VaginalMicrobiome&Pregnancy

MollyJ.StoutMDMSCIMaternalFetalMedicine

WashingtonUniversityinSt.Louis

Agenda

•  Pretermbirthepidemiology•  SeEngthestage:MajorvaginalMBpapers•  VaginalMBdatafromWashU•  NeonatalMicrobiomeDevelopment

PretermBirthEpidemiology&ClinicalConsideraLons•  Pretermbirth12%inUS•  Racialdisparity•  PredicLonpoor

–  SmallimpactonPTBrate:12.1%à11.8%for17-OHP

PetriniJR.ObstetricsandGynecology105(2).2005.

TRIMESTER'1'Weeks'1-13'

TRIMESTER'2'Weeks''''''14-27'

TRIMESTER'3'Weeks'28-40'

WEEK$23$“Viability”'

WEEK$37$“FULL$TERM”'

PRETERM''

TERM

InfecLon&PretermBirth

PRETERMBIRTH

InfecLon/InflammaLonAmnioLcFluidChorionicMembranesVaginalInfecLonsSystemicInfecLons

•  Evidenceforcausality?AnimalModels•  Nospecificagent/microbeknown

CareyJCNEJM2000;GoldenbergRAmJPerinatology1997;MeisPJAJOG1995;RiduanJAJOG1995;HillierSNEJM1995;WaesDHObstetGynecol1992;DiGiulioDBPLoSONE2008;DondersGGBJOG2009

Enigma:TreatmentwithAnLbioLcsNotEffecLve

GroupBStreptococcus(Erythromycin):NoeffectofGBSTXonPTBorLBW

(Klebanoffetal.AmericanJournalofObstetricsandGynecology)

Trichomonas(Metronidazole):NoeffectoftreatmentonPTB…infacthigherPTBrateintreatmentgroup(19%TXvs.10%placebo)

(Klebanoffetal.NEJM2001)

Chlamydia(Erythromycin):NoeffectofTXofChlamydia(MarLnetal.InfectDisObstetGynecol1997)

Ureaplasma(Erythromycin):NoeffectofTXofUreaplasmaonPTB(Eschenbachetal.AmericanJournalofObstetricsandGynecology1991)

Whytheenigma?

•  Toobroad?•  Killsbeneficialbacteria?•  Notcausal?

•  Boeomline:poorlyunderstood•  Needtoapproachthisecologically:

–  Clarifywhatisnormal–  Understandabnormal– MechanismsàSmartlydesigntherapy

“Normal”VaginalFlora

•  ConvenLonalthinking– Lactobacillusà↓pHà↓pathogenicbacteria

•  BV(alteraLoninflora):– ↑ STD,endometriLs

•  Suggests“normal”vaginalbacteriaareprotecLve

•  But,“NORMAL”:Difficulttodefine.

WisenfeldHCHIV/AIDS2003;CherpesTLClinicalInfectDis2003;TahaTEAIDS1998.

LANDMARKSTUDIES:CURRENTSTATEOFKNOWLEDGE

“Normal”VaginalFlora•  N=300ReproducLveageasymptomaLcwomen•  SingleLmepoint

Raveletal.PNAS2011

TwoMajorFindings:1) NON-lactobacilluscommunity(heterogeneous)maybeNORMAL2)  Importantracialdifferences

PregnancyVaginalMicrobiome•  Healthypregnantwomansecondtrimester(n=24)vs.non-pregnantcontrols(n=60)

•  Keyfindings:–  Uniquevaginalmicrobiomeinpregnancy

–  Decreasedspeciesrichnessanddiversity

AagaardK.PLoSOne.2012

Non-Pregnant

Pregnant

VaginalMicrobiome&PTB(EarlyStudy)

RacialDifferences

Caucasiansonly30Term7PTBSiglowerSDIinPTB

Hyman2013ReproducLveSciences

•  N=49women–sampledweekly•  VeryfewAAsubjects(n=2)•  Findings:

–  Stability/instabilitydidnotcorrelatewithPTB– NosignificantdifferenceinShannondiversityoverLmeinpregnancy

–  TaxafromhighdiversityheterogeneousgroupassociatedwithPTB(ureaplasma,gardnerella)

DiGiulioPNAS2015

WASHINGTONUNIVERSITYVAGINALMICROBIOMESTUDY

1)  Knownassocia`onbetweenmicrobialchangesandpretermbirth2)  Notableracialdifferences3)  Evidenceofpregnancyspecificchanges4)  WashingtonUniversity:highriskcohort+racialdemographics

Hypothesis&SpecificAims

Hypothesis:Differencesinvaginalcommunity(structure,taxaetc.)areassociatedwithpretermbirthSpecificAim:LongitudinallycharacterizevaginalcommuniLesofacohortofpregnantwomenfollowedprospecLvelyfortermorpretermbirth

Methods

•  ProspecLvecohort2012-2015•  Singletons• Mid-vaginalswabwithspeculum•  16SV1V3region•  Specimensobtainedbeforeevent

CohortCharacterisLcsCharacteris`c TotalCohort TermDelivery PretermDeliveryTotalSubjects 77 53(69%) 24(31%)TotalSwabs 149 101(68%) 48(32%)

Trimester1 27 18 9Trimester2 61 41 20Trimester3 61 43 18

RaceAfricanAmerican 53(69%) 37(70%) 16(67%)

Non-AA 24(31%) 16(30%) 8(33%)

CohortCharacterisLcs

Characteris`c TotalCohort TermDelivery

PretermDelivery

P-value

MeanGestaLonalAgeofDelivery

37weeks 38weeks 34weeks 0.01

BMI 32 33 30 0.3TobaccoUse 25% 25% 25% 0.9PregestaLonalDiabetes

35% 32% 41% 0.4

GestaLonalDiabetes

13% 15% 8% 0.5

FullCohort:Richness&Diversity

TT

T

T TT

PTPT

PT

PT PTPT

TermBirthStable

PretermBirthSignificantdecreaseinrichnessanddiversityoverpregnancy(p<0.01)

AASubgroupT T T

T TT

PTPT

PT

PT

PTPT

TermBirthMarginalchangeoverpregnancy(p=0.05richness,p=0.06diversity)

PretermBirthSignificantdecreaseinrichnessanddiversityoverpregnancy(p<0.01)

Blackvs.WhiteSubgroupsBlack White

QuesLon:CanwelookatasingleLmepointandpredictpretermbirth?--staLsLcallynon-significant

P=0.4

P=0.2Cut-pointtoidenLfyPTB?

Correctlycapture75%ofPTBIncorrectlycapture50%of

termbirth

BlackSubgroupCorrectlycapturePTB83%

IncorrectlycaptureTerm50%

Interes`ngIdeaMain`mingofdifferenceEARLYpregnancy—NOTimmediatelypreceding

pretermbirth

Dominanttaxa:Lactobacillus

IncreasedinPTB:Sneathia(G-Rod)Ureaplasma(G-;nocellwall)DecreasedinPTB:Coriobacteriaceae(G+acLnobacteria)

SpecificBugs?

EarlyTiming!

Summary

1)Termbirth:stablerichnessanddiversityoverpregnancy2)Pretermbirth:decreasedrichnessanddiversityoverpregnancy3)ChangesappeartooccurEARLYinpregnancy4)HighorlowdiversityaloneinanytrimesterisnotstaLsLcallyassociatedwithPTB5)SuggesLonoftaxadifferences—butnotaxa(presence/absence)predictedPTB

Conclusions

•  Predominantlyblackcohort—differentfrompublishedliteraturethusfar

•  CandidatesignatureofPTB–firsttrimesterdiscriminaLon

•  EarlypregnancyimportantecologicalLme

DEVELOPMENTOFTHENEONATALMICROBIOME

•  Background:1)  Babiesfromvaginalversuscesareandelivery

developdifferentcolonizaLon2)  BabiesfromCShaveincreased:obesity,

asthma,allergiesetc.Istherealink?

•  18infants(11CS,7VD)•  Vaginalgauze(GBSnegaLve,noacLvevaginalinfecLons)

•  “MicrobialrestoraLonprocedure”•  Vaginalgauzeàswabbaby(mouth,face,body)•  Trackedoral,skin,analx1month

ParLalMicrobialRestoraLonDay1:CSexposedtovaginalfluidresembledvaginaldeliveredpaeernWeek2:analsamplesLBandbacteroidesenrichmentinVD,andVD+seed,butnotinCS

Morecomplicatedthan“seeding”

•  Allbabieshadgut-derivedbacteriainanalsamplesimmediatelyaxerbirth

•  Majordifference:LmingandratedevelopmentofgutbacterialpopulaLons(regardlessoftreatmentgroup)

•  LargefracLonofbacteriainallgroupscouldnotbeassignedbodysiteorigin

•  PaLentswhogetVDmaybedifferentfromthosewithCS

ORMicrobiota

•  Mostsimilartohumanskin•  Skincellsdetectedbystaining/petridishdeposits

•  TopofORlamps:dustandliveskinbacteria(grow-ableinculture)

•  Goodnews:30%ofsamplesweresequencefailures(toolieleDNA)

•  SampledAFTERc-secLon

•  N=39women• Majortaxa:staph,enterobacteriaceae,pseudomonas

•  Nodifference:gestaLonalage,modeofdelivery,infantgender

•  EffectsofbacteriadirectlyORbacterialinfluenceonhumanmilkcomponents?

•  Goal:examinepaeernofhowgutmicrobiomegetsestablishedinpreterminfants

•  N=58infantsN=922specimen•  Birthweight<1500gfromSt.LouisChildren’sHospital

Paeern:Progressionfrombacillitoclostridialabundance(andflourishofGammproteobacteriasoonaxerbirth)Unrelatedto:modeofdelivery,anLbioLcs,breastversusformulafeedsWhatdrivesthis?

TeamScience•  Microbiologists•  Genomics•  InformaLcs•  Bothsidesoftheplacenta

–  Maternal–  Neonatal

•  Epidemiologists•  SeniorandNewInvesLgators•  PaLents&Babies

GeorgeMaconesMethodiusTuuliPhilTarrKrisLneWylie

QUESTIONS

stoutm@wudosis.wustl.edu