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Akilla MA, Nchor Awinibuno IA, Banyeh M, Mayeem BN, Kwofie GS, Adoko S, Nukpezah RN, Kolekang AS, Dagungong CB, Amidu N. Investigating hemolysis, elevated liver enzymes and low platelet count in preeclampsia: A case-control study in Ghana. Health Sci Rep 2024; 7:e2277. [PMID: 39086511 PMCID: PMC11286661 DOI: 10.1002/hsr2.2277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 04/07/2024] [Accepted: 07/10/2024] [Indexed: 08/02/2024] Open
Abstract
Background and Aims Preeclampsia poses a heightened risk for women, particularly in the development of hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, leading to adverse outcomes for both mothers and newborns. The incidence of HELLP syndrome tends to be notably higher among women with preeclampsia compared with those with normotensive pregnancies. However, there is a dearth of research on the frequency of HELLP syndrome within the context of preeclampsia specifically in Ghana. Furthermore, the potential predictive value of serum erythrocyte adenylate kinase (EAK), a marker of hemolysis, in anticipating the onset of preeclampsia remains largely unexplored. Methods Conducted between May 2020 and April 2022, this research employed a case-control methodology at the War Memorial and Upper East Regional Hospitals. A total of 291 pregnant women participated, comprising 111 diagnosed with preeclampsia and 180 control subjects, aged between 18 and 43 years. Venous blood samples were collected and subjected to analysis for platelet count, aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), and EAK, utilizing automated analyzers, alongside the ELISA technique. Diagnosis of HELLP syndrome was established using the Mississippi triple-class definition. Results The median serum ALT level (with interquartile range) was significantly elevated in the preeclampsia group compared with controls [20.0 (13.7-27.0) vs. 13.0 (9.4-18.6); p < 0.001]. Moreover, the frequency of Mississippi class 3 HELLP syndrome was notably higher among preeclampsia cases (2/111; 1.8%) compared with controls (1/180; 0.6%). Serum ALT emerged as the superior predictor of preeclampsia, outperforming LDH (with an area under the curve of 0.73 compared with 0.58). The sensitivity and specificity of ALT were measured at 47.8% and 87.2%, respectively. Conclusion Although the occurrence of HELLP syndrome in preeclampsia cases appears relatively low, it may escalate as the prevalence of preeclampsia is anticipated to rise in low and middle-income nations.
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Affiliation(s)
- Martin Awe Akilla
- Department of Biomedical Laboratory ScienceUniversity for Development StudiesTamaleGhana
| | | | - Moses Banyeh
- Department of Biomedical Laboratory ScienceUniversity for Development StudiesTamaleGhana
| | | | | | - Stephen Adoko
- Department of Clinical DiagnosticsShalina DiagnosticsKumasiGhana
| | - Ruth Nimota Nukpezah
- Department of Preventive Health NursingUniversity for Development StudiesTamaleGhana
| | - Augusta S. Kolekang
- Department of Epidemiology, Biostatistics and Disease ControlUniversity for Development StudiesTamaleGhana
| | | | - Nafiu Amidu
- Department of Clinical ChemistryUniversity for Development StudiesTamaleGhana
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2
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Wątroba M, Szewczyk G, Szukiewicz D. The Role of Sirtuin-1 (SIRT1) in the Physiology and Pathophysiology of the Human Placenta. Int J Mol Sci 2023; 24:16210. [PMID: 38003402 PMCID: PMC10671790 DOI: 10.3390/ijms242216210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/04/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Sirtuins, especially SIRT1, play a significant role in regulating inflammatory response, autophagy, and cell response to oxidative stress. Since their discovery, sirtuins have been regarded as anti-ageing and longevity-promoting enzymes. Sirtuin-regulated processes seem to participate in the most prevalent placental pathologies, such as pre-eclampsia. Furthermore, more and more research studies indicate that SIRT1 may prevent pre-eclampsia development or at least alleviate its manifestations. Having considered this, we reviewed recent studies on the role of sirtuins, especially SIRT1, in processes determining normal or abnormal development and functioning of the placenta.
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Affiliation(s)
| | | | - Dariusz Szukiewicz
- Department of Biophysics, Physiology & Pathophysiology, Medical University of Warsaw, Chałubinskiego 5, 02-004 Warsaw, Poland; (M.W.); (G.S.)
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Wei L, Liping Z, Suya K. Expression of insulin-like growth factor binding protein-3 in HELLP syndrome. BMC Pregnancy Childbirth 2023; 23:778. [PMID: 37950229 PMCID: PMC10637003 DOI: 10.1186/s12884-023-06074-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVE To investigate the expression of insulin-like growth factor binding protein-3(IGFBP-3) in HELLP syndrome and its possible role in the pathogenesis of this disease. METHODS 1) 87 subjects were enrolled, including 29 patients with HELLP syndrome, 29 patients with pre-eclampsia (PE), and 29 healthy gravidae as control. The levels of IGFBP-3, IGF-1, TGF-β1, and VEGF in maternal and umbilical blood of them were detected using ELISA. Correlation analysis was used to observe the correlation between IGFBP-3 and IGF-1/TGF-β1/VEGF in maternal and umbilical blood, as well as that between maternal serum IGFBP-3 and clinical diagnostic indicators of HELLP syndrome. 2) Human hepatic sinusoid endothelial cells (HLSEC) and human umbilical vein endothelial cells (HUVEC) were cultured with different concentrations of IGFBP-3. After 72 h of culture, cell apoptosis and the normal living cells rate were detected and compared. RESULTS 1) In both maternal and umbilical blood of HELLP group, levels of IGFBP-3 and TGF-β1 were higher than control and PE group, IGF-1was lower than control group, VEGF was lower than control and PE group. IGFBP-3 in maternal blood was correlated with IGF-1/TGF-β1/ VEGF, while IGFBP-3 in umbilical blood was linked to IGF-1/TGF-β1. In maternal blood, there was a negative correlation between PLT and IGFBP-3, and a positive correlation between ALT/AST/LDH and IGFBP-3. 2) After cultured with IGFBP-3, the total apoptosis rate of either HLSEC or HUVEC was considerably elevated, while the normal living rate was decreased. CONCLUSION The expression of IGFBP-3 is elevated in HELLP syndrome, which may subsequently promote cell apoptosis by affecting the expression and function of IGF-1, VEGF, and TGFβ1 in the IGF/PI3K/Akt, TGF-β1/Smad3, and VEGF/eNOS/NO pathways. IGFBP-3 aggravates inflammatory reactions of the vascular endothelium and liver under hypoxia, affects the normal function of cells, and plays a role in the pathogenesis of diseases.
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Affiliation(s)
- Li Wei
- The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, No. 26, Daoqian Street, Suzhou, Jiangsu, China
| | - Zhou Liping
- The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, No. 26, Daoqian Street, Suzhou, Jiangsu, China
| | - Kang Suya
- The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, No. 26, Daoqian Street, Suzhou, Jiangsu, China.
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4
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Woldeamanuel GG, Tlaye KG, Wu L, Poon LC, Wang CC. Platelet count in preeclampsia: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:100979. [PMID: 37098392 DOI: 10.1016/j.ajogmf.2023.100979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 04/27/2023]
Abstract
OBJECTIVE Many studies have reported the association between platelets and preeclampsia. However, sample sizes were small, and their findings were inconsistent. We conducted a systematic review and meta-analysis to evaluate the association in pooled samples and in detail. DATA SOURCES A systematic literature search was performed using Medline, Embase, ScienceDirect, Web of Science, Cochrane Library, NICHD-DASH, LILACS, and Scopus from inception to April 22, 2022. STUDY ELIGIBILITY CRITERIA Observational studies comparing platelet count between women with preeclampsia and normotensive pregnant women were included. METHODS The mean differences with 95% confidence interval in platelet count were calculated. Heterogeneity was assessed using I2 statistics. Sensitivity and subgroup analyses were conducted. Statistical analysis was performed using RevMan 5.3 and ProMeta 3 software. RESULTS A total of 56 studies comprising 4892 preeclamptic and 9947 normotensive pregnant women were included. Meta-analysis showed that platelet count was significantly lower in women with preeclampsia than in normotensive controls (overall: mean difference, -32.83; 95% confidence interval, -40.13 to -25.52; P<.00001; I2=92%; mild preeclampsia: mean difference, -18.65; 95% confidence interval, -27.17 to -10.14; P<.00001; I2=84%; severe preeclampsia: mean difference, -42.61; 95% confidence interval, -57.53 to -27.68; P<.00001; I2=94%). Significantly lower platelet count was also observed in the second trimester (mean difference, -28.84; 95% confidence interval, -44.59 to -13.08; P=.0003; I2=93%), third trimester (mean difference, -40.67; 95% confidence interval, -52.14 to -29.20; P<.00001; I2=92%), and before the diagnosis of preeclampsia (mean difference, -18.81; 95% confidence interval, -29.98 to -7.64; P=.009; I2=87%), but not in the first trimester (mean difference, -15.14; 95% confidence interval, -37.71 to 7.43; P=.19; I2=71%). Overall, the pooled sensitivity and specificity of platelet count were 0.71 and 0.77, respectively. The area under the curve was 0.80. CONCLUSION This meta-analysis confirmed that platelet count was significantly lower in preeclamptic women, irrespective of severity and presence or absence of associated complications, even before the onset of preeclampsia and in the second trimester of pregnancy. Our findings suggest that platelet count may be a potential marker to identify and predict preeclampsia.
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Affiliation(s)
- Gashaw Garedew Woldeamanuel
- Department of Obstetrics and Gynaecology, Li Ka Shing Institute of Health Sciences, School of Biomedical Sciences, Shenzhen Research Institute, The Chinese University of Hong Kong, Hong Kong SAR
| | - Kenean Getaneh Tlaye
- Department of Obstetrics and Gynaecology, Li Ka Shing Institute of Health Sciences, School of Biomedical Sciences, Shenzhen Research Institute, The Chinese University of Hong Kong, Hong Kong SAR
| | - Ling Wu
- Department of Obstetrics and Gynaecology, Li Ka Shing Institute of Health Sciences, School of Biomedical Sciences, Shenzhen Research Institute, The Chinese University of Hong Kong, Hong Kong SAR
| | - Liona C Poon
- Department of Obstetrics and Gynaecology, Li Ka Shing Institute of Health Sciences, School of Biomedical Sciences, Shenzhen Research Institute, The Chinese University of Hong Kong, Hong Kong SAR
| | - Chi Chiu Wang
- Department of Obstetrics and Gynaecology, Li Ka Shing Institute of Health Sciences, School of Biomedical Sciences, Shenzhen Research Institute, The Chinese University of Hong Kong, Hong Kong SAR.
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Tousty P, Fraszczyk-Tousty M, Dzidek S, Jasiak-Jóźwik H, Michalczyk K, Kwiatkowska E, Cymbaluk-Płoska A, Torbé A, Kwiatkowski S. Low-Dose Aspirin after ASPRE-More Questions Than Answers? Current International Approach after PE Screening in the First Trimester. Biomedicines 2023; 11:1495. [PMID: 37371598 DOI: 10.3390/biomedicines11061495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023] Open
Abstract
Preeclampsia (PE) is a multi-factorial disorder of pregnancy, and it continues to be one of the leading causes of fetal and maternal morbidity and mortality worldwide. Aspirin is universally recommended for high-risk women to reduce preeclampsia risk. The purpose of this review is to summarize the recommendations of various scientific societies on predicting preeclampsia and their indications for the inclusion of acetylsalicylic acid (ASA) prophylaxis. Fourteen guidelines were compared. The recommended dose, screening method, and gestational age at the start of the test vary depending on the recommendation. The societies are inclined to recommend using increasingly higher doses (>75 mg) of ASA, with many encouraging doses from 100 mg upward. Most societies indicate that the optimal time for implementing aspirin is prior to 16 weeks' gestation. Following the publication of the Aspirin for Evidence-Based Preeclampsia Prevention (ASPRE) trial results and other papers evaluating the Fetal Medicine Foundation (FMF) screening model, a large number of societies have changed their recommendations from those based on risk factors alone to the ones based on the risk assessment proposed by the FMF. This allows for the detection of a high-risk pregnancy population in whom aspirin will be remarkably effective in preventing preterm PE, thereby decreasing maternal and fetal morbidity.
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Affiliation(s)
- Piotr Tousty
- Department of Gynecology and Obstetrics, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Magda Fraszczyk-Tousty
- Department of Neonatology and Neonatal Intensive Care, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Sylwia Dzidek
- Department of Gynecology and Obstetrics, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Hanna Jasiak-Jóźwik
- Department of Gynecology and Obstetrics, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Kaja Michalczyk
- Department of Gynecological Surgery and Gynecological Oncology of Adults and Adolescents, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Ewa Kwiatkowska
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Aneta Cymbaluk-Płoska
- Department of Reconstructive Surgery and Gynecological Oncology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Andrzej Torbé
- Department of Gynecology and Obstetrics, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Sebastian Kwiatkowski
- Department of Gynecology and Obstetrics, Pomeranian Medical University, 70-111 Szczecin, Poland
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6
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Redline RW, Roberts DJ, Parast MM, Ernst LM, Morgan TK, Greene MF, Gyamfi-Bannerman C, Louis JM, Maltepe E, Mestan KK, Romero R, Stone J. Placental pathology is necessary to understand common pregnancy complications and achieve an improved taxonomy of obstetrical disease. Am J Obstet Gynecol 2023; 228:187-202. [PMID: 35973475 PMCID: PMC10337668 DOI: 10.1016/j.ajog.2022.08.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/08/2022] [Accepted: 08/08/2022] [Indexed: 01/28/2023]
Abstract
The importance of a fully functioning placenta for a good pregnancy outcome is unquestioned. Loss of function can lead to pregnancy complications and is often detected by a thorough placental pathologic examination. Placental pathology has advanced the science and practice of obstetrics and neonatal-perinatal medicine by classifying diseases according to underlying biology and specific patterns of injury. Many past obstacles have limited the incorporation of placental findings into both clinical studies and day-to-day practice. Limitations have included variability in the nomenclature used to describe placental lesions, a shortage of perinatal pathologists fully competent to analyze placental specimens, and a troubling lack of understanding of placental diagnoses by clinicians. However, the potential use of placental pathology for phenotypic classification, improved understanding of the biology of adverse pregnancy outcomes, the development of treatment and prevention, and patient counseling has never been greater. This review, written partly in response to a recent critique published in a major obstetrics-gynecology journal, reexamines the role of placental pathology by reviewing current concepts of biology; explaining the most recent terminology; emphasizing the usefulness of specific diagnoses for obstetrician-gynecologists, neonatologists, and patients; previewing upcoming changes in recommendations for placental submission; and suggesting future improvements. These improvements should include further consideration of overall healthcare costs, cost-effectiveness, the clinical value added of placental assessment, improvements in placental pathology education and practice, and leveraging of placental pathology to identify new biomarkers of disease and evaluate novel therapies tailored to specific clinicopathologic phenotypes of both women and infants.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology and Reproductive Biology, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center and Cleveland, OH.
| | - Drucilla J Roberts
- Department of Pathology, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Mana M Parast
- Department of Pathology, Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA
| | - Linda M Ernst
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Terry K Morgan
- Department of Pathology and Obstetrics and Gynecology, Center for Developmental Health, Oregon Health Sciences University, Portland, OR
| | - Michael F Greene
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, La Jolla, CA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University South Florida, Tampa, FL
| | - Emin Maltepe
- Department of Pediatrics, University California, San Francisco, San Francisco, CA
| | - Karen K Mestan
- Department of Pediatrics and Neonatology, University of California, San Diego, School of Medicine and Rady Children's Hospital, San Diego, CA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, Maryland, Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI
| | - Joanne Stone
- Raquel and Jaime Gilinski Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
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Diagnostic utility of serial circulating placental growth factor levels and uterine artery Doppler waveforms in diagnosing underlying placental diseases in pregnancies at high risk of placental dysfunction. Am J Obstet Gynecol 2022; 227:618.e1-618.e16. [PMID: 35644246 DOI: 10.1016/j.ajog.2022.05.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Placental pathology assessment following delivery in pregnancies complicated by preeclampsia, fetal growth restriction, abruption, and stillbirth reveals a range of underlying diseases. The most common pathology is maternal vascular malperfusion, characterized by high-resistance uterine artery Doppler waveforms and abnormal expression of circulating maternal angiogenic growth factors. Rare placental diseases (massive perivillous fibrinoid deposition and chronic histiocytic intervillositis) are reported to have high recurrence risks, but their associations with uterine artery Doppler waveforms and angiogenic growth factors are presently ill-defined. OBJECTIVE To characterize the patterns of serial placental growth factor measurements and uterine artery Doppler waveform assessments in pregnancies that develop specific types of placental pathology to gain insight into their relationships with the timing of disease onset and pregnancy outcomes. STUDY DESIGN A retrospective cohort study conducted between January 2017 and November 2021 included all singleton pregnancies with at least 1 measurement of maternal circulating placental growth factor between 16 and 36 weeks' gestation, delivery at our institution, and placental pathology analysis demonstrating diagnostic features of maternal vascular malperfusion, fetal vascular malperfusion, villitis of unknown etiology, chronic histiocytic intervillositis, or massive perivillous fibrinoid deposition. Profiles of circulating placental growth factor as gestational age advanced were compared between these placental pathologies. Maternal and perinatal outcomes were recorded. RESULTS A total of 337 pregnancies from 329 individuals met our inclusion criteria. These comprised placental pathology diagnoses of maternal vascular malperfusion (n=109), fetal vascular malperfusion (n=87), villitis of unknown etiology (n=96), chronic histiocytic intervillositis (n=16), and massive perivillous fibrinoid deposition (n=29). Among patients who developed maternal vascular malperfusion, placental growth factor levels gradually declined as pregnancy progressed (placental growth factor <10th percentile at 16-20 weeks' gestation in 42.9%; 20-24 weeks in 61.9%; 24-28 weeks in 77%; and 28-32 weeks in 81.4%) accompanied by mean uterine artery Doppler pulsatility index >95th percentile in 71.6% cases. Patients who developed either fetal vascular malperfusion or villitis of unknown etiology mostly exhibited normal circulating placental growth factor values in association with normal uterine artery Doppler waveforms (mean [standard deviation] pulsatility index values: fetal vascular malperfusion, 1.14 [0.49]; villitis of unknown etiology, 1.13 [0.45]). Patients who developed either chronic histiocytic intervillositis or massive perivillous fibrinoid deposition exhibited persistently low placental growth factor levels from the early second trimester (placental growth factor <10th centile at 16-20 weeks' gestation in 80% and 77.8%, respectively; 20-24 weeks in 88.9% and 63.6%; 24-28 weeks in 85.7% and 75%), all in combination with normal uterine artery Doppler waveforms (mean pulsatility index >95th centile: chronic histiocytic intervillositis, 25%; massive perivillous fibrinoid deposition, 37.9%). Preeclampsia developed in 83 of 337 (24.6%) patients and was most common in those developing maternal vascular malperfusion (54/109, 49.5%) followed by chronic histiocytic intervillositis (7/16, 43.8%). There were 29 stillbirths in the cohort (maternal vascular malperfusion, n=10 [9.2%]; fetal vascular malperfusion, n=5 [5.7%]; villitis of unknown etiology, n=1 [1.0%]; chronic histiocytic intervillositis, n=7 [43.8%]; massive perivillous fibrinoid deposition, n=6 [20.7%]). Most patients experiencing stillbirth exhibited normal uterine artery Doppler waveforms (21/29, 72.4%) and had nonmaternal vascular malperfusion pathologies (19/29, 65.5%). By contrast, 28 of 29 (96.5%) patients experiencing stillbirth had ≥1 low placental growth factor values before fetal death. CONCLUSION Serial circulating maternal placental growth factor tests, in combination with uterine artery Doppler waveform assessments in the second trimester, may indicate the likely underlying type of placental pathology mediating severe adverse perinatal events. This approach has the potential to test disease-specific therapeutic strategies to improve clinical outcomes. Serial placental growth factor testing, compared with uterine artery Doppler studies, identifies a greater proportion of patients destined to have a poor perinatal outcome because diseases other than maternal vascular malperfusion are characterized by normal uteroplacental circulation.
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Petca A, Miron BC, Pacu I, Dumitrașcu MC, Mehedințu C, Șandru F, Petca RC, Rotar IC. HELLP Syndrome—Holistic Insight into Pathophysiology. Medicina (B Aires) 2022; 58:medicina58020326. [PMID: 35208649 PMCID: PMC8875732 DOI: 10.3390/medicina58020326] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/10/2022] [Accepted: 02/18/2022] [Indexed: 02/07/2023] Open
Abstract
HELLP syndrome, also known as the syndrome of hemolysis, elevated liver enzymes, and low platelets, represents a severe pregnancy complication typically associated with hypertension. It is associated with increased risks of adverse complications for both mother and fetus. HELLP occurs in 0.2–0.8% of pregnancies, and, in 70–80% of cases, it coexists with preeclampsia (PE). Both of these conditions show a familial tendency. A woman with a history of HELLP pregnancy is at high risk for developing this entity in subsequent pregnancies. We cannot nominate a single worldwide genetic cause for the increased risk of HELLP. Combinations of multiple gene variants, each with a moderate risk, with concurrent maternal and environmental factors are thought to be the etiological mechanisms. This review highlights the significant role of understanding the underlying pathophysiological mechanism of HELLP syndrome. A better knowledge of the disease’s course supports early detection, an accurate diagnosis, and proper management of this life-threatening condition.
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Affiliation(s)
- Aida Petca
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.P.); (M.C.D.); (C.M.); (F.Ș.); (R.-C.P.)
- Department of Obstetrics and Gynecology, Elias University Hospital, 011461 Bucharest, Romania
| | - Bianca Corina Miron
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.P.); (M.C.D.); (C.M.); (F.Ș.); (R.-C.P.)
- Department of Obstetrics and Gynecology, Elias University Hospital, 011461 Bucharest, Romania
- Correspondence: (B.C.M.); (I.P.); Tel.: +40-757-917889 (B.C.M.); +40-722-787327 (I.P.)
| | - Irina Pacu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.P.); (M.C.D.); (C.M.); (F.Ș.); (R.-C.P.)
- Department of Obstetrics and Gynecology, “Sf. Pantelimon” Emergency Clinical Hospital, 021623 Bucharest, Romania
- Correspondence: (B.C.M.); (I.P.); Tel.: +40-757-917889 (B.C.M.); +40-722-787327 (I.P.)
| | - Mihai Cristian Dumitrașcu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.P.); (M.C.D.); (C.M.); (F.Ș.); (R.-C.P.)
- Department of Obstetrics and Gynecology, University Emergency Hospital, 050098 Bucharest, Romania
| | - Claudia Mehedințu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.P.); (M.C.D.); (C.M.); (F.Ș.); (R.-C.P.)
- Department of Obstetrics and Gynecology, Malaxa Clinical Hospital, 022441 Bucharest, Romania
| | - Florica Șandru
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.P.); (M.C.D.); (C.M.); (F.Ș.); (R.-C.P.)
- Department of Dermatology, Elias University Emergency Hospital, 011461 Bucharest, Romania
| | - Răzvan-Cosmin Petca
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.P.); (M.C.D.); (C.M.); (F.Ș.); (R.-C.P.)
- Department of Urology, “Prof. Dr. Th. Burghele” Clinical Hospital, 050659 Bucharest, Romania
| | - Ioana Cristina Rotar
- “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
- Department of Obstetrics and Gynecology, Emergency Clinical County Hospital Cluj-Napoca, 400006 Cluj-Napoca, Romania
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Mecacci F, Avagliano L, Lisi F, Clemenza S, Serena C, Vannuccini S, Rambaldi MP, Simeone S, Ottanelli S, Petraglia F. Fetal Growth Restriction: Does an Integrated Maternal Hemodynamic-Placental Model Fit Better? Reprod Sci 2021; 28:2422-2435. [PMID: 33211274 PMCID: PMC8346440 DOI: 10.1007/s43032-020-00393-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 11/09/2020] [Indexed: 11/25/2022]
Abstract
In recent years, a growing interest has arisen regarding the possible relationship between adverse pregnancy outcomes (APOs) and inadequate maternal hemodynamic adaptations to the pregnancy. A possible association between "placental syndromes," such as preeclampsia (PE) and fetal growth restriction (FGR), and subsequent maternal cardiovascular diseases (CVD) later in life has been reported. The two subtypes of FGR show different pathogenetic and clinical features. Defective placentation, due to a poor trophoblastic invasion of the maternal spiral arteries, is believed to play a central role in the pathogenesis of early-onset PE and FGR. Since placental functioning is dependent on the maternal cardiovascular system, a pre-existent or subsequent cardiovascular impairment may play a key role in the pathogenesis of early-onset FGR. Late FGR does not seem to be determined by a primary abnormal placentation in the first trimester. The pathological pathway of late-onset FGR may be due to a primary maternal cardiovascular maladaptation: CV system shows a flat profile and remains similar to those of non-pregnant women. Since the second trimester, when the placenta is already developed and increases its functional request, a hypovolemic state could lead to placental hypoperfusion and to an altered maturation of the placental villous tree and therefore to an altered fetal growth. Thus, this review focalizes on the possible relationship between maternal cardiac function and placentation in the development of both early and late-onset FGR. A better understanding of maternal hemodynamics in pregnancies complicated by FGR could bring various benefits in clinical practice, improving screening and therapeutic tools.
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Affiliation(s)
- F Mecacci
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - L Avagliano
- Department of Health Sciences, San Paolo Hospital Medical School, University of Milano, Milan, Italy
| | - F Lisi
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - S Clemenza
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - Caterina Serena
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy.
| | - S Vannuccini
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - M P Rambaldi
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - S Simeone
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - S Ottanelli
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - F Petraglia
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
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Bacon S, Burger D, Tailor M, Sanchez JJ, Tomlinson G, Murphy HR, Feig DS. Can placental growth factors explain birthweight variation in offspring of women with type 1 diabetes? Diabetologia 2021; 64:1527-1537. [PMID: 33839801 DOI: 10.1007/s00125-021-05438-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/11/2020] [Indexed: 11/26/2022]
Abstract
AIMS/HYPOTHESIS Maternal hyperglycaemia alone does not explain the incidence of large offspring amongst women with type 1 diabetes. The objective of the study was to determine if there is an association between placental function, as measured by angiogenic factors, and offspring birthweight z score in women with type 1 diabetes. METHODS This cohort study included samples from 157 Continuous Glucose Monitoring in Pregnant Women with Type 1 Diabetes (CONCEPTT) trial participants. Correlations were estimated between birthweight z score and placental growth factor (PlGF) and soluble fms-like tyrosine kinase (sFlt-1) levels measured at baseline and at 24 and 34 weeks of gestation. Linear regression was used to assess the relationship between birthweight z score and placental health, as measured by PlGF and sFlt-1/PlGF ratio, stratified by glycaemic status (continuous glucose monitoring and HbA1c measures) and adjusted for potential confounders of maternal BMI, smoking and weight gain. Higher PlGF levels and lower sFlt-1/PlGF ratios represent healthy placentas, while lower PlGF levels and higher sFlt-1/PlGF ratios represent unhealthy placentas. RESULTS Among CONCEPTT participants, the slopes relating PlGF levels to birthweight z scores differed according to maternal glycaemia at 34 weeks of gestation (p = 0.003). With optimal maternal glycaemia (HbA1c < 48 mmol/mol [6.5%]/ or continuous glucose monitoring time above range ≤ 30%), birthweight z scores were reduced towards zero (normal weight) with increasing PlGF values (representing a healthy placenta), and increased with decreasing PlGF values. With suboptimal glycaemic status (HbA1c ≥ 48 mmol/mol [6.5%] or time above range > 30%), increasing PlGF values were associated with heavier infants. Those with a healthy placenta (PlGF > 100) and suboptimal glycaemic control had a higher mean z score (2.45) than those with an unhealthy placenta (mean z score = 1.86). Similar relationships were seen when using sFlt-1/PlGF ratio as a marker for a healthy vs unhealthy placenta. CONCLUSIONS/INTERPRETATION In women with type 1 diabetes, infant birthweight is influenced by both glycaemic status and placental function. In women with suboptimal glycaemia, infant birthweight was heavier when placentas were healthy. Suboptimal placental function should be considered in the setting of suboptimal glycaemia and apparently 'normal' birthweight.
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Affiliation(s)
- Siobhan Bacon
- Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dylan Burger
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mayur Tailor
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - George Tomlinson
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Helen R Murphy
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
- Women's Health Academic Centre, Division of Women and Children's Health, Kings College London, London, UK
| | - Denice S Feig
- Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada.
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11
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Armistead B, Kadam L, Siegwald E, McCarthy FP, Kingdom JC, Kohan-Ghadr HR, Drewlo S. Induction of the PPARγ (Peroxisome Proliferator-Activated Receptor γ)-GCM1 (Glial Cell Missing 1) Syncytialization Axis Reduces sFLT1 (Soluble fms-Like Tyrosine Kinase 1) in the Preeclamptic Placenta. Hypertension 2021; 78:230-240. [PMID: 34024123 DOI: 10.1161/hypertensionaha.121.17267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Brooke Armistead
- From the Michigan State University, Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Grand Rapids (B.A., H.-R.K.-G., S.D.)
| | - Leena Kadam
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland (L.K.)
| | - Emily Siegwald
- Spectrum Health SHARE Biorepository and Office of Research and Education, Spectrum Health, Grand Rapids, MI (E.S.)
| | - Fergus P McCarthy
- Department of Obstetrics and Gynaecology, Infant Research Centre, University College Cork, Ireland (F.P.M.)
| | - John C Kingdom
- Department of Obstetrics and Gynecology, University of Toronto, ON, Canada (J.C.K.).,Department of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON, Canada (J.C.K.)
| | - Hamid-Reza Kohan-Ghadr
- From the Michigan State University, Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Grand Rapids (B.A., H.-R.K.-G., S.D.)
| | - Sascha Drewlo
- From the Michigan State University, Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Grand Rapids (B.A., H.-R.K.-G., S.D.)
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12
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Levine L, Habertheuer A, Ram C, Korutla L, Schwartz N, Hu RW, Reddy S, Freas A, Zielinski PD, Harmon J, Molugu SK, Parry S, Vallabhajosyula P. Syncytiotrophoblast extracellular microvesicle profiles in maternal circulation for noninvasive diagnosis of preeclampsia. Sci Rep 2020; 10:6398. [PMID: 32286341 PMCID: PMC7156695 DOI: 10.1038/s41598-020-62193-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 02/04/2020] [Indexed: 12/23/2022] Open
Abstract
Preeclampsia is the most common placental pathology in pregnant females, with increased morbidity and mortality incurred on the mother and the fetus. There is a need for improved biomarkers for diagnosis and monitoring of this condition. Placental syncytiotrophoblasts at the maternal-fetal interface release nanoparticles, including extracellular microvesicles, into the maternal blood during pregnancy. Syncytiotrophoblast extracellular microvesicles (STEVs) are being studied for their diagnostic potential and for their potential physiologic role in preeclampsia. We hypothesized that STEV profiles in maternal circulation would be altered under conditions of preeclampsia compared to normal pregnancy. Extracellular vesicles (EVs) released by BeWo cells in vitro showed high expression of syncytin-1, but no plac1 expression, demonstrating that trophoblast cell EVs express syncytin-1 on their surface. Placental alkaline phosphatase also showed high expression on BeWo EVs, but due to concern for cross reactivity to highly prevalent isoforms of intestinal and bone alkaline phosphatase, we utilized syncytin-1 as a marker for STEVs. In vivo, syncytin-1 protein expression was confirmed in maternal plasma EVs from Control and Preeclampsia subjects by Western blot, and overall, lower expression was noted in samples from patients with preeclampsia (n = 8). By nanoparticle analysis, EV profiles from Control and Preeclampsia groups showed similar total plasma EV quantities (p = 0.313) and size distribution (p = 0.415), but STEV quantitative signal, marked by syncytin-1 specific EVs, was significantly decreased in the Preeclampsia group (p = 2.8 × 10−11). Receiver operating characteristic curve demonstrated that STEV signal threshold cut-off of <0.316 was 95.2% sensitive and 95.6% specific for diagnosis of preeclampsia in this cohort (area under curve = 0.975 ± 0.020). In conclusion, we report that the syncytin-1 expressing EV profiles in maternal plasma might serve as a placental tissue specific biomarker for preeclampsia.
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Affiliation(s)
- Lisa Levine
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Pennsylvania, Pennsylvania, USA
| | - Andreas Habertheuer
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania, USA
| | - Chirag Ram
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania, USA
| | - Laxminarayana Korutla
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania, USA
| | - Nadav Schwartz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Pennsylvania, Pennsylvania, USA
| | - Robert W Hu
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania, USA
| | - Sanjana Reddy
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania, USA
| | - Andrew Freas
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania, USA
| | - Patrick D Zielinski
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania, USA
| | - Joey Harmon
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania, USA
| | - Sudheer Kumar Molugu
- Department of Biochemistry and Biophysics, University of Pennsylvania, Pennsylvania, USA
| | - Samuel Parry
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Pennsylvania, Pennsylvania, USA
| | - Prashanth Vallabhajosyula
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania, USA. .,Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, USA.
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13
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Farah O, Nguyen C, Tekkatte C, Parast MM. Trophoblast lineage-specific differentiation and associated alterations in preeclampsia and fetal growth restriction. Placenta 2020; 102:4-9. [PMID: 33218578 DOI: 10.1016/j.placenta.2020.02.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 02/06/2020] [Accepted: 02/09/2020] [Indexed: 12/26/2022]
Abstract
The human placenta is a poorly-understood organ, but one that is critical for proper development and growth of the fetus in-utero. The epithelial cell type that contributes to primary placental functions is called "trophoblast," including two main subtypes, villous and extravillous trophoblast. Cytotrophoblast and syncytiotrophoblast comprise the villous compartment and contribute to gas and nutrient exchange, while extravillous trophoblast invade and remodel the uterine wall and vessels, in order to supply maternal blood to the growing fetus. Abnormal differentiation of trophoblast contributes to placental dysfunction and is associated with complications of pregnancy, including preeclampsia (PE) and fetal growth restriction (FGR). This review describes what is known about the cellular organization of the placenta during both normal development and in the setting of PE/FGR. It also explains known trophoblast lineage-specific markers and pathways regulating their differentiation, and how these are altered in the setting of PE/FGR, focusing on studies which have used human placental tissues. Finally, it also highlights remaining questions and needed resources to advance this field.
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Affiliation(s)
- Omar Farah
- Department of Pathology, University of California San Diego, La Jolla, CA, 92093, USA; Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA, 92093, USA
| | - Calvin Nguyen
- Department of Pathology, University of California San Diego, La Jolla, CA, 92093, USA; Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA, 92093, USA
| | - Chandana Tekkatte
- Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA, 92093, USA; Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla, CA, 92093, USA
| | - Mana M Parast
- Department of Pathology, University of California San Diego, La Jolla, CA, 92093, USA; Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA, 92093, USA.
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14
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Loussert L, Vidal F, Parant O, Hamdi SM, Vayssiere C, Guerby P. Aspirin for prevention of preeclampsia and fetal growth restriction. Prenat Diagn 2020; 40:519-527. [PMID: 31955436 DOI: 10.1002/pd.5645] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/23/2019] [Accepted: 01/02/2020] [Indexed: 12/12/2022]
Abstract
For the past decades, growing attention has been given to aspirin use during pregnancy. It favors placentation by its proangiogenic, antithrombotic, and anti-inflammatory effects. Therefore, low doses of aspirin are prescribed in the prevention of placenta-mediated complications, mainly preeclampsia and fetal growth restriction. However, questions regarding its clinical application are still debated. Aspirin is effective in preventing preeclampsia in a high-risk population. Most guidelines recommend that risk stratification should rely on medical history. Nevertheless, screening performances dramatically improve if biochemical and biophysical markers are included. Concerning the appropriate timing and dose, latest studies suggest aspirin should be started before 16 weeks of pregnancy and at a daily dose of 100 mg or more. Further studies are needed to improve the identification of patients likely to benefit from prophylactic aspirin. Besides, the role of aspirin in the prevention of fetal growth restriction is still questioned.
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Affiliation(s)
- Lola Loussert
- Department of Obstetrics and Gynecology, Paule de Viguier Hospital, CHU Toulouse, Toulouse, France
| | - Fabien Vidal
- Department of Obstetrics and Gynecology, Paule de Viguier Hospital, CHU Toulouse, Toulouse, France
| | - Olivier Parant
- Department of Obstetrics and Gynecology, Paule de Viguier Hospital, CHU Toulouse, Toulouse, France
| | - Safouane M Hamdi
- Laboratoire de Biochimie et d'Hormonologie, Institut Fédératif de Biologie, CHU Toulouse, Toulouse, France
| | - Christophe Vayssiere
- Department of Obstetrics and Gynecology, Paule de Viguier Hospital, CHU Toulouse, Toulouse, France
| | - Paul Guerby
- Department of Obstetrics and Gynecology, Paule de Viguier Hospital, CHU Toulouse, Toulouse, France.,Inserm U-1048, Université de Toulouse, Toulouse, France
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15
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The role of hepatic sinusoidal obstruction in the pathogenesis of the hepatic involvement in HELLP syndrome: Exploring the literature. Pregnancy Hypertens 2019; 19:37-43. [PMID: 31877439 DOI: 10.1016/j.preghy.2019.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 10/11/2019] [Accepted: 11/25/2019] [Indexed: 01/17/2023]
Abstract
AIM This study aims to determine, based on existing data, whether the mechanism resulting in liver dysfunction in HELLP syndrome resembles that in Sinusoidal Obstruction Syndrome (SOS). BACKGROUND HELLP syndrome is a serious pregnancy disorder with high maternal and perinatal morbidity and mortality rates. Because of poor insight in its pathophysiology, particularly that of the liver involvement, clinical management is limited to symptomatic treatment, often followed by termination of pregnancy. SOS is a rare, potentially life-threatening complication of radio and/ or chemotherapy in the preparation of hematopoietic cell transplantation. The etiology of liver dysfunction in SOS is - unlike that in HELLP syndrome - better-understood and seems to be initiated by direct toxic damage and demise of endothelial cells, causing hepatic sinusoidal obstruction and ischemia. METHODS We searched Pubmed, Embase and Cochrane for reports on the etiology of HELLP and SOS. This yielded 73 articles, with 14 additional reports from the references listed in these articles. RESULTS The dysfunctional placenta in women developing HELLP initiates a cascade of events that eventually results in liver dysfunction. The placenta releases, besides anti-angiogenetic factors, also necrotic debris and cell-free DNA, a mixture that not only induces systemic endothelial dysfunction as in preeclampsia, but also a systemic inflammatory response. The latter aggravates the endothelio-toxic effects in the systemic cardiovascular bed, amplifying the already increased pro-thrombotic conditions. Particularly in microcirculations with extremely low shear forces, such as in the hepatic sinusoids, this will facilitate microthrombi formation and fibrin deposition eventually resulting in obstruction of the sinusoids similar as in SOS. The latter causes ischemic damage and progressive demise of hepatocytes. CONCLUSION The available information supports the concept that the liver damage in HELLP and SOS results from sinusoidal ischemia, presumably resulting from partially overlapping pathophysiological mechanisms.
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16
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Abstract
Placental dysfunction is a major contributing factor to fetal growth restriction. Placenta-mediated fetal growth restriction occurs through chronic fetal hypoxia owing to poor placental perfusion through a variety of mechanisms. Maternal vascular malperfusion is the most common placental disease contributing to fetal growth restriction; however, the role of rare placental diseases should not be overlooked. Although the features of maternal vascular malperfusion are identifiable on placental pathology, antepartum diagnostic methods are evolving. Placental imaging and uterine artery Doppler, used in conjunction with angiogenic growth factors (specifically placenta growth factor and soluble fms-like tyrosine kinase-1), play an increasingly important role.
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17
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van Lieshout LCEW, Koek GH, Spaanderman MA, van Runnard Heimel PJ. Placenta derived factors involved in the pathogenesis of the liver in the syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP): A review. Pregnancy Hypertens 2019; 18:42-48. [PMID: 31494464 DOI: 10.1016/j.preghy.2019.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 07/07/2019] [Accepted: 08/15/2019] [Indexed: 12/20/2022]
Abstract
AIM With this review we try to unravel if placenta-derived factors are able to initiate liver sinusoidal endothelial cells (LSEC) decay in HELLP syndrome and eventually cause the development of sinusoidal obstruction syndrome (SOS). BACKGROUND Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome is a severe complication of pregnancy. It is characterized by elevated liver enzymes, low platelet count and haemolytic anaemia. The risk of developing HELLP syndrome within a pregnancy is 0.1-0.8%. The mortality rate among women with HELLP syndrome is 0-24% and the perinatal death goes up to 37%. The aetiology of HELLP syndrome is not fully understood but the pathogenesis of the liver pathology in the HELLP syndrome resembles that of a SOS with endothelial damage of the LSECs which ultimately leads to liver failure. OBJECTIVES We hypothesize that placenta derived factors cause LSEC damage and thereby liver dysfunction. METHODS We searched in the PubMed database for relevant articles about placenta derived factors involved in endothelial activation especially in the liver. We yielded eventually 55 relevant articles. RESULTS Based on this literature search we associate that in HELLP syndrome there is an increase of soluble fms-like tyrosine kinase (sFlt1), vascular endothelial growth factor (VEGFR), soluble endoglin (sEng), galectin-1 (Gal-1), endothelin-1 (ET-1), Angiopoietin 2 (Angs-2), Asymmetric dimethylarginine (ADMA), activin B, inhibin A, Fas ligand (FasL) and heat shock protein 70 (Hsp70). CONCLUSION We assume that these eleven increased placenta derived factors are responsible for LSEC damage which eventually leads to liver failure. This concept shows a possible design of the complicated pathophysiology in HELLP syndrome. However further research is required.
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Affiliation(s)
- L C E W van Lieshout
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands.
| | - G H Koek
- Department of Internal Medicine, Division of Gastroenterology, Maastricht University Medical Centre, Netherlands; Department of Surgery, Klinikum RWTH Aachen, Germany
| | - M A Spaanderman
- Department of Gynaecology, Maastricht University Medical Centre, Netherlands
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Ding W, Qiu B, Cram DS, Chen X, Li S, Zhou X, Liu J, Wu Z, Song Y. Isobaric tag for relative and absolute quantitation based quantitative proteomics reveals unique urinary protein profiles in patients with preeclampsia. J Cell Mol Med 2019; 23:5822-5826. [PMID: 31232531 PMCID: PMC6652679 DOI: 10.1111/jcmm.14459] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 05/12/2019] [Accepted: 05/15/2019] [Indexed: 12/24/2022] Open
Abstract
Preeclampsia (PE) is one of the most significant pregnancy‐related hypertensive disorders. Currently, there are no useful markers to predict the onset of the condition in pregnant women. To provide further insights into the pathogenesis of PE and identify biomarkers of the condition, we used isobaric tags for relative and absolute quantitation (iTRAQ) proteomics coupled with 2‐D LC‐MS/MS, to analyze urinary protein profiles from 7 PE patients and 7 normotensive pregnant women. A total of 294 proteins were abnormally expressed in PE patients. Of these, 233 were significantly down‐regulated and 61 proteins were significantly up‐regulated. Bioinformatics analysis using the Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) database, found that the most differentially expressed proteins (DEPs) were involved in coagulation and complement pathways, the renin‐angiotensin system and cell adhesion molecules (CAMs) pathways. We further validated three of the DEPs, including serotransferrin (TF) and complement factor B (CFB) by immunoblottingand serum paraoxonase/arylesterase 1 (PON1) by ELISA using 14 pairs of urine samples from PE patients and normal pregnant women. Taken together, our results provide the basis for further understanding the pathogenesis of PE and identifying predictive biomarkers.
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Affiliation(s)
- Wenyan Ding
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Bintao Qiu
- Department of Central Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | | | - Xiuting Chen
- Department of Central Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Shengjie Li
- Department of Central Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiya Zhou
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Zhihong Wu
- Department of Central Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yijun Song
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Pham J, Arul Nambi Rajan K, Li P, Parast MM. The role of Sirtuin1-PPARγ axis in placental development and function. J Mol Endocrinol 2018; 60:R201-R212. [PMID: 29467141 PMCID: PMC8584848 DOI: 10.1530/jme-17-0315] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 02/21/2018] [Indexed: 12/11/2022]
Abstract
Placental development is important for proper in utero growth and development of the fetus, as well as maternal well-being during pregnancy. Abnormal differentiation of placental epithelial cells, called trophoblast, is at the root of multiple pregnancy complications, including miscarriage, the maternal hypertensive disorder preeclampsia and intrauterine growth restriction. The ligand-activated nuclear receptor, PPARγ, and nutrient sensor, Sirtuin-1, both play a role in numerous pathways important to cell survival and differentiation, metabolism and inflammation. However, each has also been identified as a key player in trophoblast differentiation and placental development. This review details these studies, and also describes how various stressors, including hypoxia and inflammation, alter the expression or activity of PPARγ and Sirtuin-1, thereby contributing to placenta-based pregnancy complications.
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Affiliation(s)
- Jonathan Pham
- Department of PathologyUniversity of California San Diego, La Jolla, California, USA
- Sanford Consortium for Regenerative MedicineUniversity of California San Diego, La Jolla, California, USA
| | - Kanaga Arul Nambi Rajan
- Department of PathologyUniversity of California San Diego, La Jolla, California, USA
- Sanford Consortium for Regenerative MedicineUniversity of California San Diego, La Jolla, California, USA
| | - Ping Li
- Department of PathologyMedical School of Jinan University, Guangzhou, China
| | - Mana M Parast
- Department of PathologyUniversity of California San Diego, La Jolla, California, USA
- Sanford Consortium for Regenerative MedicineUniversity of California San Diego, La Jolla, California, USA
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Kingdom JC, Audette MC, Hobson SR, Windrim RC, Morgen E. A placenta clinic approach to the diagnosis and management of fetal growth restriction. Am J Obstet Gynecol 2018; 218:S803-S817. [PMID: 29254754 DOI: 10.1016/j.ajog.2017.11.575] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 11/10/2017] [Accepted: 11/10/2017] [Indexed: 12/13/2022]
Abstract
Effective detection and management of fetal growth restriction is relevant to all obstetric care providers. Models of best practice to care for these patients and their families continue to evolve. Since much of the disease burden in fetal growth restriction originates in the placenta, the concept of a multidisciplinary placenta clinic program, managed primarily within a maternal-fetal medicine division, has gained popularity. In this context, fetal growth restriction is merely one of many placenta-related disorders that can benefit from an interdisciplinary approach, incorporating expertise from specialist perinatal ultrasound and magnetic resonance imaging, reproductive genetics, neonatal pediatrics, internal medicine subspecialties, perinatal pathology, and nursing. The accurate diagnosis and prognosis for women with fetal growth restriction is established by comprehensive clinical review and detailed sonographic evaluation of the fetus, combined with uterine artery Doppler and morphologic assessment of the placenta. Diagnostic accuracy for placenta-mediated fetal growth restriction may be enhanced by quantification of maternal serum biomarkers including placenta growth factor alone or combined with soluble fms-like tyrosine kinase-1. Uterine artery Doppler is typically abnormal in most instances of early-onset fetal growth restriction and is associated with coexistent preeclampsia and underlying maternal vascular malperfusion pathology of the placenta. By contrast, rare but potentially more serious underlying placental diagnoses, such as massive perivillous fibrinoid deposition, chronic histiocytic intervillositis, or fetal thrombotic vasculopathy, may be associated with normal uterine artery Doppler waveforms. Despite minor variations in placental size, shape, and cord insertion, placental function remains, largely normal in the general population. Consequently, morphologic assessment of the placenta is not currently incorporated into current screening programs for placental complications. However, placental ultrasound can be diagnostic in the context of fetal growth restriction, for example in Breus' mole and triploidy, which in turn may enhance diagnosis and management. Several examples are illustrated in our figures and supplementary videos. Recent advances in the ability of multiparameter screening and intervention programs to reduce the risk of severe preeclampsia will likely increase efforts to deliver similar improvements for women at risk of fetal growth restriction. Placental pathology is important because the underlying pathologies associated with fetal growth restriction have a wide range of recurrence risks. Rare conditions such as massive perivillous fibrinoid deposition or chronic histolytic intervillositis may recur in >50% of subsequent pregnancies. Postpartum care in a placenta-focused program can provide effective counseling for modifiable maternal risk factors, and can assist in planning future pregnancy care based on the pathologic basis of fetal growth restriction.
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Um-Bergström M, Papadogiannakis N, Westgren M, Vinnars MT. Antenatal corticosteroid treatment and placental pathology, with a focus on villous maturation. Acta Obstet Gynecol Scand 2017; 97:74-81. [DOI: 10.1111/aogs.13242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 09/27/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Miranda Um-Bergström
- Department of Clinical Sciences, Intervention and Technology (CLINTEC); Karolinska Institute; Stockholm Sweden
- Department of Laboratory Medicine; Karolinska Institute; Stockholm Sweden
| | - Nikos Papadogiannakis
- Department of Laboratory Medicine; Karolinska Institute; Stockholm Sweden
- Karolinska University Hospital; Stockholm Sweden
| | - Magnus Westgren
- Department of Clinical Sciences, Intervention and Technology (CLINTEC); Karolinska Institute; Stockholm Sweden
- Karolinska University Hospital; Stockholm Sweden
| | - Marie-Therese Vinnars
- Department of Clinical Sciences, Intervention and Technology (CLINTEC); Karolinska Institute; Stockholm Sweden
- Örnsköldsviks Hospital; Örnsköldsvik Sweden
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McNally R, Alqudah A, Obradovic D, McClements L. Elucidating the Pathogenesis of Pre-eclampsia Using In Vitro Models of Spiral Uterine Artery Remodelling. Curr Hypertens Rep 2017; 19:93. [PMID: 29063290 PMCID: PMC5653699 DOI: 10.1007/s11906-017-0786-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW The aim of the study is to perform a critical assessment of in vitro models of pre-eclampsia using complementary human and cell line-based studies. Molecular mechanisms involved in spiral uterine artery (SUA) remodelling and trophoblast functionality will also be discussed. RECENT FINDINGS A number of proteins and microRNAs have been implicated as key in SUA remodelling, which could be explored as early biomarkers or therapeutic targets for prevention of pre-eclampsia. Various 2D and 3D in vitro models involving trophoblast cells, endothelial cells, immune cells and placental tissue were discussed to elucidate the pathogenesis of pre-eclampsia. Nevertheless, pre-eclampsia is a multifactorial disease, and the mechanisms involved in its pathogenesis are complex and still largely unknown. Further studies are required to provide better understanding of the key processes leading to inappropriate placental development which is the root cause of pre-eclampsia. This new knowledge could identify novel biomarkers and treatment strategies.
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Affiliation(s)
- Ross McNally
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Abdelrahim Alqudah
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Danilo Obradovic
- Institute of Pathology, University of Belgrade, Belgrade, 11,000, Serbia
| | - Lana McClements
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.
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Endothelial Dysfunction in Severe Preeclampsia is Mediated by Soluble Factors, Rather than Extracellular Vesicles. Sci Rep 2017; 7:5887. [PMID: 28725005 PMCID: PMC5517616 DOI: 10.1038/s41598-017-06178-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 06/09/2017] [Indexed: 11/24/2022] Open
Abstract
In severe early-onset preeclampsia (sPE) the placenta releases soluble angiogenesis-regulating proteins, trophoblast-derived fragments, and extracellular vesicles (EVs). Their relative importance in disease pathogenesis is not presently understood. We explanted placental villi from healthy and sPE women then separated the media into: total-conditioned, EV-depleted and EV-enriched media. Three fractions were compared for; angiogenic protein secretion by ELISA, angiogenic and inflammation gene mRNA expression and leukocyte adhesion assay. sPE placental villi secreted significantly less PlGF (70 ± 18 pg/mL) than preterm controls (338 ± 203; p = 0.03). sFlt-1:PlGF ratios in total-conditioned (115 ± 29) and EV-depleted media (136 ± 40) from sPE placental villi were significantly higher than in EV-enriched media (42 ± 12; p < 0.01) or any preterm or term media. Fluorescent-labeled EVs derived across normal gestation, but not from sPE, actively entered HUVECs. From sPE placental villi, the soluble fraction, but not EV-enriched fraction, significantly repressed angiogenesis (0.83 ± 0.05 fold, p = 0.02), induced HO-1 mRNA (15.3 ± 5.1 fold, p < 0.05) and induced leukocyte adhesion (2.2 ± 0.4 fold, p = 0.04). Soluble media (total-conditioned and EV-depleted media) from sPE placental villi induced endothelial dysfunction in HUVEC, while the corresponding EV-enriched fraction showed no such effects. Our data suggest that soluble factors including angiogenesis-regulating proteins, dominate the vascular pathology of this disease.
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Is Canada Ready to Adopt Maternal Placental Growth Factor Testing to Improve Clinical Outcomes for Women with Suspected Preeclampsia? JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:580-583. [DOI: 10.1016/j.jogc.2016.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 10/18/2016] [Accepted: 10/18/2016] [Indexed: 11/19/2022]
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Rios DRA, Alpoim PN, Godoi LC, Perucci LO, de Sousa LP, Gomes KB, Dusse LMS. Increased Levels of sENG and sVCAM-1 and Decreased Levels of VEGF in Severe Preeclampsia. Am J Hypertens 2016; 29:1307-1310. [PMID: 26476083 DOI: 10.1093/ajh/hpv170] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 09/29/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Preeclampsia (PE) is characterized by hypertension and proteinuria after the 20th week in pregnant women who have had no previous symptoms. Clinically, it is important to diagnose the severe form of the disease, in which blood pressure is much higher. Imbalance between angiogenic and antiangiogenic factors, as well as changes in adhesion molecules seem to contribute to the endothelial dysfunction and PE clinical manifestations. The aim of this study was to assess plasma levels of the angiogenic factors (free vascular endothelial growth factor (VEGF) and soluble endoglin (sEng)) and adhesion molecules (soluble forms of intercellular adhesion molecule-1 (sICAM-1) and soluble forms of vascular cell adhesion molecule-1 (sVCAM-1)) in severe PE (sPE), in order to clarify the circulating profile of these factors. METHODS Sixty women with sPE (34 with early sPE and 26 with late sPE), and 60 normotensive pregnant were enrolled in this study. Free VEGF, sICAM-1, sVCAM-1, and sEng plasma levels were determined by ELISA. RESULTS Increased sEng and sVCAM-1 and decreased free VEGF plasma levels were found in women with sPE, compared with normotensive pregnant group. However, no significant difference was observed comparing early and late sPE. CONCLUSION Our data confirm the imbalance in changes in angiogenic and antiangiogenic factors, as well changes in adhesion molecule (sVCAM-1) in PE. These findings give support to the hypothesis that circulating angiogenic proteins and endothelial dysfunction may have an important biologic role in PE. Data from prospective, longitudinal studies producing serial determinations of these molecules throughout pregnancy are needed to better understanding the relevance of these markers in PE diagnosis and prognosis.
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Affiliation(s)
- Danyelle Romana Alves Rios
- Campus Centro Oeste Dona Lindu, Federal University of São João del-Rei, São João del-Rei, Minas Gerais, Brazil
| | - Patricia Nessrala Alpoim
- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Lara Carvalho Godoi
- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Luiza Oliveira Perucci
- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Lirlândia Pires de Sousa
- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Karina Braga Gomes
- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Luci Maria SantAna Dusse
- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Zozzaro-Smith PE, Bushway ME, Gerber SA, Hebert D, Pressman EK, Lord EM, Miller RK, Murphy SP. Whole mount immunofluorescence analysis of placentas from normotensive versus preeclamptic pregnancies. Placenta 2015; 36:1310-7. [PMID: 26386651 DOI: 10.1016/j.placenta.2015.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 09/01/2015] [Accepted: 09/02/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Defects in placental angiogenesis and spiral artery remodeling have been proposed to play essential roles in the development of preeclampsia. However, the specific molecular mechanism(s) responsible for aberrant placental angiogenesis in preeclampsia are incompletely understood. The vascular endothelial growth factor receptors (VEGFR1, R2, R3) and STAT3 have critical functions in normal blood vessel development, but their potential roles in preeclampsia are currently unclear. In this study, we utilized a novel whole mount immunofluorescence (WMIF) method to compare expression of VEGFR1, R2, R3 and activated, phosphorylated STAT3 (pSTAT3) in placentas of preeclamptic (PE) versus normotensive (NT) pregnancies. METHODS Placental biopsies collected from NT and PE pregnant women were fixed and stained with fluorochrome-conjugated antibodies to identify specific cell populations as follows: CD31 for blood vessel endothelial cells, cytokeratin-7 for trophoblast cells, and CD45 for immune cells. Expression of the VEGFRs and pSTAT3 were subsequently characterized by WMIF in conjunction with confocal microscopy. RESULTS A total of 18 PE and 18 NT placentas were evaluated. No significant differences in the cell type-specific expression patterns or expression levels of VEGFR1, VEGFR2 or VEGFR3 were detected between NT and PE placentas. In contrast, statistically significant increases in pSTAT3 staining were detected in endothelial cells of PE placentas versus NT controls. DISCUSSION Our study demonstrates that increased pSTAT3 expression in placental endothelial cells is associated with PE. We speculate that elevated pSTAT3 expression in the blood vessels of PE placentas may be due to aberrant angiogenesis, increased pro-inflammatory cytokine expression, and/or placental stress.
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Affiliation(s)
- P E Zozzaro-Smith
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA
| | - M E Bushway
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA; Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA
| | - S A Gerber
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA; Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA
| | - D Hebert
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA
| | - E K Pressman
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA
| | - E M Lord
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA
| | - R K Miller
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA
| | - S P Murphy
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA; Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA.
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Abstract
INTRODUCTION Early placental development depends on the correct balance of cytotrophoblast (CTB) proliferation and differentiation, into either syncytiotrophoblast (STB) involved in nutrient/gas exchange, or invasive extravillous trophoblast (EVT) involved in establishment of blood flow to the placenta. Metastasis associated protein-3 (MTA3) is a transcriptional co-repressor known to regulate cell migration. In addition, MTA3 is reportedly decreased in preeclampsia. We set out to investigate the role of MTA3 in human trophoblast differentiation. METHODS We co-stained first and third trimester placental sections with antibodies to MTA3 and other trophoblast markers. We also evaluated MTA3 expression following in vitro differentiation of primary isolated CTB. In order to evaluate the role of MTA3 in trophoblast differentiation, we used lentiviral constructs to overexpress and knock down its expression. Trophoblast differentiation was assessed by a combination of marker expression and functional assays, including hCG ELISA and cell migration. RESULTS MTA3 was abundantly expressed in CTB and proximal cell column EVT in the human placenta and decreased with further differentiation into STB and mature EVT. MTA3 knockdown in JEG3 resulted in a 2-3 fold decrease in STB markers, CGB and GCM1, as well as in hCG secretion. In terms of EVT differentiation, MTA3 knockdown led to a 1.5-2 fold increase in HLA-G and cell migration, but decreased the mature EVT marker ITGA1. DISCUSSION Taken together, our data suggest a role for MTA3 in terminal trophoblast differentiation into both hCG-secreting STB and mature EVT.
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Jardim LL, Rios DRA, Perucci LO, de Sousa LP, Gomes KB, Dusse LMS. Is the imbalance between pro-angiogenic and anti-angiogenic factors associated with preeclampsia? Clin Chim Acta 2015; 447:34-8. [PMID: 25982781 DOI: 10.1016/j.cca.2015.05.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 05/06/2015] [Accepted: 05/07/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Preeclampsia (PE) is a multisystem disease characterized by the development of hypertension and proteinuria. Although PE etiology is not fully known, the placenta seems to play a central role in the development of disease. The inadequate placentation process results in a change in angiogenic factors levels, such as vascular endothelial growth factor (VEGF), placental growth factor (PlGF), soluble form of endoglin (s-Eng) and soluble form of vascular endothelial growth factor receptor type 1 (sFlt-1). OBJECTIVE The aim of this review was to clarify if the imbalance between pro-angiogenic and anti-angiogenic factors is associated with PE. CONCLUSION It is known that inadequate placentation process is the primary mechanism suggested for PE occurrence and angiogenic factors are involved in this process. The state-of-the-art suggests that progress in grasp the imbalance of pro-angiogenic and anti-angiogenic factors is essential for the improvement of knowledge about PE. The development of prospective, longitudinal studies with serial determinations of these factors throughout pregnancy is needed to better assess the relevance of these markers for understanding the etiology, prevention, diagnosis, prognosis and treatment of this challenging disease.
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Affiliation(s)
- Letícia Lemos Jardim
- Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais, Brazil
| | | | - Luíza Oliveira Perucci
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Brazil
| | - Lirlândia Pires de Sousa
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Brazil
| | - Karina Braga Gomes
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Brazil
| | - Luci Maria S Dusse
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Brazil.
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Shu C, Liu Z, Cui L, Wei C, Wang S, Tang JJ, Cui M, Lian G, Li W, Liu X, Xu H, Jiang J, Lee P, Zhang DY, He J, Ye F. Protein profiling of preeclampsia placental tissues. PLoS One 2014; 9:e112890. [PMID: 25392996 PMCID: PMC4231077 DOI: 10.1371/journal.pone.0112890] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 10/16/2014] [Indexed: 12/18/2022] Open
Abstract
Preeclampsia is a multi-system disorder involved in pregnancy without an effective treatment except delivery. The precise pathogenesis of this complicated disorder is still not completely understood. The objective of this study is to evaluate the alterations of protein expression and phosphorylations that are important in regulating placental cell function in preterm and term preeclampsia. Using the Protein Pathway Array, 38 proteins in placental tissues were found to be differentially expressed between preterm preeclampsia and gestational age matched control, while 25 proteins were found to be expressed differentially between term preeclampsia and matched controls. Among these proteins, 16 proteins and their associated signaling pathways overlapped between preterm and term preeclampsia, suggesting the common pathogenesis of two subsets of disease. On the other hand, many proteins are uniquely altered in either preterm or term preeclampsia and correlated with severity of clinical symptoms and outcomes, therefore, providing molecular basis for these two subsets of preeclampsia. Furthermore, the expression levels of some of these proteins correlated with neonatal small for gestational age (PAI-1 and PAPP-A) and adverse outcomes (Flt-1) in women with preterm preeclampsia. These proteins could potentially be used as candidate biomarkers for predicting outcomes of preeclampsia.
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Affiliation(s)
- Chang Shu
- Department of Obstetrics and Gynecology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Zitao Liu
- Department of Obstetrics and Gynecology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Lifeng Cui
- Department of Obstetrics and Gynecology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Chengguo Wei
- Department of Medicine Bioinformatics Core, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Shuwen Wang
- Computer Center of Jilin Province, Changchun, Jilin, China
| | - Jian Jenny Tang
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Miao Cui
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Guodong Lian
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital, Jinan, Shandong, China
| | - Wei Li
- Department of Gastrointestinal Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xiufen Liu
- Department of Ophthalmology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Hongmei Xu
- Department of Obstetrics and Gynecology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jing Jiang
- Division of Clinical Epidemiology, The First Hospital of Jilin University, Chang chun, Jilin, China
| | - Peng Lee
- Departments of Pathology, Urology and New York University Cancer Institute, New York University, School of Medicine, New York, New York, United States of America
| | - David Y. Zhang
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Jin He
- Department of Obstetrics and Gynecology, The First Hospital of Jilin University, Changchun, Jilin, China
- * E-mail: (JH); (FY)
| | - Fei Ye
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
- * E-mail: (JH); (FY)
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Govender N, Moodley J, Gathiram P, Naicker T. Soluble fms-like tyrosine kinase-1 in HIV infected pre-eclamptic South African Black women. Placenta 2014; 35:618-24. [DOI: 10.1016/j.placenta.2014.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 04/14/2014] [Accepted: 04/22/2014] [Indexed: 11/24/2022]
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Yamamoto DDR, Yamamoto LDR, Rocha LP, Machado JR, Guimarães CSDO, Reis MAD, Corrêa RRM. Increase of placental sensitivity to melatonin and the alteration to its local synthesis in hypertensive syndromes in pregnancy. Hypertens Pregnancy 2014; 32:120-8. [PMID: 23725077 DOI: 10.3109/10641955.2013.784779] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the relation between hypertensive syndromes and melatonin, and its possible protective role against lesions due to hypertension. METHODS Placentas were classified into gestational hypertension (GH), chronic hypertension (CH), pre-eclampsia (PE) and pre-eclampsia superimposed on chronic hypertension, and morphologically examined by hematoxylin-eosin and periodic acid Schiff methods. Immunohistochemistry was performed to detect tryptophan hydroxylase (TH) and melatonin receptor 1A (MR-1A). RESULTS MR-1A expression was higher in all types of hypertensive syndromes in pregnancy (HSP), mainly in cases with GH, in Caesarean section delivery, preterm placentas and in the cases with alterations in the placental morphology, particularly those presenting inflammation. The expression of TH was higher in cases with CH when compared with the control. This expression was lower in primigestas, in the cases of inflammation and with PE. CONCLUSIONS HSP therapies should be considered and studied, especially in the cases of HSP associated with PE, in which the placenta is more sensitive as it has more receptors, but its synthesis ability is reduced. As for GH and CH, the possible benefits should be evaluated, since the local placental ability to produce melatonin still exists.
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Ruiz-Quiñonez G, Reza-López SA, Chávez-Corral DV, Sánchez-Ramírez B, Leal-Berumen I, Levario-Carrillo M. Placental maturity, hypertensive disorders of pregnancy and birth weight. Hypertens Pregnancy 2013; 33:132-44. [PMID: 24303980 DOI: 10.3109/10641955.2013.842583] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To compare maturity of placentas from women with hypertensive disorders with those from normotensive pregnancies and to determine the relationship between placental maturity (PM) and the diagnosis of small-for-gestational-age (SGA) in the newborns. MATERIALS AND METHODS We examined placental stained specimens from women with normotensive pregnancies (n = 100), diagnosis of gestational hypertension (n = 38), mild (n = 10), or severe preeclampsia (n = 34) in an optical microscope. Placental Maturity Index (PMI) was calculated as the number of vasculo-syncytial membranes (VSM) in 1 mm(2) divided by VSM thickness (µm). Hypermaturity was defined as >90th percentile of the PMI from placentas of normotensive pregnancies. Newborns were classified as SGA, adequate-for-gestational-age (AGA) or large-for-gestational-age (<10th, 10-90th, and >90th percentile from weight for gestational age reference tables, respectively). RESULTS PMI in preeclamptic women (taking together mild and severe preeclampsia, PMI = 43.4 ± 1.6) was significantly higher than in normotensive women (PMI = 36 ± 2, p = 0.045). Hypermaturity was more frequent (p < 0.05) in placentas from women with preeclampsia than in those from normotensive women only in preterm pregnancies (<37 weeks), but not in those at term (p = 0.41). The frequency of hypermaturity in placentas from women with gestational hypertension was not statistically different than in normotensive women. Hypermaturity was also more frequent in placentas from SGA (OR = 2.63, p < 0.05) than in AGA newborns. CONCLUSION The PMI was increased in preeclampsia, but not in gestational hypertension. Placental hypermaturity was also associated with the diagnosis of SGA in newborns. PM might have a role in the relationship between maternal factors and SGA.
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Shchyogolev AI, Dubova EA, Pavlova KA, Lyapin VM, Sukhikh GT. Expression of antiangiogenic factors in the placental structures in pre-eclampsia. Bull Exp Biol Med 2013; 154:287-91. [PMID: 23330145 DOI: 10.1007/s10517-012-1932-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Comparative morphological study of the placentas was carried out in women with pregnancy aggravated by the development of pre-eclampsia. Immunohistochemical methods showed increased expression of endoglin (CD105) and VEGFR1 in all placental structures. The intensity of endoglin and VEGFR1 expression was maximum in the syncytiotrophoblast and extravillous cytotrophoblast cells in severe pre-eclampsia.
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Affiliation(s)
- A I Shchyogolev
- V. I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, the Ministry of Health and Social Development of the Russian Federation, Moscow, Russia.
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Quinn KH, Parast MM. Decidual regulatory T cells in placental pathology and pregnancy complications. Am J Reprod Immunol 2013; 69:533-8. [PMID: 23384284 DOI: 10.1111/aji.12077] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 12/31/2012] [Indexed: 12/11/2022] Open
Abstract
Regulatory T cells (Tregs) have been identified as immunomodulatory cells, which induce tolerance. Evidence from numerous recent studies implicates these cells as critical for maternal tolerance to the fetal-derived placenta, proper functioning of which is required for normal gestation and growth and development of the fetus in utero. This review focuses on the recent studies of Tregs at the maternal-fetal interface in pregnancy complications, as well as their identification in specific inflammatory lesions in the placenta.
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Affiliation(s)
- Kristen H Quinn
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, USA
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Soluble fms-like tyrosine kinase 1 and soluble endoglin are elevated circulating anti-angiogenic factors in pre-eclampsia. Pregnancy Hypertens 2012; 2:358-67. [PMID: 26105603 DOI: 10.1016/j.preghy.2012.06.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 06/24/2012] [Indexed: 01/05/2023]
Abstract
Pre-eclampsia, characterized by hypertension and proteinuria, affects approximately 3-5% of all pregnancies worldwide and is a major cause of maternal and fetal morbidity and mortality. Maternal endothelial dysfunction is associated with disease pathogenesis. Recently, reports have shown that elevated levels of circulating soluble fms-like tyrosine kinase 1 [sFlt1] and soluble endoglin [sEng] are associated with pre-eclampsia. Flt1 is a receptor for vascular endothelial growth factor receptor [VEGF], whereas endoglin [Eng] is an auxiliary receptor for transforming growth factor-β [TGF-β] super-family members. Both signaling pathways modulate angiogenesis and are involved in vascular homeostasis. Increased levels of sFlt1 and sEng dysregulate VEGF and TGF-β signaling respectively, resulting in endothelial dysfunction of maternal blood vessels. This review summarizes our current knowledge of Flt1 and endoglin and soluble forms in pre-eclampsia. Furthermore, it highlights the predictive and early-screening value of circulating levels of sFlt1 and sEng for the risk of developing pre-eclampsia.
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Drewlo S, Levytska K, Sobel M, Baczyk D, Lye SJ, Kingdom JCP. Heparin promotes soluble VEGF receptor expression in human placental villi to impair endothelial VEGF signaling. J Thromb Haemost 2011; 9:2486-97. [PMID: 21981655 DOI: 10.1111/j.1538-7836.2011.04526.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Severe preeclampsia is characterized by hypertension, renal injury and placental dysfunction. Prothrombotic disorders are discovered in 10-20% of women with preeclampsia, providing the rationale for prescribing low-molecular-weight heparin (LMWH) in future pregnancies. Heparin has diverse molecular actions and appears to reduce the recurrence risk of preeclampsia in women without prothrombotic disorders. The placenta-derived anti-angiogenic splice-variant protein soluble vascular endothelial growth factor (VEGF) receptor-1 (sFLT1) is strongly implicated in the pathogenesis of the underlying endothelial dysfunction. As the placental syncytiotrophoblast is the principal source of sFLT1, we tested the hypothesis that heparin suppresses placental sFLT1 secretion. METHODS AND RESULTS First trimester placental villi exposed to LMWH (0.25-25 IU mL(-1)) in an in vitro explant model significantly increased the expression and release of sFLT1 by the syncytiotrophoblast into culture media, reducing phosphorylation of FLT1 and KDR receptors in cultured human umbilical vein endothelial cells. This response was significantly diminished in placental villi from healthy term pregnancies. Placental villi from severely preeclamptic pregnancies had a higher baseline sFLT1 release, compared with first trimester placental villi and did not respond to LMWH treatment. LMWH promoted villous cytotrophoblast proliferation (BrdU incorporation) and impaired syncytial fusion-differentiation, causing syncytiotrophoblast apoptosis (by caspase 3&7 activity and TUNEL staining) and necrosis (ADP/ATP ratio). CONCLUSION LMWH promotes sFLT1 synthesis and release from first trimester placental villi in a manner similar to that of severely preeclamptic placental villi, which antagonizes VEGF signaling in endothelial cells. These effects in part are mediated by an interaction between heparin and the cytotrophoblasts that regenerates the overlying syncytiotrophoblast responsible for sFLT1 secretion into the maternal blood.
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Affiliation(s)
- S Drewlo
- Program in Development and Fetal Health, Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Canada.
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Abstract
Randomized control trials show beneficial effects of heparin in high-risk pregnancies to prevent preeclampsia and intrauterine growth restriction. However, the lack of placental pathology data in these trials challenges the assumption that heparin is a placental anticoagulant. Recent data show that placental infarction is probably associated with abnormalities in development of the placenta, characterized by poor maternal perfusion and an abnormal villous trophoblast compartment in contact with maternal blood, than with maternal thrombophilia. At-risk pregnancies may therefore be predicted by noninvasive prenatal testing of placental function in mid-pregnancy. Heparin has diverse cellular functions that include direct actions on the trophoblast. Dissecting the non-anticoagulant actions of heparin may indicate novel and safer therapeutic targets to prevent the major placental complications of pregnancy.
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Quinn KH, Lacoursiere DY, Cui L, Bui J, Parast MM. The unique pathophysiology of early-onset severe preeclampsia: role of decidual T regulatory cells. J Reprod Immunol 2011; 91:76-82. [PMID: 21782252 DOI: 10.1016/j.jri.2011.05.006] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2010] [Revised: 04/29/2011] [Accepted: 05/02/2011] [Indexed: 01/16/2023]
Abstract
Immunological mechanisms play a pivotal role in the pathophysiology of preeclampsia. T regulatory cells (Treg cells, FoxP3(+)) suppress the cytotoxic T cell (CD8(+)) and natural killer (NK) cell response, thereby promoting immunological tolerance to the fetus. In peripheral blood, Treg cells are elevated during pregnancy, decrease throughout gestation, and are decreased in preeclampsia. To determine their role at the implantation site, we characterized the proportion of decidual Treg and CD8+ cells, and compared these with placental histology, villous sFlt expression, and chorionic trophoblast apoptotic index in normal and preeclamptic pregnancies. Decidua from first (n=5) and second (n=4) trimester terminations and chorioamniotic membranes, containing decidua, from term deliveries (n=14), early-onset (≤ 34 weeks) (n=12), and late-onset (>34 weeks) (n=14) severe preeclampsia were evaluated. Immunohistochemistry for CD3, CD8, and FoxP3 was performed: CD8(+) and FoxP3(+) cells were calculated as a proportion of CD3(+) cells. Placental tissue was evaluated for villous hypermaturity and sFlt staining. Chorioamniotic membranes were evaluated, via TUNEL assay, for chorionic trophoblast apoptosis. Decidual Treg cells were seen to peak in second trimester and decrease with advancing gestational age and were lower in early-onset (0.46%) compared with late-onset severe preeclampsia (3.34%) and term pregnancies (5.21%). The proportion of CD8(+) cells was higher in cases of severe preeclampsia. Early-onset severe preeclamptic cases had the highest sFlt score, placental insufficiency score, and apoptotic index. Our data suggest that early-onset severe preeclampsia has a unique pathophysiology involving defective immunoregulatory pathways, potentially causing vascular and trophoblast damage at the implantation site.
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Affiliation(s)
- Kristen H Quinn
- Department of Reproductive Medicine, Division of Maternal Fetal Medicine, University of California, San Diego Medical Center, San Diego, CA 92103, USA
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