Novel approaches to combat preeclampsia: from new drugs to innovative delivery

Pre-eclampsia: Re-visiting pathophysiology, role of immune cells, biomarker identification and recent advances in its management

Pre-eclampsia (PE) is a hypertension condition that occurs exclusively during pregnancy and has the potential to impact nearly all organ systems. It is estimated to complicate approximately 2-8% of pregnancies worldwide. PE is a prominent medical disorder that poses a significant risk to pregnant mothers and their infants. This review commences by giving the most up-to- date concepts about the pathophysiology of PE. The condition involves atypical infiltration of trophoblast cells into the spiral arteries of the decidua and myometrium, resulting in an insufficient establishment of proper blood flow between the uterus and placenta. The aberrant activation of natural killer (NK) cells in both the peripheral blood and the decidua has been identified as one of the contributing factors to the development of PE. The strong evidence for the genetic etiology of PE is provided by the association between maternal killer cell immunoglobulin-like receptor (KIR) and Human Leukocyte Antigen (HLA-C) in trophoblast cells. Recent observations provide evidence that changes in the expression of anti-angiogenic factors in the placenta are the underlying cause of the clinical symptoms associated with the condition. This review also provides a comprehensive overview of the latest advancements in understanding the underlying causes of PE. It specifically highlights the emergence of new diagnostic biomarkers and their potential implications for therapeutic interventions in managing this medical condition.

Classification of preeclampsia according to molecular clusters with the goal of achieving personalized prevention

The prevention of pre-eclampsia is difficult due to the syndromic nature and multiple underlying mechanisms of this severe complication of pregnancy. The current clinical distinction between early- and late-onset disease, although clinically useful, does not reflect the true nature and complexity of the pathologic processes leading to pre-eclampsia. The current gaps in knowledge on the heterogeneous molecular pathways of this syndrome and the lack of adequate, specific diagnostic methods are major obstacles to early screening and tailored preventive strategies. The development of novel diagnostic tools for detecting the activation of the identified disease pathways would enable early, accurate screening and personalized preventive therapies. We implemented a holistic approach that includes the utilization of different proteomic profiling methods of maternal plasma samples collected from various ethnic populations and the application of systems biology analysis to plasma proteomic, maternal demographic, clinical characteristic, and placental histopathologic data. This approach enabled the identification of four molecular subclasses of pre-eclampsia in which distinct and shared disease mechanisms are activated. The current review summarizes the results and conclusions from these studies and the research and clinical implications of our findings.

Evidence for hypoxia-induced dysregulated cholesterol homeostasis in preeclampsia: Insights into the mechanisms from human placental cells and tissues

Preeclampsia (PE) poses a considerable risk to the long-term cardiovascular health of both mothers and their offspring due to a hypoxic environment in the placenta leading to reduced fetal oxygen supply. Cholesterol is vital for fetal development by influencing placental function. Recent findings suggest an association between hypoxia, disturbed cholesterol homeostasis, and PE. This study investigates the influence of hypoxia on placental cholesterol homeostasis. Using primary human trophoblast cells and placentae from women with PE, various aspects of cholesterol homeostasis were examined under hypoxic and hypoxia/reoxygenation (H/R) conditions. Under hypoxia and H/R, intracellular total and non-esterified cholesterol levels were significantly increased. This coincided with an upregulation of HMG-CoA-reductase and HMG-CoA-synthase (key genes regulating cholesterol biosynthesis), and a decrease in acetyl-CoA-acetyltransferase-1 (ACAT1), which mediates cholesterol esterification. Hypoxia and H/R also increased the intracellular levels of reactive oxygen species and elevated the expression of hypoxia-inducible factor (HIF)-2α and sterol-regulatory-element-binding-protein (SREBP) transcription factors. Additionally, exposure of trophoblasts to hypoxia and H/R resulted in enhanced cholesterol efflux to maternal and fetal serum. This was accompanied by an increased expression of proteins involved in cholesterol transport such as the scavenger receptor class B type I (SR-BI) and the ATP-binding cassette transporter G1 (ABCG1). Despite these metabolic alterations, mitogen-activated-protein-kinase (MAPK) signaling, a key regulator of cholesterol homeostasis, was largely unaffected. Our findings indicate dysregulation of cholesterol homeostasis at multiple metabolic points in both the trophoblast hypoxia model and placentae from women with PE. The increased cholesterol efflux and intracellular accumulation of non-esterified cholesterol may have critical implications for both the mother and the fetus during pregnancy, potentially contributing to an elevated cardiovascular risk later in life.

Non-Viral RNA Delivery During Pregnancy: Opportunities and Challenges

During pregnancy, the risk of maternal and fetal adversities increases due to physiological changes, genetic predispositions, environmental factors, and infections. Unfortunately, treatment options are severely limited because many essential interventions are unsafe, inaccessible, or lacking in sufficient scientific data to support their use. One potential solution to this challenge may lie in emerging RNA therapeutics for gene therapy, protein replacement, maternal vaccination, fetal gene editing, and other prenatal treatment applications. In this review, the current landscape of RNA platforms and non-viral RNA delivery technologies that are under active development for administration during pregnancy is explored. Advancements of pregnancy-specific RNA drugs against SARS-CoV-2, Zika, influenza, preeclampsia, and for in-utero gene editing are discussed. Finally, this study highlights bottlenecks that are impeding translation efforts of RNA therapies, including the lack of accurate cell-based and animal models of human pregnancy and concerns related to toxicity and immunogenicity during pregnancy. Overcoming these challenges will facilitate the rapid development of this new class of pregnancy-safe drugs.

An LC-MS/MS method for the simultaneous quantitation of sulfasalazine and sulfapyridine in human placenta

Sulfasalazine has been identified as a candidate molecule to be investigated as an intervention to treat preterm pre-eclampsia during pregnancy. However, placental exposure of sulfasalazine and its systemically absorbed metabolite, sulfapyridine, is unknown. A robust liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed and validated to simultaneously quantitate these analytes in human placenta with an application to a pilot clinical trial. The placental tissue was homogenised using a water:methanol (1:1, v/v) mixture, followed by sample extraction using both protein precipitation and solid phase extraction. Sulfasalazine-d4 and sulfapyridine-d4 were used as internal standards. An Agilent Poroshell EC-C18 (3.0 ×100 mm, 2.7 µm) column was used for chromatographic separation, with gradient elution employed at a flow rate of 0.450 mL/min over a total run time of seven minutes. The mobile phases consisted of water with 0.1% formic acid (mobile phase A) and acetonitrile:methanol (90:10, v/v) with 0.1% formic acid (mobile phase B). A Shimadzu-8040 mass spectrometer was operated in multiple reaction monitoring (MRM) mode using positive electrospray ionisation (ESI). For both analytes, the assay was validated over the range 30-30,000 ng/mL, or 150-150,000 ng/g. During inter-day validations (n = 18), the average accuracies of quality controls ranged from 101.6% to 112.7% with corresponding precisions of 4.4-6.7% for sulfasalazine, and from 97.4% to 108.4%, with corresponding precisions of 3.7-10.0% for sulfapyridine. No significant matrix effects were observed, and the method proved to be sensitive and specific for both analytes. This study presents the first validated analytical method for quantifying sulfasalazine and sulfapyridine in human placenta as part of a pilot clinical trial to generate preliminary data on its pharmacokinetics and efficacy as in intervention for preterm pre-eclampsia.

Chorionic villus-derived mesenchymal stem cell-mediated NRG1 upregulation promotes HTR-8/SVneo cells proliferation through the activation of the NF-κB signaling pathway

In a prior study, our group found that chorionic villus-derived mesenchymal stem cells (CV-MSCs) were capable of promoting trophoblast proliferative and invasive activity. The mechanistic basis for this activity, however, has yet to be clarified. As such, an RNA-Seq analysis was conducted using trophoblasts that were treated with or without CV-MSC-conditioned media. Of the differentially expressed genes identified when comparing these two groups of cells, 23 proliferation-associated genes were identified and knocked down to test their functional roles in trophoblasts. These analyses revealed that inhibiting neuregulin 1 (NRG1) expression was sufficient to suppress proliferation and induce cell cycle arrest in trophoblasts. Placental samples from patients with preeclampsia exhibited significantly increased NRG1 expression relative to samples from healthy pregnancies. Following treatment with CV-MSC-conditioned media, NRG1 was upregulated in trophoblasts at the mRNA and protein levels. Relative to control trophoblasts, those in which NRG1 had been knocked down exhibited significantly impaired proliferation and DNA replication with the inactivation of the NF-κB signaling pathway. In contrast, overexpressing NRG1 yielded the opposite trophoblast phenotypes. Even in cells overexpressing NRG1, inhibition of NF-κB signaling was sufficient to significantly suppress trophoblast proliferation (P < 0.05). These results indicate that elevated NRG1 expression may play a role in the ability of CV-MSCs to induce proliferative activity in trophoblasts through the NF-κB signaling axis.

Nanomedicines: An approach to treat placental insufficiency and the current challenges

INTRODUCTION

Preeclampsia and fetal growth restriction are common pregnancy complications that significantly impact perinatal health and offspring development later in life. The origin of these complex syndromes overlap in placental insufficiency. Progress in developing treatments for maternal, placental or fetal health is mainly limited by the risk of maternal and fetal toxicity. Nanomedicines are a promising approach to safely treat pregnancy complications since they can regulate drug interaction with the placenta to enhance efficacy of the treatment while minimizing exposure of the fetus.

METHODS

This narrative review discusses the current developments and challenges of nanomedicines during pregnancy with a focus on preclinical models of placenta insufficiency syndromes. Firstly, we outline the safety requirements and potential therapeutic maternal and placental targets. Secondly, we review the prenatal therapeutic effects of the nanomedicines that have been tested in experimental models of placental insufficiency syndromes.

RESULTS

The majority of liposomes and polymeric drug delivery system show promising results regarding the prevention of trans-placental passage nanomedicines in uncomplicated and complicated pregnancies. The others two studied classes, quantum dots and silicon nanoparticles, have been investigated to a limited extent in placental insufficiency syndromes. Characteristics of the nanoparticles such as charge, size, and timing of administration have been shown to influence the trans-placental passage. The few available preclinical therapeutic studies on placental insufficiency syndromes predominantly show beneficial effects of nanomedicines on both maternal and fetal health, but demonstrate contradicting results on placental health. Interpretation of results in this field is complicated by the fact that results are influenced by the choice of animal species and model, gestational age, placental maturity and integrity, and nanoparticle administration route.

CONCLUSION

Nanomedicines form a promising therapeutic approach during (complicated) pregnancies mainly by reducing fetal toxicity and regulating drug interaction with the placenta. Different nanomedicines have been proven to effectively prevent trans-placental passage of encapsulated agents. This can be expected to dramatically reduce risks for fetal adverse effects. Furthermore, a number of these nanomedicines positively impacted maternal and fetal health in animal models for placental insufficiency. Demonstrating that effective drug concentrations can be reached in the target tissue. While these first animal studies are encouraging, more research is needed to better understand the influence of the pathophysiology of this multi-factorial disease before implementation in clinical practice can be considered. Therefore, extensive evaluation of safety and efficacy of these targeted nanoparticles is needed within multiple animal, in vitro, and/or ex vivo models. This may be complemented by diagnostic tools to assess the disease status to identify the best time to initiate treatment. Together these investigations should contribute to building confidence in the safety of nanomedicines for treating mother and child, as safety has, understandably, the highest priority in this sensitive patient groups.

The effect of resveratrol in cardio-metabolic disorders during pregnancy and offspring outcomes: a review

Resveratrol supplementation during pregnancy and lactation has been associated with a reduced risk of maternal obesity, gestational diabetes mellitus , and preeclampsia. In addition, emerging evidence has shown that maternal resveratrol supplementation diminishes cardio-metabolic disorders in offspring, highlighting its role in modulating adaptative responses involving phenotypical plasticity. Therefore, it is reasonable to infer that administration of resveratrol during pregnancy and lactation periods could be considered an important nutritional intervention to decrease the risk of maternal and offspring cardio-metabolic disorders. To highlight these new insights, this literature review will summarize the understanding emerging from experimental and clinical studies about resveratrol supplementation and its capacity to prevent or minimize maternal and offspring cardio-metabolic disorders.

Preeclampsia and Obesity-The Preventive Role of Exercise

Obesity is now recognized as a worldwide epidemic. An inadequate diet and reduced physical activity are acknowledged as the leading causes of excess body weight. Despite growing evidence that obesity is a risk factor for unsuccessful pregnancies, almost half of all women who become pregnant today are overweight or obese. Common complications of pregnancy in this group of women are preeclampsia and gestational hypertension. These conditions are also observed more frequently in women with excessive weight gain during pregnancy. Preeclampsia is one of the most serious pregnancy complications with an unpredictable course, which in its most severe forms, threatens the life and health of the mother and her baby. The early identification of the risk factors for preeclampsia development, including obesity, allows for the implementation of prophylaxis and a reduction in maternal and fetal complications risk. Additionally, preeclampsia and obesity are the recognized risk factors for developing cardiovascular disease in later life, so prophylaxis and treating obesity are paramount for their prevention. Thus, a proper diet and physical activity might play an essential role in the prophylaxis of preeclampsia in this group of women. Limiting weight gain during pregnancy and modifying the metabolic risk factors with regular physical exercise creates favorable metabolic conditions for pregnancy development and benefits the elements of the pathogenetic sequence for preeclampsia development. In addition, it is inexpensive, readily available and, in the absence of contraindications to its performance, safe for the mother and fetus. However, for this form of prevention to be effective, it should be applied early in pregnancy and, for overweight and obese women, proposed as an essential part of planning pregnancy. This paper aims to present the mechanisms of the development of hypertension in pregnancy in obese women and the importance of exercise in its prevention.

PREECLAMPSIA AND ITS EFFECT ON THE STATE OF CARDIOVASCULAR SYSTEM IN WOMEN

OBJECTIVE

The aim: To determine the features of the impact of preeclampsia on the development of cardiovascular disorders in women in the future.

PATIENTS AND METHODS

Materials and methods: The study involved an assessment of literary sources, which were published mainly in the last five years, using scientometric and specialized databases Pubmed, Science direct, Scopus, Web of Science, Google Scholar and V.I. Vernadskyi NLU "Scientific Periodicals of Ukraine".

CONCLUSION

Conclusions: Cardiovascular disorders are not only a medical problem, but also a social one. Preeclampsia is a dangerous condition that contributes to the development of CVDs, increases the rate of mortality and disability among women. All this makes it absolutely necessary to study the features of the pathogenesis in detail, to understand exactly how, through which mechanisms, the preeclamptic state affects the woman's body, and this will allow doctors to indirectly influence its pathogenesis and reduce negative consequences and improve the quality of life.

Augmentation index and pulse wave velocity in normotensive versus preeclamptic pregnancies: a prospective case-control study using a new oscillometric method

OBJECTIVES

The objective of this study was to investigate whether oscillometric AS measurements are different in pregnant women with and without preeclampsia (PE).

STUDY DESIGN

This was a prospective case-control study in singleton pregnancies that had been diagnosed with PE (n = 46) versus normotensive controls (n = 46) between 2014 and 2019. In the case group, pregnancies complicated by PE were classified as either early-onset (<34 weeks of gestation) or late-onset (≥34 weeks of gestation) PE and subgroup analysis was performed.

MAIN OUTCOME MEASURES

Pulse wave velocity (PWV), augmentation index (Alx), and Alx at a heart rate of 75 beats per minute (Alx-75) were measured using a brachial cuff-based automatic oscillometric device (Mobil-O-Graph 24 h PWA).

RESULTS

In pregnancies complicated by PE, in comparison with normotensive pregnancies, there were significant differences in PWV (p ˂ .001), and Alx-75 (p ˂ .001). In pregnancies complicated by early-onset PE, in comparison with pregnancies complicated by late-onset PE, there were significant differences in PWV (p = .006), and Alx-75 (p = .009). There was no significant difference in Alx in either of the analyses.

CONCLUSIONS

PWV and Alx-75 are higher in pregnancies complicated by PE, in comparison with normotensive pregnancies, as well as in early-onset PE, in comparison with late-onset PE.Key messagesPulse wave velocity is higher in pregnancies complicated by preeclampsia.Augmentation index at a heart rate of 75 beats per minute is higher in pregnancies complicated by preeclampsia.Arterial stiffness assessment is a promising risk-stratification tool for future cardiovascular complications but further studies are required.

Endothelial protein C receptor is increased in preterm preeclampsia and fetal growth restriction

Placental dysfunction is the leading cause of both preeclampsia and fetal growth restriction. This study aimed to characterize endothelial protein C receptor (EPCR) in preterm preeclampsia, term preeclampsia, and fetal growth restriction (defined by delivery of a small for gestational age [SGA] infant [<10% birthweight centile]) and examine its regulation in primary syncytiotrophoblast. Placental EPCR mRNA and protein were significantly increased in patients with preterm preeclampsia (<34 weeks gestation) compared to gestation-matched controls (p < .0001). In the plasma, EPCR was also significantly elevated (p = .01) in established preterm preeclampsia while its substrate, protein C (PC) was significantly reduced (p = .0083). Placentas from preterm small for gestational age (SGA) cases, had elevated EPCR mRNA expression (p < .0001) relative to controls. At 36 weeks, no significant changes in plasma EPCR were detected in samples from patients destined to develop preeclampsia or deliver an SGA infant at term. In terms of syncytiotrophoblast, hypoxia significantly increased EPCR mRNA expression (p = .008), but Tumor Necrosis Factor Alpha (TNF-α) decreased EPCR mRNA. Interleukin-6 (IL-6) had no significant effect on EPCR mRNA expression. When isolated syncytiotrophoblast was treated with metformin under hypoxia (1% O₂ ) or normoxia (8% O₂ ), EPCR mRNA expression was significantly reduced (p = .008) relative to control. In conclusion, EPCR is markedly elevated in the placenta and the circulation of patients with established preterm preeclampsia and placental increases may be associated with hypoxia. Additionally, fetal growth-restricted pregnancies (as defined by the delivery of an SGA infant) also demonstrated elevated placental EPCR.

A global view of hypertensive disorders and diabetes mellitus during pregnancy

Two important maternal cardiometabolic disorders (CMDs), hypertensive disorders in pregnancy (HDP) (including pre-eclampsia) and gestational diabetes mellitus (GDM), result in a large disease burden for pregnant individuals worldwide. A global consensus has not been reached about the diagnostic criteria for HDP and GDM, making it challenging to assess differences in their disease burden between countries and areas. However, both diseases show an unevenly distributed disease burden for regions with a low income or middle income, or low-income and middle-income countries (LMICs), or regions with lower sociodemographic and human development indexes. In addition to many common clinical, demographic and behavioural risk factors, the development and clinical consequences of maternal CMDs are substantially influenced by the social determinants of health, such as systemic marginalization. Although progress has been occurring in the early screening and management of HDP and GDM, the accuracy and long-term effects of such screening and management programmes are still under investigation. In addition to pharmacological therapies and lifestyle modifications at the individual level, a multilevel approach in conjunction with multisector partnership should be adopted to tackle the public health issues and health inequity resulting from maternal CMDs. The current COVID-19 pandemic has disrupted health service delivery, with women with maternal CMDs being particularly vulnerable to this public health crisis.

Hypertensive disorders of pregnancy share common cfDNA methylation profiles

Hypertensive disorders of pregnancy (HDP) contribute substantially to perinatal morbidity and mortality. Epigenetic changes point towards cardio-metabolic dysregulation for these vascular disorders. In early pregnancy, epigenetic changes using cell free DNA (cfDNA) are largely unexplored. We aimed to investigate these in HDP between 11 and 14 weeks of gestation by analysis of cfDNA methylation profiles in patients with hypertensive disorders. We identified patients without chronic hypertension but with subsequent development of preeclampsia (PE) (n = 11), with chronic hypertension (HT) but without PE development (n = 14), and lacking both PE and HT (n = 422). We matched patients according to PE risk factors into three groups (n = 5 each group): (1) PE: no HT but PE development, (2) HT: chronic hypertension but no PE and (3) Control: no PE or HT. We successfully optimized our cfDNA isolation process prior to whole genome bisulfite sequencing. Analysis of cfDNA methylation changes indicate a common predisposition in PE and HT groups, chiefly of maternal origin. Assessment of significant differentially methylated regions and annotated genes point towards a common cardiovascular predisposition in preeclampsia and hypertension groups in the first trimester. We postulate the pivotal role of the maternal cardiovascular system in HDP, which is already evident in the first trimester.

Systematic evaluation of the pre-eclampsia drugs, dietary supplements and biologicals pipeline using target product profiles

BACKGROUND

The Accelerating Innovation for Mothers (AIM) project established a database of candidate medicines in research and development (R&amp;D) between 2000 and 2021 for five pregnancy-related conditions, including pre-eclampsia. In parallel, we published target product profiles (TPPs) that describe optimal characteristics of medicines for use in preventing/treating pre-eclampsia. The study objective was to use systematic double screening and extraction to identify all candidate medicines being investigated for pre-eclampsia prevention/treatment and rank their potential based on the TPPs.

METHODS

Adis Insight, Pharmaprojects, WHO international clinical trials registry platform (ICTRP), PubMed and grant databases were searched (Jan-May 2021). The AIM database was screened for all candidates being investigated for pre-eclampsia. Candidates in clinical development were evaluated against nine prespecified criteria from TPPs identified as key for wide-scale implementation, and classified as high, medium or low potential based on matching to the TPPs. Preclinical candidates were categorised by product type, archetype and medicine subclass.

RESULTS

The AIM database identified 153 candidates for pre-eclampsia. Of the 87 candidates in clinical development, seven were classified as high potential (prevention: esomeprazole, L-arginine, chloroquine, vitamin D and metformin; treatment: sulfasalazine and metformin) and eight as medium potential (prevention: probiotic lactobacilli, dalteparin, selenium and omega-3 fatty acid; treatment: sulforaphane, pravastatin, rosuvastatin and vitamin B3). Sixty-six candidates were in preclinical development, the most common being amino acid/peptides, siRNA-based medicines and polyphenols.

CONCLUSIONS

This is a novel, evidence-informed approach to identifying promising candidates for pre-eclampsia prevention and treatment - a vital step in stimulating R&amp;D of new medicines for pre-eclampsia suitable for real-world implementation.

Emerging pharmacologic interventions for pre-eclampsia treatment

INTRODUCTION

Pre-eclampsia is a serious pregnancy complication and a major global concern for the mortality of both mother and fetus. Existing symptomatic treatments do not delay disease progression; thus, timely delivery of the baby is the most effective measure. However, the risk of various maternal and fetal injuries remains.

AREAS COVERED

In this review, we summarize the potential strategies for pharmacologic interventions in pre-eclamptic therapy. Specifically, we discuss the pathophysiological process of various effective candidate therapeutics that act on potential pathways and molecular targets to inhibit key stages of the disease. We refer to this pathogenesis-focused drug discovery model as a pathogenesis-target-drug (P-T-D) strategy. Finally, we discuss the introduction of nanotechnologies to improve the safety and efficacy of therapeutics via their specific placental targeting ability and placental retention effects.

EXPERT OPINION

Despite the active development of novel pharmacological treatments based on our current knowledge of pre-eclamptic pathogenesis, investigations are still in the early phase. Thus, further exploration of the pathological mechanisms, integrated with the P-T-D strategy and novel nanosystems, could encourage the development of more effective and safer strategies. Such advances could lead to a shift from expectant management to mechanistic-based therapy for pre-eclampsia.

Proposal to Consider Chemical/Physical Microenvironment as a New Therapeutic Off-Target Approach

The molecular revolution could lead drug discovery from chance observation to the rational design of new classes of drugs that could simultaneously be more effective and less toxic. Unfortunately, we are witnessing some failure in this sense, and the causes of the crisis involve a wide range of epistemological and scientific aspects. In pharmacology, one key point is the crisis of the paradigm the “magic bullet”, which is to design therapies based on specific molecular targets. Drug repurposing is one of the proposed ways out of the crisis and is based on the off-target effects of known drugs. Here, we propose the microenvironment as the ideal place to direct the off-targeting of known drugs. While it has been extensively investigated in tumors, the generation of a harsh microenvironment is also a phenotype of the vast majority of chronic diseases. The hostile microenvironment, on the one hand, reduces the efficacy of both chemical and biological drugs; on the other hand, it dictates a sort of “Darwinian” selection of those cells armed to survive in such hostile conditions. This opens the way to the consideration of the microenvironment as a convenient target for pharmacological action, with a clear example in proton pump inhibitors.

Diagnostic biomolecules and combination therapy for pre-eclampsia

Pre-eclampsia (PE), associated with placental malperfusion, is the primary reason for maternal and perinatal mortality and morbidity that can cause vascular endothelial injury and multi-organ injury. Despite considerable research efforts, no pharmaceutical has been shown to stop disease progression. If women precisely diagnosed with PE can achieve treatment at early gestation, the maternal and fetal outcomes can be maximally optimized by expectant management. Current diagnostic approaches applying maternal characteristics or biophysical markers, including blood test, urine analysis and biophysical profile, possess limitations in the precise diagnosis of PE. Biochemical factor research associated with PE development has generated ambitious diagnostic targets based on PE pathogenesis and dissecting molecular phenotypes. This review focuses on current developments in biochemical prediction of PE and the corresponding interventions to ameliorate disease progression, aiming to provide references for clinical diagnoses and treatments.

Potential Use of Anti-Cancer Drugs for Treatment of Preeclampsia by Targeting the miRNA-IGF1R-PI3K-AKT Axis

Aim

Preeclampsia (PE) belongs to hypertensive disorders of pregnancy (HDP), which can cause maternal death worldwide. This study aimed to identify the miRNA-mRNA-associated ceRNA network and to find new treatment schedules for PE.

Methods

4 microarray datasets were downloaded from the Gene Expression Omnibus database. We obtained 1737 differentially expressed mRNAs (865 upregulated and 872 downregulated) and 148 differentially expressed miRNAs (76 upregulated and 72 downregulated) from the placenta tissues of PE, respectively. Functional enrichment analyses of DEmRNAs were performed. The regulatory relationship between DEmiRNAs and DEmRNA was predicted via related databases. An miRNA-mRNA regulatory network was constructed.

Results

hsa-let-7c and IGF1R were identified as potential regulators for PE, and function enrichment analysis showed that the PI3K-Akt signaling pathway was closely related. Therefore, ceRNAs might regulate the PI3K-Akt signaling pathway via the upregulation of IGF1R by binding to hsa-let-7c, affecting invasion of trophoblast, angiogenesis, and proinflammation in PE. Further study demonstrated that anticancer drugs including the PI3K inhibitor, AKT inhibitor, and IGF-1 inhibitor might be a potential solution for PE treatment.

Conclusions

The hsa-let-7c/IGF1R axis might affect the PI3K-Akt signaling pathway which is involved in the pathogenesis of PE, and inhibitors targeting this pathway might be used for PE treatment.

Nanotechnologies in Obstetrics and Cancer during Pregnancy: A Narrative Review

Nanotechnology, the art of engineering structures on a molecular level, offers the opportunity to implement new strategies for the diagnosis and management of pregnancy-related disorders. This review aims to summarize the current state of nanotechnology in obstetrics and cancer in pregnancy, focusing on existing and potential applications, and provides insights on safety and future directions. A systematic and comprehensive literature assessment was performed, querying the following databases: PubMed/Medline, Scopus, and Endbase. The databases were searched from their inception to 22 March 2022. Five independent reviewers screened the items and extracted those which were more pertinent within the scope of this review. Although nanotechnology has been on the bench for many years, most of the studies in obstetrics are preclinical. Ongoing research spans from the development of diagnostic tools, including optimized strategies to selectively confine contrast agents in the maternal bloodstream and approaches to improve diagnostics tests to be used in obstetrics, to the synthesis of innovative delivery nanosystems for therapeutic interventions. Using nanotechnology to achieve spatial and temporal control over the delivery of therapeutic agents (e.g., commonly used drugs, more recently defined formulations, or gene therapy-based approaches) offers significant advantages, including the possibility to target specific cells/tissues of interest (e.g., the maternal bloodstream, uterus wall, or fetal compartment). This characteristic of nanotechnology-driven therapy reduces side effects and the amount of therapeutic agent used. However, nanotoxicology appears to be a significant obstacle to adopting these technologies in clinical therapeutic praxis. Further research is needed in order to improve these techniques, as they have tremendous potential to improve the accuracy of the tests applied in clinical praxis. This review showed the increasing interest in nanotechnology applications in obstetrics disorders and pregnancy-related pathologies to improve the diagnostic algorithms, monitor pregnancy-related diseases, and implement new treatment strategies.

MicroRNA-135b-5p regulates trophoblast cell function by targeting phosphoinositide-3-kinase regulatory subunit 2 in preeclampsia

The level of miR‑135b-5p is lower in patients with preeclampsia (PE) superimposed on chronic hypertension than in healthy controls. However, the function of miR‑135b-5p in PE progression remains unknown. In the present study, we investigated the role of miR‑135b-5p in PE development and its possible mechanism for the first time. HTR8/SVneo cells (trophoblast cell line) were exposed to hypoxia/reoxygenation (H/R) to mimic PE in vitro. Hypoxia-inducible factor-1α (HIF-1α), forkhead box O3A (FOXO3a), and miR-135b-5p levels were measured using Real-time PCR. Cell proliferation, apoptosis and migration/invasion were evaluated using the Cell Counting Kit-8 (CCK-8), flow cytometry and transwell assays, respectively. Real-time PCR and Western blotting were performed to determine the levels of several pro- and anti-angiogenic factors. The binding of miR-135b-5p to the PIK3R2-3’ untranslated region (3ʹUTR) was confirmed by bioinformatics analysis and a dual-luciferase reporter assay. H/R exposure greatly upregulated HIF-1α, FOXO3a, and PIK3R2 levels, while downregulating miR-135b-5p levels in HTR8/SVneo cells. H/R exposure resulted in the inhibition of proliferation, migration, invasion, angiogenesis, and the induction of apoptosis. MiR-135b-5p overexpression reversed the effects of H/R on trophoblast cell function, while miR-135b-5p knockdown enhanced the effects. PIK3R2 knockdown had similar effects as miR-135b-5p overexpression on proliferation, apoptosis and angiogenesis. The effect of miR-135b-5p overexpression on H/R-exposed cells was enhanced by PIK3R2 knockdown. MiR-135b-5p downregulated PIK3R2 expression by pairing with its 3ʹUTR. Therefore, miR-135b-5p may regulate trophoblast function by targeting PIK3R2 in PE and could serve as a novel therapeutic target for PE.

Human Trophoblast Cell-Derived Extracellular Vesicles Facilitate Preeclampsia by Transmitting miR-1273d, miR-4492, and miR-4417 to Target HLA-G

Extracellular vesicles (EVs) can intercellularly transmit a wide range of bioactive molecules, and these cargoes may potentially serve as therapeutic biomarkers for preeclampsia. Herein, the current study aims to elucidate the mechanism underlying the human trophoblast cell-derived EV-mediated miRNA-mRNA network that could potentially influence the development of preeclampsia based on microarray datasets from publicly available GEO databases. Preeclampsia-related genes were retrieved from the GeneCards and CTD databases, which were then subjected to GO and KEGG enrichment analyses in an effort to identify key pathways in preeclampsia. The obtained results suggested an important role of the immune- and inflammation-related pathways in preeclampsia. Infiltration proportion of 22 immune cells was subsequently analyzed using the CIBERSORT algorithm. Placental tissues of patients with preeclampsia presented with increased proportion of resting NK cells and resting dendritic cells, while there was a reduction in the proportion of activated NK cells. Differentially expressed mRNAs were additionally predicted in the preeclampsia-related datasets retrieved from the GEO database, and then intersected with preeclampsia-related genes to identify the key genes. HLA-G was indicated as a key target gene in the development of preeclampsia and further associated with hypoxia, immune, and inflammatory pathways. The upstream microRNAs (miRNAs/miRs) of the key genes were further predicted and intersected with differentially expressed miRNAs in the human trophoblast cell-derived EV-related datasets from the GEO database to obtain the key miRNAs. EVs secreted by human trophoblast cells under hypoxic conditions were associated with 3 key upstream miRNAs of HLA-G, namely miR-1273d, miR-4492, and miR-4417, which might be implicated in the development of preeclampsia via targeting of HLA-G. Collectively, our findings highlighted that EVs secreted by human trophoblast cells under hypoxic conditions transferred miR-1273d, miR-4492, and miR-4417, all of which targeted HLA-G, thus orchestrating immune- and inflammation-related pathways and consequently promoting the development of preeclampsia.

Melatonin regulates trophoblast pyroptosis, invasion and migration in preeclampsia by inhibiting HtrA1 transcription through the microRNA-520c-3p/SETD7 axis

OBJECTIVE

Melatonin has an inhibitory effect on preeclampsia (PE). This study was launched to explore the way that melatonin regulated trophoblast migration, invasion, and pyroptosis in PE and to provide new ideas for the diagnosis and treatment of PE.

METHODS

Expression levels of melatonin receptors (MT1 and MT2), microRNA (miR)-520c-3p, SETD7, and HtrA1 in placental tissues and HTR8/SVneo cells were measured by RT-qPCR and Western blot. Scratch, Transwell, and Western blot assays were performed to detect migration, invasion, and pyroptosis of hypoxia/reoxygenation (H/R)-treated HTR8/SVneo cells. Dual-luciferase reporter assay was utilized to verify the targeting relationship between miR-520c-3p and SETD7. ChIP experiment was conducted to detect the enrichment of H3K4me3 and SETD7 in HtrA1 promoter.

RESULTS

Low expression of MT1, MT2, and miR-520c-3p and high expression of SETD7 and HtrA1 were observed in the placental tissues of PE patients and H/R-treated HTR8/Svneo cells. A high concentration of melatonin promoted migration and invasion and inhibited pyroptosis of PE cell models. Knockdown of miR-520c-3p, overexpression of SETD7, or overexpression of HtrA1 impaired migration and invasion and accelerated pyroptosis of H/R-treated HTR8/SVneo cells, but these outcomes could be reversed by treatment with 1000 μM melatonin. miR-520c-3p targeted SETD7 which promoted histone methylation in the promoter region of HtrA1.

CONCLUSION

Melatonin may inhibit HtrA1 transcription through the miR-520c-3p/SETD7 axis to promote trophoblast invasion and migration and reduce trophoblast pyroptosis in PE.

Omeprazole Administration in Preterm Preeclampsia: a Randomized Controlled Trial to Study Its Effect on sFlt-1 (Soluble Fms-Like Tyrosine Kinase-1), PlGF (Placental Growth Factor), and ET-1 (Endothelin-1)

Low sFlt-1 (soluble Fms-like tyrosine kinase-1) and ET-1 (endothelin-1) levels have been reported in preeclamptic women using proton pump inhibitors.

Arterial Stiffness as a Cardiovascular Risk Factor for the Development of Preeclampsia and Pharmacopreventive Options

Arterial stiffness (AS) describes the rigidity of the arterial walls. Epidemiological studies have shown that increased AS is an independent predictive marker of cardiovascular (CV) morbidity and mortality in both pregnant and non-pregnant women. Preeclampsia (PE), a form of pregnancy-induced hypertension, affects approximately 5% of pregnancies worldwide. Preeclamptic women have a higher risk of CV disease (CVD), mainly because PE damages the heart's ability to relax between contractions. Different pharmacological approaches for the prevention of PE have been tested in clinical trials (e.g. aspirin, enoxaparin, metformin, pravastatin, and sildenafil citrate). In current clinical practice, only low-dose aspirin is used for PE pharmacoprevention. However, low-dose aspirin does not prevent term PE, which is the most common form of PE. Compromised vascular integrity precedes the onset of PE and therefore, AS assessment may constitute a promising predictive marker of PE. Several non-invasive techniques have been developed to assess AS. Compared with normotensive pregnancies, both carotid-femoral pulse wave velocity (cfPWV) and augmentation index (AIx) are increased in PE. In view of simplicity, reliability, and reproducibility, there is an interest in oscillometric AS measurements in pregnancies complicated by PE.

Drug delivery strategies for management of women's health issues in the upper genital tract

The female upper genital tract (UGT) hosts important reproductive organs including the cervix, uterus, fallopian tubes, and ovaries. Several pathologies affect these organ systems such as infections, reproductive issues, structural abnormalities, cancer, and inflammatory diseases that could have significant impact on women's overall health. Effective disease management is constrained by the multifaceted nature of the UGT, complex anatomy and a dynamic physiological environment. Development of drug delivery strategies that can overcome mucosal and safety barriers are needed for effective disease management. This review introduces the anatomy, physiology, and mucosal properties of the UGT and describes drug delivery barriers, advances in drug delivery technologies, and opportunities available for new technologies that target the UGT.