Atrial natriuretic peptide: a vasodilator of the fetoplacental circulation?

Control of the fetoplacental circulation

This year marks the 250th anniversary of the discovery by William Hunter of the existence of two distinct circulations within the human placenta. Until relatively recently the placenta has been viewed with “respect” – a passive structure which occasionally elicited fear and anxiety if implanted either too low or too deep. More recently our understanding of perinatal physiology, blood flow regulation and epidemiological data linking prenatal events with adult disease has created renewed interest in the placenta. This review will focus on the regulation of fetal blood flow in the placenta, the possible mechanisms whereby it may be deranged and why this might be relevant to adult disease.

Plasma levels of atrial natriuretic peptide in normal and hypertensive pregnancies: a meta-analysis

OBJECTIVE

Our goals were (1) to use meta-analysis to determine whether pregnancy and the puerperium are accompanied by alterations in plasma atrial natriuretic peptide levels when compared with the nonpregnant state and (2) to evaluate the additional effects of hypertensive disease during pregnancy on plasma atrial natriuretic peptide levels.

STUDY DESIGN

Articles measuring atrial natriuretic peptide levels during pregnancy were reviewed. Data from articles meeting inclusion criteria were abstracted, and a meta-analysis was performed with the use of the maximum likelihood methods of Jennrich and Schluchter (Biometrics 1986;42:805-20).

RESULTS

The mean atrial natriuretic peptide level in nonpregnant control subjects was 28.7 pg/ml (95% confidence interval 22.5 to 36.7). The mean plasma atrial natriuretic peptide level rose 41% to 40.5 pg/ml (95% confidence interval 31.7 to 51.8) in the third trimester (p < 0.0001). It was 71.1 pg/ml (95% confidence interval 51.2 to 98.7) or 148% greater than the mean nonpregnant level during the first week post partum (p < 0.0001). Compared with levels in pregnant control subjects, plasma atrial natriuretic peptide levels increased 52% to 52.1 pg/ml (95% confidence interval 32.9 to 82.5) in women with gestational hypertension (p < 0.005) and 130% to 78.8 pg/ml (95% confidence interval 52.3 to 118.8) in women with preeclampsia (p < 0.0001). Chronic hypertension did not significantly alter atrial natriuretic peptide levels.

CONCLUSIONS

The 41% increase in atrial natriuretic peptide levels in the third trimester suggests that atrial stretch receptors sense the expanded blood volume as normal to moderately increased. The rise in atrial natriuretic peptide during the first week post partum is consistent with known hemodynamic changes and suggests that atrial natriuretic peptide may be involved in the postpartum diuresis. The marked increase in plasma atrial natriuretic peptide levels observed in preeclampsia is not likely to result from elevated arterial pressures alone but may reflect underlying factors unique to this disease process.

Atrial natriuretic peptide counteracts the vasoconstrictor effects of 5-hydroxytryptamine, U46619 and endothelin-1 in the human umbilical artery

A role for atrial natriuretic peptide (ANP) in maintaining low vascular resistance within the fetoplacental circulation was investigated using isolated strips of human umbilical artery (HUA). Physiological levels of ANP significantly reduced the isometric contractile response of the HUA to U46619 (a stable thromboxane A2 mimetic), to 5-hydroxytryptamine and to endothelin-1, though no effect on agonist sensitivity could be demonstrated. These data suggest that ANP may modify vascular tone in vivo thereby counterbalancing several humoral factors which act to increase vascular resistance within the fetoplacental circulation.

Nitric oxide synthase (NOS) in the human umbilical cord vessels. An immunohistochemical study

Localization of nitric oxide synthase (NOS) in endothelial cells of umbilical cord vessels and in cultured human umbilical vein endothelial cells was investigated by light and electron-microscopical (immunogold) immunohistochemistry. We observed localization of NOS-immunoreactivity in the majority (97%) of the endothelial cells of the umbilical vein and in a subpopulation (6.7%) of endothelial cells of the umbilical arteries. NOS was observed as well in the amniotic epithelium and in the cells of Wharton's jelly. Immunogold labelling in human umbilical vein endothelial cells dominated in the cellular matrix and was not associated with cellular organelles. Since human umbilical vessels are unique in lacking innervation, the functional significance of endothelium derived relaxing factor EDRF/NO in the local control of vascular flow is discussed.

Fetal vascular atrial natriuretic peptide receptors in human placenta: alteration in intrauterine growth retardation and preeclampsia

OBJECTIVE

Our purpose was to quantify fetoplacental vascular atrial natriuretic peptide receptor subtypes in human pregnancies complicated by intrauterine growth retardation or preeclampsia and to relate these parameters to the fetoplacental vascular impedance as assessed by Doppler velocimetry.

STUDY DESIGN

Guanylate cyclase-coupled and uncoupled receptors were quantified by radioligand-binding methods in membrane fractions prepared from primary and secondary stem villous vessels. Data for 16 abnormal pregnancies delivered preterm were compared with that for six gestationally matched preterm controls.

RESULTS

The number of guanylate cyclase-coupled receptors was significantly (p < 0.001) greater in pregnancies complicated by intrauterine growth retardation or preeclampsia irrespective of normal or abnormal umbilical artery Doppler blood flow velocity pattern. The number of guanylate cyclase-uncoupled receptors was unaltered.

CONCLUSIONS

Because fetal plasma atrial natriuretic peptide concentration is normal or elevated in intrauterine growth retardation and preeclampsia, these data suggest that atrial natriuretic peptide-mediated fetoplacental vasodilation is augmented in these disorders even in the presence of increased vascular resistance within the fetoplacental unit.

Colocalization of vasoactive substances in the endothelial cells of human umbilical vessels

Human umbilical vessels are unique in lacking any innervation; thus endothelial cells may play the major role in local control and regulation of the blood flow. In the present study, we examined ultrathin sections of cultured human umbilical vein endothelial cells and tissue preparations of umbilical vein and artery, immunostained by the post-embedding colloidal gold double-labelling technique. We observed colocalization of atrial natriuretic peptide and neuropeptide Y, as well as colocalization of atrial natriuretic peptide and neuropeptide Y with other vasoactive substances, namely, vasoactive intestinal peptide, substance P, calcitonin gene-related peptide and arginine vasopressin. The functional significance of the colocalization of these vasoactive substances in the human umbilical vessel endothelial cells is discussed.

In situ hybridization of atrial natriuretic peptide mRNA in the endothelial cells of human umbilical vessels

The localization of mRNA encoding preproatrial natriuretic peptide (ANP) was investigated in cultured human umbilical vein endothelial cells (HUVEC) and tissue preparations of umbilical vein and artery. The techniques used were in situ hybridization and in situ hybridization combined with immunocytochemistry, using 32P-radiolabelled and non-radioactive digoxigenin labelled complementary RNA probes. Human ANP mRNAs are mainly localized in the endothelial cells of the umbilical vein and, to a lesser extent, in the endothelial cells of the umbilical artery. The autoradiographic labelling and the intensity of digoxigenin staining were significantly reduced by treatment with RNase before in situ hybridization. This study provides unequivocal evidence for the expression of the ANP gene in the endothelial cells of human umbilical vessels, confirming that these endothelial cells have the ability to synthesize this peptide. The functional significance of the presence of the ANP mRNA in the endothelial cells of human umbilical vessels is discussed.

Localization of neuropeptide Y and atrial natriuretic peptide in the endothelial cells of human umbilical blood vessels

The localization of neuropeptide Y (NPY) and atrial natriuretic peptide (ANP) in the endothelial cells of human umbilical blood vessels was studied using the pre-embedding peroxidase-antiperoxidase (PAP) technique for electron microscopy and avidin-biotin-complex (ABC) immunostaining for endothelial cells cultured from umbilical vein. Subpopulations of NPY- and ANP-immunoreactive endothelial cells were present in term umbilical vein and artery. The umbilical vein contained more positive cells than the artery. The percentage of NPY- and ANP-immunoreactive umbilical vein cells in culture was 32% and 44%, respectively, out of a total of 3013 cells examined. The possibility that these potent vasoactive substances located in the endothelial cells of the non-innervated umbilical vessels are involved in the local regulation of blood flow is discussed.

Maternal and fetal atrial natriuretic peptide levels at delivery from normal and growth retarded pregnancies

OBJECTIVE

To determine whether circulating fetal levels of the vasodilator atrial natriuretic peptide (ANP) are reduced in pregnancies complicated by intrauterine growth retardation (IUGR).

DESIGN

Prospective observational study.

SETTING

University teaching hospital and research laboratory.

SUBJECTS

25 normal singleton pregnancies delivered at term by spontaneous vertex delivery (n = 16) or by elective caesarean section (n = 9), and a series of 14 singleton pregnancies complicated by IUGR.

INTERVENTION

Measurement of ANP by radio-immunoassay in maternal venous, umbilical artery, and umbilical vein plasma from a series of normal, and IUGR pregnancies.

MAIN OUTCOME MEASURES

Comparison of plasma ANP levels between the three groups; relation between fetal ANP, PO2 and pH.

RESULTS

Mode of delivery did not influence either maternal, umbilical artery or umbilical vein plasma ANP levels in normal term singleton pregnancies. Umbilical vein ANP levels were significantly higher in the IUGR group when compared with normal pregnancies at term (mean 66 95%, CI 36-122 vs mean 37, 95% CI 29-47 pg/ml, P = 0.03) and were inversely related to umbilical artery pH (R2 = 65%; P = 0.003).

CONCLUSIONS

These data suggest that umbilical vein ANP levels are elevated in pregnancies complicated by IUGR, and rise appropriately in response to the stress of acidosis. In the absence of any receptor or second messenger defect within feto-placental vascular smooth muscle, these data suggest that ANP is not directly implicated in the vascular pathophysiology of IUGR.