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Andreescu M. Correlation Between Maternal-Fetus Interface and Placenta-Mediated Complications. Cureus 2024; 16:e62457. [PMID: 38882223 PMCID: PMC11180486 DOI: 10.7759/cureus.62457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2024] [Indexed: 06/18/2024] Open
Abstract
Pregnancy is a highly regulated biological phenomenon that involves the development of a semi-allogeneic fetus inside the uterus of the mother. The maternal-fetal interface is a critical junction where communication takes place between the fetal and maternal immune systems, which determine the outcome of the pregnancy. The interface is composed of the decidua and placenta. The main cells present at the maternal-fetal interface include invading trophoblasts, maternal immune cells, and decidual stromal cells. Although maternal tolerance is crucial for maintaining a successful pregnancy, the role of the placenta in pregnancy is also important. Dysregulation of the placenta leads to various placenta-mediated complications, such as preeclampsia, intrauterine growth restriction, and placental abruption. Although the exact mechanism involving these complications is unclear, research has elucidated various factors involved in these pregnancy disorders. This review aimed to provide a summary of the maternal-fetal interface and immune mechanisms involved in placenta-mediated complications.
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Affiliation(s)
- Mihaela Andreescu
- Faculty of Medicine, Titu Maiorescu University, Bucharest, ROU
- Hematology, Colentina Clinical Hospital, Bucharest, ROU
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2
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Huang CC, Hsueh YW, Chang CW, Hsu HC, Yang TC, Lin WC, Chang HM. Establishment of the fetal-maternal interface: developmental events in human implantation and placentation. Front Cell Dev Biol 2023; 11:1200330. [PMID: 37266451 PMCID: PMC10230101 DOI: 10.3389/fcell.2023.1200330] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/09/2023] [Indexed: 06/03/2023] Open
Abstract
Early pregnancy is a complex and well-orchestrated differentiation process that involves all the cellular elements of the fetal-maternal interface. Aberrant trophoblast-decidual interactions can lead to miscarriage and disorders that occur later in pregnancy, including preeclampsia, intrauterine fetal growth restriction, and preterm labor. A great deal of research on the regulation of implantation and placentation has been performed in a wide range of species. However, there is significant species variation regarding trophoblast differentiation as well as decidual-specific gene expression and regulation. Most of the relevant information has been obtained from studies using mouse models. A comprehensive understanding of the physiology and pathology of human implantation and placentation has only recently been obtained because of emerging advanced technologies. With the derivation of human trophoblast stem cells, 3D-organoid cultures, and single-cell analyses of differentiated cells, cell type-specific transcript profiles and functions were generated, and each exhibited a unique signature. Additionally, through integrative transcriptomic information, researchers can uncover the cellular dysfunction of embryonic and placental cells in peri-implantation embryos and the early pathological placenta. In fact, the clinical utility of fetal-maternal cellular trafficking has been applied for the noninvasive prenatal diagnosis of aneuploidies and the prediction of pregnancy complications. Furthermore, recent studies have proposed a viable path toward the development of therapeutic strategies targeting placenta-enriched molecules for placental dysfunction and diseases.
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Zhang S, Ding J, Zhang Y, Liu S, Yang J, Yin T. Regulation and Function of Chemokines at the Maternal–Fetal Interface. Front Cell Dev Biol 2022; 10:826053. [PMID: 35938162 PMCID: PMC9354654 DOI: 10.3389/fcell.2022.826053] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 06/22/2022] [Indexed: 11/28/2022] Open
Abstract
Successful pregnancy requires the maternal immune system to tolerate the semi-allogeneic embryo. A good trophoblast function is also essential for successful embryo implantation and subsequent placental development. Chemokines are initially described in recruiting leukocytes. There are rich chemokines and chemokine receptor system at the maternal–fetal interface. Numerous studies have reported that they not only regulate trophoblast biological behaviors but also participate in the decidual immune response. At the same time, the chemokine system builds an important communication network between fetally derived trophoblast cells and maternally derived decidual cells. However, abnormal functions of chemokines or chemokine receptors are involved in a series of pregnancy complications. As growing evidence points to the roles of chemokines in pregnancy, there is a great need to summarize the available data on this topic. This review aimed to describe the recent research progress on the regulation and function of the main chemokines in pregnancy at the maternal–fetal interface. In addition, we also discussed the potential relationship between chemokines and pregnancy complications.
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Affiliation(s)
- Sainan Zhang
- Reproductive Medical Center, Renmin Hospital of Wuhan University & Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan, China
| | - Jinli Ding
- Reproductive Medical Center, Renmin Hospital of Wuhan University & Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan, China
| | - Yan Zhang
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan, China
| | - Su Liu
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Shenzhen Zhongshan Urology Hospital, Shenzhen, China
- *Correspondence: Su Liu, ; Jing Yang, ; Tailang Yin,
| | - Jing Yang
- Reproductive Medical Center, Renmin Hospital of Wuhan University & Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan, China
- *Correspondence: Su Liu, ; Jing Yang, ; Tailang Yin,
| | - Tailang Yin
- Reproductive Medical Center, Renmin Hospital of Wuhan University & Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan, China
- *Correspondence: Su Liu, ; Jing Yang, ; Tailang Yin,
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4
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Eidizadeh A, Papert S, Valk J, Pollok-Kopp B, Goldmann M, Riggert J, Moltrecht R, Legler TJ. Adverse drug reactions following lymphocyte immunotherapy for the treatment of infertility: A retrospective study. J Obstet Gynaecol Res 2022; 48:2571-2582. [PMID: 35775609 DOI: 10.1111/jog.15348] [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: 03/30/2022] [Revised: 05/25/2022] [Accepted: 06/20/2022] [Indexed: 11/30/2022]
Abstract
AIM Unexplained infertility is a major burden for couples who want to have children. Lymphocyte immunotherapy (LIT) could be a therapeutic help for these couples. Although LIT has been carried out for decades, the data on the success of therapy are still controversial and there is hardly information on possible adverse drug reactions. METHODS In this study, we used a questionnaire to determine the frequency of local and systemic adverse drug reactions in our patients who were treated with LIT between 2017 and 2020 (n = 302). In addition, we asked about pregnancies and/or live births after LIT in a 2-year follow-up (n = 140). RESULTS Most of the patients reported the occurrence of mild local adverse drug reactions in a period of less than 4 weeks: Over 75% reported moderate erythema, itching or swelling, over 10% erythema, itching or swelling as more pronounced adverse drug reaction. Blistering was specified in 10% of the cases. Serious adverse drug reactions or adverse events were not described. In the follow-up, 69% of our patients stated a pregnancy after LIT, and 50% a life birth. CONCLUSIONS Overall, LIT represents a well-tolerated therapy for couples with unexplained infertility, however, more evidence is needed on the benefits.
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Affiliation(s)
- Abass Eidizadeh
- Institute for Clinical Chemistry/Interdisciplinary UMG Laboratory, University Medical Center Göttingen, Göttingen, Germany
| | - Susanne Papert
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Jakob Valk
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Beatrix Pollok-Kopp
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Monika Goldmann
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Joachim Riggert
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | | | - Tobias J Legler
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
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5
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Gu H, Li L, Du M, Xu H, Gao M, Liu X, Wei X, Zhong X. Key Gene and Functional Pathways Identified in Unexplained Recurrent Spontaneous Abortion Using Targeted RNA Sequencing and Clinical Analysis. Front Immunol 2021; 12:717832. [PMID: 34421922 PMCID: PMC8375436 DOI: 10.3389/fimmu.2021.717832] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/15/2021] [Indexed: 01/13/2023] Open
Abstract
Identifying the mechanisms underlying unexplained recurrent spontaneous abortion (URSA) can help develop effective treatments. This study provides novel insights into the biological characteristics and related pathways of differentially expressed genes (DEGs) in URSA. Nineteen patients with URSA and three healthy fertile women with regular menstruation (control group) were recruited. RNA was extracted from the two groups to determine the differential expression of immunoregulatory gene sequences. Gene ontology (GO) and Kyoto Encyclopaedia of Genes and Genomes (KEGG) enrichment analyses were used to identify the biological functions and pathways of the identified DEGs. A protein-protein interaction (PPI) network was constructed using the STRING database. Furthermore, qRT-PCR and ELISA were performed to validate the differential expression of the hub genes. We also explored the regulatory mechanism of Th1/Th2 imbalance. A total of 99 DEGs were identified, comprising 94 upregulated and five downregulated genes. Through GO analysis, nine immune cell function-related clusters were selected, and genes with significant differential expression were primarily enriched in eight immune regulatory functions related to the KEGG signalling pathway. Subsequently, five hub genes (TLR2, CXCL8, IFNG, IL2RA, and ITGAX) were identified using Cytoscape software; qRT-PCR confirmed the differential expression among the hub genes, whereas ELISA revealed a significant difference in extracellular IFN-γ and IL-8 levels. The levels of Th1 (IFN-γ) and the Th1/Th2 ratio were higher in the peripheral blood of URSA patients than in control group patients. These findings suggest that the occurrence of URSA may be associated with the abnormal expression of some specific immunoregulatory genes involved in T-cell activation and differentiation. Among the identified DEGs, IFNG may play a key role in regulating maternal immune response. Although further validation is required, our data provide an important theoretical basis for elucidating the pathogenesis of recurrent spontaneous abortion.
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Affiliation(s)
- Heng Gu
- Key Laboratory of Male Reproduction and Genetics of National Health Council, Family Planning Research Institute of Guangdong Province, Guangzhou, China
| | - Longyu Li
- Dongguan Institute of Reproduction and Genetics, Dongguan Maternal and Children Health Hospital, Dongguan, China
| | - Mengxuan Du
- Key Laboratory of Male Reproduction and Genetics of National Health Council, Family Planning Research Institute of Guangdong Province, Guangzhou, China.,Department of Public Health and Preventive Medicine, Jinan University, Guangzhou, China
| | - Hang Xu
- Key Laboratory of Male Reproduction and Genetics of National Health Council, Family Planning Research Institute of Guangdong Province, Guangzhou, China.,Department of Public Health and Preventive Medicine, Jinan University, Guangzhou, China
| | - Mengge Gao
- Key Laboratory of Male Reproduction and Genetics of National Health Council, Family Planning Research Institute of Guangdong Province, Guangzhou, China.,Department of Public Health and Preventive Medicine, Jinan University, Guangzhou, China
| | - Xiaohua Liu
- Key Laboratory of Male Reproduction and Genetics of National Health Council, Family Planning Research Institute of Guangdong Province, Guangzhou, China
| | - Xiangcai Wei
- Department of Public Health and Preventive Medicine, Jinan University, Guangzhou, China.,Department of Reproductive Immunity, Guangdong Women and Children Hospital, Guangzhou Medical University, Guangzhou, China
| | - Xingming Zhong
- Key Laboratory of Male Reproduction and Genetics of National Health Council, Family Planning Research Institute of Guangdong Province, Guangzhou, China.,Department of Public Health and Preventive Medicine, Jinan University, Guangzhou, China
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Chen Y, Wu Q, Wei J, Hu J, Zheng S. Effects of aspirin, vitamin D3, and progesterone on pregnancy outcomes in an autoimmune recurrent spontaneous abortion model. ACTA ACUST UNITED AC 2021; 54:e9570. [PMID: 34133541 PMCID: PMC8208775 DOI: 10.1590/1414-431x2020e9570] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 11/23/2020] [Indexed: 12/04/2022]
Abstract
High proportions of placental lymphocytes expressing DX5+/CD25+/FOXP3+/CD45+/CD4+ are beneficial to maintain immune tolerance and improve pregnancy outcomes. This study aimed to compare and evaluate the therapeutic effects of aspirin, vitamin D3 (VitD3), and progesterone on the autoimmune recurrent spontaneous abortion (RSA) model. The autoimmune RSA mouse model was constructed, and the embryo loss rate was calculated for each group. Then, primary mouse placental lymphocytes were isolated, and the expression of DX5+/CD25+/FOXP3+/CD45+/CD4+ was detected through flow cytometry. The serum levels of anti-cardiolipin antibody (ACA), β2-GP1, CXCL6, IFN-γ, and IL-6 were measured by ELISA to evaluate the proportion of Th1 and Th2 cells. Autoimmune RSA significantly increased the embryo loss rate, which was improved by aspirin, VitD3, and progesterone treatment, and progesterone treatment had the best effect among the three treatments. The positive expression of DX5+/CD25+/FOXP3+/CD45+/CD4+ in the VitD3 and progesterone groups was significantly higher than that in the autoimmune RSA group, and the expression was highest in the progesterone treatment group. In the plasma of autoimmune RSA mice, the ACA, β2-GP1, CXCL6, and IFN-γ levels were significantly higher and the IL-6 level was lower than the levels in control mice. All these changes could be reversed by aspirin and progesterone treatment. In conclusion, aspirin, VitD3 and progesterone treatment improved pregnancy outcomes in autoimmune RSA mice by regulating the Th1/Th2 balance and cytokines, and progesterone had the best effect of the three treatments.
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Affiliation(s)
- Yihong Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qiumei Wu
- Department of Ultrasound, Fujian Provincial Maternal and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Juanbing Wei
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jifen Hu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shan Zheng
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
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7
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Feng M, Feng Q, Chen Y, Liu G, Gao Z, Xiao J, Feng C. Effect of Dezocine on the Ratio of Th1/Th2 Cytokines in Patients Receiving Postoperative Analgesia Following Laparoscopic Radical Gastrectomy: A Prospective Randomised Study. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:2289-2297. [PMID: 34079227 PMCID: PMC8166330 DOI: 10.2147/dddt.s306120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022]
Abstract
Purpose To evaluate the effect of dezocine on the postoperative ratio of Th1/Th2 cytokines in patients undergoing laparoscopic radical gastrectomy. Patients and Methods Sixty patients undergoing laparoscopic radical gastrectomy were randomly divided into two groups (n=30): dezocine group (Group D) and sufentanil group (Group S). They received patient-controlled intravenous analgesia (PCIA) after the operation with either dezocine 0.8 mg/kg (Group D) or sufentanil 2 µg/kg (Group S). Both groups also received ondansetron 8 mg diluted to 100 mL with saline. The primary outcome was the Th1/Th2 cytokines ratio at predetermined intervals, 30 min before the induction of general anaesthesia and 0, 12, 24 and 48 h after surgery. The secondary endpoints were patients’ pain scores, measured on a visual analogue scale (VAS) at predetermined intervals (0, 12, 24 and 48 h after surgery), and side effects at follow-up 48 h after surgery. Results The Th1/Th2 cytokines ratio in Group D was significantly higher than Group S (P<0.05) 12, 24 and 48 h after the operation. There were no significant differences in VAS pain scores between groups at 0, 12, 24 and 48 h after surgery (P>0.05). Compared to Group S, the incidence of postoperative nausea, vomiting and lethargy was significantly lower in Group D (P<0.05). Conclusion Dezocine increases the ratio of Th1/Th2 cytokines, relieves postoperative pain and causes fewer side effects in patients undergoing laparoscopic radical gastrectomy.
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Affiliation(s)
- Man Feng
- Department of Pathology, Affiliated Hospital of Shandong Academy of Medical Sciences, Shandong First Medical University, Jinan, 250000, People's Republic of China
| | - Qinli Feng
- Department of Anesthesiology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250033, People's Republic of China
| | - Yujie Chen
- Department of Anesthesiology, Affiliated Hospital of Shandong of TCM, Jinan, 250001, People's Republic of China
| | - Ge Liu
- Department of Anesthesiology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250033, People's Republic of China
| | - Zhuanglei Gao
- Department of General Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250033, People's Republic of China
| | - Juan Xiao
- Department of Center of Evidence-Based Medicine, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250033, People's Republic of China
| | - Chang Feng
- Department of Anesthesiology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250033, People's Republic of China
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8
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Genebrier S, Tarte K. The flawless immune tolerance of pregnancy. Joint Bone Spine 2021; 88:105205. [PMID: 33962032 DOI: 10.1016/j.jbspin.2021.105205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Steve Genebrier
- Unité Inserm U1236, Faculté de médecine, Université de Rennes 1, 2, avenue du Pr Léon Bernard, 35043 Rennes, France; CHU de Rennes, Pôle Biologie, Rennes, France
| | - Karin Tarte
- Unité Inserm U1236, Faculté de médecine, Université de Rennes 1, 2, avenue du Pr Léon Bernard, 35043 Rennes, France; CHU de Rennes, Pôle Biologie, Rennes, France.
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Arefieva A, Nikolaeva M, Stepanova E, Krechetova L, Golubeva E, Tetruashvili N, Sukhikh G. Association of CD200 expression in paternal lymphocytes with female Th1/Th2 balance and pregnancy establishment at immunotherapy of recurrent spontaneous abortion. Am J Reprod Immunol 2020; 85:e13355. [PMID: 33015886 DOI: 10.1111/aji.13355] [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] [Received: 04/30/2020] [Revised: 09/11/2020] [Accepted: 09/28/2020] [Indexed: 12/20/2022] Open
Abstract
PROBLEM We hypothesized that expression of transmembrane glycoprotein CD200 on paternal lymphocytes used for pre-gestational lymphocyte immunotherapy (LIT) of recurrent spontaneous abortion (RSA) can suppress the pro-inflammatory Th1-type immunity required for successful implantation. To reveal the association between CD200 expression, female immune background after LIT, and pregnancy establishment, we have performed this work. METHOD OF STUDY Pre-gestational alloimmunizations were given to 37 women using paternal peripheral blood leukocytes, combined with additional alloimmunizations in case of pregnancy. Lymphocyte phenotypes were determined by flow cytometry. Cytokines produced by mitogen-stimulated female peripheral blood cells were estimated by FlowCytomix™ technology. RESULTS We have shown that 78.4% (29/37) of women became pregnant within 12 menstrual cycles after pre-gestational LIT. Pregnancy establishment depends on the intensity of CD200 expression, which is significantly higher on the CD200+ lymphocytes administered to women who later did not achieve pregnancy (P < .05). The expression of CD200 negatively correlates with the ratios of Th1/Th2 cytokines produced by female peripheral blood cells (P < .05) and positively correlates with the frequency of female circulating regulatory T cells after LIT (P < .05). The ROC analysis showed that the intensity of CD200 expression and the Th1/Th2 ratios are the significant predictors of pregnancy establishment after pre-gestational LIT (P < .05 and P < .01, respectively). CONCLUSION Elevated CD200 expression on allogeneic lymphocytes most likely suppresses the pro-inflammatory Th1-type immunity needed for successful embryo implantation. Therefore, a personalized approach of LIT should be applied to avoid negative effects of such immunomodulation on pregnancy establishment.
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Affiliation(s)
- Alla Arefieva
- Laboratory of Clinical Immunology, National Medical Research Center for Obstetrics, Gynecology and Perinatology of Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Marina Nikolaeva
- Laboratory of Clinical Immunology, National Medical Research Center for Obstetrics, Gynecology and Perinatology of Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Elena Stepanova
- Laboratory of Clinical Immunology, National Medical Research Center for Obstetrics, Gynecology and Perinatology of Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Lubov Krechetova
- Laboratory of Clinical Immunology, National Medical Research Center for Obstetrics, Gynecology and Perinatology of Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Elena Golubeva
- Laboratory of Clinical Immunology, National Medical Research Center for Obstetrics, Gynecology and Perinatology of Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Nana Tetruashvili
- Department of Pregnancy Loss Prevention and Therapy, National Medical Research Center for Obstetrics, Gynecology and Perinatology of Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Gennady Sukhikh
- Laboratory of Clinical Immunology, National Medical Research Center for Obstetrics, Gynecology and Perinatology of Ministry of Healthcare of Russian Federation, Moscow, Russia.,First Moscow State Medical University named after I.M. Sechenov, Moscow, Russia
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Nakagawa K, Kwak-Kim J, Hisano M, Kasahara Y, Kuroda K, Sugiyama R, Yamaguchi K. Obstetric and perinatal outcome of the women with repeated implantation failures or recurrent pregnancy losses who received pre- and post-conception tacrolimus treatment. Am J Reprod Immunol 2019; 82:e13142. [PMID: 31081959 DOI: 10.1111/aji.13142] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/10/2019] [Accepted: 04/09/2019] [Indexed: 12/11/2022] Open
Abstract
PROBLEM Previously, we reported the clinical efficacy of tacrolimus in women with repeated implantation failures (RIF) of immune etiologies. Safety of tacrolimus in pregnant women has been reported in women with organ transplantations. However, the safety of tacrolimus for women with RIF undergoing assisted reproductive technology cycles and their babies has not been reported prior. METHOD OF STUDY This study is a prospective observational study of 109 women with RIF or recurrent pregnancy losses (RPL) who showed elevated peripheral blood Th1/Th2 (CD4+ IFN-γ+ /CD4+ IL-4+ ) cell ratios (≥10.3). All received tacrolimus before and during pregnancy (1-4 mg/d) and delivered a live-born infant(s). Blood concentrations of tacrolimus were measured. Neuromotor development of the babies was also evaluated. RESULTS Total 113 babies were born from 109 women, including four twin pregnancies. Nine pregnancies including four twins were delivered prematurely (8.3%). Two of 109 women showed obstetric complications, such as hypertensive disorder of pregnancy, and only one baby (0.9%) had a congenital abnormality. There were no differences in babies' birthweight, placental weight, and lymphocyte proportion (%) of the umbilical cord among the women with different tacrolimus dosing. Tacrolimus was detected in the maternal plasma, and its concentration did not significantly fluctuate during pregnancy while on daily administration regimen. Neuromotor development of the babies exposed to tacrolimus in utero was comparable with that of babies from the general population. CONCLUSION According to our data, tacrolimus treatment for women with RIF and RPL was not associated with obstetrical and perinatal complications. A large size study is needed to confirm this finding.
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Affiliation(s)
- Koji Nakagawa
- Center for Reproductive Medicine and Implantation Research, Sugiyama Clinic Shinjuku, Tokyo, Japan
| | - Joanne Kwak-Kim
- Reproductive Medicine and Immunology, Department of Obstetrics and Gynecology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Vernon Hills, Illinois
| | - Michi Hisano
- Department of Maternal-Fetal Biology, National Center for Child Health and Development, Tokyo, Japan
| | | | - Keiji Kuroda
- Center for Reproductive Medicine and Implantation Research, Sugiyama Clinic Shinjuku, Tokyo, Japan
| | - Rikikazu Sugiyama
- Center for Reproductive Medicine and Implantation Research, Sugiyama Clinic Shinjuku, Tokyo, Japan
| | - Koushi Yamaguchi
- Department of Maternal-Fetal Biology, National Center for Child Health and Development, Tokyo, Japan
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11
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Pathogenetic factors involved in recurrent pregnancy loss from multiple aspects. Obstet Gynecol Sci 2019; 62:212-223. [PMID: 31338338 PMCID: PMC6629979 DOI: 10.5468/ogs.2019.62.4.212] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/23/2019] [Accepted: 05/06/2019] [Indexed: 12/19/2022] Open
Abstract
Recurrent pregnancy loss (RPL) is a common complication in obstetrics, affecting about 5% of women of childbearing age. An increase in the number of abortions results in escalation in the risk of miscarriage. Although concentrated research has identified numerous causes for RPL, about 50% of them remain unexplained. Pregnancy is a complex process, comprising fertilization, implantation, organ and tissue differentiation, and fetal growth, which is effectively controlled by a number of both maternal and fetal factors. An example is the immune response, in which T cells and natural killer cells participate, and inflammation mediated by tumor necrosis factor or colony-stimulating factor, which hinders embryo implantation. Furthermore, vitamin D affects glucose metabolism and inhibits embryonic development, whereas microRNA has a negative effect on the gene expression of embryo implantation and development. This review examines the causes of RPL from multiple perspectives, and focuses on the numerous factors that may result in RPL.
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12
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Sarno M, Cavalcante MB, Niag M, Pimentel K, Luz I, Figueiredo B, Michelon T, Neumann J, Lima S, Machado IN, Araujo Júnior E, Barini R. Gestational and perinatal outcomes in recurrent miscarriages couples treated with lymphocyte immunotherapy. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100036. [PMID: 31403124 PMCID: PMC6687386 DOI: 10.1016/j.eurox.2019.100036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/07/2019] [Accepted: 04/29/2019] [Indexed: 11/09/2022] Open
Abstract
Objective This study aims to elucidate which types of recurrent miscarriage (RM) patients experienced a livebirth after paternal lymphocyte immunotherapy (LIT) and to evaluate the perinatal outcome. Study design Retrospective analysis of a multicenter, observational study which enrolled 1096 couples with a history of two or more spontaneous miscarriages without any intercalated delivery. We conducted an intention-to-treat analysis of couples with RM treated with or without LIT regarding to gestational and perinatal outcomes. We compared groups by using the Student’s t-test or Kruskal–Wallis test, Fisher’s exact-test and χ2 test when appropriate. Results The success of gestation was significantly higher in the LIT group (60.1% vs. 33.1%; p < 0.001). A sub-analysis of four different immune disorder groups revealed a significantly higher success in the LIT group in all immune categories, except in patients who had autoantibodies positive. We observed no significant differences in perinatal outcomes such as gestational age at birth, preterm and extreme preterm birth, and birth weight in successful pregnancy in both groups. The success rate was significantly higher when LIT was administrated before and during pregnancy and only during pregnancy compared to only before pregnancy (p < 0.01). Conclusions Careful laboratory test phenotyping of RM patients may identify subgroups most likely to benefit and exclude those with little likelihood of benefit, and LIT during a pregnancy may significantly improve success rates.
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Affiliation(s)
- Manoel Sarno
- Department of Obstetrics and Gynecology, Federal University of Bahia (UFBA), Salvador, BA, Brazil
| | | | - Marla Niag
- Department of Obstetrics and Gynecology, Federal University of Bahia (UFBA), Salvador, BA, Brazil
| | - Kleber Pimentel
- Department of Obstetrics and Gynecology, Federal University of Bahia (UFBA), Salvador, BA, Brazil
| | - Ivana Luz
- Aloimune Reproductive Immunology Centre, Salvador, BA, Brazil
| | | | | | - Jorge Neumann
- Reproductive Immunology Centre, Porto Alegre, RS, Brazil
| | - Simone Lima
- Allovita Reproductive Immunology Centre, Campinas, SP, Brazil
| | | | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine-Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Ricardo Barini
- Department of Obstetrics and Gynecology, State University of Campinas (UNICAMP), Campinas, SP, Brazil
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Ander SE, Diamond MS, Coyne CB. Immune responses at the maternal-fetal interface. Sci Immunol 2019; 4:eaat6114. [PMID: 30635356 PMCID: PMC6744611 DOI: 10.1126/sciimmunol.aat6114] [Citation(s) in RCA: 319] [Impact Index Per Article: 63.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/29/2018] [Indexed: 12/13/2022]
Abstract
Pregnancy poses an immunological challenge because a genetically distinct (nonself) fetus must be supported within the pregnant female for the required gestational period. Placentation, or the establishment of the fetally derived placenta, is a common strategy used by eutherian mammals to protect the fetus and promote its growth. However, the substantial morphological differences of the placental architecture among species suggest that the process of placentation results from convergent evolution. Although there are considerable similarities in placental function across placental mammals, there are important differences that arise owing to species-specific immunological (and other biological) constraints. This Review focuses on the immunological similarities and differences that occur at the maternal-fetal interface in the context of human and mouse pregnancies. We discuss how the decidua and placenta of these different species form key immunological barriers that sustain maternal tolerance yet generate innate immune responses that prevent microbial infections.
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Affiliation(s)
- Stephanie E Ander
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA
- Center for Microbial Pathogenesis, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Michael S Diamond
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Carolyn B Coyne
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA.
- Center for Microbial Pathogenesis, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, PA 15219, USA
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA
- R. K. Mellon Pediatric Research Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15219, USA
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Nakagawa K, Kuroda K, Sugiyama R, Yamaguchi K. After 12 consecutive miscarriages, a patient received immunosuppressive treatment and delivered an intact baby. Reprod Med Biol 2017; 16:297-301. [PMID: 29259481 PMCID: PMC5715883 DOI: 10.1002/rmb2.12040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 05/07/2017] [Indexed: 11/17/2022] Open
Abstract
Aim An immune etiology for idiopathic recurrent miscarriage is an important issue because a fetus is allogenetically different from the mother. Type 1 T helper (Th1) and Type 2 (Th2) cells have important functions in immune responses and there is a general agreement that pregnancy is associated with Th2 cell dominance. The purpose of this case report is to establish the effectiveness of an immunosuppressive treatment for a patient who had 11 consecutive miscarriages despite several treatments, such as anticoagulation, that showed elevated Th1/Th2 cell ratios. Methods This patient visited our clinic following 11 consecutive miscarriages between 2009 and 2014 that occurred between 5 and 8 weeks’ gestation. The Th1/Th2 cell ratio was evaluated after the 12th conception and she received an immunosuppressive treatment (tacrolimus; 1 mg/d). Results The Th1/Th2 cell ratio was elevated after the 12th conception, but the patient miscarried, with a normal karyotype of chorionic villi despite the immunosuppressive treatment. After the 13th conception, she began receiving treatment with 2 mg/d of tacrolimus at 4 weeks’ gestation, which was continued until delivery. Conclusion For recurrent miscarriage cases that show an elevated Th1/Th2 cell ratio after achieving pregnancy, immunosuppressive treatment with tacrolimus could be effective.
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Affiliation(s)
- Koji Nakagawa
- Division of Reproductive Medicine Sugiyama Clinic Tokyo Japan
| | - Keiji Kuroda
- Department of Obstetrics and Gynecology Faculty of Medicine Juntendo University Tokyo Japan
| | | | - Koushi Yamaguchi
- Department of Maternal-Fetal Biology National Center for Child Health and Development Tokyo Japan
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15
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Faure E, Faure K, Figeac M, Kipnis E, Grandjean T, Dubucquoi S, Villenet C, Grandbastien B, Brabant G, Subtil D, Dessein R. Vaginal Mucosal Homeostatic Response May Determine Pregnancy Outcome in Women With Bacterial Vaginosis: A Pilot Study. Medicine (Baltimore) 2016; 95:e2668. [PMID: 26844497 PMCID: PMC4748914 DOI: 10.1097/md.0000000000002668] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Bacterial vaginosis (BV) is considered as a trigger for an inflammatory response that could promote adverse pregnancy outcome (APO). We hypothesized that BV-related inflammation could be counterbalanced by anti-inflammatory and mucosal homeostatic responses that could participate in pregnancy outcomes.A total of 402 vaginal self-samples from pregnant women in their first trimester were screened by Nugent score. In this population, we enrolled 23 pregnant women with BV but without APO, 5 pregnant women with BV and developing APO, 21 pregnant women with intermediate flora, and 28 random control samples from pregnant women without BV or APO.BV without APO in pregnant women was associated with 28-fold interleukin-8, 5-fold interleukin-10, and 40-fold interleukin-22 increases in expression compared to controls. BV associated with APO in pregnant women shared 4-fold increase in tumor necrosis factor, 100-fold decrease in interleukin-10, and no variation in interleukin-22 expressions compared to controls. Next-generation sequencing of vaginal microbiota revealed a shift from obligate anaerobic bacteria dominance in BV without APO pregnant women to Lactobacillus dominance microbiota in BV with APO.Our results show that the anti-inflammatory and mucosal homeostatic responses to BV may determine outcome of pregnancy in the setting of BV possibly through effects on the vaginal microbiota.
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Affiliation(s)
- Emmanuel Faure
- From the Faculty of Medicine of Lille, EA7366 Host-Pathogen Translational Research Group, University Lille North of France (EF, KF, EK, TG, RD); CHRU de Lille, Service de Maladies Infectieuses, Hôpital Claude Huriez (EF, KF, RD); University Lille, CHU Lille, IRCL, Structural and Functional Genomics Core Facility (MF, CV, RD); CHU Lille, Institut d'Immunologie-Centre de Biologie Pathologie et Génétique (SD, RD); UDSL, EA 2686, UFR Médecine (SD, RD); Univ Lille Nord de France (SD, BG, RD, DS); CHU Lille, Institut de Microbiologie, Laboratoire de Bactériologie Hygiène, Centre de Biologie Pathologie et Génétique (RD); UDSL, UFR Médecine (RD); CHU Lille, Service de Gestion du Risque Infectieux, des Vigilances et d'Infectiologie (BG); UDSL, EA 2694, UFR Médecine (BG, DS); Hôpital Saint Vincent, Service de Gynécologie-Obstétrique (GB); CHU Lille, Service de Gynécologie-Obstétrique Hôpital Jeanne de Flandre (DS), Lille, France
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Hu Y, Wu L, Wang C, Luo J, Liao F, Tan H, He H. Swainsonine exposure induces impairment of host immune response in pregnant BALB/c mice. BMC Immunol 2015; 16:53. [PMID: 26335138 PMCID: PMC4559345 DOI: 10.1186/s12865-015-0114-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 08/25/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Swainsonine can cause serious disorders in reproduction of livestock, affecting both corpora lutea and reproductive hormone. The purpose of this study was to investigate the mechanisms of swainsonine about the immunotoxic effects on pregnant mice in vivo. RESULTS The peripheral Th1/Th2 was detected by Ionomycin and phorbol myristate acetate (PMA)-stimulating peripheral blood mononuclear cells (PBMC) of phase pregnant mice. Relevant cytokines in serum was evaluated after exposed to different dose of swainsonine. Gene expression of IL-1β, IFN-γ, TNF-α, IL-4 and IL-10 in PBMC was assessed by real-time PCR. Swainsonine caused vacuolization phenomenon of lutein cells and a dose-effect relationship. The IL-1β, IFN-γ and TNF-α were promoted, but IL-4 and IL-10 were suppressed in serum. Swainsonine significantly increased IL-1β, IFN-γ and TNF-α nuclear translocation and decreased IL-4 and IL-10. Swainsonine resulted in a significant shift of peripheral Th1/Th2 paradigm to Th1. CONCLUSIONS Our data demonstrate that the immunomodulatory of swainsonine disturbed the regular immunologic state of the pregnant mice. This may increase the risk of abortion and probably resulted in serious disorders in reproduction of livestock.
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Affiliation(s)
- Yanchun Hu
- Institute of Zoology, Chinese Academy of Sciences, Beijing, 100101, P.R. China. .,Department of Clinical Veterinary Medicine, College of Veterinary Medicine, Sichuan Agricultural University, Wenjiang, 611130, P.R. China.
| | - Lei Wu
- Department of Clinical Veterinary Medicine, College of Veterinary Medicine, Sichuan Agricultural University, Wenjiang, 611130, P.R. China.
| | - Chengmin Wang
- Institute of Zoology, Chinese Academy of Sciences, Beijing, 100101, P.R. China.
| | - Jing Luo
- Institute of Zoology, Chinese Academy of Sciences, Beijing, 100101, P.R. China.
| | - Fei Liao
- Department of Clinical Veterinary Medicine, College of Veterinary Medicine, Sichuan Agricultural University, Wenjiang, 611130, P.R. China.
| | - Hui Tan
- Department of Clinical Veterinary Medicine, College of Veterinary Medicine, Sichuan Agricultural University, Wenjiang, 611130, P.R. China.
| | - Hongxuan He
- Institute of Zoology, Chinese Academy of Sciences, Beijing, 100101, P.R. China.
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Du MR, Wang SC, Li DJ. The integrative roles of chemokines at the maternal-fetal interface in early pregnancy. Cell Mol Immunol 2014; 11:438-48. [PMID: 25109684 DOI: 10.1038/cmi.2014.68] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 06/29/2014] [Accepted: 07/01/2014] [Indexed: 12/14/2022] Open
Abstract
Embryos express paternal antigens that are foreign to the mother, but the mother provides a special immune milieu at the fetal-maternal interface to permit rather than reject the embryo growth in the uterus until parturition by establishing precise crosstalk between the mother and the fetus. There are unanswered questions in the maintenance of pregnancy, including the poorly understood phenomenon of maternal tolerance to the allogeneic conceptus, and the remarkable biological roles of placental trophoblasts that invade the uterine wall. Chemokines are multifunctional molecules initially described as having a role in leukocyte trafficking and later found to participate in developmental processes such as differentiation and directed migration. It is increasingly evident that the gestational uterine microenvironment is characterized, at least in part, by the differential expression and secretion of chemokines that induce selective trafficking of leukocyte subsets to the maternal-fetal interface and regulate multiple events that are closely associated with normal pregnancy. Here, we review the expression and function of chemokines and their receptors at the maternal-fetal interface, with a special focus on chemokine as a key component in trophoblast invasiveness and placental angiogenesis, recruitment and instruction of immune cells so as to form a fetus-supporting milieu during pregnancy. The chemokine network is also involved in pregnancy complications.
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Xu Y, Tarquini F, Romero R, Kim CJ, Tarca AL, Bhatti G, Lee J, Sundell IB, Mittal P, Kusanovic JP, Hassan SS, Kim JS. Peripheral CD300a+CD8+ T lymphocytes with a distinct cytotoxic molecular signature increase in pregnant women with chronic chorioamnionitis. Am J Reprod Immunol 2012; 67:184-97. [PMID: 22077960 PMCID: PMC3479405 DOI: 10.1111/j.1600-0897.2011.01088.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
PROBLEM CD300a is an immunomodulatory molecule of the immunoglobulin receptor superfamily expressed in the leukocytes of myeloid and lymphoid lineages. However, its biological function on CD8+ T lymphocytes remains largely unknown. This study was conducted to assess the biological significance of CD300a expression in T lymphocytes and to determine whether its expression in peripheral T lymphocytes changes in pregnant women presenting with antifetal rejection. METHODS OF STUDY Microarray analysis was performed using total RNA isolated from peripheral CD300a+ and CD300a- T lymphocytes. Flow cytometric analysis of the peripheral blood samples of pregnant women and pathologic examination of the placentas were conducted. RESULTS A large number of genes (N = 1245) were differentially expressed between CD300a- and CD300a+ subsets of CD8+ T lymphocytes, which included CCR7, CD244, CX3CR1, GLNY, GZMB, GZMK, IL15, ITGB1, KLRG1, PRF1, and SLAMF7. Gene ontology analysis of differentially expressed genes demonstrated enrichment of biological processes such as immune response, cell death, and signal transduction. CD300a expression in CD8+ T lymphocytes was coupled to a more cytotoxic molecular signature. Of note, the proportion of CD300a+CD8+ T lymphocytes increased in pregnant women with chronic chorioamnionitis (antifetal rejection of the chorioamniotic membranes; P < 0.05). CONCLUSION The findings of this study strongly suggest an increase in systemic T-lymphocyte-mediated cytotoxicity in pregnant women with chronic chorioamnionitis as a manifestation of maternal antifetal rejection.
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Affiliation(s)
- Yi Xu
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Federica Tarquini
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Chong Jai Kim
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Pathology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Adi L. Tarca
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Computer Science, Wayne State University, Detroit, Michigan, USA
| | - Gaurav Bhatti
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - JoonHo Lee
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - I. Birgitta Sundell
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Pooja Mittal
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Juan Pedro Kusanovic
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sonia S. Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Jung-Sun Kim
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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