Chie-Pein Chen

Parallel vertical compression sutures: a technique to control bleeding from placenta praevia or accreta during caesarean section

Fourteen women with placenta praevia (including one who also had placenta accreta) undergoing caesarean section had massive bleeding after removal of the placenta. In order to preserve the uterus, two parallel vertical compression sutures were placed in the lower segment to compress the anterior and posterior walls of the lower uterine segment. The haemorrhage from the lower segment stopped immediately after the knots were tightened. All women later resumed normal menstrual flow with no apparent complications. Two of the 14 women had a spontaneous pregnancy one to two years after the operation. This parallel vertical compression suturing technique is simple, easy and effective for controlling bleeding in women with placenta praevia or accreta. We suggest that this technique be tried first before other more complex procedures are undertaken.

Acute pancreatitis in pregnancy

BACKGROUND Acute pancreatitis in pregnancy is rare. Our purpose in this study was to discuss the etiology, incidence and course of pancreatitis in pregnancy and to evaluate the maternal and perinatal outcomes. METHODS Pregnant women with pancreatitis admitted to China Medical College Hospital, Taiwan, from 1980 to 1995 were studied retrospectively. A total of 16 patients were enrolled in the study. Two patients had gallstones and hyperlipidemia; four had gallstones alone; seven had hyperlipidemia alone; one had gestational diabetes mellitus; one had hyperparathyroidism and pregnancy-induced hypertension alone; and one had Hashimotos thyroiditis. Conservative treatment and low-fat diets were administered to the patients. RESULTS The incidence of gestational pancreatitis in this series was one in 6,790 pregnancies. The fetal outcome included eight preterm deliveries and three fetal losses. There were no maternal mortalities. The etiologies of pancreatitis were primary hyperlipidemia (56.3%) and gallstones (37.5%). All patients responded favorably to supportive therapy, and most of the symptoms subsided after delivery. CONCLUSIONS Early diagnosis and treatment is of utmost importance in the management of acute pancreatitis in pregnancy. The results of this study showed good maternal outcome following appropriate treatment. Fetal prognosis was less favorable and was most often associated with hyperlipidemia. Fetal monitoring is essential during the management of pancreatitis in pregnancy.Objective. The highest maternal–fetal risk from pancreatitis in pregnancy is likely to be posed by the most severe cases, which we have compared with mild cases. Design. Retrospective observational study. Setting. A general surgery department of a university referral hospital in Nanjing, China. Population. Eighteen pregnancies complicated with severe acute pancreatitis and 51 pregnancies complicated with mild acute pancreatitis. Methods. Medical records were reviewed for every pregnant woman with mild or severe acute pancreatitis during January 1999 to December 2009. Main Outcome Measures. Information on demographics, clinical and laboratory data, maternal and fetal outcomes. Results. Gestational age of onset was significantly higher in the severe acute pancreatitis group than in the mild acute pancreatitis group. Severe hypertriglyceridemia was considered the main cause of severe acute pancreatitis (OR 20.7; 95% CI 4.6–92.4, p<0.001), while biliary disease contributed to the etiology of mild acute pancreatitis (OR 7.3; 95% CI 1.8–30.1, p<0.01). Abortions and preterm infants contributed to fetal loss in the mild group, while fetal death and stillbirth contributed in the severe group. Conclusions. Hyperlipidemic pancreatitis and biliary pancreatitis are the main causes of severe and mild disease, respectively. Severe acute pancreatitis in pregnancy usually occurs in the third trimester, and the affected severe patients are more liable to develop a critical condition that results in higher risk of intrauterine fetal death.

GCM1 Regulation of the Expression of Syncytin 2 and Its Cognate Receptor MFSD2A in Human Placenta

Syncytin 2 is a newly identified placental membrane protein with fusogenic and immunosuppressive activities. Major facilitator superfamily domain containing 2A (MFSD2A) is the cognate receptor for syncytin 2-mediated cell-cell fusion. Both syncytin 2 and MFSD2A are highly expressed in placenta. In this study to understand the regulation of syncytin 2 and MFSD2A expression in placenta, we found that syncytin 2 gene is epigenetically silenced in nonplacental cells by cytosine-phosphate-guanine (CpG) dinucleotide methylation and that expression of syncytin 2 and MFSD2A genes are regulated by the placental transcription factor GCM1 in placental cells. Functional GCM1-binding sites were identified in syncytin 2 and MFSD2A promoters based on electrophoretic mobility shift assay and chromatin immunoprecipitation assay. Because GCM1 activity is decreased in hypoxic placental cells, we further confirmed that expression of MFSD2A is downregulated in hypoxic BeWo choriocarcinoma cells. Interestingly, ectopic expression of GCM1 activated syncytin 2 and MFSD2A expression in MCF-7 breast cancer cells and facilitated MCF-7 cell fusion. The expression of syncytin 2 in MCF-7 cells was partly attributed to CpG demethylation in the syncytin 2 promoter in the presence of GCM1. Our results suggest that GCM1 is a critical factor in controlling placental cell fusion through transcriptional regulation of syncytin 2 and MFSD2A gene expression in placenta. In addition, GCM1 may also play an important role in the epigenetic regulation of syncytin 2 gene expression.

Mechanism of Hypoxia-induced GCM1 Degradation IMPLICATIONS FOR THE PATHOGENESIS OF PREECLAMPSIA

Preeclampsia is a major pregnancy-specific disorder affecting 5–7% of pregnancies worldwide. Although hypoxia caused by incomplete trophoblast invasion and impaired spiral arterial remodeling is thought to be a major cause of preeclampsia, how hypoxia affects placental development remains uncertain. GCM1 (glial cells missing homolog 1) is a transcription factor critical for placental development. In preeclampsia, GCM1 and its target genes syncytin 1 and placental growth factor, important for syncytiotrophoblast formation and placental vasculogenesis, are all decreased. Here we present evidence that GCM1 is a major target of hypoxia associated with preeclampsia. We show that hypoxia triggers GCM1 degradation by suppressing the phosphatidylinositol 3-kinase-Akt signaling pathway, leading to GSK-3β activation. Activated GSK-3β phosphorylates GCM1 on Ser322, which in turn recruits the F-box protein FBW2, leading to GCM1 ubiquitination and degradation. Importantly, the GSK-3β inhibitor LiCl prevented hypoxia-induced GCM1 degradation. Our study identifies a molecular basis for the disrupted GCM1 transcription network in preeclampsia and provides a potential avenue for therapeutic intervention.

Transforming growth factor-β induces CD44 cleavage that promotes migration of MDA-MB-435s cells through the up-regulation of membrane type 1-matrix metalloproteinase

CD44, a transmembrane receptor for hyaluronic acid, is implicated in various adhesion‐dependent cellular processes, including cell migration, tumor cell metastasis and invasion. Recent studies demonstrated that CD44 expressed in cancer cells can be proteolytically cleaved at the ectodomain by membrane type 1‐matrix metalloproteinase (MT1‐MMP) to form soluble CD44 and that CD44 cleavage plays a critical role in cancer cell migration. Here, we show that transforming growth factor‐β (TGF‐β), a multifunctional cytokine involved in cell proliferation, differentiation, migration and pathological processes, induces MT1‐MMP expression in MDA‐MB‐435s cells. TGF‐β‐induced MT1‐MMP expression was blocked by the specific extracellular regulated kinase‐1/2 (ERK1/2) inhibitor PD98059 and the specific phosphoinositide 3‐OH kinase (PI3K) inhibitor LY294002. In addition, treatment with SP600125, an inhibitor for c‐Jun NH2‐terminal kinase (JNK), resulted in a significant inhibition of MT1‐MMP production. These data suggest that ERK1/2, PI3K, and JNK likely play a role in TGF‐β‐induced MT1‐MMP expression. Interestingly, treatment of MDA‐MB‐435s cells with TGF‐β resulted in a colocalization of MT1‐MMP and CD44 in the cell membrane and in an increased level of soluble CD44. Using an electric cell‐substrate impedance sensing cell‐electrode system, we demonstrated that TGF‐β treatment promotes MDA‐MB‐435s cell migration, involving MT1‐MMP‐mediated CD44 cleavage. MT1‐MMP siRNA transfection‐inhibited TGF‐β‐induced cancer cell transendothelial migration. Thus, this study contributes to our understanding of molecular mechanisms that play a critical role in tumor cell invasion and metastasis.

Angiogenesis in Differentiated Placental Multipotent Mesenchymal Stromal Cells Is Dependent on Integrin α5β1

Human placental multipotent mesenchymal stromal cells (hPMSCs) can be isolated from term placenta, but their angiogenic ability and the regulatory pathways involved are not known. hPMSCs were shown to express integrins αv, α4, α5, β1, β3, and β5 and could be induced to differentiate into cells expressing endothelial markers. Increases in cell surface integrins α5 and β1, but not α4, αvβ3, or αvβ5, accompanied endothelial differentiation. Vascular endothelial growth factor-A augmented the effect of fibronectin in enhancing adhesion and migration of differentiated hPMSC through integrin α5β1, but not αvβ3 or αvβ5. Formation of capillary-like structures in vitro from differentiated cells was inhibited by pre-treatment with function-blocking antibodies to integrins α5 and β1. When hPMSCs were seeded onto chick chorioallantoic membranes (CAM), human von Willebrand factor-positive cells were observed to engraft in the chick endothelium. CAMs transplanted with differentiated hPMSCs had a greater number of vessels containing human cells and more incorporated cells per vessel compared to CAMs transplanted with undifferentiated hPMSCs, and overall angiogenesis was enhanced more by the differentiated cells. Function-blocking antibodies to integrins α5 and β1 inhibited angiogenesis in the CAM assay. These results suggest that differentiated hPMSCs may contribute to blood vessel formation, and this activity depends on integrin α5β1.

Renal biopsy in pregnancies complicated by undetermined renal disease

Background. The aim of this retrospective study was to verify the role of renal biopsy in pregnancies complicated by renal dysfunction.

Risk factors and prevalence rate of restless legs syndrome among pregnant women in Taiwan

BACKGROUND The goal of this study was to assess the prevalence and clinical correlates of restless legs syndrome (RLS) among pregnant Taiwanese women. METHODS We enrolled 461 pregnant women (18-45 years) admitted at Mackay Memorial Hospital for delivery from September 2010 to May 2011. The face-to-face questionnaire used to gather data included assessment of RLS diagnostic criteria, and questions related to RLS. RESULTS The overall prevalence rate of RLS among the study participants was 10.4%; 2.8% were categorized as having chronic RLS. Participants without RLS reported higher folate and iron supplement consumption than those with RLS. Multivariate analysis revealed significant associations of RLS with anemia and peptic ulcer disease. Participants with transient RLS during pregnancy reported more regular coffee consumption before pregnancy, and better sleep latency, duration, and efficiency, than those with chronic RLS. Overall, 81.2% of RLS sufferers reported sleep disturbances. CONCLUSIONS Our study revealed highly prevalent but poorly recognized RLS among Taiwanese pregnant women. The identification of predictors such as medical comorbidities, and protectors such as folate and iron supplements, is warranted for obstetric RLS. In most cases, symptoms began during the second or third trimester and resolved within a week after delivery. Restricted coffee consumption before pregnancy is encouraged, but further evidence is needed to support this recommendation.

The Changing Face of Early-onset Neonatal Sepsis After the Implementation of a Maternal Group B Streptococcus Screening and Intrapartum Prophylaxis Policy—A Study in One Medical Center

BACKGROUND Early-onset sepsis (EOS) is the major cause of neonatal morbidity and mortality. Maternal group B Streptococcus (GBS) screening and intrapartum antibiotic prophylaxis (IAP) were implemented in our hospital in 2004. Our aim was to evaluate the effectiveness of the program and changes in pathogens and antibiotic susceptibility. METHODS The medical charts of mothers and infants with EOS between January 2001 and November 2008 were retrospectively reviewed. EOS was defined as sepsis occurring within 72 hours of birth. Data were pooled and compared for January 2001 through September 2004 (Period 1, without GBS screening) and October 2004 through November 2008 (Period 2, with GBS screening and IAP). RESULTS The GBS screening rate increased from 10.11% in 2004 to 65% in 2008 and the IAP rate increased from 40% in 2004 to 90% in 2008. The most common EOS pathogen in Period 1 was GBS (45.4%), which decreased to 20% in Period 2 (p=0.081; trend p=0.009). The percentage of EOS because of Escherichia coli in Period 1 was 40.9% but increased to 70% in Period 2 (p=0.059). E coli EOS increased in extremely low birth weight premature babies weighing 500-1000g from Period 1 to Period 2 (p=0.031). The incidence of ampicillin-resistant E coli EOS was relatively high, but no significant change (88.9% vs. 92.9%) after implementation of GBS screening and IAP was noted. CONCLUSION GBS screening plus IAP is effective in decreasing the incidence of GBS EOS; however, an increase in EOS caused by E coli was noted. Monitoring of pathogens causing EOS is important for effective treatment.

The Implication of Aberrant GM-CSF Expression in Decidual Cells in the Pathogenesis of Preeclampsia

Preeclampsia is characterized by an exaggerated systemic inflammatory state as well as shallow placentation. In the decidual implantation site, preeclampsia is accompanied by an excessive number of both macrophages and dendritic cells as well as their recruiting chemokines, which have been implicated in the impairment of endovascular trophoblast invasion. Granulocyte-macrophage colony-stimulating factor is known to regulate the differentiation of both macrophages and dendritic cells, prompting both in vivo and in vitro evaluation of granulocyte-macrophage colony-stimulating factor expression in human decidua as well as in a mouse model of preeclampsia. This study revealed increased granulocyte-macrophage colony-stimulating factor expression levels in preeclamptic decidua. Moreover, both tumor necrosis factor-α and interleukin-1 β, cytokines that are implicated in the genesis of preeclampsia, markedly up-regulated granulocyte-macrophage colony-stimulating factor production in cultured first-trimester human decidual cells. The conditioned media of these cultures promoted the differentiation of both macrophages and dendritic cells from a monocyte precursor. Evaluation of a murine model of preeclampsia revealed that the decidua of affected animals displayed higher levels of immunoreactive granulocyte-macrophage colony-stimulating factor as well as increased numbers of both macrophages and dendritic cells when compared to control animals. Because granulocyte-macrophage colony-stimulating factor is a potent inducer of differentiation and activation of both macrophages and dendritic cells, these findings suggest that this factor plays a crucial role in the pathogenesis of preeclampsia.