Histological Characterization of Class I HLA Molecules in Whole Umbilical Cord Tissue Towards an Inexhaustible Graft Alternative for Reconstructive Surgery.

BACKGROUND: Limited graft availability is a constant clinical concern. Hence, the umbilical cord (UC) is an attractive alternative to autologous grafts. The UC is an inexhaustible tissue source, and its removal is harmless and part of standard of care after the birth of the baby. Minimal information exists regarding the immunological profile of a whole UC when it is considered to be used as a tissue graft. We aimed to characterize the localization and levels of class I human leukocyte antigens (HLAs) to understand the allogenicity of the UC. Additionally, HLA-E and HLA-G are putative immunosuppressive antigens that are abundant in placenta, but their profiles in UC whole tissue are unclear. HYPOTHESIS: The UC as a whole expresses a relatively low but ubiquitous level of HLA-ABC and significant levels of HLA-G and HLA-E. METHODS: Healthy patients with no known pregnancy-related complications were approached for informed consent. UCs at term and between 12 and 19 weeks were collected to compare HLA profiles by gestational age. Formalin-fixed paraffin-embedded tissues were sectioned to 5 µm and immunohistochemically stained with a pan-HLA-ABC, two HLA-G-specific, or an HLA-E-specific antibody. RESULTS: HLA-ABC was consistently found present in UCs. HLA-ABC was most concentrated in the UC vessel walls and amniotic epithelium but more dispersed in the Wharton's Jelly. HLA-E had a similar localization pattern to HLA-ABC in whole UC tissues at both gestational ages, but its protein level was lower. HLA-G localization and intensity were poor in all UC tissues analyzed, but additional analyses by Western immunoblot and mass spectrometry revealed a low level of HLA-G in the UC. CONCLUSION: The UC may address limitations of graft availability. Rather than the presence of HLA-G, the immunosuppressive properties of the UC are more likely due to the abundance of HLA-E and the interaction known to occur between HLA-E and HLA-ABC. The co-localization of HLA-E and HLA-ABC suggests that HLA-E is likely presenting HLA-ABC leader peptides to immune cells, which is known to have a primarily inhibitory effect.

The Course and Neonatal Outcome of Choroid Plexus Extension to the Anterior Horn at the Routine Anatomy Scan.

OBJECTIVES: Our objective was to examine the pregnancy course and immediate neonatal outcome of fetuses with an isolated extension of choroid plexus (CP) to the anterior horn during the second trimester. METHODS: We prospectively collected the cases referred to us between July 2012 and January 2021 with isolated finding of CP extension to the anterior horn. Relevant clinical and demographic information was recorded, and a full anatomy scan including a comprehensive neurosonogram was performed. In cases of confirmed isolated extension of CP to the anterior horns, women were offered further investigation including fetal MRI, and ultrasound follow up. RESULTS: We collected 29 eligible cases for analysis. The mean gestational age (GA ± SD) for diagnosis and referral was 19.24 ± 2.3 weeks. No other intracranial anomalies were detected in any of the cases, and the finding resolved at 25 ± 2.6 weeks. The average extension length and width to the anterior horn were 0.7 ± 0.3 cm, and 0.5 ± 0.1 cm, respectively. Eleven fetuses (38%) had choroid plexus cyst (CPC) in addition to the extension. Ten patients (35%) completed a fetal brain MRI, with no identified abnormalities. Gross neurological exam and Apgar score at birth were normal. CONCLUSION: Extension of CP to anterior horn with or without CPC at mid-trimester seems to have spontaneous resolution with likely a good prognosis and no further implications.

Amnioreduction with rescue cerclage at advanced cervical dilation or gestational age.

OBJECTIVE: To determine the feasibility of rescue cerclage and amnioreduction at advanced cervical dilation or gestational age. METHODS: We present a retrospective case series of women who underwent rescue cerclage at either an advanced gestational age (24 + 0 to 24 + 6 weeks) or cervical dilation (≥4 cm), with a subset undergoing amnioreduction prior to cerclage placement. RESULTS: Nine women were included and amnioreduction was performed in 7 (78%). A bi-modal distribution of obstetric outcomes was observed, with 5 (56%) women delivering ≥34 weeks gestation, 3 (33%) of which delivered at term. Two (22%) women experienced intra-operative rupture of membranes and subsequent perinatal deaths. Two (22%) women delivered extremely premature, with one resulting in infant death. DISCUSSION: Our data show that rescue cerclage with amnioreduction may be successful at advanced gestational ages or cervical dilations, suggesting that these women should be included in prospective studies to better establish the efficacy and safety of this procedure.

Impact of Th-17 Cytokines on the Regulation of Transporters in Human Placental Explants.

Activated T helper 17 (Th-17) cytokines play a role in the pathophysiology of autoimmune and infectious diseases. While these diseases affect many women of childbearing age, little is known about the effect of these cytokines on placental transporters. As several pro-inflammatory cytokines impact the expression of ABC and SLC placental transporters, we hypothesized that these transporters may be similarly altered by elevated levels of circulating Th-17 cytokines. Cultured term human villous explants were treated with IL-17A, IL-22, or IL-23, alone or in combination. Samples were analyzed using qRT-PCR and Western blotting. The mRNA expression of OATP2B1 was significantly downregulated in explants by all individual cytokines and combination treatments, while decreased protein expression was seen with IL-23 and combination (p < 0.01). Combination treatment decreased the mRNA expression of BCRP and OAT4 but increased that of OCT3 (p < 0.01). Decreased accumulation of the OATP substrate, cascade blue, was seen in IL-23-treated choriocarcinoma JAr cells (p < 0.01). Elevated Th-17 cytokines, which are seen in infectious and autoimmune diseases, affect the expression and activity of OATP2B1, as well as mRNA expression of placental BCRP, OAT4, and OCT3. This dysregulation could impact the fetal exposure to endogenous and exogenous substrates.

Tumor necrosis factor alpha expression is increased in maternal microvascular endothelial cells in preeclampsia.

Objective: The aim of this study was to explore the expression and effects of tumor necrosis factor alpha (TNFα) in maternal endothelial cells in preeclampsia (PE).Methods: Expression levels in primary microvascular endothelial cells (MVEC) isolated from patients with severe preeclampsia (PE) and normal pregnancies were determined by RT-qPCR with or without treatment of TNFα and inhibitors for downstream signaling.Results: PE MVEC exhibited increased basal TNFα expression. TNFα treatment increased TNFα, VCAM, and endocan expression in MVEC.Conclusion: TNFα expression is increased in PE MVEC and the treatment of these cells with exogenous TNFα modifies their gene expression.

Ceramide-Induced Lysosomal Biogenesis and Exocytosis in Early-Onset Preeclampsia Promotes Exosomal Release of SMPD1 Causing Endothelial Dysfunction.

Aberrant ceramide build-up in preeclampsia, a serious disorder of pregnancy, causes exuberant autophagy-mediated trophoblast cell death. The significance of ceramide accumulation for lysosomal biogenesis in preeclampsia is unknown. Here we report that lysosome formation is markedly increased in trophoblast cells of early-onset preeclamptic placentae, in particular in syncytiotrophoblasts. This is accompanied by augmented levels of transcription factor EB (TFEB). In vitro and in vivo experiments demonstrate that ceramide increases TFEB expression and nuclear translocation and induces lysosomal formation and exocytosis. Further, we show that TFEB directly regulates the expression of lysosomal sphingomyelin phosphodiesterase (L-SMPD1) that degrades sphingomyelin to ceramide. In early-onset preeclampsia, ceramide-induced lysosomal exocytosis carries L-SMPD1 to the apical membrane of the syncytial epithelium, resulting in ceramide accumulation in lipid rafts and release of active L-SMPD1 via ceramide-enriched exosomes into the maternal circulation. The SMPD1-containing exosomes promote endothelial activation and impair endothelial tubule formation in vitro. Both exosome-induced processes are attenuated by SMPD1 inhibitors. These findings suggest that ceramide-induced lysosomal biogenesis and exocytosis in preeclamptic placentae contributes to maternal endothelial dysfunction, characteristic of this pathology.

Committee Opinion No. 418: The Complete 11-14 Week Prenatal Sonographic Examination.

OBJECTIVE: Sonography during the first trimester provides an opportunity to assess a pregnancy in its early stage. This document provides an opinion about the implementation and content of prenatal sonographic examinations at 11-14 weeks gestation in Canada. TARGET POPULATION: Pregnant women at 11-14 weeks gestation. BENEFITS, HARMS, AND COSTS: The 11-14 week prenatal sonographic examination can provide important information that may contribute to pregnancy management. It can be used to confirm viability, establish gestational age, determine the number of fetuses, assess the adnexa/ovaries, and, in a multiple pregnancy, assess chorionicity and amnionicity. Scanning also offers an opportunity to detect fetal abnormalities and perform aneuploidy screening by measuring the nuchal translucency thickness. It may be valuable in screening for preeclampsia and other obstetrical disorders (by combining uterine artery Doppler scanning with other bio-clinical markers) and for invasive placentation. There are no physical harms to mother or fetus from offering a routine 11-14 week prenatal sonographic examination, and there are no extra costs for patients. EVIDENCE: Articles related to routine 11-14 week prenatal sonography were identified in a search of EMBASE and MEDLINE using the search terms first trimester ultrasound, nuchal translucency, and 11-14 week ultrasound. The search included all articles published on the topic until May 2019. Abstracts were reviewed by one author, and articles deemed relevant were then reviewed in full to determine whether to include them in the study. Articles that were not in English and articles that did not pertain to 11-14 week prenatal sonography were excluded. INTENDED AUDIENCE: This document is intended for sonographers, midwives, family physicians, obstetricians, and maternal-fetal medicine specialists.

Guideline No. 401: Sonographic Cervical Length in Singleton Pregnancies: Techniques and Clinical Applications.

OBJECTIVES: • To assess the association between sonography-derived cervical length measurement and preterm birth. • To describe the various techniques to measure cervical length using sonography. • To review the natural history of the short cervix. • To review the clinical uses, predictive ability, and utility of sonography-measured short cervix. OUTCOMES: Reduction in rates of prematurity and/or better identification of those at risk, as well as possible prevention of unnecessary interventions. INTENDED USERS: Clinicians involved in the obstetrical management or cervical imaging of patients at increased risk of a short cervix. TARGET POPULATION: Women at increased risk of a short cervix or at risk of preterm birth. EVIDENCE: Literature published up to June 2019 was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary and key words (preterm labour, ultrasound, cervix, cervical insufficiency, transvaginal, transperineal, cervical length, fibronectin). Results were restricted to general and systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date or language restrictions. Grey (unpublished) literature was identified through searching the websites of health technology assessment agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The evidence and this guideline were reviewed by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada, and the recommendations were made and graded according to the rankings of the Canadian Task Force on Preventive Health Care (Online Appendix Table A1). BENEFITS, HARMS, COSTS: Preterm birth is a leading cause of perinatal morbidity and mortality. Use of the sonographic technique reviewed in this guideline may help identify women at risk of preterm birth and, in some circumstances, lead to interventions that may reduce the rate of preterm birth. SUMMARY STATEMENTS (CANADIAN TASK FORCE ON PREVENTIVE HEALTH CARE GRADING IN PARENTHESES): RECOMMENDATIONS (CANADIAN TASK FORCE ON PREVENTIVE HEALTH CARE GRADING IN PARENTHESES).

Differences in fetal growth patterns between twins and singletons.

Objective: Twin fetus growth is delayed during the third trimester compared to singletons. Whether this phenomenon should be considered a normal physiologic characteristic of twins or a pathologic process inherent to twin pregnancies is currently unclear. Information on the growth rate of the individual fetal biometric indices may provide more insight into the mechanisms underlying these differences between twins and singletons. Our aim was to compare fetal growth pattern between twin and singleton fetuses.Methods: This was a retrospective study of women with an uncomplicated twin pregnancy who underwent sonographic fetal weight estimation between 16 and 38 weeks' gestation in a single referral center. Twins-specific regression models were generated for biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL) and fetal weight as a function of gestational age and were compared to published singletons-based curves.Results: Overall 543 women were eligible for the study and underwent a total of 3401 sonographic weight estimations. Estimated weight of twin fetus emerged as lower than that of singletons starting at 26 weeks of gestation, and these differences increased with gestational age, reaching a mean difference of 300-350 g or of ∼10% at term. The growth of all four biometric indices was slower in twins compared to singletons, but the differences were most pronounced for AC which had the largest relative contribution to the lower fetal weight in twins (51.7 ± 7.3%), while the relative contribution of FL, HC, and BPD was smaller (26.4 ± 10.7, 15.5 ± 3.0, and 6.4%±5.7%, respectively). This was also reflected by a higher HC/AC ratio in twins compared with singletons starting at 22 weeks of gestation. The likelihood of a twin fetus being diagnosed as small for gestational age (fetal weight <10th percentile) was significantly lower when the newly developed twins-based curves (rather than singletons-based curves) were used (OR: 0.39, 95%-CI: 0.34-0.44).Conclusion: Twin fetus experience slowing of growth beginning at ∼26 weeks of gestation and a greater degree of asymmetric growth pattern compared with singletons. These findings suggest that the slower growth of twins may reflect a state of "relative growth restriction" compared with singleton gestations.

Preterm Premature Rupture of Membranes in Twins: Comparison of Rupture in the Presenting Versus Non-presenting Sac.

OBJECTIVE: This study sought to compare the latency from membrane rupture to delivery and subsequent neonatal outcomes in twin gestations complicated by preterm premature rupture of membranes (PPROM) of the presenting versus non-presenting sac. METHODS: This was a retrospective study of twin pregnancies over a 7-year period diagnosed with PPROM between 12 and 37 weeks gestation with a latency period to delivery of >24 hours. The ruptured sac was identified by ultrasound scan. The study compared the latency period from PPROM to delivery and subsequent neonatal morbidity and mortality resulting from rupture of the presenting versus non-presenting sac. Obstetric and neonatal outcomes were evaluated using a matched-cohort subset analysis (Canadian Task Force Classification II-2). RESULTS: During the study period, 77 twin pregnancies diagnosed with PPROM satisfied the inclusion criteria. The mean latency periods from PPROM to delivery were 10.1 days (n = 7) when the presenting sac ruptured and 41.3 days (n = 10) when the non-presenting sac ruptured (P < 0.05). Neonatal death was higher with PPROM of the presenting than the non-presenting sac (21.4% vs. 0%, respectively; P = 0.05). Neonates were more likely to be affected by retinopathy of prematurity (57% vs. 19%; P < 0.05) but less likely to have persistent pulmonary hypertension of the newborn (0% vs. 25%; P < 0.05) when the rupture occurred in the presenting sac. The rates of other neonatal adverse outcomes were similar between the two groups. CONCLUSIONS: In twin gestations there is a longer latency from PPROM to delivery and fewer neonatal complications when rupture occurs in the non-presenting rather than the presenting sac.

No 374 - Évaluation systématique de la longueur cervicale.

OBJECTIF: Passer en revue les données probantes et fournir une opinion indiquant si l'évaluation systématique de la longueur cervicale pour la prévention de l'accouchement prématuré devrait être adoptée au Canada. RéSULTATS: Les issues évaluées comprennent la prévention de l'accouchement prématuré. DONNéES PROBANTES: Nous avons interrogé les bases de données Knowledge Finder, Medline et Cochrane pour en tirer les articles publiés jusqu'en avril 2018 sur la mesure de la longueur cervicale pour la prévention de l'accouchement prématuré. CRITèRES: Les données obtenues ont été examinées et évaluées par le Comité d'imagerie diagnostique de la SOGC sous la direction des auteurs principaux, et les recommandations ont été formulées selon les lignes directrices rédigées par le Groupe d'étude canadien sur les soins de santé préventifs. AVANTAGES, DéSAVANTAGES, ET COûTS: La prévention de l'accouchement prématuré sans coûts excessifs est très importante pour la santé des mères et des familles. La présente opinion de comité résume les données probantes actuelles sur l'évaluation systématique de la longueur cervicale pour prévenir l'accouchement prématuré au Canada, détermine si elle satisfait les critères de Jungner et Wilson pour un test de dépistage et formule des recommandations pour son utilisation au Canada. VALIDATION: La présente opinion a été révisée et approuvée par le comité d'imagerie diagnostique de la SOGC et la Société des obstétriciens et gynécologues du Canada (SOGC). COMMANDITAIRE: La Société des obstétriciens et gynécologues du Canada (SOGC).

No 375 - Directive clinique sur l'utilisation de l'échographie au premier trimestre.

OBJECTIF: Révision des indications cliniques de l'échographie du premier trimestre. RéSULTATS: L'échographie au premier trimestre offre des avantages cliniques démontrés. DONNéES PROBANTES: Les données probantes ont été révisées au moyen de recherche dans Medline et selon la bibliographie des articles pertinents. VALEURS: Le contenu et les recommandations ont été évalués par les auteurs principaux et le Comité d'imagerie diagnostique de la Société des obstétriciens et gynécologues du Canada. Le niveau d'évidence a été défini en fonction des critères du Groupe d'étude canadien sur les soins de santé préventifs. RECOMMANDATIONS.

No. 374-Universal Cervical Length Screening.

OBJECTIVE: To review the evidence and provide an opinion as to whether universal cervical length screening to prevent preterm birth should be adopted across Canada. OUTCOMES: Outcomes evaluated include prevention of preterm birth. EVIDENCE: Literature searches using Knowledge Finder, Medline and Cochrane databases were searched for articles published up to April 2018 on cervical length screening for prevention of preterm birth. VALUES: The evidence obtained was reviewed and evaluated by the Diagnostic Imaging Committee of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS: The prevention of preterm birth in a cost-effective manner is of significant importance to the health of mothers and their families. This committee opinion will summarize the current evidence for universal cervical length screening to prevent preterm birth in Canada, determine whether it meets the Junger and Wilson criteria for screening tests, and make recommendations as to its use in Canada. VALIDATION: These guidelines have been reviewed and approved by the Diagnostic Imaging Committee of the SOGC and The Society of Obstetricians and Gynaecologists of Canada (SOGC). SPONSORS: The Society of Obstetricians and Gynaecologists of Canada (SOGC).

No. 375-Clinical Practice Guideline on the Use of First Trimester Ultrasound.

OBJECTIVE: This guideline reviews the clinical indications for first trimester ultrasound. OUTCOME: Proven clinical benefit has been reported from first trimester ultrasound. EVIDENCE: A Medline search and bibliography reviews in relevant literature provided the evidence. VALUES: Content and recommendations were reviewed by the principal authors and the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada. Levels of evidence were judged as outlined by the Canadian Task Force on Preventive Health Care.

The effect of magnesium sulfate on gene expression in maternal microvascular endothelial cells.

Preeclampsia is a severe complication of pregnancy associated with maternal and fetal morbidity and mortality. To date, magnesium sulfate remains the preferred method of treatment used to reduce the development of eclampsia. Our aim was to investigate the effects of magnesium sulfate on the expression of genes involved with endothelial function in maternal microvascular endothelial cells from both normal and preeclamptic pregnancies. Primary cells from normal pregnancies treated with 80 mg/L magnesium sulfate for 6 h revealed an overall trend of increased expression of angiogenic and vasopressor-related factors by qPCR analyses. Primary cells from preeclamptic pregnancies revealed an overall trend of decreased expression, with significantly lowered levels for vascular endothelial growth factor receptor 2, endothelin, and vascular cell adhesion protein-1. A comparison of treated cells revealed significantly increased levels for endoglin, vascular endothelial growth factor receptor 2, soluble fms-like tyrosine kinase-1, prostacyclin synthase, tumor necrosis factor α, tumor necrosis factor receptor 1, and endothelin in normal versus preeclamptic cells following treatment. These results reveal disparate activation of overall expression activity by magnesium sulfate in maternal endothelial cells from normal pregnancies over preeclamptic pregnancies.

No. 352-Technical Update: The Role of Early Comprehensive Fetal Anatomy Ultrasound Examination.

OBJECTIVE: This guideline presents an evidence-based technical update and recommendations for the performance of early comprehensive fetal anatomic scanning (ECFAS) at 11 to 16 weeks' gestation. OPTIONS: Patients at high risk for fetal anomalies and in whom traditional mid-second trimester transabdominal imaging may be challenging or who may benefit from earlier identification of fetal anomalies may be suitable for early fetal anatomy scanning. OUTCOMES: This practice may result in earlier identification of fetal anomalies and provide earlier intervention options in high-risk populations and/or in populations where mid-second trimester transabdominal scanning is challenging. TARGET POPULATION: This population consists of obstetrical patients in whom mid-second trimester ultrasound scanning will be technically challenging and patients who are at higher risk for major fetal anomalies. EVIDENCE: Published literature was retrieved through searches of PubMed and Medline in 2016 using key words. Results were restricted to controlled clinical trials, reviews, and observational studies published in English. There were no date restrictions, and searches were updated in the guideline to 2016. Grey (unpublished) literature was identified through searching the websites of health technology assessment and clinical practice guidelines and national and international medical specialty societies. No relevant studies were found. VALIDATION METHODS: The content and recommendations were drafted and agreed on by the principal authors. The Board of the SOGC approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework. BENEFITS, HARMS, AND/OR COSTS: It is anticipated that there will be an increase in earlier detection of major fetal anomalies in the target population with the benefits of earlier interventions for those individuals. In areas where the service is not available the patient may need to travel to a nearby centre. Early fetal anatomy scanning is considered to be safe and is not expected to cause a risk to the pregnancy. GUIDELINE UPDATE: Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published before the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations. SPONSORS: This technical update was developed with resources funded by the SOGC. SUMMARY STATEMENTS: RECOMMENDATIONS.