Term labor is associated with a core inflammatory response in human fetal membranes, myometrium, and cervix.

OBJECTIVE: Identify overlap of the transcriptome of myometrium and cervix in association with human labor. STUDY DESIGN: The transcriptional profile of myometrial and cervical biopsies obtained from women in spontaneous labor at term (n = 9) and not in labor (n = 9) were characterized by Affymetrix v2 U133 plus 2 arrays. Common canonical pathways and functional groups were identified by Ingenuity Pathway Analysis. RESULTS: One hundred ten genes (false discovery rate < 1%) were commonly up-regulated by myometrium and cervix in association with labor and 29 genes (false discovery rate < 1%) down-regulated. Fold change in expression of up-regulated genes was strongly correlated; myometrium vs cervix (r = 0.51; P < .001), with no relationship in down-regulated genes (r = 0.26; P = .16). Canonical pathway analysis established up-regulation of inflammatory pathway signaling, with greatest increases in cellular movement and immune response gene ontology groups. CONCLUSION: Gestational tissues exhibit a core inflammatory response in association with human parturition, with pathways regulating cellular trafficking dominating.

Inflammatory pathways in the mechanism of parturition.

Increasing evidence suggests that parturition is an inflammatory process. In this brief overview, inflammatory events occurring in association with parturition, and the mechanism by which they may contribute to labour and delivery will be discussed. Mention will be made of how this information may be of use in regulating the timing and the onset of parturition.

IMOP: randomised placebo controlled trial of outpatient cervical ripening with isosorbide mononitrate (IMN) prior to induction of labour - clinical trial with analyses of efficacy, cost effectiveness and acceptability.

BACKGROUND: There is increasing interest in carrying out pre-induction cervical ripening on an outpatient basis. However, there are concerns about the use of prostaglandins, the agents commonly used in hospital settings for this indication, because prostaglandins induce uterine contractions that may lead to fetal hypoxia. Indeed, in a recent study we demonstrated abnormalities in 9% of fetal heart rate tracings performed following prostaglandin induced cervical ripening at term. In contrast, we confirmed in the same study that isosorbide mononitrate (IMN) (administered on an inpatient basis) was both effective in inducing cervical ripening at term, and was associated with no associated fetal heart rate abnormalities. METHODS/DESIGN: The aim of this study is to determine whether IMN self administered by women on an outpatient basis improves the process of induction of labour. Specifically, we hypothesise that the use of outpatient IMN will result in a shorter inpatient stay before delivery, decreased costs to the health service and greater maternal satisfaction with ripening and induction of labour, compared with placebo treatment. In the study described here (the "IMOP" study), women scheduled for induction of labour at term, and who require pre-induction cervical ripening will be randomised to self-administer at home either IMN 40 mg, or a placebo, each vaginally, at 48 hours, 32 hours and 16 hours before scheduled hospital admission. After admission to hospital, treatment will revert to the usual induction of labour protocol. We will compare the primary outcomes of the elapsed time interval from hospital admission to vaginal delivery, the costs to the health service of induction of labour, and women's experience of induction of labour in the two groups. DISCUSSION: This trial will provide evidence on the efficacy of outpatient IMN for pre-induction cervical ripening at term. We will study a formulation of IMN which is cheap and widely available. If the treatment is effective, acceptable to women, and cost effective, it could be implemented into obstetric practice worldwide. TRIAL REGISTRATION: The trial has been registered on the International Standard Randomised Controlled Trial Number Register (ISRCTN) and given the registration number ISRTN39772441.

Spontaneous pregnancy after bilateral salpingectomy.

OBJECTIVE: To report a rare case of spontaneous pregnancy following bilateral salpingectomy. DESIGN: Case report. SETTING: Maternity unit at a district general hospital in the United Kingdom. PATIENT(S): A healthy 38-year-old woman with a history of bilateral salpingectomy. INTERVENTION(S): Ultrasound scan and serum beta hcG used to diagnose the pregnancy and for follow-up. MAIN OUTCOME MEASURE(S): Recognition and successful management of the pregnancy. RESULT(S): The patient was diagnosed with a noncontinuing pregnancy that resolved spontaneously. CONCLUSION(S): A MEDLINE search revealed that this is the first reported case of spontaneous pregnancy following bilateral salpingectomy in the English-language literature and possibly only the second in world literature.

Postmenopausal bleeding due to chronic DIC.

'Bleeding disorders' are listed as a cause of postmenopausal bleeding even though there appear to be no reported cases. We present a case of postmenopausal bleeding, because of chronic DIC, which resulted from aortic aneurysm and was managed with replacement blood products and tranexamic acid.

The home as an appropriate setting for women undertaking cervical ripening before the induction of labour.

OBJECTIVES: to explore women's experiences of cervical ripening using isosorbide mononitrate (IMN) in the home as part of the main randomised controlled trial. DESIGN: qualitative study with semi-structured interviews carried out at three weeks post partum. Interview transcripts were analysed to identify recurrent themes, focusing on why women became involved in the study, their views about both the self-medication and the home setting, and whether they would repeat the experience. SETTING: the home. PARTICIPANTS: twenty women enrolled in the main randomised controlled trial. INTERVENTION: the study is part of a double-blind randomised controlled trial with 350 patients investigating whether a nitric oxide donor (IMN) used in cervical ripening improves the process of induction of labour. FINDINGS: women liked the opportunity to remain at home during the cervical ripening process. Timing and setting were central issues; women hoped that it would hasten labour, while the home was seen as a setting offering freedom, security and reassurance, as opposed to the hospital, seen as constraining. Two women reported problems with IMN but the remainder reported that they would repeat the experience. IMPLICATIONS FOR PRACTICE: women were very positive about the opportunity to undertake cervical ripening at home. It is important to explore this setting further for appropriate interventions.

The role of toll-like receptors (TLR-2 and -4) and triggering receptor expressed on myeloid cells 1 (TREM-1) in human term and preterm labor.

OBJECTIVE: To define the role of Toll-like receptors (TLR-2, TLR-4) and triggering receptor expressed on myeloid cells-1 (TREM-1) in pregnant human myometrium. STUDY DESIGN: Expression of TLR-2 and -4 mRNA and protein and TREM-1 mRNA was quantified in human myometrial samples. Subsequently, we investigated the effect of medroxyprogesterone acetate (MPA) as a functional inhibitor of the TLR agonist lipopolysaccharide (LPS). RESULTS: Messenger RNA expression of TLR-2 and -4 was significantly higher in myometrium at term compared with preterm (P = .009 and .016, respectively). Toll-like receptor-2 protein expression was significantly higher during labor (P = .002) compared with nonlaboring samples. Triggering receptor expressed on myeloid cells-1 mRNA expression was increased in both myometrium and cervix after labor at term (P < .05). Medroxyprogesterone acetate significantly suppressed LPS-induced production of interleukin 1b (IL-1b), IL-6, and IL-8 in vitro (P < .05). CONCLUSION: Toll-like receptors 2and 4 and TREM-1 are expressed in human myometrium and may play a role in the mechanism of labor at term, and their functional effects are inhibited by MPA.