Injectable candidate sealants for fetal membrane repair: bonding and toxicity in vitro.

OBJECTIVE: This study was undertaken to test injectable surgical sealants that are biocompatible with fetal membranes and that are to be used eventually for the closure of iatrogenic membrane defects. STUDY DESIGN: Dermabond (Ethicon Inc, Norderstedt, Germany), Histoacryl (B. Braun GmbH, Tuttlingen, Germany), and Tissucol (Baxter AG, Volketwil, Switzerland) fibrin glue, and 3 types of in situ forming poly(ethylene glycol)-based polymer hydrogels were tested for acute toxicity on direct contact with fetal membranes for 24 hours. For the determination of elution toxicity, extracts of sealants were incubated on amnion cell cultures for 72 hours. Bonding and toxicity was assessed through morphologic and/or biochemical analysis. RESULTS: Extracts of all adhesives were nontoxic for cultured cells. However, only Tissucol and 1 type of poly(ethylene glycol)-based hydrogel, which is a mussel-mimetic tissue adhesive, showed efficient, nondisruptive, nontoxic bonding to fetal membranes. Mussel-mimetic tissue adhesive that was applied over membrane defects that were created with a 3.5-mm trocar accomplished leak-proof closure that withstood membrane stretch in an in vitro model. CONCLUSION: A synthetic hydrogel-type tissue adhesive that merits further evaluation in vivo emerged as a potential sealing modality for iatrogenic membrane defects.

Concise review: isolation and characterization of cells from human term placenta: outcome of the first international Workshop on Placenta Derived Stem Cells.

Placental tissue draws great interest as a source of cells for regenerative medicine because of the phenotypic plasticity of many of the cell types isolated from this tissue. Furthermore, placenta, which is involved in maintaining fetal tolerance, contains cells that display immunomodulatory properties. These two features could prove useful for future cell therapy-based clinical applications. Placental tissue is readily available and easily procured without invasive procedures, and its use does not elicit ethical debate. Numerous reports describing stem cells from different parts of the placenta, using nearly as numerous isolation and characterization procedures, have been published. Considering the complexity of the placenta, an urgent need exists to define, as clearly as possible, the region of origin and methods of isolation of cells derived from this tissue. On March 23-24, 2007, the first international Workshop on Placenta Derived Stem Cells was held in Brescia, Italy. Most of the research published in this area focuses on mesenchymal stromal cells isolated from various parts of the placenta or epithelial cells isolated from amniotic membrane. The aim of this review is to summarize and provide the state of the art of research in this field, addressing aspects such as cell isolation protocols and characteristics of these cells, as well as providing preliminary indications of the possibilities for use of these cells in future clinical applications.

Comparative characterization of cultured human term amnion epithelial and mesenchymal stromal cells for application in cell therapy.

Emerging evidence suggests human amnion tissue as a valuable source of two distinct types of pluripotent cells, amnion epithelial cells (hAECs) and mesenchymal stromal cells (hAMSCs), for applications in cell replacement therapy. For some approaches, it may be necessary to culture and differentiate these cells before they can be transplanted. No systematic attempt has been yet made to determine the quantity and quality of amnion cells after isolation and culture. We looked at amnion cell isolates from 27 term placentas. Following our optimized protocol, primary yields were 6.3 x 10(6) hAECs and 1.7 x 10(6) hAMSCs per gram amnion. All 27 cases gave vital cultures of hAMSCs, while one third of cases (9 of 27) failed to give adherent cultures of hAECs. Primary cultures contained significantly more proliferating than apoptotic cells (hAECs: 16.4% vs. 4.0%; hAMSCs: 9.5% vs. 2.4%). Neither hAECs nor hAMSCs were clonogenic. They showed slow proliferation that almost stopped beyond passage 5. Microscopic follow-up revealed that hAEC morphology gradually changed towards mesenchymal phenotype over several passages. Flow cytometric characterization of primary cultures showed expression of mesenchymal progenitor markers CD73, CD90, CD105, and CD166, as well as the embryonic stem cell markers SSEA-3 and -4 on both amnion cell types. These profiles were grossly maintained in secondary cultures. Reverse transcriptase-PCR analysis exhibited transcripts of Oct-3/4 and stem cell factor in primary and secondary cultures of all cases, but no telomerase reverse transcriptase. Immunocytochemistry confirmed translation into Oct-3/4 protein in part of hAEC cultures, but not in hAMSCs. Further, both amnion cell types stained for CD90 and SSEA-4. Osteogenic induction studies with amnion cells from four cases showed significantly stronger differentiation of hAECs than hAMSCs; this capacity to differentiate greatly varied between cases. In conclusion, hAECs and hAMSCs in culture exhibit and maintain a similar marker profile of mesenchymal progenitors. hAECs were found as a less reliable source than hAMSCs and altered morphology during subculture.

Fetoscopic closure of punctured fetal membranes with acellular human amnion plugs in a rabbit model.

OBJECTIVE: To explore a surgical plug formed from decellularized term human amnion membrane for fetoscopic closure of iatrogenic defects in fetal membranes in a rabbit model. METHODS: The study was performed in eight rabbit does. Punctures were created at midgestational day 23 by 14-gauge needle fetoscopy on surgically exposed rabbit amniotic sacs. The entry sites were fetoscopically plugged either with decellularized term human amnion membrane (n=10) or previously successful commercial collagen matrix foil (n=10), followed by their primary fixation with fibrin glue and myometrial suturing. Seven punctured sacs without any plugging and 31 sacs without any manipulation served as two reference groups. Amniotic integrity and fetal parameters were assessed at gestational day 30. RESULTS: We established a facile method to prepare sheets of decellularized term human amnion membrane and verified its nontoxicity and cell compatibility in vitro. Decellularized term human amnion membrane sheets could be delivered precisely and controlled by fetoscopy as compact plugs into amniotic defects. The surgical handling characteristics of decellularized term human amnion membrane were better than the commercial collagen matrix foil. Treatment with human decellularized term human amnion membrane was comparable to treatment with the collagen matrix with regard to efficiency in restoring amniotic integrity. Seventy-five percent and 71.4% of amniotic sacs treated with decellularized term human amnion membrane or the commercial collagen matrix foil, respectively, showed amniotic integrity, compared with 25% in the left-open study group. Histology at the 1 week experimental endpoint showed no evidence for inflammation or beginning of anatomic healing of grafted, decellularized term human amnion membrane. CONCLUSION: Fetoscopic delivery of plugs made of decellularized term human amnion membrane presents a potentially practical surgical method to restore amniotic integrity of punctured fetal membranes. LEVEL OF EVIDENCE: III.

The Young's modulus of fetal preterm and term amniotic membranes.

OBJECTIVE: To examine the Young's modulus of the human amniotic membranes, as well as its relationship to gestational age. To determine whether cellular and material-related parameters affect this modulus. STUDY DESIGN: In a prospective study at the Obstetric outpatient clinic of the University Hospital Zurich Young's modulus, thickness and mesenchymal:epithelial cell ratio of amniotic membranes of preterm (N=23) and term (N=40) placentae were examined. Significance (P<0.05) was calculated with the Mann-Whitney two-sample rank sum test and Wilcoxon signed rank test, while correlations were made using the Spearman's correlation. RESULTS: The Young's modulus of preterm amniotic membranes was significantly higher than that of term membranes. It varied within the same amniotic membrane. The thickness of the amnion in both preterm and term membranes did not differ significantly. The thinner the preterm and term amniotic membranes, the higher the Young's modulus was. There was no relation to the mesenchymal:epithelial cell ratio in the amnion. CONCLUSIONS: Preterm amniotic membranes are stiffer than term amniotic membranes. Tentatively, we hypothesise that there may be a correlation between the extracellular matrix components and the elastic properties of the membrane.

Human preterm amnion cells cultured in 3-dimensional collagen I and fibrin matrices for tissue engineering purposes.

OBJECTIVE: In this study, human preterm amnion cells were investigated in 3-dimensional (3D) cell-matrix culture systems in an attempt to design therapeutic strategies for preterm premature rupture of the membranes. STUDY DESIGN: Three-dimensional collagen I and fibrin cell-containing biomatrices were created to mimic the architecture of native amnion. Amnion mesenchymal cells were embedded in 3D matrices, and epithelial cells were placed on top of these matrices. Cell viability and morphology were visualized by DiI-ac-LDL, F-actin, and nuclear staining. Proteolytic activity of matrix metalloproteinases (MMPs) was investigated using gelatine zymography. RESULTS: Preterm amnion epithelial and mesenchymal cells cultured in collagen I and fibrin matrices assume cell morphologies similar to those observed in vivo. Mesenchymal cells were capable of remodelling collagen I, as seen by extensive volume contraction, by 40% at day 1 and 80% at day 5. Matrix contraction was independent of the presence of epithelial cells, and could not be inhibited by GM6001 and/or aprotinin. No contraction was observed in fibrin matrices over 8 days. The migratory response of mesenchymal cells cultured in 3D fibrin matrices supplemented with fibronectin was associated with specific activated MMP-9. CONCLUSION: Three-dimensional fibrin matrices might be useful in amnion cell tissue engineering, including cell-matrix transplantation.

Relation between mechanical properties and microstructure of human fetal membranes: an attempt towards a quantitative analysis.

OBJECTIVE: We sought to measure the mechanical baseline behavior of fetal membranes in order to determine constitutive mechanical model parameters for fetal membranes, and to examine their relation to molecular correlates for mechanical function, i.e. collagen and elastin. STUDY DESIGN: The uniaxial stress-strain response of nine human term fetal membranes was measured. Methods of nonlinear continuum mechanics were applied for the analysis of the stress-strain curves. Thickness of amnion and chorion were determined from histologic sections for each fetal membrane sample. Complementary biochemical analysis was performed to quantify the soluble collagen and soluble elastin components for each sample. RESULTS: We report a straightforward histologic modality for measurements of amnion and chorion thickness. Average thickness of the amnion and chorion layers were 111+/-78 microm, and 431+/-113 microm, respectively, which are about twice larger than previously reported. The average content of acid-soluble elastin was 2.1% of wet weight and the one of pepsin/acetic acid-soluble collagen was 10.5% of dry weight. Our data show an inverse proportionality between soluble elastin and soluble collagen content. The low strain elastic modulus ranged between 10 and 25 kPa. Correlations were found between biochemical data and mechanical parameters: there is clearly a direct proportionality between small strain elastic modulus and elastin content. Further, a (less pronounced) direct correlation was observed also between soluble collagen content and the parameter governing the increase in stiffness at larger strains in the nonlinear mechanical model. The mechanical tests revealed a relatively low variability for samples from the same membrane but a large variation between donors. The proposed nonlinear model provides a good fit of the experimental data, with a coefficient of determination, R(2), typically in the range of 0.94. Membranes failure originated at the clamping points thus impairing the quantification of ultimate stress and strain. Thus, no correlation was found between maximum stress and collagen or elastin content. CONCLUSIONS: This study provides a starting point for comprehensive quantitative analysis of the relationship between fetal membranes microstructure and their nonlinear deformation behavior. These insights could become useful in identifying potential medical interventions to prevent membranes rupture.

In vitro lesion repair by human amnion epithelial and mesenchymal cells.

OBJECTIVE: The purpose of this study was to compare wound healing by human amnion epithelial and mesenchymal cells from preterm and term placenta with the use of an in vitro lesion repair assay. STUDY DESIGN: Lesions were created in confluent monolayers of amnion epithelial and mesenchymal cells from preterm and term placentas. The repair was monitored by the measurement of the lesion area and the response to potential stimulants (platelet-derived growth factor, tumor necrosis factor-alpha, fibrinogen, and phorbol myristate acetate). Cell proliferation was detected with 5-bromodeoxyuridine staining. RESULTS: Lesion repair was complete within 40 hours in control epithelial cultures from preterm and term placenta but incomplete in mesenchymal cultures (preterm cells, 80%; term cells, 40%). Platelet-derived growth factor, tumor necrosis factor-alpha, fibrinogen, and phorbol myristate acetate did not accelerate repair in either cell type. CONCLUSION: An in vitro lesion repair assay revealed the differences in lesion repair capacity between amnion epithelial and mesenchymal cells and between mesenchymal cells from preterm and term placenta.

Inducing proliferation of human amnion epithelial and mesenchymal cells for prospective engineering of membrane repair.

OBJECTIVE: To prepare a tissue engineering approach to fetal membrane repair after premature rupture of the membranes (PROM) by characterizing the proliferation potential of human amnion epithelial and mesenchymal cells from preterm and term placenta in primary culture. METHODS: Amnion epithelial and mesenchymal cells from 15 preterm (23-36 week) and 27 term placentas collected at cesarean section were separated enzymatically, characterized immunohistochemically (anti-cytokeratin 18 and anti-E-cadherin, and anti-vimentin, respectively), and their ratio determined. Proliferation on tissue culture polystyrene (TCPS) or collagen in one medium and on TCPS in four different media after 14 days was measured photometrically and compared in preterm vs. term placenta. For statistical analysis the Mann-Whitney test was used. RESULTS: Preterm and term epithelial:mesenchymal cell ratios were 4.3:1 and 7.8:1. Term epithelial cells proliferated similarly on TCPS or collagen. Mesenchymal cells proliferated only with fetal bovine serum (FBS). Proliferation of term amnion cells in medium containing FBS, epithelial growth factor (EGF), insulin, transferrin and triidothyronine(T3) was significantly increased (p < 0.001) compared with the other three media, and percentage proliferation was slightly higher in preterm cells. CONCLUSION: Characterization of human amnion epithelial and mesenchymal cells identified the most potent proliferation-inducing medium yet. Studies of the wound-healing potential of these cells are needed, examining their behavior and proliferation on fibrin microbeads and other extracellular matrixes as the next step towards engineering membrane repair in PROM.

Renal tubular epithelial expression of the costimulatory molecule B7RP-1 (inducible costimulator ligand).

MHC class II-expressing renal tubular epithelial cells (TEC) are able to present foreign peptide antigens to T cells. The costimulatory signals that are required for effective T cell activation upon antigen presentation by TEC have not been characterized. Various cultured TEC lines were examined for expression of the recently described costimulatory molecule B7RP-1 (B7h), a ligand of the T cell molecule inducible costimulator (ICOS), and expression was compared with that of B7.1, B7.2, and CD40. B7RP-1 and CD40 were abundantly expressed by cultured murine and human TEC, whereas B7.1 and B7.2 could not be detected. Stimulation with lipopolysaccharide or tumor necrosis factor-alpha did not induce B7.1 or B7.2 expression and did not alter B7RP-1 expression. Interestingly, interleukin-2 production by T cell hybridomas after antigen presentation by TEC was enhanced by blocking antibodies to B7RP-1 and ICOS. In contrast, blocking antibodies to B7RP-1 or ICOS exerted inhibitory effects on anti-CD3-activated murine splenocyte proliferation. Immunohistochemical staining of normal human kidneys demonstrated strong constitutive B7RP-1 expression in distal tubules, collecting ducts, and urothelium. In human kidneys with allograft rejection or interstitial nephritis, distinct B7RP-1 staining was also detected in proximal tubules, in areas of mononuclear infiltration. In conclusion, the B7RP-1/ICOS pathway negatively regulates T cell activation upon MHC class II-restricted antigen presentation by TEC. Because B7RP-1 is also expressed by tubules in vivo, it can be speculated that the B7RP-1/ICOS pathway could play an inhibitory role in TEC-mediated immune activation in the kidney.