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Ruiz-Durán S, Tenorio CM, Vico-Zúñiga I, Manzanares S, Puertas-Prieto A, Altmäe S, Vargas E. Microenvironment of the Lower Reproductive Tract: Focus on the Cervical Mucus Plug. Semin Reprod Med 2023; 41:200-208. [PMID: 38262442 DOI: 10.1055/s-0043-1778661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
The female lower reproductive tract microbiota is a complex ecosystem comprising various microorganisms that play a pivotal role in maintaining women's reproductive well-being. During pregnancy, the vaginal microbiota undergoes dynamic changes that are important for a successful gestation. This review summarizes the implications of the cervical mucus plug microenvironment and its profound impact on reproductive health. Further, the symbiotic relationship between the vaginal microbiome and the cervical mucus plug is highlighted, with a special emphasis on how this natural barrier serves as a guardian against ascending infections. Understanding this complex host-microbes interplay could pave the way for innovative approaches to improve women's reproductive health and fertility.
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Affiliation(s)
- Susana Ruiz-Durán
- Department of Obstetrics and Gynaecology, Virgen de las Nieves University Hospital, Granada, Spain
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
| | - Celia M Tenorio
- Department of Biochemistry and Molecular Biology, Faculty of Sciences, University of Granada, Granada, Spain
| | - Irene Vico-Zúñiga
- Department of Obstetrics and Gynaecology, Virgen de las Nieves University Hospital, Granada, Spain
| | - Sebastián Manzanares
- Department of Obstetrics and Gynaecology, Virgen de las Nieves University Hospital, Granada, Spain
| | - Alberto Puertas-Prieto
- Department of Obstetrics and Gynaecology, Virgen de las Nieves University Hospital, Granada, Spain
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
| | - Signe Altmäe
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
- Department of Biochemistry and Molecular Biology, Faculty of Sciences, University of Granada, Granada, Spain
- Division of Obstetrics and Gynaecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Eva Vargas
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
- Department of Biochemistry and Molecular Biology, Faculty of Sciences, University of Granada, Granada, Spain
- Department of Experimental Biology, Faculty of Experimental Sciences, University of Jaén, Jaén, Spain
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Ismail N, Myint K, Khaing SL, Giribabu N, Salleh N. Cervical fluid pH, electrolytes and osmolarity changes and expression of ion transporters (ENaC, CFTR and AQP) in cervix of women with primary unexplained infertility. Mol Biol Rep 2023; 50:6729-6737. [PMID: 37382776 DOI: 10.1007/s11033-023-08555-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 05/30/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Unexplained infertility could arise from a defect in the cervix. However, the contribution of abnormal cervical fluid microenvironment to this problem still needs to be identified. Therefore, this study identifies the changes in the cervical fluid microenvironment, i.e., pH, electrolytes and osmolarity as well as expression of ion transporters in the cervix including ENaC, CFTR and AQP in fertile women and in women suffering from primary unexplained infertility. METHODS Fertile women and women with unexplained infertility but having regular 28-day menstrual cycles were chosen in this study, Day-22 serum progesterone levels were determined. In the meantime, serum FSH and LH levels were determined on day 2 while, cervical flushing was performed at day 14 to analyse changes in the cervical fluid pH, osmolarity, Na+ and Cl- levels. Meanwhile, cells retrieved from cervical fluid were subjected to mRNA expression and protein distribution analysis for CFTR, AQP and ENaC by qPCR and immunofluorescence, respectively. RESULTS No significant changes in serum progesterone, FSH and LH levels were observed between the two groups. However, cervical fluid pH, osmolarity, Na+ and Cl- levels were significantly lower in primary unexplained infertile group when compared to fertile group. Expression of CFTR and AQP (AQP 1, AQP 2, AQP 5 and AQP 7) in endocervical cells was lower and expression of β-ENaC was higher in primary unexplained infertile women (p < 0.05 when compared to fertile group). CONCLUSIONS Alterations in the cervical fluid microenvironment linked to the defective ion transporter expression in the cervix might contribute towards the unfavourable condition that accounts for unexplained infertility in women.
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Affiliation(s)
- Nurain Ismail
- Department of Physiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Kyaimon Myint
- Department of Physiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Si Lay Khaing
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
- Medical Education Department, University of Medicine, Yangon, Myanmar
| | - Nelli Giribabu
- Department of Physiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Naguib Salleh
- Department of Physiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia.
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Jeong S, Cho WK, Jo Y, Choi SR, Lee N, Jeon K, Park MJ, Song W, Lee KY. Immune-checkpoint proteins, cytokines, and microbiome impact on patients with cervical insufficiency and preterm birth. Front Immunol 2023; 14:1228647. [PMID: 37554329 PMCID: PMC10404982 DOI: 10.3389/fimmu.2023.1228647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/30/2023] [Indexed: 08/10/2023] Open
Abstract
Background Microenvironmental factors, including microbe-induced inflammation and immune-checkpoint proteins that modulate immune cells have been associated with both cervical insufficiency and preterm delivery. These factors are incompletely understood. This study aimed to explore and compare interactions among microbiome and inflammatory factors, such as cytokines and immune-checkpoint proteins, in patients with cervical insufficiency and preterm birth. In particular, factors related to predicting preterm birth were identified and the performance of the combination of these factors was evaluated. Methods A total of 220 swab samples from 110 pregnant women, prospectively recruited at the High-Risk Maternal Neonatal Intensive Care Center, were collected between February 2020 and March 2021. This study included 63 patients with cervical insufficiency receiving cerclage and 47 control participants. Endo- and exocervical swabs and fluids were collected simultaneously. Shotgun metagenomic sequencing for the microbiome and the measurement of 34 immune-checkpoint proteins and inflammatory cytokines were performed. Results First, we demonstrated that immune-checkpoint proteins, the key immune-regulatory molecules, could be measured in endocervical and exocervical samples. Secondly, we identified significantly different microenvironments in cervical insufficiency and preterm birth, with precise cervical locations, to provide information about practically useful cervical locations in clinical settings. Finally, the presence of Moraxella osloensis (odds ratio = 14.785; P = 0.037) and chemokine CC motif ligand 2 levels higher than 73 pg/mL (odds ratio = 40.049; P = 0.005) in endocervical samples were associated with preterm birth. Combining M. osloensis and chemokine CC motif ligand 2 yielded excellent performance for predicting preterm birth (area under the receiver operating characteristic curve = 0.846, 95% confidence interval = 0.733-0.925). Conclusion Multiple relationships between microbiomes, immune-checkpoint proteins, and inflammatory cytokines in the cervical microenvironment were identified. We focus on these factors to aid in the comprehensive understanding and therapeutic modulation of local microbial and immunologic compositions for the management of cervical insufficiency and preterm birth.
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Affiliation(s)
- Seri Jeong
- Department of Laboratory Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Won Kyong Cho
- College of Biotechnology and Bioengineering, Sungkyunkwan University, Suwon, Republic of Korea
| | - Yeonhwa Jo
- College of Biotechnology and Bioengineering, Sungkyunkwan University, Suwon, Republic of Korea
| | - Soo-Ran Choi
- Department of Obstetrics and Gynecology, Inha University College of Medicine, Inha University Hospital, Incheon, Republic of Korea
| | - Nuri Lee
- Department of Laboratory Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Kibum Jeon
- Department of Laboratory Medicine, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Min-Jeong Park
- Department of Laboratory Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Wonkeun Song
- Department of Laboratory Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Keun-Young Lee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
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Xu ZM, Zhang J, Hong XL, Liu J, Yang ZZ, Pan M. Comparison of two stitches versus one stitch for emergency cervical cerclage to prevent preterm birth in singleton pregnancies. Int J Gynaecol Obstet 2023; 160:98-105. [PMID: 35396704 DOI: 10.1002/ijgo.14213] [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: 12/03/2021] [Revised: 03/26/2022] [Accepted: 04/04/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To compare the efficacy of two stitches versus one stitch in women with emergency cervical cerclage. METHODS A retrospective case-control study of 26 women with singleton pregnancies who underwent emergency cervical cerclage before 26 weeks. A comparison was made between patients with two stitches versus one stitch at the time of cervical cerclage placement. The primary outcome was gestational age (GA) at delivery and preterm birth (PTB) before 37, 34, 32, 28, and 24 weeks. RESULTS Average GA at delivery in the two-stitches group was significantly greater than in the one-stitch group (32.71 ± 5.54 weeks vs 27.99 ± 4.70 weeks, P = 0.028). There were significant decreases in the incidence of spontaneous PTB at <34 weeks and less than 32 weeks in the two-stitches group (P = 0.034; P = 0.013, respectively). The neonatal intensive care unit (NICU) admissions rate and length of stay in the NICU in the two-stitches group were significantly reduced (P = 0.035 and P = 0.018, respectively). However, there was no significant difference in neonatal mortality between the two groups. CONCLUSION Compared with emergency cervical cerclage placement with one stitch, the procedure with two stitches can prolong the pregnancy and improve the neonatal prognosis more effectively.
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Affiliation(s)
- Zhi-Min Xu
- Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Jun Zhang
- Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Xiao-Lan Hong
- Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Jing Liu
- Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Zhen-Zhen Yang
- Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Mian Pan
- Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
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Tantengco OAG, Richardson LS, Radnaa E, Kammala AK, Kim S, Medina PMB, Han A, Menon R. Modeling ascending Ureaplasma parvum infection through the female reproductive tract using vagina-cervix-decidua-organ-on-a-chip and feto-maternal interface-organ-on-a-chip. FASEB J 2022; 36:e22551. [PMID: 36106554 PMCID: PMC9500016 DOI: 10.1096/fj.202200872r] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/08/2022] [Accepted: 09/02/2022] [Indexed: 09/02/2023]
Abstract
Genital mycoplasmas can break the cervical barrier and cause intraamniotic infection and preterm birth. This study developed a six-chamber vagina-cervix-decidua-organ-on-a-chip (VCD-OOC) that recapitulates the female reproductive tract during pregnancy with culture chambers populated by vaginal epithelial cells, cervical epithelial and stromal cells, and decidual cells. Cells cultured in VCD-OOC were characterized by morphology and immunostaining for cell-specific markers. We transferred the media from the decidual cell chamber of the VCD-OOC to decidual cell chamber in feto-maternal interface organ-on-a-chip (FMi-OOC), which contains the fetal membrane layers. An ascending Ureaplasma parvum infection was created in VCD-OOC. U. parvum was monitored for 48 h post-infection with their cytotoxicity (LDH assay) and inflammatory effects (multiplex cytokine assay) in the cells tested. An ascending U. parvum infection model of PTB was developed using CD-1 mice. The cell morphology and expression of cell-specific markers in the VCD-OOC mimicked those seen in lower genital tract tissues. U. parvum reached the cervical epithelial cells and decidua within 48 h and did not cause cell death in VCD-OOC or FMi-OOC cells. U. parvum infection promoted minimal inflammation, while the combination of U. parvum and LPS promoted massive inflammation in the VCD-OOC and FMi-OOC cells. In the animal model, U. parvum vaginal inoculation of low-dose U. parvum did not result in PTB, and even a high dose had only some effects on PTB (20%). However, intra-amniotic injection of U. parvum resulted in 67% PTB. We report the colonization of U. parvum in various cell types; however, inconsistent, and low-grade inflammation across multiple cell types suggests poor immunogenicity induced by U. parvum.
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Affiliation(s)
- Ourlad Alzeus G. Tantengco
- Division of Basic Science and Translational Research, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Biological Models Laboratory, Department of Biochemistry and Molecular Biology, College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Lauren S. Richardson
- Division of Basic Science and Translational Research, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Enkhtuya Radnaa
- Division of Basic Science and Translational Research, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Ananth Kumar Kammala
- Division of Basic Science and Translational Research, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Sungjin Kim
- Department of Electrical and Computer Engineering, Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
| | - Paul Mark B. Medina
- Biological Models Laboratory, Department of Biochemistry and Molecular Biology, College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Arum Han
- Department of Electrical and Computer Engineering, Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
| | - Ramkumar Menon
- Division of Basic Science and Translational Research, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
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van Limburg Stirum EVJ, van der Windt LI, van Dijk CE, van Baar AL, Leemhuis AG, van Wely M, de Boer MA, van 't Hooft J, Oudijk MA, Pajkrt E. Pessary or progesterone to prevent preterm birth in women with short cervical length: protocol of the 4-6 year follow-up of a randomised controlled trial (Quadruple-P). BMJ Open 2022; 12:e064049. [PMID: 36002221 PMCID: PMC9413189 DOI: 10.1136/bmjopen-2022-064049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/19/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Vaginal progesterone and a cervical pessary are both interventions that are investigated for the prevention of preterm birth (PTB). Thus far, beneficial or harmful effects of these interventions on long-term child health and development are described, but evidence is not robust enough to draw firm conclusions. With this follow-up study, we intent to investigate if progesterone or a pessary is superior for the prevention of PTB considering the child's health at 4-6 years of corrected age. METHODS AND ANALYSIS This study is a follow-up study of the Quadruple-P trial; a multicentre, randomised clinical trial (NL42926.018.13, Eudractnumber 2013-002884-24) which randomises women with an asymptomatic midtrimester short cervix to daily progesterone or a pessary for the prevention of PTB. All children born to mothers who participated in the Quadruple-P study (n=628 singletons and n=332 multiples) will be eligible for follow-up at 4-6 years of corrected age. Children will be assessed using parental questionnaires. Main outcomes are child (neuro)development and behaviour. Other outcomes include child mortality, growth and general health. A composite of adverse child outcomes will be compared between the progesterone and pessary groups reporting OR and the corresponding 95% CI. Analyses will be performed separately for singletons and multiples and using the intention-to-treat approach. ETHICS AND DISSEMINATION The Medical Research Ethics Committee from Amsterdam UMC confirmed that de Medical Research Involving Human Subjects Act (WMO) did not apply to our study (W20_481 #20.531). Results will be published in a peer-reviewed journal and shared with stakeholders and participants. This protocol is published before analysis of the results. TRIAL REGISTRATION NUMBER Dutch Trial Register (NL9646).
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Affiliation(s)
- Emilie V J van Limburg Stirum
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Larissa I van der Windt
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Charlotte E van Dijk
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | | | - Aleid G Leemhuis
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
- Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Department of Neonatology and Paediatrics, Amsterdam, The Netherlands
| | - Madelon van Wely
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Marjon A de Boer
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands
| | - Janneke van 't Hooft
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Martijn A Oudijk
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands
| | - Eva Pajkrt
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
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Kim Y, Lee KY, Lee JJ, Tak H, Park ST, Song JE, Son GH. Expression of antimicrobial peptides in the amniotic fluid of women with cervical insufficiency. Am J Reprod Immunol 2022; 88:e13577. [PMID: 35567598 DOI: 10.1111/aji.13577] [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: 10/19/2021] [Revised: 03/28/2022] [Accepted: 05/07/2022] [Indexed: 12/29/2022] Open
Abstract
PROBLEM Cervical insufficiency (CI) is associated with intra-amniotic infection or inflammation. Antimicrobial peptides (AMPs) in amniotic fluid may protect the fetus against microbial invasion, giving their broad-spectrum microbiocidal properties. We evaluated changes in amniotic fluid AMP expression in women with CI and assessed whether these changes are related to their pregnancy outcomes. METHOD OF STUDY We evaluated amniotic fluid human neutrophil peptide 3 (HNP-3), human β-defensin-2 (hBD-2), and LL-37 levels in 66 women with CI and 25 normal controls at 16-24 weeks of gestation. The CI group was divided into short cervix and cervical dilation groups, and the cervical dilation group was further divided into preterm and full-term delivery groups according to the pregnancy outcomes, and AMP expression was analyzed in each group. RESULTS HNP-3 and hBD-2 levels were higher in women with CI than in normal controls and in the cervical dilation as compared to the short cervix group. Among women with cervical dilation, 22 delivered at full-term, and 23 had spontaneous preterm births. The hBD-2 level in amniotic fluid mid-pregnancy was higher in the full-term delivery than in the preterm delivery groups. However, LL-37 levels in amniotic fluid were low in women with CI and normal controls. CONCLUSIONS Amniotic fluid HNP-3 and hBD-2 levels increased in women with CI compared with normal controls. Moreover, increased amniotic fluid hBD-2 levels mid-pregnancy were associated with favorable pregnancy outcomes in women with CI. AMPs in the amniotic fluid may participate in host defense against ascending infection in women with CI.
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Affiliation(s)
- Youngmi Kim
- Institute of New Frontier Research Team, College of Medicine, Hallym University, Chuncheon, South Korea
| | - Keun-Young Lee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul, South Korea
| | - Jae Jun Lee
- Institute of New Frontier Research Team, College of Medicine, Hallym University, Chuncheon, South Korea.,Departments of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, South Korea
| | - Hyunjin Tak
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul, South Korea
| | - Sung-Taek Park
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul, South Korea.,Institute of New Frontier Research Team, College of Medicine, Hallym University, Chuncheon, South Korea
| | - Ji-Eun Song
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul, South Korea
| | - Ga-Hyun Son
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul, South Korea.,Institute of New Frontier Research Team, College of Medicine, Hallym University, Chuncheon, South Korea
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Adekola H, Addo J, Unal ER, James E, Prakash V, Abrams R. Outcomes following Placement and Removal of Transvaginal Cerclage in at Risk Pregnancies: A Single Center Experience. J Pregnancy 2022; 2022:4277451. [PMID: 35874435 PMCID: PMC9300365 DOI: 10.1155/2022/4277451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/30/2022] [Indexed: 11/26/2022] Open
Abstract
Objective The objective of this study was to estimate the time between removal of cerclage and delivery, stratified by indication for cerclage placement (elective or non-elective). Additionally, delivery within 72 hours after cerclage removal was compared between elective and non-elective cerclage placement, as well as between ultrasound-indicated and physical examination-indicated cerclage placement. Design A single-center retrospective cohort study. Participants/Materials, Setting, and Methods. Clinical information of 72 pregnant women who underwent transvaginal cerclage over a 4-year period was obtained. Comparisons were made between elective (history-indicated) and non-elective (ultrasound or physical examination-indicated) cerclage placement. Comparisons were also made between physical examination-indicated and ultrasound-indicated cerclage. Results Compared to those who had a non-elective cerclage, women undergoing elective cerclage were more likely to have history of cervical treatment (44% vs. 15%, p = 0.02), and spontaneous preterm delivery (92% vs. 61%, p = 0.003). There was no difference in the rate of delivery ≤72 hours following cerclage removal between women who had elective cerclage and those who had non-elective cerclage (46% vs. 58%, p = 0.47). Women who had an elective cerclage were more likely to have elective cerclage removal ≥36 weeks (71.8% vs. 39.4%, p = 0.01), compared to those who had undergone non-elective cerclage. The rate of delivery ≤72 hours following removal of cerclage was greater in women who had a physical examination-indicated cerclage compared to women who had ultrasound-indicated cerclage (80% vs. 39%, p = 0.04). Among women who had an elective cerclage, there was no difference in the rate of delivery at ≤72 hours between those who had elective cerclage removal at 36 weeks compared to those electively removed at 37 weeks (31% vs. 58%, p = 0.30). No complications such as fetal demise, iatrogenic amniotic membrane rupture, hemorrhage, or cervical laceration were reported within this cohort. Conclusion Cerclage indication should be considered prior to scheduling elective cerclage removal. Women who had an elective cerclage are most likely to get it electively removed at 36 weeks compared to their counterparts who had a non-elective cerclage. Furthermore, women who had a physical examination-indicated cerclage are most likely to deliver within 72 hours of cerclage removal.
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Affiliation(s)
- Henry Adekola
- Department of Maternal-Fetal Medicine, Southern Illinois University School of Medicine, USA
| | - Jennifer Addo
- Department of Obstetrics and Gynecology, Southern Illinois University School of Medicine, USA
| | - Elizabeth Ramsey Unal
- Department of Maternal-Fetal Medicine, Southern Illinois University School of Medicine, USA
| | - Emma James
- Department of Obstetrics and Gynecology, Southern Illinois University School of Medicine, USA
| | - Vivek Prakash
- Center for Clinical Research, Southern Illinois University School of Medicine, USA
| | - Robert Abrams
- Department of Maternal-Fetal Medicine, Southern Illinois University School of Medicine, USA
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van Limburg Stirum EVJ, Zegveld SJ, Simons NE, de Boer MA, Pajkrt E, Mol BWJ, Oudijk MA, van 't Hooft J. Consequences of cervical pessary for subsequent pregnancy: follow-up of randomized clinical trial (ProTWIN). ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:771-777. [PMID: 34826166 PMCID: PMC9328140 DOI: 10.1002/uog.24821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/20/2021] [Accepted: 11/17/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To evaluate the effect of cervical pessary, as a strategy to prevent preterm birth (PTB), on the outcome of subsequent pregnancy and maternal quality of life 4 years after the index twin pregnancy. METHODS Between 2009 and 2012, the ProTWIN trial randomized women with a multiple pregnancy to pessary use vs standard care for the prevention of PTB. The trial showed no benefit in unselected women with a twin pregnancy, but showed a 60% reduction in poor perinatal outcomes in favor of the pessary group in the subgroup of women with a mid-trimester short cervix (cervical length < 38 mm). All women were invited to participate in a follow-up study 4 years after their participation in the ProTWIN trial. In this follow-up study, maternal quality of life was assessed using the EQ-5D-3L questionnaire and women were asked separate questions about subsequent pregnancies. Results were compared between women who were randomized to the pessary vs the control group in the ProTWIN trial by calculating relative risk (RR) and 95% CI. Subgroup analysis was performed for women with a mid-trimester short cervix (cervical length < 38 mm). RESULTS Of the 813 women included in the ProTWIN trial, 408 (50.2%) participated in this follow-up study, comprising 228 randomized to the pessary group and 180 to the control group in the original trial. The median interval between participation in the ProTWIN trial and participation in this follow-up study was 4.1 (interquartile range (IQR), 3.9-7.1) years. Ninety-eight (24.0%) participants tried to conceive after their participation in the ProTWIN trial. Of those, 22 (22.4%) women did not have a subsequent pregnancy (no difference between pessary and control groups), seven (7.1%) women had at least one miscarriage but no live birth, and 67 (68.4%) women had at least one live birth (35 in the pessary vs 32 in the control group; RR, 0.93 (95% CI, 0.8-1.07)). In two women, the pregnancy outcome was unknown. Preterm delivery (< 37 weeks of gestation) of the first live birth occurred in three women in the pessary vs one woman in the control group (all singleton; RR, 2.57 (95% CI, 0.28-23.44)). No differences were found between the pessary and control groups in the subgroup of women with mid-trimester short cervix, but the numbers analyzed were small. The median health state index score was 0.95 (IQR, 0.82-0.95), with no difference between the pessary and control groups. CONCLUSION Our findings suggest that there are no long-term effects of pessary use on the outcome of subsequent pregnancies and maternal quality of life. Data on obstetric outcome were limited due to the small numbers. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E. V. J. van Limburg Stirum
- Department of Obstetrics and Gynecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
| | - S. J. Zegveld
- Department of Obstetrics and Gynecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
| | - N. E. Simons
- Department of Obstetrics and Gynecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
| | - M. A. de Boer
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
- Department of Obstetrics and Gynecology, Amsterdam UMC locationVrije UniversiteitAmsterdamThe Netherlands
| | - E. Pajkrt
- Department of Obstetrics and Gynecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
| | - B. W. J. Mol
- Department of Obstetrics and GynecologyMonash UniversityMelbourneVictoriaAustralia
- Aberdeen Centre for Women's Health Research, School of MedicineUniversity of AberdeenAberdeenUK
| | - M. A. Oudijk
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
- Department of Obstetrics and Gynecology, Amsterdam UMC locationVrije UniversiteitAmsterdamThe Netherlands
| | - J. van 't Hooft
- Department of Obstetrics and Gynecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development InstituteAmsterdamThe Netherlands
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10
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Tantengco OAG, Menon R. Breaking Down the Barrier: The Role of Cervical Infection and Inflammation in Preterm Birth. Front Glob Womens Health 2022; 2:777643. [PMID: 35118439 PMCID: PMC8803751 DOI: 10.3389/fgwh.2021.777643] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/27/2021] [Indexed: 01/06/2023] Open
Abstract
Approximately 40% of cases of spontaneous preterm birth (sPTB) are associated with ascending intrauterine infections. The cervix serves as a physical and immunological gatekeeper, preventing the ascent of microorganisms from the vagina to the amniotic cavity. The cervix undergoes remodeling during pregnancy. It remains firm and closed from the start until the late third trimester of pregnancy and then dilates and effaces to accommodate the passage of the fetus during delivery. Remodeling proceeds appropriately and timely to maintain the pregnancy until term delivery. However, risk factors, such as acute and chronic infection and local inflammation in the cervix, may compromise cervical integrity and result in premature remodeling, predisposing to sPTB. Previous clinical studies have established bacterial (i.e., chlamydia, gonorrhea, mycoplasma, etc.) and viral infections (i.e., herpesviruses and human papillomaviruses) as risk factors of PTB. However, the exact mechanism leading to PTB is still unknown. This review focuses on: (1) the epidemiology of cervical infections in pregnant patients; (2) cellular mechanisms that may explain the association of cervical infections to premature cervical ripening and PTB; (3) endogenous defense mechanisms of the cervix that protect the uterine cavity from infection and inflammation; and (4) potential inflammatory biomarkers associated with cervical infection that can serve as prognostic markers for premature cervical ripening and PTB. This review will provide mechanistic insights on cervical functions to assist in managing cervical infections during pregnancy.
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Affiliation(s)
- Ourlad Alzeus G. Tantengco
- Division of Basic and Translational Research, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, TX, United States
- Department of Biochemistry and Molecular Biology, College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Ramkumar Menon
- Division of Basic and Translational Research, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, TX, United States
- *Correspondence: Ramkumar Menon
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11
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Yang I, Lin I, Liang Y, Lin J, Chen T, Chen Z, Kuan C, Chi C, Li C, Wu H, Lin F. Development of di(2‐ethylhexyl) phthalate‐containing thioglycolic acid immobilized chitosan mucoadhesive gel as an alternative hormone therapy for menopausal syndrome. Bioeng Transl Med 2021; 7:e10267. [PMID: 35600649 PMCID: PMC9115706 DOI: 10.1002/btm2.10267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/20/2021] [Accepted: 11/02/2021] [Indexed: 01/25/2023] Open
Abstract
Menopausal syndrome includes the symptoms that most women experience owing to hormone changes after menopause. Although hormone replacement therapy is a common treatment for menopausal syndrome, there are still many side effects and challenges hindering research. In this study, thioglycolic acid (TGA)‐immobilized chitosan mucoadhesive gel was synthesized by a new method of low concentration of 1,4‐butanediol diglycidyl ether (BDDE) would encapsulate di(2‐ethylhexyl) phthalate (DEHP) as an alternative hormone replacement therapy for menopausal syndrome. The efficacies of the DEHP‐containing TGA‐chitosan gel (CT‐D) were confirmed and evaluated by materials characterization and in vitro study. Results showed that CT‐D was not cytotoxic and had better mucoadhesive ability than chitosan. The animal model was constructed 1 month after bilateral ovariectomy in SD rats. CT‐D was administered intravaginally every 3 days. Bodyweight, wet weight of the uterus and vagina, vaginal smears, histology, blood element analysis, and serological analysis was used to assess the ability of the material to relieve menopausal syndrome. The results indicated that the combination of the sustained release of DEHP and mucoadhesive TGA‐immobilized chitosan allows the developed CT‐D to relieve the menopausal syndrome through low concentrations of DEHP, which falls in the safety level of the tolerable daily intake of DEHP.
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Affiliation(s)
- I‐Hsuan Yang
- Department of Biomedical Engineering College of Medicine and College of Engineering, National Taiwan University Taipei Taiwan
| | - I‐En Lin
- Department of Biomedical Engineering College of Medicine and College of Engineering, National Taiwan University Taipei Taiwan
| | - Ya‐Jyun Liang
- Department of Biomedical Engineering College of Medicine and College of Engineering, National Taiwan University Taipei Taiwan
| | - Jhih‐Ni Lin
- Department of Biomedical Engineering College of Medicine and College of Engineering, National Taiwan University Taipei Taiwan
| | - Tzu‐Chien Chen
- Department of Biomedical Engineering College of Medicine and College of Engineering, National Taiwan University Taipei Taiwan
| | - Zhi‐Yu Chen
- Department of Biomedical Engineering College of Medicine and College of Engineering, National Taiwan University Taipei Taiwan
| | - Che‐Yung Kuan
- Department of Biomedical Engineering College of Medicine and College of Engineering, National Taiwan University Taipei Taiwan
- Institute of Biomedical Engineering and Nanomedicine National Health Research Institutes Zhunan, Miaoli County Taiwan
| | - Chih‐Ying Chi
- Institute of Biomedical Engineering and Nanomedicine National Health Research Institutes Zhunan, Miaoli County Taiwan
- PhD Program in Tissue Engineering and Regenerative Medicine National Chung Hsing University Taichung Taiwan
| | - Chi‐Han Li
- Institute of Biomedical Engineering and Nanomedicine National Health Research Institutes Zhunan, Miaoli County Taiwan
- PhD Program in Tissue Engineering and Regenerative Medicine National Chung Hsing University Taichung Taiwan
| | - Hung‐Ming Wu
- Department of Neurology Changhua Christian Hospital Changhua Taiwan
| | - Feng‐Huei Lin
- Department of Biomedical Engineering College of Medicine and College of Engineering, National Taiwan University Taipei Taiwan
- Institute of Biomedical Engineering and Nanomedicine National Health Research Institutes Zhunan, Miaoli County Taiwan
- PhD Program in Tissue Engineering and Regenerative Medicine National Chung Hsing University Taichung Taiwan
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12
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Endometrial Microbiome and Women’s Reproductive Health – Review of the Problem Endometrial Microbiome and Reproductive Health. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2021. [DOI: 10.22207/jpam.15.4.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Currently, unlike in the past, the endometrial cavity is not considered to be sterile. The endometrium is supposed to be dominated by Lactobacilli, but also their deficiency can be found in the reproductive tract of asymptomatic healthy women. Sometimes the endometrial microbiome is dominated by various pathological microorganisms, and this can lead to various conditions as chronic endometritis, chorioamnionitis and preterm birth. Their presence causes uterine inflammation and infection, release of pro-inflammatory molecules, uterine contractions, disruption of cervical barrier, premature rupture of membranes. Uterine dysbiosis is associated with recurrent implantation failure and recurrent miscarriages. As the microbiome is important for maintaining immunological homeostasis at the level of gastrointestinal tract Lactobacilli may play a similar function at the level of uterus. The lactobacillus-dominated uterine microbiome is of great importance for maintaining a hostile uterine microenvironment, embryo implantation, early pregnancy development and normal pregnancy outcome.
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13
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Brokaw A, Furuta A, Dacanay M, Rajagopal L, Adams Waldorf KM. Bacterial and Host Determinants of Group B Streptococcal Vaginal Colonization and Ascending Infection in Pregnancy. Front Cell Infect Microbiol 2021; 11:720789. [PMID: 34540718 PMCID: PMC8446444 DOI: 10.3389/fcimb.2021.720789] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/09/2021] [Indexed: 12/17/2022] Open
Abstract
Group B streptococcus (GBS) is a gram-positive bacteria that asymptomatically colonizes the vaginal tract. However, during pregnancy maternal GBS colonization greatly predisposes the mother and baby to a wide range of adverse outcomes, including preterm birth (PTB), stillbirth, and neonatal infection. Although many mechanisms involved in GBS pathogenesis are partially elucidated, there is currently no approved GBS vaccine. The development of a safe and effective vaccine that can be administered during or prior to pregnancy remains a principal objective in the field, because current antibiotic-based therapeutic strategies do not eliminate all cases of invasive GBS infections. Herein, we review our understanding of GBS disease pathogenesis at the maternal-fetal interface with a focus on the bacterial virulence factors and host defenses that modulate the outcome of infection. We follow GBS along its path from an asymptomatic colonizer of the vagina to an invasive pathogen at the maternal-fetal interface, noting factors critical for vaginal colonization, ascending infection, and vertical transmission to the fetus. Finally, at each stage of infection we emphasize important host-pathogen interactions, which, if targeted therapeutically, may help to reduce the global burden of GBS.
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Affiliation(s)
- Alyssa Brokaw
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Global Health, University of Washington, Seattle, WA, United States
| | - Anna Furuta
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Global Health, University of Washington, Seattle, WA, United States
| | - Matthew Dacanay
- Department of Obstetrics & Gynecology, University of Washington, Seattle, WA, United States
| | - Lakshmi Rajagopal
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Global Health, University of Washington, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Kristina M Adams Waldorf
- Department of Global Health, University of Washington, Seattle, WA, United States.,Department of Obstetrics & Gynecology, University of Washington, Seattle, WA, United States.,Department of Obstetrics and Gynecology, University of Washington and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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14
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Reply to "Cervical cerclage in twin pregnancies". Taiwan J Obstet Gynecol 2021; 60:962. [PMID: 34507691 DOI: 10.1016/j.tjog.2021.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 11/22/2022] Open
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15
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Hessami K, Kyvernitakis I, Cozzolino M, Moisidis-Tesch C. McDonald versus Shirodkar cervical cerclage for prevention of preterm birth: a systematic review and meta-analysis of pregnancy outcomes. J Matern Fetal Neonatal Med 2021; 35:6510-6517. [PMID: 33926339 DOI: 10.1080/14767058.2021.1916911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To compare pregnancy outcomes of patients undergoing either McDonald or Shirodkar cervical cerclage. METHODS PubMed, Web of Science, Scopus, and Google scholar were systematically searched up to June 2020. Inter-study heterogeneity was assessed using Cochrane's Q test and the I2 statistic. Data were pooled using the fixed- or random-effects model and expressed as relative risk (RR) or weighted mean difference (WMD) as appropriately. RESULTS A total of eight observational studies, reporting data on 724 pregnancies, were included in this meta-analysis. As compared to the Shirodkar cerclage, the pooled findings showed that the gestational age at delivery (WMD = -1.95, 95% CI: -2.89 to -1.01, p < .001; I2 = 57.5%) and birth weight (WMD = -355.69, 95% CI: -413.76 to -297.62, p < .001; I2 = 28.8%) were significantly lower in McDonald cerclage. The risk of preterm premature rupture of the membranes (PPROM) (RR = 1.76; 95% CI: 1.14 - 2.71; I2 = 0.0%) and neonatal intensive care unit (NICU) admission (RR = 1.61; 95% CI: 1.09 - 2.39; I2 = 62.1%) were also higher for McDonald group. However, no significant difference was observed between both groups in terms of cesarean delivery and perinatal/neonatal death. CONCLUSION McDonald cerclage is associated with a shorter duration of pregnancy, lower mean birth weight and increased risk of PPROM and NICU admission compared to the Shirodkar procedure.
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Affiliation(s)
- Kamran Hessami
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ioannis Kyvernitakis
- Department of Obstetrics and Prenatal Medicine, Asklepios Clinics Barmbek, Heidberg-Nord and Wandsbek, Hamburg, Germany
| | - Mauro Cozzolino
- IVIRMA, IVI Foundation, Valencia, Spain; Universidad Rey Juan Carlos, Móstoles, Madrid, Spain.,Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, US
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16
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Wu FT, Chen YY, Chen CP, Sun FJ, Chen CY. Outcomes of ultrasound-indicated cerclage in twin pregnancies with a short cervical length. Taiwan J Obstet Gynecol 2021; 59:508-513. [PMID: 32653121 DOI: 10.1016/j.tjog.2020.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To investigate the outcomes of ultrasound-indicated cerclage in dichorionic-diamniotic (DCDA) twin pregnancies with a short cervical length. MATERIALS AND METHODS This was a retrospective cohort study of DCDA twin pregnancies with a short cervical length (≤25 mm) from January 2000 to July 2017 to compare maternal and neonatal outcomes. Additional sub-analysis was performed by dividing the patients into two subgroups by a cervical length ≤15 mm and between 16 and 25 mm. RESULTS One hundred and eight women were initially diagnosed with twin pregnancies and cervical insufficiency. After excluding cases not meeting the study criteria, 46 women were recruited for analysis, of whom 33 underwent ultrasound-indicated cerclage. The delivery age of the cerclage group was significantly later than the non-cerclage group (34.85 ± 3.91 versus 31.08 ± 5.25 weeks, p = 0.011), and the latency was significantly longer in the cerclage group than in the non-cerclage group (86.09 ± 41.32 versus 52.31 ± 33.24 days, p = 0.014). Sub-analysis revealed that these benefits were significant in the subgroup of a cervical length ≤15 mm. Both first twin (twin A) and second twin (twin B) had a significantly decreased rate of neonatal intensive care unit admission in the cerclage group. However, twin A had more promising outcomes with significantly decreased rates of neonatal respiratory distress syndrome (6.7% versus 50.0%, p = 0.004) and sepsis (0% versus 25.0%, p = 0.019). CONCLUSION Ultrasound-indicated cerclage in DCDA twin pregnancies can decrease preterm birth and prolong the latency. It also decreases neonatal morbidity, and is especially beneficial for twin A.
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Affiliation(s)
- Fang-Tzu Wu
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Ying-Yu Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chie-Pein Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Fang-Ju Sun
- Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chen-Yu Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.
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17
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Salleh N, Ismail N, Nelli G, Myint K, Khaing SL. Changes in fluid composition and expression of ion channels in rat cervix during different phases of the estrus cycle. Biotech Histochem 2021; 97:53-66. [PMID: 33827344 DOI: 10.1080/10520295.2021.1899285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
We investigated changes in the composition of cervical fluid at different phases of the female rat reproductive cycle. Fluid was collected from the cervix of rats by direct cervical flushing and analyzed for changes in Na+ and Cl- content and osmolarity. Following sacrifice, the cervix was harvested and expressions of mRNA and protein for ENaCs, CFTR and AQPs were measured using qPCR and immunohistochemistry, respectively. Cervical fluid Na+ and Cl- content was high during estrus, but osmolarity was high during metestrus and diestrus. Expressions of CFTR, AQP-1 and AQP-2 in the cervix were high during estrus, but low during diestrus. Expression of ENaC (α, β, γ), AQP-5 and AQP-7 was high during metestrus and diestrus and low during estrus. Changes in expression of ion channels in the cervix could explain changes in cervical fluid composition during the estrus cycle phases that could affect female fertility.
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Affiliation(s)
- Naguib Salleh
- Department of Physiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nurain Ismail
- Department of Physiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Giribabu Nelli
- Department of Physiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kyaimon Myint
- Department of Physiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Si Lay Khaing
- Department of Obstetrics & Gynecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Medical Education Department, University of Medicine, Yangon, Myanmar
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18
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Chawanpaiboon S, Titapant V, Anuwutnavin S, Kanjanapongporn A, Pooliam J. Identifying the barriers to universal cervical length screening for preterm birth prevention at a tertiary hospital in Thailand (patient's perspectives): implementation research. Arch Gynecol Obstet 2021; 304:1179-1188. [PMID: 33783615 DOI: 10.1007/s00404-021-06045-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 03/18/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To identify patient perspectives of barriers to cervical length screening to prevent preterm births. METHODS In Phase I of this prospective descriptive implementation study, 40 pregnant women of up to 24 week gestation were interviewed. Phase II comprised questionnaire development and data validation. The questionnaire was subsequently administered to 400 participants in Phase III. RESULTS Most participants (74.3%) realised preterm babies have complications and high care costs (53%). They recognised that premature-birth risk identification enables appropriate pregnancy care (93.8%), but they were unaware that cervical length measurements indicate the risk (59.5%). The participants who were aware wanted to be examined (63.5%) because of concern about preterm birth (95.8%). Husbands were reported to influence decision-making about screening (81.3%) and subsequent treatment (42.5%). If the associated costs were subsidised, the majority of participants (67.3%) would undergo screening. CONCLUSION Physicians do not explain ways to prevent preterm births. Government policy on preventing preterm births is not well established. Screening and treatment costs are major barriers. TRIAL REGISTRATION Thai Clinical Trials Registry (TCTR) number: TCTR20190813003.
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Affiliation(s)
- Saifon Chawanpaiboon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand.
| | - Vitaya Titapant
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Sanitra Anuwutnavin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Attapol Kanjanapongporn
- Department of Social Sciences, Faculty of Social Sciences and Humanities, Mahidol University, Bangkok, 10700, Thailand
| | - Julaporn Pooliam
- Clinical Epidemiological Unit, Office for Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
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Son GH, Choi SY, Ju YJ, Lee KY, Lee JJ, Song JE, Kim Y, Park ST. Whole blood RNA sequencing reveals a differential transcriptomic profile associated with cervical insufficiency: a pilot study. Reprod Biol Endocrinol 2021; 19:32. [PMID: 33627129 PMCID: PMC7903645 DOI: 10.1186/s12958-021-00715-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/11/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The uterine cervix is a mechanical and immunological barrier against ascending infection during pregnancy. Cervical insufficiency (CI), a painless cervical dilation that occurs in the mid-trimester, is an important cause of extremely preterm birth. We hypothesized that women with CI have a differential transcriptomic profile. Therefore, we compared the transcriptomic profile of peripheral blood in women with CI and that of controls. METHODS RNA sequencing was used to generate the global gene expression profiles of 11 women with CI and 4 controls, and differential expression analysis was performed to identify genes showing significant expression changes between the CI (n = 11) and control (n = 4) groups as well as between the CI-preterm (n = 7) and CI-term (n = 4) groups. Gene set enrichment was assessed in terms of Gene Ontology processes, and a subset of differentially expressed genes in CI was validated in a different sample-set by qRT-PCR and ELISA. RESULTS Thirty genes were differentially expressed between the CI and control groups. Differentially upregulated genes in the CI group included neutrophil-mediated immunity-associated (DEFA3 and ELANE) and bicarbonate transport-related genes. The serum concentration of alpha defensin 3 was significantly higher in women with CI than in controls (P = 0.014). Analysis of differential gene expression according to pregnancy outcomes revealed 338 differentially expressed genes between the CI-term and CI-preterm groups. Immune and defense response to organism-associated genes and influenza A and NOD-like receptor signaling pathways were upregulated in the CI-term group. CONCLUSIONS Our results revealed significant differences in the whole blood transcriptomic profiles of women with CI compared to those of controls. Different immune responses in women with CI may affect pregnancy outcomes.
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Affiliation(s)
- Ga-Hyun Son
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, 665, Siheung-daero, Youngdeungpo-gu, Seoul, 07442, Republic of Korea
- Institute of New Frontier Research, College of Medicine, Hallym University, Hallymdaehak-gil, Chuncheon, 24252, Republic of Korea
| | - So Yeon Choi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, 665, Siheung-daero, Youngdeungpo-gu, Seoul, 07442, Republic of Korea
| | - Yeon-Ji Ju
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, 665, Siheung-daero, Youngdeungpo-gu, Seoul, 07442, Republic of Korea
| | - Keun-Young Lee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, 665, Siheung-daero, Youngdeungpo-gu, Seoul, 07442, Republic of Korea
| | - Jae Jun Lee
- Institute of New Frontier Research, College of Medicine, Hallym University, Hallymdaehak-gil, Chuncheon, 24252, Republic of Korea
- Departments of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, South Korea
| | - Ji-Eun Song
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, 665, Siheung-daero, Youngdeungpo-gu, Seoul, 07442, Republic of Korea
| | - Youngmi Kim
- Institute of New Frontier Research, College of Medicine, Hallym University, Hallymdaehak-gil, Chuncheon, 24252, Republic of Korea.
| | - Sung Taek Park
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, 665, Siheung-daero, Youngdeungpo-gu, Seoul, 07442, Republic of Korea.
- Institute of New Frontier Research, College of Medicine, Hallym University, Hallymdaehak-gil, Chuncheon, 24252, Republic of Korea.
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Romero R, Gomez-Lopez N, Winters AD, Jung E, Shaman M, Bieda J, Panaitescu B, Pacora P, Erez O, Greenberg JM, Ahmad MM, Hsu CD, Theis KR. Evidence that intra-amniotic infections are often the result of an ascending invasion - a molecular microbiological study. J Perinat Med 2019; 47:915-931. [PMID: 31693497 PMCID: PMC7147941 DOI: 10.1515/jpm-2019-0297] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 08/18/2019] [Indexed: 12/15/2022]
Abstract
Background Microbial invasion of the amniotic cavity resulting in intra-amniotic infection is associated with obstetrical complications such as preterm labor with intact or ruptured membranes, cervical insufficiency, as well as clinical and histological chorioamnionitis. The most widely accepted pathway for intra-amniotic infection is the ascension of microorganisms from the lower genital tract. However, hematogenous dissemination of microorganisms from the oral cavity or intestine, retrograde seeding from the peritoneal cavity through the fallopian tubes, and introduction through invasive medical procedures have also been suggested as potential pathways for intra-amniotic infection. The primary reason that an ascending pathway is viewed as most common is that the microorganisms most often detected in the amniotic fluid are those that are typical inhabitants of the vagina. However, thus far, no studies have shown that microorganisms in the amniotic cavity are simultaneously present in the vagina of the woman from which they were isolated. The objective of the study was to determine the frequency with which microorganisms isolated from women with intra-amniotic infection are also present in the lower genital tract. Methods This was a cross-sectional study of women with intra-amniotic infection with intact membranes. Intra-amniotic infection was defined as a positive culture and elevated concentrations of interleukin-6 (IL-6) (>2.6 ng/mL) in amniotic fluid and/or acute histologic chorioamnionitis and funisitis. Microorganisms isolated from bacterial cultures of amniotic fluid were taxonomically identified through matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF) and 16S ribosomal RNA (rRNA) gene sequencing. Vaginal swabs were obtained at the time of amniocentesis for the identification of microorganisms in the lower genital tract. The overall bacterial profiles of amniotic fluids and vaginal swabs were characterized through 16S rRNA gene sequencing. The bacterial profiles of vaginal swabs were interrogated for the presence of bacteria cultured from amniotic fluid and for the presence of prominent (>1% average relative abundance) operational taxonomic units (OTUs) within the overall 16S rRNA gene bacterial profiles of amniotic fluid. Results (1) A total of 75% (6/8) of women had bacteria cultured from their amniotic fluid that are typical residents of the vaginal ecosystem. (2) A total of 62.5% (5/8) of women with bacteria cultured from their amniotic fluid also had these bacteria present in their vagina. (3) The microorganisms cultured from amniotic fluid and also detected in the vagina were Ureaplasma urealyticum, Escherichia coli, and Streptococcus agalactiae. (4) 16S rRNA gene sequencing revealed that the amniotic fluid of women with intra-amniotic infection had bacterial profiles dominated by Sneathia, Ureaplasma, Prevotella, Lactobacillus, Escherichia, Gardnerella, Peptostreptococcus, Peptoniphilus, and Streptococcus, many of which had not been cultured from the amniotic fluid samples. (5) Seventy percent (7/10) of the prominent (>1% average relative abundance) OTUs found in amniotic fluid were also prominent in the vagina. Conclusion The majority of women with intra-amniotic infection had bacteria cultured from their amniotic fluid that were typical vaginal commensals, and these bacteria were detected within the vagina at the time of amniocentesis. Molecular microbiological interrogation of amniotic fluid from women with intra-amniotic infection revealed that the bacterial profiles of amniotic fluid were largely consistent with those of the vagina. These findings indicate that ascension from the lower genital tract is the primary pathway for intra-amniotic infection.
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA
- Detroit Medical Center, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Florida International University, Miami, FL, USA
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, MI, USA
- Perinatal Research Initiative in Maternal, Perinatal and Child Health, Wayne State University School of Medicine, Detroit, MI, USA
| | - Andrew D. Winters
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Eunjung Jung
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Majid Shaman
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Janine Bieda
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Bogdan Panaitescu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Maternity Department “D,” Division of Obstetrics and Gynecology, Soroka University Medical Center School of Medicine, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Jonathan M. Greenberg
- Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Madison M. Ahmad
- Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Perinatal Research Initiative in Maternal, Perinatal and Child Health, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Physiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Kevin R. Theis
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
- Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, MI, USA
- Perinatal Research Initiative in Maternal, Perinatal and Child Health, Wayne State University School of Medicine, Detroit, MI, USA
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Vornhagen J, Quach P, Santana-Ufret V, Alishetti V, Brokaw A, Armistead B, Qing Tang H, MacDonald JW, Bammler TK, Adams Waldorf KM, Uldbjerg N, Rajagopal L. Human Cervical Mucus Plugs Exhibit Insufficiencies in Antimicrobial Activity Towards Group B Streptococcus. J Infect Dis 2019; 217:1626-1636. [PMID: 29425317 DOI: 10.1093/infdis/jiy076] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 02/05/2018] [Indexed: 01/31/2023] Open
Abstract
Preterm birth is a leading cause of neonatal mortality and lacks an effective therapy. Ascending microbial infections from the lower genital tract lead to infection of the placenta, amniotic fluid, and fetus causing preterm birth or stillbirth. Directly in the path of an ascending infection is the cervical mucus plug (CMP), a dense mucoid structure in the cervical canal with potential antimicrobial properties. In this study, we aimed to define the components of CMP responsible for antimicrobial activity against a common lower genital tract organism associated with preterm birth and stillbirths, namely, group B streptococcus (GBS). Using a quantitative proteomic approach, we identified antimicrobial factors in CMPs that were collected from healthy human pregnancies. However, we noted that the concentration of antimicrobial peptides present in the human CMPs were insufficient to directly kill GBS, and antimicrobial activity, when observed, was due to antibiotics retained in the CMPs. Despite this insufficiency, CMP proteins were able to activate leukocytes in whole blood resulting in increased rates of bacterial killing, suggesting a role for the CMP in enhancing complement-mediated killing or leukocyte activation. This study provides new insight into how the human CMP may limit ascending bacterial infection.
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Affiliation(s)
- Jay Vornhagen
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Washington.,Department of Global Health, University of Washington, Seattle
| | - Phoenicia Quach
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Washington
| | - Verónica Santana-Ufret
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Washington
| | - Varchita Alishetti
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Washington
| | - Alyssa Brokaw
- Department of Global Health, University of Washington, Seattle
| | - Blair Armistead
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Washington.,Department of Pediatrics, University of Washington, Seattle.,Department of Global Health, University of Washington, Seattle
| | - Hai Qing Tang
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, Denmark
| | - James W MacDonald
- Environmental and Occupational Health Sciences, University of Washington, Seattle
| | - Theo K Bammler
- Environmental and Occupational Health Sciences, University of Washington, Seattle
| | - Kristina M Adams Waldorf
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Washington.,Department of Obstetrics and Gynecology, University of Washington, Seattle.,Center for Innate Immunity and Immune Disease, University of Washington, Seattle.,Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, Denmark
| | - Lakshmi Rajagopal
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Washington.,Center for Innate Immunity and Immune Disease, University of Washington, Seattle.,Department of Pediatrics, University of Washington, Seattle.,Department of Global Health, University of Washington, Seattle
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22
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23
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Heerema-McKenney A. Defense and infection of the human placenta. APMIS 2018; 126:570-588. [PMID: 30129129 DOI: 10.1111/apm.12847] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/22/2018] [Indexed: 12/14/2022]
Abstract
The placenta functions as a shield against infection of the fetus. The innate and adaptive immune defenses of the developing fetus are poorly equipped to fight infections. Infection by bacteria, viruses, and protozoa may cause infertility, spontaneous abortion, stillbirth, growth retardation, anomalies of development, premature delivery, neonatal morbidity, and mortality. However, appreciation of the human microbiome and host cell-microbe interactions must be taken into consideration as we try to determine what interactions are pathologic. Infection is typically recognized histologically by the presence of inflammation. Yet, several factors make comparison of the placenta to other human organs difficult. The placenta comprises tissues from two persons, complicating the role of the immune system. The placenta is a temporary organ. It must be eventually expelled; the processes leading to partuition involve maternal inflammation. What is normal or pathologic may be a function of timing or extent of the process. We now must consider whether bacteria, and even some viruses, are useful commensals or pathogens. Still, recognizing infection of the placenta is one of the most important contributions placental pathologic examination can give to care of the mother and neonate. This review provides a brief overview of placental defense against infection, consideration of the placental microbiome, routes of infection, and the histopathology of amniotic fluid infection and TORCH infections.
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Affiliation(s)
- Amy Heerema-McKenney
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
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24
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Prevention of spontaneous preterm birth: universal cervical length assessment and vaginal progesterone in women with a short cervix: time for action! Am J Obstet Gynecol 2018; 218:151-158. [PMID: 29422255 DOI: 10.1016/j.ajog.2017.12.222] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/20/2017] [Indexed: 01/12/2023]
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25
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Probing the potential of mucus permeability to signify preterm birth risk. Sci Rep 2017; 7:10302. [PMID: 28871085 PMCID: PMC5583328 DOI: 10.1038/s41598-017-08057-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 07/04/2017] [Indexed: 12/22/2022] Open
Abstract
Preterm birth is the leading cause of neonatal mortality, and is frequently associated with intra-amniotic infection hypothesized to arise from bacterial ascension across a dysfunctional cervical mucus plug. To study this dysfunction, we assessed the permeability of cervical mucus from non-pregnant ovulating (n = 20) and high- (n = 9) and low-risk (n = 16) pregnant women to probes of varying sizes and surface chemistries. We found that the motion of negatively charged, carboxylated microspheres in mucus from pregnant patients was significantly restricted compared to ovulating patients, but not significantly different between high- and low-risk pregnant women. In contrast, charged peptide probes small enough to avoid steric interactions, but sensitive to the biochemical modifications of mucus components exhibited significantly different transport profiles through mucus from high- and low-risk patients. Thus, although both microstructural rearrangements of the components of mucus as well as biochemical modifications to their adhesiveness may alter the overall permeability of the cervical mucus plug, our findings suggest that the latter mechanism plays a dominant role in the impairment of the function of this barrier during preterm birth. We expect that these probes may be readily adapted to study the mechanisms underlying disease progression on all mucosal epithelia, including those in the mouth, lungs, and gut.
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26
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Bayrak M, Gul A, Goynumer G. Rescue cerclage when foetal membranes prolapse into the vagina. J OBSTET GYNAECOL 2017; 37:471-475. [DOI: 10.1080/01443615.2016.1268574] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Mehmet Bayrak
- Istanbul Medeniyet University Goztepe Education and Research Hospital, Istanbul, Turkey
| | - Ahmet Gul
- Istanbul Prenatal Center, Istanbul, Turkey
| | - Gokhan Goynumer
- Istanbul Medeniyet University Goztepe Education and Research Hospital, Istanbul, Turkey
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27
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Park HJ, Kim YS, Yoon TK, Lee WS. Chronic endometritis and infertility. Clin Exp Reprod Med 2016; 43:185-192. [PMID: 28090456 PMCID: PMC5234283 DOI: 10.5653/cerm.2016.43.4.185] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 06/09/2016] [Accepted: 06/30/2016] [Indexed: 11/22/2022] Open
Abstract
Chronic endometritis (CE) is a condition involving the breakdown of the peaceful co-existence between microorganisms and the host immune system in the endometrium. A majority of CE cases produce no noticeable signs or mild symptoms, and the prevalence rate of CE has been found to be approximately 10%. Gynecologists and pathologists often do not focus much clinical attention on CE due to the time-consuming microscopic examinations necessary to diagnose CE, its mild clinical manifestations, and the benign nature of the disease. However, the relationship between CE and infertility-related conditions such as repeated implantation failure and recurrent miscarriage has recently emerged as an area of inquiry. In this study, we reviewed the literature on the pathophysiology of CE and how it may be associated with infertility, as well as the literature regarding the diagnosis and treatment of CE. In addition, we discuss the value of hysteroscopic procedures in the diagnosis and treatment of CE.
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Affiliation(s)
- Hyun Jong Park
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gumi Medical Center, CHA University, Gumi, Korea
| | - You Shin Kim
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Tae Ki Yoon
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Woo Sik Lee
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University, Seoul, Korea
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28
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Miech RP. Pathopharmacology of Excessive Hemorrhage in Mifepristone Abortions. Ann Pharmacother 2016; 41:2002-7. [DOI: 10.1345/aph.1k351] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To explain a pathopharmacologic mechanism that initiates an increase in hemorrhage following medical abortions with mifepristone. Data Sources: MEDLINE, PubMed, and Google Scholar databases were searched (1990–July 2007). Key search terms were mifepristone, RU486, medical abortion hemorrhage, bleeding, inflammation, innate immune system, phagocytes, macrocytes, cytokines, interleukins, and nitric oxide. Study Selection and Data Extraction: All articles identified from the data sources were evaluated and all information deemed relevant was included for the information related to the development of the understanding of the pathopharmacology of mifepristone as the initiating cause of increased hemorrhage in medical abortions. Mifepristone's blockade of glucocorticoid receptors, prolonged generation of nitric oxide (NO), and postabortion vasodilatation of uterine vasculature by NO that favors excessive hemontiage were the criteria used to determine whether information was relevant for inclusion. Data Synthesis: Inescapable bacterial contamination of the decidua accompanies spontaneous, surgical, and mifepristone abortions and is routinely overcome by activation of the innate immune system. The combination of the induction of NO synthase (NOS) and local production of NO is one of the key features of the activation of the innate immune system's phagocytes. NO is a potent vasodilator and is associated with menstrual menorrhagia. Glucocorticoids prevent the overproduction of NOS and NO and thereby contribute to the control of hemorrhage in the postabortion phase. Conclusions: Blockade of the glucocorticoid receptors by mifepristone can result in an excess of NO that is theorized to be the cause of excessive hemorrhage seen in mifepristone abortions.
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Affiliation(s)
- Ralph P Miech
- Department of Molecular Pharmacology (Box GB3), Warren Alpert Medical School, Brown University, Providence, RI 02912
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Bastholm SK, Samson MH, Becher N, Hansen LK, Stubbe PR, Chronakis IS, Nexo E, Uldbjerg N. Trefoil factor peptide 3 is positively correlated with the viscoelastic properties of the cervical mucus plug. Acta Obstet Gynecol Scand 2016; 96:47-52. [PMID: 27731893 DOI: 10.1111/aogs.13038] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 10/07/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The viscoelastic properties of the cervical mucus plug are considered essential for the occlusion of the cervical canal and thereby for protection against ascending infections during pregnancy. Factors controlling this property are virtually unknown. This study explores a possible role of trefoil factor peptides 1, 2 and 3 (TFF1-3); peptides believed to influence mucus viscosity. MATERIAL AND METHODS The study is based on spontaneously shed cervical mucus plugs from 14 women in active labor. The viscoelastic properties; the elastic modulus (G') and the viscous modulus (G") were determined by an oscillatory rheometer. The concentrations of TFF1-3 were measured by an in-house enzyme-linked immunosorbent assay. Associations were analyzed by random-effects generalized least-squares regression analyses. RESULTS Median (range) concentrations of TFF1, TFF2 and TFF3 were 3.1 (1.2-8.6), 1.1 (<0.006-3.7) and 1000 (170-5300) nmol/g cervical mucus plug, respectively. The TFF3 concentration was associated with G' (regression coefficient 11.7 Pa/Log nm; 95% CI 3.0-20.4, p = 0.009) and G" (regression coefficient 3.2 Pa/Log nm; 95% CI 1.5-5.0, p < 0.001). CONCLUSION We suggest that TFF3 plays a role in the viscoelastic properties of the cervical mucus plug.
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Affiliation(s)
- Sara K Bastholm
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Mie H Samson
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Naja Becher
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
| | - Lea K Hansen
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Peter R Stubbe
- Food Production Engineering Research Group, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Ioannis S Chronakis
- Nano-BioScience Research Group, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Ebba Nexo
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
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Yılanlıoğlu NC, Semiz A, Akpak YK. Management of very early preterm premature rupture of membranes (PPROM) in twin pregnancies by selective feticide. CASE REPORTS IN PERINATAL MEDICINE 2016. [DOI: 10.1515/crpm-2016-0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Aim:
To assess the efficacy of selective termination in improving pregnancy outcome in very early preterm premature rupture of membranes (PPROM) in twin pregnancies.
Methods:
A total of six dichorionic twin intracytoplasmic sperm injection (ICSI) pregnancies complicated with very early PPROM between 17+5 and 19+3 gestational weeks were admitted to our hospital and were managed by selective termination of the member with ruptured membranes and followed up. Two cases were twins reduced from triplets at our unit (33%). The fetuses with ruptured membranes were subjected to feticide by intra-cardiac injection of potassium chloride after a mean of 3.5 days following PPROM.
Results:
The overall PPROM-delivery/miscarriage time-interval was 80 days using the proposed management scheme. Two cases ended with total pregnancy loss at 21+ and 23+ weeks, respectively. Four cases progressed successfully beyond 29 weeks, reaching an average of 35+5 days.
Conclusions:
The handling of these six twin PPROM cases as described produced a healthy baby to take home in four instances, resulting in a success rate of 67%, whereas the implementation of a more conservative approach using antibiotics and steroids is expected to lead to a survival rate of around 15% and a handicap rate up to 50%.
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Tajik P, Monfrance M, van 't Hooft J, Liem SMS, Schuit E, Bloemenkamp KWM, Duvekot JJ, Nij Bijvank B, Franssen MTM, Oudijk MA, Scheepers HCJ, Sikkema JM, Woiski M, Mol BWJ, Bekedam DJ, Bossuyt PM, Zafarmand MH. A multivariable model to guide the decision for pessary placement to prevent preterm birth in women with a multiple pregnancy: a secondary analysis of the ProTWIN trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:48-55. [PMID: 26748537 DOI: 10.1002/uog.15855] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 12/16/2015] [Accepted: 12/23/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE The ProTWIN Trial (NTR1858) showed that, in women with a multiple pregnancy and a cervical length < 25(th) percentile (38 mm), prophylactic use of a cervical pessary reduced the risk of adverse perinatal outcome. We investigated whether other maternal or pregnancy characteristics collected at baseline can improve identification of women most likely to benefit from pessary placement. METHODS ProTWIN is a multicenter randomized trial in which 808 women with a multiple pregnancy were assigned to pessary or control. Using these data we developed a multivariable logistic model comprising treatment, cervical length, chorionicity, pregnancy history and number of fetuses, and the interaction of these variables with treatment as predictors of adverse perinatal outcome. RESULTS Short cervix, monochorionicity and nulliparity were predictive factors for a benefit from pessary insertion. History of previous preterm birth and triplet pregnancy were predictive factors of possible harm from pessary. The model identified 35% of women as benefiting (95% CI, 32-39%), which is 10% more than using cervical length only (25%) for pessary decisions. The model had acceptable calibration. We estimated that using the model to guide the choice of pessary placement would reduce the risk of adverse perinatal outcome significantly from 13.5% when no pessary is inserted to 8.1% (absolute risk reduction, 5.4% (95% CI, 2.1-8.6%)). CONCLUSIONS We developed and internally validated a multivariable treatment selection model, with cervical length, chorionicity, pregnancy history and number of fetuses. If externally validated, it could be used to identify women with a twin pregnancy who would benefit from a pessary, and lead to a reduction in adverse perinatal outcomes in these women. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- P Tajik
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands
| | - M Monfrance
- Department of Obstetrics and Gynaecology, Atrium Medical Centre, Heerlen, The Netherlands
| | - J van 't Hooft
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - S M S Liem
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - E Schuit
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - K W M Bloemenkamp
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - J J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - B Nij Bijvank
- Department of Obstetrics and Gynaecology, Isala Clinics, Zwolle, The Netherlands
| | - M T M Franssen
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, Groningen, The Netherlands
| | - M A Oudijk
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H C J Scheepers
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - J M Sikkema
- Department of Obstetrics and Gynaecology, ZGT, Almelo, The Netherlands
| | - M Woiski
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - B W J Mol
- The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia
| | - D J Bekedam
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - P M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands
| | - M H Zafarmand
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
- Department of Public Health, Academic Medical Centre, Amsterdam, The Netherlands
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Choi J, Park JW, Kim BJ, Choi YJ, Hwang JH, Lee SM. Funisitis is more common in cervical insufficiency than in preterm labor and preterm premature rupture of membranes. J Perinat Med 2016; 44:523-9. [PMID: 26812854 DOI: 10.1515/jpm-2015-0123] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 12/07/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare the frequency of histologic chorioamnionitis and funisitis among women experiencing preterm labor, preterm premature rupture of membranes (PROM) and cervical insufficiency. METHODS This retrospective cohort study included singleton pregnant women who delivered at ≤36 weeks of gestation. The patients with preterm birth were subdivided into preterm labor (n=117), preterm PROM (n=153), and cervical insufficiency (n=20). All placentas were examined for pathology, according to the criteria of Salafia with minor modification. Frequencies of histologic chorioamnionitis and funisitis were evaluated according to the causes of preterm birth. RESULTS 1) Histologic chorioamnionitis was diagnosed in 48.7% (57/117) of cases with preterm labor, 47.4% (73/153) with preterm PROM, and 75.0% (15/20) with cervical insufficiency. Funisitis was detected in 11.1% (13/117) of cases with preterm labor, 15.7% (24/153) with preterm PROM, and 40.0% (8/20) with cervical insufficiency. 2) Frequency of histologic chorioamnionitis was higher in cases with cervical insufficiency compared to preterm PROM. Frequency of funisitis was higher in cases with cervical insufficiency compared to both preterm labor and preterm PROM (P<0.05). The difference in frequency of funisitis remained significant after adjustment for gestational age at delivery and cervical dilatation at diagnosis. 3) Frequency of grade 2 funisitis was higher in cases with cervical insufficiency (35.0%, 7/20) compared to both preterm labor (6.8%, 8/117) and preterm PROM (9.8%, 15/153) (P=0.001). And the difference remained significant after adjustment for gestational age at delivery and cervical dilatation at diagnosis. CONCLUSION The highest frequency of funisitis was observed in cervical insufficiency among cases with spontaneous preterm birth.
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Wong CH, Chen CP, Wang KG, Sun FJ, Chen CY. Comparison of two cervical cerclages for the prevention of preterm birth and neonatal complications. J Matern Fetal Neonatal Med 2016; 30:551-555. [PMID: 27072547 DOI: 10.1080/14767058.2016.1177818] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To investigate the outcomes of singleton pregnant women with cervical insufficiency undergoing two different cervical cerclages. METHODS This is a retrospective cohort study of women who underwent a history- or ultrasound-indicated cerclage (either Shirodkar or McDonald) at a tertiary referral center from 2002 to 2014. Outcome parameters (delivery age, postoperative cervical length, preterm premature rupture of membranes, preterm delivery rate and neonatal complications) were compared between the two cerclage procedures. Multivariate logistic regression analysis was applied to control for significant variables of preterm birth. Kaplan-Meier survival analysis was used to demonstrate delivery age to percentage of term delivery by cerclage type. RESULTS Ninety-four cases were initially included. After excluding cases not meeting the study criteria, 60 pregnancies (Shirodkar 36 and McDonald 24) were recruited for analysis. The mean delivery age in the Shirodkar group was more advanced than that in the McDonald group (37.1 ± 3.3 versus 34.8 ± 4.9 weeks, p = 0.039). There were significantly fewer deliveries <37 gestational weeks in the Shirodkar group than in the McDonald group (30.6% versus 58.3%, p = 0.033) but no significant differences in deliveries <28, 32 and 34 gestational weeks. No significant differences were found in neonatal complications except for respiratory distress syndrome (5.6% in Shirodkar versus 29.2% in McDonald, p = 0.023). CONCLUSION In the setting of history-indicated or ultrasound-indicated cerclage, Shirodkar was superior to McDonald in the prevention of late preterm birth and neonatal respiratory distress syndrome.
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Affiliation(s)
- Chian-Huey Wong
- a Department of Obstetrics and Gynecology , Mackay Memorial Hospital , Taipei , Taiwan
| | - Chie-Pein Chen
- a Department of Obstetrics and Gynecology , Mackay Memorial Hospital , Taipei , Taiwan
| | - Kuo-Gon Wang
- a Department of Obstetrics and Gynecology , Mackay Memorial Hospital , Taipei , Taiwan
| | - Fang-Ju Sun
- b Department of Medical Research , Mackay Memorial Hospital , Taipei , Taiwan , and
| | - Chen-Yu Chen
- a Department of Obstetrics and Gynecology , Mackay Memorial Hospital , Taipei , Taiwan.,c Department of Medicine , Mackay Medical College , New Taipei City , Taiwan
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Liem SM, Schuit E, van Pampus MG, van Melick M, Monfrance M, Langenveld J, Mol BW, Bekedam D. Cervical pessaries to prevent preterm birth in women with a multiple pregnancy: a per-protocol analysis of a randomized clinical trial. Acta Obstet Gynecol Scand 2016; 95:444-51. [DOI: 10.1111/aogs.12849] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/10/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Sophie M.S. Liem
- Obstetrics and Gynecology; Academic Medical Center; Amsterdam the Netherlands
| | - Ewoud Schuit
- Obstetrics and Gynecology; Academic Medical Center; Amsterdam the Netherlands
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht the Netherlands
- Stanford Prevention Research Center; Stanford University; Stanford CA USA
| | - Mariëlle G. van Pampus
- Obstetrics and Gynecology; Onze Lieve Vrouwe Gasthuis Hospital; Amsterdam the Netherlands
| | - Marjo van Melick
- Department of Obstetrics and Gynecology; Academic Hospital Maastricht; Maastricht the Netherlands
| | | | - Josje Langenveld
- Obstetrics and Gynecology; Atrium Hospital; Heerlen the Netherlands
| | - Ben W.J. Mol
- Robinson Research Institute; School for Pediatrics and Reproductive Medicine; University of Adelaide; Adelaide Australia
| | - Dick Bekedam
- Obstetrics and Gynecology; Onze Lieve Vrouwe Gasthuis Hospital; Amsterdam the Netherlands
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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: 599] [Impact Index Per Article: 66.6] [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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Romero R, Miranda J, Chaiworapongsa T, Chaemsaithong P, Gotsch F, Dong Z, Ahmed AI, Yoon BH, Hassan SS, Kim CJ, Korzeniewski SJ, Yeo L, Kim YM. Sterile intra-amniotic inflammation in asymptomatic patients with a sonographic short cervix: prevalence and clinical significance. J Matern Fetal Neonatal Med 2015; 28:1343-1359. [PMID: 25123515 PMCID: PMC4372495 DOI: 10.3109/14767058.2014.954243] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 08/10/2014] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine the frequency and clinical significance of sterile and microbial-associated intra-amniotic inflammation in asymptomatic patients with a sonographic short cervix. METHODS Amniotic fluid (AF) samples obtained by transabdominal amniocentesis from 231 asymptomatic women with a sonographic short cervix [cervical length (CL) ≤25 mm] were analyzed using cultivation techniques (for aerobic and anaerobic as well as genital mycoplasmas) and broad-range polymerase chain reaction (PCR) coupled with electrospray ionization mass spectrometry (PCR/ESI-MS). The frequency and magnitude of intra-amniotic inflammation [defined as an AF interleukin (IL)-6 concentration ≥2.6 ng/mL], acute histologic placental inflammation, spontaneous preterm delivery (sPTD), and the amniocentesis-to-delivery interval were examined according to the results of AF cultures, PCR/ESI-MS and AF IL-6 concentrations. RESULTS Ten percent (24/231) of patients with a sonographic short cervix had sterile intra-amniotic inflammation (an elevated AF IL-6 concentration without evidence of microorganisms using cultivation and molecular methods). Sterile intra-amniotic inflammation was significantly more frequent than microbial-associated intra-amniotic inflammation [10.4% (24/231) versus 2.2% (5/231); p < 0.001]. Patients with sterile intra-amniotic inflammation had a significantly higher rate of sPTD <34 weeks of gestation [70.8% (17/24) versus 31.6% (55/174); p < 0.001] and a significantly shorter amniocentesis-to-delivery interval than patients without intra-amniotic inflammation [median 35, (IQR: 10-70) versus median 71, (IQR: 47-98) days, (p < 0.0001)]. CONCLUSION Sterile intra-amniotic inflammation is more common than microbial-associated intra-amniotic inflammation in asymptomatic women with a sonographic short cervix, and is associated with increased risk of sPTD (<34 weeks). Further investigation is required to determine the causes of sterile intra-amniotic inflammation and the mechanisms whereby this condition is associated with a short cervix and sPTD.
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Affiliation(s)
- 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, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
| | - Jezid Miranda
- 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, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Tinnakorn Chaiworapongsa
- 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, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - 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, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Francesca Gotsch
- 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, USA
- Integrata Verona, Ostetricia Ginecologia, Azienda Ospedaliera Universitaria, Verona, Italy
| | - Zhong Dong
- 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, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ahmed I. Ahmed
- 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, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Bo Hyun Yoon
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Sonia S. Hassan
- 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, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Chong J. 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, USA
- Department of Pathology, College of Medicine Inje University, Haeundae Paik Hospital
| | - Steven J. Korzeniewski
- 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, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Lami Yeo
- 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, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - 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, USA
- Department of Pathology, College of Medicine Inje University, Haeundae Paik Hospital
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Mitchell CM, Haick A, Nkwopara E, Garcia R, Rendi M, Agnew K, Fredricks DN, Eschenbach D. Colonization of the upper genital tract by vaginal bacterial species in nonpregnant women. Am J Obstet Gynecol 2015; 212:611.e1-9. [PMID: 25524398 DOI: 10.1016/j.ajog.2014.11.043] [Citation(s) in RCA: 197] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 11/01/2014] [Accepted: 11/24/2014] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate the upper genital tract (UGT) presence of vaginal bacterial species using sensitive molecular methods capable of detecting fastidious bacterial vaginosis (BV)-associated bacteria. STUDY DESIGN Vaginal swabs were collected prior to hysterectomy. The excised uterus was sterilely opened and swabs collected from the endometrium and upper endocervix. DNA was tested in 11 quantitative polymerase chain reaction (PCR) assays for 12 bacterial species: Lactobacillus iners, L crispatus, L jensenii, Gardnerella vaginalis, Atopobium vaginae, Megasphaera spp, Prevotella spp, Leptotrichia/Sneathia, BVAB1, BVAB2, BVAB3, and a broad-range16S ribosomal ribonucleic acid gene assay. Endometrial fluid was tested with Luminex and an enzyme-linked immunosorbent assay for cytokines and defensins and tissue for gene expression of defensins and cathelicidin. RESULTS We enrolled 58 women: mean aged 43±7 years, mostly white (n=46; 79%) and BV negative (n=43; 74%). By species-specific quantitative PCR, 55 (95%) had UGT colonization with at least 1 species (n=52) or were positive by 16S PCR (n=3). The most common species were L iners (45% UGT, 61% vagina), Prevotella spp (33% UGT, 76% vagina) and L crispatus (33% UGT, 56% vagina). Median quantities of bacteria in the UGT were lower than vaginal levels by 2-4 log10 ribosomal ribonucleic acid gene copies per swab. There were no differences in the endometrial inflammatory markers between women with no bacteria, Lactobacillus only, or any BV-associated species in the UGT. CONCLUSION Our data suggest that the endometrial cavity is not sterile in most women undergoing hysterectomy and that the presence of low levels of bacteria in the uterus is not associated with significant inflammation.
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Yarbrough VL, Winkle S, Herbst-Kralovetz MM. Antimicrobial peptides in the female reproductive tract: a critical component of the mucosal immune barrier with physiological and clinical implications. Hum Reprod Update 2014; 21:353-77. [PMID: 25547201 DOI: 10.1093/humupd/dmu065] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 12/10/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND At the interface of the external environment and the mucosal surface of the female reproductive tract (FRT) lies a first-line defense against pathogen invasion that includes antimicrobial peptides (AMP). Comprised of a unique class of multifunctional, amphipathic molecules, AMP employ a wide range of functions to limit microbial invasion and replication within host cells as well as independently modulate the immune system, dampen inflammation and maintain tissue homeostasis. The role of AMP in barrier defense at the level of the skin and gut has received much attention as of late. Given the far reaching implications for women's health, maternal and fetal morbidity and mortality, and sexually transmissible and polymicrobial diseases, we herein review the distribution and function of key AMP throughout the female reproductive mucosa and assess their role as an essential immunological barrier to microbial invasion throughout the reproductive cycle of a woman's lifetime. METHODS A comprehensive search in PubMed/Medline was conducted related to AMP general structure, function, signaling, expression, distribution and barrier function of AMP in the FRT, hormone regulation of AMP, the microbiome of the FRT, and AMP in relation to implantation, pregnancy, fertility, pelvic inflammatory disease, complications of pregnancy and assisted reproductive technology. RESULTS AMP are amphipathic peptides that target microbes for destruction and have been conserved throughout all living organisms. In the FRT, several major classes of AMP are expressed constitutively and others are inducible at the mucosal epithelium and by immune cells. AMP expression is also under the influence of sex hormones, varying throughout the menstrual cycle, and dependent on the vaginal microbiome. AMP can prevent infection with sexually transmissible and opportunistic pathogens of the female reproductive tissues, although emerging understanding of vaginal dysbiosis suggests induction of a unique AMP profile with increased susceptibility to these pathogens. During pregnancy, AMP are key immune effectors of the fetal membranes and placenta and are dysregulated in states of intrauterine infection and other complications of pregnancy. CONCLUSIONS At the level of the FRT, AMP serve to inhibit infection by sexually and vertically transmissible as well as by opportunistic bacteria, fungi, viruses, and protozoa and must do so throughout the hormone flux of menses and pregnancy. Guarding the exclusive site of reproduction, AMP modulate the vaginal microbiome of the lower FRT to aid in preventing ascending microbes into the upper FRT. Evolving in parallel with, and in response to, pathogenic insults, AMP are relatively immune to the resistance mechanisms employed by rapidly evolving pathogens and play a key role in barrier function and host defense throughout the FRT.
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Affiliation(s)
- Victoria L Yarbrough
- Department of Basic Medical Sciences, University of Arizona College of Medicine-Phoenix, , Phoenix, AZ 85004-2157, USA
| | - Sean Winkle
- Department of Basic Medical Sciences, University of Arizona College of Medicine-Phoenix, , Phoenix, AZ 85004-2157, USA
| | - Melissa M Herbst-Kralovetz
- Department of Basic Medical Sciences, University of Arizona College of Medicine-Phoenix, , Phoenix, AZ 85004-2157, USA
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Thomas JT, Petersen SG, Chua J, Connard S, Gibbons K, Cincotta R, Gardener G. Prominent cervical mucous and its impact on cervical length measurement: findings of a national survey. Aust N Z J Obstet Gynaecol 2014; 54:108-16. [PMID: 24576045 DOI: 10.1111/ajo.12173] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 11/24/2013] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Cervical length measurement by transvaginal scanning (TVS) has been proposed by some as a universal screening test for preterm labour. The presence of prominent cervical mucous may affect assessment of the cervix; however, the exact technique to measure the cervix when there is prominent mucous or funnelling has not been described. We evaluated the level of agreement in cervical length measurements amongst Australian specialists and sonographers reporting on cervical assessment using an online survey. METHODS We conducted an online survey with 11 images of the cervix to assess how obstetric sonographers and sonologists report on the cervix when there is prominent mucous or funnelling. They were asked five questions about the image of the cervix. A kappa coefficient was calculated from the responses. RESULTS We had 151 complete responses to the online survey. For the images which showed funnelling or prominent cervical mucous, there was little agreement regarding the cervix being open or closed and regards the location of the internal os. The Kappa coefficient was 0.22 indicating a low level of agreement for the location of the internal os. CONCLUSION There is lack of agreement amongst Australian specialists and sonographers reporting on cervical assessment when there is prominent mucous or funnelling seen in the cervix. We propose a method to standardise reporting on the cervix incorporating the chorioamniotic membrane for the identification of the inner cervical os when there is prominent mucous or funnelling.
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Affiliation(s)
- Joseph T Thomas
- Center for Maternal Fetal Medicine, Mater Health Services, Brisbane, Queensland, Australia; University of Queensland, Faculty of Medicine and Biomedical Sciences, Brisbane, Queensland, Australia
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Buhimschi CS, Baumbusch MA, Campbell KH, Dulay AT, Buhimschi IA. Insight into innate immunity of the uterine cervix as a host defense mechanism against infection and preterm birth. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.4.1.9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sentilhes L, Descamps P, Legendre G. Pessaire et prévention de l’accouchement prématuré. ACTA ACUST UNITED AC 2014; 42:38-44. [DOI: 10.1016/j.gyobfe.2013.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 10/08/2013] [Indexed: 11/29/2022]
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Abstract
Mid-trimester pregnancy loss (MTL) occurs between 12 and 24 weeks' gestation. The true incidence of this pregnancy complication is unknown, because research into MTL in isolation is scarce, although the estimated incidence has been noted to be 2% to 3% of pregnancies. A comprehensive preconceptual screening protocol is recommended, because the cause for an MTL may be present in isolation or combined (dual pathology), and is often heterogeneous. Patients with a history of MTL are at an increased risk of future miscarriage and preterm delivery. This risk is increased further depending on the number of associative factors diagnosed.
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Affiliation(s)
- Kelly M McNamee
- Department of Obstetrics, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK.
| | - Feroza Dawood
- Department of Obstetrics, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK
| | - Roy G Farquharson
- Department of Gynaecology, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK
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Liem S, Schuit E, Hegeman M, Bais J, de Boer K, Bloemenkamp K, Brons J, Duvekot H, Bijvank BN, Franssen M, Gaugler I, de Graaf I, Oudijk M, Papatsonis D, Pernet P, Porath M, Scheepers L, Sikkema M, Sporken J, Visser H, van Wijngaarden W, Woiski M, van Pampus M, Mol BW, Bekedam D. Cervical pessaries for prevention of preterm birth in women with a multiple pregnancy (ProTWIN): a multicentre, open-label randomised controlled trial. Lancet 2013; 382:1341-9. [PMID: 23924878 DOI: 10.1016/s0140-6736(13)61408-7] [Citation(s) in RCA: 148] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND In women with a multiple pregnancy, spontaneous preterm delivery is the leading cause of perinatal morbidity and mortality. Interventions to reduce preterm birth in these women have not been successful. We assessed whether a cervical pessary could effectively prevent poor perinatal outcomes. METHODS We undertook a multicentre, open-label randomised controlled trial in 40 hospitals in the Netherlands. We randomly assigned women with a multiple pregnancy between 12 and 20 weeks' gestation (1:1) to pessary or control groups, using a web-based application with a computer-generated list with random block sizes of two to four, stratified by hospital. Participants and investigators were aware of group allocation. For women in the pessary group, a midwife or obstetrician inserted a cervical pessary between 16 and 20 weeks' gestation. Women in the control group did not receive the pessary, but otherwise received similar obstetrical care to those in the pessary group. The primary outcome was a composite of poor perinatal outcome: stillbirth, periventricular leucomalacia, severe respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular haemorrhage, necrotising enterocolitis, proven sepsis, and neonatal death. Analyses were by modified intention to treat. This trial is registered in the Dutch trial registry, number NTR1858. FINDINGS Between Sept 21, 2009, and March 9, 2012, 813 women underwent randomisation, of whom 808 were analysed (401 in the pessary group; 407 in the control group). At least one child of 53 women (13%) in the pessary group had poor perinatal outcome, compared with 55 (14%) in the control group (relative risk 0·98, 95% CI 0·69-1·39). INTERPRETATION In unselected women with a multiple pregnancy, prophylactic use of a cervical pessary does not reduce poor perinatal outcome. FUNDING The Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Sophie Liem
- Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, Netherlands.
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Brix N, Secher NJ, McCormack CD, Helmig RB, Hein M, Weber T, Mittal S, Kurdi W, Palacio M, Henriksen TB. Randomised trial of cervical cerclage, with and without occlusion, for the prevention of preterm birth in women suspected for cervical insufficiency. BJOG 2013; 120:613-20. [DOI: 10.1111/1471-0528.12119] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2012] [Indexed: 11/30/2022]
Affiliation(s)
- N Brix
- Department of Paediatrics; Aarhus University Hospital; Skejby; Denmark
| | - NJ Secher
- Departments of Obstetrics and Gynaecology; Copenhagen University Hospital; Rigshospitalet; Denmark
| | - CD McCormack
- Women's and Children's Hospital; Adelaide; Australia
| | - RB Helmig
- Department of Obstetrics and Gynaecology; Aarhus University Hospital; Skejby; Denmark
| | - M Hein
- Department of Obstetrics and Gynaecology; Aarhus University Hospital; Skejby; Denmark
| | - T Weber
- Department of Obstetrics and Gynaecology; Copenhagen University Hospital; Hvidovre; Denmark
| | - S Mittal
- All India Institute of Medical Sciences in New Delhi; India
| | - W Kurdi
- King Faisal Specialist Hospital & Research Centre; Makkah, Saudi Arabia
| | - M Palacio
- Hospital Clínic; Universitat de Barcelona; Spain
| | - TB Henriksen
- Department of Paediatrics; Aarhus University Hospital; Skejby; Denmark
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Farzin A, Boyer P, Ank B, Nielsen-Saines K, Bryson Y. Amniotic fluid exhibits an innate inhibitory activity against HIV type 1 replication in vitro. AIDS Res Hum Retroviruses 2013; 29:77-83. [PMID: 22998428 DOI: 10.1089/aid.2011.0355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Indirect evidence suggests that amniotic fluid (AF) may play a role in the pathogenesis of in utero HIV-1 transmission. The purpose of this study was to evaluate the potential innate inhibitory role of AF on HIV replication, which may contribute to protection of the fetus against intrauterine transmission. AF was collected from term HIV-1-negative women undergoing scheduled cesarean section. The inhibitory effect of AF against HIV-1(BA-L) replication was tested in vitro with or without the addition of protease inhibitor cocktail (PIC) in PHA-stimulated PBMC cultures. Quantitative measurement of human neutrophil peptides 1-3 (HNP1-3) was performed on all AF samples, using an ELISA assay. AF exhibited a dose-dependent inhibitory activity against HIV-1(BA-L) replication, with all samples (n=12) reaching significant inhibitory effect using 50% AF. In vitro, this activity decreased over time, but was able to be sustained with the addition of PIC. The HNP1-3 concentration in AF samples (n=12) ranged from undetectable (<41 pg/ml, n=3) to >250,000 pg/ml with a median of 5,146 pg/ml. AF exhibited a significant and dose-dependent innate inhibitory activity against HIV-1 replication, which was present in all AF samples tested. This effect was prolonged in the presence of PIC, suggesting that the inhibitory factor was in the cell-free protein fraction. The HNP1-3 concentration in AF was in the subinhibitory range for HIV with no correlation between its concentration and the HIV-1 inhibitory activity. These data show the presence of a significant innate inhibitory activity against HIV in AF.
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Affiliation(s)
- Azadeh Farzin
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of California Los Angeles, Los Angeles, California
| | - Pamela Boyer
- Department of Obstetrics and Gynecology, University of California Los Angeles, Los Angeles, California
| | - Bonnie Ank
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of California Los Angeles, Los Angeles, California
| | - Karin Nielsen-Saines
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of California Los Angeles, Los Angeles, California
| | - Yvonne Bryson
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of California Los Angeles, Los Angeles, California
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Buhimschi IA, Nayeri UA, Laky CA, Razeq SA, Dulay AT, Buhimschi CS. Advances in medical diagnosis of intra-amniotic infection. ACTA ACUST UNITED AC 2012; 7:5-16. [PMID: 23530840 DOI: 10.1517/17530059.2012.709232] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Intrauterine infection is a global problem and a significant contributor to morbidity and perinatal death. The host response to infection causes an inflammatory state that acts synergistically with microbial insult to induce preterm birth and fetal damage. Prompt and accurate diagnosis of intra-amniotic infection in the asymptomatic stage of the disease is critical for improved maternal and neonatal outcomes. AREAS COVERED This article provides an overview of the most recent progress, challenges, and opportunities for discovery and clinical implementation of various maternal serum, cervicovaginal, and amniotic fluid biomarkers in pregnancies complicated by intra-amniotic infection. EXPERT OPINION Clinically relevant biomarkers are critical to the accurate diagnostic of intrauterine infection. Front-end implementation of such biomarkers will also translate in lower incidence of early-onset neonatal sepsis (EONS) which is an important determinant of neonatal morbidity and mortality associated with prematurity. However, of the hundreds of differentially expressed proteins, only few may have clinical utility and thus function as biomarkers. The small number of validation studies along with barriers to implementation of technological innovations in the clinical setting are current limitations.
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Affiliation(s)
- Irina A Buhimschi
- Yale University, Department of Obstetrics, Gynecology & Reprod. Science, New Haven, CT 06520, USA.
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Kim SM, Romero R, Lee J, Mi Lee S, Park CW, Shin Park J, Yoon BH. The frequency and clinical significance of intra-amniotic inflammation in women with preterm uterine contractility but without cervical change: do the diagnostic criteria for preterm labor need to be changed? J Matern Fetal Neonatal Med 2012; 25:1212-21. [PMID: 21999173 PMCID: PMC3288712 DOI: 10.3109/14767058.2011.629256] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The objective of this study was to determine the frequency and clinical significance of intra-amniotic inflammation in patients with preterm increased uterine contractility with intact membranes but without cervical change. METHODS Amniocentesis was performed in 132 patients with regular uterine contractions and intact membranes without cervical change. Amniotic fluid was cultured for bacteria and mycoplasmas and assayed for matrix metalloproteinase-8 (MMP-8). Intra-amniotic inflammation was defined as an elevated amniotic fluid MMP-8 concentration (>23 ng/mL). RESULTS (1) Intra-amniotic inflammation was present in 12.1% (16/132); (2) Culture-proven intra-amniotic infection was diagnosed in 3% (4/132) of patients without demonstrable cervical change on admission or during the period of observation; and (3) Patients with intra-amniotic inflammation had significantly higher rates of preterm delivery and adverse outcomes, and shorter amniocentesis-to-delivery intervals than those without intra-amniotic inflammation (P < 0.05 for each). Adverse outcomes included chorioamnionitis, funisitis, and neonatal death. CONCLUSION Intra-amniotic inflammation was present in 12% of patients with regular uterine contractions without cervical change, while culture-proven intra-amniotic infection was present in 3%. The presence of intra-amniotic inflammation was a significant risk factor for adverse neonatal outcomes. These observations question whether cervical changes should be required for the diagnosis of preterm labor, because patients without modifications in cervical status on admission or during a period of observation are at risk for adverse pregnancy outcomes.
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Affiliation(s)
- Sun Min Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
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Lee DC, Hassan SS, Romero R, Tarca AL, Bhatti G, Gervasi MT, Caruso JA, Stemmer PM, Kim CJ, Hansen LK, Becher N, Uldbjerg N. Protein profiling underscores immunological functions of uterine cervical mucus plug in human pregnancy. J Proteomics 2011; 74:817-28. [PMID: 21362502 PMCID: PMC3111960 DOI: 10.1016/j.jprot.2011.02.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 02/18/2011] [Accepted: 02/22/2011] [Indexed: 10/18/2022]
Abstract
The cervical mucus plug (CMP) differs from the cervical secretions of non-pregnant women, and is the ultimate sealant of the uterine cavity during pregnancy. Although several studies have analyzed biochemical properties of large glycoproteins in the CMP, comprehensive information about its protein composition is yet unavailable. We hypothesized that protein profiling of the CMP could provide key clues to its physiological functions in pregnancy. For this purpose, five CMPs obtained from women in labor at term were analyzed by LC-MS/MS. Out of 291 total proteins identified, 137 were detected in two or more samples, which included S100A8, S100A9, and complement proteins (C3, C4a, C4b, C6, and C8g). Several proteins, which have not been described in the cervical mucus of non-pregnant women or in cervicovaginal fluids, such as CD81 antigen and pregnancy zone protein, were also identified. Gene ontology analysis of identified proteins showed significant enrichment of 28 biological processes such as 'activation of plasma proteins involved in acute inflammatory response' and 'positive regulation of cholesterol esterification'. We report the proteome of CMPs from pregnant women at term for the first time, and the overall findings strongly suggest an important role for the CMP in the maintenance of pregnancy and parturition.
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Affiliation(s)
- Deug-Chan Lee
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Sonia S. Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
| | - Adi L. Tarca
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Computer Science, Wayne State University, Detroit, Michigan, USA
| | - Gaurav Bhatti
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | | | - Joseph A. Caruso
- Institute of Environmental Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Paul M. Stemmer
- Institute of Environmental Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Chong Jai Kim
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Pathology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Lea Kirstine Hansen
- Department of Obstetrics and Gynecology, University of Aarhus, Aarhus, Denmark
| | - Naja Becher
- Department of Obstetrics and Gynecology, University of Aarhus, Aarhus, Denmark
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, University of Aarhus, Aarhus, Denmark
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Becher N, Hein M, Danielsen CC, Uldbjerg N. Matrix metalloproteinases in the cervical mucus plug in relation to gestational age, plug compartment, and preterm labor. Reprod Biol Endocrinol 2010; 8:113. [PMID: 20868473 PMCID: PMC2954884 DOI: 10.1186/1477-7827-8-113] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Accepted: 09/24/2010] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND High concentrations of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) have been identified in the cervical mucus plug (CMP) at term of pregnancy. Their physiological and pathophysiological implications, however, remain to be elucidated, and CMPs from preterm labor have never been examined. This study was therefore conducted to describe the concentrations of MMP-2, TIMP-1, MMP-8 and MMP-9 in the CMP in relation to gestational age, IL-8 as an indicator of inflammation, compartment of the CMP, and preterm labor. METHODS An aliquot of the distal plug compartment facing the vaginal microflora (CMP-dist) was collected from non-pregnant (n = 15), early pregnant (n = 15) and term pregnant women (n = 15). Whole CMPs shed during active vaginal term (n = 15) and preterm (n = 4) labor were also included. Protein concentrations were determined by enzyme-linked immunosorbent assay (ELISA). RESULTS MMP-2 was not detectable in the non-pregnant CMP-dists whereas high concentrations were found in early pregnancy followed by an 85% decline at term. High concentrations of TIMP-1 were found in both the non-pregnant and early pregnant CMP-dists with a 90% decline at term. Consequently, the molar TIMP/MMP ratio was 40 in the non-pregnant state and 0.2 at term. The MMP-2 and TIMP-1 concentrations were alike in the CMP-dists and the whole CMPs.MMP-8, MMP-9, and IL-8 were mainly found in the distal CMP compartment. MMP-8 and MMP-9 concentrations were several fold increased in this compartment during pregnancy compared to the non-pregnant state. In the preterm whole CMPs, MMP-8, MMP-9 and IL-8 were 2 to 5 fold increased compared to term whole CMPs. CONCLUSIONS These results suggest that CMP MMP-2 reflects the non-leukocyte dependent cervical remodeling that occurs in early pregnancy, whereas MMP-8 and MMP-9 are involved in the defense against ascending infections primarily located to the distal compartment of the CMP. The upregulation of MMP-8, MMP-9 and IL-8 in whole CMPs from preterm labor may indicate the involvement of an intrauterine infection.
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Affiliation(s)
- Naja Becher
- Department of Obstetrics and Gynecology, Aarhus University Hospital Skejby, DK-8200 Aarhus N, Denmark
| | - Merete Hein
- Department of Obstetrics and Gynecology, Aarhus University Hospital Skejby, DK-8200 Aarhus N, Denmark
| | - Carl C Danielsen
- Department of Connective Tissue Biology, Institute of Anatomy, University of Aarhus, DK-8000 Aarhus C, Denmark
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital Skejby, DK-8200 Aarhus N, Denmark
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50
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Cruciani L, Romero R, Vaisbuch E, Kusanovic JP, Chaiworapongsa T, Mazaki-Tovi S, Mittal P, Ogge G, Gotsch F, Erez O, Kim SK, Dong Z, Pacora P, Lamont RF, Yeo L, Hassan SS, Di Renzo GC. Pentraxin 3 in amniotic fluid: a novel association with intra-amniotic infection and inflammation. J Perinat Med 2010; 38:161-71. [PMID: 19792835 PMCID: PMC2963028 DOI: 10.1515/jpm.2009.141] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Pentraxin 3 (PTX3) is a soluble pattern recognition receptor (PRR) that has an important role in immunoregulation and vascular integrity. The aim of this study was to determine if PTX3 is present in amniotic fluid (AF) and whether its concentration changes with gestational age (GA), in the presence of preterm or term labor, and in cases of intra-amniotic infection/inflammation (IAI) associated with spontaneous preterm labor (PTL) or preterm prelabor rupture of membranes (PROM). STUDY DESIGN This cross-sectional study included the following groups: 1) mid-trimester (n=45); 2) uncomplicated pregnancies at term with (n=48) and without (n=40) spontaneous labor; 3) women with PTL and intact membranes who: a) delivered at term (n=44); b) delivered preterm without IAI (n=40); or c) delivered preterm with IAI (n=62); 4) women with preterm PROM with (n=63) and without (n=36) IAI. PTX3 concentration in AF was determined by ELISA. Non-parametric statistics were used for analyses. RESULTS 1) Among women with PTL and intact membranes, the median AF PTX3 concentration was significantly higher in women with IAI than in those without IAI (7.95 ng/mL vs. 0.38 ng/mL; P<0.001) and than in those who delivered at term (0.55 ng/mL; P<0.001); 2) women with preterm PROM and IAI had a higher median AF PTX3 concentration than those without IAI (9.12 ng/mL vs. 0.76 ng/mL; P<0.001); 3) the median AF PTX3 concentration did not change with GA (mid-trimester: 0.79 ng/mL vs. term not in labor: 0.58 ng/mL; P=0.09); and 4) labor at term was not associated with a significant change of AF PTX 3 concentration (in labor: 0.54 ng/mL vs. not in labor: 0.58 ng/mL, P=0.9). CONCLUSIONS PTX3 is a physiologic constituent of the AF, and its median concentration is elevated in the presence of IAI, suggesting that PTX3 may play a role in the innate immune response against IAI.
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Affiliation(s)
- Laura Cruciani
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA,Wayne State University School of Medicine, Department of Obstetrics and Gynecology, Detroit, Michigan, USA,Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
| | - Edi Vaisbuch
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA,Wayne State University School of Medicine, Department of Obstetrics and Gynecology, Detroit, Michigan, USA
| | - Juan Pedro Kusanovic
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA,Wayne State University School of Medicine, Department of Obstetrics and Gynecology, Detroit, Michigan, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA,Wayne State University School of Medicine, Department of Obstetrics and Gynecology, Detroit, Michigan, USA
| | - Shali Mazaki-Tovi
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA,Wayne State University School of Medicine, Department of Obstetrics and Gynecology, Detroit, Michigan, USA
| | - Pooja Mittal
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA,Wayne State University School of Medicine, Department of Obstetrics and Gynecology, Detroit, Michigan, USA
| | - Giovanna Ogge
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA
| | - Francesca Gotsch
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA
| | - Offer Erez
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA,Wayne State University School of Medicine, Department of Obstetrics and Gynecology, Detroit, Michigan, USA
| | - Sun Kwon Kim
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA
| | - Zhong Dong
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA
| | - Percy Pacora
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA
| | - Ronald F. Lamont
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA,Wayne State University School of Medicine, Department of Obstetrics and Gynecology, Detroit, Michigan, USA
| | - Lami Yeo
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA,Wayne State University School of Medicine, Department of Obstetrics and Gynecology, Detroit, Michigan, USA
| | - Sonia S. Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA,Wayne State University School of Medicine, Department of Obstetrics and Gynecology, Detroit, Michigan, USA
| | - Gian Carlo Di Renzo
- Department of Obstetrics and Gynecology, Santa Maria della Misericordia University Hospital, Perugia, Italy
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