Preeclampsia: No longer solely a pregnancy disease

Immunological regulation and the role of autophagy in preeclampsia

Autophagy is a bulk degradation system that maintains cellular homeostasis by producing energy and/or recycling excess proteins. During early placentation, extravillous trophoblasts invade the decidua and uterine myometrium, facing maternal immune cells, which participate in the immune suppression of paternal and fetal antigens. Regulatory T cells will likely increase in response to a specific antigen before and during early pregnancy. Insufficient expansion of antigen-specific Treg cells, which possess the same T cell receptor, is associated with the pathophysiology of preeclampsia, suggesting sterile systemic inflammation. Autophagy is involved in reducing inflammation through the degradation of inflammasomes and in the differentiation and function of regulatory T cells. Autophagy dysregulation induces protein aggregation in trophoblasts, resulting in placental dysfunction. In this review, we discuss the role of regulatory T cells in normal pregnancies. In addition, we discuss the association between autophagy and regulatory T cells in the development of preeclampsia based on reports on the role of autophagy in autoimmune diseases.

Serum protein profile analysis via label-free quantitation proteomics in patients with early-onset preeclampsia

BACKGROUND

Preeclampsia (PE) is a serious pregnancy complication, resulting in potentially life-threatening conditions for both mother and foetus. It is worth noting that early-onset PE has become a great challenge for clinicians due to its complex manifestation, rapid progression and serious complications. This study aims to investigate differential serum proteome profiles in patients with early-onset PE.

METHODS

Each serum sample was separated using a nanoliter flow rate Easy-nLC chromatography system. Then the samples were analysed by mass spectrometry. Bioinformatics analyses were conducted to analyse the functional categories or signal transduction pathways for differentially abundant proteins. Key proteins identified by mass spectrometry were verified by ELISA.

RESULTS

We found 30 and 34 proteins were upregulated and downregulated in early-onset PE patients (n = 3) vs controls (n = 3), respectively. Functional enrichment analysis revealed differentially expressed proteins related to the immune response and regulation of peptidase activity. ELISA confirmed that there were lower CSH1 levels and higher LPA concentrations in the serum samples of early-onset PE patients (n = 22) than in healthy controls (n = 19) (p < 0.05 for CSH1 and p < 0.001 for LPA).

CONCLUSIONS

This study revealed the critical features of serum proteins in early-onset PE patients. LPA and CSH1 may serve as biomarkers for early-onset PE diagnosis and therapy.

Stroke vs. Preeclampsia: Dangerous Liaisons of Hypertension and Pregnancy

Stroke during pregnancy and preeclampsia are two distinct but interrelated medical conditions, sharing a common denominator-blood control failure. Along with cardiovascular diseases, diabetes, dyslipidemia, and hypercoagulability, hypertension is undoubtedly a major risk factor associated with stroke. Even though men have higher age-specific stroke rates, women are facing higher life-long stroke risk, primarily due to longer life expectancy. Sex hormones, especially estrogen and testosterone, seem to play a key link in the chain of blood pressure control differences between the genders. Women affected with stroke are more susceptible to experience some atypical stroke manifestations, which might eventually lead to delayed diagnosis establishment, and result in higher morbidity and mortality rates in the population of women. Preeclampsia is a part of hypertensive disorder of pregnancy spectrum, and it is common knowledge that women with a positive history of preeclampsia are at increased stroke risk during their lifetime. Preeclampsia and stroke display similar pathophysiological patterns, including hypertension, endothelial dysfunction, dyslipidemia, hypercoagulability, and cerebral vasomotor reactivity abnormalities. High-risk pregnancies carrying the burden of hypertensive disorder of pregnancy have up to a six-fold higher chance of suffering from stroke. Resemblance shared between placental and cerebral vascular changes, adaptations, and sophisticated auto-regulatory mechanisms are not merely coincidental, but they reflect distinctive and complex cardiovascular performances occurring in the maternal circulatory system during pregnancy. Placental and cerebral malperfusion appears to be in the midline of both of these conditions; placental malperfusion eventually leads to preeclampsia, and cerebral to stoke. Suboptimal performances of the cardiovascular system are proposed as a primary cause of uteroplacental malperfusion. Placental dysfunction is therefore designated as a secondary condition, initiated by the primary disturbances of the cardiovascular system, rather than an immunological disorder associated with abnormal trophoblast invasion. In most cases, with properly and timely applied measures of prevention, stroke is predictable, and preeclampsia is a controllable condition. Understanding the differences between preeclampsia and stroke in pregnancy is vital for healthcare providers to enhance their clinical decision-making strategies, improve patient care, and promote positive maternal and pregnancy outcomes. Management approaches for preeclampsia and stroke require a multidisciplinary approach involving obstetricians, neurologists, and other healthcare professionals.

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

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

The Autophagy-Lysosomal Machinery Enhances Cytotrophoblast–Syncytiotrophoblast Fusion Process

Poor placentation is closely related with the etiology of preeclampsia and may impact fetal growth restriction. For placental developmental growth, we have demonstrated that dysregulation of autophagy, a key mechanism to maintain cellular homeostasis, in trophoblasts contributes to the pathophysiology of preeclampsia, a severe pregnancy complication, associated with poor placentation. It remains, however, unknown whether autophagy inhibition affects trophoblast syncytialization. This study evaluated the effect of autophagy in an in vitro syncytialization method using BeWo cells and primary human trophoblasts (PHT). In this study, we observed that autophagic activity decreased in PHT and BeWo cells during syncytialization. This decreased activity was accompanied by downregulation of the transcription factor, TFEB. Next, bafilomycin A1, an inhibitor of autophagy via suppressing V-ATPase in lysosomes, inhibited hCG production, CYP11A1 expression (a marker of differentiation), p21 expression (a senescence marker), and cell fusion in BeWo cells and PHT cells. Finally, LLOMe, an agent inducing lysosomal damage, also inhibited syncytialization and led to TFEB downregulation. Taken together, the autophagy-lysosomal machinery plays an important role in cytotrophoblast fusion, resulting in syncytiotrophoblasts. As autophagy inhibition contributed to the failure of differentiation in cytotrophoblasts, this may result in the poor placentation observed in preeclampsia.

Preeclampsia and Fetal Congenital Heart Defects

Endothelial dysfunction, impaired implantation and placental insufficiency have been identified as mechanisms behind the development of pre-eclampsia, resulting in angiogenic factors' alteration. Angiogenic imbalance is also associated with congenital heart defects, and this common physiologic pathway may explain the association between them and pre-eclampsia. This review aims to understand the physiology shared by these two entities and whether women with pre-eclampsia have an increased risk of fetal congenital heart defects (or the opposite). The present research has highlighted multiple vasculogenic pathways associated with heart defects and preeclampsia, but also epigenetic and environmental factors, contributing both. It is also known that fetuses with a prenatal diagnosis of congenital heart disease have an increased risk of several comorbidities, including intrauterine growth restriction. Moreover, the impact of pre-eclampsia goes beyond pregnancy as it increases the risk for following pregnancies and for diseases later in life in both offspring and mothers. Given the morbidity and mortality associated with these conditions, it is of foremost importance to understand how they are related and its causative mechanisms. This knowledge may allow earlier diagnosis, an adequate surveillance or even the implementation of preventive strategies.

A Review of Research Progress of Pregnancy with Twins with Preeclampsia

Preeclampsia has a significant long-term effect on the health of both mothers and babies. Preeclampsia-related pregnancy complications increase the morbidity and mortality of pregnant women and their fetuses by 5-8%. The recent advancement of assisted reproductive technology, combined with a rise in the number of elderly pregnant women, has resulted in pregnancy incidence with twins. Twins pregnant women have a 2-3 times greater risk of developing preeclampsia than singleton pregnant women, and it happens sooner and progresses faster. It is more severe and may appear in an atypical way. End-organ damage, such as renal failure, stroke, cardiac arrest, pulmonary edema, placental abruption, and cesarean section, are related maternal complications. Fetal growth retardation, stillbirth, and premature delivery with obstetric signs are all fetal complications. According to studies, all multiple pregnancies can take low-dose aspirin (60-150 mg) to minimize the risk of preeclampsia. To improve pregnancy outcomes and reduce the inherent risk of pregnancy with twins, twins should be handled as a high-risk pregnancy and treated differently than singletons. The literature on twin pregnancy with preeclampsia is the subject of this review. It will examine the current state of research on preeclampsia in pregnancy with twins, including the occurrence, diagnosis, and pathophysiological process. Moreover, the effect of pregnancy with twins on the perinatal outcome and pregnancy management of pregnancy with twins, including blood pressure management and preeclampsia prevention and treatment, is examined in this literature review. The goal is to figure out what kind of diagnosis and care you may need.

Effect of Iodine and Selenium on Proliferation, Viability, and Oxidative Stress in HTR-8/SVneo Placental Cells

Adequate maternal micronutrition is vital for placental formation, fetal growth, and development. Oxidative stress adversely affects placental development and function and an association between deficient placental development, oxidative stress, and micronutrient deficiency has been observed. Selenium and iodine are two essential micronutrients with antioxidant properties. Epidemiological studies have shown that poor micronutrient status in pregnant women is associated with a higher incidence of pregnancy complications. The aim of this study was to determine how selenium, iodine, and their combination impact oxidative stress in placental trophoblast cells. HTR8/SVneo extravillous trophoblasts were supplemented with a concentration range of organic and inorganic selenium, potassium iodide, or their combination for 24 h. Oxidative stress was then induced by treating cells with menadione or H₂O₂ for 24 h. Cell viability and lipid peroxidation as the biomarker of oxidative stress were assessed at 48 h. Both menadione and H₂O₂ reduced cell viability and increased lipid peroxidation (P < 0.05). Greater cell viability was found in selenium-supplemented cells when compared with vehicle treated cells (P < 0.05). Selenium and iodine supplementation separately or together were associated with lower lipid peroxidation compared with vehicle control (P < 0.05). Supplementation with the combination of selenium and iodine resulted in a greater reduction in lipid peroxidation compared with selenium or iodine alone (P < 0.05). Oxidative stress negatively impacts trophoblast cell survival and cellular integrity. Selenium and iodine protect placental trophoblasts against oxidative stress. Further research is warranted to investigate the molecular mechanisms by which selenium and iodine act in the human placenta.

Amnion-Derived Mesenchymal Stem Cell Exosomes-Mediated Autophagy Promotes the Survival of Trophoblasts Under Hypoxia Through mTOR Pathway by the Downregulation of EZH2

Human amnion-derived mesenchymal stem cells (AD-MSCs) have been reported as a promising effective treatment to repair tissue. Trophoblast dysfunction during pregnancy is significantly involved in the pathogenesis of preeclampsia (PE). To understand how AD-MSCs regulated trophoblast function, we treated trophoblasts with AD-MSC-derived exosomes under hypoxic conditions. The treatment markedly enhanced the trophoblast proliferation and autophagy. Furthermore, significant decrease of EZH2 levels and inactivation of mTOR signaling were observed in AD-MSC exosomes-treated trophoblasts. Consistent with these findings, overexpression of EZH2 activated the mTOR signaling in trophoblasts, and reduced the autophagy and survival of trophoblasts, even in the presence of AD-MSC-derived exosomes. In addition, EZH2 inhibition exhibited the same trophoblast autophagy-promoting effect as induced by AD-MSC-derived exosomes, also accompanied by the inactivation of mTOR signaling. Importantly, when EZH2 was overexpressed in trophoblasts treated with PQR620, a specific mTOR signaling inhibitor, the autophagy and proliferation in trophoblasts were decreased. Studies on human placental explants also confirmed our findings by showing that the expression levels of EZH2 and mTOR were decreased while the autophagy-associated protein level was increased by AD-MSC-derived exosome treatment. In summary, our results suggest that EZH2-dependent mTOR signaling inactivation mediated by AD-MSC-derived exosomes is a prerequisite for autophagy augmentation in hypoxic trophoblasts.

Is snoring during pregnancy a predictor of later life obstructive sleep apnoea? A case-control study

BACKGROUND

Obstructive sleep apnoea (OSA) appears common in pregnancy. Complications of pregnancy such as gestational diabetes and hypertension predispose women to cardiometabolic disease in later life. It is unknown if snoring during pregnancy is a risk marker for later-life OSA.

METHODS

We analysed data from N = 897 women in the Sleep Apnea Global Interdisciplinary Consortium (SAGIC), which recruited patients attending sleep clinics at 11 sites. There were 577 cases with current OSA and 320 controls. Cases were further categorised into mild, moderate, and severe OSA based on apnoea-hypopnoea index. Retrospective self-report of snoring during pregnancy was the exposure of interest and was reported by 2.9% of cases and 3.4% of controls.

RESULTS

Multinomial regression demonstrated that snoring during a previous pregnancy was not significantly associated with mild (OR 0.34, 95% CI 0.09-1.25, p = 0.10), moderate (OR 0.69, 95% CI 0.21-2.19, p = 0.52), or severe OSA (OR 1.86, 95% CI 0.77-4.48, p = 0.17) compared to no snoring during pregnancy. Results were unchanged after adjustment for age, body mass index, and ethnicity. 79% of women reported current snoring but all who snored during pregnancy reported current snoring.

CONCLUSIONS

Women who snore during pregnancy continue snoring in later-life but do not appear more likely to develop OSA. These findings are limited by self-reported data, recall bias, and small numbers of women who reported snoring during pregnancy. A prospective study with objective measurement of sleep and snoring during pregnancy is needed to examine the links between sleep disorders in pregnancy with health in later life.

A Review of the Potential Interaction of Selenium and Iodine on Placental and Child Health

A healthy pregnancy is important for the growth and development of a baby. An adverse pregnancy outcome is associated with increased chronic disease risk for the mother and offspring. An optimal diet both before and during pregnancy is essential to support the health of the mother and offspring. A key mediator of the effect of maternal nutrition factors on pregnancy outcomes is the placenta. Complicated pregnancies are characterized by increased oxidative stress in the placenta. Selenium and iodine are micronutrients that are involved in oxidative stress in placental cells. To date, there has been no comprehensive review investigating the potential synergistic effect of iodine and selenium in the placenta and how maternal deficiencies may be associated with increased oxidative stress and hence adverse pregnancy outcomes. We undertook a hypothesis-generating review on selenium and iodine, to look at how they may relate to pregnancy complications through oxidative stress. We propose how they may work together to impact pregnancy and placental health and explore how deficiencies in these micronutrients during pregnancy may impact the future health of offspring.

Association of CYP11B2 gene polymorphism with preeclampsia in north east of Iran (Khorasan province)

PURPOSE

Identification the genetic factors in preeclampsia (PE) are useful to increase the current knowledge of the pathophysiology of the disorder. The genetic factors implicated for all cases of PE remain to be determined. This study was aimed to investigate association between ADD1 1378G > T, AGTR2 1675G > A, AGTR1 1166A > C, NOS3 894 G > T and CYP11B2 -344C > T gene polymorphisms in Iranian women with PE.

MATERIAL AND METHODS

117 pregnant women with PE and 103 healthy women without affected previous pregnancy by PE were selected. Genomic DNA was extracted from peripheral blood and real-time PCR was performed to investigate the polymorphisms using a commercial kit.

RESULTS

There was a significant difference in CYP11B2 -344C > T gene polymorphism between case and control groups (P = 0.025). The odds ratio was 0.71 (CI 95% = 0.28-1.79). There were no statistical significant differences between other genetic polymorphisms.

CONCLUSION

Our results showed a significant association between CYP11B2 -344C > T gene polymorphism with PE. This finding suggests that mentioned polymorphism may be associated with susceptibility to PE at least in IRAN.

Blood pressure change across pregnancy in white British and Pakistani women: analysis of data from the Born in Bradford cohort

The incidence of gestational hypertension (GH) and pre-eclampsia (PE) is increasing. Use of blood pressure (BP) change patterns may improve early detection of BP abnormalities. We used Linear spline random-effects models to estimate BP patterns across pregnancy for white British and Pakistani women. Pakistani women compared to white British women had lower BP during the first two trimesters of pregnancy, irrespective of the development of GH or PE or presence of a risk factor. Pakistani compared to white British women with GH and PE showed steeper BP increases towards the end of pregnancy. Pakistani women were half as likely to develop GH, but as likely to develop PE than white British women. To conclude; BP trajectories differ by ethnicity. Because GH developed evenly from 20 weeks gestation, and PE occurred more commonly after 36 weeks in both ethnic groups, the lower BP up to the third trimester in Pakistani women resulted in a lower GH rate, whereas PE rates, influenced by the steep third trimester BP increase were similar. Criteria for diagnosing GH and PE may benefit from considering ethnic differences in BP change across pregnancy.

Acute Cardiac Effects of Severe Pre-Eclampsia

BACKGROUND

Pre-eclampsia with severe features (PEC) is a pregnancy-specific syndrome characterized by severe hypertension and end-organ dysfunction, and is associated with short-term adverse cardiovascular events, including heart failure, pulmonary edema, and stroke.

OBJECTIVES

The authors aimed to characterize the short-term echocardiographic, clinical, and laboratory changes in women with PEC, focusing on right ventricular (RV) systolic pressure (RVSP) and echocardiographic-derived diastolic, systolic, and speckle tracking parameters.

METHODS

In this prospective observational study, the authors recruited 63 women with PEC and 36 pregnant control patients.

RESULTS

The PEC cohort had higher RVSP (31.0 ± 7.9 mm Hg vs. 22.5 ± 6.1 mm Hg; p < 0.001) and decreased global RV longitudinal systolic strain (RVLSS) (-19.6 ± 3.2% vs. -23.8 ± 2.9% [p < 0.0001]) when compared with the control cohort. For left-sided cardiac parameters, there were differences (p < 0.001) in mitral septal e' velocity (9.6 ± 2.4 cm/s vs. 11.6 ± 1.9 cm/s), septal E/e' ratio (10.8 ± 2.8 vs. 7.4 ± 1.6), left atrial area size (20.1 ± 3.8 cm² vs. 17.3 ± 2.9 cm²), and posterior and septal wall thickness (median [interquartile range]: 1.0 cm [0.9 to 1.1 cm] vs. 0.8 cm [0.7 to 0.9 cm], and 1.0 cm [0.8 to 1.2 cm] vs. 0.8 cm [0.7 to 0.9 cm]). Eight women (12.7%) with PEC had grade II diastolic dysfunction, and 6 women (9.5%) had peripartum pulmonary edema.

CONCLUSIONS

Women with PEC have higher RVSP, higher rates of abnormal diastolic function, decreased global RVLSS, increased left-sided chamber remodeling, and higher rates of peripartum pulmonary edema, when compared with healthy pregnant women.

Autonomic Dysfunction in Preeclampsia: A Systematic Review

Background: Preeclampsia (PE) is a major obstetric complication that leads to severe maternal and fetal morbidity. Early detection of preeclampsia can reduce the severity of complications and improve clinical outcomes. It is believed that the autonomic nervous system (ANS) is involved in the pathogenesis of PE. We aimed to review the current literature on the prevalence and nature of ANS dysfunction in women with PE and the possible prognostic value of ANS testing in the early detection of PE.

Methods: Literature search was performed using Medline (1966–2018), EMBase (1947–2018), Google Scholar (1970–2018), BIOSIS (1926–2018), Web of science (1900–2018); CINAHL (1937–2018); Cochrane Library, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Methodology Register (1999–2018). Additionally, the reference lists of articles included were screened.

Results: A total of 26 studies were included in the present review presenting data of 1,854 pregnant women. Among these women, 453 were diagnosed with PE, 93.6% (424/453) of which displayed autonomic dysfunction. ANS function was assessed by cardiovascular reflex tests (n = 9), heart rate variability (n = 11), cardiac baroreflex gain (n = 5), muscle sympathetic nerve activity (MSNA) (n = 3), and biomarkers of sympathetic activity (n = 4). Overall, 21 studies (80.8%) reported at least one of the following abnormalities in ANS function in women diagnosed with PE compared to healthy pregnant control women: reduced parasympathetic activity (n = 16/21, 76%), increased sympathetic activity (n = 12/20, 60%), or reduced baroreflex gain (n = 4/5, 80%). Some of these studies indicated that pressor and orthostatic stress test may be useful in early pregnancy to help estimate the risk of developing PE. However, autonomic function tests seem not to be able to differentiate between mild and severe PE.

Conclusions: Current evidence suggests that autonomic dysfunction is highly prevalent in pre-eclamptic women. Among autonomic functions, cardiovascular reflexes appear to be predominantly affected, seen as reduced cardiac parasympathetic activity and elevated cardiac sympathetic activity. The diagnostic value of autonomic testing in the prediction and monitoring of autonomic failure in pre-eclamptic women remains to be determined.

Circulating soluble LR11, a differentiation regulator for vascular cells, is increased during pregnancy and exaggerated in patients with pre-eclampsia

BACKGROUND

Pre-eclampsia is a pregnancy-specific disease characterized by onset of hypertension and proteinuria, sometimes progressing into damaging other organs. Here, we investigated the pathological significance of the soluble fragment of LR11 (sLR11), a cell differentiation regulator, in comparison to circulating IL-6 and TNF-α, in pre-eclampsia.

METHODS

The study was conducted in a cross-sectional research design with fourteen pre-eclampsia patients and fifty healthy pregnant subjects. Pre-eclampsia was defined as hypertensive disorders in pregnancy at over 20 weeks of gestation with proteinuria.

RESULTS

Plasma levels of sLR11 as well as IL-6 in pre-eclampsia were increased compared with those in the healthy pregnant subjects at the first, the second, and the third trimester. Receiver operating characteristic analysis for the detection of pre-eclampsia among third-trimester subjects showed that the areas under the curves of sLR11 and IL-6 were equivalent. sLR11 and IL-6 correlated positively with TNF-α in healthy pregnant subjects. In the pre-eclampsia patients, there was neither a correlation between sLR11 and IL-6 nor between sLR11 and TNF-α.

CONCLUSIONS

sLR11 increases during pregnancy, with levels further exaggerated in pre-eclampsia, and may be related to the pathology of pre-eclampsia.

miR-141-5p regulate ATF2 via effecting MAPK1/ERK2 signaling to promote preeclampsia

OBJECTIVE

Preeclampsia is a pregnancy-specific syndrome characterized by hypertension and proteinuria. Impaired trophoblast invasion partly modulated by abnormal MAPK1/ERK2 signaling played important roles in the pathological process of preeclampsia. The objective of this study is to investigate miR-141-5p regulate ATF2 via effecting MAPK1/ERK2 signaling to promote preeclampsia.

STUDY DESIGN

The maternal placentae and clinical data of 30 patients with preeclampsia and 30 healthy pregnant women were collected in the Second Hospital of Shanxi Medical University from July 2015 to April 2016. Transcriptional levels of miR-141-5p in placentae were monitored using quantitative real-time reverse transcription-polymerase chain reaction. The target gene of miR-141-5p was analyzed with "TargetScanHuman Release 7.2″. To evaluate the pathways of this response, MAPK1 and ERK1/2 in placentae were detected using immunohistochemistry and Western Blot. Transfection experiment was used to verify the function of miR-141-5p regulating ATF2 to effect MAPK1/ERK2 signaling in JEG-3 cells.

RESULTS

miR-141-5p was significantly down-regulated in placentae of patients with preeclampsia, in comparison to the healthy pregnant women groups. There was no difference in MAPK1 expression between placentae of patients with preeclampsia and healthy pregnant women groups. While p-MAPK1 expression was lower in preeclampsia placentae, in comparison to the healthy pregnant women groups. Moreover, inhibition and activation experiments also validate the function of miR-141-5p in effecting p-MAPK1 level in JEG-3 cells. Bioinformatic analysis identified that ATF2 was a target gene of miR-141-5p, which was one DNA-binding protein to effect phosphatase DUSP1 transcription. DUSP1 effect MAPK1/ERK2 signaling in preeclampsia.

CONCLUSION

miR-141-5p up-regulated transcription factor ATF2 to promote phosphatase DUSP1 expression. DUSP1 expression reduces p-MAPK1 and ERK1/2 expression to promote preeclampsia.

Impact of vitamin D and vitamin D receptor on the trophoblast survival capacity in preeclampsia

BACKGROUND

Preeclampsia and intra-uterine growth restriction (IUGR) are major health problems during pregnancy affecting both mother and child. Defective placental development and failure of trophoblast differentiation during pregnancy are important aspects in the pathogenesis of both syndromes. Recent studies have shown that autophagy is involved in the trophoblast survival capacity. As vitamin D has a central role in many cellular processes, we studied the relation of vitamin D and autophagy in those processes of preeclampsia and IUGR.

METHODS

Serum and placental samples from four groups of cases; normal term, IUGR, early-onset and late-onset preeclampsia, were analyzed for 25(OH)D vitamin D, sFLT1, PGF, LGALS13 in serum and vitamin D receptor (VDR), MAP1LC3B and BECN1 in placental tissues.

RESULTS

There was a significant difference in the sFLT1/PGF ratio in preeclamptic cases compared to controls and IUGR. There was a significant difference between these groups in the MAP1LC3B/BECN1 ratio as marker of the trophoblast survival capacity with a significantly reduced ratio in villous trophoblast of early-onset preeclampsia. Maternal vitamin D deficiency was found in all pathological pregnancies combined with significantly reduced staining levels of placental VDR in IUGR. Finally, there was a strong and significant negative correlation between the survival capacity (MAP1LC3B/BECN1) and both maternal vitamin D and placental VDR in the preeclampsia groups.

CONCLUSION

Vitamin D and intracellular VDR are strongly related to the trophoblast survival capacity in preeclampsia.

Dexamethasone in HELLP syndrome: experience in Bolivia

Objective: To demonstrate the utility of dexamethasone, used according to the criteria of the attending physician, in patients with HELLP syndrome.Methods: This cross-sectional study was conducted in patients with HELLP syndrome and was based on the daily, real-life management of HELLP syndrome. Patients who received dexamethasone had it administered immediately after giving birth at a dosage of 8 mg every 8 hours for 72 hours, for a total of 72 mg. The analysis was conducted between patients who received corticosteroids and those who did not, with complete or partial HELLP.Results: There were 97 women who suffered complications from HELLP syndrome, there were 43 (44.3%) received dexamethasone. The groups were comparable except for the initial platelet count because this was the criterion used to divide the groups. In addition, the group without corticosteroids comprised more patients with partial HELLP. The platelet count shows that on the third day was similar in both groups, following a difference of more than 40,000 at the beginning of the study. The average platelet increase was 27,448 in the group without corticosteroids and 88,408 in the corticosteroid group; p = .001.Conclusions: This study demonstrates that the administration of postpartum dexamethasone at a dosage of 8 mg every 8 hours for 72 hours in HELLP syndrome is associated with a significant increase in platelet count.

Mobile Health Solutions for Hypertensive Disorders in Pregnancy: Scoping Literature Review

Background

Hypertensive disorders are the most common complications during pregnancy, occurring in 5% to 11% of pregnancies; gestational hypertension and preeclampsia are the leading causes of perinatal and maternal morbidity and mortality, especially in low- and middle-income countries (LMIC) where maternal and perinatal mortality ratios are still high. Pregnant women with hypertensive disorders could greatly benefit from mobile health (mHealth) solutions as a novel way to identify and control early symptoms, as shown in an increasing number of publications in the field. Such digital health solutions may overcome access limiting factors and the lack of skilled medical professionals and finances commonly presented in resource-poor environments.

Objective

The aim of this study was to conduct a literature review of mHealth solutions used as support in hypertensive disorders during pregnancy, with the objective to identify the most relevant protocols and prototypes that could influence and improve current clinical practice.

Methods

A methodological review following a scoping methodology was conducted. Manuscripts published in research journals reporting technical information of mHealth solutions for hypertensive disorders in pregnancy were included, categorizing articles in different groups: Diagnosis and Monitoring, mHealth Decision Support System, Education, and Health Promotion, and seven research questions were posed to study the manuscripts.

Results

The search in electronic research databases yielded 327 articles. After removing duplicates, 230 articles were selected for screening. Finally, 11 articles met the inclusion criteria, and data were extracted from them. Very positive results in the improvement of maternal health and acceptability of solutions were found, although most of the studies involved a small number of participants, and none were complete clinical studies. Accordingly, none of the reported prototypes were integrated in the different health care systems. Only 4 studies used sensors for physiological measurements, and only 2 used blood pressure sensors despite the importance of this physiological parameter in the control of hypertension. The reported mHealth solutions have great potential to improve clinical practice in areas lacking skilled medical professionals or with a low health care budget, of special relevance in LMIC, although again, no extensive clinical validation has been carried out in these environments.

Conclusions

mHealth solutions hold enormous potential to support hypertensive disorders during pregnancy and improve current clinical practice. Although very positive results have been reported in terms of usability and the improvement of maternal health, rigorous complete clinical trials are still necessary to support integration in health care systems. There is a clear need for simple mHealth solutions specifically developed for resource-poor environments that meet the United Nations Sustainable Development Goal (SDG); of enormous interest in LMIC.

Wnt/β-catenin signaling pathway in severe preeclampsia

This study aims to elucidate the mechanisms of Wnt/β-catenin signaling pathway in the development of preeclampsia (PE). The mRNA levels of Wnt1, β-catenin, c-myc and cyclinD1 were determined by real-time PCR in the placentas. Moreover, the expression levels of Wnt1, β-catenin, Dickkopf-1 (DKK1) and glycogen synthase kinase 3β (GSK-3β) proteins were detected by Western blot. Immunohistochemistry was used in placental tissue microarray to localize the expression of Wnt1, β-catenin, DKK1 proteins in the placentas of two groups. Compared with the control placentas, the mRNA levels of Wnt1, β-catenin, c-myc and cyclinD1 were decreased in the severe preeclamptic placentas. The Western blot results showed that the expression levels of Wnt1, β-catenin, and GSK-3β proteins were significantly elevated in the control group, while the expression level of DKK1 was significantly decreased. In addition, the staining intensity of Wnt1, β-catenin were weaker in the placentas of the severe PE group while the staining intensity of DKK1 was significantly stronger in the placentas of the severe PE group. Wnt/β-catenin signaling pathway may play a significant role in the pathogenesis of PE by regulating the invasion and proliferation of trophoblast.

The trophoblast survival capacity in preeclampsia

BACKGROUND

Preeclampsia has become the world's major maternal health problem putting a huge burden on mothers, newborns and also on the health systems. The pathogenesis of preeclampsia seems to include events in very early pregnancy affecting differentiation of placental villous trophoblast. The arising changes of the cell death spectrum from apoptosis via increased autophagy and aponecrosis to necrosis in turn induce systemic inflammation of the mother.

METHODS

Placental tissue samples and maternal serum samples from 40 pregnant women were collected from normal pregnancy, IUGR, early-onset and late-onset preeclampsia. Immunohistochemistry for LC3B and Beclin-1 was quantified using systematic random sampling techniques. Serum levels of LDH and other markers were assessed in serum.

RESULTS

Expression of the autophagy markers LC3B and Beclin-1 was significantly different between groups as was the LC3B/Beclin-1 ratio. Early-onset preeclampsia and IUGR had the highest autophagy protein expression levels, while normal pregnancy and late-onset preeclampsia had the highest LC3B/Beclin-1 ratio. Early-onset preeclampsia had the highest negative correlation with free LDH as cell defect marker.

CONCLUSIONS

Autophagy plays a critical role in the cell death spectrum and cellular survival capacity of villous trophoblast. Alterations in autophagic protein expression are involved in pathological pregnancies such as preeclampsia.

Clinical Features and Outcomes of Acute Coronary Syndrome in Women With Previous Pregnancy Complications

BACKGROUND

Women with previous cardiometabolic complications of pregnancy experience double the risk of cardiovascular disease. However, few data exist on the clinical effect of these complications at the time of an acute coronary syndrome (ACS). The objective of this work was to compare risk factors, clinical features, and outcomes among women with premature ACS with or without previous pregnancy complications (gestational diabetes and/or hypertensive disorders of pregnancy).

METHODS

Data were obtained from a multicentre cohort of individuals hospitalized with premature ACS. A total of 251 parous women were included and provided obstetric history and blood samples. They were followed for the development of major adverse cardiac events at 12 months.

RESULTS

At presentation with ACS, women with a previous pregnancy complication (38%) were slightly younger than were women without such complications (47.4 ± 6.2 vs 49.1 ± 5.6 years; P = 0.002). They also had more traditional atherosclerotic risk factors. Specifically, women with previous preeclampsia were more likely to have chronic hypertension and an elevated ratio of soluble fms-like tyrosine kinase:placental growth factor. There was no between-group difference in Global Registry of Acute Coronary Events (GRACE) score or troponin tertile but there was a trend toward higher risk of ST-elevation myocardial infarction in women who had a previous pregnancy complication (odds ratio, 1.80; 95% confidence interval, 1.00-3.23; P = 0.05). There was also an increased risk of recurrent ACS at 12 months in women with previous preeclampsia (hazard ratio, 6.79; 95% confidence interval, 1.37-33.63; P = 0.02).

CONCLUSIONS

Among a cohort of women with ACS, previous pregnancy complications were associated with more severe disease and poorer outcome.

Metformin, the aspirin of the 21st century: its role in gestational diabetes mellitus, prevention of preeclampsia and cancer, and the promotion of longevity

Metformin is everywhere. Originally introduced in clinical practice as an antidiabetic agent, its role as a therapeutic agent is expanding to include treatment of prediabetes mellitus, gestational diabetes mellitus, and polycystic ovarian disease; more recently, experimental studies and observations in randomized clinical trials suggest that metformin could have a place in the treatment or prevention of preeclampsia. This article provides a brief overview of the history of metformin in the treatment of diabetes mellitus and reviews the results of metaanalyses of metformin in gestational diabetes mellitus as well as the treatment of obese, non-diabetic, pregnant women to prevent macrosomia. We highlight the results of a randomized clinical trial in which metformin administration in early pregnancy did not reduce the frequency of large-for-gestational-age infants (the primary endpoint) but did decrease the frequency of preeclampsia (a secondary endpoint). The mechanisms by which metformin may prevent preeclampsia include a reduction in the production of antiangiogenic factors (soluble vascular endothelial growth factor receptor-1 and soluble endoglin) and the improvement of endothelial dysfunction, probably through an effect on the mitochondria. Another potential mechanism whereby metformin may play a role in the prevention of preeclampsia is its ability to modify cellular homeostasis and energy disposition, mediated by rapamycin, a mechanistic target. Metformin has a molecular weight of 129 Daltons and therefore readily crosses the placenta. There is considerable evidence to suggest that this agent is safe during pregnancy. New literature on the role of metformin as a chemotherapeutic adjuvant in the prevention of cancer and in prolonging life and protecting against aging is reviewed briefly. Herein, we discuss the mechanisms of action and potential benefits of metformin.

Long-Term Effects of Pregnancy Complications on Maternal Health: A Review

Background: Most pregnancy-related medical complications appear to resolve at delivery or shortly thereafter. Common examples are preterm labor, placental abruption, preeclampsia, and gestational diabetes. Women who developed such complications are known to be at increased risk of developing similar complications in future pregnancies. It has recently become evident that these women are at an increased risk of long term medical complications. Methods: A search through scientific publications in English regarding the association of obstetric complications and long-term maternal illness. Results: There is a clear association between various obstetric complications and long-term effects on maternal health. Conclusions: Women with a history of adverse pregnancy outcomes are at increased risk of cardiovascular and metabolic diseases later in life. Data increasingly links maternal vascular, metabolic, and inflammatory complications of pregnancy with an increased risk of vascular disease in later life.

Comparison of risk factors and outcomes of gestational hypertension and pre-eclampsia

Background

It remains an enigma whether gestational hypertension (GH) and pre-eclampsia (PE) are distinct entities or different spectrum of the same disease. We aimed to compare the risk factors and outcomes between GH and PE.

Method

A total of 7,633 pregnant women recruited between 12 and 20 weeks of gestation in the Ottawa and Kingston Birth Cohort from 2002 to 2009 were included in the analysis. Cox proportional hazards model was used to identify and compare the risk factors for GH and PE by treating gestational age at delivery as the survival time. Logistic regression model was used to compare outcome. Subgroup analysis was performed for early- and late-onset PE.

Results

GH and PE shared most risk factors including overweight and obesity, nulliparity, PE history, type 1 and 2 diabetes, and twin birth. Effect size of PE history (RR = 14.1 for GH vs. RR = 6.4 for PE) and twin birth (RR = 4.8 for GH vs. RR = 10.3 for PE) showed substantial difference. Risk factors modified gestational age at delivery in patients with GH and PE in similar pattern. Subgroup analysis showed that early- and late-onset PE shared some risk factors with different effect sizes, whereas folic acid supplementation showed protective effect for early-onset PE only. PE was strongly associated with several adverse outcomes including cesarean section, placental abruption, small for gestational age, preterm birth, and 5 min Apgar score < 7, whereas GH was associated with increased risk of preterm birth only.

Conclusions

GH and PE shared common risk factors. Differences in effect sizes of risk factors and outcomes indicate that the conditions may have different pathophysiology and mechanism.

Sexual Dimorphism in Adverse Pregnancy Outcomes - A Retrospective Australian Population Study 1981-2011

OBJECTIVES

Sexual inequality starts in utero. The contribution of biological sex to the developmental origins of health and disease is increasingly recognized. The aim of this study was to assess and interpret sexual dimorphisms for three major adverse pregnancy outcomes which affect the health of the neonate, child and potentially adult.

METHODS

Retrospective population-based study of 574,358 South Australian singleton live births during 1981-2011. The incidence of three major adverse pregnancy outcomes [preterm birth (PTB), pregnancy induced hypertensive disorders (PIHD) and gestational diabetes mellitus (GDM)] in relation to fetal sex was compared according to traditional and fetus-at-risk (FAR) approaches.

RESULTS

The traditional approach showed male predominance for PTB [20-24 weeks: Relative Risk (RR) M/F 1.351, 95%-CI 1.274-1.445], spontaneous PTB [25-29 weeks: RR M/F 1.118, 95%-CI 1.044-1.197%], GDM [RR M/F 1.042, 95%-CI 1.011-1.074], overall PIHD [RR M/F 1.053, 95%-CI 1.034-1.072] and PIHD with term birth [RR M/F 1.074, 95%-CI 1.044-1.105]. The FAR approach showed that males were at increased risk for PTB [20-24 weeks: RR M/F 1.273, 95%-CI 1.087-1.490], for spontaneous PTB [25-29 weeks: RR M/F 1.269, 95%-CI 1.143-1.410] and PIHD with term birth [RR M/F 1.074, 95%-CI 1.044-1.105%]. The traditional approach demonstrated female predominance for iatrogenic PTB [25-29 weeks: RR M/F 0.857, 95%-CI 0.780-0.941] and PIHD associated with PTB [25-29 weeks: RR M/F 0.686, 95%-CI 0.581-0.811]. The FAR approach showed that females were at increased risk for PIHD with PTB [25-29 weeks: RR M/F 0.779, 95%-CI 0.648-0.937].

CONCLUSIONS

This study confirms the presence of sexual dimorphisms and presents a coherent framework based on two analytical approaches to assess and interpret the sexual dimorphisms for major adverse pregnancy outcomes. The mechanisms by which these occur remain elusive, but sex differences in placental gene expression and function are likely to play a key role. Further research on sex differences in placental function and maternal adaptation to pregnancy is required to delineate the causal molecular mechanisms in sex-specific pregnancy outcome. Identifying these mechanisms may inform fetal sex specific tailored antenatal and neonatal care.

Prospective cohort study of persistent hypertension following pre-eclampsia at Medani Hospital, Sudan

OBJECTIVE

To evaluate the incidence of, and factors associated with, persistent hypertension in patients with pre-eclampsia.

METHODS

A prospective cohort study enrolled patients presenting with pre-eclampsia at Wad Medani Maternity Hospital, Sudan, between March 1 and October 31, 2014. Obstetric, clinical, and biochemical variables were recorded at presentation and at 6weeks after delivery.

RESULTS

Of 188 patients enrolled in the study, 6-week follow-up data were available for 165. Among these patients, 136 (82.4%) and 29 (17.6) had mild and severe pre-eclampsia, respectively. At 6-week follow-up, 58 (35.2%) patients were experiencing persistent hypertension. Patients with persistent hypertension demonstrated significantly lower platelet counts at baseline (P=0.001) and neonatal weight at delivery (P<0.001) than patients who were normotensive at 6weeks. Severe pre-eclampsia was more common among patients who experienced persistent hypertension than those who were normotensive 6weeks after delivery (P<0.001). In a logistic-regression analysis, none of the investigated factors was associated with persistent hypertension; however, patients experiencing severe pre-eclampsia were 7.3-times more likely to experience persistent hypertension than patients with mild pre-eclampsia (95% confidence interval 1.6-32.2; P=0.008).

CONCLUSION

Persistent hypertension 6weeks after delivery was common among patients who experienced pre-eclampsia in Sudan (particularly severe pre-eclampsia) regardless of patients' age and parity.

Gene expression profiling reveals different molecular patterns in G-protein coupled receptor signaling pathways between early- and late-onset preeclampsia

Early-onset preeclampsia and late-onset preeclampsia have been regarded as two different phenotypes with heterogeneous manifestations; To gain insights into the pathogenesis of the two traits, we analyzed the gene expression profiles in preeclamptic placentas. A whole genome-wide microarray was used to determine the gene expression profiles in placental tissues from patients with early-onset (n = 7; <34 weeks), and late-onset (n = 8; >36 weeks) preeclampsia and their controls who delivered preterm (n = 5; <34 weeks) or at term (n = 5; >36 weeks). Genes were termed differentially expressed if they showed a fold-change ≥ 2 and q-value < 0.05. Quantitative real-time reverse transcriptase PCR was used to verify the results. Western blotting was performed to verify the expressions of secreted genes at the protein level.

RESULTS

Six hundred twenty-seven genes were differentially expressed in early-compared with late-onset preeclampsia (177 genes were up-regulated and 450 were down-regulated). Gene ontology analysis identified significant alterations in several biological processes; the top two were immune response and cell surface receptor linked signal transduction. Among the cell surface receptor linked signal transduction-related, differentially expressed genes, those involved in the G-protein coupled receptor protein signaling pathway were significantly enriched. G-protein coupled receptor signaling pathway related genes, such as GPR124 and MRGPRF, were both found to be down-regulated in early-onset preeclampsia. The results were consistent with those of western blotting that the abundance of GPR124 was lower in early-onset compared with late-onset preeclampsia. The different gene expression profiles reflect the different levels of transcription regulation between the two conditions and supported the hypothesis that they are separate disease entities. Moreover, the G-protein coupled receptor signaling pathway related genes may contribute to the mechanism underlying early- and late-onset preeclampsia.

Similarities and differences between the risk factors for gestational hypertension and preeclampsia: A population based cohort study in south China

OBJECTIVES

To compare the risk factors for gestational hypertension (GH) and preeclampsia (PE) in the same population, which may provide clues to better understanding of their etiologic mechanisms.

METHODS

We conducted a cohort study in Liuyang, China, during 2010-2011. Twelve potential risk factors were investigated, including maternal age, body mass index at first antenatal visit, gender of newborn, parity, abortion history, smoking history, family history of hypertension, gestational diabetes mellitus, pregnancy complications of diabetes mellitus/renal disease/cardiac disease, reproductive tract infection, season of delivery, and district level average per capita income. Logistic regression were used to estimate odds ratios for potential risk factors.

RESULTS

Of 6223 pregnancies, 1.8% was complicated by PE, and 5.4% by GH. Maternal age older than 35, body mass index above 24, and pregnancy complicated with gestational diabetes mellitus increased the risk of both PE and GH, while with different effect sizes. Primiparity and deliver in winter and spring (compared with summer delivery) were risk factors for GH only. Pregnancy complicated with diabetes mellitus/renal disease/cardiac disease was risk factor for PE only. Significantly lower risk of GH was observed for women younger than 25 or with low body mass index in the first trimester. Mothers carrying a male fetus were more likely to develop PE.

CONCLUSIONS

Risk factors for GH and PE were not exactly the same. Underling those differences might be their different etiology and mechanism. To confirm the similarities and differences been found in single study, it is important to conduct investigation in other population.

Preeclampsia in pregnancy and later use of antihypertensive drugs

We explored the association between preeclampsia and later use of antihypertensive drugs in a population-based study with data from the Medical Birth Registry of Norway and the Norwegian Prescription Database. The study cohort consisted of 980,000 women having 2.1 million pregnancies during 1967–2012. Hazard ratios (HRs) with 95 % confidence intervals (95 % CI) were estimated in multivariate time-dependent Cox proportional hazards regression models. Overall, the HR of later use of antihypertensive drugs was 2.0 (95 % CI 2.0–2.0) in women with one preeclamptic pregnancy compared to women without preeclamptic pregnancies. The HR increased by increasing number of preeclamptic pregnancies, both term and preterm pregnancies. In women with two or more preeclamptic pregnancies, the HR was 2.8 (2.7–3.0). The overall HR after 40 years of follow-up for women with one preeclamptic pregnancy was 1.3 (1.2–1.4) and for two or more preeclamptic pregnancies the HR was 1.6 (1.1–2.1). The first 5 years after the first birth, the HR of being dispensed antihypertensive drugs was higher in preterm [8.4 (7.7–9.1)] than term preeclamptic pregnancies [4.3(4.0–4.6)]. However, after 10 years, this difference was no longer present. The HR of later use of antihypertensive drugs increased with the number of preeclamptic pregnancies, and in the first 10 years the HR was higher after a preterm than a term preeclamptic pregnancy. Although the HR decreased with time since first birth, the risk was still elevated after 40 years.

Hypertension persisting after pre-eclampsia: a prospective cohort study at Mulago Hospital, Uganda

Background

Pre-eclampsia/eclampsia usually resolves after delivery but sometimes hypertension persists and cardiovascular disease develops later. Our objective was to determine the incidence and maternal socio-demographic and obstetric risk factors for persistence of hypertension in women with pre-eclampsia/eclampsia.

Methods

This was a prospective cohort study conducted from July 2009 to June 2011 at Mulago Hospital labour ward and postnatal clinics. We followed up 188 women admitted with pre-eclampsia/eclampsia until 3 months after delivery. Data was collected using interviewer-administered questionnaires, examination of participants and review of medical records. Stata (version12) software was used for data analysis. Univariable analysis was used to compute the relative risk of persistent hypertension at the 95% confidence level. This was followed by multivariable logistic regression analysis to determine factors independently associated with persistence of hypertension.

Results

64 (34%) out of the 188 women analysed had persistent hypertension three months after delivery. Maternal age, gestational age at delivery and parity were predictors of persistent hypertension.

Conclusion

The proportion of women with pre-eclampsia/eclampsia at risk of persistent hypertension at three months after delivery was high, with nearly one of three mothers remaining hypertensive. Follow up of mothers who develop pre-eclampsia is important so that early diagnosis and management of chronic hypertension can be made to avoid long term morbidity and mortality.