Pregnancy and newborns disorders followed by urine metabolomics

Chapter 1 introduces the scope of the work by identifying the clinically relevant prenatal disorders and presently available diagnostic methods. The methodology followed in this work is presented, along with a brief account of the principles of the analytical and statistical tools employed. A thorough description of the state of the art of metabolomics in prenatal research concludes the chapter, highlighting the merit of this novel strategy to identify robust disease biomarkers. The scarce use of maternal and newborn urine in previous reports enlightens the relevance of this work. Chapter 2 presents a description of all the experimental details involved in the work performed, comprising sampling, sample collection and preparation issues, data acquisition protocols and data analysis procedures. The proton Nuclear Magnetic Resonance (NMR) characterization of maternal urine composition in healthy pregnancies is presented in Chapter 3. The urinary metabolic profile characteristic of each pregnancy trimester was defined and a 21-metabolite signature found descriptive of the metabolic adaptations occurring throughout pregnancy. 8 metabolites were found, for the first time to our knowledge, to vary in connection to pregnancy, while known metabolic effects were confirmed. This chapter includes a study of the effects of non-fasting (used in this work) as a possible confounder. Chapter 4 describes the metabolomic study of 2nd trimester maternal urine for the diagnosis of fetal disorders and prediction of later-developing complications. This was achieved by applying a novel variable selection method developed in the context of this work. It was found that fetal malformations (FM) (and, specifically those of the central nervous system, CNS) and chromosomal disorders (CD) (and, specifically, trisomy 21, T21) are accompanied by changes in energy, amino acids, lipids and nucleotides metabolic pathways, with CD causing a further deregulation in sugars metabolism, urea cycle and/or creatinine biosynthesis. Multivariate analysis models´ validation revealed classification rates (CR) of 84% for FM (87%, CNS) and 85% for CD (94%, T21). For later-diagnosed preterm delivery (PTD), preeclampsia (PE) and intrauterine growth restriction (IUGR), it is found that urinary NMR profiles have early predictive value, with CRs ranging from 84% for PTD (11-20 gestational weeks, g.w., prior to diagnosis), 94% for PE (18-24 g.w. pre-diagnosis) and 94% for IUGR (2-22 g.w. pre-diagnosis). This chapter includes results obtained for an ultraperformance liquid chromatography-mass spectrometry (UPLC-MS) study of pre-PTD samples and correlation with NMR data. One possible marker was detected, although its identification was not possible. Chapter 5 relates to the NMR metabolomic study of gestational diabetes mellitus (GDM), establishing a potentially predictive urinary metabolic profile for GDM, 2-21 g.w. prior to diagnosis (CR 83%). Furthermore, the NMR spectrum was shown to carry information on individual phenotypes, able to predict future insulin treatment requirement (CR 94%). Chapter 6 describes results that demonstrate the impact of delivery mode (CR 88%) and gender (CR 76%) on newborn urinary profile. It was also found that newborn prematurity, respiratory depression, large for gestational age growth and malformations induce relevant metabolic perturbations (CR 82-92%), as well as maternal conditions, namely GDM (CR 82%) and maternal psychiatric disorders (CR 91%). Finally, the main conclusions of this thesis are presented in Chapter 7, highlighting the value of maternal or newborn urine metabolomics for pregnancy monitoring and disease prediction, towards the development of new early and non-invasive diagnostic methods.

L'endostatine et autres marqueurs angiogéniques de la prééclampsie

OBJECTIF: Évaluer le rôle de l’endostatine, un nouveau marqueur anti-angiogénique, pour prédire le risque de prééclampsie (PE). METHODES: Il s’agit d’une étude cas témoins nichée dans deux cohortes prospectives. Les échantillons sanguins étaient collectés entre 11 et 17 semaines puis entre 18 et 26 semaines d’aménorrhée. L’hypertension gestationnelle était définie par une tension artérielle supérieure ou égale à 140/90mmHg à 2 reprises. Les cas de prééclampsie étaient définis par une hypertension gestationnelle associée à une protéinurie supérieure ou égale à 0.3 g /24h après 20 semaines de grossesse. La concentration d’endostatine était mesurée par une technique d’ELISA. Les résultats étaient exprimés en multiples de la médiane (MoM) et ajustés pour l’âge maternel, l’âge gestationnel, l’ethnie, et la cohorte d’origine. Une régression logistique était utilisée pour calculer des odds ratios (OR) ajustés et prédire le risque de PE. RESULTATS: Au total nous avons étudié 77 PE et 150 témoins chez des grossesses uniques. Parmi les PE 21 étaient de survenue précoce, avec un diagnostic avant 34 semaines et 41 étaient des PE sévères. Les cas avaient un IMC plus élevé que les témoins et étaient plus souvent Africaines. Les taux médians d’endostatine étaient significativement plus élevés chez les PE que chez les témoins au 1er trimestre (94.2 versus 90.7 ng/ml, p=0.004) et 2ème trimestre (105.8 versus 99.3 ng/ml p=0.002). Le taux d’endostatine entre 18 et 26 semaines était même plus élevé chez les patientes qui développaient une PE précoce. Lorsque l’endostatine était supérieure au 75èmepercentile (exprimée en MoM), le OR ajusté était de 1.33 95IC [0.68-2.58] à 11-17 semaines et 1.77 [0.94-3.34] à 18-26 semaines. L’OR ajusté pour les PE précoces était 3.51 [1.18-10.43] entre 11-17 semaines et 2.17 [0.67-7.06] entre 18-26 semaines. CONCLUSIONS: Un taux élevé d’endostatine dès le 1er trimestre est associé à une augmentation du risque de PE et surtout d’un risque de prééclampsie précoce. Toutefois l’endostatine seule a une trop faible valeur prédictive pour avoir une utilité clinique.

Fatores de risco individuais e familiares no desenvolvimento da pré-eclâmpia

Preeclampsia is a spectral disease, with different clinical forms which can evolve with severe multisystemic complications. This present study aimed to determine the risk factors associated with preeclampsia (PE); to validate the existence of aggregation of hypertensive disease in families of women with preeclampsia and verify the existence of association between polymorphisms in the VEGF gene and level of VEGF and its soluble receptor (sFlt1). A case-control study was performed (n = 851). Genotyping of VEGF was performed and serum levels of VEGF and sFlt1 were measured by ELISA. It was observed that 38% of mothers (173, 455) of a case of preeclampsia and 30.8% (78 of 361) of controls had history of hypertension (p <0.0001). Similarly, when examining the history of maternal preeclampsia, we observed that 14.6% (48 of 328) of mothers of women with preeclampsia and 9.6% (12 of 294) of mothers of controls had a history of preeclampsia (p = 0.0001). As for maternal history of preeclampsia, we found that 5.1% (15 of 295) of cases and 3.6% (7 of 314) of controls had a history of preeclampsia (p = 0.0568). Sisters of women with preeclampsia also had a history of hypertensive disease in 9% (41 of 455) versus 6.6% (13 of 361), p = 0.002. Similarly when examining the history of preeclampsia in sisters, it was observed that 22.7% (57 of 251) of a sister of case versus 11.4% (26 of 228) of controls had a history of preeclampsia (P = 0.0011). We observed a decrease in free VEGF in the serum of patients (P <0.05) and increased soluble VEGF receptor. There was no association between polymorphisms in the VEGF gene and preeclampsia. The data obtained in this work validate that hypertensive disease in mothers and sisters with preeclampsia are risk factors for preeclampsia. The risk of illness in the family is higher according to disease severity. High incidence of preeclampsia can be assumed by the high incidence of this disease among the controls. Significant differences between the frequency of preeclampsia in mothers of cases and controls indicate familial factors. Work is being conducted with the to eventually perform genome wide association studies to identify susceptibility loci

Silibinin modulates the NF-kappa b pathway and pro-inflammatory cytokine production by mononuclear cells from preeclamptic women

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Silibinin attenuates oxidative metabolism and cytokine production by monocytes from preeclamptic women.

Silibinin is a polyphenolic plant flavonoid with anti-inflammatory properties. The present study investigated the effect of silibinin on oxidative metabolism and cytokine production - tumor necrosis factor-alpha (TNF-α), interleukin (IL)12, granulocyte-macrophage colony-stimulating factor (GM-CSF), IL-6, IL-10, and transforming growth factor beta (TGF-β1) - by peripheral blood monocytes (PBM) from preeclamptic pregnant women. It is a case-controlled study involving women with preeclampsia (PE, n = 30) compared with normotensive pregnant (NT, n = 30) and with non-pregnant (NP, n = 30) women. Monocytes were obtained and cultured with or without silibinin (5 μM or 50 μM) for 18 h. Superoxide anion (O2-) and hydrogen peroxide (H2O2) release were determined by specific assays, and cytokine levels were determined by immunoenzymatic assays (ELISA). Monocytes from preeclamptic women cultured without stimulus released higher levels of O22, H2O2 and TNF-α, and lower levels of IL-10 and TGF-β1 than did monocytes from NT and NP women. Treatment in vitro with silibinin significantly inhibited spontaneous O2- and H2O2 release and TNF-α production by monocytes from preeclamptic women. The main effect of silibinin was obtained at 50 μM concentration. Thus, silibinin exerts anti-oxidative and anti-inflammatory effects on monocytes from preeclamptic pregnant women by inhibiting the in vitro endogenous release of reactive oxygen species and TNF-α production.

Avaliação hemodinâmica por tonometria de aplanação em gestantes com pre-eclâmpsia precose e tardia

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Impedância bioelétrica na ocorrência da pré-eclâmpsia

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Determinação da ativação de monócitos e de biomarcadores celulares em gestantes portadoras de pré-eclâmpsia

Pós-graduação em Ginecologia, Obstetrícia e Mastologia - FMB

Alterações histopatológicas e expressão de citocinas e de fatores angiogênicos em placenta de gestantes portadoras de pré-eclâmpsia

Pós-graduação em Ginecologia, Obstetrícia e Mastologia - FMB

Tissue inhibitor of matrix metalloproteinase-1 polymorphism, plasma TIMP-1 levels, and antihypertensive therapy responsiveness in hypertensive disorders of pregnancy

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Associação entre expressão de receptores TLR2 e TLR4 e produção de TNF-alpha e IL-10 por monócitos de gestantes portadoras de pré-eclâmpsia

Preeclampsia (PE) is a pregnancy specific syndrome characterized by a systemic inflammatory response, with higher intensity than that observed in normal pregnancy. Cells of the immune system, such as monocytes and granulocytes are endogenously activated and secrete high levels of free radicals and inflammatory cytokines. The objective of this study was to assess the activation state of monocytes from pregnant women with preeclampsia by endogenous expression of TLR2 e TLR4 receptors and to correlate the expression of TLR2 and TLR4 on monocytes surface of pregnant women with PE with the production of tumor necrosis factor-alpha (TNF- and interleukin-10 (IL-10) by these cells stimulated or not with peptidoglycan (PG) and lipopolysaccharide (LPS), as agonists agents of TLR2 and TLR4, respectively. We evaluated 15 pregnant women with PE, 15 normotensive pregnant women (NT) and 15 non-pregnant (NP). Peripheral blood monocytes were incubates in the presence or absence of LPS or PG. The supernatant obtained after 18h of culture was aspirated and used for TNF- and IL-10 determination by enzyme immunoassay (ELISA). The endogenous expression of TLR2 and TLR4 receptors was evaluated by flow cytometry. Our results showed significant highly concentrations of TNF- and TLR4 expression in monocytes of preeclamptic women when compared with NT and NP. Normal pregnant women presented higher levels of IL-10 in comparison with PE and NP groups. TLR2 expression was similar in the three groups studied. Therefore, our study highlights the important role of TLR4 in PE and the consequent high production of TNF- by monocytes of these patients, as well as the potential mechanism involving low levels of IL-10 in the pathophysiology of the disease. These observations demonstrate the strong link between the pathology of PE and the immune system of these patients

Eficácia da haptoglobina como marcador de hemólise no diagnóstico da síndrome HELLP

Introduction: The HELLP syndrome is a severe complication of pregnant women with preeclampsia (PE), characterized by association of hemolysis, changes in liver enzymes and thrombocytopenia. Hemolysis, defined by the presence of microangiopathic hemolytic anemia, is one of the characteristics in this syndrome. However, as hemolysis occurs in a short time there is some difficulty in its laboratory diagnosis. Therefore, the search for a more sensitive and specific method for hemolysis determination may help in the early diagnosis of the HELLP syndrome. Objectives: a) To determine the plasma concentration of haptoglobin in normotensive pregnant women and in pregnant women with PE, classified into mild PE, severe PE and HELLP/partial HELLP syndrome; b) To compare the efficacy of haptoglobin plasma concentration and serum total bilirubin as criteria for hemolysis diagnosis in HELLP/partial HELLP syndrome. Methods: We conducted a cross-sectional analytical and comparative study involving 66 pregnant women diagnosed with PE, being 25 cases with mild PE, 28 with severe PE, and 13 with HELLP/partial HELLP syndrome. Twenty-one normotensive pregnant women were included for comparison of haptoglobin plasma concentration between the groups and to determine the normal values for pregnant women. The variables studied were: maternal age, gestational age, systolic and diastolic blood pressure, proteinuria, hematocrit and hemoglobin values, platelet count, serum total bilirubin, lactate dehydrogenase (LDH), glutamic oxaloacetic transaminase (AST) and glutamic-pyruvic transaminase (ALT), urea, creatinine and uric acid, and also plasma concentrations of haptoglobin. The results were analyzed by nonparametric tests, with a significance level of 5%. Results: The values of urea, uric acid, AST, ALT and LDH were significantly higher, while the number of platelets was lower in pregnant women with HELLP/partial HELLP syndrome compared to pregnant women with mild PE and ...

Effects of NAMPT polymorphisms and haplotypes on circulating visfatin/NAMPT levels in hypertensive disorders of pregnancy

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Correlations among antiangiogenic factors and trace elements in hypertensive disorders of pregnancy

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Análise de inflamassoma induzido por urato monossódico em monócitos de gestantes portadoras de pré-eclampsia

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)