The role of the placenta in the initiation of spiral artery remodelling in an early pregnant chimpanzee uterus

INTRODUCTION

In this study we evaluated the full extent of placental bed changes (centre to periphery) in a pregnant chimpanzee uterus, kept at the Museum for Central Africa in Tervuren, Belgium. According to placental size the specimen was equivalent to an 8 weeks pregnant human uterus.

METHODS

Histological sections from central to peripheral tissue blocks of the placental bed were stained to reveal the presence of trophoblast, endothelium, vascular smooth muscle and elastic laminae. As an indicator for early arterial remodelling, we evaluated endothelial nuclear rounding and subendothelial vascular changes within the maternal vasculature in decidua and adjacent inner myometrium.

RESULTS

While interstitially invading trophoblasts were present, endovascular trophoblast invasion seemed about to start into one spiral artery outlet at the centre of the placental bed, confirming our previous impression of a later onset of endovascular trophoblast invasion as compared to the human. An early sign of spiral artery remodelling was rounding of the endothelial nuclei. This phenomenon was not related to the local presence of interstitial trophoblast.

DISCUSSION

Endothelial nuclear rounding turned out to be a feature of the placental bed as a whole, being significantly less prominent in the adjacent non-placental bed part of the uterus, indicating an effect of the presence of the placenta. The different time-course of early spiral artery remodelling in the chimpanzee as compared to the human may have had a significant impact upon our evolution.

A retrospective study of the pregnancy, delivery and neonatal outcome in overweight versus normal weight women with polycystic ovary syndrome

STUDY QUESTION

Do overweight women with polycystic ovary syndrome (PCOS) have a higher risk of perinatal complications than normal weight women with PCOS?

SUMMARY ANSWER

Overweight women with PCOS with an ongoing singleton pregnancy have an increased risk of preterm birth as well as an increased risk of giving birth to a baby with a higher birthweight than normal weight women with PCOS.

WHAT IS KNOWN ALREADY

There is evidence that overweight (BMI > 25 kg/m²) has a negative influence on the prevalence of gestational diabetes mellitus and fetal macrosomia in women with PCOS.

STUDY DESIGN, SIZE, DURATION

We set up a retrospective comparative cohort study of 93 overweight (BMI ≥ 25 kg/m²) and 107 normal weight (BMI < 25 kg/m²) women with PCOS who were scheduled for fertility treatment between January 2000 and December 2009 and achieved a pregnancy as a result of a treatment cycle, or spontaneously before or between treatment cycles.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All data (patient characteristics, medical information, pregnancy, delivery and neonatal outcome) were retrieved from patient medical files. All pregnancy, delivery and neonatal outcome parameters were adjusted for age and pre-pregnancy smoking behaviour. The neonatal outcome parameters were additionally adjusted for gestational age.

MAIN RESULTS AND THE ROLE OF CHANCE

The median BMI in the overweight and normal weight women was, respectively, 30.8 kg/m² [interquartile quartile range (IQR) 5.8] and 20.9 kg/m² (IQR 2.3) (P < 0.001). Baseline characteristics did not differ between groups, except for free testosterone and fasting insulin levels, which were higher, and sex hormone-binding globulin, which was lower, in overweight versus normal weight women (all P < 0.001). The time-to-pregnancy was significantly higher in the overweight group (P = 0.01). Multivariate analyses of the ongoing singleton pregnancies showed significantly more preterm births in overweight (10/61) versus normal weight (2/71) women [adjusted odds ratio 0.1, 95% confidence interval (CI) 0-0.6, P = 0.01]. The mean birthweight of newborns was significantly higher in overweight (3386 ± 663 g) than in normal weight (3251 ± 528 g) women (adjusted mean difference 259.4, 95% CI 83.4-435.4, P = 0.004).

LIMITATIONS, REASON FOR CAUTION

Our results only represent the pregnancy, delivery and neonatal outcome of ongoing singleton pregnancies. The rather small sample size and observational nature of the study are further limitations.

WIDER IMPLICATIONS OF THE FINDINGS

Our results suggest the importance of pre-pregnancy weight loss in overweight women with PCOS in order to reduce the risk of adverse perinatal outcomes.

STUDY FUNDING/COMPETING INTERESTS

Veerle De Frène is holder of a Special PhD Fellowship by the Flemish Foundation for Scientific Research (FWO-Vlaanderen). Petra De Sutter is holder of a fundamental clinical research mandate by the Flemish Foundation for Scientific Research (FWO-Vlaanderen). There are no competing interests.

Deep trophoblast invasion and spiral artery remodelling in the placental bed of the lowland gorilla

In contrast to baboon or rhesus macaque, trophoblast invasion in the human placental bed occurs by the interstitial as well as the endovascular route and reaches as deep as the inner myometrium. We here describe two rare specimens of gorilla placenta. In the light of recent findings in the chimpanzee, we postulated the occurrence of deep invasion in gorilla pregnancy. Tissues were processed for histology (PAS, orcein), lectin staining (Ulex europaeus agglutinin 1) and immunohistochemistry (cytokeratin 7/17, α-actin). A specimen of young but undetermined gestational age included deep placental bed tissue, showing interstitial and spiral artery invasion of the inner myometrium as well as the decidua. The cell density and depth of trophoblast invasion was equivalent to a human placental bed of 10-14 weeks. Intraluminal trophoblasts were not seen in any of the invaded vessels, allowing no definite conclusions about the origin of the intramural trophoblast and the time-course of spiral artery invasion. A different late second trimester placenta specimen showed scattered extravillous trophoblast in the basal plate and underlying decidua, as well as a remodelled spiral artery containing intramural trophoblast. Absence of inner myometrial tissue precluded assessment of invasion depth in this later specimen. Despite the limited material we can conclude that key aspects of trophoblast invasion are shared by the three hominid species: gorilla, chimpanzee and human.

Deep trophoblast invasion and spiral artery remodelling in the placental bed of the chimpanzee

Deep trophoblast invasion is usually considered to be a unique feature of human placentation as compared to other primates. Because of the occasional occurrence of preeclampsia in great apes, which in the human is associated with impaired deep invasion, this uniqueness may be questioned. The availability of two well-documented pregnant chimpanzee uteri in the Hubrecht Collection (Museum für Naturkunde, Berlin) allowed us to evaluate the extent of trophoblast invasion in this species. By adjusting currently used protocols, we obtained successful immunohistochemical staining for cytokeratin and α-actin, as well as Ulex europaeus agglutinin 1 (UEA1) lectin staining, in this archival material. In both specimens interstitial trophoblast invasion had occurred in both decidua and myometrium. Because of a lack of published data on fetal growth for this species, fetal sizes (7cm and 13cm) could not be strictly related to gestational ages and thus be compared with the time-course of human trophoblast invasion. However, since the earlier specimen did not show any endovascular trophoblast invasion in spiral arteries - in contrast to pregnant human uteri with equivalent fetal sizes - endovascular migration seems to begin at a different gestational age in the chimpanzee. In the later specimen endovascular trophoblast was associated with spiral artery remodelling in the inner myometrium, and this invasion was extended to include a radial artery, which at that stage still showed relatively intact vascular smooth muscle and elastic lamina. We conclude that invasion depth and spiral artery remodelling are basically similar in chimpanzees and humans, although the seemingly different time of onset may have implications for uteroplacental oxygen supply and fetal development.

Deep placentation

Deep placentation in human pregnancy is realised by deep invasion of the placental bed by the extravillous trophoblast, involving the decidua and the inner (junctional zone) myometrium. Interstitial invasion of the stroma and endovascular trophoblast invasion of the spiral arteries both occur. Deep endovascular trophoblast invasion into the myometrial segments of spiral arteries is important for proper placental functioning. Before this extended vascular invasion begins, decidua-associated vascular remodelling, which includes swelling and disorganisation of the vascular smooth muscle, occurs during a period of rising placental oxygen. This early remodelling step may accommodate the progressively increasing maternal blood flow to the developing placenta. The subsequent trophoblast-associated remodelling step enhances and stabilises the widening of the vessels, whereas the vascular smooth muscle and elastic lamina are replaced by a fibrinoid matrix with embedded trophoblast. Defective deep remodelling contributes to placental malfunctioning in complications of pregnancy.

Changes in endovascular trophoblast invasion and spiral artery remodelling at term in a transgenic preeclamptic rat model

As a follow-up to our previous study which revealed a surprisingly deeper endovascular trophoblast (ET) invasion on day 18 in a transgenic preeclamptic (PE) rat model (hAngiotensinogen female symbol x hRenin male symbol) compared to non-PE controls, we examined further changes in ET invasion and associated spiral artery (SA) remodelling at term (day 21). PE transgenic rats and non-PE reversely mated (RM) transgenic rats were compared to normal SD rats (C). Sections were stained to visualize trophoblast, fibrinoid, vascular smooth muscle (VSM) and endothelium. SA were evaluated in three depth levels in the mesometrial triangle (MT) using the KS-400 image analysis system. In separate transgenic rats, Doppler ultrasound was performed in uterine arteries, and the resistance indices (RI) were calculated. Although for the whole MT differences in ET invasion were no longer significant between the PE and C, indicating a partial catching up in C rats, there was still significantly more ET in the deepest level in the PE group as compared to the C and RM groups. At the same time the SA walls in PE rats contained significantly more fibrinoid (versus RM and C) and VSM (versus C). In all SA cross-sections, re-endothelialisation was prominent, but significantly different between PE and C group. The Doppler results showed a significantly lower RI in the arcuate uterine artery of the PE group compared to the C group. There was no evidence of elimination of deeply invaded ET at term, previously considered as a possible mechanism for restriction of vascular remodelling in human PE. The differences in vascular remodelling, previously described on day 18 by histology and Doppler data, were maintained on day 21, but there was extensive endothelial repair in the three groups. Atherosis-like lesions were observed in the three groups, most frequently in the RM group, but were never associated with placental infarcts.

Erasmus Darwin's enlightened views on placental function

In his major work "Zoonomia", Erasmus Darwin (1731-1802) devoted one chapter to the placenta, in which the new knowledge of the recently discovered element oxygen was applied to the functioning of this organ. He considered the "cavities" or "lacunae" in the placenta as the main areas for oxygenation of the fetal blood, as he thought them to be structurally comparable to the lungs and the gills of fish. He obviously was aware of species differences in the uterine arterial blood supply to the placenta between humans and cows, assuming a higher contractility of the vasculature in the latter species. The new evidence for a primarily respiratory role overshadowed ideas of a possible nutritive function of the placenta. Since Hunter's definitive demonstration of separate maternal and fetal blood circulations, nutritive functions of the placenta needed to be explained by transmembrane transport processes, which were unknown at that time. Instead Erasmus Darwin erroneously considered the amniotic fluid as the main source of nutrients for the fetus. His understanding of placental respiration found expression in his long poem on the history of life on earth.

The Uterine Spiral Arteries In Human Pregnancy: Facts and Controversies

Uterine spiral arteries play a vital role in supplying nutrients to the placenta and fetus, and for this purpose they are remodelled into highly dilated vessels by the action of invading trophoblast (physiological change). Knowledge of the mechanisms of these changes is relevant for a better understanding of pre-eclampsia and other pregnancy complications which show incomplete spiral artery remodelling. Controversies still abound concerning different steps in these physiological changes, and several of these disagreements are highlighted in this review, thereby suggesting directions for further research. First, a better definition of the degree of decidua- versus trophoblast-associated remodelling may help to devise a more adequate terminology. Other contestable issues are the vascular plugging and its relation with oxygen, trophoblast invasion from the outside or the inside of the vessels (intravasation versus extravasation), the impact of haemodynamics on endovascular migration, the replacement of arterial components by trophoblast, maternal tissue repair mechanisms and the role of uterine natural killer (NK) cells. Several of these features may be disturbed in complicated pregnancies, including the early decidua-associated vascular remodelling, vascular plugging and haemodynamics. The hyperinflammatory condition of pre-eclampsia may be responsible for vasculopathies such as acute atherosis, although the overall impact of such lesions on placental function is far from clear. Several features of the human placental bed are mirrored by processes in other species with haemochorial placentation, and studying such models may help to illuminate poorly understood aspects of human placentation.

ACE inhibitor captopril reduces ecdysteroids and oviposition in moths

By using the selective ACE inhibitor captopril, we studied the effect of the angiotensin converting enzyme (ACE) on larval growth, metamorphosis, and reproduction in a lepidopteran species, the cotton leafworm, Spodoptera littoralis. Captopril was detrimental to adult formation and oviposition, and in female moths it elicited decreasing ecdysteroid levels, but increasing trypsin activities. Our results suggest that captopril downregulates oviposition by two independent pathways. Apparently, oviposition is influenced by a complex interaction of ACE, trypsin activity, and ecdysteroid levels.

Mathias Duval on Placental Development in Mice and Rats

Mathias Duval (1844-1907) was one of the pioneers in elucidating the intricate placental histology of different mammalian groups, notably the rodents. Using a well-dated series of mouse conceptuses, he described in detail the successive steps in placental development, and for confirmation he included observations on a (undated) collection of rat specimens. Not only was he able to identify correctly the different extra-embryonic cell layers, but he was also the first to recognize trophoblast invasion in rodents. Not all his interpretations are still valid, however. Re-reading his extensive and detailed work "Le placenta des rongeurs" (1890-1892) confronts us with still existing gaps in our present understanding of placental development, notably the morphogenesis of the different placental layers and the differentiation of invasive trophoblast. His understanding of uteroplacental blood flow was still limited, and he failed to recognize the complexity of the maternal decidua and its vasculature, which is essential for correctly understanding the pathways and extent of trophoblast invasion. Although Duval was active in promoting Darwin's evolutionary ideas, he refrained from extrapolating too quickly his findings in rodents to other mammalian groups including humans. In his view detailed histological studies on complete series of specimens had to come first, and thus provide a firm basis for a proper understanding of placental function and evolution.

Endovascular trophoblast invasion and associated structural changes in uterine spiral arteries of the pregnant rat

The involvement of endovascular trophoblast in fibrinoid deposition, replacement of the endothelium and vascular smooth muscle breakdown is studied in spiral arteries of the mesometrial triangle from day 15 to day 21 of rat pregnancy, by examining arterial cross sections after staining for cytokeratin, PAS, CD31 and alpha-actin. From day 15 to day 18 of pregnancy, fibrinoid deposition underneath the endovascular trophoblast increases gradually, whereas the amount of endovascular trophoblast in invaded arteries remains constant. CD31 staining is significantly reduced in sub-ET (= underlying the endovascular trophoblast) as compared to extra-ET (= outside the endovascular trophoblast) and no-ET (= non-invaded arterial sections) at each time-point of pregnancy examined (P < 0.005 and P < 0.0005 at each day of pregnancy), whereas alpha-actin staining is reduced both in sub-ET and in extra-ET as compared to no-ET. During pregnancy, CD31 staining in sub-ET initially declines, but increases significantly on day 21 (P < 0.001 versus d20) suggesting re-endothelialization of the vascular wall. In conclusion, changes in spiral arteries of pregnant rats reveal striking similarities with physiological changes seen in human pregnancy, thus emphasizing the usefulness of this species as an experimental model for studying normal and complicated pregnancies in humans.

The placental bed in pregnancies complicated by primary antiphospholipid syndrome

Pregnancy in women with primary antiphospholipid syndrome (APS) is frequently associated with placental insufficiency leading to intrauterine growth restriction (IUGR)+/-fetal death, pre-eclampsia, placental abruption, premature delivery or thrombosis. The aim of this study was to investigate the placental bed in APS pregnancies for evidence of impaired trophoblast invasion, endothelial cell activation (ECA) and macrophage infiltration.

METHODS

Biopsies from the presumed site of the placental bed were obtained from 12 women with treated primary APS and 16 controls. Immunohistochemical methods were employed to investigate expression of cytokeratin (trophoblasts), alpha-actin (smooth muscle), CD68 (macrophages) and VCAM-1 (as marker of ECA). Fibrinoid and elastin distribution and expression were determined by periodic acid/Schiff and orcein stain, respectively.

RESULTS

Three APS pregnancies developed IUGR, one with concurrent pre-eclampsia. Eight of 12 APS biopsies were confirmed to be from the placental bed; one patient failed to meet APS criteria and was excluded from analysis; six included spiral arteries in the biopsy; 11 of 16 controls' biopsies were from the placental bed. APS biopsies had a higher concentration of inflammatory cells (p=0.0001), particularly macrophages (p=0.014). Three APS biopsies showed necrosis with hyperplastic vessels; one demonstrated arterial thromboses, but none had profound vasculopathy/atherosis or ECA.

CONCLUSION

Inflammatory mechanisms in the placental bed may contribute to APS pregnancy complications.

Interstitial trophoblast invasion in the decidua and mesometrial triangle during the last third of pregnancy in the rat

Like other species with haemochorial placentation, pregnant rats show marked invasion of the uterine wall by trophoblast. While an endovascular pathway of invasion has been recognized for a long time, only recently, by application of cytokeratin immunostaining, the existence of an interstitial pathway of invasion has been established. Interstitial invasion is mainly effected by glycogen cell-like trophoblast arising from glycogen cell islands of the trophospongium opening up into the decidua, and from glycogen cell sheaths surrounding the intraplacental maternal arterial channels which are connected with the spiral arteries in decidua and mesometrial triangle. Quantitative evaluation of interstitial invasion in both maternal compartments was carried out on days 15-21, using PAS staining and cytokeratin and alpha-actin immunostaining for detecting trophoblast and defining maternal tissue compartments. Measurements of compartment size, cytokeratin-positive areas and invasion extent were performed using the KS400 image analysis system. A distinct pattern of interstitial trophoblast invasion emerged, starting from central decidual areas around the maternal arterial channels, and mushrooming into the mesometrial triangle reaching a peak at day 18, followed by gradual regression of the invaded areas. These measurements may serve as a basis for further experiments to evaluate factors which may influence the depth of trophoblast invasion.

The angiotensin converting enzyme inhibitor captopril reduces oviposition and ecdysteroid levels in Lepidoptera

The role of angiotensin converting enzyme (ACE, peptidyl dipeptidase A) in metamorphic- and reproductive-related events in the Egyptian cotton leafworm, Spodoptera littoralis (Lepidoptera, Noctuidae) was studied by using the selective ACE inhibitor captopril. Although oral administration of captopril had no effect on larval growth, topical administration to new pupae resulted in a large decrease of successful adult formation. Oviposition and overall appearance of adults emerging from treated larvae did not differ significantly from those emerging from non-treated larvae. In contrast, topical or oral administration of captopril to newly emerged adults caused a reduction in oviposition. By evaluating the effect of captopril on ecdysteroid titers and trypsin activity, we revealed an additional physiological role for ACE. Captopril exerted an inhibitory effect on ecdysteroid levels in female but not in male adults. Larvae fed a diet containing captopril exhibited increased trypsin activity. A similar captopril-induced increase in trypsin activity was observed in female adults. In male adults, however, captopril elicited reduced levels of trypsin activity. Our results suggest that captopril downregulates oviposition by two independent pathways, one through ecdysteroid biosynthesis regulation, and the other through regulation of trypsin activity. Apparently, fecundity is influenced by a complex interaction of ACE, trypsin activity, and ecdysteroid levels.

Thomas Huxley and the rat placenta in the early debates on evolution

The 19th century debates on mammalian classification in the light of the new evolutionary thinking led to controversies between Thomas Huxley and Richard Owen concerning the value of the placenta as a representative key organ. As a main point in his argument, Huxley provided a detailed description of a sectioned rat placenta, highlighting the importance of decidualization of the uterus as an argument supporting an evolutionary relationship between rodents, insectivores and primates, an idea hotly contested by Owen. In addition, he illustrated and correctly interpreted the maternal blood supply from uterus to placenta in striking detail. During the succeeding decades the key role of trophoblast in placenta formation was discovered, and the decidua became neglected in later comparative studies. Nevertheless, at the present time trophoblast-decidual interaction is regarded as an extremely important feature of placental development in both primates and rodents, and Huxley can therefore rightfully be considered as an early pioneer in placental research.

Cytotoxic effects of tumour necrosis factor (TNF)-alpha and interferon-gamma on cultured human trophoblast are modulated by fibronectin

Tumour necrosis factor (TNF)-alpha and interferon (IFN)-gamma, produced by maternal inflammatory cells, may compromise trophoblast survival at the trophoblast-maternal interface and notably in the placental bed which is invaded by trophoblast. Extracellular matrix components, e.g. fibronectin, may enhance trophoblast survival. A possible protective effect of fibronectin against toxic effects of TNF-alpha and IFN-gamma was investigated in cultured trophoblasts isolated from six human term placentas, grown on uncoated and fibronectin-coated plastics. IFN-gamma and increasing doses of TNF-alpha resulted in decreasing viability of trophoblast on uncoated as well as fibronectin-coated dishes, as shown by 3-[4, 5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide (MTT) assays, but for each TNF/IFN treatment condition viability on fibronectin was higher (P < 0.001). Epidermal growth factor (EGF), a growth factor reported to protect against TNF-alpha/IFN-gamma induced toxicity, resulted in further increased viability, but not if IFN-gamma was included in the treatment. EGF caused increased fibronectin secretion into the medium (P < 0.001), and double cytokeratin/fibronectin immunostaining confirmed the trophoblastic nature of fibronectin secreting cells. We conclude that fibronectin increases viability, but does not completely abolish the cytotoxic action of TNF-alpha and IFN-gamma on trophoblast. The protective effect of EGF may be related to stimulation of fibronectin secretion by trophoblast.

Pathogenesis of fetal hypomineralization in diabetic rats: evidence for delayed bone maturation

There is some evidence that fetuses of diabetic rats (FDR) are hypomineralized. To explore the pathogenic role of decreased maternal duodenal Ca absorption, fetal hypotrophy, and decreased placental calbindin-D9K, respectively, spontaneously diabetic rats fed a 1.0% Ca diet were compared with diabetic rats treated with 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] (15 ng/ 100 g) during week 3 of pregnancy, which restored duodenal calbindin-D9K concentrations to normal; with nondiabetic rats semistarved during week 3, which resulted in similar fetal hypotrophy; and with nondiabetic rats fed high cation diets (1.5% Ca-1.5% Sr and 1.5% Ca-3.5% Sr) during week 3, the latter of which repressed duodenal and placental calbindin-D9K toward concentrations measured in diabetic rats. In addition, fetal tibiae were studied histologically. Ca content was lower in 21.5-d-old FDR than in control fetuses. FDR had lower plasma osteocalcin (OC) levels and, on histomorphometry, increased hypertrophic cartilage width, indicating retarded bone maturation. Maternal 1,25(OH)2D3 treatment did not change Ca content and hypertrophic cartilage width in FDR. Fetuses of semistarved rats had plasma OC levels and hypertrophic cartilage width comparable to those of control fetuses. Fetuses of rats fed the 1.5% Ca-3.5% Sr diet were more severely hypomineralized than FDR but had higher plasma OC than both FDR and control fetuses, compatible with fetal Ca deficiency. Whereas diabetic placentas showed weak but homogeneous staining of calbindin-D9K in the labyrinth on immunohistology, degenerative zones were present in placentas of rats fed the 1.5% Ca-3.5% Sr diet. Thus, there is no mineralization defect in FDR caused by disturbed maternal duodenal Ca absorption or transplacental Ca transport, but a delay in bone maturation that is unexplained by their lower body weight.

Renin-like immunoreactivity in uterus and placenta from normotensive and hypertensive pregnancies

OBJECTIVES

(1) To identify the distribution of renin-like immunoreactivity in placental bed, placenta-free uterine wall, placenta, fetal membranes, and intertwin membranes obtained from normal pregnancies and (2) to compare the findings in normal pregnancies with those in pregnancies complicated by various hypertensive disorders.

STUDY DESIGN

Biopsies were taken from 31 normotensive pregnant women, eight of whom had twin pregnancies, and from 28 women with various hypertensive disorders of pregnancy. The anti-human renal renin monoclonal antibody, F37.1A1, was used for immunostaining. Histological structures were identified with standard H&E and PAS techniques, supplemented with immunostaining using the specific cell markers CD68 and cytokeratin.

RESULTS

Renin-like immunoreactivity was found in cytokeratin immunolabelled placental syncytiotrophoblast, amnionic and glandular epithelium, but most consistently in CD68 immunolabelled maternal and fetal macrophages. The distribution of renin-like immunoreactivity throughout the pregnant uterus roughly parallelled reported renin concentrations in the various tissues, while its localization conforms also with that of cathepsin D. There were no obvious differences in renin-like immunolabelling between normotensive or hypertensive women. Renin-like immunoreactivity was particularly common in the atherotic lesions that are observed more often in pregnancies complicated with hypertensive disorders of pregnancy and/or intra-uterine growth restriction.

CONCLUSIONS

The data complement earlier findings showing that only two of four anti-renal renin monoclonal antibodies, both of which cross-react with cathepsin D, give a positive immunostaining in placental tissue. They question whether classical concepts on renin localisation in uteroplacental tissues all relate to one and the same enzyme. The demonstration of renin-like enzymes in different cell types, including macrophages, may explain the diversity of functions that has been attributed to uterine renin. There were no differences between tissues obtained from normotensive and hypertensive pregnancies, except for the consistent presence of renin-like immunoreactivity in atherotic lesions.

Interaction of interstitial trophoblast with placental bed capillaries and venules of normotensive and pre-eclamptic pregnancies

While endovascular trophoblast invasion of the human placental bed spiral arteries has been studied extensively, no information is available on the interaction between interstitially invading trophoblast and uterine capillaries and venules. Placental bed biopsies of eight normotensive and 15 pre-eclamptic patients were double-immunostained for cytokeratin and the endothelial marker CD31, providing satisfactory staining results in six and 10 biopsies, respectively. Interstitial trophoblast tissue density did not differ between the two series of biopsies, implying that this pathway of invasion is not impaired in pre-eclampsia. Both groups showed a similar incidence of approach of non-arterial vascular structures by perivascular trophoblast. Differences in CD31 staining intensity were noticed in different vascular cross-sections. Lower staining intensity was related to the presence of perivascular trophoblast. Because of the identity of CD31 with the platelet-endothelial cell adhesion molecule (PECAM)-1, the trophoblast-dependent downregulation of CD31 may play a role in the control of leukocytic traffic within the placental bed. The phenomena described in this paper did not show any difference between the normotensive and pre-eclamptic patients, implying that interaction of interstitial trophoblast with venous and capillary structures is not related to the pathogenesis of pre-eclampsia.

Immunolocalization of tumour necrosis factor-alpha (TNF-alpha) in the placental bed of normotensive and hypertensive human pregnancies

To identify tumour necrosis factor (TNF)-alpha immunopositive cells, third trimester human placental bed biopsies were selected from nine normotensive control women, 16 severely pre-eclamptic patients and seven patients with pre-existing hypertension with superimposed pre-eclampsia. In addition, five first and early second trimester specimens were included in the study. Immunostaining was performed with a mouse IgG1 monoclonal antibody (J1D9) reactive specifically with human TNF-alpha (1:300 ascitic fluid), using a biotin-streptavidin-peroxidase technique. Variable staining of stromal cells was noted in all biopsies. Specimens of early pregnancy showed marked immunostaining for TNF-alpha on proliferating tips of anchoring villi, invasive interstitial cytotrophoblast (but not the multinuclear giant cells), and endovascular trophoblast invading the spiral arteries. At term, weak staining was found in trophoblast incorporated within spiral artery walls. In biopsies from pre-eclamptic patients, spiral arteries without physiological change showed very little staining except in atherotic vessels where the infiltrated lipophages often showed intense immunolabelling. The marked presence of TNF-alpha in extravillous cytotrophoblast of young specimens is suggestive of a role in early invasion. Immunostaining of foam cells in non-invaded spiral arteries in pre-eclampsia at or near-term indicates a potential role of this cytokine in the development of atherotic lesions.

The endocrine pancreas in virgin and pregnant offspring of diabetic pregnant rats

Diabetes of the mother during pregnancy induces structural and functional adaptations in the fetal endocrine pancreas. We have previously shown in our experimental rat model, that the impact of this abnormal intra-uterine milieu leads, in the adult offspring, to a disturbance of the glucose homeostasis and to the development of gestational diabetes. The aim of the present work is to investigate wether these functional differences can be explained by structural differences at the level of the endocrine pancreas. Therefore the size and the structure of the endocrine pancreas, as well as the contribution of the insulin-, glucagon-, somatostatin- and PP-cells, were investigated morphometrically in the adult youngsters of mildly and of severely diabetic mothers, since both display a disturbed glucose tolerance but with divergent characteristics. Also the adaptation of their endocrine pancreas to pregnancy was measured and compared to that of a control pregnancy. In the offspring of mildly diabetic mothers, the size of the endocrine pancreas and the distribution of the islets of Langerhans are normal. Also the doubling of the endocrine mass during pregnancy is similar to controls. The high proportion of A-cells, especially in relation to a normal B-cell mass and the low amount of PP-cells, might play a role in the impairment of the insulin response in these animals and in the development of gestational diabetes. In the offspring of severely diabetic mothers a clear hypertrophy of the endocrine pancreas is noted, which is mainly due to the presence of numerous small islets and which does not increase further during pregnancy. In these animals, the size of the endocrine pancreas and of the B-cell mass have reached 'pregnant' values without pregnancy, which coincides with an exaggerated insulin output and peripheral insulin resistance, as during normal pregnancy. No further increase in islet mass is seen during pregnancy, which is associated with gestational diabetes.

Quantitative differences in arterial morphometry define the placental bed in preeclampsia

The purpose of this study was to quantitatively analyze normal and preeclamptic uteroplacental vasculature. Myometrial arteries from eight placental bed biopsies from uncomplicated term deliveries and 12 from proteinuric preeclampsia were characterized as uteroplacental, spiral, or basal arteries. Basal lumens within 0.2 mm radius and spiral/uteroplacental lumens within 0.4 mm radius were considered as the same artery. The biopsy area, lumen density, and arterial density (after correction for multiple lumens), lumen area, lumen perimeter, mean wall thickness, inflated diameter, and a slant factor, measuring the obliqueness of arterial transection, and ratios of lumen characteristics to mean wall thickness were analyzed. In preeclamptic cases, there were more basal lumens/mm2 and basal arteries/mm2 (P=.003, P=.03), and more spiral lumens/mm2 and spiral arteries/mm2 (P = .01, P = .03). Basal lumen area (P = .0003) and wall thickness (P = .007), and basal and spiral artery lumen perimeters and inflated diameters (for each, P = .0001, P = .048, respectively) and inflated diameter/wall ratios (P = .04, P = .05) were reduced compared with normal cases. Preeclamptic spiral and basal arteries are more tortuous or densely distributed than normal placental bed arteries, with smaller-caliber lumens and thicker walls. Failure of proper placentation may result in abnormal spatial anatomy in the placental bed. Alternatively, an anatomic variant of spiral and basal arteries may be more susceptible to hemodynamic stresses and endothelial damage and may predispose to preeclampsia.

Evaluation of trophoblast invasion in placental bed biopsies of the baboon, with immunohistochemical localisation of cytokeratin, fibronectin, and laminin

Biopsies of placentas (n = 21), placental bed (n = 17) and decidua (n = 26) of various gestation periods (30 to 140 days) were used to study trophoblast invasion in the baboon. Application of immunohistochemical staining for cytokeratin allowed proper identification of trophoblast. Earlier reports showing restricted trophoblast invasion in this species were confirmed by the finding that endovascular trophoblast was present in only one third of biopsies containing spiral arteries. Moreover, immunostaining for cytokeratin revealed that in several arteries only a few isolated trophoblastic cells were present, while the vessel had not undergone the normal physiological change. Trophoblast invasion could only be detected within decidual, but not in myometrial, segments of spiral arteries. Interstitial trophoblast invasion was very limited and multinuclear giant cells were absent. Immunohistochemical staining suggested a contribution of laminin to the fibrinoid deposition within the physiologically changed spiral arteries, while fibronectin was present intracellularly in the invaded trophoblast. Because of differences in the trophoblast invasion pattern, the baboon cannot be regarded as a satisfactory experimental model to explore results of inadequate endovascular trophoblast invasion which, in the human, leads to pregnancy complications such a preeclampsia.

Attachment and differentiation in vitro of trophoblast from normal and preeclamptic human placentas

OBJECTIVE

Trophoblast from preeclamptic patients shows impairment of various functions, including restricted invasive behavior of extravillous trophoblast. In this light the effect of different matrix components on attachment and differentiation of primary trophoblast cultures derived from normal and preeclamptic pregnancies was investigated.

STUDY DESIGN

Trophoblast was isolated from placentas of normotensive (n = 5) and preeclamptic patients (n = 5) and cultured up to 7 days on LabTek slides precoated with fibronectin, laminin, or vitronectin. Attachment was evaluated 24 hours after plating, the degree of syncytialization was evaluated, and slides were immunocytochemically stained for cytokeratin, vimentin, human chorionic gonadotropin, and human placental lactogen.

RESULTS

Trophoblast from placentas of preeclamptic patients showed a significantly lower attachment on fibronectin and vitronectin compared with controls. Diminished multinuclear cell formation was found on uncoated and laminin-coated slides in preeclamptic cases. No difference was found in the percentage of human chorionic gonadotropin- and human placental lactogen-positive cells between groups.

CONCLUSIONS

Lower trophoblast attachment on fibronectin and vitronectin was observed in preeclamptic pregnancies, which may reflect differences in expression of matrix receptors. Lower syncytialization of trophoblast in this group indicates an intrinsic defect in differentiation, but otherwise no differences were found in differentiation between normotensive and preeclamptic patients.

Renin-like immunoreactivity in human placenta and fetal membranes

Five antibodies that stained renin in the kidney were used to investigate the presence of renin in human placenta and fetal membranes. Despite a large number of experimental approaches to enhance penetration of the immunoglobulins, only two of them showed immunostaining in placenta and fetal membranes. Staining was found in placental syncytiotrophoblast, the amnionic epithelium overlying the placenta, and in glandular epithelial cells present in the decidua adhering to the fetal membranes. It was most consistent, however, in a small infiltrating cell type dispersed through the fetoplacental layers. The two antibodies that revealed immunostaining in all preparations showed high affinity cross-reactivity with cathepsin D. Among other, less plausible, explanations, this raises the possibility that the bulk of 'renin' found in placenta and fetal membranes is not identical to renal renin, but may be cathepsin D or a substance related to both cathepsin D and renin.

Identification of 'renin'-containing cells in the choriodecidua

Chorionic trophoblast, decidual cells, and macrophages have all been named as the site of renin in the placental membranes. To establish more clearly the nature of the renin-containing cells in the placental membranes, double immunostaining techniques were used to stain renin and specific cell markers in the same tissue sections. Cytokeratin was selected as an ectodermal cell marker and CD68 as a cytoplasmic macrophage marker. Cross-binding between antibodies was prevented by blocking species-related binding sites between the first and second sequence of the double-immunostaining procedures and by using highly selective immunostaining techniques in the second sequence. The results clearly show renin immunostaining in CD68-positive macrophages and not in cytokeratin-positive trophoblast. The anti-renal renin monoclonal antibody showed high affinity cross-reactivity with cathepsin D, another aspartic proteinase that can release angiotensin I from angiotensinogen. This should be seen in the context of earlier findings that only two of four anti-renal renin monoclonal antibodies showed staining in uterine and placental tissues and both cross-reacted with cathepsin D. The results indicate that differentiation between renin and cathepsin D and, possibly, other substances with shared properties and epitope homology deserves more attention than it has received thus far.

The endocrine pancreas in nonimmune hydrops fetalis

OBJECTIVE

Our purpose was to compare the endocrine pancreas of hydropic infants of immune and nonimmune origin.

STUDY DESIGN

A quantitative morphologic study was performed on the pancreas in 10 infants with immune and nonimmune hydrops. The volume density of the endocrine pancreas in the gland was calculated, as was the numerical density of the endocrine cells in the islets. The percentage of the different cell types was measured on immunohistochemical stained slides. Ten normal infants were used as controls.

RESULTS

An increased amount of endocrine tissue and an increased total number of islet cells of immune and nonimmune origin is present in hydropic infants. However, an increased proportion of the insulin-producing B cells is not present.

CONCLUSIONS

The endocrine pancreas in hydrops fetalis of immune and nonimmune origin is equal, excluding hemolysis as the stimulating factor for equilibrated islet overgrowth. Metabolic stimuli, as seen in infants of diabetic mothers, are probably not involved, because they preferentially stimulate the insulin-producing B cells.

Tibial shaft fractures with an intact fibula

The effect of several factors on the healing rates of tibial shaft fractures with an intact fibula were examined. Those found to adversely affect healing rates included: 1. Open fractures; 2. Oblique or comminuted fractures; 3. High-velocity injuries; 4. Angulation in the sagittal plane; 5. Displacement. No other factors examined were associated with delayed union. The predictive values for delayed union are estimated for each of these factors in isolation and in combination.

The intact fibula

The notes and radiographs of 281 adult tibial shaft fractures were reviewed. In 17 per cent there was an intact fibula. Delayed union rates were lower when the fibula remained intact, thus confirming that this is a good prognostic indicator. This fracture is caused by less severe trauma than fractures where both bones are broken. It is rare over the age of 30 years.

Placental bed spiral arteries in the hypertensive disorders of pregnancy

OBJECTIVE

The investigation of the histology of the placental bed spiral arteries in normal pregnancy and in pregnancies complicated by hypertension, with or without proteinura.

DESIGN

An observational study, based on women having caesarean sections for clinical reasons.

SUBJECTS

17 normal pregnant women, 43 with gestational hypertension, of whom 39 had proteinuria, 17 with chronic hypertension, of whom 6 had proteinuria, and 5 with unclassified hypertension.

INTERVENTIONS

Placental bed biopsies obtained during caesarean section.

MAIN OUTCOME MEASURES

Histological appearance of sections stained with haematoxylin and eosin PAS and Lendrum's MSB.

RESULTS

Biopsies containing spiral arteries were obtained from 6 normotensive and 44 hypertensive women. Trophoblastic invasion was present in 5 of the 6 normotensive biopsies but absent in the majority of those with hypertension. Subintimal proliferation was seen in all the normotensive biopsies but in only 8 of 28 from those with gestational hypertension and proteinuria. Other features seen predominantly or only in the hypertensive biopsies, in order of frequency, were medial hyperplasia, fibrin deposits, acute atherosis, endothelial vacuolation and thrombosis.

CONCLUSION

Absence of physiological changes may not be peculiar to preeclampsia but may be associated or even a result of various forms of hypertension in pregnancy. Spiral arteries show a spectrum of changes in hypertensive pregnancies that do not appear to bear a clear-cut relation to the clinical signs.