In vitro recovery of FIX clotting activity as a marker of highly functional hepatocytes in a hemophilia B iPSC model.

BACKGROUND AND AIMS: Pluripotent stem cell-derived hepatocytes differentiated in monolayer culture are known to have more fetal than adult hepatocyte characteristics. If numerous studies tend to show that this immature phenotype might not necessarily be an obstacle to their use in transplantation, other applications such as drug screening, toxicological studies, or bioartificial livers are reliant on hepatocyte functionality and require full differentiation of hepatocytes. New technologies have been used to improve the differentiation process in recent years, usually evaluated by measuring the albumin production and CYP450 activity. Here we used the complex production and most importantly the activity of the coagulation factor IX (FIX) produced by mature hepatocytes to assess the differentiation of hemophilia B (HB) patient's induced pluripotent stem cells (iPSCs) in both monolayer culture and organoids. APPROACH AND RESULTS: Indeed, HB is an X-linked monogenic disease due to an impaired activity of FIX synthesized by hepatocytes in the liver. We have developed an in vitro model of HB hepatocytes using iPSCs generated from fibroblasts of a severe HB patient. We used CRISPR/Cas9 technology to target the genomic insertion of a coagulation factor 9 minigene bearing the Padua mutation to enhance FIX activity. Noncorrected and corrected iPSCs were differentiated into hepatocytes under both two-dimensional and three-dimensional differentiation protocols and deciphered the production of active FIX in vitro. Finally, we assessed the therapeutic efficacy of this approach in vivo using a mouse model of HB. CONCLUSIONS: Functional FIX, whose post-translational modifications only occur in fully mature hepatocytes, was only produced in corrected iPSCs differentiated in organoids. Immunohistochemistry analyses of mouse livers indicated a good cell engraftment, and the FIX activity detected in the plasma of transplanted animals confirmed rescue of the bleeding phenotype.

Evaluation of the Prognostic Value of the sFlt-1/PlGF Ratio in Early-Onset Preeclampsia.

OBJECTIVE: Increased expression of soluble fms-like tyrosine kinase 1 (sFlt-1), associated with a decrease in placental growth factor (PlGF), plays a key role in the pathogenesis of preeclampsia (PE). We evaluated the prognostic value of the sFlt-1/PlGF ratio for the onset of adverse maternofetal outcomes (AMFO) in case of early-onset PE with attempted expectant management. STUDY DESIGN: From October 2016 through November 2018, all singleton pregnancies complicated by early-onset PE (before 34 weeks of gestation) were included in a cohort study. The plasma levels of sFlt-1 and PlGF were blindly measured on admission. For the statistical analysis, we performed a bivariate analysis, a comparison of the receiving operating characteristic curves and a survival analysis estimated by the Kaplan-Meier method. RESULTS: Among 109 early PE, AMFO occurred in 87 pregnancies (79.8%), mainly hemolysis, elevated liver enzymes, and low platelet count syndrome and severe fetal heart rate abnormalities requiring urgent delivery. The area under the curve (AUC) of sFlt-1/PlGF ratio was 0.82 (95% confidence interval [CI]: 0.73-0.88) for the risk of AMFO and the difference between the AUCs was significant for each separate standard parameter (p = 0.018 for initial diastolic blood pressure, p = 0.013 for alanine aminotransferase, p < 0.001 for uric acid). Pregnancies were best classified by a cutoff ratio of 293, with a sensitivity of 95% and a specificity of 50%. With a ratio value less than 293, no pregnancy was complicated or had been stopped during the first 5 days. A ratio more than 293 was associated with an increased risk of AMFO onset (hazard ratio [HR]: 3.61; 95% CI: 2.13-6.10; p < 0.001) and had a significant association with the length of time between the diagnosis of PE and delivery (HR: 2.49; 95% CI: 1.56-3.96; p < 0.001). CONCLUSION: The sFlt-1/PlGF ratio is an additional tool in the prediction of AMFO in proven early-onset PE, which is likely to improve care by anticipating severe complications. KEY POINTS: · The sFlt-1/PlGF ratio is associated with AMFO.. · It is an additional tool for physician.. · We proposed a 293 cutoff value for the ratio..

Maternal and perinatal outcomes in women aged 42 years or older.

OBJECTIVE: To describe maternal and fetal outcomes of pregnancies after 42 years and to compare maternal and fetal morbidities according to the conception mode; comparing pregnancies obtained spontaneously and those resulting from assisted reproductive technology (ART). METHODS: This retrospective cohort study was conducted in a level 3 maternity hospital. This study covered all women, aged 42 years or older, who gave birth between January 1, 2014 and December 31, 2019. Univariate and multivariate analyses with logistic regression models were used to compare maternal and perinatal outcomes depending on conception mode: spontaneous or using ART. RESULTS: A sample of 532 women, including 335 spontaneous pregnancies (63%) and 147 pregnancies after ART (27.6%) were studied. Conception mode was missing for 50 (9.4%). We found increased rates not only of maternal complications such as maternal overweight and obesity, pre-eclampsia, and gestational diabetes, but also of interventions such as hospitalization during pregnancy, cesarean section, postpartum hemorrhage, and perinatal outcome like preterm birth. There were also more maternal and perinatal negative outcomes among the ART group. After multivariate analysis, pre-eclampsia was predominant in the ART group (odds ratio 0.25, 95% confidence interval 0.07-0.85, P = 0.02). CONCLUSION: While maternal and fetal risks increase for late pregnancies, there also appears to be a difference depending on the conception mode, with pregnancies resulting from ART having more pregnancy-related complications than those obtained spontaneously.

A nomogram to optimize the timing of antenatal corticosteroids in threatened preterm delivery.

BACKGROUND: Recent observational studies reported a high rate of suboptimal use of antenatal corticosteroids (too anticipated or retrospectively not indicated) for women at risk of preterm delivery despite a recommended use within 7 days before delivery. OBJECTIVE: This study aimed to elaborate a nomogram aiming at optimizing the timing of administration of antenatal corticosteroids in case of threatened preterm labor, asymptomatic short cervix, or uterine contractions. STUDY DESIGN: This was an observational retrospective study conducted in a tertiary hospital. All women between 24 and 34 weeks of gestation who received corticosteroids during hospitalization for threatened preterm delivery, asymptomatic short cervix, or uterine contractions requiring tocolysis between 2015 and 2019 were included. Clinical, biological, and sonographic data of women were used to construct logistic regression models for predicting delivery within 7 days. The model was validated on an independent series of women hospitalized in 2020. RESULTS: Among the 1343 women included in this study, the risk factors independently associated with a delivery within 7 days in multivariate analysis were vaginal bleeding (odds ratio, 14.47; 95% confidence interval, 7.81-26.81; P<.001); need for a second-line tocolysis, such as atosiban (odds ratio, 5.66; 95% confidence interval, 3.39-9.45; P<.001); C-reactive protein level (per 1 mg/L increase; odds ratio, 1.03; 95% confidence interval, 1.02-1.04; P<.001); cervical length (per 1 mm increase; odds ratio, 0.84; 95% confidence interval, 0.82-0.87; P<.001); uterine scar (odds ratio, 2.98; 95% confidence interval, 1.33-6.65; P=.008), and gestational age at admission (per week of amenorrhea increase; odds ratio, 1.10; 95% confidence interval, 1.00-1.20; P=.041). Based on these results, a nomogram was developed that, in retrospect, would have allowed physicians to avoid or delay antenatal corticosteroids in 57% of cases in our population. The discrimination of the predictive model was good when applied to the validation set of 232 women hospitalized in 2020. It would have enabled physicians to avoid or delay antenatal corticosteroids in 52% of cases. CONCLUSION: This study developed a simple use, accurate prognostic score to identify women at risk of delivery within 7 days in cases of threatened preterm delivery, asymptomatic short cervix, or uterine contractions and thereby optimized the use of antenatal corticosteroids.

Persistent occiput posterior position: predictive factors of spontaneous rotation of the fetal head.

OBJECTIVES: To assess factors associated with spontaneous rotation in the occiput anterior position for fetuses in persistent occiput posterior (OP) during the second stage of labor. To evaluate maternal and fetal outcomes after spontaneous rotation of persistent OP. METHODS: This is a prospective cohort of 495 women with fetuses in persistent OP position, confirmed with ultrasonography during the second stage of labor. We performed simple logistic regressions, followed by multiple logistic regressions. RESULTS: Among 495 women with fetuses in persistent OP position, 78 fetuses (16%) underwent a spontaneous rotation during the second stage of labor. The multivariate analysis found that a short duration of the first stage of labor (<7 h) was associated with a spontaneous rotation of the fetal head in the second stage of labor (OR 0.43 [0.23; 0.76. There were fewer episiotomies (25.6% vs 52.3%, p < .01), cesarean sections (0% v. 5.4%, p = .03), and instrumental deliveries (8.9% vs. 50%, p < .01) in the "spontaneous rotation" group, and the two groups were similar regarding post-partum hemorrhage.The newborns in the "spontaneous rotation" group had a higher Apgar score at 1 min (10 v. 9, p = .02). The two groups did not differ for other neonatal parameters, such as arterial pH value, Apgar score at 5 min, birth trauma, or transfer into the pediatric unit. CONCLUSION: A shorter duration of the first stage of labor (< 7 h) is a predictive factor of spontaneous rotation in the occiput anterior position for fetuses in persistent OP position. A spontaneous rotation in case of an OP position is associated with better maternal and fetal outcomes.

Development and validation of nomograms for predicting preterm delivery.

OBJECTIVE: The objective of the study was to develop a statistical model for predicting risk of preterm delivery after in utero transfer for threatened preterm delivery in tertiary care centers. STUDY DESIGN: This study was an observational study including a total of 906 patients transferred for threatened preterm delivery at Paule-de-Viguier and Croix-Rousse University Hospitals. Clinical and sonographic data from 1 series were used to construct logistic regression models for predicting preterm delivery and were validated on an independent series. An Internet-based tool was developed to facilitate the use of the nomograms. RESULTS: Based on multivariate analyses, 2 nomograms were built: 1 to predict delivery within 48 hours after transfer and 1 to predict delivery before 32 weeks. Discrimination and calibration of the predictive models were good when applied to the validation set (concordance index 0.73 and 0.72, respectively). CONCLUSION: We developed and validated nomograms to predict the individual probability of preterm birth after transfer for threatened preterm delivery.

Management of persistent occiput posterior position: a substantial role of instrumental rotation in the setting of failed manual rotation.

INTRODUCTION: To compare the maternal and neonatal outcomes associated with Instrumental Rotation (IR) to operative vaginal delivery in occiput posterior (OP) position with Thierry's spatulas (TS), in the setting of failed manual rotation (MR). STUDY DESIGN: We led a prospective observational cohort study in a tertiary referral hospital in Toulouse, France. All women presenting in labor with persistent OP position at full cervical dilatation and who delivered vaginally after failed MR and with IR or OP assisted delivery were included from January 2014 to December 2015. The main outcomes measured were maternal morbidity parameters including episiotomy rate, incidence and severity of perineal lacerations, perineal hematomas and postpartum hemorrhage. Severe perineal tears corresponded to third and fourth degree lacerations. Fetal morbidity outcomes comprised neonatal Apgar scores, acidemia, fetal injuries, birth trauma and neonatal intensive care unit admissions. RESULTS: Among 9762 women, 910 (9.3%) presented with persistent OP position at full cervical dilatation and 222 deliveries were enrolled. Of 111 attempted IR, 97 were successful (87.4%). The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.8% vs. 12.6%; p < 0.002). Both groups were similar regarding most fetal outcomes and no birth trauma occurred in our study population. In a multivariable logistic regression analysis, OP operative delivery was a significant risk factor of severe perineal lacerations (OR = 9.5; 95% CI: 2.05-44.05). CONCLUSION: Our results support the use of IR in order to reduce perineal morbidity associated with OP assisted delivery, in the setting of a failed manual rotation.