The Endocannabinoid System - The Prediction of Spontaneous Preterm Birth in High-Risk Women: Protocol of a Study.

Spontaneous preterm birth (sPTB) is a major cause of perinatal morbidity and mortality, even in developed countries. Prediction of sPTB is therefore a valuable tool to reduce the associated risks. The current standard for the prediction of sPTB consists, in addition to anamnestic data, of previous sPTB and previous second trimester miscarriage, measurement of cervical length by transvaginal ultrasound (TVU CL) together with assessment of fetal fibronectin levels in cervicovaginal fluid. Other evaluation parameters, such as the level of endocannabinoids in the pregnant woman's blood, could increase the sensitivity of this management. Endocannabinoids (eCBs) are a part of the endocannabinoid system (ECS); out of them anandamide (arachidonoyl-ethanolamide, AEA), in particular, plays an important role in the regulation of pregnancy and childbirth. We present the protocol for an open, non-randomized study to evaluate concentrations of AEA and other endocannabinoids: 2 linoleoylglycerol (2-AG), 2 linoleoylglycerol (2-LG), 2 oleoylglycerol (2-OG), and 2 arachidonoyldopamine (2-ADOPA or also NADA) in the blood of pregnant women as potential predictors of sPTB. In a total of 230 women with a history of sPTB or miscarriage, eCBs levels between 22 and 28 weeks of gestation will be assessed from maternal blood, in addition to the standard procedure. The aim of the study is to determine the relationship between blood concentrations of the endocannabinoids tested and the risk of sPTB. The results of this study will describe the prognostic significance of maternal blood eCBs levels for sPTB, and could subsequently enable improved screening programs for early identification of sPTB.

Steroids, steroid associated substances and gestational diabetes mellitus.

As gestational diabetes mellitus (GDM) is both a frequent and serious complication, steroid levels in pregnancy are extremely elevated and their role in pregnancy is crucial, this review focuses on the role of steroids and related substances in the GDM pathophysiology. Low SHBG levels are associated with insulin resistance and hyperinsulinemia, while also predicting a predisposition to GDM. Other relevant agents are placental hormones such as kisspeptin and CRH, playing also an important role beyond pregnancy, but which are synthesized here in smaller amounts in the hypothalamus. These hormones affect both the course of pregnancy as well as the synthesis of pregnancy steroids and may also be involved in the GDM pathophysiology. Steroids, whose biosynthesis is mainly provided by the fetal adrenal glands, placenta, maternal adrenal glands, and both maternal and fetal livers, are also synthesized in limited amounts directly in the pancreas and may influence the development of GDM. These substances involve the sulfated ?5 steroids primarily acting via modulating different ion channels and influencing the development of GDM in different directions, mostly diabetogenic progesterone and predominantly anti-diabetic estradiol acting both in genomic and non-genomic way, androgens associated with IR and hyperinsulinemia, neuroactive steroids affecting the pituitary functioning, and cortisol whose production is stimulated by CRH but which suppresses its pro-inflammatory effects. Due to the complex actions of steroids, studies assessing their predominant effect and studies assessing their predictive values for estimating predisposition to GDM are needed.

Prenatal care for woman after fertility-sparing surgery for cervical cancer.

AIM: To summarize the current knowledge about the care of pregnant women after fertility-preserving operations for cervical cancer. STUDY TYPE: Review article. SETTING: Department of Gynecology and Obstetrics, 1st Faculty of Medicine, Charles University and General University Hospital, Prague. METHODOLOGY: Search of published literature on a given topic using the PubMed database. RESULTS: Pregnant women after fertility-sparing surgery for cervical cancer can benefit from screening and treatment for asymptomatic bacteriuria, cervical incompetence screening, and progressive cervical shortening by transvaginal ultrasonography. Tests to determine the presence of biomarkers of preterm birth in cervicovaginal fluid improve the prediction of preterm birth. Vaginal progesterone supplementation should be the primary prevention of preterm birth in all women after trachelectomy. Women with a history of preterm birth or late abortion may benefit from cerclage. The preferred mode of delivery is the cesarean section after 37 weeks of gestation. CONCLUSION: Due to the lack of data, pregnancy management in women who have undergone fertility-sparing surgery for early cervical cancer is inconsistent. An increasing number of pregnancies after fertility-sparing surgery will likely prompt clinical research in this field.

Current options of prediction of preterm labour.

OBJECTIVE: A summary of current possibilities to adequately determine spontaneous preterm labour. DESIGN: Review. SETTING: Department of Obstetrics and Gynecology, 1st Faculty of Medicine and General Teaching Hospital, Charles University in Prague. METHODS: Research of literature and current studies. CONCLUSION: Based on the combination of personal medical history, clinical signs, biomarkers and transvaginal ultrasonographic measurement of cervical length, it is possible to predict preterm labour. To avoid a major prediction miscalculation, it is necessary to understand and correctly evaluate certain clinical findings. This approach decreases redundant medical intervention and therefore leads to amelioration of perinatal outcome.

Insulin-like growth factor axis in pregnancy and gestational diabetes mellitus.

The insulin-like growth factor (IGF) is involved in the regulation of growth and metabolism. The aim of this study was to determine selected parameters of IGF system at systemic and local levels [subcutaneous (SAT) and visceral adipose tissue (VAT)] to assess its possible role in gestational diabetes mellitus (GDM). 37 pregnant women (21 with GDM and 16 without GDM) and 15 age-matched non-pregnant females were included in the study. Blood samples were taken in 28-32 and 36-38 weeks of gestation and 6-12 months after delivery. SAT and VAT samples were obtained during delivery or surgery. Compared with non-pregnant women, serum IGF-1 and IGFBP-3 were increased in both groups of pregnant women. IGF-2 was elevated only in GDM women from 36 weeks of gestation culminating 6 months after delivery (p=0.003). Serum IGFBP-3 was increased and IGFBP-4 decreased in GDM women vs. pregnant women without GDM during the whole study (IGFBP-3: p?0.001 for GDM vs. non-GDM; IGFBP-4: p=0.004 for GDM vs. non-GDM). Pregnant women with GDM had decreased mRNA expression of IGF-1, IGF-1R and IGF-2R and IGFBP-4 in VAT and IGF-1R in SAT compared to pregnant women without GDM. Changes in local activity of IGF are associated with the development of GDM.

A method for determination of one hundred endogenous steroids in human serum by gas chromatography-tandem mass spectrometry.

Steroid profiling helps various pathologies to be rapidly diagnosed. Results from analyses investigating steroidogenic pathways may be used as a tool for uncovering pathology causations and proposals of new therapeutic approaches. The purpose of this study was to address still underutilized application of the advanced GC-MS/MS platform for the multicomponent quantification of endogenous steroids. We developed and validated a GC-MS/MS method for the quantification of 58 unconjugated steroids and 42 polar conjugates of steroids (after hydrolysis) in human blood. The present method was validated not only for blood of men and non-pregnant women but also for blood of pregnant women and for mixed umbilical cord blood. The spectrum of analytes includes common hormones operating via nuclear receptors as well as other bioactive substances like immunomodulatory and neuroactive steroids. Our present results are comparable with those from our previously published GC-MS method as well as the results of others. The present method was extended for corticoids and 17alpha-hydroxylated 5alpha/ß-reduced pregnanes, which are useful for the investigation of alternative "backdoor" pathway. When comparing the analytical characteristics of the present and previous method, the first exhibit by far higher selectivity, and generally higher sensitivity and better precision particularly for 17alpha-hydroxysteroids.

The incidence of gestational diabetes mellitus before and after the introduction of HAPO diagnostic criteria.

INTRODUCTION: During the years 2014-2015 new diagnostic criteria for gestational diabetes mellitus (GDM) were gradually adopted by the Czech professional societies, which emerged from the results of the large prospective multicenter HAPO study (The Hyperglycemia and Adverse Pregnancy Outcome). The adoption of the new criteria was accompanied by concerns about the increase in the number of women with GDM. The paper deals with epidemiological results of GDM incidence in the first three years since the introduction of new criteria. METHODS AND RESULTS: In the years 2013-2014 GDM screening was performed at 1,594 pregnant woman at the General Teaching Hospital in Prague. According to that time valid diagnostic criteria (fasting glucose 5.6 mmol/g and/or 8.9 mmol/l in 60 min and/or 7.7 mmol/l in 120 min 75 g OGTT) GDM was found in 324, i.e. 20 % of women. In the years 2016-2018 were 2,629 pregnant women examined. GDM based on the new criteria (fasting blood glucose 5.1 mmol/l and/or 10 mmol/l in 60 min and/or 8.5 mmol/l in 120 min OGTT) was diagnosed in significantly less women - in 375, i.e. 14.3% (p < 0.0001). Overt diabetes, i.e. fasting glucose 7.0 mmol/l and/or 11.1 mmol/l in 120 min OGTT, was newly detected in 6 pregnant women, i.e. 0.2 %. Gestational diabetes was found in 62% cases based on repeated fasting fasting blood glucose and in 38% on the basis of higher blood glucose at 60 min and/or 120 min OGTT. GDM was significantly more prevalent in the age category over 30 years. Among women aged under 25 years GDM was present at 9.9%, aged 25-29.9 years at 9.6%, aged 30-34.9 years at 14.2% and aged 35 years at 18.6 %. Hypoglycaemia < 3.5 mmol/l experienced 2.9% of women during OGTT. When the screening in 2016-2018 was evaluated according to the previous diagnostic criteria, diabetes would be diagnosed in 16.2% of pregnant women. The result of the test would be falsely negative in 6% of all pregnant women, i.e. these women have repeatedly higher fasting glucose (5.1-5.5 mmol/l) according to the current criteria which was evaluated as physiological according to the previous criteria. However, in the HAPO, these values were already associated with a significant increase of complications. A total of 50% of women with GDM diagnosed according to the previous criteria would have a false positive result of OGTT (8.9-9.9 mmol/l in 60 min and/or 7.7-8.4 mmol/l in 120 min OGTT). These values are not considered to be significantly at risk under the new criteria. CONCLUSION: Our data do not confirm the increase in GDM incidence following the introduction of new diagnostic criteria which, according to current knowledge, better reflect the real risks of complications for the child and the mother. Applying the previous criteria has led to a number of false negative and positive results, so we consider the adoption of better-funded new criteria a step in the right direction. The incidence of diabetes was significant in all age categories and significantly increased in women over 30 years of age.

May circulating steroids reveal a predisposition to intrahepatic cholestasis of pregnancy in non-pregnant women?

Intrahepatic cholestasis of pregnancy (ICP) is a frequent liver disorder, mostly occurring in the third trimester. ICP is not harmful to the mothers but threatens the fetus. The authors evaluated steroid alterations in maternal and mixed umbilical blood to elucidate their role in the ICP development. Ten women with ICP were included in the study. Steroids in the maternal blood were measured by Gas Chromatography-Mass Spectrometry (GC-MS) (n=58) and RIA (n=5) at the diagnosis of ICP, labor, day 5 postpartum, week 3 postpartum and week 6 postpartum. The results were evaluated by ANOVA consisting of the subject factor, between subject factors ICP, gestational age at the diagnosis of ICP and gestational age at labor, within-subject factor Stage and ICP × Stage interaction. The 17 controls were firstly examined in the week 36 of gestation. ICP patients showed reduced CYP17A1 activity in the C17,20 lyase step thus shifting the balance between the toxic conjugated pregnanediols and harmless sulfated 5alpha/beta-reduced-17-oxo C19 steroids. Hence, more toxic metabolites originating in maternal liver from the placental pregnanes may penetrate backward to the fetal circulation. As these alterations persist in puerperium, the circulating steroids could be potentially used for predicting the predisposition to ICP even before next pregnancy.

Changes in plasma concentrations and mRNA expression of hepatokines fetuin A, fetuin B and FGF21 in physiological pregnancy and gestational diabetes mellitus.

We measured plasma concentrations, adipose tissue and placental mRNA expression of hepatokines fetuin A, fetuin B and fibroblast growth factor 21 (FGF21) in 12 healthy pregnant women (P group), 12 pregnant women with gestational diabetes (GDM) and 10 healthy non-pregnant women (N group) to explore their potential role in the etiopathogenesis of GDM. GDM and P group had comparable BMI, C-reactive protein (CRP) and glycated hemoglobin levels while IL-10 and TNF-alpha levels were higher in GDM group. Fetuin A and fetuin B levels were higher in pregnancy as compared to N group and decreased after delivery with no apparent influence of GDM. In contrast, the pattern of changes of circulating FGF21 levels differed between GDM and P group. Fetuin A concentrations positively correlated with CRP, TNF-alpha mRNA expression in adipose tissue and IL-6 mRNA expression in placenta. Fetuin B positively correlated with CRP. FGF21 levels correlated positively with IFN-gamma mRNA in adipose tissue and inversely with IL-8 mRNA in the placenta. Taken together, fetuin A and fetuin B levels were increased during pregnancy regardless of the presence of GDM. In contrast, FGF21 patterns differed between healthy pregnant women and GDM patients suggesting a possible role of this hepatokine in the etiopathogenesis of GDM.

Low maternal serum concentrations of mannose-binding lectin are associated with the risk of shorter duration of pregnancy and lower birthweight.

Chronic inflammation has been implicated as the underlying mechanism responsible for the pathophysiology of preterm labour. Mannose-binding lectin (MBL) plays a central role in the innate immune response and is thus an important component of the first line of defense. The aim of this study was to investigate whether serum concentrations of MBL correlated with the incidence of preterm birth and low birthweight in a cohort of women with signs of threatened preterm birth. A cohort of 60 patients who presented with regular contractions and/or short cervix (group A) between 24 and 32 weeks of gestation and 20 healthy controls (group B) who had no pregnancy complications and delivered at term were recruited into a prospective study. The following outcomes were recorded: presence of preterm labour and birthweight in all patients. MBL and high sensitivity C-reactive protein levels were measured in all serum samples. The serum concentrations of MBL were significantly reduced in patients with threatened preterm labour (Group A), compared to the control Group B. Furthermore, infants born to Group A mothers with MBL deficiency (n = 13, MBL ≤100 ng/mL) had significantly lower birthweights, compared to those born to Group A women with normal MBL serum concentrations (P < .0001). Our small cohort study demonstrated a strong association between MBL deficiency and preterm delivery, and associated low birthweight. MBL deficiency could thus be considered an important risk factor for preterm birth.

Pitfalls in screening for gestational diabetes in the Czech Republic - patient survey.

OBJECTIVE: The aim of our survey was to investigate gestational diabetes (GDM) screening policy in the Czech Republic with regards to the correct methodology of the screening. MATERIALS AND METHODS: 1100 anonymous questionnaires were distributed among patients of a tertiary level obstetric department from July 2015 to September 2015. RESULTS: 958 (87.0%) questionnaires were found eligible for analysis. 794 (82.9%) of participants had at least one risk factor for GDM development. The oGTT was performed in 751 (94.6%) women at risk of GDM and 153 (93.3%) women at low risk of GDM. From the 904 performed oGTT, 154 (17.0%) were performed completely by recommended standards. In the remaining cases, at least one deviation from standard was noted. The results of oGTT were provided by 364 (40.3%) of respondents. In this subgroup, 71 (19.5%) matched International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria for GDM diagnosis. However, these women were often not those who were evaluated as screening positive by the office gynaecologist. CONCLUSION: The screening for GDM was frequently not performed in accordance with the national guidelines and the diagnostic criteria used were not uniform.

[The role of maternal imunity and woman´s microbiome in the pathogenesis of preterm labor]. / Úloha materské imunity a mikrobiomu zeny v patogenezi predcasného porodu.

OBJECTIVE: To summarize available data concerning the role of maternal imunity and woman´s microbiome in the pathogenesis of preterm labor and their use in clinical practice. SETTING: Department of Obstetrics and Gynecology od the First Faculty of Medicine, Charles University in Prague, and General Teaching Hospital. DESIGN: Review article. METHODS: Compilation od published data from scientific literature. CONCLUSION: Preterm labor complicates approximately 10% of all pregnancies and represents a serious medical, social and economic problem. In the past, a lot of causes of preterm labor were discussed; infection, uteroplacental ischemia, decidual hemorrhage, uterine overdistension, cervical disease and maternal-fetal tolerance disorder were considered the most common. However, chronic inflammation seems to be the common pathogenic process underlying preterm labor, irrespective of the original stimulus. Currently, impaired maternal-fetal immunological tolerance represents most discussed topic. Growing scientific evidence suggests that the immune regulation of the maternal-fetal interface is the result of the coordinated interaction among maternal microbiota, trophoblast and maternal cellular components. From this view we understand preterm labor as a result of disruption of this process.

The role of steroid hormones in the development of intrahepatic cholestasis of pregnancy.

Intrahepatic cholestasis of pregnancy (ICP) is a disorder of liver function, commonly occurring in the third trimester but sometimes also as soon as the end of the second trimester of pregnancy. Symptoms of this disorder include pruritus, plus abnormal values of bile acids and hepatic transaminases. After birth, symptoms disappear and liver function returns to normal. Though ICP is relatively non-complicated and often symptomatically mild from the point-of-view of the mother, it presents a serious risk to the fetus, making this disease the subject of great interest. The etiology and pathogenesis of ICP is multifactorial and as yet not fully elucidated. Hormonal factors likely play a significant role, along with genetic as well as exogenous factors. Here we summarize the knowledge of changes in steroid hormones and their role in the development of intrahepatic cholestasis of pregnancy. In addition, we consider the role of exogenous factors as possible triggers of steroid hormone changes, the relationship between metabolic steroids and bile acids, as well as the combination of these factors in the development of ICP in predisposed pregnant women.

[Amniotic fluid embolism - review]. / Embolie plodovou vodou - prehledový clánek.

UNLABELLED: Amniotic fluid embolism is a rare but mortal pregnancy complication. Presentations may vary from subtle clinical events to sudden cardiac arrest or death. Amniotic fluid embolism is one of the most common cause of maternal mortality in developed countries. Basic principle is amniotic fluid and its particles gaining access to maternal circulation. It is supposed, that these particles trigger immune-based mechanism. This results into wide spectrum of clinical symptoms, especially cardiovascular, respiratory and haematological. Treatment of these symptoms needs an acute interdisciplinary cooperation. AFE mortality is decreasing in recent times. It is mainly because of increase of quality of intensive care and inclusion of less severe episodes in perinatal pathology registries. KEYWORDS: amniotic fluid embolism, anaphylactic shock, sepsis.

Steroid metabolome in the umbilical cord: is it necessary to differentiate between arterial and venous blood?

Steroids are important markers in pregnancy. Although estimating their levels separately in umbilical arterial (UA) and venous blood (UV) enable more precise insights into the functioning fetoplacental unit compared to using mixed umbilical blood (UM), selective aspiration of UA and UV is technically more demanding than collecting UM. We measured the levels of 67 unconjugated steroids and steroid polar conjugates in UA and UV using GC-MS in 80 women giving birth within weeks 28 to 42 of gestation. The samples were sorted into three groups: women entering labor within weeks 28-32 (group A, n=19), weeks 33-37 (group B, n=19), and weeks 38-42 (group C, n=42) of gestation, respectively. The preterm labors were due to pathologies unrelated to steroid status. Most unconjugated steroids exhibited pronounced arteriovenous differences (AVD). The AVD were less distinct in more stable steroid conjugates. Most steroids positively correlate with gestational age, but unconjugated 5beta-reduced pregnanes show negative correlations, as do testosterone and androstenediol, substrates for the placental synthesis of estrogens. Tight correlations between steroids in UA and UV indicate that steroid measurements in UA, UV and UM can be accurately derived from each other, which is important for the diagnostics of steroid related diseases in newborns.

[Intrahepatic cholestasis of pregnancy]. / Intrahepatální cholestáza v tehotenství

The review of intrahepatic cholestasis of pregnancy attempts to summarize the current knowledge of this disease by analysing available literary sources. Intrahepatic cholestasis of pregnancy is a disease that typically appears in the third trimester of pregnancy, sometimes already at the end of the second trimester of pregnancy. The main symptom of the disease is pruritus. In addition, the disease is characterized by increased levels of liver enzymes and bile acids. The symptoms of the disease disappear spontaneously after delivery. The disease is associated with high incidence of fetal distress, as well as with a high risk of premature labour. The most serious obstetric complication is antenatal sudden fetal death. Fetal complications are probably caused by elevated levels of bile acids. Therefore the aim of treatment should be to minimize negative effects of bile acids on the fetus, to prolong pregnancy and reduce maternal symptoms at the same time.