Progress in understanding electro-mechanical signalling in the myometrium

In this review, we give a state-of-the-art account of uterine contractility, focussing on excitation-contraction (electro-mechanical) coupling (ECC). This will show how electrophysiological data and intracellular calcium measurements can be related to more modern techniques such as confocal microscopy and molecular biology, to advance our understanding of mechanical output and its modulation in the smooth muscle of the uterus, the myometrium. This new knowledge and understanding, for example concerning the role of the sarcoplasmic reticulum (SR), or stretch-activated K channels, when linked to biochemical and molecular pathways, provides a clearer and better informed basis for the development of new drugs and targets. These are urgently needed to combat dysfunctions in excitation-contraction coupling that are clinically challenging, such as preterm labour, slow to progress labours and post-partum haemorrhage. It remains the case that scientific progress still needs to be made in areas such as pacemaking and understanding interactions between the uterine environment and ion channel activity.

Oxytocin: its mechanism of action and receptor signalling in the myometrium

Oxytocin is a nonapeptide hormone that has a central role in the regulation of parturition and lactation. In this review, we address oxytocin receptor (OTR) signalling and its role in the myometrium during pregnancy and in labour. The OTR belongs to the rhodopsin-type (Class 1) of the G-protein coupled receptor superfamily and is regulated by changes in receptor expression, receptor desensitisation and local changes in oxytocin concentration. Receptor activation triggers a number of signalling events to stimulate contraction, primarily by elevating intracellular calcium (Ca(2+) ). This includes inositol-tris-phosphate-mediated store calcium release, store-operated Ca(2+) entry and voltage-operated Ca(2+) entry. We discuss each mechanism in turn and also discuss Ca(2+) -independent mechanisms such as Ca(2+) sensitisation. Because oxytocin induces contraction in the myometrium, both the activation and the inhibition of its receptor have long been targets in the management of dysfunctional and preterm labours, respectively. We discuss current and novel OTR agonists and antagonists and their use and potential benefit in obstetric practice. In this regard, we highlight three clinical scenarios: dysfunctional labour, postpartum haemorrhage and preterm birth.

Bombesin Receptor Gene Expression in Rat Embryos: Transient GRP-R Gene Expression in the Posterior Pituitary

Bombesin-like peptides can stimulate growth of cultured cells derived from ectoderm, endoderm, or mesenchyme and act as autocrine growth factors in some lung carcinoma cell lines. Recently, cDNA clones for two mammalian bombesin receptors (BN-R), gastrin-releasing peptide receptor (GRP-R) and neuromedin B receptor (NMB-R), were characterized and shown to be present in distinct regions of the central nervous system at birth. To determine whether the spatial and/or temporal expression of BN-R genes correlated with tissue-specific or organ-specific developmental events, the prenatal distribution of GRP-R and NMB-R mRNAs were compared by in situ hybridization histochemistry. The differential expression of these two BN-R genes was striking. From early embryonic stages, GRP-R mRNA was expressed in various organs, including nervous, urogenital, respiratory, and digestive systems. In contrast, NMB-R gene expression was detected at later embryonic stages and the distribution of expression was much more limited. In most tissues, after onset of expression, both receptor mRNAs showed a steady increase in expression throughout development. However, transient expression of GRP-R mRNA was seen in the posterior pituitary. Intense GRP-R labeling of posterior pituitary cells was seen from E12 to E20, but at birth, GRP-R mRNA levels were undetectable. These results suggest that (a) two BN-R subtypes mediate independent functions during development, (b) ontogenesis of multiple organs may involve GRP-R mediated events, and (c) GRP-R gene expression is involved in differentiation/development of the pituitary gland.

Diabetes is associated with impairment of uterine contractility and high Caesarean section rate

AIMS/HYPOTHESIS

The prevalence of births worldwide complicated by diabetes mellitus is increasing. In the UK, for example, <25% of diabetic women have a non-instrumental vaginal delivery. Strikingly, more than half the Caesarean sections (CS) in these patients are non-elective, but the reasons for this are not understood. We have tested the hypothesis that poor myometrial contractility as a consequence of the disease contributes to this high CS rate.

METHODS

We compared spontaneous, high K depolarisation and oxytocin-induced contractions from diabetic and matched control patients having an elective CS. To investigate the mechanism of any differences we measured intracellular Ca, and performed western blotting and compared the tissues histologically.

RESULTS

There was significantly decreased contraction amplitude and duration in uteri from diabetic compared with control patients, even when possible confounders such as BMI were analysed. Reduced intracellular calcium signals and expression of calcium entry channels were found in uteruses from diabetic patients, which, along with a reduction in muscle content found on histological examination, could explain the reduced force. Myometrium from diabetic patients was responsive to oxytocin, but still did not reach the levels found in non-diabetic patients.

CONCLUSIONS/INTERPRETATIONS

These are the first data investigating myometrium in diabetic patients and they support the hypothesis that there is poorer contractility even in the presence of oxytocin. The underlying mechanism is related to reduced Ca channel expression and intracellular calcium signals and a decrease in muscle mass. We conclude that these factors significantly contribute to the increased emergency CS rate in diabetic patients.

In vitro myometrial contractility reflects indication for caesarean section

OBJECTIVE

To assess the extent to which in vitro measurements of myometrial contractility reflect the clinical indication for caesarean section.

DESIGN

A prospective, observational hypothesis-generating study.

SETTING

Women were recruited from Liverpool Women's NHS Foundation Trust and experiments were performed in the Physiology Department at the University of Liverpool.

POPULATION

Myometrial samples were taken from women undergoing a caesarean section during labour (n = 50) or from women having a repeat nonlabouring caesarean section (n = 70).

METHODS

The demographic characteristics of the women and indications for current and previous caesarean sections were recorded. The force, frequency and duration of spontaneous contractions of myometrial strips, and changes in the intracellular calcium concentration of the strips, were measured. Kruskall-Wallis and post hoc tests were used to assess the significance of differences between groups.

RESULTS

Samples from women whose caesarean section was for fetal distress/acidosis (scalp pH <7.2) contracted with more force than those from women whose caesarean section was for delay in the first stage of labour (P < 0.001). For repeat, nonlabouring caesarean sections, samples from women whose first caesarean section was for fetal distress/acidosis also contracted with more force than did samples from women whose first caesarean section was for delay in the first stage of labour (P = 0.03).

CONCLUSIONS

These findings suggest that the myometrium contracts with greater force in women who have a caesarean section for fetal distress.

Maternal obesity and labour complications following induction of labour in prolonged pregnancy

OBJECTIVE

To investigate the effect of maternal obesity on mode of delivery following induction of labour (IOL) for prolonged pregnancy and subsequent intrapartum and neonatal complications.

DESIGN

Retrospective (historical) cohort study.

SETTING

Liverpool Women's Hospital NHS Foundation Trust, UK.

POPULATION

A total of 29, 224 women with singleton pregnancies between 2004 and 2008 of whom 3076 had a prolonged pregnancy (defined as ≥290 days or 41(+3) weeks of gestation) and received IOL.

METHODS

Kruskal-Wallis test, chi-square test and multivariable logistic regression.

MAIN OUTCOME MEASURES

Mode of delivery and risk of delivery and neonatal complications in obese verses non-obese women following IOL.

RESULTS

Obese women had a significantly higher rate of IOL ending in caesarean section compared with women of normal weight following IOL (38.7% versus 23.8% primiparous; 9.9% versus 7.9% multiparous women, respectively); however, length of labour, incidence of postpartum haemorrhage and third-degree tear, rate of low cord blood pH, low Apgar scores and shoulder dystocia were similar in all body mass index categories. Complications included a higher incidence of fetal macrosomia and second-degree, but not third-degree, tear in primiparous women.

CONCLUSIONS

Higher maternal body mass index at booking is associated with an increased risk of prolonged pregnancy and increased rate of IOL. Despite this, more than 60% of obese primiparous and 90% of multiparous women with prolonged pregnancies who were induced achieved vaginal delivery and labour complications in the obese women with prolonged pregnancies were largely comparable to those of normal weight women with prolonged pregnancies. Our data suggest that IOL for prolonged pregnancy in obese women is a reasonable and safe management option.

From nose to brain: development of gonadotrophin-releasing hormone-1 neurones

Gonadotrophin-releasing hormone-1 (GnRH-1) is essential for mammalian reproduction, controlling release of gonadotrophins from the anterior pituitary. GnRH-1 neurones migrate from the nasal placode into the forebrain during development. Although first located within the nasal placode, the embryonic origin/lineage of GnRH-1 neurones is still unclear. The migration of GnRH-1 cells is the best characterised example of neurophilic/axophilic migration, with the cells using a subset of olfactory-derived vomeronasal axons as their pathway and numerous molecules to guide their movement into the forebrain. Exciting work in this area is beginning to identify intersecting pathways that orchestrate the movement of these critical neuroendocrine cells into the central nervous system, both spatially and temporally, through a diverse and changing terrain. Once within the forebrain, little is known about how the axons target the median eminence and ultimately secrete GnRH-1 in a pulsatile fashion.

Sex hormones and excitation-contraction coupling in the uterus: the effects of oestrous and hormones

In this review, we examine how far the increased understanding that we have of the events in excitation contraction can explain the effects of the oestrous cycle and sex hormones on uterine function. Observational studies of electrical and mechanical activity in the rat myometrium have shown a relative quiescence during pro-oestrous, with little propagation of any electrical events. Thus, uterine activity can be said to approximately inversely reflect plasma 17beta-oestradiol concentrations. We show that Ca(2+) signalling and mechanical activity are greatest in metoestrous and dioestrous compared to pro-oestrous and oestrous. These data are discussed in terms of hormonal effects on Ca(2+) and K(+) channels. Finally, the influence of sex hormones on lipid rafts and caveolae are considered and discussed in relation to recent findings on their role in uterine signalling and contractility, and cholesterol levels and obesity.

Temporal migration of gonadotrophin-releasing hormone-1 neurones is modified in GAD67 knockout mice

Gonadotrophin-releasing hormone (GnRH-1) neurones reside in the forebrain and regulate gonadal function via the hypothalamic-pituitary-gonadal axis. Disruption of this axis results in reproductive dysfunction. During embryonic development, GnRH-1 neurones migrate from the nasal pit through the nasal/forebrain junction (NFJ) into the developing brain. Prenatally gamma-aminobutyric acid (GABA) is excitatory and has been shown to play a role in nervous system development. Both in vivo and in vitro experiments suggest that GABA inhibits migration of GnRH-1 neurones. The present study examines the migration of GnRH-1 neurones in GAD67 knockout (KO) mice to further elucidate the role of GABA on GnRH-1 neuronal development. Three stages were examined, embryonic day (E)12.5, E14.5 and E17.5. GnRH-1 cell number and location were analysed by immunocytochemistry and in situ hybridisation histochemistry. The total number of GnRH-1 immunopositive cells was similar between wild-type (WT) and KO mice. However, significant differences were found in the overall distribution of GnRH-1 immunopositive cells in GAD67 KO compared to WT mice at all stages. Subsequent analysis by area revealed differences occurred at the NFJ with an increase in GnRH-1 cells in GAD67 KO at E14.5 and a decrease in GnRH-1 cells in GAD67 KO at E17.5. Comparable counts for cells expressing GnRH-1 transcript and protein were obtained. These data indicate that attenuated levels of GABA accelerate GnRH-1 cell migration in nasal areas as well as movement of GnRH-1 cells into the central nervous system at the NFJ.

Intravenous conscious sedation in children for outpatient dentistry

The use of general anaesthesia for dental treatment in the NHS outside hospitals has changed over time. Although deaths are uncommon during or immediately after general anaesthesia for dental treatment, they are more likely to occur than with other methods of pain and anxiety reduction, such as local anaesthesia and conscious sedation. Inquiries into recent anaesthetic deaths in dental practice have been critical of the standard of care provided in areas such as pre-operative assessment, monitoring, resuscitation and transfer to specialist critical care facilities.

Nasal embryonic LHRH factor (NELF) expression within the CNS and PNS of the rodent

A novel protein (NELF) was identified screening embryonic luteinizing hormone releasing hormone (LHRH) neurons at different migrational states. Experiments in vitro revealed that NELF functions in olfactory axon outgrowth and subsequently alters LHRH neuronal migration. NELF was not restricted to LHRH neurons in the developing rodent. Multiple CNS and PNS tissues expressed this gene. To characterize the specific regions that express NELF in situ hybridization histochemistry was performed. Within the CNS, cells in the cortex, hippocampus, thalamus and olfactory regions express NELF pre- and postnatally.

Poor uterine contractility in obese women

OBJECTIVE

The aim of the study was to elucidate the reason for the high rate of caesarean section in obese women. We examined the following hypotheses: (1) obese women have a high incidence of complications related to poor uterine contractility--caesarean section for dysfunctional labour and postpartum haemorrhage. 2) The myometrium from obese women has less ability to contract in vitro.

DESIGN

First, a clinical retrospective analysis of data from 3913 completed singleton pregnancies was performed. Secondly, in a prospective study the force, frequency and intracellular [Ca(2+)] flux of spontaneously contracting myometrium were related to the maternal body mass index.

SETTING

Liverpool Women's Hospital and University of Liverpool.

POPULATION

The clinical study involved all women who delivered in one hospital in 2002. The in vitro study myometrial biopsies were obtained from 73 women who had elective caesarean section at term.

RESULTS

Maternal obesity carried significant risk of caesarean section in labour that was highest for delay in the first stage of labour (OR 3.54). The increased risk of caesarean section in obese women largely occurred in women with normal- and not with high-birthweight infants. Obese women delivering vaginally had increased risk of prolonged first stage of labour and excessive blood loss. Myometrium from obese women contracted with less force and frequency and had less [Ca(2+)] flux than that from normal-weight women.

CONCLUSIONS

We suggest that these findings indicate that obesity may impair the ability of the uterus to contract in labour.

Distribution of AQP2 and AQP3 water channels in human tissue microarrays

The objective of this investigation was to use semi-quantitative immunohistochemistry to determine the distribution and expression levels of AQP2 and AQP3 proteins in normal human Tissue MicroArrays. Expression of the vasopressin regulated AQP2 was observed in a limited number of tissues. AQP2 was prominent in the apical and subapical plasma membranes of cortical and medullary renal collecting ducts. Surprisingly, weak AQP2 immunoreactivity was also noted in pancreatic islets, fallopian tubes and peripheral nerves. AQP2 was also localized to selected parts of the central nervous system (ependymal cell layer, subcortical white matter, hippocampus, spinal cord) and selected cells in the gastrointestinal system (antral and oxyntic gastric mucosa, small intestine and colon). These findings corroborate the restricted tissue distribution of AQP2. AQP3 was strongly expressed in many of the human tissues examined particularly in basolateral membranes of the distal nephron (medullary collecting ducts), distal colon, upper airway epithelia, transitional epithelium of the urinary bladder, tracheal, bronchial and nasopharyngeal epithelium, stratified squamous epithelial cells of the esophagus, and anus. AQP3 was moderately expressed in basolateral membranes of prostatic tubuloalveolar epithelium, pancreatic ducts, uterine endometrium, choroid plexus, articular chondrocytes, subchondral osteoblasts and synovium. Low AQP3 levels were also detected in skeletal muscle, cardiac muscle, gastric pits, seminiferous tubules, lymphoid vessels, salivary and endocrine glands, amniotic membranes, placenta and ovary. The abundance of basolateral AQP3 in epithelial tissues and its expression in many non-epithelial cells suggests that this aquaglyceroporin is a major participant in barrier hydration and water and osmolyte homeostasis in the human body.

Developmental changes in GABA receptor subunit composition within the gonadotrophin-releasing hormone-1 neuronal system

It is becoming increasingly evident that GABA plays an important role in the regulation of gonadotrophin-releasing hormone (GnRH)-1 neurones via the GABAA receptor. The aim of the present study was to characterise expression of the GABAA receptor within the GnRH-1 system across development. The expression pattern of five GABAAalpha subunits and one GABAAbeta subunit was first examined within individual GnRH-1 neurones by the polymerase chain reaction. A significant increase in the expression of GABAAalpha2 and a significant decrease in the expression of GABAAalpha6 over time were found. Of the other subunits examined, two (alpha1 and alpha3) showed no differences in expression and two (alpha4 and beta3) showed variable low incidence of expression. Given the reciprocal relationship of alpha2 and alpha6 expression, we hypothesised that there is a developmental switch in the expression of these subunits in GnRH-1 neurones. To investigate this hypothesis, single- and double-label immunocytochemistry for GABAAalpha2 and alpha6 and GnRH-1 was performed in tissue from ages E12.5 to adulthood, as well as in nasal explants. We show that GABAAalpha2 and alpha6 are present in the GnRH-1 neuronal system both in vivo and in vitro and that the levels of expression are altered as a function of age.