BACKGROUND: Antenatal steroids (ANS) are routinely administered to women at risk of preterm birth to accelerate fetal lung maturation. Despite extensive clinical use, dosing and route of ANS administration remain unoptimized beyond intramuscular (IM) injection. We aimed to undertake a proof-of-principle assessment of transdermal ANS administration for accelerated fetal lung maturation. METHODS: We formulated and tested a transdermal ANS (betamethasone) patch in ex vivo studies. To confirm in vivo transdermal distribution of the ANS patch, we undertook a 24-h pharmacokinetic study in non-pregnant cynomolgus macaques (NHP). To assess the efficacy of transdermal betamethasone on fetal lung maturation, we used a preterm sheep model of pregnancy comparing postnatal ventilation outcomes. Date mated ewes received either of the following: (i) IM normal saline (Saline Control, n = 13); (ii) IM ANS (betamethasone) delivery 2 or 8 days post-treatment (2-Day IM ANS, n = 14; 8-day IM ANS Group, n = 6); (iii) IM saline + 2 × transdermal ANS (Betamethasone) patches delivery 2 days post-treatment (2-Day ANS Patch, n = 10); or (iv) IM saline + 2 × transdermal ANS (betamethasone) patches replaced with 2 × new patches after 48 h, delivery 8 days post-treatment (8-Day ANS Patch, n = 11). Lambs were delivered at 123 ± 1 dGA (term 150 days), then ventilated for 30 min to assess lung maturation status. Arterial blood gas, delivery, and ventilation data were analyzed (p < 0.05 significant). RESULTS: Transdermal administration of ANS in NHPs achieved rapid plasma accumulation, with a plasma half-life of 8.9 h, similar to that achieved with IM dosing in clinical practice. In preterm sheep, all 2- and 8-day IM and transdermal ANS patch groups had clinically important and statistically significant improvements in ventilation parameters (umbilical PaCO2, pH, tidal volume) compared to saline control. CONCLUSIONS: We demonstrate, for the first time, the potential for using transdermal ANS for preterm fetal lung maturation. Transdermal ANS administration eliminates the need for injections, pain, and infection risk. Moreover, transdermal ANS delivery demonstrates advantages in dose control, continuity of exposure, and potential to remove drug exposure should the risk of preterm birth resolve. Further development of this technology may improve preterm outcomes through delivery of a low dose, constant fetal steroid exposure.

BACKGROUND: A lack of tests to assess fetal development impacts decision making around antenatal steroid use in women at risk of preterm birth. We analyzed the expression of 21 cfRNA targets related to human fetal lung maturation. Discovery studies were performed using maternal and fetal sheep plasma, with results compared to fetal lung mRNA expression. These findings were then validated in first, second, and third trimester human maternal plasma samples. METHODS: Discovery studies utilized a preterm sheep model of pregnancy. Date mated ewes received saline (control n = 6), or antenatal steroids (dexamethasone n = 12) (betamethasone n = 11) prior to delivery and ventilation. We analyzed the expression of 21 human cfRNA targets related to lung maturation in maternal and fetal sheep plasma and compared this to mRNA expression in fetal lung tissue. Findings were first validated in a separate cohort of sheep exposed to betamethasone (n = 8), intraamniotic LPS endotoxin for lung maturation (n = 6), or untreated term animals (n = 6). Findings were further validated in maternal plasma from a human cohort of uncomplicated term pregnancies (n = 10). Delivery and ventilation data were analyzed with ANOVA, Tukey HSD, and Dunnett T3 tests. A Random Forest algorithm identified genes that separated mature from immature fetal lung subgroups and determined AUC values for maternal and fetal cell-free RNA (cfRNA) feature sets to predict fetal lung maturation. RESULTS: We demonstrate that the analysis of 21 human cfRNA targets in maternal plasma is highly predictive of fetal lung maturation status across antenatal steroid induced (Dexamethasone AUC = 0.93; Betamethasone AUC = 1) and physiological (AUC = 1) lung development models. Maternal plasma cfRNA expression in the dexamethasone antenatal steroid group closely resembled direct fetal lung tissue mRNA expression. These findings were then validated in human maternal plasma samples (1st vs. 3rd trimester AUC = 0.96; 2nd vs. 3rd trimester AUC = 1). CONCLUSIONS: Further development of this technology may provide a rapid, minimally invasive, and cost-effective clinical tool to optimize patient selection for initial and repeat courses of antenatal steroids, along with insights into the molecular mechanisms underlying fetal lung development.

The management and prevention of key inflammatory-associated pregnancy complications such as chorioamnionitis and pre-eclampsia is hampered by a lack of early gestation risk screening tools. In a proof-of-principle study we used targeted cell-free RNA analyses of maternal plasma samples from large animal (sheep) and human pregnancy cohorts to develop a minimally invasive screening test for inflammatory markers. This study utilised a preterm sheep model of sterile and bacterial chorioamnionitis. Date-mated ewes received either intraamniotic Saline Control (n = 10) or E.Coli LPS (Sterile chorioamnionitis) with 2 days (n = 9) or 8 days exposure(n = 6). Preterm lambs were delivered at 124 ± 1d gestation. Findings were validated in a bacterial model of chorioamnionitis where ewes were exposed to 7 days of intraamniotic M.Hominis with delivery at 98 d gestion(n = 8) or 128d gestation(n = 8). Maternal blood was collected prior to intervention and at delivery in each group. Random Forest algorithm was used to analyse 8 cell-free RNA(cfRNA) targets related to inflammation in maternal plasma at baseline and delivery, identifying genes that separated animals with or without intrauterine inflammation. Plasma cfRNA data was compared to mRNA expression in placental tissue. Haematological and placental mRNA comparisons were analysed with ANOVA/Tukey HSD/Dunnett T3 tests. Maternal plasma cfRNA findings of intrauterine inflammation were then validated in human plasma samples from a cohort of patients with late onset pre-eclampsia (n = 10) or uncomplicated pregnancies (n = 10). We present data showing that targeted maternal cfRNA assays can accurately identify chorioamnionitis of sterile (AUC 1.0) and infectious (AUC 0.84) origin in a sheep model of pregnancy. Findings were then validated in human maternal plasma samples from patients with late-onset pre-eclampsia in the 1st (AUC = 0.85), 2nd (AUC = 0.90) and 3rd (AUC = 0.82) trimesters. In both sheep and human model systems, cfRNA tests offered high levels of sensitivity and specificity in the absence of overt clinical symptoms. We suggest that further development of this technology may serve as a scalable, rapidly deployed and cost-effective means for predicting major inflammatory conditions in pregnancy.

Intrauterine inflammation is a significant cause of early preterm birth and fetal injury. There is a lack of effective interventions for intrauterine inflammation. This study aimed to determine whether direct fetal treatment with IL-1 receptor antagonists (IL-1RA), specifically anakinra (competitive IL-1RA) or rytvela (allosteric IL-1RA), could reduce intrauterine inflammation caused by intraamniotic injection of E. coli lipopolysaccharides (LPS) in a sheep model of pregnancy. We hypothesized the fetal intramuscular administration of IL1-RA therapy would comprehensively resolve intrauterine inflammation caused by LPS in the pregnant sheep model. Date-mated Merino ewes carrying single fetuses were randomized into four groups: LPS Group (10 mg intraamniotic LPS injection followed by saline), RYTVELA Group (10 mg LPS injection followed by 5 mg rytvela), ANAKINRA Group (LPS injection followed by 100 mg anakinra), and SALINE Group (saline injection followed by saline). All LPS-exposed fetuses had elevated bilirubin levels, leukopenia, and increased inflammatory mediators IL-1β, IL-8, tumour necrosis factor alpha (TNFα), and monocyte chemoattractant protein 1 (MCP-1) in amniotic fluid and lung tissue. Both anakinra and rytvela treatments reduced immunocyte infiltration in chorioamniotic membranes and lungs, and microglial staining, and increased the oligodendrocyte staining, but did not significantly resolve overall inflammation compared to the SALINE Group. In conclusion, fetal intramuscular administration of anakinra and rytvela did not effectively resolve intrauterine inflammation but showed potential in reducing tissue invasion and brain injury markers. These findings suggest that modest inflammation reduction may protect against brain injury and preterm birth, though no additional benefit was observed compared to intraamniotic IL-1RA treatment.

BACKGROUND: Antenatal steroid (ANS) therapy is given to women at risk of preterm delivery to accelerate fetal lung maturation. However, the benefit of ANS therapy is variable and how maternal and fetal factors contribute to this observed variability is unknown. We aimed to test the degree of concordance in preterm lung function, and correlate this with genomic, transcriptomic, and pharmacokinetic variables in preterm dizygotic twin ovine fetuses. METHODS: Thirty-one date-mated ewes carrying twin fetuses at 123 ± 1 days' gestation received maternal intramuscular injections of either (i) 1 × 0.25 mg/kg betamethasone phosphate and acetate (CS1, n = 11 twin pairs) or (ii) 2 × 0.25 mg/kg betamethasone phosphate and acetate, 24 h apart (CS2, n = 10 twin pairs) or (iii) 2 × saline, 24 h apart (negative control, n = 10 twin pairs). Fetuses were surgically delivered 24 h after their final treatment and ventilated for 30 min. RESULTS: ANS-exposed female fetuses had lower arterial partial pressure of carbon dioxide (PaCO2) values than male fetuses (76.5 ± 38.0 vs. 97.2 ± 42.5 mmHg), although the observed difference was not statistically significant (p = 0.1). Only 52% of ANS-treated twins were concordant for lung maturation responses. There was no difference in fetal lung tissue or plasma steroid concentrations within or between twin pairs. Genomic analysis identified 13 single-nucleotide polymorphisms (SNPs) statistically associated with ANS-responsiveness, including in the proto-oncogene MET and the transcription activator STAT1. CONCLUSIONS: Twin fetal responses and ANS tissue levels were comparable with those from singleton fetuses in earlier studies. Twin ovine fetuses thus benefit from ANS in a similar manner to singleton fetuses, and a larger dose of betamethasone is not required. Assuming no difference in input from the placental or maternal compartments, fetal lung responses to ANS therapy in dizygotic twin preterm lambs are dependent on the fetus itself. These data suggest a potential heritable role in determining ANS responsiveness.

OBJECTIVE: Extremely preterm infants have low Nuclear Receptor (NR) expression in their developing hepatobiliary systems, as they rely on the placenta and maternal liver for compensation. NRs play a crucial role in detoxification and the elimination of both endogenous and xenobiotic substances by regulating key genes encoding specific proteins. In this study, we utilized an Artificial Placenta Therapy (APT) platform to examine the liver tissue expression of NRs of extremely preterm ovine fetuses. This fetal model, resembling a "knockout placenta," lacks placental and maternal support, while maintaining a healthy extrauterine survival. METHODS: Six ovine fetuses at 95 ± 1 d gestational age (GA; term = ∼150 d)/∼600 g delivery weight were maintained on an APT platform for a period of 120 h (APT Group). Six age-matched, in utero control fetuses were delivered at 99-100 d GA (Control Group). Fetal liver tissue samples and blood samples were collected at delivery from both groups and assessed mRNA expression of NRs and target transporters involved in the hepatobiliary transport system using quantitative PCR. Data were tested for group differences with ANOVA (p < .05 deemed significant). RESULTS: mRNA expression of NRs was identified in both the placenta and the extremely preterm ovine fetal liver. The expression of HNF4α, LRH1, LXR, ESR1, PXR, CAR, and PPARα/γ were significantly elevated in the liver of the APT Group compared to the Control Group. Moreover, target transporters NTCP, OATP1B3, BSEP, and MRP4 were upregulated, whereas MRP2 and MRP3 were unchanged. Although there was no evidence of liver necrosis or apoptotic changes histologically, there was an impact in the fetal liver of the ATP group at the tissue level with a significant increase in TNFα mRNA, a cytokine involved in liver inflammation, and blood elevation of transaminases. CONCLUSION: A number of NRs in the fetal liver were significantly upregulated after loss of placental-maternal support. However, the expression of target transporter genes appeared to be insufficient to compensate role of the placenta and maternal liver and avoid fetal liver damage, potentially due to insufficient excretion of organic anions.

BACKGROUND: Antenatal steroid therapy for fetal lung maturation is routinely administered to women at risk of preterm delivery. There is strong evidence to demonstrate benefit from antenatal steroids in terms of survival and respiratory disease, notably in infants delivered at or below 32 weeks' gestation. However, dosing remains unoptimized and lung benefits are highly variable. Current treatment regimens generate high-concentration, pulsatile fetal steroid exposures now associated with increased risk of childhood neurodevelopmental diseases. We hypothesized that damage-associated changes in the fetal hippocampal transcriptome would be independent of preterm lung function. METHODS: Date-mated ewes carrying a single fetus at 122 ± 2dGA (term = 150dGA) were randomized into 4 groups: (i) Saline Control Group, 4×2ml maternal saline intramuscular(IM) injections at 12hr intervals (n = 11); or (ii) Dex High Group, 2×12mg maternal IM dexamethasone phosphate injections at 12hr intervals followed by 2×2ml IM saline injections at 12hr intervals (n = 12; representing a clinical regimen used in Singapore); or (iii) Dex Low Group, 4×1.5mg maternal IM dexamethasone phosphate injections 12hr intervals (n = 12); or (iv) Beta-Acetate Group, 1×0.125mg/kg maternal IM betamethasone acetate injection followed by 3×2ml IM sterile normal saline injections 12hr intervals (n = 8). Lambs were surgically delivered 48hr after first maternal injection at 122-125dGA, ventilated for 30min to establish lung function, and euthanised for necropsy and tissue collection. RESULTS: Preterm lambs from the Dex Low and Beta-Acetate Groups had statistically and biologically significant lung function improvements (measured by gas exchange, lung compliance). Compared to the Saline Control Group, hippocampal transcriptomic data identified 879 differentially significant expressed genes (at least 1.5-fold change and FDR < 5%) in the steroid-treated groups. Pulsatile dexamethasone-only exposed groups (Dex High and Dex Low) had three common positively enriched differentially expressed pathways related in part to neurodegeneration ("Prion Disease", "Alzheimer's Disease", "Arachidonic Acid metabolism"). Adverse changes were independent of respiratory function during ventilation. CONCLUSIONS: Our data suggests that exposure to antenatal steroid therapy is an independent cause of damage- associated transcriptomic changes in the brain of preterm, fetal sheep. These data highlight an urgent need for careful reconsideration and balancing of how antenatal steroids are used, both for patient selection and dosing regimens.

BACKGROUND: Postpartum vulvovaginal hematoma is a complication of vaginal delivery that may progress to life-threatening conditions. However, the management of hematomas, including conservative therapy, surgery, and arterial embolization, is yet to be standardized. OBJECTIVE: This study aimed to i) evaluate hematoma features that can be treated conservatively, and ii) determine which is superior in reducing blood transfusion between surgery and transcatheter arterial embolization. STUDY DESIGN: This cross-sectional study included postpartum women transferred to Tohoku University Hospital, Japan, between January 2016 and September 2023 for postpartum vulvovaginal hematomas. Notably, all patients except one underwent contrast-enhanced computed tomography. The patients were classified into i) the conservative group who received neither surgery nor transcatheter atrial embolization and ii) the therapeutic intervention group who received surgery or transcatheter atrial embolization. The primary analysis included all patients. Variables for the choice of therapeutic intervention, including the shock index, hemoglobin concentration at arrival, hematoma size, and presence of extravasation, were assessed using a modified Poisson regression model. The secondary analysis included patients who received therapeutic intervention (i.e. surgery or transcatheter atrial embolization). Variables for estimating the total amount of blood transfusion, including shock index, hemoglobin concentration at arrival, hematoma size, type of intervention, and presence of extravasation, were analyzed using multiple linear regression. RESULTS: Fifty-seven cases were included in this study. Patients underwent conservative treatment (n= 19), surgery (n= 11), or transcatheter arterial embolization (n= 27). In primary analysis, only the presence of extravasation was significantly associated with the choice of therapeutic intervention (adjusted risk ratio [95% confidence interval], 5.30 [1.53, 18.37]). In the secondary analysis, the therapeutic option for surgery (unstandardized coefficients [95% confidence interval], 4.64 [1.15, 8.13], reference: transcatheter atrial embolization), lower hemoglobin concentration at arrival (-2.84 [-4.71, -0.97], 1 g/dL increment), and larger hematoma size (3.38 [1.23, 5.53], 100 cm3 increments) were significantly associated with increased blood transfusion. CONCLUSIONS: When a vulvovaginal hematoma does not undergo extravasation, it can be treated conservatively regardless of size. When a therapeutic intervention is selected, transcatheter arterial embolization reduces the total amount of blood transfusion compared with surgery.

BACKGROUND: A combination of budesonide and surfactant decreases the rates of BPD in infants and lung injury in preterm sheep. Whether this combination will show benefit in the setting of chorioamnionitis and antenatal steroids is not known. METHODS: Ewes at 123 ± 1 day gestational age received intra-amniotic (IA) injections of 10 mg LPS before being randomized to receive either 0.25 mg/kg maternal betamethasone phosphate and acetate or saline by intramuscular (IM) injection at 48 and 24 h prior to delivery at 125 ± 1 day. Lambs (N = 6-9/group) underwent intentionally injurious ventilation for 15 min, then lambs received surfactant mixed with either: (1) saline; or (2) Budesonide 0.25 mg/kg and were ventilated for 4 h. RESULTS: Compared with LPS-exposed animals that received no IM steroid treatment, betamethasone exposed fetuses had improved hemodynamic stability, lung compliance, and ventilation efficiency. The addition of budesonide to surfactant further improved markers of injury and pro-inflammatory cytokine mRNA in both betamethasone IM or no IM lambs exposed to LPS IA. Antenatal betamethasone and IA LPS exposures decreased budesonide levels in the fetal lung and plasma. CONCLUSION: Antenatal betamethasone stabilizes physiologic parameters in LPS treated lambs. Budesonide mixed with surfactant further decreases injury and improves respiratory physiology in betamethasone treated animals. IMPACT: Antenatal betamethasone improved lung and systemic physiology in the setting of intra-amniotic LPS. The addition of budesonide to the surfactant further improved lung function. Budesonide levels in the plasma and lung were lower in lambs exposed to either LPS or LPS and Betamethasone animals, and these findings were not explained by increased esterification in the lungs. The combination of antenatal steroids and budesonide with surfactant had the lowest markers of pro-inflammatory cytokines in the lung of LPS exposed animals.

Background: Antenatal steroid therapy is standard of care for women at imminent risk of preterm delivery. Current dosing regimens employ supra-pharmacological doses to achieve extended fetal steroid exposures. Objective: We aimed to determine the lowest fetal plasma betamethasone concentration sufficient to achieve functional preterm lung maturation. Study design: Ewes with singles fetuses underwent surgery to install a fetal jugular catheter. Adopting a step-wise design, ewes were randomised to either a saline-only group (Negative Control Group; n=9), or one of four betamethasone-treatment groups. Each betamethasone group fetus received a fetal intravenous infusion to target a constant plasma betamethasone levels of either: i) 2 ng/ml (2 ng/ml Positive Control Group, n=9); ii) 1 ng/ml, (1 ng/ml Group, n=10); iii) 0.5 ng/ml (0.5 ng/ml Group, n=10); or iv) 0.25 ng/ml Group (0.25 ng/ml Group, n=10). Fetuses were infused for 48 hours, delivered and ventilated. The Positive Control Group, Negative Control Group and mid-point 0.5 ng/ml Group animals were tested first. An interim analysis informed the final betamethasone group tested. Results: Positive Control Group animals had large, statistically significant improvements in respiratory function. Based on an interim analysis, the 1.0 ng/ml Group was studied in favour of the 0.25 ng/ml Group. Treatment efficacy was progressively lost at plasma betamethasone concentrations lower than 2 ng/ml. Conclusion: We demonstrated that the acute respiratory benefit conveyed by antenatal steroid exposure in the fetal sheep is progressively lost when constant fetal plasma betamethasone concentrations are reduced below a targeted value of 2 ng/ml.

Introduction: Artificial placenta therapy (APT) is an experimental life support system to improve outcomes for extremely preterm infants (EPI) less than 1,000 g by obviating the need for pulmonary gas exchange. There are presently no long-term survival data for EPI supported with APT. To address this, we aimed to maintain 95d-GA (GA; term-150d) sheep fetuses for up to 2 weeks using our APT system. Methods: Pregnant ewes (n = 6) carrying singleton fetuses underwent surgical delivery at 95d GA. Fetuses were adapted to APT and maintained for up to 2 weeks with constant monitoring of key physiological parameters and extensive time-course blood and urine sampling, and ultrasound assessments. Six age-matched in-utero fetuses served as controls. Data were tested for group differences with ANOVA. Results: Six APT Group fetuses (100%) were adapted to APT successfully. The mean BW at the initiation of APT was 656 ± 42 g. Mean survival was 250 ± 72 h (Max 336 h) with systemic circulation and key physiological parameters maintained mostly within normal ranges. APT fetuses had active movements and urine output constantly exceeded infusion volume over the experiment. At delivery, there were no differences in BW (with edema in three APT group animals), brain weight, or femur length between APT and in-utero Control animals. Organ weights and humerus lengths were significantly reduced in the APT group (p &amp;lt; 0.05). Albumin, IGF-1, and phosphorus were significantly decreased in the APT group (p &amp;lt; 0.05). No cases of positive blood culture were detected. Conclusion: We report the longest use of APT to maintain extremely preterm fetuses to date. Fetal systemic circulation was maintained without infection, but growth was abnormal. This achievement suggests a need to focus not only on cardiovascular stability and health but also on the optimization of fetal growth and organ development. This new challenge will need to be overcome prior to the clinical translation of this technology.

BACKGROUND: Intraamniotic inflammation is associated with preterm birth, especially in cases occurring before 32 weeks' gestation, and is causally-linked with increased risk of neonatal mortality and morbidity. Targeted anti-inflammatory interventions may assist in improving outcomes for pregnancies impacted by intrauterine inflammation. Interleukin (IL)-1 is a central upstream mediator of inflammation. Accordingly, IL-1 is a promising candidate target for intervention therapies, and has previously been targeted using the IL-1 receptor antagonist, anakinra. Recent studies have shown that the novel non-competitive allosteric IL-1 receptor inhibitor, rytvela, partially resolved inflammation associated with preterm birth and fetal injury. In the present study, we used a preterm sheep model of chorioamnionitis to investigate the anti-inflammatory efficacy of rytvela and anakinra, administered to the amniotic fluid in the setting of intraamniotic E. coli lipopolysaccharides (LPS) exposure. OBJECTIVE: We hypothesized that both rytvela and anakinra would reduce LPS-induced intrauterine inflammation and protect the fetal brain. STUDY DESIGN: Ewes with a singleton fetus at 105 days of gestation (GA; term is ∼150 days) were randomized to one of the following groups: i) Intraamniotic (IA) injections of 2 ml saline at time = 0 and time = 24 hours as a negative control group (Saline Group, n=12); ii) IA injection of 10 mg E.coli LPS in 2 ml saline and IA injections of 2 ml saline at time = 0 hours and time = 24 hours as an inflammation positive control group (LPS Group, n=11); iii) IA injection of E.coli LPS in 2 ml saline and IA injections of 2.5 mg rytvela at time = 0 hours and time = 24 hours to test the anti-inflammatory efficacy of rytvela (LPS + rytvela Group, n=10); or iv) IA injection of E.coli LPS in 2 ml saline and IA injections of 100 mg anakinra at time = 0 hours and time = 24 hours to test the anti-inflammatory efficacy of anakinra (LPS + anakinra Group, n=12). Amniotic fluid was sampled at time = 0, 24 and 48 hours (i.e. at each intervention and at delivery). Fetal cord blood was collected at delivery for differential blood counts and chemical studies. Inflammation was characterized by the analysis of fetal tissue cytokine/chemokine levels using quantitative polymerase chain reaction (qPCR), enzyme-linked inmmunosorbent assay (ELISA), and histology. The primary study outcome of interest was the assessment of anakinra and rytvela brain-protective effects in the setting of E.coli LPS-induced intrauterine inflammation. Secondary outcomes of interest were to assess protection from fetal and intrauterine (i.e. amniotic fluid, chorioamnion) inflammation. RESULTS: IA administration of LPS caused inflammation of the fetal lung, brain and chorioamnionitis in preterm fetal sheep. Relative to treatment with saline only in the setting of LPS exposure, IA administration of both rytvela and anakinra both significantly prevented periventricular white matter injury, microglial activation, and histologic chorioamnionitis. anakinra showed additional efficacy in inhibiting fetal lung MPO activity, but its use was associated with metabolic acidaemia and reduced fetal plasma IGF-1 levels at delivery. CONCLUSION: IA administration of rytvela or anakinra significantly inhibited fetal brain inflammation and chorioamnionitis in preterm fetal sheep exposed to intraamniotic LPS animals. Additionally, anakinra treatment was associated with potential negative impacts on the developing fetus.

Despite widespread use, dosing regimens for antenatal corticosteroid (ACS) therapy are poorly unoptimized. ACS therapy exerts a programming effect on fetal development, which may be associated with an increased risk of cardiovascular disease. Having demonstrated that low-dose steroid therapy is an efficacious means of maturing the preterm lung, we hypothesized that a low-dose steroid exposure would exert fewer adverse functional and transcriptional changes on the fetal heart. We tested this hypothesis using low-dose steroid therapy (10 mg delivered to the ewe over 36 h via constant infusion) and compared cardiac effects with those of a higher dose treatment (30 mg delivered to the ewe over 24 h by intramuscular injection; simulating currently employed clinical ACS regimens). Fetal cardiac function was assessed by ultrasound on the day of ACS treatment initiation. Transcriptomic analyses were performed on fetal myocardial tissue. Relative to saline control, fetuses in the higher-dose clinical treatment group had significantly lower ratios between early diastolic ventricular filling and ventricular filling during atrial systole, and showed the differential expression of myocardial hypertrophy-associated transcripts including βMHC, GADD45γ, and PPARγ. The long-term implications of these changes remain unstudied. Irrespective, optimizing ACS dosing regimens to maximize respiratory benefit while minimizing adverse effects on key organ systems, such as the heart, offers a means of improving the acute and long-term outcomes associated with this important obstetric therapy.

INTRODUCTION: Lysophosphatidylcholine acyltransferase 1 (LPCAT1) is important for saturated phosphatidylcholine (Sat-PC) production in the lung. Sat-PC is a critical component of pulmonary surfactant, which maintains low alveolar surface tension, facilitating respiration. Previous studies have reported an association between maternal and fetal LPCAT1 levels and neonatal lung function. Using a sheep model of pregnancy, we investigated a potential correlation between glucocorticoid-induced lung maturation and LPCAT1 mRNA and/or protein levels in the fetal lung, the placenta, the fetal plasma, and the maternal plasma. METHODS: Eighty seven single pregnant ewes received maternal intramuscular injections of betamethasone. A sub-group of five animals had both maternal and fetal catheters installed to allow for sequential sampling from both plasma compartments. Lambs were surgically delivered under terminal anaesthesia between 2 and 8 days after initial ANS treatment, at a gestational age of 121-123 days. Lambs were ventilated for 30 min to determine functional lung maturation before being euthanized for necropsy and sample collection. Fetal lung, placenta, and fetal and maternal plasma samples were used to analyse LPCAT1 gene expression and protein levels. RESULTS: The expression of LPCAT1 mRNA in the fetal lung was significantly corelated to Sat-PC levels at 8 days (R2 = 0.23, p < 0.001) and lung maturation status overall (gas exchange efficiency as determined by measurements of lamb PaCO2 during ventilation, R2 = 0.20, p < 0.001). Similarly, fetal lung LPCAT1 mRNA was also significantly correlated with the individual durability of ANS effects on fetal lung maturation (R2 = 0.20, p < 0.001). Although ANS therapy altered LPCAT1 mRNA expression in the placenta, observed changes were independent of fetal lung maturation outcomes. Neither maternal nor fetal plasma LPCAT1 levels were changed by ANS therapy over the period, including in analysis of serial maternal and fetal samples from chronically catheterised animals. DISCUSSION: LPCAT1 expression in the fetal lung was associated with the durability of glucocorticoid effects on fetal lung maturation. However, LPCAT1 expression in the placenta, the fetal plasma, and the maternal plasma was neither associated with, nor predictive of fetal lung maturation after glucocorticoid treatment in a sheep model of pregnancy.

Treatment with antenatal steroids (ANS) is standard practice for reducing the risk of respiratory distress in the preterm infant. Despite clear overall benefits when appropriately administered, many fetuses fail to derive benefit from ANS therapies. In standardized experiments using a pregnant sheep model, we have demonstrated that around 40% of ANS-exposed lambs did not have functional lung maturation significantly different from that of saline-treated controls. Surfactant protein A is known to play an important role in lung function. In this genotyping study, we investigated the potential correlation between polymorphisms in SFTPA1, messenger RNA and protein levels, and ventilation outcomes in animals treated with ANS. 45 preterm lambs were delivered 48 h after initial ANS therapy and 44 lambs were delivered 8 days after initial ANS therapy. The lambs were ventilated for 30 min after delivery. SFTPA1 mRNA expression in lung tissue was not correlated with arterial blood PaCO2 values at 30 min of ventilation in lambs delivered 48 h after treatment. SFTPA1 protein in lung tissue was significantly correlated with PaCO2 at 30 min of ventilation in lambs ventilated both 48 h and 8 days after ANS treatment. Six different single nucleotide polymorphisms (SNPs) in the Ovis aries SFTPA1 sequence were detected by Sanger Sequencing. No individual SNPs or SNP haplotypes correlated with alterations in PaCO2 at 30 min of ventilation or SFTPA1 protein levels in the lung. For the subset of animals analyzed in the present study, variable lung maturation responses to ANS therapy were not associated with mutations in SFTPA1.

Antenatal steroid (ANS) therapy is standard care for women at imminent risk of preterm delivery. When deliveries occur within seven days of treatment, ANS therapy reduces the risk of neonatal death and improves preterm outcomes by exerting diverse developmental effects on the fetal organs, in particular the preterm lung and cardiovascular system. There is, however, sizable variability in ANS treatment efficacy, and an important percentage of fetuses exposed to ANS therapy do not respond sufficiently to derive benefit. Respiratory distress syndrome (RDS), for example, is a central metric of clinical trials to assess ANS outcomes. In the present analysis, we addressed the concept of ANS non-responsiveness, and defined a failed or sub-optimal response to ANS as being death or a diagnosis of RDS following treatment. For deliveries 24-35 weeks' gestation, the number needed to treat (NNT) to prevent one case of RDS is 19 (95% CI, 14-28). Reflecting gestation-dependent risk, for deliveries >34 weeks' gestation the NNT is 55 (95% CI, 30-304), whereas for elective surgical deliveries at term the NNT is 106 (95% CI, 61-421). We reviewed data from clinical and animal studies investigating ANS therapy to highlight the significant incidence of ANS therapy non-responsiveness (i.e. residual mortality or RDS after treatment), and the potential mechanisms underpinning this outcome variability. Origins of this variability may relate both to the manner in which the therapy is applied (i.e. the treatment regimen itself) and factors specific to the individual (i.e. genetic variation, stress, infection). The primary aims of this review were: i) to emphasise to the obstetric and neonatal communities the extent of ANS response variability and potential impact; ii) to propose approaches by which ANS therapy may be better applied to improve overall benefit; and iii) to stimulate further research towards the empirical optimisation of this important antenatal therapy.

[INTRODUCTION]: The intramuscular administration of antenatal steroids (ANS) to women at risk of preterm delivery achieves high maternal and fetal plasma steroid concentrations, which are associated with adverse effects and may reduce treatment efficacy. We have demonstrated that ANS efficacy is independent of peak materno-fetal steroid levels once exposure is maintained above a low threshold. [OBJECTIVES]: We aimed to test, using a sheep model of pregnancy, whether the low-dose ANS regimen proposed as part of the ACTION III Trial would achieve preterm lung maturation equivalent to that of the existing WHO dexamethasone treatment regimen, but with reduced risk of adverse outcomes. [STUDY DESIGN]: Following ethical review and approval, date-mated ewes with single fetuses received intramuscular injections of either: i) four x 6mg maternal intramuscular injections of dexamethasone phosphate q12h (n=22); or ii) four x 2 mg maternal intramuscular injections of betamethasone phosphate q12h (n=21); or ⅲ) four x 2mL maternal intramuscular injections of saline q12h (n=16). Forty-eight hours after first injection, (124±1 d), lambs were delivered, ventilated for 30 minutes, and euthanised for sampling. Arterial blood gas, respiratory, haematological and biochemical data were analysed for between-group differences with ANOVA according to distribution and variance, with p<0.05 taken as significant. [RESULTS]: After 30 minutes ventilation, lambs from both steroid-treated groups had significant and equivalent improvements in lung function relative to saline control (p<0.05). There was no significant difference in arterial blood pH, pO2, pCO2, lung compliance, ventilator efficiency index or lung volume at necropsy with a static pressure of 40cmH2O. The mRNA expression of surfactant protein (Sp)a, Spb, Spc, Spd, aquaporin (Aqp)1, Aqp5 and sodium channel epithelial 1 subunit beta (Scnn1b) was equivalent between both steroid groups. Maternal and fetal plasma neutrophil, glucose and fetal plasma c-peptide levels were significantly elevated in the dexamethasone group, relative to the betamethasone group. Fetal plasma IGF-1 was significantly reduced in the dexamethasone group compared to the betamethasone group (p<0.05). Fetal ACTH (r=0.53), maternal glucose value (r=-0.52) and fetal glucose values (r=-0.42) were correlated with maternal weight in Betamethasone Group (p<0.05) while fetal pCO2 and pO2 were not correlated. There were no significant differences between male and female lamb outcomes in any groups for any of the items evaluated. [CONCLUSIONS]: We report that, in preterm lambs, a low-dose treatment regimen of 8mg betamethasone achieves lung maturation equivalent to that of a 24mg dexamethasone-based regimen, but with smaller perturbations to the materno-fetal HPA axis. These data suggest that, given steroid pharmacokinetic differences between sheep and humans, a betamethasone dose of 2mg may remain above the minimum dose necessary for robust maturation of the preterm lung. Maternal weight-adjusted betamethasone doses might also be a key to reduce perturbations to the materno-fetal HPA axis.

Antenatal steroids (ANSs) are routinely administered to women judged to be at imminent risk of preterm delivery. Their principal benefit is precocious functional maturation of the preterm fetal lung. Current dosing regimens expose the mother and fetus to high steroid levels that may be unnecessary, increasing the potential risks of disruption to the maternal and fetal hypothalamic-pituitary-adrenal (HPA) axis and glucose regulation, alterations in placental function, and reduced fetal growth. Using a sheep model of pregnancy, we tested the hypothesis that direct fetal administration of an ultra-low dose course of betamethasone phosphate (∼0.33 mg) would be sufficient to elicit functional maturation of the fetal lung. A jugular catheter was installed in singleton ovine fetuses at 122-day gestation under general anesthesia. Animals were randomized to receive either: 1) fetal intravenous betamethasone phosphate to target fetal plasma betamethasone mean levels of 2 ng/mL for 26 h (fetal treatment group; n = 16); 2) fetal intravenous saline for 26 h and two maternal intramuscular injections of 0.25 mg/kg betamethasone phosphate + betamethasone acetate, simulating a standard clinical treatment (maternal treatment group; n = 12); or 3) fetal intravenous saline only for 26 h (negative control group; n = 10). Fetuses were delivered 48 h after surgery, ventilated for 30 min to allow the collection of lung function and physiological data, and euthanized. Quantitative PCR and Western blots were used to assess markers of lung maturation. The average total betamethasone phosphate dose for the fetal treatment group was 1% (0.3 mg) of the maternal treatment group (31-mg betamethasone phosphate + betamethasone acetate). At 30 min of ventilation, arterial [Formula: see text], pH, heart rate, and ventilation efficacy index (VEI) were significantly ( P &lt; 0.05) and equivalently improved in both the fetal treatment group and maternal treatment group, relative to the negative control group. Similarly, SP-A, SP-C, and AQ-5 mRNA expression was significantly higher in both the fetal treatment group and maternal treatment group, relative to negative control. Maternal steroid administration was not required to generate preterm fetal lung maturation in sheep. Using a low dose and targeting steroid treatments directly to the fetus has the potential to significantly reduce maternal exposures, while simultaneously reducing the potential risk of adverse outcomes associated with current clinical dosing regimens.

Being born preterm (prior to 37 weeks of completed gestation) is a leading cause of childhood death up to five years of age, and is responsible for the demise of around one million preterm infants each year. Rates of prematurity, which range from approximately 5 to 18% of births, are increasing in most countries. Babies born extremely preterm (less than 28 weeks' gestation) and in particular, in the periviable (200/7-256/7 weeks) period, are at the highest risk of death, or the development of long-term disabilities. The perinatal care of extremely preterm infants and their mothers raises a number of clinical, technical, and ethical challenges. Focusing on 'micropremmies', or those born in the periviable period, this paper provides an update regarding the aetiology and impacts of periviable preterm birth, advances in the antenatal, intrapartum, and acute post-natal management of these infants, and a review of counselling/support approaches for engaging with the infant's family. It concludes with an overview of emerging technology that may assist in improving outcomes for this at-risk population.

Background Intraamniotic inflammation is associated with up to 40% of preterm births, most notably in deliveries occurring prior to 32 weeks’ gestation. Despite this, there are few treatment options allowing the prevention of preterm birth and associated fetal injury. Recent studies have shown that the small, non-competitive allosteric interleukin (IL)-1 receptor inhibitor, rytvela, may be of use in resolving inflammation associated with preterm birth (PTB) and fetal injury. We aimed to use an extremely preterm sheep model of chorioamnionitis to investigate the anti-inflammatory efficacy of rytvela in response to established intra-amniotic (IA) lipopolysaccharide (LPS) exposure. We hypothesized that rytvela would reduce LPS-induced IA inflammation in amniotic fluid (AF) and fetal tissues. Methods Sheep with a single fetus at 95 days gestation (estimated fetal weight 1.0 kg) had surgery to place fetal jugular and IA catheters. Animals were recovered for 48 hours before being randomized to either: i) IA administration of 2 ml saline 24 hours before 2 ml IA and 2 ml fetal intravenous (IV) administration of saline (Saline Group, n = 7); ii) IA administration of 10 mg LPS in 2 ml saline 24 hours before 2 ml IA and 2 ml fetal IV saline (LPS Group, n = 10); 3) IA administration of 10 mg LPS in 2 ml saline 24 hours before 0.3 mg/fetal kg IA and 1 mg/fetal kg fetal IV rytvela in 2 ml saline, respectively (LPS + rytvela Group, n = 7). Serial AF samples were collected for 120 h. Inflammatory responses were characterized by quantitative polymerase chain reaction (qPCR), histology, fluorescent immunohistochemistry, enzyme-linked inmmunosorbent assay (ELISA), fluorescent western blotting and blood chemistry analysis. Results LPS-treated animals had endotoxin and AF monocyte chemoattractant protein (MCP)-1 concentrations that were significantly higher at 24 hours (immediately prior to rytvela administration) relative to values from Saline Group animals. Following rytvela administration, the average MCP-1 concentrations in the AF were significantly lower in the LPS + rytvela Group relative to in the LPS Group. In delivery samples, the expression of IL-1β in fetal skin was significantly lower in the LPS + rytvela Group compared to the LPS Group. Conclusion A single dose of rytvela was associated with partial, modest inhibition in the expression of a panel of cytokines/chemokines in fetal tissues undergoing an active inflammatory response.

Abstract We review the history of antenatal corticosteroid therapy (ACS) and present recent experimental data to demonstrate that this, one of the pillars of perinatal care, has been inadequately evaluated to minimize fetal exposure to these powerful medications. There have been concerns since 1972 that fetal exposures to ACS convey risk. However, this developmental modulator, with its multiple widespread biologic effects, has not been evaluated for drug choice, dose, or duration of treatment, despite over 30 randomized trials. The treatment used in the United States is two intramuscular doses of a mixture of 6 mg betamethasone phosphate (Beta P) and 6 mg betamethasone acetate (Beta Ac). To optimize outcomes with ACS, the goal should be to minimize fetal drug exposure. We have determined that the minimum exposure needed for fetal lung maturation in sheep, monkeys, and humans (based on published cord blood corticosteroid concentrations) is about 1 ng/ml for a 48-h continuous exposure, far lower than the concentration reached by the current dosing. Because the slowly released Beta Ac results in prolonged fetal exposure, a drug containing Beta Ac is not ideal for ACS use. Impact Using sheep and monkey models, we have defined the minimum corticosteroid exposure for a fetal lung maturation. These results should generate new clinical trials of antenatal corticosteroids (ACS) at much lower fetal exposures to ACS, possibly given orally, with fewer risks for the fetus.

Introduction. Power morcellation is an effective and minimally invasive technique used to remove specimen tissues or the uterus in total laparoscopic hysterectomy (TLH). However, it has the risk of intraperitoneal dissemination of tissue and can cause a parasitic myoma. We report a case of leiomyosarcoma that occurred 4 years after TLH with power morcellation for fibroids. Case. A 52-year-old woman was referred to our hospital with a pelvic mass. She was diagnosed to have submucosal fibroids and had undergone TLH with power morcellation 4 years previously. The uterus weighed 398 g at that time. At present, a parasitic myoma was suspected, owing to the diagnosis of fibroids on the initial pathological evaluation. She underwent laparotomy, and the tumor was removed. Although the pathological evaluation confirmed the tumor to be a leiomyosarcoma, a review of the initial tissue did not show the presence of any malignancy. Since there was no metastasis, she was followed-up without additional treatment. Conclusion. Even if the initial pathologic evaluation suggests a benign mass, parasitic myoma and even sarcoma can occur after TLH with power morcellation. Considering the risk of dissemination and occult malignancy, the use of power morcellation should be avoided if there are alternative options to remove the tumor.

Background: Between 5-15% of babies are born prematurely worldwide, with preterm birth defined asdelivery before 37 completed weeks of pregnancy (term is at 40 weeks of gestation). Women at risk of pretermbirth receive antenatal corticosteroids as part of standard care to accelerate fetal lung maturation and thus improveneonatal outcomes in the event of delivery. As a consequence of this treatment, the entire fetal organ system isexposed to the administered corticosteroids. The implications of this exposure, particularly the long-term impactson offspring health, are poorly understood. Aims: This review will consider the origins of antenatal corticosteroid treatment and variations in current clinicalpractices surrounding the treatment. The limitations in the evidence base supporting the use of antenatal corticosteroidsand the evidence of potential harm to offspring are also summarised. Results: Little has been done to optimise the dose and formulation of antenatal corticosteroid treatment since thefirst clinical trial in 1972. International guidelines for the use of the treatment lack clarity regarding the recommendedtype of corticosteroid and the gestational window of treatment administration. Furthermore, clinical trialscited in the most recent Cochrane Review have limitations which should be taken into account when consideringthe use of antenatal corticosteroids in clinical practice. Lastly, there is limited evidence regarding the long-termeffects on the different fetal organ systems exposed in utero, particularly when the timing of corticosteroid administrationis sub-optimal. Conclusion: Further investigations are urgently needed to determine the most safe and effective treatment regimenfor antenatal corticosteroids, particularly regarding the type of corticosteroid and optimal gestational windowof administration. A clear consensus on the use of this common treatment could maximise the benefits and minimisepotential harms to offspring.

27歳(1経妊1経産婦)。妊娠37週の胎児超音波検診にて心収縮不良、心拡大を認め、カラードプラーの併用により動脈管早期閉鎖(PCDA)と診断にされた。帝王切開術を施行し、2573gの女児を出産した。出生直後より肺高血圧による右心不全を認め、酸素投与を行うも酸素化を保てず、挿管管理となった。出生後診断はPCDAとPPHN(新生児遷延性肺高血圧症)であり、日齢0で高濃度酸素、一酸化窒素が投与され、日齢6で抜管し、日齢24に退院となった。

卵巣腫瘍茎捻転症例39例について検討した。その結果、平均年齢は42.6±16.3歳で、壊死ありは22例、壊死なしは17例であった。最大腫瘍径は平均95.5±38.9mmであった。手術術式は患側付属器切除術が25例(うち腹腔鏡下手術11例)、腫瘍摘出術が14例(うち腹腔鏡下手術8例)であった。組織型は成熟嚢胞性奇形腫が51%と半数以上を占めていた。初発症状出現から手術までの時間は48時間以上の症例では壊死ありが75%(8例中6例)と、48時間以内の症例に比べ多い傾向にあった。術前の白血球数は壊死あり群で有意に高値を示し、白血球数8000/μl以上をカットオフとすると、卵巣壊死の診断に対して感度は86%、特異度は50%であった。また、術前の血清CRP値は壊死あり群で有意に高く、血清CRP 0.3mg/dl以上を壊死陽性とすると、感度は31%、特異度は100%であった。悪性・境界悪性症例は5例で認め、うち3例は60歳以上と高齢であり、最大腫瘍径は全例で10cm以上であった。血清CA125が基準値を超えていた2例はいずれも境界悪性を含む悪性であった。