Pathogenesis of intrauterine growth restriction (IUGR)-conclusions derived from a European Union Biomed 2 Concerted Action project 'Importance of Oxygen Supply in Intrauterine Growth Restricted Pregnancies'-a workshop report

Placental physioxia is based on spatial and temporal variations of placental oxygenation throughout pregnancy

For obvious reasons, in vivo measurements of placental oxygenation are extremely rare and hence, scientists need to focus on the few studies that revealed at least some data on the topic. The scarcity of real in vivo data resulted in the development of hypotheses on placental oxygenation that blocked an objective view on the topic for decades. Only now, new hypotheses are emerging adding new views and ideas on the topic. Especially in the field of preeclampsia, hypotheses on placental oxygenation have mislead a whole generation of scientists. This review article displays the available in vivo placental oxygen data from 8 to 40 weeks of gestation. It also compares these physiological oxygen concentrations, called physioxia, with the situation in pre-placental hypoxia, i.e. pregnancies at high altitude. Finally, it summarizes what we know today about oxygen measurements in cases with preeclampsia. In early-onset preeclampsia cases, all in vivo data available today point to increased oxygen values in the intervillous space of the placenta. This is due to a reduced oxygen transfer of the placental barrier from maternal to fetal blood, resulting in hypoxia of fetal blood and the fetus.

(Dis)similarities between the Decidual and Tumor Microenvironment

Placenta-specific trophoblast and tumor cells exhibit many common characteristics. Trophoblast cells invade maternal tissues while being tolerated by the maternal immune system. Similarly, tumor cells can invade surrounding tissues and escape the immune system. Importantly, both trophoblast and tumor cells are supported by an abetting microenvironment, which influences invasion, angiogenesis, and immune tolerance/evasion, among others. However, in contrast to tumor cells, the metabolic, proliferative, migrative, and invasive states of trophoblast cells are under tight regulatory control. In this review, we provide an overview of similarities and dissimilarities in regulatory processes that drive trophoblast and tumor cell fate, particularly focusing on the role of the abetting microenvironments.

Establishment of an in vitro placental barrier model cultured under physiologically relevant oxygen levels

The human placental barrier facilitates many key functions during pregnancy, most notably the exchange of all substances between the mother and fetus. However, preclinical models of the placental barrier often lacked the multiple cell layers, syncytialization of the trophoblast cells and the low oxygen levels that are present within the body. Therefore, we aimed to design and develop an in vitro model of the placental barrier that would reinstate these factors and enable improved investigations of barrier function. BeWo placental trophoblastic cells and human umbilical vein endothelial cells were co-cultured on contralateral sides of an extracellular matrix-coated transwell insert to establish a multilayered barrier. Epidermal growth factor and forskolin led to significantly increased multi-nucleation of the BeWo cell layer and increased biochemical markers of syncytial fusion, for example syncytin-1 and hCGβ. Our in vitro placental barrier possessed size-specific permeability, with 4000-Da molecules experiencing greater transport and a lower apparent permeability coefficient than 70 000-Da molecules. We further demonstrated that the BeWo layer had greater resistance to smaller molecules compared to the endothelial layer. Chronic, physiologically low oxygen exposure (3-8%) increased the expression of hypoxia-inducible factor 1α and syncytin-1, further increased multi-nucleation of the BeWo cell layer and decreased barrier permeability only against smaller molecules (457 Da/4000 Da). In conclusion, we built a novel in vitro co-culture model of the placental barrier that possessed size-specific permeability and could function under physiologically low oxygen levels. Importantly, this will enable future researchers to better study the maternal-fetal transport of nutrients and drugs during pregnancy.

The Role of Epigenetics in Placental Development and the Etiology of Preeclampsia

In this review, we comprehensively present the function of epigenetic regulations in normal placental development as well as in a prominent disease of placental origin, preeclampsia (PE). We describe current progress concerning the impact of DNA methylation, non-coding RNA (with a special emphasis on long non-coding RNA (lncRNA) and microRNA (miRNA)) and more marginally histone post-translational modifications, in the processes leading to normal and abnormal placental function. We also explore the potential use of epigenetic marks circulating in the maternal blood flow as putative biomarkers able to prognosticate the onset of PE, as well as classifying it according to its severity. The correlation between epigenetic marks and impacts on gene expression is systematically evaluated for the different epigenetic marks analyzed.

The Critical Role of Abnormal Trophoblast Development in the Etiology of Preeclampsia

Background:

The pregnancy pathology preeclampsia is still among the leading causes of ma-ternal and perinatal morbidity and mortality. At the same time, its etiology is far from being identified and remains obscure in a number of facets.

A number of hypotheses have been developed to explain the altered interplay between placenta and mother leading to the clinical symptoms of preeclampsia. However, none of them offers the opportunity to explain the variability of cases with late-onset versus early-onset, mild versus severe and with or with-out additional fetal growth restriction.

Conclusion:

This paper identifies the weaknesses of the most important current hypothesis and at the same time offers a set of new elucidations including maternal susceptibility, and villous/extravillous trophoblast differentiation to explain the development of preeclampsia. Such elucidations allow following new scientific routes and pathways to untangle the etiology of preeclampsia.

Investigation of elevation as a risk factor for hypertensive disorders of pregnancy among Colorado women between 2007 and 2015

OBJECTIVE

The purpose of this study is to determine the association between high elevation and hypertensive disorders of pregnancy (HDP).

METHODS

Retrospective cohort study using Colorado birth certificate data to compare HDP at high (≥8,000 ft), moderate (4,501-7,999 ft), or low (≤4,500 ft) elevation using logistic regression.

RESULTS

Among the cohort (n = 314,431), 3.4% of women developed a HDP. High or moderate elevation was not significantly associated with HDP relative to low elevation (adjusted odds ratio [aOR] 1.16, 95% confidence interval [CI] 0.93-1.43; aOR 1.14, 95% CI 0.98-1.31, respectively).

CONCLUSION

Women living at high or moderate elevation do not have higher odds of HDP.

Human placental oxygenation in late gestation: experimental and theoretical approaches

The placenta is crucial for life. It is an ephemeral but complex organ acting as the barrier interface between maternal and fetal circulations, providing exchange of gases, nutrients, hormones, waste products and immunoglobulins. Many gaps exist in our understanding of the detailed placental structure and function, particularly in relation to oxygen handling and transfer in healthy and pathological states in utero. Measurements to understand oxygen transfer in vivo in the human are limited, with no general agreement on the most appropriate methods. An invasive method for measuring partial pressure of oxygen in the intervillous space through needle electrode insertion at the time of Caesarean sections has been reported. This allows for direct measurements in vivo whilst maintaining near normal placental conditions; however, there are practical and ethical implications in using this method for determination of placental oxygenation. Furthermore, oxygen levels are likely to be highly heterogeneous within the placenta. Emerging non-invasive techniques, such as MRI, and ex vivo research are capable of enhancing and improving current imaging methodology for placental villous structure and increase the precision of oxygen measurement within placental compartments. These techniques, in combination with mathematical modelling, have stimulated novel cross-disciplinary approaches that could advance our understanding of placental oxygenation and its metabolism in normal and pathological pregnancies, improving clinical treatment options and ultimately outcomes for the patient.

Matrix Metalloproteinase Release From Placental Explants of Pregnancies Complicated by Intrauterine Growth Restriction

OBJECTIVE

There is evidence of impaired placental development in intrauterine growth restriction (IUGR). Matrix metalloproteinases (MMPs) are extracellular matrix-degrading enzymes that are released by placental cells during tissue remodeling processes. We hypothesized 1) that release of MMP-2 and -9 is decreased and/or release of tissue inhibitors of metalloproteinases (TIMPs) is increased from placental explants in pregnancies complicated by IUGR and 2) that oxygen levels affect such release.

METHODS

Placental villous explants from normal (n = 7) and IUGR (n = 7) pregnancies were cultured at high (20%) and low (3%) oxygen levels for 24 hours. Supernatants were analyzed for MMP-2 and MMP-9 by zymography and for TIMP-1 and -2 by western blot analysis.

RESULTS

: At 20% oxygen there was significantly reduced MMP-2 (P < .05) and TIMP-1 (P < .01) release and a trend for decreased MMP-9 release (P = .07) in explants from IUGR pregnancies compared with normal pregnancies; however, there were no differences at 3% oxygen. TIMP-2 was below detectable levels in all samples. Although MMP-2 and TIMP-1 release was significantly reduced at 3% compared with 20% oxygen in explants from both normal (P < .001; P < .05) and IUGR (P < .05) pregnancies, MMP-2 release changed less in IUGR compared with normal explant cultures. There were no significant effects of oxygen on MMP-9 release.

CONCLUSION

Placental explants from IUGR pregnancies demonstrated reduced MMP-2, MMP-9, and TIMP-1 release compared with explants from normal pregnancies at high (20%) but not low (3%) oxygen.

Apoptosis in the Trophoblast—Role of Apoptosis in Placental Morphogenesis

Villous trophoblast is the epithelial cover of the placental villous tree and comes in direct contact with maternal blood. The turnover of villous trophoblast includes proliferation and differentiation of cytotrophoblast, syncytial fusion of cytotrophoblast with the overlying syncytiotrophoblast, differentiation in the syncytiotrophoblast, and finally extrusion of apoptotic material into the maternal circulation. In recent years, it has become clear that apoptosis is a normal constituent of trophoblast turnover and the release of apoptotic material does not lead to an inflammatory response of the mother. During preeclampsia there seems to be an altered balance between proliferation and apoptosis of villous trophoblast leading to a dysregulation of the release from the syncytiotrophoblast. The normal apoptotic release may be reduced in favor of a necrotic release. Since apoptosis is still ongoing in the syncytiotrophoblast, a necrotic release of intrasyncytial and partly apoptotic material lead us to call this type of release "aponecrotic shedding." In this situation, cell-free components such as G-actin and DNA freely floating in maternal blood may trigger damage to the maternal endothelium, thereby triggering preeclampsia. This review highlights the importance of the apoptosis cascade in permitting normal physiologic turnover of villous trophoblast. It will demonstrate the participation of initial stages of this cascade within the cytotrophoblast and of the execution stages within the syncytiotrophoblast. Moreover, this review presents hypotheses of how dysregulation of the apoptosis cascade may be linked to endothelial dysfunction of the maternal vasculature in preeclampsia.

Oxidative stress and the evolutionary origins of preeclampsia

In this speculative paper, I consider the relationship between oxidative stress and the evolution of placentation in eutherian mammals. I argue that epitheliochorial placentation, in which fetal tissues remain separated from maternal blood throughout gestation, has evolved as a protective mechanism against oxidative stress arising from pregnancy, particularly in species with unusually long gestation periods and unusually large placentas. Human beings comprise an unusual species that has the life history characteristics of an epitheliochorial species, but exhibits hemochorial placentation, in which fetal tissues come into direct contact with maternal blood. I argue that the risk of preeclampsia has arisen as a consequence of the failure of human beings to evolve epitheliochorial placentation.

Increased risk for the development of preeclampsia in obese pregnancies: weighing in on the mechanisms

Preeclampsia (PE) is a pregnancy-specific disorder typically presenting as new-onset hypertension and proteinuria. While numerous epidemiological studies have demonstrated that obesity increases the risk of PE, the mechanisms have yet to be fully elucidated. Growing evidence from animal and human studies implicate placental ischemia in the etiology of this maternal syndrome. It is thought that placental ischemia is brought about by dysfunctional cytotrophoblast migration and invasion into the uterus and subsequent lack of spiral arteriole widening and placental perfusion. Placental ischemia/hypoxia stimulates the release of soluble placental factors into the maternal circulation where they cause endothelial dysfunction, particularly in the kidney, to elicit the clinical manifestations of PE. The most recognized of these factors are the anti-angiogenic sFlt-1 and pro-inflammatory TNF-α and AT1-AA, which promote endothelial dysfunction by reducing levels of the provasodilator nitric oxide and stimulating production of the potent vasoconstrictor endothelin-1 and reactive oxygen species. We hypothesize that obesity-related metabolic factors increase the risk for developing PE by impacting various stages in the pathogenesis of PE, namely, 1) cytotrophoblast migration and placental ischemia; 2) release of soluble placental factors into the maternal circulation; and 3) maternal endothelial and vascular dysfunction. This review will summarize the current experimental evidence supporting the concept that obesity and metabolic factors like lipids, insulin, glucose, and leptin affect placental function and increase the risk for developing hypertension in pregnancy by reducing placental perfusion; enhancing placental release of soluble factors; and by increasing the sensitivity of the maternal vasculature to placental ischemia-induced soluble factors.

Placental hypoxia: the lesions of maternal malperfusion

The placental lesions classically ascribed to placental hypoxia, here denoted maternal malperfusion (MMP), are among the more significant that a placental pathologist may encounter. Yet the appearance of these lesions may be subtle, and the clinical implication of their diagnosis is frequently unclear. The aim of this review is to provide a more nuanced perspective on the clinical utility of placental pathology for the detection of MMP. The review will first detail MMP lesions in the placenta and discuss their associations with pregnancy complications. The review will then delve into the diagnostic and interpretive difficulties of these lesions. Finally, recent research findings that may aid in the development of better diagnostic tools will be briefly discussed.

Trophoblast invasion and oxygenation of the placenta: measurements versus presumptions

Invasion of extravillous trophoblast into maternal tissues has a profound effect on the oxygenation of the placenta and hence the fetus. The main route of trophoblast invasion is interstitial invasion into the tissues of the decidua and myometrium. From this main route side branches reach the spiral arteries (endovascular trophoblast) as well as the uterine glands (endoglandular trophoblast) to open both structures toward the intervillous space. This enables histiotrophic nutrition in the first trimester and hemotrophic nutrition in the second and third trimesters of pregnancy. Failure of endovascular trophoblast invasion has profound effects on the oxygenation of the placenta. Interestingly, this does not lead to hypoxia as has long been presumed. Rather, all measurements available today point to increased oxygen levels within the placenta in patients with a failure of spiral artery transformation. This should lead to a rethink regarding pathological conditions such as intrauterine growth restriction and preeclampsia.

eNOS knockout mouse as a model of fetal growth restriction with an impaired uterine artery function and placental transport phenotype

Fetal growth restriction (FGR) is the inability of a fetus to reach its genetically predetermined growth potential. In the absence of a genetic anomaly or maternal undernutrition, FGR is attributable to "placental insufficiency": inappropriate maternal/fetal blood flow, reduced nutrient transport or morphological abnormalities of the placenta (e.g., altered barrier thickness). It is not known whether these diverse factors act singly, or in combination, having additive effects that may lead to greater FGR severity. We suggest that multiplicity of such dysfunction might underlie the diverse FGR phenotypes seen in humans. Pregnant endothelial nitric oxide synthase knockout (eNOS(-/-)) dams exhibit dysregulated vascular adaptations to pregnancy, and eNOS(-/-) fetuses of such dams display FGR. We investigated the hypothesis that both altered vascular function and placental nutrient transport contribute to the FGR phenotype. eNOS(-/-) dams were hypertensive prior to and during pregnancy and at embryonic day (E) 18.5 were proteinuric. Isolated uterine artery constriction was significantly increased, and endothelium-dependent relaxation significantly reduced, compared with wild-type (WT) mice. eNOS(-/-) fetal weight and abdominal circumference were significantly reduced compared with WT. Unidirectional maternofetal (14)C-methylaminoisobutyric acid (MeAIB) clearance and sodium-dependent (14)C-MeAIB uptake into mouse placental vesicles were both significantly lower in eNOS(-/-) fetuses, indicating diminished placental nutrient transport. eNOS(-/-) mouse placentas demonstrated increased hypoxia at E17.5, with elevated superoxide compared with WT. We propose that aberrant uterine artery reactivity in eNOS(-/-) mice promotes placental hypoxia with free radical formation, reducing placental nutrient transport capacity and fetal growth. We further postulate that this mouse model demonstrates "uteroplacental hypoxia," providing a new framework for understanding the etiology of FGR in human pregnancy.

The timing and duration of hypoxia determine gene expression patterns in cultured human trophoblasts

OBJECTIVE

Exposure of cultured trophoblasts to hypoxia is commonly used to interrogate the molecular mechanisms underlying placental hypoxic injury. We examined the effect of levels, durations, and patterns of hypoxia on gene expression patterns in primary human trophoblasts.

STUDY DESIGN

We exposed primary term human trophoblasts to either standard culture conditions (O(2) = 20%) or to static or alternating levels of oxygen (O(2) = 8%, or O(2) = 0%) either early or late in culture, and analyzed the expression of 34 genes that are known to be regulated in placentas from pregnancies complicated by fetal growth restriction (FGR).

RESULTS

Using multidimensional scale analysis, Euclidean distance, and hierarchical clustering, we found that gene expression patterns in cells exposed to O(2) = 8% were similar to patterns observed in O(2) = 20%, but more distant from patterns in O(2) = 0%. Alternating atmospheric oxygen (8% vs. 0%) yielded intermediate results. Changes in oxygen levels over a longer period had a greater effect on gene expression than short-term changes. Gene expression patterns in cultured trophoblasts did not fully capture expression patterns observed in biopsies from FGR placentas vs. control.

CONCLUSIONS

The level, duration, and patterns of hypoxia are critical in determining trophoblast gene expression, and therefore germane for analysis of trophoblast hypoxic injury.

Lipid rafts and cytoskeletal proteins in placental microvilli membranes from preeclamptic and IUGR pregnancies

Intrauterine growth restriction (IUGR) and preeclampsia (PE) are leading causes of perinatal and maternal morbidity and mortality. Previously we reported the expression of lipid rafts in classical microvillous membrane (MVM) and light microvillous membrane (LMVM), two subdomains in apical membrane from the human placental syncytiotrophoblast (hSTB), which constitute the epithelium responsible for maternal-fetal transport. Here the aim was to study the raft and cytoskeletal proteins from PE and IUGR. Microdomains from MVM and LMVM were tested with raft markers (placental alkaline phosphatase, lipid ganglioside, and annexin 2) and a nonraft marker (hTf-R). No changes were detected with those markers in whole purified apical membranes in normal, PE, and IUGR pregnancies; however, their patterns of distribution in lipid rafts were different in PE and IUGR. Cholesterol depletion modified their segregation, confirming their presence in lipid rafts, although unlike normal placenta, in these pathologies there is only one type of microdomain. Additionally, the cytoskeleton proteins actin, ezrin, and cytokeratin-7 showed clear differences between normal and pathological membranes. Cytokeratin-7 expression decreased to 50% in PE, and the distribution between LMVM and MVM (~43 and 57%, respectively) changed in both PE and IUGR, in contrast with the asymmetrical enrichment obtained in normal LMVM (~62%). In conclusion, lipid rafts from IUGR and PE have different features compared to rafts from normal placentae, and this is associated with alterations in the expression and distribution of cytoskeletal proteins.

Trophoblast differentiation, fetal growth restriction and preeclampsia

The number of hypotheses trying to decipher the etiologies of preeclampsia and fetal growth restriction (FGR) is still increasing. However, for preeclampsia the actual knowledge we have is that the placenta is a prerequisite for the development of the syndrome. The recent years have seen a shift in understanding of the causes of preeclampsia from mostly focusing on the extravillous trophoblast towards the dysregulation of villous trophoblast development and maintenance. It seems as if a failure of the villous syncytiotrophoblast differentiation results in abnormal release of non-apoptotic fragments into maternal blood. In preeclampsia such necrotic or aponecrotic fragments can be found in maternal blood systemically and seem to be causative in the development of the inflammatory response of the mother. In cases with fetal growth restriction (FGR) extravillous trophoblast fails to adequately transform uterine spiral arteries. However, in FGR cases abnormal development of villous cytotrophoblast may have an impact on fetal nutrition without the induction of an inflammatory response of the mother. It is still unclear why the villous trophoblast fails to achieve an adequate turnover both in preeclampsia and in FGR. However, the detection of new biomarkers for preeclampsia such as placental protein 13 (PP13) has helped in clarifying the issue of when the syndrome starts to develop. PP13 levels in maternal serum are significantly altered already at six to seven weeks of gestation in women subsequently developing preeclampsia. Thus, there needs to be a very early alteration of villous development in such placentas. Herein the changes in villous trophoblast in preeclampsia and FGR are compared and differences between both scenarios are presented.

Caspases rather than calpains mediate remodelling of the fodrin skeleton during human placental trophoblast fusion

Fusion of cytotrophoblasts with the overlying syncytiotrophoblast is an integral step in differentiation of the human placental villous trophoblast. Multiple factors, such as growth factors, hormones, cytokines, protein kinases, transcription factors and structural membrane proteins, were described to modulate trophoblast fusion. However, the knowledge on remodelling of the membrane-associated cytoskeleton during trophoblast fusion is very limited. This study describes the link between remodelling of spectrin-like alpha-fodrin and intercellular trophoblast fusion. Experiments with primary trophoblasts isolated from term placentas and the choriocarcinoma cell line BeWo revealed a biphasic strategy of the cells to achieve reorganization of alpha-fodrin. Syncytialization of trophoblasts was accompanied by down-regulation of alpha-fodrin mRNA, whereas the full-length alpha-fodrin protein was cleaved into 120 and 150 kDa fragments. Application of calpeptin and calpain inhibitor III did not affect alpha-fodrin fragmentation in primary term trophoblasts and forskolin-treated BeWo cells, but decreased secretion of beta human chorionic gonadotropin. In contrast, inhibitors of caspases 3, 8 and 9 attenuated generation of the 120 kDa fragment and a general caspase inhibitor completely blocked fragmentation, suggesting an exclusive function of caspases in alpha-fodrin remodelling. Immunofluorescence double staining of human placenta revealed co-localization of active caspase 8 with alpha-fodrin positive vesicles in fusing villous cytotrophoblasts. These results suggest that caspase-dependent fragmentation of alpha-fodrin may be important for reorganization of the sub-membranous cytoskeleton during trophoblast fusion.

The maternal plasma soluble vascular endothelial growth factor receptor-1 concentration is elevated in SGA and the magnitude of the increase relates to Doppler abnormalities in the maternal and fetal circulation

OBJECTIVES

The soluble form of vascular endothelial growth factor receptor-1 (sVEGFR-1), an antagonist to vascular endothelial growth factor and placental growth factor, has been implicated in the pathophysiology of preeclampsia. Preeclampsia and pregnancy complicated with small for gestational age (SGA) fetuses share some pathophysiologic derangements, such as failure of physiologic transformation of the spiral arteries, endothelial cell dysfunction, and leukocyte activation. The objectives of this study were to: (1) determine whether plasma concentrations of sVEGFR-1 in mothers with SGA fetuses without preeclampsia at the time of diagnosis are different from those in patients with preeclampsia or normal pregnant women, and (2) examine the relationship between plasma concentrations of sVEGFR-1 and Doppler velocimetry in uterine and umbilical arteries in patients with preeclampsia and those with SGA.

STUDY DESIGN

A cross-sectional study was conducted to determine the concentrations of the soluble form of VEGFR-1 in plasma obtained from normal pregnant women (n = 135), women with SGA fetuses (n = 53), and patients with preeclampsia (n = 112). Patients with SGA fetuses and those with preeclampsia were sub-classified according to the results of uterine and umbilical artery Doppler velocimetry examinations. Plasma concentrations of sVEGFR-1 were determined by an ELISA. Since these concentrations change with gestational age, differences among various subgroups were statistically estimated with the delta value, defined as the difference between the observed and expected plasma sVEGFR-1 concentration. The expected values were derived from regression analysis of plasma sVEGFR-1 concentrations in normal pregnancy. Regression analysis and univariate and multivariate analysis were employed.

RESULTS

(1) Mothers with SGA fetuses had a mean plasma concentration of sVEGFR-1 higher than normal pregnant women (p < 0.001), but lower than patients with preeclampsia (p < 0.001). (2) Among patients with SGA fetuses, only those with abnormal uterine artery Doppler velocimetry had a mean plasma sVEGFR-1 concentration significantly higher than normal pregnant women (p < 0.001). (3) Among mothers with SGA fetuses in whom Doppler velocimetry was performed (n = 41), those with abnormalities in both the uterine and umbilical artery velocimetry had the highest mean delta of sVEGFR-1 plasma concentration (mean +/- standard deviation (SD): 0.69 +/- 0.29). Conversely, patients who had normal Doppler velocimetry in both uterine and umbilical arteries had the lowest mean delta (mean +/- SD: 0.09 +/- 0.29) of sVEGFR-1 plasma concentrations (ANOVA; p < 0.001). (4) Among patients with preeclampsia in whom Doppler velocimetry was performed (n = 69), those with abnormalities in both the uterine and umbilical artery velocimetry had the highest mean delta sVEGFR-1 plasma concentration (mean +/- SD: 1.01 +/- 0.22) among all groups classified (ANOVA; p < 0.001). (5) Among patients with SGA and those with preeclampsia, there was a relationship (Chi-square for trend p < 0.001 for both) between the severity of Doppler velocimetry abnormalities and the proportion of patients who had high delta sVEGFR-1 plasma concentrations (defined as a concentration two standard deviations (2SD) above the mean delta of normal pregnant women). (6) Multiple regression analysis suggested that the diagnostic category (e.g., SGA or preeclampsia), Doppler abnormalities, and gestational age at blood sampling were associated with an increase in plasma sVEGFR-1 concentrations (p < 0.001).

CONCLUSIONS

These observations provide support for the participation of the soluble receptor of vascular endothelial growth factor in the pathophysiology of SGA with abnormal uterine artery Doppler velocimetry and preeclampsia. An excess of sVEGFR-1 is released into the maternal circulation of patients with preeclampsia and those with SGA fetuses, as abnormalities of impedance to blood flow involve uterine and umbilical circulation.

Gene expression profiling of human placentas from preeclamptic and normotensive pregnancies

The aim of this study was to investigate patterns of gene expression in placental samples from patients with preeclampsia (PE), persistent bilateral uterine artery notching (without PE), and normal controls. This study included placental tissue from nine women with PE, seven with uncomplicated pregnancies and five with bilateral uterine artery notching in Doppler velocimetry tracings. Human cDNA microarrays with 6500 transcripts/genes were used and the results verified with real-time PCR and in-situ hybridization. Multidimensional scaling method and random permutation technique demonstrated significant differences among the three groups examined. Within the 6.5K arrays, 6198 elements were unique cDNA clones representing 5952 unique UniGenes and 5695 unique LocusLinks. Multidimensional scaling plots showed 5000 genes that met our quality criteria; among these, 366 genes were significantly different in at least one comparison. Differences in three genes of interest were confirmed with real-time PCR and in-situ hybridization; acid phosphatase 5 was shown to be overexpressed in PE samples and calmodulin 2 and v-rel reticuloendotheliosis viral oncogene homolog A (RELA) were downregulated in PE and uterine artery notch placentas. In conclusion downregulation of RELA and calmodulin 2 might represent an attempt by the placenta to compensate for elevations in intracellular calcium, possibly caused by hypoxia and/or apoptosis, in both pregnancies with uterine artery notching and preeclampsia.

The role of Fas mediated apoptosis in preeclampsia

It has become clear in recent years that apoptosis is a normal process in trophoblast turnover during pregnancy. Increased trophoblast apoptosis has been observed in the placenta of women with preeclampsia, serum from women with preeclampsia has been found to induce increased trophoblast sensitivity to Fas-mediated apoptosis, and serum from women with preeclampsia has elevated levels of various chemokines, growth factors and cytokines that are involved in the regulation of apoptosis. This review highlights the importance of apoptosis in normal placental development and explores the mechanisms whereby Fas-mediated apoptosis may play a role in conditions related to abnormal placentation, such as preeclampsia.

Troglitazone attenuates hypoxia-induced injury in cultured term human trophoblasts

OBJECTIVE

The purpose of this study was to test the hypothesis that the thiazolidinedione troglitazone, a peroxisome proliferator activated receptor-gamma ligand, attenuates hypoxia-induced trophoblast injury.

STUDY DESIGN

Cytotrophoblasts from 4 term human placentas were cultured in the presence or absence of 10 mumol/L troglitazone in either 20% oxygen (standard conditions) or 1% oxygen (hypoxic conditions) for variable periods before cell harvest. Medium beta-human chorionic gonadotropin and human placental lactogen were analyzed by enzyme-linked immunosorbent assay. Apoptosis was quantified by cytokeratin-18 cleavage products staining; p53 expression was examined by Western blot analysis.

RESULTS

beta-human chorionic gonadotropin and human placental lactogen levels were >/=2-fold higher in troglitazone-exposed cells at 16 hours of hypoxia, compared with vehicle control cells ( P <.05). The apoptotic index was reduced by >/=30% ( P <.001), and the expression of p53 was 2-fold lower ( P <.02) in troglitazone-exposed cells under hypoxia for </=16 hours but not different after >24 hours of low oxygen.

CONCLUSION

Troglitazone attenuates the influence of acute hypoxia on cultured term human trophoblasts.

Aspects of human fetoplacental vasculogenesis and angiogenesis. II. Changes during normal pregnancy

In this second review, we describe the main morphological events which accompany the development of the fetoplacental vascular system throughout normal human pregnancy and summarize findings on the expression of angiogenic growth factors and their receptors. Fetoplacental vasculogenesis starts at day 21 after conception by formation of haemangioblastic cords. In the following phase of branching angiogenesis (day 32 to week 25 post conception), haemangioblastic cords develop into a richly branched villous capillary bed with low fetoplacental blood flow impedance. This period is characterized by high placental levels of VEGF but moderate PlGF expression. In week 15, large centrally located villi show regression of peripheral capillary nets. In parallel, some remaining central capillaries acquire a tunica media and transform into arteries and veins. Beginning at about week 25 in the newly formed peripheral villi, angiogenesis switches from branching to non-branching and this period is accompanied by a steep drop in VEGF and a slower decline in PlGF expression. As a consequence of this switch, long poorly branched capillary loops are formed in the periphery of the fetoplacental vascular trees. These increase fetoplacental impedance but blood flow still increases due to rising fetal blood pressure. The possible interactions between (a). the biphasic development of intraplacental oxygen tensions, (b). changes in VEGF and PlGF levels and (c). developing vascular geometry are discussed. Special attention is given to the obvious discrepancy between sudden elevation of intervillous oxygen tensions which is not coincident with the appearance of angiogenic growth factor peaks and the switch from branching to non-branching angiogenesis. Finally, we deal with methods of quantifying aspects of angiogenesis in the villous vascular system and summarize the main findings during uncomplicated human pregnancy.