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Progesterone Inhibits in Vitro Fetal Membrane
Progesterone Inhibits in Vitro Fetal Membrane
org
OBSTETRICS
Progesterone inhibits in vitro fetal membrane
weakening
Deepak Kumar, MD; Edward Springel, MD; Robert M. Moore, MS; Brian M. Mercer, MD;
Elliot Philipson, MD; Joseph M. Mansour, PhD; Sam Mesiano, PhD; Fredrick Schatz, PhD;
Charles J. Lockwood, MD; John J. Moore, MD
OBJECTIVE: Inflammation/infection and abruption are leading causes of membranes were then exposed to TNF, thrombin, or GM-CSF on the
preterm premature rupture of the membranes. Recently, we identified choriodecidua side for an additional 48 hours. The fetal membrane
granulocyte-macrophage colony-stimulating factor (GM-CSF) as a crit- tissues were then strength tested, and medium from the choriodecidua
ical mediator of both tumor necrosis factor-ae (TNF; modeling and amnion compartments was assayed for GM-CSF content.
inflammation) and thrombin-induced (modeling abruption) weakening of
the fetal membranes. We found that (1) TNF and thrombin both induced RESULTS: TNF and thrombin both weakened fetal membranes and
GM-CSF in the choriodecidua, (2) blockade of GM-CSF action with elevated media GM-CSF levels on the choriodecidua side of the
neutralizing antibodies inhibited both TNF- and thrombin-induced fetal fetal membrane. Pretreatment with progesterone, MPA, or HP in-
membrane weakening, and (3) GM-CSF alone induced fetal membrane hibited both TNF- and thrombin-induced fetal membrane weakening
weakening. GM-CSF is thus part of an overlap of the inflammation and and also inhibited the induced increase in GM-CSF. GM-CSF de-
abruption-induced fetal membrane weakening pathways. The effects of creased fetal membrane rupture strength by 68%, which was inhibited
progesterone analogs on the pathways by which fetal membranes are by progestogen pretreatment with a potency order: progesterone
weakened have not been investigated. We examined the effects of <MPA <HP.
progesterone, medroxyprogesterone acetate (MPA) and 17a-hydrox-
yprogesterone (HP) on TNF- and thrombin-induced fetal membrane CONCLUSION: Progestogen pretreatment blocks TNF- and thrombin-
weakening. induced fetal membrane weakening by inhibiting both the produc-
tion and action of GM-CSF. These findings are consistent with the
STUDY DESIGN: Full-thickness fetal membranes from uncomplicated administration of progestogens in the prevention of preterm premature
term repeat cesarean deliveries were mounted in Transwell inserts in rupture of the membranes.
Minimum Essential Medium alpha and incubated at 37 C in 5% CO2.
The choriodecidua side of the fetal membrane fragments were pre- Key words: fetal membrane, GM-CSF, medroxyprogesterone acetate,
incubated with progesterone, MPA, HP, or vehicle for 24 hours. Fetal PPROM, progesterone, thrombin, TNF, weakening
Cite this article as: Kumar D, Springel E, Moore RM, et al. Progesterone inhibits in vitro fetal membrane weakening. Am J Obstet Gynecol 2015;213:520.e1-9.
From the Departments of Pediatrics (Drs Kumar and J. J. Moore and Mr R. M. Moore), Reproductive Biology (Drs Springel, Mercer, Mesiano, and J. J.
Moore), and Mechanical and Aerospace Engineering (Dr Mansour), Case Western Reserve University, and Women’s Health Institute, Cleveland Clinic (Dr
Philipson), Cleveland, OH, and the Department of Obstetrics and Gynecology, University of South Florida College of Medicine, Tampa, FL (Drs Schatz and
Lockwood).
Received March 6, 2015; revised May 13, 2015; accepted June 2, 2015.
Supported by March of Dimes Prematurity Research Center Ohio Collaborative grant number 22-FY14-470 and March of Dimes grant number 22-FY15-
003. The funding source had no influence on research or the decision to publish.
The authors report no conflict of interest.
Presented at a podium session at the 62nd annual meeting of the Society for Reproductive Investigation, San Francisco, CA, March 26-28, 2015.
Corresponding author: John J. Moore, MD. jmoore@metrohealth.org, jjm6@case.edu
0002-9378/free ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2015.06.014
Statistical analysis
All experiments were performed at least
in triplicate. Data were analyzed by
analysis of variance followed by post-
hoc pair-wise comparisons (Holm-
Sidak method) with the use of Sigmaplot
software (Systat Software, Inc, Chi-
cago, IL). Differences were considered
significant when at a probability value
of < .05.
R ESULTS
Progestogens inhibit thrombin- and
TNF-induced fetal membrane
weakening
Thrombin or TNF, with or without pro-
gestogens, were each added only to the
choriodecidua side of the fetal membr-
ane to mimic the physiologic conditions
of pregnancy in which the choriodeci-
dua is exposed to the maternal circulation
and the amnion is in contact with the
amniotic fluid.4,19,20 Compared with
control membrane strength, thrombin or
TNF each markedly decreased fetal
membrane rupture strength in all studies
=
GM-CSF released on the choriodecidua side of
the fetal membranes (left) and the amnion side
of the fetal membranes (right) in the experiment
shown in Figure 1 is shown for A, progesterone,
B, MPA, and C, 17a-hydroxyprogesterone. The
data shown in each panel are for 1 representa-
tive experiment that was performed in triplicate
with each condition. Each experiment was
repeated 3 times using 3 different placentas
(data are presented as mean SD). Symbols
designate pairs of columns with significant dif-
ferences (A, the asterisk and number symbols
indicate P < .01, and the plus symbol indicates
P < .05; B, all of the symbols indicate P < .01;
C, the asterisk, number, and plus symbols
indicate P < .01, and the circumflex accent
symbol indicates P < .05).
C, control; GM-CSF, granulocyte-macrophage colony-stimulating
factor; HP, 17a-hydroxyprogesterone; MPA, medroxyprogester-
one acetate; P, progesterone; Thr, thrombin; TNF, tumor necrosis
factor a.
Kumar. Progesterone analogs inhibit fetal membrane weak-
ening. Am J Obstet Gynecol 2015.
(both P < .01). Preincubation with membrane induced significant (P < .01)
progesterone (10e7mmol) inhibited both fetal membrane weakening (Figure 3). FIGURE 3
thrombin- and TNF-induced fetal mem- This GM-CSFeinduced fetal membrane Progestogens inhibit GM-CSFe
brane weakening (both P < .05; weakening was almost completely in- induced fetal membrane
Figure 1, A). MPA (10e7mmol) pre- hibited by preincubation with either weakening
incubation also inhibited fetal membrane MPA (10e7 mmol) or HP (10e7 mmol;
weakening that was induced by thrombin both P < .01). Although preincubation
(P ¼.01) and by TNF (P ¼.02; Figure 1, B). with progesterone (10e7 mmol) also
Finally, HP (10e7mmol) preincubation blunted GM-CSFeinduced fetal mem-
inhibited fetal membrane weakening brane weakening, its effect was not sta-
that was induced by thrombin and tistically significant. Rupture strength
TNF (both P < .01; Figure 1, C). after incubation with progesterone, HP,
Preincubation with progesterone, MPA, or MPA alone was not different from
or HP alone did not affect rupture control membranes (Figure 3).
strength (Figure 1).
RU486 blocks HP inhibition
Effect of progestogens on of GM-CSFeinduced fetal
GM-CSF production membrane weakening
Because GM-CSF is a critical interme- In the experiment with RU486, consistent
diate in both the TNF- and thrombin- with the previously presented experi- Preincubation with progesterone, MPA, or 17a-
induced fetal membrane weakening ments, GM-CSF significantly decreased hydroxyprogesterone (all 10e7 mmol) for 24
pathways,20 further studies were done fetal membrane rupture strength, and hours inhibited fetal membrane weakening by
to determine whether progestogens preincubation with HP inhibited the GM-CSF (200 ng/mL) applied for 48 additional
inhibit TNF- or thrombin-induced fetal GM-CSFeinduced fetal membrane we- hours. In all studies, all agents were applied to
membrane weakening by blocking GM- akening. RU486 (10e8 mmol) that was only the choriodecidual side of the fetal mem-
CSF production. Consistent with our applied 1 hour before HP blocked HP branes. Strength testing was done at 72 hours for
previous report, TNF and thrombin inhibition of GM-CSFeinduced weak- all fetal membrane fragments. The data shown
each increased GM-CSF release on the ening (P < .01; Figure 4). are for 1 representative experiment that was
choriodecidua side concomitant with performed in triplicate with each condition. The
fetal membrane weakening (Figure 2; C OMMENT experiment was repeated 3 times with 3 different
P < .01).20 MPA markedly inhibited The results presented here demonstrate placentas (data are presented as mean SD).
GM-CSF production by both TNF and for the first time that the natural pro- Symbols designate pairs of columns with signifi-
thrombin to control levels (P < .01). HP gestogens (progesterone and HP) and cant differences (all symbols indicate P < .01).
C, control; G, GM-CSF; GM-CSF, granulocyte-macrophage
markedly inhibited the GM-CSF in- the synthetic progestogen (MPA) inhibit colony-stimulating factor; HP, 17a-hydroxyprogesterone; MPA,
crease that was produced by TNF both TNF- and thrombin-induced we- medroxyprogesterone acetate; P, progesterone.
(P < .01) but only partially inhibited the akening of human fetal membrane Kumar. Progesterone analogs inhibit fetal membrane weak-
ening. Am J Obstet Gynecol 2015.
GM-CSF increase that was produced in vitro. These observations suggest that
by thrombin (P < .05). Finally, proges- progesterone blocks both inflammation-
terone partially inhibited the GM-CSF and bleeding-initiated fetal membrane
increase produced by TNF (P < .05). weakening. Previously, we found that GM-CSF is a pro-inflammatory me-
The progesterone effect on thrombin- GM-CSF is a critical intermediate in diator that we have previously shown
induced GM-CSF production was not TNF- and thrombin-induced weakening to be produced by choriodecidua in
significant. Only small amounts of GM- of human fetal membrane. In these ex- response to either TNF or thrombin
CSF were detected on the amnion side of periments, HP and MPA each inhibited and mediates the fetal membrane
the fetal membrane (Figure 2). both GM-CSF production by choriode- weakening action of both agents.20,24
cidua- and GM-CSF-induced fetal Decidual stromal cells have been shown
Progestogens inhibit membrane weakening. Although pro- to produce GM-CSF in response to TNF
GM-CSFeinduced fetal gesterone also decreased both GM-CSF stimulation that is inhibited by MPA.24
membrane weakening production and GM-CSFeinduced we- Our present findings confirm progesto-
Studies were then performed to deter- akening, its inhibitory effect did not gen inhibition of TNF-induced GM-CSF
mine whether progestogens inhibit attain statistical significance. Taken production in choriodecidua by MPA.
TNF- and thrombin-induced fetal mem- together, these data suggest that pro- They also demonstrate inhibition of
brane weakening by inhibiting the ac- gestogens act at multiple points in the TNF-induced GM-CSF production by
tion of GM-CSF. Consistent with our pathway to fetal membrane weakening, progesterone, and HP and inhibition of
previous report,20 GM-CSF incubation evidenced by their effect on both GM- thrombin-induced GM-CSF production
on the choriodecidua side of fetal CSF production and action. by HP and MPA (Figure 2).
progesterone receptor isoform ratio in of preterm birth.56-59 However, the late gestation fetal membrane tissue,
the cells was conducive to mediating only randomized clinical trial to use which may have implications for current
progestational effects of progesterone or MPA to prevent prematurity in at-risk therapeutic regimens for progestogen use
they were mediated through mPR for pregnancies failed to demonstrate in the prevention of PPROM that is
which changes around labor remain benefit.60 associated preterm birth. -
unclear. Because it is not clear at what Although progesterone, MPA, and HP
point in gestation or how suddenly each inhibited both TNF- and thrombin- ACKNOWLEDGMENTS
the postulated changes in nPR subty- induced fetal membrane weakening, their The investigators thank the medical and nur-
pes occur, further studies are needed effects on GM-CSF production and ac- sing staffs of MetroHealth Medical Center,
to determine whether the protective ef- tion were different. This may be the result Cleveland, OH and Hillcrest Hospital, Mayfield
fects of progestogens remain in fetal of several factors. Progesterone has been Heights, OH.
membranes that are obtained from reported to undergo rapid metabolism in
women in active labor, in whom a cell and tissue studies.27 MPA acts at the REFERENCES
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