Fetal Sexual Dimorphism and Preeclampsia Among Twin Pregnancies.

BACKGROUND: In singleton pregnancies, fetal sexual dimorphism has been observed in hypertensive disorders of pregnancy, particularly preeclampsia, a morbid syndrome that increases the risk of adult-onset cardiovascular disease for mothers and their offspring. However, few studies have explored the effect of fetal sex on hypertensive disorders of pregnancy among twin pregnancies. METHODS: We conducted a retrospective cohort study of 1032 twin pregnancies between 2011 and 2022 using data from a perinatal database that recruits participants from 3 hospitals in Houston, TX. We categorized pregnancies based on fetal sex pairings into female/female, male/male, and female/male. Pregnancies with female/female pairs were used as our reference group. Our primary outcomes included gestational hypertension, preeclampsia, superimposed preeclampsia, and preeclampsia subtyped by gestational age of delivery. A modified Poisson regression model with robust error variance was used to calculate the relative risk and 95% CI for the association between fetal sex pairs and hypertensive disorders of pregnancy. RESULTS: Adjusted models of female/male pairs were associated with preterm preeclampsia (relative risk, 2.01 [95% CI, 1.15-3.53]) relative to those with female/female pairs. No associations with other hypertensive disorders of pregnancy were observed among pregnancies with male/male pairs compared with those with female/female fetal sex pairs. CONCLUSIONS: We found some evidence of sexual dimorphism for preterm preeclampsia among female/male twin pairs. Additional research is needed to understand what biological mechanisms could explain these findings.

Validation of vaginal microbiome proxies for in vitro experiments that biomimic Lactobacillus-dominant vaginal cultures.

The vaginal microbiome includes diverse microbiota dominated by Lactobacillus [L.] spp. that protect against infections, modulate inflammation, and regulate vaginal homeostasis. Because it is challenging to incorporate vaginal microbiota into in vitro models, including organ-on-a-chip systems, we assessed microbial metabolites as reliable proxies in addition to traditional vaginal epithelial cultures (VECs). Human immortalized VECs cultured on transwells with an air-liquid interface generated stratified cell layers colonized by transplanted healthy microbiomes (L. jensenii- or L. crispatus-dominant) or a community representing bacterial vaginosis (BV). After 48-h, a qPCR array confirmed the expected donor community profiles. Pooled apical and basal supernatants were subjected to metabolomic analysis (untargeted mass spectrometry) followed by ingenuity pathways analysis (IPA). To determine the bacterial metabolites' ability to recreate the vaginal microenvironment in vitro, pooled bacteria-free metabolites were added to traditional VEC cultures. Cell morphology, viability, and cytokine production were assessed. IPA analysis of metabolites from colonized samples contained fatty acids, nucleic acids, and sugar acids that were associated with signaling networks that contribute to secondary metabolism, anti-fungal, and anti-inflammatory functions indicative of a healthy vaginal microbiome compared to sterile VEC transwell metabolites. Pooled metabolites did not affect cell morphology or induce cell death (∼5.5%) of VEC cultures (n = 3) after 72-h. However, metabolites created an anti-inflammatory milieu by increasing IL-10 production (p = .06, T-test) and significantly suppressing pro-inflammatory IL-6 (p = .0001), IL-8 (p = .009), and TNFα (p = .0007) compared to naïve VEC cultures. BV VEC conditioned-medium did not affect cell morphology nor viability; however, it induced a pro-inflammatory environment by elevating levels of IL-6 (p = .023), IL-8 (p = .031), and TNFα (p = .021) when compared to L.-dominate microbiome-conditioned medium. VEC transwells provide a suitable ex vivo system to support the production of bacterial metabolites consistent with the vaginal milieu allowing subsequent in vitro studies with enhanced accuracy and utility.

Measures of Racism and Discrimination in Preterm Birth Studies.

OBJECTIVE: Preterm birth (any birth at less than 37 weeks of gestation) disproportionally affects Black birthing people and is associated with adverse perinatal and fetal health outcomes. Racism increases the risk of preterm birth, but standardized measurement metrics are elusive. This narrative synthesis examines literature on measures of racial discrimination used in preterm birth research. DATA SOURCES: Six databases (CINAHL, Cochrane, EMBASE, PubMed [MEDLINE], Scopus, Web of Science) and ClinicalTrials.gov were searched. Search terms were categorized into three groups (racism terms, measurement terms, preterm birth terms) to identify original research articles that explored associations between racism and preterm birth. English-language, original research articles with U.S. populations were included. METHODS OF STUDY SELECTION: Studies were excluded if conducted in only White populations, if only paternal factors were included, or if only racial differences in preterm birth were described. Articles were independently reviewed by two blinded researchers for inclusion at every stage of screening and data extraction; a third reviewer resolved discrepancies. TABULATION, INTEGRATION, AND RESULTS: Sixty studies were included in the final analysis. Articles primarily included measures examining interpersonal forms of racism (n=17) through the Experiences of Discrimination and Everyday Discrimination scales, neighborhood composition (n=22) with the Neighborhood Deprivation Index and the Index of Concentration at the Extremes, policy-level racism (n=12) through institutions such as residential racial segregation or policy inequities, or multiple forms (n=9). CONCLUSION: Among studies, assessment methods and application of constructs varied. This heterogeneity poses significant challenges to understanding associations between racial discrimination and preterm birth and to describing potential etiologic pathways of preterm birth, which ultimately hinders development of effective intervention. Strategies to capture multilevel exposures to racism require the development and expansion of metrics that are culturally inclusive, empirically valid, and reliable among Black pregnant populations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022327484.

Chlamydia trachomatis antigen induces TLR4-TAB1-mediated inflammation, but not cell death, in maternal decidua cells.

BACKGROUND: During gestation, the decidua is an essential layer of the maternal-fetal interface, providing immune support and maintaining inflammatory homeostasis. Although Chlamydia (C.) trachomatis is associated with adverse pregnancy outcomes the pathogenic effects on maternal decidua contributing to adverse events are not understood. This study examined how C. trachomatis antigen affects cell signaling, cell death, and inflammation in the decidua. METHODS: Primary decidua cells (pDECs) from term, not-in-labor, fetal membrane-decidua were cultured using the following conditions: (1) control - standard cell culture conditions, (2) 100 ng/ml or (3) 200 ng/ml of C. trachomatis antigen to model decidual cell infection in vitro. Differential expression of Toll-like receptor (TLR) 4 (receptor for C. trachomatis antigen), signaling pathway markers phosphorylated TGF-Beta Activated Kinase 1 (PTAB1), TAB1, phosphorylated p38 mitogen-activated protein kinases (Pp38 MAPK), and p38 MAPK (western blot), decidual cell apoptosis and necrosis (flow cytometry), and inflammation (ELISA for cytokines) were determined in cells exposed to C. trachomatis antigen. T-test was used to assess statistical significance (p < 0.05). RESULTS: C. trachomatis antigen significantly induced expression of TLR4 (p = 0.03) and activation of TAB1 (p = 0.02) compared to controls. However, it did not induce p38 MAPK activation. In addition, pDECs maintained their stromal cell morphology when exposed to C. trachomatis antigen showing no signs of apoptosis and/or necrosis but did induce pro-inflammatory cytokine interleukin (IL)-6 (100 ng/ml: p = 0.02 and 200 ng/ml: p = 0.03), in pDECs compared to controls. CONCLUSION: Prenatal C. trachomatis infection can produce antigens that induce TLR4-TAB1 signaling and IL-6 inflammation independent of Pp38 MAPK and apoptosis and necrosis. This suggests that C. trachomatis can imbalance decidual inflammatory homeostasis, potentially contributing to adverse events during pregnancy.

The Role of Maternal Preconception Adiposity in Human Offspring Sex and Sex Ratio.

We evaluated relationships between preconception adiposity and human offspring sex and sex ratio. Using data from a prospective preconception cohort nested within a randomized controlled trial based at 4 US clinical sites (2006-2012), we used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for male:female sex ratio, and log-identity regression to estimate risk differences (RDs) and 95% CIs for male and female livebirth according to preconception adiposity measures. Inverse-probability weights accounted for potential selection bias. Among 603 women attempting pregnancy, there were meaningful reductions in sex ratio for the highest category of each adiposity measure. The lowest sex ratios were observed for obesity (body mass index of ≥30, calculated as weight (kg)/height (m)2, OR = 0.48, 95% CI: 0.26, 0.88) relative to normal body mass index, and the top tertiles (tertile 3) of serum leptin (OR = 0.50, 95% CI: 0.32, 0.80) and skinfold measurements (OR = 0.50, 95% CI: 0.32, 0.79) relative to the lowest tertiles. Reductions were driven by 11-15 fewer male livebirths per 100 women (for obesity, RD = -15, 95% CI: -23, -6.7; for leptin tertile 3, RD = -11, 95% CI: -20, -3.2; and for skinfolds tertile 3, RD = -11, 95% CI: -19, -3.3). We found that relationships between preconception adiposity measures and reduced sex ratio were driven by a reduction in male births.

Adapting an organ-on-chip device to study the effect of fetal sex and maternal race/ethnicity on preterm birth related intraamniotic inflammation leading to fetal neuroinflammation.

PROBLEM: Fetal neuroinflammation has been linked to preterm birth-related intraamniotic infection and inflammation; However, the contribution of fetal sex and maternal race/ethnicity is unknown. To determine if fetal sex and maternal race/ethnicity influence neuroinflammation, an organ-on-chip (OOC) model were established under normal or pathologic conditions utilizing amniotic fluid. METHOD OF STUDY: OOC is composed of two-cell culture chambers connected by Type IV collagen-coated microchannels. Human fetal astroglia (SVGp12) and microglia (HMC3) were co-cultured at an 80:20 ratio in the inner chamber. The outer chamber contained amniotic fluid (AF) from male and female fetuses of White Hispanic (WH) and African-American (AA) pregnant women with or without lipopolysaccharide (LPS-100 ng/ml) and incubated for 48 h. Glial migration (brightfield microscopy), activation (Immunocytochemistry), and cytokine production (Luminex assays) were quantified and compared (N = 4 for each category of sex and race/ethnicity). RESULTS: In a pooled analysis, AF+LPS did not induce glial activation or inflammatory changes compared to AF alone. When stratified by sex, male AF+LPS promoted significant glial activation (high CD11b:p < 0.05; low Iba1:p < 0.01) compared to male AF without LPS; however, this was not associated with changes in pro-inflammatory cytokines. When stratified by race/ethnicity, AF+LPS induced glial activation in both groups, but a differential increase in pro-inflammatory cytokines was seen between WH and AA AF (WH-interleukin-1ß: p < 0.05; AA-interleukin-8: p < 0.01). CONCLUSION: This OOC model of fetal neuroinflammation has determined that race/ethnicity differences do exist for perinatal brain injury. The fetal sex of neonates was not a determining factor of susceptibility to intraamniotic inflammation leading to neuroinflammation.

Genital Mycoplasmas and Biomarkers of Inflammation and Their Association With Spontaneous Preterm Birth and Preterm Prelabor Rupture of Membranes: A Systematic Review and Meta-Analysis.

Genital mycoplasmas (GM), such as Mycoplasma hominis, Mycoplasma genitalium, Ureaplasma parvum, and Ureaplasma urealyticum are commonly associated with spontaneous preterm labor (SPTL), spontaneous preterm birth (PTB), and preterm prelabor rupture of membranes (PPROM). This study determined the association between GM and such adverse pregnancy outcomes. We searched for studies published 1980-2019 in MEDLINE, EMBASE, and Web of Science. Studies were eligible when GM was detected during pregnancy. We included 93 and 51 studies in determining the prevalence and the inflammatory biomarkers associated with GM, respectively, using the "metafor" package within R. The protocol was registered with PROSPERO (registration no. CRD42016047297). Women with the studied adverse pregnancy outcomes had significantly higher odds of presence with GM compared to women who delivered at term. For PTB, the odds ratios were: M. hominis (OR: 2.25; CI: 1.35-3.75; I 2: 44%), M. genitalium (OR: 2.04; CIL 1.18-3.53; I 2: 20%), U. parvum (OR: 1.75; CI: 1.47-2.07; I 2: 0%), U. urealyticum (OR: 1.50; CI: 1.08-2.07; I 2: 58%). SPTL had significantly higher odds with M. hominis (OR: 1.96; CI: 1.19-3.23; I 2: 1%) or U. urealyticum (OR: 2.37; CI: 1.20-4.70; I 2: 76%) compared to women without SPTL. Women with PPROM had significantly higher odds with M. hominis (OR: 2.09; CI: 1.42-3.08; I 2: 0%) than women without PPROM. However, our subgroup analysis based on the diagnostic test and the sample used for detecting GM showed a higher prevalence of GM in maternal samples than in fetal samples. GM presence of the cervix and vagina was associated with lower odds of PTB and preterm labor (PTL). In contrast, GM presence in the AF, fetal membrane, and placenta was associated with increased odds of PTB and PTL. However, genital mycoplasmas may not elicit the massive inflammation required to trigger PTB. In conclusion, GM presence in the fetal tissues was associated with significantly increased odds of PTB and PTL.

Disparities in Prenatal Sexually Transmitted Infections among a Diverse Population of Foreign-Born and US-Born Women.

This study examined association between foreign-born (FB) status and a sexually transmitted infection (STI) diagnosis of Chlamydia trachomatis, Neisseria gonorrhoeae, or syphilis among a cohort of expecting mothers, and stratified by race/ethnicity. As a secondary analysis, subsequent adverse birth outcomes following STIs were examined. We used data from a large perinatal database to conduct a retrospective cohort study of 37,211 singleton births. Logistic regression was used to determine the association between FB status and STIs. We adjusted for maternal demographics, prior complications, and chronic disease. As a secondary analysis, we examined the association between STIs, and adverse birth outcomes stratified by FB status. FB women had lower odds of STI diagnosis (ORadj 0.81, 95% CI 0.71-0.93); this was observed for each STI. Among Hispanic women, FB status did not reduce odds of STIs (ORadj 0.89, 95% CI 0.76-1.04). However, FB Black women had reduced odds of STIs (ORadj 0.53, 95% CI 0.36-0.79). Secondary analyses revealed that STIs increased odds of adverse birth outcomes among US-born Black women but not US-born Hispanic women. Among FB Black women, STIs increased odds of medically indicated preterm birth (ORadj 3.77, 95% CI 1.19-12.00) and preeclampsia (ORadj 2.35, 95% CI 1.02-5.42). This was not observed among FB Hispanic women. Previous studies suggest that FB women are less likely to have adverse birth outcomes; our study extends this observation to risk of prenatal STIs. However, FB status does not protect Black women against adverse birth outcomes following an STI.

Bacterial Vaginosis and Prospective Ultrasound Measures of Uterine Fibroid Incidence and Growth.

BACKGROUND: Uterine fibroids often cause intolerable symptoms leading to invasive treatments, most commonly hysterectomy. Reproductive tract infections are hypothesized to influence uterine fibroid development, but few studies exist, especially for the highly prevalent condition bacterial vaginosis (BV). Both fibroids and BV have documented racial-ethnic disparities, with higher burden in Blacks. METHODS: With prospective data from a community-based study (four standardized ultrasound examinations over 5 years) in young Black women, we examined baseline BV associations with fibroid incidence and growth. We computed adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for incidence comparing BV and no BV (Nugent score ≥7 vs. <7) using Cox proportional hazards models among 1027 women fibroid-free at baseline. Fibroid growth associations were based on linear mixed models estimating volume change between ultrasounds indexed to 18 months. We then expressed BV association as estimated percent difference in growth per 18 months, comparing exposed and unexposed. RESULTS: There were n = 247 incident fibroids and 1181 growth measures; average fibroid growth per 18 months was a 78% (95% CI: 69 to 87) increase in volume. BV prevalence was 51% and not associated with fibroid incidence (aHR: 1.0, 95% CI: 0.80 to 1.4) or growth (estimated % difference in growth, -3% (95% CI: -12 to 6). CONCLUSIONS: In this first study (to our knowledge) of ultrasound-monitored fibroid development and Nugent-assessed BV, we found no evidence to support the hypothesis that BV increased risk of fibroid incidence or growth or BV's role in the high burden of fibroids in Black women.

Microvesicles and exosomes released by amnion epithelial cells under oxidative stress cause inflammatory changes in uterine cells†.

Extracellular vesicles play a crucial role in feto-maternal communication and provide an important paracrine signaling mechanism in pregnancy. We hypothesized that fetal cells-derived exosomes and microvesicles (MVs) under oxidative stress (OS) carry unique cargo and traffic through feto-maternal interface, which cause inflammation in uterine cells associated with parturition. Exosomes and MVs, from primary amnion epithelial cell (AEC) culture media under normal or OS-induced conditions, were isolated by optimized differential centrifugation method followed by characterization for size (nanoparticle tracking analyzer), shape (transmission electron microscopy), and protein markers (western blot and immunofluorescence). Cargo and canonical pathways were identified by mass spectroscopy and ingenuity pathway analysis. Myometrial, decidual, and cervical cells were treated with 1 × 107 control/OS-derived exosomes/MVs. Pro-inflammatory cytokines were measured using a Luminex assay. Statistical significance was determined by paired T-test (P < 0.05). AEC produced cup-shaped exosomes of 90-150 nm and circular MVs of 160-400 nm. CD9, heat shock protein 70, and Nanog were detected in exosomes, whereas OCT-4, human leukocyte antigen G, and calnexin were found in MVs. MVs, but not exosomes, were stained for phosphatidylserine. The protein profiles for control versus OS-derived exosomes and MVs were significantly different. Several inflammatory pathways related to OS were upregulated that were distinct between exosomes and MVs. Both OS-derived exosomes and MVs significantly increased pro-inflammatory cytokines (granulocyte-macrophage colony-stimulating factor, interleukin 6 (IL-6), and IL-8) in maternal cells compared with control (P < 0.05). Our findings suggest that fetal-derived exosomes and MVs under OS exhibited distinct characteristics and a synergistic inflammatory role in uterine cells associated with the initiation of parturition.

Application of the navigation guide systematic review methodology to evaluate prenatal exposure to particulate matter air pollution and infant birth weight.

Low birth weight is an important risk factor for many co-morbidities both in early life as well as in adulthood. Numerous studies report associations between prenatal exposure to particulate matter (PM) air pollution and low birth weight. Previous systematic reviews and meta-analyses report varying effect sizes and significant heterogeneity between studies, but did not systematically evaluate the quality of individual studies or the overall body of evidence. We conducted a new systematic review to determine how prenatal exposure to PM2.5, PM10, and coarse PM (PM2.5-10) by trimester and across pregnancy affects infant birth weight. Using the Navigation Guide methodology, we developed and applied a systematic review protocol [CRD42017058805] that included a comprehensive search of the epidemiological literature, risk of bias (ROB) determination, meta-analysis, and evidence evaluation, all using pre-established criteria. In total, 53 studies met our inclusion criteria, which included evaluation of birth weight as a continuous variable. For PM2.5 and PM10, we restricted meta-analyses to studies determined overall as "low" or "probably low" ROB; none of the studies evaluating coarse PM were rated as "low" or "probably low" risk of bias, so all studies were used. For PM2.5, we observed that for every 10 µg/m3 increase in exposure to PM2.5 in the 2nd or 3rd trimester, respectively, there was an associated 5.69 g decrease (I2: 68%, 95% CI: -10.58, -0.79) or 10.67 g decrease in birth weight (I2: 84%, 95% CI: -20.91, -0.43). Over the entire pregnancy, for every 10 µg/m3 increase in PM2.5 exposure, there was an associated 27.55 g decrease in birth weight (I2: 94%, 95% CI: -48.45, -6.65). However, the quality of evidence for PM2.5 was rated as "low" due to imprecision and/or unexplained heterogeneity among different studies. For PM10, we observed that for every 10 µg/m3 increase in exposure in the 3rd trimester or the entire pregnancy, there was a 6.57 g decrease (I2: 0%, 95% CI: -10.66, -2.48) or 8.65 g decrease in birth weight (I2: 84%, 95% CI: -16.83, -0.48), respectively. The quality of evidence for PM10 was rated as "moderate," as heterogeneity was either absent or could be explained. The quality of evidence for coarse PM was rated as very low/low (for risk of bias and imprecision). Overall, while evidence for PM2.5 and course PM was inadequate primarily due to heterogeneity and risk of bias, respectively, our results support the existence of an inverse association between prenatal PM10 exposure and low birth weight.

Mycoplasma genitalium and Bacterial Vaginosis-Associated Bacteria in a Non-Clinic-Based Sample of African American Women.

BACKGROUND: Mycoplasma genitalium is associated with adverse reproductive problems. However, prevalence estimates from studies that screen women not seeking care are rare. Studies have reported co-occurrence of M. genitalium with bacterial vaginosis (BV), but no prior study of specific BV-associated bacteria has been conducted in African Americans whose reproductive tract infection burden is high. METHODS: Using quantitative polymerase chain reaction, we screened vaginal swabs for M. genitalium, 9 BV-associated bacteria, and 4 Lactobacillus species from 200 participants drawn from a cohort of African Americans 23 to 35 years old. Sexual history, herpes serostatus, and Nugent score had been assessed. Prevalence of M. genitalium was computed. The associations of other vaginal bacteria with M. genitalium were examined with binomial regression. RESULTS: M. genitalium prevalence was 18%. Detection and quantity of 2 BV-associated bacteria were significantly associated with a higher prevalence of M. genitalium (Leptotrichia/Sneathia: detection prevalence ratio (PR) of 2.9 [95% confidence interval {CI}, 1.1-7.7] and quantity PR of 1.2 [95% CI, 1.0-1.3]; Megasphaera phylotype 1: detection PR of 2.2 [95% CI, 1.2-4.2] and quantity PR of 1.1 [95% CI, 1.0-1.2]). Increased quantity of L. iners was also positively associated with M. genitalium (PR, 1.3 [95% CI, 1.0-1.8]). Nugent ≥7, herpes serostatus, and lifetime number of sex partners were not associated with M. genitalium. CONCLUSIONS: Specific BV-associated microbes and L. iners were associated with M. genitalium, but Nugent ≥7 was not. Studies are needed to confirm a high prevalence of M. genitalium in African Americans and to understand its interactions with other vaginal bacteria.

Unveiling molecular signatures of preeclampsia and gestational diabetes mellitus with multi-omics and innovative cheminformatics visualization tools.

To fully enable the development of diagnostic tools and progressive pharmaceutical drugs, it is imperative to understand the molecular changes occurring before and during disease onset and progression. Systems biology assessments utilizing multi-omic analyses (e.g. the combination of proteomics, lipidomics, genomics, etc.) have shown enormous value in determining molecules prevalent in diseases and their associated mechanisms. Herein, we utilized multi-omic evaluations, multi-dimensional analysis methods, and new cheminformatics-based visualization tools to provide an in depth understanding of the molecular changes taking place in preeclampsia (PRE) and gestational diabetes mellitus (GDM) patients. Since PRE and GDM are two prevalent pregnancy complications that result in adverse health effects for both the mother and fetus during pregnancy and later in life, a better understanding of each is essential. The multi-omic evaluations performed here provide new insight into the end-stage molecular profiles of each disease, thereby supplying information potentially crucial for earlier diagnosis and treatments.

Chlamydia trachomatis Is Associated With Medically Indicated Preterm Birth and Preeclampsia in Young Pregnant Women.

BACKGROUND: Studies on Chlamydia trachomatis-associated pregnancy outcomes are largely conflicting, ignoring the heterogeneous natures of pregnancy complications and potential effect modification by maternal age. This study determined if prenatal C. trachomatis infection is associated with preterm birth (PTB) and preeclampsia subtypes. METHODS: A retrospective cohort study was conducted using 22,772 singleton pregnancies with a prenatal C. trachomatis diagnostic test. Spontaneous and medically indicated PTBs, and term and preterm preeclampsia were outcomes. Modified Poisson regression calculated relative risk (RR) and 95% confidence intervals (CI) with propensity score adjustments stratified by maternal ages <25 and ≥25 years. RESULTS: Overall, C. trachomatis was significantly associated with term preeclampsia (adjusted RR [RRadj], 1.88; 95% CI, 1.38-2.57). Among young women (age <25 years), C. trachomatis was significantly associated with medically indicated PTB (RRadj, 2.29; 95% CI, 1.38-3.78) and term preeclampsia (RRadj, 1.57; 95% CI, 1.05-2.36) in propensity-adjusted models. No significant associations in older women were detected. CONCLUSION: C. trachomatis was associated with medically indicated PTB and term preeclampsia in young women. Associations between chlamydia and perinatal outcomes may depend on the subtype of PTB and preeclampsia, which should be investigated through mechanistic studies.

Exploring Inflammatory Mediators in Fetal and Maternal Compartments During Human Parturition.

OBJECTIVE: To examine inflammatory mediators in three fetomaternal biological compartments to inform theory related to the fetal and maternal inflammatory contributions to parturition at term and preterm. METHODS: We conducted a cross-sectional study of amniotic fluid, cord blood, and maternal plasma from women with singleton pregnancies. Women had one of four conditions: term labor (n=11), term not in labor (n=13), spontaneous preterm birth with intact membranes (preterm birth; n=13), or preterm prelabor rupture of membranes (PROM; n=8). We measured two damage-associated molecular pattern markers (high-mobility group box-1 [HMGB1] and uric acid) and two acute phase response markers (interleukin [IL]-6 and C-reactive protein [CRP]) using enzyme-linked immunosorbent assay. The distribution of each analyte within amniotic fluid, cord blood, and maternal plasma across the four conditions (term not in labor, term labor, preterm birth, and preterm PROM) were calculated. To explore whether there were distributional differences in each analyte across each of the four labor conditions, we used a nonparametric Kruskal-Wallis test. For analytes that differed across groups, we further compared distributions by labor group (term labor vs term not in labor, and preterm PROM vs preterm birth). RESULTS: Fetal compartments (amniotic fluid and cord blood) showed higher HMGB1 in term labor vs term not in labor and preterm PROM vs preterm birth. Amniotic fluid IL-6, cord blood CRP and cord blood uric acid were higher in term vs term not in labor. Cord blood uric acid was higher in preterm PROM vs preterm birth. Only maternal plasma IL-6 was higher in term labor vs term not in labor. CONCLUSION: Accumulation of HMGB1 and an overall increase in inflammation observed on the fetal side, but not the maternal side, may be signals of parturition. Understanding fetal-derived proparturition inflammatory signals at term and preterm, especially in preterm PROM, might provide fetal-specific biomarkers and identify underlying mechanisms and targets for interventions to reduce the risk of preterm birth and preterm PROM.

Immediate Postpartum Long-Acting Reversible Contraception Programs in Texas Hospitals Following Changes to Medicaid Reimbursement Policy.

OBJECTIVES: Provision of long-acting reversible contraception (LARC) after delivery and prior to discharge is safe and advantageous, yet few Texas hospitals offer this service. Our study describes experiences of Texas hospitals that implemented immediate postpartum LARC (IPLARC) programs, in order to inform the development of other IPLARC programs and guide future research on system-level barriers to broader adoption. METHODS: Eight Texas hospitals that had implemented an IPLARC program were identified, and six agreed to participate in the study. Interviews with 19 key hospital staff covered (1) factors that led the development of an IPLARC program; (2) billing, pharmacy, and administrative operations related to implementation; (3) patient demand and readiness; (4) the consent process; (5) staff training; and (6) hospital plans for monitoring and evaluation of IPLARC services. RESULTS: Most hospitals in this study primarily served Medicaid and un- or under-insured populations. Participants from all six hospitals perceived high levels of patient demand for IPLARC and provider interest in providing this service. The major challenges were related to financing IPLARC programs. Participants from half of the hospitals reported that leadership had concerns about financial viability of providing IPLARC. The hospitals with the longest-running IPLARC programs were safety net hospitals with family planning training programs. CONCLUSIONS FOR PRACTICE: We found that hospitals with IPLARC programs all had strong support from both providers and hospital leadership and had funding sources to offset costs that were not reimbursed. Strategies to reduce the financial risks related to IPLARC provision could provide the impetus for new programs to launch and support their sustainability.

High-mobility group box 1 at the time of parturition in women with gestational diabetes mellitus.

PROBLEM: High-mobility group box 1 (HMGB1), a danger-associated molecular pattern marker, may indicate sterile inflammation through innate immune pathways. HMGB1 is implicated in hyperglycemia and excess glucose in trophoblast. Metabolic dysfunction and dyslipidemia are associated with gestational diabetes mellitus (GDM), but few studies examined associations between HMGB1 and GDM. We determined HMGB1 levels, and the ratio of HMGB1 to innate immune markers, in women with GDM at parturition. METHOD OF STUDY: This case-control study of 50 GDM pregnancies and 100 healthy controls utilized data and plasma samples from PeriBank. HMGB1, pentraxin-3, and interleukin (IL)-6 were measured by ELISA. Logistic regression calculated odds ratios (OR) and 95% confidence intervals (CI) adjusting for age, pre-pregnancy body mass index, and type of labor. RESULTS: There were no significant associations between HMGB1 and GDM. The ratio of HMGB1 to pentraxin-3 and IL-6 did not alter the odds of GDM. There was a significant statistical interaction between HMGB1 and maternal age (P = .02). When associations were examined by age groups, HMGB1 was associated with reduced odds of HMGB1 among women ≤25 (AOR = 0.007 CI 95% <0.001-0.3). Odds ratios increased as age increased (AOR range 1.2-3.8) but results were not statistically significant. CONCLUSION: High-mobility group box 1 was not associated with GDM. However, we found evidence that maternal age was a potential effect modifier of the relationship between HMGB1 and GDM. As there is growing evidence that HMGB1 may play important roles in reproduction, future studies should explore maternal factors that may alter HMGB1 levels.

Serum folate levels and urinary arsenic methylation profiles in the US population: NHANES, 2003-2012.

Arsenic is a prevalent environmental contaminant, and its folate-dependent methylation is important for detoxification in the body. In this study, we investigated the association between serum folate levels and methylation using data from the US National Health and Nutrition Examination Survey (NHANES) (2003-2012) (N = 11,016). Multivariate linear regression and penalized spline regression models were used to examine the association and possible upper limit of folate level regarding its impact on methylation in children (≤18 years) and adults (>18 years), respectively. Serum folate levels, methylation metabolites including urinary monomethylarsonic acid (MMA(V)) and dimethylarsinic acid (DMA(V)), and demographic variables were extracted from NHANES. Results showed that urinary percentage of DMA(V) (%DMA(V)) was positively associated with log(serum folate levels) after adjustment in children (ß = 1.93, p < 0.01); urinary percentage of MMA(V) (%MMA(V)) was positively associated with log (serum folate levels) after adjustment in adults (ß = 0.40, p < 0.01). No upper limit of folate level regarding its impact on arsenic methylation was identified. More than 50% of Non-Hispanic black and smokers with high total urinary arsenic levels had low serum folate levels. Our results indicate that folate promotes arsenic methylation, but the patterns are different in children versus in adults. Future interventions may be needed for the population exposed to high level of arsenic but with low serum folate to protect against the potential adverse health effects of arsenic.

Gene Expression Signatures Can Aid Diagnosis of Sexually Transmitted Infection-Induced Endometritis in Women.

Sexually transmitted infection (STI) of the upper reproductive tract can result in inflammation and infertility. A biomarker of STI-induced upper tract inflammation would be significant as many women are asymptomatic and delayed treatment increases risk of sequelae. Blood mRNA from 111 women from three cohorts was profiled using microarray. Unsupervised analysis revealed a transcriptional profile that distinguished 9 cases of STI-induced endometritis from 18 with cervical STI or uninfected controls. Using a hybrid feature selection algorithm we identified 21 genes that yielded maximal classification accuracy within our training dataset. Predictive accuracy was evaluated using an independent testing dataset of 5 cases and 10 controls. Sensitivity was evaluated in a separate test set of 12 women with asymptomatic STI-induced endometritis in whom cervical burden was determined by PCR; and specificity in an additional test set of 15 uninfected women with pelvic pain due to unknown cause. Disease module preservation was assessed in 42 women with a clinical diagnosis of pelvic inflammatory disease (PID). We also tested the ability of the biomarker to discriminate STI-induced endometritis from other diseases. The biomarker was 86.7% (13/15) accurate in correctly distinguishing cases from controls in the testing dataset. Sensitivity was 83.3% (5/6) in women with high cervical Chlamydia trachomatis burden and asymptomatic endometritis, but 0% (0/6) in women with low burden. Specificity in patients with non-STI-induced pelvic pain was 86.7% (13/15). Disease modules were preserved in all 8 biomarker predicted cases. The 21-gene biomarker was highly discriminatory for systemic infections, lupus, and appendicitis, but wrongly predicted tuberculosis as STI-induced endometritis in 52.4%. A 21-gene biomarker can identify asymptomatic women with STI-induced endometritis that places them at risk for chronic disease development and discriminate STI-induced endometritis from non-STI pelvic pain and other diseases.

Amnion epithelial cell-derived exosomes induce inflammatory changes in uterine cells.

BACKGROUND: Fetal endocrine signals are generally considered to contribute to the timing of birth and the initiation of labor. Fetal tissues under oxidative stress release inflammatory mediators that lead to sterile inflammation within the maternal-fetal interface. Importantly, these inflammatory mediators are packaged into exosomes, bioactive cell-derived extra cellular vesicles that function as vectors and transport them from the fetal side to the uterine tissues where they deposit their cargo into target cells enhancing uterine inflammatory load. This exosome-mediated signaling is a novel mechanism for fetal-maternal communication. OBJECTIVE: This report tested the hypothesis that oxidative stress can induce fetal amnion cells to produce exosomes, which function as a paracrine intermediary between the fetus and mother and biochemically signal readiness for parturition. STUDY DESIGN: Primary amnion epithelial cells were grown in normal cell culture (control) or exposed to oxidative stress conditions (induced by cigarette smoke extract). Exosomes were isolated from cell supernatant by sequential ultracentrifugation. Exosomes were quantified and characterized based on size, shape, and biochemical markers. Myometrial, decidual, and placental cells (BeWo) were treated with 2 × 105, 2 × 107, and 2 × 109 control or oxidative stress-derived amnion epithelial cell exosomes for 24 hours. Entry of amnion epithelial cell exosomes into cells was confirmed by confocal microscopy of fluorescent-labeled exosomes. The effect of amnion epithelial cell exosomes on target cell inflammatory status was determined by measuring production of interleukin-6, interleukin-8, interleukin-1ß, tumor necrosis factor-α, and prostaglandin E2 by enzyme-linked immunosorbent assay and inflammatory gene transcription factor (nuclear factor-κß) activation status by immunoblotting for phosphorylated RelA/p65. Localization of NANOG in term human myometrium and decidua obtained from women before labor and during labor was performed using immunohistochemistry. Data were analyzed by Wilcoxon-Mann-Whitney test to compare effects of exosomes from control and oxidative stress-treated amnion epithelial cells on inflammatory status of target cells. RESULTS: Amnion epithelial cells released ∼125 nm, cup-shaped exosomes with ∼899 and 1211 exosomes released per cell from control and oxidative stress-induced cells, respectively. Amnion epithelial cell exosomes were detected in each target cell type after treatment using confocal microscopy. Treatment with amnion epithelial cell exosomes increased secretion of interleukin-6, interleukin-8, and PGE2 and activation of NF-κß (each P < .05) in myometrial and decidual cells. Exosome treatments had no effect on interleukin-6 and PGE2 production in BeWo cells. NANOG staining was higher in term labor myometrium and decidua compared to tissues not in labor. CONCLUSION: In vitro, amnion epithelial cell exosomes lead to an increased inflammatory response in maternal uterine cells whereas placental cells showed refractoriness. Fetal cell exosomes may function to signal parturition by increasing maternal gestational cell inflammation.