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Mir IN, Chalak LF, Liao J, Johnson-Welch S, Brown LS, Longoria C, Savani RC, Rosenfeld CR. Fetal-placental crosstalk occurs through fetal cytokine synthesis and placental clearance. Placenta 2018; 69:1-8. [PMID: 30213477 DOI: 10.1016/j.placenta.2018.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/13/2018] [Accepted: 07/09/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Cytokines modulate fetal well-being and contribute to parturition. Their origin in fetal blood, whether maternal, placental or fetal, at the time of parturition remains unclear. OBJECTIVE To determine fetal and placental contributions to circulating fetal cytokines by measuring umbilical arterial (UmA) and venous (UmV) concentration differences in uncomplicated term pregnancies in the absence and presence of labor. METHODS Term uncomplicated pregnancies were assessed: Group 1 were not in labor and delivered by elective cesarean section (n = 20); Group 2 delivered vaginally following uncomplicated pregnancy and labor (n = 30). UmA and UmV blood was collected before delivery of the placenta to measure circulating cytokines. Placental tissue was collected for histology and to determine cytokine contents and localization. RESULTS Group 1 UmA and UmV IL-10 concentrations were similar (504 ± 15 and 468 ± 16 pg/ml, respectively; P ≥ 0.1); other cytokines were below level of detection. During labor, IL-10 concentrations increased 15-34%, but placental contents decreased. Group 2 UmA IL-6 and IL-8 concentrations increased (P < 0.001) to 16.7 ± 1.6 and 18.4 ± 4.3 pg/ml, respectively, but were less (P < 0.001) in UmV, 0.29 ± 0.2 and 0.74 ± 0.3 pg/ml, respectively, demonstrating placental clearances ≥97%. This was associated with >6-fold increases in placental IL-6/IL-8 contents (P < 0.001) and chorioamniotic infiltration of activated maternal neutrophils. IL-6 and IL-10 were localized to villous syncytiotrophoblasts. CONCLUSIONS In uncomplicated term pregnancies fetal circulating IL-10 is likely of placental origin, whereas IL-6/IL-8 are derived from the fetus, increase during parturition, and circulating levels are modulated by non-saturable placental clearance, revealing a novel pathway for fetal-placental crosstalk and signaling.
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Affiliation(s)
- Imran N Mir
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, USA.
| | - Lina F Chalak
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, USA
| | - Jie Liao
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, USA
| | - Sarah Johnson-Welch
- Department of Pediatrics, Department of Pathology, University of Texas Southwestern Medical Center, USA
| | | | - Christopher Longoria
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, USA
| | - Rashmin C Savani
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, USA; The Center for Pulmonary & Vascular Biology, University of Texas Southwestern Medical Center, USA
| | - Charles R Rosenfeld
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, USA
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Romero R, Chaemsaithong P, Korzeniewski SJ, Tarca AL, Bhatti G, Xu Z, Kusanovic JP, Dong Z, Docheva N, Martinez-Varea A, Yoon BH, Hassan SS, Chaiworapongsa T, Yeo L. Clinical chorioamnionitis at term II: the intra-amniotic inflammatory response. J Perinat Med 2016; 44:5-22. [PMID: 25938217 PMCID: PMC5891100 DOI: 10.1515/jpm-2015-0045] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 02/26/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Recent studies indicate that clinical chorioamnionitis is a heterogeneous condition and only approximately one-half of the patients have bacteria in the amniotic cavity, which is often associated with intra-amniotic inflammation. The objective of this study is to characterize the nature of the inflammatory response within the amniotic cavity in patients with clinical chorioamnionitis at term according to the presence or absence of 1) bacteria in the amniotic cavity and 2) intra-amniotic inflammation. MATERIALS AND METHODS A retrospective cross-sectional case-control study was conducted to examine cytokine and chemokine concentrations in the amniotic fluid (AF). Cases consisted of women with clinical chorioamnionitis at term (n=45). Controls were women with uncomplicated pregnancies at term who did not have intra-amniotic inflammation and were in labor (n=24). Women with clinical chorioamnionitis were classified according to the results of AF cultures, broad-range polymerase chain reaction coupled with electrospray ionization mass spectrometry, and AF concentration of interleukin-6 (IL-6) into those: 1) without intra-amniotic inflammation, 2) with microbial-associated intra-amniotic inflammation, and 3) with intra-amniotic inflammation without detectable bacteria. The AF concentrations of 29 cytokines/chemokines were determined using sensitive and specific V-PLEX immunoassays. RESULTS 1) The AF concentrations of pro- and anti-inflammatory cytokines/chemokines such as interferon gamma (IFN-γ), tumor necrosis factor alpha (TNF-α), interleukin-4 (IL-4), macrophage inflammatory protein-1 beta (MIP-1β), and interleukin-8 (IL-8) (except Eotaxin-3) were significantly higher in women with clinical chorioamnionitis at term than in controls (term labor without intra-amniotic inflammation); 2) patients with microbial-associated intra-amniotic inflammation, and those with intra-amniotic inflammation without detectable bacteria, had a dramatic differential expression of cytokines and chemokines in AF compared to patients with spontaneous labor without intra-amniotic inflammation. However, no difference could be detected in the pattern of the intra-amniotic inflammatory response between patients with intra-amniotic inflammation with and without detectable bacteria; and 3) in patients with clinical chorioamnionitis at term but without intra-amniotic inflammation, the behavior of cytokines and chemokines in the AF was similar to those in spontaneous labor at term. CONCLUSIONS Patients with clinical chorioamnionitis who had microbial-associated intra-amniotic inflammation or intra-amniotic inflammation without detectable bacteria had a dramatic upregulation of the intra-amniotic inflammatory response assessed by amniotic fluid concentrations of cytokines. A subset of patients with term clinical chorioamnionitis does not have intra-amniotic infection/inflammation, as demonstrated by elevated AF concentrations of inflammation-related proteins, when compared to women in term labor with uncomplicated pregnancies, suggesting over-diagnosis. These observations constitute the first characterization of the cytokine/chemokine network in the amniotic cavity of patients with clinical chorioamnionitis at term.
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
- Department of Molecular Obstetrics and Genetics, Wayne State University, Detroit, MI, USA
| | - Piya Chaemsaithong
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Steven J. Korzeniewski
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Adi L. Tarca
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Gaurav Bhatti
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Zhonghui Xu
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
| | - Juan P. Kusanovic
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Sótero del Río Hospital, Santiago, Chile
- Department of Obstetrics and Gynecology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Zhong Dong
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Nikolina Docheva
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Alicia Martinez-Varea
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Bo Hyun Yoon
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Sonia S. Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Lami Yeo
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
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Jonakait GM, Ni L. Prostaglandins compromise basal forebrain cholinergic neuron differentiation and survival: action at EP1/3 receptors results in AIF-induced death. Brain Res 2009; 1285:30-41. [PMID: 19555672 DOI: 10.1016/j.brainres.2009.06.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 01/26/2023]
Abstract
Activated microglia produce a factor or cocktail of factors that promotes cholinergic neuronal differentiation of undifferentiated precursors in the embryonic basal forebrain (BF) in vitro. To determine whether microglial prostaglandins mediate this action, microglia were stimulated in the presence of the cyclooxygenase inhibitor ibuprofen, and microglial conditioned medium (CM) was used to culture rat BF precursors at embryonic day 15. Choline acetyltransferase (ChAT) activity served as a measure of cholinergic differentiation. While inhibition of prostaglandin biosynthesis did not affect the ability of microglial CM to promote ChAT activity, treatment of microglia with prostaglandin E2 (PGE2) inhibited it. Agonists of E prostanoid receptors EP2 (butaprost) and EP1/3 (sulprostone) mimicked PGE2, while misoprostol (E1-4) actually enhanced the action of CM. PGE2 added directly to BF cultures together with microglial CM also inhibited ChAT activity. While BF cultures expressed all four prostanoid receptors, direct addition of sulprostone but not butaprost mimicked PGE2, suggesting that PGE2 engaged EP1/3 receptors in the BF. Neither PKA inhibition by H89 nor cAMP induction by forskolin or dibutyrl-cAMP altered the action of sulprostone. Sulprostone severely compromised ChAT activity, dendrite number, axonal length and axonal branching, but caspase inhibition did not restore these. However, sulprostone resulted in increased staining intensity and nuclear translocation of apoptosis-inducing factor (AIF) suggesting caspase-independent cell death. We have found that PGE2 action at microglial EP2 receptors inhibits the microglial production of the cholinergic differentiating cocktail, while action at neuronal EP3 receptors has a deleterious effect on cholinergic neurons causing neurite retraction and cell death.
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Affiliation(s)
- G Miller Jonakait
- Federated Department of Biological Sciences, New Jersey Institute of Technology, Newark, NJ 07102, USA.
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Mohan AR, Loudon JA, Bennett PR. Molecular and biochemical mechanisms of preterm labour. Semin Fetal Neonatal Med 2004; 9:437-44. [PMID: 15691781 DOI: 10.1016/j.siny.2004.08.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Parturition involves the synchronization of myometrial activity and structural changes of the cervix, leading to regular co-ordinated uterine contractions and cervical dilatation and effacement. The biochemical events involved in parturition resemble an inflammatory reaction, with growing evidence pointing to a crucial role for pro-inflammatory cytokines and prostaglandins in labour. There is accumulating evidence that there are common mediators involved in the regulation of 'labour-associated proteins', and that, in each case, an increase or decrease in gene expression mediates changes in their concentration. It is possible, therefore, that targeting these common mediators may represent newer strategies for the prevention of preterm labour. Our aim is to review the mechanical and biochemical mechanisms that may be involved in the processes of term and preterm labour. Specifically, we will consider the regulation of some of the 'labour-associated proteins', chemotactic cytokines, prostaglandins and enzymes of the prostaglandin biosynthetic pathway and the oxytocin receptor.
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Affiliation(s)
- Aarthi R Mohan
- Imperial College Parturition Research Group, Institute of Reproductive and Developmental Biology, Hammersmith Hospital Campus, Du Cane Road, London W12 ONN, UK
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Sengupta J, Dhawan L, Ghosh D. Immunohistochemical localization of leukemia inhibitory factor, interleukins 1 and 6 at the primary implantation site in the rhesus monkey. Cytokine 2003; 24:277-85. [PMID: 14609569 DOI: 10.1016/j.cyto.2003.08.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Blastocyst implantation and placentation involve localized inflammatory type of responses at and around the site of nidation. In the present study, the likely involvement of inflammatory cytokines, namely, leukemia inhibitory factor (LIF), interleukins 1 alpha and 1 beta (IL-1alpha and IL-1beta) and IL-6 at the primary implantation site of the rhesus monkey was examined immunocytochemically during lacunar (n=6) and villous (n=8) stages of gestation. Trophoblast cells and extraembryonic mesenchymal cells were immunopositive for LIF and IL-1alpha. The distribution of IL-1beta and IL-6 in trophoblast cells was low in lacunar stage samples, however, a higher degree of immunopositivity for IL-6 was observed in villous stage samples. Decidual cells were immunopositive for all the cytokines studied. In lacunar stage samples, plaque cells adjacent to implanted nidus were immunopositive for all the cytokines examined, and the degree of their immunoprecipitation increased, except that of IL-1beta, during the villous stage. Luminal and glandular epithelial cells were immunopositive for LIF, IL-1alpha, IL-1beta and IL-6 in lacunar and in villous stage samples. LIF immunopositivity was detected in endothelial cells of blood vessels within and below chorionic plate and cytotrophoblast shell, while vascular smooth muscle cells were positive for all the cytokines studied. The temporo-spatial characteristics of LIF, IL-1alpha, IL-1beta and IL-6 protein expressions in primary implantation sites of the rhesus monkey suggest that these pro-inflammatory cytokines play specific roles in regulating trophoblast cell proliferation, differentiation, invasion and associated maternal tissue remodelling during early gestation.
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Affiliation(s)
- Jayasree Sengupta
- Department of Physiology, All India Institute of Medical Sciences, New Delhi 110029, India.
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Abstract
Spontaneous preterm labour remains a major obstetric problem because of the high incidence of neonatal mortality or long-term handicap associated with it. The drugs available for the management of preterm labour are poorly effective and have potentially serious side-effects for the mother or fetus. In recent years, there has been a remarkable increase in the knowledge of the biochemical mechanism underlying uterine quiescence and contractility. Many of the G protein-coupled receptors that participate in the regulation of myometrial activity have been cloned and characterized, and their intracellular signalling pathways have been elucidated. The role of G protein receptor kinases in uterine tachyphylaxis is better understood. New developments in our understanding of the cellular mechanisms involved in uterine contractions in idiopathic and infection-associated preterm labour are expected, which will lead to better, more selective therapy for this problem. However, much research remains to be done before the mechanism of human parturition is fully understood.
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Affiliation(s)
- A López Bernal
- Nuffield Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Headington, Oxford, UK
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Alvi SA, Rajasingam D, Brown NL, Elder MG, Bennett PR, Sullivan MH. The production of interleukin-1beta from human fetal membranes is not obligatory for increased prostaglandin output. Immunology 1999; 97:249-56. [PMID: 10447739 PMCID: PMC2326835 DOI: 10.1046/j.1365-2567.1999.00769.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Bacterial endotoxin increased the expression of mRNA (maximal after 4 hr) for interleukin-1beta (IL-1beta) and the release of mature protein from intact human fetal membranes. In contrast, the change in expression of mRNA for type 2 cyclo-oxygenase (COX-2) was biphasic, with peaks after 0.5-1 hr and after 8 hr of culture. An antibody to IL-1beta was without effect after 4 hr of culture, inhibited endotoxin-stimulated prostaglandin E2 (PGE2) production after 8 hr of culture, and caused a parallel decrease in the expression of mRNA for COX-2. We conclude that endotoxin induced the expression of COX-2 through IL-1beta-independent and IL-1beta-dependent mechanisms, and these differences are time dependent. Corticotrophin-releasing hormone (CRH) or platelet-activating factor (PAF) also increased the expression of mRNA for IL-1beta and the release of IL-1beta from some, but not all, fetal membranes. The antibody to IL-1beta did not affect CRH-stimulated or PAF-stimulated PGE2 production or COX-2 expression. We conclude that CRH and PAF can induce the expression of IL-1beta, but this is not obligatory for increased PGE2 release, and the effect of these stimuli on COX-2 expression is a direct, IL-1beta-independent effect.
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Affiliation(s)
- S A Alvi
- Department of Maternal and Fetal Medicine, Division of Paediatrics, Obstetrics & Gynaecology, Imperial College School of Medicine, Queen Charlotte's & Chelsea Hospital, London, UK
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9
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Brown NL, Alvi SA, Elder MG, Bennett PR, Sullivan MH. Interleukin-1beta and bacterial endotoxin change the metabolism of prostaglandins E2 and F2alpha in intact term fetal membranes. Placenta 1998; 19:625-30. [PMID: 9859867 DOI: 10.1016/s0143-4004(98)90024-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
There is strong evidence that prostaglandins E2 and F2alpha (PGE2 and PGF2alpha) are involved in the initiation and maintenance of human parturition and that their production can be stimulated by a number of cytokines and in infection-induced preterm labour by bacterial endotoxin. This study used an intact fetal membrane disk model to investigate the regulation of PGE2 and PGF2alpha metabolism by interleukin-1 beta (IL-1beta) and bacterial endotoxin [lipopolysaccharide (LPS)]. Fetal membrane explants were incubated with IL-1beta (0.1 or 1.0 ng/ml) or LPS (10 ng/ml) for 24 h. A mixture of 3H-prostaglandin (0.1 microCi) and unlabelled prostaglandin (1 microg) was then added at selected times after the addition of inflammatory mediators. The radiolabelled prostaglandins and their metabolites were then extracted from the culture medium and quantified by high-pressure liquid chromatography. Levels of prostaglandin metabolites were generally decreased following incubation with IL-1beta or LPS, which is consistent with a decrease in the activity of 15-hydroxyprostaglandin dehydrogenase (PGDH). It is concluded that IL-1beta and LPS moderately decrease the metabolism of prostaglandins, which may contribute to increasing the local levels of active prostaglandins induced by these stimuli.
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Affiliation(s)
- N L Brown
- Department of Obstetrics and Gynaecology, Imperial College School of Medicine, Hammersmith Hospital, London, UK
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Bennett WA, Lagoo-Deenadayalan S, Stopple JA, Barber WH, Hale E, Brackin MN, Cowan BD. Cytokine expression by first-trimester human chorionic villi. Am J Reprod Immunol 1998; 40:309-18. [PMID: 9870073 DOI: 10.1111/j.1600-0897.1998.tb00059.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PROBLEM Communication at the human maternal-fetal interface occurs by an intricate cytokine network. This study examines cytokine expression by normal first-trimester human chorionic villi. METHOD OF STUDY Tissues were obtained at elective pregnancy terminations (7-9 weeks). Total RNA was isolated from chorionic villi by guanidinium isothiocynate-acid phenol extraction. A reverse transcriptase-polymerase chain reaction technique was used to examine cytokine expression. beta-Actin was used as the housekeeping gene, and mitogen-stimulated lymphocytes served as positive controls. RESULTS beta-Actin was uniformly expressed by all chorionic villous samples. Interferon (IFN)-alpha and -beta also were highly expressed. Moderate expression was noted for interleukin (IL)-10, IL-6, tumor necrosis factor (TNF)-alpha, and IL-1 beta. In contrast, transforming growth factor-beta 1, IFN-gamma, IL-2, and IL-1 alpha were either weakly expressed or absent in first-trimester villi. CONCLUSIONS Cytokines may contribute to pregnancy immunotolerance (IFN-alpha, IFN-beta, and IL-10), viral resistance (IFNs), hormone secretion (IL-1 and IL-6), and cellular remodeling (IFN-gamma and TNF-alpha) within the chorionic villous.
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Affiliation(s)
- W A Bennett
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, USA
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Rajasingam D, Bennett PR, Alvi SA, Elder MG, Sullivan MH. Stimulation of prostaglandin production from intact human fetal membranes by bacteria and bacterial products. Placenta 1998; 19:301-6. [PMID: 9639326 DOI: 10.1016/s0143-4004(98)90062-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The addition of live or sonicated Escherichia coli, or endotoxin from E. coli increased the release of prostaglandins (PG) on both sides of intact human fetal membranes after 24 h of incubation, indicating that live bacteria were not required to activate prostaglandin production. Time-course studies showed that the levels of PGE2 and PGF2alpha on the fetal side of the membrane were increased 6 h after the addition of endotoxin, whereas levels on the maternal side increased within 1-2 h. These changes were independent of the side to which the endotoxin was added, indicating that a stimulatory factor passes through the fetal membranes. This factor is not endotoxin, which did not cross the membranes, and further studies are required to identify this endogenous stimulus. Prostaglandin metabolite levels were either unaffected or increased by endotoxin, indicating that the main effect is at the level of increased prostaglandin biosynthesis rather than decreased metabolism.
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Affiliation(s)
- D Rajasingam
- ICSM Institute of Obstetrics and Gynaecology, Hammersmith Hospital, London, UK
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Ishihara O, Numari H, Saitoh M, Arai Y, Takanashi H, Kitagawa H, Kinoshita K. Prostaglandin E2 production by endogenous secretion of interleukin-1 in decidual cells from term fetal membrane. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1998; 433:419-22. [PMID: 9561185 DOI: 10.1007/978-1-4899-1810-9_92] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- O Ishihara
- Department of Obstetrics and Gynaecology, Saitama Medical Centre, Saitama Medical School, Kawagoe, Japan
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Abstract
Elevated uterine concentrations of interleukin-1beta (IL-1beta), interleukin-6 (IL-6) and tumour-necrosis factor-alpha (TNF-alpha) are suspected to cause increased prostaglandin release from gestational tissues, but little information is available about the expression pattern of cytokine receptors in these tissues. In this study, cytokine receptor positive cells in frozen tissue sections of placentae (n=70) and fetal membranes (n=50) were identified by immunohistological staining with monoclonal antibodies specific for IL-6 receptor, TNF receptors I and II, and IL-1 receptor I. Both subunits of the IL-6 receptor (gp130 and gp80) as well as TNF receptors I and II were expressed by fetal endothelial cells within placental villi, while IL-1-receptor I was detected exclusively in stromal cells of the maternal decidua. The IL-1 receptor I and TNF receptors I and II were expressed in both uterine quiescence and labour, irrespective of gestational age. Immunoreactivity of the gp130 subunit of the IL-6 receptor was found also throughout pregnancy, while the appearance of the gp80 subunit correlated with the presence of term and preterm labour. In case of preterm labour, expression of the gp80 subunit was predominantly detected in the absence of intrauterine infection. Therefore, it is concluded that the de novo expression of the gp80 subunit and consequently the appearance of entire IL-6 receptors in the placenta is associated with spontaneously occurring labour at term and also with preterm occurring labour in the absence of inrauterine infection.
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Affiliation(s)
- A Steinborn
- Department of Obstetrics and Gynaecology, University of Frankfurt, Germany
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Spaziani EP, Tsibris JC, Hunt LT, Benoit RR, O'Brien WF. The effect of interleukin-1 beta and interleukin-4 on the expression of prostaglandin receptors EP1 and EP3 in amnion WISH cells. Am J Reprod Immunol 1997; 38:279-85. [PMID: 9352015 DOI: 10.1111/j.1600-0897.1997.tb00515.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PROBLEM Although prostaglandin E2 (PGE2) is believed to modulate biochemical and immunological events leading to parturition, the role of prostaglandin E receptors during labor has not been investigated. METHOD OF STUDY Amnion WISH cells were incubated in media containing increasing concentrations of either interleukin-1 beta (IL-1 beta) or IL-4. Increased EP1 and EP3 protein expression was determined by Western blot analysis with peptide-specific antibodies. Concomitant measurements of culture media PGE2 were made by an enzyme immunoassay. RESULTS Incubation of WISH cells with IL-1 beta or IL-4 caused a two- to three-fold increase in EP1 protein levels. IL-1 beta and IL-4 also caused six- and two-fold increases, respectively, in culture fluid PGE2 concentrations. IL-1 beta or IL-4 had no effect on EP3 protein levels. CONCLUSIONS Based on these results, it is proposed that IL-1 beta and IL-4 may be involved in the initiation and promotion of labor by inducing EP1 levels and PGE2 production in amnion.
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MESH Headings
- Amnion/drug effects
- Amnion/immunology
- Amnion/metabolism
- Cell Line
- Dinoprostone/biosynthesis
- Female
- Humans
- Interleukin-1/pharmacology
- Interleukin-4/pharmacology
- Labor, Obstetric/immunology
- Labor, Obstetric/metabolism
- Obstetric Labor, Premature/etiology
- Obstetric Labor, Premature/immunology
- Obstetric Labor, Premature/metabolism
- Pregnancy
- Receptors, Prostaglandin E/metabolism
- Receptors, Prostaglandin E, EP1 Subtype
- Receptors, Prostaglandin E, EP3 Subtype
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Affiliation(s)
- E P Spaziani
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL 33612, USA
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Ishihara O, Numari H, Saitoh M, Arai Y, Takanashi H, Kitagawa H, Kinoshita K. Prostaglandin E2 production by endogenous secretion of interleukin-1 in decidual cells obtained before and after the labor. PROSTAGLANDINS 1996; 52:199-208. [PMID: 8908620 DOI: 10.1016/s0090-6980(96)00097-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Previous reports revealed that interleukin-1 (IL-1) was involved in the process of premature labor in the cases with intrauterine infection. However, the roles of the cytokine in normal spontaneous labor remain uncertain. The present studies aimed at determining the involvement of the cytokine in prostaglandin (PG)E2 production during labor by the third trimester decidual cells. The cells were obtained at the time of normal spontaneous delivery (NVD) and elective cesarean section (ECS). The NVD cells produced significantly more amount of PGE2 than the ECS cells and the both cells responded to the addition of IL-1 beta to increase PGE2 production. A specific inhibitor of cyclooxygenase-2 (COX-2), NS398, decreased basal PGE2 production and inhibited the stimulatory effect of IL-1 beta in a dose dependent manner in NVD cells. The NVD cells secreted more amount of IL-1 beta than the ECS cells and contained more amount of preprocessed 31kD IL-1 beta inside the cells. The addition of recombinant soluble human IL-1 receptor (type I) not only blocked the effect of IL-1 beta on PG secretion, but significantly reduced the basal production of PGE2 by NVD cells. These results indicate that decidual PG production depends upon COX-2 after the onset of labor. Besides it seems likely that endogenously produced IL-1 beta may be involved in autocrine or paracrine fashion in inducing COX-2 after the onset of labor.
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Affiliation(s)
- O Ishihara
- Department of Obstetrics and Gynaecology, Saitama Medical Centre, Saitama Medical School, Kawagoe, Japan
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16
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Hanson LA, Hahn-Zoric M, Wiedermann U, Lundin S, Dahlman-Höglund A, Saalman R, Erling V, Dahlgren U, Telemo E. Early dietary influence on later immunocompetence. Nutr Rev 1996; 54:S23-30. [PMID: 8710233 DOI: 10.1111/j.1753-4887.1996.tb03867.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- L A Hanson
- Department of Clinical Immunology, University of Göteborg, Sweden
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17
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Cole OF, Seki H, Elder MG, Sullivan MH. Interleukin-1 beta independently stimulates production of prostaglandin E2 and cyclic AMP from human decidual cells. BIOCHIMICA ET BIOPHYSICA ACTA 1995; 1269:139-44. [PMID: 7488646 DOI: 10.1016/0167-4889(95)00107-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Interleukin-1 beta (IL-1 beta) increased the production of cyclic AMP and prostaglandin E2 (PGE2) by cultured human decidual cells during 24 h of stimulation, but not over short incubation times (< 6 h). At concentrations of IL-1 beta ranging from 1 to 100 pg/ml, there were parallel changes in cyclic AMP and PGE2 levels, but 1000 pg of IL-1 beta/ml inhibited cyclic AMP production while still stimulating PGE2 synthesis. The possible link between cyclic AMP and PGE2 was therefore studied further. Inhibition of IL-1 beta-stimulated PGE2 synthesis by indomethacin and direct addition of PGE2 had no effect on cyclic AMP levels, indicating that PGE2 did not increase cyclic AMP production by human decidual cells and confirming the independent synthesis of cyclic AMP and PGE2. The increase in cyclic AMP production induced by IL-1 beta is dependent on protein synthesis, but it is not known which component of the adenylate cyclase is increased. A phosphodiesterase inhibitor potentiated the effects of IL-1 beta on cyclic AMP synthesis, indicating that the cytokine may increase cyclic AMP metabolism. We suggest that high concentrations of IL-1 beta activate phosphodiesterase activity more than adenylate cyclase, which gives rise to the low levels of cyclic AMP noted above. IL-1 beta also decreased forskolin-stimulated cyclic AMP production, which again indicates increased cyclic AMP metabolism. Since most concentrations of IL-1 beta alone increased cyclic AMP levels, this stimulation must out-weigh the increase in metabolism apparent in the presence of forskolin, phosphodiesterase inhibitor or high levels of interleukin. It is clear that IL-1 beta increased decidual PGE2 production independently of cyclic AMP, and that other second messenger must mediate the action of this cytokine.
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Affiliation(s)
- O F Cole
- R.P.M.S. Institute of Obstetrics and Gynaecology, Hammersmith Hospital, London, UK
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18
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Cole OF, Elder MG, Sullivan MH. Decidual adenylate cyclase and prostaglandin production in vitro. PROSTAGLANDINS 1995; 49:167-74. [PMID: 7652185 DOI: 10.1016/0090-6980(95)00017-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Human decidua contains an active adenylate cyclase, and a number of studies indicate that adenylate cyclase is functionally linked to increased in vitro prostaglandin synthesis. Increased decidual prostaglandin synthesis is associated with parturition, and therefore activation of adenylate cyclase may be involved in the control of human parturition. In this study, third trimester human decidual cells were preincubated for no more than 24 h prior to stimulation with a number of reagents which increase cellular cyclic AMP levels. Forskolin rapidly increased intracellular and extracellular cyclic AMP levels, but there was no increase in prostaglandin E2 biosynthesis during incubations ranging from 5 min up to 24 h. Dibutyryl cyclic AMP or 8-bromo-cyclic AMP were also without effect on PGE2 production, which suggests that the adenylate cyclase was not linked to the mechanisms regulating prostaglandin production. Cholera toxin increased basal cyclic AMP and PGE2 synthesis, and was without effect on IL-1 beta-stimulated PGE2 levels. PGE2 synthesis was increased by 24 h culture with IL-1 beta in all the cell preparations, indicating that the cells were biologically active, and that the lack of effect of changes in cyclic AMP synthesis on PGE2 levels could not be attributed to a defect in the prostaglandin synthetic pathway. Our findings did not agree with earlier work which showed that changes in cyclic AMP were correlated with changes in PGE2 production by human decidual cells. It is clear that in the previous studies the decidual cells were preincubated for 4-7 days prior to stimulation, in contrast with 24 h in our investigation.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- O F Cole
- R.P.M.S. Institute of Obstetrics & Gynaecology, Hammersmith Hospital, London, UK
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19
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Cole OF, Seki H, Sullivan MH, Elder MG. Interleukin-1 beta-stimulated prostaglandin synthesis by human decidual cells is independent of protein kinase C. PROSTAGLANDINS 1995; 49:69-77. [PMID: 7480798 DOI: 10.1016/0090-6980(95)00006-v] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Basal prostaglandin E2 (PGE2) synthesis by human decidual cells was stimulated by phorbol myristate acetate (PMA) which activates protein kinase C. Staurosporine, which is an inhibitor of protein kinase C in most systems, also increased basal PGE2 synthesis. Further work is needed to explain this finding, as another inhibitor of protein kinase C, H7, inhibited PGE2 production under similar culture conditions. Interleukin-1 beta (IL-1 beta)-stimulated PGE2 synthesis was potentiated by coincubation with PMA or staurosporine, indicating that IL-1 beta and protein kinase C increase decidual PGE2 synthesis through different mechanisms. Desensitization of the decidual cells for 24 h with PMA did not affect IL-1 beta-stimulated PGE2 synthesis. The complex roles of protein kinase C in regulating decidual prostaglandin synthesis require further investigation, but it is clear that the effects of IL-1 beta are not mediated by protein kinase C.
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Affiliation(s)
- O F Cole
- R.P.M.S. Institute of Obstetrics & Gynaecology, Hammersmith Hospital, London, UK
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20
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Ishihara O, Matsuoka K, Kinoshita K, Sullivan MH, Elder MG. Interleukin-1 beta-stimulated PGE2 production from early first trimester human decidual cells is inhibited by dexamethasone and progesterone. PROSTAGLANDINS 1995; 49:15-26. [PMID: 7792388 DOI: 10.1016/0090-6980(94)00009-l] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Cytokines are known to increase the production of prostaglandins by human decidual cells, but negative regulators have not been identified. We have examined the effects of dexamethasone and progesterone on prostaglandin (PG) E2 synthesis by cultured human first trimester decidual cells. The numbers of cyclooxygenase (COX) enzyme positive cells were visualised by immunocytochemistry, using antibodies specific for COX-1 and COX-2. Interleukin-1 beta stimulated the production of prostaglandins E2 and F2 alpha dose-dependently, and this was associated with increased numbers of COX-2 positive cells. Progesterone (10(-7)-10(-6) M) and dexamethasone (10(-7)-10(-6) M) inhibited basal and interleukin-1 beta-stimulated prostaglandin production, and decreased the numbers of COX-2 positive cells. Neither interleukin-1 beta nor the steroids affected numbers of COX-1 positive cells. COX-2 seems to be the main enzyme controlling the synthesis of PGE2 by human decidual cells, and may be negatively regulated by progesterone.
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Affiliation(s)
- O Ishihara
- Department of Obstetrics and Gynaecology, Saitama Medical Centre, Saitama Medical School, Kawagoe Japan
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21
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Albert TJ, Su HC, Zimmerman PD, Iams JD, Kniss DA. Interleukin-1 beta regulates the inducible cyclooxygenase in amnion-derived WISH cells. PROSTAGLANDINS 1994; 48:401-16. [PMID: 7892511 DOI: 10.1016/0090-6980(94)90006-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The purpose of this study was to determine the mechanism of enhanced prostaglandin synthesis in amnion-derived WISH cell cultures when stimulated by interleukin-1 beta (IL-1 beta). Confluent monolayer cultures of WISH cells were incubated with human recombinant IL-1 beta (0.001-10 ng/ml) for 0-24 hours, while control cells received medium alone. PGE2 production was measured by specific radioimmunoassay. IL-1 beta enhanced the production of PGE2 in a dose- and time-dependent manner with enhanced production detectable by 2 h following exposure. Immunoblot analysis using isoform-specific antibodies showed that the inducible cyclooxygenase enzyme, i.e., COX-2, was expressed by 2 h in IL-1 treated cells, while the constitutive COX-1 remained unaltered in its expression. Northern blot analysis demonstrated that COX-2 mRNA expression was not detected in untreated cells, but became evident after a 30-min exposure to IL-1 beta (10 ng/ml). COX-1 mRNA was detected under basal conditions and did not increase significantly following IL-1 beta treatment. The close parallel between the kinetics of COX-2 mRNA and protein expression and PGE2 accumulation in the medium, as well as the constitutive, unregulated nature of the COX-1 isoform, indicates that cytokine-driven PGE2 formation in WISH cells may be mediated by de novo expression of the novel COX-2 enzyme.
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Affiliation(s)
- T J Albert
- Department of Obstetrics and Gynecology, Ohio State University, College of Medicine, Columbus 43210
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22
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Lewis MP, Sullivan MH, Elder MG. Regulation by interleukin-1 beta of growth and collagenase production by choriocarcinoma cells. Placenta 1994; 15:13-20. [PMID: 8208667 DOI: 10.1016/s0143-4004(05)80232-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Impaired trophoblastic invasion and proliferation have been implicated in the pathogenesis of eclampsia, pre-eclampsia, spontaneous abortions and intra-uterine growth retardation (IUGR). First trimester trophoblast cells (which do not grow in culture) and choriocarcinoma (BeWo) (which grow spontaneously, and are used as a model for proliferating trophoblast) were incubated with interleukin-1 beta (IL-1 beta). BeWo cell growth was decreased dose-dependently by exogenous IL-1 beta at concentrations of 100-1000 pg/ml. This effect was first detected after 24 h of incubation with IL-1 beta, and persisted for up to 96 h of culture. In contrast, trophoblast cells isolated from first trimester placental tissue showed no growth response when stimulated with IL-1 beta. The levels of active interstitial collagenase produced by BeWo cells were increased by IL-1 beta (100-1000 pg/ml), which paralleled the decrease in cell growth. First trimester trophoblast cells produced lower levels of collagenase and this was not affected by incubation of the cells by IL-1 beta. These results indicate that IL-1 beta may regulate placental development, but further development of culture systems for first trimester trophoblast will be needed before this result can be confirmed.
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Affiliation(s)
- M P Lewis
- Institute of Obstetrics & Gynaecology, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK
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23
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Cole OF, Sullivan MH, Elder MG. The "interleukin 1 receptor antagonist" is a partial agonist of prostaglandin synthesis by human decidual cells. PROSTAGLANDINS 1993; 46:493-8. [PMID: 8295979 DOI: 10.1016/0090-6980(93)90068-i] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In many systems the interleukin-1 receptor antagonist opposes the effects of interleukin-1 beta. We considered that it might block interleukin-1 beta-stimulated prostaglandin production from human decidual cells. Very high levels of interleukin-1 receptor antagonist (> 1000 pg/ml) had limited inhibitory effects on IL-1 beta-stimulated PGE2 synthesis, and lower levels of antagonist (< 1000 pg/ml) increased the effects of IL-1 beta. Low concentrations of the antagonist alone (1-100 pg/ml) increased basal PGE2 production, whereas higher levels (10-100 ng/ml) had less effect. It seems, therefore, that in human decidua the "antagonist" is more accurately described as a partial agonist. It has been suggested that the IL-1 receptor antagonist could be used to inhibit decidual prostaglandin synthesis and thereby prevent preterm labor, but this report shows that caution should be exercised before using the receptor antagonist.
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Affiliation(s)
- O F Cole
- Institute of Obstetrics and Gynaecology, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK
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24
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Kent AS, Sullivan MH, Sun MY, Zosmer A, Elder MG. Effects of interleukin-6 and tumor necrosis factor-alpha on prostaglandin production by cultured human fetal membranes. PROSTAGLANDINS 1993; 46:351-9. [PMID: 8248548 DOI: 10.1016/0090-6980(93)90100-l] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In this study we investigated the effects of the cytokines interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) on prostaglandin production by cultured human fetal membranes. These cytokines stimulate prostaglandin synthesis by isolated components of human fetal membranes, but their effects on the intact tissue comprising amnion, chorion and decidua were not known. TNF-alpha added to the maternal side of the membrane activated decidual production of PGF2 alpha but had no effects on synthesis of PGE2 or PGE2 metabolites. Addition of TNF-alpha to the fetal side of the membrane increased production of PGE2 by amnion and PGE2 metabolites from chorion. The addition of IL-6 to the fetal or the maternal side of the membrane increased production of PGE2 from amnion and PGE2m from chorion, suggesting that IL-6 might pass through the fetal membrane. IL-6 had no effect on decidual PGF2 alpha production. These results suggest that TNF-alpha may be involved in labor by increasing decidual prostaglandin synthesis, whereas IL-6 is less likely to have a role.
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Affiliation(s)
- A S Kent
- Institute of Obstetrics and Gynaecology, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK
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25
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Kent AS, Sun MY, Sullivan MH, Elder MG. The effects of interleukins 1 alpha and 1 beta on prostaglandin production by cultured human fetal membranes. PROSTAGLANDINS 1993; 46:51-9. [PMID: 8378543 DOI: 10.1016/0090-6980(93)90062-c] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The effects of IL-1 alpha and IL-1 beta on cultured human fetal membranes were studied. These cytokines are known to regulate prostaglandin synthesis by the separated components of the fetal membranes (amnion, chorion and decidua), but their effects on intact tissue are unknown. IL-1 alpha increased PGE2 levels on the fetal side of the membrane, indicating increased production of prostaglandin from the amnion, but had little effect on levels of PGE2 on the maternal side of the membrane. Low levels of IL-1 beta (0.1-1.0 ng/ml) increased PGE2 levels on the fetal side of the membrane, and also increased the production of PGE2 metabolites and PGF2 alpha, suggesting that this cytokine stimulated the decidua as well as the amnion. High concentrations of both cytokines appeared able to stimulate prostaglandin production by the side of the membrane opposing that to which they were added, but it is not clear whether this was mediated by factors released by the stimulated membrane, or by direct transfer of small quantities of cytokines through the membrane. Taken together, these results indicate that IL-1 beta was a potent stimulator of the synthesis of prostaglandins by decidua and by amnion, whereas IL-1 alpha only stimulated the amnion.
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Affiliation(s)
- A S Kent
- Institute of Obstetrics and Gynaecology, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK
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26
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Khan H, Sullivan MH, Elder MG. Modulation of decidual stromal cell activity by interleukin-1 beta and interleukin-6. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1993; 100:393-4. [PMID: 8494845 DOI: 10.1111/j.1471-0528.1993.tb12989.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- H Khan
- Institute of Obstetrics and Gynaecology, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK
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