Université Paris Cité, Centre for Research in Epidemiology and Statistics, INSERM U1153, INRA, Paris, France; MaternitéPort-Royal, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Héloïse Torchin
- Université Paris Cité, Centre for Research in Epidemiology and Statistics, INSERM U1153, INRA, Paris, France; Department of Neonatology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie Houllier
- Department of Obstetrics and Gynaecology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nolwenn Le Saché
- Department of Neonatology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alexandre J Vivanti
- Department of Obstetrics and Gynaecology, Antoine Béclère Hospital, Assistance Publique-Hôpitaux de Paris, Paris, Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
| | - Daniele De Luca
- Department of Neonatology, Antoine Béclère Hospital, Assistance Publique-Hôpitaux de Paris, Paris, Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
| | - Norbert Winer
- Department of Obstetrics and Gynaecology, University Medical Centre of Nantes, Centre d'Investigation Clinique CIC Mere enfant, Nantes, France; National Institute of Agricultural Research, UMR 1280, Physiology of Nutritional Adaptations, University of Nantes, IMAD and CRNH-Ouest, Nantes, France
| | - Cyril Flamant
- Department of Neonatology, Nantes University Hospital, Nantes, France
| | - Claire Thuillier
- Department of Obstetrics and Gynaecology, Poissy Hospital Centre, Poissy, France
| | - Pascal Boileau
- Department of Neonatology, Poissy Hospital Centre, Poissy, France
| | - Julie Blanc
- Department of Obstetrics and Gynaecology, Marseille Nord University Hospital, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Véronique Brevaut
- Department of Neonatology, Marseille Nord University Hospital, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Pierre-Emmanuel Bouet
- Department of Obstetrics and Gynaecology, Angers University Hospital, Angers, France
| | - Géraldine Gascoin
- Department of Neonatology, Angers University Hospital, Angers, France
| | - Gaël Beucher
- Department of Obstetrics and Gynaecology, Caen University Hospital, Caen, France
| | | | - Stéphane Bounan
- Department of Obstetrics and Gynaecology, Saint-Denis Hospital, Saint-Denis, France
| | - Pascal Bolot
- Department of Neonatology, Saint-Denis Hospital, Saint-Denis, France
| | - Christophe Poncelet
- Department of Obstetrics and Gynaecology, Pontoise Hospital, Pontoise, France
| | - Corinne Alberti
- Clinical Epidemiology Unit, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Université Paris Cité, INSERM U1123, ECEVE, Paris, France
| | - Moreno Ursino
- Clinical Epidemiology Unit, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Centre de Recherche des Cordeliers, Université Paris Cité, INSERM U1138, Inria, HeKA, Paris, France
| | - Camille Aupiais
- Université Paris Cité, INSERM U1123, ECEVE, Paris, France; Paediatric Emergency Department, Jean Verdier Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Paris Nord University, Paris, France
| | - Olivier Baud
- Université Paris Cité, INSERM U1141, Paris, France; Division of Neonatology and Paediatric Intensive Care, Children's University Hospital of Geneva and University of Geneva, Geneva, Switzerland.
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Harding JE, Rajay AB, Alsweiler JM, Brown G, Crowther CA, Franke N, Gamble G, McKinlay C, Milne B, Rogers J, Wouldes T. Different Approaches to requesting Consent for Routine data linkage in Neonatal follow-up (ACORN): protocol for a 2×2 factorial randomised trial. BMJ Open 2022; 12:e060476. [PMID: 35831046 PMCID: PMC9280877 DOI: 10.1136/bmjopen-2021-060476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Routinely collected data can be linked to research data to create a rich dataset and inform practice. However, consent is normally required to link identifiable data. Reported rates of consent to data linkage for children ranged from 21% to 96%, but no studies have investigated different approaches to seeking consent for data linkage for school-age children. METHODS AND ANALYSIS The Approaches to Consent for Routine Data Linkage in Neonatal Follow-up (ACORN) trial is a 2×2 factorial randomised trial to assess whether, for children who participated in neonatal randomised trials (pre-hypoglycaemia Prevention with Oral Dextrose Gel (hPOD), hPOD and The Impact of Protein Intravenous Nutrition on Development in Extremely Low Birth Weight Babies (ProVIDe)) and are approached to participate in an in-person assessment at 6-7 years of age, parental consent to data linkage is higher if consent is sought (1) after the in-person assessment (delayed) or concurrently and (2) for health and education data combined or separately. The primary outcomes will be rates of consent to linkage of (1) either health or education data and (2) both health and education data. A pilot study indicates the potentially available cohort size of 2110 (80% follow-up of the neonatal trial cohorts) would be adequate to detect an absolute difference of 6%-5%-4% from a baseline consent rate of 70%-85%-90%, respectively (2-tailed alpha 0.05, 90% power). With at least 1136 participants, the ACORN trial would have 90% power to detect an absolute difference of 5% in the primary outcome for each factor, assuming a consent rate of 90% in the control groups and alpha 0.05. Data are categorical and will be presented as number and per cent. The effects of factors will be tested using generalised linear models and presented as ORs and 95% CIs. ETHICS AND DISSEMINATION Ethics approval by the New Zealand Health and Disability Ethics Committee (19/STH/202). Dissemination will be via peer-reviewed publications, scientific meetings, educational sessions and public fora. TRIAL REGISTRATION NUMBER ACTRN12621000571875 (Australian New Zealand Clinical Trials Registry).
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Affiliation(s)
- Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | | | - Jane Marie Alsweiler
- Department of Paediatrics Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Gavin Brown
- Faculty of Education and Social Work, The University of Auckland, Auckland, New Zealand
| | | | - Nike Franke
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Greg Gamble
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Christopher McKinlay
- Liggins Institute, The University of Auckland, Auckland, New Zealand
- Department of Paediatrics Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Barry Milne
- Centre of Methods and Policy Application in the Social Sciences, The University of Auckland, Auckland, New Zealand
| | - Jenny Rogers
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Trecia Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
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Aviram A, Murphy K, McDonald S, Asztalos E, Zaltz A, Redelmeier D, Shah B, Barrett J, Melamed N. Antenatal corticosteroids and neurodevelopmental outcomes in late preterm births. Arch Dis Child Fetal Neonatal Ed 2022; 107:250-255. [PMID: 34588179 DOI: 10.1136/archdischild-2021-322152] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 09/07/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Antenatal corticosteroids (ACS) decrease neonatal mortality and morbidity among preterm neonates, yet there has been concern regarding their long-term safety. We hypothesised that potential long-term adverse effects of ACS may be observed among infants born during the late preterm period (LPT, 340/7-366/7 weeks of gestation), when the benefits of ACS are subtle. DESIGN Population-based, retrospective cohort. SETTING Ontario, Canada, between 2006 and 2011. PATIENTS All live singleton infants born during the LPT period with a minimum 5-year follow-up. INTERVENTIONS Exposure to ACS prior to 340/7 weeks of gestation. MAIN OUTCOME MEASURES Suspected neurocognitive disorder, audiometry testing or visual testing. RESULTS Overall, 25 668 infants were eligible for analysis, of whom 2689 (10.5%) received ACS. Infants in the ACS group had lower mean birth weight and higher rates of birth weight <10th percentile, neonatal resuscitation and neonatal intensive care unit admission. At 5 years of age, ACS exposure was associated with an increased risk of suspected neurocognitive disorder (adjusted HR (aHR) 1.12, 95% CI 1.05 to 1.20), audiometry testing (aHR 1.20, 95% CI 1.10 to 1.31) and visual testing (aHR 1.06, 95% CI 1.01 to 1.11). CONCLUSION In children born during the LPT period, exposure to ACS prior to 340/7 weeks of gestation is associated with an increased utilisation of the healthcare system related to audiometry and visual testing and suspected neurocognitive disorders by 5 years of age.
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Affiliation(s)
- Amir Aviram
- DAN Women & Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Kellie Murphy
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
- Division of Maternal-Fetal Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Sarah McDonald
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Elizabeth Asztalos
- Newborn and Developmental Paediatrics, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
| | - Arthur Zaltz
- DAN Women & Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Donald Redelmeier
- Department of Medicine, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Baiju Shah
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jon Barrett
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nir Melamed
- DAN Women & Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
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Walters A, McKinlay C, Middleton P, Harding JE, Crowther CA. Repeat doses of prenatal corticosteroids for women at risk of preterm birth for improving neonatal health outcomes. Cochrane Database Syst Rev 2022; 4:CD003935. [PMID: 35377461 PMCID: PMC8978608 DOI: 10.1002/14651858.cd003935.pub5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Infants born preterm (before 37 weeks' gestation) are at risk of respiratory distress syndrome (RDS) and need for respiratory support due to lung immaturity. One course of prenatal corticosteroids, administered to women at risk of preterm birth, reduces the risk of respiratory morbidity and improves survival of their infants, but these benefits do not extend beyond seven days. Repeat doses of prenatal corticosteroids have been used for women at ongoing risk of preterm birth more than seven days after their first course of corticosteroids, with improvements in respiratory outcomes, but uncertainty remains about any long-term benefits and harms. This is an update of a review last published in 2015. OBJECTIVES To assess the effectiveness and safety, using the best available evidence, of a repeat dose(s) of prenatal corticosteroids, given to women who remain at risk of preterm birth seven or more days after an initial course of prenatal corticosteroids with the primary aim of reducing fetal and neonatal mortality and morbidity. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials, including cluster-randomised trials, of women who had already received one course of corticosteroids seven or more days previously and were still at risk of preterm birth, randomised to further dose(s) or no repeat doses, with or without placebo. Quasi-randomised trials were excluded. Abstracts were accepted if they met specific criteria. All trials had to meet criteria for trustworthiness, including a search of the Retraction Watch database for retractions or expressions of concern about the trials or their publications. DATA COLLECTION AND ANALYSIS We used standard Cochrane Pregnancy and Childbirth methods. Two review authors independently selected trials, extracted data, and assessed trial quality and scientific integrity. We chose primary outcomes based on clinical importance as measures of effectiveness and safety, including serious outcomes, for the women and their fetuses/infants, infants in early childhood (age two to less than five years), the infant in mid- to late childhood (age five to less than 18 years) and the infant as an adult. We assessed risk of bias at the outcome level using the RoB 2 tool and assessed certainty of evidence using GRADE. MAIN RESULTS We included 11 trials (4895 women and 5975 babies). High-certainty evidence from these trials indicated that treatment of women who remain at risk of preterm birth seven or more days after an initial course of prenatal corticosteroids with repeat dose(s) of corticosteroids, compared with no repeat corticosteroid treatment, reduced the risk of their infants experiencing the primary infant outcome of RDS (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.90; 3540 babies; number needed to treat for an additional beneficial outcome (NNTB) 16, 95% CI 11 to 29) and had little or no effect on chronic lung disease (RR 1.00, 95% CI 0.83 to 1.22; 5661 babies). Moderate-certainty evidence indicated that the composite of serious infant outcomes was probably reduced with repeat dose(s) of corticosteroids (RR 0.88, 95% CI 0.80 to 0.97; 9 trials, 5736 babies; NNTB 39, 95% CI 24 to 158), as was severe lung disease (RR 0.83, 95% CI 0.72 to 0.97; NNTB 45, 95% CI 27 to 256; 4955 babies). Moderate-certainty evidence could not exclude benefit or harm for fetal or neonatal or infant death less than one year of age (RR 0.95, 95% CI 0.73 to 1.24; 5849 babies), severe intraventricular haemorrhage (RR 1.13, 95% CI 0.69 to 1.86; 5066 babies) and necrotising enterocolitis (RR 0.84, 95% CI 0.59 to 1.22; 5736 babies). In women, moderate-certainty evidence found little or no effect on the likelihood of a caesarean birth (RR 1.03, 95% CI 0.98 to 1.09; 4266 mothers). Benefit or harm could not be excluded for maternal death (RR 0.32, 95% 0.01 to 7.81; 437 women) and maternal sepsis (RR 1.13, 95% CI 0.93 to 1.39; 4666 mothers). The evidence was unclear for risk of adverse effects and discontinuation of therapy due to maternal adverse effects. No trials reported breastfeeding status at hospital discharge or risk of admission to the intensive care unit. At early childhood follow-up, moderate- to high-certainty evidence identified little or no effect of exposure to repeat prenatal corticosteroids compared with no repeat corticosteroids for primary outcomes relating to neurodevelopment (neurodevelopmental impairment: RR 0.97, 95% CI 0.85 to 1.10; 3616 children), survival without neurodevelopmental impairment (RR 1.01, 95% CI 0.98 to 1.04; 3845 children) and survival without major neurodevelopmental impairment (RR 1.02, 95% CI 0.98 to 1.05; 1816 children). An increase or decrease in the risk of death since randomisation could not be excluded (RR 1.06, 95% CI 0.81 to 1.40; 5 trials, 4565 babies randomised). At mid-childhood follow-up, moderate-certainty evidence identified little or no effect of exposure to repeat prenatal corticosteroids compared with no repeat corticosteroids on survival free of neurocognitive impairment (RR 1.01, 95% CI 0.95 to 1.08; 963 children) or survival free of major neurocognitive impairment (RR 1.00, 95% CI 0.97 to 1.04; 2682 children). Benefit or harm could not be excluded for death since randomisation (RR 0.93, 95% CI 0.69 to 1.26; 2874 babies randomised) and any neurocognitive impairment (RR 0.96, 95% CI 0.72 to 1.29; 897 children). No trials reported data for follow-up into adolescence or adulthood. Risk of bias across outcomes was generally low although there were some concerns of bias. For childhood follow-up, most outcomes had some concerns of risk of bias due to missing data from loss to follow-up. AUTHORS' CONCLUSIONS The short-term benefits for babies included less respiratory distress and fewer serious health problems in the first few weeks after birth with repeat dose(s) of prenatal corticosteroids for women still at risk of preterm birth seven days or more after an initial course. The current available evidence reassuringly shows no significant harm for the women or child in early and mid-childhood, although no benefit. Further research is needed on the long-term benefits and risks for the baby into adulthood.
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Affiliation(s)
- Anthony Walters
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | | | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
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Di Cosmo C, De Marco G, Agretti P, Ferrarini E, Dimida A, Falcetta P, Benvenga S, Vitti P, Tonacchera M. Screening for drugs potentially interfering with MCT8-mediated T 3 transport in vitro identifies dexamethasone and some commonly used drugs as inhibitors of MCT8 activity. J Endocrinol Invest 2022; 45:803-814. [PMID: 34850364 DOI: 10.1007/s40618-021-01711-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/19/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Monocarboxylate transporter 8 (MCT8) is the first thyroid hormone transporter that has been linked to a human disease. Besides genetic alterations other factors might impair MCT8 activity. AIM This study aimed at investigating whether some common drugs having a structural similarity with TH and/or whose treatment is associated with thyroid function test abnormalities, or which behave as antagonists of TH action can inhibit MCT8-mediated T3 transport. METHODS [125I]T3 uptake and efflux were measured in COS-7 cells transiently transfected with hMCT8 before and after exposure to increasing concentrations of hydrocortisone, dexamethasone, prednisone, prednisolone, amiodarone, desethylamiodarone, dronedarone, buspirone, carbamazepine, valproic acid, and L-carnitine. The mode of inhibition was also determined. RESULTS Dexamethasone significantly inhibited T3 uptake at 10 μM; hydrocortisone reduced T3 uptake only at high concentrations, i.e. at 500 and 1000 μM; prednisone and prednisolone were devoid of inhibitory potential. Amiodarone caused a reduction of T3 uptake by MCT8 only at the highest concentrations used (44% at 50 μM and 68% at 100 μM), and this effect was weaker than that produced by desethylamiodarone and dronedarone; buspirone resulted a potent inhibitor, reducing T3 uptake at 0.1-10 μM. L-Carnitine inhibited T3 uptake only at 500 mM and 1 M. Kinetic experiments revealed a noncompetitive mode of inhibition for all compounds. All drugs inhibiting T3 uptake did not affect T3 release. CONCLUSION This study shows a novel effect of some common drugs, which is inhibition of T3 transport mediated by MCT8. Specifically, dexamethasone, buspirone, desethylamiodarone, and dronedarone behave as potent inhibitors of MCT8.
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Affiliation(s)
- C Di Cosmo
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy.
| | - G De Marco
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy
| | - P Agretti
- Laboratory of Chemistry and Endocrinology, University Hospital of Pisa, Pisa, Italy
| | - E Ferrarini
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy
| | - A Dimida
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy
| | - P Falcetta
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy
| | - S Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - P Vitti
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy
| | - M Tonacchera
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy
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Gans IM, Coffman JA. Glucocorticoid-Mediated Developmental Programming of Vertebrate Stress Responsivity. Front Physiol 2021; 12:812195. [PMID: 34992551 PMCID: PMC8724051 DOI: 10.3389/fphys.2021.812195] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/22/2021] [Indexed: 01/03/2023] Open
Abstract
Glucocorticoids, vertebrate steroid hormones produced by cells of the adrenal cortex or interrenal tissue, function dynamically to maintain homeostasis under constantly changing and occasionally stressful environmental conditions. They do so by binding and thereby activating nuclear receptor transcription factors, the Glucocorticoid and Mineralocorticoid Receptors (MR and GR, respectively). The GR, by virtue of its lower affinity for endogenous glucocorticoids (cortisol or corticosterone), is primarily responsible for transducing the dynamic signals conveyed by circadian and ultradian glucocorticoid oscillations as well as transient pulses produced in response to acute stress. These dynamics are important determinants of stress responsivity, and at the systemic level are produced by feedforward and feedback signaling along the hypothalamus-pituitary-adrenal/interrenal axis. Within receiving cells, GR signaling dynamics are controlled by the GR target gene and negative feedback regulator fkpb5. Chronic stress can alter signaling dynamics via imperfect physiological adaptation that changes systemic and/or cellular set points, resulting in chronically elevated cortisol levels and increased allostatic load, which undermines health and promotes development of disease. When this occurs during early development it can "program" the responsivity of the stress system, with persistent effects on allostatic load and disease susceptibility. An important question concerns the glucocorticoid-responsive gene regulatory network that contributes to such programming. Recent studies show that klf9, a ubiquitously expressed GR target gene that encodes a Krüppel-like transcription factor important for metabolic plasticity and neuronal differentiation, is a feedforward regulator of GR signaling impacting cellular glucocorticoid responsivity, suggesting that it may be a critical node in that regulatory network.
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Affiliation(s)
- Ian M. Gans
- MDI Biological Laboratory, Salisbury Cove, ME, United States
- Graduate School of Biomedical Science and Engineering, University of Maine, Orono, ME, United States
| | - James A. Coffman
- MDI Biological Laboratory, Salisbury Cove, ME, United States
- Graduate School of Biomedical Science and Engineering, University of Maine, Orono, ME, United States
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Anoshchenko O, Milad MA, Unadkat JD. Estimating fetal exposure to the P-gp substrates, corticosteroids, by PBPK modeling to inform prevention of neonatal respiratory distress syndrome. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2021; 10:1057-1070. [PMID: 34273255 PMCID: PMC8452292 DOI: 10.1002/psp4.12674] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 05/31/2021] [Accepted: 06/07/2021] [Indexed: 11/08/2022]
Abstract
We have previously developed a maternal-fetal physiologically-based pharmacokinetic (m-f PBPK) model to dynamically predict (and verify) fetal-maternal exposure to drugs that passively diffuse across the placenta. Here, we extended the application of this model to dynamically predict fetal exposure to drugs which are effluxed by placental P-glycoprotein, namely the antenatal corticosteroids (ACS; dexamethasone [DEX], and betamethasone [BET]). To do so, we estimated both the placental P-gp mediated efflux clearance (CL) and the passive diffusion CL of the ACS. The efficacy and toxicity of the currently used maternal ACS dosing regimens to prevent neonatal respiratory distress syndrome could be improved by altering their dosing regimens. Therefore, to illustrate the utility of our m-f PBPK model, we used it to design alternative dosing regimens of DEX and BET that could potentially improve their efficacy and reduce their toxicity. The redesigned dosing regimens are convenient to administer, maintain maternal-fetal exposure (area under the concentration-time curve [AUC]) or maximum plasma concentration (Cmax ) or both (DEX and BET) or minimize maternal exposure while maintaining fetal drug plasma concentrations above the minimum therapeutic threshold of 1 ng/ml for 48 h (BET only; based on efficacy data in sheep). To our knowledge, this is the first study to dynamically predict fetal plasma concentrations of placental P-gp effluxed drugs. Our approach and our m-f PBPK model could be used in the future to predict maternal-fetal exposure to any drug and to design alternative dosing regimens of the drug.
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Affiliation(s)
- Olena Anoshchenko
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Washington, Seattle, USA
| | - Mark A Milad
- Milad Pharmaceutical Consulting LLC, Plymouth, Michigan, USA
| | - Jashvant D Unadkat
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Washington, Seattle, USA
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18
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Glycemic control following two regimens of antenatal corticosteroids in mild gestational diabetes: a randomized controlled trial. Arch Gynecol Obstet 2021; 304:345-353. [PMID: 33452923 DOI: 10.1007/s00404-020-05950-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To compare 3 consecutive days of hyperglycemic response following antenatal dexamethasone regimens of 12-mg or 6-mg doses 12 hourly in diet-controlled gestational diabetes. METHODS A randomized controlled trial was carried out in a university hospital in Malaysia. Women with lifestyle-controlled gestational diabetes scheduled to receive clinically indicated antenatal corticosteroids (dexamethasone) were randomized to 12-mg 12 hourly for one day (2 × 12-mg) or 6-mg 12-hourly for two days (4 × 6-mg). 6-point (pre and 2-h postprandial) daily self-monitoring of capillary blood sugar profile for up to 3 consecutive days was started after the first dexamethasone injection. Hyperglycemia is defined as blood glucose pre-meal ≥ 5.3 or 2 h postprandial ≥ 6.7 mmol/L. The primary outcome was a number of hyperglycemic episodes in Day-1 (first 6 BSP points). A sample size of 30 per group (N = 60) was planned. RESULTS Median [interquartile range] hyperglycemic episodes 4 [2.5-5] vs. 4 [3-5] p = 0.3 in the first day, 3 [2-4] vs. 1 [0-3] p = 0.01 on the second day, 0 [0-1] vs. 0 [0-1] p = 0.6 on the third day and over the entire 3 trial days 7 [6-9] vs. 6 [4-8] p = 0.17 for 6-mg vs. 12-mg arms, respectively. 2/30 (7%) in each arm received an anti-glycemic agent during the 3-day trial period (capillary glucose exceeded 11 mmol/L). Mean birth weight (2.89 vs. 2.49 kg p < 0.01) and gestational age at delivery (37.7 vs. 36.6 weeks p = 0.03) were higher and median delivery blood loss (300 vs. 400 ml p = 0.02) was lower in the 12-mg arm; all other secondary outcomes were not significantly different. CONCLUSION In gestational diabetes, 2 × 12-mg could be preferred over 4 × 6-mg dexamethasone as hyperglycemic episodes were fewer on Day-2, fewer injections were needed and the regimen was completed sooner. CLINICAL TRIAL REGISTRATION http://www.isrctn.com/ISRCTN16613220 .
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Jing J, Dai Y, Li Y, Zhou P, Li X, Mei J, Zhang C, Sangild PT, Tang Z, Xu S, Su Y, He X, Zhu Y. Single-course antenatal corticosteroids is related to faster growth in very-low-birth-weight infant. BMC Pregnancy Childbirth 2021; 21:50. [PMID: 33435921 PMCID: PMC7801876 DOI: 10.1186/s12884-020-03510-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/21/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Antenatal corticosteroids (ACS) treatment is critical to support survival and lung maturation in preterm infants, however, its effect on feeding and growth is unclear. Prior preterm delivery, it remains uncertain whether ACS treatment should be continued if possible (repeated course ACS), until a certain gestational age is reached. We hypothesized that the association of single-course ACS with feeding competence and postnatal growth outcomes might be different from that of repeated course ACS in very-low-birth-weight preterm infants. METHODS A multicenter retrospective cohort study was conducted in very-low-birth-weight preterm infants born at 23-37 weeks' gestation in South China from 2011 to 2014. Data on growth, nutritional and clinical outcomes were collected. Repeated course ACS was defined in this study as two or more courses ACS (more than single-course). Infants were stratified by gestational age (GA), including GA < 28 weeks, 28 weeks ≤ GA < 32 weeks and 32 weeks ≤ GA < 37 weeks. Multiple linear regression and multilevel model were applied to analyze the association of ACS with feeding and growth outcomes. RESULTS A total of 841 infants were recruited. The results, just in very-low-birth-weight preterm infants born at 28-32 weeks' gestation, showed both single and repeated course of ACS regimens had shorter intubated ventilation time compared to non-ACS regimen. Single-course ACS promoted the earlier application of amino acid and enteral nutrition, and higher rate of weight increase (15.71; 95%CI 5.54-25.88) than non-ACS after adjusting for potential confounding factors. No associations of repeated course ACS with feeding, mean weight and weight increase rate were observed. CONCLUSIONS Single-course ACS was positively related to feeding and growth outcomes in very-low-birth-weight preterm infants born at 28-32 weeks' gestation. However, the similar phenomenon was not observed in the repeated course of ACS regimen.
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Affiliation(s)
- Jiajia Jing
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, No. 74 Zhongshang 2nd Road, Guangzhou, 510080, China
| | - Yiheng Dai
- Department of Neonatology, Foshan Woman and Children's Hospital, Foshan, China
| | - Yanqi Li
- Comparative Pediatrics and Nutrition, University of Copenhagen, Copenhagen, Denmark
| | - Ping Zhou
- Department of Neonatology, Shenzhen Bao'an Maternal and Child Health Hospital, Shenzhen, China
| | - Xiaodong Li
- Department of Neonatology, Shenzhen Nanshan People's Hospital, Shenzhen, China
| | - Jiaping Mei
- Department of Neonatology, Shenzhen Maternity & Child Health Care Hospital, Shenzhen, China
| | - Chunyi Zhang
- Department of Neonatology, Guangdong Women and Children Hospital, Guangzhou, China
| | - Per Trop Sangild
- Comparative Pediatrics and Nutrition, University of Copenhagen, Copenhagen, Denmark
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Zhaoxie Tang
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, No. 74 Zhongshang 2nd Road, Guangzhou, 510080, China
| | - Suhua Xu
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, No. 74 Zhongshang 2nd Road, Guangzhou, 510080, China
| | - Yanbin Su
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, No. 74 Zhongshang 2nd Road, Guangzhou, 510080, China
| | - Xiaoying He
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, No. 74 Zhongshang 2nd Road, Guangzhou, 510080, China
| | - Yanna Zhu
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, No. 74 Zhongshang 2nd Road, Guangzhou, 510080, China.
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Poggio F, Tagliamento M, Pirrone C, Soldato D, Conte B, Molinelli C, Cosso M, Fregatti P, Del Mastro L, Lambertini M. Update on the Management of Breast Cancer during Pregnancy. Cancers (Basel) 2020; 12:cancers12123616. [PMID: 33287242 PMCID: PMC7761659 DOI: 10.3390/cancers12123616] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/29/2020] [Accepted: 12/02/2020] [Indexed: 02/07/2023] Open
Abstract
The diagnosis of breast cancer during pregnancy represents a challenging situation for the patient, her caregivers and physicians. Pregnancy adds complexity to oncological treatment planning, as many therapies can be potentially dangerous to the fetus. Therefore, a multidisciplinary approach is needed to offer a proper care for obtaining the best possible outcomes for the mother and the future child. Breast surgery is feasible throughout the pregnancy while radiotherapy should be postponed after delivery. Administration of chemotherapy is considered safe and can be given during the second and third trimesters, while it is contraindicated in the first trimester due to the high risk of fetal malformations. Endocrine therapy and targeted agents are not recommended during the whole pregnancy period; however, limited data are available on the use of the majority of new anticancer drugs in this context. The aim of the current review is to provide an update on the current state of art about the management of women diagnosed with breast cancer during pregnancy.
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Affiliation(s)
- Francesca Poggio
- Breast Unit, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (F.P.); (L.D.M.)
| | - Marco Tagliamento
- U.O. Oncologia Medica 2, Medical Oncology Department, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (M.T.); (C.P.); (D.S.); (B.C.); (C.M.)
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, 16132 Genova, Italy
| | - Chiara Pirrone
- U.O. Oncologia Medica 2, Medical Oncology Department, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (M.T.); (C.P.); (D.S.); (B.C.); (C.M.)
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, 16132 Genova, Italy
| | - Davide Soldato
- U.O. Oncologia Medica 2, Medical Oncology Department, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (M.T.); (C.P.); (D.S.); (B.C.); (C.M.)
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, 16132 Genova, Italy
| | - Benedetta Conte
- U.O. Oncologia Medica 2, Medical Oncology Department, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (M.T.); (C.P.); (D.S.); (B.C.); (C.M.)
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, 16132 Genova, Italy
| | - Chiara Molinelli
- U.O. Oncologia Medica 2, Medical Oncology Department, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (M.T.); (C.P.); (D.S.); (B.C.); (C.M.)
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, 16132 Genova, Italy
| | - Maurizio Cosso
- Department of Radiology, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Piero Fregatti
- U.O.C. Clinica di Chirurgia Senologica, Department of Surgery, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
- Department of Integrated Diagnostic Surgical Sciences, School of Medicine, University of Genova, 16132 Genova, Italy
| | - Lucia Del Mastro
- Breast Unit, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (F.P.); (L.D.M.)
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, 16132 Genova, Italy
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, 16132 Genova, Italy
- U.O.C. Clinica di Oncologia Medica, Medical Oncology Department, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
- Correspondence:
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Lee C, Sakurai R, Shin E, Wang Y, Liu J, Rehan VK. Antenatal PPAR-γ agonist pioglitazone stimulates fetal lung maturation equally in males and females. Am J Physiol Lung Cell Mol Physiol 2020; 319:L435-L443. [PMID: 32579381 DOI: 10.1152/ajplung.00376.2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Antenatal steroids (ANS) accelerate fetal lung maturation and reduce the incidence of respiratory distress syndrome. However, sex specificity, i.e., being less effective in males, and potential long-term neurodevelopmental sequelae, particularly with repeated courses, remain significant limitations. The differential sex response to ANS is likely mediated via the inhibitory effect of fetal androgens on steroid's stimulatory effect on alveolar epithelial-mesenchymal interactions. Since peroxisome proliferator-activated receptor-γ (PPAR-γ) agonists accelerate lung maturation by stimulating alveolar epithelial-mesenchymal interactions, independent of fetal sex, we hypothesized that the effect of PPAR-γ agonist pioglitazone (PGZ) would be sex-independent. Pregnant Sprague-Dawley rat dams were intraperitoneally administered dexamethasone (DEX) or PGZ on embryonic day (e) 18 and e19. At e20, pups were delivered by cesarean section, and fetal lungs and brains were examined for markers of lung maturation and apoptosis, respectively. Mixed epithelial-fibroblast cell cultures were examined to gain mechanistic insights. Antenatal PGZ increased alveolar epithelial and mesenchymal maturation markers equally in males and females; in contrast, antenatal DEX had sex-specific effects. Additionally, unlike DEX, antenatal PGZ did not increase hippocampal apoptosis. We conclude that PPAR-γ agonist administration is an effective, and probably even a superior, alternative to ANS for accelerating fetal lung maturity equally in both males and females.
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Affiliation(s)
- Cindy Lee
- Department of Pediatrics, Harbor-University of California, Los Angleles (UCLA) Medical Center, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, David Geffen School of Medicine, Torrance, California
| | - Reiko Sakurai
- Department of Pediatrics, Harbor-University of California, Los Angleles (UCLA) Medical Center, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, David Geffen School of Medicine, Torrance, California
| | - Eugene Shin
- Department of Pediatrics, Harbor-University of California, Los Angleles (UCLA) Medical Center, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, David Geffen School of Medicine, Torrance, California
| | - Ying Wang
- Department of Pediatrics, Harbor-University of California, Los Angleles (UCLA) Medical Center, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, David Geffen School of Medicine, Torrance, California
| | - Jie Liu
- Department of Pediatrics, Harbor-University of California, Los Angleles (UCLA) Medical Center, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, David Geffen School of Medicine, Torrance, California
| | - Virender K Rehan
- Department of Pediatrics, Harbor-University of California, Los Angleles (UCLA) Medical Center, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, David Geffen School of Medicine, Torrance, California
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22
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Wynne K, Rowe C, Delbridge M, Watkins B, Brown K, Addley J, Woods A, Murray H. Antenatal corticosteroid administration for foetal lung maturation. F1000Res 2020; 9. [PMID: 32269758 PMCID: PMC7111495 DOI: 10.12688/f1000research.20550.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2020] [Indexed: 01/27/2023] Open
Abstract
Antenatal corticosteroids are an essential component in the management of women at risk for preterm labour. They promote lung maturation and reduce the risk of other preterm neonatal complications. This narrative review discusses the contentious issues and controversies around the optimal use of antenatal corticosteroids and their consequences for both the mother and the neonate. The most recent evidence base is presented.
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Affiliation(s)
- Katie Wynne
- Department of Diabetes & Endocrinology, John Hunter Hospital, New Lambton Heights, NSW, 2305, Australia.,Mothers and Babies, Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Christopher Rowe
- Department of Diabetes & Endocrinology, John Hunter Hospital, New Lambton Heights, NSW, 2305, Australia.,Mothers and Babies, Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Matthew Delbridge
- School of Medicine and Public Health, University of New England, Armidale, NSW, 2351, Australia
| | - Brendan Watkins
- School of Medicine and Public Health, University of New England, Armidale, NSW, 2351, Australia
| | - Karina Brown
- School of Medicine and Public Health, University of New England, Armidale, NSW, 2351, Australia
| | - Jordan Addley
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Andrew Woods
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.,Department of Obstetrics, John Hunter Hospital, New Lambton Heights, NSW, 2305, Australia
| | - Henry Murray
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.,Department of Obstetrics, John Hunter Hospital, New Lambton Heights, NSW, 2305, Australia
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23
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Tyul’kova EI, Vataeva LA, Stratilov VA, Barysheva VS, Vetrovoy OV. Peculiarities of DNA and Histone H3 Methylation in the Hippocampus and Neocortex of Rats Subjected to Pathological Treatments during the Prenatal Period. NEUROCHEM J+ 2020. [DOI: 10.1134/s1819712420010195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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24
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Thevathasan I, Said JM. Controversies in antenatal corticosteroid treatment. Prenat Diagn 2020; 40:1138-1149. [PMID: 32157719 DOI: 10.1002/pd.5664] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/17/2019] [Accepted: 12/08/2019] [Indexed: 12/17/2022]
Abstract
Antenatal corticosteroids are now established as one of the cornerstones of therapy in the prevention of neonatal morbidity and mortality prior to preterm birth. Although this practice is widely accepted, a significant number of controversies exist. This review explores the knowledge gaps regarding the use of antenatal corticosteroids in the preterm, late preterm and term populations. Furthermore, the role of antenatal corticosteroids in special populations, such as diabetes, multiple pregnancies and periviable gestations, where high-quality data from randomized controlled trials are lacking, is also considered.
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Affiliation(s)
- Iniyaval Thevathasan
- Maternal Fetal Medicine, Joan Kirner Women's & Children's Sunshine Hospital, Western Health, St Albans, Victoria, Australia
| | - Joanne M Said
- Maternal Fetal Medicine, Joan Kirner Women's & Children's Sunshine Hospital, Western Health, St Albans, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
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25
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Wastnedge E, Vogel J, Been JV, Bannerman-Gyamfi C, Schuit E, Roberts D, Reynolds RM, Stock S. An evaluation of the benefits and harms of antenatal corticosteroid treatment for women at risk of imminent preterm birth or prior to elective Caesarean-section: Study protocol for an individual participant data meta-analysis. Wellcome Open Res 2020; 5:38. [PMID: 32529039 PMCID: PMC7268149 DOI: 10.12688/wellcomeopenres.15661.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2020] [Indexed: 12/19/2022] Open
Abstract
Background: Antenatal corticosteroid treatment (ACT) has been widely accepted as a safe, beneficial treatment which improves outcomes following preterm birth. It has been shown to reduce respiratory distress syndrome and neonatal mortality and is commonly used in threatened or planned preterm delivery, as well as prior to elective Caesarean-section at term. There are some concerns however, that in some cases, ACT is used in patients where clinical benefit has not been established, or may potentially increase harm. Many women who receive ACT do not deliver preterm and the long-term consequences of ACT treatment are unclear. This study aims to evaluate the benefits and harms of ACT using latest trial evidence to allow refinement of current practice. Methods: This study will compare ACT with placebo or non-treatment. Inclusion criteria are: Randomised Controlled Trials (RCT) comparing ACT vs. no ACT (with or without placebo) in all settings. Exclusion criteria are: non-randomised or quasi-randomised studies and studies comparing single vs. multiple courses of ACT. Main outcomes are to evaluate, for women at risk of preterm birth or undergoing planned Caesarean- section, the benefits and harms of ACT, on maternal, fetal, newborn, and long-term offspring health outcomes. The individual participant data (IPD) of identified RCTs will be collected and consecutively synthesised using meta-analysis with both a one-stage model where all IPD is analysed together and a two-stage model where treatment effect estimates are calculated for each trial individually first and thereafter pooled in a meta-analysis. Sub-group analysis will be performed to identify heterogeneous effects of ACT across predefined risk groups. Discussion: Co-opt is the Consortium for the Study of Pregnancy Treatments and aims to complete a robust evaluation of the benefits and harms of ACT. This IPD meta-analysis will contribute to this by allowing detailed interrogation of existing trial datasets. PROSPERO registration: CRD42020167312 (03/02/2020).
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Affiliation(s)
| | - Joshua Vogel
- Maternal and Child Health Program, Burnet Institute, Melbourne, Australia
| | - Jasper V. Been
- Division of Neonatology, Department of Paediatrics, Division of Obstetrics and Gynaecology and Department of Publisc Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Ewoud Schuit
- Julian Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Rebecca M. Reynolds
- Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Sarah Stock
- Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Co_Opt collaboration
- Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
- Maternal and Child Health Program, Burnet Institute, Melbourne, Australia
- Division of Neonatology, Department of Paediatrics, Division of Obstetrics and Gynaecology and Department of Publisc Health, Erasmus MC, Rotterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Columbia University, New York, USA
- Julian Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Liverpool Women's Hospital NHS Foundation Trust, Liverpool, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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26
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Hrabalkova L, Takahashi T, Kemp MW, Stock SJ. Antenatal Corticosteroids for Fetal Lung Maturity - Too Much of a Good Thing? Curr Pharm Des 2020; 25:593-600. [PMID: 30914016 DOI: 10.2174/1381612825666190326143814] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/22/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Between 5-15% of babies are born prematurely worldwide, with preterm birth defined as delivery before 37 completed weeks of pregnancy (term is at 40 weeks of gestation). Women at risk of preterm birth receive antenatal corticosteroids as part of standard care to accelerate fetal lung maturation and thus improve neonatal outcomes in the event of delivery. As a consequence of this treatment, the entire fetal organ system is exposed to the administered corticosteroids. The implications of this exposure, particularly the long-term impacts on offspring health, are poorly understood. AIMS This review will consider the origins of antenatal corticosteroid treatment and variations in current clinical practices surrounding the treatment. The limitations in the evidence base supporting the use of antenatal corticosteroids and the evidence of potential harm to offspring are also summarised. RESULTS Little has been done to optimise the dose and formulation of antenatal corticosteroid treatment since the first clinical trial in 1972. International guidelines for the use of the treatment lack clarity regarding the recommended type of corticosteroid and the gestational window of treatment administration. Furthermore, clinical trials cited in the most recent Cochrane Review have limitations which should be taken into account when considering the use of antenatal corticosteroids in clinical practice. Lastly, there is limited evidence regarding the long-term effects on the different fetal organ systems exposed in utero, particularly when the timing of corticosteroid administration is sub-optimal. CONCLUSION Further investigations are urgently needed to determine the most safe and effective treatment regimen for antenatal corticosteroids, particularly regarding the type of corticosteroid and optimal gestational window of administration. A clear consensus on the use of this common treatment could maximise the benefits and minimise potential harms to offspring.
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Affiliation(s)
- Lenka Hrabalkova
- Tommy's Centre for Maternal and Fetal Health at the MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Matthew W Kemp
- Tohoku University Hospital, Sendai, Miyagi, Japan.,Division of Obstetrics and Gynaecology, University of Western Australia, Perth, Australia
| | - Sarah J Stock
- Tommy's Centre for Maternal and Fetal Health at the MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
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27
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Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring. J Clin Med 2019; 8:jcm8101625. [PMID: 31590294 PMCID: PMC6832549 DOI: 10.3390/jcm8101625] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 09/22/2019] [Accepted: 10/02/2019] [Indexed: 12/20/2022] Open
Abstract
Hypertensive disorders of pregnancy affect up to 10% of pregnancies worldwide, which includes the 3%–5% of all pregnancies complicated by preeclampsia. Preeclampsia is defined as new onset hypertension after 20 weeks’ gestation with evidence of maternal organ or uteroplacental dysfunction or proteinuria. Despite its prevalence, the risk factors that have been identified lack accuracy in predicting its onset and preventative therapies only moderately reduce a woman’s risk of preeclampsia. Preeclampsia is a major cause of maternal morbidity and is associated with adverse foetal outcomes including intra-uterine growth restriction, preterm birth, placental abruption, foetal distress, and foetal death in utero. At present, national guidelines for foetal surveillance in preeclamptic pregnancies are inconsistent, due to a lack of evidence detailing the most appropriate assessment modalities as well as the timing and frequency at which assessments should be conducted. Current management of the foetus in preeclampsia involves timely delivery and prevention of adverse effects of prematurity with antenatal corticosteroids and/or magnesium sulphate depending on gestation. Alongside the risks to the foetus during pregnancy, there is also growing evidence that preeclampsia has long-term adverse effects on the offspring. In particular, preeclampsia has been associated with cardiovascular sequelae in the offspring including hypertension and altered vascular function.
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28
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Melamed N, Asztalos E, Murphy K, Zaltz A, Redelmeier D, Shah BR, Barrett J. Neurodevelopmental disorders among term infants exposed to antenatal corticosteroids during pregnancy: a population-based study. BMJ Open 2019; 9:e031197. [PMID: 31575578 PMCID: PMC6773295 DOI: 10.1136/bmjopen-2019-031197] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE An increasing proportion of fetuses are exposed to antenatal corticosteroids (ACS). Despite their immediate beneficial effects, the long-term safety of ACS has been an ongoing source of concern. In the current study, we assessed the likelihood of neurodevelopmental problems among term infants exposed to ACS earlier in pregnancy compared with non-exposed term infants. DESIGN Retrospective cohort study (2006-2011). Median duration of follow-up was 7.8 (IQR 6.4-9.2) years. SETTING Population-based study, Ontario, Canada. PARTICIPANTS All live singleton infants born at term (≥370/7 weeks gestation) (n=529 205). EXPOSURE ACS during pregnancy. PRIMARY AND SECONDARY OUTCOME MEASURES A composite of diagnostic or billing codes reflecting proven or suspected neurodevelopmental problems during childhood including audiometry testing, visual testing or physician service claim with a diagnosis code related to a suspected neurocognitive disorder. RESULTS At 5 years of age, the cumulative rate for the primary outcome was higher among infants exposed to ACS compared with non-exposed infants: 61.7% (3346/5423) vs 57.8% (302 520/523 782), respectively (p<0.001; number needed to harm (NNH)=25, 95% CI 19 to 38; adjusted HR (aHR) 1.12, 95% CI 1.08 to 1.16). Similar findings were observed for each of the individual components of the primary outcome: 15.3% vs 12.7% for audiometry testing (p<0.001; NNH=39, 95% CI 29 to 63; aHR 1.18, 95% CI 1.11 to 1.25); 45.4% vs 43.5% for visual testing (p=0.006; NNH=54, 95% CI 31 to 200; aHR 1.08, 95% CI 1.04 to 1.12) and 25.8% vs 21.6% for suspected neurocognitive disorder (p<0.001; NNH=24, 95% CI 19 to 33; aHR 1.16, 95% CI 1.10 to 1.21). CONCLUSIONS We found an association among term infants between exposure to ACS during pregnancy and healthcare utilisation during childhood related to suspected neurocognitive and neurosensory disorders.
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Affiliation(s)
- Nir Melamed
- Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Elizabeth Asztalos
- Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Kellie Murphy
- Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Arthur Zaltz
- Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Baiju R Shah
- Endocrinology, Sunnybrooke Health Sciences Centre, Toronto, Ontario, Canada
| | - Jon Barrett
- Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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29
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Maternal intramuscular dexamethasone versus betamethasone before preterm birth (ASTEROID): a multicentre, double-blind, randomised controlled trial. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:769-780. [PMID: 31523039 DOI: 10.1016/s2352-4642(19)30292-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/31/2019] [Accepted: 08/02/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Antenatal corticosteroids given to women before preterm birth improve infant survival and health. However, whether dexamethasone or betamethasone have better maternal, neonatal, and childhood health outcomes remains unclear. We therefore aimed to assess whether administration of antenatal dexamethasone to women at risk of preterm birth reduced the risk of death or neurosensory disability in their children at age 2 years compared with betamethasone. We also aimed to assess whether dexamethasone reduced neonatal morbidity, had benefits for the mother, or affected childhood body size, blood pressure, behaviour, or general health compared with betamethasone. METHODS In this multicentre, double-blind, randomised controlled trial, we recruited pregnant women from 14 maternity hospitals in Australia and New Zealand that could provide care to preterm babies. Women were eligible for study inclusion if they were at risk of preterm birth before 34 weeks of gestation, had a singleton or twin pregnancy, and had no contraindications to antenatal corticosteroids. We randomly assigned women (1:1) to receive two intramuscular injections of either 12 mg dexamethasone (dexamethasone sodium phosphate) or 11·4 mg betamethasone (Celestone Chronodose), 24 h apart. The randomisation schedule used balanced, variable blocks that were stratified by hospital, gestational age, and number of fetuses (singleton or twins). We masked all participants, staff, and assessors to treatment groups. Analyses were by intention to treat. The primary outcome was death or neurosensory disability at age 2 years (corrected for prematurity). This study is registered with ANZCTR, ACTRN12608000631303. FINDINGS Between Jan 28, 2009, and Feb 1, 2013, we randomly assigned 1346 (78%) women who were pregnant with 1509 fetuses to groups: 679 (50%) women were assigned to receive dexamethasone and 667 (50%) women were assigned to receive betamethasone. 27 (4%) fetuses, infants, or children in the dexamethasone group and 28 (4%) fetuses, infants, or children in the betamethasone group died before age 2 years. The primary outcome of death or neurosensory disability at age 2 years was determined for 603 (79%) of 763 fetuses whose mothers received dexamethasone and 591 (79%) of 746 fetuses whose mothers received betamethasone. We found a similar incidence of death or neurosensory disability in the dexamethasone (198 [33%] of 603 infants) and betamethasone groups (192 [32%] of 591 infants; adjusted relative risk [adjRR] 0·97, 95% CI 0·83 to 1·13; p=0·66). 18 (3%) of 679 women in the dexamethasone group and 28 of 667 (4%) women in the betamethasone group reported side-effects. Discomfort at the injection site, the most frequent side-effect, was less likely in the dexamethasone group than in the betamethasone group (six [1%] women vs 17 [3%] women; p=0·02). INTERPRETATION The incidence of survival without neurosensory disability at age 2 years did not differ between dexamethasone and betamethasone treatment. Our findings indicate that either antenatal corticosteroid can be given to women before preterm birth to improve infant and child health. FUNDING National Health and Medical Research Council (Australia).
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30
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Crowther CA, Middleton PF, Voysey M, Askie L, Zhang S, Martlow TK, Aghajafari F, Asztalos EV, Brocklehurst P, Dutta S, Garite TJ, Guinn DA, Hallman M, Hardy P, Lee MJ, Maurel K, Mazumder P, McEvoy C, Murphy KE, Peltoniemi OM, Thom EA, Wapner RJ, Doyle LW. Effects of repeat prenatal corticosteroids given to women at risk of preterm birth: An individual participant data meta-analysis. PLoS Med 2019; 16:e1002771. [PMID: 30978205 PMCID: PMC6461224 DOI: 10.1371/journal.pmed.1002771] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/26/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Infants born preterm compared with infants born at term are at an increased risk of dying and of serious morbidities in early life, and those who survive have higher rates of neurological impairments. It remains unclear whether exposure to repeat courses of prenatal corticosteroids can reduce these risks. This individual participant data (IPD) meta-analysis (MA) assessed whether repeat prenatal corticosteroid treatment given to women at ongoing risk of preterm birth in order to benefit their infants is modified by participant or treatment factors. METHODS AND FINDINGS Trials were eligible for inclusion if they randomised women considered at risk of preterm birth who had already received an initial, single course of prenatal corticosteroid seven or more days previously and in which corticosteroids were compared with either placebo or no placebo. The primary outcomes for the infants were serious outcome, use of respiratory support, and birth weight z-scores; for the children, they were death or any neurosensory disability; and for the women, maternal sepsis. Studies were identified using the Cochrane Pregnancy and Childbirth search strategy. Date of last search was 20 January 2015. IPD were sought from investigators with eligible trials. Risk of bias was assessed using criteria from the Cochrane Collaboration. IPD were analysed using a one-stage approach. Eleven trials, conducted between 2002 and 2010, were identified as eligible, with five trials being from the United States, two from Canada, and one each from Australia and New Zealand, Finland, India, and the United Kingdom. All 11 trials were included, with 4,857 women and 5,915 infants contributing data. The mean gestational age at trial entry for the trials was between 27.4 weeks and 30.2 weeks. There was no significant difference in the proportion of infants with a serious outcome (relative risk [RR] 0.92, 95% confidence interval [CI] 0.82 to 1.04, 5,893 infants, 11 trials, p = 0.33 for heterogeneity). There was a reduction in the use of respiratory support in infants exposed to repeat prenatal corticosteroids compared with infants not exposed (RR 0.91, 95% CI 0.85 to 0.97, 5,791 infants, 10 trials, p = 0.64 for heterogeneity). The number needed to treat (NNT) to benefit was 21 (95% CI 14 to 41) women/fetus to prevent one infant from needing respiratory support. Birth weight z-scores were lower in the repeat corticosteroid group (mean difference -0.12, 95%CI -0.18 to -0.06, 5,902 infants, 11 trials, p = 0.80 for heterogeneity). No statistically significant differences were seen for any of the primary outcomes for the child (death or any neurosensory disability) or for the woman (maternal sepsis). The treatment effect varied little by reason the woman was considered to be at risk of preterm birth, the number of fetuses in utero, the gestational age when first trial treatment course was given, or the time prior to birth that the last dose was given. Infants exposed to between 2-5 courses of repeat corticosteroids showed a reduction in both serious outcome and the use of respiratory support compared with infants exposed to only a single repeat course. However, increasing numbers of repeat courses of corticosteroids were associated with larger reductions in birth z-scores for weight, length, and head circumference. Not all trials could provide data for all of the prespecified subgroups, so this limited the power to detect differences because event rates are low for some important maternal, infant, and childhood outcomes. CONCLUSIONS In this study, we found that repeat prenatal corticosteroids given to women at ongoing risk of preterm birth after an initial course reduced the likelihood of their infant needing respiratory support after birth and led to neonatal benefits. Body size measures at birth were lower in infants exposed to repeat prenatal corticosteroids. Our findings suggest that to provide clinical benefit with the least effect on growth, the number of repeat treatment courses should be limited to a maximum of three and the total dose to between 24 mg and 48 mg.
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Affiliation(s)
- Caroline A. Crowther
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
- * E-mail:
| | - Philippa F. Middleton
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
- Healthy Mothers Babies and Children, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Merryn Voysey
- Nuffield Department of Primary Care Health Sciences and Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Lisa Askie
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Sasha Zhang
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Tanya K. Martlow
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Fariba Aghajafari
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Elizabeth V. Asztalos
- Department of Paediatrics and Obstetrics/Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Sourabh Dutta
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Debra A. Guinn
- Kalispell Regional Health Care, Kalispell, Montana, United States of America
| | - Mikko Hallman
- Department of Paediatrics, University of Oulu, Oulu, Finland
| | - Pollyanna Hardy
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Men-Jean Lee
- John A Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, United States of America
| | | | - Premasish Mazumder
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Cindy McEvoy
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Kellie E. Murphy
- Department of Paediatrics and Obstetrics/Gynecology, University of Toronto, Toronto, Ontario, Canada
| | | | - Elizabeth A. Thom
- The Biostatistics Center, George Washington University, Washington, DC, United States of America
| | - Ronald J. Wapner
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Columbia University Medical Center, New York, New York, United States of America
| | - Lex W. Doyle
- Department of Obstetrics and Gynaecology, The Royal Women’s Hospital, University of Melbourne, Melbourne, Australia
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
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31
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Schmitz T, Alberti C, Ursino M, Baud O, Aupiais C. Full versus half dose of antenatal betamethasone to prevent severe neonatal respiratory distress syndrome associated with preterm birth: study protocol for a randomised, multicenter, double blind, placebo-controlled, non-inferiority trial (BETADOSE). BMC Pregnancy Childbirth 2019; 19:67. [PMID: 30755164 PMCID: PMC6373166 DOI: 10.1186/s12884-019-2206-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although antenatal betamethasone is recommended worldwide for women at risk of preterm delivery, concerns persist regarding the long-term effects associated with this treatment. Indeed, adverse events, mainly dose-related, have been reported. The current recommended dose of antenatal betamethasone directly derives from sheep experiments performed in the late 60's and has not been challenged in 45 years. Therefore, randomized trials evaluating novel dose regimens are urgently needed. METHODS A randomised, double blind, placebo-controlled, non-inferiority trial will be performed in 37 French level 3 maternity units. Women with a singleton pregnancy at risk of preterm delivery before 32 weeks of gestation having already received a first 11.4 mg injection of betamethasone will be randomised to receive either a second injection of 11.4 mg betamethasone (full dose arm) or placebo (half dose arm) administered intramuscularly 24 h after the first injection. The primary binary outcome will be the occurrence of severe respiratory distress syndrome (RDS), defined as the need for exogenous intra-tracheal surfactant in the first 48 h of life. Considering that 20% of the pregnant women receiving the full dose regimen would have a neonate with severe RDS, 1571 patients in each treatment group are required to show that the half dose regimen is not inferior to the full dose, that is the difference in severe RDS rate do not exceed 4% (corresponding to a Relative Risk of 20%), with a 1-sided 2.5% type-1 error and a 80% power. Interim analyses will be done after every 300 neonates who reach the primary outcome on the basis of intention-to-treat, using a group-sequential non-inferiority design. DISCUSSION If the 50% reduced antenatal betamethasone dose is shown to be non-inferior to the full dose to prevent severe RDS associated with preterm birth, then it should be used consistently in women at risk of preterm delivery and would be of great importance to their children. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT 02897076 (registration date 09/13/2016).
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Affiliation(s)
- Thomas Schmitz
- Service de Gynécologie Obstétrique, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, 48 boulevard Sérurier, 75019 Paris, France
- Université Paris Diderot, Site Villemin, 10 avenue de Verdun, 75010 Paris, France
- Inserm, U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, 53 avenue de l’observatoire, 75014 Paris, France
| | - Corinne Alberti
- Université Paris Diderot, Site Villemin, 10 avenue de Verdun, 75010 Paris, France
- Unité d’épidémiologie clinique, CIC-EC 1426, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France
- Inserm, U1123, ECEVE, 10 avenue de Verdun, 75010 Paris, France
| | - Moreno Ursino
- Inserm, U1138, Equipe 22, Sorbonne Université, Université Paris Descartes, 75006 Paris, France
| | - Olivier Baud
- Service de néonatalogie, Hôpitaux universitaires de Genève, 32 boulevard de la Cluse, 1205 Genève, Switzerland
- Inserm, U1141, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France
| | - Camille Aupiais
- Université Paris Diderot, Site Villemin, 10 avenue de Verdun, 75010 Paris, France
- Inserm, U1123, ECEVE, 10 avenue de Verdun, 75010 Paris, France
- Inserm, U1138, Equipe 22, Sorbonne Université, Université Paris Descartes, 75006 Paris, France
- Service d’Accueil des Urgences Pédiatriques, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France
| | - for the BETADOSE study group and the GROG (Groupe de Recherche en Gynécologie Obstétrique)
- Service de Gynécologie Obstétrique, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, 48 boulevard Sérurier, 75019 Paris, France
- Université Paris Diderot, Site Villemin, 10 avenue de Verdun, 75010 Paris, France
- Inserm, U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, 53 avenue de l’observatoire, 75014 Paris, France
- Unité d’épidémiologie clinique, CIC-EC 1426, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France
- Inserm, U1123, ECEVE, 10 avenue de Verdun, 75010 Paris, France
- Inserm, U1138, Equipe 22, Sorbonne Université, Université Paris Descartes, 75006 Paris, France
- Service de néonatalogie, Hôpitaux universitaires de Genève, 32 boulevard de la Cluse, 1205 Genève, Switzerland
- Inserm, U1141, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France
- Service d’Accueil des Urgences Pédiatriques, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France
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Cartwright RD, Crowther CA, Anderson PJ, Harding JE, Doyle LW, McKinlay CJD. Association of Fetal Growth Restriction With Neurocognitive Function After Repeated Antenatal Betamethasone Treatment vs Placebo: Secondary Analysis of the ACTORDS Randomized Clinical Trial. JAMA Netw Open 2019; 2:e187636. [PMID: 30707225 PMCID: PMC6484607 DOI: 10.1001/jamanetworkopen.2018.7636] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 12/10/2018] [Indexed: 11/24/2022] Open
Abstract
Importance Repeated doses of antenatal betamethasone are recommended for women at less than 32 weeks' gestation with ongoing risk of preterm birth. However, concern that this therapy may be associated with adverse neurocognitive effects in children with fetal growth restriction (FGR) remains. Objective To determine the influence of FGR on the effects of repeated doses of antenatal betamethasone on neurocognitive function in midchildhood. Design, Setting, and Participants This preplanned secondary analysis of data from the multicenter Australasian Collaborative Trial of Repeat Doses of Corticosteroids (ACTORDS) included women at less than 32 weeks' gestation with ongoing risk of preterm birth (<32 weeks) at least 7 days after an initial course of antenatal corticosteroids who were treated at 23 hospitals across Australia and New Zealand from April 1, 1998, through July 20, 2004. Participants were randomized to intramuscular betamethasone or saline placebo; treatment could be repeated weekly if the woman was judged to be at continued risk of preterm birth. All surviving children were invited to a midchildhood outcome study. Data for this study were collected from October 27, 2006, through March 18, 2011, and analyzed from June 1 through 30, 2018. Interventions At 6 to 8 years of corrected age, children were assessed by a pediatrician and psychologist for neurosensory and cognitive function, and parents completed standardized questionnaires. Main Outcomes and Measures The prespecified primary outcomes were survival free of any disability and death or survival with moderate to severe disability. Results Of 1059 eligible children, 988 (55.0% male; mean [SD] age at follow-up, 7.5 [1.1] years) were assessed at midchildhood. The FGR rate was 139 of 493 children (28.2%) in the repeated betamethasone treatment group and 122 of 495 (24.6%) in the placebo group (P = .20). Primary outcome rates were similar between treatment groups for the FGR and non-FGR subgroups, with no evidence of an interaction effect for survival free of any disability (FGR group, 108 of 144 [75.0%] for repeated betamethasone treatment vs 91 of 126 [72.2%] for placebo groups [odds ratio [OR], 1.1; 95% CI, 0.6-1.9]; non-FGR group, 267 of 335 [79.7%] for repeated betamethasone vs 283 of 358 [79.0%] for placebo groups [OR, 1.0; 95% CI, 0.7-1.5]; P = .77) and death or moderate to severe disability (FGR group, 21 of 144 [14.6%] for repeated betamethasone treatment vs 20 of 126 [15.9%] for placebo groups [OR, 0.9; 95% CI, 0.4-1.9]; non-FGR group, 29 of 335 [8.6%] for repeated betamethasone vs 36 of 358 [10.0%] for placebo [OR, 0.8; 95% CI, 0.4-1.3]; P = .84). Conclusions and Relevance In this study, repeated antenatal betamethasone treatment compared with placebo was not associated with adverse effects on neurocognitive function at 6 to 8 years of age, even in the presence of FGR. Physicians should use repeated doses of antenatal corticosteroids when indicated before preterm birth, regardless of FGR, in view of the associated neonatal benefits and absence of later adverse effects. Trial Registration anzctr.org.au Identifier: ACTRN12606000318583.
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Affiliation(s)
| | - Caroline A. Crowther
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Discipline of Obstetrics and Gynaecology, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Peter J. Anderson
- Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Australia
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Australia
| | - Jane E. Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Lex W. Doyle
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Department of Obstetrics and Gynaecology, The Royal Women’s Hospital, University of Melbourne, Parkville, Australia
| | - Christopher J. D. McKinlay
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
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Morrison JL, Berry MJ, Botting KJ, Darby JRT, Frasch MG, Gatford KL, Giussani DA, Gray CL, Harding R, Herrera EA, Kemp MW, Lock MC, McMillen IC, Moss TJ, Musk GC, Oliver MH, Regnault TRH, Roberts CT, Soo JY, Tellam RL. Improving pregnancy outcomes in humans through studies in sheep. Am J Physiol Regul Integr Comp Physiol 2018; 315:R1123-R1153. [PMID: 30325659 DOI: 10.1152/ajpregu.00391.2017] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Experimental studies that are relevant to human pregnancy rely on the selection of appropriate animal models as an important element in experimental design. Consideration of the strengths and weaknesses of any animal model of human disease is fundamental to effective and meaningful translation of preclinical research. Studies in sheep have made significant contributions to our understanding of the normal and abnormal development of the fetus. As a model of human pregnancy, studies in sheep have enabled scientists and clinicians to answer questions about the etiology and treatment of poor maternal, placental, and fetal health and to provide an evidence base for translation of interventions to the clinic. The aim of this review is to highlight the advances in perinatal human medicine that have been achieved following translation of research using the pregnant sheep and fetus.
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Affiliation(s)
- Janna L Morrison
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Mary J Berry
- Department of Paediatrics and Child Health, University of Otago , Wellington , New Zealand
| | - Kimberley J Botting
- Department of Physiology, Development, and Neuroscience, University of Cambridge , Cambridge , United Kingdom
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Martin G Frasch
- Department of Obstetrics and Gynecology, University of Washington , Seattle, Washington
| | - Kathryn L Gatford
- Robinson Research Institute and Adelaide Medical School, University of Adelaide , Adelaide, South Australia , Australia
| | - Dino A Giussani
- Department of Physiology, Development, and Neuroscience, University of Cambridge , Cambridge , United Kingdom
| | - Clint L Gray
- Department of Paediatrics and Child Health, University of Otago , Wellington , New Zealand
| | - Richard Harding
- Department of Anatomy and Developmental Biology, Monash University , Clayton, Victoria , Australia
| | - Emilio A Herrera
- Pathophysiology Program, Biomedical Sciences Institute (ICBM), Faculty of Medicine, University of Chile , Santiago , Chile
| | - Matthew W Kemp
- Division of Obstetrics and Gynecology, University of Western Australia , Perth, Western Australia , Australia
| | - Mitchell C Lock
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - I Caroline McMillen
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Timothy J Moss
- The Ritchie Centre, Hudson Institute of Medical Research, Department of Obstetrics and Gynaecology, Monash University , Clayton, Victoria , Australia
| | - Gabrielle C Musk
- Animal Care Services, University of Western Australia , Perth, Western Australia , Australia
| | - Mark H Oliver
- Liggins Institute, University of Auckland , Auckland , New Zealand
| | - Timothy R H Regnault
- Department of Obstetrics and Gynecology and Department of Physiology and Pharmacology, Western University, and Children's Health Research Institute , London, Ontario , Canada
| | - Claire T Roberts
- Robinson Research Institute and Adelaide Medical School, University of Adelaide , Adelaide, South Australia , Australia
| | - Jia Yin Soo
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Ross L Tellam
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
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Morsi A, DeFranco D, Witchel SF. The Hypothalamic-Pituitary-Adrenal Axis and the Fetus. Horm Res Paediatr 2018; 89:380-387. [PMID: 29874660 DOI: 10.1159/000488106] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 02/28/2018] [Indexed: 11/19/2022] Open
Abstract
Glucocorticoids (GCs), cortisol in humans, influence multiple essential maturational events during gestation. In the human fetus, fetal hypothalamic-pituitary-adrenal (HPA) axis function, fetal adrenal steroidogenesis, placental 11β- hydroxysteroid dehydrogenase type 2 activity, maternal cortisol concentrations, and environmental factors impact fetal cortisol exposure. The beneficial effects of synthetic glucocorticoids (sGCs), such as dexamethasone and betamethasone, on fetal lung maturation have significantly shifted the management of preterm labor and threatened preterm birth. Accumulating evidence suggests that exposure to sGCs in utero at critical developmental stages can alter the function of organ systems and that these effects may have sequelae that extend into adult life. Maternal stress and environmental influences may also impact fetal GC exposure. This article explores the vulnerability of the fetal HPA axis to endogenous GCs and exogenous sGCs.
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Affiliation(s)
- Amr Morsi
- Division of Pediatric Endocrinology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Donald DeFranco
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Selma F Witchel
- Division of Pediatric Endocrinology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Kemp MW, Jobe AH, Usuda H, Nathanielsz PW, Li C, Kuo A, Huber HF, Clarke GD, Saito M, Newnham JP, Stock SJ. Efficacy and safety of antenatal steroids. Am J Physiol Regul Integr Comp Physiol 2018; 315:R825-R839. [PMID: 29641233 DOI: 10.1152/ajpregu.00193.2017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Antenatal steroids (ANS) are among the most important and widely utilized interventions to improve outcomes for preterm infants. A significant body of evidence demonstrates improved outcomes in preterm infants (24-34 wk) delivered between 1 and 7 days after the administration of a single course of ANS. Moreover, ANS have the advantage of being widely available, low cost, and easily administered via maternal intramuscular injection. The use of ANS to mature the fetal lung is, however, not without contention. Their use in pregnancy is not FDA approved, and treatment doses and regimens remain largely unoptimized. Their mode of use varies considerably between countries, and there are lingering concerns regarding the safety of exposing the fetus to high doses of exogenous steroids. A significant proportion of women deliver outside the 1- to 7-day therapeutic window after ANS treatment, and this delay may be associated with an increased risk of adverse outcomes for both mother and baby. Today, animal-based studies are one means by which key questions of dosing and safety relating to ANS may be resolved, allowing for further refinement(s) of this important therapy. Complementary approaches using nonhuman primates, sheep, and rodents have provided invaluable advances to our understanding of how exogenous steroid exposure impacts fetal development. Focusing on these three major model groups, this review highlights the role of three key animal models (sheep, nonhuman primates, rodents) in the development of antenatal steroid therapy, and provides an up-to-date synthesis of current efforts to refine this therapy in an era of personalised medicine.
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Affiliation(s)
- Matthew W Kemp
- Division of Obstetrics and Gynaecology, University of Western Australia , Perth , Australia
- Tohoku University Hospital, Sendai, Miyagi , Japan
| | - Alan H Jobe
- Division of Obstetrics and Gynaecology, University of Western Australia , Perth , Australia
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Centre , Cincinnati, Ohio
| | - Haruo Usuda
- Division of Obstetrics and Gynaecology, University of Western Australia , Perth , Australia
- Tohoku University Hospital, Sendai, Miyagi , Japan
| | | | - Cun Li
- Department of Animal Science, University of Wyoming , Laramie, Wyoming
| | - Anderson Kuo
- Department of Radiology, University of Texas Health Science Center San Antonio , San Antonio, Texas
| | - Hillary F Huber
- Department of Animal Science, University of Wyoming , Laramie, Wyoming
| | - Geoffrey D Clarke
- Department of Radiology, University of Texas Health Science Center San Antonio , San Antonio, Texas
| | - Masatoshi Saito
- Division of Obstetrics and Gynaecology, University of Western Australia , Perth , Australia
- Tohoku University Hospital, Sendai, Miyagi , Japan
| | - John P Newnham
- Division of Obstetrics and Gynaecology, University of Western Australia , Perth , Australia
| | - Sarah J Stock
- Division of Obstetrics and Gynaecology, University of Western Australia , Perth , Australia
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
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Cartwright RD, Harding JE, Crowther CA, Cutfield WS, Battin MR, Dalziel SR, McKinlay CJD. Repeat Antenatal Betamethasone and Cardiometabolic Outcomes. Pediatrics 2018; 142:peds.2018-0522. [PMID: 29895522 DOI: 10.1542/peds.2018-0522] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Repeat dose(s) of antenatal betamethasone are recommended for women at <32 weeks with ongoing risk of preterm birth. However, there is concern that use of repeat dose(s) in fetal growth restriction (FGR) may increase the risk of later cardiometabolic disease. METHODS We undertook secondary analysis of data from the Australasian Collaborative Trial of Repeat Doses of Corticosteroids Midchildhood Outcome Study to determine if FGR influences the effect of repeat betamethasone on growth and cardiometabolic function. At 6 to 8 years, children underwent anthropometry, dual energy x-ray absorptiometry, intravenous glucose tolerance testing, ambulatory blood pressure monitoring, and spirometry. FGR was defined as severe FGR at entry, cesarean delivery for FGR, or customized birth weight below the third centile. RESULTS Of 266 children assessed, FGR occurred in 43 of 127 (34%) exposed to repeat betamethasone and 44 of 139 (32%) exposed to placebo. There was an interaction between FGR and repeat betamethasone treatment for the effect on height (z score mean difference [95% confidence interval]; FGR: 0.59 [0.01 to 1.17]; non-FGR: -0.29 [-0.69 to 0.10]; P = .01). However, FGR did not influence the effect of repeat betamethasone on cardiometabolic function, which was similar in treatment groups, both in FGR and non-FGR subgroups. CONCLUSIONS Repeat antenatal betamethasone treatment had no adverse effects on cardiometabolic function, even in the presence of FGR. It may have a positive effect on height in FGR. Clinicians should use repeat doses of antenatal corticosteroids when indicated before preterm birth, regardless of FGR, in view of the associated neonatal benefits.
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Affiliation(s)
| | | | - Caroline A Crowther
- Liggins Institute and.,Department of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Wayne S Cutfield
- Liggins Institute and.,A Better Start, National Science Challenge, Auckland, New Zealand
| | - Malcolm R Battin
- Liggins Institute and.,Newborn Services, National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Stuart R Dalziel
- Liggins Institute and.,Children's Emergency Department, Starship Children's Health, Auckland, New Zealand; and
| | - Christopher J D McKinlay
- Liggins Institute and .,Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand.,Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
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Slotkin TA, Ko A, Seidler FJ. Does growth impairment underlie the adverse effects of dexamethasone on development of noradrenergic systems? Toxicology 2018; 408:11-21. [PMID: 29935188 DOI: 10.1016/j.tox.2018.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/15/2018] [Accepted: 06/19/2018] [Indexed: 12/24/2022]
Abstract
Glucocorticoids are given in preterm labor to prevent respiratory distress but these agents evoke neurobehavioral deficits in association with reduced brain region volumes. To determine whether the neurodevelopmental effects are distinct from growth impairment, we gave developing rats dexamethasone at doses below or within the therapeutic range (0.05, 0.2 or 0.8 mg/kg) at different stages: gestational days (GD) 17-19, postnatal days (PN) 1-3 or PN7-9. In adolescence and adulthood, we assessed the impact on noradrenergic systems in multiple brain regions, comparing the effects to those on somatic growth or on brain region growth. Somatic growth was reduced with exposure in all three stages, with greater sensitivity for the postnatal regimens; brain region growth was impaired to a lesser extent. Norepinephrine content and concentration were reduced depending on the treatment regimen, with a rank order of deficits of PN7-9 > PN1-3 > GD17-19. However, brain growth impairment did not parallel reduced norepinephrine content in magnitude, dose threshold, sex or regional selectivity, or temporal pattern, and even when corrected for reduced brain region weights (norepinephrine per g tissue), the dexamethasone-exposed animals showed subnormal values. Regression analysis showed that somatic growth impairment accounted for an insubstantial amount of the reduction in norepinephrine content, and brain growth impairment accounted for only 12%, whereas specific effects on norepinephrine accounted for most of the effect. The adverse effects of dexamethasone on noradrenergic system development are not simply related to impaired somatic or brain region growth, but rather include specific targeting of neurodifferentiation.
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Affiliation(s)
- Theodore A Slotkin
- Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, North Carolina, 27710, USA.
| | - Ashley Ko
- Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Frederic J Seidler
- Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, North Carolina, 27710, USA
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Feng S, Liu J, Cheng B, Deng A, Zhang H. (-)-Epigallocatechin-3-gallate protects PC12 cells against corticosterone-induced neurotoxicity via the hedgehog signaling pathway. Exp Ther Med 2018; 15:4284-4290. [PMID: 29731823 PMCID: PMC5920970 DOI: 10.3892/etm.2018.5936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 06/08/2017] [Indexed: 12/21/2022] Open
Abstract
It has been acknowledged that environmental stress is a risk factor for developing mental disorders. Chronic stress may contribute to the hyperactivation of the hypothalamic-pituitary-adrenal (HPA) axis and a sustained rise in the levels of glucocorticoids (GCs). A high concentration of corticosterone (CORT) damages neuronal PC12 cells. It has been reported that (−)-Epigallocatechin-3-gallate (EGCG), a major component of green tea, exhibits neuroprotective activity. However, the protective effect of EGCG on neuronal cells injured by CORT remains to be elucidated. The present study aimed to identify the effects of EGCG on CORT-injured neuronal PC12 cells and its associated mechanisms of action. CORT-injured PC12 cells were pretreated with EGCG with or without cyclopamine. Cell viability was assessed using an MTT assay, changes in cell morphology were observed using phase-contrast microscopy, cellular apoptosis was assessed by Hoechst 33342 staining, cell proliferation was measured using a cell counting kit-8 assay, mRNA levels were measured by reverse transcription-quantitative polymerase chain reaction and protein expression was assessed using western blot analysis. The current study demonstrated that exposure to high concentrations of CORT induced cytotoxicity and downregulated the Sonic hedgehog pathway (Shh) in PC12 cells. These effects were attenuated by EGCG. However, the EGCG-mediated neuroprotective effects, as well as upregulation of the Shh pathway were all attenuated by the Shh signaling inhibitor cyclopamine. These results indicate that EGCG protects PC12 cells from CORT-induced neurotoxicity via activation of the Shh signaling pathway.
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Affiliation(s)
- Sha Feng
- Department of Pharmacy, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Jue Liu
- Department of Pharmacy, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, P.R. China
| | - Biao Cheng
- Department of Pharmacy, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, P.R. China
| | - Aiping Deng
- Department of Pharmacy, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, P.R. China
| | - Hong Zhang
- Department of Pharmacy, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
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Slotkin TA, Skavicus S, Seidler FJ. Developmental neurotoxicity resulting from pharmacotherapy of preterm labor, modeled in vitro: Terbutaline and dexamethasone, separately and together. Toxicology 2018. [PMID: 29524569 DOI: 10.1016/j.tox.2018.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Terbutaline and dexamethasone are used in the management of preterm labor, often for durations of treatment exceeding those recommended, and both have been implicated in increased risk of neurodevelopmental disorders. We used a variety of cell models to establish the critical stages at which neurodifferentiation is vulnerable to these agents and to determine whether combined exposures produce a worsened outcome. Terbutaline selectively promoted the initial emergence of glia from embryonic neural stem cells (NSCs). The target for terbutaline shifted with developmental stage: at later developmental stages modeled with C6 and PC12 cells, terbutaline had little effect on glial differentiation (C6 cells) but impaired the differentiation of neuronotypic PC12 cells into neurotransmitter phenotypes. In contrast to the specificity shown by terbutaline, dexamethasone affected both neuronal and glial differentiation at all stages, impairing the emergence of both cell types in NSCs but with a much greater impairment for glia. At later stages, dexamethasone promoted glial cell differentiation (C6 cells), while shifting neuronal cell differentiation so as to distort the balance of neurotransmitter phenotypes (PC12 cells). Finally, terbutaline and dexamethasone interacted synergistically at the level of late stage glial cell differentiation, with dexamethasone boosting the ability of terbutaline to enhance indices of glial cell growth and neurite formation while producing further decrements in glial cell numbers. Our results support the conclusion that terbutaline and dexamethasone are directly-acting neuroteratogens, and further indicate the potential for their combined use in preterm labor to worsen neurodevelopmental outcomes.
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Affiliation(s)
- Theodore A Slotkin
- Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, NC, 27710, USA.
| | - Samantha Skavicus
- Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Frederic J Seidler
- Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, NC, 27710, USA
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Effects of an antenatal dietary intervention in overweight and obese women on 6 month infant outcomes: follow-up from the LIMIT randomised trial. Int J Obes (Lond) 2018; 42:1326-1335. [PMID: 29568100 PMCID: PMC6054603 DOI: 10.1038/s41366-018-0019-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 11/12/2017] [Accepted: 01/03/2018] [Indexed: 01/20/2023]
Abstract
Background The immediate impact of providing an antenatal dietary intervention during pregnancy has been extensively studied, but little is known of the effects beyond the neonatal period. Our objective was to evaluate the effect of an antenatal dietary intervention in overweight or obese women on infant outcomes 6 months after birth. Methods We conducted a follow up study of infants born to women who participated in the LIMIT trial during pregnancy. Live-born infants at 6-months of age, and whose mother provided consent to ongoing follow-up were eligible. The primary follow-up study endpoint was the incidence of infant BMI z-score ≥90th centile for infant sex and age. Secondary study outcomes included a range of infant anthropometric measures, neurodevelopment, general health, and infant feeding. Analyses used intention to treat principles according to the treatment group allocated in pregnancy. Missing data were imputed and analyses adjusted for maternal early pregnancy BMI, parity, study centre, socioeconomic status, age, and smoking status. Outcome assessors were blinded to the allocated treatment group. Results A total of 1754 infants were assessed at age 6 months (Lifestyle Advice n = 869; Standard Care n = 885), representing 82.1% of the eligible sample (n = 2136). There were no statistically significant differences in the incidence of infant BMI z-score ≥90th centile for infants born to women in the Lifestyle Advice group, compared with the Standard Care group (Lifestyle Advice 233 (21.71%) vs. Standard Care 233 (21.90%); adjusted relative risk (aRR) 0.99; 95% confidence interval 0.82 to 1.18; p = 0.88). There were no other effects on infant growth, adiposity, or neurodevelopment. Conclusion Providing pregnant women who were overweight or obese with an antenatal dietary and lifestyle intervention did not alter 6-month infant growth and adiposity. Trial Registration: Australian and New Zealand Clinical Trials Registry (ACTRN12607000161426).
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Peccatori FA, Lambertini M, Scarfone G, Del Pup L, Codacci-Pisanelli G. Biology, staging, and treatment of breast cancer during pregnancy: reassessing the evidences. Cancer Biol Med 2018; 15:6-13. [PMID: 29545964 PMCID: PMC5842335 DOI: 10.20892/j.issn.2095-3941.2017.0146] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Breast cancer is one of the most frequently diagnosed malignancies during pregnancy. Here, we review the management of women with breast cancer during pregnancy (BCP), focusing on biology, diagnosis and staging, local and systemic treatments, obstetric care and long-term follow-up of children with prenatal exposure to anticancer treatments.
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Affiliation(s)
| | - Matteo Lambertini
- Gynecologic Oncology Department, European Institute of Oncology, Milan 20141, Italy
| | - Giovanna Scarfone
- Gynecologic Oncology Department, European Institute of Oncology, Milan 20141, Italy
| | - Lino Del Pup
- Gynecologic Oncology Department, European Institute of Oncology, Milan 20141, Italy
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McGowan PO, Matthews SG. Prenatal Stress, Glucocorticoids, and Developmental Programming of the Stress Response. Endocrinology 2018; 159:69-82. [PMID: 29136116 DOI: 10.1210/en.2017-00896] [Citation(s) in RCA: 135] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 11/06/2017] [Indexed: 01/06/2023]
Abstract
The early environment has a major impact on the developing embryo, fetus, and infant. Parental adversity (maternal and paternal) and glucocorticoid exposure before conception and during pregnancy have profound effects on the development and subsequent function of the hypothalamic-pituitary-adrenal axis and related behaviors. These effects are species-, sex-, and age-specific and depend on the timing and duration of exposure. The impact of these early exposures can extend across multiple generations, via both the maternal and paternal lineage, and recent studies have begun to determine the mechanisms by which this occurs. Improved knowledge of the mechanisms by which adversity and glucocorticoids program stress systems will allow development of strategies to ameliorate and/or reverse these long-term effects.
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Affiliation(s)
- Patrick O McGowan
- Department of Biological Sciences, University of Toronto, Toronto, Ontario, Canada
- Center for Environmental Epigenetics and Development, University of Toronto, Toronto, Ontario, Canada
- Department of Cell and Systems Biology, University of Toronto, Toronto, Ontario, Canada
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Stephen G Matthews
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Department of Obstetrics & Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
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Kirshenbaum M, Mazaki-Tovi S, Amikam U, Mazkereth R, Sivan E, Schiff E, Yinon Y. Does antenatal steroids treatment prior to elective cesarean section at 34–37 weeks of gestation reduce neonatal morbidity? Evidence from a case control study. Arch Gynecol Obstet 2017; 297:101-107. [DOI: 10.1007/s00404-017-4557-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
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Abstract
PURPOSE OF REVIEW Cancer in pregnancy has become increasingly frequent. It has become clear that for specific cancers under well defined circumstances, oncological treatment in pregnancy can be well tolerated and feasible for both mother and fetus. Continued critical assessment of the available literature and registration of cancer in pregnancy cases and outcomes for mother and child are necessary to work toward implementing optimal cancer treatment during pregnancy. RECENT FINDINGS Physiologic changes in pregnancy may alter distribution and efficacy of systemic therapy. Data on systemic therapy including, chemotherapy, hormonal therapy, and targeted therapy during pregnancy are available but incomplete. Outcomes of fetuses exposed to chemotherapy in utero are generally reassuring, but new targeted therapies are mostly discouraged in pregnancy. SUMMARY Cancer treatment during pregnancy is possible, depending on type and timing of systemic therapy and treatment modality. Available data are reassuring with a modest increase in complications such as growth restriction and preterm birth. The effect of new targeted therapies is often still unclear and therefore discouraged.
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Moisiadis VG, Constantinof A, Kostaki A, Szyf M, Matthews SG. Prenatal Glucocorticoid Exposure Modifies Endocrine Function and Behaviour for 3 Generations Following Maternal and Paternal Transmission. Sci Rep 2017; 7:11814. [PMID: 28924262 PMCID: PMC5603559 DOI: 10.1038/s41598-017-11635-w] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 08/25/2017] [Indexed: 01/18/2023] Open
Abstract
Fetal exposure to high levels of glucocorticoids programs long-term changes in the physiologic stress response and behaviours. However, it is not known whether effects manifest in subsequent generations of offspring following maternal (MT) or paternal (PT) transmission. We treated pregnant guinea pigs with three courses of saline or synthetic glucocorticoid (sGC) at a clinically relevant dose. Altered cortisol response to stress and behaviours transmitted to juvenile female and male F2 and F3 offspring from both parental lines. Behavioural effects of sGC in F1-F3 PT females associated with altered expression of genes in the prefrontal cortex and hypothalamic paraventricular nucleus (PVN). Exposure to sGC programmed large transgenerational changes in PVN gene expression, including type II diabetes, thermoregulation, and collagen formation gene networks. We demonstrate transgenerational programming to F3 following antenatal sGC. Transmission is sex- and generation-dependent, occurring through both parental lines. Paternal transmission to F3 females strongly implicates epigenetic mechanisms of transmission.
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Affiliation(s)
- Vasilis G Moisiadis
- Department of Physiology, University of Toronto, Toronto, ON, M5S1A8, Canada
| | - Andrea Constantinof
- Department of Physiology, University of Toronto, Toronto, ON, M5S1A8, Canada
| | - Alisa Kostaki
- Department of Physiology, University of Toronto, Toronto, ON, M5S1A8, Canada
| | - Moshe Szyf
- Department of Pharmacology & Therapeutics, Sackler Program for Epigenetics & Psychobiology, McGill University, Montreal, QC, H3G1Y6, Canada
| | - Stephen G Matthews
- Department of Physiology, University of Toronto, Toronto, ON, M5S1A8, Canada.
- Department of Obstetrics and Gynecology, Toronto, ON, M5S1A8, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, M5S1A8, Canada.
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McEvoy C, Schilling D, Spitale P, O'Malley J, Bowling S, Durand M. Pulmonary function and outcomes in infants randomized to a rescue course of antenatal steroids. Pediatr Pulmonol 2017; 52:1171-1178. [PMID: 28436580 PMCID: PMC5561489 DOI: 10.1002/ppul.23711] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 04/02/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND/OBJECTIVE Our objective was to obtain follow-up pulmonary function testing and assessment of clinical respiratory outcomes, at 1-2 years, in preterm infants whose mothers were randomized to a single rescue course of antenatal steroids (AS) versus placebo. METHODS Follow-up of a randomized, double-blinded trial. In the original trial pregnant women ≥14 days after initial course of AS were randomized to rescue AS or placebo. Pulmonary function testing and a standardized respiratory questionnaire were obtained at 1-2 years of corrected age. Respiratory compliance (Crs) was measured with the single-breath occlusion and functional residual capacity (FRC) with the nitrogen washout method. Analysis was by intention-to-treat. RESULTS A total of 96 (87%) of available survivors were administered a respiratory questionnaire. Seventy-seven percent of available patients had pulmonary function testing performed. There was no significant difference between groups in incidence of wheezing, asthma, respiratory syncytial virus infection, respiratory readmissions, use of bronchodilators or other medications, or in measurements of pulmonary function. There was also no significant difference in corrected age at study, race, gender, or length at the time of pulmonary function testing. Infants in the rescue group had a comparable mean FRC (249.4 mL vs 246.2 mL; adjusted 95%CI for difference -15.45, 38.20; P = 0.37) versus placebo. There were no differences in tidal volume or Crs. CONCLUSION A rescue course of AS significantly increases Crs within 72 h of age and decreases oxygen need in newborn infants, without an adverse impact on pulmonary function or clinical respiratory outcomes at 1-2 years of age [NCT00669383].
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Affiliation(s)
- Cindy McEvoy
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon.,Department of Pediatrics, Sacred Heart Hospital, Pensacola, Florida
| | - Diane Schilling
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon
| | - Patricia Spitale
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon
| | - Jean O'Malley
- Public Health and Preventive Medicine, Oregon Health & Science University, Portland, Oregon
| | - Susan Bowling
- Department of Pediatrics, Sacred Heart Hospital, Pensacola, Florida
| | - Manuel Durand
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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Committee Opinion No. 713: Antenatal Corticosteroid Therapy for Fetal Maturation. Obstet Gynecol 2017; 130:e102-e109. [DOI: 10.1097/aog.0000000000002237] [Citation(s) in RCA: 243] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Neurogenesis is currently an area of great interest in neuroscience. It is closely linked to brain diseases, including mental disorders and neurodevelopmental disease. Both embryonic and adult neurogeneses are influenced by glucocorticoids secreted from the adrenal glands in response to a variety of stressors. Moreover, proliferation/differentiation of the neural stem/progenitor cells (NSPCs) is affected by glucocorticoids through intracellular signaling pathways such as phosphoinositide 3-kinase (PI3K)/Akt, hedgehog, and Wnt. Our review presents recent evidence of the impact of glucocorticoids on NSPC behaviors and the underlying molecular mechanisms; this provides important information for understanding the pathological role of glucocorticoids on neurogenesis-associated brain diseases.
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Affiliation(s)
- Haruki Odaka
- Department of Life Science and Medical Bioscience, School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
- Department of Cell Modulation, Institute of Molecular Embryology and Genetics, Kumamoto University, Kumamoto, Japan
| | - Naoki Adachi
- Department of Biomedical Chemistry, School of Science and Technology, Kwansei Gakuin University, Hyogo, Japan
- Department of Mental Disorder Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
| | - Tadahiro Numakawa
- Department of Cell Modulation, Institute of Molecular Embryology and Genetics, Kumamoto University, Kumamoto, Japan
- Department of Mental Disorder Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
- Correspondence to: Tadahiro Numakawa, .
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Abstract
Corticosteroid administration before anticipated preterm birth is one of the most important antenatal therapies available to improve newborn outcomes. A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation, including for those with ruptured membranes and multiple gestations. It also may be considered for pregnant women starting at 23 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, based on a family's decision regarding resuscitation, irrespective of membrane rupture status and regardless of fetal number. Administration of betamethasone may be considered in pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation at imminent risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids. A single repeat course of antenatal corticosteroids should be considered in women who are less than 34 0/7 weeks of gestation who have an imminent risk of preterm delivery within the next 7 days, and whose prior course of antenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. Continued surveillance of long-term outcomes after in utero corticosteroid exposure should be supported. Quality improvement strategies to optimize appropriate and timely antenatal corticosteroid administration are encouraged.
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Tsiarli MA, Rudine A, Kendall N, Pratt MO, Krall R, Thiels E, DeFranco DB, Monaghan AP. Antenatal dexamethasone exposure differentially affects distinct cortical neural progenitor cells and triggers long-term changes in murine cerebral architecture and behavior. Transl Psychiatry 2017; 7:e1153. [PMID: 28608856 PMCID: PMC5537650 DOI: 10.1038/tp.2017.65] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 02/09/2017] [Accepted: 02/13/2017] [Indexed: 12/13/2022] Open
Abstract
Antenatal administration of synthetic glucocorticoids (sGC) is the standard of care for women at risk for preterm labor before 34 gestational weeks. Despite their widespread use, the type of sGC used and their dose or the dosing regimens are not standardized in the United States of America or worldwide. Several studies have identified neural deficits and the increased risk for cognitive and psychiatric disease later in life for children administered sGC prenatally. However, the precise molecular and cellular targets of GC action in the developing brain remain largely undefined. In this study, we demonstrate that a single dose of glucocorticoid during mid-gestation in mice leads to enhanced proliferation in select cerebral cortical neural stem/progenitor cell populations. These alterations are mediated by dose-dependent changes in the expression of cell cycle inhibitors and in genes that promote cell cycle re-entry. This leads to changes in neuronal number and density in the cerebral cortex at birth, coupled to long-term alterations in neurite complexity in the prefrontal cortex and hippocampus in adolescents, and changes in anxiety and depressive-like behaviors in adults.
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Affiliation(s)
- M A Tsiarli
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA
| | - A Rudine
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - N Kendall
- Department of Neurobiology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - M O Pratt
- Department of Neurobiology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - R Krall
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA
| | - E Thiels
- Department of Neurobiology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - D B DeFranco
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA,Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - A P Monaghan
- Department of Neurobiology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA,Department of Biomedical Sciences, University of Missouri Kansas City School of Medicine, Kansas City, MO, USA,Department of Biomedical Sciences, University of Missouri Kansas City School of Medicine, 2411 Holmes Street, Kansas City, MO 64108, USA. E-mail:
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