Obstetrics and gynecology

1. Dr. Indira Devi Ponugoti
MD,DGO,FICOG,FIAMS,FCGP.
•
• MD.DGO , Osmania University, Hyderabad - 1965,1969,1970
• FICOG 2009
• FAMS 2010
•Professor of Obstetrics and Gyneaecology - Osmania Medical College 1991--1999
•Kamineni institute of Medical Sciences HOD 2001 - 06
•Under and post graduate Examiner 1970 - 2010
•Chair person women's wing IMA - Hyderabad 2007 - 08
•Vice President OGSH 2007
•President OGSH 2008 - 2009
•Coordinator APCOG 2008 - 09
•Vice President IMA –HYD 2010 - 11
•Presented papers at national conferences
•Chaired the sessions at national and international conferences
•Contributed to FOGSI focus on Maternal Nutrition
•Life member IMA ISOPARB OGA AIAORAO
•Presently
•State council member IMA Hyderabad
•Organizing Co- Chair person & Chair Person Scientific Committee - AICOG 2011
•Dean Of Faculty CGP-IMA 2011

2. Greetings
From
Hyderabad

3. Dr. P. Indira Devi
MD,DGO,FICOG,FIAMS,FCGP.

4. Definition
Defined as 3 or more clinical pregnancies lost before the
20th week of gestation from the last menstrual period
Incidence 1 – 2% (3 or more losses)
5% (2 or more
losses)
Only 30% pregnancies result in live birth
Albemann, SalatBarour 1988

5. Significance
No. of previous
pregnancy Frequency
losses
2 24%--30%
3 37%----40%
40%
4

6. Etiology
Cause Frequency
Anatomical 10-15%
Chromosomal 2-5%
Endocrinal 17-20%
Autoimmune 20%
Infections 0.5-5%
Unexplained 40-50%

7. Reproductive Immunology
Pregnancy is Pregnancy –
associated an adaptive The
with B cells form of principle
suppression with immunity target for
of humeral & immuno involves T cells this human
cell recognition recognize response
globulin of specific antigen
mediated receptors are the
immunologic antigen & as MHC
recognize confers peptide
function to antigenic molecules
accommodat specificity & bound to expressed
position memory MHC
e the semi- of intact on donor
allogenic effect by T& cells(allo-
molecules B
graft- the MHC)
fetus* lymphocyts.
Many causes of RPL- maternal transplant rejection
*Thellin& Henwm

8. Normal Implantation
Depends on Diminished
controlled This inturn Decidua is immunologic
trophoblastic depends on supposed to al response of
invasion of uterine large be an the pregnant
maternal granular immunologic woman may
endometrium- cells-LGLs & ally be a cause for
decidua & expression of privileged survival of
spiral 3 of HLA tissue site semi allo
arterioles* class genes
graft
* Meffeh –King-
2002

9. Protective mechanisms in
pregnancy
The primary cellular 3
response that develops
against transplanted The proteins
from HLA
1 tissue is directed against
major histo genes are not
compatability expressed co
complex(MHC),proteins dominantly
on donor tissue.* on
trophoblast
cell
membrane
2 In humans MHC unlike other
proteins are human cell types.
leukocyte antigens
(HLA)
Tilburg.T,Scherjonsa,Reprod immol,2010;85:58

10. Protective mechanisms in
pregnancy
Strict regulation of the expression of HLA
class 1 molecules in sub population of
trophoblast is supposed to protect the
semi allograft against immune cells which
4 are programmed to attack cells expressing
paternal HLA class 1 antigens.*
Trophoblasts contain indoleamine 2,3
5 disoxynase(IDO , inhibits tryptophan
metabolism) there by inactivates T
cells
*362514Lebo tiller P.Mallet V-HLA G& preg-Reprod 1997;2:7
Role of HLA G in Human preg Reprd Bio Endo 2006;4 Supp,1:510

11. Expressions and Reactions At Fetomaternal interphase
by placenta & fetal membranes
Endocrine system & Under the
immurne system interact influence of sex
closely during steroids ,dramatic
implantation and increase occurs in
maintenance of unique population
pregnancy. of lymphocytes
Recruitment of
Role –not clear uterine natural
probably, promote killer cells, ( which
growth of placenta, and are derived from
trophoblast ,providing peripheral NK
immune modulation cells *
*Dysregulation of above
expressions occurs in RPL

12. Immune Response
T cell Activated T induce CD
recognition cells undergo cell + T cell
is the clonal mediated
primary expansion & cytotoxicity,
event of influence provide help
antigen interleukin 2- for B cell
growth antibody
factor, production,
Signal 1 is
provided by
the interaction
of T cell Signal 2 –by a
receptor(TCR) receptor provide help for
with antigen legend macrophages to
present as a interaction on induce delayed
peptide by T cell/APC cell hypersensitivity
antigen
presenting
surface
cell(APC).

13. Mechanisms Associated with Allo
Graft Rejection Hypothesis
 Non immunologic  Once activated CD4+ T
injury responses (,induce cells initiate
non specific inflammation) macrophage mediated
delayed hypersensivity
 Increased antigen response & provide help to B
production to T cells cells ,for allo antibody
production.
(by up regulating the
expression of adhesion
molecules ,Class 11 MHC,
Chemokines and cytokines)  CD 8 cells induce
apoptosis
 By shedding of intact  Jabs WJ etall J .infet 2004;190:1604,
 Wyburn KR,Jose et
,soluble HIA,( which may all,J.tranplantation,2005;80:164
prime the indirect allo
recognition path way.)

14. Alloimmunity and RPL
Mechanisms - Postulated
Immune
Maternal anti mediated and
fetal blocking suppressor
antibody cell
Sharing of mechanism
HLA deficiency
Existence of immunological
differences among the
individual of the same
species*

15. OMICS - Studies RPL
*Molecular,
genomics, These studies possibly reveal the
transcripto genes associated with
mics and pathogenesis witch might occur
proteomics due to aberrant expression of
studies are genes and proteins.
required to
under
stand
etiology of Also revealed immune response
Recurrent thrombosis, steroid bio
pregnancy synthesis,apoptosis,and angiogenesis
loss. related genes
*Laird Smetal 2003.Hum Reprd.update 9,163-174
Molecular medicine.vol;13:7

16. Transcriptomic analysis
Chromosomally normal
chorionic villi from RPL women
showed Expression levels of five
groups of immune suppression
related genes
Embryo
Other etiology related attachment
genes related
Angiogenesis
Apoptosis related related
Choi HK et al 2003 Mol Reprd Dev 66,24-31,
Back HH2002.Reprd Fertil dev,14,235-240 ,Lee,J 2005 Fertil Sterl 83,1047-49

17. Proteomic analysis RPL
Revealed Follicular
aberrant fluid is Cc3 is
expression of identified regulated by
C3& C4
thrombophilic with membrane
levels are
factors as differentially co factor
found to
fibrinogen – expressed protein
be high in
y& anti proteins, (MCP) and
RPL with 3
thrombin including decay
losess.
which are compliment accelerating
associated component factor (DAF)
with RPL C3c.

18. Key mechanisms in RPL

19. Role of cytokines in RPL
When HLA-G expression is down regulated, Th 1 cells are
activated and release cytokines-IFNȣ, TNF-α, IL-2
Cytokines inhibit human placental trophoblast cell growth and
metabolic activity.
IFN-ȣ inhibit secretion of (GM-CSF) which promotes growth,
differentiation of trophoblast during normal pregnancy.
Ratio of Th1/Th2 activity is critical for normal pregnancy.
Dysregulation of NK cytotoxicity and cytokine production
might be involved in RPL.
Expression of natural cytotoxicity receptors (NCRs)- NKp46,
NKp44, NKp30 and A2V-ATPase on CD56 NK cells were up-
regulated in RPL patients.

20. Role of HLA -G in RPL
Non classic MHC molecules
Expressed in extravillous cytotrophoblast
Invasion of extravillous cytotrophoblast into the uterus
is a vital stage in the establishment of pregnancy
HLA-G polymorphism → pregnancy complications-
RPL

21. Possible Immunological Mechanisms
Involved In RPL
HLA G molecules of trophoblast cells inter
act with killer activator receptor (KAR)of
uterine natural killer cells (NK)
Cytokines released from NK cells attack
trophoblast cells.
Inter action of HLA G with killer inhibitory cell (
KIR) has opposite effect.
Th1 cytokines induce cytotoxic activity in uterine NK
cells & cytotoxic T cells.
B cells release auto antibodies –APA,ANA,ATA

22. Possible Immunological Mechanism Involved In RPL
HLA G molecules
of trophoblast
Cytokines released
cells inter act with
from NK cells
killer activator
attack trophoblast
receptor (KAR)of
cells.
uterine natural
killer cells (NK)
Inter action of Th1 cytokines
HLA G with killer induce cytotoxic
inhibitory cell ( activity in uterine
KIR) has opposite NK cells &
effect. cytotoxic T cells.
B cells release auto
antibodies –
APA,ANA,ATA

23. Role of Angiogenesis
Expression levels of
Insufficient or abnormal
angiogenesis related
gestational angiogenesis
genes MMP-
resulting from aberrant
2,PAI, Integrin, TGF-
expression of angiogenesis
β, VEGF, FGF were lower
related genes lead to
in intact chorionic villi
abnormal growth of fetus
derived from RPL
or pregnancy loss.
patients.

24. Apoptosis
Fas ligand (FasL)-Fas interaction between decidual
cells expressing FasL-Fas bearing leukocytes leads to
apoptosis of activated leukocytes → down regulation
of production of cytokines TGF-β and IL-10
(↓extravillous trophoblast invasion)
High expression levels of apoptosis related
genes caspase 3,6,7,8,9,10,12,BAD, BAX, BID,
FasL, Fas in women with RPL.
Apoptosis genes directly regulate embryonic
development during normal pregnancy.

25. Regulatory T Cells (Tregs)
*Women with RPL showed
low no. and functionally
deficient T regs at both the
follicular,and luteal phases
Immunity related
genes, those encoding
PP14, HCG, mucin 1 were
aberrantly expressed in intact
chorionic villi from RPL
patients

26. Type 2 T Helper cells
IL-4 a
growth
factor for B
Th1 to
cell T cell Th 2 Type 17
Produc antibody
e IL- production
3 cytokin T cells
subse e may
4,5,10,1 ,also
t express contribu
3 and inhibits T
ion is te to
help B cell TH17 associa allograft
cell maturation secret ted with rejectio
function into Th1
. path es IL- allograft n is not
17 toleranc clear.
way(Clears
e
parasitic
infections in
mammals)

27. HLA Class 11
 Contains genes encoding HLA molecule region –
HLA-DR,DQ &DP
 These are expressed on B cells ,dendrite &
monocytes can be induced during inflammation.
 Also contain alpha & B chains on MHC.

28. Genetic predisposition RPL
Predisposition
to venous
thrombosis -
specific single
nucleotide
polymorphism
s(SNPs)in the Elevation of
homocystein
venous genes coding levels
thrombosis & for –factor v attributed to
elevation in Leiden& mutation in
homocystein prothrombin- MTHFR in
levels G20210A particular to
C677T SNP
*Nelen 1998,Lissak 1999, Finan 2002 Wang 2004,

29. Antiphospholipid Antibodies
(2%Auto immune )
Incidence of APA 2%
LA, ACl in RPL
15-20%
Prevent trophoblast proliferation,
cause early fetal loss by
complement activation
Cause thrombosis by interrupting
fibrinolysis, inhibits the
anticoagulant pathway, causes
LA& aCLAthrombin generation
elevated require plasma protein co
factors Interact with placental
interphase resulting in decidual
vasculopathy ,deposition of immune
complexes leading to lowered

30. Thrombophilias
 Pregnancy –a hypercoaguable state
 Factor VII, VIII & X shifts the thromboxane &
prostacyclin ratio , vasospasm& platelet aggregation
leading to micro thrombi and placental necrosis.
 Hypercoaguability is aggravated by thrombophilia –RPL
 Deficiency of Protein C ,S & anti thrombin III results in
Platelet aggregation,
 generation of thromboxane,
 lowered platelet reactivity to anti aggregating response
of prostacyclin

31. Schematic representation of the coagulation pathway.
•The circles depict the
prothrombin–convertase
complex (FVa + FXa) that drives
coagulation by converting
prothrombin into thrombin.
• Thrombin converts fibrinogen
to fibrin
and this is stabilized by the
crosslinking of fibrin polymers by
FXIII.
•Thrombin is inactivated by
antithrombin III (ATIII). Black
arrows indicate modification,
white arrows indicate catalytic
or modifying effects and the

32. Thyroid Disease & RPL
*Pain less thyroiditis
Positive TPO
one year after
antibody is
pregnancy loss can
associated with
cause immunological
high incidence of
changes and
RPL.
hypothyroidism
20% of TPO + will Auto antibodies
develop subclinical might cause
hypothyroidism by term growth inhibition of
if untreated. trophoblast and
thrombosis.
*Investigation RPL Fertil,Steril,2005;83:821.

33. Summary
 Programming the uterus for semi allo genic
pregnancy my occur with introduction of
semen*
 Possible causes for RPL
 Secondary immune response due to dys
regulation of HlA Expressions , cytokines and
exposed paternal antigens .are the.
 Lack of immunological protection to the embryo
 Lack of appropriate expression of compliment
regulatory proteins ,
 Apoptosis-inducing TNF super family members,
HLA G or HLA E .

34. Summary
 Extraordinary variation in upstream
regulatory regions of HLA G explains the
fetal loss rates and polymorphism.
 Polymorphism -725 C/G allele in both
partners has increased the rates of fetal
loss.
 Increased pro inflammatory cytokines and
up regulated thrombophilic tendency –a

35. Conclusion
 With introduction of” OMIC “ studies RPL
etiology has become more complex than
thought earlier.
 Functional analysis of genes and or their
products will help to recognize the
pregnancy with RPL
 A definitive approach to etiologic cal factor
and immune modulators may help.
 Understanding the agony ,counseling
,assurance on future with sympathy, are
necessary for better out come.

36. The gift of life is a marvel of divinity,
and no words can express
the awesome moment of its creation.