Chesley s hypertensive disorders in pregnancy

CHESLEY’S HYPERTENSIVE DISORDERS IN PREGNANCY FOURTH EDITION http://booksite.elsevier.com/9780124078666 Chesley's Hypertensive Disorders in Pregnancy Robert N Taylor, James M Roberts, F Gary Cunningham and Marshall D Lindheimer, Editors Resources for educators: All figures from the book available as both Power Point slides and jpeg files CHESLEY’S HYPERTENSIVE DISORDERS IN PREGNANCY FOURTH EDITION Edited by ROBERT N TAYLOR, MD, PHD Professor and Vice Chair for Research, Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA JAMES M ROBERTS, MD Senior Scientist, Magee Women’s Research Institute, Professor, Obstetrics, Gynecology, Reproductive Sciences and Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA F GARY CUNNINGHAM, MD Beatrice and Miguel Elias Distinguished Chair in Obstetrics and Gynecology, University of Texas, Southwestern Medical Center, Dallas, Texas, USA MARSHALL D LINDHEIMER, MD Professor Emeritus, Department of Obstetrics and Gynecology and Medicine, and the Committe on Clinical Pharmacology, The University of Chicago, Chicago, Illinois, USA AMSTERDAM • BOSTON • HEIDELBERG • LONDON • NEW YORK • OXFORD PARIS • SAN DIEGO • SAN FRANCISCO • SINGAPORE • SYDNEY • TOKYO Academic Press is an imprint of Elsevier Academic Press is an imprint of Elsevier 32 Jamestown Road, London NW1 7BY, UK 525 B Street, Suite 1800, San Diego, CA 92101-4495, USA 225 Wyman Street, Waltham, MA 02451, USA The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, UK Fourth edition Copyright © 2015, 2009 Elsevier Inc All rights reserved © 1999 Appleton & Lange A Pearson Education Company © 1978 Appleton-Century-Crofts as Hypertensive Disorders in Pregnancy by Leon C Chesley Cover Figure Legend: Left and middle panels show syncytial knots derived from a preeclamptic placenta, transduced with adenovirus carrying enhanced green fluorescent protein (left panel) and stained for PKH26, a yellow dye that stably integrates into plasma membranes (middle panel) The right panel shows a syncytial knot from a normal placenta stained with MitoTracker® Red, to identify mitochondria All sections were stained with DAPI (4’,6’-diamidino-2-phenylindole) a blue dye that binds strongly to A-T rich DNA, and identifies the syncytialized nuclei Courtesy of Augustine Rajakumar, PhD and S Ananth Karumanchi, MD, Harvard Medical School No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the publisher Medicine is an ever-changing field Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administrations, and contraindications It is the responsibility of the treating physician, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient Neither the publisher nor the authors assume anyliability for any injury and/or damage to persons or property arising from this publication Permissions may be sought directly from Elsevier’s Science & Technology Rights Department in Oxford, UK: phone (+44) (0) 1865 843830; fax (+44) (0) 1865 853333; email: permissions@elsevier.com Alternatively, visit the Science and Technology Books website at www.elsevierdirect.com/rights for further information Notice No responsibility is assumed by the publisher for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN: 978-0-12-407866-6 For information on all Academic Press publications visit our website at www.store.elsevier.com Typeset by MPS Limited, Chennai, India www.adi-mps.com Printed and bound in United States of America 15 16 17 18 19   10 9 8 7 6 5 4 3 2 1 List of Contributors EDGARDO J ABALOS, MD, Vice Director, Centro Rosarino de Estudios Perinatales, Rosario, Santa Fe, Argentina Fetal Medicine, and Department of Anatomy, University of California at San Francisco, San Francisico, California, USA JAMES M ALEXANDER, MD, Professor of Obstetrics & Gynecology, Southwestern Medical Center at Dallas, Texas, USA ERIC M GEORGE, PhD, Assistant Professor of Physiology and Biochemistry, University of Mississippi Medical Canter, Jackson, Mississippi, USA PHYLLIS AUGUST, MD, MPH, Ralph A Baer MD Professor of Research in Medicine, Professor of Obstetrics & Gynecology, Medicine, and Public Health, Weill Cornell Medical College, New York, New York, USA; Theresa Lang Director of Lang Center for Research and Education, New York Hospital Queens, New York, USA JOEY P GRANGER, PhD, Billy S Guyton Distinguished Professor, Professor of Physiology and Medicine, Director, Center for Excellence in Cardiovascular-Renal Research, Dean, School of Graduate Studies in the Health Sciences, University of Mississippi Medical Canter, Jackson, Mississippi, USA MARILYN J CIPOLLA, PhD, Professor, Department of Neurological Sciences, Obstetrics, Gynecology and Reproductive Sciences; Pharmacology, University of Vermont, Vermont, USA JUDITH U HIBBARD, MD, Professor and Vice Chair of Obstetrics, Department of Obstetrics & Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA AGUSTIN CONDE-AGUDELO, MD, MPH, Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Bethesda, Maryland and Detroit, Michigan, USA CARL A HUBEL, PhD, Associate Professor, Magee-Womens Research Institute; Department of Obstetrics and Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine; Department of Environmental and Occupational Health, Pittsburgh, Pennsylvania, USA KIRK P CONRAD, MD, Professor, Departments of Physiology and Functional Genomics and Obstetrics and Gynecology, University of Florida, College of Medicine, Gainesville, Florida, USA F GARY CUNNINGHAM, MD, Beatrice and Miguel Elias Distinguished Chair in Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Texas, USA ARUN JEYABALAN, MD, MS, Department of Obstetrics and Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Magee-Womens Research Institute, Clinical and Translational Research Institute, University of Pittsburgh, Pennsylvania, USA SANDRA T DAVIDGE, PhD, Professor, Departments of OB/ GYN and Physiology, Canada Research Chair in Women’s Cardiovascular Health, University of Alberta, Edmonton, Alberta, Canada S ANANTH KARUMANCHI, MD, Associate Professor of Medicine, Obstetrics & Gynecology Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA RALF DECHEND, MD, Department of Cardiology, FranzVolhard-Clinic, Max Delbruck Center for Molecular Medicine, Berlin, Germany LOUISE C KENNY, MBChB, PhD, Senior Lecturer & Consultant-Obstetrician & Gynaecologist, Cork University Maternity Hospital, Cork, Ireland CHRISTIANNE J.M DE GROOT, MD, PhD, Professor, Department of Obstetrics & Gynecology, Vrije Universiteit (VU) Medical Center, Amsterdam, The Netherlands BABBETTE LAMARCA, PhD, Associate Professor, Director, Research Division, University of Mississippi Medical Canter, Jackson, Mississippi, USA SUSAN J FISHER, PhD, The Ely and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, Center for Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal MARSHALL D LINDHEIMER, MD, Professor Emeritus, Department of Obstetrics and Gynecology and Medicine, and the Committee on Clinical Pharmacology and Pharmacogenetics, The University of Chicago, Chicago, Illinois, USA vii viii List of Contributors KEITH R MCCRAE, MD, Hematologic Oncology and Blood Disorders, Taussig Cancer Center, Department of Cellular and Molecular Medicine, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA IAN L SARGENT, BSc, PhD, Professor of Reproductive Science, Nuffield Department of Obstetrics and Gynecology, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom MICHAEL T MCMASTER, PhD, The Ely and Edythe Broad Center of Regeneration Medicine and Stem Cell Research and Department of Cell and Tissue Biology, University of California at San Francisco, San Francisco, California, USA SANJEEV G SHROFF, PhD, Distinguished Professor of & Gerald E McGinnis Chair in Bioengineering and Professor of Medicine, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA ROBERTA B NESS, MD, MPH, Dean and M David Low Chair in Public Health, The University of Texas School of Public Health, Houston, Texas, USA SAROSH RANA, MD, Assistant Professor, Obstetrics, Gynecology and Reproductive Biology, Beth Israel Deaconess Medical Center/ Harvard Medical School, Boston, Massachusetts, USA CHRISTOPHER W.G REDMAN, MB, BChr, Professor of Obstetric Medicine, Nuffield Department of Obstetrics and Gynecology, John Radcliffe Hospital, Oxford, London, United Kingdom JANET W RICH-EDWARDS, ScD, MPH, Associate Professor, Department of Medicine, Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital; Associate Professor, Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA JAMES M ROBERTS, MD, Senior Scientist, Magee-Women’s Research Institute, Professor of Obstetrics, Gynecology, Reproductive Sciences and Epidemiology and Clinical and Traslational Research University of Pittsburgh, Pittsburgh, Pennsylvania, USA ROBERTO ROMERO, MD, D Hon C, Chief, Perinatology Research Branch Program Director of Obstetrics and Perinatology, Intramural Division NICHD, NIH, DHHS, Professor, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, Professor, Department of Epidemiology and Biostatistics, Michigan State University, Michigan, USA BAHA M SIBAI, MD, Professor, Department of Obstetrics and Gynecology College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA ANNE CATHRINE STAFF, MD, PhD, Professor II, Head of the Research Center of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway ISAAC E STILLMAN, MD, Associate Professor of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA ROBERT N TAYLOR, MD, PhD, Professor and Vice Chair for Research, Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA JASON G UMANS, MD, PhD, MedStar Health Research Institute, the Departments of Medicine and of Obstetrics and Gynecology, Georgetown University; Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC, USA KENNETH WARD, MD, President and CEO, Juneau Biosciences, LLC, Salt Lake City, Utah, USA VIRGINIA D WINN, MD, PhD, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA GERDA G ZEEMAN, MD, PhD, Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands Preface PREFACE TO THE SECOND EDITION In 1996, Gary Cunningham, senior author of Williams’ Obstetrics, approached me with the idea of organizing a second edition of Chesley’s Hypertensive Disorders in Pregnancy This first edition, though published in 1978, was still a major reference text for investigators in the field, often kept locked in drawers for safe-keeping, as this out-of-print classic was difficult to locate Next we contacted Dr James Roberts, Director of the MageeWomens’ Research Institute, whose investigative team is among the leading contributors to the literature on preeclampsia this decade Of interest, their conference room, dedicated by Leon Chesley, and bearing his name, contains his framed photograph positioned to keep a watchful eye on the quality of their deliberations With three enthusiastic editors on board the second edition was born The 1999 edition is a multi-authored text, reflecting the enormous progress in the field since 1978 (and the editors’ recognition that there are few Leon Chesleys among us today as well!) To stay in the spirit of the initial edition, your editors developed the following strategy Each chapter would be first-authored by an acknowledged expert in the topic assigned, and would also be co-authored by one of the editors This was meant to insure the timeliness of the material, increase cohesiveness, minimize redundancy, and above all, to achieve the goals set for the text We believe that the strategy worked, though it may have been taxing to the co-author editor, especially when the topic deviated several degrees from his own area of expertise This edition is aimed both at investigators and practicing physicians Thus, one will find chapters designed primarily as scholarly assessments of a given research area, and others with didactic advice for the care of pregnant women with hyper tension Of interest is the considerable variability in focus from chapter to chapter, some authors reviewing the literature, primarily as those cited have presented it, others combining this with commentary, at times almost philosophical (in Chapter 4, an editors’ comment was inserted to tell the reader why!) Some authors tried to mimic the encyclopedic approach (with all encompassing tables) in Chesley’s first edition, others preferred a more concise approach, (but with extensive bibliography) Your editors decided to leave these approaches intact, the co-editor comparing the chapter’s goal and the initial Chesley text in the introductory comments Finally, Chesley’s Chapter in the first edition, “History,” is reprinted in its entirety as part of our own first chapter This historical review is a must read, and we doubt if it will be equaled for quite some time We consider Leon Chesley the father of modern research in the hypertensive disorders of pregnancy (some might say of modern research in obstetrics as well) He is now over 90 years of age, having weathered two strokes with mind and sense of humor intact We visited him several times during the genesis of this edition, receiving his blessing on each occasion We are proud to honor him with this edition COMMENTS ADDED TO THE PREFACE BY EDITORS IN 2008 Leon Chesley died shortly after publication of the second edition, and your editors missed those periodic exhilarating visits to Leon that highlighted preparation of that publication Thus this edition is both a tribute and memorial to him and we worked hard to attain the perfection he always insisted on, and hope that, wherever he is, he is proud of his disciples The third edition is patterned after the second but there are changes In the previous edition normal and abnormal aspects of organ systems were usually separated into distinct chapters, while in this edition each of these topics, such as the cardiovascular system, or kidney, is combined into a single chapter This led to another small change In the second edition each chapter, with the exception of the introductory first, was first authored by but one expert coupled to only one of the three editors as co-author, a style designed to ensure continuity and decrease excessive repetition In the current edition the complexity of several chapters required “two experts” (now able to bully their editor co-author more effectively!) Finally, there are three new chapters, each devoted to recent and exciting observations in areas unknown or given short shrift in the preceding edition These topics are angiogenic ix x Preface factors, agonistic antibodies to the angtiotensin II type receptor and immunology and inflammation Finally, the lead editor (MDL), having celebrated his diamond birthday in 2007 and golden wedding anniversary in 2008, will retire from this chore following this third edition of Chesley’s Hypertensive Disorders in Pregnancy The field is progressing quickly and developing new giants and the editors assure you that the next edition will meet the standards that Leon set with his first, and we strove to repeat in these last two editions Marshall D Lindheimer, MD PREFACE TO THE FOURTH EDITION The third edition of Chesley’s Hypertensive Disorders in Pregnancy, as the two prior ones, was widely acclaimed as an essential scholastic resource and enthusiastically endorsed by clinicians and scientists, alike In the modern digital era, “downloads” are the currency of readership Since its publication in 2009, the third edition of Chesley’s has been one of the most highly downloaded and viewed biomedical references on Science Direct Hypertension during pregnancy remains amongst the three leading killers of pregnant women and their unborn children; yet surveys show that half of physicians fail to elicit a history of pregnancy hypertension during routine encounters, despite its association with remote cardiovascular disease, and research support remains dismal compared with equally mortal diseases in terms of DALYs (Disability Adjusted Lost Years) We have optimistic expectations for this fourth edition of the textbook, which witnesses the passing of the torch from lead editor Marshall Lindheimer to me (RNT) With the prior edition, Prof Lindheimer stated his intention to retire as senior editor, having achieved a number of personal and professional milestones Fortunately for his colleagues and audience, Marshall generously supported the current effort in his critical role as “editor emeritus” and spiritual guru of the present edition It is an honor for me to accept the responsibility to assure that future generations of physicians, physiologists, educators and scholars of preeclampsia will continue to be galvanized by the information and ideas contained in these pages and challenged by the knowledge gaps that remain The overall format of the fourth edition follows that of its immediate precursor We have continued the tradition of presenting Leon Chesley’s masterfully written “History” chapter in its entirety within Chapter  Internationally renowned experts in the field, including several new authors, have been invited to collaborate with the editors to present state-of-the-art chapters designed to summarize and illuminate the horizons of knowledge in each academic domain Fundamental aspects of the principles that underpin preeclampsia pathogenesis are updated in the first half of the text, with an emphasis on new clinical and conceptual insights and their therapeutic applications in the later chapters Lest one forgets the remarkable contributions of our predecessors, we proffer the distinguished photograph below of Leon Chesley, whom all four editors had the inspiring opportunity to claim as a mentor I was struck by his curious necktie choice, with its kangaroo motif While making that specific sartorial selection for his pose on the frontispiece, Dr Chesley might have been wondering: “Had humans evolved from marsupials, with their transient embryonic attachment to a simple yolk-sac placenta, would our species have ever developed preeclampsia?” You may have to wait for the fifth edition to find out Robert N Taylor Leon C Chesley, PhD (1908–2000) CHAPTER  Introduction, History, Controversies, and Definitions MARSHALL D LINDHEIMER, ROBERT N TAYLOR, JAMES M ROBERTS, F GARY CUNNINGHAM AND LEON CHESLEY † Leon Chesley’s Hypertensive Disorders in Pregnancy was initially published in 1978.1 Then, as now, hypertension complicating pregnancy was a major cause of fetal and maternal morbidity and death, particularly in less developed nations Most of this morbidity was and remains associated with preeclampsia, a disorder with devastating effects in many organ systems, high blood pressure being but one aspect of the disease The first edition was single authored, written entirely by Dr Chesley, a PhD in physiology, who originally found employment as a chemist at the Newark New Jersey’s Margaret Hague Maternity Hospital, during the Great Depression of the 1930s Curious why certain tests were being performed on convulsing pregnant women, he went to the wards, observed, and was stimulated to study that enigmatic disorder preeclampsia, the result being signal contributions published from the late 1930s through the early 1980s His contributions included major observations in such diverse areas as epidemiology, remote prognosis, vascular and renal pathophysiology, and treatment, all focusing on hypertension in pregnancy A compendium of his achievements is but one aspect of the initial edition of this text, which for the next two decades was a leading resource for clinicians and investigators who wished to learn more about high blood pressure in pregnant women In 1978 a text devoted to the hypertensive disorders in pregnancy could be single authored, due in part to the energy, intellect, and other attributes of Leon Chesley, but also because research in this important area of reproductive medicine was still sporadic and unfocused, and progress regrettably slow Leon almost singly energized the field, and the editors of this text are among many of those for whom he served as a role model, nurturing three of us in early and mid-career The initial edition, and other signal events during the 1970s (summarized further later in this chapter as “EDITORS’ UPDATE”), spurred rapid progress in many areas including prevention trials, observations regarding pathogenesis, and management considerations Thus, just like the second and third, the fourth edition again aims to be a leading reference text, multi-authored by leaders in the field Again our stated goal of the previous editions, that this text will scholarly justice to Dr Chesley’s 1978 tour de force, remains the major and obvious goal for the fourth edition The remainder of this chapter is as follows: We reproduce Dr Chesley’s original chapter entitled “History” in its entirety Unable to improve on it, we add an EDITORS’ UPDATE, and then conclude by republishing Dr Chesley’s 1975 workshop banquet address “False Steps in the Study of Preeclampsia.”2 That meeting led to the formation of the International Society for the Study of Hypertension in Pregnancy, and Dr Chesley’s message about how to study preeclampsia remains valid today HISTORY (FIG 1.1) Several German authors, such as von Siebold, Knapp, Kossmann, Fasbender, Fischer, and Bernhart, have written on the history of eclampsia, but all too often they did not document their sources and made errors that live on in second-, third-, and nth-hand reviews.3–8 Bernhart wrote that eclampsia was mentioned in the ancient Egyptian, Chinese, Indian, and Greek medical literature.8 One of the oldest sources that he cited, without specific reference, was the Kahun (Petrie) papyrus dating from about 2200 bc His source is likely to have been Menascha.9 Griffith had translated Prescription No 33, on the third page of the papyrus, as: “To prevent (the uterus) of a woman from itching (?) auit pound — upon her jaws the day of birth It cures itching of the womb excellent truly millions of times.”10 Menascha cited Griffith’s paper but rendered the translation (in German) as: “To prevent a woman from biting her tongue auit pound — upon her jaws the day of birth It is a cure of biting excellent truly millions of times.”9 He suggested that the untranslated word “auit” †   Deceased Chesley’s Hypertensive Disorders in Pregnancy ISBN: 978-0-12-407866-6 DOI: http://dx.doi.org/10.1016/B978-0-12-407866-6.00001-8 © 2015 2014 Elsevier Inc All rights reserved  55 Rate per 1,000 deliveries 50 African-American Caucasian 45 40 35 30 25 20 15 1978 1983 1988 1993 Year 1998 2003 2008 FIGURE 3.2  Cases of preeclampsia per 1000 births by maternal race, U.S National Hospital Discharge Survey, 1979 to 2006.82 Reprinted from Breathett K, Muhlestein D, Foraker R, Gulati M The incidence of pre-eclampsia remains higher in African-American women compared to Caucasian women: trends from the National Hospital Discharge Survey 1979–2006 Circulation 2013;127:AP192, with permission  FIGURE 5.9  Heat map of the most highly upregulated and downregulated differentially expressed genes in basal plates of PE placentas as compared to the second-trimester, term and preterm labor samples The normalized log intensity values for the differentially expressed probe sets were centered to the median value of each probe set and colored on a range of −2.5 to +2.5 Red denotes upregulated and blue denotes downregulated expression levels as compared with the median value Columns contain data from a single basal plate specimen, and rows correspond to a single probe set Samples within each category are arranged from left to right, ordered by increasing gestational age Rows are ranked by fold change Reprinted with permission from Pregnancy Hypertension.51  FIGURE 5.10  Severe preeclampsia-associated aberrations in cytotrophoblast gene expression returned to control values after 48 h of culture RNA was analyzed immediately after the cells were isolated (0 h) and after 12, 24 and 48 h in culture The relative gene expression levels for cytotrophoblasts (CTBs) isolated from placentas of patients who delivered due to preterm labor with no sign of infection (nPTL; n = 5) or a severe form of preeclampsia (sPE; n = 5) are shown as a heat map, ranging from high (red) to low (blue) The sPE CTBs were from the following cases (tiled from left to right): (1) hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome and intrauterine growth restriction (IUGR); (2) sPE; (3) sPE and IUGR; (4) superimposed sPE; and (5) HELLP syndrome One sample of nPTL CTBs collected at 48 h was omitted for technical reasons The fold changes for each time point (sPE vs nPTL) are shown on the right ns, no significant difference (LIMMA); t, no significant difference in expression (sPE vs nPTL) by 48 h (maSigPro) Reprinted with permission from The Journal of Clinical Investigation.2  FIGURE 5.11  SEMA3B expression was high in the placenta and upregulated in severe preeclampsia (A) Binding of a 32P-SEMA3B probe to a multiple tissue expression array revealed high placental expression (coordinate B8) (B) Northern hybridization of polyA+ RNA extracted from chorionic villi and pooled from three placentas showed that SEMA3B expression increased over gestation and was highest in sPE (n = replicates) (C) In situ hybridization (three placentas/group) confirmed enhanced SEMA3B mRNA expression in the syncytiotrophoblast layer of the chorionic villi in sPE (25 wk) as compared to normal pregnancy (23 wk) and nPTL (34 wk) (D, left panel) Immunoblotting of CTB lysates (15 μg/lane) showed that SEMA3B protein expression was low to undetectable in control cells from normal placentas (15–39 wks) In all cases, expression was higher in sPE (26–33 wks) as compared to nPTL (30, 33 wks) A protein of the expected Mr was detected in COS-1 cells transfected with SEMA3B, but not in the SEMA3A-Fc lane Vertical lines denote noncontiguous lanes from the same gel (D, right panel) The relative intensity of the bands was quantified by densitometry The values for each sample type were averaged and expressed relative to the α-actin loading controls The entire experiment was repeated twice (E) Staining tissue sections with anti-SEMA3B showed a sPE-associated upregulation of immunoreactivity associated with the trophoblast components of chorionic villi and among extravillous CTBs within the basal plate (n = 5/group) Trophoblasts were identified by staining adjacent tissue sections with anti-cytokeratin-8/18 (data not shown) Scale bars (C, E): 100 µm NB, northern blot; GA, gestational age; IB, immunoblot; RP, recombinant protein Reprinted with permission from The Journal of Clinical Investigation.2  FIGURE 5.12  NRP-1 and -2 (protein) expression at the maternal–fetal interface in normal pregnancy and in sPE Tissue sections were double-stained with anti-cytokeratin (CK)-7, which reacts with all trophoblast (TB) subpopulations, and anti-NRP-1 or -2 (A, B) NRP-1 expression was detected in association with villous TBs Within the uterine wall, immunoreactivity associated with invasive CTBs was upregulated as the cells moved from the surface to the deeper regions (C, D) Endovascular cytotrophoblasts (CTBs) that lined a maternal blood vessel (BV) also stained (E-H) Anti-NRP-2 reacted with TB and non-TB cells in anchoring villi (AV) as well as interstitial and endovascular CTBs Essentially the same staining patterns, but with weaker intensity, were observed in sPE (data not shown) CTBs were isolated from the placentas of control nPTL cases and from the placentas of women who experienced sPE (I, J) Over 48 h in culture, NRP-1 expression was upregulated in both instances, but to a lesser degree in sPE (K, L) Control nPTL CTBs also upregulated NRP2 Expression of this receptor was reduced in sPE and the soluble form was more abundant (A–L) The data shown are representative of the analysis of a minimum of three samples from different placentas Scale bars, 100 µm IB, immunoblot Reprinted with permission from The Journal of Clinical Investigation.2  FIGURE 5.13  Exogenous SEMA3B mimicked the effects of sPE on CTBs and endothelial cells, and inhibited angiogenesis (A) The addition of anti-VEGF or SEMA3B protein significantly inhibited cytotrophoblast (CTB) invasion as compared to the addition of a control protein, CD6-Fc The removal of both ligands (anti-VEGF/NRP1-Fc, anti-VEGF/NRP2-Fc) restored invasion to control levels (B) The variables tested in panel A had the opposite effects on CTB apoptosis, suggesting that increased programmed cell death contributed to decreased invasion (C) Exogenous VEGF stimulated the migration of uterine microvascular endothelial cells (UtMVECs), which was inhibited by SEMA3B (D) The results in panel C were quantified relative to the addition of CD6-Fc (E) In UtMVECs, VEGF promoted survival and SEMA3B increased apoptosis relative to control levels (F) In the chick chorioallantoic membrane (CAM) angiogenesis assay, VEGF promoted angiogenesis by ~3-fold and SEMA3B inhibited this process ~5-fold relative to the effects of CD6-Fc Top row: arrows mark the edge of the filter paper used to apply the protein Scale bar: 200 µm Bottom row: the area of the CAM beneath the filter paper Scale bar: 100 µm A–D, n = replicates; E, F, n = replicates A,B,D,E, mean ± SEM, two-tailed Student’s t-test *p < 0.05, **p < 0.01, ***p < 0.001 Reprinted with permission from The Journal of Clinical Investigation.2  FIGURE 5.15  Model of SEMA3B effects on CTBs in sPE vs normal pregnancy Reprinted with permission from The Journal of Clinical Investigation.2  FIGURE 6.1  A schematic of placental vascular remodeling in health (upper panel) and in disease – preeclampsia (lower panel) Exchange of oxygen, nutrients, and waste products between the fetus and the mother depends on adequate placental perfusion by maternal spiral arteries Blood from the intervillous space is returned to the mother’s circulation via spiral maternal veins noted above In normal placental development, cytotrophoblasts of fetal origin invade the maternal spiral arteries, transforming them from small-caliber resistance vessels to high-caliber capacitance vessels capable of providing adequate placental perfusion to sustain the growing fetus During the process of vascular invasion, the cytotrophoblasts undergo a transformation from an epithelial to an endothelial phenotype, a process referred to as “pseudovasculogenesis” (upper panel) In preeclampsia, cytotrophoblasts fail to adopt an invasive endothelial phenotype Instead, invasion of the spiral arteries is shallow and they remain small-caliber, resistance vessels (lower panel) This is thought to lead to placental ischemia and secretion of antiangiogenic factors Figure reproduced with permission from Lam et al.12  FIGURE 6.2  Glomerular endotheliosis (A) Normal human glomerulus (B) Human preeclamptic glomerulus of 33-yr-old woman with a twin gestation and severe preeclampsia at 26 weeks gestation The urine protein/creatinine ratio was 26 at the time of biopsy (C) Electron microscopy of a glomerulus from the same patient Note the occlusion of the capillary lumens by the swollen cytoplasm of endocapillary cells Podocyte cytoplasm shows protein resorption droplets but relatively intact foot processes Original magnification 1500× (D) Control rat glomerulus: note normal cellularity and open capillary loops (E) sFlt-1 treated rat: note similar occlusion of the capillary lumens by swollen endothelial cells with minimal increase in cellularity (F) Electron microscopy of a sFlt-1 treated rat: note similar occlusion of capillary loops by swollen endocapillary cell cytoplasm accompanied by the relative preservation of podocyte foot processes Original magnification 2500× All light photomicrographs are of H&E sections taken at the identical original magnification of 40× Figure reproduced with permission from Karumanchi et al.114  PE