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Gerede A, Nikolettos K, Vavoulidis E, Margioula-Siarkou C, Petousis S, Giourga M, Fotinopoulos P, Salagianni M, Stavros S, Dinas K, Nikolettos N, Domali E. Vaginal Microbiome and Pregnancy Complications: A Review. J Clin Med 2024; 13:3875. [PMID: 38999442 PMCID: PMC11242209 DOI: 10.3390/jcm13133875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/12/2024] [Accepted: 06/29/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: There are indications that the microbial composition of the maternal mucosal surfaces is associated with adverse events during pregnancy. The aim of this review is to investigate the link between vaginal microbiome alterations and gestational complication risk. Methods: This comprehensive literature review was performed using Medline and Scopus databases. The following search algorithm was used, "Pregnancy Complications" [Mesh] AND (Vagin*), and after the literature screening, 44 studies were included in the final review. Results: The studies that were included investigated the association between vaginal microbial composition and preterm birth, miscarriage, preeclampsia, ectopic pregnancy, gestational diabetes mellitus, chorioamnionitis, and preterm premature rupture of membranes. In most of the studies, it was well established that increased microbial diversity is associated with these conditions. Also, the depletion of Lactobacillus species is linked to most of the gestational complications, while the increased relative abundance and especially Lactobacillus crispatus may exert a protective effect in favor of the pregnant woman. Several pathogenic taxa including Gardnerella, Prevotella, Sneathia, Bacterial Vaginosis-Associated Bacteria-2, Atopobium, and Megasphera seem to be correlated to higher maternal morbidity. Conclusions: Vaginal microbiome aberrations seem to have an association with pregnancy-related adverse events, but more high-quality homogenous studies are necessary to reliably verify this link.
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Affiliation(s)
- Angeliki Gerede
- Unit of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, Medical School, Democritus University of Thrake, GR-68100 Alexandroupolis, Greece
| | - Konstantinos Nikolettos
- Unit of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, Medical School, Democritus University of Thrake, GR-68100 Alexandroupolis, Greece
| | - Eleftherios Vavoulidis
- Second Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54640 Thessaloniki, Greece
| | - Chrysoula Margioula-Siarkou
- Second Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54640 Thessaloniki, Greece
| | - Stamatios Petousis
- Second Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54640 Thessaloniki, Greece
| | - Maria Giourga
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, GR-11528 Athens, Greece
| | - Panagiotis Fotinopoulos
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, GR-11528 Athens, Greece
| | - Maria Salagianni
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, GR-11528 Athens, Greece
| | - Sofoklis Stavros
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, GR-11528 Athens, Greece
| | - Konstantinos Dinas
- Second Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54640 Thessaloniki, Greece
| | - Nikolaos Nikolettos
- Unit of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, Medical School, Democritus University of Thrake, GR-68100 Alexandroupolis, Greece
| | - Ekaterini Domali
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, GR-11528 Athens, Greece
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2
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Fong Amaris WM, de Assumpção PP, Valadares LJ, Moreira FC. Microbiota changes: the unseen players in cervical cancer progression. Front Microbiol 2024; 15:1352778. [PMID: 38389527 PMCID: PMC10881787 DOI: 10.3389/fmicb.2024.1352778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/16/2024] [Indexed: 02/24/2024] Open
Abstract
Cervical cancer ranks among the most prevalent cancers globally with high-risk human papillomaviruses implicated in nearly 99% of cases. However, hidden players such as changes in the microbiota are now being examined as potential markers in the progression of this disease. Researchers suggest that changes in the vaginal microbiota might correlate with cervical cancer. This review provides a comprehensive look at the microbiota changes linked with the advancement of cervical cancer. It also scrutinizes the databases from past studies on the microbiota during healthy and cancerous stages, drawing connections between prior findings concerning the role of the microbiota in the progression of cervical cancer. Preliminary findings identify Fusobacterium spp., Peptostreptococcus spp., Campylobacter spp., and Haemophilus spp., as potential biomarkers for cervical cancer progression. Alloscardovia spp., Eubacterium spp., and Mycoplasma spp. were identified as potential biomarkers for HPVs (+), while Methylobacterium spp. may be indicative of HPV (-). However, the study's limitations, including potential biases and methodological constraints, underscore the need for further research to validate these findings and delve deeper into the microbiota's role in HPV development. Despite these limitations, the review provides valuable insights into microbiota trends during cervical cancer progression, offering direction for future research. The review summarizes key findings from previous studies on microbiota during healthy and cancerous stages, as well as other conditions such as CIN, SIL, HPV (+), and HPV (-), indicating a promising area for further investigation. The consistent presence of HPV across all reported cervical abnormalities, along with the identification of distinct bacterial genera between cancerous and control samples, suggests a potential link that merits further exploration. In conclusion, a more profound understanding of the microbial landscape could elucidate the pathogenesis of cervical diseases and inform future strategies for diagnosis, prevention, and treatment.
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Affiliation(s)
- W M Fong Amaris
- Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém, Brazil
| | - Paulo Pimentel de Assumpção
- Núcleo de Pesquisas em Oncologia, Universidade Federal do Pará, Belém, Brazil
- Hospital Universitário João de Barros Barreto, Universidade Federal do Pará, Belém, Brazil
| | - Leonardo Jacomo Valadares
- Núcleo de Pesquisas em Oncologia, Universidade Federal do Pará, Belém, Brazil
- Hospital Universitário João de Barros Barreto, Universidade Federal do Pará, Belém, Brazil
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3
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Das S, Konwar BK. Prophylactic application of vaginal lactic acid bacteria against urogenital pathogens and its prospective use in sanitary suppositories. Int Microbiol 2024; 27:179-202. [PMID: 37258658 DOI: 10.1007/s10123-023-00376-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 04/30/2023] [Accepted: 05/09/2023] [Indexed: 06/02/2023]
Abstract
Beneficial and pathogenic microbes coexist in the vaginal canal, where a diminishing population of lactic acid bacteria may cause recurring urogenital infections. Probiotic bacteria Lactobacillus crispatus, Lactobacillus gasseri, Lactobacillus vaginalis, and pathogenic microbes Enterococcus faecalis, Enterobacter cloacae, Shigella sp., Staphylococcus epidermidis, and Escherichia fergusonii were isolated from vaginal swabs. Lactobacillus sp. and their probiotic culture free supernatant (PCFS) inhibited the growth of the above-mentioned urogenital pathogens. L. crispatus produced both lactic acid and hydrogen peroxide, exhibiting the best antimicrobial potential against the studied pathogens. Lyophilized L. crispatus had a shelf life of 12 months and the lyophilized PCFS also retained its antibacterial property with a minimum inhibition concentration of 1 μg/μL. Carboxy-methyl cellulose-alginate, a green alternative to super-absorbent polymers, was encapsulated with L. crispatus cells. The probiotic in its encapsulated state retained its viability for 21 days, and the bead showed 30% solvent absorptive capacity. PCFS-laced non-woven fabric displayed antibacterial property with no change in its physicochemical properties. These probiotic and postbiotic formulations have excellent prophylactic potential for urogenital infections. Such formulations can be exploited as additives in sanitary suppositories to enhance vaginal health.
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Affiliation(s)
- Shreaya Das
- Department of MBBT, Tezpur University, Napaam-784028, Assam, India
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4
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Amato KR, Pradhan P, Mallott EK, Shirola W, Lu A. Host-gut microbiota interactions during pregnancy. Evol Med Public Health 2024; 12:7-23. [PMID: 38288320 PMCID: PMC10824165 DOI: 10.1093/emph/eoae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/07/2023] [Indexed: 01/31/2024] Open
Abstract
Mammalian pregnancy is characterized by a well-known suite of physiological changes that support fetal growth and development, thereby positively affecting both maternal and offspring fitness. However, mothers also experience trade-offs between current and future maternal reproductive success, and maternal responses to these trade-offs can result in mother-offspring fitness conflicts. Knowledge of the mechanisms through which these trade-offs operate, as well as the contexts in which they operate, is critical for understanding the evolution of reproduction. Historically, hormonal changes during pregnancy have been thought to play a pivotal role in these conflicts since they directly and indirectly influence maternal metabolism, immunity, fetal growth and other aspects of offspring development. However, recent research suggests that gut microbiota may also play an important role. Here, we create a foundation for exploring this role by constructing a mechanistic model linking changes in maternal hormones, immunity and metabolism during pregnancy to changes in the gut microbiota. We posit that marked changes in hormones alter maternal gut microbiome composition and function both directly and indirectly via impacts on the immune system. The gut microbiota then feeds back to influence maternal immunity and metabolism. We posit that these dynamics are likely to be involved in mediating maternal and offspring fitness as well as trade-offs in different aspects of maternal and offspring health and fitness during pregnancy. We also predict that the interactions we describe are likely to vary across populations in response to maternal environments. Moving forward, empirical studies that combine microbial functional data and maternal physiological data with health and fitness outcomes for both mothers and infants will allow us to test the evolutionary and fitness implications of the gestational microbiota, enriching our understanding of the ecology and evolution of reproductive physiology.
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Affiliation(s)
- Katherine R Amato
- Department of Anthropology, Northwestern University, Evanston, IL 60208, USA
| | - Priyanka Pradhan
- Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Elizabeth K Mallott
- Department of Anthropology, Northwestern University, Evanston, IL 60208, USA
- Department of Biology, Washington University in St. Louis, St. Louis, MO 63130, USA
| | - Wesley Shirola
- Department of Psychology, Northwestern University, Evanston, IL 60208, USA
| | - Amy Lu
- Department of Anthropology, Stony Brook University, Stony Brook, NY 11794, USA
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5
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Strout N, Pasic L, Hicks C, Chua XY, Tashvighi N, Butler P, Liu Z, El-Assaad F, Holmes E, Susic D, Samaras K, Craig ME, Davis GK, Henry A, Ledger WL, El-Omar EM. The MothersBabies Study, an Australian Prospective Cohort Study Analyzing the Microbiome in the Preconception and Perinatal Period to Determine Risk of Adverse Pregnancy, Postpartum, and Child-Related Health Outcomes: Study Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6736. [PMID: 37754596 PMCID: PMC10531411 DOI: 10.3390/ijerph20186736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/03/2023] [Accepted: 09/06/2023] [Indexed: 09/28/2023]
Abstract
The microbiome has emerged as a key determinant of human health and reproduction, with recent evidence suggesting a dysbiotic microbiome is implicated in adverse perinatal health outcomes. The existing research has been limited by the sample collection and timing, cohort design, sample design, and lack of data on the preconception microbiome. This prospective, longitudinal cohort study will recruit 2000 Australian women, in order to fully explore the role of the microbiome in the development of adverse perinatal outcomes. Participants are enrolled for a maximum of 7 years, from 1 year preconception, through to 5 years postpartum. Assessment occurs every three months until pregnancy occurs, then during Trimester 1 (5 + 0-12 + 6 weeks gestation), Trimester 2 (20 + 0-24 + 6 weeks gestation), Trimester 3 (32 + 0-36 + 6 weeks gestation), and postpartum at 1 week, 2 months, 6 months, and then annually from 1 to 5 years. At each assessment, maternal participants self-collect oral, skin, vaginal, urine, and stool samples. Oral, skin, urine, and stool samples will be collected from children. Blood samples will be obtained from maternal participants who can access a study collection center. The measurements taken will include anthropometric, blood pressure, heart rate, and serum hormonal and metabolic parameters. Validated self-report questionnaires will be administered to assess diet, physical activity, mental health, and child developmental milestones. Medications, medical, surgical, obstetric history, the impact of COVID-19, living environments, and pregnancy and child health outcomes will be recorded. Multiomic bioinformatic and statistical analyses will assess the association between participants who developed high-risk and low-risk pregnancies, adverse postnatal conditions, and/or childhood disease, and their microbiome for the different sample types.
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Affiliation(s)
- Naomi Strout
- UNSW Microbiome Research Centre, St George and Sutherland Clinical Campuses, UNSW Sydney, Sydney, NSW 2052, Australia; (N.S.); (L.P.); (C.H.); (X.-Y.C.); (F.E.-A.); (D.S.)
| | - Lana Pasic
- UNSW Microbiome Research Centre, St George and Sutherland Clinical Campuses, UNSW Sydney, Sydney, NSW 2052, Australia; (N.S.); (L.P.); (C.H.); (X.-Y.C.); (F.E.-A.); (D.S.)
| | - Chloe Hicks
- UNSW Microbiome Research Centre, St George and Sutherland Clinical Campuses, UNSW Sydney, Sydney, NSW 2052, Australia; (N.S.); (L.P.); (C.H.); (X.-Y.C.); (F.E.-A.); (D.S.)
| | - Xin-Yi Chua
- UNSW Microbiome Research Centre, St George and Sutherland Clinical Campuses, UNSW Sydney, Sydney, NSW 2052, Australia; (N.S.); (L.P.); (C.H.); (X.-Y.C.); (F.E.-A.); (D.S.)
| | - Niki Tashvighi
- UNSW Microbiome Research Centre, St George and Sutherland Clinical Campuses, UNSW Sydney, Sydney, NSW 2052, Australia; (N.S.); (L.P.); (C.H.); (X.-Y.C.); (F.E.-A.); (D.S.)
| | - Phoebe Butler
- UNSW Microbiome Research Centre, St George and Sutherland Clinical Campuses, UNSW Sydney, Sydney, NSW 2052, Australia; (N.S.); (L.P.); (C.H.); (X.-Y.C.); (F.E.-A.); (D.S.)
| | - Zhixin Liu
- UNSW Stats Central, Biological Sciences South Building (E26), Level 2 Kensington, UNSW Sydney, Sydney, NSW 2052, Australia
- Healthdirect Australia, Level 4, 477 Pitt Street, Sydney, NSW 2000, Australia
| | - Fatima El-Assaad
- UNSW Microbiome Research Centre, St George and Sutherland Clinical Campuses, UNSW Sydney, Sydney, NSW 2052, Australia; (N.S.); (L.P.); (C.H.); (X.-Y.C.); (F.E.-A.); (D.S.)
| | - Elaine Holmes
- The Australian National Phenome Centre, Harry Perkins Institute, Murdoch University, Perth, WA 6150, Australia;
| | - Daniella Susic
- UNSW Microbiome Research Centre, St George and Sutherland Clinical Campuses, UNSW Sydney, Sydney, NSW 2052, Australia; (N.S.); (L.P.); (C.H.); (X.-Y.C.); (F.E.-A.); (D.S.)
- Department of Women’s and Children’s Health, St George Hospital, Kogarah, NSW 2217, Australia; (G.K.D.); (A.H.)
- Discipline of Women’s Health, School of Clinical Medicine, UNSW Sydney, Sydney, NSW 2052, Australia; (M.E.C.); (W.L.L.)
| | - Katherine Samaras
- Complex Diseases Program, Garvan Institute of Medical Research, Darlinghurst, NSW 2010, Australia;
- Department of Endocrinology, St Vincent’s Hospital, Darlinghurst, NSW 2010, Australia
- St Vincent’s Clinical Campus, UNSW Sydney, Sydney, NSW 2052, Australia
| | - Maria E. Craig
- Discipline of Women’s Health, School of Clinical Medicine, UNSW Sydney, Sydney, NSW 2052, Australia; (M.E.C.); (W.L.L.)
| | - Gregory K. Davis
- Department of Women’s and Children’s Health, St George Hospital, Kogarah, NSW 2217, Australia; (G.K.D.); (A.H.)
- Discipline of Women’s Health, School of Clinical Medicine, UNSW Sydney, Sydney, NSW 2052, Australia; (M.E.C.); (W.L.L.)
| | - Amanda Henry
- Department of Women’s and Children’s Health, St George Hospital, Kogarah, NSW 2217, Australia; (G.K.D.); (A.H.)
- Discipline of Women’s Health, School of Clinical Medicine, UNSW Sydney, Sydney, NSW 2052, Australia; (M.E.C.); (W.L.L.)
| | - William L. Ledger
- Discipline of Women’s Health, School of Clinical Medicine, UNSW Sydney, Sydney, NSW 2052, Australia; (M.E.C.); (W.L.L.)
| | - Emad M. El-Omar
- UNSW Microbiome Research Centre, St George and Sutherland Clinical Campuses, UNSW Sydney, Sydney, NSW 2052, Australia; (N.S.); (L.P.); (C.H.); (X.-Y.C.); (F.E.-A.); (D.S.)
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6
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Dias S, Pheiffer C, Adam S. The Maternal Microbiome and Gestational Diabetes Mellitus: Cause and Effect. Microorganisms 2023; 11:2217. [PMID: 37764061 PMCID: PMC10535124 DOI: 10.3390/microorganisms11092217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/27/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Gestational diabetes mellitus (GDM) is a growing public health concern that affects many pregnancies globally. The condition is associated with adverse maternal and neonatal outcomes including gestational hypertension, preeclampsia, placental abruption, preterm birth, stillbirth, and fetal growth restriction. In the long-term, mothers and children have an increased risk of developing metabolic diseases such as type 2 diabetes and cardiovascular disease. Accumulating evidence suggest that alterations in the maternal microbiome may play a role in the pathogenesis of GDM and adverse pregnancy outcomes. This review describes changes in the maternal microbiome during the physiological adaptations of pregnancy, GDM and adverse maternal and neonatal outcomes. Findings from this review highlight the importance of understanding the link between the maternal microbiome and GDM. Furthermore, new therapeutic approaches to prevent or better manage GDM are discussed. Further research and clinical trials are necessary to fully realize the therapeutic potential of the maternal microbiome and translate these findings into clinical practice.
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Affiliation(s)
- Stephanie Dias
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council, Tygerberg, Cape Town 7505, South Africa; (S.D.); (C.P.)
| | - Carmen Pheiffer
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council, Tygerberg, Cape Town 7505, South Africa; (S.D.); (C.P.)
- Centre for Cardio-Metabolic Research in Africa (CARMA), Division of Medical Physiology, Faculty of Health Sciences, Stellenbosch University, Tygerberg, Cape Town 7505, South Africa
- Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria 0028, South Africa
| | - Sumaiya Adam
- Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria 0028, South Africa
- Diabetes Research Centre, Faculty of Health Sciences, University of Pretoria, Pretoria 0028, South Africa
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7
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Garg A, Ellis LB, Love RL, Grewal K, Bowden S, Bennett PR, Kyrgiou M. Vaginal microbiome in obesity and its impact on reproduction. Best Pract Res Clin Obstet Gynaecol 2023; 90:102365. [PMID: 37399714 DOI: 10.1016/j.bpobgyn.2023.102365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/25/2023] [Accepted: 06/04/2023] [Indexed: 07/05/2023]
Abstract
A number of reproductive outcomes have been increasingly found to be affected by the vaginal microbiota. Obesity has become a global epidemic, affecting increasing numbers of reproductive-age women, and has been shown to be a risk factor for a number of adverse female health outcomes. A healthy vaginal microbiome is characterized by Lactobacillus-dominance, in particular Lactobacillus crispatus; obesity has been found to be associated with higher diversity and a lower likelihood of Lactobacillus-dominance. In this review, we summarize the evidence on the vaginal microbiome in obese women and the impact on reproductive outcomes such as conception rates, early pregnancy, and preterm birth. We further explore the mechanisms by which obesity may result in an altered microbial composition and highlight future avenues for therapeutic targeting of the vaginal microbiota.
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Affiliation(s)
- Akanksha Garg
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, W12 0NN, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Laura Burney Ellis
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, W12 0NN, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Ryan Laurence Love
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, W12 0NN, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Karen Grewal
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, W12 0NN, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Sarah Bowden
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, W12 0NN, London, UK
| | - Phillip R Bennett
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, W12 0NN, London, UK
| | - Maria Kyrgiou
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, W12 0NN, London, UK; Imperial College Healthcare NHS Trust, London, UK.
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8
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Yefet E, Bejerano A, Iskander R, Zilberman Kimhi T, Nachum Z. The Association between Gestational Diabetes Mellitus and Infections in Pregnancy-Systematic Review and Meta-Analysis. Microorganisms 2023; 11:1956. [PMID: 37630515 PMCID: PMC10458027 DOI: 10.3390/microorganisms11081956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/10/2023] [Accepted: 07/28/2023] [Indexed: 08/27/2023] Open
Abstract
We conducted a systematic review and meta-analysis to evaluate the association between gestational diabetes mellitus and infections during pregnancy. We included cross-sectional, case-control, cohort studies and clinical trials, evaluating the frequency of infections in women with and without gestational diabetes mellitus. A search was conducted in Embase, PubMed, and Web of Science electronic databases and by manually searching references, until 23 March 2022, resulting in 16 studies being selected for review, with 111,649 women in the gestational diabetes mellitus group, and 1,429,659 in the controls. Cochrane's Q test of heterogeneity and I² were used to assess heterogeneity. Pooled odds ratio (OR) was calculated. Funnel plots and Egger test were used for assessment of publication bias. The results showed a significant association between gestational diabetes mellitus and infections (pooled-OR 1.3 95% CI [1.2-1.5]). Sub-analyses showed a significant association for urinary tract infections (pooled-OR of 1.2 95% CI [1.1-1.3]), bacterial infections (pooled-OR were 1.2 95% CI [1.1-1.4]), and SARS-CoV-2 (pooled-OR 1.5 95% CI [1.2-2.0]) but not to gingivitis or vaginal candidiasis. The results underscore the significance of acknowledging gestational diabetes mellitus as a risk factor for infections.
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Affiliation(s)
- Enav Yefet
- Department of Obstetrics and Gynecology, Tzafon Medical Center, Poriya 1528001, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Aviv Bejerano
- Department of Obstetrics and Gynecology, Tzafon Medical Center, Poriya 1528001, Israel
| | - Rula Iskander
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula 1834111, Israel (Z.N.)
| | - Tal Zilberman Kimhi
- Department of Obstetrics and Gynecology, Tzafon Medical Center, Poriya 1528001, Israel
| | - Zohar Nachum
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula 1834111, Israel (Z.N.)
- Rappaport Faculty of Medicine, Technion, Haifa 3109601, Israel
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9
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Singh P, Elhaj DAI, Ibrahim I, Abdullahi H, Al Khodor S. Maternal microbiota and gestational diabetes: impact on infant health. J Transl Med 2023; 21:364. [PMID: 37280680 PMCID: PMC10246335 DOI: 10.1186/s12967-023-04230-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 05/26/2023] [Indexed: 06/08/2023] Open
Abstract
Gestational diabetes mellitus (GDM) is a common complication of pregnancy that has been associated with an increased risk of obesity and diabetes in the offspring. Pregnancy is accompanied by tightly regulated changes in the endocrine, metabolic, immune, and microbial systems, and deviations from these changes can alter the mother's metabolism resulting in adverse pregnancy outcomes and a negative impact on the health of her infant. Maternal microbiomes are significant drivers of mother and child health outcomes, and many microbial metabolites are likely to influence the host health. This review discusses the current understanding of how the microbiota and microbial metabolites may contribute to the development of GDM and how GDM-associated changes in the maternal microbiome can affect infant's health. We also describe microbiota-based interventions that aim to improve metabolic health and outline future directions for precision medicine research in this emerging field.
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Affiliation(s)
- Parul Singh
- College of Health & Life Sciences, Hamad Bin Khalifa University, Qatar Foundation, Doha, Qatar
- Research Department, Sidra Medicine, Doha, Qatar
| | | | - Ibrahim Ibrahim
- Women's Department, Sidra Medicine, Weill Cornell Medical College-Qatar, Doha, Qatar
| | - Hala Abdullahi
- Women's Department, Sidra Medicine, Weill Cornell Medical College-Qatar, Doha, Qatar
| | - Souhaila Al Khodor
- College of Health & Life Sciences, Hamad Bin Khalifa University, Qatar Foundation, Doha, Qatar.
- Research Department, Sidra Medicine, Doha, Qatar.
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Panzer JJ, Romero R, Greenberg JM, Winters AD, Galaz J, Gomez-Lopez N, Theis KR. Is there a placental microbiota? A critical review and re-analysis of published placental microbiota datasets. BMC Microbiol 2023; 23:76. [PMID: 36934229 PMCID: PMC10024458 DOI: 10.1186/s12866-023-02764-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/10/2023] [Indexed: 03/20/2023] Open
Abstract
The existence of a placental microbiota is debated. The human placenta has historically been considered sterile and microbial colonization was associated with adverse pregnancy outcomes. Yet, recent DNA sequencing investigations reported a microbiota in typical human term placentas. However, this detected microbiota could represent background DNA or delivery-associated contamination. Using fifteen publicly available 16S rRNA gene datasets, existing data were uniformly re-analyzed with DADA2 to maximize comparability. While Amplicon Sequence Variants (ASVs) identified as Lactobacillus, a typical vaginal bacterium, were highly abundant and prevalent across studies, this prevalence disappeared after applying likely DNA contaminant removal to placentas from term cesarean deliveries. A six-study sub-analysis targeting the 16S rRNA gene V4 hypervariable region demonstrated that bacterial profiles of placental samples and technical controls share principal bacterial ASVs and that placental samples clustered primarily by study origin and mode of delivery. Contemporary DNA-based evidence does not support the existence of a placental microbiota.ImportanceEarly-gestational microbial influences on human development are unclear. By applying DNA sequencing technologies to placental tissue, bacterial DNA signals were observed, leading some to conclude that a live bacterial placental microbiome exists in typical term pregnancy. However, the low-biomass nature of the proposed microbiome and high sensitivity of current DNA sequencing technologies indicate that the signal may alternatively derive from environmental or delivery-associated bacterial DNA contamination. Here we address these alternatives with a re-analysis of 16S rRNA gene sequencing data from 15 publicly available placental datasets. After identical DADA2 pipeline processing of the raw data, subanalyses were performed to control for mode of delivery and environmental DNA contamination. Both environment and mode of delivery profoundly influenced the bacterial DNA signal from term-delivered placentas. Aside from these contamination-associated signals, consistency was lacking across studies. Thus, placentas delivered at term are unlikely to be the original source of observed bacterial DNA signals.
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Affiliation(s)
- Jonathan J Panzer
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI, USA
- Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI, USA.
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA.
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA.
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA.
- Detroit Medical Center, Detroit, Michigan, USA.
| | - Jonathan M Greenberg
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Andrew D Winters
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI, USA
- Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Jose Galaz
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Division of Obstetrics and Gynecology, School of Medicine, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Nardhy Gomez-Lopez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI, USA
- Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Kevin R Theis
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI, USA.
- Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit, Michigan, USA.
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA.
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11
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Giannella L, Grelloni C, Quintili D, Fiorelli A, Montironi R, Alia S, Delli Carpini G, Di Giuseppe J, Vignini A, Ciavattini A. Microbiome Changes in Pregnancy Disorders. Antioxidants (Basel) 2023; 12:antiox12020463. [PMID: 36830021 PMCID: PMC9952029 DOI: 10.3390/antiox12020463] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
The human microbiota comprises all microorganisms, such as bacteria, fungi, and viruses, found within a specific environment that live on our bodies and inside us. The last few years have witnessed an explosion of information related to the role of microbiota changes in health and disease. Even though the gut microbiota is considered the most important in maintaining our health, other regions of the human body, such as the oral cavity, lungs, vagina, and skin, possess their own microbiota. Recent work suggests a correlation between the microbiota present during pregnancy and pregnancy complications. The aim of our literature review was to provide a broad overview of this growing and important topic. We focused on the most significant changes in the microbiota in the four more common obstetric diseases affecting women's health. Thus, our attention will be focused on hypertensive disorders, gestational diabetes mellitus, preterm birth, and recurrent miscarriage. Pregnancy is a unique period in a woman's life since the body undergoes different adaptations to provide an optimal environment for fetal growth. Such changes also involve all the microorganisms, which vary in composition and quantity during the three trimesters of gestation. In addition, special attention will be devoted to the potential and fundamental advances in developing clinical applications to prevent and treat those disorders by modulating the microbiota to develop personalized therapies for disease prevention and tailored treatments.
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Affiliation(s)
- Luca Giannella
- Woman’s Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Via Filippo Corridoni, 16, 60123 Ancona, Italy
| | - Camilla Grelloni
- Woman’s Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Via Filippo Corridoni, 16, 60123 Ancona, Italy
| | - Dayana Quintili
- Woman’s Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Via Filippo Corridoni, 16, 60123 Ancona, Italy
| | - Alessia Fiorelli
- Woman’s Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Via Filippo Corridoni, 16, 60123 Ancona, Italy
| | - Ramona Montironi
- Woman’s Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Via Filippo Corridoni, 16, 60123 Ancona, Italy
| | - Sonila Alia
- Department of Clinical Sciences, Section of Biochemistry, Biology and Physics, Università Politecnica delle Marche, Via Tronto 10/A, 60126 Ancona, Italy
| | - Giovanni Delli Carpini
- Woman’s Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Via Filippo Corridoni, 16, 60123 Ancona, Italy
| | - Jacopo Di Giuseppe
- Woman’s Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Via Filippo Corridoni, 16, 60123 Ancona, Italy
| | - Arianna Vignini
- Department of Clinical Sciences, Section of Biochemistry, Biology and Physics, Università Politecnica delle Marche, Via Tronto 10/A, 60126 Ancona, Italy
- Correspondence: ; Tel.: +39-0712204675
| | - Andrea Ciavattini
- Woman’s Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Via Filippo Corridoni, 16, 60123 Ancona, Italy
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12
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Shen L, Wang W, Hou W, Jiang C, Yuan Y, Hu L, Shang A. The function and mechanism of action of uterine microecology in pregnancy immunity and its complications. Front Cell Infect Microbiol 2023; 12:1025714. [PMID: 36683698 PMCID: PMC9846260 DOI: 10.3389/fcimb.2022.1025714] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/22/2022] [Indexed: 01/06/2023] Open
Abstract
The human microbiota influences physiology, disease, and metabolic reproduction. The origin of uterine bacteria is controversial. The main assumption is that the germs enter the uterine cavity from the vagina through the cervical canal, bloodstream, fallopian tubes, and gynecological surgical channels. Understanding the microbiota at various anatomical sites is critical to the female reproductive system and pregnancy. Today's study focuses on the role of uterine bacteria in pregnancy and embryo implantation. According to our findings, the uterine microbiome influences embryo implantation and pregnancy outcome. Pregnancy is a natural, evolutionarily selected approach to human reproduction. During pregnancy, the microbiota of the reproductive tract changes, facilitating the maintenance of pregnancy, and the human immune system undergoes a series of changes that recognize and adapt to the non-self. From the beginning of pregnancy, a non-self fetus must establish a placenta of embryonic origin to protect itself and promote growth; the VMB tends to be more stable and lactobacillus-dominated in late gestation than in early gestation. Any material that disrupts this connection, such as microbial changes, is associated with a higher risk of poor health and poor pregnancy outcomes in women (eclampsia). The presence of any material that disrupts this connection, such as microbial changes, is associated with a higher risk of poor health and poor pregnancy outcomes (preeclampsia, preterm birth, gestational diabetes, etc.). In this work, we review the last decade of relevant research to improve our understanding of the mechanisms by which the microbiota of the female reproductive tract influences female reproductive health. This work discusses the mechanisms associated with the reproductive tract microbiota and pregnancy immunity, as well as the impact of an abnormal microbiota on adverse pregnancy outcomes. Emphasis is placed on the characteristics and sources of the female vaginal, uterine, and placental microbiota and the importance of a well-stabilized local human microbiota and immune system for embryo implantation, placental development, fetal growth, and pregnancy outcome.
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Affiliation(s)
- Liping Shen
- Department of Obstetrics and Gynecology, Changning Maternity & Infant Health Hospital, Shanghai, China,Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Weiwei Wang
- Department of Laboratory Medicine, The Second People's Hospital of Lianyungang & The Oncology Hospital of Lianyungang, Lianyungang, Jiangsu, P.R., China,Department of Pathology, Tinghu People's Hospital of Yancheng City, Yancheng, Jiangsu, P.R., China
| | - Weiwei Hou
- Department of Laboratory Medicine, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chenfei Jiang
- Department of Laboratory Medicine, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yi Yuan
- Department of Laboratory Medicine, The Second People's Hospital of Lianyungang & The Oncology Hospital of Lianyungang, Lianyungang, Jiangsu, P.R., China
| | - Liqing Hu
- Department of Laboratory Medicine, Ningbo First Hospital & Ningbo Hospital of Zhejiang University, Ningbo, Zhejiang, P.R., China,*Correspondence: Anquan Shang, ; Liqing Hu,
| | - Anquan Shang
- Department of Laboratory Medicine, The Second People's Hospital of Lianyungang & The Oncology Hospital of Lianyungang, Lianyungang, Jiangsu, P.R., China,*Correspondence: Anquan Shang, ; Liqing Hu,
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13
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Li M, Huang Z, Tao Z, Meng Y, Wen J, Zhang Q, Liu Y, Shang M, Wang Y, Wang Y, Chen R, Wang X, Cao Y, Zhang L, Liao Q. The role of upper and lower genital tract microbiota alterations in term chorionamnionitis: A prospective study. Front Microbiol 2022; 13:1069254. [PMID: 36605507 PMCID: PMC9808057 DOI: 10.3389/fmicb.2022.1069254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022] Open
Abstract
Objective This study aimed to compare the dynamics of lower and upper genital tract microbiota in normal term pregnancy, histological chorioamnionitis (HCA), and clinical chorioamnionitis (CCA) patients to provide a reference for the diagnosis and treatment of chorioamnionitis (CAM) patients. Methods We prospectively collected vaginal and cervical secretions, as well as placenta tissues, fetal membranes, and amniotic fluid from normal-term pregnant women, HCA and CCA patients. Then, we performed genomic DNA extraction and PCR amplification for all samples. The eligible samples were analyzed by 16S ribosomal RNA (16S rRNA) sequencing. Additionally, all placenta tissues were histopathologically examined, and neonatal pharyngeal swabs and placenta tissues from the HCA and CCA groups were subjected to microbial culture. Results A total of 85 term pregnant women were enrolled in this study, including 34 in the normal group (N), 37 in the HCA group, and 14 in the CCA group. A total of 171 qualified samples were analyzed by 16S rRNA sequencing. The results suggested that the cervical microbiota was highly similar to the vaginal microbiota in normal term parturients, with Lactobacillus as the dominant bacterium. Moreover, there was no difference in the alpha and beta diversity of vaginal microbiota between the N, HCA, and CCA groups at the genus level. Besides, no significant differences were detected in cervical microbiome among the three groups. Regarding intrauterine microorganisms, the N and HCA groups had similar microbial composition but were different from the CCA group. No microbe was detected in the placental tissue of normal term parturients, while some microorganisms were found in the intrauterine amniotic fluid and fetal membrane samples. Regardless of cultivation or 16S rRNA sequencing, an extremely low microbial positive rate was detected in HCA and CCA intrauterine samples. Compared to the normal group, Lactobacillus was significantly reduced in the CCA group intrauterine, and Ureaplasma and Enterococcus increased with no statistically significant. Conclusion The N, HCA and CCA groups had similar composition of vaginal and cervical microflora. Some normal-term pregnant women can harbor non-pathogenic microbiota in the uterine cavity. Sterile inflammation is more frequent than microbial-associated inflammation in term HCA and CCA parturients.
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Affiliation(s)
- Meng Li
- School of Clinical Medicine, Tsinghua University, Beijing, China,Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhenyu Huang
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhi Tao
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yiting Meng
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jia Wen
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Qiongqiong Zhang
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Ying Liu
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Mengyuan Shang
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Ying Wang
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yufeng Wang
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Rui Chen
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xiaoqian Wang
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yang Cao
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Lei Zhang
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China,*Correspondence: Lei Zhang, ; Qinping Liao,
| | - Qinping Liao
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China,*Correspondence: Lei Zhang, ; Qinping Liao,
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14
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Martín-Grau C, Díaz-López A, Aparicio E, Arija V. Short-Chain Fatty Acid Reference Ranges in Pregnant Women from a Mediterranean Region of Northern Spain: ECLIPSES Study. Nutrients 2022; 14:nu14183798. [PMID: 36145175 PMCID: PMC9503449 DOI: 10.3390/nu14183798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/09/2022] [Accepted: 09/13/2022] [Indexed: 01/08/2023] Open
Abstract
Maternal short-chain fatty acids (SCFAs) play a critical role in fetal development and metabolic programming. However, an important gap in the analysis of such relationships is the lack of reference values in pregnant women. Therefore, we establish serum SCFA percentile reference ranges both early and later in pregnancy in a population from a Mediterranean region of Northern Spain. A population-based follow-up study involving 455 healthy pregnant women (mean age 30.6 ± 5.0 years) from the ECLIPSES study is conducted. Sociodemographic, obstetric, anthropometric, lifestyle, dietary variables and blood samples were collected in the first and third trimesters. Serum SCFA concentrations were measured by LC-MS/MS. The 2.5/97.5 percentiles of the reference interval for serum acetic, propionic, isobutyric, and butyric acids were 16.4/103.8 µmol/L, 2.1/5.8 µmol/L, 0.16/1.01 µmol/L and 0.32/1.67 µmol/L in the first trimester of pregnancy, respectively. In the third trimester, butyrate levels increased with most of the maternal factors and categories studied, while acetic acid and isobutyric acid decreased only in some maternal categories. Propionic acid was not affected by maternal factors. Reference ranges did not vary with maternal age, body weight, social class or diet, but decreased with smoking, high physical activity, low BMI and primiparity. This study establishes for the first-time SCFAs reference ranges in serum for women in our region in both early and late pregnancy. This information can be useful to monitor pregnancy follow-up and detect risk values.
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Affiliation(s)
- Carla Martín-Grau
- Clinical Chemistry and Laboratory Medicine, Institut Català de la Salut, Generalitat de Catalunya, University Hospital Joan XXIII, 43005 Tarragona, Spain
- Department of Basic Medical Sciences, Nutrition and Mental Health Research Group (NUTRISAM), Faculty of Medicine and Health Sciences, Rovira i Virgili University (URV), 43201 Reus, Spain
- Genetics Unit, Health Research Institute of Hospital La Fe (IIS La Fe), 46026 Valencia, Spain
| | - Andrés Díaz-López
- Department of Basic Medical Sciences, Nutrition and Mental Health Research Group (NUTRISAM), Faculty of Medicine and Health Sciences, Rovira i Virgili University (URV), 43201 Reus, Spain
- Institut d’Investigació Sanitària Pere Virgili (IISPV), 43005 Tarragona, Spain
| | - Estefania Aparicio
- Department of Basic Medical Sciences, Nutrition and Mental Health Research Group (NUTRISAM), Faculty of Medicine and Health Sciences, Rovira i Virgili University (URV), 43201 Reus, Spain
- Institut d’Investigació Sanitària Pere Virgili (IISPV), 43005 Tarragona, Spain
| | - Victoria Arija
- Department of Basic Medical Sciences, Nutrition and Mental Health Research Group (NUTRISAM), Faculty of Medicine and Health Sciences, Rovira i Virgili University (URV), 43201 Reus, Spain
- Institut d’Investigació Sanitària Pere Virgili (IISPV), 43005 Tarragona, Spain
- CENIT Research Group (Collaborative Group on Lifestyles, Nutrition and Smoking), Unitat de Suport a la Recerca Tarragona-Reus, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 43202 Reus, Spain
- Correspondence: ; Tel.: +34-977-759334
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15
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Taniya MA, Chung HJ, Al Mamun A, Alam S, Aziz MA, Emon NU, Islam MM, Hong STS, Podder BR, Ara Mimi A, Aktar Suchi S, Xiao J. Role of Gut Microbiome in Autism Spectrum Disorder and Its Therapeutic Regulation. Front Cell Infect Microbiol 2022; 12:915701. [PMID: 35937689 PMCID: PMC9355470 DOI: 10.3389/fcimb.2022.915701] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/22/2022] [Indexed: 12/14/2022] Open
Abstract
Autism spectrum disorder (ASD) is a neurological disorder that affects normal brain development. The recent finding of the microbiota–gut–brain axis indicates the bidirectional connection between our gut and brain, demonstrating that gut microbiota can influence many neurological disorders such as autism. Most autistic patients suffer from gastrointestinal (GI) symptoms. Many studies have shown that early colonization, mode of delivery, and antibiotic usage significantly affect the gut microbiome and the onset of autism. Microbial fermentation of plant-based fiber can produce different types of short-chain fatty acid (SCFA) that may have a beneficial or detrimental effect on the gut and neurological development of autistic patients. Several comprehensive studies of the gut microbiome and microbiota–gut–brain axis help to understand the mechanism that leads to the onset of neurological disorders and find possible treatments for autism. This review integrates the findings of recent years on the gut microbiota and ASD association, mainly focusing on the characterization of specific microbiota that leads to ASD and addressing potential therapeutic interventions to restore a healthy balance of gut microbiome composition that can treat autism-associated symptoms.
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Affiliation(s)
- Masuma Afrin Taniya
- Department of Life Sciences, School of Environment and Life Science, Independent University, Dhaka, Bangladesh
| | - Hea-Jong Chung
- Gwanju Center, Korea Basic Science Institute, Gwanju, South Korea
- *Correspondence: Hea-Jong Chung, ; Jian Xiao,
| | - Abdullah Al Mamun
- Molecular Pharmacology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, China
| | - Safaet Alam
- Drugs and Toxins Research Division, BCSIR Laboratories, Rajshahi, Bangladesh Council of Scientific and Industrial Research, Rajshahi, Bangladesh
| | - Md. Abdul Aziz
- Department of Pharmacy, Faculty of Pharmacy and Health Sciences, State University of Bangladesh, Dhaka, Bangladesh
| | - Nazim Uddin Emon
- Department of Pharmacy, Faculty of Science and Engineering, International Islamic University Chittagong, Chattogram, Bangladesh
| | - Md. Minarul Islam
- Department of Biomedical Sciences and Institute for Medical Science, Jeonbuk National University Medical School, Jeonju, South Korea
| | - Seong-T shool Hong
- Department of Biomedical Sciences and Institute for Medical Science, Jeonbuk National University Medical School, Jeonju, South Korea
| | - Bristy Rani Podder
- Department of Biochemistry and Molecular Biology, University of Dhaka, Dhaka, Bangladesh
| | - Anjuman Ara Mimi
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka, Bangladesh
| | - Suzia Aktar Suchi
- Department of Pharmacy, College of Pharmacy, Chosun University, Gwangju, South Korea
| | - Jian Xiao
- Molecular Pharmacology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, China
- Department of Hand Surgery and Peripheral Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Hea-Jong Chung, ; Jian Xiao,
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16
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Huang Y, Li D, Cai W, Zhu H, Shane MI, Liao C, Pan S. Distribution of Vaginal and Gut Microbiome in Advanced Maternal Age. Front Cell Infect Microbiol 2022; 12:819802. [PMID: 35694547 PMCID: PMC9186158 DOI: 10.3389/fcimb.2022.819802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/20/2022] [Indexed: 11/13/2022] Open
Abstract
The distribution of the microbiome in women with advanced maternal age (AMA) is poorly understood. To gain insight into this, the vaginal and gut microbiota of 62 women were sampled and sequenced using the 16S rRNA technique. These women were divided into three groups, namely, the AMA (age ≥ 35 years, n = 13) group, the non-advanced maternal age (NMA) (age < 35 years, n = 38) group, and the control group (non-pregnant healthy women, age >35 years, n = 11). We found that the alpha diversity of vaginal microbiota in the AMA group significantly increased. However, the beta diversity significantly decreased in the AMA group compared with the control group. There was no significant difference in the diversity of gut microbiota among the three groups. The distributions of microbiota were significantly different among AMA, NMA, and control groups. In vaginal microbiota, the abundance of Lactobacillus was higher in the pregnant groups. Bifidobacterium was significantly enriched in the AMA group. In gut microbiota, Prevotella bivia was significantly enriched in the AMA group. Vaginal and gut microbiota in women with AMA were noticeably different from the NMA and non-pregnant women, and this phenomenon is probably related to the increased risk of complications in women with AMA.
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Affiliation(s)
- Yuxin Huang
- Department of Gynaecology and Obstetrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Dianjie Li
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Wei Cai
- Department of Gynaecology and Obstetrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Honglei Zhu
- Department of Gynaecology and Obstetrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Mc Intyre Shane
- Department of Gynaecology and Obstetrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Can Liao
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Prenatal Diagnostic Center, Guangzhou Women and Children’s Medical Center, Guangzhou, China
- *Correspondence: Can Liao, ; Shilei Pan,
| | - Shilei Pan
- Department of Gynaecology and Obstetrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- *Correspondence: Can Liao, ; Shilei Pan,
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17
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Wang Y, Wang X, Zhu M, Ge L, Liu X, Su K, Chen Z, Zhao W. The Interplay Between Cervicovaginal Microbial Dysbiosis and Cervicovaginal Immunity. Front Immunol 2022; 13:857299. [PMID: 35359942 PMCID: PMC8960256 DOI: 10.3389/fimmu.2022.857299] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/21/2022] [Indexed: 12/02/2022] Open
Abstract
The cervicovaginal microbiota plays a key role in the health and reproductive outcomes of women. In reality epidemiological studies have demonstrated that there is an association between the structure of cervicovaginal microbiota and reproductive health, although key mechanistic questions regarding these effects remain unanswered and understanding the interplay between the immune system and the structure of the cervicovaginal microbiota. Here, we review existing literature relating to the potential mechanisms underlying the interaction between vaginal microbes and the immune system; we also describe the composition and function of the microbiome and explain the mechanisms underlying the interactions between these microbial communities and various aspects of the immune system. Finally, we also discuss the diseases that are caused by disorders of the reproductive tract and how the immune system is involved. Finally, based on the data presented in this review, the future perspectives in research directions and therapeutic opportunities are explored.
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Affiliation(s)
- Ya Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Xiaoli Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Meiling Zhu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Li Ge
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Xiaochen Liu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Kaikai Su
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Zhengzheng Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Weidong Zhao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
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Farhat S, Hemmatabadi M, Ejtahed HS, Shirzad N, Larijani B. Microbiome alterations in women with gestational diabetes mellitus and their offspring: A systematic review. Front Endocrinol (Lausanne) 2022; 13:1060488. [PMID: 36568098 PMCID: PMC9772279 DOI: 10.3389/fendo.2022.1060488] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022] Open
Abstract
AIMS Gestational diabetes mellitus (GDM) is a metabolic disorder that might predispose pregnant women to develop type 2 Diabetes Mellitus or lead to severe adverse outcomes in their offspring. One of the factors that have been thought to be involved in the pathology behind this disorder is the microbiome. In this systematic review, we comprehensively review the documents regarding the microbiota alterations in different tracts of pregnant women with GDM and their offspring. METHODS A comprehensive search was conducted in major databases including MEDLINE (PubMed), Scopus, and Web of sciences up to August 2021. Data on the demographics, methodology, and microbiome alterations were extracted and classified according to the type of microbiome in pregnant women with GDM and their offspring. The quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). RESULTS In 49 articles which were retrieved, the findings were variable on the level of changes in alpha and beta diversity, enrichment or depletion in phyla, genera, species and OTUs, in each microbiome type. Although there were some inconsistencies among the results, a pattern of significant alterations was seen in the gut, oral, vaginal microbiome of women with GDM and gut, oral, and placental microbiome of their offspring. CONCLUSION Even though the alteration of the microbiome of the different tracts was seen in the cases of GDM, the inconsistency among the studies prevents us from identifying unique pattern. However, the results seem promising and further studies that overcome the confounding factors related to the demographics and methodology are needed.
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Affiliation(s)
- Sara Farhat
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Hemmatabadi
- Endocrine Research Center, Valiasr Hospital, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Hanieh-Sadat Ejtahed
- Obesity and Eating Habits Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- *Correspondence: Hanieh-Sadat Ejtahed, ; Nooshin Shirzad,
| | - Nooshin Shirzad
- Endocrine Research Center, Valiasr Hospital, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- *Correspondence: Hanieh-Sadat Ejtahed, ; Nooshin Shirzad,
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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KIECKA ANETA, MACURA BARBARA, SZCZEPANIK MARIAN. Can Lactobacillus spp. Be a Factor Reducing the Risk of Miscarriage? Pol J Microbiol 2021; 70:431-446. [PMID: 35003275 PMCID: PMC8702604 DOI: 10.33073/pjm-2021-043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/30/2021] [Indexed: 11/30/2022] Open
Abstract
Pregnancy loss is a common obstetric problem. Significant causes of miscarriage include genetic and epigenetic disorders of the embryo, immunological and endocrine factors, uterine malformations, improper embryo selection, and lifestyle. Perhaps a hitherto underappreciated cause of miscarriage may be an abnormal microbiota composition of the female reproductive system. Lactobacillus spp. is the most common bacteria within the reproductive tract. However, the protective role of Lactobacilli in the vagina has been well described in the literature, while it is still unknown what function Lactobacilli may have in the uterus. Moreover, new research shows that Lactobacillus spp. can have a role in miscarriage. However, both molecular and immunological mechanisms of host-Lactobacillus spp. interactions are not fully understood. Understanding these relationships will help address the importance and extent of the protective role of Lactobacillus spp. in miscarriage.
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Affiliation(s)
- ANETA KIECKA
- Jagiellonian University Medical College, Faculty of Health Sciences, Institute of Physiotherapy, Chair of Biomedical Sciences, Cracow, Poland
| | - BARBARA MACURA
- Jagiellonian University Medical College, Faculty of Health Sciences, Institute of Physiotherapy, Chair of Biomedical Sciences, Cracow, Poland
| | - MARIAN SZCZEPANIK
- Jagiellonian University Medical College, Faculty of Health Sciences, Institute of Physiotherapy, Chair of Biomedical Sciences, Cracow, Poland
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20
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Probiotic Supplements Improve Blood Glucose and Insulin Resistance/Sensitivity among Healthy and GDM Pregnant Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:9830200. [PMID: 34603479 PMCID: PMC8481047 DOI: 10.1155/2021/9830200] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/27/2021] [Indexed: 12/11/2022]
Abstract
Background Probiotic supplements may be seen as a promising way to improve glucose metabolism. This study aimed to evaluate the effects of probiotic supplements on blood glucose, insulin resistance/sensitivity, and prevention of gestational diabetes mellitus (GDM) among pregnant women. Methods Eleven electronic databases were searched from inception to May 2020. Two authors independently identified randomized controlled trials (RCTs), assessed the eligibility and quality of the included studies, and then extracted data. The primary outcomes were fasting plasma glucose (FPG), 1 h and 2 h plasma glucose after 75 g oral glucose tolerance test (OGTT), HbA1c, fasting plasma insulin, insulin resistance, and insulin sensitivity. Fixed and random effect models were used to pool the results. Results A total of 20 RCTs involving 2972 participants were included according to the inclusion and exclusion criteria. The pooled results of this research showed that probiotic supplements could reduce the level of FPG (mean difference (MD) = −0.11; 95% CI = −0.15 to −0.04; P=0.0007), serum insulin (MD = −1.68; 95% CI = −2.44 to −0.92; P < 0.00001), insulin resistance (MD = −0.36; 95% CI = −0.53 to −0.20; P < 0.00001), and insulin sensitivity (MD = −21.80; 95% CI = −31.92 to −11.67; P < 0.00001). Regarding the subgroup analysis of different pregnant women, the effects of probiotics on FPG, insulin, and insulin resistance were more obvious among GDM and healthy women than among overweight/obese women. Furthermore, the differences were not significant in HbA1c (MD = −0.05; 95% CI = −0.12 to 0.03; P=0.23), 1 h OGTT (MD = −0.07; 95% CI = −0.25 to 0.10; P=0.42), and 2 h OGTT (MD = −0.03; 95% CI = −0.17 to 0.12; P=0.72). Conclusion This review found that probiotic supplements had certain functions to reduce the level of FPG and improve insulin, insulin resistance, and insulin sensitivity, especially for GDM and healthy pregnant women.
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21
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Juliana NCA, Peters RPH, Al-Nasiry S, Budding AE, Morré SA, Ambrosino E. Composition of the vaginal microbiota during pregnancy in women living in sub-Saharan Africa: a PRISMA-compliant review. BMC Pregnancy Childbirth 2021; 21:596. [PMID: 34479485 PMCID: PMC8418042 DOI: 10.1186/s12884-021-04072-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/20/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The vaginal microbiota (VMB) are the set of microorganisms residing in the human vagina. During pregnancy, their composition is Lactobacillus-dominant in most Caucasian women. Previous studies suggest that the VMB of women with African ancestry is more likely to be non-Lactobacillus dominant (dysbiotic) compared to other populations, and possibly relate to the high incidence of pregnancy complications, such as preterm birth. This work reviewed the literature on VMB composition in pregnant women from sub-Saharan Africa. METHODS A search was conducted in PubMed and Embase databases following PRISMA guidelines. Observational and intervention studies analysing VMB communities from sub-Saharan African pregnant women using molecular techniques were included. RESULTS Ten studies performed in seven sub-Saharan African countries were identified. They independently showed that Lactobacillus-dominant VMB (particularly L. iners or L. crispatus) or VMB containing Lactobacilli are the most prevalent, followed by a more diverse anaerobe-dominant VMB, in the studied populations. The majority of pregnant women with a sexually-transmitted infection had a Lactobacillus-dominant VMB, but with a significantly higher presence of anaerobic species. CONCLUSION In agreement with studies performed in other populations, Lactobacillus species are the most prevalent VMB species during pregnancy in sub-Saharan African women. The frequency of diverse anaerobe-dominant VMB is high in these populations. In Africa, studies on VMB in pregnancy are scant, heterogeneous in methodology, and knowledge remains limited. More insights on VMB composition and their possible sequalae among these populations is needed.
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Affiliation(s)
- Naomi C A Juliana
- Department of Genetics and Cell Biology, Faculty of Health, Medicine and Life Sciences, Research School GROW (School for Oncology & Developmental Biology), Institute for Public Health Genomics, Maastricht University, Maastricht, Netherlands
| | - Remco P H Peters
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa.,Department of Medical Microbiology, School for Public Health and Primary Care (CAPRHI), Maastricht University, Maastricht, Netherlands.,Research Unit, Foundation for Professional Development, East London, South Africa
| | - Salwan Al-Nasiry
- Department of Obstetrics and Gynecology, GROW School of Oncology and Developmental Biology, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
| | | | - Servaas A Morré
- Department of Genetics and Cell Biology, Faculty of Health, Medicine and Life Sciences, Research School GROW (School for Oncology & Developmental Biology), Institute for Public Health Genomics, Maastricht University, Maastricht, Netherlands.,Laboratory of Immunogenetics, Department Medical Microbiology and Infection Control, Location AMC, Amsterdam UMC, Amsterdam, Netherlands
| | - Elena Ambrosino
- Department of Genetics and Cell Biology, Faculty of Health, Medicine and Life Sciences, Research School GROW (School for Oncology & Developmental Biology), Institute for Public Health Genomics, Maastricht University, Maastricht, Netherlands.
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22
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Composition of the microbial communities at different body sites in women with preterm birth and their newborns. MEDICINE IN MICROECOLOGY 2021. [DOI: 10.1016/j.medmic.2021.100046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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23
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Zhou Y, Qi H, Yin N. Adaptations and alterations of maternal microbiota: From physiology to pathology. MEDICINE IN MICROECOLOGY 2021. [DOI: 10.1016/j.medmic.2021.100045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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24
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Schiattarella A, Lombardo M, Morlando M, Rizzo G. The Impact of a Plant-Based Diet on Gestational Diabetes: A Review. Antioxidants (Basel) 2021; 10:antiox10040557. [PMID: 33918528 PMCID: PMC8065523 DOI: 10.3390/antiox10040557] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 12/13/2022] Open
Abstract
Gestational diabetes mellitus (GDM) represents a challenging pregnancy complication in which women present a state of glucose intolerance. GDM has been associated with various obstetric complications, such as polyhydramnios, preterm delivery, and increased cesarean delivery rate. Moreover, the fetus could suffer from congenital malformation, macrosomia, neonatal respiratory distress syndrome, and intrauterine death. It has been speculated that inflammatory markers such as tumor necrosis factor-alpha (TNF-α), interleukin (IL) 6, and C-reactive protein (CRP) impact on endothelium dysfunction and insulin resistance and contribute to the pathogenesis of GDM. Nutritional patterns enriched with plant-derived foods, such as a low glycemic or Mediterranean diet, might favorably impact on the incidence of GDM. A high intake of vegetables, fibers, and fruits seems to decrease inflammation by enhancing antioxidant compounds. This aspect contributes to improving insulin efficacy and metabolic control and could provide maternal and neonatal health benefits. Our review aims to deepen the understanding of the impact of a plant-based diet on oxidative stress in GDM.
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Affiliation(s)
- Antonio Schiattarella
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (A.S.); (M.M.)
| | - Mauro Lombardo
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, 00166 Rome, Italy;
| | - Maddalena Morlando
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (A.S.); (M.M.)
| | - Gianluca Rizzo
- Independent Researcher, Via Venezuela 66, 98121 Messina, Italy
- Correspondence: ; Tel.: +39-320-897-6687
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25
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Desai V, Kozyrskyj AL, Lau S, Sanni O, Dennett L, Walter J, Ospina MB. Effectiveness of Probiotic, Prebiotic, and Synbiotic Supplementation to Improve Perinatal Mental Health in Mothers: A Systematic Review and Meta-Analysis. Front Psychiatry 2021; 12:622181. [PMID: 33967849 PMCID: PMC8100186 DOI: 10.3389/fpsyt.2021.622181] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/22/2021] [Indexed: 12/16/2022] Open
Abstract
Introduction: There is an emerging interest in modulating the gut microbiota to target the gut-brain axis and improve maternal mental health in the perinatal period. This systematic review evaluated the effectiveness of prebiotics, probiotics, and synbiotics supplementation during pregnancy to reduce the risk of maternal mental health problems in the perinatal period. Methods: Electronic biomedical databases and clinical trial registries were searched from database inception through August 2020 to identify randomized controlled clinical trials (RCTs) evaluating the effect of probiotic, prebiotic, or synbiotic supplements administered to women during pregnancy on measures of perinatal depression, anxiety, and other mental health outcomes. Study selection, risk of bias appraisal, and data extraction were independently performed by two reviewers. Pooled mean differences (MD) and odds ratios (pOR) with 95% confidence intervals (CI) were calculated in random-effects meta-analyses for the outcomes of interest in the review. Results: From 3,868 studies identified through the search strategy, three RCTs of low risk of bias involving 713 participants were included, all three testing probiotics. There were no differences between probiotics and control groups in the mean depression scores (MD -0.46; 95% CI -2.16, 1.25) at end of follow-up. Although statistical significance was not achieved, probiotics showed an advantage in the proportion of participants scoring below an established cut-off for depression (pOR 0.68; 95% CI 0.43, 1.07). Compared to placebo, probiotics in pregnancy reduced anxiety symptoms (MD -0.99; 95% CI -1.80, -0.18); however, this advantage was not translated in a reduction in the proportion of participants scoring above an established cut-off for anxiety (pOR 0.65; 95% CI 0.23, 1.85). There were no differences between probiotics and control groups in global mental health scores at end of follow-up (MD 1.09; 95% CI -2.04, 4.22). Conclusion: There is limited but promising evidence about the effectiveness of probiotics during pregnancy to reduce anxiety symptoms and reduce the proportion of women scoring ABOVE a cut-off depression score. There is a lack of RCT evidence supporting prebiotics and synbiotics supplementation for similar purposes in the perinatal period. More research is needed before prebiotics, probiotics, and synbiotics are recommended to support maternal mental health and well-being in the perinatal period. Systematic Review Registration: PROSPERO, CRD42019137158.
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Affiliation(s)
- Vidhi Desai
- Department of Obstetrics & Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Anita L Kozyrskyj
- Department of Obstetrics & Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Stuart Lau
- Faculty of Science, McGill University, Montreal, QC, Canada
| | - Omolara Sanni
- Department of Obstetrics & Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Liz Dennett
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Jens Walter
- Department of Medicine, School of Microbiology, University College Cork, National University of Ireland, Cork, Ireland.,APC Microbiome Institute Ireland, University College Cork, National University of Ireland, Cork, Ireland
| | - Maria B Ospina
- Department of Obstetrics & Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,School of Public Health, University of Alberta, Edmonton, AB, Canada
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Neri C, Serafino E, Morlando M, Familiari A. Microbiome and Gestational Diabetes: Interactions with Pregnancy Outcome and Long-Term Infant Health. J Diabetes Res 2021; 2021:9994734. [PMID: 34869780 PMCID: PMC8639280 DOI: 10.1155/2021/9994734] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 10/26/2021] [Indexed: 12/11/2022] Open
Abstract
Microbiota composition is progressively being connected to different physiologic effects, such as glucose metabolism, and also to different pathologies, such as gestational diabetes mellitus (GDM). GDM is a public health concern that affects an important percentage of pregnancies and is correlated with many adverse maternal and neonatal outcomes. An increasing number of studies are showing some connections between specific microbial composition of the gut microbiota and development of GDM and adverse outcomes in mothers and neonates. The aim of this review is to analyze the available data on microbial changes that characterize healthy pregnancies and pregnancies complicated by GDM and to understand the correlation of these changes with adverse maternal outcomes; this review will also discuss the consequences of these maternal gut microbiome alterations on neonatal microbiota composition and neonatal long-term outcomes.
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Affiliation(s)
- Caterina Neri
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Erika Serafino
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Maddalena Morlando
- Prenatal Diagnosis and High Risk Pregnancy Unit, Department of Woman, Child and of General and Specialized Surgery, University “Luigi Vanvitelli”, Naples, Italy
| | - Alessandra Familiari
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
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Szczuko M, Kikut J, Maciejewska D, Kulpa D, Celewicz Z, Ziętek M. The Associations of SCFA with Anthropometric Parameters and Carbohydrate Metabolism in Pregnant Women. Int J Mol Sci 2020; 21:ijms21239212. [PMID: 33287163 PMCID: PMC7731050 DOI: 10.3390/ijms21239212] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 12/16/2022] Open
Abstract
Short-chain fatty acids (SCFAs) mediate the transmission of signals between the microbiome and the immune system and are responsible for maintaining balance in the anti-inflammatory reaction. Pregnancy stages alter the gut microbiota community structure, which also synthesizes SCFAs. The study involved 90 pregnant women, divided into two groups: 48 overweight/obese pregnant women (OW) and 42 pregnant women with normal BMI (CG). The blood samples for glucose, insulin, and HBA1c were analyzed as well as stool samples for SCFA isolation (C2:0; C3:0; C4:0i; C4:0n; C5:0i; C5:0n; C6:0i; C6:0n) using gas chromatography. The SCFA profile in the analyzed groups differed significantly. A significant positive correlation between C2:0, C3:0, C4:0n and anthropometric measurements, and between C2:0, C3:0, C4:0n, and C5:0n and parameters of carbohydrate metabolism was found. SCFA levels fluctuate during pregnancy and the course of pregnancy and participate in the change in carbohydrate metabolism as well. The influence of C2:0 during pregnancy on anthropometric parameters was visible in both groups (normal weight and obese). Butyrate and propionate regulate glucose metabolism by stimulating the process of intestinal gluconeogenesis. The level of propionic acid decreases with the course of pregnancy, while its increase is characteristic of obese women, which is associated with many metabolic adaptations. Propionic and linear caproic acid levels can be an important critical point in maintaining lower anthropometric parameters during pregnancy.
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Affiliation(s)
- Małgorzata Szczuko
- Department of Human Nutrition and Metabolomics, Pomeranian Medical University in Szczecin, Broniewskiego 24, 71-460 Szczecin, Poland; (J.K.); (D.M.)
- Correspondence: ; Tel.: +48-91-441-4810; Fax: +48-91-441-4807
| | - Justyna Kikut
- Department of Human Nutrition and Metabolomics, Pomeranian Medical University in Szczecin, Broniewskiego 24, 71-460 Szczecin, Poland; (J.K.); (D.M.)
| | - Dominika Maciejewska
- Department of Human Nutrition and Metabolomics, Pomeranian Medical University in Szczecin, Broniewskiego 24, 71-460 Szczecin, Poland; (J.K.); (D.M.)
| | - Danuta Kulpa
- Department of Genetics, Plant Breeding and Biotechnology, Faculty of Environmental Management and Agriculture, West Pomeranian University of Technology, Słowackiego 17, 71-434 Szczecin, Poland;
| | - Zbigniew Celewicz
- Department of Perinatology, Obstetrics and Gynecology, Pomeranian Medical University in Szczecin, Siedlecka 2, 72-010 Police, Poland; (Z.C.); (M.Z.)
| | - Maciej Ziętek
- Department of Perinatology, Obstetrics and Gynecology, Pomeranian Medical University in Szczecin, Siedlecka 2, 72-010 Police, Poland; (Z.C.); (M.Z.)
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Castanheira CP, Sallas ML, Nunes RAL, Lorenzi NPC, Termini L. Microbiome and Cervical Cancer. Pathobiology 2020; 88:187-197. [PMID: 33227782 DOI: 10.1159/000511477] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/07/2020] [Indexed: 11/19/2022] Open
Abstract
Persistent infection with some types of mucosal human papillomavirus (HPV) is the etiological factor for the development of cervical cancer and its precursor lesions. Besides, several cofactors are known to play a role in cervical disease onset and progression either by favoring or by preventing HPV infection and persistence. The microbiome of a healthy female genital tract is characterized by the presence of 1 or few varieties of lactobacilli. However, high-throughput studies addressing the bacterial diversity and abundance in the female genital tract have shown that several factors, including hormonal levels, hygiene habits, and sexually transmitted diseases may disrupt the natural balance, favoring the outgrowth of some groups of bacteria, which in turn may favor some pathological states. Recently, the vaginal microbiome has emerged as a new variable that could greatly influence the natural history of HPV infections and their clinical impact. In this context, changes in the vaginal microbiome have been detected in women infected with HPV and women with HPV-associated lesions and cancer. However, the role of specific bacteria groups in the development/progression or prevention/regression of HPV-associated pathologies is not well understood. In this review we summarize the current knowledge concerning changes in vaginal microbiome and cervical disease. We discuss the potential functional interplay between specific bacterial groups and HPV infection outcomes.
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Affiliation(s)
| | - Mayara Luciana Sallas
- Innovation in Cancer Laboratory, Centro de Investigação Translacional em Oncologia, Instituto do Câncer do Estado de São Paulo Octavio Frias de Oliveira, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Rafaella Almeida Lima Nunes
- Innovation in Cancer Laboratory, Centro de Investigação Translacional em Oncologia, Instituto do Câncer do Estado de São Paulo Octavio Frias de Oliveira, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Lara Termini
- Innovation in Cancer Laboratory, Centro de Investigação Translacional em Oncologia, Instituto do Câncer do Estado de São Paulo Octavio Frias de Oliveira, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil,
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Dinsdale NK, Castaño-Rodríguez N, Quinlivan JA, Mendz GL. Comparison of the Genital Microbiomes of Pregnant Aboriginal and Non-aboriginal Women. Front Cell Infect Microbiol 2020; 10:523764. [PMID: 33194782 PMCID: PMC7658313 DOI: 10.3389/fcimb.2020.523764] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 09/16/2020] [Indexed: 12/13/2022] Open
Abstract
The genital microbiomes of women varies with racial background. Preterm birth and early-onset neonatal sepsis are two outcomes associated with genital infections during pregnancy. The rate of preterm birth in Aboriginal Australian mothers is high, as is the rate of early-onset sepsis in their infants. To date, no studies have been conducted to investigate genital microbiome taxa associated infection in this group of women. A prospective cohort study to characterize the vaginal and placental microbiomes of a group of these women from the Pilbara region was conducted at the Hedland Health Campus in Western Australia. Included in the study were gravidae Aboriginal (n = 23) and Non-aboriginal (n = 27) women in labor or for planned lower uterine segment Caesarean section. Employing sterile swabs, vaginal samples were obtained under sterile conditions immediately prior to vaginal delivery or planned Caesarean section; and placental samples were obtained under the same conditions during labor. Taxa present in the samples were identified by 16S rRNA amplicon sequencing (V4 region, 515F-806R). Taxon identity and abundance were established from Operational Taxonomic Unit (OTU) counts. Statistical analyses combining clinical metadata and sequencing results were employed to determine associations of taxa with racial background. The findings of this work served to enhance the current understanding of microbiota associated with health and disease in Aboriginal and Non-Aboriginal women. Differences were found between the vaginal and placental microbiomes of Aboriginal and Non-aboriginal women during pregnancy, as well as notable differences between the abundance of specific taxa in each racial group. The relative abundances of specific taxa were significantly different between participants with clinical signs of infection and those with healthy pregnancies. This work will contribute to understanding the causes of differences in rates of infection-driven preterm birth in various racial populations.
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Affiliation(s)
- Nicole K Dinsdale
- School of Medicine, Perth, The University of Western Australia, Perth, WA, Australia
| | - Natalia Castaño-Rodríguez
- School of Biotechnology and Biomolecular Sciences, The University of New South Wales, Kensington, NSW, Australia
| | - Julie A Quinlivan
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, WA, Australia
| | - George L Mendz
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia
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30
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Ashary N, Singh A, Chhabria K, Modi D. Meta-analysis on prevalence of vaginal group B streptococcus colonization and preterm births in India. J Matern Fetal Neonatal Med 2020; 35:2923-2931. [PMID: 32873095 DOI: 10.1080/14767058.2020.1813705] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Preterm birth is a major cause of neonatal morbidity and mortality. Vaginal colonization of Group B Streptococci (GBS) is associated with increased risk of preterm birth. However, the association of GBS colonization and preterm births in the Indian context remains an unrecognized problem. DATA SOURCES Data was collected using various online search tools from 36 (1981-2019) Indian studies comprising 9778 cases. METHOD OF STUDY SELECTION Studies reporting the prevalence of GBS colonization in the Indian population were included. TABULATION, INTEGRATION, AND RESULTS The prevalence of GBS colonization in pregnant Indian women was estimated to be 7.8% (763/9778) with wide heterogeneity across studies. The prevalence of GBS was 7.4% when culture methods were used and 11.6% with use of immunological methods. The detection rate of GBS almost doubled when enrichment was used in the culture method (8.1 vs. 5%). The risk of preterm delivery was higher (OR 7.9) among women with GBS colonization as compared to those without GBS. CONCLUSIONS As compared to the western population, there is low prevalence of GBS colonization among Indian pregnant women; however, the risk of preterm births with GBS colonization is higher. There is a need to implement a universal GBS screening program prior to intrapartum antibiotic prophylaxis in women experiencing preterm births.
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Affiliation(s)
- Nancy Ashary
- Molecular and Cellular Biology Laboratory, ICMR-National Institute for Research in Reproductive Health, Indian Council of Medical Research (ICMR), Mumbai, India
| | - Abhishek Singh
- Molecular and Cellular Biology Laboratory, ICMR-National Institute for Research in Reproductive Health, Indian Council of Medical Research (ICMR), Mumbai, India.,Department of Microbiology, MGM Medical College, Navi Mumbai, India
| | - Karisma Chhabria
- Molecular and Cellular Biology Laboratory, ICMR-National Institute for Research in Reproductive Health, Indian Council of Medical Research (ICMR), Mumbai, India
| | - Deepak Modi
- Molecular and Cellular Biology Laboratory, ICMR-National Institute for Research in Reproductive Health, Indian Council of Medical Research (ICMR), Mumbai, India
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31
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Jayaram PM, Mohan MK, Konje J. Bacterial vaginosis in pregnancy - a storm in the cup of tea. Eur J Obstet Gynecol Reprod Biol 2020; 253:220-224. [PMID: 32889328 DOI: 10.1016/j.ejogrb.2020.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/30/2020] [Accepted: 08/21/2020] [Indexed: 01/11/2023]
Abstract
Human vaginal microbiota is dominated by Lactobacillus spp both in the non-pregnant and pregnant state. Bacterial vaginosis (BV) is an imbalance of vaginal microbiota caused by a reduction in the normal lactobacillary bacteria, and a heavy over-growth of mixed anaerobic bacteria. Various clinical (Amsel's Criteria), laboratory (Nugent's score) and molecular diagnostic method (quantitative PCR) are used for diagnosis. BV in pregnancy is associated with increased risk of preterm birth, low birth weight, chorioamnionitis and postpartum endometritis, apart from bothersome vaginal discharge. Antibiotic treatment with metronidazole or clindamycin are effective in eradicating bacterial vaginosis and safe to use in pregnancy. Treatment of bacterial vaginosis has not been shown to improve obstetric outcomes in women at low risk of preterm birth, but may reduce the risk of preterm birth and low birth weight in women at increased risk of preterm birth. Routine screening and treatment is not recommended in low risk women. Test for cure should be performed after treatment. Further research is required on other treatment modalities such as probiotic therapy and microbiota transplantation.
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Affiliation(s)
- Pradeep M Jayaram
- Sidra Medicine and Weill Cornell Medical College, PO Box 26999, Doha, Qatar.
| | - Manoj K Mohan
- Sidra Medicine and Weill Cornell Medical College, PO Box 26999, Doha, Qatar.
| | - Justin Konje
- Sidra Medicine and Weill Cornell Medical College, PO Box 26999, Doha, Qatar.
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32
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Parris KM, Amabebe E, Cohen MC, Anumba DO. Placental microbial-metabolite profiles and inflammatory mechanisms associated with preterm birth. J Clin Pathol 2020; 74:10-18. [PMID: 32796048 DOI: 10.1136/jclinpath-2020-206536] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 12/27/2022]
Abstract
There is growing emphasis on the potential significance of the placental microbiome and microbiome-metabolite interactions in immune responses and subsequent pregnancy outcome, especially in relation to preterm birth (PTB). This review discusses in detail the pathomechanisms of placental inflammatory responses and the resultant maternal-fetal allograft rejection in both microbial-induced and sterile conditions. It also highlights some potential placental-associated predictive markers of PTB for future investigation. The existence of a placental microbiome remains debatable. Therefore, an overview of our current understanding of the state and role of the placental microbiome (if it exists) and metabolome in human pregnancy is also provided. We critical evaluate the evidence for a placental microbiome, discuss its functional capacity through the elaborated metabolic products and also describe the consequent and more established fetomaternal inflammatory responses that stimulate the pathway to preterm premature rupture of membranes, preterm labour and spontaneous PTB.
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Affiliation(s)
- Kerry M Parris
- Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Marta C Cohen
- Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Histopathology, Sheffield Childrens Hospital NHS Foundation Trust, Sheffield, UK
| | - Dilly O Anumba
- Oncology and Metabolism, University of Sheffield, Sheffield, UK
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33
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Peterson LS, Stelzer IA, Tsai AS, Ghaemi MS, Han X, Ando K, Winn VD, Martinez NR, Contrepois K, Moufarrej MN, Quake S, Relman DA, Snyder MP, Shaw GM, Stevenson DK, Wong RJ, Arck P, Angst MS, Aghaeepour N, Gaudilliere B. Multiomic immune clockworks of pregnancy. Semin Immunopathol 2020; 42:397-412. [PMID: 32020337 PMCID: PMC7508753 DOI: 10.1007/s00281-019-00772-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/31/2019] [Indexed: 12/15/2022]
Abstract
Preterm birth is the leading cause of mortality in children under the age of five worldwide. Despite major efforts, we still lack the ability to accurately predict and effectively prevent preterm birth. While multiple factors contribute to preterm labor, dysregulations of immunological adaptations required for the maintenance of a healthy pregnancy is at its pathophysiological core. Consequently, a precise understanding of these chronologically paced immune adaptations and of the biological pacemakers that synchronize the pregnancy "immune clock" is a critical first step towards identifying deviations that are hallmarks of peterm birth. Here, we will review key elements of the fetal, placental, and maternal pacemakers that program the immune clock of pregnancy. We will then emphasize multiomic studies that enable a more integrated view of pregnancy-related immune adaptations. Such multiomic assessments can strengthen the biological plausibility of immunological findings and increase the power of biological signatures predictive of preterm birth.
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Affiliation(s)
- Laura S Peterson
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Ina A Stelzer
- Department of Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Amy S Tsai
- Department of Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Mohammad S Ghaemi
- Department of Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Xiaoyuan Han
- Department of Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Kazuo Ando
- Department of Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Virginia D Winn
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Nadine R Martinez
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Kevin Contrepois
- Stanford Metabolic Health Center, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Center for Genomics and Personalized Medicine, Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | - Mira N Moufarrej
- Department of Bioengineering, Stanford University School of Engineering, Stanford, CA, USA
| | - Stephen Quake
- Department of Bioengineering, Stanford University School of Engineering, Stanford, CA, USA
| | - David A Relman
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Infectious Diseases Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Michael P Snyder
- Stanford Center for Genomics and Personalized Medicine, Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | - Gary M Shaw
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - David K Stevenson
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Ronald J Wong
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Petra Arck
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin S Angst
- Department of Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Nima Aghaeepour
- Department of Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Brice Gaudilliere
- Department of Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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34
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Sparvoli LG, Cortez RV, Daher S, Padilha M, Sun SY, Nakamura MU, Taddei CR. Women's multisite microbial modulation during pregnancy. Microb Pathog 2020; 147:104230. [PMID: 32428665 DOI: 10.1016/j.micpath.2020.104230] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 12/21/2022]
Abstract
The composition of female microbiome varies with age, physiological and socio-behavior conditions. Also, changes in microbiome composition are observed as pregnancy progresses, especially in the vaginal site. Together with the physiological adaptations of gestation, changes in microbiome composition seem to be fundamental for proper fetal development. This study aimed at simultaneously evaluating the vaginal, gut, and oral microbiome of healthy pregnant women, and comparing it with those observed in healthy non-pregnant women of reproductive age. In a cross-sectional study, vaginal, oral and gut samples were collected from 42 pregnant and 18 non-pregnant women, and the microbiome composition was evaluated by 16S rRNA sequencing, using Illumina platform. In the pregnant group, we observed a positive correlation between Eubacterium and Akkermansia in the gut samples; between Eubacterium and Ruminococcus in the vaginal samples; and between Streptococcus and Gemella in the oral samples. Notwithstanding, we observed a negative correlation between Lactobacillus and Atopobium and between Lactobacillus and Gardnerella in vaginal microbiome. Prevotella was the only genus found in all three sites studied; however, there was no signal of bacterial influence between sites during pregnancy. These results suggest that in addition to hormonal and immunological variations during healthy pregnancy, the female body also undergoes microbiome modulation in multiple sites in order to maintain an eubiotic status.
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Affiliation(s)
- Luiz G Sparvoli
- Department of Clinical and Toxicological Analysis, School of Pharmaceutical Sciences, Universidade de São Paulo (USP), São Paulo, 05508-000, São Paulo, Brazil.
| | - Ramon V Cortez
- Department of Clinical and Toxicological Analysis, School of Pharmaceutical Sciences, Universidade de São Paulo (USP), São Paulo, 05508-000, São Paulo, Brazil.
| | - Silvia Daher
- Department of Obstetrics, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, 04039-002, São Paulo, Brazil.
| | - Marina Padilha
- Department of Pharmaceutical Technology, School of Pharmaceutical Sciences, Universidade de São Paulo (USP), São Paulo, 05508-000, São Paulo, Brazil.
| | - Sue Y Sun
- Department of Obstetrics, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, 04039-002, São Paulo, Brazil.
| | - Mary U Nakamura
- Department of Obstetrics, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, 04039-002, São Paulo, Brazil.
| | - Carla R Taddei
- Department of Clinical and Toxicological Analysis, School of Pharmaceutical Sciences, Universidade de São Paulo (USP), São Paulo, 05508-000, São Paulo, Brazil; School of Arts, Sciences and Humanities, Universidade de São Paulo (USP), São Paulo, 03828-000, Brazil.
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35
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Hasain Z, Mokhtar NM, Kamaruddin NA, Mohamed Ismail NA, Razalli NH, Gnanou JV, Raja Ali RA. Gut Microbiota and Gestational Diabetes Mellitus: A Review of Host-Gut Microbiota Interactions and Their Therapeutic Potential. Front Cell Infect Microbiol 2020; 10:188. [PMID: 32500037 PMCID: PMC7243459 DOI: 10.3389/fcimb.2020.00188] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 04/08/2020] [Indexed: 12/15/2022] Open
Abstract
Gestational diabetes mellitus (GDM) is defined as impaired glucose tolerance recognized during pregnancy. GDM is associated with metabolic disorder phenotypes, such as obesity, low-grade inflammation, and insulin resistance. Following delivery, nearly half of the women with a history of GDM have persistent postpartum glucose intolerance and an increased risk of developing type 2 diabetes mellitus (T2DM), as much as 7-fold. The alarming upward trend may worsen the socioeconomic burden worldwide. Accumulating evidence strongly associates gut microbiota dysbiosis in women with GDM, similar to the T2DM profile. Several metagenomics studies have shown gut microbiota, such as Ruminococcaceae, Parabacteroides distasonis, and Prevotella, were enriched in women with GDM. These microbiota populations are associated with metabolic pathways for carbohydrate metabolism and insulin signaling, suggesting a potential "gut microbiota signature" in women with GDM. Furthermore, elevated expression of serum zonulin, a marker of gut epithelial permeability, during early pregnancy in women with GDM indicates a possible link between gut microbiota and GDM. Nevertheless, few studies have revealed discrepant results, and the interplay between gut microbiota dysbiosis and host metabolism in women with GDM is yet to be elucidated. Lifestyle modification and pharmacological treatment with metformin showed evidence of modulation of gut microbiota and proved to be beneficial to maintain glucose homeostasis in T2DM. Nonetheless, post-GDM women have poor compliance toward lifestyle modification after delivery, and metformin treatment remains controversial as a T2DM preventive strategy. We hypothesized modulation of the composition of gut microbiota with probiotics supplementation may reverse postpartum glucose intolerance in post-GDM women. In this review, we addressed gut microbiota dysbiosis and the possible mechanistic links between the host and gut microbiota in women with GDM. Furthermore, this review highlights the potential therapeutic use of probiotics in post-GDM women as a T2DM preventive strategy.
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Affiliation(s)
- Zubaidah Hasain
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Malaysia.,Faculty of Medicine, National Defence University of Malaysia, Kuala Lumpur, Malaysia
| | - Norfilza Mohd Mokhtar
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Malaysia.,GUT Research Group, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nor Azmi Kamaruddin
- Endocrine Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Malaysia
| | - Nor Azlin Mohamed Ismail
- Department of Obstetrics & Gynecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nurul Huda Razalli
- GUT Research Group, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.,Dietetic Program, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | | | - Raja Affendi Raja Ali
- GUT Research Group, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.,Gastroenterology Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Malaysia
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36
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Al-Nasiry S, Ambrosino E, Schlaepfer M, Morré SA, Wieten L, Voncken JW, Spinelli M, Mueller M, Kramer BW. The Interplay Between Reproductive Tract Microbiota and Immunological System in Human Reproduction. Front Immunol 2020; 11:378. [PMID: 32231664 PMCID: PMC7087453 DOI: 10.3389/fimmu.2020.00378] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 02/17/2020] [Indexed: 12/12/2022] Open
Abstract
In the last decade, the microbiota, i.e., combined populations of microorganisms living inside and on the surface of the human body, has increasingly attracted attention of researchers in the medical field. Indeed, since the completion of the Human Microbiome Project, insight and interest in the role of microbiota in health and disease, also through study of its combined genomes, the microbiome, has been steadily expanding. One less explored field of microbiome research has been the female reproductive tract. Research mainly from the past decade suggests that microbial communities residing in the reproductive tract represent a large proportion of the female microbial network and appear to be involved in reproductive failure and pregnancy complications. Microbiome research is facing technological and methodological challenges, as detection techniques and analysis methods are far from being standardized. A further hurdle is understanding the complex host-microbiota interaction and the confounding effect of a multitude of constitutional and environmental factors. A key regulator of this interaction is the maternal immune system that, during the peri-conceptional stage and even more so during pregnancy, undergoes considerable modulation. This review aims to summarize the current literature on reproductive tract microbiota describing the composition of microbiota in different anatomical locations (vagina, cervix, endometrium, and placenta). We also discuss putative mechanisms of interaction between such microbial communities and various aspects of the immune system, with a focus on the characteristic immunological changes during normal pregnancy. Furthermore, we discuss how abnormal microbiota composition, “dysbiosis,” is linked to a spectrum of clinical disorders related to the female reproductive system and how the maternal immune system is involved. Finally, based on the data presented in this review, the future perspectives in diagnostic approaches, research directions and therapeutic opportunities are explored.
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Affiliation(s)
- Salwan Al-Nasiry
- Department of Obstetrics and Gynecology, GROW School of Oncology and Developmental Biology, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
| | - Elena Ambrosino
- Department of Genetics and Cell Biology, Faculty of Health, Medicine and Life Sciences, Research School GROW (School for Oncology & Developmental Biology), Institute for Public Health Genomics, Maastricht University, Maastricht, Netherlands
| | - Melissa Schlaepfer
- Department of Obstetrics and Gynecology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Servaas A Morré
- Department of Genetics and Cell Biology, Faculty of Health, Medicine and Life Sciences, Research School GROW (School for Oncology & Developmental Biology), Institute for Public Health Genomics, Maastricht University, Maastricht, Netherlands.,Laboratory of Immunogenetics, Department Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam UMC, Amsterdam, Netherlands
| | - Lotte Wieten
- Tissue Typing Laboratory, Department of Transplantation Immunology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jan Willem Voncken
- Department of Molecular Genetics, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Marialuigia Spinelli
- Department of Obstetrics and Gynecology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Martin Mueller
- Department of Obstetrics and Gynecology, University Hospital Bern, University of Bern, Bern, Switzerland.,Department of Pediatrics, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Boris W Kramer
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, Netherlands
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37
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Mei C, Yang W, Wei X, Wu K, Huang D. The Unique Microbiome and Innate Immunity During Pregnancy. Front Immunol 2019; 10:2886. [PMID: 31921149 PMCID: PMC6929482 DOI: 10.3389/fimmu.2019.02886] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/25/2019] [Indexed: 12/26/2022] Open
Abstract
A successful pregnancy depends on not only the tolerance of the fetal immune system by the mother but also resistance against the threat of hazardous microorganisms. Infection with pathogenic microorganisms during pregnancy may lead to premature delivery, miscarriage, growth restriction, neonatal morbidity, and other adverse outcomes. Moreover, the host also has an intact immune system to avoid these adverse outcomes. It is important to note the presence of normal bacteria in the maternal reproductive tract and the principal role of the maternal-placental-fetal interaction in antimicrobial immunity. Previous studies mainly focused on maternal infection during pregnancy. However, this review summarizes the new views on the study of the maternal microbiome and expounds the innate immune defense mechanism of the maternal vagina and decidua as well as how cytotrophoblasts and syncytiotrophoblasts recognize and kill bacteria in the placenta. Fetal immune systems, thought to be weak, also exhibit an immune defense function that is indispensable for maintaining the safety of the fetus. The skin, lungs, and intestines of the fetus during pregnancy constitute the main immune barriers. These findings will provide a new understanding of the effects of normal microbial flora and how the host resists harmful microbes during pregnancy. We believe that it may also contribute to the reference on the clinical prevention and treatment of gestational infection to avoid adverse pregnancy outcomes.
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Affiliation(s)
- Chunlei Mei
- Institute of Reproductive Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weina Yang
- Institute of Reproductive Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Wei
- Second Affiliated Hospital of Jinlin University, Changchun, China
| | - Kejia Wu
- Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Donghui Huang
- Institute of Reproductive Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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38
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Kelley AS, Smith YR, Padmanabhan V. A Narrative Review of Placental Contribution to Adverse Pregnancy Outcomes in Women With Polycystic Ovary Syndrome. J Clin Endocrinol Metab 2019; 104:5299-5315. [PMID: 31393571 PMCID: PMC6767873 DOI: 10.1210/jc.2019-00383] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/01/2019] [Indexed: 12/29/2022]
Abstract
CONTEXT Polycystic ovary syndrome (PCOS) is the most common endocrinopathy of reproductive-aged women. In pregnancy, women with PCOS experience increased risk of miscarriage, gestational diabetes, preeclampsia, and extremes of fetal birth weight, and their offspring are predisposed to reproductive and cardiometabolic dysfunction in adulthood. Pregnancy complications, adverse fetal outcomes, and developmental programming of long-term health risks are known to have placental origins. These findings highlight the plausibility of placental compromise in pregnancies of women with PCOS. EVIDENCE SYNTHESIS A comprehensive PubMed search was performed using terms "polycystic ovary syndrome," "placenta," "developmental programming," "hyperandrogenism," "androgen excess," "insulin resistance," "hyperinsulinemia," "pregnancy," and "pregnancy complications" in both human and animal experimental models. CONCLUSIONS There is limited human placental research specific to pregnancy of women with PCOS. Gestational androgen excess and insulin resistance are two clinical hallmarks of PCOS that may contribute to placental dysfunction and underlie the higher rates of maternal-fetal complications observed in pregnancies of women with PCOS. Additional research is needed to prevent adverse maternal and developmental outcomes in women with PCOS and their offspring.
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Affiliation(s)
- Angela S Kelley
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Yolanda R Smith
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Vasantha Padmanabhan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
- Correspondence and Reprint Requests: Vasantha Padmanabhan, PhD, Department of Pediatrics, University of Michigan, 7510 MSRB 1, 1500 West Medical Center Drive, Ann Arbor, Michigan 48109. E-mail:
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39
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Beckers KF, Sones JL. Maternal microbiome and the hypertensive disorder of pregnancy, preeclampsia. Am J Physiol Heart Circ Physiol 2019; 318:H1-H10. [PMID: 31626558 DOI: 10.1152/ajpheart.00469.2019] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Preeclampsia (PE) is a pregnancy-specific disorder that can be life threatening for both mother and baby. It is characterized by a new onset hypertension during the second half of pregnancy and affects ~300,000 women in the United States every year. There is no cure for PE, and the only effective treatment is delivery of the placenta and the fetus, which is often preterm. PE is believed to be a severe manifestation of placental dysfunction due to early angiogenic imbalances and inflammatory disturbances; however, the cause of this is unknown. The once thought "sterile" placenta now has been proposed to have a unique microbiome of its own. Under ideal conditions, the microbiome represents a balanced bacterial community that is important to the maintenance of a healthy environment. Dysbiosis of these communities may lead to inflammation that potentially contributes to adverse pregnancy outcomes, such as preterm birth and PE. Thus far, the female reproductive tract microbiome has been found to be influenced by periodontal disease, cardiometabolic complications, and maternal obesity, all of which have been identified as contributors to PE. This review will look at the maternal reproductive tract microbiome, evidence for and against, and its role in pregnancy and PE-related events as well as data from relevant mouse models that could be useful for further investigating the influence of the reproductive tract microbiome on the pathogenesis of PE.
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Affiliation(s)
- Kalie F Beckers
- Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana
| | - Jenny L Sones
- Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana
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40
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Cortez RV, Taddei CR, Sparvoli LG, Ângelo AGS, Padilha M, Mattar R, Daher S. Microbiome and its relation to gestational diabetes. Endocrine 2019; 64:254-264. [PMID: 30421135 DOI: 10.1007/s12020-018-1813-z] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 11/01/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE Gestational diabetes mellitus (GDM), the major endocrine pathology in pregnancy, has been associated with the development of an intense inflammatory process and increased insulin resistance. The maternal microbiota is involved in several metabolic functions; however, its role in GDM physiopathology remains unclear. The aim of this study was to assess the composition of the microbiota at different sites and evaluate its relationship with the occurrence of GDM. METHODS This cross-sectional study recruited women in the third trimester of gestation with and without GDM. Oral, vaginal, and stool samples were evaluated using next-generation sequencing. We included 68 participants: 26 with and 42 without GDM. RESULTS The analysis of the oral microbiome did not show significant differences in phyla and genus among the studied groups. In contrast, GDM patients presented a specific vaginal and intestinal microbiome composition, which was less diverse than those found in the control group, showing genera related to dysbiosis. CONCLUSIONS Our findings suggest that changes in the composition of the vaginal and intestinal microbiome might be involved in the development of GDM. The follow-up of these patients in order to evaluate vaginal and intestinal samples after delivery may contribute to understanding the development of metabolic disease in women with previous GDM.
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Affiliation(s)
- Ramon V Cortez
- Department of Obstetrics, Universidade Federal de São Paulo (UNIFESP), Rua Pedro de Toledo 669, 9 andar - 04939032, São Paulo, Brazil
| | - Carla R Taddei
- Department of Clinical and Toxicological Analysis, Universidade de São Paulo (USP), Av.Prof. Lineu Prestes 580- bloco 17- 05508000, São Paulo, Brazil
| | - Luiz G Sparvoli
- Department of Clinical and Toxicological Analysis, Universidade de São Paulo (USP), Av.Prof. Lineu Prestes 580- bloco 17- 05508000, São Paulo, Brazil
| | - Ana G S Ângelo
- Department of Obstetrics, Universidade Federal de São Paulo (UNIFESP), Rua Pedro de Toledo 669, 9 andar - 04939032, São Paulo, Brazil
| | - Marina Padilha
- Department of Clinical and Toxicological Analysis, Universidade de São Paulo (USP), Av.Prof. Lineu Prestes 580- bloco 17- 05508000, São Paulo, Brazil
| | - Rosiane Mattar
- Department of Obstetrics, Universidade Federal de São Paulo (UNIFESP), Rua Pedro de Toledo 669, 9 andar - 04939032, São Paulo, Brazil
| | - Silvia Daher
- Department of Obstetrics, Universidade Federal de São Paulo (UNIFESP), Rua Pedro de Toledo 669, 9 andar - 04939032, São Paulo, Brazil.
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