Complement Activation Fragments in Cervicovaginal Fluid Are Associated with Intra-Amniotic Infection/Inflammation and Spontaneous Preterm Birth in Women with Preterm Premature Rupture of Membranes

Abstract

Objective We sought to determine whether the levels of complement and other inflammatory and angiogenic mediators in cervicovaginal fluid (CVF) are independently associated with intra-amniotic infection and/or inflammation (IAI) and imminent spontaneous preterm birth (SPTB, £48 hours of sampling) in women with preterm premature rupture of membranes (PPROM).

Study Design This was a retrospective study consisting of 85 singleton pregnant women with PPROM at 20^0/7 to 33^6/7 weeks. Amniotic fluid (AF) obtained via amniocentesis was cultured and assayed for interleukin-6. CVF samples collected at the time of amniocentesis were assayed for complement C3a, C4a, and C5a, HSP70 (heat shock protein 70), M-CSF (macrophage colony-stimulating factor), M-CSF-R (macrophage colony-stimulating factor-receptor), S100 A8, S100 A9, thrombospondin-2, VEGF (vascular endothelial growth factor-receptor), and VEGFR-1 (vascular endothelial growth factor-receptor 1) by enzyme-linked immunosorbent assay.

Results Multivariate logistic regression analyses revealed that elevated CVF concentrations of complement C3a, 4a, and 5a were significantly associated with an increased risk of IAI and imminent SPTB, whereas those of M-CSF were associated with IAI, but not imminent SPTB (p = 0.063), after adjustment for baseline covariates (e.g., gestational age at sampling). However, univariate, and multivariate analyses showed that the CVF concentrations of angiogenic (thrombospondin-2, VEGF, and VEGFR-1) and inflammatory (HSP70, M-CSF-R, S100 A8, and S100 A9) proteins were not associated with either IAI or imminent SPTB.

Conclusion In women with PPROM, elevated CVF concentrations of complement C3a, C4a, and C5a are independently related to an increased risk of IAI and imminent SPTB. These findings suggest that complement activation in CVF is significantly involved in mechanisms underlying preterm birth and in the host response to IAI in the context of PPROM.

Key Points

• Elevated CVF levels of C3a, 4a and 5a are associated with IAI and SPTB.

• CVF C3a, 4a and 5a have better predictability for SPTB, compared to AF WBC.

• Elevated CVF levels of M-CSF were associated with IAI, but not SPTB.

Keywords

cervicovaginal fluid - complement activation - intra-amniotic infection - preterm premature rupture of membranes - proteins - spontaneous preterm birth

• References

• 1 Mercer BM. Preterm premature rupture of the membranes. Obstet Gynecol 2003; 101 (01) 178-193
• 2 Shim SS, Romero R, Hong JS. et al. Clinical significance of intra-amniotic inflammation in patients with preterm premature rupture of membranes. Am J Obstet Gynecol 2004; 191 (04) 1339-1345
• 3 Park KH, Kim SN, Oh KJ, Lee SY, Jeong EH, Ryu A. Noninvasive prediction of intra-amniotic infection and/or inflammation in preterm premature rupture of membranes. Reprod Sci 2012; 19 (06) 658-665
• 4 Musilova I, Pliskova L, Gerychova R. et al. Maternal white blood cell count cannot identify the presence of microbial invasion of the amniotic cavity or intra-amniotic inflammation in women with preterm prelabor rupture of membranes. PLoS One 2017; 12 (12) e0189394
• 5 Drassinower D, Friedman AM, Obican SG, Levin H, Gyamfi-Bannerman C. Prolonged latency of preterm premature rupture of membranes and risk of neonatal sepsis. Am J Obstet Gynecol 2016; 214 (06) 743 e741-746
• 6 Pasquier JC, Bujold E, Rabilloud M. et al. Effect of latency period after premature rupture of membranes on 2 years infant mortality (DOMINOS study). Eur J Obstet Gynecol Reprod Biol 2007; 135 (01) 21-27
• 7 Hutzal CE, Boyle EM, Kenyon SL. et al. Use of antibiotics for the treatment of preterm parturition and prevention of neonatal morbidity: a metaanalysis. Am J Obstet Gynecol 2008; 199 (06) 620 e621-628
• 8 Lucaroni F, Morciano L, Rizzo G. et al. Biomarkers for predicting spontaneous preterm birth: an umbrella systematic review. J Matern Fetal Neonatal Med 2018; 31 (06) 726-734
• 9 Chaemsaithong P, Romero R, Korzeniewski SJ. et al. A point of care test for interleukin-6 in amniotic fluid in preterm prelabor rupture of membranes: a step toward the early treatment of acute intra-amniotic inflammation/infection. J Matern Fetal Neonatal Med 2016; 29 (03) 360-367
• 10 Lee SM, Park KH, Jung EY, Kook SY, Park H, Jeon SJ. Inflammatory proteins in maternal plasma, cervicovaginal and amniotic fluids as predictors of intra-amniotic infection in preterm premature rupture of membranes. PLoS One 2018; 13 (07) e0200311
• 11 Jung EY, Park KH, Han BR, Cho SH, Ryu A. Measurement of interleukin 8 in cervicovaginal fluid in women with preterm premature rupture of membranes: a comparison of amniotic fluid samples. Reprod Sci 2017; 24 (01) 142-147
• 12 Musilova I, Andrys C, Drahosova M. et al. Cervical fluid interleukin 6 and intra-amniotic complications of preterm prelabor rupture of membranes. J Matern Fetal Neonatal Med 2018; 31 (07) 827-836
• 13 Kacerovsky M, Musilova I, Jacobsson B. et al. Cervical fluid IL-6 and IL-8 levels in pregnancies complicated by preterm prelabor rupture of membranes. J Matern Fetal Neonatal Med 2015; 28 (02) 134-140
• 14 Jun JK, Yoon BH, Romero R. et al. Interleukin 6 determinations in cervical fluid have diagnostic and prognostic value in preterm premature rupture of membranes. Am J Obstet Gynecol 2000; 183 (04) 868-873
• 15 Lee SM, Park KH, Hong S. et al. Identification of cultivable bacteria in amniotic fluid using cervicovaginal fluid protein microarray in preterm premature rupture of membranes. Reprod Sci 2020; 27 (04) 1008-1017
• 16 Kim YM, Park KH, Park H, Yoo HN, Kook SY, Jeon SJ. Complement C3a, but not C5a, levels in amniotic fluid are associated with intra-amniotic infection and/or inflammation and preterm delivery in women with cervical insufficiency or an asymptomatic short cervix (£25 mm). J Korean Med Sci 2018; 33 (35) e220
• 17 Lee SE, Kim SC, Kim KH. et al. Detection of angiogenic factors in midtrimester amniotic fluid and the prediction of preterm birth. Taiwan J Obstet Gynecol 2016; 55 (04) 539-544
• 18 Chaiworapongsa T, Erez O, Kusanovic JP. et al. Amniotic fluid heat shock protein 70 concentration in histologic chorioamnionitis, term and preterm parturition. J Matern Fetal Neonatal Med 2008; 21 (07) 449-461
• 19 Rüetschi U, Rosén A, Karlsson G. et al. Proteomic analysis using protein chips to detect biomarkers in cervical and amniotic fluid in women with intra-amniotic inflammation. J Proteome Res 2005; 4 (06) 2236-2242
• 20 Lee SY, Park KH, Jeong EH, Oh KJ, Ryu A, Kim A. Intra-amniotic infection/inflammation as a risk factor for subsequent ruptured membranes after clinically indicated amniocentesis in preterm labor. J Korean Med Sci 2013; 28 (08) 1226-1232
• 21 Ryu A, Park KH, Oh KJ, Lee SY, Jeong EH, Park JW. Predictive value of combined cervicovaginal cytokines and gestational age at sampling for intra-amniotic infection in preterm premature rupture of membranes. Acta Obstet Gynecol Scand 2013; 92 (05) 517-524
• 22 Yoon BH, Romero R, Kim CJ. et al. Amniotic fluid interleukin-6: a sensitive test for antenatal diagnosis of acute inflammatory lesions of preterm placenta and prediction of perinatal morbidity. Am J Obstet Gynecol 1995; 172 (03) 960-970
• 23 Gibbs RS, Blanco JD, St Clair PJ, Castaneda YS. Quantitative bacteriology of amniotic fluid from women with clinical intraamniotic infection at term. J Infect Dis 1982; 145 (01) 1-8
• 24 DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 1988; 44 (03) 837-845
• 25 Denny KJ, Woodruff TM, Taylor SM, Callaway LK. Complement in pregnancy: a delicate balance. Am J Reprod Immunol 2013; 69 (01) 3-11
• 26 Manthey HD, Woodruff TM, Taylor SM, Monk PN. Complement component 5a (C5a). Int J Biochem Cell Biol 2009; 41 (11) 2114-2117
• 27 Freeley S, Kemper C, Le Friec G. The “ins and outs” of complement-driven immune responses. Immunol Rev 2016; 274 (01) 16-32
• 28 Gonzalez JM, Franzke CW, Yang F, Romero R, Girardi G. Complement activation triggers metalloproteinases release inducing cervical remodeling and preterm birth in mice. Am J Pathol 2011; 179 (02) 838-849
• 29 Gonzalez JM, Dong Z, Romero R, Girardi G. Cervical remodeling/ripening at term and preterm delivery: the same mechanism initiated by different mediators and different effector cells. PLoS One 2011; 6 (11) e26877
• 30 Elimian A, Figueroa R, Canterino J, Verma U, Aguero-Rosenfeld M, Tejani N. Amniotic fluid complement C3 as a marker of intra-amniotic infection. Obstet Gynecol 1998; 92 (01) 72-76
• 31 Soto E, Romero R, Richani K. et al. Evidence for complement activation in the amniotic fluid of women with spontaneous preterm labor and intra-amniotic infection. J Matern Fetal Neonatal Med 2009; 22 (11) 983-992
• 32 Lynch AM, Gibbs RS, Murphy JR, Giclas PC, Salmon JE, Holers VM. Early elevations of the complement activation fragment C3a and adverse pregnancy outcomes. Obstet Gynecol 2011; 117 (01) 75-83
• 33 Soto E, Romero R, Richani K. et al. Anaphylatoxins in preterm and term labor. J Perinat Med 2005; 33 (04) 306-313
• 34 Hitti J, Lapidus JA, Lu X. et al. Noninvasive diagnosis of intraamniotic infection: proteomic biomarkers in vaginal fluid. Am J Obstet Gynecol 2010; 203 (01) 32.e1-32.e8
• 35 Ushach I, Zlotnik A. Biological role of granulocyte macrophage colony-stimulating factor (GM-CSF) and macrophage colony-stimulating factor (M-CSF) on cells of the myeloid lineage. J Leukoc Biol 2016; 100 (03) 481-489
• 36 Piccinni M-P, Scaletti C, Vultaggio A, Maggi E, Romagnani S. Defective production of LIF, M-CSF and Th2-type cytokines by T cells at fetomaternal interface is associated with pregnancy loss. J Reprod Immunol 2001; 52 (1-2): 35-43
• 37 Svensson J, Jenmalm MC, Matussek A, Geffers R, Berg G, Ernerudh J. Macrophages at the fetal-maternal interface express markers of alternative activation and are induced by M-CSF and IL-10. J Immunol 2011; 187 (07) 3671-3682
• 38 Hayashi M, Zhu K, Sagesaka T, Fukasawa I, Inaba N. Elevation of amniotic fluid macrophage colony-stimulating factor in normotensive pregnancies that delivered small-for-gestational-age infants. Am J Reprod Immunol 2007; 57 (06) 488-494
• 39 Hayashi M, Hoshimoto K, Ohkura T, Inaba N. Increased levels of macrophage colony-stimulating factor in the placenta and blood in preeclampsia. Am J Reprod Immunol 2002; 47 (01) 19-24
• 40 Hayashi M, Hoshimoto K, Komine F, Ohkura T, Inaba N. Macrophage colony-stimulating factor levels in amniotic fluid before and after the onset of labor do not differ in normal pregnancies. Am J Reprod Immunol 2004; 51 (05) 329-335
• 41 Lee SM, Park KH, Kim SY, Kim YM, Hong S, Shin S. Cervicovaginal fluid protein microarray for detection of microbial invasion of the amniotic cavity in preterm labor. Reprod Sci 2020; 27 (02) 713-721
• 42 Yoo H-N, Park KH, Jung EY, Kim YM, Kook SY, Jeon SJ. Non-invasive prediction of preterm birth in women with cervical insufficiency or an asymptomatic short cervix (£25 mm) by measurement of biomarkers in the cervicovaginal fluid. PLoS One 2017; 12 (07) e0180878
• 43 Liu Y, Liu Y, Du C, Zhang R, Feng Z, Zhang J. Diagnostic value of amniotic fluid inflammatory biomarkers for subclinical chorioamnionitis. Int J Gynaecol Obstet 2016; 134 (02) 160-164
• 44 Park SJ, Yoon WG, Song JS. et al. Proteome analysis of human amnion and amniotic fluid by two-dimensional electrophoresis and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Proteomics 2006; 6 (01) 349-363
• 45 Coussens LM, Werb Z. Inflammation and cancer. Nature 2002; 420 (6917): 860-867
• 46 Pacora P, Romero R, Chaiworapongsa T. et al. Amniotic fluid angiopoietin-2 in term and preterm parturition, and intra-amniotic infection/inflammation. J Perinat Med 2009; 37 (05) 503-511
• 47 Kim SK, Romero R, Savasan ZA. et al. Endoglin in amniotic fluid as a risk factor for the subsequent development of bronchopulmonary dysplasia. Am J Reprod Immunol 2013; 69 (02) 105-123
• 48 Savasan ZA, Romero R, Chaiworapongsa T. et al. Evidence in support of a role for anti-angiogenic factors in preterm prelabor rupture of membranes. J Matern Fetal Neonatal Med 2010; 23 (08) 828-841
• 49 Combs CA, Gravett M, Garite TJ. et al. Amniotic fluid infection, inflammation, and colonization in preterm labor with intact membranes. Am J Obstet Gynecol 2014; 210 (02) 125 e121-125 e115