Maternal Bloodstream Research Articles

P-538 Liquid biopsy (niPOC) as a new approach to genetic studies in early pregnancy loss. First clinical experience in Spain

Abstract Study question How accurate is the use of liquid biopsy as a new tool for aneuploidy testing in cases of pregnancy losses? Summary answer This study demonstrates that genome-wide cfDNA testing in the maternal bloodstream (niPOC) constitutes a simple, tissue-independent, straightforward and reliable complement/alternative to traditional POC analysis. What is known already Around 50-70% of clinical miscarriages are caused by aneuploidies, mostly trisomies. To date, conventional cytogenetic and advanced molecular techniques are used for the analysis of POC to identify the genetic cause of miscarriage, providing valuable information for genetic counseling. However, both approaches are based in the direct analysis of the abortive tissue, which entails several limitations due to a risk of culture failure and/or maternal cell contamination. To solve these drawbacks, maternal cell-free DNA (cfDNA) testing emerges as a promising alternative due to the accumulated evidence. Study design, size, duration Retrospective study and first clinical experience, both conducted in our facilities from January 2021 to December 2023. Before carrying out the fetal tissues collection for the POC analysis, a blood sample was drawn to evaluate possible aneuploidies by cfDNA testing. Using NGS+STR POC results as the gold standard, results derived from both studies were compared to assess the percentage of concordance and the cases of non-informativeness (fetal fraction (FF) <2%), false positives, and false negatives. Participants/materials, setting, methods Herein we present a clinical validation (n = 152) and the first clinical experience (n = 103). Maternal peripheral blood samples were extracted for aneuploidy evaluation using Illumina’s sequencing platform. Genetic testing on POCs was performed using NGS (Thermo Fisher Scientific) to detect aneuploidies, and short tandem repeats to detect cases with MCC and/or polyploidy. In both groups (niPOC and POC), the percentage of concordance and cases of non-informativeness (by fetal fraction <2%, or CCM) were evaluated. Main results and the role of chance In the validation set, no significant differences in non-informativity were observed between POC and niPOC [9.2% (14/152) vs 13.8% (21/152)]. Excluding triploids, the sensitivity of niPOC compared with the pregnancy tissue sequencing result was 90.1%, specificity of 97.1% and an accuracy of 88%. In the first clinical experience, non-informativity was similar to that found in the validation (17/103, 16.5%). The percentage of abnormal cases was 43%, very close to the 50% expected according to the scientific literature. Regarding turnaround time, reports in niPOC were released in an average of 3.8 working days. Limitations, reasons for caution Current cfDNA testing technology fails in polyploidy, uniparental disomy identification, which is a potential cause of pregnancy loss. Aneuploidy detection is only feasible if the blood collection was performed before the fetal remains evacuation. Wider implications of the findings CfDNA testing before curettage or pharmacological treatment could be an alternative to POC analysis. If optimized, cfDNA testing could be used contingently with the molecular POC analysis in cases where maternal cell contamination is present. As a result, the overall success rate in the POC program could be substantially improved. Trial registration number Not applicable

Navigating Perinatal Challenges: A Comprehensive Review of Cholestasis of Pregnancy and Its Impact on Maternal and Fetal Health.

Cholestasis of pregnancy (CP), or intrahepatic CP (ICP), represents a condition peculiar to pregnancy, marked by impaired bile acid flow and consequent accumulation in the maternal bloodstream. Primarily emerging in the third trimester, CP is linked with considerable risks to both the mother and fetus, including heightened incidences of preterm birth, fetal distress, and stillbirth, alongside maternal complications such as intense pruritus and liver dysfunction. Despite its clinical significance, the etiology of CP, which involves genetic, hormonal, and environmental factors, remains partially understood. This comprehensive review delves into the physiology and pathophysiology of CP, outlines its clinical manifestations and diagnostic criteria, and discusses the associated maternal and fetal complications. Furthermore, it evaluates current management strategies, prognostic implications, and potential long-term effects on maternal and child health. It also explores future research directions, emphasizing the need for advancements in understanding the pathophysiology of CP, developing novel therapeutic interventions, and improving risk stratification models. By offering a thorough overview of CP, this review aims to enhance clinical awareness, guide management practices, and identify areas requiring further investigation, ultimately contributing to better health outcomes for affected women and their babies.

Expanding Access to Noninvasive Prenatal Diagnosis for Monogenic Conditions to Consanguineous Families.

Cell-free fetal DNA exists within the maternal bloodstream during pregnancy and provides a means for noninvasive prenatal diagnosis (NIPD). Our accredited clinical service offers definitive NIPD for several autosomal recessive (AR) and X-linked conditions using relative haplotype dosage analysis (RHDO). RHDO involves next-generation sequencing (NGS) of thousands of common single nucleotide polymorphism (SNPs) surrounding the gene of interest in the parents and an affected or unaffected offspring to conduct haplotype phasing of the high- and low-risk alleles. NGS is carried out in parallel on the maternal cell-free DNA, and fetal inheritance is predicted using sensitive dosage calculations performed at sites where the parental genotypes differ. RHDO is not currently offered to consanguineous couples owing to the shared haplotype between parents. Here we test the expansion of RHDO for AR monogenic conditions to include consanguineous couples. The existing sequential probability ratio test analysis pipeline was modified to apply to SNPs where both parents are heterozygous for the same genotype. Quality control thresholds were developed using 33 nonconsanguineous cases. The performance of the adapted RHDO pipeline was tested on 8 consanguineous cases. The correct fetal genotype was predicted by our revised RHDO approach in all conclusive cases with known genotypes (n = 5). Haplotype block classification accuracies of 94.5% and 93.9% were obtained for the nonconsanguineous and consanguineous case cohorts, respectively. Our modified RHDO pipeline correctly predicts the genotype in fetuses from consanguineous families, allowing the potential to expand access to NIPD services for these families.

Pregnancy Associated Plasma Protein-A (PAPP-A) as a Marker to Distinguish Normotensive with Early 2nd Trimester and Late 3rd Trimester Onset of Preeclampsia

Introduction: Preeclampsia is a hypertensive condition that occurs after 20 weeks of gestation accompanied by target organ damage. Complications of preeclampsia can cause intrauterine fetal growth retardation, and placental hypoperfusion, even in the most serious situations, namely termination of pregnancy and death of the fetus and/or mother. Pregnancy-associated plasma protein-A (PAPP-A) is a high molecular weight glycoprotein that is produced in the placenta and secreted into the maternal bloodstream. However, based on several studies that have been conducted, there is uncertainty in the results of assessing PAPP-A levels obtained in pregnant women in the second and third trimesters. Aim: Proving differences in PAPP-A levels in the second and third trimesters in the incidence of early-onset preeclampsia and normotensive pregnancy. Methods: An analytic observational study with a cross-sectional approach was carried out in the delivery room of RSUP Dr. Kariadi Semarang, Halmahera Health Center, Ngesrep Health Center, Bulu Health Center, and private midwife practice in Semarang City. The subjects of the study were six 2nd-trimester preeclampsia patients, fourteen 3rd-trimester preeclampsia patients, and twenty normotensive pregnancy patients who met the inclusion and exclusion criteria. Data were analyzed using Mann Whitney with a significance of p<0.05 Results: There was a significant difference in PAPP-A levels (p<0.001) between the preeclampsia and normotensive pregnancy groups, whereas PAPP-A levels were higher in the preeclampsia group. There were significant differences in PAPP-A levels (p<0.001) between the 2nd-trimester preeclampsia, 3rd-trimester preeclampsia, and normotensive pregnancies, where the highest PAPP-A levels were found in the 2nd-trimester preeclampsia group. Conclusion: There was a significant difference in PAPP-A levels between the second and third trimesters of early-onset preeclampsia compared to normotensive pregnancies, where PAPP-A levels were higher in the second and third trimesters of early-onset preeclampsia. Elevated PAPP-A levels in the second and third trimesters are associated with an increased risk of early-onset preeclampsia.

Cell-Free DNA Screening for Single-Gene Disorders.

In pregnancy, cell-free DNA (cfDNA) represents short fragments of placental DNA released into the maternal blood stream through natural cell death. Noninvasive prenatal screening with cfDNA is commonly used in pregnancy to screen for common aneuploidies. This technology continues to evolve, and laboratories now offer cfDNA screening for single-gene disorders. This article aims to review cfDNA screening for single-gene disorders including the technology, current syndromes for which screening may be offered, limitations, and current recommendations. Original research articles, review articles, laboratory white papers, and society guidelines were reviewed. Cell-free DNA screening for single-gene disorders is not currently recommended by medical societies. There may be a role in specific circumstances and only after comprehensive pretest counseling. It can be considered in the setting of some fetal ultrasound anomalies, and usually only after diagnostic testing is offered and declined. Given the limitations of using cfDNA screening for single-gene disorders, caution is recommended when considering these tests. It should only be offered with involvement of a reproductive genetic counselor, medical geneticist, or maternal fetal medicine specialist to ensure comprehensive counseling and appropriate utilization.

Isolation of serum-derived placental/amnio-chorionic extracellular vesicles across pregnancy by immunoaffinity using PLAP and HLA-G.

Circulating extracellular vesicles of placental/amniochorionic origin carry placental/amniochorionic proteins and nucleic acids with the potential to facilitate non-invasive diagnosis of pregnancy-related disorders. The study reports an improvised method for the enriched isolation of extracellular vesicles of placental/amniochorionic origin using the two markers, PLAP and HLA-G. Extracellular vesicles (EVs) are membrane-bound nanovesicles secreted from the cells into extracellular space and body fluids. They are considered 'fingerprints of parent cells', which can reflect their physiological and functional states. During pregnancy, EVs are produced by the syncytiotrophoblasts and extravillous trophoblasts and are released into the maternal bloodstream. In the present study, placental alkaline phosphatase (PLAP)-specific extracellular vesicles were isolated from maternal serum-derived EVs (SDE) across pregnancy. Transmission electron microscopy and dynamic light scattering analysis showed that the isolated EVs exhibited a spherical morphology with ~30-150 nm size range. Nanoparticle tracking analysis indicated that the concentration of PLAP+ serum-derived EVs (PLAP+-SDE) increased across the gestation. PLAP+-SDE contained DNA with LINE1 promoter methylation pattern. C19 miRNA cluster miRNAs (miR 515-5p, 519e and 520f) were present in PLAP+-SDE along with other miRNAs (miR-133-3p, miR210-3p and miR-223-3p). PLAP+-SDE confirmed the presence of EV markers (CD63 and CD9), along with placental proteins (PLAP and cullin 7). A modified novel strategy to extract an enriched population of circulating placental/amniochorionic EVs was devised employing an additional marker of extravillous trophoblasts, human leukocyte antigen G (HLA-G), along with PLAP. The isolated pooled placental/amniochorionic (PLAP+&HLA-G+) serum-derived EVs (PP-SDE) showed ~two-fold increased protein levels of HLA-G in the third-trimester pregnant women compared to the non-pregnant controls. Future studies will be focused on validation of this novel strategy to isolate an enriched population of placental/amniochorionic EVs to facilitate a better understanding of placental physiology and pathophysiology.

Evaluation of microbiological epidemiology and clinical characteristics of maternal bloodstream infection: a 10 years retrospective study.

Although the incidence of bloodstream infection (BSI) during pregnancy is relatively low, it can lead to unfavorable outcomes. The aim of our study was to analyze the clinical and microbiological characteristics of maternal bacteremia and to assess maternal and fetal outcomes. Our study was a retrospective study conducted in a tertiary women and children's hospital in Guangzhou, China, from 2013 to 2022. Data were extracted from medical records and the laboratory information system. The participants were divided into groups, and the difference between the groups was analyzed. The incidence of maternal BSI during the 10 years study period was 10.2 cases/10,000 maternities, with a peak found from 2014 to 2016. Escherichia coli (48%) was the predominant causative pathogen, followed by Streptococcus agalactiae (13%). Gestational diabetes mellitus (GDM) (15%) was the most common underlying condition among maternal BSI episodes. Urinary tract (13%) and genital tract (28%) were the predominant source of BSI. About 14% of neonates were infected, and BSI was the most common type of infection. E. coli was the predominant pathogen in mother-neonate pairs with concurrent BSI. Premature rupture of membranes (PROM, OR:4.68) and preterm birth (OR:3.98) were the risk factors predicting neonatal infection. More than 85% of the E. coli were resistant to ampicillin (AMP) and 50% of the E. coli were extended-spectrum β-lactamase (ESBL)-producing bacteria. Maternal BSI is a rare event, but continuous monitoring on the aspects of pathogen composition, antimicrobial resistance characteristics, and risk factors for adverse outcomes remains necessary to further reduce poor outcomes and mitigate bacterial resistance.

Role of maternal serum c-reactive protein levels in early second trimester as a marker of preterm labour: A study protocol

Preterm labour is a birth that occurs between 22 and 37 weeks after conception. The primary cause of infant death is preterm birth (PTD), which is linked to long-term neurodevelopmental and behavioural effects for preterm survivors. A maternal vascular disease pathway and an inflammation/infection pathway are two suggested pathways that have collected sufficient evidence. The identification of women who are more likely to develop PTD and the understanding of the underlying physiological mechanisms would be made possible by reliable biomarkers for these pathways. Systemic maternal infections cause elevated levels of inflammatory cytokines, which then drive the creation of prostaglandins, which can cause cervical ripening and uterine contractions that result in preterm birth. Women with signs of preterm labour have been found to have high serum levels of proinflammatory which have been prospectively linked to preterm birth. A non-specific biomarker of inflammation, C-reactive protein (CRP) is an acute phase reactant in the innate immune response. The production of C-reactive protein, a serological marker that is readily identifiable, occurs largely in the hepatocytes in response to cytokine releases from the inflammatory site. Cytokines released, by an intrauterine infection go through the maternal bloodstream to the liver, where they activate the production of CRP. Forty-eight hours after stimulation the acute-phase response has reached its maximum and a meaningful measurement can be made from a blood sample. Although the exact cause of inflammation is unknown, modest and long-lasting elevations of CRP have been linked to a range of illnesses, including normal pregnancy. Elevated CRP levels in the peripheral circulation have been connected to the presence of intrauterine infection. It has been investigated to diagnose subclinical infections using the maternal CRP concentration. The purpose of this study is to determine the link between maternal serum CRP and subsequent preterm birth in single pregnant women.

SAT337 Maternal Cell free DNA Testing Reveals Incidental Finding Of Adrenocortical Carcinoma

Abstract Disclosure: F. Akanbi: None. S. Raja: None. T. Else: None. Maternal Cell-free DNA Testing Reveals Incidental Adrenocortical Carcinoma IntroductionAdrenocortical carcinoma (ACC) is rare; with 1 to 2 cases per million. It is unclear if ACC in pregnancy represents a specific association though 150 cases have been reported. We report a case of ACC detected during fetal sex determination using cell free DNA (cfDNA). Case Report: A 30 year old G1P0 woman presented at GA of 25 weeks with results of non-invasive prenatal screening (NIPS) done for fetal sex determination, which noted atypical findings concerning for possible maternal neoplasm. Pregnancy had been uncomplicated; she had no significant past medical history or features of hypercortisolism. Family history was positive for lung and prostate cancer. Physical examination revealed healthy looking female with no Cushingoid facies, abdomen matched stated GA. Full body MRI revealed 5.5 cm right adrenal mass with lymph nodes metastases. CT-guided retroperitoneal lymph node biopsy showed ACC.She was asymptomatic with significantly elevated urine free cortisol 3648 (3.5-45 mcg/24 hour), serum cortisol 67.5 (5-25 ug/dl), 11-deoxycortisol 3910 (10-79 ng/dl), and suppressed ACTH <5 (5-52 pg/ml). Electrolytes were normal, DHEAS 342 (35-430 ug/dl), aldosterone < 3 (4-31 ng/dl), renin mass 5 (4-44pg/ml), urinary free normetanephrine 0.23 (< 0.9 nmol/l), urinary free metanephrine < 0.2 (< 0.5 nmol/l). MRI of the chest and brain did not show metastases. She developed at GA 29 weeks, hypertension, proteinuria, and transaminitis. Cesarean section was done at GA 30 weeks followed the next day by right adrenalectomy, IVC repair and retroperitoneal lymph node resection. Pathology showed high-grade adrenal cortical carcinoma (12 cm size) with negative margins, vascular invasion and lymph node involvement (T3, N1, M0), no caval involvement, stage III ACC. During chemotherapy planning, metastases were noted, mitotane and pembrolizumab were initiated, but discontinued after 2 cycles on account of generalized rash and elevated liver enzymes. The tumor progressed on etoposide, doxorubicin and cisplatin (EDP), and second line therapy (gemcitabine and capecitabine) was initiated. Conclusion: Physiologic changes of pregnancy mimic clinical features of ACC and pregnancy associated changes in the HPA axis also make ACC diagnosis challenging. Short fragments of DNA (cfDNA) released into the maternal bloodstream can be detected after 7 weeks of gestation. Approximately 2-20% of total cfDNA is placental, it is used for sex determination and detection of congenital genetic abnormalities, cfDNA can also originate from maternal neoplasms and has been shown to detect lung, breast and colon while case series in patients with ACC showed detection of only 1 out of 3 cases. Surgery remains first line therapy for ACC, but adjuvant therapy, surveillance and hormone replacement are also vital in ACC management. Presentation: Saturday, June 17, 2023

Maternal Malignancy After Atypical Findings on Single-Nucleotide Polymorphism-Based Prenatal Cell-Free DNA Screening

ABSTRACT Technological advances in prenatal testing are allowing for earlier screening to detect fetal aneuploidies, infection, or abnormalities. Noninvasive tests in particular have enabled clinicians to screen early in pregnancy for conditions that severely affect fetal and neonatal outcomes (trisomies 21, 18, and 13, among others). Some of these methods rely on cell-free DNA (cfDNA) circulating in the maternal blood stream; although cfDNA can be released by the placenta, malignancy can be another cause for the release of cfDNA. The detection of such malignancies on noninvasive prenatal tests is rare but occurs. This study was designed to assess the incidence of cfDNA results indicating maternal malignancy and compare these findings to the existing literature. This was a retrospective cohort study, including data obtained from a commercial laboratory that performed single-nucleotide polymorphism (SNP)–based noninvasive prenatal screening between January 2015 and October 2021. Screenings were considered suggestive of malignancy if retrospective bioinformatics and SNP plots suggested multiple maternal copy number variants for at least 2 chromosomes; the laboratory returned these tests as fetal uninterpretable results. Of 2,004,428 samples included in the analysis, 38 (0.002%, or 1 in 52,748) were considered suggestive of malignancy. For 30 patients where follow-up was completed, health outcomes were analyzed for mother and child with maternal malignancy observed in 20 of them (66.7%). Six individuals had a preexisting diagnosis of cancer, 2 of which had a personal history of cancer but were thought to be in remission. Malignancies included lymphoma (10 patients), breast cancer (5 patients), and colon cancer (3 patients). Fetal outcomes for 15 of these patients were normal, with a few abnormal outcomes in the others; negative outcomes included fetal abnormality, multiple soft markers on prenatal ultrasound, and fetal growth restriction. Of the 10 patients without reported malignancy, 2 had identified fetal triploidy, 1 had maternal glomerulonephritis, and 1 had uterine leiomyomas. Of the original 30 patients with results suggestive of malignancy, 6 had no issues reported on follow-up. The findings reported in this study are similar to previous findings of maternal malignancy detected by noninvasive prenatal screenings. The prevalence of maternal malignancy identified in this study was lower than in previous studies, which estimated the prevalence to range from 1/2000 to 1/21,000. The percentage of patients with a confirmed malignancy after suspicious results in this study was 67% and has ranged from 8% to 73% in other studies. Some patients who had an identified malignancy were diagnosed as long as 11 months after the noninvasive prenatal screening; this indicates that longitudinal follow-up may result in higher rates of identified malignancy among those who have screening results suggestive of malignancy. Clinically, these findings highlight the need for information given to expectant mothers about incidental findings pertaining to noninvasive prenatal screenings, as well as the importance of reporting suspicious results of these screenings. Further research should focus on determining rates of underreporting for maternal malignancy, as well as obtaining more complete follow-up data and potentially developing a standardized procedure or diagnostic workup to determine the true incidence.

Placental drug transport and fetal exposure during pregnancy is determined by drug molecular size, chemistry, and conformation

Pregnant people are unable to take many prescription and over-the-counter medications because of suspected or known risk to the fetus. This undermedication contributes to the high maternal mortality rate in the United States and detracts from the quality of life of pregnant people. As such, there is an urgent need to develop safe pharmaceutical formulations for use during pregnancy. Most drugs are small molecules that easily cross the placenta, which is the biological barrier that separates the maternal and fetal bloodstreams. One potential approach to preventing fetal drug accumulation is to design drug compounds that are excluded by the placenta; however, there is little understanding of how macromolecular drug properties affect transplacental transport. To address this knowledge gap, we examined the transport behavior of fluorescently-labeled polymers with varying size, conformation, and chemistry. We compared these polymers to unconjugated fluorescein, a small molecule model drug that readily crosses biological barriers. We found that molecular size affected transplacental transport in an in vitro model, BeWo b30 monolayers, as well as in pregnant mice, with larger polymers having lower permeability. In addition to size, polymer chemistry altered behavior, with polyethylene glycol (PEG) molecules permeating the placental barrier to a greater extent than dextrans of equivalent molecular weight. PEG molecules were also more readily taken up into placental cells in vivo. These findings will inform the future development of drug conjugates or other macromolecular medicines that can safely be used during pregnancy.

Early differentiation and gene expression characteristics of trophoblast lineages.

With the development of the embryo, the totipotent blastomere undergoes the first lineage decision to the inner cell mass (ICM) and the trophectoderm (TE). The ICM forms the fetus while the TE forms the placenta, which is one of the most unique organs in mammals serving as the interface between maternal and fetal. Proper trophoblast lineage differentiation is crucial for correct placental and fetal development, including the TE progenitor self-renewal and its differentiation toward mononuclear cytotrophoblast (CTB), which later either develops into invasive extravillous trophoblast (EVT), remodeling the uterine vascular, or fuses into multinuclear syncytiotrophoblast (STB), secreting pregnancy-sustaining hormone. Aberrant differentiation and gene expression of trophoblast lineage is associated with severe pregnancy disorders and fetal growth restriction. This review focuses on the early differentiation and key regulatory factors of trophoblast lineage, which have been poorly elucidated. Meanwhile, the recent development of trophoblast stem cells (TSC), trophectoderm stem cells (TESC), and blastoids derived from pluripotent stem cells bring the accessible model to investigate the profound mystery of embryo implantation and placentation were also summarized.

Hubungan Usia Kehamilan, Riwayat Abortus Dan Paritas Terhadap Kejadian Preeklampsia Berat Di RSUD Abdoel Wahab Sjahranie Tahun 2022

Introduction : In 2021, Abdoel Wahab Sjahranie Hospital recorded a total of 55 pregnant mothers suffering from severe preeclampsia. Preeclampsia can be treated by controlling the risk factors it carries. This study examines the relationship between gestational age, prior miscarriage record, and parity which incited severe preeclampsia cases in Abdul Wahab Sjahranie Hospital.
 Method : This research is an observational analytical study with case control design. A total sample of 110 respondents was taken from medical record data in 2021. The PEB group sample was taken using total sampling and the control group was taken by quota sampling. The bivariate analysis was conducted with chi-square test.
 Results : From the test conducted, gestational age has Pvalue of 0.008 and odd ratio of 0.244 . In addition, prior miscarriage has Pvalue of 0.041 and odd ratio of 2.628. Lastly, parity has Pvalue of 0.038.
 Discussion : Growing and aging placenta with gestational age more than 34 weeks will limit intervillous perfusion which causes secondary syncytiotrophoblast stress and the release of placental factors into the maternal bloodstream, maternal alloimmune response to fetal trophoblasts resulting in miscarriage, and primiparous parity due to first-time exposure to chorionic villi, whereas the case in grandemultipara is associated with a decrease in the function of reproductive system and nutritional fulfillment which lead to preeclampsia.
 Conclusions : Early detection of preeclampsia requires a more complete diagnostic procedure and it is associated with maternal and neonatal morbidity.
 Keywords: Gestational Age, Prior Miscarriage, Parity, Preeclampsia

Estetrol: a new estrogen component in combined oral contraceptives: A review

Estetrol (E4) is a steroid hormone found in the urine of pregnant women in 1965. E4 is produced only during pregnancy and enters the maternal bloodstream through the placenta. Its concentration in maternal human plasma increases during pregnancy, reaching a maximum by the end of pregnancy (1 ng/mL). The pharmacological properties of E4 make it a promising agent for hormonal therapy and contraception. To date, phase II and III studies have shown promising results with the combination of 15 mg of E4 and 3 mg of drospirenone: this combined oral contraceptive has shown a good effect with a neutral metabolic effect. However, evidence is scarce about the effect of the new combination on the breast and bone tissue. Further studies are needed to consolidate the available data and to investigate possible side effects of prolonged use of E4-containing combined oral contraceptives compared to known ethinylestradiol and estradiol-containing combinations.

Non-invasive prenatal diagnosis (NIPD): how analysis of cell-free DNA in maternal plasma has changed prenatal diagnosis for monogenic disorders.

Cell-free fetal DNA (cffDNA) is released into the maternal circulation from trophoblastic cells during pregnancy, is detectable from 4 weeks and is representative of the entire fetal genome. The presence of this cffDNA in the maternal bloodstream has enabled clinical implementation of non-invasive prenatal diagnosis (NIPD) for monogenic disorders. Detection of paternally inherited and de novo mutations is relatively straightforward, and several methods have been developed for clinical use, including quantitative polymerase chain reaction (qPCR), and PCR followed by restriction enzyme digest (PCR-RED) or next-generation sequencing (NGS). A greater challenge has been in the detection of maternally inherited variants owing to the high background of maternal cell-free DNA (cfDNA). Molecular counting techniques have been developed to measure subtle changes in allele frequency. For instance, relative haplotype dosage analysis (RHDO), which uses single nucleotide polymorphisms (SNPs) for phasing of high- and low-risk alleles, is clinically available for several monogenic disorders. A major drawback is that RHDO requires samples from both parents and an affected or unaffected proband, therefore alternative methods, such as proband-free RHDO and relative mutation dosage (RMD), are being investigated. cffDNA was thought to exist only as short fragments (<500 bp); however, long-read sequencing technologies have recently revealed a range of sizes up to ∼23 kb. cffDNA also carries a specific placental epigenetic mark, and so fragmentomics and epigenetics are of interest for targeted enrichment of cffDNA. Cell-based NIPD approaches are also currently under investigation as a means to obtain a pure source of intact fetal genomic DNA.

Haplotype-Assisted Noninvasive Prenatal Diagnosis of Genetic Diseases by Massively Parallel Sequencing of Maternal Plasma Cell-Free DNA.

Early prenatal diagnosis of genetic diseases allows for timely intervention or prevention of thediseases in newborns. Conventional prenatal diagnosis of most genetic diseases relies on testing fetal DNA obtained by invasive procedures such as amniocentesis or chorionic villus sampling, which are associated with small risks of fetal loss. Maternal circulating blood contains cell-free DNA (cfDNA) from the fetal genome and can thus be used to noninvasively detect fetal genetic diseases such as chromosomal abnormalities, copy number variants, and single gene diseases. However, due to the presence of a high level of maternal cfDNA in the maternal blood stream, a relative haplotype dosage (RHDO) analysis is required to detect the mutant loci in the fetal genome when performing noninvasive prenatal diagnosis (NIPD) by massively parallel sequencing (MPS) of cfDNA. In this chapter, we describe a protocol utilizing the RHDO strategy for NIPD of any gene of interest associating with single gene diseases.

Ketamine as potential treatment for postpartum depression: A narrative review.

Postpartum depression (PPD) is a severe, debilitating mood disorder with consequences for both mothers and children, highlighting the need for rapid-acting and effective treatments for PPD. The aim of this narrative review is to synthesize the available literature on the administration of ketamine for PPD and propose ketamine as a viable and advantageous treatment. A search was conducted on MEDLINE/PubMed, PsycInfo, and Embase databases from inception to October 10, 2021 for preclinical studies, interventional studies (ie, open-label and randomized controlled trials), as well as systematic reviews and meta-analyses evaluating the use of ketamine in postpartum populations. Completed and ongoing clinical trials were identified on ClinicalTrials.gov. Four clinical trials were identified. Results from this review support additional investigation into ketamine as a potential treatment for PPD. Ketamine may be a favorable option for treating PPD due to its antidepressive and analgesic effects, short infusion time, and rapid clearance from the maternal bloodstream. However, there is insufficient evidence to support its use in this population, underscoring the importance of additional clinical research investigating ketamine for PPD.

Fetal-maternal incompatibility in the Rh system. Rh isoimmunization associated with hereditary spherocytosis: case presentation and review of the literature.

Next to A and B antigens, agglutinogen D exhibits the highest immunogenicity. Following the transfusion of D-positive red blood cells (RBCs), almost 80% of D-negative recipients develop anti-D antibodies (Abs). Subsequently, anti-D immunization further promotes the synthesis of Abs towards other blood group antigens in or outside the Rh system. The D antigen is also involved in 95% of cases of hemolytic disease of the newborn. Transfusions, hemotherapy, grafts, and obstetric history (abortions, ectopic pregnancy, births) are all risk factors for Rh isoimmunization. In the case of ABO compatibility between mother and fetus, Rh-positive fetal RBCs that have reached the maternal bloodstream are not destroyed by group agglutinins, and Rh antigenic sites are not hidden by the maternal immune system. But a Rh-negative mother with a homozygous Rh-positive husband will certainly have a Rh-positive fetus. As it has an irreversible evolution, the Rh isoimmunization once installed cannot be influenced in the sense of decreasing the Ab titer, therefore, injectable globulin has no effect. A particular case was that of a newborn with Rh system incompatibility associated with hereditary spherocytosis The clinical balance at birth reflects the severe jaundice of the female newborn of 3140 g, gestational age 38∕39 weeks, extracted by lower-segment transverse Caesarean section, with a double loop nuchal cord, Apgar score 8. Because the jaundice was severe and atypical (face and upper chest), we considered the possibility of coexistence of hemolytic disease of the newborn by Rh blood group incompatibility associated with hereditary spherocytosis, as it turned out to be true and mentioned. Changes in genes encoding proteins in the structure of the RBC membrane have amplified hemolysis induced by maternal-fetal isoimmunization in the Rh system. Massive hemolysis accentuated by congenital spherocytosis, confirmed later, imposed blood transfusion and dynamic monitoring.

Nanotechnologies in Obstetrics and Cancer during Pregnancy: A Narrative Review.

Nanotechnology, the art of engineering structures on a molecular level, offers the opportunity to implement new strategies for the diagnosis and management of pregnancy-related disorders. This review aims to summarize the current state of nanotechnology in obstetrics and cancer in pregnancy, focusing on existing and potential applications, and provides insights on safety and future directions. A systematic and comprehensive literature assessment was performed, querying the following databases: PubMed/Medline, Scopus, and Endbase. The databases were searched from their inception to 22 March 2022. Five independent reviewers screened the items and extracted those which were more pertinent within the scope of this review. Although nanotechnology has been on the bench for many years, most of the studies in obstetrics are preclinical. Ongoing research spans from the development of diagnostic tools, including optimized strategies to selectively confine contrast agents in the maternal bloodstream and approaches to improve diagnostics tests to be used in obstetrics, to the synthesis of innovative delivery nanosystems for therapeutic interventions. Using nanotechnology to achieve spatial and temporal control over the delivery of therapeutic agents (e.g., commonly used drugs, more recently defined formulations, or gene therapy-based approaches) offers significant advantages, including the possibility to target specific cells/tissues of interest (e.g., the maternal bloodstream, uterus wall, or fetal compartment). This characteristic of nanotechnology-driven therapy reduces side effects and the amount of therapeutic agent used. However, nanotoxicology appears to be a significant obstacle to adopting these technologies in clinical therapeutic praxis. Further research is needed in order to improve these techniques, as they have tremendous potential to improve the accuracy of the tests applied in clinical praxis. This review showed the increasing interest in nanotechnology applications in obstetrics disorders and pregnancy-related pathologies to improve the diagnostic algorithms, monitor pregnancy-related diseases, and implement new treatment strategies.

Stillbirth after COVID-19 in Unvaccinated Mothers Can Result from SARS-CoV-2 Placentitis, Placental Insufficiency, and Hypoxic Ischemic Fetal Demise, Not Direct Fetal Infection: Potential Role of Maternal Vaccination in Pregnancy.

Stillbirth is a recently recognized complication of COVID-19 in pregnant women. Other congenitally transmitted infections from viruses, bacteria and parasites can cause stillbirth by infecting fetal organs following transplacental transmission of the agent from the maternal bloodstream. However, recent research on pregnant women with COVID-19 having stillbirths indicates that there is another mechanism of stillbirth that can occur in placentas infected with SARS-CoV-2. In these cases, viral infection of the placenta results in SARS-CoV-2 placentitis, a combination of concurrent destructive findings that include increased fibrin deposition which typically reaches the level of massive perivillous fibrin deposition, chronic histiocytic intervillositis and trophoblast necrosis. These three pathological lesions, in some cases together with placental hemorrhage, thrombohematomas and villitis, result in severe and diffuse placental parenchymal destruction. This pathology can involve greater than one-half of the placental volume, averaging 77% in the largest study of 68 cases, effectively rendering the placenta incapable of performing its function of oxygenating the fetus. This destructive placental process can lead to stillbirth and neonatal death via malperfusion and placental insufficiency which is independent of fetal infection. Fetal autopsies show no evidence that direct infection of fetal organs is contributory. Because all mothers examined have been unvaccinated, maternal vaccination may prevent viremia and consequent placental infection.