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Rakers F, Schleussner E, Cornelius A, Kluckow S, Muth I, Hoyer D, Rupprecht S, Schultze T, Schiecke K, Ligges C, Schwab M, Hoyer H. Association between prenatal glucocorticoid exposure and adolescent neurodevelopment: An observational follow-up study. Acta Obstet Gynecol Scand 2024; 103:1530-1540. [PMID: 38877646 PMCID: PMC11266634 DOI: 10.1111/aogs.14885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/16/2024] [Accepted: 05/17/2024] [Indexed: 06/16/2024]
Abstract
INTRODUCTION Prenatal exposure to supraphysiological glucocorticoid (GC) levels may lead to long-lasting developmental changes in numerous biological systems. Our prior study identified an association between prenatal GC prophylaxis and reduced cognitive performance, electrocortical changes, and altered autonomic nervous system (ANS) activity in children aged 8-9 years. This follow-up study aimed to examine whether these findings persisted into adolescence. MATERIAL AND METHODS Prospective observational follow-up study involving twenty-one 14- to 15-year-old adolescents born to mothers who received betamethasone for induction of fetal lung maturation in threatened preterm birth, but who were born with a normal weight appropriate for their gestational age (median 37+4 gestational weeks). Thirty-five children not exposed to betamethasone served as the reference group (median 37+6 gestational weeks). The primary endpoint was cognitive performance, measured by intelligence quotient (IQ). Key secondary endpoints included symptoms of attention-deficit/hyperactivity disorder (ADHD) and metabolic markers. Additionally, we determined electrocortical (electroencephalogram), hypothalamus-pituitary-adrenal axis (HPAA), and ANS activity in response to a standardized stress paradigm. RESULTS No statistically significant group difference was observed in global IQ (adjusted mean: betamethasone 103.9 vs references 105.9, mean difference -2.0, 95% confidence interval [CI]: -7.12 to 3.12, p = 0.44). Similarly, ADHD symptoms, metabolic markers, the overall and stress-induced activity of the HPAA and the ANS did not differ significantly between groups. However, the betamethasone group exhibited reduced electrocortical activity in the frontal brain region (spectral edge frequency-adjusted means: 16.0 Hz vs 17.8 Hz, mean difference -1.83 Hz, 95% CI: -3.21 to -0.45, p = 0.01). CONCLUSIONS In 14- to 15-year-old adolescents, prenatal GC exposure was not associated with differences in IQ scores or ANS activity compared to unexposed controls. However, decelerated electrocortical activity in the frontal region potentially reflects disturbances in the maturation of cortical and/or subcortical brain structures. The clinical significance of these changes remains unknown. Given the small sample size, selective participation/loss of follow-up and potential residual confounding, these findings should be interpreted cautiously. Further research is required to replicate these results in larger cohorts before drawing firm clinical conclusions.
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Affiliation(s)
- Florian Rakers
- Hans Berger Department of NeurologyJena University HospitalJenaGermany
| | | | | | - Steffen Kluckow
- Hans Berger Department of NeurologyJena University HospitalJenaGermany
| | - Isabel Muth
- Department of ObstetricsJena University HospitalJenaGermany
| | - Dirk Hoyer
- Hans Berger Department of NeurologyJena University HospitalJenaGermany
| | - Sven Rupprecht
- Hans Berger Department of NeurologyJena University HospitalJenaGermany
| | - Torsten Schultze
- Hans Berger Department of NeurologyJena University HospitalJenaGermany
| | - Karin Schiecke
- Institute of Medical Statistics, Computer and Data SciencesJena University HospitalJenaGermany
| | - Carolin Ligges
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and PsychotherapyJena University HospitalJenaGermany
| | - Matthias Schwab
- Hans Berger Department of NeurologyJena University HospitalJenaGermany
| | - Heike Hoyer
- Institute of Medical Statistics, Computer and Data SciencesJena University HospitalJenaGermany
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Walters AGB, Gamble GD, Crowther CA, Dalziel SR, Eagleton CL, McKinlay CJD, Milne BJ, Harding JE. Cardiovascular outcomes 50 years after antenatal exposure to betamethasone: Follow-up of a randomised double-blind, placebo-controlled trial. PLoS Med 2024; 21:e1004378. [PMID: 38557442 PMCID: PMC11018286 DOI: 10.1371/journal.pmed.1004378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 04/15/2024] [Accepted: 03/18/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Antenatal corticosteroids for women at risk of preterm birth reduce neonatal morbidity and mortality, but there is limited evidence regarding their effects on long-term health. This study assessed cardiovascular outcomes at 50 years after antenatal exposure to corticosteroids. METHODS AND FINDINGS We assessed the adult offspring of women who participated in the first randomised, double-blind, placebo-controlled trial of antenatal betamethasone for the prevention of neonatal respiratory distress syndrome (RDS) (1969 to 1974). The first 717 mothers received 2 intramuscular injections of 12 mg betamethasone or placebo 24 h apart and the subsequent 398 received 2 injections of 24 mg betamethasone or equivalent volume of placebo. Follow-up included a health questionnaire and consent to access administrative data sources. The co-primary outcomes were the prevalence of cardiovascular risk factors (any of hypertension, hyperlipidaemia, diabetes mellitus, gestational diabetes mellitus, or prediabetes) and age at first major adverse cardiovascular event (MACE) (cardiovascular death, myocardial infarction, coronary revascularisation, stroke, admission for peripheral vascular disease, and admission for heart failure). Analyses were adjusted for gestational age at entry, sex, and clustering. Of 1,218 infants born to 1,115 mothers, we followed up 424 (46% of survivors; 212 [50%] female) at mean (standard deviation) age 49.3 (1.0) years. There were no differences between those exposed to betamethasone or placebo for cardiovascular risk factors (159/229 [69.4%] versus 131/195 [67.2%]; adjusted relative risk 1.02, 95% confidence interval [CI] [0.89, 1.18;]; p = 0.735) or age at first MACE (adjusted hazard ratio 0.58, 95% CI [0.23, 1.49]; p = 0.261). There were also no differences in the components of these composite outcomes or in any of the other secondary outcomes. Key limitations were follow-up rate and lack of in-person assessments. CONCLUSIONS There is no evidence that antenatal corticosteroids increase the prevalence of cardiovascular risk factors or incidence of cardiovascular events up to 50 years of age. Established benefits of antenatal corticosteroids are not outweighed by an increase in adult cardiovascular disease.
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Affiliation(s)
| | - Greg D. Gamble
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | | | - Stuart R. Dalziel
- Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Carl L. Eagleton
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | | | - Barry J. Milne
- Centre of Methods and Policy Application in Social Sciences, University of Auckland, Auckland, New Zealand
| | - Jane E. Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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Franke N, Wouldes TA, Brown GTL, Ward K, Rogers J, Harding JE. Perspectives of adult offspring of participants recruited to a randomised trial in pregnancy: a qualitative study. Arch Dis Child 2024; 109:209-214. [PMID: 38041673 DOI: 10.1136/archdischild-2023-326017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/06/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Routinely assessed outcomes in paediatric health studies may not reflect families' priorities. Increasing our understanding of childhood experiences of research participation may contribute to improving the quality of consent and better align study aims with the concerns of relevant communities. OBJECTIVE To explore young adults' views on their participation in medical research during their childhood, specifically around the acceptability of consent and their priorities regarding health, development and well-being as potential trial outcomes. METHODS A qualitative descriptive 20-year follow-up study of a medical trial which aimed to improve outcomes after preterm birth. Semistructured dialogue transcripts were analysed using inductive thematic analysis. SETTING AND PARTICIPANTS Seventeen young adults whose parents consented to their participation in a clinical trial when they were fetuses, and in follow-up studies as preschoolers and school-age children. RESULTS Overall, participants expressed comfort with their parents consenting to medical research on their behalf. However, autonomous child assent may not be attainable due to children's susceptibility to suggestions. Participants generally expressed satisfaction with the outcomes investigated in the follow-up studies, although some suggested other outcomes of interest such as mental health and learning disabilities. CONCLUSIONS Current consent procedures were deemed acceptable as parents hold responsibility for making decisions on behalf of their children, and their commitment to their child's well-being ensures that they make appropriate choices. The outcomes assessed in this trial and health and developmental outcomes in the follow-up assessments aligned well with outcomes of interest to the young adult participants.
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Affiliation(s)
- Nike Franke
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Trecia Ann Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | | | - Kim Ward
- Liggins Institute, The University of Auckland, Auckland, New Zealand
- School of Nursing, The University of Auckland, Auckland, New Zealand
| | - Jenny Rogers
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
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Daskalakis G, Pergialiotis V, Domellöf M, Ehrhardt H, Di Renzo GC, Koç E, Malamitsi-Puchner A, Kacerovsky M, Modi N, Shennan A, Ayres-de-Campos D, Gliozheni E, Rull K, Braun T, Beke A, Kosińska-Kaczyńska K, Areia AL, Vladareanu S, Sršen TP, Schmitz T, Jacobsson B. European guidelines on perinatal care: corticosteroids for women at risk of preterm birth. J Matern Fetal Neonatal Med 2023; 36:2160628. [PMID: 36689999 DOI: 10.1080/14767058.2022.2160628] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
of recommendationsCorticosteroids should be administered to women at a gestational age between 24+0 and 33+6 weeks, when preterm birth is anticipated in the next seven days, as these have been consistently shown to reduce neonatal mortality and morbidity. (Strong-quality evidence; strong recommendation). In selected cases, extension of this period up to 34+6 weeks may be considered (Expert opinion). Optimal benefits are found in infants delivered within 7 days of corticosteroid administration. Even a single-dose administration should be given to women with imminent preterm birth, as this is likely to improve neurodevelopmental outcome (Moderate-quality evidence; conditional recommendation).Either betamethasone (12 mg administered intramuscularly twice, 24-hours apart) or dexamethasone (6 mg administered intramuscularly in four doses, 12-hours apart, or 12 mg administered intramuscularly twice, 24-hours apart), may be used (Moderate-quality evidence; Strong recommendation). Administration of two "all" doses is named a "course of corticosteroids".Administration between 22+0 and 23+6 weeks should be considered when preterm birth is anticipated in the next seven days and active newborn life-support is indicated, taking into account parental wishes. Clear survival benefit has been observed in these cases, but the impact on short-term neurological and respiratory function, as well as long-term neurodevelopmental outcome is still unclear (Low/moderate-quality evidence; Weak recommendation).Administration between 34 + 0 and 34 + 6 weeks should only be offered to a few selected cases (Expert opinion). Administration between 35+0 and 36+6 weeks should be restricted to prospective randomized trials. Current evidence suggests that although corticosteroids reduce the incidence of transient tachypnea of the newborn, they do not affect the incidence of respiratory distress syndrome, and they increase neonatal hypoglycemia. Long-term safety data are lacking (Moderate quality evidence; Conditional recommendation).Administration in pregnancies beyond 37+0 weeks is not indicated, even for scheduled cesarean delivery, as current evidence does not suggest benefit and the long-term effects remain unknown (Low-quality evidence; Conditional recommendation).Administration should be given in twin pregnancies, with the same indication and doses as for singletons. However, existing evidence suggests that it should be reserved for pregnancies at high-risk of delivering within a 7-day interval (Low-quality evidence; Conditional recommendation). Maternal diabetes mellitus is not a contraindication to the use of antenatal corticosteroids (Moderate quality evidence; Strong recommendation).A single repeat course of corticosteroids can be considered in pregnancies at less than 34+0 weeks gestation, if the previous course was completed more than seven days earlier, and there is a renewed risk of imminent delivery (Low-quality evidence; Conditional recommendation).
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Affiliation(s)
- George Daskalakis
- 1st department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Pergialiotis
- 1st department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Harald Ehrhardt
- Department of General Pediatrics and Neonatology, Justus-Liebig-University and Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany.,German Lung Research Center (DZL), Giessen, Germany
| | - Gian Carlo Di Renzo
- Center for Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy.,PREIS International and European School of Perinatal, Neonatal and Reproductive Medicine, Florence, Italy.,Department of Obstetrics and Gynecology, I.M. Sechenov First State University of Moscow, Moscow, Russia
| | - Esin Koç
- Department of Neonatology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Ariadne Malamitsi-Puchner
- Neonatal Intensive Care Unit, 3rd Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Marian Kacerovsky
- Department of Obstetrics and Gynecology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Králové, Hradec Kralove, Czech Republic
| | - Neena Modi
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK.,Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Andrew Shennan
- Department of Women and Children's Health, King's College London, London, UK
| | - Diogo Ayres-de-Campos
- Medical School, Santa Maria University Hospital, Lisbon, Portugal.,European Board and College of Obstetrics and Gynaecology, Brussels, Belgium
| | - Elko Gliozheni
- Department of Obstetrics and Gynaecology, Maternity Koco Gliozheni Hospital, Tirana, Albania
| | - Kristiina Rull
- Women's Clinic of Tartu University Hospital, Tartu, Estonia.,Department of Obstetrics and Gynaecology, University of Tartu, Tartu Estonia.,Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Thorsten Braun
- Department of Obstetrics and Division of 'Experimental Obstetrics', Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Artur Beke
- Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Katarzyna Kosińska-Kaczyńska
- Department of Obstetrics, Perinatology and Neonatology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Ana Luisa Areia
- Obstetrics Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine; Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Centre of Investigation in Environment, Genetics and Oncobiology (CIMAGO), Coimbra, Portugal
| | - Simona Vladareanu
- Neonatology Clinic, Department of Obstetrics and Gynecology, Faculty of General Medicine, Elias University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Tanja Premru Sršen
- Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Thomas Schmitz
- Department of Obstetrics and Gynecology, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Service de gynécologie-obstétrique, hôpital Robert-Debré, Université Paris Cité, Paris, France
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Genetics and Bioinformatics, Domain of Health Data and Digitalization, Institute of Public Health, Oslo, Norway
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Wu T, Zhou K, Hua Y, Zhang W, Li Y. The molecular mechanisms in prenatal drug exposure-induced fetal programmed adult cardiovascular disease. Front Pharmacol 2023; 14:1164487. [PMID: 37153765 PMCID: PMC10157035 DOI: 10.3389/fphar.2023.1164487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 04/03/2023] [Indexed: 05/10/2023] Open
Abstract
The "developmental origins of health and disease" (DOHaD) hypothesis posits that early-life environmental exposures have a lasting impact on individual's health and permanently shape growth, structure, and metabolism. This reprogramming, which results from fetal stress, is believed to contribute to the development of adulthood cardiovascular diseases such as hypertension, coronary artery disease, heart failure, and increased susceptibility to ischemic injuries. Recent studies have shown that prenatal exposure to drugs, such as glucocorticoids, antibiotics, antidepressants, antiepileptics, and other toxins, increases the risk of adult-onset cardiovascular diseases. In addition, observational and animal experimental studies have demonstrated the association between prenatal drug exposure and the programming of cardiovascular disease in the offspring. The molecular mechanisms underlying these effects are still being explored but are thought to involve metabolism dysregulation. This review summarizes the current evidence on the relationship between prenatal drug exposure and the risk of adult cardiovascular disorders. Additionally, we present the latest insights into the molecular mechanisms that lead to programmed cardiovascular phenotypes after prenatal drug exposure.
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Affiliation(s)
- Ting Wu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, China
- Department of Ultrasonic Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Kaiyu Zhou
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, China
- Department of Ultrasonic Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yimin Hua
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, China
- Department of Ultrasonic Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Wen Zhang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, China
- Department of Ultrasonic Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wen Zhang, ; Yifei Li,
| | - Yifei Li
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wen Zhang, ; Yifei Li,
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Harding JE, Rajay AB, Alsweiler JM, Brown G, Crowther CA, Franke N, Gamble G, McKinlay C, Milne B, Rogers J, Wouldes T. Different Approaches to requesting Consent for Routine data linkage in Neonatal follow-up (ACORN): protocol for a 2×2 factorial randomised trial. BMJ Open 2022; 12:e060476. [PMID: 35831046 PMCID: PMC9280877 DOI: 10.1136/bmjopen-2021-060476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Routinely collected data can be linked to research data to create a rich dataset and inform practice. However, consent is normally required to link identifiable data. Reported rates of consent to data linkage for children ranged from 21% to 96%, but no studies have investigated different approaches to seeking consent for data linkage for school-age children. METHODS AND ANALYSIS The Approaches to Consent for Routine Data Linkage in Neonatal Follow-up (ACORN) trial is a 2×2 factorial randomised trial to assess whether, for children who participated in neonatal randomised trials (pre-hypoglycaemia Prevention with Oral Dextrose Gel (hPOD), hPOD and The Impact of Protein Intravenous Nutrition on Development in Extremely Low Birth Weight Babies (ProVIDe)) and are approached to participate in an in-person assessment at 6-7 years of age, parental consent to data linkage is higher if consent is sought (1) after the in-person assessment (delayed) or concurrently and (2) for health and education data combined or separately. The primary outcomes will be rates of consent to linkage of (1) either health or education data and (2) both health and education data. A pilot study indicates the potentially available cohort size of 2110 (80% follow-up of the neonatal trial cohorts) would be adequate to detect an absolute difference of 6%-5%-4% from a baseline consent rate of 70%-85%-90%, respectively (2-tailed alpha 0.05, 90% power). With at least 1136 participants, the ACORN trial would have 90% power to detect an absolute difference of 5% in the primary outcome for each factor, assuming a consent rate of 90% in the control groups and alpha 0.05. Data are categorical and will be presented as number and per cent. The effects of factors will be tested using generalised linear models and presented as ORs and 95% CIs. ETHICS AND DISSEMINATION Ethics approval by the New Zealand Health and Disability Ethics Committee (19/STH/202). Dissemination will be via peer-reviewed publications, scientific meetings, educational sessions and public fora. TRIAL REGISTRATION NUMBER ACTRN12621000571875 (Australian New Zealand Clinical Trials Registry).
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Affiliation(s)
- Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | | | - Jane Marie Alsweiler
- Department of Paediatrics Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Gavin Brown
- Faculty of Education and Social Work, The University of Auckland, Auckland, New Zealand
| | | | - Nike Franke
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Greg Gamble
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Christopher McKinlay
- Liggins Institute, The University of Auckland, Auckland, New Zealand
- Department of Paediatrics Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Barry Milne
- Centre of Methods and Policy Application in the Social Sciences, The University of Auckland, Auckland, New Zealand
| | - Jenny Rogers
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Trecia Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
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Karlsson L, Wallensteen L, Nordenström A, Krmar RT, Lajic S. Ambulatory Blood Pressure Monitoring in Children and Adults Prenatally Exposed to Dexamethasone Treatment. J Clin Endocrinol Metab 2022; 107:e2481-e2487. [PMID: 35148399 PMCID: PMC9113802 DOI: 10.1210/clinem/dgac081] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The clinical use of dexamethasone (DEX) prenatally to reduce virilization of external genitalia in female fetuses with congenital adrenal hyperplasia (CAH) is efficient but still controversial. It remains challenging to prevent the excessive exposure of DEX in unborn healthy babies during the first trimester of pregnancy. OBJECTIVE Since endogenous glucocorticoids contribute to the maintenance of blood pressure (BP) and since events during fetal life may program the fetus and affect future metabolic health, the aim of this study was to analyze ambulatory BP measurements in CAH-unaffected children and adults that were prenatally exposed to DEX treatment. METHODS Ambulatory BP measurements were analyzed in 33 (16 female) DEX-treated participants aged 5.1 to 26.3 years (19 participants aged ≤ 18 years) and in 54 (28 female) age- and sex-matched apparently healthy controls aged 5.5 to 25.3 years (27 participants aged ≤ 18 years) with ambulatory normotension. RESULTS Participants' age, height, weight, and body mass index were similar between the DEX-treated group and the control group. Heart rate, 24-hour BP, pulse pressure, and nighttime dipping did not statistically significantly differ between DEX-treated participants and controls. CONCLUSION Our study suggests that prenatal DEX treatment in CAH-unaffected children and adults does not appear to adversely affect ambulatory BP later in life. Our observations need to be confirmed in larger studies.
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Affiliation(s)
- Leif Karlsson
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Lena Wallensteen
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Rafael T Krmar
- Department of Physiology and Pharmacology, Biomedicum 5B, Karolinska Institutet, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
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Walters A, McKinlay C, Middleton P, Harding JE, Crowther CA. Repeat doses of prenatal corticosteroids for women at risk of preterm birth for improving neonatal health outcomes. Cochrane Database Syst Rev 2022; 4:CD003935. [PMID: 35377461 PMCID: PMC8978608 DOI: 10.1002/14651858.cd003935.pub5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Infants born preterm (before 37 weeks' gestation) are at risk of respiratory distress syndrome (RDS) and need for respiratory support due to lung immaturity. One course of prenatal corticosteroids, administered to women at risk of preterm birth, reduces the risk of respiratory morbidity and improves survival of their infants, but these benefits do not extend beyond seven days. Repeat doses of prenatal corticosteroids have been used for women at ongoing risk of preterm birth more than seven days after their first course of corticosteroids, with improvements in respiratory outcomes, but uncertainty remains about any long-term benefits and harms. This is an update of a review last published in 2015. OBJECTIVES To assess the effectiveness and safety, using the best available evidence, of a repeat dose(s) of prenatal corticosteroids, given to women who remain at risk of preterm birth seven or more days after an initial course of prenatal corticosteroids with the primary aim of reducing fetal and neonatal mortality and morbidity. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials, including cluster-randomised trials, of women who had already received one course of corticosteroids seven or more days previously and were still at risk of preterm birth, randomised to further dose(s) or no repeat doses, with or without placebo. Quasi-randomised trials were excluded. Abstracts were accepted if they met specific criteria. All trials had to meet criteria for trustworthiness, including a search of the Retraction Watch database for retractions or expressions of concern about the trials or their publications. DATA COLLECTION AND ANALYSIS We used standard Cochrane Pregnancy and Childbirth methods. Two review authors independently selected trials, extracted data, and assessed trial quality and scientific integrity. We chose primary outcomes based on clinical importance as measures of effectiveness and safety, including serious outcomes, for the women and their fetuses/infants, infants in early childhood (age two to less than five years), the infant in mid- to late childhood (age five to less than 18 years) and the infant as an adult. We assessed risk of bias at the outcome level using the RoB 2 tool and assessed certainty of evidence using GRADE. MAIN RESULTS We included 11 trials (4895 women and 5975 babies). High-certainty evidence from these trials indicated that treatment of women who remain at risk of preterm birth seven or more days after an initial course of prenatal corticosteroids with repeat dose(s) of corticosteroids, compared with no repeat corticosteroid treatment, reduced the risk of their infants experiencing the primary infant outcome of RDS (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.90; 3540 babies; number needed to treat for an additional beneficial outcome (NNTB) 16, 95% CI 11 to 29) and had little or no effect on chronic lung disease (RR 1.00, 95% CI 0.83 to 1.22; 5661 babies). Moderate-certainty evidence indicated that the composite of serious infant outcomes was probably reduced with repeat dose(s) of corticosteroids (RR 0.88, 95% CI 0.80 to 0.97; 9 trials, 5736 babies; NNTB 39, 95% CI 24 to 158), as was severe lung disease (RR 0.83, 95% CI 0.72 to 0.97; NNTB 45, 95% CI 27 to 256; 4955 babies). Moderate-certainty evidence could not exclude benefit or harm for fetal or neonatal or infant death less than one year of age (RR 0.95, 95% CI 0.73 to 1.24; 5849 babies), severe intraventricular haemorrhage (RR 1.13, 95% CI 0.69 to 1.86; 5066 babies) and necrotising enterocolitis (RR 0.84, 95% CI 0.59 to 1.22; 5736 babies). In women, moderate-certainty evidence found little or no effect on the likelihood of a caesarean birth (RR 1.03, 95% CI 0.98 to 1.09; 4266 mothers). Benefit or harm could not be excluded for maternal death (RR 0.32, 95% 0.01 to 7.81; 437 women) and maternal sepsis (RR 1.13, 95% CI 0.93 to 1.39; 4666 mothers). The evidence was unclear for risk of adverse effects and discontinuation of therapy due to maternal adverse effects. No trials reported breastfeeding status at hospital discharge or risk of admission to the intensive care unit. At early childhood follow-up, moderate- to high-certainty evidence identified little or no effect of exposure to repeat prenatal corticosteroids compared with no repeat corticosteroids for primary outcomes relating to neurodevelopment (neurodevelopmental impairment: RR 0.97, 95% CI 0.85 to 1.10; 3616 children), survival without neurodevelopmental impairment (RR 1.01, 95% CI 0.98 to 1.04; 3845 children) and survival without major neurodevelopmental impairment (RR 1.02, 95% CI 0.98 to 1.05; 1816 children). An increase or decrease in the risk of death since randomisation could not be excluded (RR 1.06, 95% CI 0.81 to 1.40; 5 trials, 4565 babies randomised). At mid-childhood follow-up, moderate-certainty evidence identified little or no effect of exposure to repeat prenatal corticosteroids compared with no repeat corticosteroids on survival free of neurocognitive impairment (RR 1.01, 95% CI 0.95 to 1.08; 963 children) or survival free of major neurocognitive impairment (RR 1.00, 95% CI 0.97 to 1.04; 2682 children). Benefit or harm could not be excluded for death since randomisation (RR 0.93, 95% CI 0.69 to 1.26; 2874 babies randomised) and any neurocognitive impairment (RR 0.96, 95% CI 0.72 to 1.29; 897 children). No trials reported data for follow-up into adolescence or adulthood. Risk of bias across outcomes was generally low although there were some concerns of bias. For childhood follow-up, most outcomes had some concerns of risk of bias due to missing data from loss to follow-up. AUTHORS' CONCLUSIONS The short-term benefits for babies included less respiratory distress and fewer serious health problems in the first few weeks after birth with repeat dose(s) of prenatal corticosteroids for women still at risk of preterm birth seven days or more after an initial course. The current available evidence reassuringly shows no significant harm for the women or child in early and mid-childhood, although no benefit. Further research is needed on the long-term benefits and risks for the baby into adulthood.
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Affiliation(s)
- Anthony Walters
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | | | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
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9
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Alawadhi M, Mouihate A, Kilarkaje N, Al-Bader M. Progesterone partially recovers placental glucose transporters in dexamethasone-induced intrauterine growth restriction. Reprod Biomed Online 2022; 44:595-607. [PMID: 35232674 DOI: 10.1016/j.rbmo.2021.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/17/2021] [Accepted: 10/20/2021] [Indexed: 10/20/2022]
Abstract
RESEARCH QUESTION How does progesterone improve fetal outcome and change the expression of placental glucose transporters (GLUT) in dexamethasone-induced intrauterine growth restriction (IUGR)? DESIGN A total of 64 rats were divided randomly into four different treatment groups based on daily i.p. injections of either saline or dexamethasone in the presence or absence of progesterone. Injections started on the 15th day of gestation (15dg) and lasted until the day of sacrifice at 19dg or 21dg. Maternal plasma progesterone concentrations were measured by enzyme-linked immunosorbent assay. The gene and protein expression of placental GLUT1 and GLUT3 were evaluated in the placental labyrinth and basal zones by real-time polymerase chain reaction and Western blotting, respectively. The localization of GLUT1 and GLUT3 was evaluated by immunohistochemistry. RESULTS Dexamethasone induced significant decreases in maternal serum progesterone concentrations (P = 0.029) and placental (P < 0.001) and fetal body (P = 0.009) weights. Dexamethasone also reduced the expression of GLUT1 in the labyrinth zone (P = 0.028) and GLUT3 in both the labyrinth (P = 0.002) and basal zones (P = 0.026). Coadministration of dexamethasone and progesterone prevented the reduction in fetal body weight, placental weight and placental GLUT expression compared with that seen in dexamethasone-treated groups. CONCLUSION These results suggest that progesterone prevents the significant reduction in fetal and placental weights in dexamethasone-induced IUGR, possibly through improving the expression of placental GLUT.
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Affiliation(s)
- Mariam Alawadhi
- Department of Physiology, Faculty of Medicine, Kuwait University Safat PO Box 13060, Kuwait
| | - Abdeslam Mouihate
- Department of Physiology, Faculty of Medicine, Kuwait University Safat PO Box 13060, Kuwait
| | - Narayana Kilarkaje
- Department of Anatomy, Faculty of Medicine, Kuwait University Safat PO Box 13060, Kuwait
| | - Maie Al-Bader
- Department of Physiology, Faculty of Medicine, Kuwait University Safat PO Box 13060, Kuwait.
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Cardiac structure and function in very preterm-born adolescents compared to term-born controls: A longitudinal cohort study. Early Hum Dev 2021; 163:105505. [PMID: 34763163 DOI: 10.1016/j.earlhumdev.2021.105505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is emerging evidence of differences in cardiac structure and function in preterm-born adults and increased risk of heart failure. However, there is a paucity of data in populations who have been exposed to modern intensive care and the impact of perinatal factors is unclear. AIMS To compare echocardiographic measures of cardiac structure and function in a regional cohort of 17-year-olds born very preterm compared to term-born peers and the influence of perinatal factors. STUDY DESIGN Observational longitudinal cohort study. SUBJECTS A regional cohort of ninety-one 17-year-olds born at <32 weeks gestation compared to sixty-two term-born controls. OUTCOME MEASURES Echocardiographic measures of cardiac structure and function. RESULTS Left ventricular and right atrial volume and left ventricular mass, indexed to body surface area, were significantly smaller in preterm-born adolescents compared to term-born controls even when adjusted for sex. There were no between group differences in cardiac function. Within those born preterm we found a significant association between gestational age and birthweight z-score and measures of cardiac function at 17 years. Within the preterm group, those with a diagnosis of bronchopulmonary dysplasia had higher left ventricular posterior wall thickness, higher mitral deceleration time and lower left atrial area and tricuspid annular plane of systolic excursion. CONCLUSIONS Adolescents born very prematurely, who have received modern intensive care, have measurable differences in heart structure compared to their term-born peers but heart function is preserved. For those born preterm, gestational age, birthweight and bronchopulmonary dysplasia are associated with differences in cardiac function.
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11
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Antenatal Corticosteroids and Magnesium Sulfate for Improved Preterm Neonatal Outcomes: A Review of Guidelines. Obstet Gynecol Surv 2021; 75:298-307. [PMID: 32469415 DOI: 10.1097/ogx.0000000000000778] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Importance In cases of anticipated preterm delivery, corticosteroids for fetal lung maturation and magnesium sulfate for fetal neuroprotection may improve neonatal outcomes. Objective The aim of this study was to summarize and compare published guidelines from 4 leading medical societies on the administration of antenatal corticosteroids and magnesium sulfate. Evidence Acquisition A descriptive review of major national guidelines on corticosteroids and magnesium sulfate was conducted: National Institute for Health and Care Excellence on "Preterm labour and birth," World Health Organization on "WHO recommendations on interventions to improve preterm birth outcomes," American College of Obstetricians and Gynecologists on "Antenatal corticosteroid therapy for fetal maturation" and "Magnesium sulfate use in obstetrics," and Society of Obstetricians and Gynecologists of Canada on "Antenatal corticosteroid therapy for improving neonatal outcomes" and "Magnesium sulphate for fetal neuroprotection." Results A variation in the appropriate timing of administration exists, whereas repeated courses are not routinely recommended for corticosteroids or magnesium sulfate. In addition, the recommendations are the same for singleton and multiple gestations, and no specific recommendation exists according to maternal body mass index. Finally, a variation in guidelines regarding the administration of corticosteroids before cesarean delivery exists. Conclusion The adoption of an international consensus on corticosteroids and magnesium sulfate may increase their endorsement by health care professionals, leading to more favorable neonatal outcomes after preterm delivery.
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12
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Glycemic control following two regimens of antenatal corticosteroids in mild gestational diabetes: a randomized controlled trial. Arch Gynecol Obstet 2021; 304:345-353. [PMID: 33452923 DOI: 10.1007/s00404-020-05950-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To compare 3 consecutive days of hyperglycemic response following antenatal dexamethasone regimens of 12-mg or 6-mg doses 12 hourly in diet-controlled gestational diabetes. METHODS A randomized controlled trial was carried out in a university hospital in Malaysia. Women with lifestyle-controlled gestational diabetes scheduled to receive clinically indicated antenatal corticosteroids (dexamethasone) were randomized to 12-mg 12 hourly for one day (2 × 12-mg) or 6-mg 12-hourly for two days (4 × 6-mg). 6-point (pre and 2-h postprandial) daily self-monitoring of capillary blood sugar profile for up to 3 consecutive days was started after the first dexamethasone injection. Hyperglycemia is defined as blood glucose pre-meal ≥ 5.3 or 2 h postprandial ≥ 6.7 mmol/L. The primary outcome was a number of hyperglycemic episodes in Day-1 (first 6 BSP points). A sample size of 30 per group (N = 60) was planned. RESULTS Median [interquartile range] hyperglycemic episodes 4 [2.5-5] vs. 4 [3-5] p = 0.3 in the first day, 3 [2-4] vs. 1 [0-3] p = 0.01 on the second day, 0 [0-1] vs. 0 [0-1] p = 0.6 on the third day and over the entire 3 trial days 7 [6-9] vs. 6 [4-8] p = 0.17 for 6-mg vs. 12-mg arms, respectively. 2/30 (7%) in each arm received an anti-glycemic agent during the 3-day trial period (capillary glucose exceeded 11 mmol/L). Mean birth weight (2.89 vs. 2.49 kg p < 0.01) and gestational age at delivery (37.7 vs. 36.6 weeks p = 0.03) were higher and median delivery blood loss (300 vs. 400 ml p = 0.02) was lower in the 12-mg arm; all other secondary outcomes were not significantly different. CONCLUSION In gestational diabetes, 2 × 12-mg could be preferred over 4 × 6-mg dexamethasone as hyperglycemic episodes were fewer on Day-2, fewer injections were needed and the regimen was completed sooner. CLINICAL TRIAL REGISTRATION http://www.isrctn.com/ISRCTN16613220 .
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Wynne K, Rowe C, Delbridge M, Watkins B, Brown K, Addley J, Woods A, Murray H. Antenatal corticosteroid administration for foetal lung maturation. F1000Res 2020; 9. [PMID: 32269758 PMCID: PMC7111495 DOI: 10.12688/f1000research.20550.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2020] [Indexed: 01/27/2023] Open
Abstract
Antenatal corticosteroids are an essential component in the management of women at risk for preterm labour. They promote lung maturation and reduce the risk of other preterm neonatal complications. This narrative review discusses the contentious issues and controversies around the optimal use of antenatal corticosteroids and their consequences for both the mother and the neonate. The most recent evidence base is presented.
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Affiliation(s)
- Katie Wynne
- Department of Diabetes & Endocrinology, John Hunter Hospital, New Lambton Heights, NSW, 2305, Australia.,Mothers and Babies, Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Christopher Rowe
- Department of Diabetes & Endocrinology, John Hunter Hospital, New Lambton Heights, NSW, 2305, Australia.,Mothers and Babies, Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Matthew Delbridge
- School of Medicine and Public Health, University of New England, Armidale, NSW, 2351, Australia
| | - Brendan Watkins
- School of Medicine and Public Health, University of New England, Armidale, NSW, 2351, Australia
| | - Karina Brown
- School of Medicine and Public Health, University of New England, Armidale, NSW, 2351, Australia
| | - Jordan Addley
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Andrew Woods
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.,Department of Obstetrics, John Hunter Hospital, New Lambton Heights, NSW, 2305, Australia
| | - Henry Murray
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.,Department of Obstetrics, John Hunter Hospital, New Lambton Heights, NSW, 2305, Australia
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Thevathasan I, Said JM. Controversies in antenatal corticosteroid treatment. Prenat Diagn 2020; 40:1138-1149. [PMID: 32157719 DOI: 10.1002/pd.5664] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/17/2019] [Accepted: 12/08/2019] [Indexed: 12/17/2022]
Abstract
Antenatal corticosteroids are now established as one of the cornerstones of therapy in the prevention of neonatal morbidity and mortality prior to preterm birth. Although this practice is widely accepted, a significant number of controversies exist. This review explores the knowledge gaps regarding the use of antenatal corticosteroids in the preterm, late preterm and term populations. Furthermore, the role of antenatal corticosteroids in special populations, such as diabetes, multiple pregnancies and periviable gestations, where high-quality data from randomized controlled trials are lacking, is also considered.
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Affiliation(s)
- Iniyaval Thevathasan
- Maternal Fetal Medicine, Joan Kirner Women's & Children's Sunshine Hospital, Western Health, St Albans, Victoria, Australia
| | - Joanne M Said
- Maternal Fetal Medicine, Joan Kirner Women's & Children's Sunshine Hospital, Western Health, St Albans, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
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15
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Jobe AH. Antenatal Corticosteroids-A Concern for Lifelong Outcomes. J Pediatr 2020; 217:184-188. [PMID: 31606149 DOI: 10.1016/j.jpeds.2019.09.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/05/2019] [Accepted: 09/10/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Alan H Jobe
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH.
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16
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Effects of preterm birth induced with or without exogenous glucocorticoids on the ovine glucose-insulin axis. J Dev Orig Health Dis 2020; 12:58-70. [PMID: 31937391 DOI: 10.1017/s2040174419000916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Antenatal exogenous glucocorticoids (ANG) are standard management for women at risk of preterm birth but are reputed to impair glucose tolerance in preterm offspring. We compared lambs born preterm (137 days gestation) following labour induced with exogenous glucocorticoids (G-Prem, glucocorticoid-induced preterm group), or with a progesterone synthesis inhibitor (NG-Prem, non-glucocorticoid-induced preterm group), with term-born lambs (Term; 149 days). We assessed glucose tolerance, insulin secretion and sensitivity at 4 and 10 months n = 11-14/group) and pancreatic and hepatic gene and protein expression at 4 weeks post-term (4 weeks; n = 6/group) and 12 months (12 months; n = 12-13/group). NG-Prem had higher plasma glucose concentrations than G-Prem, but not Term, at 4 months (Mean[SEM] mM: NG-Prem = 4.1[0.1]; G-Prem = 3.4[0.1]; Term = 3.7[0.1]; p = 0.003) and 10 months (NG-Prem = 3.9[0.1]; G-Prem = 3.5[0.1]; Term = 3.7[0.1]; p = 0.01). Insulin sensitivity decreased from 4 to 10 months, in NG-Prem but not in Term (Mean[SEM] µmol·ml-1·kg-1·min-1·ng-1, 4 vs. 10 months: NG-Prem = 18.7[2.5] vs. 9.5[1.5], p < 0.01; Term: 12.1[2.8] vs. 10.4[1.5], p = 0.44). At 12 months, β-cell mass in NG-Prem was reduced by 30% vs. G-Prem (p < 0.01) and 75% vs. Term (p < 0.01) and was accompanied by an increased β-cell apoptosis: proliferation ratio at 12 months. At 12 months, pancreatic glucokinase, igf2 and insulin mRNA levels were reduced 21%-71% in NG-Prem vs. G-Prem and 42%-80% vs. Term. Hepatic glut2 mRNA levels in NG-Prem were 250% of those in G-Prem and Term. Thus, induction of preterm birth without exogenous glucocorticoids more adversely affected pancreas and liver than induction with exogenous glucocorticoids. These findings do not support that ANG lead to long-term adverse metabolic effects, but support an effect of preterm birth itself.
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Skoll A, Boutin A, Bujold E, Burrows J, Crane J, Geary M, Jain V, Lacaze-Masmonteil T, Liauw J, Mundle W, Murphy K, Wong S, Joseph KS. No. 364-Antenatal Corticosteroid Therapy for Improving Neonatal Outcomes. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:1219-1239. [PMID: 30268316 DOI: 10.1016/j.jogc.2018.04.018] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To assess the benefits and risks of antenatal corticosteroid therapy for women at risk of preterm birth or undergoing pre-labour Caesarean section at term and to make recommendations for improving neonatal and long-term outcomes. OPTIONS To administer or withhold antenatal corticosteroid therapy for women at high risk of preterm birth or women undergoing pre-labour Caesarean section at term. OUTCOMES Perinatal morbidity, including respiratory distress syndrome, intraventricular hemorrhage, bronchopulmonary dysplasia, infection, hypoglycemia, somatic and brain growth, and neurodevelopment; perinatal mortality; and maternal morbidity, including infection and adrenal suppression. INTENDED USERS Maternity care providers including midwives, family physicians, and obstetricians. TARGET POPULATION Pregnant women. EVIDENCE Medline, PubMed, Embase, and the Cochrane Library were searched from inception to September 2017. Medical Subject Heading (MeSH) terms and key words related to pregnancy, prematurity, corticosteroids, and perinatal and neonatal mortality and morbidity were used. Statements from professional organizations including that of the National Institutes of Health, the American College of Obstetricians and Gynecologists, the Society for Maternal Fetal Medicine, the Royal College of Obstetricians and Gynaecologists, and the Canadian Pediatric Society were reviewed for additional references. Randomized controlled trials conducted in pregnant women evaluating antenatal corticosteroid therapy and previous systematic reviews on the topic were eligible. Evidence from systematic reviews of non-experimental (cohort) studies was also eligible. VALIDATION METHODS This Committee Opinion has been reviewed and approved by the Maternal-Fetal Medicine Committee of the SOGC and approved by SOGC Council. BENEFITS, HARMS, AND/OR COSTS A course of antenatal corticosteroid therapy administered within 7 days of delivery significantly reduces perinatal morbidity/mortality associated with preterm birth between 24 + 0 and 34 + 6 weeks gestation. When antenatal corticosteroid therapy is given more than 7 days prior to delivery or after 34 + 6 weeks gestation, the adverse effects may outweigh the benefits. Evidence on long-term effects is scarce, and potential neurodevelopment harms are unquantified in cases of late preterm, term, and repeated exposure to antenatal corticosteroid therapy. GUIDELINE UPDATE Evidence will be reviewed 5 years after publication to evaluate the need for a complete or partial update of the guideline. If important evidence is published prior to the 5-year time point, an update will be issued to reflect new knowledge and recommendations. SPONSORS The guideline was developed with resources provided by the Society of Obstetricians and Gynaecologists of Canada with support from the Canadian Institutes of Health Research (APR-126338). SUMMARY STATEMENTS RECOMMENDATIONS: Gestational Age Considerations Agents, Dosage, Regimen, and Target Timing Subpopulations and Special Consideration.
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18
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Cardiovascular effects of prenatal stress-Are there implications for cerebrovascular, cognitive and mental health outcome? Neurosci Biobehav Rev 2019; 117:78-97. [PMID: 31708264 DOI: 10.1016/j.neubiorev.2018.05.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/21/2018] [Accepted: 05/22/2018] [Indexed: 01/17/2023]
Abstract
Prenatal stress programs offspring cognitive and mental health outcome. We reviewed whether prenatal stress also programs cardiovascular dysfunction which potentially modulates cerebrovascular, cognitive and mental health disorders. We focused on maternal stress and prenatal glucocorticoid (GC) exposure which have different programming effects. While maternal stress induced cortisol is mostly inactivated by the placenta, synthetic GCs freely cross the placenta and have different receptor-binding characteristics. Maternal stress, particularly anxiety, but not GC exposure, has adverse effects on maternal-fetal circulation throughout pregnancy, probably by co-activation of the maternal sympathetic nervous system, and by raising fetal catecholamines. Both effects may impair neurodevelopment. Experimental data also suggest that severe maternal stress and GC exposure during early and mid-gestation may increase the risk for cardiovascular disorders. Human data are scarce and especially lacking for older age. Programming mechanisms include aberrations in cardiac and kidney development, and functional changes in the renin-angiotensin-aldosterone-system, stress axis and peripheral and coronary vasculature. Adequate experimental or human studies examining the consequences for cerebrovascular, cognitive and mental disorders are unavailable.
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19
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Antolic A, Richards EM, Wood CE, Keller-Wood M. A Transcriptomic Model of Postnatal Cardiac Effects of Prenatal Maternal Cortisol Excess in Sheep. Front Physiol 2019; 10:816. [PMID: 31333485 PMCID: PMC6616147 DOI: 10.3389/fphys.2019.00816] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/11/2019] [Indexed: 12/25/2022] Open
Abstract
In utero treatment with glucocorticoids have been suggested to reprogram postnatal cardiovascular function and stress responsiveness. However, little is known about the effects of prenatal exposure to the natural corticosteroid, cortisol, on postnatal cardiovascular system or metabolism. We have demonstrated an increased incidence of stillbirth in sheep pregnancies in which there is mild maternal hypercortisolemia caused by infusion of 1 mg/kg/d cortisol. In order to model corticosteroid effects in the neonate, we created a second model in which cortisol was infused for 12 h per day for a daily infusion of 0.5 mg/kg/d. In this model we had previously found that neonatal plasma glucose was increased and plasma insulin was decreased compared to those in the control group, and that neonatal ponderal index and kidney weight were reduced and left ventricular wall thickness was increased in the 2 week old lamb. In this study, we have used transcriptomic modeling to better understand the programming effect of this maternal hypercortisolemia in these hearts. This is a time when both terminal differentiation and a shift in the metabolism of the heart from carbohydrates to lipid oxidation are thought to be complete. The transcriptomic model indicates suppression of genes in pathways for fatty acid and ketone production and upregulation of genes in pathways for angiogenesis in the epicardial adipose fat (EAT). The transcriptomic model indicates that RNA related pathways are overrepresented by downregulated genes, but ubiquitin-mediated proteolysis and protein targeting to the mitochondria are overrepresented by upregulated genes in the intraventricular septum (IVS) and left ventricle (LV). In IVS the AMPK pathway and adipocytokine signaling pathways were also modeled based on overrepresentation by downregulated genes. Peroxisomal activity is modeled as increased in EAT, but decreased in LV and IVS. Our results suggest that pathways for lipids as well as cell proliferation and cardiac remodeling have altered activity postnatally after the in utero cortisol exposure. Together, this model is consistent with the observed increase in cardiac wall thickness at necropsy and altered glucose metabolism observed in vivo, and predicts that in utero exposure to excess maternal cortisol will cause postnatal cardiac hypertrophy and altered responses to oxidative stress.
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Affiliation(s)
- Andrew Antolic
- Department of Pharmacodynamics, University of Florida, Gainesville, FL, United States
| | - Elaine M Richards
- Department of Pharmacodynamics, University of Florida, Gainesville, FL, United States.,Department of Physiology and Functional Genomics, University of Florida, Gainesville, FL, United States
| | - Charles E Wood
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, FL, United States
| | - Maureen Keller-Wood
- Department of Pharmacodynamics, University of Florida, Gainesville, FL, United States
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McKinlay CJ, Manley BJ. Antenatal and postnatal corticosteroids: A swinging pendulum. Semin Fetal Neonatal Med 2019; 24:167-169. [PMID: 31147160 DOI: 10.1016/j.siny.2019.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Christopher Jd McKinlay
- Liggins Institute, University of Auckland, Auckland, New Zealand; Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand.
| | - Brett J Manley
- Neonatal Services and Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
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21
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Schmitz T, Alberti C, Ursino M, Baud O, Aupiais C. Full versus half dose of antenatal betamethasone to prevent severe neonatal respiratory distress syndrome associated with preterm birth: study protocol for a randomised, multicenter, double blind, placebo-controlled, non-inferiority trial (BETADOSE). BMC Pregnancy Childbirth 2019; 19:67. [PMID: 30755164 PMCID: PMC6373166 DOI: 10.1186/s12884-019-2206-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although antenatal betamethasone is recommended worldwide for women at risk of preterm delivery, concerns persist regarding the long-term effects associated with this treatment. Indeed, adverse events, mainly dose-related, have been reported. The current recommended dose of antenatal betamethasone directly derives from sheep experiments performed in the late 60's and has not been challenged in 45 years. Therefore, randomized trials evaluating novel dose regimens are urgently needed. METHODS A randomised, double blind, placebo-controlled, non-inferiority trial will be performed in 37 French level 3 maternity units. Women with a singleton pregnancy at risk of preterm delivery before 32 weeks of gestation having already received a first 11.4 mg injection of betamethasone will be randomised to receive either a second injection of 11.4 mg betamethasone (full dose arm) or placebo (half dose arm) administered intramuscularly 24 h after the first injection. The primary binary outcome will be the occurrence of severe respiratory distress syndrome (RDS), defined as the need for exogenous intra-tracheal surfactant in the first 48 h of life. Considering that 20% of the pregnant women receiving the full dose regimen would have a neonate with severe RDS, 1571 patients in each treatment group are required to show that the half dose regimen is not inferior to the full dose, that is the difference in severe RDS rate do not exceed 4% (corresponding to a Relative Risk of 20%), with a 1-sided 2.5% type-1 error and a 80% power. Interim analyses will be done after every 300 neonates who reach the primary outcome on the basis of intention-to-treat, using a group-sequential non-inferiority design. DISCUSSION If the 50% reduced antenatal betamethasone dose is shown to be non-inferior to the full dose to prevent severe RDS associated with preterm birth, then it should be used consistently in women at risk of preterm delivery and would be of great importance to their children. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT 02897076 (registration date 09/13/2016).
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Affiliation(s)
- Thomas Schmitz
- Service de Gynécologie Obstétrique, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, 48 boulevard Sérurier, 75019 Paris, France
- Université Paris Diderot, Site Villemin, 10 avenue de Verdun, 75010 Paris, France
- Inserm, U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, 53 avenue de l’observatoire, 75014 Paris, France
| | - Corinne Alberti
- Université Paris Diderot, Site Villemin, 10 avenue de Verdun, 75010 Paris, France
- Unité d’épidémiologie clinique, CIC-EC 1426, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France
- Inserm, U1123, ECEVE, 10 avenue de Verdun, 75010 Paris, France
| | - Moreno Ursino
- Inserm, U1138, Equipe 22, Sorbonne Université, Université Paris Descartes, 75006 Paris, France
| | - Olivier Baud
- Service de néonatalogie, Hôpitaux universitaires de Genève, 32 boulevard de la Cluse, 1205 Genève, Switzerland
- Inserm, U1141, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France
| | - Camille Aupiais
- Université Paris Diderot, Site Villemin, 10 avenue de Verdun, 75010 Paris, France
- Inserm, U1123, ECEVE, 10 avenue de Verdun, 75010 Paris, France
- Inserm, U1138, Equipe 22, Sorbonne Université, Université Paris Descartes, 75006 Paris, France
- Service d’Accueil des Urgences Pédiatriques, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France
| | - for the BETADOSE study group and the GROG (Groupe de Recherche en Gynécologie Obstétrique)
- Service de Gynécologie Obstétrique, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, 48 boulevard Sérurier, 75019 Paris, France
- Université Paris Diderot, Site Villemin, 10 avenue de Verdun, 75010 Paris, France
- Inserm, U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, 53 avenue de l’observatoire, 75014 Paris, France
- Unité d’épidémiologie clinique, CIC-EC 1426, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France
- Inserm, U1123, ECEVE, 10 avenue de Verdun, 75010 Paris, France
- Inserm, U1138, Equipe 22, Sorbonne Université, Université Paris Descartes, 75006 Paris, France
- Service de néonatalogie, Hôpitaux universitaires de Genève, 32 boulevard de la Cluse, 1205 Genève, Switzerland
- Inserm, U1141, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France
- Service d’Accueil des Urgences Pédiatriques, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France
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Cartwright RD, Crowther CA, Anderson PJ, Harding JE, Doyle LW, McKinlay CJD. Association of Fetal Growth Restriction With Neurocognitive Function After Repeated Antenatal Betamethasone Treatment vs Placebo: Secondary Analysis of the ACTORDS Randomized Clinical Trial. JAMA Netw Open 2019; 2:e187636. [PMID: 30707225 PMCID: PMC6484607 DOI: 10.1001/jamanetworkopen.2018.7636] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 12/10/2018] [Indexed: 11/24/2022] Open
Abstract
Importance Repeated doses of antenatal betamethasone are recommended for women at less than 32 weeks' gestation with ongoing risk of preterm birth. However, concern that this therapy may be associated with adverse neurocognitive effects in children with fetal growth restriction (FGR) remains. Objective To determine the influence of FGR on the effects of repeated doses of antenatal betamethasone on neurocognitive function in midchildhood. Design, Setting, and Participants This preplanned secondary analysis of data from the multicenter Australasian Collaborative Trial of Repeat Doses of Corticosteroids (ACTORDS) included women at less than 32 weeks' gestation with ongoing risk of preterm birth (<32 weeks) at least 7 days after an initial course of antenatal corticosteroids who were treated at 23 hospitals across Australia and New Zealand from April 1, 1998, through July 20, 2004. Participants were randomized to intramuscular betamethasone or saline placebo; treatment could be repeated weekly if the woman was judged to be at continued risk of preterm birth. All surviving children were invited to a midchildhood outcome study. Data for this study were collected from October 27, 2006, through March 18, 2011, and analyzed from June 1 through 30, 2018. Interventions At 6 to 8 years of corrected age, children were assessed by a pediatrician and psychologist for neurosensory and cognitive function, and parents completed standardized questionnaires. Main Outcomes and Measures The prespecified primary outcomes were survival free of any disability and death or survival with moderate to severe disability. Results Of 1059 eligible children, 988 (55.0% male; mean [SD] age at follow-up, 7.5 [1.1] years) were assessed at midchildhood. The FGR rate was 139 of 493 children (28.2%) in the repeated betamethasone treatment group and 122 of 495 (24.6%) in the placebo group (P = .20). Primary outcome rates were similar between treatment groups for the FGR and non-FGR subgroups, with no evidence of an interaction effect for survival free of any disability (FGR group, 108 of 144 [75.0%] for repeated betamethasone treatment vs 91 of 126 [72.2%] for placebo groups [odds ratio [OR], 1.1; 95% CI, 0.6-1.9]; non-FGR group, 267 of 335 [79.7%] for repeated betamethasone vs 283 of 358 [79.0%] for placebo groups [OR, 1.0; 95% CI, 0.7-1.5]; P = .77) and death or moderate to severe disability (FGR group, 21 of 144 [14.6%] for repeated betamethasone treatment vs 20 of 126 [15.9%] for placebo groups [OR, 0.9; 95% CI, 0.4-1.9]; non-FGR group, 29 of 335 [8.6%] for repeated betamethasone vs 36 of 358 [10.0%] for placebo [OR, 0.8; 95% CI, 0.4-1.3]; P = .84). Conclusions and Relevance In this study, repeated antenatal betamethasone treatment compared with placebo was not associated with adverse effects on neurocognitive function at 6 to 8 years of age, even in the presence of FGR. Physicians should use repeated doses of antenatal corticosteroids when indicated before preterm birth, regardless of FGR, in view of the associated neonatal benefits and absence of later adverse effects. Trial Registration anzctr.org.au Identifier: ACTRN12606000318583.
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Affiliation(s)
| | - Caroline A. Crowther
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Discipline of Obstetrics and Gynaecology, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Peter J. Anderson
- Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Australia
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Australia
| | - Jane E. Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Lex W. Doyle
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Department of Obstetrics and Gynaecology, The Royal Women’s Hospital, University of Melbourne, Parkville, Australia
| | - Christopher J. D. McKinlay
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
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Brennan GP, Vitsios DM, Casey S, Looney AM, Hallberg B, Henshall DC, Boylan GB, Murray DM, Mooney C. RNA-sequencing analysis of umbilical cord plasma microRNAs from healthy newborns. PLoS One 2018; 13:e0207952. [PMID: 30507953 PMCID: PMC6277075 DOI: 10.1371/journal.pone.0207952] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/08/2018] [Indexed: 12/13/2022] Open
Abstract
MicroRNAs are a class of small non-coding RNA that regulate gene expression at a post-transcriptional level. MicroRNAs have been identified in various body fluids under normal conditions and their stability as well as their dysregulation in disease has led to ongoing interest in their diagnostic and prognostic potential. Circulating microRNAs may be valuable predictors of early-life complications such as birth asphyxia or neonatal seizures but there are relatively few data on microRNA content in plasma from healthy babies. Here we performed small RNA-sequencing analysis of plasma processed from umbilical cord blood in a set of healthy newborns. MicroRNA levels in umbilical cord plasma of four male and four female healthy babies, from two different centres were profiled. A total of 1,004 individual microRNAs were identified, which ranged from 426 to 659 per sample, of which 269 microRNAs were common to all eight samples. Many of these microRNAs are highly expressed and consistent with previous studies using other high throughput platforms. While overall microRNA expression did not differ between male and female cord blood plasma, we did detect differentially edited microRNAs in female plasma compared to male. Of note, and consistent with other studies of this type, adenylation and uridylation were the two most prominent forms of editing. Six microRNAs, miR-128-3p, miR-29a-3p, miR-9-5p, miR-218-5p, 204-5p and miR-132-3p were consistently both uridylated and adenylated in female cord blood plasma. These results provide a benchmark for microRNA profiling and biomarker discovery using umbilical cord plasma and can be used as comparative data for future biomarker profiles from complicated births or those with early-life developmental disorders.
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Affiliation(s)
- Gary P. Brennan
- Department of Physiology & Medical Physics, Royal College of Surgeons in Ireland, Dublin, Ireland
- FutureNeuro Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Dimitrios M. Vitsios
- European Molecular Biology Laboratory–European Bioinformatics Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge CB10 1SD, United Kingdom
| | - Sophie Casey
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics & Child Health, University College Cork, Cork, Ireland
| | | | - Boubou Hallberg
- Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - David C. Henshall
- Department of Physiology & Medical Physics, Royal College of Surgeons in Ireland, Dublin, Ireland
- FutureNeuro Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Geraldine B. Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics & Child Health, University College Cork, Cork, Ireland
| | - Deirdre M. Murray
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics & Child Health, University College Cork, Cork, Ireland
| | - Catherine Mooney
- FutureNeuro Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- INFANT Research Centre, University College Cork, Cork, Ireland
- School of Computer Science, University College Dublin, Belfield, Dublin 4, Ireland
- * E-mail:
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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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Skoll A, Boutin A, Bujold E, Burrows J, Crane J, Geary M, Jain V, Lacaze-Masmonteil T, Liauw J, Mundle W, Murphy K, Wong S, Joseph KS. N° 364 - La Corticothérapie Prénatale Pour Améliorer Les Issues Néonatales. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:1240-1262. [PMID: 30268317 DOI: 10.1016/j.jogc.2018.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIF Évaluer les avantages et les risques de la corticothérapie prénatale chez les femmes qui présentent un risque d'accouchement prématuré ou qui subissent une césarienne à terme avant début de travail, et formuler des recommandations visant l'amélioration des issues néonatales et des issues à long terme. OPTIONS Administrer ou ne pas administrer une corticothérapie prénatale aux femmes qui présentent un risque élevé d'accouchement prématuré ou qui subissent une césarienne avant travail à terme. RéSULTATS: Morbidité périnatale, notamment le syndrome de détresse respiratoire, l'hémorragie intraventriculaire, la dysplasie bronchopulmonaire, l'infection, l'hypoglycémie, ainsi que les troubles de la croissance somatique et cérébrale et du neurodéveloppement; mortalité périnatale; et morbidité maternelle, notamment l'infection et la suppression surrénalienne. UTILISATEURS CIBLES Fournisseurs de soins de maternité, notamment les sages-femmes, les médecins de famille et les obstétriciens. POPULATION CIBLE Femmes enceintes. ÉVIDENCE: Nous avons interrogé les bases de données Medline, PubMed et Embase ainsi que la Bibliothèque Cochrane, de leur création au mois de septembre 2017. Nous nous sommes servis de Medical Subjet Headings (MeSH) et de mots clés en lien avec la grossesse, la prématurité, les corticostéroïdes ainsi que la mortalité et la morbidité périnatales et néonatales. Nous avons également consulté les déclarations d'organismes professionnels tels que les National Institutes of Health, l'American College of Obstetricians and Gynecologists, la Society for Maternal-Fetal Medicine, le Royal College of Obstetricians and Gynaecologists et la Société canadienne de pédiatrie pour obtenir des références additionnelles. Les essais cliniques randomisés évaluant la corticothérapie prénatale menés sur des femmes enceintes et les revues systématiques antérieures sur le sujet étaient admissibles, tout comme les données venant de revues systématiques d'études non expérimentales (études de cohorte). VALEURS La présente opinion de comité a été révisée et approuvée par le Comité de médecine fœto-maternelle de la SOGC, et approuvée par le Conseil de la SOGC. AVANTAGES, INCONVéNIENTS ET COûTS: L'administration d'une corticothérapie prénatale dans les sept jours précédant l'accouchement réduit significativement la morbidité et la mortalité périnatales associées à la naissance prématurée survenant entre 24+0 et 34+6 semaines de grossesse. Si la corticothérapie prénatale est administrée plus de sept jours avant l'accouchement ou après 34+6 semaines de grossesse, les effets indésirables peuvent surpasser les avantages. Les données probantes sur l'impact à long terme de la corticothérapie prénatale sont rares. Par ailleurs, les effets neurodéveloppementaux néfastes potentiels de l'exposition répétée à la corticothérapie prénatale ou de l'administration de corticostéroïdes en période préterme tardive ou à terme n'ont pas été quantifiés. MIS-à-JOUR à LA DIRECTIVE: Une revue des données probantes sera menée cinq ans après la publication de la présente directive clinique afin d'évaluer si une mise à jour complète ou partielle s'impose. Si de nouvelles données probantes importantes sont publiées avant la fin de ces cinq ans, une mise à jour tenant compte des nouvelles connaissances et recommandations sera publiée. COMMANDITAIRES La présente directive clinique a été élaborée à l'aide de ressources fournies par la Société des obstétriciens et gynécologues du Canada et avec l'appui des Instituts de recherche en santé du Canada (APR-126338). MOTS CLéS: Corticothérapie prénatale, maturation fœtale, prématurité, période préterme tardive, césarienne avant travail DÉCLARATION SOMMAIRES: RECOMMANDATIONS: Considérations relatives à l'âge gestationnel.
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Cartwright RD, Harding JE, Crowther CA, Cutfield WS, Battin MR, Dalziel SR, McKinlay CJD. Repeat Antenatal Betamethasone and Cardiometabolic Outcomes. Pediatrics 2018; 142:peds.2018-0522. [PMID: 29895522 DOI: 10.1542/peds.2018-0522] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Repeat dose(s) of antenatal betamethasone are recommended for women at <32 weeks with ongoing risk of preterm birth. However, there is concern that use of repeat dose(s) in fetal growth restriction (FGR) may increase the risk of later cardiometabolic disease. METHODS We undertook secondary analysis of data from the Australasian Collaborative Trial of Repeat Doses of Corticosteroids Midchildhood Outcome Study to determine if FGR influences the effect of repeat betamethasone on growth and cardiometabolic function. At 6 to 8 years, children underwent anthropometry, dual energy x-ray absorptiometry, intravenous glucose tolerance testing, ambulatory blood pressure monitoring, and spirometry. FGR was defined as severe FGR at entry, cesarean delivery for FGR, or customized birth weight below the third centile. RESULTS Of 266 children assessed, FGR occurred in 43 of 127 (34%) exposed to repeat betamethasone and 44 of 139 (32%) exposed to placebo. There was an interaction between FGR and repeat betamethasone treatment for the effect on height (z score mean difference [95% confidence interval]; FGR: 0.59 [0.01 to 1.17]; non-FGR: -0.29 [-0.69 to 0.10]; P = .01). However, FGR did not influence the effect of repeat betamethasone on cardiometabolic function, which was similar in treatment groups, both in FGR and non-FGR subgroups. CONCLUSIONS Repeat antenatal betamethasone treatment had no adverse effects on cardiometabolic function, even in the presence of FGR. It may have a positive effect on height in FGR. Clinicians should use repeat doses of antenatal corticosteroids when indicated before preterm birth, regardless of FGR, in view of the associated neonatal benefits.
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Affiliation(s)
| | | | - Caroline A Crowther
- Liggins Institute and.,Department of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Wayne S Cutfield
- Liggins Institute and.,A Better Start, National Science Challenge, Auckland, New Zealand
| | - Malcolm R Battin
- Liggins Institute and.,Newborn Services, National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Stuart R Dalziel
- Liggins Institute and.,Children's Emergency Department, Starship Children's Health, Auckland, New Zealand; and
| | - Christopher J D McKinlay
- Liggins Institute and .,Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand.,Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
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Jobe AH, Goldenberg RL. Antenatal corticosteroids: an assessment of anticipated benefits and potential risks. Am J Obstet Gynecol 2018; 219:62-74. [PMID: 29630886 DOI: 10.1016/j.ajog.2018.04.007] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 12/20/2022]
Abstract
Antenatal corticosteroids are standard of care for pregnancies at risk of preterm delivery between 24-34 weeks' gestational age. Recent trials demonstrate modest benefits from antenatal corticosteroids for late preterm and elective cesarean deliveries, and antenatal corticosteroids for periviable deliveries should be considered with family discussion. However, many women with threatened preterm deliveries receive antenatal corticosteroids but do not deliver until >34 weeks or at term. The net effect is that a substantial fraction of the delivery population will be exposed to antenatal corticosteroids. There are gaps in accurate assessments of benefits of antenatal corticosteroids because the randomized controlled trials were performed prior to about 1990 in pregnancies generally >28 weeks. The care practices for the mother and infant survival were different than today. The randomized controlled trial data also do not strongly support the optimal interval from antenatal corticosteroid treatment to delivery of 1-7 days. Epidemiology-based studies using large cohorts with >85% of at-risk pregnancies treated with antenatal corticosteroids probably overestimate the benefits of antenatal corticosteroids. Although most of the prematurity-associated mortality is in low-resource environments, the efficacy and safety of antenatal corticosteroids in those environments remain to be evaluated. The short-term benefits of antenatal corticosteroids for high-risk pregnancies in high-resource environments certainly justify antenatal corticosteroids as few risks have been identified over many years. However, cardiovascular and metabolic abnormalities have been identified in large animal models and cohorts of children exposed to antenatal corticosteroids that are consistent with fetal programming for adult diseases. These late effects of antenatal corticosteroids suggest caution for the expanded use of antenatal corticosteroids beyond at-risk pregnancies at 24-34 weeks. A way forward is to develop noninvasive fetal assessments to identify pregnancies across a wider gestational age that could benefit from antenatal corticosteroids.
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28
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Agnew EJ, Ivy JR, Stock SJ, Chapman KE. Glucocorticoids, antenatal corticosteroid therapy and fetal heart maturation. J Mol Endocrinol 2018; 61:R61-R73. [PMID: 29720513 PMCID: PMC5976079 DOI: 10.1530/jme-18-0077] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 05/02/2018] [Indexed: 01/08/2023]
Abstract
Glucocorticoids are essential in mammals to mature fetal organs and tissues in order to survive after birth. Hence, antenatal glucocorticoid treatment (termed antenatal corticosteroid therapy) can be life-saving in preterm babies and is commonly used in women at risk of preterm birth. While the effects of glucocorticoids on lung maturation have been well described, the effects on the fetal heart remain less clear. Experiments in mice have shown that endogenous glucocorticoid action is required to mature the fetal heart. However, whether the potent synthetic glucocorticoids used in antenatal corticosteroid therapy have similar maturational effects on the fetal heart is less clear. Moreover, antenatal corticosteroid therapy may increase the risk of cardiovascular disease in adulthood. Here, we present a narrative review of the evidence relating to the effects of antenatal glucocorticoid action on the fetal heart and discuss the implications for antenatal corticosteroid therapy.
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Affiliation(s)
- Emma J Agnew
- University/BHF Centre for Cardiovascular ScienceUniversity of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, UK
| | - Jessica R Ivy
- University/BHF Centre for Cardiovascular ScienceUniversity of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, UK
| | - Sarah J Stock
- MRC Centre for Reproductive HealthUniversity of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, UK
| | - Karen E Chapman
- University/BHF Centre for Cardiovascular ScienceUniversity of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, UK
- Correspondence should be addressed to K E Chapman:
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Abstract
The soon-to-be-delivered fetus and preterm infant have been treated with glucocorticoids to prepare for postnatal life, historically for more than 40 years. The use of glucocorticoids is as much for replacement of cortisol in the setting of a poorly functioning hypothalamic-pituitary-adrenal axis in the preterm infant, as it is for prevention of long-term lung dysfunction. Potential negative effects of glucocorticoid treatment on brain development and function have been observed more often with dexamethasone therapy than with use of other glucocorticoids. Overall, glucocorticoid treatment has improved the outcome of the preterm infant.
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Affiliation(s)
- Susan M Scott
- University of New Mexico School of Medicine, 2211 Lomas Boulevard, Albuquerque, NM 87131, USA.
| | - Susan R Rose
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, MLC 7012, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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James E, Wood CL, Nair H, Williams TC. Preterm birth and the timing of puberty: a systematic review. BMC Pediatr 2018; 18:3. [PMID: 29310614 PMCID: PMC5759269 DOI: 10.1186/s12887-017-0976-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 12/20/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND An estimated 11% of births occur preterm, and survival is improving. Early studies suggested an association between preterm birth and earlier puberty. Given the adverse outcomes associated with early puberty this could have significant public health implications. The objective of this review was to assess the timing of puberty after preterm birth. METHODS Pubmed, Embase, Popline, Global Health and Global Health Library were searched using terms relating to "premature birth", "menarche", "puberty" and "follow up studies". Inclusion criteria were a population consisting of pubertal or post-pubertal adolescents and adults; studies which defined preterm delivery in participants and compared outcomes to those after term delivery; and a quantitative assessment of pubertal onset. Assessment of risk of bias was conducted using principles from the Critical Appraisal Study Process. RESULTS Our search identified 1051 studies, of which 16 met the inclusion criteria. In females, 8 studies found no association between preterm birth and the timing of menarche. Five studies found earlier onset in preterm infants, 1 found later onset, and 1 showed both earlier and later menarche, depending on birth weight. The range of effect of studies showing earlier menarche was - 0.94 to -0.07 years in the preterm group, with a median of - 0.3 years. In males, 2 studies showed earlier onset of puberty in the preterm group, 5 showed no difference, and 1 showed later onset. Most studies did not present outcomes in the form of a mean with standard deviation, precluding a meta-analysis. There was insufficient data to address potential confounding factors. CONCLUSIONS The published evidence does not suggest that being born preterm leads to a significant acceleration in the onset of puberty. This should prove reassuring for public health purposes, and for clinicians counseling parents of infants born preterm.
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Affiliation(s)
- Evlyn James
- Royal Oldham Hospital, Rochdale Road, Oldham, UK
| | - Claire L. Wood
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Harish Nair
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Thomas C. Williams
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU UK
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McKinlay CJD, Cutfield WS, Battin MR, Dalziel SR, Crowther CA, Harding JE. Mid-Childhood Bone Mass After Exposure to Repeat Doses of Antenatal Glucocorticoids: A Randomized Trial. Pediatrics 2017; 139:peds.2016-4250. [PMID: 28557758 DOI: 10.1542/peds.2016-4250] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Treatment of women at risk for preterm birth with repeat doses of glucocorticoids reduces neonatal morbidity, but could have adverse effects on skeletal development. We assessed whether exposure to repeat antenatal betamethasone alters bone mass in children whose mothers participated in the Australasian Collaborative Trial of Repeat Doses of Corticosteroids. METHODS Women were randomized to a single dose of betamethasone or placebo, ≥7 days after an initial course of glucocorticoids, repeated each week that they remained at risk for preterm birth at <32 weeks' gestation. In this follow-up study, children underwent whole-body dual-energy radiograph absorptiometry at 6 to 8 years' corrected age. RESULTS Of 212 eligible childhood survivors, 185 were studied (87%; 91 repeat betamethasone group; 94 placebo [single course] group). Children exposed to repeat antenatal betamethasone and those exposed to placebo had similar whole-body bone mineral content (median repeat betamethasone: 553 g, interquartile range: 442-712 g; placebo: 567 g, interquartile range: 447-750 g; geometric mean ratio: 0.99; 95% confidence interval: 0.94-1.03, P = .55) and bone area (median repeat betamethasone 832 cm2, interquartile range: 693-963 cm2; placebo: 822 cm2, interquartile range: 710-1020 cm2; geometric mean ratio: 0.99, 95% confidence interval: 0.92-1.07, P = .75). CONCLUSIONS Exposure to repeat doses of antenatal betamethasone compared with a single course of glucocorticoids does not alter bone mass in mid-childhood.
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Affiliation(s)
- Christopher J D McKinlay
- Liggins Institute and.,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.,Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
| | - Wayne S Cutfield
- Liggins Institute and.,A Better Start, National Science Challenge, Auckland, New Zealand
| | - Malcolm R Battin
- Liggins Institute and.,Newborn Services, National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Stuart R Dalziel
- Liggins Institute and.,Children's Emergency Department, Starship Children's Health, Auckland, New Zealand; and
| | - Caroline A Crowther
- Liggins Institute and.,Australian Research Centre for Health of Women and Babies, Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Norman M. Repeat doses of antenatal betamethasone and risk factors for cardiometabolic disease at early school age. Acta Paediatr 2017; 106:846. [PMID: 28127797 DOI: 10.1111/apa.13726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Mikael Norman
- Department of Neonatal Medicine; K78; Karolinska Institutet and University Hospital; Stockholm Sweden
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Raju TNK, Pemberton VL, Saigal S, Blaisdell CJ, Moxey-Mims M, Buist S. Long-Term Healthcare Outcomes of Preterm Birth: An Executive Summary of a Conference Sponsored by the National Institutes of Health. J Pediatr 2017; 181:309-318.e1. [PMID: 27806833 DOI: 10.1016/j.jpeds.2016.10.015] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/17/2016] [Accepted: 10/04/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Tonse N K Raju
- Eunice Kennedy Shriver National Institutes of Child Health and Human Development, National Institutes of Health, Bethesda, MD.
| | | | - Saroj Saigal
- National Heart, Lung, and Blood Institute, Bethesda, MD
| | | | - Marva Moxey-Mims
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Sonia Buist
- Oregon Health & Sciences University, Portland, OR
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34
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Effect of perinatal glucocorticoids on vascular health and disease. Pediatr Res 2017; 81:4-10. [PMID: 27656772 DOI: 10.1038/pr.2016.188] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 07/26/2016] [Indexed: 11/09/2022]
Abstract
The benefits of antenatal glucocorticoids are now firmly established in the perinatal management of threatened preterm birth. Postnatal glucocorticoid therapy, however, remains controversial in neonatal medicine, with the need to balance short-term physiological benefits against the potential for long-term adverse consequences. This review focuses on the vascular effects of prenatal and postnatal glucocorticoids, synthesizing data from both experimental animal models and human infants with the goal of better appreciation of the short and long-term effects of these commonly used drugs. Due to their widespread and varied use, improved understanding of the cellular and molecular impact of glucocorticoids is important in guiding current practice and future research.
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Schmitz T. Prévention des complications de la prématurité par l’administration anténatale de corticoïdes. ACTA ACUST UNITED AC 2016; 45:1399-1417. [DOI: 10.1016/j.jgyn.2016.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 10/20/2022]
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36
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Crowther CA, Anderson PJ, McKinlay CJD, Harding JE, Ashwood PJ, Haslam RR, Robinson JS, Doyle LW. Mid-Childhood Outcomes of Repeat Antenatal Corticosteroids: A Randomized Controlled Trial. Pediatrics 2016; 138:peds.2016-0947. [PMID: 27650051 DOI: 10.1542/peds.2016-0947] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To assess if exposure to repeat dose(s) of antenatal corticosteroids has beneficial effects on neurodevelopment and general health in mid-childhood, at 6 to 8 years' corrected age. METHODS Women at risk for very preterm birth, who had received a course of corticosteroids ≥7 days previously, were randomized to intramuscular betamethasone (11.4 mg Celestone Chronodose) or saline placebo, repeated weekly if risk of very preterm birth remained. Mid-childhood assessments included neurocognitive function, behavior, growth, lung function, blood pressure, health-related quality of life, and health service utilization. The primary outcome was survival free of neurosensory disability. RESULTS Of the 1059 eligible long-term survivors, 963 (91%) were included in the primary outcome; 479 (91%) in the repeat corticosteroid group and 484 (91%) in the placebo group. The rate of survival free of neurosensory disability was similar in both groups (78.3% repeat versus 77.3% placebo; risk ratio 1.00, 95% confidence interval, 0.94-1.08). Neurodevelopment, including cognitive function, and behavior, body size, blood pressure, spirometry, and health-related quality of life were similar in both groups, as was the use of health services. CONCLUSIONS Treatment with repeat dose(s) of antenatal corticosteroids was associated with neither benefit nor harm in mid-childhood. Our finding of long-term safety supports the use of repeat dose(s) of antenatal corticosteroids, in view of the related neonatal benefits. For women at risk for preterm birth before 32 weeks' gestation, ≥7 days after an initial course of antenatal corticosteroids, clinicians could consider using a single injection of betamethasone, repeated weekly if risk remains.
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Affiliation(s)
- Caroline A Crowther
- Liggins Institute, University of Auckland, Auckland, New Zealand; .,Discipline of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Peter J Anderson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | | | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Pat J Ashwood
- Discipline of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Ross R Haslam
- The Women's and Children's Hospital, Adelaide, South Australia, Australia; and
| | - Jeffery S Robinson
- Discipline of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Lex W Doyle
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The Royal Women's Hospital, University of Melbourne, Parkville, Victoria, Australia
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McGoldrick E, Brown J, Middleton P, McKinlay CJD, Haas DM, Crowther CA. Antenatal corticosteroids for fetal lung maturation: an overview of Cochrane reviews. Hippokratia 2016. [DOI: 10.1002/14651858.cd012156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Emma McGoldrick
- The University of Auckland; Liggins Institute; Auckland New Zealand
| | - Julie Brown
- The University of Auckland; Liggins Institute; Auckland New Zealand
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute; Women's and Children's Hospital 72 King William Road Adelaide South Australia Australia 5006
- The University of Adelaide; ARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and Gynaecology; Adelaide SA Australia
| | | | - David M Haas
- Indiana University School of Medicine; Department of Obstetrics and Gynecology; 1001 West 10th Street, F-5 Indianapolis Indiana USA 46202
| | - Caroline A Crowther
- The University of Auckland; Liggins Institute; Auckland New Zealand
- The University of Adelaide; ARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and Gynaecology; Adelaide SA Australia
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Morton JS, Cooke CL, Davidge ST. In Utero Origins of Hypertension: Mechanisms and Targets for Therapy. Physiol Rev 2016; 96:549-603. [DOI: 10.1152/physrev.00015.2015] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The developmental origins of health and disease theory is based on evidence that a suboptimal environment during fetal and neonatal development can significantly impact the evolution of adult-onset disease. Abundant evidence exists that a compromised prenatal (and early postnatal) environment leads to an increased risk of hypertension later in life. Hypertension is a silent, chronic, and progressive disease defined by elevated blood pressure (>140/90 mmHg) and is strongly correlated with cardiovascular morbidity/mortality. The pathophysiological mechanisms, however, are complex and poorly understood, and hypertension continues to be one of the most resilient health problems in modern society. Research into the programming of hypertension has proposed pharmacological treatment strategies to reverse and/or prevent disease. In addition, modifications to the lifestyle of pregnant women might impart far-reaching benefits to the health of their children. As more information is discovered, more successful management of hypertension can be expected to follow; however, while pregnancy complications such as fetal growth restriction, preeclampsia, preterm birth, etc., continue to occur, their offspring will be at increased risk for hypertension. This article reviews the current knowledge surrounding the developmental origins of hypertension, with a focus on mechanistic pathways and targets for therapeutic and pharmacologic interventions.
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Affiliation(s)
- Jude S. Morton
- Departments of Obstetrics and Gynaecology and of Physiology, University of Alberta, Edmonton, Canada; Women and Children's Health Research Institute, Edmonton, Canada; and Cardiovascular Research Centre, Edmonton, Canada
| | - Christy-Lynn Cooke
- Departments of Obstetrics and Gynaecology and of Physiology, University of Alberta, Edmonton, Canada; Women and Children's Health Research Institute, Edmonton, Canada; and Cardiovascular Research Centre, Edmonton, Canada
| | - Sandra T. Davidge
- Departments of Obstetrics and Gynaecology and of Physiology, University of Alberta, Edmonton, Canada; Women and Children's Health Research Institute, Edmonton, Canada; and Cardiovascular Research Centre, Edmonton, Canada
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Freeman CI, Hezelgrave NL, Shennan AH. Antenatal steroids for fetal lung maturity: Time to target more frequent doses to fewer women? Obstet Med 2015; 8:172-6. [PMID: 27512476 PMCID: PMC4935049 DOI: 10.1177/1753495x15601772] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 07/23/2015] [Indexed: 11/17/2022] Open
Abstract
Antenatal corticosteroids for fetal lung maturation have become mainstay treatment in women thought to be at high-risk of premature birth. To ensure treatment efficacy before delivery, the current practice is to administer steroids early to a woman considered at risk; however, neonatal benefit is lost after the seven-day treatment-to-delivery window. Over half of women who deliver before 34 weeks' gestation do not receive antenatal corticosteroids within this timeframe, but many still deliver prematurely; however, clinicians are reluctant to administer repeated courses of steroids due to concerns, among others, of impaired fetal growth. However, evidence is mounting regarding the optimal timing for steroids, including substantive benefits close to delivery, and the benefits of repeated courses if delivery has not occurred. Better targeted treatment is required to allow for maximum benefit; reducing unnecessary treatment in low-risk women, while targeting therapy in the high-risk cohort and offering repeat courses if the seven-day window is exceeded. Novel tools to aid prediction may help implement this strategy.
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Affiliation(s)
| | | | - Andrew H Shennan
- Women’s Health Academic Centre, King’s College London, London, UK
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40
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Kemp MW, Newnham JP, Challis JG, Jobe AH, Stock SJ. The clinical use of corticosteroids in pregnancy. Hum Reprod Update 2015; 22:240-59. [PMID: 26590298 DOI: 10.1093/humupd/dmv047] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/13/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The use of antenatal steroid therapy is common in pregnancy. In early pregnancy, steroids may be used in women for the treatment of recurrent miscarriage or fetal abnormalities such as congenital adrenal hyperplasia. In mid-late pregnancy, the antenatal administration of corticosteroids to expectant mothers in anticipation of preterm birth is one of the most important advances in perinatal medicine; antenatal corticosteroids are now standard care for pregnancies at risk of premature delivery in high- and middle-income countries. The widespread uptake of this therapy is due to a compelling body of evidence demonstrating improved neonatal outcomes following antenatal corticosteroid exposure, stemming most notably from corticosteroid-driven maturation of fetal pulmonary function. As we approach the 50th anniversary of landmark work in this area by Liggins and Howie, it is apparent that much remains to be understood with regards to how we might best apply antenatal corticosteroid therapy to improve pregnancy outcomes at both early and mid to late gestation. METHODS Drawing on advances in laboratory science, pre-clinical and clinical studies, we performed a narrative review of the scientific literature to provide a timely update on the benefits, risks and uncertainties regarding antenatal corticosteroid use in pregnancy. Three, well-established therapeutic uses of antenatal steroids, namely recurrent miscarriage, congenital adrenal hyperplasia and preterm birth, were selected to frame the review. RESULTS Even the most well-established antenatal steroid therapies lack the comprehensive pharmacokinetic and dose-response data necessary to optimize dosing regimens. New insights into complex, tissue-specific corticosteroid signalling by genomic-dependent and independent mechanisms have not been used to inform corticosteroid treatment strategies. There is growing evidence that some fetal corticosteroid treatments are either ineffective, or may result in adverse outcomes, in addition to lasting epigenetic changes in a variety of homeostatic mechanisms. Nowhere is the need to better understand the intricacies of corticosteroid therapy better conveyed than in the findings of Althabe and colleagues who recently reported an increase in overall neonatal mortality and maternal morbidity in association with antenatal corticosteroid administration in low-resource settings. CONCLUSIONS New research to clarify the benefits and potential risks of antenatal corticosteroid therapy is urgently needed, especially with regard to corticosteroid use in low-resource environments. We conclude that there is both significant scope and an urgent need for further research-informed refinement to the use of antenatal corticosteroids in pregnancy.
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Affiliation(s)
- M W Kemp
- School of Women's and Infants' Health, The University of Western Australia, Perth, Western Australia, Australia
| | - J P Newnham
- School of Women's and Infants' Health, The University of Western Australia, Perth, Western Australia, Australia
| | - J G Challis
- Office of the Pro Vice-Chancellor (Health and Medical Research), The University of Western Australia, Perth, Western Australia, Australia
| | - A H Jobe
- School of Women's and Infants' Health, The University of Western Australia, Perth, Western Australia, Australia Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Centre, Cincinnati, OH, USA
| | - S J Stock
- Tommy's Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, Queen's Medical Research Institute, Edinburgh, UK
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Crowther CA, McKinlay CJD, Middleton P, Harding JE. Repeat doses of prenatal corticosteroids for women at risk of preterm birth for improving neonatal health outcomes. Cochrane Database Syst Rev 2015; 2015:CD003935. [PMID: 26142898 PMCID: PMC7104525 DOI: 10.1002/14651858.cd003935.pub4] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND It has been unclear whether repeat dose(s) of prenatal corticosteroids are beneficial. OBJECTIVES To assess the effectiveness and safety of repeat dose(s) of prenatal corticosteroids. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 January 2015), searched reference lists of retrieved studies and contacted authors for further data. SELECTION CRITERIA Randomised controlled trials of women who had already received a single course of corticosteroids seven or more days previously and considered still at risk of preterm birth. DATA COLLECTION AND ANALYSIS We assessed trial quality and extracted data independently. MAIN RESULTS We included 10 trials (a total of 4733 women and 5700 babies) with low to moderate risk of bias. Treatment of women who remain at risk of preterm birth seven or more days after an initial course of prenatal corticosteroids with repeat dose(s), compared with no repeat corticosteroid treatment, reduced the risk of their infants experiencing the primary outcomes respiratory distress syndrome (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.75 to 0.91, eight trials, 3206 infants, number needed to treat to benefit (NNTB) 17, 95% CI 11 to 32) and serious infant outcome (RR 0.84, 95% CI 0.75 to 0.94, seven trials, 5094 infants, NNTB 30, 95% CI 19 to 79).Treatment with repeat dose(s) of corticosteroid was associated with a reduction in mean birthweight (mean difference (MD) -75.79 g, 95% CI -117.63 to -33.96, nine trials, 5626 infants). However, outcomes that adjusted birthweight for gestational age (birthweight Z scores, birthweight multiples of the median and small-for-gestational age) did not differ between treatment groups.At early childhood follow-up, no statistically significant differences were seen for infants exposed to repeat prenatal corticosteroids compared with unexposed infants for the primary outcomes (total deaths; survival free of any disability or major disability; disability; or serious outcome) or in the secondary outcome growth assessments. In women, for the two primary outcomes, there was no increase in infectious morbidity of chorioamnionitis or puerperal sepsis, and the likelihood of a caesarean birth was unchanged. AUTHORS' CONCLUSIONS The short-term benefits for babies of less respiratory distress and fewer serious health problems in the first few weeks after birth support the use of repeat dose(s) of prenatal corticosteroids for women still at risk of preterm birth seven days or more after an initial course. These benefits were associated with a small reduction in size at birth. The current available evidence reassuringly shows no significant harm in early childhood, although no benefit.Further research is needed on the long-term benefits and risks for the woman and baby. Individual patient data meta-analysis may clarify how to maximise benefit and minimise harm.
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Affiliation(s)
- Caroline A Crowther
- The University of AucklandLiggins InstitutePrivate Bag 9201985 Park RoadAucklandNew Zealand
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | | | - Philippa Middleton
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
- The University of AdelaideWomen's and Children's Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Jane E Harding
- The University of AucklandLiggins InstitutePrivate Bag 9201985 Park RoadAucklandNew Zealand
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