1. 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.

2. Pathogenesis of Preeclampsia “Disease of theories"

3. Poor Placentation and Preeclampsia

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

5. Glomerular Endotheliosis Control Preeclampsia

6. Abnormal Placenta and Placental Factors - neurokinin B Nature. 2000 Jun 15;405(6788):797-800 - thromboplastin Nature. 1963 Sep 14;199:1105-6 - magnesium deficiency Science. 1983 Jul 22;221(4608):376-8 - adrenomedullinLancet. 1997 Nov 29;350(9091):1600

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

8. Annual Reviews

9. Plasma sFlt1 in Pregnancy Levine et al 2004

10. In vivo Effects of sFlt1 Maynard et al, 2003

12. Cytotrophoblast Response to Hypoxia Nagamatsu et al 2004

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

14. Utero-placental Ischemia in Primates

15. 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

16. Oxygen Sensing HIF1α VEGF α α α

17. 2-Methoxyestradiol Inhibits EC Growth, Angiogenesis and Tumor Growth Fibroblats EC Fotsis et al, 1994

18. 2-Methoxyestradiol CYP450 COMT - pM in control Plasma - nM in plasma of pregnancy - μM in ovaries & tissues with high [estradiol]

19. Catechol-O-methyl Transferase

20. 2-Methoxyestradiol Inhibits HIF1α Mabjessh et al 2003 α-tubulin HIF1α

21. 2-Methoxyestradiol and HIF

22. COMT-/-

23. COMT in Placenta

24. Placenta

25. +/+ -/- +/+ -/- -/- + 2ME -/- +2ME 2/56 32/64 Eosin + deposition Thrombosis arterial lumen

26. Placenta IgM vWF +ME

27. Blood Pressure

28. Non-pregnant Blood Pressure

29. Proteinuria

30. Kidney WT WT+Ro41-0960 COMT-/- COMT-/- + ME EC swelling, detachment and vacualization (“endotheliosis”)

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

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

33. Placental HIF1α WT -/- -/- + ME

34. Plasma sFLT-1

35. Plasma Catecholamines WT + MAO inhibitor

36. Placental Vasodilators RT-PCR Western

37. Inflammatory Mediators

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

39. 2-Methoxyestradiol Effects in Cytotrophoblast Cell Line Tubulin microtubule disruption

40. Human Pregnancy

41. 2-Methoxyestradiol and COMT in Human Pregnancy Plasma 2-ME Placental COMT

42. 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

43. Proposed Model