A Triple-blinded, Randomized, Parallel-group Placebo-controlled Trial to Assess the Impact of Maternal Antenatal Melatonin Supplementation on Early Childhood Neurodevelopmental Outcomes in the Setting of Severe Preterm Fetal Growth Restriction
Phase: PHASE3
Conditions: Fetal Growth Retardation, Stillbirth and Fetal Death, Pregnancy Preterm
Sponsor: Monash University

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
 
 
 
 
 
Title: A Randomised Controlled Trial of Antenatal Melatonin 
Supplementation in Fetal Growth Restriction for Fetal 
Neuroprotection.  
 
 
 
Protocol V2.16 9 July 2024 
 
 
 
 
NCT 05651347 
 
 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
 
A Randomised Controlled Trial of Antenatal Melatonin Supplementation in Fetal Growth 
Restriction for Fetal Neuroprotection.  
 
Complete Title:  
A triple-blinded, randomized, parallel-group placebo-controlled trial (PROTECT Me 
trial) to assess the impact of maternal antenatal melatonin supplementation on early 
childhood neurodevelopmental outcomes in the setting of severe preterm fetal 
growth restriction.  
Short Title:  
A Randomised Controlled Trial of Antenatal Melatonin Supplementation in Fetal 
Growth Restriction for Fetal Neuroprotection: The PROTECT Me trial  
Version & date:   
Version 2.16, 09 July 2024 
Phase of trial:  
  
Phase III  
HREC registration:  
Monash Health HREC 17-0000-583A  
ANZCTR registration:  
ACTRN12617001515381  
Universal Trial Number:  U1111-1203-6718  
Lead Principal  
  
Dr Kirsten Palmer B.BioMed Sci, MBBS (Hons), PhD, FRANZCOG, CMFM  
Investigator:  
  
Obstetrician, Monash Health  
 
  
  
 Senior Research Fellow, Monash University  
Principal Investigator  
Prof. Euan Wallace AM MBChB MD FRCOG FRANZCOG  
and Trial Supervisor:  
Carl Wood Professor and Head of Department of Obstetrics & Gynaecology, Monash  
University  
Trial Institution:   
Department of Obstetrics & Gynaecology,   
Monash University and Monash Health   
Monash Medical Centre    
  
246 Clayton Rd, Clayton VIC 3168   
  
Phone +61 3 9594 6666  
  
  
Fax +61 3 9594 6389  
  
  
Trial Sponsor:  
  
Monash University  
Wellington Road  
  
  
Clayton VIC 3800  
 
 
 
 
  
   
  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
Protocol version control and change history  
  
Version  
Date from  
Date to  
Amendment  
1.3  
18th October  
2017  
26th December 2017  
Ethics application, submission to Monash 
Health HREC 
2.0  
27th December 
2017  
22nd May 2018  
HREC approval subject to conditions. 
Addition of DSMB Information. Inclusion of 
information regarding the treatment of 
tissue(s) following laboratory analysis, 
specifically, any future use. 
2.1  
27th June 2018  
  
Following feedback from IMPACT clinical 
trials network. 
2.2  
1st April 2019  
  
Addition of new trial personnel 
2.3 
1st August 2019 
 12th November 2019 
Following peer review feedback and BMJ 
article publication 
2.4 
13th November 
2019 
 
Following finalisation of Baby Moves 
involvement for GMA assessment. 
2.5 
15th January 2020 
 
Feedback from the trial steering committee 
to create a more generic protocol better 
suited to trial expansion to additional sites. 
 
2.6 
 
24th July 2020 
 
Feedback from the trial steering committee 
to edit wording of MRI assessment 
2.7 
7th August 2020 
 
Insertion of detailed information regarding 
MRI data sharing for post-processing analysis 
2.8 
23rd October 2020 
 
Change 2-yr developmental outcome 
measure from the Bayley III to Bayley-4 to 
reflect newly updated version. 
Addition of Neonatal Cardiac and 
Cerebrovascular assessment sub-study 
2.9 
16 June 2021 
 
Clarification for 48 hr assessment process to 
include fetal wellbeing assessment. 
 
2.10 
21 July 2021 
 
Addition of the Fetal movement substudy 
2.11 
18 February 2022 
 
Addition of new participating sites 
2.11 
9th May 2022 
 
Change of timelines for initial ultrasound 
scans 
2.12 
13 June 2022 
 
Combination of changes for two versions of 
2.11 
2.13 
12 July 2022 
 
Corrected date of protocol version on p.1 
2.14 
23 August 2022 
 
Addition of new participating sites 
Update of proposed study timeline 
Amendment trial team members 
2.15 
9 October 2023 
08 July 2024 
Addition of data sharing process between 
research teams for participants enrolled in 
multiple studies 
2.16 
09 July 2024 
 
Amendment to data sharing process to 
include consent to collect data performed for 
clinical care 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
  
   
  
 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
Contents:  
LIST OF ABBREVIATIONS ............................................................................................................................. 8 
AUTHORS ROLES AND RESPONSIBILITIES: .................................................................................................... 9 
1. SUMMARY ............................................................................................................................................ 14 
2. BACKGROUND ...................................................................................................................................... 15 
2.1 FETAL GROWTH RESTRICTION .............................................................................................................................. 15 
2.2 PATHOPHYSIOLOGY............................................................................................................................................ 16 
2.3 CURRENT CLINICAL MANAGEMENT OF FETAL GROWTH RESTRICTION .......................................................................... 17 
2.4 MELATONIN AS AN ANTI-OXIDANT ....................................................................................................................... 17 
2.5 MELATONIN USE IN PREGNANCY .......................................................................................................................... 17 
2.6 MELATONIN USE IN FGR .................................................................................................................................... 19 
3. TRIAL HYPOTHESIS AND AIMS ............................................................................................................... 20 
3.1 HYPOTHESIS: .................................................................................................................................................... 20 
3.2 PRIMARY AIM: .................................................................................................................................................. 20 
3.3 SECONDARY AIMS: ............................................................................................................................................ 20 
4. TRIAL AND DRUG SAFETY ...................................................................................................................... 20 
4.1 RISKS OF FGR TO THE FETUS ............................................................................................................................... 20 
4.2 RISKS OF FGR TO THE MOTHER ........................................................................................................................... 20 
4.3 POTENTIAL RISKS OF MELATONIN TREATMENT ....................................................................................................... 20 
5. TRIAL DESIGN ....................................................................................................................................... 21 
5.1 COLLABORATING CENTRES .................................................................................................................................. 21 
6. TRIAL POPULATION ............................................................................................................................... 22 
6.1 - INCLUSION CRITERIA ........................................................................................................................................ 22 
6.2 - EXCLUSION CRITERIA ........................................................................................................................................ 22 
6.3 - WITHDRAWAL OF TRIAL PARTICIPANTS ................................................................................................................ 22 
7. SAMPLE SIZE AND POWER CALCULATIONS ............................................................................................. 23 
8. PARTICIPANT SELECTION AND RECRUITMENT ........................................................................................ 24 
9. RANDOMISATION ................................................................................................................................. 25 
10. TRIAL STUDY GROUPS ......................................................................................................................... 26 
10.1 – TRIAL STUDY GROUPS ................................................................................................................................... 26 
10.2 – DRUG SUPPLY AND STORAGE .......................................................................................................................... 26 
11. DURATION OF ADMINISTRATION OF THE TRIAL INTERVENTION ............................................................ 26 
11.1 – DURATION OF TRIAL INTERVENTION ................................................................................................................. 26 
11.2 - INDICATIONS TO CEASE ADMINISTRATION OF THE TRIAL INTERVENTION .................................................................... 26 
12. PARTICIPANT TRIAL SCHEDULE ............................................................................................................ 27 
12.1 BASELINE DATA COLLECTION .............................................................................................................................. 27 
12.2 PARTICIPANT SURVEILLANCE .............................................................................................................................. 27 
12.3 PARTICIPANT BLOOD TESTS AND TISSUE SAMPLES ................................................................................................... 27 
12.4 ULTRASOUND SCANS ........................................................................................................................................ 28 
12.5 NEURODEVELOPMENTAL ASSESSMENTS ............................................................................................................... 28 
12.5.1 - GMA ................................................................................................................................................. 28 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
12.5.2 – MRI .................................................................................................................................................. 29 
12.5.4 – ITSEA ................................................................................................................................................ 30 
12.6 CONCOMITANT CLINICAL MANAGEMENT AND CO-INTERVENTIONS ............................................................................ 30 
12.7 OUTCOME DATA COLLECTION ............................................................................................................................ 30 
12.8 DATA COLLECTION AND RECORD ......................................................................................................................... 31 
12.9 DISPOSAL OF REMAINING TISSUE SAMPLES AND OPTIONAL FUTURE USE...................................................................... 31 
13. ASSESSMENT OF COMPLIANCE WITH THE TRIAL INTERVENTION ........................................................... 32 
14. OUTCOME MEASURES ......................................................................................................................... 32 
14.1 - PRIMARY OUTCOME ...................................................................................................................................... 32 
14.2 - SECONDARY OUTCOMES ................................................................................................................................. 32 
15. STATISTICAL ANALYSES........................................................................................................................ 32 
16. SAFETY ISSUES AND MONITORING ....................................................................................................... 33 
16.1 - ELICITING AND DOCUMENTING AE AND SAE ...................................................................................................... 33 
16.2 – DEFINITIONS ................................................................................................................................................ 34 
16.2.1 - Adverse Event (or Adverse Experience) ............................................................................................ 34 
16.2.2 - Adverse Drug Reaction (ADR) .......................................................................................................... 34 
16.2.3 - Serious Adverse Event (SAE) or Adverse Drug Reaction (ADR) ........................................................ 34 
16.2.4 - Suspected Unexpected Serious Adverse Reactions (SUSAR) ............................................................ 35 
16.3 - ASSESSMENT OF SEVERITY/INTENSITY ............................................................................................................... 36 
16.4 - ASSESSMENT OF CAUSALITY ............................................................................................................................. 36 
16.5 - RECORDING AND REPORTING ADVERSE EVENTS AND REACTIONS TO THE SPONSOR ..................................................... 37 
16.5.1 - Suspected Unexpected Serious Adverse Reactions (SUSAR) ............................................................ 37 
16.5.2 - Serious Adverse Events (SAEs) .......................................................................................................... 37 
16.5.3 - Adverse Events (AE).......................................................................................................................... 38 
16.6 - LINE LISTINGS ............................................................................................................................................... 38 
16.7 – DATA SAFETY MONITORING COMMITTEE .......................................................................................................... 38 
16.7.1 - Purpose of the DSMC ....................................................................................................................... 39 
16.7.2 - Rationale for the DSMC .................................................................................................................... 39 
16.7.3 - Information presented to the DSMC ................................................................................................ 40 
16.7.4 - Frequency of DSMC reporting .......................................................................................................... 40 
16.7.5 - Notification to the Monash Health Research Directorate and HREC of DSMC findings .................. 40 
16.8 - REPORTING TO RESEARCH SUPPORT SERVICES .................................................................................................... 40 
16.9 - EVENTS THAT WILL NOT BE REPORTED ............................................................................................................... 40 
17. MONITORING OF TRIAL PROGRESS ...................................................................................................... 41 
18. PROPOSED TIMELINE........................................................................................................................... 42 
19. ETHICS ................................................................................................................................................ 43 
20. FUNDING ............................................................................................................................................ 43 
21. INSURANCE ......................................................................................................................................... 43 
22. DECLARATION OF INTERESTS ............................................................................................................... 43 
23. DISSEMINATION AND PUBLICATION POLICY ......................................................................................... 43 
24. APPENDIX 1 - ADDITIONAL RESEARCH COMPONENTS ........................................................................... 44 
24.1 – ADDITIONAL SECONDARY AIMS ....................................................................................................................... 44 
24.2 – ADDITIONS TO THE INDIVIDUAL PARTICIPANT TRIAL SCHEDULE .............................................................................. 44 
24.2.1 - Maternal blood tests ........................................................................................................................ 44 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
24.2.2 – Participant tissue samples. .............................................................................................................. 44 
24.2.3 – Neonatal Cardiac and Cerebrovascular Assessment ....................................................................... 45 
24.2.4 – Fetal Movements Questionnaire ..................................................................................................... 45 
25. REFERENCES........................................................................................................................................ 47 
 
 
 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
LIST OF ABBREVIATIONS  
  
Abbreviation  
Meaning  
AC  
Abdominal Circumference  
AE  
Adverse event  
AFI  
Amniotic Fluid Index  
ALT  
Alanine aminotransferase  
AR  
Adverse Reaction  
BMI  
Body Mass Index  
BPD  
Biparietal Diameter  
BPPS  
Biophysical profile score  
Bayley-4 
Bayley Scales of Infant and Toddler Development 4th edition 
CSIRO 
Commonwealth Scientific and Industrial Research Organisation 
DWI  
Diffusion-Weighted Imaging  
FGR  
Fetal Growth Restriction  
FL  
Femur Length  
GMA  
General Movement Assessment  
HC  
Head Circumference  
ID  
Identification  
ITSEA  
Infant Toddler Social-Emotional Assessment  
IUGR  
Intrauterine growth restriction  
NICU  
Neonatal Intensive Care Unit  
NOAEL  
No observable adverse effect level  
MFM  
Maternal Fetal Medicine  
PI  
Perfusion Index  
PSV  
Peak systolic velocity  
RI  
Resistance Index  
SAE  
Serious Adverse Event  
SCN  
Special Care Nursery  
SFH  
Symphysio-fundal height  
SUSAR  
Suspected unexpected serious adverse reactions  
TGA  
Therapeutic Goods Administration  
USS  
Ultrasound Scan  
VMIA  
Victorian Managed Insurance Agency  
  
  
 
 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
AUTHORS ROLES AND RESPONSIBILITIES:  
Role  
Contact information  
Trial responsibilities  
Lead PI  
Dr Kirsten R Palmer  
B.BioMed Sci, MBBS (Hons), PhD, FRANZCOG  
  
Obstetrician and MFM fellow, Monash Health  
Research Fellow, Monash University  
Monash Medical Centre  
246 Clayton Rd, Clayton, Vic, 3168  
E-mail: kirsten.palmer@monash.edu  
Tel: +61 3 9594 5145  
Fax: +61 3 9594 5003  
  
Development of trial design and co-
author of protocol  
  
Principal Investigator with ultimate 
responsibility for trial conduct and 
oversight, including delegation of 
significant trial related duties  
  
Medical Doctor (Obstetrician) 
responsible for all trial related 
medical decisions.   
  
Interpretation of trial data   
  
Co-author of resultant 
publication(s)  
PI  
  
  
Professor Euan M Wallace   
AM MBChB MD FRCOG FRANZCOG FAHMS  
  
Carl Wood Professor of Obstetrics and  
Gynaecology  
Department of Obstetrics and Gynaecology  
Monash University  
Level 5, Monash Medical Centre  
246 Clayton Road  
Clayton  
Victoria 3168  
AUSTRALIA  
  
Email: euan.wallace@monash.edu  
Tel: +61 3 9594 5145  
Fax: +61 3 9594 5003  
  
Development of trial design and co-
author of protocol  
  
Role in trial conduct and oversight, 
as well as the assessment of SAE’s.  
  
Interpretation of trial data   
  
Co-author of resultant 
publication(s)  
 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
AI 
Ms Joanne C. Mockler  
Msc Bsc (Hons) DPSM RM RN DN (UK) CRCC 
(ACRP) 
 
Research Midwife/Clinical Trial Coordinator  
Monash Health and Department of Obstetrics 
and Gynaecology, Monash University 
Level 5, Monash Medical Centre 
246 Clayton Road 
Clayton 
Victoria 3168 
AUSTRALIA 
 
Email: joanne.mockler@monash.edu 
Tel: +61 3 8572 2840 
Preparation of ethics application 
and assistance with ongoing trial 
oversight and governance. 
 
Co-author on relevant 
publication(s) 
 
Trial 
Coordinator  
  
Ms Ebony LaPosta  
Bsc RM/RN 
Research Midwife/Clinical Trial Coordinator  
Clinical Midwife Specialist 
Monash Health and Department of Obstetrics 
and Gynaecology, Monash University  
Level 5, Monash Medical Centre  
246 Clayton Road  
Clayton  
Victoria 3168  
AUSTRALIA  
 
Email: ebony.laposta@monashhealth.org  
Tel: +61 422 765 812  
Preparation of ethics revisions.  
  
Responsibility for day-to-day clinical 
oversight, conduct and coordination 
of the trial, including: informed 
consent discussions, data collection 
and entry and maintenance of trial 
documentation.  
  
 
 Trial 
Coordinator  
 
Ms Harriet Dinning   
Grad. Dip., Bsc, RM/RN 
Research Midwife/Clinical Trial Coordinator  
Clinical Midwife Specialist, Monash Health 
and Department of Obstetrics and 
Gynaecology, Monash University  
Level 5, Monash Medical Centre  
246 Clayton Road  
Clayton  
Victoria 3168  
AUSTRALIA  
  
Email: harriet.dinning@monash.edu  
Tel: +61 419 345 317  
Preparation of ethics revisions.  
  
Responsibility for day-to-day clinical 
oversight, conduct and coordination 
of the trial, including: informed 
consent discussions, data collection 
and entry and maintenance of trial 
documentation.  
  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
AI  
Associate Professor Katie Groom  
MBChB, FRANZCOG, CMFM, PhD  
  
The Liggins Institute  
The University of Auckland  
Building 503, Level 2, 85 Park Road, Grafton  
Auckland, New Zealand  
Phone: +64 9 923 9823  
  
  
Email: k.groom@auckland.ac.nz  
  
Medical doctor (obstetrician) with 
expertise in clinical trial design, 
conduct and analysis.  
  
Assistance in trial design and trial 
leadership in New Zealand.  
  
Co-author on relevant 
publication(s)  
AI   
  
Dr. Miranda Davies-Tuck   
BBioMedSci(Hons), PhD  
  
NHMRC Early Career Research Fellow.  
Hudson Institute of Medical Research, The 
Ritchie Centre.   
27 - 31 Wright Street, Clayton VIC 3168  
Phone: +61 3 8572 2700  
  
Email: Miranda.davies@hudson.org.au  
  
Statistical expertise with power 
calculations, 
participant 
numbers and statistical analysis.  
  
Co-author on relevant 
publication(s)  
AI  
Professor Peter Anderson  
BA, GradDip (AppPsych), PhD, MAPS  
  
Turner Institute for Brain and Mental Health 
Monash University, Clayton, Vic 3168  
E-mail: peter.j.anderson@monash.edu  
  
  
  
  
Expert in paediatric 
neuropsychology. Assistance in 
designing, undertaking and 
interpreting neurodevelopmental 
assessments.  
  
Co-author on relevant 
publication(s)  
AI  
A/Prof Michael C Fahey  
MBBS (Hons), PhD, FRACP  
  
Head of Pediatric Neurology  
Monash Health, 246 Clayton Rd, Clayton, Vic, 
3168.  
E-mail: Michael.Fahey@monash.edu  
  
Expert in paediatric neurology. 
Assistance in trial design, 
undertaking and interpreting 
neurodevelopmental assessments.  
  
Co-author on relevant 
publication(s)  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
AI  
A/Prof Suzanne Miller  
BSc (Hons), PhD  
  
The Ritchie Centre,  
Hudson Institute of Medical Research,  
Clayton, Vic, 3168  
E-mail: suzie.miller@hudson.org.au  
  
Expert in melatonin and laboratory 
assessment of the impact on 
oxidative stress. Assistance in trial 
design and laboratory analysis.  
  
Interpretation of laboratory data.  
  
Co-author on relevant 
publication(s)  
AI  
Prof Stacy Goergan  
MBBS (Hons), FRANZCR, MCE  
Department of Imaging  
Monash Health, 246 Clayton Rd, Clayton, Vic, 
3168.  
E-mail: Stacy.Goergen@monashhealth.org  
  
Expert in fetal and infant magnetic 
resonance imaging. Assistance in 
trial design, undertaking and 
interpreting the MRI’s performed.  
  
Co-author on relevant 
publication(s)  
AI 
Dr Kerstin Pannek 
MSc, PhD 
Australian E-Health Research Centre, CSIRO 
Level 5 UQ Health Sciences Building 
Royal Brisbane and Women's Hospital 
Herston, Queensland 4029  
 
E-mail: Kerstin.Pannek@csiro.au 
Expert in Brain MRI, particularly 
Diffusion MRI in the newborn brain. 
Assistance in interpreting the MRI’s 
performed. 
 
Co-author on relevant 
publication(s) 
  
  
 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
PRINCIPAL INVESTIGATOR STATEMENT OF COMPLIANCE  
  
  
I have read and understand the contents of this clinical trial protocol. In my formal capacity as 
Principal Investigator, I agree to conduct the trial in compliance with all stipulations of this 
protocol, the conditions of Monash Health Human Research Ethics Committee (HREC) 
approval, The National Health and Medical Research Council (NHMRC), National Statement 
on Ethical Conduct in Human Research 2007 (Updated March 2014), the NHMRC/ARC Code 
For The Responsible Conduct Of Research (2007), International Conference of Harmonisation 
(ICH)/Good Clinical Practice, and other relevant local and national guidelines.  
  
Furthermore, my duties also include ensuring the safety of the participants in this clinical trial 
and providing the sponsor, Monash Health, with complete and timely information, as outlined 
in the protocol.  It is understood that all information pertaining to the trial will be strictly 
confidential, and this confidentiality requirement applies to all the research staff at this site.   
  
Lead Principal Investigator  
  
  
  
  
Signature: _________________________                              Date: 13th November 2019                     
Dr Kirsten Palmer  
  
  
Principal Investigator  
  
  
  
  
Signature: _________________________                              Date: 13th November 2019                     
Professor Euan Wallace  
  
 
 
 
 
 
 
 
 
 
  
  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
1. SUMMARY  
Fetal growth restriction (FGR) is a significant health care issue, affecting 20,000 Australian 
pregnancies every year 1. Undetected FGR is one of the key risk factors for stillbirth, but FGR 
can also cause significant impairments in short and long-term health outcomes for the child. 
It is a major risk factor for preterm birth and is a recognised causal pathway to the 
neurodevelopmental injury underlying cognitive and behavioural impairment and cerebral 
palsy.  
Current obstetric care is focused on the detection of the growth restricted fetus and then 
ultrasound assessment of fetal wellbeing to guide timing of delivery. This approach seeks to 
maximize the gestational age of the fetus at delivery to minimise the risks of prematurity, 
while delivering the fetus in time to reduce the likelihood of stillbirth. Currently, no therapies 
exist that can maximize fetal wellbeing in the setting of growth restriction and minimise the 
frequency of antenatally acquired brain injury due to in-utero hypoxia.  
This triple-blind, randomized, parallel group, placebo-controlled trial will administer maternal 
melatonin or placebo supplementation antenatally in the setting of early-onset severe FGR to 
determine whether melatonin can PROTECT the fetal brain and lead to improved 
neurodevelopmental outcomes.   
  
  
 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
  
2. BACKGROUND  
2.1 Fetal Growth Restriction  
In Australia, 1 in 16 babies are born with a low birthweight (<2500g) 1, however many more 
will have failed to reach their true growth potential. Identifying those babies that are 
genuinely growth restricted compared to those that are constitutionally small is an ongoing 
challenge in the field of obstetrics. Currently, many different definitions exist to try and 
improve our accuracy at identifying those babies unable to reach their growth potential. The 
definition is important as those babies that are small (traditionally classified at <10th centile) 
or those failing to achieve their growth potential are at significantly increased risk of stillbirth  
2.   
FGR can also cause significant impairments in short and long-term health outcomes for the 
child. For example, FGR is a major risk factor for preterm birth and is a recognised causal 
pathway to the neurodevelopmental injury underlying cognitive and behavioural impairment 
and cerebral palsy 3–6. Indeed, premature growth restricted infants have a 4-6-fold increased 
risk of cerebral palsy 4 and are more likely to have persisting structural brain changes, as well 
as worse neurodevelopmental outcomes 3,5,6.  
Not surprisingly, the impact of FGR extends beyond the individual child: potentially affecting 
the health and wellbeing of the parents, as well as having significant economic costs for the 
healthcare system and broader community. Indeed, stillbirth alone is estimated to cost the 
Australian economy $7.6 billion annually 7, and it is likely that the long-term financial 
repercussions of FGR are considerably higher.   
While the complications of FGR are becoming increasingly understood, many challenges 
remain. Current methods for the clinical detection of the growth-restricted fetus are limited, 
particularly for FGR at term. In routine pregnancy care, fetal growth is still determined by 
measuring the symphyseal-fundal height through abdominal palpation. A measurement more 
than 2 cm smaller than expected for the gestation suggests FGR. Such an approach, which has 
been the foundation of pregnancy care for nearly a hundred years, detects, at best, less than 
half of all cases, and as few as 12-15% of cases in low-risk women 8. Accurate detection is 
essential because undetected FGR babies are disproportionately represented in the stillborn 
population 8. Where FGR is detected, the rate of stillbirth is halved because of timely 
intervention, including delivery 8.  
In contrast, early-onset FGR is often more readily diagnosed through identification of growth 
restriction on the mid-trimester morphology ultrasound or through serial ultrasound 
assessments of fetal growth in women at high risk of FGR 9. Therefore, the challenge with term 
FGR is its detection and diagnosis to enable timely delivery and minimise stillbirth, whereas 
with early-onset FGR the challenge is the prevention of impaired neurodevelopmental 
outcomes.  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
Early-onset FGR has multiple causes, such as underlying genetic abnormalities, environmental 
events, infections or placental insufficiency 10. Placental insufficiency is the most common 
cause of early-onset FGR 10. In the setting of impaired placentation, the fetus must make a 
number of compensatory adaptations in order to cope with the inadequate oxygen and 
nutrient supply. These adaptions serve to protect its vital organs, especially the heart and 
brain. It is now appreciated, however, that even with these physiological adaptions, significant 
structural brain changes can still occur.   
Evidence derived from multiple animal models has demonstrated that severe FGR, is a 
significant antecedent to perinatal brain injury 11. It is postulated that the cerebral insult is 
most likely attributable to the resultant hypoxia-ischaemia as a consequence of placental 
dysfunction 11,12. Such prolonged compromise can give rise to intracranial haemorrhage (ICH) 
and periventricular leukomalacia (PVL) (both risk factors for cerebral palsy), as well as white 
matter hypomyelination and axonal injury 13. It is these structural brain changes, which 
underpin the neurodevelopmental impairment seen in the newborn and infant 11,12. 
Consequently, these children are at increased risk of cerebral palsy, learning difficulties at 
school, a lower IQ, as well as problems in executive function, behaviour, and language 5,9,14.  
  
2.2 Pathophysiology  
Inadequate placental implantation is a critical feature in early-onset FGR. In early pregnancy, 
the trophoblastic cells invade and remodel the maternal uterine spiral arteries within the inner 
third of the myometrial wall. In turn, this alters narrow, high-resistance vessels to lower 
resistance, dilated vessels capable of delivering the significantly larger volumes of oxygenated 
blood to the placental bed and developing fetus. If this process is impaired, the spiral arteries 
are only superficially or partially remodeled within the uterine decidua, blood flow to the 
placental bed is limited. This leads to ischaemia – reperfusion injuries within the placental bed, 
upregulation of hypoxia-induced genes and increased production of free radicals secondary 
to oxidative stress. Clinically, this process is associated with pregnancy loss, FGR and 
preeclampsia.  
Indeed, pregnancy is a time of increased metabolic challenge for both mother and baby, and 
as such even normal pregnancy is associated with a state of oxidative stress compared with 
non-pregnancy [15], [16]. The placenta is a key source of this oxidative stress, due to its high 
metabolic rate and level of mitochondrial activity 17,18. Oxidative stress occurs when the 
production of pro-oxidant free radical species exceeds the capacity of cells within an organ to 
neutralize or scavenge them. The capability of placental antioxidant defenses to ameliorate 
the effects of these potentially damaging free radicals is fundamental for healthy placental 
function and therefore optimal growth and development of the fetus. While a variety of fetal 
adaptations exist to allow the fetus to withstand acute or chronic changes in oxygenation, in 
the setting of impaired placentation, the developing fetus may be exposed to high levels of 
oxidative stress due to overproduction of oxygen free radicals and a decrease in the mitigating 
activity of available antioxidants.  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
Overproduction of reactive oxygen species from any cause leads to a well-described causal 
pathway of cellular damage through lipid and protein peroxidation, and cell death via 
apoptotic or necrotic pathways 19,20. The relationship between oxidative stress and 
proinflammatory processes is also noteworthy 2122. When immune cells are activated, many 
produce oxygen free radicals, which in turn incite a further inflammatory response. The 
developing fetal brain is particularly vulnerable to both free radical-induced damage and 
systemic inflammatory stressors, and intuitively, in the context of low oxygen availability, the 
fetus may benefit from novel focused antioxidant neuroprotective strategies.  
2.3 Current Clinical Management of Fetal Growth Restriction  
Following detection of FGR, current goals in clinical care center on assessment of fetal 
wellbeing and evidence of a physiological adaption to placental insufficiency. This information 
guides the timing of steroids, if indicated, and planning of delivery to minimise the likelihood 
of stillbirth. Magnesium sulphate is the only available therapy shown to improve fetal brain 
development in the setting of placental insufficiency and hypoxia. Magnesium sulphate works 
through reducing glutamate release in a hypoxic environment, likely minimising hypoxic brain 
injury 23. It appears to reduce the risk of subsequent cerebral palsy by approximately 30% 24. 
However, magnesium sulphate is only used in the hours immediately before birth, while a 
significant proportion of underlying brain injury in FGR probably occurs over the preceding 
days to weeks. The use of a safe, maternally administered supplement commenced in the 
weeks prior to birth could provide further significant benefits in reducing the complications 
faced by premature infants in the setting of placental insufficiency.  
2.4 Melatonin as an Anti-Oxidant  
Melatonin (5-methoxy-N-acetyltryptamine) is an endogenous lipid-soluble hormone produced 
primarily by the pineal gland in humans. It provides circadian and seasonal timing cues due to 
neuroendocrine control in response to daylight. As such, melatonin secretion is relatively low 
during the daytime, with an exponential increase in synthesis and secretion occurring from 
mid-afternoon and peaking at midnight.   
In addition to timing cues, melatonin is a powerful antioxidant, acting both as a direct 
scavenger of oxygen free radicals, especially the highly damaging hydroxyl radical, and 
indirectly via up-regulation of antioxidant enzymes including glutathione peroxidase, 
glutathione-reductase, superoxide dismutase and catalase 25,26. The metabolites of melatonin 
provide further anti-oxidant effect 27.  
2.5 Melatonin Use in Pregnancy  
Melatonin is an appealing treatment for use as a fetal neuroprotectant in pregnancy, as it 
freely crosses the placenta 28 and blood-brain barrier 29. It also has an excellent safety profile 
with no known adverse effects 30,31. Placentae express receptors for melatonin32, and thus 
melatonin may protect against oxidative stress generated by ischaemia-reperfusion injury of 
the placenta.   
Melatonin has been studied in several clinical trials related to human reproduction and for 
different purposes. However, no randomized trial assessing the role of melatonin in fetal 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
neuroprotection has been completed 33. Melatonin has been evaluated in assisted 
reproductive technology where the quality of oocytes is vital for the success of in-vitro 
fertilization (IVF). Melatonin and myo-inositol are two compounds found in the follicular fluid 
that are important for oocyte maturation and quality. Tamura et al. (2008) 34 and Rizzo et al. 
(2010) 35 conducted clinical studies where they co-treated patients with 2mg and 3mg 
melatonin respectively. The patients in the Tamura et al. (2008) study were given melatonin 
from the fifth day of the previous menstrual cycle until the day of oocyte retrieval. Both studies 
revealed improved oocyte quality, but the tendency to increase pregnancy rates failed to 
reach statistical significance. Unfer et al. (2011) administered 2g myo-inositol, 200µg folic acid 
plus 3mg melatonin per day for 3-months to women who failed to become pregnant in 
previous IVF cycles, at the commencement of a new IVF cycle36. This treatment resulted in a 
total of 13 pregnancies, 9 of which were confirmed ultrasonographically and 4 undergoing 
spontaneous abortion. Treatment continued after completion of the IVF cycle, throughout 
pregnancy until delivery. Treatment was associated with better quality oocytes and more 
successful pregnancies. All babies that were born from melatonin-treated pregnancies were 
in healthy condition with no abnormalities (Unfer, personal communication in 2012).  
To evaluate the maternal-fetal transfer of melatonin Okatani et al. (1998) 37 administered a 
single oral dose of 3mg melatonin to 33 women at term (37-40 weeks gestation) 1- to 4-hours 
before a planned caesarean section. Levels of melatonin were evaluated in maternal venous 
blood and umbilical venous and arterial blood. A total of 12 healthy pregnant women 
delivered by vaginal birth served as controls. Administration of melatonin led to a rapid (<120 
minutes) and marked (>20-fold) increase in the fetal serum levels. There were no differences 
between maternal and fetal serum levels of melatonin, suggesting a rapid and unrestricted 
transfer of melatonin from mother to fetus.  
The same authors tested whether melatonin could up-regulate antioxidant enzymes 37. No 
longer than 12 hours before voluntary termination of pregnancy (between 7- and 9-weeks 
gestation), an oral dose of 6mg melatonin was administered to 47 pregnant women. A 
significant increase of the antioxidant enzyme glutathione peroxidase was observed in 
chorionic homogenates derived after the procedure, leading to the conclusion that melatonin 
might provide an indirect protection against injury caused by reactive oxygen species as seen 
in preeclampsia, FGR and fetal hypoxia.  
The dose used in this trial is based on data from a clinical trial of melatonin for preeclampsia 
38 showing that 30mg per day was safe for mother and baby without any apparent adverse 
effects 39. Venous cord blood concentrations of melatonin achieved were unchanged between 
a mother receiving 8mg and 30mg per day of melatonin (melatonin concentration 
~2100pg/mL). This cord blood concentration would appear sufficient for neuroprotection 
according to information in sheep models. However, the degree of oxidative stress reduction 
achieved within the placental bed was less in mothers receiving 8mg melatonin per day. As 
such, it was felt that the higher dose of 30mg per day was more likely to achieve a clinically 
significant result.  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
2.6 Melatonin Use in FGR  
Our group has shown that melatonin supplementation exerts multiple anti-oxidant and anti-
inflammatory effects, leading to a significant reduction in oxidative stress and lipid 
peroxidation within the fetal brain in an ovine model of FGR 13. In the absence of melatonin, 
this study showed that lipid peroxidation within the fetal brain led to significant white matter 
hypomyelination and axonal injury, causing impaired neurological performance in the lambs. 
Injury was ameliorated entirely in those exposed to melatonin supplementation, with no 
structural brain injury seen and neurodevelopmental outcomes normalised.   
As a result, a small (n=12) phase 1 trial was conducted at Monash Health supplementing 
pregnancies affected by severe FGR with 8mg of melatonin per day. Melatonin use was well 
tolerated with no adverse effects seen. A reduction in the degree of placental lipid 
peroxidation was seen (n=6) 13.    
 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
3. TRIAL HYPOTHESIS AND AIMS  
3.1 Hypothesis:   
Improved neurodevelopmental outcomes will be observed in children affected by fetal growth 
restriction who receive antenatal maternal melatonin supplementation in comparison to 
those who receive placebo.  
3.2 Primary Aim:  
The primary aim is to determine whether neurodevelopment at two years of life is improved 
among survivors of FGR who receive melatonin antenatally compared with those who receive 
placebo.  
3.3 Secondary Aims:  
1. To determine the impact of melatonin supplementation on fetal growth and wellbeing.  
2. To determine whether antenatal melatonin supplementation in fetal growth restriction is 
associated with less structural brain injuries at term corrected age.  
3. To report the occurrence of any adverse and serious adverse events associated with 
melatonin use.  
  
4. TRIAL AND DRUG SAFETY  
4.1 Risks of FGR to the Fetus  
Early-onset FGR carries significant fetal risks of premature birth. Following diagnosis, those 
babies requiring delivery <32 weeks gestation carry approximately an 8% risk of stillbirth or 
neonatal death, with those born <28 weeks gestation having a significantly higher perinatal 
mortality rate 40,41. Around 30% of survivors will suffer serious neonatal morbidity 40. 
Furthermore, 8% are found to have neurodevelopmental impairment at two years of life 42. 
These numbers are likely to be an underrepresentation as they are from a trial population, 
which was closely surveyed compared to the general population.   
4.2 Risks of FGR to the Mother  
With approximately 97% of FGR infants born <32 weeks delivered by caesarean section, the 
mother of a preterm FGR fetus faces the risks associated with morbidity and mortality relating 
to caesarean birth 40. Furthermore, they also face a significant risk of morbidity and mortality 
from pre-eclampsia, which develops among 15 - 40% of women who have a growth-restricted 
fetus 43,44.  
4.3 Potential Risks of Melatonin Treatment  
The most common side effects of melatonin are headache, dizziness, nausea and sleepiness 
45. Melatonin does not have any acute pharmacological effects on the nervous or vascular 
systems, apart from its benign but active impact on sleep mechanisms 46. Extremely high doses 
of up to 800mg/kg of melatonin were safely administered to animals without deaths, meaning 
a median lethal dose could not be established. In humans, long-term treatment with high, 
daily doses of up to 10g melatonin did not cause any toxicity except for isolated cases of 
cutaneous flushing, abdominal cramps, diarrhoea, scotoma lucidum and migraine 47.  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
Prolonged ingestion of 1g melatonin per day caused only subjective drowsiness but did not 
provoke any toxicity in the eyes, liver, kidneys and bone marrow 48. In a phase II clinical trial 
conducted in the Netherlands, 1400 women were given 75mg melatonin nightly over 4-years, 
with no side effects reported 49.  
The safety of melatonin use in pregnancy was explored in early pregnant Sprague-Dawley rats, 
at doses ranging from 1 to 200mg/kg/day and did not affect antenatal mortality, fetal body 
weight or other measures of fetal wellbeing 50. Maternal adverse effects seen at high doses, 
included mild sedation, reduced maternal weight gain and reduced food intake. This study 
sought to determine the maternal and fetal no adverse effect level (NOAEL). The NOAEL is the 
exposure level where a particular substance does not statistically or biologically significantly 
increase the frequency or severity of adverse effects in an exposed population compared to a 
suitable control population. The maternal NOAEL in this study was found to be 100mg/kg/day, 
the fetal NOAEL was established at ≥200mg/kg/day when administered to the mother. The 
maternal lowest observed adverse effect level toxicity was 200mg/kg/day. With the above 
information taken in context, the Australian Therapeutic Goods Administration (TGA) has 
assigned melatonin a Pregnancy Category B3 classification.  
We have recently completed a phase 1 trial (NCT01695070) using melatonin supplementation 
in pregnancy, as well as a clinical trial in women with pre-eclampsia (ACTRN12613000476730) 
using the same dose as proposed for this trial, and to date no adverse effects have been 
identified in the mother, fetus or neonate 13,38,51,39.  
  
5. TRIAL DESIGN  
PROTECT Me aims to be a multicentre, triple-blinded, randomized, parallel group, placebo 
controlled trial.   
5.1 Collaborating Centres  
This trial will be undertaken and co-ordinated by Monash Health.   
Other perinatal hospitals across Australia and New Zealand that have agreed to join the trial 
as additional recruitment sites include:  
• Auckland City Hospital, Auckland, New Zealand  
• Middlemore Hospital, Auckland, New Zealand  
• Christchurch Hospital, Christchurch, New Zealand  
• Palmerston North Hospital, Palmerston North, New Zealand 
• Royal Women’s Hospital, Melbourne, Australia  
• Mercy Hospital for Women, Melbourne, Australia  
• Royal Hobart Hospital, Hobart, Australia  
• Royal Prince Alfred Hospital, Sydney, Australia  
• Royal North Shore, Sydney, Australia 
• John Hunter Hospital, Newcastle, Australia 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
• Mater Hospital, Brisbane, Australia  
• Townsville University Hospital, Townsville, Australia   
• Women’s and Children’s Hospital, Adelaide, Australia 
• Sunshine Hospital, Melbourne, Australia 
• St Vincent’s Private Hospital, Melbourne, Australia 
• Gold Coast Hospital and Health Services, Southport, Australia 
• Wellington Regional Hospital, Wellington, New Zealand 
Each centre will nominate a local investigator +/- a researcher to oversee local recruitment.  
  
6. TRIAL POPULATION  
Pregnant women with a singleton pregnancy complicated by severe fetal growth restriction 
identified at 23+0 – 31+6 weeks’ gestation will be approached for recruitment.   
 6.1 - Inclusion Criteria  
1. Singleton Pregnancy  
2. Severe fetal growth restriction, defined as:  
• 
Abdominal circumference ≤3rd centile for gestational age according to charts 
supplied that have been adapted from Westerway et al 52; or  
• 
Abdominal circumference <10th centile 52 in combination with at least one 
abnormal fetoplacental Doppler study, being:  
- 
Uterine artery (raised pulsatility index ≥95th centile)53  
- 
Umbilical artery (pulsatility index ≥95th centile54 or absent/reversed 
end-diastolic flow)  
3. Confirmed 23+0 – 31+6 weeks’ gestation  
4. Age ≥18 years  
5. Understand English  
6.2 - Exclusion Criteria   
1. A fetus with a known chromosomal, major structural anomaly or non-placental cause 
of fetal growth restriction   
2. Pregnancies requiring immediate delivery (e.g. absent A wave in ductus venosus, 
preterminal CTG or biophysical profile)   
3. Co-recruitment in another clinical trial where a pharmaceutical product or nutritional 
supplement impacting on oxidative stress is the trial intervention. 
4. Currently prescribed Fluvoxamine   
6.3 - Withdrawal of Trial Participants  
All participants are free to withdraw from the trial at any point if they wish. The study power 
calculation allows for a 5% drop-out rate. This drop-out rate is a conservative estimate of what 
has been observed in other clinical trials performed within our institution. Ongoing clinical 
care will continue as determined by the treating clinical team following best practice 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
guidelines. Data collected to the point of withdrawal will be retained unless the participant 
specifically advises against this.  
Pregnancy, birth and postnatal outcome data will be collected from the participant’s hard copy 
clinical notes, relevant Hospital databases and directly from the participant. Data related to 
the baby/child will similarly be collected from hard copy clinical notes and relevant Hospital 
databases. If the participant chooses to discontinue the trial intervention, participation in 
sample collection at birth and the neonatal outcome follow-up will still be offered.  
  
7. SAMPLE SIZE AND POWER CALCULATIONS  
The required sample size has been calculated to detect if melatonin supplementation affords 
a clinically relevant difference in neurodevelopmental outcomes among survivors. An increase 
of 4-5 quotient points in the Bayley-4 Cognitive scale has been deemed sufficiently clinically 
meaningful to drive changes in health policy previously 55. Power analysis shows that 69 
participants per group will allow the detection of a difference in the Bayley-4 cognitive score 
of 5 points between the two groups, with a power of 90% and an alpha level of 0.05, using 
2sided T test for comparison. This assumes a standard deviation of 9  6 and that, on average, 
the growth restricted infant has been shown to have a cognitive score 5 points lower than the 
healthy preterm infant and 8 points lower than the healthy term infant 6. Typically, the Bayley-
4 score has a standard deviation of 15, however reduced variability has been seen in the FGR 
population and this has informed the standard deviation used here. Among pregnancies 
complicated by early onset FGR a perinatal loss rate of ~15% is commonly observed 41,56. 
Allowing for a perinatal loss rate of 15%, an extra 42 women will be recruited. Assuming an 
additional 5% loss to follow-up rate, we will aim to recruit an extra 14 participants.   
This trial also aims to assess whether the impact of melatonin is different at different 
gestational ages. Therefore, a sub-analysis will be undertaken to compare those with early 
onset FGR identified <28 weeks’ gestation to those with late-onset FGR identified between 
28-31+6 weeks gestation. To ensure that this sub-analysis is adequately powered, participants 
recruited will be randomized to either melatonin or placebo based on their gestational age at 
diagnosis. Therefore, recruiting 83 participants per group will see the overall trial aiming to 
recruit 332 participants (see figure 1).  
  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
 
  
Figure 1: Flowchart of Participant Assignment to Trial Arms.  
8. PARTICIPANT SELECTION AND RECRUITMENT  
The proposed process for participant selection and recruitment to be adopted for the research 
study is:   
a) The site trial coordinator/research nurse/midwife will identify women who may be eligible 
for trial participation.  
b) Eligible women will be invited to participate by the site trial coordinator/research 
nurse/midwife (researcher). The researcher will introduce themselves and the research 
environment of the hospital and university. The researcher will explain that the mother is 
identified as potentially suitable for participation in this research project and seek the 
mother’s permission to describe the research project to her  
c) Provide the mother with the Participant Information and Consent Form (PI&CF) for the 
research project   
d) Give a full verbal explanation of the purpose of the research project and a comprehensive 
description of what their participation entails, covering all elements that are stated in the  
Participant Information sheets   
e) Inform the mother that participation in this, and any other, research project is voluntary, 
and her clinical care will not be affected if she chooses to decline   
f) Encourage the mother to ask questions about the research project and to discuss it with 
their partner/family/doctor/midwife or any others of their choosing, before making a final 
decision   
g) All women will be given as much time as they require to fully consider whether they enrol. 
Contact telephone numbers of a researcher(s) will be provided for any questions that the 
woman would like answered in the interim.    
FGR identified between 23+0  –   
 weeks gestation.  
31+6 
Approached for recruitment  
Stratified by gestational age   
28+0  –   31+6  
n = 166  
23+0  –   
  
27+6   
n = 166  
  
Melatonin  
n = 83  
Placebo  
n = 83  
Melatonin  
n = 83  
Placebo  
n = 83  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
h) The researcher will meet the women again and, if she wishes to participate in the trial and 
remains eligible, written, informed consent will be obtained by the researcher(s) once the 
researcher is satisfied that the mother understands the implications of participating in the 
study 
i) The participant’s consent to share data between the research and clinical teams for 
neonatal and/or paediatric assessments that are commonly performed across multiple 
studies or for clinical care will be discussed and she will be asked to sign a separate consent 
form for this data sharing process.   
j) Provide a copy of the signed Consent Form, together with the Participant Information 
sheets to the now participant   
k) Place a signed copy of the Consent Form and Participant Information sheets in the medical 
records belonging to the participant  
l) Keep the original signed Consent Form on file in the trial office for verification and audit 
purposes   
m) No trial related procedure(s) will be undertaken until the consent process has been 
completed  
n) Consent is an ongoing process throughout the trial. The researcher(s) will communicate 
with the participant throughout. Verbal consent will be obtained before the 
administration of the trial intervention (tablets) as well as for any other trial-related 
procedures, e.g. venepuncture and collection of, per protocol, blood samples  
o) For those women who decline to take part in the trial, their routine antenatal care will not 
change.  Melatonin is not available as part of this standard of care.  
  
9. RANDOMISATION  
Randomisation will be via an on-line computerised randomisation service. Randomisation will 
occur on a 1:1 ratio of melatonin to placebo with the goal of 83 participants randomized to 
each of the two trial arms stratified by gestational age at recruitment and the presence or 
absence of abnormal Dopplers. At the time of recruitment, each participant will be assigned a 
unique trial code. Subsequently, all data and tissue samples collected from the participant will 
be stored only with this associated code. Thus, all data and tissue samples are deidentified at 
the point of collection, but with the capability to re-identify them in the future for data 
verification, research audit or safety (e.g. needle-stick injury).  
Furthermore, it will be possible to break the randomization code and reveal treatment group 
if necessary, such as in the event of a potential treatment-related serious adverse event 
occurring.  
  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
10. TRIAL STUDY GROUPS   
10.1 – Trial Study Groups  
Once informed, written consent has been obtained, participants will be stratified by 
gestational age. Hereafter, participants will subsequently be randomized into one of two 
groups to receive the trial intervention, either:  
1. Melatonin  
10mg melatonin tablets, administered three times a day (tds) (a total daily dose 
of 30mg per day) or  
2. Placebo  
Visually identical placebo tablets containing no active ingredient, administered 
three times a day (tds)   
Participants, their healthcare providers and the research team will be blinded to the trial 
intervention the participant has received throughout the trial and during follow-up of the 
children until all participants have completed all the stages of the trial as per protocol.  
  
10.2 – Drug Supply and Storage  
Melatonin 10mg tablets with a Certificate of Analysis will be sourced by Akesa Pharma 
(Melbourne, Australia). A matched placebo will then be produced by the Pharmaceutical 
Packaging Professionals (Port Melbourne, Australia), who will repackage all trial medication to 
maintain blinding and manage its storage and distribution. Trial medication will be supplied in 
bottles containing 42 tablets to cover trial medication for a 2-week period. Trial medication 
will then be dispensed to participating sites designated trial pharmacies for dispensing to the 
individual trial participants on a fortnightly basis.   
  
11. DURATION OF ADMINISTRATION OF THE TRIAL INTERVENTION  
11.1 – Duration of Trial Intervention  
The administration of the trial intervention i.e. melatonin or placebo tablets, will commence 
after informed, written consent has been obtained. Participants will continue to take the trial 
tablets, per protocol, three times daily (tds) until delivery at which time administration will 
immediately cease.  
11.2 - Indications to cease administration of the trial intervention  
1. Delivery of fetus  
2. Request by the Principal Investigator responsible for trial-related medical decisions, 
for example, following a serious adverse event (SAE) or adverse event that is assessed 
by the PI, as being directly related to the administration of the trial intervention or as 
a consequence of trial participation.  
3. Request by the Human Research Ethics Committee/Research Directorate  
4. Recommendation by the Data Safety and Monitoring Committee (DSMB)  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
5. Participant request  
12. PARTICIPANT TRIAL SCHEDULE  
Participant flow through the trial is demonstrated in figure 2.  
 
Figure 2: Individual Participant Trial Schedule. Investigations during fetal life will be performed as 
outlined until birth occurs. 3m = 3 months and 24 - 36m = 24-36 months corrected age. Note, some 
of the biological sample collections are optional. 
  
12.1 Baseline data collection  
Data for each participant will be collected, including details of age, ethnicity, height and 
weight, BMI, past obstetric history, past medical history, medication use, details of aneuploidy 
screening and invasive tests and fetal infection screen.  
Previous USS data will be collected for growth, liquor volume, anatomy scan details and 
uteroplacental and fetal Doppler indices (where done).   
12.2 Participant surveillance  
Blood pressure measurement, maternal weight and urinalysis (dipstick for proteinuria) will be 
performed fortnightly. Ongoing monitoring for adverse effects will occur through the use of 
questionnaire and participant medication diary. Assessment of the newborn sleep patterns 
will occur over the first week after birth with a parent completed sleep-wake diary.  
12.3 Participant blood tests and tissue samples  
Full blood count, renal (urea, electrolytes, creatinine, urate) and liver (ALT, bilirubin, albumin) 
function will be tested before the commencement of treatment, 48 hours +/- 24 hours and 14 
days (+/- 2 days) after commencement of trial medication and on the day of delivery. Results 
will be available to the treating clinical team.   
Maternal and umbilical cord blood samples will be collected at the time of delivery for 
assessing melatonin concentrations within both the maternal and fetal circulations 
respectively. These results will not be available to the treating team.  
Fetal Life
Infancy
Early 
Childhood
Identified as FGR
23+0 – 31+6 weeks
Birth
Term 
Corrected
3m 
Corrected
24m 
Corrected
Recruit
Randomise
GMA
GMA
BSID - IV
ITSEA
= Fortnightly biometry USS
= Maternal blood test
= 48 hr Fetal wellbeing assessment
Key
MRI
= Maternal & Fetal sample 
collection (placenta at Monash)

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
12.4 Ultrasound scans  
All of the following measurements will be made on the day of recruitment, or within 3 days 
prior, and then ongoing as described: 
• Fetal wellbeing assessment at 48 hours (+/- 24 hours) including amniotic fluid index 
(AFI), single deepest vertical pocket, umbilical artery (PI and presence/absence or 
reversed end diastolic flow), umbilical vein (pulsatile or non-pulsatile), ductus venosus 
(PI, presence of positive a wave), middle cerebral artery (MCA) PI and uterine artery 
PI. 
• Fetal growth measurements: abdominal circumference (AC), biparietal diameter 
(BPD), head circumference (HC) and femur length (FL). Growth parameters will then be 
repeated on a fortnightly basis.   
• Amniotic fluid measurement: four quadrant AFI and single deepest vertical pocket will 
be performed fortnightly.  
• Doppler waveforms: umbilical artery (PI and presence/absence or reversed end 
diastolic flow), umbilical vein (pulsatile or non-pulsatile), ductus venosus (PI, presence 
of positive a wave), middle cerebral artery (MCA) PI and uterine artery PI will be 
performed fortnightly.   
Scans are performed in routine clinical practice at this frequency for assessment and 
surveillance of severe FGR. Standard operating procedures will be supplied for trial purposes. 
The timing of scans stated here are required for trial purposes; it is likely that scans may be 
performed more frequently.   
These assessments will continue until delivery and be performed blinded to treatment group. 
The ultrasound images will be collected using standard approaches and images reviewed to 
ensure appropriate. The ultrasound results will be available to the treating team to guide 
clinical decision-making. However, the clinical team will also be blinded to treatment group.  
12.5 Neurodevelopmental Assessments  
Neurodevelopmental assessments will be performed using a General Movement Assessment  
(GMA), magnetic resonance imaging (MRI), Bayley Scales of Infant and Toddler Development 
4th edition (Bayley-4) and the Infant Toddler Social-Emotional Assessment (ITSEA). GMA and 
MRI will be performed at term corrected, GMA will be repeated a further two times at 3 
months corrected age ± 2 weeks, while Bayley-4 and ITSEA will be performed at 24-36 months 
corrected age. If participants are enrolled in concurrent studies where the same assessments 
are involved, or if the clinical team has flagged for this assessment to be complete, patient 
data will be shared between research and/or clinical teams to minimise the inconvenience for 
the participants. The research team will seek formal consent for this data sharing 
arrangements from these participants. 
12.5.1 - GMA   
GMA is a non-invasive measure of spontaneous infant movement. Episodes of spontaneous 
movements are assessed via video recordings using established methodology57, with 
movements classified as normal, abnormal, or absent depending on the gestational age of the 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
infant and number of weeks post birth. While a simple measure that is easily learned, it has 
been shown to be a clinically useful indicator of an individual’s likelihood of developing 
cerebral palsy with high positive and negative predictive values. This assessment is not 
currently in routine clinical use across all health services. All GMA’s will be collected using the 
Baby Moves App (Murdoch Children’s Research Institute) and assessed by assessors blinded 
to treatment group. One GMA will be collected at term equivalent, then two separate video’s 
collected at 3 months corrected age a couple of weeks apart to assist the GMA assessors in 
reliably determining a reduction or absence of fidgety movements. For sites where the GMA 
is part of routine care and with established clinical follow-up pathways in place, GMA results 
will be available to the treating team and additional interventional care offered if indicated, 
as is usual practice at Monash Health. The research team will not be involved in this care or 
the decisions regarding the need for interventional therapy. However, at sites where the GMA 
is not clinically used, results will not be disclosed. 
12.5.2 – MRI  
MRI will be performed of the infant with a ‘feed and wrap’ technique. High-resolution axial 
imaging using T1, T2 and DWI sequences will be obtained. Diffusion tensor imaging (DTI) will 
be used to study white matter tract microstructure. This technique allows calculation of 
fractional anisotropy (FA), axial diffusion (AD) and radial diffusion (RD) of cerebral white 
matter tracts.  
For sites contributing to the MRI specific study, a standard operating procedure will be 
provided including a scanning protocol. Each site will nominate a local radiologist for clinical 
reporting. All MRI studies should be reported by a single radiologist at each site blinded to 
treatment group. The MRI results will be available to the treating team to guide clinical 
decision making, the clinical team will also be blinded to treatment group. Each site will be 
responsible for the development of a local plan for the management of potential incidental 
findings and the local site team will take responsibility for sharing results with families and 
arranging any ongoing investigations and/or care. 
To enable the detailed analysis of the white matter tract microstructure, acquired de-
identified MRI data in digital form of DICOM files (there will be no hardcopy films) will be 
securely transferred to Commonwealth Scientific and Industrial Research Organisation 
(CSIRO) using CloudStor, the secure file transfer solution hosted on the AARNet network 
(Australia’s national research and education network). Transferred data will be securely stored 
at CSIRO’s servers which are directly managed by CSIRO’s central Information Management 
and Technology department and ensures an extremely high level of data storage safety 
(multiple backups) and confidentiality (encryption, strong access controls). This will be for a 
term of 15 years, in keeping with the NHMRC’s guidelines on responsible conduct of research. 
This is readily achievable thanks to the enormous storage capacity in CSIRO’s servers. A copy 
will be stored in CSIRO’s Australian E-Health Research Centre’s (affiliation of the investigators 
of the project) Xnat and RedCap database. Similar very high levels of data storage safety and 
confidentiality are implemented for the Xnat and RedCap databases as for CSIRO’s servers.  
The results from the analysis of the white matter tract microstructure will not be made 
available to clinical treating teams, as this is not an analysis that is in clinical use. 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
 
12.5.3 - Bayley-4 
The primary outcome is a clinically meaningful difference in cognitive development at 24-36 
months corrected age identified by a change in the Bayley-4 Cognitive score of 5 points. We 
will administer the cognitive, language and motor domains of the Bayley-4. The Bayley-4 is a 
direct assessment of neurodevelopment and will be performed by an experienced paediatric 
developmental psychologist blinded to (i) treatment group and (ii) GMA scores. Any 
concerning results will be discussed with the family and when appropriate referral onto 
appropriate specialists/services made.  
12.5.4 – ITSEA  
The ITSEA assesses a wide array of social-emotional and behavioural problems and 
competencies. It is validated for use between 12-36 months of age and will be applied to our 
trial cohort at 24-36 months corrected age. It is a parent-reported assessment undertaken in 
the form of a questionnaire. Results will be analysed by an experienced paediatric 
developmental psychologist blinded to treatment group, GMA and Bayley-4 data.  
Any concerning results will be discussed with the family and when appropriate referral onto 
appropriate specialists/services made.  
 
12.6 Concomitant clinical management and co-interventions  
Women with severe early-onset FGR are also at high risk of developing preeclampsia. In this 
occurrence, additional therapies, surveillance and possibly delivery indicated on maternal 
rather than fetal grounds.    
All women with severe early-onset FGR, regardless of co-existing preeclampsia, will require 
intense fetal surveillance, possible in-patient stay and early delivery. Once the fetus has 
reached an appropriate gestational age and size (and is deemed viable) corticosteroids will be 
administered to improve fetal lung maturity and once delivery is planned magnesium sulphate 
therapy will be considered for perinatal neuroprotection per institutional guidelines. These 
additional therapies and management will be provided at the discretion of the clinician/trial 
centre caring for each woman. Trial investigators will collect data regarding these co-
interventions.  
12.7 Outcome data collection  
The researcher will collect relevant data regarding pregnancy outcomes from the maternal 
clinical record (hard copy and online hospital databases). Neonatal and child (up to 3 years) 
outcome data will be collected from the hospital records (hard copy and online hospital 
records) from the time of birth up to 3 years corrected age. Consent will also be sought to 
access longer term childhood outcome data, such as educational performance. If participants 
are enrolled in concurrent studies where the same assessments are involved, or if the clinical 
team has flagged for particular common assessments to be complete, patient data will be 
shared between research and/or clinical teams to minimise the inconvenience for the 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
participants. The research team will seek formal consent for this data sharing arrangements 
from these participants. 
12.8 Data collection and record  
At the time of recruitment, each participant will be assigned a unique trial code. Hereafter, all 
data collected from the participant will be used and then stored only with this unique code 
associated with it. All electronic data, including GMA assessments using Baby Moves, will be 
stored on a RedCap database, that is password protected with restricted access limited only 
to the named principal investigators and the trial researchers. Likewise, any hard copies of 
material bearing participant information e.g. signed Consent Forms or Case Report Forms will 
be stored securely e.g. locked filing cabinet with restricted access, limited only to the named 
principal investigators and the trial researchers.  
Upon trial completion, all data and records will be stored in the Department of Obstetrics and 
Gynaecology, Monash University, or another off-site secure location, and participating sites 
will also store their site specific trial related records for the duration of >25 years.   
The principal investigator will be responsible for data storage, retention and destruction. 
Should the principal investigator leave the institution prior to the trial completion or the 25 
years has been reached, the responsibility for record retention, storage and destruction will 
be passed to another individual nominated by the PI to assume responsibility.   
12.9 Disposal of remaining tissue samples and optional future use  
At the time of consent, participants will be given an option to agree to any remaining tissue(s) 
being stored and used, in any future related pregnancy/birth FGR related research project for 
which HREC approval is sought and given. The PI&CF clearly states that this is an optional 
component of the now proposed research project and does not impact upon (current) trial 
participation should the potential participant choose to decline this option for the future use 
of their tissue(s).  
  
If a participant chooses to take part in the optional component of the research project and 
permit donation of any remaining tissues to any future related FGR research project, the 
PI&CF states that the future use may involve genetic testing. Specifically,  "The tissue(s) that 
you donate for any future, related FGR research could one day be used for genetic testing to 
learn about the role genes play in FGR. Genes are the basic “instruction book” for the cells that 
make up our bodies and may be passed on from generation to generation within families.  
Since the significance of any future genetic tests is not known for you, we will not release the 
results of any genetic testing nor will the results be used in the planning of your clinical care, 
or that of your child".  
  
For those participants who choose not to take part in the optional component and donate 
tissue(s) to any future, FGR related research projects, following the laboratory analyses of 
samples for this project, any remaining tissue(s) will be disposed of as clinical waste in line 
with site specific institutional policies on the handling and disposal of human tissues.  
  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
 13. ASSESSMENT OF COMPLIANCE WITH THE TRIAL INTERVENTION  
The trial intervention will be prescribed, as per protocol, on a fortnightly basis by the named 
investigators who hold medical doctor (MD) status, full registration with the relevant 
regulatory body e.g. AHPRA or the medical council of NZ and are employed at the trial 
institution. Subsequently, the prescription will be dispensed and stored according to the 
institution’s policy for the handling and storage of tablets to be administered to participants 
in a clinical trial.   
Participants will be asked to complete a trial intervention Compliance Log and return all 
containers including any remaining tablets, to the researcher to determine compliance with 
the administration of the trial intervention.  
  
14. OUTCOME MEASURES  
14.1 - Primary Outcome  
Improved neurodevelopmental performance at 2 years of life among survivors of early onset 
FGR.  
The ability of melatonin to protect the fetal brain in the setting of severe early-onset fetal 
growth restriction will be assessed by multiple assessments across the first 2 years of life. The 
trial is powered to detect a difference in neurodevelopmental performance at 24-36 months 
corrected age on the Bayley-4. Other tools of assessing brain development and neurocognitive 
performance will also include GMA and MRI at term, GMA again at 3-months corrected age 
and ITSEA at 24-36 months corrected age. These assessments will also be stratified depending 
on the fetal gestation and fetal Dopplers at the time of FGR diagnosis, with outcomes for those 
<28 weeks and between 28-31+6 weeks compared as a sub-analysis. Total mortality will be 
compared between melatonin and placebo.  
14.2 - Secondary Outcomes  
o Assessment of drug safety and tolerability: Maternal side effect profiles experienced, 
such as symptoms of drowsiness, abdominal cramps, flushing, migraines, 
gastrointestinal disturbance. This information will be collected from the participant 
medication diary.  
o Maternal end-organ performance monitored through haematological and 
biochemical tests  
o Fetal effects through assessing ultrasound parameters of fetal biometry (HC, BPD, AC 
and FL) and wellbeing (AFI, Doppler indices).  
  
15. STATISTICAL ANALYSES  
Outcome measures between the melatonin treatment and placebo groups will be analysed on 
an intention to treat basis. GMA, MRI, ITSEA and Bayley-4 scores will be compared between 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
groups using parametric or non-parametric testing, depending on their distribution. Simple 
regression analyses will be performed to explore relationships with functional outcomes.  
  
16. SAFETY ISSUES AND MONITORING  
There may be unexpected serious adverse reactions associated with melatonin when used in 
pregnancy. To date, clinical studies have not demonstrated any serious adverse reactions to 
melatonin, however metabolic changes during pregnancy may alter the pharmacological 
properties in unanticipated ways.  
16.1 - Eliciting and documenting AE and SAE  
The recording of adverse experiences is an important aspect of the trial’s conduct. The lead PI 
responsible for trial-related medical decisions will be designated as the person responsible for 
the assessment, documentation and reporting of all events to the sponsor, Monash Health, 
that meet the definition of an AE, SAE or SUSAR. All site PI’s are responsible for notifying the 
lead PI of SAE and SUSAR’s as outlined below in section 16.5. 
   
Assessment and reporting will be undertaken in line with the requirements of the Sponsor, 
Monash Health and the National Health Medical Research Council (NHMRC)58. For this trial, it 
is a stipulation of Monash Health Human Research Ethics Committee (HREC) that if a 
participant experiences a serious adverse event that is related/possibly related/unknown if 
related to the study drug, a report will be provided to the HREC and a copy will also be 
forwarded to the Pharmacy.  
  
All AE/SAE will be recorded from the time of signing the consent form, until the participant 
has completed all trial related follow-up procedures i.e. until all follow-up visits and 
assessments of the child at approximately 2 years corrected age have been completed.   
  
All observed or volunteered AE/SAE regardless of causal relationship will be recorded and 
reported. These events may be declared by the participant or legal guardian and/or identified 
in response to an open-ended question from the researchers or revealed by observation, 
physical examination, or while undertaking other trial related procedures.  
  
The researchers are not obligated to actively seek AE/SAE in former trial participants. 
However, if the lead PI learns of any SAE, including a death, at any time after a participant or 
their child has been discharged from the trial, and the lead PI considers the event reasonably 
related to the trial participation, the PI would promptly notify the sponsor, Monash University. 
For all adverse events as detailed below, a notification email must be sent to scs-
protectme@monash.edu, and enrolled patients will be alerted to this.   
  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
16.2 – Definitions  
16.2.1 - Adverse Event (or Adverse Experience)  
Any untoward medical occurrence in a participant or clinical investigation participant 
administered a pharmaceutical product and which does not necessarily have to have a causal 
relationship with this treatment.   
  
An adverse event (AE) can therefore be any unfavourable and unintended sign (including an 
abnormal laboratory finding, for example), symptom, or disease temporally associated with 
the use of a pharmaceutical product, whether or not considered related to the pharmaceutical 
product.   
  
 
16.2.2 - Adverse Drug Reaction (ADR)   
For marketed pharmaceutical products, a definition of an adverse drug reaction in the post 
marketing setting is found in the Australian Code for the Responsible Conduct of Research  
59:  
  
 “A response to a drug which is noxious and unintended and which occurs at doses normally 
used in man for prophylaxis, diagnosis, or therapy of disease or for modification of 
physiological function” p28.  
  
The old term "side effect" has been used in various ways in the past, usually to describe 
negative (un-favourable) effects, but also positive (favourable) effects. It is recommended that 
this term no longer be used and particularly should not be regarded as synonymous with 
adverse event or adverse reaction.   
  
16.2.3 - Serious Adverse Event (SAE) or Adverse Drug Reaction (ADR)   
During the conduct of the trial, adverse events may occur which, if suspected to be related to 
the pharmaceutical product administered (adverse drug reactions), might be significant 
enough to lead to important changes in the way the pharmaceutical product is used (e.g. 
change in dose, population, monitoring required, consent forms). This is particularly true for 
reactions that, in their most severe forms, threaten life or function. Such reactions will be 
reported promptly to the sponsor, Monash Health and if necessary also the VMIA and TGA.  
To ensure no confusion or misunderstanding of the difference between the terms "serious" 
and "severe," which are not synonymous, the following note of clarification is provided:   
The term "severe" is often used to describe the intensity (severity) of a specific event (as in 
mild, moderate, or severe myocardial infarction); the event itself, however, may be of 
relatively minor medical significance (such as severe headache). This is not the same as 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
"serious," which is based on participant/event outcome or action criteria usually associated 
with events that pose a threat to a participant's life or functioning. Seriousness (not severity) 
serves as a guide for defining regulatory reporting obligations.   
A serious adverse event (experience) or reaction is any untoward medical occurrence that at 
any dose:   
1) Results in death    
2) Is life-threatening    
3) Requires hospitalisation or prolongation of hospitalisation  
4) Results in persistent or significant disability/incapacity  
5) Is a congenital anomaly/birth defect   
6) Is an important medical event  
  
The term "life-threatening" in the definition of "serious" refers to an event in which the 
participant was at risk of death at the time of the event; it does not refer to an event, which 
hypothetically might have caused death if it were more severe.   
The term disability means a substantial disruption of a person’s ability to conduct normal life 
functions. This definition is not intended to include experiences of relatively minor medical 
significance such as: uncomplicated headache, nausea, vomiting, diarrhoea, influenza, and 
accidental trauma (e.g. sprained ankle) which may interfere or prevent everyday life functions 
but do not constitute a substantial disruption.  
Important Medical Event: Medical and scientific judgment should be exercised in deciding 
whether expedited reporting is appropriate in other situations, such as important medical 
events that may not be immediately life-threatening or result in death or hospitalisation but 
may jeopardize the participant or may require intervention to prevent one of the other 
outcomes listed in the definition above. These should also usually be considered serious. 
Examples of such events are intensive treatment in an emergency room or at home for allergic 
bronchospasm; blood dyscrasias or convulsions that do not result in hospitalisation; or 
development of drug dependency or drug abuse.  
16.2.4 - Suspected Unexpected Serious Adverse Reactions (SUSAR)   
Melatonin is a marketed medical product thus an unexpected drug reaction will be defined as 
a response that is noxious and unintended and which occurs at doses normally used for 
prophylaxis, diagnosis or therapy of diseases or for modification of physiological function. The 
reaction will be considered unexpected in nature if the nature or severity of which is not 
consistent with the applicable scientific information e.g. Product Information document or 
similar for this product.   
  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
The named Lead principal investigator with responsibility for trial related medical decisions 
will be responsible for determining whether an adverse drug reaction is expected or 
unexpected.    
  
16.3 - Assessment of Severity/Intensity  
Severity and seriousness must be differentiated. Severity describes the intensity of an AE, 
while the term seriousness refers to an AE that has met the criteria for an SAE as described 
above.  
  
The investigator will make an assessment of intensity for each AE and SAE reported during the 
trial and will assign it to one of the following categories:  
• Mild: an event that is easily tolerated, requires minimal or no treatment, causes minimal 
discomfort and does not interfere with the participant’s daily activities.   
• Moderate: events result in a low level of inconvenience or concerns with the 
pharmaceutical product, minimal, local, or non-invasive intervention indicated. 
Moderate 
events 
may 
cause 
some 
interference 
with 
normal 
everyday 
activities/functioning.    
• Severe: events interrupt a participant’s usual daily activity and may require the 
participant to seek and receive medical attention, systemic drug therapy or other 
treatment. Severe events are usually incapacitating.   
  
Changes in the severity of an AE should be documented to allow an assessment of the duration 
of the event at each level of intensity to be performed. Adverse events characterized as 
intermittent require documentation of onset and duration of each episode if the severity of 
the intermittent event changes. An AE that is assessed as severe will not be confused with an  
SAE.  Severity is a category utilized for rating the intensity of an event; and both AEs and SAEs 
can be assessed as severe.  An event is defined as ‘serious’ when it meets at least one of the 
pre-defined outcomes as described in the definition of an SAE.  
  
16.4 - Assessment of causality  
All adverse events must have their relationship to trial intervention (melatonin) or trial 
participation assessed as either related or not related. Evaluation of relatedness must consider 
etiologies such as natural history of the underlying disease, concurrent illness, concomitant 
therapy, trial-related procedures, accidents, and other external factors.   
To assess relationship of an event to the trial drug (melatonin), the following guidelines will 
be used:  
• 
Not related (unrelated): This relationship suggests that there is no association between 
the trial drug and the reported event.    
• 
Unlikely related: This relationship suggests that the clinical picture is highly consistent 
with a cause other than the trial drug but attribution cannot be made with absolute 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
certainty and a relationship between the trial drug and AE cannot be excluded with 
complete confidence.    
• 
Possibly related: This relationship suggests that treatment with the trial drug may have 
caused or contributed to the AE, i.e., the event follows a reasonable temporal 
sequence from the time of drug administration and/or follows a known response 
pattern to the trial drug, but could also have been produced by other factors.    
• 
Probably related: This relationship suggests that a reasonable temporal sequence of 
the event with the trial drug administration exists and the likely association of the 
event with the trial drug. This will be based upon the known pharmacological action of 
the trial drug, known or previously reported adverse reactions to the trial drug or class 
of drugs, or judgment based on the Principal Investigator’s clinical experience.    
• 
Definitely related: Temporal relationship to the trial drug. Other conditions 
(concurrent illness, concurrent medication reaction, or progression/expression of 
disease state) do not appear to explain event, corresponds with the known 
pharmaceutical profile, improvement on discontinuation, re-appearance on re- 
challenge.    
16.5 - Recording and reporting adverse events and reactions to the Sponsor   
16.5.1 - Suspected Unexpected Serious Adverse Reactions (SUSAR)  
  
SUSAR (Suspected Unexpected Serious Adverse Reaction) that occur with a Monash Health 
participant or with a participant from a site that Monash Health has provided HREC Review 
through multi-site trial approval are to be reported to Research Support Services within 24 
hours.  
These  events  are  reported  on  the  SUSAR/USADE  site  report  available  at:  
http://www.health.vic.gov.au/clinicaltrials/application-instructions.htm  
All SUSAR that are reported to Research Support Services will require an action plan from 
the investigator, specifying what action is being undertaken and a follow up report within 30 
days of reporting.  If Investigators suspect an adverse event may be a SUSAR, they should 
report it immediately to the TGA.  
 
For SUSAR, it is mandatory to include the UR number, date of birth and participants initials as 
the SUSAR report is forwarded to the VMIA.   
16.5.2 - Serious Adverse Events (SAEs)  
All SAE that occur with a Monash Health participant or with a participant from a site that 
Monash Health has provided HREC Review through multi-site trial approval, which are 
considered by the investigator as being definitely related, probably related, possibly related 
and unknown are to be reported within 72 hours to Research Support Services.    

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
These  
reports  
for  
AE  
and  
SAE  
are  
available  
at:  
http://www.health.vic.gov.au/clinicaltrials/application-instructions.htm  
All SAE that are reported will require an action plan from the investigator, specifying what 
action is being undertaken and a follow up report is to be provided within 30 days of the 
initial report.   
  
SAE should be reported immediately to the sponsor and the TGA, except for those SAE that 
the protocol identifies as not needing immediate reporting.  
In the event of a death of a trial participant, sites should follow local site recommendations in 
addition to completing an SAE report. For example, for Monash Health participants, it is also 
mandatory for the death notification to be entered into the Riskman module.  
16.5.3 - Adverse Events (AE)    
The reporting of AE is at the discretion of the investigator based on whether the investigator 
is concerned that the adverse event poses a safety risk.  
In addition, if the researchers or the sponsor is of the opinion that an adverse event, which is 
not graded 3 or above but poses a safety risk, should also be reported.  Adverse events must 
be reported to the Research Support Services, Monash Health within 60 days of the date of 
the researcher learning of the event. These reports are available at:  
http://www.health.vic.gov.au/clinicaltrials/application-instructions.htm  
16.6 - Line Listings  
A quarterly/six-monthly or annual line listing report which details all of the SUSAR and SAE 
that have occurred in that period must be submitted to Research Support Services 
accompanied with the Form 15 Summary Report. This form is to be completed by the sponsor.  
16.7 – Data Safety Monitoring Committee  
As this is a phase III trial, a Data Safety Monitoring Committee (DSMC) is required.  The 
DSMC has been established and consists of:  
  
Professor Paul Colditz  (MBBS, FRACP, FRCPCH, MBiomedEng, DPhil (Oxon), GAICD)  
Professor of Perinatal Medicine, The University of Queensland    
Neonatal Paediatrician, RBWH  
Director, Perinatal Research Centre, Faculty of Medicine  
Deputy Director, University of Queensland Centre for Clinical Research  
Group Head, Clinical Neurosciences Laboratory  
Perinatal Research Centre, Faculty of Medicine  
UQ Centre for Clinical Research, (Building 71/918)   
Royal Brisbane and Women’s Hospital   
QLD 4029  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
 Telephone: +61 7 33466014, E-mail: p.colditz@uq.edu.au  
  
Associate Professor Joanne Said (MBBS, PhD, FRANZCOG, CMFM, PDipEpid)  
Maternal Fetal Medicine Subspecialist, Sunshine Hospital  
Centre for Health, Research & Education NorthWest Academic Centre  
The University of Melbourne  
176 Furlong Rd,  
St Albans, 3021   
Telephone: 8395 8103, Email: jsaid@unimelb.edu.au  
  
Dr Stella May Gwini   
Biostatistician  
Biostatistics Consulting Platform  
Monash Health Translation Precinct, Monash University  
27-31 Wright St, Clayton, Vic 3168  
Phone: +61 3 8572 2458  
Email: Stella.Gwini@monash.edu  
  
16.7.1 - Purpose of the DSMC  
Melatonin is not currently indicated as an antenatal fetal neuroprotective agent during 
pregnancies with FGR, therefore for reasons of participant and fetal safety a DSMC has been 
established. The DSMC will consist of two Australian Health Professional Regulatory Agency  
(AHPRA) registered medical doctors, being a neonatologist and an obstetrician, as well as a 
biostatistician. At least one member of the DSMC must have clinical trials experience and have 
participated as a member of a DSMC before.  
16.7.2 - Rationale for the DSMC  
The DSMC was established because Melatonin is not currently administered as an antenatal 
fetal neuroprotective agent during pregnancies with FGR, or for use in pregnancy.   
For reasons of safety, the DSMC will review de-identified (but potentially re-identifiable) data 
on the following:  
• 
Interim data for evidence of trial-related adverse events  
• 
Data quality, completeness and timeliness  
• 
Adherence to trial protocol  
• 
Adequacy of compliance with goals for recruitment and retention  
• 
Factors that might affect trial outcome:  
o Compromise of confidentiality of data, such as protocol violations, unblinding 
etc.  
o Scientific or therapeutic advances that may impact on participant safety or the 
ethics of the study  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
We would advise the DSMC to advocate complete cessation, or re-evaluation, of the trial 
conduct, if it is evident that either arm of the trial is associated with a statistically significant 
increase in or a 50% increased rate above the baseline ratio of any adverse events.  
16.7.3 - Information presented to the DSMC  
All data will be presented to the DSMC without any participant personal identifiers associated 
with it. The interim analysis results will not be available to anyone external to the DSMC unless 
the trial is required to cease prematurely.  
16.7.4 - Frequency of DSMC reporting  
We will provide information to the DSMB following the recruitment of 100 participants and 
again following recruitment of 200 participants. Information will be provided at other times if 
requested by the DSMC or the Sponsor, Monash Health Research Directorate and Human 
Research Ethics Committee. No interim statistical analyses of the primary or secondary 
outcomes are planned.   
16.7.5 - Notification to the Monash Health Research Directorate and HREC of DSMC findings  
The Lead PI will notify the sponsor, Monash Health Research Directorate and the Human 
Research Ethics Committee, of the DSMC’s findings at each of the safety assessment time 
points.   
  
The Lead PI will notify the DSMC of all SAE/AEs submitted to the sponsor, Monash Health.  
  
16.8 - Reporting to Research Support Services  
Forms  
will  
be  
emailed  
to  
Research  
Support  
Services  
at:  
Research@monashhealth.org  
AE correspondence will be included in the next HREC agenda. Within a week of the meeting, 
acknowledgement will be forwarded to the Lead Principal Investigator and Study Coordinator. 
In order to respond to researchers in a timely manner, the Research Support Services will not 
send a formal letter. Instead, the cover letter/report form submitted by the researcher will be 
signed and dated by the HREC Chair or designee. A copy of the stamped letter will be scanned 
to the Lead Principal Investigator and Study Coordinator as verification.  
16.9 - Events that will not be reported  
It may be the events may occur that are not related to the trial or therapeutic intervention. 
Such as, prolongation of hospitalisation for a reason that is not related to trial participation 
e.g. social reasons. The details surrounding these events will be assessed by the Lead Principal 
Investigator and if deemed not-related, they will not be reported. The details of these events 
will however be stored.  
  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
17. MONITORING OF TRIAL PROGRESS  
Regular progress reports will be circulated to all local investigators on a bimonthly basis. 
Reports will include information such as number of participants recruited, number of 
participants completing the trial and any AE or SAE that have been assessed as being directly 
attributed to trial participation.  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
18. PROPOSED TIMELINE 
 
  
 
 
  
  
August 2017  –  August 2018  
Protocol preparation, Monash Health ethics, recruitment of further centres both nationally  
and internationally  
  
October  2017  –  April  2018  
Grant applications to major funding bodies, recruitment of trial co - ordinator and research  
midwife , purchase and packaging of trial intervention.  
Submission to Monash Health HREC  
Set - up of trial database and randomisation service.  
  
Ma y  201 9  
Commence recruitment 
  
Ongoing data collection  
  
  
  
End recruitment  
  
     
  
Perform laboratory analysis to determine the impact of melatonin on oxidative stress within  
the mother, fetus and placenta.  
Analyse da ta regarding the safety and tolerability in mother and fetus  
  
  
  
Complete  2 - year  follow - up neurodevelopmental assessments and data collection.  
  
    
  
Complete data analysis  
Publication preparation  
December 2023 
January – June 2024 
December 2025 
January – April 2026 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
19. ETHICS  
Ethics approval for this trial has been obtained through both the Monash Health Research 
Ethics Committee (RES-17-0000-583A) and Monash University.  
20. FUNDING  
Funding has been obtained from local and national funding bodies.   
This study is fully funded by funds secured from Equity trustee’s, the Cerebral Palsy Alliance, 
as well as the National Health and Medical Research Council (NHMRC).  
21. INSURANCE  
The sponsor, Monash Health, is responsible for the provision of insurance for the trial through 
the Victorian Managed Insurance Agency (VMIA). This insurance provides cover for damage 
to research participants through injury or death.   
22. DECLARATION OF INTERESTS   
None declared for the authors listed.  
  
23. DISSEMINATION AND PUBLICATION POLICY  
Ownership of the data arising from this trial resides with the named PI(s) who will have the 
right to publish orally or in writing the results of the trial. On completion of the trial, it is 
intended that the aggregated data generated from it, will be used both for publication in 
scientific, peer-reviewed journals and presented at scientific meetings.   
  
Authorship will be granted by the Principal Investigators to those who have contributed to the 
work in the capacities defined by: Monash University, NHMRC 59 and specific journal guidelines 
regarding the attribution of authorship.  
  
  
 
 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
24. APPENDIX 1 - ADDITIONAL RESEARCH COMPONENTS  
In addition to the trial outlined above, there will be further research elements also undertaken 
at Monash Health. Other participating institutions are welcome to undertake these further 
components and contribute to data collection.  
24.1 – Additional Secondary Aims  
These are:  
1. To assess biomarkers of oxidative stress and melatonin levels within the maternal, fetal and 
placental compartments.  
These additional research components would be incorporated into the individual participant 
trial schedule (as outlined in figure 1).  
24.2 – Additions to the Individual Participant Trial Schedule  
24.2.1 - Maternal blood tests  
Further blood samples will also be collected at the time of maternal sample collection as 
outlined in section 12.3 (recruitment, 48 hours and 14 days). The total blood sample volume 
collected will not exceed 20 ml. These samples will be used for assessment of circulating 
melatonin levels and markers of oxidative stress.  
These results will not be available to the treating clinical team.  
24.2.2 – Participant tissue samples.   
Following birth (20 minutes), placental samples will be collected as described in section 12.3.   
All tissue samples will be collected without compromising or obstructing a participant’s clinical 
care, at all times participant well-being and treatment will remain the priority.   
The researcher is responsible for the collection and de-identification of all tissue samples, as 
site storage at -80°C until recruitment has been completed. The lead trial team will be 
responsible for subsequent transportation to Monash Medical Centre for analysis.  
The samples will be collected and processed with researchers blinded to the intervention that 
the participant has received and neurodevelopmental outcome assessments.   
Using each participant’s unique code, tissue samples will be reconciled with the intervention 
that the participant has received only at the time of data analysis.  
The tissue samples will be used for measuring melatonin levels within the maternal and 
placental circulations. Markers of oxidative stress, such as malondialdehyde and 
8hydroxyguanosine, will also be assessed to determine the potential action through which 
melatonin is exerting its effects.  
 
 
 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
24.2.3 – Neonatal Cardiac and Cerebrovascular Assessment 
PROTECT Me trial participants delivering between 28‐32 weeks’ gestation will be invited to 
also take part in this additional sub‐study. This sub‐study seeks to assess whether melatonin 
supplementation antenatally can improve neonatal cardiac and cerebrovascular performance. 
This will be assessed using near infrared spectroscopy (NIRS) performed on day 2, 10, 17 of 
age for 2 hours each measuring the brain oxygenation, and a single functional 
echocardiography (fEcho) in the second postnatal week.  
FGR neonates with in-utero haemodynamic redistribution and preferential perfusion of the 
brain (brain-sparing) have been associated with impaired cerebral autoregulation, 
predisposing to fluctuations in cerebral blood flow and oxygenation in the neonatal period 
(60). Evidence suggests that both postnatal cerebral hypo- and hyperoxia are associated with 
brain injury and neurodevelopmental delay (61). Therefore, we will use Near infrared 
spectroscopy (NIRS) to measure cerebral oxygenation postnatally. NIRS (NIRO 200NX, 
Hamamatsu Photonics, Japan) allows non-invasive monitoring of the cerebral oxygenation as 
tissue oxygenation index (TOI, %), using a self-adhesive infant-neonatal sensor placed on the 
neonatal head. Differences in near infrared-light absorption are detected by the sensor and 
used to calculate the concentrations of oxygenated (O2Hb) and deoxygenated (HHb) 
hemoglobin levels of the brain. The ratio between O2Hb and total Hb (O2Hb+HHb) is 
expressed as the tissue oxygenation index (TOI). Using TOI and the arterial oxygen saturation 
measured by pulse oximetry (SaO2), fractional oxygen extraction (FOE) will be calculated 
which indicates the ratio between tissue oxygen consumption and delivery. TOI and FOE have 
been shown to be altered in FGR infants in the first 1-2 weeks of life (62,63) 
Studies have also shown that FGR neonates have altered cardiac function in the postnatal 
period (64,65). The functional echocardiography (fEcho) performed would be limited to 
haemodynamic assessment and would not include full anatomical assessment. The study 
would use the commonly used echocardiography views and will assess left ventricular 
function and cardiac output (superior vena cava flow, right ventricular and left Ventricular 
Output). The fEcho study would be limited to 10 minutes duration. Offline analysis that would 
be done from the bedside obtained data will give quantitative assessment of cardiac output 
from the left and right heart, systolic and diastolic left ventricle size and shortening fraction. 
The fEcho and NIRS data will be stored on password protected computer. 
 
24.2.4 – Fetal Movements Questionnaire 
 
Information on fetal movement patterns in women taking melatonin would be useful in the 
future, should melatonin therapy for fetal neuroprotection become a supported approach. 
Moreover, information on fetal movement patterns in early and late onset FGR may be 
informative for researchers attempting to understand fetal behavioural adaptations in the 
context of placental insufficiency 
All women at participating centres enrolled in ProtectMe are eligible for this sub-study.  

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
ProtectMe participants will be invited to complete a questionnaire about fetal movements at 
enrolment, 2 weeks after randomisation and at 34 weeks’ gestation (if ongoing pregnancy and 
live fetus). The questionnaire is a modified version of a fetal movement tool previously used 
in two New Zealand pregnancy studies.66,67 It takes around 5-10 minutes to complete.  
The fetal movement questionnaire will be administered electronically, where possible, using 
the REDCap system. If women do not have email/internet access, a hard copy questionnaire 
will be available. All data will be entered and stored in the ProtectMe REDCap trial database, 
administered by the Clinical Data Research Hub, Liggins Institute, University of Auckland.  
 
 
 
  
  
 

PROTECT Me Trial Protocol, v2.16. dated 09 July 2024 based on v2.15, 09 October 2023 
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