The effect of an animation video on consultation time, anxiety and satisfaction in women with abnormal cervical cytology: Animation video reduces colposcopy time.

The objective was to assess whether supplementing hospital-dependent standard information with a hospital-independent animation video might reduce consultation time, pre-colposcopy anxiety levels and increase post-colposcopy satisfaction. Between November 2016 and May 2018, women were included if they were referred to the department of Obstetrics and Gynaecology in one of the three participating hospitals in the Netherlands due to an abnormal cervical smear. Exclusion criteria were colposcopy in the medical history or inability to understand, speak or read Dutch. Two consecutive cohorts were created: a control group that received standard information and an intervention group that received the same plus the animation video. Outcome measures were consultation time, pre-colposcopy anxiety level and post-colposcopy satisfaction. Consultation time was measured using stopwatch. Anxiety was measured using the State-Trait Anxiety Inventory (STAI) and the Hospital Anxiety and Depression Scale (HADS). Satisfaction was measured with the Patient's Experience and Attitude Colposcopy Eindhoven questionnaire (PEACE-q). In total, 122 women were included, 61 in each group. Baseline characteristics were similar between the two groups. Pre-colposcopy consultation time was significantly reduced in the intervention group (median 140 s) compared to the control group (median 269 s). However, overall consultation time was not reduced. The outcome measures anxiety and satisfaction were not significantly different. A hospital-independent animation video did significantly reduced pre-colposcopy consultation time but did not reduce anxiety or increase satisfaction in women with abnormal cervical cytology. Further research should focus on the effects of animation video in a primary care setting.

Pericellular-acting proteases in human first trimester decidua.

Proteolysis is essential for decidual development during embryonic implantation, but little is known regarding the expression and functions of membrane-type matrix metalloproteinases (MT-MMPs) and urokinase-type plasminogen activator (uPA) and its receptor uPAR in decidua. Therefore, their protein and mRNA levels were analysed in three first trimester decidual tissues, decidual secretory endometrium (DSE), decidua parietalis (DP) and basalis (DB). Decidua was obtained during first trimester pregnancy termination. uPA, uPAR, and MT1/2/3/5-MMP expression were studied by RT-PCR and immunohistochemistry, and CD56-positive uNK cells and CD68-positive macrophages were quantified in serial sections. The mRNAs and antigens of all proteases and uPAR were detectable in the decidual tissues and extravillous trophoblasts (EVT). mRNA levels of all proteases and uPAR, except MT5-MMP, were elevated in both DB and DP compared to DSE, being significant for MT1-MMP and uPAR in DP. MT2- and MT3-MMP mRNAs in DB were 24- and 10-fold higher than in DSE, and 19- and 7-fold increased compared to DP. At the protein level uPA and uPAR were particularly elevated in DB, while pro-angiogenic MT1- and MT3-MMPs were elevated in both DB and DP compared to DSE. MT2-MMP was prominently present in all conditions. The number of uNK cells was increased in DB and DP versus DSE, while a comparable increase in macrophages did not reach statistical significance. These data are consistent with a differential regulation of pericellular proteases in decidua by pregnancy-induced hormones, immune cells and EVT.

Involvement of membrane-type matrix metalloproteinases (MT-MMPs) in capillary tube formation by human endometrial microvascular endothelial cells: role of MT3-MMP.

In the endometrium, angiogenesis is a physiological process, whereas in most adult tissues neovascularization is initiated only during tissue repair or pathological conditions. Pericellular proteolysis plays an important role in angiogenesis being required for endothelial cell migration, invasion, and tube formation. We studied the expression of proteases by human endometrial microvascular endothelial cells (hEMVECs) and their involvement in the formation of capillary tubes and compared these requirements with those of foreskin MVECs (hFMVECs). Inhibition of urokinase and matrix metalloproteinase (MMP) both reduced tube formation in a fibrin or fibrin/collagen matrix. hEMVECs expressed various MMP mRNAs and proteins; in particular MMP-1, MMP-2, and membrane-type (MT)1-, MT3-, and MT4-MMPs. MT3- and MT4-MMP mRNA expressions were significantly higher in hEMVECs than in hFMVECs. Other MT-MMP mRNAs and MMP-9 were hardly detectable. Immunohistochemistry confirmed the presence of MT3-MMP in endothelial cells of endometrial tissue. Overexpression of tissue inhibitor of MMP (TIMP)-1 or TIMP-3 by adenoviral transduction of hEMVECs reduced tube formation to the same extent, whereas only TIMP-3 was able to inhibit tube formation by hFMVECs. Tube formation by hEMVECs was partly inhibited by the presence of anti-MT3-MMP IgG. Thus, in contrast to tube formation by hFMVECs, which largely depends on MT1-MMP, capillary-like tube formation by hEMVECs is, at least in part, regulated by MT3-MMP.

Decidualisation and angiogenesis.

The timing of decidualisation and vascular processes during the implantation period is of paramount importance for the development of a receptive endometrium suitable for implantation. The endometrium transforms during the secretory phase into a well-vascularised receptive tissue characterised by increased vascular permeability, oedema, proliferation and differentiation of stromal cells into decidual cells, invasion of leucocytes, vascular remodelling and angiogenesis. Decidualisation continues in the presence of conception and an influx of immune cells, trophoblasts and vascular adaptation will occur. Vascular changes include spiral artery remodelling, angiogenesis and the induction of angiogenic factors. Disturbances in uterine blood supply are associated with first-trimester miscarriages and third-trimester perinatal morbidity and mortality caused by pre-eclampsia and foetal growth restriction. This article assesses decidual vascular changes during human implantation, and evaluates the involvement of angiogenesis in the pathogenesis of miscarriages, pre-eclampsia and intrauterine growth restriction.

Different degrees of vascularization and their relationship to the expression of vascular endothelial growth factor, placental growth factor, angiopoietins, and their receptors in first-trimester decidual tissues.

OBJECTIVE: To evaluate vascular adaptation to implantation by studying vascularization and angiogenic factors in the decidua basalis (DB), decidua parietalis, and decidual secretory endometrium of first-trimester pregnancies. Comparison of these tissues provides information about the regulation of vascularization by pregnancy-induced hormones and/or the extravillous trophoblast (EVT). DESIGN: Prospective study. SETTING: Leids University Medical Center (LUMC). PATIENT(S): Women (n = 32) undergoing voluntarily first-trimester termination of pregnancy. INTERVENTION(S): Decidual samples from vacuum-aspiration. MAIN OUTCOME MEASURE(S): Evaluation of vascularization, determined by CD34 immunohistochemistry, and vascular endothelial growth factor-A, placental growth factor (PlGF), vascular endothelial growth factor receptor 1 (Flt-1), vascular endothelial growth factor receptor 2, angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2), and TIE-2 protein and messenger RNA (mRNA) expression, determined by reverse transcriptase-polymerase chain reaction and immunohistochemistry, in serial paraffin sections. RESULT(S): Pregnancy-induced hormones and EVT influence vascularization by enhancing the vascular and luminal surface, and by reducing vessel density at the implantation site. These changes correlate with differences in gene and protein expression. Placental growth factor mRNA and PlGF and Flt-1 protein expressions were elevated in DB under the influence of EVT. In addition, the angiopoietins were differentially expressed, in favor of Ang-2, in DB. CONCLUSION(S): The EVT and pregnancy-induced hormones might be associated with the regulation of vascularization and the expression of angiogenic factors in decidua. The induction of PlGF and Flt-1, and the Ang-2:Ang-1 ratio in DB, suggest that these factors play a role in regulating angiogenesis at the implantation site.

Human embryo-conditioned medium stimulates in vitro endometrial angiogenesis.

OBJECTIVE: Successful implantation and placentation depend on the interaction between the endometrium and the embryo. Angiogenesis is crucial at this time. In this article we investigate the direct influence of the human embryo on in vitro endometrial angiogenesis. DESIGN: In vitro study. SETTING: Human endometrial microvascular endothelial cells (hEMVEC) grown on an in vitro angiogenesis model. INTERVENTION(S): Conditioned media (CM) of human embryos were used to stimulate in vitro angiogenesis. MAIN OUTCOME MEASURE(S): In vitro angiogenesis of hEMVEC. RESULT(S): Conditioned media of human embryos, containing significant amounts of vascular endothelial growth factor (VEGF)-A, as determined by enzyme-linked immunosorbent assay (ELISA), caused an increase in hEMVEC tube formation. This effect was prevented by soluble VEGF receptor 1, which quenches VEGF-A activity. Recombinant EGF alone and leukemia inhibitory factor in combination with VEGF-A stimulated hEMVEC tube formation. None of the other tested recombinant mediators, which have been described as produced by the early embryo/trophoblast (interleukin (IL) 10, transforming growth factor (TGF) beta, placental growth factor, hCG, colony-stimulating factor 1, interferon-gamma, insulin-like growth factor I and II, IL-6, platelet-derived growth factor, and TGFalpha), had an effect on tube formation by hEMVEC. CONCLUSION(S): For the first time, it is shown that the human embryo is able to stimulate in vitro endometrial angiogenesis at the time of implantation, a process that is mediated by VEGF-A.

Membrane-type matrix metalloproteinases and vascularization in human endometrium during the menstrual cycle.

Endometrial angiogenesis is essential for a vascularized receptive endometrium. Previously, we described that membrane type-3 metalloproteinase (MT3-MMP) is associated with endometrial angiogenesis in vitro. The association of MT-MMPs with endometrial angiogenesis in vivo is unknown. Therefore, this study analysed the presence of MT-MMPs in human endometrium and their correlation with neovascularization. RNA/protein expressions of the six MT-MMPs were determined in cultured endometrial cells. Vascularization parameters and MT-MMP expressions in vivo were evaluated by immunohistochemistry in serial endometrium sections. MT1-, MT2-, MT3- and MT4-MMP antigens were expressed in cultured endometrial endothelial cells. MT2-, MT3- and MT4-MMP were expressed by endothelium during the proliferative and secretory phase. Strikingly, these phases showed elevated vascularization, elevated total vascular surface in proliferative phases, elevated number of vessels in proliferative/late secretory phases and increased luminal surface in the proliferative phases. All MT-MMP antigens were expressed in various endometrial cell types in vivo, with decreased levels during the early secretory phase. In conclusion, all MT-MMPs are expressed in endometrium in a cycle-dependent pattern. The vascular expression of MT2-, MT3- and MT4-MMP correlated with angiogenic episodes of the cycle. Since MT2- and MT3-MMP are known to regulate tube formation, these findings support earlier in vitro data on the role of MT3-MMP in endometrial angiogenesis. Additionally, MT2-MMP appears to be associated with endometrial neovascularization also.