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Luncan M, Huniadi A, Bimbo-Szuhai E, Botea M, Zaha I, Stefan L, Beiusanu C, Romanescu D, Pallag A, Bodog A, Pop LO, Șandor MI. The effectiveness of intrauterine antibiotic infusion versus oral antibiotic therapy in the treatment of chronic endometritis in patients during IVF (in vitro fertilization) procedures. BMC Womens Health 2022; 22:529. [PMID: 36528581 PMCID: PMC9759887 DOI: 10.1186/s12905-022-02128-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Chronic Endometritis (CE) is a subtle pathology, likely infectious in most cases, with a negative impact on the female fertility, but often overlooked even among fertility specialists. The purpose of the study is to demonstrate the predominant infectious nature of CE and to find the best therapeutic option by comparing the results of oral antibiotic therapy versus intrauterine antibiotic infusion in patients with CE undergoing IVF procedures. The objective was to compare the cure rate of CE-defined as the percentage of patients without CE at the test of cure, between the two groups and, the hysteroscopic aspect with the positive CD 138 staining. METHODS This was a prospective, case-control study that took place in a single university fertility clinic, in Oradea, Romania and included 57 patients with CE divided into 2 groups: orally administered antibiotics group who received a combination of antibiotics compared to intrauterine infusion group who received intrauterine infusion of antibiotic. Chronic Endometritis was diagnosed through hysteroscopy and immunohistochemistry for CD 138. Patients in both groups were tested for CE twice to evaluate the cure rate after oral combination antibiotic therapy versus intrauterine infusion of antibiotic. RESULTS Out of 115 patients with endometrial biopsies 57 tested positive for CE, with a 49.6% chronic endometritis prevalence. Among the group that was administered oral antibiotics, 11 patients (45.83%) experienced CE resolution after triple antibiotic therapy. Of the intrauterine infusion group, 25 patients (89.29%) presented negative results (p 0.0020). The normal hysteroscopic aspect had a similar prevalence in the patients with immunohistochemical positive and negative CD 138. CONCLUSIONS Our study demonstrated the effectiveness and superiority of intrauterine antibiotic infusion over the use of oral combination antibiotic therapy for CE cure. TRIAL REGISTRATION ISRCTN17542620/14.09.2022.
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Affiliation(s)
- Mihai Luncan
- grid.19723.3e0000 0001 1087 4092Faculty of Medicine and Pharmacy, University of Oradea, 1St December Square 10, 410073 Oradea, Romania ,Pelican Clinical Hospital, Corneliu Coposu Street, 2, 41045Ö, Oradea, Romania
| | - Anca Huniadi
- grid.19723.3e0000 0001 1087 4092Faculty of Medicine and Pharmacy, University of Oradea, 1St December Square 10, 410073 Oradea, Romania ,Pelican Clinical Hospital, Corneliu Coposu Street, 2, 41045Ö, Oradea, Romania ,Calla-Infertility Diagnostic and Treatment Center, Constantin A. Rosetti Street, 410103 Oradea, Romania
| | - Erika Bimbo-Szuhai
- grid.19723.3e0000 0001 1087 4092Faculty of Medicine and Pharmacy, University of Oradea, 1St December Square 10, 410073 Oradea, Romania ,Pelican Clinical Hospital, Corneliu Coposu Street, 2, 41045Ö, Oradea, Romania
| | - Mihai Botea
- grid.19723.3e0000 0001 1087 4092Faculty of Medicine and Pharmacy, University of Oradea, 1St December Square 10, 410073 Oradea, Romania ,Pelican Clinical Hospital, Corneliu Coposu Street, 2, 41045Ö, Oradea, Romania
| | - Ioana Zaha
- grid.19723.3e0000 0001 1087 4092Faculty of Medicine and Pharmacy, University of Oradea, 1St December Square 10, 410073 Oradea, Romania ,Calla-Infertility Diagnostic and Treatment Center, Constantin A. Rosetti Street, 410103 Oradea, Romania
| | - Liana Stefan
- grid.19723.3e0000 0001 1087 4092Faculty of Medicine and Pharmacy, University of Oradea, 1St December Square 10, 410073 Oradea, Romania ,Pelican Clinical Hospital, Corneliu Coposu Street, 2, 41045Ö, Oradea, Romania ,Calla-Infertility Diagnostic and Treatment Center, Constantin A. Rosetti Street, 410103 Oradea, Romania
| | - Corina Beiusanu
- grid.19723.3e0000 0001 1087 4092Faculty of Medicine and Pharmacy, University of Oradea, 1St December Square 10, 410073 Oradea, Romania
| | - Dana Romanescu
- grid.19723.3e0000 0001 1087 4092Faculty of Medicine and Pharmacy, University of Oradea, 1St December Square 10, 410073 Oradea, Romania
| | - Annamaria Pallag
- grid.19723.3e0000 0001 1087 4092Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 29 Nicolae Jiga Street, 410028 Oradea, Romania
| | - Alin Bodog
- grid.19723.3e0000 0001 1087 4092Faculty of Medicine and Pharmacy, University of Oradea, 1St December Square 10, 410073 Oradea, Romania
| | - Laurean Ovidiu Pop
- grid.19723.3e0000 0001 1087 4092Faculty of Medicine and Pharmacy, University of Oradea, 1St December Square 10, 410073 Oradea, Romania
| | - Mircea Ioan Șandor
- grid.19723.3e0000 0001 1087 4092Faculty of Medicine and Pharmacy, University of Oradea, 1St December Square 10, 410073 Oradea, Romania
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Wang H, Liu C, Hao C. Association between hysteroscopic features of chronic endometritis and pregnancy outcomes of patients after in vitro fertilization: a retrospective cohort study. J OBSTET GYNAECOL 2022; 42:3651-3657. [PMID: 36503380 DOI: 10.1080/01443615.2022.2152659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This retrospective cohort study explored the morphological features of chronic endometritis (CE) and pregnancy outcomes during in vitro fertilization (IVF) in women with CE (429) at Yantai Yuhuangding Hospital between January 2017 and September 2018. The primary outcome was the clinical pregnancy rate (CPR). The women displayed haemorrhagic spots (175), hyperaemia (122), micropolyps (75), hyperaemia combined with micropolyps (49) and others (8). The CPR and live birth rate (LBR) were different among the hysteroscopic features of CE in fresh embryo transfer cycles (p = .002, p = .011). The miscarriage and premature birth rates were not significantly different among groups (p > .05). Hyperaemia (0.47 [95% CI, 0.29; 0.77]), micropolyps (0.40 [95% CI, 0.23; 0.72]), hyperaemia combined with micropolyps (0.35 [95% CI, 0.18; 0.69]) and others (0.36 [95% CI, 0.19; 0.69]) were associated with the CPR. In conclusion, the hysteroscopic features of CE are associated with IVF pregnancy outcomes, and there were differences in pregnancy outcomes with different CE hysteroscopic features.IMPACT STATEMENTWhat is already known on this subject? Chronic endometritis (CE) is associated with adverse pregnancy outcomes such as infertility, premature delivery and miscarriage. CE can reduce the success rate of pregnancy and even lead to obstetric and neonatal complications, and is an adverse factor for the success of in vitro fertilization (IVF). There are different types of CE, but their impact on IVF outcomes is unknown.What the results of this study add? The CPR and LBR were different among the hysteroscopic features of CE in fresh embryo transfer cycles (p = .002, p = .011). The miscarriage and premature birth rates were not significantly different among groups (p > .05). After adjustment, the multivariable analysis showed that hyperaemia (OR = 0.47, p = .002), micropolyps (OR = 0.40, p = .002), hyperaemia combined with micropolyps (OR = 0.35, p = .002) and others (OR = 0.36, p = .002) were associated with the CPR among patients with CE.What the implications are of these findings for clinical practice and/or further research? The hysteroscopic features of CE are associated with IVF pregnancy outcomes, and there were differences in pregnancy outcomes with different CE hysteroscopic features. Hence, women with repeated IVF failure should undergo hysteroscopy to examine for the presence of CE and its nature.
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Affiliation(s)
- Hui Wang
- Department of Reproduction, Yantaishan Hospital, Yantai, China
| | - Changhong Liu
- Department of Reproduction, Yantaishan Hospital, Yantai, China
| | - Cuifang Hao
- Department of Reproduction, Qingdao Women and Children’s Hospital, Shandong University, Qingdao, China
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Understanding the Immune System in Fetal Protection and Maternal Infections during Pregnancy. J Immunol Res 2022; 2022:7567708. [PMID: 35785037 PMCID: PMC9249541 DOI: 10.1155/2022/7567708] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/20/2022] [Indexed: 11/18/2022] Open
Abstract
The fetal-maternal immune system determines the fate of pregnancy. The trophoblast cells not only give an active response against external stimuli but are also involved in secreting most of the cytokines. These cells have an essential function in fetal acceptance or fetal rejection. Other immune cells also play a pivotal role in carrying out a successful pregnancy. The disruption in this mechanism may lead to harmful effects on pregnancy. The placenta serves as an immune barrier in fetus protection against invading pathogens. Once the infections prevail, they may localize in placental and fetal tissues, and the presence of inflammation due to cytokines may have detrimental effects on pregnancy. Moreover, some pathogens are responsible for congenital fetal anomalies and affect almost all organs of the developing fetus. This review article is designed to address the bacterial and viral infections that threaten pregnancy and their possible outcomes. Moreover, training of the fetal immune system against the exposure of infections and the role of CD49a + NK cells in embryonic development will also be highlighted.
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Duan H, Li X, Hao Y, Shi J, Cai H. Risk of spontaneous abortion after antibiotic therapy for chronic endometritis before in vitro fertilization and intracytoplasmic sperm injection stimulation. Fertil Steril 2022; 118:337-346. [PMID: 35691723 DOI: 10.1016/j.fertnstert.2022.04.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/26/2022] [Accepted: 04/26/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate whether cured chronic endometritis (CE) from antibiotic treatment would be associated with a higher risk of spontaneous abortion in the following in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment. DESIGN Prospective cohort study. SETTING Tertiary reproductive medicine center. PATIENT(S) Patients with infertility who underwent a routine hysteroscopy underwent an IVF/ICSI stimulation between January 1, 2019, and December 31, 2020. Women with CE (N = 338) underwent antibiotic therapy, and the assisted reproductive outcomes were then compared with women without CE (N = 7,962). INTERVENTION(S) Chronic endometritis was diagnosed through hysteroscopy and confirmed by histology and immunohistochemistry for CD138. MAIN OUTCOME MEASURE(S) Spontaneous abortion rate after the initial embryo transfer. RESULT(S) A total of 7,218 patients underwent embryo transfer, with 330 in the cured CE group and 6,888 in the non-CE group. Women with cured CE had a higher rate of spontaneous abortion than did those without CE (11.8% vs. 9.2%; crude odds ratio [OR], 1.32 [0.94, 1.86]), and this difference was statistically significant after adjusting for confounding variables (adjusted OR, 1.49 [1.01, 2.19]). The live birth rate was 43.9% in the cured CE group and 50.5% in the non-CE group (crude OR, 0.77 [0.62, 0.96]; adjusted OR, 0.73 [0.59, 0.92]). The incidence of clinical pregnancy did not differ significantly between the 2 groups (56.1% vs. 60.0%; crude OR, 0.85 [0.68, 1.06]; adjusted OR, 0.83 [0.66, 1.03]). Sensitivity analyses stratified by initial fresh- or frozen-thawed embryo transfer cycles resulted in similar results. CONCLUSION(S) Chronic endometritis cured with antibiotic therapy was associated with an increased risk of spontaneous abortion among women undergoing IVF/ICSI treatment. The interpretation of the findings is limited by a potential confounding bias.
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Affiliation(s)
- Haixia Duan
- Department of Hysteroscopic Centre, Northwest Women's and Children's Hospital, Xi'an, People's Republic of China
| | - Xiaojuan Li
- Department of Hysteroscopic Centre, Northwest Women's and Children's Hospital, Xi'an, People's Republic of China
| | - Yuan Hao
- Department of Hysteroscopic Centre, Northwest Women's and Children's Hospital, Xi'an, People's Republic of China
| | - Juanzi Shi
- Reproductive Medicine Center, Northwest Women's and Children's Hospital, Xi'an, People's Republic of China
| | - He Cai
- Reproductive Medicine Center, Northwest Women's and Children's Hospital, Xi'an, People's Republic of China.
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Ding J, Maxwell A, Adzibolosu N, Hu A, You Y, Liao A, Mor G. Mechanisms of immune regulation by the placenta: Role of type I interferon and interferon‐stimulated genes signaling during pregnancy*. Immunol Rev 2022; 308:9-24. [DOI: 10.1111/imr.13077] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 12/18/2022]
Affiliation(s)
- Jiahui Ding
- C.S Mott Center for Human Growth and Development Department of Obstetrics and Gynecology Wayne State University Detroit Michigan USA
| | - Anthony Maxwell
- C.S Mott Center for Human Growth and Development Department of Obstetrics and Gynecology Wayne State University Detroit Michigan USA
- Department of Physiology Wayne State University Detroit Michigan USA
| | - Nicholas Adzibolosu
- C.S Mott Center for Human Growth and Development Department of Obstetrics and Gynecology Wayne State University Detroit Michigan USA
- Department of Physiology Wayne State University Detroit Michigan USA
| | - Anna Hu
- C.S Mott Center for Human Growth and Development Department of Obstetrics and Gynecology Wayne State University Detroit Michigan USA
| | - Yuan You
- C.S Mott Center for Human Growth and Development Department of Obstetrics and Gynecology Wayne State University Detroit Michigan USA
| | - Aihua Liao
- Institute of Reproductive Health Center for Reproductive Medicine Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Gil Mor
- C.S Mott Center for Human Growth and Development Department of Obstetrics and Gynecology Wayne State University Detroit Michigan USA
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Demirdag E, Guler I, Cevher Akdulum MF, Sahin E, Erdem O, Erdem A, Erdem M. Subsequent IVF outcomes following antibiotic therapy for chronic endometritis in patients with recurrent implantation failure. J Obstet Gynaecol Res 2021; 47:4350-4356. [PMID: 34549486 DOI: 10.1111/jog.15037] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/01/2021] [Accepted: 09/12/2021] [Indexed: 11/27/2022]
Abstract
AIM The aim is to identify the chronic endometritis (CE) incidence in recurrent implantation failure (RIF) patients undergoing in vitro fertilization (IVF) treatment and compare the IVF outcomes of RIF patients with CE following antibiotic therapy with RIF patients without CE. Another purpose is to compare the IVF outcomes of described RIF patients with patients undergoing the first cycle of IVF. METHODS In this retrospective cohort study, CE was diagnosed with CD-138 immunohistochemical staining. Among RIF patients, two groups were formed as group 1, including patients diagnosed with CE and treated by antibiotics (n = 129), and group 2, including patients without CE (n = 103). Patients with the first IVF cycle having similar infertility etiologies with RIF patients were reviewed as group 3 (n = 932). RESULTS CE was diagnosed in 55.6% of RIF patients. The number of oocytes retrieved was not different between groups. Implantation rates (IR) were similar after antibiotic treatment in RIF patients with or without CE. However, Group 3 had a higher IR (41.1%) than group 1 and 2 (23.1% and 30.1%, respectively) (p < 0.001). Clinical pregnancy (CPR) and live birth rates (LBR) were comparable between RIF groups. However, CPR and LBR were significantly higher in group 3 (48.6% and 40.5%) than group 1 (36.4% and 27.9%), and group 2 (37.9% and 30.1%) (p = 0.007 and p = 0.005, respectively). CONCLUSION Unidentified endometrial factors except CE may also affect the implantation process, although CE is a frequent finding in patients with RIF. Reproductive outcomes may not be improved only with antibiotics in RIF patients with CE.
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Affiliation(s)
- Erhan Demirdag
- Department of Obstetrics and Gynecology, Gazi University Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, Yenimahalle/Ankara, Turkey
| | - Ismail Guler
- Department of Obstetrics and Gynecology, Gazi University Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, Yenimahalle/Ankara, Turkey
| | - Munire Funda Cevher Akdulum
- Department of Obstetrics and Gynecology, Gazi University Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, Yenimahalle/Ankara, Turkey
| | - Esin Sahin
- Department of Obstetrics and Gynecology, Gazi University Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, Yenimahalle/Ankara, Turkey
| | - Ozlem Erdem
- Department of Medical Pathology, Gazi University Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, Yenimahalle/Ankara, Turkey
| | - Ahmet Erdem
- Department of Obstetrics and Gynecology, Gazi University Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, Yenimahalle/Ankara, Turkey
| | - Mehmet Erdem
- Department of Obstetrics and Gynecology, Gazi University Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, Yenimahalle/Ankara, Turkey
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Song D, He Y, Wang Y, Liu Z, Xia E, Huang X, Xiao Y, Li TC. Impact of antibiotic therapy on the rate of negative test results for chronic endometritis: a prospective randomized control trial. Fertil Steril 2021; 115:1549-1556. [PMID: 33549312 DOI: 10.1016/j.fertnstert.2020.12.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To compare the rates of negative test results for chronic endometritis (CE) between subjects who did and did not receive antibiotic treatment. DESIGN Prospective, single-blind randomized controlled trial. SETTING Tertiary hysteroscopic center in a university teaching hospital. PATIENT(S) A total of 132 women with CE confirmed with immunohistochemical study with CD138 epitope. INTERVENTION(S) Women randomized to antibiotic therapy received oral levofloxacin 500 mg and tinidazole 1,000 mg daily for 14 days. Women randomized to the control group did not receive any treatment. A repeated endometrial biopsy was performed 4 to 8 weeks after the initial biopsy to determine whether CE was still present. MAIN OUTCOME MEASURE(S) The rate of negative test results for CE (from positive to negative). RESULT(S) The CE rate of negative test results in the treatment group (89.3%) after one course of antibiotic treatment was significantly higher than that in the control group (12.7%). Among subjects who attempted pregnancy, there was no significant difference in ongoing pregnancy rates and miscarriage rates between the treatment arm (43.2%, 5.4%) and the control arm (25.7%, 14.3%). Among subjects randomized, there was also no significant difference in ongoing pregnancy rates and miscarriage rates between the treatment arm (27.1%, 3.4%) and the control arm (16.4%, 9.1%). CONCLUSION A course of broad-spectrum oral antibiotic therapy for 14 days is effective in the treatment of CE in >89.8% of cases. However, it is not yet clear whether treatment improved pregnancy outcomes. CLINICAL TRIAL IDENTIFICATION NUMBER NCT02648698.
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Affiliation(s)
- Dongmei Song
- Department of Hysteroscopic Centre, Fuxing Hospital, the Eighth Clinical Medical College, Capital Medical University, Beijing, People's Republic of China
| | - Yanfei He
- Reproductive Health Department, Dezhou Decheng Maternal and Child Health Hospital, Shandong, People's Republic of China
| | - Yixuan Wang
- University of Science and Technology, Beijing, People's Republic of China
| | - Ziyu Liu
- Department of Gynecology, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, People's Republic of China
| | - Enlan Xia
- Department of Hysteroscopic Centre, Fuxing Hospital, the Eighth Clinical Medical College, Capital Medical University, Beijing, People's Republic of China
| | - Xiaowu Huang
- Department of Hysteroscopic Centre, Fuxing Hospital, the Eighth Clinical Medical College, Capital Medical University, Beijing, People's Republic of China
| | - Yu Xiao
- Department of Hysteroscopic Centre, Fuxing Hospital, the Eighth Clinical Medical College, Capital Medical University, Beijing, People's Republic of China
| | - Tin-Chiu Li
- Department of Hysteroscopic Centre, Fuxing Hospital, the Eighth Clinical Medical College, Capital Medical University, Beijing, People's Republic of China; Assisted Conception Unit, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, People's Republic of China.
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Buzzaccarini G, Vitagliano A, Andrisani A, Santarsiero CM, Cicinelli R, Nardelli C, Ambrosini G, Cicinelli E. Chronic endometritis and altered embryo implantation: a unified pathophysiological theory from a literature systematic review. J Assist Reprod Genet 2020; 37:2897-2911. [PMID: 33025403 PMCID: PMC7714873 DOI: 10.1007/s10815-020-01955-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Chronic endometritis (CE) is a frequent hysteroscopic and histological finding which affects embryo transfer implantation during IVF-ICSI cycles. In particular, CE impairs proper decidualization and, subsequently, implantation. Although this correlation has been clearly clarified, a pathophysiological explanation assembling all the studies performed has not been elucidated yet. For this reason, we have structured a systematic review considering all the original articles that evaluated a pathological element involved in CE and implantation impairment. METHODS The authors searched electronic databases and, after screening, collected 15 original articles. These were fully scanned and used to create a summary pathway. RESULTS CE is primarily caused by infections, which lead to a specific cytokine and leukocyte pattern in order to prepare the uterus to fight the noxa. In particular, the immunosuppression requested for a proper semi-allogenic embryo transfer implantation is converted into an immunoreaction, which hampers correct embryo implantation. Moreover, endometrial vascularization is affected and both irregular vessel density and luminal thickening and thrombosis reduce what we have first identified as endometrial flow reserve. Finally, incorrect uterine wave propagation could affect embryo contact with decidua. CONCLUSION This is the first summary of evidence on CE pathophysiology and its relationship with infertility. Understanding the CE pathophysiology could improve our knowledge in embryo transfer success.
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Affiliation(s)
- Giovanni Buzzaccarini
- Gynecological Clinic, UOS Medically Assisted Procreation, University of Padova, via Nicolò Giustiniani 3, Padova, Italy.
| | - Amerigo Vitagliano
- Gynecological Clinic, UOS Medically Assisted Procreation, University of Padova, via Nicolò Giustiniani 3, Padova, Italy
| | - Alessandra Andrisani
- Gynecological Clinic, UOS Medically Assisted Procreation, University of Padova, via Nicolò Giustiniani 3, Padova, Italy
| | - Carla Mariaflavia Santarsiero
- Second Unit of Obstetrics and Gynecology, Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", Piazza G. Cesare 11, Bari, Italy
| | - Rossana Cicinelli
- Second Unit of Obstetrics and Gynecology, Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", Piazza G. Cesare 11, Bari, Italy
| | - Claudia Nardelli
- Second Unit of Obstetrics and Gynecology, Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", Piazza G. Cesare 11, Bari, Italy
| | - Guido Ambrosini
- Gynecological Clinic, UOS Medically Assisted Procreation, University of Padova, via Nicolò Giustiniani 3, Padova, Italy
| | - Ettore Cicinelli
- Second Unit of Obstetrics and Gynecology, Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", Piazza G. Cesare 11, Bari, Italy
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Eleje GU, Eke AC, Ikechebelu JI, Ezebialu IU, Okam PC, Ilika CP. Cervical stitch (cerclage) in combination with other treatments for preventing spontaneous preterm birth in singleton pregnancies. Cochrane Database Syst Rev 2020; 9:CD012871. [PMID: 32970845 PMCID: PMC8094629 DOI: 10.1002/14651858.cd012871.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Preterm birth (PTB) remains the foremost global cause of perinatal morbidity and mortality. Thus, the prevention of spontaneous PTB still remains of critical importance. In an attempt to prevent PTB in singleton pregnancies, cervical cerclage, in combination with other treatments, has been advocated. This is because, cervical cerclage is an intervention that is commonly recommended in women with a short cervix at high risk of preterm birth but, despite this, many women still deliver prematurely, as the biological mechanism is incompletely understood. Additionally, previous Cochrane Reviews have been published on the effectiveness of cervical cerclage in singleton and multiple pregnancies, however, none has evaluated the effectiveness of using cervical cerclage in combination with other treatments. OBJECTIVES To assess whether antibiotics administration, vaginal pessary, reinforcing or second cerclage placement, tocolytic, progesterone, or other interventions at the time of cervical cerclage placement prolong singleton gestation in women at high risk of pregnancy loss based on prior history and/or ultrasound finding of 'short cervix' and/or physical examination. History-indicated cerclage is defined as a cerclage placed usually between 12 and 15 weeks gestation based solely on poor prior obstetrical history, e.g. multiple second trimester losses due to painless dilatation. Ultrasound-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation for transvaginal ultrasound cervical length < 20 mm in a woman without cervical dilatation. Physical exam-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation because of cervical dilatation of one or more centimetres detected on physical (manual) examination. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (26 September 2019), and reference lists of retrieved studies. SELECTION CRITERIA We included published, unpublished or ongoing randomised controlled trial (RCTs). Studies using a cluster-RCT design were also eligible for inclusion in this review but none were identified. We excluded quasi-RCTs (e.g. those randomised by date of birth or hospital number) and studies using a cross-over design. We also excluded studies that specified addition of the combination therapy after cervical cerclage because the woman subsequently became symptomatic. We included studies comparing cervical cerclage in combination with one, two or more interventions with cervical cerclage alone in singleton pregnancies. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts of all retrieved articles, selected studies for inclusion, extracted data, assessed risk of bias, and evaluated the certainty of the evidence for this review's main outcomes. Data were checked for accuracy. Standard Cochrane review methods were used throughout. MAIN RESULTS We identified two studies (involving a total of 73 women) comparing cervical cerclage alone to a different comparator. We also identified three ongoing studies (one investigating vaginal progesterone after cerclage, and two investigating cerclage plus pessary). One study (20 women), conducted in the UK, comparing cervical cerclage in combination with a tocolytic (salbutamol) with cervical cerclage alone in women with singleton pregnancy did not provide any useable data for this review. The other study (involving 53 women, with data from 50 women) took place in the USA and compared cervical cerclage in combination with a tocolytic (indomethacin) and antibiotics (cefazolin or clindamycin) versus cervical cerclage alone - this study did provide useable data for this review (and the study authors also provided additional data on request) but meta-analyses were not possible. This study was generally at a low risk of bias, apart from issues relating to blinding. We downgraded the certainty of evidence for serious risk of bias and imprecision (few participants, few events and wide 95% confidence intervals). Cervical cerclage in combination with an antibiotic and tocolytic versus cervical cerclage alone (one study, 50 women/babies) We are unclear about the effect of cervical cerclage in combination with antibiotics and a tocolytic compared with cervical cerclage alone on the risk of serious neonatal morbidity (RR 0.62, 95% CI 0.31 to 1.24; very low-certainty evidence); perinatal loss (data for miscarriage and stillbirth only - data not available for neonatal death) (RR 0.46, 95% CI 0.13 to 1.64; very low-certainty evidence) or preterm birth < 34 completed weeks of pregnancy (RR 0.78, 95% CI 0.44 to 1.40; very low-certainty evidence). There were no stillbirths (intrauterine death at 24 or more weeks). The trial authors did not report on the numbers of babies discharged home healthy (without obvious pathology) or on the risk of neonatal death. AUTHORS' CONCLUSIONS Currently, there is insufficient evidence to evaluate the effect of combining a tocolytic (indomethacin) and antibiotics (cefazolin/clindamycin) with cervical cerclage compared with cervical cerclage alone for preventing spontaneous PTB in women with singleton pregnancies. Future studies should recruit sufficient numbers of women to provide meaningful results and should measure neonatal death and numbers of babies discharged home healthy, as well as other important outcomes listed in this review. We did not identify any studies looking at other treatments in combination with cervical cerclage. Future research needs to focus on the role of other interventions such as vaginal support pessary, reinforcing or second cervical cerclage placement, 17-alpha-hydroxyprogesterone caproate or dydrogesterone or vaginal micronised progesterone, omega-3 long chain polyunsaturated fatty acid supplementation and bed rest.
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Affiliation(s)
- George U Eleje
- Effective Care Research Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, PMB 5001, Nnewi, Nigeria
| | - Ahizechukwu C Eke
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph I Ikechebelu
- Department of Obstetrics/Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Ifeanyichukwu U Ezebialu
- Department of Obstetrics and Gynaecology, Faculty of Clinical medicine, College of Medicine, Anambra State University Amaku, Awka, Nigeria
| | - Princeston C Okam
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Chito P Ilika
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
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10
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Green ES, Arck PC. Pathogenesis of preterm birth: bidirectional inflammation in mother and fetus. Semin Immunopathol 2020; 42:413-429. [PMID: 32894326 PMCID: PMC7508962 DOI: 10.1007/s00281-020-00807-y] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/14/2020] [Indexed: 12/18/2022]
Abstract
Preterm birth (PTB) complicates 5–18% of pregnancies globally and is a leading cause of maternal and fetal morbidity and mortality. Most PTB is spontaneous and idiopathic, with largely undefined causes. To increase understanding of PTB, much research in recent years has focused on using animal models to recapitulate the pathophysiology of PTB. Dysfunctions of maternal immune adaptations have been implicated in a range of pregnancy pathologies, including PTB. A wealth of evidence arising from mouse models as well as human studies is now available to support that PTB results from a breakdown in fetal-maternal tolerance, along with excessive, premature inflammation. In this review, we examine the current knowledge of the bidirectional communication between fetal and maternal systems and its role in the immunopathogenesis of PTB. These recent insights significantly advance our understanding of the pathogenesis of PTB, which is essential to ultimately designing more effective strategies for early prediction and subsequent prevention of PTB.
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Affiliation(s)
- Ella Shana Green
- Department of Obstetrics and Fetal Medicine, Laboratory for Experimental Feto-Maternal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Petra Clara Arck
- Department of Obstetrics and Fetal Medicine, Laboratory for Experimental Feto-Maternal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany.
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11
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Firmal P, Shah VK, Chattopadhyay S. Insight Into TLR4-Mediated Immunomodulation in Normal Pregnancy and Related Disorders. Front Immunol 2020; 11:807. [PMID: 32508811 PMCID: PMC7248557 DOI: 10.3389/fimmu.2020.00807] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/08/2020] [Indexed: 12/12/2022] Open
Abstract
Unlike organ transplants where an immunosuppressive environment is required, a successful pregnancy involves an extremely robust, dynamic, and responsive maternal immune system to maintain the development of the fetus. A specific set of hormones and cytokines are associated with a particular stage of pregnancy. Any disturbance that alters this fine balance could compromise the development and function of the placenta. Although there are numerous underlying causes of pregnancy-related complications, untimely activation of Toll-like receptors (TLR), primarily TLR4, by intrauterine microbes poses the greatest risk. TLR4 is an important Pattern Recognition Receptor (PRR), which activates both innate and adaptive immune cells. TLR4 activation by LPS or DAMPs leads to the production of pro-inflammatory cytokines via the MyD88 dependent or independent pathway. Immune cells modulate the materno–fetal interface by TLR4-mediated cytokine production, which changes at different stages of pregnancy. In most pregnancy disorders, such as PTB, PE, or placental malaria, the TLR4 expression is upregulated in immune cells or in maternal derived cells, leading to the aberrant production of pro-inflammatory cytokines at the materno–fetal interface. Lack of functional TLR4 in mice has reduced the pro-inflammatory responses, leading to an improved pregnancy, which further strengthens the fact that abnormal TLR4 activation creates a hostile environment for the developing fetus. A recent study proposed that endothelial and perivascular stromal cells should interact with each other in order to maintain a homeostatic balance during TLR4-mediated inflammation. It has been reported that depleting immune cells or supplying anti-inflammatory cytokines can prevent PTB, PE, or fetal death. Blocking TLR4 signaling or its downstream molecule by inhibitors or antagonists has proven to improve pregnancy-related complications to some extent in clinical and animal models. To date, there has been a lack of knowledge regarding whether TLR4 accessories such as CD14 and MD-2 are important in pregnancy and whether these accessory molecules could be promising drug targets for combinatorial treatment of various pregnancy disorders. This review mainly focuses on the activation of TLR4 during pregnancy, its immunomodulatory functions, and the upcoming advancement in this field regarding the improvement of pregnancy-related issues by various therapeutic approaches.
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Affiliation(s)
- Priyanka Firmal
- National Centre for Cell Science, S. P. Pune University Campus, Pune, India
| | - Vibhuti Kumar Shah
- National Centre for Cell Science, S. P. Pune University Campus, Pune, India
| | - Samit Chattopadhyay
- National Centre for Cell Science, S. P. Pune University Campus, Pune, India.,Department of Biological Sciences, BITS Pilani, K. K. Birla Goa Campus, Goa, India.,Indian Institute of Chemical Biology, Kolkata, India
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12
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Voroshilina E, Zornikov D, Koposova O, Islamidi D, Ignatova K, Abakumova E, Kurbatova N, Plotko E. The use of real-time PCR for evaluation of endometrial microbiota. BULLETIN OF RUSSIAN STATE MEDICAL UNIVERSITY 2020. [DOI: 10.24075/brsmu.2020.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Chronic endometritis (CE) in women of the reproductive age is associated with infertility and recurrent pregnancy loss. The aim of this study was to evaluate the endometrial microbiota by means of real-time PCR in reproductive-age women depending on the morphological pattern of the endometrium. Using the Androflor real-time PCR kit, we analyzed endometrial aspirate collected from 23 patients with chronic endometritis, 30 patients with endometrial hyperplasia, and 19 healthy women. DNA of up to 9 groups of microorganisms was detected in all the analyzed samples in the amounts exceeding negative control. The total bacterial load (TBL) of the detected microorganisms was 10<sup>3</sup>–10<sup>6,4</sup> (median 10<sup>3,8</sup>) GE/ml. Lactobacillus spp. were detected the most often (86.1% of all samples). Opportunistic microorganisms (OM) were identified in 36.1% of all samples, including 22.2% of samples with lactobacilli and 13.9% — without lactobacilli. The variant of microbiota composition with Lactobacillus-dominance (more than 90%. in the TBL) was detected significantly less often in women with chronic endometritis compared to healthy women. Real-time PCR could be used for assessment of endometrial microbiota and allows us to determine its characteristics depending on the morphological pattern.
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Affiliation(s)
- E.S. Voroshilina
- Medical Center “Garmonia”, Yekaterinburg, Russia; Ural State Medical University of the Ministry of health, Yekaterinburg, Russia
| | | | | | - D.K. Islamidi
- Medical Center “Garmonia”, Yekaterinburg, Russia; Ural State Medical University of the Ministry of health, Yekaterinburg, Russia
| | - K.Yu. Ignatova
- Ural State Medical University of the Ministry of health, Yekaterinburg, Russia
| | - E.I. Abakumova
- Ural State Medical University of the Ministry of health, Yekaterinburg, Russia
| | - N.V. Kurbatova
- Ural State Medical University of the Ministry of health, Yekaterinburg, Russia
| | - E.E. Plotko
- Ural State Medical University of the Ministry of health, Yekaterinburg, Russia
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13
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Miranda M, Saccone G, Ammendola A, Salzano E, Iannicelli M, De Rosa R, Nazzaro G, Locci M. Vaginal lactoferrin in prevention of preterm birth in women with bacterial vaginosis. J Matern Fetal Neonatal Med 2019; 34:3704-3708. [PMID: 31722591 DOI: 10.1080/14767058.2019.1690445] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To evaluate use of vaginal lactoferrin in prevention of preterm birth (PTB) in women with first trimester bacterial vaginosis and prior spontaneous PTB.Methods: This is a retrospective cohort study of all consecutive singleton gestations with prior PTB, and first trimester diagnosis of bacterial vaginosis. Women who were found to have bacterial vaginosis were recommended lactoferrin 300 mg vaginal tablets daily for 21 days. The primary outcome was the incidence of PTB at less than 37 weeks of gestations. Outcomes were compared in women who received daily lactoferrin with those who did notResults: During the study period, 847 pregnant women with prior spontaneous PTB were screened for bacterial vaginosis. Of them, 193 were found to have bacterial vaginosis in the first trimester, with an overall incidence of 22.8%. Out of the 193 women, 125 met the inclusion criteria for the study and were analyzed. Sixty of the included women received vaginal lactoferrin, while 65 did not. Women who received supplementation with lactoferrin had a significantly lower rate of PTB < 37 weeks (25.0 versus 44.6%; p = .02), lower mean gestational age at delivery (37.7 ± 3.2 versus 35.9 ± 4.1 weeks; p = .01), and lower rate of admission for threatened PTL (45.0 versus 70.8%; p = .04). No between-group differences were noticed in the other outcomes, including chorioamnionitis, PPROM < 34 weeks, and neonatal outcomes. No cases of late miscarriage were reported in our cohort. No cases of adverse events were reported.Conclusion: Based on this small single-center retrospective study, supplementation with vaginal lactoferrin in women with first trimester bacterial vaginosis may be an option to reduce the risk of preterm delivery.
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Affiliation(s)
- Marilena Miranda
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Alessandra Ammendola
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Emilia Salzano
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Marisa Iannicelli
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Rossella De Rosa
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Giovanni Nazzaro
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Mariavittoria Locci
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
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14
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Puente E, Alonso L, Laganà AS, Ghezzi F, Casarin J, Carugno J. Chronic Endometritis: Old Problem, Novel Insights and Future Challenges. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2019; 13:250-256. [PMID: 31710184 PMCID: PMC6875860 DOI: 10.22074/ijfs.2020.5779] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 03/10/2019] [Indexed: 11/04/2022]
Abstract
Chronic endometritis (CE) is a poorly investigated pathology which has been related to adverse reproductive outcomes, such as implantation failure and recurrent miscarriage. In this paper, we aim to provide an overview of diagnosis, etiology, pathophysiology and treatment of CE, its impact on endometrial microenvironment and its association with infertility. We present a narrative review of the current literatures, synthesizing the findings retrieved from searches of computerized databases. CE is more prevalent in infertile patients. Effective antibiotic treatment of CE seems to improve the pregnancy and live birth rate in patients with unexplained recurrent pregnancy loss (RPL), and increase ongoing pregnancy rate in patients with recurrent implantation failure. In order to increase the diagnostic accuracy, immunohistochemistry is recommended besides the conventional histology. In addition, hysteroscopy could be considered as gold standard tool for diagnosis, considering its high correlation with histological findings. CE, as the chronic inflammation of endometrium, is usually asymptomatic and probably underestimated. Interaction of bacteria with endometrial microenvironment promotes changes in leukocyte population, cytokine production and growth factors which support its negative impact on endometrial receptivity. Nevertheless, standardization of the criteria for histopathological diagnosis and immunohistochemistry technique needs to be defined.
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Affiliation(s)
- Elena Puente
- Assisted Reproduction Unit, Fertia Clinic, Fuengirola, Málaga, Spain
| | - Luis Alonso
- Unidad de Endoscopia Ginecológica, Centro Gutenberg, Málaga, Spain
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy. Electronic Address:
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Jose Carugno
- Obstetrics and Gynecology Department, University of Miami, Miller School of Medicine, Miami, Florida, USA
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15
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Extracellular vesicles in host-pathogen interactions and immune regulation - exosomes as emerging actors in the immunological theater of pregnancy. Heliyon 2019; 5:e02355. [PMID: 31592031 PMCID: PMC6771614 DOI: 10.1016/j.heliyon.2019.e02355] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 06/30/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023] Open
Abstract
This review correlates and summarizes the role of the maternal-fetal interface in the immune tolerance of the fetus and the processes that lead to infection avoidance, emphasizing the participation of exosomes and other extracellular vesicles in both situations. Exosomes are released into the extracellular medium by several cell types and are excellent carriers of biomolecules. Host-derived exosomes and the transport of pathogen-derived molecules by exosomes impact infections in different ways. The interactions of exosomes with the maternal immune system are pivotal to a favorable gestational outcome. In this review, we highlight the potential role of exosomes in the establishment of an adequate milieu that enables embryo implantation and discuss the participation of exosomes released at the maternal-fetal interface during the establishment of an immune-privileged compartment for fetal development. The placenta is a component where important strategies are used to minimize the risk of infection. To present a contrast, we also discuss possible mechanisms used by pathogens to cross the maternal-fetal interface. We review the processes, mechanisms, and potential consequences of dysregulation in all of the abovementioned phenomena. Basic information about exosomes and their roles in viral immune evasion is also presented. The interactions between extracellular vesicles and bacteria, fungi, parasites and proteinaceous infectious agents are addressed. The discovery of the placental microbiota and the implications of this new microbiota are also discussed, and current proposals that explain fetal/placental colonization by both pathogenic and commensal microbes are addressed. The comprehension of such interactions will help us to understand the immune dynamics of human pregnancy and the mechanisms of immune evasion used by different pathogens.
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16
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Association of pelvic inflammatory disease (PID) with ectopic pregnancy and preterm labor in Taiwan: A nationwide population-based retrospective cohort study. PLoS One 2019; 14:e0219351. [PMID: 31408465 PMCID: PMC6692029 DOI: 10.1371/journal.pone.0219351] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 06/23/2019] [Indexed: 12/18/2022] Open
Abstract
Background Pelvic inflammatory disease (PID) is an infectious disease that causes tubal occlusion and other pelvic and abdominal adhesions. The incidence of pelvic inflammatory disease (PID) has increased due to the sexually active status of the young population. This leads to a more serious problem and a larger effect than previously observed. However, there have been few studies on this topic in Asian populations. Aim We aimed to evaluate the risk of preterm labor and/or ectopic pregnancy in Taiwanese women following PID. Design Using the Taiwan National Health Insurance Database, we designed a retrospective cohort study that included 12- to 55-year-old pregnant women between 2000 and 2010. We selected a 1:3 age-matched control group of non-PID women. The endpoint was any episode of preterm labor or ectopic pregnancy; otherwise, the patients were tracked until 31 December 2010. Methods The risk factors for preterm labor or ectopic pregnancy were explored. For cases included from the index date until the end of 2010, we analyzed the risk of incident preterm labor or ectopic pregnancy. With the use of a multivariate Cox proportional hazard regression analysis, we calculated the hazard ratio (HR) with a 95% CI and compared it with that of the control group. Results This study examined 30,450 patients with PID and 91,350 controls. During the follow-up period, patients in the PID group were more likely to develop preterm labor or ectopic pregnancy than patients in the control group. The cumulative incidence rates for developing preterm labor were 1.84% (561/30,450 individuals) in patients with PID and 1.63% (1492/91,350 individuals) in patients without PID. On the other hand, the cumulative incidence rate for developing ectopic pregnancy in patients with PID was 0.05% (14/30,450 individuals) but was only 0.04% (33/91,350 individuals) in patients without PID. Compared with those without PID, the patients with PID had a 1.864 times (P<0.001) higher risk of developing preterm labor and a 2.121 times (P = 0.003) higher risk of developing ectopic pregnancy. Conclusion Our study provided evidence of an increased risk of preterm labor or ectopic pregnancy in PID patients.
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17
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Zhou M, Yi Y, Hong L. Oridonin Ameliorates Lipopolysaccharide-Induced Endometritis in Mice via Inhibition of the TLR-4/NF-κBpathway. Inflammation 2019; 42:81-90. [PMID: 30132202 DOI: 10.1007/s10753-018-0874-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Endometritis is a health threat to both humans and animals and poses a huge economic burden. Oridonin (Ori) is a natural diterpenoid isolated from the traditional Chinese herb Rabdosiarubescens (R. rubescens) and has multiple health-promoting effects, including antioxidant, anti-inflammatory, and antitumor effects. There is little evidence showing that Ori can effectively treat endometritis, and the relevant mechanisms need to be further clarified. In this study, we investigated the effects of Ori on LPS-induced endometritis in vivo. Additionally, we examined the effects of Ori on LPS-stimulated mouse endometrial epithelial cells (mEECs). The results showed that Ori treatment significantly alleviated LPS-induced endometritis and reduced the activity of myeloperoxidase. ELISA and qPCR results indicated that Ori dose-dependently decreased the expression of TNF-α, IL-1β, and IL-6 both in tissues and in mEECs. In addition, Ori was found to inhibit LPS-induced TLR4/NF-κB signaling pathway activation. These results suggest that Ori effectively attenuates LPS-induced endometritis by inhibiting the TLR4/NF-κB signaling pathway and that Ori might be an effective drug for the prevention and treatment of LPS-induced endometritis.
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Affiliation(s)
- Min Zhou
- Department of Gynecology and Obstetrics, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan City, Hubei Province, People's Republic of China
| | - Yinyi Yi
- Department of Gynecology and Obstetrics, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan City, Hubei Province, People's Republic of China
| | - Li Hong
- Department of Gynecology and Obstetrics, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan City, Hubei Province, People's Republic of China.
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18
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Benner M, Ferwerda G, Joosten I, van der Molen RG. How uterine microbiota might be responsible for a receptive, fertile endometrium. Hum Reprod Update 2019; 24:393-415. [PMID: 29668899 DOI: 10.1093/humupd/dmy012] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 03/27/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Fertility depends on a receptive state of the endometrium, influenced by hormonal and anatomical adaptations, as well as the immune system. Local and systemic immunity is greatly influenced by microbiota. Recent discoveries of 16S rRNA in the endometrium and the ability to detect low-biomass microbiota fueled the notion that the uterus may be indeed a non-sterile compartment. To date, the concept of the 'sterile womb' focuses on in utero effects of microbiota on offspring and neonatal immunity. However, little awareness has been raised regarding the importance of uterine microbiota for endometrial physiology in reproductive health; manifested in fertility and placentation. OBJECTIVE AND RATIONALE Commensal colonization of the uterus has been widely discussed in the literature. The objective of this review is to outline the possible importance of this uterine colonization for a healthy, fertile uterus. We present the available evidence regarding uterine microbiota, focusing on recent findings based on 16S rRNA, and depict the possible importance of uterine colonization for a receptive endometrium. We highlight a possible role of uterine microbiota for host immunity and tissue adaptation, as well as conferring protection against pathogens. Based on knowledge of the interaction of the mucosal immune cells of the gut with the local microbiome, we want to investigate the potential implications of commensal colonization for uterine health. SEARCH METHODS PubMed and Google Scholar were searched for articles in English indexed from 1 January 2008 to 1 March 2018 for '16S rRNA', 'uterus' and related search terms to assess available evidence on uterine microbiome analysis. A manual search of the references within the resulting articles was performed. To investigate possible functional contributions of uterine microbiota to health, studies on microbiota of other body sites were additionally assessed. OUTCOMES Challenging the view of a sterile uterus is in its infancy and, to date, no conclusions on a 'core uterine microbiome' can be drawn. Nevertheless, evidence for certain microbiota and/or associated compounds in the uterus accumulates. The presence of microbiota or their constituent molecules, such as polysaccharide A of the Bacteroides fragilis capsule, go together with healthy physiological function. Lessons learned from the gut microbiome suggest that the microbiota of the uterus may potentially modulate immune cell subsets needed for implantation and have implications for tissue morphology. Microbiota can also be crucial in protection against uterine infections by defending their niche and competing with pathogens. Our review highlights the need for well-designed studies on a 'baseline' microbial state of the uterus representing the optimal starting point for implantation and subsequent placenta formation. WIDER IMPLICATIONS The complex interplay of processes and cells involved in healthy pregnancy is still poorly understood. The correct receptive endometrial state, including the local immune environment, is crucial not only for fertility but also placenta formation since initiation of placentation highly depends on interaction with immune cells. Implantation failure, recurrent pregnancy loss, and other pathologies of endometrium and placenta, such as pre-eclampsia, represent an increasing societal burden. More robust studies are needed to investigate uterine colonization. Based on current data, future research needs to include the uterine microbiome as a relevant factor in order to understand the players needed for healthy pregnancy.
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Affiliation(s)
- Marilen Benner
- Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Geert Grooteplein 10, PO Box 9101, Internal mail 469, 6500 HB Nijmegen, The Netherlands
| | - Gerben Ferwerda
- Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Geert Grooteplein 10, PO Box 9101, Internal mail 469, 6500 HB Nijmegen, The Netherlands
| | - Irma Joosten
- Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Geert Grooteplein 10, PO Box 9101, Internal mail 469, 6500 HB Nijmegen, The Netherlands
| | - Renate G van der Molen
- Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Geert Grooteplein 10, PO Box 9101, Internal mail 469, 6500 HB Nijmegen, The Netherlands
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19
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D'Ippolito S, Di Nicuolo F, Pontecorvi A, Gratta M, Scambia G, Di Simone N. Endometrial microbes and microbiome: Recent insights on the inflammatory and immune "players" of the human endometrium. Am J Reprod Immunol 2018; 80:e13065. [PMID: 30375712 DOI: 10.1111/aji.13065] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/22/2018] [Accepted: 09/24/2018] [Indexed: 12/29/2022] Open
Abstract
In recent years, extended scientific works shed light on the important role played by the endometrium in early pregnancy. This review examines our current knowledge about the delicate balance between microbial and cellular immune agents at endometrial level: All of them might affect endometrial receptivity. In contrast to the classical thinking of human endometrium as a sterile tissue, several recent studies have drawn attention to a resident population of microorganisms, which reaches only a 30% of concordance with those of the cervical-vaginal flora. At present, the understanding of the microbiome in relation to human reproduction is in its infancy and further studies are needed to clarify the activity of endometrial microbiome and the possible effects of a "reproductive tract dysbiosis" on fertility. Moreover, in the human endometrium, there is a complex system works preventing the risk of infection as well as enabling, when pregnancy occurs, the acceptance of the blastocyst. In this way, the endometrium plays a central role in the uterine immune surveillance. A better understanding of the different agents that may affect endometrial receptivity would improve the diagnosis and treatment of obstetric complications related to defective implantation and placentation.
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Affiliation(s)
- Silvia D'Ippolito
- Dipartimento di Scienze della Salute della Donna e del Bambino, Area Salute Donna, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italia.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italia
| | - Fiorella Di Nicuolo
- Dipartimento di Scienze della Salute della Donna e del Bambino, Area Salute Donna, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italia.,Paolo VI International Scientific Institute, Università Cattolica del Sacro Cuore, Rome, Italia
| | - Alfredo Pontecorvi
- Paolo VI International Scientific Institute, Università Cattolica del Sacro Cuore, Rome, Italia.,Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Area Endocrino-Metabolica e Dermo-Reumatologica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italia.,Istituto di Patologia Medica, Università Cattolica del Sacro Cuore, Rome, Italia
| | - Matteo Gratta
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italia
| | - Giovanni Scambia
- Dipartimento di Scienze della Salute della Donna e del Bambino, Area Salute Donna, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italia.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italia
| | - Nicoletta Di Simone
- Dipartimento di Scienze della Salute della Donna e del Bambino, Area Salute Donna, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italia.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italia
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Ferlita AL, Battaglia R, Andronico F, Caruso S, Cianci A, Purrello M, Pietro CD. Non-Coding RNAs in Endometrial Physiopathology. Int J Mol Sci 2018; 19:ijms19072120. [PMID: 30037059 PMCID: PMC6073439 DOI: 10.3390/ijms19072120] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 07/12/2018] [Accepted: 07/14/2018] [Indexed: 12/18/2022] Open
Abstract
The Human Genome Project led to the discovery that about 80% of our DNA is transcribed in RNA molecules. Only 2% of the human genome is translated into proteins, the rest mostly produces molecules called non-coding RNAs, which are a heterogeneous class of RNAs involved in different steps of gene regulation. They have been classified, according to their length, into small non-coding RNAs and long non-coding RNAs, or to their function, into housekeeping non-coding RNAs and regulatory non-coding RNAs. Their involvement has been widely demonstrated in all cellular processes, as well as their dysregulation in human pathologies. In this review, we discuss the function of non-coding RNAs in endometrial physiology, analysing their involvement in embryo implantation. Moreover, we explore their role in endometrial pathologies such as endometrial cancer, endometriosis and chronic endometritis.
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Affiliation(s)
- Alessandro La Ferlita
- Department of Biomedical and Biotechnological Sciences, Biology and Genetics Section G. Sichel, University of Catania, 95123 Catania, Italy.
| | - Rosalia Battaglia
- Department of Biomedical and Biotechnological Sciences, Biology and Genetics Section G. Sichel, University of Catania, 95123 Catania, Italy.
| | - Francesca Andronico
- Department of Biomedical and Biotechnological Sciences, Biology and Genetics Section G. Sichel, University of Catania, 95123 Catania, Italy.
| | - Salvatore Caruso
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95123 Catania, Italy.
| | - Antonio Cianci
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95123 Catania, Italy.
| | - Michele Purrello
- Department of Biomedical and Biotechnological Sciences, Biology and Genetics Section G. Sichel, University of Catania, 95123 Catania, Italy.
| | - Cinzia Di Pietro
- Department of Biomedical and Biotechnological Sciences, Biology and Genetics Section G. Sichel, University of Catania, 95123 Catania, Italy.
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The diagnosis of chronic endometritis in infertile asymptomatic women: a comparative study of histology, microbial cultures, hysteroscopy, and molecular microbiology. Am J Obstet Gynecol 2018; 218:602.e1-602.e16. [PMID: 29477653 DOI: 10.1016/j.ajog.2018.02.012] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/07/2018] [Accepted: 02/15/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Chronic endometritis is a persistent inflammation of the endometrial mucosa caused by bacterial pathogens such as Enterobacteriaceae, Enterococcus, Streptococcus, Staphylococcus, Mycoplasma, and Ureaplasma. Although chronic endometritis can be asymptomatic, it is found in up to 40% of infertile patients and is responsible for repeated implantation failure and recurrent miscarriage. Diagnosis of chronic endometritis is based on hysteroscopy of the uterine cavity, endometrial biopsy with plasma cells being identified histologically, while specific treatment is determined based on microbial culture. However, not all microorganisms implicated are easily or readily culturable needing a turnaround time of up to 1 week. OBJECTIVE We sought to develop a molecular diagnostic tool for chronic endometritis based on real-time polymerase chain reaction equivalent to using the 3 classic methods together, overcoming the bias of using any of them alone. STUDY DESIGN Endometrial samples from patients assessed for chronic endometritis (n = 113) using at least 1 or several conventional diagnostic methods namely histology, hysteroscopy, and/or microbial culture, were blindly evaluated by real-time polymerase chain reaction for the presence of 9 chronic endometritis pathogens: Chlamydia trachomatis, Enterococcus, Escherichia coli, Gardnerella vaginalis, Klebsiella pneumoniae, Mycoplasma hominis, Neisseria gonorrhoeae, Staphylococcus, and Streptococcus. The sensitivity and specificity of the molecular analysis vs the classic diagnostic techniques were compared in the 65 patients assessed by all 3 recognized classic methods. RESULTS The molecular method showed concordant results with histological diagnosis in 30 samples (14 double positive and 16 double negative) with a matching accuracy of 46.15%. Concordance of molecular and hysteroscopic diagnosis was observed in 38 samples (37 double positive and 1 double negative), with an accuracy of 58.46%. When the molecular method was compared to microbial culture, concordance was present in 37 samples (22 double positive and 15 double negative), a matching rate of 56.92%. When cases of potential contamination and/or noncultivable bacteria were considered, the accuracy increased to 66.15%. Of these 65 patients, only 27 patients had consistent histological + hysteroscopic diagnosis, revealing 58.64% of nonconcordant results. Only 13 of 65 patients (20%) had consistent histology + hysteroscopy + microbial culture results. In these cases, the molecular microbiology matched in 10 cases showing a diagnostic accuracy of 76.92%. Interestingly, the molecular microbiology confirmed over half of the isolated pathogens and provided additional detection of nonculturable microorganisms. These results were confirmed by the microbiome assessed by next-generation sequencing. In the endometrial samples with concordant histology + hysteroscopy + microbial culture results, the molecular microbiology diagnosis demonstrates 75% sensitivity, 100% specificity, 100% positive and 25% negative predictive values, and 0% false-positive and 25% false-negative rates. CONCLUSION The molecular microbiology method describe herein is a fast and inexpensive diagnostic tool that allows for the identification of culturable and nonculturable endometrial pathogens associated with chronic endometritis. The results obtained were similar to all 3 classic diagnostic methods together with a degree of concordance of 76.92% providing an opportunity to improve the clinical management of infertile patients with a risk of experiencing this ghost endometrial pathology.
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Cross SN, Nelson RA, Potter JA, Norwitz ER, Abrahams VM. Magnesium sulfate differentially modulates fetal membrane inflammation in a time-dependent manner. Am J Reprod Immunol 2018; 80:e12861. [PMID: 29709093 DOI: 10.1111/aji.12861] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 03/27/2018] [Indexed: 12/17/2022] Open
Abstract
PROBLEM Chorioamnionitis and infection-associated inflammation are major causes of preterm birth. Magnesium sulfate (MgSO4 ) is widely used in obstetrics as a tocolytic; however, its mechanism of action is unclear. This study sought to investigate how MgSO4 modulates infection-associated inflammation in fetal membranes (FMs), and whether the response was time dependent. METHOD OF STUDY Human FM explants were treated with or without bacterial lipopolysaccharide (LPS); with or without MgSO4 added either: 1 hour before LPS; at the same time as LPS; 1 hour post-LPS; or 2 hours post-LPS. Explants were also treated with or without viral dsRNA and LPS, alone or in combination; and MgSO4 added 1 hour post-LPS After 24 hours, supernatants were measured for cytokines/chemokines; and tissue lysates measured for caspase-1 activity. RESULTS Lipopolysaccharide-induced FM inflammation by upregulating the secretion of a number of inflammatory cytokines/chemokines. Magnesium sulfate administered 1-hour post-LPS inhibited FM secretion of IL-1β, IL-6, G-CSF, RANTES, and TNFα. Magnesium sulfate administered 2 hours post-LPS augmented FM secretion of these factors as well as IL-8, IFNγ, VEGF, GROα and IP-10. Magnesium sulfate delivered 1- hour post-LPS inhibited LPS-induced caspase-1 activity, and inhibited the augmented IL-1β response triggered by combination viral dsRNA and LPS. CONCLUSION Magnesium sulfate differentially modulates LPS-induced FM inflammation in a time-dependent manner, in part through its modulation of caspase-1 activity. Thus, the timing of MgSO4 administration may be critical in optimizing its anti-inflammatory effects in the clinical setting. MgSO4 might also be useful at preventing FM inflammation triggered by a polymicrobial viral-bacterial infection.
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Affiliation(s)
- Sarah N Cross
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Rachel A Nelson
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Julie A Potter
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Errol R Norwitz
- Department of Obstetrics & Gynecology, Tufts University School of Medicine, Boston, MA, USA
| | - Vikki M Abrahams
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
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23
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Di Pietro C, Caruso S, Battaglia R, Iraci Sareri M, La Ferlita A, Strino F, Bonaventura G, Di Mauro M, Barcellona ML, Perciavalle V, Purrello M, Cianci A. MiR-27a-3p and miR-124-3p, upregulated in endometrium and serum from women affected by Chronic Endometritis, are new potential molecular markers of endometrial receptivity. Am J Reprod Immunol 2018; 80:e12858. [DOI: 10.1111/aji.12858] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 03/27/2018] [Indexed: 12/11/2022] Open
Affiliation(s)
- Cinzia Di Pietro
- Biology and Genetics Section; Department of Biomedical and Biotechnological Sciences; University of Catania; Catania Italy
| | - Salvatore Caruso
- Department of General Surgery and Medical Surgical Specialties; University of Catania; Catania Italy
| | - Rosalia Battaglia
- Biology and Genetics Section; Department of Biomedical and Biotechnological Sciences; University of Catania; Catania Italy
| | - Marco Iraci Sareri
- Department of General Surgery and Medical Surgical Specialties; University of Catania; Catania Italy
| | - Alessandro La Ferlita
- Biology and Genetics Section; Department of Biomedical and Biotechnological Sciences; University of Catania; Catania Italy
| | - Fabrizio Strino
- Biology and Genetics Section; Department of Biomedical and Biotechnological Sciences; University of Catania; Catania Italy
| | - Gabriele Bonaventura
- Biochemistry Section; Department of Pharmaceutical Science; University of Catania; Catania Italy
| | - Maurizio Di Mauro
- Department of Clinical and Experimental Medicine; University of Catania; Catania Italy
| | - Maria Luisa Barcellona
- Biochemistry Section; Department of Pharmaceutical Science; University of Catania; Catania Italy
| | - Vincenzo Perciavalle
- Physiology Section; Department of Biomedical and Biotechnological Sciences; University of Catania; Catania Italy
| | - Michele Purrello
- Biology and Genetics Section; Department of Biomedical and Biotechnological Sciences; University of Catania; Catania Italy
| | - Antonio Cianci
- Department of General Surgery and Medical Surgical Specialties; University of Catania; Catania Italy
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Kenny LC, Kell DB. Immunological Tolerance, Pregnancy, and Preeclampsia: The Roles of Semen Microbes and the Father. Front Med (Lausanne) 2018; 4:239. [PMID: 29354635 PMCID: PMC5758600 DOI: 10.3389/fmed.2017.00239] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/12/2017] [Indexed: 12/18/2022] Open
Abstract
Although it is widely considered, in many cases, to involve two separable stages (poor placentation followed by oxidative stress/inflammation), the precise originating causes of preeclampsia (PE) remain elusive. We have previously brought together some of the considerable evidence that a (dormant) microbial component is commonly a significant part of its etiology. However, apart from recognizing, consistent with this view, that the many inflammatory markers of PE are also increased in infection, we had little to say about immunity, whether innate or adaptive. In addition, we focused on the gut, oral and female urinary tract microbiomes as the main sources of the infection. We here marshall further evidence for an infectious component in PE, focusing on the immunological tolerance characteristic of pregnancy, and the well-established fact that increased exposure to the father's semen assists this immunological tolerance. As well as these benefits, however, semen is not sterile, microbial tolerance mechanisms may exist, and we also review the evidence that semen may be responsible for inoculating the developing conceptus (and maybe the placenta) with microbes, not all of which are benign. It is suggested that when they are not, this may be a significant cause of PE. A variety of epidemiological and other evidence is entirely consistent with this, not least correlations between semen infection, infertility and PE. Our view also leads to a series of other, testable predictions. Overall, we argue for a significant paternal role in the development of PE through microbial infection of the mother via insemination.
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Affiliation(s)
- Louise C. Kenny
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
- Department of Obstetrics and Gynecology, University College Cork, Cork, Ireland
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Douglas B. Kell
- School of Chemistry, The University of Manchester, Manchester, United Kingdom
- The Manchester Institute of Biotechnology, The University of Manchester, Manchester, United Kingdom
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25
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Eleje GU, Ikechebelu JI, Eke AC, Okam PC, Ezebialu IU, Ilika CP. Cervical cerclage in combination with other treatments for preventing preterm birth in singleton pregnancies. Hippokratia 2017. [DOI: 10.1002/14651858.cd012871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- George U Eleje
- Faculty of Medicine, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus; Effective Care Research Unit, Department of Obstetrics and Gynaecology; PMB 5001, Nnewi Anambra State Nigeria
| | - Joseph I Ikechebelu
- Nnamdi Azikiwe University Teaching Hospital; Department of Obstetrics/Gynaecology; Nnewi Nigeria
| | - Ahizechukwu C Eke
- Johns Hopkins University School of Medicine; Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics; 600 N Wolfe Street Phipps 228 Baltimore Maryland USA 21287-1228
| | - Princeston C Okam
- Nnamdi Azikiwe University Teaching Hospital; Department of Obstetrics and Gynaecology; PMB 5025 Nnewi Anambra Nigeria
| | - Ifeanyichukwu U Ezebialu
- Faculty of Clinical medicine, College of Medicine, Anambra State University Amaku; Department of Obstetrics and Gynaecology; Awka Nigeria
| | - Chito P Ilika
- Nnamdi Azikiwe University Teaching Hospital; Department of Obstetrics and Gynaecology; PMB 5025 Nnewi Anambra Nigeria
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Abstract
The comparison of the immunological state of pregnancy to an immunosuppressed host-graft model continues to lead research and clinical practice to ill-defined approaches. This Review discusses recent evidence that supports the idea that immunological responses at the receptive maternal-fetal interface are not simply suppressed but are instead highly dynamic. We discuss the crucial role of trophoblast cells in shaping not only the way in which immune cells respond to the invading blastocyst but also how they collectively react to external stimuli. We also discuss the role of the microbiota in promoting a tolerogenic maternal immune system and highlight how subclinical viral infections can disrupt this status quo, leading to pregnancy complications.
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Affiliation(s)
- Gil Mor
- Division of Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06510, USA
| | - Paulomi Aldo
- Division of Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06510, USA
| | - Ayesha B Alvero
- Division of Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06510, USA
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27
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Mhatre MV, Potter JA, Lockwood CJ, Krikun G, Abrahams VM. Thrombin Augments LPS-Induced Human Endometrial Endothelial Cell Inflammation via PAR1 Activation. Am J Reprod Immunol 2016; 76:29-37. [PMID: 27108773 DOI: 10.1111/aji.12517] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/07/2016] [Indexed: 12/29/2022] Open
Abstract
PROBLEM Risk factors for preterm birth include placental abruption, giving rise to excessive decidual thrombin, and intrauterine bacterial infection. Human endometrial endothelial cells (HEECs) express Toll-like receptors (TLRs), and infection-derived agonists trigger HEECs to generate specific inflammatory responses. As thrombin, in addition to inducing coagulation, can contribute to inflammation, its effect on HEEC inflammatory responses to the TLR4 agonist, bacterial lipopolysaccharide (LPS), was investigated. METHOD OF STUDY HEECs were pre-treated with or without thrombin or specific protease-activated receptor (PAR) agonists, followed by treatment with or without LPS. Supernatants were measured for cytokines and chemokines by ELISA and multiplex analysis. RESULTS Thrombin significantly and synergistically augmented LPS-induced HEEC secretion of interleukin (IL)-6, IL-8, granulocyte colony-stimulating factor (G-CSF), and growth-regulated oncogene-alpha (GRO-α), and significantly augmented monocyte chemotactic protein (MCP)-1, tumor necrosis factor-alpha (TNF-α), and vascular endothelial growth factor (VEGF) secretion additively. Similar to thrombin, a PAR1 agonist synergistically augmented the LPS-induced HEEC secretion of inflammatory IL-6, IL-8, G-CSF, and GRO-α. CONCLUSION Thrombin, via PAR1 activation, synergistically augments LPS-induced HEEC production of chemokines involved in immune cell recruitment and survival, suggesting a mechanism by which intrauterine abruption and bacterial infection may together be associated with an aggravated uterine inflammatory response.
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Affiliation(s)
- Mohak V Mhatre
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Julie A Potter
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Charles J Lockwood
- Department of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Graciela Krikun
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Vikki M Abrahams
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
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Verstraelen H, Vilchez-Vargas R, Desimpel F, Jauregui R, Vankeirsbilck N, Weyers S, Verhelst R, De Sutter P, Pieper DH, Van De Wiele T. Characterisation of the human uterine microbiome in non-pregnant women through deep sequencing of the V1-2 region of the 16S rRNA gene. PeerJ 2016; 4:e1602. [PMID: 26823997 PMCID: PMC4730988 DOI: 10.7717/peerj.1602] [Citation(s) in RCA: 170] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 12/23/2015] [Indexed: 12/16/2022] Open
Abstract
Background. It is widely assumed that the uterine cavity in non-pregnant women is physiologically sterile, also as a premise to the long-held view that human infants develop in a sterile uterine environment, though likely reflecting under-appraisal of the extent of the human bacterial metacommunity. In an exploratory study, we aimed to investigate the putative presence of a uterine microbiome in a selected series of non-pregnant women through deep sequencing of the V1-2 hypervariable region of the 16S ribosomal RNA (rRNA) gene. Methods. Nineteen women with various reproductive conditions, including subfertility, scheduled for hysteroscopy and not showing uterine anomalies were recruited. Subjects were highly diverse with regard to demographic and medical history and included nulliparous and parous women. Endometrial tissue and mucus harvesting was performed by use of a transcervical device designed to obtain endometrial biopsy, while avoiding cervicovaginal contamination. Bacteria were targeted by use of a barcoded Illumina MiSeq paired-end sequencing method targeting the 16S rRNA gene V1-2 region, yielding an average of 41,194 reads per sample after quality filtering. Taxonomic annotation was pursued by comparison with sequences available through the Ribosomal Database Project and the NCBI database. Results. Out of 183 unique 16S rRNA gene amplicon sequences, 15 phylotypes were present in all samples. In some 90% of the women included, community architecture was fairly similar inasmuch B. xylanisolvens, B. thetaiotaomicron, B. fragilis and an undetermined Pelomonas taxon constituted over one third of the endometrial bacterial community. On the singular phylotype level, six women showed predominance of L. crispatus or L. iners in the presence of the Bacteroides core. Two endometrial communities were highly dissimilar, largely lacking the Bacteroides core, one dominated by L. crispatus and another consisting of a highly diverse community, including Prevotella spp., Atopobium vaginae, and Mobiluncus curtisii. Discussion. Our findings are, albeit not necessarily generalizable, consistent with the presence of a unique microbiota dominated by Bacteroides residing on the endometrium of the human non-pregnant uterus. The transcervical sampling approach may be influenced to an unknown extent by endocervical microbiota, which remain uncharacterised, and therefore warrants further validation. Nonetheless, consistent with our understanding of the human microbiome, the uterine microbiota are likely to have a previously unrecognized role in uterine physiology and human reproduction. Further study is therefore warranted to document community ecology and dynamics of the uterine microbiota, as well as the role of the uterine microbiome in health and disease.
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Affiliation(s)
- Hans Verstraelen
- Department of Obstetrics and Gynaecology, Ghent University , Ghent , Belgium
| | - Ramiro Vilchez-Vargas
- Laboratory of Microbial Ecology and Technology (LabMET), Ghent University , Ghent , Belgium
| | - Fabian Desimpel
- Faculty of Medicine and Health Sciences, Ghent University , Ghent , Belgium
| | - Ruy Jauregui
- Microbial Interactions and Processes (MINP) Research Group, Helmholtz Centre for Infection Research , Braunschweig , Germany
| | - Nele Vankeirsbilck
- Department of Obstetrics and Gynaecology, Ghent University , Ghent , Belgium
| | - Steven Weyers
- Department of Obstetrics and Gynaecology, Ghent University , Ghent , Belgium
| | - Rita Verhelst
- Department of Obstetrics and Gynaecology, Ghent University , Ghent , Belgium
| | - Petra De Sutter
- Department of Obstetrics and Gynaecology, Ghent University , Ghent , Belgium
| | - Dietmar H Pieper
- Microbial Interactions and Processes (MINP) Research Group, Helmholtz Centre for Infection Research , Braunschweig , Germany
| | - Tom Van De Wiele
- Laboratory of Microbial Ecology and Technology (LabMET), Ghent University , Ghent , Belgium
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29
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Kell DB, Kenny LC. A Dormant Microbial Component in the Development of Preeclampsia. Front Med (Lausanne) 2016; 3:60. [PMID: 27965958 PMCID: PMC5126693 DOI: 10.3389/fmed.2016.00060] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 11/04/2016] [Indexed: 12/12/2022] Open
Abstract
Preeclampsia (PE) is a complex, multisystem disorder that remains a leading cause of morbidity and mortality in pregnancy. Four main classes of dysregulation accompany PE and are widely considered to contribute to its severity. These are abnormal trophoblast invasion of the placenta, anti-angiogenic responses, oxidative stress, and inflammation. What is lacking, however, is an explanation of how these themselves are caused. We here develop the unifying idea, and the considerable evidence for it, that the originating cause of PE (and of the four classes of dysregulation) is, in fact, microbial infection, that most such microbes are dormant and hence resist detection by conventional (replication-dependent) microbiology, and that by occasional resuscitation and growth it is they that are responsible for all the observable sequelae, including the continuing, chronic inflammation. In particular, bacterial products such as lipopolysaccharide (LPS), also known as endotoxin, are well known as highly inflammagenic and stimulate an innate (and possibly trained) immune response that exacerbates the inflammation further. The known need of microbes for free iron can explain the iron dysregulation that accompanies PE. We describe the main routes of infection (gut, oral, and urinary tract infection) and the regularly observed presence of microbes in placental and other tissues in PE. Every known proteomic biomarker of "preeclampsia" that we assessed has, in fact, also been shown to be raised in response to infection. An infectious component to PE fulfills the Bradford Hill criteria for ascribing a disease to an environmental cause and suggests a number of treatments, some of which have, in fact, been shown to be successful. PE was classically referred to as endotoxemia or toxemia of pregnancy, and it is ironic that it seems that LPS and other microbial endotoxins really are involved. Overall, the recognition of an infectious component in the etiology of PE mirrors that for ulcers and other diseases that were previously considered to lack one.
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Affiliation(s)
- Douglas B. Kell
- School of Chemistry, The University of Manchester, Manchester, UK
- The Manchester Institute of Biotechnology, The University of Manchester, Manchester, UK
- Centre for Synthetic Biology of Fine and Speciality Chemicals, The University of Manchester, Manchester, UK
- *Correspondence: Douglas B. Kell,
| | - Louise C. Kenny
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
- Department of Obstetrics and Gynecology, University College Cork, Cork, Ireland
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30
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Kim CJ, Romero R, Chaemsaithong P, Chaiyasit N, Yoon BH, Kim YM. Acute chorioamnionitis and funisitis: definition, pathologic features, and clinical significance. Am J Obstet Gynecol 2015; 213:S29-52. [PMID: 26428501 PMCID: PMC4774647 DOI: 10.1016/j.ajog.2015.08.040] [Citation(s) in RCA: 561] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 08/12/2015] [Accepted: 08/16/2015] [Indexed: 12/25/2022]
Abstract
Acute inflammatory lesions of the placenta consist of diffuse infiltration of neutrophils at different sites in the organ. These lesions include acute chorioamnionitis, funisitis, and chorionic vasculitis and represent a host response (maternal or fetal) to a chemotactic gradient in the amniotic cavity. While acute chorioamnionitis is evidence of a maternal host response, funisitis and chorionic vasculitis represent fetal inflammatory responses. Intraamniotic infection generally has been considered to be the cause of acute chorioamnionitis and funisitis; however, recent evidence indicates that "sterile" intraamniotic inflammation, which occurs in the absence of demonstrable microorganisms induced by "danger signals," is frequently associated with these lesions. In the context of intraamniotic infection, chemokines (such as interleukin-8 and granulocyte chemotactic protein) establish a gradient that favors the migration of neutrophils from the maternal or fetal circulation into the chorioamniotic membranes or umbilical cord, respectively. Danger signals that are released during the course of cellular stress or cell death can also induce the release of neutrophil chemokines. The prevalence of chorioamnionitis is a function of gestational age at birth, and present in 3-5% of term placentas and in 94% of placentas delivered at 21-24 weeks of gestation. The frequency is higher in patients with spontaneous labor, preterm labor, clinical chorioamnionitis (preterm or term), or ruptured membranes. Funisitis and chorionic vasculitis are the hallmarks of the fetal inflammatory response syndrome, a condition characterized by an elevation in the fetal plasma concentration of interleukin-6, and associated with the impending onset of preterm labor, a higher rate of neonatal morbidity (after adjustment for gestational age), and multiorgan fetal involvement. This syndrome is the counterpart of the systemic inflammatory response syndrome in adults: a risk factor for short- and long-term complications (ie, sterile inflammation in fetuses, neonatal sepsis, bronchopulmonary dysplasia, periventricular leukomalacia, and cerebral palsy). This article reviews the definition, pathogenesis, grading and staging, and clinical significance of the most common lesions in placental disease. Illustrations of the lesions and diagrams of the mechanisms of disease are provided.
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Affiliation(s)
- Chong Jai Kim
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea; Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI.
| | - Piya Chaemsaithong
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Noppadol Chaiyasit
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Bo Hyun Yoon
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI; Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Yeon Mee Kim
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI; Department of Pathology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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Trophoblast-microbiome interaction: a new paradigm on immune regulation. Am J Obstet Gynecol 2015; 213:S131-7. [PMID: 26428492 DOI: 10.1016/j.ajog.2015.06.039] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 06/12/2015] [Accepted: 06/16/2015] [Indexed: 01/12/2023]
Abstract
The immunologic paradigm of pregnancy led to the conceptualization of pregnancy as an organ transplant that requires, for its success, suppression of the maternal immune system. Growing scientific evidence suggests that in many ways the placenta functions as a tumor rather than a transplant and the immune regulation of the maternal-fetal interface is the result of the coordinated interaction between all its cellular components, including bacteria. Examining the role of microbiota in reproduction is in its infancy, but there is growing literature that supports its relevance. We discuss a potential normal function of bacteria in the establishment of immune tolerance and compelling evidence that a viral infection might be the underlying cause of perturbation of homeostasis. There is compelling evidence that many infectious diseases of human beings are caused by >1 microorganism and are defined as polymicrobial infections. We propose that pregnancy complications, such as preterm birth, are the result of polymicrobial infections. We examine the potential cellular and molecular mechanisms by which a viral infection of the placenta might disrupt the normal interaction between the cellular component of the implantation site and bacteria. As we better understand the normal homeostasis among the maternal immune system, placenta, and commensal, we will be able to elucidate pathogenic conditions and design better approaches to treat pregnancy complications associated with infection.
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Tapilskaya NI, Karpeyev SA, Gaidukov SN. Justification of the efficacy of antibacterial therapy for the treatment of chronic endometritis. VESTNIK DERMATOLOGII I VENEROLOGII 2015. [DOI: 10.25208/0042-4609-2015-91-2-130-138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
A review of studies on chronic endometritis enables the authors to conclude that bacterially contaminated endometrium is the reason causing reduced fertility in case of confirmed subclinical inflammation. Chronic subclinical inflammation of the endometrium is often associated with genital endometriosis, which apparently leads to abnormal uterine bleedings. The identification of a microbial agent in case of endometritis in the routine outpatient practice is not mandatory because global experience including high-level evidence-based studies confirms the expediency of an empirical therapy based on minimum clinical criteria; otherwise, there may be irreversible consequences for the reproductive system. A preventive antibacterial therapy during the pre-conception period in infertile patients suffering from recurrent miscarriages is an efficient method to prevent reproductive losses.
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Bacterial colonization with balloon uterine stent placement in the uterus for 30 days: a randomized controlled clinical trial. Fertil Steril 2015; 103:513-8.e2. [DOI: 10.1016/j.fertnstert.2014.10.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 09/04/2014] [Accepted: 10/17/2014] [Indexed: 11/24/2022]
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Potter JA, Garg M, Girard S, Abrahams VM. Viral single stranded RNA induces a trophoblast pro-inflammatory and antiviral response in a TLR8-dependent and -independent manner. Biol Reprod 2014; 92:17. [PMID: 25429091 DOI: 10.1095/biolreprod.114.124032] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Interest is growing in the role of viral infections and their association with adverse pregnancy outcomes. The trophoblast is permissive to viruses, but little is known about their impact on the placenta. We previously established that viral single stranded RNA (ssRNA), a Toll-like receptor 8 (TLR8) agonist, induces a restricted trophoblast pro-inflammatory cytokine/chemokine response by upregulating the secretion of interleukin (IL)-6 and IL-8. In parallel, the type I interferon, IFNbeta, is produced and acts back on the cell in an autocrine/paracrine manner to trigger caspase-3-dependent apoptosis. In this study, we sought to extend these findings by determining the mechanisms involved, examining whether viral ssRNA could induce a trophoblast antiviral response, and evaluating the influence of viral ssRNA on pregnancy outcome using a mouse model. Viral ssRNA induced human first-trimester trophoblast inflammation, type I interferon production, an antiviral response, and apoptosis in both a TLR8/MyD88-dependent and -independent manner. Furthermore, administration of viral ssRNA to pregnant mice induced placental caspase-3 activation, a pro-inflammatory cytokine/chemokine, type I interferon, and antiviral response as well as immune cell infiltration. Thus, ssRNA viral infections may compromise pregnancy by altering placental trophoblast survival and function through both TLR8 and non-TLR8 signaling pathways, leading to immune changes at the maternal-fetal interface.
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Affiliation(s)
- Julie A Potter
- Department of Obstetrics, Gynecology, & Reproductive Sciences, Divisions of Reproductive Sciences and Maternal-Fetal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Manish Garg
- Maternal and Fetal Health Research Centre, University of Manchester, Manchester, United Kingdom
| | - Sylvie Girard
- Department of Obstetrics, Gynecology, & Reproductive Sciences, Divisions of Reproductive Sciences and Maternal-Fetal Medicine, Yale School of Medicine, New Haven, Connecticut Maternal and Fetal Health Research Centre, University of Manchester, Manchester, United Kingdom
| | - Vikki M Abrahams
- Department of Obstetrics, Gynecology, & Reproductive Sciences, Divisions of Reproductive Sciences and Maternal-Fetal Medicine, Yale School of Medicine, New Haven, Connecticut
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Cicinelli E, Matteo M, Tinelli R, Lepera A, Alfonso R, Indraccolo U, Marrocchella S, Greco P, Resta L. Prevalence of chronic endometritis in repeated unexplained implantation failure and the IVF success rate after antibiotic therapy. Hum Reprod 2014; 30:323-30. [DOI: 10.1093/humrep/deu292] [Citation(s) in RCA: 242] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Racicot K, Kwon JY, Aldo P, Silasi M, Mor G. Understanding the complexity of the immune system during pregnancy. Am J Reprod Immunol 2014; 72:107-16. [PMID: 24995526 DOI: 10.1111/aji.12289] [Citation(s) in RCA: 222] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 06/16/2014] [Indexed: 12/14/2022] Open
Abstract
Progress in our understanding of the role of the maternal immune system during healthy pregnancy will help us better understand the role of the immune system in adverse pregnancy outcomes. In this review, we discuss our present understanding of the 'immunity of pregnancy' in the context of the response to cervical and placental infections and how these responses affect both the mother and the fetus. We discuss novel and challenging concepts that help explain the immunological aspects of pregnancy and how the mother and fetus respond to infection.
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Affiliation(s)
- Karen Racicot
- Division of Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
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Cicinelli E, Matteo M, Tinelli R, Pinto V, Marinaccio M, Indraccolo U, De Ziegler D, Resta L. Chronic endometritis due to common bacteria is prevalent in women with recurrent miscarriage as confirmed by improved pregnancy outcome after antibiotic treatment. Reprod Sci 2014; 21:640-7. [PMID: 24177713 PMCID: PMC3984485 DOI: 10.1177/1933719113508817] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Recurrent miscarriage (RM) is defined as 3 or more miscarriages before 20 weeks' pregnancy. In recent years, interest has been focused on chronic endometritis (CE), a subtle inflammation thought to be associated with RM. We aimed to evaluate the relationships between CE and RM. The records of 360 women with unexplained RM were retrospectively analyzed. Data from hysteroscopy, endometrial histology, endometrial culture, and polymerase chain reaction for chlamydia, performed before and after antibiotic treatment for CE, were analyzed. The occurrence of successful pregnancies within 1 year after treatment was also evaluated. Results showed that 208 (57.8%) women with RM showed CE at hysteroscopy; 190 (91.3%), positive at hysteroscopy, were also positive at histology, and 142 (68.3%) had positive cultures. Common bacteria were found in 110 (77.5%) patients. Mycoplasma and Ureaplasma were found in 36 (25.3%) patients and Chlamydia in 18 patients (12.7%). In 102 (71%) women, antibiogram-based antibiotic treatment normalized hysteroscopy, histology, and cultures (group 1); while in 40 (28.2%) patients, CE was still present at hysteroscopy (group 2). In 16 of the 66 patients positive at hysteroscopy, but not at cultures, the hysteroscopy becomes normal (group 3) after a Centers for Disease Control and Prevention-based therapy; while in 50 women, CE was still present (group 4). One year after treatment, group 1 showed a significantly higher number of pregnancies (78.4%) compared to group 2 (17.5%; P < .001) and group 4 (15.3%; P = .005). The CE is frequent in women with RM. Antibiotic treatment seems to be associated with an improved reproductive outcome.
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Affiliation(s)
- Ettore Cicinelli
- Department of Biomedical and Human Oncological Science (DIMO), 3rd Unit of Obstetrics and Gynecology, University of Bari, Bari, Italy
- Ettore Cicinelli, Department of Biomedical and Human Oncological Science (DIMO), 3rd Unit of Obstetrics and Gynecology, University of Bari, Piazza Giulio Cesare, 70124 Bari, Italy.
| | - Maria Matteo
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Raffaele Tinelli
- Department of Obstetrics and Gynecology, San Bastiano Hospital, Bassano del Grappa, Vicenza, Italy
| | - Vincenzo Pinto
- Department of Biomedical and Human Oncological Science (DIMO), 3rd Unit of Obstetrics and Gynecology, University of Bari, Bari, Italy
| | - Marco Marinaccio
- Department of Biomedical and Human Oncological Science (DIMO), 3rd Unit of Obstetrics and Gynecology, University of Bari, Bari, Italy
| | - Ugo Indraccolo
- Operative Unit of Obstetric and Gynecology of Civitanova Marche, Civitanova Marche, Italy
| | - Dominique De Ziegler
- Department of Obstetrics, Gynecology and Reproductive Medicine, Université Paris Descartes, Paris Sorbonne Cité-Assistance Publique Hôpitaux de Paris, CHU Cochin, Paris, France
| | - Leonardo Resta
- Department of Pathology, University of Bari, Bari, Italy
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Hoang M, Potter JA, Gysler SM, Han CS, Guller S, Norwitz ER, Abrahams VM. Human fetal membranes generate distinct cytokine profiles in response to bacterial Toll-like receptor and nod-like receptor agonists. Biol Reprod 2014; 90:39. [PMID: 24429216 DOI: 10.1095/biolreprod.113.115428] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Bacterial infection-associated inflammation is thought to be a major cause of preterm premature rupture of membranes. Proinflammatory cytokines, such as interleukin 1B (IL1B), can weaken fetal membranes (FM) by upregulating matrix metalloproteinases and inducing apoptosis. The mechanism by which infection leads to inflammation at the maternal-fetal interface and subsequent preterm birth is thought to involve innate immune pattern recognition receptors (PRR), such as the Toll-like receptors (TLR) and Nod-like receptors (NLR), which recognize pathogen-associated molecular patterns (PAMPs). The objective of this study was to determine the cytokine profile generated by FMs in response to the bacterial TLR and NLR agonists peptidoglycan (PDG; TLR2), lipopolysaccharide (LPS; TLR4), flagellin (TLR5), CpG ODN (TLR9), iE-DAP (Nod1), and MDP (Nod2). PDG, LPS, flagellin, iE-DAP, and MDP triggered FMs to generate an inflammatory response, but the cytokine profiles were distinct for each TLR and NLR agonist, and only IL1B and RANTES were commonly upregulated in response to all five PAMPs. CpG ODN, in contrast, had a mild stimulatory effect only on MCP-1 and primarily downregulated basal FM cytokine production. IL1B secretion induced by PDG, LPS, flagellin, iE-DAP, and MDP was associated with its processing. Furthermore, FM IL1B secretion in response to TLR2, TLR4, and TLR5 activation was caspase 1-dependent, whereas Nod1 and Nod2 induced IL1B secretion independent of caspase 1. These findings demonstrate that FMs respond to different bacterial TLR and NLR PAMPs by generating distinct inflammatory cytokine profiles through distinct mechanisms that are specific to the innate immune PRR activated.
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Affiliation(s)
- Mai Hoang
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
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The hysteroscopy and histological diagnosis and treatment value of chronic endometritis in recurrent implantation failure patients. Arch Gynecol Obstet 2014; 289:1363-9. [PMID: 24395012 DOI: 10.1007/s00404-013-3131-2] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 12/11/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE To study the consistency of hysteroscopy findings and histological chronic endometritis (CE) in recurrent implantation failure (RIF) cases, and to compare their values in indicating antibiotic treatment. METHODS Sixty RIF cases (January 2009-January 2010) and 202 consecutive RIF cases (May 2010-April 2012) in Peking University Third Hospital reproductive medical center were studied. 60 RIF patients' endometrial samples redid section and CD38/CD138 immunohistochemical stain for CE screening. In 202 RIF cases, the presence of hyperemia, mucosal edema, and micropolyps under hysteroscopy were considered CE diagnostic parameters. Antibiotic was offered to part of the patients. The patients' clinical outcomes were analyzed by statistical methods. RESULTS In 202 RIF cases, the hysteroscopy CE rate was 66.3 %, while histological CE rate was 43.6 %. The sensitivity and specificity of hysteroscopy were 35.2 and 67.5 %. In histological CE patients, 68 cases underwent regular antibiotic treatment and 20 did not. Two groups had similar clinical pregnancy rates (35.3 vs. 30.0 %), embryo implantation rates (18.9 vs. 20.4 %) and ongoing pregnancy rates (29.4 vs. 25.0 %). In hysteroscopy CE patients, the implantation rate (18.6 vs. 4.9 %) and ongoing pregnancy rate (29.3 vs. 7.4 %) significantly increased (P < 0.05) with antibiotic treatment, and higher intrauterine pregnancy rate in treatment group (29.3 vs. 11.1 %). In reviewing the chosen 60 RIF cases, the histological CE rates were similar in both pregnancy and non-pregnancy group after subsequent embryo transfer. CONCLUSIONS CE occurs frequently in RIF patients; hysteroscopy has more diagnostic and treatment value for them.
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Racicot K, Cardenas I, Wünsche V, Aldo P, Guller S, Means R, Romero R, Mor G. Viral infection of the pregnant cervix predisposes to ascending bacterial infection. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2013; 191:934-41. [PMID: 23752614 PMCID: PMC4153356 DOI: 10.4049/jimmunol.1300661] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Preterm birth is the major cause of neonatal mortality and morbidity, and bacterial infections that ascend from the lower female reproductive tract are the most common route of uterine infection leading to preterm birth. The uterus and growing fetus are protected from ascending infection by the cervix, which controls and limits microbial access by the production of mucus, cytokines, and antimicrobial peptides. If this barrier is compromised, bacteria may enter the uterine cavity, leading to preterm birth. Using a mouse model, we demonstrate, to our knowledge for the first time, that viral infection of the cervix during pregnancy reduces the capacity of the female reproductive tract to prevent bacterial infection of the uterus. This is due to differences in susceptibility of the cervix to infection by virus during pregnancy and the associated changes in TLR and antimicrobial peptide expression and function. We suggest that preterm labor is a polymicrobial disease, which requires a multifactorial approach for its prevention and treatment.
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Affiliation(s)
- Karen Racicot
- Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, CT
| | - Ingrid Cardenas
- Department of Obstetrics and Gynecology Tuffs University, Boston MA
| | - Vera Wünsche
- Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, CT
| | - Paulomi Aldo
- Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, CT
| | - Seth Guller
- Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, CT
| | - Robert Means
- Department of Pathology, Yale School of Medicine, New Haven, CT
| | - Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, DHHS, Detroit
| | - Gil Mor
- Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, CT
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Krikun G, Potter JA, Abrahams VM. Human endometrial endothelial cells generate distinct inflammatory and antiviral responses to the TLR3 agonist, Poly(I:C) and the TLR8 agonist, viral ssRNA. Am J Reprod Immunol 2013; 70:190-8. [PMID: 23621614 DOI: 10.1111/aji.12128] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 03/27/2013] [Indexed: 12/25/2022] Open
Abstract
PROBLEM Human endometrial endothelial cell (HEEC) innate immunity remains poorly characterized. Based on their direct contact with the circulation, HEECs are uniquely positioned to be exposed to viral infections. This study evaluated the innate immune response generated by HEECs after exposure to the TLR3 agonist, Poly(I:C) and the TLR8 agonist, viral ssRNA. METHOD OF STUDY HEECs were treated with or without Poly(I:C) or ssRNA. Culture supernatants were measured for cytokines by multiplex analysis. RNA was analyzed by qRT-PCR for type I interferons and antiviral factors. RESULTS Treatment of HEECs with Poly(I:C) rapidly upregulated the secretion of IL-2, IL-6, IL-8, IFN-γ, G-CSF, GM-CSF, MCP-1, MIP-1β, RANTES, and GRO-α after 12 hr, while ssRNA treatment induced the slower secretion of IL-6, IL-8, IFN-γ, G-CSF, VEGF, and GRO-α after 24 hr. Both viral components induced HEEC IFN-α and IFN-β expression. While treatment with Poly(I:C) induced APOBEC3G and OAS expression, treatment with ssRNA upregulated APOBEC3G and M×A mRNA. CONCLUSION Our findings demonstrate that HEECs can differentially sense and respond to viral components by generating distinct inflammatory and antiviral immune responses, indicating that these cells likely play an active role in the immune protection of the uterus toward viral infections.
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Affiliation(s)
- Graciela Krikun
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
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42
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Presence of a polymicrobial endometrial biofilm in patients with bacterial vaginosis. PLoS One 2013; 8:e53997. [PMID: 23320114 PMCID: PMC3540019 DOI: 10.1371/journal.pone.0053997] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 12/07/2012] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To assess whether the bacterial vaginosis biofilm extends into the upper female genital tract. STUDY DESIGN Endometrial samples obtained during curettage and fallopian tube samples obtained during salpingectomy were collected. Endometrial and fallopian tube samples were analyzed for the presence of bacteria with fluorescence-in-situ-hybridisation (FISH) analysis with probes targeting bacterial vaginosis-associated and other bacteria. RESULTS A structured polymicrobial Gardnerella vaginalis biofilm could be detected in part of the endometrial and fallopian tube specimens. Women with bacterial vaginosis had a 50.0% (95% CI 24.0-76.0) risk of presenting with an endometrial Gardnerella vaginalis biofilm. Pregnancy (AOR = 41.5, 95% CI 5.0-341.9, p<0.001) and the presence of bacterial vaginosis (AOR = 23.2, 95% CI 2.6-205.9, p<0.001) were highly predictive of the presence of uterine or fallopian bacterial colonisation when compared to non-pregnant women without bacterial vaginosis. CONCLUSION Bacterial vaginosis is frequently associated with the presence of a structured polymicrobial Gardnerella vaginalis biofilm attached to the endometrium. This may have major implications for our understanding of the pathogenesis of adverse pregnancy outcome in association with bacterial vaginosis.
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Castro AS, Alves CMOS, Angeloni MB, Gomes AO, Barbosa BF, Franco PS, Silva DAO, Martins-Filho OA, Mineo JR, Mineo TWP, Ferro EAV. Trophoblast cells are able to regulate monocyte activity to control Toxoplasma gondii infection. Placenta 2013; 34:240-7. [PMID: 23294571 DOI: 10.1016/j.placenta.2012.12.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 11/30/2012] [Accepted: 12/12/2012] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Toxoplasma gondii is an intracellular parasite that causes severe disease when the infection occurs during pregnancy. Trophoblast cells constitute an important maternal-fetal barrier, with monocytes concentrating around them. Thus, interactions between trophoblasts and monocytes are important for maintaining a successful pregnancy, especially in cases of infection. This study aimed to evaluate the role of trophoblast cells (BeWo line) on monocyte (THP-1 line) activity in the presence or absence of T. gondii infection. METHODS THP-1 cells were stimulated with supernatants of BeWo cells, previously infected or not with T. gondii, and then infected with parasites. The supernatant of both cells were collected and analyzed for cytokine production and T. gondii proliferation in THP-1 cells was determined. RESULTS The results showed that after infection, the pattern of cytokines secreted by THP-1 and BeWo cells was characterized as a pro-inflammatory profile. Furthermore, supernatant of BeWo cells infected or not, was able to change the cytokine profile secreted by infected THP-1 cells, and this supernatant became THP-1 cells more able to control T. gondii proliferation than those that had not been stimulated. DISCUSSION This effect was associated with secretion of interleukin (IL)-6 by the THP-1 cells and soluble factors secreted by BeWo cells, such as IL-6 and MIF. CONCLUSION Together, these results suggest that trophoblast cells are able to modulate monocyte activity, resulting in the control of T. gondii infection and subsequent maintenance of pregnancy.
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Affiliation(s)
- A S Castro
- Laboratory of Histology and Embryology, Institute of Biomedical Sciences, Federal University of Uberlândia, Av. Pará, 1720, 38405-320 Uberlândia, MG, Brazil.
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Romero R, Yeo L, Miranda J, Hassan S, Conde-Agudelo A, Chaiworapongsa T. A blueprint for the prevention of preterm birth: vaginal progesterone in women with a short cervix. J Perinat Med 2013; 41:27-44. [PMID: 23314512 PMCID: PMC4151573 DOI: 10.1515/jpm-2012-0272] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 12/07/2012] [Indexed: 12/11/2022]
Abstract
Preterm birth is the leading cause of perinatal morbidity and mortality worldwide, and is the most important challenge to modern obstetrics. A major obstacle has been that preterm birth is treated (implicitly or explicitly) as a single condition. Two thirds of preterm births occur after the spontaneous onset of labor, and the remaining one third after "indicated" preterm birth; however, the causes of spontaneous preterm labor and "indicated" preterm birth are different. Spontaneous preterm birth is a syndrome caused by multiple etiologies, one of which is a decline in progesterone action, which induces cervical ripening. A sonographic short cervix (identified in the midtrimester) is a powerful predictor of spontaneous preterm delivery. Randomized clinical trials and individual patient meta-analyses have shown that vaginal progesterone reduces the rate of preterm delivery at <33 weeks of gestation by 44%, along with the rate of admission to the neonatal intensive care unit, respiratory distress syndrome, requirement for mechanical ventilation, and composite neonatal morbidity/mortality score. There is no evidence that 17-α-hydroxyprogesterone caproate can reduce the rate of preterm delivery in women with a short cervix, and therefore, the compound of choice is natural progesterone (not the synthetic progestin). Routine assessment of the risk of preterm birth with cervical ultrasound coupled with vaginal progesterone for women with a short cervix is cost-effective, and the implementation of such a policy is urgently needed. Vaginal progesterone is as effective as cervical cerclage in reducing the rate of preterm delivery in women with a singleton gestation, history of preterm birth, and a short cervix (<25 mm).
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, MD, USA.
| | - Lami Yeo
- Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, Maryland, and Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Jezid Miranda
- Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Sonia Hassan
- Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, Maryland, and Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Agustin Conde-Agudelo
- Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, Maryland, and Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
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Abrahams VM, Potter JA, Bhat G, Peltier MR, Saade G, Menon R. Bacterial modulation of human fetal membrane Toll-like receptor expression. Am J Reprod Immunol 2012; 69:33-40. [PMID: 22967004 DOI: 10.1111/aji.12016] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 08/01/2012] [Indexed: 01/04/2023] Open
Abstract
PROBLEM Preterm premature rupture of fetal membranes (pPROM) occurs in 30-40% of spontaneous preterm births (PTB) and is associated with intra-amniotic infection and inflammation. The membranes may sense and respond to microbes via Toll-like receptors (TLRs); however, little is known about their expression and regulation in this tissue. The objective of this study was to evaluate the expression of TLRs 1-10 in fetal membranes after exposure to pathogens associated with intra-amniotic infection and PTB. METHOD OF STUDY Normal human term fetal membrane explants were exposed to various bacteria. After 24 hrs, RNA was extracted and quantitative RT-PCR performed for TLRs1-10. RESULTS Treatment of fetal membranes with Mycoplasma hominis increased expression of TLR4, TLR6, and TLR8 mRNA. Ureaplasma parvum upregulated TLR8 mRNA, and Porphyromonas gingivalis significantly increased fetal membrane TLR7 expression. In contrast, treatment with Gram-negative Escherichia coli (and its cell wall component lipopolysaccharide) downregulated TLR10 mRNA. No effect was detected for Ureaplasma urealyticum, Gardnerella vaginalis, or Group B Streptococcus. CONCLUSION These findings demonstrate that different types of bacteria have distinct effects on fetal membrane TLR expression patterns. Moreover, these findings highlight the disparity of fetal membrane responses to infection and thus suggest heterogeneity in the mechanisms by which infection-associated pregnancy complications, such as pPROM and PTB, arise.
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Affiliation(s)
- Vikki M Abrahams
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT 06510, USA.
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Radtke AL, Quayle AJ, Herbst-Kralovetz MM. Microbial products alter the expression of membrane-associated mucin and antimicrobial peptides in a three-dimensional human endocervical epithelial cell model. Biol Reprod 2012; 87:132. [PMID: 23053434 PMCID: PMC4435425 DOI: 10.1095/biolreprod.112.103366] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 08/02/2012] [Accepted: 10/05/2012] [Indexed: 11/01/2022] Open
Abstract
Our understanding of the mechanisms that regulate tissue-specific mucosal defense can be limited by the lack of appropriate human in vitro models. The endocervix lies between the microbe-rich vaginal cavity and the relatively sterile endometrium and is a major portal of entry for Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, human immunodeficiency virus (HIV), and herpes simplex virus (HSV) infection in women. The endocervix is lined with a simple epithelium, and these cells produce mucus, which plays a key role in immune defense and reproduction. Here we describe the development of a human three-dimensional endocervical epithelial cell model generated by rotating wall vessel bioreactor technology. The model is composed of cellular aggregates that recapitulate major structural and barrier properties essential for the function and protection of the endocervix, including junctional complexes, microvilli, innate immune receptors, antimicrobial peptides, and mucins, the major structural component of mucus. Using this model, we also report, for the first time, that the membrane-associated mucin genes MUC1, MUC4, and MUC16 are differentially regulated in these aggregates by different bacterial and viral products. Differential induction of antimicrobial peptides was also observed with these products. Together these data define unique and flexible innate endocervical immune signatures that follow exposure to microbial products and that likely play a critical role in the outcome of pathogen challenge at this site.
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Affiliation(s)
- Andrea L. Radtke
- Department of Basic Medical Sciences, University of Arizona College of Medicine–Phoenix, Phoenix, Arizona
| | - Alison J. Quayle
- Department of Microbiology, Immunology, and Parasitology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
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Abstract
Preterm birth (delivery before 37 completed weeks of gestation) is common and rates are increasing. In the past, medical efforts focused on ameliorating the consequences of prematurity rather than preventing its occurrence. This approach resulted in improved neonatal outcomes, but it remains costly in terms of both the suffering of infants and their families and the economic burden on society. Increased understanding of the pathophysiology of preterm labor has altered the approach to this problem, with increased focus on preventive strategies. Primary prevention is a limited strategy which involves public education, smoking cessation, improved nutritional status and avoidance of late preterm births. Secondary prevention focuses on recurrent preterm birth which is the most recognisable risk factor. Widely accepted strategies include cervical cerclage, progesterone and dedicated clinics. However, more research is needed to explore the role of antibiotics and anti-inflammatory treatments in the prevention of this complex problem.
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Affiliation(s)
- Karen Flood
- Royal College of Surgeons in Ireland, Department of Obstetrics and Gynaecology, Dublin, Ireland
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Abstract
Preterm labor is defined as labor that begins before 37 completed weeks of pregnancy. More than 12% of infants born in the USA are preterm. At least 40% of preterm births are associated with intrauterine infection. Toll-like receptors (TLRs) are members of a family of cell-surface proteins responsible for recognition of a diverse spectrum of bacterial, viral and fungal pathogens. TLRs initiate the host innate (i.e. non-adaptive) immune response, inducing a proinflammatory cascade involving cytokines, chemokines, prostaglandins, and other effector molecules that result in the characteristic phenomena of labor, such as uterine contractions and rupture of fetal membranes. These cascades may also be activated by mechanisms that are not primarily infectious but are accompanied by inflammatory responses. Now that the molecular mechanisms linking infection and labor have been, to a large extent, elucidated, the challenge is to identify points of overlap with non-infectious causes of labor and to find intervention strategies that can minimize the negative impact of preterm delivery.
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Affiliation(s)
- Varkha Agrawal
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Emmet Hirsch
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201, USA
- Department of Obstetrics and Gynecology, Pritzker School of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
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Abstract
Acute chorioamnionitis is the principal antecedent of premature birth and an important contributor to specific neonatal and other complications that may extend throughout subsequent life. A large number of studies have addressed surrogate markers of in-utero inflammation including cytokines, chemokines, pathogen-associated molecular patterns, and elicited host proteins. However, chorioamnionitis means inflammation occurring within the chorioamnion and the only practical direct measure available to assess this finding in most placentas is histopathology. The maternal and fetal inflammatory response to the presence of organisms within the placental membranes, so-called histologic chorioamnionitis, is the focus of this review. The issues addressed are the nature and origin of the eliciting antigen, mode of spread to the placenta, general characteristics of placental immunity, and a specific characterization of the spectrum of pathologic lesions observed in placentas with membrane infection.
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Affiliation(s)
- Raymond W Redline
- Pediatric and Perinatal Pathology, Case Western Reserve University School of Medicine, OH 44106, USA.
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Cicinelli E, Ballini A, Marinaccio M, Poliseno A, Coscia MF, Monno R, De Vito D. Microbiological findings in endometrial specimen: our experience. Arch Gynecol Obstet 2011; 285:1325-9. [PMID: 22113463 DOI: 10.1007/s00404-011-2138-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 11/02/2011] [Indexed: 11/28/2022]
Abstract
PURPOSE Collection of an endometrial specimen for investigating infectious agents in the endometrial cavity is an invasive technique that is at times difficult and painful. In order to avoid the need for endometrial sampling in the cases of suspected or evident endometrial pathology, the aim of this study is to investigate the reliability of cervical cultures for detecting infectious agents present at the endometrial level, comparing the results between cervical cultures and endometrial cultures in women with clinical signs of endometrial inflammation. METHODS In a prospective diagnostic study, in the period from January 2009 to October 2010, we enrolled 404 women referred to the Department of Obstetrics and Gynecology for diagnostic hysteroscopy. All the patients underwent cervical and endometrial sampling. Cultures for common bacteria, Neisseria gonorrhoeae, yeast, and Ureaplasma urealyticum were performed. RESULTS The most frequent infectious agents detected at the endometrial level were common bacteria, which accounted for 69% of all cases. In particular, streptococci were found in 27% of cases, and bacteria from intestinal flora (Enterococcus faecalis and Escherichia coli) was recovered in 31% of cases. U. urealyticum was detected in 10% and Mycoplasma in only one patient (0.2% of cases). No cases of N. gonorrhoeae were found. CONCLUSIONS Cervical culture has a low concordance with endometrial culture. In fact in only 33% of cases was the microorganism found in the cervix the same as that found in the endometrium. These results infer that an endometrial culture is a useful investigative tool for determining the microorganisms in endometrial pathology.
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Affiliation(s)
- Ettore Cicinelli
- Department of Obstetrics and Gynecology, University of Bari Aldo Moro, Bari, Italy
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