Recent advances in the understanding of the pathophysiology of preeclampsia

Non-Viral RNA Delivery During Pregnancy: Opportunities and Challenges

During pregnancy, the risk of maternal and fetal adversities increases due to physiological changes, genetic predispositions, environmental factors, and infections. Unfortunately, treatment options are severely limited because many essential interventions are unsafe, inaccessible, or lacking in sufficient scientific data to support their use. One potential solution to this challenge may lie in emerging RNA therapeutics for gene therapy, protein replacement, maternal vaccination, fetal gene editing, and other prenatal treatment applications. In this review, the current landscape of RNA platforms and non-viral RNA delivery technologies that are under active development for administration during pregnancy is explored. Advancements of pregnancy-specific RNA drugs against SARS-CoV-2, Zika, influenza, preeclampsia, and for in-utero gene editing are discussed. Finally, this study highlights bottlenecks that are impeding translation efforts of RNA therapies, including the lack of accurate cell-based and animal models of human pregnancy and concerns related to toxicity and immunogenicity during pregnancy. Overcoming these challenges will facilitate the rapid development of this new class of pregnancy-safe drugs.

Risk factors for severe postpartum hemorrhage requiring blood transfusion after cesarean delivery for twin pregnancy: a nationwide cohort study

BACKGROUND

Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality. Twin pregnancy and cesarean delivery are well-known risk factors for PPH. However, few studies have investigated PPH risk factors in mothers who have undergone cesarean delivery for twin pregnancies. Therefore, this study investigated the risk factors associated with severe PPH after cesarean delivery for twin pregnancies.

METHODS

We searched and reviewed the Korean Health Insurance Review and Assessment Service's claims data from July 2008 to June 2021 using the code corresponding to cesarean delivery for twin pregnancy. Severe PPH was defined as hemorrhage requiring red blood cell (RBC) transfusion during the peripartum period. The risk factors associated with severe PPH were identified among the procedure and diagnosis code variables and analyzed using univariate and multivariate logistic regressions.

RESULTS

We analyzed 31,074 cesarean deliveries for twin pregnancies, and 4,892 patients who underwent cesarean deliveries for twin pregnancies and received RBC transfusions for severe PPH were included. According to the multivariate analysis, placental disorders (odds ratio, 4.50; 95% confidence interval, 4.09- 4.95; P < 0.001), general anesthesia (2.33, 2.18-2.49; P < 0.001), preeclampsia (2.20, 1.99-2.43; P < 0.001), hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome (2.12, 1.22-3.68; P = 0.008), induction failure (1.37, 1.07-1.76; P = 0.014), and hypertension (1.31, 1.18-1.44; P < 0.001) predicted severe PPH.

CONCLUSIONS

Placental disorders, hypertensive disorders such as preeclampsia and HELLP syndrome, and induction failure increased the risk of severe PPH after cesarean delivery for twin pregnancy.

Preeclampsia history and postpartum risk of cerebrovascular disease and cognitive impairment: Potential mechanisms

Hypertensive disorders of pregnancy such as preeclampsia, eclampsia, superimposed preeclampsia, and gestational hypertension are major causes of fetal and maternal morbidity and mortality. Women with a history of hypertensive pregnancy disorders have increased risk of stroke and cognitive impairments later in life. Moreover, women with a history of preeclampsia have increased risk of mortality from diseases including stroke, Alzheimer's disease, and cardiovascular disease. The underlying pathophysiological mechanisms are currently not fully known. Here, we present clinical, epidemiological, and preclinical studies focused on evaluating the long-term cerebrovascular and cognitive dysfunction that affect women with a history of hypertensive pregnancy disorders and discuss potential underlying pathophysiological mechanisms.

Down-regulation of autophagy proteins is associated with higher mTOR expression in the placenta of pregnant women with preeclampsia

Autophagy is a lysosomal degradation pathway that removes protein aggregates and damaged organelles maintaining cellular integrity. It seems to be essential for cell survival during stress, starvation, hypoxia, and consequently to the placenta implantation and development. Preeclampsia (PE) is a multisystemic disorder characterized by the onset of hypertension associated or not with proteinuria and other maternal complications. Considering that the placenta seems to play an important role in the pathogenesis of PE, the objective of the present study was to evaluate protein levels of light chain protein (LC3), beclin-1, and the mammalian target of rapamycin (mTOR) in the placenta of pregnant women with PE. Placental tissues collected from 20 women with PE and 20 normotensive (NT) pregnant women were evaluated for LC3, beclin-1, and mTOR expression by qPCR and immunohistochemistry. The mRNA for LC3 and beclin-1 were significantly lower, while mTOR gene expression was significantly higher in the placenta of pregnant women with PE than in the NT group. Placentas of PE women showed significantly decreased protein expression of LC3-II and beclin-1, whereas mTOR was significantly increased compared with the NT pregnant women. There was a negative correlation between protein expression of mTOR and LC3-II in the placental tissue of PE women. In conclusion, the results showed autophagy deficiency suggesting that failure in this degradation process may contribute to the pathogenesis of PE; however, new studies involving cross-talk between autophagy and inflammatory molecular mechanisms might help to better understand the autophagy process in this obstetric pathology.

Hes-related family BHLH transcription factor with YRPW motif 1-activated proteasome 26S subunit, non-ATPase 14 regulates trophoblast function and endometrial angiogenesis

Proteasome 26S subunit, non-ATPase 14 (PSMD14) expression has been previously reported to be reduced in patients with pre-eclampsia (PE). The present study investigated the interaction network associated with the role of PSMD14 in PE. Reverse transcription-quantitative PCR (RT-qPCR) and western blotting were performed to determine the transfection efficacy following plasmid-based gene transfer of PSMD14 into HTR-8/SVneo cells. Cell proliferation was measured using an MTT assay and 5-ethynyl-2'-deoxyuridine staining. The expression of proliferation-related proteins, including Ki67 and PCNA, was determined using western blotting. Wound healing and Transwell assays were performed to measure cell invasion and migration, whilst the expression of migration-related proteins, including MMP2 and MMP9, was measured using western blotting. The angiogenesis of HUVECs following treatment with the HTR-8/SVneo cell culture supernatant was examined using tube formation assay. Following overexpression of Hes-related family BHLH transcription factor with YRPW motif 1 (HEY1) by transfection of pcDNA3.1 expression vector containing full-length human HEY1 or knockdown by transfection of shRNA plasmids targeting HEY1, the expression of HEY1 and PSMD14 was detected using RT-qPCR and western blotting. The potential interaction between HEY1 and the PSMD14 promoter was examined using dual-luciferase reporter and chromatin immunoprecipitation assays. PSMD14 overexpression was found to promote the proliferation, invasion, migration of HTR-8/SVneo cells and the angiogenesis of HUVECs following treatment with the HTR-8/SVneo cell culture supernatant, accompanied by enhanced expression of proliferation and migration-related proteins. Furthermore, the transcription factor HEY1 activated the expression of PSMD14. Knocking down HEY1 expression partially reversed the promoting effects of PSMD14 overexpression on the proliferation, invasion, migration, angiogenesis, proliferation and migration-related protein expression in trophoblasts. In conclusion, HEY1-activated PSMD14 promoted trophoblast proliferation, invasion and angiogenesis. Therefore, HEY1 and PSMD14 can be potential targets for PE treatment.

Study on lipid nanomicelles targeting placenta for the treatment of preeclampsia

In view of the serious clinical harm of preeclampsia and the lack of effective treatment methods, a PEG-modified lipid hybrid micelle was designed with folic acid molecule on the surface, containing siRNA, targeted delivery to the placenta, interfering the expression of sFlt-1 and treating preeclampsia. In this paper, the preparation and characterization of lipid hybrid micelles were investigated in detail, the cytology in vitro and in vivo distribution, pharmacodynamics, safety and action mechanism of the preparation were studied, which laid a foundation for gene therapy of preeclampsia.

Increase of autophagy marker p62 in the placenta from pregnant women with preeclampsia

Preeclampsia (PE) is a multisystemic disorder characterized by abnormal placentation. Autophagy is a lysosomal degradation pathway that removes protein aggregates and damaged organelles, and it seems to be essential for cell survival during stress, hypoxia, and for implantation and development of the placenta. p62/SQSTM1 is an autophagy marker that not only binds proteins destined for elimination but is also constitutively degraded by this mechanism. Considering that the placenta plays an important role in the pathogenesis of PE, the present study aimed to evaluate the gene and protein expression of p62/SQSTM1 in placentas from pregnant women with PE. Placental tissues from 20 women with PE classified into three groups according to gestational age, 27-31 weeks (n = 8); 32-36 weeks (n = 6); 37-39 weeks (n = 6), and 20 normotensives (NT) pregnant women were collected and employed for p62/SQSTM1 expression by quantitative polymerase chain reaction (qPCR), immunohistochemistry and enzyme-linked immunosorbent assay (ELISA) techniques. p62/SQSTM1 mRNA levels were significantly lower, while protein expression was significantly higher in the placenta of pregnant women with PE than in NT pregnant women, and these results remained similar after separating the groups by gestational age. In conclusion, the results suggest that there is a reduction of autophagic activity in pregnant women with PE. Studies involving cross-talk between autophagy, inflammasomes, nuclear transcription factor (NF-κB) activation pathways, and aggregation of protein in the placenta from women with PE might help to better understand the pathogenesis of this important obstetric pathology.

The role of junctional adhesion molecule-C in trophoblast differentiation and function during normal pregnancy and preeclampsia

INTRODUCTION

Junctional adhesion molecule-C (JAM-C) is an important regulator of many physiological processes, ranging from maintenance of tight junction integrity of epithelia to regulation of cell migration, homing and proliferation. Preeclampsia (PE) is a trophoblast-related syndrome with abnormal placentation and insufficient trophoblast invasion. However, the role of JAM-C in normal pregnancy and PE pathogenesis is unknown.

METHODS

The expression and location of JAM-C in placentas were determined by quantitative real-time PCR (qRT-PCR), western blot and immunohistochemistry. The expression of differentiation and invasion markers were detected by qRT-PCR or western blot. The effects of JAM-C on migration and invasion of trophoblasts were examined using wound-healing and invasion assays. Additionally, a mouse model was established by injection of JAM-C-positive adenovirus to explore the effects of JAM-C in vivo.

RESULTS

In normal pregnancy, JAM-C was preferentially expressed on cytotrophoblast (CTB) progenitors and progressively decreased when acquiring invasion properties with gestation advance. However, in PE patients, the expression of JAM-C was upregulated in extravillous trophoblasts (EVTs) and syncytiotrophoblasts (SynTs) of placentas. It was also demonstrated that JAM-C suppressed the differentiation of CTBs into EVTs in vitro. Consistently, JAM-C inhibited the migration and invasion capacities of EVTs through GSK3β/β-catenin signaling pathway. Importantly, Ad-JAMC-infected mouse model mimicked the phenotype of human PE.

DISCUSSION

JAM-C plays an important role in normal placentation and upregulated JAM-C in placentas contributes to PE development.

Propofol rescues LPS-induced toxicity in HRT-8/SVneo cells via miR-216a-5p/TLR4 axis

OBJECTIVE

The purpose of this study was to evaluate the effect of propofol on lipopolysaccharide (LPS)-induced toxicity in HTR-8/SVneo cells.

METHODS

In this study, HTR-8/SVneo cells were induced by LPS. The cells were treated with different concentrations of propofol. Cell proliferation, apoptosis, invasion, and wound healing rate were measured by MTT, flow cytometry, Transwell, and wound-healing assay. The relative mRNA expression levels of miR-216a-5p, TLR, MyD88, and NF-κB(p65) were measured by qRT-PCR. The protein expression levels of TLR, MyD88, and p-NF-κB(p65) were detected by western blot. The p-NF-κB(p65) nuclear volume was evaluated by cell immunofluorescence.

RESULTS

Compared with control group, the cell proliferation, invasion, and wound healing rate were significantly decreased and the cell apoptosis rate was significantly increased in LPS- induced HTR-8/SVneo cells (P < 0.01). With propofol supplement, the cell proliferation, migration, and invasion abilities were significantly recovered and apoptosis rate was significantly inhibited (P < 0.05). The expression levels of miR-216a-5p, TLR4, MyD88, NF-κB(p65), and p-NF-κB(p65), and p-NF-κB(p65) nuclear volume were significantly different between propofol group and model group (P < 0.05). However, after knockdown of miR-216a-5p expression by si-miR-216a-5p transfection, the cell proliferation, migration, and invasion abilities were significantly inhibited and apoptosis rate was notably increased (P < 0.05).

CONCLUSION

Propofol improves LPS-induced toxicity in HTR-8/SVneo cells via regulation miR-216a-5p/TLR4 axis.

Use of Race, Ethnicity, and National Origin in Studies Assessing Cardiovascular Risk in Women With a History of Hypertensive Disorders of Pregnancy

Women with a history of hyperBtensive disorders of pregnancy (HDP) are at particularly high risk for cardiovascular disease (CVD) and CVD-related death, and certain racial and ethnic subpopulations are disproportionately affected by these conditions. We examined the use of race, ethnicity, and national origin in observational studies assessing CVD morbidity and mortality in women with a history of HDP. A total of 124 studies, published between 1976 and 2021, were reviewed. We found that white women were heavily overrepresented, encompassing 53% of all participants with HDP. There was limited and heterogeneous reporting of race and ethnicity information across studies and only 27 studies reported including race and/or ethnicity variables in at least 1 statistical analysis. Only 2 studies mentioned the use of these variables as a strength; several others (k = 18) reported a lack of diversity among participants as a study limitation. Just over half of included articles (k = 68) reported at least 1 sociodemographic variable other than race and ethnicity (eg, marital status and income); however, none investigated how they might have worked synergistically or antagonistically with race and/or ethnicity to influence participants' risk of CVD. These findings highlight significant areas for improvement in cardiovascular obstetrics research, including the need for more robust and standardized methods for collecting, reporting, and using sociodemographic information. Future studies of CVD risk in women with a history of HDP should explicitly examine racial and ethnic differences and use an intersectional approach.

A Novel Peptide Ameliorates TNFα- and LPS-Induced Endothelia Dysfunction in Preeclampsia

BACKGROUND

To investigate the protective effects of the novel peptide antiendothelial dysfunction peptide in preeclampsia (AEDPPE) on tumor necrosis factor α (TNFα)- and lipopolysaccharide (LPS)-induced injury in the vascular endothelium in preeclampsia.

METHODS

The effects of AEDPPE on TNFα-induced vascular endothelial injury were assessed by enzyme-linked immunosorbent assay, quantitative real-time PCR, mitochondrial membrane potential assay, Cell Counting Kit-8 assay, THP-1 monocyte-human umbilical vein endothelial cell (HUVEC) adhesion assay, endothelial tube-forming assay, transcriptomic analysis, preeclamptic symptom analysis, and histological analysis in preeclampsia-like rat models induced by LPS.

RESULTS

AEDPPE alleviated the upregulation of antiangiogenic factors including soluble fms-like tyrosine kinase-1, endothelin-1, and tissue plasminogen activator and attenuated the reduction in mitochondrial potential induced by TNFα in HUVECs. In addition, AEDPPE treatment counteracted the decrease in tube formation and decreased the numbers of THP-1 monocytes attached to HUVECs caused by TNFα. Mechanistically, cytokine-cytokine receptor interactions enriched many genes and the TNF signaling pathway may be involved in this phenomenon. Moreover, cotreatment with LPS and AEDPPE significantly reversed the preeclampsia-like phenotype including hypertension and proteinuria and improved the functions of the kidney and placenta.

CONCLUSIONS

AEDPPE effectively ameliorated the vascular endothelial injury induced by TNFα and LPS in preeclampsia. We suggest that AEDPPE may be a novel therapeutic candidate for preeclampsia treatment. These findings demonstrate that AEDPPE may play an effective role in ameliorating vascular endothelial dysfunction and be a potential therapeutic agent for preeclampsia.

Efficacy of Magnesium Sulfate on Maternal Mortality in Eclampsia

Eclampsia is a common complication of preeclampsia patients and can be life-threatening for both the mother and the fetus. Hence, timely intervention and appropriate management of this detrimental condition are extremely crucial. Eclampsia is described as the occurrence of generalized convulsions in patients with preeclampsia. Magnesium sulfate (MgSO₄) is the drug of choice for treating and preventing eclampsia. This review aims to study and analyze the available literature on the pathogenesis of eclampsia, the pharmacology of MgSO₄, and its effectiveness in the management of eclampsia. Other proposed treatments and their comparative study with MgSO₄ are also discussed. Additionally, we examine the data regarding the impact of eclampsia, its public health burden, and the cost-effectiveness of MgSO₄. One of the major drawbacks associated with the use of MgSO₄ in low-income countries has been the cost of treatment and the lack of resources. We have analyzed the trials that have proposed alternate treatment regimens which could shape new guidelines to resolve these issues. For this review, we extensively studied abstract and full-text articles from multiple databases. This article discusses the pathophysiology of eclampsia, the pharmacology of MgSO₄, the issues surrounding eclampsia management, and how MgSO₄ benefits these patients.

Assembly of Cytoplasmic Stress Granules in Placentas in Women with Preeclampsia

Inflammation is a well-recognized factor associated with preeclampsia (PE). Stress granules (SGs) have been shown to play an important role in regulating inflammation and immune responses. However, whether SGs are involved in the pathogenesis of PE has not been studied. Here, we evaluated the expression of SG components in placenta of pregnancies with PE. Placental samples or serum were collected from PE patients (n = 31) or healthy age-matched pregnancy (n = 17). mRNA expressions of SG-associated genes in placenta from PE or normal pregnancies were detected by real-time quantitative PCR, and protein expressions of HuR and G3BP were detected using western blot. Immunofluorescence staining was performed to evaluate SG components expression in placentas or 10% serum treated HTR-8/Svneo cells using antibodies against HuR and G3BP. Our study showed higher levels of elavl1, lsm2, lsm4, and ago1 mRNA expression and SG marker proteins expression in placental homogenates of PE patients. HuR/G3BP-positive SG structure was further observed in placental villi of PE by immunofluorescence assay. Besides, serum from PE patients could induce SG aggregation in human trophoblast cell line HTR-8/Svneo cells, suggesting the involvement of SGs in the development of PE.

NAMPT single-nucleotide polymorphism rs1319501 and visfatin/NAMPT affect nitric oxide formation, sFlt-1 and antihypertensive therapy response in preeclampsia

Aim: We examined the relationships between visfatin/NAMPT and nitrite concentrations (a marker of nitric oxide [NO] formation) or sFlt-1 levels in 205 patients with preeclampsia (PE) responsive or nonresponsive to antihypertensive therapy, and whether NAMPT SNPs rs1319501 and rs3801266 affect nitrite concentrations in PE and 206 healthy pregnant women. Patients & methods: Circulating visfatin/NAMPT and sFlt-1 levels were measured by ELISA, and nitrite concentrations by using an ozone-based chemiluminescence assay. Results: In nonresponsive PE patients, visfatin/NAMPT levels were inversely related to nitrite concentrations and positively related to sFlt-1 levels. NAMPT SNP rs1319501 affected nitrite concentrations in nonresponsive PE patients and was tightly linked with NAMPT functional SNPs in Europeans. Conclusion: NAMPT SNP rs1319501 and visfatin/NAMPT affect NO formation, sFlt-1 levels and antihypertensive therapy response in PE.

Non-Criteria Antiphospholipid Antibodies: Risk Factors for Endothelial Dysfunction in Women with Pre-Eclampsia

The association between unconventional antiphospholipid antibodies and pre-eclampsia in patients without thrombotic manifestations and its relationship with endothelial dysfunction after delivery has been studied poorly. We included 157 pregnant women, 122 of them having developed pre-eclampsia (56 non-severe and 66 severe). The determination of classical and unconventional, as well as pulse wave velocity and ankle-brachial index were performed at three months after delivery. The prevalence of unconventional antiphospholipid antibodies was 22.9% and 54.9% in patients included in control and pre-eclampsia groups, respectively (p = 0.001). The most frequent antiphospholipid antibody was IgM anti-phosphatidylserine/prothrombin in both cohorts. The presence of IgM anti-phosphatidylserine/prothrombin showed an association with the development of pre-eclampsia (OR = 5.4; CI 95% (2.0–14.9), p = 0.001) with an AUC of 0.744 (p < 0.001). Likewise, IgM anti-phosphatidylserine/prothrombin exhibited a positive linear correlation with pulse wave velocity values (rho = 0.830; p < 0.001) and an association with the presence of pulse wave velocity altered values (OR = 1.33; CI95% (1.10–1.59), p = 0.002). With regard to ankle braquial index values, the presence of IgM anti-phosphatidylserine/prothrombin displayed a weak negative correlation (rho = −0.466; p < 0.001) and an association with altered ankle braquial index values (OR = 1.08; CI 95% (1.04–1.13), p < 0.001). In patients who developed preeclampsia, the presence of IgM anti-phosphatidylserine/prothrombin could be associated with endothelial dysfunction, causing alteration of cardiovascular parameters.

Association between ELABELA Serum Concentrations in First Trimester and Pregnancy-Induced Hypertension

ELABELA (ELA) is considered to be implicated in the pathophysiology of preeclampsia (PE), since ELA-deficient mice exhibited PE-like symptoms and infusion of exogenous ELA normalized the gestational hypertension (GH) and proteinuria. However, no evidence show that circulating ELA is deficient in early placental development among women who destined to develop GH/PE. This nested case-control study was conducted to investigate the association between serum ELA concentration in early pregnancy and the risk of later GH/PE. Participants were recruited and sampled in 10-14⁺⁶ weeks of gestation. Definite GH/PE cases were matched 1 : 3 to controls with respect to age and gestational age. Serum concentration of ELA was measured using enzyme immunoassay. Women with later GH (N = 28) had a slightly lower median concentration of ELA (46.72 ng/mL versus 53.54 ng/mL), while those with later PE (N = 16) had a slightly higher median concentration of ELA (74.8 ng/mL versus 66.30 ng/mL) compared to the controls. Yet, both the increments did not reach statistically significant difference (GH: P = 0.380, PE: P = 0.799). ELA serum concentrations were unchanged in first trimester in women with GH/PE. Further studies are still needed to identify the dynamic changes in serum ELA concentrations during the whole pregnancy, especially in those with pregnancy-induced hypertensive disorders.

Protein-9 (CTRP9) levels associated with C1q tumor necrosis factor in obese preeclamptic, non-obese preeclamptic, obese and normal pregnant women

AIM

The incidence of obesity and preeclampsia is increasing more and more all over the world. Inflammation and endovascular dysfunction play an important role in the etiopathogenesis of preeclampsia. Obesity has been reported to contribute to the development of preeclampsia by developing a low-grade inflammatory environment and adversely affecting maternal endothelial function. Studies on the relationship between obesity and preeclampsia and how this relationship contributes to endothelial dysfunction continue. The complement C1q tumor necrosis factor-associated protein (CTRP) family (CTRP1-15) secreted from the adipose tissue is a new generation adipokine family with important functions in the immunomodulatory, anti-inflammatory, apoptosis, autoimmunity, vascular system, glucose and lipid metabolism in the body. In recent years, CTRP9, a member of this family, has been shown to have a strong vasorelaxation effect with the Adiponectin Receptor-1/AMPK/eNOS/Nitric Oxide Signaling Pathway. The study aims to find out the role of CTRP9, an adipocytokine, in the pathogenesis of obesity and preeclampsia.

MATERIAL AND METHOD

The CTRP9 levels were measured by the enzyme-linked immunosorbent assay (ELISA) in 40 obese preeclamptic, 40 non-obese preeclamptic, 40 obese pregnant women and 40 normal BMI (Body mass index) pregnant women.

RESULTS

The CTRP9 level of the obese preeclampsia group was found to be lower compared to the non-obese preeclampsia, obese pregnant and normal BMI pregnant control groups (p < .001). The obese preeclampsia group had higher systolic and diastolic blood pressure values compared to the non-obese preeclampsia group (p < .001). There was no difference between the CTRP9 levels of the normal BMI and non-obese preeclampsia groups (p > .05). The serum CTRP9 levels were inversely correlated with age, BMI, blood pressure, and aspartate aminotransferase (AST) (p < .001).

CONCLUSION

Obesity causes a decrease in CTRP9 levels and contributes to the pathogenesis of preeclampsia with adverse effects on the vascular and placental system. Serum CTRP9 levels in pregnant women help identify pregnancies at risk in terms of obesity and preeclampsia.

Cys-peptide mediates the protective role in preeclampsia-like rat and cell models

OBJECTIVE

The present study was designed to investigate whether the novel peptide cysteine-based peptide (Cys-peptide) had protective effects on preeclamptic animal and cell models.

METHODS

We investigated effects of Cys-peptide on (1) preeclamptic symptoms (e.g. hypertension, proteinuria, fetal growth restriction (FGR)) in preeclampia-like rat models induced by lipopolysaccharides (LPS), (2) TNFα-induced cytotoxicity of human umbilical vascular endothelial cells (HUVECs) and HTR-8 cells (an immortalised human trophoblast cell line), (3) endothelial dysfunction and injured angiogenesis, (4) migration and invasion of trophoblast cells induced by TNFα.

RESULTS

Cys-peptide ameliorated LPS-induced hypertension, proteinuria and FGR and other PE symptoms in preeclampia-like rat models. In addition, Cys-peptide attenuated TNFα-induced cytotoxicity by decreasing soluble fms-like tyrosine kinase-1 (sFlt-1), endothelin-1 (ET-1) and tissue plasminogen activator (tPA) mRNA expression in both cells. Furthermore, Cys-peptide restored endothelial dysfunction and rescued angiogenesis caused by TNFα in vitro. Importantly, Cys-peptide could reverse insufficient ability to invade and migrate of trophoblast cells.

CONCLUSIONS

These results suggest Cys-peptide can play beneficial roles in preeclampsia-like rat and cell models. Therefore, we propose that Cys-peptide is probably a novel therapeutic candidate for PE.

Blood pressure changes during twin pregnancies: the Japan Environment and Children's Study

OBJECTIVES

Although a twin pregnancy is a risk factor for hypertensive disorders of pregnancy, studies investigating longitudinal blood pressure changes during twin pregnancies are uncommon. The aims of this study were to evaluate the longitudinal blood pressure changes during twin pregnancies and to compare blood pressure levels between twin and singleton pregnancies.

METHODS

Five hundred dichorionic diamniotic twin, 240 monochorionic diamniotic twin, and 80 775 singleton pregnancies were included in this Japanese prospective birth cohort study. A marginal model was applied to evaluate the SBP, DBP, and mean arterial pressure levels during early gestation, mid-gestation, and late gestation.

RESULTS

The blood pressure levels fell from early-to-mid-gestation and rose after mid-gestation in the dichorionic and monochorionic diamniotic twin pregnancies. The SBP and mean arterial pressure levels during early gestation and the DBP and mean arterial pressure levels during late gestation were higher in the dichorionic diamniotic twin pregnancies than those in the singleton pregnancies. The blood pressure levels in the monochorionic diamniotic twin pregnancies were higher than those in the singleton pregnancies at each gestational stage, except for the SBP during late gestation.

CONCLUSION

Although the longitudinal blood pressure changes during twin pregnancies were similar to those during singleton pregnancies, the blood pressure levels during twin pregnancies were higher. Further studies that examine the associations between the longitudinal blood pressure changes during pregnancy and the perinatal outcomes in twin pregnancies are necessary.

Expression of ESRP1 at human fetomaternal interface and involvement in trophoblast migration and invasion

INTRODUCTION

Studies have reported that villous cytotrophoblasts (CTBs) undergo a partial epithelial to mesenchymal transition (EMT) when differentiating into extravillous cytotrophoblasts (EVTs). Epithelial splicing-regulatory protein 1 (ESRP1), an alternative splicing regulator, has been demonstrated to play important roles in the EMT process. Nevertheless, the roles of ESRP1 in the placentation remain undefined.

METHODS

ESRP1 expression in placental tissues throughout pregnancy was determined by immunohistochemistry and western blotting. The effect of ESRP1 knockdown by using small-interfering RNAs (siRNAs) on the phenotype of trophoblast cell line (HTR-8/SVneo) and villous explants was evaluated.

RESULTS

ESRP1 was localized within the CTBs, trophoblast columns, and EVTs located in the decidua. ESRP1 expression was changed during pregnancy, with the highest expression level in term placentae. ESRP1 knockdown significantly increased the migration and invasion of HTR-8/SVneo cells, as well as the outgrowth of EVTs from villous explants, without affecting cell proliferation. This enhanced effect was associated with the increased expression of N-cadherin, vimentin and CD44.

DISCUSSION

Our results suggested an important role for ESRP1 in regulating trophoblast migration and invasion during placentation.

Circ_0063517 acts as ceRNA, targeting the miR-31-5p-ETBR axis to regulate angiogenesis of vascular endothelial cells in preeclampsia

AIMS

Accumulated evidence indicates that the dysregulation of circular RNAs (circRNAs) plays pivotal roles in many human diseases including preeclampsia (PE). Circ_0063517 has been verified to be down-regulated in PE. But the role of circ_0063517 in PE is still unclear. This research aims to probe into the effect of circ_0063517 on angiogenesis in PE development.

MAIN METHODS

The expression of circ_0063517, endothelin receptor type B (ETBR) and miR-31-5p was assessed by quantitative reverse transcription polymerase chain reaction (RT-qPCR). MTT assay, colony formation assay, scratch assay, transwell assay, and tube formation assay were performed to detect proliferation, migration, and angiogenesis, respectively. Dual luciferase reporter system and RNA immunoprecipitation (RIP) assay were carried out to determine the interaction between miR-31-5p and circ_0063517(or ETBR). ETBR, VEGFRA, and VEGFR2 levels were detected by western blot analysis. The effect of circ_0063517 and ETBR on angiogenesis was evaluated in N-nitro-L-arginine methyl ester hydrochloride (L-NAME)-induced PE in vivo.

KEY FINDINGS

The levels of circ_0063517 and ETBR were down-regulated in the placenta tissue of PE patients. Conversely, the level of miR-31-5p was up-regulated in PE. Overexpression of circ_0063517 or knockdown of miR-31-5p facilitated growth, migration, and angiogenesis of vascular endothelial cells. Circ_0063517 knockdown-induced repression of the expression of ETBR, VEGFA, and VEGFR2 was partly counteracted by ETBR overexpression. Mechanistically, circ_0063517 sponged miR-31-5p to regulate ETBR expression. Finally, circ_0063517 promoted angiogenesis via enhancing ETBR expression in PE in vivo.

SIGNIFICANCE

Our findings suggest that circ_0063517-miR-31-5p-ETBR axis regulates angiogenesis during the pathological process of PE.

The need for implementation of first trimester screening for preeclampsia and fetal growth restriction in low resource settings

Background: Preeclampsia [PE] and fetal growth restriction [FGR] is a major cause of perinatal morbidity in both developed and developing countries but the disease leaves a severe impact in developing countries, due to the late presentation of cases where prevention and treatment becomes impossible. Routine antenatal ultrasound and health checkups in periphery are usually done in first trimester for dating and viability scan, in midtrimester for anomaly scan and in third trimester for safe confinement. Underlying disorder of deep placentation which is unidentified can lead to increased maternal morbidity and fetal compromise between 26 to 34 weeks of gestation The complications present at an irreversible stage where there is no sufficient time even for referral to tertiary care center. Frequent antenatal visits as suggested by WHO would definitely bring down maternal mortality but this increased surveillance when offered to all might be a huge burden to health care providers in low resource settings. An acceptable screening test should help in triaging the high risk group in first trimester itself targeting about only one third of the population for prophylactic therapy and increased antenatal surveillance.The objective of this study is to evaluate the performance and feasibility of different screening protocols in low resource settings.Methodology: Screening for PE and FGR was done at the 11-14 weeks aneuploidy scan as per FMF guidelines. Group I included 6289 women whose risk prediction was done with maternal characteristics [MC], mean arterial pressure [MAP] and Uterine artery Doppler [UAD]. Group II included 2067 women whose risk was predicted with MC, MAP, UAD and PAPP-A. Group III included 576 women whose risk prediction included all parameters with PLGF.Results: Two thousand five hundred fifty-seven cases were screen positive in group I and 602 were screen positive in group II. In group III which included PLGF, 24 were positive for early onset PE and 36 for late onset PE. The number needed to treat [NNT] was 35.9, 29.1 and 10% in Group I, II and III respectively. The detection rate [DR] for PE and FGR was 60% in Group I and DR for FGR in Group II was 85%. In Group III, for early onset PE the DR was 98% and 68% for late onset PE.Conclusion: Screening for PE with available resources in the periphery needs to be implemented to avoid its grave complications. Traditional screening for PE by NICE guidelines can be adopted but may have a detection rate of only 30-40%. Though screening by ACOG criteria may have good detection rates but more than two thirds of the population would become screen positive which nullifies this approach as a good screening methodology in low resource settings. Multiparametric approach for screening in first trimester serves as a better screening tool to enable higher detection rate of disease with least false positive rates. Uterine artery Doppler when combined with maternal characteristics and mean arterial pressure could achieve a detection rate of about 60% and would still target only one third of the population for increased antenatal surveillance. This requires training healthcare professionals in the periphery for this approach and this should be our prime focus in the current scenario. Inclusion of serum biochemistry would still bring down the target population to 10% and increase the DR and can be considered as an additional test in economically feasible population. In low resource settings a better screening approach to PE would be a combination of maternal history, biophysical or biochemical parameters whichever is feasible considering the economy and availability of resources.

The glucagon-like peptide 1 receptor agonist liraglutide attenuates placental ischemia-induced hypertension

Preeclampsia is a hypertensive disorder of pregnancy characterized by systemic perturbations of nitric oxide function, reflective of generalized endothelial dysfunction. Therapies that target the nitric oxide pathway have shown promise in both clinical and preclinical studies of preeclampsia. The glucagon-like peptide 1 agonists have been shown to increase nitric oxide and lower blood pressure in patients with diabetes, in part, through activation of nitric oxide synthase (NOS). Therefore, we hypothesized that a direct acting glucagon-like peptide 1 receptor agonist would improve stigmata of the preeclampsia syndrome. Using the reduced uterine perfusion pressure rat model, we found that treatment with liraglutide significantly lowered blood pressure, improved renal function, and upregulated NOS3 protein expression in the mesenteric arterial bed. However, there were adverse effects on pup growth that were likely related to diminished food intake in the dams. Collectively, these data support the premise that the use of drugs that improve NOS abundance, including the glucagon-like peptide 1 agonists, is a rational therapeutic approach to the treatment of preeclampsia, but suggest cautious and careful study of their safety before potential clinical use in humans.NEW & NOTEWORTHY Drugs that target the glucagon-like peptide-1 pathway such as liraglutide are already used clinically, and it has been shown to promote endothelial nitric oxide synthase (NOS3) expression. We demonstrate that liraglutide, a glucagon-like peptide 1 receptor (GLP-1R) agonist, lowers blood pressure, improves renal function, and upregulates NOS3 in a rat model of placental ischemia. These data suggest that drugs that target the nitric oxide system, including GLP-1R agonists, are a potential therapeutic option for preeclampsia.

Pregnancy complications and risk of preterm birth according to maternal age: A population-based study of delivery hospitalizations in Alberta

INTRODUCTION

Pregnancy-related medical complications are associated with a 2- to 5-fold increased risk of preterm birth (PTB), but the nature of this etiologic relation in context with maternal factors remains poorly understood. Previous studies have generally treated maternal age as a confounder but overlooked its potential as an effect modifier, whereby the magnitude of the effect of complications on PTB could differ significantly across age groups. We investigated whether advanced maternal age (≥35 years) modified the association between pregnancy complications and PTB, and compared population-attributable fractions of PTB from complications in women older vs younger than 35 years.

MATERIAL AND METHODS

We analyzed population-based, cross-sectional data from the Alberta Discharge Abstract Database for women aged 18-50 years with singleton live births in hospital between 2014 and 2017 (n = 152 246). Complications were preeclampsia, gestational diabetes, and placental disorders identified using diagnostic codes. Outcomes were spontaneous (sPTB) or iatrogenic (iPTB) PTB before 37 weeks of gestation. We estimated risk ratios and risk differences using modified Poisson and log binomial regression, respectively, adjusting for confounders (pregnancy history, comorbidities). Population-attributable fractions estimates were calculated from risk ratios. Age modification was tested using interaction terms and Z-tests.

RESULTS

Prevalence of advanced maternal age was 19.2%. Pregnancy complications and s/iPTB were more common among women aged ≥35 years. Age modified the risk of PTB from preeclampsia only, with risk differences of 9.9% (95% CI 7.2%-12.6%) in older women vs 6.1% (95% CI 4.8%-7.4%) in younger women (P-interaction = 0.012) for sPTB, and 29.5% (95% CI 26.0%-33.1%) vs 20.8% (95% CI 18.9%-22.6%, P-interaction <0.001) for iPTB. Population-attributable fractions of s/iPTB types for all complications were consistently 2%-5% larger in women aged ≥35 years, and significantly larger for preeclampsia (sPTB: 5.1% vs 2.7%, P = 0.002; iPTB: 18.8% vs 14.0%, P < 0.001) and placental disorders (sPTB: 12.5% vs 8.7%, P < 0.001; iPTB: 13.2% vs 8.9%, P < 0.001).

CONCLUSIONS

Of the pregnancy complications studied, advanced maternal age only modified the association between PTB and preeclampsia, such that older women with preeclampsia have a higher risk for s/iPTB than younger counterparts. Pregnancy complications contribute to a sizable proportion of PTBs in Alberta, especially among women aged ≥35 years. Findings may inform clinical risk assessment and population-level policy targeting PTB.

Angiogenic factors during pregnancy in Asian women with elevated blood pressure in early pregnancy and the risk of preeclampsia: a longitudinal cohort study

OBJECTIVE

It remains unclear what roles placenta-originated angiogenic factors play in the pathogenesis of preeclampsia among hypertensive women. We compared maternal soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF) levels throughout pregnancy in women with normal blood pressure (BP), elevated BP and hypertension in early pregnancy and their risks of developing preeclampsia.

DESIGN

A prospective cohort study.

SETTING

KK Women's and Children's Hospital, Singapore.

PARTICIPANTS

923 women with singleton pregnancy <14 weeks of gestation were included in the prospective Neonatal and Obstetrics Risks Assessment cohort between September 2010 and October 2014. Systolic, diastolic, mean arterial blood pressure (MAP) were measured at 11-14 weeks.

PRIMARY AND SECONDARY OUTCOMES

Maternal serum sFlt-1, PlGF and sFlt-1/PlGF ratio were tested at 11-14, 18-22, 28-32 and 34 weeks onwards of gestation. Preeclampsia was main pregnancy outcome.

RESULTS

Women were divided based on their BP in early pregnancy: normal (n=750), elevated BP (n=98) and hypertension (n=75). Maternal sFlt-1 levels and sFlt-1/PlGF ratios were higher in hypertensive women throughout pregnancy, but maternal PlGF levels were not significantly lower. Rise in maternal systolic, diastolic BP and MAP at 11-14 weeks were significantly associated with higher sFlt-1/PlGF ratios during pregnancy. A 10 mm Hg increase in MAP was associated with a 5.6-fold increase in risk of preterm preeclampsia and a 3.3-fold increase in risk of term preeclampsia, respectively.

CONCLUSION

Women with elevated BP in early pregnancy already had a higher sFlt-1/PlGF ratio in early gestation and throughout pregnancy, and an increased risk of preeclampsia. In contrast, PlGF levels in these women remained normal.

Profound Decrease in Glomerular Arginine Transport by CAT (Cationic Amino Acid Transporter)-1 Contributes to the FLT-1 (FMS-Like Tyrosine Kinase 1) Induced Preeclampsia in the Pregnant Mice

Endothelial dysfunction because of nitric oxide inactivation has been suggested to play a role in the pathogenesis of preeclampsia. During pregnancy, L-arginine transport by CAT-1 (cationic amino acid transporter 1), the only transporter for eNOS (endothelial nitric oxide synthase) is inhibited. We hypothesize that maternal arginine deficiency contributes to the development of preeclampsia. Adenovirus-mediated overexpression of sFlt-1 (soluble fms-like tyrosine kinase 1) in virgin and pregnant mice resulted in glomerular endotheliosis, hypertension, and albuminuria. L-arginine prevented the increase in blood pressure and albuminuria in Flt-1 pregnant but not in Flt-1 virgin mice. Flt-1 augmented arginine transport in pregnant but not in virgin dames. Ex vivo inhibition of CAT-2 leaving exclusively CAT-1 activity, decreased arginine transport velocities in Flt-1 animals more prominently in pregnant dames. Phosphorylated CAT-1/CAT-1 increased in pregnant, sFlt-1-pregnant, and sFlt-1 virgin mice. CAT-2 increased in Flt-1-pregnant and Flt-1-virgin dames. L-arginine augmented arginine transport in pregnant and Flt-pregnant mice and prevented the increase in pCAT-1 and CAT-2 expression. Glomerular cGMP (cyclic guanosine monophosphate) generation as a measure of eNOS activity was decreased in all Flt-1 treated animals. L-arginine abolished the decrease in cGMP levels only in Flt-1-pregnant mice. In conclusion, glomerular endothelial NO generation is compromised in Flt-1-pregnant mice because of CAT-1 inhibition induced by a combined effect of pregnancy and preeclampsia which involves: phosphorylation of CAT-1 and induction of CAT-2. These processes contribute to the clinical syndrome of preeclampsia in mice and are prevented by L-arginine.

ANXA7 regulates trophoblast proliferation and apoptosis in preeclampsia

PROBLEM

Preeclampsia (PE) is a unique gestational disorder leading to maternal and neonatal morbidity and mortality. AnnexinA7 (ANXA7) is a calcium-dependent phospholipid-binding protein that promotes membrane fusion during exocytosis. However, the function of ANXA7 in placental trophoblast is poorly understood. The present study aimed to investigate a possible association between ANXA7 and human trophoblast apoptosis.

METHODS

We collected human placental tissues from patients with PE and normal pregnant women to elucidate the expression level of ANXA7. The ANXA7-knockdown and ANXA7-overexpressing HTR8/SVneo cells were utilized for studying the function of ANXA7 in trophoblast. The proliferation and apoptosis levels of trophoblast were examined with Western blot assay, flow cytometry, Cell Counting Kit-8 assay, and immunohistochemistry.

RESULTS

ANXA7 expression was significantly lower in placentas from patients with PE patients compared with that in from normal pregnant controls. Knockdown of ANXA7 induced cell apoptosis and inhibited cell proliferation in HTR-8 via by downregulating BCL2 protein levels. Overexpression of ANXA7 reduced apoptosis and promoted HTR8 proliferation. Further analyses showed that ANXA7 knockdown inhibited the activation of the JAK1/STAT3 pathway in HTR-8 cells.

CONCLUSION

Our findings revealed a new regulatory pathway of ANXA7/JAK1/STAT3 in trophoblast apoptosis in preeclampsia, suggesting that ANXA7 is a potential therapeutic target for preeclampsia.

Selective feticide as a treatment of severe preeclampsia in discordant twins

Multifetal gestation is often complicated by the development of preeclampsia. In some twin gestations, preeclampsia develops in association with restricted fetal growth of only one fetus. Instead of termination of the entire pregnancy, we investigated an alternative approach to the management of such pregnancies that might allow unharmed survival of the normal twin. We present a case of preeclampsia in twin discordance with severe fetal growth restriction at 25 weeks of gestation. Preeclampsia was linked to a lethal condition in one twin and was treated with selective feticide in an effort to reverse preeclampsia. Inasmuch as the fetal prognosis was extremely poor for the abnormal fetus, selective feticide was a reasonable therapeutic option. Maternal symptoms resolved, allowing continuation of the pregnancy for 4 weeks before delivery of the healthy fetus. We maintain that selective termination induced a decrease in the release of substances involved in the physiopathology of preeclampsia, which allowed the continuation of the pregnancy with close follow-up. This report highlights the link between placental pathology and the disease process of preeclampsia and further supports selective termination as a reasonable management strategy in carefully selected cases of discordant twins.

Pathophysiology of Cerebral Vascular Dysfunction in Pregnancy-Induced Hypertension

PURPOSE OF REVIEW

To review and summarize what is known about cerebrovascular derangements during preeclampsia.

RECENT FINDINGS

Preeclampsia is a devastating disorder of pregnancy with no known cure. Little is known about the pathophysiological mechanisms which lead to the symptoms of the disorder, particularly with regard to individual vascular beds such as the cerebral circulation. Studies suggest that the cerebrovascular dysfunction characteristic of the preeclampsia syndrome is characterized by alterations in cerebral blood flow autoregulation and opening of the blood-brain barrier. Mechanistic studies demonstrate that the same circulating factors implicated in the pathophysiology of other vascular beds may be operative in the cerebral circulation as well. However, significant knowledge gaps still exist, highlighting the need for more intense research in this field. Little is known about cerebrovascular dysfunction during preeclampsia, and detailed mechanistic studies are needed to identify the molecular pathways involved, the interactions thereof, and how those pathways lead to clinical disease.

Associations of macro and micronutrients and antioxidants intakes with preeclampsia: A case-control study in Jordanian pregnant women

BACKGROUND AND OBJECTIVES

A study was conducted to evaluate whether preeclampsia in pregnant women is associated with dietary factors and antioxidant intake (vitamin C, vitamin E, vitamin A, and selenium).

METHODS AND RESULTS

In this case-control study, a group of 79 pregnant Jordanian women (36 preeclamptic pregnant women and 43 healthy pregnant women aged 18-45 years with a gestational age ≥20th week of pregnancy) were recruited from the obstetrics and gynecology clinics at Royal Medical Services, King Hussein Medical Center, Amman, Jordan. Information about socio-demographics, anthropometric measurements, biochemical measurements, nutritional intake, and dietary habits was collected through a structured interview. Three 24-hour dietary records were also made. Data were analyzed using Statistical Package for the Social Sciences (SPSS), and dietary intake was analyzed using ESHA software. Prepregnancy BMI, age, multiple pregnancies, energy intake, beta-carotene, vitamin C, and sodium showed significant difference between preeclamptic pregnant women and healthy pregnant women. The odds ratio (OR) and the corresponding 95% confidence interval (CI) show that a strong association with preeclampsia exists for the intake of fat (OR = 6.40, 95% CI: 1.85-22.17) and saturated fat (OR = 3.35, 95% CI: 1.0-11.54). Inverse associations with preeclampsia were found for fruit intake (OR = 0.16, 95% CI: 0.47-0.55) and olive oil intake (OR = 0.20, 95% CI: 0.05-0.78).

CONCLUSION

In this case-control study in Jordanian pregnant women, preeclampsia was associated with a high intake of fat, saturated fat, and sodium and a low intake of fruits, fiber, vitamin C, B-carotene, and olive oil.

Chronic infusion of interleukin-17 promotes hypertension, activation of cytolytic natural killer cells, and vascular dysfunction in pregnant rats

Previous studies by our lab have established that placental-ischemia stimulated T-helper 17 cells (TH 17s) cause increased cytolytic natural killer (cNK) cell proliferation and activation during pregnancy; however, the exact mechanism is unknown. The objective of this study was to investigate the role of interlukin 17 (IL-17) in inducing cNK cell activation in pregnancy. We infused 150 pg/day of recombinant IL-17 into a subset of normal pregnant (NP) Sprague Dawley rats from gestation day (GD) 12-19 (NP+IL-17). On GD 19, mean arterial pressure (MAP), fetal and placental weights, cytokines, cNK cell activation, cytotoxic enzymes, and vascular reactivity were assessed. MAP significantly increased from 99 ± 3 mmHg in NP to 120 ± 1 mmHg in NP+IL-17 (P < 0.05). Fetal weight significantly decreased from 2.52 ± 0.04 g in NP to 2.32 ± 0.03 g in NP+IL-17 as did placental weight (NP: 0.65 ± 0.03 g; NP+IL-17: 0.54 ± 0.01 g, P < 0.05). Plasma levels of TNF-α increased to 281.4 ± 55.07 pg/mL in NP+IL-17 from 145.3 ± 16.03 pg/mL in NP (P < 0.05) while placental levels of VEGF decreased from 74.2 ± 6.48 pg/mg in NP to 54.2 ± 3.19 pg/mg in NP+IL-17. Total NK cells were increased in the placenta (NP: 14.3 ± 3.49%; NP+IL-17: 29.33 ± 2.76%, P < 0.05) as were cytolytic NK cells (NP: 3.31 ± 1.25%; NP+IL-17: 13.41 ± 1.81%, P < 0.05). A similar trend was observed in circulating NK cells. Plasma granzyme K increased from 3.55 ± 2.29 pg/mL in NP to 20.9 ± 7.76 pg/mL in NP+IL-17 (P < 0.05), and plasma granzyme B increased from 10.95 ± 0.64 pg/mL in NP to 14.9 ± 0.98 pg/mL in NP+IL-17(P < 0.05). In the placenta, both granzyme A (NP: 246.1 ± 16.7 pg/mg; NP+IL-17: 324.3 ± 15.07 pg/mg, P < 0.05) and granzyme B (NP: 15.18 ± 3.79 pg/mg; NP+IL-17: 27.25 ± 2.34 pg/mg, P < 0.05) increased in response to IL-17 infusion. Finally, vascular reactivity of uterine arteries was significantly impaired in response to IL-17 infusion. The results of this study suggest that IL-17 plays a significant role in the activation of cNK cells during pregnancy.

Copeptin in Preeclampsia Development

Background:

Preeclampsia complicates 2-8% of all pregnancies worldwide and is one of the leading causes of maternal and neonatal morbidity and mortality. It occurs after the 20th week of gestation and is characterized by high blood pressure, proteinuria or end-organ disease. The heterogeneous and multi-systemic nature of this disease has led to the elusive pathophysiology which delays timely diagnoses and the clinical treatment of those affected.

Objective:

Despite the extensive investigations surrounding the inclusion of various potential markers for PE prediction, early diagnosis remains unresolved. Quantification of copeptin, a stable component of the arginine vasopressin (AVP) precursor is shown to be relatively reliable in confirming the circulating levels of AVP.

Conclusion:

Elevated copeptin levels confirmed in pregnant women have also provided clinical support for its role in PE development. However, its clinical use in predicting disease severity in early-onset pre-eclampsia has been debatable. This review thus recapitulates the current literature surrounding copeptin and its potential as a risk indicator for PE development.</P>

Sympathetic nervous system control of vascular function and blood pressure during pregnancy and preeclampsia

: Proper vascular tone and blood pressure regulation during pregnancy are important for immediate and long-term cardiovascular health of the mother and her offspring. Preeclampsia is clinically defined as new-onset maternal hypertension accompanied by cardiovascular, renal, and/or neural abnormalities presenting in the second half of pregnancy. There is strong evidence to support that preeclampsia is mediated by attenuations in uteroplacental vascular remodeling and increases in vasoconstriction with subsequent placental ischemia/reperfusion-induced release of hypertensive substances into the maternal circulation. These include antiangiogenic and pro-inflammatory factors. There is also evidence implicating increased sympathetic nervous system activity (SNA) in this maternal disorder, but this mostly includes data correlating severity of disease with catecholamine levels and elevated muscle SNA. These measurements have not confirmed a causative role for SNA in the pathogenesis of preeclampsia. Therefore, studies are needed to provide a comprehensive understanding of SNA and its control of vascular function and blood pressure regulation during normal pregnancy in order to set the stage for exploring the mechanisms mediating the exaggerated SNA and signaling during preeclampsia. This review examines the role of SNA in control of uteroplacental vascular tone and blood pressure regulation during normal pregnancy. Furthermore, it is proposed that over-activation of the SNA contributes to altered uteroplacental vascular tone and perfusion leading to placental ischemic events and modulates the systemic vasoconstriction and hypertensive responses to soluble placenta ischemic factors. Recognizing the integrative role and importance of SNA in the pathophysiology of preeclampsia will advance our understanding of this maternal disorder.

Maternal pregnancy-induced hypertension increases the subsequent risk of transient tachypnea of the newborn: A nationwide population-based cohort study

OBJECTIVE

To determine the association between pregnancy-induced hypertension (PIH) and transient tachypnea of the newborn (TTN) and to identify the predictive risk factors.

MATERIALS AND METHODS

Pregnant women with a newly diagnosed PIH (between 2000 and 2013) from the Taiwan National Health Insurance Research Database (NHIRD) were compared with a matched (with respect to age and year of delivery) cohort of pregnant women without PIH. The occurrence of TTN was evaluated in both cohorts.

RESULTS

Among the 23.3 million individuals registered in the NHIRD, 29,013 patients with PIH and 116,052 matched controls were identified. According to a multivariate analysis, PIH (odds ratio [OR] = 1.85, 95% confidence interval [CI] = 1.69-2.03, p < 0.0001), age ≥ 30 years (OR = 1.38, 95% CI = 1.26-1.51, p < 0.0001), primiparity (OR = 1.37, 95% CI = 1.24-1.5, p < 0.0001), preterm birth (OR = 3.4, 95% CI = 3.09-3.75, p < 0.0001), multiple births (OR = 2.54, 95% CI = 2.24-2.89, p < 0.0001), and cesarean section (OR = 1.71, 95% CI = 1.56-1.88, p < 0.0001) were independent risk factors for the development of TTN.

CONCLUSION

Women with PIH have an increased risk of having infants who develop TTN compared with those without PIH. Additionally, age ≥30 years, primiparity, preterm birth, multiple births, and cesarean section were independent risk factors for the development of TTN.

Upregulation of DAPK2 ameliorates oxidative damage and apoptosis of placental cells in hypertensive disorder complicating pregnancy by suppressing human placental microvascular endothelial cell autophagy through the mTOR signaling pathway

Death-associated protein kinase 2 (DAPK2) has indicated functional roles in cellular processes, including survival, apoptosis, and autophagy. This study is aimed to identify the effect of DAPK2 on oxidative damage and apoptosis of placental cells in hypertensive disorder complicating pregnancy (HDCP) through mTOR pathway. Microarray-based gene expression analysis was performed to predict the differentially expressed genes related to HDCP. To investigate the specific mechanism of DAPK2 in HDCP cells, placental microvascular endothelial cells were treated with mimic or siRNA of DAPK2 and mTOR to detect the expression of related genes, cell autophagy and apoptosis and oxidative damage. Finally, rats were modeled with HDCP to verify the cell experiment results. DAPK2 was downregulated in HDCP, and could activate mTOR. Besides, DAPK2 overexpression led to decreases in autophagy in HPVECs as well as apoptosis and oxidative damage in placental cells indicated by a substantial decrease in Beclin-1, LC3 II/LC3 I and Bax along with an increase in Bcl-2, 4EBP1 and p70S6K. It also ameliorates blood pressure elevation in HDCP rats. The study defined remission effect of DAPK2 on placental cell oxidative damage and apoptosis in HDCP via mTOR activation. Together, DAPK2 regulating mTOR pathway presents a promising therapy for HDCP treatment.

Residual vascular dysfunction in women with a history of preeclampsia

Preeclampsia is a hypertensive disorder of pregnancy characterized by new-onset hypertension, proteinuria, and edema occurring after 20 wk of gestation, with a prevalence of ~7-10% of pregnancies in the United States and ~8 million pregnancies worldwide. Despite the postpartum remission of preeclamptic symptoms, women who have had preeclampsia are two to four times more likely to develop cardiovascular disease (CVD) and are significantly more likely to die of CVD compared with women with a history of normal pregnancy. Although the relation between history of preeclampsia and elevated CVD risk is well documented, the mechanism(s) underlying this association remains unclear. One hypothesis explaining this association is that the initial vascular damage and dysfunction sustained during the preeclamptic pregnancy persist chronically. Indeed, even in the absence of, or in advance of, overt CVD women who have had preeclampsia have compromised vascular endothelial function. Emerging mechanistic studies in these women have provided some insight into the underlying mechanisms of this persistent vascular dysfunction and have begun to identify potential therapeutic targets for the prevention or mitigation of CVD progression in this vulnerable population. This review summarizes the existing literature examining vascular function and dysfunction in women with a history of preeclampsia and highlights future directions for mechanistic investigations and development of novel intervention strategies aimed at halting or slowing the progression of CVD in these women.

Clinical Presentation of Preeclampsia and the Diagnostic Value of Proteins and Their Methylation Products as Biomarkers in Pregnant Women with Preeclampsia and Their Newborns

Preeclampsia (PE) is a disorder which affects 1-10% of pregnant women worldwide. It is characterised by hypertension and proteinuria in the later stages of gestation and can lead to maternal and perinatal morbidity and mortality. Other than the delivery of the foetus and the removal of the placenta, to date there are no therapeutic approaches to treat or prevent PE. It is thus only possible to reduce PE-related mortality through early detection, careful monitoring, and treatment of the symptoms. For these reasons the search for noninvasive, blood-borne, or urinary biochemical markers that could be used for the screening, presymptomatic diagnosis, and prediction of the development of PE is of great urgency. So far, a number of biomarkers have been proposed for predicting PE, based on pathophysiological observations, but these have mostly proven to be unreliable and inconsistent between different studies. The clinical presentation of PE and data gathered for the biochemical markers placental growth factor (PlGF), soluble Feline McDonough Sarcoma- (fms-) like tyrosine kinase-1 (sFlt-1), asymmetric dimethylarginine (ADMA), and methyl-lysine is being reviewed with the aim of providing both a clinical and biochemical understanding of how these biomarkers might assist in the diagnosis of PE or indicate its severity.

Hypertensive disorders of pregnancy and future heart failure risk: A nationwide population-based retrospective cohort study

OBJECTIVE

To assess whether hypertensive disorders of pregnancy (HDP) increased the risk of subsequent heart failure (HF) and identify possible risk factors.

STUDY DESIGN

A nationwide population-based retrospective cohort study.

MAIN OUTCOME MEASURES

Incidence of heart failure.

RESULTS

Among the 23.3 million individuals registered in the National Health Insurance Research Database in Taiwan, 29,186 patients with HDP and 116,744 matched controls were identified. The overall incidence of HF was greater in the HDP group than it was in the control group (9.83 vs. 1.67 per 10,000 person-years), with a significant incidence rate ratio (IRR = 5.88, 95% confidence interval [CI] 5.84-5.92, p < 0.0001). When stratified by age, parity, gestational age, gestational number, and follow-up years, the IRR for subsequent HF remained significantly higher in the HDP group in all stratifications. Additionally, the Kaplan-Meier analysis indicated that the cumulative incidence rate of HF was higher in the HDP group than it was in the control group. The Cox proportional-hazard model analysis showed that in addition to HDP, single parity, preterm and hypertension were independent risk factors for developing HF. Moreover, HF was more likely to develop within 5 years post-partum. Among patients with a history of HDP, the Cox proportional-hazard model showed that severe forms of HDP and increased HDP occurrences were independently associated with the subsequent development of HF.

CONCLUSIONS

Patients who have experienced HDP presented an increased risk for developing HF later in life. Moreover, among individuals with a history of HDP, those with severe forms of HDP or recurrent HDP displayed an increased subsequent risk of HF.

Hypertensive Disorders of Pregnancy: Overview and Current Recommendations

Hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, preeclampsia-eclampsia, and chronic hypertension with superimposed preeclampsia. These disorders are an important cause of maternal and fetal morbidity and mortality. Although advances in effective treatments have been made, current research has yet to identify a biochemical or diagnostic imaging marker to reliably predict preeclampsia. Despite current guidelines that address diagnosis and management of hypertensive disorders in pregnancy, health care providers may overlook or be unaware of signs that require immediate evaluation and treatment. This article reviews the definitions of hypertensive disorders of pregnancy, diagnosis, pathophysiology of preeclampsia, indications for treatment, neurologic sequelae, and counseling about the implications of hypertension in pregnancy for subsequent health.

Maternal lipids, BMI and IL-17/IL-35 imbalance in concurrent gestational diabetes mellitus and preeclampsia

The objective of the present study was to investigate the role of blood glucose, lipid metabolism, body mass index (BMI), C-reactive protein (CRP) as well as an interleukin (IL)-17/IL-35 imbalance in the pathogenesis of concurrent gestational diabetes mellitus (GDM) and preeclampsia (PE) (DPE). The mRNA expression of forkhead box protein 3 (FoxP3), IL-35 [including Epstein-Barr virus-induced gene 3 (EBI3) and P35 subunits] and IL-17 in the peripheral blood mononuclear cells of patients with DPE (n=30), GDM (n=33), PE (n=33) and normal pregnancy (n=33) were determined by reverse transcription-quantitative polymerase chain reaction. The serum levels of IL-35, IL-17 and CRP were analyzed using ELISA. Serum total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL) and fasting blood glucose (FBG) were also detected. The levels of low-density lipoprotein (LDL) were calculated using the Friedewald formula. Body weight and height were determined in order to calculate the BMI. It was observed that the levels of FBG were markedly elevated in patients with GDM, PE and DPE. In addition, significantly higher serum TG, TC, LDL and very LDL were detected in patients with GDM, PE and DPE compared with those in subjects with normal pregnancies. By contrast, the concentration of HDL was lower in the patient groups. In addition, higher BMI values were identified in patients with GDM, PE and DPE. A decreased expression of FoxP3, P35 and EBI3 mRNA, and an elevated expression of IL-17 in PBMCs was detected in patients with GDM, PE and DPE. In addition, higher serum levels of IL-17 and CRP, as well as lower levels of IL-35, were observed. Furthermore, in patients with DPE, positive correlations of diastolic blood pressure with IL-17 levels, BMI and TG, as well as IL-17 levels with BMI and proteinuria were identified. In conclusion, the present study indicated that abnormal maternal lipids, hyperglycemia, high BMI, high CRP and IL-17/IL-35 imbalance may have a role in the pathophysiology of DPE. Therefore, pregnant women and clinicians should be made aware that maternal hyperlipidaemia, hyperglycemia, high BMI, high CRP levels and IL-17/IL-35 imbalance may lead to DPE.

The Endothelin System: A Critical Player in the Pathophysiology of Preeclampsia

PURPOSE OF REVIEW

Preeclampsia (PE) is a disorder of pregnancy typically characterized by new-onset hypertension and proteinuria after gestational week 20. Although preeclampsia is one of the leading causes of maternal and perinatal morbidity and death worldwide, the mechanisms of the pathogenesis of the disorder remain unclear and treatment options are limited. Placental ischemic events and the release of placental factors appear to play a critical role in the pathophysiology. These factors contribute to a generalized systemic vascular endothelial dysfunction and result in increased systemic vascular resistance and hypertension.

RECENT FINDINGS

There is increasing evidence to suggest that endothelin-1 (ET-1) in the maternal vascular endothelium is a critical final common pathway, whereby placental ischemic factors cause cardiovascular and renal dysfunction in the mother. Multiple studies report increased levels of ET-1 in PE. A number of experimental models of PE are also associated with elevated tissue levels of prepro-ET-1 mRNA. Moreover, experimental models of PE (placental ischemia, sFlt-1 excess, TNF-α excess, and AT1-AA infusion) have proven to be responsive to ET type A receptor antagonism. Recent studies also suggest that abnormalities in ET type B receptor signaling may also play a role in PE. Although numerous studies highlight the importance of the ET system in the pathogenesis of PE, further work is needed to determine whether ET receptor antagonists could provide an effective therapy for the management of this disease.

Utility of metabolic profiling of serum in the diagnosis of pregnancy complications

INTRODUCTION

Currently there are no clinical screening tests available to identify pregnancies at risk of developing preeclampsia (PET) and/or intrauterine growth restriction (IUGR), both of which are associated with abnormal placentation. Metabolic profiling is now a stable analytical platform used in many laboratories and has successfully been used to identify biomarkers associated with various pathological states.

METHODS

We used nuclear magnetic resonance spectroscopy (NMR) to metabolically profile serum samples collected from 143 pregnant women at 26-41 weeks gestation with pregnancy outcomes of PET, IUGR, PET IUGR or small for gestational age (SGA) that were age-matched to normal pre/term pregnancies.

RESULTS

Spectral analysis found no difference in the measured metabolites from normal term, pre-term and SGA samples, and of 25 identified metabolites, only glutamate was marginally different between groups. Of the identified metabolites, 3-methylhistidine, creatinine, acetyl groups and acetate, were determined to be independent predictors of PET and produced area under the curves (AUC) = 0.938 and 0.936 for the discovery and validation sets. Only 3-hydroxybutyrate was determined to be an independent predictor of IUGR, however the model had low predictive power (AUC = 0.623 and 0.581 for the discovery and validation sets).

CONCLUSIONS

A sub-panel of metabolites had strong predictive power for identifying PET samples in a validation dataset, however prediction of IUGR was more difficult using the identified metabolites. NMR based metabolomics can identify metabolites strongly associated with disease and has the potential to be useful in developing early clinical screening tests for at risk pregnancies.

The effect of pre-eclampsia on retinal microvascular caliber at delivery and post-partum

Background

The retinal microcirculation provides a unique view of microvessel structure by means of non-invasive, retinal image analysis. The aim of the study was to compare the retinal vessel caliber at delivery and one-year post-partum between women who have had pre-eclampsia during pregnancy to a normotensive control group.

Methods

Digital photos of the eye were taken at delivery and one-year post-partum. Retinal vessels were analysed and summarised as the corrected central retinal arteriolar equivalent and corrected central retinal venular equivalent.

Results

The corrected central retinal arteriolar equivalent and corrected central retinal venular equivalent were significantly lower in the pre-eclamptic group compared to the control group both at delivery and one-year post-partum (p < 0.001).

Conclusion

Retinal artery and venular caliber changes that occur during pregnancies affected by pre-eclampsia persist for up to one-year post-partum. These changes may reflect a permanent, long-term microvascular dysfunction and may be useful as a biomarker of future vascular risk.

Placental hypoxia inducible factor -1α & CHOP immuno-histochemical expression relative to maternal circulatory syncytiotrophoblast micro-vesicles in preeclamptic and normotensive pregnancies

OBJECTIVES

Preeclampsia (PE) occurs as a result placental hypoxia-induced oxidative and endoplasmic reticulum stress, and is associated with the activation of hypoxia inducible factor-1α (HIF-1α) and apoptotic CHOP pathways with the consequential shedding of syncytiotrophoblast microvesicles which may be central in mediating the maternal systemic immune response. The aim of this study was to immune-localise and morphometrically analyse CHOP and HIF-1α within the placenta of normotensive and pre-eclamptic pregnancies and concomitantly quantify syncytiotrophoblast released microvesicles in maternal circulation.

STUDY DESIGN

Placental tissue and plasma were obtained from normotensive and pre-eclamptic pregnant women. The expression of CHOP and HIF-1α was analysed using immunohistochemistry. Isolation and size distribution of the circulating maternal microvesicles was determined using nanoparticle tracking analysis. The concentration of syncytiotrophoblast microvesicles was determined using the placental alkaline phosphatase ELISA.

RESULTS

This study demonstrates a significant increase in immunohistochemical expression of HIF-1 α and CHOP in preeclampsia compared to the normotensive women (p<0.05). In keeping with this, a significant increase in the mean syncytiotrophoblast microvesicles concentration was observed in PE, compared to normotensives (p<0.05). A positive correlation between placental expression of CHOP and HIF-1α and STBMs was obtained.

CONCLUSION

This study demonstrates increased placental expression of HIF-1α and CHOP in preeclampsia compared to normotensive pregnancies which correlate to their increased syncytiotrophoblast microvesicles concentration in maternal circulation. These findings indicate that placental hypoxia and ER stress are interrelated contributory factors to the pathogenesis of PE and the consequential release of placental derived debris into the maternal circulation.

Intrauterine growth restriction and placental gene expression in severe preeclampsia, comparing early-onset and late-onset forms

OBJECTIVE

To evaluate placental gene expression in severe early- or late-onset preeclampsia with intrauterine growth restriction compared to controls.

STUDY DESIGN

Chorionic villus sampling was conducted after cesarean section from the placentas of five women with early- or late-onset severe preeclampsia and five controls for each preeclampsia group. Microarray analysis was performed to identify gene expression differences between the groups.

RESULTS

Pathway analysis showed over-representation of gene ontology (GO) biological process terms related to inflammatory and immune response pathways, platelet development, vascular development, female pregnancy and reproduction in early-onset preeclampsia. Pathways related to immunity, complement and coagulation cascade were overrepresented in the hypergeometric test for the Kyoto Encyclopedia of Genes and Genomes (KEGG) database. Ten genes (ABI3BP, C7, HLA-G, IL2RB, KRBOX1, LRRC15, METTL7B, MPP5, RFLNB and SLC20A) had a ≥±1 fold expression difference in severe early-onset preeclampsia group compared to early controls. There were 362 genes that had a ≥±1 fold expression difference in severe early-onset preeclampsia group compared to late-onset preeclampsia group including ABI3BP, C7, HLA-G and IL2RB.

CONCLUSION

There are significant differences in placental gene expression between severe early- and late-onset preeclampsia when both are associated with intrauterine growth restriction. ABI3BP, C7, HLA-G and IL2RB might contribute to the development of early form of severe preeclampsia.