Objective:Although pegylated liposomal doxorubicin (PLD) has a more favorable side-effect profile compared to doxorubicin, the FDA label for PLD includes a warning listing cardiotoxicity. Our objective was to evaluate predictors of pre- and post-treatment cardiac testing and quantify the effect of PLD on cardiac function in patients treated for gynecologic malignancies. Methods:Retrospective chart review of gynecologic oncology patients who received PLD over a 10-year period at a single institution. Cardiac studies were aligned to PLD treatment and ejection fractions (EF) were compared pre- and post-treatment. Results:A total of 453 patients who had received PLD were identified; 216 (48 %) had pre-PLD treatment cardiac function testing. Predictors of pre-chemotherapy testing were diabetes (p = 0.015), higher ECOG score (p = 0.004), and cardiac disease (p = 0.032). Eighty-three (18.3 %) patients had pre- and post-PLD treatment cardiac function testing. Predictors of pre- and post- testing were number of cycles of PLD (p < 0.0001) and total dose of PLD (p < 0.0001). Seventy-five (90 %) patients had no change in EF (defined as < 10 %), while 2 (2.4 %) had improvement in EF > 10 %, and 6 (7.2 %) had a decrease in EF > 10 %. Initial EF in patients with > 10 % decrease was higher than in those without change or improvement (p = 0.0004). One (1.2 %) patient had a clinically significant decrease in EF (32.5 %) resulting in interruption of treatment. Conclusion:Risk of cardiac toxicity from administration of PLD for patients undergoing treatment for gynecologic cancers appears to be low. Selective screening of cardiac function should be employed for these patients.

OBJECTIVE:The goals of this study were to describe opioid and benzodiazepine prescribing practices in the gynecologic oncology patient population and determine risks for opioid misuse in these patients.METHODS:Retrospective study of opioid and benzodiazepine prescriptions for patients treated for cervical, ovarian (including fallopian tube/primary peritoneal), and uterine cancers within a single healthcare system from January 2016 to August 2018.RESULTS:A total of 7643 prescriptions for opioids and/or benzodiazepines were dispensed to 3252 patients over 5754 prescribing encounters for cervical (n=2602, 34.1%), ovarian (n=2468, 32.3%), and uterine (n=2572, 33.7%) cancer. Prescriptions were most often written in an outpatient setting (51.0%) compared with inpatient discharge (25.8%). Cervical cancer patients were more likely to have received a prescription in an emergency department or from a pain/palliative care specialist (p=0.0001). Cervical cancer patients were least likely to have prescriptions associated with surgery (6.1%) compared with ovarian cancer (15.1%) or uterine cancer (22.9%) patients. The morphine milligram equivalents prescribed were higher for patients with cervical cancer (62.6) compared with patients with ovarian and uterine cancer (46.0 and 45.7, respectively) (p=0.0001). Risk factors for opioid misuse were present in 25% of patients studied; cervical cancer patients were more likely to have at least one risk factor present during a prescribing encounter (p=0.0001). Cervical cancer was associated with a higher number of risk factors (p<0.001).CONCLUSIONS:Opioid and benzodiazepine prescribing patterns differ for cervical, ovarian, and uterine cancer patients. Gynecologic oncology patients are overall at low risk for opioid misuse; however, patients with cervical cancer are more likely to have risk factors present for opioid misuse.

OBJECTIVE:Enhanced recovery after surgery (ERAS) has decreased hospital opioid use, but less attention has been directed towards its impact on clinic burden with respect to post-operative care. Our objective was to determine the impact of an ERAS protocol on post-operative opioid prescribing, and the subsequent number of pain medication refill requests and unscheduled patient-provider interactions in the 30-day post-operative period.METHODS:IRB-approved retrospective study comparing post-operative opioid prescription practices 10 months before and 10 months after ERAS protocol implementation after minimally invasive gynecologic surgery. Opioid doses in morphine milligram equivalents (MMEs), number of unscheduled visits, and phone calls were compared before and after ERAS implementation.RESULTS:A total of 791 patients were included; 445 without and 346 with ERAS implementation. ERAS was associated with higher rates of same day discharge (49% vs 39%, p = 0.003) and lower readmission rates (2.0% vs 5.6%, p = 0.011). Post-operatively, patients who received the ERAS protocol were prescribed less opioids (197.8 vs. 223.5 MMEs, p = 0.0087). There was a trend towards less refill requests with ERAS (1.7% vs 3.6%, p = 0.11). ERAS was associated with a decreased number of post-operative phone calls (38% vs 46%, p = 0.023), including calls for pain (10% vs 16%, p = 0.021), and fewer unscheduled visits related to pain (1.5% vs 5.8%, p = 0.001).CONCLUSIONS:Implementation of the ERAS protocol resulted in a decrease in post-operative opioid prescribing. Despite the lower amount of prescribed post-operative opioids, the ERAS protocol translated into a decrease in the need for post-operative interactions with the clinic staff, specifically encounters associated with pain.

Objectives Pegylated liposomal doxorubicin (PLD) has a more favorable side-effect profile compared to doxorubicin. While the FDA label for PLD includes a black box warning concerning cardiac toxicity, the actual risk of cardiotoxicity is unknown and it may be substantially less than that of doxorubicin. Methods All gynecologic malignancy cases with PLD use were reviewed over a 10-year period. Cardiac studies were aligned to PLD chemotherapy treatment and ejection fractions were compared pre- and post-treatment. Results A total of 453 patients were identified; 216 (48%) had pre-treatment testing. Predictors of pre-chemotherapy testing were diabetes (p=0.015), higher ECOG score (p=0.004), and cardiac disease (p=0.032). Hypertension, BMI, and prior/concurrent bevacizumab treatment did not influence the likelihood of pre-treatment evaluation. Eighty-three (18.3%) patients had pre- and post-treatment testing. Predictors of pre- and post- testing were number of cycles of PLD (p<0.0001) and total dose of PLD (p<0.0001). Seventy-five (90%) patients had <10% change in EF, 2 (2.4%) had improvement in EF>10%, and 6 (7.2%) had a decrease in EF>10%. Initial EF in patients with >10% decrease was higher than those without change or improvement (p=0.0004). BMI, obesity, hypertension, DM, cardiac disease, total PLD dose, number of cycles, and use of bevacizumab predicted changes in EF. One (1.2%) patient had a clinically significant decrease in EF (32.5%) resulting in interruption of treatment. Conclusions Risk of cardiac toxicity from administration of PLD for patients undergoing treatment for gynecologic cancers appears to be low and routine screening does not appear to be warranted, even in the presence of cardiac risk factors.

Introduction:Pregnant women affected by coronavirus disease 2019 (COVID-19) are at increased risk of severe disease, admission to an intensive care unit, and adverse pregnancy outcomes. In contrast, children typically experience a mild form of COVID-19. Nonetheless, there is a risk of multisystem inflammatory syndrome in children (MIS-C) following a SARS-CoV-2 infection.Case:A healthy 16-year-old, G1P0, presented with MIS-C in the second trimester and was treated with intravenous immunoglobulin. She subsequently developed transient mild hypertension, proteinuria, and transaminitis, which ultimately was thought to be secondary to MIS-C rather than pre-eclampsia.Discussion:MIS-C is an important COVID-19 complication in pediatric patients. This case offers guidance on expectant management of hypertension, transaminitis, and proteinuria during an episode of MIS-C in pregnant patients, as opposed to preterm delivery for a misdiagnosis of severe pre-eclampsia.

Objectives: Patients receiving postoperative opioids have a dosedependent risk of misuse and addiction. While the introduction of the enhanced recovery after surgery (ERAS) protocol has been shown to decrease hospital narcotic use, less attention has been directed towards the impact of ERAS on the clinic burden with respect to postoperative care. The objective of our study was to determine the impact of an ERAS protocol on narcotic prescription patterns after laparoscopic gynecologic surgery measured as the number of prescription pain medication refill requests, clinic phone calls, and unscheduled visits in the 30-day postoperative period. Methods: This retrospective study compared postoperative narcotic prescriptions and clinic burden ten months prior to and ten months following the implementation of a standard ERAS protocol after laparoscopic gynecologic surgery. The study included patients who underwent surgeries between January 2018, and July 2019, with the ERAS implementation in November 2018. The total oral morphine milligram equivalents (MMEs) prescribed postoperatively, and the number of unscheduled clinic visits and phone calls were compared before and after the implementation of the ERAS protocol. Postoperative prescribing practices were not standardized during the study period. Results: A total of 791 patients were identified with clinic follow-up; 445 before and 346 after ERAS implementation. All patients underwent laparoscopic or robotic-assisted surgery alone or in combination with mini-laparotomy. Baseline characteristics, including procedure, diagnosis, smoking, and alcohol use did not differ between groups. Use of ERAS was associated with higher rates of same-day discharge (49% vs 39%, p=0.003) and lower readmission rates (2.0% vs 5.6%, p=0.011). Postoperatively, patients who received the ERAS protocol were prescribed significantly less narcotics (197.8 vs 223.5 MMEs, p=0.0087) even though the postop narcotic doses were not specified. The number of refill requests was lower with ERAS (1.7% vs 3.6%, p=0.11). ERAS was associated with a lower chance of postoperative clinic phone calls (38% vs 46%, p=0.023), including calls for pain (10% vs 16%, p=0.021). There was a decrease in unscheduled visits related to pain (1.5% vs 5.8%, p=0.001), and a trend towards a decrease in the number of overall unscheduled visits (14% vs 18%; p=0.08) after ERAS implementation. Conclusions: Implementation of the ERAS protocol after laparoscopic gynecologic surgery resulted in a decrease in postoperative opioid prescribing and a lower incidence of unplanned interactions with the clinic staff, despite the lower amount of prescribed postoperative narcotics. Objectives: Patients receiving postoperative opioids have a dosedependent risk of misuse and addiction. While the introduction of the enhanced recovery after surgery (ERAS) protocol has been shown to decrease hospital narcotic use, less attention has been directed towards the impact of ERAS on the clinic burden with respect to postoperative care. The objective of our study was to determine the impact of an ERAS protocol on narcotic prescription patterns after laparoscopic gynecologic surgery measured as the number of prescription pain medication refill requests, clinic phone calls, and unscheduled visits in the 30-day postoperative period. Methods: This retrospective study compared postoperative narcotic prescriptions and clinic burden ten months prior to and ten months following the implementation of a standard ERAS protocol after laparoscopic gynecologic surgery. The study included patients who underwent surgeries between January 2018, and July 2019, with the ERAS implementation in November 2018. The total oral morphine milligram equivalents (MMEs) prescribed postoperatively, and the number of unscheduled clinic visits and phone calls were compared before and after the implementation of the ERAS protocol. Postoperative prescribing practices were not standardized during the study period. Results: A total of 791 patients were identified with clinic follow-up; 445 before and 346 after ERAS implementation. All patients underwent laparoscopic or robotic-assisted surgery alone or in combination with mini-laparotomy. Baseline characteristics, including procedure, diagnosis, smoking, and alcohol use did not differ between groups. Use of ERAS was associated with higher rates of same-day discharge (49% vs 39%, p=0.003) and lower readmission rates (2.0% vs 5.6%, p=0.011). Postoperatively, patients who received the ERAS protocol were prescribed significantly less narcotics (197.8 vs 223.5 MMEs, p=0.0087) even though the postop narcotic doses were not specified. The number of refill requests was lower with ERAS (1.7% vs 3.6%, p=0.11). ERAS was associated with a lower chance of postoperative clinic phone calls (38% vs 46%, p=0.023), including calls for pain (10% vs 16%, p=0.021). There was a decrease in unscheduled visits related to pain (1.5% vs 5.8%, p=0.001), and a trend towards a decrease in the number of overall unscheduled visits (14% vs 18%; p=0.08) after ERAS implementation. Conclusions: Implementation of the ERAS protocol after laparoscopic gynecologic surgery resulted in a decrease in postoperative opioid prescribing and a lower incidence of unplanned interactions with the clinic staff, despite the lower amount of prescribed postoperative narcotics.

Objective: The study aimed to assess the current state of medical genetics and genomics (MGG) education amongst maternal-fetal medicine (MFM) program directors (PDs) and clinical fellows. Methods: An online questionnaire was generated and distributed to all current program directors and fellows in ACGME-accredited MFM fellowships across the USA in 2018. Results: A total of 13 program directors and 54 MFM fellows responded to our survey. Of the respondents, 73% of the MFM fellows mentioned having dedicated structured MGG rotations as part of their training. Only 12% of fellows reported a high level of satisfaction with their programs' structured MGG rotations and almost 40% reported dissatisfaction, compared to 56% of PDs who reported very high satisfaction. Furthermore, 84% of PDs reported high levels of satisfaction with MGG didactics currently in place compared to only 24% of fellows sharing the same opinion. When compared to PDs, fellows reported a significantly lower satisfaction score toward their MGG rotations (p < .05) and didactic sessions (p < .05). More than 62% of PDs were satisfied with the number of MGG-faculty in their division compared to 80% of fellows who thought more faculty is needed. Thirty-eight percent of PDs quoted curricular overload and lack of time as the most important obstacles to MGG education, compared to 43% of fellows citing a limited number of genetics services providers as the most important obstacles to their MGG education. Conclusion: MFM fellows and PDs differ in their satisfaction with the current state of MGG didactics and rotations in their programs, the number of MGG faculty in their divisions, and the perceived obstacles to MGG education . Our study illustrates the need for MGG curriculum development in MFM fellowships as this subspecialty relies heavily on the use of genetics and genomics services.

IntroductionRates of some placental-associated pregnancy complications vary by ethnicity, though the strength of association with underlying placental pathology is presently unknown. Our objective was to determine whether an association between ethnicity and placental pathology occurs in low-risk pregnancies.Methods829 low-risk nulliparous pregnant women were prospectively studied. Data were obtained from standardized obstetrical appointments (clinical history, serum biomarkers, placental ultrasound) and hospital delivery records (pregnancy complications, delivery details and perinatal outcomes). Placental pathology was performed in all subjects using standard criteria.ResultsIn our cohort, 72% of women were Caucasian, 14% East Asian, 8% South Asian, 4% Afro-Caribbean and 3% Hispanic women. 81% of couples were concordant (same ethnic background) and 19% discordant (mixed ethnicities). South Asian women had the highest rate of small for gestational age (SGA) birth (customized birthweight <10th percentile) (24.2%), which was associated with the placental features of uteroplacental vascular insufficiency (placental weight <10th percentile with decidual vasculopathy, focal infarction, and/or syncytial knot formation) (p = 0.05). Placental efficiency varied significantly by ethnicity; Caucasian women had the highest efficiency (7.1 ± 1.2) and Afro-Caribbean women the lowest (6.5 ± 0.9) (p < 0.003). Afro-Caribbean women had the highest rate of marginal cord insertion. Placental efficiency, was higher in concordant vs. discordant couples (7.0 ± 1.2 vs. 6.8 ± 1.1; p < 0.05). Placental histopathology was not affected by parental ethnic discordance.DiscussionMaternal ethnicity influences placental efficiency and relationship between uteroplacental vascular insufficiency and SGA birth, but was not associated with other placental pathologies. Discordant parental ethnicity did not affect the development of placental pathologies or adverse pregnancy outcomes.

Background Small ubiquitin-like modifiers (SUMOs) conjugate to proteins post-translationally, thereby affecting target localization, activity and stability. Functional SUMO family members identified in the human placenta include SUMO-1 to SUMO-3, which are elevated in pre-eclampsia. Whether the fourth isoform, SUMO-4, plays a role in placental development and function remains unknown. Objectives We tested the hypothesis that SUMO-4 is expressed in the human placenta and demonstrates altered SUMOylation in pre-eclamptic pregnancies. Methods SUMO-4 mRNA (qRT-PCR) and protein (Western blot and immunohistochemistry) were measured in Jar cells, BeWo cells, first trimester placental villous explants and placental tissues across normal gestation and in pre-eclampsia. SUMO-4 expression in response to oxidative stress (H2O2: 0, 0.1, 1 and 5mM), as well as, hypoxia-reperfusion (O2: 1%, 8% and 20%) was measured. Lastly, SUMO-4 binding (covalently vs. non-covalently) to target proteins was investigated. Results SUMO-4 mRNA and protein were unchanged across gestation. SUMO-4 was present in the villous trophoblast layer throughout gestation. SUMO-4 mRNA expression and protein levels were increased ~2.2-fold and ~1.8-fold in pre-eclamptic placentas compared to age-matched controls, respectively (p<0.01). SUMO-4 mRNA and protein expression increased in Jars, BeWos and first trimester placental explants with 5mM H2O2 treatment, as well as with exposure to hypoxia-reperfusion. SUMO-1 to SUMO-3 did not show consistent trends across models. SUMO-4 hyper-SUMOylation was predominantly covalent in nature. Conclusions SUMO-4 is expressed in normal placental development. SUMO-4 expression was increased in pre-eclamptic placentas and in models of oxidative stress and hypoxic injury. These data suggests that SUMO-4 hyper-SUMOylation may be a potential post-translational mechanism in the stressed pre-eclamptic placenta.

Objective: To compare neonatal growth outcomes determined by birth weight (BW), placental assessment (Plac Assess) and individualized growth assessment (IGA).Methods: This retrospective analysis was carried out in 45 selected pregnancies at risk for fetal growth restriction. Serial fetal biometry was carried out in the 2nd and 3rd trimester. First and second trimester placental biomarkers, 2nd trimester uterine artery (Ut A) velocimetry and postnatal placental pathology were evaluated as indicators of placental insufficiency. At delivery, weight (WT), head circumference (HC) and crown-heel length (CHL) were measured. BWs were categorized as large-for-gestational-age (LGA), appropriate-for-gestational-age (AGA) and small-for-gestational age (SGA) (<10th, 10th-90th and >90th percentiles). In these categories, neonatal growth outcomes were classified as growth restricted (GR), normal (NORMAL) or macrosomic (MACRO) based on BW plus Plac Assess (Ut A velocimetry, biomarkers, pathology) or IGA [growth potential realization index profile (WT, HC and CHL)].Results: There were 6 LGA, 14 AGA and 25 SGA neonates in this sample. All 14 AGA neonates were considered NORMAL by both IGA and BW+Plac Assess. All six LGA neonates were classified as MACRO by BW+Plac Assess but only four by IGA (the remaining two were NORMAL and high NORMAL). The 25 SGA cases could be divided into five subgroups based on IGA and BW+Plac Assess. The largest subgroup (56%) was GR and the next largest (24%) was NORMAL by both classification methods. In the remaining 20%, there was some evidence of GR but IGA and BW+Plac Assess were not in complete agreement.Conclusions: Agreement was good for all three methods in the LGA and AGA groups. The SGA group was heterogeneous but agreement between IGA and BW+Plac Assess was 89%. These results, using more sophisticated growth assessment methods, confirm placental insufficiency as a primary cause of growth restriction. Most normal and GR SGA neonates can be identified with conventional anatomical measurements if IGA is used.

Objectives Current guidelines for diagnosis and management of early-onset intrauterine growth restriction (IUGR) rely on umbilical artery Doppler (UAD), without including uterine artery Doppler (UtAD). We hypothesized that IUGR cases with abnormal UAD but normal UtAD has a different spectrum of placental pathology compared with those with abnormal UtAD. Study Design Retrospective review of pregnancies with sonographic evidence of IUGR and abnormal UAD prior to delivery. Cases with ≥ 1 UtAD record(s) after 18+0 weeks' gestation and placental pathology were included. Cases were stratified according to initial UtAD pulsatility index (PI) values (n = 196): normal (n = 19; PI < 95th centile for gestational age/no notching), intermediate (n = 69; PI ≥ 95th centile/no/unilateral notching) and abnormal (n = 108; PI ≥ 95th centile/bilateral notching). Pregnancy outcomes and placental pathology were compared between groups. Results Women in the normal group delivered later than those in the abnormal group (30.1 ± 3.5 vs. 28.0 ± 3.5 weeks; mean ± standard deviation; p = 0.03). Their placentas exhibited higher rates of chronic intervillositis (15.8 vs. 0.9%; p = 0.01), chorangiosis (15.8 vs. 0.9%; p < 0.0001), and massive perivillous fibrin deposition (21.1 vs. 7.4%; p = 0.05), but had lower rates of uteroplacental vascular insufficiency (26.3 vs. 79.6%; p < 0.0001). Conclusion Approximately 10% of pregnancies with early-onset IUGR and abnormal UAD exhibited normal UtAD waveforms. They delivered later, and their placentas exhibited unusual placental pathologies.

Screening programs for placentally-mediated complications in nulliparous pregnancies have focused on the prediction of specific clinical complications rather than objective placental disease. To date, no program has comprehensively integrated clinical, biochemical and sonographic characteristics as predictors of placental pathology. We report the pilot phase of a single-center screening program comprising of clinical characteristics (ethnicity, mode of conception, BMI, blood pressure, family history); integrated prenatal screening (IPS) values for PAPP-A (abnormal <0.35 MoM) and AFP (abnormal >2.0 MoM); and an ultrasound done at 20-22 weeks for maximum placental length (abnormal <5th %ile for gestational age) and mean uterine artery Doppler pulsatility index (abnormal >95th %ile for gestational age). Clinical outcomes and all placental pathologies were recorded. The gold standard pathology was defined as: chorion regression syndrome (CRS; placental weight <10th %ile with marginal/velamentous cord or distal villous hypoplasia) or utero-placental vascular insufficiency (UPVI; placental weight <10th %ile with decidual vasculopathy, full-thickness or multi-focal infarction, or accelerated villous maturation). 441 healthy nulliparous women have completed the study; 10.4% had CRS and/or UPVI and 10.0% exhibited maternal inflammation. Clinical history in combination with IPS data was non-discriminatory while ultrasound alone had the best test characteristics (Table 1). 4.8% developed hypertension in pregnancy, 3.0% delivered <34+0 weeks' gestation, and 10.7% had birth weight <10th %ile for gestation. The relative risk(RR) and 95% confidence interval(CI) for these clinical outcomes are stratified by placental pathology diagnosis (Table 2). Nulliparous women exhibit a surprising diversity of chronic placental diseases that confound the development of effective screening. Placental disease-specific screening strategies are needed to correlate the breadth of pathologies with adverse clinical outcomes.Tabled 1Test characteristics of clinical history, IPS and placental ultrasoundIPS, integrated prenatal screening; CI, confidence interval. Open table in a new tab Tabled 1View Large Image Figure ViewerDownload Hi-res image Download (PPT)CI, confidence interval; HTN, development of hypertension in pregnancy; BW, birthweight; CRS, chorion regression syndrome; UPVI, utero-placental vascular insufficiency; Inflammation: including deciduitis, villitis and intervillositis; Other: including hemorrhage, fetal vascular disease, chorangiosis, distal villous immaturity, massive perivillous fibrinoid deposition. Open table in a new tab

Common pregnancy complications, such as severe preeclampsia and intrauterine growth restriction, disrupt pregnancy progression and impair maternal and fetal wellbeing. Placentas from such pregnancies exhibit lesions principally within the syncytiotrophoblast (SCT), a layer in direct contact with maternal blood. In humans and mice, glial cell missing-1 (GCM-1) promotes differentiation of underlying cytotrophoblast cells into the outer SCT layer. GCM-1 may be regulated by the transcription factor peroxisome proliferator-activated receptor-gamma (PPAR- γ ); in mice, PPAR- γ promotes labyrinthine trophoblast differentiation via Gcm-1, and, as we previously demonstrated, PPAR- γ activation ameliorates disease features in rat model of preeclampsia. Here, we aimed to characterize the baseline activity of PPAR- γ in the human choriocarcinoma BeWo cell line that mimics SCT formation in vitro and modulate PPAR- γ activity to study its effects on cell proliferation versus differentiation. We report a novel negative autoregulatory mechanism between PPAR- γ activity and expression and show that blocking PPAR- γ activity induces cell proliferation at the expense of differentiation, while these remain unaltered following treatment with the agonist rosiglitazone. Gaining a deeper understanding of the role and activity of PPAR- γ in placental physiology will offer new avenues for the development of secondary prevention and/or treatment options for placentally-mediated pregnancy complications.

The trophoblast transcription factor glial cell missing-1 (GCM1) regulates differentiation of placental cytotrophoblasts into the syncytiotrophoblast layer in contact with maternal blood. Reduced placental expression of GCM1 and abnormal syncytiotrophoblast structure are features of hypertensive disorder of pregnancy--preeclampsia. In-silico techniques identified the calcium-regulated transcriptional repressor--DREAM (Downstream Regulatory Element Antagonist Modulator)--as a candidate for GCM1 gene expression. Our objective was to determine if DREAM represses GCM1 regulated syncytiotrophoblast formation. EMSA and ChIP assays revealed a direct interaction between DREAM and the GCM1 promoter. siRNA-mediated DREAM silencing in cell culture and placental explant models significantly up-regulated GCM1 expression and reduced cytotrophoblast proliferation. DREAM calcium dependency was verified using ionomycin. Furthermore, the increased DREAM protein expression in preeclamptic placental villi was predominantly nuclear, coinciding with an overall increase in sumolylated DREAM and correlating inversely with GCM1 levels. In conclusion, our data reveal a calcium-regulated pathway whereby GCM1-directed villous trophoblast differentiation is repressed by DREAM. This pathway may be relevant to disease prevention via calcium-supplementation.

Pregnancy is accompanied by several adaptations in the mother, such as increased blood volume, higher cardiac output and reduced peripheral vascular resistance. Inability to accomplish these changes places both her and her pregnancy at risk of major placental complications such severe pre-eclampsia (sPE) or severe intra-uterine growth restriction (sIUGR). sPE is characterized by wide-spread maternal vascular dysfunction expressed as increased systemic vascular resistance; this state is accompanied by elevated levels of anti-angiogenic factors and lower production of vasodilatory gases. One of the key molecules implicated in sPE pathogenesis is heme oxygenase-1 (HO-1), a rate-limiting enzyme that breaks down heme into carbon monoxide (CO), biliverdin and free iron. CO and bilirubin (a downstream product of biliverdin processing) account for the angiogenic, vasodilatory and anti-oxidant properties of HO-1. These collective actions of the heme breakdown metabolites generated by HO-1 offer protection against cytotoxicity, inflammation, hypoxia and other forms of cellular stress that are central to the pathogenesis of sPE. Placental HO-1 expression and exhaled CO levels are both lower in women with sPE, consistent with a pathogenic role of HO-1. In vitro experiments demonstrate that induction of HO-1 downregulates secretion of the anti-angiogenic factor soluble fms-like tyrosine kinase-1 (sFLT-1) and increases CO production. Advancing our understanding of regulatory pathways promoting placental HO-1 expression may offer new pharmacological tools to reduce maternal and perinatal morbidity in severe placental insufficiency syndromes, especially in women at greatest risk of developing sPE.

Gene expression analysis using semi-quantitative RT-PCR is a common tool in placental research. However the comparison of steady-state gene transcription between different clinical groups is dependent upon comparison of target mRNA data with mRNA obtained from so-called housekeeping (HK) genes whose steady-state transcription does not differ significantly between the groups. In this communication, we evaluated the performance of candidate HK genes across nine clinical groups commonly used in placental research. We used the GeNorm method to evaluate qRT-PCR data to determine the performance of candidate HKs.

BACKGROUND:Severe preeclampsia is characterized by hypertension, renal injury and placental dysfunction. Prothrombotic disorders are discovered in 10-20% of women with preeclampsia, providing the rationale for prescribing low-molecular-weight heparin (LMWH) in future pregnancies. Heparin has diverse molecular actions and appears to reduce the recurrence risk of preeclampsia in women without prothrombotic disorders. The placenta-derived anti-angiogenic splice-variant protein soluble vascular endothelial growth factor (VEGF) receptor-1 (sFLT1) is strongly implicated in the pathogenesis of the underlying endothelial dysfunction. As the placental syncytiotrophoblast is the principal source of sFLT1, we tested the hypothesis that heparin suppresses placental sFLT1 secretion.METHODS AND RESULTS:First trimester placental villi exposed to LMWH (0.25-25 IU mL(-1)) in an in vitro explant model significantly increased the expression and release of sFLT1 by the syncytiotrophoblast into culture media, reducing phosphorylation of FLT1 and KDR receptors in cultured human umbilical vein endothelial cells. This response was significantly diminished in placental villi from healthy term pregnancies. Placental villi from severely preeclamptic pregnancies had a higher baseline sFLT1 release, compared with first trimester placental villi and did not respond to LMWH treatment. LMWH promoted villous cytotrophoblast proliferation (BrdU incorporation) and impaired syncytial fusion-differentiation, causing syncytiotrophoblast apoptosis (by caspase 3&7 activity and TUNEL staining) and necrosis (ADP/ATP ratio).CONCLUSION:LMWH promotes sFLT1 synthesis and release from first trimester placental villi in a manner similar to that of severely preeclamptic placental villi, which antagonizes VEGF signaling in endothelial cells. These effects in part are mediated by an interaction between heparin and the cytotrophoblasts that regenerates the overlying syncytiotrophoblast responsible for sFLT1 secretion into the maternal blood.

Elevated levels of the maternal prenatal screening markers hCG and inhibin-A, measured at 15-20 weeks gestation, increase the subsequent risk of severe pre-eclampsia and intra-uterine growth restriction (IUGR). Since both markers are produced by syncytiotrophoblast, we tested the hypothesis that these elevations were due to accelerated differentiation of the villous trophoblast compartment. We performed a retrospective study of 12 cases from our Placenta Clinic with total hCG and/or inhibin-A levels of ≥3.0 multiples of the median that subsequently delivered by 28 weeks gestation and compared their placental pathology findings with 24 gestational age-matched controls. Morphometric analysis demonstrated a 41% reduction in the volume ratio of Ki67 positive cytotrophoblast nuclei to total trophoblast in cases vs controls (Student's T-test; p = 0.028). Distal villous hypoplasia (DVH) was significantly more common in cases (10/12) than controls (4/24); Fisher's exact test, p = 0.002. Wave-like syncytial knot (WLSK) formation was significantly more common in cases (9/12) than controls (1/24); Fisher's exact test, p < 0.0001. WLSK formation was associated with DVH and resulted from accumulation of senescent/apoptotic syncytiotrophoblast nuclei along inherent lines of syncytial nuclear organization. Our data support the hypothesis that elevated second trimester maternal serum levels of total hCG and/or inhibin-A may result from premature accelerated differentiation of the villous cytotrophoblasts. The subsequent pathologic findings in the syncytiotrophoblast could render the pregnancy at risk of severe pre-eclampsia and IUGR.