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Marozio L, Nuzzo AM, Gullo E, Moretti L, Canuto EM, Tancredi A, Goia M, Cosma S, Revelli A, Rolfo A, Benedetto C. Immune Checkpoints in Recurrent Pregnancy Loss: New Insights into a Detrimental and Elusive Disorder. Int J Mol Sci 2023; 24:13071. [PMID: 37685876 PMCID: PMC10488095 DOI: 10.3390/ijms241713071] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Recurrent pregnancy loss (RPL) refers to two or more miscarriages before 20 weeks gestation. Its prevalence is 1-2%; its pathogenesis remains unexplained in more than 50% of cases, in which the cause is thought to be abnormal immune activity during placentation leading to a lack of pregnancy-induced immune tolerance. It is unknown whether immune activity is deranged in the endometrium of women with RPL. We studied the gene expression and the quantitative tissue protein levels of three immune checkpoints (CD276, which enhances cytotoxic T-cell activity, cytotoxic T-lymphocyte-associated antigen-4 [CTL-4], which reduces Th1 cytokine production, and lymphocyte activation gene-3 [LAG-3], which shows suppressive activity on Tregs and CD4+ T-cells) in endometrial samples from 27 women with unexplained RPL and in 29 women with dysfunctional uterine bleeding and previous uneventful pregnancies as controls. RNA isolation, real-time PCR, protein isolation, and ELISA were performed. CD276 gene expression and protein tissue levels were significantly lower in the endometrium of the RPL group than in the controls, whereas both CTL-4 and LAG-3 were significantly higher. This difference suggests defective endometrial immune regulation and overactivation of immune response in women with a history of RPL, at least in relation to controls with dysfunctional uterine bleeding and previous normal reproductive history.
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Affiliation(s)
- Luca Marozio
- Department of Surgical Sciences, Obstetrics and Gynecology 1, University of Turin, Via Ventimiglia 1, 10126 Turin, Italy; (E.G.); (E.M.C.); (A.T.); (S.C.); (C.B.)
| | - Anna Maria Nuzzo
- Department of Surgical Sciences, University of Turin, Via Ventimiglia 1, 10126 Turin, Italy; (A.M.N.); (L.M.); (A.R.)
| | - Eugenio Gullo
- Department of Surgical Sciences, Obstetrics and Gynecology 1, University of Turin, Via Ventimiglia 1, 10126 Turin, Italy; (E.G.); (E.M.C.); (A.T.); (S.C.); (C.B.)
| | - Laura Moretti
- Department of Surgical Sciences, University of Turin, Via Ventimiglia 1, 10126 Turin, Italy; (A.M.N.); (L.M.); (A.R.)
| | - Emilie M. Canuto
- Department of Surgical Sciences, Obstetrics and Gynecology 1, University of Turin, Via Ventimiglia 1, 10126 Turin, Italy; (E.G.); (E.M.C.); (A.T.); (S.C.); (C.B.)
| | - Annalisa Tancredi
- Department of Surgical Sciences, Obstetrics and Gynecology 1, University of Turin, Via Ventimiglia 1, 10126 Turin, Italy; (E.G.); (E.M.C.); (A.T.); (S.C.); (C.B.)
| | - Margherita Goia
- Unit of Pathology, Department of Medical Sciences, University of Turin, Via Santena 7, 10126 Turin, Italy;
| | - Stefano Cosma
- Department of Surgical Sciences, Obstetrics and Gynecology 1, University of Turin, Via Ventimiglia 1, 10126 Turin, Italy; (E.G.); (E.M.C.); (A.T.); (S.C.); (C.B.)
| | - Alberto Revelli
- Department of Surgical Sciences, Obstetrics and Gynecology 2, University of Turin, Via Ventimiglia 1, 10126 Turin, Italy;
| | - Alessandro Rolfo
- Department of Surgical Sciences, University of Turin, Via Ventimiglia 1, 10126 Turin, Italy; (A.M.N.); (L.M.); (A.R.)
| | - Chiara Benedetto
- Department of Surgical Sciences, Obstetrics and Gynecology 1, University of Turin, Via Ventimiglia 1, 10126 Turin, Italy; (E.G.); (E.M.C.); (A.T.); (S.C.); (C.B.)
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Hessler A. Women's and Fetal Issues in Neurotoxicology. Neurol Clin 2021; 38:897-912. [PMID: 33040868 DOI: 10.1016/j.ncl.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Management of the pregnant patient with neurologic disease is challenging. Ideally, preconception planning can optimize the woman's neurologic condition before pregnancy. More than half of pregnancies are unplanned which makes careful consideration of medications vitally important. This article focuses on potential toxic risk to the fetus of medications deemed necessary to manage several common maternal neurologic issues: multiple sclerosis, epilepsy, and headache during pregnancy and postpartum. It is important for the practitioner to have an understanding beyond the category system to understand the potential toxic risks to the infant.
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Affiliation(s)
- Amy Hessler
- Neurology, University of Kentucky, 740 South Limestone, Lexington, KY 40536, USA.
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Deshmukh H, Way SS. Immunological Basis for Recurrent Fetal Loss and Pregnancy Complications. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2018; 14:185-210. [PMID: 30183507 DOI: 10.1146/annurev-pathmechdis-012418-012743] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pregnancy stimulates an elaborate assortment of dynamic changes, allowing intimate approximation of genetically discordant maternal and fetal tissues. Although the cellular and molecular details about how this works remain largely undefined, important clues arise from evaluating how a prior pregnancy influences the outcome of a future pregnancy. The risk of complications is consistently increased when complications occurred in a prior pregnancy. Reciprocally, a prior successful pregnancy protects against complications in a future pregnancy. Here, we summarize immunological perturbations associated with fetal loss, with particular focus on how both harmful and protective adaptations may persist in mothers. Immunological aberrancy as a root cause of pregnancy complications is also considered, given their shared overlapping risk factors and the sustained requirement for averting maternal-fetal conflict throughout pregnancy. Understanding pregnancy-induced immunological changes may expose not only new therapeutic strategies for improving pregnancy outcomes but also new facets of how immune tolerance works that may be applicable to other physiological and pathological contexts.
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Affiliation(s)
- Hitesh Deshmukh
- Division of Pulmonary Biology, Center for Inflammation and Tolerance, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, USA
| | - Sing Sing Way
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, USA.,Division of Infectious Diseases, Center for Inflammation and Tolerance, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA;
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Khalid F, Healy BC, Dupuy SL, Chu R, Chitnis T, Bakshi R, Houtchens M. Quantitative MRI analysis of cerebral lesions and atrophy in post-partum patients with multiple sclerosis. J Neurol Sci 2018; 392:94-99. [DOI: 10.1016/j.jns.2018.06.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/06/2018] [Accepted: 06/28/2018] [Indexed: 12/31/2022]
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Abstract
Concern about what is best practice when caring for women with neurologic disease is a common clinical scenario. Therefore, knowledge about women's health issues and their intersection with neurologic disorders is imperative. This review will discuss the appropriate gender-based considerations in epilepsy, multiple sclerosis, migraine, autoimmune disease, sleep disorders, stroke, and paraneoplastic disorders.
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Salpietro V, Polizzi A, Recca G, Ruggieri M. The role of puberty and adolescence in the pathobiology of pediatric multiple sclerosis. ACTA ACUST UNITED AC 2018. [DOI: 10.1186/s40893-017-0032-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Altintas A, Najar B, Gozubatik-Celik G, Menku SF. Pregnancy Data in a Turkish Multiple Sclerosis Population. Eur Neurol 2015; 74:296-302. [PMID: 26656283 DOI: 10.1159/000441450] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 10/04/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND To conduct the first retrospective clinical study investigating pregnancy in Turkish multiple sclerosis (MS) patients. SUMMARY We evaluated 558 pregnancies in 199 MS patients and results were compared with general Turkish population's data. The fertility rate in the MS group was found to be lower than that in the general population, even before MS diagnosis was established. Our study suggests that the higher number of pregnancies may have a favorable effect on transition from relapsing-remitting MS to secondary progressive MS, although no effect has been shown regarding the possibility to reach EDSS 6.0 as a milestone. KEY MESSAGES Our data support the conclusion that MS does not have a negative effect on the MS course and disability.
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Affiliation(s)
- Ayse Altintas
- Department of Neurology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Triantafyllou N, Thoda P, Armeni E, Rizos D, Kaparos G, Augoulea A, Alexandrou A, Creatsa M, Tsivgoulis G, Artemiades A, Panoulis C, Lambrinoudaki I. Association of sex hormones and glucose metabolism with the severity of multiple sclerosis. Int J Neurosci 2015; 126:797-804. [PMID: 26407165 DOI: 10.3109/00207454.2015.1069825] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE/AIM OF THE STUDY We evaluated possible associations between the severity of multiple sclerosis (MS) and levels of sex hormones as well as biochemical parameters in a sample of ambulatory patients. MATERIAL AND METHODS This cross-sectional study recruited 133 adults (52 men, 66 premenopausal and 15 postmenopausal women), with relapsing-remitting MS. Fasting venous blood samples were drawn for biochemical and hormonal evaluation. These parameters were tested for possible associations with MS severity, assessed using the Expanded Disability Status Scale (EDSS)-scores. RESULTS Follicle-stimulating hormone correlated with mean EDSS scores (r = -0.369, p = 0.038) in the premenopausal subgroup. However, this association became non-significant in the age-adjusted multivariate analysis (p = 0.141; power = 67%, type α error 0.10). Free androgen exhibited a borderline negative effect on EDSS-scores in the subgroup of men (r = -0.367, p = 0.093), which was lost after adjusting for age and duration of disease (p = 0.192; statistical power = 93%, type α error 0.05). Levels of estradiol tended to affect disability status of postmenopausal women (normal-mild vs. severe impairment: 23.33 ± 11.73pg/mL vs. 14.74 ± 6.30pg/mL, p = 0.095). Levels of sex hormones or indices of glycemic metabolism did not differ between patients presenting with EDSS scores higher or lower than the median value. CONCLUSION Sex hormones and indices of glucose metabolism exhibited only a middle effect on EDSS scoring, which was not independent from the presence of confounders like age and duration of MS. The present study highlights the need for additional research, in order to elucidate the role of sex hormones and insulin resistance in the course of MS.
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Affiliation(s)
- Nikolaos Triantafyllou
- a 1 1st Department of Neurology , University of Athens , Aiginiteio Hospital, Athens , Greece
| | - Pinelopi Thoda
- b 2 2nd Department of Obstetrics and Gynecology , University of Athens , Aretaieio Hospital, Athens , Greece
| | - Eleni Armeni
- b 2 2nd Department of Obstetrics and Gynecology , University of Athens , Aretaieio Hospital, Athens , Greece
| | - Demetrios Rizos
- c 3 Hormonal and Biochemical Laboratory , University of Athens , Aretaieio Hospital, Athens , Greece
| | - George Kaparos
- c 3 Hormonal and Biochemical Laboratory , University of Athens , Aretaieio Hospital, Athens , Greece
| | - Areti Augoulea
- b 2 2nd Department of Obstetrics and Gynecology , University of Athens , Aretaieio Hospital, Athens , Greece
| | - Andreas Alexandrou
- b 2 2nd Department of Obstetrics and Gynecology , University of Athens , Aretaieio Hospital, Athens , Greece
| | - Maria Creatsa
- b 2 2nd Department of Obstetrics and Gynecology , University of Athens , Aretaieio Hospital, Athens , Greece
| | - Georgios Tsivgoulis
- d 4 2nd Department of Neurology , University of Athens , Attiko Hospital, Athens , Greece
| | - Artemios Artemiades
- a 1 1st Department of Neurology , University of Athens , Aiginiteio Hospital, Athens , Greece
| | - Constantinos Panoulis
- b 2 2nd Department of Obstetrics and Gynecology , University of Athens , Aretaieio Hospital, Athens , Greece
| | - Irene Lambrinoudaki
- b 2 2nd Department of Obstetrics and Gynecology , University of Athens , Aretaieio Hospital, Athens , Greece
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Ghezzi A, Annovazzi P, Portaccio E, Cesari E, Amato MP. Current recommendations for multiple sclerosis treatment in pregnancy and puerperium. Expert Rev Clin Immunol 2014; 9:683-91; quiz 692. [PMID: 23899239 DOI: 10.1586/1744666x.2013.811046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
As multiple sclerosis (MS) typically starts at about 30 years of age, and is twice more frequent in females than in males, women with MS frequently face issues related to pregnancy and to the effects of medications commonly used in MS treatment. In this review, the authors provide and summarize literature data addressing the effect of MS and its treatments on pregnancy, delivery, postpartum and conception. There is a strong evidence that relapses are fewer during pregnancy but more frequent during postpartum, and that IFN-β and glatiramer acetate do not expose patients and their babies to relevant adverse events; nevertheless, these drugs should be discontinued during pregnancy and before conception. However, if their preventive withdrawal exposes patients to a high risk of disease activity, these medications could be continued until proven conception. Little information is available on the effect of natalizumab and fingolimod.
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Affiliation(s)
- Angelo Ghezzi
- UO Neurologia 2 - Centro Studi Sclerosi Multipla, Ospedale di Gallarate, Via Pastori 4, 21013 Gallarate, Italy.
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Abstract
PURPOSE OF REVIEW This article reviews the current understanding of the interactions between multiple sclerosis (MS) and pregnancy, and implications for reproductive counseling. This is a key topic in MS because the typical patient is a young woman of childbearing age. RECENT FINDINGS It has been known for some time that MS disease activity markedly reduces during the last trimester of pregnancy, then markedly increases in the 3 months postpartum before returning to the prepregnancy baseline. High relapse rate or disability before pregnancy, as well as relapse during pregnancy, have been associated with increased risk for postpartum attacks. Recent data continue to support the conclusion that long-term disease progression is not worsened (and may actually be lessened) with pregnancy in patients with relapsing MS; the data are not so clear for those with progressive MS. Among the MS disease-modifying therapies, the only one that requires contraception use by men is the new oral agent teriflunomide, because the drug is present in semen. It is reassuring that, to date, no human teratogenic effects have been documented for any of the MS disease-modifying therapies. SUMMARY Pregnancy has a profound effect on MS disease activity. Identification of the responsible mechanisms for this effect should lead to new disease insights and therapeutic strategies.
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Abstract
PURPOSE OF REVIEW This review discusses evaluation and treatment of neuro-ophthalmic disorders in the pregnant patient. RECENT FINDINGS Any neuro-ophthalmic abnormality seen in nonpregnant women can be seen in pregnant women. Pregnancy-specific complications (preeclampsia and eclampsia) cause visual symptoms and can affect the entire visual axis. SUMMARY Appropriate evaluation and examination is important to preserve the health and vision of the mother and prevent complications in the fetus. Evaluation should proceed in the same way for a pregnant patient as it would for a nonpregnant patient, with few exceptions. Treatment decisions may be influenced by stage of pregnancy.
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Abstract
Pregnancy creates alterations in maternal physiology which predispose to unique neurologic disorders. Pre-eclampsia, eclampsia, certain types of ischemic and hemorrhagic stroke, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and thunderclap headache all appear to share a common origin from vascular endothelial dysfunction, with overlapping clinical presentations. Multiple sclerosis often improves during pregnancy. Compression mononeuropathies may occur in the extremities. Myasthenia gravis may affect second stage labor. Various inflammatory peripheral neuropathies, dystrophies, myopathies may occur during pregnancy. The safety of specific immune suppressants is reviewed. Epilepsy does not have a significant effect upon the course of pregnancy, albeit there is a modest increase in the need for cesarean section. Certain antiepileptic drugs may produce fetal malformations, most notably valproic acid. Brain tumors are rare during pregnancy, but may increase in size due to activation of hormonal receptors on tumor cells surfaces, water retention, and engorged blood vessels.
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Affiliation(s)
- H Steven Block
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - José Biller
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA.
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Sempere AP, Berenguer-Ruiz L, Feliu-Rey E. Rebound of disease activity during pregnancy after withdrawal of fingolimod. Eur J Neurol 2013; 20:e109-10. [DOI: 10.1111/ene.12195] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 04/15/2013] [Indexed: 11/28/2022]
Affiliation(s)
- A. P. Sempere
- Department of Neurology; Hospital General Universitario de Alicante; Alicante; Spain
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