Cardiovascular Immaturity in Extremely Low Gestational Age Newborns: a Fundamental Prospective Study

NCT06737965 | Not Yet Recruiting

• 2 other identifiers: RECHMPL24_0118AO Tremplin
• Study Type: observational
• Target: 15
• Locations: 1 country
• Sites: 1

Brief Summary

Birth is a major turning point in the life of the newborn, as it moves from intrauterine life to extrauterine life. This sudden transition forces the newborn to adapt quickly. Oxygenation, which was only provided by the placenta during uterine life, will have to be provided by the lungs, which will open when the newborn cries for the first time. This phenomenon will change the way blood reaches the lungs and will require the newborn's heart to work harder. In addition, the cardiac workload will also increase due to the clamping of the umbilical cord, which will force the heart to pump through more resistant blood vessels. This transition, generally well tolerated in newborns at term, can be much more complicated in premature newborns, particularly in extremely low gestational age newborns (e.g. ELGAN, born before 28 weeks of amenorrhoea). There are several causes of this difficult adaptation on the cardiovascular system: poor heart function, difficulty in revascularizing lungs due to the physiological characteristics of premature newborns (high pulmonary vascular resistance, persistence of the ductus arteriosus), and a tone of the blood vessel muscles that is probably immature. In addition, respiratory failure is often associated with pulmonary immaturity. The consequences of a difficult adaptation to extrauterine life, combined with cardiovascular failure, will be poor organ perfusion, whose brain. Moreover, ELGANs have immature regulation of their brain vascularisation. Variations in the vascularisation of the brain (in the event of cardiovascular failure) may be responsible for irreversible lesions with intraventricular hemorrhage. Ultimately, these bleedings carry a high risk of mortality or severe disability in premature infants. Several hypotheses have been put forward as to the causes of this poor adaptation to extrauterine life, but there are few recommendations on adapted medical management. Cardiac ultrasound and the use of drugs to support the heart and blood vessels have been suggested. However, a large number of ELGANs will develop complications that investigators cannot predict or intervene in time. In addition, studies on the drugs used have not been carried out on ELGANs, which limits the conclusions investigators can draw. These factors encourage us to improve our fundamental knowledge of the cardiovascular system in the ELGANs. The aim is to identify the most effective clinical tools and treatments for assessing and treating neonatal cardiovascular failure at an early stage, before complications appear. Investigators aim to compare the architecture and composition of the heart, blood vessels, and blood of fetuses under 28 weeks of amenorrhea gestation with those of fetuses over or equal to 34 weeks of amenorrhea gestation. For this research, investigators need tissues (heart muscle, blood, and vessels) from fetuses of different ages. These tissues are usually already taken during the foetopathology examination to try to provide a medical explanation of the medical abortion. There will be no change to the foetopathology examination carried out on the foetus, with the exception that some of the tissue taken will have additional analyses carried out in our INSERM laboratory attached to the Montpellier University Hospital. Population resulting from medical abortion is motivated by the ethical impossibility of taking such invasive samples from live newborns. The non-use of animals is justified by the difficulty of extrapolating results to humans. The indication for abortion and its performance will be carried out by current practice. Participants will be offered and explained the study during the pre abortion visit. This research does not alter the patient's care. No additional examination or consultation is required. No personal benefit is expected from the study, but it will enable us to gain a better understanding of ELGAN's hemodynamics and to consider future clinical studies.

Conditions

ELGAN (22-28SA); Extremely Low Gestational Age Newborns; Cardiovascular Immaturity

Keywords

Cardiovascular immaturity in extremely premature infants; vasoactive agent; vascular reactivity; cardiac adrenergic receptor; cardiac architecture; vascular response; Extremely low gestational age newborns; cardio-circulatory insufficiency; myocardial contraction

Outcome Measures

Primary Outcomes (2)

• Comparison of the quantity of beta adrenergic receptor linked to myocardial contraction according to the term of foetal death

  Comparison between the two groups of beta-adrenergic receptor \- ß-adrenergic receptor levels: ß-adrenergic expression / GAPDH (Glyceraldehyde-3-phosphate dehydrogenase) expression. Expressed as a percentage

  After foetopathology exam within 48 hours of the abortion

• Comparison of the quantity of phosphodiesterase 3 linked to myocardial contraction according to the term of foetal death

  Comparison between the two groups of the quantity of phosphodiesterase 3 (PDE3) : \- Phosphodiesterase 3 levels: PDE3 expression / Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) expression. Expressed as a percentage

  After foetopathology exam within 48 hours of the abortion

Secondary Outcomes (11)

• Comparison of the quantity of cyclic AMP linked to myocardial contraction according to the term of foetal death

  After foetopathology exam within 48 hours of the abortion

• Comparison of the quantity of protein kinase A linked to myocardial contraction according to the term of foetal death

  After foetopathology exam within 48 hours of the abortion

• Comparison of the quantity of type 2 ryanodine receptor linked to myocardial contraction according to the term of foetal death

  After foetopathology exam within 48 hours of the abortion

• Comparison of the quantity of troponin linked to myocardial contraction according to the term of foetal death

  After foetopathology exam within 48 hours of the abortion

• Comparison of the vascular response of smooth muscle according to the term of foetal death

  After foetopathology exam within 48 hours of the abortion

Study Arms (2)

Extremely low gestational age foetuses

Material (cord blood/myocardial tissu/ vascular segment) from foetuses resulting from medical abortion before 28 weeks of gestation (and after 22 weeks of gestation)

Other: Medical abortion; Other: Foetopathology exam; Other: Outcomes mesurement

Control group : foetuses ≥ 34 weeks of gestation

Material (cord blood/myocardial tissu/ vascular segment) from foetuses resulting from medical abortion after or during 34 weeks of gestation

Other: Medical abortion; Other: Foetopathology exam; Other: Outcomes mesurement

Interventions

Medical abortion OTHER

Medical abortion performed according to standard practice with cord blood sample (1 to 10ml) collected on EDTA tube before injection of foeto toxic agent. EDTA tube transfered to laboratory on ambient temperature. Blood sample will be centrifuged to isolate the extracellular vesicles once in the laboratory.

Also known as: Cord blood sample / Blood analyse

Control group : foetuses ≥ 34 weeks of gestation; Extremely low gestational age foetuses

Foetopathology exam OTHER

Foetopathology exam is performed according to standard practice on the day after abortion (H12 to H48 from foetus death). Investigator will recover 2 horizontal slices (in line with the heart) between 3 and 5 mm thick, including the right and left ventricles put them in a cold physiological saline solution, and transfer them rapidly to the laboratory. Investigator will also recover segments of the descending aorta (approximately 2cm, between the ductus arteriosus and the celiac trunk) and the left renal artery. The isolated segments will be separated from the fat and connective tissue by the foetopathology team and put in a cold physiological saline solution.

Also known as: Sampling of myocardial tissue and vascular segments

Control group : foetuses ≥ 34 weeks of gestation; Extremely low gestational age foetuses

Outcomes mesurement OTHER

* From the myocardial samples, 10 µm thick sections will be prepared and slides will be incubated with antibodies directed against proteins of interest (adrenergic receptors, protein kinase A, ryanodine receptor, PDE3, troponin). After washing, fluorescent secondary antibodies will be used and slides will be observed under a fluorescence microscope. Rest of the cardiac tissue will be frozen in liquid nitrogen in order to perform Western blots. * Vessel samples will be put in a myograph to study contractile function. Concentration-response curves will be constructed by cumulative application of noradrenaline or U46619. For the study of endothelial function, arteries with and without functional endothelium will be pre-contracted to 80% of maximal contraction with U46619. When contraction reaches a plate, cumulative addition of different vasodilating agents will be performed. The vessels will also be cannulated on an arteriograph to assess dilation in response to flow and myogenic tone.

Control group : foetuses ≥ 34 weeks of gestation; Extremely low gestational age foetuses

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)
• Sampling Method: Non-Probability Sample

Study Population

All pregnant woman who will receive a medical abortion at Montpellier Hospital and who present eligibility criteria for her and her foetus will be invited to participate to the study

You may qualify if:

• For the pregnant women:
• Over 18 years old.
• Speaks and understands French.
• Medical abortion requested by the participant, scheduled and validated by the CPDPN of the Montpellier University Hospital.
• Participant's agreement to use for research purposes the biological tissues from the systematic foetopathological examination.
• For fetuses:
• Interest group: Fœtus ≥ 22 WA and \<28 WA
• Control group: Fœtus ≥ 34 WA

You may not qualify if:

• For the pregnant women :
• Injection of betamethasone or maternal use of dexamethasone in the month before foeticide
• Known family genetic mutation that may be linked with cardiomyopathy
• Failure to obtain consent (adults, unemancipated minors, persons unable to give consent)
• Not affiliated to a social security
• Persons under legal protection
• For fetuses:
• Fetus from unplanned in-utero death
• Significant cardiac malformation suspected antenatally (excluding atrial septal defect ostium secundum and isolated muscular ventricular septal defect).
• Suspected abnormality of myocardial tissue
• Biological tissue sampling more than 48 hours after fœticide

Sponsors & Collaborators

• University Hospital, Montpellier: lead
• INSERM U1046 Physiologie et médecine expérimentale du coeur et des muscles: collaborator

Study Sites (1)

CHU Montpellier

Montpellier, 34000, France

Location

Related Publications (25)

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Central Study Contacts

Arthur Gavotto, Doctor

CONTACT

+33 04 67 33 66 09; a-gavotto@chu-montpellier.fr

Study Design

• Study Type: observational
• Observational Model: CASE CONTROL
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: December 12, 2024
• First Posted: December 17, 2024
• Study Start: January 1, 2025
• Primary Completion: December 31, 2025
• Study Completion: December 31, 2025
• Last Updated: December 17, 2024

Record last verified: 2024-10

Data Sharing

• IPD Sharing: Will share

Locations

FR (1)