Vladimir Toder

Karyotype of the abortus in recurrent miscarriage.

Abstract Objective: To assess the chromosomal aberrations in the abortus in recurrent miscarriage and the live birth rate after a euploid or aneuploid miscarriage. Design: Retrospective analysis. Setting: Tertiary referral unit in university hospital. Patient(s): One hundred sixty-seven patients with 3 to 16 miscarriages before 20 weeks. Intervention(s): Material collected at curettage from 167 abortuses was analyzed by standard G-banding techniques. Main Outcome Measure(s): The incidence of aberrations and the outcome of the subsequent pregnancy were assessed according to the embryonic karyotype. Result(s): In this study 125 specimens were successfully karyotyped. Of these, 29% (36 of 125) had chromosome aberrations; 94% of the aberrations were aneuploidy, and 6% were structural. The most prevalent anomalies were chromosome 16, 18, and 21 trisomies, triploidy, and monosomy X. After an aneuploid miscarriage, there was a 68% subsequent live birth rate (13 of 19) compared to the 41% (16 of 39) rate after a euploid abortion. Conclusion(s): The low (29%) incidence of aberrations indicates that alternative mechanisms may be responsible for the majority of recurrent miscarriages. These figures provide a basis for assessing the efficacy of therapy for recurrent miscarriage. If further studies confirm that patients with karyotypically abnormal fetuses have a good prognosis, an informed decision can be made as to whether further investigations and treatment should be undertaken.

The role of apoptosis in normal and abnormal embryonic development.

Programmed cell death or apoptosis is a widespread biological phenomenon. Apoptosis is characterized by typical cell features such as membrane blebbing, chromatin condensation, and DNA fragmentation. It involves a number of membrane receptors (e.g., Fas, TNFR) and a cascade of signal transduction steps resulting in the activation of a number of cysteine proteases known as caspases. Disordered apoptosis may lead to carcinogenesis and participates in the pathogenesis of Alzheimer disease, Parkinson disease, or AIDS. Programmed cell death plays an important role in the processes of gamete maturation as well as in embryo development, contributing to the appropriate formation of various organs and structures. Apoptosis is one of the mechanisms of action of various cytotoxic agents and teratogens. Teratogen-induced excessive death of embryonic cells is undoubtedly one of the most important events preceding the occurrence of structural abnormalities, regardless of their nature. Therefore understanding the mechanisms involved in physiological as well as in disturbed or dysregulated apoptosis may lead to the development of new methods of preventive treatment of various developmental abnormalities. The present review summarizes data on the mechanisms of programmed cell death and concentrates on apoptosis involved in normal or disturbed gametogenesis and in normal and abnormal embryonic development.

TNF-α in pregnancy loss and embryo maldevelopment: A mediator of detrimental stimuli or a protector of the fetoplacental unit?

AbstractPurpose: Tumor necrosis factor alpha (TNF-α), a multifunctional cytokine, has been identified in the ovary, oviduct, uterus, and placenta, and is expressed in embryonic tissues. For many years TNF-α was mainly considered to be a cytokine involved in triggering immunological pregnancy loss and as a mediator of various embryopathic stresses. However, data collected during the last decade has characterized TNF-α not only as a powerful activator of apoptotic, but also antiapoptotic signaling cascades, as well as revealed its regulatory role in cell proliferation. This review summarizes and conceptualizes the studies addressing TNF-α-activated intracellular signaling and the possible functional role of TNF-α in embryonic development. Methods: Studies addressing the role of TNF-α in intercellular signaling, in vivo studies addressing the functional role TNF-α in spontaneous and induced pregnancy loss, and studies addressing the role of TNF-α in fetal malformations were reviewed. Comparative studies in TNF-α knockout and TNF-α positive mice were performed to evaluate embryonic death, structural anomalies in fetuses, the degree of apoptosis and cell proliferation, and the activity of molecules such as caspases 3 and 8, the NF-κB, (RelA), IκBα in some target embryonic organs shortly after exposure to embryopathic stresses. Results: It is proposed that the possible essential function of TNF-α may be to prevent the birth of offspring with structural anomalies. Conclusions: TNF-α will boost death signaling to kill the embryo if initial events (damages) triggered by detrimental stimuli may culminate in structural anomalies, and stimulate protective mechanisms if the repair of these damages may prevent maldevelopment.

Intravenous immunoglobulin in the prevention of recurrent miscarriage

adrenal insufficiency in a study of 71 fetuses of asthmatic mothers receiving predntsolone. The adrenocortical reserve of six newborns whose mothers had received steroids long term was assessed and the response to exogenous ACTH found to be normal (Arad & Landau 1984). Chan and Wilson draw attention to a recognised complication of prolonged or high dose steroid therapy. We accept that avascular necrosis in their patient is likely to have been related directly to the use of steroids to treat her hyperemesis. However, the dose of steroids used was extremely high; 24 mg dexamethasone is equivalent to 640 mg hydrocortisone. Their patient therefore received a dosage of glucocorticoid equivalent to 160-640 mg hydrocortisone (40-160 mg prednisolone) for a total of six to seven weeks. In our experience lower initial doses (200-300 mg hydrocortisone, 50-75 mg prednisolone) have been sufficient. After control of symptoms is achieved, patients can usually be weaned to a dose of 30-40 mg prednisolone per day within a few days, and thereafter to 20 mg per day within four weeks of starting treatment. In addition, avascular necrosis may rarely occur as a complication of pregnancy itself (Kay et al. 1972; Zolla-Pazna et a/ . 1980). It is important, and part of our practice, to discuss the possible risks of steroid therapy with the pregnant woman as Oladipo suggests. Since our original case report was accepted for publication, we have treated (or recommended the treatment of via telephone consultation) an additional six women with severe hyperemesis gravidarum with corticosteroid therapy. All 10 patients in this series had complete remission of their symptoms within 48 hours of starting treatment. We accept that parenteral steroid therapy may be required as Wong and Daniel suggest, and six out of ten women in our series required intravenous steroids. However, we fail to see the advantage of dexamethasone over hydrocortisone, and there are theoretical disadvantages since relatively more dexamethasone reaches the fetus. These pilot data support a beneficial role for corticosteroids in the treatment of severe hyperemesis gravidarum, but a definitive, randomised, double-blind, placebo-controlled trial is now in progress. Since the natural history of hyperemesis gravidarum is of gradual improvement with increasing gestation, the design of this multicentre study incorporates strict inclusion criteria. An intravenous arm to the study will ensure that steroids receive a fair trial.

TNF‐α Protects Embryos Exposed to Developmental Toxicants

BACKGROUND:  Tumor necrosis factor α (ΤNF‐α) has been implicated in mediating post‐implantation embryo loss or the embryonic maldevelopment induced by development toxicants or maternal metabolic imbalances. In order to clarify the role of TNF‐α further, a comparative study was performed in TNF‐α knockout and TNF‐α positive mice, exposed to a reference teratogen, cyclophosphamide (CP).

Apoptosis in the Uterus of Mice with Pregnancy Loss

PROBLEM: The mechanisms mediating pregnancy loss induced by various agents are far from being understood. Thus, we investigated the possible involvement of one such mechanism, the apoptotic process, in pregnancy loss induced by lipopolysaccharide (LPS) or cyclophosphamide (CP) as well as the associated changes in the apoptosis‐regulating gene products p53 and bcl‐2.

Ciprofloxacin immunomodulation of experimental antiphospholipid syndrome associated with elevation of interleukin‐3 and granulocyte‐macrophage colony‐stimulating factor expression

OBJECTIVE To evaluate the immunomodulatory potential of ciprofloxacin in mice with experimental antiphospholipid syndrome (APS). METHODS Ciprofloxacin or ceftazidime (control antibiotic) was given to mice with experimentally induced APS. The titers of autoantibodies, levels of cytokines, and number of cytokine-producing cells were determined by enzyme-linked immunosorbent assay. Myeloid progenitor cells were determined by granulocyte-macrophage colony-forming unit, and interleukin-3 (IL-3) messenger RNA (mRNA) was tested by Northern analysis. RESULTS A decrease in the incidence of pregnancy loss and an improvement in the clinical manifestations of APS were noted in the mice treated with ciprofloxacin, compared with the mice given ceftazidime. The effect of ciprofloxacin was found to be associated with increased serum levels of IL-3 and with increased IL-3 mRNA transcription in the splenocytes. Expression of granulocyte-macrophage colony-stimulating factor (GM-CSF) was documented by elevated titers in the sera and elevated numbers of colony-forming cells in the bone marrow. CONCLUSION Ciprofloxacin prevents the manifestations of experimental APS. This effect may be associated with increased IL-3 levels and GM-CSF expression.

Immunization by Paternal Leukocytes for Prevention of Primary Habitual Abortion: Results of a Matched Controlled Trial

Habitual abortion is a difficult clinical problem, as no cause can be found for abortion in over 50% of patients. At the habitual abortion clinic of the Sheba Medical Center, immunological activity is tested and patients who are considered suitable are offered immunopotentiation with paternal leukocytes. Patients are only treated if they have no other cause for habitual abortion, no lupus anticoagulant and no antipaternal complement-dependent antibodies (APCA). Immunization is thought to potentiate the maternal immune response to paternal antigens encountered on the trophoblast. The production of APCA antibody indicates that an immune response has occurred. Of the 156 patients so far immunized, 109 have developed these antibodies. To date, 79 of these 156 patients have become pregnant. Sixty-seven patients (with 3-12 miscarriages each) belong to the antibody-positive group. Sixty-four of the 89 subsequent pregnancies have been carried past their previous dates of abortion. Forty-seven live births have occurred. By contrast, 12 patients have been pregnant in the antibody-negative group, of the 16 subsequent pregnancies only 6 were successful. A control group is available for comparison. This consists of patients suitable for immunization, but not immunized. Of these patients, only 11 of 30 pregnancies have been carried to term.

Nonspecific immunopotentiators and pregnancy loss: complete Freund adjuvant reverses high fetal resorption rate in CBA × DBA/2 mouse combination.

ABSTRACT: CBA/J female mice mated with DBA/ 2J males show a high incidence of fetal resorptions. This paper presents data demonstrating that nonspecific immunopotentiation by complete Freund adjuvant (CFA) reversed pregnancy loss in CBA/J mothers. Immunization of more than 70 CBA/J females mated with DBA/2J males with CFA reduced the incidence of fetal resorption from 27.3 ± 1.9 to 7.9 ± 1.5%. The injection of Thymus Humoral Factor known to be a potent T cell stimulator did not reduce the number of fetal resportions. The route of CFA distribution was found to be important—only foot pad injections were effective in fetal protection, whereas i.p. treatment did not reduce fetal resorptions. Fetal protection could be transferred by splenocytes of CFA‐injected CBA/J mothers (9.6 ± 5.0% fetal resorptions). Sera from treated CBA/J mice could not cause such an effect (17.6 ± 4.6 vs. 21.3 ± 6.1 in control animals). Thus, stimulation of the maternal immune system by nonspecific immunopotentiators can improve reproductive performance of this mouse combination which has an increased rate of pregnancy loss. Possible mechanisms of this fetal protection are discussed.

Activity of natural killer cells in normal pregnancy and edema-proteinuria-hypertension gestosis

Natural killer cytotoxicity of peripheral blood lymphocytes in normal pregnancy and edema-proteinuria-hypertension (EPH) gestosis was investigated and compared to natural killer cytotoxicity in lymphocytes of normal nonpregnant control donors. These lymphocytes were also compared for their ability to respond to interferon treatment in vitro. Natural killer activity was found to be only slightly decreased in normal pregnant women but was found to be increased in patients with EPH gestosis. Interferon treatment of peripheral lymphocytes caused strong enhancement of natural killer activity in lymphocytes of normal pregnant women but resulted in only weak activities in lymphocytes from patients with EPH gestosis. We consequently concluded that pre-natural killer lymphocyte subpopulations from patients with EPH gestosis have already been activated by a presently still unknown stimulator.