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Gumusoglu SB, Kiel MD, Gugel A, Schickling BM, Weaver KR, Lauffer MC, Sullivan HR, Coulter KJ, Blaine BM, Kamal M, Zhang Y, Devor EJ, Santillan DA, Gantz SC, Santillan MK. Anti-angiogenic mechanisms and serotonergic dysfunction in the Rgs2 knockout model for the study of psycho-obstetric risk. Neuropsychopharmacology 2024; 49:864-875. [PMID: 37848733 PMCID: PMC10948883 DOI: 10.1038/s41386-023-01749-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/26/2023] [Accepted: 09/28/2023] [Indexed: 10/19/2023]
Abstract
Psychiatric and obstetric diseases are growing threats to public health and share high rates of co-morbidity. G protein-coupled receptor signaling (e.g., vasopressin, serotonin) may be a convergent psycho-obstetric risk mechanism. Regulator of G Protein Signaling 2 (RGS2) mutations increase risk for both the gestational disease preeclampsia and for depression. We previously found preeclampsia-like, anti-angiogenic obstetric phenotypes with reduced placental Rgs2 expression in mice. Here, we extend this to test whether conserved cerebrovascular and serotonergic mechanisms are also associated with risk for neurobiological phenotypes in the Rgs2 KO mouse. Rgs2 KO exhibited anxiety-, depression-, and hedonic-like behaviors. Cortical vascular density and vessel length decreased in Rgs2 KO; cortical and white matter thickness and cell densities were unchanged. In Rgs2 KO, serotonergic gene expression was sex-specifically changed (e.g., cortical Htr2a, Maoa increased in females but all serotonin targets unchanged or decreased in males); redox-related expression increased in paraventricular nucleus and aorta; and angiogenic gene expression was changed in male but not female cortex. Whole-cell recordings from dorsal raphe serotonin neurons revealed altered 5-HT1A receptor-dependent inhibitory postsynaptic currents (5-HT1A-IPSCs) in female but not male KO neurons. Additionally, serotonin transporter blockade by the SSRI sertraline increased the amplitude and time-to-peak of 5-HT1A-IPSCs in KO neurons to a greater extent than in WT neurons in females only. These results demonstrate behavioral, cerebrovascular, and sertraline hypersensitivity phenotypes in Rgs2 KOs, some of which are sex-specific. Disruptions may be driven by vascular and cell stress mechanisms linking the shared pathogenesis of psychiatric and obstetric disease to reveal future targets.
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Affiliation(s)
- Serena B Gumusoglu
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, USA
- Iowa Neuroscience Institute, University of Iowa, Iowa City, USA
| | - Michaela D Kiel
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Aleigha Gugel
- Iowa Neuroscience Institute, University of Iowa, Iowa City, USA
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Brandon M Schickling
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Kaylee R Weaver
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Marisol C Lauffer
- Iowa Neuroscience Institute, University of Iowa, Iowa City, USA
- Neural Circuits and Behavior Core, Iowa Neuroscience Institute, University of Iowa, Iowa City, USA
| | - Hannah R Sullivan
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Kaylie J Coulter
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Brianna M Blaine
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Mushroor Kamal
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Yuping Zhang
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Eric J Devor
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Donna A Santillan
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Stephanie C Gantz
- Iowa Neuroscience Institute, University of Iowa, Iowa City, USA
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Mark K Santillan
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, USA.
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Rajagopalan V, Truong V, Wang S, Lopez J, Rosas V, Borzage M, Votava-Smith JK, Ponrartana S, Panigrahy A, Detterich J, Wood J. Non-invasive in-utero quantification of vascular reactivity in human placenta. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:481-488. [PMID: 37820067 DOI: 10.1002/uog.27512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE Placental vascular reactivity (PlVR) indicates the ability of the placental vasculature to match blood supply to fetal demand. Many pregnancy disorders alter the characteristics of PlVR, resulting in suboptimal oxygen delivery, although current understanding is limited by the lack of non-invasive, repeatable methods to measure PlVR in utero. Our objective was to quantify PlVR by measuring the placental response to transient changes in maternal carbon dioxide (CO2) using blood-oxygen-level-dependent (BOLD) magnetic resonance imaging (MRI). We hypothesized that PlVR will increase with gestational age to meet the changing demands of a growing fetus, and that PlVR will be driven by a maternal response to changes in CO2 concentration. METHODS This was a cross-sectional study of 35 women with a healthy singleton pregnancy, of whom 31 were included in the analysis. The median gestational age was 32.6 (range, 22.6-38.4) weeks. Pregnant women were instructed to follow audiovisual breathing cues during a MRI scan. Maternal end-tidal CO2 (EtCO2) was measured concurrently with resting placental BOLD MRI for a total of 7-8 min. Preprocessing of magnetic resonance images consisted of manual delineation of placental anatomy and motion correction. In each placental voxel, vascular reactivity was computed using a coherence-weighted general linear model between MRI signal and EtCO2 stimulus. Global PlVR was computed as the mean of voxel-wise PlVR values across the placenta. RESULTS PlVR, quantified by the placental response to induced, transient changes in maternal CO2, was consistently measured in utero using BOLD MRI. PlVR increased non-linearly with advancing gestational age (P < 0.001) and was higher on the fetal side of the placenta. PlVR was associated positively with fetal brain volume after accounting for gestational age. PlVR did not show any significant associations with maternal characteristics. CONCLUSIONS We present, for the first time, a non-invasive paradigm to quantify PlVR in ongoing human pregnancies without the use of exogenous gases or contrast agents. Our findings suggest that PlVR is driven by a fetal response to changes in maternal CO2. Ease of translation to the clinical setting makes PlVR a promising biomarker for the identification and management of high-risk pregnancies. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- V Rajagopalan
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
| | - V Truong
- University of Southern California, Los Angeles, CA, USA
| | - S Wang
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
| | - J Lopez
- Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - V Rosas
- Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - M Borzage
- Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
| | - J K Votava-Smith
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
| | - S Ponrartana
- University of Southern California, Los Angeles, CA, USA
| | - A Panigrahy
- Pediatric Imaging Research Lab, Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J Detterich
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
| | - J Wood
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
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Zampieri GM, Nunes PR, Abbade JF, Dias CA, Sandrim VC. Vascular contraction of umbilical arteries of pregnant women with preeclampsia. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2024; 46:e-rbgo2. [PMID: 38765503 PMCID: PMC11075432 DOI: 10.61622/rbgo/2024ao02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/21/2023] [Indexed: 05/22/2024] Open
Abstract
Objective Potassium channels have an important role in the vascular adaptation during pregnancy and a reduction in the expression of adenosine triphosphate-sensitive potassium channels (Katp) has been linked to preeclampsia. Activation of Katp induces vasodilation; however, no previous study has been conducted to evaluate the effects of the inhibition of these channels in the contractility of preeclamptic arteries. Glibenclamide is an oral antihyperglycemic agent that inhibits Katp and has been widely used in vascular studies. Methods To investigate the effects of the inhibition of Katp, umbilical arteries of preeclamptic women and women with healthy pregnancies were assessed by vascular contractility experiments, in the presence or absence of glibenclamide. The umbilical arteries were challenged with cumulative concentrations of potassium chloride (KCl) and serotonin. Results There were no differences between the groups concerning the maternal age and gestational age of the patients. The percentage of smokers, caucasians and primiparae per group was also similar. On the other hand, blood pressure parameters were elevated in the preeclamptic group. In addition, the preeclamptic group presented a significantly higher body mass index. The newborns of both groups presented similar APGAR scores and weights. Conclusion In the presence of glibenclamide, there was an increase in the KCl-induced contractions only in vessels from the PE group, showing a possible involvement of these channels in the disorder.
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Affiliation(s)
- Gabriela Morelli Zampieri
- Universidade Estadual Paulista "Julio de Mesquita Filho"BotucatuSPBrazilUniversidade Estadual Paulista "Julio de Mesquita Filho", Botucatu, SP, Brazil.
| | - Priscila Rezeck Nunes
- Universidade Estadual Paulista "Julio de Mesquita Filho"BotucatuSPBrazilUniversidade Estadual Paulista "Julio de Mesquita Filho", Botucatu, SP, Brazil.
| | - Joelcio Francisco Abbade
- Universidade Estadual Paulista "Julio de Mesquita Filho"BotucatuSPBrazilUniversidade Estadual Paulista "Julio de Mesquita Filho", Botucatu, SP, Brazil.
| | - Carlos Alan Dias
- Universidade Estadual Paulista "Julio de Mesquita Filho"BotucatuSPBrazilUniversidade Estadual Paulista "Julio de Mesquita Filho", Botucatu, SP, Brazil.
| | - Valeria Cristina Sandrim
- Universidade Estadual Paulista "Julio de Mesquita Filho"BotucatuSPBrazilUniversidade Estadual Paulista "Julio de Mesquita Filho", Botucatu, SP, Brazil.
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Ramírez-Armas RM, Garza-Veloz I, Olivas-Chávez JC, Covarrubias-Carrillo RM, Martínez-Vázquez MC, Monárrez-Espino J, Ayala-Haro AE, Serrano-Amaya CV, Delgado-Enciso I, Rodriguez-Sanchez IP, Martinez-Fierro ML. The S/S Genotype of the 5-HTTLPR (Serotonin-Transporter-Linked Promoter Region) Variant of the SLC6A4 Gene Decreases the Risk of Pre-Eclampsia. J Pers Med 2023; 13:1535. [PMID: 38003850 PMCID: PMC10671924 DOI: 10.3390/jpm13111535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/25/2023] [Accepted: 10/24/2023] [Indexed: 11/26/2023] Open
Abstract
Pre-eclampsia (PE) is a disorder characterized by hypertension in the second trimester of pregnancy that results from abnormal placentation affecting fetal development and maternal health. Previous studies have shown the role of serotonin (5-HT) that leads to poor placental perfusion, where S/S and S/L polymorphisms promote the solute carrier family 6 member 4 (SLC6A4) gene associated with the risk of developing changes in the microvasculature of the placenta. This study looked at the association between the gene variant 5-HTTLPR (serotonin-transporter-linked promoter region) of the SLC6A4 gene and the occurrence of PE. A total of 200 women were included: 100 cases (pregnant with PE) and 100 controls (pregnant without complications). Genotyping of the 5-HTTLPR variant was performed using polymerase chain reaction (PCR). Associations between the presence of the genetic variant of interest and PE and other clinical features were evaluated statistically. The frequencies of S/S, S/L, and L/L genotypes were 32%, 53%, and 15% for the cases and 55%, 25%, and 20% in the control group. Compared to the controls, the genotype frequencies S/S vs. S/L + L/L (recessive model) in the cases group were different (p = 0.002). The S/S genotype decreased the probability of PE (OR = 0.39, 95% IC: 0.22-0.69, p = 0.002) and PE with severity criteria (OR = 0.39, 95% IC: 0.17-0.91, p = 0.045). The 5-HTTLPR gene variant of the SLC6A4 gene modifies the risk of PE development among the studied population.
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Affiliation(s)
- Rebeca Mónica Ramírez-Armas
- Molecular Medicine Laboratory, Academic Unit of Human and Health Sciences, Autonomous University of Zacatecas, Zacatecas 98160, Mexico; (R.M.R.-A.); (I.G.-V.); (R.M.C.-C.); (M.C.M.-V.); (J.M.-E.); (A.E.A.-H.); (C.V.S.-A.)
| | - Idalia Garza-Veloz
- Molecular Medicine Laboratory, Academic Unit of Human and Health Sciences, Autonomous University of Zacatecas, Zacatecas 98160, Mexico; (R.M.R.-A.); (I.G.-V.); (R.M.C.-C.); (M.C.M.-V.); (J.M.-E.); (A.E.A.-H.); (C.V.S.-A.)
| | | | - Rosa Martha Covarrubias-Carrillo
- Molecular Medicine Laboratory, Academic Unit of Human and Health Sciences, Autonomous University of Zacatecas, Zacatecas 98160, Mexico; (R.M.R.-A.); (I.G.-V.); (R.M.C.-C.); (M.C.M.-V.); (J.M.-E.); (A.E.A.-H.); (C.V.S.-A.)
| | - Maria Calixta Martínez-Vázquez
- Molecular Medicine Laboratory, Academic Unit of Human and Health Sciences, Autonomous University of Zacatecas, Zacatecas 98160, Mexico; (R.M.R.-A.); (I.G.-V.); (R.M.C.-C.); (M.C.M.-V.); (J.M.-E.); (A.E.A.-H.); (C.V.S.-A.)
| | - Joel Monárrez-Espino
- Molecular Medicine Laboratory, Academic Unit of Human and Health Sciences, Autonomous University of Zacatecas, Zacatecas 98160, Mexico; (R.M.R.-A.); (I.G.-V.); (R.M.C.-C.); (M.C.M.-V.); (J.M.-E.); (A.E.A.-H.); (C.V.S.-A.)
- Department of Health Research, Christus Muguerza del Parque Hospital, Chihuahua 31000, Mexico
| | - Anayantzin E. Ayala-Haro
- Molecular Medicine Laboratory, Academic Unit of Human and Health Sciences, Autonomous University of Zacatecas, Zacatecas 98160, Mexico; (R.M.R.-A.); (I.G.-V.); (R.M.C.-C.); (M.C.M.-V.); (J.M.-E.); (A.E.A.-H.); (C.V.S.-A.)
| | - Claudia Vanessa Serrano-Amaya
- Molecular Medicine Laboratory, Academic Unit of Human and Health Sciences, Autonomous University of Zacatecas, Zacatecas 98160, Mexico; (R.M.R.-A.); (I.G.-V.); (R.M.C.-C.); (M.C.M.-V.); (J.M.-E.); (A.E.A.-H.); (C.V.S.-A.)
| | - Ivan Delgado-Enciso
- School of Medicine, University of Colima, Colima 28040, Mexico;
- Cancerology State Institute, Colima State Health Services, Colima 28085, Mexico
| | - Iram Pablo Rodriguez-Sanchez
- Laboratorio de Fisiología Molecular y Estructural, Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza 66455, Mexico;
| | - Margarita L. Martinez-Fierro
- Molecular Medicine Laboratory, Academic Unit of Human and Health Sciences, Autonomous University of Zacatecas, Zacatecas 98160, Mexico; (R.M.R.-A.); (I.G.-V.); (R.M.C.-C.); (M.C.M.-V.); (J.M.-E.); (A.E.A.-H.); (C.V.S.-A.)
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Abstract
Pre-eclampsia is a life-threatening disease of pregnancy unique to humans and a leading cause of maternal and neonatal morbidity and mortality. Women who survive pre-eclampsia have reduced life expectancy, with increased risks of stroke, cardiovascular disease and diabetes, while babies from a pre-eclamptic pregnancy have increased risks of preterm birth, perinatal death and neurodevelopmental disability and cardiovascular and metabolic disease later in life. Pre-eclampsia is a complex multisystem disease, diagnosed by sudden-onset hypertension (>20 weeks of gestation) and at least one other associated complication, including proteinuria, maternal organ dysfunction or uteroplacental dysfunction. Pre-eclampsia is found only when a placenta is or was recently present and is classified as preterm (delivery <37 weeks of gestation), term (delivery ≥37 weeks of gestation) and postpartum pre-eclampsia. The maternal syndrome of pre-eclampsia is driven by a dysfunctional placenta, which releases factors into maternal blood causing systemic inflammation and widespread maternal endothelial dysfunction. Available treatments target maternal hypertension and seizures, but the only 'cure' for pre-eclampsia is delivery of the dysfunctional placenta and baby, often prematurely. Despite decades of research, the aetiology of pre-eclampsia, particularly of term and postpartum pre-eclampsia, remains poorly defined. Significant advances have been made in the prediction and prevention of preterm pre-eclampsia, which is predicted in early pregnancy through combined screening and is prevented with daily low-dose aspirin, starting before 16 weeks of gestation. By contrast, the prediction of term and postpartum pre-eclampsia is limited and there are no preventive treatments. Future research must investigate the pathogenesis of pre-eclampsia, in particular of term and postpartum pre-eclampsia, and evaluate new prognostic tests and treatments in adequately powered clinical trials.
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Gumusoglu S, Scroggins S, Vignato J, Santillan D, Santillan M. The Serotonin-Immune Axis in Preeclampsia. Curr Hypertens Rep 2021; 23:37. [PMID: 34351543 DOI: 10.1007/s11906-021-01155-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW To review the literature and detail the potential immune mechanisms by which hyperserotonemia may drive pro-inflammation in preeclampsia and to provide insights into potential avenues for therapeutic discovery. RECENT FINDINGS Preeclampsia is a severe hypertensive complication of pregnancy associated with significant maternal and fetal risk. Though it lacks any effective treatment aside from delivery of the fetus and placenta, recent work suggests that targeting serotonin systems may be one effective therapeutic avenue. Serotonin dysregulation underlies multiple domains of physiologic dysfunction in preeclampsia, including vascular hyporeactivity and excess platelet aggregation. Broadly, serotonin is increased across maternal and placental domains, driven by decreased catabolism and increased availability of tryptophan precursor. Pro-inflammation, another hallmark of the disease, may drive hyperserotonemia in preeclampsia. Interactions between immunologic dysfunction and hyperserotonemia in preeclampsia depend on multiple mechanisms, which we discuss in the present review. These include altered immune cell, kynurenine pathway metabolism, and aberrant cytokine production mechanisms, which we detail. Future work may leverage animal and in vitro models to reveal serotonin targets in the context of preeclampsia's immune biology, and ultimately to mitigate vascular and platelet dysfunction in the disease. Hyperserotonemia in preeclampsia drives pro-inflammation via metabolic, immune cell, and cytokine-based mechanisms. These immune mechanisms may be targeted to treat vascular and platelet endophenotypes in preeclampsia.
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Affiliation(s)
- Serena Gumusoglu
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
| | - Sabrina Scroggins
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Julie Vignato
- University of Iowa College of Nursing, Iowa City, Iowa, USA
| | - Donna Santillan
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Mark Santillan
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Feng X, Liu Y, Zhang Y, Zhang Y, Li H, Zheng Q, Li N, Tang J, Xu Z. New views on endothelial dysfunction in gestational hypertension and potential therapy targets. Drug Discov Today 2021; 26:1420-1436. [PMID: 33677145 DOI: 10.1016/j.drudis.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/10/2020] [Accepted: 03/01/2021] [Indexed: 12/14/2022]
Abstract
The placenta has vital roles in metabolite exchange, fetal growth, and pre-eclampsia (PE). In this review, we discuss the pathogenesis of hypertension in pregnancy, focusing on four major theories to explain PE, discussing endothelial roles in those theories. We focus in particular on the roles of nitric oxide (NO) and prostacyclin (PGI2) in placental endothelium, and propose new hypotheses for the influence and mechanisms of endothelial NO and PGI2 signaling pathways in PE.
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Affiliation(s)
- Xueqin Feng
- First Hospital of Soochow University & Maternal and Child Health Care Hospital of Wuxi, Jiangsu, China; Department of Obstetrics, Affiliated Hospital of Jining Medical University, Shandong, China
| | - Yanping Liu
- First Hospital of Soochow University & Maternal and Child Health Care Hospital of Wuxi, Jiangsu, China
| | - Yingying Zhang
- First Hospital of Soochow University & Maternal and Child Health Care Hospital of Wuxi, Jiangsu, China
| | - Yumeng Zhang
- First Hospital of Soochow University & Maternal and Child Health Care Hospital of Wuxi, Jiangsu, China
| | - Huan Li
- First Hospital of Soochow University & Maternal and Child Health Care Hospital of Wuxi, Jiangsu, China
| | - Qiutong Zheng
- First Hospital of Soochow University & Maternal and Child Health Care Hospital of Wuxi, Jiangsu, China
| | - Na Li
- First Hospital of Soochow University & Maternal and Child Health Care Hospital of Wuxi, Jiangsu, China
| | - Jiaqi Tang
- First Hospital of Soochow University & Maternal and Child Health Care Hospital of Wuxi, Jiangsu, China.
| | - Zhice Xu
- First Hospital of Soochow University & Maternal and Child Health Care Hospital of Wuxi, Jiangsu, China.
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