Absence of a prelabor relaxin surge in women

Recombinant human relaxin versus placebo for cervical ripening: a double-blind randomised trial in pregnant women scheduled for induction of labour

BACKGROUND

Nonclinical studies indicate that the hormone relaxin is a good candidate for a safe cervical ripening agent that does not cause uterine contractions.

METHODS

This Phase II study (conducted November 2, 2005-October 20, 2006) was a randomised, double blind, placebo controlled trial testing 24-h intravenous infusion of serelaxin (recombinant human relaxin) or placebo for cervical ripening in 72 healthy, primiparous women. Eligible subjects had a singleton pregnancy ≥40 weeks, were planned for elective induction, had vertex presentation of the fetus, intact membranes and a Bishop score at screening ≤4. In Part A of the study, safety evaluation of three escalating doses of serelaxin (7.5, 25 or 75 μg/kg/day) or placebo was performed in 22 subjects admitted to the hospital 24 h prior to scheduled induction (n = 7, 4, 4, and 7 subjects, respectively). The highest safe dose from Part A and placebo were then tested in Part B for safety and cervical ripening (n = 25 subjects/arm). Planned randomisation ratio was of 4:2 (serelaxin:placebo) for each dose group in Part A and 1:1 for Part B. For analysis, subjects in Part B were pooled with those receiving the same dose in Part A and all subjects receiving placebo were pooled. The primary efficacy endpoint was change from baseline in Bishop score at 6, 12 and 24 h or end of study drug administration. Maternal safety evaluations included adverse events and vital signs through 4 weeks. Fetal assessments included serial heart rate monitoring and nonstress testing. Neonatal assessments included Apgar scores, NICU admissions, and adverse events through 4 weeks.

RESULTS

Overall, 74 subjects were randomized and 72 were treated. There were no significant differences between the groups receiving the highest safe dose of serelaxin (75 μg/kg/day) and placebo in the primary or secondary efficacy endpoints. Changes from baseline in Bishop score at 24 h were 4.19 ± 1.9 and 3.26 ± 2.26 in the pooled placebo and serelaxin groups, respectively (p = 0.2507). Serelaxin was well tolerated and no anti-serelaxin antibodies were detected in either subjects or neonates.

CONCLUSION

Serelaxin infusion at the end of pregnancy was well tolerated but did not advance cervical ripening.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT00259103 (15 November 2005).

Mechanisms of Relaxin-Mediated Premature Birth

In women, circulating relaxin is produced by the corpus luteum of pregnancy. The levels of relaxin are predominantly determined by the luteal mass, the number of corpora lutea present. Relaxin levels are highest after ovulation induction, which stimulates formation of many corpora lutea. Elevated relaxin levels in the first trimester of pregnancy are maintained throughout pregnancy and are linearly related to preterm birth. In an in vitro model of late human pregnancy cervix, relaxin increases MMP-1 and MMP-3 and decreases TIMP-1 levels, thus acting as a positive regulator of matrix metalloproteinases. In an in vivo rhesus monkey model of early pregnancy, relaxin decreases cervical collagen content, decreases cervical lumican levels, and stimulates MMP-7 levels. Early effects of relaxin in the uterus include increasing endometrial arteriole number and increasing the number of leukocytes, uterine natural killer cells, macrophages, and neutrophils. These cells release many cytokines which contribute to changes that stimulate and facilitate uterine contractility. If these changes persist in late pregnancy, relaxin may be a mediator of labor. Excess relaxin may produce these changes at an accelerated rate, causing preterm birth.

Implantation and Pregnancy Following In Vitro Fertilization and the Effect of Recombinant Human Relaxin Administration in Macaca fascicularis1

Implantation and early pregnancy, and the potential effects of the reproductive-hormone relaxin, were examined in the cynomolgus macaque (Macaca fascicularis) following in vitro fertilization and embryo transfer. Mature oocytes were collected from regularly cycling, female cynomolgus monkeys subjected to ovarian superovulation using recombinant human FSH and hCG. Oocytes fertilized in vitro were cultured to the 4- to 8-cell stage, slow-cooled, and stored in liquid nitrogen before thawing and embryo transfer. Regularly cycling recipients were administered recombinant human relaxin or vehicle for 21 days through the peri-implantation period (Day 0 = pump implantation), during which time the thawed embryos were transferred (Day 7). Endometrial thickness and the number of gestational sacs were monitored by ultrasound at three time points (Days 7, 21, and 28). The number of days of placental sign (implantation bleeding) in pregnant females and menses in nonpregnant females were also recorded. Implantation (gestational sacs/embryo transferred) and multiple pregnancy (multiple gestations/ pregnant recipient) rates were slightly higher in relaxin-treated recipients compared to vehicle-treated recipients. Administration of relaxin was associated with increased implantation bleeding in pregnant females. Endometrial thickness was increased in relaxin-treated recipients at Days 7 and 28 compared to Day 0, but these differences were not observed at the same time points in vehicle-treated females. Systemic administration of recombinant human relaxin in an in vitro fertilization/embryo transfer setting was associated with effects consistent with a role for this hormone in endometrial physiology in primates.

Plasma concentrations of immunoreactive relaxin activity and progesterone in the pregnant Asian elephant (Elephas maximus)

Immunoreactive relaxin activity and progesterone concentrations in weekly plasma samples were measured throughout six pregnancies in five Asian elephants (Elephas maximus). One animal aborted, one delivered a stillborn calf at term and the remaining pregnancies concluded normally with living young. Immunoreactive relaxin activity increased by week 20 of pregnancy to reach a mean peak concentrations of > 6 ng/ml in the second trimester. This was followed by a slow decline beginning approximately at 30 weeks before term. A smaller, secondary relaxin rise was observed during the final eight weeks preceding parturition and circulating concentrations remained above pre-pregnancy baseline values for 72 h after birth. In contrast, progesterone concentrations increased immediately after mating and rose to a maximum of > 2 ng/ml by mid-gestation. As with relaxin, progesterone concentrations began to decline gradually approximately 30 weeks before birth. More frequently collected samples before, during and after parturition revealed a decline to pre-pregnancy levels between 2-5 days before parturition, in contrast to elevated relaxin levels (1 ng/ml) during this time. The aborted pregnancy at week 35 was accompanied by a precipitous decline in both immunoreactive relaxin and progesterone concentrations one week before the visible termination of the pregnancy. The delivery of the term stillborn calf occurred five weeks after both immunoreactive relaxin and progesterone concentrations had declined to pre-pregnancy values. Results suggest that immunoreactive relaxin may be important, along with progesterone, in the maintenance of pregnancy in the Asian elephant as well as playing a role in preparation for birth and possibly to indicate foetal well-being.