Obstetrics and Gynaecology - Theses
Permanent URI for this collection
Search Results
1 - 2 of 2
-
ItemUnderstanding placental and cardiovascular adaptations in pregnancy: implications for therapeutic development for fetal growth restriction and preeclampsia.( 2021)Preeclampsia and fetal growth restriction are among the most serious obstetric conditions worldwide. Though they affect so many, we still do not completely understand their pathogenesis, nor have good ways to detect or treat them. In this thesis, I aimed to: improve our understanding of placental and vascular adaptations in preeclampsia and growth restriction, assess the ability of candidate therapeutics to mediate vascular dysfunction associated with preeclampsia, and to explore new models of preeclampsia and the long-term impacts on maternal cardiovascular health. DAAM2 and NR4A2 transcripts are elevated in the circulation of individuals whose pregnancies are complicated by fetal growth restriction (with or without preeclampsia). In Chapters 2 and 3 of this thesis, I identified these transcripts are expressed in the placenta, but their expression in either growth restricted or preeclamptic placenta does not mirror the increased expression of DAAM2 and NR4A2 in the maternal circulation. Thus, they are unlikely to originate from the dysfunctional placenta. However, their expression in the placenta throughout gestation, and clear regulation under hypoxia suggest they have roles in normal placental development and placental dysfunction. LOX-1 is elevated in the maternal vasculature in preeclampsia. In contrast to this, I identified in Chapter 4 that LOX-1 expression is reduced in the preeclamptic placenta. Furthermore, its expression is reduced in trophoblast under hypoxia. Treatment of trophoblasts with candidate preeclampsia therapeutics, esomeprazole and lansoprazole, (proton pump inhibitors) increased LOX-1 expression. These findings suggest that LOX-1 has a distinct role in the placenta compared to the vasculature. In Chapters 5 and 6, I assessed the ability of statins and new generation antiplatelets to mitigate preeclampsia-associated vascular dysfunction. In a model of endothelial dysfunction, pravastatin and simvastatin reduced secretion of vasoconstrictor, endothelin-1 and anti-angiogenic factor, sFLT-1. The new generation antiplatelet agents clopidogrel, prasugrel and ticagrelor reduced vasoconstriction of pregnant human omental (healthy and preeclamptic) and mouse mesenteric arteries through three different vasoconstrictors. Therefore, these candidate therapeutics can mitigate a key aspect of the pathogenesis driving preeclampsia. In Chapter 7, we established a model of preeclampsia in our laboratory through the blockade of nitric oxide synthesis (using L-NAME) to induce vasoconstriction. This led to elevated blood pressure, impaired fetal growth and elevated circulating levels of ‘toxic’ factors associated with preeclampsia. We were able to use this model to assess the effects of the new generation antiplatelet prasugrel, as a therapeutic, finding that prasugrel administration alongside L-NAME could reduce maternal blood pressure. I followed the dams post-delivery to investigate whether this model could simulate the long-term effects of preeclampsia on maternal cardiovascular health. I found that blood pressure and circulating toxic factors recovered as soon as 1 week post-delivery. At 10 weeks post-delivery, mice administered L-NAME during pregnancy demonstrated altered vascular reactivity, and increased expression of genes associated with inflammation in both the heart and kidney. However, these changes did not model the breadth of effects we anticipated, based on what is seen clinically post-preeclampsia. Overall, this thesis has added critical new knowledge regarding placental development, placental dysfunction, and vascular dysfunction. It provides further insight into the capability of novel candidate therapies for the prevention and treatment of preeclampsia, and provides new models of preeclampsia that can be used to enhance both our understanding of disease, and to assess future therapeutic potential.
-
ItemIdentifying biomarkers for preeclampsia: from bedside to benchtop( 2021)Preeclampsia is a hypertensive disorder of pregnancy which claims the lives of thousands of mothers and babies every year. It is a major cause of both maternal and fetal morbidity and mortality throughout the world. There is no cure for preeclampsia but maintaining tight blood pressure control from the earliest possible gestation, alongside frequent medical reviews to identify progression of the disease, allows timely delivery to obtain the best outcome for both mum and baby. Further, the recently discovered benefits of instituting aspirin therapy before 16 weeks to prevent the development of the disease clearly demonstrates the need for a test to predict which patients are most likely to develop preeclampsia in their pregnancy. The current means sought to identify patients at risk of future preeclampsia is based on maternal risk factors. However, there is growing interest in detecting predictive biomarkers in the maternal circulation that are released as ‘distress signals’ from organs affected by preeclampsia: the placenta or the maternal endothelium. It is widely believed that the pathophysiology of preeclampsia originates in early placentation. Poor implantation very early in the pregnancy leads to a hypoxic placental environment. The hypoxic placenta then releases antiangiogenic factors into the maternal circulation which cause widespread maternal endothelial dysfunction. Examples of biomarkers for preeclampsia in current literature include soluble Flt1 (sFlt1) and placental growth factor (PlGF). There has also been significant investigation toward understanding the mechanisms by which such biomarkers may contribute to disease pathogenesis - which is key in allowing better understanding of the underlying pathophysiology. The theme of this PhD is biomarker discovery and ‘reverse translation’: potential biomarkers will be identified in blood samples collected from patients who participated in a large prospective cohort. The biomarkers were then studied in the laboratory, taking the samples from bedside to benchtop. The first aim of this PhD was to investigate potential predictive biomarkers originating from dysfunctional maternal endothelial cells. I have investigated the mechanisms by which the biomarkers are altered, carrying out functional studies to observe how placental factors influence the expression of these markers of endothelial cell dysfunction, and whether there are any specific implicated placental factors. Indeed, I identified that mRNA for the transcription factor GATA2 is differentially expressed in the maternal circulation up to 12 weeks before the clinical diagnosis of preeclampsia. Further, the vasoactive peptide hormone adrenomedullin is similarly dysregulated. While GATA2 is likely endothelial in origin, adrenomedullin may originate from maternal endothelium or the placenta. The second aim of this PhD was to investigate the possible use of circulating microRNAs (miRs) to predict preeclampsia. Their use in distant cell signalling has been investigated for prediction and detection of cancer and other diseases. The C19MC miRNA cluster is a primate specific cluster of miR genes that is highly expressed in the placenta. Using microarray technology, I have identified miRs from this cluster, alongside those involved in endothelial cell dysfunction, which are altered in preeclamptic placentas and in the blood of women destined to develop preeclampsia. Of note, two microRNAs which are involved in regulating endothelial cell function (miRs 363 and 149), I demonstrated are dysregulated in the circulation and placentas of women with diagnosed preterm preeclampsia, as well as in the blood at 36 weeks’ gestation preceding term preeclampsia onset. In the third aim of this PhD, I have investigated the mechanisms by which placental growth factor (PlGF) may be regulated. PLGF is a proangiogenic molecule which is highly expressed in placental trophoblast cells and is vital for angiogenesis. Circulating PlGF has been implicated as a potential predictive biomarker of disease especially when used in combination with sFlt1 in the sFlt1:PlGF ratio. However, the pathways involved in the regulation of PlGF are still poorly understood. Due to the close relationship between sFlt1 and PlGF, I have assessed the impact of known regulatory pathways of sFlt1, on the secretion of PlGF. I have identified molecules in the EGFR pathway which regulate PlGF secretion and ruled out the mitochondrial electron transport chain as a means of enhancing PlGF production. In conclusion, this thesis has demonstrated that endothelial produced biomarkers (GATA2, Adrenomedullin and miRs363 and 149) hold perhaps the greatest potential as predictors of term preeclampsia. Although also dysregulated in the blood of women with established preterm disease, whether they might also be predictive of preterm preeclampsia remains to be assessed. While circulating levels of placental specific miRNAs were unchanged in term disease, their potential as biomarkers for preterm preeclampsia also remains unexplored. Notably this work also identified the EGFR superhighway as a negative regulator of PlGF production and suggested that future identification of therapeutics that reduce EGFR signalling, may hold potential for enhancing PlGF production and release in preeclampsia. Overall, it is my hope that this work has significantly contributed to the future development of novel screening tests that will lead to improved outcomes for women and their babies.