Impact of Maternal Pomegranate Juice on Brain Injury in Infants With Intrauterine Growth Restriction (IUGR)

This study is divided into two separate phases.

Phase I evaluated if the antioxidants produced from pomegranate juice cross the placenta in
normal healthy pregnancies. Twenty women were enrolled, 10 who will take 8 oz of
pomegranate juice daily and then 10 others who will take 8 oz of placebo juice without
pomegranate daily. Blood samples were first collected from the woman at the time enrollment
and then from both the woman and the cord blood at the time of delivery. These blood samples
were analyzed to measure the levels of antioxidant metabolites from the pomegranate juice.
This phase was deigned to confirm placental transfer of antioxidant pomegranate metabolites.
The results confirmed placenta transfer of pomegranate metabolites. Further, placental
tissues from 12 patients (4 in the pomegranate group and 8 in the control group) were
collected for analysis of oxidative stress. The preliminary in vivo results were extended to
oxidative stress and cell death assays in vitro. Placental explants and cultured primary
human trophoblasts were exposed to pomegranate juice or glucose (control) under defined
oxygen tensions and chemical stimuli. We found decreased oxidative stress in term human
placentas from women who labored after prenatal ingestion of pomegranate juice compared with
apple juice as control. Moreover, pomegranate juice reduced in vitro oxidative stress,
apoptosis, and global cell death in term villous explants and primary trophoblast cultures
exposed to hypoxia, the hypoxia mimetic cobalt chloride, and the kinase inhibitor
staurosporine. Punicalagin, but not ellagic acid, both prominent polyphenols in pomegranate
juice, reduced oxidative stress and stimulus-induced apoptosis in cultured
syncytiotrophoblasts.

Phase II focuses on pregnancies with intrauterine growth restriction. If they meet entry
criteria, then woman will be enrolled and randomized into 1 of 2 groups.

Treatment group: Expecting mothers in this group will start a daily regimen of 8 oz glass
of pomegranate juice. They will keep a daily diary documenting their compliance. They will
continue this daily intake up until delivery of their infant.

Placebo group: These women will start a daily regimen of an 8 oz of pomegranate free juice
placebo that matches taste, calories, and appearance to regular pomegranate juice but lacks
polyphenols. They will also keep a diary of daily intake to help ensure compliance similar
to the treatment group. They too will continue to take the placebos up until the time they
deliver.

Both groups: All women will be followed up on a weekly basis to assess compliance. A
detailed diet history will be collected from the women at the time of enrollment, midway
through the 3rd trimester and at the time of delivery. Furthermore, all women will have a
detailed social history collected at the time of enrollment. Upon delivery, cord blood
will be collected and sent for ellagic acid, a polyphenic component. All placental material
will be sent for formal pathological exam and analyzed for markers of placental injury.

If clinically stable, the infants will receive MRI evaluations to evaluate for possible
brain injury.

Phase I:

Inclusion Criteria:

- Healthy expecting mothers two weeks from their expected due dates

- No evidence of IUGR

- No evidence of fetal problems

Phase II:

Inclusion Criteria:

1. Expecting mother with a fetal diagnosis of intrauterine growth restriction (IUGR)
defined by estimated fetal weight <10th percentile for gestational age

2. 24 - 34 weeks gestation

Exclusion Criteria:

1. Major congenital abnormalities

2. Known fetal chromosomal disorder

3. Maternal illicit drug use

4. Maternal IV and Hepatitis C infection

5. Premature rupture of membranes