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Manuck TA, Gyamfi-Bannerman C, Saade G. What now? A critical evaluation of over 20 years of clinical and research experience with 17-alpha hydroxyprogesterone caproate for recurrent preterm birth prevention. Am J Obstet Gynecol MFM 2023; 5:101108. [PMID: 37527737 PMCID: PMC10591827 DOI: 10.1016/j.ajogmf.2023.101108] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/08/2023] [Accepted: 07/14/2023] [Indexed: 08/03/2023]
Abstract
Spontaneous preterm birth is multifactorial, and underlying etiologies remain incompletely understood. Supplementation with progestogens, including 17-alpha hydroxyprogesterone caproate has been a mainstay of prematurity prevention strategies in the United States in the last 2 decades. Following a recent negative confirmatory trial, 17-alpha hydroxyprogesterone caproate was withdrawn from the US market and is currently available only through clinical research studies. This expert review summarized clinical and research data regarding the use of 17-alpha hydroxyprogesterone caproate in the United States from 2003 to 2023 for recurrent prematurity prevention. In 17-alpha hydroxyprogesterone caproate. The history of the use, mechanisms of action, clinical trial results, and efficacy by clinical and biologic criteria of 17-alpha hydroxyprogesterone caproate are presented. We report that disparate findings and conclusions between similarly designed rigorous studies may reflect differences in a priori risk and population incidence and extreme care should be taken in interpreting the studies and making decisions regarding efficacy of 17-alpha hydroxyprogesterone caproate for the prevention of preterm birth. The likelihood of improved obstetrical outcomes after receiving 17-alpha hydroxyprogesterone caproate may vary by clinical factors (eg, body mass index), plasma drug concentrations, and genetic factors, although the identification of individuals most likely to benefit remains imperfect. It is crucial for the medical community to recognize the importance of preserving the decades-long efforts invested in preventing recurrent preterm birth in the United States. Moreover, it is important that we thoroughly and thoughtfully evaluate 17-alpha hydroxyprogesterone caproate as a promising contender for future well-executed prematurity studies.
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Affiliation(s)
- Tracy A Manuck
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Dr Manuck); Institute for Environmental Health Solutions, Gillings School of Global Public Health, Chapel Hill, NC (Dr Manuck).
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, San Diego, CA (Dr Gyamfi-Bannerman)
| | - George Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Dr Saade)
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2
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17-α Hydroxyprogesterone Caproate Immunology, a Special Focus on Preterm Labor, Preeclampsia, and COVID-19. REPRODUCTIVE MEDICINE 2022. [DOI: 10.3390/reprodmed3030019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
17-α hydroxyprogesterone caproate (17-OHPC) could alter the immune response and inflammation, specifically affecting the risk of preterm labor and preeclampsia. However, the exact immune and inflammatory effects of 17-OHPC remain hard to be identified. The current literature on 17-OHPC immune effects is limited and more research is needed to identify these mechanistic pathways. Further, coronavirus disease 2019 (COVID-19) infection in pregnancy involves heightened immune response, widespread inflammation and high rates of preterm labor and preeclampsia. Since the pathogenesis of preterm labor, preeclampsia and COVID-19 involves inflammation and altered immune response, it is important to explore the possible immune effects of 17-OHPC in pregnant women with COVID-19. This commentary article will explain the immune effects of 17-OHPC and their implications in preterm labor, preeclampsia and COVID-19.
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Eastman AJ, Noble KN, Pensabene V, Aronoff DM. Leveraging bioengineering to assess cellular functions and communication within human fetal membranes. J Matern Fetal Neonatal Med 2022; 35:2795-2807. [PMID: 32787482 PMCID: PMC7878582 DOI: 10.1080/14767058.2020.1802716] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The fetal membranes enclose the growing fetus and amniotic fluid. Preterm prelabor rupture of fetal membranes is a leading cause of preterm birth. Fetal membranes are composed of many different cell types, both structural and immune. These cells must coordinate functions for tensile strength and membrane integrity to contain the growing fetus and amniotic fluid. They must also balance immune responses to pathogens with maintaining maternal-fetal tolerance. Perturbation of this equilibrium can lead to preterm premature rupture of membranes without labor. In this review, we describe the formation of the fetal membranes to orient the reader, discuss some of the common forms of communication between the cell types of the fetal membranes, and delve into the methods used to tease apart this paracrine signaling within the membranes, including emerging technologies such as organ-on-chip models of membrane immunobiology.
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Affiliation(s)
- Alison J. Eastman
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Kristen N. Noble
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN 37202 USA
| | - Virginia Pensabene
- School of Electronic and Electrical Engineering, University of Leeds, Leeds, UK,School of Medicine, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - David M. Aronoff
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, USA,Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN 37232, USA,Corresponding author: David M. Aronoff, MD, 1161 21st Ave South, A-2200 MCN, Nashville, TN 37232-2582, (615) 322-8972 (tel),
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Immune effects of 17α-hydroxyprogesterone caproate. Am J Obstet Gynecol 2022; 227:671-675. [PMID: 35779586 DOI: 10.1016/j.ajog.2022.06.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/23/2022] [Indexed: 01/04/2023]
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Firmal P, Shah VK, Chattopadhyay S. Insight Into TLR4-Mediated Immunomodulation in Normal Pregnancy and Related Disorders. Front Immunol 2020; 11:807. [PMID: 32508811 PMCID: PMC7248557 DOI: 10.3389/fimmu.2020.00807] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/08/2020] [Indexed: 12/12/2022] Open
Abstract
Unlike organ transplants where an immunosuppressive environment is required, a successful pregnancy involves an extremely robust, dynamic, and responsive maternal immune system to maintain the development of the fetus. A specific set of hormones and cytokines are associated with a particular stage of pregnancy. Any disturbance that alters this fine balance could compromise the development and function of the placenta. Although there are numerous underlying causes of pregnancy-related complications, untimely activation of Toll-like receptors (TLR), primarily TLR4, by intrauterine microbes poses the greatest risk. TLR4 is an important Pattern Recognition Receptor (PRR), which activates both innate and adaptive immune cells. TLR4 activation by LPS or DAMPs leads to the production of pro-inflammatory cytokines via the MyD88 dependent or independent pathway. Immune cells modulate the materno–fetal interface by TLR4-mediated cytokine production, which changes at different stages of pregnancy. In most pregnancy disorders, such as PTB, PE, or placental malaria, the TLR4 expression is upregulated in immune cells or in maternal derived cells, leading to the aberrant production of pro-inflammatory cytokines at the materno–fetal interface. Lack of functional TLR4 in mice has reduced the pro-inflammatory responses, leading to an improved pregnancy, which further strengthens the fact that abnormal TLR4 activation creates a hostile environment for the developing fetus. A recent study proposed that endothelial and perivascular stromal cells should interact with each other in order to maintain a homeostatic balance during TLR4-mediated inflammation. It has been reported that depleting immune cells or supplying anti-inflammatory cytokines can prevent PTB, PE, or fetal death. Blocking TLR4 signaling or its downstream molecule by inhibitors or antagonists has proven to improve pregnancy-related complications to some extent in clinical and animal models. To date, there has been a lack of knowledge regarding whether TLR4 accessories such as CD14 and MD-2 are important in pregnancy and whether these accessory molecules could be promising drug targets for combinatorial treatment of various pregnancy disorders. This review mainly focuses on the activation of TLR4 during pregnancy, its immunomodulatory functions, and the upcoming advancement in this field regarding the improvement of pregnancy-related issues by various therapeutic approaches.
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Affiliation(s)
- Priyanka Firmal
- National Centre for Cell Science, S. P. Pune University Campus, Pune, India
| | - Vibhuti Kumar Shah
- National Centre for Cell Science, S. P. Pune University Campus, Pune, India
| | - Samit Chattopadhyay
- National Centre for Cell Science, S. P. Pune University Campus, Pune, India.,Department of Biological Sciences, BITS Pilani, K. K. Birla Goa Campus, Goa, India.,Indian Institute of Chemical Biology, Kolkata, India
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Snijesh V, Matchado MS, Singh S. Classifying Rheumatoid Arthritis gene network signatures for identifying key regulatory molecules and their altered pathways by adopting network biology approach. GENE REPORTS 2018. [DOI: 10.1016/j.genrep.2018.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rogers LM, Anders AP, Doster RS, Gill EA, Gnecco JS, Holley JM, Randis TM, Ratner AJ, Gaddy JA, Osteen K, Aronoff DM. Decidual stromal cell-derived PGE 2 regulates macrophage responses to microbial threat. Am J Reprod Immunol 2018; 80:e13032. [PMID: 30084522 DOI: 10.1111/aji.13032] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 07/16/2018] [Indexed: 12/30/2022] Open
Abstract
PROBLEM Bacterial chorioamnionitis causes adverse pregnancy outcomes, yet host-microbial interactions are not well characterized within gestational membranes. The decidua, the outermost region of the membranes, is a potential point of entry for bacteria ascending from the vagina to cause chorioamnionitis. We sought to determine whether paracrine communication between decidual stromal cells and macrophages shaped immune responses to microbial sensing. METHOD OF STUDY Decidual cell-macrophage interactions were modeled in vitro utilizing decidualized, telomerase-immortalized human endometrial stromal cells (dTHESCs) and phorbol ester-differentiated THP-1 macrophage-like cells. The production of inflammatory mediators in response to LPS was monitored by ELISA for both cell types, while phagocytosis of bacterial pathogens (Escherichia coli and Group B Streptococcus (GBS)) was measured in THP-1 cells or primary human placental macrophages. Diclofenac, a non-selective cyclooxygenase inhibitor, and prostaglandin E2 (PGE2 ) were utilized to interrogate prostaglandins as decidual cell-derived paracrine immunomodulators. A mouse model of ascending chorioamnionitis caused by GBS was utilized to assess the colocalization of bacteria and macrophages in vivo and assess PGE2 production. RESULTS In response to LPS, dTHESC and THP-1 coculture demonstrated enhancement of most inflammatory mediators, but a potent suppression of macrophage TNF-α generation was observed. This appeared to reflect a paracrine-mediated effect of decidual cell-derived PGE2 . In mice with GBS chorioamnionitis, macrophages accumulated at sites of bacterial invasion with increased PGE2 in amniotic fluid, suggesting such paracrine effects might hold relevance in vivo. CONCLUSION These data suggest key roles for decidual stromal cells in modulating tissue responses to microbial threat through release of PGE2 .
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Affiliation(s)
- Lisa M Rogers
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anjali P Anders
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Ryan S Doster
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Juan S Gnecco
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacob M Holley
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tara M Randis
- Department of Pediatrics, New York University School of Medicine, New York, New York.,Department of Microbiology, New York University School of Medicine, New York, New York
| | - Adam J Ratner
- Department of Pediatrics, New York University School of Medicine, New York, New York.,Department of Microbiology, New York University School of Medicine, New York, New York
| | - Jennifer A Gaddy
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Veteran Affairs, Tennessee Valley Healthcare Systems, Nashville, Tennessee
| | - Kevin Osteen
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Veteran Affairs, Tennessee Valley Healthcare Systems, Nashville, Tennessee
| | - David M Aronoff
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
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Anders AP, Gaddy JA, Doster RS, Aronoff DM. Current concepts in maternal-fetal immunology: Recognition and response to microbial pathogens by decidual stromal cells. Am J Reprod Immunol 2017; 77. [PMID: 28044385 DOI: 10.1111/aji.12623] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 11/21/2016] [Indexed: 12/29/2022] Open
Abstract
Chorioamnionitis is an acute inflammation of the gestational (extraplacental) membranes, most commonly caused by ascending microbial infection. It is associated with adverse neonatal outcomes including preterm birth, neonatal sepsis, and cerebral palsy. The decidua is the outermost layer of the gestational membranes and is likely an important initial site of contact with microbes during ascending infection. However, little is known about how decidual stromal cells (DSCs) respond to microbial threat. Defining the contributions of individual cell types to the complex medley of inflammatory signals during chorioamnionitis could lead to improved interventions aimed at halting this disease. We review available published data supporting the role for DSCs in responding to microbial infection, with a special focus on their expression of pattern recognition receptors and evidence of their responsiveness to pathogen sensing. While DSCs likely play an important role in sensing and responding to infection during the pathogenesis of chorioamnionitis, important knowledge gaps and areas for future research are highlighted.
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Affiliation(s)
- Anjali P Anders
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer A Gaddy
- Tennessee Valley Healthcare Systems, Department of Veterans Affairs, Nashville, TN, USA.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan S Doster
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David M Aronoff
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
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Himes KP, Handley D, Chu T, Burke B, Bunce K, Simhan HN, Peters DG. Comprehensive analysis of the transcriptional response of human decidual cells to lipopolysaccharide stimulation. J Reprod Immunol 2011; 93:17-27. [PMID: 22196106 DOI: 10.1016/j.jri.2011.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 10/17/2011] [Accepted: 11/08/2011] [Indexed: 01/19/2023]
Abstract
Decidual cells are central to innate immunity at the maternal/fetal interface. We sought to characterize the response of decidual cells to stimulation and then removal of lipopolysaccharide (LPS) using a whole genome approach. Decidual cells were isolated from term unlabored cesarean sections. Cells were stimulated with LPS and RNA isolated both pre-stimulation and 2 and 24 h post-stimulation. Media were changed and RNA extracted 48 h later. Gene expression was measured using Agilent 44K whole genome microarrays. Data were visualized and interpreted using Ingenuity Pathway Analysis (IPA) software and selected (n=5) target gene expression was verified with quantitative real-time PCR. Genes related to immune function were up-regulated at 2 and 24 h after LPS exposure and then generally returned to baseline or were at least substantially reduced after LPS removal. Pathway analysis also revealed that genes involved in lipid metabolism (specifically cholesterol and steroid biosynthesis), iron metabolism, and the plasminogen system were coordinately altered following exposure to LPS. Our novel, preliminary findings provide insight into possible mechanisms via which the host inflammatory response could contribute to preterm birth and warrant further investigation in preterm samples.
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Affiliation(s)
- Katherine P Himes
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal Fetal Medicine, University of Pittsburgh, PA 15213, USA
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King AE, Critchley HOD. Oestrogen and progesterone regulation of inflammatory processes in the human endometrium. J Steroid Biochem Mol Biol 2010; 120:116-26. [PMID: 20067835 DOI: 10.1016/j.jsbmb.2010.01.003] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 12/23/2009] [Accepted: 01/05/2010] [Indexed: 01/14/2023]
Abstract
The human endometrium is a unique tissue that has to undergo cycles of proliferation, differentiation, destruction and repair. This ensures that the endometrium is optimally prepared for potential embryo implantation but in the absence of an embryo, menstruation occurs to allow endometrial regeneration. These cycles of tissue remodelling occur under the sequential influence of the sex steroid hormones, oestrogen and progesterone. The physiological events of implantation and menstruation display features of inflammation, tightly regulated by oestrogen and progesterone. After menstruation cellular proliferation and blood vessel growth is modulated by oestrogen while after ovulation progesterone is the dominant hormone. In preparation for implantation, progesterone regulates decidualization of the endometrium, uterine natural killer cell numbers within the endometrium and chemokine and cytokine expression. Menstruation, in contrast, is preceded by progesterone withdrawal, which results in an influx of leukocytes into the endometrium and increased production of chemokines and matrix metalloproteinases allowing tissue degradation. The aim of this article is to review the current knowledge on the regulation of inflammatory events within the endometrium by oestrogen and progesterone, in relation to two pivotal events for human reproduction, implantation and menstruation.
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Affiliation(s)
- Anne E King
- University of Edinburgh, Centre for Reproductive Biology, The Queen's Medical Research Institute, United Kingdom
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Yu L, Wang L, Chen S. REVIEW ARTICLE: Toll-Like Receptors, Inflammation and Tumor in the Human Female Reproductive Tract. Am J Reprod Immunol 2009; 62:1-8. [DOI: 10.1111/j.1600-0897.2009.00712.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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