The fetal inflammatory response syndrome: the origins of a concept, pathophysiology, diagnosis, and obstetrical implications

Ascending Vaginal Infection in Mice Induces Preterm Birth and Neonatal Morbidity

Preterm birth (PTB; delivery before 37 weeks), the main cause of neonatal death worldwide, can lead to adverse neurodevelopmental outcomes, as well as lung and gut pathology. PTB can be associated with ascending vaginal infection. Ascending Escherichia coli infection in pregnant mice induces PTB and reduces pup survival. The current study demonstrated that this model recapitulates the pathology observed in human preterm neonates (namely, neuroinflammation, lung injury, and gut inflammation). In neonatal brains, there is widespread cell death, microglial activation, astrogliosis, and reduced neuronal density. The utility of this model was validated by assessing the efficacy of maternal cervical gene therapy with an adeno-associated viral vector containing human β defensin 3. This improved pup survival and reduced tumor necrosis factor alpha mRNA expression in perinatal pup brains exposed to E. coli. This model provides a unique opportunity to evaluate the therapeutic benefit of preterm labor interventions on perinatal pathology.

Interactions among factors affecting stillbirths in Egyptian buffaloes (Bubalus bubalis)

In buffaloes, stillbirth (SB) is a major source of reproductive and economic losses. Hence, the objectives of this study were: 1) investigating the relationship between potential risk factors (body condition score [BCS], gestation period, calving season, calf sex, and dam parity) and SB occurrence in Egyptian buffaloes; and 2) identifying blood metabolites, the redox status, and immune-inflammatory attributes in calves that may be related to SB. The incidence of SB was 6.64%. Among the evaluated risk factors, BCS was a significant risk factor for SB. There was a 73.7% lower odds (lower odds odd ratio, OR = 0.246) of SB for dams with a gestation length ≥ 305 days, compared to those with a gestation length < 305 days. The risk of SB decreased steadily with increasing dam parity. The odds of SB were 2.48 times higher in male calves compared to female calves. In comparison to the spring season, the probability of SB doubled during the summer season. Calf blood serum analysis showed that SB-born calves had higher blood biochemical and cytokines alterations than normal-born calves. On the other hand, immunoglobulins and glutathione peroxidase were significantly lower in SB-born calves. Our results indicated that factors related to the induction of inflammation and/or disrupted immune system responses, such as obesity, high temperature, and oxidative stress, are the main evoking factors for SB in buffaloes; therefore, protective measures against SB in Egyptian buffaloes should be based on controlling these factors, either by nutritional interventions or management practices.

The accuracy of presepsin in diagnosing neonatal late-onset sepsis in critically ill neonates: a prospective study

OBJECTIVES

The diagnostic accuracy of presepsin (P-SEP) in the newborn is still under evaluation.

METHODS

In a multicenter study, we studied the accuracy of P-SEP as a diagnostic marker of late-onset sepsis (LOS) in critical newborns with underlying disorders, to define the most accurate cut-off to distinguish infected from uninfected patients.

RESULTS

Sixty-nine/351 newborns without infections at admission developed LOS. The median P-SEP value at T0 (admission) was 518.0 ng/L (IQR 313.0-789.0), without significant differences related to underlying diseases (p=0.52). In neonates who developed LOS, P-SEP increased at the onset of infection (T1) (median: 816.0 ng/L) and after 24-48 h (median: 901.0 ng/L) compared with their value at admission (median: 560.0 ng/L) (p<0.01 and p=0.03, respectively). The area under the ROC curve at T1 was 0.71 (95 % CI 0.65-0.78) when all cases of sepsis were included in the analysis and increased to 0.74 (95 % CI 0.66-0.81) considering only confirmed sepsis. Approximately two-thirds of patients were correctly classified, setting the cut-off at 713 ng/L, with a negative predictive value of 89.0 %.

CONCLUSIONS

At a cut-off of 713 ng/L, P-SEP has good accuracy in diagnosing LOS in critically ill newborns. In uninfected newborns, the median value of P-SEP is not influenced by any underlying pathology.

Placental histology for infants with hypoxic ischaemic encephalopathy compared with healthy controls: a case-control study

BACKGROUND

The role of the placenta in the development of hypoxic ischaemic encephalopathy (HIE) remains undefined. There is limited research comparing placental histology for infants with HIE and healthy controls. This is limiting our ability to understand its role in HIE. This study hypothesised that placental pathology is more common in infants with HIE compared with healthy infants and aimed to report the differences in placental histology between infants with HIE and healthy controls.

METHODS

A case-control study of infants with moderate andsevere HIE and healthy controls at a single tertiary Neonatal Intensive Care Unit. Placental histology was reviewed by one perinatal histopathologist using consensus guidelines.

RESULTS

Seventy-four cases and 98 controls were included. Cases had a higher incidence of pathology, including fetal vascular malperfusion, histological chorioamnionitis and delayed villous maturation.

CONCLUSION

This study demonstrates a higher incidence of placental pathology for infants born with HIE suggesting that the placenta is an important factor in the pathogenesis of HIE. Further research is required to delineate this relationship.

Systemic Inflammatory Response Syndrome, Thromboinflammation, and Septic Shock in Fetuses and Neonates

This article explores systemic inflammatory response syndrome (SIRS), thromboinflammation, and septic shock in fetuses and neonates, offering a comprehensive examination of their pathophysiology, diagnostic criteria, and clinical implications. It identifies SIRS as an exaggerated response to external stress, disrupting the balance between inflammation and adaptive mechanisms, driven by cytokines such as TNF-α and IL-1. The fetal inflammatory response syndrome (FIRS), a subset of SIRS, is noted for its role in adverse neonatal outcomes, including organ damage, inflammation, and long-term developmental disorders. The article discusses the extensive effects of FIRS on critical systems, including the blood, lungs, central nervous system, and kidneys. It highlights the challenges in diagnosing and managing septic shock in neonates, focusing on the relationship between inflammation and the hemostatic system. Additionally, the paper points out recent advancements, such as the convergent model of coagulation and emerging biomarkers like microRNAs for early detection. Despite this progress, gaps remain in understanding the molecular mechanisms underlying these conditions and in developing effective therapeutic strategies. This highlights the necessity for targeted research to mitigate the morbidity and mortality associated with septic shock in neonates.

Systemic inflammatory responses to repeated and increasing endotoxin challenges in fetal sheep

Repeated low-dose administration of lipopolysaccharide (LPS) attenuates subsequent fetal responses, which makes it challenging to investigate interventions to prolonged exposure. Our aim was to develop a fetal inflammatory response syndrome (FIRS) model that consistently and effectively elicits a marked physiological response to increasing LPS doses. Four intravenous LPS boluses (0.3, 1.5, 3, and 15 μg) were administered to fetal sheep over 5 days. Physiological responses were measured via blood gases, pH, lactate, and cortisol concentrations. Fetal peripheral blood mononuclear cells (PBMCs) were analyzed for transcriptomic changes and tissue cytokine expression postmortem. All LPS challenges increased lactate, cortisol, and pCO2 concentrations and decreased pH and pO2 levels at 3 and 5 hours. No interaction was found between day (increasing LPS doses) and hour (LPS response to each dose). PBMC numbers increase with LPS challenges. Transcriptional analysis on PBMCs identified several enriched gene clusters indicating upregulation of inflammatory gene signatures along with complement activation and NFκB signaling pathways. Expression of pro-inflammatory cytokines (TNFα, IL-6, or IL-1β) was measured in lung, heart, liver, placenta, and spleen. Physiological indices show both respiratory and metabolic acidosis with successive and increasing LPS challenges that demonstrate a robust systemic response despite tachyphylaxis to LPS in fetal sheep.

Whole blood biophysical immune profiling of newborn infants correlates with immune responses

BACKGROUND

There is a current, absence of reliable, blood-sparing, diagnostic tools to measure and trend real-time changes in the levels of inflammation and its effects on the immune cells in the infant.

METHODS

We deployed the BiophysicaL Immune Profiling for Infants (BLIPI) system in the neonatal intensive care unit to describe immune cell biophysical profiles using 50 microliters of blood per sample from term and preterm infants.

RESULTS

A total of 19 infants (8 term, 11 preterm) were recruited and 24 blood samples were collected in their first month. Based on the profiles of immune cells' size and deformation, there was a clear distinction between term and preterm infants, with 48/50 markers significantly different. A preterm infant with late-onset bacterial sepsis had notable size and deformability differences compared to the rest of the preterm cohort. There was a significant correlation between immune cell biophysical profiles and clinical markers such as C-reactive protein, white blood cell counts, and immature-to-total neutrophil (I:T) ratios, with Pearson correlation coefficients for linear regression models of 0.98, 0.97 and 0.94 respectively.

CONCLUSION

This study highlights the potential for the biophysical immune cell profiling system to provide an overview of the infant's current immune activation and response.

IMPACT

We present a novel, minimally invasive diagnostic system that leverages the physical properties of immune cells to provide a rapid and direct assessment of the immune status, requiring 20 times less blood volume than standard tests. This study demonstrates the potential of a compact, deployable system that is capable of performing biophysical profiling to assess immune cell activation in term and preterm infants, by revealing distinct differences in cell size and deformation between groups. The system's sensitive, quantitative measures were correlated with routine clinical biomarkers, highlighting its ability to provide a rapid, minimally invasive, real-time monitoring of neonatal immune status.

Placental Molecular Expression of Different Pathogenic Vaginal Infections

This study evaluated the differential expression of four placental markers-vitamin D receptor (VDR), Cluster of Differentiation 44 (CD44), osteopontin (OPN), and cyclooxygenase-2 (COX-2)-in response to pathogens, which may contribute to our understanding of pathogen-specific impacts on pregnancy outcomes. We immunohistochemically (IHC) analyzed placental tissues obtained from 70 healthy-term pregnant women in the control group and compared them to tissues obtained from 78 women with pregnancy above 24 weeks of gestation, single-pathogen vaginal infection, and premature rupture of membranes/preterm premature rupture of membranes (PROM/PPROM). We detected high expression of these four molecules in cases of Group B Streptococcus (GBS) and Ureaplasma urealyticum vaginal infections, and moderate expression in cases of Enterobacteriaceae infections, except for Klebsiella; the cases with Klebsiella and Candida species (spp.) vaginitis exhibited a lower expression compared to the healthy control group. VDR, CD44, and OPN had increased placental expression in GBS and Ureaplasma urealyticum vaginal infections; the opportunistic pathogenicity of both Escherichia coli and Candida spp. explains their low IHC positivity, and the tremendous ability of Gram-negative bacteria to elude the host immunity is revealed by the negative IHC staining in cases of Klebsiella vaginitis. These findings suggest that pathogen-specific alterations in the expression of these markers may contribute to the differential risk stratification of pregnancy complications and may mitigate the risks of adverse maternal and fetal outcomes. Interventions aiming to modulate these pathways might improve pregnancy outcomes.

Immunological role of zinc in preterm neonates

Zinc (Zn), an essential trace element, plays a significant role in fetal development and biological defense during the embryonic and neonatal periods. Therefore, exploring the kinetics of Zn related to immune disturbances in preterm neonates is important. We here performed the measurement of Zn concentration along with immunological analysis of neonates and investigated the role of Zn in the neonatal period. Serum Zn concentrations were measured immediately after birth in neonates (329 cases). Moreover, for 25 cases, the kinetics of various immune cells and cytokines were measured by flow cytometry and electrochemiluminescence. We observed that Zn levels were inversely correlated with gestational weeks. Immune cell and cytokine analysis revealed an inverse correlation between HLA-DR on monocytes and Zn levels and between inflammatory cytokine interleukin-12 and Zn levels. Furthermore, oxidative stress status was inversely correlated with Zn levels. Our results suggested that the Zn dynamics immediately after birth, which show a negative correlation with the gestational week, can provide an anti-inflammatory and anti-oxidative environment for preterm neonates. The increased Zn concentration in the blood of preterm neonates may consequently protect neonates from perinatal stress.

Diagnostic Value of Umbilical Cord Blood Interleukin-6 Level in Premature Infants with Early-Onset Sepsis

OBJECTIVE

Early-onset sepsis (EOS) is a serious, grave, and frequently fatal condition in premature infants. This study aimed to assess the diagnostic value of interleukin-6 (IL-6) levels in umbilical cord blood for identifying EOS in preterm infants.

METHODS

This prospective cohort study was conducted on preterm infants between May 2019 and April 2021. Based on the diagnostic criteria for EOS, the participants were divided into EOS and non-EOS groups. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic efficacy of cord blood IL-6 levels for EOS.

RESULTS

The levels of IL-6 were significantly higher in the EOS group (n = 10) compared to the non-EOS group (n = 178) [617.5 pg/mL (323.3, 1579.8) vs. 49.7 pg/mL (15.8, 142.8), respectively; p = 0.000]. ROC curve analysis demonstrated that a cutoff value of 250.5 pg/mL for cord blood IL-6 yielded a sensitivity of 90%, specificity of 82%, and area under the curve of 0.876, with a confidence interval of 0.753-0.999, indicating its high accuracy as a diagnostic marker for EOS among preterm infants (p < 0.001).

CONCLUSIONS

The detection of IL-6 in the umbilical cord blood offers convenience and exhibits significant diagnostic potential for EOS in preterm infants, thereby providing valuable support for clinical decision-making.

Structural Characterization of APSN from Astragalus membranaceus and Its Potential Therapeutic Effect on Immune Dysregulation and Tissue Damage

Addressing the global health impact of inflammatory and immune-mediated diseases, this study focused on purifying and characterizing a neutral polysaccharide, APSN, from the Astragalus membranaceus. Employing high-performance gel permeation chromatography (HPGPC), Fourier-transform infrared spectroscopy (FTIR), and nuclear magnetic resonance (NMR) spectroscopy, we elucidated APSN's structural features, revealing a highly branched glucan with a 1,4-α-d-glucopyranosyl main chain and side chains at the O-6 position. Separately, we assessed APSN's biological activity, finding that it significantly modulates immune responses by inhibiting the NF-κB pathway in RAW264.7 macrophages and promotes endothelial cell proliferation and angiogenesis-related gene expression in HUVECs. These results position APSN as a potential therapeutic for diseases characterized by immune dysregulation and tissue damage, warranting further investigation of its mechanisms and clinical efficacy.

Zika virus-induced fetal demise is driven by strain- and dose-specific RLR-driven activation of the interferon response in the decidua, placenta, and fetus in Ifnar1 -/- mice

Congenital Zika syndrome (CZS), the set of fetal and neonatal complications associated with Zika virus (ZIKV) infection in pregnancy, was first noted during the outbreak in the Americas in 2015-16. However, there was an unequal distribution of ZIKV cases and severe outcomes in all areas where ZIKV emerged in the Americas, demonstrating that the risk of CZS varied over space and time. Recently, we demonstrated that phenotypic heterogeneity existed between closely-related ZIKV strains. All ZIKV strains tested infected the placenta but varied in their capacity to cause overt fetal harm. Here, we further characterized the relative contributions of virus genotype and infecting dose of two phenotypically distinct ZIKV strains across multiple timepoints in gestation in pregnant mice that lack type-I interferon receptor function ( Ifnar1 -/- ). To better understand the underlying causes of adverse fetal outcomes, we used RNA sequencing to compare ZIKV-infected and uninfected tissues. We found that ZIKV infection triggers retinoic acid-inducible gene I (RIG-I)-like receptor-mediated activation of the interferon response at the maternal-fetal interface. However, modest chemical inhibition of RIG-I activation in the decidua and placenta did not protect against fetal demise. Instead, the fetal interferon response was significantly associated with fetal demise. Together, these findings suggest that the response to ZIKV at the maternal-fetal interface can vary depending on the infecting ZIKV genotype and dose, and that the fetal immune response is an important mediator of fetal harm.

IMPORTANCE

Previously, we used a mouse model of ZIKV infection during pregnancy to assess the pathogenic potential to the fetus of a panel of five, low-passage ZIKV strains representing the viral genetic diversity in the Americas. We found that phenotypic heterogeneity existed between these closely-related ZIKV strains. Here, we show that this heterogeneity is driven by retinoic acid-inducible gene I (RIG-I)-like receptor-mediated activation of the interferon response at the maternal-fetal interface. We used chemical inhibition of the RIG-I pathway and measured the transcriptional activity of interferon stimulated genes in fetuses to demonstrate that the fetal immune response may contribute to fetal demise.

Diagnostic tests for the prediction of histological chorioamnionitis and funisitis in pregnant women with preterm premature rupture of membranes: A systematic review

BACKGROUND

Infection of the amniotic cavity is an important driver and/or consequence of preterm prelabour rupture of membranes (PPROM). Prediction of infection is challenging, limiting guidance for interventions during the antenatal period. Infection typically triggers a host inflammatory response, and non-invasive indirect markers of the maternal or fetal inflammatory response have been reported in the context of PPROM and intra-amniotic infection. Some of these markers have also been tested in amniotic fluid (AF) samples.

AIMS

This study compared markers of the inflammatory response in women with PPROM against the outcome standard of histological chorioamnionitis (HCA) or funisitis (FUS).

METHODS

Searches were conducted for studies reporting diagnostic test sensitivity and specificity for proven HCA or FUS in pregnant women with PPROM after 20 weeks' gestation. Weighted mean pooled sensitivity (Se), specificity (Sp), positive predictive value, negative predictive value, diagnostic odds ratio and 95% confidence intervals were calculated for each of the selected diagnostic tests.

RESULTS

Except ultrasonographic detection of fetal thymic involution, almost all index tests analysed showed relatively low sensitivity. Maternal white cell count, interleukin-6 (IL-6) and AF IL-6 had credible specificity. Testing of AF markers, while more consistent than serum markers, showed no clear diagnostic accuracy improvement.

CONCLUSIONS

There is a clear lack of evidence for the reliability of any individual diagnostic test to assist in the detection of HCA or FUS in women with PPROM. Combining several markers into a predictive model for improved diagnosis may be worth investigating.

A pragmatic approach to recognize intrapartum chorioamnionitis

Chorioamnionitis is a significant contributor to non-hypoxic fetal compromise, increasing the risk of neonatal encephalopathy and cerebral palsy. This paper highlights the limitations of traditional diagnostic methods for chorioamnionitis, which rely on histopathology, microbiology, and clinical signs, and emphasizes the importance of recognizing the fetal inflammatory response using intrapartum cardiotocography (CTG). By understanding the physiological pathways of inflammation, clinicians can identify characteristic CTG patterns. This pragmatic approach allows for earlier detection and intervention, potentially improving perinatal outcomes. The paper calls for a re-evaluation of clinical management practices and advocates for a multifaceted approach that incorporates CTG findings into the diagnosis of chorioamnionitis to prevent adverse neonatal outcomes.

Analysis of Salivary Cytokines in Retinopathy of Prematurity

BACKGROUND/OBJECTIVES

This cohort study aimed to establish a correlation between salivary cytokines and retinopathy of prematurity (ROP) in premature neonates. Additionally, we sought to identify a minimally invasive method for cytokine detection in this population.

METHODS

We recruited premature neonates born at less than 34 weeks gestational age (GA), with no history of maternal or neonatal infections. Salivary samples were collected on their first (D1) and seventh (D7) days of life, and cytokine levels were measured using the MILLPLEXMAP Human multiplex assay.

RESULTS

A total of 125 neonates were included in the study, categorized into two groups based on the severity of ROP: None to Mild and Moderate to Severe. The salivary levels of interleukin (IL)-6, IL-8, vascular endothelial growth factor (VEGF), and tumor necrosis factor (TNF)-α on D1 and D7 were significantly higher in the Moderate to Severe ROP group compared to the None to Mild ROP group (p = 0.005, 0.004, 0.026, 0.018, 0.001, 0.007, 0.025, and 0.002, respectively). After adjusting for GA, the levels of IL-6 and VEGF on D7 were significantly elevated in the Moderate to Severe ROP group compared to the None to Mild ROP group (p = 0.024 and 0.016, respectively).

CONCLUSIONS

This study establishes a novel, non-invasive method for the early prediction of ROP in premature neonates by correlating salivary cytokine levels in early life with the subsequent development of ROP.

Placental methylation and pro-inflammatory protein levels in cord blood

INTRODUCTION

The neonates' inflammatory response may in part be shaped during development by the placental epigenome, but evidence is scarce. We investigated the association between placental DNA methylation and pro-inflammatory proteins in cord blood.

METHODS

A total of 249 mother-child dyads from the Harvard Epigenetic Birth Cohort were included in this study. Genome-wide methylation in placental DNA was assessed using the Illumina Human Methylation 450 Bead Chip array and verified by pyrosequencing. Cord blood inflammation markers assessed were interleukin-6, interleukin-8 and tumor necrosis factor α, intercellular adhesion molecule 1, serum amyloid A, and C-reactive protein.

RESULTS

We identified differential placental DNA methylation of three loci in the HIVEP3 gene shore region that were associated with TNFα protein levels in cord blood. TNFα levels were associated with mode of delivery, gestational age and birth order. Three other loci located in the open sea region of the BCL11B gene were associated with SAA protein levels in cord blood. SAA levels were associated with birthweight, gestational age, and infant sex.

CONCLUSIONS

Our results suggest a potential role for HIVEP3 and BCL11B placental DNA methylation in the acute immune response of the neonate. These immune markers were correlated with several mother and child characteristics.

Homeostatic Macrophages Prevent Preterm Birth and Improve Neonatal Outcomes by Mitigating In Utero Sterile Inflammation in Mice

Preterm birth (PTB), often preceded by preterm labor, is a major cause of neonatal morbidity and mortality worldwide. Most PTB cases involve intra-amniotic inflammation without detectable microorganisms, termed in utero sterile inflammation, for which there is no established treatment. In this study, we propose homeostatic macrophages to prevent PTB and adverse neonatal outcomes caused by in utero sterile inflammation. Single-cell atlases of the maternal-fetal interface revealed that homeostatic maternal macrophages are reduced with human labor. M2 macrophage treatment prevented PTB and reduced adverse neonatal outcomes in mice with in utero sterile inflammation. Specifically, M2 macrophages halted premature labor by suppressing inflammatory responses in the amniotic cavity, including inflammasome activation, and mitigated placental and offspring lung inflammation. Moreover, M2 macrophages boosted gut inflammation in neonates and improved their ability to fight systemic bacterial infections. Our findings show that M2 macrophages are a promising strategy to mitigate PTB and improve neonatal outcomes resulting from in utero sterile inflammation.

Molecular evidence that GBS early neonatal sepsis results from ascending infection: comparative hybrid genomics analyses show that microorganisms in the vaginal ecosystem, amniotic fluid, chorioamniotic membranes, and neonatal blood are the same

OBJECTIVES

Streptococcus agalactiae, or Group B Streptococcus (GBS), is a leading cause of neonatal sepsis. Materno-fetal transmission of the microorganisms present in the lower genital tract/perineum is considered to be the most frequent mode for acquisition of infection. It has also been proposed that, in a subset of cases, GBS causes acute chorioamnionitis, intraamniotic infection, and fetal/neonatal sepsis. However, the evidence to support this ascending pathway is derived from microbiologic studies that rely on cultivation methods, which do not have the resolution to determine if the microorganisms causing neonatal sepsis are the same as those found in the amniotic fluid and the vaginal ecosystem.

METHODS

We used whole genome sequencing of the microorganisms isolated from the vagina, amniotic fluid, chorioamniotic membranes, and neonatal blood (four isolates) in a case of early neonatal sepsis. Using hybrid genome assembly, we characterized the genomic features including virulence factors and antimicrobial resistance in four isolates from the same mother, placenta, and newborn.

RESULTS

Whole genome sequencing revealed that the microorganisms in the four clinical isolates corresponded to S. agalactiae sequence type 1, clonal complexes 1, and serotype Ib. Comparative genomic analysis illustrated similar DNA sequences of the four genomes.

CONCLUSIONS

This study presents the first evidence of the genomic similarity of microorganisms in the vaginal ecosystem, the space between the chorioamniotic membranes of the placenta, amniotic fluid, and neonatal blood.

Neutrophil phenotypes in prolonged labor: Implications for therapeutic strategies

Prolonged labor, defined as labor extending beyond 20 hours for nulliparas and 14 hours for multiparas, poses significant risks to both maternal and neonatal health. The inflammatory response plays a crucial role in the pathophysiology of prolonged labor, with neutrophils being key players in this process. Neutrophils, the most abundant leukocytes, exhibit diverse phenotypes and functions in response to prolonged labor, influencing both the onset and progression of labor through their inflammatory actions. Classical neutrophils (N1) are involved in acute inflammatory responses, aiding in tissue remodeling and labor onset, but their prolonged activation can lead to tissue damage. Regulatory neutrophils (N2), which produce anti-inflammatory cytokines, help resolve inflammation and facilitate labor progression. Low-density granulocytes and aged neutrophils, associated with chronic inflammation and impaired function respectively, contribute to labor complications. The balance among these neutrophil phenotypes is crucial for maintaining a controlled inflammatory response during labor. Therapeutic strategies targeting neutrophil recruitment, NETosis, and cytokine production hold promise for managing prolonged labor. Modulating chemokine pathways, regulating NET formation, and balancing cytokine profiles may reduce inflammation and improve labor outcomes. Further research into the mechanisms of neutrophil regulation and the development of targeted therapies is essential for mitigating the adverse effects of prolonged labor and enhancing maternal and neonatal health.

Preventive, rescue and reparative neuroprotective strategies for the fetus and neonate

Neonatal encephalopathy remains a major contributor to death and disability around the world. Acute hypoxia-ischaemia before, during or after birth creates a series of events that can lead to neonatal brain injury. Understanding the evolution of injury underpinned the development of therapeutic hypothermia. This review discusses the determinants of injury, including maturity, the pattern of exposure to HI, impaired placental function, often associated with fetal growth restriction and in the long-term, socio-economic deprivation. Chorioamnionitis has been associated with the presence of NE, but it is important to note that experimentally, inflammation can either sensitize to greater neural injury after HI or alleviate injury, depending on its precise timing. As fetal surveillance tools improve it is likely that improved detection of specific pathways will offer future opportunities for preventive and reparative interventions in utero and after birth.

Galectin-1 Elicits a Tissue-Specific Anti-Inflammatory and Anti-Degradative Effect Upon LPS-Induced Response in an Ex Vivo Model of Human Fetal Membranes Modeling an Intraamniotic Inflammation

PROBLEM

Intrauterine infection is one of the most jeopardizing conditions associated with adverse outcomes, including preterm birth; however, multiple tolerance mechanisms operate at the maternal-fetal interface to avoid the rejection of the fetus. Among the factors that maintain the uterus as an immunoprivileged site, Galectin-1 (Gal-1), an immunomodulatory glycan-binding protein secreted by the maternal-fetal unit, is pivotal in promoting immune cell homeostasis. This work aimed to evaluate the role of Gal-1 during a lipopolysaccharide (LPS)-induced-inflammatory milieu.

METHOD OF STUDY

Using an ex vivo culture with two independent compartments, human fetal membranes at term were pretreated with 40 and 80 ng/mL of Gal-1, then to reproduce an intraamniotic inflammation, the fetal side of membranes was stimulated with 500 ng/mL of LPS for 24 h. The concentrations of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, monocyte chemoattractant protein (MCP1), macrophage inflammatory protein (MIP1) α, regulated upon activation normal T cell expressed and secreted (RANTES), and matrix metalloproteinase (MMP)-9 were measured in both amnion and choriodecidua compartments.

RESULTS

In a tissue-specific fashion profile, pretreatment with the physiologic concentration of Gal-1 significantly diminished the LPS-dependent secretion of TNF-α, IL-1β, Il-6, MCP1, MIP1α, RANTES, and MMP-9.

CONCLUSION

Gal-1 elicits an anti-inflammatory effect on the human fetal membranes stimulated with LPS, which supports the hypothesis that Gal-1 is part of the immunomodulatory mechanisms intended to stop the harmful effect of inflammation of the maternal-fetal interface.

Novel Biomarkers: Soluble Urokinase-Type Plasminogen Activator Receptor and Procalcitonin- and Histological Chorioamnionitis after Preterm Premature Rupture of Membranes

Fetal inflammatory response syndrome or infection after preterm premature rupture of membranes (PPROM) increases neonatal morbidity in preterm deliveries. Biochemical markers from the amniotic fluid (AF) have been used to evaluate possible intra-amniotic infection during the asymptomatic phase after PPROM. This study aimed to describe whether soluble urokinase-type plasminogen activator receptor (suPAR) or procalcitonin (PCT) from AF or maternal sera could reveal fetal inflammatory response or infection after PPROM. AF and maternal serum samples were collected weekly after PPROM (23+ 0 - 34+ 6 gestational weeks) until delivery from twenty women and two women with possible chorioamnionitis with intact membranes. Levels of suPAR, PCT, interleukin-6 (IL-6), glucose, lactate dehydrogenase (LDH), and bacterial PCR were determined from AF and suPAR and PCT and IL-6 from maternal sera. Fetal infection or inflammation response were determined by the histology of the placenta after delivery. AF glucose was significantly lower and AF LDH higher in the fetal site histologic chorioamnionitis (HCA) group, while AF suPAR concentrations tended to be higher in this group. AF suPAR correlated significantly with AF glucose and LDH. Based on receiver operating characteristic (ROC) analysis, AF glucose had the best predictability for fetal site histological chorioamnionitis. The findings of AF PCT were insignificant considering HCA. AF glucose had the highest accuracy in predicting fetal site histologic chorioamnionitis. AF suPAR may be a promising marker; however, our findings were limited by a small study population.

Fetal origin of bronchopulmonary dysplasia: contribution of intrauterine inflammation

Bronchopulmonary dysplasia (BPD) is a common chronic lung disease in infants and the most frequent adverse outcome of premature birth, despite major efforts to minimize injury. It is thought to result from aberrant repair response triggered by either prenatal or recurrent postnatal injury to the lungs during development. Intrauterine inflammation is an important risk factor for prenatal lung injury, which is also increasingly linked to BPD. However, the specific mechanisms remain unclear. This review summarizes clinical and animal research linking intrauterine inflammation to BPD. We assess how intrauterine inflammation affects lung alveolarization and vascular development. In addition, we discuss prenatal therapeutic strategies targeting intrauterine inflammation to prevent or treat BPD.

The dual role of glucocorticoid regeneration in inflammation at parturition

Introduction

Fetal membrane inflammation is an integral event of parturition. However, excessive pro-inflammatory cytokines can impose threats to the fetus. Coincidentally, the fetal membranes express abundant 11β-hydroxysteroid dehydrogenase 1 (11β-HSD1), which generates biologically active cortisol to promote labor through induction of prostaglandin synthesis. Given the well-recognized anti-inflammatory actions of glucocorticoids, we hypothesized that cortisol regenerated in the fetal membranes might be engaged in restraining fetus-hazardous pro-inflammatory cytokine production for the safety of the fetus, while reserving pro-labor effect on prostaglandin synthesis to ensure safe delivery of the fetus.

Methods

The hypothesis was examined in human amnion tissue and cultured primary human amnion fibroblasts as well as a mouse model.

Results

11β-HSD1 was significantly increased in the human amnion in infection-induced preterm birth. Studies in human amnion fibroblasts showed that lipopolysaccharide (LPS) induced 11β-HSD1 expression synergistically with cortisol. Cortisol completely blocked NF-κB-mediated pro-inflammatory cytokine expression by LPS, but STAT3-mediated cyclooxygenase 2 expression, a crucial prostaglandin synthetic enzyme, remained. Further studies in pregnant mice showed that corticosterone did not delay LPS-induced preterm birth, but alleviated LPS-induced fetal organ damages, along with increased 11β-HSD1, cyclooxygenase 2, and decreased pro-inflammatory cytokine in the fetal membranes.

Discussion

There is a feed-forward cortisol regeneration in the fetal membranes in infection, and cortisol regenerated restrains pro-inflammatory cytokine expression, while reserves pro-labor effect on prostaglandin synthesis. This dual role of cortisol regeneration can prevent excessive pro-inflammatory cytokine production, while ensure in-time delivery for the safety of the fetus.

Epidemiology and placental pathology of intrauterine fetal demise in a tertiary hospital in the Philippines

Objectives

The Philippines has at least 25,000 stillbirth or intrauterine fetal demise (IUFD) cases every year. Despite its burden, there is scarce information on IUFD epidemiology in the Philippines. Hence, this study reported the epidemiology and placental pathology of IUFD in a tertiary hospital in the Philippines.

Study design

This cross-sectional study analyzed second- and third-trimester IUFD cases at the Philippine General Hospital from 2012 to 2021. We reviewed maternal sociodemographic and clinical characteristics and evaluated placental pathology. All statistical tests were done with GraphPad Prism software version 8.0.

Results

We recorded 947 (2.28 %) cases of IUFD out of 41,562 obstetric deliveries from 2012 to 2021. Out of 947 IUFD cases, 532 had placental pathology reports. Second-trimester IUFD cases showed higher rates of no antenatal care (42.86 %) compared to third-trimester cases (10.61 %). Hypertensive disorders were more common in third-trimester IUFD. Infarcts (23.34 %), calcifications (4.12 %), and hemorrhages/hematomas (3.00 %) were the most prevalent placental abnormalities. While these abnormalities were more common in third-trimester IUFD, placental and fetal membrane infections like chorioamnionitis were more frequent in second-trimester IUFD.

Conclusion

The results highlighted the differences in maternal sociodemographic and clinical characteristics, and placental pathology between second- and third-trimester cases of IUFD. These observations revealed distinct pathological processes and potential etiologies contributing to IUFD in the Philippines.

Changes in Relative Counts of Different Leukocyte Subpopulations in Peripheral and Umbilical Cord Blood of Women With Preterm Prelabor Rupture of Membranes With Respect to Intraamniotic Inflammation and Fetal Inflammatory Response Syndrome

OBJECTIVE

The aim of this study was to evaluate changes in the relative counts of different leukocyte subsets in peripheral and umbilical cord blood in pregnancies complicated by preterm prelabor rupture of membranes (PPROM) with respect to the presence of intraamniotic inflammation (IAI) and fetal inflammatory response syndrome (FIRS).

METHODS

Fifty-two women with singleton pregnancies complicated by PPROM were included in this study. From samples of peripheral and umbilical cord blood, relative counts of these leukocyte subpopulations were determined using multicolor flow cytometry: granulocytes, monocytes, lymphocytes, T cells and their subpopulations, B cells and their subpopulations, and NK cells and their subpopulations. IAI was defined as increased concentrations of interleukin 6 in the amniotic fluid. Amniotic fluid samples were obtained by transabdominal amniocentesis.

RESULTS

Women with IAI had higher relative counts of monocytes (p = 0.04) in peripheral blood. There was an increased relative number of granulocytes (p = 0.003) and a decreased number of lymphocytes (p = 0.0048), helper CD4+ T cells (p = 0.019), NK cells (p = 0.0001) within leukocytes, NK cells within lymphocytes (p = 0.003) and CD16+ NK cells within NK cells (p = 0.005) in umbilical cord blood samples of women with FIRS. However, after adjusting the results for gestational age at sampling, all differences disappeared.

CONCLUSIONS

The presence of IAI or FIRS is not accompanied by significant changes in the relative counts of immune cells in peripheral blood or umbilical cord blood in pregnancies complicated by PPROM.

Two cases of Leukemoid reaction in premature infants caused by fetal inflammatory response syndrome

BACKGROUND

Fetal inflammatory response syndrome (FIRS) is a systemic inflammatory response caused by the activation of the fetal immune system. The serological diagnostic criterion for fetal inflammatory response syndrome is a cord blood interleukin-6 concentration that exceeds 11 pg/mL, while pathologic evidence indicates the presence of funisitis or chorionic vasculitis. It can affect all systems of the fetus. Alterations in patients' hematopoietic system are primarily reflected by changes in peripheral blood leukocyte and neutrophil counts.

CASE PRESENTATION

We performed placental pathology to identify FIRS and showed two cases of neonatal leukemoid reaction caused by FIRS. These two babies' alterations in hematopoietic system resolves spontaneously with the inflammation relief, without specific interventions. During the 16‑month and14- month follow‑up period, their motor and intellectual development was normal.

CONCLUSIONS

. Neonatal leukemoid reaction is a reactive disease characterized by abnormal blood parameters similar to those of leukemia, but not leukemia. It is an aberrant hematopoietic response that typically resolves spontaneously with cause relief without requiring specific interventions.

[Clinical characteristics of Ureaplasma urealyticum infection and colonization in extremely preterm infants]

OBJECTIVES

To investigate the clinical characteristics of Ureaplasma urealyticum (UU) infection and colonization in extremely preterm infants and its impact on the incidence of bronchopulmonary dysplasia (BPD).

METHODS

A retrospective analysis was conducted on 258 extremely preterm infants who were admitted to the Department of Neonatology, Shenzhen Maternity and Child Healthcare Hospital, from September 2018 to September 2022. According to the results of UU nucleic acid testing and the evaluation criteria for UU infection and colonization, the subjects were divided into three groups: UU-negative group (155 infants), UU infection group (70 infants), and UU colonization group (33 infants). The three groups were compared in terms of general information and primary and secondary clinical outcomes.

RESULTS

Compared with the UU-negative group, the UU infection group had significant increases in the incidence rate of BPD, total oxygen supply time, and the length of hospital stay (P<0.05), while there were no significant differences in the incidence rates of BPD and moderate/severe BPD between the UU colonization group and the UU-negative group (P>0.05).

CONCLUSIONS

The impact of UU on the incidence of BPD in extremely preterm infants is associated with the pathogenic state of UU (i.e., infection or colonization), and there are significant increases in the incidence rate of BPD, total oxygen supply time, and the length of hospital stay in extremely preterm infants with UU infection. UU colonization is not associated with the incidence of BPD and moderate/severe BPD in extremely preterm infants.

Neurodevelopmental outcomes in extremely preterm infants with placental pathologic evidence of fetal inflammatroy response

OBJECTIVES

Neonates born with fetal inflammatory response (FIR) are at increased risk for adverse neonatal outcomes. Our objective was to determine whether FIR and its severity is associated with neurodevelopmental impairment (NDI) at 2 years of age or death among preterm infants.

METHODS

A retrospective cohort study of prospectively collected data of all infants born <29 weeks gestational age (GA). FIR and its severity were diagnosed according to the Amsterdam Placental Workshop Group Consensus Statement. Neurodevelopmental outcomes among all participants were quantified according to Bayley III.

RESULTS

Mothers of infants with FIR were significantly younger (P = 0.04) and had a greater prevalence of antenatal steroid use (P < 0.01), infection during pregnancy (P = 0.01), PPROM (P < 0.01), and clinical chorioamnionitis (P < 0.01). Infants with FIR had longer duration of hospitalization (P < 0.01), days on oxygen (P < 0.01), congenital pneumonia (P = 0.03), moderate/severe bronchopulmonary dysplasia (BPD; P < 0.01). Notably, infants with FIR were not at increased risk of NDI or death (primary outcome). Those with moderate to severe FIR (≥ stage 2 FIR) were at increased risk of developing motor & language impairment or death (P < 0.01).

CONCLUSION

This is the first report demonstrating an association between the severity of FIR and subsequent NDI in preterm infants born.

IMPACT STATEMENT

Fetal Inflammatory Response (FIR) is not associated Neurodevelopmental Impairement (NDI) or Death in preterm infants However, there is significant relationship between moderate to severe FIR and NDI at 2 years of age in preterm infants. This is the first study demonstrating the impact of progression and severity of FIR on NDI or Death in preterm infants. These observations provide additional insight into understanding the impact of intrauterine exposure to inflammation on the NDI or death in preterm infants.

Organ-on-a-chip: future of female reproductive pathophysiological models

The female reproductive system comprises the internal and external genitalia, which communicate through intricate endocrine pathways. Besides secreting hormones that maintain the female secondary sexual characteristics, it also produces follicles and offspring. However, the in vitro systems have been very limited in recapitulating the specific anatomy and pathophysiology of women. Organ-on-a-chip technology, based on microfluidics, can better simulate the cellular microenvironment in vivo, opening a new field for the basic and clinical research of female reproductive system diseases. This technology can not only reconstruct the organ structure but also emulate the organ function as much as possible. The precisely controlled fluidic microenvironment provided by microfluidics vividly mimics the complex endocrine hormone crosstalk among various organs of the female reproductive system, making it a powerful preclinical tool and the future of pathophysiological models of the female reproductive system. Here, we review the research on the application of organ-on-a-chip platforms in the female reproductive systems, focusing on the latest progress in developing models that reproduce the physiological functions or disease features of female reproductive organs and tissues, and highlighting the challenges and future directions in this field.

Viral infections in pregnancy and impact on offspring neurodevelopment: mechanisms and lessons learned

Pregnant individuals with viral illness may experience significant morbidity and have higher rates of pregnancy and neonatal complications. With the growing number of viral infections and new viral pandemics, it is important to examine the effects of infection during pregnancy on both the gestational parent and the offspring. Febrile illness and inflammation during pregnancy are correlated with risk for autism, attention deficit/hyperactivity disorder, and developmental delay in the offspring in human and animal models. Historical viral epidemics had limited follow-up of the offspring of affected pregnancies. Infants exposed to seasonal influenza and the 2009 H1N1 influenza virus experienced increased risks of congenital malformations and neuropsychiatric conditions. Zika virus exposure in utero can lead to a spectrum of abnormalities, ranging from severe microcephaly to neurodevelopmental delays which may appear later in childhood and in the absence of Zika-related birth defects. Vertical infection with severe acute respiratory syndrome coronavirus-2 has occurred rarely, but there appears to be a risk for developmental delays in the infants with antenatal exposure. Determining how illness from infection during pregnancy and specific viral pathogens can affect pregnancy and neurodevelopmental outcomes of offspring can better prepare the community to care for these children as they grow. IMPACT: Viral infections have impacted pregnant people and their offspring throughout history. Antenatal exposure to maternal fever and inflammation may increase risk of developmental and neurobehavioral disorders in infants and children. The recent SARS-CoV-2 pandemic stresses the importance of longitudinal studies to follow pregnancies and offspring neurodevelopment.

Value of fetal echocardiographic examination in pregnancies complicated by preterm premature rupture of membranes

OBJECTIVES

Cardiopulmonary and infectious complications are more common in preterm newborns after preterm premature rupture of membranes (pPROM). Fetal echocardiography may be helpful in predicting neonatal condition. Our aim was to assess the cardiovascular changes in fetuses from pregnancies complicated by pPROM and possible utility in predicting the intrauterine or neonatal infection, and neonatal heart failure (HF).

METHODS

It was a prospective study enrolling 46 women with singleton pregnancies complicated by pPROM between 18+0 and 33+6 weeks of gestation and followed until delivery. 46 women with uncomplicated pregnancies served as a control group. Fetal echocardiographic examinations with the assessment of cardiac structure and function (including pulmonary circulation) were performed in all patients.

RESULTS

Mean gestational age of pPROM patients was 26 weeks. Parameters suggesting impaired cardiac function in fetuses from pPROM were: higher right ventricle Tei index (0.48 vs. 0.42 p<0.001), lower blood flow velocity in Ao z-score (0.14 vs. 0.84 p=0.005), lower cardiovascular profile score (CVPS), higher rate of tricuspid regurgitation (18.2 % vs. 4.4 % p=0.04) and pericardial effusion (32.6 vs. 0 %). Intrauterine infection was diagnosed in 18 patients (39 %). 4 (8.7 %) newborns met the criteria of early onset sepsis (EOS). HF was diagnosed in 9 newborns. In fetal echocardiographic examination HF group had shorter mitral valve inflow time and higher left ventricle Tei index (0.58 vs. 0.49 p=0.007).

CONCLUSIONS

Worse cardiac function was observed in fetuses from pPROM compared to fetuses from uncomplicated pregnancies.

Biomaterial strategies for regulating the neuroinflammatory response

Injury and disease in the central nervous system (CNS) can result in a dysregulated inflammatory environment that inhibits the repair of functional tissue. Biomaterials present a promising approach to tackle this complex inhibitory environment and modulate the mechanisms involved in neuroinflammation to halt the progression of secondary injury and promote the repair of functional tissue. In this review, we will cover recent advances in biomaterial strategies, including nanoparticles, hydrogels, implantable scaffolds, and neural probe coatings, that have been used to modulate the innate immune response to injury and disease within the CNS. The stages of inflammation following CNS injury and the main inflammatory contributors involved in common neurodegenerative diseases will be discussed, as understanding the inflammatory response to injury and disease is critical for identifying therapeutic targets and designing effective biomaterial-based treatment strategies. Biomaterials and novel composites will then be discussed with an emphasis on strategies that deliver immunomodulatory agents or utilize cell-material interactions to modulate inflammation and promote functional tissue repair. We will explore the application of these biomaterial-based strategies in the context of nanoparticle- and hydrogel-mediated delivery of small molecule drugs and therapeutic proteins to inflamed nervous tissue, implantation of hydrogels and scaffolds to modulate immune cell behavior and guide axon elongation, and neural probe coatings to mitigate glial scarring and enhance signaling at the tissue-device interface. Finally, we will present a future outlook on the growing role of biomaterial-based strategies for immunomodulation in regenerative medicine and neuroengineering applications in the CNS.

Clinical risk factors for preterm birth and evaluating maternal psychology in the postpartum period

BACKGROUND

Although the specific pathogenesis of preterm birth (PTB) has not been thoroughly clarified, it is known to be related to various factors, such as pregnancy complications, maternal socioeconomic factors, lifestyle habits, reproductive history, environmental and psychological factors, prenatal care, and nutritional status. PTB has serious implications for newborns and families and is associated with high mortality and complications. Therefore, the prediction of PTB risk can facilitate early intervention and reduce its resultant adverse consequences.

AIM

To analyze the risk factors for PTB to establish a PTB risk prediction model and to assess postpartum anxiety and depression in mothers.

METHODS

A retrospective analysis of 648 consecutive parturients who delivered at Shenzhen Bao'an District Songgang People's Hospital between January 2019 and January 2022 was performed. According to the diagnostic criteria for premature infants, the parturients were divided into a PTB group (n = 60) and a full-term (FT) group (n = 588). Puerperae were assessed by the Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS), based on which the mothers with anxiety and depression symptoms were screened for further analysis. The factors affecting PTB were analyzed by univariate analysis, and the related risk factors were identified by logistic regression.

RESULTS

According to univariate analysis, the PTB group was older than the FT group, with a smaller weight change and greater proportions of women who underwent artificial insemination and had gestational diabetes mellitus (P < 0.05). In addition, greater proportions of women with reproductive tract infections and greater white blood cell (WBC) counts (P < 0.05), shorter cervical lengths in the second trimester and lower neutrophil percentages (P < 0.001) were detected in the PTB group than in the FT group. The PTB group exhibited higher postpartum SAS and SDS scores than did the FT group (P < 0.0001), with a higher number of mothers experiencing anxiety and depression (P < 0.001). Multivariate logistic regression analysis revealed that a greater maternal weight change, the presence of gestational diabetes mellitus, a shorter cervical length in the second trimester, a greater WBC count, and the presence of maternal anxiety and depression were risk factors for PTB (P < 0.01). Moreover, the risk score of the FT group was lower than that of the PTB group, and the area under the curve of the risk score for predicting PTB was greater than 0.9.

CONCLUSION

This study highlights the complex interplay between postpartum anxiety and PTB, where maternal anxiety may be a potential risk factor for PTB, with PTB potentially increasing the incidence of postpartum anxiety in mothers. In addition, a greater maternal weight change, the presence of gestational diabetes mellitus, a shorter cervical length, a greater WBC count, and postpartum anxiety and depression were identified as risk factors for PTB.

Distinct cytokine profiles in late pregnancy in Ugandan people with HIV

During pregnancy, multiple immune regulatory mechanisms establish an immune-tolerant environment for the allogeneic fetus, including cellular signals called cytokines that modify immune responses. However, the impact of maternal HIV infection on these responses is incompletely characterized. We analyzed paired maternal and umbilical cord plasma collected during labor from 147 people with HIV taking antiretroviral therapy and 142 HIV-uninfected comparators. Though cytokine concentrations were overall similar between groups, using Partial Least Squares Discriminant Analysis we identified distinct cytokine profiles in each group, driven by higher IL-5 and lower IL-8 and MIP-1α levels in pregnant people with HIV and higher RANTES and E-selectin in HIV-unexposed umbilical cord plasma (P-value < 0.01). Furthermore, maternal RANTES, SDF-α, gro α -KC, IL-6, and IP-10 levels differed significantly by HIV serostatus (P < 0.01). Although global maternal and umbilical cord cytokine profiles differed significantly (P < 0.01), umbilical cord plasma profiles were similar by maternal HIV serostatus. We demonstrate that HIV infection is associated with a distinct maternal plasma cytokine profile which is not transferred across the placenta, indicating a placental role in coordinating local inflammatory response. Furthermore, maternal cytokine profiles in people with HIV suggest an incomplete shift from Th2 to Th1 immune phenotype at the end of pregnancy.

The histologic fetal inflammatory response and neonatal outcomes: systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate the prognostic role of concomitant histological fetal inflammatory response with chorioamnionitis on neonatal outcomes through a systematic review and meta-analysis of existing literature.

DATA SOURCES

The primary search was conducted on October 17, 2021, and it was updated on May 26, 2023, across 4 separate databases (MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, and Scopus) without using any filters.

STUDY ELIGIBILITY CRITERIA

Observational studies reporting obstetrical and neonatal outcomes of infant-mother dyads with histological chorioamnionitis and histological fetal inflammatory response vs infant-mother dyads with histological chorioamnionitis alone were eligible. Studies that enrolled only preterm neonates, studies on neonates born before 37 weeks of gestation, or studies on neonates with very low birthweight (birthweight <1500 g) were included. The protocol was registered with the International Prospective Register of Systematic Reviews (registration number: CRD42021283448).

METHODS

The records were selected by title, abstract, and full text, and disagreements were resolved by consensus. Random-effect model-based pooled odds ratios with corresponding 95% confidence intervals were calculated for dichotomous outcomes.

RESULTS

Overall, 50 studies were identified. A quantitative analysis of 14 outcomes was performed. Subgroup analysis using the mean gestational age of the studies was performed, and a cutoff of 28 weeks of gestation was implemented. Among neonates with lower gestational ages, early-onset sepsis (pooled odds ratio, 2.23; 95% confidence interval, 1.76-2.84) and bronchopulmonary dysplasia (pooled odds ratio, 1.30; 95% confidence interval, 1.02-1.66) were associated with histological fetal inflammatory response. Our analysis showed that preterm neonates with a concomitant histological fetal inflammatory response are more likely to develop intraventricular hemorrhage (pooled odds ratio, 1.54; 95% confidence interval, 1.18-2.02) and retinopathy of prematurity (pooled odds ratio, 1.37; 95% confidence interval, 1.03-1.82). The odds of clinical chorioamnionitis were almost 3-fold higher among infant-mother dyads with histological fetal inflammatory response than among infant-mother dyads with histological chorioamnionitis alone (pooled odds ratio, 2.99; 95% confidence interval, 1.96-4.55).

CONCLUSION

This study investigated multiple neonatal outcomes and found association in the case of 4 major morbidities: early-onset sepsis, bronchopulmonary dysplasia, intraventricular hemorrhage, and retinopathy of prematurity.

Histological chorioamnionitis and pathological stages on very preterm infant outcomes

AIMS

Histological chorioamnionitis (HCA) is a condition linked to preterm birth and neonatal infection and its relationship with various pathological stages in extremely preterm neonates, and with their associated short- and long-term consequences, remains a subject of research. This study investigated the connection between different pathological stages of HCA and both short-term complications and long-term outcomes in preterm infants born at or before 32 weeks of gestational age.

METHODS

Preterm infants born at ≤ 32 weeks of gestation who underwent placental pathology evaluation and were followed-up at 18-24 months of corrected age were included. Neonates were classified based on their exposure to HCA and were further subdivided into different groups according to maternal inflammatory responses (MIR) and fetal inflammatory responses (FIR) stages. We compared short-term complications during their hospital stay between the HCA-exposed and -unexposed groups and examined the influence of HCA stages on long-term outcomes.

RESULTS

The HCA group exhibited distinct characteristics such as higher rates of premature rupture of membranes > 18 h, reduced amniotic fluid, early-onset sepsis, bronchopulmonary dysplasia and intraventricular haemorrhage (IVH) grades III-IV (P < 0.05). The moderate-severe HCA group displayed lower gestational age, lower birth weight and higher incidence of IVH (grades III-IV) and preterm sepsis compared with the mild HCA group (P < 0.05). After adjusting for confounders, the MIR stages 2-3 group showed associations with cognitive impairment and cerebral palsy (P < 0.05), and the FIR stages 2-3 group also showed poor long-term outcomes and cognitive impairment (P < 0.05).

CONCLUSIONS

Moderate-severe HCA was associated with increased early-onset sepsis, severe IVH and poor long-term outcomes, including cognitive impairment and cerebral palsy. Vigilant prevention strategies are warranted for severe HCA cases in order to mitigate poorer clinical outcomes.

Maternal biomarkers in predicting neonatal sepsis after preterm premature rupture of membranes in preterm infants

AIM

This retrospective cohort study aimed to assess the utility of maternal C-reactive protein (CRP) and leukocyte levels in predicting neonatal sepsis after preterm premature rupture of membranes (pPROM).

METHODS

We conducted a retrospective cohort study (2009-2021), encompassing preterm infants born ≤29 + 6 weeks of gestation following pPROM. The primary outcome was early-onset neonatal sepsis within the initial 72 h of life.

RESULTS

We analysed data from 706 patients with a median gestational age at pPROM of 25.1 weeks and a median gestational age at birth of 26.4 weeks. Overall survival rate was 86.1%, with 65.7% survival without severe morbidities. These rates were significantly worse in preterm infants with sepsis. Maternal CRP and leukocyte levels correlated significantly with neonatal infection markers and sepsis. However, their predictive values, correlation coefficients, and area under the curve values were generally low. Using maternal CRP ≥2 mg/dL to predict neonatal sepsis yielded a positive predictive value of 18.5%, negative predictive value of 91.5%, AUC of 0.589, 45.5% sensitivity, and 74.5% specificity.

CONCLUSION

Maternal CRP and leukocyte levels were ineffective as a tool for predicting early-onset neonatal sepsis following early pPROM. Consequently, these biomarkers lack the reliability required for clinical decision-making in this context.

Histological Chorioamnionitis and Funisitis as New Risk Factors for Retinopathy of Prematurity: A Meta-analysis

OBJECTIVE

 The role of placental inflammation in neonatal morbidities is underestimated due to lack of placental examination. This meta-analysis aims to assess the association between histological chorioamnionitis (HCA) with and without funisitis (FUN) and risk of retinopathy of prematurity (ROP).

STUDY DESIGN

 Forty-five studies reporting (unadjusted) data on HCA without FUN and HCA with FUN in neonates with ROP were included. Primary outcomes were any stage ROP and severe ROP. Potential confounders explored were gestational age (GA) at birth, birthweight, maternal steroid use, necrotizing enterocolitis, sepsis (suspected/proven) and mechanical ventilation duration.

RESULTS

 Neonates with HCA had increased risk for any stage ROP (odds ratio [OR] 1.8; 95% confidence interval [CI] 1.3-2.4) and severe ROP (OR 1.5; 95% CI 1.2-1.8) compared with neonates without HCA. The rates of any stage ROP (OR 1.8; 95% CI 1.4-2.2) and severe ROP (OR 1.4; 95% CI 1.1-1.6) were higher in neonates with FUN compared with neonates without FUN. Multivariate meta-regression analysis suggests that lower GA increases the effect size between FUN and severe ROP.

CONCLUSION

 This meta-analysis confirms that presence of HCA and FUN are risk factors for any stage ROP and severe ROP. Structured histological placental examination of HCA and FUN may be a tool to further refine the ROP risk profile.

KEY POINTS

· This systematic review confirms that HCA is a risk factor for ROP.. · This meta-analysis reveals that FUN results in an even higher risk for developing ROP.. · Placental examination of HCA/FUN may be a tool to further refine the ROP risk profile..

Neonatal immune cells have heightened responses following in-utero exposure to chorioamnionitis or COVID-19

BACKGROUND

Chorioamnionitis alters neonatal immune responses. Gestational COVID-19 infection is associated with adverse pregnancy outcomes, but its impact on neonatal immunity is unclear. We hypothesized that gestational COVID-19 exposure would result in exaggerated neonatal immune responses, similar to chorioamnionitis-exposed neonates.

METHODS

Term umbilical cord blood mononuclear cells (CBMCs) were isolated from neonates exposed to chorioamnionitis, gestational COVID-19 or unexposed controls. CBMCs were cultured and stimulated with heat-killed Escherichia coli, Streptococcus agalactiae or Staphylococcus epidermidis. A multiplexed protein assay was used to measure cytokine levels in cell culture supernatants and flow cytometry was used to evaluate cellular-level cytokine expression.

RESULTS

Both chorioamnionitis-exposed and COVID-19 exposed CBMCs demonstrated upregulation of IL-1β and IL-6 compared to unexposed CBMCs, while only COVID-19 exposure resulted in IL-8 upregulation. There were no differences between chorioamnionitis-exposed and COVID-19 exposed CBMCs when these groups were directly compared. Flow cytometry demonstrated immune cell subset specific differences in cytokine expression between the exposure groups.

CONCLUSION

The fetal/neonatal response to maternal inflammation differed based on immune cell subset and etiology of inflammation, but the global neonatal cytokine responses were similar between exposure groups. This suggests that targeting perinatal inflammation rather than the specific etiology may be a possible therapeutic approach.

IMPACT

Neonatal immune cells have similar pathogen-associated global cytokine responses, but different cell-level immune responses, following in-utero exposure to chorioamnionitis or COVID-19. This is the first study to directly compare immune responses between neonates exposed to chorioamnionitis and COVID-19. This suggests that the fetal/neonatal cellular response to perinatal inflammation differs based on the etiology and severity of maternal inflammation, but still results in a similar overall inflammatory profile regardless of the cause of perinatal inflammation.

Maternal COVID-19 Infection Associated with Fetal Systemic Inflammatory Complications in COVID-19-Negative Neonates: A Case-Series

OBJECTIVE

This study aimed to examine fetal and neonatal inflammatory and neurologic complications associated with maternal coronavirus disease 2019 (COVID-19) infection.

STUDY DESIGN

Case-series using a convenience sample of neonates cared for in a large referral-based children's hospital neonatal intensive care unit between September 2021 and May 2022.

RESULTS

We identified seven neonates with exposure to maternal severe acute respiratory syndrome related coronavirus 2 (SARS-CoV-2) and a presentation consistent with inflammatory complications. All had some degree of neurologic injury with neuroimaging findings including restricted diffusion indicating injury in the white matter, cortex, deep gray structures, and splenium of the corpus callosum as well as intracranial hemorrhage. In addition, many infants had cytopenia and abnormal coagulation studies. Placental pathology, when available, revealed inflammation, clot with calcifications, and hematomas with associated infarcts.

CONCLUSION

Neonates born to mothers with SARS-CoV-2, even when negative for the virus themselves, may have complications consistent with a systemic inflammatory syndrome. Placental pathology as well as neurologic imaging in infants with neurologic findings may help to support this diagnosis.

KEY POINTS

· A systemic inflammatory response may cause illness in babies born to mothers with a history of COVID-19.. · Inflammatory markers and placental pathology are helpful in supporting this diagnosis.. · Consider neuroimaging in infants of mothers with a history of COVID-19 with neurologic findings..

Extracellular Nicotinamide Phosphoribosyltransferase Is a Therapeutic Target in Experimental Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency of prematurity. Postulated mechanisms leading to inflammatory necrosis of the ileum and colon include activation of the pathogen recognition receptor Toll-like receptor 4 (TLR4) and decreased levels of transforming growth factor beta (TGFβ). Extracellular nicotinamide phosphoribosyltransferase (eNAMPT), a novel damage-associated molecular pattern (DAMP), is a TLR4 ligand and plays a role in a number of inflammatory disease processes. To test the hypothesis that eNAMPT is involved in NEC, an eNAMPT-neutralizing monoclonal antibody, ALT-100, was used in a well-established animal model of NEC. Preterm Sprague-Dawley pups delivered prematurely from timed-pregnant dams were exposed to hypoxia/hypothermia and randomized to control-foster mother dam-fed rats, injected IP with saline (vehicle) 48 h after delivery; control + mAB-foster dam-fed rats, injected IP with 10 µg of ALT-100 at 48 h post-delivery; NEC-orally gavaged, formula-fed rats injected with saline; and NEC + mAb-formula-fed rats, injected IP with 10 µg of ALT-100 at 48 h. The distal ileum was processed 96 h after C-section delivery for histological, biochemical, molecular, and RNA sequencing studies. Saline-treated NEC pups exhibited markedly increased fecal blood and histologic ileal damage compared to controls (q < 0.0001), and findings significantly reduced in ALT-100 mAb-treated NEC pups (q < 0.01). Real-time PCR in ileal tissues revealed increased NAMPT in NEC pups compared to pups that received the ALT-100 mAb (p < 0.01). Elevated serum levels of tumor necrosis factor alpha (TNFα), interleukin 6 (IL-6), interleukin-8 (IL-8), and NAMPT were observed in NEC pups compared to NEC + mAb pups (p < 0.01). Finally, RNA-Seq confirmed dysregulated TGFβ and TLR4 signaling pathways in NEC pups that were attenuated by ALT-100 mAb treatment. These data strongly support the involvement of eNAMPT in NEC pathobiology and eNAMPT neutralization as a strategy to address the unmet need for NEC therapeutics.

Bioinformatics-based discovery of biomarkers and immunoinflammatory targets in children with cerebral palsy: An observational study

Cerebral palsy (CP) is the most common disabling disease in children, and motor dysfunction is the core symptom of CP. Although relevant risk factors have been found to be closely associated with CP: congenital malformations, multiple gestation, prematurity, intrauterine inflammation and infection, birth asphyxia, thrombophilia, and perinatal stroke. Its important pathophysiological mechanism is amniotic fluid infection and intraamniotic inflammation leading to fetal developing brain damage, which may last for many years. However, the molecular mechanism of CP is still not well explained. This study aimed to use bioinformatics to identify key biomarker-related signaling pathways in CP. The expression profile of children with CP was selected from the Gene Expression Comprehensive Database, and the CP disease gene data set was obtained from GeneCards. A protein-protein interaction network was established and functional enrichment analysis was performed using Gene Ontology and Kyoto Encyclopedia of Genes and Genomes databases. A total of 144 differential key intersection genes and 10 hub genes were identified through molecular biology. Gene Ontology functional enrichment analysis results show that differentially expressed genes are mainly concentrated in biological processes, such as immune response and neurogenesis. The cellular components involved mainly include axons, postsynaptic membranes, etc, and their molecular functions mainly involve proteoglycan binding, collagen binding, etc. Kyoto Encyclopedia of Genes and Genomes analysis shows that the intersection genes are mainly in signaling pathways related to the immune system, inflammatory response, and nervous system, such as Th17 cell differentiation, Toll-like receptor signaling pathway, tumor necrosis factor signaling pathway, NF-κB signaling pathway, axon guidance, PI3K-Akt signaling pathway, HIF-1 signaling pathway, gap junction, etc. Jak-STAT signaling pathway, mTOR signaling pathway, and related hub genes regulate immune cells and inflammatory factors and play an important role in the development and progression of CP.

Congenital infectious encephalopathies from the intrapartum period to postnatal life

Congenital infections are a common but often underrecognized cause of fetal brain abnormalities, as well as fetal-neonatal morbidity and mortality, that should be considered by all healthcare professionals providing neurological care to fetuses and newborns. Maternal infection with various pathogens (cytomegalovirus, Toxoplasmosis, Rubella virus, Parvovirus B19, lymphocytic choriomeningitis virus, syphilis, Zika virus, varicella zoster virus) during pregnancy can be transmitted to the developing fetus, which can cause multisystem dysfunction and destructive or malformative central nervous system lesions. These can be recognized on fetal and neonatal imaging, including ultrasound and MRI. Imaging and clinical features often overlap, but some distinguishing features can help identify specific pathogens and guide subsequent testing strategies. Some pathogens can be specifically treated, and others can be managed with targeted interventions or symptomatic therapy based on expected complications. Neurological and neurodevelopmental complications related to congenital infections vary widely and are likely driven by a combination of pathophysiologic factors, alone or in combination. These include direct invasion of the fetal central nervous system by pathogens, inflammation of the maternal-placental-fetal triad in response to infection, and long-term effects of immunogenic and epigenetic changes in the fetus in response to maternal-fetal infection. Congenital infections and their neurodevelopmental impacts should be seen as an issue of public health policy, given that infection and the associated complications disproportionately affect woman and children from low- and middle-income countries and those with lower socio-economic status in high-income countries. Congenital infections may be preventable and treatable, which can improve long-term neurodevelopmental outcomes in children.

Clinical Chorioamnionitis and Neurodevelopment at 5 Years of Age in Children Born Preterm: The EPIPAGE-2 Cohort Study

OBJECTIVE

To assess the association between clinical chorioamnionitis and neurodevelopmental disorders at 5 years of age in children born preterm.

STUDY DESIGN

EPIPAGE 2 is a national, population-based cohort study of children born before 35 weeks of gestation in France in 2011. We included infants born alive between 240/7 and 346/7 weeks after preterm labor or preterm premature rupture of membranes. Clinical chorioamnionitis was defined as maternal fever before labor (>37.8°C) with ≥2 of the following criteria: maternal tachycardia, hyperleukocytosis, uterine contractions, purulent amniotic fluid, or fetal tachycardia. The primary outcome was a composite, including cerebral palsy, coordination disorders, cognitive disorders, sensory disorders, or behavioral disorders. We also analyzed each of these disorders separately as secondary outcomes. We performed a multivariable analysis using logistic regression models. We accounted for the nonindependence of twins and missing data by generalized estimating equation models and multiple imputations, respectively.

RESULTS

Among 2927 children alive at 5 years of age, 124 (3%) were born in a context of clinical chorioamnionitis. Overall, 8.2% and 9.6% of children exposed and unexposed, respectively, to clinical chorioamnionitis had moderate-to-severe neurodevelopmental disorders. After multiple imputations and multivariable analysis, clinical chorioamnionitis was not associated with the occurrence of moderate-to-severe neurodevelopmental disorders (aOR, 0.9; 95% CI, 0.5-1.8).

CONCLUSIONS

We did not find any association between clinical chorioamnionitis and neurodevelopmental disorders at 5 years of age in children born at <35 weeks of gestation after preterm labor or preterm premature rupture of membrane.

Anaphylaxis-induced premature uterine contractions: a case report and literature review

BACKGROUND

Preterm labor is caused by multiple etiologies, including intra-amniotic infection and/or intra-amniotic inflammation, vascular disorders, cervical disease, decidual senescence, and breakdown of maternal-fetal tolerance. Accumulating evidence in vivo and in vitro has shown that an allergic reaction, including anaphylaxis, can induce preterm uterine contractions. This report describes a case of a pregnant woman who developed anaphylaxis and regular uterine contractions after the ingestion of a strawberry-coated biscuit. We also review the mechanism of allergic reaction (hypersensitivity)-induced preterm labor. Case presentation A 31-year-old woman (gravida 1, para 0) at 30+2 weeks of gestation was admitted to the labor and delivery unit with regular uterine contractions and anaphylactic symptoms after she ingested a strawberry-coated biscuit as a snack. The uterine contractions resolved after the treatment of anaphylaxis by administering antihistamines and epinephrine. The patient subsequently delivered at 39+3 weeks of gestation. The amniotic fluid profile showed no infection or inflammation. A postpartum skin-prick test confirmed a positive type 1 hypersensitivity reaction to the strawberry-coated biscuit.

CONCLUSIONS

We report a case of anaphylaxis-induced uterine contractility in which uterine contractions subsided after the treatment of anaphylaxis. The absence of intra-amniotic infection and/or intra-amniotic inflammation and the cause of the anaphylaxis were confirmed. Our findings indicate that maternal allergic reactions may be one of the mechanisms of preterm labor.

Risk of adverse perinatal outcomes among women with clinical and subclinical histopathological chorioamnionitis

Introduction

Histologic chorioamnionitis (HCA) is a placental inflammatory condition associated with adverse perinatal outcomes (APOs). This historical cohort study explores the risk of APOs in pregnant women with HCA and compares the impact of clinical chorioamnionitis (CCA) with subclinical chorioamnionitis (SCCA).

Methodology

Placentas were evaluated by a perinatal pathologist tand all women with HCA were included. Two groups were integrated: (1) women with clinical chorioamnionitis (CCA) and (2) women with subclinical chorioamnionitis (SCCA). Additionally, we conducted a secondary analysis to compare the prevalence of APOs among stage 1, 2 and 3 of HCA and the risk of APOs between grades 1 and 2 of HCA. The APOs analyzed were preterm birth, stillbirth, neonatal weight < 1,500 g, neonatal sepsis. Relative risk with 95% confidence interval was calculated.

Results

The study included 41 cases of CCA and 270 cases of SCCA. The mean gestational age at diagnosis and birth was 30.2 ± 5.4 weeks and 32.5 ± 5.1 weeks, for group 1 and 2, respectively. The study also found that women with HCA stage 3 and grade 2 had a higher prevalence and risk of adverse perinatal outcomes.

Discussion

The findings of this study suggest the importance of placental histological study to excluded SCCA, which represents a significant risk to both maternal and neonatal health, contributing to high morbidity and mortality.