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The Role of Antenatal Factors on Neonatal Outcome
Jonathan M. Davis, MD
Vice-Chair of Pediatrics, Chief of Newborn Medicine
Floating Hospital for Children/Tufts Medical Center
Professor of Pediatrics
Tufts University School of Medicine
Boston, MA
Chair, Child Health Oversight Committee, NIH
Chair, Neonatal Advisory Committee, FDA
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No relevant financial relationships to disclose
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Outpatient deck, 1906
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6
1999
Obesity in the US – A Major Public Health Problem
2009
1990
No Data <10% 10%–14 15%–19% 20%–24% 25%–29% ≥30%
CDC database
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Obesity and Inflammation
Obesity is associated with marked inflammation and immune dysregulationAdipocytes undergo necrosis, promoting inflammation and macrophage recruitmentHigher circulating levels of TNF-α, IL-6, MCP-1, and TGF-β
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Obesity in Pregnancy – Harmful to Mother and Infant
Schmatz et al, J Perinatology, 2010.
Obesity↑CRP ↑IL-6, IL-8↑TNFα↑leptin,↑adiponectin↑macrophages
Pregnancy↑CRP↑macrophages↑neutrophils↑IL-10
↑Inflammation
Disease
Maternal DisPre-eclampsiaGestational DMDysfunctional Labor
Lifetime Disease RiskHypertensionDMHyperlipidemiaMI
Neonatal DisLow ApgarsNICU admissionMacrosomiaPrematurity
Child/Adult DiseaseObesityDMMetabolic Syndrome
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Obesity in Pregnancy is Associated with Increased Infections
Heslehurt et al. Obesity Reviews, 2008.
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Obesity in Pregnancy
• Increased risks of antenatal, intrapartum, and neonatal complications
• 2-5 X increased risk of:• Diabetes
• Pre-eclampsia
• Induction of labor, emergency C-section
• Intrapartum & postpartum hemorrhage
• Chorioamnionitis
• Macrosomic infants, lower Apgars, NICU admissions
• Intrauterine death
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Results: 1981-2005
• 219,173 pregnant women over 25 year period
• Mean maternal weight increased linearly → 139 lbs in 1981 to 161 lbs in 2005, or 22 pounds
• For 27 year old mothers only, mean weights increased 25 pounds in 25 years
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Results
Medians (interquartile ranges); Kruskal-Wallis ANOVA test
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Major Risk Factors for Prematurity by Multivariate Analysis
• PROM
• Obesity
• Pre-existing diabetes
• Pre-eclampsia/hypertension
• Previous preterm/SGA infant
• In vitro fertilization
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Obesity in Pregnancy Changes Immune Cell Populations
Cell Populations
Obese (n=15)
Lean (n=15)
p value
CD4+ (% lymphocytes)
45.8+9.4 44.3+12.7 ns
CD8+ (% lymphocytes)
16.4+5.8 23.5+7.4 <0.05
NKT cells 22.9+6.1 27.9+4.1 <0.05
B cells 21.9+6.2 13.3+5.3 <0.05
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Maternal Obesity Impairs Cytokine Production
* p < 0.05
*
Interferon gamma response to stimulation
0
100
200
300
400
500
600
700
CD8+ cells CD4+ cells
geo
met
ric
mea
n (
MF
U)
Lean
Obese
**
TNF alpha response to stimulation
0
100
200
300
400
500
600
700
800
CD8+ cells CD4+ cells
geo
metr
ic m
ean
(M
FU
)
Lean
Obese
*
*
TNFα response to stimulation
IFNγ response to stimulation
*
* *
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Obese Pregnant Women Have Reduced Micronutrients
Lean (n=15) Obese (n=15)
RBC folate (ng/ml)
1606+559 1131+446*
Vitamin C (mg/dL)
1.3+0.2 0.9+0.3*
Vitamin E (ug/dL)
1720+394 1393+282*
(1,25) OH Vitamin D (ng/ml)
34.8+10.2 27.4+8*
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Fat (%)
Protein (%)
Carb (%)
Kcal/g Vit A (g/kg)
Vit C (g/kg)
Vit E (g/kg)
Selenium (g/kg)
Control 8 16 45 3.2 4,600 0 86 0.165
Control+ AOX
8 16 45 3.2 23,000 5.6 260 0.5
Western 16 21 50 4.3 4,600 0 86 0.165
Western+ AOX
16 22 50 4.3 23,000 5.6 260 0.5
Diet Composition for Dams
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Offspring Adiposity at 2 weeks
0
5
10
15
20
25
Control Control+Aox Western Western+Aox
Fa
t P
erc
en
tag
e
*
** *
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Conclusions
• Mean maternal weights have increased significantly over time
• Obesity in pregnancy - increased inflammation, immune dysregulation, PPROM, chorioamnionitis, and prematurity
• Obesity one of multiple factors that increases the risk of prematurity
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Fetal Inflammatory
Response
time
Trimester II Delivery
Intrauterine
infection
Preterm
birth
Brain/Lung damage
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Bacterial Infection within the Uterus
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Markers of Preterm Delivery
Cervix / Vagina Amniotic Fluid Serum
Bacterial vaginosis WBC CRP
G-CSF G-CSF G-CSF
TNF- TNF- TNF-
IL-1 Glucose IL-6
IL-6 IL-6
IL-8 Bacteria
FFN
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RISK FACTORS: INTRAPARTUM
• Fever
• Urinary tract infection
• Premature rupture of membranes
• Chorioamnionitis/funicitis (many organisms, e.g. ureaplasma)
• Low Apgars, encephalopathy, seizures, poor neonatal outcome
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Adj OR : 3.8 (0.97-15)
Fever
No Fever
Cognitive Development
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Infection in the Placenta and Neonatal Brain Injury
• Bacteria present >80% by PCR, no correlation with chorioamnionits/preterm labor
• Fetal inflammation needed for brain injury
• Role of endotoxin (LPS injections in rabbits), oxidative stress (deficiency of antioxidants), cytokines (CSF) in white matter injury
• Sensitizes fetal brain to hypoxia
• May have brain anomalies at birth
• In utero insult may continue post-partum
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FIR: Role for White Cell Activation
Dammann O, et al. 2001
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Pathogenetic Mechanisms in PVL
Maternal infection/ Prematurity Fetal inflammation
Cytokines Ischaemia/ Microglia reperfusion
Fe++ IVH Glutamate Antioxidants
Reactive oxygen species Reactive nitrogen species
Oligodendroglial death
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Slide Courtesy of Alan Leviton
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PVL on MRIincreased signal intensity in white matter,
volume loss in grey matter
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Growth Factorsand Hormones
Long-term Disability
ChemokinesCytokines
AdhesionMolecules
?
PrenatalInfection
Inflammatory Response
White Matter Damage
Lung Injury
Other poor outcomes
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Future Research• Molecular Epidemiology
Genetic polymorphisms Genetic susceptibility
• Directed TherapiesProtectors (antenatal steroids)Anti-inflammatory agents (IL-10, CC10, ibuprofen)Antioxidants (rhSOD)
• Maternal and Neonatal Conditions Chorioamnionitis/funicitis (new FHR monitors)BPD, PVL, ROP, NEC (salivary gene analyses)
• Laboratory Techniques (microarray, Luminex)
• Assessment Techniques (PFT, CT, MRI, EEG)
….
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Neonatal Abstinence SyndromeNeonatal Abstinence Syndrome
• Opioid exposure in pregnancy - 5.6 infants/1,000 births
• Incidence has tripled in the past decade• The mother may also be smoking or
taking other medications • Signs of withdrawal in 60-80% of infants
exposed to opioids
• Dysfunction of the central nervous system, gastrointestinal tract, and/or respiratory system
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Neonatal Abstinence Syndrome Neonatal Abstinence Syndrome
• Prolonged treatment in hospital, high healthcare costs
• Safety and efficacy of agents not well established
• Significant variability in the incidence and severity
• Factors influencing this variability are unknown
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Neonatal Abstinence Syndrome
• Genetic factors may be important
• Single nucleotide polymorphisms (SNPs): Single base pair changes that can alter protein’s function
• SNPs influence opioid dosing, metabolism, and addiction in adults
• No prior studies of genetic links to NAS
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Candidate Genes for NAS
• SNPs present in 40-50% of the population have been studied in adults
• Mu Opioid Receptor (OPRM1) = Site of Action
• 118A>G SNP
• Multi-Drug Resistance Gene (ABCB1) = Transporter
• 1236C>T SNP
• 3435C>T SNP
• 2677G/T/A SNP
• Catechol-O-methyltransferase (COMT) = Modulator
• 158A>G SNP
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Methods• 86 opioid exposed term infants• Mothers receiving methadone or
buprenorphine
• Infants treated with morphine or methadone
• If severe - additional medications given
• A sample of blood or saliva collected from each infant
• Incidence and severity correlated with changes in genetic profiles
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Results
DEMOGRAPHICS
White 98%
Maternal Methadone 64%
Maternal Buprenorphine 36%
Maternal Smoking 78%
Maternal Benzodiazepines 12%
LOS All Infants Mean 22.3 days
LOS Treated Infants Mean 31.6 days
Treatment for NAS 65%
Treated with >2 medications 24%
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OPRM1 118A>G Results
• AA vs AG/GG infants compared in models that adjust for breastfeeding and study site
• Those with the AG/GG genotype - treated less frequently and had shorter LOS
OUTCOME UNADJUSTEDRESULTS
ADJUSTED RESULTS
P-VALUE
Infant Treated
72% vs 48% OR = 0.76 (CI 0.63, 0.96)
0.006
Mean LOS 24.1 vs 17.6 days - 8.5 days 0.009
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COMT 158A>G Results
• AA infants vs AG/GG infants in models that adjusted for breastfeeding and site
• AG/GG infants were treated less frequently and had shorter LOS than AA infants
OUTCOME UNADJUSTED RESULTS
ADJUSTED RESULTS
P-VALUE
Infant Treated
88% vs 60% OR = 0.79(CI 0.61, 0.99)
0.02
Mean LOS 31.1 vs 20.4 days - 10.8 days 0.005
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Conclusions• NAS is a complex disorder with many
factors contributing to the incidence and severity
• SNPs in the OPRM1 and COMT genes - reduced treatment and LOS
• No associations found with ABCB1 SNPs
• Combining clinical risk factors with genetic profiling would permit personalized genetic medicine and targeted treatment regimens
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Challenges in Neonatal Drug Development
• Most drugs used in newborn infants not FDA approved - safety and efficacy not established
• Small market, high liability, ethical concerns
• Significant variability in NAS treatment protocols
• Many NAS medications include alcohol or propylene glycol
• Concern for adverse long-term developmental outcomes
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Future Directions
• NIH Grant – “Improving Outcomes in Neonatal Abstinence Syndrome”
• Randomize infants to receive morphine or methadone (determine best practice)
• Evaluate long-term neurodevelopmental outcomes of infants treated for NAS
• Establish other genetic factors - Addiction Array (1350 SNPs for addiction disorders)