Bradley Stetzer

Proinflammatory Cytokines Found in Amniotic Fluid Induce Collagen Remodeling, Apoptosis, and Biophysical Weakening of Cultured Human Fetal Membranes

Abstract The mechanisms by which fetal membranes (FM) rupture during the birth process are unknown. We have recently reported that FM weaken, at least in part, because of a developmental process of extracellular matrix remodeling and apoptosis. We now hypothesize that cytokines that normally increase in amniotic fluid at term induce FM collagen remodeling and apoptosis with concomitant weakening. Full-thickness FM fragments were cultured with (0–100ng/ml) or without tumor necrosis factor (TNF) or interleukin 1, beta (IL1B). Physical properties were then examined with specially adapted industrial rupture strength testing equipment. Cultured FM were also evaluated for evidence of collagen remodeling and apoptosis. Cytokine-treated FM exhibited a dose-dependent decrease in strength and work to rupture. Compared with controls, the highest TNF dose caused maximal decrease in FM rupture strength (13.2 ± 1.2 N versus 3.8 ± 1.5 N; P = 0.0003) and work to rupture (0.035 ± 0.005 J versus 0.005 ± 0.002 J; P < 0.0001). The highest IL1B dose also decreased rupture strength (12.9 ± 3.2 versus 4.6 ± 1.1 N; P = 0.0027) and work to rupture (0.018 ± 0.005 J versus 0.005 ± 0.002 J; P < 0.01). Matrix metalloproteinase 9 (MMP9) protein increased, tissue inhibitor of matrix metalloproteinase 3 (TIMP3) protein decreased, and poly (ADP-ribose) polymerase (PARP1) cleavage increased with increasing TNF or IL1B doses (all P < 0.05), suggesting collagen remodeling and apoptosis. TNF and IL1B cause significant weakening of cultured FM. Both cytokines induce biochemical markers in the FM in a manner characteristic of the weak zone of FM overlying the cervix. TNF and or IL1B may be involved in the development of the weak zone of the FM.

Term Human Fetal Membranes Have a Weak Zone Overlying the Lower Uterine Pole and Cervix Before Onset of Labor

Abstract The etiology of fetal membrane (FM) rupture is unknown. A hypothesis that the FM weakens by a process of collagen remodeling and apoptosis to facilitate rupture has been proposed. Human FMs reportedly exhibit a zone of altered histology, postulated to be the FM rupture site, but concomitant FM weakness has not been demonstrated. We hypothesized that a discrete zone of FM with marked weakness, histological change, and evidence of remodeling and apoptosis, develops in late gestation in the FM overlying the cervix. FM tissue from women undergoing prelabor cesarean delivery were perioperatively marked to identify the FM overlying the cervix, cut with a procedure that facilitates remapping the rupture strength of FM pieces to their former location and orientation on a three-dimensional model, and tested for strength. A 10-cm FM zone centered at the cervical mark was compared with the remaining FM. Mean rupture strength within the cervical zone was 55% of the remaining FM. The cervical zone also exhibited increased MMP-9 protein, decreased tissue inhibitor of metalloproteinases-3 (TIMP-3) protein, and increased PARP cleavage coincident with the previously reported zone of altered histology. A discrete zone of weakness is present in term prelabor FMs overlying the cervix and has biochemical characteristics consistent with tissue remodeling and apoptosis.

Fetal membranes from term vaginal deliveries have a zone of weakness exhibiting characteristics of apoptosis and remodeling.

Background: Recently we identified a weak zone in term, pre-labor (repeat Cesarean section) human fetal membranes (FM) overlying the cervix with biochemical characteristics suggestive of apoptosis and collagen remodeling. We suggested that this weak zone is the FM rupture initiation site. Vaginally delivered patients have a weak zone in their FM overlying the cervix; a comparable weak zone lies adjacent to the tear line in FM after spontaneous rupture (SROM). Methods: FM From vaginally delivered patients with artificial rupture (AROM) and SROM were collected. FM of AROM patients were marked per agina to identify the FM zone overlying the cervix. Postpartum FM were cut, strength tested and piece strengths were remapped to their former location on a three-dimensional model. A 10-cm diameter zone centered on the marked area (AROM), or defined weak zone (SROM) was compared with the remaining FM. Results: AROM FM exhibit a para-cervical weak zone. SROM FM exhibit a comparable zone on the tear line. The mean rupture strength within weak zones was 60% of the remaining membranes (P < .001). AROM and SROM FM weak zones both exhibit increased matrix metalloproteinase 9, increased poly (ADP-ribose) polymerase I cleavage, decreased tissue inhibitor of metalloproteinase 3 protein, and histology consistent with remodeling and apoptosis. Conclusion: Vaginally delivered AROM FM contain a weak zone overlying the cervix. Vaginally delivered ASORM FM contain a weak zone adjacent to the tear line that exhibits biochemical and mechanical characteristics suggestive of collagen remodeling and apoptosis comparable to those of the AR FM weak zone.

Decreased adherence and spontaneous separation of fetal membrane layers--amnion and choriodecidua--a possible part of the normal weakening process.

INTRODUCTION The fetal membrane (FM) layers, amnion and choriodecidua, are frequently noted to have varying degrees of separation following delivery. FM layers normally separate prior to rupture during in vitro biomechanical testing. We hypothesized that the adherence between amnion and choriodecidua decreases prior to delivery resulting in separation of the FM layers and facilitating FM rupture. METHODS FM from 232 consecutively delivered patients were examined to determine the extent of spontaneous separation of the FM layers at delivery. Percent separation was determined by the weight of separated FM tissue divided by the total FM weight. Separately, the adherence between intact FM layers was determined. FM adherence was tested following term vaginal delivery (13), term unlabored cesarean section (10), and preterm delivery (6). RESULTS Subjects enrolled in the two studies had similar demographic and clinical characteristics. FM separation was present in 92.1% of membranes. Only 4.3% of FM delivered following spontaneous rupture of the fetal membranes (SROM) had no detectable separation. 64.7% of FM had greater than 10% separation. FM from term vaginal deliveries had significantly more separation and were less adherent than FM of term unlabored, elective cesarean section (39.0+/-34.4% vs 22.5+/-30.9%, p=.046 and 0.041+/-0.018N/cm vs 0.048+/-0.019N/cm, p<.005). Preterm FM had less separation and were more adherent than term FM (9.95+/-17.7% vs 37.5+/-34.4% and 0.070+/-0.040N/cm vs 0.044+/-0.020N/cm; both p<.001). CONCLUSIONS Separation of the amnion from choriodecidua at delivery is almost universal. Increased separation is associated with decreased adherence as measured in vitro. Increased separation and decreased adherence are seen both with increasing gestation and with labor suggesting both biochemical and mechanical etiologies. The data are consistent with the hypothesis that FM layer separation is part of the FM weakening process during normal parturition.

Autoimmune disease as a cause of reproductive failure

High-risk pregnancy is the most common clinical association with antiphospholipid antibodies; the principal manifestations are pregnancy loss and early preeclampsia. Membership in this family of antibodies is continually growing and includes antibodies against a variety of phospholipids, phospholipid-protein complexes, and phospholipid-binding proteins. The current information in the literature is inadequate to clearly implicate a subgroup of antiphospholipid antibodies or a particular pathophysiologic mechanism as being responsible for poor pregnancy outcomes. It is clear, however, that prevalent diagnostic tests for LA and aCL are extremely useful to identify many of these patients, but are inadequate for diagnosis of all patients with autoimmune pregnancy loss or to elucidate the pathophysiology. Many patients who present clinically with autoimmune-like pregnancy complications currently are negative in tests for LA or aCL, but have antibodies against annexin V, phosphatidylserine, or other relevant antigens. The greatest risk for a complicated pregnancy is conveyed by a subgroup of antibodies that affect the normal function of placental trophoblast. As clinical laboratory tests designed to detect more members of the antiphospholipid antibody family become available, understanding of this complicated disease (APS) will increase.

Exercise Training and Dietary Glycemic Load May Have Synergistic Effects on Insulin Resistance in Older Obese Adults

Background/Aims: The aim of this study was to assess the combined effects of exercise and dietary glycemic load on insulin resistance in older obese adults. Methods: Eleven men and women (62 ± 2 years; 97.6 ± 4.8 kg; body mass index 33.2 ± 2.0) participated in a 12-week supervised exercise program, 5 days/week, for about 1 h/day, at 80–85% of maximum heart rate. Dietary glycemic load was calculated from dietary intake records. Insulin resistance was determined using the euglycemic (5.0 mM) hyperinsulinemic (40 mU/m2/min) clamp. Results: The intervention improved insulin sensitivity (2.37 ± 0.37 to 3.28 ± 0.52 mg/kg/min, p < 0.004), increased VO2max (p < 0.009), and decreased body weight (p < 0.009). Despite similar caloric intakes (1,816 ± 128 vs. 1,610 ± 100 kcal/day), dietary glycemic load trended towards a decrease during the study (140 ± 10 g before, vs. 115 ± 8 g during, p < 0.04). The change in insulin sensitivity correlated with the change in glycemic load (r = 0.84, p < 0.009). Four subjects reduced their glycemic load by 61 ± 8%, and had significantly greater increases in insulin sensitivity (78 ± 11 vs. 23 ± 8%, p < 0.003), and decreases in body weight (p < 0.004) and plasma triglycerides (p < 0.04) compared to the rest of the group. Conclusion: The data suggest that combining a low-glycemic diet with exercise may provide an alternative and more effective treatment for insulin resistance in older obese adults.

Neonatal anthropometric measurements to predict birth weight by ultrasound.

OBJECTIVE: To develop a more accurate ultrasound birth weight (BW) model using neonatal anthropometric measurements.STUDY DESIGN: Two hundred thirty-one newborns were evaluated. Measurements included weight; head, chest, and abdominal circumferences (umbilicus and liver), humerus, and femur lengths. Infants were randomly assigned into two groups (G1 and G2). Anthropometric measurements that are obtainable by ultrasound were generated from G1. Stepwise regression and a bootstrap analysis were used to create the prediction models. The models were validated using G2.RESULTS: The final stepwise regression model included FL and circumferences of the head, chest, and abdomen. The correlations were: G1: R2=0.91, p<0.001; G2: R2=0.90 p<0.001. There was no difference between derived and actual BW in G1 (p=0.42) or G2 (p=0.28). The mean absolute percent error between the prediction model and actual BW was 3.8%.CONCLUSION: Neonatal anthropometric models are strongly predictive of actual BW. This model will be tested prospectively using ultrasound to predict fetal weight.

A randomized open-label controlled trial of chlorhexidine-alcohol vs povidone-iodine for cesarean antisepsis: the CAPICA trial

BACKGROUND: Identification of optimal surgical site antisepsis preparations may reduce cesarean‐related surgical site infections. Two recently published investigations examined efficacy of chlorhexidine‐alcohol and iodine‐alcohol preparations. No previous randomized controlled trial has compared chlorhexidine‐alcohol to povidone‐iodine aqueous scrub and paint in reduction of cesarean‐related surgical site infection. OBJECTIVE: The purpose of the study was to determine if chlorhexidine‐alcohol would result in fewer surgical site infections than povidone‐iodine when used as skin antisepsis preparation prior to cesarean delivery. STUDY DESIGN: This study was a single‐center pragmatic randomized controlled trial at an urban tertiary care institution to compare chlorhexidine‐alcohol 26‐mL single‐step applicator to povidone‐iodine aqueous scrub and paint 236‐mL wet skin tray as preoperative skin antiseptic preparation for women undergoing cesarean delivery. Patients were eligible for study participation if they could provide informed consent in English or Spanish, were ≥18 years of age, did not have clinical chorioamnionitis, were unlikely to be lost to follow‐up, and had no sensitivities to chlorhexidine, betadine, or iodine. Treatment was assigned by computer‐generated simple 1:1 randomization immediately before skin preparation. The primary outcome was surgical site infection occurring within 30 days of cesarean delivery including ≥1 of: superficial or deep surgical site infection, or endometritis, according to Centers for Disease Control and Prevention definitions. Analysis was by intent to treat. Categorical outcomes were compared using Fisher exact test. The Wilcoxon rank‐sum test was performed for continuous outcomes. This trial was institutional review board approved and registered at ClinicalTrials.gov (NCT02202577). RESULTS: In all, 932 subjects (461 assigned to chlorhexidine‐alcohol, 471 assigned to povidone‐iodine) were randomized from February 2013 through May 2016. Rate of follow‐up evaluation after 30 days was 99% (455) in the chlorhexidine‐alcohol group and 97% (455) in the povidone‐iodine group. Surgical site infection occurred in 29 (6.3%) of the chlorhexidine‐alcohol group and 33 (7.0%) in the povidone‐iodine group (P = .38). The rates of individual components of the primary outcome were as follows: superficial surgical site infection (4.6% v 5.5%; P = .55), deep surgical site infection (0.0% v 0.4%; P = .50), and endometritis (1.7% v 1.1%; P = .42) in chlorhexidine‐alcohol vs povidone‐iodine arms, respectively. All results were similar in per protocol analysis. CONCLUSION: Preoperative antiseptic skin preparation with chlorhexidine‐alcohol 26‐mL single‐step applicator before cesarean did not result in less frequent surgical site infection when compared with povidone‐iodine aqueous scrub and paint 236‐mL wet skin preparation tray. Povidone‐iodine should still be considered as acceptable for preoperative surgical site antisepsis for cesarean delivery.

Comparison of 2- and 3-Dimensional Sonography for Estimation of Birth Weight and Neonatal Adiposity in the Setting of Suspected Fetal Macrosomia

To compare the accuracy of 2‐dimensional (2D) and 3‐dimensional (3D) fetal measurements for prediction of birth weight Z score and neonatal adiposity (percent body fat) in the setting of suspected fetal macrosomia.

Acknowledgement to the 2009 Reviewers

Helmut Heseker, Paderborn, Germany Manfred Hüttinger, Vienna, Austria Mohsen Janghorbani, Isfahan, Iran Miroslaw Jarosz, Warsaw, Poland Majken K. Jensen, Boston, Mass., USA Alex Johnstone, Aberdeen, UK Anthony Kafatos, Heraklion, Greece Andre Pascal Kengne, Camperdown, N.S.W., Australia Arthur Klatsky, Oakland, Calif., USA Nanne Kleefstra, Zwolle, The Netherlands Marlena Kruger, Palmerston North, New Zealand Anura Kurpad, Bangalore, India Denis Lairon, Marseille, France Wolfgang Langhans, Zürich, Switzerland Mark Lawrence, Melbourne, Vic., Australia Donald K. Layman, Urbana, Ill., USA James V. Leonard, London, UK Lars Libuda, Dortmund, Germany Xu Lin, Shanghai, China Jakob Linseisen, Munich, Germany Dieter Luetjohann, Bonn, Germany Silvia Maggini, Basel, Switzerland Philippe Marmillot, Washington, D.C., USA Franscesco Marotta, Milano, Italy Eva Martos, Budapest, Hungary Velimir Matkovic, Columbus, Ohio, USA Regis Moreau, Corvallis, Oreg., USA Luis A. Moreno, Zaragoza, Spain Yuji Naito, Kyoto, Japan Serge Nef, Geneva, Switzerland Hee Young Paik, Seoul, Korea Mihalis I. Panagiotidis, Reno, Nev., USA Sun Ming Park, Asan-si, Korea Kristina Pentieva, Ulster, UK Carmen Perez-Rodrigo, Bilbao, Spain Nancy M. Petry, Farmington, Conn., USA John M. Pettifor, Johannesburg, South Africa Spencer Proctor, Edmonton, Alta., Canada Ana Maria Proenza Arenas, Palma de Mallorca, Spain Giuliano Ramadori, Göttingen, Germany Aune Rehema, Tartu, Estonia Lajos Rethy, Budapest, Hungary Gerald Rimbach, Kiel, Germany Glorimar Rosa, Rio de Janeiro, Brazil Catherine A. Ross, University Park, Pa., USA Elaine Rush, Auckland, NZ Lydia Afman, Wageningen, The Netherlands Tasnime Akbaraly, London, UK Anthony Alberg, Baltimore, Md., USA Hooman Allayee, Los Angeles, Calif., USA James W. Anderson, Lexington, Ky., USA Bahram Arjmandi, Tallahassee, Fla., USA Georgianne L. Arnold, Rochester, N.Y., USA Benoit Arsenault, Québec, Qué., Canada Fereidoun Azizi, Tehran, Iran Matthias Baum, Kaiserslautern, Germany Giorgio Bedogni, Milano, Italy Joe Begley, Poole, UK Aloys Berg, Freiburg, Germany Renate Bergmann, Berlin, Germany Odilia I. Bermudez, Boston, Mass., USA Francisco Blanco-Vaca, Barcelona, Spain William S. Blaner, New York, N.Y., USA Pontus Boström, Göteborg, Sweden Regina Brigelius-Flohé, Nuthetal, Germany Veronika Butterweck, Gainesville, Fla., USA Anette Buyken, Dortmund, Germany Philip C. Calder, Southampton, UK Dexter Canoy, Manchester, UK Namsoo Chang, Seoul, Korea Supranee Changbumrung, Bangkok, Thailand Marie-Aline Charles, Villejuif, France Armand B. Christophe, Ghent, Belgium Nain-Feng Chu, Taipei, Taiwan Dolores Corella, Valencia, Spain Lindsey Darrow, Atlanta, Ga., USA Tamás Decsi, Pécs, Hungary Antonio Di Stefano, Chieti, Italy Marie-Claude Dop, Rome, Italy Klaus Eder, Freising, Germany Mathias Fasshauer, Leipzig, Germany Annie Ferland, Québec, Qué., Canada Jose Fernandez, Birmingham, Ala., USA Nicola Fuiano, Foggia, Italy Claudio Galli, Milano, Italy Dieter Genser, Vienna, Austria Frank Greer, Madison, Wisc., USA M.H. Hamdaoui, Tunis, Tunisia Igor Harsch, Erlangen, Germany Hans Hauner, Munich, Germany Alan S. Hazell, Montréal, Qué., Canada Erik Hemmingsson, Stockholm, Sweden