COMPARISON OF PLACENTAL INTERFERON GAMMA (IFN-ɣ) RECEPTOR

EXPRESSION IN INFECTIOUS AND NON-INFECTIOUS SPONTANEOUS ABORTIONS

AT RSUD SAIFUL ANWAR MALANG AND RSUD BANGIL

PERBANDINGAN EKSPRESI RESEPTOR INTERFERON GAMMA (IFN-ɣ)

PLASENTA PADA ABORTUS SPONTAN INFEKSI DAN NON INFEKSI
DI RSUD SAIFUL ANWAR MALANG DAN RSUD BANGIL

Ery Yuliana, Kusnarman Keman, Sutrisno

Obstetrics and Gynecology Department, Faculty of Medicine Brawijaya University /

Saiful Anwar General Hospital Malang, Fertility and Endocrinology Division

ABSTRAK
LATAR BELAKANG: Risiko abortus dapat dihubungkan
dengan umur kehamilan, pendidikan, pekerjaan, usia ibu
dan infeksi. Produksi dan aktivasi sitokin-sitokin pro-
inflamasi seperti IFN-γ diketahui meningkat pada proses
infeksi akut. Kadar IFN-γ yang meningkat berlebihan akibat
dipicu oleh infeksi dapat menginduksi apoptosis trofoblas
menyebabkan abortus.
TUJUAN: Membandingkan ekpresi reseptor IFN-γ
plasenta pada abortus spontan infeksi dan non infeksi di
RSUD Saiful Anwar Malang dan RSUD Bangil
METODE: Penelitian observasional analitik ini
menggunakan desain cross sectional. Sampel penelitian
menggunakan 47 jaringan kuret plasenta abortus. Ekspresi
reseptor IFN-ɣ diperiksa dengan menggunakan immuno
ratio image analyzer. Hasil pengukuran dinyatakan dalam
persen (%). Perbedaan ekspresi reseptor IFN-ɣ dengan
faktor risiko umur kehamilan, pendidikan, pekerjaan, usia
ibu dan kelompok pemicu dianalisis secara statistik dengan
uji ANCOVA.
HASIL: Rerata usia ibu pada kelompok abortus infeksi dan
non-infeksi yaitu 28.4 ± 5.5% dan 28.1 ± 5% (p = 0,656).
Abortus didapatkan paling banyak pada usia kehamilan
10-12 minggu, pendidikan SMA/sederajat dan pekerjaan
ibu rumah tangga (p>0,05). Rerata ekspresi IFN-ɣ yaitu
60.8 ± 15.9 % pada kelompok infeksi dan 24.3 ± 10.5 %
non infeksi. Hasil analisis ANCOVA menunjukkan p-value
ekspresi IFN-ɣ dibandingkan dengan faktor risiko umur
kehamilan (p=0,807), pendidikan (p=0,086), pekerjaan
(p=0,805), usia ibu (p=0,301) dan kelompok pemicu
(p=0,000).
KESIMPULAN: Terdapat peningkatan ekspresi IFN-ɣ pada
abortus spontan infeksi dibandingkan dengan non infeksi
yang signifikan secara statistik. Tidak didapatkan
perbedaan bermakna antara ekspresi IFN-ɣ dengan faktor
risiko umur kehamilan, pendidikan, pekerjaan, dan usia
ibu.
KATA KUNCI: Abortus, IFN-ɣ, infeksi, RSUD Saiful Anwar,
RSUD Bangil
ABSTRACT
BACKGROUND: The risk of abortion can be related to
gestational age, education, employment, l age and
infection. Increase production and activation of pro-
inflammatory cytokines such as IFN-γ is known in the acute
infection. Dramatically increase of IFN-γ levels as a result
of infection may induce trophoblast apoptosis trigger
abortion.
PURPOSE: To compare the expression of placental IFN-γ
receptors in infectious and non-infectious spontaneous
abortions at RSUD Saiful Anwar Malang and RSUD Bangil.
METHOD: This analytic observational study used a cross
sectional design. Sample used 47 placental abortion from
curette tissue. IFN-γ receptors expression examined using
the immuno ratio image analyzer and expressed in percent
(%). Comparison of IFN-γ receptors expression with risk
factors: gestational age, education, occupation, age and
trigger group was analyzed statistically by ANCOVA test.
RESULTS: The mean maternal age was 28.4 ± 5.5% in
infectious and 28.1 ± 5% in non-infectious groups (p =
0.656). Abortion was obtained at most at 10-12 weeks of
gestation, high school/equivalent education and housewife
(p>0.05). Mean IFN-ɣ expression was 60.8 ± 15.9% and in
infection and 24.3 ± 10.5% in non-infectious groups.
ANCOVA analysis showed p-value of IFN-ɣ receptor
expression compared with risk factors for gestational age
(p = 0.807), education (p = 0.086), employment (p =
0.805), age (p = 0.301) and trigger groups (p = 0,000).
CONCLUSION: There was a statistically significant
increase of IFN-γ receptors expression in infectious
spontaneous abortion compared with non-infectious. This
study observed no significant differences between IFN-ɣ
expression and risk factors for gestational age, education,
employment, and age.
KEYWORDS: Abortion, IFN-ɣ, infection, RSUD Saiful
Anwar, RSUD Bangil
 Introduction γ) plays an important role in controlling
the invasion of trophoblast cells by
Abortion is a pregnancy inducing apoptotic trophoblast extrusion,
complication that often happens. Abortion thereby increasing maternal immune
is disturbed or partial discharge or all tolerance to the fetus. The gamma
conception results that cause fetal death, interferon receptor is a receptor that
and fetal or embryonic expulsion at less binds to interferon gamma and is the only
than 20 weeks' gestation or fetal weight type II interferon group.
less than 500 grams (Chunningham et
al., 2014). The trigger factor for the Because of the finding of an
occurrence of abotus can be caused due increase in interferon gamma in the
to infection and non-infection factors. placenta abortus and the existence of a
Infection triggers abortion or premature bond between interferon gamma and the
labor through pro-inflammatory cytokines interferon gamma receptor, the
production and activation (Renaund et researcher is interested in conducting
al., 2011). In addition to infectious research on this basis.
factors, non-infectious factors are also
consider to play a role in causing Research Method
abortion, including hormone
Research Design
abnormalities, chromosomal
abnormalities, immunological Observational research and the
abnormalities, uterine abnormalities and type chosen were cross sectional.
maternal diseases (Chunningham et al., Observational is research without giving
2014). treatment from researchers to the
subject. Researchers only observe
In normal pregnancy, the role and
behavior or characteristics and cause
balance between production and
and effect on an event.
interactions between various types of
cytokines, both pro-inflammatory (Th1) Sample and Population
and anti-inflammatory (Th2), greatly
determine the success and continuity of The sample of this study was
pregnancy. Gamma interferon (IFN-γ) is pregnant women who experienced
a pro-inflammatory cytokine secreted in spontaneous abortion triggered by
the uterus during early pregnancy, infection and non-infection. Pregnant
produced not only by natural killer cells women who experience abortion are
(NK cells) but also by trophoblast cells of grouped according to the triggers of
several species. Gamma interferon (IFN- infection and non-infection. The research
sample was taken at RSUD Saiful Anwar
in Malang and at RSUD Bangil.
Result
To find out the difference in IFN--
ɣ expression in spontaneous placental
abortion in infectious women and non-
infectious women, the analysis process
can be carried out using ANCOVA. The
analysis process using ANCOVA is
carried out with the consideration that
there are several confounding factors that
are expected to influence IFN - ɣ
expression - which includes age,
gestational age, education level, and
occupation. The following are the results
of analysis with ANCOVA using SPSS
software:
Table 1: ANCOVA analysis results of
IFN- ɣ Expressions Variable
Based on the ANCOVA analysis
results, it is shown that in the group
factor, the p-value is 0.000 (p <0.05). The
test results showed that there were
differences in IFN - ɣ expression that
were statistically significant in the group
of Infected women with a group of non-
infectious women.
As explained in the ANCOVA
analysis results, it was shown that there
was a difference in IFN - ɣ expression
which was statistically significant in the
group of Infected women with a group of
Non-Infected women. The following are
the results of further testing using LSD
5%:
100
p=0.000
Ekspresi IFN-g (%)
80
60
60.8 ±
40 15.9
24.3 ±
20
10.5
0
Infeksi Non-Infeksi
Diagram 1: Comparison of IFN-ɣ
Expressions in Infected Women and Non-
Infected Women
Based on Figure 5.1, it is shown
that the average expression of IFN - ɣ in
the infectious female group is 60.8 ±
15.9%. Whereas in the non-infectious
female group is 24.3 ± 10.5%. From this
test it is proven that IFN-ɣ expression in
infected women is higher than for Non-
Infected women.
Discussion
There was a significant difference
between IFN-ɣ receptor expression in the
infectious and non-infectious abortion
group (60.8 ± 15.9% and 24.3 ± 10.5%, p
= 0,000). Increased expression of IFN-ɣ
gamma interferon receptors shows a induces apoptosis from trophoblasts
cellular immune system response to causing abortion (He Y and Sun Q,
pathogens, especially viruses and 2018).
bacteria. IFN-ɣ can induce abortion
through Treg suppression and Th17 The conducted research shows
polarization. IFN-ɣ levels that are that most spontaneous abortions that
sufficiently needed in the first trimester of occur often are associated with the
pregnancy are characterized by the presence of severe infectious and
discovery of IFN-ɣ in the supernatant of inflammatory agents. There was

first trimester pregnant women but not in evidence that most of the placenta
the second and third trimesters. IFN-ɣ obtained from the spontaneous abortion
levels that are maintained high will cause patients scraping showed pathological
interference with fetal development. Treg signs that could occur from a number of
suppression causes loss of maternal pathogenic agents. Known infections are
immunity protective factors to tolerate associated with abortion, namely
fetal implantation (Liu et al., 2014). Vaginosis bacterial, malaria, CMV,
dengue fever, brucellosis and HIV. The
Infection is one of the factors presence of infection can cause
causing spontaneous abortion that can activation of the unbalanced immune
induce an inflammatory response and system causing a maternal rejection of
cellular inflammation mediator. The the fetus (Giakoumelou et al., 2015).
presence of infectious agents can trigger
Th1 and Th2 cellular immune responses. Research conducted to determine
Inappropriate Th1 and Th2 responses the mechanism for the occurrence of
during pregnancy can cause abortion. abortion in response to pathogenic

The literature study reveals that decidua
and syncytiotrophoblasts can synthesize
IFN-ɣ in sufficient levels to support the
success of pregnancy, especially in the
implantation phase. If an infection occurs
at this stage, it can trigger an imbalance
agents (bacterial and viral) needs to
consider several important factors. The
first factor, the entry route of pathogenic
agents into the host determines how the
inflammatory response occurs, so it is
thought that the mechanism underlying

of the immune response. Th1 cytokines the initiation of abortion depends on the
are known as proinflammatory cytokines. organ or tissue where the pathogenic
IFN-ɣ and TNF-α can cause impaired agent enters. Pathogens penetrate the

fetal development because at high levels placental barrier through various

it activates decidual macrophages and mechanisms. The CMV virus can
replicate trophoblast cells, epithelial cells,
stroma and macrophages which are the agents. Gamma interferon (IFN-γ) is the
target cells of the virus. In trophoblast main cytokine involved in the protective
cells, CMV can trigger an inflammatory immune response against microbial
response that increases apoptosis. CMV infections. The effects that are involved
has also been prven to activate IFN-ɣ, include activating macrophages to
thus triggering cell death (Chou et al., increase phagocytosis and the ability to
2006). From experiments Isolation of kill tumor cells activating and increasing
Mycoplasma hominis and Ureaplasma the growth of cytolytic T cells and NK
urelyticum found in the genital tract of cells (Ragupathy et al., 2008). Interferon
some women who experience abortion, gamma is also associated with the
shows that mycoplasma infection occurrence of abortion. In addition, as
regarding the genital tract is abortifacient, one of the proinflammatory cytokines,
so that it is suspected infection factor as gamma interferon (IFN-ɣ) produced by
a cause of abortion (Cunningham et al., pathogenic agents has been shown to be
2014). This condition is characterized by associated with embryonic resorption
an increase in pro-inflammatory cytokines (Entrican, 2002).
such as IFN-ɣ in amniotic fluid,
myometrium, decidua, fetal membrane, Interferon gamma known as IFN
and maternal serum (Jerala, 2017). The type II is produced as long as the
second factor, different pathogens can immune response takes place by T
provide a different inflammatory lymphocyte cells in the presence of T cell
response. The abortion occurrence specific antigens and natural killer cells
mechanism caused by infection by (NK cells) collected by IL-2, and are the
pathogens has not been clearly main cytokines involved in protective
explained. Bacteria, protozoa, and immune response against microbial
viruses, have different mechanisms in the infections. The effects it causes include
infection process of the host. Each activating macrophages to increase
pathogen will trigger a unique cascade in phagocytosis and the ability to kill tumor
relation to feto-maternal interactions cells as well as activating and increasing
(Moreno-Perez et al., 2013). the growth of cytolytic T cells and NK
cells. In the mechanism of IFN-γ abortion
Explanations that support the associated with a number of
initiation mechanism of different immune autoinflamatory and autoimmune
pathways with feto-maternal interactions diseases by activating the innate immune
by increasing pro-inflammatory cytokines system pathway. The most important
in response to infection with pathogenic factor of IFN-γ role in the immune system
is the ability to inhibit direct
replication, role (IFN-γ) as
immunostimulator and immunomodulator
(Ragupathy et al., 2008).
Interferon Gamma
regulates the expression of class I MHC
antigen, MHC class II, Fcγ receptor
expression on macrophages and other
cells including lymphocyte
endothelial cells, mast cells
fibroblasts so that IFN-γ affects the ability
of these cells to present antigens and is
an APC co-stimulator. By activating MHC
class II in endothelial cells, these cells
then become sensitive to the action of
class II specific cytolytic T cells.
Interferon Gamma (IFN-γ) increases Th1
cell expression production and prevents
Th2 cell proliferation (Ragupathy et al.,
2008).
In humans IFN-γ is secreted by
placental cells. Interferon gamma will
bind to the interferon gamma II receptor
(Bazer et al., 2013). Cytokines that have
an effect on the placenta include IL-2,
TNF-β (Maksheed et al., 2001). Hill and
colleaques (2008), conducted a study on
several women who had a history of
recurrent abortion, the results of this
study showed that there was an increase
in interferon gamma levels in abortion
women compared to normal pregnant
women. Research on genetic rats in the
CBA/J X DBA/2 type abortion model
found an increase in levels (IFN-γ) in the
viral abortion incidence (Renaud et al., 2011).
an
In the BALB/c rat model studies in
the incidence of abortion found an
increase in interferon gamma receptors in
(IFN-γ) the uterus (Liu et al., 2014). In the rat
model, IFN-ɣ has been shown to cause
fetal resorption through activation of NK
cells, macrophages, and Th1 type
cells, cytokines (Aisemberg et al., 2010).
and
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