Histo-topographic distribution of acute inflammation of the human umbilical cord

The Molecular and Histopathological Assessment of Inflammatory Status in Very and Extremely Premature Infants: A Prospective Study

Prematurity comes with a varying range of complications, implying a high prevalence of complications and mortality and depending on the severity of prematurity and the sustained inflammation among these infants, which recently sparked an important scientific interest. The primary objective of this prospective study was to establish the degree of inflammation in very (VPIs) and extremely preterm infants (EPIs) in association with the histology findings of the umbilical cord (UC), while the secondary objective was to study the inflammatory markers in the neonates' blood as predictors of fetal inflammatory response (FIR). A total of thirty neonates were analyzed, ten of them being born extremely premature (<28 weeks of gestation) and twenty very premature (28-32 weeks of gestation). The EPIs had considerably higher levels of IL-6 at birth than VPIs (638.2 pg/mL vs. 151.1 pg/mL). The CRP levels at delivery did not vary substantially across groups; however, after days, the EPIs had significantly higher CRP levels (11.0 mg/dL vs. 7.2 mg/dL). In contrast, the LDH was considerably higher in the extremely preterm infants at birth and four days after birth. Surprisingly, the proportions of infants with pathologically increased inflammatory markers did not differ between the EPIs and VPIs. The LDH increased considerably in both groups, although the CRP levels increased exclusively among the VPIs. The stage of inflammation in the UC did not vary substantially between the EPIs and VPIs. The majority of infants were identified with Stage 0 UC inflammation (40% in EPI vs. 55% in VPIs). There was a substantial correlation link between gestational age and newborn weight and a significant inverse correlation among gestational age and IL-6 and LDH levels. There was a strong negative association between weight and IL-6 (rho = -0.349) and LDH (rho = -0.261). The stage of the UC inflammation demonstrated a statistically significant direct connection with IL-6 (rho = 0.461) and LDH (rho = 0.293), but none with the CRP. Further studies involving a bigger population size of preterm newborns are required to validate the findings and analyze more inflammatory markers, while prediction models on inflammatory markers that are measured expectantly, before the onset of preterm labor, need to be created.

Changing Laboratory Practice for Early Detection of a Fetal Inflammatory Response: A Contemporary Approach

Neonates born with the fetal inflammatory response (FIR) are at risk of complications such as early-onset neonatal sepsis, meningitis, and pneumonia. Providing an early histopathological diagnosis of FIR is important to guide management but can be a challenge in busy laboratories. This is a retrospective cross-sectional study over a four-month duration recruiting all placental cases with histological chorioamnionitis in our institution. The diagnostic performance of the umbilical cord (UC) section in identifying FIR, relative to the corresponding subsequent placental sections, was assessed. Clinical predictors of umbilical cord FIR were also investigated. A total of 390 UC sections were analyzed, of which 206 (52.8%) were found positive for FIR: 111 cases (53.9%) stage 1, 87 (42.2%) stage 2, and 8 (3.9%) stage 3. Our data revealed a good diagnostic sensitivity, specificity, positive predictive value, and accuracy of 76.2% (95%CI: 68.6-82.7%), 82.4% (95%CI: 65.5-93.2%), 95.0% (95%CI: 90.2-97.6%), and 77.3% (95%CI: 70.6-83.1%) respectively, in cases when clinical chorioamnionitis, fever and/or prolonged rupture of membrane (PROM) were suspected, with the area under the curve of 0.793. A maternal inflammatory response (MIR) was correlated with FIR (p < 0.001). Multivariate logistic regression analysis indicated that the higher the gestational age, clinical suspicion of chorioamnionitis, fever, and/or PROM, and the higher the stage of MIR significantly increased the odds of FIR (p < 0.001). UC section diagnosis of FIR is reasonably accurate in cases with clinical chorioamnionitis, fever, and/or PROM. Changing current laboratory practice to rapid processing of UC ahead of the rest of the other placental sections can be recommended in busy pathology departments.

Loss of CXC-Chemokine Receptor 1 Expression in Chorioamnionitis Is Associated with Adverse Perinatal Outcomes

Background: Chorioamnionitis complicates about 1−5% of deliveries at term and causes about one-third of stillbirths. CXC-chemokine receptor 1 (CXCR1) binds IL-8 with high affinity and regulates neutrophil recruitment. We aimed to determine the immunoexpression of CXCR1 in placentas with chorioamnionitis, and its association with adverse perinatal outcomes. Methods: A total of 101 cases of chorioamnionitis and 32 cases of non-chorioamnionitis were recruited over a period of 2 years. CXCR1 immunohistochemistry was performed, and its immunoexpression in placentas was evaluated. The adverse perinatal outcomes included intrauterine death, poor APGAR score, early neonatal death, and respiratory complications. Results: Seventeen cases (17/101, 16.8%) with chorioamnionitis presented as preterm deliveries. Lung complications were more common in mothers who were >35 years (p = 0.003) and with a higher stage in the foetal inflammatory response (p = 0.03). Notably, 24 cases (23.8%) of histological chorioamnionitis were not detected clinically. Interestingly, the loss of CXCR1 immunoexpression in the umbilical cord endothelial cells (UCECs) was significantly associated with foetal death (p = 0.009). Conclusion: The loss of CXCR1 expression in UCECs was significantly associated with an increased risk of adverse perinatal outcomes and could be used as a biomarker to predict adverse perinatal outcomes in chorioamnionitis. Further study is warranted to study the pathophysiology involved in the failure of CXCR1 expression in these cells.

Clinically relevant umbilical cord inflammation identified based on CD15-associated vasculitis patterning

INTRODUCTION

Acute funisitis, a granulocyte-related inflammation of the umbilical cord, is associated with chorioamnionitis and perinatal adverse events. However, there is no efficient procedure for detecting clinically relevant umbilical cord inflammation. The objective of this study was to identify such inflammation, based on immunohistochemical assessment of umbilical cord vasculitis patterns.

METHODS

Accordingly, 261 cases were retrieved from a single medical institute. Using the well-established granulocyte marker CD15, we developed a five-tier umbilical cord inflammation-scoring system. Additionally, previous morphological assessments from pathological reports were compared to the immunohistochemical findings.

RESULTS

Analysis of results based on our new scoring system revealed that severe umbilical phlebitis (score 3) was significantly associated with maternal inflammatory response and that severe umbilical arteriophlebitis (score 4) was correlated with low umbilical arterial blood pH, a feature linked to fetal mortality and morbidity. These results corresponded with and were validated by the morphology-based assessments. Additionally, immunohistochemical analysis revealed the clinical and pathological relevance of vitelline vasculitis, a recently proposed condition. We found that analyzing three umbilical cord sections enabled superior detection of severe umbilical vasculitis than analyzing two sections. However, whether these sections were sampled from multiple distant sites or a single localized site did not significantly affect the detection of clinically relevant inflammation.

DISCUSSION

CD15 immunohistochemistry is a potent tool for observing the patterns of clinically relevant umbilical vasculitis, especially in cases that were indeterminate according to morphology alone. Sampling three umbilical cord sections was an efficient procedure for addressing the spatial heterogeneity of umbilical cord inflammation. CD15 immunohistochemistry is a potent tool for observing the patterns of clinically relevant umbilical vasculitis, especially in cases that were indeterminate according to morphology alone. Sampling three umbilical cord sections was an efficient procedure for addressing the spatial heterogeneity of umbilical cord inflammation.

10 cases of umbilical cord thrombosis in the third trimester

BACKGROUND

Thrombosis of umbilical vessels is a rare occurrence that is difficult to detect during routine antenatal examinations but can lead to poor perinatal outcomes.

OBJECTIVE

The aim of this study is to examine the association between meaningful clinical manifestations and features associated with thrombosis of umbilical vessels, and to evaluate optimal management options.

METHODS

A retrospective study of umbilical cord thrombi cases enrolled between 2015-2019 was carried out. Data were analyzed from the medical archives where the diagnosis of all cases was established by histopathology.

RESULTS

Gross examination reported additional cord abnormalities (7/10), including the irregular length of the umbilical cord, narrowed cord with hyper-coiling, swollen cord with deficiency of Wharton's jelly, placenta velamentous and umbilical infarction. Pathological examination accounted for 10 cases of umbilical cord thrombosis including umbilical artery embolism (3/10), umbilical vein thrombi (5/10) and funisitis (2/10). Clinical findings depicted that the chief complaint was decreased fetal movement companied by nonreactive NST tests (5/10). With the exception of two stillbirths, the remaining pregnancies (8/10) were terminated by cesarean section. All neonates are alive, including one VLBW and three LBW cases.

CONCLUSION

We have observed that umbilical structural dysplasia, maternal coagulation disorder, vascular endothelial injury and elevated blood glucose may lead to the formation of thrombosis. Focus on specific signs during a prenatal ultrasound, EFM monitoring and counting fetal movements can help in early identification of umbilical cord thrombi. Our results support the more effective approach of emergency cesarean section during the third trimester.

Histopathology of the fetal inflammatory response to intra-amniotic pathogens

Obstetric endorsement of the utility of placental histologic examination remains infrequent, especially from obstetricians who do not have a placental pathologist as part of their own local clinical care team. Placental pathologic examinations are viewed as useless if they do not provide answers to urgent clinical questions. Increasingly, however, it is appreciated that while placental analysis should be considered with regard to its longer term value; results can assess lifelong risks of a wide range of diseases that have been tied to prenatal exposures (e.g., [1]), including distinguishing sex-specific differences in those risks. (e.g., [2]) This review will focus solely on acute fetal (?) inflammation, more specifically, the fetal neutrophil responses in umbilical cord, chorionic plate vessels and to some degree, the fetal system as a whole. This histologic fetal inflammatory response is often the most readily accessible aspect of "FIR" piece of FIRS (the fetal inflammatory response syndrome). Some researchers have defined FIRS by a combination of both cytokine (especially IL-6) levels and the histopathologic FIR (Musilova et al., 2018) [3]. As we and others have noted, many histology based FIR cases, even those associated with neurodevelopmental outcomes such as cerebral palsy, are clinically silent.(e.g., [4]) Current clinical diagnostic criteria may have high specificity as they are very good at identifying non-FIR cases. However, that high specificity is coupled with very low specificity, identifying only 10% of FIR (Doty et al., 2018 Jul) [5]. Our aim is to provide a conceptual framework for the readers of the journal to better understand how to answer the following questions: What is a neutrophil and how is it important in FIR? What is the differential diagnosis for histologic FIR? How long has there been FIR? What secondary processes may have been recruited (and when) to contribute to the final pathology and pathophysiology of the given pregnancy?

The fetal inflammatory response syndrome: the origins of a concept, pathophysiology, diagnosis, and obstetrical implications

The fetus can deploy a local or systemic inflammatory response when exposed to microorganisms or, alternatively, to non-infection-related stimuli (e.g., danger signals or alarmins). The term "Fetal Inflammatory Response Syndrome" (FIRS) was coined to describe a condition characterized by evidence of a systemic inflammatory response, frequently a result of the activation of the innate limb of the immune response. FIRS can be diagnosed by an increased concentration of umbilical cord plasma or serum acute phase reactants such as C-reactive protein or cytokines (e.g., interleukin-6). Pathologic evidence of a systemic fetal inflammatory response indicates the presence of funisitis or chorionic vasculitis. FIRS was first described in patients at risk for intraamniotic infection who presented preterm labor with intact membranes or preterm prelabor rupture of the membranes. However, FIRS can also be observed in patients with sterile intra-amniotic inflammation, alloimmunization (e.g., Rh disease), and active autoimmune disorders. Neonates born with FIRS have a higher rate of complications, such as early-onset neonatal sepsis, intraventricular hemorrhage, periventricular leukomalacia, and death, than those born without FIRS. Survivors are at risk for long-term sequelae that may include bronchopulmonary dysplasia, neurodevelopmental disorders, such as cerebral palsy, retinopathy of prematurity, and sensorineuronal hearing loss. Experimental FIRS can be induced by intra-amniotic administration of bacteria, microbial products (such as endotoxin), or inflammatory cytokines (such as interleukin-1), and animal models have provided important insights about the mechanisms responsible for multiple organ involvement and dysfunction. A systemic fetal inflammatory response is thought to be adaptive, but, on occasion, may become dysregulated whereby a fetal cytokine storm ensues and can lead to multiple organ dysfunction and even fetal death if delivery does not occur ("rescued by birth"). Thus, the onset of preterm labor in this context can be considered to have survival value. The evidence so far suggests that FIRS may compound the effects of immaturity and neonatal inflammation, thus increasing the risk of neonatal complications and long-term morbidity. Modulation of a dysregulated fetal inflammatory response by the administration of antimicrobial agents, anti-inflammatory agents, or cell-based therapy holds promise to reduce infant morbidity and mortality.

Fetal exposure to maternal inflammation interrupts murine intestinal development and increases susceptibility to neonatal intestinal injury

Fetal exposure to chorioamnionitis can impact the outcomes of the developing fetus both at the time of birth and in the subsequent neonatal period. Infants exposed to chorioamnionitis have a higher incidence of gastrointestinal (GI) pathology, including necrotizing enterocolitis (NEC); however, the mechanism remains undefined. To simulate the fetal exposure to maternal inflammation (FEMI) induced by chorioamnionitis, pregnant mice (C57BL/6J, IL-6 ^-/-, RAG ^-/- or TNFR1 ^-/-) were injected intraperitoneally on embryonic day (E)15.5 with lipopolysaccharide (LPS; 100 µg/kg body weight). Pups were delivered at term, and reared to postnatal day (P)0, P7, P14, P28 or P56. Serum and intestinal tissue samples were collected to quantify growth, inflammatory markers, histological intestinal injury, and goblet and Paneth cells. To determine whether FEMI increased subsequent susceptibility to intestinal injury, a secondary dose of LPS (100 µg/kg body weight) was given on P5, prior to tissue harvesting on P7. FEMI had no effect on growth of the offspring or their small intestine. FEMI significantly decreased both goblet and Paneth cell numbers while simultaneously increasing serum levels of IL-1β, IL-10, KC/GRO (CXCL1 and CXCL2), TNF and IL-6. These alterations were IL-6 dependent and, importantly, increased susceptibility to LPS-induced intestinal injury later in life. Our data show that FEMI impairs normal intestinal development by decreasing components of innate immunity and simultaneously increasing markers of inflammation. These changes increase susceptibility to intestinal injury later in life and provide novel mechanistic data to potentially explain why preterm infants exposed to chorioamnionitis prior to birth have a higher incidence of NEC and other GI disorders.

Preterm labor and preterm premature rupture of membranes have a different pattern in the involved compartments of acute histologoic chorioamnionitis and/or funisitis: Patho-physiologic implication related to different clinical manifestations

It is unknown whether histo-topographic findings about the involved compartments (i.e., choriodecidua, amnion, chorionic-plate) of acute-histologic chorioamnionitis (acute-HCA) and/or funisitis according to the presence or absence of intra-amniotic inflammation (IAI) and/or fetal inflammatory response syndrome (FIRS) are different between preterm labor and intact membranes (PTL) and preterm premature rupture of membranes (preterm-PROM). The involved compartments of acute-HCA and/or funisitis were examined in 161 singleton preterm-births (<34 weeks) due to PTL (n = 88) and preterm-PROM (n = 73). The study-population was divided into IAI(-)/FIRS(-), IAI(+)/FIRS(-), and IAI(+)/FIRS(+) groups according to the presence or absence of IAI (amniotic-fluid MMP-8 ≥ 23 ng/ml) and/or FIRS (umbilical-cord plasma CRP ≥ 200 ng/ml). Histological inflammation was not detected in any-compartment except choriodecidua in IAI(-)/FIRS(-) group with PTL while inflammation appeared in all-compartment0s (choriodeciduitis-46.2 %; amnionitis-23.1 %; funisitis-30.8 %; chorionic-plate inflammation-7.7 %) in IAI(-)/FIRS(-) group with preterm-PROM. IAI(+)/FIRS(-) group had a significantly higher frequency of inflammation in each-compartment than IAI(-)/FIRS(-) group in PTL (each-for P < 0.01), but not preterm-PROM (each-for P > 0.1). However, IAI(+)/FIRS(+) group had a significantly higher rate of inflammation in each compartment than IAI(+)/FIRS(-) group in both PTL and preterm-PROM (each-for P < 0.05). We first demonstrated that PTL and preterm-PROM had a different pattern in the involved compartments of acute-HCA and/or funisitis in the IAI(-)/FIRS(--) group and in the change of involved compartments from IAI(-)/FIRS(-) to IAI(+)/FIRS(-).

Acute chorioamnionitis and funisitis: definition, pathologic features, and clinical significance

Acute inflammatory lesions of the placenta consist of diffuse infiltration of neutrophils at different sites in the organ. These lesions include acute chorioamnionitis, funisitis, and chorionic vasculitis and represent a host response (maternal or fetal) to a chemotactic gradient in the amniotic cavity. While acute chorioamnionitis is evidence of a maternal host response, funisitis and chorionic vasculitis represent fetal inflammatory responses. Intraamniotic infection generally has been considered to be the cause of acute chorioamnionitis and funisitis; however, recent evidence indicates that "sterile" intraamniotic inflammation, which occurs in the absence of demonstrable microorganisms induced by "danger signals," is frequently associated with these lesions. In the context of intraamniotic infection, chemokines (such as interleukin-8 and granulocyte chemotactic protein) establish a gradient that favors the migration of neutrophils from the maternal or fetal circulation into the chorioamniotic membranes or umbilical cord, respectively. Danger signals that are released during the course of cellular stress or cell death can also induce the release of neutrophil chemokines. The prevalence of chorioamnionitis is a function of gestational age at birth, and present in 3-5% of term placentas and in 94% of placentas delivered at 21-24 weeks of gestation. The frequency is higher in patients with spontaneous labor, preterm labor, clinical chorioamnionitis (preterm or term), or ruptured membranes. Funisitis and chorionic vasculitis are the hallmarks of the fetal inflammatory response syndrome, a condition characterized by an elevation in the fetal plasma concentration of interleukin-6, and associated with the impending onset of preterm labor, a higher rate of neonatal morbidity (after adjustment for gestational age), and multiorgan fetal involvement. This syndrome is the counterpart of the systemic inflammatory response syndrome in adults: a risk factor for short- and long-term complications (ie, sterile inflammation in fetuses, neonatal sepsis, bronchopulmonary dysplasia, periventricular leukomalacia, and cerebral palsy). This article reviews the definition, pathogenesis, grading and staging, and clinical significance of the most common lesions in placental disease. Illustrations of the lesions and diagrams of the mechanisms of disease are provided.

Inflammatory response in acute chorioamnionitis

Acute chorioamnionitis is the principal antecedent of premature birth and an important contributor to specific neonatal and other complications that may extend throughout subsequent life. A large number of studies have addressed surrogate markers of in-utero inflammation including cytokines, chemokines, pathogen-associated molecular patterns, and elicited host proteins. However, chorioamnionitis means inflammation occurring within the chorioamnion and the only practical direct measure available to assess this finding in most placentas is histopathology. The maternal and fetal inflammatory response to the presence of organisms within the placental membranes, so-called histologic chorioamnionitis, is the focus of this review. The issues addressed are the nature and origin of the eliciting antigen, mode of spread to the placenta, general characteristics of placental immunity, and a specific characterization of the spectrum of pathologic lesions observed in placentas with membrane infection.

Eosinophilic/T-cell chorionic vasculitis: a clinicopathologic and immunohistochemical study of 51 cases

We report 51 placentas diagnosed with eosinophilic/T-cell chorionic vasculitis (E/TCV), an unusual form of chorionic vasculitis characterized by an infiltrate composed predominantly of CD3+ T cells and eosinophils. The placentas were all 3rd trimester, with 48 (94.1%) being term. Forty-seven (92.2%) were singleton placentas, and the remaining 4 were twins. The E/TCV was limited to 1 chorionic surface vessel in 40 (78.4%) and involved 50% or less of the vessel circumference in 30 (58.8%) placentas. The inflammation faced the intervillous space in 12 (23.5%) and the amniotic cavity in 8 (15.7%) and had no distinct predominant direction in the remaining 31 (60.8%) placentas. Twelve (25.5%) placentas showed mural thrombi or intramural fibrin in association with the E/TCV. One hundred six term singleton placentas were selected as the control group, and the 47 singleton placentas with E/TCV made up the study group for comparison of demographic and histopathologic features. Villitis of unknown etiology was identified more frequently in study group placentas (20 [42.6%]) compared with control group placentas (14 [13.2%]) (P < 0.001). Vascular changes of fetal vascular thrombo-occlusive disease were identified away from the E/TCV more frequently in study group placentas (8 [17.0%]) compared with control group placentas (4 [3.8%]) (P  =  0.008). There were no significant differences in the frequencies of other placental lesions studied, including acute inflammatory lesions and lesions related to maternal underperfusion. There were no significant differences in maternal age, race, parity, birth weight, allergy history, blood type, or medication use.

Funisitis and chorionic vasculitis: relation to chorioamnionitis, timing and scoring

Five hundred consecutive cases with histologic chorioamnionitis and umbilical cord inflammation were analyzed to develop a staging system for funisitis and to correlate stage of funisitis with stage of chorioamnionitis in order to estimate the timing of various stages of funisitis. Funisitis progresses through venous involvement (with or without Wharton's jelly inflammation) to arterial involvement without Wharton's jelly and then full involvement of all three vessels and surrounding Wharton's jelly. Arterial involvement and full funisitis are strongly associated with stage III/IV chorioamnionitis, and imply a significant time interval following the onset of amniotic cavity inflammation.

Fetal inflammatory response is often present at early stages of intra-amniotic infection, and its distribution along cord is variable

This study investigates the hypotheses that (1) the fetal inflammatory response to intra-amniotic infection can occur in early stages of maternal inflammatory response and (2) a difference in early cord inflammation exists at different sites in the cord. Placentas accessioned in our department over a 4-year period with a differential in umbilical vessel inflammation between proximal and distal sections were evaluated for cord inflammation using a 0 to 4 graded scale. Cases were also evaluated for acute chorionic vasculitis and extent of maternal inflammatory response. Of 5566 placentas, 1004 (18%) had some degree of cord inflammation; 120 (12%) had a differential in inflammation between the 2 cord sites. Greater cord inflammation was divided almost equally between proximal (59) and distal (61) sections. Twenty-two cases had 1 or both arteries involved in 1 cord section only. The proximal section had the greater degree of inflammation in 21 (95%) of these cases. Early or no maternal inflammatory response was seen in 63 of 120 cases (52%). Acute chorionic vasculitis was identified in 57 of 106 cases (54%) with at least 2 chorionic vessels present. Fetal inflammatory response can be seen in early amniotic infection, occasionally without finding maternal inflammatory response. The absence of differences in cord vein inflammation depending on cord site and the finding that arteritis occurs close to the placental cord insertion site suggest that cord vessel blood flow dynamics play a role in neutrophil margination. At least 2 cord sections representing proximal and distal sites are recommended to exclude fetal inflammatory response.

Simulation of intra-amniotic infection and the fetal inflammatory response in a novel ex-vivo human umbilical cord perfusion model

OBJECTIVE

We aimed to design and test an ex-vivo human umbilical cord (HUC) perfusion model simulating a fetal inflammatory response (FIR) during intra-amniotic infection.

STUDY DESIGN

A 2-chamber model was designed to accommodate 2 pieces of umbilical cord. Cord perfusion was performed with placental blood. Intra-amniotic exposure to infectious organisms was simulated by adding lipopolysaccharide to the artificial amniotic fluid (AAF) compartment. As a measure of inflammatory response, we used interleukin 8 (IL-8) concentration in AAF and plasma by enzyme-linked immunosorbent assay (ELISA). Wilcoxon signed rank test was used for statistical analysis.

RESULTS

We established a stable physiological setup. Results revealed significantly elevated plasma IL-8 concentrations (n = 6, P < .05) in the blood compartment of umbilical cords exposed to lipopolysaccharide. Concentrations within AAF were not significantly elevated (n = 6, P = .3095).

CONCLUSION

Simulation of a FIR in an ex-vivo model of HUC perfusion under physiological conditions is possible. Further work is necessary to establish histological funisitis.

Regulation of arterial-venous differences in tumor necrosis factor responsiveness of endothelial cells by anatomic context

We analyzed tumor necrosis factor (TNF) responses of human umbilical artery and vein endothelial cells (HUAECs and HUVECs) in organ and cell culture. In organ culture, TNF induced expression of E-selectin, VCAM-1, and ICAM-1 on HUVECs but only ICAM-1 on HUAECs. Activation of nuclear factor-kappaB, c-jun, and ATF2 by TNF was comparable in HUAECs and HUVECs, whereas binding of transcription factors and p300 co-activator to the E-selectin enhancer was lower in HUAECs compared to HUVECs. In cell culture, HUAECs rapidly acquired inducible E-selectin and VCAM-1 whereas ICAM-1 inducibility decreased. Culture of HUVECs rapidly decreased TNF responses of all three genes. By 72 hours in cell culture, TNF-treated HUVECs and HUAECs showed comparable adhesion molecule induction and transcription factor binding to the E-selectin enhancer. Freshly isolated HUAECs expressed higher levels of Kruppel-like factor 2 (KLF2) than HUVECs, consistent with greater KLF2 induction by arterial levels of shear stress in vitro. KLF2 expression decreased rapidly in both cell types during culture. Transduction of HUVECs with KLF2 reduced TNF-mediated induction of E-selectin and VCAM-1 while increasing ICAM-1 induction and reduced transcription factor/co-activator binding to the E-selectin enhancer. In conclusion, the differential responses of HUAECs and HUVECs to TNF in organ culture correlate with transcription factor/co-activator binding to DNA and converge during cell culture. Flow-induced expression of KLF2 contributes to the in situ responses of HUAECs but not of HUVECs.

Proteomic biomarkers of intra-amniotic inflammation: relationship with funisitis and early-onset sepsis in the premature neonate

Our goal was to determine the relationship between 4 amniotic fluid (AF) proteomic biomarkers (human neutrophil defensins 2 and 1, calgranulins C and A) characteristic of intra-amniotic inflammation, and funisitis and early-onset sepsis in premature neonates. The mass restricted (MR) score was generated from AF obtained from women in preterm labor (n = 123). The MR score ranged from 0-4 (none to all biomarkers present). Funisitis was graded histologically and interpreted in relation to the MR scores. Neonates (n = 97) were evaluated for early-onset sepsis. There was significant correlation between the severity of AF inflammation and the presence (53/123) and grades of funisitis (p < 0.001). Funisitis occurred independently of the amniocentesis-to-delivery interval or status of the membranes and was best predicted by an MR score 3-4 and an earlier gestational age (GA) at delivery. Neonates born to women with an MR score 3-4 had an increased incidence of suspected/confirmed sepsis, even after adjusting for GA at birth. Calgranulin C had the highest association with clinically significant funisitis, while calgranulin A had the strongest association with early-onset sepsis. To conclude, AF proteomic analysis shows that women with MR scores 3-4 are more likely to have histologic funisitis, and deliver neonates with early-onset sepsis.

Dermatitis as a component of the fetal inflammatory response syndrome is associated with activation of Toll-like receptors in epidermal keratinocytes

Aims

Microbial invasion of the amniotic cavity (MIAC) elicits a fetal inflammatory response such as funisitis and chorionic vasculitis. However, little is known about the changes of fetal skin during MIAC. Toll-like receptors recognize microbial products and initiate an immune response. The aims of this study were to examine histopathological features of fetal skin exposed to MIAC and to assess the changes in Toll-like receptor (TLR)-2 and TLR-4 expression.

Methods and results

Skin samples were obtained from fetal autopsies (n = 12). The cases were classified according to the presence (n = 8) or absence (n = 4) of acute chorioamnionitis and analysed by immunohistochemistry using a panel of antibodies. Leucocytic infiltrates into the superficial dermis were observed in cases with chorioamnionitis; the majority of inflammatory cells were neutrophils, lymphocytes and histiocytes. TLR-2 immunoreactivity in the skin was stronger in fetuses with chorioamnionitis than in those without this condition. However, immunoreactivity of TLR-4 in the fetal skin was constitutively expressed, regardless of the presence or absence of chorioamnionitis.

Conclusions

This study demonstrates for the first time that fetal dermatitis can be detected and is part of the fetal inflammatory response syndrome (FIRS). We propose that this ‘FIRS-associated fetal dermatitis’ is a fetal counterpart of chorioamnionitis.

Inflammatory responses in the placenta and umbilical cord

Histopathological examination of the placenta is the gold standard for evaluating antenatal inflammatory processes that might influence fetal development. Histological chorioamnionitis develops through a well-characterised stereotyped progression of maternal and fetal cellular stages that vary from patient to patient and are amenable to quantification. Increases in the intensity of these responses and their gradual transformation into a chronic phase are important variables that can adversely affect fetal physiology. Under recognised placental inflammatory lesions affecting the decidua, placental villi and fetal vessels are also potentially informative factors that should be taken into account in the studies of adverse pregnancy outcomes. This review summarises the relationships between aetiology, intensity, duration, characteristics and site of histological placental inflammation and suggests how these data may help to better understand the antenatal environment.

Chorionic plate vessels as an origin of amniotic fluid neutrophils

The present study was conducted to investigate the potential anatomical source of amniotic fluid neutrophils. Microdissection of neutrophils from the chorioamnion of the fetal membranes and the amnion of the chorionic plates of 10 preterm placentas with acute chorioamnionitis was performed and the genotypes of the neutrophils were compared with those of the mother and fetus using polymerase chain reaction of nine autosomal STR loci. In separate analyses, we reviewed eight cases of fetal autopsies with increased amniotic fluid neutrophils for the presence of neutrophils in the alveoli, and also analyzed the relationship between the amniotic fluid white blood cell (WBC) count and the histological pattern of placental inflammation. The genotypes of all of the neutrophils found in the chorioamnion of the fetal membrane matched those of the mother (n = 10). The genotypes of neutrophils found in the chorionic plate were of mixed maternal and fetal origin (n = 4). In the autopsy series of the fetuses with amniotic fluid WBC (n = 8), only five cases showed neutrophils in the alveolar space, while all the placentas had chorioamnionitis. There was no significant difference in amniotic fluid WBC count between the cases with or without acute membranitis, while among the cases with placental inflammation, those with inflammation of the chorionic plate had a significantly higher amniotic fluid WBC count than both the membranitis-only cases (P < 0.001) and the membranitis and funisitis cases (P < 0.05). These results imply that fetal vasculature at the chorionic plate is the main source of amniotic fluid neutrophils, especially in the cases without funisitis.