Pathophysiology of preeclampsia: an angiogenic imbalance and long-lasting systemic vascular dysfunction

Prepregnancy physiology and subsequent preterm preeclampsia

BACKGROUND

Preeclampsia is a common pregnancy complication with debated etiology.

OBJECTIVE

To evaluate the contribution of prepregnancy physiology, biochemistry, and anthropometrics to the subsequent development of preterm preeclampsia.

STUDY DESIGN

One hundred twenty-four participants were recruited through open recruitment and targeted mailings. Participants included 81 nulliparous women and 43 with a history of preterm preeclampsia. We characterized cardiovascular function, metabolic profile, and body composition in 100 nonpregnant women who went on to subsequent pregnancy. Measures included plasma volume, baseline cardiovascular function and cardiovascular response to volume challenge, body composition, and circulating biochemical measures. Pregnancy outcome was obtained through chart review. Prepregnancy metrics for women who developed preterm preeclampsia were compared with measurements for those who did not, with adjustment for a history of prior preterm preeclampsia. Logistic regression modeling was used to identify the strongest prepregnancy factors associated with preterm preeclampsia.

RESULTS

Pregnancy outcomes included 11 women with preterm preeclampsia, 7 women with term preeclampsia, 20 women with other hypertension affecting their pregnancy, and 62 with uncomplicated pregnancies. We observed no difference in maternal age, study cycle day, lean body mass, uterine hemodynamics, or flow-mediated dilation across groups. Women with preterm preeclampsia had greater android fat content 3215±1143 vs 1918±1510 g (P=.002), faster supine pulse, 77±7 vs 67±10 beats per minute (P=.001), higher supine diastolic blood pressure 82±6 vs 68±6 mmHg (P<.001), increased cardiac output 5.6±1.1 vs 4.6±1 L/min (P=.002), faster aortic-popliteal pulse wave velocity 4.5±0.7 vs 3.8±0.5 m/sec (P<.001), and exaggerated cardiac output response to volume challenge 20±9 vs 9±12 L/min (P=.002) compared to those with other pregnancy outcomes. Women who developed preterm preeclampsia also had reduced renal vascular resistance index 0.86±0.08 vs 0.97±0.12 (P=.005) compared with other pregnancy outcomes when assessed prior to pregnancy. Women with subsequent preterm preeclampsia had higher serum c-reactive protein 10.7±12.5 vs 4.1±5.8 mg/mL (P=.003) and greater insulin resistance, as assessed by Homeostatic Model Assessment for Insulin Resistance calculation 2.2±1.1 vs 1.2±0.9 (P<.001).

CONCLUSION

Prepregnancy physiology is linked to subsequent preterm preeclampsia. The same factors associated with metabolic syndrome are more prominent in patients who develop preterm preeclampsia than those who do not, including increased vessel stiffness, low vascular compliance, high cardiac output, reduced renal vascular resistance index, insulin resistance, and increased android fat, all consistent with subclinical features of the metabolic syndrome.

Streamlined Analysis of Maternal Plasma Indicates Small Extracellular Vesicles are Significantly Elevated in Early-Onset Preeclampsia

Preeclampsia (PE) is a leading cause of maternal and fetal mortality and morbidity. While placental dysfunction is a core underlying issue, the pathogenesis of this disorder is thought to differ between early-onset (EOPE) and late-onset (LOPE) subtypes. As recent reports suggest that small extracellular vesicles (sEVs) contribute to the development of PE, we have compared systemic sEV concentrations between normotensive, EOPE, and LOPE pregnancies. To circumvent lengthy isolation techniques and intermediate filtration steps, a streamlined approach was developed to evaluate circulating plasma sEVs from maternal plasma. Polymer-based precipitation and purification were used to isolate total systemic circulating maternal sEVs, free from bias toward specific surface marker expression or extensive subpurification. Immediate Nanoparticle Tracking Analysis (NTA) of freshly isolated sEV samples afforded a comprehensive analysis that can be completed within hours, avoiding confounding freeze-thaw effects of particle aggregation and degradation.Rather than exosomal subpopulations, our findings indicate a significant elevation in the total number of circulating maternal sEVs in patients with EOPE. This streamlined approach also preserves sEV-bound protein and microRNA (miRNA) that can be used for potential biomarker analysis. This study is one of the first to demonstrate that maternal plasma sEVs harbor full-length hypoxia inducible factor 1 alpha (HIF-1α) protein, with EOPE sEVs carrying higher levels of HIF-1α compared to control sEVs. The detection of HIF-1α and its direct signaling partner microRNA-210 (miR-210) within systemic maternal sEVs lays the groundwork for identifying how sEV signaling contributes to the development of preeclampsia. When taken together, our quantitative and qualitative results provide compelling evidence to support the translational potential of streamlined sEV analysis for future use in the clinical management of patients with EOPE.

Adipokines in pregnancy

Reproductive success consists of a sequential events chronology, starting with the ovum fertilization, implantation of the embryo, placentation, and cellular processes like proliferation, apoptosis, angiogenesis, endocrinology, or metabolic changes, which taken together finally conduct the birth of healthy offspring. Currently, many factors are known that affect the regulation and proper maintenance of pregnancy in humans, domestic animals, or rodents. Among the determinants of reproductive success should be distinguished: the maternal microenvironment, genes, and proteins as well as numerous pregnancy hormones that regulate the most important processes and ensure organism homeostasis. It is well known that white adipose tissue, as the largest endocrine gland in our body, participates in the synthesis and secretion of numerous hormones belonging to the adipokine family, which also may regulate the course of pregnancy. Unfortunately, overweight and obesity lead to the expansion of adipose tissue in the body, and its excess in both women and animals contributes to changes in the synthesis and release of adipokines, which in turn translates into dramatic changes during pregnancy, including those taking place in the organ that is crucial for the proper progress of pregnancy, i.e. the placenta. In this chapter, we are summarizing the current knowledge about levels of adipokines and their role in the placenta, taking into account the physiological and pathological conditions of pregnancy, e.g. gestational diabetes mellitus, preeclampsia, or intrauterine growth restriction in humans, domestic animals, and rodents.

The Pathophysiological, Genetic, and Hormonal Changes in Preeclampsia: A Systematic Review of the Molecular Mechanisms

Preeclampsia, a serious complication of pregnancy, involves intricate molecular and cellular mechanisms. Fetal microchimerism, where fetal cells persist within maternal tissues and in circulation, acts as a mechanistic link between placental dysfunction and maternal complications in the two-stage model of preeclampsia. Hormones, complements, and cytokines play pivotal roles in the pathophysiology, influencing immune responses, arterial remodeling, and endothelial function. Also, soluble HLA-G, involved in maternal-fetal immune tolerance, is reduced in preeclampsia. Hypoxia-inducible factor 1-alpha (Hif-α) dysregulation leads to placental abnormalities and preeclampsia-like symptoms. Alterations in matrix metalloproteinases (MMPs), endothelins (ETs), chemokines, and cytokines contribute to defective trophoblast invasion, endothelial dysfunction, and inflammation. Preeclampsia's genetic complexity includes circRNAs, miRNAs, and lncRNAs. CircRNA_06354 is linked to early-onset preeclampsia by influencing trophoblast invasion via the hsa-miR-92a-3p/VEGF-A pathway. The dysregulation of C19MC, especially miR-519d and miR-517-5p, affects trophoblast function. Additionally, lncRNAs like IGFBP1 and EGFR-AS1, along with protein-coding genes, impact trophoblast regulation and angiogenesis, influencing both preeclampsia and fetal growth. Besides aberrations in CD31+ cells, other potential biomarkers such as MMPs, soluble HLA-G, and hCG hold promise for predicting preeclampsia and its complications. Therapeutic interventions targeting factors such as peroxisome PPAR-γ and endothelin receptors show potential in mitigating preeclampsia-related complications. In conclusion, preeclampsia is a complex disorder with a multifactorial etiology and pathogenesis. Fetal microchimerism, hormones, complements, and cytokines contribute to placental and endothelial dysfunction with inflammation. Identifying novel biomarkers and therapeutic targets offers promise for early diagnosis and effective management, ultimately reducing maternal and fetal morbidity and mortality. However, further research is warranted to translate these findings into clinical practice and enhance outcomes for at-risk women.

Neurodevelopmental Disruptions in Children of Preeclamptic Mothers: Pathophysiological Mechanisms and Consequences

Preeclampsia (PE) is a multisystem disorder characterized by elevated blood pressure in the mother, typically occurring after 20 weeks of gestation and posing risks to both maternal and fetal health. PE causes placental changes that can affect the fetus, particularly neurodevelopment. Its key pathophysiological mechanisms encompass hypoxia, vascular and angiogenic dysregulation, inflammation, neuronal and glial alterations, and disruptions in neuronal signaling. Animal models indicate that PE is correlated with neurodevelopmental alterations and cognitive dysfunctions in offspring and in humans, an association between PE and conditions such as cerebral palsy, autism spectrum disorder, attention deficit hyperactivity disorder, and sexual dimorphism has been observed. Considering the relevance for mothers and children, we conducted a narrative literature review to describe the relationships between the pathophysiological mechanisms behind neurodevelopmental alterations in the offspring of PE mothers, along with their potential consequences. Furthermore, we emphasize aspects pertinent to the prevention/treatment of PE in pregnant mothers and alterations observed in their offspring. The present narrative review offers a current, complete, and exhaustive analysis of (i) the pathophysiological mechanisms that can affect neurodevelopment in the children of PE mothers, (ii) the relationship between PE and neurological alterations in offspring, and (iii) the prevention/treatment of PE.

An integral role of mitochondrial function in the pathophysiology of preeclampsia

Preeclampsia (PE) is associated with high maternal and perinatal morbidity and mortality. The development of effective treatment strategies remains a major challenge due to the limited understanding of the pathogenesis. In this review, we summarize the current understanding of PE research, focusing on the molecular basis of mitochondrial function in normal and PE placentas, and discuss perspectives on future research directions. Mitochondria integrate numerous physiological processes such as energy production, cellular redox homeostasis, mitochondrial dynamics, and mitophagy, a selective autophagic clearance of damaged or dysfunctional mitochondria. Normal placental mitochondria have evolved innovative survival strategies to cope with uncertain environments (e.g., hypoxia and nutrient starvation). Cytotrophoblasts, extravillous trophoblast cells, and syncytiotrophoblasts all have distinct mitochondrial morphology and function. Recent advances in molecular studies on the spatial and temporal changes in normal mitochondrial function are providing valuable insight into PE pathogenesis. In PE placentas, hypoxia-mediated mitochondrial fission may induce activation of mitophagy machinery, leading to increased mitochondrial fragmentation and placental tissue damage over time. Repair mechanisms in mitochondrial function restore placental function, but disruption of compensatory mechanisms can induce apoptotic death of trophoblast cells. Additionally, molecular markers associated with repair or compensatory mechanisms that may influence the development and progression of PE are beginning to be identified. However, contradictory results have been obtained regarding some of the molecules that control mitochondrial biogenesis, dynamics, and mitophagy in PE placentas. In conclusion, understanding how the mitochondrial morphology and function influence cell fate decisions of trophoblast cells is an important issue in normal as well as pathological placentation biology. Research focusing on mitochondrial function will become increasingly important for elucidating the pathogenesis and effective treatment strategies of PE.

Understanding Patient Perspectives on Specialized, Longitudinal, Postpartum, Cardiovascular Risk-Reduction Clinics

Background

Females who experience hypertensive disorders of pregnancy (HDP) have an increased lifelong risk of cardiovascular disease. Thus, Canadian clinical practice guidelines recommend cardiovascular risk reduction follow-up after a patient has HDP. This study examined the experiences of patients with HDP who attended a specialized, longitudinal general internal medicine postpartum cardiovascular risk reduction clinic called PreVASC. PreVASC focuses on comprehensive cardiovascular risk reduction through cardiovascular risk factor screening and management tailored specifically for female patients after they have HDP.

Methods

This multimethod study examined the experiences of female patients with HDP via the following: (i) a quantitative survey (summarized with descriptive statistics); (ii) semistructured qualitative patient phone interviews (results grouped thematically); and (iii) triangulation of qualitative themes with quantitative survey results.

Results

Overall, 37% of eligible clinic patients (42 of 115) participated; 79% of participants (n = 33) reported being "very satisfied" with the PreVASC clinic's specialized longitudinal model of care, and 95% (n = 40) reported making at least one preventive health behaviour change after receiving individualized counselling on cardiovascular risk reduction. Qualitative results found improvements in patient-reported cardiovascular health knowledge, health behaviours, and health-related anxiety. A preference for in-person vs phone clinic visits was reported by participants.

Conclusions

An in-person, general internal medicine specialist-led, longitudinal model of cardiovascular disease preventive care focused specifically on cardiovascular risk reduction after HDP had positive impacts on patient experience, health knowledge, and preventive health behaviours. This novel knowledge on patient preferences for a longitudinal, specialized model of care advances cardiovascular risk reduction tailored specifically for high-risk people after HDP.

Unraveling the Predictive Power: Placenta Growth Factor and Pregnancy-Associated Plasma Protein A in Pre-eclampsia

This review provides a comprehensive exploration of the roles of placenta growth factor (PlGF) and pregnancy-associated plasma protein A (PAPP-A) in the context of pre-eclampsia, a pregnancy-related hypertensive disorder with significant implications for maternal and fetal health. The background elucidates the clinical significance of pre-eclampsia, highlighting its prevalence and impact. The review delves into the biological importance of PlGF and PAPP-A, emphasizing their critical roles in normal placental development and their dysregulation in pre-eclampsia. Notably, altered levels of these biomarkers emerge as potential diagnostic indicators, offering insights into the pathophysiology of the disorder. The exploration of pathophysiological mechanisms, including angiogenic imbalance and placental dysfunction, provides a nuanced understanding of pre-eclampsia's molecular landscape. The therapeutic implications of targeting PlGF and PAPP-A open avenues for future research, aiming at effective intervention strategies. The conclusion summarizes key findings, outlines implications for future research, and underscores the crucial role of PlGF and PAPP-A in understanding and managing pre-eclampsia, with the ultimate goal of improving outcomes for both mothers and infants.

Human Placenta and Evolving Insights into Pathological Changes of Preeclampsia: A Comprehensive Review of the Last Decade

The placenta, the foremost and multifaceted organ in fetal and maternal biology, is pivotal in facilitating optimal intrauterine fetal development. Remarkably, despite its paramount significance, the placenta remains enigmatic, meriting greater comprehension given its central influence on the health trajectories of both the fetus and the mother. Preeclampsia (PE) and intrauterine fetal growth restriction (IUGR), prevailing disorders of pregnancy, stem from compromised placental development. PE, characterized by heightened mortality and morbidity risks, afflicts 5-7% of global pregnancies, its etiology shrouded in ambiguity. Pertinent pathogenic hallmarks of PE encompass inadequate restructuring of uteroplacental spiral arteries, placental ischemia, and elevated levels of vascular endothelial growth factor receptor-1 (VEGFR-1), also recognized as soluble FMS-like tyrosine kinase-1 (sFlt-1). During gestation, the placental derivation of sFlt-1 accentuates its role as an inhibitory receptor binding to VEGF-A and placental growth factor (PlGF), curtailing target cell accessibility. This review expounds upon the placenta's defining cellular component of the trophoblast, elucidates the intricacies of PE pathogenesis, underscores the pivotal contribution of sFlt-1 to maternal pathology and fetal safeguarding, and surveys recent therapeutic strides witnessed in the past decade.

Apelin/APJ system protects placental trophoblasts from hypoxia-induced oxidative stress through activating PI3K/Akt signaling pathway in preeclampsia

BACKGROUND

Preeclampsia is a placentally induced syndrome with diverse clinical presentation that currently has no cure. Oxidative stress is a potent inducer of placental dysfunction. The apelin receptor (APJ) system is a pleiotropic pathway with a potential for therapeutic targeting in preeclampsia. This study examines the alteration of circulating apelin levels and placental APJ expression in preeclampsia and investigates whether apelin/APJ system can protect placental trophoblast from hypoxia-induced oxidative stress injury through PI3K/AKT signaling pathway.

RESULTS

Our results confirmed that maternal apelin concentration was increased in women with preeclampsia, but APJ expression was reduced in the preeclamptic placentas. Apelin-13 treatment not only specifically attenuated CoCl2-induced superoxide production, but also prevented CoCl2-induced reduction of SOD activity and SOD1 expression. In addition, apelin-13 suppressed CoCl2-induced apoptosis by increasing the expression of bcl-2/bax ratio and by decreasing the expression of active caspase-3 in placental trophoblasts. Furthermore, we found that apelin-13 binding APJ activated the PI3K and AKT kinases and inhibition of PI3K kinase significantly blocked the anti-oxidative effects of apelin-13 in placental trophoblasts.

CONCLUSIONS

Decrease of placental APJ expression is associated with oxidative stress-induced placental dysfunction in preeclampsia, and increased circulating apelin could be a moderately successful marker to differentiate subjects with preeclampsia from healthy pregnant women. Inhibition of superoxide production and caspase-3 cleavage, together with upregulation of SOD activity/expression and bcl-2/bax ratio, could be the potential molecular mechanisms by which apelin-13/APJ protects placental trophoblasts from oxidative stress injury.

First Trimester CD93 as a Novel Marker of Preeclampsia and Its Complications: A Pilot Study

INTRODUCTION

CD93 plays a crucial role in endothelial homeostasis and angiogenesis. Recently its role in hypertension has been investigated, holding promise for novel targeted diagnostic and therapeutic strategies.

AIM

We assessed for the first time differences in first trimester serum CD93 levels in women who lately developed preeclampsia (PE) vs. normotensive pregnancy (NP).

METHODS

First trimester serum CD93 concentrations were assessed in a multicenter cohort of 83 women (34 PE and 49 NP) by ELISA Immunoassay.

RESULTS

Serum CD93 was lower in women who developed PE vs. NP (111.8 ± 24.4 vs. 137.5 ± 22.3 ng/ml; p < 0.001). Serum CD93 was associated with a decreased risk of developing PE (OR 0.950, 95% CI 0.922-0.978) and composite neonatal outcome (OR 0.952, CI 0.923-0.982), after adjustment for confounders.

CONCLUSIONS

PE is accompanied by decreased serum CD93 levels. CD93 might play a role during placentation leading to defective angiogenesis, vascular dysfunction, and PE development.

Advances in preeclampsia testing

Preeclampsia is a multisystem hypertensive disorder and one of the leading causes of maternal and fetal morbidity and mortality. The clinical hallmarks such as hypertension and proteinuria, and additional laboratory tests currently available including liver enzyme testing, are neither specific nor sufficiently sensitive. Therefore, biomarkers for timely and accurate identification of patients at risk of developing preeclampsia are extremely valuable to improve patient outcomes and safety. In this chapter, we will first discuss the clinical characteristics of preeclampsia and current evidence of the role of angiogenic factors, such as placental growth factor (PlGF) and soluble FMS like tyrosine kinase 1 (sFlt-1) in the pathogenesis of preeclampsia. Second, we will review the clinical practice guidelines for preeclampsia diagnostic criteria and their recommendations on laboratory testing. Third, we will review the currently available PlGF and sFlt-1 assays in terms of their methodologies, analytical performance, and clinical diagnostic values. Finally, we will discuss the future research needs from both an analytical and clinical perspective.

Comparison of clinical outcomes and biochemical markers in normal and preeclamptic pregnancies: a prospective cohort study

Background

Preeclampsia (PreE), the de novo onset of hypertension and proteinuria at 20 weeks of gestation, is a leading cause of maternal and fetal morbidity and mortality. This study compared inflammatory biomarkers in PreE and normal pregnancies using paired samples of mothers and neonates.

Methods

Twenty normal pregnant and 27 PreE patients were monitored for biomarkers, neonatal outcomes, and placental morphologies. Fetal and maternal serum levels of vascular endothelial growth factor (VEGF), placental growth factor (PlGF), soluble endoglin (sENG), and soluble fms-like tyrosine kinase-1 (sFLT-1) were measured by enzyme-linked immunosorbent assay.

Results

Placental thickness was 25 mm in early PreE subjects compared to 32 mm in late PreE subjects (P < 0.05). Placental volume was 296 cm3 in early PreE compared to 393 cm3 in late PreE (P < 0.05). The average hospital stay for PreE babies was longer (20 ± 5 days) compared to babies from normal pregnancies (2 ± 1 days; P < 0.05). PreE babies had a lower Ponderal index (2.28 ± 0.3) than those from normal pregnancies (2.95 ± 0.2; P < 0.05). sENG and sFLT-1 had cord values like the maternal values, while VEGF and PlGF did not.

Conclusion

PreE alters the intrauterine environment by activating chemical mediators that result in maternal and fetal complications.

Beta-Blockers in Pregnancy: Clinical Update

PURPOSE OF REVIEW

The aim of this review was to determine the anticipated benefits and adverse effects of beta-blockers in pregnant women with hypertension. The other issue was to assess the possible adverse effects of beta-blockers for their babies and provide current consensus recommendations for appropriate selection and individualized antihypertensive treatment with beta-blockers in pregnancy-associated hypertension.

RECENT FINDINGS

Hypertensive disorders of pregnancy are a major cause of maternal and fetal morbidity, with consequences later in life. Certain beta-blockers are useful for ameliorating hypertension in pregnancy and may have a protective role in endothelial dysfunction. However, some aspects of beta-blocker use in pregnancy are contentious among providers. Evidence on their safety, although well documented, is variable, and recent research reveals areas of controversy. Besides intrauterine growth restriction, other neonatal and obstetric complications remain a concern and should be explored thoroughly. Attention is necessary when treating pregnancy-associated hypertensive disorders with beta-blockers. Specific beta-blockers are considered safe in pregnancy, although the associated effects in the fetus are not clearly known and evidence is lacking for many safety outcomes, other than intrauterine growth restriction. Nevertheless, beta-blockers with specific indications in pregnancy under individualized selection and monitoring may confer substantial improvements in pregnant women with hypertension.

Effect and mechanism of microRNA-515-5p in proliferation and apoptosis of trophoblast cells in preeclampsia via manipulating histone deacetylase 2

Preeclampsia (PE) refers to a pregnancy-specific disease that begins with the placenta. Differentially expressed microRNAs (miRs) are a feature of PE. This study tried to elicit the functional mechanism of miR-515-5p in trophoblast cell behaviors in PE. First, HTR-8/SVneo cells were transfected with miR-515-5p mimic or miR-515-5p inhibitor. Then, relative expression levels of miR-515-5p and histone deacetylase 2 (HDAC2) in HTR-8/SVneo cells were determined by reverse transcription-quantitative polymerase chain reaction. The potential binding site of miR-515-5p and HDAC2 was predicted on Targetscan and their binding relationship was verified via dual-luciferase assay. Proliferation, apoptosis, invasion, and migration of HTR-8/SVneo cells were assessed via cell counting kit-8, flow cytometry, Transwell, and wound healing assays, respectively. Protein levels of Cleaved caspase-3, Bcl-2, and Bax were determined via Western blot. Overexpressed miR-515-5p impeded proliferation and stimulated apoptosis of HTR-8/SVneo cells, and decreased levels of Cleaved caspase-3 and Bax and elevated Bcl-2, whilst opposite results were observed after miR-515-5p inhibition. miR-515-5p targeted HDAC2. Knockdown of HDAC2 annulled the promotional action of miR-515-5p inhibition on proliferative, invasive, and migratory abilities and its antiapoptotic action on HTR-8/SVneo cells. In brief, miR-515-5p affected the proliferation, apoptosis, invasion, and migration of HTR-8/SVneo cells by targeting HDAC2.

Evidence of Nitric Oxide Impairment During Hypertensive Pregnancies

Hypertensive disorders of pregnancy complicate up to 10% of pregnancies worldwide, and they can be classified into (1) gestational hypertension, (2) preeclampsia, (3) chronic hypertension and (4) chronic hypertension with preeclampsia. Nitric oxide (NO) plays an essential role in the haemodynamic adaptations observed during pregnancy. It has been shown that the nitric oxide pathway's dysfunction during pregnancy is associated with placental- and vascular-related diseases such as hypertensive disorders of pregnancy. This review aims to present a brief definition of hypertensive disorders of pregnancy and physiological maternal cardiovascular adaptations during pregnancy. We also detail how NO signalling is altered in the (a) systemic vasculature, (b) uterine artery/spiral arteries, (c) implantation and (d) placenta of hypertensive disorders during pregnancy. We conclude by summarizing the anti-hypertensive therapy of hypertensive disorders of pregnancy as a specific management strategy.

Hyponatremia among preeclampsia patients - a potential sign of severity

OBJECTIVES

Although hyponatremia in preeclamptic patients was previously described, its significance remains unknown. We aimed to describe the prevalence and clinical significance of hyponatremia among a cohort of preeclamptic patients.

METHODS

An electronic medical record based retrospective cohort study included all singleton deliveries at Hadassah University Medical Center between 2003 and 2015. Preeclampsia, with and without severe features, was defined using the American College of Obstetrics and Gynecology (ACOG) Hypertension in Pregnancy Guidelines. Hyponatremia was defined as a sodium (Na) level ≤130 mEq/L, and severe hyponatremia as <125 mEq/L. A group of normotensive pregnant women, matched for gestational age, gravdity and parity, served as control.

RESULTS

A total of 700 preeclamptic patients were identified during the study period. Hyponatremia was noted in 14.6% compared to 0 of 79 patients in the control group. Hyponatremia was strongly correlated with severe features of preeclampsia, adverse neonatal and obstetrical outcome. Severe hyponatremia was strongly correlated with preeclampsia with severe features. Furthermore, even among subgroup of preeclamptic patients without severe features, hyponatremia correlated with less favorable pregnancy outcomes.

CONCLUSIONS

Among relatively large cohort of preeclamptic patients, hyponatremia was not a rare finding. We found it more common in patients with preeclampsia and severe features. As women with preeclampsia are at risk for hyponatremia, serum sodium levels should be monitored, especially in those with severe features. In preeclamptic patients without severe features, hyponatremia may indicate a need for closer surveillance. However, larger studies are needed to establish hyponatremia as a marker of severity.

Performance of sFlt-1/PIGF Ratio for the Prediction of Perinatal Outcome in Obese Pre-Eclamptic Women

Obese women are at high risk of developing pre-eclampsia (PE). As an altered angiogenic profile is characteristic for PE, measurement of soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PIGF) ratio in the maternal serum can be helpful for PE diagnosis, as well as for adverse perinatal outcome (APO) prediction. There is growing evidence that obesity might influence the level of sFlt-1/PIGF and, therefore, the aim of the study was the evaluation of sFlt-1/PIGF as an APO predictor in obese women with PE. Pre-eclamptic women who had an sFlt-1/PIGF measurement at the time of diagnosis were retrospectively included. Women were classified according to their pre-pregnancy body mass index (BMI) as normal weight (BMI < 25 kg/m2), overweight (BMI > 25−29.9 kg/m2) or obese (BMI ≥ 30 kg/m2). APO was defined as the occurrence of one of the following outcomes: Small for gestational age, defined as a birthweight < 3rd centile, neonatal mortality, neonatal seizures, admission to neonatal unit required (NICU) or respiratory support. A total of 141 women were included. Of them, 28 (20%) patients were obese. ROC (receiver operating characteristic) analysis revealed a high predictive value for sFlt-1/PIGF and APO across the whole study cohort (AUC = 0.880, 95% CI: 0.826−0.936; p < 0.001). However, the subgroup of obese women showed a significantly lower level of sFlt-1 and, therefore, the performance of sFlt-1/PIGF as APO predictor was poorer compared to normal or overweight PE women (AUC = 0.754, 95% CI: 0.552−0.956, p = 0.025). In contrast to normal or overweight women, a ratio of sFlt-1/PIGF < 38 could not rule out APO in women with obesity.

Establishment of a nomogram model for predicting adverse outcomes in advanced-age pregnant women with preterm preeclampsia

Aim

To establish a model for predicting adverse outcomes in advanced-age pregnant women with preterm preeclampsia in China.

Methods

We retrospectively collected the medical records of 896 pregnant women with preterm preeclampsia who were older than 35 years and delivered at the Affiliated Hospital of Qingdao University from June 2018 to December 2020. The pregnant women were divided into an adverse outcome group and a non-adverse outcome group according to the occurrence of adverse outcomes. The data were divided into a training set and a verification set at a ratio of 8:2. A nomogram model was developed according to a binary logistic regression model created to predict the adverse outcomes in advanced-age pregnant women with preterm preeclampsia. ROC curves and their AUCs were used to evaluate the predictive ability of the model. The model was internally verified by using 1000 bootstrap samples, and a calibration diagram was drawn.

Results

Binary logistic regression analysis showed that platelet count (PLT), uric acid (UA), blood urea nitrogen (BUN), prothrombin time (PT), and lactate dehydrogenase (LDH) were the factors that independently influenced adverse outcomes (P < 0.05). The AUCs of the internal and external verification of the model were 0.788 (95% CI: 0.737 ~ 0.764) and 0.742 (95% CI: 0.565 ~ 0.847), respectively. The calibration curve was close to the diagonal.

Conclusions

The model we constructed can accurately predict the risk of adverse outcomes of pregnant women of advanced age with preterm preeclampsia, providing corresponding guidance and serving as a basis for preventing adverse outcomes and improving clinical treatment and maternal and infant prognosis.

Apelin, APJ, and ELABELA: Role in Placental Function, Pregnancy, and Foetal Development-An Overview

The apelinergic system, which includes the apelin receptor (APJ) as well as its two specific ligands, namely apelin and ELABELA (ELA/APELA/Toddler), have been the subject of many recent studies due to their pleiotropic effects in humans and other animals. Expression of these factors has been investigated in numerous tissues and organs—for example, the lungs, heart, uterus, and ovary. Moreover, a number of studies have been devoted to understanding the role of apelin and the entire apelinergic system in the most important processes in the body, starting from early stages of human life with regulation of placental function and the proper course of pregnancy. Disturbances in the balance of placental processes such as proliferation, apoptosis, angiogenesis, or hormone secretion may lead to specific pregnancy pathologies; therefore, there is a great need to search for substances that would help in their early diagnosis or treatment. A number of studies have indicated that compounds of the apelinergic system could serve this purpose. Hence, in this review, we summarized the most important reports about the role of apelin and the entire apelinergic system in the regulation of placental physiology and pregnancy.

Upregulation of circRNA hsa_circ_0008726 in Pre-eclampsia Inhibits Trophoblast Migration, Invasion, and EMT by Regulating miR-345-3p/RYBP Axis

Accumulating evidence shows that impaired spiral artery remodeling, placental dysfunction, and insufficient trophoblast infiltration contribute to the etiology and pathogenesis of pre-eclampsia (PE). circRNAs are a class of endogenous non-coding RNAs implicated in the pathogenesis of many diseases, including PE. This study aims to investigate the role of circRNA hsa_circ_0008726 in regulating the migration and invasion of extravillous trophoblast cells. RNase R assay was performed to confirm that circ_0008726 was a circular transcript. The expression of circ_0008726, RYBP, and miR-345-3p was examined by qRT-PCR. The functional interaction between miR-345-3p and circ_0008726 or RYBP was confirmed using dual-luciferase reporter assay and RNA immunoprecipitation (RIP). Cell migration and invasion ability was analyzed by Transwell assays. Western blot was used for the quantification of RYBP protein level. Circ_0008726 expression was significantly increased in PE placenta tissues as compared with normal placenta tissues. Circ_0008726 was resistant to RNase R digestion and was predominately located in the cytoplasm of HTR-8/SVneo cells. Silencing circ_0008726 promoted cell migration and EMT (epithelial-mesenchymal transition), while circ_0008726 overexpression suppressed these processes. Mechanistically, circ_0008726 sponged miR-345-3p to negatively regulate its expression, and miR-345-3p negatively modulated the expression of RYBP. In PE samples, the expression level of circ_0008726 was negatively correlated with miR-345-3p level, but was positively correlated with RYBP expression. Transfection of miR-345-3p mimic or RYBP knockdown counteracted the effects of circ_0008726 overexpression on cell migration and EMT. Our data demonstrate the upregulation of circ_0008726 in PE placenta, which inhibits the migration, invasion, and EMT of HTR-8/SVneo cells by targeting miR-345-3p/RYBP axis. These data suggest that circ_0008726 could be a potential biomarker and therapeutic target for PE.

Efficacy of Magnesium Sulfate on Maternal Mortality in Eclampsia

Eclampsia is a common complication of preeclampsia patients and can be life-threatening for both the mother and the fetus. Hence, timely intervention and appropriate management of this detrimental condition are extremely crucial. Eclampsia is described as the occurrence of generalized convulsions in patients with preeclampsia. Magnesium sulfate (MgSO₄) is the drug of choice for treating and preventing eclampsia. This review aims to study and analyze the available literature on the pathogenesis of eclampsia, the pharmacology of MgSO₄, and its effectiveness in the management of eclampsia. Other proposed treatments and their comparative study with MgSO₄ are also discussed. Additionally, we examine the data regarding the impact of eclampsia, its public health burden, and the cost-effectiveness of MgSO₄. One of the major drawbacks associated with the use of MgSO₄ in low-income countries has been the cost of treatment and the lack of resources. We have analyzed the trials that have proposed alternate treatment regimens which could shape new guidelines to resolve these issues. For this review, we extensively studied abstract and full-text articles from multiple databases. This article discusses the pathophysiology of eclampsia, the pharmacology of MgSO₄, the issues surrounding eclampsia management, and how MgSO₄ benefits these patients.

Good performance of bioimpedance in early pregnancy to predict preeclampsia

INTRODUCTION

Preeclampsia (PE) affects 2-8% of pregnancies and is one of the main causes of maternal morbidity and mortality worldwide. Early identification of pregnant women at higher risk for PE would allow the use of interventions to reduce adverse maternal and perinatal outcomes.

OBJECTIVE

To assess the ability of bioelectrical impedance analysis (BIA) in pregnancy to predict the development of PE.

METHODS

This prospective cohort involved healthy nulliparas who underwent BIA at 17-20 weekś gestation and were followed until delivery. We used univariate and multivariate logistic regression to assess the ability of BIA measures to predict the occurrence of PE. We used an adjusted regression model to estimate the probability of developing PE, the Hosmer-Lemeshow test to assess the adequacy of the final model, and ROC curves to assess the sensitivity and specificity of different BIA measures in the prediction of PE.

RESULTS

Twelve (6.1%) of the 196 participants developed PE. In the final multivariate model, the following BIA measures were associated with the occurrence of PE: extracellular water/intracellular water ≤ 0.618, skeletal muscle mass ≥ 25 Kg, and body fat percentage ≥ 44%. The combination of these three measures had a predictive accuracy of 83.7%, a sensitivity of 83.3%, a specificity of 83.7%, and a negative predictive value of 98.7% for PE.

CONCLUSION

BIA done on nulliparous women at 17-20 weekś gestation has a good accuracy and high negative predictive value for the risk of developing PE.

Elevated Serum SFRP5 Levels During Preeclampsia and Its Potential Association with Trophoblast Dysfunction via Wnt/β-Catenin Suppression

Preeclampsia (PE) is a life-threatening pregnancy complication associated with diminished trophoblast migration and invasion. Wnt signalling is one of the most important regulators of placentation. Secreted frizzled-related protein 5 (SFRP5) is an anti-inflammatory adipokine that may inhibit Wnt signalling. In this study, we aimed to investigate the relationship between SFRP5 and PE and its effect on trophoblast function, as well as the underlying signalling pathways. SFRP5 levels in the serum and placental tissues were detected using enzyme-linked immunosorbent assay and immunohistochemistry, respectively. To evaluate the effect of SFRP5 on Wnt signalling, the human trophoblast cell line HTR8/SVneo was treated with recombinant human SFRP5 and Dickkopf-related protein 1 (Dkk-1, canonical Wnt inhibitor) proteins and lithium chloride (LiCl, canonical Wnt agonist). The migration and invasion ability of HTR8/SVneo cells was evaluated using wound-healing and Matrigel Transwell assays. The activities of multiple matrix metalloproteinases (MMP)-2/9 were detected using gelatin zymography. Expression of glycogen synthase kinase-3 beta (GSK3β) and β-catenin proteins was investigated using western blotting. The serum SFRP5 levels were elevated in patients with PE, but SFRP5 expression was not detected in the placental tissues. Furthermore, SFRP5 inhibited the migration and invasion of HTR8/SVneo cells in vitro, increased GSK3β, and decreased β-catenin expression and MMP-2/9 activity in HTR8/SVneo cells. In conclusion, this study suggests that SFRP5 inhibits trophoblast migration and invasion potentially via the inhibition of Wnt/β-catenin signalling, which might be involved in the development of PE. However, the primary cause of the increased SFRP5 levels needs to be investigated.

Exploring the choroidal vascular labyrinth and its molecular and structural roles in health and disease

The choroid is a key player in maintaining ocular homeostasis and plays a role in a variety of chorioretinal diseases, many of which are poorly understood. Recent advances in the field of single-cell RNA sequencing have yielded valuable insights into the properties of choroidal endothelial cells (CECs). Here, we review the role of the choroid in various physiological and pathophysiological mechanisms, focusing on the role of CECs. We also discuss new insights regarding the phenotypic properties of CECs, CEC subpopulations, and the value of measuring transcriptomics in primary CEC cultures derived from post-mortem eyes. In addition, we discuss key phenotypic, structural, and functional differences that distinguish CECs from other endothelial cells such as retinal vascular endothelial cells. Understanding the specific clinical and molecular properties of the choroid will shed new light on the pathogenesis of the broad clinical range of chorioretinal diseases such as age-related macular degeneration, central serous chorioretinopathy and other diseases within the pachychoroid spectrum, uveitis, and diabetic choroidopathy. Although our knowledge is still relatively limited with respect to the clinical features and molecular pathways that underlie these chorioretinal diseases, we summarise new approaches and discuss future directions for gaining new insights into these sight-threatening diseases and highlight new therapeutic strategies such as pluripotent stem cell‒based technologies and gene therapy.

An autophagic deficit in the uterine vessel microenvironment provokes hyperpermeability through deregulated VEGFA, NOS1, and CTNNB1

The uterus undergoes vascular changes during the reproductive cycle and pregnancy. Steroid hormone deprivation induces macroautophagy/autophagy in major uterine cell types. Herein, we explored the functions of uterine autophagy using the Amhr2-Cre-driven atg7 deletion model. Deletion of Atg7 was confirmed by functional deficit of autophagy in uterine stromal, myometrial, and vascular smooth muscle cells, but not in endothelial cells. atg7d/d uteri exhibited enhanced stromal edema accompanied by dilation of blood vessels. Ovariectomized atg7d/d uteri showed decreased expression of endothelial junction-related proteins, such as CTNNB1/beta-catenin, with increased vascular permeability, and increased expression of VEGFA and NOS1. Nitric oxide (NO) was shown to mediate VEGFA-induced vascular permeability by targeting CTNNB1. NO involvement in maintaining endothelial junctional stability in atg7d/d uteri was confirmed by the reduction in extravasation following treatment with a NOS inhibitor. We also showed that atg7d/d uterine phenotype improved the fetal weight:placental weight ratio, which is one of the indicators of assessing the status of preeclampsia. We showed that autophagic deficit in the uterine vessel microenvironment provokes hyperpermeability through the deregulation of VEGFA, NOS1, and CTNNB1.Abbreviations: ACTA2: actin, alpha 2, smooth muscle, aortic; Amhr2: anti-Mullerian hormone type 2 receptor; ANGPT1: angiopoietin 1; ATG: autophagy-related; CDH5: cadherin 5; CLDN5: claudin 5; COL1A1: collagen, type I, alpha 1; CSPG4/NG2: chondroitin sulfate proteoglycan 4; CTNNB1: catenin (cadherin associated protein), beta 1; DES: desmin; EDN1: endothelin 1; EDNRB: endothelin receptor type B; F3: coagulation factor III; KDR/FLK1/VEGFR2: kinase insert domain protein receptor; LYVE1: lymphatic vessel endothelial hyaluronan receptor 1; MAP1LC3B: microtubule-associated protein 1 light chain 3 beta; MCAM/CD146: melanoma cell adhesion molecule; MYL2: myosin, light polypeptide 2, regulatory, cardiac, slow; MYLK: myosin, light polypeptide kinase; NOS1/nNOS: nitric oxide synthase 1, neuronal; NOS2/iNOS: nitric oxide synthase 2, inducible; NOS3/eNOS: nitric oxide synthase 3, endothelial cell; OVX: ovariectomy; PECAM1/CD31: platelet/endothelial cell adhesion molecule 1; POSTN: periostin, osteoblast specific factor; SQSTM1: sequestosome 1; TEK/Tie2: TEK receptor tyrosine kinase; TJP1/ZO-1: tight junction protein 1; TUBB1, tubulin, beta 1 class VI; USC: uterine stromal cell; VEGFA: vascular endothelial growth factor A; VSMC: vascular smooth muscle cell.

Diagnostic value of doppler ultrasound indices of maternal renal interlobar vasculature in the prediction of preeclampsia

We aimed to determine the diagnostic accuracy of maternal renal vasculature Doppler ultrasound indices in the prediction of preeclampsia. A total of 40 pregnant women with a gestational age of more than 20 weeks were included and followed. The pregnant women underwent a Doppler ultrasound examination to measure the resistance index (RI) of the interlobar arteries of right and left kidneys and the renal interlobar vein impedance index (RIVI). Of the included women, 15 patients developed preeclampsia based on clinical and laboratory criteria. The renal vascular Doppler ultrasound indices were compared between the two groups. Then, using the Receiver Operating Characteristic (ROC) analysis, the diagnostic accuracy of interlobar artery RI and RIVI were investigated in the prediction of preeclampsia occurrence. RIVI values of right and left kidneys were significantly higher in the preeclampsia group compared to the normal pregnancy group. The left kidney interlobar artery RI at a cut-point of 0.59 had a sensitivity of 100% and a specificity of 40% (area under curve=0.7, P-0.03) in the prediction of preeclampsia. The RIVI of the left kidney (adjusted odds ratio=17.14, 95% CI = 3.46 to 47.28) was statistically significant in predicting preeclampsia (P-0.006). We found that, besides other routine methods, using Doppler ultrasound and measuring RIVI can be reliable in the prediction of preeclampsia.

LncRNA SNHG16 regulates trophoblast functions by the miR-218-5p/LASP1 axis

Altered placental development and function lead to placental diseases such as preeclampsia (PE) which is mainly characterized by insufficient trophoblast invasion and abnormally invasive placenta disorders. Long noncoding RNAs (lncRNAs) are widely reported to function as crucial players in the pathogenesis of PE. The present investigation clarified the role of lncRNA small nucleolar RNA host gene 16 (SNHG16) in PE. RT-qPCR was used to measure gene expression. The proliferation of trophoblast cells was examined using CCK-8 and EdU assays. Trophoblast migration and invasion were assessed using wound healing and transwell assays. The apoptosis was estimated by flow cytometry. Luciferase reporter and RNA pull-down assays were performed to explore the molecular mechanisms in trophoblast cells. We found that SNHG16 was downregulated in placenta from patients with PE. Moreover, SNHG16 depletion significantly inhibited trophoblast cell proliferation, migration, and invasion and stimulated apoptosis, while SNHG16 overexpression exerted an opposite effect. Subsequently, we confirmed that SNHG16 acted as a competing RNA (ceRNA) of miR-218-5p that was verified to directly target LASP1. Both miR-218-5p depletion and LASP1 upregulation antagonized the effect of SNHG16 knockdown on HTR-8/SVneo cell functions. In conclusion, SNHG16 facilitates trophoblast cell migration and invasion by the miR-218-5p/LASP1 axis.

Complement activation by an angiogenic imbalance leads to systemic vascular endothelial dysfunction: A new proposal for the pathophysiology of preeclampsia

The underlying mechanism of preeclampsia by which an angiogenic imbalance results in systemic vascular endothelial dysfunction remains unclear. Complement activation directly induces endothelial dysfunction and is known to be involved in preeclampsia; nevertheless, the association between complement activation and angiogenic imbalance has not been established. This study aimed to evaluate whether angiogenic imbalance affects the expression and secretion of inhibitory complement factor H (CFH) in endothelial cells, resulting in complement activation and systemic vascular endothelial dysfunction. Viability of human umbilical vein endothelial cells (HUVECs) was assessed upon CFH knockdown by targeted-siRNA, and were incubated with complement factors. HUVECs were also treated with placental growth factor (PlGF) and/or soluble fms-like tyrosine kinase 1 (sFlt1), and CFH expression and secretion were measured. These cells were evaluated by cell viability assay and cell surface complement activation was quantified by immunocytochemical assessment of C5b-9 deposition. HUVECs transfected with CFH-siRNA had significantly lower viability than that of control cells. Moreover, the expression and secretion of CFH were significantly increased upon PlGF treatment compared with PlGF + sFlt1 combo. HUVECs treated with PlGF had less C5b-9 deposition and higher viability than HUVECs treated with PlGF + sFlt1. In summary, CFH was found to be essential for endothelial cell survival by inhibiting complement activation. An angiogenic imbalance, including decreased PlGF and increased sFlt1, suppresses CFH expression and secretion, resulting in complement activation on the surface of endothelial cells and systemic vascular endothelial dysfunction.

New views on endothelial dysfunction in gestational hypertension and potential therapy targets

The placenta has vital roles in metabolite exchange, fetal growth, and pre-eclampsia (PE). In this review, we discuss the pathogenesis of hypertension in pregnancy, focusing on four major theories to explain PE, discussing endothelial roles in those theories. We focus in particular on the roles of nitric oxide (NO) and prostacyclin (PGI₂) in placental endothelium, and propose new hypotheses for the influence and mechanisms of endothelial NO and PGI₂ signaling pathways in PE.

Prediction of adverse perinatal outcome and the mean time until delivery in twin pregnancies with suspected pre-eclampsia using sFlt-1/PIGF ratio

PURPOSE

An elevated soluble fms-like tyrosine kinase-1 (sFlt-1) / placental growth factor (PlGF) ratio is associated with adverse perinatal outcome (APO) and the mean time until delivery (MTUD) in singleton pregnancies complicated by pre-eclampsia (PE). Data on APO and MTUD prediction in twin pregnancies using sFlt-1/PlGF ratio are scarce. We evaluated the predictive value of the sFlt-1/PIGF ratio regarding APO and MTUD in twin pregnancies with suspected PE and/or HELLP syndrome.

METHODS

This is a single center retrospective cohort study. All twin pregnancies with suspected PE/HELLP and determined sFlt-1/PIGF were included. Composite APO (CAPO) was defined as the presence of at least one of the following outcomes: respiratory distress syndrome (RDS), intubation, admission to neonatal intensive care unit (NICU) and arterial umbilical cord pH value < 7.10. Selective fetal growth restriction (s-FGR) was analyzed separately.

RESULTS

For final analysis, 49 twin pregnancies were included. Median sFlt-1/PIGF ratio was not significantly different in patients with CAPO compared to those without (89.45 vs. 62.00, p = 0.669). MTUD was significantly negative correlated with sFlt-1/PIGF ratio (r = -0.409, p < 0.001). For the whole study cohort, ROC analysis revealed no predictive value for sFlt-1/PIGF and CAPO (AUC = 0.618, 95% CI: 0.387-0.849, p = 0.254). However, sFlt-1/PIGF ratio showed a predictive value for s-FGR (AUC = 0.755, 95% CI: 0.545-0.965, p = 0.032).

CONCLUSION

In twin pregnancies with PE and/or HELLP, sFlt-1/PIGF ratio may be helpful for s-FGR prediction and decision-making regarding close monitoring of high-risk patients. However, further prospective studies are warranted to define the role of sFlt-1/PlGF ratio as outcome predictor in twin pregnancies.

Overexpression of LVRN impedes the invasion of trophoblasts by inhibiting epithelial-mesenchymal transition

Laeverin (LVRN) was first detected on the outer layer of the chorion laeve and migrating extravillous trophoblasts (EVTs). It is an enzyme that plays an important role in the placentation and pathophysiology of preeclampsia (PE). Previous studies have indicated that LVRN may be required for the invasion of human trophoblast cells. Paradoxically, LVRN was found to be highly expressed in the trophoblasts of PE patients with impaired invasive capacities. In this study, we detected the expression of LVRN in the placentas of PE patients (n=5) and normal term pregnancy women (n=5) as a control group by immunohistochemistry. LVRN was elevated in decidua (P=0.0083) and villi (P=0.0079) of PE patients. Next, LVRN was overexpressed via adeno-associated virus-mediated gene transfer in trophoblastic cell lines HTR8, Swan71, and JAR. Matrigel transwell assay and wound healing assay showed that overexpression of LVRN impeded the invasion of these three cell lines. Western blot analysis showed that LVRN overexpression caused downregulation of N-cadherin and vimentin and upregulation of E-cadherin, suggesting the inhibitory role of LVRN in epithelial-mesenchymal transition (EMT). Moreover, our data indicated that long noncoding RNA NONSTAT103348 (lnc10-7) was elevated in PE patients. Silencing lnc10-7 led to decreased LVRN expression. Taken together, although the basal level of LVRN may be crucial for cell invasion, overexpression of LVRN may abrogate the cell invasiveness, suggesting a multifaceted role of LVRN in the pathogenesis of PE.

Preeclampsia-Pathophysiology and Clinical Presentations: JACC State-of-the-Art Review

Preeclampsia is a hypertensive disorder of pregnancy. It affects 2% to 8% of pregnancies worldwide and causes significant maternal and perinatal morbidity and mortality. Hypertension and proteinuria are the cornerstone of the disease, though systemic organ dysfunction may ensue. The clinical syndrome begins with abnormal placentation with subsequent release of antiangiogenic markers, mediated primarily by soluble fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng). High levels of sFlt-1 and sEng result in endothelial dysfunction, vasoconstriction, and immune dysregulation, which can negatively impact every maternal organ system and the fetus. This review comprehensively examines the pathogenesis of preeclampsia with a specific focus on the mechanisms underlying the clinical features. Delivery is the only definitive treatment. Low-dose aspirin is recommended for prophylaxis in high-risk populations. Other treatment options are limited. Additional research is needed to clarify the pathophysiology, and thus, identify potential therapeutic targets for improved treatment and, ultimately, outcomes of this prevalent disease.

The impact of advanced maternal age on pregnancy and offspring health: A mechanistic role for placental angiogenic growth mediators

The birth rates among women of advanced maternal age (AMA) have risen over the last two decades; yet, pregnancies with AMA are considered high-risk and are associated with a significant increase in pregnancy complications. Although the mechanisms leading to pregnancy complications in women with AMA are not fully understood, it has been well established in the literature that offspring exposed to unfavorable environmental conditions in utero, such as gestational diabetes, preeclampsia, and/or intrauterine growth restriction during the early stages of development are subject to long-term health consequences. Additionally, angiogenic growth mediators, which drive vascular development of the placenta, are imbalanced in pregnancies with AMA. These same imbalances also occur in pregnancies complicated by preeclampsia, gestational diabetes, and obesity. This review discusses the impact of AMA on pregnancy and offspring health, and the potential mechanistic role of placental angiogenic growth mediators in the development of pregnancy complications at AMA.

Nanoparticles in pregnancy: the next frontier in reproductive therapeutics

BACKGROUND

Nanotechnology involves the engineering of structures on a molecular level. Nanomedicine and nano-delivery systems have been designed to deliver therapeutic agents to a target site or organ in a controlled manner, maximizing efficacy while minimizing off-target effects of the therapeutic agent administered. In both reproductive medicine and obstetrics, developing innovative therapeutics is often tempered by fears of damage to the gamete, embryo or developing foetus or of negatively impacting a woman's reproductive potential. Thus, nanomedicine delivery systems may provide alternative targeted intervention strategies, treating the source of the disease and minimizing long-term consequences for the mother and/or her foetus.

OBJECTIVE AND RATIONALE

This review summarizes the current state of nanomedicine technology in reproductive medicine and obstetrics, including safety, potential applications, future directions and the hurdles for translation.

SEARCH METHODS

A comprehensive electronic literature search of PubMed and Web of Science databases was performed to identify studies published in English up until February 2020. Relevant keywords were used to obtain information regarding use of nanoparticle technology in fertility and gene therapy, early pregnancy complications (ectopic pregnancy and gestational trophoblastic disease) and obstetric complications (preeclampsia, foetal growth restriction, preterm birth and gestational diabetes) and for selective treatment of the mother or foetus. Safety of specific nanoparticles to the gamete, embryo and foetus was also investigated.

OUTCOMES

Pre-clinical research in the development of nanoparticle therapeutic delivery is being undertaken in many fields of reproductive medicine. Non-hormonal-targeted nanoparticle therapy for fibroids and endometriosis may provide fertility-sparing medical management. Delivery of interventions via nanotechnology provides opportunities for gene manipulation and delivery in mammalian gametes. Targeting cytotoxic treatments to early pregnancy tissue provides an alternative approach to manage ectopic pregnancies and gestational trophoblastic disease. In pregnancy, nanotherapeutic delivery offers options to stably deliver silencing RNA and microRNA inhibitors to the placenta to regulate gene expression, opening doors to novel genetic treatments for preeclampsia and foetal growth restriction. Restricting delivery of teratogenic drugs to the maternal compartment (such as warfarin) may reduce risks to the foetus. Alternatively, targeted delivery of drugs to the foetus (such as those to treat foetal arrythmias) may minimize side effects for the mother.

WIDER IMPLICATIONS

We expect that further development of targeted therapies using nanoparticles in a reproductive setting has promise to eventually allow safe and directed treatments for conditions impacting the health and reproductive capacity of women and for the management of pregnancy and serious pregnancy complications.

Long non-coding RNA FAM99A modulated YAP1 to affect trophoblast cell behaviors in preeclampsia by sponging miR-134-5p

Preeclampsia (PE) is a complex pregnancy syndrome. Convincing evidence indicates that long non-coding RNAs (lncRNAs) are involved in the pathogenesis of PE. This research mainly investigated the mechanism of family with sequence similarity 99 member A (FAM99A) in PE. The expressions of FAM99A, miR-134-5p, and YAP1 were detected by quantitative real-time polymerase chain reaction (qRT-PCR). Cell apoptosis, migration, and invasion were detected by flow cytometry or transwell assay. The interaction between miR-134-5p and FAM99A or YAP1 was confirmed by dual-luciferase reporter assay. The protein expression of YAP1 was determined by western blot assay. FAM99A and YAP1 were significantly up-regulated, and miR-134-5p was significantly down-regulated in PE tissues (n=30). miR-134-5p was verified as a candidate of FAM99A and YAP1. FAM99A promoted cell metastasis, but reduced apoptosis in HTR8/SVneo cells by regulating miR-134-5p. miR-134-5p down-regulated YAP1 expression to suppress cell metastasis, while it induced apoptosis in HTR8/SVneo cells. FAM99A positively modulated YAP1 expression by sponging miR-134-5p. FAM99A modulated YAP1 to accelerate cell migration and invasion, and inhibited cell apoptosis in PE cells by sponging miR-134-5p. The novel regulatory network may shed light on the pathogenesis of PE.

Reduced Intellectual Ability in Offspring Born from Preeclamptic Mothers: A Prospective Cohort Study

Background

Severe preeclampsia may affect placental development, and high homocysteine (Hcy) levels are linked to intellectual disability. However, the correlation between perinatal Hcy levels and intellectual ability remains unknown in severe preeclampsia-affected offspring.

Objective

We aimed to investigate the intellectual ability in offspring born from preeclamptic mothers and examine the role of prenatal Hcy in the prediction of intellectual disability in preschool-aged offspring.

Methods

The IQ scores were compared between 101 children born to mothers with severe preeclampsia and 202 offsprings born to normotensive mothers. Maternal Hcy levels within 7 days prior to delivery and postnatal cord blood Hcy were measured. The associations of Hcy with IQ scores were evaluated, and the optimal cut-off values for predicting intellectual disability in the offspring were estimated.

Results

The children born to mothers with severe preeclampsia had a greater postnatal cord blood Hcy than those born from normotensive mothers (P < 0.001), and the mothers with severe preeclampsia presented a higher prenatal Hcy (P < 0.001). The children born to mothers with severe preeclampsia had significantly lower IQ scores than those born from normotensive mothers, and a higher Hcy was associated with a lower IQ in preeclampsia-affected offspring. The prevalence of intellectual disability was 2.86 times higher in severe preeclampsia-affected offspring than in children born from normotensive mothers, and the prevalence of low IQ was greater in children born to mothers with severe preeclampsia than in those from normotensive mothers. ROC curve analysis showed that both maternal and cord blood Hcy were predictors of intellectual disability, and the optimal cut-off for predicting intellectual disability was 17.7 and 9.75 μmol/L for maternal and cord blood Hcy.

Conclusion

Perinatal exposure to severe preeclampsia has an adverse effect on postnatal intellectual development, and high maternal and cord blood Hcy may contribute to this association.

Evaluation of Vascular Reactivity of Maternal Vascular Adaptations of Pregnancy With Quantitative MRI: Pilot Study

BACKGROUND

Abnormal maternal vascular function during pregnancy stemming from systemic endothelial dysfunction (EDF) has a central role in the pathophysiology of preeclampsia (PE).

PURPOSE

To utilize quantitative MRI to investigate changes in physiological measures of vascular reactivity during normal pregnancy, and to explore EDF associated with preeclampsia.

STUDY TYPE

Prospective.

POPULATION

Healthy pregnant (HP) (n = 14, mean GA = 26 ± 7 weeks) and nonpregnant women (NP; n = 14); newly postpartum (PP <48 hours) women with severe PE (PP-PE; n = 4) and normotensive pregnancy (PP-HP; n = 5).

FIELD STRENGTH/SEQUENCE

1.5T/3T. RF spoiled multiecho gradient-recalled echo, 1D phase-contrast MRI, time-of-flight.

ASSESSMENT

The micro- and macrovascular function (vasodilatory capacity of arterioles and conduit arteries, respectively) of the femoral vascular bed was evaluated with MRI-based venous oximetry, arterial velocimetry, and luminal flow-mediated dilation quantification, during cuff-induced reactive hyperemia. Aortic arch pulse-wave velocity (aPWV) was quantified to assess arterial stiffness using an ungated 1D technique.

STATISTICAL TESTS

Two-tailed unpaired t-tests were performed to address our two, primary a priori comparisons, HP vs. NP, and PP-PE vs. PP-HP. Given the pilot nature of this study, adjustments for multiple comparisons were not performed.

RESULTS

In HP, microvascular function was attenuated compared to NP by a significant increase in the washout time (10 ± 2 vs. 8 ± 2 sec; P < 0.05) and reduced upslope (2.1 ± 0.5 vs. 3.2 ± 0.8%HbO₂ /s; P < 0.05), time of forward flow (28 ± 5 vs. 33 ± 6 sec, P < 0.05), and hyperemic index (11 ± 3 vs. 16 ± 4 cm/s² ; P < 0.05), but luminal flow-mediated dilatation (FMD_L )was comparable between HP and NP. PP-PE exhibited significant vascular dysfunction compared to PP-HP, as evidenced by differences in upslope (2.2 ± 0.6 vs. 1.3 ± 0.2%HbO₂ /s, P < 0.05), overshoot (16 ± 5 vs. 7 ± 3%HbO₂ , P < 0.05), time of forward flow (28 ± 6 vs. 15 ± 7 s, P < 0.05), and aPWV (7 ± 1 vs. 8 ± 1 m/s, P < 0.05).

DATA CONCLUSION

Attenuated vascular reactivity during pregnancy suggests that the systemic vasodilatory state partially depletes nitric oxide bioavailability. Preliminary data support the potential for MRI to identify vascular dysfunction in vivo that underlies PE. Level of Evidence 2 Technical Efficacy Stage 1 J. MAGN. RESON. IMAGING 2021;53:447-455.

Magnesium sulfate prophylaxis attenuates the postpartum effects of preeclampsia by promoting M2 macrophage polarization

Preeclampsia is a complex disorder that is characterized by new onset hypertension and proteinuria at or after 20 weeks of gestation. Preeclampsia is a leading cause of maternal and fetal morbidity and mortality. MgSO₄ is commonly used to treat severe preeclampsia, but its mechanism of action is poorly understood, and investigations into the effects of MgSO₄ during the postpartum period are lacking. In this study, timed-pregnant Sprague-Dawley rats received low-dose lipopolysaccharide (LPS) on gestational day 14 to induce preeclampsia. Maternal and fetal outcomes and the macrophage profile 1 week after delivery were explored. On postpartum day (PD) 7, the maternal systolic blood pressure and urinary protein level were significantly increased, the number of M1 macrophages was increased and the number of M2 macrophages was decreased in the maternal kidney and brain; the median duration of gestation, the number of live fetuses, and the fetal weight/placenta weight ratio were significantly decreased; and the percentage of growth-restricted pups and fetal mortality were significantly increased in preeclampsia rats compared to normal pregnant control rats. Prophylactic MgSO₄ decreased blood pressure at PD7, improved pregnancy outcomes, and promoted the polarization of M2 macrophages in the kidney and of M2 microglia in the brain of preeclampsia rats. These findings confirm that the pathophysiology of preeclampsia involves the dysregulation of the inflammatory response and the activation of M1 macrophages in several target organs during pregnancy. MgSO₄ prophylaxis attenuates the postpartum effects of preeclampsia by promoting M2 macrophage polarization in the maternal kidney and brain.

Podocytes-The Most Vulnerable Renal Cells in Preeclampsia

Preeclampsia (PE) is a disorder that affects 3–5% of normal pregnancies. It was believed for a long time that the kidney, similarly to all vessels in the whole system, only sustained endothelial damage. The current knowledge gives rise to a presumption that the main role in the development of proteinuria is played by damage to the podocytes and their slit diaphragm. The podocyte damage mechanism in preeclampsia is connected to free VEGF and nitric oxide (NO) deficiency, and an increased concentration of endothelin-1 and oxidative stress. From national cohort studies, we know that women who had preeclampsia in at least one pregnancy carried five times the risk of developing end-stage renal disease (ESRD) when compared to women with physiological pregnancies. The focal segmental glomerulosclerosis (FSGS) is the dominant histopathological lesion in women with a history of PE. The kidney’s podocytes are not subject to replacement or proliferation. Podocyte depletion exceeding 20% resulted in FSGS, which is a reason for the later development of ESRD. In this review, we present the mechanism of kidney (especially podocytes) injury in preeclampsia. We try to explain how this damage affects further changes in the morphology and function of the kidneys after pregnancy.

Premature Atherosclerotic Cardiovascular Disease: What Have We Learned Recently?

PURPOSE OF REVIEW

In contrast to patients with non-premature atherosclerotic cardiovascular disease (ASCVD), patients with premature ASCVD have not observed a similar decline in cardiovascular mortality and recurrent adverse events. We sought to review the underlying risk factors, potential gaps in medical management, associated outcomes, and tools for risk prognostication among patients with premature ASCVD.

RECENT FINDINGS

In addition to traditional cardiovascular risk factors (i.e., diabetes, familial hypercholesterolemia), non-traditional risk factors such as chronic inflammatory conditions, recreational drug use, genetics, and pregnancy-related complications play a key role in development and progression of premature ASCVD. Patients with premature ASCVD, and especially women, receive less optimal medical management as compared to their non-premature counterparts. There is an increasing prevalence of cardiovascular risk factors among young adults. Hence, this population remains at an elevated risk for premature ASCVD and subsequent adverse cardiovascular events. Future studies evaluating different risk assessment tools and focusing on young patients across all three major domains of ASCVD are needed.

Postnatal exposure to endosulfan affects uterine development and fertility

Endosulfan is an organochlorine pesticide (OCP) used in large-scale agriculture for controlling a variety of insects and mites that attack food and non-food crops. Although endosulfan has been listed in the Stockholm Convention as a persistent organic pollutant to be worldwide banned, it is still in use in some countries. Like other OCPs, endosulfan is bioaccumulative, toxic and persistent in the environment. Human unintentional exposure may occur through air inhalation, dietary, skin contact, as well as, via transplacental route and breast feeding. Due to its lipophilic nature, endosulfan is rapidly absorbed into the gastrointestinal tract and bioaccumulates in the fatty tissues. Similar to other OCPs, endosulfan has been classified as an endocrine disrupting chemical (EDC). Endocrine action of endosulfan on development and reproductive function of males has been extensively discussed; however, endosulfan effects on the female reproductive tract have received less attention. This review provides an overview of: i) the fate and levels of endosulfan in the environment and human population, ii) the potential estrogenic properties of endosulfan in vitro and in vivo, iii) its effects on uterine development, and iv) the long-term effects on female fertility and uterine functional differentiation during early gestation.

The Inhibition of Protein Kinase C β Contributes to the Pathogenesis of Preeclampsia by Activating Autophagy

Background

Preeclampsia is a devastating hypertensive disorder of pregnancy with unknown mechanism. Recent studies have considered abnormal autophagy as a new cellular mechanism for this disorder, while little is known about how autophagy is specifically involved and what factors are implicated. Here, we report a previously unrecognized preeclampsia-associated autophagic regulator, PKCβ, that is involved in placental angiogenesis.

Methods

PKCβ levels were evaluated by quantitative real-time PCR, western blotting, immunofluorescence and by the analysis of public data. The autophagy-regulating role of PKCβ inhibition in preeclampsia pathogenesis was studied in a mouse model, and in human umbilical vein endothelial cells (HUVECs) and human choriocarcinoma cells (JEG-3).

Findings

PKCβ was significantly downregulated in human preeclamptic placentas. In a mouse model, the selective inhibition of PKCβ by Ruboxistaurin was sufficient to induce preeclampsia-like symptoms, accompanied by excessive autophagic flux and a disruption in the balance of pro- and anti-angiogenic factors in mouse placentas. In contrast, autophagic inhibition by 3-methyladenine partially normalized hypertension, proteinuria and placental angiogenic imbalance in PKCβ-inhibited mice. Our in vitro experiments demonstrated that PKCβ inhibition activated autophagy, thus blocking VEGFA-induced HUVEC tube formation and resulting in the significant upregulation of sFLT1 and downregulation of VEGFA in JEG-3 cells.

Interpretation

These data support a novel model in which autophagic activation due to PKCβ inhibition leads to the impairment of angiogenesis and eventually results in preeclampsia.

Funding

Shanghai Key Program of Clinical Science and Technology Innovation, National Natural Science Foundation of China and Shanghai Medical Center of Key Programs for Female Reproductive Diseases.

Immediate postpartum management of patients with severe hypertensive disorders of pregnancy: pathophysiology guiding practice

Developing clinically-focused evidence and experience-based approaches to improve maternity care is a national priority. Safety and quality collaborative initiatives related to management of hypertensive disorders of pregnancy are vital in the implementation of improved care. We reviewed the obstetric literature to construct a concise summary of the core pathophysiologic issues, practice principles and clinical interventions which are foundational for physicians providing immediate postpartum care for patients with severe pregnancy-related hypertension (including those with eclampsia, HELLP syndrome, and superimposed preeclampsia inclusive of those with gestational hypertension that develop severe range blood pressures). While based largely upon the American College of Obstetrics and Gynecology (ACOG) Hypertension Task Force Guidelines released in 2013 as well as updated 2018 guidelines set forth by ACOG for hypertensive disorders of pregnancy, this summary goes beyond the basic safety bundles for hypertension management and lays a pathophysiologic foundation for the immediate postpartum care of patients with severe hypertensive disorders of pregnancy.

Is female genital mutilation associated with eclampsia? Evidence from a nationally representative survey data

Background

Studies have shown the impact of female genital mutilation (FGM), especially infibulation (WHO type III), on reproductive health, and adverse obstetric outcomes like postpartum haemorrhage and obstructed labour. However, whether an association exists with maternal hypertensive complication is not known. The present study sought to investigate the role of the different types of FGM on the occurrence of eclampsia.

Methods

The study used data from the 2006 Demographic and health survey of Mali. The proportion of eclampsia in women with each type of FGM and the unadjusted and adjusted odds ratios (OR) were calculated, using women without FGM as reference group. Unadjusted and adjusted OR were also calculated for women who underwent infibulation compared to the rest of the population under study (women without FGM and women with FGM type I, II, and IV).

Results

In the 3997 women included, the prevalence of infibulation was 10.2% (n = 407) while 331 women did not report FGM (8.3%). The proportion of women reporting signs and symptoms suggestive of eclampsia was 5.9% (n = 234).

Compared with the absence of female genital mutilation and adjusted for covariates, infibulation was associated with eclampsia (aOR 2.5; 95% CI:1.4–4.6), while the association was not significant in women with other categories of FGM. A similar aOR was found when comparing women with infibulation with the pooled sample of women without FGM and women with the other forms of FGM.

Conclusion

The present study suggests a possible association between infibulation and eclampsia. Future studies could investigate this association in other settings. If these findings are confirmed, the possible biological mechanisms and preventive strategies should be investigated.

Sulforaphane improves syncytiotrophoblast mitochondrial function after in vitro hypoxic and superoxide injury

INTRODUCTION

Placental mitochondrial dysfunction contributes to the oxidative stress that underlies preeclampsia. Here, we assessed whether sulforaphane (SFN) could improve syncytiotrophoblast mitochondrial function after in vitro hypoxic and superoxide injury.

METHODS

Placental cytotrophoblasts were isolated from healthy term placentae (n = 12) and incubated for 48 h in 8% O₂ ± 1 μM SFN before acute (4hrs) or chronic (24hrs) hypoxic (1% O₂), or superoxide (xanthine/xanthine oxidase) injury. Cytotrophoblasts were also isolated from preeclamptic placentae (n = 5) and cultured in 8% O₂ ± 1 μM SFN. Mitochondrial respiration was measured using the Seahorse MitoStress XF assay. Cells were stained with mitotracker red to assess mitochondrial membrane health and mitochondrial gene expression assessed using RT-qPCR.

RESULTS

SFN prevented significant reductions in syncytiotrophoblast mitochondrial maximal respiration, spare respiratory capacity, basal respiration and ATP production following acute hypoxia. Chronic hypoxia only reduced maximal and spare respiratory capacity. SFN prevented these negative changes and increased respiration overall. Alternatively, acute superoxide injury significantly increased mitochondrial maximal respiration and spare respiratory capacity. SFN treatment further increased basal respiration following superoxide injury and prevented significant decreases in ATP production and coupling efficiency. In preeclamptic placentae, SFN significantly increased mitochondrial maximal respiration, spare respiratory capacity, basal respiration and ATP production, and decreased proton leak. SFN up-regulated mRNA expression of mitochondrial complexes and corrected an up-regulation in fission gene expression observed after hypoxic-superoxide injury. Finally, preliminary results suggest SFN prevented hypoxia-induced impairment of mitochondrial membrane structure.

DISCUSSION

SFN mitigated hypoxia and superoxide induced changes to syncytiotrophoblast mitochondrial function in vitro, and improved mitochondrial respiration in trophoblast cells from preeclamptic placentae.

The Effect of Exercise Training During Pregnancy to Improve Maternal Vascular Health: Focus on Gestational Hypertensive Disorders

Hypertensive disorders of pregnancy, including gestational hypertension and pre-eclampsia, occur in up to 10% of pregnancies and are associated with increased life-long cardiovascular risk. Physical activity improves cardiovascular health in pregnancy and may lower the risk of developing hypertensive disorders of pregnancy. However, a minority of pregnant women comply with the recommended level of physical activity. Adequate knowledge on the physiological effects of exercise in healthy pregnancy could help to overcome potential barriers as pregnancy is a unique window of opportunity to improve health outcomes for both mother and child. In this mini review, we discuss structural and functional vascular adaptations during healthy and hypertensive pregnancies, we elaborate on the effects of exercise on the vasculature and review the safety and existing evidence of exercise training as preventive therapy for gestational hypertensive disorders.