George R. Saade - US grants

Cervical ripening is of crucial importance for reproduction in mammals. The cervix, an organ mainly composed of connective tissue, softens during the last third of pregnancy to facilitate effacement and dilatation during delivery of the newborn. Any change in this physiological pattern, resulting either in preterm or delayed cervical ripening, may have significant consequences. The mechanisms controlling cervical ripening during pregnancy are not completely understood. The known uterotonic properties of platelet-activating factor (PAF), a phospholipid- derived autacoid, and our recent functional studies regarding its effect on the uterine cervix indicate a potential key-role for PAF in parturition. The primary objective of our studies is to further define the role of PAF in cervical ripening in pregnant rats and investigate putative pathways involved in this effect. Furthermore, we propose to determine the effect of different PAF-antagonists on the process of cervical ripening. Our specific aims are to use timed-pregnant Sprague-Dawley rats to 1) determine the mRNA and protein expression of PAF-acetylhydrolase, the enzyme controlling PAF metabolism, in the uterine cervix at different times of gestation using RT-PCR and Western blot; 2) compare the effects of different doses of PAF, PAF antagonists, and vehicle on cervical ripening as evaluated by measurement of cervical resistance and light induced fluorescence; 3) examine the timing of delivery and duration of parturition in animals treated with PAF, PAF antagonist, or vehicle; and 4) estimate the expressions of iNOS and COX2 mRNA and protein in the cervix of animals treated with PAF, PAF antagonist, or vehicle. These studies would lead to a better understanding of the mechanisms responsible for cervical ripening and therefore might improve our ability to control cervical ripening clinically.

DESCRIPTION (provided by applicant): The University of Texas Medical Branch at Galveston (UTMB) has the capability to participate actively as a member of the NIH multisite Stillbirth Network. PI George R. Saade, MD, offers extensive experience within several NIH multisite clinical trials og: First and Second Trimester Evaluation of Risk of Aneuploidy (FASTER);First Trimester Nuchal Translucency and the Risk of Congenital Heart Disease;Twin-Twin Transfusion Syndrome Trial;and Beneficial Effects of Antenatal Magnesium Sulfate Study (BEAM). We have achieved successful patient recruitment and retention by frequent involvement with UTMB's extensive Regional Maternal &Child Health Program (RMCHP). All of RMCHP's clinics follow protocols established by the Maternal-Fetal Medicine division, and the patients are delivered at UTMB in Galveston. Pregnant women in two counties served by UTMB--Galveston and Brazoria--will constitute the geographic-based population. More than 90% of these patients are cared for at a UTMB clinic and deliver at John Sealy Hospital. If needed, this target population can be expanded to other RMCHP clinics based on zip codes or counties, as appropriate. Further, the Department's Electronic Medical Record captures antepartum and intrapartum information, entered on-line, that is readily available for query by authorized investigators. In like manner, our Department's Tissue Bank has added broad efficiencies to clinical investigation. The excellent and productive collaboration between PI and Co-I, Radec Bukowski, MD, PhD, offers further benefits to the Stillbirth Network. In addition, our Department's genetics counselor, Jennifer Lee, who will serve as our site's outreach worker, brings considerable experience as an established grief counselor. Our Department has a very productive and well-funded basic science research group with expertise in many areas of relevance to the RFA, such as infection, vascular physiology, placental function, and fetal growth. Finally, we have well-established collaborative ties with our University's Department of Pathology and divisions of Genetics and Neonatology (see letters of support). In particular, UTMB has a highly regarded Perinatal Pathology division with expertise in various areas of interest to this RFA, including neuropathology and placental pathology. Following on our current interest in DNA microarray technology, our proposed study concept is to determine a single nucleotide polymorphism (SNP) marker profile particular to stillbirth. We accept the capitation and participatory stipulations of this RFA and stand ready to become a contributinq member of the NIH Stillbirth Network.

DESCRIPTION (provided by applicant): The University of Texas Medical Branch (UTMB) has the required elements to actively participate in the Cooperative Multicenter MFMU Network. The PI, George Saade, and the alternate PI, Gary Hankins, bring extensive experience in study design, recruitment, data analysis, and publications from several NIH multisite clinical trials (First and Second Trimester Evaluation of Risk of Aneuploidy, Beneficial Effects of Antenatal Magnesium Sulfate Study, Twin-Twin Transfusion Syndrome Trial, Vaginal Ultrasound Cerclage Trial, Stillbirth Collaborative Research Network, Obstetric-Fetal Pharmacology Research Units Network, Genomic/Proteomic Network for Premature Birth Research). We achieve successful patient recruitment/retention through use of the Ob/Gyn Departments's broad Regional Maternal &Child Health Program (RMCHP). The RMCHP provides prenatal care to over 11,000 multiethnic pregnant women a year. All RMCHP clinics follow protocols set by the Maternal-Fetal Medicine Division, and all antepartum and intrapartum patients are under Departmental control. Our clinical infrastructure and patient population make us well prepared to participate in the Network as we deliver over 5,000 high-risk pregnancies a year, more than 90% receiving prenatal care in our system. The Department's Electronic Medical Record System (EMR) captures antepartum and intrapartum data, entered on-line and readily available to authorize research personnel for query as well as automatic notification. The EMR and policies/procedures have been successfully adapted to maximize our research productivity compared with other collaborating sites. The Department's team of dedicated research nurses and coordinators (Chairman's Research Division [CRD]) and the Tissue BioBank, both under the direction of the PI, have broadened efficiency in clinical investigations. Other key personnel in this application, including Garland Anderson, Chair of our Department as well as the current MFMU Network, Janet Brandon, CRD Nursing Director, and Joan Moss, CRD Coordinator, bring extensive experience and expertise to the team. The excellent and prolific collaboration between PI and alternate PI, who is also the MFM Division Director and RMCHP Medical Director, offers further benefit and efficacy to the Network. Our Department has a productive and well-funded basic science research group, with expertise in many areas of relevance to the RFA. Finally, we have well-established collaborative ties with our University's Divisions of Neonatology, Genetics, Perinatal Pathology, Clinical Laboratory, and Radiology. At all levels, UTMB emphasizes research in general, with multiple core facilities available to the Network including the GCRC, and obstetrical research in particular (our Department ranks 9th in NIH funding nationally, and 1 in Texas). Our concept protocol compares the efficacy and safety of single versus multiple courses of antenatal corticosteroids. We accept the RFA's capitation and participatory stipulations and stand ready to contribute as a productive member of the Network.

The reported association between an unfavorable fetal environment and adult diseases may be confounded by a genetic predisposition toward specific diseases (eg, vascular diseases) as the maternal genes that are transmitted o the fetus may also set the uterine environment. Epidemiological studies may not differentiate between the unfavorable uterine environment vs the hereditary predisposition common to mother and fetus. As endothelial nitric oxide synthase (NOS3) is important in determining vascular function in adults, and deficiency in its function leads to abnormal vascular adaptations in pregnancy and an unfavorable fetal environment, we crossbred transgenic mice lacking a functional NOS3 gene (NOS3-/-KO) and their wild-type control (NOS3+/+WT) to clarify the roles of the fetal environment vs genetics in determining adult vascular function. Our preliminary results show that the vascular phenotype in heterozygous adult that inherit the functional NOS3 allele from the father and therefore develop in NOS3-/-KO mothers (NOS3+Pat/-Mat) is similar to NOS3-/-KO mice. In contrast, the vascular phenotype in heterozygous adults that inherit the father's nonfunctional NOS3 allele and develop in NOS3+/+WT mothers (NOS3+Mat/-Pat) is similar to NOS3+/+WT mice. We hypothesize that the observed difference between the heterozygous mice is due to fetal programming caused by an unfavorable uterine environment resulting from altered vascular adaptations in the NOS3-/-KO pregnancy secondary to lack of NOS3 function. To test this hypothesis, we propose the following aims: 1) determine vascular function and blood pressure in adult offspring born to NOS3-/-KO females bred with NOS3-/-KO or NOS3+/+WT males, and compare them to offspring of NOS3+/+WT females bred with NOS3-/-KO or NOS3+/+WT males;2) determine the roles of uterine environment vs genetics by comparing the vascular phenotype in later life in NOS3-+Pat/-Mat, NOS3+Mat/-Pat, NOS3-/-KO and NOS3+/+WT embryos transferred into NOS3-/-KO surrogate mothers to those transferred into NOS3+/+WT surrogate mothers;3) determine the transgenerational consequences of fetal programming by examining the vascular phenotype in NOS3+Pat/-Mat, NOS3+Mat/-Pat, NOS3-/-KO and NOS3+/+WT during pregnancy (aim 3a), as well as in their offspring in adult life (aim 3b);4) compare adult vascular phenotype between NOS3+Pat/-Mat , NOS3+Mat/-Pat, NOS3-/-KO and NOS3+/+WT offspring born to the same dams in the 1st, 2nd, and 5th pregnancies: This unique model is relevant to adverse pregnancy outcomes related to abnormal uterine environment, such as preeclampsia and fetal growth restriction, and has significant implications regarding the long-term health of offspring.

DESCRIPTION (provided by applicant): During our first cycle in the MFMU Network, we demonstrated the ability of our clinical and research infrastructure at The University of Texas Medical Branch (UTMB) to effectively contribute to multisite trials. In addition to productivity in the MFMU Network, the PI, George Saade, and alternate PI, Gary Hankins, bring extensive experience in study design, recruitment, data analysis, and publications from several non-MFMU Networks, such as the Stillbirth Collaborative Research Network, Obstetric Pharmacology Research Units Network, and Genomic/Proteomic Network for Premature Birth Research. We achieved successful patient recruitment and retention through our Department's Regional Maternal & Child Health Program (RMCHP). RMCHP clinics, following protocols set by the Maternal-Fetal Medicine Division, provided prenatal care for more than 12,000 multiethnic pregnant women in 2009. We deliver over 5,000 high-risk pregnancies a year, with more than 90% receiving prenatal care in our system. The Department's Electronic Medical Record System (EMR) captures antepartum and intrapartum data online and is readily available to authorized research personnel for query as well as automatic notification. The EMR and policies/procedures have been successfully adapted to maximize our research productivity. The MFM Division, Tissue BioBank, and team of dedicated research staff in the Perinatal Research Division (PRD), all under the direction of the PI, have broadened efficiency in clinical investigations. Joan Moss, MFMU Research Nurse Coordinator, brings extensive experience and expertise to the team. The prolific collaboration between PI and alternate PI, who is also Department Chair and RMCHP Medical Director, offers further benefit and efficacy to the Network. As the chief of OB, the PI directs the medical management of all Obstetrical patients at UTMB. Our Department has a well-funded basic science research group with expertise in many areas of relevance to the RFA. Finally, we have well-established collaborative ties with our University's Divisions of Neonatology, Genetics, Perinatal Pathology, Clinical Laboratory, and Radiology. At all levels, UTMB emphasizes research in general, with multiple core facilities available to the Network, including the Institute of Translational Research, the home for UTMB's CTSA. Our Department is consistently one of the top NIH- funded Ob/Gyn departments in the nation. In our concept protocol, we propose to compare the neonatal outcomes following acute tocolysis with nifedipine vs. indomethacin. We accept the RFA's capitation and participatory stipulations and stand ready to continue as productive members of the Network.

? DESCRIPTION (provided by applicant): Mounting evidence suggests that abnormal placental development in early gestation is highly associated with many maternal and fetal pathologic conditions, which can manifest later in pregnancy. The ability to evaluate in real time human placental structure and function in early gestation by using novel ultrasound tools will allow for the identification of early markers of placental dysfunction with the ultimate long- term goal of prevention of adverse pregnancy outcomes. As initial steps in accomplishing this long-term goal, we propose this study designed to find which of the novel ultrasound tools are best at discriminating between women who will develop adverse pregnancy outcomes and those who will not. We have formed collaboration with Toshiba Medical Systems, one of the ultrasound industry leaders, that is focused on evaluating recently developed novel ultrasound tools that substantially expand our ability to study placental structure and function in vivo. This collaboration will advance the field through technology development and translational research. Our collaboration brings together novel tools, strong technological expertise, leadership in obstetrical ultrasound, and a track record of clinical research. The novel ultrasound tools that will be used in our study include Superb Micro-Vascular Imaging (SMI) for the comprehensive assessment of placental microvasculature, Shear Wave Elastography (SWE) for the evaluation of placental tissue stiffness and MicroPure(r) for the visualization of placental microcalcificatios content. We plan to apply these novel ultrasound tools, along with fetal and placental biometric and 3D ultrasound measurements, on a control group of normal pregnancies and a study group of at-risk pregnancies starting from early gestation and in a longitudinal cohort design. Maternal and neonatal outcome will be collected along with storage of biospecimen and placental pathology for future evaluation. Pregnancy ending at less than 37 0/7 weeks' gestation for any cause will be the primary study outcome and will differentiate normal from abnormal pregnancy. The ultrasound data will be analyzed to identify significant early markers of placental dysfunction. We have 3 study aims. First is to develop longitudinal nomograms for the novel ultrasound tools in normal human pregnancies. Second is to apply these novel ultrasound tools to study placental development in at-risk human pregnancies. Third to develop and evaluate an overall novel placental ultrasound marker: The Placental Index as an early gestation, non-invasive, marker of placental dysfunction for the prediction of adverse human pregnancy outcomes.

? DESCRIPTION (provided by applicant): During our 2 cycles in the MFMU Network, we demonstrated the ability of our clinical and research infrastructure at The University of Texas Medical Branch (UTMB) to effectively contribute to multisite trials. In addition to productivity in the MFMU Network, the PI, George Saade, and alternate PI, Gary Hankins, bring extensive experience in study design, recruitment, data analysis, and publications from several non-MFMU Networks, such as the Stillbirth Collaborative Research Network, Obstetric Pharmacology Research Units Network, and Genomic/ Proteomic Network for Premature Birth Research. We achieved successful patient recruitment and retention through our Department's Regional Maternal & Child Health Program (RMCHP). RMCHP clinics, following protocols set by the Maternal-Fetal Medicine Division, provide prenatal care for more than 10,000 multiethnic pregnant women annually. We deliver more than 5,000 pregnancies a year-many of them high risk-with more than 90% receiving prenatal care in our system. The Department's Electronic Medical Record System (EMR) captures antepartum and intrapartum data online and is readily available to authorized research personnel for query as well as automatic notification. The EMR and policies/procedures have been successfully adapted to maximize our research productivity. The MFM Division and team of dedicated research staff in the Perinatal Research Division (PRD), all under the direction of the PI, have broadened efficiency in clinical investigations. Ashley Salazar, MFMU Research Nurse Coordinator, brings extensive experience and expertise to the team. The prolific collaboration between PI and alternate PI, who is also Department Chair and RMCHP Medical Director, offers further benefit and efficacy to the Network. As the chief of OB, the PI directs the medical management of all Obstetrical patients at UTMB. Our Department has a well-funded basic science research group with expertise in many areas of relevance to the RFA. Finally, we have well-established collaborative ties with our University's Divisions of Neonatology, Genetics, Perinatal Pathology, Clinical Laboratory, and Radiology. At all levels, UTMB emphasizes research in general, with multiple core facilities available to the Network, including the Institute of Translational Research, the home for UTMB's CTSA. Our Department is consistently one of the top NIH-funded Ob/Gyn departments in the nation. We accept the RFA's capitation and participatory stipulations and stand ready to continue as productive members of the Network.

ABSTRACT Preeclampsia complicates approximately 3% to 5% of pregnancies and remains a major cause of maternal and neonatal morbidity and mortality. Women who have experienced preeclampsia in one pregnancy are at high risk for preeclampsia in subsequent pregnancies with the magnitude of the risk depending on the severity and gestational age at delivery in the index pregnancy. Preeclampsia shares pathogenic similarities with adult cardiovascular diseases as well as many risk factors. Endothelial dysfunction and inflammation are fundamental for the initiation and progression of both. Prevention of preeclampsia using various supplements and medications have had limited success. In contrast, there is strong evidence that 3-hydroxy-3- methylglutaryl-coenzyme A reductase inhibitors (statins) are beneficial in primary and secondary prevention of cardiovascular mortality and other cardiovascular events. Biological plausibility, animal data, and pilot clinical trials support a similar role for pravastatin, a hydrophilic statin with a favorable safety profile, in preventing preeclampsia prevention. In addition, the current evidence from animal studies and human pregnancy exposure cohorts do not support previous teratogenicity claims of pravastatin. Therefore, we propose a multicenter, double-blind, placebo-controlled randomized clinical trial to determine whether prophylactic treatment with pravastatin administered early in pregnancy reduces preeclampsia in high-risk women. A total of 1,760 pregnant women at high risk for preeclampsia (due to history of preeclampsia in a prior pregnancy that required delivery before 360/7 weeks) will be randomized between 100/7 and 166/7 weeks to pravastatin 10 mg or similar-appearing placebo, daily at bedtime until delivery. Women and their neonates will be followed throughout pregnancy and up to 6 weeks post partum to address the primary aim: evaluate whether treatment with pravastatin reduces the recurrence rate of preeclampsia; as well as the following secondary aims: (1) evaluate whether pravastatin improves maternal and neonatal outcomes; (2) assess the maternal and fetal/ neonatal safety profile of pravastatin during pregnancy; and (3) determine whether pravastatin administration in pregnancy reverses the angiogenic imbalance associated with preeclampsia by reducing the concentrations of the anti-angiogenic factors soluble Fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng), and increasing that of placental growth factor PlGF (angiogenic).