Kara Rood

High Mobility Group-Box 1 (HMGB1) levels are increased in amniotic fluid of women with intra-amniotic inflammation-determined preterm birth, and the source may be the damaged fetal membranes

BACKGROUND High Mobility Group Box-1 (HMGB1) is considered a prototype alarmin molecule. Upon its extracellular release, HMGB1 engages pattern recognition receptors and the Receptor for Advanced Glycation End-products (RAGE) followed by an outpouring of inflammatory cytokines, including interleukin (IL)-6. METHODS We assayed the amniotic fluid (AF) levels of HMGB1 and IL-6 in 255 women that either had a normal pregnancy outcome or delivered preterm. Immunohistochemistry on fetal membranes was used for cellular localization and validation of immunoassay findings. HMGB1 also was analyzed in amniochorion tissue explants subjected to endotoxin. RESULTS AF HMGB1 levels are not gestational age regulated but are increased in women with intra-amniotic inflammation and preterm birth. The likely source is the damaged amniochorion, as demonstrated by immunohistochemistry and explant experiments. CONCLUSIONS Our research supports a role for HMGB1 in the inflammatory response leading to preterm birth. As a delayed phase cytokine, in utero exposure to elevated AF HMGB1 levels may have an impact on the newborn beyond the time of birth.

Skin Microbiota in Obese Women at Risk for Surgical Site Infection After Cesarean Delivery

The obesity pandemic in the obstetrical population plus increased frequency of Cesarean delivery (CD) has increased vulnerability to surgical site infection (SSI). Here we characterized the microbiome at the site of skin incision before and after CD. Skin and relevant surgical sites were sampled before and after surgical antisepsis from obese (n = 31) and non-obese (n = 27) pregnant women. We quantified bacterial biomass by qPCR, microbial community composition by 16sRNA sequencing, assigned operational taxonomic units, and stained skin biopsies from incision for bacteria and biofilms. In obese women, incision site harbors significantly higher bacterial biomass of lower diversity. Phylum Firmicutes predominated over Actinobacteria, with phylotypes Clostridales and Bacteroidales over commensal Staphylococcus and Propionbacterium spp. Skin dysbiosis increased post-surgical prep and at end of surgery. Biofilms were identified post-prep in the majority (73%) of skin biopsies. At end of surgery, incision had significant gains in bacterial DNA and diversity, and obese women shared more genera with vagina and surgeon’s glove in CD. Our findings suggest microbiota at incision differs between obese and non-obese pregnant women, and changes throughout CD. An interaction between vaginal and cutaneous dysbiosis at the incision site may explain the a priori increased risk for SSI among obese pregnant women.

Serum and Urine Thioflavin-T–Enhanced Fluorescence in Severe PreeclampsiaNovelty and Significance

Common features of amyloid-like proteotoxic aggregates are the ability to bind Congo red (congophilia) and to induce fluorescence of thioflavin-T (ThT). Based on the prior discovery that women with preeclampsia exhibit urine congophilia, we proposed that amyloid-like protein aggregates present in urine also circulate in the bloodstream and this feature is linked to disease severity and clinical phenotype. ThT fluorescence was investigated in 217 paired serum and urine samples from women with severe features of preeclampsia (n=101; median [interquartile range] gestational age [GA], 32 [29–35] weeks), mild features of preeclampsia (n=22; GA, 36 [36–37] weeks), chronic hypertension (n=15; GA, 38 [37–39] weeks), healthy pregnant controls (n=57; GA, 39 [38–39] weeks), and nonpregnant controls (n=22). Serum and urine fluorescence attributable to advanced glycation end products was measured in the same samples with correction for autofluorescence. There were no GA-related changes in ThT fluorescence, although near-term serum ThT fluorescence increased compared with nonpregnant state. Compared with healthy pregnant controls, serum and urine ThT fluorescence was increased in severe features of preeclampsia (P<0.001 for both) but not in mild features of preeclampsia or chronic hypertension. Except for chronic hypertension, advanced glycation end products–related fluorescence of serum or urine did not differ from controls. Urine congophilia had a stronger relationship with preeclampsia severity compared with either urine or serum ThT fluorescence. However, serum ThT fluorescence was independently associated with clinical features of hemolysis, elevated liver enzyme levels, and low platelet levels syndrome (P=0.003). We demonstrate that ThT fluorescence, a marker of amyloid-like aggregates, is increased in serum of women with preeclampsia and likely because of their cytotoxicity associated with hemolysis, elevated liver enzyme levels, and low platelet levels syndrome.

An evaluation of fetal heart rate characteristics associated with neonatal encephalopathy: a case‐control study

We sought to identify fetal heart rate (FHR) characteristics that are associated with neonatal encephalopathy (NE).

Integrated microRNA and mRNA network analysis of the human myometrial transcriptome in the transition from quiescence to labor

Abstract We conducted integrated transcriptomics network analyses of miRNA and mRNA interactions in human myometrium to identify novel molecular candidates potentially involved in human parturition. Myometrial biopsies were collected from women undergoing primary Cesarean deliveries in well-characterized clinical scenarios: (1) spontaneous term labor (TL, n = 5); (2) term nonlabor (TNL, n = 5); (3) spontaneous preterm birth (PTB) with histologic chorioamnionitis (PTB-HCA, n = 5); and (4) indicated PTB nonlabor (PTB-NL, n = 5). RNAs were profiled using RNA sequencing, and miRNA-target interaction networks were mined for key discriminatory subnetworks. Forty miRNAs differed between TL and TNL myometrium, while seven miRNAs differed between PTB-HCA vs. PTB-NL specimens; six of these were cross-validated using quantitative PCR. Based on the combined sequencing data, unsupervised clustering revealed two nonoverlapping cohorts that differed primarily by absence or presence of uterine quiescence, rather than gestational age or original clinical cohort. The intersection of differentially expressed miRNAs and their targets predicted 22 subnetworks with enriched representation of miR-146b-5p, miR-223-3p, and miR-150-5p among miRNAs, and of myocyte enhancer factor-2C (MEF2C) among mRNAs. Of four known MEF2 transcription factors, decreased MEF2A and MEF2C expression in women with uterine nonquiescence was observed in the sequencing data, and validated in a second cohort by quantitative PCR. Immunohistochemistry localized MEF2A and MEF2C to myometrial smooth muscle cells and confirmed decreased abundance with labor. Collectively, these results suggest altered MEF2 expression may represent a previously unrecognized process through which miRNAs contribute to the phenotypic switch from quiescence to labor in human myometrium. Summary Sentence Integrated miRNA–mRNA study in human myometrium.

Tenascin-x in Amniotic Fluid and Reproductive Tissues of Pregnancies Complicated by Infection and Preterm Prelabor Rupture of Membranes†

Abstract Preterm prelabor rupture of membranes (PPROM), which can precede or follow intra‐amniotic infection/inflammation (IAI), is a poorly understood pregnancy complication. Tenascin‐X (TNX) is a connective tissue extracellular matrix protein that regulates fibrillogenesis of collagens I, III, and V. Our goal was to investigate the presence and level of soluble TNX (sTNX) in amniotic fluid (AF) and TNX expression in reproductive tissues of pregnancies complicated by PPROM and IAI. We prospectively recruited 334 women pregnant with singletons who had a clinically indicated amniocentesis for genetic karyotyping, lung maturity testing, or rule‐out IAI in the presence or absence of PPROM. We quantified TNX expression in fetal membranes, myometrium, cervix, and placenta using immunological methods and qRT‐PCR. In pregnancies with normal outcomes, AF sTNX levels were GA‐regulated with lower levels toward term. IAI significantly upregulated AF sTNX levels independent of membrane status. AF sTNX levels inversely correlated with fetal membranes tenascin XB (TNXB) mRNA level, which was significantly downregulated by IAI. Western blotting identified characteristic ˜75 and ˜140 kDa sTNX forms in both AF and fetal membranes. Fetal membranes, placenta, and cervix constitutively express TNX with the highest abundance in the amnion. Amnion TNX richness is significantly lost in the setting of IAI. Our results suggest that fetal membranes may be a source of AF sTNX whereby protein and mRNA expression seem to be significantly impacted by inflammation independent of fetal membrane status. A more thorough understanding of TNX changes may be valuable for understanding spontaneous PPROM and to potentially develop therapeutic targets.

Evidence for participation of neutrophil gelatinase-associated lipocalin/matrix metalloproteinase-9 (NGAL•MMP-9) complex in the inflammatory response to infection in pregnancies complicated by preterm birth.

Neutrophil gelatinase‐associated lipocalin (NGAL) is expressed in neutrophils and involved in innate immunity by sequestering iron. NGALs ability to complex with matrix metalloproteinase‐9 (MMP‐9) and extend its gelatinolytic activity led us to investigate its role in pregnancies complicated by preterm birth (PTB) and intra‐amniotic infection/inflammation (IAI).

Torsion of a Term Gravid Uterus: A Possible Cause of Intrauterine Growth Restriction and Abnormal Umbilical Artery Doppler Findings

Due to the increased uterine size and the presence of the rectosigmoid colon, dextro-rotation of the gravid uterus up to 45° is common. Uterine torsion, defined as rotation greater than 45°, is a rare occurrence, and, consequently, its potential implications and effects on pregnancy are underreported in the literature. The diagnosis is often made incidentally at the time of cesarean delivery, but complications such as abdominal pain, fetal malpresentation, and maternal death have previously been reported.1,2 The following represents the first reported case of concern for intrauterine growth restriction and newly diagnosed abnormal umbilical artery Doppler findings in the setting of uterine torsion. A 22-year-old woman, gravida 2, para 1, presented at a gestational age of 37 weeks 2 days for evaluation of fetal growth. The patient’s medical history included idiopathic thrombocytopenic purpura as well as new diagnoses of atrial tachycardia, a small perimembranous ventricular septal defect, and a slightly dilated aortic root and pulmonary artery. Previous sonography had revealed a velamentous cord insertion, for which serial growth assessment was recommended, with documentation of an appropriately grown fetus in the cephalic presentation at 35 weeks’ gestation. Follow-up growth sonography was then performed at 37 weeks 2 days due to concerns that her fundal height was measuring smaller than expected for gestational age. This sonogram revealed a singleton intrauterine fetus in the breech presentation with an estimated fetal weight of 2314 g (corresponding to <10th percentile) and a normal amniotic fluid index. Umbilical artery Doppler values were obtained because of these concerns about fetal weight, with an elevated systolic-to-diastolic ratio of 3.8 (corresponding to >97.5th percentile). Delivery was therefore recommended in light of the abnormal Doppler findings. On presentation to the labor suite, the patient’s platelet count was found to be 68,000/μL, and general anesthesia was therefore recommended for the planned cesarean delivery. In an effort to minimize fetal exposure to systemic anesthetic agents, delivery was conducted in an expeditious fashion. On entry into the abdominal cavity, one of the fallopian tubes and one of the ovaries were identified anterior to the uterus but not in such a position that the lower uterine segment was obstructed. A low transverse hysterotomy incision was made, and a 2500-g male neonate (consistent with 10th–25th percentile) was delivered in the breech presentation by standard breech maneuvers. Apgar scores were 1 and 9 at 1 and 5 minutes, respectfully. After delivery, the uterus was exteriorized for the repair, at which time it was found to be axially rotated by 180° to the right, such that the hysterotomy had been made on the posterior uterine wall (Figure 1A). The hysterotomy incision was repaired in a standard fashion using 1-0 Polypore sutures (Covidien, Mansfield, MA), resulting in excellent homeostasis. Examination of the uterus revealed no obvious anomalies or fibroids. The uterus was then rotated back to its normal anatomic position before returning the organ back into the abdomen without difficultly. The mother recovered uneventfully, and both the mother and neonate were discharged home on postoperative day 3. After delivery, the patient’s prior serial growth sonograms were reviewed in detail. Interestingly, an anterior placenta was identified at 17, 23, and 31 weeks’ gestation, with a posterior placenta visualized at 35 and 37 weeks (Figure 1, B and C). Fetal growth was likewise reviewed, with an estimated growth of 1856 g (56th percentile) at 31 weeks, 1993 g (17th percentile) at 35 weeks, and 2314 g (<10th percentile) at 37 weeks. Uterine torsion is defined as uterine rotation exceeding 45° along the long axis, with a maximum rotation of 720° reported in the literature.3 Since this finding is often inci-