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Baschat AA, Darwin K, Vaught AJ. Hypertensive Disorders of Pregnancy and the Cardiovascular System: Causes, Consequences, Therapy, and Prevention. Am J Perinatol 2024; 41:1298-1310. [PMID: 36894160 DOI: 10.1055/a-2051-2127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Hypertensive disorders of pregnancy continue to be significant contributors to adverse perinatal outcome and maternal mortality, as well as inducing life-long cardiovascular health impacts that are proportional to the severity and frequency of pregnancy complications. The placenta is the interface between the mother and fetus and its failure to undergo vascular maturation in tandem with maternal cardiovascular adaptation by the end of the first trimester predisposes to hypertensive disorders and fetal growth restriction. While primary failure of trophoblastic invasion with incomplete maternal spiral artery remodeling has been considered central to the pathogenesis of preeclampsia, cardiovascular risk factors associated with abnormal first trimester maternal blood pressure and cardiovascular adaptation produce identical placental pathology leading to hypertensive pregnancy disorders. Outside pregnancy blood pressure treatment thresholds are identified with the goal to prevent immediate risks from severe hypertension >160/100 mm Hg and long-term health impacts that arise from elevated blood pressures as low as 120/80 mm Hg. Until recently, the trend for less aggressive blood pressure management during pregnancy was driven by fear of inducing placental malperfusion without a clear clinical benefit. However, placental perfusion is not dependent on maternal perfusion pressure during the first trimester and risk-appropriate blood pressure normalization may provide the opportunity to protect from the placental maldevelopment that predisposes to hypertensive disorders of pregnancy. Recent randomized trials set the stage for more aggressive risk-appropriate blood pressure management that may offer a greater potential for prevention for hypertensive disorders of pregnancy. KEY POINTS: · Optimal management of maternal blood pressure to prevent preeclampsia and its risks is undefined.. · Early gestational rheological damage to the intervillous space predisposes to preeclampsia and FGR.. · First trimester blood pressure management may need to aim for normotension to prevent preeclampsia..
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Affiliation(s)
| | - Kristin Darwin
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Arthur J Vaught
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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Kember AJ, Anderson JL, House SC, Reuter DG, Goergen CJ, Hobson SR. Impact of maternal posture on fetal physiology in human pregnancy: a narrative review. Front Physiol 2024; 15:1394707. [PMID: 38827993 PMCID: PMC11140392 DOI: 10.3389/fphys.2024.1394707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/24/2024] [Indexed: 06/05/2024] Open
Abstract
In numerous medical conditions, including pregnancy, gravity and posture interact to impact physiology and pathophysiology. Recent investigations, for example, pertaining to maternal sleeping posture during the third trimester and possible impact on fetal growth and stillbirth risk highlight the importance and potential clinical implications of the subject. In this review, we provide an extensive discussion of the impact of maternal posture on fetal physiology from conception to the postpartum period in human pregnancy. We conducted a systematic literature search of the MEDLINE database and identified 242 studies from 1991 through 2021, inclusive, that met our inclusion criteria. Herein, we provide a synthesis of the resulting literature. In the first section of the review, we group the results by the impact of maternal posture at rest on the cervix, uterus, placenta, umbilical cord, amniotic fluid, and fetus. In the second section of the review, we address the impact on fetal-related outcomes of maternal posture during various maternal activities (e.g., sleep, work, exercise), medical procedures (e.g., fertility, imaging, surgery), and labor and birth. We present the published literature, highlight gaps and discrepancies, and suggest future research opportunities and clinical practice changes. In sum, we anticipate that this review will shed light on the impact of maternal posture on fetal physiology in a manner that lends utility to researchers and clinicians who are working to improve maternal, fetal, and child health.
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Affiliation(s)
- Allan J. Kember
- Temerty Faculty of Medicine, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
- Shiphrah Biomedical Inc., Toronto, ON, Canada
| | - Jennifer L. Anderson
- Larner College of Medicine, University of Vermont, Burlington, VT, United States
| | - Sarah C. House
- Temerty Faculty of Medicine, Medical Education, University of Toronto, Toronto, ON, Canada
| | - David G. Reuter
- Cardiac Innovations, Seattle Children’s Hospital, Seattle, WA, United States
| | - Craig J. Goergen
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, United States
| | - Sebastian R. Hobson
- Temerty Faculty of Medicine, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Maternal-Fetal Medicine Division, Mount Sinai Hospital, Toronto, ON, Canada
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3
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Coleman J, Grewal S, Warland J, Hobson S, Liu K, Kember A. Maternal positional therapy for fetal growth and customised birth weight centile benefit in a Bayesian reanalysis of a double-blind, sham-controlled, randomised clinical trial. BMJ Open 2024; 14:e078315. [PMID: 38684260 PMCID: PMC11057287 DOI: 10.1136/bmjopen-2023-078315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 03/28/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES To update the Ghana PrenaBelt Trial's (GPT) primary outcome data with the latest fetal growth standard and reanalyse it. To estimate the posterior probability, under various clinically relevant prior probabilities, of maternal nightly positional therapy (PT) throughout the third-trimester having a beneficial effect on customised birth weight centile (CBWC) using Bayesian analyses. DESIGN A reanalysis of a double-blind, sham-controlled, randomised clinical trial. SETTING A single, tertiary-level centre in Accra, Ghana. PARTICIPANTS Two-hundred participants entered, 181 completed and 167 were included in the final analysis. Participants were Ghanaian, healthy, aged 18-35 years, with low-risk, singleton pregnancies in their third-trimester, with Body Mass Index<35 kg/m2 at the first antenatal appointment for the index pregnancy and without known fetal abnormalities, pregnancy complications or medical conditions complicating sleep. INTERVENTIONS Participants were randomised to receive treatment with either a PT or sham-PT device. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the CBWC using the latest Perinatal Institute, Gestation-Related Optimal Weight calculator. Using Bayesian methods, posterior probabilities of achieving a greater than 0%, 5% and 10% benefit in CBWC with PT were estimated. There was no secondary outcome. RESULTS The median (IQR) CBWC was 42% (15-71) and 28% (9-52) in the PT and sham-PT groups, respectively (difference 8.4%; 95% CI -0.30 to 18.2; p=0.06). For achieving a >0%, >5% and >10% gain in CBWC with PT, the posterior probabilities were highly probable, probable and unlikely, respectively, given a range of prior probabilities reflecting varying degrees of pre-existing enthusiasm and scepticism. CONCLUSIONS Maternal nightly PT throughout the third-trimester did not have a statistically significant effect on CBWC on a frequentist analysis using the latest fetal growth standard. However, from a Bayesian analysis, clinicians can infer that PT is likely to benefit fetal growth but with a modest effect size. TRIAL REGISTRATION NUMBER NCT02379728.
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Affiliation(s)
- Jerry Coleman
- Obstetrics & Gynaecology, Korle Bu Teaching Hospital, Accra, Greater Accra, Ghana
| | - Sahibjot Grewal
- University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Jane Warland
- The University of Adelaide Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - Sebastian Hobson
- Department of Obstetrics & Gynaecology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Kuan Liu
- Institute of Health Policy, Management, and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Allan Kember
- Department of Obstetrics & Gynaecology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
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Sutovska H, Babarikova K, Zeman M, Molcan L. Prenatal Hypoxia Affects Foetal Cardiovascular Regulatory Mechanisms in a Sex- and Circadian-Dependent Manner: A Review. Int J Mol Sci 2022; 23:2885. [PMID: 35270026 PMCID: PMC8910900 DOI: 10.3390/ijms23052885] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 02/28/2022] [Accepted: 03/05/2022] [Indexed: 11/17/2022] Open
Abstract
Prenatal hypoxia during the prenatal period can interfere with the developmental trajectory and lead to developing hypertension in adulthood. Prenatal hypoxia is often associated with intrauterine growth restriction that interferes with metabolism and can lead to multilevel changes. Therefore, we analysed the effects of prenatal hypoxia predominantly not associated with intrauterine growth restriction using publications up to September 2021. We focused on: (1) The response of cardiovascular regulatory mechanisms, such as the chemoreflex, adenosine, nitric oxide, and angiotensin II on prenatal hypoxia. (2) The role of the placenta in causing and attenuating the effects of hypoxia. (3) Environmental conditions and the mother's health contribution to the development of prenatal hypoxia. (4) The sex-dependent effects of prenatal hypoxia on cardiovascular regulatory mechanisms and the connection between hypoxia-inducible factors and circadian variability. We identified that the possible relationship between the effects of prenatal hypoxia on the cardiovascular regulatory mechanism may vary depending on circadian variability and phase of the days. In summary, even short-term prenatal hypoxia significantly affects cardiovascular regulatory mechanisms and programs hypertension in adulthood, while prenatal programming effects are not only dependent on the critical period, and sensitivity can change within circadian oscillations.
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Affiliation(s)
| | | | - Michal Zeman
- Department of Animal Physiology and Ethology, Faculty of Natural Sciences, Comenius University, 842 15 Bratislava, Slovakia; (H.S.); (K.B.); (L.M.)
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Siegmund AS, Pieper PG, Bilardo CM, Gordijn SJ, Khong TY, Gyselaers W, van Veldhuisen DJ, Dickinson MG. Cardiovascular determinants of impaired placental function in women with cardiac dysfunction. Am Heart J 2022; 245:126-135. [PMID: 34902313 DOI: 10.1016/j.ahj.2021.11.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 11/16/2021] [Accepted: 11/19/2021] [Indexed: 01/22/2023]
Abstract
Female heart disease has for a long time been an underrecognized problem in the field of cardiology. With an ever-growing number of these patients getting pregnant, cardiac dysfunction during pregnancy is an increasingly large medical problem. Previous work has shown that maternal heart disease may have an adverse effect on pregnancy outcome in both mother and child. The placenta forms the connection and it is postulated that cardiac dysfunction negatively affects the placenta, and consequently, neonatal outcome. Given the paucity of data in this field, more research on the influence of cardiac (mal)function on placental (mal)function is needed. The present review describes placental function in women with various types of cardiac dysfunction, thereby aiming to provide more insight into possible underlying mechanisms of placental malfunction. Organ dysfunction in patients with heart failure is for an important part based on reduced perfusion and venous congestion. This has been shown in other organs such as kidneys, liver and brain. In pregnant women with cardiac dysfunction, placental dysfunction may follow similar patterns. Moreover, other factors, such as pre-existing hypertension and chronic hypoxia may lead to further impairment of placental function, through abnormal vascular remodeling of the uterine spiral arteries. The pathophysiology of placental dysfunction in pregnant women with cardiac dysfunction may thus be multifactorial. It is therefore important to monitor closely cardiac and placental function in such high-risk pregnancies. Gaining a better understanding of the underlying pathophysiological mechanisms may have important clinical implications in terms of pregnancy counseling, monitoring and outcome.
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Link-Sourani D, Avisdris N, Harel S, Ben-Sira L, Ganot T, Gordon Z, Many A, Ben Bashat D. Ex-Vivo MRI of the Normal Human Placenta: Structural-Functional Interplay and the Association With Birth Weight. J Magn Reson Imaging 2021; 56:134-144. [PMID: 34799945 DOI: 10.1002/jmri.28002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advanced magnetic resonance imaging (MRI) methods are increasingly being used to assess the human placenta. Yet, the structure-function interplay in normal placentas and their associations with pregnancy risks are not fully understood. PURPOSE To characterize the normal human placental structure (volume and umbilical cord centricity index (CI)) and function (perfusion) ex-vivo using MRI, to assess their association with birth weight (BW), and identify imaging-markers for placentas at risk for dysfunction. STUDY TYPE Prospective. POPULATION Twenty normal term ex-vivo placentas. FIELD STRENGTH/SEQUENCE 3 T/ T1 and T2 weighted (T1 W, T2 W) turbo spin-echo, three-dimensional susceptibility-weighted image, and time-resolved angiography with interleaved stochastic trajectories (TWIST), during passage of a contrast agent using MRI compatible perfusion system that mimics placental flow. ASSESSMENT Placental volume and CI were manually extracted from the T1 W images by a fetal-placental MRI scientist (D.L., 7 years of experience). Perfusion maps including bolus arrival-time and full-width at half maximum were calculated from the TWIST data. Mean values, entropy, and asymmetries were calculated from each perfusion map, relating to both the whole placenta and volumes of interest (VOIs) within the umbilical cord and its daughter blood vessels. STATISTICAL TESTS Pearson correlations with correction for multiple comparisons using false discovery rate were performed between structural and functional parameters, and with BW, with P < 0.05 considered significant. RESULTS All placentas were successfully perfused and scanned. Significant correlations were found between whole placenta and VOIs perfusion parameters (mean R = 0.76 ± 0.06, range = 0.67-0.89), which were also significantly correlated with CI (mean R = 0.72 ± 0.05, range = 0.65-0.79). BW was correlated with placental volume (R = 0.62), but not with CI (P = 0.40). BW was also correlated with local perfusion asymmetry (R = -0.71). DATA CONCLUSION Results demonstrate a gradient of placental function, associated with CI and suggest several ex-vivo imaging-markers that might indicate an increased risk for placental dysfunction. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY: Stage 1.
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Affiliation(s)
| | - Netanell Avisdris
- Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shaul Harel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Liat Ben-Sira
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Pediatric Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Tuvia Ganot
- Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Zoya Gordon
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Department of Medical Engineering, Afeka, Tel Aviv Academic College of Engineering, Tel Aviv, Israel
| | - Ariel Many
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Dafna Ben Bashat
- Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
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7
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Silva P, Maronezi MC, Padilha-Nakaghi LC, Gasser B, Pavan L, Nogueira Aires LP, Russo M, Spada S, Ramirez Uscategui RA, Moraes PC, Rossi Feliciano MA. Contrast-enhanced ultrasound evaluation of placental perfusion in brachicephalic bitches. Theriogenology 2021; 173:230-240. [PMID: 34399387 DOI: 10.1016/j.theriogenology.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 10/20/2022]
Abstract
The present study aimed to investigate placental hemodynamics to determine quantitative and qualitative parameters for pregnant brachycephalic bitches as well as describe placental vascularization and perfusion in females with fetal abnormalities close to delivery. Forty-four healthy fetuses from 22 brachycephalic bitches and 9 fetuses with gestational abnormalities (anasarca and hydrocephalus) from 8 brachycephalic bitches were evaluated. All female dogs were artificially inseminated intravaginally and underwent cesarean section at the end of gestation. Pregnancy diagnosis was made on the 25th day and experimental evaluations were performed on Days 25 (M1), 45 (M2), and 58 (M3) of gestation in normal pregnancies. Fetuses with gestational abnormalities were evaluated at the last time point. Biometric values of the fetuses were determined by B-mode and vascular indices by Doppler fluxometry of the umbilical artery, whereas qualitative assessment of contrast filling and quantitative parameters of placental perfusion were performed using CEUS. Parameter comparisons among the examined fetuses (normal and abnormal) and between the moments (M1, M2, and M3) were performed by Student's t-test and ANOVA tests, and then correlated using the Spearman test. In healthy fetuses, systolic and diastolic velocities as well as the time averages of minimum and maximum velocities increased significantly from M2 to M3 (P < 0.05), whereas the pulsatility index (P < 0.043) and vascular resistance (P < 0.001) decreased. Contrast distribution was always homogeneous in placental tissues and CEUS filling parameters remained constant during the evaluated periods (P < 0.05). In fetuses with hydrops, Doppler values were similar to those obtained in healthy subjects (P > 0.05), but CEUS evaluation demonstrated a heterogeneous distribution with lower intensity of placental tissue filling and a delay in perfusion time (P < 0.05) with a diagnostic accuracy of 75%. The association of dopplerfluxometry and CEUS allowed evaluation of qualitative and quantitative parameters of physiological pregnancy hemodynamics in all gestational thirds without evidence of significant changes in the physiology of the maternal-fetal binomial, and CEUS was shown to be applicable in the detection of failures in placental vascular filling (tissue dysfunction) in fetuses with anasarca and hydrocephaly.
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Affiliation(s)
- Priscila Silva
- School of Agricultural and Veterinarian Sciences, São Paulo State University (Unesp), Jaboticabal, São Paulo, Brazil
| | - Marjury Cristina Maronezi
- School of Agricultural and Veterinarian Sciences, São Paulo State University (Unesp), Jaboticabal, São Paulo, Brazil
| | | | - Beatriz Gasser
- School of Agricultural and Veterinarian Sciences, São Paulo State University (Unesp), Jaboticabal, São Paulo, Brazil
| | | | - Luiz Paulo Nogueira Aires
- School of Agricultural and Veterinarian Sciences, São Paulo State University (Unesp), Jaboticabal, São Paulo, Brazil
| | - Marco Russo
- Department of Veterinary Medicine and Animal Sciences University of Naples "Federico II", Italy
| | - Stefano Spada
- Department of Veterinary Medicine and Animal Sciences University of Naples "Federico II", Italy
| | - Ricardo Andrés Ramirez Uscategui
- Institute of Agricultural Sciences, Federal University of the Jequitinhonha and Mucuri Valleys (UFVJM), Unaí, Minas Gerais, Brazil
| | - Paola Castro Moraes
- School of Agricultural and Veterinarian Sciences, São Paulo State University (Unesp), Jaboticabal, São Paulo, Brazil
| | - Marcus Antônio Rossi Feliciano
- School of Agricultural and Veterinarian Sciences, São Paulo State University (Unesp), Jaboticabal, São Paulo, Brazil; Diagnostic Imaging Service, Department of Large Animal Clinic, Federal University of Santa Maria (UFSM), Santa Maria, Rio Grande do Sul, Brazil.
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Sola IM, Serman A, Karin-Kujundzic V, Paic F, Skrtic A, Slatina P, Kakarigi L, Vranic S, Serman L. Dishevelled family proteins (DVL1-3) expression in intrauterine growth restriction (IUGR) placentas. Bosn J Basic Med Sci 2021; 21:447-453. [PMID: 33485290 PMCID: PMC8292871 DOI: 10.17305/bjbms.2020.5422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/26/2020] [Indexed: 11/26/2022] Open
Abstract
Dishevelled family proteins (DVL1, DVL2, and DVL3) are cytoplasmic proteins that are involved in canonical and non-canonical Wnt signaling pathway during embryonic development. The role of DVL proteins in the placental tissue remains mostly unknown. In the current study, we explored the role of Dishevelled proteins in naturally invasive tissue, trophoblast. Formalin-fixed paraffin-embedded samples of 15 term placentas from physiologic term pregnancies and 15 term placentas from pregnancies complicated with intrauterine growth restrictions (IUGR) were used for the study. Expression levels of mRNA for DVL1, DVL2, and DVL3 in placentas were analyzed by quantitative real-time PCR (qRT-PCR). DVL1, DVL2, and DVL3 protein expression were semi-quantitatively analyzed using immunohistochemistry. The expression of DVL3 protein was significantly higher in trophoblasts and endothelial cells in placental villi from IUGR pregnancies compared with the control group of term placentas, while DVL2 protein expression was significantly higher in trophoblasts in placental villi from IUGR pregnancies compared with normal term placentas. The observed differences at protein levels between normal and IUGR placentas were not confirmed at the mRNA levels of DVL genes. Our data indicate the active involvement of DVL proteins in IUGR-related placentas. No significant changes were observed in DVL mRNA levels between the two groups of placentas. Further studies are required to explore the clinical relevance of these observations.
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Affiliation(s)
- Ida Marija Sola
- Department of Obstetrics and Gynecology, University Hospital "Sestre Milosrdnice", Zagreb, Croatia
| | - Alan Serman
- Department of Gynecology and Obstetrics, School of Medicine, University of Zagreb, Zagreb, Croatia; Clinic of Obstetrics and Gynecology, Clinical Hospital "Sveti Duh", Zagreb, Croatia; Centre of Excellence in Reproductive and Regenerative Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Valentina Karin-Kujundzic
- Centre of Excellence in Reproductive and Regenerative Medicine, University of Zagreb School of Medicine, Zagreb, Croatia; Department of Biology, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Frane Paic
- Department of Biology, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Anita Skrtic
- Centre of Excellence in Reproductive and Regenerative Medicine, University of Zagreb School of Medicine, Zagreb, Croatia; Department of Pathology, School of Medicine, University of Zagreb, Zagreb, Croatia; Department of Pathology, University Hospital "Merkur", Zagreb, Croatia
| | - Paula Slatina
- Department of Biology, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Luka Kakarigi
- Department of Biology, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Semir Vranic
- College of Medicine, QU Health, Qatar University, Doha, Qatar; Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha, Qatar
| | - Ljiljana Serman
- Centre of Excellence in Reproductive and Regenerative Medicine, University of Zagreb School of Medicine, Zagreb, Croatia; Department of Biology, School of Medicine, University of Zagreb, Zagreb, Croatia
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Resta L, Vimercati A, Cazzato G, Mazzia G, Cicinelli E, Colagrande A, Fanelli M, Scarcella SV, Ceci O, Rossi R. SARS-CoV-2 and Placenta: New Insights and Perspectives. Viruses 2021; 13:723. [PMID: 33919284 PMCID: PMC8143362 DOI: 10.3390/v13050723] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 02/05/2023] Open
Abstract
The study of SARS-CoV-2 positive pregnant women is of some importance for gynecologists, obstetricians, neonatologists and women themselves. In recent months, new works have tried to clarify what happens at the fetal-placental level in women positive for the virus, and different pathogenesis mechanisms have been proposed. Here, we present the results of a large series of placentas of Coronavirus disease (COVID) positive women, in a reference center for COVID-positive pregnancies, on which we conducted histological, immunohistochemical and electron microscopy investigations. A case-control study was conducted in order to highlight any histopathological alterations attributable to SARS-CoV-2. The prevalence of maternal vascular malperfusion was not significantly different between cases and controls (54.3% vs. 43.7% p = 0.19), whereas the differences with regard to fetal vascular malperfusion (21.1% vs. 4.2% p < 0.001) were significant. More frequent in cases with respect to controls were decidual arteriopathy (40.9% vs. 1.4% p < 0.0001), decidual inflammation (32.4% vs. 0.7% p < 0.0001), perivillous fibrin deposition (36.6% vs. 3.5% p < 0.0001) and fetal vessel thrombi (22.5% vs. 0.7% p < 0.0001). No significant differences in the percentage of terminal villous hyperplasia and chorioamnionitis were observed between the two groups. As the pandemic continues, these studies will become more urgent in order to clarify the possible mechanism of maternal-fetal transmission of the virus.
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Affiliation(s)
- Leonardo Resta
- Section of Pathology, Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.R.); (G.M.); (A.C.); (S.V.S.); (O.C.); (R.R.)
| | - Antonella Vimercati
- Department of Biomedical Sciences and Human Oncology, Gynecologic and Obstetrics Clinic, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.V.); (E.C.)
| | - Gerardo Cazzato
- Section of Pathology, Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.R.); (G.M.); (A.C.); (S.V.S.); (O.C.); (R.R.)
| | - Giulia Mazzia
- Section of Pathology, Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.R.); (G.M.); (A.C.); (S.V.S.); (O.C.); (R.R.)
| | - Ettore Cicinelli
- Department of Biomedical Sciences and Human Oncology, Gynecologic and Obstetrics Clinic, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.V.); (E.C.)
| | - Anna Colagrande
- Section of Pathology, Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.R.); (G.M.); (A.C.); (S.V.S.); (O.C.); (R.R.)
| | - Margherita Fanelli
- Medical Statistic, Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy;
| | - Sara Vincenza Scarcella
- Section of Pathology, Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.R.); (G.M.); (A.C.); (S.V.S.); (O.C.); (R.R.)
| | - Oronzo Ceci
- Section of Pathology, Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.R.); (G.M.); (A.C.); (S.V.S.); (O.C.); (R.R.)
| | - Roberta Rossi
- Section of Pathology, Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.R.); (G.M.); (A.C.); (S.V.S.); (O.C.); (R.R.)
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10
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Bhattacharjee J, Mohammad S, Adamo KB. Does exercise during pregnancy impact organs or structures of the maternal-fetal interface? Tissue Cell 2021; 72:101543. [PMID: 33940567 DOI: 10.1016/j.tice.2021.101543] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/07/2021] [Accepted: 04/10/2021] [Indexed: 12/12/2022]
Abstract
Exercise during pregnancy has been shown to be associated with improved health outcomes both during and after pregnancy for mother and fetus across the lifespan. Increasing physical activity and reducing sedentary behaviour during pregnancy have been recommended by many researchers and clinicians-alike. It is thought that the placenta plays a central role in mediating any positive or negative pregnancy outcomes. The positive outcomes obtained through prenatal exercise are postulated to result from exercise-induced regulation of maternal physiology and placental development. Considerable research has been performed to understand the placenta's role in pregnancy-related diseases, such as preeclampsia, fetal growth restriction, and gestational diabetes mellitus. However, little research has examined the potential for healthy lifestyle and behavioural changes to improve placental growth, development, and function. While the placenta represents the critical maternal-fetal interface responsible for all gas, nutrient, and waste exchange between the mother and fetus, the impact of exercise during pregnancy on placental biology and function is not well known. This review will focus on prenatal exercise and its promising influence on the structures of the maternal-fetal interface, with particular emphasis on the placenta. Potential molecular mechanistic hypotheses are presented to aid future investigations of prenatal exercise and placental health.
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Affiliation(s)
- Jayonta Bhattacharjee
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Shuhiba Mohammad
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Kristi B Adamo
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada.
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11
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Abstract
Normal pregnancy is a complex and dynamic process that requires significant adaptation from the maternal system. Failure of this adaptive process in pregnancy contributes to many pregnancy related disorders, including the hypertensive disorders of pregnancy. This article discusses placental development and how abnormalities in the process of vascular remodeling contribute to the multisystem maternal and fetal disease that is preeclampsia and fetal growth restriction. We review some of the consequences of this condition on the mother and fetus, aspects of the clinical management of preeclampsia and how it can influence both mother and infant in the postnatal period and beyond.
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12
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Kretschmer T, Schulze-Edinghausen M, Turnwald EM, Janoschek R, Bae-Gartz I, Zentis P, Handwerk M, Wohlfarth M, Schauss A, Hucklenbruch-Rother E, Dötsch J, Appel S. Effect of Maternal Obesity in Mice on IL-6 Levels and Placental Endothelial Cell Homeostasis. Nutrients 2020; 12:nu12020296. [PMID: 31979004 PMCID: PMC7071123 DOI: 10.3390/nu12020296] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/17/2020] [Accepted: 01/20/2020] [Indexed: 12/29/2022] Open
Abstract
Obesity during pregnancy is a known health risk for mother and child. Since obesity is associated with increased inflammatory markers, our objectives were to determine interleukin-6 (IL-6) levels in obese mice and to examine the effect of IL-6 on placental endothelial cells. Placentas, blood, and adipose tissue of C57BL/6N mice, kept on high fat diet before and during pregnancy, were harvested at E15.5. Serum IL-6 levels were determined and endothelial cell markers and IL-6 expression were measured by qRT-PCR and western blot. Immunostaining was used to determine surface and length densities of fetal capillary profiles and placental endothelial cell homeostasis. Human placental vein endothelial cells were cultured and subjected to proliferation, apoptosis, senescence, and tube formation assays after stimulation with hyperIL-6. Placental endothelial cell markers were downregulated and the percentage of senescent endothelial cells was higher in the placental exchange zone of obese dams and placental vascularization was strongly reduced. Additionally, maternal IL-6 serum levels and IL-6 protein levels in adipose tissue were increased. Stimulation with hyperIL-6 provoked a dose dependent increase of senescence in cultured endothelial cells without any effects on proliferation or apoptosis. Diet-induced maternal obesity led to an IUGR phenotype accompanied by increased maternal IL-6 serum levels. In the placenta of obese dams, this may result in a disturbed endothelial cell homeostasis and impaired fetal vasculature. Cell culture experiments confirmed that IL-6 is capable of inducing endothelial cell senescence.
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Affiliation(s)
- Tobias Kretschmer
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (M.S.-E.); (E.-M.T.); (R.J.); (I.B.-G.); (M.H.); (M.W.); (E.H.-R.); (J.D.); (S.A.)
- Center for Molecular Medicine Cologne (CMMC), University of Cologne, Robert-Koch-Strasse 21, 50931 Cologne, Germany
- Correspondence: ; Tel.: +49-221-478-89672
| | - Merle Schulze-Edinghausen
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (M.S.-E.); (E.-M.T.); (R.J.); (I.B.-G.); (M.H.); (M.W.); (E.H.-R.); (J.D.); (S.A.)
| | - Eva-Maria Turnwald
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (M.S.-E.); (E.-M.T.); (R.J.); (I.B.-G.); (M.H.); (M.W.); (E.H.-R.); (J.D.); (S.A.)
| | - Ruth Janoschek
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (M.S.-E.); (E.-M.T.); (R.J.); (I.B.-G.); (M.H.); (M.W.); (E.H.-R.); (J.D.); (S.A.)
| | - Inga Bae-Gartz
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (M.S.-E.); (E.-M.T.); (R.J.); (I.B.-G.); (M.H.); (M.W.); (E.H.-R.); (J.D.); (S.A.)
| | - Peter Zentis
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Core Facility Imaging, University of Cologne, Joseph-Stelzmann-Strasse 26, 50931 Cologne, Germany; (P.Z.); (A.S.)
| | - Marion Handwerk
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (M.S.-E.); (E.-M.T.); (R.J.); (I.B.-G.); (M.H.); (M.W.); (E.H.-R.); (J.D.); (S.A.)
| | - Maria Wohlfarth
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (M.S.-E.); (E.-M.T.); (R.J.); (I.B.-G.); (M.H.); (M.W.); (E.H.-R.); (J.D.); (S.A.)
| | - Astrid Schauss
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Core Facility Imaging, University of Cologne, Joseph-Stelzmann-Strasse 26, 50931 Cologne, Germany; (P.Z.); (A.S.)
| | - Eva Hucklenbruch-Rother
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (M.S.-E.); (E.-M.T.); (R.J.); (I.B.-G.); (M.H.); (M.W.); (E.H.-R.); (J.D.); (S.A.)
| | - Jörg Dötsch
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (M.S.-E.); (E.-M.T.); (R.J.); (I.B.-G.); (M.H.); (M.W.); (E.H.-R.); (J.D.); (S.A.)
| | - Sarah Appel
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (M.S.-E.); (E.-M.T.); (R.J.); (I.B.-G.); (M.H.); (M.W.); (E.H.-R.); (J.D.); (S.A.)
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Michelsen TM, Holme AM, Holm MB, Roland MC, Haugen G, Powell TL, Jansson T, Henriksen T. Uteroplacental Glucose Uptake and Fetal Glucose Consumption: A Quantitative Study in Human Pregnancies. J Clin Endocrinol Metab 2019; 104:873-882. [PMID: 30339207 DOI: 10.1210/jc.2018-01154] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 10/15/2018] [Indexed: 12/16/2022]
Abstract
CONTEXT Maternal glucose levels and body mass index (BMI) are determinants of fetal overgrowth, but their relation to fetal glucose consumption is not well characterized in human pregnancy. OBJECTIVES To quantify uteroplacental glucose uptake and the allocation of glucose between the placenta and fetus and to identify factors that affect fetal glucose consumption. DESIGN Human in vivo study in term pregnancies. SETTING Oslo University Hospital, Norway. PARTICIPANTS One hundred seventy-nine healthy women with elective cesarean section. INTERVENTIONS Uterine and umbilical blood flow was determined using Doppler ultrasonography. Glucose and insulin were measured in the maternal radial artery and uterine vein and the umbilical artery and vein. In a subcohort (n = 33), GLUT1 expression was determined in isolated syncytiotrophoblast basal and microvillous plasma membranes. MAIN OUTCOME MEASURES Uteroplacental glucose uptake and placental and fetal glucose consumption quantified by the Fick principle. RESULTS Median (Q1, Q3) uteroplacental glucose uptake was 117.1 (59.1, 224.9) μmol⋅min-1, and fetal and placental glucose consumptions were 28.9 (15.4, 41.8) µmol⋅min-1⋅kg fetus-1 and 51.4 (-65.8, 185.4) µmol⋅min-1⋅kg placenta-1, respectively. Fetal glucose consumption correlated with birth weight (ρ: 0.34; P < 0.001) and maternal-fetal glucose gradient (ρ: 0.60; P < 0.001), but not with maternal BMI or uteroplacental glucose uptake. Uteroplacental glucose uptake was correlated to placental glucose consumption (ρ: 0.77; P < 0.001). Fetal and placental glucose consumptions were inversely correlated (ρ: -0.47; P < 0.001), but neither was correlated with placental GLUT1 expression. CONCLUSION These findings suggest that fetal glucose consumption is balanced against the placental needs for glucose and that placental glucose consumption is a key modulator of maternal-fetal glucose transfer in women.
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Affiliation(s)
- Trond M Michelsen
- Department of Obstetrics Rikshospitalet, Division of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Research Unit, Sørlandet Hospital, Arendal, Norway
| | - Ane M Holme
- Department of Obstetrics Rikshospitalet, Division of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Maia B Holm
- Department of Obstetrics Rikshospitalet, Division of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Marie C Roland
- Department of Obstetrics Rikshospitalet, Division of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
- Norwegian Advisory Unit on Women's Health, Oslo University Hospital, Oslo, Norway
| | - Guttorm Haugen
- University of Oslo, Oslo, Norway
- Department of Fetal Medicine, Division of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
| | - Theresa L Powell
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Division of Neonatology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Thomas Jansson
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Tore Henriksen
- Department of Obstetrics Rikshospitalet, Division of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
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14
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Jensen OE, Chernyavsky IL. Blood flow and transport in the human placenta. ANNUAL REVIEW OF FLUID MECHANICS 2019; 51:25-47. [PMID: 38410641 PMCID: PMC7615669 DOI: 10.1146/annurev-fluid-010518-040219] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
The placenta is a multi-functional organ that exchanges blood gases and nutrients between a mother and her developing fetus. In humans, fetal blood flows through intricate networks of vessels confined within villous trees, the branches of which are bathed in pools of maternal blood. Fluid mechanics and transport processes play a central role in understanding how these elaborate structures contribute to the function of the placenta, and how their disorganization may lead to disease. Recent advances in imaging and computation have spurred significant advances in simulations of fetal and maternal flows within the placenta, across a range of lengthscales. Models describe jets of maternal blood emerging from spiral arteries into a disordered and deformable porous medium, and solute uptake by fetal blood flowing through elaborate three-dimensional capillary networks. We survey recent developments and emerging challenges in modeling flow and transport in this complex organ.
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Affiliation(s)
| | - Igor L. Chernyavsky
- School of Mathematics, University of Manchester, UK
- Maternal and Fetal Health Research Centre, Division of Developmental
Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine
& Health, University of Manchester, UK
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15
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Cahill LS, Rennie MY, Hoggarth J, Yu LX, Rahman A, Kingdom JC, Seed M, Macgowan CK, Sled JG. Feto- and utero-placental vascular adaptations to chronic maternal hypoxia in the mouse. J Physiol 2017; 596:3285-3297. [PMID: 28861917 DOI: 10.1113/jp274845] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 08/25/2017] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS Chronic fetal hypoxia is one of the most common complications of pregnancy and is known to cause fetal growth restriction. The structural adaptations of the placental vasculature responsible for growth restriction with chronic hypoxia are not well elucidated. Using a mouse model of chronic maternal hypoxia in combination with micro-computed tomography and scanning electron microscopy, we found several placental adaptations that were beneficial to fetal growth including capillary expansion, thinning of the interhaemal membrane and increased radial artery diameters, resulting in a large drop in total utero-placental vascular resistance. One of the mechanisms used to achieve the rapid increase in capillaries was intussusceptive angiogenesis, a strategy used in human placental development to form terminal gas-exchanging villi. These results contribute to our understanding of the structural mechanisms of the placental vasculature responsible for fetal growth restriction and provide a baseline for understanding adaptive physiological responses of the placenta to chronic hypoxia. ABSTRACT The fetus and the placenta in eutherian mammals have a unique set of compensatory mechanisms to respond to several pregnancy complications including chronic maternal hypoxia. This study examined the structural adaptations of the feto- and utero-placental vasculature in an experimental mouse model of chronic maternal hypoxia (11% O2 from embryonic day (E) 14.5-E17.5). While placental weights were unaffected by exposure to chronic hypoxia, using micro-computed tomography, we found a 44% decrease in the absolute feto-placental arterial vascular volume and a 30% decrease in total vessel segments in the chronic hypoxia group compared to control group. Scanning electron microscopy imaging showed significant expansion of the capillary network; consequently, the interhaemal membrane was 11% thinner to facilitate maternal-fetal exchange in the chronic hypoxia placentas. One of the mechanisms for the rapid capillary expansion was intussusceptive angiogenesis. Analysis of the utero-placental arterial tree showed significant increases (24%) in the diameter of the radial arteries, resulting in a decrease in the total utero-placental resistance by 2.6-fold in the mice exposed to chronic maternal hypoxia. Together these adaptations acted to preserve placental weight whereas fetal weight was decreased.
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Affiliation(s)
- Lindsay S Cahill
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Monique Y Rennie
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Johnathan Hoggarth
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lisa X Yu
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anum Rahman
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - John C Kingdom
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Mike Seed
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christopher K Macgowan
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - John G Sled
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
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16
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Rennie MY, Cahill LS, Adamson SL, Sled JG. Arterio-venous fetoplacental vascular geometry and hemodynamics in the mouse placenta. Placenta 2017; 58:46-51. [PMID: 28962695 DOI: 10.1016/j.placenta.2017.08.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/08/2017] [Accepted: 08/11/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The fetoplacental vasculature network is essential for the exchange of nutrients, gases and wastes with the maternal circulation and for normal fetal development. The present study quantitatively compares arterial and venous morphological and functional differences in the mouse fetoplacental vascular network. METHODS High resolution X-ray micro-computed tomography was used to visualize the 3D geometry of the arterial and venous fetoplacental vasculature in embryonic day 15.5 CD-1 mice (n = 5). Automated image analysis was used to measure the vascular geometry of the approximately 4100 arterial segments and 3200 venous segments per specimen to simulate blood flow through these networks. RESULTS Both the arterial and venous trees demonstrated a hierarchical branching structure with 8 or 9 (arterial) or 8 (venous) orders. The venous tree was smaller in volume and overall dimensions than the arterial tree. Venous vessel diameters increased more rapidly than arteries with each successive order, leading to lower overall resistance, although the umbilical vein was notably smaller and of higher resistance than these scaling relationships would predict. Simulation of blood flow for these vascular networks showed that 57% of total resistance resides in the umbilical artery and arterial tree, 17% in the capillary bed, and 26% in the venous tree and umbilical vein. DISCUSSION A detailed examination of the mouse fetoplacental arterial and venous tree revealed features, such as the distribution of resistance and the dimension of the venous tree, that were both morphologically distinct from other vascular beds and that appeared adapted to the specialized requirements of sustaining a fetus.
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Affiliation(s)
- Monique Y Rennie
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lindsay S Cahill
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - S Lee Adamson
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario Canada
| | - John G Sled
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario Canada; Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.
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17
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Dynamic modeling of uteroplacental blood flow in IUGR indicates vortices and elevated pressure in the intervillous space - a pilot study. Sci Rep 2017; 7:40771. [PMID: 28102332 PMCID: PMC5244422 DOI: 10.1038/srep40771] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 12/12/2016] [Indexed: 01/14/2023] Open
Abstract
Ischemic placental disease is a concept that links intrauterine growth retardation (IUGR) and preeclampsia (PE) back to insufficient remodeling of uterine spiral arteries. The rheological consequences of insufficient remodeling of uterine spiral arteries were hypothesized to mediate the considerably later manifestation of obstetric disease. However, the micro-rheology in the intervillous space (IVS) cannot be examined clinically and rheological animal models of the human IVS do not exist. Thus, an in silico approach was implemented to provide in vivo inaccessible data. The morphology of a spiral artery and the inflow region of the IVS were three-dimensionally reconstructed to provide a morphological stage for the simulations. Advanced high-end supercomputing resources were used to provide blood flow simulations at high spatial resolution. Our simulations revealed turbulent blood flow (high-velocity jets and vortices) combined with elevated blood pressure in the IVS and increased wall shear stress at the villous surface in conjunction with insufficient spiral artery remodeling only. Post-hoc histological analysis of uterine veins showed evidence of increased trophoblast shedding in an IUGR placenta. Our data support that rheological alteration in the IVS is a relevant mechanism linking ischemic placental disease to altered structural integrity and function of the placenta.
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18
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Pearce P, Brownbill P, Janáček J, Jirkovská M, Kubínová L, Chernyavsky IL, Jensen OE. Image-Based Modeling of Blood Flow and Oxygen Transfer in Feto-Placental Capillaries. PLoS One 2016; 11:e0165369. [PMID: 27788214 PMCID: PMC5082864 DOI: 10.1371/journal.pone.0165369] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 10/11/2016] [Indexed: 11/29/2022] Open
Abstract
During pregnancy, oxygen diffuses from maternal to fetal blood through villous trees in the placenta. In this paper, we simulate blood flow and oxygen transfer in feto-placental capillaries by converting three-dimensional representations of villous and capillary surfaces, reconstructed from confocal laser scanning microscopy, to finite-element meshes, and calculating values of vascular flow resistance and total oxygen transfer. The relationship between the total oxygen transfer rate and the pressure drop through the capillary is shown to be captured across a wide range of pressure drops by physical scaling laws and an upper bound on the oxygen transfer rate. A regression equation is introduced that can be used to estimate the oxygen transfer in a capillary using the vascular resistance. Two techniques for quantifying the effects of statistical variability, experimental uncertainty and pathological placental structure on the calculated properties are then introduced. First, scaling arguments are used to quantify the sensitivity of the model to uncertainties in the geometry and the parameters. Second, the effects of localized dilations in fetal capillaries are investigated using an idealized axisymmetric model, to quantify the possible effect of pathological placental structure on oxygen transfer. The model predicts how, for a fixed pressure drop through a capillary, oxygen transfer is maximized by an optimal width of the dilation. The results could explain the prevalence of fetal hypoxia in cases of delayed villous maturation, a pathology characterized by a lack of the vasculo-syncytial membranes often seen in conjunction with localized capillary dilations.
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Affiliation(s)
- Philip Pearce
- School of Mathematics, University of Manchester, Manchester, M13 9PL, United Kingdom
- * E-mail:
| | - Paul Brownbill
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, United Kingdom
- Maternal and Fetal Health Research Centre, St. Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom
| | - Jiří Janáček
- Department of Biomathematics, Institute of Physiology, v.v.i., Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - Marie Jirkovská
- Institute of Histology and Embryology, First Faculty of Medicine, Charles University, Albertov 4, CZ-12801 Prague 2, Czech Republic
| | - Lucie Kubínová
- Department of Biomathematics, Institute of Physiology, v.v.i., Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - Igor L. Chernyavsky
- School of Mathematics, University of Manchester, Manchester, M13 9PL, United Kingdom
| | - Oliver E. Jensen
- School of Mathematics, University of Manchester, Manchester, M13 9PL, United Kingdom
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19
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Luckhardt M, Leiser R, Kingdom J, Malek A, Sager R, Kaisig C, Schneider H. Effect of Physiologic Perfusion-Fixation on the Morphometrically Evaluated Dimensions of the Term Placental Cotyledon. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/107155769600300402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Rudolf Leiser
- Department of Obstetrics and Gynaecology, University of Berne, Berne, Switzerland: the Department of Veterinary Anatomy, Justus Liebig University, Giessen, Germany: and the Department of Obstetrics and Gynaecology, University College London Medical School, London, United Kingdom
| | - John Kingdom
- Department of Obstetrics and Gynaecology, University of Berne, Berne, Switzerland: the Department of Veterinary Anatomy, Justus Liebig University, Giessen, Germany: and the Department of Obstetrics and Gynaecology, University College London Medical School, London, United Kingdom; Department of Obstetrics and Gynaecology, UCL Medical School, 86-96 Chenies Mews, London WC1E 6HX, United Kingdom
| | | | | | - Christoph Kaisig
- Department of Obstetrics and Gynaecology, University of Berne, Berne, Switzerland: the Department of Veterinary Anatomy, Justus Liebig University, Giessen, Germany: and the Department of Obstetrics and Gynaecology, University College London Medical School, London, United Kingdom
| | - Henning Schneider
- Department of Obstetrics and Gynaecology, University of Berne, Berne, Switzerland: the Department of Veterinary Anatomy, Justus Liebig University, Giessen, Germany: and the Department of Obstetrics and Gynaecology, University College London Medical School, London, United Kingdom; Department of Obstetrics and Gynaecology, Schanzeneckstrasse 1, CH-3012 Berne, Switzerland
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Salafia CM, Ghidini A, Lopèz-Zeno JM, Pezzullo JC. Uteroplacental Pathology and Maternal Arterial Mean Blood Pressure in Spontaneous Prematurity. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/107155769800500203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | - John C. Pezzullo
- Department of Pathology, Montefiore Medical Center, Bronx, New York; Department of Obstetrics and Gynecology, Georgetown University Medical Center, Washington, D.C.; Ponce School of Medicine, Ponce, Puerto Rico
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21
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Rennie MY, Whiteley KJ, Adamson SL, Sled JG. Quantification of Gestational Changes in the Uteroplacental Vascular Tree Reveals Vessel Specific Hemodynamic Roles During Pregnancy in Mice. Biol Reprod 2016; 95:43. [PMID: 27335074 PMCID: PMC5029476 DOI: 10.1095/biolreprod.116.140681] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/05/2016] [Indexed: 12/26/2022] Open
Abstract
The purpose of this study was to establish the time course and hemodynamic significance of de novo formed and enlarged uteroplacental arteries during pregnancy. Using x-ray microcomputed tomography (n = 4–7 placentas from 2–4 dams/gestational group), uteroplacental arterial vascular dimensions were measured at individual implantation sites. Dimensions and topology were used to compute total and vessel-specific resistances and cross-sectional areas. Diameter enlargement of the uterine artery (+55% by Embryonic Day 5.5 [E5.5]) and preplacental radial arteries (+30% by E8.5) was significant only in early gestation. Formation of spiral arteries (E9.5–E11.5), maternal canals, and canal branches (E11.5–E13.5) during midgestation was followed by enlargement of these vessels such that, from E9.5 to E17.5 (near term), spiral artery resistance dropped 9-fold, and canal resistance became negligible. A 12-fold increase in terminal vessel cross-sectional area was nearly sufficient to offset known increases in flow so that blood velocity entering the exchange region was predicted to increase by only 2-fold. The calculated 47% decrease in total resistance downstream of the uterine artery, determined from vascular geometry, was in accord with prior uterine blood flow data in vivo and was due to enlarging spiral artery diameters. Interestingly, radial artery resistance was unchanged after E9.5 so that radial arteries accounted for 91% of resistance and pressure drop in the uteroplacental arterial network by E17.5. These findings led us to propose functional roles for the three morphologically defined vessel types: radial arteries to reduce pressure, spiral artery enlargement to increase flow with gestation, and maternal canal elaboration and enlargement to maintain low exit velocities into the exchange region.
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Affiliation(s)
- Monique Y Rennie
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, Ontario, Canada Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Kathie J Whiteley
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - S Lee Adamson
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada Department of Physiology, University of Toronto, Toronto, Ontario, Canada Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - John G Sled
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, Ontario, Canada Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
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Plitman Mayo R, Charnock-Jones DS, Burton GJ, Oyen ML. Three-dimensional modeling of human placental terminal villi. Placenta 2016; 43:54-60. [PMID: 27324100 DOI: 10.1016/j.placenta.2016.05.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 04/28/2016] [Accepted: 05/04/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Placental transport is the main factor affecting the health and development of the fetus. Due to the placenta's geometrical and mathematical complexity, the structure-function relations of placental terminal villi have not been successfully modeled. Hence, a novel modeling approach is proposed. METHODS Computational models of four different specimens were generated from the three-dimensional reconstruction of confocal laser scanning microscopic image stacks. To evaluate the capabilities of the proposed methodology, stationary oxygen diffusion transport was calculated in the terminal villus volumes. RESULTS The reconstructions automatically provided the spatial arrangement of the fetal capillaries inside the terminal villi. The surface and volume ratios between the fetal capillaries and the villus were also calculated, and the effects of model parameters on the placental diffusive capacity were assessed by parametric analysis. DISCUSSION The potential of three-dimensional reconstructions combined with finite element analysis as a research tool for the human placenta was tested. The methodology herein could serve in the future as a simulation platform for complicated in vivo and in vitro scenarios.
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Affiliation(s)
- Romina Plitman Mayo
- Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK; Nanoscience Centre, Department of Engineering, University of Cambridge, Cambridge, UK
| | - D Stephen Charnock-Jones
- Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK; Department of Obstetrics & Gynaecology, University of Cambridge, Cambridge, UK
| | - Graham J Burton
- Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Michelle L Oyen
- Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK; Nanoscience Centre, Department of Engineering, University of Cambridge, Cambridge, UK.
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23
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Gordon Z, Glaubach L, Elad D, Zaretsky U, Jaffa AJ. Ex Vivo Human Placental Perfusion Model for Analysis of Fetal Circulation in the Chorionic Plate. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:553-560. [PMID: 26892818 DOI: 10.7863/ultra.15.04080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 06/27/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The purpose of this study was to develop an ex vivo placental perfusion model to assess changes in the umbilical artery systolic-to-diastolic (S/D) ratio due to progressive occlusion of the placental arterial system. METHODS Ex vivo human placentas were connected to a computerized pulse duplicator mimicking pulsatile flow from the fetal heart. Doppler sonographic measurements were conducted on the umbilical and chorionic arteries of 25 mature placentas. Simulation of placental occlusion was performed by progressive ligature of the chorionic arteries, including one umbilical artery. The correlation between the umbilical artery S/D ratio and the severity of simulated placental occlusion was analyzed. RESULTS The normal mean S/D ratio ± SD decreased gradually along the chorionic plate from 2.66 ± 0.47 at the cord insertion to 1.90 ± 0.59 in generation IV of the chorionic vessels. The Doppler index initially increased slowly with simulated placental occlusion. Only when all 4 generations were occluded was the umbilical artery S/D ratio elevated. Complete occlusion of one umbilical artery resulted in a 39% increase in the umbilical artery S/D ratio. CONCLUSIONS This unique model combining Doppler sonography with perfusion of an ex vivo placenta can be used for a better understudying of pathologic placental blood flow circulation.
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Affiliation(s)
- Zoya Gordon
- Ultrasound Unit in Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel (Z.G., A.J.J.); Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel (L.G.); Department of Biomedical Engineering, Faculty of Engineering (D.E., U.Z.), and Sackler Faculty of Medicine (D.E., A.J.J.), Tel-Aviv University, Tel-Aviv, Israel; and Department of Medical Engineering, Afeka, Tel-Aviv Academic College of Engineering, Tel Aviv, Israel (Z.G.).
| | - Lilia Glaubach
- Ultrasound Unit in Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel (Z.G., A.J.J.); Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel (L.G.); Department of Biomedical Engineering, Faculty of Engineering (D.E., U.Z.), and Sackler Faculty of Medicine (D.E., A.J.J.), Tel-Aviv University, Tel-Aviv, Israel; and Department of Medical Engineering, Afeka, Tel-Aviv Academic College of Engineering, Tel Aviv, Israel (Z.G.)
| | - David Elad
- Ultrasound Unit in Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel (Z.G., A.J.J.); Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel (L.G.); Department of Biomedical Engineering, Faculty of Engineering (D.E., U.Z.), and Sackler Faculty of Medicine (D.E., A.J.J.), Tel-Aviv University, Tel-Aviv, Israel; and Department of Medical Engineering, Afeka, Tel-Aviv Academic College of Engineering, Tel Aviv, Israel (Z.G.)
| | - Uri Zaretsky
- Ultrasound Unit in Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel (Z.G., A.J.J.); Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel (L.G.); Department of Biomedical Engineering, Faculty of Engineering (D.E., U.Z.), and Sackler Faculty of Medicine (D.E., A.J.J.), Tel-Aviv University, Tel-Aviv, Israel; and Department of Medical Engineering, Afeka, Tel-Aviv Academic College of Engineering, Tel Aviv, Israel (Z.G.)
| | - Ariel J Jaffa
- Ultrasound Unit in Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel (Z.G., A.J.J.); Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel (L.G.); Department of Biomedical Engineering, Faculty of Engineering (D.E., U.Z.), and Sackler Faculty of Medicine (D.E., A.J.J.), Tel-Aviv University, Tel-Aviv, Israel; and Department of Medical Engineering, Afeka, Tel-Aviv Academic College of Engineering, Tel Aviv, Israel (Z.G.)
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24
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Boulenouar S, Doisne JM, Sferruzzi-Perri A, Gaynor LM, Kieckbusch J, Balmas E, Yung HW, Javadzadeh S, Volmer L, Hawkes DA, Phillips K, Brady HJM, Fowden AL, Burton GJ, Moffett A, Colucci F. The Residual Innate Lymphoid Cells in NFIL3-Deficient Mice Support Suboptimal Maternal Adaptations to Pregnancy. Front Immunol 2016; 7:43. [PMID: 26925058 PMCID: PMC4759249 DOI: 10.3389/fimmu.2016.00043] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 01/29/2016] [Indexed: 01/20/2023] Open
Abstract
Uterine NK cells are innate lymphoid cells (ILC) that populate the uterus and expand during pregnancy, regulating placental development and fetal growth in humans and mice. We have recently characterized the composition of uterine ILCs (uILCs), some of which require the transcription factor NFIL3, but the extent to which NFIL3-dependent cells support successful reproduction in mice is unknown. By mating Nfil3−/− females with wild-type males, here we show the effects of NFIL3 deficiency in maternal cells on both the changes in uILCs during pregnancy and the downstream consequences on reproduction. Despite the presence of CD49a+Eomes− uILC1s and the considerable expansion of residual CD49a+Eomes+ tissue-resident NK cells and uILC3s in pregnant Nfil3−/− mice, we found incomplete remodeling of uterine arteries and decidua, placental defects, and fetal growth restriction in litters of normal size. These results show that maternal NFIL3 mediates non-redundant functions in mouse reproduction.
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Affiliation(s)
- Selma Boulenouar
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK; Department of Obstetrics and Gynaecology, University of Cambridge School of Clinical Medicine, National Institute for Health Research Cambridge Biomedical Research Centre, The Rosie Hospital, Cambridge, UK
| | - Jean-Marc Doisne
- Department of Obstetrics and Gynaecology, University of Cambridge School of Clinical Medicine, National Institute for Health Research Cambridge Biomedical Research Centre, The Rosie Hospital , Cambridge , UK
| | - Amanda Sferruzzi-Perri
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK; Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Louise M Gaynor
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK; Department of Obstetrics and Gynaecology, University of Cambridge School of Clinical Medicine, National Institute for Health Research Cambridge Biomedical Research Centre, The Rosie Hospital, Cambridge, UK
| | - Jens Kieckbusch
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK; Department of Obstetrics and Gynaecology, University of Cambridge School of Clinical Medicine, National Institute for Health Research Cambridge Biomedical Research Centre, The Rosie Hospital, Cambridge, UK
| | - Elisa Balmas
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK; Department of Obstetrics and Gynaecology, University of Cambridge School of Clinical Medicine, National Institute for Health Research Cambridge Biomedical Research Centre, The Rosie Hospital, Cambridge, UK
| | - Hong Wa Yung
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK; Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Shagayegh Javadzadeh
- Department of Obstetrics and Gynaecology, University of Cambridge School of Clinical Medicine, National Institute for Health Research Cambridge Biomedical Research Centre, The Rosie Hospital , Cambridge , UK
| | - Léa Volmer
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK; Department of Obstetrics and Gynaecology, University of Cambridge School of Clinical Medicine, National Institute for Health Research Cambridge Biomedical Research Centre, The Rosie Hospital, Cambridge, UK
| | - Delia A Hawkes
- Department of Obstetrics and Gynaecology, University of Cambridge School of Clinical Medicine, National Institute for Health Research Cambridge Biomedical Research Centre, The Rosie Hospital , Cambridge , UK
| | - Keli Phillips
- University of Cambridge Metabolic Research Laboratories , Cambridge , UK
| | - Hugh J M Brady
- Department of Life Sciences, Imperial College London , London , UK
| | - Abigail L Fowden
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK; Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Graham J Burton
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK; Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Ashley Moffett
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK; Department of Pathology, University of Cambridge, Cambridge, UK
| | - Francesco Colucci
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK; Department of Obstetrics and Gynaecology, University of Cambridge School of Clinical Medicine, National Institute for Health Research Cambridge Biomedical Research Centre, The Rosie Hospital, Cambridge, UK
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25
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Burton GJ, Fowden AL. The placenta: a multifaceted, transient organ. Philos Trans R Soc Lond B Biol Sci 2016; 370:20140066. [PMID: 25602070 DOI: 10.1098/rstb.2014.0066] [Citation(s) in RCA: 416] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The placenta is arguably the most important organ of the body, but paradoxically the most poorly understood. During its transient existence, it performs actions that are later taken on by diverse separate organs, including the lungs, liver, gut, kidneys and endocrine glands. Its principal function is to supply the fetus, and in particular, the fetal brain, with oxygen and nutrients. The placenta is structurally adapted to achieve this, possessing a large surface area for exchange and a thin interhaemal membrane separating the maternal and fetal circulations. In addition, it adopts other strategies that are key to facilitating transfer, including remodelling of the maternal uterine arteries that supply the placenta to ensure optimal perfusion. Furthermore, placental hormones have profound effects on maternal metabolism, initially building up her energy reserves and then releasing these to support fetal growth in later pregnancy and lactation post-natally. Bipedalism has posed unique haemodynamic challenges to the placental circulation, as pressure applied to the vena cava by the pregnant uterus may compromise venous return to the heart. These challenges, along with the immune interactions involved in maternal arterial remodelling, may explain complications of pregnancy that are almost unique to the human, including pre-eclampsia. Such complications may represent a trade-off against the provision for a large fetal brain.
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Affiliation(s)
- Graham J Burton
- Centre for Trophoblast Research and Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Abigail L Fowden
- Centre for Trophoblast Research and Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
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26
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George EM, Granger JP. Recent insights into the pathophysiology of preeclampsia. ACTA ACUST UNITED AC 2014; 5:557-566. [PMID: 21170149 DOI: 10.1586/eog.10.45] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Preeclampsia, characterized by new-onset gestational hypertension and proteinuria, is a common and serious complication of pregnancy. Evidence from both animal and human studies has implicated placental ischemia and hypoxia as a central causative factor in the etiology of the disorder. The ischemic placenta in turn initiates a cascade of secondary effector mechanisms, including altered proangiogenic and antiangiogenic factor balance, increase in maternal oxidative stress and endothelial and immunological dysfunction. The full elucidation of these mechanisms will hopefully lead to a more complete understanding of the etiology of preeclampsia and lead to successful therapeutic intervention through the targeted disruption of new and novel pathways.
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Affiliation(s)
- Eric M George
- Department of Physiology and Biophysics and the Center for Excellence in Cardiovascular-Renal Research, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216, USA
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27
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Gyselaers W, Peeters L. Physiological implications of arteriovenous anastomoses and venous hemodynamic dysfunction in early gestational uterine circulation: a review. J Matern Fetal Neonatal Med 2013; 26:841-6. [DOI: 10.3109/14767058.2013.766705] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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28
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James JL, Whitley GS, Cartwright JE. Pre-eclampsia: fitting together the placental, immune and cardiovascular pieces. J Pathol 2010; 221:363-78. [PMID: 20593492 DOI: 10.1002/path.2719] [Citation(s) in RCA: 145] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The success of pregnancy is a result of countless ongoing interactions between the placenta and the maternal immune and cardiovascular systems. Pre-eclampsia is a serious pregnancy complication that arises from multiple potential aberrations in these systems. The pathophysiology of pre-eclampsia is established in the first trimester of pregnancy, when a range of deficiencies in placentation affect the key process of spiral artery remodelling. As pregnancy progresses to the third trimester, inadequate spiral artery remodelling along with multiple haemodynamic, placental and maternal factors converge to activate the maternal immune and cardiovascular systems, events which may in part result from increased shedding of placental debris. As we understand more about the pathophysiology of pre-eclampsia, it is becoming clear that the development of early- and late-onset pre-eclampsia, as well as intrauterine growth restriction (IUGR), does not necessarily arise from the same underlying pathology.
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Affiliation(s)
- Joanna L James
- Division of Basic Medical Sciences, St George's University of London, London, UK.
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29
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Luria O, Bar J, Kovo M, Golan A, Barnea O. Feto-maternal interaction: a mathematical model simulating placental response in hypertensive disorders of pregnancy. Reprod Sci 2010; 17:963-9. [PMID: 20625179 DOI: 10.1177/1933719110376091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Elevated maternal blood pressure (BP) is common in pregnancies complicated by hypertensive disorders. In response, increased production and accumulation of elastin occurs in the feto-placental blood vessels. This results in increased vascular wall stiffness that increases the resistance to flow. To study the interaction between the stiffness of the fetoplacental blood vessels, fetoplacental blood flow and BP, a mathematical model of the fetoplacental vascular tree was developed. The model describes an elastic structure exposed to external pressure. Model results indicate that increased vascular stiffness in the fetal blood vessels may contribute to optimizing fetoplacental blood flow in hypertensive pregnancies. According to model predictions, uncontrolled lowering of BP following vascular adaptation may adversely affect fetoplacental blood flow.
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Affiliation(s)
- Oded Luria
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
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30
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Burton GJ, Charnock-Jones DS, Jauniaux E. Regulation of vascular growth and function in the human placenta. Reproduction 2009; 138:895-902. [DOI: 10.1530/rep-09-0092] [Citation(s) in RCA: 214] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
During the course of 9 months, the human placenta develops into a highly vascular organ. Vasculogenesis starts during the third week post-conception. Hemangioblastic cell cords differentiatein situfrom mesenchymal cells in the villous cores, most probably under the influence of vascular endothelial growth factor (VEGFA) secreted by the overlying trophoblast. The cords elongate through proliferation and cell recruitment, and connect with the vasculature of the developing fetus. A feto-placental circulation starts around 8 weeks of gestation. Elongation of the capillaries outstrips that of the containing villi, leading to looping of the vessels. The obtrusion of both capillary loops and new sprouts results in the formation of terminal villi. Branching and non-branching angiogenesis therefore play key roles in villous morphogenesis throughout pregnancy. Maternal circulating levels of VEGFA and placental growth factor vary across normal pregnancy, and in complicated pregnancies. Determining the impact of these changes on placental angiogenesis is difficult, as the relationship between levels of factors in the maternal circulation and their effects on fetal vessels within the placenta remains unclear. Furthermore, the trophoblast secretes large quantities of soluble receptors capable of binding both growth factors, influencing their bioavailability. Villous endothelial cells are prone to oxidative stress, which activates the apoptotic cascade. Oxidative stress associated with onset of the maternal circulation, and with incomplete conversion of the spiral arteries in pathological pregnancies, plays an important role in sculpting the villous tree. Suppression of placental angiogenesis results in impoverished development of the placenta, leading ultimately to fetal growth restriction.
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Abstract
Preeclampsia is a systemic disease that results from placental defects and occurs in about 5-8% of pregnancies worldwide. Preeclampsia is a disease of many theories, wherein investigators put forward their favorite mechanistic ideas, each with a causal appeal for the pathogenesis of preeclampsia. In reality, the patho-mechanism of preeclampsia remains largely unknown. Preeclampsia, as diagnosed in patients today, is likely a heterogeneous collection of disease entities that share some common features but also show important differences. Therefore, one single mechanism may never be found to explain all the variants of preeclampsia. Current research must focus on evaluating such diverse mechanisms, as well as the possible common effector pathways. Here, we provide a discussion of several possible mechanisms and putative theories proposed for preeclampsia, with particular emphasis on the recent discovery of a new genetic mouse model offering new opportunities to explore experimental therapies.
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Affiliation(s)
- Keizo Kanasaki
- Division of Matrix Biology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Raghu Kalluri
- Division of Matrix Biology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Harvard-MIT Division of Health Sciences and Technology, Boston, MA 02215
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston MA 02215
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32
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Burton GJ, Woods AW, Jauniaux E, Kingdom JCP. Rheological and physiological consequences of conversion of the maternal spiral arteries for uteroplacental blood flow during human pregnancy. Placenta 2009; 30:473-82. [PMID: 19375795 PMCID: PMC2697319 DOI: 10.1016/j.placenta.2009.02.009] [Citation(s) in RCA: 804] [Impact Index Per Article: 53.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Revised: 02/24/2009] [Accepted: 02/25/2009] [Indexed: 11/25/2022]
Abstract
Physiological conversion of the maternal spiral arteries is key to a successful human pregnancy. It involves loss of smooth muscle and the elastic lamina from the vessel wall as far as the inner third of the myometrium, and is associated with a 5–10-fold dilation at the vessel mouth. Failure of conversion accompanies common complications of pregnancy, such as early-onset preeclampsia and fetal growth restriction. Here, we model the effects of terminal dilation on inflow of blood into the placental intervillous space at term, using dimensions in the literature derived from three-dimensional reconstructions. We observe that dilation slows the rate of flow from 2 to 3 m/s in the non-dilated part of an artery of 0.4–0.5 mm diameter to approximately 10 cm/s at the 2.5 mm diameter mouth, depending on the exact radius and viscosity. This rate predicts a transit time through the intervillous space of approximately 25 s, which matches observed times closely. The model shows that in the absence of conversion blood will enter the intervillous space as a turbulent jet at rates of 1–2 m/s. We speculate that the high momentum will damage villous architecture, rupturing anchoring villi and creating echogenic cystic lesions as evidenced by ultrasound. The retention of smooth muscle will also increase the risk of spontaneous vasoconstriction and ischaemia–reperfusion injury, generating oxidative stress. Dilation has a surprisingly modest impact on total blood flow, and so we suggest the placental pathology associated with deficient conversion is dominated by rheological consequences rather than chronic hypoxia.
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Affiliation(s)
- G J Burton
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK.
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33
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Abstract
The placenta, as the vector for all maternal-fetal oxygen and nutrient exchange, is a principal influence on birthweight. Placental weight summarizes laterally expanding growth of the chorionic disc, and villous arborization yielding the nutrient exchange surface. These different growth dimensions alter fetoplacental weight ratio and ponderal index, and thus may modify placental functional efficiency. The placenta may show a range of histopathologies, some of which are also associated with fetal growth restriction. Different fetal intrinsic abilities to compensate for gross and histo-pathology may clarify the imperfect relationships between fetal growth and both intrauterine pathology, and the long-term health risks associated with poor fetal growth.
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Affiliation(s)
- Carolyn M Salafia
- Department of Epidemiology, Mailman School of Public Health, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA.
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34
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Struijk PC, Fernando KL, Mathews VJ, Steegers EAP, Wladimiroff JW, Clark EB, Varner MW. Application of the magnitude-squared coherence function between uterine and umbilical flow velocity waveforms for predicting placental dysfunction: a preliminary study. ULTRASOUND IN MEDICINE & BIOLOGY 2007; 33:1057-63. [PMID: 17448590 DOI: 10.1016/j.ultrasmedbio.2007.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2006] [Accepted: 01/25/2007] [Indexed: 05/15/2023]
Abstract
To examine whether the magnitude-squared coherence between uterine and umbilical blood flow velocity waveforms can, in conjunction with estimated fetal weight, uterine and umbilical pulsatility indices, fetal and maternal heart rates, diastolic notching and the amniotic fluid index, create a sensitive and specific model for the prediction of placental dysfunction. Binary logistic prediction models are created for preeclampsia, pregnancy induced hypertension and intrauterine growth restriction in a study group of 284 unselected midtrimester pregnancies. In each study group, the median value of derived parameters were compared with the uncomplicated pregnancy control group. The magnitude-squared coherence function between the uterine and umbilical flow velocity waveforms was found to be a statistically significant predictor of preeclampsia during the midtrimester of pregnancy. The magnitude-squared coherence did not improve the prediction of intrauterine growth restriction or pregnancy induced hypertension. The inclusion of magnitude-squared coherence as one of the prediction parameters may improve the early identification of pregnancies subsequently complicated by preeclampsia.
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Affiliation(s)
- Pieter C Struijk
- Department of Obstetrics & Gynecology, Erasmus MC, Division Obstetrics and Prenatal Medicine, Rotterdam, The Netherlands.
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35
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Costa AMA, Maximiano EBB, Avvad-Portari E, Jésus NR, Levy RA, Porto LC. Contractile cells and fibrillin-1 distribution is disturbed in terminal villi of placentae from patients with preeclampsia and systemic lupus erythematosus. Placenta 2006; 27:234-43. [PMID: 16338469 DOI: 10.1016/j.placenta.2005.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2003] [Revised: 11/19/2004] [Accepted: 02/25/2005] [Indexed: 10/25/2022]
Abstract
Placentae from patients with preeclampsia (PE) and systemic lupus erythematosus (SLE) present many alterations that may impair materno-fetal exchange. We investigated the distribution of contractile cells and fibrillin-1 in terminal villi of term placentae from patients with PE or SLE and compared to control placentae. Stroma in terminal villi exhibited intense labelling for fibrillin-1. The fibrillin-1 villi surface fraction was greater in PE and SLE placentae than in controls (13+/-0.4%, 14+/-0.5%, 10+/-0.4%; p=0.0001). Immunohistochemistry for alpha-smooth muscle (SM) actin showed few contractile cells in control terminal villi stroma, localized around fetal capillaries and showed rare processes in vasculo-syncytial membrane. PE and SLE placentae exhibited an increase in the number of capillaries presenting alpha-SM actin adventitial positive cells. The presence of alpha-SM actin processes interposed in the vasculo-syncytial membrane was greater in SLE villi than in PE and controls. Ultrastructural observations confirmed in SLE and PE terminal villi the presence of these processes in vasculo-syncytial membrane and also showed a thickened trophoblastic basement membrane. The present study demonstrates that an important myofibroelastic system is present in term terminal villi, and that this system is actively remodelled in PE and SLE placentae.
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Affiliation(s)
- A M A Costa
- Histology and Embryology Department, State University of Rio de Janeiro, Rua Prof Manoel de Abreu, 20550-170 Rio de Janeiro RJ, Brazil.
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Coan PM, Ferguson-Smith AC, Burton GJ. Developmental dynamics of the definitive mouse placenta assessed by stereology. Biol Reprod 2004; 70:1806-13. [PMID: 14973263 DOI: 10.1095/biolreprod.103.024166] [Citation(s) in RCA: 198] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The mouse is an excellent model for studying the genetic basis of placental development, but analyses are restricted by the lack of quantitative data describing normal murine placental structure. This study establishes a technique for generating such data, applies stereological techniques on systematic uniform random sections of placentas between E12.5-E18.5 of gestation (E1.0 = day of the vaginal plug), and considers the results in the context of development of the labyrinth zone. Half of each placenta was wax embedded and exhaustively sectioned to determine absolute volumes of the labyrinth zone (Lz), junctional zone (Jz), and decidua using the Cavalieri principle. The other half was resin embedded and 1-microm sections were used to generate all volume, surface, and length densities within the Lz. Maximum placental volume is reached by E16.5, whereas the Lz volume fraction increases until E18.5 at the expense of the Jz and decidua. Within the Lz, the absolute volume and surface area of maternal blood spaces (MBS) expand rapidly between E14.5 and E16.5, with no increase thereafter. In contrast, fetal capillary development is linear and continues for longer than that of the MBS. The interhemal membrane separating maternal and fetal circulations undergoes thinning prior to expansion of maternal and fetal surface areas, achieving a harmonic mean thickness of 4.39 microm by E18.5. The specific diffusion capacity for oxygen of the interhemal membrane is maximal by E16.5, which may be necessary to support rapid fetal growth until the end of gestation.
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Affiliation(s)
- Philip M Coan
- Department of Anatomy, University of Cambridge, Cambridge CB2 3DY, United Kingdom
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Sebire NJ, Talbert D. The role of intraplacental vascular smooth muscle in the dynamic placenta: a conceptual framework for understanding uteroplacental disease. Med Hypotheses 2002; 58:347-51. [PMID: 12027531 DOI: 10.1054/mehy.2001.1538] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although non-innervated, the placenta must continually accommodate changes in uteroplacental pressure (due to spiral artery failure, maternal position, maternal emotional state, etc.), which might otherwise be expected to result in rapid feto-maternal water fluxes in the highly water-permeable human hemochorial placenta. Uteroplacental flow must also be under the same influences, producing temporary, or permanent, regions of poor intervillous flow, yet the reduction of umbilical vein oxygen content that would be expected to be produced by such shunts of feto-placental blood do not occur in the normal fetus. We suggest that there is a local villus tree mechanism matching intravillus flow of fetal blood to local uteroplacental oxygen content. By analogy to ventilation/perfusion (V/Q) matching in the postnatal lung we suggest the term U/Q matching for this mechanism in the placenta. We further suggest that such disturbances in flow matching are compensated for by the fetus, via complementary adjustment of umbilico-chorionic artery and umbilical venous flow resistances, utilizing the differing sensitivities of vascular smooth muscle tissues of embryonic and extra-embryonic origin to vasoactive agents.
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Affiliation(s)
- N J Sebire
- Department of Histopathology, Great Ormond Street Hospital, London, UK.
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Kranenburg-Lakeman P, Boer K, van Gemert MJ, Vergroesen I. In vitro placental pressure-flow behaviour is non-linear and depends on the external pressure. Eur J Obstet Gynecol Reprod Biol 2001; 99:77-84. [PMID: 11604190 DOI: 10.1016/s0301-2115(01)00375-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To study pressure-flow behaviour of in vitro placentas under normal simulated conditions and during raised external pressures, to simulate in vivo placental hemodynamic function, and as a model for polyhydramnios and the supine hypotension syndrome. DESIGN Eleven normal term human singleton in vitro placentas were perfused under optimal physiologic conditions. Perfusion pressures varied between 5 and 90 mmHg, external pressures between 4 and 30 mmHg. Venous-external pressure (mmHg) combinations included 10-4, 10-10, 20-20, 25-25, 30-30 and 10-20. RESULTS Pressure-flow curves varied markedly among the 11 placentas, but all showed a non-linear, perfusion pressure-dependent resistance. The in vitro placental resistances were significantly higher than estimated in vivo values. All placentas showed inevitable leakage at the maternal side due to damage during delivery. Increased external pressures increased the placental resistance at lower perfusion pressures. CONCLUSION Placental damage reduces the number of perfused cotyledonic capillaries. This increases the placental resistance but preserves circulatory properties. Our findings therefore, represent in vivo placental function. They may explain why polyhydramnios often persists and that polyhydramnios and the supine hypotension syndrome are likely to be more detrimental in hypotensive than in normotensive or hypertensive fetuses.
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Affiliation(s)
- P Kranenburg-Lakeman
- Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Sebire NJ, Talbert D, Fisk NM. Twin-to-Twin Transfusion Syndrome Results From Dynamic Asymmetrical Reduction in Placental Anastomoses: A Hypothesis. Placenta 2001; 22:383-91. [PMID: 11373147 DOI: 10.1053/plac.2001.0631] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although placental vascular anastomoses between the fetoplacental circulations are ubiquitous in monochorionic twin pregnancies, the factors regulating their formation and maintenance are not understood. Increasing evidence implicates asymmetric anastomotic patterns in the aetiology of severe twin-to-twin transfusion syndrome (TTTS). The authors propose that anastomoses between placental circulations in monochorionic twins occur in a random manner at the embryological stage of connection of embryonic and extra-embryonic circulations. Placental expansion is then associated with random disruption of anastomoses and regression of their associated villus districts. TTTS develops as discordant loss of anastomoses results in asymmetrical flow resistance. Pregnancies with fetal growth concordance but discordant nuchal translucency at 10-14 weeks are at increased risk of developing subsequent severe TTTS because these clinical features indicate significant pressure differentials in the presence of a placentoplacental circulation, consistent with the presence of numerous, asymmetric anastomoses. However, since the anastomotic pattern is dynamic in the first half of pregnancy this hypothesis predicts that it will not be possible to devise a clinical test at 12 weeks that will predict with certainty the outcome of monochorionic twin pregnancies in relation to TTTS because this depends on random subsequent events.
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Affiliation(s)
- N J Sebire
- Centre for Fetal Care, Department of Maternal-Fetal Medicine, Imperial College School of Medicine at Queen Charlotte's, Hammersmith Hospital Site, Du Cane Road, London, UK
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Skulstad SM, Rasmussen S, Iversen OE, Kiserud T. The development of high venous velocity at the fetal umbilical ring during gestational weeks 11-19. BJOG 2001; 108:248-53. [PMID: 11281463 DOI: 10.1111/j.1471-0528.2001.00067.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the occurrence of high venous velocities at the umbilical ring in the normal early second trimester, based on the assumption that a narrow umbilical ring may cause obstruction and increased venous blood velocity at the abdominal wall. DESIGN Cross-sectional study. SETTING Hospital antenatal clinic. POPULATION One hundred and one low risk singleton pregnancies specifically recruited for the study. METHODS Ultrasound was used at 11-19 weeks to determine the diameter and velocity in the umbilical vein at the fetal end of the cord and at the inlet through the abdominal wall. Outcome measures 10th, 50th and 90th centiles were estimated for the time-averaged maximum velocity in the cord and at the abdominal inlet. The increase of velocity as the blood entered the abdominal wall was calculated in percent of the velocity in the cord. RESULTS During weeks 11-12 there was hardly any difference between blood velocity in the umbilical vein at the umbilical ring and that in the cord. From week 13 onwards it was increasingly common to find blood acceleration at the umbilical ring of 50-500%. Velocity increment >50% was found in 0/12 fetuses (0%) at 11-12 weeks, 5/20 (25%) at 13-14 weeks, and in 21/28 (75%) at 17-19 weeks. CONCLUSIONS Blood velocity is higher in the umbilical vein at the abdominal wall than the cord, particularly after 13 weeks of gestation. If acceleration of blood velocity at the umbilical ring is a sign of a narrow inlet, it seems that a progressive tightening occurs during the second trimester.
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Affiliation(s)
- S M Skulstad
- Department of Obstetrics and Gynaecology, Bergen University Hospital, Norway
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Skulstad SM, Rasmussen S, Iversen OE, Kiserud T. The development of high venous velocity at the fetal umbilical ring during gestational weeks 11–19. ACTA ACUST UNITED AC 2001. [DOI: 10.1016/s0306-5456(00)00067-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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van Gemert MJ, Kranenburg-Lakeman P, Milovanović Z, Vergroesen I, Boer K. Polyhydramnios and arterio-arterial placental anastomoses may beneficially affect monochorionic twin pregnancies. Phys Med Biol 2001; 46:N57-63. [PMID: 11277233 DOI: 10.1088/0031-9155/46/3/401] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Our objective was to appraise whether an increased amniotic fluid pressure by polyhydramnios can beneficially affect monochorionic twins that are haemodynamically connected by arterio-venous plus arterio-arterial placental anastomoses. We assessed the effects of polyhydramnios in monochorionic twin placentas, combining (a) data from previous in vitro placental perfusion experiments in singleton term placentas under simulated normal and increased amniotic fluid pressures with (b) logical deduction from observations made in monochorionic twins. Our hypothesis is that in monochorionic placentas, an increased amniotic fluid pressure increases the placental microvascular resistance but not the resistance of placental chorionic plate arteries. Hence, an increased amniotic fluid pressure increases the microvascular resistance of the joint cotyledon, the arterio-venous resistance, but not the arterioarterial resistance. This proposed mechanism reduces arterio-venous but not oppositely directed arterio-arterial transfusion. Therefore, reversal of the normal direction of net foeto-foetal transfusion may develop, which will reduce the circulatory imbalance that evolved between the monochorionic foetal twins. In contrast, in monochorionic twins connected by unidirectional or bidirectional arterio-venous anastomoses reversal of the normal direction of net foeto-foetal transfusion will not occur. In conclusion, reversal of the normal direction of net foeto-foetal transfusion, induced by polyhydramnios, is protective against the onset and severity of twin-twin transfusion syndrome in monochorionic twins connected by arterio-venous plus arterio-arterial anastomoses, but not by unidirectional or bidirectional arterio-venous anastomoses.
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Affiliation(s)
- M J van Gemert
- Laser Centre, Academic Medical Centre, University of Amsterdam, The Netherlands.
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Abstract
Appropriate growth and development of the placenta is essential for fetal growth and wellbeing, and indeed may be an important factor in determining adult health. As the fetus grows its demands increase and the capacity of the placenta to facilitate transfer between the fetal and maternal circulations increases as gestation progresses. The principal units for diffusional exchange of oxygen are the terminal villi, and these develop in the third trimester. It is thought that capillary growth within the villi drives the growth of these structures which are characterized by a high proportion of their volume being occupied by fetal capillaries and extreme thinning of the trophoblast and endothelial cell layers. In the first trimester the PO2 in the intervillous space is low and rises sharply at the start of the second. Endothelial growth is influenced by a variety of soluble factors, and several of these are regulated by oxygen, for example, vascular endothelial growth factor (VEGF), angiopoietin 2, and soluble flt (a VEGF antagonist). Thus, fetal demand may regulate villous growth and differentiation by altering local PO2 which, in turn, modulates growth factors (or their antagonists) to regulate endothelial growth and vessel re-modelling.
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Affiliation(s)
- D S Charnock-Jones
- Department of Obstetrics and Gynaecology, University of Cambridge, The Rosie Hospital, Cambridge, CB2 2SW, UK
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Challis DE, Pfarrer CD, Ritchie JW, Koren G, Adamson SL. Glucose metabolism is elevated and vascular resistance and maternofetal transfer is normal in perfused placental cotyledons from severely growth-restricted fetuses. Pediatr Res 2000; 47:309-15. [PMID: 10709728 DOI: 10.1203/00006450-200003000-00005] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We hypothesized that placental resistance was elevated and transfer reduced in cotyledons from intrauterine growth-restricted (IUGR) fetuses. We perfused 10 cotyledons from term, normally grown fetuses, six from preterm, normally grown fetuses with normal umbilical arterial end-diastolic velocities (EDV), and six from preterm IUGR fetuses (<3rd centile) with absent or reversed umbilical arterial EDV. Perfused cotyledons were pressure-fixed, and villi were observed by scanning electron microscopy. The groups did not differ in fetoplacental resistance at baseline; neither did they differ in the change in resistance that followed the administration of nitroglycerin or angiotensin II. The increase in resistance during hypoxia was similar in the two preterm groups but greater in the term than in the preterm normally grown group (p < 0.05). Groups did not differ in net maternofetal transfer of oxygen or glucose, or in clearance of aminoisobutyric acid or antipyrine. However, glucose consumption was doubled in cotyledons of preterm IUGR versus preterm normally grown fetuses (p < 0.05). Terminal villi of perfused cotyledons from preterm IUGR fetuses displayed less terminal villous branching and budding than preterm controls, as anticipated from previous work. IUGR fetuses with absent or reversed umbilical arterial EDV in vivo may have high placental resistance due to a vasoconstrictive rather than anatomic abnormality and an elevated placental glucose consumption that may impair glucose transfer.
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Affiliation(s)
- D E Challis
- Department of Obstretrics and Gynecology, University of Toronto, Ontario, Canada
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45
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Robinson JS, Hartwich KM, Walker SK, Erwich JJ, Owens JA. Early influences on embryonic and placental growth. ACTA PAEDIATRICA (OSLO, NORWAY : 1992). SUPPLEMENT 1997; 423:159-63; discussion 164. [PMID: 9401564 DOI: 10.1111/j.1651-2227.1997.tb18401.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Growth of the placenta is influenced by events before and during early pregnancy. Some of these events set the growth trajectory of the placenta and the fetus for the remainder of the pregnancy. Maternal size and nutrition, and the local metabolic, cytokine and hormonal environment of the embryo all affect growth of the placenta.
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Affiliation(s)
- J S Robinson
- Department of Obstetrics and Gynaecology, University of Adelaide, Australia
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47
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Demir R, Kosanke G, Kohnen G, Kertschanska S, Kaufmann P. Classification of human placental stem villi: review of structural and functional aspects. Microsc Res Tech 1997; 38:29-41. [PMID: 9260835 DOI: 10.1002/(sici)1097-0029(19970701/15)38:1/2<29::aid-jemt5>3.0.co;2-p] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The stem villi of the human placenta represent the central branches of the villous trees. They are characterized by a condensed fibrous stroma in which the fetal arteries and veins as well as the arterioles and venules are embedded. Functionally they are accepted as the mechanically supporting structures of the villous trees, and they are supposed to control fetal blood flow to the maternofetal exchange area, which is located in the peripheral villi. To obtain further insights into the functions of the stem villi, the recent literature has been reviewed, and some immunohistochemical, ultrastructural, and reconstruction studies have been added. These new studies were aimed at identifying immunohistochemically different subtypes of stem villi, their branching patterns, the distribution of macrophages, the stromal proliferation patterns, and the differentiation of extravascular stromal cells. Our findings demonstrate that the stem villi and their precursors, the immature intermediate villi, can selectively be identified by anti-gamma-smooth muscle (sm) actin staining. Furthermore, the existence of three different subtypes of stem villi is shown; these differ regarding the presence and distribution of gamma-sm actin-positive cells. These cells were immunohistochemically and ultrastructurally identified as smooth muscle cells and myofibroblasts. Increasingly complex coexpression patterns of cytoskeletal proteins reflect a clearly defined differentiation gradient of extravascular stromal cells, which covers the whole range of an undifferentiated germinative layer beneath the trophoblast to highly differentiated myofibroblasts surrounding the medias of the stem vessels. Possible functions of the extravascular contractile system include the regulation of villous turgor and the control of intervillous blood flow impedance.
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Affiliation(s)
- R Demir
- Department of Histology and Embryology, Medical Faculty, Akdeniz University, Antalya, Turkey
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Ockleford CD, Mongan LC, Hubbard AR. Techniques of advanced light microscopy and their applications to morphological analysis of human extra-embryonic membranes. Microsc Res Tech 1997; 38:153-64. [PMID: 9260846 DOI: 10.1002/(sici)1097-0029(19970701/15)38:1/2<153::aid-jemt16>3.0.co;2-o] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The science of light microscopy has advanced dramatically in recent years through the introduction of new technology. A brief description of scanning light microscopes, laser illumination, the confocal principle, digital imaging, and image processing reveals a number of theoretical advantages which are particularly useful in improving epifluorescence microscope images. Examples of results from several studies of human extra-embryonic membranes conducted in our laboratory show how the application of these techniques has been used to describe structures such as microtrabeculae and rivets for the first time, to map the microscopic distribution of a wide range of proteins, and to observe the activity of placental villi at the microscopic level in an environmentally controlled microscope stage. High-sensitivity detectors have permitted the "super-resolution" detection of structures smaller than the theoretically calculated limits of light microscope resolution. Rendering images in false colour is demonstrably useful in detecting subtle variations in fluorescence intensity at different intracellular sites and at different sites within tissues of fetal membranes. Processing stacks of digital images using appropriate software allows the 3-D reconstruction of suitably sized extra-embryonic membrane components. These digital images created from optical sections through the tissue are obtained non-destructively, and the relationships in space of the components are well preserved.
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Affiliation(s)
- C D Ockleford
- Department of Pre-Clinical Sciences, University of Leicester Medical School, UK
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Abstract
The new stereology permits the objective, quantitative description of morphology by efficient and design-based methods. Applications to placentas in normal and abnormal pregnancies have proved of great value for challenging earlier misconceptions and interpreting better the processes of growth, morphogenesis, adaptation, and functioning at the whole-organ level. This contribution reviews the essential features of the stereological approach, identifies useful structural quantities, and provides examples of their application in various experiments of nature. We focus particularly on normal gestation and the effects of pregnancies associated with high altitude, maternal diabetes mellitus, preeclampsia, and maternal smoking.
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Affiliation(s)
- T M Mayhew
- Department of Human Anatomy & Cell Biology, Queen's Medical Centre, University of Nottingham, United Kingdom
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