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Creisher PS, Klein SL. Pathogenesis of viral infections during pregnancy. Clin Microbiol Rev 2024; 37:e0007323. [PMID: 38421182 DOI: 10.1128/cmr.00073-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
SUMMARYViral infections during pregnancy are associated with significant adverse perinatal and fetal outcomes. Pregnancy is a unique immunologic and physiologic state, which can influence control of virus replication, severity of disease, and vertical transmission. The placenta is the organ of the maternal-fetal interface and provides defense against microbial infection while supporting the semi-allogeneic fetus via tolerogenic immune responses. Some viruses, such as cytomegalovirus, Zika virus, and rubella virus, can breach these defenses, directly infecting the fetus and having long-lasting consequences. Even without direct placental infection, other viruses, including respiratory viruses like influenza viruses and severe acute respiratory syndrome coronavirus 2, still cause placental damage and inflammation. Concentrations of progesterone and estrogens rise during pregnancy and contribute to immunological adaptations, placentation, and placental development and play a pivotal role in creating a tolerogenic environment at the maternal-fetal interface. Animal models, including mice, nonhuman primates, rabbits, and guinea pigs, are instrumental for mechanistic insights into the pathogenesis of viral infections during pregnancy and identification of targetable treatments to improve health outcomes of pregnant individuals and offspring.
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Affiliation(s)
- Patrick S Creisher
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sabra L Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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Creisher PS, Parish MA, Lei J, Liu J, Perry JL, Campbell AD, Sherer ML, Burd I, Klein SL. Suppression of progesterone by influenza A virus mediates adverse maternal and fetal outcomes in mice. mBio 2024; 15:e0306523. [PMID: 38190129 PMCID: PMC10865978 DOI: 10.1128/mbio.03065-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
Influenza A virus infection during pregnancy can cause adverse maternal and fetal outcomes but the mechanism responsible remains elusive. Infection of outbred mice with 2009 H1N1 at embryonic day (E) 10 resulted in significant maternal morbidity, placental tissue damage and inflammation, fetal growth restriction, and developmental delays that lasted through weaning. Restriction of pulmonary virus replication was not inhibited during pregnancy, but infected dams had suppressed circulating and placental progesterone (P4) concentrations that were caused by H1N1-induced upregulation of pulmonary cyclooxygenase (COX)-1-, but not COX-2-, dependent synthesis and secretion of prostaglandin (PG) F2α. Treatment with 17-α-hydroxyprogesterone caproate (17-OHPC), a synthetic progestin that is safe to use in pregnancy, ameliorated the adverse maternal and fetal outcomes from H1N1 infection and prevented placental cell death and inflammation. These findings highlight the therapeutic potential of progestin treatments for influenza during pregnancy.IMPORTANCEPregnant individuals are at risk of severe outcomes from both seasonal and pandemic influenza A viruses. Influenza infection during pregnancy is associated with adverse fetal outcomes at birth and adverse consequences for offspring into adulthood. When outbred dams, with semi-allogenic fetuses, were infected with 2009 H1N1, in addition to pulmonary virus replication, lung damage, and inflammation, the placenta showed evidence of transient cell death and inflammation that was mediated by increased activity along the arachidonic acid pathway leading to suppression of circulating progesterone. Placental damage and suppressed progesterone were associated with detrimental effects on perinatal growth and developmental delays in offspring. Treatment of H1N1-infected pregnant mice with 17-OHPC, a synthetic progestin treatment that is safe to use in pregnancy, prevented placental damage and inflammation and adverse fetal outcomes. This novel therapeutic option for the treatment of influenza during pregnancy should be explored clinically.
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Affiliation(s)
- Patrick S. Creisher
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Maclaine A. Parish
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jun Lei
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jin Liu
- Department of Gynecology and Obstetrics, Integrated Research Center for Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jamie L. Perry
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ariana D. Campbell
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Morgan L. Sherer
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Irina Burd
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sabra L. Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Creisher PS, Parish MA, Lei J, Liu J, Perry JL, Campbell AD, Sherer ML, Burd I, Klein SL. Suppression of progesterone by influenza A virus mediates adverse maternal and fetal outcomes in mice. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.09.11.557146. [PMID: 37745453 PMCID: PMC10515826 DOI: 10.1101/2023.09.11.557146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Influenza A virus infection during pregnancy can cause adverse maternal and fetal outcomes, but the mechanism responsible remains elusive. Infection of outbred mice with 2009 H1N1 at embryonic day (E) 10 resulted in significant maternal morbidity, placental tissue damage and inflammation, fetal growth restriction, and developmental delays that lasted through weaning. Restriction of pulmonary virus replication was not inhibited during pregnancy, but infected dams had suppressed circulating and placental progesterone (P4) concentrations that were caused by H1N1-induced upregulation of pulmonary cyclooxygenase (COX)-1, but not COX-2-, dependent synthesis and secretion of prostaglandin (PG) F2α. Treatment with 17-α-hydroxyprogesterone caproate (17-OHPC), a synthetic progestin that is safe to use in pregnancy, ameliorated the adverse maternal and fetal outcomes from H1N1 infection and prevented placental cell death and inflammation. These findings highlight the therapeutic potential of progestin treatments for influenza during pregnancy.
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Creisher PS, Seddu K, Mueller AL, Klein SL. Biological Sex and Pregnancy Affect Influenza Pathogenesis and Vaccination. Curr Top Microbiol Immunol 2023; 441:111-137. [PMID: 37695427 DOI: 10.1007/978-3-031-35139-6_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Males and females differ in the outcome of influenza A virus (IAV) infections, which depends significantly on age. During seasonal influenza epidemics, young children (< 5 years of age) and aged adults (65+ years of age) are at greatest risk for severe disease, and among these age groups, males tend to suffer a worse outcome from IAV infection than females. Following infection with pandemic strains of IAVs, females of reproductive ages (i.e., 15-49 years of age) experience a worse outcome than their male counterparts. Although females of reproductive ages experience worse outcomes from IAV infection, females typically have greater immune responses to influenza vaccination as compared with males. Among females of reproductive ages, pregnancy is one factor linked to an increased risk of severe outcome of influenza. Small animal models of influenza virus infection and vaccination illustrate that immune responses and repair of damaged tissue following IAV infection also differ between the sexes and impact the outcome of infection. There is growing evidence that sex steroid hormones, including estrogens, progesterone, and testosterone, directly impact immune responses during IAV infection and vaccination. Greater consideration of the combined effects of sex and age as biological variables in epidemiological, clinical, and animal studies of influenza pathogenesis is needed.
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Affiliation(s)
- Patrick S Creisher
- Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD, United States
| | - Kumba Seddu
- Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD, United States
| | - Alice L Mueller
- Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD, United States
| | - Sabra L Klein
- Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD, United States.
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Cervantes O, Talavera IC, Every E, Coler B, Li M, Li A, Li H, Adams Waldorf K. Role of hormones in the pregnancy and sex-specific outcomes to infections with respiratory viruses. Immunol Rev 2022; 308:123-148. [PMID: 35373371 PMCID: PMC9189035 DOI: 10.1111/imr.13078] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 01/13/2023]
Abstract
Pregnant women infected with pathogenic respiratory viruses, such as influenza A viruses (IAV) and coronaviruses, are at higher risk for mortality, hospitalization, preterm birth, and stillbirth. Several factors are likely to contribute to the susceptibility of pregnant individuals to severe lung disease including changes in pulmonary physiology, immune defenses, and effector functions of some immune cells. Pregnancy is also a physiologic state characterized by higher levels of multiple hormones that may impact the effector functions of immune cells, such as progesterone, estrogen, human chorionic gonadotropin, prolactin, and relaxin. Each of these hormones acts to support a tolerogenic immune state of pregnancy, which helps prevent fetal rejection, but may also contribute to an impaired antiviral response. In this review, we address the unique role of adaptive and innate immune cells in the control of pathogenic respiratory viruses and how pregnancy and specific hormones can impact their effector actions. We highlight viruses with sex-specific differences in infection outcomes and why pregnancy hormones may contribute to fetal protection but aid the virus at the expense of the mother's health.
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Affiliation(s)
- Orlando Cervantes
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Irene Cruz Talavera
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Emma Every
- University of Washington School of Medicine, Spokane, Washington, United States of America
| | - Brahm Coler
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, United States of America
| | - Miranda Li
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
- Department of Biological Sciences, Columbia University, New York City, New York, United States of America
| | - Amanda Li
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
- Case Western Reserve, Cleveland, Ohio, United States of America
| | - Hanning Li
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Kristina Adams Waldorf
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
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Chow EJ, Beigi RH, Riley LE, Uyeki TM. Clinical Effectiveness and Safety of Antivirals for Influenza in Pregnancy. Open Forum Infect Dis 2021; 8:ofab138. [PMID: 34189160 DOI: 10.1093/ofid/ofab138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/19/2021] [Indexed: 11/14/2022] Open
Abstract
Seasonal influenza epidemics result in substantial health care burden annually. Early initiation of antiviral treatment of influenza has been shown to reduce the risk of complications and duration of illness. Pregnant and postpartum women may be at increased risk for influenza-associated complications; however, pregnant women have been generally excluded from clinical trials of antiviral treatment of influenza. In this review, we summarize the available evidence on the clinical effectiveness and safety of antiviral treatment of pregnant women with influenza. Observational data show a reduction of severe outcomes when pregnant and postpartum women are treated with oseltamivir and other neuraminidase inhibitors without increased risk of adverse maternal, fetal, or neonatal outcomes. Due to lack of safety and efficacy data for baloxavir treatment of pregnant and postpartum women, baloxavir is currently not recommended for use in these populations.
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Affiliation(s)
- Eric J Chow
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Richard H Beigi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh Magee-Womens Hospital, Pittsburgh, Pennsylvania, USA
| | - Laura E Riley
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Timothy M Uyeki
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Immunological Changes in Pregnancy and Its Relation to COVID-19 Infection. COVID-19 INFECTIONS AND PREGNANCY 2021. [PMCID: PMC8298321 DOI: 10.1016/b978-0-323-90595-4.00006-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This chapter describes the immunological adaptation to pregnancy. A special focus is drawn on the susceptibility to viral infections, especially COVID-19. Older literature refers to the pregnancy as an immunosuppressive state, while recent studies show an immunomodulation to adapt to the growing semiallograftic fetus. Despite this, pregnant women are not susceptible to all viral infections. Regarding influenza, pregnant women are not more susceptible to the infection, but more severe maternal courses. To prevent this, influenza vaccination is recommended for pregnant women. Based on the available evidence, pregnant patients are also not more susceptible to infection with regard to COVID-19 infection. Yet, more severe courses are described throughout gestation with the onset of obstetrical complications.
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