Yalda Afshar

Notch1 mediates uterine stromal differentiation and is critical for complete decidualization in the mouse.

Uterine receptivity implies a dialogue between the hormonally primed maternal endometrium and the free‐floating blastocyst. Endometrial stromal cells proliferate, avert apoptosis, and undergo decidualization in preparation for implantation; however, the molecular mechanisms that underlie differentiation into the decidual phenotype remain largely undefined. The Notch family of transmembrane receptors transduce extracellular signals responsible for cell survival, cell‐to‐cell communication, and differentiation, all fundamental processes for decidualization and pregnancy. Using a murine artificial decidualization model, pharmacological inhibition of Notch signaling by γ‐secretase inhibition resulted in a significantly decreased deciduoma. Furthermore, a progesterone receptor (PR)‐Cre Notch1 bigenic (Notch1d/d) confirmed a Notch1‐dependent hypomorphic decidual phenotype. Microarray and pathway analysis, following Notch1 ablation, demonstrated significantly altered signaling repertoire. Concomitantly, hierarchical clustering demonstrated Notch1‐dependent differences in gene expression. Uteri deprived of Notch1 signaling demonstrated decreased cellular proliferation; namely, reduced proliferation‐specific antigen, Ki67, altered p21, cdk6, and cyclinD activity and an increased apoptotic‐profile, cleaved caspase‐3, Bad, and attenuated Bcl2. The results demonstrate that the preimplantation uterus relies on Notch signaling to inhibit apoptosis of stromal fibroblasts and regulate cell cycle progression, which together promotes successful decidualization. In summary, Notch1 signaling modulates multiple signaling mechanisms crucial for decidualization and these studies provide additional perspectives to the coordination of multiple signaling modalities required during decidualization.—Afshar, Y., Jeong, J.‐W., Roqueiro, D., DeMayo, F., Lydon, J., Radtke, F., Radnor, R., Miele, L., Fazleabas, A. Notch1 mediates uterine stromal differentiation and is critical for complete decidualization in the mouse. FASEB J. 26, 282–294 (2012). www.fasebj.org

BRCA1 germline mutations may be associated with reduced ovarian reserve

OBJECTIVE To determine whether BRCA carriers have a decreased ovarian reserve compared with women without BRCA mutations, because BRCA mutations may lead to accelerated oocyte apoptosis due to accumulation of damaged DNA. DESIGN Cross-sectional study. SETTING Academic tertiary care center. PATIENT(S) A total of 143 women, aged 18-45 years, who underwent clinical genetic testing for BRCA deleterious mutations because of a family history of cancer, were included. The cohort was classified into three groups: BRCA1 carriers, BRCA2 carriers, and women without BRCA mutations (controls). None had a personal history of breast or ovarian cancer. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The main outcome was serum antimüllerian hormone (AMH) level. Linear and logistic regression models adjusting for age and body mass index (BMI) were performed to determine the association between BRCA mutations and AMH. RESULT(S) BRCA1 mutation carriers had a significant decrease in AMH levels compared with controls after adjusting for age and BMI (0.53 ng/mL [95% confidence interval (CI) 0.33-0.77 ng/mL] vs. 1.05 ng/mL [95% CI 0.76-1.40 ng/mL]). Logistic regression confirmed that BRCA1 carriers had a fourfold greater odds of having AMH <1 ng/mL compared with controls (odds ratio 4.22, 95% CI 1.48-12.0). There was no difference in AMH levels between BRCA2 carriers and controls. CONCLUSION(S) BRCA1 carriers have lower age- and BMI-adjusted serum AMH levels compared with women without BRCA mutations. Our results contribute to the current body of literature regarding BRCA carriers and their reproductive outcomes. Larger prospective studies with clinical outcomes such as infertility and age at menopause in this population are needed to further substantiate our findings.

Changes in Eutopic Endometrial Gene Expression During the Progression of Experimental Endometriosis in the Baboon, Papio Anubis

ABSTRACT Endometriosis is associated with aberrant gene expression in the eutopic endometrium of women with disease. To determine if the development of endometriotic lesions directly impacts eutopic endometrial gene expression, we sequentially analyzed the eutopic endometrium across the time course of disease progression in a baboon model of induced disease. Endometriosis was induced in baboons (n = 4) by intraperitoneal inoculation of autologous menstrual endometrium. Eutopic endometria were collected during the midsecretory phase (Days 9–11 postovulation) at 1, 3, 6–7, 10–12, and 15–16 mo after disease induction and compared with tissue from disease-free baboons. RNA was hybridized to Human Genome U133 Plus 2.0 Arrays, and data were extracted using Gene-Chip Operating Software. Subsequently, both Gene Set Enrichment Analysis and Ingenuity Pathways Analysis were used to find biological states that have a statistically significant enrichment concomitant with pairwise comparison of human endometriosis arrays. Within 1 mo of induction of the disease, 4331 genes were differentially expressed (P < 0.05). Hierarchical clustering revealed self-segregation into two groups—a) 1, 3, and 10–12 mo and b) 6–7 and 15–16 mo—together with controls. Clustering analysis at each stage of disease validated dysregulation of several signaling pathways, including Nodal-like receptor, EGF, ERK/MAPK, and PI3/AKT. Sequential analysis of the same animals during disease progression demonstrated an early disease insult and a transitory dominance of an estrogenic phenotype; however, as the disease progressed, a progesterone-resistant phenotype became evident. Furthermore, we demonstrate a 38.6% differential gene expression overlap with endometrial samples in the midsecretory phase from women with endometriosis, concomitant with similar dysregulation in human disease candidate genes Fos, Nodal, Suclg2, and Kras, among others. Molecular changes in the eutopic endometrium, associated with endometriosis, are directly impacted by endometriotic lesions, providing strong evidence that it is the disease rather than inherent defective endometrium that results in aberrant gene expression in the eutopic endometrium. Furthermore, this baboon model provides a powerful means whereby the early events associated with the pathology of disease and the resulting infertility may be elucidated.

Notch1 is regulated by chorionic gonadotropin and progesterone in endometrial stromal cells and modulates decidualization in primates.

No other tissue in the body undergoes such a vast and extensive growth and remodeling in a relatively short period of time as the primate endometrium. Endometrial integrity is coordinated by ovarian hormones, namely, estrogens, progesterone, and the embryonic hormone chorionic gonadotropin (CG). These regulated events modulate the menstrual cycle and decidualization. The Notch family of transmembrane receptors regulate cellular proliferation, differentiation, and apoptosis, cellular processes required to maintain endometrial integrity. In two primate models, the human and the simulated pregnant baboon model, we demonstrated that Notch1 is increased during the window of uterine receptivity, concomitant with CG. Furthermore, CG combined with estrogens and progesterone up-regulate the level of Notch1, whereas progesterone increases the intracellular transcriptionally competent Notch1, which binds in a complex with progesterone receptor. Inhibition of Notch1 prevented decidualization, and alternatively, when decidualization is biochemically recapitulated in vitro, Notch1 is down-regulated. A focused microarray demonstrated that the Notch inhibitor, Numb, dramatically increased when Notch1 decreased during decidualization. We propose that in the endometrium, Notch has a dual role during the window of uterine receptivity. Initially, Notch1 mediates a survival signal in the uterine endometrium in response to CG from the implanting blastocyst and progesterone, so that menstrual sloughing is averted. Subsequently, Notch1 down-regulation may be critical for the transition of stromal fibroblast to decidual cells, which is essential for the establishment of a successful pregnancy.

The role of chorionic gonadotropin and Notch1 in implantation

PurposeFailed implantation is a major limiting factor in infertility and early pregnancy loss. In primates, human chorionic gonadotropin mediated inhibition of stromal cell apoptosis and their subsequent differentiation into decidual cells is critical for successful embryo implantation. A major regulator of cell survival and differentiation is the Notch receptor, which transduces extracellular signals responsible for cell fate determination during development. Proteolytic cleavage of full-length Notch1 releases an active intracellular peptide, which later translocates to the nucleus and activates gene transcription. Induction of Notch1 during the window of uterine receptivity in stromal fibroblasts in response to chorionic gonadotropin upregulates anti- apoptotic genes and induces α-smooth muscle actin, enabling stromal cells to proliferate and differentiate into a decidualized phenotype. As such, prior to implantation the embryonic signal, chorionic gonadotropin, rescues stromal fibroblasts from normal regression at the end of each ovarian cycle.ConclusionWe are suggesting that chorionic gonadotropin and Notch1 coordinately regulate decidualization by preventing apoptosis of endometrial stromal fibroblasts, averting uterine sloughing, and promoting cell survival and differentiation into the decidualized phenotype, which is critical for the maintenance of pregnancy.

Birth Plans: What Matters for Birth Experience Satisfaction

BACKGROUND To categorize individual birth plan requests and determine if number of requests and request fulfillment is associated with birth experience satisfaction. METHODS This is a sub-analysis of a prospective cohort study of 302 women with singleton pregnancies with and without birth plans. Women with a hard copy of their birth plans who completed a postdelivery satisfaction survey were included in this study. We described the number and type of birth plan requests and associated the number of requests and request fulfillment with overall satisfaction, expectations met, and sense of control. Differences between groups were analyzed using chi-square, Spearman rank correlation, and logistic regression. RESULTS One hundred and nine women presented to Labor and Delivery with a hard copy of their prewritten birth plan. We identified 23 unique requests. The most common requests were no intravenous analgesia (82%) and exclusive breastfeeding (74%). The requests most fulfilled were avoidance of episiotomy (100%) and no operative vaginal delivery (89%). Having a higher number of requests fulfilled correlated with greater overall satisfaction (p = 0.03), higher chance of expectations being met (p < 0.01), and feeling more in control (p < 0.01). Having a high number of requests was associated with an 80 percent reduction in overall satisfaction with the birth experience (p < 0.01). CONCLUSIONS Having a higher number of requests fulfilled was positively associated with birth experience satisfaction, while having a high number of requests was inversely associated with birth experience satisfaction. Further research is needed to understand how to improve birth plan-related birth experience satisfaction.

Progesterone Resistance in Endometriosis Is Modulated by the Altered Expression of MicroRNA-29c and FKBP4

Context Endometriosis results in aberrant gene expression in the eutopic endometrium (EuE) and subsequent progesterone resistance. MicroRNA (miR) microarray data in a baboon model of endometriosis showed an increased expression of miR-29c. Objectives To explore the role of miR-29c in progesterone resistance in a subset of women with endometriosis. Design MiR-29c expression was analyzed in the endometrium of baboons and women with or without endometriosis. The role in progesterone resistance and decidualization was analyzed by transfecting human uterine fibroblast cells with miR-29c. Patients Subjects diagnosed with deep infiltrative endometriosis (DIE) by transvaginal ultrasound with bowel preparation underwent surgical excision of endometriosis. Eutopic secretory endometrium was collected pre- and postoperatively. Women with normal EuE and without DIE served as controls. Results Quantitative reverse transcription polymerase chain reaction demonstrated that miR-29c expression increased, while the transcript levels of its target, FK506-binding protein 4 (FKBP4), decreased in the EuE of baboons following the induction of endometriosis. FKBP4 messenger RNA and decidual markers were statistically significantly decreased in decidualized human uterine fibroblast cells transfected with a miR-29c mimic compared with controls. Human data corroborated our baboon data and demonstrated higher expression of miR-29c in endometriosis EuE compared with normal EuE. MiR-29c was significantly decreased in endometriosis EuE postoperatively compared with preoperative tissues, and FKBP4 showed an inverse trend following radical laparoscopic resection surgery. Conclusions We demonstrate that miR-29c expression is increased in EuE of baboons and women with endometriosis, which might contribute to a compromised progesterone response by diminishing the levels of FKBP4. Resection of DIE is likely to reverse the progesterone resistance associated with endometriosis in women.

Updates in uterine fibroid tissue extraction

Purpose of review Safety concerns regarding morcellation of presumed benign fibroid disease have led to an increase in recent research activity on this topic, as well as advances in surgical technique. Recent findings The prevalence of occult leiomyosarcoma is debated; however, estimates from a robust meta-analysis suggest it may be in the range of 1 case per 1960–8300 fibroid surgeries. Advancing age is an important clinical risk factor for occult malignancy. The impact of tumor morcellation may vary by mode of tissue removal, though tissue fragmentation is consistently associated with poorer outcomes. Decision and cost analyses continue to support laparoscopic hysterectomy as a low-morbidity and cost-effective approach. The increased scrutiny on fibroid procedures in the past few years may lead to changes in surgical approach; however, alternative tissue extraction options are evolving, including incorporation of contained morcellation. Summary Although the incidence of occult leiomyosarcoma is low, outcomes are poor and may be worsened by morcellation. By addressing risk factors for malignancy and incorporating evolving surgical techniques into practice, gynecologists can continue to offer patients a minimally invasive approach for fibroid management.

Guidelines and consensus: statement on pregnancy in pulmonary hypertension from the Pulmonary Vascular Research Institute.

Editor: We read with interest the 2015 Statement on Pregnancy in Pulmonary Hypertension from the Pulmonary Vascular Research Institute.1 It aimed to provide evidence-based guidelines for the management of pregnancies complicated by pulmonary hypertension. Specifically, the authors staunchly recommend cesarean delivery between 34 and 36 weeks gestation as the preferred mode of delivery. The authors assert that cesarean delivery “bypasses the hemodynamic complications associated with labor … and also the auto transfusion associated with vaginal contractions.”1(p454) We find fault with both this recommendation and its justification, and we are troubled that the authors obtained limited obstetric input (only 1 of the 9 authors was affiliated with a department of obstetrics) and did not utilize specialty and interdisciplinary working groups when drafting pregnancy-related guidelines. We assert that route and timing of delivery in the setting of pulmonary hypertension complicating pregnancy remains controversial. Although recent management trends favor planned cesarean delivery, there is little evidence that cesarean delivery improves maternal outcomes over vaginal delivery.2,3 Although cardiac output can increase by up to 25% in active labor and by 50% during maternal pushing efforts, assisted second-stage labor and laboring in the lateral decubitus position can both greatly offset these changes.4 Moreover, cardiac output in the postpartum period can increase by as much as 80% regardless of delivery route. It is also relevant to consider that induction of regional anesthesia for cesarean delivery can result in hypotension in up to 30% of cases.4 Overall, cesarean delivery results in higher rates of severe maternal morbidity and mortality, including higher rates of death, hemorrhage, shock, cardiac arrest, renal failure, venous thromboembolic event, and infection.5 Both the severity of pulmonary disease and the woman’s pregnancy history must be considered in any delivery recommendation. A woman with mild, stable pulmonary hypertension is very different from one with severe right ventricular failure requiring, for example, parenteral prostanoid or nitric oxide therapy. Likewise, an urgent cesarean delivery involving a multiparous woman presenting in rapidly progressive labor can cause more harm than vaginal delivery. Successful management of the gravid woman with pulmonary hypertension requires a multidisciplinary team comprising individuals from obstetrics, anesthesiology, and neonatology departments, as well as a pulmonary hypertension specialist, working with experienced support staff. We advocate for an individualized delivery plan taking relevant maternal and pregnancy characteristics into consideration.

P19.06: Increased intertwin discrepancy in cerebroplacental ratio (CPR-Δ) is predictive of earlier age at delivery in monochorionic-diamniotic (MCDA) twins: Poster discussion hub abstracts

Objectives: To investigate the role of CPRfor the prediction of gestational age (GA) of delivery in MCDA pregnancies. Methods: This was a retrospective cohort study of all MCDA pregnancies at a maternal fetal medicine referral centre between 1/2007-2/2017. Exclusion criteria were structural or chromosomal anomalies, intrauterine fetal demise (IUFD) < 16 weeks, or referral after development of Twin–twin transfusion syndrome (TTTS) or twin anemia polycythemia sequence (TAPS). Ultrasounds were performed biweekly from 16-37 weeks to survey umbilical artery (UA) and middle cerebral artery (MCA) Dopplers. CPR was calculated as MCA-PI:UA-PI. CPRwas defined as the absolute difference between the twins and calculated at each visit. The maximum CPRin both the second and third trimester were assessed as predictors of adverse birth outcomes by logistic regression analysis. Pearson’s correlation coefficients were calculated to assess the relationship between CPRand birth outcomes. Results: 143 MCDA twin pregnancies (16 were lost to follow up) and 249 newborns met inclusion criteria: 16 pregnancies (11.2%) were complicated by TTTS, 7 (4.9%) were complicated by TAPS, 41 (28.7%) were complicated by sIUGR, and 8 (5.6%) developed an IUFD of one twin. Mean GA at delivery was 34.9 weeks, of which 73.4% were via Caesarean. Mean birth weight was 2157 g (range: 540 g-3980 g), and 76 (58.7%) pregnancies had NICU admission of at least one twin. There was a significant correlation between maximum CPRin the second trimester to GA at delivery (r = -0.2955, p = 0.0017) and average birth weight (r = -0.3778, p < 0.0001). Logistic regression analysis showed a significant association between maximum CPRin the second trimester and NICU admissions (OR 3.94, 95% CI 1.31-11.85; p = 0.0146). Conclusions: In MCDA twin pregnancies, increasing intertwin CPRis correlated with earlier GA at delivery, lower average birth weight, and NICU admissions. CPR evaluation may be of clinical utility in the surveillance of MCDA twin pregnancies.