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Bezemer RE, Faas MM, van Goor H, Gordijn SJ, Prins JR. Decidual macrophages and Hofbauer cells in fetal growth restriction. Front Immunol 2024; 15:1379537. [PMID: 39007150 PMCID: PMC11239338 DOI: 10.3389/fimmu.2024.1379537] [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: 01/31/2024] [Accepted: 06/14/2024] [Indexed: 07/16/2024] Open
Abstract
Placental macrophages, which include maternal decidual macrophages and fetal Hofbauer cells, display a high degree of phenotypical and functional plasticity. This provides these macrophages with a key role in immunologically driven events in pregnancy like host defense, establishing and maintaining maternal-fetal tolerance. Moreover, placental macrophages have an important role in placental development, including implantation of the conceptus and remodeling of the intrauterine vasculature. To facilitate these processes, it is crucial that placental macrophages adapt accordingly to the needs of each phase of pregnancy. Dysregulated functionalities of placental macrophages are related to placental malfunctioning and have been associated with several adverse pregnancy outcomes. Although fetal growth restriction is specifically associated with placental insufficiency, knowledge on the role of macrophages in fetal growth restriction remains limited. This review provides an overview of the distinct functionalities of decidual macrophages and Hofbauer cells in each trimester of a healthy pregnancy and aims to elucidate the mechanisms by which placental macrophages could be involved in the pathogenesis of fetal growth restriction. Additionally, potential immune targeted therapies for fetal growth restriction are discussed.
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Affiliation(s)
- Romy Elisa Bezemer
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, Netherlands
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, Netherlands
| | - Marijke M Faas
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, Netherlands
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, Netherlands
| | - Harry van Goor
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, Netherlands
| | - Sanne Jehanne Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, Netherlands
| | - Jelmer R Prins
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, Netherlands
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Louwen F, Kreis NN, Ritter A, Yuan J. Maternal obesity and placental function: impaired maternal-fetal axis. Arch Gynecol Obstet 2024; 309:2279-2288. [PMID: 38494514 PMCID: PMC11147848 DOI: 10.1007/s00404-024-07462-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/04/2024] [Indexed: 03/19/2024]
Abstract
The prevalence of maternal obesity rapidly increases, which represents a major public health concern worldwide. Maternal obesity is characteristic by metabolic dysfunction and chronic inflammation. It is associated with health problems in both mother and offspring. Increasing evidence indicates that the placenta is an axis connecting maternal obesity with poor outcomes in the offspring. In this brief review, we have summarized the current data regarding deregulated placental function in maternal obesity. The data show that maternal obesity induces numerous placental defects, including lipid and glucose metabolism, stress response, inflammation, immune regulation and epigenetics. These placental defects affect each other and result in a stressful intrauterine environment, which transduces and mediates the adverse effects of maternal obesity to the fetus. Further investigations are required to explore the exact molecular alterations in the placenta in maternal obesity, which may pave the way to develop specific interventions for preventing epigenetic and metabolic programming in the fetus.
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Affiliation(s)
- Frank Louwen
- Obstetrics and Prenatal Medicine, Gynecology and Obstetrics, University Hospital Frankfurt, J. W. Goethe-University, Theodor Stern-Kai 7, 60590, Frankfurt, Germany
| | - Nina-Naomi Kreis
- Obstetrics and Prenatal Medicine, Gynecology and Obstetrics, University Hospital Frankfurt, J. W. Goethe-University, Theodor Stern-Kai 7, 60590, Frankfurt, Germany
| | - Andreas Ritter
- Obstetrics and Prenatal Medicine, Gynecology and Obstetrics, University Hospital Frankfurt, J. W. Goethe-University, Theodor Stern-Kai 7, 60590, Frankfurt, Germany
| | - Juping Yuan
- Obstetrics and Prenatal Medicine, Gynecology and Obstetrics, University Hospital Frankfurt, J. W. Goethe-University, Theodor Stern-Kai 7, 60590, Frankfurt, Germany.
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Qian L, Ding J, Shi L, Yu Q, Zhu J, Huang A. Analysis of hemi-uterus pregnancy outcomes in uterine malformations: a retrospective observational study. BMC Pregnancy Childbirth 2023; 23:836. [PMID: 38049742 PMCID: PMC10696795 DOI: 10.1186/s12884-023-06136-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 11/17/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND The association between uterine malformations and adverse pregnancy outcomes is well recognized. However, studies on adverse pregnancy outcomes based on one kind of anatomical commonality between different uterine anomalies have not been reported. This study aimed to investigate pregnancy outcomes in pregnancies with uterine malformations when the pregnancy is confined to a hemi-uterus. METHODS A retrospective observational study of 336 women who gave birth at our hospital from 2015 to 2021 was performed. Women (n = 112) with a unicornuate, complete bicornuate, or didelphic uterus were set as the study group, and women (n = 224) with a normal uterus were set as the reference group. Maternal and neonatal outcomes were evaluated and compared between the two groups using Student's t-test, one-way ANOVA, Chi-squared test, Yates correction for continuity, or Fisher's exact test. Modified Poisson regression analyses were used to estimate the relationships between the hemi-uterus pregnancy and preterm birth, preterm premature rupture of membranes, and cesarean section rates by adjusting for potential confounders. A P value < 0.05 was considered significant. RESULTS Women in the study group had a higher history of spontaneous abortion (24.1% vs. 10.7%, P = 0.002) and intrauterine fetal death (5.4% vs. 0.4, P = 0.006). Compared with the reference group, the study group had significantly higher rates of assisted reproductive technology (9.4% vs. 2.2%, P = 0.001) and cord-around-the neck (54.5% vs. 29.9%, P = 0.000). Modified Poisson regression analyses showed that the study group was at higher risk for preterm birth (aRR, 6.8; 95% CI 2.7-16.7), preterm premature rupture of membranes (aRR, 14.1; 95% CI 3.2-62.5), malpresentation (aRR, 13.2; 95% CI 6.3-27.7), and cesarean section (aRR, 4.4; 95% CI 3.3-5.7). CONCLUSION Women with a unicornuate, didelphic, or complete bicornuate uterus are at higher risk for some adverse pregnancy outcomes than those with a normal uterus.
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Affiliation(s)
- Liang Qian
- Department of Obstetrics, Hangzhou Women's Hospital (Hangzhou Maternity and Child Health Care Hospital), Hangzhou, 310008, Zhejiang, China
| | - Jiashan Ding
- Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Lan Shi
- Department of Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Qing Yu
- Department of Obstetrics, Hangzhou Women's Hospital (Hangzhou Maternity and Child Health Care Hospital), Hangzhou, 310008, Zhejiang, China
| | - Jiawei Zhu
- Department of Obstetrics, Hangzhou Women's Hospital (Hangzhou Maternity and Child Health Care Hospital), Hangzhou, 310008, Zhejiang, China
| | - Anfeng Huang
- Department of Obstetrics, Hangzhou Women's Hospital (Hangzhou Maternity and Child Health Care Hospital), Hangzhou, 310008, Zhejiang, China.
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Liang L, Chen Y, Wu C, Cao Z, Xia L, Meng J, He L, Yang C, Wang Z. MicroRNAs: key regulators of the trophoblast function in pregnancy disorders. J Assist Reprod Genet 2023; 40:3-17. [PMID: 36508034 PMCID: PMC9742672 DOI: 10.1007/s10815-022-02677-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022] Open
Abstract
The placenta is essential for a successful pregnancy and healthy intrauterine development in mammals. During human pregnancy, the growth and development of the placenta are inseparable from the rapid proliferation, invasion, and migration of trophoblast cells. Previous reports have shown that the occurrence of many pregnancy disorders may be closely related to the dysfunction of trophoblasts. However, the function regulation of human trophoblast cells in the placenta is poorly understood. Therefore, studying the factors that regulate the function of trophoblast cells is necessary. MicroRNAs (miRNAs) are small, non-coding, single-stranded RNA molecules. Increasing evidence suggests that miRNAs play a crucial role in regulating trophoblast functions. This review outlines the role of miRNAs in regulating the function of trophoblast cells and several common signaling pathways related to miRNA regulation in pregnancy disorders.
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Affiliation(s)
- Lingli Liang
- grid.412017.10000 0001 0266 8918Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, Hunan International Scientific and Technological Cooperation Base of Arteriosclerotic Disease, Hengyang Medical College, University of South China, Hengyang, 421001 China
| | - Yanjun Chen
- grid.412017.10000 0001 0266 8918Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, Hunan International Scientific and Technological Cooperation Base of Arteriosclerotic Disease, Hengyang Medical College, University of South China, Hengyang, 421001 China
| | - Chunyan Wu
- grid.412017.10000 0001 0266 8918Department of Cardiovascular, The Third Affiliated Hospital of University of South China, Hengyang, 421001 China
| | - Zitong Cao
- grid.412017.10000 0001 0266 8918Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, Hunan International Scientific and Technological Cooperation Base of Arteriosclerotic Disease, Hengyang Medical College, University of South China, Hengyang, 421001 China
| | - Linzhen Xia
- grid.412017.10000 0001 0266 8918Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, Hunan International Scientific and Technological Cooperation Base of Arteriosclerotic Disease, Hengyang Medical College, University of South China, Hengyang, 421001 China
| | - Jun Meng
- grid.461579.8Department of Function, The First Affiliated Hospital of University of South China, Hengyang, 421001 China
| | - Lu He
- grid.461579.8Department of Gynecology, The First Affiliated Hospital of University of South China, Hengyang, 421001 China
| | - Chunfen Yang
- grid.461579.8Department of Gynecology, The First Affiliated Hospital of University of South China, Hengyang, 421001 China
| | - Zuo Wang
- grid.412017.10000 0001 0266 8918Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, Hunan International Scientific and Technological Cooperation Base of Arteriosclerotic Disease, Hengyang Medical College, University of South China, Hengyang, 421001 China
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Interrelation between miRNAs Expression Associated with Redox State Fluctuations, Immune and Inflammatory Response Activation, and Neonatal Outcomes in Complicated Pregnancy, Accompanied by Placental Insufficiency. Antioxidants (Basel) 2022; 12:antiox12010006. [PMID: 36670868 PMCID: PMC9854567 DOI: 10.3390/antiox12010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Redox disbalance in placental cells leads to the hyperproduction of reactive oxygen species (ROS), it mediates the dysregulation of the maternal immune tolerance to a semi-allogenic fetus, inducing pro-inflammatory reactions, and it plays a central role in perinatal complications and neonatal disease programming. Microvesicles, which provide transplacental communication between a mother and fetus, contain microRNAs (miRNAs) that are sensitive to oxidative stress (OS) mediators and can control the balance of ROS production and utilization in target cells. In the context of this paradigm, we evaluated the markers of redox balance—MDA and 4-HNE for OS and GPx, and SOD, CAT, and GSH for the antioxidant system in the cord blood plasma of newborns diagnosed with fetal growth restriction (FGR)—by using polarography, spectrophotometry, and Western blotting. The expression of miRNAs associated with OS, immune and inflammatory responses in the blood plasma of newborns with intrauterine pneumonia (IP), neonatal sepsis (NS) and respiratory distress syndrome (RDS) was evaluated by a quantitative RT-PCR. Significant differences in the MDA level and reduced GPx and CAT activity were co-found for early-onset FGR (i.e., <34 gestational age). Significant correlations were found with a low birth weight by Apgar scores with reduced levels of antioxidant enzymes. Indeed, the level of OS markers increased in early-onset FGR in newborns with an extremely low body weight and high echogenicity of the periventricular zones, and reduced in late-onset FGR in newborns with IP, hyperbilirubinemia, intraventricular hemorrhage (IVH) and cerebral cysts. A prognostic model (AUC = 1; cutoff—0.5) was developed to assess the risk of IVH in newborns diagnosed with FGR based on the assessment of the OS markers (i.e., MDA + 4 HNE + CAT + GSH). A significant increase in the miR-127-3p expression was found in the plasma of newborns with NS (<32 GA; p ≤ 0.03 and >32 GA; p ≤ 0.009), IP (>32 GA; p ≤ 0.0001), and RDS (>32 GA; p ≤ 0.03). At the same time, the expression of miR-25-3p (p ≤ 0.03) was increased only in newborns with NS (>32 GA; p ≤ 0.03). The risk of developing IVH for premature newborns with IP (AUC = 0.8; cutoff—0.6) and NS (AUC = 0.68; cutoff—0.49) was assessed based on the miR-25-3p and miR-127-3p expression. Several key transcription factors were identified as the targets of studied miRNA since they are involved in the regulation of OS (NRF2), signaling and activation of the immune response (PRDM1, CCL26) and, also, inflammatory responses (NFKB1). The study of these miRNAs showed that they are involved in the modulation of processes leading to perinatal complications. Moreover, miR-127-3p is related to pro-inflammatory reactions and the formation of the macrophage phenotype in newborns with IP, NS, and RDS, while miR-25-3p is associated with an inhibition of macrophage migration and activation of antioxidant enzymes, which may prevent the development of oxidative damage in newborns with NS.
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Morales‐Roselló J, Loscalzo G, García‐Lopez EM, García‐Gimenez JL, Perales‐Marín A. MicroRNA‐132 is overexpressed in fetuses with late‐onset fetal growth restriction. Health Sci Rep 2022; 5:e558. [PMID: 35317418 PMCID: PMC8922531 DOI: 10.1002/hsr2.558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 12/25/2021] [Accepted: 02/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Aims To evaluate the expression of microRNA 132 (miR‐132) in fetuses with normal growth and in fetuses with late‐onset growth restriction (FGR). Methods In a prospective cohort study, 48 fetuses (24 with late‐onset FGR and 24 with normal growth) were scanned with Doppler ultrasound after 34 weeks to measure the umbilical artery and middle cerebral artery pulsatility indices and followed until birth. Subsequently, blood samples from the umbilical cord were collected to evaluate the expression of miR‐132 by means of Real‐time quantitative polymerase chain reaction, determining the existence of normality cut‐offs and associations with birth weight (BW) centile, cerebroplacental ratio multiples of the median (CPR MoM), and intrapartum fetal compromise (IFC). Results In comparison with normal fetuses, late‐onset FGR fetuses showed upregulation of miR‐132 (33.94 ± 45.04 vs. 2.88 ± 9.32 2−ddCt, p < 0.001). Using 5 as a cut‐off we obtained a sensitivity of 50% and a specificity of 96% for the diagnosis of FGR, while for IFC these values were respectively 27% and 73%. Expression of miR‐132 was associated with BW centile but not with CPR MoM. Finally, the best detection of IFC was achieved combining miR‐132 expression and CPR MoM (AUC = 0.69, p < 0.05). Conclusion Fetuses with late‐onset FGR show upregulation of miR‐132. Further studies are needed to investigate the role of miR‐132 in the management of late‐onset FGR.
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Affiliation(s)
- José Morales‐Roselló
- Servicio de Obstetricia y Ginecología Hospital Universitario y Politécnico La Fe Valencia Spain
- Departamento de Pediatría, Obstetricia y Ginecología Universidad de Valencia Valencia Spain
| | - Gabriela Loscalzo
- Servicio de Obstetricia y Ginecología Hospital Universitario y Politécnico La Fe Valencia Spain
| | - Eva María García‐Lopez
- EpiDisease SL, and Consortium Center for Biomedical Network Research on Rare Diseases (CIBERER) Institute of Health Carlos III Valencia Spain
| | - José Luis García‐Gimenez
- EpiDisease SL, and Consortium Center for Biomedical Network Research on Rare Diseases (CIBERER) Institute of Health Carlos III Valencia Spain
- Departamento de Fisiología Universidad de Valencia Valencia Spain
| | - Alfredo Perales‐Marín
- Servicio de Obstetricia y Ginecología Hospital Universitario y Politécnico La Fe Valencia Spain
- Departamento de Pediatría, Obstetricia y Ginecología Universidad de Valencia Valencia Spain
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Sun F, Cai H, Tan L, Qin D, Zhang J, Hua J, Fan X, Peng S. Placenta-Specific miR-125b Overexpression Leads to Increased Rates of Pregnancy Loss in Mice. Int J Mol Sci 2022; 23:ijms23020943. [PMID: 35055127 PMCID: PMC8779150 DOI: 10.3390/ijms23020943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/09/2022] [Accepted: 01/11/2022] [Indexed: 02/01/2023] Open
Abstract
Pregnancy loss (PL) is one of the common complications that women can experience during pregnancy, with an occurrence rate of 1 to 5%. The potential causes of pregnancy loss are unclear, with no effective treatment modalities being available. It has been previously reported that the level of miR-125b was significantly increased in placentas of PL patients. However, the role of miR-125b in the development of PL still remains unknown. In the current study, an miR-125b placenta-specific over-expression model was constructed by lentiviral transfecting zona-free mouse embryos followed by embryo transfer. On gestation day 15, it was observed that the placenta was significantly smaller in the miR-125b placenta-specific overexpression group than the control group. Additionally, the abortion rate of the miR-125b placenta-specific overexpression group was markedly higher than in the control group. The blood vessel diameter was larger in the miR-125b-overexpressing specific placenta. In addition, miR-125b-overexpressing HTR8 and JEG3 cell lines were also generated to analyze the migration and invasion ability of trophoblasts. The results showed that miR-125b overexpression significantly suppressed the migration and invasion ability of HTR8 and JEG3 cells. Overall, our results demonstrated that miR-125b can affect embryo implantation through modulating placenta angiogenesis and trophoblast cell invasion capacity that can lead to PL.
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Affiliation(s)
- Fen Sun
- Shaanxi Centre of Stem Cells Engineering & Technology, College of Veterinary Medicine, Northwest A&F University, Yangling, Xianyang 712100, China; (F.S.); (H.C.); (D.Q.); (J.H.)
| | - Hui Cai
- Shaanxi Centre of Stem Cells Engineering & Technology, College of Veterinary Medicine, Northwest A&F University, Yangling, Xianyang 712100, China; (F.S.); (H.C.); (D.Q.); (J.H.)
| | - Lunbo Tan
- Laboratory of Reproductive Health, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China;
| | - Dezhe Qin
- Shaanxi Centre of Stem Cells Engineering & Technology, College of Veterinary Medicine, Northwest A&F University, Yangling, Xianyang 712100, China; (F.S.); (H.C.); (D.Q.); (J.H.)
| | - Jian Zhang
- Center for Reproduction and Health Development, Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China;
| | - Jinlian Hua
- Shaanxi Centre of Stem Cells Engineering & Technology, College of Veterinary Medicine, Northwest A&F University, Yangling, Xianyang 712100, China; (F.S.); (H.C.); (D.Q.); (J.H.)
| | - Xiujun Fan
- Center for Reproduction and Health Development, Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China;
- Correspondence: (X.F.); (S.P.)
| | - Sha Peng
- Shaanxi Centre of Stem Cells Engineering & Technology, College of Veterinary Medicine, Northwest A&F University, Yangling, Xianyang 712100, China; (F.S.); (H.C.); (D.Q.); (J.H.)
- Correspondence: (X.F.); (S.P.)
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Monaco-Brown M, Lawrence DA. Obesity and Maternal-Placental-Fetal Immunology and Health. Front Pediatr 2022; 10:859885. [PMID: 35573953 PMCID: PMC9100592 DOI: 10.3389/fped.2022.859885] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/30/2022] [Indexed: 12/12/2022] Open
Abstract
Obesity rates in women of childbearing age is now at 29%, according to recent CDC reports. It is known that obesity is associated with oxidative stress and inflammation, including disruptions in cellular function and cytokine levels. In pregnant women who are obese, associated placental dysfunction can lead to small for gestational age (SGA) infants. More frequently, however, maternal obesity is associated with large for gestational age (LGA) newborns, who also have higher incidence of metabolic disease and asthma due to elevated levels of inflammation. In addition, anthropogenic environmental exposures to "endocrine disrupting" and "forever" chemicals affect obesity, as well as maternal physiology, the placenta, and fetal development. Placental function is intimately associated with the control of inflammation during pregnancy. There is a large amount of literature examining the relationship of placental immunology, both cellular and humoral, with pregnancy and neonatal outcomes. Cells such as placental macrophages and NK cells have been implicated in spontaneous miscarriage, preeclampsia, preterm birth, perinatal neuroinflammation, and other post-natal conditions. Differing levels of placental cytokines and molecular inflammatory mediators also have known associations with preeclampsia and developmental outcomes. In this review, we will specifically examine the literature regarding maternal, placental, and fetal immunology and how it is altered by maternal obesity and environmental chemicals. We will additionally describe the relationship between placental immune function and clinical outcomes, including neonatal conditions, autoimmune disease, allergies, immunodeficiency, metabolic and endocrine conditions, neurodevelopment, and psychiatric disorders.
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Affiliation(s)
- Meredith Monaco-Brown
- Department of Pediatrics, Bernard and Millie Duker Children's Hospital at Albany Medical Center, Albany, NY, United States
| | - David A Lawrence
- New York State Department of Health, Wadsworth Center, Albany, NY, United States.,Department of Environmental Health Sciences, University at Albany School of Public Health, Rensselaer, NY, United States
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