Hydroxychloroquine in obstetrics: potential implications of the prophylactic use of hydroxychloroquine for placental insufficiency during pregnancy

Proper placentation during early pregnancy is a key factor for maintaining a healthy pregnancy. Placental insufficiency leads to critical complications such as preeclampsia, fetal growth restriction, and fetal demise. These complications are often associated with pathological findings of restricted remodeling and obstructive lesions of the myometrial spiral arteries, which have high recurrence rates during subsequent pregnancies. Currently, there are no pharmacological interventions other than aspirin for the prevention of preeclampsia. Hydroxychloroquine (HCQ), a well-known antimalarial drug, reduces inflammatory and thrombotic changes in vessels. For decades, the use of HCQ for autoimmune diseases has resulted in the successful prevention of both arterial and venous thrombotic events and has been extended to the treatment of lupus and antiphospholipid antibody syndrome during pregnancy. HCQ reduces the risk of preeclampsia with lupus by up to 90%. Several recent studies have investigated whether HCQ improves pregnancy outcomes in women with a history of poor outcomes. In addition, in vitro and animal studies have demonstrated the beneficial effects of HCQ in improving endothelial dysfunction and alleviating hypertension and proteinuria. Therefore, we hypothesized that HCQ has the potential to attenuate the vascular inflammatory and thrombogenic pathways associated with placental insufficiency and conducted a multicenter clinical trial on the efficacy of combining aspirin with HCQ for pregnancies at high risk for preeclampsia in Korea. This study summarizes the potential effects of HCQ on pregnancies with placental insufficiency and the implications of HCQ treatment in the field of obstetrics.

Analysis of single nucleotide polymorphisms associated with the vitamin D pathway in the placentas of women with gestational diabetes mellitus: a laboratory study

BACKGROUND

The aim of this study was to analyze the single nucleotide polymorphisms (SNPs) of genes known to be involved in vitamin D metabolism in the placenta using the placental tissue of mothers diagnosed with gestational diabetes mellitus (GDM) to determine whether the SNPs and occurrence of GDM are related.

METHODS

We enrolled 80 women of the same gestational age, 40 with and 40 without GDM. The placenta was obtained from each woman after delivery and SNP genotyping was performed on seven SNPs in the CYP27B1 (rs10877012), CYP24A1 (rs2248359, rs6013897, and rs2209314), and GC (rs2282679, rs16847024, and rs3733359) genes. Maternal serum 25-hydroxyvitamin D levels were measured during the first trimester of pregnancy and before delivery.

RESULTS

At the time of delivery, vitamin D levels were lower (21.05±12.05 mg/dL vs. 31.31±20.72 mg/dL, p=0.012) and the frequency of vitamin D deficiency was higher (60.7% vs. 32.5%, p=0.040) in the GDM group. In women with GDM, the G allele of rs10877012 was more common (86.3% vs. 65.0%, p=0.002). The rs10877012 GG genotype was more common in the GDM group (72.5% vs. 42.5%, p=0.007) and the rs10877012 TT genotype was more common in the control group (12.5% vs. 0%, p=0.007).

CONCLUSION

Mothers with GDM have lower serum concentrations of vitamin D before delivery than healthy controls and vitamin D deficiency is common. A polymorphism in CYP27B1 (rs10877012), is considered to be a cause of GDM pathogenesis.

Relationship between maternal Group B Streptococcal colonization and gestational vaginal microbiome composition: A pilot study

PURPOSE

Group B Streptococcus (GBS) colonization and vaginal microbiome (VMB) dysbiosis are associated with adverse perinatal outcomes. However, the role of GBS colonization in maternal VMB remains unclear. Herein, we aimed to investigate this relationship and identify additional pathogens associated with GBS colonization for potential implications in understanding their clinical significance.

MATERIALS AND METHODS

Vaginal swab samples were obtained before delivery from nine women with normal pregnancies for GBS detection and 16S rRNA gene sequencing. The diversity analysis and community state types clustering were used to compare the GBS-positive vs. GBS-negative groups. ANCOM-BC was implemented to identify differentially abundant microbes (DAMs) associated with GBS colonization. The correlation and receiver operating characteristic analysis were used to evaluate the relationship between DMAs and clinical parameters.

RESULTS

There were 6/9 (66,7%) GBS-negative pregnant women. The α-diversity index (p ​= ​0.71 for observed operational taxonomic units and p ​= ​0.90 for Shannon diversity), β-diversity index (p ​= ​0.583), and community state types clustering (p ​= ​0.23) were not significantly different between the GBS-positive and -negative groups. Four DAMs, namely, Actinomyces, Shigella, Fenollaria, and Gemella, were significantly associated with GBS colonization, reflecting the dynamicity of the gestational VMB. Their abundances were negatively correlated with birth weight and had acceptable discriminating ability in premature membrane rupture (area under the curve, 0.9).

CONCLUSIONS

Despite the absence of significant effects on overall VMB composition, our preliminary results investigated that maternal GBS colonization related to high abundance of four pathogens with potential clinical utility as microbial signatures.

Infection-Induced Rhabdomyolysis in a Pregnant Woman with Undiagnosed Myotonic Dystrophy: A Case Report

A 34-year-old nulliparous gravid female presented with acute bilateral pyelonephritis at 29 + 5 weeks gestation. The patient was relatively well until two weeks ago when a slight increase in amniotic fluid was noted. Further investigation revealed myoglobinuria and significantly elevated levels of creatine phosphokinase. The patient was subsequently diagnosed with rhabdomyolysis. Twelve hours after admission, the patient noted reduced fetal movements. A non-stress test revealed fetal bradycardia and non-reassuring variability in fetal heart rate. An emergency cesarean section was performed, and a "floppy" female child was delivered. Genetic testing revealed congenital myotonic dystrophy, and the mother was also diagnosed with myotonic dystrophy. Rhabdomyolysis has a very low incidence in pregnancy. Herein, we report a rare case of myotonic dystrophy with rhabdomyolysis in a gravid female with no history of myotonic dystrophy. Acute pyelonephritis is a causative agent of rhabdomyolysis that results in preterm birth.

Acute Twin-to-Twin Transfusion Syndrome Resulting in Fetal Bradycardia and Neonatal Death: A Case Report

In monochorionic twins with no evidence of chronic twin-to-twin transfusion syndrome or twin anemia-polycythemia sequence, a sudden onset of fetal transfusion syndrome after the second trimester of pregnancy is defined as acute twin-to-twin transfusion syndrome. Labor pain, change in the fetal position, and birth order are known risk factors for this condition, and the hemoglobin level of the donor twin is usually reported to be <12 g/dL. We report a recent case of acute twin-to-twin transfusion syndrome without effective labor pain causing cervical changes, resulting in fetal bradycardia and neonatal death after birth; however, the anemia of the donor twin was not as severe as has been reported previously in twin-to-twin transfusion syndrome cases.

Updates on Group B Streptococcus Infection in the Field of Obstetrics and Gynecology

Group B Streptococcus (GBS, Streptococcus agalactiae) is a Gram-positive bacterium that is commonly found in the gastrointestinal and urogenital tracts. However, its colonization during pregnancy is an important cause of maternal and neonatal morbidity and mortality worldwide. Herein, we specifically looked at GBS in relation to the field of Obstetrics (OB) along with the field of Gynecology (GY). In this review, based on the clinical significance of GBS in the field of OBGY, topics of how GBS is being detected, treated, and should be prevented are addressed.

Prediction of maternal complications and neonatal outcome in dichorionic diamniotic twins with fetal weight discordancy measured by ultrasonography

This study aimed to determine the relationship between estimated fetal weight discordance by ultrasonography and maternal and neonatal outcomes in dichorionic diamniotic twin pregnancies. We conducted a retrospective review of the medical records of 106 twin pregnancies delivered at a single tertiary center between January 2011 and February 2020. At 20–24 and 28–32 weeks of gestation, participants were divided into two groups: discordant twins with an estimated fetal weight difference of more than 20% and concordant twins with a weight difference of less than 20%. Maternal complications and neonatal outcomes were compared between the two groups. Although the incidences of preeclampsia and placenta previa were significantly higher in discordant twins measured between 20 and 24 weeks, no statistical significance was found in neonatal outcomes. Delivery times were earlier, and neonatal weights were lower in discordant twins measured between 28 and 32 weeks. Neonatal outcomes such as ventilator use and neurodevelopment were also significantly different. Discordance in estimated fetal weight measured using ultrasonography between 20 and 24 weeks can be a risk factor for maternal preeclampsia and placenta previa, whereas discordance at 28–32 weeks may predict poor neonatal outcomes.

Midtrimester cervical elastography in pregnant women with a history of loop electrosurgical excision procedure (LEEP)

We aimed to compare cervical elastographic parameters based on a previous loop electrosurgical excision procedure (LEEP) and to determine whether they can predict preterm delivery in pregnant women with a history of LEEP. This multicenter prospective case-control study included 71 singleton pregnant women at 14-24 weeks of gestation with a history of LEEP and 1:2 gestational age-matched controls. We performed cervical elastography using E-cervix and compared maternal characteristics, delivery outcomes, cervical length (CL), and elastographic parameters between the two groups. The median mid-trimester CL was significantly shorter in the LEEP group. Most elastographic parameters, including internal os (IOS), external os (EOS), elasticity contrast index (ECI), and hardness ratio (HR), were significantly different in the two groups. In the LEEP group, the sPTD group compared to the term delivery (TD) group showed a higher rate of previous sPTD (50% vs. 1.7%, p < 0.001), higher IOS and ECI (IOS: 0.28 [0.12-0.37] vs. 0.19 [0.10-0.37], p = 0.029; ECI: 3.89 [1.79-4.86] vs. 2.73 [1.48-5.43], p = 0.019), and lower HR (59.97 [43.88-92.43] vs. 79.06 [36.87-95.40], p = 0.028), but there was no significant difference in CL (2.92 [2.16-3.76] vs. 3.13 [1.50-3.16], p = 0.247). In conclusion, we demonstrated that a history of LEEP was associated with a change in cervical strain measured in mid-trimester as well as with CL shortening. We also showed that cervical elastography can be useful in predicting sPTD in pregnant women with previous LEEP.

Diagnosis of gestational diabetes: Are five rounds of blood sampling necessary?

We aimed to determine the upper and lower cutoff values to simplify the diagnosis of gestational diabetes mellitus (GDM). We investigated the 50-g oral glucose tolerance test (OGTT) results from 1441 pregnancies and identified 423 gravidas who underwent the 100-g OGTT from 2011 to 2019. We collected the results of 50- and 100-g OGTTs. Moreover, we obtained the sum of the 50-g OGTT and 0-hour values, and the sum of those levels and 1-hour values. We determined the upper cutoff at 50-g OGTT, 0-, 1-hour, sum of 50-g OGTT and 0-hour results, and sum of those levels and 1-hour results for the confirmation of GDM. Also, we determined the lower cutoff at these tests for the exclusion of GDM. The upper cutoffs in 50-g OGTT, 0-, 1-hour, the sum of 50-g OGTT and 0-hour were 222, 115, 212, and 315 mg/dL, respectively. The lower cutoffs in 50-g OGTT, 0-, 1-hour, the sum of 50-g OGTT and 0-hour were 131, 65, 151, and 208 mg/dL, respectively. In addition, we discovered that the upper and lower cutoffs in the sum of 50-g OGTT, 0- and 1-hour values were >516 and <373 mg/dL, respectively. We implemented these cutoffs to our study group at 50-g OGTT and 0-, 1-hour of 100-g OGTT. It could omit 2- and 3-hour sampling in 216 gravidas (51.1%). Our approach was able to simplify GDM diagnostic steps in half of our study group.

Prediction of Adverse Outcomes among Women in the Third Trimester of Pregnancy with Coronavirus Disease 2019

Background

This study aimed to compare the clinical and laboratory characteristics of two groups of women (favorable and adverse outcome groups) in the third trimester of pregnancy with coronavirus disease 2019 (COVID-19) and to investigate the predictors of specific adverse outcomes.

Materials and Methods

We retrospectively reviewed the medical records of patients hospitalized with COVID-19 between November 2020 and October 2021 at Kyungpook National University Chilgok Hospital. Adverse outcomes were clinically defined using the Novel Coronavirus Pneumonia Emergency Response Epidemiology Team criteria. The group without adverse outcomes was defined as the “favorable outcome” group and the rest as the “adverse outcome” group. We compared the clinical characteristics between the two groups and examined the correlation between their laboratory results and adverse outcomes.

Results

Of the 70 pregnant women included, 37 were in their third trimester. No significant differences in clinical characteristics, except the length of hospitalization, were noted between the groups. In laboratory tests conducted immediately after hospitalization, C-reactive protein (CRP) (1.0 [0.3 - 1.4] vs. 2.3 [1.3 - 3.6], P = 0.001) and ferritin (25.0 [14.5 - 34.5] vs. 53.1 [36.0 - 98.0], P <0.03) levels were significantly different between the groups. Logistic regression analysis revealed that CRP (odds ratio [OR]: 2.26; 95% confidence interval [CI]: 1.09 - 5.51, P = 0.040) and ferritin (OR: 1.06; 95% CI: 1.01 - 1.15, P = 0.047) levels were predictors of adverse outcomes.

Conclusion

CRP and ferritin levels are associated with poor prognosis and can predict adverse outcomes in women with COVID-19 in the third trimester of pregnancy.

Pulmonary atresia with a ventricular septal defect and left pulmonary artery discontinuity: a case report

Background

Unilateral pulmonary artery discontinuity is a rare malformation that is associated with other intracardiac abnormalities. Cases accompanied by other cardiac abnormalities are often missed on prenatal echocardiography. The prenatal diagnosis of isolated unilateral pulmonary artery discontinuity can also be delayed. However, undiagnosed this malformation would have an effect on further prognosis. We report our case of a prenatal diagnosis of pulmonary atresia with ventricular septal defect and left pulmonary artery discontinuity.

Case presentation

A 33-year-old Asian woman visited our institution at 24 weeks of gestation because of suspected fetal congenital heart disease. Fetal echocardiography revealed a small atretic main pulmonary artery giving rise to the right pulmonary artery without bifurcation and the left pulmonary artery arising from the ductus arteriosus originating from the left subclavian artery. The neonate was delivered by cesarean section at 37^6/7 weeks of gestation. Postnatal echocardiography and multidetector computed tomography showed a right aortic arch, with the small right pulmonary artery originating from the atretic main pulmonary artery and the left pulmonary artery originating from the left subclavian artery. Patency of the ductus arteriosus from the left subclavian artery was maintained with prostaglandin E1. Right ventricular outflow tract reconstruction and pulmonary angioplasty with Gore-Tex graft patch was performed 25th day after birth. Unfortunately, the neonate died because of right heart failure 8 days postoperation.

Conclusion

There is a possibility that both pulmonary arteries do not arise from the same great artery (main pulmonary artery or common arterial trunk). Therefore, clinicians should check the origin of both pulmonary arteries.

The diagnosis of an imperforate anus in female fetuses

Imperforate anus is an anomaly caused by a defect in the development of the hindgut during early pregnancy. It is a relatively common congenital malformation and is more common in males. Although there are cases of a solitary imperforate anus, the condition is more commonly found as a part of a wider spectrum of other congenital anomalies. Although urgent reconstructive anorectal surgery is not necessary, immediate evaluation is important and urgent decompressive surgery may be required. Moreover, as there are often other anomalies that can affect management, prenatal diagnosis can help in optimizing perinatal care and prepare parents through prenatal counseling. In the past, imperforate anus was diagnosed by prenatal ultrasonography based on indirect signs such as bowel dilatation or intraluminal calcified meconium. Currently, it is diagnosed by directly checking the perineum with prenatal ultrasonography. Despite advances in ultrasound technology, accurate prenatal diagnosis is impossible in most cases and imperforate anus is detected after birth. Here, we present two cases of imperforate anus in female fetuses that were not diagnosed prenatally.

Association between gestational age at delivery and lymphocyte-monocyte ratio in the routine second trimester complete blood cell count

BACKGROUND

We aimed to determine whether routine second trimester complete blood cell (CBC) count parameters, including neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), and platelet-lymphocyte ratio (PLR), could predict obstetric outcomes.

METHODS

We included singleton pregnancies for which the 50-g oral glucose tolerance test and CBC were routinely performed between 24 and 28 weeks of gestation in our outpatient clinic from January 2015 to December 2017. The subjects were divided into three groups according to their pregnancy outcomes as follows: group 1, spontaneous preterm births, including preterm labor and preterm premature rupture of membranes; group 2, indicated preterm birth due to maternal, fetal, or placental causes (hypertensive disorder, fetal growth restriction, or placental abruption); and group 3, term deliveries, regardless of the indication of delivery. We compared the CBC parameters using a bivariate correlation test.

RESULTS

The study included 356 pregnancies. Twenty-eight subjects were in group 1, 20 in group 2, and 308 in group 3. There were no significant differences between the three groups in neutrophil, monocyte, lymphocyte, and platelet counts. Although there was no significant difference in NLR, LMR, and PLR between the three groups, LMR showed a negative correlation with gestational age at delivery (r=-0.126, p=0.016).

CONCLUSION

We found that a higher LMR in the second trimester was associated with decreased gestational age at delivery. CBC parameters in the second trimester of pregnancy could be used to predict adverse obstetric outcomes.

The Clinical Usefulness of Predictive Models for Preterm Birth with Potential Benefits: A KOrean Preterm collaboratE Network (KOPEN) Registry-Linked Data-Based Cohort Study

Background: Preterm birth is strongly associated with increasing mortality, incidence of disability, intensity of neonatal care required, and consequent costs. We examined the clinical utility of the potential preterm birth risk factors from admitted pregnant women with symptomatic preterm labor and developed prediction models to obtain information for prolonging pregnancies. Methods: This retrospective study included pregnant women registered with the KOrean Preterm collaboratE Network (KOPEN) who had symptomatic preterm labor, between 16 and 34 gestational weeks, in a tertiary care center from March to November 2016. Demographics, obstetric and medical histories, and basic laboratory test results obtained at admission were evaluated. The preterm birth probability was assessed using a nomogram and decision tree according to birth gestational age: early preterm, before 32 weeks; late preterm, between 32 and 37 weeks; and term, after 37 weeks. Results: Of 879 registered pregnant women, 727 who gave birth at a designated institute were analyzed. The rates of early preterm, late preterm, and term births were 18.16%, 44.02%, and 37.83%, respectively. With the developed nomogram, the concordance index for early and late preterm births was 0.824 (95% CI: 0.785-0.864) and 0.717 (95% CI: 0.675-0.759) respectively. Preterm birth was significantly more likely among women with multiple pregnancy and had water leakage due to premature rupture of membrane. The prediction rate for preterm birth based on decision tree analysis was 86.9% for early preterm and 73.9% for late preterm; the most important nodes are watery leakage for early preterm birth and multiple pregnancy for late preterm birth. Conclusion: This study aims to develop an individual overall probability of preterm birth based on specific risk factors at critical gestational times of preterm birth using a range of clinical variables recorded at the initial hospital admission. Therefore, these models may be useful for clinicians and patients in clinical decision-making and for hospitalization or lifestyle coaching in an outpatient setting.

Evaluation of the effectiveness of foetal fibronectin as a predictor of preterm birth in symptomatic preterm labour women

BACKGROUND

The prediction of preterm birth (PTB) is important in the management of symptomatic preterm labour women. We evaluated the effectiveness of the foetal fibronectin (fFN) test for predicting PTB in symptomatic preterm labour women with consideration of physiologic changes in cervical length (CL) during pregnancy.

METHODS

This prospective study included 85 women with symptomatic preterm labour of a singleton pregnancy. Positive fFN was defined as a fFN level of > 50 ng/mL in cervicovaginal secretion, while a short CL was defined as that below 25th percentile at the corresponding gestational age. We evaluated effectiveness of the fFN test, CL, and the combination of these two tests, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), positive likelihood ratio (LR⁺), negative likelihood ratio (LR^-) to predict the PTB within 7 and 14 days of testing and PTB at < 34 and 37 weeks of gestation. We also present the odds ratios (ORs) of the test results, defining the women with both negative results as the reference group.

RESULTS

Of the 85 women, 31 (36.5%) showed a positive fFN and 44 (51.8%) had a short CL. PTB occurred within 7 and 14 days of testing and before 34 and 37 weeks of gestation in 17.6, 20.0, 23.5 and 49.4% of the women, respectively. The fFN and CL results showed low predictive effectiveness for the studied outcomes with LR⁺ (fFN, 1.5-1.9; CL, 1.0-1.5) and LR^- (fFN, 0.7; CL, 0.7-0.9). The combined use of fFN and CL could not improve these results (LR⁺, 1.4-2.3; LR^-, 0.7-0.9). However, the risk of PTB before 37 weeks was increased in women with positive fFN but not CL shortening compared to the reference group (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.1-1.3). The risk of PTB before 34 weeks was increased in both positive fFN and CL compared to the reference group (OR, 8.1; 95% CI, 1.9-34.5).

CONCLUSION

Although, our approach could not improve the ability to predict PTB, it could identify women at risk for delivery before 34 or 37 weeks of gestation. Therefore, it could be used to manage women with symptomatic preterm labour.

Changes in calcium channel proteins according to magnesium sulfate administration in placentas from pregnancies with pre-eclampsia or fetal growth restriction

We aimed to evaluate the changes in plasma membrane Ca²⁺-ATPase (PMCA) and sarcoendoplasmic reticulum CA²⁺-ATPase (SERCA-2) according to the antepartal magnesium sulfate (MgSO₄) administration in the placentas from pregnancies with pre-eclampsia (PE) or fetal growth restriction (FGR). Pregnant women were classified as follows: (group 1) pregnancies without PE or FGR (n=16), (group 2) pregnancies with PE or FGR but without MgSO₄ administration (n=14), and (group 3) pregnancies with PE or FGR and with MgSO₄ administration (n=28). We observed the localization of PMCA and SERCA-2 in placentas and compared its expression among 3 groups. And we observed its expression in BeWo cells following treatment with MgSO₄ and CoCl₂. PMCA staining was more observed in the basal membrane, whereas SERCA-2 staining was observed predominantly under the microvillous membrane. SERCA-2 expression was significantly increased in group 3 compared with that in group 1. Considering the gestational age at delivery, PMCA expression was increased in group 2 and group 3 compared with that in group 1 after 36 weeks of gestation. SERCA-2 was increased in group 3, but not in group 2 compared with that in group 1 after 36 weeks of gestation. In BeWo cells, MgSO₄ treatment increased PMCA and SERCA-2 expression. PMCA expression was influenced by gestational age at delivery, and SERCA-2 expression was increased in the presence of PE and antepartal MgSO₄ administration. This indicates that antepartal MgSO₄ administration has a greater influence on SERCA-2 than PMCA.

Short- and long-term neonatal outcomes according to differential exposure to antenatal corticosteroid therapy in preterm births prior to 24 weeks of gestation

AIM

To assess the effects of differential exposure to antenatal corticosteroid (ACS) on short- and long-term outcomes of infants born before 24 weeks of gestation.

METHODS

This is a retrospective cohort study of 147 infants delivered by 116 women at 21-23 weeks of gestation between January 2001 and December 2016 at a tertiary referral hospital in Seoul, Korea. Eligible subjects were categorized into the following three groups according to ACS exposure: non-user (n = 53), partial-course (n = 44), and complete-course (n = 50). Univariable and multivariable analyses were used to compare neonatal mortality, neonatal morbidities including intraventricular hemorrhage (IVH), and neurodevelopmental impairment including cerebral palsy among the three groups.

RESULTS

Neonatal mortality rate was significantly lower in the ACS-user groups (non-user, 52.8%; partial-course, 27.3%; complete-course, 28.0%; P = 0.01), but complete-course of ACS therapy had no advantages over partial-course. A lower incidence of IVH was observed in the complete-course group (non-users, 54.8%; partial-course, 48.6%; complete-course, 20.5%; P = 0.003). Multiple logistic regression analysis showed that ACS therapy, either partial- or complete-course, was associated with a lower rate of neonatal mortality (adjusted odds ratio (aOR) 0.375; 95% confidence interval (CI) 0.141-0.996 in partial-course; aOR 0.173; 95% CI 0.052-0.574) in complete-course). IVH (aOR 0.191; 95% CI 0.071-0.516) was less likely to occur in the complete-course group than in the non-user group. Neurodevelopmental impairment of survivors at 18-22 month after birth was not significantly different among the three groups.

CONCLUSION

ACS therapy in preterm births at 21-23 weeks of gestation was associated with significantly reduced rates of neonatal mortality and IVH, especially with complete administration.

Comparison of single nucleotide polymorphisms in the 3' untranslated region of HLA-G in placentas between spontaneous preterm birth and preeclampsia

OBJECTIVE

To compare single nucleotide polymorphisms (SNPs) in the 3'-untranslated region (3'UTR) of human leukocyte antigen (HLA)-G in placentas between spontaneous preterm birth and preeclampsia pregnancies.

RESULTS

Placental samples matched for gestational age were obtained from 20 cases of spontaneous preterm births and 19 cases of preeclampsia. Genomic deoxyribonucleic acid was extracted from placenta tissue and the 3'UTR region of HLA-G was amplified via polymerase chain reaction. Nine SNPs were analyzed by direct Sanger sequencing. There was no significant difference in gestational age at delivery or birth weight between two groups. And there were no significant differences in the allele and phenotype frequencies between two groups.

Amino-Terminal proB-Type Natriuretic Peptide Levels in the Umbilical Cord Blood of Neonates Differ According to the Type of Prenatally Diagnosed Congenital Heart Disease

The aim of this study was to investigate differences in amino-terminal proB-type natriuretic peptide (NT-proBNP) levels in the cord blood of neonates according to the type of congenital heart disease (CHD) and to evaluate the usefulness of NT-proBNP as a prognostic marker. We included 76 neonates with prenatally diagnosed CHD and 45 controls without CHD. Neonates were classified into five groups based on echocardiographic findings. The levels of NT-proBNP in the cord blood were examined and analyzed according to the neonatal outcomes. The levels of NT-proBNP were significantly elevated in the cord blood of neonates with CHD compared with that in the cord blood of controls. The levels of NT-proBNP in the group with right ventricular outflow tract obstruction without a ventricular septal defect were significantly increased compared to that in the other groups. The neonates that required acute surgical correction had higher levels of NT-proBNP in the cord blood, though they were not statistically significant. Meanwhile, NT-proBNP levels in the cord blood of neonates with functional single ventricle were significantly higher than that in the cord blood of those with functional biventricles. Significant differences in the levels of NT-proBNP between survivors and nonsurvivors were observed within 1 year of birth. In this study, we found that the levels of NT-proBNP in the cord blood of neonates with CHD were higher than the levels in controls. This finding was striking in the group with right ventricular outflow tract obstruction, and it was associated with surgery for functional single ventricle and 1-year survival.

Prenatal diagnosis of multiple ventriculocoronary connections in pulmonary atresia with an intact ventricular septum: a case report

We report a case of prenatally detected pulmonary atresia with an intact ventricular septum accompanied by multiple ventriculocoronary connections. This lesion was diagnosed by using ultrasonography at 20 weeks' gestation, and this antepartum diagnosis was confirmed with both postnatal echocardiography and chest computed tomography. The neonate underwent a modified Blalock-Taussig shunt on the 15th day of life, and was discharged 8 days after the surgery.

Autophagy induced by tumor necrosis factor α mediates intrinsic apoptosis in trophoblastic cells

To investigate the interconnection of apoptosis and autophagy in trophoblastic cells, we treated JEG-3 cells with tumor necrosis factor α (TNF-α) after transfecting LC3 or Beclin 1 or calpain small interfering RNA (siRNA), which blocks cleavage of autophagy-related gene 5 (Atg5) into N-terminal truncated Atg5 (tAtg5), a mediator between apoptosis and autophagy, and assessed the changes in LC3-II, caspase 9, caspase 3, and tAtg5. We also assessed the TNF-α-induced changes in LC3-II, caspase 9, and caspase 3 in primary trophoblasts from term placentae after transfecting siRNA for LC3 or Beclin 1. In both types of cells, transfection of LC3 or Beclin 1 siRNA significantly attenuated TNF-α-induced increases in LC3-II and activations of caspase 9 and caspase 3. There was significant abrogation of TNF-α-induced expression of tAtg5 after transfection with LC3 or Beclin 1 siRNA. Moreover, transfection with calpain siRNA significantly decreased TNF-α-induced changes in caspase 3 and caspase 9 in addition to tAtg5 in JEG-3 cells. Our data suggest that TNF-α-induced autophagy mediates intrinsic apoptosis, probably through tAtg5, in trophoblastic cells.

Optimal time interval between a single course of antenatal corticosteroids and delivery for reduction of respiratory distress syndrome in preterm twins

OBJECTIVE

The objective of the study was to investigate the effect of a single course of antenatal corticosteroid (ACS) therapy on the incidence of respiratory distress syndrome (RDS) in preterm twins according to the time interval between ACS administration and delivery.

STUDY DESIGN

We performed a retrospective cohort study of twins born between 24 and 34 weeks of gestation from November 1995 to May 2011. Subjects were grouped on the basis of the time interval between the first ACS dose and delivery: the ACS-to-delivery interval of less than 2 days (n = 166), 2-7 days (n = 114), and more than 7 days (n = 66). Pregnancy and neonatal outcomes of each group were compared with a control group of twins who were not exposed to ACS (n = 122). Multiple logistic regression analysis was used to examine the association between the ACS-to-delivery interval and the incidence of RDS after adjusting for potential confounding variables.

RESULTS

Compared with the ACS nonexposure group, the incidence of RDS in the group with an ACS-to-delivery interval of less than 2 days was not significantly different (adjusted odds ratio [aOR], 1.089; 95% confidence interval [CI], 0.524-2.262; P = .819). RDS occurred significantly less frequently when the ACS-to-delivery interval was between 2 and 7 days (aOR, 0.419; 95% CI, 0.181-0.968; P = .042). However, there was no significant reduction in the incidence of RDS when the ACS-to-delivery interval exceeded 7 days (aOR, 2.205; 95% CI, 0.773-6.292; P = .139).

CONCLUSION

In twin pregnancies, a single course of ACS treatment was associated with a decreased rate of RDS only when the ACS-to-delivery interval was between 2 and 7 days.

Outcome of isolated fetal renal pyelectasis diagnosed during midtrimester screening ultrasound and cut-off value to predict a persistent or progressive pyelectasis in utero

AIM

To define a better cut-off value of the renal pelvis anteroposterior diameter (RPAPD) to predict persistent or progressive pyelectasis during pregnancy.

METHODS

We retrospectively reviewed 8873 women whose fetal RPAPD was measured. Midtrimester pyelectasis was defined as a RPAPD of ≥4 mm. Persistent/progressive pyelectasis was defined as a RPAPD of ≥10 mm before delivery. A RPAPD cut-off value to predict a persistent/progressive pyelectasis was determined by receiver operating characteristic curve analysis.

RESULTS

Among 249 isolated cases of pyelectasis, persistent/progressive pyelectasis was found in 6.9% before delivery. The midtrimester RPAPD cut-off value that best predicted persistent/progressive pyelectasis before delivery was ≥6 mm with sensitivity, specificity, positive and negative predictive values of 64.3%, 88.7%, 30.0%, and 97.1%, respectively.

CONCLUSIONS

Although most cases of midtrimester fetal pyelectasis regress to normal during pregnancy, those with a RPAPD of ≥6 mm in the midtrimester are at higher risk for persistent or progressive pyelectasis.

Can a customized standard for large for gestational age identify women at risk of operative delivery and shoulder dystocia?

OBJECTIVE

To determine whether a customized standard for large for gestational age (LGA) identifies undiagnosed women at risk of operative delivery and shoulder dystocia.

METHODS

We previously generated customized standards from our institution. We compared the baseline maternal characteristics and neonatal outcomes between LGA and non-LGA births, which were classified by both population-based and customized standards. The risk of operative delivery (vacuum delivery or emergent cesarean section) and shoulder dystocia was compared by logistic regression analysis in LGA pregnancies that were identified by a population-based birth weight standard and a customized standard after adjusting for maternal age, parity, body mass index, and neonatal gender.

RESULTS

Multivariable analysis revealed that the pregnancies identified as LGA by a customized standard were associated with an increased risk of emergent cesarean section [odds ratio (OR), 4.09; 95% confidence interval (CI), 3.00-5.74] and shoulder dystocia (OR, 10.56; 95% CI, 5.52-20.19). However, there was no association between an increased risk of vacuum delivery (OR, 1.45; 95% CI, 0.92-2.30) and pregnancies identified as non-LGA, using both standards. In addition, customized LGA infants were at increased risk of admission to neonatal intensive care unit (OR 1.63; 95% CI, 1.09-2.43).

CONCLUSION

A customized standard of LGA is useful in identifying previously unrecognized women at risk of emergent cesarean section and shoulder dystocia.

Molecular mechanisms underlying chemopreventive activities of anti-inflammatory phytochemicals: down-regulation of COX-2 and iNOS through suppression of NF-kappa B activation

A wide array of phenolic substances, particularly those present in edible and medicinal plants, have been reported to possess substantial anticarcinogenic and antimutagenic activities. The majority of naturally occurring phenolics retain antioxidative and anti-inflammatory properties which appear to contribute to their chemopreventive or chemoprotective activity. Cyclooxygenase-2 (COX-2) inducible and nitric oxide synthase (iNOS) are important enzymes that mediate inflammatory processes. Improper up-regulation of COX-2 and/or iNOS has been associated with pathophysiology of certain types of human cancers as well as inflammatory disorders. Since inflammation is closely linked to tumor promotion, substances with potent anti-inflammatory activities are anticipated to exert chemopreventive effects on carcinogenesis, particularly in the promotion stage. Examples are curcumin, a yellow pigment of turmeric (Curcuma longa L., Zingiberaceae), the green tea polyphenol epigallocatechin gallate (EGCG), and resveratrol from grapes (Vitis vinifera, Vitaceae) that strongly suppress tumor promotion. Recent studies have demonstrated that eukaryotic transcription factor nuclear factor-kappa B (NF-kappa B) is involved in regulation of COX-2 and iNOS expression. Several chemopreventive phytochemicals have been shown to inhibit COX-2 and iNOS expression by blocking improper NF-kappa B activation. Multiple lines of compelling evidence indicate that extracellular-regulated protein kinase and p38 mitogen-activated protein kinase are key elements of the intracellular signaling cascades responsible for NF-kappa B activation in response to a wide array of external stimuli. Curcumin, EGCG and resveratrol have been shown to suppress activation of NF-kappa B. One of the plausible mechanisms underlying inhibition of NF-kappa B activation by aforementioned phytochemicals involves repression of degradation of the inhibitory unit I kappa B alpha, which hampers subsequent nuclear translocation of the functionally active subunit of NF-kappa B.

Role of the CCAAT/enhancer binding protein-alpha transcription factor in the glucocorticoid stimulation of p21waf1/cip1 gene promoter activity in growth-arrested rat hepatoma cells

The preceding paper (Cha, H. H., Cram, E. J., Wang, E. C., Huang, A. J., Kasler, H. G., and Firestone, G. L. (1998) J. Biol. Chem. 273, 0000-0000(478563) defined a glucocorticoid responsive region within teh promoter of the p21 CDK inhibitor gene that contains a putative DNA-binding site for the transcription factor CCAAT/ enhancer binding protein-alpha (C/EBP alpha). Wild type rat BDS1 hepatoma cells as well as as4 hepatoma cells, which express antisense sequences to C/EBP alpha and ablate its protein production, were utilized to investigate the role of this transcription factor in the glucocorticoid regulation of p21 gene expression. The stimulation of p21 protein levels and promoter activity, as well as inhibition of CDK2-mediated retinoblastoma protein phosphorylation, by the synthetic glucocorticoid, dexamethasone, required the expression of C/EBP alpha. Overexpression of C/EBP alpha in as4 cells rescued the dexamethasone responsiveness of the p21 promoter. Site-directed mutagenesis of the p21 promoter revealed that dexamethasone stimulation of p21 promoter activity required the C/EBP consensus DNA-binding site. Furthermore, in glucocorticoid receptor-defective EDR1 hepatoma cells, dexamethasone failed to stimulate C/EBP alpha and p21 protein expression and promoter activities. Our results have established a functional link between the glucocorticoid receptor signaling pathway that mediates a G1 cell cycle arrest of rat hepatoma cells and the transcriptional control of p21 by a cascade that requires the steroid induction of C/EBP alpha gene expression.

Glucocorticoids stimulate p21 gene expression by targeting multiple transcriptional elements within a steroid responsive region of the p21waf1/cip1 promoter in rat hepatoma cells

Glucocorticoids can induce a G1 arrest in the cell cycle progression of BDS1 rat hepatoma cells. In these cells, dexamethasone, a synthetic glucocorticoid, stimulated a rapid and selective increase in expression of the p21 cyclin-dependent kinase (CDK) inhibitor mRNA and protein and virtually abolished CDK2 phosphorylation of the retinoblastoma protein. Expression of the p27 CDK inhibitor, and other G1-acting cell cycle proteins, remained unaffected. Dexamethasone stimulated p21 promoter activity in a p53-independent manner that required functional glucocorticoid receptors. Transforming growth factor-beta, which also induced a G1 cell cycle arrest of the hepatoma cells, failed to elicit this response. Analysis of 5' deletions of the p21 promoter uncovered a glucocorticoid responsive region between nucleotides -1481 and -1184, which does not contain a canonical glucocorticoid response element but which can confer dexamethasone responsiveness to a heterologous promoter. Fine mapping of this region uncovered three distinct 50-60-base pair transcriptional elements that likely function as targets of glucocorticoid receptor signaling. Finally, ectopic expression of p21 had no effect on hepatoma cell growth in the absence of glucocorticoids but facilitated the ability of dexamethasone to inhibit cell proliferation. Thus, our results have established a direct transcriptional link between glucocorticoid receptor signaling and the regulated promoter activity of a CDK inhibitor gene that is involved in the cell cycle arrest of hepatoma cells.

p53 stimulates promoter activity of the sgk. serum/glucocorticoid-inducible serine/threonine protein kinase gene in rodent mammary epithelial cells

sgk is a novel member of the serine/threonine protein kinase gene family that is transcriptionally regulated by serum and glucocorticoids in mammary epithelial cells. To functionally determine if the sgk promoter is regulated by the p53 tumor suppressor protein in mammary cells, a series of sgk promoter fragments with 5'-deletions were linked to the bacterial chloramphenicol acetyltransferase gene (sgk-CAT) and transiently co-transfected into nontumorigenic NMuMG or transformed Con8Hd6 mammary epithelial cells with p53 expression plasmids. Wild-type p53, but not mutant p53, strongly stimulated sgk promoter activity in both mammary epithelial cell lines. These effects were mediated by specific regions within the sgk promoter containing p53 DNA-binding sites. The sgk p53 sequence at-1380 to-1345 (site IV) was sufficient to confer p53-dependent transactivation to a heterologous promoter, and p53 was capable of binding to this sequence in vitro as assessed by gel shift analysis. In the nontumorigenic NMuMG epithelial cell line, cotransfection of wild-type p53 strongly stimulated the activities of both the sgk promoter and the well characterized p53-responsive p21/Waf1 promoter, whereas in Rat-2 fibroblasts, wild-type p53 repressed the basal activities of both promoters, revealing that sgk and p21/Waf1 are similarly regulated in a cell type-specific manner. Taken together, these results demonstrate that sgk is a new transcriptional target of p53 in mammary epithelial cells and represent the first example of a hormone-regulated protein kinase gene with a functionally defined p53 promoter recognition element.

Antagonistic regulation of tight junction dynamics by glucocorticoids and transforming growth factor-beta in mouse mammary epithelial cells

The synthetic glucocorticoid, dexamethasone, stimulated the transepithelial electrical resistance and suppressed the DNA synthesis of 31EG4 nontransformed mouse mammary epithelial cells. The addition of transforming growth factor-beta 1 (TGF-beta) to mammary cells simultaneously with or up to 24 h after dexamethasone treatment prevented the steroid induction of transepithelial electrical resistance and stimulated the incorporation of [3H]thymidine. However, the TGF-beta inhibition of tight junction formation did not require de novo DNA synthesis. Confocal microscopy revealed that the organized immunostaining pattern of the tight junction protein, ZO-1, and F-actin at the cell periphery was disrupted by TGF-beta, resulting in disorganized and diffuse staining patterns throughout the cell. Western blot analysis demonstrated that TGF-beta did not alter the protein levels of ZO-1. In contrast to cells not treated or pretreated with steroid for up to 24 h, TGF-beta had no effect on cells pretreated with dexamethasone for 48 h. Transfection of chimeric reporter genes containing promoters responsive to either glucocorticoid or TGF-beta demonstrated that the mutual antagonism of tight junction dynamics by dexamethasone and TGF-beta occurs in the presence of intact signaling pathways. Taken together, our results establish for the first time that glucocorticoids and TGF-beta can antagonistically regulate tight junction formation in a nontransformed mammary cell line.

Transforming growth factor beta down-regulation of CKShs1 transcripts in growth-inhibited epithelial cells

CKShs1 is a mammalian homologue of the yeast suc1 and CKS1 genes, for which the null mutation leads to arrest in both the G1 and G2 phases of the cell cycle in Saccharomyces cerevisiae. Northern blot analysis revealed that transcript levels of CKShs1 are strongly down-regulated in mink lung cells and moderately down-regulated in BALB keratinocytes within 10 h of exposure to transforming growth factor beta (TGF-beta), whereas growth arrest of both cell lines requires at least 15 h of TGF-beta treatment. As a genetic test for the potential role of CKShs1 in TGF-beta growth regulation, we analyzed a stably transfected derivative of mink lung cells that constitutively overexpresses a truncated form of the type 2 TGF-beta receptor and is resistant to TGF-beta growth inhibition; CKShs1 transcripts are not down-regulated by TGF-beta in this mutant cell line. TGF-beta down-regulation of CKShs1 transcripts is specific, since mRNA levels of mammalian G1 cyclins D1, D2, and D3 do not change in response to TGF-beta in either cell line. Cyclin D1 and cyclin D2 transcripts are strongly induced by epidermal growth factor, and beta 2-microglobulin transcripts are strongly induced by TGF-beta in BALB keratinocytes released from quiescence by addition of epidermal growth factor. Our results suggest a role for CKShs1 gene products in TGF-beta growth arrest of epithelial cells.

Transforming growth factor-alpha abrogates glucocorticoid-stimulated tight junction formation and growth suppression in rat mammary epithelial tumor cells

The glucocorticoid and transforming growth factor-alpha (TGF-alpha) regulation of growth and cell-cell contact was investigated in the Con8 mammary epithelial tumor cell line derived from a 7,12-dimethylbenz(alpha)anthracene-induced rat mammary adenocarcinoma. In Con8 cell monolayers cultured on permeable filter supports, the synthetic glucocorticoid, dexamethasone, coordinately suppressed [3H]thymidine incorporation, stimulated monolayer transepithelial electrical resistance (TER), and decreased the paracellular leakage of [3H]inulin or [14C]mannitol across the monolayer. These processes dose dependently correlated with glucocorticoid receptor occupancy and function. Constitutive production of TGF-alpha in transfected cells or exogenous treatment with TGF-alpha prevented the glucocorticoid growth suppression response and disrupted tight junction formation without affecting glucocorticoid responsiveness. Treatment with hydroxyurea or araC demonstrated that de novo DNA synthesis is not a requirement for the growth factor disruption of tight junctions. Immunofluorescence analysis revealed that the ZO-1 tight junction protein is localized exclusively at the cell periphery in dexamethasone-treated cells and that TGF-alpha caused-ZO-1 to relocalize from the cell periphery back to a cytoplasmic compartment. Taken together, our results demonstrate that glucocorticoids can coordinately regulate growth inhibition and cell-cell contact of mammary tumor cells and that TGF-alpha, can override both effects of glucocorticoids. These results have uncovered a novel functional "cross-talk" between glucocorticoids and TGF-alpha which potentially regulates the proliferation and differentiation of mammary epithelial cells.