Insufficient maternal folate during pregnancy increases the risk of the baby being small for gestational age (SGA). Studies in teenagers, a population vulnerable to folate deficiency and SGA birth, have shown that low maternal folate status is associated with impaired placental cell turnover and reduced transport suggesting placental dysfunction underlies SGA in maternal folate deficiency. Mechanisms through which folate-depletion compromises placental function are currently unknown. In non-placental cells, folate modulates microRNAs (miRs), post-transcriptional regulators of cellular functions. Expression of miRs is altered in placentas of SGA compared to normally grown babies but there are no data on differential miR expression or regulation in placentas from folate deficient women. This PhD investigated the hypothesis that placental dysfunction observed in folate deficient women is mediated by altered miR expression. Three placental preparations were compared (villous tissue in explant culture, BeWo choriocarcinoma cells and isolated cytotrophoblast cells) to determine the optimum in vitro system to study the direct effects of folate deficiency. In cytotrophoblast cells, folate deficiency significantly elevated apoptosis and reduced the activity of the system A amino acid transporter, consistent with observations in the placentas of folate-deficient teenagers. The reduction in system A activity by low folate was not associated with altered mRNA expression for the isoforms of system A, implicating an effect of low folate on post-translational regulation of the nutrient transporter. Targeted examination of villous tissue from teenagers with low folate status identified up-regulation of miR-222-3p a folate-sensitive miR. An unbiased miR array identified up-regulation of a further 16 miRs suggesting that maternal folate deficiency in vivo results in aberrant placental miR expression. Bioinformatic analysis of the folate sensitive miRs predicted gene targets known to be altered in placentas from SGA pregnancy that were likely to alter placental function. Two miRs altered in placentas from women with low folate status, miR-30e-3p and miR-34b-5p, were also significantly altered in folate deficient cytotrophoblasts confirming a direct effect of folate on trophoblast miR expression. Inhibition of these miRs in vitro had no effects on placental functions that are altered in vivo in folate-deficient women. Gene array and in silico analysis identified functional endpoints affected by these folate sensitive miRs, including cell signalling for proliferation and survival and oxidative stress, which might contribute to placental dysfunction in folate deplete women. Overall, this study has demonstrated for the first time that folate deficient conditions can directly alter trophoblast system A transport and cell survival and thus could contribute to the increased susceptibility to SGA births in folate deficient women. It has also contributed to the knowledge that miR expression is differentially altered in placentas exposed to folate-deficient versus sufficient conditions in vivo and that miRs are directly altered by folate depletion in vitro. These studies provide the foundation for future research to define the functional consequences of altered expression of folate-sensitive miRs and their target genes to explain how altered miRs could be affecting placental function resulting in development of SGA.

A vital factor for foetal development is the nutrient transport at placental level. This is because any disturbances in the maternal compartments, for example due to maternal stress or nutritional status, which will affect foetal development, will involve the foetal-placental barrier. Moreover, numerous studies have linked other factors such as preterm labour as the leading cause of perinatal morbidity and mortality in the developed world. To this date, despite a numerous epidemiological and clinical studies that identify potential risk factors for the mother as well as the foetus, there is no comprehensive analysis at all these levels taken from the same cohort of patients. Our working hypothesis is that for a successful pregnancy certain events at nutritional, biochemical, genetic and molecular level could be tightly linked. Therefore, in this study we followed a “holistic” approach investigating how maternal stress, nutrition, placental mTOR and glucocorticoid receptor (GR) signalling can influence pregnancy outcome. We have decided to map in detail the components of these two signalling pathways as they appear to cross-talk as well as been implicated in stress responses. The largest part of the questionnaire was focused on the nutritional status with questions targeting the maternal dietary habits before, as well as during, pregnancy. The collection of data took place at the Department of Obstetrics and Gynecology, University of Crete Medical School. With regards to this profile, key findings included the significant reduction in the intake of alcohol, caffeine-containing and sugar-containing refreshments, whereas passive smoking during pregnancy stayed the same. Another major finding of this part of the study was the effects of maternal stress on foetal weight and how pregnancy planning was implicated in this complex relation. In our cohort, women with negative attitudes during pregnancy gave birth to infants with significantly lower birth weights (2.5Kg) than those women showing positive or neutral attitudes towards their pregnancy (2.9Kg). We then assessed how maternal stress might affect this signalling cascade using two placental models (BeWo and JEG-3 cell lines) mimicking a stress milieu in vitro. Treatment of these cell lines with cortisol (100nM and 1000nM) significantly downregulated Deptor and upregulated GAS5 at mRNA level. In an attempt to dissect further a potential gene-environment interaction, we have assessed how 4 well-characterised polymorphisms (ThtIII 1, Bcl I, ER22/23EK, N363S) of the GR gene might affect foetal and placental weight. We have demonstrated that only the maternal ThtIII 1 polymorphism was suggestive of a nature-nurture interaction since only in ThtIII 1 II (CC), maternal stress attitude predicts foetal weight-reduction, but not in ThtIII 1 (GC) independent of confounders such as BMI, pregnancy planning or fast food eating during pregnancy. This is the first time that a gene-environment interaction between a common GR polymorphism and foetal weight was noted. Finally, one of the most important findings of our study came from the preclinical studies using placental tissues. Quantitative PCR revealed that the major transcripts in the human placenta are GRα, GAS5 (decoy for GR DNA binding) and Deptor. We have shown for first time that there are marked differences in the relative mRNA abundance of these components between term and preterm labour as well as colocalisation of GRα with GAS5. With regards to placental regulation these data conclusively demonstrate that: a) there is evidence of gene-environment interaction between maternal stress, pregnancy planning, glucocorticoid receptor polymorphisms and foetal weight and b) potential cross-talk of mTOR and glucocorticoid signalling. We propose that measuring maternal stress levels in addition to circulating cortisol and mapping for known GR polymorphisms could become a useful non-invasive tool of diagnostic and prognostic value, with implications for preterm labour.

Estudo longitudinal, prospectivo, comparativo de avaliação dopplervelocimétrica das artérias uterinas direita e esquerda em 37 gestantes normais em três períodos da gestação, acompanhadas na Clínica Obstétrica do HCFMUSP. Análise da relação S/D, índice de pulsatilidade e índice de resistência, relação com o número de incisuras e com posição da placenta. Foi observada redução nos valores dos índices durante a gestação. A relação S/D AUTE com placenta a direita apresentou média superior. A incidência de incisura foi maior no período entre a 16ª e a 24ª semana de gestação. A análise da relação entre os índices dopplervelocimétricos e a presença de incisura não teve resultados significativos / Prospective, longitudinal, comparative study of Doppler evaluation of the right and left uterine arteries of 37 healthy women with singleton pregnancies, performed in three periods of pregnancy, at the Pre-Natal Care Unit HCFMUSP. S/D ratio, pulsatility index and resistance index, number of notches and placental position were analysed. A decrease in the indices was observed with advancing gestation. When placenta was on the right side, the left uterine artery S/D ratio showed increased mean values. The incidence of uterine notch was higher between the 16th and 24th week of gestation in both arteries. No correlation was found between the presence of uterine notch and the placental position

Estudo longitudinal, prospectivo, comparativo de avaliação dopplervelocimétrica das artérias uterinas direita e esquerda em 37 gestantes normais em três períodos da gestação, acompanhadas na Clínica Obstétrica do HCFMUSP. Análise da relação S/D, índice de pulsatilidade e índice de resistência, relação com o número de incisuras e com posição da placenta. Foi observada redução nos valores dos índices durante a gestação. A relação S/D AUTE com placenta a direita apresentou média superior. A incidência de incisura foi maior no período entre a 16ª e a 24ª semana de gestação. A análise da relação entre os índices dopplervelocimétricos e a presença de incisura não teve resultados significativos / Prospective, longitudinal, comparative study of Doppler evaluation of the right and left uterine arteries of 37 healthy women with singleton pregnancies, performed in three periods of pregnancy, at the Pre-Natal Care Unit HCFMUSP. S/D ratio, pulsatility index and resistance index, number of notches and placental position were analysed. A decrease in the indices was observed with advancing gestation. When placenta was on the right side, the left uterine artery S/D ratio showed increased mean values. The incidence of uterine notch was higher between the 16th and 24th week of gestation in both arteries. No correlation was found between the presence of uterine notch and the placental position

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