Gadd45 in Preeclampsia.

Preeclampsia is a pregnancy-induced complex of multiple pathological changes. Numerous stresses during pregnancy, including hypoxia, immune activation, inflammatory cytokines, and oxidative stress were reported as contributing factors to the preeclamptic pathology. Seeking common sensors of various stressors in preeclampsia is of new interest and can potentially benefit in disease prevention and treatment. Recent studies have highlighted the role of the Gadd45a protein as a stress sensor in preeclampsia. In response to various pathophysiological stressors, notably hypoxia, oxidative stress, inflammatory cytokines, and AT1-AAs, Gadd45a activates Mkk3-p38 and or JNK signaling. This, in turn, results in immunological and inflammatory changes as well as triggering the production of circulating factors such as sFlt-1, which are believed to account for many of the pathophysiological-related symptoms of preeclampsia. Activation of inflammatory/immune responses in preeclampsia may function in a feedback loop to maintain elevated expression of Gadd45a protein.

First trimester noninvasive fetal RHD genotyping using maternal dried blood spots.

OBJECTIVE: This study was aimed to evaluate whether maternal dried blood spots could be a potential source for the noninvasive fetal RHD genotyping, serving as a combined one-step test for both the First Trimester Screen and the fetal RHD genotyping. METHOD: Both the maternal dried blood spots and the peripheral blood samples from 19 RhD-negative pregnant women were obtained during the First Trimester Screen. DNA was extracted and sequential real-time PCRs were performed to determine the fetal RHD genotypes. Fetal RhD serological types were obtained after delivery. This study was approved by the Institutional Review Board, and informed consents were obtained. RESULTS: A total of 19/19 fetal RHD genotyping with maternal DBS were consistent with the follow-up serological RhD test results after birth. Eleven were RhD positive, and eight were RhD negative (RHD deletion or RHD-CE-D = 6, RHD pseudogene = 1, RHDVI = 1). Sensitivity = 100%, specificity = 100%, positive predictive value = 100%, negative predictive value = 100%. A total of 18/19 fetal gender were determined correctly with maternal DBS. One female fetus was falsely determined as male. Sensitivity = 100%, specificity = 91.6%, positive predictive value = 87.5%, negative predictive value = 100%. CONCLUSION: Maternal dried blood spots, with the benefits of flexible sample transportation and processing, could be utilized for the noninvasive prenatal fetal RHD genotyping and potentially be incorporated into the routine First Trimester Screen. Larger scale study is in progress to implement fetal RHD genotyping in routine prenatal care. © 2017 John Wiley & Sons, Ltd.

Gadd45 stress sensors in preeclampsia.

Preeclampsia is a pregnancy-induced complex of multiple pathological changes. Numerous stresses during pregnancy, including hypoxia, immune activation, inflammatory cytokines, and oxidative stress were reported as contributing factors to the preeclamptic pathology. Seeking common sensors of various stressors in preeclampsia is of new interest and can potentially benefit in disease prevention and treatment. Recent studies have highlighted the role of the Gadd45a protein as a stress sensor in preeclampsia. In response to various pathophysiological stressors, notably hypoxia, inflammatory cytokines, and AT1-AAs, Gadd45a activates Mkk3-p38 and or JNK signaling. This, in turn, results in immunological and inflammatory changes as well as triggering the production of circulating factors such as sFlt-1, which are believed to account for many of the pathophysiological-related symptoms of preeclampsia. Activation of inflammatory/immune responses in preeclampsia may function in a feedback loop to maintain elevated expression of Gadd45a protein.

Preeclampsia-associated stresses activate Gadd45a signaling and sFlt-1 in placental explants.

Accumulating evidence suggests that placental stresses during pregnancy can play an important role in the pathogenesis of preeclampsia. A common signal pathway that senses and converts placental stresses into intracellular stress response may be contributing to this pathology. Based on our previous findings, we extended our investigation to establish that Gadd45a stress signaling regulates sFlt-1 levels, particularly in placenta, when exposed to various preeclampsia-associated stresses including AT-1 receptor agonist (Angiotensin II), hypoxia, and inflammatory cytokines. Using a placental explant model, we found that Gadd45a was induced in response to all the preeclampsia stresses stated above. Although stress induced Gadd45a was associated with the activation of its downstream effectors phospho-p38 and phospho-JNK, the subsequent regulation of sFlt-1 levels occurred through either one of these effectors, but not both. These observations indicate that Gadd45a signaling may work as a hub connecting placental stresses and the pathogenesis of preeclampsia. It also provides evidence to justify testing the role of Gadd45 in the etiology of preeclampsia using in vivo mouse (i.e., Gadd45a null mice) models.

Transvaginal ultrasound of cervical length and its correlation to digital cervical examination, time to spontaneous labor and mode of delivery.

PURPOSE: The objective of this study was to determine if transvaginal ultrasound (TVUS) examination of cervical length correlates to digital pelvic examination and if it can predict time to and mode of delivery in term pregnancies. METHODS: We conducted a prospective cohort study of 726 consecutive non-laboring, term pregnant women presenting to University-based antenatal testing unit between 1 July 2001 and 31 March 2002. Subjects underwent a TVUS for cervical length followed by a digital cervical examination by a physician blinded to the results of the ultrasound. Linear regression analysis was used to correlate the findings of cervical length by ultrasound with cervical dilatation and effacement by digital examination. RESULTS: In 726 women, the relationship between TVUS cervical length and cervical dilatation and effacement measured digitally were found to be significantly related (p < 0.001), but weak, with a 15 and 23% goodness of fit, respectively, based on the linear model. Using multivariate logistic and linear regression, respectively, TVUS cervical length predicted mode of delivery but did not predict time to spontaneous labor. Digital measurement of cervical dilatation was predictive of time to spontaneous labor. CONCLUSIONS: There is a statistically significant correlation between TVUS measurement of cervical length and digital cervical exam though the correlation is weak. TVUS measurement of cervical length was predictive of mode of delivery while controlling for digital cervical examination, parity and time to spontaneous labor. Digital cervical dilatation was predictive of time to spontaneous delivery.

URAT1 mutations cause renal hypouricemia type 1 in Iraqi Jews.

BACKGROUND: Hereditary renal hypouricemia may be complicated by nephrolithiasis or exercise-induced acute renal failure. Most patients described so far are of Japanese origin and carry the truncating mutation W258X in the uric acid transporter URAT1 encoded by SLC22A12. Recently, we described severe renal hypouricemia in Israeli patients with uric acid transporter GLUT9 (SLC2A9) loss-of-function mutations. Renal hypouricemia in Iraqi Jews has been previously reported, but its molecular basis has not been ascertained. METHODS: Three Jewish Israeli families of Iraqi origin with hereditary hypouricemia and hyperuricosuria were clinically characterized. DNA was extracted and the URAT1 gene was sequenced. Transport studies into Xenopus laevis oocytes were utilized to evaluate the function of URAT1 mutants found. RESULTS: A missense URAT1 mutation, R406C, was detected in all three families. Two affected siblings were found to carry in addition a homozygous missense URAT1 mutation, G444R. Both mutations dramatically impaired urate uptake into X. laevis oocytes. Moreover, we demonstrate for the first time that URAT1 facilitates urate efflux, which was abolished in the mutants, indicating also a secretion defect. Homozygous patients had serum uric acid concentrations of 0.5-0.8 mg% and a fractional excretion of uric acid of 50-85%. Most individuals studied were asymptomatic, two had nephrolithiasis and none developed exercise-induced acute renal failure. CONCLUSIONS: The URAT1 R406C mutation detected in all three families is likely to be the founder mutation in Iraqi Jews. Our findings contribute to a better definition of the different types of hereditary renal hypouricemia and suggest that the phenotype of this disorder depends mainly on the degree of inhibition of uric acid transport.

Increased placental telomerase mRNA in hypertensive disorders of pregnancy.

OBJECTIVE: We assessed hTERT mRNA levels in normal versus preeclamptic placental samples, examining hTERT expression levels in different clinical manifestations of hypertensive disorder of pregnancy. METHODS: We performed a single-site, prospective case-control study of hTERT mRNA levels in placentas from term and preterm pregnancies with hypertensive disorders compared with unaffected pregnancies. Placental biopsies were collected from 61 patients (preeclamptic: 32; non-preeclamptic (control): 29). Total RNA from placenta was isolated and reversely transcribed to c-DNA. A probe-specific real-time quantitative PCR assay was employed to determine the relative expressional levels of hTERT mRNA levels in these placentas from both unaffected and affected pregnancies with different categories of hypertensive disorders including preeclampsia, severe preeclampsia, eclampsia and HELLP syndrome (Hemolysis, Elevated Liver function tests, Low Platelet). RESULTS: The average ratio of hTERT mRNA levels was 1.73 in the preeclamptic group and 1.02 for control group (p < 0.0001). The hTERT expression levels were elevated for each of the different categories of hypertensive disorders of pregnancy compared with control: HELLP syndrome 1.86, severe preeclampsia 1.81, eclampsia 1.71 and mild preeclampsia 1.63. In addition, hTERT levels were higher in severe than mild preeclampsia (p < 0.01). CONCLUSIONS: Elevated hTERT mRNA expression is observed in placentas from pregnancies with different clinical manifestations of hypertensive disorders of pregnancy. The patho-physiological significance of this finding awaits further studies.

The clinical utility of oral glucose tolerance test at term: can it predict fetal macrosomia?

OBJECTIVE: The goal of this study was to assess the correlation between true fetal macrosomia and abnormal oral glucose tolerance test (OGTT) in pregnant women at term gestation who had a negative glucose challenge screen (GCT) at 24-28 weeks. STUDY DESIGN: In this cohort observational study, we enrolled all term pregnant patients who presented to our antenatal unit with estimated fetal weight >90th percentile (or >4,000 g) and negative 50 g GCT. The women underwent a 3-h (100 g) OGTT test. Patient's demographics, GCT and OGTT test results, mode of delivery and pregnancy outcomes were recorded and analyzed. RESULTS: One hundred and seventy women (mean age 30.2+4.6 years, range 19-44) were recruited over 15-month period. Ten patients (5.9%) were identified as having impaired glucose metabolism at term. In this sub-group, we found no correlation between GCT values at 24-28 weeks, family history of diabetes mellitus, the patient's BMI or weight at term, and the diagnosis of impaired glucose metabolism. There was no statistically significant difference in the mean fetal weight in patients with normal and abnormal OGTT. No shoulder dystocia or third and fourth degree vaginal tears were reported among the women with suspected fetal macrosomia and impaired glucose metabolism. CONCLUSIONS: There was no correlation between true fetal macrosomia and an abnormal 3-h (100 g) OGTT at term. A larger-scale study is needed to determine the clinical significance of performing an OGTT at term for all patients with macrosomia and negative gestational diabetes screen.

Gadd45a stress signaling regulates sFlt-1 expression in preeclampsia.

Preeclampsia, which affects approximately 5-8% of all pregnancies and is one of the leading causes of maternal and fetal morbidity and mortality, is a pregnancy induced complex of multiple pathological changes, including elevated blood pressure, proteinuria and edema manifested after 20 weeks gestation. There is growing evidence that placental stresses during pregnancy, notably hypoxia, and an increase in circulating soluble Flt-1 (sFlt-1) are important in the etiopathogenesis of preeclampsia. How placental stress results in elevated sFlt-1 expression is currently unknown. Here we provide novel data implicating the Gadd45a stress sensor protein as an upstream modulator of pathophysiological changes observed in preeclampsia. It is shown that Gadd45a expression and activation of its downstream effector p38 kinase are elevated in preeclamptic placentas compared to non-preeclamptic controls, and correlate with elevated sFlt-1. Furthermore, a regulatory loop is demonstrated where stress, including hypoxia, IL-6 or hypertonic stress, caused induction of Gadd45a, leading to p38 activation and ultimately increasing sFlt-1 secretion in endothelial cells. These data provide a compelling working frame to further test the role of Gadd45 stress sensors in the etiology of preeclampsia, and set the stage for considering novel therapeutic regimens, including p38 inhibitors, for treatment of preeclampsia.

Prenatal diagnosis: update on invasive versus noninvasive fetal diagnostic testing from maternal blood.

The modern obstetrics care includes noninvasive prenatal diagnosis testing such as first trimester screening performed between 11 and 14 weeks' gestation and second trimester screening performed between 15 and 20 weeks. In these screening tests, biochemical markers are measured in the maternal blood with or without ultrasound for fetal nuchal translucency with reported accuracy of up to 90%. Invasive procedures, including amniocentesis or chorionic villi sampling, are used to achieve over 99% accuracy. During these procedures direct fetal material is examined and, therefore, these tests are highly accurate with the caveat of a small risk for pregnancy loss. Much research now focuses on other noninvasive highly accurate and risk-free tests that will identify fetal material in the maternal blood. Fetal cells and fetal DNA/RNA provide fetal information but are hard to find in an overwhelming background of maternal cells and in the absence of specific fetal cell markers. The most experience has been accumulated with fetal rhesus and fetal sex determination from maternal blood, with an accuracy of up to 100% by using gene sequences that are absent from maternal blood. Although not clinically applicable yet, fetal cells, fetal DNA/RNA and fetal proteomics in combination with cutting edge technology are described to prenatally diagnose aneuploidies and single-gene disorders.

Obstetric outcomes with a false-positive one-hour glucose challenge test by the Carpenter-Coustan criteria.

OBJECTIVE: Pregnancies complicated by a false-positive one-hour glucose challenge test (GCT), as determined by the National Diabetes Data Group (NDDG) criteria, have higher rates of adverse maternal and neonatal outcomes. This study was conducted to determine if pregnancies complicated by a false-positive GCT, as determined by the Carpenter-Coustan (CC) criteria, also have higher rates of adverse maternal and neonatal outcomes. STUDY DESIGN: In this retrospective case-control study, we compared 165 patients with a false-positive GCT, as determined by the Carpenter-Coustan criteria, to a cohort of 165 pregnant controls with a normal screening GCT. Multiple variables for maternal and neonatal outcomes were compared between the two groups. RESULTS: The racial distribution and gestational age of delivery were similar in both groups. The study group had a higher one-hour GCT (148.2 mg/dl vs. 95.3 mg/dl, p < 0.001), was older (27.4 yrs vs. 23.8 years, p < 0.001), was more likely to be multiparous (71.5% vs. 58.2%, p = 0.011), and had a higher BMI (26.7 kg/m2 vs. 24.6 kg/m2, p = 0.002). There were no differences between the two groups in mode of delivery, birth weight, rates of macrosomia, shoulder dystocia, antenatal death and maternal laceration. There were also no differences between the two groups in rates of preeclampsia, chorioamnionitis, endometritis, ICN admission, neonatal hypoglycemia, Erb's palsy, clavicular fracture, neonatal sepsis, neonatal death or use of phototherapy. CONCLUSION: Women with a false-positive one-hour GCT by the Carpenter-Coustan criteria do not have higher rates of adverse perinatal outcomes. Using the Carpenter-Coustan criteria to diagnose GDM appears to be superior to NDDG criteria in terms of avoiding adverse maternal and neonatal outcomes.

Diagnostic accuracy of noninvasive fetal Rh genotyping from maternal blood--a meta-analysis.

OBJECTIVE: The purpose of this study was to determine the reported diagnostic accuracy, the validity, and the current limitations of fetal Rh genotyping from peripheral maternal blood based on the existing English-written publications. STUDY DESIGN: A search of the English literature describing fetal RhD determination from maternal blood was conducted. From each study, we determined the number of samples tested, fetal RhD genotype, the source of the fetal DNA (maternal plasma, serum, or fetal cells), gestational age, and confirmation of fetal Rh type. The presence of alloimmunization and exclusions of tested samples were noted. For the meta-analysis we calculated composite estimates using 2 random effects models, weighted GLM and Bayesian. Sensitivity, specificity, positive and negative predictive values were calculated. RESULTS: We identified 37 English-written publications that included 44 protocols reporting noninvasive Rh genotyping using fetal DNA obtained from maternal blood on a total of 3261 samples. A total of 183 (183/3261, 5.6%) samples were excluded from the meta-analysis. The overall diagnostic accuracy after exclusions was 94.8%. The gestational ages ranged between 8 and 42 weeks gestation. Maternal serum and plasma were found to be the best source for accurate diagnosis of fetal RhD type in 394/410 (96.1%) and 2293/2377 (96.5%), respectively. There were 719/783 (91.8%) alloimmunized patients that were correctly diagnosed. There were 16 studies that reported 100% diagnostic accuracy in their fetal RhD genotyping. CONCLUSION: The diagnostic accuracy of noninvasive fetal Rh determination using maternal peripheral blood is 94.8%. Its use can be applicable to Rh prophylaxis and to the management of Rh alloimmunized pregnancies. Improvements of the technique and further study of structure and rearrangements of the RhD gene may improve accuracy of testing and enable large-scale, risk-free fetal RhD genotyping using maternal blood.

Baking soda pica: a case of hypokalemic metabolic alkalosis and rhabdomyolysis in pregnancy.

BACKGROUND: We report a case of baking soda pica in a woman at 31 weeks of pregnancy causing severe hypokalemic metabolic alkalosis and rhabdomyolysis. CASE: A multigravida at 31 weeks of gestation presented with weakness and muscle pain. She was found to have severe hypokalemic metabolic alkalosis and rhabdomyolysis, with elevation in serum transaminases and hypertension. We initially thought the patient had an atypical presentation of preeclampsia until it was realized that she was ingesting 1 full box of baking soda (454 g sodium bicarbonate) per day. Symptoms and abnormal laboratory findings resolved with discontinuation of the patient's pica practices. CONCLUSION: Pica is a common but often overlooked practice that can potentially lead to life-threatening disorders. A thorough evaluation of a patient's dietary intake is extremely important, especially in the setting of atypical presentations of disease in pregnancy.