Cytokine release from placental endothelial cells, a process associated with preterm labour in the absence of intrauterine infection

There is currently a great deal of interest in the role that cytokines may play in the processes mediating preterm as well as normal term labour. In case of preterm delivery a cause-effect relationship between infection, uncontrollable preterm labour, and increased uterine cytokine concentrations is widely accepted, but there is considerable information that increased uterine cytokine release is also a condition in normal term labour and preterm labour not due to infection. Thereby, the exact cellular sources of cytokine production have not yet been identified. In the present study, the authors used immunohistochemical analysis to localize interleukin 1beta (IL-1beta) interleukin 6 (IL-6) and tumour necrosis factor alpha (TNF-alpha) immunoreactivity within trophoblastic villi and fetal membranes. In the absence of chorioamnionitis, uncontrollable preterm labour, and also normal term labour was associated with strong immunoreactivity for IL-1beta and IL-6 in the endothelial cells within trophoblastic villi. In contrast, preterm delivery accompanied by histologically confirmed chorioamnionitis, was not associated with increased expression of cytokine antigens within endothelial cells of the fetal vascular system, but strong cytokine activity was found in polymorphonuclear cells infiltrating the amniochorionic membranes. Therefore, the data suggest two well-defined subgroups among patients delivering preterm. Thereby, increased uterine cytokine concentrations may be realized in both groups, but the cellular sources of cytokine production may be different.     

Local and systemic control of myometrial contractile activity during labour in the sheep

The relative contribution of systemic versus local (intrauterine) factors in the activation and stimulation of the sheep myometrium during labour was examined using an in-vivo myometrial explant preparation. Myometrial tissue alone (MYO) or with attached endometrium (ENDO/MYO) was removed from the pregnant uterine horn, sutured to a stainless-steel frame and placed into the omental fat. After 7-10 days the explants developed a pattern of electromyographic activity qualitatively similar to that of the uterine myometrium. Induction of preterm labour by infusion of ACTH (66.6 ng/min for 15 min every 2 h) to the fetus resulted in a reduction in plasma progesterone concentrations and increases in values of oestradiol-17 beta and 13,14-dihydro 15-keto PGF-2 alpha in maternal plasma. The onset of labour, which followed these endocrine changes, was characterized by an increase in EMG burst frequency and reduction in burst duration occurring simultaneously in both the uterine myometrium and in the explants. The response of the uterine and explant myometrium to oxytocin also exhibited a parallel significant increase over the 24-h period leading to delivery. No differences were apparent between the explants containing myometrial tissue alone or those comprising endometrial and myometrial tissue. There was no significant change in uterine or explant EMG activity, or oxytocin responsiveness, after saline administration to the fetus. The pattern of EMG activity changes during spontaneous labour were not distinguishable from those during ACTH-induced labour. As with oxytocin, the responsiveness of the explants to electrical stimulation increased significantly at labour compared to pre-labour. These data suggest that factors within the systemic circulation play a major role in both the onset of labour contractions and the increased response to electrical or hormonal (oxytocin) stimulation during parturition in sheep.     

Effect of alpha-adrenergic blocking agents on uterine activity in the ewe at the end of gestation

The electromyographic activity (EMG) of the uterus was recorded in vivo in 8 unanaesthetized ewes from the 140th day of gestation up to parturition. The effects on uterine activity of treatments with an alpha 1-receptor blocker (prazosin) and an alpha 2-receptor blocker (yohimbine) were studied. During the last days of gestation, EMG activity consisted of periodic active phases (1-2/h). During the last 16-17 hours, uterine activity increased sharply; this period was referred to a labour. Intravenous perfusion of prazosin (0.03 mg/kg/mn over 1 h) or intravenous injections (1 mg/kg) did not modify uterine activity either before or during labour. Intravenous perfusion of yohimbine (0.03 mg/kg/mn during 1h) inhibited uterine activity before and during labour. In all cases, lambing occurred between the 142nd and 145th day of gestation, which corresponds to the normal lambing period. These results suggest that, in the ewe, uterine alpha 2-receptors are important for normal uterine activity at the end of gestation and in. parturition.     

Progesterone Deficiency and Premature Labour

Plasma oestradiol 17β and progesterone levels in 11 patients admitted to hospital for threatened premature labour of unknown aetiology were compared with those of women at similar stages of gestation whose pregnancy was normal. Oestradiol levels in the study group were slightly higher than in the normal controls but their progesterone levels were significantly lower. This progesterone deficiency increased the oestradiol/progesterone ratio in the study group patients, and it increased still more as the progesterone withdrawal continued during premature labour.Since uterine activity during pregnancy is regulated by a balanced action of several factors a deficiency in progesterone, an opponent of uterine activity, creates a regulatory imbalance which, if uncorrected, provokes premature labour. An increase in uterine volume stimulates uterine activity, and the present study reinforced our previous conclusion that the uterine-volume/plasma-progesterone ratio is a more accurate measure of the state of regulatory balance than the progesterone level alone.The cause of the progesterone deficiency in these cases remains unexplained, but we suggest that placental growth and function are contributory factors. We are investigating ways of correcting the resulting imbalance in the regulatory mechanism.     

The effect of experimentally induced hypocalcaemia on uterine activity at parturition in the ewe

The effect of hypocalcaemia experimentally induced by the intravenous infusion of ethylene-diamine tetraacetic acid, disodium salt (Na(2)EDTA) upon myometrial activity at parturition was studied in eleven ewes. Infusions of Na(2)EDTA were performed during first stage of labour (three animals), second stage (four animals), third stage (three animals) and postpartum (two animals); one in the latter group had been previously treated during second and third stages. Uterine activity was recorded using balloon-tipped catheters surgically implanted into the uterus and was expressed in Montevideo Units (M.U.). Plasma calcium (nonchelated) concentrations were monitored throughout the infusion. Induced hypocalcaemia resulted in a reduction of the activity of the uterus when Na(2)EDTA was administered during the first stage of labour. In the ewes infused during the second stage of labour, there was difficulty in reducing the activity of the uterus and, consequently, in delaying parturition. Reduction in uterine activity was easier in the ewes infused during the third stage of labour and during postpartum. Uterine activity started decreasing when plasma calcium concentrations were 6.6 and 7.1 mg/100 ml in the ewes infused during third stage of labour and postpartum, respectively, compared with 4.9 mg/100 ml in those infused during first stage of labour; the difference between this last group and the first two was significant (p < 0.05). After the end of the infusion, the plasma calcium started rising and normal uterine activity quickly resumed.     

The role of prostaglandins for the coordination of myometrial forces during labour

Systematic studies using a superfusion technique for recording myometrial contractility in vitro have been conducted in our department to explore whether prostaglandins (PG) have a differential action on the different segments of the pregnant uterus and also whether the qualitative and quantitative response undergoes a change during spontaneous labour. Myometrial specimens were excised from the fundal area and from the lower uterine segment at elective caesarean section in the 39th week of pregnancy before commencement of labour and at acute caesarean section during ongoing labour. Before labour PGF2 alpha was without or had a very weak effect on upper segment preparations but was stimulatory on lower segment specimens. PGE2 and PGI2 generally induced a biphasic dose-dependent response (stimulation followed by inhibition). During spontaneous labour PGF2 alpha and PGE2 always stimulated upper segment preparations while the contractile activity of specimens from the lower segment was inhibited by PGE2, PGF2 alpha was generally without effect. PGI2 had the same biphasic action before as during labour. With all reservations for the validity of in vitro experiments, the results favour the hypothesis that initiation of labour in the human involves a qualitative shift in the myometrial reactivity to prostaglandins. These alterations may involve suppression of expulsive forces and perhaps some tightening of the lower uterine segment during pregnancy. Following initiation of labour there is a marked increase in the excitatory action of both PGE2 and PGF2 alpha in the fundal area while the lower uterine segment reacts in a way that favours dilatation.     

Effets immédiats du dimenhydrinate sur la contraction utérine e le rythme cardiaque foetal durant le travail.

The effects of intravenous administration of 100 mg of dimenhydrinate (Gravol) were studied in 20 patients during active spontaneous labour. The uterine activity and the fetal heart rate were monitored by an invasive technique. After administration of the medication the uterine activity increases significantly, and in 20% of the cases decelerations in the fetal heart rate of the hypoxic type occurred. Because of its unpredictable effects, this drug should be used with care during labour.     

Prostaglandin F2α Concentrations in Peripheral Blood During the First Stage of Normal Labour

Plasma prostaglandin F₂α (PGF₂α) concentrations were measured by radioimmunoassay in women in normal first stage labour. A continuous sampling technique was used spanning uterine contractions, and blood samples were divided into 15-second aliquots.A regular pattern of rise in prostaglandin levels in peripheral plasma was observed, with maximum concentrations in the antecubital vein being reached in most cases 15-45 seconds after the peak of a uterine contraction. The most likely explanation of this finding is that prostaglandins are released as a result of uterine contractions. The alternative possibility is that prostaglandins initiate uterine contractions. Further studies of the time taken for blood to reach the antecubital vein are needed to clarify the position.     

Studies on serum progesterone levels in relation to occurrence of uterine torsion in buffaloes (Bubalus bubalis )

Serum samples from 32 buffaloes suffering from uterine torsion at approximately the completion of the gestation period were analyzed for progesterone concentrations by radioimmunoassay. Fifteen buffaloes had progesterone concentrations of more than 1.0 ng/ml (1.65 +/- 0.13 ng/ml; 1.1 to 2.8 ng/ml), while the serum progesterone concentrations of the remaining 17 buffaloes were below 1.0 ng/ml (599 +/- 59 pg/ml; 200 to 900 pg/ml). The occurrence of uterine torsion was associated with labour and/or abdominal pain around the expected time of parturition at the completion of the gestation period. High progesterone concentrations at labour in cases of torsion in almost half of the buffaloes may suggest that there were instances of premature labour resulting from an impaired hormonal milieu. Disturbances in the onset of labour owing to hormonal imbalance as evidenced by high progesterone levels may also contribute to the causation of uterine torsion. Cases of uterine torsion having low progesterone values are also discussed in this study.     

Effect of Intra-amniotic Oestriol Sulphate on Uterine Contractions

The effects of oestriol sulphate on myometrial activity in a group of young primigravidae, who were at 41 or more weeks'' gestation, are compared with those of a placebo in a double-blind trial. Both compounds were administered over a period of six hours directly into the uterine cavity following artificial rupture of membranes. Intra-amniotic pressure recordings demonstrated a peak in the mean intensity in uterine contractions in the oestriol-treated and placebo-treated groups at six and four hours, respectively. The length of labour tended to be shorter in those patients having greater uterine activity.     

Estrogen-induced uterine abnormalities in TIMP-1 deficient mice are associated with elevated plasmin activity and reduced expression of the novel uterine plasmin protease inhibitor serpinb7

Tissue inhibitor of metalloproteinase-1 (TIMP-1) is a multifunctional protein capable of regulating a variety of biological processes in a wide array of tissue and cell types. We have previously demonstrated that TIMP-1 deficient mice exhibit alterations in normal uterine morphology and physiology. Most notably, absence of TIMP-1 is associated with an altered uterine phenotype characterized by profound branching of the uterine lumen and altered adenogenesis. To begin to assess the mechanism by which TIMP-1 may control these uterine events, we utilized steroid-treated ovariectomized wild-type and TIMP-1 null mice exposed to estrogen for 72 hr. Administration of estrogen to TIMP-1 deficient mice resulted in development of an abnormal uterine histo-architecture characterized by increased endometrial gland density, luminal epithelial cell height, and abnormal lumen structure. To determine the mediators which may contribute to the abnormal uterine morphology in the TIMP-1 deficient mice, cDNA microarray analysis was performed. Analysis revealed that expression of two plasmin inhibitors (serpbinb2 and serbinb7) was significantly reduced in the TIMP-1 null mice. Associated with the reduction in expression of these inhibitors was a significant increase in plasmin activity. Localization of the novel uterine serpinb7 revealed that expression was confined to the luminal and glandular epithelial cells. Further, expression of uterine serpinb7 was decreased by estrogen and showed an inverse relationship with plasmin activity. We conclude from these studies that in addition to controlling MMP activity, TIMP-1 may also control activity of serine proteases through modulation of serine protease inhibitors such as serpinb7.     

Design, synthesis and evaluation of racemic 1-(4-hydroxyphenyl)-2-[3-(substituted phenoxy)-2-hydroxy-1-propyl]amino-1-propanol hydrochlorides as novel uterine relaxants

Novel 1-(4-hydroxyphenyl)-2-[3-(substituted phenoxy)-2-hydroxy-1-propyl]amino-1-propanol hydrochlorides were designed based on the pharmacophore for potent uterine relaxant activity and by utilizing the principles of structural hybridization. The designed molecules were synthesized as racemates by a novel route and were evaluated for uterine relaxant activity in vitro on isolated rat uterus and in vivo in pregnant rats. Their cAMP-releasing potential was studied using rat uterus tissue homogenates by the cAMP [(3)H] assay, and cardiac stimulant potential was evaluated on isolated guinea pig right atrium. All compounds exhibited potent uterine relaxant activity in vitro and produced a significant delay in the onset of labour in pregnant rats; their cAMP-releasing potential was slightly less, while their cardiac stimulant potential was insignificant as compared to isoxsuprine hydrochloride.     

The regulation of uterine relaxation

The regulation of uterine relaxation is poorly understood but research in myometrial tissue and other types of smooth muscle has defined a number of receptors, ion channels and regulatory proteins that are likely to be involved. Some of these proteins are substrates for protein kinases, especially cyclic nucleotide dependent kinases. More research is necessary to identify the key molecules involved in the maintenance of uterine quiescence in pregnancy. The use of tocolytics in preterm labour remains controversial; there is a need to identify better pharmacological targets to provoke safe and selective uterine relaxation and improve neonatal outcome.     

Renal prostaglandins for induction of labour — A dual clinical advantage in toxemia of pregnancy

Prostaglandin A₁ is known to be an antihypertensive vasodepressor agent produced by the kidney and has the basic potentialities of a hormone. No information is available at present concerning its effect on the human pregnant uterus and whether it can be used as an oxytocic compound to induce labour. The uterine stimulating and labour inducing ability of PGA₁ was evaluated in 10 cases ; seven patients were suffering from pregnancy toxemia while three were normal pregnancies near full term. Cardiotocographic tracings showed that uterine activity was markedly stimulated to a degree sufficient to induce labour. Continuous i.v. infusions at a rate of 0.25–1.0 μg/Kgm/min given over a fixed period of only 6 hours resulted in delivery in all cases except one following the discontinuation of administration. Beneficial effects on blood pressure were observed in toxemic subjects. Potentially serious FHR patterns and occasional hypertonus during therapy were seen and stress the need for more information to evaluate the safety, optimum dosage and duration of infusion as well as the place of this approach in clinical practice for the management of pregnancy toxemia. The absence of antidiuretic effect, the hypotensive response and uterine stimulating property of PGA₁ indicate a possible advantage in toxemia of pregnancy as compared to oxytocin infusions.     

In-vivo response of the Human Uterus to Orciprenaline in Early Labour

The effect of orciprenaline on uterine activity in 10 women in early induced labour at term with intact membranes was studied. Nine had uterine contractions in response to intravenous oxytocin and one to prostaglandin E₂. The inhibition of uterine contractility was dose-dependent. The effective dose varied between 10 and 20 μg/minute. Tachyphylaxis was not observed. The only significant effects noted in the mother were tachycardia and increased pulse pressure and in the fetus a smaller increase in heart rate.     

Can Intrapartum Cardiotocography Predict Uterine Rupture among Women with Prior Caesarean Delivery?: A Population Based Case-Control Study

Objective

To compare cardiotocographic abnormalities recorded during labour in women with prior caesarean delivery (CD) and complete uterine rupture with those recorded in controls with prior CD without uterine rupture.

Study Design

Women with complete uterine rupture during labour between 1997 and 2008 were identified in the Danish Medical Birth Registry (n = 181). Cases were validated by review of medical records and 53 cases with prior CD, trial of labour, available cardiotocogram (CTG) and complete uterine rupture were included and compared with 43 controls with prior CD, trial of labour and available CTG. The CTG tracings were assessed by 19 independent experts divided into groups of three different experts for each tracing. The assessors were blinded to group, outcome and clinical data. They analyzed occurrence of defined abnormalities and classified the traces as normal, suspicious, pathological or pre-terminal according to international guidelines (FIGO).

Results

A pathological CTG during the first stage of labour was present in 77% of cases and in 53% of the controls (OR 2.58 [CI: 0.96–6.94] P = 0.066). Fetal tachycardia was more frequent in cases with uterine rupture (OR 2.50 [CI: 1.0–6.26] P = 0.053). Significantly more cases showed more than 10 severe variable decelerations compared with controls (OR 22 [CI: 1.54–314.2] P = 0.022). Uterine tachysystole was not correlated with the presence of uterine rupture.

Conclusion

A pathological cardiotocogram should lead to particular attention on threatening uterine rupture but cannot be considered a strong predictor as it is common in all women with trial of labour after caesarean delivery.     

The effect of labour on uterine blood flow in the pregnant ewe.

The effect of labour on cardiac output and uterine blood flow was measured in pregnant ewes at a mean gestation of 124 days using radioactive microspheres labelled with 169Yb and 85Sr. Labour was induced by a continuous infusion of ACTH into the foetal circulation. Cardiac ouput measured before ACTH infusion in seven ewes was 5234 +/- 175-9 ml./min (mean +/- S.E.) and total uterine blood flow was 732 +/- 57-9 ml./min (mean +/- S.E.). Measurements during labour in six ewes showed a significant increase in cardiac output to 6175 +/- 149-6 ml./min (P less than 0-005) but no significant change in uterine blood flow. However, the partition of blood flow was altered; thus myometrial flow increased by 67% from 114 +/- 15-4 ml./min to 190 +/- 13-2 ml./min (P less than 0-005) while placental blood flow decreased, although not significantly, from 618 +/- 55-9 ml./min to 575 +/- 40-7 ml./min. Similar changes were observed in one ewe in spontaneous labour at term and in another ewe receiving an infusion of 4 mg oestradiol 17beta over a 24 hr period. It is concluded that labour is not associated with any major alternation in total uterine blood flow although myometrial blood flow is increased. It is not known whether this is due to the rise in circulating oestrogens which occurs prior to parturition in the ewe, or to other factors such as the work of uterine muscle during labour.     

The use of synthetic prostaglandin analogue (fluprostenol) to induce foaling.

The synthetic prostaglandin (PG) analogue fluprostenol was used to induce parturition in mares and its mode of action was investigated by measuring endocrine changes before and during the induction period. Progestagens and unconjugated oestrogens showed little change during the induction period, but two different patterns in plasma PGFM levels were observed. The first was seen when foaling occurred within 90 min of injection; PGFM levels rose soon after injection and peaked during the maximum expulsive stage of labour, thus resembling events during natural foaling. The second occurred when foaling took longer than 90 min, and in these mares PGFM levels rose at various times after injection and peaked well before the onset of the expulsive stage of labour. It is suggested that these differences reflect the hormonal readiness of the mares to foal. Other procedures, such as rupture of the allantochorion, and dilatation of the cervix and injection of fluprostenol into the allantois, produced no uterine activity and did not stimulate labour or PGFM release.     

Creatine phosphokinase and aspartate aminotransverase profiles and its relation to the severity of uterine torsion in Egyptian buffalo

Thirty-five female buffalo suffering from uterine torsion were brought to the veterinary clinic and were clinically examined as well as monitored using trans-rectal and trans-abdominal ultrasonography. Three blood samples were taken from each animal (before re-torsion, 1h and 24h after delivery) to investigate the relationship between the serum concentrations of creatine phosphokinase (CPK), aspartate aminotransverase (AST) and the severity of uterine torsion. The incidence of uterine torsion was greater in multiparous than young buffalo. The concentration of CPK and AST showed a significant (P<0.05) increase with increased duration and severity of uterine torsion. However, the concentration of CPK was less in the cases delivering a live foetus than a dead one. Animals with CPK above 450 IU usually had uterine rupture during labour (85.7%) and CPK level above 500 U/l did not respond to treatment. After labour, the AST concentration reached normal in some cases (1-6 and 24-48h). Animals with AST above 100 U/l may be either not respond to the re-torsion procedures or respond but exposed to uterine rupture during vaginal delivery. Occurrence of the uterine torsion is usually accompanied by an elevation (P<0.05) of AST concentration regardless the degree, position and viability of the foetus (76.47-100.25 U/l vs. 59.43 U/l). Animals with severe torsion or carrying a dead foetus had greater (P<0.05) AST compared to those having a mild degree or carrying live foetus. After labour, the concentration of AST decreased (P<0.05) but never reached normal concentrations up to 24h except in animals having a live foetus. In conclusion, concentration of CPK and AST can be used as a prognostic indicator for the occurrence of uterine torsion in Egyptian buffalo.     

The induction of labour by the intravenous infusion of prostaglandin F2α

labour was induced by the intravenous infusion of prostaglandin F_2α in 106 patients at 36–44 weeks of pregnancy. The induction was successful in 80% of the women. The total dose needed ranged from 0.1 to 14.2 mg of PGF_2α. The uterine activity and fetal heart rate were recorded by cardiotocography. The contraction pattern and induction-delivery time were the same as reported for induction with oxytocin. In one case uterine hyperactivity occurred after rupture of the membranes. No serious adverse effects were seen, but in a few cases local irritation was noted at the site of infusion. The condition of the infants was generally good.It might be concluded that PGF_2α seems valuable for the induction of labour, but due to the risk for overstimulation careful supervision is needed.