CURRICULUM VITAE

Nama : dr. SarmaLumbanraja, SpOG(K) Tpt/tgl. Lahir : Pakpahan, 30 Juli 1959 Agama : Kristen JenisKelamin : Perempuan Pendidikan : SpesialisObstetridanGinekologi FK USU (1998) Jabatan : StafObstetridanGinekologi FK USU Alamat : PabrikTenun 35A, Medan 20118 No. Telp : (061) 4523-085 No. HP : 08126536472

HELLP SYNDROME AS COMPLICATION OF PREECLAMPSIA

Sarma LUMBANRAJA Department of Obstetrics and Gynecology Faculty of Medicine, Universitas Sumatera Utara

Introduction
Pregnancy Induced Hypertension:
BP > 140/90 mmHg after 20 weeks of gestation

Preeclampsia:
+ Proteinuria> 300 mg/24 h

Introduction
HELLP Syndrome:
0.2-0.6 % in all pregnancy Severe preeclampsia 4-12 % HELLP Hemolysis Elevated liver enzymes Low platelet

Abnormal Plasentation Hypoxia Placenta-derived agents : ??? Microvascular endothelial damage Intravascular platelet activation and deposition Stimulates secretion of Thromboxane A2 & serotonin Vasoconstriction & more platelet deposition/agregation & damage to the blood vessel wall

Vasoconstriction & more platelet deposition/agregation & damage to the blood vessel wall
Hypertension Circulating (serum) platelets Actual platelet count Further vessel narrowing Hepatocellular hypoxia RBC damage

Hepatocellular& Microangiopathiche periportal molysis necrosis Liver enzyme Liver rupture LDH Hemoglobin

Preeclampsia is an endothelial disease

Hipertenson

Proteinuria

HELLP

Eclampsia

Preeclampsia is an endothelial disease

Normal Glomerulus

Glomerulusw/ Endotheliosis

Placenta, the Origin of this disease

Vascular Defect

Placental ischemia

Production and secretion of a substance, toxic to mother

What is the problem?

Preeclampsia is a disease of theories

Two-stage model of the pathophysiology of preeclampsia

Roberts, J. M. et al. Hypertension 2005;46:12431249 Used with permission

Stage 2 develops in some, but not all women with stage 1

Copyright 2005 American Heart Association

DEVELOPMENT OF STAGE 1
Poor placentation

Normal Placental Development

From 9-12 weeks gestation the uterine spiral arteriesare transformed from thick-walled, muscular vessels, to more flaccid tubes to accommodate a 10-fold increase in uterine blood flow to support the pregnancy.

Uterine spiral Uterine spiral arteries arteries

C. W. Redman et al., Science 308, 1592 -1594 (2005) Used with permission

National Institute of Health (NIH) National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy, (2000)

Normal Placental Development

Uterine spiral artery remodeling takes place by the invasion of trophoblastcells into the uterine lining. These trophoblasts enter the arterial walls and replace parts of the vascular endothelium so that smooth muscle is lost and the artery dilates.

Placental Pathophysiology in Stage 1

Trophoblasts fail to completely remodel the uterine spiral arteries.
Remodeling either absent or Remodeling limited to the superficial portion of the artery located in the decidua, rather than extending into the inner third of the myometrium.

Redman, C.W., Sargent, I.L. (2005)

Theoretical basis for incomplete remodeling:

Production failure of endothelial adhesion molecules from trophoblasts or Failure of/ or weak signaling of immune cells by trophoblasts prevents deep invasion necessary for normal artery remodeling.
(NIH 2000) Redman, C.W., Sargent, I.L .(2005)

Poor placentation and preeclampsia

C. W. Redman et al., Science 308, 1592 -1594 (2005) Used with permission

Uterine spiral artery unwinds and becomes a wider, flaccid tube to accommodate increased blood flow.

Uterine spiral artery remains tightly coiled, diminishing placental blood flow

THE RESULT:
Poor placentation, or a decreased capacity of the uteroplacental circulation. This causes placental hypoxia, resulting in oxidative stress.
Pathophysiology is generally established before 20 weeks.

(NIH, 2000)

DEVELOPMENT OF STAGE 2
Evidence of Maternal Disease Process

The beginnings of the maternal disease process:

Stage 2 begins when maternal clinical features appear.
Cause is most likely related to the hypoxic and dysfunctional placenta releasing factors into the maternal circulation resulting from cell death. These factors target the maternal endothelium, causing vascular damage.

Roberts, J.M., Gammill H.S. (2005)

Stage 2: Multisystemic, maternal syndrome

Reduced Placental perfusion

Perfusion is reduced to virtually every organ

Reduced uterine blood flow

Release of ToxinsMaternal Endothelial damage

Roberts, J.M., Gammill H.S. (2005)

Normal function of endothelial cells

Line all blood vessels providing vessel wall integrity Prevent intravascular coagulation Regulate smooth muscle contractility Mediate immune and inflammatory responses

Gilbert E.S., & Harmon J.S. (2003). Hypertensive Disorders. In Manual of High Risk Pregnancy and Delivery ( p. 451). St Louis, MO: Mosby.

Toxic factors released by the placenta are believed to cause maternal endothelial dysfunction by one or more of following mechanisms: 1. The factors are directly toxic to endothelial cells 2. The factors stimulate maternal oxidative stress 3. The factors stimulate/activate inflammatory cytokines
Roberts, J.M., Gammill H.S. (2005) Gilbert & Harmon (2003) p. 451

With maternal endothelial damage:

Decreased production of vasodilators (prostacyclin and nitric oxide)
VASOSPASM

Poor tissue perfusion to all maternal organs

Inactivation of circulating nitric oxide (vasodilator).

Increases total peripheral resistance resulting in elevated blood pressure

Gilbert & Harmon (2003) pp. 451-452

Maternal vasospasm also causes:

Increases endothelial cell permeability, (leaky capillaries) fluid shifts from intravascular to intracellular space resulting in:
Decreased plasma volume, increased hematocrit Generalized tissue and organ edema

Gilbert & Harmon (2003) pp. 451-452

Additionally, damage to the vascular endothelium causes:

Increased production ofthromboxanewhich leads to clot formation through increasing platelet adhesion. Activation of the clotting cascade Decreased production of platelets

Gilbert & Harmon (2003) pp. 451-452

Identification of circulating factor

Increased endothelial cell permeability Lipid peroxidation Oxidative stress Platelet activation Increased circulating fibronectin, factor VII antigen, thrombomodulin Diminished production of endothelial-derived-vasodilators such as prostacyclins and increased vascular sensitivity to angiotensin II and norepinephrine-mediated vascular constriction Increased placental production and maternal serum level of sFlt-1 and sEng Etc.

Hypertriglyceridemia Reduced HDL Predominance of small, dense LDL cholesterol

Insulin resistance Hyperinsulinemia Hypertriglyceridemia

Reduced Placental Perfusion

Abnormal vascular remodeling of spiral arteries

Release of toxic factors

Stage 1

Maternal Endothelial Damage VASOSPASM

Stage 2

Maternal Disease

Fetal Effects

Increased production of free radicals and lipid peroxides +endothelial cell damage Inflammatory cytokines + endothelial damage

Role of angiogenic factors in Preeclampsia and HELLP syndrome

2002 Phase 2 study of the use of bevacisumab (VEGF neutralizing antibody) in colorectal cancer
Tumor progression is slower Better survival

BUT
HYPERTENSION (19/68) AND PROTEINURIA (17/68) WAS FOUND

Hypertension
VEGF interaction with VEGF-R on endothelial cells induces the production NO and PG

Proteinuria
VEGF is critically involved in the maintenance of GBM barrier Excision of one VEGF A allele in the podocyte of mice causes endotheliosis and proteinuria (Eremina, 2003)

Was the same process happened in PE??

Relevant protein
Soluble Small enough to cross placental barrier Able to target endothelium

Soluble Vascular Endothelial Growth Factor receptor -1 (sVEGFR-1 a.k.a sFlt1)

Excess placental soluble fms-like tyrosine kinase 1 (sFlt1) may contribute to endothelial dysfunction, hypertension, and proteinuria in preeclampsia.
Sharon E. Maynard, Jiang-Yong Min,JaimeMerchan,Kee-Hak Lim, Jianyi Li, SusantaMondal,Towia A. Libermann,James P. Morgan,Frank W. Sellke, Isaac E. Stillman, Franklin H. Epstein, Vikas P. Sukhatme, and S. AnanthKarumanchi J Clin Invest 2003; 111: 649-658

PROANGIOGENIC vs ANTIANGIOGENIC

PIGF VEGF

SfLT1

PROANGIOGENIC (Normal)

ANTIANGIOGENIC (PE)

Normal pregnancy: very few of molecules are caught by soluble receptor

In Preeclampsia, the soluble receptor sFlt catches many VEGF and PLGF molecules

HYPOTHESIS

Could sFlt-1 lead to maternal syndrome of PE?

i.e to: Hypertension? Proteinuria/GlomerularEndotheliosis? In severe form (HELLP): Liver disorder?

Histopathological analysis of renal tissue from one representative Fc-treated pregnant rat (upper panel), one sFlt1treated pregnant rat (middle panel). H&E stain shows capillary occlusion in the sFlt1 treated animal with enlarged glomeruli and swollen endothelial cells compared to Fc control animal.

IN NORMAL PREGNANCY
Increased of sFlt-1 Strevens (2003): in kidney biopsy of normal pregnant women 1 month beforedelivery, glomerularendotheliosis is found in 5/12 patients.

Yoshimatsu J, Eur J ObstGyn 2006; 128:204-8

Preeclampsia could be the occurrence of a PHYSIOLOGICAL process during which the maternal endothelium is impaired because of presence of circulating placental factor

sFlt-1 doesnt explain everything

Soluble endoglin contributes to the pathogenesis of preeclampsia

ShivalingappaVenkatesha, MouradToporsian, Chun Lam, Jun-ichiHanai, Tadanori Mammoto, Yeon M Kim, Yuval Bdolah, Kee-Hak Lim, Hai-Tao Yuan, Towia A Libermann, Isaac E Stillman, Drucilla Roberts, Patricia A DAmore, Franklin H Epstein, Frank W Sellke, Roberto Romero, Vikas P Sukhatme, Michelle Letarte& S AnanthKarumanchi Nature med Jun 2006 12(6): 642-689

EndoglinAccessory receptor for TGF-

TGF-

Signaling by TGF-b family members, which includes TGF-bs, activins and BMPs, occurs via specic cell surface type I and type II receptors that are endowed with serine/threoninekinase activity. Accessory receptors endoglin and betaglycan modulate TGF-b family signaling via type I and type II receptors. Soluble endoglin and betaglycan can sequester ligand and thereby inhibit receptor binding. In most cells TGF-b signals via TbRII and ALK5. In endothelial cells (depicted here) it signals also via another type I receptor ALK1. Activins signal via ActRII and ALK4. BMPs signal via BMPRII and ActRII and type I receptors ALK1, ALK2, ALK3 and ALK6. The type I receptors act downstream of type II receptor and determine the signaling specicity of the receptor complex. Activated type I receptors initiate intracellular signaling by phosphorylatingspecic R-Smads. Activation of ALK1, ALK23, ALK3 and ALK6 leads to phosphorylation of Smad1, Smad5 and Smad8, and Smad2 and Smad3 are phosphorylated by ALK4, ALK5 and ALK7. Activated R- Smads assemble with Smad4 in heteromeric complexes that accu- mulate in the nucleus. There these complexes regulate specic gene expression responses by binding to DNA together with other DNA binding transcription factors. Abbreviatons: ActR, activin receptor; BMP, bone morphogenetic protein; BMPR, BMP receptor; sEnd, soluble endoglin; transforming growth factor-b; TbR, TGF-brecep- tor; TF, transcription factor

TGF-
TGF-1 induces vasorelaxation through activation of eNOS TGF-1 stimulate production of PGI2

sEng joins the sFlt-1 receptor as a preeclampsia molecule

Infection of gestant rats with a virus encoding :

sFlt-1: preeclampsia Soluble endoglins: HT and modest proteinuria

Infection of gestant rats with a virus encoding :

sFlt-1: preeclampsia Soluble endoglins: HT + modest Proteinuria sFlt-1 + sEng: PE + Liver disorder

Glomerular disorder

sFlt1-injected rats showed moderate to severe endotheliosis with complete occlusion of capillary lumens. sFlt1+sEng-treated rats showed extremely swollen glomeruli and marked endotheliosis with protein resorption droplets in the podocytes.

Liver disorder

Liver histology in the control, sEng, sFlt1 and sFlt1+sEng groups. Ischemic changes with multifocal necrosis were noted in the sFlt1+sEng group. Control group and rats given sEng or sFlt1 showed no changes.

Peripheral blood smear

Peripheral blood smear (Wright stain) of control, sEng, sFlt1 and sFlt1+sEng groups. A representative smear in the sFlt1+sEng group showed active schistocytes (arrowheads) and reticulocytosis (arrows). No hemolysis was seen in the other groups.

 Recombinant VEGF-121 was shown to suppress the maternal syndrome of preeclampsia in rats. Tobacco smoke (?) was found to suppress the secretion of sFlt-1 by syncytiotrophoblasts The role of endoglin in HELLP syndrome has not been confirmed

Preeclampsia remains the disease of theories

Take Home Points

The maternal syndrome of PE is consecutive to excessive concentrations of anti-angiogenic factors These factors are produced by an ischemic placenta The cause for this disease remains unelucidated