Signals of cell death and tissue turnover during physiological pregnancy, pre-eclampsia, and autoimmunity

The Correlation Between Neutrophil Elastase and Neutrophil-Lymphocyte Ratio in Endothelial Dysfunction of Preeclampsia

BACKGROUND

Preeclampsia (PE) is a serious inflammatory process that is unique to pregnancy, occurring at or after the 20th week of pregnancy, and leading to maternal and neonatal illness and systemic disruptions. Placental hypoxia leads to increased levels of cytokines and inflammatory syncytiotrophoblast microvillus membrane microparticles (STBM) which activates neutrophils leading to oxidative stress and endothelial dysfunction in preeclampsia. The mechanisms that cause PE in people remain unknown. To understand the pathophysiology of PE, numerous theories have been given. There is currently no proven treatment or early detecting marker for PE available so far.

METHODS

The present study includes 40 patients (20 controls and 20 PE patients) aged 20-45 years hospitalized at the Department of Obstetrics and Gynecology, Hamdard Institute of Medical Sciences and Research (HIMSR) and Hakeem Abdul Hameed Centenary (HAHC) Hospital, Jamia Hamdard, New Delhi. Nitric oxide (NO), neutrophil elastase (NE), and the neutrophil-to-lymphocyte ratio were measured. The blood and biochemical parameters in PE patients were also analyzed.

RESULTS

The neutrophil-to-lymphocyte ratio (NLR) was significantly increased in PE patients as compared to healthy pregnant. All the biochemical and hemodynamic parameters were assessed. The serum NO concentrations were lower in PE patients and endothelial dysfunction markers (NE and von Willebrand factor {vWF}) were markedly increased in PE patients. The difference was statistically significant with a p-value <0.05.

CONCLUSIONS

NLR is greatly increased in PE patients. An increase in NLR in PE patients occurs due to an increase in inflammatory markers and endothelial damage. Hence, the NLR could act as a novel diagnostic biomarker for depicting PE progression.

Apoptotic and non-apoptotic roles of caspases in placenta physiology and pathology

Caspases, a family of cysteine proteases, are pivotal regulators of apoptosis, the tightly controlled cell death process crucial for eliminating excessive or unnecessary cells during development, including placental development. Collecting research has unveiled the multifaceted roles of caspases in the placenta, extending beyond apoptosis. Apart from their involvement in placental tissue remodeling via apoptosis, caspases actively participate in essential regulatory processes, such as trophoblast fusion and differentiation, significantly influencing placental growth and functionality. In addition, growing evidence indicates an elevation in caspase activity under pathological conditions like pre-eclampsia (PE) and intrauterine growth restriction (IUGR), leading to excessive cell death as well as inflammation. Drawing from advancements in caspase research and placental development under both normal and abnormal conditions, we examine the significance of caspases in both cell death (apoptosis) and non-cell death-related processes within the placenta. We also discuss potential therapeutics targeting caspase-related pathways for placenta disorders.

Is the First-Trimester Systemic Immune-Inflammation Index Associated With Preeclampsia?

OBJECTIVE

Preeclampsia (PE) is a serious and common pregnancy issue. There is a systemic inflammation in PE and it is accompanied by increased oxidative stress, but the clear etiology has not been revealed. We aimed to predict PE with the systemic immune-inflammation index (SII) value calculated in the first trimester.

MATERIAL AND METHODS

 This is a retrospective study. One hundred fifty-seven pregnant women were included in the study. Twenty-seven pregnant women were excluded from the study. Age, gravida, parity, and hemogram values were recorded in the patients' first visit file records. The time and mode of delivery, birth weight, and APGAR scores were obtained from the file records of the patients. SII was created using the formula (neutrophil x platelet/lymphocyte).  Result: The study group included 30 pregnant women who had been diagnosed with PE. The control group consisted of the remaining 100 pregnant women. There was a statistically significant difference between PE and control groups in terms of SII (p=0.03). The SII level cut-off value for predicting PE was determined to be 836.83. This value's area was found to be 0.635 (0.519-0.752). Furthermore, the selectivity is 0.60 and the sensitivity is 0.40 for these values.  Conclusion: SII was found to be significantly higher in people with PE in the study. We showed that the SII value measured in the first trimester can be used to predict PE. It might make sense to combine this marker with the patient's history and other risk factors due to its low selectivity and sensitivity.

Placenta-mediated complications: Nucleosomes and free DNA concentrations differ depending on subtypes

BACKGROUND

Placenta-mediated pregnancy complications generate short- and long-term adverse medical outcomes for both the mother and the fetus. Nucleosomes and free DNA (fDNA) have been described in patients suffering from a wide range of inflammatory conditions.

OBJECTIVE

The objective of our study was to compare nucleosomes and fDNA circulating levels during pregnancy and particularly in women developing a placenta-mediated complication according to the subtype (preeclampsia or intrauterine growth restriction) (NCT01736826).

PATIENTS/METHODS

A total of 115 women were prospectively included in the study across three groups: 30 healthy non-pregnant women, 50 with normal pregnancy, and 35 with a complicated pregnancy. Blood samples were taken up to every 4 weeks for several women with normal pregnancy and nucleosomes and fDNA were quantified using enzyme-linked immunosorbent assay and quantitative polymerase chain reaction, respectively.

RESULTS

We show that nucleosomes and fDNA concentrations significantly increase during normal pregnancy, with concentrations at delivery differing between the two groups. Interestingly, we show that concentrations differ according to the type of placenta-mediated complications, with higher levels in preeclampsia compared to intrauterine growth restriction.

CONCLUSIONS

These data suggest that nucleosomes and fDNA may be additional actors participating in placenta-mediated pregnancy complications.

Cooperative inflammation: The recruitment of inflammatory signaling in marsupial and eutherian pregnancy

The evolution of viviparity in therian mammals, i.e. marsupials and "placental" mammals, occurred by retention of the conceptus in the female reproductive tract and precocious "hatching" from the shell coat. Both eutherian embryo implantation and the opossum embryo attachment reaction are evolutionarily derived from and homologous to a defensive inflammatory process induced after shell coat hatching. However, both lineages, marsupials and placental mammals, have modified the inflammatory response substantially. We review the induction, maintenance, and effects of inflammation throughout pregnancy, with special attention to the role of prostaglandins and the mucosal inflammatory response, both of which likely had roles in early mammalian viviparity. We propose that the key step was not only suppression of the inflammatory response after implantation in placental mammals, but also the transfer of the inflammatory cell-cell communication network to a different set of cell types than in generic inflammation. To support this conclusion we discuss evidence that pro-inflammatory signal production in the opossum is not limited to maternal cells, as expected in bona fide defensive inflammation, but also includes fetal tissues, in a process we term cooperative inflammation. The ways in which the inflammatory reaction was independently modified in these two lineages helps explain major life history differences between extant marsupials and eutherians.

Diagnostic value of neutrophil-lymphocyte ratio in preeclampsia: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Neutrophil-lymphocyte ratio (NLR) is one of the markers of systemic inflammation. Recent studies have associated NLR with diagnosis of preeclampsia (PE). However, due to small sample sizes and different research design, the diagnostic value of NLR in PE patients is not well understood. In this study, we evaluate the potential diagnostic value of NLR in PE.

METHODS

We searched PubMed, Embase, Cochrane Library, the Chinese National Knowledge Infrastructure (CNKI) databases, Wanfang data, VIP database and China Biomedical Literature Database systematically for relevant literatures up to May 20, 2018. All analyses were conducted using Meta-DiSc1.4 and Stata 12.0 software. Sensitivity, specificity and other measures of accuracy of NLR for the diagnosis of PE were pooled. Meta-regression was performed to identify the sources of heterogeneity.

RESULTS

This meta-analysis included a total of 7 studies. The pooled sensitivity and specificity were 0.74 (95% CI 0.71-0.76) and 0.64 (95%CI 0.61-0.68), positive likelihood ratio, 2.62 (95%CI1.79-3.84); negative likelihood ratio, 0.34 (95%CI 0.24-0.48); diagnostic odds ratio, 8.44 (95%CI 4-17.78), and area under the curve was 0.82. Meta regression showed that sample size was the main source of heterogeneity. Deeks funnel plot showed that there was no statistical significance for the evaluation of publication bias (P = .16).

CONCLUSION

Current evidence suggests that the diagnostic accuracy of NLR has unsatisfactory specificity but acceptable sensitivity for diagnosis of PE. Further large-scale prospective studies are required to validate the potential applicability of using NLR alone or in combination other markers as PE diagnostic biomarker and explore potential factors that may influence the accuracy of NLR for PE diagnosis.

The Neutrophil's Choice: Phagocytose vs Make Neutrophil Extracellular Traps

Neutrophils recognize particulate substrates of microbial or endogenous origin and react by sequestering the cargo via phagocytosis or by releasing neutrophil extracellular traps (NETs) outside the cell, thus modifying and alerting the environment and bystander leukocytes. The signals that determine the choice between phagocytosis and the generation of NETs are still poorly characterized. Neutrophils that had phagocytosed bulky particulate substrates, such as apoptotic cells and activated platelets, appear to be “poised” in an unresponsive state. Environmental conditions, the metabolic, adhesive and activation state of the phagocyte, and the size of and signals associated with the tethered phagocytic cargo influence the choice of the neutrophils, prompting either phagocytic clearance or the generation of NETs. The choice is dichotomic and apparently irreversible. Defects in phagocytosis may foster the intravascular generation of NETs, thus promoting vascular inflammation and morbidities associated with diseases characterized by defective phagocytic clearance, such as systemic lupus erythematosus. There is a strong potential for novel treatments based on new knowledge of the events determining the inflammatory and pro-thrombotic function of inflammatory leukocytes.

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.

Is neutrophil/lymphocyte ratio a useful marker to predict the severity of pre-eclampsia?

OBJECTIVE

To evaluate the relationship of neutrophil/lymphocyte ratio (NLR) with proteinuria and blood pressure level in patients with pre-eclampsia and to investigate whether or not NLR has a role in predicting the severity of pre-eclampsia.

STUDY DESIGN

The study comprised 30 healthy pregnant females (Group 1), 37 females with mild pre-eclampsia (Group 2) and 40 with severe pre-eclampsia (Group 3). All the study participants were statistically compared in respect of demographic data, proteinuria levels, and blood pressure levels.

RESULT

Age, body mass index, and gestational weeks were similar in all the groups. Maternal NLR was determined to be significantly high in the pre-eclamptic patients (Groups 2 and 3) compared to the healthy pregnant patients (Group 1) (p=0.017). NLR was significantly higher in the severe pre-eclampsia group than in the mild pre-eclampsia group (p=0.032). A significant positive correlation was determined in correlation analysis between NLR and proteinuria (p=0.013, r=0.319). There was also a significant and positive correlation between NLR and systolic/diastolic arterial pressure (p=0.007, r=0.285; p=0.044, r=0.213, respectively).

CONCLUSION

In conclusion, while NLR was determined as significantly high in patients with pre-eclampsia, to be able to use this in the classification of the severity of pre-eclampsia, there is a need for further studies on a more extensive population.

Chronic histiocytic intervillositis: outcome, associated diseases and treatment in a multicenter prospective study

Introduction: In this prospective multicenter study, we aimed to describe (1) the outcome of pregnancy in the case of previous chronic histiocytic intervillositis (CHI), (2) the immunological findings and associated diseases, (3) the treatments, and (4) the factors associated with pregnancy loss.

METHODS

We prospectively included all patients with a prior CHI with ongoing pregnancy between 2011 and 2013.

RESULTS

Twenty-four women (age 34±5 years) were included in this study. An autoimmune disease was present in seven (29%) cases. Twenty-one prospective pregnancies were treated. The number of live births was more frequent comparatively to the previous obstetrical issues (16/24 versus 24/76; p=0.003). Most of the pregnancies were treated (88%), whereas only 13% of previous pregnancies were treated (p<0.05). No difference was found with respect to the pregnancy outcome in the different treatment regimens. In univariate analyses, a prior history of intrauterine death and intrauterine growth restriction and the presence of CHI in prospective placentas were associated with failure to have a live birth.

DISCUSSION

In this multicenter study, we show the frequency of the associated autoimmune diseases in CHI, as well as the presence of autoantibodies without characterized autoimmune disease. The number of live births increased from 32% to 67% in the treated pregnancies. Despite the treatment intervention, the risk of preterm delivery remained at 30%. Last, we show that the recurrence rate of an adverse pregnancy outcome persisted at 30% despite treatment intervention.

CONCLUSION

CHI is associated with high recurrence rate and the combined regimen seems to be necessary, in particular, in the presence of previous intrauterine death.

Circulating microparticles in severe preeclampsia

The present study aimed to evaluate microparticles (MPs) from different sources in women with severe preeclampsia (PE) compared with normotensive pregnant women and non-pregnant women. This case-control study evaluated 28 pregnant women with severe PE, 30 normotensive pregnant women, and 29 non-pregnant women. MPs from neutrophils, endothelial cells, monocytes, platelets, leukocytes, erythrocytes, and syncytiotrophoblast were evaluated using flow cytometry. A higher total number of MPs were observed in women with severe PE compared with normotensive pregnant women and non-pregnant women (P=0.004 and P=0.001, respectively). MPs derived from erythrocytes were increased in women with severe PE compared with normotensive pregnant women (P=0.002). A trend towards association was observed between platelet count and the number of MPs derived from platelets (P=0.09) in severe PE group. A positive correlation was also found between the number of endothelial cell-derived MPs and the number of platelet-derived MPs, leukocyte-derived MPs, neutrophil-derived MPs, and lymphocyte-derived MPs (P<0.05) in severe PE pregnant women. MP counts can be increased in severe PE, and erythrocyte and endothelial cell-derived MPs seem to be associated to severe PE.

Hypertension negatively affects the pregnancy outcome in patients with antiphospholipid syndrome

The impact of hypertension in the pregnancies from autoimmune patients is not unequivocally defined. We have prospectively followed 168 pregnancies from 135 patients from four Italian centres to verify the potential impact of hypertension in the antiphospholipid syndrome (APS). The rate of preeclampsia, mean neonatal weight and gestational age at delivery were significantly lower in patients with both APS and hypertension than in patients with hypertension or APS alone. This information may be relevant for counselling and care of these patients.

Pentraxin 3 in maternal circulation: an association with preterm labor and preterm PROM, but not with intra-amniotic infection/inflammation

OBJECTIVE

Pentraxin 3 (PTX3) is an acute-phase protein that has an important role in the regulation of the innate immune response. The aim of this study was to determine if maternal plasma PTX3 concentration changes in the presence of intra-amniotic infection and/or inflammation (IAI) in women with preterm labor (PTL) and intact membranes, as well as those with preterm prelabor rupture of membranes (preterm PROM).

STUDY DESIGN

This cross-sectional study included women in the following groups: (1) nonpregnant (n=40); (2) uncomplicated pregnancies in the first (n=22), second (n=22) or third trimester (n=71, including 50 women at term not in labor); (3) uncomplicated pregnancies at term with spontaneous labor (n=49); (4) PTL and intact membranes who delivered at term (n=49); (5) PTL without IAI who delivered preterm (n=26); (6) PTL with IAI (n=65); (7) preterm PROM without IAI (n=25); and (8) preterm PROM with IAI (n=77). Maternal plasma PTX3 concentrations were determined by ELISA.

RESULTS

(1) Maternal plasma PTX3 concentrations increased with advancing gestational age (r=0.62, p<0.001); (2) women at term with spontaneous labor had a higher median plasma PTX3 concentration than those at term not in labor (8.29 ng/ml vs. 5.98  ng/ml, p=0.013); (3) patients with an episode of PTL, regardless of the presence or absence of IAI and whether these patients delivered preterm or at term had a higher median plasma PTX3 concentration than normal pregnant women (p<0.001 for all comparisons); (4) similarly, patients with preterm PROM, with or without IAI had a higher median plasma PTX3 concentration than normal pregnant women (p<0.001 for both comparisons); and (5) among patients with PTL and those with preterm PROM, IAI was not associated with significant changes in the median maternal plasma PTX3 concentrations.

CONCLUSIONS

The maternal plasma PTX3 concentration increases with advancing gestational age and is significantly elevated during labor at term and in the presence of spontaneous preterm labor or preterm PROM. These findings could not be explained by the presence of IAI, suggesting that the increased PTX3 concentration is part of the physiologic or pathologic activation of the pro-inflammatory response in the maternal circulation during the process of labor at term or preterm.

High-mobility group box 1 (HMGB1) as a master regulator of innate immunity

Damage-associated molecular patterns (DAMPs) comprise intracellular molecules characterized by the ability to reach the extracellular environment, where they prompt inflammation and tissue repair. The high-mobility box group 1 (HMGB1) protein is a prototypic DAMP and is highly conserved in evolution. HMGB1 is released upon cell and tissue necrosis and is actively produced by immune cells. Evidence suggests that HMGB1 acts as a key molecule of innate immunity, downstream of persistent tissue injury, orchestrating inflammation, stem cell recruitment/activation, and eventual tissue remodeling.

Distribution and maturity of dendritic cells in diseases of insufficient placentation

PROBLEM

The immunological equilibrium at the feto-maternal interphase contributes towards late gestational diseases like growth restriction (IUGR) pre-eclampsia (PE) and hemolysis, elevated liver enzymes, low platelets (HELLP)-syndrome. The state of activation of decidual dendritic cells (DC) has emerged as one of the central players influencing this immunological equilibrium.

METHOD OF STUDY

Paraffin-embedded tissue sections from 27 pregnancies were immunostained for DC markers DEC-205, DC-SIGN, DC-LAMP and costained for DC-SIGN/CD56 and DC-SIGN/ vascular endothelial growth factor receptor (VEGFR) -1 and -2. We investigated placental tissue of IUGR fetuses and of patients who developed PE or HELLP-syndrome as well as placental tissue derived from normal pregnancies.

RESULTS

We found that expression of DEC-205 and DC-SIGN was significantly upregulated in HELLP placentas, whereas expression of DC-LAMP was abrogated almost entirely. Costaining showed an interaction between DC-SIGN(+) DC and natural killer cells as well as costaining of VEGFR-1 and -2 and DC-SIGN. Pre-eclamptic and IUGR placentas showed no significant change in any of the investigated markers compared to normal controls.

CONCLUSION

Our data suggest a participation of DC-mediated immunological mechanisms in HELLP syndrome.

The long pentraxin 3 and its role in autoimmunity

OBJECTIVES

To review the physiological and physiopathological roles of pentraxin 3 (PTX3), focusing on autoimmunity and vascular pathology.

METHODS

A systematic literature review using the keywords "pentraxin 3," "innate immunity," "apoptosis," "autoimmunity," and "endothelial dysfunction" from 1990 to 2007 was performed. All relevant articles and pertinent secondary references in English were reviewed.

RESULTS

PTX3 has a large number of multiple functions in different contexts. PTX3 plays an important role in innate immunity, inflammation, vascular integrity, fertility, pregnancy, and also in the central nervous system. In innate immunity, its normal function is to increase the immune response to selected pathogens while also exerting control over potential autoimmune reactions. It maintains a tightly homeostatic equilibrium in the local immune microenvironment by avoiding an exaggerated immune response and controlling peripheral tolerance to self-antigens. In contrast, in some autoimmune diseases, PTX3 appears to be involved in the development of autoimmune phenomena. A possible explanation for these apparent paradoxical functions may be related to the highly polymorphic PTX3 gene.

CONCLUSION

PTX3 is physiologically a protective molecule. However, in several autoimmune diseases PTX3 appears to facilitate the development of autoimmunity. The PTX3 gene could influence the development of autoimmune reactions and vascular involvement in human pathology.