A Sustainable Translational Sheep Model for Planned Cesarean Delivery of Contraction-Free Ewes.

We evaluated whether the sheep constitutes a useful translational model to evaluate anatomical and surgical aspects of cesarean delivery (CD) from a human medical perspective with the aim of both maternal and neonatal well-being. Our hypothesis was that CD in contraction-free ewes is not associated with major complications. Primary endpoint was the transferability of anatomical conditions and surgical techniques of CD from the ewe to the human. Secondary endpoints were maternal and fetal survival, occurrence of retained fetal membranes, metritis, mastitis, or wound infections. Forty-eight Merino ewes were delivered by CD after 95% gestation (142-144 days). Both ewes and newborn lambs were cared for intensively after the delivery. Ovine uterine anatomy during CD appeared slightly different but comparable to the human uterus. Uterine incisions were mostly performed in the uterine horns, not in the uterine corpus. The ovine uterine wall is thinner than in humans. All ewes survived without any major complications. Seventy-seven (88.5%) out of 87 live-born lambs survived without any complications. The contraction-free ewe constitutes an appropriate and safe model to evaluate anatomical and surgical aspects of CD from a human medical perspective. We present a step-by-step manual for successfully planned cesarean delivery for sheep including the perioperative management illustrated with photographs and a five-minute video. With adequate planning and a reasonable number of staff, it is possible to safeguard both maternal and neonatal survival. This sustainable translational medicine model offers additional potential for the offspring to be used for further research studies (e.g., transgenerational inheritance research).

Uterine scars after caesarean delivery: From histology to the molecular and ultrastructural level.

Uterine rupture during a trial of labor after caesarean delivery (CD) is a serious complication for mother and fetus. The lack of knowledge on histological features and molecular pathways of uterine wound healing has hindered research in this area from evolving over time. We analysed collagen content and turnover in uterine scars on a histological, molecular and ultrastructural level. Therefore, tissue samples from the lower uterine segment were obtained during CD from 16 pregnant women with at least one previous CD, from 16 pregnant women without previous CD, and from 16 non-pregnant premenopausal women after hysterectomy for a benign disease. Histomorphometrical collagen quantification showed, that the collagen content of the scar area in uterine wall specimens after previous CD was significantly higher than in the unscarred myometrium of the same women and the control groups. Quantitative real-time PCR of uterine scar tissue from FFPE samples delineated by laser microdissection yielded a significantly higher COL3A1 expression and a significantly lower COL1A2/COL3A1 ratio in scarred uteri than in samples from unscarred uteri. Histological collagen content and the expression of COL1A2 and COL3A1 were positively correlated, while COL1A2/COL3A1 ratio was negatively correlated with the histological collagen content. Transmission electron microscopy revealed a destroyed myometrial ultrastructure in uterine scars with increased collagen density. We conclude that the high collagen content in uterine scars results from an ongoing overexpression of collagen I and III. This is a proof of concept to enable further analyses of specific factors that mediate uterine wound healing.

Alterations of materno-placento-fetal glucose homeostasis after a single course of antenatal betamethasone.

INTRODUCTION: Intrauterine growth impairment is associated with long-term metabolic changes (perinatal programming). We recently demonstrated that antenatal betamethasone (BET) decreased head circumference in term born females. Since glucose is the main energy source for fetal growth, BET-induced changes in maternal glucose homeostasis, a reduced transplacental glucose transfer or an altered fetal glucose utilization may be linked with the observed growth impairment. METHODS: 86 pregnant women exposed to BET (single course, <34 + 0 weeks of gestation (wks)) were compared to 92 gestational-age/sex-matched controls. Glucose, insulin, leptin, insulin-like growth factors (IGF-1, IGF-2) and their binding proteins (IGFBP-1, IGFBP-3) were measured in maternal and umbilical cord blood samples. Homeostasis Model Assessment (HOMA-IR) was calculated. Placental glucose transporter 1 and 3 (GLUT1, GLUT3) protein levels were determined. Statistics were performed for overall and subgroup analysis (gestational age, sex). RESULTS: After BET maternal HOMA-IR was elevated, IGFBP-1 reduced. In female pregnancies, glucose levels ≥37 + 0 wks and IGF-1 levels <37 + 0 wks were tendentially increased. Placental GLUT1 and GLUT3 protein levels were not significantly altered. Fetal umbilical venous glucose levels ≥37 + 0 wks were increased. HOMA-IR tended to be elevated in females. DISCUSSION: Growth impairment after BET appears neither caused by maternal nor fetal hypoglycemia nor changes of GLUT1 and GLUT3 total protein levels. Nonetheless, glucose homeostasis of mothers and daughters was altered even beyond the BET time frame (hyperglycemia, enhanced insulin resistance). Despite glucose supply was sufficient, an anabolic effect was apparently absent. Overall, our results highlight the relevance of adequate glucose management after BET and peripartum.

Intraoperative ultrasound during repeat cesarean delivery facilitates sampling of uterine scar tissue.

OBJECTIVES: Histological examination of uterine scars provides insight into uterine wound healing and helps to develop prevention methods of uterine wall rupture after previous uterine surgery. Therefore, exact intraoperative scar identification is needed for specimen collection from the actual scar tissue. The aim of this study was to correlate pre- and intraoperative ultrasound measurements of the lower uterine segment (LUS) with histological findings of scar tissue and to evaluate the relevance of intraoperative ultrasound. METHODS: In a prospective observational study, preoperative and intraoperative sonographic measurements of the LUS thickness were performed in 33 women with a history of at least one cesarean delivery. Intraoperative ultrasound with a linear transducer placed directly on the uterus identified the scar area and uterotomy was performed 2 cm cranially. Tissue samples were taken after extraction of the fetus, embedded in paraffin wax, and stained according to Gomori Trichrome to identify scar tissue. Collagen content was evaluated with imaging software Fiji (NIH, Bethesda, USA). Preoperative and intraoperative sonographic measurements were correlated with histologic evidence of scar tissue. RESULTS: Histological evidence of scar tissue was found in 11 out of 33 samples with significantly lower ultrasonographic thickness of the lower uterine segment compared to the other 22 samples, both antepartum (1.4 mm [1.3-1.9] vs. 2.0 mm [1.6-2.6], p=0.03) and intrapartum (1.6 mm [1.3-1.9] vs. 3.7 mm [2.0-4.7], p<0.01). Intraoperative ultrasound had a significantly higher predictive power (AUC difference 0.18 [0.03-0.33], p=0.01). CONCLUSIONS: Intraoperative sonography identifies the uterine wall area with histologically confirmable scar tissue far better than preoperative sonography.

Optimized RNA isolation of FFPE uterine scar tissues for RNA expression analyses delineated by laser microdissection.

Samples for histological analyses are often formalin-fixed paraffin-embedded (FFPE) and slide-mounted, which complicates RNA extraction for many downstream molecular applications. Furthermore, when the region of interest is extremely small due to isolation with laser microdissection (LMD), extracting RNA of adequate quality and quantity is difficult. We describe an optimized protocol for maximizing RNA output from FFPE tissue devised to identify and analyze gene expression of human maternal uterine scar tissue obtained from uterotomy scars resulting from prior cesarean deliveries. Gomori trichrome staining allowed for region identification for LMD. Successful RNA isolation, reverse transcription and, importantly, quantitative real-time PCR (qRT-PCR) were performed. This report provides an optimized step-by-step protocol yielding sufficient RNA for qRT-PCR analyses from challenging tissue/LMD-FFPE samples.

Placenta Percreta Presents with Neoangiogenesis of Arteries with Von Willebrand Factor-Negative Endothelium.

In placenta percreta cases, large vessels are present on the precrete surface area. As these vessels are not found in normal placentation, we examined their histological structure for features that might explain the pathogenesis of neoangiogenesis induced by placenta accreta spectrum disorders (PAS). In two patients with placenta percreta (FIGO grade 3a) of the anterior uterine wall, one strikingly large vessel of 2 cm length was excised. The samples were formalin fixed and paraffin-embedded. Gomori trichrome staining was used to evaluate the muscular layers and Weigert-Van Gieson staining for elastic fibers. Immunohistochemical staining of the vessel endothelium was performed for Von Willebrand factor (VWF), platelet endothelial cell adhesion molecule (CD31), Ephrin B2, and EPH receptor B4. The structure of the vessel walls appeared artery-like. The vessel of patient one further exhibited an unorderly muscular layer and a lack of elastic laminae, whereas these features appeared normal in the vessel of the other patient. The endothelium of both vessels stained VWF-negative and CD31-positive. In conclusion, this study showed VWF-negative vessel endothelia of epiplacental arteries in placenta accreta spectrum. VWF is known to regulate artery formation, as the absence of VWF has been shown to cause enhanced vascularization. Therefore, we suppose that PAS provokes increased vascularization through suppression of VWF. This process might be associated with the immature vessel architecture as found in one of the vessels and Ephrin B2 and EPH receptor B4 negativity of both artery-like vessels. The underlying pathomechanism needs to be evaluated in a greater set of patients.

Detection of Microplastic in Human Placenta and Meconium in a Clinical Setting.

Environmental pollution with microplastics (MPs) is a major and worldwide concern. Involuntary exposure to MPs by ingestion or inhalation is unavoidable. The effects on human health are still under debate, while in animals, cellular MP translocation and subsequent deleterious effects were shown. First reports indicate a potential intrauterine exposure with MPs, yet readouts are prone to contamination. METHOD: To establish a thorough protocol for the detection of MPs in human placenta and fetal meconium in a real-life clinical setting, a pilot study was set up to screen for MPs > 50 µm in placental tissue and meconium sampled during two cesarean sections for breech deliveries. After chemical digestion of non-plastic material, Fourier-transform infrared (FTIR) microspectroscopy was used to analyze the presence of 10 common types of microplastic in placenta and stool samples. RESULTS: Human placenta and meconium samples were screened positive for polyethylene, polypropylene, polystyrene, and polyurethane, of which only the latter one was also detected as airborne fallout in the operating room-thus representing potential contamination. CONCLUSION: We found MPs > 50 µm in placenta and meconium acquired from cesarean delivery. Critical evaluation of potential contamination sources is pivotal and may guide future clinical studies to improve the correct detection of MPs in organ tissue. Studies investigating nano-sized plastics in human tissue are warranted.

Maternal Serum VEGF Predicts Abnormally Invasive Placenta Better than NT-proBNP: a Multicenter Case-Control Study.

The aim of this study was to test if maternal serum vascular endothelial growth factor (VEGF) or N-terminal pro B-type natriuretic peptide (NT-proBNP) predicts abnormally invasive placenta (AIP) better. Secondary objective was to test whether the serum levels of VEGF and NT-proBNP can predict the degree of invasion. In a multicenter case-control study design, gestational age-matched serum samples from pregnant women with AIP (n = 44) and uncomplicated pregnancies (n = 55) who had been enrolled at Charité - Universitätsmedizin Berlin, Germany and Centre Hospitalier Régional de la Citadelle in Liège, Belgium were analyzed. Maternal blood serum VEGF and NT-proBNP levels were immunoassayed from samples taken immediately before delivery (GA median: 35 weeks). Biomarker levels were compared between AIP and control group. The correlation of biomarker levels with the clinical AIP degree was assessed. The predictive biomarker ability was characterized through a multivariate regression model and receiver operating characteristic curves. Women with AIP had significantly lower maternal serum VEGF levels (AIP mean 285 pg/ml, 95% CI 248-322, vs. control: 391 pg/ml, 95% CI 356-426, p < 0.01) and higher NT-proBNP levels (AIP median 329 pg/ml, IQR 287-385, vs. control 295 pg/ml, IQR 273-356, p = 0.03). Maternal serum VEGF levels were able to predict AIP better (AUC = 0.729, 0.622-0.836, p < 0.001; VEGF + number of previous cesarean deliveries: AUC = 0.915, 0.853-0.977, p < 0.001). Maternal serum VEGF levels correlated inversely with the clinical AIP degree (r = - 0.32, p < 0.01). In short, maternal serum VEGF, more than NT-proBNP, can help in predicting AIP and hints at the degree of invasion.

The dilution effect and the importance of selecting the right internal control genes for RT-qPCR: a paradigmatic approach in fetal sheep.

BACKGROUND: The key to understanding changes in gene expression levels using reverse transcription real-time quantitative polymerase chain reaction (RT-qPCR) relies on the ability to rationalize the technique using internal control genes (ICGs). However, the use of ICGs has become increasingly problematic given that any genes, including housekeeping genes, thought to be stable across different tissue types, ages and treatment protocols, can be regulated at transcriptomic level. Our interest in prenatal glucocorticoid (GC) effects on fetal growth has resulted in our investigation of suitable ICGs relevant in this model. The usefulness of RNA18S, ACTB, HPRT1, RPLP0, PPIA and TUBB as ICGs was analyzed according to effects of early dexamethasone (DEX) treatment, gender, and gestational age by two approaches: (1) the classical approach where raw (i.e., not normalized) RT-qPCR data of tested ICGs were statistically analyzed and the best ICG selected based on absence of any significant effect; (2) used of published algorithms. For the latter the geNorm Visual Basic application was mainly used, but data were also analyzed by Normfinder and Bestkeeper. In order to account for confounding effects on the geNorm analysis due to co-regulation among ICGs tested, network analysis was performed using Ingenuity Pathway Analysis software. The expression of RNA18S, the most abundant transcript, and correlation of ICGs with RNA18S, total RNA, and liver-specific genes were also performed to assess potential dilution effect of raw RT-qPCR data. The effect of the two approaches used to select the best ICG(s) was compared by normalization of NR3C1 (glucocorticoid receptor) mRNA expression, as an example for a target gene. RESULTS: Raw RT-qPCR data of all the tested ICGs was significantly reduced across gestation. TUBB was the only ICG that was affected by DEX treatment. Using approach (1) all tested ICGs would have been rejected because they would initially appear as not reliable for normalization. However, geNorm analysis (approach 2) of the ICGs indicated that the geometrical mean of PPIA, HPRT1, RNA18S and RPLPO can be considered a reliable approach for normalization of target genes in both control and DEX treated groups. Different subset of ICGs were tested for normalization of NR3C1 expression and, despite the overall pattern of the mean was not extremely different, the statistical analysis uncovered a significant influence of the use of different normalization approaches on the expression of the target gene. We observed a decrease of total RNA through gestation, a lower decrease in raw RT-qPCR data of the two rRNA measured compared to ICGs, and a positive correlation between raw RT-qPCR data of ICGs and total RNA. Based on the same amount of total RNA to performed RT-qPCR analysis, those data indicated that other mRNA might have had a large increase in expression and, as consequence, had artificially diluted the stably expressed genes, such as ICGs. This point was demonstrated by a significant negative correlation of raw RT-qPCR data between ICGs and liver-specific genes. CONCLUSION: The study confirmed the necessity of assessing multiple ICGs using algorithms in order to obtain a reliable normalization of RT-qPCR data. Our data indicated that the use of the geometrical mean of PPIA, HPRT1, RNA18S and RPLPO can provide a reliable normalization for the proposed study. Furthermore, the dilution effect observed support the unreliability of the classical approach to test ICGs. Finally, the observed change in the composition of RNA species through time reveals the limitation of the use of ICGs to normalize RT-qPCR data, especially if absolute quantification is required.

Early dexamethasone treatment induces placental apoptosis in sheep.

Glucocorticoid treatment given in late pregnancy in sheep resulted in altered placental development and function. An imbalance of placental survival and apoptotic factors resulting in an increased rate of apoptosis may be involved. We have now investigated the effects of dexamethasone (DEX) in early pregnancy on binucleate cells (BNCs), placental apoptosis, and fetal sex as a determinant of these responses. Pregnant ewes carrying singleton fetuses (n = 105) were randomized to control (n = 56, 2 mL saline/ewe) or DEX treatment (n = 49, intramuscular injections of 0.14 mg/kg ewe weight per 12 hours over 48 hours) at 40 to 41 days of gestation (dG). Placentomes were collected at 50, 100, 125, and 140 dG. At 100 dG, DEX in females reduced BNC numbers, placental antiapoptotic (proliferating cell nuclear antigen), and increased proapoptotic factors (Bax, p53), associated with a temporarily decrease in fetal growth. At 125 dG, BNC numbers and apoptotic markers were restored to normal. In males, ovine placental lactogen-protein levels after DEX were increased at 50 dG, but at 100 and 140 dG significantly decreased compared to controls. In contrast to females, these changes were independent of altered BNC numbers or apoptotic markers. Early DEX was associated with sex-specific, transient alterations in BNC numbers, which may contribute to changes in placental and fetal development. Furthermore, in females, altered placental apoptosis markers may be involved.