1. Placental M-CSF, GM-CSF and G-CSF alterations in Small for Gestational Age infants. U. Rajesh ٭, A.L. Seager, R.H. Jones, T.V. Macfarlane,B. Manshian, M. Moller, G. Morgan, C.A. Thornton. ٭ Singleton Hospital,Swansea. Institute of Life Science, School of Medicine, Swansea University, Swansea.

2. SGA Physiologic adaptive response to various stimuli acting to limit 50-70% 50-70% of fetuses with a birth weight below the 10th centile for gestational age are constitutionally small (Ott WJ 1988, Wilcox AJ,1983). Heterogenous group of fetuses that have failed to achieve their growth potential-IUGR Fetuses that are constitutionallly small throughout pregnancy-SFD

3. Background Cytokines provide an important communication system in coordinating immune and inflammatory responses.  Several cytokines have been identified in placenta and/or uterus. A number of colony stimulating factors (CSFs), which are named for their major target cells, Granulocyte -G-CSF Granulocyte-macrophage- GM-CSF Macrophage-MCSF

4. Background M-CSF - Macrophage Colony Stimulating Factor- It is a Haematopoietic cytokine mediating  placental growth,  development and proliferation of myeloid haematopoietic cells.  M-CSF is secreted by uterine gland cells, and the levels increased in the first few days of pregnancy, with receptor present on invasive trophoblast cells. Pollard et al., Nature. 1987.

5. Background There is evidence for expression of M-CSF, GM- CSF and G-CSF in the Feto-Maternal interface. Ringler,1989, Robertson 1990 Few studies have shown alterations in levels of M-CSF, GM CSF in placental tissue in intrauterine disease. Hayashi 1996 &1998, Stallmach 1995.

6. Objectives To evaluate whether M-CSF, GM-CSF and G-CSF levels in placentas of SGA (Small for Gestational Age) differ from AGA (Appropriate for Gestational Age) controls. To correlate alterations in these essential cytokines in placentas of SGA infants while attempting to classify clinical phenotypes of SGA. Understand placental role in pathophysiology of SGA better.

7. Methods Definitions of SGA LREC approval Consent Recruitment IUGR Constitutionally small for dates (SFD) Controls (AGA)

8. Customised growth chart Fundal Ht

9. Methods Cord Blood &Placenta Collection Placental Explant culture Sandwich ELISA  Quantikine kit (R&D Systems, UK) used  Quantify cytokines in stored supernatants  Cord blood serum analysis SPSS Version 13 Mann Whitney U test

10. Results n=65 14=Term SFD12=Term IUGR5=Preterm IUGR32=Term Controls2=Preterm Controls

11. Results ParametersIUGRSFDControls n=17n=14n=34 Maternal Age262928 Parity- Primi- gravidas 10512 Mode of Delivery- Vaginal9819 C. Section8515 Gestation (Wks)3738.539 Mean Birth Weight (g)216727203230 Head Circumference3334 Placenta weight442527657 SCBU admission702 TERM

12. Results GM-CSF(pg/0.2g tissue/ml)G-CSF (pg/0.2g tissue /ml) IUGR SFD Control IUGRSFD Control

13. Results p=0.005 P=0.090 Placental M-CSF(pg/0.2g tissue/ml) IUGRSFDCONTROL

14. Results Serum M-CSF(pg/ml)

15. Conclusions First report distinguishing clinical phenotypes of SGA (IUGR and SFD) and correlating with cytokine alterations. The reduced M-CSF in placenta of IUGR and SFD infants probably reflects poor placental development and function. Increased M-CSF in maternal serum has been noted in IUGR pregnancies.  Does Maternal M-CSF down regulate the placental and fetal production of M-CSF?

16. Future directions Study maternal blood along with cord blood and placenta to correlate changes Redistribution Doppler studies to identify severe IUGR and correlate findings. Further study of amniotic fluid, placenta, cord blood &maternal serum for cytokine changes.

17. Therapeutic implications Methods of diagnosing and treating pre eclampsia Methods are provided for the diagnosis and treatment of patients with increased risk of gestational hypertension or pre eclampsia. The methods involve measuring serum M-CSF levels, and administration of M-CSF.

18. Thank you cds ILS MUMBLES

19. GM-CSF G-CSF M-CSF GroupMean(pg/ml) Std.Deviation Mean(pg/ml)Std.DeviationMean(pg/ml)Std.Deviation 149.6952.7322968.316305.58579.95351.12 249.0251.2 24.659.826863.4774.96319.85 338.9827.3824177.422310.11455.631349.22

20. Extra stuff GM-CSF G-CSF M-CSF GroupMean(pg/ml ) Std.Devia tion Mean(pg/ml ) Std.Deviatio n Mean(pg/ml ) Std.Deviatio n 149.6952.7322968.316305.58579.95351.12 249.0251.2 24.659.826863.4774.96319.85 338.9827.3824177.422310.11455.631349.22

21. Background In humans, the expression and localization of mRNA for M-CSF have been demonstrated in mesenchymal cells of the chorionic villous stroma, particularly in cytotrophoblasts lining the villous core and in the cytotrophoblastic core in the first trimester; in villous mesenchymal cells in the second trimester; and in cells lining the villous vessels in the third trimester.  Kanazaki et al., Human Reprod., 7:563-567 (1992);  Daiter et al., J. Clin. Endocrinol. Metab. 74:850-858 (1992). Circulating levels of macrophage M-CSF during pregnancy are also higher than those of non-pregnant women. Yong et al., Blood, 180:2897-2902 (1992).