Best Practice & Research Clinical Obstetrics and Gynaecology

Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2018) 1e12
Contents lists available at ScienceDirect
Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn
Preventing preterm birth: New approaches to

labour therapeutics using Nanoparticles
Jonathan W. Paul a, b, *, Roger Smith a, b, c
a
Mothers and Babies Research Centre, School of Medicine and Public Health, Faculty of Health and Medicine,
University of Newcastle, Callaghan, NSW, 2308 Australia
b
Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW, 2305 Australia
c
John Hunter Hospital, New Lambton Heights, NSW, 2305 Australia
a b s t r a c t
Keywords:
Preterm birth Preterm birth remains a major obstetric problem with ramifica-
Tocolysis tions that extend beyond immediate health and safety concerns for
Nanoparticles the newborn to include massive societal and economic burden.
Drug delivery Although three quarters of preterm birth-related deaths could be
Targeting prevented with cost-effective interventions, there has been little
Liposomes
progress towards achieving sustained tocolysis that translates into
improved outcomes for the newborn. With private enterprise
reluctant to venture into the sphere of tocolysis, due to potential
litigation, advances in the field may fall to new approaches
using existing tocolytic resources more effectively. An emerging
approach is the utilisation of nanoparticles, which have been
established as versatile drug carriers with the power to modify the
pharmacokinetics of entrapped therapeutics. In this article, we
examine the development of nanoparticle-based drug delivery in
pregnancy, with a focus on new approaches to therapeutics for
preterm birth and modifying the labour process more generally.
© 2018 Published by Elsevier Ltd.
* Corresponding author. Hunter Medical Research Institute, Lot 1, Kookaburra Circuit, New Lambton Heights 2305, NSW,
Australia.
E-mail address: jonathan.paul@newcastle.edu.au (J.W. Paul).
https://doi.org/10.1016/j.bpobgyn.2018.03.005
1521-6934/© 2018 Published by Elsevier Ltd.
Please cite this article in press as: Paul JW, Smith R, Preventing preterm birth: New approaches to labour
therapeutics using Nanoparticles, Best Practice & Research Clinical Obstetrics and Gynaecology (2018),
2 J.W. Paul, R. Smith / Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2018) 1e12
Introduction
Treating medical conditions frequently requires therapeutic intervention, which is the adminis-
tration of a medicine or therapy to cure disease or alleviate pain. The ability to utilise therapeutic
intervention depends upon numerous factors. Important among these is the availability of a thera-
peutic agent to treat the disease or medical condition, but equally important, is whether utilising the
therapeutic will ultimately improve outcomes for the patient. Preterm birth, defined as birth before 37
completed weeks of foetal gestation [1], is one such condition where therapeutic intervention rarely
translates into improved outcomes for the mother or foetus [2]. Although this shortcoming has long
been recognised, there has been a spate of recent developments that seek to take new approaches to
therapeutic intervention during preterm labour. At the centre of these new approaches has been
the utilisation of nanoparticles, which have emerged as robust and versatile drug carriers with the
potential to finally change the therapeutic risk-to-benefit ratio [3]. This article examines the new
approaches to therapeutic intervention during preterm labour, with a particular focus towards the
utilisation of nanoparticle technologies. (see Fig. 1)
Preterm birth
Preterm birth is the leading cause of neonatal mortality and morbidity, accounting for approxi-
mately 75% of perinatal deaths and more than 50% of long-term infant morbidities [1]. Across 184
countries, between 5% and 18% of babies are born preterm, affecting approximately 15 million preg-
nancies annually worldwide [1]. Surviving premature neonates have an increased risk of both short-
and long-term complications [4e6]. Short-term morbidities include respiratory distress syndrome,
intraventricular haemorrhage, necrotising enterocolitis, and patent ductus arteriosus, while long-term
morbidities include cerebral palsy, mental retardation, learning difficulties, and both visual and
hearing problems [5e7]. Due to the severity of the outcomes, preterm birth has enormous social and
economic cost. Social costs include families suffering the loss of a newborn, or having to support
children with varying severities of disability(s), while the economic costs include the immediate
expenses of neonatal intensive care [8] and the long-term costs of ongoing management of disabilities
and diseases. Achieving reduced rates of preterm birth with improved neonatal outcomes would
therefore have immense ramifications at the community level. As such, the development of effective
therapeutic strategies for achieving tocolysis remains a high priority.
Tocolysis
Tocolysis is the administration of therapeutic agents to prevent preterm birth. In the case of
threatened preterm birth due to the premature onset of uterine contractions, tocolytic agents typically
work through blocking the components of the signalling pathways that drive contractions in uterine
myocytes, the smooth muscle cells of the uterus. ‘Primary tocolysis’ refers to initial tocolysis admin-
istered when a woman presents with preterm labour, while ‘maintenance tocolysis’ refers to tocolysis
given after the successful arrest of preterm labour with another primary agent. Many different classes
of drugs have been utilised as tocolytics, and the agents employed vary from country to country. Agents
utilised as tocolytics up to this point include calcium channel blockers, such as nifedipine; b2-adren-
ergic receptor agonists, such as ritodrine, terbutaline and salbutamol; oxytocin receptor (OTR) an-
tagonists, such as atosiban; inhibitors of prostaglandin synthesis, such as indomethacin and ketorolac;
nitrates, such as nitroglycerine; and sulphates, such as magnesium sulphate. The use of these agents as
tocolytics, and their effectiveness in preventing preterm birth, has already been reviewed multiple
times [2,9e11]. As such, these agents and their modes of action will not be individually discussed in this
article. Nevertheless, some key points should be noted. First, while the mechanism of action varies
between the different classes of compounds, each function prevents preterm birth by promoting
uterine relaxation, in the form of either suppression of threatened preterm labour or through blocking
established preterm labour. Second, each function is associated with known or potential undesired side
effects on the mother and/or the foetus. These side effects are attributable to the drugs reaching other
organs and tissues where similar signalling pathways are affected. Importantly, this includes small
J.W. Paul, R. Smith / Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2018) 1e12 3
Fig. 1. Schematic overview of different types of nanoparticle drug carriers. Nanoparticles with applications toward drug delivery
include nanotubes, Qdots, micelles, dendrimers and liposomes, as well as modifications therefore, such as ligand-targeted stealth
liposomes.
molecules being able to cross the placenta into the foetal circulation, where they can affect the foetal
physiology and development [12]. Third, systematic review and meta-analysis indicate that calcium
channel blockers and prostaglandin synthesis inhibitors have the highest probability of delaying labour
and improving both neonatal and maternal outcomes [2]. In light of this latter finding, tocolytics such
as nifedipine and indomethacin may be regarded as strong candidates upon which to develop new
therapeutic approaches to prevent preterm birth. One such approach is the utilisation of nanoparticle-
based targeted drug delivery platforms.
Nanoparticles and drug delivery
Nanoparticles are defined as nanoscale materials ranging in size from 1 to 100 nm; however, the
term is often used to refer to particles up to 1000 nm [13,14]. Nanoparticles can be prepared from
assorted materials, ranging from organic substances, such as phospholipids, lipids, polypeptides, lactic
acid, dextran and chitosan, through to more chemical-based materials, such as polymers, carbon,
silica and metals [3]. Nanoparticles now have well-established applications, including drug delivery,
diagnostics, prognostics and the treatment of diseases [15].
Application of nanoparticles for drug delivery is facilitated through different types of nanomaterials
being able to interact with drug molecules in a variety of ways. For instance, the nanoparticle surface
may be coated with drug molecules, which is facilitated by their high surface area to volume ratio, as
well as the ability to modify properties, such as surface charge, or the nanoparticles may entrap or
encapsulate the drug molecules, such as with liposomes [3,15,16], which will be discussed later. Along
with liposomes, the types of nanoparticles used for drug delivery include carbon nanotubes, quantum
dots, dendrimers, polymeric micelles, magnetic nanoparticles, metallic nanoparticles and variations
thereof [15].
Nanoparticles are employed as drug carriers to modify the pharmacokinetic properties of the drug.
Because drugs adopt the pharmacokinetic properties of the carrier [17], incorporation into nano-
particles can be used to modify critical pharmacological properties, such as liberation of the drug from
the pharmaceutical formulation, absorption into the bloodstream, distribution of the drug throughout
the body, metabolism or inactivation of the drug, and excretion from the body. Modifying these
properties can lead to multiple benefits, such as extending the half-life of a drug, lowering the ther-
apeutic dose necessary to achieve efficacy and reducing off-target side effects [18,19], particularly
where nanoparticles are targeted to a specific ligand to achieve localised biodistribution [20]. However,
implementing nanoparticle-based carrier systems is not without complications. In addition to being
able to encapsulate the drug, nanoparticle carriers need to be able to evade destruction and elimi-
nation, while in the circulation, they enter the target organ or tissue by penetrating the endothelium
and extracellular matrix and then penetrate the desired cell [16]. Once inside the cell, the nanoparticle
drug carriers must then evade endosomal or lysosomal destruction and release its contents [16].
Despite these obstacles, nanoparticles already have a demonstrated capacity to facilitate drug delivery
for a broad range of purposes, cancer treatment in particular [21,22], and in recent years, have seen
applications developed that target pregnancy.
Drug delivery platforms and pregnancy
Pregnancy is a dangerous time for both the mother and foetus. When complications arise, systemic
administration of therapeutics puts both the mother and foetus at risk of adverse side effects. This is
because most therapeutics lack specificity and being small molecules they can cross the placenta to
enter the foetus, where they can affect foetal development [12]. A prominent example is indomethacin,
which upon crossing the placenta and entering the foetus [23] can cause necrotising enterocolitis [24]
and intraventricular haemorrhage [25] and affect closure of the ductus arteriosus [26e28]. Despite
prostaglandin synthesis inhibitors, such as indomethacin, having one of the highest probabilities of
delaying labour and improving neonatal and maternal outcomes [2], the associated side effects are
sufficient to negate their use. With foetal transfer being a prominent obstacle, multiple studies have
examined the ability of nanoparticle-based drug formulations to avoid foetal transfer.
Few studies have examined maternal-to-foetal transfer using human tissue, but of those, two
studies have utilised the ex vivo dually perfused placental cotyledon model. Myllynen et al. [29]
perfused the maternal face of human placenta with PEGylated gold nanoparticles and found that the
nanoparticles did not cross the foetal face in detectable amounts during the 6-h timeframe of the study
[29]. Nevertheless, the nanoparticles were indeed taken up by the syncytiotrophoblast layer, and
accordingly, concentrations in the maternal perfusate decreased significantly, consistent with the
placental sequestration of the nanoparticles [29]. Wick et al. [30] used the human cotyledon model to
examine the uptake and transfer of fluorescently labelled polystyrene beads, ranging from 50 to
500 nm in diameter. They found that particles <240 nm in diameter crossed the placental barrier and
entered the foetal circuit of the dually perfused model [30].
Numerous other studies have similarly investigated maternal-to-foetal transfer, but in pregnant
rodent models. An early study was performed by Tuzel et al. in 1980 [31], who produced 30e270 nm
liposomes that entrapped radioactive [14C] insulin or [14C] penicillin, as model drugs, as well as
incorporated [3H] cholesterol in the membranes. Following intravenous administration to pregnant
rats, localisation of [14C] and [3H] within the uterus, placenta, amniotic fluid, and amniotic cavity was
determined, as well as transfer to the foetus [31]. Intact liposomes reached both the uterus and
placenta of pregnant rats. Interestingly, liposomally entrapped [14C] insulin was not detected in the
foetus whereas liposomally entrapped [14C] penicillin was. To account for this difference, the authors
proposed that intact liposomes may first need to be taken up by the placenta, at which point they are
broken down, and the released drug contents then cross the placental barrier as a free drug. With
insulin being unable to cross the placental barrier, but penicillin being permeable, the authors pro-
posed that this could account for the difference [31]. Based on their observations, the authors proposed
that liposomes can be used as drug carriers for the delivery of therapeutic agents to the uterus and
placenta, such as antibiotics and antimitotic agents, as possible treatments for infections or tumours.
In 2011, Refuerzo et al. [32] examined whether the size of silicon nanovectors (SNVs) affected their
entrance into the foetal circulation. They found that silicon levels were significantly higher in the
maternal organs of animals injected with SNVs of 834 and 1000 nm in diameter, compared to control
animals. In contrast, placental and foetal silicon levels were similar in both groups. These results
suggested that large SNV did not cross the placenta barrier into the foetus. Nevertheless, they found
that foetal silicon levels were significantly higher in the animals that received 519 nm SNV, compared
to control animals. This suggests that smaller silicon particles lead to some passage across the placenta
into the foetal circulation [32].
In 2013, Campagnolo et al. [33] investigated the safety of single-wall carbon nanotubes (SWCNTs)
coated with polyethylene glycol chains (PEG-SWCNTs) for use as a drug carrier during pregnancy. A
class of fibre-shaped nanoparticles, SWCNTs, have been considered a good candidate for biomedical
applications. However, upon intravenous administration of PEG-SWCNTs to pregnant mice, occasional
teratogenic effects were detected, which were determined to be associated with placental damage.
Prevalence of malformed embryos was significantly elevated in mice treated with 30 mg of PEG-
SWCNTs, compared to the control group. Furthermore, examination of organs at different stages of
pregnancy revealed hepatic damage in mice that received multiple exposures to PEG-SWCNTs,
compared to mice in the single exposure group and control group. Upon injection, fluorescently
labelled PEG-SWCNTs were not detected in foetal tissues, but were detected in the placenta, as well as
the yolk sac. These findings suggested that transfer to the foetus may occur under certain circum-
stances, and Campagnolo et al. [33] concluded that PEG-SWCNTs should be used with caution as a
nano-delivery system during pregnancy.
In 2012, Kaga et al. [34] developed liposome-encapsulated haemoglobin for use as an artificial oxygen
carrier, with prospective use as an alternative to blood transfusion. Using a rat model, Kaga et al.
examined the effect of daily repeated infusions of the 250-nm haemoglobin vesicles on the physiology of
pregnant rats, as well as on placental/foetal homeostasis and potential side effects [34]. They found that
both the pregnant animals and foetuses tolerated 7 days of daily repeated infusions well, with no signs of
deterioration in maternal organ functions and foetal development. Furthermore, the authors determined
that no placental transfer of haemoglobin liposomes had occurred after the 7 days of repeated infusions.
The liposomes were found to have accumulated in the maternal spleen, liver, kidney and placenta, but
not in the foetus. This was the first animal model study to illustrate the safety of liposomal haemoglobin-
based oxygen carriers in pregnant animals and foetuses and raised the possibility that this liposome-
based system may have low toxicity for the foetus when used in other settings [34].
Quantum dots (Qdots) are highly fluorescent nanoparticles of size 1e10 nm, comprised of a
cadmium-containing inorganic core enclosed within an organic shell coating [15,16]. Chu et al. [35]
exposed pregnant mice to Qdots coated with 3-mercaptopropionic acid [MPA] to study their bio-
distribution in vivo. They found that 0.23e0.61% of cadmium was transferred to the foetus, with high
rates of foetal demise observed for the higher Qdot doses [35]. Chu et al. [35] also exposed pregnant
mice to Qdots coated with inorganic silica (SiO2) or PEG and found that cadmium was again detected in
the foetus, albeit at reduced levels compared to MPA-coated Qdots. The study provided evidence
of toxic foetal transfer of Qdots, which the authors suggest may have occurred through trans-
trophoblastic channels or endocytosis [35].
Semmler-Behnke et al. [36] exposed pregnant rats to 1.4- or 18-nm-diameter monodisperse gold
nanoparticles, administered via intravenous injection. They found that foetal transfer of gold was
inversely proportional to particle size. That is, placentas accumulated approximately 0.03% and 0.0002%
of the 1.4 and 18 nm nanoparticles, respectively. Gold levels were orders of magnitude lower in the
foetus, with the 18-nm nanoparticles again resulting in lower levels than the 1.4-nm particles [36].
Collectively, these studies into maternal-to-foetal transfer highlight a potential application for the
use of nanoparticle-based carriers during pregnancy. Evidence does, however, indicate that the ability
of nanoparticle carriers to prevent passage to the foetus is associated with nanoparticle size, in that
smaller nanoparticles are more likely to result in maternal-to-foetal transfer of the incorporated drug.
The data also indicate toxicity of some systems and that liposomes are relatively free of toxicity, as
reflected in their current clinical use for oncological purposes [37e39]. In the latest advance, evidence
suggests that maternal-to-foetal transfer may be further reduced by employing nanoparticle systems
specifically targeted to the myometrium for the deployment of tocolytic agents.
Targeted drug delivery for preterm labour
The potential benefits of achieving targeted drug delivery to the myometrium were realised as early
as 1982. Huszar and Roberts (1982) stated that side effects associated with prostaglandin inhibitors
‘could be avoided if prostaglandin synthesis inhibitors were specifically targeted at the myometrium’ [40].
In the absence of any known mechanisms at the time, Huszar and Roberts prophesised that ‘such
specificity might be achieved through a “silver bullet” agent, in which the inhibitors would be linked to
molecules that either could not cross the placenta or had specific affinity for the myometrium tissue’ [40].
Although no further details were provided as to what this ‘silver bullet’ agent might be, recent progress
has seen the development of drug delivery platforms able to target the myometrium, with intended
applications being the delivery of therapeutics for the prevention of preterm birth.
The first targeted drug delivery system for preventing preterm birth targeted the myometrium and
was reported by Paul et al. in 2015 [41]. The team created liposomes loaded with various tocolytics and
conjugated to an antibody that specifically recognised an extracellular domain of the OTR. Liposomes
have been extensively explored as drug delivery platforms, and benefits of their use include biocom-
patibility and low immunogenicity, due to being comprised of natural phospholipids, the capacity for
self-assembly, the ability to entrap large amounts of both lipophilic and hydrophilic drugs, and the
ability to be extensively modified to control their interaction with biological fluids, cells and barriers
[42e45].
When loaded with nifedipine, salbutamol or rolipram, the OTR-targeted liposomes produced by
Paul et al. abolished spontaneous contractions in strips of both human and mouse myometrium
ex vivo, whereas non-targeted liposomes loaded with these drugs had no effect [41]. When loaded
with an inhibitor of the human ether-a-go-go related gene (hERG) potassium channel, dofetilide,
which increases the duration of uterine contractions ex vivo [46], OTR-targeted liposomes signifi-
cantly increased the duration of contractions, demonstrating the versatility of the platform for po-
tential applications beyond tocolysis [41]. Paul et al. further demonstrated that upon intravenous
injection into pregnant mice, OTR targeting resulted in a significant 7-fold increase in uterine
localisation of liposomes, compared to non-targeted liposomes. That is, while non-targeted lipo-
somes were detected only in the liver of term pregnant mice, which is a primary site of liposomal
clearance [47,48], OTR-targeted liposomes consistently exhibited strong localisation to the uterine
horns, with low-level localisation also detected in mammary tissue, another oxytocin-sensitive tissue
[49]. Additionally, OTR-targeted liposomes were not detected in other major organs, including the
brain, heart, lungs or kidneys and, importantly, were not detected in neonates. Paul et al. subse-
quently advanced this work and were the first to demonstrate the application of uterine-targeted
liposomes for the prevention of preterm birth (epublished August 2016) [50]. Utilising a lipopoly-
saccharide (LPS)-induced model of mouse preterm birth, Paul et al. demonstrated that the intrave-
nous administration of OTR-targeted liposomes loaded with indomethacin significantly reduced
preterm birth rates, achieving a 3.7-fold reduction relative to animals injected with LPS only, and a
3.2-fold reduction in preterm birth rates relative to animals injected with non-targeted indometh-
acin-loaded liposomes. While having no effect on the average number of live offspring, the admin-
istration of indomethacin via OTR-targeted liposomes significantly increased the time between LPS
administration and labour by 2-fold, whereas indomethacin administration by non-targeted lipo-
somes did not. Together, the reports by Paul et al. were the first proof-of-concept that targeted de-
livery of drugs to the myometrium could not only be achieved, but that this 'silver bullet' was indeed
a feasible approach for preventing preterm birth. (see Fig. 2).
In addition to achieve targeting via antibodies, the OTR can be targeted via other binding moieties.
Atosiban, barusiban and retosiban are antagonists with high specificities for the OTR [51], intended for
the treatment of preterm labour. Evidence does not support the effectiveness of atosiban and barusiban
for use as tocolytics [52]; however, in women with spontaneous preterm labour, reports from phase-II
clinical trials with retosiban appear to be more promising with respect to delaying birth [53]. Like
Fig. 2. Principle behind using targeted nanoparticles for therapeutic intervention during pregnancy. Systemic administration
of non-encapsulated drugs affects uterine contractility, but may also affect non-target organs, as well as cross the placenta to enter
the foetus. Encapsulation inside targeted nanoparticles, as drug delivery platforms, has the capacity to prevent or reduce off-target
biodistribution and trans-placental passage to the foetus.
antibodies, these OTR-binding moieties can be conjugated to the surface of drug delivery platforms,
where they may better serve as targeting ligands, as opposed to tocolytics.
Refuerzo et al. [54] also manufactured liposomes loaded with indomethacin, but instead coated
with atosiban. Dubbed ‘LIP-IND-ORA’ (liposome-indomethacin-oxytocin receptor antagonist), the
platform was similarly intended to the direct delivery of indomethacin specifically to the pregnant
uterus to inhibit contractions, reduce preterm birth rates and reduce foetal transfer of indomethacin.
During in vivo localisation studies in pregnant mice, LIP-IND-ORA was primarily detected within the
uterus, minimally detected within the liver and placenta and absent in the foetus. Compared to
indomethacin free drug, administering indomethacin via LIP-IND-ORA increased the concentration of
indomethacin in the pregnant uterus 2-fold, prevented indomethacin passage across the placenta into
the foetus, significantly reduced the rate of LPS-induced preterm birth by 15% and prolonged the length
of pregnancy by 31% [54].
Although the studies by Paul et al. [50] and Refuerzo et al. [54] have their similarities, there are some
important differences. While Paul et al. [50] demonstrated the superiority of OTR-targeted immuno-
liposomes against non-targeted liposomes (as well as indomethacin free drug), Refuerzo et al. [54]
demonstrated the superiority of LIP-IND-ORA against indomethacin as free drug, in that no data
were provided comparing LIP-IND-ORA against non-targeted indomethacin-loaded liposomes during
in vivo studies. In their 2015 study, Refuerzo et al. [55] demonstrated that administering indomethacin
in the form of non-targeted indomethacin-loaded liposomes, called LIP-IND, reduced foetal levels
of indomethacin 7.6-fold, compared to indomethacin administered as free drug (IND 81.3 ± 24.7 vs
LIP-IND 10.7 ± 17.1 ng/g). Later, in their 2016 study, Refuerzo et al. [54] reported that administering
indomethacin via OTR-targeted LIP-IND-ORA reduced foetal indomethacin levels by 2-fold, again
compared to indomethacin as free drug (IND 245.3 ± 61.7 vs LIP-IND-ORA 121.3 ± 16.8 ng/g). In the
absence of direct comparison between LIP-IND and LIP-IND-ORA, it is difficult to ascertain whether
LIP-IND-ORA is the superior system in terms reducing foetal transfer, as non-targeted LIP-IND achieved
a greater fold reduction, albeit in a different study. In terms of preventing foetal transfer of drugs,
questions therefore remain as to whether the added time and costs of coupling indomethacin-loaded
liposomes to atosiban are warranted over results achieved by the non-targeted liposomal preparations.
Similarly, although comparisons were made between LIP-IND and LIP-IND-ORA during in vitro binding
and contractility studies [54], the effectiveness of LIP-IND-ORA in preventing preterm birth was also
demonstrated relative to indomethacin free drug, as opposed to non-targeted LIP-IND liposomes.
Given that non-targeted LIP-IND increased the uterine levels of indomethacin 1.3-fold, relative to
indomethacin free drug [55], it would be interesting to see results of a direct comparison between
LIP-IND and LIP-IND-ORA in terms of preventing LPS-induced preterm birth in mice.
Unlike the antibody-conjugated immunoliposomes developed by Paul et al. [50], atosiban-
conjugated LIP-IND-ORA was only minimally detected in the liver [54]. While one might be tempted
to infer that LIP-IND-ORA liposomes have a greater capacity to evade clearance by the reticuloendo-
thelial system [56], substantial differences in the imaging protocols between the two studies likely
account for the difference. That is, Paul et al. [50] assessed OTR-targeted immunoliposome bio-
distribution after two rounds of daily liposome injections (foetal gestation days 17 and 18), with iso-
lated organs imaged 17 h later after mice had laboured; whereas Refuerzo et al. [54] imaged
biodistribution just 4 h after a single injection of LIP-IND-ORA. Greater detection of immunoliposomes
in liver would therefore be expected, given that the immunoliposomes of Paul et al. [50] had been in
the circulation, and undergoing clearance, for 65 h at the time of imaging, which was 16 times longer
than when imaging was performed by Refuerzo et al. [54] As such, it would be a remiss to attempt to
directly compare the biodistribution profiles reported in the two studies.
The utilisation of targeted drug delivery platforms for tocolysis therefore appears to have great
potential as a new approach to therapeutic intervention during preterm labour, in that successful
uterine targeting and prevention of preterm birth reported by Paul et al. [41,50] was independently
supported by Refuerzo et al. [54] While Paul et al. [41,50] and Refuerzo et al. [54] are thus far the only
groups to target the myometrium for the prevention of preterm birth, targeted nanoparticle-based
platforms have been utilised to direct therapeutics to other reproductive tissues, with clinical impli-
cations that warrant discussion.
Other reproductive applications of targeted drug delivery platforms
Endometriosis is a debilitating inflammatory condition characterised by the growth of endometrial

cells outside the uterus, typically on the ovaries, fallopian tubes and other immediate tissues [57]. It is
one of the most common benign gynaecological proliferations, estimated to affect 10e15% of women of
reproductive age [57] and is encountered in 25e35% of women suffering from infertility [58]. Eluci-
dating the exact mechanism by which endometriosis causes infertility remains a challenge, as does
diagnosis and effective treatment. The relatively poor efficacy of current treatment options, such as
hormonal therapy, led researchers to consider, and devise, new targeted approaches to therapy.
Schwager et al. [59] demonstrated that a derivative of the antibody, F8, which recognises the
alternatively splice extra-domain A (EDA) of fibronectin (Fn), could be used to label endometriotic
lesions in vivo in a mouse model of endometriosis. By coupling the F8 antibody to the anti-
inflammatory cytokine, interleukin-10 (IL-10), Schwager et al. [59] were able to achieve targeted de-
livery of IL-10 to endometriotic lesions, which reduced both the frequency of lesions and average lesion
weight. In contrast, F8-mediated targeted delivery of the pro-inflammatory cytokine, interleukin-2
(IL-2), had no effect. It should be noted, however, that the effectiveness of the F8-IL10 conjugate in
preventing/reducing lesions was relative to a saline control, as opposed to non-targeted IL-10 [59].
In a similar approach, Quattrone et al. [60] later used the F8 antibody and mouse model of endo-
metriosis to target the anti-inflammatory cytokine, interleukin 4 (IL-4), to endometriotic lesions.
Administration of non-targeted IL-4 had no effect on the lesion number or total lesion size, relative to
saline-treated control mice, whereas administration of F8-IL4 significantly reduced both the total
number of lesions per mouse and total volume of lesions per mouse [60]. Additionally, expression of
genes involved in cell adhesion, extracellular matrix invasion and neovascularisation were significantly
downregulated in mice treated with F8-IL4 [60].
These results imply that there is a strong rationale for performing clinical investigations into the
targeted delivery of anti-inflammatory cytokines to treat endometriosis. In light of the positive results
obtained for antibody-based targeting of the myometrium [50], a new approach may be the production
of liposomes loaded with anti-inflammatory cytokines, such as IL-4 and IL-10, that are targeted to
endometriotic lesions by conjugation to the F8 antibody. Indeed, a patent filed in 2009, titled ‘Antigens
associated with endometriosis’, outlines EDA as a marker for endometriotic lesions, and the use of
antibodies with affinity for EDA, such as F8, for purposes of detecting and treating endometriosis [61].
As such, we may soon see reports of antibody-targeted, nanoparticle-based therapies for endometriosis.
In a more recent development, King et al. [62] developed a targeted drug delivery system for the
placenta, for the purpose of delivering therapeutics that promote placental growth and function, such
as insulin-like growth factor 2 (IGF-2). The system utilised the tumour-homing peptide sequences,
CGKRK and iRGD, which were found to accumulate in the syncytiotrophoblast layer of first trimester
and term human placental explants by selectively binding to calreticulin and integrin avb3, respectively
[62]. Repeated administration of CGKRK and iRGD to pregnant mice had no adverse effects on preg-
nancy outcomes. When conjugated to liposomes, CGKRK-coated liposomes predominantly accumu-
lated in the labyrinth zone of mouse placentae, while iRGD-coated liposomes localised to the spiral
arteries. When IGF-2 was administered to normal pregnant mice via iRGD-coated liposomes, the mean
placental weight was significantly increased relative to control treatments, which included empty
iRGD-coated liposomes and IGF-2 as free drug. Using a mouse model of growth restriction, King et al.
further demonstrated that administration of IGF-2 via iRGD-coated liposomes significantly increased
the weight of growth-restricted foetuses and altered foetal weight distribution [62].
The outcomes achieved in relation to targeting endometriotic lesions and growth-restricted
foetuses/placentae are clinically relevant and warrant ongoing development. The preclinical success
of these approaches also supports broadening consideration as to how other gynaecological compli-
cations could potentially be addressed using nanoparticle-based drug carrier platforms targeted to
specific reproductive cell types or tissues.
Conclusion
Spontaneous preterm birth is a multi-factorial syndrome that arises from the interplay of complex
signalling pathways that drive phenotypic transformation of the myometrium from a state of quies-
cence to contractility [63e65]. The ability to prevent preterm birth via sustained tocolysis that achieves
improved patient outcomes remains a vital societal need. Introduction of nanoparticles as drug carriers
represents an exciting new approach with the potential to change how we utilise existing therapeutics.
Evidence supports the use of tocolytics to achieve at least a 48-h delay in pregnancy, to allow for
administration of antenatal steroids [9]. As such, nanoparticle-based drug carriers and targeted
delivery platforms may, at the very least, open up new avenues for achieving this short-term delay with
Practice Points
Evidence supports the use of tocolysis to achieve a 48-h delay in pregnancy to allow for the
administration of antenatal steroids.
Tocolysis is associated with risks to the mother, due to the lack of specificity of administered
therapeutics, as well as risks to the foetus, due the ability of some therapeutics to cross the
placenta.
Development of more effective strategies for achieving tocolysis remains a pressing concern;
however, new strategies must translate into improved outcomes for the mother and/or
foetus.
Research Agenda
Targeted nanoparticle-based drug delivery platforms continue to evolve and improve. It is

important that these platforms are considered for the development of new approaches for
preventing preterm birth, as well as other obstetric complications.
The oxytocin receptor presents an opportunity to utilise targeted nanoparticle-based carriers
for achieving restricted biodistribution of therapeutics to the uterus, as well as reduced foetal
transfer. Strategies for targeting the oxytocin receptor must now be fully explored for their
potential to improve the efficacy and safety of existing tocolytics and improve outcomes of
the mother and foetus.
These explorations should include investigating the application of numerous types of
nanoparticle-based carriers (dedrimers, micelles, etc), as well as investigations into what
types of molecules can and cannot be delivered to the myometrium to effect change (drugs,
nucleotides, etc).
While the oxytocin receptor presents an excellent opportunity to target the myometrium, we
should remain open to identify other myometrium-specific/over-expressed cell surface
markers that could also be used to target the myometrium.
Finally, the lessons learnt from targeting the myometrium for the prevention of preterm birth
should be applied to other reproductive tissues for the development of novel approaches for
treating other gynaecological complications.
greater tocolytic efficacy, while simultaneously reducing risks for both the mother and foetus. In ful-
filling such a role, the safety and toxicity of nanoparticles must of course remain a vital consideration,
as reviewed by Keelan et al. [66] Looking beyond the short-term, the authors have ideas as to how
targeted nanoparticles could be applied toward maintenance tocolysis strategies, which we will
endeavour to explore in the near future.
Declaration of interests
R.S. and J.W.P. have a patent application through Newcastle Innovation related to targeted
liposomes.
Funding
This work was supported by grants from the National Health and Medical Research Council
(NHMRC), Hunter Medical Research Institute (HMRI) and Global Alliance to Prevent Prematurity and
Stillbirth (GAPPS). The funding providers had no involvement in the study or production of this article.
Acknowledgements
We are grateful to the funding bodies that have facilitated our research into the application of
targeted nanoparticles for the prevention of preterm birth, and we acknowledge support from the
National Health and Medical Research Council (NHMRC), the Hunter Medical Research Institute
(HMRI), and the Global Alliance to Prevent Prematurity and Stillbirth (GAPPS). Additionally, Dr. J. Paul
thanks Dr. M. Ilicic for valuable assistance with the preparation of this article.
References
[1] Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet 2008;371:75e84.
[2] Haas DM, Caldwell DM, Kirkpatrick P, McIntosh JJ, Welton NJ. Tocolytic therapy for preterm delivery: systematic review
and network meta-analysis. BMJ 2012;345:e6226.
[3] De Jong WH, Borm PJ. Drug delivery and nanoparticles:applications and hazards. Int J Nanomed 2008;3:133e49.
[4] Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet 2008;371:
261e9.
[5] Goldenberg RL. The management of preterm labor. Obstet Gynecol 2002;100:1020e37.
[6] Di Renzo GC, Roura LC. Guidelines for the management of spontaneous preterm labor. J Perinat Med 2006;34:359e66.
[7] Faye-Petersen OM. The placenta in preterm birth. J Clin Pathol 2008;61:1261e75.
[8] Khan KA, Petrou S, Dritsaki M, Johnson SJ, Manktelow B, Draper ES, et al. Economic costs associated with moderate and
late preterm birth: a prospective population-based study. BJOG 2015;122:1495e505.
[9] Haas DM, Benjamin T, Sawyer R, Quinney SK. Short-term tocolytics for preterm delivery - current perspectives. Int J
Womens Health 2014;6:343e9.
[10] Haram K, Mortensen JH, Morrison JC. Tocolysis for acute preterm labor: does anything work. J Matern Fetal Neonatal Med
2015;28:371e8.
[11] van Vliet EO, Boormans EM, de Lange TS, Mol BW, Oudijk MA. Preterm labor: current pharmacotherapy options for
tocolysis. Expet Opin Pharmacother 2014;15:787e97.
[12] Syme MR, Paxton JW, Keelan JA. Drug transfer and metabolism by the human placenta. Clin Pharmacokinet 2004;43:
487e514.
[13] Cho K, Wang X, Nie S, Chen ZG, Shin DM. Therapeutic nanoparticles for drug delivery in cancer. Clin Cancer Res. 2008;14:
1310e6.
[14] Panyam J, Labhasetwar V. Biodegradable nanoparticles for drug and gene delivery to cells and tissue. Adv Drug Deliv Rev
2003;55:329e47.
[15] Bhatia S. Nanoparticles types, classification, characterization, fabrication methods and drug delivery applications. Natural
polymer drug delivery systems. Cham: Springer; 2016.
[16] Menezes V, Malek A, Keelan JA. Nanoparticulate drug delivery in pregnancy: placental passage and fetal exposure. Curr
Pharmaceut Biotechnol 2011;12:731e42.
[17] Hua S, Wu SY. The use of lipid-based nanocarriers for targeted pain therapies. Front Pharmacol 2013;4:143.
[18] Alexis F, Pridgen E, Molnar LK, Farokhzad OC. Factors affecting the clearance and biodistribution of polymeric nano-
particles. Mol Pharm 2008;5:505e15.
[19] Salata O. Applications of nanoparticles in biology and medicine. J Nanobiotechnol 2004;2:3.
[20] Moghimi SM, Hunter AC, Murray JC. Long-circulating and target-specific nanoparticles: theory to practice. Pharmacol Rev
2001;53:283e318.
[21] Hull LC, Farrell D, Grodzinski P. Highlights of recent developments and trends in cancer nanotechnology researcheview
from NCI alliance for nanotechnology in Cancer. Biotechnol Adv 2014;32:666e78.
[22] Morris SA, Farrell D, Grodzinski P. Nanotechnologies in cancer treatment and diagnosis. J Natl Compr Cancer Netw JNCCN
2014;12:1727e33.
[23] Moise Jr KJ, Ou CN, Kirshon B, Cano LE, Rognerud C, Carpenter Jr RJ. Placental transfer of indomethacin in the human
pregnancy. Am J Obstet Gynecol 1990;162:549e54.
[24] Major CA, Lewis DF, Harding JA, Porto MA, Garite TJ. Tocolysis with indomethacin increases the incidence of necrotizing
enterocolitis in the low-birth-weight neonate. Am J Obstet Gynecol 1994;170:102e6.
[25] Suarez RD, Grobman WA, Parilla BV. Indomethacin tocolysis and intraventricular hemorrhage. Obstet Gynecol 2001;97:
921e5.
[26] Moise Jr KJ. Effect of advancing gestational age on the frequency of fetal ductal constriction in association with maternal
indomethacin use. Am J Obstet Gynecol 1993;168:1350e3.
[27] Suarez VR, Thompson LL, Jain V, Olson GL, Hankins GD, Belfort MA, et al. The effect of in utero exposure to indomethacin
on the need for surgical closure of a patent ductus arteriosus in the neonate. Am J Obstet Gynecol 2002;187:886e8.
[28] Vermillion ST, Scardo JA, Lashus AG, Wiles HB. The effect of indomethacin tocolysis on fetal ductus arteriosus constriction
with advancing gestational age. Am J Obstet Gynecol 1997;177:256e9. discussion 9e61.
[29] Myllynen PK, Loughran MJ, Howard CV, Sormunen R, Walsh AA, Vahakangas KH. Kinetics of gold nanoparticles in the
human placenta. Reprod Toxicol 2008;26:130e7.
[30] Wick P, Malek A, Manser P, Meili D, Maeder-Althaus X, Diener L, et al. Barrier capacity of human placenta for nanosized
materials. Environ Health Perspect 2010;118:432e6.
[31] Tuzel NS, Patel HM, Ryman BE. The fate in vivo of liposomally entrapped drugs in pregnant rats. Biochem Soc Trans 1980;
8:559e60.
[32] Refuerzo JS, Godin B, Bishop K, Srinivasan S, Shah SK, Amra S, et al. Size of the nanovectors determines the transplacental
passage in pregnancy: study in rats. Am J Obstet Gynecol 2011;204(546):e5e9.
[33] Campagnolo L, Massimiani M, Palmieri G, Bernardini R, Sacchetti C, Bergamaschi A, et al. Biodistribution and toxicity of
pegylated single wall carbon nanotubes in pregnant mice. Part Fibre Toxicol 2013;10:21.
[34] Kaga M, Li H, Ohta H, Taguchi K, Ogaki S, Izumi H, et al. Liposome-encapsulated hemoglobin (hemoglobin-vesicle) is not
transferred from mother to fetus at the late stage of pregnancy in the rat model. Life Sci 2012;91:420e8.
[35] Chu M, Wu Q, Yang H, Yuan R, Hou S, Yang Y, et al. Transfer of quantum dots from pregnant mice to pups across the
placental barrier. Small 2010;6:670e8.
[36] Semmler-Behnke M, Kreyling WG, Lipka J, Fertsch S, Wenk A, Takenaka S, et al. Biodistribution of 1.4- and 18-nm gold
particles in rats. Small 2008;4:2108e11.
[37] Lonner JH, Scuderi GR, Lieberman JR. Potential utility of liposome bupivacaine in orthopedic surgery. Am J Orthop (Belle
Mead NJ) 2015;44:111e7.
[38] Stone NR, Bicanic T, Salim R, Hope W. Liposomal amphotericin B (AmBisome((R))): a review of the pharmacokinetics,
pharmacodynamics, clinical experience and future directions. Drugs 2016;76:485e500.
[39] Xing M, Yan F, Yu S, Shen P. Efficacy and cardiotoxicity of liposomal doxorubicin-based chemotherapy in advanced breast
cancer: a meta-analysis of ten randomized controlled trials. PLoS One 2015;10:e0133569.
[40] Huszar G, Roberts JM. Biochemistry and pharmacology of the myometrium and labor: regulation at the cellular and
molecular levels. Am J Obstet Gynecol 1982;142:225e37.
[41] Paul JW, Hua S, Smith R. A targeted drug delivery system for the uterus. Reproductive Sciences: Society of Reproductive
Investigation. SAGE PUBLICATIONS; 2015. p. 57A.
[42] Ding BS, Dziubla T, Shuvaev VV, Muro S, Muzykantov VR. Advanced drug delivery systems that target the vascular
endothelium. Mol Interv 2006;6:98e112.
[43] Hua S. Targeting sites of inflammation: intercellular adhesion molecule-1 as a target for novel inflammatory therapies.
Front Pharmacol 2013;4:127.
[44] Koning GA, Storm G. Targeted drug delivery systems for the intracellular delivery of macromolecular drugs. Drug Discov
Today 2003;8:482e3.
[45] Metselaar JM, Storm G. Liposomes in the treatment of inflammatory disorders. Expet Opin Drug Deliv 2005;2:465e76.
[46] Parkington HC, Stevenson J, Tonta MA, Paul J, Butler T, Maiti K, et al. Diminished hERG Kþ channel activity facilitates strong
human labour contractions but is dysregulated in obese women. Nat Commun 2014;5:4108.
[47] Poste G, Papahadjopoulos D, Vail WJ. Lipid vesicles as carriers for introducing biologically active materials into cells. Meth
Cell Biol 1976;14:33e71.
[48] Senior JH. Fate and behavior of liposomes in vivo: a review of controlling factors. Crit Rev Ther Drug Carrier Syst 1987;3:
123e93.
[49] Adan RA, Van Leeuwen FW, Sonnemans MA, Brouns M, Hoffman G, Verbalis JG, et al. Rat oxytocin receptor in brain,
pituitary, mammary gland, and uterus: partial sequence and immunocytochemical localization. Endocrinology 1995;136:
4022e8.
[50] Paul JW, Hua S, Ilicic M, Tolosa JM, Butler T, Robertson S, et al. Drug delivery to the human and mouse uterus using
immunoliposomes targeted to the oxytocin receptor. Am J Obstet Gynecol 2017;216:283 e1- e14.
[51] Vrachnis N, Malamas FM, Sifakis S, Deligeoroglou E, Iliodromiti Z. The oxytocin-oxytocin receptor system and its antag-
onists as tocolytic agents. Int J Endocrinol 2011;2011:350546.
[52] Flenady V, Reinebrant HE, Liley HG, Tambimuttu EG, Papatsonis DN. Oxytocin receptor antagonists for inhibiting preterm
labour. Cochrane Database Syst Rev 2014:Cd004452.
[53] Thornton S, Miller H, Valenzuela G, Snidow J, Stier B, Fossler MJ, et al. Treatment of spontaneous preterm labour with
retosiban: a phase 2 proof-of-concept study. Br J Clin Pharmacol 2015;80:740e9.
[54] Refuerzo JS, Leonard F, Bulayeva N, Gorenstein D, Chiossi G, Ontiveros A, et al. Uterus-targeted liposomes for preterm labor
management: studies in pregnant mice. Sci Rep 2016;6:34710.
[55] Refuerzo JS, Alexander JF, Leonard F, Leon M, Longo M, Godin B. Liposomes: a nanoscale drug carrying system to prevent
indomethacin passage to the fetus in a pregnant mouse model. Am J Obstet Gynecol 2015;212:508.e1-7.
[56] Poste G, Papahadjopoulos D. Lipid vesicles as carriers for introducing materials into cultured cells: influence of vesicle lipid
composition on mechanism(s) of vesicle incorporation into cells. Proc Natl Acad Sci U S A 1976;73:1603e7.
[57] Mehedintu C, Plotogea MN, Ionescu S, Antonovici M. Endometriosis still a challenge. J Med life 2014;7:349e57.
[58] Polat M, Yarali I, Boynukalin K, Yarali H. In vitro fertilization for endometriosis-associated infertility. Women's health
(London, England) 2015;11:633e41.
[59] Schwager K, Bootz F, Imesch P, Kaspar M, Trachsel E, Neri D. The antibody-mediated targeted delivery of interleukin-10
inhibits endometriosis in a syngeneic mouse model. Hum Reprod 2011;26:2344e52.
[60] Quattrone F, Sanchez AM, Pannese M, Hemmerle T, Vigano P, Candiani M, et al. The targeted delivery of interleukin 4
inhibits development of endometriotic lesions in a mouse model. Reprod Sci 2015;22:1143e52.
[61] Schwager K. Antigens associated with endometriosis. Philogen S.p.A; 2009.
[62] King A, Ndifon C, Lui S, Widdows K, Kotamraju VR, Agemy L, et al. Tumor-homing peptides as tools for targeted delivery of
payloads to the placenta. Sci adv 2016;2:e1600349.
[63] Blencowe H, Cousens S, Chou D, Oestergaard M, Say L, Moller AB, et al. Born too soon: the global epidemiology of 15
million preterm births. Reprod Health 2013;10(Suppl 1):S2.
[64] Ilicic M, Butler T, Zakar T, Paul JW. The expression of genes involved in myometrial contractility changes during ex situ
culture of pregnant human uterine smooth muscle tissue. J Smooth Muscle Res 2017;53:73e89.
[65] Ilicic M, Zakar T, Paul JW. Modulation of progesterone receptor isoform expression in pregnant human myometrium.
BioMed Res Int 2017;2017:4589214.
[66] Keelan JA, Leong JW, Ho D, Iyer KS. Therapeutic and safety considerations of nanoparticle-mediated drug delivery in
pregnancy. Nanomedicine (Lond) 2015;10:2229e47.

Best Practice & Research Clinical Obstetrics and Gynaecology

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Best Practice & Research Clinical Obstetrics and Gynaecology

Transféré par

Droits d'auteur :

Formats disponibles

Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2018) 1e12

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Preventing preterm birth: New approaches to

Nanoparticles and drug delivery

Drug delivery platforms and pregnancy

Targeted drug delivery for preterm labour

Other reproductive applications of targeted drug delivery platforms

Endometriosis is a debilitating inﬂammatory condition characterised by the growth of endometrial

Targeted nanoparticle-based drug delivery platforms continue to evolve and improve. It is

Vous aimerez peut-être aussi