Is inflammation the cause of pre-eclampsia?

Prediction of Preterm Birth among Infants with Orofacial Cleft Defects

OBJECTIVE

To develop risk prediction models for preterm birth among infants with orofacial clefts.

DESIGN

Data from the Texas Birth Defects Registry for infants with orofacial clefts born between 1999-2014 were used to develop preterm birth predictive models. Logistic regression was used to consider maternal and infant characteristics, and internal validation of the final model was performed using bootstrapping methods. The area under the curve (AUC) statistic was generated to assess model performance, and separate predictive models were built and validated for infants with cleft lip and cleft palate alone. Several secondary analyses were conducted among subgroups of interest.

SETTING

State-wide, population-based Registry data.

PATIENTS/PARTICIPANTS

6774 infants with orofacial clefts born in Texas between 1999-2014.

MAIN OUTCOME MEASURE(S)

Preterm birth among infants with orofacial clefts.

RESULTS

The final predictive model performed modestly, with an optimism-corrected AUC of 0.67 among all infants with orofacial clefts. The optimism-corrected models for cleft lip (with or without cleft palate) and cleft palate alone had similar predictive capability, with AUCs of 0.66 and 0.67, respectively. Secondary analyses had similar results, but the model among infants with delivery prior to 32 weeks demonstrated higher optimism-corrected predictive capability (AUC = 0.74).

CONCLUSIONS

This study provides a first step towards predicting preterm birth risk among infants with orofacial clefts. Identifying pregnancies affected by orofacial clefts at the highest risk for preterm birth may lead to new avenues for improving outcomes among these infants.

The Black-White Disparity in Preterm Birth: Race or Racism?

Policy Points Racism is an upstream determinant of health that influences health through many midstream and downstream factors. This Perspective traces multiple plausible causal pathways from racism to preterm birth. Although the article focuses on the Black-White disparity in preterm birth, a key population health indicator, it has implications for many other health outcomes. It is erroneous to assume by default that underlying biological differences explain racial disparities in health. Appropriate science-based policies are needed to address racial disparities in health; this will require addressing racism.

Elevated Expression of miR-296 in Human Placentas and Serum Samples From Pregnancies With Preeclampsia

Background: Preeclampsia (PE) is a hypertensive disorder of pregnancy characterized by widespread maternal endothelial dysfunction. Although clinical signs subside following delivery, long-term risks associated with PE include hypertension, stroke, and cardiovascular disease. MicroRNAs (miRNAs) are emerging as critical regulators of biological function, and while alterations to the miRNAs have been described in the context of pregnancy and PE, the postpartum implications of PE on miRNA expression are unknown. In the present study, we aimed to determine the clinical performance of miR-296 in PE. Methods: First, the clinical information and outcomes of all the participants were collected and analyzed. Afterward, the miR-296 expressions in the serum samples from healthy pregnant women and women with PE at different periods were detected using quantitative real-time polymerase chain reaction (qRT-PCR). Then, the receive operation characteristic (ROC) curve was used to determine the diagnostic value of miR-296 in PE. Finally, the at-term placentals were collected, the expressions of miR-296 in different groups were compared at first blood collection and at delivery. Results: In this study, we found that miR-296 expression was significantly increased in the placenta samples from PE patients compared with that in healthy controls both in early onset group (EOPE, p < 0.01) and late onset group (LOPE, p < 0.01). Furthermore, results of ROC analysis showed miR-296 might be a putative biomarker for early onset preeclampsia and late onset preeclampsia diagnosis with an area under the curve (AUC) of 0.84 (95% confidence interval 0.75-0.92) and 0.85 (95% confidence interval 0.77-0.93). Last but not the least, the expressions of miR-296 were significantly increased (p < 0.05) in serum samples of EOPE and LOPE patients (p < 0.001), and serum and placental levels of the miR-296 was positively correlated for EOPE (r = 0.5574, p < 0.001) and LOPE (r = 0.6613, p < 0.001) patients, respectively. Meanwhile, compared with those at first blood collection, the expression of miR-296 in EOPE (p = 0.05) and LOPE (p = 0.01) were significantly decreased at delivery. Conclusion: miR-296 may function as a putative diagnostic biomarker for PE and contribute to identifying at-risk mothers in pregnancy.

Moringa Leaf Powder (Moringa oleifera) Decrease of Inflammation Plasma Cytokine of Pregnant Rats with Diabetes Mellitus

BACKGROUND: Preeclampsia is a major obstetric problem worldwide, especially in developing countries that can cause maternal and fetal morbidity and mortality that affect 2–10% of pregnancies worldwide. More than 4 million pregnant women each year develop preeclampsia and cause 15–20% of maternal deaths worldwide. There are several high-risk factors associated with preeclampsia. Diabetes mellitus is one of the risk factors for preeclampsia. Preeclampsia has been shown to have higher levels of Th1 (pro-inflammatory) products and lower levels of Th2 (anti-inflammatory) products compared to normal pregnancy in blood serum. Interleukin (IL) 1, IL-2, IL-8, tumor necrosis factor (TNF)-alpha, and interferon gamma are Th1 cytokines or pro-inflammatory cytokines that can induce inflammatory reactions and are associated with pregnancy complications such as repeated abortion, preterm labor, rupture of membranes. preeclampsia, and stunted fetal growth. In contrast, Th2 cytokines such as transforming growth factor-β (TGF-β), IL-4, IL-5, IL6, and IL-10 are associated with normal pregnancy. AIM: This study aims to prove the effect of giving Moringa leaf powder (M. oleifera) to decrease blood levels, , so this study will answer the effect of Moringa oleifera leaf powder on blood level of IL-6, IL-10, TNF-α and TGF-β METHODS: A total of 30 rats were checked for sugar levels on day 4 after being induced by alloxan for 18 days to see if the rats were already in a hyperglycemic state. Then, they were divided into six groups, each group contained five pregnant white rats. Group 1 was the negative group (without being given alloxan), Group 2 was positive (given alloxan 150 mg/day/kg BW), and Groups 3, 4, 5, and 6 were given alloxan 150 mg/day/kg BW and each given a dose of 100 Moringa leaf powder; 200, 400, and 800 mg/day/kg body weight. After alloxan was induced and given a dose of Moringa leaf powder according to each group, blood samples were taken to separate the serum and continued with the ELISA method to calculate the levels of IL-6, IL-10, TNF-α, and TGF-β. RESULTS: The administration of Moringa leaf powder at a dose of 800 mg/day/kg BW was able to increase the levels of IL-10 in the positive control Group 4 by 7.211 mIU/ml and reduced levels of IL-6 in the 8th dose group by giving Moringa leaf powder as much as 800 mg/day/kg body weight by 2.112 mIU/ml, was able to increase TGF-β levels in the dose Group 4 by giving Moringa leaf powder as much as 800 mg/day/kg BW, amounted to 1049.066 mIU/ml, and decreased TNF-α levels in the dose Group 4 by giving Moringa leaf powder as much as 800 mg/day/kg BW mIU/ml. CONCLUSION:The administration of Moringa leaf powder was able to increase the levels of IL-10 in the positive control Group, reduced levels of IL-6, was able to increase TGF-β levels, and decreased TNF-α levels.

Explaining the Black-White Disparity in Preterm Birth: A Consensus Statement From a Multi-Disciplinary Scientific Work Group Convened by the March of Dimes

In 2017–2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparity's social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a woman's microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black women in stressful surroundings and exposes them to environmental hazards. Race-based discriminatory treatment is a pervasive stressor for Black women of all socioeconomic levels, considering both incidents and the constant vigilance needed to prepare oneself for potential incidents. Racism is a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.

Angiogenic Properties of Placenta-Derived Extracellular Vesicles in Normal Pregnancy and in Preeclampsia

Angiogenesis is one of the main processes that coordinate the biological events leading to a successful pregnancy, and its imbalance characterizes several pregnancy-related diseases, including preeclampsia. Intracellular interactions via extracellular vesicles (EVs) contribute to pregnancy's physiology and pathophysiology, and to the fetal-maternal interaction. The present review outlines the implications of EV-mediated crosstalk in the angiogenic process in healthy pregnancy and its dysregulation in preeclampsia. In particular, the effect of EVs derived from gestational tissues in pro and anti-angiogenic processes in the physiological and pathological setting is described. Moreover, the application of EVs from placental stem cells in the clinical setting is reported.

Association of high maternal triglyceride levels early and late in pregnancy with adverse outcomes: A retrospective cohort study

BACKGROUND

Excess maternal triglyceride (mTG) exposure during early or late pregnancy increases risks of adverse pregnancy outcomes. However, it is inconclusive whether persistently high maternal triglyceride during whole pregnancy has more negative associations.

OBJECTIVE

To explore whether persistently high maternal triglyceride (mTG) levels from early to late pregnancy further increases the risk of adverse pregnancy outcomes.

METHODS

We included 12,715 women who had a singleton birth and who underwent routine serum lipid screenings in both early (9-13 weeks) and late (28-42 weeks) pregnancy during May 2018 to July 2019 in a university-based maternity center. Risks for gestational diabetes mellitus (GDM), preeclampsia, preterm delivery, small/large for gestational age (LGA) were estimated.

RESULTS

Elevated mTG levels during early pregnancy were associated with increased risks of preterm delivery (AOR, 1.52; 95% CI, 1.21 to 1.90), preeclampsia (1.75; 1.29 to 2.36), gestational diabetes mellitus (1.95; 1.69 to 2.25), and LGA (1.28; 1.12 to 1.46). Compared with those with low mTG levels both in the 1st and 3rd trimesters, persistently high mTG levels increased the risks of preeclampsia (2.53; 1.66 to 3.84), GDM (1.97; 1.57 to 2.47), and LGA (1.68; 1.37 to 2.07). However, persistently high mTG levels only slightly increased risk of LGA when compared with high mTG levels during the 1st trimester alone (1.34, 1.01 to 1.77).

CONCLUSIONS

Elevated mTG levels during early pregnancy not in late pregnancy could be the crucial risk factor associated with adverse pregnancy outcomes. These results suggest the importance of lipid screenings and preventions during early pregnancy, which may help to improve pregnancy outcomes.

HSPA1L rs1061581 polymorphism is associated with the risk of preeclampsia in Han Chinese women

Preeclampsia (PE) is an excessive systemic inflammation response with dysfunction of endothelial. As a stress protein, heat shock protein 70 (HSP70) plays a pivotal role in protecting cells against apoptosis, oxidative damage and genetic damage. In humans, three genes encode members of the HSP70 class: HSPA1A, HSPA1B and HSPA1L. Our study was to investigate the association between genetic variations of HSPA1L and the susceptibility for PE in Chinese Han population. The polymorphisms of rs2227956, rs1043618 and rs1061581 in HSPA1L were genotyped by TaqMan allelic discrimination real time polymerase chain reaction (PCR) in 929 PE patients and 1024 healthy pregnant women. Statistic difference of the genotypic and allelic frequencies were found in HSPA1L rs1061581 between PE patients and controls (χ2 = 29.863, P < 0.001 by genotype; χ2 = 27.298, P < 0.001, OR = 1.874, 95%CI 1.476-2.379 by allele) and HSPA1L rs1061581 A alleles occurred more frequently in PE patients compared with healthy controls (PE vs. controls 10.28% vs. 5.76%). Furthermore, we divided the PE cases into early-onset/late-onset PE and mild/severe PE subgroups and found statistical differences in genotypic and allelic frequencies of the HSPA1L rs1061581 between early-onset PE, late-onset PE, mild PE, severe PE and controls, respectively. Moreover, HSPA1L rs1061581 A alleles were more frequent in early-onset PE, late-onset PE, mild PE and severe PE than controls respectively. Therefore, we concluded that HSPA1L rs1061581 polymorphism is associated with the risk of PE in Han Chinese women and A alleles may play a role in the susceptibility for PE.

Sevoflurane inhibited inflammatory response induced by TNF-α in human trophoblastic cells through p38MAPK signaling pathway

Purpose: Excessive inflammatory response is one of the possible pathogenic mechanisms of preeclampsia (PE). It remains unclear whether sevoflurane has an anti-inflammatory effect in human trophoblastic cells, which are corresponding to the dysfunction of placentas in PE. This study probed into the regulatory function of sevoflurane toward HTR8/SVneo cells so as to find PE pathology and PE treatment.Materials and methods: HTR8/SVneo cells were treated with sevoflurane, TNF-α with different concentrations, sevoflurane plus 10 ng/mL TNF-α and SB203580 plus 10 ng/mL TNF-α. Cell counting kit-8 (CCK-8) assays were performed to detect cell viability, while enzyme linked immunoSorbent assay (ELISA) was used to measure IL-6, IL-8, GM-CSF and MCP-1 levels in HTR8/SVneo cells. Besides, relative mRNA expression levels of IL-6 and IL-8 were tested via quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR), and p38 phosphorylation-related protein expressions were assessed through western blot.Results: Cell viability remained stable when HTR8/SVneo cells were treated with or without sevoflurane and SB203580 in inflammatory microenvironment created by TNF-α. MCP-1 and GM-CSF levels, as well as gene expressions of IL-6 and IL-8 in HTR8/SVneo cells were greatly increased by TNF-α (5, 10 and 20 ng/mL), but reversed by sevoflurane and SB203580. Simultaneously, TNF-α-induced phosphorylation of p38MAPK signaling pathway was inhibited by sevoflurane and SB203580.Conclusions: Sevoflurane inhibited inflammatory response induced by TNF-α in human trophoblastic cells HTR8/SVneo through suppressing the phosphorylation of p38MAPK signaling pathway.

Systematic review with meta-analysis: risk of adverse pregnancy-related outcomes in inflammatory bowel disease

BACKGROUND

The effect of inflammatory bowel disease (IBD) on pregnancy-related outcomes remains unknown.

AIM

To determine the risk of adverse maternal, placental and obstetric outcomes in IBD METHODS: We searched Medline, Embase and Cochrane library through May 2019 for studies reporting adverse maternal, placental and obstetric outcomes in patients with IBD. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for these outcomes in patients with IBD compared to healthy controls.

RESULTS

Fifty-three studies were included (7917 IBD pregnancies and 3253 healthy control pregnancies). Caesarean delivery was more common in patients with IBD compared to healthy controls (OR 1.79, 95% CI, 1.16-2.77). This remained significant for UC (OR 1.80, 95% CI, 1.21-2.90) but not CD (OR 1.48, 95% CI, 0.94-2.34). Similarly, gestational diabetes occurred more commonly in IBD (OR 2.96, 95% CI, 1.47-5.98). The incidences of placental diseases were 2.0% (95% CI, 0.9%-3.1%) for pre-eclampsia, 3.3% (95% CI, 0%-7.2%) for placental abruption, 0.5% (95% CI, 0.2%-0.9%) for placenta previa and 0.3% (95% CI, 0%-0.5%) for chorioamnionitis. Patients with IBD were more likely to experience preterm prelabour rupture of membranes (OR 12.10, 95% CI, 2.15-67.98), but not early pregnancy loss (OR 1.63, 95% CI 0.49-5.43). Anti-tumour necrosis factor therapy was not associated with chorioamnionitis (OR 1.12, 95% CI, 0.16-7.67), early pregnancy loss (OR 1.49, 95% CI, 0.83-2.64) or placenta previa (OR 1.58, 95% CI, 0.30-8.47).

CONCLUSIONS

Gestational diabetes and preterm prelabour rupture of membranes occurs more commonly in patients with IBD, although the incidence of placental diseases remains low.

HMOX1 is partly responsible for phenotypic and functional abnormalities in mesenchymal stem cells/stromal cells from placenta of preeclampsia (PE) patients

Background

Preeclampsia is a common obstetric syndrome affecting women in their first pregnancy and characterized by hypertension and proteinuria, which appears after 20 weeks of gestation. It is characterized by high blood pressure and occasional damage to another organ system most often the liver and kidneys. Currently, the etiology and pathogenesis of this syndrome are not fully understood. Since mesenchymal stem cells/stromal cells (MSCs) are intimately associated with endothelial cells that line vessel walls in the decidua they may play some role in the pathogenesis of this syndrome. In this study, we have partly, unveiled the mechanism of preeclampsia pathogenesis at the stem cells level.

Methods

We have isolated and characterized MSCs from decidua basalis of preeclampsia placenta (PE-DBMSCs) and showed their decreased functionality in terms of proliferation, migration, adhesion and clone formation potential as compared to MSCs isolated from decidua region of normal placentae (DBMSCs). The cells were preconditioned with H₂O₂ and the functional characteristics were evaluated. Differentially expressed genes were analyzed using mass spectrometry. Immunoblotting confirmed the expression of these proteins.

Results

Pre-conditioning with H₂O₂ restored the functional outcome of PE-DBMSCs. Mass spectrometry (MS) analysis of differentially expressed proteins revealed HMOX1 as one of the major candidates missing in PE-DBMSCs. HMOX1 inhibition by tin protoporphyrin (SnPP) in normal DBMSCs resulted in a reduction in proliferation, migration, adhesion, and clone formation processes as compared to the untreated controls. mRNA and protein analyses of PE-DBMSCs preconditioned with H₂O₂ at lower doses showed upregulation of HMOX1 expression.

Conclusions

We hereby show for the first time that loss of function of stem cells/stromal cells isolated from the patients with preeclampsia may contribute towards the disease exacerbation. Our results suggest that HMOX1 may be partially responsible for the loss of functionality in PE-DBMSCs and contribute significantly towards the pathophysiology of preeclampsia. However, further investigation is required to decipher its exact role in the development and onset of the disorder.

Cyclosporin A ameliorates eclampsia seizure through reducing systemic inflammation in an eclampsia-like rat model

Our previous studies have shown that the maternal hyperinflammatory response in pre-eclampsia lowered the eclampsia-like seizure threshold. Cyclosporin A (CsA), which is an effective immunosuppressant, could attenuate the inflammatory responses in LPS-induced pre-eclampsia rats. Here, we hypothesized that CsA may ameliorate seizure severity through reducing systemic inflammation in pre-eclampsia/eclampsia. In the current study, the effects of CsA on pre-eclampsia manifestation, eclampsia-like seizure activities and systemic inflammation were examined in a pre-eclampsia model. Pregnant rats were given an intraperitoneal injection of the epileptogenic drug pentylenetetrazol (PTZ) following a tail vein injection of lipopolysaccharide to establish the eclampsia-like seizure model. CsA (5 mg/kg) was administered intravenously through the tail after LPS infusion. Mean systolic blood pressure and proteinuria in pre-eclampsia were detected. After PTZ injection, seizure activity was assessed, inflammatory responses were determined and pregnancy outcomes were analyzed. The results showed that CsA treatment significantly decreased blood pressure and proteinuria and increased the fetal and placental weight (P < 0.01). Meanwhile, CsA treatment significantly reduced serum IL-1β, TNF-α, and IL-17 levels (P < 0.01), decreased the seizure scores and prolonged the latency to seizure (P < 0.01). CsA effectively attenuated pre-eclampsia manifestation and eclampsia-like seizure severity. In addition, CsA treatment significantly reduced the inflammatory cytokine levels and improved pregnancy outcomes following eclampsia-like seizures. The decreased inflammatory cytokines in pre-eclampsia are coincident with attenuated pre-eclampsia manifestation after CsA treatment, suggesting that CsA treatment might decrease the eclampsia-like seizure severity through decreasing systemic inflammation in pre-eclasmpsia/eclampsia.

Placental colonization with periodontal pathogens: the potential missing link

Observational studies demonstrate that women with severe periodontitis have a higher risk of adverse pregnancy outcomes like preterm birth and low birthweight. Standard treatment for periodontitis in the form of scaling and root planing during the second trimester failed to reduce the risk of preterm or low birthweight. It is premature to dismiss the association between periodontitis and adverse pregnancy outcomes because one explanation for the failure of scaling and root planing to reduce the risk of adverse pregnancy outcomes is that periodontal pathogens spread to the placental tissue prior to periodontal treatment. In the placenta, orally derived organisms could cause direct tissue damage or mediate a maternal immune response that impairs the growth of the developing fetus. Sequencing studies demonstrate the presence of organisms derived from the oral microbiome in the placenta, but DNA-based sequencing studies should not be the only technique to evaluate the placental microbiome because they may not detect important shifts in the metabolic capability of the microbiome. In humans, polymerase chain reaction and histology have detected periodontal pathogens in placental tissue in association with multiple adverse pregnancy outcomes. We conclude that both placental and oral microbiomes may play a role in periodontitis-associated adverse pregnancy outcomes. However, the measure to determine the association between periodontal pathogens in the placenta and adverse pregnancy outcomes should be the amount and prevalence, not the mere presence of such microorganisms. Placental colonization with periodontal pathogens thus potentially represents the missing link between periodontitis and adverse pregnancy outcomes.

Hypertensive disorders of pregnancy are associated with an inflammatory state: evidence from hematological findings and cytokine levels

Background

Abnormalities of blood cell counts and of cytokine profiles in women with hypertensive disorders of pregnancy (HDP) have been reported in several studies. Although their cause-effect relationships to HDP are not yet clear, detecting and monitoring these alterations can be of use for prognosis and management of HDP. This study aimed to determine hematological, coagulation and cytokine profiles in hypertensive as compared to normotensive pregnancy and to identify correlations between these profiles.

Methods

This was a hospital-based comparative cross-sectional study conducted from September 2017 to February 2018. There were two groups: the comparison group consisted of 77 normotensive pregnant women attending the antenatal clinic of Muhimbili National Hospital (MNH); the index group consisted of 76 hypertensive pregnant women admitted to the maternity block of the same hospital. Hematological and cytokine parameters were compared between the hypertensive and the normotensive group. We analyzed the data using Student’s independent t-test when the data were normally distributed; and the Mann–Whitney U-test when the data were not normally distributed. Kruskal Wallis with Dunn’s multiple comparison tests was run for subgroup analysis and correlation studies were done using Spearman ranking.

Results

Hemoglobin levels were slightly but significantly lower, (P < 0.01) in women with HDP compared to normotensive (N) women; the same was true for platelet counts (P < 0.001). The red cell distribution width (RDW) was slightly but significantly higher in HDP than in N. Neutrophil counts and Interleukin 6 (IL-6) levels were significantly (P < 0.001) higher in HDP than in N; and within HDP IL-6 levels increased with increasing severity of HDP. A novel remarkable finding was that eosinophil counts, normal in N, were lower and lower with increasing severity of HDP, to the point that they were nearly absent in women with eclampsia.

Conclusion

There are significant changes in hematological, cytokine and coagulation parameters in pregnant women with hypertensive disorders compared to normotensive pregnant women. The picture that emerges is that of an inflammatory state associated with hypertensive disorders of pregnancy.

Preeclampsia: Acute Complications and Management Priorities

Acute complications of preeclampsia contribute substantially to maternal and fetal morbidity and mortality. The considerable variation in onset, clinical presentation, and severity of this hypertensive disease that is unique to pregnancy creates challenges in identifying risk factors for clinical deterioration. Delivery of the fetus remains the only definitive treatment for preeclampsia. Surveillance of signs and symptoms and laboratory parameters consistent with progression in severity requires an appreciation of the dynamic and progressive nature of the disease. This article provides a comprehensive overview of the pathophysiology of preeclampsia, setting the foundation for discussion of management priorities for acute complications that pose the greatest risks to maternal health.

Circulating levels of prolactin are elevated in patients with rheumatoid arthritis: a meta-analysis

BACKGROUND

Prolactin (PRL), an inflammatory hormone with cytokine properties, has long been proposed to play a crucial role in the pathogenesis of autoimmune disorders, including rheumatoid arthritis (RA). However, the circulating levels of PRL in RA were discordant among published studies.

METHODS

PubMed, Embase, and The Cochrane Library database were systematically searched from inception up to 30 June 2018. The available studies were obtained from the initial search in accordance with the rigorous inclusion and exclusion criteria. Relevant data from the included literatures were extracted. Methodological quality was evaluated in order to refine the final search results. All statistical analyses were conducted using software STATA version 12.0.

RESULTS

Of 698 articles were yielded for eligibility, a finally analysis involving 628 RA cases and 430 controls from 14 published studies were included. When compared to healthy controls, there was a significantly higher level of circulating PRL in patients with RA with a pooled SMD of 1.08 (95% CI = 0.41 to 1.74, P< 0.001), particularly in Asians, age ≥50, enzyme-linked immunosorbent assay (ELISA) group and subjects with erythrocyte sedimentation rate (ESR) ≥25 mm/h.

CONCLUSIONS

Our meta-analysis demonstrates a significantly higher level of circulating PRL in RA patients when compared to healthy controls, and it was associated with region, age, measurement type and ESR.

Preeclampsia: Disease biology and burden, its management strategies with reference to India

Preeclampsia is the cause of significant maternal and fetal mortality and morbidity. It is characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. Preeclamptic women and children born from preeclamptic pregnancies are at greater risk to develop severe cardiovascular complications and metabolic syndromes later in life. The incidence of preeclampsia is estimated to be seven times higher in developing countries as compared to the developed countries. This review summarizes the pathophysiology of preeclampsia, emerging new hypothesis of its origin, risk factors that make women susceptible to developing preeclampsia and the potential of various biomarkers being studied to predict preeclampsia. The health care of developing countries is continuously challenged by substantial burden of maternal and fetal mortality. India despite being a fast developing country, is still far behind in achieving the required maternal mortality rates as per Millennium Development Goals set by the World Health Organization. Further, this review discusses the prevalence of preeclampsia in India, health facilities to manage preeclampsia, current guidelines and protocols followed and government policies to combat this complication in Indian condition.

Antigen Analysis of Pre-Eclamptic Plasma Antibodies Using Escherichia Coli Proteome Chips

Pre-eclampsia is one of the main causes of perinatal mortality and morbidity. Many biomarkers for diagnosing pre-eclampsia have been found but most have low accuracy. Therefore, a potential marker that can detect pre-eclampsia with high accuracy is required. Infection has been reported as a cause of pre-eclampsia. In recent years, protein microarray chips have been recognized as a strong and robust tool for profiling antibodies for infection diagnoses. The purpose of the present study was to profile antibodies in the human plasma of healthy and pre-eclamptic pregnancies to identify suitable biomarkers. In this study, an Escherichia coli chip was probed with samples from 29 individuals (16 pre-eclamptic women and 13 healthy pregnant women) to profile plasma antibodies. Bioinformatics tools were used to analyze the results, discover conserved motifs, compare against the entire human proteome, and perform protein functional analysis. An antibody classifier was identified using k-top scoring pairs and additional samples for a blinded test were collected. The findings indicated that compared with the healthy women, the pre-eclamptic women exhibited 108 and 130 differentially immunogenic proteins against human immunoglobulins G and M, respectively. In addition, pre-eclamptic women developed more immunoglobulin G but less immunoglobulin M against bacterial surface proteins compared with healthy women. The k-top scoring pairs identified five pairs of immunogenic proteins as classifiers with a high accuracy of 90% in the blind test. [AG] [ISV] GV [AE] L [LF] and [IV] [IV] RI [AG] [AD] E were the consensus motifs observed in immunogenic proteins in the immunoglobulin G and immunoglobulin M of pre-eclamptic women, respectively, whereas GA [AG] [AL] L [LF] and [SRY] [IQML] [ILV] [ILV] [ACG] GI [GH] [AEF] [AK] [ATY] [RG] N [IV] were observed in the immunoglobulins G and immunoglobulin M of healthy women, respectively.

Impact of IL-22 and IL-22 receptor alpha 1 polymorphisms on preeclampsia risk in Chinese Han women

Previous studies have indicated that an increased inflammatory response plays an important role in preeclampsia (PE), and rising levels of interleukin (IL)-22 can trigger inflammation and hyperproliferation, leading to increased production of several pro-inflammatory cytokines such as IL-1, IL-6, and IL-8. We aimed to investigate the association between polymorphisms of IL-22 and IL-22 receptor alpha 1 gene (IL-22RA1) and PE in Chinese Han population. Single nucleotide polymorphisms (SNPs) rs2227485 in IL-22 and rs3795299 in IL-22RA were genotyped by Taqman real-time PCR in 1071 PE patients and 1263 control subjects. Differences in genetic distribution were compared between two groups using the chi-square test. Significant differences were observed in genotypic and allelic frequencies of IL-22RA1 rs3795299 between healthy controls and PE patients (P < 0.001 by genotype; P = 0.001, odds ratio = 1.253, 95% confidence interval 1.103-1.424 by allele). There were also significant differences in genotypic and allelic frequencies of rs3795299 between late-onset/mild PE and control groups. In addition, we found obvious statistic difference for the allele of early-onset PE/the genotype of late-onset PE and control subgroups for IL-22 rs2227485. IL-22 rs2227485 and IL-22RA1 rs3795299 may be associated with the development of PE in Chinese Han population. However, further validation is required in other populations, as well as an evaluation of the association of other SNPs in IL-22 and IL-22RA1 with PE.

Bromodomain protein BRD4 is increased in human placentas from women with early-onset preeclampsia

Preeclampsia affects 5% of all pregnancies and is a serious disorder of pregnancy, characterised by high maternal blood pressure, placental hypoxia, fluid retention (oedema) and proteinuria. Women with preeclampsia are associated with exaggerated levels of pro-inflammatory cytokines, chemokines and anti-angiogenic factors such as soluble fms-like tyrosine kinase-1 (sFLT1). Studies in non-gestational tissues have described the bromodomain (BRD) and extraterminal family of proteins, in particular BRD4 to play a critical role in propagating inflammation and is currently a therapeutic target for treating cancer, lung inflammation and asthma. The aims of this study were to: (i) determine the effect of severe early-onset preeclampsia on placental BRD4 expression; (ii) the effect of loss of BRD4 function by siRNA-targeted knockdown or with the BRD inhibitor JQ1 in human primary trophoblast cells and human umbilical vein endothelial cells (HUVECs) on TNF-stimulated production of pro-inflammatory mediators, cell adhesion molecules and anti-angiogenic markers and (iii) the effect of BRD4 suppression on placental sFLT1 secretion under hypoxia conditions and in preeclampic placenta. BRD4 mRNA expression was significantly increased (sevenfold) in severe early-onset preeclampsia placenta. BRD4 silencing resulted in a significant reduction in TNF-induced IL6, CXCL8, CCL2, CXCL1 and sFLT1-e15a mRNA expression and IL6, CXCL8, CCL2, CXCL1 and sFLT1 secretion in primary trophoblast and HUVECs. Additionally, JQ1 treatment significantly reduced placental sFLT1 secretion under hypoxic conditions and in preterm preeclamptic placenta. In conclusion, these findings suggest BRD4 may play a central role in propagating inflammation and endothelial dysfunction associated with the pathophysiology of early-onset preeclampsia.

The association of pri-miRNA- 26a1 rs7372209 polymorphism and Preeclampsia susceptibility

MicroRNAs (miRNAs) are a class of noncoding small RNAs which regulate gene expression through post-transcriptional repression or degradation of messenger RNA. They play very important roles in various biological processes including growth, differentiation, and proliferation, as well as apoptosis, angiogenesis, and metabolism. Therefore, in the present study, we evaluated the possible effect of functional rs7372209C/T polymorphism in the 5'- region of pri-miRNA- 26a1gene on preeclampsia(PE) susceptibility. This case-control study was conducted on 219 PE women and 204 unrelated healthy controls. The amplification refractory mutation system-polymerase chain reaction method was used for rs7372209C/T genotyping. The pri-miRNA- 26a1 rs7372209CT genotype was associated with decreased PE risk (OR, 0.5 [95% CI, 0.3-0.8], P = 0.001). The frequency of rs7372209TT genotype did not differ between two groups. In addition, the pri-miRNA- 26a1 rs7372209 polymorphism was associated with lower risk of PE in dominant model (CT+TT vs CC) (OR, 0.5 [95% CI, 0.4-0.8], P = 0.002). Although there was no significant difference between mild and severe PE women according to rs7372209CT genotype, the differences between mild and severe PE groups with controls remained significant. The frequency of pri-miRNA-26a1 rs7372209CT genotype was not different between late-onset PE and early onset PE groups. The present study showed for the first time that the pri-miRNA- 26a1 rs7372209 polymorphism was associated with lower risk of mild and severe PE in the dominant model and this polymorphism could be a protective factor for PE susceptibility.

Persistence of risk factors associated with maternal cardiovascular disease following aberrant inflammation in rat pregnancy

Introduction

Pre-eclampsia is associated with increased risk of subsequent cardiovascular and metabolic disease in the affected mothers. While aberrant inflammation contributes to the pathophysiology of pre-eclampsia, it is unclear whether maternal inflammation contributes to the increased risk of disease. Here, we determined the effect of aberrant inflammation in pregnancy on cardiovascular and metabolic disease risk factors.

Methods

Wistar rats were administered low doses of lipopolysaccharide (LPS) on gestational days (GD) 13.5-16.5 to induce inflammation. Controls included pregnant rats treated with saline and nonpregnant rats treated with LPS or saline. We previously showed that LPS-treated pregnant rats exhibit key features of pre-eclampsia. Echocardiographic parameters, heart weight, blood pressure, blood lipids, pulse-wave velocity, and glucose tolerance, were assessed at 16 weeks postpartum. Messenger RNA levels of transcription factors associated with cardiac growth were measured in left ventricular tissue; histone modifications and global DNA methylation were determined in hearts and livers at GD 17.5 and at 16 weeks postpartum.

Results

Compared with saline-treated pregnant rats and nonpregnant rats treated with LPS or saline, LPS-treated pregnant rats exhibited left ventricular hypertrophy and increased blood cholesterol and low-density lipoprotein levels at 16 weeks postdelivery. LPS-treated rats had increased left ventricular mRNA levels of hypertrophy-associated transcription factors at GD 17.5 and increased levels of modified histones in hearts and livers at GD 17.5 and 16 weeks postpartum. Other parameters remained unchanged.

Conclusion

Aberrant inflammation during pregnancy results in persistent alterations in maternal physiological parameters and epigenetic modifications that could contribute to the pathophysiology of cardiovascular disease.

HSV infection is associated with gestational hypertension: results from the US National inpatient sample

The purpose of this study was to determine if there is an association between maternal herpes simplex virus (HSV) infection and pre-eclampsia/eclampsia or gestational hypertension. The US Nationwide Inpatient Sample database was searched for women aged 15–44 years who delivered in a hospital between 2005 and 2014. The patients were categorized into those with and without HSV and pre-eclampsia/eclampsia and gestational hypertension were compared between the groups. The analytic sample size (n=8 264 076) was equivalent to a population-based sample size of 40 653 030 patients. After adjusting for significant variables including age, race, income, insurance status, diabetes mellitus (DM), gestational DM, obesity, and multiple gestations, multivariate regression analysis indicated that HSV was associated with a higher OR for gestational hypertension (adjusted OR 1.038; 95% CI 1.004 to 1.072). However, HSV was not associated with pre-eclampsia/eclampsia (OR 1.001; 95% CI 0.968 to 1.035) in univariate regression analysis. The results of the current study suggest that HSV infection is associated with gestational hypertension but not pre-eclampsia. Given the prevalence of HSV infection and its potential association with hypertensive disorders of pregnancy, further study of HSV and hypertension in pregnancy is warranted.

Serum protein marker panel for predicting preeclampsia

BACKGROUND

Preeclampsia is a multi-system disorder in pregnancy which has no effective treatment. The diagnosis of preeclampsia is based on clinical presentation and routine laboratory tests.

OBJECTIVE

This study aimed at identifying serum protein markers for diagnosis of preeclampsia and predicting its severe features.

STUDY DESIGN

In total, 172 pregnant women were enrolled in this study including 110 subjects with preeclampsia and 62 normotensive subjects. Eleven serum proteins (VEGF, sFlt-1, sEndoglin, PlGF, sEGFR, prolactin, PTX3, PAI-1, NGAL, IL-27, COX-2) were assessed using Luminex multiplex immunoassay and ELISA.

RESULTS

The levels of seven proteins (sFlt-1, VEGF, sEndoglin, sEGFR, PlGF, NGAL, COX-2) correlated with preeclampsia, and 4 proteins (VEGF, sEndoglin, PlGF, sEGFR) were identified as independent factors associated with preeclampsia. The levels of three proteins (sEndoglin, PTX3, sFlt-1) correlated with severe features of preeclampsia, and three variables (serum creatinine, platelet count and sEndoglin) were identified as independent factors in predicting severe features of preeclampsia.

CONCLUSIONS

A combination of serum protein markers (VEGF, sEndoglin, PlGF, sEGFR) and clinical variables (serum creatinine, platelet count and sEndoglin) could be used as analytical tool in diagnosis of preeclampsia and its severe features, respectively. Serum sEGFR, a novel biomarker in preeclampsia, may be involved in the pathogenesis of preeclampsia.

Lipid profile and cytokines in hypertension of pregnancy: A comparison of preeclampsia therapies

Hypertensive disorders complicating pregnancy can be classified as gestational hypertension, mild preeclampsia, and severe preeclampsia. It is necessary to evaluate and predict the grade in advance. The first study comprised 40 healthy pregnancies, 40 gestational hypertension, 40 mild preeclampsia, and 40 severe preeclampsia cases. The participants' lipid profile and cytokine levels were statistically compared. The efficacy and safety of oral nifedipine (n = 71) and intravenous labetalol (n = 72) for the treatment of severe preeclampsia were evaluated in the next study according to maternal and neonatal outcomes. The levels of lipid profile and cytokines were linked with the presence and severity of hypertensive disorders complicating pregnancy. Both oral nifedipine and intravenous labetalol are effective for safely reducing blood pressure to target levels in patients with severe preeclampsia. Our study suggests that lipid profile and cytokines can be used in the evaluation of the severity of hypertensive disorders complicating pregnancy, and oral nifedipine requires more study.

Immunohaemostasis: a new view on haemostasis during sepsis

Host infection by a micro-organism triggers systemic inflammation, innate immunity and complement pathways, but also haemostasis activation. The role of thrombin and fibrin generation in host defence is now recognised, and thrombin has become a partner for survival, while it was seen only as one of the "principal suspects" of multiple organ failure and death during septic shock. This review is first focused on pathophysiology. The role of contact activation system, polyphosphates and neutrophil extracellular traps has emerged, offering new potential therapeutic targets. Interestingly, newly recognised host defence peptides (HDPs), derived from thrombin and other "coagulation" factors, are potent inhibitors of bacterial growth. Inhibition of thrombin generation could promote bacterial growth, while HDPs could become novel therapeutic agents against pathogens when resistance to conventional therapies grows. In a second part, we focused on sepsis-induced coagulopathy diagnostic challenge and stratification from "adaptive" haemostasis to "noxious" disseminated intravascular coagulation (DIC) either thrombotic or haemorrhagic. Besides usual coagulation tests, we discussed cellular haemostasis assessment including neutrophil, platelet and endothelial cell activation. Then, we examined therapeutic opportunities to prevent or to reduce "excess" thrombin generation, while preserving "adaptive" haemostasis. The fail of international randomised trials involving anticoagulants during septic shock may modify the hypothesis considering the end of haemostasis as a target to improve survival. On the one hand, patients at low risk of mortality may not be treated to preserve "immunothrombosis" as a defence when, on the other hand, patients at high risk with patent excess thrombin and fibrin generation could benefit from available (antithrombin, soluble thrombomodulin) or ongoing (FXI and FXII inhibitors) therapies. We propose to better assess coagulation response during infection by an improved knowledge of pathophysiology and systematic testing including determination of DIC scores. This is one of the clues to allocate the right treatment for the right patient at the right moment.

Circulating soluble endoglin modifies the inflammatory response in mice

Inflammation is associated with every health condition, and is an important component of many pathologies such as cardiovascular diseases. Circulating levels of soluble endoglin have been shown to be higher in the serum of patients with cardiovascular diseases with a significant inflammatory component. The aim of this study was to evaluate the implication of circulating soluble endoglin in the inflammatory response. For this purpose, a transgenic mouse expressing human soluble endoglin (sEng+) was employed, and three different inflammatory approaches were used to mimic inflammatory conditions in different tissues. This study shows that control sEng+ mice have a normal inflammatory state. The lung and kidney injury induced by the inflammatory agents was reduced in sEng+ mice, especially the intra-alveolar and kidney infiltrates, suggesting a possible reduction in inflammation induced by soluble endoglin. To deepen into this possible effect, the leukocyte number in the bronchoalveolar lavage and air pouch lavage was evaluated and a significant reduction of neutrophil infiltration in LPS-treated lungs and ischemic kidneys from sEng+ with respect to WT mice was observed. Additionally, the mechanisms through which soluble endoglin prevents inflammation were studied. We found that in sEng+ animals the increment of proinflammatory cytokines, TNFα, IL1β and IL6, induced by the inflammatory stimulus was reduced. Soluble endoglin also prevents the augmented adhesion molecules, ICAM, VCAM and E-selectin induced by the inflammatory stimulus. In addition, vascular permeability increased by inflammatory agents was also reduced by soluble endoglin. These results suggest that soluble endoglin modulates inflammatory-related diseases and open new perspectives leading to the development of novel and targeted approaches for the prevention and treatment of cardiovascular diseases.

Influence of serum HMW adiponectin level in patients with pregnancy-induced hypertension syndrome on the occurrence of eclampsia in secondary pregnancy

In the present study, we studied the influence of serum high-molecular weight adiponectin (HMWA) levels in patients with pregnancy-induced hypertension (PIH) on the occurrence of eclampsia in secondary pregnancy and its related mechanisms. In total, 130 patients who were diagnosed with PIH for the first time were selected for this study; the median interval of the secondary pregnancy was 28.5 months. The serum HMWA and leptin levels both times were detected, and the insulin resistance indexes (HOMA-IR) were calculated. The serum inflammatory indexes in the secondary pregnancy included interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) levels, and the oxidative stress indexes included methane dicarboxylic aldehyde (MDA) and oxidized low-density lipoprotein (ox-LDL) levels. The expression levels of adiponectin receptor 2 and cyclooxygenase-2 (COX-2) in placental tissue were detected. In secondary pregnancy, there were a total of 20 cases of eclampsia (15.38%), including 2 cases of mild PIH, 8 cases of moderate PIH and 10 cases of severe PIH; differences were statistically significant when compared to patients without eclampsia (p<0.001). The serum HMWA levels in patients with severe PIH in the first pregnancy were significantly lower than those in patients with mild and moderate PIH, and the serum levels in patients with mild PIH were the highest. The leptin levels in patients with severe PIH were significantly higher than those in patients with mild and moderate PIH, and the leptin levels in patients with mild PIH were the lowest (p<0.05). The HMWA levels in patients with eclampsia in the secondary pregnancy was significantly lower than those in patients without eclampsia, and the leptin levels in patients with eclampsia were significantly increased. The HMWA levels in patients with eclampsia in the secondary pregnancy were lower than that in the first pregnancy, whereas the leptin levels were higher than that in the first pregnancy (p<0.05). HOMA-IR, IL-6, TNF-α, MDA and ox-LDL levels in patients with eclampsia were significantly higher than those in patients without eclampsia (p<0.05), and the adiponectin receptor 2 and COX-2 expression levels in the placental tissue were significantly higher than those in patients without eclampsia (p<0.05). Therefore, the serum HMWA levels are closely related to the occurrence of eclampsia in PIH patients in secondary pregnancy, and it influences insulin resistance, inflammatory response and oxidative stress response, which is correlated with increased adiponectin receptor 2 and COX-2 protein expression in placental tissue. Consequently, HMWA may be an important target for the intervention of preventing eclampsia for PIH patients in secondary pregnancy.

MicroRNA-146a rs2910164 is associated with severe preeclampsia in Black South African women on HAART

BACKGROUND

South African (SA) Black women have a high prevalence of preeclampsia and HIV, both conditions associated with increased inflammation. miR-146a is an inflammatory-associated miR and a common single nucleotide polymorphism (rs2910164) has been associated with several disease conditions. To date, this SNP has not been investigated in SA Black women. We therefore aimed to investigate the miR-146a G > C SNP in SA Blacks with preeclampsia, and further examine possible association among preeclamptic (PE) women with HIV infection on HAART.

METHODS

This hospital-based, case-control study included 95 normotensive and 98 PE Black SA women (aged 16-46 years old). Patients and controls were genotyped by PCR-RFLP. Using a Cytometric Bead Array assay, serum cytokine levels (including Th1- and Th2-related cytokines) were determined in 4 groups of pregnant women, viz: normotensive, HIV infected, PE + HIV infected, and PE women.

RESULTS

There was no significant association between the miR-146a polymorphism and PE susceptibility in our data. However, in the subgroup analyses, the variant genotypes (GC/CC) were significantly associated with lower severe PE risk (p = 0.0497), more especially in the presence of HIV and HAART (p = 0.017). In the normotensive group, the variant genotypes were associated with lower IL-2 in both the total normotensive group (269 ± 1.26 (36) vs 273 ± 1.31 (23); p = 0.035) and the PE HIV+ sub-group 265 ± 1.54 (19) vs 271 ± 1.38 (11); p = 0.008).

CONCLUSIONS

Our study suggests that miR-146a rs2910164 polymorphism might not be associated with PE susceptibility, cytokines or related features. However, the miR-146a GC/CC genotype might reduce susceptibility to severe PE, which might be further influenced by the presence of co-morbid HIV infection among pregnant women on HAART. This variant genotype may also be associated with reduced circulating IL-2 levels and thus reduced pro-inflammatory response in normotensive women, which may be further influenced by the presence of HIV infection and HAART.

Effect of a small dose of aspirin on quantitative test of 24-h urinary protein in patients with hypertension in pregnancy

The aim of the present study was to determine the effect of a small dose of aspirin on a quantitative test of 24-h urinary protein in patients with hypertension in pregnancy. In total, 224 patients with hypertension in pregnancy were continuously selected and were randomly divided into the control group (50 cases with conventional therapy), aspirin 50 mg/day group (60 cases), aspirin 75 mg/day group (58 cases), and aspirin 100 mg/day group (56 cases). Clinical effects were compared from 16 gestational weeks to childbirth. According to the comparison in the four groups, there was no statistical difference in the mean arterial pressure, pre-eclampsia rate, gestational weeks, and caesarean section rate (p>0.05). The 24-h urinary protein and endothelin-1 (ET-1) level were significantly decreased following treatment, and were less than the control and 50 mg/day groups. The superoxide dismutase (SOD) level was significantly increased, and higher than the control and 50 mg/day groups. In terms of the 75 and 100 mg/day, control and 50 mg/day groups, there was no statistical difference (p>0.05). A comparison of the complication rate in the four groups of fetuses during the perinatal period, no statistical difference was observed (p>0.05). Thus, the results show that, regarding patients with hypertension in pregnancy, 75 mg/day aspirin can decrease the 24-h urinary protein, SOD, and ET-1 level. However, the results remain to be confirmed to improve maternal and infant outcome in delivery.

Relationship of Liver X Receptors α and Endoglin Levels in Serum and Placenta with Preeclampsia

Background

Liver X receptor alpha (LXRα) and endoglin have been postulated to play roles in trophoblast invasion and lipid metabolic disturbances. However, the relationship between LXRα and endoglin levels in serum and placenta of patients with preeclampsia remains poorly understood. The objective of this study was to identify correlations between LXRα, endoglin and preeclampsia and provide new feasible methods of clinical prediction and treatment for preeclampsia.

Methods

We enrolled 45 patients with preeclampsia (24 with moderate preeclampsia and 21 with severe preeclampsia) and 15 normal pregnant women (control group) who were admitted to the Department of Obstetrics of the General Hospital of Beijing Command between October 2012 and July 2013 in this study. Serum and placental LXRα and endoglin levels were analyzed by enzyme-linked immunosorbent assay, real-time quantitative PCR, tissue microarray and immunohistochemistry.

Results

Serum and placental LXRα and endoglin levels were significantly higher in patients with preeclampsia than those in control group (P<0.05, each). Moreover, patients with severe preeclampsia displayed significantly higher LXRα and endoglin levels than those with moderate preeclampsia (P<0.05, each). The LXRα sensitivity, specificity and positive and negative predictive values were 66.00%, 80.00%, 89.19% and 48.48%, respectively, while those of endoglin levels were 62.00%, 85.00%, 91.18% and 47.22%, respectively. LXRα and endoglin levels in serum and placenta from patients with preeclampsia were positively correlated (serum: r = 0.486, P<0.01; placenta: r = 0.569, P<0.01).

Conclusions

Elevated LXRα and endoglin levels may be associated with preeclampsia pathogenesis and development and could be used as potential predictors for this disorder.

Lipoxin A4 Is Increased in the Plasma of Preeclamptic Women

BACKGROUND

Excessive inflammation is involved in preeclampsia (PE) pathogenesis. Lipoxin A4 (LXA4) is an eicosanoid that counter-regulates inflammation. The main objective of this study was to determine LXA4 plasma levels in PE women. The correlations among LXA4 levels, ultrasensitive C-reactive protein (us-CRP) levels, and clinical/laboratory parameters of the studied participants were also investigated.

METHODS

LXA4 plasma levels were determined by ELISA in 23 nonpregnant, 26 normotensive pregnant, and 27 PE women (early PE (N = 10) and late PE (N = 17)), according to gestational age (GA) at clinical symptoms onset). The clinical/laboratory parameters included in Spearman's correlation analysis were: systolic and diastolic blood pressure (SBP and DBP, respectively), lactate dehydrogenase (LDH) activity, platelet count, proteinuria, and white blood cell count (WBC).

RESULTS

LXA4 levels were higher in PE women than in nonpregnant and normotensive pregnant women, and similar between nonpregnant and normotensive pregnant women. LXA4 plasma levels were higher in early PE vs. normotensive pregnancy (GA < 34 weeks) and in late PE vs. normotensive pregnancy (GA ≥ 34 weeks). No significant differences were detected between early and late PE. LXA4 levels were positively correlated with us-CRP levels, SBP, DBP, and WBC. No significant correlation was detected between LXA4 levels and the other laboratory parameters.

CONCLUSIONS

Chronic inflammation in PE, in spite of increased levels of LXA4, points to a possible failure in this regulatory pathway. Further studies are necessary to clarify this issue and to evaluate the role of LXA4 and other proresolving mediators of inflammation in the pathogenesis of PE.

Experience of Preeclampsia and Bed Rest: Mental Health Implications

Preeclampsia is a major cause of maternal and fetal morbidity and mortality affecting 5-10% of pregnancies. Mental health issues are often exhibited in this vulnerable population partly due to the rigid management of this condition including prolonged bed rest. The purpose of this qualitative study is to describe women's experience with preeclampsia and being placed on bed rest. Six themes emerged including: negative feelings and thoughts, lack of guidelines about their diagnosis, family stressors, lack of social support, not being heard, loss of normal pregnancy, and physical symptoms. The identified categories provide insight into improving care for these women.

The role of the prolactin/vasoinhibin axis in rheumatoid arthritis: an integrative overview

Rheumatoid arthritis (RA) is a chronic, autoimmune, inflammatory disease destroying articular cartilage and bone. The female preponderance and the influence of reproductive states in RA have long linked this disease to sexually dimorphic, reproductive hormones such as prolactin (PRL). PRL has immune-enhancing properties and increases in the circulation of some patients with RA. However, PRL also suppresses the immune system, stimulates the formation and survival of joint tissues, acquires antiangiogenic properties upon its cleavage to vasoinhibins, and protects against joint destruction and inflammation in the adjuvant-induced model of RA. This review addresses risk factors for RA linked to PRL, the effects of PRL and vasoinhibins on joint tissues, blood vessels, and immune cells, and the clinical and experimental data associating PRL with RA. This information provides important insights into the pathophysiology of RA and highlights protective actions of the PRL/vasoinhibin axis that could lead to therapeutic benefits.

Safety and pharmacokinetics of pravastatin used for the prevention of preeclampsia in high-risk pregnant women: a pilot randomized controlled trial

BACKGROUND

Preeclampsia complicates approximately 3-5% of pregnancies and remains a major cause of maternal and neonatal morbidity and mortality. It shares pathogenic similarities with adult cardiovascular disease as well as many risk factors. Pravastatin, a hydrophilic, 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitor, has been shown in preclinical studies to reverse various pathophysiological pathways associated with preeclampsia, providing biological plausibility for its use for preeclampsia prevention. However, human trials are lacking.

OBJECTIVE

As an initial step in evaluating the utility of pravastatin in preventing preeclampsia and after consultation with the US Food and Drug Administration, we undertook a pilot randomized controlled trial with the objective to determine pravastatin safety and pharmacokinetic parameters when used in pregnant women at high risk of preeclampsia.

STUDY DESIGN

We conducted a pilot, multicenter, double-blind, placebo-controlled, randomized trial of women with singleton, nonanomalous pregnancies at high risk for preeclampsia. Women between 12(0/7) and 16(6/7) weeks' gestation were assigned to daily pravastatin 10 mg or placebo orally until delivery. Primary outcomes were maternal-fetal safety and pharmacokinetic parameters of pravastatin during pregnancy. Secondary outcomes included rates of preeclampsia and preterm delivery, gestational age at delivery, birthweight, and maternal and cord blood lipid profile (clinicaltrials.gov identifier NCT01717586).

RESULTS

Ten women assigned to pravastatin and 10 to placebo completed the trial. There were no differences between the 2 groups in rates of study drug side effects, congenital anomalies, or other adverse or serious adverse events. There was no maternal, fetal, or neonatal death. Pravastatin renal clearance was significantly higher in pregnancy compared with postpartum. Four subjects in the placebo group developed preeclampsia compared with none in the pravastatin group. Although pravastatin reduced maternal cholesterol concentrations, umbilical cord cholesterol concentrations and infant birthweight were not different between the groups. The majority of umbilical cord and maternal pravastatin plasma concentrations at the time of delivery were below the lower limit of quantification of the assay. Pravastatin use was associated with a more favorable pregnancy angiogenic profile.

CONCLUSION

This study provides preliminary safety and pharmacokinetic data regarding the use of pravastatin for preventing preeclampsia in high-risk pregnant women. Although the data are preliminary, no identifiable safety risks were associated with pravastatin use in this cohort. This favorable risk-benefit analysis justifies using pravastatin in a larger clinical trial with dose escalation.

Differences in Liver Injury and Trophoblastic Mitochondrial Damage in Different Preeclampsia-like Mouse Models

Background:

Preeclampsia is a multifactorial disease during pregnancy. Dysregulated lipid metabolism may be related to some preeclampsia. We investigated the relationship between triglycerides (TGs) and liver injury in different preeclampsia-like mouse models and their potential common pathways.

Methods:

Preeclampsia-like models (Nw-nitro-L-arginine-methyl ester [L-NAME], lipopolysaccharide [LPS], apolipoprotein C-III [Apo] transgnic mice + L-NAME, β2 glycoprotein I [βGPI]) were used in four experimental groups: L-NAME (LN), LPS, Apo-LN and βGPI, respectively, and controls received saline (LN-C, LPS-C, Apo-C, βGPI-C). The first three models were established in preimplantation (PI), early-, mid- and late-gestation (EG, MG and LG). βGPI and controls were injected before implantation. Mean arterial pressure (MAP), 24-hour urine protein, placental and fetal weight, serum TGs, total cholesterol (TC) and pathologic liver and trophocyte changes were assessed.

Results:

MAP and proteinuria were significantly increased in the experimental groups. Placenta and fetal weight in PI, EP and MP subgroups were significantly lower than LP. Serum TGs significantly increased in most groups but controls. TC was not different between experimental and control groups. Spotty hepatic cell necrosis was observed in PI, EG, MG in LN, Apo-LN and βGPI, but no morphologic changes were observed in the LPS group. Similar trophoblastic mitochondrial damage was observed in every experimental group.

Conclusions:

Earlier preeclampsia onset causes a higher MAP and urine protein level, and more severe placental and fetal damage. Preeclampsia-like models generated by varied means lead to different changes in lipid metabolism and associated with liver injury. Trophoblastic mitochondrial damage may be the common terminal pathway in different preeclampsia-like models.

Evaluation of maternal systemic inflammatory response in preeclampsia

OBJECTIVE

To evaluate the systemic inflammatory response in preeclampsia compared to normal pregnancy.

MATERIALS AND METHODS

The following serum parameters were determined in three groups of patients: leukocytes, neutrophils, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), C-reactive protein (CRP), and certain markers of oxidative stress. Fetal status was assessed based on the gestational age at which birth occurred, on the Apgar score, and on fetal weight.

RESULTS

In preeclampsia, a higher systemic inflammatory status was found compared to normal pregnancy. Gestational age at birth, fetal weight, and Apgar score were significantly lower in the group with preeclampsia compared to normal pregnancy.

CONCLUSION

In preeclampsia, there is an increased systemic inflammatory response compared to normal pregnancy, which can influence fetal status at birth.

Unravelling the theories of pre-eclampsia: are the protective pathways the new paradigm?

Pre-eclampsia is a vascular disorder of pregnancy where anti-angiogenic factors, systemic inflammation and oxidative stress predominate, but none can claim to cause pre-eclampsia. This review provides an alternative to the ‘two-stage model’ of pre-eclampsia in which abnormal spiral arteries modification leads to placental hypoxia, oxidative stress and aberrant maternal systemic inflammation. Very high maternal soluble fms-like tyrosine kinase-1 (sFlt-1 also known as sVEGFR) and very low placenta growth factor (PlGF) are unique to pre-eclampsia; however, abnormal spiral arteries and excessive inflammation are also prevalent in other placental disorders. Metaphorically speaking, pregnancy can be viewed as a car with an accelerator and brakes, where inflammation, oxidative stress and an imbalance in the angiogenic milieu act as the ‘accelerator’. The ‘braking system’ includes the protective pathways of haem oxygenase 1 (also referred as Hmox1 or HO-1) and cystathionine-γ-lyase (also known as CSE or Cth), which generate carbon monoxide (CO) and hydrogen sulphide (H₂S) respectively. The failure in these pathways (brakes) results in the pregnancy going out of control and the system crashing. Put simply, pre-eclampsia is an accelerator–brake defect disorder. CO and H₂S hold great promise because of their unique ability to suppress the anti-angiogenic factors sFlt-1 and soluble endoglin as well as to promote PlGF and endothelial NOS activity. The key to finding a cure lies in the identification of cheap, safe and effective drugs that induce the braking system to keep the pregnancy vehicle on track past the finishing line.

Evidence-Based Revised View of the Pathophysiology of Preeclampsia

Preeclampsia is a life-threatening vascular disorder of pregnancy due to a failing stressed placenta. Millions of women risk death to give birth each year and globally each year, almost 300,000 lose their life in this process and over 500,000 babies die as a consequence of preeclampsia. Despite decades of research, we lack pharmacological agents to treat it. Maternal endothelial oxidative stress is a central phenomenon responsible for the preeclampsia phenotype of high maternal blood pressure and proteinuria. In 1997, it was proposed that preeclampsia arises due to the loss of VEGF activity, possibly due to elevation in anti-angiogenic factor, soluble Flt-1 (sFlt-1). Researchers showed that high sFlt-1 and soluble endoglin (sEng) elicit the severe preeclampsia phenotype in pregnant rodents. We demonstrated that heme oxygenase-1 (HO-1)/carbon monoxide (CO) pathway prevents placental stress and suppresses sFlt-1 and sEng release. Likewise, hydrogen sulphide (H₂S)/cystathionine-γ-lyase (Cth) systems limit sFlt-1 and sEng and protect against the preeclampsia phenotype in mice. Importantly, H₂S restores placental vasculature, and in doing so improves lagging fetal growth. These molecules act as the inhibitor systems in pregnancy and when they fail, preeclampsia is triggered. In this review, we discuss what are the hypotheses and models for the pathophysiology of preeclampsia on the basis of Bradford Hill causation criteria for disease causation and how further in vivo experimentation is needed to establish 'proof of principle'. Hypotheses that fail to meet the Bradford Hill causation criteria include abnormal spiral artery remodelling and inflammation and should be considered associated or consequential to the disorder. In contrast, the protection against cellular stress hypothesis that states that the protective pathways mitigate cellular stress by limiting elevation of anti-angiogenic factors or oxidative stress and the subsequent clinical signs of preeclampsia appear to fulfil most of Bradford Hill causation criteria. Identifying the candidates on the roadmap to this pathway is essential in developing diagnostics and therapeutics to target the pathogenesis of preeclampsia.

Complement Split Products C3a/C5a and Receptors: Are They Regulated by Circulating Angiotensin II Type 1 Receptor Autoantibody in Severe Preeclampsia?

BACKGROUND

This study measured the serum levels of complement component (C)3a and C5a and the placental expressions of C3a receptor (R) and C5aR to determine a potential correlation with circulating angiotensin II type 1 (AT1) receptor agonistic autoantibody (AT1-AA) in severe pre-eclampsia.

METHODS

A total of 118 women were recruited and divided into 2 groups: the control group (normotensive preterm pregnancies, n = 66) and severe pre-eclampsia group (n = 52). Levels of C3a, C5a and AT1-AA in serum were measured by enzyme-linked immunosorbent assay and C3aR and C5aR in placenta by Western blotting.

RESULTS

Levels of C3a, C5a and AT1-AA in serum from the severe pre-eclampsia group were significantly higher than in controls (p < 0.05). Placental expression of C3aR and C5aR in the pre-eclampsia group was lower than that in controls (p < 0.05). There were significant positive correlations between levels of C3a, C5a and AT1-AA in serum from the pre-eclampsia group (p < 0.05). In contrast, there was no correlation between C3aR and C5aR in the placenta and AT1-AA in serum in the pre-eclampsia group (p > 0.05).

CONCLUSION

Increased C3a, C5a and AT1-AA in the serum provide indirect evidence that AT1-AA-mediated activation contributes to activate complement, which is a key mechanism underlying the pathogenesis of severe pre-eclampsia.

Heme oxygenase and the immune system in normal and pathological pregnancies

Normal pregnancy is an immunotolerant state. Many factors, including environmental, socioeconomic, genetic, and immunologic changes by infection and/or other causes of inflammation, may contribute to inter-individual differences resulting in a normal or pathologic pregnancy. In particular, imbalances in the immune system can cause many pregnancy-related diseases, such as infertility, abortions, pre-eclampsia, and preterm labor, which result in maternal/fetal death, prematurity, or small-for-gestational age newborns. New findings imply that myeloid regulatory cells and regulatory T cells (Tregs) may mediate immunotolerance during normal pregnancy. Effector T cells (Teffs) have, in contrast, been implicated to cause adverse pregnancy outcomes. Furthermore, feto-maternal tolerance affects the developing fetus. It has been shown that the Treg/Teff balance affects litter size and adoptive transfer of pregnancy-induced Tregs can prevent fetal rejection in the mouse. Heme oxygenase-1 (HO-1) has a protective role in many conditions through its anti-inflammatory, anti-apoptotic, antioxidative, and anti-proliferative actions. HO-1 is highly expressed in the placenta and plays a role in angiogenesis and placental vascular development and in regulating vascular tone in pregnancy. In addition, HO-1 is a major regulator of immune homeostasis by mediating crosstalk between innate and adaptive immune systems. Moreover, HO-1 can inhibit inflammation-induced phenotypic maturation of immune effector cells and pro-inflammatory cytokine secretion and promote anti-inflammatory cytokine production. HO-1 may also be associated with T-cell activation and can limit immune-based tissue injury by promoting Treg suppression of effector responses. Thus, HO-1 and its byproducts may protect against pregnancy complications by its immunomodulatory effects, and the regulation of HO-1 or its downstream effects has the potential to prevent or treat pregnancy complications and prematurity.