Activation of the alternative pathway of complement is a feature of pre-term parturition but not of spontaneous labor at term

Pregnancy-specific transcriptional changes upon endotoxin exposure in mice

Objectives Pregnant women are more susceptible to certain infections; however, this increased susceptibility is not fully understood. Herein, systems biology approaches were utilized to elucidate how pregnancy modulates tissue-specific host responses to a bacterial product, endotoxin. Methods Pregnant and non-pregnant mice were injected with endotoxin or saline on 16.5 days post coitum (n=8-11 per group). The uterus, cervix, liver, adrenal gland, kidney, lung, and brain were collected 12 h after injection and transcriptomes were measured using microarrays. Heatmaps and principal component analysis were used for visualization. Differentially expressed genes between groups were assessed using linear models that included interaction terms to determine whether the effect of infection differed with pregnancy status. Pathway analysis was conducted to interpret gene expression changes. Results We report herein a multi-organ atlas of the transcript perturbations in pregnant and non-pregnant mice in response to endotoxin. Pregnancy strongly modified the host responses to endotoxin in the uterus, cervix, and liver. In contrast, pregnancy had a milder effect on the host response to endotoxin in the adrenal gland, lung, and kidney. However, pregnancy did not drastically affect the host response to endotoxin in the brain. Conclusions Pregnancy imprints organ-specific host immune responses upon endotoxin exposure. These findings provide insight into the host-response against microbes during pregnancy.

Essential Role of Complement in Pregnancy: From Implantation to Parturition and Beyond

The complement cascade was identified over 100 years ago, yet investigation of its role in pregnancy remains an area of intense research. Complement inhibitors at the maternal-fetal interface prevent inappropriate complement activation to protect the fetus. However, this versatile proteolytic cascade also favorably influences numerous stages of pregnancy, including implantation, fetal development, and labor. Inappropriate complement activation in pregnancy can have adverse lifelong sequelae for both mother and child. This review summarizes the current understanding of complement activation during all stages of pregnancy. In addition, consequences of complement dysregulation during adverse pregnancy outcomes from miscarriage, preeclampsia, and pre-term birth are examined. Finally, future research directions into complement activation during pregnancy are considered.

Normal range of complement components during pregnancy: A prospective study

PROBLEM

The complement system plays a key role in normal placentation, and delicate regulation of complement system activation is critical for successful pregnancy. Therefore, establishing a normal range of complement components during pregnancy is important for clinical evaluation and research.

METHODS

We performed a prospective study to investigate the normal range of complement components in circulation during different stages of pregnancy. Plasma concentrations of complement factor B (CFB), C1q, complement factor H (CFH), C3, C3c, and C4 were measured using an immunoturbidimetric assay; mannan-binding lectin (MBL), C3a, C5a, and soluble C5b-9 (sC5b-9) levels at different time points of pregnancy were determined by enzyme-linked immunosorbent assay (ELISA).

RESULTS

A total of 733 plasma samples were collected from 362 women with a normal pregnancy and 65 samples from non-pregnant women. In the first trimester of pregnancy, the levels of CFB, CFH, MBL, C3c, C4, and C3a were 414.5 ± 85.9 mg/L (95% CI for mean: 402.4-426.6 mg/L), 381.0 ± 89.0 mg/L (95% CI for mean: 368.5-393.6 mg/L), 4274.5 ± 2752 ng/mL (95% CI for mean: 3881.1-4656.4 ng/mL), 1346.9 ± 419.8 mg/L (95% CI for mean: 1287.7-1406.0 mg/L), 357.4 ± 101.8 mg/L (95% CI for mean: 343.0-371.7 mg/L), and 182.5 ± 150.0 ng/mL (95% CI for mean: 186.9-229.1 ng/mL), respectively. The levels of C3 and C4 increased gradually throughout pregnancy. The levels of C1q, C5a, and sC5b-9 in the first and second trimesters were nearly the same as those in non-pregnant women.

CONCLUSION

The results of this study show that pregnancy itself may influence the plasma levels of complement system components.

Population-Based Estimation of the Preterm Birth Rate in Lilongwe, Malawi: Making Every Birth Count

Objective  The objective of this study was to perform a population-based estimation of the preterm birth (PTB) rate in regions surrounding Lilongwe, Malawi. Study Design  We partnered with obstetrician specialists, community health workers, local midwives, and clinicians in a 50 km region surrounding Lilongwe, Malawi, to perform a population-based estimation of the PTB rate during the study period from December 1, 2012 to May 19, 2015. Results  Of the 14,792 births captured, 19.3% of births were preterm, including preterm early neonatal deaths. Additional PTB risk factors were similarly prevalent including domestic violence, HIV, malaria, anemia, and malnutrition. Conclusion  When performing a population-based estimation of the rate of PTB, including women without antenatal care and women delivering at home, the 19.3% rate of PTB is among the highest recorded globally. This is accompanied by a high rate of risk factors and comorbid conditions.

The role of complement in preterm birth and prematurity

Complications of preterm birth (PTB) are the global leading cause of death in children younger than 5 years of age. Almost 15 million children are born prematurely in the world each year. Increasing evidence suggests that labor and delivery have many hallmarks of an inflammatory reaction, where complement activation has an active participation. As one of the most important components of inflammation, the role of complement during labor and PTB is becoming an attractive research target. The complement components C1q and C5b-9 are deposited on fetal membranes and release inflammatory mediators that contribute to uterine contractions, cervical ripening, cell chemotaxis, metalloproteinases production, membrane awaking and rupture, and it participates as a co-adjuvant in the onset and progress of labor. This article reviews a basic description of the complement system, its role in preterm birth and current concepts regarding its contribution in novel therapy strategies and new biomarkers.

Brief Report: Markers of Spontaneous Preterm Delivery in Women Living With HIV: Relationship With Protease Inhibitors and Vitamin D

BACKGROUND

Women living with HIV (WLHIV) have increased risk of spontaneous preterm delivery (SPTD). We sought to identify plasma predictors of SPTD and their correlations with factors that increase the risk of SPTD, such as vitamin D deficiency and use of protease inhibitors.

DESIGN

Plasma was obtained from 103 WLHIV with SPTD (≤35 weeks gestation) and 205 controls with term deliveries (TDs; ≥37 weeds) matched to cases 2:1 by race and gestational age at blood draw. TNFα, IFNγ, IL6, IL8, IL1β, IL18, IL17, granulocyte colony stimulating factor (GCSF), MCP1, IP10, sIL2Rα, sCD14, vascular endothelial factor a, monocyte colony stimulation factor, GROα, MMP9, IL10, TGFβ, sCTLA4, and eicosanoids were compared between cases adjusting for known SPTD risk factors.

RESULTS

Participants had similar demographic characteristics, but cases had higher plasma HIV RNA, lower CD4 cells, and more advanced HIV disease compared with controls. High sIL2Rα was associated with increased risk of SPTD. High sCD14, GCSF, PGF2α, and 5-HEPE were marginally associated with increased risk of SPTD. Women who initiated protease inhibitors-containing antiretroviral treatment before or during the first trimester had higher levels of GCSF and 5-HEPE compared with women without such exposure before plasma collection. Vitamin D insufficiency was associated with higher inflammatory sCD14 and PGF2α, and lower anti-inflammatory 5-HEPE.

CONCLUSIONS

The best plasma predictor of SPTD in WLHIV was sIL2Rα, a marker of T-cell activation. Markers of monocyte activation and eicosanoids were marginally increased in WLHIV and SPTD, suggesting that they may also play a role in the pathogenesis of this disorder.

The role of innate immunity in spontaneous preterm labor: A systematic review

BACKGROUND

Immunoinflammatory response by innate immunity components is a field with increasing interest in understanding the mechanisms behind preterm labor (PTL).

OBJECTIVES

Systematic review of the role of innate immunity in spontaneous PTL.

STUDY DESIGN

PubMed, Scopus, ClinicalTrials.gov and Web of Science were searched using pregnancy AND innate OR toll-like OR natural-killer OR dendritic AND delivery OR premature OR rupture of membranes.

MAIN OUTCOME MEASURES

All article titles and abstracts were evaluated by two individuals, based in strict predefined inclusion criteria. For relevant studies, title, abstract, and full text were assessed to identify PTL and innate immunity studies, excluding multiple pregnancies, cervical insufficiency and indicated PTL.

RESULTS

From 894 articles evaluated, 101 full texts articles were assessed independently. For this systematic review 44 studies were finally included. Toll-like receptors 2 and 4 mediated immune dysfunction and inflammation can result in PTL. Moreover, PTL is linked to high levels of CD14⁺ monocytes; neutrophils seem important in inflammation-associated PTL and in pathological preterm premature rupture of membranes. Besides, decidual natural-killer cells and premature activation of dendritic cells may also participate in the etiology of PTL. Finally, dysregulation of maternal complement might increase the risk of PTL, characterized by high levels of innate lymphoid cells 2 and 3.

CONCLUSIONS

Further research is warranted to ascertain the precise role of innate immunity in PTL. Nonetheless, our results indicate that Toll-like receptors, monocytes, natural-killer cells, dendritic cells and complement have significant roles in PTL.

Qualitative assessment of knowledge transfer regarding preterm birth in Malawi following the implementation of targeted health messages over 3 years

Background

In 2012, we performed a needs assessment and gap analysis to qualitatively assess providers’ and patients’ knowledge and perceptions regarding preterm birth (PTB). During the study, we identified knowledge gaps surrounding methods to reduce the risk of occurrence of PTB and management options if preterm labor/birth occur. We targeted health messages toward these gaps. The objective of the present study was to assess the impact of our community health worker-based patient education program 3 years after it was implemented.

Methods

Fifteen focus groups including 70 participants were included in the study. The groups comprised either patients/patient couples or health providers. A minimum of two facilitators led each group using 22 a priori designed and standardized lead-in prompts for participants with four additional prompts for providers only. A single researcher recorded responses, and transcript notes were reviewed by the facilitators and interpreters immediately following each group discussion to ensure accuracy.

Results

The understanding of term vs preterm gestation was generally accurate. Every participant knew of women who had experienced PTB, and the general perception was that two to three women out of every ten had this experience. The majority of respondents thought that women should present to their local health clinic if they experience preterm contractions; few were aware of the use of antenatal steroids for promoting fetal lung maturity, but many acknowledged that the neonate may be able to receive life-sustaining treatment if born at a higher level of care facility. The majority of participants were aware that PTB could recur in subsequent pregnancies. All respondents were able to list ways that women could potentially reduce the risk of PTB.

Conclusion

After employing targeted health messages, the majority of participants expressed improved understanding of the definition of PTB, methods to prevent risk of PTB, and management options for preterm labor or PTB.

Complement C3a, But Not C5a, Levels in Amniotic Fluid Are Associated with Intra-amniotic Infection and/or Inflammation and Preterm Delivery in Women with Cervical Insufficiency or an Asymptomatic Short Cervix (≤ 25 mm)

BACKGROUND

We aimed to estimate whether elevated levels of complement C3a and C5a in amniotic fluid (AF) are independently associated with increased risks of intra-amniotic infection and/or inflammation (IAI) and spontaneous preterm delivery (SPTD) in women with cervical insufficiency or a short cervix (≤ 25 mm).

METHODS

We conducted a retrospective cohort study of 96 consecutive women with cervical insufficiency (n = 62) or a short cervix (n = 34) at 17 to 27 weeks, and who underwent an amniocentesis. AF was cultured and analyzed for C3a and C5a by enzyme-linked immunosorbent assay kits. The primary outcome measures were IAI (defined as a positive AF culture and/or an elevated AF interleukin-6 level [≥ 7.6 ng/mL]) and SPTD at < 32 weeks.

RESULTS

In multivariable analysis, AF level of C3a was the only variable significantly associated with IAI, whereas C5a level in AF and serum C-reactive protein level were not associated with IAI. Using SPTD at < 32 weeks as the outcome variable in logistic regression, elevated AF levels of C3a were associated with increased risk of SPTD at < 32 weeks after adjusting for other baseline confounders, whereas elevated AF levels of C5a were not.

CONCLUSION

In women with cervical insufficiency or a short cervix, elevated AF level of C3a, but not C5a, is independently associated with increased risks of IAI and SPTD at < 32 weeks. These findings suggest that subclinical IAI or SPTD in the context of cervical insufficiency is related to activation of complement system in AF.

Innate lymphoid cells at the human maternal-fetal interface in spontaneous preterm labor

PROBLEM

Pathological inflammation is causally linked to preterm labor and birth, the leading cause of neonatal morbidity and mortality worldwide. Our aims were to investigate whether (i) the newly described family of innate lymphoid cells (ILCs) was present at the human maternal-fetal interface and (ii) ILC inflammatory subsets were associated with the pathological process of preterm labor.

METHODS OF STUDY

Decidual leukocytes were isolated from women with preterm or term labor as well as from gestational age-matched non-labor controls. ILCs (CD15- CD14- CD3- CD19- CD56- CD11b- CD127+ cells) and their subsets (ILC1, T-bet+ ILCs; ILC2, GATA3+ ILCs; and ILC3, RORγt+ ILCs) and cytokine expression were identified in the decidual tissues using immunophenotyping.

RESULTS

(i) The proportion of total ILCs was increased in the decidua parietalis of women with preterm labor; (ii) ILC1s were a minor subset of decidual ILCs during preterm and term gestations; (iii) ILC2s were the most abundant ILC subset in the decidua during preterm and term gestations; (iv) the proportion of ILC2s was increased in the decidua basalis of women with preterm labor; (v) the proportion of ILC3s was increased in the decidua parietalis of women with preterm labor; and (vi) during preterm labor, ILC3s had higher expression of IL-22, IL-17A, IL-13, and IFN-γ compared to ILC2s in the decidua.

CONCLUSION

ILC2s were the most abundant ILC subset at the human maternal-fetal interface during preterm and term gestations. Yet, during preterm labor, an increase in ILC2s and ILC3s was observed in the decidua basalis and decidua parietalis, respectively. These findings provide evidence demonstrating a role for ILCs at the maternal-fetal interface during the pathological process of preterm labor.

Choriodecidual leukocytes display a unique gene expression signature in spontaneous labor at term

Prior to and during the process of human labor, maternal circulating leukocytes infiltrate the maternal-fetal interface (choriodecidua) and become activated resembling choriodecidual leukocytes. Since, there is no evidence comparing maternal circulating and choriodecidual leukocytes, herein, we characterized their transcriptome and explored the biological processes enriched in choriodecidual leukocytes. From women undergoing spontaneous term labor we isolated circulating and choriodecidual leukocytes, performed microarray analysis (n = 5) and qRT-PCR validation (n = 9) and interaction network analysis with up-regulated genes. We found 270 genes up-regulated and only 17 genes down-regulated in choriodecidual leukocytes compared to maternal circulating leukocytes. The most up-regulated genes were CCL18, GPNMB, SEPP1, FN1, RNASE1, SPP1, C1QC, and PLTP. The biological processes enriched in choriodecidual leukocytes were cell migration and regulation of immune response, chemotaxis, and humoral immune responses. Our results show striking differences between the transcriptome of choriodecidual and maternal circulating leukocytes. Choriodecidual leukocytes are enriched in immune mediators implicated in the spontaneous process of labor at term.

In vivo activation of invariant natural killer T cells induces systemic and local alterations in T-cell subsets prior to preterm birth

Preterm birth, the leading cause of neonatal morbidity and mortality worldwide, is frequently preceded by spontaneous preterm labour, a syndrome of multiple aetiologies. Pathological inflammation is causally linked to spontaneous preterm labour. Indeed, direct activation of invariant natural killer T (iNKT) cells via α-galactosylceramide induces preterm labour/birth largely by initiating systemic and local (i.e. decidua and myometrium) innate immune responses. Herein, we investigated whether iNKT-cell activation altered local and systemic T-cell subsets. Administration of α-galactosylceramide induced an expansion of activated CD1d-restricted iNKT cells in the decidua and a reduction in the number of: (1) total T cells (conventional CD4⁺ and CD8⁺ T cells) through the down-regulation of the CD3ɛ molecule in the peripheral circulation, spleen, uterine-draining lymph nodes (ULNs), decidua and/or myometrium; (2) CD4⁺ regulatory T cells in the spleen, ULNs and decidua; (3) T helper type 17 (Th17) cells in the ULNs but an increase in the number of decidual Th17 cells; (4) CD8⁺ regulatory T cells in the spleen and ULNs; and (5) CD4⁺ and CD8⁺ forkhead box protein 3 negative (Foxp3^- ) responder T cells in the spleen and ULNs. As treatment with rosiglitazone prevents iNKT-cell activation-induced preterm labour/birth, we also explored whether the administration of this peroxisome proliferator-activated receptor gamma (PPARγ) agonist would restore the number of T cells. Treating α-galactosylceramide-injected mice with rosiglitazone partially restored the number of T cells in the spleen but not in the decidua. In summary, iNKT-cell activation altered the systemic and local T-cell subsets prior to preterm labour/birth; however, treatment with rosiglitazone partially reversed such effects.

An M1-like Macrophage Polarization in Decidual Tissue during Spontaneous Preterm Labor That Is Attenuated by Rosiglitazone Treatment

Decidual macrophages are implicated in the local inflammatory response that accompanies spontaneous preterm labor/birth; however, their role is poorly understood. We hypothesized that decidual macrophages undergo a proinflammatory (M1) polarization during spontaneous preterm labor and that PPARγ activation via rosiglitazone (RSG) would attenuate the macrophage-mediated inflammatory response, preventing preterm birth. In this study, we show that: 1) decidual macrophages undergo an M1-like polarization during spontaneous term and preterm labor; 2) anti-inflammatory (M2)-like macrophages are more abundant than M1-like macrophages in decidual tissue; 3) decidual M2-like macrophages are reduced in preterm pregnancies compared with term pregnancies, regardless of the presence of labor; 4) decidual macrophages express high levels of TNF and IL-12 but low levels of peroxisome proliferator-activated receptor γ (PPARγ) during spontaneous preterm labor; 5) decidual macrophages from women who underwent spontaneous preterm labor display plasticity by M1↔M2 polarization in vitro; 6) incubation with RSG reduces the expression of TNF and IL-12 in decidual macrophages from women who underwent spontaneous preterm labor; and 7) treatment with RSG reduces the rate of LPS-induced preterm birth and improves neonatal outcomes by reducing the systemic proinflammatory response and downregulating mRNA and protein expression of NF-κB, TNF, and IL-10 in decidual and myometrial macrophages in C57BL/6J mice. In summary, we demonstrated that decidual M1-like macrophages are associated with spontaneous preterm labor and that PPARγ activation via RSG can attenuate the macrophage-mediated proinflammatory response, preventing preterm birth and improving neonatal outcomes. These findings suggest that the PPARγ pathway is a new molecular target for future preventative strategies for spontaneous preterm labor/birth.

Trophoblast-microbiome interaction: a new paradigm on immune regulation

The immunologic paradigm of pregnancy led to the conceptualization of pregnancy as an organ transplant that requires, for its success, suppression of the maternal immune system. Growing scientific evidence suggests that in many ways the placenta functions as a tumor rather than a transplant and the immune regulation of the maternal-fetal interface is the result of the coordinated interaction between all its cellular components, including bacteria. Examining the role of microbiota in reproduction is in its infancy, but there is growing literature that supports its relevance. We discuss a potential normal function of bacteria in the establishment of immune tolerance and compelling evidence that a viral infection might be the underlying cause of perturbation of homeostasis. There is compelling evidence that many infectious diseases of human beings are caused by >1 microorganism and are defined as polymicrobial infections. We propose that pregnancy complications, such as preterm birth, are the result of polymicrobial infections. We examine the potential cellular and molecular mechanisms by which a viral infection of the placenta might disrupt the normal interaction between the cellular component of the implantation site and bacteria. As we better understand the normal homeostasis among the maternal immune system, placenta, and commensal, we will be able to elucidate pathogenic conditions and design better approaches to treat pregnancy complications associated with infection.

Mild hypothermia inhibits systemic and cerebral complement activation in a swine model of cardiac arrest

Complement activation has been implicated in ischemia/reperfusion injury. This study aimed to determine whether mild hypothermia (HT) inhibits systemic and cerebral complement activation after resuscitation from cardiac arrest. Sixteen minipigs resuscitated from 8 minutes of untreated ventricular fibrillation were randomized into two groups: HT group (n=8), treated with HT (33°C) for 12 hours; and normothermia group (n=8), treated similarly as HT group except for cooling. Blood samples were collected at baseline and 0.5, 6, 12, and 24 hours after return of spontaneous circulation (ROSC). The brain cortex was harvested 24 hours after ROSC. Complement and pro-inflammatory markers were detected using enzyme-linked immunosorbent assay. Neurologic deficit scores were evaluated 24 hours after ROSC. C1q, Bb, mannose-binding lectin (MBL), C3b, C3a, C5a, interleukin-6, and tumor necrosis factor-α levels were significantly increased under normothermia within 24 hours after ROSC. However, these increases were significantly reduced by HT. Hypothermia decreased brain C1q, MBL, C3b, and C5a contents 24 hours after ROSC. Hypothermic pigs had a better neurologic outcome than normothermic pigs. In conclusion, complement is activated through classic, alternative, and MBL pathways after ROSC. Hypothermia inhibits systemic and cerebral complement activation, which may provide an additional mechanism of cerebral protection.

The preterm placental microbiome varies in association with excess maternal gestational weight gain

OBJECTIVE

Although a higher maternal body mass index is associated with preterm birth, it is unclear whether excess gestational weight gain (GWG) or obesity drives increased risk. We and others have shown that the placenta harbors microbiota, which is significantly different among preterm births. Our aim in this study was to investigate whether the preterm placental microbiome varies by virtue of obesity or alternately by excess GWG.

STUDY DESIGN

Placentas (n=320) were collected from term and preterm pregnancies. Genomic DNA was extracted and subjected to metagenomic sequencing. Data were analyzed by clinical covariates that included the 2009 Institute of Medicine's GWG guideline and obesity.

RESULTS

Analysis of 16S recombinant RNA-based metagenomics revealed no clustering of the microbiome by virtue of obesity (P=.161). Among women who spontaneously delivered preterm, there was again no clustering by obesity (P=.480), but there was significant clustering by excess GWG (P=.022). Moreover, among preterm births, detailed analysis identified microbial genera (family and genus level) and bacterial metabolic gene pathways that varied among pregnancies with excess GWG. Notably, excess GWG was associated with decreased microbial folate biosynthesis pathways and decreased butanoate metabolism (linear discriminate analysis, >3.0-fold).

CONCLUSION

Although there were no significant alterations in the microbiome by virtue of obesity per se, excess GWG was associated with an altered microbiome and its metabolic profile among those women who experienced a preterm birth.

Blood SC5b-9 complement levels increase at parturition during term and preterm labor

We explored the hypothesis that complement, an innate and adaptive immune effector, is active in the plasma of parturient women and is deposited on fetal membranes collected after delivery. A cross-sectional study was designed to evaluate complement activity at parturition. Pregnant women (n = 97) between 15 and 41 years of age were enrolled in a hospital protocol during the perinatal period to assess both SC5b-9 complement activity in blood and complement deposition on fetal membranes during parturition. Soluble SC5b-9 complement activity in plasma fractions was measured using a standard enzyme-linked immunosorbent assay (ELISA) that included specific anti-complement antibodies. Complement deposition on membranes was analyzed using immuno-dot blots and immunohistochemistry. Soluble SC5b-9 complement complex levels were increased in the plasma of women during term labor (TL; median 3361; range 1726-5670 ng/mL), preterm labor (PL; median 2958; range 1552-7092 ng/mL), and preterm premature rupture of membranes (PPROM; median 2272; range 167-6540 ng/mL) compared with pregnant women who were not in labor (P; median 1384; range 174-4570 ng/mL; P < 0.001, Kruskal-Wallis test). Active complement, as assessed by the C9 neo-antigen in C5b-9 complexes, was deposited on fetal membranes, with no difference between term and preterm delivery. The deposition of active complement on fetal membranes was confirmed by immunohistochemistry. Women who underwent non-labor-indicated Cesarean sections did not exhibit complement deposition. Soluble SC5b-9 complement complex levels increased in the plasma of women during parturition, and complement C5b-9 complexes were deposited on fetal membranes.

The complement system and adverse pregnancy outcomes

Adverse pregnancy outcomes significantly contribute to morbidity and mortality for mother and child, with lifelong health consequences for both. The innate and adaptive immune system must be regulated to insure survival of the fetal allograft, and the complement system is no exception. An intact complement system optimizes placental development and function and is essential to maintain host defense and fetal survival. Complement regulation is apparent at the placental interface from early pregnancy with some degree of complement activation occurring normally throughout gestation. However, a number of pregnancy complications including early pregnancy loss, fetal growth restriction, hypertensive disorders of pregnancy and preterm birth are associated with excessive or misdirected complement activation, and are more frequent in women with inherited or acquired complement system disorders or complement gene mutations. Clinical studies employing complement biomarkers in plasma and urine implicate dysregulated complement activation in components of each of the adverse pregnancy outcomes. In addition, mechanistic studies in rat and mouse models of adverse pregnancy outcomes address the complement pathways or activation products of importance and allow critical analysis of the pathophysiology. Targeted complement therapeutics are already in use to control adverse pregnancy outcomes in select situations. A clearer understanding of the role of the complement system in both normal pregnancy and complicated or failed pregnancy will allow a rational approach to future therapeutic strategies for manipulating complement with the goal of mitigating adverse pregnancy outcomes, preserving host defense, and improving long term outcomes for both mother and child.

Early elevations of the complement activation fragment C3a and adverse pregnancy outcomes

OBJECTIVE

To estimate whether elevations of complement C3a early in pregnancy are predictive of the subsequent development of adverse pregnancy outcomes.

METHODS

A plasma sample was obtained from each enrolled pregnant woman before 20 weeks of gestation. The cohort (n=1,002) was evaluated for the development of adverse pregnancy outcomes defined as hypertensive diseases of pregnancy (gestational hypertension or preeclampsia), preterm birth (before 37 weeks of gestation), premature rupture of the membranes, pregnancy loss (during the embryonic and fetal period), intrauterine growth restriction, and the composite outcome of any adverse outcome.

RESULTS

One or more adverse pregnancy outcomes occurred in 211 (21%) of the cohort. The mean levels (ng/mL) of C3a in early pregnancy were significantly (P=<.001) higher among women with one or more adverse outcomes (858±435) compared with women with an uncomplicated pregnancy (741±407). Adjusted for parity and prepregnancy body mass index, women with levels of C3a in the upper quartile in early pregnancy were three times more likely to have an adverse outcome later in pregnancy compared with women in the lowest quartile (95% confidence interval, 1.8-4.8; P<.001). The link between early elevated C3a levels and adverse pregnancy outcomes was driven primarily by individual significant (P<.05) associations of C3a with hypertensive diseases of pregnancy, preterm birth, and premature rupture of the membranes.

CONCLUSION

Elevated C3a as early as the first trimester of pregnancy is an independent predictive factor for adverse pregnancy outcomes, suggesting that complement-related inflammatory events in pregnancy contribute to the subsequent development of poor outcomes at later stages of pregnancy.

LEVEL OF EVIDENCE

II.

New insights into the relationship between viral infection and pregnancy complications

A recent study by McDonnold and coinvestigators published in Am J Obstet Gynecol reports an association between human papillomavirus (HPV) infection and preeclampsia. The investigation was based on the hypothesis that HPV trophoblast infection results in failed trophoblast invasion, and placental dysfunction and hypoxia. The findings from this study along with previous data addressing the relationship between viral infection and obstetrical complications highlight the relevance of viral infection during pregnancy. A better understanding of mechanisms via which virus leads to pregnancy complications will drive us closer to finding a strategy to prevent adverse outcomes.

Maternal and fetal alternative complement pathway activation in early severe preeclampsia

PROBLEM

We sought to determine whether alternative complement activation fragment Bb (Bb) levels are elevated in the maternal, fetal, and placental blood in cases of severe preeclampsia (PE) compared with normotensive controls.

METHOD OF STUDY

This was a cross-sectional study of women admitted at ≥24 weeks gestation with or without severe PE. Maternal plasma was collected at the time of enrollment. Umbilical venous cord and intervillous space blood were collected at delivery. Plasma Bb levels were assessed using ELISA. Bb levels were compared between cases and controls.

RESULTS

Median Bb levels were higher in the maternal plasma of severe PE subjects (n = 24) than in controls (n = 20), 1.45 ± 1.03 versus 0.65 ± 0.23 μg/mL, P < 0.001. In umbilical venous plasma, Bb levels were higher in severe PE subjects (n = 15) compared with controls (n = 15), 2.48 ± 1.40 versus 1.01 ± 0.57 μg/mL, P = 0.01.

CONCLUSION

Activation fragment Bb is increased in the maternal and umbilical venous blood of cases of severe PE when compared with normotensive controls. These data provide support for alternative complement pathway involvement in the pathogenesis of severe PE and demonstrate that alternative complement activation occurs not only in the maternal but also in the fetal compartment.

Maternal coding variants in complement receptor 1 and spontaneous idiopathic preterm birth

Preterm birth (PTB) is a major global public health concern. However, little is known about the pathophysiology of spontaneous idiopathic PTB. We tested the hypothesis that rare variants in families would target specific genes and pathways that contribute to PTB risk in the general population. Whole-exome sequencing was performed on 10 PTB mothers from densely affected families including two mother-daughter pairs. We identified novel variants shared between the two mother-daughter pairs when compared to a 1000 Genomes Project background exome file and investigated these genes for pathway aggregation using the Kyoto Encyclopedia of Genes and Genomes (KEGG). Genes in enriched pathways were then surveyed in the other six PTB exomes and tested for association in a larger number of nuclear families. The KEGG complement and coagulation cascade was one of the most enriched pathways in our two mother-daughter pairs. When the six genes found in this pathway (CFH, CR1, F13B, F5, CR2, and C4BPA) were examined for novel missense variants, half of all the exomes harbored at least one. Association analysis of variants in these six gene regions in nuclear families from Finland (237 cases and 328 controls) found statistically significant associations after multiple test corrections in three CR1 SNPs; the strongest in an exonic missense SNP, rs6691117, p value = 6.91e-5, OR = 1.71. Our results demonstrate the importance of the complement and coagulation cascades in the pathophysiology of PTB, and suggest potential screening and intervention approaches to prevent prematurity that target this pathway.

Comparison of the mechanisms responsible for cervical remodeling in preterm and term labor

Understanding the mechanisms of term and preterm cervical remodeling is essential to prevent prematurity. Is preterm cervical remodeling caused by the same mechanisms that cause cervical remodeling at term, and are these changes accelerated in time? This question has been pondered by obstetricians seeking strategies to prevent preterm labor for many years. Mice represent an informative model of preterm birth. Thus, in this review we discuss the recent findings from mouse models that identify and characterize the initiators and cellular effectors of cervical remodeling at term and preterm labor/delivery. These studies suggest that similarities and differences exist between term and preterm cervical remodeling. Complement is an initiator or mediator in preterm labor/delivery, but is not involved in the physiological process that leads to term delivery. Therefore, complememt constitutes a specific and selective target for potentially preventing preterm delivery, thus improving neonatal health.

Unexplained fetal death has a biological signature of maternal anti-fetal rejection: chronic chorioamnionitis and alloimmune anti-human leucocyte antigen antibodies

AIMS

Chronic chorioamnionitis is a histological manifestation of maternal anti-fetal cellular rejection. As failure of graft survival is the most catastrophic event in organ transplantation, we hypothesized that fetal death could be a consequence of maternal rejection. The aim of this study was to assess whether there is evidence of cellular and antibody-mediated rejection in fetal death.

METHODS AND RESULTS

Placental histology was reviewed for the presence of chronic chorioamnionitis in unexplained preterm fetal death (n=30) and preterm live birth (n=103). Amniotic fluid CXCL10 concentrations were measured with a specific immunoassay. Chronic chorioamnionitis was more frequent in fetal death than in live birth (60.0% versus 37.9%; P<0.05) and fetal death had a higher median amniotic fluid CXCL10 concentration than live birth (2.0 versus 1.8 ng/ml, P<0.05), after adjusting for gestational age at amniocentesis. Maternal anti-human leucocyte antigen class II panel-reactive seropositivity determined by flow cytometry was higher in fetal death compared to live birth (35.7% versus 10.9%; P<0.05).

CONCLUSIONS

Chronic chorioamnionitis is a common pathologic feature in unexplained preterm fetal death. This novel finding suggests that cellular and antibody-mediated anti-fetal rejection of the mother is associated with fetal death (graft failure) in human pregnancy.

Pregnancy outcome in women following splenectomy

OBJECTIVE

To investigate pregnancy outcome of patients following splenectomy.

METHODS

A retrospective study comparing pregnancies of women who have and have not undergone splenectomy was performed. The study investigated a select population representing the south of Israel. Women lacking antenatal care as well as those having multiple gestations were excluded from the analysis. Stratified analysis, using a multiple logistic regression model, was performed to control for confounders.

RESULTS

During the study period, there were 219,656 deliveries, of which 150 occurred in women who underwent splenectomy. Postsplenectomy women tended to be older, were more likely to be Jewish, and had a lower number of deliveries and an earlier gestational age at delivery. Higher rates of fertility treatment, previous cesarean delivery, and severe preeclampsia were found among postsplenectomy women. In addition, splenectomy was significantly associated with pregnancy and labor complications, such as cesarean delivery, pneumonia during pregnancy, and complications of anesthesia and sedation during labor. Using a multivariate analysis with backward elimination, the following conditions were independently associated with splenectomy: previous cesarean delivery (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1-2.3, p=0.039), fertility treatment (OR 2.6, 95% CI 1.3-5.4, p=0.008), preterm delivery (OR 1.9, 95% CI 1.3-3.1, p=0.003), and maternal age (OR 1.04, 95% CI 1.015-1.07, p=0.002). After controlling for possible confounders by using another multivariate analysis with preterm delivery as the outcome variable, splenectomy was found to be an independent risk factor for preterm delivery (OR 2.1, 95% CI 1.4-3.3, p=0.001).

CONCLUSION

Splenectomy is an independent risk factor for preterm delivery.

A molecular signature of an arrest of descent in human parturition

OBJECTIVE

This study was undertaken to identify the molecular basis of an arrest of descent.

STUDY DESIGN

Human myometrium was obtained from women in term labor (TL; n = 29) and arrest of descent (AODes; n = 21). Gene expression was characterized using Illumina HumanHT-12 microarrays. A moderated Student t test and false discovery rate adjustment were applied for analysis. Confirmatory quantitative reverse transcription-polymerase chain reaction and immunoblot were performed in an independent sample set.

RESULTS

Four hundred genes were differentially expressed between women with an AODes compared with those with TL. Gene Ontology analysis indicated enrichment of biological processes and molecular functions related to inflammation and muscle function. Impacted pathways included inflammation and the actin cytoskeleton. Overexpression of hypoxia inducible factor-1a, interleukin -6, and prostaglandin-endoperoxide synthase 2 in AODes was confirmed.

CONCLUSION

We have identified a stereotypic pattern of gene expression in the myometrium of women with an arrest of descent. This represents the first study examining the molecular basis of an arrest of descent using a genome-wide approach.

Fragment Bb: evidence for activation of the alternative pathway of the complement system in pregnant women with acute pyelonephritis

OBJECTIVE

Pyelonephritis during pregnancy is associated with a more severe course than in the non-pregnant state. This has been attributed to an increased susceptibility of pregnant women to microbial products. The complement system is part of innate immunity and its alternative pathway is activated mainly by microorganisms. The purpose of this study was to determine if activation of the alternative pathway of the complement system (determined by maternal fragment Bb concentrations) occurs in pregnant women with acute pyelonephritis.

METHODS

This cross-sectional study included the following groups: (1) normal pregnant women (n=62) and (2) pregnant women with pyelonephritis (n=38). Maternal plasma fragment Bb concentrations were determined by ELISA. Non-parametric statistics were used for analyses.

RESULTS

(1) Pregnant women with pyelonephritis had a higher median plasma concentration of fragment Bb than those with a normal pregnancy (1.3 μg/ml, IQR: 1.1-1.9 vs. 0.8 μg/ml, IQR: 0.7-0.9; p<0.001); (2) No significant differences were observed in the median maternal plasma concentration of fragment Bb between pregnant women with pyelonephritis who had a positive blood culture and those with a negative blood culture (1.4 μg/ml, IQR: 1.1-3.5 vs. 1.3 μg/ml, IQR: 1.1-1.9; p=0.2).

CONCLUSIONS

Pregnant women with acute pyelonephritis have evidence of activation of the alternative pathway of the complement system, regardless of the presence or absence of a positive blood culture.

Characterization of the myometrial transcriptome and biological pathways of spontaneous human labor at term

AIMS

to characterize the transcriptome of human myometrium during spontaneous labor at term.

METHODS

myometrium was obtained from women with (n=19) and without labor (n=20). Illumina HumanHT-12 microarrays were utilized. Moderated t-tests and false discovery rate adjustment of P-values were applied. Real-time quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) was performed for a select set of differentially expressed genes in a separate set of samples. Enzyme-linked immunosorbent assay and Western blot were utilized to confirm differential protein production in a third sample set.

RESULTS

1) Four hundred and seventy-one genes were differentially expressed; 2) gene ontology analysis indicated enrichment of 103 biological processes and 18 molecular functions including: a) inflammatory response; b) cytokine activity; and c) chemokine activity; 3) systems biology pathway analysis using signaling pathway impact analysis indicated six significant pathways: a) cytokine-cytokine receptor interaction; b) Jak-STAT signaling; and c) complement and coagulation cascades; d) NOD-like receptor signaling pathway; e) systemic lupus erythematosus; and f) chemokine signaling pathway; 4) qRT-PCR confirmed over-expression of prostaglandin-endoperoxide synthase-2, heparin binding epidermal growth factor (EGF)-like growth factor, chemokine C-C motif ligand 2 (CCL2/MCP1), leukocyte immunoglobulin-like receptor, subfamily A member 5, interleukin (IL)-8, IL-6, chemokine C-X-C motif ligand 6 (CXCL6/GCP2), nuclear factor of kappa light chain gene enhancer in B-cells inhibitor zeta, suppressor of cytokine signaling 3 (SOCS3) and decreased expression of FK506 binding-protein 5 and aldehyde dehydrogenase in labor; 5) IL-6, CXCL6, CCL2 and SOCS3 protein expression was significantly higher in the term labor group compared to the term not in labor group.

CONCLUSIONS

myometrium of women in spontaneous labor at term is characterized by a stereotypic gene expression pattern consistent with over-expression of the inflammatory response and leukocyte chemotaxis. Differential gene expression identified with microarray was confirmed with qRT-PCR using an independent set of samples. This study represents an unbiased description of the biological processes involved in spontaneous labor at term based on transcriptomics.