The role of corticoliberin concentration levels and placental CRH receptors 1 and 2 in the prolongation of pregnancy.

OBJECTIVE: To examine the changes in CRH concentrations in the blood serum of pregnant women and in the placenta of patients after the 41st week of gestation, and to determine its influence on the effectiveness of inducing labor and its progress. MATERIALS AND METHODS: The study group comprised pregnant patients who did not deliver until the 41 week of gestation (n = 114). The control group was divided into two subgroups: patients in whom delivery started spontaneously before the 41st week of gestation (n = 24) and pregnant patients in whom delivery started spontaneously after the 41st week of gestation (n = 23). Blood serum and placenta were obtained from the patients. Corticoliberin originating from blood serum was assessed with the use of ELISA Kit. Parts of the placenta were stained with monoclonal antibodies for the presence of corticoliberin, corticoliberin receptors 1 and 2. RESULTS: No statistically significant differences were found with regard to corticoliberin concentrations in the blood or during a qualitative assessment of the number of CRH R1 in the placenta between the research groups. However, corticoliberin receptor 2 had a statistically higher expression rate in the control group in which the delivery started spontaneously before the 41st week of gestation. CONCLUSION: In post-term pregnancy, the up-regulation of CRH R2 receptor is disturbed with no change in CRH R1 expression, which complicates the initiation of labor despite correct corticoliberin levels in both blood serum and the placenta. Pregnancy duration over 41 weeks and the effectiveness of preinducing or inducing labor do not depend on corticoliberin concentrations.

The Polish Society of Gynecologists and Obstetricians Guideline for the diagnostic assessment and management of multiple-gestation pregnancy complicated by fetal growth restriction.

The aim of the Guideline is to unify the diagnostic-therapeutic management of multiple-gestation pregnancies complicated by fetal growth restriction in at least one fetus.

Outcome dependent twin growth curves based on birth weight percentiles for Polish population.

OBJECTIVE: The objective of this study is to determine a healthy fetal growth pattern of twins from a Polish population based on an outcome-dependent growth curve. METHODS: The fetal growth data of live-born twin pregnancies between 25th and 40th week gestation in the period of 1 January 2005 to 31 March 2018 from the database of a tertiary care women's hospital in Western Poland was used to calculate birth weight percentiles. The growth curves of singletons from the same database were used as comparison. Because this study aimed for an outcome-dependent approach for the calculation of fetal growth curves, all babies born that may have high risk of unfavorable outcome were excluded. After application of all exclusion criteria, 1317 records referring to 2634 children were included in our analysis. Growth curves of singletons from the same database were used as reference for this study. RESULTS: A linear relationship between 10th, 50th, and 90th percentiles and gestational age were found for twins but not for singletons suggesting the different mechanisms of intrauterine growth between singleton and twin pregnancies. Week-to-week weight gain equal to or higher than 150 g in twins also predict a favorable outcome in absence of other pathologies. CONCLUSION: The calculated outcome-dependent fetal growth curves for twins in this study may help in the accurate diagnosis of small or large twin fetuses for their gestational age in this Western Poland population.

Fetal growth trajectory in type 1 pregestational diabetes (PGDM) - an ultrasound study.

OBJECTIVES: Growth disorders are frequent in diabetic pregnancies. However, they are difficult to predict and capture early during pregnancy. These newborns are at risk of obesity, diabetes, and cardiovascular disease. While developing, fetal growth abnormalities are typically progressive. Therefore, capturing the earliest moment when they emerge is essential to guide subsequent obstetric management. MATERIAL AND METHODS: We aimed to analyze fetal ultrasound growth trajectories in type 1 diabetics. Moreover, we aimed to establish time points when first ultrasound manifestations of fetal growth abnormalities appear and to identify factors that affect fetal growth in women with diabetes. We collected clinical and ultrasound data from 200 patients with PGDM managed in the third-referential centre for diabetes in pregnancy. During every visit, patients underwent an ultrasound examination according to a standard protocol giving 1072 ultrasound scan's records. Every ultrasound consisted of fetal weight estimation, according to the Hadlock 3 formula. Retrospectively patients were divided into three groups depending on neonatal weight. In the group of 200 patients, 60 (30%) delivered LGA and 9 (4.5%) SGA newborns. RESULTS: Fetal growth trajectories show different patterns among fetuses with growth abnormalities in women with type 1 diabetes. The moment, when fetal growth curves diverge, seems to take place in the second trimester, just after the 23rd week of gestation. CONCLUSIONS: It suggests that fetal growth abnormalities in type 1 diabetes may have its roots much earlier than expected. In the first trimester, there were differences in LDL-cholesterol, total cholesterol, triglyceride levels and in insulin requirements between AGA, SGA and LGA subgroups.

Serum endocan concentration and its correlation with severity of hypertensive disorders in pregnancy.

Introduction: Endocan plays a role in the development of vascular tissue in health and disease and is an indicator of endothelial cells activation and angiogenesis.Objective: The aim of this study was to investigate the relationship between endocan serum levels and various types of hypertensive disorders in pregnant women.Patients and methods: We created three study groups (preeclampsia [n = 60], chronic hypertension [n = 39], gestational hypertension [n = 58]) and the control group consisting of 59 healthy pregnant women. The endocan serum concentration was assessed using commercially available ELISA kit.Results: There were no statistically significant differences in endocan serum levels (pg/mL) in each study group compared to controls. The multiple regression did not reveal significant differences between endocan levels in each study group after adjustment for prepregnancy BMI. We did not find any significant correlations between the endocan serum level and patients' age, gestational age (GA) at sample collection, prepregnancy BMI, systolic blood pressure, diastolic blood pressure, and 24-hour urinary protein excretion in each analyzed group. Moreover, in the preeclamptic participants, we did not observe a significant relationship between the endocan concentration and the features indicating the severity of the disease other than elevated blood pressure. There were no differences in endocan serum level in preeclampsia subgroups: early-onset versus late-onset and mild versus severe preeclampsia.Conclusions: Endocan is not involved in the pathogenesis of hypertensive disorders in pregnant women and could not be regarded as a marker of endothelial dysfunction in these cases.

Cortisol metabolism in pregnancies with small for gestational age neonates.

Small for gestational age (SGA) newborns are often born from hypertensive pregnancies. This study aimed to compare the systemic metabolism of cortisol (F) in pregnancies with SGA and appropriate for gestational age (AGA) infants, considering both the normotensive (NT) and hypertensive patients. We hypothesized that the disturbances in systemic metabolism of F in pre-eclampsia (PE) might be attributed not to hypertension only, but to SGA. The study included 117 pregnants in the third trimester, divided into groups: NT pregnancy and SGA neonate (SGA-NT); NT pregnancy and AGA neonate (AGA-NT; controls), and respective groups with PE: SGA-PE and AGA-PE. We assessed the glucocorticoid balance with the function of enzymes involved in systemic metabolism of F: 11ß-hydroxysteroid dehydrogenase type 1 and 2 (11ß-HSD1 and 11ß-HSD2), 5α- and 5ß-reductase. The enzymes' functions were estimated with the levels of F, cortisone (E), and their metabolites in plasma or urine, which we measured with HPLC-FLD and HPLC-MS/MS. The plasma F/E and urinary free F/E (UFF/UFE) ratios correlated significantly only in patients with the normal function of 5α- and 5ß-reductase. The increased function of 11ß-HSD2 was noted in all pre-eclamptic pregnancies. Increased function of 5α- and 5ß-reductase was specific only for SGA-PE pregnancies, and the function of 5α-reductase was dependent on fetal sex. The SGA-NT pregnancies with male fetuses trended towards the higher function of renal 11ß-HSD2 and 5ß-reductase; SGA-NT pregnancies with female fetuses lacked any systemic glucocorticoid imbalance. In conclusion, systemic metabolism of F is the most intensive in pre-eclamptic pregnancies complicated by SGA with female fetuses. Our study supports the hypothesis about the different origins of PE and idiopathic intrauterine growth restriction and suggests the sex-specific mechanisms responsible for fetal growth restriction.

Preeclampsia with Intrauterine Growth Restriction Generates Morphological Changes in Endothelial Cells Associated with Mitochondrial Swelling-An In Vitro Study.

Pregnancy complicated by preeclampsia (PE) and intrauterine growth restriction (IUGR) promotes endothelial cell (EC) dysfunction. Our in vitro study aimed to evaluate the endothelial cell morphology after acute and chronic exposition to medium supplemented with serum taken from healthy pregnant women and women with IUGR and IUGR with PE. In the same condition, ECs viability, proliferation, reactive oxygen species (ROS) production, and serum concentration of vascular endothelial growth factor (VEGF) were also measured. Pregnant women with IUGR and IUGR with PE-delivered babies with reduced body mass and were characterized in elevated blood pressure, urine protein loss, and reduced level of VEGF. The 24 hours of exposition did not exert any morphological changes in ECs, except the reduction in cell viability, but prolonged exposition resulted in significant morphological changes concerning mostly the swelling of mitochondria with accompanying ROS production, cell autophagy, reduced cell viability, and proliferation only in complicated pregnancies. In conclusion, the sera taken from women with IUGR and IUGR with PE show a detrimental effect on ECs, reducing their viability, proliferation, and generating oxidative stress due to dysfunctional mitochondria. This multidirectional effect might have an adverse impact on the cardiovascular system in women with IUGR and PE.

Nutritional behavior in pregnancy.

OBJECTIVES: The aim of the study was to characterize nutritional behavior in pregnancy. MATERIAL AND METHODS: The survey study included 250 pregnant women. The survey concerned dietary behavior refferedto the type of diet, the number of meals per day, snacking between meals, consumption of meat, fish, dairy products,bread, fruits and vegetables. RESULTS: 88.8% of the respondents were not on a special diet. The most of the women ate more than three times a day.The women usually ate fruits and vegetables, yogurt and sweets as snacks between meals. The majority of respondentsconsumed meat and sliced meats twice or once a day with the preference of poultry. Only 17.6% of them ate fish with therecommended frequency and as much as 21.2% chose not-recommended species. Almost 29.6% of patients consumed3 to 4 servings of milk or milk products a day and 16.8% of them excluded milk. Half of the respondents declared eatingwheat bread and 24% of them chose wheat roll during pregnancy. Despite the large number of women who consumedwheat baking, a considerable amount of women chose wholemeal bread and wholemeal rolls. Nutritional behaviors werecorrelated with on education level and weight gain during pregnancy. CONCLUSIONS: The frequency of meals was adequate for the most of pregnant women as well as recommended consumptionof meat with poultry preference. However, the inappropriate nutrition was also observed in a low consumption of fishand dairy products, a high consumption of wheat breadstuff and sweets, as well as in a small intake of milk. Education leveland weight gain during pregnancy were associated with nutritional behaviors.

The agonistic autoantibodies to the angiotensin II type 1 receptor in pregnancies complicated by hypertensive disorders.

Introduction: The etiology and pathogenesis of pregnancy-related hypertensive disorders is complex and multifactorial. The aim of our study is the investigation of the differences in the autoantibodies against angiotensin II type 1 receptor (AT1-AA) titers among pregnant patients with chronic hypertension, gestational hypertension, and preeclampsia compared to the healthy pregnant women. Patients and methods: We created three study groups (preeclampsia [n = 16], chronic hypertension [n = 13], gestational hypertension [n = 17]) and the control group consisting of 17 healthy pregnant women. Every compared group was matched for mother's age, parity, prepregnancy BMI, and gestational age at time of recruitment into study. The autoantibodies titer were assessed using commercially available ELISA kit. Results: We found a statistically higher AT1-AA titer in the group of patients with gestational hypertension (GH) and preeclampsia (PE) compared to healthy normotensive pregnant women (median 9.6 versus 7.8 ng/ml, p = .01 and 10.9 ng/ml versus 7.8 ng/ml, p = .02, respectively). There was no correlation between blood pressure values and AT1-AA titer in any group. We found no correlation in group with preeclampsia between urinary protein excretion and AT1-AA titer (p = .23, R = 0.32). Conclusions: We assume that pregnancy-related hypertensive disorders might be autoimmune diseases and AT1-AA contribute to the pathophysiology of the disease. Our study may have some therapeutic implications and shows the necessity of new research into the mechanisms involved in the production of AT1-AA. Such investigations might enable to inhibit the formation of these autoantibodies or elaborate another method for AT1-AA removal.

High-performance liquid chromatography methods for the analysis of endogenous cortisol and cortisone in human urine: comparison of mass spectrometry and fluorescence detection.

BACKGROUND: The analysis of steroids in biological matrices is challenging. One can apply immunoassay as well as gas and liquid chromatography with various types of detection, depending on the available equipment and the experience of the analyst. The question is how the methods are interchangeable between themselves. Doubts were reported having compared immunoassays and chromatography-mass spectrometry, but there are scarce data on chromatographic methods with detection types other than mass spectrometry. METHODS: Here, we present the detailed comparison of two liquid chromatographic methods for the determination of free urinary cortisol and cortisone: one with fluorescence detection (high-performance liquid chromatography [HPLC-FLD]) and the other with tandem mass spectrometry (HPLC-MS/MS). The comparison was made with 199 human urine samples. The data analysis included Passing-Bablok and Deming regression, Bland-Altman test, Wilcoxon test, mountain plot and Lin's concordance correlation coefficient. RESULTS: The validation data indicated that both methods met the requirements of the European Medicines Agency. However, the statistical analysis revealed the systematic bias between the two assays. The Passing-Bablok and the Deming tests showed that the HPLC-FLD method overestimated results for cortisol and underestimated measurements for cortisone. The Bland-Altman analysis estimated the mean differences between the methods: 18.8 nmol/L for cortisol and -16.9 nmol/L for cortisone measurement. CONCLUSIONS: Both methods' results led to the same conclusion in observational studies, but the techniques are not interchangeable. The literature data, the observations from the clinical setting and our experience clearly indicate that the future of steroid measurements will belong to chromatography coupled with mass spectrometry.

Maternal Serum Endocan Concentration in Pregnancies Complicated by Intrauterine Growth Restriction.

OBJECTIVES: Endocan plays a role in the development of vascular tissue in health and disease and is an indicator of endothelial cells activation and angiogenesis. Therefore, this study aimed to investigate the relationship between maternal endocan serum level and intrauterine growth restriction (IUGR) as well as ultrasound Doppler flow measurements indicating placental insufficiency. METHODS: This study included a group of women with IUGR (n = 37) and a group of healthy pregnant women (controls, n = 37). The endocan serum concentrations were assessed using commercially available enzyme-linked immunosorbent assay kit. Every woman underwent an ultrasound examination with Doppler flow measurements of the uterine arteries, umbilical vessels, and fetal middle cerebral artery. We used the cerebroplacental ratio (CPR) to determine placental insufficiency. RESULTS: We found significant differences in median (interquartile) endocan serum level (pg/mL) between study and control groups (464 [374-532] vs 339 [189-496], respectively; P < .001). The endocan serum level correlated neither with umbilical cord blood gases nor with Apgar score. Ultrasound Doppler findings revealed significant differences in middle cerebral artery pulsatility index (PI), umbilical artery PI, CPR, as well as mean uterine arteries PI between IUGR group and controls. In the study group, we found significant correlations between the serum endocan and CPR ( R = 0.56, P < .001) as well as between serum endocan and mean uterine arteries PI ( R = 0.46, P = .006). CONCLUSION: Endocan is likely involved in the pathogenesis of IUGR in pregnant women and possibly is a useful marker of endothelial dysfunction in these cases.

Uterine arteriovenous malformation - diagnosis and management.

Uterine arteriovenous malformations are uncommon but potentially life-threatening conditions. They can be congenital or acquired and should be suspected in cases of severe or persistent uterine bleeding. In recent years, there has been an in-creasing number of reports of acquired vascular lesions of the uterus following pregnancy, abortion, caesarean delivery and curettage. This paper presents the review of the literature considered epidemiology, pathophysiology, diagnostic methods and treatment options. Unexplained uterine bleeding should be always an indication for colour Doppler ultrasonography and the presence of arteriovenous malformation should be always excluded.

Acquired uterine arteriovenous malformation - a diagnostic dilemma.

Uterine arteriovenous malformations are uncommon but potentially life-threatening condition. They can be congenital or acquired and should be suspected in cases of severe or persistent uterine bleeding. In recent years, there has been an increasing number of reports of acquired vascular lesions of the uterus following pregnancy, abortion, caesarean delivery and curettage. This paper presents the case of unexplained vaginal bleeding with subsequent suspicion and diagnosis of uterine arteriovenous malformation. Unexplained uterine bleeding should be always an indication for colour Doppler ultrasonography and the presence of AVM should be always excluded.

Differences in the Expression of TLR-2, NOD2, and NF-κB in Placenta Between Twins.

Dizygotic twins share the same type of genetic relationship as non-twin siblings. Whereas monozygotic (MZ) twins are considered to have identical genetic material, they still differ. There is a number of reasons for early MZ twin discordance, including differences in the in utero environment, stochasticity, genetic mosaicism, and epigenetic factors. During gestation, the efficient innate immune system is of utmost importance. Our study was based on immunohistochemical evaluation of the differences in innate immune protein expression (TLR-2, NOD2, and NF-κB) in the 95 placentas between twins. Our study revealed statistical significant differences between diamniotic-dichorionic and monoamniotic-dichorionic twins. Monoamniotic-monochorionic twins exhibited no significant differences in protein expressions. To identify epigenetic factors causing the differences between twins, we made a series of comparisons with clinical data. The study revealed more cases with infections, miscarriages, in vitro fertilization, and premature rupture of membranes within the group with higher differences level of NF-κB, NOD2 and TLR-2 between twins. In case of twin-to-twin transfusion syndrome, there were no significant differences in innate immune protein expressions between twins. These results show that dissimilar genetic material and separate in utero environment promote discordance in innate immune protein expressions between twins. Moreover, additional blood flow between twins may be favorable in life-threatening conditions ensuring similar microenvironment.

Relationship between the von Willebrand Factor Plasma Concentration and Ultrasonographic Doppler Findings in Pregnancies Complicated by Hypertensive Disorders: A Pilot Study.

BACKGROUND/AIMS: Recent evidence suggests that impaired cytotrophoblast proliferation and migration are major factors responsible for the development of hypertension in pregnancy. Studies report that von Willebrand factor (vWf) is a specific endothelial damage plasma marker. The aim of this study was to evaluate the relationship between vWf maternal plasma concentration and maternal and fetal Doppler flow measurements in pregnancies complicated by hypertension. It may provide additional insight into the pathophysiology of pregnancy-related hypertension and show the potential method for disease prevention and therapy. METHODS: We created 3 study groups: pregnant women with chronic hypertension (n = 10), gestational hypertension (n = 18), preeclampsia (n = 21), and control (22 healthy pregnant women). Every woman underwent ultrasound Doppler flow measurements performed simultaneously with venous blood collection. The vWf plasma concentrations were assessed using the commercially available enzyme-linked immunosorbent assay kit. RESULTS: The preeclampsia group had significantly higher vWf plasma concentrations in those patients with ultrasonographic features of placental insufficiency than in those without these characteristics (638 ± 208 vs. 377 ± 74 ng/mL; p < 0.017). CONCLUSION: Our results may confirm the arrangement and severity of endothelial damage in preeclamptic patients and may have identified those patients with a significantly higher risk of developing cardiovascular disease.

Increased cortisol metabolism in women with pregnancy-related hypertension.

PURPOSE: The diminished function of 11ß-hydroxysteroid dehydrogenase 2 (11ß-HSD2) was found in placentae from preeclamptic pregnancies. Here, we examine the overall maternal glucocorticoid balance in pregnancy-related hypertension. We aim to answer the question if the functions of primary enzymes involved in cortisol metabolism: 11ß-HSD1 and 11ß-HSD2 and 5-reductases (both 5α- and 5ß) are altered in the course of hypertensive pregnancy. METHODS: We determined plasma and urinary cortisol and cortisone as well as their urinary tetrahydro- and allo-tetrahydrometabolites, both in free and conjugated forms in samples obtained from 181 Polish women in the third trimester of pregnancy. We compared steroid profiles in women with preeclampsia (PE), gestational hypertension (GH), chronic hypertension (CH) and in normotensives (controls). RESULTS: We found significant differences in glucocorticoid balance in pregnancy-related hypertension. Plasma cortisol to cortisone was significantly lower in PE than in controls (3.00 vs. 4.79; p < 0.001). Increased function of renal 11ß-HSD2 in PE and GH was manifested by significantly lower urinary free cortisol to cortisone ratio (0.169 and 0.206 vs. 0.277 in controls; p < 0.005). Markedly enhanced metabolism of cortisol was observed in pregnancy-related hypertension, with no significant alterations in CH, and the changes were more clearly expressed in PE than in GH. CONCLUSIONS: The glucocorticoid balance in PE and GH is shifted towards decreasing cortisol concentration either due to intensified conversion to cortisone or enhanced production of tetrahydro and allo-tetrahydrometabolites.

Screening for trisomy 21 based on maternal age, nuchal translucency measurement, first trimester biochemistry and quantitative and qualitative assessment of the flow in the DV - the assessment of efficacy.

OBJECTIVES: The aim of the study was to compare effects of addition of two methods of ductus venosus (DV) flow assessment: qualitative - the assessment of shape of the A-wave (positive or negative), and quantitative - based on the pulsatility index for veins (DVPI) to the basic screening for trisomy 21 at 11 to 13 + 6 weeks of pregnancy. MATERIAL AND METHODS: The ultrasound examination was performed in 8230 fetuses in singleton pregnancies at 11- -13 + 6 wks, as a part of a routine screening for chromosomal defects. In DV A-wave was assessed and DVPI was calculated. After the scan blood sample was taken for first trimester biochemistry (BC). Risk for chromosomal defects was calculated and high-risk patients were offered an invasive test for karyotyping. RESULTS: Basic screening with following combination of markers: MA, NT and BC provided lowest detection rate (DR) 87.50% for FPR = 6.94%. After adding qualitative DV A-wave assessment DR increased to 88.75% for FPR = 5.65%. The best DR = 93.75% for FPR = 5.55% was achieved when quantitative DVPI was added. The application of the Receiver Operating Curves curve confirmed validity of the addition of DV flow assessment to the screening model. The highest diagnostic power of the test was achieved when DVPI was added, with the ROC AUC of 0.974. CONCLUSIONS: The assessment of DV flow performed at 11-13 + 6 weeks increases DR for trisomy 21 and reduces FPR. The screening model based on the quantitative DV flow analysis (DVPI) gives better results compared to the qualitative flow assessment.