Changes in PGRMC1, a potential progesterone receptor, in human myometrium during pregnancy and labour at term and preterm.

This study assesses the role of progesterone receptor membrane component 1 (PGRMC1) in actions of progesterone (P4) on human myometrium during pregnancy and labour. Myometrial tissues were obtained from non-pregnant patients during hysterectomy or pregnant women undergoing C-section at term and preterm, before and during labour. PGRMC1 expression in myometrial tissues and in a human myometrial cell line (HM9) was assessed by western blots and RT-PCR. The subcellular localization of PGRMC1 in HM9 was performed by immunofluorescence staining. Isometric contractions of myometrial tissues were obtained in response to P4 with and without addition of specific antibodies against PGRMC1. Endogenous and over-expressed PGRMC1 proteins are detected by western blots in myometrial tissues, HM9 and 293 cells, respectively. PGRMC1 is localized to the plasma membrane, cytoplasm and nuclear membranes. PGRMC1 is lower in myometrium of women at term either not in labour (P = 0.004) or in labour (P = 0.005) compared with tissues from women in preterm non-labour. PGRMC1 levels are also decreased (P = 0.02) in myometrial tissues from women during preterm labour compared with preterm non-labour. P4 rapidly inhibits contractions of myometrial tissues compared with control (P < 0.05) in vitro. Pretreatment of myometrial strips with PGRMC1 antibody, suppresses the P4-induced relaxation (P < 0.05). PGRMC1 may mediate the non-genomic action of P4 and the relaxation effect on human myometrium during pregnancy. A decrease in PGRMC1 during term or preterm labour might contribute to the 'functional withdrawal' of P4 action and shift the balance to a state of heightened uterine contractility.

Differential roles of ERK and Akt pathways in regulation of EGFR-mediated signaling and motility in prostate cancer cells.

Upregulation of epidermal growth factor receptor (EGFR) and subsequent increases in extracellular-regulated kinase (ERK) and Akt signaling are implicated in prostate cancer progression. Impaired endocytic downregulation of EGFR also contributes to oncogenic phenotypes such as metastasis. Thus, understanding the roles of divergent signaling pathways in the regulation of EGFR trafficking and EGFR-driven invasive migration may enable the development of more effective therapies. In this study, we use the human prostate cancer cell lines, DU145 and PC3, to investigate the effects of both the ERK and Akt pathways on epidermal growth factor (EGF)-mediated EGFR signaling, trafficking and cell motility. We show that DU145 and PC3 cells overexpress EGFR and migrate in a ligand (EGF)-dependent manner. Next, we show that pharmacological inhibition of ERK (but not Akt) signaling enhances EGF-induced EGFR activation, ubiquitination and downregulation, and may lead to enhanced receptor turnover. These findings negatively correlate with ERK-mediated threonine phosphorylation of EGFR, implicating it as a possible mechanism. Further, we uncover that EGF promotes disassembly of cell-cell junctions, downregulation of E-cadherin and upregulation of the transcriptional repressor, Snail, typical characteristics of epithelial-mesenchymal transition (EMT). These effects are dependent on activation of Akt, as inhibition of Akt signaling abolishes EGF/EGFR-driven cell migration and EMT. Knockdown of endogenous Snail also prevents EGFR-mediated downregulation of E-cadherin, EMT and cell migration. Surprisingly, inhibition of the ERK pathway augments EGFR-dependent motility, occurring concomitantly with elevation of EGF-induced Akt activity. Collectively, our results suggest that EGF-triggered ERK activation has profound feedback on EGFR signaling and trafficking by EGFR threonine phosphorylation, and Akt has a pivotal role in EGFR-mediated cell migration by activating EMT. More important, our results also suggest that therapeutic targeting of ERK signaling may have undesirable outcomes (for example, augmenting EGFR-driven motility).

Preinduction cervical ripening. A randomized trial of intravaginal misoprostol alone vs. a combination of transcervical Foley balloon and intravaginal misoprostol.

OBJECTIVE: To determine if the addition of a mechanical ripening agent (transcervical Foley balloon) to a pharmacologic agent (intravaginal misoprostol) improves the efficiency of preinduction cervical ripening. STUDY DESIGN: Singleton patients with an indication for delivery, unfavorable cervix (Bishop score < or = 5) and no contraindication to labor were randomly assigned to two groups: misoprostol alone (25 micrograms intravaginally every 3 hours for no more than 12 hr) or combination therapy (25-French transcervical Foley balloon inflated to 50 mL of sterile water with identical intravaginal misoprostol dosing). All patients received a history and physical examination (including Bishop score), preripening ultrasound, electronic fetal heart rate and contraction monitoring (to rule out spontaneous labor and document fetal well-being). Multiple variables of perinatal outcome were analyzed, including the main outcome variables of ripening-to-delivery time and cesarean section rate. RESULTS: During August 1998 to August 1999, 81 patients were randomized, 40 to misoprostol alone and 41 to combination therapy. There were no differences between the groups with respect to maternal demographics, preripening Bishop score, maternal complications, intrapartum intervention or neonatal outcome. The misoprostol group spent longer periods of time in active labor, and there was a trend for the combination group to require oxytocin for longer intervals. These findings did not significantly affect the total ripening-to-delivery time or cesarean section rate which were similar for both groups. CONCLUSION: The addition of mechanical ripening with a transcervical Foley balloon to intravaginal misoprostol did not improve the efficiency of preinduction cervical ripening. Mechanical and pharmacologic cervical ripening agents appear to act independently rather than synergistically.

Revisiting the short cervix detected by transvaginal ultrasound in the second trimester: why cerclage therapy may not help.

OBJECTIVE: The purpose of this study was to identify the risk factors that are associated with increased neonatal morbidity in patients who were treated for sonographic evidence of internal os dilation and distal cervical shortening during the second trimester. STUDY DESIGN: From May 1998 to June 2000 patients between 16 and 24 weeks of gestation with the following sonographic criteria were randomly assigned to McDonald cerclage or no cerclage: internal os dilation and either membrane prolapse into the endocervical canal at least 25% of the total cervical length but not beyond the external os or a shortened distal cervix <2.5 cm. Before randomization, all patients were treated identically with an amniocentesis, multiple urogenital cultures, and therapy with indomethacin and clindamycin for 48 to 72 hours. Except for the cerclage, all patients were treated identically after randomization. Multiple variables of perinatal outcome were analyzed. A regression model with gestational age at delivery as the dependent variable was constructed and repeated with neonatal morbidity as the dependent variable. This model was applied to 3 populations: the cerclage group, the no cerclage group, and both groups combined. RESULTS: Of the 135 patients, 20 patients declined randomization, and 2 patients were diagnosed with acute chorioamnionitis. Of the 113 patients remaining, 55 patients were randomly assigned to the cerclage group, and 58 patients were randomly assigned to the no cerclage group. There were 8 rescue cerclage procedures (4 in each group). Regression analysis showed that readmission for preterm labor, chorioamnionitis, and abruption were consistently associated with early gestational age at delivery and increased morbidity. Cerclage did not affect perinatal outcome. CONCLUSION: The sonographic findings of second trimester internal os dilation, membrane prolapse, and distal cervical shortening likely represent a common pathway of several pathophysiologic processes. Use of cerclage does not alter any perinatal outcome variables. Increased neonatal morbidity in these patients appears to be associated with subclinical infection, preterm labor, and abruption.

Preinduction cervical ripening techniques compared.

OBJECTIVE: To assess the clinical efficacy of pharmacologic, mechanical and combination techniques of cervical ripening. STUDY DESIGN: From March 1997 to August 1998, all cervical-ripening patients at Lehigh Valley Hospital were randomly assigned to three groups: intravaginal misoprostol, intracervical Foley catheter, or combination prostaglandin E2 (PGE2) gel and Foley catheter. Inclusion criteria included Bishop score < or = 5 and no contraindication to labor. The remaining delivery process was actively managed according to established guidelines. Multiple variables in perinatal outcome were analyzed, with the cesarean section rate and time from ripening to delivery as the main outcome variables. RESULTS: Of the 205 patients, 65 were randomized to the misoprostol group, 71 to the Foley group and 69 to the catheter-and-gel group. There were no differences between groups in delivery indications, maternal demographics, ultrasound findings, labor interventions, intrapartum times, mode of delivery, postpartum complications or neonatal outcomes. The misoprostol group demonstrated a higher rate of uterine tachysystole and required oxytocin less when compared to the two catheter groups. CONCLUSION: The higher rate of uterine tachysystole with misoprostol did not increase the cesarean section rate. The higher rate of oxytocin required by the two catheter groups did not increase the delivery time intervals. There appears to be no benefit to adding intracervical or intravaginal PGE2 gel to the intracervical Foley balloon. The misoprostol and catheter ripening techniques have similar safety and efficacy.

A randomized trial of cerclage versus no cerclage among patients with ultrasonographically detected second-trimester preterm dilatation of the internal os.

OBJECTIVE: The aim of this study was to compare perinatal outcomes of patients with second-trimester ultrasonographic evidence of preterm dilatation of the internal os treated with cerclage versus those of patients not treated with cerclage. STUDY DESIGN: From May 1998 through June 1999 patients with ultrasonographic evidence of preterm dilatation of the internal os between 16 and 24 weeks' gestation were randomly assigned to receive a McDonald cerclage or no cerclage. Before random assignment all patients underwent amniocentesis and urogenital cultures and then received 48 hours of therapy with indomethacin and antibiotics. After treatment each patient was followed up as an outpatient with bed rest and weekly ultrasonographic evaluation. RESULTS: Of the 61 patients 31 were randomly assigned to cerclage and 30 were randomly assigned to no cerclage. There were no differences between groups with respect to maternal demographic characteristics, risk factors for preterm birth, cervical measurements, rescue procedures, readmission, chorioamnionitis, and abruptio placentae. The mean gestational age at delivery (33.5 +/- 6.3 weeks) and the perinatal death rate (12. 9%) in the cerclage group were similar to the mean gestational age at delivery (34.7 +/- 4.7 weeks; P =.4) and the perinatal death rate (10.0%; P =.9) in the no-cerclage group. CONCLUSION: Treatment with McDonald cerclage of preterm dilatation of the cervix detected ultrasonographically during the second trimester did not improve perinatal outcomes.

Does centralized monitoring affect perinatal outcome?

A retrospective study was performed comparing centralized monitoring to noncentralized monitoring in regard to perinatal outcome. The study was conducted at Lehigh Valley Hospital (Allentown, PA) between August 1994 and February 1995. All deliveries during a 28-week-period were studied retrospectively. The study was designed such that for 14 weeks all patients were centrally monitored (Group A). During the following 14 weeks, no patients were centrally monitored (Group B). Patients not requiring monitoring, such as elective cesarean sections, were excluded from the study. The variables that were studied were the 5-minute Apgar, cord blood pH, perinatal mortality, admissions to the neonatal intensive care unit (NICU), spontaneous vaginal deliveries, cesarean sections, and operative vaginal deliveries. A total of 1,622 deliveries occurred during the 28 weeks of antenatal care. Group A consisted of 805 centralized monitored patients and Group B had 817 noncentralized monitored patients. There was no statistical difference in the 5-minute Apgar, umbilical artery pH, perinatal mortality, or the NICU admissions between the two groups. However, there was a significant statistical difference in the percent of cesarean sections performed for nonreassuring fetal heart rate tracings (Group A, 17.89% vs. Group B, 12.16%; P = 0.02). The overall cesarean section rate was increased in the centrally monitored group (Group A, 23.6% vs. Group B, 18.1%; P = 0.01). There were also statistically significant differences in operative vaginal deliveries (forceps and vacuum) for fetal heart rate abnormalities between Group A, 0.52% vs. Group B, .39% (P = 0.05). Centralized monitoring may be associated with an increase in the overall cesarean section rate. In addition, the rate of operative vaginal and abdominal deliveries appears to be increased for the indication of nonreassuring fetal heart rate tracings with the use of centralized monitoring.

Preeclampsia: immunologic alteration of Nitabuch's membrane? Clinical sequelae.

OBJECTIVE: To determine if preeclampsia is an immunologic disease process consistent with a host-vs.-graft reaction by examining differences in immunoglobulin deposition at the maternal fetal interface (Nitabuch's layer) in preeclamptic patients. STUDY DESIGN: A prospective study of patients at Lehigh Valley Hospital was conducted between July 1993 and April 1994. Group 1 (study) consisted of 11 primigravid women meeting the criteria for the diagnosis of preeclampsia. Group 2 (control) consisted of 11 primigravid women who had an uncomplicated pregnancy. At delivery, basal plate placental specimens were obtained, fixed, and processed for study by a blinded observer utilizing IgG, IgA, IgM, IgE immunofluorescence techniques. The placenta was then sent to a gynecologic pathologist for blinded evaluation and measurement of Nitabuch's membrane by light microscopy. RESULTS: Taking the average width of 3 measurements of Nitabuch's membrane by light microscopy revealed no significant difference (group 1, .1839 mm vs. group 2, .1555 mm). Immunofluorescence techniques revealed that the thickness of immunofluorescence of Nitabuch's membrane was significantly greater in the study group vs. the control group (157.48 pixels vs. 63.80 pixels, P = .006, respectively). CONCLUSION: Evaluation of the maternal-fetal interface reveals the deposition of increased immunoglobulins, the physiology of which may be similar to nephropathies as seen in systemic disease processes. The deposition of immunoglobulins may be associated with a common antigen which may point to an immunologic etiology for preeclampsia in some women.

Fetal seizures: a case study.

BACKGROUND: A review of the literature and an extensive Medline search revealed that this is the first case report of fetal seizures diagnosed by ultrasound. CASE: A 23-year-old woman was found to have a fetus with bilateral choroid plexus cysts during a second-trimester ultrasound examination. Karyotype and alpha-fetoprotein level were normal. The cysts resolved, but idiopathic polyhydramnios was noted. Fetal testing beginning at 32 weeks revealed abnormal fetal behavior patterns on ultrasound and documented fetal seizures with rapid, repetitive limb movements noted on several occasions and lasting 30-60 seconds. Similar movements continued after birth as tonic-clonic seizure activity. CONCLUSION: Qualitative changes in movement patterns are common in neurologically impaired fetuses. Ultrasound may be used to diagnose these neurologic abnormalities that can be connected with clinical outcomes. This will better prepare the parents and hospital staff members for delivery and may also decrease medicolegal risk for the obstetrician because the abnormal behavior predates the birth process.

The impact of mandated in-hospital coverage on primary cesarean delivery rates in a large nonuniversity teaching hospital.

OBJECTIVE: Our purpose was to determine whether attending physician call status affected the primary cesarean delivery rates of the resident or private services after institution of in-hospital coverage. STUDY DESIGN: Data for the study year, during which in-hospital attending coverage was in place, were compared with those of the previous year, during which in-hospital attending coverage of residents was not in place. Birth records were analyzed retrospectively for physician and patient factors. RESULTS: For the year before in-hospital coverage the institutional total cesarean rate was 24.9%, with a primary cesarean section rate of 17.6%. In the first year of coverage the total cesarean delivery was 21.7%, with a decrease in the primary rate to 15.3%. The resident service primary cesarean delivery rate was 10.6% during the study year, which was unchanged from 10.9% the prior year and did not contribute to the overall decrease. Conversely, the private service primary cesarean rate decreased from 18.0% in the prestudy year to 13.4% when the attending physician was on call in the hospital but remained higher at 17.5% when the attending physician was on call not in the hospital. CONCLUSIONS: In-hospital attending physician coverage lowered individual attending physicians' private service primary cesarean rates. Resident service primary cesarean rates were lower than private service and were unaffected by the initiation of in-hospital coverage.

Gap junction formation in human myometrium: a key to preterm labor?

OBJECTIVE: The purpose of this study was to determine if gap junctions are a necessary component of the human laboring uterus and if their presence in myometrium is a prerequisite for both term and preterm labor. STUDY DESIGN: We obtained 27 human myometrial samples at cesarean section or nongravid hysterectomy. Gap junction formation was analyzed in a blind fashion by freeze fracture and indirect immunofluorescence. Six samples were obtained from term patients with no labor, six from term patients in labor, six from preterm patients with no labor, six from patients in preterm labor, and three from nongravid hysterectomy specimens. RESULTS: Gap junction structures were identified in the human myometrium of patients in term and in preterm labor but not in the other patient samples. In addition, evidence was obtained for the expression of (alpha 1) gap junction ribonucleic acid and (alpha 1) gap junction protein in term samples of human myometrium. CONCLUSION: Gap junctions are a necessary component of the human myometrium during term and preterm labor. The formation of gap junctions may be a final common event for the development of labor, and inhibition of gap junction activity could be a novel approach for the treatment of preterm labor.

Pregnancy outcome following first-trimester varicella infection.

Varicella infection in the first trimester has been associated with a constellation of congenital abnormalities. The incidence of the congenital varicella syndrome is unknown, although it has been reported to be as high as 9%. In a prospective study performed between 1986-1990, 40 patients were identified who had first-trimester varicella infection. Pregnant patients were referred from physicians in the perinatal regional network after developing the classical picture of varicella infection. Targeted fetal ultrasound examinations were performed between 16-20 weeks' gestation in all cases and neonatal outcome was determined. Of the 40 patients, three had first-trimester losses and another underwent an elective termination of pregnancy after counseling. Of the remaining 36 women, one had fetal omphalocele. Thirty-five pregnancies continued until term, and no infant had features of the congenital varicella syndrome at birth. Other than the case of omphalocele, no major congenital anomalies were identified. This study, the largest series of patients with first-trimester varicella infection, showed an incidence of congenital varicella syndrome of 0% and an incidence of congenital anomalies of 3% (range 0-8% at 95% confidence level).

Relationship between fetal biophysical activities and umbilical cord blood gas values.

In a prospective study of 62 patients undergoing cesarean section before the onset of labor a fetal biophysical profile assessment was performed within 3 hours before the cesarean section. The presence or absence of the individual fetal biophysical activities (fetal heart rate reactivity, fetal breathing movements, fetal body movements, and fetal tone) were correlated with umbilical cord blood gas and acid-base measurements (artery and vein). Fetuses with nonreactive nonstress test results or the absence of breathing had significantly lower cord artery pH, PO2 bicarbonate, and base excess measurements but not a significantly different PCO2 level as compared with fetuses that had these activities present. Fetuses with the absence of movements or tone had lower pH, PO2 bicarbonate, and base excess levels and higher PCO2 levels as compared with fetuses with the presence of movements or tone, respectively. These blood gas and acid-base differences were observed in both umbilical cord artery and vein. Subsequent analysis of the blood gas and acid-base measurements of the fetuses with compromised biophysical activities revealed that there are different levels of acidemia, hypoxemia, and hypercapnia at which the individual biophysical activities are compromised. These data suggest that the first manifestations of fetal hypoxemia and acidemia are nonreactive nonstress test results and loss of fetal breathing; in advanced acidemia, hypoxemia, and hypercapnia fetal movements and fetal tone are compromised.