Unique alterations in infection-induced immune activation during pregnancy.

BACKGROUND: Immune responses to infection are uniquely regulated during gestation to allow for antimicrobial defence and tissue repair, whilst preventing damage to developing fetal organs or the triggering of preterm labour. OBJECTIVE: A review and analysis of studies delineating gestation-specific immune modulation and intra-amniotic regulation of pro-inflammatory immunity. SEARCH STRATEGY: Identification of the alterations between the fetus/neonate and adult with regard to the endogenous and infection-induced expression of molecules with immune regulatory properties, and the characterisation of intra-amniotic immune mediators that inhibit bacterial-induced pro-inflammatory cytokine production. SELECTION CRITERIA: English and non-English publications from 1985 to the present. DATA COLLECTION AND ANALYSIS: An electronic literature search using MEDLINE, PubMed, articles cited in the primary sources, as well as pregnancy-related immunology research from our laboratory at Weill Medical College of Cornell University. MAIN RESULTS: During fetal development, interleukin (IL)-23, IL-10 and IL-6, as well as T-helper-17 (Th17)-mediated immune responses, are upregulated, whereas tumour necrosis factor-α (TNF-α) and IL-1ß- and Th1-mediated immune responses are downregulated in the intrauterine environment (both the fetal compartment and the amniotic compartment). Infection-related immunity during gestation is preferentially directed towards combating extracellular microbial pathogens. Amniotic fluid and the neonatal circulation contain multiple components that improve the ability of the developing neonate to tolerate microbial-induced immune activation. CONCLUSIONS: The repertoire of immune mechanisms to control infection and inflammation differ between fetal and adult life. The dual mechanisms of resistance to infection and tolerance to infection-induced immune activation prevent damage to the developing fetus and the triggering of premature labour.

Endocervical hyaluronan and ultrasound-indicated cerclage.

OBJECTIVE: To investigate whether, at the time of ultrasound-indicated cerclage, the endocervical concentration of hyaluronan (HA), 27-kDa heat shock protein (HSP-27) and/or interleukin-8 (IL-8) would predict pregnancy outcome. METHODS: Endocervical samples, obtained from 40 women undergoing ultrasound-indicated cerclage at 15 + 3 to 25 + 0 weeks' gestation, were assayed by enzyme-linked immunosorbent assay for HA, HSP-27 and IL-8. All subjects had a cervical length of < 1.5 cm or dramatic cervical length change on serial endovaginal ultrasound, no uterine contractions or tenderness, no fever and intact membranes and underwent a modified Shirodkar cerclage. RESULTS: The median HA level was 10.0 ng/mL in the 12 women who delivered at < 37 weeks' gestation as opposed to 39.7 ng/mL in the 28 women delivering at 37-41 weeks (P = 0.017). Median HSP-27 and IL-8 concentrations were not significantly different in these groups. CONCLUSION: A higher endocervical HA level at the time of ultrasound-indicated cerclage is associated with a longer interval before birth.

Urinary excretion of pregnanetriol and 5 -pregnenetriol in two forms of congenital adrenal hyperplasia.

Although congenital adrenal hyperplasia due to 3beta-hydroxysteroid dehydrogenase deficiency generally reveals a predominance of Delta(5)-3beta-hydroxysteroids, on occasion substantial quantities of pregnanetriol have been found as well. It appears that the latter steroid more often occurs in the subjects who have survived beyond infancy. The use of the measurement of pregnanetriol alone may therefore not be relied upon as a sole determinant of the specific form of defective steroidal biogenesis. It is more characteristic of the 21-hydroxylase deficiency. However when both Delta(5)-pregnenetriol and pregnanetriol are measured the ratio of the former to the latter is always considerably below 1.0 in 21-hydroxylase deficiency and always above 1.0 in 3beta-hydroxysteroid dehydrogenase. Furthermore, 11-ketopregnanetriol has been found only in the urine of subjects with the 21-hydroxylase deficiency. Thus, these two forms of defective steroidal biogenesis may be distinguished by the measurement of these three urinary steroidal metabolites.

Persistent testicular delta5-isomerase-3beta-hydroxysteroid dehydrogenase (delta5-3beta-HSD) deficiency in the delta5-3beta-HSD form of congenital adrenal hyperplasia.

A partial testicular defect in testosterone secretion has been documented in a pubertal male with a congenital adrenal hyperplasia due to hereditary deficiency of the delta5-isomerase-3beta-hydroxysteroid dehydrogenase enzyme complex (delta5-3beta-HSD). Diagnosis of the enzymatic defect is based on the clinical picture of ambiguous genitalia and salt-losing crisis in infancy, together with high urinary delta5-pregnenetriol and plasma dehydroepiandrosterone when the patient was taken off replacement corticoid treatment. No hormonal response to ACTH or salt deprivation was demonstrable. In addition, in vivo studies revealed a partial enzymatic defect in the testis. Although plasma testosterone was low-normal (250 ng/100 ml), plasma delta5-androstenediol was markedly elevated and rose to a greater extent than testosterone after human chorionic gonadotropin administration. In vitro testicular incubation studies suggested a testicular delta5-3beta-HSD enzyme defect with less delta4 products formed from delta5 precursors than in a control testis. Histochemical studies of the testis were also consistent with this defect. Testicular biopsy revealed spermatogenic arrest, generally diminished Leydig cells, but with focal areas of Leydig cell hyperplasia as well as benign Leydig cell hyperplasia as well as benign Leudig cell nodules within the spermatic cord. In vivo studies of steroid metabolism suggested intact peripheral or hepatic delta5-3beta-HSD activity. These studies imply that delta5-3beta-HSD activity differs in the gonad, adrenal, and peripheral organs. These findings are compatible with the concept that the enzyme complex consists of subunits and/or that enzymes in these organs are under different genetic control.

Sperm-related antigens, antibodies, and circulating immune complexes in sera of recently vasectomized men.

Sera from 35 men were collected before and at timed intervals subsequent to vasectomy and examined for the presence of (a) antibody reactive with human spermatozoa, (b) sperm-related antigen, and (c) circulating immune complexes (CIC). Fewer than 10% of the men examined were ever positive for antisperm antibodies. However, sperm-related antigens were elevated in the sera of 18, 18, and 26% of the mean at 2 wk, 2 mo, and 4 mo postvasectomy, respectively. CIC were detected in the sera of some vasectomized men by three different assays. The CIC in patients' sera were precipitated with polyethylene glycol, dissociated, and the individual CIC components identified by an enzyme-linked immunosorbent assay. Most, but not all, of the CIC contained antigen reactive with antisperm immunoglobulin (Ig)G and some also contained complement components C3 and/or Clq. IgA was identified in some of the CIC positive for IgG and sperm antigen and two men had IgM-containing CIC. Analysis of the CIC by sucrose gradient centrifugation revealed them to be heterogeneous in size.

Are ovarian steroids required for ovum maturation and fertilization? Effects of cyanoketone on the in vitro perfused rabbit ovary.

An isolated perfused rabbit ovary preparation was used to determine the effects of cyanoketone, a potent inhibitor of 3 beta-hydroxysteroid dehydrogenase, on ovulation, ovum maturation and fertilizability, and steroid production. In the first experiment, cyanoketone (10(-4) M) was added to the perfusate of one ovary. The contralateral control ovary was perfused with medium alone. Thirty minutes after the onset of perfusion, hCG (50 IU) was added to the perfusate of both ovaries. The ovulatory efficiency of ovaries treated with cyanoketone plus hCG (82.3 +/- 4.6%) was similar to that of ovaries treated with hCG alone (84.8 +/- 4.4%). No difference was observed in the degree of ovum maturity or degeneration between control and cyanoketone-treated ovaries. Progesterone and estradiol production were significantly reduced by cyanoketone treatment; concentrations in the perfusate of ovaries treated with cyanoketone were 9.7% and 8.0% of the control values, respectively, 2 h after exposure to hCG. The concentration of 17-hydroxypregnenolone was not affected by cyanoketone treatment. Exposure to cyanoketone resulted in a significant (P less than 0.005) reduction in the fertilizability of ova ovulated and fertilized in vitro. In the second experiment, the percentage of ova that showed evidence of normal fertilization was significantly (P less than 0.025) increased in ovaries perfused with cyanoketone plus estradiol (64.5%) compared to that in ovaries perfused with cyanoketone alone (32.4%). In the third experiment, the addition of progesterone to the perfusate did not affect fertilizability of ovulated ova in ovaries perfused with cyanoketone plus estradiol. These results suggest that the presence of estradiol in the ovarian steroid environment may be essential for fertilizability of ova, but not for the processes of ovulation or meiotic maturation.

Characterization of somatogenic and lactogenic binding sites in isolated rat hepatocytes.

Suspensions of rat hepatocytes isolated enzymatically by the method of Berry and Friend were used to study the binding of 125I-labeled human (hGH) and bovine (bGH) growth hormones and ovine prolactin (oPRL). Displacement of these labeled hormones by their unlabeled analogues was analyzed by means of Scatchard plots and affinity constants (K) and the number of binding sites per cell (q) were calculated. Specificity of binding was studied using hGH, bGH oPRL and rat growth hormone (rGH) and rat prolactin (rPRL). Rat hepatocytes contained two types of binding sites which bound hGH. The first, somatogenic, was specific for the growth-promoting hormones bGH and rGH. The second, lactogenic, was specific for lactogenic hormones, oPRL and rPRL. Human GH, which has both lactogenic and growth-promoting properties in rodents, bound to both sites. The somatogenic binding sites were present in both males and females, and the number of sites was similar in females and in males and was not affected by hypophysectomy. The lactogenic binding sites were present only in females, and the number of lactogenic and somatogenic sites was similar (40,000/cell). The affinity of hGH for the lactogenic binding sites was less than for the somatogenic (0.37 X 10(9) vs. 1 X 10(9)M-1). The lactogenic binding sites were lost when female rats were hypophysectomized and could not be restored by estrogen treatment.

Basal and stimulated serum growth hormone concentrations in inflammatory bowel disease.

Patients with inflammatory bowel disease (IBD) manifest growth failure which may antecede abdominal symptoms by some years. Eight of ten children with documented IBD had records of decreasing growth velocities. Investigation of growth hormone reserves showed excessive rather than impaired responses. Mean basal GH level was 6.2 +/- 0.75 (SEM) ng/ml. During sleep, the mean GH level rose to 26.0 +/- 4.7 ng/ml and following propranolol-glucagon stimulation, to 46.0 +/- 4.5 ng/ml. All values were significantly higher than levels obtained in a control population of 25 children investigated for short stature who were not GH deficient. The mean peak GH response following insulin in the IBD group (10.8 +/- 3.8 ng/ml), however, did not differ from the mean peak response in the control group (13.5 +/- 3.3 ng/ml). Growth failure in patients with IBD is not the result of GH deficiency and is not an irreversible phenomenon. On the contrary, judicious use of glucocorticoids aimed at the control of the disease usually produces compensatory growth acceleration ("catch-up growth").

Evidence for an aldosterone biosynthetic defect in congenital adrenal hyperplasia.

A search was made for an abnormality in aldosterone biosynthesis in congenital adrenal hyperplasia due to a cortisol 21-hydroxylation defect. Examination of the urinary metabolites of potential C-18-oxygenated steroid precursors revealed an abnormal pattern; however, the locus of the defect was not at the C-21 hydroxylation step, but consisted of overproduction of glomerulosa 18-hydroxylation step, but consisted of overproduction of glomerulus 18-hydroxycorticosterone relative to aldosterone, as seen in the type II corticosterone methyl oxidase defect. This abnormality, which was seen in all salt losers and most nonsalt losers, provided evidence for diminished aldosterone secretory reserve even when values of the hormone are normal or elevated. These findings support the concept that salt-losing and nonsalt-losing forms of the cortisol 21-hydroxylation defect differ only in degree and are not different genotypes. An implication of these findings is that all patients with congenital adrenal hyperplasia with an elevated 18-hydroxycorticosterone to aldosterone metabolite ratio should be considered for mineralocorticoid replacement therapy even if their absolute aldosterone values appear to be normal or elevated.

Low serum triiodothyronine in patients with anorexia nervosa.

Patients with anorexia nervosa can demonstrate clinical and/or laboratory findings suggestive of reduced thyroid hormone secretion. In this study, the thyroxine (T4) and triiodothyronine (T3) serum concentrations, and thyrotropin (TSH) response to intravenous administration of thyrotropin releasing hormone (TRH) were determined in 6 patients (aged 9 to 15 yr) with anorexia nervosa and the results compared to those found in a group of 15 normal subjects. The mean basal TSH concentration and mean maximum increase in TSH after TRH were comparable to those in the normal subjects. The mean T4 concentration (7.2 mug/100 ml) in the anorexia nerovsa group was slightly but significantly lower than in the normal group (9.5 mug/100 ml). Five of the 6 patients had serum T3 concentrations below the lower limits of normal and the mean T3 concentrations (49.7 ng/100 ml) was significantly lower than in the normal group (106 ng/100 ml). The extremely low serum levels of T3 in these patients with anorexia nervosa suggest that peripheral conversion of T4 to T3 is impaired during chronic starvation.

Bilateral testicular tumors in congenital adrenal hyperplasia.

A 22-year-old male with bilateral testicular tumors and the 21-hydroxylase variety of congenital adrenal hyperplasia (CAH) was studied. Preoperatively, on his usual glucocorticoid regimen, his urinary pregnanetriol excretion was increased (8.0-23.5 mg/day), serum LH and FSH were normal to increased (14.3-28.7 mIU/ml and 13.2-19.5 mIU/ml, respectively) and testosterone (T) was normal to decreased (176-600 ng/dl). At surgery, testicular vein concentrations of 17-alpha-hydroxyprogesterone (17-OHP) and adnrostenedione (delta) were increased (30.1 mug/dl and 38.3 mug/dl respectively) while T was decreased (1,503 ng/dl); a positive peripheral vein--testicular vein gradient was not seen for these steroids. Following injection of 10 U of crystalline ACTH into the testicular artery; testicular vein concentrations of 17-OHP, delta and T increased to 729 mug/dl, 2,390 mug/dl and 9,660 ng/dl respectively. Microscopic examination of the testes revealed multinodular tumors composed of polygonal or rounded eosinophilic cells, arranged in cords, nests and clusters. The tumors extended from the hilus and compressed the adjacent testicular tissue. Electron microscopic examination of the tumors showed features, common to steroid-secreting tissues, with abundant smooth endoplasmic reticulum in close proximity to mitochondria which was moderate in number. The adjacent testicular tissue was composed of immature tubules with normally developed Leydig cells in the interstitial tissues. From these data and a survey of previous works, it was postulated that these tumors were dependent upon ACTH for growth and steroid secretion. In view of the high serum LH concentration seen in association with incomplete suppression of adrenal steroid secretion in this study and the association of evidence of gonadotropin secretion with testicular tumors in other CAH patients, LH may also have contributed to the growth of these tumors.

Adrenocortical response to ACTH stimulation in postmature newborns.

Diminished total plasma cortisol levels have been demonstrated in postmature neonates, suggesting that fetal glucocorticoids may be involved in the cause of postmaturity. This hypothesis was tested by adrenocortical stimulation in 32 newborns: 12 were postmature; 12 were postterm, but not postmature; and 8 were normal term neonates. The mean pre- and poststimulation total plasma cortisol levels were 3.9 and 50.9 microgram/100 ml, respectively, for the postmature newborns, 9.7 and 44.0 microgram/100 ml for the postterm, but nonpostmature newborns, and 9.8 and 37.1 microgram/100 ml for the normal term newborns. The differences in the poststimulation rise in plasma cortisol between the postmature and merely postterm infants or between the postterm and normal term infants were not statistically significant. The mean poststimulation cortisol rise in the postmature group exceeded that of the normal term group (P less than 0.05). The adequacy and promptness of response to adrenocortical stimulation eliminate the likelihood of adrenal insufficiency in postmature infants.

Amniotic fluid cortisol concentrations in normal labor, premature labor, and postmature pregnancy.

Amniotic fluid cortisol concentration was measured in 61 gravidas during the third trimester prior to onset of labor. These patients had had normal prenatal courses and served as controls. Cortisol values obtained were compared with those of 1) gravidas with prolonged pregnancy (greater than 42 weeks) who delivered post-mature neonates (N=6), 2) gravidas in spontaneous term labor (N = 10), and 3) gravidas in premature labor (N=10). The mean level of amniotic fluid cortisol (+/-SD) found in those women with premature labor was significantly elevated compared to control values (P less than 0.05). Levels recorded in premature labor patients were in the same range as in the term spontaneous labor group (3.7+/-2.5 vs. 2.7+/-1.5; P greater than 0.3). No difference was found between the spontaneous labor group or the postmature group and their respective controls.

Parturition-induced changes in maternal plasma cortisol levels.

Total maternal plasma cortisol levels were measured by a radioassay method in 9 patients who were in spontaneous labor and 10 patients who were electively induced at term with oxytocin. Determinations were made at onset of labor and repeated at full cervical dilatation. Total maternal plasma cortisol levels were also measured in 7 patients undergoing elective cesarean section without labor, determinations being made just prior to the procedure and at the time of uterine incision. Computerized analysis showed the mean initial cortisol level (+/- SE) in the spontaneous labor group (15.4 +/- 1.6 mug/100 ml) to be significantly less than the mean initial level of the group electively delivered by oxytocin induction (37.2 +/- 6 mug/100 ml), with P less than 0.01. The former value was also found to be significantly less than that of the group electively delivered by cesarean section (32.1 +/- 9.3 mug/100 ml), with P less than 0.05. A significant rise was noted at full cervical dilatation in the spontaneous labor group (P less than 0.05), whereas no change occurred in the two elective groups. No significant correlation was found between the maternal cortisol levels on the one hand and the cord cortisol levels. These findings indicate that a) maternal participation is unlikely in bringing about a surge of fetal plasma cortisol which is thought to precede spontaneous labor, b) elective termination of term pregnancy by oxytocin induction or cesarean section may be initially more stress-provoking to the mother than spontaneous labor, and c) maternal stress as measured by plasma cortisol level is not reflected in the fetus.

Acquired adrenal hyperplasia: with special reference to 3 beta-hydroxysteroid dehydrogenase.

Acquired virilism in adult females amy be due to a number of primary disorder of the adrenal or the ovary, or both. In this review, HSD deficiency has been presented as one distinct cause. Its diagnosis as described in the report by Rosenfield and his co-workers depends upon several features. The urinary pattern of delta 5-3 beta-ol metabolites should be typical of that of congenital HSD deficiency. The excretion of pregnenetriol as compared with pregnanetriol (although the latter is usually high) should show a preponderance of the former. The elevation of 16-hydroxy compounds in the urine is also characteristic. The plasma steroids having the delta 5-3 beta-ol configuration should be elevated to an extent not seen in any other disorder except with an adrenal tumor. Specifically, plasma 17-hydroxypregnenolone levels will be extremely elevated, as will DHEA and the DHEAS levels. In the initial stage of diagnosis, one might initiate the work-up by determining the plasma DHEA and DHEAS concentrations so that, when these are distinctly elevated, one may proceed to further study. In the extremely mild forms it will probably be necessary to apply adrenal stimulation with ACTH in order to bring the abnormal pattern into perspective.

Detection and characterization of immune complexes in the circulation of infertile women.

The incidence of circulating immune complexes (CICs) was evaluated in sera from 39 female partners of infertile marriages and from 38 fertile women. Fifteen (38%) of the infertile women had CICs, as determined by the Raji cell assay, in levels ranging from 300 to 8000 micrograms/ml; whereas only 1 (3%) of the fertile women displayed CICs (P less than 0.001). Analysis of the CICs from nine of the women following polyethylene glycol precipitation and acid dissociation revealed that four contained C1q and three contained an antigen reactive with rabbit antibody to human spermatozoa. These latter three women all lacked free sperm antibody, as determined by enzyme-linked immunosorbent assay and agglutination. Thus, CICs are not uncommon as a manifestation of infertility in females. Their presence may lead to an underestimation of sperm antibody levels and may be indicative of underlying infection or autoimmunity.