Corticotrophin-releasing hormone and corticotrophin-releasing hormone binding protein in normal and pre-eclamptic human pregnancies

Ramadan fasting in the third trimester of pregnancy and postpartum colostrum cortisol concentrations in Morocco

Breast milk cortisol concentration varies among and within lactating women, but the causes and consequences of variation are not yet fully understood. This study investigated whether maternal fasting from food and water for over 16 h per day during the third trimester of pregnancy was associated with increased concentrations of cortisol in colostrum during the month of Ramadan in a Moroccan sample. Participants were women who gave birth at the public maternity hospital in Rabat, Morocco throughout the month of and month following Ramadan. Participants completed interviews (N = 92), underwent anthropometric assessment (N = 73), and colostrum samples (N = 63) were collected approximately 48-72 h postpartum. Cortisol analysis was completed on a subset of colostrum samples (N = 43). Women were categorized as fasting every day of Ramadan before giving birth (N = 52/92, 57%), fasting some days (N = 29/92, 32%), and not fasting (N = 11/92, 11%). For women who fasted, average fasting duration was 19.5 days (range: 1-29 days), and average time between the last day of fasting and birth was 8.8 days (range: 0-43 days). The number of days of fasting was positively associated with cortisol concentrations in colostrum (p < .009) in a multivariate analysis controlling for maternal anthropometry, hypertension and/or diabetes, and reasons for opting out of fasting. Each day of fasting was associated with a 4.05% increase in colostrum cortisol. Results are consistent with the hypothesis that maternal fasting during the third trimester of pregnancy increases breast milk cortisol and thus alters the hormonal milieu to which the infant is exposed.

Cohort profile: the ECHO prenatal and early childhood pathways to health consortium (ECHO-PATHWAYS)

PURPOSE

Exposures early in life, beginning in utero, have long-term impacts on mental and physical health. The ECHO prenatal and early childhood pathways to health consortium (ECHO-PATHWAYS) was established to examine the independent and combined impact of pregnancy and childhood chemical exposures and psychosocial stressors on child neurodevelopment and airway health, as well as the placental mechanisms underlying these associations.

PARTICIPANTS

The ECHO-PATHWAYS consortium harmonises extant data from 2684 mother-child dyads in three pregnancy cohort studies (CANDLE [Conditions Affecting Neurocognitive Development and Learning in Early Childhood], TIDES [The Infant Development and Environment Study] and GAPPS [Global Alliance to Prevent Prematurity and Stillbirth]) and collects prospective data under a unified protocol. Study participants are socioeconomically diverse and include a large proportion of Black families (38% Black and 51% White), often under-represented in research. Children are currently 5-15 years old. New data collection includes multimodal assessments of primary outcomes (airway health and neurodevelopment) and exposures (air pollution, phthalates and psychosocial stress) as well as rich covariate characterisation. ECHO-PATHWAYS is compiling extant and new biospecimens in a central biorepository and generating the largest placental transcriptomics data set to date (N=1083).

FINDINGS TO DATE

Early analyses demonstrate adverse associations of prenatal exposure to air pollution, phthalates and maternal stress with early childhood airway outcomes and neurodevelopment. Placental transcriptomics work suggests that phthalate exposure alters placental gene expression, pointing to mechanistic pathways for the developmental toxicity of phthalates. We also observe associations between prenatal maternal stress and placental corticotropin releasing hormone, a marker of hormonal activation during pregnancy relevant for child health. Other publications describe novel methods for examining exposure mixtures and the development of a national spatiotemporal model of ambient outdoor air pollution.

FUTURE PLANS

The first wave of data from the unified protocol (child age 8-9) is nearly complete. Future work will leverage these data to examine the combined impact of early life social and chemical exposures on middle childhood health outcomes and underlying placental mechanisms.

Syncytiotrophoblast stress in preeclampsia: the convergence point for multiple pathways

Preeclampsia evolves in 2 stages: a placental problem that generates signals to the mother to cause a range of responses that comprise the second stage (preeclampsia syndrome). The first stage of early-onset preeclampsia is poor placentation, which we here call malplacentation. The spiral arteries are incompletely remodeled, leading to later placental malperfusion, relatively early in the second half of pregnancy. The long duration of the first stage (several months) is unsurprisingly associated with fetal growth restriction. The first stage of late-onset preeclampsia, approximately 80% of total cases, is shorter (several weeks) and part of a process that is common to all pregnancies. Placental function declines as it outgrows uterine capacity, with increasing chorionic villous packing, compression of the intervillous space, and fetal hypoxia, and causes late-onset clinical presentations such as "unexplained" stillbirths, late-onset fetal growth restriction, or preeclampsia. The second stages of early- and late-onset preeclampsia share syncytiotrophoblast stress as the most relevant feature that causes the maternal syndrome. Syncytiotrophoblast stress signals in the maternal circulation are probably the most specific biomarkers for preeclampsia. In addition, soluble fms-like tyrosine kinase-1 (mainly produced by syncytiotrophoblast) is the best-known biomarker and is routinely used in clinical practice in many locations. How the stress signals change over time in normal pregnancies indicates that syncytiotrophoblast stress begins on average at 30 to 32 weeks' gestation and progresses to term. At term, syncytiotrophoblast shows increasing markers of stress, including apoptosis, pyroptosis, autophagy, syncytial knots, and necrosis. We label this phenotype the "twilight placenta" and argue that it accounts for the clinical problems of postmature pregnancies. Senescence as a stress response differs in multinuclear syncytiotrophoblast from that of mononuclear cells. Syncytiotrophoblast irreversibly acquires part of the senescence phenotype (cell cycle arrest) when it is formed by cell fusion. The 2 pathways converge on the common pathologic endpoint, syncytiotrophoblast stress, and contribute to preeclampsia subtypes. We highlight that the well-known heterogeneity of the preeclampsia syndrome arises from different pathways to this common endpoint, influenced by maternal genetics, epigenetics, lifestyle, and environmental factors with different fetal and maternal responses to the ensuing insults. This complexity mandates a reassessment of our approach to predicting and preventing preeclampsia, and we summarize research priorities to maximize what we can learn about these important issues.

Prenatal phthalate exposure in relation to placental corticotropin releasing hormone (pCRH) in the CANDLE cohort

CONTEXT

Phthalates may disrupt maternal-fetal-placental endocrine pathways, affecting pregnancy outcomes and child development. Placental corticotropin releasing hormone (pCRH) is critical for healthy pregnancy and child development, but understudied as a target of endocrine disruption.

OBJECTIVE

To examine phthalate metabolite concentrations (as mixtures and individually) in relation to pCRH.

DESIGN

Secondary data analysis from a prospective cohort study.

SETTING

Prenatal clinics in Tennessee, USA.

PATIENTS

1018 pregnant women (61.4% non-Hispanic Black, 32% non-Hispanic White, 6.6% other) participated in the CANDLE study and provided data. Inclusion criteria included: low-medical-risk singleton pregnancy, age 16-40, and gestational weeks 16-29.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Plasma pCRH at two visits (mean gestational ages 23.0 and 31.8 weeks) and change in pCRH between visits (ΔpCRH).

RESULTS

In weighted quantile sums (WQS) regression models, phthalate mixtures were associated with higher pCRH at Visit 1 (β = 0.07, 95 %CI: 0.02, 0.11) but lower pCRH at Visit 2 (β = -0.08, 95 %CI: -0.14, -0.02). In stratified analyses, among women with gestational diabetes (n = 59), phthalate mixtures were associated with lower pCRH at Visit 1 (β = -0.17, 95 %CI: -0.35, 0.0006) and Visit 2 (β = -0.35, 95 %CI: -0.50, -0.19), as well as greater ΔpCRH (β = 0.16, 95 %CI: 0.07, 0.25). Among women with gestational hypertension (n = 102), phthalate mixtures were associated with higher pCRH at Visit 1 (β = 0.20, 95 %CI: 0.03, 0.36) and Visit 2 (β = 0.42; 95 %CI: 0.19, 0.64) and lower ΔpCRH (β = -0.17, 95 %CI: -0.29, -0.06). Significant interactions between individual phthalate metabolites and pregnancy complications were observed.

CONCLUSIONS

Phthalates may impact placental CRH secretion, with differing effects across pregnancy. Differences in results between women with and without gestational diabetes and gestational hypertension suggest a need for further research examining whether women with pregnancy complications may be more vulnerable to endocrine-disrupting effects of phthalates.

Lifetime Psychosocial Stress Exposure Associated with Hypertensive Disorders of Pregnancy

OBJECTIVE

Hypertensive disorders of pregnancy (HDP) complicate 5 to 10% of all pregnancies and are a major cause of pregnancy-related morbidity. Exposure to psychosocial stress has been associated with systemic inflammation and adverse birth outcomes in pregnant women. Thus, it is probable that psychosocial stress and inflammation play a role in the development of HDP. The primary objective of this analysis was to determine if a woman's lifetime psychosocial stress exposure was associated with an increased risk of HDP. Additionally, we examined whether serum inflammation was an underlying biological mediator for this relationship.

STUDY DESIGN

A multisite prospective study was conducted in a sociodemographically diverse cohort of 647 pregnant women. At a study visit between 12 and 20^6/7 weeks' gestation, maternal psychosocial stress was assessed with six validated assessments and inflammation was measured via log-transformed serum concentrations of interferon-γ, interleukin (IL)-10, IL-13, IL-6, IL-8, and tumor necrosis factor-α. A composite stress score was calculated for each participant from the six stress assessments. The diagnosis of HDP was abstracted from the medical record and was defined as the presence of gestational hypertension after 20 weeks of pregnancy and/or preeclampsia. The association between composite stress and HDP was determined using binary logistic regression. Inflammation, using the six inflammatory biomarkers, was tested as a potential mediator between stress and HDP.

RESULTS

Participants with higher composite stress scores were more likely to develop HDP (odds ratio [OR]: 1.50, 95% confidence interval [CI]: 1.06-2.12). When adjusted for known risk modifiers, including maternal age, race/ethnicity, parity, pre-pregnancy body mass index, diabetes, chronic hypertension, and smoking during pregnancy, the risk remained unchanged (OR: 1.50, 95% CI: 1.03-2.20). No mediation effect by inflammation was observed.

CONCLUSION

Independent of known risk factors, women exposed to greater composite stress burden across the life course are at increased risk of developing HDP.

KEY POINTS

· This study was conducted to determine if women with high levels of psychosocial stress have differences in risk for hypertensive disorders of pregnancy (HDP).. · Independent of known risk factors, women with increased lifetime psychosocial burden are at higher risk for HDP.. · A model that captures multiple domains of life stress may better predict HDP than a unimodal stress assessment..

Maternal Vitamin D and its Role in Determining Fetal Origins of Mental Health

There is evidence that mental health disorders may have roots in fetal life and are associated with deficiencies in various micronutrients, including vitamin D. During pregnancy, vitamin D balance is influenced by an increase in maternal calcitriol and a substantial increase in maternal Vitamin D Binding Protein concentrations. In the early stages of life, vitamin D is necessary to mediate numerous brain processes such as proliferation, apoptosis, and neurotransmission. Furthermore, Vitamin D has a recognized anti-inflammatory activity that normally suppresses inflammation. Increased activation of hypothalamo-pituitary-adrenal axis (HPA) and inflammation during gestation may influence maternal health and fetal neurodevelopment during and beyond pregnancy. A deficit of Vitamin D and maternal stressful events during gestation, such as perinatal depression, could influence the efficacy of the immune system altering its activity. Vitamin D deficiency during gestation associated with a reduction in fetal brain development has been widely described and correlated with alteration in the production of the brain-derived neurotrophic factor. To this regard, many studies highlights that low maternal vitamin D dosage during gestation has been related to a significantly greater risk to develop schizophrenia and other severe mental illnesses in later life. The objective of this paper is a comprehensive overview of maternal vitamin D balance in determining the fetal origins of mental health with some references to the link between vitamin D levels, inflammatory responses to stress and mental disorders in adult life.

Maternal exposure to childhood traumatic events, but not multi-domain psychosocial stressors, predict placental corticotrophin releasing hormone across pregnancy

Maternal psychosocial stress increases the risk of adverse birth and postnatal outcomes for the mother and child, but the role of maternal exposure to childhood traumatic events (CTE) and multi-domain psychosocial stressors for the level and rise of placental Corticotrophin-Releasing Hormone (pCRH) across pregnancy has been understudied. In a sociodemographically and racially diverse sample of 1303 women (64% Black, 36% White/others) with low-medical risk pregnancies at enrollment from Shelby County, Tennessee, USA, blood samples were drawn twice, corresponding roughly to second and third trimester, and extracted prior to conducting radioimmune assays for pCRH. Mothers reported CTE (physical abuse, sexual abuse, or family violence, in childhood), adulthood traumatic events, and interpersonal violence during pregnancy. Neighborhood crime/deprivation was derived using geospatially-linked objective databases. General linear and mixed models tested associations between stress exposure variables and pCRH levels and rate of rise, adjusting for obstetric/clinical/health related factors. Maternal CTE did not predict pCRH levels at time 1, but positively predicted levels at time 2, and the rate of rise in pCRH across pregnancy. Race did not moderate this association. No additional maternal stress exposures across adulthood or during pregnancy predicted pCRH outcomes. Findings indicate that childhood violence or abuse exposure can become biologically embedded in a manner predicting later prenatal physiology relevant for maternal and offspring health, and that such embedding may be specific to childhood, but not adulthood, stress. Findings also highlight the placental-fetal unit as a mechanistic pathway through which intergenerational transmission of the adverse effects of childhood adversities may occur.

Corticotropin-Releasing Factor Family: A Stress Hormone-Receptor System's Emerging Role in Mediating Sex-Specific Signaling

No organ in the body is impervious to the effects of stress, and a coordinated response from all organs is essential to deal with stressors. A dysregulated stress response that fails to bring systems back to homeostasis leads to compromised function and ultimately a diseased state. The components of the corticotropin-releasing factor (CRF) family, an ancient and evolutionarily conserved stress hormone-receptor system, helps both initiate stress responses and bring systems back to homeostasis once the stressors are removed. The mammalian CRF family comprises of four known agonists, CRF and urocortins (UCN1–3), and two known G protein-coupled receptors (GPCRs), CRF₁ and CRF₂. Evolutionarily, precursors of CRF- and urocortin-like peptides and their receptors were involved in osmoregulation/diuretic functions, in addition to nutrient sensing. Both CRF and UCN1 peptide hormones as well as their receptors appeared after a duplication event nearly 400 million years ago. All four agonists and both CRF receptors show sex-specific changes in expression and/or function, and single nucleotide polymorphisms are associated with a plethora of human diseases. CRF receptors harbor N-terminal cleavable peptide sequences, conferring biased ligand properties. CRF receptors have the ability to heteromerize with each other as well as with other GPCRs. Taken together, CRF receptors and their agonists due to their versatile functional adaptability mediate nuanced responses and are uniquely positioned to orchestrate sex-specific signaling and function in several tissues.

Hypertensive Disorders of Pregnancy and Symptoms of Depression and Anxiety as Related to Gestational Age at Birth: Findings From the All Our Families Study

OBJECTIVE

The aim of the study was to investigate whether symptoms of depression or state anxiety changed the strength or nature of the association between hypertensive disorders of pregnancy (HDP) and gestational age at birth.

METHODS

We conducted a secondary analysis of data from the All Our Families Cohort, a prospective pregnancy cohort study based in Calgary, Alberta, Canada. Self-reported depressive symptoms and state anxiety were assessed between 3 and 5 months of gestation, and obstetrical information, including diagnosis of HDP, parity, type of delivery, and gestational age at birth, was retrieved from the maternal discharge abstract. All models were adjusted for sociodemographic and obstetric confounders.

RESULTS

Of 2763 women who had a singleton pregnancy and live birth, 247 (9%) were diagnosed with HDP. Women with HDP had significantly shorter gestational length relative to those without the diagnosis (M = 37.87 versus M = 38.99 weeks of gestation), t(2761) = 9.43, p < .001. Moderation analyses showed significant HDP by depressive symptoms and HDP by state anxiety interactions, such that the strength of the association between HDP and gestational age at birth increased alongside greater depressive symptom and state anxiety severity.

CONCLUSIONS

Results suggest that depressive symptoms and state anxiety may add to the increased risk for shortened gestation associated with HDP. Women at high risk of cardiovascular complications during pregnancy may benefit from additional resources to manage symptoms of depression or anxiety.

Are there differences in birth weight according to sex and associations with maternal exposure to air pollutants? A cohort study

CONTEXT AND OBJECTIVE

Several effects of exposure to air pollutants on human health are known. The aim of this study was to identify whether exposure of pregnant women to air pollutants contributes towards low birth weight and which sex is more affected.

DESIGN AND SETTING

Longitudinal study using data on newborns from mothers living in São José do Rio Preto (SP) who were exposed to air pollutants in 2012-2013.

METHODS

A hierarchical model on three levels was built using maternal and newborn variables and environmental concentrations of particulate matter, ozone and nitrogen dioxide in quartiles. Preterm new-borns, twins and newborns with birth defects were excluded and exposure windows of 30, 60 and 90 days before delivery were considered.

RESULTS

8,948 newborns were included: 4,491 males (50.2%) and 4,457 females (49.8%); 301 newborns presented low birth weight (3.4%). The mean weight differed between males (3281.0 g) and females (3146.4 g) (P < 0.001). Exposure to ozone was significantly associated with low birth weight in both sexes in the 30-day window (odds ratio, OR = 1.38) and 90-day window (OR = 1.48); and among females, in the 30-day window (OR = 1.58) and 90-day window (OR = 1.59). Exposure to particulate matter had a paradoxical protective effect. No association was found among male newborns.

CONCLUSIONS

Female newborns showed greater susceptibility to maternal exposure to air pollutants. Studies on low birth weight in relation to maternal exposure to air pollutants should deal with males and females separately.

Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia

BACKGROUND

Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy.

METHODS

This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery).

RESULTS

Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery.

CONCLUSIONS

The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health.

Role of urocortin in pregnancy: An update and future perspectives

The activities of corticotropin-releasing factor (CRF) and related peptides are mediated a number of receptors with seven transmembrane domains that are coupled to the Gs and Gq proteins. These receptors are known as CRF-Rs. In vitro studies have evidenced that urocortin (UCN) and CRF provoke an increase in the contractility of the uterus which is induced by endometrial prostaglandin F2a. Furthermore, through trophoblasts, it stimulates the secretion of adrenocorticotropic hormone (ACTH) and prostaglandin PGE2 and has a vasodilatory effect on the placenta. While it is well known that the placenta produces considerable quantities of CRF, several studies have, however, excluded that the placenta can generate significant quantities of UCN. In the short term, the human fetal adrenal gland produces more cortisol and dehydroepiandrosterone sulfate. The gestational tissues express UCN3 and UCN2 mRNA in cytotrophoblast and syncytiotrophoblast cells, while UCN2 is only to be found in the maternal and fetal vessels and amniotic cells. Nevertheless, gestational tissues express UCN2 and UCN3 differentially and do not stimulate placental ACTH secretion. In term pregnancies, maternal plasma levels of CRF and UCN are lower than at the beginning of pregnancy and are correlated to labor onset. Conversely, they do not decrease in post-term pregnancies. This evidence would seem to indicate that the fine-regulated expression of these neuropeptides is important in determining the duration of human gestation. In this scenario, low concentrations of UCN in the amniotic fluid at mid-term may be considered a sign of predisposition to preterm birth.

Treatment with serotonin reuptake inhibitors during pregnancy is associated with elevated corticotropin-releasing hormone levels

Treatment with serotonin reuptake inhibitors (SSRI) has been associated with an increased risk of preterm birth, but causality remains unclear. While placental CRH production is correlated with gestational length and preterm birth, it has been difficult to establish if psychological stress or mental health problems are associated with increased CRH levels. This study compared second trimester CRH serum concentrations in pregnant women on SSRI treatment (n=207) with untreated depressed women (n=56) and controls (n=609). A secondary aim was to investigate the combined effect of SSRI treatment and CRH levels on gestational length and risk for preterm birth. Women on SSRI treatment had significantly higher second trimester CRH levels than controls, and untreated depressed women. CRH levels and SSRI treatment were independently associated with shorter gestational length. The combined effect of SSRI treatment and high CRH levels yielded the highest risk estimate for preterm birth. SSRI treatment during pregnancy is associated with increased CRH levels. However, the elevated risk for preterm birth in SSRI users appear not to be mediated by increased placental CRH production, instead CRH appear as an independent risk factor for shorter gestational length and preterm birth.

Parental Neuropathic Pain Influences Emotion-Related Behavior in Offspring Through Maternal Feeding Associated with DNA Methylation of Amygdale in Rats

Chronic neuropathic pain has currently become a remarkable public health concern, considerably damaging not only the physiological but also the psychological aspects of humans. This study investigated whether neuropathic pain affects maternal care and assessed the effect of parental neuropathic pain on the development of neuropathic pain and emotion among offspring. Our results showed that mother rats suffered from chronic constriction injury (CCI) exhibited defective maternal care. The offspring fed by CCI mother rats (own or cross-fed) showed a significant increase in anxiety and anxiety-related behavior compared with that fed by sham-operated mother rats. The offspring fed by CCI mother rats also displayed decreased oxytocin expression in their supraoptic nucleus than that fed by sham-operated mother rats. Moreover, DNA methyltransferase (DNMT)1 expression in the amygdale was increased, whereas DNMT3a and DNMT3b expressions remained the same in offspring fed by CCI mother rats, as detected with immunohistochemistry and western blot analysis. In addition, the total DNA methylation in amygdale was upregulated in offspring fed by CCI mother rats. Considering the above findings, the data of this study suggest that parental neuropathic pain influences emotion-related behavior in offspring through maternal feeding behavior rather than through genetic factors and pregnancy experience that was associated with DNA methylation of amygdale in offspring.

The combined association of psychosocial stress and chronic hypertension with preeclampsia

OBJECTIVE

This study aims to evaluate perceived lifetime stress, perceived stress during pregnancy, chronic hypertension, and their joint association with preeclampsia risk.

STUDY DESIGN

This study includes 4314 women who delivered a singleton live birth at the Boston Medical Center from October 1998 through February 2008. Chronic hypertension was defined as hypertension diagnosed before pregnancy. Information regarding lifetime stress and perceived stress during pregnancy was collected by questionnaire. Preeclampsia was diagnosed by clinical criteria.

RESULTS

Lifetime stress (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.6-2.9), perceived stress during pregnancy (OR, 1.7; 95% CI, 1.3-2.2), and chronic hypertension (OR, 10.4; 95% CI, 7.5-14.4) were each associated with an increased risk of preeclampsia. Compared to normotensive pregnancy with low lifetime stress, both normotensive pregnancy with high lifetime stress (OR, 2.1; 95% CI, 1.6-2.9) and pregnancy with chronic hypertension and low lifetime stress (OR, 10.2; 95% CI, 7.0-14.9) showed an increased risk of preeclampsia, while pregnancy with high lifetime stress and chronic hypertension yielded the highest risk of preeclampsia (OR, 21.3; 95% CI, 10.2-44.3). The joint association of perceived stress during pregnancy and chronic hypertension with preeclampsia was very similar to that of the joint association of lifetime stress and chronic hypertension with preeclampsia.

CONCLUSION

This finding indicates that high psychosocial stress and chronic hypertension can act in combination to increase the risk of preeclampsia up to 20-fold. This finding underscores the importance of efforts to prevent, screen, and manage chronic hypertension, along with those to reduce psychosocial stress, particularly among women with chronic hypertension.

Differential gene expression at the maternal-fetal interface in preeclampsia is influenced by gestational age

Genome-wide transcription data of utero-placental tissue has been used to identify altered gene expression associated with preeclampsia (PE). As many women with PE deliver preterm, there is often a difference in gestational age between PE women and healthy pregnant controls. This may pose a potential bias since gestational age has been shown to dramatically influence gene expression in utero-placental tissue. By pooling data from three genome-wide transcription studies of the maternal-fetal interface, we have evaluated the relative effect of gestational age and PE on gene expression. A total of 18,180 transcripts were evaluated in 49 PE cases and 105 controls, with gestational age ranging from week 14 to 42. A total of 22 transcripts were associated with PE, whereas 92 transcripts with gestational age (nominal P value <1.51*10⁻⁶, Bonferroni adjusted P value <0.05). Our results indicate that gestational age has a great influence on gene expression both in normal and PE-complicated pregnancies. This effect might introduce serious bias in data analyses and needs to be carefully assessed in future genome-wide transcription studies.

Corticotropin-releasing factor receptor 2 mediates sex-specific cellular stress responses

Although females suffer twice as much as males from stress-related disorders, sex-specific participating and pathogenic cellular stress mechanisms remain uncharacterized. Using corticotropin-releasing factor receptor 2-deficient (Crhr2-/-) and wild-type (WT) mice, we show that CRF receptor type 2 (CRF2) and its high-affinity ligand, urocortin 1 (Ucn1), are key mediators of the endoplasmic reticulum (ER) stress response in a murine model of acute pancreatic inflammation. Ucn1 was expressed de novo in acinar cells of male, but not female WT mice during acute inflammation. Upon insult, acinar Ucn1 induction was markedly attenuated in male but not female Crhr2-/- mice. Crhr2-/- mice of both sexes show exacerbated acinar cell inflammation and necrosis. Electron microscopy showed mild ER damage in WT male mice and markedly distorted ER structure in Crhr2-/- male mice during pancreatitis. WT and Crhr2-/- female mice showed similarly distorted ER ultrastructure that was less severe than distortion seen in Crhr2-/- male mice. Damage in ER structure was accompanied by increased ubiquitination, peIF2, and mistargeted localization of vimentin in WT mice that was further exacerbated in Crhr2-/- mice of both sexes during pancreatitis. Exogenous Ucn1 rescued many aspects of histological damage and cellular stress response, including restoration of ER structure in male WT and Crhr2-/- mice, but not in females. Instead, females often showed increased damage. Thus, specific cellular pathways involved in coping and resolution seem to be distinct to each sex. Our results demonstrate the importance of identifying sex-specific pathogenic mechanisms and their value in designing effective therapeutics.

Differentially expressed genes in the pre-eclamptic placenta: a systematic review and meta-analysis

Objective

To systematically review the literature on human gene expression data of placental tissue in pre-eclampsia and to characterize a meta-signature of differentially expressed genes in order to identify novel putative diagnostic markers.

Data Sources

Medline through 11 February 2011 using MeSH terms and keywords related to placenta, gene expression and gene expression arrays; GEO database using the term “placent*”; and reference lists of eligible primary studies, without constraints.

Methods

From 1068 studies retrieved from the search, we included original publications that had performed gene expression array analyses of placental tissue in the third trimester and that reported on differentially expressed genes in pre-eclampsia versus normotensive controls. Two reviewers independently identified eligible studies, extracted descriptive and gene expression data and assessed study quality. Using a vote-counting method based on a comparative meta-profiling algorithm, we determined a meta-signature that characterizes the significant intersection of differentially expressed genes from the collection of independent gene signatures.

Results

We identified 33 eligible gene expression array studies of placental tissue in the 3^rd trimester comprising 30 datasets on mRNA expression and 4 datasets on microRNA expression. The pre-eclamptic placental meta-signature consisted of 40 annotated gene transcripts and 17 microRNAs. At least half of the mRNA transcripts encode a protein that is secreted from the cell and could potentially serve as a biomarker.

Conclusions

In addition to well-known and validated genes, we identified 14 transcripts not reported previously in relation to pre-eclampsia of which the majority is also expressed in the 1^st trimester placenta, and three encode a secreted protein.

Systemic inflammatory stimulation by microparticles derived from hypoxic trophoblast as a model for inflammatory response in preeclampsia

OBJECTIVE

To determine whether trophoblast-derived microparticles can induce different inflammatory responses of the peripheral blood mononuclear cells depending upon the state of trophoblast when the microparticles are generated.

STUDY DESIGN

A trophoblast-derived cell line (ATCC no. CRL-1584) was cultured under normal or hypoxic conditions. Microparticles were isolated from the cell culture supernatants (microparticles from normal trophoblast; microparticles from hypoxic trophoblast). Peripheral blood mononuclear cells were cultured alone or cocultured with either microparticles from normal trophoblast or microparticles from hypoxic trophoblast.

RESULTS

After 48 hours, the peripheral blood mononuclear cells cocultured with microparticles from normal trophoblast released higher concentrations of interleukin-6 than peripheral blood mononuclear cells cultured alone. The peripheral blood mononuclear cells cocultured with microparticles from hypoxic trophoblast showed higher concentration of interleukin-6 and tumor necrosis factor alpha than peripheral blood mononuclear cells cocultured with microparticles from normal trophoblast, after 24 hours and 48 hours.

CONCLUSION

More intense and rapid inflammatory response of peripheral blood mononuclear cells was observed with microparticles from hypoxic trophoblast than with microparticles from normal trophoblast. This difference might explain the exaggerated systemic inflammatory response as a result of placental hypoxia in preeclampsia.

Neuroendocrine aspects of placenta and pregnancy

Placenta plays a central role in the regulation of physiological mechanisms of pregnancy, and in particular is the organ of communication between mother and fetus. This action is also related to its ability to produce hormones, growth factors and cytokines during the progression of pregnancy, and in response to stimuli such as stress and inflammation/infection. In the last years the understanding of the physiological and pathological functions of human placenta revealed the hypersecretion of hormones in presence of gestational diseases and raised the question whether this mechanism is cause of disorders of pregnancy, or part of an adaptive response of placenta to resolve adverse conditions. However, there are evidences indicating that changes of placental hormone secretion may have clinical usefulness, since they are measurable in biological fluids, and may be used as predictive markers or prognostic tools. Of particular interest is the role of corticotropin releasing hormone, urocortins and activins in the maintaining physiological pregnancy and in the pathogenesis of diseases (preterm birth and preeclampsia).

The contribution of maternal stress to preterm birth: issues and considerations

Preterm birth represents the most significant problem in maternal-child health, with maternal stress identified as a variable of interest. The effects of maternal stress on risk of preterm birth may vary as a function of context. This article focuses on select key issues and questions highlighting the need to develop a better understanding of which particular subgroups of pregnant women may be especially vulnerable to the potentially detrimental effects of maternal stress, and under what circumstances and at which stages of gestation. Issues related to the characterization and assessment of maternal stress and candidate biologic mechanisms are addressed.

Circulating predictive biomarkers in preeclampsia

The aim of the paper was to review promising prediction biomarkers for preeclampsia. The methods included review of abstracts on PubMed, using "preeclampsia", "biomarker", "prediction" as key words, followed by review of primary papers investigating blood based biomarkers. Angiogenic factors, such as PlGf and sFlt1, and PP13 seem presently to have the best predictive test values for preeclampsia, but sensitivity and specificity is still too low to prove useful in a population screening setting. Biomarker testing should still be part of research protocols. Biomarkers could provide useful in selecting high-risk women for prophylactic trials as well as identifying pregnancies that could profit from closer follow-up.

The role of stress in female reproduction and pregnancy: an update

Life exists by establishing a balanced equilibrium, called homeostasis, constantly challenged by adverse stimuli, called stressors. In response to these stimuli, a complex neurohormonal reaction exerted by the activation of the so-called stress system is initiated. The latter is activated in a coordinated fashion, leading to behavioral and peripheral changes that improve the ability of the organism to adjust homeostasis and increase its chance for survival. The stress system suppressive effects on female reproduction involve suppression of the hypothalamic-pituitary-ovarian axis at the hypothalamic, pituitary, ovarian, and uterine levels. Experimental and human data suggest that adverse prenatal stimuli, of either maternal or fetal origin, acting in the developing embryo in utero, can lead to the development of short- and long-term health disorders. These include preterm birth of the offspring, low birth weight, and the development of adult diseases ranging from the metabolic syndrome to several neurodevelopmental disorders.

Severe preeclampsia-related changes in gene expression at the maternal-fetal interface include sialic acid-binding immunoglobulin-like lectin-6 and pappalysin-2

Preeclampsia (PE), which affects 4-8% of human pregnancies, causes significant maternal and neonatal morbidity and mortality. Within the basal plate, placental cytotrophoblasts (CTBs) of fetal origin invade the uterus and extensively remodel the maternal vasculature. In PE, CTB invasion is often shallow, and vascular remodeling is rudimentary. To better understand possible causes, we conducted a global analysis of gene expression at the maternal-fetal interface in placental samples from women with PE (n = 12; 24-36 wk) vs. samples from women who delivered due to preterm labor with no evidence of infection (n = 11; 24-36 wk), a condition that our previous work showed is associated with normal CTB invasion. Using the HG-U133A&B Affymetrix GeneChip platform, and statistical significance set at log odds-ratio of B >0, 55 genes were differentially expressed in PE. They encoded proteins previously associated with PE [e.g. Flt-1 (vascular endothelial growth factor receptor-1), leptin, CRH, and inhibin] and novel molecules [e.g. sialic acid binding Ig-like lectin 6 (Siglec-6), a potential leptin receptor, and pappalysin-2 (PAPP-A2), a protease that cleaves IGF-binding proteins]. We used quantitative PCR to validate the expression patterns of a subset of the genes. At the protein level, we confirmed PE-related changes in the expression of Siglec-6 and PAPP-A2, which localized to invasive CTBs and syncytiotrophoblasts. Notably, Siglec-6 placental expression is uniquely human, as is spontaneous PE. The functional significance of these novel observations may provide new insights into the pathogenesis of PE, and assaying the circulating levels of these proteins could have clinical utility for predicting and/or diagnosing PE.

Elevated midpregnancy corticotropin-releasing hormone is associated with prenatal, but not postpartum, maternal depression

CONTEXT

Elevated hypothalamic CRH has been implicated in melancholic major depression in nonpregnant individuals, but the role of placental CRH in maternal prenatal and postpartum depression is largely unexplored.

OBJECTIVE

The objective of the study was to examine the association of maternal midpregnancy plasma CRH levels with prenatal and postpartum depression.

PARTICIPANTS

The study included 800 participants in Project Viva, a pregnancy and childhood cohort.

METHODS

CRH levels were analyzed from blood samples obtained at mean 27.9 wk gestation (+/- 1.3 sd; range 24.6-37.4 wk) and were normalized on the logarithmic scale. Depression was assessed with the Edinburgh Postpartum Depression Scale (range 0-30 points) in midpregnancy and at 6 months postpartum. We used logistic regression to estimate the odds of scoring 13 or more points on the Edinburgh Postpartum Depression Scale as indicative of major or minor depression.

RESULTS

Seventy (8.8%) and 46 (7.5%) women had prenatal and postpartum depression symptoms, respectively. Mean log CRH was 4.93 (+/- 0.62 sd). After adjusting for confounders, an sd increase in log CRH was associated with nearly 50% higher odds of prenatal depression symptoms (odds ratio 1.48, 95% confidence interval 1.14-1.93). Higher CRH levels during pregnancy were unassociated with greater risk of postpartum depressive symptoms. In fact, there was a suggestion that prenatal CRH levels might be inversely associated with risk of postpartum depressive symptoms (odds ratio 0.82, 95% confidence interval 0.58-1.15).

CONCLUSIONS

Elevated placental CRH levels in midpregnancy are positively associated with risk of prenatal depression symptoms but not postpartum depression symptoms.

Immune function in pregnancy: the role of corticotropin-releasing hormone

Pregnancy represents a major challenge to the maternal immune system since it has to tolerate the semi-allograft fetus. Indeed, the success of pregnancy requires an appropriate immunological interaction between the mother and the fetus. Furthermore, evidence suggests that some pregnancy complications, such as spontaneous abortions, preeclampsia and intrauterine growth restriction, are associated with abnormal maternal-fetal immune responses. Corticotropin-releasing hormone (CRH), a 41-amino acid peptide originally found in the hypothalamus, appears to have a fundamental role in the mechanisms responsible for the implantation and maintenance of human pregnancy. Reproductive CRH is a form of tissue CRH (CRH found in peripheral tissues), analogous to the immune CRH detected in peripheral inflammatory sites. Reproductive CRH has been identified in the endometrial glands, the decidualized endometrial stroma and the placental trophoblast, synctiotrophoblast and decidua. Reproductive CRH participates in various reproductive functions with an inflammatory component, where it serves as an autocrine/paracrine modulator. The immunological mechanisms contributing to the establishment and maintenance of pregnancy are not fully understood. The present article focuses on the potential roles of CRH on the physiology and pathophysiology of pregnancy and highlights its participation in implantation, early fetal immunotolerance and parturition.

Is psychosocial stress in first ongoing pregnancies associated with pre-eclampsia and gestational hypertension?

OBJECTIVE

Investigating the association of pre-eclampsia and gestational hypertension with psychosocial stress in the first half of pregnancy.

DESIGN

Prospective community-based cohort study.

SETTING

Amsterdam, The Netherlands.

POPULATION

Between January 2003 and March 2004, all pregnant Amsterdam women (n = 12 377) were invited to fill in a questionnaire with sociodemographic and psychosocial variables (response rate 67%). Only nulliparous women with a singleton pregnancy, who completed the questionnaire before 24 weeks, and delivered after 24 weeks, were included.

METHODS

A postpartum questionnaire was used to gather information on hypertension or proteinuria. If this questionnaire was not available, the national obstetric register was used for pregnancy outcome. Medical files were examined for women with hypertension and/or proteinuria to confirm the diagnosis of pre-eclampsia and gestational hypertension according to the International Society for the Study of Hypertension in Pregnancy guidelines. Psychosocial stress was defined as workstress (Work Experience and Appreciation Questionnaire partly based on the Job Content Instrument of Karasek et al.), anxiety (the State-Trait Anxiety Inventory), depression (Center for Epidemiological Studies Depression Scale) and pregnancy-related anxiety (PRAQ-R). The association of psychosocial stress with the incidence of pre-eclampsia and gestational hypertension was explored by multivariate analysis adjusted for sociodemographic and medical confounders.

MAIN OUTCOME MEASURES

Incidence of pre-eclampsia and gestational hypertension.

RESULTS

A total of 3679 women were included. The incidence of pre-eclampsia and gestational hypertension was 3.5 and 4.4%, respectively. Workstress, anxiety, pregnancy-related anxiety or depression had no effect on the incidence of pre-eclampsia or gestational hypertension.

CONCLUSION

Psychosocial stress in the first half of pregnancy does not influence the incidence of pre-eclampsia and gestational hypertension in nulliparous women.

Placental corticotrophin-releasing hormone and its receptors in human pregnancy and labour: still a scientific enigma

It is now accepted that, in humans, placental corticotrophin-releasing hormone (CRH) is involved in the mechanisms controlling the onset of labour; however, the precise biological role in foeto-maternal tissues remain enigmatic. Maternal plasma levels of CRH rise exponentially as pregnancy progresses towards term and peak during labour; however, evidence to link this with an active role in the onset and progression of labour, is still inconclusive. Certainly, one of the tissues targeted by CRH is the myometrial smooth muscle, which expresses a plethora of specific CRH receptors. This finding implicates CRH in the mechanisms preparing the myometrial microenvironment for the onset of labour and possibly in the regulation of active contractility during labour. Other gestational tissues also targeted by CRH include the placenta, foetal membranes and foetal adrenals, where CRH might regulate distinct physiological functions, ranging from control of vascular tone to adrenal steroidogenesis and prostaglandin synthesis and activity. Given the unique, among mammals, pattern of human placental CRH secretion and CRH receptor expression and signalling during pregnancy and labour, there are only limited biological tools available to delineate the actions of CRH in foeto-maternal tissues, primarily based on in vitro characterisation of the signalling and molecular events driven by CRH. This review will set in context the current concepts about the role of CRH and its receptors during pregnancy and labour, focusing on the unresolved questions and paradoxes that currently exist.

The long-term behavioural consequences of prenatal stress

Maternal distress during pregnancy increases plasma levels of cortisol and corticotrophin releasing hormone in the mother and foetus. These may contribute to insulin resistance and behaviour disorders in their offspring that include attention and learning deficits, generalized anxiety and depression. The changes in behaviour, with or independent of alterations in the function of the hypothalamic pituitary adrenal (HPA) axis, can be induced by prenatal stress in laboratory rodents and non-human primates. The appearance of such changes depends on the timing of the maternal stress, its intensity and duration, gender of the offspring and is associated with structural changes in the hippocampus, frontal cortex, amygdala and nucleus accumbens. The dysregulation of the HPA axis and behaviour changes can be prevented by maternal adrenalectomy. However, only the increased anxiety and alterations in HPA axis are re-instated by maternal injection of corticosterone.

CONCLUSION

Excess circulating maternal stress hormones alter the programming of foetal neurons, and together with genetic factors, the postnatal environment and quality of maternal attention, determine the behaviour of the offspring.

Intimate partner violence (IPV) and preeclampsia among Peruvian women

OBJECTIVE

Mounting evidence supports the view that intimate partner violence (IPV) is an important cause of maternal mortality. Some, but not all, prior studies suggest that IPV is associated with increased risks of maternal medical conditions such as hypertensive disorders of pregnancy which are leading causes of maternal mortality worldwide. We assessed the relation between IPV and risk of preeclampsia among Peruvian women.

STUDY DESIGN

We conducted a case-control study at two large hospitals in Lima, Peru. Preeclampsia cases were 339 women with pregnancy-induced hypertension and proteinuria (i.e., preeclampsia). Controls were 337 normotensive women. Information concerning women's exposure to physical and emotional violence during pregnancy was collected during in-person interviews conducted after delivery and while patients were in hospital. Odds ratios (OR) and 95% confidence intervals (CI) were estimated from logistic regression models.

RESULTS

The prevalence of IPV was 43.1% among cases and 24.3% among controls. Compared with those reporting never exposure to IPV during pregnancy, women reporting any exposure had a 2.4-fold increased risk of preeclampsia (OR=2.4; 95% CI: 1.7-3.3). The association was strengthened slightly after adjusting for maternal age, parity and pre-pregnancy adiposity (OR=2.7; 95% CI: 1.9-3.9). Emotional abuse in the absence of physical violence was associated with a 3.2-fold (95% CI: 2.1-4.9) increased risk of preeclampsia. Emotional and physical abuse during pregnancy was associated with a 1.9-fold increased risk of preeclampsia (95% CI: 1.1-3.5).

CONCLUSIONS

IPV among pregnant women is common and is associated with an increased risk of preeclampsia. These data support recent calls for coordinated global health efforts to prevent violence against women.

Cord blood cortisol level is lower in growth-restricted newborns

AIM

To establish the difference in plasma cortisol concentrations between newborns with intrauterine growth-restricted (IUGR) and appropriate for gestational age (AGA) birthweights.

SUBJECTS AND METHODS

We measured plasma cortisol concentrations in the umbilical venous cord blood of 68 IUGR newborns and 71 AGA birthweight newborns. All newborns were delivered in term, vaginally, in the morning, within 8 hours and had APGAR scores greater or equal to eight.

RESULTS

There was no significant difference between compared groups according to maternal age, parity, gestational age and neonatal gender. Neonatal plasma cortisol levels were significantly lower in the IUGR (median: 312.3 mmol/L, min-max: 158.9-588.1 mmol/L) compared to the AGA group (median: 458.7 mmol/L, min-max: 314.5-718.5 mmol/L) (Mann-Whitney U-test; P<0000). The probability of having a cortisol plasma level greater than or equal to 458.7 mmol/L for IUGR newborns was only 1:12, and to have cortisol plasma level less than or equal to 312.3 mmol/L for AGA newborns was much lower (0:34). In the range of plasma cortisol level between 312.3 mmol/L and 458.7 mmol/L, no statistically significant difference in the plasma cortisol level between IUGR and AGA newborns was found.

CONCLUSIONS

Neonatal plasma cortisol level is lower in the IUGR compared to the AGA group. Our results suggest that endocrine relationships seem to be lost in a specific group of the IUGR newborns. Although we usually tend to simplify the problem and declare only one cause, this time it is impossible. It is probable that the cause is hidden in small and insufficient placenta with deranged auto-regulation of placental 11beta-HSD-2 mechanism.

Prenatal predictors of infant temperament

Emerging data suggest that prenatal factors influence children's temperament. In 50 dyads, we examined fetal heart rate (FHR) activity and women's antenatal psychiatric illness as predictors of infant temperament at 4 months (response to novelty and the Infant Behavior Checklist). FHR change during maternal challenge was positively associated with observed infant motor reactivity to novelty (p = .02). The odds of being classified as high versus low motor among fetuses who had an increase in FHR during maternal stress was 11 times those who had a decrease in FHR (p = .0006). Antenatal psychiatric diagnosis was associated with an almost fourfold greater odds of having a high cry reactivity classification (p = .03). There also were modest associations between baseline FHR and maternal reports of infant temperament and between observed temperament and that based on mothers' reports. All of the infant results were found independent of the influence of women's postnatal anxiety. These data indicate that physiological markers of individual differences in infant temperament are identifiable in the fetal period, and possibly shaped by the prenatal environment.

Identification of two novel quantitative trait loci for pre-eclampsia susceptibility on chromosomes 5q and 13q using a variance components-based linkage approach

Pre-eclampsia/eclampsia (PE/E) is a common and serious disorder of human pregnancy that is associated with substantial maternal and perinatal morbidity and mortality. The suspected aetiology of PE/E is complex, with susceptibility being attributable to multiple environmental factors and a large genetic component. By assuming that the underlying liability towards PE/E susceptibility is inherently quantitative, any PE/E susceptibility gene would represent a quantitative trait locus (QTL). This assumption enables a more refined and powerful variance components procedure using a threshold model for our PE/E statistical analysis. Using this more efficient linkage approach, we have now re-analysed our previously completed Australian/New Zealand genome scan data to identify two novel PE/E susceptibility QTLs on chromosomes 5q and 13q. We have obtained strong evidence of linkage on 5q with a peak logarithm-of-odds (LOD) score of 3.12 between D5S644 and D5S433 [at approximately 121 centimorgan (cM)] and strong evidence of linkage on 13q with a peak LOD score of 3.10 between D13S1265 and D13S173 (at approximately 123 cM). Objective identification and prioritization of positional candidate genes using the quantitative bioinformatics program GeneSniffer revealed highly plausible PE/E candidate genes encoding aminopeptidase enzymes and a placental peptide hormone on the 5q QTL and two type IV collagens on the 13q QTL regions, respectively.

Prenatal depression effects on the fetus and newborn: a review

A review of research on prenatal depression effects on the fetus and newborn suggests that they experience prenatal, perinatal and postnatal complications. Fetal activity is elevated, prenatal growth is delayed, and prematurity and low birthweight occur more often. Newborns of depressed mothers then show a biochemical/physiological profile that mimics their mothers' prenatal biochemical/physiological profile including elevated cortisol, lower levels of dopamine and serotonin, greater relative right frontal EEG activation and lower vagal tone. Elevated prenatal maternal cortisol is the strongest predictor of these neonatal outcomes. Moderate pressure massage can alleviate these effects including reducing prematurity.

Corticotropin-releasing hormone modulates human trophoblast invasion through carcinoembryonic antigen-related cell adhesion molecule-1 regulation

Abnormalities in the process of trophoblast invasion may result in abnormal placentation. Both the embryonic trophoblast and maternal decidua produce corticotropin-releasing hormone (CRH), which promotes implantation. Carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1), which is expressed in extravillous trophoblasts (EVTs) of normal human placenta, may also function in tro-phoblast/endometrial interactions. We investigated whether locally produced CRH plays a role in trophoblast invasion, primarily by regulating CEACAM1 expression. We examined cultures of freshly isolated human EVTs, which express CEACAM1, and an EVT-based hybridoma cell line, which is devoid of endogenous CEACAM1. CRH inhibited EVT invasion in Matrigel invasion assays, and this effect was blocked by the CRH receptor type 1 (CRHR1)-specific antagonist antalarmin. Additionally, CRH decreased CEACAM1 expression in EVTs in a dose-dependent manner. After transfection of the hybridoma cell line with a CEACAM1 expression vector, the invasiveness of these cells was strongly enhanced. This effect was inhibited by addition of blocking monoclonal antibody against CEACAM1. Furthermore, blocking of endogenous CEACAM1 in EVTs inhibited the invasive potential of these cells. Taken together these findings suggest that CRH inhibits trophoblast invasion by decreasing the expression of CEACAM1 through CRHR1, an effect that might be involved in the pathophysiology of clinical conditions, such as preeclampsia and placenta accreta.

Relação entre baixo peso ao nascer e a poluição do ar no Município de São Paulo

OBJETIVO: A poluição do ar tem sido investigada como possível determinante do baixo peso ao nascer. O objetivo do estudo foi verificar o efeito da poluição do ar sobre o peso ao nascer. MÉTODOS: Foram analisados todos os partos de mães residentes no Município de São Paulo, nos anos de 1998 a 2000. Estimaram-se as prevalências de baixo peso ao nascer conforme características do recém-nascido, da mãe e do parto. Apenas os distritos mais centrais de São Paulo foram incluídos, totalizando uma amostra de 311.735 nascimentos. Para avaliação do efeito da poluição do ar foram excluídos os prematuros, gemelares e analisados somente os nascimentos das áreas mais centrais da cidade. Os elementos poluentes analisados foram ozônio (O3), dióxido de enxofre (SO2), dióxido de nitrogênio (NO2), partículas em suspensão (PM10) e monóxido de carbono (CO). O efeito da exposição materna à poluição do ar no peso ao nascer foi avaliado por meio de regressão linear e logística. RESULTADOS: Do total analisado, 4,6% dos recém-nascidos apresentaram menos de 2.500 g ao nascer. A exposição materna ao CO, PM10 e NO2 durante o primeiro trimestre de gestação mostrou associação estatisticamente significante com a diminuição no peso do recém-nascido. CONCLUSÕES: Os resultados reforçam que a exposição materna à poluição do ar no primeiro trimestre de gestação pode contribuir para o menor ganho de peso do feto.

Maternal stress and fetal responses: evolutionary perspectives on preterm delivery

New epidemiological and neurohormonal evidence provides insights into the persistent public health issue of preterm delivery and its long-term health consequences for the newborn. Mechanisms linked to preterm delivery may originate early in gestation as a result of maternal cues signaling a stressful intrauterine environment. When these signals are present, the fetus responds with a series of facultative responses, including accelerated organ maturation. If these responses are unsuccessful and the environment remains insufficient, a series of feed-forward mechanisms initiate the hormonal cascade that leads to parturition, and thus, early expulsion from a stressful environment. The internal environmental cues are delivered via glucocorticoids (stress hormones) in the circulatory system, but fetal responses and the initiation of the final terminal pathway to parturition are regulated by placentally derived corticotropin-releasing hormone (CRH). The potential costs of early expulsion from a stressful intrauterine environment are high and include an increased likelihood of perinatal and infant mortality. Permanent alterations in organ and metabolic functioning may occur, suggesting considerable fitness trade-offs. There is some evidence that preterm parturition is a maternal adaptation to limit the energetic costs of individual pregnancies in the face of poor condition at the time of conception. Moreover, nutritional stress is not the only indicator that signals a stressful environment: maternal psychosocial stress, and thus her response to an assessment of the social environment, also signal an insufficient internal environment to the fetus. The epidemiological and neurohormonal evidence for these relationships and mechanisms responsible for regulating such delicate negotiations are explored. In turn, the implications of such findings are examined from life history and public health perspectives.

Efficacy of Yoga on Pregnancy Outcome

OBJECTIVE

To study the efficacy of yoga on pregnancy outcomes.

DESIGN AND SETTING

Three hundred thirty five (335) women attending the antenatal clinic at Gunasheela Surgical and Maternity Hospital in Bangalore, India, were enrolled between 18 and 20 weeks of pregnancy in a prospective, matched, observational study; 169 women in the yoga group and 166 women in the control group.

METHODS

Women were matched for age, parity, body weight, and Doppler velocimetry scores of umbilical and uterine arteries. Yoga practices, including physical postures, breathing, and meditation were practiced by the yoga group one hour daily, from the date of entry into the study until delivery. The control group walked 30 minutes twice a day (standard obstetric advice) during the study period. Compliance in both groups was ensured by frequent telephone calls and strict maintenance of an activity diary.

MAIN OUTCOMES

Birth weight and gestational age at delivery were primary outcomes.

RESULTS

The number of babies with birth weight > or = 2500 grams was significantly higher (p < 0.01) in the yoga group. Preterm labor was significantly lower (p < 0.0006) in the yoga group. Complications such as isolated intrauterine growth retardation (IUGR) (p < 0.003) and pregnancy-induced hypertension (PIH) with associated IUGR (p < 0.025) were also significantly lower in the yoga group. There were no significant adverse effects noted in the yoga group.

CONCLUSIONS

An integrated approach to yoga during pregnancy is safe. It improves birth weight, decreases preterm labor, and decreases IUGR either in isolation or associated with PIH, with no increased complications.

Physiological stress reactivity in human pregnancy—a review

Prenatal maternal stress has been found to have long-lasting effects on the behavioral and physiological development of the offspring. These programming effects on the fetus would be physiologically mediated through heightened and/or abnormal activity of the maternal sympathetic-adrenal-medullary system (SAM) and especially of her hypothalamic-pituitary-adrenocortical axis (HPA-axis). The abnormalities in maternal physiology could be present in her basal functioning, but also in her physiological reactivity to stressors, which constitutes the topic of this paper. This article reviews studies that have used laboratory challenges to study physiological stress reactivity in pregnant women. It concentrates on stress tests designed to produce pain or discomfort, or cognitive and psychological stress, and that assess changes in blood pressure, heart rate and/or cortisol as reactivity measures. The general conclusion is that physiological stress reactivity appears to be dampened during pregnancy. Nonetheless, the physiological responses to laboratory challenges are clearly present and display enough inter-individual variability to enable the study of links between responsivity patterns, psychosocial variables, fetal behavior, pregnancy outcome and offspring development. This paper also looks into the methodological limitations present in the reviewed studies. Options for sound design of stress test protocols are discussed and recommendations for future studies are presented. These methodological points are general and can therefore also be of use for researchers studying human stress reactivity in other populations and ages.

Prediction of preeclampsia: can it be achieved?

In this review, the various biochemical tests that have been proposed for the prediction of preeclampsia are described and evaluated. Placenta hormone markers do not predict future disease. They denounce the early placental changes that are part of the evolving disease and only predict the imminent of preeclamptic syndrome. This explains why tests are better predictors when preeclampsia supervenes shortly, and why screening in the first trimester is unlikely to work as well as in the second trimester. The use of multiple markers in the screening should reflect different aspects of the disease process and could increase the specificity and sensitivity of the screening and work on different etiologic factors. The possible use of second-trimester biochemical screening to predict the risk of preeclampsia remains to be investigated in the high-risk population.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader should be able to list the various theories on the etiology of preeclampsia, to relate the various risk factors for the development of preeclampsia, and to describe the various screening tests for preeclampsia.

Women's mental health during pregnancy influences fetal and infant developmental and health outcomes

Women's mental health during pregnancy has important implications not only for the well-being of the mother, but also for the development, health, and well-being of her unborn child. A growing body of empirical evidence from population-based studies suggests that two indicators of women's mental health during pregnancy--psychosocial stress and social support--may exert a significant influence on fetal development and infant birth outcomes, such as birth weight and length of gestation, even after controlling for the effects of established sociodemographic, obstetric, and behavioral risk factors. This paper describes the role of three major biological systems involved in the physiology of pregnancy and stress physiology: neuroendocrine, immune/inflammatory, and cardiovascular systems. These systems have been hypothesized to mediate the effects of maternal mental health on fetal developmental and health outcomes, and a central role has been proposed for placental corticotropin-releasing hormone in this process. However, not all women reporting high prenatal stress and/or low social support proceed to develop adverse birth outcomes, raising the question of the determinants of susceptibility/vulnerability in the context of high stress and/or low social support. In this context, the role of race/ethnicity and genetic predisposition are discussed as two promising avenues of further investigation.

Trophoblast deportation and the maternal inflammatory response in pre-eclampsia

We have proposed that the maternal syndrome of pre-eclampsia is caused by a systemic inflammatory response involving both leucocytes and endothelium. This inflammatory response is present also in normal pregnancy, but in a milder form. The inflammatory stimulus is most likely to come from the placenta. Syncytiotrophoblast apoptotic debris, which is shed into the maternal circulation in normal pregnancy and in increased amounts in pre-eclampsia, may be the stimulus for this response. It may also contribute to the suppression of Th1 responses seen in pregnancy.

Prenatal screening, epidemiology, diagnosis, and management of preeclampsia

The cause of preeclampsia remains unknown. The disease manifests itself across a broad clinical spectrum from mild to severe, conferring vastly different morbidities and suggesting possibly different disease processes. Oxidative stress, endothelial dysfunction, maternal-fetal immune incompatibility, and abnormal placental implantation are among the suggested causes. The need for a marker or set of markers that allow for definitive diagnosis and assessment of future risk of preeclampsia is tremendous. Ultrasound techniques and several markers have been identified that are increased among patients with preeclampsia, but no test is highly sensitive. In the future, a combination of markers likely will be used to assess risk and, establish the diagnosis, and test treatment strategies. Such an approach would allow for more refined treatment studies of patients who are at highest risk for preeclampsia.