Dominant immune cells in pregnancy and pregnancy complications: T helper cells (TH1/TH2, TH17/Treg cells), NK cells, MDSCs, and the immune checkpoints.

Pregnancy problems including recurrent pregnancy loss, repeated implantation failure and pre-eclampsia  are common problems in the reproductive ages. Different reasons such as genetic, immunological, and environmental agents and also infections could develop these complications. In those cases in which the cause of the abortion is diagnosed, the chance of a successful pregnancy is increased by eliminating defective factors. However, in patients with unknown causes, there may be an imbalance in immune cells pattern. As a matter of fact, an inappropriate immune response is often associated with a failed pregnancy. Hence, the focus of treatment is to increase tolerance, not to suppress maternal immune system. These findings are linked to an elevated number of Treg cells and immune checkpoints through normal pregnancy. The present review discusses the balance of myeloid-derived suppressor cells, natural killer cells, T cells, and immune checkpoints, and also targeting them to maintain pregnancy and prevent associated complications.

Evaluation of CD39, CD73, HIF-1α, and their related miRNAs expression in decidua of preeclampsia cases compared to healthy pregnant women.

BACKGROUND: The Preeclampsia (PE) molecular mechanisms are not fully revealed and different biological processes are involved in the pathogenesis of PE. We aimed to evaluate adenosine and hypoxia-related signaling molecules in PE patients in the current study. METHODS: Decidua tissue and peripheral blood samples were taken from 25 healthy pregnant and 25 PE women at delivery time. CD39, CD73, and Hypoxia-inducible factor-alpha (HIF-α) were evaluated in mRNA and protein level using real-time PCR and western blotting techniques, respectively. Also, miR-30a, miR-206, and miR-18a expression were evaluated by real-time PCR. At last, secretion levels of IGF and TGF-ß in the taken serum of blood samples were measured by ELISA. RESULTS: Our results revealed that Expression of CD39 is decreased in PE cases versus healthy controls at mRNA and protein levels (p = 0.0003 for both). CD73 and HIF-α showed an increased level of expression in PE patients at RNA and protein status (p = 0.0157 and p < 0.0001 for protein evaluation of CD73 and HIF-α, respectively). The miRNA-30a (p = 0.0037) and miR-206 (p = 0.0113) showed elevated expression in the decidua of the PE group. The concentration of secreted IGF-1 (p = 0.0002) and TGF-ß (p = 0.0101) in serum samples of PE cases compared to the healthy group were decreased. CONCLUSION: In conclusion, our results showed that aberrant expression of molecules that are involved in ATP catabolism and the hypoxic conditions is observed in PE cases and involved in their hypertension and inflammation could be served as PE prognosis by more confirming in comprehensive future studies. miR-206 and miR-30a play a role by regulating CD39 and CD73 as molecules that are involved in ATP catabolism as well as regulating the production of IGF-1 in the process of hypertension, which is the main feature in patients with preeclampsia. On the other hand, decreased level of miR-18a lead to upregulation of HIF-1a, and the consequence condition of hypoxia increases hypertension and inflammation in these patients.

Expression level of immune checkpoint inhibitory factors in preeclampsia.

Preeclampsia (PE) is a severe complication in pregnancy, and its symptoms (proteinuria and hypertension) manifest after 20 weeks of gestation, affecting up to 8 % of pregnancies. The pregnant women's immune system uses different tolerance mechanisms to deal with a semi-allogeneic fetus. The T-cell subsets including CD8+, CD4+, and Treg play a critical role in maintaining pregnancies. The expression of immune checkpoint molecules in T-cells can ensure pregnancy at the feto-maternal interface by controlling immune responses. This research aims to evaluate the expression level of immune checkpoint factors, including PD-1, LAG-3, CTLA-4, and TIM-3 in normal pregnant women and PE patients. Decidual tissue was collected from 50 participants (25 PE and 25 control). For evaluating the genes expression, real-time PCR was employed. The western blot was used to assess the proteins level. The results of real-time PCR indicated significantly decreased expression level of these immune checkpoints in PE patients. In parallel to gene expression results, the protein level of PD-1, LAG-3, CTLA-4, and TIM-3 in the PE group was also reduced. We revealed that the profile of proteins and genes expression of immune checkpoints in the decidua of PE mothers are different from normal pregnancy and these results indicate aberrant expression of immune checkpoints such as PD-1, LAG-3, CTLA-4, and TIM-3 may cause maladaptation immune response which results in PE manifestation.

Effect of plantar reflexology on labor pain and childbirth experience: A randomized controlled clinical trial.

AIM: This study aimed to determine the effect of plantar reflexology on the severity of labor pain and childbirth experience (primary outcomes) and the duration of labor stages (secondary outcomes). METHODS: This single-blind randomized controlled trial was performed on 90 women in Al-Zahra and Taleghani hospitals in Tabriz-Iran. Participants were randomly assigned into three groups; Intervention 1 (two 30-min massages at the effective point of pain for each sole), intervention 2 (one 30-min massage at the effective point of pain and one 30-min massage at the heel for each sole), and control (two 30-minute heel massages). Massage was performed once in 4-cm dilatation and the second time in 7-cm dilatation. The severity of pain and childbirth experience were measured by Visual Analogue Scale and Labor Agentry Scale, respectively. Partograph chart was used to measure the length of labor stages. RESULTS: The severity of pain in intervention group 1 was significantly lower than the control group (AMD: -1.7; 9% confidence interval: -2.8 to -0.6; p = 0.001), but there was no significant difference between intervention groups 1 and 2 (p = 0.066) and intervention group 2 and control (p = 0.336). A significant difference was observed between groups in terms of length of the third stage of labor (p = 0.04). There was no significant difference between groups in terms of mean childbirth experience score (p = 0.217), duration of active phase (p = 0.099), and second stage of labor (p = 0.114). CONCLUSION: The results of the study showed that plantar reflexology can reduce the severity of labor pain and the length of third stage of labor.

Comparing levels of vitamin D, calcium and phosphorus in normotensive pregnant women and pregnant women with preeclampsia.

Vitamin D and calcium deficiency have been reported as one of the causes of preeclampsia. In this study, levels of vitamin D, calcium and phosphorus were evaluated in 51 normotensive pregnant women and 52 women with preeclampsia at the gestational age between 28 and 36 weeks in Tabriz. Logistic regression and general linear models were used for comparing levels and means of vitamin D, calcium and phosphorus between the two groups adjusting for education and Body Mass Index (BMI). The results showed that mean serum vitamin D (p = .73), calcium (p = .12) and phosphorus (p = .60) levels were not significantly different between the groups after adjusting for education and BMI. Based on this study, no relationship was observed between vitamin D deficiency and preeclampsia; however, it was seen that the hypocalcaemia could increase the risk of preeclampsia up to 8.5 times. Based on our results and the literature, it seems that further studies need to be done to provide more insights into this area.Impact statementWhat is already known on this subject? Preeclampsia is one of the three leading causes of maternal morbidity and mortality worldwide. Despite the importance of preeclampsia, the causes and methods of prevention of this disease are still unknown. Deficiency of vitamin D affects the calcium balance of mothers and fetuses and has also been reported as one of the causes of preeclampsia disease. Reducing serum calcium can lead to increased blood pressure in preeclamptic women. Changes in calcium metabolism during pregnancy could be one of the potential causes of preeclampsia. Although the association of vitamin D, calcium and phosphorus with preeclampsia have been discussed previously, the results are not consistent.What do the results of this study add? The results showed that mean serum vitamin D, calcium and phosphorus levels were not significantly different between the groups.What are the implications of these findings for clinical practice and/or future research? Based on this study, no relationship was observed between vitamin D deficiency and preeclampsia; however, it was seen that the hypocalcaemia could increase the risk of preeclampsia by up to 8.5 times. Based on our results and the literature, it seems that further studies need to be done to provide more insights into this area.

The imbalance of Th17/Treg axis involved in the pathogenesis of preeclampsia.

PROBLEM: Inappropriate activation of the immune system, particularly the imbalance of T-helper type 17 (Th17)/regulatory T (Treg) cells is thought to play considerable roles in preeclampsia (PE). To investigate the probable effects of the adaptive immune system in the pathophysiology of PE, we analyzed the dynamic changes of Th17/Treg cells, cytokines profile, and transcription pattern of Th17/Treg-related genes and microRNAs (miRNAs) in 50 women suffering from PE in comparison with 50 healthy pregnant women. METHODS: Expressions of cytokines, specific transcription factors, and related miRNAs were measured by real-time polymerase chain reaction (PCR). Enzyme-linked immunosorbent assay (ELISA) was used to test the interleukin (IL)-17, IL-23, IL-6, and IL-10 and transforming growth factor ß in serum and supernatant of peripheral blood mononuclear cells (PBMCs). The frequency of Th17 and Treg cells were determined by flow cytometry. RESULTS: PE patients exhibited a decreased number of Treg cells (p = 0.006), while Th17 cells were increased ( p = 0.004). Forkhead box P3 and IL-10 mRNA expressions were reduced ( p = 0.0001 and 0.0028, respectively), while expressions of retinoic acid receptor-related orphan nuclear receptor γt, IL-17, IL-23, and IL-6 were enhanced ( p < 0.0001, 0.0018, 0.0014, and 0.027, respectively). ELISA results also showed increased levels of IL-6, IL-17, and IL-23 ( p = 0.022, 0.0005, 0.0081, respectively), and decreased levels of IL-10 in the supernatant of PBMCs of PE patients compared with control group ( p = 0.0011). There was significant upregulation of miR-106b and miR-326 ( p = 0.0048 and 0.028, respectively) in PE patients in comparison with the control group. CONCLUSIONS: These findings suggest that imbalance of Th17/Treg cells, regulated possibly via microRNAs, may be involved in the pathogenesis of PE, emphasizing on the importance of these cells in feto-maternal immune cross-talk.

Association study of CTLA-4 +49A/G gene polymorphism with recurrent pregnancy loss in the Iranian Azeri Turkish ethnic group.

BACKGROUND/AIM: Recurrent pregnancy loss (RPL) is defined as two or more pregnancy losses. T-regulatory cells play an important role in the feto-maternal interface. Cytotoxic-T-lymphocyte antigen-4 (CTLA-4) is a molecule that downregulates the activation and proliferation of T cells. The objective of the current study was to investigate the possible association of CTLA-4+49A/G gene polymorphism with RPL among patients from the Iranian Azeri Turkish ethnic group. MATERIALS AND METHODS: The study group/patients consisted of 101 women with the experience of two or more pregnancy losses and the control group consisted of 101 women with at least two live births, without any previous history of pregnancy loss and autoimmune diseases from the same ethnic group. The CTLA-4+49A/G was detected by polymerase chain reaction-restriction fragment length polymorphisms assay. RESULTS: The distribution of CTLA-4+49A/G genotype was AA, 38.61%; AG, 51.48%; GG, 9.9% in patients and AA, 37.62%; AG, 47.52%; GG,14.85% in controls (P-value: 0.2). Furthermore, no association in G-allele was observed in the patient and control groups (P-value: 0.5). CONCLUSION: The results of the present study suggest that CTLA-4 does not have any association with RPL in the Iranian Azeri Turkish ethnic group.

Effect of Progesterone on Latent Phase Prolongation in Patients With Preterm Premature Rupture of Membranes.

Preterm premature rupture of membranes (PPROM) is a condition leading to an increased risk of maternal and neonatal morbidity and mortality in pregnant women. To prevent this complication, some studies have proposed using prophylactic progesterone. However, due to lack of sufficient relevant data, there is still need for further studies in this regard. This study was performed to determine the effect of rectal progesterone on the latent phase and maternal and neonatal outcome variables in females with PPROM. During the present randomized clinical trial study (IRCT201512077676N4), a total of 120 patients with PPROM at pregnancy ages between 26 and 32 weeks were randomly assigned to 2 equal intervention and control groups. In the intervention group, progesterone suppositories (400 mg per night) were administered until delivery or completion of the 34th gestational week and was compared with placebo effect in control group. The latent phase and maternal and neonatal outcome variables were compared between the two groups. The mean age of patients was 29.56±5.66 (19-42) and 29.88±5.57 (17-40) years in the intervention and control group, respectively. The two groups were almost identical in the confounding factors. The median latent phase was 8.5 days in the intervention group vs. 5 days in the control group in the 28th-30th weeks of gestation, which was significantly higher in the intervention group (P=0.001). Among maternal and neonatal outcome variables, only the mean birth-weight was significantly higher in the intervention group than that in the controls (1609.92±417.28 gr vs. 1452.03±342.35 gr, P=0.03). Administration of progesterone suppository in patients with PPROM at gestational ages of 28 to 30 weeks is effective in elongating the latent phase and increasing birth-weight with no significant complications.

Percutaneous balloon mitral valvotomy during pregnancy.

Rheumatic mitral valve stenosis continues to be the most frequently encountered clinically significant valvular abnormality in pregnant women. We retrospectively studied the fetal outcomes of patients with severe rheumatic Mitral Valve Stenosis (MS) admitted to hospital with heart failure and underwent Percutaneous Balloon Mitral Valvotomy (PBMV) during pregnancy. We identified all of the pregnant cases with rheumatic MS from February 1st 1994 till February 1st 2011 who underwent PBMV from medical records in the tertiary referral center of Madani Heart Hospital in Tabriz, Iran. Follow up was done by phone call and office visit. During this period 24 pregnant patients with mean ages of 29.45 +/- 5.05 (19-38) had undergone PBMV for severe MS. Fourteen patients could not be reached and were lost to follow-up. PBMV had been performed during second trimester of pregnancy in 20 cases (83.3%) and during third trimester in 4 patients (16.6%). The success rate of PBMV was 100%. Pulmonary artery pressure reduced from 58.88 +/- 21.97 to 38.50 +/- 8.87 (p < 0.05), peak and mean transmitral valve gradient reduced 25.20 +/- 9.71 to 11.03 +/- 3.61 (p < 0.0001), 14.18 +/- 7.60 to 5.00 +/- 1.39 (p = 0.004), respectively. We conducted follow up in 10 patients with good fetal outcome in all except in 2 infants who died during follow up with intractable heart failure. Twenty patients were in normal sinus rhythm at the time of procedure (83.3%) and 4 of them (16.7%) had arterial fibrillation. PBMV during pregnancy could be recommended as a relatively safe procedure for mother and fetus.

Pregnancy in mothers with prosthetic heart valves.

Prosthetic mechanical valves have a high risk condition for patients in pregnancy. The aim of this study was to evaluate the safety of pregnancy in mothers with prosthetic heart valves. In this cross sectional study, we compared incidence of thromboembolic attacks abortion and maternal and fetal complications in 19 patients with prosthetic heart valves. We reviewed medical records, also office visit and follow up of these women for 10 years. Between 10 years we studied 19 patients, 13 had mechanical heart valves with mean ages of 28.2 +/- 5.43, 4 cases with bioprosthetic valves with mean age of 25.4 +/- 4.12 and 2 cases of valve repaired 27.00 +/- 7.07. Seven women were uniparous 8 cases were in second pregnancy, one had 3rd and another one were gravid 4th. There was a mean interval between valve surgery and pregnancy of 7.65 +/- 6.07 (1-23) years. Dominant underling disease for valve replacement was rheumatic. In conclusion bridge anticoagulation during pregnancy is safe for mother and fetus in women with mechanical heart valves.

The effect of erythropoietin against oxidative damage associated with reperfusion following ovarian detorsion.

OBJECTIVE: To determine the effect of recombinant erythropoietin on serum oxidants and the viability of ischemic ovaries after detorsion. STUDY DESIGN: A non-randomized single-blind clinical trial was conducted from December 2009 to January 2011 in a University Teaching Hospital affiliated with the School of Medicine, Tabriz University of Medical Sciences. Surgery was carried out on 40 patients, aged 18-35 years, with signs and symptoms of ovarian torsion. The patients were divided into two equal groups: group 1 received recombinant erythropoietin 150 IU/kg subcutaneously during the operation and 72 h after detorsion, and group 2 received no medication. Blood samples were taken before and 72 h after detorsion to determine the plasma levels of malondialdehyde, xanthine oxidase, glutathione, superoxide dismutase, nitric oxide, and total antioxidants. In both groups, the arterial and venous blood supply of the ovary and arterial blood flow resistance were evaluated before surgery and 72 h after detorsion of the ovary. The main outcome measures were improving ovarian blood flow and reducing oxidative damage. SPSS 17.0 was used for statistical analyses. RESULTS: The levels of malondialdehyde, glutathione, superoxide dismutase, nitric oxide, and total antioxidants 72 h after detorsion were significantly different between the interventional and non-interventional groups (p<0.001). There was no significant difference in the levels of xanthine oxidase (p=0.13). The difference between groups in the blood flow of the ovary 72 h after surgery was not statistically significant (p=0.61). CONCLUSION: Recombinant erythropoietin was effective in reducing the oxidative damage of ovarian torsion.

Neonatal C-reactive protein value in prediction of outcome of preterm premature rupture of membranes: comparison of singleton and twin pregnancies.

AIM: The clinical importance of preterm premature rupture of the membranes (PPROM) is its relationship to maternal and neonatal mortality and morbidity, especially in twin pregnancies. The aim of this study was to determine and compare the role of inflammatory factors as predictors of the PPROM outcome between singleton and twin pregnancies. METHODS: The medical records of 22 twins delivered between 28 and 34 weeks and complicated by PPROM were reviewed at the Al-Zahra Hospital in Tabriz, Iran. Also among singletons, 55 cases of matched gestational age were randomly selected as a control group. Three laboratory indices of neonatal white blood cell (WBC) count and C-reactive protein (CRP) in the two groups were measured immediately after delivery and the effects of two factors on neonatal outcome were assessed. RESULTS: In singletons, there was adverse relationship between the mean of WBC count and duration of latency (P = 0.007). Also, a positive relationship between the means of ventilation time and WBC count in second twins was found (P = 0.034). Positive CRP was the main predictor of neonatal intensive care unit admission in both singletons (odds ratio: 4.929, P = 0.042) and first twins (odds ratio: 9.000, P = 0.005). However, positive CRP did not influence the existence of metabolic acidosis or duration of latency in either of the two groups. CONCLUSION: Neonatal WBC count was a predictor for the duration of latency in singletons and for ventilation time in twins. Positive neonatal CRP was an important factor for the prediction of neonatal intensive care unit admission in both types of pregnancy; its role in twins is clearer than in singletons.