Role of recombinant factor VIIa in the clinical management of severe postpartum hemorrhage: consensus among European experts.

OBJECTIVES: There have been significant advances in the medical management of severe postpartum hemorrhage (sPPH) over recent decades, which is reflected in numerous published guidelines. To date, many of the currently available national and international guidelines recommend recombinant factor VIIa (rFVIIa) to be used only at a very late stage in the course of sPPH, as a "last resort", before or after hysterectomy. Based on new safety data, rFVIIa has recently been approved by the European Medicines Agency (EMA) and Swissmedic for use in sPPH, if uterotonics are insufficient to achieve hemostasis, which in fact is significantly earlier in the course of postpartum hemorrhage (PPH). We therefore aimed to develop expert consensus guidance as a step toward standardizing care with the use of rFVIIa for clinicians managing women experiencing life-threatening sPPH. METHODS: The consensus process consisted of one face-to-face meeting with a group of nine experts, including eight obstetrician-gynecologists and a hematologist highly experienced in sPPH care in tertiary care perinatal centers. The panel was representative of multidisciplinary expertise in the European obstetrics community and provided consensus opinion in answer to pre-defined questions around clinical practice with rFVIIa in the management of sPPH. Recommendations have been based on current national and international guidelines, extensive clinical experience, and consensus opinion, as well as the availability of efficacy and new safety data. RESULTS: The expert panel developed 17 consensus statements in response to the 13 pre-defined questions on the use of rFVIIa in the management of sPPH including: available efficacy and safety data and the need for interdisciplinary expertise between obstetricians, anesthesiologists, and hematologists in the management of sPPH. Based on novel data, the experts recommend: (1) earlier administration of rFVIIa in patients with sPPH who do not respond to uterotonic administration to optimize the efficacy of rFVIIa; (2) the importance of hematological parameter prerequisites prior to the administration of rFVIIa to maximize efficacy; and (3) continued evaluation or initiation of further invasive procedures according to standard practice. Furthermore, recommendations on the timing of rFVIIa treatment within the sPPH management algorithm are outlined in a range of specified clinical scenarios and settings, including vaginal delivery, cesarean section, and smaller birthing units before transfer to a tertiary care center. The panel agreed that according to available, and new data, as well as real-world experience, there is no evidence that the use of rFVIIa in patients with sPPH increases the risk of thromboembolism. The authors acknowledge that there is still limited clinical effectiveness data, as well as pharmacoeconomic data, on the use of rFVIIa in sPPH, and recommend further clinical trials and efficacy investigation. CONCLUSIONS: This expert panel provides consensus guidance based on recently available data, clinical experience, and expert opinion, augmented by the recent approval of rFVIIa for use in sPPH by the EMA. These consensus statements are intended to support clinical care for sPPH and may help to provide the impetus and a starting point for updates to existing clinical practice guidelines.

Clinical utility of sFlt-1 and PlGF in screening, prediction, diagnosis and monitoring of pre-eclampsia and fetal growth restriction.

Pre-eclampsia (PE) is characterized by placental and maternal endothelial dysfunction, and associated with fetal growth restriction (FGR), placental abruption, preterm delivery and stillbirth. The angiogenic factors soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) are altered in pregnancies complicated by placenta-related disorders. In this Review, we summarize the existing knowledge, examining the performance of maternal PlGF, sFlt-1 and the sFlt-1/PlGF ratio for screening PE, predicting development of PE in the short term, diagnosing PE, monitoring established PE and predicting other placenta-related disorders in singleton pregnancy. We also discuss the performance of PlGF and the sFlt-1/PlGF ratio for predicting PE in twin pregnancy. For first-trimester screening in singleton pregnancy, a more accurate way of identifying high-risk women than current practice is to combine maternal PlGF levels with clinical risk factors and ultrasound markers. Later in pregnancy, the sFlt-1/PlGF ratio has advantages over PlGF because it has a higher pooled sensitivity and specificity for diagnosing and monitoring PE. It has clinical value because it can rule out the development of PE in the 1-4-week period after the test. Once a diagnosis of PE is established, repeat measurement of sFlt-1 and PlGF can help monitor progression of the condition and may inform clinical decision-making regarding the optimal time for delivery. The sFlt-1/PlGF ratio is useful for predicting FGR and preterm delivery, but the association between stillbirth and the angiogenic factors is unclear. The sFlt-1/PlGF ratio can be used to predict PE in twin pregnancy, although different sFlt-1/PlGF ratio cut-offs from those for singleton pregnancy should be applied for optimal performance. In summary, PlGF, sFlt-1 and the sFlt-1/PlGF ratio are useful for screening, diagnosing, predicting and monitoring placenta-related disorders in singleton and twin pregnancy. We propose that tests for these angiogenic factors are integrated more fully into clinical practice.© 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The "vermian-crest angle": does it allow accurate categorisation of fetal upward rotation of cerebellar vermis on intrauterine MRI? A pilot study.

AIM: To test a new parameter to assess the position of the fetal cerebellar vermis in the posterior fossa (PF) using intrauterine magnetic resonance imaging (MRI). MATERIALS AND METHODS: The angle between the cerebellar vermis and the internal occipital crest (vermian-crest angle, VCA) was assessed retrospectively using MRI in fetuses with and without PF anomalies. Spearman's rank test was used to investigate correlation of the VCA with gestational age (GA). Groups were compared using Student's t-test and the one-way analysis of variance (ANOVA) with the Bonferroni adjustment. Box-and-whisker plots were also used. RESULTS: One hundred and two normal cases were identified. Mean±SD GA at MRI was 26.5±2.8 weeks (range: 22-32 weeks). The VCA was 64.49±11.5° independently of GA (r=0.19; p=0.12). In addition, 30 fetuses at 19-28 weeks were identified with Blake's pouch cyst (BPC; n=5), Dandy-Walker malformation (DWM; n=12), mega cisterna magna (MCM; n=10), and vermian hypoplasia (VH; n=3). The VCA was significantly different in the DWM (p<0.001) and BPC (p<0.001) subgroups, but was not significantly different in cases of VH (p=0.84) and MCM (p=0.95) in comparison with controls. CONCLUSIONS: A new method to assess vermian position within the PF using intrauterine MRI was assessed. In combination with the other existing parameters, it may be helpful for addressing the categorisation of upward rotation of the fetal cerebellar vermis; however, further studies are necessary to strengthen the present findings.

Effectiveness of seminal plasma in in vitro fertilisation treatment: a systematic review and meta-analysis.

BACKGROUND: With in vitro fertilization (IVF) techniques, only 20-25% of the transferred embryos lead to a pregnancy. OBJECTIVE: To evaluate the beneficial effects of seminal plasma (SP) or semen applied at the time of oocyte aspiration or embryo transfer. SEARCH STRATEGY: Electronic databases were searched from their inception up to August 2017. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) evaluating the effects of SP or semen in IVF treatment. Trials were considered if women were exposed to any kind of SP or semen (either SP/semen injection or sexual intercourse) around the time of oocyte pickup and embryo transfer. DATA COLLECTION AND ANALYSIS: The primary outcome was clinical pregnancy rate (CPR). MAIN RESULTS: Eight RCTs on women undergoing IVF (2128 in total) were included in the meta-analysis. Women randomized in the intervention group had a significantly higher CPR compared with controls (30.0 versus 25.1%; RR 1.20; 95% CI, 1.04-1.39). No significant differences were found in the secondary outcomes, including livebirth rate, biochemical pregnancy, miscarriage, multiple pregnancies, and birth weight. The subgroup analyses (four RCTs, 780 participants), including only those RCTs in which prepared undiluted SP was injected just after oocyte pickup, conformed with the overall analysis for the primary outcome (46.3 versus 37.2%; RR 1.23; 95% CI, 1.05-1.45). CONCLUSION: Because intravaginal or intracervical SP application around the time of oocyte pickup is associated with higher CPR, local application SP may be considered as a potential treatment to improve implantation. TWEETABLE ABSTRACT: SP at the time of oocyte pickup is associated with higher CPR.

Prediction of preterm delivery in symptomatic women using PAMG-1, fetal fibronectin and phIGFBP-1 tests: systematic review and meta-analysis.

OBJECTIVE: To assess the accuracy of placental alpha microglobulin-1 (PAMG-1), fetal fibronectin (fFN) and phosphorylated insulin-like growth factor-binding protein-1 (phIGFBP-1) tests in predicting spontaneous preterm birth (sPTB) within 7 days of testing in women with symptoms of preterm labor, through a systematic review and meta-analysis of the literature. The test performance of each biomarker was also assessed according to pretest probability of sPTB ≤ 7 days. METHODS: The Cochrane, MEDLINE, PubMed and ResearchGate bibliographic databases were searched from inception until October 2017. Cohort studies that reported on the predictive accuracy of PAMG-1, fFN and phIGFBP-1 for the prediction of sPTB within 7 days of testing in women with symptoms of preterm labor were included. Summary receiver-operating characteristics (ROC) curves and sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and positive (LR+) and negative (LR-) likelihood ratios were generated using indirect methods for the calculation of pooled effect sizes with a bivariate linear mixed model for the logit of sensitivity and specificity, with each diagnostic test as a covariate, as described by the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. RESULTS: Bivariate mixed model pooled sensitivity of PAMG-1, fFN and phIGFBP-1 for the prediction of sPTB ≤ 7 days was 76% (95% CI, 57-89%), 58% (95% CI, 47-68%) and 93% (95% CI, 88-96%), respectively; pooled specificity was 97% (95% CI, 95-98%), 84% (95% CI, 81-87%) and 76% (95% CI, 70-80%) respectively; pooled PPV was 76.3% (95% CI, 69-84%) (P < 0.05), 34.1% (95% CI, 29-39%) and 35.2% (95% CI, 31-40%), respectively; pooled NPV was 96.6% (95% CI, 94-99%), 93.3% (95% CI, 92-95%) and 98.7% (95% CI, 98-99%), respectively; pooled LR+ was 22.51 (95% CI, 15.09-33.60) (P < 0.05), 3.63 (95% CI, 2.93-4.50) and 3.80 (95% CI, 3.11-4.66), respectively; and pooled LR- was 0.24 (95% CI, 0.12-0.48) (P < 0.05), 0.50 (95% CI, 0.39-0.64) and 0.09 (95% CI, 0.05-0.16), respectively. The areas under the ROC curves for PAMG-1, fFN and phIGFBP-1 for sPTB ≤ 7 days were 0.961, 0.874 and 0.801, respectively. CONCLUSIONS: In the prediction of sPTB within 7 days of testing in women with signs and symptoms of preterm labor, the PPV of PAMG-1 was significantly higher than that of phIGFBP-1 or fFN. Other diagnostic accuracy measures did not differ between the three biomarker tests. As prevalence affects the predictive performance of a diagnostic test, use of a highly specific assay for a lower-prevalence syndrome such as sPTB may optimize management. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Correction to: Predictors of cerclage failure in patients with singleton pregnancy undergoing prophylactic cervical cerclage.

The original version of this article unfortunately contained a mistake. The presentation of Table 3 was incorrect. The corrected Table 3 is given below.

Predictors of cerclage failure in patients with singleton pregnancy undergoing prophylactic cervical cerclage.

PURPOSE: The role of cervical cerclage to prevent preterm birth (PTB) remains controversial. The aim of this study was to identify prognostic factors for cerclage failure among singleton pregnant women following prophylactic cerclage (PC). METHODS: A retrospective analysis of PC was performed in a single center. The main outcome measure was cerclage failure, defined by spontaneous early PTB prior to 32 weeks' gestation. Age, BMI, history of instrumentation of the uterus, history of second trimester miscarriage, previous conization, positive vaginal swab prior cerclage, gestational age at time of cerclage, CRP 1 week after cerclage and post-cerclage US changes of cervical length were tested as predictive factors. Descriptive statistical and binary logistic regression analyses were performed. RESULTS: 141 women underwent cerclage procedures between 2007 and 2016. 39 patients had PC with McDonald suture, singleton pregnancy and complete clinical follow-up information, thus fulfilling the inclusion criteria. Multivariate analysis showed that history of instrumentation of the uterus was the only independent prognostic factor [OR = 0.14 (0.03, 0.72) p = 0.019] for cerclage failure. CONCLUSION: This is the first study showing that a history of previous uterine instrumentation is an independent predictor of cerclage failure. This finding has significant clinical implications for women of childbearing age, particularly when management of miscarriage/abortion is being considered. Women should be informed about the potential risks when counseled prior to surgical evacuation and medical management or cervical ripening should be considered. These results are also helpful in counseling patients undergoing cerclage, when a prior uterine instrumentation has been performed.

Efficacy of pelvic artery embolisation for severe postpartum hemorrhage.

PURPOSE: The purpose of our study was to evaluate the outcome of selective pelvic arterial embolisation (PAE) in women with severe postpartum hemorrhage (PPH). METHODS: We performed a retrospective, controlled, single-center cohort study. A total of 16 consecutive women with PPH who underwent therapeutic PAE were included. As historical control group, we included 22 women with similar severity of PPH who were managed without PAE. Outcome measures included necessity of surgical interventions such as postpartum hysterectomy and laparotomy after vaginal delivery, the amount of red blood cell transfusions, and hematologic findings after the procedure. RESULTS: PAE was successful in stopping PPH and preserving the uterus in all 16 women in the study group. No woman in the PAE group required a postpartum hysterectomy, whereas postpartum hysterectomy was unavoidable in two women in the control group. Laparotomy after vaginal delivery was necessary in two women of the group without embolisation. Hematologic parameters after the treatment were better in the PAE group than in the control group, although these differences were only in part statistically significant. There were no unwarranted effects of PAE identifiable in the study group. CONCLUSION: This is the first controlled study assessing the efficacy of PAE for the treatment of PPH. Our data suggest that PAE is effective for the treatment of severe PPH. In view of the lack of complications and unwarranted effects, clinical use of PAE in severe PPH seems justified, particularly in view of the life-threatening condition and the potential to preserve fertility in affected patients. Further evidence from well-designed prospective randomized-controlled trials would be nevertheless desirable in the future.

Diagnosis and treatment of iron-deficiency anaemia in pregnancy and postpartum.

Iron deficiency occurs frequently in pregnancy and can be diagnosed by serum ferritin-level measurement (threshold value < 30 µg/L). Screening for iron-deficiency anemia is recommended in every pregnant women, and should be done by serum ferritin-level screening in the first trimester and regular hemoglobin checks at least once per trimester. In the case of iron deficiency with or without anaemia in pregnancy, oral iron therapy should be given as first-line treatment. In the case of severe iron-deficiency anemia, intolerance of oral iron, lack of response to oral iron, or in the case of a clinical need for rapid and efficient treatment of anaemia (e.g., advanced pregnancy), intravenous iron therapy should be administered. In the postpartum period, oral iron therapy should be administered for mild iron-deficiency anemia (haemorrhagic anemia), and intravenous iron therapy for moderately severe-to-severe anemia (Hb < 95 g/L). If there is an indication for intravenous iron therapy in pregnancy or postpartum, iron-containing drugs which have been studied in well-controlled clinical trials in pregnancy and postpartum such as ferric carboxymaltose must be preferred for safety reasons. While anaphylactic reactions are extremely are with non-dextrane products, close surveillance during administration is recommended for all intravenous iron products.

Decreased neonatal pain response after vaginal-operative delivery with Kiwi OmniCup versus metal ventouse.

BACKGROUND: Vaginal delivery, especially operative assisted vaginal delivery, seems to be a major stressor for the neonate. The objective of this study was to evaluate the stress response after metal cup versus Kiwi Omnicup® ventouse delivery. METHODS: The study was a secondary observational analysis of data from a former prospective randomised placebo controlled multicentre study on the analgesic effect of acetaminophen in neonates after operative vaginal delivery and took place at three Swiss tertiary hospitals. Healthy pregnant women ≥35 weeks of gestation with an estimated fetal birth weight above 2000 g were recruited after admission to the labour ward. Pain reaction was analysed by pain expression score EDIN scale (Échelle Douleur Inconfort Nouveau-Né, neonatal pain and discomfort scale) directly after delivery. For measurement of the biochemical stress response, salivary cortisol as well as the Bernese Pain Scale of Newborns (BPSN) were evaluated before and after an acute pain stimulus (the standard heel prick for metabolic testing (Guthrie test)) at 48-72 h. RESULTS: Infants born by vaginal operative delivery displayed a lower pain response after plastic cup than metal cup ventouse delivery (p < 0.001), but the pain response was generally lower than expected and they recovered fully within 72 h. CONCLUSIONS: Neonatal pain response is slightly reduced after use of Kiwi OmniCup® versus metal cup ventouse. TRIAL REGISTRATION: Trial was registered under under NCT00488540 on 19th June 2007.

Fetal Cerebellar Vermis Circumference Measured by 2-Dimensional Ultrasound Scan: Reference Range, Feasibility and Reproducibility.

Purpose: To provide 2-dimensional ultrasonographic (2D-US) normograms of cerebellar vermis biometry, as well as to evaluate the feasibility and the reproducibility of these measurements in clinical practice. Materials and Methods: A prospective cross-sectional study of 328 normal singleton pregnancies between 18 and 33 weeks of gestation. Measurements of the fetal cerebellar vermis circumference (VC) in the mid-sagittal plane were performed by both a senior and a junior operator using 2D-US. VC as a function of gestational age (GA) was expressed by regression equations. In 24 fetuses 3-dimensional (3D) reconstructed planes were obtained in order to allow comparisons with 2D-US measurements. The agreement between 2D and 3D measurements and the interobserver variability were assessed by interclass correlation coefficients (ICC). Results: Satisfactory vermis measurements could be obtained in 89.9% of cases. The VC (constant= - 12.21; slope=2.447; r=0.887, p<0.0001) correlated linearly with GA. A high degree of consistency was observed between 2D and 3D ultrasound measurements (ICC=0.846 95% CI 679-0.930) as well as between measurements obtained by different examiners (ICC=0.890 95% CI 989-0.945). Conclusion: 2-dimensional ultrasonographic measurements of cerebellar vermis throughout gestation in the mid-sagittal view seem to be feasible and reproducible enough to be potentially used in clinical practice. Such measurements may supply a tool for accurate identification of posterior fossa anomalies, providing the basis for proper counseling and management and of these conditions.

PreImplantation Factor bolsters neuroprotection via modulating Protein Kinase A and Protein Kinase C signaling.

A synthetic peptide (sPIF) analogous to the mammalian embryo-derived PreImplantation Factor (PIF) enables neuroprotection in rodent models of experimental autoimmune encephalomyelitis and perinatal brain injury. The protective effects have been attributed, in part, to sPIF's ability to inhibit the biogenesis of microRNA let-7, which is released from injured cells during central nervous system (CNS) damage and induces neuronal death. Here, we uncover another novel mechanism of sPIF-mediated neuroprotection. Using a clinically relevant rat newborn brain injury model, we demonstrate that sPIF, when subcutaneously administrated, is able to reduce cell death, reverse neuronal loss and restore proper cortical architecture. We show, both in vivo and in vitro, that sPIF activates cyclic AMP dependent protein kinase (PKA) and calcium-dependent protein kinase (PKC) signaling, leading to increased phosphorylation of major neuroprotective substrates GAP-43, BAD and CREB. Phosphorylated CREB in turn facilitates expression of Gap43, Bdnf and Bcl2 known to have important roles in regulating neuronal growth, survival and remodeling. As is the case in sPIF-mediated let-7 repression, we provide evidence that sPIF-mediated PKA/PKC activation is dependent on TLR4 expression. Thus, we propose that sPIF imparts neuroprotection via multiple mechanisms at multiple levels downstream of TLR4. Given the recent FDA fast-track approval of sPIF for clinical trials, its potential clinical application for treating other CNS diseases can be envisioned.

Prevention of preterm delivery with vaginal progesterone in women with preterm labour (4P): randomised double-blind placebo-controlled trial.

OBJECTIVE: To evaluate the effectiveness of 200 mg of daily vaginal natural progesterone to prevent preterm birth in women with preterm labour. DESIGN: Multicentre, randomised, double-blind, placebo-controlled trial. SETTING: Twenty-nine centres in Switzerland and Argentina. POPULATION: A total of 385 women with preterm labour (24(0/7) to 33(6/7) weeks of gestation) treated with acute tocolysis. METHODS: Participants were randomly allocated to either 200 mg daily of self-administered vaginal progesterone or placebo within 48 hours of starting acute tocolysis. MAIN OUTCOME MEASURES: Primary outcome was delivery before 37 weeks of gestation. Secondary outcomes were delivery before 32 and 34 weeks, adverse effects, duration of tocolysis, re-admissions for preterm labour, length of hospital stay, and neonatal morbidity and mortality. The study was ended prematurely based on results of the intermediate analysis. RESULTS: Preterm birth occurred in 42.5% of women in the progesterone group versus 35.5% in the placebo group (relative risk [RR] 1.2; 95% confidence interval [95% CI] 0.93-1.5). Delivery at <32 and <34 weeks did not differ between the two groups (12.9 versus 9.7%; [RR 1.3; 95% CI 0.7-2.5] and 19.7 versus 12.9% [RR 1.5; 95% CI 0.9-2.4], respectively). The duration of tocolysis, hospitalisation, and recurrence of preterm labour were comparable between groups. Neonatal morbidity occurred in 44 (22.8%) cases on progesterone versus 35 (18.8%) cases on placebo (RR: 1.2; 95% CI 0.82-1.8), whereas there were 4 (2%) neonatal deaths in each study group. CONCLUSION: There is no evidence that the daily administration of 200 mg vaginal progesterone decreases preterm birth or improves neonatal outcome in women with preterm labour.

[Management of postpartum hemorrhage (PPH): algorithm of the interdisciplinary D-A-CH consensus group PPH (Germany - Austria - Switzerland)]. / Management der postpartalen Blutung (PPH): Algorithmus der Interdisziplinären D-A-CH-Konsensusgruppe PPH (Deutschland - Österreich - Schweiz).

Postpartum hemorrhage (PPH) is one of the main causes of maternal deaths even in industrialized countries. It represents an emergency situation which necessitates a rapid decision and in particular an exact diagnosis and root cause analysis in order to initiate the correct therapeutic measures in an interdisciplinary cooperation. In addition to established guidelines, the benefits of standardized therapy algorithms have been demonstrated. A therapy algorithm for the obstetric emergency of postpartum hemorrhage in the German language is not yet available. The establishment of an international (Germany, Austria and Switzerland D-A-CH) "treatment algorithm for postpartum hemorrhage" was an interdisciplinary project based on the guidelines of the corresponding specialist societies (anesthesia and intensive care medicine and obstetrics) in the three countries as well as comparable international algorithms for therapy of PPH.The obstetrics and anesthesiology personnel must possess sufficient expertise for emergency situations despite lower case numbers. The rarity of occurrence for individual patients and the life-threatening situation necessitate a structured approach according to predetermined treatment algorithms. This can then be carried out according to the established algorithm. Furthermore, this algorithm presents the opportunity to train for emergency situations in an interdisciplinary team.

Placental ABCA1 and ABCG1 expression in gestational disease: Pre-eclampsia affects ABCA1 levels in syncytiotrophoblasts.

INTRODUCTION: Transplacental feto-maternal lipid exchange through the ATP-binding cassette transporters ABCA1 and ABCG1 is important for normal fetal development. However, only scarce and conflicting data exist on the involvement of these transporters in gestational disease. METHODS: Placenta samples (n = 72) derived from common gestational diseases, including pre-eclampsia (PE), HELLP, intrauterine growth restriction (IUGR), intrahepatic cholestasis of pregnancy and gestational diabetes, were assessed for their ABCA1 and ABCG1 expression levels and compared to age-matched control placentas with qRT-PCR and immunohistochemistry. ABCA1 expression was additionally investigated with immunoblot in placental membrane vesicles. Furthermore, placental cholesterol and phospholipid contents were assessed. RESULTS: ABCA1 mRNA levels differed significantly between preterm and term control placentas (p = 0.0013). They were down-regulated in isolated PE and PE with IUGR (p = 0.0006 and p = 0.0012, respectively), but unchanged in isolated IUGR, isolated HELLP and other gestational diseases compared to gestational age-matched controls. Correspondingly, in PE, ABCA1 protein expression was significantly reduced in the apical membrane of the villous syncytiotrophoblast (p = 0.011) and in villous fetal endothelial cells (p = 0.036). Furthermore, in PE there was a significant increase in the placental content of total and individual classes of phospholipids which were partially correlated with diminished ABCA1 expression. Conversely, ABCG1 mRNA and protein levels were stable in the investigated conditions. CONCLUSIONS: In gestational disease, there is a specific down-regulation of placental ABCA1 expression at sites of feto-maternal lipid exchange in PE. At a functional level, the increase in placental lipid concentrations provides indirect evidence of an impaired transport capacity of ABCA1 in this disease.

RNA degradation differentially affects quantitative mRNA measurements of endogenous reference genes in human placenta.

It has been highlighted that RNA quality and appropriate reference gene selection is crucial for the interpretation of RT-qPCR results in human placental samples. In this context we investigated the effect of RNA degradation on the mRNA abundance of seven frequently used reference genes in 119 human placental samples. Combining RNA integrity measurements, RT-qPCR analysis and mathematical modeling we found major differences regarding the effect of RNA degradation on the measured expression levels between the different reference genes. Furthermore, we demonstrated that a modified RNA extraction method significantly improved RNA quality and consequently increased transcript levels of all reference genes.

PP010. Does aldosterone participate in placental angiogenesis via PLGF?

INTRODUCTION: Angiogenic signals are a vital signal of placental integrity. Aldosterone has recently been shown to enhance placental growth factor (PlGF) expression in the peripheral vasculature [1] and to promote trophoblast growth [2]. The plgf gene possesses a functional mineralocorticoid receptor responsive element in the promoter region. OBJECTIVES: Thus, we hypothesized that aldosterone adapts placental angiogenesis to trophoblast growth by secreting PlGF. METHODS: The human choriocarcinoma cell line BeWo and first and third trimester human primary trophoblasts cells were subjected to several syncytialization signals. Upon visual confirmation, the cultured cells were subjected to either control conditions, the known stimulator forskolin, and increasing amounts of aldosterone (10(-9) to 10(-6)M) with and without the competitive aldosterone receptor blocker spironolactone. After 6 and 24h of incubation, RNA and protein were extracted. PlGF transcripts were quantified by Taqman PCR normalized to several housekeeping genes. Protein expression was quantified by ELISA. RESULTS: PlGF mRNA expression increased 3-fold with forskolin in BeWo cells. In this cell line, aldosterone could slightly stimulate PlGF production. In non-syncytialized primary human first trimester trophoblasts, aldosterone did not exert a specific effect. In contrast, the term primary human trophoblasts did respond with a 2.5-fold increase after incubation with aldosterone (10(-7)M) in the presence of forskolin to allow forming a syncytial layer. PlGF protein was already slightly upregulated following 6h of incubation with aldosterone. CONCLUSION: We concluded that aldosterone does regulate PlGF expression in specified conditions during pregnancy. Inappropriately low aldosterone levels such as in preeclampsia might such not only compromise plasma volume and trophoblast growth but also placental vascularization and systemic PlGF availability. These observations merit further investigation.

PP118. Is the placental mass associated with the severity of preeclampsia?

INTRODUCTION: Preeclampsia contributes to an increased perinatal morbidity and mortality of both the mother and the fetus. The exact pathogenesis of PE is unclear; it is generally believed, however, that the placenta plays a pivotal role in this process. OBJECTIVES: The aim of this study was to analyse the effect of the placental mass on the severity of PE. METHODS: Following PE placentae were analyzed and their weights were compared with those of normal pregnancies [1]. Moderate and severe PE as well as HELLP syndrome were defined according to international guidelines. To compare placental weights obtained at different gestational ages, a ratio between observed (O) and expected (E) weights were calculated. Chi(2)-test and Kruskal-Wallis-test were used for statistical analysis and significance was considered when p<0.05. RESULTS: Two hundred and eight placentae following singleton pregnancies complicated by preeclampsia were enrolled. The mean gestational age at birth was 31.8±3.8 weeks, 130 (62.5%) cases delivered before the 34th week. The group with severe PE delivered earlier than that with moderate PE (mean±SD, 32±3.9 vs. 34±3 weeks; p<0.01). Severe PE was found in 176 (84.6%) cases; 85 of this group were associated with a HELLP-syndrome. Isolated HELLP were found in 4 (1.9%) cases. In 144 (69.2%) cases placental weight was below the 10th percentile. The mean of the weights was higher in the group with moderate PE than in those with severe PE, PE with HELLP and isolated HELLP (410±67g, respectively, 376±79g, 344±86g, 341±88g). When normalized using the O/E-ratio (in order to correct for gestational age) these differences were not significant (moderate PE 0.75±0.24; severe PE 0.74±0.22, PE with HELLP 0.73±0.22; isolated HELLP 0.88±0.05; p=NS). CONCLUSION: Our data show that the placental mass is not associated with the severity of PE. We hypothesize that once the pathogenesis of PE is triggered (by placental factors), the severity of the disease is modulated mainly by the maternal response and not by the placental mass.