Oxytocin and the initiation of human parturition. I. Prostaglandin release during induction of labor by oxytocin

Oxytocin receptors in the human uterus during pregnancy and parturition

We have determined the concentration and distribution of oxytocin receptors in myometrial and decidual tissues obtained at cesarean section or hysterectomy during pregnancy. Myometrial receptor concentration was low at 13 to 17 weeks but had risen about twelvefold by 37 to 41 weeks. After the onset of labor, either preterm or term, the receptor levels were maximal and significantly higher than before the onset of labor. In cases of failed induction of labor with oxytocin and in postterm pregnancies (43 to 46 weeks), the receptor concentration was significantly lower than in spontaneous labor. Myometrial receptor concentrations in the fundus and the corpus were similar and significantly higher than in the lower part of the uterine segment, and the cervix had the lowest concentration. The parietal decidua had oxytocin receptor concentrations of the same magnitude as the myometrium. These results are consistent with a functional role of endogenous oxytocin in the activation of the human uterus during pregnancy and parturition.

Endocrinology of human parturition: a review

The existing data on the hormonal factors involved in human parturition indicate that the steroid hormones, progesterone and the oestrogens, play only a facilitatory role in the initiation of labour. A definite role for fetal adrenal steroids in this process has yet to be established, and they too may serve only a facilitating function. The stimulation of the uterine muscle during labour results from an interaction of oxytocin and prostaglandin (PG) F2 alpha. Recent evidence suggests that oxytocin is most important for the initial phase of labour, whereas increased synthesis of PGF2 alpha is essential for the progression of labour. The role of PGE2 remains unclear, but this PG may play an important role in the ripening of the cervix which in turn is essential for successful parturition. The finding of maximal oxytocin receptor concentrations in the myometrium in labour adds strong support to the notion that oxytocin is the trigger for uterine contractions. The factors which control oxytocin receptor formation are therefore important; this may be one of the processes where the steroids play a crucial role. Oxytocin is also one of the stimuli that increase uterine PG synthesis; the coupling of oxytocin receptor occupancy and PG synthetase activity in uterine tissues may be another crucial factor in the mechanism of labour. The formation of gap junctions between the myometrial cells also seems essential for the synchronization and progression of myometrial activity. We propose, therefore, that the co-ordinating of oxytocin receptor formation, PG synthesis and gap junction formation is a key to the initiation and maintenance of human labour. The fetus may fulfil such a co-ordinating role through its influence on placental oestrogen production, through mechanical distention of the uterus, and through its secretion of neuro-hypophysial hormones and other stimulators of PG synthesis.

Prostaglandin F2 alpha, oxytocin, and uterine activation in hypertonic saline-induced abortions

Intra-amniotic injections of hypertonic saline at midgestation induce uterine activity, which evolves into a laborlike pattern in less than 24 hours and is associated with progressive increase in uterine oxytocin response. This uterine activation occurred in the absence of a measurable increase in plasma 13,14-dihydro-15-keto-prostaglandin F2 alpha (PGFM). Only after 25 to 27 hours was a rise in plasma concentration of PGFM detected, which then increased in a parallel manner with cervical dilatation. By contrast, plasma oxytocin levels increased by almost 100% soon after the injection of hypertonic saline, declining to initial levels by 24 to 28 hours. Oxytocin infusion given after the intra-amniotic injection at rates resulting in about a fivefold increase in plasma oxytocin significantly accelerated cervical dilatation and the rise in plasma PGFM. Oxytocin infused before induction of abortion resulted in only a small and transient rise in plasma PGFM. Hypertonic saline injections thus increase the prostaglandin F2 alpha-stimulating action of oxytocin, which in turn may be responsible for the enhanced contractile response to the hormone. Myometrial activation after hypertonic saline injections is probably caused by an interaction of oxytocin and prostaglandin F2 alpha, and cervical dilatation depends on contractile activity and a critical increase in prostaglandin production.

Cervical ripening and plasma prostaglandin levels. Comparison of endocervical and extra-amniotic PGE2

Two modes of cervical application of a gel containing PGE2 have been compared in a total of 30 patients with indication for induction of labor and unripe cervix. Fifteen patients had gel injected endocervically; in 10 patients the gel contained 400 micrograms PGE2, in 5 controls the gel was inactive. Fifteen subjects had a 15 ml Foley catheter passed through the cervix and placed extra-amniotically; in 10 of them 3 ml gel with 400 or 800 micrograms PGE2 was injected, while 5 controls received inactive gel. Plasma levels of 13,14-dihydro-15-keto-PGE2 alpha (PGFM) were measured in blood samples drawn before and 1/2, 1, 2, 4, 6, and 8 hours after gel application. Neither the Foley catheter nor the application of inactive gel caused significant changes in the cervical scores or the PGFM levels. PGE2 in the endocervix increased cervical scores without altering plasma PGFM levels. Extra-amniotic PGE2 caused a more rapid increase of the cervical scores and a progressive rise in PGFM levels. The plasma (PGFM) levels were found to be related to the degree and to the rate of cervical dilatation. The correlation with cervical dilatation was highly significant. Labor began spontaneously or after artificial rupture of the membranes in 80% of the extra-amniotic, and 50% of the endocervical PGE2-group, but in none of the controls. These data indicate that increased uterine PGF2 alpha production is not necessary for the early stages of cervical ripening, whereas dilatation beyond 4 cm does not proceed without such increase.

Concentration of 13,14-dihydro-15-keto-prostaglandin E2 in the maternal peripheral plasma during labour of spontaneous onset

The concentration of 13,14-dihydro-15-keto-PGE2 (PGEM) was measured by radioimmunoassay in pregnant women in the third trimester, in women at term but not in labour and during labour of spontaneous onset. The plasma concentration of PGEM in pregnant women was elevated above that in a non-pregnant control group. Before the onset of labour no increase of PGEM concentration could be identified. Women in labour had higher PGEM plasma concentrations than before the onset of labour, although there was no progressive increase. Immediately after delivery PGEM levels reached a maximum, which decreased significantly to pre-labour values within 30 min. Artificial rupture of the membranes had no influence on plasma PGEM levels. It is concluded that labour is associated with an increased synthesis of PGE2 and that PGE2 may be involved in the mechanism of placental separation. The rapid disappearance of high PGEM levels after labour confirms that PGE2 is probably synthesized mainly in the fetal compartment.

The effect of oxytocin, estrogen, calcium ionophore A23187 and hydrocortisone on prostaglandin F2 alpha and 6-oxo-prostaglandin F1 alpha production by cultured human endometrial and myometrial explants

Normal human endometrium (classified by histology and date after last menstrual period) was cultured for 72h, and the output of prostaglandin F2 alpha and 6-oxo-prostaglandin F1 alpha detected by radioimmunoassay. Hormones/stimuli were added to the culture during the second day of culture for 5h and 19h periods. The output of prostaglandin F2 alpha from cultured endometrium was significantly higher (p less than 0.05) at the beginning (d4-8) and end (d25-30) of the menstrual cycle, compared to mid-cycle (d13-24) endometrium. Significantly more prostaglandin F2 alpha was released from proliferative than from secretory phase endometrium (p less than 0.02). Prostaglandin F2 alpha release was rapidly stimulated by sodium arachidonate (20-300 micrograms/ml), and by calcium ionophore A23187 (5 micrograms/ml) at an extracellular calcium ion concentration of 1.8mM. The ionophore stimulation was greater in mid-cycle endometrium than in endometrium from the beginning or the end of the menstrual cycle. Estradiol-17 beta (10 ng/ml) gradually increased the output of prostaglandin F2 alpha from secretory phase endometrium, and this stimulation was observed in the post-incubation period after hormone had been removed from the incubation medium. Oxytocin (1 X 10(-5) U/ml caused a more rapid stimulation of prostaglandin F2 alpha output from secretory phase tissue (p less than 0.05 during the first 5h incubation period with hormone). Oxytocin (1 X 10(-5) U/ml) and estradiol (10ng/ml) together significantly stimulated prostaglandin F2 alpha production by proliferative as well as secretory phase endometria. A high dose of hydrocortisone (100 micrograms/ml) inhibited the output of prostaglandin F2 alpha from proliferative and secretory phase endometrium and also from ionophore-stimulated endometrium. However, this dose of hydrocortisone did not inhibit the synthesis of prostaglandin F2 alpha from exogenous arachidonic acid, or the estradiol-induced increase in prostaglandin F2 alpha production. Co-culture of endometrium with myometrium did not modify the output of prostaglandin F2 alpha or of 6-oxo-prostaglandin F1 alpha from cultured tissues. These experiments suggest that arachidonic acid supply to the cyclooxygenase enzyme may vary during the menstrual cycle; and indicate a gradual increase in prostaglandin synthesising capacity in response to estrogen, more rapid control via oxytocin, and an interaction between estrogen and oxytocin to modulate prostaglandin F2 alpha synthesis in human endometrium.

Stimulation of myometrial and decidual prostaglandin production by amniotic fluid from term, but not midtrimester pregnancies

The effect of amniotic fluid obtained from second trimester (16-20 wks) and term pregnancies (38-41 wks) on the production of PGE and F by human amnion, decidua and myometrium at term was determined using tissue slices incubated in vitro. Midpregnancy amniotic fluid neither inhibited nor stimulated the prostanoid production by any of the tissues. In contrast, term amniotic fluid obtained before as well as after the onset of labor markedly increased the production of both PGE and PGF in decidua and myometrium from levels in Krebs solution. The prostanoid production (PGE + PGF) in amnion was not significantly increased but the proportion of PGF was raised during incubations in term amniotic fluid. In decidua and myometrium the increase in PGE and PGF production in term amniotic fluid was approximately 200 and 400 percent respectively, from control values in Krebs solution. We propose that the stimulatory activity in term amniotic fluid is responsible for the accelerated synthesis of prostaglandins after rupture of membranes, which is reflected in raised PGF metabolite levels in maternal circulation. It may also be the reason for the rise in amniotic fluid prostaglandin levels around the 35th week of gestation, and perhaps for the onset of labor.

Comparison of plasma oxytocin levels during spontaneous labor and labor induced by amniotomy, prostaglandin F2 alpha, and prostaglandin E2

Plasma concentrations of oxytocin in nine spontaneous labors (group 1), nine amniotomy-induced labors (group 2), six prostaglandin F2 alpha-induced labors (group 3), and five prostaglandin E2-induced labors (group 4) were determined at the stages of 1 to 7 days preceding the onset of labor, onset of labor, and established labor, by means of unextracted radioimmunoassay. The levels of oxytocin in the stage preceding the onset of labor in group 1 were not significantly different from the levels of oxytocin in the corresponding stages in groups 2, 3, and 4. However, the levels of oxytocin in the stages of onset of labor and established labor in group 1 were significantly higher than those in the corresponding stages in groups 2, 3, and 4. These results suggest that oxytocin plays a leading role in the onset and progress of spontaneous labor, whereas something other than oxytocin might be involved in the labor induced by amniotomy alone or by prostaglandins.

Prolactin secretion by human chorion-decidua in vitro: influences of mode of delivery and agents that modify prostaglandin synthesis

Prolactin production by human decidua was examined with the use of a short-term tissue explant system. Decidua obtained after normal spontaneous vaginal deliveries produced significantly more prolactin than did tissue obtained after elective repeat cesarean section deliveries in the absence of labor (P less than 0.005). Cytosolic prolactin levels did not differ between the two delivery modes. Oxytocin (4.3 X 10(-11) M to 4.3 X 10(-6) M) and eicosatetraenoic acid (10(-7) M to 10(-4) M) had no effect on prolactin production or storage by decidual tissue. Indomethacin at 10(-4) M reduced only levels of stored prolactin but had no effect on stored or produced prolactin at lower concentrations (10(-7) M to 10(-5) M). Arachidonic acid (10(-4) M) suppressed both production and storage of prolactin (P less than 0.05). Decidual tissue from the two delivery modes did not differ in response to the above agents. Although the exact mechanism(s) remains obscure, these results indicate decidual prolactin production is altered by some aspect of labor. The possible involvement of prostaglandin precursors in mediating this production cannot be excluded.

Prostaglandin production by the pregnant and non-pregnant rabbit uterus

We have studied the prostaglandin synthesis of the pregnant and non-pregnant rabbit uterus in a microsomal membrane preparation, and in an ex vivo perfused uterus preparation which retains agonist stimulated prostaglandin production. In both the microsomal and isolated perfused system, prostacyclin was the major arachidonic acid metabolite produced; PGE2 was also produced in substantial quantities while TxB2 and PGF2 alpha were not detectable. Moreover, oxytocin was a specific stimulus of PGE2 release. The steroid hormone milieu influenced the level of agonist stimulated prostaglandin release; in general, ovariectomized, estrogen treated animals were more responsive to agonist stimulation than those treated with estrogen followed by progesterone. The microsomal studies indicated that the pregnant animal had a greatly enhanced capacity to metabolize arachidonic acid when compared with the non-pregnant animal. However, this was not reflected in the ability of agonists to stimulate prostaglandin release in the ex vivo perfused preparation.

Effect of cervical application of prostaglandin (PG) E2 on plasma 13,14-dihydro-15-keto-PGF2 alpha and oxytocin in pregnant women at term

The concentrations of 13,14-dihydro-15-keto-prostaglandin F2 alpha (PGFM) and oxytocin were measured by radioimmunoassay in the peripheral plasma of 21 women with low Bishop scores in whom cervical ripening and labour were induced with a cervical cap containing 1.5 mg of prostaglandin (PG) E2, left in place for 6 h. Blood samples were taken before and at 3, 6, 9 and 24 h after the cap was applied. Four women (control group) had a cap without PGE2. Labour began in 13 women receiving PGE2, 12 of whom were delivered within 24 h. In these women plasma PGFM rose progressively to levels seen during spontaneous labour, paralleling the changes in cervical dilatation. The increase became significant at 6 h, when cervical dilatation was 4.5 cm (SEM 0.5). Plasma oxytocin also increased significantly while the cap was in place and then decreased. Plasma PGFM and oxytocin did not change in the control subjects, and in the eight women needing further induction of labour the initial rises were transient and not statistically significant.

Involvement of prostaglandins in vasopressin stimulation of the human uterus

The involvement of prostaglandins (PG) in the vasopressin (VP) action on the human uterus was investigated in healthy women during three menstruations. Intrauterine pressure was recorded and total pressure area measured. Repeated plasma samples were taken for estimations of arginine(A)- and lysine(L)-VP, 15-keto-13,14-dihydro-PGF2 alpha and 11-ketotetranor PGF metabolites. During the first menstruation LVP was infused in a dose of 0.08 micrograms/min. During the second menstruation the infusion of LVP was repeated with the same dose, but 70 min before infusion the women received an oral dose of 500 mg of naproxen. During the third menstruation PGF2 alpha was administered intravenously in a dose of 25 micrograms/min. LVP infusion per se caused a significant increase in uterine activity and plasma levels of LVP and PG metabolites. When the women were pretreated with naproxen practically the same uterine activity was induced and closely similar plasma levels of LVP were obtained, but the levels of PG metabolites decreased significantly in comparison with the first series of experiments. Infusion of PGF2 alpha caused an increase in uterine activity but no change in the plasma levels of AVP. The results indicate that uterine stimulation with VP is possible without an obligatory last step of PG synthesis and release. The results also support the concept that an elevated VP level in primary dysmenorrhoea may be of aetiological importance and is not just released as a 'stress'-hormone because of the dysmenorrhoeic pain.

Review: significance of the inhibition by prostaglandins and cyclic GMP of oxytocinase activity in human pregnancy and labour

The uterotonic action of oxytocin has been known for many decades. This neurohypophysial hormone is thought to play a functional role in human parturition. Since 1968, prostaglandins have also been implicated in parturition. These two groups of uterotonic agents have now a recognized therapeutic role, and are widely used in the induction of labour and in fertility control. However, the mechanism of action and the interrelationship between these endogenous compounds in pregnancy are poorly understood. In this article, the role and interaction of oxytocin, oxytocinase and prostaglandins in human pregnancy and labour have been reviewed. Inhibition of oxytocinase activity by prostaglandins has been suggested as a mechanism in parturition. Possible involvement of cyclic GMP in the initiation of labour has also been discussed.

Plasma levels of oxytocin and 13, 14-dihydro-15-keto prostaglandin F2 alpha in preterm labor and the effect of ethanol and ritodrine

We have measured the concentrations of circulating oxytocin and the 13, 14-dihydro, 15-keto-metabolite of prostaglandin F2 alpha (PGFM) in women during preterm labor. Twelve women were given intravenous ethanol and 11 women received intravenous ritodrine for the prevention of preterm birth. Blood samples were obtained before and 1/2, 1, 2, 4, 12, and/or 24 hours after treatment began. On admission, the plasma concentrations of both oxytocin and PGFM were raised over levels observed in women with normal pregnancies of similar gestational age, 25 to 36 weeks. The initial oxytocin level was 58.5 +/- 8.2 pg/ml (mean +/- SE, n = 23) and the mean initial PGFM level was 264 +/ 33.1 pg/ml (n = 15); both values were significantly higher than in 10 control subjects (17.4 +/- 4.8 and 156 +/- 21.8 pg/ml, respectively). During infusion of ethanol, the plasma oxytocin level fell rapidly, the levels at 1/2 and 1 hour after infusion being significantly lower than before the infusion (29.0 +/- 5.5 and 27.8 +/- 3.5 pg/ml, respectively). The plasma oxytocin level remained low in women in whom the treatment arrested labor and prevented preterm birth (n = 8) but rose 2 to 4 hours after the infusion began in women in whom the treatment failed to arrest labor (n = 4). Ritodrine, on the other hand, had no significant effect on circulating oxytocin levels. The plasma PGFM level decreased significantly during ritodrine treatment only in the successfully treated patients. Ethanol had no consistent effect on plasma PGFM levels in the four patients in whom PGFM levels were measured. In the ritodrine-treated patients, the plasma PGFM level was positively correlated with the frequency of uterine contractions whereas in the ethanol-treated patients a correlation of plasma oxytocin to the frequency of contractions was observed. Thus, oxytocin secretion is increased during preterm labor, and the release of prostaglandin F is also increased. While it is not possible to determine whether any or both of these oxytocic agents actually trigger preterm labor, both seem to play a role in its mechanism.

The origin of circulating 13,14-dihydro-15-keto-prostaglandin F2 alpha during delivery

All uterine tissues as well as the fetal membranes and the placenta can form prostaglandins from endogenous precursors in vitro but it is not clear which of the tissues is the main site for the increase in PGF2 alpha production during human parturition. To examine this question, we measured plasma prostaglandin levels before and at intervals after expulsion of the fetus, placenta, and membranes. The concentration of PGFM at the beginning of the second stage of labor was significantly higher than before the onset of labor. Five minutes after the birth of the infant, the concentration had doubled. Thirty minutes after the expulsion of placenta and membranes, plasma PGFM had fallen to the levels at full dilatation; two hours postpartum it was still significantly raised over levels before labor. Since the halflife of PGFM in the circulation is about 7 minutes, these findings indicate that the uterine tissues are important sources of PGFM during labor. In contrast, endogenous oxytocin levels, which were significantly raised over control levels at the second stage of labor, did not change during the third stage, and declined postpartum to control levels. Oxytocin infusion did not influence PGFM levels at 5 and at 30 minutes postpartum, but raised them at 2 hours.

Oxytocin receptors and human parturition: a dual role for oxytocin in the initiation of labor

The concentration of oxytocin receptors increased in the myometrium of pregnant women and reached maximum levels in early labor. Concentrations of oxytocin receptors were also high in the decidua and reached a maximum at parturition. In vitro, prostaglandin production by the decidua, but not by the myometrium, was increased by the addition of oxytocin. Oxytocin may therefore stimulate uterine contractions by acting both directly on the myometrium and indirectly on decidual prostaglandin production. Oxytocin receptors are probably crucial for the onset of human labor, and the stimulus for the increase in uterine prostaglandins may be oxytocin originating from the fetus.

Oxytocin and the initiation of human parturition. II. Stimulation of prostaglandin production in human decidua by oxytocin

In the present study we have investigated the effect of oxytocin on the production of prostaglandins E and F (PGE and PGF) by human decidua, amnion, and myometrium in vitro. We found that oxytocin causes a significant increase in the production of both PGE and PGF in the decidua and in the production of PGE in the amnion. In the myometrium the stimulatory effect of oxytocin on PGF production was small and not statistically significant, and PGE production was not affected at all. On the basis of these results, we propose that oxytocin provides the stimulus for the accelerated prostaglandin production in decidua and fetal membranes at the onset of labor. Since oxytocin levels rise in the fetal circulation at this time, the oxytocin stimulus may be of fetal origin as well as of maternal origin.