Dj Carr

Treatment of poor placentation and the prevention of associated adverse outcomes - what does the future hold?

Poor placentation, which manifests as pre‐eclampsia and fetal growth restriction, is a major pregnancy complication. The underlying cause is a deficiency in normal trophoblast invasion of the spiral arteries, associated with placental inflammation, oxidative stress, and an antiangiogenic state. Peripartum therapies, such as prenatal maternal corticosteroids and magnesium sulphate, can prevent some of the adverse neonatal outcomes, but there is currently no treatment for poor placentation itself. Instead, management relies on identifying the consequences of poor placentation in the mother and fetus, with iatrogenic preterm delivery to minimise mortality and morbidity. Several promising therapies are currently under development to treat poor placentation, to improve fetal growth, and to prevent adverse neonatal outcomes. Interventions such as maternal nitric oxide donors, sildenafil citrate, vascular endothelial growth factor gene therapy, hydrogen sulphide donors, and statins address the underlying pathology, while maternal melatonin administration may provide fetal neuroprotection. In the future, these may provide a range of synergistic therapies for pre‐eclampsia and fetal growth restriction, depending on the severity and gestation of onset.

Ultrasonographic Assessment of Growth and Estimation of Birthweight in Late Gestation Fetal Sheep

Our aim was to identify which ultrasound parameters can be most accurately measured and best predict ovine fetal weight in late gestation. Singleton pregnancies were established using embryo transfer in 32 adolescent ewes, which were subsequently overnourished to produce fetuses of variable size (1720-6260 g). Ultrasound measurements at 126-133 days gestation were compared with fetal weight/biometry at late-gestation necropsy (n = 19) or term delivery (n = 13). Abdominal circumference (AC) and renal volume (RV) correlated best with physical measurements (r = 0.78-0.83) and necropsy/birth weight (r = 0.79-0.84). Combination of AC + RV produced an estimated fetal weight equation [Log EFW = 2.115 + 0.003 AC + 0.12 RV - 0.005 RV(2)] with highest adjusted R(2) (0.72) and lowest mean absolute/percentage prediction error (396-550 g/11.1%-13.2%). In conclusion, AC and RV are parameters of choice for assessment of late-gestation ovine fetal growth and can be used to estimate fetal weight with similar accuracy to human fetuses.

Peri- and Postnatal Effects of Prenatal Adenoviral VEGF Gene Therapy in Growth-Restricted Sheep

ABSTRACT Uterine artery (UtA) adenovirus (Ad) vector-mediated overexpression of vascular endothelial growth factor (VEGF) enhances uterine blood flow in normal sheep pregnancy and increases fetal growth in the overnourished adolescent sheep model of fetal growth restriction (FGR). Herein, we examined its impact on gestation length, neonatal survival, early postnatal growth and metabolism. Singleton-bearing ewes were evenly allocated to receive Ad.VEGF-A165 (5 × 1010 particles/ml, 10 ml, n = 17) or saline (10 ml, n = 16) injected into each UtA at laparotomy (0.6 gestation). Fetal growth was serially monitored (blind) by ultrasound until delivery. Lambs were weighed and blood was sampled weekly and a glucose tolerance test performed (68-day postnatal age). Hepatic DNA/RNA was extracted at necropsy (83-day postnatal age) to examine methylation status of eight somatotropic axis genes. IGF1 mRNA and protein expression were measured by RT-PCR and radioimmunoassay, respectively. All pregnancies remained viable following Ad.VEGF-A165 treatment. Fetal abdominal circumference and renal volume were greater in the Ad.VEGF-A165 group compared with the saline group at 21/28 days (P ≤ 0.04) postinjection. At delivery, gestation length (P = 0.07), lamb birthweight (P = 0.08), umbilical girth (P = 0.06), and plasma glucose (P = 0.09) tended to be greater in Ad.VEGF-A165-treated lambs. Levels of neonatal intervention required to ensure survival was equivalent between groups. Absolute postnatal growth rate (P = 0.02), insulin area under the curve (P = 0.04) and carcass weight at necropsy (P = 0.04) were increased by Ad.VEGF-A165 treatment. There was no impact on markers of insulin sensitivity or methylation/expression of key genes involved in somatic growth. Ad.VEGF-A165 gene therapy increased fetal growth in a sheep FGR model, and lambs continued to thrive during the neonatal and early postnatal period.

Raising the bar on the ethical standards of acupuncture research

Seeking prospective ethical approval from an institutional review board is an essential first step in both basic science and clinical acupuncture research. However, ethical responsibility extends well beyond this preliminary stage, covering both the conduct and reporting of research. The aim of this editorial is to define the minimum ethical standards required for publication in Acupuncture in Medicine and to highlight the two aspects with the poorest compliance among recently submitted articles—namely, prospective registration of clinical trials and detailed reporting of laboratory animal welfare. It has been over a decade since the International Committee of Medical Journal Editors (ICMJE) announced, in September 2004, that ICMJE-listed journals (including Acupuncture in Medicine and most mainstream biomedical publications) should not consider publishing clinical trials that started after 1 July 2005 unless they had prospective registration at or before the time of first patient enrolment.1 The ICMJE uses the WHO definition of a clinical trial, which is widely encompassing and includes “any research study that prospectively assigns human participants or groups of humans to one or more health-related interventions to evaluate the effects on health outcomes” (http://www.icmje.org/recommendations). A current list of acceptable clinical trials registries is available on the WHO International Clinical Trials Registry Platform. A comprehensive overview of the rationale behind clinical trial registration is …

The safety of obstetric acupuncture: forbidden points revisited

Background/Aim Although the safety of acupuncture per se in pregnancy is reasonably well accepted, there remains debate regarding needling at points historically considered to be ‘forbidden’ during pregnancy. This article reviews the scientific literature on this topic. Main Findings There is no objective evidence of harm following needling at forbidden points, summarised by the following four lines of evidence. (1) In 15 clinical trials (n=823 women receiving n=4549–7234 acupuncture treatments at one or more forbidden points) rates of preterm birth (PTB) and stillbirth following are equivalent to those in untreated control groups and consistent with background rates of these complications in the general population. (2) Observational studies, including a large cohort of 5885 pregnant women needled at forbidden points at all stage of pregnancy, demonstrate that rates of miscarriage, PTB, preterm prelabour rupture of membranes (PPROM), and preterm contractions (preterm labour (PTL) or threatened PTL) are comparable with untreated controls and/or consistent with their anticipated incidence. (3) There is no reliable evidence that acupuncture/electroacupuncture (EA) can induce miscarriage/labour, even under otherwise favourable circumstances such as post-dates pregnancy or intrauterine fetal death. (4) Laboratory experiments using pregnant rats have demonstrated that repeated EA at forbidden points throughout gestation does not influence rates of post-implantation embryonic demise or cause miscarriage, fetal loss or resorption. Conclusions These findings are reassuring and will help individualised risk:benefit assessment before treating pregnant women. Given the numerous evidence-based indications for obstetric acupuncture and lack of evidence of harm, risk:benefit assessments will often fall in favour of treatment.

Maternal testosterone and placental function: Effect of electroacupuncture on placental expression of angiogenic markers and fetal growth

Women with polycystic ovary syndrome (PCOS) have elevated circulating androgens during pregnancy and are at an increased risk of adverse pregnancy outcomes. Here we tested the hypotheses that maternal androgen excess decrease placental and fetal growth, and placental expression of markers of steroidogenesis, angiogenesis and sympathetic activity, and that acupuncture with low-frequency electrical stimulation prevents these changes. Pregnant rats were exposed to vehicle or testosterone on gestational day (GD)15-19. Low-frequency electroacupuncture (EA) or handling, as a control for the EA procedure, was given to control or testosterone exposed dams on GD16-20. On GD21, blood pressure was measured and maternal blood, fetuses and placentas collected. Placental steroid receptor expression and proteins involved in angiogenic, neurotrophic and adrenergic signaling were analyzed. EA did not affect any variables in control rats except maternal serum corticosterone, which was reduced. EA in testosterone exposed dams compared with controls increased systolic pressure by 30%, decreased circulating norepinephrine and corticosterone, fetal and placental weight and placental VEGFR1 and proNGF protein expression, and increased the VEGFA/VEGFR1 ratio, mature NGF (mNGF) and the mNGF/proNGF ratio. In conclusion, low-frequency EA in control animals did not have any negative influence on any of the studied variables. In contrast, EA in pregnant dams exposed to testosterone increased blood pressure and impaired placental growth and function, leading to decreased fetal growth.

Placental vascularity and markers of angiogenesis in relation to prenatal growth status in overnourished adolescent ewes

Introduction Placental vascularity may be important in the development of fetal growth restriction (FGR). The overnourished adolescent ewe is a robust model of the condition, with ∼50% of offspring demonstrating FGR (birthweight >2 standard deviations below optimally-fed control mean). We studied whether placental vascularity, angiogenesis and glucose transport reflect FGR severity. Methods Singleton pregnancies were established in adolescent ewes either overnourished to putatively restrict fetoplacental growth (n = 27) or control-fed (n = 12). At 131d (term = 145d) pregnancies were interrupted and fetuses classified as FGR (n = 17, <4222 g, -2SD below control-fed mean) or non-FGR (n = 10). Placentome capillary area density (CAD), number density (CND), surface density (CSD), and area per capillary (APC) in the fetal cotyledon (COT) and maternal caruncle (CAR) were analysed using immunostaining. COT/CAR mRNA expression of angiogenic ligands/receptors and glucose transporters were measured by qRT-PCR. Results Fetal weight was reduced in FGR vs. Non-FGR/Control groups. Total placentome weight was Control > Non-FGR > FGR and fetal:placental weight ratios were higher in overnourished versus Control groups. COT vascular indices were Non-FGR > FGR > Control. COT-CAD, CSD and APC were significantly greater in Non-FGR overnourished versus Control and intermediate in FGR groups. CAR vascularity did not differ. CAR-VEGFA/FLT1/KDR/ANGPT1/ANGPT2/SLC2A1/SLC2A3 mRNA was lower and COT-ANGPT2 higher in overnourished versus Control groups. Discussion Relative to control-intake pregnancy, overnourished pregnancies are characterised by higher COT vascularity, potentially a compensatory response to reduced nutrient supply, reflected by higher fetal:placental weight ratios. Compared with overnourished pregnancies where fetal growth is relatively preserved, overnourished pregnancies culminating in marked FGR have less placental vascularity, suggesting incomplete adaptation to the prenatal insult.

Somatosensory stimulation and assisted reproduction.

The role of somatosensory stimulation (acupuncture and related techniques) as an adjunct to assisted reproductive technology (ART) has been hotly debated over the past decade. In the last 6 years there have been no fewer than 12 meta-analyses of 34 randomised controlled trials (table 1). Systematic and narrative reviews of the literature often report conflicting findings and opinions. Despite this controversy, subfertility remains one of the most common reasons that women consult an acupuncturist.47 Meta-analysis of acupuncture trials is often challenging due to methodological diversity, and this is especially true for in vitro fertilisation (IVF) due to marked differences in timing (treatment given during the follicular phase, at the time of oocyte retrieval and/or embryo transfer (ET), and/or as luteal phase support) and the variety of interventions including manual acupuncture, electroacupuncture (EA), transcutaneous electrical acupuncture point stimulation (TEAS) and laser acupuncture. Various outcome measures have been used ranging from biochemical pregnancy rate to live birth rate (LBR), depending on the duration of follow-up. LBR (‘take home baby rate’) is considered to be the ideal primary outcome measure and is clearly most important to patients. Interestingly, concordance between studies with respect to point location is relatively high. The acupuncture points targeted generally correspond anatomically to the segmental innervation of the uterus and ovaries, irrespective of whether the primary approach to point selection is traditional or neurophysiological. …

Monitoring for Potential Adverse Effects of Prenatal Gene Therapy: Use of Large Animal Models with Relevance to Human Application

Safety is an absolute prerequisite for introducing any new therapy, and the need to monitor the consequences of administration of both vector and transgene to the fetus is particularly important. The unique features of fetal development that make it an attractive target for gene therapy, such as its immature immune system and rapidly dividing populations of stem cells, also mean that small perturbations in pregnancy can have significant short- and long-term consequences. Certain features of the viral vectors used, the product of the delivered gene, and sometimes the invasive techniques necessary to deliver the construct to the fetus in utero have the potential to do harm. An important goal of prenatal gene therapy research is to develop clinically relevant techniques that could be applied to cure or ameliorate human disease in utero on large animal models such as sheep or nonhuman primates. Equally important is the use of these models to monitor for potential adverse effects of such interventions. These large animal models provide good representation of individual patient-based investigations. However, analyses that require defined genetic backgrounds, high throughput, defined variability and statistical analyses, e.g. for initial studies on teratogenic and oncogenic effects, are best performed on larger groups of small animals, in particular mice. This chapter gives an overview of the potential adverse effects in relation to prenatal gene therapy and describes the techniques that can be used experimentally in a large animal model to monitor the potential adverse consequences of prenatal gene therapy, with relevance to clinical application. The sheep model is particularly useful to allow serial monitoring of fetal growth and well-being after delivery of prenatal gene therapy. It is also amenable to serially sampling using minimally invasive and clinically relevant techniques such as ultrasound-guided blood sampling. For more invasive long-term monitoring, we describe telemetric techniques to measure the haemodynamics of the mother or fetus, for example, that interferes minimally with normal animal behaviour. Implanted catheters can also be used for serial fetal blood sampling during gestation. Finally, we describe methods to monitor events around birth and long-term neonatal follow-up that are important when considering human translation of this therapy.

Alterations in postnatal growth and metabolism following prenatal treatment of intrauterine growth restriction with Ad.VEGF gene therapy in the sheep

Background Adenovirus (Ad) mediated overexpression of vascular endothelial growth factor (VEGF) in the uterine arteries of pregnant sheep increases uterine blood flow1. We recently demonstrated significantly increased fetal growth velocity following Ad. VEGF gene therapy in growth-restricted sheep fetuses2. Herein the subsequent effect on postnatal growth, metabolism and body composition in the same cohort was investigated. Methods Growth rate was determined weekly from birth until weaning in 31 lambs born following maternal administration of Ad. VEGF (n=16) or control saline (n=15) mid-pregnancy. At 7 weeks of age, following a 3 h fast, lambs were blood-sampled at −20, −10, 0, +5, +10, +15, +20, +25, +30, +45, +60, +90 and +120 min relative to an intravenous glucose bolus (0.25 g/kg). Plasma was analysed for insulin, glucose and non-esterified fatty acids (NEFA). At 12 weeks, lambs underwent necropsy and complete dissection. Results Postnatal growth velocity was increased in Ad. VEGF-treated lambs compared to controls (397 g/day vs 363 g/day, p=0.023). There was no difference in fractional growth rate, which was inversely related to birthweight (r=–0.910, p=<0.001) irrespective of treatment. Following glucose challenge, insulin area under the curve (AUC) was increased (p=0.04) and NEFA AUC increased (p=0.038) in Ad. VEGF versus saline groups. At necropsy there were no significant differences in perirenal fat or major organ weights. Conclusion Prenatal gene therapy for ovine fetal growth restriction results in enhanced postnatal accretion of lean tissue and altered metabolic function. This may indicate altered fetal programming secondary to therapeutic manipulation of the intrauterine environment.