1. Dr. Indira Devi PonugotiMD,DGO,FICOG,FIAMS,FCGP. MD.DGO , Osmania University, Hyderabad - 1965,1969,1970 FICOG 2009 FAMS2010Professor of Obstetrics and Gyneaecology - Osmania Medical College 1991--1999Kamineni institute of Medical Sciences HOD 2001 - 06Under and post graduate Examiner 1970 - 2010Chair person womens wing IMA - Hyderabad2007 - 08Vice President OGSH2007President OGSH 2008 - 2009Coordinator APCOG2008 - 09Vice President IMA HYD 2010 - 11Presented papers at national conferencesChaired the sessions at national and international conferencesContributed to FOGSI focus on Maternal NutritionLife member IMA ISOPARB OGAAIAORAOPresentlyState council member IMA HyderabadOrganizing Co- Chair person & Chair Person Scientific Committee - AICOG 2011Dean Of Faculty CGP-IMA 2011

2. GreetingsFromHyderabad 3. Dr. P. Indira Devi MD,DGO,FICOG,FIAMS,FCGP. 4. DefinitionDefined as 3 or more clinical pregnancies lost before the 20th week of gestation from the last menstrual periodIncidence 1 2% (3 or more losses) 5% (2 or morelosses) Only 30% pregnancies result in live birthAlbemann, SalatBarour 1988 5. SignificanceNo. of previouspregnancy Frequency losses2 24%--30%3 37%----40% 40%4 6. EtiologyCauseFrequencyAnatomical 10-15% Chromosomal2-5%Endocrinal 17-20% Autoimmune 20%Infections 0.5-5% Unexplained 40-50% 7. Reproductive ImmunologyPregnancy is Pregnancy associated an adaptiveThewith B cells form of principle suppressionwith immunity target forof humeral &immunoinvolves T cells this human cell recognitionrecognizeresponse globulinof specificantigen mediated receptors are theimmunologicantigen & asMHCrecognizeconferspeptidefunction to antigenic moleculesaccommodat specificity & bound to expressed position memory MHC e the semi- of intacton donor allogenic effect by T& cells(allo-molecules B graft- theMHC) fetus*lymphocyts.Many causes of RPL- maternal transplant rejection*Thellin& Henwm 8. Normal ImplantationDepends on Diminishedcontrolled This inturn Decidua isimmunologictrophoblasticdepends onsupposed to al response ofinvasion ofuterine large be an the pregnantmaternal granularimmunologic woman mayendometrium- cells-LGLs &allybe a cause fordecidua &expression of privilegedsurvival ofspiral 3 of HLAtissue site semi alloarterioles*class genes graft * Meffeh King- 2002 9. Protective mechanisms in pregnancy The primary cellular 3 response that developsagainst transplanted The proteins from HLA 1tissue is directed against major histo genes are not compatability expressed cocomplex(MHC),proteins dominantlyon donor tissue.*ontrophoblastcell membrane 2In humans MHCunlike other proteins are humancell types. leukocyte antigens (HLA)Tilburg.T,Scherjonsa,Reprod immol,2010;85:58 10. Protective mechanisms inpregnancyStrict regulation of the expression of HLAclass 1 molecules in sub population oftrophoblast is supposed to protect thesemi allograft against immune cells which4 are programmed to attack cells expressingpaternal 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;2:7Role 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 duringsteroids ,dramatic implantation andincrease occurs in maintenance ofunique population pregnancy.of lymphocytes Recruitment of Role not clear uterine natural probably, promote killer cells, ( which growth of placenta, and are derived from trophoblast ,providingperipheral NK immune modulation cells * *Dysregulation of above expressions occurs in RPL 12. Immune Response T cellActivated Tinduce CDrecognitioncells undergocell + T cell is the clonal mediatedprimary expansion &cytotoxicity,event ofinfluenceprovide helpantigeninterleukin 2-for B cell growthantibodyfactor,production,Signal 1 is provided by the interaction of T cellSignal 2 by a receptor(TCR)receptor provide help forwith antigen legendmacrophages to present as ainteraction oninduce delayedpeptide by T cell/APC cell hypersensitivity antigen presenting surfacecell(APC). 13. Mechanisms Associated with AlloGraft Rejection Hypothesis Non immunologic Once activated CD4+ Tinjury responses (,induce cells initiatenon specific inflammation)macrophage mediateddelayed hypersensivity Increased antigen response & provide help to Bproduction to T cells cells ,for allo antibodyproduction.(by up regulating theexpression of adhesionmolecules ,Class 11 MHC,Chemokines and cytokines) CD 8 cells induceapoptosis By shedding of intact Jabs WJ etall J .infet 2004;190:1604, Wyburn KR,Jose et,soluble HIA,( which may all,J.tranplantation,2005;80:164prime the indirect allorecognition path way.) 14. Alloimmunity and RPLMechanisms - PostulatedImmune Maternal antimediated and fetal blocking suppressor antibody cell Sharing of mechanism HLA deficiencyExistence of immunologicaldifferences among theindividual of the samespecies* 15. OMICS - Studies RPL *Molecular,genomics, These studies possibly reveal the transcripto genes associated withmics andpathogenesis witch might occur proteomicsdue to aberrant expression of studies aregenes and proteins. required tounderstand etiology ofAlso revealed immune responseRecurrent thrombosis, steroid biopregnancy synthesis,apoptosis,and angiogenesis loss.related genes*Laird Smetal 2003.Hum Reprd.update 9,163-174Molecular medicine.vol;13:7 16. Transcriptomic analysis Chromosomally normalchorionic villi from RPL womenshowed Expression levels of fivegroups of immune suppression related genesEmbryoOther etiology relatedattachmentgenes relatedAngiogenesis Apoptosis relatedrelatedChoi 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 RevealedFollicularaberrant fluid is Cc3 is expression of identified regulated by C3& C4thrombophilicwithmembranelevels are factors asdifferentially co factorfound to fibrinogen expressed protein be high in y& antiproteins,(MCP) and RPL with 3 thrombinincludingdecaylosess. which are compliment acceleratingassociatedcomponent factor (DAF) with RPLC3c. 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-IFN, TNF-, IL-2 Cytokines inhibit human placental trophoblast cell growth andmetabolic activity. IFN- 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 productionmight 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 RPLHLA G molecules of trophoblast cells interact with killer activator receptor (KAR)of uterine natural killer cells (NK) Cytokines released from NK cells attacktrophoblast 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 RPLHLA G moleculesof trophoblast Cytokines releasedcells inter act withfrom NK cellskiller activator attack trophoblast receptor (KAR)ofcells.uterine naturalkiller cells (NK)Inter action ofTh1 cytokinesHLA G with killer induce cytotoxic inhibitory cell ( activity in uterineKIR) has oppositeNK cells &effect. cytotoxic T cells. B cells release auto antibodies APA,ANA,ATA 23. Role of AngiogenesisExpression levels of Insufficient or abnormalangiogenesis related gestational angiogenesisgenes MMP-resulting from aberrant 2,PAI, Integrin, TGF-expression of angiogenesis, VEGF, FGF were lowerrelated genes lead toin intact chorionic villi abnormal growth of fetusderived from RPL or pregnancy loss.patients. 24. Apoptosis Fas ligand (FasL)-Fas interaction between decidualcells expressing FasL-Fas bearing leukocytes leads toapoptosis of activated leukocytes down regulation of production of cytokines TGF- and IL-10 (extravillous trophoblast invasion) High expression levels of apoptosis relatedgenes caspase 3,6,7,8,9,10,12,BAD, BAX, BID, FasL, Fas in women with RPL.Apoptosis genes directly regulate embryonicdevelopment during normal pregnancy. 25. Regulatory T Cells (Tregs)*Women with RPL showedlow no. and functionallydeficient T regs at both thefollicular,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 cellsIL-4 a growthfactor for B Th1 tocell T cellTh 2 Type 17 Producantibodye IL- production 3 cytokin T cells subsee may4,5,10,1 ,alsot express contribu3 andinhibits Tion iste to help B cell TH17 associa allograft cell maturation secret ted withrejectiofunctioninto Th1 . pathes IL- allograft n is not 17 toleranc clear.way(Clearseparasitic infections inmammals) 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 RPLPredisposition to venous thrombosis -specific single nucleotidepolymorphism s(SNPs)in theElevation ofhomocysteinvenous genes coding levels thrombosis & for factor v attributed toelevation inLeiden& mutation in homocysteinprothrombin- 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 RPL15-20%Prevent trophoblast proliferation,cause early fetal loss bycomplement activationCause thrombosis by interruptingfibrinolysis, inhibits theanticoagulant pathway, causes LA& aCLAthrombin generationelevated 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 aggregationleading 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 responseof prostacyclin 31. Schematic representation of the coagulation pathway.The circles depict theprothrombinconvertasecomplex (FVa + FXa) that drivescoagulation by convertingprothrombin into thrombin. Thrombin converts fibrinogento fibrinand this is stabilized by thecrosslinking of fibrin polymers byFXIII.Thrombin is inactivated byantithrombin III (ATIII). Blackarrows indicate modification,white arrows indicate catalyticor modifying effects and the 32. Thyroid Disease & RPL *Pain less thyroiditis Positive TPO one year afterantibody ispregnancy loss canassociated with cause immunological high incidence of changes and RPL.hypothyroidism20% of TPO + will Auto antibodiesdevelop subclinicalmight causehypothyroidism 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 genicpregnancy my occur with introduction ofsemen* Possible causes for RPL Secondary immune response due to dysregulation of HlA Expressions , cytokines andexposed paternal antigens .are the. Lack of immunological protection to the embryo Lack of appropriate expression of complimentregulatory 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 RPLetiology has become more complex thanthought earlier. Functional analysis of genes and or theirproducts will help to recognize thepregnancy with RPL A definitive approach to etiologic cal factorand immune modulators may help. Understanding the agony ,counseling,assurance on future with sympathy, arenecessary for better out come. 36. The gift of life is a marvel of divinity, and no words can expressthe awesome moment of its creation.