Preterm Cervical Ripening in humans.

Preterm birth (PTB) is the leading cause of neonatal mortality and morbidity. Despite the current treatment procedures, the incidence of PTB has not changed in the past thirty years. Incomplete understanding of the biological and patophysiological mechanisms underlying preterm delivery is the major obstacle to prevent PTB. Cervical ripening is necessary for vaginal delivery and understanding of preterm cervical ripening is required for developing new treatment strategies. Several important substances such as HMGB1 and its receptors, CRH and its receptors and numerous cytokines are localized in the cervix and undergo distinct changes in labour. Other important -molecules, such as CRH, CRH-BP, CRH-R1, CRH-R2, HMGB1, TLR2, TLR4, IL-10, IL-12, are localized in the cervical epithelium, also indicating their role in the process of cervical ripening during labour. Furthermore, CRH stimulates IL-8 secretion from both preterm and term cervical fibroblasts. Recent studies from our group show that major -inflammatory changes occur in the cervix at labour irrespective of gestational age. This indicates that cervical ripening at both term and preterm is an inflammatory process even if no infection is present. However, preterm cervical ripening still entails some differences from term cervical ripening, for example in the down-regulation of mRNA expression of Toll-like receptors (TLR-2 and TLR-4) and IL-12, higher levels of IL-10 in cervical epithelium, and presents different secretion patterns of cervical fibroblasts. Moreover, preterm cervical ripening, like preterm delivery itself, is a multifactorial disorder with pathways which are partly different from those involved in PPROM and infected preterm labour.

Different secretion patterns of matrix metalloproteinases and IL-8 and effect of corticotropin-releasing hormone in preterm and term cervical fibroblasts.

The aims of the present study were to compare the levels of mRNA and protein expression of matrix metalloproteinase (MMP)-1, -3, -8 and -9 in human cervical tissue in preterm and term labor as well as not in labor and to determine if corticotropin-releasing hormone (CRH) has an effect on MMP-1, -3 and interleukin (IL)-8 secretion in both preterm and term cervical fibroblasts. Cervical biopsies were taken from 60 women: 18 at preterm labor, 7 at preterm not in labor, 18 at term labor and 17 at term not in labor. ELISA and Immulite were used for protein and real-time RT-PCR for mRNA analysis. Cervical fibroblast cultures were incubated for 18 h with different CRH concentrations (10(-13)-10(-6) M). The mRNA expression of MMP-1, -3 and -9 was higher in laboring groups compared with term not in labor. Protein levels of MMP-8 and -9 were higher in term in labor group compared with non-laboring groups. There were no significant differences in mRNA and protein expression between the preterm and respective term control groups. CRH significantly increased secretion of IL-8 in preterm and term cervical fibroblasts compared with controls. The secretion of IL-8 and MMP-1 was significantly higher and MMP-3 secretion lower in preterm cervical fibroblasts. In conclusion, cervical ripening at preterm seems to be a similar inflammatory process as at term with CRH involved. However, preterm and term cervical fibroblasts might have different phenotypes based on different secretion patterns of IL-8, MMP-1 and MMP-3.

Identification of the major proteoglycans from human myometrium.

BACKGROUND: During pregnancy and parturition a remodeling within the extracellular matrix of the cervix and the corpus uteri occurs, which is of fundamental importance to a normal labor. The aim of this study is to identify the major proteoglycans in corpus uteri of non-pregnant subjects. METHODS: From human uterine tissue proteoglycans were extracted and purified using CsCl-density gradient centrifugation, gel and ion-exchange chromatography. The proteoglycans were quantified and identified by Alcian Blue before and after ABC-digestion and by Western blotting. RESULTS: The results showed that the corpus uteri contains a substantial amount of proteoglycans, 1.825 microg/mg wet weight. Decorin is dominating, constituting 63% of the total amount of proteoglycans. Heparan sulphate proteoglycans accounted for 20% and biglycan for 16%. Less than 1% consisted of the large proteoglycan versican. CONCLUSIONS: Further investigations must be performed to provide more information of the biological role of the proteoglycans in the uterus, especially during labor, by the presence of heparan sulphate proteoglycans and the minute presence of versican which indicate that the proteoglycan composition and organization is different to that of the cervix.

Obstetric outcome following epidural analgesia with bupivacaine-adrenaline 0.25% or bupivacaine 0.125% with sufentanil--a prospective randomized controlled study in 1000 parturients.

BACKGROUND: Epidural analgesia (EDA) is the most efficient method for pain relief during labour, but there is still a debate as to whether it interferes with the normal process of delivery. Some authors argue that the incidence of instrumental deliveries, Caesarean section, malrotation and protracted labour is increased in parturients receiving EDA. METHODS: 1000 parturients were prospectively randomized to receive EDA either with a high dose of local anaesthetic (0.25% bupivacaine with adrenaline = HD) or with a low dose (0.125% bupivacaine with sufentanil 10 micrograms = LD). RESULTS: The incidence of instrumental delivery and Caesarean section and the need for oxytocin was reduced in the LD compared to HD group. The delivery time was similar with HD and LD among primiparous, but decreased significantly among multiparous in the LD group. The incidence of malrotation was low in both groups. The quality of analgesia was equal during the first stage in the 2 groups, but was lower in the LD group during the second stage. More parturients in the LD group ambulated, but this did not affect the incidence of instrumental delivery. CONCLUSION: It is concluded that a lower dosage of bupivacaine combined with sufentanil in epidural analgesia significantly improves the obstetric outcome as compared to a higher dosage of bupivacaine with adrenaline using intermittent bolus technique.

Different organization of collagen fibrils in stress-incontinent women of fertile age.

OBJECTIVE: The objective was to test the hypothesis that stress urinary incontinence in women is correlated to changes in the paraurethral connective tissue ultrastructure and metabolism. METHODS: Transvaginal biopsies were obtained from the paraurethral connective tissue in women of fertile age with stress urinary incontinence and in matched continent controls. All the stress-incontinent women were characterized with urodynamic investigation. In the biopsies, collagen concentration, measured as hydroxyproline, and the degree of extraction by pepsin digestion were quantified. Proteoglycan composition and concentration were analyzed using Alcian blue precipitation, followed by electrophoretic separation and quantification. Using Northern blots mRNA levels for the collagens I and III, the small proteoglycans decorin and biglycan, and the large proteoglycan versican, were quantified. Collagen organization was examined with transmission electron microscopy and the diameters of collagen fibrils were analyzed with an interactive image analysis system (IBAS, Zeiss/Kontron). RESULTS: The biochemical and morphological analyses exposed a significant difference in the paraurethral connective tissue between stress urinary incontinent women before menopause and comparable controls. The collagen concentration was almost 30% higher and the diameters of the collagen fibrils were 30% larger in the incontinent group of women. Also the organization of the collagen fibrils differed, with considerably higher cross-linking. A higher level of mRNA for collagen I and III in the incontinent group indicates that the differences can be related to an altered collagen metabolism. No change of proteoglycan amount or composition was observed, resulting in a significantly lower proteoglycan/collagen ratio in the incontinent group of women. CONCLUSION: Stress urinary incontinence in fertile women is associated with a change in collagen metabolism resulting in an increased concentration of collagen and larger collagen fibrils. These alterations should result in a more rigid form of extracellular matrix, suggesting a connective tissue with impaired mechanical function.

Paraurethral connective tissue in stress-incontinent women after menopause.

OBJECTIVE: To study whether stress urinary incontinence after menopause is correlated to changes in the paraurethral connective tissue ultrastructure and metabolism. METHODS: Transvaginal biopsies were obtained from the paraurethral connective tissue in stress urinary incontinent women after menopause with and without estrogen replacement therapy, and from comparable controls. All the stress-incontinent women underwent urodynamic investigation. In the specimens, collagen concentration, measured as hydroxyproline, and the degree of extractability by pepsin digestion, were quantified. Proteoglycan composition and concentration were analyzed using Alcian Blue precipitation, followed by electro-phoretic separation and quantification. Using Northern blots, mRNA levels for the collagens I and III, the small proteoglycans decorin and biglycan, and the large proteoglycan versican, were quantified. Collagen structure was examined with transmission electron microscopy, and the diameters of collagen fibrils were analyzed with an interactive image analysis system (IBAS, Zeiss/Kontron). RESULTS: No significant difference in paraurethral connective tissue biochemistry or ultrastructure was registered between women with stress incontinence and controls. Estrogen replacement therapy resulted in a lower collagen concentration both between the controls (p = 0.02) and between the incontinent women (0.02). In the women with stress incontinence also the extractability by pepsin digestion was higher in the group with estrogen treatment (p = 0.004), indicating a decrease in cross-linking. The proteoglycan/collagen ratio was higher in the control group with estrogen treatment compared to untreated (p = 0.02), but no difference was found between estrogen treated and untreated incontinent women. The median collagen fibril diameter was 15% larger in the incontinent group of women without estrogen therapy compared to the control group and 5% larger when comparing the incontinent group on estrogen replacement therapy to the corresponding control group. CONCLUSION: The extracellular matrix of paraurethral connective tissue in stress urinary incontinent women after menopause reacted differently to estrogen replacement therapy compared to continent controls. In contrast to incontinent women of fertile age no major changes in collagen metabolism were found in stress urinary incontinent women after menopause.

Decreased innervation of the paraurethral epithelium in stress urinary incontinent women.

OBJECTIVE: To determine whether there is a difference in the innervation of the paraurethral vaginal epithelium between stress urinary incontinent women of fertile age and comparable controls. METHODS: Transvaginal biopsies close to the external orifice of the urethra were obtained from 11 stress urinary incontinent women and from ten comparable controls. The specimens were processed for indirect immunohistochemistry using protein gene product 9.5 (PGP 9.5) as a general neuronal marker. From each biopsy, ten randomly selected fields of 1 mm2 projected area were investigated and nerve fibre profiles were quantificated in a microscope equipped with light- and dark-field optics. RESULTS: Nerve fibre profiles/mm2 of projected epithelial area were significantly lower in the incontinent group than in the control group (P < 0.01). CONCLUSION: Our study indicates that stress urinary incontinent women have a significantly lower total innervation of the paraurethral vaginal epithelium than continent controls.

Increased cerebrospinal fluid concentration of aspartate but decreased concentration of nitric oxide breakdown products in women experiencing visceral pain during active labour.

The aim of the present study was to investigate some putative neurotransmitters involved in nociception and pain in parturients during active labour experiencing intense visceral pain. The concentration of the excitatory amino acid aspartate was significantly increased, and there was a tendency for an increase in glutamate, in lumbar cerebrospinal fluid (CSF) of parturients in active vaginal labour compared with control patients without pain subjected to elective caesarean section. The CSF concentration of the nitric oxide breakdown product nitrate was significantly decreased in parturients compared with control patients and healthy volunteers. No significant differences in the concentrations of substance P, substance P-endopeptidase or met-enkephalin were detected between parturients and controls. Our data suggest a paradoxical negative relationship between CSF concentrations of excitatory amino acids and nitric oxide in labour pain. The mechanisms behind this finding is unclear at present.

Post-partum urinary retention: a comparison between two methods of epidural analgesia.

OBJECTIVE: To compare two methods of epidural labor analgesia regarding the incidence of post-partum urinary retention. STUDY DESIGN: One thousand parturients who requested epidural analgesia for the relief of labor pain received, at random, either bupivacaine 0.25% with adrenaline 1:200 000 (n = 500) or bupivacaine 0.125% with 10 micrograms sufentanil (n = 500). During the same observation period all women with clinically significant urinary retention (> 500 ml, requiring indwelling catheter) were registered. RESULT: Altogether 30/3.364 parturients had clinically significant urinary retention. Twenty-seven of these had received epidural analgesia (EDA) (17 with bupivacaine/adrenaline and ten with bupivacaine/sufentanil, a non-significant differences). The number of parturients with urinary retention was highly increased following EDA (27/1000) as compared to those not receiving EDA (3/2364), P < 0.001 (Fisher's exact test). In patients with EDA and urinary retention there were no difference between the groups in the incidence of instrumental deliveries or vaginal/perirectal tears. All parturients regained normal bladder function. CONCLUSION: EDA significantly increased the risk of post-partum urinary retention but no difference was found between the two epidural techniques.

Lack of analgesic effect of systemically administered morphine or pethidine on labour pain.

OBJECTIVE: To evaluate the true analgesic effect of morphine and pethidine on labour pain. DESIGN: The analgesic and sedative effects of intravenous morphine or pethidine and their effect on anxiety were compared in a prospective, double-blind, randomised dose-response study. SETTING: A Stockholm teaching hospital obstetric unit. PARTICIPANTS: Ten healthy nulliparous parturients in active labour were included in each group. RESULTS: Even after repeated doses (up to 0.15 mg/kg body weight morphine and up to 1.5 mg/kg body weight pethidine) the findings were uniform, with very high pain scores maintained in each group as assessed with visual analogue scale. The parturients were all significantly sedated and several fell asleep but were awakened by pain during contractions. CONCLUSION: It is concluded that labour pain is not sensitive to systemically administered morphine or pethidine. These drugs only cause heavy sedation. It therefore seems unethical and medically incorrect to meet parturients' requests for pain relief by giving them sedation. Considering the well documented negative effects on newborn infants we also believe systemic pethidine should be avoided in labour.

Analgesic efficacy of intravenous morphine in labour pain: a reappraisal.

The aim of the present study was to investigate the dose-related analgesic effect of intravenous (i.v.) morphine during spontaneous term first stage labour. This was an open study in 17 parturients who requested analgesia for severe labour pain. All women were given morphine i.v. in repeated doses of 0.05 mg/kg following every third contraction until a final dose of 0.20 mg/kg was reached. The decrease in overall pain intensity, from median visual analogue scale (VAS) 85 (range 52-100) to median VAS 70 (range 46-99), was clinically insignificant. The number of women experiencing back pain, however, decreased significantly following morphine. The most striking effect of morphine (7.2-18 mg) was pronounced sedation. No adverse reactions related to morphine were noted in the neonates. We conclude that i.v. morphine does not significantly reduce overall labour pain intensity. Thus, if a real analgesic effect is desired, systemically given morphine seems inappropriate and other techniques should be used.

Changes in paraurethral connective tissue at menopause are counteracted by estrogen.

OBJECTIVE: To study whether the transition to menopause is accompanied by changes in the paraurethral connective tissue and if these changes are modified by estrogen replacement therapy. STUDY DESIGN: Biopsies were obtained from the paraurethral tissue from 34 women; 12 menstruating, 14 postmenopausal without estrogen treatment, and 8 with estrogen treatment. Collagen concentration and collagen extractability by pepsin digestion were measured. Proteoglycan composition and concentration were analysed using Alcian blue. The mRNA levels for collagen I and III, the small proteoglycans (PGS) decorin and biglycan, and the large proteoglycan versican, were estimated. RESULTS: The paraurethral biopsies consisted of fibrous connective tissue, with collagen fibers as dominating structure. Several proteoglycans were identified; versican, heparansulphate proteoglycans, biglycan and decorin. The small proteoglycan decorin represented 85% of all proteoglycans. The collagen concentration was almost doubled in postmenopausal biopsies compared to premenopausal. The collagen fibril organization was also changed with higher cross-linking after menopause whereas the amount and the composition of the proteoglycans were unchanged. The proteoglycan/collagen ratio was significantly decreased. Estrogen replacement therapy resulted in decreased collagen concentration, decreased cross-linking of the collagen and reversal of the PGS/collagen ratio to almost premenopausal level. The therapy resulted in increased levels of mRNA for collagen I and III which suggests that the changes are due to an increased turnover. CONCLUSION: The decrease in estrogen levels at menopause results in a connective tissue with different qualities after menopause. Estrogen replacement therapy tends to restore the metabolism of the genitourinary connective tissue to premenopausal conditions.

Clinical outcome and changes in connective tissue metabolism after intravaginal slingplasty in stress incontinent women.

The intravaginal slingplasty procedure (IVS) was carried out on 75 patients with genuine stress urinary incontinence. The main aims of the operation are to create an artificial pubourethral ligament and to tighten the suburethral vaginal wall. An important ingredient in the supportive structures of the genitourinary region is fibrous connective tissue, consisting mainly of collagen. To analyse this component biopsies were obtained transvaginally, close to the position of the sling, both preoperatively and 2 years after surgery, from 6 patients. Collagen was analysed for concentration and extractability. Extractability by pepsin digestion was increased by 60% 2 years following surgery. Postoperative follow-up studies from 12 months to 3 years showed complete restoration of continence in 63 patients (84%) and considerable improvement in 4 others (5%). The 8 failures (9%) were all related to early rejection of the sling. The IVS procedure is an attractive surgical procedure as it necessitates minimum invasion and can be performed under local anesthesia, with a short hospital stay and sick-leave period. The enhanced collagen extractability indicates a changed metabolism, most likely induced by the implanted sling, resulting in a restoration of the elastic properties of the connective tissue.

Innervation of the human vaginal mucosa as revealed by PGP 9.5 immunohistochemistry.

In order to obtain a description of the innervation of the vaginal wall we employed an antiserum against the general neuronal marker, protein gene product 9.5, on normal human vaginal mucosa. Specimens were taken from the anterior and posterior fornices, from the anterior vaginal wall at the bladder neck level and from the introitus vaginae region, and then processed for indirect immunohistochemistry. All regions studied revealed a profound innervation, although regional differences were noted. The more distal areas of the vaginal wall had more nerve fibers compared to the more proximal parts. Also, biopsies from the anterior wall generally were more densely innervated than the posterior wall. Some large nerve coils were observed in lamina propria of the anterior wall as well as gatherings of thick-walled medium-sized blood vessels. Free intraepithelial nerve endings were only detected in the introitus vaginae region. These fibers were very thin, always varicose and could be observed just a few cell layers from the surface. In this part of the vagina, protein gene product 9.5 antibodies also stained cells within the basal parts of the epithelium. These cells were also neurone-specific enolase positive and resembled, from a morphological point of view, Merkel cells.

Carpal tunnel syndrome in pregnancy. A prospective study.

In this prospective study, 56 women (2.3%) of 2,358 (47% nulliparous and 53% multiparous) delivered during a 12-month period at the Department of Obstetrics and Gynecology, Malmö General Hospital, had symptoms of carpal tunnel syndrome during pregnancy. All (33 nulliparous and 23 multiparous women) were examined, at the outpatient's maternity care unit and within 4-5 weeks from the time of debut of symptoms, by a specialist in hand surgery. At that time the most common symptoms were paresthesia and nocturnal pain. Twenty-nine had signs of reduced sensibility and 14 of them had a positive two-point discrimination test. All had generalized edema. Conservative treatment with splinting of the wrist at night made 46 out of 56 symptom-free. Of the remaining 10 women, 3 had to be operated on, whereas 7 received only conservative treatment, as the expected time for parturition was very close. One of them had to be operated on after delivery. In conclusion, carpal tunnel syndrome during pregnancy is most common in primiparas with generalized edema. Conservative treatment is sufficient for symptom relief in most women (80%) but a few cases need operative intervention to abolish the severe pain and to avoid disturbances of hand function.

Comparison of intravenous oxytocin and vaginal prostaglandin E2 gel in women with unripe cervixes and premature rupture of the membranes.

To induce cervical priming and labor, 20 nulliparous term pregnant women with premature rupture of the membranes and unfavorable cervical states were randomly given either oxytocin intravenously or 4 mg prostaglandin E2 in gel intravaginally. One of ten women receiving oxytocin had a favorable cervical state within five hours and vaginal delivery within 24 hours after the start of the infusion compared with six of ten women after prostaglandin E2 gel application. This difference is statistically significant (P less than .01). The number of instrumental deliveries was nine (four cesarean sections and five vacuum extractions) in the oxytocin-treated patients compared with only two vacuum extractions in women who received prostaglandin E2 gel. This difference is also statistically significant (P less than .01, Fischer exact test). In a subsequent open study, 4 mg prostaglandin E2 gel was applied vaginally to 17 term pregnant women of mixed parity with premature rupture of the membranes and unfavorable cervixes. In 12 women a favorable cervical state was achieved within five hours after gel application, and all these women were delivered within 24 hours. None of the women required cesarean section but two required delivery by vacuum extraction. There were no perinatal losses, but two infants in the oxytocin-treated group had Apgar scores less than 7 at five minutes. At pediatric follow-up after two and six months, all infants were normal. In both obstetric and perinatal outcome prostaglandin E2 gel thus seems to be superior to oxytocin for labor induction in term pregnant patients with premature rupture of the membranes and unfavorable cervixes.