Sherri Longo

Gastrointestinal Conditions during Pregnancy

Pregnancy causes anatomic and physiologic changes in the gastrointestinal tract. Pregnant women with intestinal disease such as Crohn disease or ulcerative colitis pose a management challenge in clinical diagnosis, radiologic evaluation, and treatment secondary to potential risk to the fetus. Heightened physician awareness on possible etiologies such as appendicitis, diverticulitis, and rarely colorectal cancer is required for rapid diagnosis and treatment to improve maternal/fetal outcome. A multidisciplinary approach to evaluation is a necessity because radiologic procedures and treatment medications commonly used in nonpregnant patients may have a potential harmful effect on the fetus. The authors review several gastrointestinal conditions encountered during pregnancy and address presentation, diagnosis, and treatment of each condition.

Placental exosomes as early biomarker of preeclampsia - Potential role of exosomal microRNAs across gestation.

Context: There is a need to develop strategies for early prediction of patients who will develop preeclampsia (PE) to establish preventive strategies to reduce the prevalence and severity of the disease and their associated complications. Objective: The objective of this study was to investigate whether exosomes and their microRNA cargo present in maternal circulation can be used as early biomarker for PE. Design, Setting, Patients, and Interventions: A retrospective stratified study design was used to quantify total exosomes and placenta‐derived exosomes present in maternal plasma of normal (n = 32 per time point) and PE (n = 15 per time point) pregnancies. Exosomes present in maternal circulation were determined by nanoparticle tracking analysis. An Illumina TruSeq® Small RNA Library Prep Kit was used to construct a small RNA library from exosomal RNA obtained from plasma samples. Results: In presymptomatic women, who subsequently developed PE, the concentration of total exosomes and placenta‐derived exosomes in maternal plasma was significantly greater than those observed in controls, throughout pregnancy. The area under the receiver operating characteristic curves for total exosome and placenta‐derived exosome concentrations were 0.745 ± 0.094 and 0.829 ± 0.077, respectively. In total, over 300 microRNAs were identified in exosomes across gestation, where hsa‐miR‐486‐1‐5p and hsa‐miR‐486‐2‐5p were identified as the candidate microRNAs. Conclusions: Although the role of exosomes during PE remains to be fully elucidated, we suggest that the concentration and content of exosomes may be of diagnostic utility for women at risk for developing PE.

Familial ebstein anomaly, left ventricular hypertrabeculation, and ventricular septal defect associated with a MYH7 mutation

Ebstein anomaly is a rare congenital heart defect that most often occurs sporadically within a kindred. Familial cases, although reported, are uncommon. At this time, the genetic etiology of Ebstein anomaly is not fully elucidated. Here, we describe clinical and molecular investigations of a rare case of familial Ebstein anomaly in association with a likely pathogenic mutation of the MYH7 gene. The severity of presentation varies, and Ebstein anomaly can be observed in association with such other heart defects as ventricular septal defect and left ventricular (LV) hypertrabeculation, as seen in our family of study. In our family of study, the 31‐year‐old father and four of his children have been diagnosed with Ebstein anomaly. Genetic testing revealed that the father was heterozygous for the Glu1220del variant detected in exon 27 of the MYH7 gene. The MYH7 gene encodes the β‐myosin heavy chain and is expressed in cardiac muscle. DNA sequencing of three of his affected children confirmed that they carried the same variant while the fourth affected child was not available for testing. This is the first report of familial Ebstein anomaly associated with the Glu1220del mutation of the MYH7 gene. The mutation segregates with disease in a family with autosomal dominant transmission of congenital heart defects including Ebstein anomaly and other associated cardiovascular defects including LV hypertrabeculation and ventricular septal defect.

Combination antiretroviral therapy with protease inhibitors in HIV-infected pregnancy.

Abstract Objective: To evaluate the possible association between protease inhibitor (PI) and premature birth and low birth-weight in HIV-infected pregnancies. Materials and methods: Data were collected retrospectively for maternal and pregnancy characteristics, antiretroviral medication, lowest CD4 count and highest viral load during pregnancy, and pregnancy outcomes. χ2 Analysis, Student’s t-test, and multiple logistic regression analysis were performed. Results: Data from 161 HIV-infected women who delivered singleton gestation were analyzed. Fifty-three received an antepartum regimen with PI, 84 received a regimen without PI, and six did not receive antepartum treatment. The mean estimated gestational age (EGA)±SD at delivery was 37.7±3.2 weeks. The premature birth rate was 18.4%. No difference was detected between women receiving the antiretroviral regimen including PI and those on the regimen without PI or on no antepartum medication with regard to: EGA±SD at delivery (37.7±3.2 vs. 37.6±3.1 weeks, respectively, P=0.87), rate of premature birth (14% vs. 20.6%, respectively, P=0.32) and low birth-weight (12.5% vs. 20.2%, respectively, P=0.25). In multiple logistic regression analysis, PI was not associated with premature birth or low birth-weight. Conclusion: Women receiving antiretroviral therapy with PI have a similar rate of premature birth and low birth-weight as women receiving antiretroviral therapy without PI or on no medication.

Oxygen tension regulates the miRNA profile and bioactivity of exosomes released from extravillous trophoblast cells-liquid biopsies for monitoring complications of pregnancy

Our understanding of how cells communicate has undergone a paradigm shift since the recent recognition of the role of exosomes in intercellular signaling. In this study, we investigated whether oxygen tension alters the exosome release and miRNA profile from extravillous trophoblast (EVT) cells, modifying their bioactivity on endothelial cells (EC). Furthermore, we have established the exosomal miRNA profile at early gestation in women who develop pre-eclampsia (PE) and spontaneous preterm birth (SPTB). HTR-8/SVneo cells were used as an EVT model. The effect of oxygen tension (i.e. 8% and 1% oxygen) on exosome release was quantified using nanocrystals (Qdot®) coupled to CD63 by fluorescence NTA. A real-time, live-cell imaging system (Incucyte™) was used to establish the effect of exosomes on EC. Plasma samples were obtained at early gestation (<18 weeks) and classified according to pregnancy outcomes. An Illumina TrueSeq Small RNA kit was used to construct a small RNA library from exosomal RNA obtained from EVT and plasma samples. The number of exosomes was significantly higher in EVT cultured under 1% compared to 8% oxygen. In total, 741 miRNA were identified in exosomes from EVT. Bioinformatic analysis revealed that these miRNA were associated with cell migration and cytokine production. Interestingly, exosomes isolated from EVT cultured at 8% oxygen increased EC migration, whilst exosomes cultured at 1% oxygen decreased EC migration. These changes were inversely proportional to TNF-α released from EC. Finally, we have identified a set of unique miRNAs in exosomes from EVT cultured at 1% oxygen and exosomes isolated from the circulation of mothers at early gestation, who later developed PE and SPTB. We suggest that aberrant exosomal signalling by placental cells is a common aetiological factor in pregnancy complications characterised by incomplete SpA remodeling and is therefore a clinically relevant biomarker of pregnancy complications.

Placenta-derived exosomes promote trophoblast invasion and spiral arterial remodeling - A possible role in the physiopathology of preeclampsia

Figures will be available only online at UNIV OF PITTSBURGH on June 19, 2015 rsx.sagepub.com Downloaded from at UNIV OF PITTSBURGH on June 19, 2015 rsx.sagepub.com Downloaded from Thrsday O als Scientific Abstracts Reproductive Sciences Vol. 22, Supplement 1, March 2015 57AINTRODUCTION: Statin use inadvertently during pregnancy and proposed use of statins for the treatment of preeclampsia, led us to question the evidence behind their current contraindicated status. Several studies have evaluated the relationship between statin use in pregnancy with fetal outcome but their results have not been quantitatively assessed by meta-analysis. Our objective was to undertake a systematic review of all published clinical evidence to assess the effects of statin use in pregnancy on subsequent fetal wellbeing. METHODS: A comprehensive search strategy was performed of all electronic databases and the Merck reporting database for studies published from 1966 to 2014. Two reviewers independently screened citations and undertook study quality assessment and data extraction. We obtained summary estimates of adverse fetal events that were classified as potentially fatal, clinically significant morbidity or minor adverse event. We identified 602 titles and reviewed 30 articles for inclusion and exclusion criteria. Meta-analysis was performed on seven studies (3 cohort, 3 case-series and 1 case-control). RESULTS: Of the 922 cases of statin exposure in pregnancy, 27 exposures were associated with lethal or clinically significant fetal morbidity and 10 with minor adverse events. Statin exposure was limited to the first trimester in all but two cases. The pooled rate of lethal or clinically significant fetal abnormalities in pregnant women exposed to statins was 0.01 (95% CI 0.00-0.04), less than the European rate of 0.026 (95% CI 2.54- 2.57)EUROCAT. The rate of fetal abnormality for simvastatin was 0.03 (95% CI 0.00-0.08), atorvostatin 0.11 (95% CI 0.00-0.52), pravastatin 0.01 (95% CI 0.00-0.2) and lovastatin use 0.04 (95% CI 0.00-0.28). Systems based anomalies were also calculated, congenital heart disease was 0.8 (95% CI 0.02-0.12) compared with the background rate of 0.79 (95% CI 0.78- 0.80). CONCLUSIONS: The published data suggests that statins may not be teratogenic when given inadvertently during pregnancy and prospective studies such as The StAmP Trial may provide more dataIntroduction. Being born small increases cardio-renal disease risk, with males exhibiting more se vere phenotypes than females. These disease risks are not limited to the first generation (F1) but may be transmitted to subsequent generations (F2 and F3). The F3 maternal line represents the first generation that is not directly exposed to the initial insults. There is limited evidence of paternal line transmission. W e characterized nephron number and cardio-renal phenotype of F3 of fspring born to normally grown and growth restricted (F1) mothers or fathers. Methods. Late gestation rat uteroplacental insuf ficiency was induced (Restricted) or sham (Control) surgery in F0. Rats were anaesthetized with 4% isoflurane and 650ml.min -1 oxygen flow (reduced to 3.2% isoflurane and 250ml.min -1 oxygen flow when suturing). T o generate F3 paternal line offspring, F1 Control and Restricted males were mated with normal females and the F2 Control and Restricted males were then mated with normal females. F3 maternal line of fspring were similarily generated. F3 body weights were measured from birth to 12 months. Nephron number w as quantified using unbiased sterology at postnatal day 35. 24h renal excretions, creatinine clearance and tail cuf f blood pressure were measured at 6 (maternal and paternal lines) and 12 (maternal line only) months of age. All data were analysed by t-test within a gender and line. Results. Although F1 offspring were born small, F2 and F3 offspring (both maternal and paternal lines) had normal birth weights. F3 body weight was not dif ferent from birth to 12 months of age with no dif ferences in kidney, heart or adipose weights at 6 months between groups or lines. F3 male and female nephron endowment and blood pressure w as not different between groups for paternal and maternal lines. F3 maternal line renal function was normal at 6 months of age. Ho wever, at 12 months, although creatinine clearance (eGFR) was normal, renal dysfunction emerged in F3 maternal line males (proteinuria) and females (increased urinary creatinine excretion). F3 offspring from fathers born small had e vidence of impaired eGFR (reduced creatinine clearance). Conclusions. F3 offspring, born to F1 growth restricted mothers or f athers are not programmed to be born of low birth weight but de veloped renal dysfunction in the absence of obesity . The proteinuria that emerged with aging in the F3 maternal line male of fspring in the absence of nephron deficits, hypertension and reduced eGFR, suggests tubulointerstitial injury mediated either through podocyte dysfunction/depletion or solely via proteinuria. In contrast, F3 paternal line of fspring had glomerular dysfunction (reduced eGFR), indicati ve of glomerular filtration deficits. Our paternal line results highlight sustained transgenerational inheritance of renal dysfunction. Since nephron number was preserved our results propose the progression of renal dysfunction via the “fibrosis hypothesis” rather than the “Brenner h ypothesis”. Our findings provide no vel evidence of transgenerational transmission of renal dysfunction to F3 offspring from both maternal and paternal lines.INTRODUCTION: Preeclampsia is a vascular disorder in pregnancyand is biochemical characterization by high soluble Flt-1 and lowplacenta growth factor as well as an imbalance in redox homeostasis.During conditions of high oxidative stress, cysteine residues on keyproteins are reversibly altered by S-glutathionylation, modifying theirfunction. Glutaredoxin-1 (Glrx) enzymatically catalyzes the removal of S-glutathione adducts, conferring reversible signaling dynamics toproteins with redox-sensitive cysteines. The role of Glrx in preeclampsiais unknown.METHODS: Immunohistochemistry and Western blot analysis for Glrx orglutathione were conducted on human placenta samples collected pre-termfrom early onset preeclamptic patients (n=10) or non-preeclamptic induceddeliveries (n=9). Human endothelial cells were infected with adenovirusencoding Glrx or LacZ prior to the cells being exposed to hypoxia (0.1%O2, 24h) to measure changes in soluble Flt-1 (sFlt-1). Quantitative PCRand ELISA were used to measure sFlt-1 at mRNA and protein level.RESULTS: Immunohistochemical staining for GSH revealed lowerS-glutathionylation adducts in preeclampsia placenta in comparison tocontrols. Glrx expression, which catalyses de-glutathionylation wasenhanced in early onset preeclampsia compared to pre-term controlsamples. In contrast, no change was observed in preeclamptic and IUGRplacentas at full term. In endothelial cells overexpressing Glrx, sFlt-1expression was dramatically enhanced at mRNA (3-fold P 0.01, n=4) after hypoxia andoverexpressing Glrxin mice enhanced levels of circulating sFlt-1 during in vivo ischemia.CONCLUSIONS: Enhanced Glrx expression in preeclamptic placentain line with an apparent decrease in S-glutathionylation may leavekey proteins susceptible to irreversible oxidation in conditions of highoxidative stress.

Hypoxia regulates the response of trophoblast-derived exosomes to hyperglycemia and displays a difference placental exosome profile in plasma from patients with gestational diabetes mellitus

Figures will be available only online at UNIV OF PITTSBURGH on June 19, 2015 rsx.sagepub.com Downloaded from at UNIV OF PITTSBURGH on June 19, 2015 rsx.sagepub.com Downloaded from Thrsday O als Scientific Abstracts Reproductive Sciences Vol. 22, Supplement 1, March 2015 57AINTRODUCTION: Statin use inadvertently during pregnancy and proposed use of statins for the treatment of preeclampsia, led us to question the evidence behind their current contraindicated status. Several studies have evaluated the relationship between statin use in pregnancy with fetal outcome but their results have not been quantitatively assessed by meta-analysis. Our objective was to undertake a systematic review of all published clinical evidence to assess the effects of statin use in pregnancy on subsequent fetal wellbeing. METHODS: A comprehensive search strategy was performed of all electronic databases and the Merck reporting database for studies published from 1966 to 2014. Two reviewers independently screened citations and undertook study quality assessment and data extraction. We obtained summary estimates of adverse fetal events that were classified as potentially fatal, clinically significant morbidity or minor adverse event. We identified 602 titles and reviewed 30 articles for inclusion and exclusion criteria. Meta-analysis was performed on seven studies (3 cohort, 3 case-series and 1 case-control). RESULTS: Of the 922 cases of statin exposure in pregnancy, 27 exposures were associated with lethal or clinically significant fetal morbidity and 10 with minor adverse events. Statin exposure was limited to the first trimester in all but two cases. The pooled rate of lethal or clinically significant fetal abnormalities in pregnant women exposed to statins was 0.01 (95% CI 0.00-0.04), less than the European rate of 0.026 (95% CI 2.54- 2.57)EUROCAT. The rate of fetal abnormality for simvastatin was 0.03 (95% CI 0.00-0.08), atorvostatin 0.11 (95% CI 0.00-0.52), pravastatin 0.01 (95% CI 0.00-0.2) and lovastatin use 0.04 (95% CI 0.00-0.28). Systems based anomalies were also calculated, congenital heart disease was 0.8 (95% CI 0.02-0.12) compared with the background rate of 0.79 (95% CI 0.78- 0.80). CONCLUSIONS: The published data suggests that statins may not be teratogenic when given inadvertently during pregnancy and prospective studies such as The StAmP Trial may provide more dataIntroduction. Being born small increases cardio-renal disease risk, with males exhibiting more se vere phenotypes than females. These disease risks are not limited to the first generation (F1) but may be transmitted to subsequent generations (F2 and F3). The F3 maternal line represents the first generation that is not directly exposed to the initial insults. There is limited evidence of paternal line transmission. W e characterized nephron number and cardio-renal phenotype of F3 of fspring born to normally grown and growth restricted (F1) mothers or fathers. Methods. Late gestation rat uteroplacental insuf ficiency was induced (Restricted) or sham (Control) surgery in F0. Rats were anaesthetized with 4% isoflurane and 650ml.min -1 oxygen flow (reduced to 3.2% isoflurane and 250ml.min -1 oxygen flow when suturing). T o generate F3 paternal line offspring, F1 Control and Restricted males were mated with normal females and the F2 Control and Restricted males were then mated with normal females. F3 maternal line of fspring were similarily generated. F3 body weights were measured from birth to 12 months. Nephron number w as quantified using unbiased sterology at postnatal day 35. 24h renal excretions, creatinine clearance and tail cuf f blood pressure were measured at 6 (maternal and paternal lines) and 12 (maternal line only) months of age. All data were analysed by t-test within a gender and line. Results. Although F1 offspring were born small, F2 and F3 offspring (both maternal and paternal lines) had normal birth weights. F3 body weight was not dif ferent from birth to 12 months of age with no dif ferences in kidney, heart or adipose weights at 6 months between groups or lines. F3 male and female nephron endowment and blood pressure w as not different between groups for paternal and maternal lines. F3 maternal line renal function was normal at 6 months of age. Ho wever, at 12 months, although creatinine clearance (eGFR) was normal, renal dysfunction emerged in F3 maternal line males (proteinuria) and females (increased urinary creatinine excretion). F3 offspring from fathers born small had e vidence of impaired eGFR (reduced creatinine clearance). Conclusions. F3 offspring, born to F1 growth restricted mothers or f athers are not programmed to be born of low birth weight but de veloped renal dysfunction in the absence of obesity . The proteinuria that emerged with aging in the F3 maternal line male of fspring in the absence of nephron deficits, hypertension and reduced eGFR, suggests tubulointerstitial injury mediated either through podocyte dysfunction/depletion or solely via proteinuria. In contrast, F3 paternal line of fspring had glomerular dysfunction (reduced eGFR), indicati ve of glomerular filtration deficits. Our paternal line results highlight sustained transgenerational inheritance of renal dysfunction. Since nephron number was preserved our results propose the progression of renal dysfunction via the “fibrosis hypothesis” rather than the “Brenner h ypothesis”. Our findings provide no vel evidence of transgenerational transmission of renal dysfunction to F3 offspring from both maternal and paternal lines.INTRODUCTION: Preeclampsia is a vascular disorder in pregnancyand is biochemical characterization by high soluble Flt-1 and lowplacenta growth factor as well as an imbalance in redox homeostasis.During conditions of high oxidative stress, cysteine residues on keyproteins are reversibly altered by S-glutathionylation, modifying theirfunction. Glutaredoxin-1 (Glrx) enzymatically catalyzes the removal of S-glutathione adducts, conferring reversible signaling dynamics toproteins with redox-sensitive cysteines. The role of Glrx in preeclampsiais unknown.METHODS: Immunohistochemistry and Western blot analysis for Glrx orglutathione were conducted on human placenta samples collected pre-termfrom early onset preeclamptic patients (n=10) or non-preeclamptic induceddeliveries (n=9). Human endothelial cells were infected with adenovirusencoding Glrx or LacZ prior to the cells being exposed to hypoxia (0.1%O2, 24h) to measure changes in soluble Flt-1 (sFlt-1). Quantitative PCRand ELISA were used to measure sFlt-1 at mRNA and protein level.RESULTS: Immunohistochemical staining for GSH revealed lowerS-glutathionylation adducts in preeclampsia placenta in comparison tocontrols. Glrx expression, which catalyses de-glutathionylation wasenhanced in early onset preeclampsia compared to pre-term controlsamples. In contrast, no change was observed in preeclamptic and IUGRplacentas at full term. In endothelial cells overexpressing Glrx, sFlt-1expression was dramatically enhanced at mRNA (3-fold P 0.01, n=4) after hypoxia andoverexpressing Glrxin mice enhanced levels of circulating sFlt-1 during in vivo ischemia.CONCLUSIONS: Enhanced Glrx expression in preeclamptic placentain line with an apparent decrease in S-glutathionylation may leavekey proteins susceptible to irreversible oxidation in conditions of highoxidative stress.

Maternal BMI Regulates the Exosomal Bioactivity on Cytokine Release from Endothelial Cells

Figures will be available only online Underline represents presenting author; Asterisk represents senior author; Dagger represents an in-training author.

Next-Generation miRNA Sequencing Reveals That Exosomes Present in Maternal Circulation of Gestational Diabetes Pregnancies Regulate Glucose Metabolism in Placental Cells

Figures will be available only online Underline represents presenting author; Asterisk represents senior author; Dagger represents an in-training author.