Neonatal Uterine Research Articles

Neonatal uterine bleeding: Risk factors and its association with endometriosis-related symptoms later in life

ObjectiveWe examined the prevalence and risk factors in association with neonatal uterine bleeding (NUB) by retrospective search of contemporary and historical medical records and investigated the possible association between the history of NUB at birth and endometriosis-related symptoms later in life who are now young women. Study designThis was a retrospective case-controlled cohort study and prospective evaluation of web-based questionnaire survey on symptoms related to endometriosis among young women born with and without NUB. Multiple regression analysis was performed incorporating various confounding variables that may influence the occurrence of NUB or the reporting of endometriosis symptoms later in life. ResultsAmong the 1093 female neonates born between 1996 and 2000, 105 of them had NUB, yielding with a prevalence of 9.6 %. Of the 807 female babies born between 2013 and 2017, 25 (3.1 %) had NUB. Multiple Logistic regression analysis indicated that younger age of the mother [odds ratio (OR) = 0.92, 95 % confidence interval (CI) = 0.85–1.00, P = 0.048] and longer gestational age of 39 weeks (OR = 3.04, 95 % CI = 1.43–6.45, P = 0.004) and of ≥ 40 weeks (OR = 4.54, 95 % CI = 2.20–9.39, P < 0.0001) of gestation were significantly associated with the occurrence of NUB. While the possibility of recall bias cannot be ruled out, newborn females who had a history of NUB appeared to complain of various endometriosis-related symptoms later in life during adulthood. ConclusionsWe confirmed the validity of the reported prevalence and risk factors of NUB. NUB indeed occurs with a prevalence of 3–10% during the historical and contemporary period. Longer gestational age and younger maternal age may be considered as high-risk factors for the occurrence of NUB. The clinical relevance of our findings remains to be elucidated. Future prospective studies, preferably with larger sample sizes and the inclusion of NUB cases after discharge from the hospital, may further illuminate some unresolved issues. We also need to confirm the endometriosis-related symptoms in women with and without history of NUB via more definitive diagnosis such as imaging and histology.

The development of the human uterus: morphogenesis to menarche.

There is emerging evidence that early uterine development in humans is an important determinant of conditions such as ontogenetic progesterone resistance, menstrual preconditioning, defective deep placentation and pre-eclampsia in young adolescents. A key observation is the relative infrequency of neonatal uterine bleeding and hormone withdrawal at birth. The origin of the uterus from the fusion of the two paramesonephric, or Müllerian, ducts was described almost 200 years ago. The uterus forms around the 10th week of foetal life. The uterine corpus and the cervix react differently to the circulating steroid hormones during pregnancy. Adult uterine proportions are not attained until after puberty. It is unclear if the endometrial microbiome and immune response-which are areas of growing interest in the adult-play a role in the early stages of uterine development. The aim is to review the phases of uterine development up until the onset of puberty in order to trace the origin of abnormal development and to assess current knowledge for features that may be linked to conditions encountered later in life. The narrative review incorporates literature searches of Medline, PubMed and Scopus using the broad terms individually and then in combination: uterus, development, anatomy, microscopy, embryology, foetus, (pre)-puberty, menarche, microbiome and immune cells. Identified articles were assessed manually for relevance, any linked articles and historical textbooks. We included some animal studies of molecular mechanisms. There are competing theories about the contributions of the Müllerian and Wolffian ducts to the developing uterus. Endometrium features are suggestive of an oestrogen effect at 16-20 weeks gestation. The discrepancy in the reported expression of oestrogen receptor is likely to be related to the higher sensitivity of more recent techniques. Primitive endometrial glands appear around 20 weeks. Features of progestogen action are expressed late in the third trimester. Interestingly, progesterone receptor expression is higher at mid-gestation than at birth when features of endometrial maturation are rare. Neonatal uterine bleeding occurs in around 5% of neonates. Myometrial differentiation progresses from the mesenchyme surrounding the endometrium at the level of the cervix. During infancy, the uterus and endometrium remain inactive. The beginning of uterine growth precedes the onset of puberty and continues for several years after menarche. Uterine anomalies may result from fusion defects or atresia of one or both Müllerian ducts. Organogenetic differentiation of Müllerian epithelium to form the endometrial and endocervical epithelium may be independent of circulating steroids. A number of genes have been identified that are involved in endometrial and myometrial differentiation although gene mutations have not been demonstrated to be common in cases of uterine malformation. The role, if any, of the microbiome in relation to uterine development remains speculative. Modern molecular techniques applied to rodent models have enhanced our understanding of uterine molecular mechanisms and their interactions. However, little is known about functional correlates or features with relevance to adult onset of uterine disease in humans. Prepubertal growth and development lends itself to non-invasive diagnostics such as ultrasound and MRI. Increased awareness of the occurrence of neonatal uterine bleeding and of the potential impact on adult onset disease may stimulate renewed research in this area.

Defining age- and lactocrine-sensitive elements of the neonatal porcine uterine microRNA-mRNA interactome.

Factors delivered to offspring in colostrum within 2 days of birth support neonatal porcine uterine development. The uterine mRNA transcriptome is affected by age and nursing during this period. Whether uterine microRNA (miRNA) expression is affected similarly is unknown. Objectives were to (1) determine effects of age and nursing on porcine uterine miRNA expression between birth and postnatal day (PND) 2 using miRNA sequencing (miRNAseq) and; (2) define affected miRNA–mRNA interactions and associated biological processes using integrated target prediction analysis. At birth (PND 0), gilts were euthanized, nursed ad libitum, or gavage-fed milk replacer for 48 h. Uteri were collected at birth or 50 h postnatal. MicroRNAseq data were validated using quantitative real-time PCR. Targets were predicted using an established mRNA database generated from the same tissues. For PND 2 versus PND 0 comparisons, 31 differentially expressed (DE) miRNAs were identified for nursed, and 42 DE miRNAs were identified for replacer-fed gilts. Six DE miRNAs were identified for nursed versus replacer-fed gilts on PND 2. Target prediction for inversely correlated DE miRNA–mRNA pairings indicated 20 miRNAs targeting 251 mRNAs in nursed, versus 29 miRNAs targeting 585 mRNAs in replacer-fed gilts for PND 2 versus PND 0 comparisons, and 5 miRNAs targeting 81 mRNAs for nursed versus replacer-fed gilts on PND 2. Biological processes predicted to be affected by age and nursing included cell-to-cell signaling, cell morphology, and tissue morphology. Results indicate novel age- and lactocrine-sensitive miRNA–mRNA relationships associated with porcine neonatal uterine development between birth and PND 2.

Neonatal uterine bleeding as antecedent of pelvic endometriosis

We elaborate on a new theory to explain pelvic endometriosis, including endometriosis in premenarcheal girls, based on the finding that the neonatal endometrium can display secretory activity immediately after birth and, in some cases, changes analogous to those seen at menstruation in adults. The neonatal uterus is therefore capable of shedding its endometrium. Indeed, occult vaginal bleeding occurs in a majority of neonates, although overt bleeding is estimated to occur in only 5% of neonates. This may be due to functional plugging of the endocervical canal in the neonate, which in turn would promote retrograde flux of endometrial cells contained in menstrual debris. Ectopic endometrial implantation in a newborn with hydrometrocolpos has been documented. These data, coupled with the observation of a significantly increased risk of endometriosis in adolescents with cervical outflow obstruction and patent Fallopian tubes, indicate that endometriosis, especially in children and young adolescents, may originate from retrograde uterine bleeding soon after birth.

134. DIFFERENTIATION OF HUMAN EMBRYONIC STEM CELLS TO MULLERIAN TISSUE

The human uterus develops from the distal Mullerian Duct, a derivative of the mesoderm germ layer. Unlike other mammalian species (eg. mouse) the endometrium of the human uterus develops prenatally during gestation. Little is known about the developmental process involved. A better understanding of human endometrial development may shed light on the mechanisms involved in endometrial regeneration and pathogenesis of adult proliferative endometrial diseases. Mouse neonatal uterine mesenchyme (mNUM) is inductive and can maintain the phenotype of normal adult human endometrial epithelial cells [1]. Both adult human endometrial stroma and neonatal mouse endometrial mesenchyme secrete growth factors of the TGF-beta family including BMPs which have been shown to play an important role in differentiation of human embryonic stem cells (HESC) [2, 3]. Hypothesis: mNUM will direct differentiation of HESC to form Mullerian Duct-like epithelium. Aim: to investigate the role of mNUM in differentiating HESC in vitro and in vivo using A tissue recombination technique. Method: Embryoid bodies (EB) were formed from GFP labelled HESC (ENVY) and GFP-MIXL1 HESC reporter line [4, 5] and recombined with 2 × 0.5 mm pieces of day 1 epithelial cell-free mNUM. Recombinant tissues were either harvested for gene expression analysis or grafted under the kidney capsule of NOD/SCID mice. Results: We found by qRT-PCR that mNUM induces HESC to form mesendoderm/mesoderm progenitors in vitro, obligate intermediates of the developing Mullerian Duct. After further incubation in vivo under the guidance of mNUM, HESC differentiated to form duct-like structures comprising mesoepithelial cells that co-expressed several key developmental proteins of the Mullerian Duct including Emx2, Pax2, Hoxa10, CA125, and also intermediate filament markers such as CK8/18, Vimentin (n = 8). Conclusion: Our study demonstrated for the first time that mNUM can direct HESC to form a mesodermally derived epithelium that is Mullerian Duct-like, providing a novel model for studying human uterine development. (1) Kurita T, et al., The activation function-1 domain of estrogen receptor alpha in uterine stromal cells is required for mouse but not human uterine epithelial response to estrogen. Differentiation, 2005. 73(6): 313–22.(2) Hu J, Gray CA, Spencer TE, Gene expression profiling of neonatal mouse uterine development. Biol Reprod, 2004. 70(6): 1870–6.(3) Stoikos CJ, et al., A distinct cohort of the TGFbeta superfamily members expressed in human endometrium regulate decidualization. Hum Reprod, 2008. 23(6): 1447–56.(4) Davis R, et al., Targeting a GFP reporter gene to the MIXL1 locus of human embryonic stem cells identifies human primitive streak-like cells and enables isolation of primitive hematopoietic precursors. Blood, 2008. 111(4): 1876–84.(5) Costa M, et al., The hESC line Envy expresses high levels of GFP in all differentiated progeny. Nat Methods, 2005. 2(4): 259–60.

Transient estrogen exposure from birth affects uterine expression of developmental markers in neonatal gilts with lasting consequences in pregnant adults

Disruption of estrogen-sensitive, estrogen receptor (ER)-dependent events during porcine uterine development between birth (postnatal day=PND 0) and PND 14 affects patterns of uterine morphoregulatory gene expression in the neonate with lasting consequences for reproductive success. Uterine capacity for conceptus support is reduced in pregnant adult gilts exposed to estradiol valerate (EV) for 14 days from birth. Objectives here were to determine effects of EV exposure from birth through PND 13 on neonatal uterine and adult endometrial markers of growth, patterning, and remodeling. Targets included the relaxin receptor (RXFP1), estrogen receptor-alpha (ESR1) and vascular endothelial growth factor (VEGFA), morphoregulatory markers HOXA10 and WNT7A, and the matrix metalloproteinases (MMP)2 and MMP9. Gilts were treated daily with EV (50 microg/kg body weight per day, i.m.) or corn oil vehicle from birth through PND 13. Uteri were obtained from neonates on PND 14 and from adults on pregnancy day 12 (PxD 12). In neonates, EV exposure from birth increased uterine RXFP1 gene expression, and both ESR1 and VEGFA proteins. At PxD 12, endometrial RXFP1 mRNA remained elevated, while ESR1 protein was reduced. Early EV treatment decreased neonatal uterine WNT7A, but increased HOXA10 expression. WNT7A expression was reduced in EV-treated adults. Transient EV exposure increased MMP9 transcripts at PND 14, whereas both latent and active MMP9 activity was increased due to early EV treatment in adults on PxD 12. Results support the hypothesis that transient, estrogen-induced disruption of porcine uterine development from birth alters early programming events that lead to functional consequences in the adult.

Perinatal Zearalenone Exposure Affects RXFP1, RXFP2, and Morphoregulatory Gene Expression in the Neonatal Porcine Uterus

The mycotoxin zearalenone (ZEA) is a selective estrogen receptor modulator that can contaminate cereal feeds and lead to reproductive disorders. To determine effects of perinatal ZEA exposure on uterine expression of genes associated with endometrial development in the neonatal gilt, pregnant sows were fed ZEA (1500 microg ZEA/kg of feed/day) or vehicle from 14 days before farrowing through postnatal day (PND) 20-21, when neonatal uterine tissues were collected. At birth, gilts were cross-fostered to generate four ZEA exposure groups (n= 5-6/group): unexposed controls or exposures limited to prenatal, postnatal, or pre- and postnatal (continuous) periods. Results showed that at PND 20-21, uterine Wnt7a, Hoxa10, estrogen receptor alpha, and RXFP2 mRNA levels were decreased in neonates exposed continuously to ZEA (P < 0.05). Uterine RXFP1 transcripts were decreased in postnatally and continuously exposed groups (P < 0.05). Neonatal uterine Wnt4 mRNA levels were unchanged.

Keratinocyte growth factor injected into female mouse neonates stimulates uterine and vaginal epithelial growth.

Estradiol (E2) stimulates epithelial growth in the female genital tract via estrogen receptors (ER) in the stroma using paracrine mechanisms. Keratinocyte growth factor (KGF), a member of the fibroblast growth factor family, is produced by mesenchymal cells and is mitogenic for epithelial cells making it a strong candidate as a paracrine mediator. Transcripts for KGF and the KGF receptor were detected in the neonatal mouse uterus and vagina. Treatment of neonatal mice with KGF elicited changes in uterine and vaginal epithelium within five days and induced long term effects in these tissues. Newborn female Balb/c mice were injected daily with 5 microg/g body weight of KGF or saline for five days. KGF-treated mice exhibited a 5- to 6-fold increase in uterine epithelial BrdU-labeling index and a 4- and 5-fold increase in vaginal epithelial BrdU-labeling index vs. respective saline-treated controls. Histological sections of KGF-treated uteri revealed dramatic increases in epithelial surface area due to extensive folding of the luminal epithelium. In some areas, the evaginated luminal epithelium invaded zones normally occupied by myometrium. Vaginal epithelium was thicker than that of saline-treated controls following 5 days of KGF treatment. When KGF-treated newborn mice grew to adulthood and were ovariectomized, vaginal smears exhibited persistent diestrus in all animals. Histologic analysis demonstrated a thick parakeratotic vaginal epithelium (approximately 10 cell layers) 9 days postovariectomy in adult neonatally KGF-treated mice. Our studies indicate that KGF injected into neonates markedly stimulated proliferation of neonatal uterine and vaginal epithelium and elicited long-term, persistent abnormal changes in vaginal epithelium.

Effects of toremifene on neonatal rat uterine growth and differentiation.

In the developing rodent uterus, the estrogen agonist activity of triphenylethylene antiestrogens such as tamoxifen alters uterine luminal epithelium morphology and inhibits uterine gland genesis. We examined uterine growth and differentiation in female offspring from date-mated Sprague-Dawley rats given the structurally related antiestrogen, toremifene, by s.c. injection in 10 microl of sesame oil on postnatal days (PND) 1-5, 10-14, or 20-24. Toremifene given on PND 10-14, a period of rapid uterine gland differentiation, caused a dose-related increase in uterine weight, tripled luminal epithelium cell height, and completely inhibited uterine gland development on PND 14 at doses of 10 microg or higher. Based on this dose-response analysis, a 10-microg dose of toremifene was chosen to assess uterine development after neonatal exposure (PND 1-5). Uterine weights and luminal epithelium cell heights were significantly increased by toremifene on PND 5 but returned to control levels by PND 26. Uterine gland numbers were reduced to 50% those of controls on PND 26. Dose-related uterine weight and luminal epithelium cell height increases were also observed in rats given toremifene on PND 20-24. This estrogen agonist activity of toremifene, revealed primarily in the uterine luminal epithelium, indicates that toremifene is developmentally toxic.

Growth of separated and recombined neonatal rat uterine luminal epithelium and stroma on extracellular matrix: Effects of in vivo tamoxifen exposure

We have developed a system for serum-free culture of separated uterine epithelium and stroma from 11-day-old rats recombined on extracellular matrix extracted from Englebreth-Holm-Swarm tumors. Epithelium grew and, after 2 days in culture, developed into luminal epithelial spheres (LES) surrounding a fluid-filled lumen. Individual LES cells maintained epithelial cell characteristics such as basally located nuclei, apical microvilli (oriented toward the lumen), lateral membranes with interdigitations and desmosomes, secretory Golgi complexes, and abundant mitochondria and rough endoplasmic reticulum. Secretory vesicles were ubiquitous throughout the luminal fluid. Addition of 17 beta-estradiol to the growth medium increased the number and longevity of the LES. Prior exposure of uteri to tamoxifen via s.c. injection in vivo on postnatal Days 1 to 5 reduced or completely inhibited formation of LES in vitro. These effects occurred regardless of whether the stromal or epithelial component of the recombinant tissue was exposed to tamoxifen. These data suggest a directive property of neonatal stroma in culture resulting in the formation of highly secretory spherical epithelial structures completely enclosing a lumen. LES formation is responsive to both estrogen (positive response) and antiestrogen (negative response).

Genotoxic effects of estrogens in epithelial cells from the neonatal mouse uterine cervix: Modifications by metabolic modifiers

Epithelium from the neonatal mouse uterine cervix and uppermost part of vagina was cultured in vitro. The culture medium was supplemented with 17 beta-estradiol (E2; 10(-6)-10(-5) M) or diethylstilbestrol (DES; 10(-8)-10(-5) M) alone or in combination with different metabolic modifiers (alpha-naphthoflavone, beta-naphthoflavone, phenobarbital, metyrapone, indomethacin) with postulated activating or inhibitory effects on DES metabolizing enzymes (cytochrome P-448- and P-450-dependent microsomal monooxidases, prostaglandin cyclooxygenase). E2 at 10(-5) M and DES at 10(-6) and 10(-5) M concentrations increased the incidence of cells with a high number of sister chromatid exchanges (high-frequency chromatid exchange cells, HFCEC). Indomethacin partially depressed DES-induced HFCEC, whereas the incidence was increased by alpha-naphthoflavone, which may be a result of stimulation of the fetal type of P-448-dependent enzyme activity or of DES increasing the metabolic activation of alpha-naphthoflavone. Phenobarbital and beta-naphthoflavone did not affect the incidence of DES-induced HFCEC. Metyrapone alone induced the highest incidence of HFCEC observed in this study, and this effect was inactivated by phenobarbital and/or DES. The mechanisms behind these results are discussed. This study shows that E2 and DES have a genotoxic effect (sister chromatid exchanges) in vitro in epithelial cells from the same target organ as in which epithelial aberrations occur after in vivo estrogen treatment in the neonatal period. The difference in incidence of tetraploid cells between stroma and epithelium is stressed (less than 5% vs. 16-47% depending on experimental group).