Evidence that prostacyclin deficiency is a specific feature in preeclampsia

Vegetarian diets during pregnancy: effects on the mother's health. A systematic review

While interest in vegetarian nutrition has been steadily increasing, some aspects have not yet been consistently investigated. One topic requiring evidence-based confirmation is the adoption of a vegetarian diet during pregnancy and lactation. Maternal diet is not only correlated with the fetus's and infant's health, but appears relevant for that of the mother as well. Not only is an adequate delivery of nutrients to the fetus and infant mandatory, but the increased physiological needs of the maternal body require an adequate supply of nutrients and can represent harmful stress events that may lead to well-defined pathological conditions. In this review, we aim to systematically investigate state-of-the-art of vegetarian diets during pregnancy and lactation, focusing on maternal nutritional status and pregnancy outcomes. Data are scarce, often inconsistent and not homogeneous for many of the topics we considered, mainly because only a few studies have been performed in developed countries, whereas other studies have derived from developing countries, where vegetarianism can be a proxy indicator of malnutrition. For this reason, we did not find sufficient data to provide evidence-based information and recommendations. To date, the available literature does not clearly support a negative impact on the mother's health and pregnancy outcomes, but, analogously with the findings in the vegetarian adult population, an improvement in the quality of studies might facilitate finding more information on the possible positive impact of well-planned vegetarian diets during pregnancy and lactation. More epidemiological and interventional studies are warranted, in order to address the question as to whether vegetarian nutrition represents an advantage for the mother or poses nutritional issues that need further attention.

Eicosanoids and preterm labour

Products of arachidonic acid metabolism (eicosanoids, e.g. some prostaglandins and leukotrienes) have important roles in the maintenance of pregnancy, and certain diseases of pregnancy such as pregnancy-induced hypertension and the machanism(s) of parturition both at term and before term. The volume of literature describing these last relationships dictates that the present review has to be focused rather than global in nature. Only studies of preterm labour in women and the use of human tissues will be discussed in detail despite the limitations in experimental designs that are imposed on such studies. Emphasis will be placed on studies of cyclo-oxygenase and to a lesser extant lipoxygenase pathways of arachidonic acid metabolism mentioning only briefly the pathways for catabolism of these eicosanoids. It should be noted also that eicosanoids from the epoxygenase pathways and those not derived from arachidonic acid will not be discussed here. The review of literature will not be comprehensive but rather selective in order to focus on specific issues of importance or controversy. In developing concepts of regulation I have emphasized studies with amnion since this tissue has received most attention experimentally. The significance of the eicosanoids in the mechanisms of labour at term and before will be described primarily in a section in which I have attempted to deleneate those regulatory mechanisms that are considered most significant in, or specific to, pregnancy and parturition. Studies of labour at term will be freely interspersed with studies specific to preterm labour since the latter are limited, and we need a ‘strandard’ for comparison; moreover, results from one series of studies helps the development of concepts for the other. Finally, the reader is directed to several excellent reviews that concentrate on areas not emphasized in this review.1–7

Eicosanoids in preeclampsia

Preeclampsia is characterized by an imbalance between two cyclooxygenase metabolites of arachidonic acid, thromboxane and prostacyclin, that favors thromboxane. Because of the biologic actions of these two eicosanoids, this imbalance might explain major clinical symptoms of preeclampsia, such as hypertension, platelet aggregation and reduced uteroplacental blood flow. In the maternal circulation, this imbalance is primarily manifested by decreased production of prostacyclin by endothelial cells. Platelet thromboxane synthesis is only increased in severe preeclampsia. In the placenta and in leukocytes, the imbalance is exacerbated by increased production of thromboxane coupled with decreased production of prostacyclin in both mild and severe preeclampsia. Longitudinal measurements of urinary metabolites of thromboxane and prostacyclin reveal that the thromboxane/prostacyclin imbalance predates the onset of clinical symptoms of preeclampsia. The imbalance between thromboxane and prostacyclin is most likely caused by oxidative stress, which is manifest in preeclampsia by increased lipid peroxidation and decreased antioxidant protection. Oxidative stress may drive this imbalance because lipid peroxides activate the cyclooxygenase enzyme to increase thromboxane synthesis, but at the same time they inhibit prostacyclin synthase to decrease prostacyclin synthesis. Low-dose aspirin therapy (50-150 mg/day) has been considered for the prevention of preeclampsia because it selectively inhibits thromboxane synthesis. Several studies reported dramatic decreases in the incidence of preeclampsia with low-dose aspirin therapy. However, two large multicenter studies reported only modest decreases, which dampened enthusiasm. The two large studies were "intent to treat" studies which included patients who were noncompliant and who discontinued the use of aspirin. In one of the studies for which compliance statistics were available only 53% of the aspirin group had a compliance rate greater than 75%, which raises a question as to whether the effectiveness of aspirin was being tested. Low-dose aspirin therapy should not yet be dismissed for the prevention of preeclampsia, but be reconsidered with emphasis on compliance using doses of aspirin in the range of 100-150 mg/day combined with antioxidants.

An imbalance between prostacyclin and thromboxane in relation to cerebral blood flow in neonates with maternal preeclampsia

OBJECTIVE

A disturbance of prostacyclin (PGI2) and thromboxane A2 (TXA2) balance has been reported in preeclampsia. However, little is known about the concentrations of these prostanoids in neonates born to preeclamptic pregnant women. The purpose of this study is to determine whether the PGI2 and TXA2 concentrations are altered and whether the prostanoid balance correlates to the cerebral blood flow in neonates born to preeclampsia.

METHODS

Spontaneously voided urine samples were collected from 20 neonates of normotensive and 16 neonates of preeclamptic women during the first 24 h after birth. We measured by radioimmunoassay the concentrations of urinary 6-keto-prostaglandin F1alpha (6-keto-PGF1alpha) and 11-dehydro-thromboxane B2 (11-dehydro-TXB2), respectively. Blood flow velocity in the middle cerebral artery was studied by pulsed Doppler ultrasonography in the neonates between 17 and 38 h after birth.

RESULTS

There was no significant difference between the urinary 6-keto-PGF1alpha in the neonates of mothers with and without preeclampsia (median, 5.3 vs. 3.6 ng/mg of creatinine). In contrast, the urinary 11-dehydro-TXB2 and the ratio of 11-dehydro-TXB2 to 6-keto-PGF1alpha in the neonates of mothers with preeclampsia were significantly lower as compared with the neonates without preeclampsia, respectively (13.7 vs. 20.6 ng/mg of creatinine and 3.0 vs. 5.2, median). The resistance index in the middle cerebral artery was significantly reduced in the neonates with preeclampsia than without preeclampsia (0.67 +/- 0.01 vs. 0.74 +/- 0.02, mean +/- SEM).

CONCLUSIONS

There was an association between maternal preeclampsia and the imbalance in the neonatal urinary excretion of PGI2 and TXA2 metabolites. This imbalance may contribute to the regulation of cerebral blood flow.

Maternal cigarette smoking increases F2-isoprostanes and reduces prostacyclin and nitric oxide in umbilical vessels

The objective of this study was to evaluate the influence of smoking on F2-isoprostanes, prostacylin and nitric oxide in human umbilical vessels. Umbilical cords from 13 babies of smoking mothers and from 28 babies of non-smoking mothers were examined for levels of F2-isoprostanes, prostacyclin, L-arginine, and L-citrulline. Forty-one umbilical arteries and eleven umbilical veins were analyzed. Statistical analysis of data was done using modified t-test. Cigarette smoking increased F2-isoprostane levels and reduced the generation of prostacyclin, L-arginine and L-citrulline comparably in umbilical arteries and veins. Notably, in umbilical cords of babies of non-smoking mothers the F2-isoprostane level was significantly higher in arteries. Cigarette smoking correlates with a direct vasoconstrictive effect. We suggest that smoking might enhance the vasoconstrictory capacity in umbilical arteries by increased F2-isoprostanes and by a simultaneous decrease in the production of the vasodilatory compounds, prostacyclin, and nitric oxide.

Increased levels of intercellular adhesion molecules and vascular cell adhesion molecules in pre-eclampsia

OBJECTIVE

To investigate the correlation between soluble forms of the intercellular adhesion molecule (sICAM-1) and vascular cell adhesion molecule (sVCAM-1) and the severity of pre-eclampsia or its possible consequences for fetal growth.

DESIGN

Prospective observational study.

SETTING

Institute of Medical Genetics, University of Oslo, Department of Medical Genetics and Haematological Research Laboratory, Ullevål University Hospital; and the Department of Obstetrics and Gynaecology, The National Hospital, Oslo, Norway.

PARTICIPANTS

Seventy-six women with normotensive pregnancies and 157 women with pre-eclampsia divided into three subgroups: mild, severe and pre-eclampsia with fetal growth retardation.

METHODS

ELISA-measurements of plasma sICAM-1 and sVCAM-1 were performed in a group of healthy pregnant normotensive women and three groups of women with varying degrees of pre-eclampsia.

RESULTS

sICAM-1 concentrations were higher in the pre-eclampsia group compared with the control group, but this difference was not statistically significant. Plasma concentrations of sVCAM-1 were significantly greater (P < 0.0001) in all pre-eclampsia subgroups (835.34, 855.25 and 964.05 ng/mL) compared with the control group (667.62 ng/mL). Within the pre-eclampsia group, plasma concentration of sVCAM-1 was significantly higher in the subgroup exhibiting fetal growth retardation (P = 0.03) compared with mild pre-eclampsia.

CONCLUSION

The observed increases in plasma concentrations of sVCAM-1 suggest that measurements of this adhesion molecule may be useful in monitoring pregnancies with respect to the development of pre-eclampsia or fetal growth retardation.

Calcium supplementation prevents pregnancy-induced hypertension by increasing the production of vascular nitric oxide

Pregnancy-induced hypertension (PIH) remains a common cause of maternal and fetal morbidity and mortality. During the past 7 years, some progress has been made in the prevention of PIH. Specifically, clinical studies have shown that supplementation with calcium can significantly reduce the frequency of PIH, specially in populations with a low calcium intake. We have suggested that, in such a population, calcium supplementation is a safe and effective measure for reducing the frequency of PIH. Thus, the purpose of this article is to advance a hypothesis about the mechanism by which calcium supplementation reduces the risk of PIH. We propose that dietary calcium supplementation reduces the frequency of PIH by maintaining the serum ionized calcium level which is crucial for the production of endothelial nitric oxide, the increased generation of which maintains the vasodilatation that is characteristic of normal pregnancy.

Activities of phospholipase A2, cyclooxygenase, and PGI2 synthase of umbilical venous endothelial cells in preeclamptic women

To elucidate the cause of low prostacyclin (PGI2) production in severe preeclampsia (PE), we studied the activities of phospholipase A2, cyclooxygenase, and PGI2 synthase in umbilical venous endothelial cells obtained from healthy pregnant women and from patients with mild or severe PE. Umbilical venous endothelial cells homogenized in a buffer solution were analysed by calculating the apparent Vmax (mean +/- SEM: p mol/min mg protein) and Km (mean +/- SEM: microM) values for phospholipase A2 activity by the release of arachidonic acid from phosphatidylcholine, for the activity of a complex of cyclooxygenase and PGI2 synthase by the conversion of arachidonic acid to PGI2, and the activity of PGI2 synthase by conversion of PGH2 to PGI2. The phospholipase A2 activity of normal-pregnancy cells (Vmax: 17.0 +/- 2.7 Km: 0.26 +/- 0.04) (n = 10) significantly exceeded that of cells from women with either mild PE (5.8 +/- 0.5, 0.12 +/- 0.02) (n = 4) or severe PE (6.3 +/- 2.0, 0.08 +/- 0.03) (n = 5). The apparent combined activity of cyclooxygenase and PGI2 synthase in mild PE (552 +/- 142, 0.29 +/- 0.07) (n = 8) significantly exceeded that of a normal pregnancy (176 +/- 42, 0.76 +/- 0.25) (n = 7), whereas that in severe PE (326 +/- 36, 3.26 +/- 0.78) (n = 3) was significantly lower than that of a normal pregnancy. PGI2 synthase activity in mild PE (305 +/- 50, 0.12 +/- 0.07) (n = 4) exceeded that of a normal pregnancy (220 +/- 45, 0.13 +/- 0.06) (n = 5), whereas that in severe PE (55 +/- 12, 0.16 +/- 0.04) (n = 3) was lower than that of a normal pregnancy. The phospholipase A2 activity in cells of normal pregnant women exceeded that of cells of women with mild or severe PE. The combined activity of cyclooxygenase and PGI2 synthase in a normal pregnancy was lower than in mild PE, but higher than in severe PE. Similar results were found for PGI2 synthase activity; in normal pregnancy the activity was less than in mild PE, but higher than in severe PE.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of ridogrel on the prostacyclin-thromboxane ratio in nulliparous third trimester-pregnant rhesus monkeys

The effects of ridogrel, a thromboxane synthetase inhibitor and endoperoxide receptor antagonist, were studied in twelve pregnant, nulliparous Rhesus monkeys (Macaca mulatta) during the last trimester of pregnancy. Ridogrel was administered intravenously in two groups of animals (n = 6), at either 0.1 mg/kg or 1.0 mg/kg. Ultrasonic assessment of the fetuses during and after the infusion period revealed no obvious changes in fetal condition. Both dosages reduced serum thromboxane levels 30 minutes after administration, 96.6% and 99.6% suppression, 0.1 mg/kg and 1.0 mg/kg, respectively (P < 0.0001), while the 1.0 mg/kg dose produced continued suppression for 24 hours (78% suppression, P < 0.0001) and was lower than the 0.1 mg/kg 24 hour value (P < 0.008). Prostacyclin levels increased to 340% and 472% of baseline values, 0.1 mg/kg and 1.0 mg/kg, respectively at 30 minutes and to 928% and 255% of baseline at 24 and 48 hours after treatment in the 1.0 mg/kg group (P < 0.0003). Ridogrel caused no changes in maternal or neonatal outcome. The potential for the use of this compound for the treatment of preeclampsia is discussed.

Thromboxane synthetase inhibition as a new therapy for preeclampsia: animal and human studies minireview

The role of the eicosanoids in the pathophysiology of preeclampsia is reviewed, and the results of animal model and human studies with thromboxane synthetase inhibitors in preeclampsia are described. Potential benefits and limitations of therapy are discussed.

The role of prostaglandins in obstetrical disorders

All pregnancy-associated tissues are capable of producing prostaglandins including PGI2 and TXA2. In normal pregnancy there is a dominance of PGI2 over TXA2 which may contribute to the maternal circulatory adaptation to pregnancy. Furthermore, both fetoplacental PGI2 and TXA2 production are important regulators of the fetal blood supply. It has been clearly established that in pre-eclampsia PGI2 production decreases in the fetoplacental tissues and quite probably also in the maternal tissues. The effect of this change may be further exaggerated by the simultaneous stimulation in pre-eclampsia of TXA2 production. The reason for PGI2 deficiency is not known. Other vasoactive agents, such as endothelin, may act in concert with prostaglandins. Relative PGI2 deficiency is likely to exist also in IUGR and lupus anticoagulant syndrome of pregnancy. In the latter, lupus anticoagulant may directly inhibit the synthesis of PGI2. One study suggests PGI2 deficiency also in early pregnancies of women with a history of repeated abortions. Prostaglandin production increases during full-term labour, and similar but smaller changes also occur in preterm labour. A silent bacterial infection may trigger the onset of preterm labour through cytokine-stimulated increase of prostaglandin production. No data were found on prostaglandin production in post-term pregnancies. That oligo-polyhydramnios is possibly prostaglandin mediated is suggested by the control of polyhydramnios by indomethacin treatment. Smoking decreases the production of PGI2 and possibly increases that of TXA2, which may lead to decreased blood flow and IUGR. Which constituent of cigarette smoke exerts this effect is not known. Ethanol consumption causes aberrations in prostaglandin metabolism which cannot be directly connected with fetal alcohol effects.

Prostacyclin rather than nitric oxide lowers human umbilical artery tone in vitro

This study was designed to determine vasodilator activities of two endothelium-derived relaxing factors: prostacyclin (PGI2) and nitric oxide (NO) in human umbilical arteries. Isolated vessel segments were contracted by submaximal concentrations of serotonin and bradykinin. These contractions were enhanced after inhibition of prostaglandin formation by the cyclooxygenase inhibitor indomethacin and after removal of the endothelium, both resulting in a pronounced decrease in PGI2 formation. Contractions remained unchanged after treatment of the vessels with nitro-L-arginine, a selective inhibitor of endogenous NO biosynthesis. The efficacy of inhibition of NO biosynthesis was established by a more than 60% reduction in cyclic GMP accumulation. Even inhibition of stimulated NO formation by histamine did not change vascular tone. These data suggest that PGI2 rather than NO is an endothelium-derived relaxing factor in human umbilical arteries.

The effect of pregnancy on renal function: physiology and pathophysiology

Marked changes in renal function occur with pregnancy. We present a summary of these changes in this review and give insight into possible mechanisms if they are known. Controversies exist regarding the therapy of pregnancy-induced hypertension and asymptomatic and recurrent bacteriuria. The current views on these topics are given. Specific renal diseases are summarized, including transplantation, and optimum management strategies and maternal and fetal prognosis during pregnancy are given.

Prostaglandin deficiency

Healthy cells from virtually all tissues synthesize a variety of prostaglandins, autacoids which can significantly alter cellular functions. An absolute or relative deficiency of prostaglandins has now been demonstrated in many diseases or clinical conditions. These include 'natural' disorders such as peptic ulcer disease and diabetes mellitus. These also include 'acquired' or iatrogenic conditions such as cyclosporine nephrotoxicity and the gastropathy induced by nonsteroidal anti-inflammatory drugs. We believe that the diversity of the disorders associated with prostaglandin deficiency may be wider and of greater pathogenetic importance than is currently recognized. We propose: 1) that prostaglandin deficiency will be demonstrated in many abnormalities which are now described as of uncertain etiology; and 2) that adverse effects from many commonly prescribed drugs may also be related to an unrecognized and unfavorable alteration in prostaglandin synthesis, disposal, or activity.

Serum prostacyclin binding and half-life in the umbilical circulation

Serum prostacyclin binding and half-life was measured in twenty pairs of maternal and umbilical venous samples and in twenty non-pregnant controls. When compared to non-pregnant values both umbilical and maternal samples demonstrated significantly lower albumin concentrations, percentage of prostacyclin binding and shorter prostacyclin half-life.

Umbilical artery reactivity and ultrastructural changes in pregnancy-induced hypertension and other complicated pregnancies

Abnormal pressor responses are known to occur in the maternal circulation in pregnancy-induced hypertension (PIH), but little is know of the response of the foetal circulation. The responsiveness of umbilical arteries in PIH can be studied after delivery, and this is a useful model to explore the pathophysiological mechanisms involved. In the present experiments, the in vitro response of umbilical artery rings to bradykinin and 5-hydroxytryptamine (5-HT) was tested and ultrastructural changes investigated. Umbilical arteries from 48 cords were studied. Fifteen of the mothers had PIH, five had essential hypertension pre-dating the pregnancy and five had diabetes. Twenty-three women had pregnancies uncomplicated by hypertension or serious medical or obstetric problems and these served as controls. Umbilical arteries from the severe proteinuric PIH group were significantly more responsive to 5-HT as assessed by affinity constants (P less than 0.05). The responsiveness of arteries from all other groups did not differ from the normal cases. A probable mechanism for the findings is endothelial damage as a result of pre-eclamptic disease. This was substantiated by ultrastructural evidence.

In vitro activity of nicotinamide adenine dinucleotide- and nicotinamide adenine dinucleotide phosphate-linked 15-hydroxyprostaglandin dehydrogenases in placentas from normotensive and preeclamptic/eclamptic pregnancies

Concentrations of prostaglandins E2 and I2 may be decreased in preeclamptic and eclamptic pregnancies. Because these prostaglandins produce vasodilation and inhibit platelet aggregation it has been suggested that a reduction in their biosynthesis might play an important role in the pathogenesis of the hypertension and coagulation abnormalities associated with preeclampsia. Placental tissue is an extremely rich source of several enzymes that catalyze the catabolism of prostaglandins. The present study was initiated to determine whether one of these catabolic enzymes might be increased in preeclamptic/eclamptic pregnancies. The activities of the NAD- and the NADP-linked 15-hydroxyprostaglandin dehydrogenases were measured in 16 preeclamptics (mean diastolic pressure, 108 +/- 13 mmHg) and compared with 16 normotensive controls matched for age (20.8 +/- 5.43 vs. 20.6 +/- 5.16) and gestational week of delivery (34.6 +/- 5.40 vs. 35.0 +/- 5.06). These results indicate that the activity of the placental NAD-linked 15-hydroxyprostaglandin dehydrogenase is elevated in preeclampsia (40.1 +/- 31.3 vs. 14.9 +/- 8.30 mU/g tissue, P less than 0.01). If this increase were also expressed in vivo, its effect on prostaglandin metabolism could be mistaken for impaired prostacyclin biosynthesis unless both the 6-keto- and 6,15-diketo-metabolites of prostacyclin were measured.

Beneficial effects of U-63,557A, a thromboxane synthetase inhibitor, in an ovine model of pregnancy-induced hypertension

Pregnancy-induced hypertension was induced in five ewes (gestational day 135; term 150 days) by 72 hours of food deprivation. Maternal arterial pressure, uterine blood flow, platelet function, renal function, and plasma levels of 6-ketoprostaglandin F1 alpha and thromboxane B2 were measured before and during hypertension and after three intravenous injections of U-63,557A; sodium 5-(3'-pyridinylmethyl) benzofuran-2-carboxylate, monohydrate (30 mg/kg every 8 hours). Blood pressure increased (p less than 0.03), and returned to normal after U-63,557A. Left uterine artery blood flow increased after U-63,557A (p less than 0.03). Creatinine clearance decreased during hypertension (p less than 0.03) and increased after U-63,557A. Urine protein increased during hypertension (p less than 0.03) and decreased after treatment. Platelet count dropped during hypertension (p less than 0.03) and was elevated after treatment. Collagen lag phase decreased during hypertension (p less than 0.03) and increased after treatment. After U-63,557A, 6-ketoprostaglandin F1 alpha levels were higher (p less than 0.04) than baseline or hypertensive values. Administration of a thromboxane synthetase inhibitor caused resolution of hemodynamic, renal, and coagulation dysfunctions that occurred in ovine pregnancy-induced hypertension.

Decreased prostacyclin biosynthesis preceding the clinical manifestation of pregnancy-induced hypertension

Patients who develop pregnancy-induced hypertension exhibit a lesser increment in prostacyclin biosynthesis than healthy pregnant subjects. Whether this precedes the development of clinical disease and therefore may be important in the pathogenesis of pregnancy-induced hypertension or is a secondary event is unknown. We prospectively determined prostacyclin biosynthesis in pregnant subjects at risk of developing pregnancy-induced hypertension by use of noninvasive approach, measurement of the urinary metabolite 2,3-dinor-6-keto-prostaglandin F1 alpha. Patients were recruited at less than 20 weeks gestation. After delivery, patients were retrospectively allocated by use of preset criteria, to one of four groups: pregnancy-induced hypertension (n = 12), hypertension in labor (n = 22), chronic hypertension (n = 9), and normotension (n = 24). There was a significant increase in prostacyclin biosynthesis in all study groups during gestation. However, patients who developed pregnancy-induced hypertension exhibited a lesser increment and this difference persisted throughout gestation. These results are consistent with a pathophysiologic role for altered prostacyclin biosynthesis in women with pregnancy-induced hypertension. In addition, decreased prostacyclin formation identifies a population at risk of developing pregnancy-induced hypertension. Such information would assist the design of clinical trials of drugs, such as aspirin, that might prevent the development of this disease.

Effects of plasma on the platelet antiaggregatory action of prostacyclin in pregnancy

Platelet-poor plasma from 13 nonpregnant, 33 normally pregnant, and eight preeclamptic women was incubated with prostacyclin. The ability of platelet-poor plasma to diminish the antiaggregatory effect of prostacyclin was assessed by measuring this effect on arachidonic acid-induced platelet aggregation. Platelet aggregation greater than 95% in response to arachidonic acid was observed when incubated plasma without exogenous prostacyclin was assayed. When prostacyclin and platelet-poor plasma were preincubated together, subsequent arachidonic acid-induced platelet aggregation measured 9.6% in samples from nonpregnant patients, 40.3% in samples from normally pregnant patients, and 78.2% in samples from patients with preeclampsia. The ability of exogenous prostacyclin to inhibit arachidonic acid-induced platelet aggregation was significantly different in the presence of plasma from nonpregnant, normally pregnant, and preeclamptic women. These observations suggest that a plasma factor may affect the action of prostacyclin during pregnancy.

Pregnancy-induced hypertension: development of a model in the pregnant sheep

Selected hemodynamic, renal, and biochemical parameters were assessed in chronically instrumented third-trimester pregnant ewes and in the same ewes after induction of pregnancy toxemia. Ewes with induced pregnancy toxemia developed hypertension, proteinuria, ketonuria, decreased glomerular filtration rate, decreased cardiac output, and decreased left uterine artery blood flow. Histological and transmission electron microscopy revealed the development of renal morphologic changes consistent with those observed in human pregnancy-induced hypertension. These studies have elucidated that pregnancy-induced hypertension can be produced experimentally in the pregnant ewe. Furthermore, the pathophysiologic features of ovine pregnancy toxemia are similar to those of human preeclampsia, and therefore the sheep provides a suitable animal model to study the human condition, which still remains a major complication of pregnancy, jeopardizing both mother and fetus.

Anaesthetic considerations in high-risk pregnancy

The pathophysiology, and principles of obstetric and anaesthetic management, of two high-risk situations have been reviewed. Information sources related to two additional problems are provided. The encouraging decline witnessed in perinatal morbidity and mortality in recent years, stems from multidisciplinary team care in tertiary centres. The obstetric anaesthetist who understands the pathophysiology of high-risk pregnancy, and the principles which underlie patient management, becomes an irreplaceable member of such perinatal care teams.

Not prostacyclin synthase but prostaglandin endoperoxide synthase increases with human placental development

Prostaglandin endoperoxide synthase (i.e. cyclooxygenase; PGH synthase) and prostacyclin synthase (PGI synthase) were quantitated with specific immunoradiometric assays in microsomes from human placentae (n = 20) obtained from 7 up to 17 weeks of gestation. Over that period, wherein trophoblastic invasion of the uterine spiral arteries occurs, the placentae showed a significant increase in concentrations of PGH synthase (r = 0.73, p less than 0.001; n = 20), but not in those of PGI synthase. While the variation between individual placentae was much larger for PGI synthase than for PGH synthase concentrations, there was no evidence for a large excess of PGI synthase over that of PGH synthase in any of these early placentae. The data indicate, first, that the developing placenta contains PGI synthase, but in amounts which are relatively small and do not appear to increase with advancing gestation. Second, they seem to indicate that the capacity for bioconversion of arachidonic acid into prostaglandin endoperoxides increases markedly with placental development.

Prostacyclin and thromboxane in gynecology and obstetrics

The gynecologic and obstetric implications of the smooth muscle-relaxing, antiaggregatory prostacyclin and its endogenous antagonist, thromboxane A2, are reviewed. In addition to the vascular wall and circulating platelets, which are primary sources for prostacyclin and thromboxane A2, respectively, reproductive tissues produce great amounts of these prostanoids, evidently for the regulation of the vascular tone and/or vascular platelet interaction. Several gynecologic and obstetric disorders are characterized by abnormalities in prostacyclin and/or thromboxane A2. In primary menorrhagia the uterine release of prostacyclin is increased, and consequently menstrual blood loss can be reduced with various prostaglandin synthesis inhibitors. Prostacyclin relaxes the nonpregnant myometrium in vitro and may also do so in vivo, although intravenous infusion of prostacyclin has no effect upon the uterine contractility in nonpregnant or pregnant subjects. Patients with pelvic endometriosis may have increased levels of prostacyclin and thromboxane A2 metabolites in the peritoneal fluid. The prostacyclin/thromboxane A2 balance shifts to thromboxane A2 dominance in patients with gynecologic cancer. During pregnancy the production of prostacyclin and thromboxane A2 increases in the mother and fetoplacental tissue. Preeclampsia and other chronic placental insufficiency syndromes are accompanied by prostacyclin deficiency in the mother and in fetomaternal tissues and by an overproduction of thromboxane A2, at least in the placenta. These changes may account for the vasoconstriction and platelet hyperactivity, which are pathognomonic for hypertensive pregnancies. By directing the prostacyclin/thromboxane A2 balance to prostacyclin dominance (by dietary manipulation, administration of prostacyclin and/or its analogues, drugs with prostacyclin-stimulating and/or thromboxane A2-inhibiting action), it may be possible to prevent and/or treat hypertensive pregnancy complications in the future.

Histomorphometry of the human placenta in maternal preeclampsia

The placentas of five mothers with severe preeclampsia who gave birth to moderately growth-retarded term infants were compared to a group of placentas collected from mothers who had uncomplicated pregnancies and normal term infants who were appropriate for gestational age. This study demonstrated that, on a quantitative histologic basis, the placentas of the preeclamptic mothers were morphologically very similar to the control placentas in terms of weight, parenchymal and cellular content, and surface areas of exchange between mother and fetus. The findings of this study support the hypothesis that, in preeclampsia not associated with severe intrauterine growth retardation, the perinatal morbidity associated with this condition is probably related more to some alterations in uteroplacental and, possibly, umbilical blood flows than to significant changes in placental structure and function. This may be due to compensatory repair mechanisms and extensive functional reserve capacities in these placentas.

Control of prostacyclin synthesis in pregnancy-induced hypertension

Uterine prostacyclin synthase (PGI synthase) and prostaglandin endoperoxide synthase (PGH synthase) concentrations, measured by specific immunoradiometric assays, did not differ between patients with severe pregnancy-induced hypertension (syn. pre-eclampsia; n = 5) and normotensive gravidae (n = 6) with comparable gestational ages (34 - 38 weeks). Myometrial microsomes from pre-eclamptic women contained ten times more PGI synthase than PGH synthase and the ratio of PGI synthase to PGH synthase (mean +/- SD; 10.1 +/- 3.9) was not different from that in normotensive pregnancies. None of the pre-eclamptic patients had myometrial enzyme levels that were more than one standard deviation below the mean established previously for pregnancies ranging from 32 to 42 weeks of gestation. These findings indicate that the commonly observed association between deficient PGI2 production and pregnancy-induced hypertension cannot be explained in terms of a generalized lack of immunoassayable prostacyclin or prostaglandin endoperoxide synthases.

Failure of exogenous prostacyclin to change placental and fetal blood flow in preeclampsia

Seven patients with acute preeclampsia and six with superimposed preeclampsia were infused intravenously with incremental doses of prostacyclin (up to 8 ng/min/kg during 80 minutes). Prostacyclin infusion was accompanied by significant decreases in maternal blood pressure and consistent rises in maternal plasma or urinary 6-keto-prostaglandin F1 alpha, but it caused no changes in maternal or fetal pulse rate or uterine contractility. Moreover, prostacyclin did not change the placental and umbilical blood flow, which were measured before and at the end of infusion. All women experienced facial flushing and two complained of headache during infusion. There was no difference in prostacyclin effects between women with acute or superimposed preeclampsia. These results may be taken as evidence that intravenous prostacyclin is not a specific therapy to increase placental or umbilical blood flow in preeclampsia.