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Preeclampsia results from incomplete trophoblast invasion of the spiral arteries during early pregnancy. Vascular endothelial growth factor (VEGF) and plasminogen activator inhibitor-1 (PAI-1) are critical factors involved in angiogenesis, invasion and hemostasis at the maternal-fetal interface. Both factors are transcriptionally regulated by hypoxia inducible factor (HIF), a heterodimeric complex consisting of HIF-1[beta] and either HIF-1[alpha] or -2[alpha] whose specificity or redundancy in gene regulation is cell-type specific. This study uses siRNA technology to dissect the mechanisms of hypoxia-mediated regulation of PAI-1 and VEGF expression in first trimester trophoblasts. Immortalized first trimester human extravillous trophoblasts (HTR8/SVneo cells) were maintained in serum-free and serum-containing media for 4h (n=3-4), 8h (n=6), 24h (n=5) and 48h (n=5) under normoxic (21% O2) and hypoxic (1-2% O2) conditions to determine a time of maximum induction of both VEGF and PAI-1. Subsequently, cells were maintained for 48h in the presence or absence of siRNA for HIF-1[alpha], HIF-2[alpha], HIF-1[alpha] + -2[alpha], a non-targeting (NT) sequence or Cyclophilin B (CB). Media were then removed, cells lysed, and Western blotting used to assess HIF-[alpha] knockdown. VEGF and PAI-1 levels in the media were quantified by ELISA and results expressed as pg or ng/[micro]g protein. Results from 3 to 8 independent experiments were analyzed using unpaired t-tests. Under hypoxic conditions treatment of cells with HIF-1[alpha], HIF-2[alpha] or HIF -1[alpha] + -2[alpha] siRNA resulted in >90% HIF-Ñ protein knockdown as determined by Western blotting. 48h of hypoxic treatment caused a statistically significant increase in PAI-1 levels (p<0.01) and VEGF levels (p<0.001) compared to normoxic controls. Under hypoxic conditions, PAI-1 levels were 4.75 [plus-minus] 0.46 ng/[micro]g protein and VEGF levels were 7.27 [plus-minus] 1.08 pg/[micro]g protein. Treatment with siRNA to HIF-1[alpha], HIF-2[alpha] and HIF-1[alpha] + -2[alpha] significantly reduced PAI-1 levels to 3.3 [plus-minus] 0.35 (p<0.02), 3.1 [plus-minus] 0.38 (p<0.03) and 2.4 [plus-minus] 0.19 (p<0.003), respectively. No significant difference in PAI-1 reduction was noted between the three HIF siRNA conditions. Under hypoxic conditions, levels of VEGF in cells treated with siRNA to HIF-1[alpha] (5.79 [plus-minus] 0.55), HIF-2[alpha] (5.50 [plus-minus] 1.24) and HIF-1[alpha] + -2[alpha] (4.24 [plus-minus] 0.93) were reduced compared to the hypoxic control (7.27 [plus-minus] 1.08), yet these effects did not reach statistical significance. However, when compared with the levels observed in cells treated with NT siRNA (9.90 [plus-minus] .98), all HIF siRNA treatments promoted a significant reduction in VEGF expression (p<0.003, p<0.02 and p<0.003 for HIF-1[alpha], HIF-2[alpha] and HIF-1[alpha]+ -2[alpha], respectively). In conclusion, these results indicate that hypoxia-mediated changes in PAI-1 and VEGF expression in trophoblasts are regulated similarly by both HIF-1[alpha] and HIF-2[alpha]. This provides important insight into the molecular mechanisms regulating hemostasis and trophoblast invasion as well as their potential dysfunction in pregnancies complicated by preeclampsia

Le placenta est l'organe essentiel au succès de la grossesse et la différenciation des trophoblastes est fondamentale pour son bon fonctionnement. La présence d’une inflammation non contrôlée, habituellement induite par des médiateurs inflammatoires endogènes, est associée à plusieurs complications de la grossesse. High Mobility Group Box 1 (HMGB1), une protéine nucléaire qui peut avoir des actions inflammatoires lorsque secrétée dans le milieu extracellulaire, est un des médiateurs inflammatoires endogènes augmentés lors des grossesses pathologiques. Cependant, la manière dont HMGB1 agit à l’interface materno-foetale est encore inconnue. Ce travail de maîtrise a comme objectifs d’évaluer la concentration, la localisation subcellulaire et la sécrétion de HMGB1 lors de la différentiation des trophoblastes et d’étudier sa distribution dans le placenta de grossesses compliquées par une préeclampsie (PE). Dans ces travaux, nous avons démontré une augmentation de la concentration nucléaire de HMGB1 lors de la différenciation spontanée des trophoblastes. De plus, l’utilisation d’un inhibiteur d’histones déacétylases (c.-à-d. NaB) mène à une accumulation de HMGB1 dans le cytoplasme et favorise la différenciation, tandis que l’utilisation d’un inhibiteur de l’export nucléaire (c.-à-d. leptomycine) mène à une diminution de la différenciation. En ce qui concerne les grossesses compliquées par la PE, il y a une redistribution de HMGB1 avec une accumulation cytoplasmique. En conclusion, ces travaux démontrent l’association entre la modulation de HMGB1 et la différentiation des trophoblastes, bien que le lien causal reste à déterminer. / The placenta plays a crucial role during pregnancy and trophoblast differentiation is fundamental to its proper functioning. The absence of inflammation is also essential for the success of gestation, the presence of uncontrolled inflammation is associated with several pregnancy complications, such as preeclampsia (PE) and preterm delivery. High Mobility Group Box 1 (HMGB1), a nuclear protein that acts as a pro-inflammatory mediator when secreted into the extracellular media, is one of the endogenous inflammatory mediators increased during pathological pregnancies. However, the actions of HMGB1 at the materno-fetal interface are still unknown. The aim of this work was to evaluate the concentration, subcellular localization and secretion of HMGB1 during trophoblast differentiation and to evaluate the distribution of HMGB1 in the placenta from pregnancies complicated with PE. In my studies I have shown an increase of HMGB1’s nuclear concentration during the spontaneous differentiation of trophoblasts. Moreover, the use of a histone deacetylase inhibitor (i.e. NaB) leads to an accumulation of HMGB1 in the cytoplasm and promotes differentiation, while the use of a nuclear export inhibitor (i.e. leptomycin) leads to a decrease in differentiation. Concerning pregnancies complicated with PE, there is a redistribution of HMGB1 with cytoplasmic accumulation. In conclusion, this work demonstrates the association between the modulation of HMGB1 localisation with trophoblasts differentiation, although the causal link remains to be determined.

INTRODUÇÃO: A definição de fatores preditivos de lesão morfológica e funcional da tuba uterina poderia colaborar na escolha do tratamento de pacientes com gestação ectópica. O objetivo deste estudo foi verificar o comportamento do tecido trofoblástico em relação à sua penetração na parede da tuba uterina em gestações ampulares, relacionar a profundidade dessa penetração com idade gestacional, concentração de beta-hCG, tipo de imagem ultra-sonográfica e dimensão da massa ectópica à ultra-sonografia e avaliar a possibilidade de predição dessa invasão pelos parâmetros estudados. MÉTODOS: realizou-se estudo retrospectivo, entre 1° de janeiro de 2000 a 31 de março de 2004, com 105 pacientes com gestação tubária ampular submetidas à salpingectomia. As imagens ectópicas foram classificadas pelo aspecto ultra-sonográfico em anel tubário, massa complexa e embrião com atividade cardíaca e sua dimensão foi obtida pela medida do maior eixo. Histologicamente a invasão trofoblástica na parede tubária foi classificada em grau I: quando limitada à mucosa da tuba uterina; grau II: até a camada muscular; grau III: invasão de toda a espessura da tuba uterina. RESULTADOS: 29 pacientes tiveram infiltração tubária grau I, 30 pacientes infiltração grau II e 46 pacientes infiltração grau III. Os graus de invasão trofoblástica não estiveram associados à idade gestacional (p = 0,53) nem ao maior diâmetro da imagem à ultra-sonografia (p = 0,43). Os diferentes graus de invasão trofoblástica apresentaram diferença significativa da beta-hCG (p < 0,001). O grau I apresentou valores menores que os graus II e III (p < 0,05) e o grau II valores menores que o grau III (p < 0,05). Houve associação entre o grau de invasão trofoblástica e a descrição do tipo de imagem identificada à ultra-sonografia (p = 0,001). Embrião com atividade cardíaca foi mais prevalente nos casos de invasão grau III. O valor de 2 400 mUI/ml apresentou sensibilidade de 82,8%, especificidade de 85,5%, valor preditivo positivo de 68,6% e valor preditivo negativo de 92,7% (acurácia de 84,8%) para determinar invasão trofoblástica grau I. beta-hCG de 5 990 mUI/ml foi o melhor ponto de corte para predição de invasão trofoblástica grau III: sensibilidade de 82,6%, especificidade de 74,6%, valor preditivo positivo de 71,7% e valor preditivo negativo de 84,6% (acurácia de 78,1%). CONCLUSÕES: Em gestações ampulares, o tecido trofoblástico se desenvolve a partir de sua penetração na parede tubária, a profundidade da penetração do trofoblasto na tuba uterina relaciona-se às concentrações séricas de beta-hCG e ao tipo de imagem ultra-sonográfica, sendo que a concentração sérica da beta-hCG é a melhor preditora da profundidade da invasão na tuba uterina. / INTRODUCTION: The definition of predictive factors of morphologic and functional damage to the Fallopian tube may help in the choice of treatment for patients with ectopic pregnancy. The objective of the present study was to verify the presence of trophoblastic invasion into the tubal wall in ampular pregnancies, correlate the depth of penetration of trophoblastic tissue into the tubal wall with gestational age, beta-hCG concentration, type of ultrasonographic image and dimension of the ectopic mass upon ultrasound, and to evaluate the possible prediction of this invasion based on the parameters studied. METHODS: A retrospective study was conducted on 105 patients with ampular pregnancy submitted to salpingectomy between January 1, 2000 and March 31, 2004. Ectopic images were classified based on ultrasonographic findings in tubal ring, complex mass and embryonic heart activity. The dimension of the mass was determined by measuring the major axis. Histologically, trophoblastic invasion into the tubal wall was classified as grade I when limited to the tubal mucosa, grade II when reaching the muscle layer, and grade III when comprising the full thickness of the Fallopian tube. RESULTS: Twenty-nine patients had tubal infiltration grade I, 30 had grade II and 46 had grade III. The level of trophoblastic invasion was associated neither with gestational age (p = 0.53) nor with a greater diameter of the ultrasound image (p = 0.43). The different levels of trophoblastic invasion were significantly associated with beta-hCG concentration (p < 0.001), with lower concentrations being observed for grade I compared to grades II and III (p < 0.05) and for grade II compared to grade III (p < 0.05). There was an association between the level of trophoblastic invasion and the type of ultrasonographic image (p = 0.001). Embryos with heart activity were more prevalent in cases of grade III invasion. beta-hCG levels of 2 400 mIU/ml showed 82.8% sensitivity, 85.5% specificity, a positive predictive value of 68.6% and a negative predictive value of 92.7% (84.8% accuracy) for the diagnosis of grade I trophoblastic invasion. A beta-hCG titer of 5990 mIU/ml was the best cut-off for the prediction of grade III trophoblastic invasion: 82.6% sensitivity, 74.6% specificity, positive predictive value of 71.7% and negative predictive value of 84.6% (78.1% accuracy). CONCLUSIONS: trophoblastic tissue penetrate tubal wall in ampular pregnancies, the depth of penetration of trophoblastic tissue is correlated with beta-hCG concentration and type of ultrasonographic image and beta-hCG titer is the best predictor of the depth of penetration into tubal wall.

La membrane plasmique est un assemblage supramoléculaire qui délimite la cellule. C’est une structure fine, complexe et dynamique assurant des fonctions multiples et vitales pour la cellule. Sa rupture est un évènement physiologique pour les cellules soumises à des stress mécaniques fréquents et/ou importants, comme les cellules épithéliales, les cellules endothéliales ou les cellules musculaires. Dans des conditions physiopathologiques, la membrane plasmique peut également être endommagée par l’insertion de toxines bactériennes formant des pores (PFTs, pour « pore forming toxins »). Le processus de réparation membranaire et la machinerie protéique associée sont encore mal connus. Connaître les partenaires protéiques et comprendre les mécanismes mis en jeu durant le processus de réparation de la membrane plasmique sont deux enjeux fondamentaux majeurs. En effet, il a été établi qu’une défaillance du processus de réparation membranaire pour les fibres musculaires est la cause principale de certaines dystrophies musculaires. La machinerie protéique de réparation comprend des protéines comme la dysferline, la cavéoline-3 et certaines Annexines (Anx). Les Anx appartiennent à une superfamille de protéines répandue chez la plupart des eucaryotes, qui ont la propriété commune de se lier aux membranes biologiques en présence de calcium (Ca2+). Certaines Anx, comme l’AnxA5, une fois liées aux membranes biologiques s’auto-assemblent spontanément en réseau-2D. Lors de ce travail de thèse, nous avons étudié le rôle de l’AnxA5 dans la réparation membranaire des trophoblastes placentaires et des cellules du muscle squelettique humain. Pour les deux types cellulaires, nous avons montré que l’AnxA5 est un acteur indispensable du processus de réparation membranaire dans le cas de ruptures mécaniques. En associant des approches de microscopie de fluorescence et de microscopie électronique à transmission (MET), nous avons mis en évidence que dans ces cellules, le mécanisme de réparation est principalement basé sur la formation d’un « patch » lipidique. Dans les cellules musculaires, les expériences de MET ont mis en évidence qu’un pool d’AnxA5 endogène se lie aux bords du site de rupture quelques secondes après la lésion du sarcolemme. Ceci suggère qu’après rupture de la membrane plasmique, l’augmentation locale de la concentration calcique intracellulaire provoque la liaison de l’AnxA5 spécifiquement aux bords de la région membranaire lésée où elle forme un réseau-2D. Le réseau-2D stabiliserait localement la membrane et préviendrait sa déchirure, induite par les forces de tensions exercées par le cytosquelette cortical. Nous avons également montré que l’AnxA5 ne semble pas impliquée dans la réparation de la membrane plasmique après insertion de PFTs. Ceci suggère que différents mécanismes de réparation existent et que leur mise en place dépend probablement du type ou de l’importance des dommages. Finalement nous avons étendu notre étude à des lignées cellulaires établies à partir de patients diagnostiqués comme souffrant de dystrophies des ceintures de type 2B (déficience en dysferline) et 1C (déficience en cavéoline-3), respectivement. Nous avons montré, pour ces lignées, que la déficience en dysferline ou cavéoline-3 provoque un défaut de réparation dans le cas des ruptures mécaniques de la membrane plasmique. Dans ces cellules musculaires pathologiques intactes ou endommagées, l’AnxA5 a le même comportement, ce qui suggère que l’action de l’AnxA5 est indépendante de ces protéines. A la différence des cellules déficientes en dysferline, nous avons observé que les cellules déficientes en cavéoline-3 sont capables de réparer efficacement des lésions créées par l’insertion de PFTs dans le sarcolemme. Ce résultat supporte l’hypothèse de l’existence de plusieurs mécanismes de réparation. En conclusion, ce travail montre que l’AnxA5 est un composant clé de la machinerie de réparation dans le cas des ruptures mécaniques. / Plasma membrane is the supramolecular assembly that delimits the cell. It is a thin, dynamic and complex structure, ensuring multiple and vital cell functions. Its disruption is a physiological event occurring in cells submitted to frequent mechanical stresses, such as endothelial cells, epithelial cells and muscle cells. It is also a physiological event for cells exposed to pore forming bacterial toxins (PFTs). Membrane repair mechanisms and associated protein machinery are still poorly understood. This knowledge is, however, essential for obvious physiopathological issues. Indeed, a defect of membrane repair in muscle cells leads to some muscular dystrophies. Membrane repair machinery includes proteins such as dysferlin, MG-53, caveolin-3 and some Annexins (Anx). Anx belong to a superfamily of proteins widely spread in most of eukaryotes, which share the property of binding to biological membranes in the presence of calcium (Ca2+). Here, we investigated the role of AnxA5 in cell membrane repair of human trophoblastic and skeletal muscle cells. We showed that AnxA5 is required for membrane repair of mechanical damages in the two cell types. By combining fluorescence and transmission electron microscopy approaches, we evidenced that membrane repair mechanism in these cells is based on the formation of a lipid “patch”. In human muscle cells, TEM experiments revealed that a pool of endogenous AnxA5 binds to the edges of the torn sarcolemma as soon as a few seconds after membrane disruption. Our results suggest the following mechanism: triggered by the local increase in Ca2+ concentration, AnxA5 molecules bind to PS exposed at the edges of the torn membrane, where they self-assemble into 2D arrays. The formation of 2D arrays strengthens the damaged sarcolemma, counteracts the tensions exerted by the cortical cytoskeleton and thus prevents the expansion of the tear. We showed also that a pool of endogenous AnxA5 binds to intracellular vesicles that obstruct the wounding site. It is likely these vesicles, once associated one to each other, ensure membrane resealing. Our results suggest that sarcolemma repair of damages caused by PFTs is independent of AnxA5. Therefore, different membrane repair mechanisms may exist, their occurrence probably depending on the type and/or the size of damages. Finally, we performed studies on muscle cells established from patients diagnosed with limb girdle muscular dystrophies type 2B (dysferlin-deficient) and 1C (caveolin-3-deficient), respectively. We found that dysferlin or caveolin-3 deficiency leads to a defect of membrane repair, in the case of mechanical damages. AnxA5 behaved similarly in these damaged cells and wild-type cells, suggesting that its function is independent of dysferlin or caveolin-3. Unlike dysferlin-deficient cells, damages created by PFTs are efficiently repaired in caveolin- 3-deficient cells. This result supports the hypothesis that different mechanisms occur in muscle cells, depending on the type of damage. In conclusion, this work indicates that AnxA5 is a key component of the membrane repair machinery, in the case of mechanical disruptions. Our results enable to propose a detailed mode of action for AnxA5.

INTRODUÇÃO: A definição de fatores preditivos de lesão morfológica e funcional da tuba uterina poderia colaborar na escolha do tratamento de pacientes com gestação ectópica. O objetivo deste estudo foi verificar o comportamento do tecido trofoblástico em relação à sua penetração na parede da tuba uterina em gestações ampulares, relacionar a profundidade dessa penetração com idade gestacional, concentração de beta-hCG, tipo de imagem ultra-sonográfica e dimensão da massa ectópica à ultra-sonografia e avaliar a possibilidade de predição dessa invasão pelos parâmetros estudados. MÉTODOS: realizou-se estudo retrospectivo, entre 1° de janeiro de 2000 a 31 de março de 2004, com 105 pacientes com gestação tubária ampular submetidas à salpingectomia. As imagens ectópicas foram classificadas pelo aspecto ultra-sonográfico em anel tubário, massa complexa e embrião com atividade cardíaca e sua dimensão foi obtida pela medida do maior eixo. Histologicamente a invasão trofoblástica na parede tubária foi classificada em grau I: quando limitada à mucosa da tuba uterina; grau II: até a camada muscular; grau III: invasão de toda a espessura da tuba uterina. RESULTADOS: 29 pacientes tiveram infiltração tubária grau I, 30 pacientes infiltração grau II e 46 pacientes infiltração grau III. Os graus de invasão trofoblástica não estiveram associados à idade gestacional (p = 0,53) nem ao maior diâmetro da imagem à ultra-sonografia (p = 0,43). Os diferentes graus de invasão trofoblástica apresentaram diferença significativa da beta-hCG (p < 0,001). O grau I apresentou valores menores que os graus II e III (p < 0,05) e o grau II valores menores que o grau III (p < 0,05). Houve associação entre o grau de invasão trofoblástica e a descrição do tipo de imagem identificada à ultra-sonografia (p = 0,001). Embrião com atividade cardíaca foi mais prevalente nos casos de invasão grau III. O valor de 2 400 mUI/ml apresentou sensibilidade de 82,8%, especificidade de 85,5%, valor preditivo positivo de 68,6% e valor preditivo negativo de 92,7% (acurácia de 84,8%) para determinar invasão trofoblástica grau I. beta-hCG de 5 990 mUI/ml foi o melhor ponto de corte para predição de invasão trofoblástica grau III: sensibilidade de 82,6%, especificidade de 74,6%, valor preditivo positivo de 71,7% e valor preditivo negativo de 84,6% (acurácia de 78,1%). CONCLUSÕES: Em gestações ampulares, o tecido trofoblástico se desenvolve a partir de sua penetração na parede tubária, a profundidade da penetração do trofoblasto na tuba uterina relaciona-se às concentrações séricas de beta-hCG e ao tipo de imagem ultra-sonográfica, sendo que a concentração sérica da beta-hCG é a melhor preditora da profundidade da invasão na tuba uterina. / INTRODUCTION: The definition of predictive factors of morphologic and functional damage to the Fallopian tube may help in the choice of treatment for patients with ectopic pregnancy. The objective of the present study was to verify the presence of trophoblastic invasion into the tubal wall in ampular pregnancies, correlate the depth of penetration of trophoblastic tissue into the tubal wall with gestational age, beta-hCG concentration, type of ultrasonographic image and dimension of the ectopic mass upon ultrasound, and to evaluate the possible prediction of this invasion based on the parameters studied. METHODS: A retrospective study was conducted on 105 patients with ampular pregnancy submitted to salpingectomy between January 1, 2000 and March 31, 2004. Ectopic images were classified based on ultrasonographic findings in tubal ring, complex mass and embryonic heart activity. The dimension of the mass was determined by measuring the major axis. Histologically, trophoblastic invasion into the tubal wall was classified as grade I when limited to the tubal mucosa, grade II when reaching the muscle layer, and grade III when comprising the full thickness of the Fallopian tube. RESULTS: Twenty-nine patients had tubal infiltration grade I, 30 had grade II and 46 had grade III. The level of trophoblastic invasion was associated neither with gestational age (p = 0.53) nor with a greater diameter of the ultrasound image (p = 0.43). The different levels of trophoblastic invasion were significantly associated with beta-hCG concentration (p < 0.001), with lower concentrations being observed for grade I compared to grades II and III (p < 0.05) and for grade II compared to grade III (p < 0.05). There was an association between the level of trophoblastic invasion and the type of ultrasonographic image (p = 0.001). Embryos with heart activity were more prevalent in cases of grade III invasion. beta-hCG levels of 2 400 mIU/ml showed 82.8% sensitivity, 85.5% specificity, a positive predictive value of 68.6% and a negative predictive value of 92.7% (84.8% accuracy) for the diagnosis of grade I trophoblastic invasion. A beta-hCG titer of 5990 mIU/ml was the best cut-off for the prediction of grade III trophoblastic invasion: 82.6% sensitivity, 74.6% specificity, positive predictive value of 71.7% and negative predictive value of 84.6% (78.1% accuracy). CONCLUSIONS: trophoblastic tissue penetrate tubal wall in ampular pregnancies, the depth of penetration of trophoblastic tissue is correlated with beta-hCG concentration and type of ultrasonographic image and beta-hCG titer is the best predictor of the depth of penetration into tubal wall.

INTRODUÇÃO: A definição de fatores preditivos de lesão morfológica e funcional da tuba uterina poderia colaborar na escolha do tratamento de pacientes com gestação ectópica. O objetivo deste estudo foi relacionar a penetração do tecido trofoblástico na parede tubária acometida por gestação ampular com a concentração sérica materna de VEGF, avaliar a possibilidade do VEGF predizer a profundidade da invasão do tecido trofoblástico, comparando o desempenho do VEGF com o desempenho das concentrações séricas de beta-hCG na predição da profundidade da invasão do trofoblasto. MÉTODOS: realizou-se estudo prospectivo, entre 21 de dezembro de 2006 a 30 de setembro de 2007, com 30 pacientes com gestação tubária ampular submetidas à salpingectomia. Foram dosadas as concentrações séricas maternas de VEGF após confirmação do diagnóstico de gestação tubária e antes da realização da salpingectomia. Histologicamente a invasão trofoblástica na parede tubária foi classificada em grau I: quando limitada à mucosa da tuba uterina; grau II: até a camada muscular; grau III: invasão de toda a espessura da tuba uterina. RESULTADOS: 10 pacientes tiveram infiltração tubária grau I, 9 pacientes infiltração grau II e 11 pacientes infiltração grau III. Os diferentes graus de invasão trofoblástica apresentaram diferença significativa das concentrações séricas de VEGF (p< 0,001). O título sérico de VEGF de 305 pg/mL apresentou sensibilidade de 100,0%, especificidade de 85,0%, valor preditivo positivo de 76,9% e valor preditivo negativo de 100,0% para determinar invasão trofoblástica grau I. Título sérico de 425,9 pg/mL foi o melhor ponto de corte para predição de invasão trofoblástica grau III: sensibilidade de 81,8%, especificidade de 94,7%, valor preditivo positivo de 90,0% e valor preditivo negativo de 90,0%. Regressão logística selecionou a concentração sérica de VEGF como fator de melhor desempenho na predição da invasão trofoblástica quando comparado com título sérico de beta-hCG. CONCLUSÕES: em gestações ampulares, a profundidade da penetração do tecido trofoblástico na parede tubária acometida por gestação ectópica se relaciona com a concentração sérica de VEGF, a concentração sérica de VEGF é preditora da profundidade da invasão do tecido trofoblasto na parede tubária acometida por GE e a concentração sérica de VEGF apresenta melhor desempenho que a concentração sérica de beta-hCG como preditora da profundidade da invasão do trofoblasto na parede da tuba uterina acometida por gestação ampular / INTRODUCTION: The definition of predictive factors of morphologic and functional damage to the Fallopian tube may help in the choice of treatment for patients with ectopic pregnancy. The objective of the present study was to correlate the depth of penetration of trophoblastic tissue into the tubal wall with maternal serum VEGF concentrations, to evaluate the prediction of this invasion based on these concentrations and to compare the performances of VEGF and beta-hCG as predictors of trophoblastic invasion. METHODS: A prospective study was conducted on 30 patients with ampular pregnancy submitted to salpingectomy between December 21st, 2006 and September 30th, 2007. Maternal serum VEGF concentrations were measured after the diagnosis confirmation and before salpingectomy was performed. Histologically, trophoblastic invasion into the tubal wall was classified as grade I when limited to the tubal mucosa, grade II when reaching the muscle layer, and grade III when comprising the full thickness of the Fallopian tube. RESULTS: ten patients had tubal infiltration grade I, nine had grade II and eleven had grade III. The different levels of trophoblastic invasion were significantly associated with VEGF concentrations (p< 0.001). VEGF levels of 305.0 pg/mL showed 100.0% sensitivity, 85.0% specificity, a positive predictive value of 76.9% and a negative predictive value of 100.0% for the diagnosis of grade I trophoblastic invasion. A VEGF titer of 425.9 pg/mL was the best cut-off for the prediction of grade III trophoblastic invasion: 81.8% sensitivity, 94.7% specificity, positive predictive value of 90.0% and negative predictive value of 90.0%. Logistic regression showed that VEGF presented higher performance as a predictor of trophoblastic invasion than beta-hCG. CONCLUSIONS: in ampullary pregnancies, the depth of penetration of trophoblastic tissue into the tubal wall is correlated with serum VEGF concentrations, serum VEGF titer is predictor of the depth of penetration into tubal wall and VEGF concentrations present higher performance than beta-hCG as predictor of the trophoblastic invasion

INTRODUÇÃO: A definição de fatores preditivos de lesão morfológica e funcional da tuba uterina poderia colaborar na escolha do tratamento de pacientes com gestação ectópica. O objetivo deste estudo foi relacionar a penetração do tecido trofoblástico na parede tubária acometida por gestação ampular com a concentração sérica materna de VEGF, avaliar a possibilidade do VEGF predizer a profundidade da invasão do tecido trofoblástico, comparando o desempenho do VEGF com o desempenho das concentrações séricas de beta-hCG na predição da profundidade da invasão do trofoblasto. MÉTODOS: realizou-se estudo prospectivo, entre 21 de dezembro de 2006 a 30 de setembro de 2007, com 30 pacientes com gestação tubária ampular submetidas à salpingectomia. Foram dosadas as concentrações séricas maternas de VEGF após confirmação do diagnóstico de gestação tubária e antes da realização da salpingectomia. Histologicamente a invasão trofoblástica na parede tubária foi classificada em grau I: quando limitada à mucosa da tuba uterina; grau II: até a camada muscular; grau III: invasão de toda a espessura da tuba uterina. RESULTADOS: 10 pacientes tiveram infiltração tubária grau I, 9 pacientes infiltração grau II e 11 pacientes infiltração grau III. Os diferentes graus de invasão trofoblástica apresentaram diferença significativa das concentrações séricas de VEGF (p< 0,001). O título sérico de VEGF de 305 pg/mL apresentou sensibilidade de 100,0%, especificidade de 85,0%, valor preditivo positivo de 76,9% e valor preditivo negativo de 100,0% para determinar invasão trofoblástica grau I. Título sérico de 425,9 pg/mL foi o melhor ponto de corte para predição de invasão trofoblástica grau III: sensibilidade de 81,8%, especificidade de 94,7%, valor preditivo positivo de 90,0% e valor preditivo negativo de 90,0%. Regressão logística selecionou a concentração sérica de VEGF como fator de melhor desempenho na predição da invasão trofoblástica quando comparado com título sérico de beta-hCG. CONCLUSÕES: em gestações ampulares, a profundidade da penetração do tecido trofoblástico na parede tubária acometida por gestação ectópica se relaciona com a concentração sérica de VEGF, a concentração sérica de VEGF é preditora da profundidade da invasão do tecido trofoblasto na parede tubária acometida por GE e a concentração sérica de VEGF apresenta melhor desempenho que a concentração sérica de beta-hCG como preditora da profundidade da invasão do trofoblasto na parede da tuba uterina acometida por gestação ampular / INTRODUCTION: The definition of predictive factors of morphologic and functional damage to the Fallopian tube may help in the choice of treatment for patients with ectopic pregnancy. The objective of the present study was to correlate the depth of penetration of trophoblastic tissue into the tubal wall with maternal serum VEGF concentrations, to evaluate the prediction of this invasion based on these concentrations and to compare the performances of VEGF and beta-hCG as predictors of trophoblastic invasion. METHODS: A prospective study was conducted on 30 patients with ampular pregnancy submitted to salpingectomy between December 21st, 2006 and September 30th, 2007. Maternal serum VEGF concentrations were measured after the diagnosis confirmation and before salpingectomy was performed. Histologically, trophoblastic invasion into the tubal wall was classified as grade I when limited to the tubal mucosa, grade II when reaching the muscle layer, and grade III when comprising the full thickness of the Fallopian tube. RESULTS: ten patients had tubal infiltration grade I, nine had grade II and eleven had grade III. The different levels of trophoblastic invasion were significantly associated with VEGF concentrations (p< 0.001). VEGF levels of 305.0 pg/mL showed 100.0% sensitivity, 85.0% specificity, a positive predictive value of 76.9% and a negative predictive value of 100.0% for the diagnosis of grade I trophoblastic invasion. A VEGF titer of 425.9 pg/mL was the best cut-off for the prediction of grade III trophoblastic invasion: 81.8% sensitivity, 94.7% specificity, positive predictive value of 90.0% and negative predictive value of 90.0%. Logistic regression showed that VEGF presented higher performance as a predictor of trophoblastic invasion than beta-hCG. CONCLUSIONS: in ampullary pregnancies, the depth of penetration of trophoblastic tissue into the tubal wall is correlated with serum VEGF concentrations, serum VEGF titer is predictor of the depth of penetration into tubal wall and VEGF concentrations present higher performance than beta-hCG as predictor of the trophoblastic invasion

Placenta is a transient association of the fetal and maternal tissues, that develops during pregnancy, in most viviparous animals. The evolution of placenta ensured the development of the fetus inside the womb of the mother, providing a protected environment for the development of the fetus, and preventing the loss of progeny due to unfavorable environmental conditions. Because it is strategically poised at the maternal and fetal interface, the placenta is ideally suited to carry out alimentary, respiratory and excretory functions for the developing fetus. In addition, it serves as an immunological barrier preventing the rejection of the fetal semi-allograft, by the maternal immune system. Furthermore, the placenta elaborates a variety of protein, polypeptide and steroid hormones. These include growth factors, growth factor receptors, neuropeptides, opioids, progesterone and estrogen, whose secretion is dependent on the gestational age of the placenta and its differentiation status. The human placenta, adapts itself remarkably to cater to the changing requirements of the developing fetus. For instance, during the first trimester of pregnancy, the placenta is an actively dividing, a highly invasive and a rapidly differentiating organ; while near term, it represents a fully differentiated and a non-invasive unit. Furthermore, the placenta of the first trimester and that at term differ in their hormone profiles, extents of apoptosis, expression of several transcription factors, etc. This dramatic change in the phenotype of the human placenta can be considered to be the outcome of an intrinsically programmed pattern of differentiation, which may be referred to as the functional differentiation of the placenta. It may be hypothesized therefore, that this functional differentiation could be brought about by the differential expression of genes in the first trimester and the term placenta. The objectives of the present study were: 1. To gain an insight into this process of " functional differentiation” by investigating the differential expression of genes in the two developmentally distinct stages during gestation, viz. during the first trimester and at term. 2. To understand the functional relevance of the differentially expressed genes. A general introduction of the human placenta, describing the importance of differential expression in modulating placental function, is discussed in chapter 1. The functions of the human placenta along with a brief description of its development and differentiation are also briefly described. A Differential Display RT-PCR-based (DD RT-PCR) approach, using total RNA from the first-trimester and term placental villi, was employed to display the differentially expressed genes in the first trimester and the term placenta. The display so generated was used to identify a few differentially expressed cDNAs. This study was aimed at understanding the functional significance of the transcripts which were identified from the display, rather than just concentrate on documenting the differences in the gene expression patterns in the first trimester and the term placental tissue. A detailed description of the methodology adopted for performing DD-PCR using placental tissue, discussing the advantages and disadvantages of using differential display PCR, is described in chapter2. The use of DD-PCR for studying differential gene expression in the human placenta was validated by the finding that one of the cDNAs that was differentially expressed in the first trimester placental tissue, is a fragment of β-hCG cDNA. It is well documented that the differential expression of the β-subunit of hCG (human chorionic gondatrophin) during the first eight weeks of gestation is the rate limiting step in the synthesis and secretion of the functional hormone, which comprises the α and the β-subunits. Furthermore, the use of the model system viz., the first trimester and term placental tissue, was also validated for carrying out DD-PCR by ensuring that all placental samples used for DD analysis were free of endometrial contamination. A detailed description of optimization and validation of DD-PCR in human placental tissues is given in chapter 2. Cloning and sequencing of yet another cDNA from the first trimester differential display revealed that it is T-Plastin. T-Plastin is a member of a family of proteins that are involved in actin-bundling. Northern blot analysis and immunohistochemical studies using an antibody generated to a peptide corresponding to human T-Plastin, confirmed its differential expression and localization in the first trimester placenta. Considering the fact that several carcinomas show enhanced expression of T-Plastin, we tested the hypothesis that its differential expression is correlated with the proliferative potential of the first-trimester placenta It was observed that the first-trimester tissue expressed high levels of beta-actin as compared to the term placental tissue. This is in agreement with the up-regulation of beta-actin following mitogenic stimulation/proliferation and during neoplastic transformation or transformation-associated invasive behaviour of cells, two characteristic features shared by the early placenta with cancerous tissues. Based on our studies and available information in the literature, it is proposed that T-Plastin expression in the first trimester placenta is a growth-associated phenomenon which is partially responsible for the tumor-like phenotype of the first trimester tissue. Studies carried out with the partial T-Plastin cDNA clone that was isolated from the first trimester differential display, are presented in chapter 3. Sequencing of yet another cDNA clone identified from the term placental differential display, T-18 revealed that it had no homology to any known sequence in the nucleotide or est databases. The sequence corresponding to this clone was submitted to the GenBank and was assigned an accession number- AF089811. The differential expression of T-18 was confirmed by Northern blot analysis and RT-PCR analysis. Attempts were made to isolate the full-length cDNA corresponding to T-18 from a commercially available library from Clontech. However, repeated trials to identify the clone corresponding to T-18 did not yield any positive results. However, a genome database search revealed that T-18 was a portion of a large contig contained in chromosome 15. Analysis of the annotated gene sequences in and around the region in which T-18 is located in chromosome 15, revealed that there are very few ests reported in this contig and quite a few repeat sequences reported. Interestingly, it was observed that 6 kb downstream of the region in which T-18 is located, there was an est that had homology to a Bcl-2 precursor protein (an evolutionarily conserved, anti-apoptotic protein, capable of conferring protection against death-inducing signals) and the death adaptor protein, CRADD {Caspase and RIP adapter with death domain). Further updating of the ests in the database might probably be of help in the identification of the full-length cDNA corresponding to T-18 and confirm as to whether T-18 is a part of the gene/gene cluster that comprises the afore-mentioned est. An account of the identification and cloning of T-18 from the term placenta and the attempts to isolate the full-length cDNA clone corresponding to T-18 from a term placental cDNA library, is described in chapter 4. In the absence of any information on the identity of T-18, a study to understand the functional significance of T-18 expression was carried out. Since it was not possible to carry out studies pertaining to the temporal expression of T-18 throughout gestation on the human placenta for ethical reasons, alternate animal/organ models were employed to study T-18 expression. Rat placenta and rat Corpus Luteum (CL) were chosen as alternate models for studying T-18 expression as these two organs/tissues underwent dynamic changes in their function throughout pregnancy. For instance, it is well known that CL is the primary source of progesterone for maintaining pregnancy in the rat and that the progesterone secreting capacity of the luteal cells peak on day 16 of gestation and decline thereafter. Interestingly, a common feature among all the tissues that were chosen for investigating the regulation of T-18 expression, is the fact that they underwent apoptosis with increase in gestational age. The expression of T-18, in tissues exhibiting increased incidence of apoptosis suggested that T-18 maybe an apoptosis-associated gene. Using an explant culture model it was demonstrated that placental villi when cultured in vitro underwent spontaneous apoptosis and that the levels of T-18 message increased, under these conditions. Furthermore, this spontaneous induction of apoptosis in explant cultures could be blocked when villi were cultured in the presence of superoxide dismutase, a free radical scavenging enzyme. In addition, the expression of T-18 was shown to be modulated following treatment with SOD, or in response to oxidative stress. These studies clearly indicate a role for T-18 in placental apoptosis and moreover, implicate the usefulness of explant culture to examine the molecular mechanisms involved in placental apoptosis. Furthermore, the expression of the anti- and pro-apoptotic genes, bcl-x and bax respectively, were investigated, in an attempt to elucidate the signalling pathway(s) that led to the activation of an important downstream protease, caspase-3, in placental apoptosis. The present study revealed that induction of apoptosis in the placenta in vitro involved a bcl/bax independent, caspase-3 dependant pathway. The validation of an explant culture model for studying placental apoptosis and data pertaining to the role of T-18, bcl-x, bax and CPP32 in placental apoptosis, in response to oxidative stress, are presented in chapter 5. The last section titled general discussion summarizes the work carried out in this study and proposes a model for the apoptotic mechanism(s) that may be operating in placenta In conclusion, the present study has led to the identification of two developmentally-regulated factors, T-Plastin and T-18 in the first trimester and term placenta, respectively. The differential expression of these genes, in addition to several other molecular players, is proposed to be responsible for the overall functional differentiation of the placenta through the course of gestation.