Variations in fibrinolytic parameters and inhibin-A in pregnancy: related hypertensive disorders

Blood laboratory testing for early prediction of preeclampsia: chasing the finish line or at the starting blocks?

Preeclampsia (PE) affects 2-8% of pregnancies worldwide, thus representing an important cause of maternal and neonatal morbidity, up to death. Many studies have been designed to identify putative biomarkers for accurate and timely diagnosing PE, but only some of them were focused on specific and sensitive biomarkers for early prediction of this life-threatening condition. In particular, some prospective studies aimed to investigate the predictive role of circulating biomarkers before 20 weeks of gestation in the general pregnant population yielded conflicting results. This article is hence centered on results obtained in studies investigating the predictive performances of angiogenic, anti-angiogenic, inflammatory, endocrine, and epigenetic biomarkers. The available evidence suggests that angiogenic and anti-angiogenic molecules, in particular the sFlt1:PlGF ratio, may be considered the biomarkers with the best diagnostic performance in the second trimester. However, doubts remain about their use in clinical settings before the 20th gestational week. Even lower evidence is available for other biomarkers, due to the fact that some positive results have not been confirmed in ensuing investigations, whereas unresolved analytical issues still contribute to make their clinical reliability rather questionable. Differential expression of microRNAs seems also a promising evidence for early prediction of PE, but additional research and well-designed prospective studies are needed to identify and validate routine predictive tests. KEY MESSAGES Preeclampsia affects 2-8% of pregnant women worldwide, thus remaining one of the leading causes of maternal and neonatal morbidity and mortality. Several studies have investigated the predictive role of circulating biomarkers before 20th week of gestation with conflicting results. Additional research and well-designed prospective studies are needed to identify and validate predictive tests in clinical practice.

Increased Systolic and Diastolic Blood Pressure Is Associated With Altered Gut Microbiota Composition and Butyrate Production in Early Pregnancy

The risk of developing pregnancy-induced hypertension and preeclampsia is higher in obese pregnant women. In obesity, the composition of the gut microbiota is altered. Obesity is also associated with low-grade inflammation. Metabolites from the gut microbiota may contribute to both hypertension and inflammation. The aim of this study is to investigate whether the composition of the gut microbiota in overweight and obese pregnant women is associated with blood pressure and levels of plasminogen activator inhibitor-1. The composition of the gut microbiota was determined with 16S ribosomal RNA sequencing in 205 women at 16 weeks gestation from the SPRING study (the Study of Probiotics in Gestational Diabetes). Expression of butyrate-producing genes in the gut microbiota was assessed by real-time polymerase chain reaction. Plasminogen activator inhibitor-1 levels were measured in fasting serum of a subset of 70 women. Blood pressure was slightly but significantly higher in obese compared with overweight women. The abundance of the butyrate-producing genus Odoribacter was inversely correlated with systolic blood pressure. Butyrate production capacity was decreased, but plasminogen activator inhibitor-1 concentrations increased in obese pregnant women. Plasminogen activator inhibitor-1 levels were inversely correlated with expression of butyrate kinase and Odoribacter abundance. This study shows that in overweight and obese pregnant women at 16 weeks gestation, the abundance of butyrate-producing bacteria and butyrate production in the gut microbiota is significantly negatively associated with blood pressure and with plasminogen activator inhibitor-1 levels. Increasing butyrate-producing capacity may contribute to maintenance of normal blood pressure in obese pregnant women.

Gene expression in peripheral blood of patients with hypertension and patients with type 2 diabetes

AIM

To evaluate the expression of atherosclerosis-associated genes in patients with hypertension and type 2 diabetes mellitus.

MATERIAL AND METHODS

Twenty-seven patients (14 men, 13 women), mean age 43.26 ± 11.69 years, were included in the study, which was divided into three groups: group 1 - patients with newly diagnosed hypertension and normal glucose tolerance (n = 9), group 2 - normotensive individuals with newly diagnosed type 2 diabetes (n = 9), and control group - normotensive individuals with normal glucose tolerance (n = 9). Gene expression analysis was performed with Human Atherosclerosis RT2 Profiler PCR Array.

RESULTS

In patients with hypertension, we found eight genes with increased expression - FABP3, FAS, FN1, IL1R2, LPL, SERPINE1, TGFB1, and VCAM1. Decreased expression was observed for two genes - SELPLG and SERPINEB2. In patients with type 2 diabetes we found seven up-regulated genes - APOE, BAX, MMP1, NFKB1, PDGFB, SPP1, and TGFB2, whereas no specifically down-regulated genes were observed. Three genes - KLF2, PDGFRB, and PPARD were found to be expressed only in groups 1 and 2.

CONCLUSION

Hypertension is associated with increased expression of FABP3, FAS, FN1, IL1R2, LPL, SERPINE1, TGFB1, and VCAM1 and decreased expression of SELPLG and SERPINEB2. The up-regulation of FAS, FN1, SERPINE1, TGFB1, and VCAM1 might be associated with an increased cardiovascular risk. Type 2 diabetes is associated with increased expression of APOE, BAX, MMP1, NFKB1, PDGFB, SPP1, and TGFB2. KLF2 and PPARD might be part of protective mechanisms that limit target organ damage in both disease conditions. Expression of PDGFRB might play an important role in the pathogenesis of both hypertension and type 2 diabetes.

Coagulation and Fibrinolytic System Protein Profiles in Women with Normal Pregnancies and Pregnancies Complicated by Hypertension

OBJECTIVE: The current study longitudinally evaluated concentrations of fibrinogen (Fib), D-Dimer, plasminogen activator type-1 (PAI-1) and tissue type plasminogen activator (T-Pa) before pregnancy and in the first and third trimesters of pregnancy with a focus on the pregnancy transition. STUDY DESIGN: Twenty healthy, nonsmoking, nulliparous women, aged 29.8 ± 3.0 years, BMI 23.3 ± 3.2 kg/m(2) were studied during menstrual cycle day 8 ± 4 and again in early (11 - 15 wks) and late (31 - 34 wks) pregnancy. Seventeen women had singleton conceptions and delivered at term with uncomplicated pregnancies (CTL) and three women developed complicated hypertension (CH) during pregnancy after the third trimester (late pregnancy) evaluation. Data are means ± SEM, Significance was based on p < 0.05. RESULTS: Fib was the only protein evaluated that increased in early pregnancy relative to the prepregnancy assessment. D-dimer, PAI-1 and T-Pa increased in the third trimester compared with prepregnant and early pregnant values (p < .001). T-PA was significantly higher during late pregnancy in CH subjects compared with CTL (8.1 ± 0.7 ng/ml vs. 5.0 ± 0.2 ng/ml, p = .02). There were no other differences between groups. CONCLUSIONS: Increases in fibrinogen are evident in early pregnancy whereas fibrinolysis, perhaps in response to the procoagulant environment of pregnancy, is increased during late pregnancy. Before development of clinically overt hypertension, T-Pa is increased without concomitant changes in other proteins assessed. This is consistent with altered endothelial function with preeclampsia that may contribute to, or reflect, the vasculopathy accompanying this disorder.

Transient reduction of placental angiogenesis in PAI-1-deficient mice

Murine placentation is associated with the invasion of maternal endometrium by trophoblasts and an extensive maternal and fetal angiogenesis. Plasminogen activator inhibitor-1 (PAI-1) is transiently produced by spongiotrophoblasts and trophoblast giant cells at 10.5-11.5 days postcoitum (dpc). Knowing the key contribution of PAI-1 in the regulation of angiogenesis, we have now analyzed the consequence of PAI-1 deficiency on murine placentation. Morphological and quantitative computer-assisted image analysis revealed abnormal placental morphology in PAI-1-/- mice at 10.5 and 12.5 dpc. At 10.5 dpc, the genetic ablation of PAI-1 resulted in a transient reduction of both maternal and fetal vascularizations in the placenta and increased trophoblast cell density. This was associated with a poorer development of the labyrinth and an extension of the decidua. A larger spongiotrophoblast layer appeared at 12.5 dpc in PAI-1-deficient mice. Placental morphology was normalized at 14.5 dpc. Microarray analyses performed on laser capture microdissected labyrinths revealed that 46 genes were differentially expressed between the two genotypes at 10.5 dpc. However, only 11 genes were still differently modulated at 14.5 dpc, when normalization of placental morphology had taken place. This transcriptomic profiling highlighted a dysregulation in the expression of placenta-related cathepsin family members. Altogether our data provide evidence for a transient impaired placental morphology in PAI-1-deficient mice that is then normalized, leading to normal embryonic development.

Coagulation and fibrinolysis related cytokine imbalance in preeclampsia: the role of placental trophoblasts

OBJECTIVE

Cytokine imbalance might have a pivotal role in hypercoagulability seen in preeclampsia. Our objective was to determine the relationship of blood coagulation related factors in placental tissue and peripheral blood in preeclamptic and normal pregnancies.

METHODS

We compared mRNA and protein levels of tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor-1 (PAI-1), and tissue factor (TF) in the placenta of normal and preeclamptic pregnancies. Placental and peripheral blood t-PA and PAI-1 levels were examined. Trophoblasts were used to study the effects of hypoxia, hypoxia-reperfusion, and inflammatory cytokines on t-PA, PAI-1, tissue factor pathway inhibitor (TFPI), and TF.

RESULTS

PAI-1 and TF mRNA and protein levels were higher in placental tissue of preeclamptic pregnancies and in the peripheral blood of patients with preeclampsia. mRNA and protein secretion of TF, TFPI, PAI-1, but not t-PA, was increased in trophoblast cell culture under hypoxia and hypoxia-reoxygenation. Cell cultures with high levels of tumor necrosis factor-alpha (TNF-alpha) exhibited increased expression and secretion of TF and PAI-1, decreased TFPI, and no significant change of t-PA.

CONCLUSIONS

Imbalanced synthesis of t-PA, PAI-1, TFPI, and TF in trophoblasts may contribute to hypercoagulability in patients with preeclampsia.

A new strategy of treatment with low-dosage acetyl salicylic acid in patients affected by central serous chorioretinopathy

Central serous chorioretinopathy (CSCR) is an ocular disease characterized by serous detachment of the neurosensory retina at the posterior pole, with or without an associated retinal pigment epithelium (RPE) detachment. It is associated with different systemic diseases although the pathogenesis is unknown. Different therapies have been applied to treat CSCR with poor results. We reviewed the literature and found that in all the diseases associated with CSCR plasminogen activator inhibitor 1 (PAI-1) was increased. Acetyl salicylic acid (Aspirin) is effective in lowering PAI-1 levels and platelets aggregation; as such we decided to treat patients affected by CSCR with low dose Aspirin. From January 2005 to December 2008 we enrolled 107 patients, 85 male and 22 female, affected with active CSCR or the multifocal variant. Aspirin was administrated at an oral dose of 100 mg. per day for a month and then 100 mg. every other day for five months. After the first week of therapy and for the following three months the visual acuity improved and remained stable to the end of the follow-up (median follow-up 20 months). A recurrence of the disease interested the 6% of the patients. In this study low-dose Aspirin was able to treat central serous chorioretinopathy with a quick recovery of the visual acuity and a reduced number of recurrences during the follow-up. Besides the effectiveness of the treatment with Aspirin supports our observation regarding the role of impaired fibrinolysis and increased platelets aggregation in the choriocapillaris as genesis of CSCR.