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Zhao LR, Lu SJ, Liu Q, Yu YC, Xiao L. Impact of prolonged use of adjuvant tocolytics after cervical cerclage on late abortion and premature delivery. J OBSTET GYNAECOL 2023; 43:2128997. [PMID: 36205080 DOI: 10.1080/01443615.2022.2128997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
We evaluated the impact of cervical cerclage combined with one or more uterine contraction inhibitors in persistent inhibition of uterine contraction for the treatment of late abortion and premature delivery. This retrospective case series study analysed the medical data of 58 patients who underwent cervical cerclage for cervical insufficiency and simultaneously received one or more uterine contraction inhibitors (indomethacin, ritodrine, and atosiban) and magnesium sulphate at the Zibo Maternal and Child Health Hospital between January 2019 and December 2020.Patients are normal pregnancy who received cervical cerclage without complications. The rate of successful treatment was 74.14% (43/58). The prolonged gestation duration was 16.42 ± 7.84 weeks, and the average delivery gestational age was 35.91 ± 5.16 weeks. The longest duration of treatment with a uterine contraction inhibitor or inhibitors in combination or with magnesium sulphate alone was 15.34 ± 13.16 days, and nine cases developed adverse reactions. Persistent uterine contraction inhibition after cervical cerclage could prolong pregnancy and improve pregnancy outcomes.Impact statementWhat is already known on this subject? A crucial reason for treatment failure of cervical cerclage is that uterine contraction was not effectively inhibited.What do the results of this study add? Persistent inhibition of uterine contraction after cervical cerclage prolonged pregnancy duration, increased gestational age at delivery, and improved pregnancy outcomes.What are the implications of these findings for clinical practice and/or further research? This study may provide a clinical basis for prolonging gestational age, preventing late abortion and premature delivery, and improving the survival rate and quality of life of premature infants.
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Affiliation(s)
- Li-Rong Zhao
- Department of Obstetric, Zibo Maternal and Child Health Hospital, Zibo, China
| | - Shu-Jing Lu
- Department of Obstetric, Zibo Maternal and Child Health Hospital, Zibo, China
| | - Qing Liu
- Department of Obstetric, Zibo Maternal and Child Health Hospital, Zibo, China
| | - Ying-Chun Yu
- Department of Obstetric, Zibo Maternal and Child Health Hospital, Zibo, China
| | - Li Xiao
- Department of Obstetric, Maternal and Child Health Care of Shandong Province Affiliated to Shandong University, Jinan, China
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Siricilla S, Hansen CJ, Rogers JH, De D, Simpson CL, Waterson AG, Sulikowski GA, Crockett SL, Boatwright N, Reese J, Paria BC, Newton J, Herington JL. Arrest of mouse preterm labor until term delivery by combination therapy with atosiban and mundulone, a natural product with tocolytic efficacy. Pharmacol Res 2023; 195:106876. [PMID: 37536638 DOI: 10.1016/j.phrs.2023.106876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 07/17/2023] [Accepted: 07/28/2023] [Indexed: 08/05/2023]
Abstract
There is a lack of FDA-approved tocolytics for the management of preterm labor (PL). In prior drug discovery efforts, we identified mundulone and mundulone acetate (MA) as inhibitors of in vitro intracellular Ca2+-regulated myometrial contractility. In this study, we probed the tocolytic potential of these compounds using human myometrial samples and a mouse model of preterm birth. In a phenotypic assay, mundulone displayed greater efficacy, while MA showed greater potency and uterine-selectivity in the inhibition of intracellular-Ca2+ mobilization. Cell viability assays revealed that MA was significantly less cytotoxic. Organ bath and vessel myography studies showed that only mundulone exerted inhibition of myometrial contractions and that neither compounds affected vasoreactivity of ductus arteriosus. A high-throughput combination screen identified that mundulone exhibits synergism with two clinical-tocolytics (atosiban and nifedipine), and MA displayed synergistic efficacy with nifedipine. Of these combinations, mundulone+atosiban demonstrated a significant improvement in the in vitro therapeutic index compared to mundulone alone. The ex vivo and in vivo synergism of mundulone+atosiban was substantiated, yielding greater tocolytic efficacy and potency on myometrial tissue and reduced preterm birth rates in a mouse model of PL compared to each single agent. Treatment with mundulone after mifepristone administration dose-dependently delayed the timing of delivery. Importantly, mundulone+atosiban permitted long-term management of PL, allowing 71% dams to deliver viable pups at term (>day 19, 4-5 days post-mifepristone exposure) without visible maternal and fetal consequences. Collectively, these studies provide a strong foundation for the development of mundulone as a single or combination tocolytic for management of PL.
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Affiliation(s)
- Shajila Siricilla
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher J Hansen
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University, Nashville, TN, USA
| | - Jackson H Rogers
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Debasmita De
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carolyn L Simpson
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alex G Waterson
- Department of Pharmacology, Vanderbilt University, Nashville, TN, USA; Department of Chemistry, Vanderbilt University, Nashville, TN, USA; Vanderbilt Institute of Chemical Biology, Vanderbilt University, Nashville, TN, USA
| | - Gary A Sulikowski
- Department of Chemistry, Vanderbilt University, Nashville, TN, USA; Vanderbilt Institute of Chemical Biology, Vanderbilt University, Nashville, TN, USA
| | - Stacey L Crockett
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Naoko Boatwright
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeff Reese
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA; Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN, USA
| | - Bibhash C Paria
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer L Herington
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University, Nashville, TN, USA.
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Siricilla S, Hansen CJ, Rogers JH, De D, Simpson CL, Waterson AG, Sulikowski GA, Crockett SL, Boatwright N, Reese J, Paria BC, Newton J, Herington JL. Arrest of mouse preterm labor until term delivery by combination therapy with atosiban and mundulone, a natural product with tocolytic efficacy. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.06.06.543921. [PMID: 37333338 PMCID: PMC10274706 DOI: 10.1101/2023.06.06.543921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Currently, there is a lack of FDA-approved tocolytics for the management of preterm labor (PL). In prior drug discovery efforts, we identified mundulone and its analog mundulone acetate (MA) as inhibitors of in vitro intracellular Ca 2+ -regulated myometrial contractility. In this study, we probed the tocolytic and therapeutic potential of these small molecules using myometrial cells and tissues obtained from patients receiving cesarean deliveries, as well as a mouse model of PL resulting in preterm birth. In a phenotypic assay, mundulone displayed greater efficacy in the inhibition of intracellular-Ca 2+ from myometrial cells; however, MA showed greater potency and uterine-selectivity, based IC 50 and E max values between myometrial cells compared to aorta vascular smooth muscle cells, a major maternal off-target site of current tocolytics. Cell viability assays revealed that MA was significantly less cytotoxic. Organ bath and vessel myography studies showed that only mundulone exerted concentration-dependent inhibition of ex vivo myometrial contractions and that neither mundulone or MA affected vasoreactivity of ductus arteriosus, a major fetal off-target of current tocolytics. A high-throughput combination screen of in vitro intracellular Ca 2+ -mobilization identified that mundulone exhibits synergism with two clinical-tocolytics (atosiban and nifedipine), and MA displayed synergistic efficacy with nifedipine. Of these synergistic combinations, mundulone + atosiban demonstrated a favorable in vitro therapeutic index (TI)=10, a substantial improvement compared to TI=0.8 for mundulone alone. The ex vivo and in vivo synergism of mundulone and atosiban was substantiated, yielding greater tocolytic efficacy and potency on isolated mouse and human myometrial tissue and reduced preterm birth rates in a mouse model of PL compared to each single agent. Treatment with mundulone 5hrs after mifepristone administration (and PL induction) dose-dependently delayed the timing of delivery. Importantly, mundulone in combination with atosiban (FR 3.7:1, 6.5mg/kg + 1.75mg/kg) permitted long-term management of PL after induction with 30 μg mifepristone, allowing 71% dams to deliver viable pups at term (> day 19, 4-5 days post-mifepristone exposure) without any visible maternal and fetal consequences. Collectively, these studies provide a strong foundation for the future development of mundulone as a stand-alone single- and/or combination-tocolytic therapy for management of PL.
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Young Park J, Hong S, Hye Jo J, Hye Shin I, Young Kim G, Sun Ko H, Yang Park I. The effect of tocolytics in women with preterm labor after 34 weeks of gestation: A propensity score-matched study. Eur J Obstet Gynecol Reprod Biol 2022; 277:1-6. [DOI: 10.1016/j.ejogrb.2022.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 06/30/2022] [Accepted: 07/26/2022] [Indexed: 11/04/2022]
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Yart L, Frieden M, Konig S, Cohen M, Martinez de Tejada B. Dual effect of nifedipine on pregnant human myometrium contractility: Implication of TRPC1. J Cell Physiol 2022; 237:1980-1991. [PMID: 34988986 PMCID: PMC9306527 DOI: 10.1002/jcp.30666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 11/19/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022]
Abstract
Nifedipine, an L‐type voltage‐gated Ca2+ channel (L‐VGCC) blocker, is one of the most used tocolytics to treat preterm labor. In clinical practice, nifedipine efficiently decreases uterine contractions, but its efficacy is limited over time, and repeated or maintained nifedipine‐based tocolysis appears to be ineffective in preventing preterm birth. We aimed to understand why nifedipine has short‐lasting efficiency for the inhibition of uterine contractions. We used ex vivo term pregnant human myometrial strips treated with cumulative doses of nifedipine. We observed that nifedipine inhibited spontaneous myometrial contractions in tissues with high and regular spontaneous contractions. By contrast, nifedipine appeared to increase contractions in tissues with low and/or irregular spontaneous contractions. To investigate the molecular mechanisms activated by nifedipine in myometrial cells, we used the pregnant human myometrial cell line PHM1‐41 that does not express L‐VGCC. The in vitro measurement of intracellular Ca2+ showed that high doses of nifedipine induced an important intracellular Ca2+ entry in myometrial cells. The inhibition or downregulation of the genes encoding for store‐operated Ca2+ entry channels from the Orai and transient receptor potential‐canonical (TRPC) families in PHM1‐41 cells highlighted the implication of TRPC1 in nifedipine‐induced Ca2+ entry. In addition, the use of 2‐APB in combination with nifedipine on human myometrial strips tends to confirm that the pro‐contractile effect induced by nifedipine on myometrial tissues may involve the activation of TRPC channels.
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Affiliation(s)
- Lucile Yart
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals and University of Geneva Faculty of Medicine, Geneva, Switzerland.,Translational Research Center in Oncohaematology, University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Maud Frieden
- Department of Cell Physiology and Metabolism, University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Stéphane Konig
- Department of Cell Physiology and Metabolism, University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Marie Cohen
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals and University of Geneva Faculty of Medicine, Geneva, Switzerland.,Translational Research Center in Oncohaematology, University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Begoña Martinez de Tejada
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals and University of Geneva Faculty of Medicine, Geneva, Switzerland
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Malik M, Roh M, England SK. Uterine contractions in rodent models and humans. Acta Physiol (Oxf) 2021; 231:e13607. [PMID: 33337577 PMCID: PMC8047897 DOI: 10.1111/apha.13607] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/07/2020] [Accepted: 12/11/2020] [Indexed: 12/18/2022]
Abstract
Aberrant uterine contractions can lead to preterm birth and other labour complications and are a significant cause of maternal morbidity and mortality. To investigate the mechanisms underlying dysfunctional uterine contractions, researchers have used experimentally tractable small animal models. However, biological differences between humans and rodents change how researchers select their animal model and interpret their results. Here, we provide a general review of studies of uterine excitation and contractions in mice, rats, guinea pigs, and humans, in an effort to introduce new researchers to the field and help in the design and interpretation of experiments in rodent models.
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Affiliation(s)
- Manasi Malik
- Center for Reproductive Health Sciences Department of Obstetrics and Gynecology Washington University School of Medicine St. Louis MO USA
| | - Michelle Roh
- Center for Reproductive Health Sciences Department of Obstetrics and Gynecology Washington University School of Medicine St. Louis MO USA
| | - Sarah K. England
- Center for Reproductive Health Sciences Department of Obstetrics and Gynecology Washington University School of Medicine St. Louis MO USA
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Stoiber B, Haslinger C, Schäffer MK, Zimmermann R, Schäffer L. Effect of dual tocolysis with fenoterol and atosiban in human myometrium. J Perinat Med 2019; 47:190-194. [PMID: 30218606 DOI: 10.1515/jpm-2018-0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 08/14/2018] [Indexed: 11/15/2022]
Abstract
Objectives To measure the tocolytic effect of the combination of the oxytocin receptor antagonist atosiban with the β-mimetic agent fenoterol on human myometrium of pregnant women. Methods An in vitro study of contractility in human myometrium at the Laboratory of the Department of Obstetrics, University Hospital of Zürich, Switzerland, was performed. Thirty-six human myometrial biopsies were obtained during elective caesarean sections of singleton pregnancies at term. Tissue samples were exposed to atosiban, fenoterol and the combination of atosiban with fenoterol. Contractility was measured as area under the curve during 30 min of spontaneous contractions. The effect of treatment was expressed as the percentage of change from basal activity during 30 min of exposure. Differences were calculated using a paired Wilcoxon signed-rank test. An additive effect of dual tocolysis was assumed when no significant difference was detected between the observed and expected inhibition of dual tocolysis. When inhibition was greater or lower than expected, the dual combination was characterised as "synergistic" or "antagonistic", respectively. Results Atosiban and fenoterol alone suppressed contractions by a median of 43.2% and 29.8%, respectively. The combination of atosiban plus fenoterol was measured at a level of 67.3% inhibition. There was no significant difference in the expected (63.2%) and observed inhibition effect of dual tocolysis (P=0.945). Conclusion This study demonstrated an additive effect of dual tocolysis of atosiban and fenoterol on human myometrium in vitro, but no synergistic or antagonistic effect.
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Affiliation(s)
- Bernhard Stoiber
- Department of Obstetrics and Gynecology, Danube Hospital, SMZ Ost, Langobardenstr. 122, Vienna 1220, Austria
| | | | | | - Roland Zimmermann
- Division of Obstetrics, University Hospital of Zürich, Zurich, Switzerland
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Kashanian M, Shirvani S, Sheikhansari N, Javanmanesh F. A comparative study on the efficacy of nifedipine and indomethacin for prevention of preterm birth as monotherapy and combination therapy: a randomized clinical trial. J Matern Fetal Neonatal Med 2019; 33:3215-3220. [PMID: 30696306 DOI: 10.1080/14767058.2019.1570117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Preterm delivery is an important issue in obstetrics, which is the most common cause of neonatal mortality and morbidity. Therefore, finding a way to prevent it is always under serious concern.Objective: The study aimed to compare the efficacy of two tocolytic agents, nifedipine and indomethacin, for inhibiting preterm uterine contractions as monotherapy and combination therapy.Materials and methods: A double-blind randomized clinical trial was performed on pregnant women with gestational age of 26-34 weeks of pregnancy who referred to hospital for preterm labor. They were randomly assigned to three groups. Indomethacin plus placebo, nifedipine plus placebo, and a combination of indomethacin and nifedipine were administered to the three groups. Inhibiting contractions for 2 hours and prevention of delivery for 48 hours and 7 days were evaluated. Also, duration of pregnancy, the number of preterm births, and the interval between entering the study and delivery were compared between three groups.Results: One hundred fifty women were eligible for the study. Two women in the nifedipine group and one woman in the combined group were excluded from the study because of hypotension. The women of the three groups did not have significant difference according to age, BMI, gravidity, parity, Bishop score, gestational age, and the number of contractions at entering the study. Thirty-six women (72%) in the indomethacin group, 36 women (72%) in the nifedipine group, and 41 women (89.4%) in the combination group had stopped contractions within the first 2 hours of intervention (p = .002). Inhibiting contractions for 48 hours (p = .003), inhibiting contractions for 7 days (p = .021), gestational age at birth (p = .001), number of pregnancies more than 37 weeks (p = .007), and neonatal weight (p = .020) were significantly more in the combination group.Conclusion: Combination therapy with nifedipine and indomethacin was more effective than monotherapy with either of these two medications for inhibiting preterm labor, delaying delivery, and prolongation of the duration of pregnancy.
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Affiliation(s)
- Maryam Kashanian
- Department of Obstetrics and Gynecology, Iran University of Medical Sciences, Tehran, Iran
| | - Shaghayegh Shirvani
- Department of Obstetrics and Gynecology, Iran University of Medical Sciences, Tehran, Iran
| | | | - Forough Javanmanesh
- Department of Obstetrics and Gynecology, Iran University of Medical Sciences, Tehran, Iran
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Maduro MR. A Potentially New Tocolytic Agent. Reprod Sci 2018; 25:1529-1530. [PMID: 30326820 DOI: 10.1177/1933719118802730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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