NIH Public Access: Author Manuscript

NIH Public Access
Author Manuscript
J Immunol. Author manuscript; available in PMC 2010 March 1.
Published in final edited form as:
NIH-PA Author Manuscript
J Immunol. 2009 March 1; 182(5): 27002707. doi:10.4049/jimmunol.0803138.
Temporal Changes in Myeloid Cells in the Cervix during

Pregnancy and Parturition
Brenda C Timmons*, AnnaMarie Fairhurst, and Mala S Mahendroo*

*Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center,
5323 Harry Hines Blvd, Dallas, TX 75390-9032
Department of Immunology, The University of Texas Southwestern Medical Center, 5323 Harry
Hines Blvd, Dallas, TX 75390-9032
Abstract
Preterm birth occurs at a rate of 12.7% in the United States and is the primary cause of fetal morbidity
in the first year of life as well as the cause of later health problems. Elucidation of mechanisms
controlling cervical remodeling is critical for development of therapies to reduce the incidence of
prematurity. The cervical extracellular matrix must be disorganized during labor to allow birth
followed by a rapid repair postpartum. Leukocytes infiltrate the cervix prior to and after birth and
are proposed to regulate matrix remodeling during cervical ripening via release of proteolytic
enzymes. In the current study, flow cytometry and cell sorting were utilized to determine the role of
immune cells in cervical matrix remodeling before, during, and after parturition. Markers of myeloid
cell differentiation and activation were assessed to define phenotype and function. Tissue monocytes
and eosinophils increased in the cervix prior to birth in a progesterone regulated fashion while
macrophage numbers were unchanged. Neutrophils increased in the postpartum period. Increased
mRNA expression of Csfr1 and markers of alternatively activated M2 macrophages during labor or
shortly postpartum suggest a function of M2 macrophages in postpartum tissue repair. Changes in
cervical myeloid cell numbers are not reflected in the peripheral blood. These data along with our
previous studies suggest that myeloid derived cells do not orchestrate processes required for initiation
of cervical ripening prior to birth. Additionally, macrophages with diverse phenotypes (M1 and M2)
are present in the cervix and likely involved in the postpartum repair of tissue.
Introduction
Preterm birth is the number one cause of infant morbidity in the first year of life (1,2).
Identification of the specific functions of immune cells in the normal parturition process is
critical for understanding the causes of preterm birth. Parturition involves the coordination of
two major events: uterine contractions and remodeling of the cervical extracellular matrix
(ECM). The cervical ECM is comprised primarily of fibrilar collagen, proteoglycans, and
elastin (3). The cervical collagen fibers maintain a structure that provides strength and rigidity
to the tissue during pregnancy. During parturition, collagen fiber structure must be extensively
altered to allow the cervix to open sufficiently for safe delivery of the fetus. The first phase of
remodeling, termed softening, is gradual beginning with increased collagen solubility and
increased tissue compliance (4). Cervical softening overlaps with an accelerated phase termed
ripening at the end of pregnancy. In the mouse, ripening is preceded by a decline in progesterone
Corresponding author: Mala Mahendroo, Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical
Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9032. Phone: 214 648 3091, fax: 214 648 9242, email:
mala.mahendroo@utsouthwestern.edu.
Timmons et al. Page 2
synthesis and increase in progesterone metabolism and is characterized by further matrix

disorganization, altered proteoglycan composition, and increased synthesis of hyaluronan, a
space-filling glycosaminoglycan that promotes increased tissue viscoelasticity and loss of
tissue integrity (57). Upon initiation of uterine contractions the cervix dilates and birth occurs.
Immediately following parturition, a repair process is initiated in which inappropriately
assembled matrix molecules must be removed as the cervix regains its rigidity and tensile
strength.
The molecular processes that bring about the dramatic changes in the cervical matrix during
parturition have been attributed to activation of the immune response system during ripening
(814). Histological assessments of cervices from numerous species identify an increased
migration of leukocytes into the cervical stroma matrix during ripening. This led to a model in
which these cells release proteolytic enzymes, which in turn degrade ECM components leading
to increased tissue compliance. Certainly, monocytes/macrophages have the capacity to
generate large amounts of pro-inflammatory mediators, particularly TNF (15). In addition,
they generate reactive oxygen species (ROS) and enzymes which have the capacity to degrade
the structure and integrity of tissue. Neutrophils also may be stimulated to release ROS and
proteolytic enzymes (16,17). Therefore myeloid lineage cells could be important candidates
orchestrating the structural changes occurring during pregnancy and labor. Moreover,
determining the specific role that leukocytes play at each stage of cervical remodeling prior to
and after birth may be important for understanding mechanisms leading to preterm birth.
Human studies have demonstrated that inflammatory cells migrate into the cervix and secrete
proinflammatory cytokines at term. Nonetheless, it remains unclear as to whether leukocytes
are required for ripening prior to birth or during postpartum repair of the cervix given variations
in timing of tissue collection as well as numerous studies which question the necessity of
functional neutrophils and the timing of macrophage activation relative to birth (12,1824).
We have previously reported no change in macrophage distribution during ripening as
compared to earlier in pregnancy though other studies suggest increases in macrophage
numbers during ripening (11,24). The requirement for macrophage derived proteases in
cervical ripening is unclear given the activity of collagenase, a proteolytic enzyme made by
leukocytes, is not increased in the term cervix of numerous species (25,26). Moreover,
exogenous collagenase treatment of rat cervices does not replicate the natural remodeling
process (27).
To better define the role of myeloid cells at each phase of cervical remodeling prior to, during
and after birth, we have measured myeloid infiltration and activation in the cervix during
softening, ripening and postpartum (PP) phases. Using multi-parameter flow cytometry and
cell sorting, the expression of multiple markers was analyzed simultaneously on mouse cervical
immune cell populations during pregnancy, parturition, and postpartum. We demonstrate that
eosinophils are increased in numbers at the time of labor. In addition, a progesterone regulated
monocyte infiltration occurs in the cervix during ripening, and these cells are phenotypically
distinct from the resident macrophage population. We also provide evidence that macrophages
with phenotypes similar to classically activated proinflammatory M1 macrophages and
alternatively activated M2 macrophages are both present in the cervix shortly after birth. These
studies support a role of eosinophils in the final stages of labor or postpartum and they suggest
the importance of macrophages in the postpartum phase of remodeling in clean up of the
disorganized matrix and in the suppression of uncontrolled tissue damage thus promoting rapid
and appropriate repair of the cervix back to the non-pregnant state.

Material and Methods

Mice
Steroid 5-reductase type 1 deficient mice (Srd5a1/) were generated and genotyped as
described previously (28). Timed pregnant NIH Swiss (Harlan, Indianapolis, IN), and HSD:
ICR (CD-1 ) (Harlan) were obtained from Jackson Laboratories, Bar Harbor, ME.
C57BL6/129 SvEv timed matings were carried out in our colony by housing one male with
four females in a cage from 5:00 PM to 8:00 AM. Females were checked at 8:00AM for vaginal
plugs. Plug day was determined as day 0 and birth occurred in the early hours on d19. All
studies were conducted in accordance with the standards of humane animal care described in
the NIH Guide for the Care and Use of Laboratory Animals using protocols approved by an
institutional animal care and research advisory committee.
Tissue Collection and Dispersal

Cervical tissue and blood were collected at midday for all days with the exception of gestation
d18.75 which were collected after 6:30 PM and postpartum samples collected at time
designated for each experiment. Peripheral blood was collected by submandibular bleeding
using Goldenrod Animal Lancets (MEDIpoint, Inc., Mineola, NY). Cervices were isolated by
transection at the utero-cervical junction (caudal to the uterine bifurcation) and all vaginal
tissue removed. Cervical cells were dispersed by mincing fresh tissue and incubating each
cervix in 5mls of buffer (2% FBS, 0.75% HEPES in PBS) with 200 l Liberase Blendzyme 3
(Roche, Indianapolis, IN), 12.5 l of a 1mg/ml DNAse I (Sigma, St. Louis, MO), and 10 TRU
Hyaluronidase (Seikagaku, Tokyo, Japan) for 1.5h at 37C. The tissue was manually pipetted
every 30 min to improve dispersion. After incubation, the cells were passed three times through
a syringe with an 18 gauge needle followed by three passes through a 23 gauge needle, filtered
with 100m Nitex (SEFAR, Depew, NY) and pelleted by centrifugation (500 g, for 5 min at
4C).
Staining Procedure
One hundred microliters of heparinized whole blood was pelleted in 96 well polypropylene
plates at 1900 rpm for 2 min at 4C. Each sample was stained with 100 l of diluted antibodies
for 30 min on ice as described below. Cervical cells were stained in 96 well polypropylene
plates (Greiner Bio-One, Monroe, NC). Dispersed cells from each cervix were pipetted into
separate wells and the plate was centrifuged (600 g for 1 min at 4C). Cells and reagents
were kept on ice for the remainder of the experiment. Cell suspensions were washed with
staining buffer and suspended in Fc-block (mAb 24G2) (BD Biosciences (San Jose, CA))
together with a combination of up to 6 directly conjugated fluorescent antibodies and 1
biotinylated antibody as described previously (29). (Neutrophil 7/4-PE and Neutrophil 7/4-
biotin (Serotec, Raleigh, NC), F4/80-APC, CD45-PE-Cy7, CD11b-Pacific Blue, CD4-PE,

CD8-PECy5, CD3-Pacific Blue and/or CD19-biotin (eBiosciences)), and Gr-1 (Ly6C/Ly6G)
-APC-Cy7, Siglec F- PE, and Ly6G-FITC (BD Biosciences). Cells were incubated for 30min
in the dark on ice. Cells were washed 3 times in staining buffer and then incubated in
Streptavidin QDot655 (Invitrogen, Carlsbad, CA) at 1:600 dilution of stock for 30mins in the
dark. Red blood cell lysis and cellular fixation was completed using BD Facs Lysing solution
(BD Biosciences). Cells were washed as above and samples were maintained in 1%
paraformaldehyde and run within 24hr on a BD Biosciences LSRII flow cytometer using BD
FACSDiva (BD Biosciences) software and analyzed with FloJo 7.1 analysis software (Tree
Star, Ashland, OR). Cells were sorted on a Beckman Coulter MoFlow Cell Sorter (Beckman
Coulter, Fullerton, CA), cytospun onto slides and stained with a HEMA 3 Stain Set (Fisher,
Middletown, VA) according to manufacturers protocols.

Quantitative real time PCR

Total RNA was extracted from frozen mouse tissue using RNA Stat 60 (Tel-Test B Inc.,
Friendswood, Texas). Subsequently, total RNA was treated with DNAse I to remove any
genomic DNA using DNA-free (Ambion Inc., Austin, Texas). CDNA synthesis was performed
per manufacturers protocols (TaqMan cDNA synthesis kit, Applied Biosystems, Foster City,
CA). Quantitative real time PCR was performed using SYBR Green and a PRISM7900HT
Sequence Detection System (Applied Biosystems). Aliquots (20 ng) of cDNA were used for
each quantitative PCR reaction, and each reaction was run in triplicate. Each gene was
normalized to the expression of the housekeeping gene cyclophillin B and relative expression
was calculated using the average of the d18.75 cervices as the external calibrator in the ddCt
method as described in User Bulletin #2 (Applied Biosystems). Data are presented as the
average relative gene expression SEM.
ELISA
Frozen tissues (36 animals for each time point) were homogenized in 0.01M PBS with 10%
proteinase inhibitor (Sigma). The samples were then sonicated on ice for 2 5 seconds and
centrifuged at 15,000 g, 4C, for 20 min. IL10, M-CSF, IL13 (R&D Systems, Minneapolis,
MN), and IL4 (eBiosciences) were analyzed in supernatants by commercially available ELISA
kits and used according to manufacturers instruction. Absorbance was read at 450nm using a
Safire 2 microplate reader (Tecan, San Jose, CA). Tissue cytokine levels were expressed
relative to total protein as determined by the bichonic acid assay (Thermo Scientific, Rockford,
IL).
Protein blotting
Mouse cervical extracts were prepared by homogenization in 0.01M PBS containing 3%
protease inhibitor (catalog no. 2714; Sigma, St. Louis, MO). Forty microgramsof protein was
diluted in 2 Lammeli buffer (Bio-Rad, Hercules, CA), boiled for 5 min, and run on a 10%
reducing Tris-HCl gel (Bio-Rad) along with protein size standards (Precision Plus Protein
Kaleidoscope, Bio-Rad). Proteins were transferred to nitrocellulose membrane (Pall
Corporation, Pensacola, FL). Nonspecific antibody binding was blocked by an overnight
incubation with Tris-buffered saline with Tween20 (TBST) [10 mm Tris (pH7.5), 150 mM
NaCl, and 0.05% Tween 20] containing 3% nonfat dry milk. Blots were then incubated for 2
h with the primary antibody, YM1 (StemCell Technologies Inc., Vancouver, BC, Canada)
(1:1000) in blocking solution, washed in TBST, incubated with horseradish peroxidase-labeled
antirabbit IgG (1:10,000) (Jackson Immunoresearch Laboratories, West Grove, PA) for 45
min, and washed again in TBST. Chemiluminescence detection was performed using the
ECL Western Blotting Analysis System (GE Healthcare, Buckinghampshire, UK.). A rabbit
polyclonal anti-Calnexin antibody(Santa Cruz Biotechnology, Santa Cruz, CA) (1:1000) was
used as a loading control. This experiment was conductedusing protein extracts from three to
nine animals per time point.
Statistics
Data were analyzed using one-way analysis of variance with pairwise multiple comparisons
performed with Tukey test for data normally distributed. Non-parametric methods were
employed for non-normal data. This included the Kruskal-Wallis test for one-way analysis of
variance with multiple comparisons using Dunns method. P<0.05 are considered statistically
significant. Data are displayed as mean + SEM. Data analyses were performed using Sigma
Stat V2.03 (SPSS, Chicago, IL).

Results
Monocyte and eosinophil but not neutrophil or macrophage numbers are increased prior to
parturition
Approximately 1020% of cervical cells expressed the pan leukocyte marker, CD45 (data not
shown). The population of cervical cells that expressed CD45 was assessed for Gr1, Ly6G,
Neutrophil (Neu) 7/4, F4/80, CD11b, CD11c, and Siglec-F expression in order to distinguish
tissue monocytes, neutrophils, macrophages, eosinophils and dendritic cells. The identities of
some populations were further confirmed by visualization of cell morphology after cell sorting
and staining with a modified Wrights stain. Neutrophils, defined as Gr1++, Neu 7/4+, were
observed in the cervix prior to cervical ripening [gestation day 15 (d15)] and did not
significantly increase until 24h postpartum (PP) (Fig. 1) (2931). Monocytes, defined as
Gr1+/ and Neu 7/4++, significantly increased in numbers between d15 and late on gestation
day 18 (d18.75) (30,31). The high numbers of monocytes remained throughout labor and PP
(Fig. 1). Macrophages, defined as F4/80++, Neu 7/4 were present in the cervix prior to (d15)
and during (d18.75) cervical ripening and 24 hours PP with no significant change in numbers
during this period (Fig. 2) (30,31). Cell morphology of all three myeloid cell types was
consistent with phenotypes defined using expression markers in flow cytometry (Fig 1 and 2).
In addition to neutrophils, monocytes, and macrophages, another distinct myeloid population
was identified as Neu 7/4low, F4/80low shown in (Fig 2A). Based on cell morphology and
Siglec-F++ expression (Fig 2A and 2B), the cells were identified as eosinophils (3234). These
cells, were recruited to the cervix by d18.75 with a statistically significant increase during labor
(IL) (Fig 2E). The eosinophil subset was further shown to be distinct from neutrophils based
on both low Neu 7/4 and Gr1 staining (Fig 2C) and absence of neutrophil specific Ly6G
expression (Fig 2D) (35). Dendritic cells were also evaluated and were identified as F480,
CD11c+, CD11b+/ with no significant changes during gestation or postpartum (data not
shown).
Recruitment of monocytes is dependent on steroid hormone environment

Loss of progesterone hormone action precedes onset of parturition in humans and numerous
animal species (36,37). Our previous studies have described a lack of migration of Neu 7/4+
cells into the cervical stroma of a cervical ripening defective model, the Srd5a1 null mouse, in
which cervical tissue progesterone levels are elevated on gestation day 18.75 (24). Cervical
tissue from this mouse model was utilized to determine if the recruitment of myeloid cells that
occurs in the term cervix is progesterone dependent. Monocytes, neutrophils, and eosinophils
were significantly lower in the knockout mouse cervix at d18.75 when analyzed by flow
cytometry though macrophage numbers were unchanged (Fig. 3A). To further demonstrate the
effect of progesterone on leukocyte recruitment, the progesterone receptor antagonist,
ZK98299 (Onapristone; Shering Corp., Kenilworth, NJ), was administered to pregnant WT

mice on gestation d15 and myeloid cell populations were identified by flow cytometry after
13 hours of treatment. Blocking progesterone action with agonist treatment causes premature
cervical ripening in human and other species and the agonist ZK98299 has previously been
shown to cause a premature infiltration of leukocytes into the cervical stroma (24,37). In the
current study, ZK98299 treatment resulted in a significant increase in both monocytes and
eosinophils (Fig. 3B). Taken together, these studies suggest that progesterone withdrawal
which normally begins prior to cervical ripening is required for appropriate migration of
specific myeloid cell populations into the cervix.
mRNA expression of genes associated with macrophage differentiation and activation are
upregulated after parturition
A decline in progesterone action is required for the migration of monocytes and eosinophils
into the cervical matrix during cervical ripening. Identification of the timing and regulation of

macrophage differentiation before or after birth is necessary to understand the role of these
inflammatory cells in cervical ripening/dilation and/or in the postpartum tissue repair of the
cervix. Colony stimulating factor 1 (Csf1) expressed in various cell types such as fibroblasts
and endothelial cells and its receptor, Csf1r, expressed by all mononuclear phagocytes and
some epithelial cells are upregulated during the differentiation of monocytes to macrophages
and is an important factor in normal macrophage function in the uterus (3841). CSF protein
and Csf1r mRNA was measured by ELISA and quantitative real time PCR (QRTPCR)
respectively to determine expression in cervical tissue during pregnancy, parturition, and PP
repair (Fig. 4). CSF1 expression was highest at gestation day 15 and then declined during
cervical ripening (d18.75) and postpartum. The receptor was expressed at all time points though
maximal expression was observed 24h postpartum. Significant upregulation of Csf1r by 2h
PP suggests an increase in the differentiation commitment of the monocytes to macrophages
pathway occurs once labor has begun and/or during postpartum recovery period. Transcripts
encoding Csf2 were low to undetectable in the cervix in contrast to Csf1 (Data not shown).
Gene expression patterns support a role of alternatively activated M2-polarized

macrophages during postpartum cervical tissue repair
As described in Figure 2, macrophage numbers are unchanged during cervical ripening,
parturition and postpartum. Macrophage phenotypes are heterogeneous and are influenced by
changes in the tissue microenvironment (31,42). Polarization of macrophages into either M1
or M2 subpopulations within a microenvironment can influence their function. In previous
studies from our laboratory we observed an upregulation of genes associated with classically
activated (M1) macrophages after birth during postpartum repair of the cervix such as Il1a,
Tnfa and Mcp1 (24). In the current study we sought to determine if the increased tissue
monocyte population in the cervix during ripening is followed by an upregulation of genes
associated with alternatively activated M2 macrophages which along with M1 macrophage
subpopulations may also contribute to the tissue repair phase of remodeling. M2 macrophages
express arginase 1 (Arg1), chitinase 3-like 3 (Chi3l3,Ym1), interleukin 1 receptor antagonist
(Il1ra), interleukin 13 receptor alpha 1 (Il13ra1) and transforming growth factor beta (Tgfb).
Expression of these genes was evaluated in the mouse cervix by QRTPCR. As described in
Figure 5, expression of Il13ra1, Arg1 and Il1ra was significantly upregulated postpartum.
Ym1 expression was increased in labor and remained elevated postpartum while Tgfb had
variable expression late on gestation d18 and a significant increase was observed between d15
and term, not in labor (NIL). YM1 protein expression was similar to mRNA expression
increasing PP (Fig. 6). In contrast to induction of M2 macrophage gene expression markers in
the cervix, the expression of these genes was low to undetectable in the fetal membranes on
gestation days 15, 18.75 and 19 NIL (data not shown). This data, along with our previous
studies reporting increased expression of genes expressed by classically activated M1
macrophages, suggest that M2 macrophages play little role in remodeling of fetal membranes
during parturition.
Characterization of myeloid cells in peripheral blood during pregnancy and postpartum

To determine if changes in myeloid cell populations observed in cervical tissue during
pregnancy and parturition was similarly reflected in peripheral blood, staining for myeloid
markers was carried out using whole blood obtained from mice before, during, and after
cervical ripening. Neutrophil numbers were significantly increased PP similar to the pattern in
the cervix (Fig. 7). In contrast, monocyte numbers in peripheral blood did not change during
pregnancy or postpartum suggesting quantification of these cell types in blood is not reflective
of local changes in the cervix during ripening, dilation, and PP repair.

Discussion
Temporal changes in immune cell phenotype during pregnancy, parturition and postpartum
(PP) in the mouse cervix reveal dynamic and multifaceted functions of inflammatory cells
during cervical remodeling. The data from this study suggest that the contribution of
macrophages to matrix remodeling predominates in the (PP) tissue repair phase of remodeling
rather than the cervical ripening phase prior to birth while eosinophils may contribute to
cervical dilation or postpartum repair. Matrix remodeling of the cervix in preparation for birth
requires extensive disorganization of the collagen rich matrix while postpartum remodeling
requires removal of inappropriately assembled matrix molecules that contribute to matrix
disarray. Appropriate and efficient postpartum remodeling is necessary to protect the entire
reproductive tract from pathogens and to allow subsequent pregnancy. This work advances our
understanding of the presence and contribution of myeloid cells to specific phases of cervical
remodeling.
Cervical tissue monocytes are increased in number during cervical ripening and this migration
is dependent on the withdrawal of progesterone. Both morphology and surface marker
expression (Neutrophil 7/4++ and F4/80+) of these cells are similar to blood monocytes and
distinct from macrophages (Neutrophil 7/4 and F4/80+) (43). In contrast to the cervix,
monocytes in blood were not increased during cervical ripening indicative that changes in this
tissue are not reflected in the peripheral blood. Since perfusion of mice at gestation d18.75 did
not alter the retrieval of monocytes, it is unlikely that changes in monocytes arise from
alterations in the cervical vasculature, and therefore the increases are a real determination of
the changes within the tissue (data not shown).
While monocytes are increased during cervical ripening and CSF1 is expressed during
pregnancy, the mRNA expression of the monocyte to macrophage differentiation factor
receptor Csf1r, as well as gene markers specific for both polarized activation states of
macrophage were not upregulated until labor began and/or postpartum. This would suggest an
increase in monocyte to macrophage differentiation during labor and PP. The recruitment of
monocytes to cervix, however, was not followed by an increase in macrophage numbers
presumably due to the increased turnover of activated macrophages during this process.
Macrophages show significant heterogeneity in function as the microenvironment influences

their properties and activation state (42,44). Macrophage activation can be described as a
continuum between two different polarization phenotypes, M1 and M2. Numerous biological
systems exist in which both macrophage subsets coexist and a shift in the balance of the two
subsets occurs upon changes in physiological or pathophysiological conditions (4547). The
M1s are classically activated by proinflammatory mediators such as LPS and IFN and produce
proinflammatory cytokines such as IL-6, IL-12, and TNF (42,44). In contrast, M2
macrophages termed alternatively activated are activated by IL-4 or IL-13 and express anti-
inflammatory cytokines such as IL-10 and TGF along with IL1 receptor antagonist (IL1ra)
and YM1. M2 macrophages also produce arginase 1 (Arg1) which reduces the amount of the
substrate arginine required for NO production and increases the production of ornithine
necessary for collagen synthesis. M2 macrophages, therefore, are involved in down regulation
of the inflammatory response and help promote tissue repair.
While macrophages are present in the cervix prior to cervical ripening (gestation day 15), it is
of interest that neither M1 nor M2 markers are expressed at this time. Similar to the recently
described endometrial NK cell that is present but inactive until pregnancy, these macrophages
may be a unique subset of cells that are inactive or inert until parturition or else infection ensues
(48). Our previous studies report an upregulation of proinflammatory cytokines IL-1a and
TNFa as well as chemoattractants (MCP-1) in the cervix as early as two hours after birth

(24). This would suggest that M1 macrophages are present at this time. More recently we have
determined little to no mRNA expression of Ifng, Il6, Il12 and iNos in the cervix before or after
birth (data not shown) suggesting that M1 proinflammatory macrophages may play a minor
role in remodeling either during cervical ripening or PP. Upregulation of Ym1, Arg1, and
Il13ra1 mRNA and protein expression in labor and PP from this investigation suggests that
M2 macrophages are also present in the PP cervix. The expression of CSF1 in the cervix may
also predispose recruited monocytes or resident macrophages towards the M2 phenotype as
has been described in other systems (44,49). Flow cytometry using surface markers specific
for M1 and M2 macrophages will be required to quantify the relative numbers of M1 versus
M2 macrophages in postpartum remodeling.
M2 macrophages may be activated by IL-13 or Il-4. IL-13 expression in the cervix, was low
to undetectable (data not shown) in whole tissue protein extracts. Furthermore, neither IL 4 nor
the immunosuppressive cytokine IL10 were detectable in the cervix during ripening or
postpartum emphasizing the fact that macrophage phenotypes are distinct within the cervix
microenvironment when compared to macrophages in other tissues. A mixed population of
macrophages displaying phenotypes across both polarization states may have evolved to ensure
optimal postpartum cervical remodeling. We hypothesize that M1s would be necessary to
protect against microorganism invasion during delivery as well as facilitate removal of ECM
components while macrophages with a polarized activation state similar to M2 would function
to suppress excessive proinflammatory responses and to promote tissue repair.
Evidence for the contribution of both M1 and M2 polarized macrophages to maintenance of

pregnancy and parturition is mounting. Macrophages present in first trimester human decidua
express markers of M2 polarized macrophages consistent with their role in immune tolerance
at the maternal-fetal interface (45). In contrast, remodeling of the fetal membranes during
parturition may require primarily an M1 activation phenotype. Increased expression of
proinflammatory genes occurs in term fetal membranes (Il1a, Ccl3, Tnf and Cxcl2) (24). More
recently we have evaluated the expression of Ym1, Arg1 and Il1ra in gestation d18.75 fetal
membranes and found little to no expression of these M2 marker genes (data not shown). At
the end of pregnancy the fetal membranes undergo remodeling resulting in rapid loss of tensile
strength and membrane rupture (50). Since fetal membranes need not be preserved once
parturition is complete, we speculate that the immunosuppressive and repair actions of M2
macrophages are unnecessary as compared to the cervix whose integrity must be rapidly
regained. Tissue specific macrophage phenotypes are required for maintenance of pregnancy
and successful parturition and clearly emphasize the varied functions of immune cells in this
critical process.
The increase in cervical eosinophils during labor that was observed in this study has previously
been described and is preceded by an increased expression of the eosinophil chemoattractant,

eotaxin (10,14,24). While classically thought to be involved in host protection against parasites,
eosinophils more recently are appreciated to be multifunctional leukocytes involved in
inflammatory responses as well as modulators of innate and adaptive immunity (51).
Eosinophils are a prevalent cell population in the female reproductive tract, are regulated by
steroid hormones and thought to be important in uterine preparation for pregnancy (51,52).
While their presence in the cervix at the time of labor may have a function in late stages of
remodeling, their functions are not essential to this process as mice depleted of eosinophils
(eotaxin null mice) have normal parturition (52). Further studies are required to appreciate the
specific functions eosinophils may play in cervical remodeling.
These findings propose a paradigm shift from the idea that inflammatory cells orchestrate
changes in the extracellular matrix required for initiation of cervical ripening. During cervical
ripening, monocytes extravasate to the cervical tissue in a progesterone regulated manner and

after a delay of several hours this influx is followed by increased gene or protein expression
of M2 polarized macrophage markers and to a lesser extent M1 polarized macrophage markers
during labor or within a few hours postpartum. These data support a model in which
macrophage recruitment and heterogeneity facilitate efficient recovery and repair of the cervix
after birth thus ensuring protection of the entire reproductive tract from microbial infection
and the ability to initiate and maintain a subsequent pregnancy. Future studies will focus on
identifying progesterone regulated factors that allow monocyte migration to the cervix during
ripening and studies to better understand the relative contributions of both alternatively
activated M2 and classically activated M1 macrophages to postpartum cervical remodeling.
Acknowledgments
The authors would like to thank Ms. Angela Mobley for her invaluable assistance with the flow cytometry and cell
sorting. We thank Dr. Petra Cravens and Dr. David Farrar for their helpful discussions and critical reading of the
manuscript. The technical assistance of Monika Ruschiensky and Joseph Davis is also gratefully acknowledged.
This work is supported by NIH R01 HD043154 (M.S.M.).
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FIGURE 1.
Cervical tissue monocytes but not neutrophils increase prior to parturition. Cervical
suspensions were stained with anti-CD45, -Gr1, and -Neutrophil 7/4. (Panel A) Leukocytes
were gated on CD45 and further analyzed on the Neu 7/4 versus Gr1 dot plot. Monocyte were
identified as Neu 7/4 ++ and Gr1 low to intermediate. Neutrophils were defined as Neu 7/4 +,
Gr1 ++. These populations were sorted, cytospun onto slides, and stained to visualize cell
morphology. Bar of measure represents 20 m. (Panel B) Neutrophils are present before
cervical ripening but do not increase significantly until postpartum (PP). Monocytes
significantly increase by late on gestation day 18 and remain high through PP. Data represents
mean SEM of 6 to 10 cervices as indicated. * P 0.05 compared to day 15. IL indicates in
labor samples.

FIGURE 2.
Eosinophils are increased during labor while macrophage numbers do not significantly change
during pregnancy or PP. Cervical suspensions were stained with anti-CD45, F4/80, Siglec-F,
Ly6G, Gr1, and Neu7/4. (Panel A) Leukocytes were gated through CD45. Macrophages were
defined as F4/80 ++ and Neu 7/4 low. (Panel B) Population defined as F4/80 +, Neu 7/4 low cells
(green) strongly express the eosinophil specific marker, Siglec-F. (Panel C) Gating on the
eosinophil population and comparing Neu 7/4 vs. Gr1 reveals that the eosinophils fall on a
different location on the dot plot as compared to neutrophils (blue) suggesting they are distinct
populations. (Panel D) Further confirmation that eosinophil population (Ly6G) is distinct
from neutrophil (Ly6G+) population. (Panel E) Macrophage numbers do not change during

gestation. Eosinophils appear to increase significantly from d15 to in labor (IL). Data represents
mean SEM of 6 to 10 cervices as indicated. * P 0.05 compared to day 15.

FIGURE 3.
Migration of tissue monocytes and eosinophils is dependent on the withdrawal of progesterone.
(Panel A) Flow cytometry was used to identify changes in myeloid cell numbers in the cervix
from wild type (WT) and a cervical ripening defective mouse Srd5a1 /. Cervical progesterone
levels remain high in the Srd5a1 / mouse at d18.75. All myeloid populations, with the
exception of macrophages, were decreased in number in the knockout mice. (Panel B) WT
animals at gestation day 15 were treated with progesterone receptor antagonist ZK98299 (ZK)
for 13 hours prior to tissue harvest. This led to a premature increase in monocytes and
eosinophils. Data represents the mean SEM of 4 to 7 cervices as indicated. * P 0.05
compared to d15.

FIGURE 4.
Expression of colony stimulating factor 1 and colony stimulating factor 1 receptor in the cervix.
ELISA or quantitative real time PCR was performed to determine the change in CSF1 protein
and Csf1r mRNA expression, respectively. CSF1 protein expression was highest on gestation
day 15 and decreased later in gestation and postpartum. CSF1 receptor, (Csf1r) expression
increased postpartum with significant upregulation by 10 to 12h PP. Data represents the mean
SEM of 5 to 8 cervices as indicated. Significance (P 0.05) is indicated by an asterisk when
compared to d15, an (a) compared to days 15, 18.75, and in labor (IL), and a (b) when compared
to 24h PP.

FIGURE 5.
Quantitative real time PCR analysis of genes expressed by alternatively activated (M2)
macrophages. Expression of interleukin 13 receptor alpha 1 (IL13ra1), arginase 1 (Arg1), and
interleukin 1 receptor antagonist (IL1ra) was significantly upregulated postpartum. YM1
expression significantly increased in labor (IL) and remained elevated up to 10h postpartum.
Transforming growth factor-beta (TGFb) had variable expression late on day 18 and a
significant increase was observed between d15 and term, not in labor (NIL). TGFb expression
remained high through PP. Data represents the mean SEM of 5 to 7 cervices as indicated.
Significance (P 0.05) is indicated by (a) compared to d15, (b) compared to d18.75, (c)
compared to term, not in labor (d19 NIL), and (d) in labor (IL).

FIGURE 6.
Temporal changes in protein expression of YM1. Western blot containing 40 g of total cervical
protein from gestation day 15, 18.75, in labor (IL), 24h and 1d postpartum (PP) was probed
with anti-YM1 antibody (upper panel). YM1 protein migrates at 40kDa. To ensure equal
loading, the blot was stripped and probed with anti-calnexin antibody (bottom panel). Calnexin
protein migrates at 90kDa.

FIGURE 7.
Myeloid cells in the peripheral blood do not parallel temporal changes in the cervix. Cells were
stained with anti-CD45, -Gr1, -Neutrophil 7/4, and F4/80. Neutrophil but not monocytes are
increased in the blood postpartum (PP). Data represents the mean SEM of 4 to 9 animals as
indicated. An asterisk indicates significance (P 0.05) when compared to day 15.

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J Immunol. 2009 March 1; 182(5): 27002707. doi:10.4049/jimmunol.0803138.

Temporal Changes in Myeloid Cells in the Cervix during

Brenda C Timmons*, AnnaMarie Fairhurst, and Mala S Mahendroo*

synthesis and increase in progesterone metabolism and is characterized by further matrix

J Immunol. Author manuscript; available in PMC 2010 March 1.

Material and Methods

Tissue Collection and Dispersal

biotin (Serotec, Raleigh, NC), F4/80-APC, CD45-PE-Cy7, CD11b-Pacific Blue, CD4-PE,

J Immunol. Author manuscript; available in PMC 2010 March 1.

Quantitative real time PCR

J Immunol. Author manuscript; available in PMC 2010 March 1.

Recruitment of monocytes is dependent on steroid hormone environment

ZK98299 (Onapristone; Shering Corp., Kenilworth, NJ), was administered to pregnant WT

J Immunol. Author manuscript; available in PMC 2010 March 1.

Gene expression patterns support a role of alternatively activated M2-polarized

Characterization of myeloid cells in peripheral blood during pregnancy and postpartum

J Immunol. Author manuscript; available in PMC 2010 March 1.

Macrophages show significant heterogeneity in function as the microenvironment influences

J Immunol. Author manuscript; available in PMC 2010 March 1.

Evidence for the contribution of both M1 and M2 polarized macrophages to maintenance of

been described and is preceded by an increased expression of the eosinophil chemoattractant,

J Immunol. Author manuscript; available in PMC 2010 March 1.

This work is supported by NIH R01 HD043154 (M.S.M.).

9. Junqueira L, Zugaib M, Montes G, Toledo OM, Krisztan R, Shigihara K. Morphologic and

J Immunol. Author manuscript; available in PMC 2010 March 1.

B6.Sle123 mice. Eur J Immunol 2008;38:19481960. [PubMed: 18506882]

J Immunol. Author manuscript; available in PMC 2010 March 1.

immature cells that await pregnancy. J Immunol 2008;181:18691876. [PubMed: 18641324]

J Immunol. Author manuscript; available in PMC 2010 March 1.

J Immunol. Author manuscript; available in PMC 2010 March 1.

J Immunol. Author manuscript; available in PMC 2010 March 1.

J Immunol. Author manuscript; available in PMC 2010 March 1.

J Immunol. Author manuscript; available in PMC 2010 March 1.

J Immunol. Author manuscript; available in PMC 2010 March 1.

J Immunol. Author manuscript; available in PMC 2010 March 1.

J Immunol. Author manuscript; available in PMC 2010 March 1.

J Immunol. Author manuscript; available in PMC 2010 March 1.

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Brenda C Timmons, AnnaMarie Fairhurst, and Mala S Mahendroo