Emmet Hirsch

Intrauterine infection and preterm labor

Preterm labor is defined as labor that begins before 37 completed weeks of pregnancy. More than 12% of infants born in the USA are preterm. At least 40% of preterm births are associated with intrauterine infection. Toll-like receptors (TLRs) are members of a family of cell-surface proteins responsible for recognition of a diverse spectrum of bacterial, viral and fungal pathogens. TLRs initiate the host innate (i.e. non-adaptive) immune response, inducing a proinflammatory cascade involving cytokines, chemokines, prostaglandins, and other effector molecules that result in the characteristic phenomena of labor, such as uterine contractions and rupture of fetal membranes. These cascades may also be activated by mechanisms that are not primarily infectious but are accompanied by inflammatory responses. Now that the molecular mechanisms linking infection and labor have been, to a large extent, elucidated, the challenge is to identify points of overlap with non-infectious causes of labor and to find intervention strategies that can minimize the negative impact of preterm delivery.

Activation of Toll-like Receptors 2 or 3 and Preterm Delivery in the Mouse

The objective of this study is to test whether the activation of toll-like receptors (TLRs) 2 and 3 (innate immune receptors for gram-positive and viral pathogens, respectively) can induce preterm delivery. One uterine horn of preterm pregnant CD-1 mice at approximately 75% of gestation was injected with TLR-2 ligands (lipoteichoic acid [LTA] or peptidoglycan [PGN]) or the TLR-3 ligand polyinosinic:cytidylic acid (poly[I:C]). Preterm delivery was recorded. In a separate group of mice, tissue mRNAs were quantified by reverse transcriptase polymerase chain reaction 5 hours after treatment with PGN or poly(I:C). Intrauterine PGN and LTA induced preterm delivery, reaching 100% at maximal doses. Intraperitoneal PGN also induced preterm delivery but at lower rates (maximum = 55%). Intrauterine poly(I:C) induced preterm birth in up to 31% of mice. Poly(I:C) induced uterine interferon β and chemokine (C-C motif) ligand 5 (CCL5, also known as RANTES) but not interleukin 1β, tumor necrosis factor, or lipopolysaccharide-induced CXC chemokine. PGN did not alter these mRNAs when compared with saline. Neither treatment induced gene expression in fetal membranes. Activation of either TLR-2 or -3 can induce preterm delivery in the mouse. Activation of TLR-3 with poly(I:C) induces interferon β and the chemokine CCL5 in uterine tissues but not in fetal membranes.

The Molecular Pathophysiology of Bacterially Induced Preterm Labor: Insights From the Murine Model:

Premature delivery, the most important problem in obstetrics in developed countries, continues to vex clinicians and researchers. Despite decades of investigation, the pathophysiology of premature labor is incompletely understood, and therapies or preventive strategies tailored to each of the many potential causes do not exist. The present review addresses one cause of prematurity, namely, intrauterine bacterial infection. Given the vastness of the literature for even this single etiology, we focus on the mouse as a model organism from which much can be learned about mammalian parturition. The underpinnings of bacterially induced labor are believed to involve a signaling cascade that begins with recognition of offending pathogens by cell-surface receptors (toll-like receptors). This cascade then operates through multiple branching and redundant pathways to bring about the changes within the gestational compartment that produce cervical ripening, labor, and ultimately delivery. The major challenge facing researchers is to understand the levels of complexity in the host response, so that prevention and treatment strategies may be sufficiently focused to minimize unwanted side effects, yet sufficiently broad to be effective. Given the complexity of the problem, this understanding can be aided by efficient model systems, of which one in vivo example is the mouse, an organism that shares with humans many similarities in the biochemical and molecular aspects of inflammation-induced preterm labor. We propose that tools with the power to assess simultaneously the myriad elements of the hypothesized signaling cascade (ie, genomic and proteomic technologies) are important components of the solution to the puzzle of parturition.

Synergy Between Viral and Bacterial Toll-Like Receptors Leads to Amplification of Inflammatory Responses and Preterm Labor in the Mouse

Toll-like receptors (TLRs) recognize molecular constituents of pathogens and activate host innate immune responses. TLR2 responds to Gram-positive organisms and components of their cell walls. TLR3 responds to double-stranded RNA (an intermediate in viral replication). A mouse macrophage cell line (RAW 264.7) and freshly obtained mouse peritoneal macrophages were treated in tissue culture for 5 or 10 h with either peptidoglycan (PGN; a TLR2 ligand, 1 μg/ml), polyinosinic:cytidylic acid (poly(I:C); a TLR3 ligand, 10 μg/ml), both PGN and poly(I:C), or neither. Total RNA was extracted, and RT-PCR was performed. A mouse model of preterm birth induced by intrauterine injection of TLR ligands was used to test in vivo effects. Compared to stimulation with either PGN or poly(I:C) alone, stimulation of macrophages with both ligands (whether simultaneously or sequentially) resulted in synergistic expression of inflammatory mediators, including inducible nitric oxide synthase, interleukin 1 beta, tumor necrosis factor alpha, and the chemokine CCL5 (RANTES). Using peritoneal macrophages obtained from mutant and control mice, this synergy was determined to be dependent upon TLR2 and the TLR-related intracellular adaptor proteins MYD88 and TICAM1 (TRIF). Simultaneous administration of both PGN and poly(I:C) to pregnant mice also produced dramatic synergy in the occurrence of preterm delivery. These results support a possible role for viral infection in preterm labor. Synergy in the mechanisms of parturition suggests the existence of a “two-hit” trigger mechanism that minimizes responses to stimuli of limited biological significance while providing an efficient amplification strategy for rapid activation of labor in response to multiple or more severe insults.

Inflammatory Cytokines in a Murine Model of Infection-Induced Preterm Labor: Cause or Effect?

Objective: To characterize the expression of inflammatory cytokines in a murine model of preterm delivery induced by heat-killed bacteria. Methods: The right uterine horns of female CD-1 mice on day 14.5 of 19-20 days of gestation were inoculated with either sterile media or killed Excherichia coli bacteria (105-1010 organisms per mouse). The incidence of preterm delivery was recorded. The concentrations of cytokines (itnerleukin [IL-] 1α, IL-1β, IL-1 receptor antagonist [IL-1ra], IL-6, and tumor necrosis factor α [TNFα]) within maternal and fetal tissue homogenates were determined by enzyme-linked immunosorbent assay at various times after inoculation. Results: Killed E. coli induced preterm delivery in a dose-dependent fashion. Inoculation with 1010 bacteria (sufficient to cause delivery in all mice) produced increases in IL-1α, IL-1β, IL-6, and TNFα within uteri and fetal membranes, but not within placentas, fetal bodies, and maternal serum. Maximum mean uterine levels of IL-1 and IL-6 exceeded those of fetal tissues (membranes, placentas, and fetal bodies) by greater than 15-fold. Maximal uterine IL-1 and TNFα levels following inoculation with 1010 bacteria exceeded those that followed inoculation with 107 bacteria (below the threshold for delivery) by 2.5- to 5-fold. The anti-inflammatory cytokine IL-1ra was expressed in higher concentrations in fetal than in maternal tissues and was unaltered by the bacterial inoculum. Conclusions: E. coli induce labor in mice even in the absence of bacterial viability. Although IL-1 and TNFα were upregulated by bacterial inocula causing delivery, peak levels were only 2.5- to 5-fold higher than those that occurred with inocula below the threshold for delivery (1000-fold fewer bacteria). Whether IL-1 and TNFα mediate labor during in vivo infection, or whether the upregulation of these cytokines merely represents an epiphenomenon accompanying infection, remains unknown.

Regulation of Apoptosis and Innate Immune Stimuli in Inflammation-Induced Preterm Labor

An innate immune response is required for successful implantation and placentation. This is regulated, in part, by the a2 isoform of V-ATPase (a2V) and the concurrent infiltration of M1 (inflammatory) and M2 (anti-inflammatory) macrophages to the uterus and placenta. The objective of the present study was to identify the role of a2V during inflammation-induced preterm labor in mice and its relationship to the regulation of apoptosis and innate immune responses. Using a mouse model of infection-induced preterm delivery, gestational tissues were collected 8 h after intrauterine inoculation on day 14.5 of pregnancy with either saline or peptidoglycan (PGN; a TLR 2 agonist) and polyinosinic-polycytidylic acid [poly(I:C); a TLR3 agonist], modeling Gram-positive bacterial and viral infections, respectively. Expression of a2V decreased significantly in the placenta, uterus, and fetal membranes during PGN+poly(I:C)-induced preterm labor. Expression of inducible NO synthase was significantly upregulated in PGN+poly(I:C)-treated placenta and uterus. PGN+poly(I:C) treatment disturbed adherens junction proteins and increased apoptotic cell death via an extrinsic pathway of apoptosis among uterine decidual cells and spongiotrophoblasts. F4/80+ macrophages were increased and polarization was skewed in PGN+poly(I:C)-treated uterus toward double-positive CD11c+ (M1) and CD206+ (M2) cells, which are critical for the clearance of dying cells and rapid resolution of inflammation. Expression of Nlrp3 and activation of caspase-1 were increased in PGN+poly(I:C)-treated uterus, which could induce pyroptosis. These results suggest that the double hit of PGN+poly(I:C) induces preterm labor via reduction of a2V expression and simultaneous activation of apoptosis and inflammatory processes.

Surfactant Protein (SP)-A Suppresses Preterm Delivery and Inflammation via TLR2

Toll like receptors (TLRs) are pattern-recognition molecules that initiate the innate immune response to pathogens. Pulmonary surfactant protein (SP)-A is an endogenously produced ligand for TLR2 and TLR4. SP-A has been proposed as a fetally produced signal for the onset of parturition in the mouse. We examined the effect of interactions between SP-A and the pathogenic TLR agonists lipopolysaccharide (LPS), peptidoglycan (PGN) and polyinosinic:cytidylic acid (poly(I:C)) (ligands for TLR4, TLR2 and TLR3, respectively) on the expression of inflammatory mediators and preterm delivery. Three types of mouse macrophages (the cell line RAW 264.7, and fresh amniotic fluid and peritoneal macrophages, including macrophages from TLR4 and TLR2 knockout mice) were treated for up to 7 hours with pathogenic TLR agonists with or without SP-A. SP-A alone had no effect upon inflammatory mediators in mouse macrophages and did not independently induce preterm labor. SP-A significantly suppressed TLR ligand-induced expression of inflammatory mediators (interleukin (IL)-1β, tumor necrosis factor (TNF)-α and the chemokine CCL5) via a TLR2 dependent mechanism. In a mouse inflammation-induced preterm delivery model, intrauterine administration of SP-A significantly inhibited preterm delivery, suppressed the expression of proinflammatory mediators and enhanced the expression of the CXCL1 and anti-inflammatory mediator IL-10. We conclude that SP-A acts via TLR2 to suppress TLR ligand-induced preterm delivery and inflammatory responses.

Interleukin-6 Is Neither Necessary Nor Sufficient for Preterm Labor in a Murine Infection Model:

Objective: The aim of this study was to investigate the role of interleukin 6 (IL-6) in a murine model of bacterially induced preterm delivery. Methods: On day 14.5 of a 19-20-day gestation, female mice underwent one of two interventions. In experiment 1, pregnant right uterine horns were injected at laparotomy with 0.5-20 μg of recombinant human IL-6 (rhIL-6). In experiment 2, IL-6-deficient (IL-6-/-) and wild-type control (IL-6+/+) mice underwent intrauterine inoculation with 105 to 108 heat-killed Excherichia coli organisms. Preterm delivery and maternal survival rates were recorded. Results: In experiment 1, doses as high as 20 μg of IL-6 per mouse resulted in up-regulation of acute phase reactants but did not cause preterm delivery or other adverse maternal or fetal effects. In experiment 2, in bacterially inoculated mice, the absence of matrnal and fetal IL-6 had no effect on preterm delivery rates. Conclusion: IL-6 was neither sufficient nor necessary for preterm delivery in these murine models.

Effect of Stimulation and Antagonism of Interleukin-1 Signaling on Preterm Delivery in Mice

Objective: Transgenic mice that overexpress the interleukin-1 receptor antagonist (IL-1ra), an endogenous competitive inhibitor of interleukin-1 (IL-1) signaling, were used to test whether blockade of IL-1 can prevent bacterially induced preterm delivery in a validated murine model. These IL-1ra transgenic mice have been shown previously to be protected from lethal endotoxin shock. Methods: In a series of four separate experiments, 201 female wild-type and transgenic mice on day 14.5 of a 19-20 day gestation underwent intrauterine injection with either 0.5-20 μg of recombinant human IL-1β (rhIL-1β) or 105-108 heat-killed Escherichia coli organisms. Fetuses were either all wild-type, all transgenic, or of mixed genotype (see below). Preterm delivery and maternal survival rates were recorded. IL-1ra protein levels were determined by enzyme-linked immunosorbent assay (ELISA). Results: Intrauterine administration of IL-1β induced preterm delivery in a dose-dependent manner and did not cause other adverse maternal effects. In bacterially inoculated mice, neither maternal nor fetal carriage of the IL-1ra overrexpression transgene affected preterm delivery rates. Fetal carriage of the IL-1ra transgene did not up-regulate IL-1ra protein levels in maternal or fetal tissues. Conclusion: Although intrauterine IL-1 exposure is sufficient for induction of preterm delivery, it was not possible to prevent bacterially induced preterm birth using the IL-1ra transgene. This may be either because the timing or magnitude of IL-1ra up-regulation in transgenic mice was insufficient to block IL-1s interaction with its receptor, or because bacterially induced laboar in this model does not depend on IL-1 signaling alone.

Altered autophagic flux enhances inflammatory responses during inflammation-induced preterm labor

Cellular organelles and proteins are degraded and recycled through autophagy, a process during which vesicles known as autophagosomes fuse with lysosomes. Altered autophagy occurs in various diseases, but its role in preterm labor (PTL) is unknown. We investigated the role of autophagic flux in two mouse models of PTL compared to controls: 1) inflammation-induced PTL (IPTL), induced by toll-like receptor agonists; and 2) non-inflammation (hormonally)-induced PTL (NIPTL). We demonstrate that the autophagy related genes Atg4c and Atg7 (involved in the lipidation of microtubule-associated protein 1 light chain 3 (LC3) B-I to the autophagosome-associated form, LC3B-II) decrease significantly in uterus and placenta during IPTL but not NIPTL. Autophagic flux is altered in IPTL, as shown by the accumulation of LC3B paralogues and diminishment of lysosome associated membrane protein (LAMP)-1, LAMP-2 and the a2 isoform of V-ATPase (a2V, an enzyme involved in lysosome acidification). These alterations in autophagy are associated with increased activation of NF-κB and proinflammatory cytokines/chemokines in both uterus and placenta. Similar changes are seen in macrophages exposed to TLR ligands and are enhanced with blockade of a2V. These novel findings represent the first evidence of an association between altered autophagic flux and hyper-inflammation and labor in IPTL.