Diabetes during Pregnancy: A Transgenerational Challenge

For many years, gestational diabetes mellitus (GDM) has been defined as “a glucose intolerance of variable magnitude that begins or is first diagnosed in pregnancy” and that, in most cases, resolves after delivery [...]

Cervical pessary for preterm birth prevention after an episode of arrested preterm labor: a retrospective cohort study with targeted maximum likelihood estimation of the average treatment effect

OBJECTIVE

To evaluate whether cervical pessary effectively reduces the preterm birth < 37 weeks rate in patients who have not delivered after an episode of arrested preterm labor.

PATIENTS AND METHODS

Retrospective cohort study was conducted on singleton pregnant patients admitted to our institution between January 2016 and June 2021 for threatened preterm labor and who had a cervical length < 25 mm. Women in whom a cervical pessary was placed were considered as exposed, while women in whom expectant management was preferred were considered as unexposed. The primary outcome was the rate of preterm birth before 37 weeks. A targeted maximum likelihood estimation was used to estimate the average treatment effect of cervical pessary by adjusting for a-priori-defined confounders.

RESULTS

A cervical pessary was placed in 152 (36.6%) patients (exposed), while the remaining 263 (63.4%) were managed expectantly (unexposed). The adjusted average treatment effect was -14% (-18 to -11%), -17% (-20 to -13%), and -16% (-20 to -12%) for preterm birth < 37 weeks, < 34 weeks, and < 32 weeks, respectively. The average treatment effect for adverse neonatal outcomes was -7% (-8 to -5%). No difference in gestational weeks at delivery between exposed and unexposed emerged when gestational age at first admission was > 30.1 gestational weeks.

CONCLUSIONS

The positioning of a cervical pessary placement may be evaluated to reduce the risk of a subsequent preterm birth after an episode of arrested preterm labor in pregnant patients with onset of symptoms before 30 gestational weeks.

Maternal Inherited Thrombophilia in Monochorionic Twin Pregnancy with Twin-Twin Transfusion Syndrome

BACKGROUND

To study the frequency of inherited thrombophilia in monochorionic twin pregnancies with twin-twin transfusion syndrome (TTTS).

METHODS

At the Department of Obstetrics of the Polytechnic University of Marche (Ancona, Italy) a population of monochorionic diamniotic pregnant women was selected retrospectively. After termination of the pregnancy, genotyping for Factor I, Factor V Leiden, Factor II and Methylenetetrahydrofolate Reductase (MTHFR), as well as activities of the plasma proteins C and S, was performed.

RESULTS

Regarding the 32 patients with TTTS, from a cohort of 104 monochorionic pregnancies recruited, at least one thrombophilic defect was more frequent (OR: 3.24), and the allele polymorphism frequency was higher for Factor I (OR: 4.4) and for Factor V Leiden (OR: 11.66).

CONCLUSIONS

Maternal inherited thrombophilia, possibly also inherited from monochorial fetuses, may result in impaired development of the placental vascular architecture. This inheritance hypothesis may explain why only a fraction of monochorionic diamniotic twins develop TTTS.

Modulation of matrix metalloproteases by ciliary neurotrophic factor in human placental development

Ciliary neurotrophic factor (CNTF) is a pleiotropic cytokine that signals through a receptor complex containing a specific subunit, CNTF receptor α (CNTFRα). The two molecules are constitutively expressed in key structures for human placental growth and differentiation. The possible role of CNTF in enhancing cell proliferation and/or invasion during placental development and remodelling was investigated using HTR-8/SVneo and BeWo cells, taken respectively as cytotrophoblast and syncytiotrophoblast models. In both cell lines, treatment with human recombinant (hr) CNTF activated JAK2/STAT3 signalling and inhibited the ERK pathway. Interestingly, in HTR-8/SVneo cells, 50 ng hrCNTF induced significant downregulation of matrix metalloprotease (MMP)-1 and significant upregulation of MMP-9. Moreover, pharmacological inhibition of JAK2/STAT3 signalling by AG490 and curcumin resulted in MMP-9 downregulation; it activated the ERK signalling pathway and upregulated MMP-1 expression. Collectively, these data suggest a role for CNTF signalling in extravillous cytotrophoblast invasion through the modulation of specific MMPs.

CD93 a potential player in cytotrophoblast and endothelial cell migration

CD93, also known as complement component C1q receptor, is expressed on the surface of different cellular types such as monocytes, neutrophils, platelets, microglia, and endothelial cells, and it plays a pivotal role in cell proliferation, cell migration, and formation of capillary-like structures. These processes are strictly regulated, and many fetal and maternal players are involved during placental development. At present, there are no studies in literature regarding CD93 in placental development, so we investigated CD93 expression in first and third trimester and PE placentas by immunohistochemistry and western blotting analysis. In addition, we performed in vitro experiments under oxidative stress conditions to demonstrate how oxidative stress acts on CD93 protein expression. Our data showed that CD93 was expressed in villous cytotrophoblast cells, in some fetal vessels of first and third trimester and PE placentas and in the extravillous cytotrophoblast of cell columns in the first trimester placentas. Moreover, we detected a significant decrease of CD93 expression in third trimester and PE placentas compared to first trimester placentas, while no differences were detected between third and PE placentas. No differences of CD93 expression were detected in oxidative stress conditions. We suggest that CD93 can guide extravillous cytotrophoblast migration through β1-integrin in uterine spiral arteries during placentation in the first trimester of pregnancy and that the decrease of CD93 expression in third trimester and PE placentas could be linked to the poor extravillous cytotrophoblast cells migration. So, it might be interesting to understand the role of CD93 in the first phases of PE onset.

HTRA family proteins in pregnancy outcome

HTRA (High temperature requirement protease A) family proteins includes HTRA1 (L56 or PRSS11), HTRA2/Omi, HTRA3 (PRSP) and HTRA4. These are oligomeric serine proteases highly conserved from bacteria to humans and are involved in a variety of biological functions including the maintenance of normal cell physiology and pathogenicity such as cell growth, apoptosis, neurodegenerative disorders, inflammation diseases and cancer. These proteins are normally expressed in placental villi during all pregnancy but their expression is found to be altered in pathological pregnancies suggesting a possible role of those proteins in the development of human placenta. Moreover, some HTRA family proteins have also been found in maternal blood and were impaired in pathological pregnancy suggesting a possible role of some of these proteins as early markers of pregnancy outcome. The aim of this review is to summarize the data currently available on the role of HTRA family proteins in pregnancy focalizing their role in pregnancy complications such as Preeclampsia (PE), IntraUterine Growth Restriction (IUGR) and Spontaneus PreTerm Birth (SPTB).

Pre-eclampsia predictive ability of maternal miR-125b: a clinical and experimental study

Pre-eclampsia (PE) is a systemic maternal syndrome affecting 2-8% of pregnancies worldwide and involving poor placental perfusion and impaired blood supply to the foetus. It manifests after the 20th week of pregnancy as new-onset hypertension and substantial proteinuria and is responsible for severe maternal and newborn morbidity and mortality. Identifying biomarkers that predict PE onset prior to its establishment would critically help treatment and attenuate outcome severity. MicroRNAs are ubiquitous gene expression modulators found in blood and tissues. Trophoblast cell surface antigen (Trop)-2 promotes cell growth and is involved in several cancers. We assessed the PE predictive ability of maternal miR-125b in the first trimester of pregnancy by measuring its plasma levels in women with normal pregnancies and with pregnancies complicated by PE on the 12th week of gestation. To gain insight into PE pathogenesis we investigated whether Trop-2 is targeted by miR-125b in placental tissue. Data analysis demonstrated a significant association between plasma miR-125b levels and PE, which together with maternal body mass index before pregnancy provided a predictive model with an area under the curve of 0.85 (95% confidence interval, 0.70-1.00). We also found that Trop-2 is a target of miR-125b in placental cells; its localization in the basal part of the syncytiotrophoblast plasma membrane suggests a role for it in the early onset of PE. Altogether, maternal miR-125b proved a promising early biomarker of PE, suggesting that it may be involved in placental development through its action on Trop-2 well before the clinical manifestations of PE.

Association between first trimester plasma htra1 level and subsequent preeclampsia: A possible early marker?

INTRODUCTION

Preeclampsia (PE) is associated with risk of maternal and fetal mortality and morbidity. Several promising predictors of PE have been identified, but early pregnancy screening for PE remains insufficient, and randomized controlled trials that used biomarkers to identify high-risk women have been disappointed. Our aim is to identify a possible early marker of PE.

METHODS

158 women attending a routine antenatal care visit were recruited from 2014 to 2016 and prospectively followed until delivery (14 of whom had a diagnosis of PE). We have tested the plasma concentration of High temperature requirement factor A1 (HtrA1) at 12 weeks of gestation by ELISA technique in order to identify women at risk for developing PE. A multiple logistic regression analysis was used to estimate the independent effect of women' characteristics on the probability of developing PE. Likelihood ratio test and Hosmer-Lemeshow test were used to select the most parsimonious model and to evaluate the model's goodness of fit. Predictiveness of preeclampsia was estimated by ROC curve.

RESULTS

PE cases had significantly higher BMI, before and after pregnancy, shorter gestational age at delivery and higher HtrA1values than healthy women. In addition, higher HtrA1 values in the first trimester maternal plasma, BMI before pregnancy and gestational age at delivery are significantly associated with subsequent development of PE. ROC curve showed a good accuracy in predicting preeclampsia, with an AUC of 0.83.

CONCLUSIONS

These results suggest the HtrA1 as early predictive marker of PE having a strong clinical relevance for disease prevention.

Pre-eclampsia onset and SPARC: A possible involvement in placenta development

Pre-eclampsia (PE) is a multisystem disorder commonly diagnosed in the latter half of pregnancy and it is a leading cause of intrauterine fetal growth retardation (IUGR). The aim of this study was to investigate the localization and the role of SPARC, secreted protein acidic, and rich in cysteine, in PE and PE-IUGR placentas in comparison with normal placentas. SPARC was mainly expressed in the villous and extravillous cytotrophoblastic cells in first trimester, whereas in PE, PE-IUGR and at term placentas, SPARC immunostaining was visible in both cytotrophoblastic cells and syncytiotrophoblast. SPARC expression significantly decreased in normal placenta from first to third trimester and a further significant reduction was demonstrated in PE and PE-IUGR. The latter downregulation of SPARC depends on hypoxic condition as shown by in vitro models. In conclusion, SPARC can play a pivotal role in PE and PE-IUGR onset and it should be considered as a key molecule for future investigations in such pathologies.

Expression of extracellular matrix and adhesion proteins in pelvic organ prolapse

Pelvic organ prolapse (POP) is a common disorder in women. It is characterized by the descent of the vaginal wall with consequent drop of pelvic organs. Pregnancy, labour and childbirth seem to be important events leading to the development of POP, since they are associated with prolonged stretch and mechanical stress of muscles, ligaments and connective tissue supporting pelvic organs. In pubocervical fascia, we explored the expression level of extracellular matrix and adhesion molecules. Tissue samples were obtained from twenty patients with POP who underwent cystocele repair, and from twenty control subjects during hysterectomy surgery. The PCR array analysis was performed and data were confirmed by Real-Time PCR and Western Blot.  Real-Time PCR results showed a significant upregulation for extracellular matrix protein 1 (ECM1) and integrin beta 3 (ITGB3) and a significant downregulation for FBLN5 in POP group. The decreased mRNA expression of FBLN5 in pathological samples was paralleled by a quantitative decrease in the corresponding protein, as Western Blot test highlighted. Our data provide an understanding of molecular mechanisms involved in POP-related pathophysiological processes and might represent an important tool to develop novel therapeutic agents for the treatment of this condition.

Omega-3 fatty acids modulate the lipid profile, membrane architecture, and gene expression of leiomyoma cells

Uterine leiomyomas (fibroids or myomas) are the most common benign tumors of premenopausal women and new medical treatments are needed. This study aimed to determine the effects of omega-3 fatty acids on the lipid profile, membrane architecture and gene expression patterns of extracellular matrix components (collagen1A1, fibronectin, versican, or activin A), mechanical signaling (integrin β1, FAK, and AKAP13), sterol regulatory molecules (ABCG1, ABCA1, CAV1, and SREBF2), and mitochondrial enzyme (CYP11A1) in myometrial and leiomyoma cells. Myometrial tissues had a higher amount of arachidonic acid than leiomyoma tissues while leiomyoma tissues had a higher level of linoleic acid than myometrial tissues. Treatment of primary myometrial and leiomyoma cells with eicosapentaenoic acid (EPA) or docosahexaenoic acid (DHA) reduced the monounsaturated fatty acid (MUFA) content and increased the polyunsaturated fatty acid (PUFA) content in both cell types. Myometrial and leiomyoma cell membranes were in the liquid-crystalline phase, but EPA- and DHA-treated cells had decreased membrane fluidity. While we found no changes in the mRNA expression of ECM components, EPA and DHA treatment reduced levels of ABCG1, ABCA1, and AKAP13 in both cell types. EPA and DHA also reduced FAK and CYP11A1 expression in myometrial cells. The ability of omega-3 fatty acids to remodel membrane architecture and downregulate the expression of genes involved in mechanical signaling and lipid accumulation in leiomyoma cells offers to further investigate this compound as preventive and/or therapeutic option.

Molecular analysis of endometrial inflammation in preterm birth

Spontaneous preterm birth (sPTB) represents the 35%-45% of all preterm birth (PTB) cases and its etiology is unknown. We investigated if the expression level of endometrial cytokines and angiogenetic factors is related to the onset of sPTB.Endometrial tissues from non-pregnant women who experienced sPTB and from non-pregnant women who did not experience sPTB were collected and examined for their expression profile. With this aim, the PCR Array analysis was performed and data were confirmed by Real-Time PCR. Differential gene expression measurements (pathological vs control tissues) showed a significant up-regulation for genes codifying for two angiogenetic factors known as connective tissue growth factor (CTGF), and coagulation factor III (F3). An increased level of expression was detected both for tyrosine kinase endothelial (TEK) and for transforming growth factor beta 2 (TGF-β2) genes but without reaching the statistical significance. The expression level of interleukin 10 receptor alpha (IL10RA) gene was slightly decreased in pathological group compared to control one but, as well as forTEK and TGF-β2 measurements, without reaching the statistical significance. Our work is the first to correlate the imbalance in endometrial district of non -pregnant women with sPTB. These data could suggest a new point of view whence to read sPTB. We need additional clinical and biological studies to clarify sPTB pathogenesis.

Cesarean Section Revealing an Unsuspected Renal Angiomyolipoma in a Woman with Severe Hypertension During Pregnancy: A Case Report

BACKGROUND

Renal angiomyolipomas are uncommon during pregnancy, but it is important to consider them in the differential diagnosis, for the increased risk of complications such as bleeding, renal artery compression, and renovascular hypertension.

CASE

A 42-year-old woman was admitted at 34 weeks of gestation for severe abdominal pain in the right flank associated with severe hypertension. During the postadmission immediate cesarean section for fetal compromise, abdominal exploration revealed a massive retroperitoneal hematoma (around 30 cm) up to the cecal region until the lower edge of the liver. The diagnosis was the rupture of a renal angiomyolipoma causing renovascular hypertension.

CONCLUSION

Renovascular hypertension should be considered in patients who present with accelerated hypertension, particularly if the hypertension is resistant to medical therapy and not associated with laboratory features of preeclampsia/eclampsia.

High temperature requirement A1 and fibronectin: two possible players in placental tissue remodelling

High temperature requirement A1 (HtrA1) is a secreted protease involved in placental development. Fibronectin (FN) is involved in important process such as wound healing, cell adhesion and spreading, growth, migration, and differentiation. The purpose of this study was to analyse the expression patterns of HtrA1 in relationship to FN and to the key growth zones of placenta such as mesenchymal villi as well as cell islands and cell columns. We demonstrated that FN and HtrA1 are localized in the placental key growth zones suggesting a pivotal role in maintaining the balance among the molecules involved in the placental development and differentiation.

The effect of astaxanthin on the aging rat brain: gender-related differences in modulating inflammation

BACKGROUND

Astaxanthin (Ax) is a ketocarotenoid of the xanthophyll family with activities such as antioxidation, preservation of the integrity of cell membranes and protection of the redox state and functional integrity of mitochondria. The aim of this study was to investigate potential gender-related differences in the effect of Ax on the aging rat brain.

RESULTS

In females, interleukin 1 beta (IL1β) was significantly lower in treated rats in both cerebral areas, and in the cerebellum, treated animals also had significantly higher IL10. In males, no differences were found in the cerebellum, but in the hippocampus, IL1β and IL10 were significantly higher in treated rats.

CONCLUSION

These are the first results to show gender-related differences in the effect of Ax on the aging brain, emphasizing the necessity to carefully analyze female and male peculiarities when the anti-aging potentialities of this ketocarotenoid are evaluated. The observations lead to the hypothesis that Ax exerts different anti-inflammatory effects in female and male brains.

Placental expression of endothelial and inducible nitric oxide synthase and NO metabolism in gestational hypertension: a case-control study

OBJECTIVE

Hypertension is one of the most common medical disorders in pregnancy and a role of nitric oxide (NO) metabolism has been described. Thus, the present work aimed at determining placental gene expression of eNOS and iNOS, to measure NO and ONOO(-) levels in patients with gestational hypertension (GH).

METHODS

Fifteen patients with GH and 15 healthy pregnant controls were enrolled in the study. Placental tissue was taken immediately after delivery and was stored at -80 °C until analysis. A piece of frozen tissue was homogenized in the appropriate buffer. Total RNA was extracted and was reverse transcribed to obtain complementary DNA that was used for real-time PCR for iNOS and eNOS expression, whereas NO and ONOO(-) production were measured by commercially available kits.

RESULTS

Placental eNOS and iNOS mRNA levels were significantly reduced in GH when compared to controls. NO and ONOO(-) production were both significantly higher in GH than controls.

CONCLUSIONS

The reduced eNOS and iNOS gene expression in women with GH reinforces the hypothesis that the mechanisms involving NO pathways, may promote oxidative damage, by contributing to the reduced blood flow and increased resistance in the feto-maternal circulation and suggests the use of NO modulators as useful tools in GH management.

Noninvasive fetal electrocardiography: an overview of the signal electrophysiological meaning, recording procedures, and processing techniques

BACKGROUND

Noninvasive fetal electrocardiography (fECG), obtained positioning electrodes on the maternal abdomen, is important in safeguarding the life and the health of the unborn child. This study aims to provide a review of the state of the art of fECG, and includes a description of the parameters useful for fetus clinical evaluation; of the fECG recording procedures; and of the techniques to extract the fECG signal from the abdominal recordings.

METHODS

The fetus clinical status is inferred by analyzing growth parameters, supraventricular arrhythmias, ST-segment variability, and fetal-movement parameters from the fECG signal. This can be extracted from an abdominal recording obtained using one of the following two electrode-types configurations: pure-abdominal and mixed. Differently from the former, the latter also provides pure maternal ECG tracings. From a mathematical point of view, the abdominal recording is a summation of three signal components: the fECG signal (i.e., the signal of interest to be extracted), the abdominal maternal ECG (amECG), and the noise. Automatic extraction of fECG includes noise removal by abdominal signal prefiltration (0.5-45 Hz bandpass filter) and amECG cancellation.

CONCLUSIONS

Differences among methods rely on different techniques used to extract fECG. If pure abdominal electrode configurations are used, fECG is extracted directly from the abdominal recording using independent component analysis or template subtraction. Eventually, if mixed electrode configurations are used, the fECG can be extracted using the adaptive filtering fed with the maternal ECG recorded by the electrodes located in the woman thorax or shoulder.

Contribution of adenosine-producing ectoenzymes to the mechanisms underlying the mitigation of maternal-fetal conflicts

The interactions taking place between mother and embryo have been the focus of detailed studies in recent years, where pregnancy is considered as an in vivo transplant. The immune systems of the mother and the embryo together establish a condition of tolerance, which lasts throughout the pregnancy. Alongside immunogenetic components, a contribution is provided by the ectoenzyme network, a chain of surface molecules mainly operating in closed environments and potentially providing inhibitory or activator signals. One of the soluble products of the ectoenzyme network with immunosuppressory potential is adenosine, a purine nucleoside that plays multiple roles in almost all tissues and organs. The hypothesis behind the work was studied in patients with recurrent pregnancy loss (RPL), an event which remains unexplained in over 50 percent of cases. To this aim, we analyzed the expression of CD39 (ectonucleoside triphosphate diphosphohydrolase 1, ENTPD1) and CD73 (ecto-5’-nucleotidase, NT5E), the main pathway for adenosine generation, in samples obtained from women with RPL. The study included the evaluation of the expression of TNF-alpha (a pro-inflammatory cytokine) and of an alternative pathway of adenosine generation run by CD38 (ADP-ribosyl cyclase/cyclic ADP-ribose hydrolase) and PC-1 (ectonucleotide pyrophosphatase/phosphodiesterase 1, ENPP1). The results of this study highlight the existence of a network of surface enzymes expressed at the maternal/fetal interface and addressed to the production of adenosine. Perturbation of this network may induce a rescue pathway driven by CD38 and ENPP1. Ectoenzyme and inflammation may be considered now key elements in orchestrating the events leading to the interruption of pregnancy in the RPL sample analyzed and at the same potentially becoming therapeutic targets.

Anticoagulant therapy during pregnancy for maternal and fetal acquired and inherited thrombophilia

Thromboembolism is an infrequent, yet serious cause of both maternal and fetal morbidity and death during pregnancy and the puerperium. Antithrombotic treatment and prophylaxis both before and during pregnancy are based on unfractionated heparin (UH), low-molecularweight heparin (LMWH), Warfarin and Aspirin. The prevalence and severity of thromboembolism during pregnancy and puerperium warrant special consideration of management and therapy. Such therapy includes the treatment of acute thrombotic events and prophylaxis for those at increased risk of thrombotic events. This paper assesses the safety and efficacy of antithrombotic therapy during pregnancy and the peripartum period. Its cardiovascular and obstetric indications, the evidence of association between thrombophilias and adverse pregnancy outcome, regimens and maternal and fetal side-effects are also discussed.

Alterations of maternal plasma HTRA1 level in preeclampsia complicated by IUGR

We evaluated the presence of HtrA1 in maternal plasma of normal pregnancies and of pregnancies complicated by preeclampsia (PE) without and with Intrauterine Growth Restriction (IUGR). We demonstrate that HtrA1 maternal plasma levels show significant different concentrations in first, second and third trimester of gestation and that HtrA1 concentration increases in maternal plasma of gestations complicated by PE with IUGR compared with control maternal plasma matched for gestational age. Based on these data high maternal plasma levels of HtrA1 could be considered as a possible marker of an occurring IUGR in preeclamptic women.

Clues to apoptosis pathway involvement in hemolysis, elevated liver enzyme, and low platelet (HELLP) syndrome and intrauterine growth restriction (IUGR)

OBJECTIVE

The neurotrophin family comprises molecules involved in growth, differentiation, survival, regeneration, normal functions of the neuronal system, and in angiogenesis. We have investigated the expression pattern of neurotrophic signaling molecules in pregnancies complicated by elevated liver enzyme, and low platelet (HELLP) syndrome and intrauterine growth restriction (IUGR).

METHODS

Placentas from normal and pathological pregnancies were collected. Macroarray analysis was performed and the data were confirmed by real-time PCR.

RESULTS

Real-time PCR analyses (pathological vs. normal pregnancies) confirmed a significant down-regulation for IL-6, STAT3α, STAT3β, and Bcl-2. The expression of Mcl-1 isoform 1 (long) was significantly increased.

CONCLUSIONS

We suggest that decreased expression of IL-6 could mean that abnormalities in the immunological system function involve inflammatory cytokines other than IL-6 in examined pathological pregnancies. The STAT3α and STAT3β down-regulation lead to a marked reduction of cellular transcriptional activity. Decreased expression of IL-6 is associated with a down-regulation of Bcl-2 but not of Mcl-1 isoform 1, suggesting that these two antiapoptotic proteins may function independently and that Mcl-1 may have a distinct role in controlling apoptotic pathway.

PP073. Gestational hypertension: A study on placental expression of endothelial and inducible nitric oxide synthase and no metabolism

INTRODUCTION

Hypertension is one of the most common medical disorders in pregnancy and a major cause of maternal and perinatal morbidity and death. In primates adequate development of the embryo, and later of the fetus, depends on a successful hemomonochorial placentation. Nitric oxide (NO) a low molecular weight mediator, induces vasodilatation, inhibits platelet aggregation, and prevents the adhesion of platelets to endothelial cells. Till date, no data are available regarding gestational hypertension (GH) placenta and no metabolism and related enzyme expression and activity.

OBJECTIVES

The present study aimed to evaluate eNOS and iNOS expression in the placentas of both normal and GH patients, by means of Real-Time quantitative PCR, measure placental nitric oxide and peroxynitrite levels in the same group of subjects, and correlate such findings with HELLP group already published.

METHODS

Fifteen patients with gestational hypertension and thirty healthy pregnant controls comparable for maternal and gestational age were enrolled in the study. Placental tissue was taken immediately after delivery. eNOS and iNOS mRNA levels were evaluated Real-Time quantitative PCR, whereas nitric oxide and peroxynitrite production was measured by a commercially available kit.

RESULTS

Placental eNOS and iNOS mRNA levels were significantly reduced in GH (2,02-fold reduction and 2,33-fold reduction, respectively) when compared to controls. Conversely, NO and ONOO(-) production were significantly higher in GH group compared to control group (31.56±4.15nmol NO/mg prot vs. 23.98±5.14nmol NO/mg prot and 68.49±8.57 arbitrary fluorescence units vs 17.31±2.25 arbitrary fluorescence units; p<0, 05). Such results were compared to HELLP group obtained in an already published study.

CONCLUSION

As from results herein reported, we can hypothesize that complex mechanisms involving NO pathways cause a placental vasculature damage. However, it is not easy to understand if these changes could be interpreted as causes or consequences of this pathologic state.

The involvement of inflammatory cytokines in the pathogenesis of recurrent miscarriage

OBJECTIVE

To investigate the inflammatory cytokine expression pattern in trophoblastic tissue from women with unexplained recurrent miscarriage (RM).

STUDY DESIGN

Trophoblasts were obtained during uterine evacuation from 11 women with RM and from 20 healthy pregnant women undergoing elective termination of pregnancy, who served as controls. The array was performed using GEArray Q Series Human Inflammatory Cytokines & Receptors Gene Array HS-015 membranes. Data were confirmed by quantitative real-time PCR. The Mann-Whitney U test was performed for statistical analysis.

RESULTS

Microarray analysis identified three genes that were differentially expressed between RM patients and controls. We observed significant downregulation of Transforming Growth Factor beta 3 (TGF-β3) and Interleukin 25 (IL-25) (5-fold reduction and 2.5-fold reduction, respectively) and significant upregulation of CD-25, also known as Interleukin 2 receptor alpha (IL-2RA) (7-fold increase) in women with RM compared with controls. The median ΔC(t) of TGF-β3 was 8.2 (interquartile range, 7.67-8.9) in RM patients vs. 5.85 (interquartile range, 5.3-6.09) in controls; the median ΔC(t) of IL-25 was 5.18 (interquartile range, 4.46-5.76) in RM patients vs. 3.85 (interquartile range, 3.6-4.51) in controls, and the median ΔC(t) of CD-25 was 9.62 (interquartile range, 7.81-12.42) in RM patients vs. 12.44 (interquartile range, 11.02-13.86) in controls.

DISCUSSION

Our results suggest that the immunological and inflammatory regulation mechanisms of the placental environment play a key role in recurrent miscarriage. The observed trophoblast cytokine expression pattern at the maternal-fetal interface confirms the immunotrophic theory, as demonstrated by a switch from a T-helper-1 (Th1) profile to a T-helper-2 (Th2) profile in women who experience recurrent miscarriages.

Placental expression of endothelial and inducible nitric oxide synthase and nitric oxide levels in patients with HELLP syndrome

OBJECTIVE

To determine placental gene expression of endothelial and inducible nitric oxide synthases and measure nitric oxide levels in patients with hemolysis, elevated liver enzyme levels, and low platelet count syndrome.

STUDY DESIGN

Preterm placentas were obtained from 15 patients with hemolysis, elevated liver enzyme levels, and low platelet count syndrome and 30 controls matched for age, parity, and gestational age. mRNA levels were evaluated by real-time polymerase chain reaction, whereas nitric oxide and peroxynitrite production was measured by a commercially available kit.

RESULTS

Placental gene expression of inducible nitric oxide and endothelial nitric oxide synthases were significantly lower in the hemolysis, elevated liver enzyme levels, and low platelet count syndrome group than in controls, whereas nitric oxide and peroxynitrite production were significantly higher in hemolysis, elevated liver enzyme levels, and low platelet count syndrome compared with controls.

CONCLUSION

The reduced endothelial nitric oxide and inducible nitric oxide synthases gene expression in women with hemolysis, elevated liver enzyme levels, and low platelet count syndrome may indicate extreme placental dysfunction that is unable to compensate the endothelial derangement and the related hypertension. The higher nitric oxide formation found in hemolysis, elevated liver enzyme levels, and low platelet count syndrome placentas could be explained as a counteraction to the impaired fetoplacental perfusion, typical of the syndrome.

Nitric oxide and peroxynitrite platelet levels in gestational hypertension and preeclampsia

The aim of the study was to investigate platelet nitric oxide (NO) pathways in women with Gestational Hypertension (GH), Preeclampsia (PE) and Controls. Platelet NO(x) and peroxynitrite (ONOO(-)) levels, inducible (iNOS) and endothelial nitric oxide synthase (eNOS) and Nitrotyrosine expression (N-Tyr) in 30 women with GH, 30 with PE and 30 healthy pregnant controls, age, parity and gestational age-matched, were assessed. Platelet NO(x) and ONOO(-) levels were significantly higher in GH and PE vs. Controls, with higher levels in GH vs. PE. At the same way, iNOS and N-Tyr were significantly higher in GH and PE vs. Controls, with higher levels in GH vs. PE. Since GH expressed higher amount of NO metabolites and higher activation of iNOS compared to PE, we can hypothesize that the severity of hypertensive pathology is almost not related to only NO metabolism, this research confirmed that GH and PE are associated with marked changes in NO pathways; it is not easy to understand if they could be interpreted as causes or consequence of these pathologic states.

HLA-G and pregnancy adverse outcomes

There is growing evidence that pregnancy complications such as preeclampsia, recurrent pregnancy loss (RPL), IUGR, and premature birth could be associated with abnormal immunologic interactions at the fetal-maternal interface. The restricted expression of HLA-G to the subpopulation of trophoblast cells which invade the uterus has generated much interest. The alternative splicing of HLA-G primary transcript, gives origin to seven isoforms, including both membrane-bound forms (HLA-G1, G2, G3, G4) and soluble forms (sHLA-G: sHLA-G5, G6, G7). sHLA-G consists predominantly of sHLA-G1 after its shedding by metalloproteinases, and secreted sHLA-G5 representing the quantitatively dominating and full-length isoforms. HLA-G expression and HLA-G genetic variations in both the mother and the embryo/fetus may be important for pregnancy outcome. It is also intuitively apparent that a gene with putative immunosuppressive and immunotolerant potential might be functional in both the mother and the embryo/fetus/placenta. Reduced or aberrant HLA-G expression seems to be associated with certain complications of pregnancy, among which preeclampsia and possibly the risk of miscarriage, and that this may be further linked to HLA-G polymorphisms. Most of the studies aimed at assessing the role of HLA-G in pregnant diseases have considered only the maternal genotype and ignored the contribution of the fetus. In this regard, the mother, placenta and the fetus form a synthesis. Therefore, studies on placental diseases should address HLA-G expression and genetic variations also to the fetus/placenta.

Neurogenic potential of mesenchymal-like stem cells from human amniotic fluid: the influence of extracellular growth factors

Amniotic fluids contain human stem cells, among which mesenchymal stem cells could be isolated. These cells have multipotent differentiation ability and no tumorigenic potential after transplantation in mice. These features make them good candidates for in vitro studies and for therapeutic purposes. The aim of this study was to isolate mesenchymal stem cell-like cultures from different amniotic fluids in order to study in vitro their neurogenic potential and assess if this process could be reproducible and standardized. We focused attention on the possible differential effects of soluble growth factors. Immunophenotypical and molecular characterization showed that the 31 amniotic fluid-derived cultures expressed mesenchymal markers as well as some stemness properties. These cells also appeared to be responsive to purines or acetylcholine showing an intracellular calcium increase, also reported for mesenchymal stem cells derived from other sources. Interestingly, in the presence of retinoic acid, these cells assumed a neuronal-like morphology. In addition, functional and molecular analyses revealed that retinoic acid-treated cells showed immature electric functional properties, the expression of neuronal markers and stemness genes. In conclusion, even if further investigations are required, the results presented here contribute to support the finding that amniotic fluid contains cells able to differentiate in vitro towards neural-like lineage in the presence of retinoic acid. The ability of retinoic acid to induce a possible neuronal progenitor culture makes the model useful to study a possible in vivo transplantation of these cells and to contribute to define the protocols for cell therapy.

Placental thrombomodulin expression in recurrent miscarriage

BACKGROUND

Early pregnancy loss can be associated with trophoblast insufficiency and coagulation defects. Thrombomodulin is an endothelial-associated anticoagulant protein involved in the control of hemostasis and inflammation at the vascular beds and it's also a cofactor of the protein C anticoagulant pathway.

DISCUSSION

We evaluate the Thrombomodulin expression in placental tissue from spontaneous recurrent miscarriage and voluntary abortion as controls. Thrombomodulin mRNA was determined using real-time quantitative polymerase chain reaction. Reduced expression levels of thrombomodulin were found in recurrent miscarriage group compared to controls (1.82-fold of reduction), that corresponds to a reduction of 45% (from control group Delta CT) of thrombomodulin expression in spontaneous miscarriage group respect the control groups.

SUMMARY

We cannot state at present the exact meaning of a reduced expression of Thrombomodulin in placental tissue. Further studies are needed to elucidate the biological pathway of this important factor in the physiopathology of the trophoblast and in reproductive biology.

The role of p38alpha mitogen-activated protein kinase gene in the HELLP syndrome

Mitogen-activated protein kinase (MAPK) p38alpha was shown to be implicated in the organogenesis of the placenta, and such placental alteration is crucial for the development of hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. We aimed to analyze for the first time human placental expression of MAPK p38alpha in pregnancies complicated by HELLP. The placental expression of MAPK p38alpha was investigated by semiquantitative polymerase chain reaction using cDNA extracted from placental tissue of 15 pregnancies with HELLP syndrome and 15 gestational age-matched controls. Seven patients with HELLP also had intrauterine fetal growth restriction (IUGR). In placenta from pregnancy complicated by HELLP, the expression of MAPK p38alpha is significantly decreased compared to the group with normal pregnancy (p < 0.001), while no difference was found between the HELLP and HELLP with IUGR subpopulations. Our study shows for the first time that MAPK p38alpha is expressed in the human placenta. Pregnancies with placental dysfunction and hypertensive complications are characterized by a significantly decreased expression of MAPK p38alpha. Our observations suggest that p38 MAPK signaling may be essential in placental angiogenesis and functioning.

Computerized analysis of heart rate in fetuses from mothers under levothyroxin treatment

OBJECTIVE

To investigate fetal heart rate (FHR) of fetuses whose mothers are under levothyroxin treatment for chronic hypothyroidism.

STUDY DESIGN

Sixty women under chronic therapy with levothyroxin and 180 controls at 37-39 weeks' gestation were studied by Sonycaid Sistem 8002(R) computerized cardiotocography (cCTG) for 30 min. cCTG parameters were expressed as mean and SD and the differences tested for statistics by Student t-test. Furthermore, cCTG parameters were related to levothyroxin dose by regression analysis. Significance was assessed at p < 0.05.

RESULTS

Computerized cardiotocographic tracings of fetuses from mothers under levothyroxin treatment revealed: significant reduction of baseline FHR (130.1 +/- 9.47 vs. 134.9 +/- 4.68 bpm); increased number of FHR decelerations greater than 20 bpm (0.2 +/- 0.41 vs. 0.05 +/- 0.22); reduction of body movements per hour (6.68 +/- 11.72 vs. 10.65 +/- 11.74); and increased uterine contraction peaks (5.15 +/- 4.69 vs. 2.7 +/- 2.57). Those fetuses also showed significantly reduced neonatal weight (2668.2 +/- 766.65 vs. 3215.44 + 523.88 g) and lower 1-min Apgar score (8.6 +/- 0.95 vs. 9.3 +/- 1.11). Regression analysis showed a significant correlation between levothyroxin dose and baseline FHR (r = 0.60; p < 0.0001) and fetal body movements per hour (r = 0.52; p < 0.0001), and an inverse relationship with uterine contraction peaks (r = -0.35; p < 0.006), whilst no correlation was found with the number of FHR decelerations greater than 20 bpm.

CONCLUSIONS

Maternal hypothyroidism and levothyroxin treatment influence FHR and cCTG is a sensible tool to reveal that influence.

Placental Alpha Hemoglobin Stabilizing Protein (AHSP) and recurrent miscarriage

AHSP inhibits cellular production of the reactive oxygen species. Reduced AHSP indicates reduced protection against oxidative stressors. Our objective was to investigate AHSP levels in recurrent miscarriage (RM). Trophoblast was collected from women of 10 weeks gestation: voluntary abortion controls (VA, n = 10); spontaneous first miscarriage with subsequent normal pregnancy (SMSN, n = 15) or with subsequent miscarriage (SMSM, n = 5); RM previously investigated (RMPS, n = 5) or not previously investigated (RM, n = 5). AHSP mRNA and protein were determined using real-time quantitative polymerase chain reaction (PCR) and Western blot, respectively. One-way ANOVA was performed to assess statistical significance (p < 0.05). ahsp mRNA levels were maximally reduced in RM and RMPS (8.0 x 10(-6) +/- 1.3 and 8.1 x 10(-6) +/- 0.7, respectively) compared with SMSN and VA (16.1 x 10(-6) +/- 2.3 and 26.1 x 10(-6) +/- 2.7, respectively). SMSM showed levels significantly reduced as well (9.0 x 10(-6) +/- 2.3). In RM, a reduced defense from oxidative stressors is evident at first miscarriage, identifying women at high risk for subsequent eventful pregnancy. Reduced AHSP may identify women at risk of experiencing further miscarriages.

Doppler analysis and placental nitric oxide synthase expression during fetal growth restriction

OBJECTIVE

To assess placental nitric oxide (NO) metabolism related to changes in the uteroplacental circulation during fetal growth restriction (FGR).

METHODS

The resistance index (RI) from the uterine arteries and pulsatility index (PI) from the umbilical artery were determined by Doppler analysis in 15 patients with FGR and 12 healthy controls, before elective cesarean section. Inducible (iNOS) and endothelial (eNOS) NO synthase expression were measured in placental samples. Immunohistochemistry was performed for iNOS location in the placenta.

RESULTS

During FGR, we observed a significant elevation of iNOS when compared with controls. Conversely, eNOS did not differ between the two groups. A negative correlation with eNOS (r = -0.85) and a positive correlation with iNOS (r = 0.91) was found correlating to umbilical PI. The iNOS proteins were reduced in syncytiotrophoblast cells and increased in endothelium in the FGR group compared to the controls.

CONCLUSIONS

During FGR, placental iNOS expression is significantly increased; this increase possibly represents an adaptive physiological mechanism for overcoming a fetoplacental circulation deficiency.

Nitric oxide and peroxynitrite platelet levels in women with small-for-gestational-age fetuses

OBJECTIVE

The placenta produces reactive oxygen species (ROS) including nitric oxide (NO) and peroxynitrite (ONOO(-)) that have pronounced effects on placental function. Excessive ROS production may occur in pathological pregnancies, such as those complicated by small-for-gestational-age (SGA) fetuses.

DESIGN

The aim of the present work was to study NO and ONOO(-) levels in platelets of pregnant women with SGA fetuses compared with a control group.

SETTING AND POPULATION

The study was performed on 30 pregnant women with SGA fetuses (SGA group) and on 30 healthy pregnant women (appropriate-for-gestational-age [AGA] group) matched for maternal and gestational age. All women included in this study were in the third trimester of pregnancy.

METHODS

Platelets were isolated by differential centrifugation. NO metabolites, after enzymatic conversion followed by the Griess reaction, were measured as nitrite by spectrophotometric detection. Peroxynitrite (ONOO(-)) levels were evaluated using the fluorescence probe 2,7-dichlorofluorescein diacetate (DCFDA).

MAIN OUTCOME MEASURES

The following determinations were made: platelet nitric oxide and peroxynitrite levels in the SGA group and controls; inducible nitric oxide synthase (iNOS), endothelial nitric oxide synthase (eNOS) and nitrotyrosine (N-Tyr) expression in the same groups.

RESULTS

Our results show that both platelet NO and ONOO(-) levels were significantly higher in the SGA group than in the controls.

CONCLUSION

Increased platelets levels of nitric oxide and peroxynitrite might play a role in the pathophysiology of intrauterine growth restriction. Further investigations are in progress to clarify if these molecules are pathogenetic factors, an epiphenomenon or a pathophysiological marker.

Placental overexpression of transforming growth factor-beta3 in the HELLP syndrome

OBJECTIVE

To evaluate the placental expression of transforming growth factor-beta3 (TGF-beta3) in patients with HELLP syndrome and pre-eclampsia compared to controls, and its correlation to Doppler velocimetry analysis of the utero-placental blood flow.

STUDY DESIGN

Real-time PCR analysis was performed, after cesarean section, in placental samples from 10 women affected by HELLP syndrome, 10 women with pre-eclampsia and 10 controls. Pulsatility indices on Doppler waveform analysis from uterine and umbilical arteries were measured.

RESULTS

The mean TGF-beta3 expression was significantly higher in patients with HELLP syndrome compared with the control group (p < 0.001), and no difference was observed in the pre-eclampsia group. TGF-beta3 expression correlated positively with umbilical PI (p < 0.001).

CONCLUSIONS

TGF-beta3 may play a key role as regulator of a variety of cellular events occurring during HELLP syndrome, high local expression of this growth factor may be responsible for remodeling of the placental structure, which results in the dysfunction of maternal-fetal circulation.

Computerized analysis of the fetal heart rate in pregnancies complicated by preterm premature rupture of membranes (pPROM)

OBJECTIVE

We aimed to show that in pregnancies complicated by preterm premature rupture of membranes (pPROM), there are alterations to the fetal heart rate pattern that can be detected by computerized analysis.

METHODS

The study population consisted of 27 pregnant women with pPROM at 29-34 weeks of gestation and 33 normal pregnancies matched according to age, parity and gestation. A 30-minute fetal heart rate (FHR) tracing was analyzed by computer and umbilical artery cord blood was collected at birth.

RESULTS

The baseline heart rate, the number of decelerations exceeding 20 beats per minute and the duration of episodes of low variation were higher in the pPROM group versus the controls. The number of decelerations exceeding 20 beats per minute had an independent, statistically significant association with umbilical artery pH at birth.

CONCLUSIONS

Even if our data require a prospective validation involving a larger number of pathological cases, a computerized FHR tracing analysis may improve the clinical care and the timing of delivery during pPROM by definition of the risk of acidemia and pre-acidemia.

Placental expression of nitric oxide synthase during HELLP syndrome: the correlation with maternal-fetal Doppler velocimetry

BACKGROUND

To correlate Doppler waveform of the uterine and umbilical vessels to placental nitric oxide synthase (NOS) expression in pregnant women with HELLP (hemolysis, elevated liver enzymes, low platelets count) syndrome.

METHODS

mRNA expression of inducible NOS (iNOS) and endothelial NOS (eNOS) was assessed, after cesarean section, in placental samples from 10 women affected by HELLP syndrome and 10 controls. Pulsatility indices on Doppler waveform analysis from uterine and umbilical arteries were measured.

RESULTS

iNOS expression was significantly lower in placenta from women with HELLP syndrome than controls. When comparing the results with Doppler flow measurements, we found a negative correlation between umbilical pulsatility index and eNOS expression (r = -0.91) and a positive correlation with iNOS expression (r = 0.86).

CONCLUSIONS

The reduced iNOS expression in women with HELLP syndrome may indicate the extreme placental dysfunction that is unable to compensate for the endothelial derangement and related hypertension in spite of trying to improve fetoplacental perfusion and the delivery of nutrients to the fetus.

Placental CoQ10 levels in HELLP syndrome

Oxidative stress is considered a key factor in HELLP syndrome, a severe complication of preeclampsia in pregnancy. In the present study we analysed the content of Coenzyme Q(10) (CoQ(10)), a fundamental component of the mitochondrial respiratory chain and recognized lipophilic antioxidant, in placentas from women affected by HELLP syndrome and compared them with the relative controls. Twenty-eight patients with HELLP syndrome and twenty-eight age-matched healthy pregnant controls were enrolled. Two aliquots of placental tissue were taken immediately after delivery and placed into liquid nitrogen. Thawed samples were homogenised by Ultra-Turrax; total protein and CoQ(10) concentration were thereafter analysed. CoQ(10) concentration was 0.162 +/- 0.07 microg/mg protein in HELLP syndrome versus 0.87 +/- 0.003 microg/mg protein in controls, the difference being highly significant. A positive correlation, within the placentas from HELLP, was found between the weight of the new-born and CoQ(10)/protein ratio. A significant positive correlation was also present between CoQ(10)/protein ratio and Apgar at 1st and 5th minute as well as between CoQ(10)/protein ratio and the median cerebral artery pulsatility index. The increase in placental CoQ(10) in this syndrome might derive from a compensatory mechanism in a situation of increased oxidative stress.

Adverse pregnancy outcomes are associated with multiple maternal thrombophilic factors

OBJECTIVE

To determine to what extent adverse pregnancy outcomes are associated with thrombophilia.

STUDY DESIGN

We studied 31 women who had HELLP syndrome, placental abruption, fetal growth restriction or unexplained stillbirth (study group), matched with 12 controls. All women were tested for: Factor V, Prothrombin, methylenetetrahydrofolate reductase gene (MTHFR) mutations; for Protein C, S and Antithrombin III deficiency; for lupus anticoagulant. Correlation with 24h BP monitoring and uterine Doppler velocimetry indexes at 22-24 weeks' gestation was performed.

RESULTS

Women with multiple thrombophilic factors had a significant lower birth weight (1568.33+/-146.8 g versus 2546.45+/-438 g), higher 24 h mean diastolic blood pressure at second trimester (76.3+/-12.5 mmHg versus 65.2+/-7.8 mmHg) and higher RI of uterine arteries (0.69+/-0.05 versus 0.50+/-0.15) than women with single thrombophilic factor.

CONCLUSION

Multiple thrombophilic factors carry a major additional risk for adverse maternal and fetal outcomes and correlate well with placental maladaptation as indicated by uterine Doppler velocimetry and 24h BP monitoring.

Amniotic levels of nitric oxide and vascular endothelial growth factor in pregnancy with subsequent intrauterine fetal death

OBJECTIVE

Nitric oxide (NO) and vascular endothelial growth factor (VEGF) regulate angiogenesis and seem involved in the early stages of placentation. If angiogenesis is reduced, this may lead to poor placentation and fetal death. This study was aimed to determine whether VEGF and NO are associated to subsequent fetal death.

STUDY DESIGN

We retrospectively assessed NO and VEGF on midtrimetster amniotic fluid from seven women who had subsequently had intrauterine fetal death before 20 weeks, and compared the results with those of 14 controls matched for age and gestation. All women had undergone amniocentesis for maternal age. All were at 16 weeks of gestation. None had shown chromosomal abnormalities. Results (mean+/-S.D.) were tested for statistics with Student's t-test with significance at P<0.05.

RESULTS

Women with subsequent fetal death had both amniotic NO and VEGF lower than women with normal pregnancy (NO 3.28+/-1.20 microg/mg creatinine versus 6.02+/-1.57 microg/mg creatinine, P<0.05; VEGF 210.10+/-69.55 pg/ml versus 255.05+/-88.66 pg/ml).

CONCLUSIONS

An early reduction of both NO and VEGF may be responsible of an impaired placental vascular development and endothelial regulation that may lead to fetal death.

Amniotic vascular endothelial growth factor (VEGF) and nitric oxide (NO) in women with subsequent preeclampsia

OBJECTIVE

To assess whether amniotic fluid concentrations of nitric oxide (NO) and vascular endothelial growth factor (VEGF) in early pregnancy correlate to subsequent preeclampsia.

STUDY DESIGN

We performed a retrospective study to assess VEGF and NO on the second trimester amniotic fluid of 15 healthy women, and 15 women who subsequently developed preeclampsia.

RESULTS

In women with subsequent preeclampsia, both VEGF (213.19+/-78.42 pg/ml) and NO concentrations (4.31+/-1.02 micromol/mg creatinine) were significantly lower than healthy controls (VEGF 255.05+/-88.66 pg/ml; NO 5.02+/-1.57 microg/mg creatinine; P<0.05).

CONCLUSIONS

Our findings suggest that reduced VEGF may be responsible, at least in part, for the impaired vascular development which occurs in preeclampsia. Low concentrations of VEGF and NO in the second trimester may represent an impaired stimulus to vascular formation and endothelial regulation that induce placental disease and preeclampsia.