Cervicovaginal Fluid Research Articles

Rationale & design of the PROMISES study: a prospective assessment and validation study of salivary progesterone as a test for preterm birth in pregnant women from rural India

BackgroundIn India, 3.6 million pregnancies are affected by preterm birth annually, with many infants dying or surviving with disability. Currently, there is no simple test available for screening all women at risk of spontaneous PTB in low income setting, although high resource settings routinely use cervical length measurement and cervico-vaginal fluid fetal fibronectin for identification and care of women at risk due to clinical history. In rural India, where the public health system has limited infrastructure, trained staff and equipment, there is a greater need to develop a low-cost screening approach for providing early referral, treatment and remedial support for pregnant women at risk of preterm birth. There is interest in the use of a salivary progesterone test as a screening tool preliminary evidence from India, Egypt and UK has shown promise for this type of test. The test requires further validation in a low resource community setting.MethodsThe Promises study aims to validate and test the feasibility of introducing a low-cost salivary progesterone preterm birth prediction test in two rural districts in India with high rates of prematurity. It is a prospective study of 2000 pregnant women recruited from Panna and Satna in Madhya Pradesh over approximately 24 months. Demographic and pregnancy outcome data will be collected, and pregnancies will be dated by ultrasound sonography. Saliva progesterone will be measured by ELISA in samples obtained between 24–28 weeks of gestation. The association between salivary progesterone and preterm birth will be determined and the utility of salivary progesterone to predict preterm birth < 34, as well as < 30 and < 37 weeks assessed. Additional qualitative data will be obtained in terms of acceptability and feasibility of saliva progesterone testing and knowledge of PTB.DiscussionA validated cost-effective saliva test, which has potential for further adaptation to a ‘point of care’ setting will allow early identification of pregnant women at risk of preterm birth, who can be linked to an effective pathway of care and support to reduce preterm birth and associated adverse consequences. This will reduce both economic and emotional burden on the affected women and their families.

Cervico-vaginal secretion cytokine profile: A non-invasive approach to study the endometrial receptivity in IVF cycles.

Cytokines have a significant role in the process of embryo implantation, trophoblast growth, and differentiation by modulating the immune and endocrine system. The aim of this study was to investigate the profile of a large set of cytokines in the cervico-vaginal washing of women undergoing IVF, to explore the association of these proteins with a good receptive endometrium. A cohort of 155 women scheduled for IVF cycle was recruited. All patients were asymptomatic for genitourinary infections and had been screened for chlamydia, mycoplasma, and other bacterial infections. All IVF subjects were treated according to standard clinical and laboratory protocols. A panel of 48 immune factors was analyzed on cervico-vaginal washing, using magnetic bead-based multiplex immunoassays (Bio-Plex, BIO-RAD Laboratories, Milano, Italy). A total of 99 patients reached embryo transfer, of which 31 had a clinical pregnancy. A pattern of four pro-inflammatory immune molecules, IL-12p40, IFN-a, MIF, and MCP3 (P<0.001), was found significantly up-regulated in the cervico-vaginal fluid of women with clinical pregnancy. A significantly increased expression of IL-9, Groα , and SDF-1α (P<0.05) was observed in the presence of endometriosis, while high levels of IL-13 and L-15 were associated with ovulatory infertility factor (P<0.05). In this pilot study, we demonstrated that the expression of specific cytokines in the cervico-vaginal washing on the day of oocyte retrieval might have a positive correlation with the potential clinical pregnancy. Therefore, cervico-vaginal secretion cytokine profiling might be a new, non-invasive approach to study the endometrial receptivity in IVF management.

First Sequence Analysis of Genes Mediating Extended-Spectrum Beta-Lactamase (ESBL) bla-TEM, SHV- and CTX-M Production in Isolates of Enterobacteriaceae in Southern Benin

: The production of extended-spectrum beta-lactamase (ESBL) by Enterobacteriaceae is a global public health problem. The present study was carried out on 156 strains of enteric bacteria isolated from urinary and cervicovaginal fluid samples. Identification of the strains was performed using MALDI-TOF MS and antibiotic susceptibility tests by disk diffusion method on Mueller Hinton agar in accordance with the recommendations of the Antibiogram Committee of the French Society for Microbiology. ESBL genes were sought by real time-polymerase chain reaction (RT-PCR) and by gel-based PCR. Gel-based PCR products were used for sequencing of the resistance genes, which were analyzed in the NCBI and Arg Annot databases. Results showed a predominance of Escherichia coli both in the urinary and cervicovaginal fluid samples. Klebsiella pneumoniae was the second most isolated bacterium in the specimens. Sensitivity to antibiotics revealed high levels of cephalosporin resistance but low resistance to carbapenem. No resistance was noted to colistine. The bla-TEM gene was present in Escherichia coli, while bla-SHV was found in Klebsiella pneumoniae and bla-CTX-M was recovered in both strains. Analysis of the sequences revealed that bla-Tem1 was predominant in bla-TEM and bla-CTX-M-15 was most represented by bla-CTX-M. This study confirms the presence of ESBL-producing Enterobacteria in Benin. This was an epidemiological study aimed at detecting cephalosporin resistance in gram-negative Bacillus isolated from urinary tract and genital infections developed by women. Since the advent of molecular biology techniques for the identification of resistance in bacteria including determination of ESBL resistance genes (i.e., TEM, SHV, CTX-M), no study has been conducted to identify the different variants that circulate in Benin by sequencing these resistance genes. This sequencing is essential in order to differentiate the non-ESBL parental enzymes, which is not possible with the commonly used PCR techniques that do not permit differentiation of the point generating different variants of the ESBL genes. The present study then helped to identify those variants, in particular Tem1, SHV1, and CTX-M15, which are most encountered in Benin and around the world.

Mycoplasma genitalium Infection in Kenyan and US Women.

Little is known about the natural history of Mycoplasma genitalium (MG) infection in women. We retrospectively tested archived vaginal fluid samples to assess MG prevalence, incidence, persistence, recurrence and antimicrobial resistance markers among women participating in the Preventing Vaginal Infections trial, a randomized trial of monthly presumptive treatment to reduce vaginal infections. High-risk, nonpregnant, HIV-negative women aged 18 to 45 years from Kenya and the United States were randomized to receive metronidazole 750 mg + miconazole 200 mg intravaginal suppositories or placebo for 5 consecutive nights each month for 12 months. Clinician-collected swabs containing cervicovaginal fluid were tested for MG using Hologic nucleic acid amplification testing at enrollment and every other month thereafter. Specimens that were MG+ underwent additional testing for macrolide resistance-mediating mutations by DNA sequencing. Of 234 women enrolled, 221 had available specimens and 25 (11.3%) had MG at enrollment. Among 196 women without MG at enrollment, there were 52 incident MG infections (incidence, 33.4 per 100 person-years). Smoking was independently associated with incident MG infection (adjusted hazard ratio, 3.02; 95% confidence interval, 1.32-6.93), and age less than 25 years trended toward an association (adjusted hazard ratio, 1.70; 95% confidence interval, 0.95-3.06). Median time to clearance of incident MG infections was 1.5 months (interquartile range, 1.4-3.0 months). Of the 120 MG+ specimens, 16 specimens from 15 different women were macrolide resistance-mediating mutation positive (13.3%), with no difference by country. M. genitalium infection is common among sexually active women in Kenya and the Southern United States. Given associations between MG and adverse reproductive health outcomes, this high burden of MG in reproductive-aged women could contribute to substantial morbidity.

Inflammatory proteins in maternal plasma, cervicovaginal and amniotic fluids as predictors of intra-amniotic infection in preterm premature rupture of membranes.

ObjectiveWe aimed to assess the correlations among multiple cytokine concentrations in the maternal plasma, cervicovaginal fluid (CVF), and amniotic fluid (AF) compartments in women with preterm premature rupture of membranes (pPROM), and to develop a prediction model based on non-invasive measures, having better sensitivity and specificity for the identification of microbial invasion of amniotic cavity (MIAC).MethodThis retrospective study included 75 consecutive women with pPROM (20+0–34+0 weeks), who underwent amniocentesis. Both maternal plasma and CVF samples were collected at the time of amniocentesis. Stored AF, plasma and CVF samples were assayed for cytokine levels [interleukin (IL)-6, IL-8, monocyte chemotactic protein-1, macrophage inflammatory protein (MIP)-1α, MIP-1β] using a multiplex immunoassay kit.ResultsLevels of inflammatory proteins measured in the CVF were significantly correlated with AF proteins levels, whereas none of the proteins in plasma correlated significantly with any in the AF or CVF. Proteins levels measured in the AF and CVF were significantly higher in women with MIAC compared to those without, whereas only high levels of IL-6 in plasma were significantly associated with MIAC. By using stepwise regression analysis, a non-invasive model (using clinical factors and CVF cytokine levels) for the prediction of MIAC was developed; the area under curve of this non-invasive model was similar to that of the invasive model (using clinical factors and AF cytokines).ConclusionsThe levels of inflammatory proteins in the CVF correlated with those in the AF, whereas those in the plasma showed no correlation. A non-invasive model using clinical factors and CVF cytokine levels predicted the risk of MIAC in women with pPROM.

Anti-HIV-1 Activity of Lactic Acid in Human Cervicovaginal Fluid.

Women of reproductive age with a Lactobacillus-dominated vaginal microbiota have a reduced risk of acquiring and transmitting HIV and a vaginal pH of ~4 due to the presence of ~1% (wt/vol) lactic acid. While lactic acid has potent HIV virucidal activity in vitro, whether lactic acid present in the vaginal lumen inactivates HIV has not been investigated. Here we evaluated the anti-HIV-1 activity of native, minimally diluted cervicovaginal fluid obtained from women of reproductive age (n = 20) with vaginal microbiota dominated by Lactobacillus spp. Inhibition of HIVBa-L was significantly associated with the protonated form of lactic acid in cervicovaginal fluid. The HIVBa-L inhibitory activity observed in the <3-kDa acidic filtrate was similar to that of the corresponding untreated native cervicovaginal fluid as well as that of clarified neat cervicovaginal fluid subjected to protease digestion. These ex vivo studies indicate that protonated lactic acid is a major anti-HIV-1 metabolite present in acidic cervicovaginal fluid, suggesting a potential role in reducing HIV transmission by inactivating virus introduced or shed into the cervicovaginal lumen.IMPORTANCE The Lactobacillus-dominated vaginal microbiota is associated with a reduced risk of acquiring and transmitting HIV and other sexually transmitted infections (STIs). Lactic acid is a major organic acid metabolite produced by lactobacilli that acidifies the vagina and has been reported to have inhibitory activity in vitro against bacterial, protozoan, and viral STIs, including HIV infections. However, the anti-HIV properties of lactic acid in native vaginal lumen fluids of women colonized with Lactobacillus spp. have not yet been established. Our study, using native cervicovaginal fluid from women, found that potent and irreversible anti-HIV-1 activity is significantly associated with the concentration of the protonated (acidic, uncharged) form of lactic acid. This work advances our understanding of the mechanisms by which vaginal microbiota modulate HIV susceptibility and could lead to novel strategies to prevent women from acquiring HIV or transmitting the virus during vaginal intercourse and vaginal birth.

Rilpivirine Plasma and Cervicovaginal Concentrations in Women During Pregnancy and Postpartum.

Concentrations of antiretrovirals in the genital tract play a key role in preexposure prophylaxis. This study aims to describe rilpivirine (Edurant) concentrations in the genital tract in pregnant and postpartum women. International Maternal Pediatric Adolescent AIDS Clinical Trials Protocol P1026s is an ongoing, prospective study of antiretroviral pharmacokinetics in HIV-infected pregnant women that include a cohort receiving rilpivirine combination regimen. Intensive pharmacokinetics evaluations were performed at steady state during the second and third trimester, and postpartum. Plasma and directly aspirated cervicovaginal fluid (CVF) samples were collected at 4 time points around an observed dose and measured using high-performance liquid chromatography with ultraviolet detection, [plasma; lower limit of quantification (LLQ) = 10 ng/mL] or liquid chromatography-tandem mass spectrometry (CVF; LLQ = 1 ng/mL). A total of 24 women were included in the analysis. For all time points combined, median (interquartile range) rilpivirine concentrations were 70 ng/mL (23-121) in CVF and 92 ng/mL (49-147) in plasma. The CVF to plasma AUC(0-4) ratios were significantly higher in the second (0.90, 90% CI: 0.61 to 1.46) and third trimesters of pregnancy compared with postpartum (0.40, 90% CI: 0.19 to 0.87). Three of 189 (1.6%) plasma samples in 2 women were below the LLQ and the corresponding CVF concentrations. Seventeen additional CVF concentrations (10.6%) were below LLQ in 13 participants. No major safety concerns were noted. Rilpivirine concentrations were higher in the CVF during pregnancy compared with postpartum. CVF Rilpivirine is likely to achieve inhibitory concentrations effective for preventing peripartum HIV transmission.

Biofluid Metabolomics in Preterm Birth Research.

This article presents an account of the research carried out so far in the use of metabolomics to find biomarkers of preterm birth (PTB) in fetal, maternal, and newborn biofluids. Metabolomic studies have employed mainly nuclear magnetic resonance spectroscopy or mass spectrometry-based methodologies to analyze, on one hand, prenatal biofluids (amniotic fluid, maternal urine/maternal blood, cervicovaginal fluid) to identify predictive biomarkers of PTB, and on the other hand, biofluids collected at or after birth (amniotic fluid, umbilical cord blood, newborn urine, and newborn blood, maternal blood, or breast milk) to assess and follow up the health status of PTB babies. Besides advancing on the biochemical knowledge of PTB metabolism mainly during the in utero period and at birth, the work carried out has also helped to identify important requirements related to experimental design and analytical protocol that need to be addressed, if translation of these biomarkers to the clinic is to be envisaged. An outlook of possible future developments for the translation of laboratory results to the clinic is presented.

Optimising the collection of female genital tract fluid for cytokine analysis in pregnant women

IntroductionTo better understand the immunology of pregnancy, study of female genital tract fluid (FGF) is desirable. However the optimum method of collection of FGF in pregnant women for immunological methods, specifically cytokine measurement, is unknown. MethodsA prospective study of HIV-uninfected pregnant women comparing two methods of FGF collection: polyvinyl acetal sponge collection of cervical fluid (CF) and menstrual cup collection of cervicovaginal fluid (CVF). Samples were collected at 3 time points across the second and third trimesters: 14–21, 22–25 and 26–31 weeks. Multiplex chemi-luminescent assays were used to measure: IFN-γ, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IL-13 and TNF-α. Optimal methodology for cytokine normalisation (sample weight, volume and total protein) was explored. ResultsAll cytokines were measurable in both fluid types. IL-1β, IL-8 and IL-6 were detected at the highest concentrations (ranking order CF > CVF > plasma). CVF collection was simpler, provided the largest volume of sample (median 0.5 g) with the potential for undiluted usage, and allowed for self-insertion. CF cytokine concentrations were intrinsically associated with sample weight and protein concentration however CVF cytokines were independent of these. ConclusionBoth methods of collection are robust for measurement of FGF cytokines during pregnancy. We recommend CVF collection using a menstrual cup as a viable option in pregnant women for high dimensional biological techniques.

Comparison of Serum and Cervical Cytokine Levels throughout Pregnancy between Preterm and Term Births.

Objective To assess differences in cytokine levels in cervicovaginal fluid (CVF) and serum across trimesters between women with preterm births (PTBs) and full-term births. Study Design This multicenter study enrolled 302 women with a singleton gestation. CVF and serum cytokines, interleukin 1α (IL-1α), IL-1β, IL-6, IL-8, IL-10, C-reactive protein (CRP), tumor necrosis factor (TNF)-α, and matrix metalloproteinase (MMP)-8, were measured. Women with at least one cytokine assessment and noted PTB status in their medical record were retained in the study ( N = 272). Data were analyzed using mixed modeling (main effects of PTBs and time/trimester). Results For the CVF values of IL-6, IL-8, IL-10, TNF-α, and CRP, and serum MMP-8, those who delivered preterm had significantly higher values than the full-term group regardless of trimester. For the serum values of IL-1β, IL-6, and TNF-α, those delivering preterm had significantly lower values than those delivering full-term regardless of trimester. For IL-1β in CVF, the cytokine was significantly higher in the PTB group for second and third trimesters only, relative to the full-term group. Conclusion For each CVF cytokine that differed by birth status, values were higher for PTB than term, averaged over trimester. Numerous cytokine profiles varied across trimesters in women delivering term versus preterm in both CVF and serum.

Protein Content of Cervicovaginal Fluid Is Altered During Bacterial Vaginosis.

The aim of the study was to compare, using a proteomic approach, cervicovaginal fluid (CVF) proteins of women with bacterial vaginosis (BV) with those presenting normal microbiota. A total of 309 reproductive-aged women were cross-sectionally enrolled. Participants were tested for vaginal candidosis, Trichomonas vaginalis, Chlamydia trachomatis, and Neisseria gonorrhoeae and excluded if positive. Vaginal microbiota was classified microscopically according to Nugent criteria in normal, intermediate, and BV. Randomly selected CVF samples of 29 women with BV and an equal number with normal microbiota were subjected to proteomic analysis. Thus, a total of 58 CVF samples were evaluated using shotgun liquid chromatography-tandem mass spectrometry in a Q-Tof PREMIER API mass spectrometer (MicroMass/Waters) for peptide detection and relative quantification. Of the 309 women enrolled, 63 (20.4%) were excluded after testing positive for at least one of the tested co-infections or because of low-quality samples. Microscopic classification of vaginal microbiota on the remaining 246 samples revealed that 132 women (53.6%) had normal microbiota, 33 (13.4%) had intermediate microbiota, and 81 (33.0%) had BV. Proteomic analysis of CVF of 58 randomly selected women with normal microbiota (n = 29) or BV (n = 29) successfully identified 74 proteins. In addition, the comparison of abundance of those proteins between the groups showed that the following five (6.7%) were enriched in BV: neutrophil elastase, kaliocin-1, neutrophil defensin-1, Ig lambda-2 chain C regions, and protein S100-A7. All of which have a recognized role in host's immunity. Exclusive finding of BV affects immunity-related CVF components of reproductive-aged women.

Stress, anxiety, and depression of both partners in infertile couples are associated with cytokine levels and adverse IVF outcome.

Psychiatric disorders and stress in women have been associated with poor IVF outcome. We hypothesized that both partners in the infertile couples are emotionally affected, and cytokines in both may link psychological to reproductive outcome. Forty-five IVF couples completed questionnaires and visual analog scales for stress and psychiatric disorders and had cytokines measured in serum, semen, cervicovaginal, and follicular fluids. Multivariable analyses, t tests, maximum likelihood estimates, Spearman correlation, and data mining were applied. Psychopathology was found in 72% of the couples. Female and male stress were associated with stress, anxiety, and depression in the respective partner, and with a lower likelihood of clinical pregnancy and live birth. Lower serum TGF-β and higher cervicovaginal IL-6 and IL-1β were associated with stress. In data decision trees, cytokines in relation to stress and depression in both partners were found indicative of IVF failure. Infertile couples may benefit from psychiatric evaluation and treatment of both partners.

Streptococcus agalactiae Inhibits Candida albicans Hyphal Development and Diminishes Host Vaginal Mucosal TH17 Response.

Streptococcus agalactiae and Candida albicans often co-colonize the female genital tract, and under certain conditions induce mucosal inflammation. The role of the interaction between the two organisms in candidal vaginitis is not known. In this study, we found that co-infection with S. agalactiae significantly attenuated the hyphal development of C. albicans, and that EFG1-Hwp1 signal pathway of C. albicans was involved in this process. In a mouse model of vulvovaginal candidiasis (VVC), the fungal burden and the levels of pro-inflammatory cytokines, IL-1β, IL-6 and TNF-α showed a increase on co-infection with S. agalactiae, while the level of TH17 T cells and IL-17 in the cervicovaginal lavage fluid were significantly decreased. Our results indicate that S. agalactiae inhibits C. albicans hyphal development by downregulating the expression of EFG1-Hwp1. The interaction between S. agalactiae and C. albicans may attenuate host vaginal mucosal TH17 immunity and contribute to mucosal colonization by C. albicans.

Colonization of the cervicovaginal space with Gardnerella vaginalis leads to local inflammation and cervical remodeling in pregnant mice.

The role of the cervicovaginal (CV) microbiome in regulating cervical function during pregnancy is poorly understood. Gardnerella vaginalis (G. vaginalis) is the most common bacteria associated with the diagnosis of bacterial vaginosis (BV). While BV has been associated with preterm birth (PTB), clinical trials targeting BV do not decrease PTB rates. It remains unknown if G. vaginalis is capable of triggering molecular, biomechanical and cellular events that could lead to PTB. The objective of this study was to determine if cervicovaginal colonization with G. vaginalis, in pregnant mice, induced cervical remodeling and modified cervical function. CD-1 timed-pregnant mice received a 5X108 CFU/mL intravaginal inoculation of G. vaginalis or control on embryonic day 12 (E12) and E13. On E15, the mice were sacrificed and cervicovaginal fluid (CVF), amniotic fluid (AF), cervix, uterus, placentas and fetal membranes (FM) were collected. Genomic DNA was isolated from the CVF, placenta, uterus and FM and QPCR was performed to confirm colonization. IL-6 was measured in the CVF and AF and soluble e-cadherin (seCAD) was assessed in the CVF by ELISA. RNA was extracted from the cervices to evaluate IL-10, IL-8, IL-1β, TNF-α, Tff-1, SPINK-5, HAS-1 and LOX expression via QPCR. Mucicarmine and trichrome staining was used to assess cervical mucin and collagen. Biomechanical properties of the cervix were studied using quasi-static tensile load-to-failure biomechanical tests. G. vaginalis successfully colonized the CV space. This colonization induced immune responses (increased IL-6 levels in CVF and AF, increased mRNA expression of cervical cytokines), altered the epithelial barrier (increased seCAD in the CVF), induced cervical remodeling (increased mucin production, altered collagen) and altered cervical biomechanical properties (a decrease in biomechanical modulus and an increase in maximum strain). The ability of G. vaginalis to induce these molecular, immune, cellular and biomechanical changes suggests that this bacterium may play a pathogenic role in premature cervical remodeling leading to PTB.

Mid-gestational changes in cervicovaginal fluid cytokine levels in asymptomatic pregnant women are predictive markers of inflammation-associated spontaneous preterm birth

ObjectivesPerturbation of the choriodecidual space before the onset of spontaneous preterm birth (sPTB) could lead to a concomitant rise in both cervicovaginal fluid (CVF) cytokine and fetal fibronectin (FFN), and assessing the concentrations of both markers could improve the prediction of sPTB (delivery before 37 completed weeks of gestation). Therefore, we prospectively determined mid-trimester changes in CVF cytokine and FFN concentrations, and their predictive capacity for sPTB in asymptomatic pregnant women. Study designCVF collected at 20+0–22+6 weeks (n = 47: Preterm-delivered = 22, Term-delivered = 25) and 26+0–28+6 weeks (n = 50: Preterm-delivered = 17, Term-delivered = 33) from 63 asymptomatic pregnant women at risk of sPTB were examined. Cytokine and FFN concentrations were determined by multiplexed bead-based immunoassay and 10Q Rapid analysis (Hologic, MA, USA) respectively. The 20+0–22+6/26+0–28+6 weeks ratios of cytokines and FFN concentrations were compared between preterm- and term-delivered women using Receiver Operating Characteristics curves to predict sPTB. Also, bacterial 16S rDNA from 64 samples (20+0–22+6 weeks n = 36, 26+0–28+6 weeks n = 28) was amplified by polymerase chain reaction to determine associations between vaginal microflora, cytokine and FFN concentrations. ResultsChanges in RANTES and IL-1β concentrations between 20+0–22+6 and 26+0–28+6 weeks, expressed as a ratios, were predictive of sPTB, RANTES (AUC = 0.82, CI = 0.62–0.94) more so than IL-1β (AUC = 0.71, CI = 0.53–0.85) and FFN (not predictive). Combining these markers (AUC = 0.83, CI = 0.63–0.95) showed similar predictive capacity as RANTES alone. FFN concentrations at 26+0–28+6 weeks correlated with IL-1β (r = 0.4, P = 0.002) and RANTES (r = 0.3, P = 0.03). In addition, there was increased prevalence of vaginal anaerobes including Bacteroides, Fusobacterium and Mobiluncus between gestational time points in women who experienced sPTB compared to the term women (P = 0.0006). ConclusionsCVF RANTES and IL-1β in mid-trimester of pregnancy correlate with quantitative FFN. The levels of CVF RANTES and IL-1β decline significantly in women who deliver at term unlike women who deliver preterm. This observation suggests that sPTB may be characterised by sustained choriodecidual inflammation and may have clinical value in serial screening for sPTB if confirmed by larger studies.

Qualitative cervicovaginal fluid β-hCG versus cervicovaginal fluid fetal fibronectin assessment in prediction of preterm labor in asymptomatic high risk women

Context: Preterm births occur in 11% of all births worldwide, but account for more than 85% of perinatal morbidity and mortality. One of the best predictors to assess the risk of preterm labor (PTL) is by measuring fetal fibronectin (fFN) in cervicovaginal secretions (CVS). In addition, measurement of cervicovaginal fluid fFN is a good negative predictor of spontaneous PTL in both symptomatic and asymptomatic high‑risk women after 22 weeks of pregnancy. Aim: We aimed to evaluate the diagnostic accuracy of qualitative cervicovaginal beta‑human chorionic gonadotropin (β‑hCG) versus qualitative fFN for prediction of PTL in asymptomatic high‑risk women during antenatal care. Settings and Design: This prospective observational study was undertaken at Egypt, Zagazig University Hospitals. In all, 220 with singleton pregnancies and having risk factors for spontaneous preterm birth were included in this study. Materials and Methods: Cervicovaginal fluid sampling was undertaken at 24 weeks gestational age for qualitative β‑hCG and qualitative fFN assessment. Women were categorized into two arms: women who delivered preterm and women who delivered at term. Statistical Analysis Used: Data were presented as mean, ±standard deviation, number, and percentage. Chi‑square test ( χ 2 ) was used for comparison between groups with regard to qualitative variables; validity of the test is done using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results: As regarding qualitative β‑hCG assessment for prediction of PTL, sensitivity, specificity, PPV, and NPV were 72%, 85%, 41%, and 95.5%, respectively. As regarding qualitative fFN assessment for prediction of PTL in the same studied group, sensitivity, specificity, PPV, and NPV were 73%, 87%, 38%, and 96%, respectively. Conclusion: Our study showed that qualitative β‑hCG assessment in cervicovaginal fluid can be used as an alternative method to qualitative fFN assessment as it is a valid test, more available, and not expensive in prediction of PTL in asymptomatic high‑risk patients. Keywords: β‑hCG; fetal fibronectin; preterm labor

519: Serum and Cervicovaginal Fluid (CVF) inflammatory analytes in pregnancy as predictors of Small for Gestational Age (SGA) neonates

Small for gestational age (SGA) neonates face several complications in the immediate neonatal period as well as long-term impairment in psychomotor and developmental outcomes. Fetal growth restriction is shown to have multiple etiologies, however the relationship between inflammatory dysregulation in pregnancy and birth weight remains incompletely understood. Our objective for this study was to evaluate a central link between systemic maternal inflammation and birth weight. This was a secondary analysis of a longitudinal multicenter study of women with singleton gestations. Maternal serum and cervico-vaginal fluid (CVF) specimens were collected in all trimesters. Cytokines (IL-1α, IL-1β, IL-6, IL-8, IL-10, TNF-α, CRP) were measured using a multiplex beadlyte assay on a luminex IS-100. SGA (defined as birth weight less than 10th percentile for gestational age) was determined using the Fenton Growth Chart. Repeated measures analysis was used to evaluate differences in cytokine profiles by SGA infant status, adjusting for maternal age and first trimester smoking status. Cytokine values were log-transformed prior to all data analyses. Statistical analyses were performed using SAS 9.4 with an alpha level of 0.05 throughout. Pregnant women (n= 317) underwent screening in each trimester. The rate of SGA infants among the study subjects was 7% (n=23). Serum cytokine data was available for 240, 227 and 214 subjects in the first, second and third trimesters, respectively; CVF data was available for 226, 210 and 187 subjects, respectively. In the bivariate analysis, first trimester serum IL-10 was significantly higher in women with SGA infants (p=0.044), while first trimester CVF IL-10 was lower in patients with SGA infants, trending towards significance (p=0.063). In the adjusted analysis, serum IL-1β levels were significantly higher (p=0.043) and serum CRP levels were significantly lower (p=0.036) among women who delivered SGA infants versus those who delivered infants of normal weight, regardless of trimester. Our results indicate that altered levels of inflammatory cytokines over the pregnancy time course may be associated with small for gestational age neonates. Further research is warranted to understand the immunomodulatory mechanisms involved in affecting fetal growth.

Diagnostic Accuracy of PremaQuick versus Actim Partus in Prediction of Preterm Labor in Symptomatic Women within 14 Days

Background: Preterm labor (PTL) remains a major source of neonatal morbidity, and mortality. Currently the trans-vaginal cervical length (TVCL), and/or cervico-vaginal fetal fibronectin (fFN) are the common diagnostic tools used for prediction of PTL. Consequently, many women and their fetuses are exposed unnecessarily tocolysis and hospital admission. Objectives: This study was designed to compare the diagnostic accuracy of PremaQuick versus Actim Partus in prediction of PTL in symptomatic women within 14 days. Patients and Methods: Two-hundred and twenty women (220) were included in this comparative prospective study and classified into two groups: 110 women with threatened preterm labor (TPTL) in the study group, and 110 controls (no TPTL). Women included in the study were subjected to: through history, collection of the cervico-vaginal fluid (CVF) samples for assessment by PremaQuick and Actim Partus tests, followed by trans-vaginal cervical length (TVCL) assessment. Studied women managed according to the hospitals protocol, with follow-up weekly in the obstetrics outpatients’ clinic after discharge from the hospital until delivery. The main outcome measures the diagnostic accuracy of PremaQuick versus Actim Partus in prediction of PTL in symptomatic women within 14 days of admission. Results: PremaQuick test was significantly more specific with higher positive predictive value (PPV) in prediction of PTL in symptomatic women within 14 days (95.5% and 89.6%; respectively) compared to CL < 25 mm (56.3% and 54.6%; respectively), (P = 0.02 and 0.03; respectively). In addition, PremaQuick test was significantly more sensitive with higher positive predictive value (PPV) in prediction of PTL in symptomatic women within 14 days (39.8% and 89.6%; respectively) compared to Actim Partus (13.9% and 55.5%; respectively), (P = 0.001 and 0.01; respectively). The Odds ratio and the relative risk for prediction of PTL in symptomatic women within 14 days were significantly high for PremaQuick compared to the CL < 25 mm, and Actim Partus. Conclusion: PremaQuick test seems to be the best complementary test to the CL < 25 in prediction of PTL in symptomatic women within 14 days. PremaQuick test compensates the low specificity and low PPV of the CL < 25 mm in prediction of PTL.

715: Cervicovaginal fluid analytes at the time of cervical shortening as a predictor of cerclage effectiveness in women with prior spontaneous preterm birth

715: Cervicovaginal fluid analytes at the time of cervical shortening as a predictor of cerclage effectiveness in women with prior spontaneous preterm birth

Suspected hypersensitivity to cervicovaginal fluid - what can we learn from the seminal plasma allergy story?

After the first report of seminal plasma hypersensitivity (SPH) in 1958, it took more than 40 years to identify the allergen responsible for these reactions.1, 2 Even in the middle of the 70s, women suffering from allergic reactions against the ejaculate of their partners received the recommendation, ‘that she avoids this gentleman’.3 The first publication about SPH is written in Dutch language.1 The authors used the term ‘merkwaardig’ to describe the reaction of their female patient against seminal plasma. It is worth mentioning that ‘merkwaardig’ may mean ‘remarkable’, ‘strange’, but also ‘funny’ implicating some uncertainty concerning the severity of this reaction. The manuscript by Jankowski et al. reminds one very much of the situation in 1958. Nothing is known about hypersensitivity to cervicovaginal fluid (CVFH). The characterization of this potentially new disease is based on subjective reports from patients and the personal opinion of dermatologists. However, prick tests or determination of specific IgE are not available. This is not surprising, as the allergen(s), that may be responsible for CVFH, have not yet been identified. The fact that CVF contains a variety of components and is mixed with secretions of genital accessory glands does not necessarily mean that isolation of the allergen is not possible. Seminal plasma is also composed of proteins and substances from different anatomical structures such as testicles, epididymis, prostate gland and seminal vesicles (and more!). Suspected CVFH and SPH have one common problem. Genital or general discomfort after sexual intercourse may be caused by organic or psychogenic factors. However, the most important difference is that the composition of CVF differs according to the female cycle and is also influenced by the microbiological microflora.4, 5 Considering these aspects, the Internet-based questionnaire by Jankowski et al. is an important step to draw attention to a problem we do not have enough knowledge about, but we need more data ‘to characterize the population of men with suspected hypersensitivity to cervicovaginal fluid’ and to calculate the prevalence of CVFH. Do men with suspected CVFH notice differences in their complaints, when they have sexual intercourse at different times of their partner's cycle? Do oral contraceptives show effects on the reaction against CVF? Do men with suspected CVFH react differently to different sexual partners? If these data are available, it would be interesting to present them. As several studies have focussed on components of the vaginal or cervical–vaginal fluid,4, 5 it should be technically possible, to gain enough material for allergological tests. In addition, men with suspected CVFH need to be evaluated by physicians trained in sexual medicine. It is likely that some men have really IgE-mediated allergies against CVF. Witkin et al. 6 demonstrated that some men (without symptoms) have IgE antibodies in their seminal plasma that reacted with components of the vaginal fluid of their partners or (in one case) also with that of another woman. The allergens involved were not further characterized. In principle, it seems to be possible that men react specifically to their partners CVF. The consequence of the manuscript by Jankowski et al. will be that more reports about suspected CVFH will be published in the future. This will enable the allergological workup of these patients and their problems. It is hoped that it will not take 50 years to clarify this interesting problem!