The increased of MMP-9 and MMP-2 with the decreased of TIMP-1 on the uterosacral ligament after childbirth

Introduction Pelvic floor dysfunction is one of the causes of morbidity that have very active role in the degradation of collagen and elastin through an intermediary changes in matrix metalloproteinases (MMP) and its regulation. This research to evaluate level of MMP-9, MMP-2 and TIMP-1 expression on uterosacral ligament in women after vaginal delivery. Methods This research was conducted by collecting samples in consecutive sampling of biopsy uterosacral ligament from primigravida who underwent cesarean section because of obstructive labor at stage 1 and 2. As control, biopsy samples were taken from uterosacral ligament of primigravida a term who have not entered the labor phase and undergoing elective caesarean section surgery. The method in this study was cross sectional. The examination of MMP-9, MMP-2, and TIMP-1 expression by immunohistochemistry based on comparison of the sample and the control differences. Results There are differences in the levels of Matrix Metalloproteinase-9, Matrix Metalloproteinase-2, and TIMP-1 in the uterosacral ligament of primigravida women in labor compared with women who are never in labor. Conclusion There are increased levels of Matrix Metalloproteinase-9 and Matrix Metalloproteinase-2 with the decreased of TIMP-1 in the uterosacral ligament of primigravida women who underwent cesarean section because of obstructive labor at stage 1 and 2.


Introduction
Pelvic floor dysfunction is one of the causes of morbidity that can degrade the quality of high prevalence life, although the main cause is unknown [1]. Pelvic organ prolapse (POP) or urogenital prolapse, is a decline in the pelvic organs that cause protrusion of the vagina, uterus or both. This situation can damage the walls of the anterior, posterior vagina, and uterus or vagina peak, which is generally seen as a combination of several circumstances above [2]. It is estimated that 11% of all women have underwent at least one surgical procedure POP [3]. In 1997, more than 225,000 patients who have pelvic organ prolapse surgery in the USA (22.7/10000 women), with estimates of more than 1 billion financing US$. POP is an indication of the hysterectomy in postmenopausal women and about 15-18% of all procedures in all age groups. This condition rarely causes severe morbidity or mortality; but quite a symptomatic lower genital, urinary and gastro intestinal tract that can affect women daily activities and quality of women life [2]. Although the mechanism of pelvic organ prolapse in women and the factors that led to the failure of the repair operation is not yet fully understood, there are some evidences to suggest that abnormalities in the structure of connective tissue is a predisposing factor [1]. In spite of the high incidence of POP, only a little cases is known underlying pathophysiological basis. Age, occupation, weight/body mass index (BMI), parity, type of delivery, vaginal delivery using a vacuum or forceps, the child´s weight biggest born, surgical history, history of medical ailments, menopausal status and the use of hormone replacement therapy are risk factors which often associated with the incidence of POP [4]. The process of pregnancy and childbirth are closely related to the incidence of pelvic organ prolapse. This is because the fetus through the birth canal during delivery causes maximum distensibility in the pelvic floor, causing an injury to the pelvic floor. In addition, tissue trauma including pelvic floor can be followed by imperfect healing of laceration postpartum so it will cause permanent damage to the network. This damage causes the failure of the pelvic floor serves as a support and thus increases the risk of pelvic organ prolapse [5].
The strength of the pelvic organs rely on muscle and loose connective tissue that binds to bone to form a proponent of the pelvic floor that is beneath the abdominal cavity [6]. Pelvic organs are supported by the pelvic floor muscles and fascia attachments on endopelvic [2]. The knowledge of the normal pelvic organ support is required to understand the pathophysiology of pelvic organ prolapse. The strength of the pelvic floor ligaments and fascia that vary among individuals is one of the important factors of prolapse incidence. One important part of the pelvic supporting system is the pelvic uterosacral ligament. This ligament provides major support to the cervix and upper vagina wall [7]. In vitro studies indicate that the cervical portion of the uterosacral ligament supporting over 17 kg weight before decreasing function [1]. The key element of this network is the quantity of stability, ultra structure, and organization of extracellular matrix proteins such as collagen, fibronectin, and elastin, includes receptors such as integrins [8]. The degradation process depends on the activity of matrix metalloproteinases (MMP) and its regulation, activation or sequestration growth factor, growth factor binding protein, cell surface receptors, and adhesion between cells. MMP is a protein that is structurally interconnected that degrade the extracellular matrix and basement of membrane components. The degradation process of collagen and elastin is mainly depend on the activity of regulatory MMP [9]. There is an Statistical analysis: Independent sample t test is a statistical analysis method to prove the hypothesis of the study that has been submitted. It will be used to test the statistical parametric to compare the mean of the levels of MMP-9, MMP-2 and TIMP-1 in the sacrouterine ligament among inpartu pregnant women and noninpartu pregnant women. The criteria for the decision was by looking at the value of p-value, if it was greater than the significance level α=0.05 then the conclusion will be there was no significantly increase/decrease in inpartu pregnant women and if it is smaller than the significance level α=0.05, the conclusion will be there was an significantly increase/decrease in inpartu pregnant women. Before the data samples were analyzed using t-test (one side/one-tailed) mentioned above, the data will be analyzed with the prerequisite parametric test data normality by using Normal Probability Plot test, the value of the ratio of inclination and kurtosis ratio. The decision criteria when the Normal Probability Plot observed values around a diagonal line (green) and no observed values are out of the red boundary lines and the value of the ratio of inclination and kurtosis ratio is between -2 and +2, then concluded that the data were normally distributed [10]. As for all the calculation used data analysis software tools GENSTAT

Results
The result showed that there are significant differences mean levels

Discussion
In the comparative test results mean levels of MMP-9, MMP-2 in the sacrouterine ligament of women in labor groups compared to Page number not for citation purposes 4 women who are not in labor groups using independent samples ttest (independent sample t test) showed no statistically significant difference (p < 0.001). The presence of strain during childbirth which significantly affects the levels of Matrix Metalloproteinase-9 and MMP-2 are found in the extracellular matrix at uterosacral ligaments of pregnant women in labor. This process allows the baby's head stretches the stress strain of the pelvic floor tissue [11].
Stimuli strain which received by the extracellular matrix (MES) will be delivered to this .Stimuli fibroblast cells will through the role of integrins and fibronectin. This stimuli will give a signal to fibroblasts to differentiate and provide a signal transduction pathway to upregulation of MMP-9 and TIMP-1 [12]. MMP-9 thought to be related to cell migration, invasion and tissue remodeling in the reproductive process [13]. In the mouse model, the pregnancy