Genetic variants of progesterone receptor in etiology of preterm delivery.

OBJECTIVES: Preterm delivery (PTD) accounts for around 11% of pregnancies worldwide. Unfortunately, no diagnostic indicator, specific mechanism or genetic predisposition has yet been identified. One of the hypotheses suggest local or functional progesterone decrease as a potential reason for preterm uterine contractions leading to preterm delivery. It is believed that any change in progesterone receptor DNA may be crucial for higher risk of preterm delivery due to abnormal response to prostaglandins, normally inhibited by properly built progesterone. The aim of this study was to determine whether there is an association between progesterone gene polymorphisms (PROGINS and +331G/A) and preterm birth. MATERIAL AND METHODS: A total of 230 women were enrolled, including 115 cases of preterm deliveries (between 22 and 36 weeks of gestation) and 115 healthy mothers of full-term infants. Genomic DNA was isolated from the blood sample. Polymerase chain reaction (PCR) amplification was carried out in a final volume of 25 µL. Genotyping was assayed by PCR. Statistical analysis of the results was conducted with p < 0.05 accepted as statistically significant. RESULTS: For both PROGINS (Alu ins/del) and +331G/A (rs10895068) polymorphisms were equally frequent in case and control group. The prevalence of PGR alleles in both groups was also comparable. CONCLUSIONS: The results of our study showed no association between progesterone gene polymorphisms (PROGINS and +331G/A) and risk of preterm delivery. Identifying mechanisms to prolong the length of gestation, particularly in women at risk for preterm delivery, will improve both maternal and fetal outcomes.

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.

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.

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.

Prenatal and postnatal detection of congenital heart diseases.

Congenital heart defects are among the most common birth defects and represent a major challenge in prenatal diagnosis and therapy of a newborn.

Detailed analysis of cortisol, cortisone and their tetrahydro- and allo-tetrahydrometabolites in human urine by LC-MS/MS.

Cortisol (F) and cortisone (E) are metabolized to A-ring reduced metabolites in the reactions catalyzed by 5α- and 5ß-reductase. 5α-tetrahydrocortisol (alloTHF) and 5ß-tetrahydrocortisol (THF) are produced from F. The metabolism of E takes place in analogy to form alloTHE and THE. Up to now, the analysis of endogenous glucocorticoids did not consider alloTHE, limiting the metabolism of E to THE only. Nevertheless, such simplification can generate inaccuracy in the assessment of the function of enzymes crucial for glucocorticoids metabolism: 11ß-hydroxysteroid dehydrogenase type 1 and type 2 (11ß-HSD1 and 11ß-HSD2), as well as 5α- and 5ß-reductase. The paper presents the new LC-MS/MS method for the simultaneous analysis of F and E with their tetrahydro- (THF and THE) and allo-tetrahydrometabolites (alloTHF and alloTHE) in urine. The method was fully validated and allows determining both the unconjugated and total concentrations of urinary glucocorticoids. The method meets the EMA's recommendations and was proved to be useful in the analysis of clinical samples. The LLOQ of 1ng/mL allows the determination of free urinary F, E, THF and THE, but not alloTHF and alloTHE, in samples obtained from pregnant women. The range of concentrations is wide enough for the analysis of total levels of F, E, THF, alloTHF, THE and alloTHE. The undisputed advantage of the method, distinguishing it among others, is the ability to determine F and E and their both 5α- and 5ß-metabolites. Taking alloTHE into consideration enables the thorough analysis of the glucocorticoid equilibrium in human.

Circulating endothelial cells, circulating endothelial progenitor cells, and von Willebrand factor in pregnancies complicated by hypertensive disorders.

PROBLEM: We tested the hypothesis that the number of both CECs and CEPCs as well as the vWf blood plasma concentration are altered in pregnant women with hypertensive disorders. METHOD OF STUDY: Seventy-five pregnant women were enrolled in our study. We used multicolor flow cytometry for CEC and CEPC analysis and the commercial human VWF ELISA kit to measure vWf blood plasma concentration. RESULTS: The highest number of CECs was found in the chronic hypertension group and the lowest number in the healthy pregnant control group. The highest number of CEPCs was found in the control group and the lowest number in the chronic hypertension group. The vWf blood plasma concentration was the highest in the pre-eclampsia group. The CEPC/CEC ratio reached its lowest value in the chronic hypertension group and its highest value in the control group. CONCLUSION: The number of both CECs and CEPCs as well as the vWf blood plasma concentration depends on the type of hypertension complicating the pregnancy.

Smith-Lemli-Opitz Syndrome- a challenging prenatal diagnosis.

OBJECTIVES: The aim of the study was to present a case of Smith-Lemli-Opitz syndrome (SLOS) in a fetus of a 33-year-old patient. At 31 weeks of gestation, the following fetal malformations were detected on an ultrasound: atrioventricular septal defect (AVSD), aortic coarctation, shortening of the lower limbs, narrow forehead, hyperthelorism, micrognathia, anteverted nares, ambiguous genitalia, and signs of intrauterine growth restriction. The baby died 11 days after birth. Further genetic screening of the parents revealed the 7-DHCR enzyme mutation in both of them. Although the prenatal diagnosis of SLOS presents a challenge due to the fact that little is known about its prenatal phenotype but it may be vital while attempting to treat the fetus in utero.

Prenatal diagnosis of vasa previa.

Vasa previa is a rare condition in which unsupported by the placenta, umbilical cord blood vessels runs within the placental membranes between internal os of the cervix and presenting part of the fetus. We report an antenatal diagnostic procedure and management of a patient with low-lying placenta and velamentous cord insertion near to the internal os with two large fetal blood vessels coursing between the internal cervical os and fetal presenting part. An elective cesarean section was performed at 36 weeks gestation.

Endothelial dysfunction in the pathogenesis of pre-eclampsia.

There are many theories regarding the ultimate cause of pre-eclampsia, and nowadays it is thought that the mechanism of pathogenesis is most likely multifactorial. The pathophysiology probably involves both fetal or placental and maternal factors. The most likely relevant factors in the pathogenesis are the abnormal development of the placenta, systemic endothelial dysfunction or cell activation, and an imbalance between pro-angiogenic and anti-angiogenic proteins with a predominance of anti-angiogenic factors. In women with pre-eclampsia, placental tissue overproduces two main anti-angiogenic proteins which enter into the maternal circulation: soluble Fms- such as tyrosine kinase 1 (sFlt1 or sVEGFR1) and soluble endoglin (sEng). Moreover, these patients have low circulating blood levels of two pro-angiogenic peptides: placental growth factor (PlGF) and vascular endothelial growth factor (VEGF). Adequate levels of CECs (circulating endothelial cells), EPCs (endothelial progenitor cells) and microparticles most likely play an important part in the development and regulation of vascularization in pregnancy but the exact role of these cells and micropatticles in the pathogenesis of pre-eclampsia is unknown. Some imbalances in these levels are associated with endothelial insufficiency.

Conservative management of placenta previa complicated by abnormal placentation.

OBJECTIVE: Abnormal implantation of placenta previa is life-threatening condition. The purpose of this study was to evaluate the impact of the conservative management of pregnancies with such complication on maternal morbidity rate and the chance for uterine preservation (fertility). METHODS: Eleven patients with abnormal implantation of placenta previa were analyzed prospectively. This complication was diagnosed antenatally by two-dimensional ultrasound and color flow Doppler. The following outcomes were analyzed: need for blood transfusion, admission and duration of stay in intensive care unit, infections, coagulopathies, time between cesarean section and delivery of placenta, hysterectomy and preservation of uterus. RESULTS: Among the 20 085 women who had a singleton gestation, 11 (0.054%) were identified with placenta previa with abnormal placentation. In five patients (group A), hysterectomy was performed because of hemorrhage or placenta ablation. In six patients (group B), conservative management succeeded and placenta were preserved. In group A, placenta were delivered earlier (2 d-8 weeks) in comparison with group B (6-15 weeks). Estimated blood loss during the delayed delivery of placenta was higher in the group with hysterectomy (respectively, 450-1600 and 300-500 ml). CONCLUSIONS: Conservative management of placenta previa with abnormal implantation decreases the risk of severe hemorrhage at the time of delivery and can preserve fertility.