Chronic Endometritis and Uterine Endometrium Microbiota in Recurrent Implantation Failure and Recurrent Pregnancy Loss.

The aim of this study was to evaluate whether chronic endometritis (CE) and uterine endometrium microbiota were associated with repeated implantation failures (RIFs) and recurrent pregnancy losses (RPLs). In this prospective study, uterine endometrial specimens were obtained from 24 women with RIF, 27 with RPL, and 29 fertile control women. Immunohistochemical staining of CD138 for CE and 16S ribosomal RNA (rRNA) sequencing analysis for uterine endometrium microbiota were performed simultaneously. To assess CE, Liu's method, McQueen scores and plasma cell count/10 mm2 were used. The frequency of CE (plasma cells > 5.15/10 mm2) was higher in women with RPL (29.6%) than in fertile controls (6.8%, p < 0.05). The plasma cell count/10 mm2 in women with RPL (median 1.53, range 0-252.6, p < 0.01) and women with RIF (median 0.6, range 0-6.98, p < 0.05) was higher than in fertile controls (median 0, range 0-29). The uterine endometrium microbiota in women with RPL or RIF was not significantly different from that in fertile controls. However, the relative dominance rate of Lactobacillus iners (median 4.7%, range 0-99.9 vs. median 0%, range 0-100, p < 0.001) and the positive rate of Ureaplasma species (36.3% vs. 8.6%, p < 0.05) were higher in 11 women with CE than in 69 women without CE. The results suggest that CE may be involved in the pathophysiology of RPL and RIF. Lactobacillus iners and Ureaplasma species may be associated with the etiology of CE.

Increased IL-10-competent regulatory B cells in the decidua of early human pregnancy.

Regulatory B cells (Bregs) may play a pivotal role in maintaining human pregnancy. For the first time, to the best of our knowledge, this study noted that cell percentages of CD24hiCD38hi Bregs and CD24hiCD27+ Bregs, which can potentially produce IL-10, are increased in human decidua compared with the mid-luteal phase endometrium. In each case of decidua, the correlation between Bregs and dendritic cell (DC) or natural killer (NK) cell expression was further explored. A positive correlation between the percentage of CD24hiCD38hi Bregs and CD123-CD11c+ myeloid DCs (mDCs) was noted. Furthermore, a significant positive correlation was also observed between the percentage of CD24hiCD27+ Bregs and CD94+CD56brightCD16- suppressive NK cells. These findings regarding decidual Bregs deepen the understanding of the harmonious immunological microenvironment that sustains early human pregnancy.

Molecular characterization and antimicrobial resistance of Streptococcus agalactiae isolated from pregnant women in Japan, 2017-2021.

Objectives: This study aimed to elucidate the molecular characteristics and antimicrobial resistance of Streptococcus agalactiae (group B streptococcus, GBS) colonizing pregnant women in Japan. Methods: GBS isolates obtained from screening of pregnant women from 2017 to 2021 were analyzed for capsular serotype, sequence type (ST), and antimicrobial susceptibility. For levofloxacin-resistant isolates, mutations in the quinolone resistance-determining regions (QRDRs) of the gyrA, gyrB, and parC genes were analyzed. Results: Seventy-six GBS isolates were recovered from 1090 women (isolation rate: 7.0%). Of the 76 isolates, serotype III (31.6%) was the most prevalent, followed by V (19.7%), Ia (17.1%), and Ib (10.5%). Among the 22 STs identified, capsular serotype III/ST335-clonal complex (CC) 19 lineage was dominant (13.2%), followed by Ia/ST23, III/ST17, and V/ST1. Levofloxacin resistance was detected in 15.8% (n=12) of all the isolates, with serotype Ib being the most common. Most levofloxacin resistant isolates belonged to serotype Ib/CC10 or serotype V/CC19, with double mutations in the QRDRs, Ser81Leu in GyrA and Ser79Phe in ParC. Conclusions: The present study indicates the prevalence of the serotype III/ST335 (CC19) lineage, and the spread of serotype Ib/CC10 and serotype V/CC19 lineages, which are responsible for levofloxacin resistance in colonizing GBS in pregnant women in Japan.

Decidual CD68+ HLA-DR+ CD163- M1 macrophages increase in miscarriages with normal fetal chromosome.

PROBLEM: Is an abnormal increase or decrease of M1/M2 macrophages observed in the deciduae of miscarriages with normal fetal chromosome (MN)? METHODS OF STUDY: Deciduae of 18 MN and 26 miscarriages with abnormal fetal chromosome (MA) were obtained. Additionally, deciduae from 15 women whose pregnancies ended in induced abortions (IA) and endometriums at the mid-luteal phase from 19 non-pregnant women endomeriums of mid-luteal phases (EM) were obtained. Macrophages were analyzed by flow cytometry using monoclonal antibodies for CD68, HLA-DR, and CD163. RESULTS: M1 macrophages, defined as CD68+ HLA-DR+ CD163- cells, increased in MN compared with MA or IA. M2 macrophages, defined as CD68+ HLA-DR- CD163+ cells, increased in the deciduae of MA and IA compared with EM. However, this increase was not observed in the deciduae of MN. CONCLUSION: Our findings of phenotypic characters of decidual macrophages in MN provide additional evidence that M2 polarization is favorable for the maintenance of early stages of pregnancy.

Divergence of helper, cytotoxic, and regulatory T cells in the decidua from miscarriage.

PROBLEM: The aim of this prospective study was to evaluate phenotypic differences of helper T (Th), cytotoxic T (Tc), and regulatory T (Treg) cells in the deciduae of missed miscarriage with a normal chromosome karyotype of a fetus (MN) and missed miscarriage with an abnormal chromosome karyotype of a fetus (MA). METHODS OF STUDY: The decidua of 19 MN and 28 MA was obtained. Additionally, the decidua of 15 induced abortion (IA) and the endometrium of 19 non-pregnant women (EM) were obtained. IFN-γ(+) , IL-17(+) , CD25(high) Foxp3(+) cells in CD4(+) (Th) cells, and IFN-γ(+) cells in CD8(+) (Tc) cells were evaluated by flow cytometry. RESULTS: The percentages of IFN-γ(+) Tc and CD4(+) CD25(high) Foxp3(+) (Treg) cells in MN were significantly increased as compared with MA and IA. The percentage of IFN-γ(+) Th in MN was increased as compared with IA. CONCLUSION: Activation of IFN-γ(+) Tc and Treg cells in the decidua might be associated with the pathophysiology underlying MN.

A high dose intravenous immunoglobulin therapy for women with four or more recurrent spontaneous abortions.

Recurrent spontaneous abortion (RSA) may have immunological etiology. The aim of this study was to assess the efficacy of a high dose intravenous immunoglobulin (HIVIg) therapy, in which 20 g of intact type immunoglobulin was infused daily for 5 days during early gestation, for women who had a history of four or more consecutive spontaneous abortions of unexplained etiology. A total of 60 pregnant RSA women underwent HIVIg therapy, and the pregnancy outcome was assessed. The live birth rate was 73.3% (44/60). Fifteen pregnancies ended in spontaneous abortion, and one ended in intrauterine fetal death. In 11 of the 15 spontaneous abortions, fetuses had abnormal chromosome karyotype. When the 11 pregnancies with abnormal chromosome karyotype were excluded, the live birth rate was as high as 89.8% (44/49). The HIVIg therapy may be effective for severe cases of unexplained RSA.

Prenatal diagnosis of short-rib polydactyly syndrome type 3 (Verma-Naumoff type) by three-dimensional helical computed tomography.

We present a case of short-rib polydactyly syndrome (SRPs) type 3 in which accurate prenatal diagnosis was feasible using both ultrasonography and 3D-CT. SRP encompass a heterogeneous group of lethal skeletal dysplasias. However, the phenotypes overlap with those of nonlethal skeletal dysplasias (i.e. Ellis-van Creveld syndrome and Jeune syndrome). As accurate prenatal diagnosis of SRP is helpful for parents, we used 3D-CT in the early third trimester to examine a fetus suggested to have phenotypes of 'short-rib dysplasia group' on ultrasonography. 3D-CT showed mild modification of the vertebral bodies, small ilia with horizontal acetabula and triangular partial ossification defects, and subtle metaphyseal irregularities of the femora. These CT findings and an extensive literature search regarding the phenotypes of various diseases categorized as short-rib dysplasia group led to a correct prenatal diagnosis of SRP type 3. This case exemplified the usefulness of 3D-CT for the precise prenatal diagnosis of skeletal dysplasias.

Marked gestational edema as a clinical sign of life-threatening condition.

A 35-year-old Japanese nulliparous woman exhibited rapid weight gain (6 kg/7 days), reduced antithrombin activity and platelet count at 37 weeks of gestation without hypertension or proteinuria, and underwent cesarean section. Postnatally, pulmonary edema developed for 7 days, with transient hypertension and proteinuria, and bodyweight loss (14.6 kg) by 14 days postpartum. Platelet count and antithrombin activity normalized promptly postpartum. Despite a life-threatening clinical condition due to enhanced vascular permeability, neither hypertension nor proteinuria appeared antenatally. Determining antithrombin activity and platelet count may be useful for distinguishing between women with pathological edema and physiological edema.

Pregnancy-induced antithrombin deficiency.

OBJECTIVE: This retrospective study was performed to characterize the laboratory features and water metabolism of women with pregnancy-induced antithrombin deficiency (PIATD). METHODS: Among 1493 women who gave birth to a singleton infant at our institution, 114 women who developed PIATD and/or pregnancy-induced hypertension (PIH) were reviewed with respect to perinatal changes in laboratory variables (hematocrit value, fibrinogen, fibrinogen degradation product, D-dimer, uric acid, aspartate aminotransferase, lactate dehydrogenase) and body weight. PIATD was defined as a gradual decline in antithrombin (AT) activity to

Invasive group A streptococcal infection in pregnancy.

We conducted a literature review of 55 pregnancies with symptomatic Group A streptococcus (Streptococcus pyogenes) infection reported in English (20 cases), French (2 cases) and Japanese (33 cases) to seek ways of improving prognosis. Multiparous women (83% [39/47]) in the third trimester (90% [47/52]) were prone to infection from winter to spring (75% [21/28]). Onset was heralded by flu-like symptoms, such as high fever (94% [46/49]), with upper respiratory (40% [22/55]) and/or gastrointestinal symptoms (49% [27/55]). Characteristic findings were early onset of shock (91% [50/55]) and infection-induced strong uterine contraction (73% [40/55]) suggestive of placental abruption. The clinical course was too acute and severe to rescue the mother (58% [32/55] died) and/or infant (66% [39/59] died). However, outcome has improved over the last decade, with rescue of 68% (15/22) of the mothers since 2000, and early use of antibiotics (71% [22/31] survived) and use of intravenous immunoglobulin (91% [10/11] survived) were associated with favourable outcome. Early use of antibiotics and intravenous immunoglobulin may improve outcome of pregnant women suffering from flu-like symptoms, shock and strong uterine contractions suggestive of placental abruption.

Intravenous immunoglobulin therapy for aspirin-heparinoid-resistant antiphospholipid syndrome.

We encountered a woman who had a history of repeated fetal losses and positive tests for lupus anticoagulant, phosphatidylserine-dependent antiprothrombin (aPS/PT) IgG, IgM and kininogen-dependent antiphosphatidylethanolamine (aPE) IgG, IgM. Her previous pregnancy had ended in intrauterine fetal death at 24 weeks of gestation despite a therapy of low-dose aspirin, prednisolone and danaparoid. During the present pregnancy, she was treated with repeated intravenous infusions of immunoglobulin (IVIg) together with low-dose aspirin, prednisolone and heparin. When thrombocytopenia developed, she delivered a female baby weighing 2,152 g at 34 weeks of gestation by cesarean section. Titers of aPS/PT IgM and aPE IgM were reduced or maintained at low levels by repeated IVIg therapies. The IVIg therapy might be effective for aspirin-heparinoid-resistant antiphospholipid syndrome.

A high dose of intravenous immunoglobulin increases CD94 expression on natural killer cells in women with recurrent spontaneous abortion.

PROBLEM: A high dose of intravenous immunoglobulin (HIVIg) therapy is effective in various diseases such as autoimmune diseases, and also is expected to have efficacy in recurrent spontaneous abortion (RSA). The aim of this study was to understand immunological mechanisms of this therapy. METHOD OF STUDY: By flowcytometric analyses, we examined phenotypic changes of a variety of immunological cells including natural killer (NK) cells, cytotoxic T cells, regulatory T cells and macrophages in peripheral blood of RSA women with HIVIg therapy (n = 8). RESULTS: Expression percentages of inhibitory CD94 on NK cells significantly (P = 0.01) increased after the therapy (58.8 +/- 21.4% versus 71.0 +/- 17.6%). CONCLUSION: Mechanisms of possible efficacy of HIVIg therapy for RSA may include enhancement of CD94 expression and subsequent suppression of NK cell cytotoxicity.

Specific ultrasound findings associated with fetal chromosome abnormalities.

Cytogenetic amniocentesis (CA) has been performed as a reliable prenatal diagnostic method for decades. The aims of the present study were to reveal the frequency of fetal chromosome abnormalities according to medical indications of CA, and to assess the risks of specific abnormal ultrasound findings. Data on chromosome karyotypes of fetuses from 5043 Japanese mothers were collected. Group I comprised 4626 fetuses whose mothers underwent CA due to a variety of parental reasons. Group II comprised 417 fetuses whose mothers underwent CA due to fetal abnormality, abnormality of amniotic fluid volume and fetal growth restriction. The frequency of chromosome abnormalities in Group II (17.7%) was significantly higher than in Group I (1.8%). The frequencies of chromosome abnormalities in Group II singleton fetuses with fetal abnormality, polyhydramnios and fetal growth restriction were 21.5, 22.9 and 19.6%, respectively. By multivariate analyses, we found that cystic hygroma (odds ratio 5.6, 95% CI 2.7-11.6), abnormal extremity (5.0, 1.7-14.4) and cardiovascular abnormality (3.3, 1.1-10.1) were significant variants associated with fetal chromosomal abnormalities. Information revealed in the present study constitutes a beneficial reference for genetic counseling.

Administration of high-dose intact immunoglobulin has an anti-resorption effect in a mouse model of reproductive failure.

Administration of high-dose intact human immunoglobulin (IH-Ig) has been applied to treat a variety of inflammatory and autoimmune diseases, and is expected to have beneficial effects on human fecundity. In the present study, we investigated whether Ig had anti-resorption effects using polyinosinic-polycytidylic acid sodium salt [poly (I:C)]-induced enhancement of fetal resorption in the mating of CBA/J x DBA/2J resorption-prone mouse model. Furthermore, we investigated the mechanism of the effect by examining the mRNA expression of interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha, IL-10, IL-4 and TGF-beta(1) in spleens and placentas from the resorption-prone model treated with IH-Ig, by reverse transcription (RT)-polymerase chain reaction (PCR). Administration of high-dose IH-Ig significantly reduced the fetal resorption rate from 55% to 10%. This anti-resorption effect, however, was not detected in mice administered with Fab fragments of human Ig. We then performed adoptive transfer experiments to examine whether cellular components could transfer the effect. A remarkable anti-resorption effect was seen in poly (I:C)-injected pregnant recipients transferred with spleen cells from IH-Ig-treated donor mice. The RT-PCR study showed that IH-Ig reduced the expression of IFN-gamma and TNF-alpha mRNA in placentas of poly (I:C)-injected pregnant mice. The present findings demonstrate that intact Ig, particularly its Fc portion, possesses anti-resorption activity. The effect might be attributed to the suppressed production of pro-inflammatory cytokines at the maternofetal interface.

Cell surface 4-1BBL mediates sequential signaling pathways 'downstream' of TLR and is required for sustained TNF production in macrophages.

The stimulation of Toll-like receptors (TLRs) on macrophages triggers production of the cytokine tumor necrosis factor (TNF). TNF production occurs within 1 h of TLR stimulation and is sustained for 1 d. Here we document a function for the TNF family member 4-1BB ligand (4-1BBL) in sustaining TLR-induced TNF production. TLR signaling induced 4-1BBL, and 4-1BBL interacted with TLRs on the macrophage surface. The influence of 4-1BBL on TNF production was independent of its receptor (4-1BB) and did not require the adaptors MyD88 or TRIF. It did not influence TLR4-induced activation of transcription factor NF-kappaB (an early response) but was required for TLR4-induced activation of transcription factors CREB and C/EBP (a late event). Transient TLR4-MyD88 complexes appeared during the first hour after lipopolysaccharide stimulation, and TLR4-4-1BBL interactions were detected between 2 h and 8 h after lipopolysaccharide stimulation. Our results indicate that two different TLR4 complexes sequentially form and selectively control early and late TNF production.

Topological factors in placental surface arteries correlate with neonatal birth weight.

OBJECTIVES: There has been no study concerning association between topological factors of placental vascularization and neonatal growth in humans. The aim of study was to assess whether any network index of placental surface arteries was associated with neonatal birth weight. MATERIALS AND METHODS: Twenty-six placentas were randomly selected between 34 and 41 weeks of gestational ages. Placental weights ranged 385 to 770 g; and neonatal weights ranged 1960 to 3680 g. After visualization of placental surface arteries by a milk injection method, network indices including the number of nodes, network density, network diameter, average distance of nodes, and the degree centralization were determined. These network indices and placental weights were compared with neonatal birth weights. RESULTS: The number of nodes, network density, network diameter, average distance of nodes, and the degree centralization were found to be as follows (Mean +/- SD); 84.7 +/- 29.3, 0.0262 +/- 0.0088, 15.8 +/- 2.77, 7.83 +/- 1.13, 0.0263 +/- 0.0091, respectively. We found that neonatal birth weights correlated with the number of nodes of placental surface arteries (correlation coefficient R = 0.40) and placental weights (R = 0.52) both. However, the number of nodes of placental surface arteries was not associated with the placental weights or the gestational age. CONCLUSIONS: We for the first time found that a topological factor, i.e., the number of nodes of placental surface arteries correlated with neonatal growth. There was no correlation between numbers of nodes and placental weights. This suggests that the number of nodes affects fetal growth independent of placental weights. A topological factor of placental vascularization might significantly affect fetal growth in utero and determine risks of vascular diseases in their future lives.

Natural killer, natural killer T, helper and cytotoxic T cells in the decidua from sporadic miscarriage.

PROBLEM: The aim of this cohort study was to assess natural killer (NK) cell and natural killer T (NKT) cell populations and cytokine expressions of helper T (Th) and cytotoxic T (Tc) cells in the decidua of sporadic miscarriage (MS) and induced abortion (IA). METHODS: The deciduae were obtained from consecutive 40 women whose pregnancies ended in the first trimester MS, and the fetal chromosome karyotypes were analyzed. The cell populations were measured by flow cytometry. RESULTS: No significant differences in NK cell or NKT cell percentages were found among MS with normal chromosome karyotype (MSNK, n = 14), MS with abnormal karyotype (MSAK, n = 26) and IA (n = 14). Interferon (IFN)-gamma(+) cell percentage and interleukin (IL)-4(+)/tumor necrosis factor (TNF)-alpha(+) ratio of Th cells in MS groups were increased, while IL-4(+) cell percentage, IL-4(+)/IFN-gamma(+) and IL-4(+)/TNF-alpha(+) ratios of Tc cells in MS groups were decreased as compared with those in IA. No significant difference in these parameters between MSNK and MSAK was found. CONCLUSIONS: These results suggested that Tc1 predominance existed in the decidua of MS. Th1 predominance was not found in MSNK.

MTHFR C677T Polymorphism and factor V Leiden mutation are not associated with recurrent spontaneous abortion of unexplained etiology in Japanese women.

To determine whether the C677T polymorphism of the methylenetetrahydrofolate reductase ( MTHFR) gene and the Leiden mutation of coagulation factor V (FV) are associated with recurrent spontaneous abortion (RSA) of unexplained etiology in Japanese participants, the genotypes of the two polymorphisms were determined and compared between cases of unexplained RSA and normal pregnant controls. Eighty-three Japanese participants, consisting of 45 women with explained RSA and 38 women with unexplained RSA, and 174 controls were recruited in the study. The frequencies of the T677 allele/TT genotype were not significantly different among women with explained RSA (35.6%/13.3%), women with unexplained RSA (34.2%/7.9%), primigravid controls (35.1%/11.7%), and multigravid controls (39.7%/16.5%). In the cases of unexplained RSA, the frequencies of the T677 allele and TT genotype tended to increase according to the number of previous spontaneous abortions, but the increase was without statistical significance: the frequencies of the T677 allele and TT genotype in women with two abortions were 18.2% and 0%, whereas in women with three abortions the frequencies were 38.0% and 9.5%, and in women with four or more abortions the frequencies were 50.0% and 16.7%, respectively. In addition, no Leiden mutation of FV was detected in the women with RSA or the controls. Neither T677 of the MTHFR nor the Leiden mutation of FV was associated with unexplained RSA in the Japanese population.

Divergence of natural killer cell receptor and related molecule in the decidua from sporadic miscarriage with normal chromosome karyotype.

The aim of this cohort study was to investigate immunophenotypic characteristics of natural killer (NK) cells by assessing specific molecules expressed in the decidua of sporadic miscarriages and induced abortions. The deciduae were obtained from 29 consecutively seen women whose pregnancies ended in first trimester miscarriages (MS), and the fetal chromosome karyotype of these MS was analysed. Additionally, 13 deciduae were obtained from induced abortion (IA) with informed consent. The expression of perforin, CD94, CD161, CD158a, CD158b, CD244 on CD3-CD56+NK cells, and perforin on CD3+CD8+ T cells was analysed by flow cytometry. The CD158a (mean+/-SD, 26.2+/-14.7%) and CD94 (50.2+/-25.7%) expressions in MS with normal chromosome karyotype (MSNK; n=11) were significantly decreased as compared with those (41.5+/-19.5%, 71.4+/-20.4%) in MS with abnormal karyotype (MSAK; n=18) and those (44.3+/-21.9%, 80.8+/-17.5%) in IA (n=13). Conversely, the perforin expression on CD3-CD8-CD56+NK cells (76.3+/-11.0%) and CD3+CD8+T cells (30.6+/-9.2%) in MSNK was significantly increased as compared with those (66.8+/-16.6%, 23.6+/-8.7%) in MSAK and those (62.9+/-11.6%, 19.7+/-8.1%) in IA. A positive correlation between CD94 and CD158a expressions on NK cells, negative correlations between CD94 on NK cells and perforin on NK cells/T cells, and between CD158a on NK cells and perforin on T cells were found in the decidua. A divergence of NK cell repertoire in the decidua might be related to aetiology of sporadic MSNK.

Embryo loss pattern is predominant in miscarriages with normal chromosome karyotype among women with repeated miscarriage.

OBJECTIVE: The aim of this study was to assess pregnancy loss patterns in women with repeated miscarriage (RM), according to fetal chromosome karyotypes and aetiologies of RM. METHODS: In this cohort study, 168 fetal chromosome karyotypes of miscarriages were investigated. The pregnancy loss patterns were compared between 75 miscarriages from RM women who had a history of two or more consecutive miscarriages and 93 miscarriages from control women whose previous pregnancies ended in live births without a history of RM. By serial ultrasonography, embryo loss (EL) was defined as miscarriage before fetal heat movement was identified and fetal loss (FL) as miscarriage after fetal heat movement was identified. The EL rate was calculated as EL/(EL+FL). RESULTS: The EL rate (66.7%) in miscarriages with normal karyotypes among RM women (n=42) was higher (P<0.05) than that (45.7%) in controls (n=46), while the EL rate (30.3%) in miscarriages with abnormal karyotypes among RM women (n=33) did not differ from that (25.5%) in the controls (n=47). The EL rate (71.4%) in miscarriages with normal karyotypes among unexplained RM women (n=21) was much higher (P<0.05) than that in the controls. CONCLUSIONS: By evaluating fetal karyotypes, we demonstrated for the first time that EL was predominant in miscarriages with normal karyotype among RM women.