Extracellular vesicles as markers and mediators of pregnancy complications: gestational diabetes, pre-eclampsia, preterm birth and fetal growth restriction

The revolutionary role of placental derivatives in biomedical research

The human placenta is a transient yet crucial organ that plays a key role in sustaining the relationship between the maternal and fetal organisms. Despite its historical classification as "biowaste," placental tissues have garnered increasing attention since the early 1900s for their significant medical potential, particularly in wound repair and surgical application. As ethical considerations regarding human placental derivatives have largely been assuaged in many countries, they have gained significant attention due to their versatile applications in various biomedical fields, such as biomedical engineering, regenerative medicine, and pharmacology. Moreover, there is a substantial trend toward various animal product substitutions in laboratory research with human placental derivatives, reflecting a broader commitment to advancing ethical and sustainable research methodologies. This review provides a comprehensive examination of the current applications of human placental derivatives, explores the mechanisms behind their therapeutic effects, and outlines the future potential and directions of this rapidly advancing field.

Extracellular vesicles and preterm infant diseases

With the continuous improvement in perinatal care, the number of viable preterm infants is gradually increasing, along with the rise in preterm-related diseases such as necrotizing enterocolitis, bronchopulmonary dysplasia, perinatal brain injury, retinopathy of prematurity, and sepsis. Due to the unique pathophysiology of preterm infants, diagnosing and treating these diseases has become particularly challenging, significantly affecting their survival rate and long-term quality of life. Extracellular vesicles (EVs), as key mediators of intercellular communication, play an important regulatory role in the pathophysiology of these diseases. Because of their biological characteristics, EVs could serve as biomarkers and potential therapeutic agents for preterm-related diseases. This review summarizes the biological properties of EVs, their relationship with preterm-related diseases, and their prospects for diagnosis and treatment. EVs face unique challenges and opportunities for clinical applications.

Regulatory roles of extracellular vesicles in pregnancy complications

BACKGROUND

Extracellular vesicles (EVs) are heterogeneous membranous structures released by various cell types, including large vesicles, microvesicles (MVs), and exosomes. These vesicles play crucial roles in intercellular communication within interstitial fluids and are involved in numerous physiological and pathological processes.

AIM OF REVIEW

This review aims to examine the regulatory roles of EVs in pregnancy complications, focusing on their involvement in gestational diabetes mellitus (GDM), preeclampsia (PE), and preterm birth (PTB).

KEY SCIENTIFIC CONCEPTS OF REVIEW

Placenta- and embryo-derived EVs have gained significant attention for their biological roles due to their effects on inflammation, immune response and immunomodulation. Recent research highlights the importance of EVs in embryonic development and gestation. During pregnancy, several EVs functioned in complex endocrine regulation and pregnancy complications that can affect both the mother and fetus, with long-term cardiovascular and metabolic risks. This review discusses the current evidence on how EVs modulate pregnancy outcomes and explores their biological roles in the pathology of GDM, PE, and PTB. In spite of the current difficulties in relating these findings to the pathogenesis of pregnancy complications and the insufficient evidence for clinical practice, the potential impact of specific proteins and miRNAs transported by EVs is noteworthy on the emergence of pregnancy complications. Future research should continue to explore the complex interactions mediated by EVs to develop novel diagnostic and therapeutic strategies for pregnancy-related disorders.

Clostridium difficile-derived membrane vesicles promote fetal growth restriction via inhibiting trophoblast motility through PPARγ/RXRα/ANGPTL4 axis

Fetal growth restriction (FGR) is a common complication of pregnancy, which seriously endangers fetal health and still lacks effective therapeutic targets. Clostridium difficile (C. difficile) is associated with fetal birth weight, and its membrane vesicles (MVs) are pathogenic vectors. However, the role of C. difficile and its MVs in FGR remains unclear. Here we found that supplementation with C. difficile altered the characteristics of gut microbiota and reduced the birth weight in mice. Interestingly, C. difficile MVs entered placenta, inhibited trophoblast motility, and induced fetal weight loss in mice. Mechanistically, C. difficile MVs activated the PPAR pathway via enhancing the transcriptional activity of PPARγ promoter, consequently inhibiting trophoblast motility. Moreover, PPARγ expression was significantly elevated in FGR placenta, and negatively correlated with fetal birth weight. Together, our findings reveal the significance of C. difficile and its MVs in FGR, providing new insights into the mechanisms of FGR development.

A multi-platform assessment of extracellular vesicles from the plasma and urine of women with preeclampsia

INTRODUCTION

MicroRNAs (miRNAs), packaged within extracellular vesicles (EVs), have been used to interrogate the pathogenesis of preeclampsia and to identify its biomarkers. We have previously shown that miRNA species were differentially expressed in small plasma EVs from women with preeclampsia vs healthy controls. We sought to assess the use of rapid technologies for isolation of plasma and urine EVs from parturients with preeclampsia and determine differences in the expression of selected EV miRNA species.

METHODS

We collected blood and urine samples before delivery from parturients with severe preeclampsia vs healthy controls and used size exclusion chromatography (SEC) as an acceptable standard for rapid isolation of plasma EVs. We also isolated urine and plasma EVs using ExoDisc, a rapid nanofiltration technology for EV isolation. All samples were examined using a nanoparticle tracking analyzer, immunoblotting, and RT-qPCR for selected miRNA levels.

RESULTS

Whereas the concentration of EVs was higher in the urine from preeclampsia compared to controls, we observed the opposite change in plasma EVs, with no difference in EV size. Comparing the two patient groups for miRNA levels in EVs isolated by ExoDisc or SEC, we found that EV miR-93-5p was upregulated in the plasma and urine of parturients with preeclampsia vs healthy controls. Notably, miR-31-5p was upregulated in SEC- or ExoDisc-isolated plasma EVs, and miR-92-3p was upregulated in or ExoDisc-isolated plasma or urine EVs of parturients with preeclampsia.

DISCUSSION

Technologies for rapid analysis of plasma and urine EVs and their miRNA cargo provide complementary information that might be useful for deciphering pathways leading to preeclampsia and biomarkers for this disease.

β'-COP mediated loading of PPARγ into trophoblast-derived extracellular vesicles

Fetal growth restriction (FGR) is characterized by impaired fetal growth and dysregulated lipid metabolism. Extracellular vesicles (EVs) have been proved playing a crucial role in transporting biomolecules from the mother to the fetus. However, the mechanisms underlying cargo sorting and loading into trophoblastic EVs remain elusive. This study focuses on examining how the essential fatty acid regulator, peroxisome proliferator-activated receptor gamma (PPARγ), is sorted and loaded into EVs originating from trophoblasts. We conducted proteomic analysis on placenta-derived EVs from normal and FGR pregnancies. Interactions between PPARγ and coat protein complex I (COPI) subunit were evaluated using co-immunoprecipitation and bioinformatics simulation. Molecular dynamics simulations were conducted to identify critical binding sites between β'-coat protein complex I (β'-COP), a subunit of COPI, and PPARγ. lentivirus-mediated knockout and overexpression techniques were employed to elucidate the role of β'-COP in PPARγ loading into EVs. Our findings demonstrate that PPARγ protein levels are significantly decreased in EVs from FGR placentas. β'-COP subunit directly interacts with PPARγ in trophoblasts, mediating its sorting into early endosomes and multivesicular bodies for EVs incorporation. Knockout of β'-COP impaired PPARγ loading into EVs. Molecular dynamics simulations identified critical binding sites for the interaction between β'-COP and PPARγ. Mutation of these sites significantly weakened the β'-COP-PPARγ interaction and reduced PPARγ levels in trophoblastic EVs. In conclusion, β'-COP mediates sorting and loading of PPARγ into trophoblastic EVs. This study provides insights into regulating EVs cargo loading and potential strategies for targeted cargo delivery from the maternal to the fetal circulation.

Proteomic Profiles of Maternal Plasma Extracellular Vesicles for Prediction of Preeclampsia

PROBLEM

Preeclampsia is a heterogeneous syndrome of diverse etiologies and molecular pathways leading to distinct clinical subtypes. Herein, we aimed to characterize the extracellular vesicle (EV)-associated and soluble fractions of the maternal plasma proteome in patients with preeclampsia and to assess their value for disease prediction.

METHOD OF STUDY

This case-control study included 24 women with term preeclampsia, 23 women with preterm preeclampsia, and 94 healthy pregnant controls. Blood samples were collected from cases on average 7 weeks before the diagnosis of preeclampsia and were matched to control samples. Soluble and EV fractions were separated from maternal plasma; EVs were confirmed by cryo-EM, NanoSight, and flow cytometry; and 82 proteins were analyzed with bead-based, multiplexed immunoassays. Quantile regression analysis and random forest models were implemented to evaluate protein concentration differences and their predictive accuracy. Preeclampsia subgroups defined by molecular profiles were identified by hierarchical cluster analysis. Significance was set at p < 0.05 or false discovery rate-adjusted q < 0.1.

RESULTS

In preterm preeclampsia, PlGF, PTX3, and VEGFR-1 displayed differential abundance in both soluble and EV fractions, whereas angiogenin, CD40L, endoglin, galectin-1, IL-27, CCL19, and TIMP1 were changed only in the soluble fraction (q < 0.1). The direction of changes in the EV fraction was consistent with that in the soluble fraction for nine proteins. In term preeclampsia, CCL3 had increased abundance in both fractions (q < 0.1). The combined EV and soluble fraction proteomic profiles predicted preterm and term preeclampsia with an AUC of 78% (95% CI, 66%-90%) and 68% (95% CI, 56%-80%), respectively. Three clusters of preeclampsia featuring distinct clinical characteristics and placental pathology were identified based on combined protein data.

CONCLUSIONS

Our findings reveal distinct alterations of the maternal EV-associated and soluble plasma proteome in preterm and term preeclampsia and identify molecular subgroups of patients with distinct clinical and placental histopathologic features.

Circulating extracellular vesicular microRNA signatures in early gestation show an association with subsequent clinical features of pre-eclampsia

In a prospective cohort of subjects who subsequently developed preeclampsia (PE, n = 14) versus remaining healthy (NORM, n = 12), early gestation circulating extracellular vesicles (EVs) containing a panel of microRNA signatures were characterized and their biological networks of targets deciphered. Multiple microRNAs of which some arose from the placenta (19MC and 14MC) demonstrated changes in association with advancing gestation, while others expressed were pathognomonic of the subsequent development of characteristic clinical features of PE which set in as a late-onset subtype. This panel of miRNAs demonstrated a predictability with an area under the curve of 0.96 using leave-one-out cross-validation training in a logistic regression model with elastic-net regularization and precautions against overfitting. In addition, this panel of miRNAs, some of which were previously detected in either placental tissue or as maternal cell-free non-coding transcripts, lent further validation to our EV studies and the observed association with PE. Further, the identified biological networks of targets of these detected miRNAs revealed biological functions related to vascular remodeling, cellular proliferation, growth, VEGF, EGF and the PIP3/Akt signaling pathways, all mediating key cellular functions. We conclude that we have demonstrated a proof-of-principle by detecting a panel of EV packaged miRNAs in the maternal circulation early in gestation with possibilities of biological function in the placenta and other maternal tissues, along with the probability of predicting the subsequent clinical appearance of PE, particularly the late-onset subtype.

Regulation of placental amino acid transport in health and disease

Abnormal fetal growth, i.e., intrauterine growth restriction (IUGR) or fetal growth restriction (FGR) and fetal overgrowth, is associated with increased perinatal morbidity and mortality and is strongly linked to the development of metabolic and cardiovascular disease in childhood and later in life. Emerging evidence suggests that changes in placental amino acid transport may contribute to abnormal fetal growth. This review is focused on amino acid transport in the human placenta, however, relevant animal models will be discussed to add mechanistic insights. At least 25 distinct amino acid transporters with different characteristics and substrate preferences have been identified in the human placenta. Of these, System A, transporting neutral nonessential amino acids, and System L, mediating the transport of essential amino acids, have been studied in some detail. Importantly, decreased placental Systems A and L transporter activity is strongly associated with IUGR and increased placental activity of these two amino acid transporters has been linked to fetal overgrowth in human pregnancy. An array of factors in the maternal circulation, including insulin, IGF-1, and adiponectin, and placental signaling pathways such as mTOR, have been identified as key regulators of placental Systems A and L. Studies using trophoblast-specific gene targeting in mice have provided compelling evidence that changes in placental Systems A and L are mechanistically linked to altered fetal growth. It is possible that targeting specific placental amino acid transporters or their upstream regulators represents a novel intervention to alleviate the short- and long-term consequences of abnormal fetal growth in the future.

Cargo exchange between human and bacterial extracellular vesicles in gestational tissues: a new paradigm in communication and immune development

Host-bacteria and bacteria-bacteria interactions can be facilitated by extracellular vesicles (EVs) secreted by both human and bacterial cells. Human and bacterial EVs (BEVs) propagate and transfer immunogenic cargos that may elicit immune responses in nearby or distant recipient cells/tissues. Hence, direct colonization of tissues by bacterial cells is not required for immunogenic stimulation. This phenomenon is important in the feto-maternal interface, where optimum tolerance between the mother and fetus is required for a successful pregnancy. Though the intrauterine cavity is widely considered sterile, BEVs from diverse sources have been identified in the placenta and amniotic cavity. These BEVs can be internalized by human cells, which may help them evade host immune surveillance. Though it appears logical, whether bacterial cells internalize human EVs or human EV cargo is yet to be determined. However, the presence of BEVs in placental tissues or amniotic cavity is believed to trigger a low-grade immune response that primes the fetal immune system for ex-utero survival, but is insufficient to disrupt the progression of pregnancy or cause immune intolerance required for adverse pregnancy events. Nevertheless, the exchange of bioactive cargos between human and BEVs, and the mechanical underpinnings and health implications of such interactions, especially during pregnancy, are still understudied. Therefore, while focusing on the feto-maternal interface, we discussed how human cells take up BEVs and whether bacterial cells take up human EVs or their cargo, the exchange of cargos between human and BEVs, host cell (feto-maternal) inflammatory responses to BEV immunogenic stimulation, and associations of these interactions with fetal immune priming and adverse reproductive outcomes such as preeclampsia and preterm birth.

Analyzing molecular signatures in preeclampsia and fetal growth restriction: Identifying key genes, pathways, and therapeutic targets for preterm birth

Background

Intrauterine growth restriction (IUGR) and preeclampsia (PE) are intricately linked with specific maternal health conditions, exhibit shared placental abnormalities, and play pivotal roles in precipitating preterm birth (PTB) incidences. However, the molecular mechanism underlying the association between PE and IUGR has not been determined. Therefore, we aimed to analyze the data of females with PE and those with PE + IUGR to identify the key gene(s), their molecular pathways, and potential therapeutic interactions.

Methods

In this study, a comprehensive relationship analysis of both PE and PE + IUGR was conducted using RNA sequence datasets. Using two datasets (GSE148241 and GSE114691), differential gene expression analysis via DESeq2 through R-programming was performed. Gene set enrichment analysis was performed using ClusterProfiler, protein‒protein interaction (PPI) networks were constructed, and cluster analyses were conducted using String and MCODE in Cytoscape. Functional enrichment analyses of the resulting subnetworks were performed using ClueGO software. The hub genes were identified under both conditions using the CytoHubba method. Finally, the most common hub protein was docked against a library of bioactive flavonoids and PTB drugs using the PyRx AutoDock tool, followed by molecular dynamic (MD) simulation analysis. Pharmacokinetic analysis was performed to determine the ADMET properties of the compounds using pkCSM.

Results

We identified eight hub genes highly expressed in the case of PE, namely, PTGS2, ENG, KIT, MME, CGA, GAPDH, GPX3, and P4HA1, and the network of the PE + IUGR gene set demonstrated that nine hub genes were overexpressed, namely, PTGS2, FGF7, FGF10, IL10, SPP1, MPO, THBS1, CYBB, and PF4. PTGS2 was the most common hub gene found under both conditions (PE and PEIUGR). Moreover, the greater (-9.1 kcal/mol) molecular binding of flavoxate to PTGS2 was found to have satisfactory pharmacokinetic properties compared with those of other compounds. The flavoxate-bound PTGS2 protein complex remained stable throughout the simulation; with a ligand fit to protein, i.e., a RMSD ranging from ∼2.0 to 4.0 Å and a RMSF ranging from ∼0.5 to 2.9 Å, was observed throughout the 100 ns analysis.

Conclusion

The findings of this study may be useful for treating PE and IUGR in the management of PTB.

Down-Regulation of CPEB4 Alleviates Preeclampsia through the Inhibition of Ferroptosis by PFKFB3

Gestational diabetes mellitus (GDM) complicated with preeclampsia can lead to polyhydramnios, ketosis. Herein, we explored that CPEB4 in cancer progression of preeclampsia and its underlying mechanism. All the serum samples were collected from patients with preeclampsia. These was the induction of CPEB4 in patients with preeclampsia. The serum of CPEB4 mRNA expression was positive correlation with Proteinuria, systolic blood pressure and diastolic blood pressure in patients. The serum of CPEB4 mRNA expression was also negative correlation with body weight of infant in patients. The serum of CPEB4 mRNA expression also was negative correlation with GPX4 level and GSH activity level in patients. The serum of CPEB4 mRNA expression was positive correlation with iron content in patients. CPEB4 gene inhibited trophoblast cell proliferation. CPEB4 gene promoted trophoblast cell ferroptosis by mitochondrial damage. CPEB4 gene induced PFKFB3 expression by the inhibition of PFKFB3 Ubiquitination. PFKFB3 inhibitor reduced the effects of CPEB4 on cell proliferation and ferroptosis of trophoblast cell. Taken together, the CPEB4 promoted trophoblast cell ferroptosis through mitochondrial damage by the induction of PFKFB3 expression, CPEB4 as an represents a potential therapeutic strategy for the treatment of preeclampsia or various types of GDM.