Journal of Reproductive Immunology 116 (2016) 7680

Contents lists available at ScienceDirect

Journal of Reproductive Immunology

journal homepage: www.elsevier.com/locate/jreprimm

Soluble HLA-G concentrations in maternal blood and cervical vaginal

uid of pregnant women with preterm premature rupture of
membranes
Fausta Beneventi a , Elena Locatelli a, , Mara De Amici b , Margherita Simonetta a ,
Chiara Cavagnoli a , Camilla Bellingeri a , Chiara Scancarello a , AntonioMaria Ierullo a ,
Miryam Martinetti c , Arsenio Spinillo a
a

Department of Obstetrics and Gynecology, IRCCS Foundation Policlinico San Matteo and University of Pavia, 27100 Pavia, Italy
Department of Pediatrics, University of Pavia, IRCCS Foundation Policlinico San Matteo and University of Pavia, 27100 Pavia, Italy
c
Immunogenetics Laboratory, Immunohematology and Transfusion Center, IRCCS Foundation Policlinico San Matteo and University of Pavia, 27100 Pavia,
Italy
b

a r t i c l e

i n f o

Article history:
Received 21 January 2016
Received in revised form 3 May 2016
Accepted 11 May 2016
Keywords:
Vaginal and serum sHLA-G
IL-6
Preterm premature rupture of membranes

a b s t r a c t
Objective: To evaluate soluble HLA-G (sHLA-G) concentrations in maternal blood serum and cervical vaginal uid in pregnancies complicated by preterm premature rupture of membranes (PPROM) compared
to controls.
Study design: Case-control study of 24 women with PPROM and 40 controls.
Main outcome measures: Vaginal and serum sHLA-G and IL-6 concentrations.
Findings: Women with PPROM had signicantly higher serum and vaginal sHLA-G concentrations compared to controls (respectively median 31.48 U\ml versus 13.9 U\ml p < 0.001 and 1.7 U\ml versus
0.1 U\ml p < 0.001). Vaginal expression of IL-6 was higher in PPROM cases compared to controls
(respectively, median 31.19 pg\ml versus 6.67 pg\ml; p < 0.001). Higher serum and vaginal sHLA-G were
associated with both a shorter length of pregnancy and histological chorioamnionitis in the PPROM group.
Conclusions: Higher vaginal and serum sHLA-G in PPROM cases may be a sign of local and systemic
inammation.
2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Preterm premature rupture of membranes (PPROM) and
preterm birth (PTB), dened as a delivery before 37 weeks of
gestation (Liu et al., 2012), are the leading causes of perinatal morbidity and mortality (Holst and Garnier, 2008). Multiple etiologies
can activate the common terminal pathway of parturition, and
intrauterine infection is one of the most important mechanisms
of diseases causally linked to PTB (Kusanovic et al., 2009). Investigators have hypothesized that understanding markers of infection
may alter clinical care and thus lead to better neonatal outcomes
(Galazios et al., 2011; Tosun et al., 2010).
Among pro-inammatory cytokines, interleukin-6 (IL-6) is the
most studied for a higher predictive value of chorioamnionitis

Corresponding author at: Department of Obstetrics and Gynecology, IRCCS Foundation Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy.
E-mail address: elena.loc@libero.it (E. Locatelli).
http://dx.doi.org/10.1016/j.jri.2016.05.004
0165-0378/ 2016 Elsevier Ireland Ltd. All rights reserved.

(Wei et al., 2010; Young et al., 2002; Kacerovsky et al., 2015) and
of neonatal infection (Kurt et al., 2007); nevertheless, its clinical
usefulness is limited by the large variability in threshold used in
different studies and the lack of routine measure (Taylor et al.,
2013).
Inammation at the maternal-foetal interface may play a critic
role in the etiology of spontaneous PTB (Wei et al., 2010). Pregnancy
represents a unique immune status wherein the maternal immune
system has to accept allogenic foetus by appropriate modulation of
the inammatory responses at the maternal-foetal interface.
Human leukocyte antigen-G (HLA-G), a member of non classic
HLA class I molecules characterized by low allelic polymorphism
and restricted tissue expression, and its soluble form, (sHLA-G),
has a crucial role in immune-tolerant mechanism of pregnancy by
inhibiting natural killer (NK) cell function (Hunt and Langat, 2009;
Rizzo et al., 2009). Altered serum levels of sHLA-G in maternal blood
are associated with recurrent spontaneous abortion, preeclampsia,
intrauterine growth restriction, PTB, and PPROM (Rizzo et al., 2015;
Biyik, 2014; Cecati et al., 2011; Steinborn et al., 2007). Increased

F. Beneventi et al. / Journal of Reproductive Immunology 116 (2016) 7680

expression of HLA-G has been reported in infections (Thibodeau

et al., 2011; Oliveira-Souza et al., 2015; Souto et al., 2011; RobertGagneux et al., 2011; Onno et al., 2000; Yan et al., 2009) and
autoimmune\inammatory diseases (Rizzo et al., 2012; Beneventi
et al., 2015). Some investigators have found higher sHLA-G in amniotic uid in preterm labour associated with intraamniotic infection
(IAI) as well as in histological chorioamnionitis, suggesting a role
of sHLA-G in the control or expression of intraamniotic infections
(Kusanovic et al., 2009).
The main purpose of our study was to evaluate sHLA-G in maternal blood and cervical vaginal uid in pregnancies complicated by
PPROM compared to controls.

2. Material and methods

2.1. Study population
We performed a prospective cross-sectional study. All women
were enrolled from January 2012 and December 2013, during the
admission to our Department of Obstetrics and Gynaecology. We
enrolled 24 women with a PPROM before 37 weeks of gestation
and 40 women with normal ongoing pregnancies matched for gestational age chosen as controls.

77

2.3. Physical examination and placenta collection

Obstetric parameters, as birth weight and gestational age at
delivery, and neonatal outcomes (admission in Neonatal Intensive
Care Unit (NICU) or presence of respiratory distress syndrome (RDS)
were recorded.
At the moment of delivery we collected placenta of all the
women enrolled for histological analysis. Histological chorioamnionitis was diagnosed by neutrophils inltration of the chorionic
plate or of the extraplacental membranes (Pacora et al., 2002).
2.4. Statistical analysis
Quantitative variables were expressed as median and interquantile range (IQR; 25th 75thpercentile). T-test for independent
data was used to analyse differences between two groups, depending on the data distribution. Qualitative variables were summarized
as counts and percentages and differences among group were evaluated with chi-square or Fishers exact test, as appropriate. P < 0.05
was considered statistically signicant and all tests were two-sided.
To evaluate the simultaneous effect of serum and vaginal concentrations sHLA-G on the likelihood of delivery associated with a
shorter interval from enrolment to delivery we used Cox regression
modelling using time from enrolment to delivery as time variable.
The results are expressed as Hazard Ratio (HR). Data analyses were
performed with the STATA statistical package (release 13.1, 2014,
Stata Corporation, College Station, Texas, USA).

2.2. Serum, cervical vaginal and amniotic uid samples

2.5. Ethics
We collected serum samples and cervical vaginal swabs of all the
women at the moment of the admission to hospital for detection
of sHLA-G and IL-6.
We also performed microbiological cervical-vaginal for the
detection of vaginal infections, and bacterial vaginosis, according to previously described denitions (Palmeira-de-Oliveira et al.,
2005). In addition, all women with PPROM underwent amniocentesis for microorganism detection. Amniotic uid samples were
obtained from transabdominal amniocentesis, Samples of amniotic
uid were transported to the laboratory in a sterile capped syringe
and cultured for aerobic/anaerobic bacteria and mycoplasmas using
standard methods (Kusanovic et al., 2008). We performed amniotic
uid culture only from amniocentesis samples, not from vaginal
samples. Intraamniotic infection (IAI) was dened as a positive
amniotic uid culture for microorganisms (Yoon et al., 2001). In
all cases, biological samples were collected prior to the administration of antenatal steroids or antibiotics and prior to the onset of
labor.
Peripheral blood samples were obtained from an antecubital
vein of the forearm of each study subject; serum was centrifuged for
15 min at 1000g, and then frozen at 20 C for subsequent analysis.
Cervical-vaginal swab specimens were collected by a physician,
using Dacron swabs then transferred to a sterile 10 ml conical test
tube with 5 ml Dulbeccos phosphate buffered saline without Ca
and Mg (DPBS-EuroClone). Samples were centrifuged for 5 min at
1000g and stored at 70 C for following analysis.
Soluble HLA-G was measured using a commercial available
immunoenzymatic assay (EXBIO, Praha, Czech Republic) following
the manufacturers instructions and the results were expressed as
Units/ml. The calculated inter- and intra-assay coefcients of variation for sHLA-G immunoassays in our laboratory were 7.6% and
5.8%. Interleukine-6 was measured using a commercial enzymelinked immunoassorbent assay kit (Human IL-6 Immunoassay, R&D
Systems, Minneapolis, MN) following the manufacturers instructions and the results were expressed as pg/ml. The calculated interand intra-assay coefcients of variation for IL-6 in our laboratory
were 4.2% and 3.8%.

The study was approved by the Ethical Committee of S. Matteo

Hospital and University of Pavia, Italy (project number 668rcr2011-bis-23). All women gave their written informed consent
for the study. The study was performed according to the Helsinki II
declaration.
3. Results
The baseline characteristics of the cases and controls are
reported in Table 1. Birth weight and gestational age were signicantly lower in the PPROM group when compared to controls
(p < 0.001).
Serum and vaginal sHLA-G and IL-6 concentrations are reported
in Table 2. Patients with PPROM had signicantly higher serum and
vaginal sHLA-G concentrations compared to controls (respectively,
median 31.48 U\ml versus 13.9 U\ml p < 0.001 and 1.7 U\ml versus
0.1 U\ml p < 0.001).
Also, vaginal IL-6 level was higher in PPROM compared to controls (median 31.19 pg\ml versus 6.67 pg\ml p < 0.001). There were
no signicant differences in the serum IL-6 concentration between
PPROM and controls (median 3.53 pg\ml versus 5.94 pg\ml, p = 0.9).
No intraamniotic infections were detected in PPROM group.
In the PPROM group the median time from admission to delivery was 8 days (range 152). To evaluate the simultaneous effect
serum and vaginal concentrations of sHLA-G on the likelihood of
delivery we used Cox regression modelling using time from enrolment to delivery as time variable. The nal results of this analysis
are reported in Table 3. In PPROM group, the major variable associated with a shorter interval from enrolment to delivery was the
sHLA-G concentration (p < 0.05).
We found histological chorioamnionitis in 13 of the PPROM
cases (54.16%). None were found among the controls.
Serum and vaginal sHLA-G and vaginal IL-6 levels were
signicantly higher in PPROM with histological chorioamnionitis compared to PPROM without chorioamnionitis (respectively,
median 35.65 U\ml and 2.8 U\ml versus 25.17 U\ml and 1.8 U\ml

78

F. Beneventi et al. / Journal of Reproductive Immunology 116 (2016) 7680

Table 1
Demographic and clinical characteristics of controls and women with preterm premature rupture of membranes.

Maternal age (years)

Gestational age at enrolment (weeks)

WBC (103\ml)
PCR (mg\dL)
Cervix length (mm)
Gestational age at delivery (weeks)
Birth weight (gr)
Arterial cord blood pH

Controls n = 40 median (IQR)

Preterm Premature Rupture of Membranes n = 24 median (IQR)

33 (2546)
30 (2436)
7.75 (5.3315.80)
0.0 (00.14)
34 (2741)
39.2 (3741.3)
3372.5 (28703850)
7.30 (7.107.44)

32 (2441)
30 (2333)
15.65 (8.5924.70)
0.84 (0.05.0)
17.5 (5.529)
31.5 (25.334)
1702.5 (6052760)
7.34 (7.217.47)

0.3
0.4
<0.001
<0.001
<0.001
<0.001
<0.001
0.007

IQR = range inter-quantile.

WBC = White blood cells.
PCR = Protein C reactive.
Table 2
Cervical and serum concentrations of sHLA-G and IL-6 in controls and in women with preterm premature rupture of membranes.

Cervical sHLA-G (U\ml)

Serum sHLA-G (U\ml)
Cervical IL-6 (pg\ml)
Serum IL-6 (pg\ml)

Controls n = 40 median (IQR)

Preterm Premature rupture of membranes n = 24 median (IQR)

0.1 (0.13.0)
13.92 (8.8255.42)
6.67 (0.1024.26)
5.94 (0.41102.3)

1.7 (0.14.1)
31.48 (3.2686.60)
31.19 (0.69345.21)
3.53 (0.2945.95)

<0.001
<0.001
<0.001
0.9

IQR = range inter-quantile.

sHLA-G = soluble HLA-G.
IL = interleukin.
Table 3
Hazard Ratio (HR) of the likelihood of delivery associated with a shorter interval from enrollment to delivery in the PPROM group.

Serum sHLA-G
Vaginal sHLA-G

Preterm Premature rupture of membranes HR (95%CI)

p value

1.03 (1.001.07)
1.02 (1.001.06)

0.030
0.033

Table 4
Median and IQR serum and vaginal sHLA-G in PPROM with and without histological chorioamnionitis (HC).

Vaginal IL-6 pg\ml

Vaginal sHLA-G U\ml
Serum sHLA-G U\ml

PPROM with HC Median(IQR)

PPROM without HC Median(IQR)

59.97 (0.71345.9)
2.8 (0.104.13)
35.65 (3.2686.60)

15.9 (0.69225.20)
1.8 (0.102.6)
25.17 (8.6936.72)

0.038
0.024
0.034

IQR = range inter-quantile.

for serum and vaginal sHLA-G versus controls, p = 0.034 and

p = 0.024; median 59.97 pg\ml versus 15.9 pg\ml for vaginal IL6 versus controls, p = 0.038), as reported in Table 4. Six PPROM
patients with histological chorioamnionitis (66.6% of PPROM
group) had vaginal samples positive for Ureaplasma, Escherichia
coli, and Klebsiella; vaginal and serum sHLA-G concentrations
were signicantly higher in these compared to controls (respectively, 2.1 U\ml versus 0.1 U\ml for vaginal and 38.2 U\ml versus
13.92 U\ml for serum sHLA-G, p < 0.001).
4. Discussion
Our study investigated vaginal and serum sHLA-G and IL-6
concentrations in pregnant women admitted with a diagnosis of
PPROM. In keeping with previous work, we found higher levels of
vaginal and serum sHLA-G at the moment of admission in PPROM
patients compared to controls. These ndings are similar, but not
identical, to those of others. Rizzo et al. (2009) found higher plasma
sHLA-G5 concentrations in women with PTB compared with the
control group. Steinborn et al. (2007) detected higher plasma levels
of sHLA-G in preterm labour patients compared to controls, though
not in women with PPROM.
Increased levels of local and circulating sHLA-G and local IL-6
was observed in PPROM with histological chorioamnionitis even
in absence of intraamniotic infections. Kusanovic et al. (2009)
also detected higher sHLA-G in amniotic uid of subjects with

preterm labour and PPROM associated with IAI well as histological

chorioamnionitis.
In our study levels of vaginal but not serum IL-6 was signicantly
increased in PPROM compared to controls, in keeping with the
ndings of others (Popowski et al., 2011; Kacerovsky et al., 2015).
However, conicting results have been reported by others, perhaps
reecting the great individual variability in sensing inammation
(Wei et al., 2010). In some studies, maternal blood, vaginal uid,
and amniotic uid levels of IL-6 were higher and directly correlated to more pathological, as to preterm labour, chorioamnionitis
and neonatal sepsis (Cernada et al., 2012; Naugler and Karin, 2008;
Prins et al., 2012).
Interestingly, shorter time from admission to delivery was associated to increased levels of vaginal and serum sHLA-G in PPROM
patients. Thus, serum and vaginal sHLA-G levels could be predictive of time to delivery before an overt infection arises as in our
PPROM group, probably because it is a signal of generalized immune
activation leading to PTB.
Moreover, we found a positive correlation of vaginal sHLA-G
and IL-6 levels with high prevalence of bacterial vaginosis. Bacterial vaginosis, associated with increased sHLA-G concentrations,
was previously described in nonpregnant women (Thibodeau et al.,
2011), with higher sHLA-G in genital mucosa independently associated with both HIV-1 and bacterial infections. Bacterial vaginosis is
a risk factor for preterm birth and premature rupture of membranes
(Hillier et al., 1995; Goldenberg et al., 1998), associated with higher

F. Beneventi et al. / Journal of Reproductive Immunology 116 (2016) 7680

levels of proinammatory cytokines (Tosun et al., 2010; Kacerovsky

et al., 2015). In another study, Oliveira-Souza et al. (2015) evaluated the role of sHLA-G in bacterial infection by H. pylori. Milder
gastric colonization predominantly expressed HLA-G, suggesting a
modulating role of HLA-G in inammatory processes.
We could explain our results by considering also the role of
sHLA-G as a master switch molecule of tolerance during pregnancy
(Morandi et al., 2014). In a previous work (Beneventi et al., 2015)
we found higher sHLA-G in maternal and cord blood of pregnant
women with autoimmune rheumatic diseases, as a mechanism of
maternal and foetal immune reaction towards inammation.
One limitation of the study might be the small simple size and
the lack serial sampling, as the samples were collected only at the
moment of admission to hospital and we could not evaluate a trend
from the admission to the delivery. However, our data are free from
biases derived by antibiotic therapy, antenatal steroids, and tocolysis that might alter the inammatory parameters (Chandiramani
et al., 2012; Mercer et al., 2012).
Finally, similar upregulation of IL-6 and sHLA-G was recently
demonstrated in the supernatants of T-cell lines isolated from
inamed colonic mucosa of patients with Crohns disease
(Ciccocioppo et al., 2015). Thus, our analogous ndings in the
vaginal site sustain the pleiotropic function of IL-6 and sHLA-G
molecules and suggest a positive feed-back lop in the control of
the local inammation.
In conclusion, levels of serum and vaginal sHLA-G were higher in
PPROM group compared to controls, and higher levels were associated with the presence of histological chorioamnionitis, Higher
vaginal and serum sHLA-G in PPROM could be local and generalized
signals of immune activation against inammation. Longitudinal
evaluation of vaginal and serum sHLA-G in PPROM patients should
be the subject of further study.
Authors roles
F. Beneventi organised the study, discussed the data, edited and
approved the article. E. Locatelli organised the study, interpreted
and discussed the data, wrote and approved the article. De Amici
M was responsible of serum and cervical vaginal analysis, discussed
the data and approved the article. A. Spinillo organised the study,
interpreted and discussed the data, edited and approved the article. AM Ierullo organised the study, collected the data, revised and
approved the article. M. Simonetta and C. Cavagnoli interpreted
the data, edited and approved the article. M. Martinetti interpreted
data, revised and approved the article. C. Bellingeri and C. Scancarello collected the data, edited and approved the article.
Conict of interest
None declared.
Funding
The study was supported by the S. Matteo Hospital as Current
research project.
Acknowledgments
We wish to thank Cristina Torre for performing sHLA-G and IL-6
analysis.
References
Beneventi, F., Badulli, C., Locatelli, E., Caporali, R., Ramoni, V., Cavagnoli, C.,
Simonetta, M., Garbin, G., Tinelli, C., Alpini, C., et al., 2015. Soluble HLA-G in

79

pregnancies complicated by autoimmune rheumatic diseases. J. Reprod.

Immunol. 110, 6773.
Biyik, I., 2014. Maternal serum soluble HLA-G in complicated pregnancies. J.
Matern. Fetal Neonatal Med. 27, 381384.
Cecati, M., Giannubilo, S.R., Emanuelli, M., Tranquilli, A.L., Saccucci, F., 2011. HLA-G
and pregnancy adverse outcomes. Med. Hypotheses 76, 782784.
Cernada, M., Badia, N., Modesto, V., Alonso, R., Mejias, A., Golombek, S., Vento, M.,
2012. Cord blood interleukin-6 as a predictor of early-onset neonatal sepsis.
Acta Paediatr. 101, e203e207.
Chandiramani, M., Seed, P.T., Orsi, N.M., Ekbote, U.V., Bennett, P.R., Shennan, A.H.,
Tribe, R.M., 2012. Limited relationship between cervico-vaginal uid cytokine
proles and cervical shortening in women at high risk of spontaneous preterm
birth. PLoS One. 7, e52412.
Ciccocioppo, R., Cangemi, G.C., Kruzliak, P., Gallia, A., Betti, E., Badulli, C., Martinetti,
M., Cervio, M., Pecci, A., Bozzi, V., Dionigi, P., Visai, L., Gurrado, A., Alvisi, C.,
Picone, C., Monti, M., Bernardo, M.E., Gobbi, P., Corazza, G.R., 2015. Ex vivo
immunosuppressive effects of mesenchymal stem cells on Crohns disease
mucosal T cells are largely dependent on indoleamine 2,3-dioxygenase activity
and cellcell contact. Stem Cell Res. Ther. 6 (July 24), 137.
Galazios, G., Tsoulou, S., Zografou, C., Tripsianis, G., Koutlaki, N., Papazoglou, D.,
Tsikouras, P., Maltezos, E., Liberis, V., 2011. The role of cytokines IL-6 and IL-8
in the pathogenesis of spontaneous abortions. J. Matern. Fetal Neonatal Med.
24, 12831285.
Goldenberg, R.L., Iams, J.D., Mercer, B.M., Meis, P.J., MoawadA.H. Copper, R.L., Das,
A., Thom, E., Johnson, F., McNellis, D., et al., 1998. The Preterm Prediction
Study: the value of new vs standard risk factors in predicting early and all
spontaneous preterm births. Am. J. Public Health 88 (2), 233238.
Hillier, S.L., Nugent, R.P., Eschenbach, D.A., Krohn, M.A., Gibbs, R.S., Martin, D.H.,
Cotch, M.F., Edelman, R., Patorek, J.G., Rao, A.V., et al., 1995. Association
between bacterial vaginosis and preterm delivery of a low-birth-weight infant.
The vaginal infections and prematurity study group. N. Engl. J. Med. 333 (26),
17371742.
Holst, D., Garnier, Y., 2008. Preterm birth and inammation-The role of genetic
polymorphisms. Eur. J. Obstet. Gynecol. Reprod. Biol. 141, 39.
Hunt, J.S., Langat, D.L., 2009. HLA-G: a human pregnancy-related
immunomodulator. Curr. Opin. Pharmacol. 9, 462469.
Kacerovsky, M., Musilova, I., Jacobsson, B., Drahosova, M., Hornychova, H., Janku, P.,
Prochazka, M., Simetka, O., Andrys, C., 2015. Vaginal uid IL-6 and IL-8 levels in
pregnancies complicated by preterm prelabor membrane ruptures. J. Matern.
Fetal Neonatal Med. 28, 392398.
Kurt, A.N., Aygun, A.D., Godekmerdan, A., Kurt, A., Dogan, Y., Yilmaz, E., 2007.
Serum IL-1beta, IL-6, IL-8, and TNF-alpha levels in early diagnosis and
management of neonatal sepsis. Mediators Inamm. 2007, 31397.
Kusanovic, J.P., Romero, R., Mazaki-Tovi, S., Chaiworapongsa, T., Mittal, P., Gotsch,
F., Erez, O., Vaisbuch, E., Edwin, S.S., Than, N.G., et al., 2008. Resistin in amniotic
uid and its association with intraamniotic infection and inammation. J.
Matern. Fetal Neonatal Med. 21, 902916.
Kusanovic, J.P., Romero, R., Jodicke, C., Mazaki-Tovi, S., Vaisbuch, E., Erez, O., Mittal,
P., Gotsch, F., Chaiworapongsa, T., Edwin, S.S., et al., 2009. Amniotic uid
soluble human leukocyte antigen-G in term and preterm parturition, and
intra-amniotic infection/inammation. J. Matern. Fetal Neonatal Med. 22,
11511166.
Liu, L., Johnson, H.L., Cousens, S., Perin, J., Scott, S., Lawn, J.E., et al., 2012. Global,
regional, and national causes of child mortality: an updated systematic
analysis for 2010 with time trends since 2000. Lancet 379 (9832), 21512161.
Mercer, B.M., Crouse, D.T., Goldenberg, R.L., Miodovnik, M., Mapp, D.C., Meis, P.J.,
Dombrowski, M.P., Eunice Nennedy Nhriver National Institute of Child Health
and Human Development Maternal-Fetal Medicine Units Network, 2012. The
antibiotic treatment of PPROM study: systemic maternal and foetal markers
and perinatal outcomes. Am. J. Obstet. Gynecol. 206, 145 (e1-145. e9).
Morandi, F., Rouas-Freiss, N., Pistoia, V., 2014. The emerging role of soluble HLA-G
in the control of chemotaxis. Cytokine Growth Factor Rev. 25, 327335.
Naugler, W.E., Karin, M., 2008. The wolf in sheeps clothing: the role of
interleukin-6 in immunity, inammation and cancer. Trends Mol. Med. 14,
109119.
Oliveira-Souza, D.M.B., Genre, J., Alves Silva, T.G., Soares, C.P., Borges Ferreira
Rocha, K., Nunes Oliveira, C., 2015. Upregulation of soluble HLA-G5 and HLA-G6
isoforms I the milder histopathological stages of Helicobacter pylori infection: a
role for subverting immune responses? Scand. J. Immunol. 83, 3843.
Onno, M., Pangault, C., Le FriecG. Guilloux, V., Andr, P., Fauchet, R., 2000.
Modulation of HLA-G antigens expression by human Cytomegalovirus: specic
induction in activated macrophages harboring human Cytomegalovirus
infection. J. Immunol. 164, 64266434.
Pacora, P., Chaiworapongsa, T., Maymon, E., Kim, Y.M., Gomez, R., Yoon, B.H.,
Ghezzi, F., Berry, S.M., Qureshi, F., Jacques, S.M., et al., 2002. Funisitis and
chronic vasculitis: the histological counterpart of the fetal inammatory
response syndrome. J. Matern. Fetal Neonatal Med. 11, 1825.
Palmeira-de-Oliveira, R., Palmeira-de Oliveira, A., Martinez-de Oliveira, J., 2005.
New strategies for local tretment of vaginal infections. Adv. Drug Deliv. Rev. 92
(September 15), 105122.
Popowski, T., Gofnet, F., Batteux, F., Maillard, F., Kayem, G., 2011. Prediction of
maternofoetal infection in preterm premature rupture of membranes: serum
maternal markers. Gynecol. Obstet. Fertil. 39, 302308.
Prins, J.R., Gomez-Lopez, N., Robertson, S.A., 2012. Interleukin-6 in pregnancy and
gestational disorders. J. Reprod. Immunol. 95, 114.

80

F. Beneventi et al. / Journal of Reproductive Immunology 116 (2016) 7680

Rizzo, R., Andersen, A.S., Lassen, M.R., Sorensen, H.C., Bergholt, T., Larsen, M.H.,
Melchiorri, L., Stignani, M., Baricordi, O.R., Hviid, T.V., 2009. Soluble human
leukocyte antigen-G isoforms in maternal plasma in early and late pregnancy.
Am. J. Reprod. Immunol. 62, 320338.
Rizzo, R., Bortolotti, D., Baricordi, O.R., Fainardi, E., 2012. New insights into HLA-G
and inammatory diseases. Inamm. Allergy Drug Targets 11, 448463.
Rizzo, R., Lo Monte, G., Bortolotti, D., Graziano, A., Gentili, V., Di Luca, D., Marci, R.,
2015. Impact of soluble HLA-G levels and endometrial NK cells in uterine
ushing samples from primary and secondary unexplained infertile women.
Int. J. Mol. Sci. 16, 55105516.
Robert- Gagneux, F., Gagneux, J.P., Vu, N., Jaillard, S., Guiguen, C., Amiot, L., 2011.
High Levels od soluble HLA- G in amniotic uid is correlated with congemnital
transmission of Toxoplasma Gondii. Clin. Immunol. 138, 129134.
Souto, F.J.D., Crispim, J.C.O., Ferreira, S.C., da Silva, A.S.M., Bassi, C.L., Soares, C.P.,
Zucoloto, S., 2011. Liver HLA-G expression is associated with multiple clinical
and histopatological forms of chronic hepatitis B virus infection. J. Viral Hepat.
18, 102105.
Steinborn, A., Varkonyi, T., Scharf, A., Bahlmann, F., Klee, A., Sohn, C., 2007. Early
detection of decreased soluble HLA-G levels in the maternal circulation
predicts the occurrence of preeclampsia and intrauterine growth retardation
during further course of pregnancy. Am. J. Reprod. Immunol. 57, 277286.
Taylor, B.D., Holzman, C.B., Fichorova, R.N., Tian, Y., Jones, N.M., Fu, W., Senagore,
P.K., 2013. Inammation biomarkers in vaginal uid and preterm delivery.
Hum. Reprod. 28, 942952.

Thibodeau, V., Lajoie, J., Labbe, A.C., Zannou, M.D., Fowke, K.R., Alary, M., Poudrier,
J., Roger, M., 2011. High level of soluble HLA-G in the female genital tract of
Beninese commercial sex workers is associated with HIV-1 infection. PLoS One.
6, e25185.
Tosun, M., Celik, H., Avci, B., Yavuz, E., Alper, T., Malatyalioglu, E., 2010. Maternal
and umbilical serum levels of interleukin-6, interleukin-8, and tumor necrosis
factor-alpha in normal pregnancies and in pregnancies complicated by
preeclampsia. J. Matern. Fetal Neonatal Med. 23, 880886.
Wei, S.Q., Fraser, W., Luo, Z.C., 2010. Inammatory cytokines and spontaneous
preterm birth in asymptomatic women: a systematic review. Obstet. Gynecol.
116, 393401.
Yan, W.H., Lin, A., Chen, B.G., Chen, S.Y., 2009. Induction of both membrane-bound
and soluble HLA-G expression in active human Cytomegalovirus infection. JID
200, 820826.
Yoon, B.H., Romero, R., Moon, J.B., Shim, S.S., Kim, M., Kim, G., Jun, J.K., 2001.
Clinical signicance of intra-amniotic inammation in patients with preterm
labor and intact membranes. Am. J. Obstet. Gynecol. 185, 11301136.
Young, A., Thomson, A.J., Ledingham, M., Jordan, F., Greer, I.A., Norman, J.E., 2002.
Immunolocalization of proinammatory cytokines in myometrium, cervix, and
foetal membranes during human parturition at term. Biol. Reprod. 66,
445449.