Clinical trial NCT02596594: Intraumbilical Amino Acids and Glucose Supplementation Via Port by Severe IUGR in Human Fetuses
Official title: Intraumbilical Amino Acids and Glucose Supplementation Via Subcutaneously Implanted Port System by Severe IUGR Human Fetuses
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Intrauterine Growth Restriction
Keywords: IUGR
severe IUGR
brain sparing
fetal nutrition
Prolongation
pregnancy
neonatal outcome
Lead sponsor: Martin-Luther-Universität Halle-Wittenberg
Sponsor class: OTHER
First posted: 2015-11-04
Enrollment: 14
Sex: FEMALE
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NON_RANDOMIZED
Intervention model: PARALLEL
Intervention model description: Intraumbilical amino acid and glucose suplementation of human fetuses with a severe IUGR via a subcutaneously implanted port system
Primary purpose: SUPPORTIVE_CARE

Brief summary: Placental insufficiency is responsible for fetal loss in about 40% of all stillbirths and long term neurological deficits. The mean interval from diagnosis of brain sparing of severe IUGR fetuses to delivery has been recently identified by only seven days (Flood K et al, Am J Obstetrics and Gynecology 2014).

The critical placental player in the active amino acids (AA) transport from the mother to the fetus is the trophoblast, which is irreversibly changed in severe IUGR fetuses caused by placental insufficiency. Thus, a logical partial solution of IUGR could be the direct supply of AAs and glucose to the fetus, in order to improve the fetal growth, normalize the fetal programming and to prolong the pregnancy.

The aim of this prospective pilot study is to further test the efficacy of the administration of AAs and glucose supplementation with hyperbaric oxygenation (HBO), via a subcutaneously implanted intraumbilical perinatal port system, as a treatment option for severe IUGR human fetuses with brain sparing.

Detailed description: Placental insufficiency is the main source of the development of intrauterine growth restriction (IUGR) caused by one of a variety of factors including chronic placental infections, many maternal diseases, abnormal genome and intravascular trophoblast invasion impairment. Placental insufficiency is responsible for fetal loss in about 40% of all stillbirths and long term neurological deficits. The reduction of blood flow resistance of cerebral arteries in severe IUGR conditions with reduced pulsatility index (PI) in the medial cerebral artery predicts the 11 fold increased risk of intraventricular hemorrhage, periventricular leukomalacia, hypoxic ischemic encephalopathy, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, and death. The mean interval from diagnosis of brain sparing of severe IUGR fetuses to delivery has been recently identified by only seven days (ranging 2-15 days).

The amino acids (AA) concentration of fetal plasma is many times higher than in mother because of active transplacental transport of AA and additional AA synthesis in the placenta.

The critical placental player in the active AA transport from the mother to the fetus is the trophoblast, which is irreversibly changed in severe IUGR fetuses caused by placental insufficiency. Thus, a logical partial solution of IUGR could be the direct supply of AAs and glucose to the fetus, in order to improve the fetal growth, normalize the IUGR changed fetal programming and to prolong the pregnancy. Additional oxygen supply of fetal tissues could also be important in improving the uptake of injected nutritional supplements and may avoid the development of lactate acidosis in IUGR fetuses.

The aim of this prospective pilot study was to further test the efficacy of the administration of AAs and glucose supplementation with hyperbaric oxygenation (HBO), via a subcutaneously implanted intraumbilical perinatal port system, as a treatment option for severe IUGR human fetuses with brain sparing.

Study design - IUGR was defined in this study as an estimated fetal weight of \< 5%, combined with increased resistance in both uterine arteries with pulsatility index (PI) \> 95%. Fetuses with morphological and/or chromosomal abnormalities were not included in the final analysis.

Eligibility criteria: Inclusion Criteria:

1. clinical diagnosis of severe intrauterine growth restricted fetuses with the cerebroplacental ratio less than 1 (CPR= PI middle cerebral artery / PI umbilical artery)
2. gestational age between 24/0 and 30/0 weeks
3. single pregnancy
4. anterior or lateral location of the placenta

Exclusion Criteria:

1. multiple pregnancy
2. fetal genetic anomalities,
3. fetal morphologic anomalities
4. BMI \> 35
5. placenta praevia
6. vaginal bleeding
7. uterine contractions
8. vasa praevia
9. posterior location of the placenta
10. severe maternal morbidities
11. Infections
12. preliminary rupture of the membranes

Primary outcomes:
measure: The mean interval from diagnosis of brain sparing of severe IUGR fetuses to delivery
timeFrame: through study completion, up to 2 years
Secondary outcomes:
measure: neonatal weight
timeFrame: through study completion, up to 2 years
measure: fetal weight gain
timeFrame: through study completion, up to 2 years
measure: blood gas analysis in the umbilical artery
timeFrame: through study completion, up to 2 years
Other outcomes:
Locations:
Study officials:
affiliation: Martin-Luther University Halle-Wittenberg
name: Michael Tchirikov, MD, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Tchirikov M, Kharkevich O, Steetskamp J, Beluga M, Strohner M. Treatment of growth-restricted human fetuses with amino acids and glucose supplementation through a chronic fetal intravascular perinatal port system. Eur Surg Res. 2010;45(1):45-9. doi: 10.1159/000318859. Epub 2010 Aug 20.