Assessment of angiogenesis modulators in pregnant women with pre-eclampsia: a case-control study

Neuroserpin: A potential biomarker for early-onset severe preeclampsia

Preeclampsia is a hypertensive disease of pregnancy associated with intense inflammatory and pro-coagulant responses. Neuroserpin is a serine protease inhibitor that has been involved in neurological and immune processes and has not yet been investigated in preeclampsia. Herein, we evaluated neuroserpin levels in association with other inflammatory mediators (IL-17A, IL-33, and CXCL-16) during severe preeclampsia. The mediators' plasma levels were measured by immunoassays in 24 pregnant women with severe preeclampsia (early preeclampsia: N = 17, late preeclampsia: N = 7), 34 normotensive pregnant women, and 32 non-pregnant women. In general, pregnancy was associated with higher levels of neuroserpin, IL-17A, IL-33, and CXCL-16 than the non-pregnant state. However, this increase was attenuated in pregnancies complicated by severe preeclampsia. Although neuroserpin levels did not differ between normotensive pregnant women and pregnant women with severe preeclampsia, neuroserpin levels tended to be lower in early-onset than in late-onset severe preeclampsia. There were positive correlations between neuroserpin and IL-17A, neuroserpin and CXCL-16, and IL-17A and CXCL-16 levels in women with severe preeclampsia. In addition, although the risk for developing severe preeclampsia was higher in older women in this study, maternal age did not significantly influence the mediators' levels, nor their correlations in the preeclampsia group. In summary, our data suggest that neuroserpin might be a potential biomarker for early-onset severe preeclampsia and, that the imbalance among neuroserpin, IL-17A, IL-33, and CXCL-16 levels may be associated with the pathogenesis of preeclampsia, regardless of the maternal age.

Overexpression of microRNA-100-5p attenuates the endothelial cell dysfunction by targeting HIPK2 under hypoxia and reoxygenation treatment

MicroRNAs (miRNAs) are important regulators of many cellular processes, and the dysregulation of miRNAs is associated with various diseases. MiR-100-5p is revealed to be downregulated in gestational hypertension, while its underlying regulatory mechanism remains unclear. The pathological condition of gestational hypertension was mimicked by the hypoxia and reoxygenation (H/R) treatment to human placental microvascular endothelial cells (HPMECs). RT-qPCR and western blotting were conducted to detect the mRNA and protein expression of RNAs. HPMEC viability was assessed by CCK-8 assay. HPMEC angiogenesis was examined using tube formation assay. The concentrations of ANG-1 and ANG-2 in HPMECs were detected by ELISA. The binding relationship between miR-100-5p and homeodomain interacting protein kinase 2 (HIPK2) was investigated using luciferase reporter assay. MiR-100-5p was downregulated in HPMECs after H/R treatment. MiR-100-5p overexpression reversed the H/R-induced decrease in viability, angiogenesis of HPMECs. HIPK2 was targeted by miR-100-5p in HPMECs, and miR-100-5p negatively modulated HIPK2 expression at the mRNA and protein levels. MiR-100-5p activated the PI3K/AKT pathway by downregulating HIPK2. Rescue assays demonstrated that miR-100-5p promoted the viability and angiogenesis of H/R treated HPMECs by targeting HIPK2 to activate the PI3K/AKT pathway. MiR-100-5p overexpression inhibits the dysfunction of HPMECs under hypoxia and reoxygenation by downregulating HIPK2 to activate the PI3K/AKT pathway.

Maternal Serum Cytokine Concentrations in Healthy Pregnancy and Preeclampsia

The maternal immune response is essential for successful pregnancy, promoting immune tolerance to the fetus while maintaining innate and adaptive immunity. Uncontrolled, increased proinflammatory responses are a contributing factor to the pathogenesis of preeclampsia. The Th1/Th2 cytokine shift theory, characterised by bias production of Th2 anti-inflammatory cytokine midgestation, was frequently used to reflect the maternal immune response in pregnancy. This theory is simplistic as it is based on limited information and does not consider the role of other T cell subsets, Th17 and Tregs. A range of maternal peripheral cytokines have been measured in pregnancy cohorts, albeit the changes in individual cytokine concentrations across gestation is not well summarised. Using available data, this review was aimed at summarising changes in individual maternal serum cytokine concentrations throughout healthy pregnancy and evaluating their association with preeclampsia. We report that TNF-α increases as pregnancy progresses, IL-8 decreases in the second trimester, and IL-4 concentrations remain consistent throughout gestation. Lower second trimester IL-10 concentrations may be an early predictor for developing preeclampsia. Proinflammatory cytokines (TNF-α, IFN-γ, IL-2, IL-8, and IL-6) are significantly elevated in preeclampsia. More research is required to determine the usefulness of using cytokines, particularly IL-10, as early biomarkers of pregnancy health.

Elevated MicroRNA 183 Impairs Trophoblast Migration and Invasiveness by Downregulating FOXP1 Expression and Elevating GNG7 Expression during Preeclampsia

Preeclampsia (PE) is a hypertensive disorder of uncertain etiology that is the leading cause of maternal and fetal morbidity or mortality. The dysregulation of microRNAs (miRNAs) has been highlighted as a potential factor involved in the development of PE. Therefore, our study investigated a novel miRNA, miRNA 183 (miR-183), and its underlying association with PE. Expression of miR-183, forkhead box P1 (FOXP1), and G protein subunit gamma 7 (GNG7) in placental tissues of patients with PE was determined. Gain- and loss-of-function experiments were conducted to explore modulatory effects of miR-183, FOXP1, and GNG7 on the viability, invasion, and angiogenesis of trophoblast cells in PE. Finally, we undertook in vivo studies to explore effects of FOXP1 in the PE model. The results revealed suppressed expression of FOXP1 and significant elevations in miR-183 and GNG7 expression in placental tissues of PE patients. FOXP1 was observed to promote proliferation, invasion, and angiogenesis in human chorionic trophoblastic cells. miR-183 resulted in depletion of FOXP1 expression, while FOXP1 was capable of restraining GNG7 expression and promoting the mTOR pathway. The findings confirmed the effects of FOXP1 on PE. In conclusion, miR-183 exhibits an inhibitory role in PE through suppression of FOXP1 and upregulation of GNG7.

Preeclamptic Women Have Decreased Circulating IL-10 (Interleukin-10) Values at the Time of Preeclampsia Diagnosis: Systematic Review and Meta-Analysis

A key immunomodulatory cytokine, IL-10 (interleukin-10), has been shown to be dysregulated in preeclampsia, a pregnancy-specific hypertensive disorder, further characterized by multi-system involvement. However, studies have reported inconsistent findings about circulating IL-10 levels in preeclamptic versus normotensive pregnancies. The aim of the present systematic review and meta-analysis was to assess circulating IL-10 levels in preeclamptic and normotensive pregnancies at 2 time points: before, and at the time of preeclampsia diagnosis. PubMED, EMBASE, and Web of Science databases were searched to include all published studies examining circulating IL-10 levels in preeclamptic and normotensive pregnancies. Differences in IL-10 levels were evaluated by standardized mean differences. Of 876 abstracts screened, 56 studies were included in the meta-analysis. Circulating IL-10 levels were not different before the time of active disease (standardized mean differences, -0.01 [95% CI, -0.11 to 0.08]; P=0.76). At the time of active disease, women with preeclampsia (n=1599) had significantly lower IL-10 levels compared with normotensive controls (n=1998; standardized mean differences, -0.79 [95% CI, -1.22 to -0.35]; P=0.0004). IL-10 levels were lower in both early/severe and late/mild forms of preeclampsia. Subgroup analysis revealed that IL-10 measurement methodology (ELISA or multiplex bead array) and the sample type (plasma or serum) significantly influenced the observed differences, with the use of sera paired with ELISA technology providing the best distinction in IL-10 levels between preeclamptic and normotensive pregnancies. These findings support the role of decreased IL-10 levels in the pathophysiology of preeclampsia. Future studies should address the therapeutic potential of IL-10 in preeclampsia.

Circulating levels of IFN-γ, IL-1, IL-17 and IL-22 in pre-eclampsia: A systematic review and meta-analysis

OBJECTIVE

Pre-eclampsia (PE) is a common multi-systemic disease, and the effect of cytokines on PE is not clear. The purpose of this meta-analysis was to evaluate the circulating levels of interferon gamma (IFN-γ), interleukin (IL)-1, IL-17 and IL-22 in patients with PE.

STUDY DESIGN

Relevant studies were identified after a preliminary investigation of studies published up to May 2019 using PubMed and Embase. In this study, all 27 included articles underwent quality rating, with a total of 495 patients with PE and 557 controls. Among them, eight papers and 932 subjects contributed to the meta-analysis of IFN-γ, and six papers and 343 subjects contributed to the meta-analysis of IL-17. Based on the inclusion and exclusion criteria, the retrieved papers were screened and evaluated independently. Relevant data for IFN-γ and IL-17 were extracted for meta-analysis and subgroup analysis, and the stability of the results was evaluated by sensitivity analysis. At the same time, a systematic evaluation was carried out for IL-1 and IL-22 with a small number of included papers.

RESULTS

Several papers included in the systematic review showed that the circulating levels of IL-22 were higher in patients with severe PE than in controls, while IL-1 levels did not differ significantly between the two groups. The meta-analysis showed that patients with PE had higher circulating levels of IFN-γ than controls [standardized mean difference (SMD) 1.45, 95 % confidence interval (CI) 0.56-2.34]. There was no evidence of a difference in the circulating levels of IL-17 between patients with PE and controls (SMD 0.53, 95 %CI -0.43 to 1.48).

CONCLUSION

This meta-analysis suggested that changes in circulating levels of IFN-γ might be associated with PE.

Serum Levels of Angiogenic Factors Distinguish Between Women with Preeclampsia and Normotensive Pregnant Women But Not Severity of Preeclampsia in an Obstetric Center in Turkey

Background

This study aimed to compare serum levels of vascular endothelial growth factor (VEGF) and the VEGF receptors, VEGFR-1 and VEGFR-2, free placental growth factor (fPGF), endostatin, and serum pregnancy-associated plasma protein-A (PAPP-A) levels in women with mild and severe preeclampsia and healthy pregnant women.

Material/Methods

A included patients diagnosed with mild preeclampsia (n=32), severe preeclampsia (n=32), and healthy pregnant women (n=24). Serum levels of VEGF-A, VEGFR-1, VEGFR-2, fPGF, endostatin, and PAPP-A levels were measured by enzyme-linked immunosorbent assay (ELISA).

Results

In women with mild and severe preeclampsia, the gestation age at birth and birth weight were found to be significantly lower than the control group (p<0.001). Serum levels of endostatin, VEGFR-1, and VEGF-A levels were significantly increased in pregnant women with preeclampsia compared with healthy pregnant women (p<0.001). Serum levels of PAPP-A, VEGFR-2, and fPGF were significantly higher in healthy pregnant women when compared with women with preeclampsia (p=0.024, p<0.001, and p<0.001, respectively), but there were no significant differences between women with mild and severe preeclampsia.

Conclusions

Reduced serum levels of the angiogenic factors PAPP-A, VEGFR-2, and fPGF distinguished between women with preeclampsia and normotensive pregnant women but did not significantly distinguish between mild and severe preeclampsia.

Glutathione-S-transferase M1 polymorphism and pro-inflammatory cytokines tumour necrosis factor-α and interleukin-1β are associated with preeclampsia in Serbian women

PROBLEM

Preeclampsia has a multifactorial origin with genetic, immunological, and environmental factors described as main contributors to its onset. This study aimed to investigate glutathione-S-transferase M1 (GSTM1) and glutathione-S-transferase T1 (GSTT1) gene polymorphisms, the expression of pro-inflammatory cytokines (TNF-α, IL-1β, IL-6), and the potential relationship between GST polymorphisms and cytokine expression levels in preeclampsia and uncomplicated pregnancy.

METHOD OF STUDY

This prospective case-control study included 50 women with preeclampsia and 50 healthy pregnant women. DNA and RNA were extracted from women leukocytes. Deletion polymorphisms were analyzed by PCR, while cytokine mRNA expression was analyzed by real-time PCR.

RESULTS

GSTM1 null genotype with present GSTT1 increased the risk for preeclampsia development. Deletion of GSTT1 without deletion of GSTM1 increased the risk for early preeclampsia. Relative mRNA expression of TNF-α was significantly higher in preeclampsia compared to healthy pregnant women (P = 0.006). Expression of IL-1β was significantly higher in severe and late preeclampsia compared to the control group (P = 0.005, P = 0.007, respectively). A significant positive correlation between TNF-α and IL-1β was observed (Spearman's ρ = 0.312, P = 0.028) and between IL-1β and IL-6, in preeclampsia group (Spearman's ρ = 0.296, P = 0.037). IL-1β was significantly increased in patients with GSTT1 null genotype (P = 0.015) while IL-6 was increased in patients with GSTM1 null genotype (P = 0.015).

CONCLUSIONS

GSTM1 null genotype represents a risk factor for preeclampsia development, while GSTT1 null genotype favors early preeclampsia. Preeclampsia is also associated with increased expression of pro-inflammatory cytokines, predominantly TNF-α and IL-1β.

The role of interleukins in preeclampsia: A comprehensive review

Preeclampsia is a multi-system hypertensive disorder of pregnancy, with significant rates of maternal and neonatal morbidity. It represents a major cause of preterm birth, as definitive treatment demands fetal delivery. Although its pathophysiology is complicated, placental hypoxia and endothelial dysfunction constitute established pathogenetic steps of the disease. Inflammation is considered to be a crucial mediator of preeclampsia process, as an imbalance between T_H 1, T_H 2, and T_H 17 immune responses is observed. The present review accumulates current knowledge about the contribution of interleukins in preeclampsia, summarizing the pathways through which each interleukin exerts its function in the disease. Also, the role of genetic polymorphisms is explored and the predictive efficacy of maternal serum interleukin levels is evaluated. Finally, recommendations about the safe interpretation of the outcomes, as well as guidance for future research, are provided.

Preeclampsia and coronary plaque erosion: Manifestations of endothelial dysfunction resulting in cardiovascular events in women

Atherosclerosis is the major underlying pathology of cardiovascular disease (CVD). The risk for CVD is increased in women with a history of preeclampsia. Multiple studies have indicated that accelerated atherosclerosis underlies this increased CVD risk. Furthermore, it has been suggested that endothelial dysfunction and inflammation play an important role in the increased CVD risk of women with preeclampsia. Rupture or erosion of atherosclerotic plaques can induce the formation of thrombi that underlie the onset of acute clinical CVD such as myocardial infarction and stroke. In relatively young women, cardiovascular events are mainly due to plaque erosions. Eroded plaques have a distinct morphology compared to ruptured plaques, but have been understudied as a substrate for CVD. The currently available evidence points towards lesions with features of stability such as high collagen content and smooth muscle cells and with distinct mechanisms that further promote the pro-thrombotic environment such as Toll Like Receptor (TLR) signaling and endothelial apoptosis. These suggested mechanisms, that point to endothelial dysfunction and intimal thickening, may also play a role in preeclampsia. Pregnancy is considered a stress test for the cardiovascular system with preeclampsia as an additional pathological substrate for earlier manifestation of vascular disease. This review provides a summary of the possible common mechanisms involved in preeclampsia and accelerated atherosclerosis in young females and highlights plaque erosion as a likely substrate for CVD events in women with a history of preeclampsia.

Total and Fetal Circulating Cell-Free DNA, Angiogenic, and Antiangiogenic Factors in Preeclampsia and HELLP Syndrome

BACKGROUND

Preeclampsia (PE) is a hypertensive disorder of pregnancy characterized by hypertension and proteinuria. The HELLP syndrome is the most severe form of PE. The aim of the present study was to determine different potential biomarkers that may help us perform an early diagnosis of the disease, assess on the severity of the disease, and/or predict maternal or fetal adverse outcomes.

METHODS

We measured serum levels of total and fetal circulating cell-free DNA (cfDNA), soluble endoglin, soluble form of vascular endothelial growth factor receptor, and placental growth factor in a healthy control group of pregnant women (n = 26), patients with mild (n = 37) and severe PE (n = 25), and patients with HELLP syndrome (n = 16).

RESULTS

We observed a gradual and strong relationship between all the biomarkers mentioned and the range of severity of PE, with the highest levels in patients with HELLP syndrome. Nevertheless, only the values of total cfDNA were able to significantly differentiate severe PE and HELLP syndrome (20957 ± 2784 vs. 43184 ± 8647 GE/ml, P = 0.01). Receiver operating characteristic (ROC) curves were constructed (i) for the healthy group with respect to the groups with PE and (ii) for patients with PE with respect to the group with HELLP syndrome; sensitivity and specificity values at different cutoff levels were calculated in each case. The maximum ROC area under the curve value for PE and HELLP syndrome (with respect to controls) was 0.91 (P < 0.001).

CONCLUSIONS

The measured biomarkers of cell damage, angiogenesis, and antiangiogenesis may reflect the severity of PE, with higher levels in patients who develop HELLP syndrome. In addition, these biomarkers may also help predict adverse fetal and maternal outcomes.

Intra-laboratory validated human cell-based in vitro vasculogenesis/angiogenesis test with serum-free medium

Vasculogenesis and angiogenesis are the processes by which new blood vessels are formed. We have developed a serum-free human adipose stromal cell and umbilical cord vein endothelial cell based vasculogenesis/angiogenesis test. In this study, the test was validated in our GLP laboratory following the OECD Guidance Document 34 [1] using erlotinib, acetylic salicylic acid, levamisole, 2-methoxyestradiol, anti-VEGF, methimazole, and D-mannitol to show its reproducibility, repeatability, and predictivity for humans. The results were obtained from immunostained tubule structures and cytotoxicity assessment. The performance of the test was evaluated using 26 suspected teratogens and non-teratogens. The positive predictive value was 71.4% and the negative predictive value was 50.0%, indicating that inhibition of vasculogenesis is a significant mechanism behind teratogenesis. In conclusion, this test has great potential to be a screening test for prioritization purposes of chemicals and to be a test in a battery to predict developmental hazards in a regulatory context.

First and second trimester immune biomarkers in preeclamptic and normotensive women

INTRODUCTION

Circulating immune markers may be associated with preeclampsia but further investigations in early pregnancy and among preeclampsia subtypes are warranted. We examined immune markers in 208 preeclamptic women and 411 normotensive controls.

METHODS

Our study was nested within the Collaborative Perinatal Project. A total of 242 women had first trimester serum samples and 392 had second trimester serum samples. Preeclampsia was defined as hypertension >20weeks of gestation with proteinuria or pulmonary edema, oliguria, or convulsions. Preterm preeclampsia was defined as preeclampsia with delivery less than 37weeks of gestation. Associations between immune markers RANTES, interleukin (IL)-6, IL4, IL5, IL12, IL10, IL8, IL1-beta, interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha and beta, transforming growth factor (TGF)-beta and preeclampsia were explored using a modified version of cox regression developed to address data with non-detectable levels. Models were adjusted for body mass index, gestational age of blood sampling, fetal sex, smoking, socioeconomic status and maternal age.

RESULTS

In first trimester samples, IL-12 was associated with preeclampsia (p=0.0255). IFN-gamma (p=0.0063), IL1-beta (p=0.0006), IL5 (p=0.0422) and TNFr (p=0.0460) were associated with preterm preeclampsia only. In second trimester samples, IL1-beta was associated with preeclampsia (p=0.0180) and term preeclampsia (p=0.0454). After correction for multiple comparisons, only IL1-beta remained associated with preterm preeclampsia in the first trimester (p=0.0288).

DISCUSSION

Elevated first trimester IL1-beta appears to be associated with preterm preeclampsia. However, few associations were observed in the second trimester. Systemic immune markers alone may not be useful for preeclampsia prediction.

Using the angiogenic factors sFlt-1 and PlGF with Doppler ultrasound of the uterine artery for confirming preeclampsia

PURPOSE

The aim of this study is to assess the value of the angiogenic factors for diagnosing preeclampsia and predicting the severity of manifestation. A secondary aim is assessing the combination of the uterine artery Doppler with the angiogenic factors for improving the diagnostic power.

METHODS

This is a prospective single center study in a tertiary referral hospital. This study includes 728 individual patients. Inclusion criteria were singleton pregnancies, a referral to the hospital with suspicion of preeclampsia and any one or combination of the following symptoms: headache, upper abdominal pain, edema, and hypertension. Patients with complications that would affect the course of the pregnancy, such as placenta praevia, premature preterm rupture of membranes, breech presentation, and fetal chromosomal or structural anomalies, were excluded from the study. Blood samples collection and uterine artery Doppler ultrasound were performed at time of recruitment. The differences in sFlt-1, PlGF, and their quotient among normal collective and patients with preeclampsia were analyzed. Doppler ultrasound was performed by one of four highly qualified sonographers. Wilcoxon-Mann-Whitney U test, Spearman's rank correlation, receiver operating characteristic curves, Chi-square test, and logistic regression were used in the analysis.

RESULTS

A total of 1003 individual samples for the angiogenic factors were included in the analysis. 584 out of the recruited 728 patients had follow-up data with delivery information at the study hospital. Patients with preeclampsia show a significant increase in sFlt-1, which directly correlate with the increased severity of manifestation (Spearman's ρ 0.49). The sFlt-1 cut-off value of 5424 pg/ml confirms preeclampsia with 83.7 % sensitivity, 68.1 % specificity, and 24 % misclassification rate. Preeclampsia patients also show a significant decrease in PlGF, which negatively correlates with the increased severity of manifestation (Spearman's ρ -0.39). A PlGF cut-off value of 118 pg/ml confirms preeclampsia with 47.6 % sensitivity, 71.4 % specificity, and 27 % misclassification rate. Logistic regression shows that a combination of the quotient from sFlt-1/PlGF with notching and uterine artery PI provides a valid model for diagnosing preeclampsia with a diagnostic power of 74.4 %.

CONCLUSIONS

The study confirms the use of the sFlt-1 and PlGF for diagnosing preeclampsia. It also shows their significance in differentiating between different categories of preeclampsia according to severity. This study shows that the use of angiogenic factors in combination with ultrasound findings provides valid models for confirming preeclampsia.