Placental expression of endothelial and inducible nitric oxide synthase and NO metabolism in gestational hypertension: a case-control study.

OBJECTIVE: Hypertension is one of the most common medical disorders in pregnancy and a role of nitric oxide (NO) metabolism has been described. Thus, the present work aimed at determining placental gene expression of eNOS and iNOS, to measure NO and ONOO(-) levels in patients with gestational hypertension (GH). METHODS: Fifteen patients with GH and 15 healthy pregnant controls were enrolled in the study. Placental tissue was taken immediately after delivery and was stored at -80 °C until analysis. A piece of frozen tissue was homogenized in the appropriate buffer. Total RNA was extracted and was reverse transcribed to obtain complementary DNA that was used for real-time PCR for iNOS and eNOS expression, whereas NO and ONOO(-) production were measured by commercially available kits. RESULTS: Placental eNOS and iNOS mRNA levels were significantly reduced in GH when compared to controls. NO and ONOO(-) production were both significantly higher in GH than controls. CONCLUSIONS: The reduced eNOS and iNOS gene expression in women with GH reinforces the hypothesis that the mechanisms involving NO pathways, may promote oxidative damage, by contributing to the reduced blood flow and increased resistance in the feto-maternal circulation and suggests the use of NO modulators as useful tools in GH management.

Gynecologic laparoscopy in patients aged 65 or more: feasibility and safety in the presence of increased comorbidity.

OBJECTIVES: To evaluate the feasibility, operative outcome and postoperative complications of laparoscopic gynaecologic surgery in patients aged 65 or more, with increased comorbidity and obesity. STUDY DESIGN: The medical records of patients aged 65 or more with uterine or ovarian disease admitted to minimally invasive gynecologic surgery units from January 2009 to December 2011 were retrospectively analyzed in an observational cohort study. Surgical outcomes of the laparoscopic cohort (n=65) were compared with the outcomes of those who had laparotomy (n=67) at general gynecologic surgery units, and evaluated with respect to indication for surgery, medical comorbidity and obesity. Laparoscopic surgery was attempted in women who accepted minimally invasive management and who had no absolute contraindications to laparoscopy. Surgical inclusion criteria were benign and malignant uterine and adnexal pathologies; benign uterine pathologies when uterine size was less than 18 weeks' gestation or myoma smaller than 10cm; malignancies in apparent early-stage disease. There was no attempt to use laparoscopy for tumor debulking and cytoreductive surgery. Exclusion criteria were patients with emergency operations or a concomitant urogynecologic procedure. Data were analyzed using Student's t-test, the Mann-Whitney U test, χ(2) testing and the Fisher exact test. RESULTS: Patients undergoing laparoscopy had a significantly shorter hospital stay (p<0.001), less intraoperative bleeding (p<0.001), less postoperative hemoglobin decline (p<0.001), less need for blood transfusions (p=0.007) and a generally lower incidence of complications compared to women who had laparotomy, regardless of medical comorbidity. Obese patients who had laparoscopy had significantly less intraoperative bleeding and a smaller postoperative hemoglobin drop; no adjunctive complication was observed. In patients over 70 (80 cases) the laparoscopic group (39 cases) maintained significantly less intraoperative bleeding (p<0.001) and a smaller hemoglobin drop (p<0.001) with respect to laparotomy, with few postoperative complications. CONCLUSIONS: According to the results of the study, laparoscopic surgery appears feasible and safe in elderly patients, regardless of medical comorbidity and obesity.

Female fetuses are more reactive when mother eats chocolate.

OBJECTIVE: The aim of our study was to analyze whether there is a gender difference in the effects of maternal chocolate ingestion (80% cocoa) on the fetus, as expressed by the fetal heart rate (FHR). STUDY DESIGN: One hundred pregnant women with uncomplicated term gestation, matched for age and parity, underwent computerized FHR recording before and after eating 30 g of 80% cocoa chocolate; 46 carried a male fetus, and 54 carried a female. Computerized cardiotocography parameters (baseline FHR in beats per minute, number of contractions/hour, fetal movements/hour, accelerations of at least 15 bpm for 15 s, episodes of high variation/min and short-term variation in ms) were expressed as the mean and SD. We calculated the difference before and after maternal chocolate eating both in male and female fetuses and then compared the gender differences in the FHR variation. Statistical significance was set at p < 0.05. RESULTS: While baseline FHR and number of contractions did not change, the number of: fetal movements/hour, accelerations, episodes of high variation/min, and the short-term variation significantly increased after chocolate ingestion. The percent variation of the movements (101.7 ± 89.23 males versus 252.0 ± 297.6 females; p = 0.002), accelerations (70.90 ± 46.98 males versus 153.3 ± 178.5 females; p = 0.004) and short-term FHR variation (21.47 ± 18.73 males versus 37.35 ± 27.46 females; p = 0.002) increased to a greater degree in the female fetuses than in the males. CONCLUSIONS: The maternal ingestion of dark chocolate induces much more reactivity in female fetuses than in males. This finding supports the existence of an innate gender difference for the effects of chocolate, present even since the fetal period.

Uterine fibroids: pathogenesis and interactions with endometrium and endomyometrial junction.

Uterine leiomyomas (fibroids or myomas) are benign tumors of uterus and clinically apparent in a large part of reproductive aged women. Clinically, they present with a variety of symptoms: excessive menstrual bleeding, dysmenorrhoea and intermenstrual bleeding, chronic pelvic pain, and pressure symptoms such as a sensation of bloatedness, increased urinary frequency, and bowel disturbance. In addition, they may compromise reproductive functions, possibly contributing to subfertility, early pregnancy loss, and later pregnancy complications. Despite the prevalence of this condition, myoma research is underfunded compared to other nonmalignant diseases. To date, several pathogenetic factors such as genetics, microRNA, steroids, growth factors, cytokines, chemokines, and extracellular matrix components have been implicated in the development and growth of leiomyoma. This paper summarizes the available literature regarding the ultimate relative knowledge on pathogenesis of uterine fibroids and their interactions with endometrium and subendometrial myometrium.

The correlation between fetal bradycardia area in the second stage of labor and acidemia at birth.

OBJECTIVE: To quantify fetal bradycardia in the second stage of labor and to determine the threshold of the area that correlates with neonatal acidemia. METHOD: We analyzed the cardiotocograms of 33 women with single pregnancy and term spontaneous labor who presented fetal bradycardia in the second stage of labor. We retrospectively calculated the fetal bradycardia area in the last 60 min before delivery with an upper limit of 90 bpm and correlated the area with neonatal pH. The study of the regression line determined the cut-off threshold between fetal well-being and distress. Significance was set at p < 0.05. RESULTS: The linear correlation between the bradycardia area and neonatal pH indicate that increasing bradycardia area was correlated with significant pH decrease. The threshold value of the area indicative of severe acidemia was ≥ 12.72 cm(2) (Pearson r = -0.76, p < 0.002). The diagnostic accuracy of the test was 73%. The PPV = 78.5% and the NPV = 68.4%. With such a cut-off, the timing of acidemia can be calculated as 25 min for a fetal heart rate (FHR) of 80 bpm, 13 min for a FHR of 70 bpm, 8 min for a FHR of 60 bpm, 6 min for a FHR of 50 bpm and 5 min for a FHR of 40 bpm. CONCLUSION: The bradycardia area in the second stage of labor significantly correlates with an accurate timing of fetal acidemia. Regardless of the cause of the bradycardia, the time for intervention is often short, meaning that any available intervention may be ineffective in preventing acidemia or even injury.

Perinatal outcomes in oocyte donor pregnancies.

OBJECTIVE: To assess the obstetric outcomes of pregnancy following intracytoplasmic sperm injection (ICSI) using donor oocytes. METHODS: Twenty-six deliveries from oocyte donor ICSI (d-ICSI) were compared to the next two consecutive deliveries from homologous ICSI (h-ICSI group) (n = 52) and with the two consecutive deliveries from women older than 40 years (Advanced Maternal Age: AMA) (n = 52). We evaluated the occurrence of gestational hypertension (GH), preeclampsia (PE), fetal growth restriction (IUGR), gestational diabetes mellitus (GDM), preterm premature rupture of membranes (pPROM), preterm birth, placental anomalies, mode of delivery, hemorrhage, gestational age at birth and birth weight. RESULTS: d-ICSI had significantly more PE (d-ICSI 19.2%, h-ICSI 0%, AMA 0%, p < 0.001); higher rates of IUGR than AMA pregnancies (d-ICSI 19.2%, AMA 3.8%, p < 0.025). Placental accretism was found only in the d-ICSI group (15.4%, p < 0.043). No postpartum bleeding was observed. CONCLUSIONS: This is the first study that compares the obstetric outcomes of donor pregnancies to the outcomes of h-ICSI and AMA. Obstetricians who deal with pregnancies from oocyte donation need to be aware of the more severe obstetric outcomes, especially placenta accreta and preeclampsia. All women who conceive through oocyte donation should be counseled as early as the pre-conception period and referred to specific centers for high-risk pregnancies.

Clues to apoptosis pathway involvement in hemolysis, elevated liver enzyme, and low platelet (HELLP) syndrome and intrauterine growth restriction (IUGR).

OBJECTIVE: The neurotrophin family comprises molecules involved in growth, differentiation, survival, regeneration, normal functions of the neuronal system, and in angiogenesis. We have investigated the expression pattern of neurotrophic signaling molecules in pregnancies complicated by elevated liver enzyme, and low platelet (HELLP) syndrome and intrauterine growth restriction (IUGR). METHODS: Placentas from normal and pathological pregnancies were collected. Macroarray analysis was performed and the data were confirmed by real-time PCR. RESULTS: Real-time PCR analyses (pathological vs. normal pregnancies) confirmed a significant down-regulation for IL-6, STAT3α, STAT3ß, and Bcl-2. The expression of Mcl-1 isoform 1 (long) was significantly increased. CONCLUSIONS: We suggest that decreased expression of IL-6 could mean that abnormalities in the immunological system function involve inflammatory cytokines other than IL-6 in examined pathological pregnancies. The STAT3α and STAT3ß down-regulation lead to a marked reduction of cellular transcriptional activity. Decreased expression of IL-6 is associated with a down-regulation of Bcl-2 but not of Mcl-1 isoform 1, suggesting that these two antiapoptotic proteins may function independently and that Mcl-1 may have a distinct role in controlling apoptotic pathway.

The definition of severe and early-onset preeclampsia. Statements from the International Society for the Study of Hypertension in Pregnancy (ISSHP).

OBJECTIVE: There is discrepancy in the literature on the definitions of severe and early-onset pre-eclampsia. We aimed to determine those definitions for clinical purposes and to introduce them in the classification of the hypertensive disorders of pregnancy for publication purposes. METHODS: We circulated a questionnaire to the International Committee of the International Society for the Study of Hypertension in Pregnancy focusing on the thresholds for defining severe preeclampsia and the gestation at which to define early-onset preeclampsia, and on the definition and inclusion of the HELLP syndrome or other clinical features in severe preeclampsia. The questions were closed, but all answers had space for more open detailed comments. RESULTS: There was a general agreement to define preeclampsia as severe if blood pressure was >160mmHg systolic or 110mmHg diastolic. There was scarce agreement on the amount of proteinuria to define severity. The HELLP syndrome was considered a feature to include in the severe classification. Most investigators considered early-onset preeclampsia as that occurring before 34weeks. CONCLUSIONS: A definition of pre-eclampsia is paramount for driving good clinical practice. Classifications on the other hand are useful to enable international comparisons of clinical data and outcomes. We used the results of this survey to update our previous classification for the purposes of providing clinical research definitions of severe and early onset pre-eclampsia that will hopefully be accepted in the international literature.

Introduction to ISSHP new classification of preeclampsia.

The classification of the hypertensive disorders of pregnancy has always been a crucial point, especially in the scientific literature, to compare results from different series. Some of the classes have been reviewed during time, and some new ones have been added, paralleling the increased knowledge of the diseases and syndromes. Among the interests of a society there is the sharing of a common language and the guidance to give to scientific authors and editors for better presentation of their results and outcomes. Still leaving unchanged the definition of the five major classes of the hypertensive disorders of pregnancy (gestational hypertension, preeclampsia, chronic hypertension, preeclampsia superimposed on chronic hypertension, eclampsia) we realized that in the last years emerged a need to better define some forms of preeclampsia, especially in terms of severity and time of onset and indicated delivery. This is why the International Committee of the International Society for the Study of Hypertension in Pregnancy (ISSHP) was requested to come to a consensus, by responding to a questionnaire, on the thresholds to define "severe preeclampsia", and "early onset preeclampsia", and on which parameters to use to define the HELLP Syndrome and which other definitions may be added. There was an agreement to define "severe preeclampsia" by blood pressure values >160mmHg systolic or 110mmHg diastolic. The amount of proteinuria was considered not useful to define the severity. The HELLP syndrome was considered a feature to include in the severe classification, and that could be identified by a reduction of platelet count below <100,000/dl, an elevation of ALT or AST twofold the upper limit of normal, and an elevated LDH (twofold the upper reference limit or greater than 650IU/l). There was an agreement to define "early-onset preeclampsia" as that occurring before 34 weeks. The results of this survey can help in updating the previous ISSHP classification.

Fetal heart rate in the second stage of labor: recording, reading, interpreting and acting.

Although central to the cardinal movements that lead to the delivery of the fetus, the second stage of labor is often neglected from a cultural and clinical viewpoint. In this phase, acquisition is more difficult, and reading and interpretation may not be the same as in the active first phase. Namely, the most relevant findings are the occurrence and depth of bradycardia and its duration. This allows the evaluation of fetal heart rate (FHR) even without cardiotocographic recording. Instead, FHR can be accurately detected using Doppler auscultation, and it is reasonable to speak of "FHR during the second stage of labor" instead of "cardiotocography in the second stage of labor." Regardless of the cause, including head compression, umbilical cord knots, loops around the fetal neck or body, and cord entanglement, the time for intervention is often so short that any intervention may be unable to prevent injury.

Nifedipine versus labetalol in the treatment of hypertensive disorders of pregnancy.

PURPOSE: To assess the maternal and fetal outcomes of pregnancies affected by hypertensive disorders treated with nifedipine versus labetalol. METHODS: A retrospective study in hypertensive patients treated during pregnancy with nifedipine or labetalol was conducted. After the charts review the patients were divided in the four groups: gestational hypertension (113 patients); mild preeclampsia (77 patients); severe preeclampsia (31 patients); HELLP syndrome (21 patients). The pregnancy and neonatal records were analyzed by paired and unpaired t test. RESULTS: We found that there was an higher rate of intrauterine growth restriction infants among women treated with labetalol compared with those treated with nifedipine (38.8 vs. 15.5 %; p < 0.05), but only in the subgroup of women affected by Gestational Hypertension and Mild Preeclampsia. In this group was also higher the rate of fetal worsening assessed by fetal heart rate tracing (33.3 vs. 14.2 %; p < 0.05). No neonatal malformations and no differences in the rate of adverse side effects were observed. CONCLUSIONS: Antihypertensive therapy in pregnancy with Labetalol may have the potential to impair fetal behavior in low degrees hypertensive diseases of pregnancy. Optimal care must balance the potentially conflicting risks and benefits to mother and fetus.

The effects of maternal caffeine and chocolate intake on fetal heart rate.

OBJECTIVE: The aim of our study was to analyze the effects of caffeine and chocolate (70% cocoa) on fetal heart rate (FHR). STUDY DESIGN: Fifty pregnant women with uncomplicated gestation, matched for age and parity, underwent computerized FHR recording before and after the consumption of caffeine and then, after one week, before and after 70% cocoa chocolate intake. Computerized cardiotocography (cCTG) parameters were expressed as mean and SD. The differences were tested for statistical significance using the paired t-test, with significance at p < 0.05. RESULTS: The number of uterine contraction peaks, the number of small and large accelerations (10 and 15 beats per minute for 15 seconds), the duration of episodes of high variation and the short-term FHR variation were significantly higher (p < 0.001) after maternal coffee intake. The number of large accelerations, the duration of episodes of high variation and the short-term FHR variation were significantly higher (p < 0.001) after maternal consumption of chocolate, whilst no effect of cocoa was found during contractions. CONCLUSIONS: Our results suggest that maternal intake of both caffeine and 70% cocoa have a stimulating action on fetal reactivity. This finding is likely due to the pharmacological action of theobromine, a methilxanthine present in coffee and in chocolate. The correlation between maternal caffeine intake and increased uterine contraction peaks is likely due to the effect of caffeine on the uterine muscle.

The involvement of inflammatory cytokines in the pathogenesis of recurrent miscarriage.

OBJECTIVE: To investigate the inflammatory cytokine expression pattern in trophoblastic tissue from women with unexplained recurrent miscarriage (RM). STUDY DESIGN: Trophoblasts were obtained during uterine evacuation from 11 women with RM and from 20 healthy pregnant women undergoing elective termination of pregnancy, who served as controls. The array was performed using GEArray Q Series Human Inflammatory Cytokines & Receptors Gene Array HS-015 membranes. Data were confirmed by quantitative real-time PCR. The Mann-Whitney U test was performed for statistical analysis. RESULTS: Microarray analysis identified three genes that were differentially expressed between RM patients and controls. We observed significant downregulation of Transforming Growth Factor beta 3 (TGF-ß3) and Interleukin 25 (IL-25) (5-fold reduction and 2.5-fold reduction, respectively) and significant upregulation of CD-25, also known as Interleukin 2 receptor alpha (IL-2RA) (7-fold increase) in women with RM compared with controls. The median ΔC(t) of TGF-ß3 was 8.2 (interquartile range, 7.67-8.9) in RM patients vs. 5.85 (interquartile range, 5.3-6.09) in controls; the median ΔC(t) of IL-25 was 5.18 (interquartile range, 4.46-5.76) in RM patients vs. 3.85 (interquartile range, 3.6-4.51) in controls, and the median ΔC(t) of CD-25 was 9.62 (interquartile range, 7.81-12.42) in RM patients vs. 12.44 (interquartile range, 11.02-13.86) in controls. DISCUSSION: Our results suggest that the immunological and inflammatory regulation mechanisms of the placental environment play a key role in recurrent miscarriage. The observed trophoblast cytokine expression pattern at the maternal-fetal interface confirms the immunotrophic theory, as demonstrated by a switch from a T-helper-1 (Th1) profile to a T-helper-2 (Th2) profile in women who experience recurrent miscarriages.

Nitric oxide and peroxynitrite platelet levels in gestational hypertension and preeclampsia.

The aim of the study was to investigate platelet nitric oxide (NO) pathways in women with Gestational Hypertension (GH), Preeclampsia (PE) and Controls. Platelet NO(x) and peroxynitrite (ONOO(-)) levels, inducible (iNOS) and endothelial nitric oxide synthase (eNOS) and Nitrotyrosine expression (N-Tyr) in 30 women with GH, 30 with PE and 30 healthy pregnant controls, age, parity and gestational age-matched, were assessed. Platelet NO(x) and ONOO(-) levels were significantly higher in GH and PE vs. Controls, with higher levels in GH vs. PE. At the same way, iNOS and N-Tyr were significantly higher in GH and PE vs. Controls, with higher levels in GH vs. PE. Since GH expressed higher amount of NO metabolites and higher activation of iNOS compared to PE, we can hypothesize that the severity of hypertensive pathology is almost not related to only NO metabolism, this research confirmed that GH and PE are associated with marked changes in NO pathways; it is not easy to understand if they could be interpreted as causes or consequence of these pathologic states.

Preeclampsia: No longer solely a pregnancy disease.

Preeclampsia, the leading cause of maternal and perinatal morbidity and mortality, has been recently considered not only a pregnancy disease but also a risk factor for developing diseases later in life. Preeclampsia is becoming a disease of interest to internists and not just obstetricians. Women who have had preeclampsia seem to be at higher risk of premature death, mortality from ischemic heart disease, cardiovascular diseases including ischemic heart disease and hypertension, fatal and non-fatal stroke, venous thromboembolism, renal failure, type 2 diabetes mellitus, hypothyroidism, and cognitive defects, although they appear surprisingly protected from cancer. Furthermore, having had preeclampsia is a problem not only for the mother's future health, but it also affects the offspring's adult health. Children born from preeclamptic pregnancies are more prone to hypertension, insulin resistance and diabetes mellitus, neurological problems, stroke, and mental disorders along their life. Whether preeclampsia is a risk factor for disease later in life or it creates long-term organ damage is an intriguing question. This review analyzes recent epidemiological evidence of the long-term outcomes of preeclampsia and the background mechanisms of this phenomenon. Understanding the etiological background may provide guidance for the prevention and follow-up of women who experience preeclampsia.

Modulation of syndecans in the uterus throughout the menstrual cycle: comparison between endometrium and myometrium.

Immunohistochemistry and semiquantitative analysis were used to examine and compare the expression of syndecans 1-4 in the endometrium and myometrium throughout the menstrual cycle. Syndecans molecules show different temporal and spatial expression during the menstrual cycle, and the modulation of syn-2 expression is statistically significantly correlated to morphologic and functional changes of the endometrium, particularly in the periovulatory period.

Placental expression of endothelial and inducible nitric oxide synthase and nitric oxide levels in patients with HELLP syndrome.

OBJECTIVE: To determine placental gene expression of endothelial and inducible nitric oxide synthases and measure nitric oxide levels in patients with hemolysis, elevated liver enzyme levels, and low platelet count syndrome. STUDY DESIGN: Preterm placentas were obtained from 15 patients with hemolysis, elevated liver enzyme levels, and low platelet count syndrome and 30 controls matched for age, parity, and gestational age. mRNA levels were evaluated by real-time polymerase chain reaction, whereas nitric oxide and peroxynitrite production was measured by a commercially available kit. RESULTS: Placental gene expression of inducible nitric oxide and endothelial nitric oxide synthases were significantly lower in the hemolysis, elevated liver enzyme levels, and low platelet count syndrome group than in controls, whereas nitric oxide and peroxynitrite production were significantly higher in hemolysis, elevated liver enzyme levels, and low platelet count syndrome compared with controls. CONCLUSION: The reduced endothelial nitric oxide and inducible nitric oxide synthases gene expression in women with hemolysis, elevated liver enzyme levels, and low platelet count syndrome may indicate extreme placental dysfunction that is unable to compensate the endothelial derangement and the related hypertension. The higher nitric oxide formation found in hemolysis, elevated liver enzyme levels, and low platelet count syndrome placentas could be explained as a counteraction to the impaired fetoplacental perfusion, typical of the syndrome.