Stephen C. Bell

Structural characteristics of term human fetal membranes: a novel zone of extreme morphological alteration within the rupture site

Objective To determine the structural characteristics of the rupture site of term fetal membranes (amniochorion and decidua) that rupture spontaneously after the onset of labour.

Confocal immunofluorescence localization of collagen types I, III, IV, V and VI and their ultrastructural organization in term human fetal membranes

The distribution of collagen types I, III, IV, V and VI in term human fetal membranes was examined using conventional and confocal indirect immunofluorescence techniques. Collagens I and III were present in most of the layers of fetal membranes except in the trophoblast layer contrary to what has been previously reported. Although collagen IV is considered to be a basement membrane component our study, using monoclonal and polyclonal antibodies, showed its consistent presence in the spongy and reticular layers in high intensity. This was first report on the distribution of type V collagen in the chorion where it was found in the reticular and in the trophoblast layers. Type VI collagen was present mainly in the amnion and the reticular layer. The ultrastructural examination of the extracellular matrix showed that the main fibrous skeleton of the fetal membranes was formed of large banded fibres (Ultrastructurally identical to collagens types I and III) connected together and to the epithelial basement membranes by networks of unbanded filaments (collagen types V, VI and other components). The extensive and continuous networks formed by these collagens may be a major factor responsible for the mechanical integrity of the fetal membranes.

Endometrial protection from tamoxifen-stimulated changes by a levonorgestrel-releasing intrauterine system: a randomised controlled trial

INTRODUCTION Tamoxifen is currently the most commonly used adjuvant treatment for breast cancer, however, it frequently causes episodes of unscheduled uterine bleeding, which could be associated with proliferative changes of the endometrium, or even endometrial cancer. We aimed to assess whether a levonorgestrel intrauterine system could modulate the uterine responses to tamoxifen. We also aimed to assess womens tolerance of the screening procedures, the insertion, removal, and potential side-effects of the device. METHODS We did a randomised controlled trial, in which postmenopausal women who had had at least 1 year of adjuvant tamoxifen treatment and who were undergoing regular follow-up for breast cancer were randomly assigned to either endometrial surveillance alone, or endometrial surveillance before and after insertion of the levonorgestrel intrauterine system for 12 months. We assessed tolerance of the surveillance procedures and the device with visual analogue scales. FINDINGS Baseline assessment showed only benign uterine changes in all women (n=122). Hysteroscopic assessment indicated a uniform decidual response (confirmed histologically in 40 of 41 cases) in all women fitted with the intrauterine system; there were no new polyps in these women and 13% had fewer fibroids than in controls. Both screening procedures and device were well tolerated. There was an excess of bleeding in the women fitted with intrauterine systems but this resolved to a baseline similar to those receiving surveillance only. INTERPRETATION The levonorgestrel-releasing intrauterine system had a protective action against the uterine effects of tamoxifen. The effectiveness of this device in preventing uterine changes in the endometrium needs to be assessed in the context of decreasing the need for repeated investigations of postmenopausal bleeding in women taking tamoxifen.

Relationship between antenatal inflammation and antenatal infection identified by detection of microbial genes by polymerase chain reaction.

Although antenatal infection is thought to play an important role in the pathogenesis of preterm labor and neonatal diseases, the exact mechanisms are largely unknown. We sought to clarify the relationship between antenatal infection and intrauterine and neonatal inflammation. Samples were obtained from 41 preterm infants of <33 wk gestation delivered to 36 mothers and analyzed for the presence of 16s ribosomal RNA (16s rRNA) genes using PCR and for the proinflammatory cytokines IL-6 and IL-8. In 16 (44%) mother-baby pairings, at least one sample was found to be positive for the presence of 16s rRNA genes. All but one of the positive samples were from mothers presenting with preterm prelabor rupture of membranes (pPROM) or in spontaneous idiopathic preterm labor. A strong association was found between the presence of 16s rRNA genes and chorioamnionitis and with funisitis. A marked increase in IL-6 and IL-8 was noted in all tissues positive for 16s rRNA genes, including placenta, fetal membranes, cord blood serum, and, where samples were available, in bronchoalveolar lavage fluid (BAL) and in amniotic fluid. Interestingly, gastric fluid was always positive for 16s rRNA genes if any other intrauterine or BAL sample was positive, suggesting that this sample may provide an alternative to amniotic fluid to identify antenatal infection. In conclusion, we have found that microbial genes are particularly prevalent in pPROM and spontaneous preterm labor groups and that their presence is strongly associated with a marked intrauterine inflammatory response.

Protein synthesis and secretion by the human endometrium and decidua during early pregnancy

To investigate the role of the endometrium in sustaining early pregnancy, specimens of endometrium from early pregnancy were incubated in vitro with radiolabelled amino acids, and protein synthesis and secretion were studied by subsequent fluorographic analysis of one-and two-dimensional polyacrylamide gels. Seventeen secreted endometrial proteins (EP) were identified. Changes were demonstrated in the rate of synthesis and/or secretion of a number of these proteins during early pregnancy. Two proteins, EP 14 and EP 15, are the principal secretory proteins of pregnancy endometrium. EP 14 (subunit mol. wt 32 000) is associated with decidualized endometrium and its rate of synthesis/secretion increases during early pregnancy. EP 15 (subunit mol. wt 28 000) is also synthesized and secreted by the secretory endometrium during the menstrual cycle, and during early pregnancy, but its secretion declines to undetectable levels by week 15-16. These proteins may provide useful markers of endometrial function and differentiation during the menstrual cycle and pregnancy.

Optimal bedside urinalysis for the detection of proteinuria in hypertensive pregnancy: a study of diagnostic accuracy

Objective  To compare semi‐quantitative visual and automated methods of urine testing with fully quantitative point of care urinalysis for the detection of significant proteinuria (0.3 g/24 hours) in pregnancy complicated by hypertension.

Immunochemical and biochemical relationship between human pregnancy-associated secreted endometrial α1- and α2-globulins (α1- and α2-PEG) and the soluble placental proteins 12 and 14 (PP12 and PP14)

Two proteins, pregnancy-associated endometrial alpha 1- and alpha 2-globulins (alpha 1- and alpha 2-PEG), synthesized de novo and secreted by the human endometrium and decidua during pregnancy, have been demonstrated to be immunochemically related to the soluble placental proteins PP12 and PP14 isolated from term placenta. However, although these immunochemically similar endometrially- and placentally-derived proteins differ in their reported biochemical properties, in this report we have demonstrated that PP12 and PP14 are biochemically identical to alpha 1- and alpha 2-PEG with respect to subunit size. We conclude that these placental proteins are derived from the endometrium by de novo synthesis, and we suggest that the localization of these proteins to the placenta reflects either absorption, specific binding or processing by the trophoblast. The significance of clinical studies involving PP12 and PP14 measurement must therefore be reassessed in the light of their exclusive endometrial origin.

Expression of the Endocannabinoid System in Human First Trimester Placenta and Its Role in Trophoblast Proliferation

The endocannabinoid, anandamide, which binds to two major receptor proteins, the cannabinoid receptors (CBs) 1 and 2 (CB1 and CB2), has been shown to play a role in first trimester miscarriage possibly through impairment of the developing trophoblast. Although the precise molecular mechanisms underlying this are unknown, plasma anandamide levels are known to be regulated by the progesterone-induced enzyme, fatty acid amide hydrolase (FAAH). Here, we tested the hypothesis that temporal-spatial expression of FAAH, CB1, and CB2 is regulated during early pregnancy and that anandamide detrimentally alters trophoblast proliferation. Transcripts for CB1, CB2, and FAAH were demonstrated in first trimester trophoblast extracts with only the CB1 transcript being significantly regulated. The significant 4.7-fold increase in expression at wk 10 gestation was reduced to 8.9% of the peak value by wk 12. Transcripts for CB2 showed a similar pattern of expression but were not significantly induced. By contrast, FAAH transcript levels appeared to increase toward the end of the first trimester, but again did not reach significance. These observations were supported by immunohistochemical studies that demonstrated a similar pattern of expression at the protein level, with cellular localization for all three proteins concentrated within the syncytiotrophoblast layer. Anandamide also prevented BeWo trophoblast cell proliferation in a dose-dependent manner, with a 50-60% significant inhibition of cell proliferation with concentrations in excess of 3 mum. This effect was mediated through CB2. Together, these data provide insights into how elevated plasma anandamide levels increase the risk of first trimester miscarriage.

Fetal fibronectin in cervicovaginal secretions as a predictor of preterm birth

Objective To determine whether fetal fibronectin detected in cervicovaginal secretions of patients with symptoms suggestive of preterm labour is a predictor for preterm birth.

Estrogen and progesterone receptor isoform distribution through the menstrual cycle in uteri with and without adenomyosis.

OBJECTIVE To test the hypothesis that the expression of the different isoforms of the estrogen receptor alpha (ER-α) and beta (ER-β) and the progesterone receptor A (PR-A) and B (PR-B) would be differentially modulated in uteri with adenomyosis compared with controls and that modulation would be related to the menstrual cycle. DESIGN Case control, blinded comparison. SETTING University department. PATIENT(S) 54 premenopausal women with and 35 without uterine adenomyosis as the sole pathology. INTERVENTION(S) Multiple samples studied using immunohistochemistry for estrogen and progesterone receptors. MAIN OUTCOME MEASURE(S) Histomorphometric analysis of receptor expression. RESULT(S) The ER-α expression in the adenomyotic endometrium was different from that of the normal endometrium and the foci in the midsecretory phase of the cycle, but expression of ER-α in the inner and outer myometrium was not statistically significantly different. The ER-β expression was statistically significantly elevated in the adenomyotic functionalis gland during the proliferative phase and throughout the myometrium across the entire menstrual cycle. Expression of PR-A was similar to that of PR-B, with reduced expression in the basalis stroma, and inner and outer myometrium in the adenomyotic samples. The pattern of ER-β, PR-A, and PR-B expression was similar in the endometrial basalis and adenomyotic foci. CONCLUSION(S) These data suggest ER-β expression and the lack of PR expression are related to the development and/or progression of adenomyosis and might explain the poor response of adenomyosis-associated menstrual symptoms to progestational agents.