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Siricilla S, Hansen CJ, Rogers JH, De D, Simpson CL, Waterson AG, Sulikowski GA, Crockett SL, Boatwright N, Reese J, Paria BC, Newton J, Herington JL. Arrest of mouse preterm labor until term delivery by combination therapy with atosiban and mundulone, a natural product with tocolytic efficacy. Pharmacol Res 2023; 195:106876. [PMID: 37536638 DOI: 10.1016/j.phrs.2023.106876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 07/17/2023] [Accepted: 07/28/2023] [Indexed: 08/05/2023]
Abstract
There is a lack of FDA-approved tocolytics for the management of preterm labor (PL). In prior drug discovery efforts, we identified mundulone and mundulone acetate (MA) as inhibitors of in vitro intracellular Ca2+-regulated myometrial contractility. In this study, we probed the tocolytic potential of these compounds using human myometrial samples and a mouse model of preterm birth. In a phenotypic assay, mundulone displayed greater efficacy, while MA showed greater potency and uterine-selectivity in the inhibition of intracellular-Ca2+ mobilization. Cell viability assays revealed that MA was significantly less cytotoxic. Organ bath and vessel myography studies showed that only mundulone exerted inhibition of myometrial contractions and that neither compounds affected vasoreactivity of ductus arteriosus. A high-throughput combination screen identified that mundulone exhibits synergism with two clinical-tocolytics (atosiban and nifedipine), and MA displayed synergistic efficacy with nifedipine. Of these combinations, mundulone+atosiban demonstrated a significant improvement in the in vitro therapeutic index compared to mundulone alone. The ex vivo and in vivo synergism of mundulone+atosiban was substantiated, yielding greater tocolytic efficacy and potency on myometrial tissue and reduced preterm birth rates in a mouse model of PL compared to each single agent. Treatment with mundulone after mifepristone administration dose-dependently delayed the timing of delivery. Importantly, mundulone+atosiban permitted long-term management of PL, allowing 71% dams to deliver viable pups at term (>day 19, 4-5 days post-mifepristone exposure) without visible maternal and fetal consequences. Collectively, these studies provide a strong foundation for the development of mundulone as a single or combination tocolytic for management of PL.
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Affiliation(s)
- Shajila Siricilla
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher J Hansen
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University, Nashville, TN, USA
| | - Jackson H Rogers
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Debasmita De
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carolyn L Simpson
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alex G Waterson
- Department of Pharmacology, Vanderbilt University, Nashville, TN, USA; Department of Chemistry, Vanderbilt University, Nashville, TN, USA; Vanderbilt Institute of Chemical Biology, Vanderbilt University, Nashville, TN, USA
| | - Gary A Sulikowski
- Department of Chemistry, Vanderbilt University, Nashville, TN, USA; Vanderbilt Institute of Chemical Biology, Vanderbilt University, Nashville, TN, USA
| | - Stacey L Crockett
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Naoko Boatwright
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeff Reese
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA; Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN, USA
| | - Bibhash C Paria
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer L Herington
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University, Nashville, TN, USA.
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Siricilla S, Hansen CJ, Rogers JH, De D, Simpson CL, Waterson AG, Sulikowski GA, Crockett SL, Boatwright N, Reese J, Paria BC, Newton J, Herington JL. Arrest of mouse preterm labor until term delivery by combination therapy with atosiban and mundulone, a natural product with tocolytic efficacy. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.06.06.543921. [PMID: 37333338 PMCID: PMC10274706 DOI: 10.1101/2023.06.06.543921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Currently, there is a lack of FDA-approved tocolytics for the management of preterm labor (PL). In prior drug discovery efforts, we identified mundulone and its analog mundulone acetate (MA) as inhibitors of in vitro intracellular Ca 2+ -regulated myometrial contractility. In this study, we probed the tocolytic and therapeutic potential of these small molecules using myometrial cells and tissues obtained from patients receiving cesarean deliveries, as well as a mouse model of PL resulting in preterm birth. In a phenotypic assay, mundulone displayed greater efficacy in the inhibition of intracellular-Ca 2+ from myometrial cells; however, MA showed greater potency and uterine-selectivity, based IC 50 and E max values between myometrial cells compared to aorta vascular smooth muscle cells, a major maternal off-target site of current tocolytics. Cell viability assays revealed that MA was significantly less cytotoxic. Organ bath and vessel myography studies showed that only mundulone exerted concentration-dependent inhibition of ex vivo myometrial contractions and that neither mundulone or MA affected vasoreactivity of ductus arteriosus, a major fetal off-target of current tocolytics. A high-throughput combination screen of in vitro intracellular Ca 2+ -mobilization identified that mundulone exhibits synergism with two clinical-tocolytics (atosiban and nifedipine), and MA displayed synergistic efficacy with nifedipine. Of these synergistic combinations, mundulone + atosiban demonstrated a favorable in vitro therapeutic index (TI)=10, a substantial improvement compared to TI=0.8 for mundulone alone. The ex vivo and in vivo synergism of mundulone and atosiban was substantiated, yielding greater tocolytic efficacy and potency on isolated mouse and human myometrial tissue and reduced preterm birth rates in a mouse model of PL compared to each single agent. Treatment with mundulone 5hrs after mifepristone administration (and PL induction) dose-dependently delayed the timing of delivery. Importantly, mundulone in combination with atosiban (FR 3.7:1, 6.5mg/kg + 1.75mg/kg) permitted long-term management of PL after induction with 30 μg mifepristone, allowing 71% dams to deliver viable pups at term (> day 19, 4-5 days post-mifepristone exposure) without any visible maternal and fetal consequences. Collectively, these studies provide a strong foundation for the future development of mundulone as a stand-alone single- and/or combination-tocolytic therapy for management of PL.
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Maxey AP, McCain ML. Tools, techniques, and future opportunities for characterizing the mechanobiology of uterine myometrium. Exp Biol Med (Maywood) 2021; 246:1025-1035. [PMID: 33554648 DOI: 10.1177/1535370221989259] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The myometrium is the smooth muscle layer of the uterus that generates the contractions that drive processes such as menstruation and childbirth. Aberrant contractions of the myometrium can result in preterm birth, insufficient progression of labor, or other difficulties that can lead to maternal or fetal complications or even death. To investigate the underlying mechanisms of these conditions, the most common model systems have conventionally been animal models and human tissue strips, which have limitations mostly related to relevance and scalability, respectively. Myometrial smooth muscle cells have also been isolated from patient biopsies and cultured in vitro as a more controlled experimental system. However, in vitro approaches have focused primarily on measuring the effects of biochemical stimuli and neglected biomechanical stimuli, despite the extensive evidence indicating that remodeling of tissue rigidity or excessive strain is associated with uterine disorders. In this review, we first describe the existing approaches for modeling human myometrium with animal models and human tissue strips and compare their advantages and disadvantages. Next, we introduce existing in vitro techniques and assays for assessing contractility and summarize their applications in elucidating the role of biochemical or biomechanical stimuli on human myometrium. Finally, we conclude by proposing the translation of "organ on chip" approaches to myometrial smooth muscle cells as new paradigms for establishing their fundamental mechanobiology and to serve as next-generation platforms for drug development.
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Affiliation(s)
- Antonina P Maxey
- Laboratory for Living Systems Engineering, Department of Biomedical Engineering, USC Viterbi School of Engineering, University of Southern California, Los Angeles, CA 90089, USA
| | - Megan L McCain
- Laboratory for Living Systems Engineering, Department of Biomedical Engineering, USC Viterbi School of Engineering, University of Southern California, Los Angeles, CA 90089, USA.,Department of Stem Cell Biology and Regenerative Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA 90033, USA
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Hyett J, Asadi N, Zare Khafri M, Vafaei H, Kasraeian M, Salehi A, Saadati N, Bazrafshan K. The use of vaginal progesterone as a maintenance therapy in women with arrested preterm labor: a double-blind placebo-randomized controlled trial. J Matern Fetal Neonatal Med 2020; 35:1134-1140. [PMID: 32216490 DOI: 10.1080/14767058.2020.1743662] [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: 10/24/2022]
Abstract
Background: The efficacy of maintenance tocolytic therapy after successful arrest of preterm labor remains controversial. The purpose of this study was to evaluate the efficacy of 400 mg of daily vaginal progesterone (cyclogest) after successful parenteral tocolysis to increase latency period and improvement of neonatal outcomes in women with threatened preterm labor.Materials and methods: In this randomized, double-blind, placebo-controlled trial, 85 participants were randomly allocated to either 400 mg daily of vaginal progesterone (n = 45) or placebo (n = 40) until 34 weeks of gestation. The primary outcomes were the time until delivery (latency period) and cervical length after 1 week of treatment. Secondary outcome were GA on delivery, type of delivery, incidence of low birth weight, perinatal morbidity and mortality.Results: Longer mean latency until delivery (53.6 ± 16.8 versus 34.5 ± 12.9) days p = .0001; longer mean of gestational age on delivery (37.5 ± 2.2 versus 34.2 ± 2.1) weeks p = .0001; cervical length after 1 week of treatment (27.5 ± 5.5 versus 20.7 ± 3.1) mm p = .0001; low birth weight 12 (29.3%) versus 19 (57.6%) p = .01; and NICU admission 9 (22%) versus 15 (45.5%), were significantly different between the two groups. No significant differences were found between neonatal death 1 (2.4%) versus 2 (6.1%), p = .43; RDS 5 (12.2%) versus 8 (24.2%), p = .17; and need to mechanical ventilator 2 (5.4%) versus 6 (18.2%) p = .136, for the progesterone and placebo groups, respectively.Conclusion: Daily administration of 400 mg vaginal progesterone after successful parenteral tocolysis may increase latency preceding delivery and improves cervical shortening and neonatal outcome in women with preterm labor. Further confirmatory studies are warranted.
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Affiliation(s)
- Jon Hyett
- Royal Prince Alfred Hospital, Camperdown, Australia
| | - Nasrin Asadi
- Maternal-fetal medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Zare Khafri
- Maternal-Fetal Medicine Research Center, OB & GYN Ward, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Homeira Vafaei
- Maternal-fetal medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Kasraeian
- Maternal-fetal medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Salehi
- Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Najmieh Saadati
- Fertility, Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Khadije Bazrafshan
- Maternal-fetal medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Zamłyński M, Zamłyński J, Horzelska E, Maruniak-Chudek I, Bablok R, Szukiewicz D, Herman-Sucharska I, Kluczewska E, Olejek A. The Use of Indomethacin with Complete Amniotic Fluid Replacement and Classic Hysterotomy for the Reduction of Perinatal Complications of Intrauterine Myelomeningocele Repair. Fetal Diagn Ther 2019; 46:415-424. [PMID: 31085918 DOI: 10.1159/000496811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 01/09/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study presented outcomes of classical hysterotomy with modified antiprostaglandin therapy for intrauterine repair of foetal myelomeningocele (fMMC) performed in a single perinatal centre. STUDY DESIGN Forty-nine pregnant women diagnosed with fMMC underwent classic hysterotomy with anti-prostaglandin management, complete amniotic fluid replacement and high dose indomethacin application. RESULTS The average gestational age (GA) at delivery was 34.4 ± 3.4 weeks, with no births before 30 weeks GA. There were 2 foetal deaths. Complete reversal of hindbrain herniation (HH), assessed in magnetic resonance imaging at 30-31 weeks GA was found in 72% of foetuses (mostly with HH grade I prior to fMMC repair). Our protocol resulted in rare use of magnesium sulphate (6%), low incidence of chorioamniotic membrane separation - chorioamniotic membrane separation (6%), preterm premature rupture of membranes - preterm premature rupture of membranes (pPROM; 15%) and preterm labour - preterm labour (PTL; 17%). The postoperative wound continuity of the uterus was usually stable (in 72% of patients), with low frequency of scar thinning (23%). CONCLUSION Our protocol results in rare use of tocolytics, and the low occurrences of CMS, pPROM and PTL in relation to other study cohorts: Management of Myelomeningocele Study, Children's Hospital of Philadelphia, and Vanderbilt University Medical Centre.
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Affiliation(s)
- Mateusz Zamłyński
- Department of Gynecology, Obstetrics and Gynecologic Oncology Medical University of Silesia in Katowice, Bytom, Poland,
| | - Jacek Zamłyński
- Department of Gynecology, Obstetrics and Gynecologic Oncology Medical University of Silesia in Katowice, Bytom, Poland
| | - Ewa Horzelska
- Department of Gynecology, Obstetrics and Gynecologic Oncology Medical University of Silesia in Katowice, Bytom, Poland
| | - Iwona Maruniak-Chudek
- Department of Intensive Care and Neonatal Pathology Medical University of Silesia Upper Silesian Centre of Child's Health, Katowice, Poland
| | - Rafał Bablok
- Department of Gynecology, Obstetrics and Gynecologic Oncology Medical University of Silesia in Katowice, Bytom, Poland
| | - Dariusz Szukiewicz
- Department of General and Experimental Pathology with Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
| | - Izabela Herman-Sucharska
- Electroradiology Department, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, Krakow, Poland
| | - Ewa Kluczewska
- Department of Radiology and Radiodiagnostics School of Medicine with the Division of Dentistry in Zabrze Medical University of Silesia in Katowice, Zabrze, Poland
| | - Anita Olejek
- Department of Gynecology, Obstetrics and Gynecologic Oncology Medical University of Silesia in Katowice, Bytom, Poland
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Rath W, Kuon RJ. Progesterone - Effective for Tocolysis and Maintenance Treatment After Arrested Preterm Labour?: Critical Analysis of the Evidence. Geburtshilfe Frauenheilkd 2019; 79:834-843. [PMID: 31423018 PMCID: PMC6690738 DOI: 10.1055/a-0829-3992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/05/2019] [Accepted: 01/07/2019] [Indexed: 12/19/2022] Open
Abstract
Numerous experimental studies indicate that natural progesterone, through various mechanisms, exerts an inhibitory effect on uterine contractility and sensitises the myometrium for tocolytics. It was therefore appropriate to investigate the possible benefits of oral/vaginal progesterone and the synthetic progesterone derivative 17-α-hydroxyprogesterone caproate, applied intramuscularly, in clinical studies on primary tocolysis, additively to established tocolytics ("adjunctive tocolysis") and as maintenance treatment after successful tocolysis in cases of threatened preterm birth. Three studies with a small number of cases do not yield any sufficient evidence for recommending progesterone/17-α-hydroxyprogesterone caproate as primary tocolysis in women with preterm labour. There is also no evidence that progesterone or 17-α-hydroxyprogesterone caproate combined with commonly used tocolytics leads to a prolongation of pregnancy and a significant decrease in the rate of preterm birth. The data on the use of progesterone as maintenance treatment is controversial. While randomised, controlled studies with low quality showed promising results, studies with high quality did not reveal any significant differences with regard to the rate of preterm birth < 37 weeks of gestation, the latency period until delivery and in the neonatal outcome between progesterone/17-α-hydroxyprogesterone caproate and placebo or no treatment. Significant differences in the methodology, the inclusion and outcome criteria, the mode of application and the dosages of the substances as well as the inadequate statistical power as a result of low numbers of cases make interpretation and comparability of the studies difficult. Therefore, well-designed randomised, placebo-controlled, double-blind studies with uniform primary outcome criteria are needed in order to clarify whether progesterone and via which route of administration and at which dosage is of clinical benefit for patients with manifest preterm contractions and as maintenance treatment after arrested preterm labour.
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Affiliation(s)
- Werner Rath
- Medizinische Fakultät Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ruben-J Kuon
- Universitätsklinikum Heidelberg, Abteilung für Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Germany
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Pustotina O. Effects of antibiotic therapy in women with the amniotic fluid "sludge" at 15-24 weeks of gestation on pregnancy outcomes. J Matern Fetal Neonatal Med 2019; 33:3016-3027. [PMID: 30621474 DOI: 10.1080/14767058.2019.1567706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective: The aim of this prospective study was to assess the efficacy of antibiotic therapy for the prevention of adverse pregnancy outcomes in women with the amniotic fluid "sludge" at 15-24 weeks of gestation.Methods: 245 women underwent transvaginal ultrasound cervical length measurement at 15-24 weeks of pregnancy and 29 out of them with amniotic fluid "sludge" were included in the study. Eight women with the "sludge" had cervical length >25 mm (Group I), seven-an asymptomatic short cervix (Group IIa) and 14 women with a short cervix had symptoms like low abdominal pain, back pain, and menstrual-like cramps (Group IIb). All participants received intravenous, oral and/or vaginal antibiotic therapy. Participants in Group IIa were additionally given vaginal progesterone (VP), and in Group IIb-VP and indomethacin. Placentas from women with preterm birth (PTB) underwent histological examination.Results: The amniotic fluid "sludge" detected at an ultrasound scan between 15-24 weeks of gestation was associated with long-term maternal infections, histological chorioamnionitis, and was viewed as a marker of intra-amniotic infection. Absence of intravenous antibiotic therapy during midtrimester of pregnancy in these women was associated with neonatal infection with intrauterine onset in 61.1%, postpartum endometritis in 23.1%, and rate of PTB 46.2%. Intravenous antibiotic therapy eliminated sonographic presence of the sludge and resulted in prevented of neonatal and postpartum infections, prevented the risk of PTB in women with the cervical length >25 mm, in those with an asymptomatic short cervix receiving VP, and in 70% of symptomatic women with a short cervix, who received them in combination VP/indomethacin. For those women whose approach was not fully beneficial, it allowed to delay delivery in 11-17 weeks.Conclusions: Although we found that intravenous antibiotic therapy at 15-24 weeks of gestation in women with amniotic fluid "sludge" can protect from infection-related complications and demonstrated high beneficial effects of adding antibiotics to anti-inflammatory drug (indomethacin) and/or VP in women with a short cervix, further larger studies are needed.
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Affiliation(s)
- Olga Pustotina
- Obstetrics, Gynecology and Perinatology, Peoples' Friendship University of Russia, Moscow, Russia
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Di Renzo GC, Cabero Roura L, Facchinetti F, Helmer H, Hubinont C, Jacobsson B, Jørgensen JS, Lamont RF, Mikhailov A, Papantoniou N, Radzinsky V, Shennan A, Ville Y, Wielgos M, Visser GHA. Preterm Labor and Birth Management: Recommendations from the European Association of Perinatal Medicine. J Matern Fetal Neonatal Med 2018; 30:2011-2030. [PMID: 28482713 DOI: 10.1080/14767058.2017.1323860] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- G C Di Renzo
- a Department of Obstetrics and Gynecology , University of Perugia , Perugia , Italy
| | - L Cabero Roura
- b Department of Obstetrics and Gynecology , Hospital Vall D'Hebron , Barcelona , Spain
| | - F Facchinetti
- c Mother-Infant Department, School of Midwifery , University of Modena and Reggio Emilia , Italy
| | - H Helmer
- d Department of Obstetrics and Gynaecology , General Hospital, University of Vienna , Vienna , Austria
| | - C Hubinont
- e Department of Obstetrics , Saint Luc University Hospital, Université de Louvain , Brussels , Belgium
| | - B Jacobsson
- f Department of Obstetrics and Gynecology , Institute of Clinical Sciences, University of Gothenburg , Gothenburg , Sweden
| | - J S Jørgensen
- g Department of Obstetrics and Gynaecology , Odense University Hospital , Odense , Denmark
| | - R F Lamont
- h Department of Gynaecology and Obstetrics , University of Southern Denmark, Odense University Hospital , Odense , Denmark.,i Division of Surgery , University College London, Northwick Park Institute of Medical Research Campus , London , UK
| | - A Mikhailov
- j Department of Obstetrics and Gynecology , 1st Maternity Hospital, State University of St. Petersburg , Russia
| | - N Papantoniou
- k Department of Obstetrics and Gynaecology , Athens University School of Medicine , Athens , Greece
| | - V Radzinsky
- l Department of Medicine , Peoples' Friendship University of Russia , Moscow , Russia
| | - A Shennan
- m St. Thomas Hospital, Kings College London , UK
| | - Y Ville
- n Service d'Obstétrique et de Médecine Foetale , Hôpital Necker Enfants Malades , Paris , France
| | - M Wielgos
- p Department of Obstetrics and Gynecology , Medical University of Warsaw , Warsaw , Poland
| | - G H A Visser
- o Department of Obstetrics , University Medical Center , Utrecht , The Netherlands
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Quist-Nelson J, Parker P, Mokhtari N, Di Sarno R, Saccone G, Berghella V. Progestogens in singleton gestations with preterm prelabor rupture of membranes: a systematic review and metaanalysis of randomized controlled trials. Am J Obstet Gynecol 2018; 219:346-355.e2. [PMID: 29614278 DOI: 10.1016/j.ajog.2018.03.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/20/2018] [Accepted: 03/24/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE DATA Preterm prelabor rupture of membranes occurs in 3% of all pregnancies. Neonatal benefit is seen in uninfected women who do not deliver immediately after preterm prelabor rupture of membranes. The purpose of this study was to evaluate whether the administration of progestogens in singleton pregnancies prolongs pregnancy after preterm prelabor rupture of membranes. STUDY Searches were performed in MEDLINE, OVID, Scopus, EMBASE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials with the use of a combination of keywords and text words related to "progesterone," "progestogen," "prematurity," and "preterm premature rupture of membranes" from the inception of the databases until January 2018. We included all randomized controlled trials of singleton gestations after preterm prelabor rupture of membranes that were randomized to either progestogens or control (either placebo or no treatment). Exclusion criteria were trials that included women who had contraindications to expectant management after preterm prelabor rupture of membranes (ie, chorioamnionitis, severe preeclampsia, and nonreassuring fetal status) and trials on multiple gestations. We planned to include all progestogens, including but not limited to 17-α hydroxyprogesterone caproate, and natural progesterone. STUDY APPRAISAL AND SYNTHESIS METHODS The primary outcome was latency from randomization to delivery. Metaanalysis was performed with the use of the random effects model of DerSimonian and Laird to produce relative risk with 95% confidence interval. Analysis was performed for each mode of progestogen administration separately. RESULTS Six randomized controlled trials (n=545 participants) were included. Four of the included trials assessed the efficacy of 17-α hydroxyprogesterone caproate; 1 trial assessed rectal progestogen, and 1 trial had 3 arms that compared 17-α hydroxyprogesterone caproate, rectal progestogen, and placebo. The mean gestational age at time randomization was 26.9 weeks in the 17-α hydroxyprogesterone caproate group and 27.3 weeks in the control group. 17-α Hydroxyprogesterone caproate administration was not found to prolong the latency period between randomization and delivery (mean difference, 0.11 days; 95% confidence interval, -3.30 to 3.53). There were no differences in mean gestational age at delivery, mode of delivery, or maternal or neonatal outcomes between the 2 groups. Similarly, there was no difference in latency for those women who received rectal progesterone (mean difference, 4.00 days; 95% confidence interval, -0.72 to 8.72). CONCLUSION Progestogen administration does not prolong pregnancy in singleton gestations with preterm prelabor rupture of membranes.
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Robuck MF, O'Brien CM, Knapp KM, Shay SD, West JD, Newton JM, Slaughter JC, Paria BC, Reese J, Herington JL. Monitoring uterine contractility in mice using a transcervical intrauterine pressure catheter. Reproduction 2018; 155:447-456. [PMID: 29500186 DOI: 10.1530/rep-17-0647] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 03/02/2018] [Indexed: 12/31/2022]
Abstract
In mouse models used to study parturition or pre-clinical therapeutic testing, measurement of uterine contractions is limited to either ex vivo isometric tension or operative intrauterine pressure (IUP). The goal of this study was to: (1) develop a method for transcervical insertion of a pressure catheter to measure in vivo intrauterine contractile pressure during mouse pregnancy, (2) determine whether this method can be utilized numerous times in a single mouse pregnancy without affecting the timing of delivery or fetal outcome and (3) compare the in vivo contractile activity between mouse models of term and preterm labor (PTL). Visualization of the cervix allowed intrauterine pressure catheter (IUPC) placement into anesthetized pregnant mice (plug = day 1, delivery = day 19.5). The amplitude, frequency, duration and area under the curve (AUC) of IUP was lowest on days 16-18, increased significantly (P < 0.05) on the morning of day 19 and reached maximal levels during by the afternoon of day 19 and into the intrapartum period. An AUC threshold of 2.77 mmHg discriminated between inactive labor (day 19 am) and active labor (day 19 pm and intrapartum period). Mice examined on a single vs every experimental timepoint did not have significantly different IUP, timing of delivery, offspring number or fetal/neonatal weight. The IUP was significantly greater in LPS-treated and RU486-treated mouse models of PTL compared to time-matched vehicle control mice. Intrapartum IUP was not significantly different between term and preterm mice. We conclude that utilization of a transcervical IUPC allows sensitive assessment of in vivo uterine contractile activity and labor progression in mouse models without the need for operative approaches.
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Affiliation(s)
- Michael F Robuck
- Division of NeonatologyDepartment of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christine M O'Brien
- Department of Biomedical EngineeringVanderbilt University, Nashville, Tennessee, USA
| | - Kelsi M Knapp
- Division of NeonatologyDepartment of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sheila D Shay
- Division of AllergyPulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James D West
- Division of AllergyPulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J M Newton
- Division of Maternal Fetal MedicineDepartment of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James C Slaughter
- Department of BiostatisticsVanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bibhash C Paria
- Division of NeonatologyDepartment of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeff Reese
- Division of NeonatologyDepartment of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical EngineeringVanderbilt University, Nashville, Tennessee, USA
| | - Jennifer L Herington
- Division of NeonatologyDepartment of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA .,Department of PharmacologyVanderbilt University, Nashville, Tennessee, USA
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Ilicic M, Butler T, Zakar T, Paul JW. The expression of genes involved in myometrial contractility changes during ex situ culture of pregnant human uterine smooth muscle tissue. J Smooth Muscle Res 2018; 53:73-89. [PMID: 28652518 PMCID: PMC5487834 DOI: 10.1540/jsmr.53.73] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Ex situ analyses of human myometrial tissue has been used to
investigate the regulation of uterine quiescence and transition to a contractile
phenotype. Following concerns about the validity of cultured primary cells, we examined
whether myometrial tissue undergoes culture-induced changes ex situ that
may affect the validity of in vitro models. Objectives: To determine
whether human myometrial tissue undergoes culture-induced changes ex situ
in Estrogen receptor 1 (ESR1), Prostaglandin-endoperoxide synthase 2
(PTGS2) and Oxytocin receptor (OXTR) expression.
Additionally, to determine whether culture conditions approaching the in
vivo environment influence the expression of these key genes. Methods: Term
non-laboring human myometrial tissues were cultured in the presence of specific
treatments, including; serum supplementation, progesterone and estrogen, cAMP, PMA,
stretch or NF-κB inhibitors. ESR1, PTGS2 and
OXTR mRNA abundance after 48 h culture was determined using
quantitative RT-PCR. Results: Myometrial tissue in culture exhibited culture-induced
up-regulation of ESR1 and PTGS2 and down-regulation of
OXTR mRNA expression. Progesterone prevented culture-induced increase
in ESR1 expression. Estrogen further up-regulated PTGS2
expression. Stretch had no direct effect, but blocked the effects of progesterone and
estrogen on ESR1 and PTGS2 expression. cAMP had no
effect whereas PMA further up-regulated PTGS2 expression and prevented
decline of OXTR expression. Conclusion: Human myometrial tissue in
culture undergoes culture-induced gene expression changes consistent with transition
toward a laboring phenotype. Changes in ESR1, PTGS2 and
OXTR expression could not be controlled simultaneously. Until optimal
culture conditions are determined, results of in vitro experiments with
myometrial tissues should be interpreted with caution.
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Affiliation(s)
- Marina Ilicic
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia.,Priority Research Centre for Reproductive Science, University of Newcastle, Callaghan, NSW 2308, Australia.,Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
| | - Trent Butler
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia.,Priority Research Centre for Reproductive Science, University of Newcastle, Callaghan, NSW 2308, Australia.,Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
| | - Tamas Zakar
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia.,Priority Research Centre for Reproductive Science, University of Newcastle, Callaghan, NSW 2308, Australia.,Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia.,John Hunter Hospital, New Lambton Heights, NSW 2305, Australia
| | - Jonathan W Paul
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia.,Priority Research Centre for Reproductive Science, University of Newcastle, Callaghan, NSW 2308, Australia.,Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
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12
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Abstract
PURPOSE OF REVIEW Tocolytic agents have been used for over 60 years in the fight against preterm labor, which ultimately can lead to preterm birth. Currently, clinicians can choose from a variety of drug classes to achieve the primary goal of delaying delivery by 48 h, thereby allowing time for administration of corticosteroids for fetal lung maturity, and if appropriate, starting magnesium sulfate for fetal neuroprotection. However, there are currently no known therapies to maintain the tocolytic effect beyond those initial 48 h. RECENT FINDINGS Progesterone, which has been used in the prevention of preterm birth for over 10 years, has long been known to have the effect of uterine quiescence. It was first studied as a tocolytic agent in the 1960s. In the last several years, more studies have been done that suggest a potential use for maintenance tocolysis after the successful arrest of preterm labor. Although the studies are conflicting, the meta-analyses on progesterone show some promise in different outcomes of delayed delivery, reduced incidence of preterm birth, and reduced neonatal morbidity. SUMMARY Progesterone is currently the most promising agent for maintenance tocolysis. Although further trials are certainly needed, this is an exciting advancement in the realm of tocolysis.
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13
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Pustotina O. Effectiveness of dydrogesterone, 17-OH progesterone and micronized progesterone in prevention of preterm birth in women with a short cervix. J Matern Fetal Neonatal Med 2017; 31:1830-1838. [PMID: 28502186 DOI: 10.1080/14767058.2017.1330406] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To compare the efficacy of dydrogesterone, 17-OH progesterone (17OHP) and oral or vaginal micronized progesterone with cerclage for the prevention of preterm birth in women with a short cervix. METHODS The study included 95 women with singleton gestation and cervical length (CL) ≤ 25 mm. Among these, 35 women were asymptomatic at 15-24 weeks and 60 had symptoms of threatened late miscarriage (LM) or preterm delivery (PD) at 15-32 weeks. Patients were randomized to receive dydrogesterone, 17OHP or oral/vaginal micronized progesterone; after one week of therapy 15 women underwent cerclage. RESULTS Efficacy of vaginal progesterone (VP) for the prevention of preterm birth reached 94.1%. In asymptomatic women pregnancy outcomes were comparable to cerclage. In women with threatened LM/PD, combination therapy with VP, indomethacin and treatment of bacterial vaginosis (BV) with the subsequent use VP until 36 weeks together with CL monitoring significantly decreased the rate of preterm birth (RR 0.01; 0.0001-0.24) and low birth weight (LBW) (RR 0.04; 0.01-0.96). CL increase during the first week of treatment with a subsequent plateau phase indicated treatment efficacy. Dydrogesterone, 17OHP, and micronized oral progesterone (OP) were associated with PD in 91.7% of women. CONCLUSIONS Combination management strategy including VP significantly benefits pregnancy outcomes in women with a short cervix compared with cerclage. Dydrogesterone, 17OHP, and OP were not found to be efficacious.
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Affiliation(s)
- Olga Pustotina
- a Department of Obstetrics, Gynecology and Perinatology , Peoples' Friendship University of Russia , Moscow , Russian Federation
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14
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Modulation of Progesterone Receptor Isoform Expression in Pregnant Human Myometrium. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4589214. [PMID: 28540297 PMCID: PMC5433421 DOI: 10.1155/2017/4589214] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 04/06/2017] [Indexed: 12/17/2022]
Abstract
Background. Regulation of myometrial progesterone receptor (PR) expression is an unresolved issue central to understanding the mechanism of functional progesterone withdrawal and initiation of labor in women. Objectives. To determine whether pregnant human myometrium undergoes culture-induced changes in PR isoform expression ex situ and, further, to determine if conditions approaching the in vivo environment stabilise PR isoform expression in culture. Methods. Term nonlaboring human myometrial tissues were cultured under specific conditions: serum supplementation, steroids, stretch, cAMP, PMA, PGF2α , NF-κB inhibitors, or TSA. Following 48 h culture, PR-T, PR-A, and PR-B mRNA levels were determined using qRT-PCR. PR-A/PR-B ratios were calculated. Results. PR-T and PR-A expression and the PR-A/PR-B ratio significantly increased in culture. Steroids prevented the culture-induced increase in PR-T and PR-A expression. Stretch blocked the effects of steroids on PR-T and PR-A expression. PMA further increased the PR-A/PR-B ratio, while TSA blocked culture-induced increases of PR-A expression and the PR-A/PR-B ratio. Conclusion. Human myometrial tissue in culture undergoes changes in PR gene expression consistent with transition toward a laboring phenotype. TSA maintained the nonlaboring PR isoform expression pattern. This suggests that preserving histone and/or nonhistone protein acetylation is critical for maintaining the progesterone dependent quiescent phenotype of human myometrium in culture.
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15
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Di Renzo GC, Giardina I, Clerici G, Brillo E, Gerli S. Progesterone in normal and pathological pregnancy. Horm Mol Biol Clin Investig 2017; 27:35-48. [PMID: 27662646 DOI: 10.1515/hmbci-2016-0038] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 08/04/2016] [Indexed: 11/15/2022]
Abstract
Progesterone is an essential hormone in the process of reproduction. It is involved in the menstrual cycle, implantation and is essential for pregnancy maintenance. It has been proposed and extensively used in the treatment of different gynecological pathologies as well as in assisted reproductive technologies and in the maintenance of pregnancy. Called "the pregnancy hormone", natural progesterone is essential before pregnancy and has a crucial role in its maintenance based on different mechanisms such as: modulation of maternal immune response and suppression of inflammatory response (the presence of progesterone and its interaction with progesterone receptors at the decidua level appears to play a major role in the maternal defense strategy), reduction of uterine contractility (adequate progesterone concentrations in myometrium are able to counteract prostaglandin stimulatory activity as well as oxytocin), improvement of utero-placental circulation and luteal phase support (it has been demonstrated that progesterone may promote the invasion of extravillous trophoblasts to the decidua by inhibiting apoptosis of extravillous trophoblasts). Once the therapeutic need of progesterone is established, the key factor is the decision of the best route to administer the hormone and the optimal dosage determination. Progesterone can be administered by many different routes, but the most utilized are oral, the vaginal and intramuscular administration. The main uses of progesterone are represented by: threatened miscarriage, recurrent miscarriage and preterm birth (in the prevention strategy, as a tocolytic agent and also in the maintenance of uterine quiescence).
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16
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Palacio M, Cobo T, Antolín E, Ramirez M, Cabrera F, Mozo de Rosales F, Bartha JL, Juan M, Martí A, Oros D, Rodríguez À, Scazzocchio E, Olivares JM, Varea S, Ríos J, Gratacós E. Vaginal progesterone as maintenance treatment after an episode of preterm labour (PROMISE) study: a multicentre, double-blind, randomised, placebo-controlled trial. BJOG 2016; 123:1990-1999. [DOI: 10.1111/1471-0528.13956] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2016] [Indexed: 11/30/2022]
Affiliation(s)
- M Palacio
- BCNatal; Hospital Clínic of Barcelona and Hospital Sant Joan de Déu; Fetal i+D Fetal Medicine Research Centre; IDIBAPS; University of Barcelona; Barcelona Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER); Barcelona Spain
| | - T Cobo
- BCNatal; Hospital Clínic of Barcelona and Hospital Sant Joan de Déu; Fetal i+D Fetal Medicine Research Centre; IDIBAPS; University of Barcelona; Barcelona Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER); Barcelona Spain
| | - E Antolín
- Hospital General Universitario Gregorio Marañón; Madrid Spain
| | - M Ramirez
- Hospital Universitario Virgen Macarena; Sevilla Spain
| | - F Cabrera
- Complejo Hospitalario Universitario lnsular Materno Infantil; Las Palmas de Gran Canaria Spain
| | | | - JL Bartha
- Hospital Puerta del Mar; Cádiz Spain
| | - M Juan
- Hospital de Son Llàtzer; Mallorca Spain
| | - A Martí
- Althaia Xarxa Assistencial Universitària de Manresa; Hospital de Sant Joan de Déu; Manresa Spain
| | - D Oros
- Hospital Clínico Universitario Lozano Blesa; Instituto de Investigación Sanitaria de Aragón; Red SAMID, RETICS; Zaragoza Spain
| | - À Rodríguez
- Hospital de Sabadell, Corporació Sanitària Parc Taulí; Sabadell Spain
- Institut Universitari Parc Taulí - UAB. Universitat Autónoma de Barcelona; Barcelona Spain
| | - E Scazzocchio
- Hospital Universitario Quirón-Dexeus; Barcelona Spain
| | - JM Olivares
- Consorci Sanitari de Terrassa; Terrassa Spain
| | - S Varea
- Hospital Clínic of Barcelona; Clinical Trials Unit/Clinical Pharmacology Department; Hospital Clinic Barcelona; Barcelona Spain
| | - J Ríos
- Biostatistics and Data Management Core Facility; IDIBAPS; Hospital Clinic Barcelona; Barcelona Spain
- Biostatistics Unit; School of Medicine; Universitat Autònoma de Barcelona; Barcelona Spain
| | - E Gratacós
- BCNatal; Hospital Clínic of Barcelona and Hospital Sant Joan de Déu; Fetal i+D Fetal Medicine Research Centre; IDIBAPS; University of Barcelona; Barcelona Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER); Barcelona Spain
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17
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Herington JL, Swale DR, Brown N, Shelton EL, Choi H, Williams CH, Hong CC, Paria BC, Denton JS, Reese J. High-Throughput Screening of Myometrial Calcium-Mobilization to Identify Modulators of Uterine Contractility. PLoS One 2015; 10:e0143243. [PMID: 26600013 PMCID: PMC4658040 DOI: 10.1371/journal.pone.0143243] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 11/02/2015] [Indexed: 12/27/2022] Open
Abstract
The uterine myometrium (UT-myo) is a therapeutic target for preterm labor, labor induction, and postpartum hemorrhage. Stimulation of intracellular Ca2+-release in UT-myo cells by oxytocin is a final pathway controlling myometrial contractions. The goal of this study was to develop a dual-addition assay for high-throughput screening of small molecular compounds, which could regulate Ca2+-mobilization in UT-myo cells, and hence, myometrial contractions. Primary murine UT-myo cells in 384-well plates were loaded with a Ca2+-sensitive fluorescent probe, and then screened for inducers of Ca2+-mobilization and inhibitors of oxytocin-induced Ca2+-mobilization. The assay exhibited robust screening statistics (Z´ = 0.73), DMSO-tolerance, and was validated for high-throughput screening against 2,727 small molecules from the Spectrum, NIH Clinical I and II collections of well-annotated compounds. The screen revealed a hit-rate of 1.80% for agonist and 1.39% for antagonist compounds. Concentration-dependent responses of hit-compounds demonstrated an EC50 less than 10μM for 21 hit-antagonist compounds, compared to only 7 hit-agonist compounds. Subsequent studies focused on hit-antagonist compounds. Based on the percent inhibition and functional annotation analyses, we selected 4 confirmed hit-antagonist compounds (benzbromarone, dipyridamole, fenoterol hydrobromide and nisoldipine) for further analysis. Using an ex vivo isometric contractility assay, each compound significantly inhibited uterine contractility, at different potencies (IC50). Overall, these results demonstrate for the first time that high-throughput small-molecules screening of myometrial Ca2+-mobilization is an ideal primary approach for discovering modulators of uterine contractility.
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Affiliation(s)
- Jennifer L. Herington
- Department of Pediatrics, Division of Neonatology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- * E-mail:
| | - Daniel R. Swale
- Department of Entomology, Louisiana State University Agricultural Center, Baton Rouge, Louisiana, United States of America
| | - Naoko Brown
- Department of Pediatrics, Division of Neonatology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Elaine L. Shelton
- Department of Pediatrics, Division of Neonatology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Hyehun Choi
- Department of Pediatrics, Division of Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Charles H. Williams
- Department of Cell and Developmental Biology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Charles C. Hong
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Bibhash C. Paria
- Department of Pediatrics, Division of Neonatology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Jerod S. Denton
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Jeff Reese
- Department of Pediatrics, Division of Neonatology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Cell and Developmental Biology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
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18
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Martinez de Tejada B, Karolinski A, Ocampo MC, Laterra C, Hösli I, Fernández D, Surbek D, Huespe M, Drack G, Bunader A, Rouillier S, López de Degani G, Seidenstein E, Prentl E, Antón J, Krähenmann F, Nowacki D, Poncelas M, Nassif JC, Papera R, Tuma C, Espoile R, Tiberio O, Breccia G, Messina A, Peker B, Schinner E, Mol BW, Kanterewicz L, Wainer V, Boulvain M, Othenin-Girard V, Bertolino MV, Irion O. Prevention of preterm delivery with vaginal progesterone in women with preterm labour (4P): randomised double-blind placebo-controlled trial. BJOG 2014; 122:80-91. [DOI: 10.1111/1471-0528.13061] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2014] [Indexed: 02/01/2023]
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19
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Haram K, Mortensen JHS, Morrison JC. Tocolysis for acute preterm labor: does anything work. J Matern Fetal Neonatal Med 2014; 28:371-8. [DOI: 10.3109/14767058.2014.918095] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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20
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Crankshaw DJ, Sweeney EM, O'Brien YM, Walsh JM, Dockery P, Morrison JJ. The influence of smooth muscle content and orientation in dissected human pregnant myometrial strips on contractility measurements. Eur J Pharmacol 2014; 738:245-9. [PMID: 24886879 DOI: 10.1016/j.ejphar.2014.05.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 05/20/2014] [Accepted: 05/21/2014] [Indexed: 11/19/2022]
Abstract
This study examined the hypothesis that the force generated by myometrial strips from pregnant women is influenced by the smooth muscle content and fibre orientation of the strips and that correcting for these structural variables will provide a more accurate measure of contractility. Myometrial strips (n=72) were contracted by exposure to KCl, oxytocin, U44619 and phenylephrine and maximum responses were recorded. Morphological techniques were used to determine the cross-sectional area of the strips, the area occupied by smooth muscle and the area occupied by smooth muscle longitudinal in the strip. Maximum responses to contractile agents were expressed in terms of these three variables. The mean cross sectional area of strips was 2.01 ± 0.06 mm(2), of which 50% was smooth muscle, and 18% was smooth muscle longitudinal in the strip (n=72). There was much heterogeneity in responses, smooth muscle content and fibre orientation. Correction for morphological variability did not improve the heterogeneity in responses where coefficients of variation among strips from the same donor ranged from 43% to 63% when expressed in relation to longitudinal smooth muscle cross-sectional area. The standard method of preparation of myometrial strips for in vitro recording results in samples that are not structurally uniform. Correcting for the known structural variables does not provide a more accurate measure of maximum contractile responses. Because of the heterogeneity shown here, experiments that are dependent upon accurate estimation of maximum contractile responses require a large number of replicates to reach meaningful conclusions.
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Affiliation(s)
- Denis J Crankshaw
- Department of Obstetrics and Gynaecology, National University of Ireland Galway, Galway, Ireland
| | - Eva M Sweeney
- Department of Anatomy, National University of Ireland Galway, Galway, Ireland
| | - Yvonne M O'Brien
- Department of Obstetrics and Gynaecology, National University of Ireland Galway, Galway, Ireland
| | - Jennifer M Walsh
- Department of Obstetrics and Gynaecology, National University of Ireland Galway, Galway, Ireland
| | - Peter Dockery
- Department of Anatomy, National University of Ireland Galway, Galway, Ireland
| | - John J Morrison
- Department of Obstetrics and Gynaecology, National University of Ireland Galway, Galway, Ireland.
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21
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Calcium channel blockers as tocolytics: principles of their actions, adverse effects and therapeutic combinations. Pharmaceuticals (Basel) 2013; 6:689-99. [PMID: 24276256 PMCID: PMC3816733 DOI: 10.3390/ph6060689] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 04/15/2013] [Accepted: 05/02/2013] [Indexed: 11/17/2022] Open
Abstract
Dihydropyridine Ca2+ channel blockers (CCBs) are widely accepted in the treatment of premature labour. Their mechanism of action in tocolysis involves the blockade of L-type Ca2+ channels, influenced by the Ca2+-activated K+ channels, beta-adrenergic receptors (β-ARs) and sexual hormones. In clinical practice, most experience has been gained with the use of nifedipine, whose efficacy is superior or comparable to those of β-agonists and oxytocin antagonists. Additionally, it has a favourable adverse effect profile as compared with the majority of other tocolytics. The most frequent and well-tolerated side-effects of CCBs are tachycardia, headache and hypotension. In tocolytic therapy efforts are currently being made to find combinations of tocolytic agents that yield better therapeutic action. The available human and animal studies suggest that the combination of CCBs with β-AR agonists is beneficial, although such combinations can pose risk of pulmonary oedema in multiple pregnancies and maternal cardiovascular diseases. Preclinical data indicate the potential benefit of combinations of CCBs and oxytocin antagonists. However, the combinations of CCBs with progesterone or cyclooxygenase inhibitors may decrease their efficacy. The CCBs are likely to remain one of the most important groups of drugs for the rapid inhibition of premature uterine contractions. Their significance may be magnified by further clinical studies on their combined use for tocolysis.
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22
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Conde-Agudelo A, Romero R, Nicolaides K, Chaiworapongsa T, O'Brien JM, Cetingoz E, da Fonseca E, Creasy G, Soma-Pillay P, Fusey S, Cam C, Alfirevic Z, Hassan SS. Vaginal progesterone vs. cervical cerclage for the prevention of preterm birth in women with a sonographic short cervix, previous preterm birth, and singleton gestation: a systematic review and indirect comparison metaanalysis. Am J Obstet Gynecol 2013; 208:42.e1-42.e18. [PMID: 23157855 PMCID: PMC3529767 DOI: 10.1016/j.ajog.2012.10.877] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 10/12/2012] [Accepted: 10/17/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE No randomized controlled trial has compared vaginal progesterone and cervical cerclage directly for the prevention of preterm birth in women with a sonographic short cervix in the mid trimester, singleton gestation, and previous spontaneous preterm birth. We performed an indirect comparison of vaginal progesterone vs cerclage using placebo/no cerclage as the common comparator. STUDY DESIGN Adjusted indirect metaanalysis of randomized controlled trials. RESULTS Four studies that evaluated vaginal progesterone vs placebo (158 patients) and 5 studies that evaluated cerclage vs no cerclage (504 patients) were included. Both interventions were associated with a statistically significant reduction in the risk of preterm birth at <32 weeks of gestation and composite perinatal morbidity and mortality compared with placebo/no cerclage. Adjusted indirect metaanalyses did not show statistically significant differences between vaginal progesterone and cerclage in the reduction of preterm birth or adverse perinatal outcomes. CONCLUSION Based on state-of-the-art methods for indirect comparisons, either vaginal progesterone or cerclage are equally efficacious in the prevention of preterm birth in women with a sonographic short cervix in the mid trimester, singleton gestation, and previous preterm birth. Selection of the optimal treatment needs to consider adverse events, cost and patient/clinician preferences.
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