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Mir IN, Uddin N, Liao J, Brown LS, Leon R, Chalak LF, Savani RC, Rosenfeld CR. Placental clearance not synthesis tempers exaggerated pro-inflammatory cytokine response in neonates exposed to chorioamnionitis. Pediatr Res 2023; 93:675-681. [PMID: 35690685 DOI: 10.1038/s41390-022-02147-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/03/2022] [Accepted: 05/17/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The source and clearance of cytokines in the fetal circulation in term pregnancies complicated by chorioamnionitis remains unclear as are the contributions of placental transport, synthesis, and clearance. The objectives of the study were to determine (1) fetal and/or placental contributions to synthesis and/or clearance of inflammatory and anti-inflammatory cytokines in term pregnancies complicated by chorioamnionitis and (2) whether this differs in pregnancies further complicated by fetal hypoxia. METHODS Prospective cohort study of pregnancies >37 weeks gestational age that included: Group 1, uncomplicated cesarean delivery without labor (n = 20); Group 2, uncomplicated vaginal delivery (n = 30); Group 3, pregnancies complicated by chorioamnionitis (n = 10); Group 4, complicated by chorioamnionitis + fetal hypoxia (n = 10). Umbilical arterial (UmA) and venous (UmV) blood were assayed for IL-1β, IL-2, IL-6, IL-8, TNFα, and IL-10. RESULTS IL-6 and IL-8 were below assay detection in UmA and UmV blood in Group 1 and increased in Group 2 (P < 0.01), UmA»UmV (P < 0.01). Their concentrations increased further in Groups 3 and 4 (P = 0.003), UmA»UmV. Placental clearance was concentration dependent that approaches saturation in the presence of chorioamnionitis. CONCLUSIONS Marked increases in fetal synthesis of IL-6 and IL-8 occur in chorioamnionitis. Synthesis increase further when complicated by fetal hypoxia. Cytokine removal occurs via placental concentration-dependent mechanisms, potentially contributing to adverse fetal effects. IMPACT The source and role of the placenta in synthesis and/or clearance of inflammatory mediators in term pregnancies complicated by clinical chorioamnionitis are unclear; however, conventional wisdom suggests the placenta is their source. This is the first study demonstrating that circulating concentrations of fetal IL-6 and IL-8 in clinical chorioamnionitis ± birth asphyxia in term pregnancies are of fetal origin. Circulating fetal inflammatory cytokines are cleared by concentration-dependent placental mechanisms that are nearly saturated in chorioamnionitis ± fetal hypoxia. These observations provide additional insight into understanding the fetal immune response in term pregnancies complicated by clinical chorioamnionitis.
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Affiliation(s)
- Imran N Mir
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Naseem Uddin
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jie Liao
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.,The Center for Pulmonary & Vascular Biology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Larry S Brown
- Parkland Health and Hospital Systems, Dallas, TX, USA
| | - Rachel Leon
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lina F Chalak
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rashmin C Savani
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.,The Center for Pulmonary & Vascular Biology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Charles R Rosenfeld
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Zarate MA, Wesolowski SR, Nguyen LM, De Dios RK, Wilkening RB, Rozance PJ, Wright CJ. In utero inflammatory challenge induces an early activation of the hepatic innate immune response in late gestation fetal sheep. Innate Immun 2020; 26:549-564. [PMID: 32538259 PMCID: PMC7556190 DOI: 10.1177/1753425920928388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/20/2020] [Accepted: 04/26/2020] [Indexed: 12/15/2022] Open
Abstract
Chorioamnionitis is associated with inflammatory end-organ damage in the fetus. Tissues in direct contact with amniotic fluid drive a pro-inflammatory response and contribute to this injury. However, due to a lack of direct contact with the amniotic fluid, the liver contribution to this response has not been fully characterized. Given its role as an immunologic organ, we hypothesized that the fetal liver would demonstrate an early innate immune response to an in utero inflammatory challenge. Fetal sheep (131 ± 1 d gestation) demonstrated metabolic acidosis and high cortisol and norepinephrine values within 5 h of exposure to intra-amniotic LPS. Likewise, expression of pro-inflammatory cytokines increased significantly at 1 and 5 h of exposure. This was associated with NF-κB activation, by inhibitory protein IκBα degradation, and nuclear translocation of NF-κB subunits (p65/p50). Corroborating these findings, LPS exposure significantly increased pro-inflammatory innate immune gene expression in fetal sheep hepatic macrophages in vitro. Thus, an in utero inflammatory challenge induces an early hepatic innate immune response with systemic metabolic and stress responses. Within the fetal liver, hepatic macrophages respond robustly to LPS exposure. Our results demonstrate that the fetal hepatic innate immune response must be considered when developing therapeutic approaches to attenuate end-organ injury associated with in utero inflammation.
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Affiliation(s)
- Miguel A Zarate
- Section of Neonatology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Stephanie R Wesolowski
- Section of Neonatology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Leanna M Nguyen
- Section of Neonatology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Robyn K De Dios
- Section of Neonatology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Randall B Wilkening
- Section of Neonatology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Paul J Rozance
- Section of Neonatology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Zhang J, Luo X, Huang C, Pei Z, Xiao H, Luo X, Huang S, Chang Y. Erythropoietin prevents LPS-induced preterm birth and increases offspring survival. Am J Reprod Immunol 2020; 84:e13283. [PMID: 32506750 PMCID: PMC7507205 DOI: 10.1111/aji.13283] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/13/2020] [Accepted: 06/01/2020] [Indexed: 12/17/2022] Open
Abstract
Problem Preterm delivery is the leading cause of neonatal mortality and contributes to delayed physical and cognitive development in children. At present, there is no efficient therapy to prevent preterm labor. A large body of evidence suggests that infections might play a significant and potentially preventable cause of premature birth. This work assessed the effects of erythropoietin (EPO) in a murine model of inflammation‐associated preterm delivery, which mimics central features of preterm infections in humans. Method of study BALB/c mice were injected i.p. with 20 000 IU/kg EPO or normal saline twice on gestational day (GD) 15, with a 3 hours time interval between injections. An hour after the first EPO or normal saline injection, all mice received two injections of 50 μg/kg LPS, also given 3 hours apart. Results EPO significantly prevented preterm labor and increased offspring survival in an LPS induced preterm delivery model. EPO prevented LPS‐induced leukocyte infiltration into the placenta. Moreover, EPO inhibited the expression of pro‐inflammatory cytokines, interleukin‐1β (IL‐1β), interleukin‐6 (IL‐6), and tumour necrosis factor‐α (TNF‐α) in maternal serum and amniotic fluid. EPO also prevented LPS‐induced increase in placental prostaglandin (PG)E2 and uterine inducible nitric oxide synthase (iNOS) production, while decreasing nuclear factor kappa‐B (NF‐κβ) activity in the myometrium. EPO also increased the gene expression of placental programmed cell death ligand 1 (PD‐L1) in LPS‐treated mice. Conclusions Our results suggest that EPO could be a potential novel therapeutic strategy to tackle infection‐related preterm labor.
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Affiliation(s)
- Jie Zhang
- Department of Rehabilitation, Guangdong Women and Children Hospital, Guangzhou, China
| | - Xianqiong Luo
- Department of Pediatrics, Guangdong Women and Children Hospital, Guangzhou, China
| | - Caicai Huang
- Department of Obstetrics, Guangdong Women and Children Hospital, Guangzhou, China
| | - Zheng Pei
- Department of Rehabilitation, Guangdong Women and Children Hospital, Guangzhou, China
| | - Huimei Xiao
- Department of Rehabilitation, Guangdong Women and Children Hospital, Guangzhou, China
| | - Xingang Luo
- Department of Rehabilitation, Guangdong Women and Children Hospital, Guangzhou, China
| | - Shuangmiao Huang
- Department of Rehabilitation, Guangdong Women and Children Hospital, Guangzhou, China
| | - Yanqun Chang
- Department of Rehabilitation, Guangdong Women and Children Hospital, Guangzhou, China
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Christensen RD. Medicinal Uses of Hematopoietic Growth Factors in Neonatal Medicine. Handb Exp Pharmacol 2019; 261:257-283. [PMID: 31451971 DOI: 10.1007/164_2019_261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
This review focuses on certain hematopoietic growth factors that are used as medications in clinical neonatology. It is important to note at the chapter onset that although all of the pharmacological agents mentioned in this review have been approved by the US Food and Drug administration for use in humans, none have been granted a specific FDA indication for neonates. Thus, in a sense, all of the agents mentioned in this chapter could be considered experimental, when used in neonates. However, a great many of the pharmacological agents utilized routinely in neonatology practice do not have a specific FDA indication for this population of patients. Consequently, many of the agents reviewed in this chapter are considered by some practitioners to be nonexperimental and are used when they judge such use to be "best practice" for the disorders under treatment.The medicinal uses of the agents in this chapter vary considerably, between geographic locations, and sometimes even within an institutions. "Consistent approaches" aimed at using these agents in uniform ways in the practice of neonatology are encouraged. Indeed some healthcare systems, and some individual NICUs, have developed written guidelines for using these agents within the practice group. Some such guidelines are provided in this review. It should be noted that these guidelines, or "consistent approaches," must be viewed as dynamic and changing, requiring adjustment and refinement as additional evidence accrues.
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Affiliation(s)
- Robert D Christensen
- Divisions of Neonatology and Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA. .,Intermountain Healthcare, Salt Lake City, UT, USA.
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Mejaddam AY, Hornick MA, McGovern PE, Baumgarten HD, Lawrence KM, Rossidis AC, Hwang G, Young K, Abdulmalik O, Partridge EA, Peranteau WH, Davey MG, Flake AW. Erythropoietin Prevents Anemia and Transfusions in Extremely Premature Lambs Supported by an EXTrauterine Environment for Neonatal Development (EXTEND). Fetal Diagn Ther 2019; 46:231-237. [PMID: 30703769 DOI: 10.1159/000493680] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 09/11/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND We recently developed an EXTrauterine Environment for Neonatal Development (EXTEND) that provides physiologic support for premature lambs. Here, we assess the efficacy of exogenous erythropoietin (EPO) to prevent anemia and transfusions on EXTEND. MATERIALS AND METHODS Lambs were cannulated at 0.7 gestation and supported on EXTEND for up to 4 weeks. The lambs were divided into three groups: (1) No EPO, (2) Low EPO (300 U kg-1 per day), and (3) High EPO (800 U kg-1 per day). Daily hematocrit and weekly complete blood count were assessed. RESULTS The mean percentage change in hematocrit from baseline was significantly different between the groups (No EPO -23.6 ± 7.8% vs. Low EPO -16.6 ± 6.4% vs. High EPO +2.6 ± 6.6%; p = 0.02). This occurred despite a greater median number of blood transfusions in the No EPO group (5 vs. 1 vs. 0; p = 0.02). EPO administration was associated with a higher mean corpuscular volume (MCV; p < 0.01) and reticulocyte count (p = 0.02). The High EPO group was comparable to in utero control fetuses with respect to hematocrit (p = 0.49), MCV (p = 0.24), and reticulocyte count (p = 0.68). CONCLUSIONS EPO (800 U kg-1 per day) prevents anemia, eliminates transfusions, and restores normal red blood cell indices in premature lambs supported by EXTEND.
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Affiliation(s)
- Ali Y Mejaddam
- The Center for Fetal Research, Division of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew A Hornick
- The Center for Fetal Research, Division of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Patrick E McGovern
- The Center for Fetal Research, Division of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heron D Baumgarten
- The Center for Fetal Research, Division of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kendall M Lawrence
- The Center for Fetal Research, Division of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Avery C Rossidis
- The Center for Fetal Research, Division of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Grace Hwang
- The Center for Fetal Research, Division of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kathleen Young
- The Center for Fetal Research, Division of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Osheiza Abdulmalik
- Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Emily A Partridge
- The Center for Fetal Research, Division of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - William H Peranteau
- The Center for Fetal Research, Division of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marcus G Davey
- The Center for Fetal Research, Division of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alan W Flake
- The Center for Fetal Research, Division of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,
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Chang YL, Chao AS, Peng HH, Chang SD, Chen KJ, Cheng PJ, Wang TH. Placental erythropoietin expression is upregulated in growth-restricted fetuses with abnormal umbilical artery Doppler findings: a case-control study of monochorionic twins. BMC Pregnancy Childbirth 2018; 18:321. [PMID: 30089456 PMCID: PMC6083520 DOI: 10.1186/s12884-018-1963-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 08/03/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND We previously reported that fetal plasma erythropoietin (EPO) concentrations are significantly increased in growth-restricted fetuses with abnormal umbilical artery (UA) Doppler. During hypoxia in an ovine model, the primary site of fetal EPO synthesis was switched from the kidneys to the placenta. Therefore, we designed this study to evaluate human placental EPO gene expression and the correlation to fetal serum EPO concentration in growth-restricted fetuses in a monochorionic (MC) twin model. METHODS In MC twin pairs, selective intrauterine growth restriction (sIUGR) was defined as the presence of (i) birth weight discordance of > 20% and (ii) a smaller twin with a birth weight less than the 10th percentile. Fetal UA and middle cerebral artery (MCA) Doppler were checked within 1 week before delivery. An abnormal UA Doppler was defined as persistently absent or reverse end-diastolic flow. Cerebroplacental ratio (CPR) was defined as MCA-pulsatility index (PI)/UA-PI. Fetal plasma EPO concentrations were measured in cord blood, and EPO gene expression was assayed in each twin's placental territory. The intertwin plasma EPO ratio was calculated as the cord plasma EPO level of the smaller (or sIUGR) twin divided by the EPO concentration of the larger (or appropriate-for-gestational-age (AGA)) twin, and the intertwin placental EPO gene expression ratio was calculated similarly. RESULTS Twenty-six MC twins were analyzed, including normal twins (Group 1, n = 9), twins with sIUGR without UA Doppler abnormalities (Group 2, n = 9), and twins with sIUGR and UA Doppler abnormalities (Group 3, n = 8). The CPRs of smaller (sIUGR) fetuses were significantly decreased in Group 3 MC twins (p < 0.001), but not significantly different between Group 1 and Group 2. The highest fetal plasma EPO ratio and placental EPO gene expression ratio were identified in Group 3 MC twins (p < 0.001). The placental EPO gene expression ratios were significantly correlated with the fetal plasma EPO ratios (Pearson's correlation test, p = 0.004). CONCLUSION This study provides evidence of increased placental EPO expression in MC twin fetuses with sIUGR and abnormal UA Doppler. Future studies are needed to confirm the similar role of placental EPO in severe IUGR singletons.
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Affiliation(s)
- Yao-Lung Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No.5, Fu-Shin Road, Gwei-Shan District, Taoyuan City, Taiwan
| | - An-Shine Chao
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No.5, Fu-Shin Road, Gwei-Shan District, Taoyuan City, Taiwan
| | - Hsiu-Huei Peng
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No.5, Fu-Shin Road, Gwei-Shan District, Taoyuan City, Taiwan
| | - Shuenn-Dyh Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No.5, Fu-Shin Road, Gwei-Shan District, Taoyuan City, Taiwan
| | - Kuan-Ju Chen
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No.5, Fu-Shin Road, Gwei-Shan District, Taoyuan City, Taiwan
| | - Po-Jen Cheng
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No.5, Fu-Shin Road, Gwei-Shan District, Taoyuan City, Taiwan
| | - Tzu-Hao Wang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No.5, Fu-Shin Road, Gwei-Shan District, Taoyuan City, Taiwan. .,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, No.5, Fu-Shin Road, Gwei-Shan District, Taoyuan City, Taiwan. .,Genomic Medicine Research Core Laboratory (GMRCL), Chang Gung Memorial Hospital, No.5, Fu-Shin Road, Gwei-Shan District, Taoyuan City, Taiwan.
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Abstract
OBJECTIVE The objectives of this study were to survey the current research and provide an update on the uses and benefits of erythropoietin (EPO) in pregnancy and the postpartum period. DATA SOURCES A review of MEDLINE (1947 to present) was performed. Search terms included "erythropoietin," "pregnan*," with subheadings of "administration & dosage," "pharmacokinetics," "therapeutic use," "fetus," "fertility." METHOD OF STUDY SELECTION We reviewed relevant articles published from 2002 to 2012. Case reports, observational studies, case-control studies, randomized controlled trials, retrospective analyses, animal studies, and review articles were included. Articles were selected if they discussed a use of EPO in pregnancy or the immediate postpartum period, as well as use of EPO in the neonate. TABULATION, INTEGRATION, AND RESULTS Authors independently reviewed and extracted data. Of the 65 articles reviewed, 45 were included. Erythropoietin was used in the treatment of maternal anemia. Because of the molecule's large size, recombinant EPO does not appear to cross the placenta. No fetal morbidity or mortality was noted. Therefore, this is a safe therapy that can be used in pregnancy. Use of EPO may be especially important for women who decline blood products. Neonatal uses of EPO show benefit in the treatment of anemia due to blood type incompatibility. CONCLUSIONS Erythropoietin is gaining popularity as a therapeutic option during pregnancy and the postpartum period. Further investigation is needed to establish a standard dosage and dosing interval. New studies reviewing its use in the neonate for perinatal-hypoxic injury and anemia due to blood type incompatibility provide exciting opportunities for further therapeutic use. TARGET AUDIENCE Obstetricians and gynecologists, family physicians. LEARNING OBJECTIVES After completing this CME activity, physicians should be better able to treat anemia in pregnancy, including causes and interventions; assess renal disease in pregnancy, targets of hemoglobin, precautions, and treatment considerations; and evaluate erythropoietin use in neonates and fetuses, including benefits, complications, and areas for upcoming research/uses.
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Rees S, Harding R, Walker D. The biological basis of injury and neuroprotection in the fetal and neonatal brain. Int J Dev Neurosci 2011; 29:551-63. [PMID: 21527338 PMCID: PMC3168707 DOI: 10.1016/j.ijdevneu.2011.04.004] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 04/08/2011] [Indexed: 12/29/2022] Open
Abstract
A compromised intrauterine environment that delivers low levels of oxygen and/or nutrients, or is infected or inflammatory, can result in fetal brain injury, abnormal brain development and in cases of chronic compromise, intrauterine growth restriction. Preterm birth can also be associated with injury to the developing brain and affect the normal trajectory of brain growth. This review will focus on the effects that episodes of perinatal hypoxia (acute, chronic, associated with inflammation or as an antecedent of preterm birth) can have on the developing brain. In animal models of these conditions we have found that relatively brief (acute) periods of fetal hypoxemia can have significant effects on the fetal brain, for example death of susceptible neuronal populations (cerebellum, hippocampus, cortex) and cerebral white matter damage. Chronic placental insufficiency which includes fetal hypoxemia, nutrient restriction and altered endocrine status can result in fetal growth restriction and long-term deficits in neural connectivity in addition to altered postnatal function, for example in the auditory and visual systems. Maternal/fetal inflammation can result in fetal brain damage, particularly but not exclusively in the white matter; injury is more pronounced when associated with fetal hypoxemia. In the baboon, in which the normal trajectory of growth is affected by preterm birth, there is a direct correlation between a higher flux in oxygen saturation and a greater extent of neuropathological damage. Currently, the only established therapy for neonatal encephalopathy in full term neonates is moderate hypothermia although this only offers some protection to moderately but not severely affected brains. There is no accepted therapy for injured preterm brains. Consequently the search for more efficacious treatments continues; we discuss neuroprotective agents (erythropoietin, N-acetyl cysteine, melatonin, creatine, neurosteroids) which we have trialed in appropriate animal models. The possibility of combining hypothermia with such agents or growth factors is now being considered. A deeper understanding of causal pathways in brain injury is essential for the development of efficacious strategies for neuroprotection.
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Affiliation(s)
- Sandra Rees
- Department of Anatomy and Cell Biology, University of Melbourne, Vic. 3010, Australia.
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Romero R, Alpay Savasan Z, Chaiworapongsa T, Berry SM, Kusanovic JP, Hassan SS, Yoon BH, Edwin S, Mazor M. Hematologic profile of the fetus with systemic inflammatory response syndrome. J Perinat Med 2011; 40:19-32. [PMID: 21957997 PMCID: PMC3380620 DOI: 10.1515/jpm.2011.100] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Accepted: 07/19/2011] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The fetal inflammatory response syndrome (FIRS) is associated with impending onset of preterm labor/delivery, microbial invasion of the amniotic cavity and increased perinatal morbidity. FIRS has been defined by an elevated fetal plasma interleukin (IL)-6, a cytokine with potent effects on the differentiation and proliferation of hematopoietic precursors. The objective of this study was to characterize the hematologic profile of fetuses with FIRS. STUDY DESIGN Fetal blood sampling was performed in patients with preterm prelabor rupture of membranes and preterm labor with intact membranes (n=152). A fetal plasma IL-6 concentration ≥ 11 pg/mL was used to define FIRS. Hemoglobin concentration, platelet count, total white blood cell (WBC) count, differential count, and nucleated red blood cell (NRBC) count were obtained. Since blood cell count varies with gestational age, the observed values were corrected for fetal age by calculating a ratio between the observed and expected mean value for gestational age. RESULTS 1) The prevalence of FIRS was 28.9% (44/152); 2) fetuses with FIRS had a higher median corrected WBC and corrected neutrophil count than those without FIRS (WBC: median 1.4, range 0.3-5.6, vs. median 1.1, range 0.4-2.9, P=0.001; neutrophils: median 3.6, range 0.1-57.5, vs. median 1.8, range 0.2-13.9, P<0.001); 3) neutrophilia (defined as a neutrophil count >95th centile of gestational age) was significantly more common in fetuses with FIRS than in those without FIRS (71%, 30/42, vs. 35%, 37/105; P<0.001); 4) more than two-thirds of fetuses with FIRS had neutrophilia, whereas neutropenia was present in only 4.8% (2/42); 5) FIRS was not associated with detectable changes in hemoglobin concentration, platelet, lymphocyte, monocyte, basophil or eosinophil counts; and 6) fetuses with FIRS had a median corrected NRBC count higher than those without FIRS. However, the difference did not reach statistical significance (NRBC median 0.07, range 0-1.3, vs. median 0.04, range 0-2.3, P=0.06). CONCLUSION The hematologic profile of the human fetus with FIRS is characterized by significant changes in the total WBC and neutrophil counts. The NRBC count in fetuses with FIRS tends to be higher than fetuses without FIRS.
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver, National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Detroit, MI 48201, USA.
| | - Zeynep Alpay Savasan
- Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Hutzel Women’s Hospital, Bethesda, MD, and Detroit, MI, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine/Hutzel Women’s Hospital, Detroit, MI, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Hutzel Women’s Hospital, Bethesda, MD, and Detroit, MI, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine/Hutzel Women’s Hospital, Detroit, MI, USA
| | | | - Juan Pedro Kusanovic
- Department of Obstetrics and Gynecology, Pontificia Universidad Católica de Chile, Santiago, Chile,Center for Perinatal Research, Sótero del Río Hospital, Santiago, Chile
| | - Sonia S. Hassan
- Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Hutzel Women’s Hospital, Bethesda, MD, and Detroit, MI, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine/Hutzel Women’s Hospital, Detroit, MI, USA
| | - Bo Hyun Yoon
- Seoul National University College of Medicine, Seoul, Korea
| | | | - Moshe Mazor
- Department of Obstetrics and Gynecology, Soroka Medical Center, Ben Gurion University of Negev, Beer Sheva, Israel
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