Evaluation of maternal systemic inflammatory response in preeclampsia

Targeting oxidative stress in preeclampsia

Preeclampsia is a complex condition characterized by elevated blood pressure and organ damage involving kidneys or liver, resulting in significant morbidity and mortality for both the mother and the fetus. Increasing evidence suggests that oxidative stress, often caused by mitochondrial dysfunction within fetal trophoblast cells may play a major role in the development and progression of preeclampsia. Oxidative stress occurs as a result of an imbalance between the production of reactive oxygen species (ROS) and the capacity of antioxidant defenses, which can lead to placental cellular damage and endothelial cell dysfunction. Targeting oxidative stress appears to be a promising therapeutic approach that has the potential to improve both short- and long-term maternal and fetal outcomes, thus reducing the global burden of preeclampsia. The purpose of this review is to provide a comprehensive account of the mechanisms of oxidative stress in preeclampsia. Furthermore, it also examines potential interventions for reducing oxidative stress in preeclampsia, including natural antioxidant supplements, lifestyle modifications, mitochondrial targeting antioxidants, and pharmacological agents.A better understanding of the mechanism of action of proposed therapeutic strategies targeting oxidative stress is essential for the identification of companion biomarkers and personalized medicine approaches for the development of effective treatments of preeclampsia.

Investigation of serum neuroserpin levels in pregnant women diagnosed with pre-eclampsia: a prospective case-control study

OBJECTIVE

Neuroserpin, a serine protease inhibitor, is recognized for its anti-inflammatory and neuroprotective properties. Given the central role of inflammation and neurological involvement in the pathophysiology of preeclampsia, this study aimed to assess maternal serum neuroserpin levels in preeclamptic pregnancies and explore their association with disease severity.

DESIGN

Prospective case-control study.

SETTING

A tertiary referral center in Ankara, Türkiye.

POPULATION

Singleton pregnant women with a diagnosis of preeclampsia (n = 44) and gestational age-matched normotensive pregnant women as controls (n = 44).

METHODS

Participants were assigned to preeclampsia and control groups. Serum neuroserpin levels were quantified using enzyme-linked immunosorbent assay (ELISA). Subgroup analysis was conducted based on the clinical severity of preeclampsia. Statistical analysis included group comparisons, receiver operating characteristic (ROC) curve analysis, and correlation testing.

MAIN OUTCOME MEASURES

The primary outcome was maternal serum neuroserpin level. Secondary outcomes included obstetric and neonatal parameters such as gestational age at delivery, delivery mode, NICU admission, and Apgar scores.

RESULTS

Serum neuroserpin levels were significantly reduced in the preeclampsia group compared to controls (p = 0.018). Within the preeclampsia cohort, patients with severe disease exhibited even lower neuroserpin concentrations than those with mild preeclampsia. ROC curve analysis determined a neuroserpin cutoff value of ≤ 22.95 ng/mL for identifying preeclampsia (AUC: 0.647, p = 0.013) and ≤ 14.7 ng/mL for severe preeclampsia (AUC: 0.740, p = 0.007).

CONCLUSION

Reduced maternal serum neuroserpin levels are associated with both the diagnosis and severity of preeclampsia. These findings highlight the potential role of neuroserpin in the disease's inflammatory mechanisms and support its utility as a candidate biomarker in clinical prediction models.

CLINICAL TRIAL REGISTRATION

Not applicable.

Association between retinal vessels caliber and systemic health: A comprehensive review

The unique nature of the retinal microvasculature that permits non-invasive visualization has garnered interest as a potential method for detecting microvascular alterations indicative of systemic diseases. This concept, supported by advancements in imaging technologies, has been increasingly validated by studies linking retinal microvasculature with systemic conditions such as diabetes, hypertension, and cerebrovascular disease. Structural changes in the retinal microvasculature are associated with cardiovascular risk factors, metabolic diseases, and are significant predictors of systemic hypertensive damage and mortality. Given that most systemic diseases present life-long burdens and complications if undetected or untreated, the development of diagnostic tools like retinal vascular imaging becomes important for early detection, monitoring of disease progression, and facilitating timely interventions. Technological advancements have enabled objective and accurate quantification of retinal microvascular characteristics. We consolidate current literature on retinal vascular changes across various systemic health conditions, including metabolic diseases, cerebrovascular diseases, pregnancy complications, systemic inflammatory conditions, leukemia, human immunodeficiency virus infection, and COVID-19. We also emphasizes the need for dynamic parameters, an understanding of 3-dimensional vascular architecture, and larger-scale longitudinal studies to elucidate the temporal relationship between retinal vascular changes and systemic diseases, helping shape future diagnostic and monitoring approaches.

Role of Systemic Immune-Inflammation Index, Systemic Inflammation Response Index, and Pan-Immune Inflammation Value in the Prediction of Preeclampsia: A Retrospective Cohort Study

OBJECTIVE

The aim of the study was to investigate the role of systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and pan-immune inflammation value (PIV) calculated from first trimester complete blood count (CBC) in predicting preeclampsia without (PE) and with severe features (PE-SF).

METHODS

This retrospective cohort study included 126 women with PE, 126 women with PE-SF, and 126 women with healthy, normotensive pregnancies delivered at a large tertiary referral hospital between 2018 and 2022. The main outcome measures were SII, SIRI, and PIV.

RESULTS

SII scores differed significantly between the control versus PE and control versus PE-SF groups, while SIRI scores showed a significant difference between the control versus PE and PE versus PE-SF groups. However, the PIV values showed a significant difference in all three groups. According to the receiver operating characteristic analysis performed for the discriminatory power of SII, SIRI, and PIV, the area under the curve (AUC) values were 0.801, 0.609, and 0.774 for the prediction of PE and 0.535, 0.701, and 0751 for the prediction of PE-SF, respectively. An SII with a cutoff value of > 620.59×103/µL (sensitivity 81%, specificity 67%) and an SIRI with a cutoff value of > 0.94×103/µL (sensitivity 74%, specificity 69%) had the highest discriminatory power for the prediction of PE and PE-SF, respectively.

CONCLUSION

Our results suggest an association between high SII, PIV, and SIRI results and an increased risk of future PE and could be used as a first trimester screening test to improve decision making in the prediction of PE.

Biomarkers and point of care screening approaches for the management of preeclampsia

Preeclampsia is a multi-organ pregnancy complication, that is primarily detected when pregnant people have high blood pressure, and is confirmed by testing for the presence of protein in the urine. While more specific and accurate diagnostic and imaging tests are becoming available, they are still in the process of undergoing widespread regulatory adoption, and so are not yet the standard of care. Since biochemical processes are a precursor to the systemic progression of disease, we review some established, emerging, and promising biomarkers that are proposed to be associated with preeclampsia, and newly developed approaches for screening them at the point of care, to reduce the burden of the disease.

Diagnostic value of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratio to predict recurrent pregnancy loss and abortion; a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the diagnostic value of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in women with a history of abortion (missed and threatened) and recurrent pregnancy loss (RPL) in comparison with healthy pregnancies.

METHODS

Electronic databases including MEDLINE, Scopus, Web of Science, Embase, and Cochrane Library were searched for NLR and PLR in women who experienced early pregnancy loss up to January 1, 2023 with a combination of proper keywords. Meta-analysis was done for comparison with three or more studies and summary estimates were measured.

RESULTS

A total of 390 citations were retrieved initially, and after screening, 16 articles were deemed eligible for the final review. Among these, 14 studies underwent meta-analysis. The meta-analysis revealed that the standard mean of the NLR was significantly higher in abortion cases compared to the control group. However, there was no significant difference in the PLR between the pregnancy loss group and the control group.

CONCLUSION

NLR was significantly higher among RPL patients compared to the control group, according to these data, NLR may be capable of being used in the diagnosis of RPL as an easy, cheap, and accessible modality. Further studies, which take these variables into account, will need to be undertaken to determine the diagnostic value of NLR and PLR in early pregnancy loss.

Platelet-to-lymphocyte ratio and serum hsCRP levels in third trimester and adverse pregnancy outcomes in women with gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is a major complication of pregnancy. GDM is associated with a higher risk of adverse pregnancy outcomes (APO). The purpose of this study was to assess the association between third-trimester platelet to lymphocyte ratio (PLR) and high-sensitivity C-reactive protein (hsCRP) concentration and the risk of APO in GDM pregnant women. This study selected 406 non-elderly gestational diabetes patients diagnosed in the Renmin Hospital of Wuhan University from May 2021 to February 2023 as the research objects. According to the presence or absence of APO, they were divided into an APO group (n = 171) and a non-APO group (n = 235). Logistic regression model to evaluate the correlation between PLR and hsCRP and APO in women with GDM; Restricted cubic spline analyses was used to explore nonlinear correlations between PLR or hsCRP and the risk of APO; ROC curve analysis of the diagnostic performance of PLR and hsCRP for APO in women with GDM. APO occurred in 171 of the 406 included participants. Compared with the non-APO group, patients in the APO group had higher PLR and hsCRP levels. The incidence of APO was positively associated with PLR and the hsCRP level in each logistic regression model (P < 0.05). After adjusting for all the risk factors included in this study, restricted cubic spline analyses found that the PLR and the hsCRP level were positively associated with the risk of APO. The levels of PLR and hsCRP in the third trimester are related to the occurrence of APO in women with GDM, and high levels of PLR and hsCRP may indicate the occurrence of APO.

The role of haptoglobin in the diagnosis of preeclampsia and HELLP syndrome and in predicting neonatal outcomes

OBJECTIVE

The study aimed to determine whether maternal serum haptoglobin values could have an effect on predicting diagnosis and neonatal outcomes in preeclampsia and HELLP syndrome.

MATERIALS AND METHODS

Hundred sixteen pregnant women who met the inclusion criteria were included in the study. To evaluate whether serum haptoglobin level in maternal blood could be used in early diagnosis of preeclampsia and HELLP syndrome, 49 pregnant women diagnosed with preeclampsia and 13 pregnant women diagnosed with HELLP syndrome were included in the study group, and 54 healthy pregnant women in the control group. The groups were compared regarding maternal serum haptoglobin level, platelet count, ALT, AST, LDH, and uric acid levels. Moreover, the age, obstetric histories, and newborn outcomes of all pregnant women were recorded and compared between groups.

RESULTS

The mean haptoglobin values were 0.29 ± 0.23 g/L in the HELLP syndrome group, 1.01 ± 0.52 g/L in the preeclampsia group, and 1.16 ± 0.37 g/L in the control group. The mean haptoglobin result was lower in the HELLP syndrome group compared to the preeclampsia and control groups (p < 0.001). While the differences between HELLP syndrome and the control and preeclampsia groups were statistically significant, no significant difference was determined between the preeclampsia and control groups. There was a significant positive correlation between haptoglobin value with the week of delivery, umbilical cord pH value, and the first and fifth-minute Apgar scores (p < 0.05).

CONCLUSION

It was concluded that haptoglobin values could be used together with other biochemical parameters to diagnose HELLP syndrome and predict newborn outcomes.

Circulatory Maternal Endothelin 1 and Matrix Metalloproteinase-9 Gene Expression in PREECLAMPSIA: A Study in Western Uttar Pradesh, India

Introduction

Preeclampsia (PE) is a multiorgan disease of pregnant women. The main pathophysiology of PE is a trophoblastic invasion into maternal circulation leading to alterations in circulatory levels of matrix metalloproteinases (MMPs), inflammatory markers, and endothelin 1(ET1) levels. Therefore, the present study has explored the role of MMP-9 and ET1 and their association in PE. The advantage of the study is to provide insight into the pathology of PE. These markers may help in the early diagnosis and prognosis of PE.

Objective

To investigate MMP-9 gene expression, ET1 level in PE cases and their correlation with blood pressure (BP), gestational age, weight, and height.

Methods

The study design was a case-control observational study, which included 70 subjects in each case (PE) and controls (normal pregnant women (NPW)). Whole blood (250 ul) was utilized for RNA extraction (Trizol method) and synthesized cDNA as per manufacturer protocol. MMP-9 gene expression was analyzed by real-time PCR. Serum was utilized for ET1 estimation by sandwich ELISA.

Results

The ET1 levels and MMP-9 gene expression were significantly increased in preeclamptic women as compared to controls. There was no significant correlation between MMP-9 gene expression and serum ET1 levels. However, a significant moderate association between systolic BP and diastolic BP with ET1 levels and MMP9 gene expression was seen in both PE and NPW.

Conclusion

A significantly increased circulatory concentration of ET1 and MMP-9 gene expression in PE might be used as an early diagnostic as well as a prognostic marker of PE.

The central role of natural killer cells in preeclampsia

Preeclampsia (PE) is a disease that is unique to pregnancy and affects multiple systems. It can lead to maternal and perinatal mortality. The precise etiology of PE is unclear. Patients with PE may have systemic or local immune abnormalities. A group of researchers has proposed that the immune communication between the fetus and mother is primarily moderated by natural killer (NK) cells as opposed to T cells, since NK cells are the most abundant immune cells in the uterus. This review examines the immunological roles of NK cells in the pathogenesis of PE. Our aim is to provide obstetricians with a comprehensive and updated research progress report on NK cells in PE patients. It has been reported that decidual NK (dNK) cells contribute to the process of uterine spiral artery remodeling and can modulate trophoblast invasion. Additionally, dNK cells can stimulate fetal growth and regulate delivery. It appears that the count or proportion of circulating NK cells is elevated in patients with or at risk for PE. Changes in the number or function of dNK cells may be the cause of PE. The Th1/Th2 equilibrium in PE has gradually shifted to an NK1/NK2 equilibrium based on cytokine production. An improper combination of killer cell immunoglobulin-like receptor (KIR) and human leukocyte antigen (HLA)-C may lead to insufficient activation of dNK cells, thereby causing PE. In the etiology of PE, NK cells appear to exert a central effect in both peripheral blood and the maternal-fetal interface. To maintain immune equilibrium both locally and systemically, it is necessary to take therapeutic measures directed at NK cells.

The role of miRNA-210 in pre-eclampsia development

MicroRNAs (miRNAs) are a class of small non-coding, single-stranded RNAs (ribonucleic acids) that play important roles in many vital processes through their impact on gene expression. One such miRNA, miR210, represents a hypoxia-induced cellular miRNA group that hold a variety of functions. This review article highlights the importance of miR-210 in the development of pre-eclampsia.KEY MESSAGEmiR-210 is a promising biomarker for monitoring pregnancy with pre-eclampsia. Overexpression of miR-210 had a negative impact on the process of cell migration and trophoblast invasion.

Maternal plasma proteome profiling of biomarkers and pathogenic mechanisms of early-onset and late-onset preeclampsia

Preeclampsia is still the leading cause of morbidity and mortality in pregnancy without a cure. There are two phenotypes of preeclampsia, early-onset (EOPE) and late-onset (LOPE) with poorly defined pathogenic differences. This study aimed to facilitate better understanding of the mechanisms of pathophysiology of EOPE and LOPE, and identify specific biomarkers or therapeutic targets. In this study, we conducted an untargeted, label-free quantitative proteomic analyses of plasma samples from pregnant women with EOPE (n = 17) and LOPE (n = 11), and age, BMI-matched normotensive controls (n = 18). Targeted proteomics approach was also employed to validate a subset of proteins (n = 17). In total, there were 26 and 20 differentially abundant proteins between EOPE or LOPE, and normotensive controls, respectively. A series of angiogenic and inflammatory proteins, including insulin-like growth factor-binding protein 4 (IGFBP4; EOPE: FDR = 0.0030 and LOPE: FDR = 0.00396) and inter-alpha-trypsin inhibitor heavy chain H2-4 (ITIH2-4), were significantly altered in abundance in both phenotypes. Through validation we confirmed that ITIH2 was perturbed only in LOPE (p = 0.005) whereas ITIH3 and ITIH4 were perturbed in both phenotypes (p < 0.05). Overall, lipid metabolism/transport proteins associated with atherosclerosis were highly abundant in LOPE, however, ECM proteins had a more pronounced role in EOPE. The complement cascade and binding and uptake of ligands by scavenger receptors, pathways, were associated with both EOPE and LOPE.

Effect of Compound Danshen Injection Combined with Magnesium Sulfate on Oxidative Stress, TNF-α, NO, and Therapeutic Efficacy in Severe Preeclampsia

Aims

This study is designed to explore the effect of compound Danshen injection combined with magnesium sulfate on TNF-α, NO, oxidative stress, and therapeutic efficacy in severe preeclampsia (S-PE).

Methods

Sixty S-PE patients were placed into the control group and the therapy group, randomly. The control group was under the treatment of magnesium sulfate, and the therapy group was under the treatment of compound Danshen injection with magnesium sulfate. After treatment, the therapeutic efficacy of the two groups was comparatively analyzed.

Results

7 days after treatment, DBP, SBP, and 24 h urinary protein were sharply lower than those before treatment. The 24 h urinary protein was notably lower in the therapy group. After treatment, the expression level of TNF-α in both groups was notably higher than before treatment, while NO level was higher than that before treatment. Furthermore, D-D level in two groups was dramatically decreased compared to that before treatment. Moreover, Fib, PT, and APTT in two groups showed statistically significant differences after 7 days. The contents of ALT, AST, BUN, and Scr in therapy group were notably lower than those in control group.

Conclusion

Our results indicated that compound Danshen injection could improve renal function, blood hypercoagulability, and oxidative stress level and had a better therapeutic effect on S-PE.

Relation of Serum and Salivary Total Sialic Acid and Total Sialic Acid/Total Protein Ratio with Clinical Parameters of Disease Progression in Preeclampsia

Sialic acid is a terminal component of carbohydrate chains of glycoproteins and glycolipids. The present study estimated total sialic acid (TSA) and its ratio with total proteins (TP), in serum and saliva of preeclampsia. The study further investigated the association of these parameters with clinical variables of disease progression. 50 preeclampsia patients (32 mild preclampsia and 18 severe preeclampsia cases) and 50 pregnant controls were included in the study. Serum and salivary free sialic acid, protein bound sialic acid and TP were measured spectrophotometrically. Serum and salivary TSA and its ratio with TP were calculated. There was a significant increase in serum TSA and its ratio with TP in preeclampsia compared to the controls. The increase reflected with the severity of the disease. Serum TSA and TSA/TP showed a significant positive correlation with blood pressure, proteinuria and a significant negative correlation with infant birth weight. In saliva, there was no statistical difference between TSA in preeclampsia and controls. Salivary TSA/TP increased significantly in preeclampsia. However the increase was not in accordance to the disease severity. Salivary TSA and TSA/TP were not significantly associated with any of the clinical parameters of disease progression. Significant increase in seum TSA reflects the disturbance in sialyation of serum proteins in preeclampsia, that could not be depicted in the saliva of these patients. Disturbance in serum protein sialyation is further exaggerated with the severity of the disease. Serum TSA and TSA/TP and not the respective salivary parameters, could serve as useful indicators in assessment of clinical progression of the disease.

Association of prenatal modifiable risk factors with attention-deficit hyperactivity disorder outcomes at age 10 and 15 in an extremely low gestational age cohort

Background

The increased risk of developing attention-deficit hyperactivity disorder (ADHD) in extremely preterm infants is well-documented. Better understanding of perinatal risk factors, particularly those that are modifiable, can inform prevention efforts.

Methods

We examined data from the Extremely Low Gestational Age Newborns (ELGAN) Study. Participants were screened for ADHD at age 10 with the Child Symptom Inventory-4 (N = 734) and assessed at age 15 with a structured diagnostic interview (MINI-KID) to evaluate for the diagnosis of ADHD (N = 575). We studied associations of pre-pregnancy maternal body mass index (BMI), pregestational and/or gestational diabetes, maternal smoking during pregnancy (MSDP), and hypertensive disorders of pregnancy (HDP) with 10-year and 15-year ADHD outcomes. Relative risks were calculated using Poisson regression models with robust error variance, adjusted for maternal age, maternal educational status, use of food stamps, public insurance status, marital status at birth, and family history of ADHD. We defined ADHD as a positive screen on the CSI-4 at age 10 and/or meeting DSM-5 criteria at age 15 on the MINI-KID. We evaluated the robustness of the associations to broadening or restricting the definition of ADHD. We limited the analysis to individuals with IQ ≥ 70 to decrease confounding by cognitive functioning. We evaluated interactions between maternal BMI and diabetes status. We assessed for mediation of risk increase by alterations in inflammatory or neurotrophic protein levels in the first week of life.

Results

Elevated maternal BMI and maternal diabetes were each associated with a 55-65% increase in risk of ADHD, with evidence of both additive and multiplicative interactions between the two exposures. MSDP and HDP were not associated with the risk of ADHD outcomes. There was some evidence for association of ADHD outcomes with high levels of inflammatory proteins or moderate levels of neurotrophic proteins, but there was no evidence that these mediated the risk associated with maternal BMI or diabetes.

Conclusion

Contrary to previous population-based studies, MSDP and HDP did not predict ADHD outcomes in this extremely preterm cohort, but elevated maternal pre-pregnancy BMI, maternal diabetes, and perinatal inflammatory markers were associated with increased risk of ADHD at age 10 and/or 15, with positive interaction between pre-pregnancy BMI and maternal diabetes.

Comparison of three neuraxial anesthesia approaches in parturient women with obesity and pregnancy-induced hypertension who underwent cesarean section

OBJECTIVE

To compare the effectiveness of different approaches of neuraxial anesthesia in parturient women with obesity and pregnancy-induced hypertension (PIH) who undergo cesarean section (CS).

METHODS

We retrospectively analyzed data from 108 parturient women with obesity and PIH who underwent CS. All women were divided into the following three groups according to the neuraxial anesthesia approach: spinal anesthesia (SA), epidural anesthesia (EA), and combined spinal-epidural anesthesia (CSE). Clinical variables were compared.

RESULTS

The mean age of the patients was 27.3 ± 2.2 years. Women in the CSE group had a longer duration from puncture to surgery, smaller intraoperative change in mean arterial pressure, higher Apgar scores at 1 and 5 minutes, shorter surgery time, lower rates of nausea and vomiting, and lower rate of intraoperative hypotension compared with those in the SA and EA groups.

CONCLUSION

CSE takes longer to administer in parturient women with obesity and PIH who undergo CS compared with those who have SA or EA. However, CSE has several advantages over SA or EA, including a shorter surgery time, more stable intraoperative mean arterial pressure, lower rates of nausea, vomiting, and intraoperative hypotension, and better Apgar scores at 1 and 5 minutes.

Comparative Characteristics of the Expression of Fucosylated Glycans and Morphometric Parameters of Terminal Placental Villi Depending on the Severity of Preeclampsia

We performed a comparative analysis of the expression of fucosylated glycans and morphometric characteristics of the terminal villi of the placenta, depending on the severity of preeclampsia (PE). Similar patterns of the expression of fucosylated glycans in the syncytiotrophoblast glycocalyx were revealed in the placental tissue of patients with normal pregnancy and with mild and severe PE: predominance of glycans with α1,6-fucose in the core, clustered fucose residues, and LeX glycan over α1,2-fucose-containing glycans. The expression pattern of fucosylated glycans and the composition of the endothelial glycocalyx are normally close to the expression pattern and composition of the syncytiotrophoblast glycocalyx; in case of mild and severe PE, the expression pattern of fucosylated glycans was changed uniformly, and α1,2-fucose-containing glycans significantly prevailed in the endothelial glycocalyx. According to the results of Fisher's LSD test, in patients with severe PE, the total vascular area in the villus prevailed over the indices established during physiological course of pregnancy (p=0.04) and mild PE (p=0.04). Correlation analysis revealed direct and reciprocal relationships between the morphometric characteristics of the terminal villi of the placenta and the expression of fucosylated glycans in the syncytiotrophoblast and endothelium in PE. Our results indicate a changed expression of fucosylated glycans in the glycocalyx of placental barrier structures and the morphometric parameters of villi in PE of different severity, which can affect the function of the placental barrier.

Formulas, Algorithms and Examples for Binomial Distributed Data Confidence Interval Calculation: Excess Risk, Relative Risk and Odds Ratio

Medical studies often involve a comparison between two outcomes, each collected from a sample. The probability associated with, and confidence in the result of the study is of most importance, since one may argue that having been wrong with a percent could be what killed a patient. Sampling is usually done from a finite and discrete population and it follows a Bernoulli trial, leading to a contingency of two binomially distributed samples (better known as 2×2 contingency table). Current guidelines recommend reporting relative measures of association (such as the relative risk and odds ratio) in conjunction with absolute measures of association (which include risk difference or excess risk). Because the distribution is discrete, the evaluation of the exact confidence interval for either of those measures of association is a mathematical challenge. Some alternate scenarios were analyzed (continuous vs. discrete; hypergeometric vs. binomial), and in the main case—bivariate binomial experiment—a strategy for providing exact p-values and confidence intervals is proposed. Algorithms implementing the strategy are given.

Preeclampsia and Cardiovascular Risk for Offspring

There is growing evidence of long-term cardiovascular sequelae in children after in utero exposure to preeclampsia. Maternal hypertension and/or placental ischaemia during pregnancy increase the risk of hypertension, stroke, diabetes, and cardiovascular disease (CVD) in the offspring later in life. The mechanisms associated with CVD seem to be a combination of genetic, molecular, and environmental factors which can be defined as fetal and postnatal programming. The aim of this paper is to discuss the relationship between pregnancy complicated by preeclampsia and possibility of CVD in the offspring. Unfortunately, due to its multifactorial nature, a clear dependency mechanism between preeclampsia and CVD is difficult to establish.

Effects of Maternal Obesity and Gestational Diabetes Mellitus on the Placenta: Current Knowledge and Targets for Therapeutic Interventions

Obesity and gestational diabetes mellitus (GDM) are becoming more common among pregnant women worldwide and are individually associated with a number of placenta-mediated obstetric complications, including preeclampsia, macrosomia, intrauterine growth restriction and stillbirth. The placenta serves several functions throughout pregnancy and is the main exchange site for the transfer of nutrients and gas from mother to fetus. In pregnancies complicated by maternal obesity or GDM, the placenta is exposed to environmental changes, such as increased inflammation and oxidative stress, dyslipidemia, and altered hormone levels. These changes can affect placental development and function and lead to abnormal fetal growth and development as well as metabolic and cardiovascular abnormalities in the offspring. This review aims to summarize current knowledge on the effects of obesity and GDM on placental development and function. Understanding these processes is key in developing therapeutic interventions with the goal of mitigating these effects and preventing future cardiovascular and metabolic pathology in subsequent generations.

Circulating levels of angiogenic factors and their association with preeclampsia among pregnant women at Mulago National Referral Hospital in Uganda

Preeclampsia (PE) is a major cause of maternal and new-born morbidity and mortality. Angiogenic factors contribute a major role in the vascular dysfunction associated with PE. We investigated the circulating levels of vascular endothelial growth factor (VEGF), placental growth factor (PlGF) and soluble Feline McDonough Sarcoma (fms)-like tyrosine kinase-1 (sFlt1), their association with PE and diagnostic performance of disease among pregnant women in Uganda. Using a case-control study design, 106 women with PE and 106 with normal pregnancy were enrolled. Demographic and clinical characteristics, and anticoagulated blood samples were collected from participants. Plasma VEGF, PlGF and sFlt1 levels were measured using Luminex and enzyme linked immunosorbent assays (ELISA). Conditional logistic regression was used to explore association of angiogenic factors with PE and receiver operating characteristic analysis was performed to investigate PE diagnostic performance. Levels of VEGF and PIGF were significantly lower in cases compared to controls (VEGF: median = 0.71 pg/ml (IQR = 0.38-1.11) Vs 1.20 pg/ml (0.64-1.91), p-value<0.001 and PlGF: 2.20 pg/ml (1.08-5.86) Vs 84.62 pg/ml (34.00-154.45), p-value<0.001). Plasma levels of sFlt1 were significantly higher in cases than controls (median = 141.13 (71.76-227.10) x103 pg/ml Vs 19.86 (14.20-29.37) x103 pg/ml). Increasing sFlt1 levels were associated with increased likelihood of PE (aOR = 4.73; 95% CI, 1.18-19.01; p-value = 0.0287). The sFlt1/PlGF ratio and sFlt1 had a better performance for diagnosis of PE, with AUC = 0.95 (95% CI, 0.93-0.98) followed by PlGF with AUC = 0.94 (95% CI, 0.91-0.97). Therefore, sFlt1, sFlt1/PlGF ratio and PlGF are potential candidates for incorporation into algorithms for PE diagnosis in the Ugandan population.

Stimulation of α7 Nicotinic Acetylcholine Receptor by Nicotine Suppresses Decidual M1 Macrophage Polarization Against Inflammation in Lipopolysaccharide-Induced Preeclampsia-Like Mouse Model

Changes in decidual macrophage polarization affect local inflammatory microenvironment and lead to adverse pregnancy outcomes. However, the regulatory mechanism of macrophage polarization in preeclampsia (PE) remains unclear. In this study, we found that α7nAChR expression was significantly down-regulated in decidual macrophages in PE patients compared to normal pregnant women, accompanied by a reduced proportion of M2 phenotype and an increased proportion of M1 phenotype; these results suggested that the reduced α7nAChR activity might contribute to changes in the polarization of decidual macrophages. Then, we further investigated the regulatory role of α7nAChR activation by nicotine on decidual macrophage polarization and placental remodeling in the PE-like mouse model. The PE mice were obtained by i.p. injection of 10 µg/kg lipopolysaccharide (LPS) gestational day (GD) 13, and 40 µg/kg LPS daily until GD16. Subcutaneous injection of 1.0 mg/kg nicotine was administrated from GD14 to GD18. Nicotine treatment increased the decreased M2 phenotype and inhibited the increased M1 phenotype in decidua of pregnant mice induced by LPS. The levels of pro-inflammatory cytokines in decidua were higher but the levels of anti-inflammatory cytokines were lower in PE mice compared to the controls, nicotine reversed these changes. The level of choline acetyltransferase (CHAT) was reduced in the LPS-treated group, it was increased following nicotine treatment. Damage of spiral artery remodeling and down-regulation of markers related to trophoblast invasion in placentas were found in PE mice; nicotine improved these pathological structures of placentas. α-bungarotoxin (α-BGT) which is specific antagonist for α7nAChR could abolish the effects of nicotine on decidual macrophage polarization, trophoblast arrangement and vascular structure in placental tissue in PE mice. These results suggest that α7nAChR plays an important regulatory role in maternal-fetal inflammation and placental remodeling in preeclampsia and may provide a theoretical basis for the discovery of new strategies for preeclampsia.

INTERGROWTH-21 Identifies High Prevalence of Low Symphysis-Fundal Height in Indigenous Pregnant Women Experiencing Multiple Infections, Nutrient Deficiencies, and Inflammation: The Maternal Infections, Nutrient Deficiencies, and Inflammation (MINDI) Cohort

BACKGROUND

In the absence of ultrasound, symphysis-fundal height (SFH) can assess maternal-fetal well-being as it is associated with gestational age, fetal weight, and amniotic fluid volume. However, other modifiers of SFH, including maternal infections, nutrient deficiencies, and inflammation (MINDI), have not been widely explored.

OBJECTIVES

Our objectives were 2-fold: 1) to assess prevalence of low SFH in indigenous Panamanian women using both Pan-American Health Organization (PAHO) and INTERGROWTH-21 standards and 2) to explore associations of SFH with maternal health indicators: infections (oral, skin, urogenital, nematode infections), nutrient deficiencies [protein and iron indicators (ferritin, serum iron, serum transferrin receptor, hepcidin), folate, and vitamins A, D, and B-12], and inflammation [leukocytes, C-reactive protein (CRP), cytokines].

METHODS

For this cross-sectional study, low-SFH-for-gestational-age was assessed using PAHO and INTERGROWTH <10th centile in 174 women at ≥16 weeks of gestation. Bootstrapping selected MINDI variables for inclusion in multivariable fractional polynomial (MFP) logistic regressions for low SFH. Associations of MINDI variables with hepcidin were also investigated.

RESULTS

Prevalence of low SFH was 8% using PAHO, but using INTERGROWTH, 50.6% had SFH <10th centile, including 37.9% <3rd centile. Both PAHO-SFH <10th centile and INTERGROWTH-SFH <3rd centile were associated with higher hepcidin (OR = 1.12, P = 0.008, and OR = 3.04, P = 0.001, respectively) and with lower TNF-α (OR = 0.73, P = 0.012, and OR = 0.93, P = 0.015, respectively). Wood-smoke exposure increased the odds of PAHO-SFH <10th centile (OR = 1.19, P = 0.009), whereas higher BMI decreased the odds of INTERGROWTH-SFH <3rd centile (OR = 0.87, P = 0.012). Lower pulse pressure (OR = 0.90, P = 0.009) and lower inflammatory responses [lower lymphocytes (OR = 0.21, P = 0.026), IL-17 (OR = 0.89, P = 0.011)] distinguished SFH <3rd centile from SFH ≥3rd to <10th centiles using INTERGROWTH-21 standards. The MFP regression for hepcidin controlling for SFH (adjusted R 2 = 0.40, P = 0.001) revealed associations with indicators of inflammation (CRP, P < 0.0001; IL-17, P = 0.012), acidic urinary pH (P = 0.008), and higher intake of supplements (P = 0.035).

CONCLUSIONS

Associations of low SFH with MINDI variables, including hepcidin, highlight its potential for early detection of multicausal in utero growth faltering.

Maternal Serum Cytokine Concentrations in Healthy Pregnancy and Preeclampsia

The maternal immune response is essential for successful pregnancy, promoting immune tolerance to the fetus while maintaining innate and adaptive immunity. Uncontrolled, increased proinflammatory responses are a contributing factor to the pathogenesis of preeclampsia. The Th1/Th2 cytokine shift theory, characterised by bias production of Th2 anti-inflammatory cytokine midgestation, was frequently used to reflect the maternal immune response in pregnancy. This theory is simplistic as it is based on limited information and does not consider the role of other T cell subsets, Th17 and Tregs. A range of maternal peripheral cytokines have been measured in pregnancy cohorts, albeit the changes in individual cytokine concentrations across gestation is not well summarised. Using available data, this review was aimed at summarising changes in individual maternal serum cytokine concentrations throughout healthy pregnancy and evaluating their association with preeclampsia. We report that TNF-α increases as pregnancy progresses, IL-8 decreases in the second trimester, and IL-4 concentrations remain consistent throughout gestation. Lower second trimester IL-10 concentrations may be an early predictor for developing preeclampsia. Proinflammatory cytokines (TNF-α, IFN-γ, IL-2, IL-8, and IL-6) are significantly elevated in preeclampsia. More research is required to determine the usefulness of using cytokines, particularly IL-10, as early biomarkers of pregnancy health.

Preeclampsia and Neurodevelopmental Outcomes: Potential Pathogenic Roles for Inflammation and Oxidative Stress?

Preeclampsia (PE) is a common and serious hypertensive disorder of pregnancy that occurs in approximately 3-5% of first-time pregnancies and is a well-known leading cause of maternal and neonatal mortality and morbidity. In recent years, there has been accumulating evidence that in utero exposure to PE acts as an environmental risk factor for various neurodevelopmental disorders, particularly autism spectrum disorder and ADHD. At present, the mechanism(s) mediating this relationship are uncertain. In this review, we outline the most recent evidence implicating a causal role for PE exposure in the aetiology of various neurodevelopmental disorders and provide a novel interpretation of neuroanatomical alterations in PE-exposed offspring and how these relate to their sub-optimal neurodevelopmental trajectory. We then postulate that inflammation and oxidative stress, two prominent features of the pathophysiology of PE, are likely to play a major role in mediating this association. The increased inflammation in the maternal circulation, placenta and fetal circulation in PE expose the offspring to both prenatal maternal immune activation-a risk factor for neurodevelopmental disorders, which has been well-characterised in animal models-and directly higher concentrations of pro-inflammatory cytokines, which adversely affect neuronal development. Similarly, the exaggerated oxidative stress in the mother, placenta and foetus induces the placenta to secrete factors deleterious to neurons, and exposes the fetal brain to directly elevated oxidative stress and thus adversely affects neurodevelopmental processes. Finally, we describe the interplay between inflammation and oxidative stress in PE, and how both systems interact to potentially alter neurodevelopmental trajectory in exposed offspring.

Preeclampsia and the Risk of Pancreatitis: A Nationwide, Population-Based Cohort Study

Background

Preeclampsia is a multiple organ dysfunction during pregnancy, including hepatic, renal, and neurological dysfunction, and is defined as hypertension and proteinuria occurring after 20 weeks of pregnancy. Clinical features seen in preeclampsia are due to relatively poorly perfused placenta and maternal endothelial dysfunction. Some studies have found that preeclampsia may cause acute pancreatitis due to microvascular abnormalities and visceral ischemia. This retrospective cohort study used the Taiwanese National Health Insurance Research Databases (NHIRD) to study the relationship between preeclampsia and the risk of pancreatitis.

Methods

In total, 606,538 pregnant women were selected from the NHIRD between January 1, 1998 and December 31, 2010. They were divided into a preeclampsia cohort (n = 485,211) and a nonpreeclampsia cohort (n = 121,327). After adjusting for comorbidities that may induce pancreatitis, we analyzed and compared the incidence of pancreatitis in the two cohorts.

Results

The overall incidence of pancreatitis in the preeclampsia cohort was significantly higher than that in the control cohort (4.29 vs. 2.33 per 10,000 person-years). The adjusted HR of developing pancreatitis increased 1.68-fold (95% CI: 1.19-2.36) in the preeclampsia cohort. In addition, pregnant women with preeclampsia without comorbidities had a significantly high risk of pancreatitis (aHR = 1.83, 95% CI 1.27-2.63). The combined effect of preeclampsia and alcohol-related diseases resulted in the highest risk of pancreatitis (aHR = 43.4, 95% CI: 6.06-311.3).

Conclusion

Compared with patients without preeclampsia, the risk of pancreatitis in patients with preeclampsia is significantly increased after adjusting for demographics and comorbidities. The risk of pancreatitis is greatly increased when preeclampsia is accompanied by alcohol-related diseases, hepatitis C, gallstones, diabetes, or age of 26–35 years. Early identification and effective control of preeclampsia and the associated comorbidities can reduce the risk of pancreatitis and the associated morbidity and mortality.

Mechanisms of Key Innate Immune Cells in Early- and Late-Onset Preeclampsia

Preeclampsia is a complex cardiovascular disorder of pregnancy with underlying multifactorial pathogeneses; however, its etiology is not fully understood. It is characterized by the new onset of maternal hypertension after 20 weeks of gestation, accompanied by proteinuria, maternal organ damage, and/or uteroplacental dysfunction. Preeclampsia can be subdivided into early- and late-onset phenotypes (EOPE and LOPE), diagnosed before 34 weeks or from 34 weeks of gestation, respectively. Impaired placental development in early pregnancy and subsequent growth restriction is often associated with EOPE, while LOPE is associated with maternal endothelial dysfunction. The innate immune system plays an essential role in normal progression of physiological pregnancy and fetal development. However, inappropriate or excessive activation of this system can lead to placental dysfunction or poor maternal vascular adaptation and contribute to the development of preeclampsia. This review aims to comprehensively outline the mechanisms of key innate immune cells including macrophages, neutrophils, natural killer (NK) cells, and innate B1 cells, in normal physiological pregnancy, EOPE and LOPE. The roles of the complement system, syncytiotrophoblast extracellular vesicles and mesenchymal stem cells (MSCs) are also discussed in the context of innate immune system regulation and preeclampsia. The outlined molecular mechanisms, which represent potential therapeutic targets, and associated emerging treatments, are evaluated as treatments for preeclampsia. Therefore, by addressing the current understanding of innate immunity in the pathogenesis of EOPE and LOPE, this review will contribute to the body of research that could lead to the development of better diagnosis, prevention, and treatment strategies. Importantly, it will delineate the differences in the mechanisms of the innate immune system in two different types of preeclampsia, which is necessary for a more personalized approach to the monitoring and treatment of affected women.

Nicotine Alleviates Cortical Neuronal Injury by Suppressing Neuroinflammation and Upregulating Neuronal PI3K-AKT Signaling in an Eclampsia-Like Seizure Model

Our previous studies showed that treatment with alpha7 nicotinic acetylcholine receptor (α7nAChR) agonist nicotine could alleviate systemic inflammation and reduce neuronal loss in the hippocampus and seizure severity in eclampsia. In this study, we further investigated whether there is also neuronal damage in the cortex after eclamptic seizure, elucidated the potential mechanisms underlying the neuroprotective roles of nicotine in eclampsia. Retrospective analysis of MRI data of severe preeclampsia (SPE) patients was conducted. A preeclampsia model was established by lipopolysaccharide injection (PE group), and pentylenetetrazol was used to induce eclamptic seizure (E group). α7nAChR agonist nicotine and its antagonist (α-BGT) and PI3K inhibitor wortmannin were used for drug administration. Neuronal damage was detected by Nissl staining, and changes in neuroinflammation, neuronal apoptosis, α7nAChR expression, and PI3K-AKT signaling on cortical neurons were detected by immunohistochemistry and western blotting. MRI images showed that most abnormal signals from the brain of SPE patients were located in the cortex. The neuron survival ratio was lower in the cortex than in the hippocampus within the E group; such ratios in the cortex were significantly lower in the E and PE groups compared with those of the control group. Nicotine markedly decreased the production of inflammatory cytokines and microglial activation in the cortex of the E group. Moreover, nicotine increased p-AKT levels and decreased cleaved caspase-3 levels in cortical neurons. Treatment with α-BGT reversed effects of nicotine. Wortmannin also blocked the anti-neuronal apoptosis action of nicotine. Our results suggest that nicotine protects against neuronal injury in the cortex following eclampsia possibly by inhibiting neuroinflammation and activating neuronal PI3K-AKT pathway.

Association between pentraxin-3 and the risk of preeclampsia: A meta-analysis

An association between circulating pentraxin-3 (PTX3) and the risk of preeclampsia (PE) remains to be established. We performed a meta-analysis of observational studies to evaluate their relationship.The PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and WanFang databases were searched for related observational studies evaluating PTX3 and PE risk. A random-effects or a fixed-effects model was used in the meta-analysis, depending on the heterogeneity among the included studies.Nine case-control studies were included, with 396 PE patients and 438 controls. The results showed that PTX3 was significantly higher in pregnant women with PE as compared to those without PE (standardized mean difference [SMD] = 2.48, P < .001), with significant heterogeneity (I2 = 98%), particularly for those over 30 years old (SMD = 3.75, P < .001). Subsequent analyses showed that patients with severe or early-onset PE had higher PTX3 levels compared to those with mild or late-onset PE (SMD = 0.93, P = .01), suggesting that PTX3 may be a marker of PE severity. The association between PTX3 and PE was not significantly affected by the statistical method used. Sensitivity analyses by omitting one study at a time did not significantly affect the results. However, the funnel plots were asymmetric, suggesting the potential existence of publication bias.PTX3 may be related to the risk and severity of PE in pregnant women. These results should be evaluated and confirmed in cohort studies.

Maternal and umbilical cord procalcitonin, high-sensitivity C-reactive protein, and interleukin-6 levels in preeclamptic and normotensive patients: A cross-sectional study

OBJECTIVES

To report maternal and umbilical vein levels of procalcitonin (PCT) in patients with preeclampsia (PE) compared to controls. As secondary aims, we measured high-sensitivity C-reactive protein (hs-CRP), and interleukin-6 (IL-6). Moreover, correlation analyses were performed between the inflammatory biomarkers and mean arterial pressure (MAP).

STUDY DESIGN

This was a single center, cross-sectional study.

MAIN OUTCOME MEASURES

After Institutional Review Board approval and written informed consent, patients with or without PE were enrolled. PCT, hs-CRP, and IL-6 levels were compared between groups using multiple linear regression models. We calculated the adjusted ratios of geometric means (aRGM) for the comparison of patients with and without PE. Correlation analysis between the inflammatory biomarkers and MAP was performed using Spearman's method.

RESULTS

A total of 156 participants were enrolled, yielding 156 venous blood samples and umbilical venous blood samples. Seventy-six patients were in the PE group, and 80 patients were in the control group. Maternal plasma and serum concentrations of PCT (aRGM 3.35 (95% confidence interval [CI]: 2.26, 4.95; p < 0.001)), hs-CRP (aRGM 1.85 (95% CI: 1.30, 2.63; p = 0.003)), and IL-6 (aRGM 1.49 (95% CI: 1.08, 2.04; p = 0.045)) were higher in the PE group. In umbilical venous samples, the concentrations of PCT (aRGM 2.54 (95% CI: 1.46, 4.44; p = 0.003)) and hs-CRP (aRGM 1.45 (95% CI: 1.13, 1.87; p = 0.012)) in the PE group were higher than the controls. No difference in umbilical venous IL-6 concentrations were detected between PE vs. control groups (aRGM 1.46; 95% CI: 1.07, 1.98; p = 0.051). There was positive correlation for both PCT and hs-CRP with MAP in maternal and umbilical venous samples. However, there was no correlation between IL and 6 and MAP in maternal or umbilical venous samples.

CONCLUSIONS

PCT levels were elevated in maternal and umbilical venous samples of patients with PE, and correlated with disease severity.

Comparative gene expression analysis of Fas and related genes in preeclamptic and healthy women: A cross-sectional study

BACKGROUND

Preeclampsia is a hypertensive disorder of pregnancy affecting about 2-10% pregnancies worldwide. mRNA expression of tumor necrosis factor alpha (TNF- α ), Fas, and FasL have been reported to be altered in placental bed in preeclamptic pregnancies. We hypothesized that the expression of these genes is also altered in peripheral blood mononuclear cells (PBMCs) in preeclampsia.

OBJECTIVE

To compare the expression of Fas receptor and related genes in PBMCs of preeclamptic and normotensive pregnant women.

MATERIALS AND METHODS

A cross-sectional comparative study comprising of 18 cases and 18 controls was designed. 5 ml of venous blood was drawn and collected considering aseptic measures. Buffy coat was separated by centrifugation and stored at -20°C. Favor Prep total RNA Isolation Kit (Favorgen, Taiwan) was used for RNA extraction. The mRNA expression of TNF- α , Fas, and FasL was measured by real-time polymerase chain reaction in PBMCs in preeclamptic and normal pregnancies.

RESULTS

A significant increase in mRNA expression of TNF- α , Fas, and FasL (p ≤ 0.001) was observed in PBMCs of preeclamptic pregnancies compared to the control group (p ≤ 0.001). Moreover, a significant positive correlation was found between the TNF- α mRNA expression and Fas and FasL (p ≤ 0.001).

CONCLUSION

The results lead to the conclusion that mRNA expression of TNF- α , Fas, and FasL in the maternal PBMCs is altered in preeclamptic pregnancies and might contribute to the pathogenesis of the disease.

Antiapolipoprotein A-1 Autoantibody Positivity Is Associated with Threatened Abortion

BACKGROUND

Autoantibodies against apolipoprotein A-1 (anti-ApoA-1 IgG) were demonstrated to be associated with cardiovascular outcomes in several inflammatory diseases. As balanced inflammation is critical for uncomplicated pregnancy, we aimed to investigate the prevalence of anti-ApoA-1 IgG and anti-c-terminal ApoA-1 autoantibodies (Ac-terAA1 IgG) in a cohort of pregnant women and their potential relationship with threatened abortion (TA).

METHODS

Between 2012 and 2014, 371 consecutive outpatient pregnant women were included in this study and followed until delivery. Anti-ApoA-1 and anti-Ac-terAA1 IgG were measured by ELISA technique on serum samples collected between the 24th and 26th week of pregnancy. Associations with TA were tested using linear regression analysis and C-statistics.

RESULTS

Median age was 34 with a prevalence of the Caucasian ethnicity (90.5%). TA occurred in 10 women (2.7%). C-statistics indicated that anti-ApoA-1 and anti-Ac-terAA1 IgG levels upon study inclusion were predictive of TA (0.73, 95% confidence interval [CI] 0.69-0.78, p < 0.001 and 0.76, 95% CI 0.71-0.80, p < 0.001 and 0.76, 95% CI 0.71-0.80, p < 0.001 and 0.76, 95% CI 0.71-0.80, p < 0.001 and 0.76, 95% CI 0.71-0.80.

CONCLUSION

Anti-ApoA-1 and anti-Ac-terAA1 IgG are independently associated with TA during pregnancy with an appealing NPV. The causal biological mechanisms underlying this association as well as the possible clinical relevance of these findings require further investigations.

Role of Elevated SFLT-1 on the Regulation of Placental Transporters in Women With Pre-Eclampsia

Pre-eclampsia (PE) is an obstetric complication associated with elevated levels of fms-like tyrosine kinase 1 (sFlt-1) and dysregulated trophoblast differentiation. However, limited information exists on the expression and regulation of placental drug transporters in PE. Transporter mRNA and protein expression were analyzed in human placentas diagnosed with PE (n = 34) and gestational age-matched controls (n = 24), whereas placental BeWo cells were treated with angiogenic factors in vitro. Significant downregulation of breast cancer resistance protein (BCRP) and several other transporters were seen in placentas complicated by PE compared with controls, whereas mRNA levels of sFlt-1 were induced by 2.5-fold in PE placentas (P < 0.01). Treatment of BeWo cells with sFlt-1 resulted in an 85-90% downregulation of BCRP, which was attenuated by vascular endothelial growth factor. Our findings suggest that placental function is compromised during PE due to altered expression of clinically important transporters. Furthermore, our in vitro results show that sFlt-1 is involved in the regulation of BCRP.

Enhanced Expression of TLR8 in Placental Tissue in Preeclampsia

The expression of TLR8 in the placental tissue was studied in specimens from women of reproductive age with early- and late-onset preeclampsia (12 and 8 patients, respectively). The reference groups included 15 women: 10 with uneventful full-term pregnancy and 5 with preterm operative delivery on gestation weeks 28-33. The expression of TLR8 in placental structures was maximum in early-onset preeclampsia (p<0.01) characterized by the gravest clinical course, while the expression of TLR8 in late-onset preeclampsia was comparable with that in full-term pregnancy. This significant increase of TLR8 expression in placental tissue seemed to reflect activation of the key proinflammatory factors of congenital immunity and induction of the systemic inflammatory response. Manifest differences in the expression of TLR8 in late- and early-onset preeclampsia confirmed the hypothesis on different variants of this condition.

Cyclosporin A ameliorates eclampsia seizure through reducing systemic inflammation in an eclampsia-like rat model

Our previous studies have shown that the maternal hyperinflammatory response in pre-eclampsia lowered the eclampsia-like seizure threshold. Cyclosporin A (CsA), which is an effective immunosuppressant, could attenuate the inflammatory responses in LPS-induced pre-eclampsia rats. Here, we hypothesized that CsA may ameliorate seizure severity through reducing systemic inflammation in pre-eclampsia/eclampsia. In the current study, the effects of CsA on pre-eclampsia manifestation, eclampsia-like seizure activities and systemic inflammation were examined in a pre-eclampsia model. Pregnant rats were given an intraperitoneal injection of the epileptogenic drug pentylenetetrazol (PTZ) following a tail vein injection of lipopolysaccharide to establish the eclampsia-like seizure model. CsA (5 mg/kg) was administered intravenously through the tail after LPS infusion. Mean systolic blood pressure and proteinuria in pre-eclampsia were detected. After PTZ injection, seizure activity was assessed, inflammatory responses were determined and pregnancy outcomes were analyzed. The results showed that CsA treatment significantly decreased blood pressure and proteinuria and increased the fetal and placental weight (P < 0.01). Meanwhile, CsA treatment significantly reduced serum IL-1β, TNF-α, and IL-17 levels (P < 0.01), decreased the seizure scores and prolonged the latency to seizure (P < 0.01). CsA effectively attenuated pre-eclampsia manifestation and eclampsia-like seizure severity. In addition, CsA treatment significantly reduced the inflammatory cytokine levels and improved pregnancy outcomes following eclampsia-like seizures. The decreased inflammatory cytokines in pre-eclampsia are coincident with attenuated pre-eclampsia manifestation after CsA treatment, suggesting that CsA treatment might decrease the eclampsia-like seizure severity through decreasing systemic inflammation in pre-eclasmpsia/eclampsia.

The effects of estradiol on inflammatory and endothelial dysfunction in rats with preeclampsia

Preeclampsia (PE), a hypertensive disorder during pregnancy, has adverse effects to both the mother and the fetus. Maternal inflammatory and vascular endothelial dysfunction are important factors in the pathogenesis of PE. The present study aimed to investigate the effects of estradiol (E2) on inflammatory and endothelial dysfunction in an N (omega)-nitro-L-arginine methyl ester (L-NAME)-induced rat model of PE. Adult pregnant female Sprague-Dawley rats were divided into four equal groups between days 7 and 11 of gestation and treated as follows: i) Pregnant rats receiving daily intraperitoneal (i.p.) injections of equal volume of 0.9% normal saline (NS) (Control group, n=12); ii) pregnant rats receiving daily i.p. injections of L-NAME at 50 mg/kg (L-NAME group, n=12); iii) pregnant rats receiving a daily i.p. injection of 50 mg/kg L-NAME and NS from day 11 (L-NAME + NS group, n=12); and iv) pregnant rats receiving daily i.p. injections of 50 mg/kg L-NAME and 100 µg/kg/day E2 from day 11 (L-NAME + E2 group, n=12). On day 21, blood pressure (BP) and the level of 24-h urine protein in the maternal rats, fetal weight and percentage of stillbirths following a cesarean section were recorded. The activities of nitric oxide (NO) and inducible NO synthase (iNOS), the levels of inflammatory cytokines [interleukin (IL)-1β, IL-6, interferon-γ and monocyte chemoattractant protein-1], adherence factors (CD49d, intracellular adhesion molecule 1 and lymphocyte function-associated antigen-1) and uterine angiogenic status (Fms-like tyrosine kinase-1, vascular cell adhesion molecule and matrix metalloproteinase 2/9) were also assessed. In addition, the histopathology of the placenta, the expression of estrogen receptor α 36 (ERα36), ERα, ERβ and G protein-coupled ER, as well as the activation of the toll-like receptor 4 (TLR4) signaling pathway (TLR4, myeloid differentiation primary response 88, IL-1 receptor-associated kinase 4 and tumor necrosis factor receptor-associated factor 6) were evaluated by H&E staining, immunofluorescence and western blot assays. Treatment with L-NAME increased the BP, urine protein and rate of stillbirths and suppressed fetal weight compared with those in the control group. The L-NAME-induced effects were attenuated by the administration of E2. In addition, the administration of E2 decreased inflammation and NO levels and altered the uterine angiogenic status. The histological analysis of PE rat placenta in the E2-treated group confirmed the effects on biochemical parameters. Of note, E2 treatment significantly suppressed the TLR4 signaling pathway. In the rat model of PE, adverse outcomes including BP, fetal rat weight and proteinuria, high neonatal death rate, inflammatory response, oxidative stress and endothelial dysfunction were attenuated by exogenous E2 administration, which may present a novel approach for the clinical treatment of PE.

Activation of a TLR9 mediated innate immune response in preeclampsia

Preeclampsia is a multisystemic disorder leading to the development of a placental ischemic microenvironment with a resultant increase in oxidative stress. There is evidence that mitochondrial dysfunction and the innate immune system both play a role in the pathophysiology of this disease. Mitochondrial DAMPs such as mtDNA bind specific pattern recognition receptors such as Toll-like receptor 9 (TLR9) on the endosomal surface of immune cells, in particular neutrophils, subsequently activating them and triggering an innate response. We hypothesised that the exaggerated innate immune response seen in preeclampsia is provoked by dysfunctional mitochondria. Here we provide evidence that TLR9 activity is significantly increased at time of disease in women with preeclampsia. Furthermore, we show activation of neutrophil markers, Calprotectin, Myeloperoxidase (MPO), and IL-8 are significantly increased at time of disease compared to uncomplicated pregnancies. This research supports a potential role of TLR9 activation of an innate immune response evident in preeclampsia which may possibly be initially triggered by dysfunctional mitochondria.

Glutathione-S-transferase M1 polymorphism and pro-inflammatory cytokines tumour necrosis factor-α and interleukin-1β are associated with preeclampsia in Serbian women

PROBLEM

Preeclampsia has a multifactorial origin with genetic, immunological, and environmental factors described as main contributors to its onset. This study aimed to investigate glutathione-S-transferase M1 (GSTM1) and glutathione-S-transferase T1 (GSTT1) gene polymorphisms, the expression of pro-inflammatory cytokines (TNF-α, IL-1β, IL-6), and the potential relationship between GST polymorphisms and cytokine expression levels in preeclampsia and uncomplicated pregnancy.

METHOD OF STUDY

This prospective case-control study included 50 women with preeclampsia and 50 healthy pregnant women. DNA and RNA were extracted from women leukocytes. Deletion polymorphisms were analyzed by PCR, while cytokine mRNA expression was analyzed by real-time PCR.

RESULTS

GSTM1 null genotype with present GSTT1 increased the risk for preeclampsia development. Deletion of GSTT1 without deletion of GSTM1 increased the risk for early preeclampsia. Relative mRNA expression of TNF-α was significantly higher in preeclampsia compared to healthy pregnant women (P = 0.006). Expression of IL-1β was significantly higher in severe and late preeclampsia compared to the control group (P = 0.005, P = 0.007, respectively). A significant positive correlation between TNF-α and IL-1β was observed (Spearman's ρ = 0.312, P = 0.028) and between IL-1β and IL-6, in preeclampsia group (Spearman's ρ = 0.296, P = 0.037). IL-1β was significantly increased in patients with GSTT1 null genotype (P = 0.015) while IL-6 was increased in patients with GSTM1 null genotype (P = 0.015).

CONCLUSIONS

GSTM1 null genotype represents a risk factor for preeclampsia development, while GSTT1 null genotype favors early preeclampsia. Preeclampsia is also associated with increased expression of pro-inflammatory cytokines, predominantly TNF-α and IL-1β.

C-Reactive Protein Levels at the Midpregnancy Can Predict Gestational Complications

Although essential for a successful pregnancy, a growing body of evidence suggests that maternal inflammation, when dysregulated, may represent a risk factor for both maternal and neonatal outcomes. Here, we assessed the accuracy of maternal C-reactive protein (CRP) concentrations at the middle phase of pregnancy in the identification of maternal adverse outcomes (MAO) until delivery. A correlation between CRP and a complicated pregnancy including both maternal and neonatal adverse outcomes has been investigated, too. In this retrospective study, conducted at the Diabetology Unit of IRCCS Ospedale Policlinico San Martino, Genoa (Italy), 380 outpatient pregnant women have been enrolled at the prenatal visit before performing a 75 g oral glucose tolerance test at 24th-26th gestational week for gestational diabetes mellitus (GDM) screening. Demographic, medical, and reproductive history has been obtained by verbal interview. Data about pregnancy and delivery have been retrieved from medical records. The median value of maternal baseline serum CRP was 3.25 μg/mL. Women experiencing MAO were older, more frequently suffering from hypertension, and showed higher CRP concentrations, with a cutoff value >1.86 μg/mL found by a ROC curve analysis to be accurately predictive for MAO. By a logistic regression analysis, serum CRP levels >1.86 μg/mL have been found to predict MAO also considering maternal age, hypertension, and GDM. Maternal CRP levels have been positively associated with overall pregnancy adverse outcomes (maternal and neonatal), too. In conclusion, in pregnant women serum levels of CRP can early recognize subjects at higher risk for maternal and neonatal complications needing a more stringent follow-up.

A perspective on pre-eclampsia and neurodevelopmental outcomes in the offspring: Does maternal inflammation play a role?

Pre-eclampsia is a leading cause of maternal death and maternal and perinatal morbidity. Whilst the clinical manifestations of pre-eclampsia often occur in late pregnancy, the molecular events leading into the onset of this disease are thought to originate in early pregnancy and result in insufficient placentation. Although the causative molecular basis of pre-eclampsia remains poorly understood, maternal inflammation is recognised as a core clinical feature. While the adverse effects of pre-eclampsia on maternal and fetal health in pregnancy is well-recognised, the long-term impact of pre-eclampsia exposure on the risk of autism spectrum disorder (ASD) in exposed offspring is a topic of on-going debate. In particular, a recent systematic review has reported an association between exposure to pre-eclampsia and increased risk of ASD, however the molecular basis of this association is unknown. Here we review recent evidence for; 1) maternal inflammation in pre-eclampsia; 2) epidemiological evidence for alterations in neurodevelopmental outcomes in offspring exposed to pre-eclampsia; 3) long-term changes in the brains of offspring exposed to pre-eclampsia; and 4) how maternal inflammation may lead to altered neurodevelopmental outcomes in pre-eclampsia exposed offspring. Finally, we discuss the implications of this for the development of future studies in this field.

Silencing of Annexin A1 suppressed the apoptosis and inflammatory response of preeclampsia rat trophoblasts

Preeclampsia (PE) is a disorder that is characterized by pregnancy-induced hypertension. It has been reported that Annexin A1 (ANXA1) is highly expressed in the plasma of women diagnosed with PE. Therefore, the present study aimed to examine the effect of ANXA1 on PE rats. The PE animal model was constructed in rats using Nω-nitro-L-arginine methyl ester (L-NAME), and the blood pressure and urine protein levels of rats were detected. The pathological features of placental tissue, and the levels of inflammatory factors and ANXA1 were respectively measured by hematoxylin-eosin staining, enzyme-linked immunosorbent assay and immunohistochemical assay. The activity of trophoblasts obtained from PE placental tissue was measured using immunofluorescence staining, while cell apoptosis was assessed using flow cytometry. The levels of associated factors were determined by reverse transcription-quantitative polymerase chain reaction and western blot analysis. The results identified that systolic blood pressure, diastolic blood pressure, mean arterial pressure and urine protein levels were enhanced, and that the contents of ANXA1, tumor necrosis factor alpha (TNF-α), interleukin (IL)-1β, IL-6 and IL-8 were increased in the L-NAME group. Transfection with small interfering RNA (siRNA)-ANXA1 markedly decreased the apoptosis and inflammatory response of trophoblasts. In addition, siRNA-ANXA1 upregulated the levels of B-cell lymphoma-2 (Bcl-2) and pro-caspase-3, and downregulated the levels of Bcl-2-associated X protein, cleaved-caspase-3, TNF-α, IL-1β, IL-6 and IL-8. Furthermore, siRNA-ANXA1 repressed the phosphorylation of Janus kinase 2 (JAK2) and signal transducer and activator of transcription 3 (STAT3); however, siRNA-ANXA1 did not alter the levels of JAK2 and STAT3. Therefore, silencing of ANXA1 suppressed the apoptosis and inflammatory response of PE rat trophoblasts, and downregulated JAK2/STAK3 pathway.

Preeclampsia: A review of the pathogenesis and possible management strategies based on its pathophysiological derangements

This review is divided into three parts. The first part briefly describes the pathogenesis of preeclampsia. This is followed by reviewing previously reported management strategies of the disease based on its pathophysiological derangements. Finally, the author defines the safe and acceptable methods/medications that may be used to 'prevent' preeclampsia (in high risk patients) and those that may be used to 'treat' preeclampsia (meant to prolong the pregnancy in patients with established preeclampsia). The review concludes that multi-center trials are required to include multiple drugs in the same management protocol.

Overexpressed HO-1 is associated with reduced STAT3 activation in preeclampsia placenta and inhibits STAT3 phosphorylation in placental JEG-3 cells under hypoxia

INTRODUCTION

Inadequate trophoblast invasion and placentation are widely believed to contribute to preeclampsia, and multiple lines of evidence indicate the involvement of hypoxia in preeclampsia. However, the molecular mechanisms underlying the association of placental hypoxia with preeclampsia are not clear.

MATERIAL AND METHODS

The present study focused on the role in preeclampsia of heme oxygenase 1 (HO-1), which is an inducible isoform of HO in response to hypoxia, via examining the expression of HO-1 and the expression and phosphorylation (Tyr705) of Signal transducer and activator of transcription (STAT) 3 in preeclamptic placentas via the immunohistochemical method, western blotting assay and RT-qPCR method. Then we investigated the regulation by HO-1 of the expression and phosphorylation of STAT3 in human placental choriocarcinoma JEG-3 cells under hypoxia.

RESULTS

There was upregulation of HO-1 at both mRNA (1.506 ±0.08347 (N = 37) vs. 1.000 ±0.08854 (N = 31), p < 0.0001) and protein (0.630 ±0.155 (N = 35) vs. 0.310 ±0.052, 0.630 ±0.155 (N = 35), p < 0.001) levels and a reduced level of STAT3 phosphorylation (Tyr 705) in the preeclamptic placental tissues, compared to normal placental tissues (0.143 ±0.027 (N = 35) vs. 0.194 ±0.028 (N = 35), p < 0.01). Also, in vitro experiments demonstrated that HO-1 was markedly promoted by hypoxia in human placental choriocarcinoma JEG-3 cells, 6 or 12 h post treatment (p < 0.05 or p < 0.01). However, the STAT3 phosphorylation (Tyr 705) was attenuated by sustained hypoxia (p < 0.01). Moreover, it was demonstrated that HO-1 overexpression significantly inhibited the hypoxia-promoted STAT3 phosphorylation (Tyr 705).

CONCLUSIONS

HO-1 was overexpressed in PE placenta, in association with reduced STAT3 phosphorylation (Tyr 705). HO-1 inhibits the STAT3 phosphorylation in placental JEG-3 cells under hypoxia. Thus, we speculate that overexpressed HO-1 might contribute to the reduced STAT3 phosphorylation (Tyr 705) and the pathogenesis of preeclampsia.

Interleukin-10 rs1800871 (-819C/T) and ATA haplotype are associated with preeclampsia in a Tunisian population

OBJECTIVES

Interleukin-10 (IL-10) is implicated in several aspects of pregnancy. As genetic predisposition can be involved in the development of preeclampsia, the association between IL-10's promoter region polymorphisms and this pathology has been investigated, although with conflicting results. To date, only a small cohort study (total n = 40) has evaluated this association in the African continent, and none have been conducted in Tunisia. Hence, we evaluated the association between these polymorphisms and the risk of preeclampsia in a large Tunisian cohort.

STUDY DESIGN

345 preeclampsia patients and 300 controls were genotyped for the IL-10 promoter region variants -1082A/G, -819C/T and -592A/C using real-time PCR.

MAIN OUTCOME MEASURES

Differences in means were determined by Student's t-test, while intergroup significance was assessed by Pearson χ² or 2-way ANOVA. Genotypes were tested for Hardy-Weinberg equilibrium (HWE) in the control and cases. Logistic regression analysis was performed in order to determine the odds ratios and 95% confidence intervals associated with the linkage disequilibrium risk.

RESULTS

An increased frequency of the -819 T (minor) allele and the -819 T/T genotype was seen in preeclampsia cases. Also, three-locus haplotype (-1082AG/-819CT/-592AC) analysis identified the ATA haplotype as having a higher incidence in women with preeclampsia (OR = 1.48, 95% CI: 1.03-2.11) and this was confirmed by multivariate regression analysis (OR = 1.65, 95% CI: 1.13-2.43) after controlling for covariates.

CONCLUSIONS

We suggest that the IL-10 -819 T/T variant and the ATA haplotype, which are associated with low production of IL 10, represent genetic risk factors for preeclampsia in Tunisian women.

Uterine Artery Flow and Offspring Growth in Long-Evans Rats following Maternal Exposure to Ozone during Implantation

BACKGROUND

Epidemiological studies suggest that increased ozone exposure during gestation may compromise fetal growth. In particular, the implantation stage of pregnancy is considered a key window of susceptibility for this outcome.

OBJECTIVES

The main goals of this study were to investigate the effects of short-term ozone inhalation during implantation on fetal growth outcomes and to explore the potential for alterations in uterine arterial flow as a contributing mechanism.

METHODS

Pregnant Long-Evans rats were exposed to filtered air, 0.4 ppm ozone, or 0.8 ppm ozone for 4 h/d during implantation, on gestation days (GD) 5 and 6. Tail cuff blood pressure and uterine artery Doppler ultrasound were measured on GD 15, 19, and 21. To assess whether peri-implantation ozone exposure resulted in sustained pulmonary or systemic health effects, bronchoalveolar lavage fluid, serum metabolic and inflammatory end points, and kidney histopathology were evaluated in dams at GD 21. Growth parameters assessed in GD 21 offspring included fetal weight, length, and body composition.

RESULTS

Measures of maternal uterine arterial flow, including resistance index and mean velocity, indicated that resistance increased between GD 15 and GD 21 in 0.8 ppm dams but decreased in controls, although absolute values were similar in both groups on GD 21. Ozone-exposed dams also had lower serum glucose and higher free fatty acid concentrations than controls on GD 21. On GD 21, both male and female offspring had lower body weight than controls, and pooled subsets of 3 male and 3 female fetuses from litters exposed to 0.8 ppm ozone had lower lean mass and fat mass than pooled control offspring.

CONCLUSIONS

Findings from our experimental model suggest that the offspring of dams exposed to ozone during implantation had reduced growth compared with controls, possibly as a consequence of ozone-induced vascular dysfunction. https://doi.org/10.1289/EHP2019.

Circulating soluble endoglin modifies the inflammatory response in mice

Inflammation is associated with every health condition, and is an important component of many pathologies such as cardiovascular diseases. Circulating levels of soluble endoglin have been shown to be higher in the serum of patients with cardiovascular diseases with a significant inflammatory component. The aim of this study was to evaluate the implication of circulating soluble endoglin in the inflammatory response. For this purpose, a transgenic mouse expressing human soluble endoglin (sEng+) was employed, and three different inflammatory approaches were used to mimic inflammatory conditions in different tissues. This study shows that control sEng+ mice have a normal inflammatory state. The lung and kidney injury induced by the inflammatory agents was reduced in sEng+ mice, especially the intra-alveolar and kidney infiltrates, suggesting a possible reduction in inflammation induced by soluble endoglin. To deepen into this possible effect, the leukocyte number in the bronchoalveolar lavage and air pouch lavage was evaluated and a significant reduction of neutrophil infiltration in LPS-treated lungs and ischemic kidneys from sEng+ with respect to WT mice was observed. Additionally, the mechanisms through which soluble endoglin prevents inflammation were studied. We found that in sEng+ animals the increment of proinflammatory cytokines, TNFα, IL1β and IL6, induced by the inflammatory stimulus was reduced. Soluble endoglin also prevents the augmented adhesion molecules, ICAM, VCAM and E-selectin induced by the inflammatory stimulus. In addition, vascular permeability increased by inflammatory agents was also reduced by soluble endoglin. These results suggest that soluble endoglin modulates inflammatory-related diseases and open new perspectives leading to the development of novel and targeted approaches for the prevention and treatment of cardiovascular diseases.

Blood laboratory testing for early prediction of preeclampsia: chasing the finish line or at the starting blocks?

Preeclampsia (PE) affects 2-8% of pregnancies worldwide, thus representing an important cause of maternal and neonatal morbidity, up to death. Many studies have been designed to identify putative biomarkers for accurate and timely diagnosing PE, but only some of them were focused on specific and sensitive biomarkers for early prediction of this life-threatening condition. In particular, some prospective studies aimed to investigate the predictive role of circulating biomarkers before 20 weeks of gestation in the general pregnant population yielded conflicting results. This article is hence centered on results obtained in studies investigating the predictive performances of angiogenic, anti-angiogenic, inflammatory, endocrine, and epigenetic biomarkers. The available evidence suggests that angiogenic and anti-angiogenic molecules, in particular the sFlt1:PlGF ratio, may be considered the biomarkers with the best diagnostic performance in the second trimester. However, doubts remain about their use in clinical settings before the 20th gestational week. Even lower evidence is available for other biomarkers, due to the fact that some positive results have not been confirmed in ensuing investigations, whereas unresolved analytical issues still contribute to make their clinical reliability rather questionable. Differential expression of microRNAs seems also a promising evidence for early prediction of PE, but additional research and well-designed prospective studies are needed to identify and validate routine predictive tests. KEY MESSAGES Preeclampsia affects 2-8% of pregnant women worldwide, thus remaining one of the leading causes of maternal and neonatal morbidity and mortality. Several studies have investigated the predictive role of circulating biomarkers before 20th week of gestation with conflicting results. Additional research and well-designed prospective studies are needed to identify and validate predictive tests in clinical practice.

Biomarkers of oxidative stress in pregnancy complications

Pregnancy complications including pre-eclampsia, gestational-diabetes mellitus, preterm birth and intrauterine growth restriction can cause acute and chronic health problems for the mother and lead to fetal loss or dysregulation of infant physiology. The human placenta is susceptible to oxidative stress and oxidative damage in early gestation contributes to the onset of these conditions later in pregnancy. Current methods of predicting pregnancy complications are limited and although a large number of factors are associated with disease progression, few biomarkers have been used to aid in disease diagnosis early in gestation. This review discusses the detection of oxidative stress markers in biological fluids and highlights the need for further studies to validate their use in the prediction or diagnosis of pregnancy disorders.