Inflammation triggers coagulation. Gestational inflammation, with its vascular implications, is the cause of major obstetric complications, from sporadic and recurrent miscarriage to foetal growth restriction, premature delivery with all its nefarious perinatal sequels, up to the most dramatic scenarios of foetal and maternal death: it is neither adequately diagnosed nor promptly and exhaustively counteracted by current obstetrics. Controlling gestational inflammation in normal pregnancy is primarily a foetus’s job. The vast majority of aneuploid foetuses are unable to control normal gestational inflammation and are therefore spontaneously aborted. Euploid foetuses may be unable to control normal gestational inflammation, and in this case, they are aborted or suffer from the inflammatory complications of advanced pregnancy. This article reports a selection of the best scientific evidence on gestational inflammation. It also analyses the current therapeutic approach, with particular regard to the use of glucocorticoids throughout pregnancy.

The article is an attempt to investigate the role of mutation-limited and selection-limited immunity-evading variants of SARS-CoV2, and the decline of immunity as a cause of new waves of infection. The Authors premise that the new waves of infection are generally believed to derive from variants evading both natural and vaccine immunity, but the role of these variants has not been adequately evaluated. They also report that the study models that divide the population into two groups, susceptible and immune, are inadequate, because immunity is not a binary process, but is constantly evolving. There are also models that consider three groups: S = susceptible (i.e. not immune and therefore capable of being infected, thus becoming ill and infecting others?); I = infectious (i.e. positive to the viral test and therefore able to infect others?); R = ‘recovered’, (i.e. healed, and therefore immune, unable to infect others?). Furthermore, the Authors report that the new variants appear during the acute phase of the pandemic, when viral shedding is highest. In this circumstance the new variant gradually replaces the one for which the immune system already produced the antibodies. But it is also possible that a new variant is produced independently of the immune response against the previous virus, without a selection process, with a completely unknown mechanism. A decline of immunity independent of the new variants is also hypothesized among the causes of a new infectious wave. The Authors recognize that the immune response is largely unknown. However it seems that they refer this statement solely to the production of antibodics, i.e. to humoral

Pregnancy can be defined a vascular event upon endocrine control. In the human hemo-chorial placentation the chorionic villi penetrate the wall of the uterine spiral arteries, to provide increasing amounts of nutrients and oxygen for optimal fetal growth. In any physiological pregnancy the natural maternal response is of a Th1 inflammatory type, aimed at avoiding blood loss through the arteriolar wall openings. The control of the vascular function, during gestation as in any other condition, is achieved through the action of two main types of prostanoids: prostaglandin E2 and thromboxane on the one hand (for vasoconstriction and coagulation), prostacyclin on the other (for vasodilation and blood fluidification). The control of the maternal immune response is upon the responsibility of the fetus itself. Indeed, the chorionic villi are able to counteract the natural maternal response, thus changing the inflammatory Th1 type into the anti-inflammatory Th2. Clinical and experimental research in the past half century address to inflammation as the leading cause of abortion, pregnancy loss, premature delivery and related pulmonary, cerebral, intestinal fetal syndromes. Increased level of Interleukin 6, Interleukin 1-beta, Tumor Necrosis Factor-alfa, Interferon-gamma, are some among the well-known markers of gestational inflammation. On the other side, COVID-19 pneumonia is a result of extensive inflammation induced by viral replication within the cells of the respiratory tract. As it may happen in the uterine arteries in the absence of an effective fetal control, viral pneumonia triggers pulmonary vascular coagulation. The cytokines involved in the process are the same as those in gestational inflammation. As the fetus breathes throughout the placenta, fetal death from placental thrombosis is similar to adult death from pulmonary thrombosis. Preventing and counteracting inflammation is mandatory in both conditions. The most relevant literature dealing with the above-mentioned concepts is reviewed in the present article.

Large scientific evidence achieved during the second half of the past century points to a leading role of inflammation in the pathogenic mechanism of the main pregnancy complications, such as abortion, pregnancy loss, premature delivery, infection, fetal encephalopathy, enterocolitis, pulmonary hyaline membrane diseases and death. Thinking about pregnancy inflammation, one must refer today to the umbalance of the normal mediators of organic functions: cytokins, peptides, nucleosides, prostanoids. Indeed, according to the order and quantity of their release, they are involved either in physiology or in pathology of pregnancy. At this regard, it has been shown that Th1-type immunity is incompatible with successful pregnancy. Regulation of the mediators of maternal functions is largely under fetal genetic control. Assessment of the fetal role derives from studies showing an umbalance of cytokines and plasminogen activator system, an increase of endothelin, a downregulation of adenosine receptors, in the fetal compartment, in aneuploid pregnancies. The resulting functional deviations deal with inflammation, imfection, coagulation, impaired utero-placental perfusion, possibly leading to fetal demise and ominus maternal complications. SARS-COV-2 infection, on the other hand, is characterized by a similar umbalance of the inflammatory mediators, leading to hyperactivation of a type-1 lymphobyte T-helper response, which ends in a possibly fatal cytokine storm syndrome. While SARS-COV-2 infection recognizes a viral etiology, the cause of pregnancy inflammation must be recognized in the inability of the fetus to control the maternal immune response. Therefore, the preventive measures are quite different, although both benefit of a similar anti-inflammatory, antibiotic and anti-coagulant therapy.

Objectives Polyomavirus (PyV) infections have been associated with different diseases. BK (BKPyV), JC (JCPyV) and simian virus 40 (SV40) are the three main PyVs whose primary infection occurs early in life. Their vertical transmission was investigated in this study. Methods PyV sequences were analyzed by the digital droplet PCR in blood, serum, placenta, amniotic fluid, vaginal smear from two independent cohorts of pregnant females and umbilical cord blood (UCB) samples. IgG antibodies against the three PyVs were investigated by indirect E.L.I.S.As with viral mimotopes. Results DNAs from blood, vaginal smear and placenta tested BKPyV-, JCPyV- and SV40-positive with a distinct prevalence, while amniotic fluids were all PyVs-negative. A prevalence of 3%, 7%, and 3% for BKPyV, JCPyV and SV40 DNA sequences, respectively, was obtained in UCBs. Serum IgG antibodies from pregnant females reached an overall prevalence of 62%, 42% and 17% for BKPyV, JCPyV and SV40, respectively. Sera from newborns (UCB) tested IgG-positive with a prevalence of 10% for BKPyV/JCPyV and 3% for SV40. Conclusions In this investigation, PyV vertical transmission was revealed by detecting PyV DNA sequences and IgG antibodies in samples from females and their offspring suggesting a potential risk of diseases in newborns.

Viral infections are considered to be risk factors for spontaneous abortion (SA). Conflicting results have been reported on the association between Human Papillomavirus (HPV) and SA. HPV DNA was investigated in matched chorionic villi tissues and peripheral blood mononuclear cells (PBMCs) from women who experienced SA (n = 80, cases) and women who underwent a voluntary interruption of pregnancy (VI; n = 80, controls) by qualitative PCR and quantitative droplet digital PCR (ddPCR). Viral genotyping was performed using real-time PCR in HPV-positive samples. Specific IgG antibodies against HPV16 were investigated in sera from SA (n = 80) and VI (n = 80) females using indirect ELISA assays. None of the DNA samples from SA subjects was HPV-positive (0/80), whilst HPV DNA was detected in 2.5% of VI women (p > 0.05), with a mean viral DNA load of 7.12 copy/cell. VI samples (n = 2) were found to be positive for the HPV45 genotype. The ddPCR assay revealed a higher number of HPV-positive samples. HPV DNA was detected in 3.7% and 5% of SA and VI chorionic tissues, respectively, with mean viral DNA loads of 0.13 copy/cell in SA and 1.79 copy/cell in VI (p >0.05) samples. All DNA samples from the PBMCs of SA and VI females tested HPV-negative by both PCR and ddPCR. The overall prevalence of serum anti-HPV16 IgG antibodies was 37.5% in SA and 30% in VI (p > 0.05) women. For the first time, HPV DNA was detected and quantitatively analyzed using ddPCR in chorionic villi tissues and PBMCs from SA and VI women. Circulating IgG antibodies against HPV16 were detected in sera from SA and VI females. Our results suggest that HPV infection in chorionic villi may be a rare event. Accordingly, it is likely that HPV has no significant role in SA.

Until less than two decades ago, all known human coronaviruses (CoV) caused diseases so mild that they did not stimulate further advanced CoV research. In 2002 and following years, the scenario changed dramatically with the advent of the new more pathogenic CoVs, including Severe Acute Respiratory Syndome (SARS-CoV-1), Middle Eastern respiratory syndrome (MERS)-CoV, and the new zoonotic SARS-CoV-2, likely originated from bat species and responsible for the present coronavirus disease (COVID-19), which to date has caused 15,581,007 confirmed cases and 635,173 deaths in 208 countries, including Italy. SARS-CoV-2 transmission is mainly airborne via droplets generated by symptomatic patients, and possibly asymptomatic individuals during incubation of the disease, although for the latter, there are no certain data yet. However, research on asymptomatic viral infection is currently ongoing worldwide to elucidate the real prevalence and mortality of the disease. From a clinical point of view, COVID-19 would be defined as “COVID Planet “ because it presents as a multifaceted disease, due to the large number of organs and tissues infected by the virus. Overall, based on the available published data, 80.9% of patients infected by SARS-CoV-2 develop a mild disease/infection, 13.8% severe pneumonia, 4.7% respiratory failure, septic shock, or multi-organ failure, and 3% of these cases are fatal, but mortality parameter is highly variable in different countries. Clinically, SARS-CoV-2 causes severe primary interstitial viral pneumonia and a “cytokine storm syndrome”, characterized by a severe and fatal uncontrolled systemic inflammatory response triggered by the activation of interleukin 6 (IL-6) with development of endothelitis and generalized thrombosis that can lead to organ failure and death. Risk factors include advanced age and comorbidities including hypertension, diabetes, and cardiovascular disease. Virus entry occurs via binding the angiotensin-converting enzyme 2 (ACE2) receptor present in almost all tissues and organs through the Spike (S) protein. Currently, SARS-CoV-2 infection is prevented by the use of masks, social distancing, and improved hand hygiene measures. This review summarizes the current knowledge on the main biological and clinical features of the SARS-CoV-2 pandemic, also focusing on the principal measures taken in some Italian regions to face the emergency and on the most important treatments used to manage the COVID-19 pandemic.

Droplet-digital polymerase chain reaction (ddPCR) technique was set up to detect/quantify Merkel cell polyomavirus (MCPyV) DNA in clinical specimens, including chorionic villi and peripheral blood mononuclear cells (PBMCs) from spontaneous abortion (SA)-affected females. This ddPCR assay showed high accuracy, sensitivity, and specificity in detecting MCPyV DNA cloned in a recombinant plasmid vector, the control. ddPCR was extended to MCPyV DNA to investigate/quantify its sequences in clinical samples. Overall, 400 samples were analyzed, that is, 100 chorionic villi and 100 PBMCs, from SA females (n = 100), the cases, and 100 chorionic villi and 100 PBMCs from females who underwent voluntary pregnancy interruption (VI, n = 100), the control. MCPyV DNA was detected in 4/100 (4%) and 5/100 (5%) of SA and VI chorionic villi, respectively. The mean viral DNA load was 1.99 ( +/- 0.94 standard mean deviation [SD]) copy/10(4) cells in SA and 3.02 ( +/- 1.86 [SD]) copy/10(4) cells in VI. In PBMCs, MCPyV DNA was revealed in 9/100 (9%) and 14/100 (14%) of SA and VI, with a mean of 2.09 ( +/- 1.17 [SD]) copy/10(4) cells and 4.09 ( +/- 4.26 [SD]) copy/10(4) cells in SA and VI, respectively. MCPyV gene expression analysis by quantitative PCR for the large T antigen (LT) and viral capsid protein 1 (VP1) showed their mRNAs in 2/4 (50%) SA- and 2/5 (40%) VI-MCPyV-positive samples. MCPyV DNA was detected/quantified using the ddPCR technique, in chorionic villi and PBMCs from SA and VI. In our experimental conditions, ddPCR provided a powerful tool to detect/quantify MCPyV DNA sequences in clinical samples.

Miscarriage is one of the main complications occurring in pregnancy. The association between adverse pregnancy outcomes and silent bacterial infections has been poorly investigated. Ureaplasma parvum and urealiticum, Mycoplasma genitalium and hominis and Chlamydia trachomatis DNA sequences have been investigated by polymerase chain reaction (PCR) methods in chorionic villi tissues and peripheral blood mononuclear cells (PBMCs) from females with spontaneous abortion (SA, n = 100) and females who underwent voluntary interruption of pregnancy (VI, n = 100). U. parvum DNA was detected in 14% and 15% of SA and VI, respectively, with a mean of bacterial DNA load of 1.3 × 10 −1 copy/cell in SA and 2.8 × 10 −3 copy/cell in VI; U. urealiticum DNA was detected in 3% and 2% of SA and VI specimens, respectively, with a mean DNA load of 3.3 × 10 −3 copy/cell in SA and 1.6 × 10 −3 copy/cell in VI; M. hominis DNA was detected in 5% of SA specimens with a DNA load of 1.3 × 10 −4 copy/cell and in 6% of VI specimens with a DNA load of 1.4 × 10 −4 copy/cell; C. trachomatis DNA was detected in 3% of SA specimens with a DNA load of 1.5 × 10 −4 copy/cell and in 4% of VI specimens with a mean DNA load of 1.4 × 10 −4 copy/cell. In PBMCs from the SA and VI groups, Ureaplasma spp, Mycoplasma spp and C. trachomatis DNAs were detected with a prevalence of 1%–3%. Bacteria were investigated, for the first time, by quantitative real‐time PCR (qPCR) in chorionic villi tissues and PBMCs from women affected by SA and VI. These data may help to understand the role and our knowledge of the silent infections in SA.

Background. The role of viruses in spontaneous abortion (SA) in not completely known. Methods. Merkel cell polyomavirus (MCPyV) and Human papillomavirus (HPV), two small DNA tumor viruses, were investigated in SA. MCPyV/HPV DNAs were investigated by PCR and droplet-digital/quantitative PCRs (ddPCR/qPCR) in chorionic villi and peripheral blood mononuclear cells (PBMCs) from SA females (n=100), the cases, and voluntary interruption (VI, n=100) of pregnancy females, the controls. Results. MCPyV DNAs were detected in 4% and 5% of SA and VI chorionic villi, respectively, with a mean DNA load of 1.99 copy/104 cells in SA and 3.02 copy/10,000 cells in VI (p>0.05). HPV DNAs were detected in 2% of VI chorionic villi, with a mean DNA load of 7.12 copy/cell. Two cases in the VI samples were HPV-45 positive. In PBMCs, MCPyV DNA was detected in 9% and 14% of SA and VI samples, with a mean viral DNA load of 2.09 and 4.70 copy/10,000 cells in SA and VI samples, respectively (p>0.05). None of PBMCs samples tested HPV-positive. Conclusions. MCPyV and HPV DNAs were quantified, for the first time, by ddPCR/qPCR in SA and VI chorionic villi and PBMCs. Data of the present study may help to better understand the role of MCPyV/HPV in SA.

STUDY QUESTION:Are JC polyomavirus (JCPyV) and BK polyomavirus (BKPyV) infections associated with spontaneous abortion (SA)? SUMMARY ANSWER:There is no association of JCPyV or BKPyV with SA. WHAT IS KNOWN ALREADY:A large number of risk factors have been associated with SA. The role of polyomaviruses, including JCPyV and BKPyV, in SA remains to be clarified. STUDY DESIGN, SIZE, DURATION:This is a case-control study including women affected by spontaneous abortion (SA, n = 100, the cases) and women who underwent voluntary interruption of pregnancy (VI, n = 100, the controls). PARTICIPANTS/MATERIALS, SETTING, METHODS:Viral DNAs were investigated by qualitative PCR and quantitative droplet-digital PCR (ddPCR) in matched chorionic villi tissues and peripheral blood mononuclear cells (PBMCs) from SA (n = 100) and VI (n = 100). Indirect ELISAs with mimotopes/synthetic peptides corresponding to JCPyV and BKPyV viral capsid protein 1 epitopes were then employed to investigate specific IgG antibodies against JCPyV and BKPyV in human sera from SA (n = 80) and VI (n = 80) cohorts. MAIN RESULTS AND THE ROLE OF CHANCE:JCPyV DNA was detected in 51% and 61% of SA and VI samples, respectively, with a mean viral DNA load of 7.92 copy/104 cells in SA and 5.91 copy/104 cells in VI (P > 0.05); BKPyV DNA was detected in 11% and 12% of SA and VI specimens, respectively, with a mean viral DNA load of 2.7 copy/104 cells in SA and 3.08 copy/104 cells in VI (P > 0.05). JCPyV was more prevalent than BKPyV in both SA and VI specimens (P < 0.0001). In PBMCs from the SA and VI cohorts, JCPyV DNA was detected with a prevalence of 8% and 12%, respectively, with a mean viral DNA load of 2.29 copy/104 cells in SA and 1.88 copy/104 cells in VI (P > 0.05). The overall prevalence of serum IgG antibodies against JCPyV detected by indirect ELISAs was 52.5% and 48.7% in SA and VI groups, respectively, whereas BKPyV-positive sera were found in 80% SA and 78.7% VI samples. LIMITATIONS, REASONS FOR CAUTION:This study did not investigate the presence of viral mRNA and/or proteins, which are indicative of an active viral infection, and these might be taken into consideration in future studies. WIDER IMPLICATIONS OF THE FINDINGS:JCPyV and BKPyV DNA sequences were detected and quantitatively analyzed for the first time by PCR/ddPCR in chorionic villi tissues and PBMCs from SA and VI specimens. Moreover specific immunological approaches detected serum IgG against JCPyV/BKPyV. Statistical analyses, however, do not indicate an association between these polyomaviruses and SA. STUDY FUNDING/COMPETING INTEREST(S):This work was supported by the University of Ferrara, FAR research grants and the University Hospital of Ferrara/University of Ferrara joint grant. No potential conflicts of interest were disclosed.

Simian virus 40 (SV40) large T antigen (LT) coding sequences were revealed in different human samples, whereas SV40 antibodies (Ab) were detected in human sera of cancer patients and healthy individuals, although with a lower prevalence. Previous studies carried out by the neutralization assay gave a SV40 seroprevalence, in the general population, up to 8%, although higher rates, 12%, were detected in kidney transplant children, in a group of HIV-positive patients, and in healthy females. In this study, serum samples from pregnant women, together with those from non-pregnant women, were analyzed to check the prevalence of IgG Ab reacting to SV40 LT antigens. Serum samples were collected from pregnant and non-pregnant women, with the same mean age. Women were in the range of 15–48 years old. Samples were assayed by an indirect ELISA employing specific SV40 LT mimotopes as antigens, whereas functional analysis was performed by neutralization of the viral infectivity in cell cultures. As a control, sera were analyzed for Ab against BK polyomavirus (BKPyV), which is a human polyomavirus homologous to SV40. Statistical analyses employed chi-square with Yates’ correction, and Student’s t tests. Indirect ELISAs indicated that pregnant women tested SV40 LT-positive with a prevalence of 17% (23/134), whereas non-pregnant women had a prevalence of 20% (36/180) (P > 0.05). Ab against BKPyV were detected with a prevalence of 80% in pregnant women and with a prevalence of 78% in non-pregnant women. These data indicate that SV40 infects at a low prevalence pregnant women. We may speculate that SV40, or a close human polyomavirus still undetected, could be transmitted from mother to fetus.

An altered amniotic cytokine profile has been reported in inflammatory pregnancy complications with a leading role for IL-6, a marker of the foetal systemic inflammatory response. Up to this date there is no exhaustive information neither on the foetal cytokine balance nor on the best method for its modulation. We aimed to evaluate the influence of vaginal lactoferrin administration on amniotic fluid concentration of 47 cytokines, chemokines and growth factors.

Inflammation plays an important role in pregnancy, and cytokine and matrix metalloproteases (MMPs) imbalance has been associated with premature rupture of membranes and increased risk of preterm delivery. Previous studies have demonstrated that lactoferrin (LF), an iron-binding protein with anti-inflammatory properties, is able to decrease amniotic fluid (AF) levels of IL-6. Therefore, we aimed to evaluate the effect of vaginal LF administration on amniotic fluid PGE2 level and MMP-TIMP system in women undergoing genetic amniocentesis. One hundred and eleven women were randomly divided into controls (n = 57) or treated with LF 4 hours before amniocentesis (n = 54). Amniotic fluid PGE2, active MMP-9 and MMP-2, and TIMP-1 and TIMP-2 concentrations were determined by commercially available assays and the values were normalized by AF creatinine concentration. PGE2, active MMP-9, and its inhibitor TIMP-1 were lower in LF-treated group than in controls (p < 0.01, p < 0.005, and p < 0.001, resp.). Conversely, active MMP-2 (p < 0.0001) and MMP-2/TIMP-2 molar ratio (p < 0.001) were increased, whilst TIMP-2 was unchanged. Our data suggest that LF administration is able to modulate the inflammatory response following amniocentesis, which may counteract cytokine and prostanoid imbalance that leads to abortion. This trial is registered with Clinical Trial number NCT02695563.

ABSTRACTBackgroundTo test the velocimetric pattern of the ovarian artery as a routine ovarian reserve test.MethodsWe enrolled 317 consecutive patients from January 2011 to June 2012. At the second day of the menstrual cycle, a transvaginal ultrasound was performed to evaluate the antral follicle count and ovarian volume, and Doppler of both ovarian arteries was also performed. Controlled ovarian stimulation was performed and the patients were divided in two groups according to the result of the intrauterine insemination: group A (nonpregnant women) and group B (pregnant women).ResultsOvarian velocimetric pattern was similar between the two groups. Follicle stimulating hormone value had a significant correlation with the ultrasound markers; however, the multiple regression linear analysis showed that the only independent variables were the antral follicle count (t = −2.74, p = 0.008) and the systolic/diastolic ratio (t = 3.95, p = 0.0005). The best parameters in predicting the pregnancy were the mean ovarian volume, total and partial antral follicle count between 7 and 10 mm, and the mean resistance index (area under the curve: 0.744, 0.671, 0.667, 0.573, respectively).ConclusionsThe Doppler study of the ovarian arteries did not add significant information about the ovarian reserve status. Only the mean resistance index had a significant diagnostic accuracy, but its specificity (53%) is too low to consider it a screening test. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 42:331–335, 2014