The molecular mechanisms of term and preterm labor: recent progress and clinical implications

Phenanthroline relaxes uterine contractions induced by diverse contractile agents by decreasing cytosolic calcium concentration

Uterine contractions during labor and preterm labor are influenced by a complex interplay of factors, including hormones and inflammatory mediators. This complexity may contribute to the limited efficacy of current tocolytics for preterm labor, a significant challenge in obstetrics with 15 million cases annually and approximately 1 million resulting deaths worldwide. We have previously shown that the myometrium expresses bitter taste receptors (TAS2Rs) and that their activation leads to uterine relaxation. Here, we investigated whether the selective TAS2R5 agonist phenanthroline can induce relaxation across a spectrum of human uterine contractions and whether the underlying mechanism involves changes in intracellular Ca2+ signaling. We performed experiments using samples from pregnant women undergoing scheduled cesarean delivery, assessing responses to various inflammatory mediators and oxytocin with and without phenanthroline. Our results showed that phenanthroline concentration-dependently inhibited contractions induced by PGF2α, U46619, 5-HT, endothelin-1 and oxytocin. Furthermore, in hTERT-infected human myometrial cells exposed to uterotonics, phenanthroline effectively suppressed the increase in intracellular Ca2+ concentration induced by PGF2α, U46619, oxytocin, and endothelin-1. These results suggest that the selective TAS2R5 agonist may not only significantly reduce uterine contractions but also decrease intracellular Ca2+ levels. This study highlights the potential development of TAS2R5 agonists as a new class of uterine relaxants, providing a novel avenue for improving the management of preterm labor.

Progesterone receptor isoform B regulates the Oxtr-Plcl2-Trpc3 pathway to suppress uterine contractility

Uterine contractile dysfunction leads to pregnancy complications such as preterm birth and labor dystocia. In humans, it is hypothesized that progesterone receptor isoform PGR-B promotes a relaxed state of the myometrium, and PGR-A facilitates uterine contraction. This hypothesis was tested in vivo using transgenic mouse models that overexpress PGR-A or PGR-B in smooth muscle cells. Elevated PGR-B abundance results in a marked increase in gestational length compared to control mice (21.1 versus 19.1 d respectively, P < 0.05). In both ex vivo and in vivo experiments, PGR-B overexpression leads to prolonged labor, a significant decrease in uterine contractility, and a high incidence of labor dystocia. Conversely, PGR-A overexpression leads to an increase in uterine contractility without a change in gestational length. Uterine RNA sequencing at midpregnancy identified 1,174 isoform-specific downstream targets and 424 genes that are commonly regulated by both PGR isoforms. Gene signature analyses further reveal PGR-B for muscle relaxation and PGR-A being proinflammatory. Elevated PGR-B abundance reduces Oxtr and Trpc3 and increases Plcl2 expression, which manifests a genetic profile of compromised oxytocin signaling. Functionally, both endogenous PLCL2 and its paralog PLCL1 can attenuate uterine muscle cell contraction in a CRISPRa-based assay system. These findings provide in vivo support that PGR isoform levels determine distinct transcriptomic landscapes and pathways in myometrial function and labor, which may help further the understanding of abnormal uterine function in the clinical setting.

Heat stress during late gestation disrupts maternal microbial transmission with altered offspring's gut microbial colonization and serum metabolites in a pig model

Heat stress (HS) during gestation has been associated with negative outcomes, such as preterm birth or postnatal metabolic syndromes. The intestinal microbiota is a unique ecosystem playing an essential role in mediating the metabolism and health of mammals. Here we hypothesize late gestational HS alters maternal microbial transmission and structures offspring's intestinal microbiota and serum metabolic profiles. Our results show maternal HS alters bacterial β-diversity and composition in sows and their piglets. In the maternal intestine, genera Ruminococcaceae UCG-005, [Eubacterium] coprostanoligenes group and Halomonas are higher by HS (q < 0.05), whereas the populations of Streptococcus, Bacteroidales RF16 group_norank and Roseburia are decreased (q < 0.05). In the maternal vagina, HS mainly elevates the proportions of phylum Bacteroidetes and Fusobacteria (q < 0.05), whereas reduces the population of Clostridiales Family XI (q < 0.05). In the neonatal intestine, maternal HS promotes the population of Proteobacteria but reduces the relative abundance of Firmicutes (q < 0.05). Moreover, the core Operational taxonomic units (OTU) analysis indicates the proportions of Clostridium sensu stricto 1, Romboutsia and Turicibacter are decreased by maternal HS in the intestinal and vaginal co-transmission, whereas that of phylum Proteobacteria and Epsilonbacteraeota, such as Escherichia-Shigella, Klebsiella, Acinetobacter, and Comamonas are increased in both the intestinal and vaginal co-transmission and the vagina. Additionally, Aeromonas is the only genus that is transmitted from environmental sources. Lastly, we evaluate the importance of neonatal differential OTU for the differential serum metabolites. The results indicate Acinetobacter significantly contributes to the differences in the adrenocorticotropic hormone (ACTH) and glucose levels due to HS (P < 0.05). Further, Stenotrophomonas is the most important variable for Cholesterol, low-density lipoprotein (LDL), diamine oxidase (DAO), blood urea nitrogen (BUN) and 5-hydroxytryptamine (5-HT) (P < 0.10). Overall, our data provides evidence for the maternal HS in establishing the neonatal microbiota via affecting maternal transmission, which in turn affects the maintenance of metabolic health.

Fetal Membranes, Not a Mere Appendage of the Placenta, but a Critical Part of the Fetal-Maternal Interface Controlling Parturition

Fetal membranes (FMs) play a role in pregnancy maintenance and promoting parturition at term. The FMs are not just part of the placenta, structurally or functionally. Although attached to the placenta, the amnion has a separate embryologic origin, and the chorion deviates from the placenta by the first month of pregnancy. Other than immune protection, these FM functions are not those of the placenta. FM dysfunction is associated with and may cause adverse pregnancy outcomes. Ongoing research may identify biomarkers for pending preterm premature rupture of the FMs as well as therapeutic agents, to prevent it and resulting preterm birth.

Initiation of human parturition: signaling from senescent fetal tissues via extracellular vesicle mediated paracrine mechanism

A better understanding of the underlying mechanisms by which signals from the fetus initiate human parturition is required. Our recent findings support the core hypothesis that oxidative stress (OS) and cellular senescence of the fetal membranes (amnion and chorion) trigger human parturition. Fetal membrane cell senescence at term is a natural physiological response to OS that occurs as a result of increased metabolic demands by the maturing fetus. Fetal membrane senescence is affected by the activation of the p38 mitogen activated kinase-mediated pathway. Similarly, various risk factors of preterm labor and premature rupture of the membranes also cause OS-induced senescence. Data suggest that fetal cell senescence causes inflammatory senescence-associated secretory phenotype (SASP) release. Besides SASP, high mobility group box 1 and cell-free fetal telomere fragments translocate from the nucleus to the cytosol in senescent cells, where they represent damage-associated molecular pattern markers (DAMPs). In fetal membranes, both SASPs and DAMPs augment fetal cell senescence and an associated ‘sterile’ inflammatory reaction. In senescent cells, DAMPs are encapsulated in extracellular vesicles, specifically exosomes, which are 30–150 nm particles, and propagated to distant sites. Exosomes traffic from the fetus to the maternal side and cause labor-associated inflammatory changes in maternal uterine tissues. Thus, fetal membrane senescence and the inflammation generated from this process functions as a paracrine signaling system during parturition. A better understanding of the premature activation of these signals can provide insights into the mechanisms by which fetal signals initiate preterm parturition.

Group B streptococcus activates transcriptomic pathways related to premature birth in human extraplacental membranes in vitro

Streptococcus agalactiae (group B streptococcus [GBS]) infection in pregnant women is the leading cause of infectious neonatal morbidity and mortality in the United States. Although inflammation during infection has been associated with preterm birth, the contribution of GBS to preterm birth is less certain. Moreover, the early mechanisms by which GBS interacts with the gestational tissue to affect adverse pregnancy outcomes are poorly understood. We hypothesized that short-term GBS inoculation activates pathways related to inflammation and premature birth in human extraplacental membranes. We tested this hypothesis using GBS-inoculated human extraplacental membranes in vitro. In agreement with our hypothesis, a microarray-based transcriptomics analysis of gene expression changes in GBS-inoculated membranes revealed that GBS activated pathways related to inflammation and preterm birth with significant gene expression changes occurring as early as 4 h postinoculation. In addition, pathways related to DNA replication and repair were downregulated with GBS treatment. Conclusions based on our transcriptomics data were further supported by responses of prostaglandin E2 (PGE2), and matrix metalloproteinases 1 (MMP1) and 3 (MMP3), all of which are known to be involved in parturition and premature rupture of membranes. These results support our initial hypothesis and provide new information on molecular targets of GBS infection in human extraplacental membranes.

Cyclic AMP Effectors Regulate Myometrial Oxytocin Receptor Expression

The factors that initiate human labor are poorly understood. We have tested the hypothesis that a decline in cAMP/protein kinase A (PKA) function leads to the onset of labor. Initially, we identified myometrial cAMP/PKA-responsive genes (six up-regulated and five down-regulated genes) and assessed their expression in myometrial samples taken from different stages of pregnancy and labor. We found that the oxytocin receptor (OTR) was one of the cAMP-repressed genes, and, given the importance of OTR in the labor process, we studied the mechanisms involved in greater detail using small interfering RNA, chemical agonists, and antagonists of the cAMP effectors. We found that cAMP-repressed genes, including OTR, increased with the onset of labor. Our in vitro studies showed that cAMP acting via PKA reduced OTR expression but that in the absence of PKA, cAMP acts via exchange protein activated by cAMP (EPAC) to increase OTR expression. In early labor myometrial samples, PKA levels and activity declined and Epac1 levels increased, perhaps accounting for the increase in myometrial OTR mRNA and protein levels at this time. In vitro exposure of myometrial cells to stretch and IL-1β increased OTR levels and reduced basal and forskolin-stimulated cAMP and PKA activity, as judged by phospho-cAMP response element-binding protein levels, but neither stretch nor IL-1β had any effect on PKA or EPAC1 levels. In summary, there is a reduction in the activity of the cAMP/PKA pathway with the onset of human labor potentially playing a critical role in regulating OTR expression and the transition from myometrial quiescence to activation.

Human fetal membranes at term: Dead tissue or signalers of parturition?

Various endocrine, immune, and mechanical factors produced by feto-maternal compartments at term increase intrauterine inflammatory loads to induce labor. The role of fetal (placental) membranes (amniochorion) as providers of parturition signals has not been well investigated. Fetal membranes line the intrauterine cavity and grow with and protect the fetus. Fetal membranes exist as an entity between the mother and fetus and perform unique functions during pregnancy. Membranes undergo a telomere-dependent p38 MAPK-induced senescence and demonstrate a decline in functional and mechanical abilities at term, showing signs of aging. Fetal membrane senescence is also allied with completion of fetal maturation at term as the fetus readies for delivery, which may also indicate the end of independent life and longevity of fetal membranes as their functional role concludes. Fetal membrane senescence is accelerated at term because of oxidative stress and increased stretching. Senescent fetal membranes cells produce senescence-associated secretory phenotype (SASP-inflammation) and also release proinflammatory damage-associated molecular patterns (DAMPs), namely HMGB1 and cell-free fetal telomere fragments. In a feedback loop, SASP and DAMPs increase senescence and enhance the inflammatory load to promote labor. Membranes increase the inflammatory load to disrupt homeostatic balance to transition quiescent uterine tissues toward a labor phenotype. Therefore, along with other well-described labor-promoting signals, senescent fetal membranes may also contribute to human term parturition.

Chorioamniotic membrane senescence: a signal for parturition?

OBJECTIVE

Senescence is an important biological phenomenon involved in both physiologic and pathologic processes. We propose that chorioamniotic membrane senescence is a mechanism associated with human parturition. The present study was conducted to explore the association between senescence and normal term parturition by examining the morphologic and biochemical evidences in chorioamniotic membranes.

STUDY DESIGN

Chorioamniotic membranes were collected from normal term deliveries; group 1: term labor and group 2: term, not in labor. Senescence-related morphologic changes were determined by transmission electron microscopy and biochemical changes were studied by senescence-associated (SA) β-galactosidase staining. Amniotic fluid samples collected from both term labor and term not in labor were analyzed for 14 SA secretory phenotype (SASP) markers.

RESULTS

Morphologic evidence of cellular senescence (enlarged cells and organelles) and a higher number of SA β-galactosidase-stained amnion and chorion cells were observed in chorioamniotic membranes obtained from women in labor at term, when compared to term not in labor. The concentration of proinflammatory SASP markers (granulocyte macrophage colony-stimulating factor, interleukin-6 and -8) was significantly higher in the amniotic fluid of women in labor at term than women not in labor. In contrast, SASP factors that protect against cell death (eotaxin-1, soluble Fas ligand, osteoprotegerin, and intercellular adhesion molecule-1) were significantly lower in the amniotic fluid samples from term labor.

CONCLUSION

Morphologic and biochemical features of senescence were more frequent in chorioamniotic membranes from women who experienced term labor. Senescence of chorioamniotic membranes were also associated with amniotic fluid SASP markers.

Functional and morphological development of the womb throughout life

The uterus undergoes changes throughout a woman's life, beginning with her own embryonic development when she is still in the womb, commencing a monthly cycle at the onset of adulthood, and undergoing dramatic changes during pregnancy and parturition. The impact of preterm labour and other perinatal health problems is significant, both in human and financial terms; therefore the study of the physiological and regulatory changes which the uterus undergoes can be of enormous potential benefit. Here we briefly review the current state of knowledge, with an emphasis on the importance of changes in connectivity in the uterine smooth muscle cell network and on recent mathematical modelling work aimed at elucidating the role of spatial heterogeneity in this connected network.

Low abundance plasma proteins in labour

Every year, millions of births worldwide are complicated by prematurity or difficult post-term deliveries, resulting in a high incidence of perinatal mortality and morbidity. Our poor understanding of human parturition is a key reason for our inability to improve the management of preterm and post-term birth. In this study, we used proteomic techniques to look into protein changes in placental blood plasma obtained from women before or after spontaneous or induced labour, with vaginal or caesarean section deliveries. Our aim was to understand the basic mechanisms of human parturition regardless of whether the signals that trigger labour are of maternal and/or fetal origin. We found proteins from 33 genes with significantly altered expression profiles in relation to mode of labour and delivery. Most changes in labour occurred in proteins associated with ‘immune and defence responses’. Although the signal transduction and regulation of these pathways varied among modes of delivery, hepatocyte nuclear factor 1 homeobox A emerged as a shared protein in the mechanism of labour. Moreover, several apolipoproteins such as apolipoprotein A-IV and APOE were found to change with labour, and these changes were also confirmed in maternal plasma. This study has identified significant protein changes in placental intervillous plasma with labour and has revealed several pathways related to human parturition.

Immunolocalization of adipocytes and prostaglandin E2 and its four receptor proteins EP1, EP2, EP3, and EP4 in the caprine cervix during spontaneous term labor

The mechanisms of cervical ripening and dilation in mammals remain obscure. Information is lacking about the localization of prostaglandin E(2) (PGE(2))-producing cells and PGE(2) receptors (EP) in intrapartum cervix and whether cervical dilation at parturition is an active process. To reveal these mechanisms, immunolocalization of EP1-EP4 (official gene symbols PTGER1-PTGER4) and PGE(2)-producing cells in caprine cervix during nonpregnancy, pregnancy, and parturition was assayed by immunohistochemistry (IHC); the mRNA expression levels of PTGS2, PTGER2 (EP2), and PTGER4 (EP4) were determined using quantitative PCR; and the existence of adipocytes in the cervix at various stages was demonstrated with Oil Red O staining and IHC of perilipin A. The results suggested that in intrapartum caprine cervix staining of the PGE(2) was observed in the overall tissues, for example, blood vessels, canal or glandular epithelia, serosa, circular and longitudinal muscles, and stroma in addition to adipocytes; EP2 was detectable in all the tissues other than glandular epithelia; EP4 was strongly expressed in all the tissues other than serosa; EP1 was detected mainly in arterioles and canal or glandular epithelia; and EP3 was poorly expressed only in stroma, canal epithelia, and circular muscles. Little or no expression of EP2, EP3, and EP4 as well as PGE(2) in all cervical tissues was observed during nonpregnancy and pregnancy except for the strong expression of EP1 in canal or glandular epithelia during pregnancy. The mRNA expression levels of PTGS2, PTGER2, and PTGER4 were significantly higher in intrapartum than nonpregnant and midpregnant cervices (P < 0.01). Adipocytes appear only in the intrapartum cervix. These results support the concept that PGE(2) modulates specific functions in various anatomical structures of the caprine cervix at labor and the appearance of adipocytes at labor is likely related to caprine cervical dilation.

A single-nucleotide polymorphism in the fetal catechol-O-methyltransferase gene is associated with spontaneous preterm birth in African Americans

Catechol-O-methyltransferase (COMT) activity has been reported to be higher in African Americans (AA) than Caucasians (Cau). COMT converts 2- and 4-hydroxy (OH) estrogens to 2- and 4-methoxyestrogens, respectively, and can increase estrogenic milieu locally in tissues. To assess whether the increased incidence of preterm birth (PTB) among AA women is associated with single-nucleotide polymorphism (SNP) in the COMT gene, we examined variations in maternal and fetal COMT genes and their association with pregnancy outcomes (term vs preterm pregnancies) using 4 functional SNPs: rs4633, rs4680, rs4818, and rs6269 in both AA and Cau. We analyzed samples from 267 AA women (191 term and 76 preterm pregnancies) and 339 Cau (194 term and 145 preterm pregnancies) in this study. The results showed a significant difference (P < .05) in allele and genotype frequencies between term and preterm AA and Cau women in 3 SNPs in both maternal and fetal DNA. The analysis revealed that in AA fetal COMT genes, SNP rs4818 is associated with PTB at the allele (C; P < .001), genotype (C/C; P < .01), and 2- (P < .03) and 3 (P < .04)-window haplotype levels. Multidimensionality reduction analysis also showed a significant (P < .01) association between rs4818 and PTB. In conclusion, our study demonstrated that a synonymous polymorphism, rs4818 in the fetal COMT gene, is associated with PTB in AA.

The effect of continuous morphine administration on maternal plasma oxytocin concentration and uterine contractions after open fetal surgery

OBJECTIVE

A major complication of open fetal surgery is prematurity. We propose that fetal and maternal stress/pain after surgery may affect the concentration of circulating oxytocin and the frequency of uterine contractions, thus increasing the risk of preterm delivery. The objective of this study was to test whether continuous morphine sulfate administration after open fetal surgery has an effect on maternal plasma oxytocin concentration and the frequency of uterine contractions.

METHODS

An established time-pregnant primate model for open fetal surgery was used. From the time of surgery until the end of the three-day study period, three animals received prophylactic antibiotics, a bolus of indomethacin, and a bolus of morphine sulfate (group I). Three other animals received the same prophylactic antibiotics and an i.v. bolus of indomethacin, as well as a continuous i.v. infusion of morphine sulfate throughout the entire study period (group II). Maternal blood samples were collected to determine oxytocin plasma concentrations. Oxytocin was measured by radioimmunoassay. Uterine activity was continuously recorded through an amniotic fluid catheter and quantified as number of contractions (10 mmHg increase from base line in intrauterine pressure) per hour (UCs/h).

RESULTS

The mean maternal plasma oxytocin concentration was higher (p < 0.01) and the number of uterine contractions more frequent (p < 0.05) in the group of animals with intermittent doses of morphine than in the group that received morphine continuously.

CONCLUSIONS

These data suggest that maternal plasma oxytocin concentration and uterine activity after open fetal surgery may be related to inadequate maternal/fetal analgesia/sedation.

V-chain preference of gamma/delta T-cell receptors in peripheral blood during term labor

PROBLEM

An altered function of the maternal immune system creates a favorable environment for the developing fetus during pregnancy. At term, new regulatory mechanisms are activated, to initiate labor. Earlier we showed that in peripheral blood of pregnant women gamma/delta T cells of cytotoxic phenotype are replaced by those of a non-cytotoxic phenotype. Here we studied the Vgamma and Vdelta chain usage of peripheral gamma/delta T cells from women in labor.

METHOD OF STUDY

Vgamma and Vdelta chain expression on peripheral blood lymphocytes obtained at the 3rd trimester of pregnancy and during parturition were examined by immuncytochemistry and flow cytometry.

RESULTS

Increased % of Vgamma9/Vdelta2 and decreased % of Vgamma4/Vdelta1 T cells were found in peripheral blood during labor, together with unaltered percentages of single Vgamma+ or Vdelta+ cells. The initially high Vgamma4/Vdelta1 to Vgamma9/Vdelta2 ratio decreased during labor.

CONCLUSION

The initiation of labor is characterized by an altered V-chain usage of gamma/delta T cells.

Reductionist and system approaches to study the role of infection in preterm labor and delivery

A substantial number of patients with preterm labor and delivery do not show clinical signs of infection, however, it is the subclinical form which is the main causative factor and often results in premature delivery. The hitherto commonly applied methods of inflammation detection are based either on potentially hazardous amniocentesis or still insufficient inflammation-related protein measurement in the serum or other biological fluids. The advent of new "omics" technologies has led to a paradigm-shift in experimental approach which tends to primarily generate rather than form hypotheses. This has resulted in a surge of wealth of data composed of sets of individual or clusters of new genes and proteins that can be of potential importance as new markers of inflammation leading to preterm labor. It is hoped that as a result of those new methodologies the overall perception of medical research and practice would gradually change from reductionist to systems approach. Despite several successes of reductionism in the diagnosis and treatment of preterm labor it seems that system-based methodology would contribute to a more favorable personalized rather than one-for-all patient assistance. In this review we present the current knowledge on this new attractive field of medical studies with emphasis on early detection of infection related with preterm labor.

Positive association of serum interleukin-1beta and CRH levels in women with pre-term labor

OBJECTIVE

The aim of this study was to investigate the hypothesis that interleukin-1beta (IL-1beta) might be involved in the increase of the circulating levels of placental-derived CRH leading to the initiation of pre-term labor.

SUBJECTS AND METHODS

Forty-eight primigravidae with a singleton viable pregnancy between 28 and 34 weeks of gestation were studied. The subjects were divided in two groups: group A consisted of 30 pregnant women (mean age+/-SD; 22+/-1.1 yr old) presented with pre-term labor (mean gestational age+/-SD; 30.6+/-2.3 weeks) and group B consisted of 18 pregnant women (24+/-2.6 yr old) with normal pregnancies (29.8+/-3.1 weeks). CRH and IL-1beta levels were measured in blood specimens collected from all the study subjects on admission.

RESULTS

Women of group A presented significantly higher serum CRH levels (mean+/-SE; 1.18+/-1.83 ng/ml) compared to those of group B (0.48+/-0.67 ng/ml) (p<0.01). Similarly, serum IL-1beta levels were significantly higher in women of group A (0.45+/-0.12 pg/ml) compared to those of group B (0.31+/-0.08 pg/ml) (p<0.01). A positive correlation was found between serum IL-1beta and CRH (r=0.68, p=0.001) in women of group A (pre-term labor).

CONCLUSIONS

Our findings suggest that the increased levels of IL-1beta and CRH found in pregnant women presented with pre-term labor might be involved in the pathophysiologic mechanism of the latter. Furthermore, a positive interaction might exist between IL-1beta and placental CRH which might lead to enhanced production of the second, facilitating, thus, the onset of labor.

Management of preterm prelabour rupture of membranes: an audit. How do the results compare with clinical practice guidelines?

BACKGROUND

Preterm prelabour rupture of membranes is a common clinical event. It is associated with infection in approximately 50% of cases. Clinical practice guidelines have been developed at the Royal Women's Hospital, Melbourne, Australia for investigation and management of this condition.

AIM

To perform an audit of management of women presenting with this diagnosis and assess how inpatient management compares with the Hospital's current clinical practice guideline and how the clinical practice guideline compares with the evidence in the literature.

METHODS

Retrospective audit over a 3-month period collecting data on maternal age, gestation, microbiological results, other investigations, pharmacological treatment and outcome.

RESULTS

All the 56 women admitted for this reason received at least one dose of antibiotic, most commonly erythromycin. More than two thirds of patients had the antibiotic changed at least once during their admission. Ten patients were prescribed intravenous antibiotics without a clear indication. Sixty-four percent received steroids for lung maturation of the neonate and 30% received tocolysis with nifedipine. Almost two thirds of patients delivered within 7 days and there were four neonatal deaths.

CONCLUSION

In general management of women with premature rupture of membranes is in keeping with the current clinical practice guideline at the Royal Women's Hospital although antibiotic prescribing and management of Group B streptococcus colonisation could be improved. In addition, routine measurement of C reactive protein should cease. The current clinical practice guideline should be modified to reflect the current evidence in the literature.

Hormonal changes accompanying cigarette smoke-induced preterm births in a mouse model

Epidemiologic evidence indicates that maternal smoking increases the risk of preterm birth. While a number of plausible mechanisms for early delivery have been offered, the role of gestational hormones in this smoke-induced outcome is uncertain. Thus, a toxicologic study was performed to examine the effects and underlying hormonal mechanisms of mainstream cigarette smoke (MCS) exposure on gestational duration. Pregnant B6C3F1 mice were exposed by inhalation to MCS for 5 days/week (4 hrs/day) from Gestational Day (GD) 4 to parturition. Smoke-induced effects on gestational length, interpubic ligament length, maternal hormone secretion patterns (estradiol-17beta, progesterone, prolactin, and relaxin), body weight gain, postimplantation loss, litter size, and offspring sex ratio were examined. Dams exposed to MCS at a concentration equivalent to smoking less than one pack of cigarettes/day (carbon monoxide = 25 parts per million, total suspended particulates = 16 mg/m3) demonstrated a significant (P < 0.05) shortening of gestational duration (compared with pregnant, air-exposed mice). In addition, MCS-exposed mice sacrificed on GD 18 had significantly (P < 0.05) increased interpubic ligament length, elevated serum estrogen levels, and a reduced progesterone to estradiol-17beta ratio (compared with air-exposed controls); levels of progesterone and prolactin were only modestly decreased and increased, respectively, in the MCS-exposed mice. Smoke exposure had no significant effects on maternal relaxin levels, body weight gain, postimplantation loss, litter size, or sex ratio. Results of this study demonstrate that inhalation exposure of pregnant mice to a low dose of MCS shortens gestation and alters hormone secretory patterns, which are important for maintaining pregnancy and inducing parturition. These findings support the view that pregnant women who smoke (even modestly) may be at increased risk for preterm birth, and that early delivery may be related (at least partly) to MCS-induced.

Association between serum tumor necrosis factor-? and corticotropin-releasing hormone levels in women with preterm labor

AIM

To evaluate the association of serum corticotropin-releasing hormone (CRH) and tumor necrosis factor-alpha (TNF-alpha) in preterm labor.

METHODS

Forty-nine primigravidas with a singleton viable pregnancy between 28 and 34 weeks of gestation were studied. They were divided into two groups. Group A consisted of 30 pregnant women (mean gestational age: 30.6 week) who presented with preterm labor and group B consisted of 19 pregnant women (mean gestational age: 29.8 week) with normal pregnancies.

RESULTS

Women of group A had significantly higher serum CRH levels compared to those of group B (P < 0.01). Similarly, serum TNF-alpha levels were significantly higher in women of group A when compared to women of group B (7.8 +/- 3.72 pg/mL and 5.1 +/- 3.72 pg/mL, respectively). Furthermore, a positive correlation was found between serum CRH and TNF-alpha levels in both groups, which was stronger in women of group A.

CONCLUSIONS

Our findings suggest that the increased levels of TNF-alpha and CRH found in pregnant women presenting with preterm labor may be involved in the pathophysiological mechanism of the latter. Furthermore, a positive interaction may exist between TNF-alpha and placental CRH, which may lead to enhanced production of the second and, therefore, facilitate the onset of labor.

Genetic influences on preterm birth

This article summarizes the scientific evidence supporting a genetic predisposition to preterm birth (PTB) and current molecular methods used to study the genetic links. Selected candidate genes currently under consideration for study are also discussed. Understanding the etiology and pathophysiology of PTB remains at the forefront of research efforts to solve this critical problem. Awareness of the contributing factors is imperative to the development of prevention and early intervention strategies that can reduce the incidence of PTB and the consequence of long-term neonatal complications. The possibility of a genetic predisposition to preterm delivery is a relatively new area of study to emerge over the past few years, although for a long time it has been suspected that PTB results from gene-environment interactions. More advanced genetic research methods are now being applied to study this hypothesis. A sample of candidate genes under study and their speculated role in PTB are presented in this article. There will be more research that links genetic influences and environmental factors to PTB in future, and researchers are hopeful that genetic knowledge can be applied to better understand the entire spectrum of prematurity.

Mechanisms underlying "functional" progesterone withdrawal at parturition

Progesterone is a major factor maintaining uterine quiescence throughout pregnancy. In most species, peripheral progesterone levels decline before initiation of labor, and treatments that inhibit progesterone synthesis or action cause termination of pregnancy and/or premature deliveries. These findings suggest that progesterone withdrawal is required for activation of myometrial contractions. However, in humans, circulating progesterone levels remain elevated until birth, which leads to the notion that a "functional" progesterone withdrawal occurs before parturition. The apparent loss of progesterone sensitivity at term could be a consequence of several different mechanisms including: (1) the catabolism of progesterone in the uterus into inactive compounds; (2) alterations in progesterone receptor (PR) isoform ratios; (3) changes in cofactor protein levels affecting PR transactivation; and (4) inflammation-induced trans-repression of PR by nuclear factor kappaB. All of these mechanisms are potentially capable of decreasing uterine progesterone responsiveness at term, thus enabling the expression of pathways that originally were blocked by progesterone in early pregnancy. However, the specific uterine genes whose transcription is directly controlled by PR, and thus affected by "functional" progesterone withdrawal, remain to be identified.

Fetal membrane inflammatory cytokines: a switching mechanism between the preterm premature rupture of the membranes and preterm labor pathways

Inflammatory cytokines are involved in both preterm labor and preterm premature of the membranes pathways; however, the interaction between TNF-alpha and its receptors may dictate the clinical outcome of pregnancy.

Tumor necrosis factor-alpha suppresses the expression of steroid receptor coactivator-1 and -2: a possible mechanism contributing to changes in steroid hormone responsiveness

Inflammation is associated in some tissues with diminished responsiveness to steroid hormone action. We hypothesized that proinflammatory cytokines alter steroid hormone sensitivity, in part, by reducing levels of key nuclear receptor coactivators. Treatment of cultured human uterine smooth muscle cells (UtSMC) with TNF-alpha significantly reduced mRNA for the coactivators, SRC-1 (42%, P<0.01) and 2 (47%, P<0.03), and diminished the respective protein levels, but did not significantly alter the mRNAs encoding SRC-3, CBP and the corepressors, NCoR and SMRT; or progesterone receptor protein levels. To assess TNF-alpha effects on steroid hormone-mediated transcriptional activity, UtSMC were transfected with progesterone receptor B (PR-B) and a model PRE2-luciferase reporter construct. Transfected UtSMC were treated with progesterone alone or in the presence of TNF-alpha, and assayed for luciferase activity. TNF-alpha (10 ng/ml) diminished progesterone-stimulated PR-B-mediated transactivation by approximately 60% (P<0.02). The TNF-alpha-dependent decrease in PRE-luciferase activity was fully prevented by cotransfection with SRC-2, and partially prevented with exogenous SRC-1. In conclusion, TNF-alpha impairs progesterone-stimulated PR-B-mediated transactivation, and these effects appear to be due, in part, to reduced expression of SRC-1 and -2, which is a novel mechanism by which inflammation can functionally block steroid hormone action.

Comprehending the role of LPS in Gram-negative bacterial vaginosis: ogling into the causes of unfulfilled child-wish

INTRODUCTION

Intrauterine infection is frequently associated with pregnancy loss in pregnant women.

DISCUSSION

This article reviews the role of Gram-negative bacterial infection in various complications related to early pregnancy and subsequent pregnancy loss. Here we discuss the pathways of ascending intrauterine infection, microbiology and the pathophysiology of such infections. The clinical impact, therapy, consequences, prevention and implications of Gram-negative bacterial infections in women during their reproductive life span is also discussed. This article also makes an attempt to discuss our studies and findings, related to the effect of the LPS component of the Gram-negative bacterial endotoxin on preimplantation stage embryonic development and implantation. This early phase of pregnancy remains mostly unnoticed by the mother as well as the health care provider, and therefore holds more threat to the life of the fetus and the mother. The molecular mechanisms of LPS-induced pregnancy losses through abnormal embryonic development, implantation failure, and preterm labor and birth with specific references to the role of proinflammatory cytokines like IL-1 and TNF are discussed.

CONCLUSION

Once these inflammatory mediators have increased in the feto-maternal tissues, it may be too late or harmful to try and prevent the adverse outcomes of pregnancy.

Gram-Negative Bacterial Endotoxin- Induced Infertility: A Birds Eye View

Alleviation of infertility on the one hand and development of improved methods of contraception on the other are global concerns to woman's health. The molecular signals that regulate implantation are of clinical relevance since understanding the nature of these signals may lead to strategies to correct implantation failure and to develop novel contraceptive approaches. The other pressing concern is the poor pregnancy rate resulting from in vitro fertilization (IVF). The pregnancy rate in IVF programs remains about 20-30% in spite of the high rate of successful fertilization. This has led to the proposition that additional uterine factors, critical for the implantation process, must be limiting. Identification of such parameters could help in determining the appropriate physiological state of the uterus for embryo transfer. Several factors are known to have a direct or indirect impact on the ability of the uterus to develop to a functionally receptive state. This would disrupt the normal coordination between embryonic and uterine development even though all molecular players may seem otherwise normal.

Tabagismo e suas peculiaridades durante a gestação: uma revisão crítica

A gestação é uma ocasião especial para a promoção da cessação do tabagismo. A preocupação com a saúde do feto gera uma motivação extraordinária na gestante. Os resultados e a relação custo-efetividade das intervenções são melhores neste grupo do que na população em geral. Os ganhos extrapolam os benefícios à saúde da mulher, pois permitem também o desenvolvimento de um feto mais saudável. O conhecimento das peculiaridades do tabagismo durante a gestação é fundamental para uma abordagem direcionada e com maior probabilidade de sucesso. Este trabalho de revisão tem o objetivo de ressaltar a extensão dos malefícios do fumo, tanto para a mulher gestante quanto para seu feto, e estimular o uso de técnicas apropriadas para a suspensão do tabagismo nesta população.

Nuclear prostaglandin receptors: role in pregnancy and parturition?

The key regulatory role of prostanoids [prostaglandins (PGs) and thromboxanes (TXs)] in the maintenance of pregnancy and initiation of parturition has been established. However, our understanding of how these events are fine-tuned by the recruitment of specific signaling pathways remains unclear. Whereas, initial thoughts were that PGs were lipophilic and would easily cross cell membranes without specific receptors or transport processes, it has since been realized that PG signaling occurs via specific cell surface G-protein coupled receptors (GPCRs) coupled to classical adenylate cyclase or inositol phosphate signaling pathways. Furthermore, specific PG transporters have been identified and cloned adding a further level of complexity to the regulation of paracrine action of these potent bioactive molecules. It is now apparent that PGs also activate nuclear receptors, opening the possibility of novel intracrine signaling mechanisms. The existence of intracrine signaling pathways is further supported by accumulating evidence linking the perinuclear localization of PG synthesizing enzymes with intracellular PG synthesis. This review will focus on the evidence for a role of nuclear actions of PGs in the regulation of pregnancy and parturition.

Maternal and fetal hypothalamic-pituitary-adrenal axes during pregnancy and postpartum

The principal modulators of the hypothalamic-pituitary-adrenal (HPA) axis are corticotropin-releasing hormone (CRH) and arginine-vasopressin (AVP). Corticotropin-releasing hormone is not exclusively produced in the hypothalamus. Its presence has been demonstrated at peripheral inflammatory sites. Ovulation and luteolysis bear characteristics of an aseptic inflammation. CRH was found in the theca and stromal cells as well as in cells of the corpora lutea of human and rat ovaries. The cytoplasm of the glandular epithelial cells of the endometrium has been shown to contain CRH and the myometrium contains specific CRH receptors. It has been suggested that CRH of fetal and maternal origin regulates FasL production, thus affecting the invasion (implantation) process through a local auto-paracrine regulatory loop involving the cytotrophoblast cells. Thus, the latter may regulate their own apoptosis. During pregnancy, the plasma level of circulating maternal immunoreactive CRH increases exponentially from the first trimester of gestation due to the CRH production in the placenta, decidua, and fetal membranes. The presence in plasma and amniotic fluid of a CRH-binding protein (CRHbp) that reduces the bioactivity of circulating CRH by binding is unique to humans. Maternal pituitary ACTH secretion and plasma ACTH levels rise during pregnancy-though remaining within normal limits-paralleling the rise of plasma cortisol levels. The maternal adrenal glands during pregnancy gradually become hypertrophic. Pregnancy is a transient, but physiologic, period of hypercortisolism. The diurnal variation of plasma cortisol levels is maintained in pregnancy, probably due to the secretion of AVP from the parvicellular paraventricular nuclei. CRH is detected in the fetal hypothalamus as early as the 12th week of gestation. CRH levels in fetal plasma are 50% less than in maternal plasma. The circulating fetal CRH is almost exclusively of placental origin. The placenta secretes CRH at a slower rate in the fetal compartment. AVP is detected in some neurons of the fetal hypothalamus together with CRH. AVP is usually detectable in the human fetal neurohypophysis at 11 to 12 weeks gestation and increases over 1000-fold over the next 12 to 16 weeks. The role of fetal AVP is unclear. Labor appears to be a stimulus for AVP release by the fetus. The processing of POMC differs in the anterior and intermediate lobes of the fetal pituitary gland. Corticotropin (ACTH) is detectable by radioimmunoassay in fetal plasma at 12 weeks gestation. Concentrations are higher before 34 weeks gestation, with a significant fall in late gestation. The human fetal adrenal is enormous relative to that of the adult organ. Adrenal steroid synthesis is increased in the fetus. The major steroid produced by the fetal adrenal zone is sulfoconjugated dehydroepiandrosterone (DHEAS). The majority of cortisol present in the fetal circulation appears to be of maternal origin, at least in the nonhuman primate. The fetal adrenal uses the large amounts of progesterone supplied by the placenta to make cortisol. Another source of cortisol for the fetus is the amniotic fluid where cortisol converted from cortisone by the choriodecidua, is found. In humans, maternal plasma CRH, ACTH, and cortisol levels increase during normal labor and drop at about four days postpartum; however, maternal ACTH and cortisol levels at this stage are not correlated. In sheep, placental CRH stimulates the fetal production of ACTH, which in turn leads to a surge of fetal cortisol secretion that precipitates parturition. The 10-day-long intravenous administration of antalarmin, a CRH receptor antagonist, significantly prolonged gestation compared to the control group of animals. Thus, CRH receptor antagonism in the fetus can also delay parturition. The HPA axis during the postpartum period gradually recovers from its activated state during pregnancy. The adrenals are mildly suppressed in a way analogous to postcure Cushing's syndrome. Provocation testing has shown that hypothalamic CRH secretion is transiently suppriently suppressed at three and six weeks postpartum, normalizing at 12 weeks.

Women's recognition of the spontaneous onset of labor

BACKGROUND

Despite extensive research on the onset of labor, almost no data are available on women's perception of labor onset. We undertook a study to assess how women experience spontaneous onset of term labor.

METHODS

A semistructured questionnaire was given to 235 women admitted in spontaneous labor at term. Women noted when labor had started, whether and when membranes had ruptured, and answered an open question about how labor had announced itself. Two investigators independently subdivided women's experiences on how labor had started into 369 sampling units corresponding to 8 predefined categories.

RESULTS

Nearly two-thirds of the sampling units (63.4%) related to recurrent and nonrecurrent pain, and the ratio between the two types was higher for multiparas than for nulliparas. The number of women and sampling units were identical for each of the following categories: watery fluid (n = 47), blood-stained loss (n = 33), gastrointestinal symptoms (n = 10) and altered sleep patterns (n = 11); 22 sampling units relating to emotional upheaval were mentioned by 16 women. Although 33.6 percent of women experienced rupture of membranes before admission, only 21.6 percent associated it with their onset of labor, either alone (11.5%) or in association with other categories (10.1%).

CONCLUSIONS

Although women experience onset of labor in a variety of ways, for most it is a concrete event. Studies on duration of labor should take women's perception of onset of labor as a starting point rather than rely on surrogate measures.

Mechanisms, organisms and markers of infection in pregnancy

Premature delivery is still a significant problem in Obstetrics. It has multiple causes, with around 50% thought due to infection. Of note infection as a pathogenesis is more likely in those pre-term births occurring <30 weeks gestation and is largely sub-clinical. Potential pathogens largely arise from the ascending route and from the endogenous vaginal flora, causing chorioamnionitis. Resultant morbidity from the release of endo+/exotoxins from such pathogens, the stimulation and production of inflammatory cytokine pathways, prostaglandins, metalloproteinases includes maternal sepsis (chorioamnionitis, septicaemia, post-partum endometritis), pre-term delivery (infant pre-maturity and its consequences, increased susceptibility to cerebral palsy and neonatal sepsis). As well, infection increases mortality due to fetal loss (extreme pre-maturity) as well as severe neonatal sepsis.

Cytokines of the placenta and extra-placental membranes: roles and regulation during human pregnancy and parturition

Summary In an earlier, companion, review, we concluded that cytokines produced by the placenta and associated membranes are likely to be involved in control of the processes of implantation and placental development (Bowen et al., 2002). In this review, we discuss evidence that cytokines continue to be part of a paracrine/autocrine regulatory network in the placenta and membranes throughout the mid and late stages of gestation. Cytokines are involved in regulation of placental growth during these later stages of pregnancy and also function to protect the fetus from pathological organisms. The evidence, while not entirely consistent, suggests that production of certain cytokines within the extraplacental membranes is altered during normal term parturition, whereas in the villous placenta evidence of labour-associated changes is much more equivocal. Roles for cytokines have been postulated in many facets of parturition, including expulsion of the fetus by uterine contractions, membrane rupture, and dilation of the cervix. Imbalances and disruptions to the cytokine milieu have been implicated in a number of diseases of pregnancy involving abnormalities of both placental growth/establishment and initiation of parturition. Cytokine secretion induced by intrauterine infection is associated with increased occurrence or severity of some neonatal diseases. This wealth of data supports the view that cytokines are an integral part of a functional regulatory/communication network operating within the placental-maternal unit during normal gestation.

[Value of fetal fibronectin research for predicting premature delivery]

OBJECTIVE

To estimate the performance of the foetal fibronectin test as a predictor of preterm delivery.

PATIENTS AND METHODS

This prospective study concern 61 patients who had a singleton pregnancy between 24 and 36 weeks of gestation and were hospitalized because of a threatened preterm labor without premature rupture of the membranes. For each patient the presence of foetal fibronectin in cervicovaginal secretions was determined with a rapid swab-test.

RESULTS

Prematurity rate was 38% (23 patients). In case of positive result, delivery became before 37 weeks in 75% (12/16) against 24% in case of negative result (11/45). The prolongation of pregnancy after the test was on average 21 days in the positive group and 44 days in the negative group. About the prediction of preterm delivery, the results showed a sensibility of 52%, a specificity of 89%, a positive predictive value of 75%, a negative predictive value of 76%. To predict a delivery within the two weeks after the test, the sensibility was 88%, the specificity 83%, and the negative predictive value 98%.

CONCLUSION

The presence of foetal fibronectin in cervicovaginal secretions represent an increased risk of preterm delivery, whereas its excellent negative predictive value allow to be reassuring, especially within a period of 15 days.

Risks and benefits of nicotine to aid smoking cessation in pregnancy

Cigarette smoking during pregnancy is the single largest modifiable risk for pregnancy-related morbidity and mortality in the US. Addiction to nicotine prevents many pregnant women who wish to quit smoking from doing so. The safety and efficacy of nicotine replacement therapy (NRT) for smoking cessation during pregnancy have not been well studied. Nicotine is classified by the US Food and Drug Administration as a Pregnancy Category D drug. Animal studies indicate that nicotine adversely affects the developing fetal CNS, and nicotine effects on the brain may be involved in the pathophysiology of sudden infant death syndrome (SIDS). It has been assumed that the cardiovascular effects of nicotine resulting in reduced blood flow to the placenta (uteroplacental insufficiency) is the predominant mechanism of the reproductive toxicity of cigarette smoking during pregnancy. Short term high doses of nicotine in pregnant animals do adversely affect the maternal and fetal cardiovascular systems. However, studies of the acute effects of NRT in pregnant humans indicate that nicotine alone has minimal effects upon the maternal and fetal cardiovascular systems. Cigarette smoking delivers thousands of chemicals, some of which are well documented reproductive toxins (e.g. carbon monoxide and lead). A myriad of cellular and molecular biological abnormalities have been documented in placentas, fetuses, and newborns of pregnant women who smoke. The cumulative abnormalities produced by the various toxins in cigarette smoke are probably responsible for the numerous adverse reproductive outcomes associated with smoking. It is doubtful that the reproductive toxicity of cigarette smoking is primarily related to nicotine. We recommend the following. Efficacy trials of NRT as adjunctive therapy for smoking cessation during pregnancy should be conducted. The initial dose of nicotine in NRT should be similar to the dose of nicotine that the pregnant woman received from smoking. Intermittent-use formulations of NRT (gum, spray, inhaler) are preferred because the total dose of nicotine delivered to the fetus will be less than with continuous-use formulations (transdermal patch). A national registry for NRT use during pregnancy should be created to prospectively collect obstetrical outcome data from NRT efficacy trials and from individual use. The goal of this registry would be to determine the safety of NRT use during pregnancy, especially with respect to uncommon outcomes such as placental abruption. Finally, our review of the data indicate that minimal amounts of nicotine are excreted into breast milk and that NRT can be safely used by breast-feeding mothers.

Progesterone receptor isoform A inhibits isoform B-mediated transactivation in human amnion

Human amnion cells were transfected with progesterone receptor A and/or B, and the progesterone-dependent reporter construct, mouse mammary tumor virus promoter (MMTV), linked to a luciferase gene. In progesterone receptor B-expressing amnion that had been cultured before the onset of labour, treatment with progesterone resulted in an eightfold increase of the reporter activity, whereas in laboured cells, no such increase was seen. In contrast, progesterone receptor A was a weak activator of transcription in laboured and non-laboured amniocytes. When the isoforms A and B of the progesterone receptor were co-transfected, progesterone receptor A exhibited a marked inhibitory effect on progesterone receptor B-mediated transcription. These results show that progesterone receptors A and B function differentially, and progesterone receptor A is a transdominant repressor of progesterone receptor B-mediated transcription in human term amnion.

Maternal risk factors for fetal and neonatal brain damage

Prematurity is probably the major factor associated with brain damage in newborns. Our growing knowledge of the biochemical mechanisms leading to the onset of labour at term allows the biochemical correlates of the epidemiological risk factors for prematurity to be understood. Infection is the major cause of early preterm labour and is now recognised to be a major cause of fetal cerebral damage leading to cerebral palsy. Only some 5% of cerebral palsy is due to intrapartum asphyxia at term. This may occur due to an obstetric catastrophe or through inadequate placental function leading to chronic intrapartum asphyxia.

Support for an infection-induced apoptotic pathway in human fetal membranes

OBJECTIVE

Lipopolysaccharide and tumor necrosis factor alpha levels are both elevated in the amniotic fluid of women during infection-associated preterm labor and premature rupture of fetal membranes. Our laboratory has shown that apoptosis is associated with premature rupture of fetal membranes but is not associated with preterm labor. The exact pathway that leads to apoptosis-mediated premature rupture of fetal membranes is still unclear. Because infection and increased inflammatory cytokine response are associated with the majority of cases of premature rupture of fetal membranes, we examined the roles of bacterial lipopolysaccharide and tumor necrosis factor alpha in inducing the proapoptotic caspase pathway in fetal membranes.

STUDY DESIGN

Amniochorionic membranes collected from women undergoing elective repeat cesarean delivery at term were placed in an organ explant system. At the end of a 48-hour incubation period, membranes were stimulated with lipopolysaccharide (50 ng/mL) and recombinant tumor necrosis factor (50 ng/mL). Total ribonucleic acid extracted from these samples was subjected to reverse transcription and two separate sets of multiple polymerase chain reaction. One set studied the expression of Fas, Fas ligand, caspase 8, Fas-associated death domain, and tumor necrosis factor receptor-associated death domain genes and the second set studied the expression of caspase 2, 4, 6, 7, and 10. Caspase 2, 3, and 9 expression was also studied by reverse transcriptase-polymerase chain reaction.

RESULTS

Multiple polymerase chain reactions and reverse transcriptase-polymerase chain reactions documented the induction of Fas and caspase 2, 3, 7, 8, and 9 genes in amniochorion after lipopolysaccharide and tumor necrosis factor stimulation compared with the nonstimulated controls. Neither lipopolysaccharide nor tumor necrosis factor induced Fas ligand expression in human fetal membranes. Caspase 3, 4, and 6, Fas-associated death domain, and tumor necrosis factor receptor-associated death domain expressions were constitutive in all the tissues tested; however, tumor necrosis factor receptor-associated death domain expression appeared stronger in tumor necrosis factor-stimulated tissues.

CONCLUSION

The presence of the signal docking proteins tumor necrosis factor receptor-associated death domain and Fas-associated death domain and the induction of caspase cascade initiators (caspase 2, 8, and 10) and effector caspases (caspase 3, 6, 7, and 9) by lipopolysaccharide and tumor necrosis factor suggest that tumor necrosis factor-tumor necrosis factor receptor-mediated apoptosis may occur in the human fetal membrane.

Distinct molecular events suggest different pathways for preterm labor and premature rupture of membranes

OBJECTIVE

On a clinical level, the etiologies associated with premature rupture of the membranes and preterm labor are virtually identical, though these conditions end in distinctly different events. This study was designed to determine differences between preterm labor and preterm premature rupture of membranes by using molecular markers of extracellular matrix degradation and apoptosis.

STUDY DESIGN

Amniochorion and amniotic fluid samples were collected from gestational age-matched groups of women undergoing cesarean delivery before term. Samples were collected from 2 groups of women, women with premature rupture of membranes and women with preterm labor with no rupture of membranes. Changes in the expression pattern of messenger ribonucleic acid for matrix metalloproteinases (MMP), tissue inhibitor of metalloproteinases (TIMP), and pro-apoptotic (p53 and Bax) and anti-apoptotic (Bcl-2) proteins were identified by quantitative polymerase chain reaction. Enzyme-linked immunosorbent assay was used to determine the levels of these proteins in the amniotic fluid. Multiplex polymerase chain reaction was performed to study the expression of Fas-Fas ligand-associated pro-apoptotic genes. Unpaired nonparametric, 2-tailed Mann-Whitney U test was used to determine statistical significance of quantitative polymerase chain reaction and enzyme-linked immunosorbent assay (P <.05 was considered significant).

RESULTS

Quantitative polymerase chain reaction results demonstrated an increased mRNA expression for MMP2, MMP9, and MT1-MMP and a decreased expression for TIMP2 in prematurely ruptured membranes compared with preterm labor membranes. Enzyme-linked immunosorbent assay documented increases in the amniotic fluid concentrations of immunoreactive and bioactive MMP2 and MMP9 and immunoreactive MMP3 and a decreased TIMP2 concentration in fluids obtained from the premature rupture of membranes group compared with the preterm labor group. The pro-apoptotic genes p53 and bax were up-regulated in premature rupture of membranes when compared with preterm labor. Anti-apoptotic gene (Bcl-2 ) expression was increased in preterm labor membranes compared with prematurely ruptured membranes. Interleukin-18 (a pro-apoptotic cytokine) was increased in the amniotic fluid during premature rupture of membranes compared with preterm labor. Prematurely ruptured membranes also demonstrated fragmented deoxyribonucleic acid and expression of Fas and caspase 8 (apoptosis initiator), which were all absent in preterm labor membranes.

CONCLUSIONS

We have begun to delineate 2 divergent molecular pathways for premature rupture of membranes and preterm labor. Most likely, this is the beginning of the identification of differences that will become evident with the use of molecular biology.

Structure-activity relationship investigations of a potent and selective benzodiazepine oxytocin antagonist

We have investigated the structure-activity relationships of the 1- and 3-substituents and replacements of the 5-phenyl group of GW405212X 1, a potent selective oxytocin antagonist. The effect of these modifications on oxytocin binding antagonism and on pharmacokinetic parameters is reported.

Enhancement of amniotic cyclooxygenase type 2 activity in women with preterm delivery associated with twins or polyhydramnios

OBJECTIVE

We tested the hypothesis that preterm delivery in women with twins or polyhydramnios is associated with enhanced expression and activity of cyclooxygenase type 2 in the amnion.

STUDY DESIGN

We obtained amniotic tissue samples from women undergoing preterm delivery complicated by either twins or polyhydramnios and also from women undergoing preterm cesarean delivery before or after labor. We measured amniotic prostaglandin E2 content and determined cyclooxygenase type 1 and type 2 expressions. We inhibited cyclooxygenase type 1 and type 2 activities with selective inhibitors.

RESULTS

Preterm delivery attributed to twins or polyhydramnios was associated with higher prostaglandin E2 production and enhanced amniotic expression of cyclooxygenase type 2. In contrast, cyclooxygenase type 1 expression was unchanged. Incubation of amniotic samples in vitro with either indomethacin or the selective cyclooxygenase type 2 inhibitor SC-236, but not with the cyclooxygenase type 1 inhibitor SC-560, effectively reduced prostaglandin E2 production.

CONCLUSION

Preterm delivery related to multiple gestation or polyhydramnios was associated with enhanced amniotic expression and activity of cyclooxygenase type 2.

Endocrinology of preterm labor

The clinical importance of preterm labor and delivery dictates that we understand the physiology and diagnostic usefulness of endocrine as well as other agents that may be helpful in this regard. Clearly, estrogen and progesterone establish the environment that allows parturition and probably preterm labor to occur. The use of salivary estriol, though not a foolproof test, is becoming more frequent and is commercially available. Fibronectin, though not an endocrine test, has a similar diagnostic usefulness. In the future, we would expect to see CRH and even the use of selective cytokines, probably IL-6, as possible diagnostic tests. Whereas all of these agents have some diagnostic usefulness, none of them can be expected to predict every case of preterm delivery and some battery of tests, not unlike the triple or quadruple tests that are used for prenatal diagnosis of Down syndrome, may be effective and should be examined in the future. The use of these tests, salivary estriol and fetal fibronectin in particular, has already had an effect on management and decision making involved in preterm labor, and the future should give us more options and hopefully, better choices to manage this most difficult condition.

The onset of human labor: current theories

Innovative research has led to marked improvement in medical knowledge. Advances in technology have allowed us to attain a clearer understanding of many physiologic processes. Despite these impressive gains in knowledge, the cause of the initiation of the process of human labor remains unclear. Potential factors include changes in hormonal levels of estrogen and progesterone, increased production of prostaglandins, and elevation of levels of corticotropin-releasing hormone, as well as increased sensitivity of the myometrium to endogenous oxytocin. It is most likely that interactions between these factors play an essential role in the process of labor, but the precise mechanism of onset still eludes us.

Corticotropin-releasing hormone, corticotropin-releasing hormone-binding protein, and activin A in maternal serum: prediction of preterm delivery and response to glucocorticoids in women with symptoms of preterm labor

OBJECTIVE

The aim of this study was to determine prospectively whether serum concentrations of corticotropin-releasing hormone, corticotropin-releasing hormone-binding protein, and activin A (1) predict preterm birth within 10 days of hospital admission or at <37 weeks' gestation among women with symptoms of preterm labor and (2) are affected by glucocorticoid therapy.

STUDY DESIGN

Serum concentrations of corticotropin-releasing hormone and activin A were measured in 94 women with symptoms of preterm labor between 24 and 34 weeks' gestation, and delivery outcomes were monitored. Corticotropin-releasing hormone-binding protein concentrations were measured in 71 of these women. In a subgroup of 15 women the serum analytes were assayed in conjunction with estriol before and 12 to 24 hours after administration of dexamethasone.

RESULTS

Forty-six percent (6/13) of the women who were delivered within 10 days of hospital admission had a raised serum corticotropin-releasing hormone level, but the predictive relationship was not significant (chi(2) = 1.7; P =.2). Among the 31 women (including the 6 previously mentioned) who were delivered at <37 weeks' gestation, 39% (12/31) had a raised corticotropin-releasing hormone level. Although a raised corticotropin-releasing hormone concentration was positively associated with delivery at <37 weeks' gestation (chi(2) = 9; P =.003), the predictive diagnostic value was poor, with sensitivity, specificity, and positive and negative predictive values of 39%, 90%, 67%, and 75%, respectively. The serum concentrations of corticotropin-releasing hormone-binding protein and activin A were unrelated to gestational age at delivery. Dexamethasone markedly lowered the serum estriol level (P <.001) but had no effect on concentrations of corticotropinreleasing hormone, corticotropin-releasing hormone-binding protein, and activin A.

CONCLUSION

Serum concentrations of corticotropin-releasing hormone, corticotropin-releasing hormone-binding protein, and activin A are not clinically useful for the prediction of preterm delivery among women with symptoms of preterm labor and are not affected by administration of glucocorticoids.

Maternal hypothalamic-pituitary-adrenal axis in pregnancy and the postpartum period. Postpartum-related disorders

During pregnancy, placenta-derived CRH increases exponentially in the plasma. Circulating levels of CRH-binding protein decrease considerably in the last trimester of pregnancy, resulting in further elevation of bioavailable plasma CRH. The adrenal glands during pregnancy gradually become hypertrophic because of the increase in ACTH, which parallels that of CRH. Thus, pregnancy is a transient period of relative hypercortisolism. The activation of the hypothalamic-pituitary-adrenal axis during pregnancy has been proposed to function as a biological clock. In this model, the placenta is perceived as a stress-sensitive organ and placental CRH as a timing starter, determining a preterm, term, or postterm labor. During pregnancy, as well as during the immediate postpartum period, the hypothalamic maternal CRH secretion is suppressed, because of the circulating levels of cortisol. Hypothalamic CRH secretion normalizes within 12 weeks. This transient postpartum maternal hypothalamic CRH suppression, together with the steroid withdrawal that follows parturition, might be causally related to the mood disorders and the vulnerability to autoimmune diseases such as thyroiditis or rheumatoid arthritis often observed during the postpartum period.

Activin A exerts both pro- and anti-inflammatory effects on human term gestational tissues

There is a growing appreciation of the importance of activin as a modulator of immune function. The aim of the present study was to determine whether activin A exerts any effects on cytokine and prostaglandin (PG) production by the tissues of pregnancy. Explant cultures were established for amnion, choriodecidual and placental tissues derived from pregnancies delivered at term by Caesarean section (n=5 placentae). Explants were treated with activin A (0.5, 5 and 50 ng/ml) in serum-free Ham's F12/DME media for 24 h (n=3-4 replicates). Production rates of interleukin (IL)-1beta, IL-6, IL-8, tumour necrosis factor-alpha (TNF-alpha) and PGE(2)were determined using immunoassay. Differences between treatment groups were analysed by ANOVA followed by Dunnett's test;P< 0.05 was considered to be significant. Amnion IL-6 production exhibited biphasic responses to activin A: at 5 ng/ml activin A, IL-6 production was significantly stimulated (to 246+/-74.6 per cent of control (mean+/-sem), while at 50 ng/ml it was significantly inhibited (to 46+/-7.4 per cent of control). IL-8 and PGE(2)production by amnion showed significant responses to activin A that were similar to those of IL-6. No significant effects of activin A were observed on choriodecidual and placental IL-6, IL-8 and PGE(2)production. However, TNF-alpha production was significantly inhibited by 50 ng/ml activin A in both choriodecidual and placental explants (to 43+/-9.7 per cent and 51+/-6.7 per cent of control, respectively). Placental IL-1beta production was not altered by treatment with activin A at any concentration. These findings support the concept of activin as an immune modulator in tissues of pregnancy.

The expression of interleukin-6 (IL-6), IL-6 receptor, and gp130-kilodalton glycoprotein in the rat decidua and a decidual cell line: regulation by 17beta-estradiol and prolactin

The cytokine interleukin 6 (IL-6), a major mediator of immune and acute phase responses of the liver, has been implicated in the termination of pregnancy once expressed in the uterus. This study was undertaken to investigate the expression and regulation of genes encoding IL-6 and IL-6 receptor (IL-6R) in rat decidual tissue. Total RNA obtained from rat decidual tissue on different days of pseudopregnancy was analyzed by RT-PCR using specific primers for IL-6, IL-6R, and 130-kDa glycoprotein (gp130). Ribosomal L19 primers served as an internal control. IL-6R and gp130 were found to be expressed in the decidua throughout development, while no messenger RNA (mRNA) for IL-6 was detected. Interestingly, within several hours of culture, decidual explants acquired the ability to express IL-6. The apparent ability of decidual cells to express IL-6 and its lack of expression in vivo led us to examine whether the IL-6 gene is actively inhibited. Primary decidual cells were cultured in the presence of estradiol, progesterone, or PRL. Progesterone showed no effect, whereas estradiol and PRL reduced the level of IL-6 mRNA expression. To examine the mechanism by which these hormones inhibit IL-6 expression, we used a simian virus 40-transformed decidual cell line (GG-AD), which expresses only estrogen receptor-beta (ERbeta). Like primary decidual cells in culture, GG-AD cells express IL-6, IL-6R, and gp130 mRNA. When cultured in the presence of estradiol (0-100 ng/ml), mRNA for IL-6 and its receptor components were down-regulated in a dose-dependent manner. Estradiol also caused a dose-dependent decrease in IL-6 protein secretion into the culture medium. The inhibitory effect of estradiol on IL-6 mRNA expression was reversed by the antiestrogen ICI-164,384. Similar inhibition of IL-6 and gp130 mRNA expression was observed with PRL treatment. However, PRL had no effect on IL-6R mRNA levels. PRL inhibition of IL-6 expression was totally reversed by tyrphostin AG490, a JAK2 inhibitor. In summary, the results of this investigation indicate that IL-6 expression, which is detrimental to the maintenance of pregnancy, is inhibited in the rat decidual tissue. This inhibition is induced by PRL and estradiol, which down-regulate not only IL-6 expression, but also the expression of IL-6 receptor and signaling proteins. The results also suggest that PRL signaling to the IL-6 gene is mediated through the long form of PRL receptor and involves JAK2 activation, whereas that of estradiol can be transduced by estrogen receptor-beta.

Development of orally active oxytocin antagonists: studies on 1-(1-[4-[1-(2-methyl-1-oxidopyridin-3-ylmethyl)piperidin-4-yloxy]-2- methoxybenzoyl]piperidin-4-yl)-1,4-dihydrobenz[d][1,3]oxazin-2-one (L-372,662) and related pyridines

The previously reported oxytocin antagonist L-371,257 (2) has been modified at its acetylpiperidine terminus to incorporate various pyridine N-oxide groups. This modification has led to the identification of compounds with improved pharmacokinetics and excellent oral bioavailability. The pyridine N-oxide series is exemplified by L-372,662 (30), which possessed good potency in vitro (Ki = 4.1 nM, cloned human oxytocin receptor) and in vivo (intravenous AD50 = 0.71 mg/kg in the rat), excellent oral bioavailability (90% in the rat, 96% in the dog), good aqueous solubility (>8.5 mg/mL at pH 5.2) which should facilitate formulation for iv administration, and excellent selectivity against the human arginine vasopressin receptors. Incorporation of a 5-fluoro substituent on the central benzoyl ring of this class of oxytocin antagonists enhanced in vitro and in vivo potency but was detrimental to the pharmacokinetic profiles of these compounds. Although lipophilic substitution around the pyridine ring of compound 30 gave higher affinity in vitro, such substituents were a metabolic liability and caused shortfalls in vivo. Two approaches to prevent this metabolism, addition of a cyclic constraint and incorporation of trifluoromethyl groups, were examined. The former approach was ineffective because of metabolic hydroxylation on the constrained ring system, whereas the latter showed improvement in plasma pharmacokinetics in some cases.