Hypoxia-induced Autophagy in the Pathogenesis of MAP

Study Overview
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Brief Summary
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To investigate the role of HIF 1α and LC3B in the pathogenesis of MAP, to evaluate the role of MMP-9 in the antenatal prediction of MAP, and to compare the expression of HIF1α, LC3B, and level MMP-9 between patients of placenta previa with MAP and patients with normal placentation.

Detailed Description
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Cesarean section (CS) rate has been rising rapidly in the recent years.One of the complications of repeated CS is placenta previa, an implantation of placenta on or near internal os. Morbidly adherent placenta (MAP), known also as placenta accreta spectrum, has histopathologic and clinical types. The placenta becomes abnormally adherent to the uterine wall, fails to separate leading to massive blood loss and possible hysterectomy. The risk of MAP in patient with placenta previa increases with repeated CS. Theories for development of MAP include abnormal trophoblastic invasion of myometrium, abnormal decidualization, neovascularization and reduction of apoptosis of trophobalsts. In early pregnancy: the trophoblasts invade spiral arteries and reduce blood flow to the placenta 00leading to hypoxia. Hypoxia inducible factor 1 alpha (HIF-1α), a protein involved in cellular adaptation to hypoxia, increases throughout pregnancy and contributes in the invasion of trophoblasts. Excessive invasion in MAP might prolong the hypoxia, increasing the expression of HIF1α. Autophagy is a process for managing and removing the damaged organelles and cellular proteins in hypoxia. It supports the trophoblasts. Hypoxia induced autophagy markers such as LC3B might be enhanced by MAP. Matrix metalloproteinase-9 (MMP-9) plays an important role in cell invasion and placental implantation. Disturbance of MMP-9 might alter the trophobalsts invasion resulting in MAP . The investigators hypothesize that hypoxia, autophagy and invasiveness are linked to the pathophysiology of MAP, so we will assess the expression of HIF1α, LC3B to estimate their role beside MMP-9.

Official Title
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The Possible Role of Hypoxia-induced Autophagy and Matrix Metalloproteinase-9 in the Pathogenesis of Morbidly Adherent Placenta.

Conditions
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Hypoxia, Autophagy, Placenta, Morbidly Adherent Placenta

Intervention / Treatment
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* Diagnostic Test: HIF 1α and LC3B expression and MMP-9 level


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Gestational age: more than 28 weeks up to 40 weeks. Pregnant women with at least one previous CS. Singleton pregnancy. Patient known to have placenta previa by 2D ultrasound. Heamodynamically stable patient. Exclusion Criteria: Multiple pregnancy. Gestational age less than 28 weeks. Heamodynamically unstable patient. Hypertensive disorder with pregnancy. Gestational diabetes. IUGR. Patient with bleeding tendency or using anticoagulant.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 45 Years

Sexes Eligible for Study
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Female

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| control group<br>40 pregnant women with normal placentation having no pregnancy related disorders according to the physical examination and laboratory findings. | Diagnostic Test: HIF 1α and LC3B expression and MMP-9 level<br>* 5ml of venous blood samples will be taken from all participants at 28-40 weeks of gestation for detcetion of MMP-9 level by Enzyme-Linked Immune Sorbent Assay (ELISA) kit. Placental tissue sample in the maternal surface will be taken during CS in placenta previa group and similar location in maternal surface will be sampled after placental delivery in control group for histopathology and immunohistochemistry for detection of HIF 1α and LC3B expression<br>|
| placenta previa group<br>40 pregnant women that will be diagnosed according to the ultrasound diagnostic criteria. Then according to the histopathological examination, placenta previa group will be subdivided into 2 groups, placenta previa with MAP and placenta previa without MAP | Diagnostic Test: HIF 1α and LC3B expression and MMP-9 level<br>* 5ml of venous blood samples will be taken from all participants at 28-40 weeks of gestation for detcetion of MMP-9 level by Enzyme-Linked Immune Sorbent Assay (ELISA) kit. Placental tissue sample in the maternal surface will be taken during CS in placenta previa group and similar location in maternal surface will be sampled after placental delivery in control group for histopathology and immunohistochemistry for detection of HIF 1α and LC3B expression<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Compare the expression of HIF 1α and LC3B by immunohistochemistry and the level of MMP-9 | To explore the mechanism of abnormal trophoblasts invasion in MAP. | 28-40 weeks of gestation. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Measure MMP-9 concentration in the maternal plasma | To verify its usefulness as an antenatal predictor of MAP | 28-40 weeks of gestation. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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HIF1α, hypoxia-induced autophagy, LC3B, invasion-related markers, MMP-9, Morbidly Adherent Placenta