The pathophysiology of pre-eclampsia: Current clinical concepts

The effects of proton pump inhibitors during pregnancy on treatment of preeclampsia and related outcomes: a systematic review and meta-analysis

OBJECTIVE

This systematic review evaluated the available evidence on the effects of proton pump inhibitors during pregnancy on preeclampsia and related maternal, fetal, and neonatal outcomes.

DATA SOURCES

Five electronic databases (MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and Global Medicus Index) were searched on November 17, 2023.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials of pregnant women who used any class or dose of proton pump inhibitor were eligible.

METHODS

A meta-analysis was conducted for all outcomes of interest using random-effects models. Results were presented as risk ratios or mean difference. Quality assessment was performed using the Risk of Bias 2 tool, and Grading of Recommendations, Assessment, Development, and Evaluations assessment was completed to evaluate the certainty of the evidence. The study was registered in the International Prospective Register of Systematic Reviews under identifier CRD42023423673.

RESULTS

Our search identified 3879 records that were screened independently by 2 authors. Nine reports (describing 8 trials) met our eligibility criteria, however, 6 trials were ultimately excluded from our analysis because women were only given proton pump inhibitors immediately before cesarean delivery for acid aspiration prevention. The 2 trials that were included in the meta-analysis evaluated the treatment of 177 women with diagnosed preeclampsia. For the primary outcomes, moderate-certainty evidence showed that the use of proton pump inhibitors likely has no effect on the risk for hemolysis, elevated liver enzymes, and low platelet count syndrome (risk ratio, 1.21; 95% confidence interval, 0.37-3.99; I²=0%) or perinatal mortality (risk ratio, 0.81; 95% confidence interval, 0.36-1.79; I²=0%), and there were insufficient data to conduct a meta-analysis on all other primary outcomes, including eclampsia and neonatal mortality. No trials investigated the use of proton pump inhibitors for the prevention of preeclampsia.

CONCLUSION

Given the limited outcome data, we are uncertain about the effect of proton pump inhibitors on women with preeclampsia. Further trials are required to determine what (if any) effects proton pump inhibitors might have for preeclampsia prevention or treatment.

Correlation of Serum Cancer Antigen-125 (CA-125) Levels with Severity of Pre-eclampsia

Background

Pre-eclampsia is often associated with unfavourable feto-maternal outcomes. There is a lacuna in its pathophysiology, which emphasizes the need to research for tests, which can predict or correlate with the severity of pre-eclampsia. Cancer antigen-125 (CA-125) is a simple, readily available biomarker with evidence of its secretion at the choriodecidual unit and may have a possible role. This study compared serum CA-125 levels between normal pregnant and pre-eclamptic women and determined its clinical usefulness in correlating with the severity of pre-eclampsia.

Methods

A case-control study was conducted enrolling 58 women with pre-eclampsia further divided into severe and non-severe groups and 62 gestational age-matched healthy, pregnant controls. Serum CA-125 levels were compared between the two groups.

Results

The mean serum CA-125 in the controls was 16.44 ± 8.28 IU/ml, 13.82 ± 9.18 IU/ml in the non-severe and 23.55 ± 30.55 IU/ml in the severe pre-eclampsia group (p = 0.134). Serum CA-125 had a significant association with systolic blood pressure (SBP) p = 0.002), diastolic blood pressure (DBP) (p = 0.026), foetal growth restriction (p = 0.025), pre-term birth (p = 0.039) and a highly significant association with 24-h urinary protein, liver enzymes, placental abruption, need of maternal intensive care as well as with poor neonatal outcome including stillbirth and neonatal mortality (p < 0.001).

Conclusion

Serum CA-125 levels were found to be higher in the severe pre-eclampsia group as compared to non-severe pre-eclampsia and normotensive group, but the difference was not statistically significant. More studies on a larger scale are required to prove the usefulness of this marker with respect to maternal and perinatal outcome as well as its association with pre-eclampsia and its severity.

The Effect of Sickle Cell Hemoglobinopathy on Pregnancy, Labor, Puerperium, and Fetal Outcome: A Retrospective Cohort Study From a Single Centre

INTRODUCTION

Sickle cell disease (SCD) is a major risk factor as far as pregnancy and obstetric complications are concerned. It possesses major perinatal and postnatal mortality. The management of pregnancy along with SCD requires a multispecialty team consisting of hematologists, obstetricians, anesthesiologists, neonatologists and intensivists.

OBJECTIVES

The objective of this study was to investigate the effect of sickle cell hemoglobinopathy on pregnancy, labor, puerperium, and fetal outcome in the rural and urban localities of Maharashtra, India.

MATERIAL AND METHODS

The present study is a comparative retrospective analysis of 225 pregnant women with SCD (genotype AS and SS) and 100 age- and gravida-matched pregnant women with normal hemoglobin (genotype AA) as a control who were treated between June 2013 to June 2015, in Indira Gandhi Government Medical College (IGGMC), Nagpur, India. We analyzed various data regarding obstetrical outcomes and complications in sickle cell disease mothers.

RESULTS

Out of 225 pregnant women, 38 (16.89%) were diagnosed with homozygous sickle cell disease (SS group) while 187 (83.11%) were diagnosed with sickle cell trait (AS group). The most common antenatal complications were sickle cell crisis (17; 44.74%) and jaundice (15; 39.47%) in the SS group whereas pregnancy-induced hypertension (PIH) was noted in 33 (17.65%) in the AS group. Intrauterine growth restriction (IUGR) was recorded in 57.89% of the SS group and 21.39% of the AS group. A higher chance of emergency lower segment cesarean section (LSCS; 66.67% in the SS group and 79.09% in the AS group) was recorded as compared with the control group at 32%.

CONCLUSION

In order to minimize risks to the mother and fetus and for better outcomes it is prudent to manage pregnancy with SCD vigilantly in the antenatal period. In the antenatal period mothers with this disease should be screened for hydrops or bleeding manifestations such as intracerebral hemorrhage in the fetus. Better feto-maternal outcomes can be achieved by effective multispecialty intervention.

Maternal tumour necrosis factor-alpha levels in preeclamptic pregnancies in Lagos, South-West Nigeria

OBJECTIVE

This study aimed to assess the association between maternal serum levels of TNF-α and preeclampsia.

METHODS

An analytical cross-sectional study involving 45 women diagnosed with preeclampsia and 45 healthy normotensive pregnant women matched for age, and gestational age at enrolment. Venous samples were collected from each participant after informed consent was obtained. Serum TNF-α level was determined using the human TNF-α competitive enzyme-linked immunosorbent assay (ELISA) technique with ELISA Kit. Hypothesis testing was done using the Chi-square test for categorical variables, the independent samples t-test and the Kruskal-Wallis test for numerical variables. All significances were reported at P < 0.05.

RESULTS

The median concentrations of TNF-α in women with preeclampsia of varying severity were significantly higher than those with normotensive pregnancies (P = 0.001). The median level of TNF-α was also significantly higher in patients with severe features of preeclampsia than in those without. The estimated cut-off levels of serum TNF-α were 15.6 ng/mL and 26.4 ng/mL respectively for the development and severity of preeclampsia. Maternal serum TNF-α level in preeclamptic patients is strongly correlated with systolic and diastolic BP, serum uric acid and alkaline phosphatase levels, proteinuria, and platelet count (P < 0.05).

CONCLUSION

We can infer from this study that increased maternal serum levels of TNF-α may play a significant role in the pathogenesis of preeclampsia. We recommend further validation of these findings with a more robust longitudinal characterization of maternal serum TNF-α profiles in pregnancy through a well-designed prospective cohort study.

Are alterations in estradiol, cortisol, and inflammatory cytokines associated with depression during pregnancy and postpartum? An exploratory study

Background

Pregnant veterans are a subpopulation known to be at elevated risk of developing mental health symptoms, such as depression and suicidal ideation. Inflammation has been associated with depression, specifically during the perinatal period. Critical changes in estradiol, cortisol, and inflammatory cytokines are necessary for the progression of a healthy pregnancy, which are then rapidly altered in the postpartum period. We explored changes in estradiol, cortisol, and pro-inflammatory cytokines relative to depressive symptoms and suicidal thoughts across pregnancy and postpartum in this pilot and feasibility study.

Methods

We measured estradiol, cortisol, and the inflammatory cytokines IL-1β, IL-6, IL-8, IFN-γ, and TNF-α in 18 pregnant veterans and analyzed the data using descriptive statistics, dependent t-tests, and correlation analyses. We assessed depression severity with the Edinburgh Postnatal Depression Scale and suicidality with the Columbia-Suicide Severity Rating Scale. Thirteen of the women repeated assessments in the early postpartum period at an average of 6.7 weeks after birth.

Results

As anticipated, estradiol (t(12) ​= ​12.47, p ​< ​.001) and cortisol (t(12) ​= ​9.43, p ​< ​.001) significantly decreased from pregnancy to postpartum. There were no differences in the means of gestational and postpartum IL-1β, IL-6, TNF-α, or IFN-γ, but IL-8 was significantly increased from pregnancy to postpartum (t(12) ​= ​-4.60, p ​= ​.001). Estradiol during pregnancy was positively correlated with IL-6 levels both during pregnancy (r _p  ​= ​.656, p ​= ​.008) and postpartum (r ​= ​0.648, p ​= ​.023). Elevated IL-1β was associated with suicidal thoughts during pregnancy (r ​= ​0.529, p ​= ​.029). Although not statistically significant, depressive symptom severity trended towards a positive association with larger increases in IL-1β (r ​= ​0.535, p ​= ​.09) and TNF-α (r ​= ​0.501, p ​= ​.08) from pregnancy to postpartum.

Conclusion

This preliminary study suggests the feasibility of our approach for exploring a complex interplay between hormonal and pro-inflammatory changes from pregnancy to postpartum, and their relationship with depressive symptoms. Given our small sample and the relatively exploratory nature of our analyses, additional investigation focusing on hormonal and inflammatory changes and their potential associations with perinatal mental health is necessary to confirm and extend our preliminary findings and examine additional potential covariates.

Abnormal expression of the costimulatory molecule B7-H4 in placental chorionic villous and decidual basalis tissues of patients with preeclampsia and HELLP syndrome

BACKGROUND

B7-H4, a checkpoint molecule of the B7 family, regulates a broad spectrum such as T-cell activation, cytokine secretion, tumour progression, and invasion capacities. Our previous data revealed that soluble B7-H4 (sB7-H4) blood serum levels are elevated in women at high risk for the hypertensive pregnancy disorder preeclampsia (PE) in the first trimester, as well as in patients with confirmed early/late-onset PE.

AIM

We here aim to investigate the expression pattern of B7-H4 in placental tissues of PE and HELLP Syndrome versus control group.

METHODS

B7-H4 protein expression and localization were investigated by immunoblotting and co-immunohistochemistry in placental chorionic villous and decidual basalis tissues.

RESULTS

B7-H4 protein was prominently expressed at the cell membrane, in the cytoplasm of the syncytiotrophoblast (STB) and interstitial extravillous trophoblast (EVT). B7-H4 protein levels in placental chorionic villous tissue were significantly higher in women with early-onset/late-onset PE and HELLP, while it was decreased in decidual basalis tissues of early-onset PE and HELLP compared with controls.

CONCLUSION

B7-H4 was inversely expressed in placental chorionic villous and decidual basalis tissues of PE and HELLP patients. The increase in B7-H4 in the STB in PE and HELLP may lead to excessive apical expression and release of soluble B7-H4 in the maternal circulation. In contrast, the decrease in B7-H4 in decidual basalis tissues could be related to the decrease in invasion ability of the EVT in PE. Thus, the current results strongly suggest that B7-H4 is involved in the pathogenesis of PE and HELLP.

Paternally expressed retrotransposon Gag-like 1 gene, RTL1, is one of the crucial elements for placental angiogenesis in horses†

RTL1 (retrotransposon Gag-like 1) is an essential gene in the development of the human and murine placenta. Several fetal and placental abnormalities such as intrauterine growth restriction (IUGR) and hydrops conditions have been associated with altered expression of this gene. However, the function of RTL1 has not been identified. RTL1 is located on a highly conserved region in eutherian mammals. Therefore, the genetic and molecular analysis in horses could hold important implications for other species, including humans. Here, we demonstrated that RTL1 is paternally expressed and is localized within the endothelial cells of the equine (Equus caballus) chorioallantois. We developed an equine placental microvasculature primary cell culture and demonstrated that RTL1 knockdown leads to loss of the sprouting ability of these endothelial cells. We further demonstrated an association between abnormal expression of RTL1 and development of hydrallantois. Our data suggest that RTL1 may be essential for placental angiogenesis, and its abnormal expression can lead to placental insufficiency. This placental insufficiency could be the reason for IUGR and hydrops conditions reported in other species, including humans.

Changes and significance of plasma fibrinogen gamma-chain concentration in preeclampsia patients

OBJECTIVE

To investigate the plasma fibrinogen gamma-chain concentration in preeclampsia patients and explore its value in preeclampsia prediction and auxiliary diagnosis.

METHODS

Follow-up of pregnant women who regularly attended perinatal care at two hospitals in China was performed, and clinical data and plasma samples were collected at each examination until delivery. The gamma-chain concentration was detected by Western blotting, and Quantity One Software was used for gamma-chain grayscale value measurements.

RESULTS

Forty-two patients with preeclampsia and 42 control patients completed the follow-up. In the control group, the gamma-chain concentration at 32 weeks of gestation was higher than that at 20 weeks of gestation, but the difference was not statistically significant (p > 0.05). In the experimental group, the gamma-chain concentration at preeclampsia diagnosis was significantly higher than that at 20 weeks of gestation (p < 0.05). Compared with the control group, the gamma-chain concentration was higher at 20 weeks of gestation in the experimental group, but the difference was not statistically significant. However, at 32 weeks of gestation and at the time of diagnosis, the gamma-chain concentration in the experimental group was significantly higher than that in the control group (p < 0.05). At 32 weeks of gestation and at the time of diagnosis, the AUCs from ROC curve analysis of plasma fibrinogen gamma-chain concentrations were 0.64 and 0.71, respectively.

CONCLUSION

Plasma fibrinogen synthesis and degradation were disrupted in preeclampsia patients before and after diagnosis, and gamma-chain concentration was significantly increased. Plasma fibrinogen gamma chain may be of some value in preeclampsia prediction and auxiliary diagnosis.

Decidual memory T-cell subsets and memory T-cell stimulatory cytokines in early- and late-onset preeclampsia

PROBLEM

Preeclampsia is a major cause of fetal and maternal mortality and morbidity. Disturbed fetal-maternal immune tolerance, and therewith memory T cells, might be involved in its etiology. This study aims to give insight into memory T-cell populations and its associated cytokines in the decidual layers in early-onset preeclampsia (EO-PE) and late-onset preeclampsia (LO-PE).

METHOD OF STUDY

Lymphocytes were isolated from the decidua parietalis and basalis from EO-PE (n = 6), LO-PE (n = 8) and healthy (n = 15) pregnancies. CD4+ and CD8+ central- (CCR7+ ), effector- (CCR7- ), tissue resident- (CD103+ ), and regulatory- (Foxp3+ ) memory cell (CD45RO+ ) populations and their activation status (CD69+ ) were analyzed using flow cytometry. qRT-PCR analysis was performed on decidua parietalis and basalis biopsies to detect mRNA expression of interferon-gamma, interleukin-1B, IL2, IL6, IL7, IL8, IL10, IL15, and IL23.

RESULTS

CD4+ central-memory (CM) cell proportions were lower in the decidua parietalis in LO-PE (P < .0001) and EO-PE (P < .01) compared to healthy pregnancies. CD8+ memory (P < .05) and CD8+ CM (P < .01) cell proportions were also lower in the decidua parietalis in EO-PE compared to healthy pregnancies. This was accompanied by higher IL15 (P < .05) and IL23 (P < .05) and lower IL7 (P < .05) mRNA expression in decidua basalis biopsies from EO-PE compared to healthy pregnancies, analyzed by qPCR.

CONCLUSION

In conclusion, decidual memory T-cell proportions, their activation status, and associated cytokines are altered in preeclampsia and might therefore be involved in fetal-maternal immune tolerance and the pathophysiology of preeclampsia.

miR‑181b‑5p inhibits trophoblast cell migration and invasion through targeting S1PR1 in multiple abnormal trophoblast invasion‑related events

Normal placentation and successful maintenance of pregnancy depend on the successful migration and invasion of trophoblasts into maternal tissues. Previous studies reported that microRNAs (miRs) are expressed in trophoblasts, and can regulate their migration and invasion. The present study aimed to investigate miR‑181b‑5p function in HTR‑8/SVneo trophoblasts and explore its underlying mechanism in the pathogenesis of multiple abnormal trophoblast invasion‑related events. Reverse‑transcription quantitative PCR and western blotting were used to test the expression of miR‑181b‑5p and sphingosine‑1‑phosphate receptor 1 (S1PR1) in samples of multiple abnormal trophoblast invasion‑related events. Transwell invasion and wound healing assays were performed to determine cell invasion and migration abilities. A luciferase reporter assay was conducted to identify the downstream target of miR‑181b‑5p. Overexpression of miR‑181b‑5p suppressed HTR‑8/SVneo cell migration and invasion, whereas inhibition of miR‑181b‑5p induced an opposite effect. The S1PR1 gene was further identified as a novel direct target of miR‑181b‑5p. Specifically, miR‑181b‑5p bound directly to the 3'‑untranslated region of S1PR1 and suppressed its expression. Moreover, overexpression of S1PR1 reversed the inhibitory effect of miR‑181b‑5p. Taken together, ectopic expression of miR‑181b‑5p impaired the migration and invasion of trophoblasts by directly targeting S1PR1, thereby providing new insights into the pathogenesis of multiple abnormal trophoblast invasion‑related events.

Gut Microbiota Dysbiosis and Increased Plasma LPS and TMAO Levels in Patients With Preeclampsia

Objective: To characterize the gut microbiota in patients with preeclampsia (PE) compared with healthy controls.

Methods: We analyzed and compared the microbiota communities in the feces of 48 PE patients with 48 age-, gestational weeks-, and pre-pregnancy body mass index-matched healthy controls using 16S rRNA gene sequencing, and also we tested fecal and plasma lipopolysaccharide (LPS) and plasma trimethylamine-N-oxide (TMAO) concentration levels in the two groups.

Results: Compared with the control group, microbial alpha diversity was lower in the PE group, but there was no statistically significant difference between the two groups. At the phylum level, Firmicutes (51.64% PE vs. 59.62% Control, P < 0.05), Bacteroidetes (40.51% PE vs. 34.81% Control, P< 0.05), Proteobacteria (4.51% PE vs. 2.56% Control, P < 0.05), and Actinobacteria (2.90% PE vs. 1.77% Control, P < 0.05), exhibited significant differences between the PE group and the control group. LEfSe analysis found 17 differentially abundant taxa between the two groups. PICRUSt analysis found that in the KEGG pathways, the microbial gene functions related to LPS biosynthesis were higher in the fecal microbiome of the PE group. The fecal and plasma LPS concentrations and plasma TMAO concentrations of PE patients were higher than those of the healthy controls.

Conclusion: PE patients had gut microbiota dysbiosis and increased plasma LPS and TMAO levels, which will lead to a better understanding of the relationship between the gut microbiota and PE.

Early Onset Pre-Eclampsia with Nephrotic Range Proteinuria as the Initial Manifestation of Lupus Nephritis: Report of three cases

Early onset pre-eclampsia (pre-eclampsia at less than 34 gestational weeks) is a severe form of preeclampsia; in addition, some women may also develop nephrotic range proteinuria. De novo diagnosis of lupus nephritis (LN) in pregnancy is challenging as it may present with features similar to commonly occurring preeclampsia. We report three cases of early onset pre-eclampsia with nephrotic range proteinuria and subsequent diagnosis of LN at the Women and Children hospital attached to Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, between 2014 and 2017. These cases highlights the need for further evaluation of the association between nephrotic-range proteinuria and early onset pre-eclampsia. The index of suspicion for underlying LN of these type of cases should be high. Earlier detection of LN will prompt better management that can avert or delay short- and long-term morbidity.

Memory T Cells in Pregnancy

Adaptations of the maternal immune response are necessary for pregnancy success. Insufficient immune adaption is associated with pregnancy pathologies such as infertility, recurrent miscarriage, fetal growth restriction, spontaneous preterm birth, and preeclampsia. The maternal immune system is continuously exposed to paternal-fetal antigens; through semen exposure from before pregnancy, through fetal cell exposure in pregnancy, and through microchimerism after pregnancy. This results in the generation of paternal-fetal antigen specific memory T cells. Memory T cells have the ability to remember previously encountered antigens to elicit a quicker, more substantial and focused immune response upon antigen reencounter. Such fetal antigen specific memory T cells could be unfavorable in pregnancy as they could potentially drive fetal rejection. However, knowledge on memory T cells in pregnancy has shown that these cells might play a favorable role in fetal-maternal tolerance rather than rejection of the fetus. In recent years, various aspects of immunologic memory in pregnancy have been elucidated and the relevance and working mechanisms of paternal-fetal antigen specific memory T cells in pregnancy have been evaluated. The data indicate that a delicate balance of memory T cells seems necessary for reproductive success and that immunologic memory in reproduction might not be harmful for pregnancy. This review provides an overview of the different memory T cell subtypes and their function in the physiology and in complications of pregnancy. Current findings in the field and possible therapeutic targets are discussed. The findings of our review raise new research questions for further studies regarding the role of memory T cells in immune-associated pregnancy complications. These studies are needed for the identification of possible targets related to memory mechanisms for studies on preventive therapies.

MicroRNAs in Preeclampsia

Preeclampsia (PE) continues to represent a worldwide problem and challenge for both clinicians and laboratory-based doctors. Despite many efforts, the knowledge acquired regarding its pathogenesis and pathophysiology does not allow us to treat it efficiently. It is not possible to arrest its progressive nature, and the available therapies are limited to symptomatic treatment. Furthermore, both the diagnosis and prognosis are frequently uncertain, whilst the ability to predict its occurrence is very limited. MicroRNAs are small non-coding RNAs discovered two decades ago, and present great interest given their ability to regulate almost every aspect of the cell function. A lot of evidence regarding the role of miRNAs in pre-eclampsia has been accumulated in the last 10 years. Differentially expressed miRNAs are characteristic of both mild and severe PE. In many cases they target signaling pathway-related genes that result in altered processes which are directly involved in PE. Immune system, angiogenesis and trophoblast proliferation and invasion, all fundamental aspects of placentation, are controlled in various degrees by miRNAs which are up- or downregulated. Finally, miRNAs represent a potential therapeutic target and a diagnostic tool.

Candidate Gene, Genome-Wide Association and Bioinformatic Studies in Pre-eclampsia: a Review

PURPOSE OF REVIEW

Regardless of the familial linkage reported in pre-eclampsia development, understanding the polymorphic genes associated with pre-eclampsia remains limited. Hence, this review aims to outline the main genetic factors that have been investigated in respect to pre-eclampsia development.

RECENT FINDINGS

It is apparent that different genes show significance in varying populations. Notably, it is reported that apolipoprotein-1 gene polymorphisms are associated with pre-eclampsia development in an African-American population, which may be worthwhile to investigate in a Black South African cohort. Despite the research attention that is focused on this surreptitious syndrome, a definitive cause eludes scientists and physicians, alike. Genetic studies can fulfil a dual purpose of suggesting novel hypotheses through genome-wide screening and testing these hypotheses via candidate gene studies. However, publications to date have only presented inconsistent and conflicting results regarding candidate gene analysis.

miR-362-3p regulates cell proliferation, migration and invasion of trophoblastic cells under hypoxia through targeting Pax3

Preeclampsia (PE), a common obstetrical disorder, is one of the leading causes of pregnancy associated death. PE is closely linked with impaired migration and invasion ability of trophoblastic cells. miR-362-3p recently received our particular attention due not only to its aberrant expression in the placentas of patients with PE, but also to its important roles in regulating migration and invasion of various cells. This study was thus conducted to investigate the roles of miR-362-3p in PE and the related mechanism. The expression of miR-362-3p and Pax3 was examined in placentas of patients with PE and in normal placentas. HTR8/SVneo cells were cultured under hypoxia and transfected with miR-362-3p mimics, miR-362-3p inhibitors or Pax3 over-expression vectors. Results showed up-regulation of miR-362-3p but down-regulation of Pax3 in placentas of preeclamptic pregnancies. Luciferase report assay confirmed that Pax3 is a direct target of miR-362-3p. Although Pax3 was predicted to be targeted by miR-30a-3p and miR-181a-5p as well, their expression either had no difference between placentas of PE patients and normal placentas or showed less increment in placentas of PE patients than miR-362-3p. Exposure to hypoxia inhibited cell viability, migration and invasion of HTR8/SVneo cells. Increasing miR-362-3p by the mimics conferred improved effects on the inhibition. However, deletion of miR-362-3p or overexpression of Pax3 abolished the inhibiton. These results suggest that miR-362-3p/Pax3 axis regulates cell viability, migration and invasion of HTR8/SVneo cells under hypoxia. The present study adds to the further understanding of the pathogenesis of PE.

Timing of probiotic milk consumption during pregnancy and effects on the incidence of preeclampsia and preterm delivery: a prospective observational cohort study in Norway

OBJECTIVES

To investigate whether the timing of probiotic milk intake before, during early or late pregnancy influences associations with preeclampsia and preterm delivery.

DESIGN

Population based prospective cohort study.

SETTING

Norway, between 1999 and 2008.

PARTICIPANTS

70 149 singleton pregnancies resulting in live-born babies from the Norwegian Mother and Child Cohort Study (no chronic disease, answered questionnaires, no placenta previa/cerclage/serious malformation of fetus, first enrolment pregnancy). Only nulliparous women (n=37 050) were included in the preeclampsia analysis. Both iatrogenic and spontaneous preterm delivery (between gestational weeks 22+0 and 36+6) with spontaneous term controls (between gestational weeks 39+0 and 40+6) were included in the preterm delivery analysis resulting in 34 458 cases.

MAIN OUTCOME MEASURES

Adjusted OR for preeclampsia and preterm delivery according to consumption of probiotic milk at three different time periods (before pregnancy, during early and late pregnancy).

RESULTS

Probiotic milk intake in late pregnancy (but not before or in early pregnancy) was significantly associated with lower preeclampsia risk (adjusted OR: 0.80 (95% CI 0.68 to 0.94) p-value: 0.007). Probiotic intake during early (but not before or during late pregnancy) was significantly associated with lower risk of preterm delivery (adjusted OR: 0.79 (0.64 to 0.97) p-value: 0.03).

CONCLUSIONS

In this observational study, we found an association between timing of probiotic milk consumption during pregnancy and the incidence of the adverse pregnancy outcomes preeclampsia and preterm delivery. If future randomised controlled trials could establish a causal association between probiotics consumption and reduced risk of preeclampsia and preterm delivery, recommending probiotics would be a promising public health measure to reduce these adverse pregnancy outcomes.

Immunological Tolerance, Pregnancy, and Preeclampsia: The Roles of Semen Microbes and the Father

Although it is widely considered, in many cases, to involve two separable stages (poor placentation followed by oxidative stress/inflammation), the precise originating causes of preeclampsia (PE) remain elusive. We have previously brought together some of the considerable evidence that a (dormant) microbial component is commonly a significant part of its etiology. However, apart from recognizing, consistent with this view, that the many inflammatory markers of PE are also increased in infection, we had little to say about immunity, whether innate or adaptive. In addition, we focused on the gut, oral and female urinary tract microbiomes as the main sources of the infection. We here marshall further evidence for an infectious component in PE, focusing on the immunological tolerance characteristic of pregnancy, and the well-established fact that increased exposure to the father's semen assists this immunological tolerance. As well as these benefits, however, semen is not sterile, microbial tolerance mechanisms may exist, and we also review the evidence that semen may be responsible for inoculating the developing conceptus (and maybe the placenta) with microbes, not all of which are benign. It is suggested that when they are not, this may be a significant cause of PE. A variety of epidemiological and other evidence is entirely consistent with this, not least correlations between semen infection, infertility and PE. Our view also leads to a series of other, testable predictions. Overall, we argue for a significant paternal role in the development of PE through microbial infection of the mother via insemination.

Thromboprophylaxis and maternal-fetal outcomes of women with serum markers for hereditary thrombophilia and previous obstetric complications

Abstract Objectives: to evaluate the maternalfetal outcomes of thromboprophylaxis with enoxa parin based on scoring system in women with serum markers for hereditary thrombophilia and previous obstetric complications. Methods: a retrospective study was undertaken based on data collected from clinical records. We included 54 pregnant women with serum markers for hereditary thrombophilia undergoing therapeutic intervention with enoxaparin in the period from November 2009 to December 2013. The initial dose of low molecular weight heparin was guided by a scoring system. The maternalfetal outcomes of previous pregnancies and, subsequently, the treatment were compared using the chisquare (χ2) test with the Yates correction and Fisher's Exact Test; p<0.05 was considered significant. Results: we observed significant reduction in fetal/perinatal deaths (p<0.05) and spontaneous abortions (p<0.001) after intervention. The live births at fullterm delivery (p<0.001) and live births at preterm delivery (p<0.05) increased significantly after intervention. Conclusions: the therapeutic intervention with enoxaparin based on scoring system during pregnancy seems to improve the fetal prognosis.

Maternal-Fetal rejection reactions are unconstrained in preeclamptic women

The risk factors for preeclampsia, extremes of maternal age, changing paternity, concomitant maternal autoimmunity, and/or birth intervals greater than 5 years, suggest an underlying immunopathology. We used peripheral blood and lymphocytes from the UteroPlacental Interface (UPI) of 3rd trimester healthy pregnant women in multicolor flow cytometry-and in vitro suppression assays. The major end-point was the characterization of activation markers, and potential effector functions of different CD4-and CD8 subsets as well as T regulatory cells (Treg). We observed a significant shift of peripheral CD4 -and CD8- T cells from naïve to memory phenotype in preeclamptic women compared to healthy pregnant women consistent with long-standing immune activation. While the proportions of the highly suppressive Cytokine and Activated Treg were increased in preeclampsia, Treg tolerance toward fetal antigens was dysfunctional. Thus, our observations indicate a long-standing inflammatory derangement driving immune activation in preeclampsia; in how far the Treg dysfunction is caused by/causes this immune activation in preeclampsia will be the object of future studies.

Natural killer cells mediate pathophysiology in response to reduced uterine perfusion pressure

Preeclampsia is associated with hypertension, small-for-gestational-age babies, and increased cytolytic natural killer (NK) cells. The specific role of cytolytic NK cells in the pathophysiology of preeclampsia has not been clearly defined. We hypothesized that Reduced Uterine Perfusion Pressure (RUPP) stimulates proliferation and cytolytic activation of NK cells, and that reducing NK cells in RUPP would prevent hypertension, intrauterine growth restriction, and inflammation in response to placental ischemia. RUPP was induced on gestation day (GD) 14 in pregnant rats. NK cells were depleted by i.p. administration of anti-asialo GM1 antibody on GDs 15 and 17. Placental and circulating NK cells were quantified via flow cytometry, mean arterial pressure (MAP), fetal weights, and cytokines were measured on GD 19. Total placental NK cells were 7.4 ± 2% of gated cells in normal pregnant (NP; n=10) and 16.5 ± 3% of gated cells in RUPP (n=10) rats. Furthermore, cytolytic placental NK cells also increased in RUPP. Depletion of NK cells in RUPP (RUPP + anti-ASGM1) significantly improved MAP and fetal weights. MAP was 108 ± 2 mmHg in NP, 125 ± 2 mmHg in RUPP, and 112 ± 2 mmHg in RUPP + anti-ASGM1 (n=12). Fetal weight was 2.32 ± 0.05 in NP, 1.8 ± 0.04g in RUPP, and increased to 2.0 ± 0.04g in RUPP + anti-ASGM1. Placental interferon-γ (IFN-γ) was 40.4 ± 5.2 pg/mg in NP, 72.17 ± 3.2 pg/mg in RUPP, and 44.0 ± 6.5 pg/mg in RUPP + anti-ASGM1 (P<0.05). Placental tumor necrosis factor-α (TNF-α) was 17.9 ± 1.7 pg/mg in NP, 23.9 ± 2.2 pg/mg in RUPP, and 12.9 ± 2.3 pg/mg in RUPP + anti-ASGM1 (P<0.05). Depletion of NK cells significantly lowered MAP, intrauterine growth restriction, and inflammation in RUPP rats indicating that cytolytic NK cells are important in preeclampsia pathophysiology.

A Simplified Regimen Compared with WHO Guidelines Decreases Antenatal Calcium Supplement Intake for Prevention of Preeclampsia in a Cluster-Randomized Noninferiority Trial in Rural Kenya

Background: To prevent preeclampsia, the WHO recommends antenatal calcium supplementation in populations with inadequate habitual intake. The WHO recommends 1500-2000 mg Ca/d with iron-folic acid (IFA) taken separately, a complex pill-taking regimen. Objective: The objective of this study was to test the hypothesis that simpler regimens with lower daily dosages would lead to higher adherence and similar supplement intake.Methods: In the Micronutrient Initiative Calcium Supplementation study, we compared the mean daily supplement intake associated with 2 dosing regimens with the use of a parallel, cluster-randomized noninferiority trial implemented in 16 primary health care facilities in rural Kenya. The standard regimen was 3 × 500 mg Ca/d in 3 pill-taking events, and the low-dose regimen was 2 × 500 mg Ca/d in 2 pill-taking events; both regimens included a 200 IU cholecalciferol and calcium pill and a separate IFA pill. We enrolled 990 pregnant women between 16 and 30 wk of gestation. The primary outcome was supplemental calcium intake measured by pill counts 4 and 8 wk after recruitment. We carried out intention-to-treat analyses with the use of mixed-effect models, with regimen as the fixed effect and health care facilities as a random effect, by using a noninferiority margin of 125 mg Ca/d.Results: Women in facilities assigned to the standard regimen consumed a mean of 1198 mg Ca/d, whereas those assigned to the low-dose regimen consumed 810 mg Ca/d. The difference in intake was 388 mg Ca/d (95% CI = 341, 434 mg Ca/d), exceeding the prespecified margin of 125 mg Ca/d. The overall adherence rate was 80% and did not differ between study arms.Conclusions: Contrary to our expectation, a simpler, lower-dose regimen led to significantly lower supplement intake than the regimen recommended by the WHO. Further studies are needed to precisely characterize the dose-response relation of calcium supplementation and preeclampsia risk and to examine cost effectiveness of lower and simpler regimens in program settings. This trial was registered at clinicaltrials.gov as NCT02238704.

Maternal and Perinatal Outcome in Women with Systemic Lupus Erythematosus: A Retrospective Bicenter Cohort Study

Objective

To investigate disease activity around and during pregnancy and pregnancy outcome in women with systemic lupus erythematosus (SLE) considering antiphospholipid antibody status. Moreover, differences between first and consecutive pregnancies were examined.

Methods

Pregnancies > 16 weeks gestation of SLE patients receiving joint care from rheumatologists and gynecologists in two tertiary centers in the Netherlands between 2000 and 2015 were included. Disease activity, flare rate, and pregnancy outcomes and complications were assessed.

Results

Ninety-six women (84% Caucasian) with 144 pregnancies were included. The median SLE(P)DAI score was 2 before, during, and after pregnancy. Flare rates were 6.3%, 20.1%, and 15.3%, respectively. Severe hypertensive disorder of pregnancy, intrauterine fetal death, preterm birth, and small-for-gestational age infants occurred in 18.1%, 4.1%, 32.7%, and 14.8%, respectively. Complication rates were similar in the first and consecutive pregnancies. Half of the women did not experience any pregnancy complication whereas 42.7% developed a complication during all pregnancies. Mean number of pregnancies was 2.4 and live births 1.7.

Conclusion

In this SLE population with low disease activity, pregnancy complications were present irrespective of antiphospholipid antibody status. Furthermore, there were no differences in complication rates between the first and consecutive pregnancies as seen in healthy mothers. This information is useful for patient counseling.

Macrophages modulate the growth and differentiation of rhesus monkey embryonic trophoblasts

PROBLEM

Immune cells within the endometrium at implantation are thought to play an important role in implantation, although their exact role is not well understood.

METHOD OF STUDY

A co-culture system of rhesus monkey embryos and maternal immune cells was established. Blastocysts obtained by in vitro fertilization were co-cultured with peripheral blood cells or decidual macrophages. Culture media were collected to assess secretions. Embryo growth was monitored, and trophoblasts were evaluated for proliferation, apoptosis, and differentiation.

RESULTS

Embryonic trophoblast outgrowths were visible within 6 days of culture, and the area of embryo outgrowth was reduced when blastocysts were cultured with peripheral-derived or decidual macrophages. Trophoblast proliferation was not significantly affected with macrophage co-culture while chorionic gonadotropin secretion was increased. Trophoblast expression of CDH 11 and GJA1 was increased, suggesting that macrophages accelerate differentiation of peri-implantation trophoblasts.

CONCLUSIONS

These results indicate an important role of macrophages in placentation and pregnancy success.

Racial-ethnic differences in midtrimester maternal serum levels of angiogenic and antiangiogenic factors

BACKGROUND

Little is known about racial-ethnic differences in the distribution of maternal serum levels of angiogenic and antiangiogenic factors and their associations with early-onset preeclampsia.

OBJECTIVE

We sought to investigate the distribution of midtrimester maternal serum levels of placental growth factor, soluble endoglin, and soluble vascular endothelial growth factor receptor 1 and their associations with early-onset preeclampsia in whites, Hispanics, and blacks.

STUDY DESIGN

A population-based nested case-control design was used to identify cases and controls of white, Hispanic, and black origin from a 2000 through 2007 live-birth cohort in 5 southern California counties. Cases included 197 women (90 whites, 67 Hispanics, and 40 blacks) with early-onset preeclampsia defined as hypertension and proteinuria with onset <32 weeks according to hospital records. Controls included a random sample of 2363 women without early-onset preeclampsia. Maternal serum specimens collected at 15-20 weeks' gestation as part of routine prenatal screening were tested for placental growth factor, soluble endoglin, and soluble vascular endothelial growth factor receptor 1. Serum levels of the 3 factors were log-normally distributed. Adjusted natural logarithmic means were compared between cases and controls and between racial-ethnic groups. Odds ratios and 95% confidence intervals derived from logistic regression models were calculated to measure the magnitude of the associations.

RESULTS

Cases showed lower adjusted logarithmic means of placental growth factor but higher adjusted logarithmic means of soluble endoglin than controls across all 3 groups (P < .05). Cases also had higher adjusted means of soluble vascular endothelial growth factor receptor 1 than controls in whites (7.75 vs 7.52 log pg/mL, P < .05) and Hispanics (7.73 vs 7.40 log pg/mL, P < .05) but not in blacks (7.85 vs 7.69 log pg/mL, P = .47). Blacks were found to have higher levels of placental growth factor in both cases and controls when compared to whites and Hispanics (adjusted means: 4.69 and 5.20 log pg/mL in blacks, 4.08 and 4.78 log pg/mL in whites, and 3.89 and 4.70 log pg/mL in Hispanics, respectively, P < .05). Hispanic cases had the highest adjusted mean of soluble endoglin compared to white and black cases (9.24, 9.05, and 8.93 log pg/mL, respectively, P < .05). The weakest association of early-onset preeclampsia with placental growth factor and soluble endoglin was observed in blacks. The adjusted odds ratio per log pg/mL increase of the 2 analytes were 0.219 (95% confidence interval, 0.124-0.385) and 5.02 (95% confidence interval, 2.56-9.86) in blacks in comparison to 0.048 (95% confidence interval, 0.026-0.088) and 36.87 (95% confidence interval, 17.00-79.96) in whites (P < .05) and 0.028 (95% confidence interval, 0.013-0.060) and 86.68 (95% confidence interval, 31.46-238.81) in Hispanics (P < .05), respectively. As for soluble vascular endothelial growth factor receptor 1, the association was not significantly different among the racial-ethnic groups.

CONCLUSION

Racial-ethnic differences were observed in the distribution of midtrimester maternal levels of placental growth factor and soluble endoglin and in the associations with early-onset preeclampsia. These differences should be considered in future studies to improve etiologic and prognostic understanding of early-onset preeclampsia.

Assessment, Management, and Health Implications of Early-Onset Preeclampsia

Early-onset preeclampsia is a serious condition of pregnancy with the potential for adverse maternal and fetal health outcomes. A strong body of evidence supports the need for postpartum follow-up and health counseling, because these women and their offspring are at risk for future cardiovascular disease; nurses play a key role in this education. An understanding of the diagnosis, risk screening for, pathogenesis, and management of severe preeclampsia and its sequelae, such as intrauterine growth restriction and pulmonary edema, enables nurses to develop a comprehensive plan of care that will support women and their families through this challenging and dynamic complication of pregnancy.

Calcium Supplementation to Prevent Preeclampsia: Translating Guidelines into Practice in Low-Income Countries

The WHO issued a strong recommendation that pregnant women be provided calcium supplements to prevent preeclampsia. This is the first recommended nutritional intervention to prevent this condition, a leading cause of maternal mortality globally. As health systems seek to implement this new intervention, a number of issues require further clarification and guidance, including dosage regimen, supplement formulation, and alignment with other antenatal nutritional interventions. We summarize key evidence on the above points and offer our views on good practices. Most developing countries have low calcium intake, so where habitual calcium intake is unknown, calcium supplements are likely beneficial. In our view, policymakers and program planners should consider adopting doses between 1.0 and 1.5 g elemental calcium/d, depending on the local average and variation in dietary calcium intake, logistical feasibility, and acceptability in the target population. Prudent practice would entail daily administration as calcium carbonate administered in divided doses of not >500 mg elemental calcium per dose. For ease of prescribing and adherence, calcium [as with iron and folic acid (IFA)] should be administered routinely to pregnant women from the earliest contact in pregnancy until delivery. Calcium's acute inhibitory effect on iron absorption translates to minimal effects in clinical studies. Therefore, to simplify the regimen and facilitate adherence, providers should not counsel that calcium and IFA pills must be taken separately. Although further research will shed more light on clinical and programmatic issues, policies can be implemented with ongoing revision as we continue to learn what works to improve maternal and newborn health.

Effects of Lipopolysaccharide on Human First Trimester Villous Cytotrophoblast Cell Function In Vitro

It has been shown that adverse obstetrical outcomes such as pre-eclampsia and intrauterine growth retardation correlate with maternal infection. In this study, we investigated mechanisms involved in infection-associated abnormalities in cytotrophoblast function. Primary human first trimester cytotrophoblast cells were isolated and treated with lipopolysaccharide (LPS). Levels of the cytokines and chemokines were measured and cytotrophoblast invasion was investigated. In addition, first trimester decidual macrophages were isolated and treated with the conditioned medium from LPS-treated cytotrophoblast cells, and macrophage migration was assessed. Coculturing decidual macrophages with cytotrophoblast cells was conducted to investigate macrophage costimulatory molecule and receptor expression and intracellular cytokine production. We found that LPS exposure increased cytotrophoblast production of pro-inflammatory cytokines tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta and IL-6, and chemokines IL-8, macrophage inflammatory protein (MIP)-1alpha, and CXCL12 in a dose-dependent manner. In addition, LPS decreased cytotrophoblast invasion, and its effect was Toll-like receptor 4 (TLR4)-dependent and partly TNF-alpha-dependent. Conditioned medium from LPS-stimulated cytotrophoblast cells increased decidual macrophage migration and this effect was partly TLR4-dependent. Furthermore, coculturing decidual macrophages with LPS-exposed cytotrophoblast cells up-regulated macrophage CD80 and CD86 expression and intracellular TNF-alpha and IL-12p40 production, while down-regulating macrophage CD206 and CD209 expression and intracellular IL-10 secretion. LPS-stimulated macrophages also inhibited cytotrophoblast invasion. In conclusion, our results indicate that LPS increases the production of a subset of proinflammatory cytokines and chemokines by human first trimester cytotrophoblast cells, decreases cytotrophoblast invasion, and alters the cross talk between cytotrophoblast cells and decidual macrophages.

Cluster-Randomized Non-Inferiority Trial to Compare Supplement Consumption and Adherence to Different Dosing Regimens for Antenatal Calcium and Iron-Folic Acid Supplementation to Prevent Preeclampsia and Anaemia: Rationale and Design of the Micronutrient Initiative Study

Background:

To prevent pre-eclampsia in populations with insufficient dietary calcium (Ca) intake, the World Health Organisation (WHO) recommends routine Ca supplementation during antenatal care (ANC). WHO guidelines suggest a complex dosing regimen, requiring as many as 5 pill-taking events per day when combined with iron and folic acid (IFA) supplements. Poor adherence may undermine public health effectiveness, so simpler regimens may be preferable. This trial will compare the effect of the WHO-recommended (higher-dose) regimen vs. a simpler, lower-dose regimen on supplement consumption and pill-taking behaviours in Kenyan ANC clients.

Design and methods:

This is a parallel, non-inferiority, cluster-randomized trial; we examined 16 primary care health facilities in Kenya, 1047 pregnant women between 16-30 weeks gestational age. Higher-dose regimen: 1.5 g elemental calcium in 3 separate doses (500 mg Ca/pill) and IFA (60 mg Fe + 400 µg folic acid) taken with evening dose. Lower-dose regimen: 1.0 g calcium in 2 separate doses (500 mg Ca/pill) with IFA taken as above. Measurements: Primary outcome is Ca pills consumed per day, measured by pill counts. Secondary outcomes include IFA pills consumed per day, client knowledge, motivation, social support, and satisfaction, measured at 4 to 10 weeks post-enrolment. Statistical analyses: Unit of randomization is the healthcare facility; unit of analysis is individual client. Intent-to-treat analysis will be implemented with multi-level models to account for clustering.

Expected public health impact:

If pregnant women prescribed lower doses of Ca ingest as many pills as women prescribed the WHO-recommended regimen, developing a lower-dose recommendation for antenatal Ca and IFA supplementation programs could save resources.

Preeclampsia is Characterized by Fetal NK Cell Activation and a Reduction in Regulatory T Cells

Problem

Preeclampsia affects 3–17% of pregnancies worldwide and has serious consequences for both the mother and the fetus. As maternal–fetal immune tolerance is bidirectional, fetal immunopathology may play a significant role in the pathogenesis of pregnancy disorders. Nevertheless, the impact of preeclampsia on the fetal immune system is unclear.

Method of study

In this case–control study, we examined the phenotype of innate and adaptive immune cells from the cord blood of 3rd trimester babies born to healthy mothers and compared them to cord blood from 3rd trimester babies born to mothers with symptomatic preeclampsia.

Results

The ratio of CD56hi CD16− non‐activated/regulatory NK cells to CD56lo CD16+ activated/effector NK cells as well as the proportion of CD4+ T cells was significantly decreased in the cord blood of babies born to preeclamptic mothers. The percentage of FoxP3+ Treg, especially the FoxP3lo populations (resting Treg and cytokine Treg), were significantly reduced. Importantly, this reduction in FoxP3+ Treg affected the ratio of CD8+ effector T cells per FoxP3+ Treg in the cord blood of babies born to preeclamptic mothers.

Conclusion

These observations indicate that there are significant fetal immune system derangements during preeclampsia.

Localization of folate metabolic enzymes, methionine synthase and 5,10-methylenetetrahydrofolate reductase in human placenta

BACKGROUND

Normal fetal development requires adequate folate levels during pregnancy. Although folate metabolic enzymes have important roles in the maintenance of normal fetal development, the location of folate metabolic enzymes, methionine synthase (MTR) and 5,10-methylenetetrahydrofolate reductase (MTHFR), has not been previously examined.

METHODS

We investigated the expression of MTR and MTHFR in human term placenta obtained from normal and pregnancy-induced hypertension (PIH) patients.

RESULTS

MTR is expressed in the villous syncytiotrophoblast and MTHFR is expressed in the extravillous trophoblast. There was no difference in the quantity and location of these enzymes between control and PIH patients.

CONCLUSION

These results suggest that MTR in the villous trophoblast participates in the metabolism of homocysteine by using folate, and MTHFR in the extravillous trophoblast is associated with extratrophoblast invasion.

TNF α G308A gene polymorphism has an impact on renal function, microvascular permeability, organ involvement and severity of preeclampsia

BACKGROUND/AIMS

Preeclampsia (PE) is a life-threatening complication of pregnancy that is associated with a high rate of maternal and perinatal morbidity and/or mortality worldwide. If untreated, it can progress to eclampsia, which can result in the death of the mother, the fetus or both. The etiology of PE is still uncertain; however, recently the role of the immune system has gained in importance. The role of tumor necrosis factor-α (TNF-α), a cytokine involved in inflammation processes, has been widely investigated in obstetric disorders. The aims of the present study were to investigate the effect of TNF-α gene G308A (rs1800629) polymorphism on disease risk, renal function, microvascular permeability, endothelial cell dysfunction and organ involvement in women with PE.

METHODS

Initially, 102 3rd-trimester pregnant women (preeclamptic cases and healthy controls) with singleton pregnancy were invited for participation, of which 76 were genotyped for TNF-α G308A polymorphism and evaluated for plasma levels of soluble vascular cell adhesion molecule-1 (sVCAM-1), fibronectin and TNF-α, which were tested for correlations with the profile of PE. The odds ratio (OR) and 95% confidence intervals obtained from unconditional logistic regression were used to test the association between the TNF-α polymorphism and PE risk. For continuous variables, we applied Student's t test and, for categorical variables, the Pearson χ(2) or Fisher's exact test. The two-way ANOVA test with Bonferroni correction was used in multivariate analyses.

RESULTS

The A allele was more frequent in cases than controls (22.4 vs. 13.2%), which increased disease risk (OR = 2.73). Maternal serum levels of TNF-α, sVCAM-1 and fibronectin were significantly increased in cases (855.8 ± 385.1 pg/ml, 1,243 ± 671 ng/ml, 0.308 ± 0.231 g/l, respectively) compared to controls (301.1 ± 156.1 pg/ml, 651 ± 250 ng/ml, 0.218 ± 0.101 g/l, respectively; p < 0.0001, p < 0.0001 and p = 0.031, respectively), and these levels showed an increasing trend with the mutant allele genotype. Moderate and severe proteinuria was higher in rs1800629 allele A subjects compared to G/G carriers (53.8 vs. 14.3% (p < 0.05) and 13.0 vs. 4.7% (p < 0.01), respectively). The adverse effect of rs1800629 allele A on renal function was confirmed by increased plasma creatine levels, urinary protein excretion and lower tubular resorption rate in preeclamptic patients. Moreover, rs1800629 allele A preeclamptic carriers showed higher serum levels of fibronectin and sVCAM-1 compared to G/G homozygotes.

CONCLUSION

This study reveals a possible association between clinical and laboratory manifestations of PE and the TNF-α gene G308A (rs1800629) polymorphism.

Assessment of endothelial function in pregnant women with preeclampsia and gestational diabetes mellitus by flow-mediated dilation of brachial artery

PURPOSE

To compare endothelial function, as assessed by flow-mediated dilation (FMD) in pregnant women with preeclampsia (PE), gestational diabetes mellitus (GDM) and healthy pregnant women.

METHODS

We conducted a cross-sectional study of eighty women who were selected and divided into three groups: Group A comprising 42 pregnant women with PE, Group B (control) consisting of 19 normotensive pregnant women with no comorbidities and Group C consisting of 19 pregnant women with GDM. The women underwent FMD and the results were compared between groups. The data were obtained from the Center for Fetal Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Brazil (CEMEFE-HC-UFMG) after approval by the Ethics and Research Committee on June 4, 2008 under no CAAE-0280.0.203.000-08.

RESULTS

Nonparametric variance analysis showed no statistically significant difference between the characteristics of the three groups. The comparison between the results of the mean values of brachial artery FMD groups of pregnant women with preeclampsia (FMD = 5.36 ± 4.61 %), gestational diabetes (FMD = 9,18 ± 5.98 %) and pregnant women in the control group (FMD = 17.55 ± 8.35 %) showed that a statistically significant difference was found between groups using the Dunn test. The comparison between groups PE × GDM was not statistically significant. The group consisting of pregnant women with GDM associated with those with PE had significantly lower results for FMD (6.55 ± 5.33 %) than the control group (17.55 ± 8.35 %, p = 0.00).

CONCLUSIONS

The group consisting of pregnant women with GDM or PE showed results for FMD significantly lower than the control group, suggesting possible endothelial injury in these patients.

Macrophages: are they involved in endometriosis, abortion and preeclampsia and how?

Macrophages hold a key role in both regulating and executing the body's own immune response under various conditions. Hence, although endometriosis, preeclampsia and abortions are clinically different, all three are regarded to involve highly complex immunological processes. The aim of our current work was to evaluate the role of macrophages within these gynaecological disorders. Macrophages have been shown to invade endometriosis lesions and to mediate propagation of endometriotic cyst growth. However this is the first time that significant GPER up-regulation in macrophages is demonstrated. This highlights a potential alternative way through which estrogen may modulate immune response of macrophages in endometriosis. In addition, during spontaneous miscarriages the macrophage population increases significantly. This deregulation may possibly support an inflammatory scheme further triggering abortive procedures. Macrophage-mediated apoptosis of extravillous trophoblasts (EVT) has been associated with preeclampsia. Larger numbers of apoptotic EVT were detected in preeclamptic placentas compared with normal. In preeclamptic placentas, decidual macrophages were found to be Fas ligand (FasL)-positive. Our results highlight a new aspect of macrophage biology in endometriosis and pregnancy physiology and patho-physiology. Further studies with larger samples are needed to verify the current results and evaluate their clinical impact. Our data strongly indicate that macrophages hold key roles in various gynaecological disorders and might be crucial to further elucidate their patho-physiology.

Progesterone-induced blocking factor differentially regulates trophoblast and tumor invasion by altering matrix metalloproteinase activity

Invasiveness is a common feature of trophoblast and tumors; however, while tumor invasion is uncontrolled, trophoblast invasion is strictly regulated. Both trophoblast and tumor cells express high levels of the immunomodulatory progesterone-induced blocking factor (PIBF), therefore, we aimed to test the possibility that PIBF might be involved in invasion. To this aim, we used PIBF-silenced or PIBF-treated trophoblast (HTR8/Svneo, and primary trophoblast) and tumor (HT-1080, A549, HCT116, PC3) cell lines. Silencing of PIBF increased invasiveness as well as MMP-2,-9 secretion of HTR8/SVneo, and decreased those of HT-1080 cells. PIBF induced immediate STAT6 activation in both cell lines. Silencing of IL-4Rα abrogated all the above effects of PIBF, suggesting that invasion-related signaling by PIBF is initiated through the IL-4Rα/PIBF-receptor complex. In HTR-8/SVneo, PIBF induced fast, but transient Akt and ERK phosphorylation, whereas in tumor cells, PIBF triggered sustained Akt, ERK, and late STAT3 activation. The late signaling events might be due to indirect action of PIBF. PIBF induced the expression of EGF and HB-EGF in HT-1080 cells. The STAT3-activating effect of PIBF was reduced in HB-EGF-deficient HT-1080 cells, suggesting that PIBF-induced HB-EGF contributes to late STAT3 activation. PIBF binds to the promoters of IL-6, EGF, and HB-EGF; however, the protein profile of the protein/DNA complex is different in the two cell lines. We conclude that in tumor cells, PIBF induces proteins, which activate invasion signaling, while-based on our previous data-PIBF might control trophoblast invasion by suppressing proinvasive genes.

Perinatal depression--the fourth inflammatory morbidity of pregnancy?: Theory and literature review

Perinatal depression is one of the leading causes of maternal morbidity and mortality. The biological etiology of this disorder remains in question, despite considerable research into the contributions of hormonal imbalance, the role of monoamines, and dysregulation of the HPA axis. Because inflammation is known to be associated with major depression in men and non-perinatal women as well as with other important morbidities of pregnancy (such as preeclampsia, preterm birth, and gestational diabetes), and because these morbidities may correlate with perinatal depression, inflammation may be a common physiological pathway that can also help explain perinatal depression. In this paper, we review the theoretical background of inflammation in perinatal depression and then review the literature concerning immune and inflammatory factors in the etiology and course of perinatal depression. We close with recommendations for future studies in this still relatively unexplored area. Identification and understanding of a common pathophysiology between other pregnancy morbidities and perinatal depression would link physical and mental well-being, likely leading to better treatment and prevention.

MicroRNA expression profiles in placenta with severe preeclampsia using a PNA-based microarray

INTRODUCTION

Preeclampsia (PE) is a leading cause of maternal and neonatal mortality and morbidity worldwide. However, the pathophysiology of this disease is not yet fully understood. MiRNA plays an important role in post-transcriptional gene regulation. Recent studies have suggested that dysregulation of miRNAs in placental tissue is involved in the pathogenesis of PE. Therefore, we investigated miRNA profiles in PE placenta to understand the miRNA function in PE pathogenesis.

METHODS

MiRNA profiling was performed in 20 formalin-fixed and paraffin-embedded samples (10 placentas from severe PE and 10 from a control group). We used a hybridization-based microarray with a PNA-probe comprised of 158 miRNAs.

RESULTS

Thirteen miRNAs (miR-92b, miR-197, miR-342-3p, miR-296-5p, miR-26b, miR-25, miR-296-3p, miR-26a, miR-198, miR-202, miR-191, miR-95, and miR-204) were significantly overexpressed and two miRNAs (miR-21 and miR-223) were underexpressed in PE compared with the control group. Among 15 differentially expressed miRNAs, miR-26b, miR-296-5p, and miR-223 were found to be consistent with results from previous studies. We identified 893 genes that were predicted by at least three of four computational algorithms. Target genes participated in several signaling pathways, adherens junction, focal adhesion, and regulation of the actin cytoskeleton.

CONCLUSIONS

Several miRNAs are found to be dysregulated in placentas of PE patients and they seem to be closely associated with the early pathogenesis of PE. Further study is necessary to develop tools for early detection and management.

Association between pre-eclampsia and inherited thrombophilias

OBJECTIVE

The aim was to determine whether inherited thrombophilia increases the risk of pre-eclampsia (PE) or interferes with its clinical course.

MATERIAL AND METHODS

We included 50 patients with severe PE and 50 healthy pregnant women. Patients were evaluated for inherited thrombophilia.

RESULTS

Fourteen patients in the study group was factor V Leiden (FVL) carrier while it was 12% in the control group. In women with PE, FVL and other inherited thrombophilic factors were not more prevalent than in the controls.

CONCLUSION

The present study failed to demonstrate an association between the inherited thrombophilias and PE.

Altered expression of norepinephrine transporter and norepinephrine in human placenta cause pre-eclampsia through regulated trophoblast invasion

Objective

We investigated the norepinephrine transporter (NET) expression in normal and pre-eclamptic placentas and analyzed the invasion activity of trophoblastic cells based on norepinephrine (NE)-NET regulation.

Methods

NET and NE expression levels were examined by western blot and enzyme-linked immunosorbent assay, respectively. Trophoblast invasion activity, depending on NE-NET regulation, was determined by NET-small interfering RNA (siRNA) and NET transfection into the human extravillous trophoblast cells with or without NE treatment and invasion rates were analyzed by zymography and an invasion assay.

Results

NET mRNA was expressed at a low level in pre-eclamptic placentas compared with normal placentas and NE concentration in maternal plasma increased significantly in pre-eclamptic women compared to normal pregnant women (p<0.05). NET gene upregulation and NE treatment stimulated trophoblast cell invasion up to 2.5-fold (p<0.05) by stimulating matrix metalloproteinase-9 activity via the phosphoinositol-3-kinase/AKT signaling pathway, whereas NET-siRNA with NE treatment reduced invasion rates.

Conclusion

NET expression is reduced by inadequate regulation of NE levels during placental development. This suggests that a complementary balance between NET and NE regulates trophoblast cell invasion activities during placental development.