The maternal immune system must be able to adjust during pregnancy and accept the foetus that expresses paternal antigens. These changes are found both in placenta and circulation, including a mild inflammatory response. NK cells are abundant during the early part of pregnancy in placenta and are thought to be important for placental development. During preeclampsia the placenta is poorly developed, together with an escalated pro-inflammatory profile noticed in both placenta and circulation. We wanted to study NK cells in placenta and circulation from preeclamptic cases as well as levels of cytokines. HMGB1, an alarmin involved in inflammation, was also measured in preeclamptic placentae. When studying preeclamptic placentae in third trimester we found higher numbers of NK cells as well as a higher expression of CD94+ NK cells. We also found slightly elevated levels of HMGB1 together with significantly lower expression of IL-12 in preeclamptic placentae. Further, the NK cell activating cytokines IL-12/IL-23p40 and IL-15 in sera from preeclamptic women were increased compared to healthy pregnancies. The elevated levels of NK cell activating IL-12/IL-23p40 and IL-15 found in preeclamptic sera, made us investigate the circulating NK cells in preeclampsia. However, no differences were seen between healthy and preeclamptic pregnancies. The main immunological alterations in third trimester preeclamptic pregnancies with regard to NK cells were found in placenta. Altered maternal cytokine levels in placenta could influence decidual NK cells in preeclampsia, noticed by their higher numbers and altered receptor expression. If these alterations also exist during early pregnancy it could result in a poorly developed and dysfunctional placenta.

Objetivo: Determinar el valor predictivo de la Prueba de Gant en gestantes del Hospital Nacional Docente Madre Niño “San Bartolomé”. Materiales y Métodos: Estudio analítico, prospectivo, constituido por 50 gestantes, (25 con prueba de Gant positiva y 25 con prueba de Gant Negativa). Los criterios de inclusión fueron Gestantes que aceptaron entrar al estudio, previo consentimiento informado, con edad gestacional entre 28 a 32 semanas, sin antecedente personales ni familiares de Enfermedad Hipertensiva, que no tengan ninguna otra patología asociada al embrazo, que asistan al programa de Estimulación Prenatal y Psicoprofilaxis Obstétrica, que lleven sus controles y que culminen el embarazo en la institución. Se excluyeron gestantes con embarazo múltiple, con Diagnóstico de Hipertensión, daño renal u otra patología asociada al embarazo. La recolección de datos se realizó a través de un instrumento en base a estudios previos, Historia Clínica y el Cartón Perinatal, dividido en 5 áreas o ítems. Todos los datos se analizaron vía estadística inferencial y descriptiva. Resultados: El mayor porcentaje de edad fue 30 años, siendo el 24% con Prueba de Gant Positiva, a diferencia de una minoría que tuvo menos de 20 años en un 20%. Del total de pacientes con preeclampsia el 4% correspondía a pacientes con Prueba de Gant Negativa y un 12% con Prueba de Gant Positiva, a diferencia de las gestantes normales, se observó un 96% con Prueba de Gant Negativa y un 88% con Prueba de Gant Positiva.

El objetivo del estudio fue determinar las características del manejo anestesiológico en gestantes con síndrome HELLP que requirieron cesárea en el Hospital Nacional Docente Madre Niño San Bartolomé de Lima – Perú durante el período comprendido entre enero 1998 – diciembre 2002. Se realizó un estudio observacional descriptivo, retrospectivo de corte transversal. Se aplicó un formulario incluyendo como variables: edad, paridad, edad gestacional al momento de la operación, presión arterial media intraoperatoria, necesidad de transfusión de hemoderivados, volumen total intraoperatorio de cristaloides administrado vía endovenosa, menor recuento preoperatorio de plaquetas en sangre y complicaciones anestésicas. Estas incluyeron: presencia de hematoma epidural, hipotensión arterial, hipertensión arterial, intubación fallida o difícil, edema de glotis, edema pulmonar, efusión pleural o injuria neurológica. El análisis estadístico se realizó con el programa SPSS 11.0. Se estudió un total de 42 pacientes. La mayoría de pacientes eran nulíparas. La edad de presentación estuvo comprendida entre los 18 y 41 años. La edad gestacional media al momento de la cirugía fue 34,5 semanas. El 92,8% de las pacientes recibieron anestesia epidural, el 4,8% anestesia general y el 2,4% anestesia raquídea. La presión arterial media promedio fue 109,9 +/- 8,0 mmHg y el volumen promedio de cristaloides administrado vía endovenosa fue 1455 +/- 486 mL Las complicaciones anestésicas más frecuentes fueron hipo e hipertensión arterial intraoperatoria, con 9,5% y 7,1%; respectivamente. Ambas se presentaron en pacientes que recibieron anestesia epidural. Se concluyó que el método anestésico usado con más frecuencia en pacientes con síndrome HELLP que requirieron cesárea es la anestesia epidural y las complicaciones anestésicas asociadas con su uso son la hipo e hipertensión arterial intraoperatoria.

Preeclampsia is an increasingly prevalent disorder of placentation that has very limited options for treatment. The disease is characterized by aberrant invasion of placental trophoblasts into the decidualized maternal endometrium. In order to identify pathways of therapeutic interest during placentation, we are focusing on the pathway of the neuropeptide kisspeptin and its receptor KISS1R, both highly expressed in the human placenta. Early functional studies of the ligand-receptor system identified a role for kisspeptin in the inhibition of cancer metastasis. Parallels exist between cancer and placentation, suggesting the possibility of an inhibitory role for kisspeptin during pregnancy as well. Existing functional data supports kisspeptin's inhibitory influence on cellular invasion, but the mechanism remains unknown. Evidence for the localization of the KISS1R receptor in the current literature was established via a nonspecific antibody and requires further investigation. Current literature suggests involvement of the ERK (extracellular signal-regulated kinase) pathway as well. Our work aims to solidify the localization of kisspeptin and KISS1R, avoiding the use of KISS1R antibodies. Using immunohistochemistry for protein localization of kisspeptin and placental fractionation followed by quantitative PCR analysis for gene expression, we provide evidence of kisspeptin's restriction to the syncytiotrophoblast layer of the placenta, and KISS1R gene expression limited to the villous cytotrophoblast layer. This distribution of ligand and receptor suggests a paracrine mechanism for kisspeptin action, with syncytiotrophoblasts secreting kisspeptin to act on its receptor on the villous cytotrophoblast layer, and thus restricting cytotrophoblast invasion. We further attempt to support these data with the use of laser capture microdissection of placental tissue to isolate the different layers, followed by quantitative PCR. This technique introduced a particularly challenging aspect of working with the placenta: maintaining tissue morphology while also preserving RNA integrity. This thesis outlines our troubleshooting process for that technique and introduces alternatives for future work. We also employed Western blot analysis of ERK activation to establish the mechanism of kisspeptin's inhibitory effect on fractionated trophoblasts.

Fibrinogen-like protein 2 (FGL2) is a known immunomodulator and prothrombinase, expressed by several subsets of immune cells. This thesis explores its potential role during the establishment of pregnancy, in mice, as well as in trophoblast function and in an immune-mediated subtype of preeclampsia (PE), in humans. We first noticed a marked subfertility in Fgl2 knockout (ko) and Fgl2 overexpressing (tg) colonies, where litters were fewer and smaller. To explain this, we mapped spatiotemporal patterns of FGL2 expression in the female reproductive tract and through the estrous cycle. FGL2 is expressed in the ovarian stroma and theca cell layer, peaking shortly before ovulation. Fgl2 ko and tg mice do not show a defect in natural or induced ovulation. FGL2 is expressed in secretory cells of the oviductal epithelium, and Fgl2 ko mice have reduced fertilization efficiency. Fgl2 tg pups are noticeably small, and we find that a reduced ratio of glycogen cells in the junctional zone of their placenta partly explains this. We next investigated the role of FGL2 in trophoblast function, using BeWo and HTR-8/SVneo cell lines. Inflammatory cytokines increase FGL2 expression in BeWo, and FGL2 overexpression promotes syncytialization. We show that it therefore rescues the deleterious effect of inflammation on syncytium formation. In a large cohort of PE and non-PE human placentas, FGL2 is high in a subtype with immune activation, and low in a canonical, anti-angiogenic subtype. Its expression correlates with incidence of chronic inflammatory histopathological lesions, likely driven by immune rejection gene sets. High FGL2 also associates with a high incidence of fibrin deposition in the placenta. Overall, we conclude that FGL2 is involved in several steps of maternal immune adaptation, both before and after pregnancy. Its absence and excess both contribute to mouse subfertility. In the developing and mature placenta, FGL2 is increased by inflammation in the trophoblast and immune compartment of the mature placenta, as a physiological attempt to re-establish immune equilibrium and protect the ongoing pregnancy.

BACKGROUND: Preeclampsia is one of the leading causes of maternal and perinatal morbidity and mortality, affecting 2-8% of pregnancies worldwide. It is estimated that 76,000 women and 500,000 babies die from this disease each year globally. Preeclampsia is characterized as hypertension associated with the onset of proteinuria, maternal organ dysfunction or uteroplacental dysfunction occurring at or after 20 weeks of gestation. In addition to its effects on pregnancy, preeclampsia may also have long-term adverse effects on women who experience the disorder and their children later on in life. Currently, the only cure for preeclampsia is delivery, which is often associated with preterm birth, increasing the risk of neonatal death. Daily low-dose aspirin (81mg) has been shown to have a preventive effect on preeclampsia in women at high risk of developing the disorder. OBJECTIVE: To analyze patient data collected at Boston Medical Center to determine the effects of prescribed low dose prenatal aspirin (81 mg) on pregnancy outcomes. METHODS: There were 2648 obstetric deliveries at Boston Medical Center in the two-year span of 2017-2018. Using R, statistical analyses were performed to determine the difference in birth outcomes between the prenatal aspirin prescribed group and the non-aspirin prescribed group as well as the effect of prenatal aspirin on pregnancy outcomes. Logarithmic and linear models as well as basic statistical methods were employed for the analyses. RESULTS: The prenatal aspirin prescribed population had higher major and moderate risk factors as well as worse birth outcomes, Apgar scores and birthweight as compared with the non-prescribed population. However, prenatal aspirin may reduce the adverse effects of both major and moderate risk factors on birth outcomes. CONCLUSIONS: Prenatal aspirin may have beneficial effects on birth outcomes, and the pregnant population at Boston Medical Center may benefit from taking low-dose aspirin. This study was carried out retrospectively with a cohort that was not randomized, so this conclusion needs to be verified by future studies.

Objetivos: Determinar si el período intergenésico prolongado es un factor de riesgo para el desarrollo de la preeclampsia. Materiales y métodos: Estudio caso – control, en el Instituto Nacional Materno Perinatal, en el período de enero a marzo del 2013. Se estudió 78 puérperas, en donde se comparó 39 de ellas que tuvieron preeclampsia (casos) con 39 puérperas que no tuvieron la enfermedad (controles) a las cuales se les midió el período intergenésico prolongado (mayor a 48 meses), características maternas, obstétricas y hábitos psicobiológicos. Se analizó el factor potencial asociado a preeclampsia usando la prueba de asociación Odd Ratio (OR). Resultados: Existe mayor riesgo de presentar preeclampsia en mujeres con período intergenésico prolongado (mayor a 48 meses), en los casos se observó que un 69.2% presentaron esta patología a diferencia de los controles que lo presentaron un 38.5% (OR: 5.4, IC=95%) Conclusiones: El período intergenésico prolongado (mayor a 48 meses) es un factor de riesgo de preeclampsia. Las mujeres que tienen este factor poseen un riesgo incrementado para que su embarazo sea complicado con preeclampsia. Palabras Claves: Preeclampsia, Período Intergenésico Prolongado, Embarazo. / Tesis

Memoria para optar al Titulo Profesional de Médico Veterinario / La preeclampsia (PE) es una de las complicaciones más frecuentes del embarazo, siendo una de las principales causas de morbi-mortalidad materna y perinatal. A pesar de la importancia de este síndrome, el conocimiento que se tiene sobre su etiopatogenia es limitado. Sin embargo, existen diversas teorías que incluyen la participación de factores genéticos, nutricionales, vasculares y autoinmunes. Existe evidencia que indica que el estrés oxidativo de la placenta está involucrado en la fisiopatología de la PE y se le ha propuesto como promotor de disfunción de células endoteliales y de un desarrollo insuficiente de la placenta, por una disminución de la angiogénesis normal, ambos característicos en los casos de PE. El presente estudio incluyó 220 muestras sanguíneas obtenidas de 1051 pacientes con control perinatal completo, que acudieron a la Unidad de Medicina Fetal del Hospital Clínico de la Universidad de Chile con 11-14 semanas de gestación entre los meses de Agosto 2004 y Marzo 2006. Las pacientes resultantes después de aplicar los criterios de exclusión detallados más adelante, se separaron en 3 grupos: preeclámpticas (32), pacientes con restricciones de crecimiento fetal (45) y el grupo control (143). Las determinaciones incluyeron: concentración de marcadores de estrés oxidativo (ácido úrico y MDA), marcadores de disfunción endotelial (PAI-1, PAI-2, ICAM, VCAM) y marcadores de actividad angiogénica (sFlt1, PIGF) en plasma de mujeres embarazadas durante el primer tercio de la gestación. Para esto se utilizaron las técnicas de HPLC, espectrofotometría, ELISA y FRAP. El análisis estadístico se realizó mediante la prueba t de Student (p<0,05) y prueba de correlación de Pearson (p<0,05). Se incluyó un control obtenido de forma aleatoria por cada paciente con patología. Los resultados mostraron que el promedio para sFlt1 en el grupo de pacientes con PE (1846,05 ± 222,30 nM/ml) fue estadísticamente diferente del grupo control (1176,44 ± 131,61 nM/ml) (p = 0,016). Para las demás variables no se observaron diferencias significativas entre los grupos. Al aumentar los niveles séricos de sFlt1, los niveles séricos de FRAP disminuyen (r = -0,56; p = 0,002), lo que indica que existe una relación inversa entre estas 2 variables. Las demás variables no presentaron correlación estadísticamente válida en esta edad gestacional. De esto se deduce que existe asociación entre la concentración plasmática de esta variable y la presentación de la enfermedad. Se concluye que de las variables medidas precozmente, la única que se encuentra asociada a la presentación de la enfermedad en este estado de gestación precoz es sFlt1. Con esto se confirma la participación de esta molécula en la patogénesis de la PE, lo cual deja abierto el tema a nuevos estudios que se realicen en etapas tempranas de gestación y que comprendan tratamientos posibles de realizar en una etapa temprana con miras a la prevención de la enfermedad / Proyecto FONDECYT N°1050482

Eclampsia is defined as de novo seizure in a woman with the hypertensive complication of pregnancy known as preeclampsia (PE), and is a leading cause of maternal and fetal morbidity and mortality worldwide. The pathogenesis of eclamptic seizure remains unknown, but is considered a form of hypertensive encephalopathy where an acute rise in blood pressure causes loss of cerebral blood flow (CBF) autoregulation and hyperperfusion of the brain that results in vasogenic edema formation and subsequent seizure. However, eclamptic seizure can occur during seemingly uncomplicated pregnancies, in the absence of hypertension and PE, suggesting that normal pregnancy may predispose the brain to hypertensive encephalopathy or seizure, independently of PE. The overall goal of this dissertation was to investigate the effect of pregnancy and PE on the cerebrovasculature and neurophysiological properties that may promote brain injury and eclamptic seizure. For this dissertation project, a rat model of PE was established that combined placental ischemia, induced by restricting blood flow to the uteroplacental unit, and maternal endothelial dysfunction that was induced by a prolonged high cholesterol diet. Rats with PE developed several PE-like symptoms, including elevated blood pressure, fetal growth restriction, placental dysfunction, and were in a state of oxidative stress and endothelial dysfunction. We found that pregnancy had an overall protective effect on the maintenance of CBF that was potentially due to a nitric-oxide dependent enhancement of the vasodilation of cerebral arteries to decreased intravascular pressure. Further, maintenance of CBF during acute hypertension was similar in pregnancy and PE. Thus, it does not appear that pregnancy and PE are states during which CBF autoregulation is compromised in a manner that would promote the development of hypertensive encephalopathy. However, the brain was found to be in a hyperexcitable state during normal pregnancy that was augmented in PE, and could contribute to onset of eclamptic seizure. Under chloral hydrate anesthesia, generalized seizure was induced by timed infusion of the convulsant pentylenetetrazole (PTZ), with simultaneous electroencephalography that was stopped at the first onset of spikewave discharge indicative of electrical seizure. Seizure threshold was determined as the amount of PTZ required to elicit seizure. Compared to the nonpregnant state, seizure threshold was ~44% lower in pregnant rats and ~80% lower in rats with PE. Further, pregnant rats were more susceptible to seizure-induced vasogenic edema formation than the nonpregnant state. Mechanisms by which pregnancy and PE lowered seizure threshold appeared to be through pregnancy-associated decreases in cortical gamma-aminobutyric acid type A receptor (GABAAR) subunits and PE-induced disruption of the blood-brain barrier (BBB) and microglial activation, indicative of neuroinflammation. Magnesium sulfate (MgSO4), the leading treatment for seizure prophylaxis in women with PE, restored seizure threshold to control levels by reversing neuroinflammation in PE rats, without affecting BBB permeability. Overall, this dissertation provides evidence that pregnancy increases susceptibility of the brain to seizure and vasogenic edema formation that likely contribute to the onset of eclampsia during seemingly uncomplicated pregnancies. Further, the pathogenesis of eclampsia during PE likely involves breakdown of the BBB and subsequent neuroinflammation, resulting in a state of greater seizure susceptibility that is ameliorated by MgSO4 treatment.

Objetivo: Relacionar los conocimientos, actitudes y prácticas de los signos y síntomas de preeclampsia en puérperas con este síndrome durante la gestación y los resultados perinatales, atendidos en el Instituto Nacional Materno Perinatal, durante el año 2010. Diseño: Estudio descriptivo - correlacional, transversal, prospectivo. Metodología: Se aplicó una entrevista estructurada con 19 preguntas cerradas a 203 puérperas seleccionadas aleatoriamente con diagnostico de preeclampsia durante la gestación y los datos perinatales se obtuvo de las historias clínicas. Resultados: Se encontró una asociación estadísticamente significativa (p < 0,05) entre el peso, edad gestacional y el peso en relación a la edad gestacional y los conocimientos, actitudes y prácticas de los signos y síntomas de preeclampsia. Las pacientes con conocimientos buenos, actitudes positivas y prácticas adecuadas tienen neonatos con peso normal en un 54,2%, 51,4% y 53,6% respectivamente. Las pacientes con conocimientos buenos, actitudes positivas y prácticas adecuadas tuvieron neonatos a término en un 48,7%, 46,2% y 51,9% respectivamente. Por último, las pacientes con conocimientos buenos, actitudes positivas y prácticas adecuadas tuvieron neonatos adecuados para la edad gestacional en un 52,1%, 49,1% y 52,8% respectivamente. Según los resultados no existe una asociación significativa entre el apgar del recién nacido y los conocimientos, actitudes y prácticas (p> 0,05). Conclusiones: Los conocimientos, actitudes y prácticas de los signos y síntomas de preeclampsia repercuten favorablemente en los resultados perinatales. Palabras claves: Preeclampsia, conocimientos, actitudes y prácticas de los signos y síntomas de preeclampsia y resultados perinatales.