Elastic tissue in uterine blood vessels

Cyclic processes in the uterine tubes, endometrium, myometrium, and cervix: pathways and perturbations

This review leads the 2023 Call for Papers in MHR: 'Cyclical function of the female reproductive tract' and will outline the complex and fascinating changes that take place in the reproductive tract during the menstrual cycle. We will also explore associated reproductive tract abnormalities that impact or are impacted by the menstrual cycle. Between menarche and menopause, women and people who menstruate living in high-income countries can expect to experience ∼450 menstrual cycles. The primary function of the menstrual cycle is to prepare the reproductive system for pregnancy in the event of fertilization. In the absence of pregnancy, ovarian hormone levels fall, triggering the end of the menstrual cycle and onset of menstruation. We have chosen to exclude the ovaries and focus on the other structures that make up the reproductive tract: uterine tubes, endometrium, myometrium, and cervix, which also functionally change in response to fluctuations in ovarian hormone production across the menstrual cycle. This inaugural paper for the 2023 MHR special collection will discuss our current understanding of the normal physiological processes involved in uterine cyclicity (limited specifically to the uterine tubes, endometrium, myometrium, and cervix) in humans, and other mammals where relevant. We will emphasize where knowledge gaps exist and highlight the impact that reproductive tract and uterine cycle perturbations have on health and fertility.

Endovascular trophoblast and preeclampsia: A reassessment

Since the earliest report on impaired spiral artery remodelling in preeclamptic human pregnancies, numerous studies have been devoted to possible mechanisms of impaired trophoblast invasion. A better knowledge of early uteroplacental blood flow has provided a physiological context for the processes of spiral artery invasion and associated remodelling, revealing a closely timed relationship between increasing flow and early steps in vascular remodelling. Concerning the impaired trophoblast invasion in preeclampsia, it has also to be considered that impaired invasion not only concerns invasion depth per se, but also the extension of this deep invasion from the central towards the more lateral spiral arteries of the placental bed. Since also in preeclampsia the very central spiral arteries may be normally invaded, the existence of such spatial gradient provides a further dimension to the problem. A practical consequence is that frequently used rodent models, which show invasion of two or three spiral arteries only, may be less useful for studying this particular aspect of the disease. Amongst non-human primates, baboons and rhesus monkeys are 'shallow invaders', and only in some of the great apes deep trophoblast invasion and associated spiral artery remodelling occurs. A better knowledge of the evolutionary history of deep invasion and its possible selective benefit might ultimately improve our understanding of failed deep invasion and impaired spiral artery remodelling in preeclampsia.

Trophoblast invasion

The establishment of a pregnancy depends upon mechanisms of forming close contacts between embryonic/fetal and maternal tissues. The starting point is the attachment of the blastocyst to the uterine wall, and this critical step is followed by a series of different morphogenetic events leading to placentation. These processes depend on the invasive properties of extra-embryonic trophectoderm-derived cells that show their highest expression in species with haemochorial placentation, i.e. Insectivores, rodents, and primates including the human. In this review we will concentrate upon the human with occasional reference to other species.

Oxygen as modulator of trophoblast invasion

At the time of blastocyst implantation the uterine spiral arteries have already undergone morphological changes in the absence of any extravillous trophoblast invasion. Only 2 weeks after implantation, extravillous trophoblast cells develop and come into first contact with decidual tissues. Invading through the decidual interstitium, extravillous trophoblasts potentially reach and transform spiral arteries into uteroplacental arteries. Spiral arterial erosion starts at about mid-first trimester, whereas flow of maternal blood into the intervillous space is continuously established only at the beginning of the second trimester. One key regulator of the number of extravillous trophoblasts is oxygen. The steep gradient in oxygen concentration within the first trimester placenta is diminished with the onset of maternal blood flow. This gradient is used by the trophoblast to generate a large number of invasive cells to adapt the arterial vasculature in the placental bed to the growing needs of the fetus. Changes in oxygen concentrations or other factors leading to alterations in the rates of proliferation and/or apoptosis of extravillous trophoblast clearly impact on the remodelling of the vessels. The respective consequences of a failure in trophoblast invasion are growth restrictions of the baby and perhaps other pregnancy complications.

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.

The Openings of Uteroplacental Vessels With Villous Infiltration at Different Gestational Ages

Context.—The number of uteroplacental vessels flowing into the intervillous space in mature placentas has been reported in some studies to increase and in others to decrease. Both villous infiltration and proliferation in the vessels have been neglected in histologic examinations and need to be studied.

Objective.—To clarify these conflicting findings regarding villous infiltration and proliferation in the uteroplacental vessels.

Design.—A retrospective study was done using placental sections of different gestational ages. The openings of the vessels in each section were counted, noting if they were with or without villous infiltration. The frequency of openings per section was calculated, and the findings were grouped by gestational age.

Results.—The frequency of total openings was significantly lower in the 41 to 37 weeks group (1.2) than in the 36 to 30 weeks group (2.0), the 29 to 20 weeks group (2.2), and the 19 to 13 weeks group (2.4) (P < .001). The frequency of openings with villous infiltration decreased similarly in mature placentas. Chorionic villi infiltrated the openings and proliferated in uteroplacental vessels. Differentiation between arteries and veins was difficult in the basal plate, because all vessels had veinlike structures.

Conclusions.—This decreasing frequency of openings in mature placentas suggests that the amount of intervillous blood flow is limited in full-term and postterm pregnancy. Villous infiltration into the vessels is considered a normal finding with gestation and can provide trophoblast for uteroplacental arteries. The relationship between placental development and villous proliferation in the vessels is presented.

Endovascular trophoblast invasion: implications for the pathogenesis of intrauterine growth retardation and preeclampsia

Maternal uteroplacental blood flow increases during pregnancy. Altered uteroplacental blood flow is a core predictor of abnormal pregnancy. Normally, the uteroplacental arteries are invaded by endovascular trophoblast and remodeled into dilated, inelastic tubes without maternal vasomotor control. Disturbed remodeling is associated with maintenance of high uteroplacental vascular resistance and intrauterine growth restriction (IUGR) and preeclampsia. Herein, we review routes, mechanisms, and control of endovascular trophoblast invasion. The reviewed data suggest that endovascular trophoblast invasion involves a side route of interstitial invasion. Failure of vascular invasion is preceded by impaired interstitial trophoblast invasion. Extravillous trophoblast synthesis of nitric oxide is discussed in relation to arterial dilation that paves the way for endovascular trophoblast. Moreover, molecular mimicry of invading trophoblast-expressing endothelial adhesion molecules is discussed in relation to replacement of endothelium by trophoblast. Also, maternal uterine endothelial cells actively prepare endovascular invasion by expression of selectins that enable trophoblast to adhere to maternal endothelium. Finally, the mother can prevent endovascular invasion by activated macrophage-induced apoptosis of trophoblast. These data are partially controversial because of methodological restrictions associated with limitations of human tissue investigations and animal studies. Animal models require special care when extrapolating data to the human due to extreme species variations regarding trophoblast invasion. Basal plates of delivered placentas or curettage specimens have been used to describe failure of trophoblast invasion associated with IUGR and preeclampsia; however, they are unsuitable for these kinds of studies, since they do not include the area of pathogenic events, i.e., the placental bed.

On an anatomical basis for the increase in birth weight in second and subsequent born children

OBJECTIVE

Structural changes of the spiral arteries needed for the pregnancy do not completely resolve following parturition. We tested the hypothesis that these anatomical changes are related to the number of previous pregnancies.

METHODS

Video image analysis was performed on Masson-stained sections from 28 hysterectomy specimens, examining the proportion of non-muscular tissue within the spiral arterial walls. Semi-quantitative analysis of changes of the internal elastic lamina was performed on orcein-stained sections. The extent of changes was tested for correlation with parity using regression analysis.

RESULTS

Duplication and fragmentation of the internal elastic lamina increased with increasing parity (P=0.019) with differences between nulliparity and parity 1, 2, 3 or 4 but not between other parity pairings. The proportion of non-muscular tissue increased with increasing parity (P=0.010).

CONCLUSIONS

These results suggest that pregnancy results in permanent anatomical changes in the spiral arteries that may modify subsequent vascular remodelling in the next pregnancy. This could provide an anatomical basis to explain the epidemiological data showing an increasing birth weight with increasing parity, particularly of the second born.

Endometrial arteriogenesis: vascular smooth muscle cell proliferation and differentiation during the menstrual cycle and changes associated with endometrial bleeding disorders

The cyclical regrowth of the human endometrial vasculature every 28 days following menstruation provides an excellent opportunity for studying arteriogenesis in a human tissue. Despite this, very little has been published to date about temporal or spatial changes in endometrial arteriolar structure or function. Immunohistochemical studies using vascular smooth muscle cell (VSMC) differentiation markers have identified spatially organised differences in VSMC phenotype. However, these have not significantly increased our understanding of how or when arteriogenesis occurs. Endometrial VSMC proliferation continues at a steady rate throughout the cycle, increasing in the specialised spiral arterioles in the mid and late secretory phases. Although estrogen and progesterone play a dominant role in regulating endometrial growth and regression, their direct involvement in arteriogenesis is less clear. Estrogen and progesterone receptors have been reported in endometrial VSMC, although heterogeneity of expression occurs. The angiopoietin/Tie axis has been investigated in endometrium, although the results of 3 studies published to date are contradictory, making conclusions about a role in arteriogenesis problematic. Abnormalities of arteriogenesis may play a role in disorders such as menorrhagia and breakthrough bleeding in contraceptive and hormone replacement therapy users. There is evidence that VSMC proliferation is reduced in spiral arterioles of women with menorrhagia, along with reduced pulsatility index of the uterine artery as shown by Doppler ultrasound. In women taking progestin-only contraception, endometrial perivascular alpha smooth muscle actin is reduced in those who suffer from breakthrough bleeding compared to those that don't. Considerable work is still required to elucidate when in the cycle, where in the tissue, and what mechanisms regulate endometrial arteriogenesis.

Maternal risk factors in fetal alcohol syndrome: provocative and permissive influences

We present an hypothesis integrating epidemiological, clinical case, and basic biomedical research to explain why only relatively few women who drink alcohol during pregnancy give birth to children with alcohol-related birth defects (ARBDs), in particular, Fetal Alcohol Syndrome (FAS). We argue that specific sociobehavioral risk factors, e.g., low socioeconomic status, are permissive for FAS in that they provide the context for increased vulnerability. We illustrate how these permissive factors are related to biological factors, e.g., decreased antioxidant status, which in conjunction with alcohol, provoke FAS/ARBDs in vulnerable fetuses. We propose an integrative heuristic model hypothesizing that these permissive and provocative factors increase the likelihood of FAS/ARBDs because they potentiate two related mechanisms of alcohol-induced teratogenesis, specifically, maternal/fetal hypoxia and free radical formation.

Quantitative uterine histology during the menstrual cycle in relation to measured menstrual blood loss

Endometrium and myometrium were collected at hysterectomy from 42 women with measured menstrual blood loss (range 4-840 ml). The specimens, obtained throughout the menstrual cycle, showed no evidence of organic disease on histological examination. The volume fraction occupied by arteries at the myometrial-endometrial junction, and by glandular tissue throughout the endometrium was estimated with a point counting technique. The index of volume-to-surface ratio of endometrial glandular tissue was examined by a combination of point counting and linear intercept methods. No correlation was found between menstrual blood loss and endometrial and myometrial arterial density, endometrial glandular density and volume-to-surface ratio. Consequently, menorrhagia, occurring in the absence of obvious pathology, does not appear to result from an excessive number of arteries of from abnormal glandular distribution.

Uteroplacental arterial changes related to interstitial trophoblast migration in early human pregnancy

Morphometric and statistical techniques were used to assess the relation of myometrial interstitial trophoblast to the uteroplacental vasculature in 27 intact hysterectomy specimens ranging from 8 to 18 weeks' gestation. It was found that the volume density of cytotrophoblast in the myometrium and in particular the proximity of such trophoblast to the placental bed spiral arteries correlated significantly with morphological alterations in these vessels. The changes included swelling of endothelium, hypertrophy of individual medial smooth muscle cells, and oedema and disruption of the architecture of the vessel wall as a time-related continuum. Some of the changes, such as swollen endothelium and basophilia of medial smooth muscle cells were noted also in spiral arteries in the non-placental bed endometrium but to a considerably less extent than in the placental bed. Intimal vacuolation was common to placental bed and non-placental bed arteries, increased with gestational age and can be considered as a non-specific feature. The migration of endovascular trophoblast into the myometrial spiral arteries in the second trimester occurred only when these arteries had been considerably altered in their morphology. These findings indicate that migratory interstitial cytotrophoblast probably has a role to play in the preparation of the myometrial segments of the uteroplacental arteries for the second wave of endovascular trophoblast migration that occurs in the second trimester of human pregnancy.

Uteroplacental vasculature

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