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Malhotra A, Rocha AKAA, Yawno T, Sutherland AE, Allison BJ, Nitsos I, Pham Y, Jenkin G, Castillo-Melendez M, Miller SL. Neuroprotective effects of maternal melatonin administration in early-onset placental insufficiency and fetal growth restriction. Pediatr Res 2024; 95:1510-1518. [PMID: 38225450 PMCID: PMC11126390 DOI: 10.1038/s41390-024-03027-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Early-onset fetal growth restriction (FGR) is associated with adverse outcomes. We hypothesised that maternal melatonin administration will improve fetal brain structure in FGR. METHODS Surgery was performed on twin-bearing ewes at 88 days (0.6 gestation), and FGR induced in one twin via single umbilical artery ligation. Melatonin was administered intravenously (6 mg/day) to a group of ewes commencing on day of surgery until 127 days (0.85 gestation), when the ewe/fetuses were euthanized, and fetal brains collected. RESULTS Study groups were control (n = 5), FGR (n = 5), control+melatonin (control+MLT; n = 6) and FGR+melatonin (FGR + MLT; n = 6). Melatonin administration did not significantly alter fetal body or brain weights. Myelin (CNPase+) fibre density was reduced in FGR vs. control animals in most brain regions examined (p < 0.05) and melatonin treatment restored CNPase fibre density. Similar but less pronounced effect was seen with mature myelin (MBP+) staining. Significant differences in activated microglia (Iba-1) activity were seen between lamb groups (MLT mitigated FGR effect) in periventricular white matter, subventricular zone and external capsule (p < 0.05). Similar effects were seen in astrogliosis (GFAP) in intragyral white matter and cortex. CONCLUSIONS Maternal melatonin administration in early onset FGR led to improved myelination of white matter brain regions, possibly mediated by decreased inflammation. IMPACT Maternal melatonin administration might lead to neuroprotection in the growth-restricted fetus, possibly via dampening neuroinflammation and enhancing myelination. This preclinical study adds to the body of work on this topic, and informs clinical translation. Neuroprotection likely to improve long-term outcomes of this vulnerable infant group.
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Affiliation(s)
- Atul Malhotra
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.
| | - Anna K A A Rocha
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Tamara Yawno
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Amy E Sutherland
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Beth J Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Ilias Nitsos
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Yen Pham
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Margie Castillo-Melendez
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
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White TA, Miller SL, Sutherland AE, Allison BJ, Camm EJ. Perinatal compromise affects development, form, and function of the hippocampus part two; preclinical studies. Pediatr Res 2024:10.1038/s41390-024-03144-0. [PMID: 38519795 DOI: 10.1038/s41390-024-03144-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/15/2024] [Accepted: 03/03/2024] [Indexed: 03/25/2024]
Abstract
The hippocampus is a vital brain structure deep in the medial temporal lobe that mediates a range of functions encompassing emotional regulation, learning, memory, and cognition. Hippocampal development is exquisitely sensitive to perturbations and adverse conditions during pregnancy and at birth, including preterm birth, fetal growth restriction (FGR), acute hypoxic-ischaemic encephalopathy (HIE), and intrauterine inflammation. Disruptions to hippocampal development due to these conditions can have long-lasting functional impacts. Here, we discuss a range of preclinical models of prematurity and FGR and conditions that induce hypoxia and inflammation, which have been critical in elucidating the underlying mechanisms and cellular and subcellular structures implicated in hippocampal dysfunction. Finally, we discuss potential therapeutic targets to reduce the burden of these perinatal insults on the developing hippocampus. IMPACT: The review explores the preclinical literature examining the association between pregnancy and birth complications, and hippocampal form and function. The developmental processes and cellular mechanisms that are disrupted within the hippocampus following perinatal compromise are described, and potential therapeutic targets are discussed.
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Affiliation(s)
- Tegan A White
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia.
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Amy E Sutherland
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Beth J Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Emily J Camm
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia.
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3
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Wu BA, Chand KK, Bell A, Miller SL, Colditz PB, Malhotra A, Wixey JA. Effects of fetal growth restriction on the perinatal neurovascular unit and possible treatment targets. Pediatr Res 2024; 95:59-69. [PMID: 37674023 PMCID: PMC10798895 DOI: 10.1038/s41390-023-02805-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/04/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
The neurovascular unit (NVU) within the brain is a multicellular unit that synergistically acts to maintain blood-brain barrier function and meet cerebral metabolic demand. Recent studies have indicated disruption to the NVU is associated with neuropathology in the perinatal brain. Infants with fetal growth restriction (FGR) are known to be at increased risk of neurodevelopmental conditions including motor, learning, and behavioural deficits. There are currently no neuroprotective treatments for these conditions. In this review, we analyse large animal studies examining the effects of FGR on the perinatal NVU. These studies show altered vascularity in the FGR brain as well as blood-brain barrier dysfunction due to underlying cellular changes, mediated by neuroinflammation. Neuroinflammation is a key mechanism associated with pathological effects in the FGR brain. Hence, targeting inflammation may be key to preserving the multicellular NVU and providing neuroprotection in FGR. A number of maternal and postnatal therapies with anti-inflammatory components have been investigated in FGR animal models examining targets for amelioration of NVU disruption. Each therapy showed promise by uniquely ameliorating the adverse effects of FGR on multiple aspects of the NVU. The successful implementation of a clinically viable neuroprotective treatment has the potential to improve outcomes for neonates affected by FGR. IMPACT: Disruption to the neurovascular unit is associated with neuropathology in fetal growth restriction. Inflammation is a key mechanism associated with neurovascular unit disruption in the growth-restricted brain. Anti-inflammatory treatments ameliorate adverse effects on the neurovascular unit and may provide neuroprotection.
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Affiliation(s)
- Bing Anthony Wu
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Kirat K Chand
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Alexander Bell
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Suzanne L Miller
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Paul B Colditz
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Perinatal Research Centre, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Atul Malhotra
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Julie A Wixey
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
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Häusler S, Robertson NJ, Golhen K, van den Anker J, Tucker K, Felder TK. Melatonin as a Therapy for Preterm Brain Injury: What Is the Evidence? Antioxidants (Basel) 2023; 12:1630. [PMID: 37627625 PMCID: PMC10451719 DOI: 10.3390/antiox12081630] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 07/28/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Despite significant improvements in survival following preterm birth in recent years, the neurodevelopmental burden of prematurity, with its long-term cognitive and behavioral consequences, remains a significant challenge in neonatology. Neuroprotective treatment options to improve neurodevelopmental outcomes in preterm infants are therefore urgently needed. Alleviating inflammatory and oxidative stress (OS), melatonin might modify important triggers of preterm brain injury, a complex combination of destructive and developmental abnormalities termed encephalopathy of prematurity (EoP). Preliminary data also suggests that melatonin has a direct neurotrophic impact, emphasizing its therapeutic potential with a favorable safety profile in the preterm setting. The current review outlines the most important pathomechanisms underlying preterm brain injury and correlates them with melatonin's neuroprotective potential, while underlining significant pharmacokinetic/pharmacodynamic uncertainties that need to be addressed in future studies.
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Affiliation(s)
- Silke Häusler
- Division of Neonatology, Department of Pediatrics, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
| | - Nicola J. Robertson
- EGA Institute for Women’s Health, University College London, London WC1E 6HX, UK; (N.J.R.); (K.T.)
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Klervi Golhen
- Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel (UKBB), University of Basel, 4001 Basel, Switzerland; (K.G.); (J.v.d.A.)
| | - John van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel (UKBB), University of Basel, 4001 Basel, Switzerland; (K.G.); (J.v.d.A.)
- Division of Clinical Pharmacology, Children’s National Hospital, Washington, DC 20001, USA
| | - Katie Tucker
- EGA Institute for Women’s Health, University College London, London WC1E 6HX, UK; (N.J.R.); (K.T.)
| | - Thomas K. Felder
- Department of Laboratory Medicine, Paracelsus Medical University, 5020 Salzburg, Austria;
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5
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Miller SL, Bennet L, Sutherland AE, Pham Y, McDonald C, Castillo‐Melendez M, Allison BJ, Mihelakis J, Nitsos I, Boyd BJ, Hirst JJ, Walker DW, Hunt RW, Jenkin G, Wong F, Malhotra A, Fahey MC, Yawno T. Ganaxolone versus Phenobarbital for Neonatal Seizure Management. Ann Neurol 2022; 92:1066-1079. [PMID: 36054160 PMCID: PMC9828769 DOI: 10.1002/ana.26493] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Seizures are more common in the neonatal period than at any other stage of life. Phenobarbital is the first-line treatment for neonatal seizures and is at best effective in approximately 50% of babies, but may contribute to neuronal injury. Here, we assessed the efficacy of phenobarbital versus the synthetic neurosteroid, ganaxolone, to moderate seizure activity and neuropathology in neonatal lambs exposed to perinatal asphyxia. METHODS Asphyxia was induced via umbilical cord occlusion in term lambs at birth. Lambs were treated with ganaxolone (5mg/kg/bolus then 5mg/kg/day for 2 days) or phenobarbital (20mg/kg/bolus then 5mg/kg/day for 2 days) at 6 hours. Abnormal brain activity was classified as stereotypic evolving (SE) seizures, epileptiform discharges (EDs), and epileptiform transients (ETs) using continuous amplitude-integrated electroencephalographic recordings. At 48 hours, lambs were euthanized for brain pathology. RESULTS Asphyxia caused abnormal brain activity, including SE seizures that peaked at 18 to 20 hours, EDs, and ETs, and induced neuronal degeneration and neuroinflammation. Ganaxolone treatment was associated with an 86.4% reduction in the number of seizures compared to the asphyxia group. The total seizure duration in the asphyxia+ganaxolone group was less than the untreated asphyxia group. There was no difference in the number of SE seizures between the asphyxia and asphyxia+phenobarbital groups or duration of SE seizures. Ganaxolone treatment, but not phenobarbital, reduced neuronal degeneration within hippocampal CA1 and CA3 regions, and cortical neurons, and ganaxolone reduced neuroinflammation within the thalamus. INTERPRETATION Ganaxolone provided better seizure control than phenobarbital in this perinatal asphyxia model and was neuroprotective for the newborn brain, affording a new therapeutic opportunity for treatment of neonatal seizures. ANN NEUROL 2022;92:1066-1079.
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Affiliation(s)
- Suzanne L. Miller
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Laura Bennet
- Department of PhysiologyUniversity of AucklandAucklandNew Zealand
| | - Amy E. Sutherland
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Yen Pham
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Courtney McDonald
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Margie Castillo‐Melendez
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Beth J. Allison
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Jamie Mihelakis
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Ilias Nitsos
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Ben J. Boyd
- Monash Institute of Pharmaceutical SciencesMonash UniversityParkvilleVictoriaAustralia
| | - Jonathan J. Hirst
- School of Biomedical Sciences and Pharmacy, University of NewcastleNewcastleNew South WalesAustralia
| | - David W. Walker
- School of Health and Biomedical Sciences, RMIT UniversityBundooraVictoriaAustralia
| | - Rodney W. Hunt
- Department of PaediatricsMonash UniversityClaytonVictoriaAustralia
| | - Graham Jenkin
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Flora Wong
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,School of Health and Biomedical Sciences, RMIT UniversityBundooraVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia
| | - Atul Malhotra
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia,Monash Children's HospitalClaytonVictoriaAustralia
| | - Michael C. Fahey
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia,Monash Children's HospitalClaytonVictoriaAustralia
| | - Tamara Yawno
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia
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6
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Mike JK, Wu KY, White Y, Pathipati P, Ndjamen B, Hutchings RS, Losser C, Vento C, Arellano K, Vanhatalo O, Ostrin S, Windsor C, Ha J, Alhassen Z, Goudy BD, Vali P, Lakshminrusimha S, Gobburu JVS, Long-Boyle J, Chen P, Wu YW, Fineman JR, Ferriero DM, Maltepe E. Defining longer term outcomes in an ovine model of moderate perinatal hypoxia-ischemia. Dev Neurosci 2022; 44:277-294. [PMID: 35588703 DOI: 10.1159/000525150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 04/06/2022] [Indexed: 11/19/2022] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) is the leading cause of neonatal morbidity and mortality worldwide. Approximately 1 million infants born with HIE each year survive with cerebral palsy (CP) and/or serious cognitive disabilities. While infants born with mild and severe HIE frequently result in predictable outcomes, infants born with moderate HIE exhibit variable outcomes that are highly unpredictable. Here, we describe an umbilical cord occlusion (UCO) model of moderate HIE with a 6-day follow-up. Near term lambs (n=27) are resuscitated after the induction of 5 minutes of asystole. Following recovery, lambs are assessed to define neurodevelopmental outcomes. At the end of this period, lambs are euthanized, and brains harvested for histological analysis. Compared with prior models that typically follow lambs for 3 days, the observation of neurobehavioral outcomes for 6 days enables identification of animals that recover significant neurological function. Approximately 35 % of lambs exhibited severe motor deficits throughout the entirety of the 6-day course and, in the most severely affected lambs, developed spastic diparesis similar to that observed in infants who survive severe neonatal HIE (severe, UCOs). Importantly, and similar to outcomes in human neonates, while initially developing significant acidosis and encephalopathy, the remainder of the lambs in this model recovered normal motor activity and exhibited normal neurodevelopmental outcomes by 6 days of life (improved, UCOi). The UCOs group exhibited gliosis and inflammation in both white and gray matter, oligodendrocyte loss, and neuronal loss and cellular death in the hippocampus and cingulate cortex. While the UCOi group exhibited more cellular death and gliosis in the parasagittal cortex and demonstrated more preserved white matter markers, along with reduced markers of inflammation and lower cellular death and neuronal loss in Ca3 of the hippocampus compared with UCOs lambs. Our large animal model of moderate HIE with prolonged follow-up will help further define pathophysiologic drivers of brain injury while enabling identification of predictive biomarkers that correlate with disease outcomes and ultimately help support development of therapeutic approaches to this challenging clinical scenario.
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Affiliation(s)
- Jana Krystofova Mike
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Katherine Y Wu
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Yasmine White
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Praneeti Pathipati
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
| | - Blaise Ndjamen
- Histology and Microscopy Core, Gladstone Institutes University of California San Francisco, San Francisco, California, USA
| | - Rachel S Hutchings
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Courtney Losser
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Christian Vento
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Kimberly Arellano
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Oona Vanhatalo
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Samuel Ostrin
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Christine Windsor
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Janica Ha
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Ziad Alhassen
- Department of Pediatrics, University of California Davis, Davis, California, USA
| | - Brian D Goudy
- Department of Pediatrics, University of California Davis, Davis, California, USA
| | - Payam Vali
- Department of Pediatrics, University of California Davis, Davis, California, USA
| | | | - Jogarao V S Gobburu
- School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
- Initiative for Pediatric Drug and Device Development, San Francisco, California, USA
| | - Janel Long-Boyle
- Initiative for Pediatric Drug and Device Development, San Francisco, California, USA
- School of Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Peggy Chen
- Department of Pediatrics, University of California Davis, Davis, California, USA
| | - Yvonne W Wu
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
| | - Jeffrey R Fineman
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Initiative for Pediatric Drug and Device Development, San Francisco, California, USA
| | - Donna M Ferriero
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
| | - Emin Maltepe
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Initiative for Pediatric Drug and Device Development, San Francisco, California, USA
- Department of Biomedical Sciences, University of California San Francisco, San Francisco, California, USA
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7
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Pang R, Han HJ, Meehan C, Golay X, Miller SL, Robertson NJ. Efficacy of melatonin in term neonatal models of perinatal hypoxia-ischaemia. Ann Clin Transl Neurol 2022; 9:795-809. [PMID: 35413154 PMCID: PMC9186150 DOI: 10.1002/acn3.51559] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 03/29/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Neonatal encephalopathy (NE) is an important cause of mortality and disability worldwide. Therapeutic hypothermia (HT) is an effective therapy, however not all babies benefit. Novel agents are urgently needed to improve outcomes. Melatonin in preclinical studies has promising neuroprotective properties. This meta-analysis assessed the efficacy of melatonin in term animal models of NE on cerebral infarct size, neurobehavioural tests and cell death. METHODS A literature search was carried out using Embase, MEDLINE and Web of Science (31 May 2021). We identified 14 studies and performed a meta-analysis with a random effects model using standardised mean difference (SMD) as the effect size. The risk of bias was assessed using the Systematic Review Centre for Laboratory animal Experimentation tool and publication bias was assessed with funnel plots, and adjusted using trim and fill analysis. Subgroup and meta-regression analyses were performed to assess the effects of study design variables. RESULTS We observed significant reduction in brain infarct size (SMD -2.05, 95% CI [-2.93, -1.16]), improved neurobehavioural outcomes (SMD -0.86, 95% CI [-1.23, -0.53]) and reduction in cell death (SMD -0.60, 95% CI [-1.06, -0.14]) favouring treatment with melatonin. Neuroprotection was evident as a single therapy and combined with HT. Subgroup analysis showed greater efficacy with melatonin given before or immediately after injury and with ethanol excipients. The overall effect size remained robust even after adjustment for publication bias. INTERPRETATION These studies demonstrate a significant neuroprotective efficacy of melatonin in term neonatal models of hypoxia-ischaemia, and suggest melatonin is a strong candidate for translation to clinical trials in babies with moderate-severe NE.
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Affiliation(s)
- Raymand Pang
- Institute for Women's Health, University College London, London, UK
| | - Hyun Jee Han
- Institute for Women's Health, University College London, London, UK
| | | | - Xavier Golay
- Institute of Neurology, Queen's Square, University College London, London, UK
| | - Suzanne L Miller
- The Ritchie Centre, Translational Research Facility, Hudson Institute of Medical Research, Clayton, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK.,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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8
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The Effects of In Utero Fetal Hypoxia and Creatine Treatment on Mitochondrial Function in the Late Gestation Fetal Sheep Brain. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:3255296. [PMID: 35132347 PMCID: PMC8817846 DOI: 10.1155/2022/3255296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/13/2021] [Accepted: 01/05/2022] [Indexed: 12/21/2022]
Abstract
Near-term acute hypoxia in utero can result in significant fetal brain injury, with some brain regions more vulnerable than others. As mitochondrial dysfunction is an underlying feature of the injury cascade following hypoxia, this study is aimed at characterizing mitochondrial function at a region-specific level in the near-term fetal brain after a period of acute hypoxia. We hypothesized that regional differences in mitochondrial function would be evident, and that prophylactic creatine treatment would mitigate mitochondrial dysfunction following hypoxia; thereby reducing fetal brain injury. Pregnant Border-Leicester/Merino ewes with singleton fetuses were surgically instrumented at 118 days of gestation (dGa; term is ~145 dGA). A continuous infusion of either creatine (n = 15; 6 mg/kg/h) or isovolumetric saline (n = 16; 1.5 ml/kg/h) was administered to the fetuses from 121 dGa. After 10 days of infusion, a subset of fetuses (8 saline-, 7 creatine-treated) were subjected to 10 minutes of umbilical cord occlusion (UCO) to induce a mild global fetal hypoxia. At 72 hours after UCO, the fetal brain was collected for high-resolution mitochondrial respirometry and molecular and histological analyses. The results show that the transient UCO-induced acute hypoxia impaired mitochondrial function in the hippocampus and the periventricular white matter and increased the incidence of cell death in the hippocampus. Creatine treatment did not rectify the changes in mitochondrial respiration associated with hypoxia, but there was a negative relationship between cell death and creatine content following treatment. Irrespective of UCO, creatine increased the proportion of cytochrome c bound to the inner mitochondrial membrane, upregulated the mRNA expression of the antiapoptotic gene Bcl2, and of PCG1-α, a driver of mitogenesis, in the hippocampus. We conclude that creatine treatment prior to brief, acute hypoxia does not fundamentally modify mitochondrial respiratory function, but may improve mitochondrial structural integrity and potentially increase mitogenesis and activity of antiapoptotic pathways.
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9
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Dulay S, Rivas L, Pla L, Berdún S, Eixarch E, Gratacós E, Illa M, Mir M, Samitier J. Fetal ischemia monitoring with in vivo implanted electrochemical multiparametric microsensors. J Biol Eng 2021; 15:28. [PMID: 34930385 PMCID: PMC8691007 DOI: 10.1186/s13036-021-00280-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/30/2021] [Indexed: 12/15/2022] Open
Abstract
Under intrauterine growth restriction (IUGR), abnormal attainment of the nutrients and oxygen by the fetus restricts the normal evolution of the prenatal causing in many cases high morbidity being one of the top-ten causes of neonatal death. The current gold standards in hospitals to detect this relevant problem is the clinical observation by echography, cardiotocography and Doppler. These qualitative techniques are not conclusive and requires risky invasive fetal scalp blood testing and/or amniocentesis. We developed micro-implantable multiparametric electrochemical sensors for measuring ischemia in real time in fetal tissue and vascular. This implantable technology is designed to continuous monitoring for an early detection of ischemia to avoid potential fetal injury. Two miniaturized electrochemical sensors were developed based on oxygen and pH detection. The sensors were optimized in vitro under controlled concentration, to assess the selectivity and sensitivity required. The sensors were then validated in vivo in the ewe fetus model, by means of their insertion in the muscle leg and inside the iliac artery of the fetus. Ischemia was achieved by gradually obstructing the umbilical cord to regulate the amount of blood reaching the fetus. An important challenge in fetal monitoring is the detection of low levels of oxygen and pH changes under ischemic conditions, requiring high sensitivity sensors. Significant differences were observed in both; pH and pO2 sensors under changes from normoxia to hypoxia states in the fetus tissue and vascular with both sensors. Herein, we demonstrate the feasibility of the developed sensors for future fetal monitoring in medical applications.
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Affiliation(s)
- Samuel Dulay
- Nanobioengineering group, Institute for Bioengineering of Catalonia (IBEC) Barcelona Institute of Science and Technology (BIST), 12 Baldiri Reixac 15-21, 08028, Barcelona, Spain
| | - Lourdes Rivas
- Nanobioengineering group, Institute for Bioengineering of Catalonia (IBEC) Barcelona Institute of Science and Technology (BIST), 12 Baldiri Reixac 15-21, 08028, Barcelona, Spain
| | - Laura Pla
- Fetal Medicine Research Center, BCNatal. Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Building Helios 2, Sabino Arana Street 1, 08028, Barcelona, Spain
| | - Sergio Berdún
- Fetal Medicine Research Center, BCNatal. Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Building Helios 2, Sabino Arana Street 1, 08028, Barcelona, Spain
| | - Elisenda Eixarch
- Fetal Medicine Research Center, BCNatal. Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Building Helios 2, Sabino Arana Street 1, 08028, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Eduard Gratacós
- Fetal Medicine Research Center, BCNatal. Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Building Helios 2, Sabino Arana Street 1, 08028, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Miriam Illa
- Fetal Medicine Research Center, BCNatal. Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Building Helios 2, Sabino Arana Street 1, 08028, Barcelona, Spain
| | - Mònica Mir
- Nanobioengineering group, Institute for Bioengineering of Catalonia (IBEC) Barcelona Institute of Science and Technology (BIST), 12 Baldiri Reixac 15-21, 08028, Barcelona, Spain. .,Biomedical Research Networking Center in Bioengineering, Biomaterials, and Nanomedicine (CIBER-BBN), Monforte de Lemos 3-5, Pabellón 11, 28029, Madrid, Spain. .,Department of Electronics and Biomedical Engineering, University of Barcelona, Martí i Franquès 1, 08028, Barcelona, Spain.
| | - Josep Samitier
- Nanobioengineering group, Institute for Bioengineering of Catalonia (IBEC) Barcelona Institute of Science and Technology (BIST), 12 Baldiri Reixac 15-21, 08028, Barcelona, Spain.,Biomedical Research Networking Center in Bioengineering, Biomaterials, and Nanomedicine (CIBER-BBN), Monforte de Lemos 3-5, Pabellón 11, 28029, Madrid, Spain.,Department of Electronics and Biomedical Engineering, University of Barcelona, Martí i Franquès 1, 08028, Barcelona, Spain
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10
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Miniaturized Electrochemical Sensors to Monitor Fetal Hypoxia and Acidosis in a Pregnant Sheep Model. Biomedicines 2021; 9:biomedicines9101344. [PMID: 34680459 PMCID: PMC8533400 DOI: 10.3390/biomedicines9101344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 11/25/2022] Open
Abstract
Perinatal asphyxia is a major cause of severe brain damage and death. For its prenatal identification, Doppler ultrasound has been used as a surrogate marker of fetal hypoxia. However, Doppler evaluation cannot be performed continuously. We have evaluated the performance of a miniaturized multiparametric sensor aiming to evaluate tissular oxygen and pH changes continuously in an umbilical cord occlusion (UCO) sheep model. The electrochemical sensors were inserted in fetal hindlimb skeletal muscle and electrochemical signals were recorded. Fetal hemodynamic changes and metabolic status were also monitored during the experiment. Additionally, histological assessment of the tissue surrounding the sensors was performed. Both electrochemical sensors detected the pO2 and pH changes induced by the UCO and these changes were correlated with hemodynamic parameters as well as with pH and oxygen content in the blood. Finally, histological assessment revealed no signs of alteration on the same day of insertion. This study provides the first evidence showing the application of miniaturized multiparametric electrochemical sensors detecting changes in oxygen and pH in skeletal muscular tissue in a fetal sheep model.
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11
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Du X, Mi X, Liu X, Mawolo JB. Comparative study on the distribution and expression of Neuroglobin and Hypoxia-inducible factor-1α in the telencephalon of yak and cattle. BRAZ J BIOL 2021; 83:e248911. [PMID: 34495167 DOI: 10.1590/1519-6984.248911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/11/2021] [Indexed: 12/16/2022] Open
Abstract
The telencephalon refers to the most highly developed and anterior part of the forebrain, consisting mainly of the cerebral hemispheres. The study determined Neuroglobin (Ngb) and Hypoxia-inducible factor (HIF-1α) expression in the telencephalon of yak and cattle, and compare the expression and distribution pattern of Ngb and HIF-1α in the two animals. Immunohistochemistry (IHC), quantitative real-time Polymerase Chain Reaction (qRT-PCR), and Western blot (WB) were employed to investigate Ngb and Hif-1α expression in the telencephalon of yak and cattle. mRNA and protein expressions of Ngb and HIF-1α showed positive in different tissues of the yak and cattle telencephalon. Ngb expression in tissues of the yak recorded higher as compare to cattle while HIF-1α expression was found higher in cattle than yak. The HIF-1α expression in some tissues of yak telencephalon was consistent with the cattle. The results documented that HIF-1α may have a direct or indirect synergistic effect on Ngb expression in the yak telencephalon to improve hypoxia adaptation. It is suggested that yak may need more Ngb expression for adaptation, but the expression of HIF-1α seems to be down-regulated during long-term adaptation, and the specific causes of this phenomenon needs to be further verified.
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Affiliation(s)
- X Du
- Gansu Agricultural University, College of Veterinary Medicine, Lanzhou City, Gansu Province, People's Republic of China
| | - X Mi
- Gansu Agricultural University, College of Life Science and Technology, Lanzhou City, Gansu Province, People's Republic of China
| | - X Liu
- Gansu Agricultural University, College of Life Science and Technology, Lanzhou City, Gansu Province, People's Republic of China
| | - J B Mawolo
- Gansu Agricultural University, College of Life Science and Technology, Lanzhou City, Gansu Province, People's Republic of China
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12
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Aridas JD, Yawno T, Sutherland AE, Nitsos I, Wong FY, Hunt RW, Ditchfield M, Fahey MC, Malhotra A, Wallace EM, Gunn AJ, Jenkin G, Miller SL. Melatonin augments the neuroprotective effects of hypothermia in lambs following perinatal asphyxia. J Pineal Res 2021; 71:e12744. [PMID: 34032315 DOI: 10.1111/jpi.12744] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 12/12/2022]
Abstract
Therapeutic hypothermia (TH) is standard care in high-resource birth settings for infants with neonatal encephalopathy. TH is partially effective and adjuvant therapies are needed. Here, we examined whether the antioxidant melatonin (MLT) provides additive benefit with TH, compared to TH alone or MLT alone, to improve recovery from acute encephalopathy in newborn lambs. Immediately before cesarean section delivery, we induced asphyxia in fetal sheep via umbilical cord occlusion until mean arterial blood pressure fell from 55 ± 3 mm Hg in sham controls to 18-20 mm Hg (10.1 ± 1.5 minutes). Lambs were delivered and randomized to control, control + MLT (60 mg iv, from 30 minutes to 24 hours), asphyxia, asphyxia + TH (whole-body cooling to 35.1 ± 0.8°C vs. 38.3 ± 0.17°C in sham controls, from 4-28 hours), asphyxia + MLT, and asphyxia + TH + MLT. At 72 hours, magnetic resonance spectroscopy (MRS) was undertaken, and then brains were collected for neuropathology assessment. Asphyxia induced abnormal brain metabolism on MRS with increased Lactate:NAA (P = .003) and reduced NAA:Choline (P = .005), induced apoptotic and necrotic cell death across gray and white matter brain regions (P < .05), and increased neuroinflammation and oxidative stress (P < .05). TH and MLT were independently associated with region-specific reductions in oxidative stress, inflammation, and cell death, compared to asphyxia alone. There was an interaction between TH and MLT such that the NAA:Choline ratio was not significantly different after asphyxia + TH + MLT compared to sham controls but had a greater overall reduction in neuropathology than either treatment alone. This study demonstrates that, in newborn lambs, combined TH + MLT for neonatal encephalopathy provides significantly greater neuroprotection than either alone. These results will guide the development of further trials for neonatal encephalopathy.
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Affiliation(s)
- James Ds Aridas
- Hudson Institute of Medical Research, The Ritchie Centre, Clayton, Vic., Australia
| | - Tamara Yawno
- Hudson Institute of Medical Research, The Ritchie Centre, Clayton, Vic., Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Vic., Australia
| | - Amy E Sutherland
- Hudson Institute of Medical Research, The Ritchie Centre, Clayton, Vic., Australia
| | - Ilias Nitsos
- Hudson Institute of Medical Research, The Ritchie Centre, Clayton, Vic., Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Vic., Australia
| | - Flora Y Wong
- Hudson Institute of Medical Research, The Ritchie Centre, Clayton, Vic., Australia
- Department of Paediatrics, Monash University, Clayton, Vic., Australia
- Monash Children's Hospital, Monash Health, Clayton, Vic., Australia
| | - Rod W Hunt
- Department of Paediatrics, Monash University, Clayton, Vic., Australia
- Monash Children's Hospital, Monash Health, Clayton, Vic., Australia
- Murdoch Children's Research Institute, Melbourne, Vic., Australia
| | | | - Michael C Fahey
- Hudson Institute of Medical Research, The Ritchie Centre, Clayton, Vic., Australia
- Department of Paediatrics, Monash University, Clayton, Vic., Australia
- Monash Children's Hospital, Monash Health, Clayton, Vic., Australia
| | - Atul Malhotra
- Hudson Institute of Medical Research, The Ritchie Centre, Clayton, Vic., Australia
- Department of Paediatrics, Monash University, Clayton, Vic., Australia
- Monash Children's Hospital, Monash Health, Clayton, Vic., Australia
| | - Euan M Wallace
- Hudson Institute of Medical Research, The Ritchie Centre, Clayton, Vic., Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Vic., Australia
| | - Alistair J Gunn
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Graham Jenkin
- Hudson Institute of Medical Research, The Ritchie Centre, Clayton, Vic., Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Vic., Australia
| | - Suzanne L Miller
- Hudson Institute of Medical Research, The Ritchie Centre, Clayton, Vic., Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Vic., Australia
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13
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Baburamani AA, Tran NT, Castillo-Melendez M, Yawno T, Walker DW. Brief hypoxia in late gestation sheep causes prolonged disruption of fetal electrographic, breathing behaviours and can result in early labour. J Physiol 2021; 599:3221-3236. [PMID: 33977538 DOI: 10.1113/jp281266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/21/2021] [Indexed: 01/22/2023] Open
Abstract
KEY POINTS Brief episodes of severe fetal hypoxia can arise in late gestation as a result of interruption of normal umbilical blood flow Systemic parameters and blood chemistry indicate complete recovery within 1-2 hours, although the long-term effects on fetal brain functions are unknown Fetal sheep were subjected to umbilical cord occlusion (UCO) for 10 min at 131 days of gestation, and then monitored intensively until onset of labour or delivery (<145 days of gestation) Normal patterns of fetal behaviour, including breathing movements, episodes of high and low voltage electorcortical activity, eye movements and postural (neck) muscle activity, were disrupted for 3-10 days after the UCO Preterm labour and delivery occurred in a significant number of the pregnancies after UCO compared to the control (sham-UCO) cohort. ABSTRACT Complications arising from antepartum events such as impaired umbilical blood flow can cause significant fetal hypoxia. These complications can be unpredictable, as well as difficult to detect, and thus we lack a detailed understanding of the (patho)physiological changes that occur between the antenatal in utero event and birth. In the present study, we assessed the consequences of brief (∼10 min) umbilical cord occlusion (UCO) in fetal sheep at ∼0.88 gestation on fetal plasma cortisol concentrations and fetal behaviour [electrocortical (EcoG), electo-oculargram (EOG), nuchal muscle electromyography (EMG) and breathing activities] in the days following UCO. UCO caused a rapid onset of fetal hypoxaemia, hypercapnia, and acidosis; however, by 6 h, all blood parameters and cardiovascular status were normalized and not different from the control (Sham-UCO) cohort. Subsequently, the incidence of fetal breathing movements decreased compared to the control group, and abnormal behavioural patterns developed over the days following UCO and leading up to the onset of labour, which included increased high voltage and sub-low voltage ECoG and EOG activities, as well as decreased nuchal EMG activity. Fetuses subjected to UCO went into labour 7.9 ± 3.6 days post-UCO (139.5 ± 3.2 days of gestation) compared to the control group fetuses at 13.6 ± 3.3 days post-sham UCO (144 ± 2.2 days of gestation; P < 0.05), despite comparable increases in fetal plasma cortisol and a similar body weight at birth. Thus, a single transient episode of complete UCO late in gestation in fetal sheep can result in prolonged effects on fetal brain activity and premature labour, suggesting persisting effects on fetal cerebral metabolism.
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Affiliation(s)
- Ana A Baburamani
- Department of Perinatal Imaging and Health, Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Nhi T Tran
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Margie Castillo-Melendez
- The Ritchie Centre, Hudson Institute of Medical Research, and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Tamara Yawno
- The Ritchie Centre, Hudson Institute of Medical Research, and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - David W Walker
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
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14
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Kim JM, Lee SY, Lee JY. Melatonin for the prevention of fetal injury associated with intrauterine inflammation. Am J Reprod Immunol 2021; 86:e13402. [PMID: 33583108 DOI: 10.1111/aji.13402] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/08/2021] [Accepted: 02/10/2021] [Indexed: 01/06/2023] Open
Abstract
Intrauterine inflammation is shown to be associated with preterm birth, fetal inflammatory response syndrome, and other pregnancy-related comorbidities such as central nervous system diseases including cerebral palsy and periventricular leukomalacia, pulmonary diseases such as bronchopulmonary dysplasia and respiratory distress syndrome, and necrotizing enterocolitis, to name a few. Many animal studies on intrauterine inflammation demonstrate that ascending infection of reproductive organs or the production of proinflammatory cytokines by some stimuli in utero results in such manifestations. Melatonin, known for its primary function in maintaining circadian rhythm, is now recognized as one of the most potent antioxidant and anti-inflammatory drugs. In some studies, melatonin injection in pregnant animals with intrauterine inflammation significantly reduced the number of preterm births, the severity of structural disintegration of the fetal lungs observed in bronchopulmonary dysplasia, and perinatal brain injuries with improvement in neuromotor function. These implicated benefits of melatonin in pregnant women with intrauterine inflammation seem promising in many research studies, strongly supporting the hypothesis that melatonin has antioxidative and anti-inflammatory properties that can potentially be taken by pregnant women who are at risk of having intrauterine inflammation. In this review, the potential of melatonin for improving outcomes of the pregnancies with intrauterine inflammation will be discussed.
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Affiliation(s)
- Jang Mee Kim
- Department of Medicine, CHA University School of Medicine, Pocheon, Korea
| | - Seung-Yun Lee
- Educational Competence Support Center, Hanshin University, Osan, Korea
| | - Ji Yeon Lee
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
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15
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Maternal Melatonin Deficiency Leads to Endocrine Pathologies in Children in Early Ontogenesis. Int J Mol Sci 2021; 22:ijms22042058. [PMID: 33669686 PMCID: PMC7922827 DOI: 10.3390/ijms22042058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/08/2021] [Accepted: 02/15/2021] [Indexed: 12/17/2022] Open
Abstract
The review summarizes the results of experimental and clinical studies aimed at elucidating the causes and pathophysiological mechanisms of the development of endocrine pathology in children. The modern data on the role of epigenetic influences in the early ontogenesis of unfavorable factors that violate the patterns of the formation of regulatory mechanisms during periods of critical development of fetal organs and systems and contribute to the delayed development of pathological conditions are considered. The mechanisms of the participation of melatonin in the regulation of metabolic processes and the key role of maternal melatonin in the formation of the circadian system of regulation in the fetus and in the protection of the genetic program of its morphofunctional development during pregnancy complications are presented. Melatonin, by controlling DNA methylation and histone modification, prevents changes in gene expression that are directly related to the programming of endocrine pathology in offspring. Deficiency and absence of the circadian rhythm of maternal melatonin underlies violations of the genetic program for the development of hormonal and metabolic regulatory mechanisms of the functional systems of the child, which determines the programming and implementation of endocrine pathology in early ontogenesis, contributing to its development in later life. The significance of this factor in the pathophysiological mechanisms of endocrine disorders determines a new approach to risk assessment and timely prevention of offspring diseases even at the stage of family planning.
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16
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17
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El-Malkey NF, Aref M, Emam H, Khalil SS. Impact of Melatonin on Full-Term Fetal Brain Development and Transforming Growth Factor-β Level in a Rat Model of Preeclampsia. Reprod Sci 2021; 28:2278-2291. [PMID: 33591564 DOI: 10.1007/s43032-021-00497-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 02/08/2021] [Indexed: 01/27/2023]
Abstract
Preeclampsia (PE) is a leading cause of stroke and cognitive impairment in the offspring. Melatonin is involved in the outcome of normal pregnancy. Its receptors are widespread in the embryo. This study aimed to investigate the fetal neuroprotective effect of melatonin in experimentally induced PE. After induction of pregnancy in 18 female rats, they were divided into three equal groups. PE was induced in groups II and III by injection of deoxycorticosterone acetate and drinking isotonic saline. Melatonin was supplied to group III orally (10 mg/kg body weight) throughout pregnancy. Pregnancy was terminated on day 20, and macroanatomical investigation of three fetuses from each pregnant rat and their placentae was performed. Placental and brain homogenates were analyzed for malondialdehyde (MDA), placental growth factor (PLGF), tumor necrosis factor-α (TNF-α), and brain transforming growth factor-β (TGF-β). Histopathological analysis of fetal brain sections was performed. Melatonin improved placental, fetal, and brain weight; significantly reduced fetal death rate; significantly increased PLGF, placental and brain superoxide dismutase, and brain TGF-β; and significantly decreased placental TNF-α and brain MDA. Brain micromorphological study found normal glial cells and neuropil in the melatonin-treated group and a loss of neuronal cell outlines with an accumulation of cellular debris in the untreated group. In conclusion, melatonin approximately showed a neuroprotective activity by managing PE-induced oxidative stress in the placenta and fetal cerebral cortex of rats.
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Affiliation(s)
| | - Mohammed Aref
- Anatomy and Embryology Department, Faculty of Veterinary Medicine, Zagazig University, Al Sharqiya, Egypt
| | - Hassan Emam
- Anatomy and Embryology Department, Faculty of Veterinary Medicine, Zagazig University, Al Sharqiya, Egypt
| | - Sama Salah Khalil
- Physiology Department, Faculty of Medicine, Zagazig University, Al Sharqiya, Egypt
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18
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Flinn T, Gunn JR, Kind KL, Swinbourne AM, Weaver AC, Kelly JM, Walker SK, Gatford KL, van Wettere WHEJ, Kleemann DO. Maternal melatonin implants improve twin Merino lamb survival. J Anim Sci 2021; 98:5935828. [PMID: 33091925 DOI: 10.1093/jas/skaa344] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/20/2020] [Indexed: 12/14/2022] Open
Abstract
High preweaning mortality rates cost the Australian sheep industry an estimated $540 million annually in lost production, with losses significantly greater in twin (≥30%) compared with singleton lambs (≥10%). Previous intensive studies demonstrated that supplementing pregnant ewes with melatonin reduces adverse effects of fetal growth restriction and perinatal hypoxia on the neonatal brain via increased umbilical blood flow, placental efficiency, and antioxidant actions. The current study examined the effects of supplementing ewes with melatonin on the survival of twin Merino lambs under extensive grazing conditions. Pregnant mixed age ewes were implanted with 1 (M1, n = 50) or 2 (M2, n = 53) slow-release melatonin implants (18 mg, Regulin) at gestational days 70 to 90. Control ewes received no supplementation (CTL, n = 54). Ewes were monitored twice daily throughout the lambing period. Lamb survival, weight, and rectal temperature were recorded on the day of birth. Lamb blood samples were taken the following day for serum immunoglobulin G (IgG) analysis. Lamb survival and weight were recorded again at marking (30.6 ± 0.6 d postpartum) and weaning (70.7 ± 0.6 d postpartum). Lamb survival was increased in both melatonin treatments to 3 d postpartum (M1 = 98.0%; M2 = 95.3%; CTL = 83.3%; each P < 0.01), and this improvement was maintained to weaning (M1 = 94.0%; M2 = 92.5%; CTL = 79.6%; each P < 0.01). Melatonin did not affect lamb birthweight, rectal temperature, or growth rate. However, the rates of parturition-related death (dystocia, stillbirth, and birth injury) were greater in CTL lambs than M1 (P = 0.009) and M2 (P = 0.035). This suggests that improved survival is primarily due to melatonin-induced neuroprotection, although further studies are required to clarify the underlying mechanisms. These data provide evidence that supplementing pregnant twin-bearing Merino ewes with melatonin may be a practical strategy to reduce neonatal mortality and improve weaning rates in extensively managed sheep flocks. Although the present data are promising, this study is limited by small sample size and requires further replication.
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Affiliation(s)
- Tom Flinn
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, South Australia, Australia
| | - Jessica R Gunn
- Minnipa Agricultural Centre, South Australian Research and Development Institute, Minnipa, South Australia, Australia
| | - Karen L Kind
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, South Australia, Australia.,Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Alyce M Swinbourne
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, South Australia, Australia
| | - Alice C Weaver
- Turretfield Research Centre, South Australian Research and Development Institute, Rosedale, South Australia, Australia
| | - Jennifer M Kelly
- Turretfield Research Centre, South Australian Research and Development Institute, Rosedale, South Australia, Australia
| | - Simon K Walker
- Turretfield Research Centre, South Australian Research and Development Institute, Rosedale, South Australia, Australia
| | - Kathryn L Gatford
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - William H E J van Wettere
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, South Australia, Australia
| | - David O Kleemann
- Turretfield Research Centre, South Australian Research and Development Institute, Rosedale, South Australia, Australia
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19
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Flinn T, McCarthy NL, Swinbourne AM, Gatford KL, Weaver AC, McGrice HA, Kelly JM, Walker SK, Kind KL, Kleemann DO, van Wettere WHEJ. Supplementing Merino ewes with melatonin during the last half of pregnancy improves tolerance of prolonged parturition and survival of second-born twin lambs. J Anim Sci 2021; 98:5986736. [PMID: 33205209 DOI: 10.1093/jas/skaa372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/10/2020] [Indexed: 11/14/2022] Open
Abstract
High preweaning mortality rates continue to limit sheep production globally, constituting a major economic and welfare concern. Greater losses in twin lambs (≥30%) compared with singletons (≥10%) are attributed primarily to lower birth weight and increased risk of intrapartum hypoxia, leading to impairment of thermoregulation, neuromotor activity, and maternal bonding behavior. Previous intensive studies demonstrated that supplementing pregnant ewes with melatonin reduced the adverse effects of fetal growth restriction and perinatal hypoxia on the neonatal brain via increased umbilical blood flow, placental efficiency, and antioxidant actions. The current study examined the effects of supplementing pregnant ewes with melatonin on lamb survival, birth weight, and behavior under intensive conditions. From gestational day (gD) 80 until parturition, pregnant singleton and twin-bearing ewes were supplemented with melatonin via a 2-mg capsule fed daily (Mel-FED, n = 61) or 18 mg subcutaneous implant (Regulin), with one implant administered at gD80 and another at gD125 (Mel-IMP, n = 60). Control ewes received no supplementation (CTL, n = 60). Ewes and lambs were monitored via video throughout parturition. Postpartum measures were taken from lambs at 4 and 24 h (live weight [LW], rectal temperature, serum immunoglobulin G, and latency to stand and suck after birth) and LW at 72 h, 7 d, marking (49.7 ± 0.2 d), and weaning (124.2 ± 0.8 d). Chi-square analysis was used to compare lamb survival between treatment groups. There were no treatment effects on singleton lamb survival. Melatonin supplementation tended to increase the proportion of twin lambs surviving from birth to weaning (Mel-FED = 85.5%; Mel-IMP = 85.9%; CTL = 72.9%; each P < 0.1). Survival of first-born twins did not differ between treatment (each ~90%, P = 0.745) but within second-born twins, survival of Mel-FED was greater than CTL (81.6 vs. 57.1%, P = 0.023), and Mel-IMP (78.1%) tended to be greater than CTL (P = 0.068). Similarly, in second-born twins exposed to prolonged parturition (≥ 90 min), survival of lambs from Mel-FED ewes was greater than CTL (86.7% vs. 42.9%, P = 0.032), while Mel-IMP was intermediate (66.7%). These data suggest that the neuroprotective actions of melatonin may improve twin lamb survival by increasing tolerance of prolonged parturition and provide a sound basis for continued testing in extensively managed sheep flocks.
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Affiliation(s)
- Tom Flinn
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, SA, Australia
| | - Niki L McCarthy
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, SA, Australia
| | - Alyce M Swinbourne
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, SA, Australia
| | - Kathryn L Gatford
- Robinson Research Institute, The University of Adelaide, Adelaide, SA, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Alice C Weaver
- Turretfield Research Centre, South Australian Research and Development Institute, Rosedale, SA, Australia
| | - Hayley A McGrice
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, SA, Australia
| | - Jennifer M Kelly
- Turretfield Research Centre, South Australian Research and Development Institute, Rosedale, SA, Australia
| | - Simon K Walker
- Turretfield Research Centre, South Australian Research and Development Institute, Rosedale, SA, Australia
| | - Karen L Kind
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, SA, Australia.,Robinson Research Institute, The University of Adelaide, Adelaide, SA, Australia
| | - David O Kleemann
- Turretfield Research Centre, South Australian Research and Development Institute, Rosedale, SA, Australia
| | - William H E J van Wettere
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, SA, Australia
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20
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Pang R, Avdic-Belltheus A, Meehan C, Martinello K, Mutshiya T, Yang Q, Sokolska M, Torrealdea F, Hristova M, Bainbridge A, Golay X, Juul SE, Robertson NJ. Melatonin and/or erythropoietin combined with hypothermia in a piglet model of perinatal asphyxia. Brain Commun 2020; 3:fcaa211. [PMID: 33604569 PMCID: PMC7876304 DOI: 10.1093/braincomms/fcaa211] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 12/11/2022] Open
Abstract
As therapeutic hypothermia is only partially protective for neonatal encephalopathy, safe and effective adjunct therapies are urgently needed. Melatonin and erythropoietin show promise as safe and effective neuroprotective therapies. We hypothesized that melatonin and erythropoietin individually augment 12-h hypothermia (double therapies) and hypothermia + melatonin + erythropoietin (triple therapy) leads to optimal brain protection. Following carotid artery occlusion and hypoxia, 49 male piglets (<48 h old) were randomized to: (i) hypothermia + vehicle (n = 12), (ii) hypothermia + melatonin (20 mg/kg over 2 h) (n = 12), (iii) hypothermia + erythropoietin (3000 U/kg bolus) (n = 13) or (iv) tripletherapy (n = 12). Melatonin, erythropoietin or vehicle were given at 1, 24 and 48 h after hypoxia–ischaemia. Hypoxia–ischaemia severity was similar across groups. Therapeutic levels were achieved 3 hours after hypoxia–ischaemia for melatonin (15–30 mg/l) and within 30 min of erythropoietin administration (maximum concentration 10 000 mU/ml). Compared to hypothermia + vehicle, we observed faster amplitude-integrated EEG recovery from 25 to 30 h with hypothermia + melatonin (P = 0.02) and hypothermia + erythropoietin (P = 0.033) and from 55 to 60 h with tripletherapy (P = 0.042). Magnetic resonance spectroscopy lactate/N-acetyl aspartate peak ratio was lower at 66 h in hypothermia + melatonin (P = 0.012) and tripletherapy (P = 0.032). With hypothermia + melatonin, terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labelled-positive cells were reduced in sensorimotor cortex (P = 0.017) and oligodendrocyte transcription factor 2 labelled-positive counts increased in hippocampus (P = 0.014) and periventricular white matter (P = 0.039). There was no reduction in terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labelled-positive cells with hypothermia + erythropoietin, but increased oligodendrocyte transcription factor 2 labelled-positive cells in 5 of 8 brain regions (P < 0.05). Overall, melatonin and erythropoietin were safe and effective adjunct therapies to hypothermia. Hypothermia + melatonin double therapy led to faster amplitude-integrated EEG recovery, amelioration of lactate/N-acetyl aspartate rise and reduction in terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labelled-positive cells in the sensorimotor cortex. Hypothermia + erythropoietin doubletherapy was in association with EEG recovery and was most effective in promoting oligodendrocyte survival. Tripletherapy provided no added benefit over the double therapies in this 72-h study. Melatonin and erythropoietin influenced cell death and oligodendrocyte survival differently, reflecting distinct neuroprotective mechanisms which may become more visible with longer-term studies. Staggering the administration of therapies with early melatonin and later erythropoietin (after hypothermia) may provide better protection; each therapy has complementary actions which may be time critical during the neurotoxic cascade after hypoxia–ischaemia.
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Affiliation(s)
- Raymand Pang
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Adnan Avdic-Belltheus
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Christopher Meehan
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Kathryn Martinello
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Tatenda Mutshiya
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Qin Yang
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Magdalena Sokolska
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Francisco Torrealdea
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Mariya Hristova
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Alan Bainbridge
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Xavier Golay
- Department of Brain Repair and Rehabilitation, Institute of Neurology, Queen's Square, University College London, London, UK
| | - Sandra E Juul
- Department of Pediatrics, University of Washington, Seattle, Washington, DC, USA
| | - Nicola J Robertson
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
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21
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Flinn T, Kleemann DO, Swinbourne AM, Kelly JM, Weaver AC, Walker SK, Gatford KL, Kind KL, van Wettere WHEJ. Neonatal lamb mortality: major risk factors and the potential ameliorative role of melatonin. J Anim Sci Biotechnol 2020; 11:107. [PMID: 33292527 PMCID: PMC7643391 DOI: 10.1186/s40104-020-00510-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/07/2020] [Indexed: 12/19/2022] Open
Abstract
High incidences of pre-weaning mortality continue to limit global sheep production, constituting a major economic and welfare concern. Despite significant advances in genetics, nutrition, and management, the proportion of lamb deaths has remained stable at 15–20% over the past four decades. There is mounting evidence that melatonin can improve outcomes in compromised ovine pregnancies via enhanced uterine bloodflow and neonatal neuroprotection. This review provides an overview of the major risk factors and underlying mechanisms involved in perinatal lamb mortality and discusses the potential of melatonin treatment as a remedial strategy. Supplementing pregnant ewes with melatonin enhances uterine bloodflow and fetal oxygenation, and potentially birthweight and neonatal thermogenic capacity. Melatonin freely crosses the ovine placenta and blood-brain barrier and provides neuroprotection to the fetal lamb during periods of chronic and acute hypoxia throughout gestation, with improved behavioural outcomes in hypoxic neonates. The current literature provides strong evidence that maternal melatonin treatment improves outcomes for lambs which experience compromised in utero development or prolonged parturition, though to date this has not been investigated in livestock production systems. As such there is a clear basis for continued research into the effects of maternal melatonin supplementation during gestation on pre-weaning survival under extensive production conditions.
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Affiliation(s)
- Tom Flinn
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, SA, Australia.
| | - David O Kleemann
- Turretfield Research Centre, South Australian Research and Development Institute, Rosedale, SA, Australia
| | - Alyce M Swinbourne
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, SA, Australia
| | - Jennifer M Kelly
- Turretfield Research Centre, South Australian Research and Development Institute, Rosedale, SA, Australia
| | - Alice C Weaver
- Turretfield Research Centre, South Australian Research and Development Institute, Rosedale, SA, Australia
| | - Simon K Walker
- Turretfield Research Centre, South Australian Research and Development Institute, Rosedale, SA, Australia
| | - Kathryn L Gatford
- Robinson Research Institute, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Karen L Kind
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, SA, Australia
| | - William H E J van Wettere
- Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, SA, Australia
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22
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Zhou KQ, Davidson JO, Bennet L, Gunn AJ. Combination treatments with therapeutic hypothermia for hypoxic-ischemic neuroprotection. Dev Med Child Neurol 2020; 62:1131-1137. [PMID: 32614467 DOI: 10.1111/dmcn.14610] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2020] [Indexed: 12/12/2022]
Abstract
Therapeutic hypothermia is now proven to reduce death or disability in term and near-term born infants with moderate to severe hypoxic-ischemic encephalopathy. Nevertheless, many infants still survive with disability, despite treatment with hypothermia. Recent preclinical and clinical studies suggest that current protocols for therapeutic hypothermia are near-optimal. The obvious strategy, in addition to improving early initiation of therapeutic hypothermia after birth, is to combine hypothermia with other neuroprotective agents. We review evidence that the mechanisms of action of many promising agents overlap with the anti-excitotoxic, anti-apoptotic, and anti-inflammatory mechanisms of hypothermia, leading to a lack of benefit from combination treatment. Moreover, even apparently beneficial combinations have failed to translate in clinical trials. These considerations highlight the need for preclinical studies to test clinically realistic protocols of timing and duration of treatment, before committing to large randomized controlled trials.
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Affiliation(s)
- Kelly Q Zhou
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Department of Physiology, The University of Auckland, Auckland, New Zealand
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23
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DISDIER C, STONESTREET BS. Hypoxic-ischemic-related cerebrovascular changes and potential therapeutic strategies in the neonatal brain. J Neurosci Res 2020; 98:1468-1484. [PMID: 32060970 PMCID: PMC7242133 DOI: 10.1002/jnr.24590] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/20/2020] [Accepted: 01/28/2020] [Indexed: 12/11/2022]
Abstract
Perinatal hypoxic-ischemic (HI)-related brain injury is an important cause of morbidity and long-standing disability in newborns. The only currently approved therapeutic strategy available to reduce brain injury in the newborn is hypothermia. Therapeutic hypothermia can only be used to treat HI encephalopathy in full-term infants and survivors remain at high risk for a wide spectrum of neurodevelopmental abnormalities as a result of residual brain injury. Therefore, there is an urgent need for adjunctive therapeutic strategies. Inflammation and neurovascular damage are important factors that contribute to the pathophysiology of HI-related brain injury and represent exciting potential targets for therapeutic intervention. In this review, we address the role of each component of the neurovascular unit (NVU) in the pathophysiology of HI-related injury in the neonatal brain. Disruption of the blood-brain barrier (BBB) observed in the early hours after an HI-related event is associated with a response at the basal lamina level, which comprises astrocytes, pericytes, and immune cells, all of which could affect BBB function to further exacerbate parenchymal injury. Future research is required to determine potential drugs that could prevent or attenuate neurovascular damage and/or augment repair. However, some studies have reported beneficial effects of hypothermia, erythropoietin, stem cell therapy, anti-cytokine therapy and metformin in ameliorating several different facets of damage to the NVU after HI-related brain injury in the perinatal period.
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Affiliation(s)
- Clémence DISDIER
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, The Alpert Medical School of Brown University, Providence, RI 02905, USA
| | - Barbara S STONESTREET
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, The Alpert Medical School of Brown University, Providence, RI 02905, USA
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24
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Shi Y, Cai EL, Yang C, Ye CY, Zeng P, Wang XM, Fang YY, Cheng ZK, Wang Q, Cao FY, Zhou XW, Tian Q. Protection of melatonin against acidosis-induced neuronal injuries. J Cell Mol Med 2020; 24:6928-6942. [PMID: 32364678 PMCID: PMC7299701 DOI: 10.1111/jcmm.15351] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 01/13/2020] [Accepted: 04/12/2020] [Indexed: 12/23/2022] Open
Abstract
Acidosis, a common feature of cerebral ischaemia and hypoxia, plays a key role in these pathological processes by aggravating the ischaemic and hypoxic injuries. To explore the mechanisms, in this research, we cultured primary neurons in an acidic environment (potential of hydrogen [pH]6.2, 24 hours) to mimic the acidosis. By proteomic analysis, 69 differentially expressed proteins in the acidic neurons were found, mainly related to stress and cell death, synaptic plasticity and gene transcription. And, the acidotic neurons developed obvious alterations including increased neuronal death, reduced dendritic length and complexity, reduced synaptic proteins, tau hyperphosphorylation, endoplasmic reticulum (ER) stress activation, abnormal lysosome‐related signals, imbalanced oxidative stress/anti‐oxidative stress and decreased Golgi matrix proteins. Then, melatonin (1 × 10−4 mol/L) was used to pre‐treat the cultured primary neurons before acidic treatment (pH6.2). The results showed that melatonin partially reversed the acidosis‐induced neuronal death, abnormal dendritic complexity, reductions of synaptic proteins, tau hyperphosphorylation and imbalance of kinase/phosphatase. In addition, acidosis related the activations of glycogen synthase kinase‐3β and nuclear factor‐κB signals, ER stress and Golgi stress, and the abnormal autophagy‐lysosome signals were completely reversed by melatonin. These data indicate that melatonin is beneficial for neurons against acidosis‐induced injuries.
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Affiliation(s)
- Yan Shi
- Department of Pathology and Pathophysiology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Neurological Disease of National Education Ministry, Institute for Brain Research, Huazhong University of Science and Technology, Wuhan, China.,School of Medicine, Hunan Normal University, Changsha, China
| | - Er-Li Cai
- Department of Pathology and Pathophysiology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Neurological Disease of National Education Ministry, Institute for Brain Research, Huazhong University of Science and Technology, Wuhan, China
| | - Can Yang
- Department of Pathology and Pathophysiology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Neurological Disease of National Education Ministry, Institute for Brain Research, Huazhong University of Science and Technology, Wuhan, China.,Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Chao-Yuan Ye
- Department of Pathology and Pathophysiology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Neurological Disease of National Education Ministry, Institute for Brain Research, Huazhong University of Science and Technology, Wuhan, China
| | - Peng Zeng
- Department of Pathology and Pathophysiology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Neurological Disease of National Education Ministry, Institute for Brain Research, Huazhong University of Science and Technology, Wuhan, China
| | - Xiao-Ming Wang
- Department of Pathology and Pathophysiology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Neurological Disease of National Education Ministry, Institute for Brain Research, Huazhong University of Science and Technology, Wuhan, China
| | - Ying-Yan Fang
- Department of Pathology and Pathophysiology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Neurological Disease of National Education Ministry, Institute for Brain Research, Huazhong University of Science and Technology, Wuhan, China
| | - Zhi-Kang Cheng
- Department of Pathology and Pathophysiology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Neurological Disease of National Education Ministry, Institute for Brain Research, Huazhong University of Science and Technology, Wuhan, China
| | - Qun Wang
- Department of Pathology and Pathophysiology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Neurological Disease of National Education Ministry, Institute for Brain Research, Huazhong University of Science and Technology, Wuhan, China
| | - Fu-Yuan Cao
- Department of Pathology and Pathophysiology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Neurological Disease of National Education Ministry, Institute for Brain Research, Huazhong University of Science and Technology, Wuhan, China
| | - Xin-Wen Zhou
- Department of Pathology and Pathophysiology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Neurological Disease of National Education Ministry, Institute for Brain Research, Huazhong University of Science and Technology, Wuhan, China
| | - Qing Tian
- Department of Pathology and Pathophysiology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Neurological Disease of National Education Ministry, Institute for Brain Research, Huazhong University of Science and Technology, Wuhan, China
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25
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Abstract
Perinatal brain injury is a major cause of neurological disability in both premature and term infants. In this review, we summarize the evidence behind some established neuroprotective practices such as administration of antenatal steroids, intrapartum magnesium for preterm delivery, and therapeutic hypothermia. In addition, we examine emerging practices such as delayed cord clamping, postnatal magnesium administration, recombinant erythropoietin, and non-steroidal anti-inflammatory agents and finally inform the reader about novel interventions, some of which are currently in trials, such as xenon, melatonin, topiramate, allopurinol, creatine, and autologous cord cell therapy.
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Affiliation(s)
- Samata Singhi
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland, 21205, USA.,Department of Pediatric Neurology, Johns Hopkins Medicine, Baltimore, MD, 21287, USA
| | - Michael Johnston
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland, 21205, USA
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26
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Perinatal Use of Melatonin for Offspring Health: Focus on Cardiovascular and Neurological Diseases. Int J Mol Sci 2019; 20:ijms20225681. [PMID: 31766163 PMCID: PMC6888176 DOI: 10.3390/ijms20225681] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 11/06/2019] [Accepted: 11/12/2019] [Indexed: 12/16/2022] Open
Abstract
Cardiovascular and neurological diseases can originate in early life. Melatonin, a biologically active substance, acts as a pleiotropic hormone essential for pregnancy and fetal development. Maternal melatonin can easily pass the placenta and provide photoperiodic signals to the fetus. Though melatonin uses in pregnant or lactating women have not yet been recommended, there is a growing body of evidence from animal studies in support of melatonin as a reprogramming strategy to prevent the developmental programming of cardiovascular and neurological diseases. Here, we review several key themes in melatonin use in pregnancy and lactation within offspring health and disease. We have particularly focused on the following areas: the pathophysiological roles of melatonin in pregnancy, lactation, and fetal development; clinical uses of melatonin in fetal and neonatal diseases; experimental evidence supporting melatonin as a reprogramming therapy to prevent cardiovascular and neurological diseases; and reprogramming mechanisms of melatonin within developmental programming. The targeting of melatonin uses in pregnancy and lactation will be valuable in the prevention of various adult chronic diseases in later life, and especially cardiovascular and neurological diseases.
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27
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Solevåg AL, Schmölzer GM, Cheung PY. Novel interventions to reduce oxidative-stress related brain injury in neonatal asphyxia. Free Radic Biol Med 2019; 142:113-122. [PMID: 31039399 DOI: 10.1016/j.freeradbiomed.2019.04.028] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 04/15/2019] [Accepted: 04/23/2019] [Indexed: 01/10/2023]
Abstract
Perinatal asphyxia-induced brain injury may present as hypoxic-ischemic encephalopathy in the neonatal period, and disability including cerebral palsy in the long term. The brain injury is secondary to both the hypoxic-ischemic event and the reoxygenation-reperfusion following resuscitation. Early events in the cascade of brain injury can be classified as either inflammation or oxidative stress through the generation of free radicals. The objective of this paper is to present efforts that have been made to limit the oxidative stress associated with hypoxic-ischemic encephalopathy. In the acute phase of ischemia/hypoxia and reperfusion/reoxygenation, the outcomes of asphyxiated infants can be improved by optimizing the initial delivery room stabilization. Interventions include limiting oxygen exposure, and shortening the time to return of spontaneous circulation through improved methods for supporting hemodynamics and ventilation. Allopurinol, melatonin, noble gases such as xenon and argon, and magnesium administration also target the acute injury phase. Therapeutic hypothermia, N-acetylcysteine2-iminobiotin, remote ischemic postconditioning, cannabinoids and doxycycline target the subacute phase. Erythropoietin, mesenchymal stem cells, topiramate and memantine could potentially limit injury in the repair phase after asphyxia. To limit the injurious biochemical processes during the different stages of brain injury, determination of the stage of injury in any particular infant remains essential. Currently, therapeutic hypothermia is the only established treatment in the subacute phase of asphyxia-induced brain injury. The effects and side effects of oxidative stress reducing/limiting medications may however be difficult to predict in infants during therapeutic hypothermia. Future neuroprotection in asphyxiated infants may indeed include a combination of therapies. Challenges include timing, dosing and administration route for each neuroprotectant.
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Affiliation(s)
- A L Solevåg
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway
| | - G M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - P-Y Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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28
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Abstract
It is well-documented in the literature that infants who suffer from hypoxic ischemic encephalopathy are at high risk for neurologic sequelae or even death. With the addition of therapeutic hypothermia into the treatment regimen for neonatal hypoxic ischemic encephalopathy, newborns afflicted with hypoxic ischemic encephalopathy were given the opportunity for a better outcome. Questions linger as to the most optimal treatment strategy of therapeutic hypothermia for these newborns. The goal of this article is to discuss current management strategies, as well as future trends, for infants with hypoxic ischemic encephalopathy.
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Affiliation(s)
- Elizabeth A Schump
- Overland Park Regional Medical Center, NICU, 10500 Quivira Road, Overland Park, KS 66215, USA.
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29
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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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30
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Davidson JO, Dhillon SK, Wassink G, Zhou KQ, Bennet L, Gunn AJ. Endogenous neuroprotection after perinatal hypoxia-ischaemia: the resilient developing brain. J R Soc N Z 2018. [DOI: 10.1080/03036758.2018.1529685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Joanne O. Davidson
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Simerdeep K. Dhillon
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Guido Wassink
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Kelly Q. Zhou
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Alistair J. Gunn
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
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31
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Preventing childhood and lifelong disability: Maternal dietary supplementation for perinatal brain injury. Pharmacol Res 2018; 139:228-242. [PMID: 30227261 DOI: 10.1016/j.phrs.2018.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 07/29/2018] [Accepted: 08/24/2018] [Indexed: 12/30/2022]
Abstract
The majority of brain injuries that lead to cerebral palsy, developmental disability, and mental health disorders have their onset in utero. These lifelong conditions come with great economic and emotional burden as they impact function in nearly all domains of affected individuals' lives. Unfortunately, current therapeutic options are limited. There remains a focus on rescue, rehabilitation, and regeneration after the injury has occurred, rather than aiming to prevent the initial injury. Prevention would imply treating the mother during pregnancy to alter the fetal environment and in turn, treat the fetus. Fear of harming the developing fetus remains as a result of errors of the past such as the release of thalidomide. In this review, we outline evidence from animal studies and clinical trials that have explored maternal dietary supplementation with natural health products (including nutraceuticals and functional foods) for perinatal brain injury prevention. Namely, we discuss magnesium sulphate, creatine, choline, melatonin, resveratrol and broccoli sprouts/sulforaphane. Although clinical trials have only been completed in this realm for magnesium sulphate, results in animal models have been promising, suggesting that this is a productive avenue for further research. Natural health products may provide safe, effective, affordable, and easily accessible prevention of fetal brain injury and resulting lifelong disabilities.
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Aridas JDS, Yawno T, Sutherland AE, Nitsos I, Ditchfield M, Wong FY, Hunt RW, Fahey MC, Malhotra A, Wallace EM, Jenkin G, Miller SL. Systemic and transdermal melatonin administration prevents neuropathology in response to perinatal asphyxia in newborn lambs. J Pineal Res 2018; 64:e12479. [PMID: 29464766 PMCID: PMC5947141 DOI: 10.1111/jpi.12479] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 02/06/2018] [Indexed: 01/19/2023]
Abstract
Perinatal asphyxia remains a principal cause of infant mortality and long-term neurological morbidity, particularly in low-resource countries. No neuroprotective interventions are currently available. Melatonin (MLT), a potent antioxidant, anti-inflammatory and antiapoptotic agent, offers promise as an intravenous (IV) or transdermal therapy to protect the brain. We aimed to determine the effect of melatonin (IV or transdermal patch) on neuropathology in a lamb model of perinatal asphyxia. Asphyxia was induced in newborn lambs via umbilical cord occlusion at birth. Animals were randomly allocated to melatonin commencing 30 minutes after birth (60 mg in 24 hours; IV or transdermal patch). Brain magnetic resonance spectroscopy (MRS) was undertaken at 12 and 72 hours. Animals (control n = 9; control+MLT n = 6; asphyxia n = 16; asphyxia+MLT [IV n = 14; patch n = 4]) were euthanised at 72 hours, and cerebrospinal fluid (CSF) and brains were collected for analysis. Asphyxia resulted in severe acidosis (pH 6.9 ± 0.0; lactate 9 ± 2 mmol/L) and altered determinants of encephalopathy. MRS lactate:N-acetyl aspartate ratio was 2.5-fold higher in asphyxia lambs compared with controls at 12 hours and 3-fold higher at 72 hours (P < .05). Melatonin prevented this rise (3.5-fold reduced vs asphyxia; P = .02). Asphyxia significantly increased brain white and grey matter apoptotic cell death (activated caspase-3), lipid peroxidation (4HNE) and neuroinflammation (IBA-1). These changes were significantly mitigated by both IV and patch melatonin. Systemic or transdermal neonatal melatonin administration significantly reduces the neuropathology and encephalopathy signs associated with perinatal asphyxia. A simple melatonin patch, administered soon after birth, may improve outcome in infants affected by asphyxia, especially in low-resource settings.
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Affiliation(s)
- James D. S. Aridas
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
| | - Tamara Yawno
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVic.Australia
| | - Amy E. Sutherland
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
| | - Ilias Nitsos
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVic.Australia
| | | | - Flora Y. Wong
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Monash Children's HospitalMonash HealthClaytonVic.Australia
| | - Rod W. Hunt
- Murdoch Children's Research InstituteMelbourneVic.Australia
| | - Michael C. Fahey
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Monash Children's HospitalMonash HealthClaytonVic.Australia
| | - Atul Malhotra
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Monash Children's HospitalMonash HealthClaytonVic.Australia
| | - Euan M. Wallace
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVic.Australia
| | - Graham Jenkin
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVic.Australia
| | - Suzanne L. Miller
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVic.Australia
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Yawno T, Mahen M, Li J, Fahey MC, Jenkin G, Miller SL. The Beneficial Effects of Melatonin Administration Following Hypoxia-Ischemia in Preterm Fetal Sheep. Front Cell Neurosci 2017; 11:296. [PMID: 29018332 PMCID: PMC5615225 DOI: 10.3389/fncel.2017.00296] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 09/06/2017] [Indexed: 11/24/2022] Open
Abstract
Melatonin (MLT) is an endogenous hormone that controls circadian cycle. MLT has additional important properties that make it appealing as a neuroprotective agent—it is a potent anti-oxidant, with anti-apoptotic and anti-inflammatory properties. MLT is safe for administration during pregnancy or to the newborn after birth, and can reduce white matter brain injury under conditions of chronic fetal hypoxia. Accordingly, in the current study, we examined whether an intermediate dose of MLT could restore white matter brain development when administered after an acute hypoxic ischemic (HI) insult in preterm fetal sheep. Fifteen fetal sheep at 95–98 days gestation were instrumented with femoral artery and vein catheters, and a silastic cuff placed around the umbilical cord. At 102 days gestation, the cuff was inflated, causing complete umbilical cord occlusion for 25 min in 10 fetuses, to induce acute severe HI. Five HI fetuses received intravenous MLT for 24 h beginning at 2 h after HI. The remaining five fetuses were administered saline alone. Ten days after HI, the fetal brain was collected from each animal and white and gray matter neuropathology assessed. HI caused a significant increase in apoptotic cell death (TUNEL+), activated microglia (Iba-1+), and oxidative stress (8-OHdG+) within the subventricular and subcortical white matter. HI reduced the total number of oligodendrocytes and CNPase+ myelin density. MLT administration following HI decreased apoptosis, inflammation and oxidative stress within the white matter. MLT had intermediate benefits for the developing white matter: it increased oligodendrocyte cell number within the periventricular white matter only, and improved CNPase+ myelin density within the subcortical but not the striatal white matter. MLT administration following HI was also associated with improved neuronal survival within the cortex. Neuropathology in preterm infants is complex and mediated by multiple mechanisms, including inflammation, oxidative stress and apoptotic pathways. Treatment with MLT presents a safe approach to neuroprotective therapy in preterm infants but appears to have brain region-specific benefits within the white matter.
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Affiliation(s)
- Tamara Yawno
- The Ritchie Centre, Hudson Institute of Medical Research, ClaytonVIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, ClaytonVIC, Australia
| | - Mawin Mahen
- The Ritchie Centre, Hudson Institute of Medical Research, ClaytonVIC, Australia
| | - Jingang Li
- The Ritchie Centre, Hudson Institute of Medical Research, ClaytonVIC, Australia
| | - Michael C Fahey
- The Ritchie Centre, Hudson Institute of Medical Research, ClaytonVIC, Australia.,Department of Paediatrics, Monash Medical Centre, ClaytonVIC, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, ClaytonVIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, ClaytonVIC, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, ClaytonVIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, ClaytonVIC, Australia
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Polglase GR, Barbuto J, Allison BJ, Yawno T, Sutherland AE, Malhotra A, Schulze KE, Wallace EM, Jenkin G, Ricardo SD, Miller SL. Effects of antenatal melatonin therapy on lung structure in growth-restricted newborn lambs. J Appl Physiol (1985) 2017; 123:1195-1203. [PMID: 28819007 DOI: 10.1152/japplphysiol.00783.2016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 08/03/2017] [Accepted: 08/08/2017] [Indexed: 11/22/2022] Open
Abstract
Oxidative stress arising from suboptimal placental function contributes to a multitude of pathologies in infants compromised by fetal growth restriction (FGR). FGR infants are at high risk for respiratory dysfunction after birth and poor long-term lung function. Our objective was to investigate the contribution of oxidative stress to adverse lung development and the effects of melatonin administration, a powerful antioxidant, on lung structure in FGR lambs. Placental insufficiency and FGR was surgically induced in 13 fetal sheep at ∼105 days of gestation by ligation of a single umbilical artery. Maternal intravenous melatonin infusion was commenced in seven of the ewes 4 h after surgery and continued until birth. Lambs delivered normally at term and lungs were collected 24 h after birth for histological assessment of lung structure and injury and compared with appropriately grown control lambs (n = 8). FGR fetuses were hypoxic and had lower glucose during gestation compared with controls. Melatonin administration prevented chronic hypoxia. Within the lung, FGR caused reduced secondary septal crest density and altered elastin deposition compared with controls. Melatonin administration had no effect on the changes to lung structure induced by FGR. We conclude that chronic FGR disrupts septation of the developing alveoli, which is not altered by melatonin administration. These findings suggest that oxidative stress is not the mechanism driving altered lung structure in FGR neonates. Melatonin administration did not prevent disrupted airway development but also had no apparent adverse effects on fetal lung development.NEW & NOTEWORTHY Fetal growth restriction (FGR) results in poor respiratory outcomes, which may be caused by oxidation in utero. We investigated the contribution of oxidative stress to adverse lung development and the effects of melatonin administration, a powerful antioxidant, on lung structure in FGR lambs. FGR disrupted septation of the developing alveoli, which is not altered by melatonin administration. Oxidative stress may not be the mechanism driving altered lung structure in FGR neonates.
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Affiliation(s)
- Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Jade Barbuto
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Beth J Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Tamara Yawno
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Amy E Sutherland
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Atul Malhotra
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Monash Newborn, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Keith E Schulze
- Monash Micro Imaging, Monash University Clayton, Victoria, Australia; and
| | - Euan M Wallace
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Sharon D Ricardo
- Department of Anatomy, Biochemistry, and Molecular Biology, Monash University, Clayton, Victoria, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia; .,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
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Sukhanova IA, Sebentsova EA, Levitskaya NG. The acute and delayed effects of perinatal hypoxic brain damage in children and in model experiments with rodents. NEUROCHEM J+ 2016. [DOI: 10.1134/s1819712416040127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Hendaus MA, Jomha FA, Alhammadi AH. Melatonin in the management of perinatal hypoxic-ischemic encephalopathy: light at the end of the tunnel? Neuropsychiatr Dis Treat 2016; 12:2473-2479. [PMID: 27729791 PMCID: PMC5045913 DOI: 10.2147/ndt.s115533] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Perinatal hypoxic-ischemic encephalopathy (HIE) affects one to three per 1,000 live full-term births and can lead to severe and permanent neuropsychological sequelae, such as cerebral palsy, epilepsy, mental retardation, and visual motor or visual perceptive dysfunction. Melatonin has begun to be contemplated as a good choice in order to diminish the neurological sequelae from hypoxic-ischemic brain injury. Melatonin emerges as a very interesting medication, because of its capacity to cross all physiological barriers extending to subcellular compartments and its safety and effectiveness. The purpose of this commentary is to detail the evidence on the use of melatonin as a neuroprotection agent. The pharmacologic aspects of the drug as well as its potential neuroprotective characteristics in human and animal studies are described in this study. Melatonin seems to be safe and beneficial in protecting neonatal brains from perinatal HIE. Larger randomized controlled trials in humans are required, to implement a long-awaited feasible treatment in order to avoid the dreaded sequelae of HIE.
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Affiliation(s)
- Mohamed A Hendaus
- Department of Pediatrics, Section of Academic General Pediatrics, Hamad Medical Corporation
- Department of Clinical Pediatrics, Weill-Cornell Medical College, Doha, Qatar
| | - Fatima A Jomha
- School of Pharmacy, Lebanese International University, Khiara, Lebanon
| | - Ahmed H Alhammadi
- Department of Pediatrics, Section of Academic General Pediatrics, Hamad Medical Corporation
- Department of Clinical Pediatrics, Weill-Cornell Medical College, Doha, Qatar
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Abstract
BACKGROUND Melatonin is an antioxidant with anti-inflammatory and anti-apoptotic effects. Animal studies have supported a fetal neuroprotective role for melatonin when administered maternally. It is important to assess whether melatonin, given to the mother, can reduce the risk of neurosensory disabilities (including cerebral palsy) and death, associated with fetal brain injury, for the preterm or term compromised fetus. OBJECTIVES To assess the effects of melatonin when used for neuroprotection of the fetus. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016). SELECTION CRITERIA We planned to include randomised controlled trials and quasi-randomised controlled trials comparing melatonin given to women in pregnancy (regardless of the route, timing, dose and duration of administration) for fetal neuroprotection with placebo, no treatment, or with an alternative agent aimed at providing fetal neuroprotection. We also planned to include comparisons of different regimens for administration of melatonin. DATA COLLECTION AND ANALYSIS Two review authors planned to independently assess trial eligibility, trial quality and extract the data. MAIN RESULTS We found no randomised trials for inclusion in this review. One study is ongoing. AUTHORS' CONCLUSIONS As we did not identify any randomised trials for inclusion in this review, we are unable to comment on implications for practice at this stage.Although evidence from animals studies has supported a fetal neuroprotective role for melatonin when administered to the mother during pregnancy, no trials assessing melatonin for fetal neuroprotection in pregnant women have been completed to date. However, there is currently one ongoing randomised controlled trial (with an estimated enrolment target of 60 pregnant women) which examines the dose of melatonin, administered to women at risk of imminent very preterm birth (less than 28 weeks' gestation) required to reduce brain damage in the white matter of the babies that were born very preterm.Further high-quality research is needed and research efforts should directed towards trials comparing melatonin with either no intervention (no treatment or placebo), or with alternative agents aimed at providing fetal neuroprotection (such as magnesium sulphate for the very preterm infant). Such trials should evaluate maternal and infant short- and longer-term outcomes (including neurosensory disabilities such as cerebral palsy), and consider the costs of care.
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Affiliation(s)
- Dominic Wilkinson
- University of OxfordOxford Uehiro Centre for Practical EthicsOxfordUK
| | - Emily Shepherd
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSouth AustraliaAustralia5006
| | - Euan M Wallace
- Monash UniversityThe Ritchie CentreMelbourneVictoriaAustralia3168
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Barton SK, Tolcos M, Miller SL, Christoph-Roehr C, Schmölzer GM, Moss TJM, Hooper SB, Wallace EM, Polglase GR. Ventilation-Induced Brain Injury in Preterm Neonates: A Review of Potential Therapies. Neonatology 2016; 110:155-62. [PMID: 27105430 DOI: 10.1159/000444918] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 02/23/2016] [Indexed: 11/19/2022]
Abstract
Mechanical ventilation is a risk factor for cerebral inflammation and brain injury in preterm neonates. The risk increases proportionally with the intensity of treatment. Recent studies have shown that cerebral inflammation and injury can be initiated in the delivery room. At present, initiation of intermittent positive pressure ventilation (IPPV) in the delivery room is one of the least controlled interventions a preterm infant will likely face. Varying pressures and volumes administered shortly after birth are sufficient to trigger pathways of ventilation-induced lung and brain injury. The pathways involved in ventilation-induced brain injury include a complex inflammatory cascade and haemodynamic instability, both of which have an impact on the brain. However, regardless of the strategy employed to deliver IPPV, any ventilation has the potential to have an impact on the immature brain. This is particularly important given that preterm infants are already at a high risk for brain injury simply due to immaturity. This highlights the importance of improving the initial respiratory support in the delivery room. We review the mechanisms of ventilation-induced brain injury and discuss the need for, and the most likely, current therapeutic agents to protect the preterm brain. These include therapies already employed clinically, such as maternal glucocorticoid therapy and allopurinol, as well as other agents, such as erythropoietin, human amnion epithelial cells and melatonin, already showing promise in preclinical studies. Their mechanisms of action are discussed, highlighting their potential for use immediately after birth.
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Affiliation(s)
- Samantha K Barton
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Vic., UK
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Hassell KJ, Ezzati M, Alonso-Alconada D, Hausenloy DJ, Robertson NJ. New horizons for newborn brain protection: enhancing endogenous neuroprotection. Arch Dis Child Fetal Neonatal Ed 2015; 100:F541-52. [PMID: 26063194 PMCID: PMC4680177 DOI: 10.1136/archdischild-2014-306284] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/28/2015] [Indexed: 01/09/2023]
Abstract
Intrapartum-related events are the third leading cause of childhood mortality worldwide and result in one million neurodisabled survivors each year. Infants exposed to a perinatal insult typically present with neonatal encephalopathy (NE). The contribution of pure hypoxia-ischaemia (HI) to NE has been debated; over the last decade, the sensitising effect of inflammation in the aetiology of NE and neurodisability is recognised. Therapeutic hypothermia is standard care for NE in high-income countries; however, its benefit in encephalopathic babies with sepsis or in those born following chorioamnionitis is unclear. It is now recognised that the phases of brain injury extend into a tertiary phase, which lasts for weeks to years after the initial insult and opens up new possibilities for therapy.There has been a recent focus on understanding endogenous neuroprotection and how to boost it or to supplement its effectors therapeutically once damage to the brain has occurred as in NE. In this review, we focus on strategies that can augment the body's own endogenous neuroprotection. We discuss in particular remote ischaemic postconditioning whereby endogenous brain tolerance can be activated through hypoxia/reperfusion stimuli started immediately after the index hypoxic-ischaemic insult. Therapeutic hypothermia, melatonin, erythropoietin and cannabinoids are examples of ways we can supplement the endogenous response to HI to obtain its full neuroprotective potential. Achieving the correct balance of interventions at the correct time in relation to the nature and stage of injury will be a significant challenge in the next decade.
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Affiliation(s)
- K Jane Hassell
- Institute for Women's Health, University College London, London, UK
| | - Mojgan Ezzati
- Institute for Women's Health, University College London, London, UK
| | | | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, NIHR University College London Hospitals Biomedical Research Centre, University College London Hospital & Medical School, London, UK
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Davidson JO, Wassink G, van den Heuij LG, Bennet L, Gunn AJ. Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy - Where to from Here? Front Neurol 2015; 6:198. [PMID: 26441818 PMCID: PMC4568393 DOI: 10.3389/fneur.2015.00198] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 08/31/2015] [Indexed: 11/13/2022] Open
Abstract
Hypoxia-ischemia before or around the time of birth occurs in approximately 2/1000 live births and is associated with a high risk of death or lifelong disability. Therapeutic hypothermia is now well established as standard treatment for infants with moderate to severe hypoxic-ischemic encephalopathy but is only partially effective. There is compelling preclinical and clinical evidence that hypothermia is most protective when it is started as early as possible after hypoxia-ischemia. Further improvements in outcome from therapeutic hypothermia are very likely to arise from strategies to reduce the delay before starting treatment of affected infants. In this review, we examine evidence that current protocols are reasonably close to the optimal depth and duration of cooling, but that the optimal rate of rewarming after hypothermia is unclear. The potential for combination treatments to augment hypothermic neuroprotection has considerable promise, particularly with endogenous targets such as melatonin and erythropoietin, and noble gases such as xenon. We dissect the critical importance of preclinical studies using realistic delays in treatment and clinically relevant cooling protocols when examining combination treatment, and that for many strategies overlapping mechanisms of action can substantially attenuate any effects.
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Affiliation(s)
- Joanne O Davidson
- The Department of Physiology, The University of Auckland , Auckland , New Zealand
| | - Guido Wassink
- The Department of Physiology, The University of Auckland , Auckland , New Zealand
| | | | - Laura Bennet
- The Department of Physiology, The University of Auckland , Auckland , New Zealand
| | - Alistair J Gunn
- The Department of Physiology, The University of Auckland , Auckland , New Zealand
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Yiallourou SR, Wallace EM, Miller SL, Horne RSC. Effects of intrauterine growth restriction on sleep and the cardiovascular system: The use of melatonin as a potential therapy? Sleep Med Rev 2015; 26:64-73. [PMID: 26140865 DOI: 10.1016/j.smrv.2015.04.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 04/14/2015] [Accepted: 04/14/2015] [Indexed: 12/28/2022]
Abstract
Intrauterine growth restriction (IUGR) complicates 5-10% of pregnancies and is associated with increased risk of preterm birth, mortality and neurodevelopmental delay. The development of sleep and cardiovascular control are closely coupled and IUGR is known to alter this development. In the long-term, IUGR is associated with altered sleep and an increased risk of hypertension in adulthood. Melatonin plays an important role in the sleep-wake cycle. Experimental animal studies have shown that melatonin therapy has neuroprotective and cardioprotective effects in the IUGR fetus. Consequently, clinical trials are currently underway to assess the short and long term effects of antenatal melatonin therapy in IUGR pregnancies. Given melatonin's role in sleep regulation, this hormone could affect the developing infants' sleep-wake cycle and cardiovascular function after birth. In this review, we will 1) examine the role of melatonin as a therapy for IUGR pregnancies and the potential implications on sleep and the cardiovascular system; 2) examine the development of sleep-wake cycle in fetal and neonatal life; 3) discuss the development of cardiovascular control during sleep; 4) discuss the effect of IUGR on sleep and the cardiovascular system and 5) discuss the future implications of melatonin therapy in IUGR pregnancies.
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Affiliation(s)
- Stephanie R Yiallourou
- The Ritchie Centre, Monash Institute of Medical Research and Prince Henry's Institute and Monash University, Melbourne, Australia; Department of Paediatrics, Monash University, Melbourne, Australia.
| | - Euan M Wallace
- The Ritchie Centre, Monash Institute of Medical Research and Prince Henry's Institute and Monash University, Melbourne, Australia; Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Monash Institute of Medical Research and Prince Henry's Institute and Monash University, Melbourne, Australia; Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Rosemary S C Horne
- The Ritchie Centre, Monash Institute of Medical Research and Prince Henry's Institute and Monash University, Melbourne, Australia; Department of Paediatrics, Monash University, Melbourne, Australia
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Hagberg H, Mallard C, Ferriero DM, Vannucci SJ, Levison SW, Vexler ZS, Gressens P. The role of inflammation in perinatal brain injury. Nat Rev Neurol 2015; 11:192-208. [PMID: 25686754 PMCID: PMC4664161 DOI: 10.1038/nrneurol.2015.13] [Citation(s) in RCA: 561] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Inflammation is increasingly recognized as being a critical contributor to both normal development and injury outcome in the immature brain. The focus of this Review is to highlight important differences in innate and adaptive immunity in immature versus adult brain, which support the notion that the consequences of inflammation will be entirely different depending on context and stage of CNS development. Perinatal brain injury can result from neonatal encephalopathy and perinatal arterial ischaemic stroke, usually at term, but also in preterm infants. Inflammation occurs before, during and after brain injury at term, and modulates vulnerability to and development of brain injury. Preterm birth, on the other hand, is often a result of exposure to inflammation at a very early developmental phase, which affects the brain not only during fetal life, but also over a protracted period of postnatal life in a neonatal intensive care setting, influencing critical phases of myelination and cortical plasticity. Neuroinflammation during the perinatal period can increase the risk of neurological and neuropsychiatric disease throughout childhood and adulthood, and is, therefore, of concern to the broader group of physicians who care for these individuals.
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Affiliation(s)
- Henrik Hagberg
- 1] Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St Thomas' Hospital, London SE1 7EH, UK. [2] Perinatal Center, Institute of Physiology and Neurosciences and Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 435 43 Gothenburg, Sweden
| | - Carina Mallard
- Perinatal Center, Institute of Physiology and Neurosciences and Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 435 43 Gothenburg, Sweden
| | - Donna M Ferriero
- Departments of Neurology and Pediatrics, University of California San Francisco, San Francisco, CA 94158, USA
| | - Susan J Vannucci
- Department of Pediatrics/Newborn Medicine, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
| | - Steven W Levison
- Department of Neurology and Neuroscience, Rutgers University, RBHS-New Jersey Medical School, Cancer Center, H-1226 205 South Orange Avenue, Newark, NJ 07103, USA
| | - Zinaida S Vexler
- Departments of Neurology and Pediatrics, University of California San Francisco, San Francisco, CA 94158, USA
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Marseglia L, D'Angelo G, Manti S, Arrigo T, Barberi I, Reiter RJ, Gitto E. Oxidative stress-mediated aging during the fetal and perinatal periods. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2014; 2014:358375. [PMID: 25202436 PMCID: PMC4151547 DOI: 10.1155/2014/358375] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/18/2014] [Accepted: 08/05/2014] [Indexed: 12/14/2022]
Abstract
Oxidative stress is worldwide recognized as a fundamental component of the aging, a process that begins before birth. There is a critical balance between free radical generation and antioxidant defenses. Oxidative stress is caused by an imbalance between the production of free radicals and the ability of antioxidant system to detoxify them. Oxidative stress can occur early in pregnancy and continue in the postnatal period; this damage is implicated in the pathophysiology of pregnancy-related disorders, including recurrent pregnancy loss, preeclampsia and preterm premature rupture of membranes. Moreover, diseases of the neonatal period such as bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, and periventricular leukomalacia are related to free radical damage. The specific contribution of oxidative stress to the pathogenesis and progression of these neonatal diseases is only partially understood. This review summarizes what is known about the role of oxidative stress in pregnancy and in the pathogenesis of common disorders of the newborn, as a component of the early aging process.
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Affiliation(s)
- Lucia Marseglia
- Neonatal and Pediatric Intensive Care Unit, Department of Pediatrics, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy
| | - Gabriella D'Angelo
- Neonatal and Pediatric Intensive Care Unit, Department of Pediatrics, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy
| | - Sara Manti
- Unit of Pediatric Genetics and Immunology, Department of Pediatrics, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy
| | - Teresa Arrigo
- Unit of Pediatric Genetics and Immunology, Department of Pediatrics, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy
| | - Ignazio Barberi
- Neonatal and Pediatric Intensive Care Unit, Department of Pediatrics, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy
| | - Russel J. Reiter
- Department of Cellular and Structural Biology, University of Texas Health Science Center at San Antonio, San Antonio, TX 40729, USA
| | - Eloisa Gitto
- Neonatal and Pediatric Intensive Care Unit, Department of Pediatrics, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy
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Herrera EA, Macchiavello R, Montt C, Ebensperger G, Díaz M, Ramírez S, Parer JT, Serón-Ferré M, Reyes RV, Llanos AJ. Melatonin improves cerebrovascular function and decreases oxidative stress in chronically hypoxic lambs. J Pineal Res 2014; 57:33-42. [PMID: 24811332 DOI: 10.1111/jpi.12141] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 04/25/2014] [Indexed: 01/06/2023]
Abstract
Chronic hypoxia during gestation and delivery results in oxidative stress and cerebrovascular dysfunction in the neonate. We assessed whether melatonin, a potent antioxidant and potential vasodilator, improves the cerebral vascular function in chronically hypoxic neonatal lambs gestated and born in the highlands (3600 m). Six lambs received melatonin (1 mg/kg per day oral) and six received vehicle, once a day for 8 days. During treatment, biometry and hemodynamic variables were recorded. After treatment, lambs were submitted to a graded FiO2 protocol to assess cardiovascular responses to oxygenation changes. At 12 days old, middle cerebral arteries (MCA) were collected for vascular reactivity, morphostructural, and immunostaining evaluation. Melatonin increased fractional growth at the beginning and improved carotid blood flow at all arterial PO2 levels by the end of the treatment (P < 0.05). Further, melatonin treatment improved vascular responses to potassium, serotonin, methacholine, and melatonin itself (P < 0.05). In addition, melatonin enhanced the endothelial response via nitric oxide-independent mechanisms in isolated arteries (162 ± 26 versus 266 ± 34 AUC, P < 0.05). Finally, nitrotyrosine staining as an oxidative stress marker decreased in the MCA media layer of melatonin-treated animals (0.01357 ± 0.00089 versus 0.00837 ± 0.00164 pixels/μm2 , P < 0.05). All the melatonin-induced changes were associated with no systemic cardiovascular alterations in vivo. In conclusion, oral treatment with melatonin modulates cerebral vascular function, resulting in a better cerebral perfusion and reduced oxidative stress in the neonatal period in chronically hypoxic lambs. Melatonin is a potential therapeutic agent for treating cerebrovascular dysfunction associated with oxidative stress and developmental hypoxia in neonates.
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Affiliation(s)
- Emilio A Herrera
- Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; International Center for Andean Studies (INCAS), Universidad de Chile, Putre, Chile
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45
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Aridas JDS, Yawno T, Sutherland AE, Nitsos I, Ditchfield M, Wong FY, Fahey MC, Malhotra A, Wallace EM, Jenkin G, Miller SL. Detecting brain injury in neonatal hypoxic ischemic encephalopathy: closing the gap between experimental and clinical research. Exp Neurol 2014; 261:281-90. [PMID: 25079368 DOI: 10.1016/j.expneurol.2014.07.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 07/03/2014] [Accepted: 07/20/2014] [Indexed: 12/11/2022]
Abstract
Moderate to severe neonatal hypoxic ischemic encephalopathy remains an important cause of infant death and childhood disability. Early and accurate diagnosis of encephalopathy is difficult but critical for timely intervention. Thus, we have utilized a clinically relevant large animal model of asphyxia in-utero, followed by immediate lamb delivery, resuscitation and clinical care over the next 72h for assessment of potential biomarkers of brain injury. In-utero asphyxia was induced in twelve near-term lambs and outcomes compared with seven controls. Asphyxia resulted in bradycardia (97±12beats/min), hypotension (12.1±1mm Hg) and metabolic acidosis (pH6.9±0.02; base-excess -13.8±0.8mmol/l). 72h following asphyxia, cerebrospinal concentrations of malondialdehyde and S100B were elevated 2-fold and 5-fold, respectively, in asphyxic lambs compared to control lambs. Magnetic resonance spectroscopy (MRS) at 72h showed a significant decrease in n-acetyl aspartate: choline ratio in asphyxia lambs compared to that observed at 12h (0.56±0.23 vs. 0.82±0.15, respectively); lactate:choline ratio was not changed over this time. Marked neuropathology was observed in asphyxia lambs with neuronal degeneration in the hippocampus, thalamus, striatum and cortex. Astrogliosis was observed in the hippocampus and thalamus. Early blood markers of metabolic state showed limited predictive value of histological damage at 72h. MRS outcomes at 72h showed a modest but significant correlation with histological evidence of neuronal brain injury (lactate:N-acetyl aspartate ratio in the thalamus r(2)=0.2, p<0.01). MRS at 72h was best able to detect established brain injury, but a combination of biomarkers over multiple phases of injury may be able to assess the evolution of neonatal brain injury.
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Affiliation(s)
- James D S Aridas
- The Ritchie Centre, MIMR-PHI Institute, Clayton, Victoria, Australia
| | - Tamara Yawno
- The Ritchie Centre, MIMR-PHI Institute, Clayton, Victoria, Australia
| | - Amy E Sutherland
- The Ritchie Centre, MIMR-PHI Institute, Clayton, Victoria, Australia
| | - Ilias Nitsos
- The Ritchie Centre, MIMR-PHI Institute, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | | | - Flora Y Wong
- The Ritchie Centre, MIMR-PHI Institute, Clayton, Victoria, Australia; Monash Children's, Monash Health, Clayton, Victoria, Australia
| | - Michael C Fahey
- The Ritchie Centre, MIMR-PHI Institute, Clayton, Victoria, Australia; Monash Children's, Monash Health, Clayton, Victoria, Australia
| | - Atul Malhotra
- The Ritchie Centre, MIMR-PHI Institute, Clayton, Victoria, Australia; Monash Children's, Monash Health, Clayton, Victoria, Australia
| | - Euan M Wallace
- The Ritchie Centre, MIMR-PHI Institute, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Graham Jenkin
- The Ritchie Centre, MIMR-PHI Institute, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Suzanne L Miller
- The Ritchie Centre, MIMR-PHI Institute, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.
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Reiter RJ, Tamura H, Tan DX, Xu XY. Melatonin and the circadian system: contributions to successful female reproduction. Fertil Steril 2014; 102:321-8. [PMID: 24996495 DOI: 10.1016/j.fertnstert.2014.06.014] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 05/29/2014] [Accepted: 06/10/2014] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To summarize the role of melatonin and circadian rhythms in determining optimal female reproductive physiology, especially at the peripheral level. DESIGN Databases were searched for the related English-language literature published up to March 1, 2014. Only papers in peer-reviewed journals are cited. SETTING Not applicable. PATIENT(S) Not applicable. INTERVENTION(S) Melatonin treatment, alterations of the normal light:dark cycle and light exposure at night. MAIN OUTCOME MEASURE(S) Melatonin levels in the blood and in the ovarian follicular fluid and melatonin synthesis, oxidative damage and circadian rhythm disturbances in peripheral reproductive organs. RESULT(S) The central circadian regulatory system is located in the suprachiasmatic nucleus (SCN). The output of this master clock is synchronized to 24 hours by the prevailing light-dark cycle. The SCN regulates rhythms in peripheral cells via the autonomic nervous system and it sends a neural message to the pineal gland where it controls the cyclic production of melatonin; after its release, the melatonin rhythm strengthens peripheral oscillators. Melatonin is also produced in the peripheral reproductive organs, including granulosa cells, the cumulus oophorus, and the oocyte. These cells, along with the blood, may contribute melatonin to the follicular fluid, which has melatonin levels higher than those in the blood. Melatonin is a powerful free radical scavenger and protects the oocyte from oxidative stress, especially at the time of ovulation. The cyclic levels of melatonin in the blood pass through the placenta and aid in the organization of the fetal SCN. In the absence of this synchronizing effect, the offspring may exhibit neurobehavioral deficits. Also, melatonin protects the developing fetus from oxidative stress. Melatonin produced in the placenta likewise may preserve the optimal function of this organ. CONCLUSION(S) Both stable circadian rhythms and cyclic melatonin availability are critical for optimal ovarian physiology and placental function. Because light exposure after darkness onset at night disrupts the master circadian clock and suppresses elevated nocturnal melatonin levels, light at night should be avoided.
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Affiliation(s)
- Russel J Reiter
- Department of Cellular and Structural Biology, University of Texas Health Science Center, San Antonio, Texas.
| | - Hiroshi Tamura
- Department of Cellular and Structural Biology, University of Texas Health Science Center, San Antonio, Texas
| | - Dun Xian Tan
- Department of Cellular and Structural Biology, University of Texas Health Science Center, San Antonio, Texas
| | - Xiao-Ying Xu
- Department of Cellular and Structural Biology, University of Texas Health Science Center, San Antonio, Texas
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Miller SL, Yawno T, Alers NO, Castillo-Melendez M, Supramaniam VG, VanZyl N, Sabaretnam T, Loose JM, Drummond GR, Walker DW, Jenkin G, Wallace EM. Antenatal antioxidant treatment with melatonin to decrease newborn neurodevelopmental deficits and brain injury caused by fetal growth restriction. J Pineal Res 2014; 56:283-94. [PMID: 24456220 DOI: 10.1111/jpi.12121] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 01/17/2014] [Indexed: 12/12/2022]
Abstract
Fetal intrauterine growth restriction (IUGR) is a serious pregnancy complication associated with increased rates of perinatal morbidity and mortality, and ultimately with long-term neurodevelopmental impairments. No intervention currently exists that can improve the structure and function of the IUGR brain before birth. Here, we investigated whether maternal antenatal melatonin administration reduced brain injury in ovine IUGR. IUGR was induced in pregnant sheep at 0.7 gestation and a subset of ewes received melatonin via intravenous infusion until term. IUGR, IUGR + melatonin (IUGR + MLT) and control lambs were born naturally, neonatal behavioral assessment was used to examine neurological function and at 24 hr after birth the brain was collected for the examination of neuropathology. Compared to control lambs, IUGR lambs took significantly longer to achieve normal neonatal lamb behaviors, such as standing and suckling. IUGR brains showed widespread cellular and axonal lipid peroxidation, and white matter hypomyelination and axonal damage. Maternal melatonin administration ameliorated oxidative stress, normalized myelination and rescued axonopathy within IUGR lamb brains, and IUGR + MLT lambs demonstrated significant functional improvements including a reduced time taken to attach to and suckle at the udder after birth. Based on these observations, we began a pilot clinical trial of oral melatonin administration to women with an IUGR fetus. Maternal melatonin was not associated with adverse maternal or fetal effects and it significantly reduced oxidative stress, as evidenced by reduced malondialdehyde levels, in the IUGR + MLT placenta compared to IUGR alone. Melatonin should be considered for antenatal neuroprotective therapy in human IUGR.
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Affiliation(s)
- Suzanne L Miller
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Clayton, Vic., Australia; Department of Obstetrics & Gynaecology, Southern Clinical School, Monash University, Clayton, Vic., Australia
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48
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Domínguez Rubio AP, Sordelli MS, Salazar AI, Aisemberg J, Bariani MV, Cella M, Rosenstein RE, Franchi AM. Melatonin prevents experimental preterm labor and increases offspring survival. J Pineal Res 2014; 56:154-62. [PMID: 24313220 DOI: 10.1111/jpi.12108] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 12/03/2013] [Indexed: 01/08/2023]
Abstract
Preterm delivery is the leading cause of neonatal mortality and contributes to delayed physical and cognitive development in children. At present, there is no efficient therapy to prevent preterm labor. A large body of evidence suggests that intra-amniotic infections may be a significant and potentially preventable cause of preterm birth. This work assessed the effect of melatonin in a murine model of inflammation-associated preterm delivery which mimics central features of preterm infection in humans. For this purpose, preterm labor was induced in BALB/c mice by intraperitoneal injections of bacterial lipopolysaccharide (LPS) at 10.00 hr (10 μg LPS) and 13.00 hr (20 μg LPS) on day 15 of pregnancy. On day 14 of pregnancy, a pellet of melatonin (25 mg) had been subcutaneously implanted into a group of animals. In the absence of melatonin, a 100% incidence of preterm birth was observed in LPS-treated animals, and the fetuses showed widespread damage. By comparison, treatment with melatonin prevented preterm birth in 50% of the cases, and all pups from melatonin-treated females were born alive and their body weight did not differ from control animals. Melatonin significantly prevented the LPS-induced rises in uterine prostaglandin (PG) E2 , PGF2α, and cyclooxygenase-2 protein levels. In addition, melatonin prevented the LPS-induced increase in uterine nitric oxide (NO) production, inducible NO synthase protein, and tumor necrosis factor-alpha (TNFα) levels. Collectively, our results suggest that melatonin could be a new therapeutic tool to prevent preterm labor and to increase offspring survival.
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Affiliation(s)
- Ana P Domínguez Rubio
- Laboratory of Physiopathology of Pregnancy and Labor, CEFyBO (CONICET/UBA), Buenos Aires, Argentina
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49
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Drury PP, Davidson JO, Bennet L, Booth LC, Tan S, Fraser M, van den Heuij LG, Gunn AJ. Partial neural protection with prophylactic low-dose melatonin after asphyxia in preterm fetal sheep. J Cereb Blood Flow Metab 2014; 34:126-35. [PMID: 24103904 PMCID: PMC3887352 DOI: 10.1038/jcbfm.2013.174] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 08/13/2013] [Accepted: 09/09/2013] [Indexed: 12/11/2022]
Abstract
Melatonin is a naturally occurring indolamine with mild antioxidant properties that is neuroprotective in perinatal animals. There is limited information on its effects on preterm brain injury. In this study, 23 chronically instrumented fetal sheep received 25 minutes of complete umbilical cord occlusion at 101 to 104 days gestation (term is 147 days). Melatonin was administered to the ewe 15 minutes before occlusion (0.1 mg/kg bolus followed by 0.1 mg/kg per hour for 6 hours, n=8), or the equivalent volume of vehicle (2% ethanol, n=7), or saline (n=8), or maternal saline plus sham occlusion (n=8). Sheep were killed after 7 days recovery in utero. Fetal blood pressure, heart rate, nuchal activity, and temperature were similar between groups. Vehicle infusion was associated with improved neuronal survival in the caudate nucleus, but greater neuronal loss in the regions of the hippocampus, with reduced proliferation and increased ameboid microglia in the white matter (P<0.05). Maternal melatonin infusion was associated with faster recovery of fetal EEG, prolonged reduction in carotid blood flow, similar neuronal survival to vehicle, improved numbers of mature oligodendrocytes, and reduced microglial activation in the white matter (P<0.05). Prophylactic maternal melatonin treatment is partially protective but its effects may be partly confounded by ethanol used to dissolve melatonin.
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Affiliation(s)
- Paul P Drury
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Lindsea C Booth
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Sidhartha Tan
- Department of Pediatrics, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Mhoyra Fraser
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | | | - Alistair J Gunn
- Department of Physiology, University of Auckland, Auckland, New Zealand
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50
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Alers NO, Jenkin G, Miller SL, Wallace EM. Antenatal melatonin as an antioxidant in human pregnancies complicated by fetal growth restriction--a phase I pilot clinical trial: study protocol. BMJ Open 2013; 3:e004141. [PMID: 24366583 PMCID: PMC3884842 DOI: 10.1136/bmjopen-2013-004141] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Fetal growth restriction complicates about 5% of pregnancies and is commonly caused by placental dysfunction. It is associated with increased risks of perinatal mortality and short-term and long-term morbidity, such as cerebral palsy. Chronic in utero hypoxaemia, inflammation and oxidative stress are likely culprits contributing to the long-term neurological sequelae of fetal growth restriction. In this regard, we propose that melatonin, a powerful antioxidant, might mitigate morbidity and/or mortality associated with fetal growth restriction. Melatonin has an excellent biosafety profile and crosses the placenta and blood-brain barrier. We present the protocol for a phase I clinical trial to investigate the efficacy of maternal oral melatonin administration in women with a pregnancy complicated by fetal growth restriction. METHODS AND ANALYSIS The proposed trial is a single-arm, open-label clinical trial involving 12 women. Severe, early onset fetal growth restriction will be diagnosed by an estimated fetal weight ≤10th centile in combination with abnormal fetoplacental Doppler studies, occurring before 34 weeks of pregnancy. Baseline measurements of maternal and fetal well-being, levels of oxidative stress and ultrasound and Doppler measurements will be obtained at the time of diagnosis of fetal growth restriction. Women will then start melatonin treatment (4 mg) twice daily until birth. The primary outcomes are the levels of oxidative stress in the maternal and fetal circulation and placenta. Secondary outcomes are fetoplacental Doppler studies (uterine artery, umbilical artery middle cerebral artery and ductus venosus), fetal biometry, fetal biophysical profile and a composite determination of neonatal outcome. A historical cohort of gestational-matched fetal growth restriction and a healthy pregnancy cohort will be used as comparators. ETHICS AND DISSEMINATION Ethical approval has been obtained from Monash Health Human Research Ethics Committee B (HREC12133B). Data will be presented at international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER Clinical Trials, protocol registration system: NCT01695070.
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Affiliation(s)
- Nicole O Alers
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Graham Jenkin
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Euan M Wallace
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
- Monash Women's Services, Monash Health, Clayton, Victoria, Australia
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