Preeclampsia - Hypertension & proteinuria in last trimester of pregnancy - Complicates 2-3 % pregnancies - Requires placenta (even if no fetus; hydatidiform pregnancy) - Remits post-partum - Placenta is frequently abnormal with ischemic/hypoperfusion lesions - In severe PE, there is micro-angiopathy and endothelial dysfunction with many target organs potentially involved: liver, kidney, CNS, etc.

Pathogenesis of Preeclampsia “Disease of theories"

Poor Placentation and Preeclampsia

Placental Vascular Pathology in Preeclampsia “Placental vascular insufficiency” Normal Preeclampsia

Glomerular Endotheliosis Control Preeclampsia

Abnormal Placenta and Placental Factors - neurokinin B Nature Jun 15;405(6788): thromboplastin Nature Sep 14;199: magnesium deficiency Science Jul 22;221(4608): adrenomedullinLancet Nov 29;350(9091):1600

EPO and sVEGFR1 (sFlt1) in Amniotic Fluid Vuorela et al, 2000

Annual Reviews

Plasma sFlt1 in Pregnancy Levine et al 2004

In vivo Effects of sFlt1 Maynard et al, 2003

Cytotrophoblast Response to Hypoxia Nagamatsu et al 2004

Utero-placental Ischemia in Primates Makris et al, KI 2007 Placental perfusion reduced by ~ 30-50%

Utero-placental Ischemia in Primates

Preeclampsia - Increased in some factors that are activated during hypoxia - Can be induced by reduction of placental blood flow - Hence, either there is ischemia (with appropriate hypoxic response) or there is an abnormality in the hypoxia-regulated response

Oxygen Sensing HIF1α VEGF α α α

2-Methoxyestradiol Inhibits EC Growth, Angiogenesis and Tumor Growth Fibroblats EC Fotsis et al, 1994

2-Methoxyestradiol CYP450 COMT - pM in control Plasma - nM in plasma of pregnancy - μM in ovaries & tissues with high [estradiol]

Catechol-O-methyl Transferase

2-Methoxyestradiol Inhibits HIF1α Mabjessh et al 2003 α-tubulin HIF1α

2-Methoxyestradiol and HIF

COMT-/-

COMT in Placenta

Placenta

+/+ -/- +/+ -/- -/- + 2ME -/- +2ME 2/56 32/64 Eosin + deposition Thrombosis arterial lumen

Placenta IgM vWF +ME

Blood Pressure

Non-pregnant Blood Pressure

Proteinuria

Kidney WT WT+Ro COMT-/- COMT-/- + ME EC swelling, detachment and vacualization (“endotheliosis”)

Placental Hypoxia WT COMT-/- COMT-/- + ME WT -/- -/- + ME

Placental HIF1α WT COMT-/- COMT-/- + ME SP, spongiotrophoblast layer

Placental HIF1α WT -/- -/- + ME

Plasma sFLT-1

Plasma Catecholamines WT + MAO inhibitor

Placental Vasodilators RT-PCR Western

Inflammatory Mediators

Decidual IFN-γ and NK Cells IFN-γ NK Cells NKp46+ CD3-

2-Methoxyestradiol Effects in Cytotrophoblast Cell Line Tubulin microtubule disruption

Human Pregnancy

2-Methoxyestradiol and COMT in Human Pregnancy Plasma 2-ME Placental COMT

Summary -2-methoxyestradiol inhibits HIF1α - Placenta expresses catechol-O-methyl transferase and 2-ME increases during pregnancy - COMT KO and COMT inhibitors cause pre-eclampsia - 2-ME prevents pre-eclampsia in COMT KO mice; thus, PE in these mice its unlikely due to excess catecholamines and vasoconstriction - Women with PE have low plasma levels of 2-ME and lower COMT protein in their placenta; 2-ME may provide a therapy for pre-eclampsia

Proposed Model