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Antenatal steroid therapy is standard care for women at imminent risk of preterm delivery. When deliveries occur within 7 days of treatment, antenatal steroid 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 antenatal steroid treatment efficacy, and an important percentage of fetuses exposed to antenatal steroid therapy do not respond sufficiently to derive benefit. Respiratory distress syndrome, for example, is a central metric of clinical trials to assess antenatal steroid outcomes. In the present analysis, we addressed the concept of antenatal steroid nonresponsiveness, and defined a failed or suboptimal response to antenatal steroids as death or a diagnosis of respiratory distress syndrome following treatment. For deliveries at 24 to 35 weeks’ gestation, the number needed to treat to prevent 1 case of respiratory distress syndrome was 19 (95% confidence interval, 14–28). Reflecting gestation-dependent risk, for deliveries at >34 weeks’ gestation the number needed to treat was 55 (95% confidence interval, 30–304), whereas for elective surgical deliveries at term this number was 106 (95% confidence interval, 61–421). We reviewed data from clinical and animal studies investigating antenatal steroid therapy to highlight the significant incidence of antenatal steroid therapy nonresponsiveness (ie, residual mortality or respiratory distress syndrome after treatment), and the potential mechanisms underpinning this outcome variability. The origins of this variability may be related to both the manner in which the therapy is applied (ie, the treatment regimen itself) and factors specific to the individual (ie, genetic variation, stress, infection). The primary aims of this review were: (1) to emphasize to the obstetrical and neonatal communities the extent of antenatal steroid response v

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 the standard care for women at imminent risk of preterm labor. Despite extensive and long-standing use, 40%–50% of babies exposed antenatally to steroids do not derive benefit; remaining undelivered 7 days or more after ANS treatment is associated with a lack of treatment benefit and increased risk of harm. We used a pregnant sheep model to evaluate the impact of continuous versus pulsed ANS treatments on fetal lung maturation at an extended, 8-day treatment to delivery interval. Continuous low-dose ANS treatments for more than 72 h in duration improved fetal lung maturation at 8 days after treatment initiation. If fetal ANS exposure was interrupted, the beneficial ANS effect was lost. Truncated treatments, including that simulating the current clinical treatment regimen, did not improve lung function. Variable fetal lung maturation was correlated to the amount of saturated phosphatidylcholine present in the lung fluid. These data demonstrate that 1) the durability of ANS therapy may be enhanced by employing an extended, low-dose treatment regimen by reducing total dose and 2) interrupting the continuity of fetal exposure by allowing it to fall below a minimal threshold was associated with comparably poor functional maturation of the preterm ovine lung.

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.

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 PaCO2, pH, heart rate, and ventilation efficacy index (VEI) were significantly (P < 0.05) and equivalently improved in both the fetal treatment group and maternal treatment group, relative to the negative control group. Similarly, S

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 administr

Background Antenatal corticosteroid (ACS) therapy is standard of care for women at imminent risk of preterm labour. Despite this, much remains to be understood regarding an optimal (maximum benefit, minimal risk of side effects) ACS dosing strategy. Although conveying overall benefit when given to the right patient at the right time, ACS treatment efficacy is highly variable, and is not risk-free. Building on earlier findings, we hypothesized that when administered in combination with slow-release betamethasone acetate, betamethasone phosphate and the high materno-fetal betamethasone concentrations it generates are redundant for fetal lung maturation. Objective Using an established sheep model of prematurity and post-natal ventilation of the preterm lamb, we aimed to compare the pharmacodynamic effects of a low-dose treatment with betamethasone acetate only against a standard dose of betamethasone phosphate and betamethasone acetate as recommended by the American College of Obstetricians and Gynaecologists for women at risk of imminent preterm delivery between 24 and 35+6 weeks’ gestation. Methods Ewes carrying a single fetus at 122±1 d gestational age (term=150d) were randomized to receive either: i) maternal intramuscular injections of sterile saline (the Saline Negative Control Group, n=12), ii) two maternal intramuscular injections of 0.25 mg/kg betamethasone phosphate + acetate spaced by 24h (the Beta-P+Ac Group, n=12); or iii) two maternal intramuscular injections of 0.125 mg/kg betamethasone acetate spaced by 24h (the Beta-Ac Group, n=11). Fetuses were surgically delivered 48h after treatment initiation and ventilated for 30 minutes to determine functional lung maturation. Fetuses were euthanized after ventilation and lung were collected for analysis using quantitative polymerase chain reaction and western blot assays. Fetal plasma ACTH levels were measured in the cord blood samples taken at delivery. Results Preterm lambs were defined as either ACS treatment

Background Artificial placenta therapy (APT) is an experimental care strategy for extremely preterm infants born at 21–24 weeks’ gestation. In our previous studies, blood taken from the maternal ewe was used as the basis of priming solutions for the artificial placenta circuit. However, the use of maternal blood as a priming solution is accompanied by several challenges. We explored the use of synthetic red cells (hemoglobin vesicles; HbV) as the basis of a priming solution for APT used to manage extremely early preterm ovine fetuses. Methods Six ewes with singleton pregnancies at 95 d gestation (term = 150 d) were adapted to APT and maintained with constant monitoring of key vital parameters. The target maintenance period was 72 h in duration. A synthetic red cell solution consisting of HbV, sheep albumin and electrolytes was used as priming solutions for the APT circuit. Fetuses were evaluated on gross appearance, physiological parameters and bleeding after euthanasia. Results Two out of six APT fetuses were successfully maintained for the targeted 72 h experimental period with controllable anemia (>10 g/dl) and methemoglobinemia (<10%) using an infusion of blood transfusion and nitroglycerin delivered >1 h after APT commencement, a sufficient period of time to cross-match blood products and screen for viral agents of concern. Conclusions Extremely preterm sheep fetuses were maintained for a period of up to 72 h using APT in combination with circuit priming using a synthetic red cell (HbV) preparation. Although significant further refinements are required, these findings demonstrated the potential clinical utility of synthetic blood products in the eventual clinical translation of artificial placenta technology to support extremely preterm infants.

An artificial placenta is a life support platform for babies born preterm, or prior to 37 weeks’ completed gestation. Although there is potential to use this platform for the intraoperative repair of congenital abnormalities (e.g. congenital diaphragmatic hernia) in late preterm babies, or for the study of fetal development, the primary target for this technology is currently treatment of extremely preterm infants, or those delivered during the peri-viable period between 21-24 weeks’ completed gestation. Babies born in this peri-viable period generally have poor outcomes due to the need to mechanically ventilate their extremely immature lungs–often at high peak pressures. Artificial placenta-based life support platforms are designed to obviate the need to ventilate as a means of facilitating gas exchange, and thus avoid injury to the immature preterm lung. Instead, highly efficient, and easily regulated gas exchange is performed by gas-exchange devices connected to the fetal vasculature. Depending on the form of the system used, venous-venous and arterio-venous circuit designs have been trialled, with the more recent arterio-venous prototypes using the fetal heart, rather than an external pump, to generate circuit pressure. Despite having the appearance of a futuristic concept, work to develop an artificial placenta has been undertaken intermittently since at least the late 1950s. That the technology is yet to enter clinical service, despite 60-plus years of work, reflects the technical challenges surrounding the development and use of the artificial placenta. This delay in introduction also reflects the changing neonatal care landscape, and notably advances in mechanical ventilation and non-invasive respiratory support modes such as continuous positive airway pressure, the introduction of antenatal steroids, and the availability of exogenous surfactant therapy. As such, it is reasonable to argue that the target demographic for artificial placenta technology has cha

To determine the incidence of ex vivo incompatibility between ovine maternal RBCs and fetal plasma, we performed cross-matching of blood samples from ewes and from lambs delivered by cesarean section. Twenty-one date-mated singleton pregnant Merino ewes were anesthetized for cesarean delivery of the fetus. At the time of delivery, paired maternal and fetal blood samples were collected and subsequently separated for storage as packed red blood cells and fresh frozen plasma. Gel column major cross matching was performed within 2 wk. All fetus-dam crossmatches were major crossmatches, combining fetal (recipient) plasma with dam (donor) RBCs. 172 individual dam-dam cross matches were performed. Two of these tests were incompatible (1.2%). In addition, 19 fetal blood samples collected immediately after cesarean delivery were crossmatched with 21 maternal samples to generate 174 maternal-fetal individual cross matches. No maternal-fetal incompatibility reactions were observed. The results of this study demonstrate that all maternal donors and fetal recipients were compatible. In addition, the incidence of an incompatible crossmatch between adult ewes was 1.2%. These data suggest that lambs may not be born with antibodies against other blood types, but rather may acquire such antibodies at some time during early life. In addition, these data suggest the risk of incompatibility reactions between ewes of a similar breed and from a single farm of origin is very low.

Background Antenatal steroids (ANS) are standard of care for women judged to be at imminent risk of preterm delivery. Worldwide, there is significant variation in ANS dosing strategy, selection for treatment criteria, and agent choice. This, combined with very limited optimization of ANS use per se means that treatment efficacy is highly variable and the rate of respiratory distress syndrome is decreased perhaps as little as 40%. In some cases, ANS use is associated with limited benefit and potential harm. Objective We hypothesized that individual differences in maternal and fetal steroid exposure would contribute to observed variability in ANS treatment efficacy. Using a chronically catheterized sheep model of pregnancy, we aimed to explore the relationship between materno-fetal steroid exposure and ANS treatment efficacy as determined by functional lung maturation in preterm lambs undergoing ventilation. Methods Ewes carrying a single fetus had surgery to catheterize a fetal and maternal jugular vein at 119 days’ gestation. Animals recovered for 24h before being randomized to either: i) a single maternal intramuscular injection (IM) of 2ml saline (Negative Control Group, n=10); or ii) a single maternal IM of 0.25mg/kg betamethasone phosphate + acetate (ANS Group, n=20). Serial maternal and fetal plasma samples were collected from each animal over 48h before fetuses were delivered and ventilated for 30 minutes. Total and free plasma betamethasone concentration was measured by mass spectrometry. Fetal lung tissue was collected for analysis using quantitative polymerase chain reaction. Results One animal of the Control Group and one animal from the ANS Group had did not complete their treatment protocol and were removed from analyses. Animals in the ANS Group were divided into a Responder (n=12/19) Sub-Group and a Non-Responder Sub-Group (n=7/19) using a cut-off of a PaCO2 at 30 minutes ventilation within 2SD of the mean value from saline-treated Negative Control Gro

Michael L. Beeton was not included as an author in the published article. The corrected Author Contributions Statement appears below.

[Introduction] Ex-vivo uterine environment (EVE) therapy is an experimental intensive care strategy for extremely preterm infants born between 21 and 24 weeks of gestation. Gas exchange is performed by membranous oxygenators connected by catheters to the umbilical vessels. The fetus is submerged in a bath of synthetic amniotic fluid. The lungs remain fluid-filled and pulmonary respiration does not occur. Intrauterine inflammation is strongly associated with extremely early preterm birth and fetal injury. Presently, there are no data of which we are aware to show that artificial placenta-based systems can be used to support extremely preterm fetuses compromised by exposure to intrauterine inflammation. [Objectives] To evaluate the ability of our EVE therapy platform to support extremely preterm ovine fetuses (95 d gestational age; approximately equivalent to 24 weeks of human gestation) exposed to intrauterine inflammation for a period of 120 hours, the following primary endpoints were chosen: i) maintenance of key physiological variables within normal ranges; ii) absence of infection and inflammation; iii) absence of brain injury; and iv) gross fetal growth and cardiovascular function matching that of age-matched in utero controls. [Study Design] Ten ewes with singleton pregnancies were each given a single intraamniotic injection of 10 mg E.coli lipopolysaccharides (LPS) under ultrasound guidance 48h before undergoing surgical delivery for adaptation to EVE therapy at 95d gestation (term=150d). Fetuses were adapted to EVE therapy and maintained for 120h with constant monitoring of key vital parameters (EVE Group) before being euthanised at 100d equivalent gestational age. Umbilical artery blood samples were regularly collected to assess blood gas data, differential counts, biochemical parameters, inflammatory markers and microbial load to exclude infection. Ultrasound was conducted at 48 h after intraamniotic LPS (before surgery) to confirm fetal viability and at th

Introduction: Antenatal corticosteroids (ACS) alter the functional trajectory of key fetal organs, including the lung and heart. Although lung effects are well characterized, less is known about impacts on the developing heart. Herein, we aimed to investigate the functional (via ultrasound) and transcriptional (via array and qPCR) impacts of low-dose vs standard clinical ACS dosing on the fetal heart. Methods: Ewes with single fetuses at 114±1d gestation received either: i) a low-dose maternal intravenous bolus and maintenance infusion of betamethasone phosphate to target fetal plasma concentration of 2 ng/ ml for 36h (low-dose group; n=6); ii) two maternal IM injections of 0.25 mg/kg Celestone Chronodose® (1:1 betamethasone phosphate and betamethasone acetate) spaced at 24h replicating a standard clinical protocol (IM group; n=6); or iii) IM saline (control group; n=6). Functional cardiac analysis was performed by ultrasound 8hrs after steroid treatment at maximum fetal steroid exposure. Lambs were surgically delivered 7 days after treatment. Microarray analysis was performed on fetal left ventricle tissue using Ingenuity Pathway Analysis Software at p<0.01 significance. Differentially expressed genes (low-dose or IM group vs. control) were identified by 2-sample t-tests. Changes in differentially expressed genes were confirmed by qPCR (data not shown). Results: Ultrasound studies showed significantly impaired relaxation in mitral and tricuspid valve E/A ratios, consistent with increased peripheral resistance. Microarray analysis revealed: i) low-dose group, 6 transcripts differentially regulated (1 up and 5 down); and ii) IM group, 43 transcripts regulated (4 up and 39 down). There was no predicted modulation of signaling pathways involved in fetal cardiac hypertrophy either group, although three transcripts, GADD45G, PPPARG, and ADIPOQ (associated with myocardial hypertrophy) were differentially expressed in the IM group only (p-value=5.7E-03, 5.1E-03, and 4.9E-0

Background: The use of antenatal corticosteroids (ACS) in low-resource environments is sporadic. Further, drug choice, dose, and route of ACS are not optimized. We report the pharmacokinetics and pharmacodynamics of oral dosing of ACS using a preterm sheep model. Methods: We measured pharmacokinetics of oral betamethasone-phosphate (Beta-P) and dexamethasone-phosphate (Dex-P) using catheterized pregnant sheep. We compared fetal lung maturation responses of oral Beta-P and Dex-P to the standard treatment with 2 doses of the i.m. mixture of Beta-P and betamethasone-acetate at 2, 5, and 7 days after initiation of ACS. Results: Oral Dex-P had lower bioavailability than Beta-P, giving a lower maximum maternal and fetal concentration. A single oral dose of 0.33 mg/kg of Beta-P was equivalent to the standard clinical treatment assessed at 2 days; 2 doses of 0.16 mg/kg of oral Beta-P were equivalent to the standard clinical treatment at 7 days as assessed by lung mechanics and gas exchange after preterm delivery and ventilation. In contrast, oral Dex-P was ineffective because of its decreased bioavailability. Conclusion: Using a sheep model, we demonstrate the use of pharmacokinetics to develop oral dosing strategies for ACS. Oral dosing is feasible and may facilitate access to ACS in low-resource environments

Objective Antenatal corticosteroids (ACS) are the standard of care for maturing the fetal lung and improving outcomes for preterm infants. ACS dosing remains un-optimized, and there is little understanding of how different treatment to delivery intervals may affect treatment efficacy. The durability of a lung maturational response is important because the majority of women treated with ACS do not deliver within the widely accepted 1-7 day window of treatment efficacy. We used a sheep model to test duration of fetal exposures for efficacy at delivery intervals from 1 to 10 days. Methods For infusion studies, ewes with single fetuses were randomised to receive an intravenous bolus and maintenance infusion of betamethasone phosphate to target 1-4ng/mL fetal plasma betamethasone for 36 hours, with delivery at either 2, 4 or 7 days-post treatment or sterile saline as control. Animals receiving the clinical treatment were randomised to receive either:i) a single injection of 0.25mg/kg with a 1:1 mixture of betamethasone phosphate + betamethasone acetate with delivery at either 1 or 7 days post treatment; or ii) two treatments of 0.25 mg/kg betamethasone phosphate + betamethasone acetate spaced at 24 hours (giving approximately 48 hours of fetal steroid exposure) with delivery at 2, 5, 7 or 10 days post-treatment. Negative control animals were treated with saline. All lambs were delivered at 121±3 days gestational age and ventilated for 30 minutes to assess lung function. Results Preterm lambs delivered at 1 or 2 days post-ACS treatment had significant improvements in lung maturation for both intravenous and single dose intramuscular treatments. After 2 days the efficacy of 36 hour betamethasone phosphate infusions was lost. The single dose of 1:1 betamethasone phosphate + betamethasone acetate also was ineffective at 7 days. In contrast, animals treated with two doses had significant improvements in lung maturation at 2, 5 and 7 days, with treatment efficacy reduced by 10

Refers to: Haruo Usuda, Shimpei Watanabe, Masatoshi Saito, Shinichi Sato, Gabrielle C. Musk, Ms Erin Fee, Sean Carter, Yusaku Kumagai, Tsukasa Takahashi, Mr Shinichi Kawamura, Takushi Hanita, Shigeo Kure, Nobuo Yaegashi, John P. Newnham, Matthew W. Kemp Successful use of an artificial placenta to support extremely preterm ovine fetuses at the border of viability American Journal of Obstetrics and Gynecology, Volume 221, Issue 1, July 2019, Pages 69.e1-69.e17

No abstract available

Background Ex-vivo uterine environment (EVE) therapy is an experimental life support platform designed to reduce the risk of morbidity and mortality for extremely preterm infants born at the border of viability (21-24 weeks gestation). To spare the functionally immature lung, this platform performs gas exchange via a membranous oxygenator connected to the umbilical vessels, and the fetus is submerged in a protective bath of artificial amniotic fluid. We and others have demonstrated the feasibility of extended survival with EVE therapy in late preterm fetuses; however, there is presently no evidence to show that the use of such a platform can support extremely preterm fetuses, the eventual translational target for therapy of this nature. Objectives To use our EVE therapy platform to support the healthy maintenance of 600-700 g / 95 d gestational age (equivalent to 24 weeks of human gestation) sheep fetuses. Primary outcome measures were: i) maintenance of key physiological variables; ii) absence of infection; iii) absence of brain injury; and iv) growth and cardiovascular function patterns matching that of non-instrumented, age-matched in utero controls. Study Design Singleton fetuses from eight ewes underwent surgical delivery at 95 d gestation (term=150 d). Fetuses were adapted to EVE therapy and maintained for 120 h with real-time monitoring of key physiological variables. Umbilical artery blood samples were regularly collected to assess blood gas data, differential counts, inflammation and microbial load to exclude infection. Brain injury was evaluated by gross anatomical and histopathological approaches after euthanasia. Nine pregnant control animals were euthanised at 100 d gestation to allow comparative post-mortem analyses. Data were tested for mean differences with ANOVA. Results Seven of eight EVE group fetuses (87.5%) completed 120 h of therapy with key parameters maintained in a normal physiological range. There were no significant inter-group differences

We investigated the incidence of ex vivo incompatibility between ovine maternal RBC and fetal plasma. Time-mated singleton pregnant ewes (n = 8) underwent cesarean delivery of the fetus; at the time of delivery, paired maternal and fetal blood samples were collected and subsequently separated for storage as packed RBC and fresh frozen plasma. Gel column crossmatching was performed 3 to 4 wk later. All fetus–dam crossmatches were considered major crossmatches, combining fetal (recipient) plasma with dam (donor) RBC. The plasma of 8 fetuses was cross-matched with RBC from 5 dams; all autologous controls were negative, and all but one crossmatch (1 of 40, 2.5%) were considered compatible. In addition, the plasma of 3 dams was crossmatched with RBC from 5 dams; all autologous controls were negative; however, significant incompatibility was noted. In total, 4 of 13 (30.8%) dam–dam crossmatches were considered incompatible. The results of this initial study suggest that when a single animal receives multiple blood-product transfusions, the risk of an immunologic transfusion reaction can be reduced by ensuring that the blood products are obtained from a single donor, performing a crossmatch prior to transfusion, and the use of synthetic products to increase the oxygen carrying capacity of fetal blood.

INTRODUCTION: Ex vivo uterine environment (EVE) therapy is an experimental neonatal intensive care model for extremely preterm infants who, due to their extreme prematurity, are unable to survive on mechanical ventilation. EVE therapy involves surgical cannulation and ligation of umbilical vessels to connect parallel membranous oxygenators for fetal gas exchange, obviating the need to ventilate the extremely immature preterm lung. The aim of the current study was to evaluate the impact of the cannulation on fetal circulation and cardiac function using ultrasound measurements. METHODS: The study was performed on preterm lambs at gestational age (GA) of 115±3 days. Fetuses received either 8 Fr arterial and 10 Fr venous catheters (n=5, Group A) or 10 Fr arterial 10 Fr venous catheters n=5, Group B), which were placed into umbilical vessels. Fetal circulation (flow direction of ductus arteriosus; DA and foramen ovale; FO) and cardiac function (early and late diastolic filling ratio of mitral valve and tricuspid valve; MV-E/A and TV-E/A, left myocardial performance index; MPI, maximum systolic velocity of descending aorta; Ao-Vmax, and pre-load index of inferior vena cava; PLI) were measured immediately after surgery. Identical fetal measurements were performed using control (non-surgery) ewes of corresponding GA (n=6, Group C). The data were analyzed using the one-way analysis of variance (ANOVA) and Tukey honestly significant difference (HSD) test. RESULTS: Blood flow at DA and FO was maintained in a right to left direction in all groups. Regarding MV-E/A and TV-E/A, Group A had a significantly higher value than Group B or C. There was no significant difference between Group B and C. For MPI and Ao-Vmax, both Groups A and B were significantly different from C, and there was no significant difference between Group A and B. No difference was observed for PLI among the three groups. CONCLUSION: Fetal circulation was maintained immediately after surgery in both catheter gr

Introduction Ex-vivo uterine environment (EVE) therapy uses an artificial placenta to provide gas exchange and nutrient delivery to a fetus submerged in an amniotic fluid bath. Development of EVE may allow us to treat very premature neonates without mechanical ventilation. Meanwhile, elevations in fetal inflammation are associated with adverse neonatal outcomes. In the present study, we analysed fetal survival, inflammation and pulmonary maturation in preterm lambs maintained on EVE therapy using a parallelised umbilical circuit system with a low priming volume. Methods Ewes underwent surgical delivery at 115 days of gestation (term is 150 days), and fetuses were transferred to EVE therapy (EVE group; n = 5). Physiological parameters were continuously monitored; fetal blood samples were intermittently obtained to assess wellbeing and targeted to reference range values for 2 days. Age-matched animals (Control group; n = 6) were surgically delivered at 117 days of gestation. Fetal blood and tissue samples were analysed and compared between the two groups. Results Fetal survival time in the EVE group was 27.0 ± 15.5 (group mean ± SD) hours. Only one fetus completed the pre-determined study period with optimal physiological parameters, while the other 4 animals demonstrated physiological deterioration or death prior to the pre-determined study end point. Significant elevations (p<0.05) in: i) inflammatory proteins in fetal plasma; ii) selected cytokine/chemokine mRNA expression levels in fetal tissues; and iii) histological inflammatory score in fetal lung, were observed in the EVE group compared to the Control group. There was no significant difference (p>0.05) in surfactant protein mRNA expression level between the two groups. Conclusion In this study, we achieved limited fetal survival using EVE therapy. Despite this, EVE therapy only induced a modest fetal inflammatory response and did not promote lung maturation. These data provide additional insight into markers o