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CHAPTER 8
NK Cells and Pregnancy
Mikael Eriksson, Satarupa Basu and Charles L. Sentman
Abstract
N
atural killer cells are found in large numbers in the endometrium and decidua, and
data suggest that NK cell functions and interactions with fetal-derived trophoblasts
can have a profound impact on pregnancy. Altered NK cell numbers and activity have
been associated with a variety of clinical conditions such as endometriosis, recurrent pregnancy
loss, and preeclampsia. Uterine NK cells have a unique phenotype compared to blood NK cells
and this is likely due to the specific tissue environment in which they reside. Specific chemokines
produced by human endometrium and trophoblasts have been identified that may be respon-
sible for recruitment of NK cells. Uterine NK cells can produce cytokines and may be an
important part of vascular remodelling during placental development. This chapter summa-
rizes current knowledge of NK cells in the uterus and their role in pregnancy and reproductive
disorders.
Introduction
A mothers immunological tolerance to a semi-allogeneic fetus has long been puzzling for
immunologists. The endometrium must be ready to respond to potential pathogen challenges,
yet be able to control immune cell responses to allow the development of a semi-allogeneic
fetus. Data have accumulated that there are extensive interactions between fetal cells and the
mothers immune system. The immune system is often described as engaged in a struggle against
all kinds of invaders, including allogeneic fetal tissue. However, an alternative viewpoint gain-
ing support is that the maternal immune system may work together with fetal derived cells to
create a hospitable environment in which the fetus may develop.
Natural killer (NK) cells account for a substantial presence in the uterus and data suggest
that NK cell functions and interactions with fetal-derived trophoblasts can have a profound
impact on pregnancy.
1
This review summarizes current knowledge of NK cells in the uterus
and their role in pregnancy and reproductive disorders. We have focused on our understanding
of human uterine NK (uNK) cells and also discuss particularly noteworthy findings from ani-
mal studies. Valuable data have been derived from animal studies, but significant differences
exist in the structure of the placenta between species. Human NK cells are present in nonpreg-
nant endometrium and are found throughout the endometrium and decidua, while NK cells
are absent in mice prior to implantation and are restricted to the mesometrial triangle and
decidua basalis. In humans, decidualization occurs during every menstrual cycle and there is
extensive invasion of trophoblasts into maternal tissues. Decidualization occurs in mice after
implantation, and trophoblast invasion into maternal tissue is minimal. These differences make
extrapolation of data between species very difficult, so conclusions made in one species will not
always be applicable to another.
2
Immunology of Pregnancy, edited by Gil Mor. 2005 Eurekah.com
and Springer Science+Business Media.

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Immunology of Pregnancy 2
NK cells, also referred to as large granular lymphocytes or LGLs, have the ability to sponta-
neously kill tumor cells and secrete cytokines that can have powerful effects on immune- and
nonimmune cells. As part of the innate immune system, NK cells are believed to act as sentinel
cells prepared to attack foreign pathogens and promote host immune defenses.
3-5
Altered NK
cell numbers and activity have been associated with a variety of clinical conditions involving
reproductive organs and reproductive failure. Reduced NK cell activity is associated with an
increase in the incidence of ovarian cancer, uterine cancer, and endometriosis.
6-9
Higher NK
cell activity has been associated with recurrent pregnancy loss,
10,11
while NK cell function and
specific NK cell receptors may be involved in the development of preeclampsia.
12,13
Thus,
proper NK cell function in the uterus is an integral part of successful pregnancy.
Uterine NK Cells
Human NK cells are found in the blood, lymphoid organs, liver, and various mucosal tis-
sues including lung, intestine, and uterus. Human peripheral blood NK cells can be divided
into two major subsets based on the density of CD56 expression. CD56
dim
cells account for
90% of blood NK cells and have a high spontaneous lytic activity against tumor cells. This NK
cell subset expresses CD16 (FcRIII), killer cell immunoglobulin-like receptors (KIRs) and
many of these cells express CD57.
14
The CD56
bright
NK cells account for approximately 10%
of blood NK cells and these cells have less spontaneous lytic activity and have a high capacity to
produce proinflammatory cytokines upon stimulation with monokines.
15
This NK cell subset
expresses CD94/NKG2A/C dimers but contains only a small percentage of cells that express
CD16 or KIRs and these cells lack CD57 expression.
16
Although comprising only a fraction of
NK cells found in the peripheral blood, the CD56
bright
subset is the primary NK cell subset
found in lymph nodes.
17,18
In addition to the markers mentioned above, there are a large
number of other cell surface molecules that can be used to further subdivide NK cell sub-
sets.
16,19
Uterine NK cells have a unique phenotype compared to blood NK cells. uNK cells have
previously been described as endometrial granulocytes, granular endometrial stromal cells, K
cells, or even decidual NK (dNK) cells.
20
NK cells in the uterus express CD56 and CD94, few
express CD16, and none express CD57 or CD8.
21,22
Most CD57
+
cells in the endometrium
are T cells.
23
A significant percentage of uNK cells express KIRs on their cell surface.
22,24
Unlike blood NK cells, uNK cells express CD9 and CD69 on their cell surface.
22,25
Thus uNK
cells have a cell surface phenotype that is unique. A summary of molecules and receptors on
uNK- and blood NK cells is shown in Table 1. Recent molecular analysis of NK cells from
decidua using gene array technology revealed 278 genes that were differentially expressed be-
tween decidual NK cells and blood NK cells.
25
This study indicated that decidual NK cells
were more similar in their gene expression profile to CD56
bright
NK cells than to CD56
dim
NK
cells. It remains unclear whether decidual NK cells are derived from blood NK cells that have
differentiated in the unique environment of the decidua, or if they represent a special lineage of
NK cells that are selectively produced for the decidua. Most evidence seem to favor the idea
that the NK cells in the decidua are derived from uNK cells in the endometrium at the time of
implantation or from newly recruited blood NK cells. These NK cells may respond to external
signals to change their gene expression profile and presumably their function to respond to the
unique requirements of the decidua. NK cells do not express receptors for estradiol and proges-
terone, so the action of sex hormones on NK cell function or recruitment is likely mediated via
hormone action on other cells, such as fibroblasts or epithelial cells.
26,27
One report indicated
that human uNK cells express glucocorticoid- and estrogen-1 receptors but it is not known if
this estrogen receptor functions in uNK cells.
26
NK cells isolated from the nonpregnant en-
dometrium and decidua may not represent distinct phenotypes, but there may be a continuous
process of differentiation such that the phenotype and functional activity of uNK cells may
change as the local environment adapts to alterations in hormone levels and changes in the
stromal cell environment.

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3 NK Cells and Pregnancy
One complication is that some studies have used NK cells isolated from first term decidua
while others study NK cells from nonpregnant endometrium, and the hormonal status and
local tissue microenvironment can be quite different between endometrium and decidua. En-
dometrial uNK cells are isolated from hysterectomy tissue or from microcurettage scraping of
the endometrial lining. Even for endometrium from nonpregnant women, NK cells found in
the proliferative phase and those from the secretory phase are in distinct tissue microenviron-
ments and hormonal conditions. Thus, when reading the literature care must be taken to
understand the tissue environment from where uNK cells have been isolated.
Recruitment of NK Cells into the Endometrium and Decidua
The human uterine endometrium is a complex mucosal tissue that is regulated by sex hor-
mones throughout the menstrual cycle.
34,35
NK cell numbers are low early in the proliferative
phase and increase as the menstrual cycle progresses.
36-38
NK cells may account for up to 70%
of the leukocytes in the endometrium late in the secretory phase. At least two possible mecha-
nisms have been hypothesized to be responsible for the drastic increase of uNK cells within the
uterus: either in situ proliferation and/or a selective recruitment from the peripheral NK cell
pool have been suggested.
34,39,40
Although proliferation could explain some of the increased
numbers of NK cells, an active recruitment of these cells to the uterus is likely to play a major
role. Data from murine studies indicate that uNK cells are derived from blood cells or bone
marrow cells and not from NK cells within the uterus,
41
although in humans it has not been
ruled out that NK cells may be renewed from a precursor within the noncycling part of the
endometrium.
Table 1. Comparison between uterine NK (uNK) cells, CD56
bright
and CD56
dim
blood
NK cells
Markers uNK cells
a
Blood CD56
bright
Blood CD56
dim
CD56 ++
b
++ +
CD16 +/- +/- +
CD69,CD9,CD151 + - -
L-selectin - ++ +/-
CD57 - - +
CD49a ++ - -
CD44 ++ ++ +
PEN5-PSGL1 +/- - +
CD94 ++ ++ +/-
KIR
c
+ +/- +
KIR/NKAT 2 ++ - ++
NKG2E/C/A ++ + +/-
CXCR1 - - ++
CXCR2 - - +
CXCR3 ++ ++ +
CXCR4 + ++ ++
CXCR5 - - -
CCR1,CCR2,CCR3,CCR4 - - -
CCR5,CCR7 + ++ -
CX3CR1 +/- ++
a
Some studies used NK cells from endometrium and others used decidual NK cells;
b
++: high
expression; +: low expression; +/-: expression on subsets; -: no expression;
c
KIR = Killer cell
immunoglobulin-like receptor family. References 15, 25 and 28-33.

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Immunology of Pregnancy 4
Given the increase in NK cells during the menstrual cycle and the role of sex hormones in
modifying changes in endometrium, it has been proposed that sex hormones may regulate NK
cell recruitment and expansion in the endometrium. Migration of cells into tissue involves a
variety of molecules, including adhesion molecules and chemokines. Cells in blood must bind
to the endothelium and firmly adhere so that they can follow chemotactic gradients into tis-
sues. Many blood cells express several different chemokine receptors and more than one may
be involved in proper migration of cells into tissues. NK cells are found widely within nonpreg-
nant endometrium and they can be associated with other leukocytes in small aggregates.
36,42,43
In the first trimester of pregnancy, uNK cells accumulate as a dense infiltrate around the tro-
phoblast cells and spiral arteries.
20
As pregnancy progresses, uNK cells disappear from the
decidua and are absent at term. These findings suggest that specific signals are involved in the
recruitment and localization of NK cells within the uterus.
Blood NK cells express a variety of chemokine receptors, such as CCR5, CXCR3, and
CXCR4, and specific migration of NK cells has been induced by chemokines in vitro.
31,38,44
uNK cells have been shown to express CXCR3, CCR5, and CCR7, but not other chemokine
receptors.
29
Not all chemokine receptors have been analyzed on uNK cells and low levels of
receptor expression may be functionally relevant. Kitaya and colleagues have examined the
expression of chemokines within the endometrium at different stages of the menstrual cycle.
They have reported that the expression of CCL4, CXCL9, and CXCL10 increases during the
menstrual cycle and correlates with the increase in the number of NK cells in the en-
dometrium.
45,46
The authors analyzed the expression of these chemokines by immunohistochem-
istry and found chemokines expressed in epithelial and perivascular stromal cells. It has been
demonstrated that estrogen and progesterone are able to induce the expression of CXCL10 and
CXCL11, but not other chemokines in primary human endometrium.
29
Several potential
chemokine receptor-ligand pairs have been described in the decidua that could be involved in
the leukocyte trafficking. Trophoblasts have been reported to express CXCL12, a ligand for
CXCR4.
30
This study also shows that in vitro, CXCL12 preferentially recruits CD56
bright
NK
cells compared to CD56
dim
NK cells. Placenta and endometrium have been shown to produce
CCL3 that can recruit blood NK cells.
47,48
It has also been reported that CD16
-
/CD56
bright
NK cells express chemokine receptor CCR5 and that its ligand CCL4 acts as a strong
chemoattractant for these cells.
49
However, murine studies have shown normal uNK cell re-
cruitment in mice deficient in CCR2 or CCR5.
50
Thus, a large number of studies show that the
endometrium and decidua can produce chemokines that can recruit NK cells. Which chemokines
are involved in NK cell recruitment in vivo remains to be determined, and it is possible that
more than one chemokine is involved.
51
For example, CXCL10 induced by sex hormones in
endometrium prior to implantation may recruit NK cells into the endometrium. As tropho-
blasts invade the decidua, chemokines derived from trophoblasts (e.g., CXCL12) may recruit
uNK cells to reorganize placental arteries and facilitate trophoblast invasion of maternal tissue.
Studies have identified specific adhesion molecules involved in NK cell attachment to uter-
ine endometrium. It has been established that L-selectins and 4 integrins are important for
the binding of lymphocytes possibly facilitating extravasation into tissues.
52-55
Adhesion of
CD56
bright
cells to uteri from pregnant or hormone-treated ovariectomized mice was enhanced
through L-selectin- and 4 integrin-dependent mechanisms.
56
The ability of human CD56
bright
NK cells to adhere to mouse uteri is associated with successful outcome of in vitro fertilization
(IVF) treatment.
57
The binding of NK cells also involved VCAM-1 and peripheral lymph node
addressin. VCAM-1 is expressed at the site of trophoblast invasion and might allow NK cells to
migrate continuously to these sites.
56,58,59
The proper migration of NK cells into the endometrium
and localization to specific areas may be critical for NK cell function in the uterus.
Function and Regulation of uNK Cells
Human decidua contains a large number of NK cells and many of them localize near
trophoblasts. Uterine NK cells have been proposed to have several different functions in

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5 NK Cells and Pregnancy
pregnancy, including to: (i) help shield trophoblasts bearing paternal antigens from the ma-
ternal immune system, (ii) protect the mother from trophoblast invasion and limit expansion
of trophoblasts, (iii) be involved in regulation and restructuring of maternal spiral arteries,
and (iv) be part of the innate defense system and protect against infection in the uterus. These
ideas are not mutually exclusive and there is evidence to support each of them.
Regulation of uNK Cells
It has been proposed several years ago that successful pregnancy was associated with Th2-type
environment rather than a Th1-type environment.
60
It has become clear that the reality is more
complex, and there is evidence that both Th1 and Th2 cytokines are produced in decidua. Like
blood NK cells, uNK cells can produce IFN-, GM-CSF, IL-10, TGF-1, and IL-8 among
other cytokines.
22,61-63
One study indicated that fresh decidual NK cells produce cytokines
spontaneously.
64
uNK cell derived cytokines may have significant effects on decidualization
and trophoblast invasion. Human endometrium expresses a wide range of angiogenic growth
factors, and uNK cells may play an important role in abnormal endometrial angiogenesis.
65
uNK cells produce cytokines that are not normally made by blood NK cells such as angiogenic
growth factors and leukemia inhibitory factor (LIF).
61,65
LIF is considered an essential cytokine
for implantation in mice.
66
Many different cytokines that alter NK cell function have been shown to be present in
the human endometrium.
67,68
Endometrium is a source of both IL-15 and prolactin,
69-71
and both of these have been implicated in the proliferation and differentiation of uNK cells.
There are data that uNK cells express prolactin receptors.
72,73
Evidence suggest that IL-15 is
required by uNK cells for survival and proliferation.
74-78
In humans, IL-15 is present through-
out the menstrual cycle, is increased during the secretory stage and early pregnancy, and is
produced by stromal cells during decidualization.
69,79-81
It has been suggested that IL-15
expression in endothelium may be important for NK cell attachment, and perhaps IL-15
expression by decidual endothelium may be involved in specific localization of uNK cells
close to spiral arteries.
59,82,83
Several reports have observed effects of TGF- on NK cells.
84-88
Members of the TGF-
family are powerful immunoregulatory molecules that act on a range of different immune
cells and can demonstrate both activating and inhibitory function.
89-92
TGF- proteins are
produced as inactive precursors that bind to extracellular matrix and cell surface proteins
where they can be activated.
93
The mechanisms that regulate and activate TGF- proteins
remain unclear. A recent paper shows that endogenous TGF--mediated inhibition is a mecha-
nism that regulates uNK cell-derived cytokine production.
22
Another study reported that
CD56
+
lymphoid cells in human first trimester pregnancy decidua are a source of novel
transforming growth factor-2-related immunosuppressive factors.
94
Furthermore, data sug-
gest that TGF-1 may be necessary to maintain pregnancy but may also be a risk factor for
recurrent miscarriages.
95
Molecules that differentiate NK cells in the endometrium are poorly understood. IL-11 has
been implicated in the differentiation of uNK cells. IL-11 deficient mice have been shown to
lack NK cells at implantation sites.
96
Although NK cell precursors could home to the uterus of
IL-11 receptor -/- mice, the NK cell defect was not thought to be due to the NK cells them-
selves but to signals within the environment. This study showed that the requirement for IL-11
to induce NK cell differentiation was tissue specific and that IL-11 signaling indirectly affected
uNK cell differentiation. Many other factors are likely involved in uNK cell differentiation and
they remain to be discovered.
NK Cell Trophoblast Interactions
NK cells and macrophages are found near trophoblasts in the first trimester of pregnancy.
20,97
Due to trophoblast expression of paternal antigens, low MHC expression, and their association
with NK cells, it has been theorized that the trophoblast-NK cell interaction is a key part in the

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Immunology of Pregnancy 6
control of placental development. Trophoblasts express three different HLA molecules that
can interact with NK cell receptors, HLA-C, HLA-E, and HLA-G. CD158 receptors (mem-
bers of the KIR family) bind to different HLA-C alleles and data suggest that this
receptor-ligand interaction is involved in development of preeclampsia (see below). CD94/
NKG2A dimers recognize HLA-E, and KIR2DL4 is expressed on uNK cells and recognizes
HLA-G molecules. Many of these receptor-ligand interactions have been shown to alter NK
cell function.
Much effort has focused on the susceptibility of trophoblasts to NK cell mediated cytotox-
icity. Most studies have indicated that human trophoblasts are resistant to NK cell mediated
killing.
98,99
Since most decidual NK cells express CD94/NKG2A dimers, it has been suggested
that uNK cells could recognize HLA-E expressed on trophoblasts and inhibit NK cell activa-
tion. However, lysis of trophoblasts could not be induced even after blocking CD94/NKG2
receptors on NK cells or MHC class I molecules on trophoblasts.
98
Removing MHC class I on
trophoblasts by acid treatment could not induce lysis by decidual NK cells. Lysis of tropho-
blasts could only be observed using IL-2 activated decidual NK cells. One study with murine
trophoblasts demonstrated trophoblast rejection in nonpregnant allogeneic mice at extra-uterine
sites, supporting the idea that trophoblasts are not inherently resistant to NK cells but that
local factors in decidua protect them from immune attack.
100
The inability of trophoblast cells
to act as target cells for NK cell cytotoxicity, even when known inhibitory receptors were blocked,
implies that alternative inhibitory pathways exist or that trophoblasts are unable to trigger
uNK cell activating receptors.
HLA-G is only expressed by trophoblasts and can interact with KIR2DL4 receptors on
uNK cells. Data have suggested that HLA-G may inhibit NK cell activation, but ligation of
KIR2DL4 led to stimulation of IFN- but not the triggering of cytotoxicity.
101
A recent pub-
lication suggested that membrane-bound HLA-G is able to stimulate purified uNK cells while
it suppressed unfractionated mononuclear cell effector functions.
102
Because IFN- produc-
tion by uNK cells is believed to be important for vascular remodelling (see below), the recogni-
tion of HLA-G on trophoblasts by uNK cells may be important for placental development.
The fact that trophoblast protection from NK cell lysis appears to be largely independent of
HLA class I expression suggests a modulatory function for HLA-E and HLA-G rather than a
strict inhibitory effect on uNK cell effector functions. These receptor-ligand interactions may
modulate uNK cell production of cytokines and angiogenic factors promoting trophoblast
invasion and differentiation or tissue remodelling.
65
NK Cell Regulation of Spiral Arteries
Key observations in murine studies have been made using mice deficient in NK cells or
specific effector molecules. NK cell deficient mice do have offspring, but the litters are smaller
in number. Although it remains unclear how much can be extrapolated to human placenta
formation, careful analysis demonstrated ultra-structural consequences for implantation and
placental formation in the absence of uNK cells in NK cell deficient mice.
41,103
Failure to
sustain decidual integrity and loss of spiral artery modifications were the two key features
affected in these mice. Additional studies also suggested that uNK cell derived IFN- was
necessary for the proper structure of spiral arteries and placental formation.
104
In humans,
uterine NK cells are nearly absent by 20 weeks of gestation, a time when vascular changes are
complete. In the placenta, uNK cells are often seen in close proximity to transformed and
nontransformed spiral arteries. Moreover, uNK cells can be a source of angiogenic growth
factors such as NO synthase or Ang2 that may be involved in destabilizing blood vessel struc-
ture and promoting blood vessel remodelling.
65,105
The role of uNK cells in remodelling hu-
man spiral arteries remains unknown, but data suggest involvement of NK cell receptors in the
development of preeclampsia that supports a role for human uNK cells in vessel remodelling
(see next section).

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7 NK Cells and Pregnancy
NK Cells in Reproductive Disorders
Recurrent Pregnancy Loss
Recurrent pregnancy loss (RPL) is defined as three or more consecutive spontaneous abor-
tions with the same partner. About half of all cases are explained by universally accepted aeti-
ologies. Thus, proposed immune based aetiologies are being studied as a possible explanation
for some of the other cases. Activated CD56
+
NK cells are present in increased numbers in
peripheral blood in women with RPL.
106-110
NK cells produce IFN- which is a Th1 cytokine
that is associated with RPL,
111,112
and LIF is down-regulated by IFN-.
113
It has been demon-
strated that CD56
bright
NK cells are decreased in the secretory phase endometrium in patients with
unexplained recurrent miscarriage
114
and in vitro fertilization-embryo transfer failure.
115
One possibility
is that some of these patients have an influx of CD56
dim
NK cells that respond against fetal
cells. There is evidence that NK cells and PBMCs from women with unexplained RPL respond
to trophoblast extracts in vitro by proliferating and releasing embryotoxic factors that adversely
affect embryo growth, while cells from women with normal pregnancies do not show such a
response.
116
An increase in the absolute count of activated NK cells (CD56
dim
/CD16
+
/CD69
+
)
in the peripheral blood is associated with a reduced rate of embryo implantation during IVF
treatment. Furthermore, women with high numbers of CD56
dim
/CD69
+
blood NK cells who
were able to achieve pregnancy had a significantly higher rate of miscarriage.
10
However, one
must remember that the local maternal immune response to the fetus-derived cells may not be
similar to the systemic response against fetal cells. Correlative data implicate NK cells in RPL,
but a direct link has not been established. It is unclear whether an increase in NK cell cytotoxic
activity and/or a decrease in other NK cell functions may account for some cases of RPL.
Endometriosis
Endometriosis is a condition where there is an ectopic occurrence of endometrial tissue,
often in the peritoneal cavity. One theory is that endometrial cells move into the peritoneal
cavity due to aberrant menstrual flow, and women with endometriosis frequently have diffi-
culty becoming pregnant. Decreased NK cell activity in peripheral blood and peritoneal fluid
of women with endometriosis has been established.
117
One mechanism for decreased NK cell
activity may be increased KIR expression on NK cells, because increased expression of KIRs is
generally associated with decreased NK cell activity.
8,9,118
Thus, NK cells may help prevent the
development of endometriosis by removing endometrial cells in the peritoneum.
Preeclampsia
Preeclampsia is a serious complication of pregnancy and leads to high maternal blood pres-
sure, elevated concentrations of urinary protein and poor fetal growth.
119,120
It can be caused
by inadequate remodelling of spiral arteries and lead to the life-threatening condition of ec-
lampsia. Alterations of NK cell function may be important in failure to reorganize blood ves-
sels at the maternal-fetal interface and account in part for preeclampsia.
13
There is an increased
incidence of preeclampsia in mothers who lacked most or all activating KIR genes (the AA KIR
genotype) when the fetus possessed HLA-C genes of the C2 subgroup.
12
This combination
leads to the greatest inhibition of NK cells via KIR-HLA-C interactions. These data support
the idea that without the presence of activating receptors on NK cells, these cells may be pre-
vented from completing the task of vasculature remodelling and result in preeclampsia.
Other studies suggest that preeclampsia is associated with a Th1/Th2 imbalance with a
predominant Th1 immunity.
121
This may be considered a failure of tolerance (i.e., a decrease
in NK cell inhibition) or an increase in NK cell activity. Serum levels of granulysin, a cytotoxic
granule protein of natural killer (NK) cells and cytotoxic T lymphocytes, were significantly
elevated in preeclampsia patients when compared to those in normal pregnancy subjects.
13
Preeclampsia was associated with an increased number of CD56
dim
NK cells in umbilical cord
blood compared to the control group.
122
Thus, aberrant NK cell activity may have a significant
role in the pathogenesis of this disorder.

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Immunology of Pregnancy 8
Summary
Natural killer cells are found in large numbers in the endometrium and decidua and data
suggest that NK cell functions and interactions with fetal derived trophoblasts can have a
profound impact on pregnancy. Uterine NK cells have a unique phenotype compared to blood
NK cells and this is likely due to the specific tissue environment in which they reside. We are
beginning to understand the role of uNK cells, their cytokines and key receptors that allow
them to function to establish a functional and supportive maternal-fetal interface. Data exist to
implicate both excessive NK cell activation and the lack of NK cell function in reproductive
disorders. This suggests there is a delicate balance that must be maintained where fetal-derived
trophoblasts and maternal decidual cells work together to allow proper placental development
and fetal growth.
Acknowledgements
This work was supported in part by a grant from the National Institutes of Health (AI51877).
References
1. Trundley A, Moffett A. Human uterine leukocytes and pregnancy. Tissue Antigens 2004; 63(1):1-12.
2. Moffett-King A. Natural killer cells and pregnancy. Nat Rev Immunol 2002; 2(9):656-663.
3. Biron CA, Nguyen KB, Pien GC et al. Natural killer cells in antiviral defense: Function and
regulation by innate cytokines. Annu Rev Immunol 1999; 17:189-220.
4. Ferlazzo G, Morandi B, DAgostino A et al. The interaction between NK cells and dendritic cells
in bacterial infections results in rapid induction of NK cell activation and in the lysis of uninfected
dendritic cells. Eur J Immunol 2003; 33(2):306-313.
5. Bellone G, Valiante NM, Viale O et al. Regulation of hematopoiesis in vitro by alloreactive natu-
ral killer cell clones. J Exp Med 1993; 177(4):1117-1125.
6. Rebmann V, Regel J, Stolke D et al. Secretion of sHLA-G molecules in malignancies. Semin Can-
cer Biol 2003; 13(5):371-377.
7. Ma D, Gu MJ, Liu BQ. A preliminary study on natural killer activity in patients with gynecologic
malignancies. J Tongji Med Univ 1990; 10(3):159-163.
8. Yang JH, Chen MJ, Chen HF et al. Decreased expression of killer cell inhibitory receptors on
natural killer cells in eutopic endometrium in women with adenomyosis. Hum Reprod 2004;
19(9):1974-1978.
9. Maeda N, Izumiya C, Yamamoto Y et al. Increased killer inhibitory receptor KIR2DL1 expression among
natural killer cells in women with pelvic endometriosis. Fertil Steril 2002; 77(2):297-302.
10. Thum MY, Bhaskaran S, Abdalla HI et al. An increase in the absolute count of CD56dimCD16+CD69+
NK cells in the peripheral blood is associated with a poorer IVF treatment and pregnancy outcome. Hum
Reprod 2004; 19(10):2395-2400.
11. Dosiou C, Giudice LC. Natural killer cells in pregnancy and recurrent pregnancy loss: Endocrine and im-
munologic perspectives. Endocr Rev 2004; 26(1):44-62.
12. Hiby SE, Walker JJ, OShaughnessy KM et al. Combinations of maternal KIR and fetal HLA-C genes
influence the risk of preeclampsia and reproductive success. J Exp Med 2004; 200(8):957-965.
13. Sakai M, Ogawa K, Shiozaki A et al. Serum granulysin is a marker for Th1 type immunity in preeclampsia.
Clin Exp Immunol 2004; 136(1):114-119.
14. Jacobs R, Hintzen G, Kemper A et al. CD56bright cells differ in their KIR repertoire and cytotoxic features
from CD56dim NK cells. Eur J Immunol 2001; 31(10):3121-3127.
15. Cooper MA, Fehniger TA, Caligiuri MA. The biology of human natural killer-cell subsets. Trends Immunol
2001; 22(11):633-640.
16. Jonges LE, Albertsson P, van Vlierberghe RL et al. The phenotypic heterogeneity of human natural killer
cells: Presence of at least 48 different subsets in the peripheral blood. Scand J Immunol 2001; 53(2):103-110.
17. Fehniger TA, Cooper MA, Nuovo GJ et al. CD56bright natural killer cells are present in human lymph
nodes and are activated by T cell-derived IL-2: A potential new link between adaptive and innate immunity.
Blood 2003; 101(8):3052-3057.
18. Ferlazzo G, Pack M, Thomas D et al. Distinct roles of IL-12 and IL-15 in human natural killer cell
activation by dendritic cells from secondary lymphoid organs. Proc Natl Acad Sci USA 2004;
101(47):16606-16611.
19. Moretta A, Bottino C, Vitale M et al. Activating receptors and coreceptors involved in human natural killer
cell-mediated cytolysis. Annu Rev Immunol 2001; 19:197-223.

2
0
0
5

C
o
p
y
r
i
g
h
t
E
u
r
e
k
a
h

/

L
a
n
d
e
s

B
i
o
s
c
i
e
n
c
e
D
o

N
o
t

D
i
s
t
r
i
b
u
t
e
9 NK Cells and Pregnancy
20. Bulmer JN, Morrison L, Longfellow M et al. Granulated lymphocytes in human endometrium: Histochemical
and immunohistochemical studies. Hum Reprod 1991; 6(6):791-798.
21. King A, Hiby SE, Verma S et al. Uterine NK cells and trophoblast HLA class I molecules. Am J Reprod
Immunol 1997; 37(6):459-462.
22. Eriksson M, Meadows SK, Wira CR et al. Unique phenotype of human uterine NK cells and their regula-
tion by endogenous TGF-beta. J Leukoc Biol 2004; 76(3):667-675.
23. Ho HN, Chao KH, Chen CK et al. Activation status of T and NK cells in the endometrium throughout
menstrual cycle and normal and abnormal early pregnancy. Hum Immunol 1996; 49(2):130-136.
24. Verma S, King A, Loke YW. Expression of killer cell inhibitory receptors on human uterine natural killer
cells. Eur J Immunol 1997; 27(4):979-983.
25. Koopman LA, Kopcow HD, Rybalov B et al. Human decidual natural killer cells are a unique NK cell
subset with immunomodulatory potential. J Exp Med 2003; 198(8):1201-1212.
26. Henderson TA, Saunders PT, Moffett-King A et al. Steroid receptor expression in uterine natural killer cells.
J Clin Endocrinol Metab 2003; 88(1):440-449.
27. King A. Uterine leukocytes and decidualization. Hum Reprod Update 2000; 6(1):28-36.
28. Eidukaite A, Siaurys A, Tamosiunas V. Differential expression of KIR/NKAT2 and CD94 molecules on
decidual and peripheral blood CD56bright and CD56dim natural killer cell subsets. Fertil Steril 2004;
81(Suppl 1):863-868.
29. Sentman CL, Meadows SK, Wira CR et al. Recruitment of uterine NK cells: Induction of CXC chemokine
ligands 10 and 11 in human endometrium by estradiol and progesterone. J Immunol 2004;
173(11):6760-6766.
30. Hanna J, Wald O, Goldman-Wohl D et al. CXCL12 expression by invasive trophoblasts induces the spe-
cific migration of CD16- human natural killer cells. Blood 2003; 102(5):1569-1577.
31. Campbell JJ, Qin S, Unutmaz D et al. Unique subpopulations of CD56+ NK and NK-T peripheral blood
lymphocytes identified by chemokine receptor expression repertoire. J Immunol 2001; 166(11):6477-6482.
32. Slukvin II, Chernyshov VP, Merkulova AA et al. Differential expression of adhesion and homing molecules
by human decidual and peripheral blood lymphocytes in early pregnancy. Cell Immunol 1994; 158(1):29-45.
33. Calatayud S, Vivier E, Bernaud J et al. Expression of a NK cell-restricted epitope on decidual large
granular lymphocytes. Int Immunol 1996; 8(10):1637-1642.
34. Tabibzadeh S. Proliferative activity of lymphoid cells in human endometrium throughout the men-
strual cycle. J Clin Endocrinol Metab 1990; 70(2):437-443.
35. Wira CR, Fahey JV, White HD et al. The mucosal immune system in the human female repro-
ductive tract: Influence of stage of the menstrual cycle and menopause on mucosal immunity in
the uterus. In: Glasser S, Aplin J, Giudice L, Tabibzadeh S, eds. Endometrium. UK: Harwood
Academic Publishers, 2002:371-404.
36. Givan AL, White HD, Stern JE et al. Flow cytometric analysis of leukocytes in the human female
reproductive tract: Comparison of fallopian tube, uterus, cervix, and vagina. Am J Reprod Immunol
1997; 38(5):350-359.
37. Hunt JS. Immunologically relevant cells in the uterus. Biol Reprod 1994; 50(3):461-466.
38. King A, Wellings V, Gardner L et al. Immunocytochemical characterization of the unusual large
granular lymphocytes in human endometrium throughout the menstrual cycle. Hum Immunol 1989;
24(3):195-205.
39. King A, Balendran N, Wooding P et al. CD3- leukocytes present in the human uterus during early
placentation: Phenotypic and morphologic characterization of the CD56++ population. Dev Immunol
1991; 1(3):169-190.
40. Kammerer U, Marzusch K, Krober S et al. A subset of CD56+ large granular lymphocytes in
first-trimester human decidua are proliferating cells. Fertil Steril 1999; 71(1):74-79.
41. Guimond MJ, Wang B, Croy BA. Engraftment of bone marrow from severe combined immunode-
ficient (SCID) mice reverses the reproductive deficits in natural killer cell-deficient tg epsilon 26
mice. J Exp Med 1998; 187(2):217-223.
42. White HD, Crassi KM, Givan AL et al. CD3+ CD8+ CTL activity within the human female
reproductive tract: Influence of stage of the menstrual cycle and menopause. J Immunol 1997;
158(6):3017-3027.
43. Yeaman GR, Guyre PM, Fanger MW et al. Unique CD8+ T cell-rich lymphoid aggregates in
human uterine endometrium. J Leukoc Biol 1997; 61(4):427-435.
44. Inngjerdingen M, Damaj B, Maghazachi AA. Expression and regulation of chemokine receptors in
human natural killer cells. Blood 2001; 97(2):367-375.
45. Kitaya K, Nakayama T, Okubo T et al. Expression of macrophage inflammatory protein-1beta in
human endometrium: Its role in endometrial recruitment of natural killer cells. J Clin Endocrinol
Metab 2003; 88(4):1809-1814.

2
0
0
5

C
o
p
y
r
i
g
h
t
E
u
r
e
k
a
h

/

L
a
n
d
e
s

B
i
o
s
c
i
e
n
c
e
D
o

N
o
t

D
i
s
t
r
i
b
u
t
e
Immunology of Pregnancy 10
46. Kitaya K, Nakayama T, Daikoku N et al. Spatial and temporal expression of ligands for CXCR3
and CXCR4 in human endometrium. J Clin Endocrinol Metab 2004; 89(5):2470-2476.
47. Drake PM, Gunn MD, Charo IF et al. Human placental cytotrophoblasts attract monocytes and
CD56(bright) natural killer cells via the actions of monocyte inflammatory protein-1alpha. J Exp
Med 2001; 193(10):1199-1212.
48. Akiyama M, Okabe H, Takakura K et al. Expression of macrophage inflammatory protein-1alpha
(MIP-1alpha) in human endometrium throughout the menstrual cycle. Br J Obstet Gynaecol 1999;
106(7):725-730.
49. Red-Horse K, Drake PM, Gunn MD et al. Chemokine ligand and receptor expression in the
pregnant uterus: Reciprocal patterns in complementary cell subsets suggest functional roles. Am J
Pathol 2001; 159(6):2199-2213.
50. Chantakru S, Kuziel WA, Maeda N et al. A study on the density and distribution of uterine
Natural Killer cells at mid pregnancy in mice genetically-ablated for CCR2, CCR 5 and the CCR5
receptor ligand, MIP-1 alpha. J Reprod Immunol 2001; 49(1):33-47.
51. Rot A, Von Andrian UH. Chemokines in innate and adaptive host defense: Basic chemokinese
grammar for immune cells. Annu Rev Immunol 2004; 22:891-928.
52. Butcher EC, Williams M, Youngman K et al. Lymphocyte trafficking and regional immunity. Adv
Immunol 1999; 72:209-253.
53. Burrows TD, King A, Loke YW. Expression of adhesion molecules by human decidual large granular
lymphocytes. Cell Immunol 1993; 147(1):81-94.
54. Kruse A, Martens N, Fernekorn U et al. Alterations in the expression of homing-associated mol-
ecules at the maternal/fetal interface during the course of pregnancy. Biol Reprod 2002;
66(2):333-345.
55. Frey M, Packianathan NB, Fehniger TA et al. Differential expression and function of L-selectin on
CD56bright and CD56dim natural killer cell subsets. J Immunol 1998; 161(1):400-408.
56. Chantakru S, Wang WC, van den Heuvel M et al. Coordinate regulation of lymphocyte-endothelial
interactions by pregnancy-associated hormones. J Immunol 2003; 171(8):4011-4019.
57. van den Heuvel M, Bashar S, Junkins ME et al. Functional adhesion of CD56 cells to decidual
endothelium predicts pregnancy success in in vitro fertilization. Montreal, Canada: Paper presented
at: 12th International Congress of Immunology and 4th Annual Conference of FOCIS, 2004.
58. Marzusch K, Ruck P, Geiselhart A et al. Distribution of cell adhesion molecules on CD56++,
CD3-, CD16- large granular lymphocytes and endothelial cells in first-trimester human decidua.
Hum Reprod 1993; 8(8):1203-1208.
59. Kruse A, Merchant MJ, Hallmann R et al. Evidence of specialized leukocyte-vascular homing in-
teractions at the maternal/fetal interface. Eur J Immunol 1999; 29(4):1116-1126.
60. Wegmann TG, Lin H, Guilbert L et al. Bidirectional cytokine interactions in the maternal-fetal
relationship: Is successful pregnancy a TH2 phenomenon? Immunol Today 1993; 14(7):353-356.
61. Jokhi PP, King A, Sharkey AM et al. Screening for cytokine messenger ribonucleic acids in puri-
fied human decidual lymphocyte populations by the reverse-transcriptase polymerase chain reac-
tion. J Immunol 1994; 153(10):4427-4435.
62. Jokhi PP, King A, Loke YW. Cytokine production and cytokine receptor expression by cells of the
human first trimester placental-uterine interface. Cytokine 1997; 9(2):126-137.
63. Rieger L, Kammerer U, Hofmann J et al. Choriocarcinoma cells modulate the cytokine production
of decidual large granular lymphocytes in coculture. Am J Reprod Immunol 2001; 46(2):137-143.
64. Lidstrom C, Matthiesen L, Berg G et al. Cytokine secretion patterns of NK cells and macrophages
in early human pregnancy decidua and blood: Implications for suppressor macrophages in decidua.
Am J Reprod Immunol 2003; 50(6):444-452.
65. Li XF, Charnock-Jones DS, Zhang E et al. Angiogenic growth factor messenger ribonucleic acids
in uterine natural killer cells. J Clin Endocrinol Metab 2001; 86(4):1823-1834.
66. Stewart CL, Kaspar P, Brunet LJ et al. Blastocyst implantation depends on maternal expression of
leukaemia inhibitory factor. Nature 1992; 359(6390):76-79.
67. Kelly RW, King AE, Critchley HO. Cytokine control in human endometrium. Reproduction 2001;
121(1):3-19.
68. Chaouat G, Zourbas S, Ostojic S et al. A brief review of recent data on some cytokine expressions
at the materno-foetal interface which might challenge the classical Th1/Th2 dichotomy. J Reprod
Immunol 2002; 53(1-2):241-256.
69. Kitaya K, Yasuda J, Yagi I et al. IL-15 expression at human endometrium and decidua. Biol Reprod
2000; 63(3):683-687.
70. Golander A, Barrett JR, Tyrey L et al. Differential synthesis of human placental lactogen and
human chorionic gonadotropin in vitro. Endocrinology 1978; 102(2):597-605.

2
0
0
5

C
o
p
y
r
i
g
h
t
E
u
r
e
k
a
h

/

L
a
n
d
e
s

B
i
o
s
c
i
e
n
c
e
D
o

N
o
t

D
i
s
t
r
i
b
u
t
e
11 NK Cells and Pregnancy
71. Maslar IA, Riddick DH. Prolactin production by human endometrium during the normal men-
strual cycle. Am J Obstet Gynecol 1979; 135(6):751-754.
72. Gubbay O, Critchley HO, Bowen JM et al. Prolactin induces ERK phosphorylation in epithelial
and CD56(+) natural killer cells of the human endometrium. J Clin Endocrinol Metab 2002;
87(5):2329-2335.
73. Chambers WH, Amoscato AA, Smith MS et al. Prolactin receptor expression by rat NK cells. Nat
Immun 1995; 14(3):145-156.
74. Waldmann TA, Tagaya Y. The multifaceted regulation of interleukin-15 expression and the role of
this cytokine in NK cell differentiation and host response to intracellular pathogens. Annu Rev
Immunol 1999; 17:19-49.
75. Rosmaraki EE, Douagi I, Roth C et al. Identification of committed NK cell progenitors in adult
murine bone marrow. Eur J Immunol 2001; 31(6):1900-1909.
76. Ye W, Zheng LM, Young JD et al. The involvement of interleukin (IL)-15 in regulating the
differentiation of granulated metrial gland cells in mouse pregnant uterus. J Exp Med 1996;
184(6):2405-2410.
77. Okada H, Nakajima T, Sanezumi M et al. Progesterone enhances interleukin-15 production in
human endometrial stromal cells in vitro. J Clin Endocrinol Metab 2000; 85(12):4765-4770.
78. Barber EM, Pollard JW. The uterine NK cell population requires IL-15 but these cells are not
required for pregnancy nor the resolution of a Listeria monocytogenes infection. J Immunol 2003;
171(1):37-46.
79. Okada S, Okada H, Sanezumi M et al. Expression of interleukin-15 in human endometrium and
decidua. Mol Hum Reprod 2000; 6(1):75-80.
80. Dunn CL, Critchley HO, Kelly RW. IL-15 regulation in human endometrial stromal cells. J Clin
Endocrinol Metab 2002; 87(4):1898-1901.
81. Chegini N, Ma C, Roberts M et al. Differential expression of interleukins (IL) IL-13 and IL-15
throughout the menstrual cycle in endometrium of normal fertile women and women with recur-
rent spontaneous abortion. J Reprod Immunol 2002; 56(1-2):93-110.
82. Peel S. Granulated metrial gland cells. Adv Anat Embryol Cell Biol 1989; 115:1-112.
83. Allavena P, Giardina G, Bianchi G et al. IL-15 is chemotactic for natural killer cells and stimulates
their adhesion to vascular endothelium. J Leukoc Biol 1997; 61(6):72-735.
84. Castriconi R, Cantoni C, Della Chiesa M et al. Transforming growth factor beta 1 inhibits expres-
sion of NKp30 and NKG2D receptors: Consequences for the NK-mediated killing of dendritic
cells. Proc Natl Acad Sci USA 2003; 100(7):4120-4125.
85. Hayashi H, Inoue Y, Tsutsui H et al. TGFbeta down-regulates IFN-gamma production in IL-18
treated NK cell line LNK5E6. Biochem Biophys Res Commun 2003; 300(4):980-985.
86. Seo N, Tokura Y, Takigawa M et al. Depletion of IL-10- and TGF-beta-producing regulatory
gamma delta T cells by administering a daunomycin-conjugated specific monoclonal antibody in
early tumor lesions augments the activity of CTLs and NK cells. J Immunol 1999; 163(1):242-249.
87. Naganuma H, Sasaki A, Satoh E et al. Transforming growth factor-beta inhibits interferon-gamma
secretion by lymphokine-activated killer cells stimulated with tumor cells. Neurol Med Chir (To-
kyo) 1996; 36(11):789-795.
88. Bellone G, Aste-Amezaga M, Trinchieri G et al. Regulation of NK cell functions by TGF-beta 1.
J Immunol 1995; 155(3):1066-1073.
89. Kehrl JH, Wakefield LM, Roberts AB et al. Production of transforming growth factor beta by
human T lymphocytes and its potential role in the regulation of T cell growth. J Exp Med 1986;
163(5):1037-1050.
90. Ruegemer JJ, Ho SN, Augustine JA et al. Regulatory effects of transforming growth factor-beta on
IL-2- and IL-4-dependent T cell-cycle progression. J Immunol 1990; 144(5):1767-1776.
91. Wira CR, Roche MA, Rossoll RM. Antigen presentation by vaginal cells: Role of TGFbeta as a
mediator of estradiol inhibition of antigen presentation. Endocrinology 2002; 143(8):2872-2879.
92. Nelson BJ, Ralph P, Green SJ et al. Differential susceptibility of activated macrophage cytotoxic
effector reactions to the suppressive effects of transforming growth factor-beta 1. J Immunol 1991;
146(6):1849-1857.
93. Khalil N. Post translational activation of latent transforming growth factor beta (L-TGF-beta):
Clinical implications. Histol Histopathol 2001; 16(2):541-551.
94. Clark DA, Vince G, Flanders KC et al. CD56+ lymphoid cells in human first trimester pregnancy
decidua as a source of novel transforming growth factor-beta 2-related immunosuppressive factors.
Hum Reprod 1994; 9(12):2270-2277.
95. Ogasawara MS, Aoki K, Aoyama T et al. Elevation of transforming growth factor-beta1 is associ-
ated with recurrent miscarriage. J Clin Immunol 2000; 20(6):453-457.

2
0
0
5

C
o
p
y
r
i
g
h
t
E
u
r
e
k
a
h

/

L
a
n
d
e
s

B
i
o
s
c
i
e
n
c
e
D
o

N
o
t

D
i
s
t
r
i
b
u
t
e
Immunology of Pregnancy 12
96. Ain R, Trinh ML, Soares MJ. Interleukin-11 signaling is required for the differentiation of natural
killer cells at the maternal-fetal interface. Dev Dyn 2004; 231(4):700-708.
97. Bulmer JN, Lash GE. Human uterine natural killer cells: A reappraisal. Mol Immunol 2005;
42(4):511-521.
98. King A, Loke YW. Human trophoblast and JEG choriocarcinoma cells are sensitive to lysis by
IL-2-stimulated decidual NK cells. Cell Immunol 1990; 129(2):435-448.
99. Verma S, Hiby SE, Loke YW et al. Human decidual natural killer cells express the receptor for
and respond to the cytokine interleukin 15. Biol Reprod 2000; 62(4):959-968.
100. Erlebacher A, Lukens AK, Glimcher LH. Intrinsic susceptibility of mouse trophoblasts to natural
killer cell-mediated attack in vivo. Proc Natl Acad Sci USA 2002; 99(26):16940-16945.
101. Rajagopalan S, Fu J, Long EO. Cutting edge: Induction of IFN-gamma production but not cyto-
toxicity by the killer cell Ig-like receptor KIR2DL4 (CD158d) in resting NK cells. J Immunol
2001; 167(4):1877-1881.
102. van der Meer A, Lukassen HG, van Lierop MJ et al. Membrane-bound HLA-G activates prolifera-
tion and interferon-gamma production by uterine natural killer cells. Mol Hum Reprod 2004;
10(3):189-195.
103. Greenwood JD, Minhas K, di Santo JP et al. Ultrastructural studies of implantation sites from
mice deficient in uterine natural killer cells. Placenta 2000; 21(7):693-702.
104. Ashkar AA, Black GP, Wei Q et al. Assessment of requirements for IL-15 and IFN regulatory
factors in uterine NK cell differentiation and function during pregnancy. J Immunol 2003;
171(6):2937-2944.
105. Hunt JS, Miller L, Vassmer D et al. Expression of the inducible nitric oxide synthase gene in
mouse uterine leukocytes and potential relationships with uterine function during pregnancy. Biol
Reprod 1997; 57(4):827-836.
106. Aoki K, Kajiura S, Matsumoto Y et al. Preconceptional natural-killer-cell activity as a predictor of
miscarriage. Lancet 1995; 345(8961):1340-1342.
107. Coulam CB, Goodman C, Roussev RG et al. Systemic CD56+ cells can predict pregnancy out-
come. Am J Reprod Immunol 1995; 33(1):40-46.
108. Kwak JY, Beaman KD, Gilman-Sachs A et al. Up-regulated expression of CD56+, CD56+/CD16+,
and CD19+ cells in peripheral blood lymphocytes in pregnant women with recurrent pregnancy losses.
Am J Reprod Immunol 1995; 34(2):93-99.
109. Emmer PM, Nelen WL, Steegers EA et al. Peripheral natural killer cytotoxicity and CD56(pos)CD16(pos)
cells increase during early pregnancy in women with a history of recurrent spontaneous abortion. Hum
Reprod 2000; 15(5):1163-1169.
110. Ntrivalas EI, Kwak-Kim JY, Gilman-Sachs A et al. Status of peripheral blood natural killer cells in women
with recurrent spontaneous abortions and infertility of unknown aetiology. Hum Reprod 2001; 16(5):855-861.
111. Raghupathy R. Th1-type immunity is incompatible with successful pregnancy. Immunol Today 1997;
18(10):478-482.
112. Raghupathy R. Pregnancy: Success and failure within the Th1/Th2/Th3 paradigm. Semin Immunol 2001;
13(4):219-227.
113. Piccinni MP, Beloni L, Livi C et al. Defective production of both leukemia inhibitory factor and type 2
T-helper cytokines by decidual T cells in unexplained recurrent abortions. Nat Med 1998; 4(9):1020-1024.
114. Lachapelle MH, Miron P, Hemmings R et al. Endometrial T, B, and NK cells in patients with recurrent
spontaneous abortion. Altered profile and pregnancy outcome. J Immunol 1996; 156(10):4027-4034.
115. Fukui A, Fujii S, Yamaguchi E et al. Natural killer cell subpopulations and cytotoxicity for infertile patients
undergoing in vitro fertilization. Am J Reprod Immunol 1999; 41(6):413-422.
116. Yamada H, Polgar K, Hill JA. Cell-mediated immunity to trophoblast antigens in women with recurrent
spontaneous abortion. Am J Obstet Gynecol 1994; 170(5 Pt 1):1339-1344.
117. Ho HN, Chao KH, Chen HF et al. Peritoneal natural killer cytotoxicity and CD25+ CD3+ lymphocyte
subpopulation are decreased in women with stage III-IV endometriosis. Hum Reprod 1995;
10(10):2671-2675.
118. Wu MY, Yang JH, Chao KH et al. Increase in the expression of killer cell inhibitory receptors on peritoneal
natural killer cells in women with endometriosis. Fertil Steril 2000; 74(6):1187-1191.
119. Wagner LK. Diagnosis and management of preeclampsia. Am Fam Physician 2004; 70(12):2317-2324.
120. Parham P. NK cells and trophoblasts: Partners in pregnancy. J Exp Med 2004; 200(8):951-955.
121. Darmochwal-Kolarz D, Rolinski J, Leszczynska-Goarzelak B et al. The expressions of intracellular cytokines
in the lymphocytes of preeclamptic patients. Am J Reprod Immunol 2002; 48(6):381-386.
122. Bujold E, Chaiworapongsa T, Romero R et al. Neonates born to preeclamptic mothers have a higher
percentage of natural killer cells (CD3-/CD56+16+) in umbilical cord blood than those without preeclamp-
sia. J Matern Fetal Neonatal Med 2003; 14(5):305-312.