Unique alterations in infection-induced immune activation during pregnancy.

BACKGROUND: Immune responses to infection are uniquely regulated during gestation to allow for antimicrobial defence and tissue repair, whilst preventing damage to developing fetal organs or the triggering of preterm labour. OBJECTIVE: A review and analysis of studies delineating gestation-specific immune modulation and intra-amniotic regulation of pro-inflammatory immunity. SEARCH STRATEGY: Identification of the alterations between the fetus/neonate and adult with regard to the endogenous and infection-induced expression of molecules with immune regulatory properties, and the characterisation of intra-amniotic immune mediators that inhibit bacterial-induced pro-inflammatory cytokine production. SELECTION CRITERIA: English and non-English publications from 1985 to the present. DATA COLLECTION AND ANALYSIS: An electronic literature search using MEDLINE, PubMed, articles cited in the primary sources, as well as pregnancy-related immunology research from our laboratory at Weill Medical College of Cornell University. MAIN RESULTS: During fetal development, interleukin (IL)-23, IL-10 and IL-6, as well as T-helper-17 (Th17)-mediated immune responses, are upregulated, whereas tumour necrosis factor-α (TNF-α) and IL-1ß- and Th1-mediated immune responses are downregulated in the intrauterine environment (both the fetal compartment and the amniotic compartment). Infection-related immunity during gestation is preferentially directed towards combating extracellular microbial pathogens. Amniotic fluid and the neonatal circulation contain multiple components that improve the ability of the developing neonate to tolerate microbial-induced immune activation. CONCLUSIONS: The repertoire of immune mechanisms to control infection and inflammation differ between fetal and adult life. The dual mechanisms of resistance to infection and tolerance to infection-induced immune activation prevent damage to the developing fetus and the triggering of premature labour.

Endocervical hyaluronan and ultrasound-indicated cerclage.

OBJECTIVE: To investigate whether, at the time of ultrasound-indicated cerclage, the endocervical concentration of hyaluronan (HA), 27-kDa heat shock protein (HSP-27) and/or interleukin-8 (IL-8) would predict pregnancy outcome. METHODS: Endocervical samples, obtained from 40 women undergoing ultrasound-indicated cerclage at 15 + 3 to 25 + 0 weeks' gestation, were assayed by enzyme-linked immunosorbent assay for HA, HSP-27 and IL-8. All subjects had a cervical length of < 1.5 cm or dramatic cervical length change on serial endovaginal ultrasound, no uterine contractions or tenderness, no fever and intact membranes and underwent a modified Shirodkar cerclage. RESULTS: The median HA level was 10.0 ng/mL in the 12 women who delivered at < 37 weeks' gestation as opposed to 39.7 ng/mL in the 28 women delivering at 37-41 weeks (P = 0.017). Median HSP-27 and IL-8 concentrations were not significantly different in these groups. CONCLUSION: A higher endocervical HA level at the time of ultrasound-indicated cerclage is associated with a longer interval before birth.

Fetal intraperitoneal transfusion for iatrogenic twin anemia-polycythemia sequence after laser therapy.

Twin anemia-polycythemia sequence (TAPS) is a rare variant of twin-twin transfusion syndrome (TTTS) without the characteristic twin oligohydramnios-polyhydramnios sequence and cardiovascular milieu attributed to renin-angiotensin system mediators. It can occur spontaneously or iatrogenically after fetoscopic laser surgery. We report the case of a woman, gravida 2 para 1, with a monochorionic diamniotic pregnancy who developed Quintero Stage III TTTS. She underwent laser photocoagulation of identifiable anastomotic vessels and subsequently developed suspected TAPS 2 weeks later. The pregnancy was successfully treated with serial intrauterine intraperitoneal transfusions (IUT-PTs) of red blood cells. Although TAPS is a rare condition, serial middle cerebral artery peak systolic velocity measurements are warranted as follow-up in patients who have undergone fetoscopic laser surgery for TTTS. IUT-PTs may be superior to intravascular intrauterine transfusions in the treatment of this condition.