Placenta 31 (2010) 951e957

Contents lists available at ScienceDirect

Placenta
journal homepage: www.elsevier.com/locate/placenta

Current Opinion

Regulation of Hypoxia Inducible Factors (HIF) in Hypoxia and Normoxia During

Placental Development
J. Patel a, b, *, K. Landers b, R.H. Mortimer a, b, c, K. Richard a, b
a
School of Medicine, The University of Queensland, Royal Brisbane and Women’s Hospital, Herston, Queensland 4029, Australia
b
Conjoint Endocrine Laboratory, Pathology Queensland and Department of Endocrinology, Royal Brisbane and Women’s Hospital, Herston, Queensland 4029, Australia
c
Disciplines of Medicine, Obstetrics and Gynaecology, The University of Queensland, Herston, Queensland 4029, Australia

a r t i c l e i n f o a b s t r a c t

Article history: During the first trimester of pregnancy the human placenta develops in an hypoxic environment caused
Accepted 17 August 2010 by the occlusion of uterine spiral arterioles by extravillous trophoblasts (EVT). This period of low oxygen
tension is crucial for successful pregnancy. In low oxygen environments, Hypoxia Inducible Factors (HIF)
Keywords: are the main regulators in the transcription of a number of genes. Target genes can induce anaerobic
Hypoxia inducible factor processes, reducing oxygen consumption, or promote angiogenesis, which establishes and enhances the
Placenta
vascular environment. The HIFs can function throughout all stages of placental differentiation and
Oxygen
growth both in normal and pathological pregnancies (compromised by hypoxia/ischemia). Interestingly,
Trophoblast
HIFs respond to a multitude of changes during pregnancy, including 1) low oxygen, 2) renineangiotensin
system (RAS), 3) cytokines, and 4) growth factors, all of which regulate placental function. This review
explores oxygen-dependent and oxygen-independent regulation and the role of HIF in placental
development and differentiation.
Ó 2010 Elsevier Ltd. All rights reserved.

1. Introduction
The placenta is a remarkable organ derived from cells origi-
nating in the extra-embryonic conceptus and maternal decidua
that provides the conduit for materno-fetal transport/exchange of
nutrients and waste. Development and maturation of the placenta
is a complex process, requiring coordinated regulation of tropho-
blast invasion and proliferation and differentiation into the
maternal decidua [1e3]. This results in an adequate blood supply
for continuing normal placental and fetal development.
In the first trimester, extravillous trophoblast (EVT) cells invade
into the decidua, occluding uterine spiral arterioles (Fig. 1) [4]. This
restricts blood flow into the intervillous space (IVS) resulting in a low
oxygen environment that is essential for placental and embryonic
development [3,5e7]. Measurements with oxygen sensitive probes
during ultrasonography at 8 weeks gestation have established that
the oxygen concentration within the IVS is <20 mmHg or 3e5% O2
[8]. Oxygen concentrations within the underlying maternal decidua
are approximately 60 mmHg or 8e10% O2. Between weeks 11e12
of gestation, uterine spiral arterioles become patent, allowing
* Corresponding author. QIMR Bancroft Centre, 300 Herston Rd, Herston,
Queensland 4029, Australia. Tel.: þ617 3362 0496; fax: þ617 3636 8842.
E-mail address: jatin.patel@qimr.edu.au (J. Patel).
significant maternal blood flow and increasing oxygen levels (Fig. 1)
[8e10]. Recent in vitro studies have demonstrated the capacity of
EVTs to initiate apoptosis of vascular smooth muscle cells (VSMC)
and endothelial cells. This may represent the mechanism of the
physiological modification of the uterine spiral arterioles that leads
to the increased vascular compliance and circumference of early
pregnancy (Fig. 1) [11e14]. The resulting increased blood flow and
growth of the vascular and capillary network meets the demands of
the growing fetus [15].
Impaired placental invasion and development during the first
trimester can cause deleterious outcomes such as intrauterine
growth restriction (IUGR), preeclampsia, unexplained miscarriage,
pre-term labour, placental abruption and stillbirth. Paradoxically,
excess blood flow early in pregnancy leads to reduced blood flow
later in gestation [16e18].
A low oxygen tension has been implicated as the key factor in the
process of placental invasion and development [3]. Although this
low oxygen tension is physiological at this stage of development it is
usually described as hypoxia and this review will use that term. All
cells respond to hypoxia with a series of adaptive modifications of
gene expression. This is particularly true in early pregnancy when
the feto-placental unit is developing in a low oxygen environment.
The Hypoxia Inducible Factors (HIFs) are the key mediators of this
process and facilitate placental vascularisation as well as signalling

0143-4004/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.placenta.2010.08.008
952 J. Patel et al. / Placenta 31 (2010) 951e957

Fig. 1. (A) Demonstrates the narrow, small calibre nature of spiral arteries prior to pregnancy, which forms a capillary plexus below the uterine surface. (B) During the first trimester
of pregnancy invasion of endovascular EVT from the placental villi occurs. This leads to occlusion of the terminal portions of spiral arteries, creating a low oxygen environment
within the IVS (3e5% O2) that is essential for early placental and fetal development. (C) Late in the first trimester of pregnancy, the EVT invasion will cause changes in spiral artery
architecture, resulting in the formation of funnel-shaped flaccid arterioles with increased vascular compliance and circumference [8e13]. This results in increased oxygen levels
(8e10% O2) within the IVS for the rest of gestation. (Modified image by Moffet-King et al. [14]).

for trophoblast differentiation [3]. Interestingly, recent evidence
suggests that HIFs are also activated by non-hypoxic stimuli such as
the renineangiotensin system (RAS), growth factors and immuno-
genic cytokines, all of which play important roles in the regulation of
placental development and maturation [19]. However, further
insight into the control of HIF-1a regulation under normoxic
conditions by needs to be elucidated, to provide additional and
definitive evidence for its role in the complexities of placentology.
In this review we investigate the role of the well-characterised
oxygen-dependent pathways of HIF modulation in placental
development and differentiation but also consider the roles of the
less well-characterised oxygen-independent pathways in HIF
regulation.
2. Hypoxia inducible factors (HIFs)
To maintain cell survival, higher eukaryotes have cellular
mechanisms to adjust to low oxygen tensions. These oxygen-
dependent pathways are conserved and expressed in almost every
mammalian cell type [20]. The transcription factors activated
during low oxygen conditions are called Hypoxia Inducible Factors
(HIF). They are hetero-dimeric consisting of two subunits, HIF-
a and aryl hydrocarbon receptor nuclear translocator (Arnt; also
called HIF-1b) [21]. They bring about their effects through inter-
action through two Per-Arnt-Sim (PAS) domains, bind DNA via N-
terminal basic Helix-Loop-Helix (bHLH) domains, and activate
transcription with C-terminal transcriptional transactivation
 J. Patel et al. / Placenta 31 (2010) 951e957 953

domains (TADs) [22]. HIF-1b is constitutively expressed whereas

the activity and expression of HIF-a depends on cellular oxygen
concentrations. In mammalian cells there are three HIF-a genes
(HIF-1a, HIF-2a and HIF-3a). HIF-1a is expressed ubiquitously,
while the expression of HIF-2a and HIF-3a are more restricted [21].
HIF-1a and HIF-2a dimerise with HIF-1b forming HIF-1 and HIF-2,
both leading to activation of key transcription factors. HIF-3a is
found in three isoforms (HIF-3a, neonatal and embryonic PAS
(NEPAS) and inhibitory PAS protein (IPAS)). HIF-3a isoforms
dimerise with HIF-1b forming HIF-3 and HIF-3NEPAS. In general, HIFs
mediate their effects by binding to Hypoxia Response Elements
(HREs) on DNA, which leads to the regulation of some 200 genes, of
which 70 have been studied in detail (Fig. 2). Of note, HIF-1 plays
a key role in maintaining homeostasis, inducing transcription of
key genes such as vascular endothelial growth factor (VEGF) and
erythropoietin (EPO), whereas HIF-2 and -3 have more specialised
and tissue specific regulatory roles (Fig. 2) [21e24].

3. Regulation of HIF through oxygen-dependent mechanisms

Under normoxic conditions (oxygen concentrations above 5%)

HIF-1a undergoes rapid degradation (<5 min) [25]. Hydroxylation
of conserved proline residues (HIF-1a Pro402 and Pro564) occurs via
prolyl hydroxylase domain proteins (PHD1-3), which are located
within a unique oxygen-dependent protein degradation domain.
This leads to proteosomal degradation by ubiquitinase, a prerequi-
site for von Hippel-Lindau (Pvhl) E3 ubiquitin ligase complex (also
containing elongin B, elongin C, Cul 2 and Rbx1), which interact
only with hydroxylated proteins [26e28].
In addition, there are two other oxygen-dependent inhibitors of
HIF-1a known as Factor inhibiting HIF-1 (FIH-1) and p300/CBP
interacting transactivator with ED-rich tail 2 (CITED2) [22]. FIH-1 is
an Fe(II)-dependent asparaginyl hydroxylase acting on the aspar-
agines residue in the TAD region, inhibiting the interaction of HIF- Fig. 3. During normoxic conditions three mechanisms can lead to the proteosomal
1a and HIF-2a with transcriptional coactivators p300/CBP [29,30]. degradation of HIF-1a. 1) Prolyl hydroxylase 1 (PHD1) prepares HIF-1a for degradation
via ubiquitinase by hydroxylating two conserved proline residues. 2) Factor inhibiting
Conversely, CITED2 is a negative regulator of HIF-1 that actively HIF-1 (FIH-1) and 3) p300/CBP interacting transactivator with ED-rich tail 2 (CITED2),
competes for p300/CBP binding (Fig. 3). In an hypoxic environment both prevent or compete for the binding of HIF-1a to p300/CBP, priming HIF-1a for
CITED2 is activated through hypoxia response elements (HRE) [31]. proteosomal degradation [25e27].
More importantly, CITED2 null mice have impaired trophoblast

invasion and inadequate placental blood supply suggesting that

CITED2 plays a vital role in placental development and differenti-
ation by controlling HIF-1[32].

4. Regulation of HIF through oxygen-independent

mechanisms

There is a growing body of evidence suggesting that HIF-1 is

regulated through oxygen-independent factors that include
hormones, cytokines and growth factors. For the purpose of this
review we have focused on the hormone Angiotensin II (Ang II), the
cytokines interleukin-1b (IL-1b), tumour necrosis factor a (TNF-a)
and NF-kb and the growth factors, transforming growth factor-b1
(TGF-b1) and insulin-like growth factor (IGF) (Table 1). Interest-
ingly, many of these are up-regulated during pregnancy, resulting
in increased levels in the maternal circulation, which affect
placental development and maturation throughout gestation
[19,33e36].

4.1. Angiotensin II (Ang II)

Fig. 2. During hypoxia, HIF-1a translocates into the nucleus dimerising with HIF-1b
The role that Ang II plays in early trophoblast invasion and
(Arnt) to form a complex. This protein complex will bind to associated Hypoxia differentiation is well documented. There are increases in angio-
Response Elements (HREs), leading to the transcription of HIF-1 target genes [18e21]. tensin (AT1) receptor concentration and mRNA expression in the
954 J. Patel et al. / Placenta 31 (2010) 951e957

Table 1
Stimuli known to affect placental function: RenineAngiotensin System (RAS), immunogenic cytokines and growth factorsa.

Regulator of HIF-1a Effect on Placental Function References

Angiotensin (II) Increased EVT outgrowth, increased cellular proliferation and increased expression of sFlt-1. [40,42,43]
Interleukin-1b (IL-1b) Up-regulation of uPA, MMP-2 and MMP-9 [52e54]
Uterine specific natural killer cells (uNK) Up-regulation of MMP-9, decreased apoptosis [57]
Transforming Growth Factor-b1 (TGF-b1) Inhibition of trophoblast invasion, increased secretion of PAI-1 and PAI-2, reduction in uPA [65e67]
activity and MMP-2 and MMP-9 secretion
Insulin-Like Growth Factor-II (IGF-II) Increased trophoblast outgrowth [76,77]
a
HIF-1a, hypoxia inducible factor-1a; EVT, extravillous trophoblast cells; sFlt-1, soluble fms-like receptor-1; uPA, urokinase plasminogen activator; MMP, matrix metal-
loproteases; PAI, plasminogen activator inhibitor.

first trimester placenta [33]. The maternal renineangiotensin
system (RAS) undergoes major changes following conception. A
spike in plasma RAS concentrations early in pregnancy is due to
increased release of renin from the kidneys, ovaries and maternal
decidua [37]. mRNA expression of the precursor angiotensinogen
from the liver is increased in response to rising circulating estrogen
during pregnancy, providing further evidence of an intricate rela-
tionship shared by the early placenta and the RAS [38]. Craven et al.
(1998) also suggested that RAS may play a role in assisting uteri-
ne spiral artery dilatation and VSMC and endothelial cell dis-
organisation, prior to EVT invasion [39]. Current evidence suggests
that AT1 receptor activation via Ang II leads to cascade signalling
affecting a number of cellular systems associated with trophoblast
invasion and angiogenesis, including plasminogen activator inhib-
itor-1 (PAI-1) and soluble fms-like receptor-1 (sFlt-1) that are
essential in the first trimester of pregnancy [33,39].
A recent study of first trimester placental explants by Araki-
Taguchi et al. (2008) revealed that Ang II mimicked the effects of
hypoxia by up-regulating the expression of HIF-1a mRNA expression
and protein [40]. This study also demonstrated EVT outgrowth and
an increase in the expression of nuclear protein Ki67, which is
associated with cellular proliferation, providing further evidence for
the roles of Ang II and HIF-1a in placental maturation during nor-
moxic (>5% O2) conditions [40]. Conversely, Ang II has also been
implicated as a leading cause of IUGR and preeclampsia [33]. In 1999,
Wallukat et al. discovered that preeclamptic women produced auto-
antibodies known as AT1 receptor agonistic autoantibody (AT1-AA),
which binds to a seven amino acid sequence on the second extra-
cellular loop of the AT1 receptor [33,41]. Overstimulation of the AT1
receptor dramatically increases the expression and production of
sFlt-1, which is a potent antagonist of angiogenesis by binding and
inhibiting VEGF and placental growth factor (PIGF), reportedly
seen only very early in normotensive pregnancies [42,43]. There
is approximately a two to five times greater expression of
sFlt-1 in preeclamptic placentas than in placentas of normal preg-
nancies [44,45].
4.2. Cytokines (IL-1b, TNF-a)
Evidence is emerging of the interaction between cytokines (inter-
leukins (IL), tumour necrosis factors (TNF), natural killer cells (NK)) and
the maternal decidua, particularly just after conception and in early
placental development [19,34]. This suggests that the role of cytokines
is to ensure that the endometrium is receptive to the implanting
blastocyst [46]. Endometrial receptivity is characterised by differenti-
ation and maturation of the endometrial glands into a secretory phase,
as well as increasing the level of production of luminal epithelium cell
surface adhesion and extracellular matrix molecules [35]. Furthermore,
there is differentiation of stromal fibroblasts into decidual cells and
influx and proliferation of uterine specific natural killer cells (uNK).
Successful implantation requires adequate decidualisation to assist in
the regulation of early trophoblast invasion and development [34].
However, in times of exaggerated immunological response, trophoblast
invasion can be dysregulated leading to deleterious outcomes such as
1) failure to maintain implantation resulting in miscarriage and 2)
inadequate spiral artery remodelling leading to preeclampsia later in
pregnancy [47].
Many of the uterine changes mediated through immunological
processes described above occur in an hypoxic environment,
leading to the accumulation and cellular downstream effects of
HIF-1a. The notion that cytokines may cause immunomodulatory
changes during normoxic conditions is intriguing. Matrix metal-
loproteases (MMP-2 and MMP-9) and urokinase plasminogen
activator (uPA), have both been shown to be major targets of HIF
gene regulation in placental development [19]. Firstly, uPA plays
a central role in placental migration and invasion into the maternal
decidua [48]. It binds to its associated receptor (uPAR) on the
maternal decidual surface causing a downstream activation of
MMPs [49]. MMPs are essential in the degradation of extracellular
matrix (ECM), required for trophoblast invasion and remodelling of
the maternal decidua [50,51]. Studies in the human trophoblast cell
line JEG-3 and in primary cultures of trophoblast cells from term
placentas have demonstrated that addition of IL-1b under normal
cell culture conditions (21% O2) leads to up-regulation of uPA and
MMP-2 and MMP-9 [52e54]. Qian et al. (2004) have demonstrated
HIF-1a activation by IL-1b and TNF-a results in increased secretion
of VEGF, a potent activator of angiogenesis during times of hypoxia
[55]. The process of HIF-1a activation was driven by both IL-1b and
TNF-a, up-regulating expression of the extracellular signal-regu-
lated kinase (ERK) phosphorylation pathway [56].
Lash et al. (2010) demonstrated that decidual uNK cell superna-
tants from 12 to 14 weeks gestation stimulated EVT invasion from
placental villous explants [57]. This was associated with increased
MMP-9 levels and decreased apoptosis [57]. This provides further
support to the notion that cytokines released by uNK cells may act
via HIF-1a to activate HIF-1a targets such as MMP-9. This hypothesis
does, however, require further research, as suggested by Lash et al.
Other cell lines such as human hepatoma cells (HepG2) up-regulate
HIF-1a protein after IL-1b and HIF-1 binding to nuclear target sites
following the addition of TNF-a [56]. Further studies have high-
lighted effects of TNF-a in stabilising HIF-1a in tubular LLC-PK(1)
cells [58]. This provides clear evidence of the key role cytokines can
play in mediating the effects of HIF-1 at normoxia in a number of
tissue types, including placenta.
NF-kB is the key link that drives cytokine cellular signalling.
There is a close relationship between HIF-1a and NF-kb during
hypoxia, which leads to the up-regulation of inflammatory modu-
lators such as cycloxygenase-2 (COX-2), TNF-a and IL-6 [59].
However, studies have now demonstrated the ability of NF-kb to
up-regulate expression of HIF-1a under normoxic conditions. Jung
et al. (2003) observed IL-1b activation of NF-kb via the PI3K/AKT/
mTOR cellular signalling pathway resulted in the increase of COX-2,
which drove the increase of HIF-1a protein expression within
adenocarcinomic human alveolar (A549), Jurkat, MCF-7 and NIH-
3T3 fibroblast cell lines [60,61]. Furthermore, using placental
explants for hypoxia/reperfusion experiments, showed increases in
 J. Patel et al. / Placenta 31 (2010) 951e957
protein expression of HIF-1a, sFlt-1 and VEGF, which were reduced
using sulfasalazine, an NF-kb antagonist [62]. Similar findings were
also obtained using labored placental samples. Increased level of
NF-kb due to the inflammatory response of labor lead to the
production of increased levels of HIF-1a and sFlt-1.
4.3. Growth factors
The process of implantation and early placental development
occurs via the controlled regulation of growth factors such as
transforming growth factors (TGF-b), insulin-like growth factors
(IGF-I and IGF-II), and epidermal growth factors (EGF).
4.3.1. Transforming growth factor-1 (TGF-b1)
The effects of TGF-b on placental development have been
studied extensively [3,63,64]. TGF-b has three isoforms, b1, b2 and
b3, all of which are produced and secreted by the maternal decidua
[50,64]. TGF-b1 and b2 have been found in the placenta throughout
gestation, whereas TGF-b3 exhibits time specific regulation, with
mRNA levels highest until the 10th week of gestation, with
a marked drop in mRNA levels thereafter [63]. TGF-b3 has been
implicated as an inhibitor of trophoblast differentiation, thus
playing a key role in the regulation of the level of early placental
invasion [50]. It is important to note that TGF-b3 is over expressed
in preeclamptic tissue, providing further evidence of its role in
inhibiting placental development [63]. TGF-b1 has been studied to
a lesser extent, with conflicting data from numerous studies. Some
studies have observed the inhibitory effects by TGF-b1 on tropho-
blast invasion via the RhoA/Rho-associated kinase (ROCK) pathway
that causes increases in the secretion of PAI-1 and PAI-2, whereas
others have observed a reduction in uPA activity and MMP-2 and
MMP-9 secretion [65e67]. Conversely, TGF-b1 treatment of
primary isolated first trimester trophoblasts, did not alter the
extent of trophoblast invasion [66]. It is also important to note the
capacity of TGF-b1 to stabilise HIF-1a protein under normoxic
conditions. A study by Görlach et al. (2001) demonstrated TGF-b1
up-regulation of HIF-1a protein within human vascular smooth
muscle cells (VSMC) as well as the increased translocation of HIF-1
into the nucleus [68]. A further study by McMahon et al. (2006)
using the hepatoma cell line HepG2 and the fibrosarcoma cell line
HT1080, demonstrated that TGF-b1 inhibited prolyl hydroxylase 2
(PHD2), a potent oxygen sensor, leading to degradation of HIF-1a
protein during normoxia [26,69]. The inhibition of PHD2 results in
preventing Vhl from binding to the HIF-1a protein, resulting in
protein stability [69]. This increases tumour growth by activation of
VEGF and other similar growth factors. The role of TGF-b1 in the
complex processes involved in placental invasion and maturation
deserves further investigation, particularly in the second and third
trimesters of pregnancy. TGF-b1 may well activate genes associated
with the inhibition of trophoblast invasion and maturation leading
to pathologies such as IUGR and preeclampsia.
4.3.2. Insulin-like growth factor (IGF)
IGF is found in two isoforms in the placenta (IGF-I and IGF-II) and
has been observed in almost all cell types of the placenta including
the maternal interface, as early as six weeks of pregnancy [70]. IGFs
are also known to be key HIF-1 target genes. The placenta produces
a range of IGF binding proteins (IGFBP 1e6), which bind the IGFs
more strongly than their associated cell membrane receptors [71].
During pregnancy, post-translational modifications (phosphoryla-
tion and proteolysis) of the binding proteins are altered, reducing
binding affinity and hence increased bioavailability of IGF [36,71].
Interestingly, IGFBP-1, 2 and 3 are also HIF-1 regulated proteins,
emphasising their importance in early placental development
[19,72]. Maternal circulation of IGF-II also increases during early
955
pregnancy leading to increased bioavailability, with both IGF-I and II
having roles in trophoblast invasion, proliferation and survival (by
reducing trophoblast apoptosis) [73]. IGF-II protein expression is
also elevated in preeclamptic placentas, although its direct role in
preeclamptic pathogenesis is unknown [36]. It is critical to note
however the ability of IGF-I and II to activate HIF-1a protein
production under normoxic conditions. Although it has been argued
that the level of protein activation is very low, in some studies this
has resulted in altered cellular function [74e77]. IGF-I has been
shown to up-regulate HIF-1a protein expression in a number of cell
lines including HepG2 and L8 rat skeletal muscle myoblasts [75].
IGF-I has also been shown to lead to the up-regulation and secretion
of VEGF from human osteoblast-like cells through activation of HIF-
2a [74,75]. Furthermore, a study by Pringle et al. demonstrated an
increase of both HIF-1a and HIF-2a expression and trophoblast
outgrowth, following the addition of IGF-II to early murine tropho-
blasts under normoxic conditions [76,77]. This supports the view
that additional research in this area is required to elucidate the role
of IGFs in placental maturation, especially through their capacity to
activate HIFs during normoxic conditions.
5. Conclusion
The role of hypoxia in regulating trophoblast invasion and
maturation throughout pregnancy is well recognised. Our under-
standing of the molecular mechanisms, including HIF-1a, HIF-1b,
HIF-2a, that regulate these effects is rapidly expanding. Further
development in this area requires an understanding of how these
molecular regulators affect the growth and maturation of the
placenta under normoxic conditions. In this review we have dis-
cussed three key components (RAS, immunogenic cytokines and
growth factors) that assist in placental development and which
have also been demonstrated to be key modulators of HIF-1. There
is now growing evidence that the RAS, cytokines and growth factors
can change cellular functions by up-regulating the HIF pathway
under normoxic conditions. Relatively few studies have been per-
formed on isolated placental cells or tissue, which warrants further
investigation. Activation of HIFs during late pregnancy may play
a role in the pathogenesis of IUGR and preeclampsia and conse-
quent adverse pregnancy outcomes.
References
[1] Huppertz B. The anatomy of the normal placenta. J Clin Pathol 2008;
61(12):1296e302.
[2] Jackson MR, Mayhew TM, Boyd PA. Quantitative description of the elaboration
and maturation of villi from 10 weeks of gestation to term. Placenta 1992;
13(4):357e70.
[3] Genbacev O, Zhou Y, Ludlow JW, Fisher SJ. Regulation of human placental
development by oxygen tension. Science 1997;277(5332):1669e72.
[4] Jauniaux E, Gulbis B, Burton GJ. The human first trimester gestational sac
limits rather than facilitates oxygen transfer to the fetusea review. Placenta
2003;24(Suppl. A):S86e93.
[5] Huppertz B, Peeters LL. Vascular biology in implantation and placentation.
Angiogenesis 2005;8(2):157e67.
[6] Osol G, Mandala M. Maternal uterine vascular remodeling during pregnancy.
Physiology (Bethesda) 2009;24:58e71.
[7] Burton GJ, Jauniaux E, Watson AL. Maternal arterial connections to the
placental intervillous space during the first trimester of human pregnancy:
the Boyd collection revisited. Am J Obstet Gynecol 1999;181(3):718e24.
[8] Rodesch F, Simon P, Donner C, Jauniaux E. Oxygen measurements in endo-
metrial and trophoblastic tissues during early pregnancy. Obstet Gynecol
1992;80(2):283e5.
[9] Jauniaux E, Watson AL, Hempstock J, Bao YP, Skepper JN, Burton GJ. Onset of
maternal arterial blood flow and placental oxidative stress. A possible factor in
human early pregnancy failure. Am J Pathol 2000;157(6):2111e22.
[10] Carter AM. Evolution of factors affecting placental oxygen transfer. Placenta
2009;30(Suppl. A):S19e25.
[11] Harris LK, Keogh RJ, Wareing M, Baker PN, Cartwright JE, Aplin JD, et al.
Invasive trophoblasts stimulate vascular smooth muscle cell apoptosis by a fas
ligand-dependent mechanism. Am J Pathol 2006;169(5):1863e74.
956 J. Patel et al. / Placenta 31 (2010) 951e957
[12] Zygmunt M, Herr F, Munstedt K, Lang U, Liang OD. Angiogenesis and vascu-
logenesis in pregnancy. Eur J Obstet Gynecol Reprod Biol 2003;110(Suppl. 1):
S10e8.
[13] Ashton SV, Whitley GS, Dash PR, Wareing M, Crocker IP, Baker PN, et al.
Uterine spiral artery remodeling involves endothelial apoptosis induced by
extravillous trophoblasts through Fas/FasL interactions. Arterioscler Thromb
Vasc Biol 2005;25(1):102e8.
[14] Moffett-King A. Natural killer cells and pregnancy. Nat Rev Immunol 2002;
2(9):656e63.
[15] Burton GJ. Oxygen, the Janus gas; its effects on human placental development
and function. J Anat 2009;215(1):27e35.
[16] Pijnenborg R, Anthony J, Davey DA, Rees A, Tiltman A, Vercruysse L, et al.
Placental bed spiral arteries in the hypertensive disorders of pregnancy. Br J
Obstet Gynaecol 1991;98(7):648e55.
[17] Pijnenborg R, Luyten C, Vercruysse L, Van Assche FA. Attachment and differ-
entiation in vitro of trophoblast from normal and preeclamptic human
placentas. Am J Obstet Gynecol 1996;175(1):30e6.
[18] Brosens IA, Robertson WB, Dixon HG. The role of the spiral arteries in the
pathogenesis of pre-eclampsia. J Pathol 1970;101(4):Pvi.
[19] Pringle KG, Kind KL, Sferruzzi-Perri AN, Thompson JG, Roberts CT. Beyond
oxygen: complex regulation and activity of hypoxia inducible factors in
pregnancy. Hum Reprod Update; 2009.
[20] Lee JW, Bae SH, Jeong JW, Kim SH, Kim KW. Hypoxia-inducible factor (HIF-1)
alpha: its protein stability and biological functions. Exp Mol Med 2004;
36(1):1e12.
[21] Chen L, Endler A, Shibasaki F. Hypoxia and angiogenesis: regulation of
hypoxia-inducible factors via novel binding factors. Exp Mol Med 2009;
41(12):849e57.
[22] Dunwoodie SL. The role of hypoxia in development of the mammalian
embryo. Dev Cell 2009;17(6):755e73.
[23] Ietta F, Wu Y, Winter J, Xu J, Wang J, Post M, et al. Dynamic HIF1A regulation
during human placental development. Biol Reprod 2006;75(1):112e21.
[24] Carroll VA, Ashcroft M. Targeting the molecular basis for tumour hypoxia.
Expert Rev Mol Med 2005;7(6):1e16.
[25] Jewell UR, Kvietikova I, Scheid A, Bauer C, Wenger RH, Gassmann M. Induction
of HIF-1alpha in response to hypoxia is instantaneous. FASEB J 2001;
15(7):1312e4.
[26] Jaakkola P, Mole DR, Tian YM, Wilson MI, Gielbert J, Gaskell SJ, et al. Targeting
of HIF-alpha to the von Hippel-Lindau ubiquitylation complex by O2-regu-
lated prolyl hydroxylation. Science 2001;292(5516):468e72.
[27] Ivan M, Kondo K, Yang H, Kim W, Valiando J, Ohh M, et al. HIFalpha targeted
for VHL-mediated destruction by proline hydroxylation: implications for O2
sensing. Science 2001;292(5516):464e8.
[28] Kaelin Jr WG. Molecular basis of the VHL hereditary cancer syndrome. Nat Rev
Cancer 2002;2(9):673e82.
[29] Koivunen P, Hirsila M, Gunzler V, Kivirikko KI, Myllyharju J. Catalytic prop-
erties of the asparaginyl hydroxylase (FIH) in the oxygen sensing pathway are
distinct from those of its prolyl 4-hydroxylases. J Biol Chem 2004;
279(11):9899e904.
[30] McNeill LA, Hewitson KS, Claridge TD, Seibel JF, Horsfall LE, Schofield CJ.
Hypoxia-inducible factor asparaginyl hydroxylase (FIH-1) catalyses hydrox-
ylation at the beta-carbon of asparagine-803. Biochem J 2002;367
(Pt 3):571e5.
[31] Freedman SJ, Sun ZY, Kung AL, France DS, Wagner G, Eck MJ. Structural basis
for negative regulation of hypoxia-inducible factor-1alpha by CITED2. Nat
Struct Biol 2003;10(7):504e12.
[32] Withington SL, Scott AN, Saunders DN, Lopes Floro K, Preis JI, Michalicek J,
et al. Loss of Cited2 affects trophoblast formation and vascularization of the
mouse placenta. Dev Biol 2006;294(1):67e82.
[33] Irani RA, Xia Y. The functional role of the renineangiotensin system in
pregnancy and preeclampsia. Placenta 2008;29(9):763e71.
[34] Dimitriadis E, Menkhorst E, Salamonsen LA and Paiva P. Review: LIF and IL11
in trophoblasteendometrial interactions during the establishment of preg-
nancy. Placenta, 31:S99eS104.
[35] Dimitriadis E, Nie G, Hannan NJ, Paiva P and Salamonsen LA. Local regulation
of implantation at the human fetal-maternal interface. Int J Dev Biol 54
(2e3):313e322.
[36] Forbes K, Westwood M. The IGF axis and placental function. A mini review.
Horm Res 2008;69(3):129e37.
[37] Hsueh WA, Luetscher JA, Carlson EJ, Grislis G, Fraze E, McHargue A. Changes in
active and inactive renin throughout pregnancy. J Clin Endocrinol Metab
1982;54(5):1010e6.
[38] Brown MA, Gallery ED, Ross MR, Esber RP. Sodium excretion in normal and
hypertensive pregnancy: a prospective study. Am J Obstet Gynecol 1988;159
(2):297e307.
[39] Morgan T, Craven C, Ward K. Human spiral artery renineangiotensin system.
Hypertension 1998;32(4):683e7.
[40] Araki-Taguchi M, Nomura S, Ino K, Sumigama S, Yamamoto E, Kotani-Ito T,
et al. Angiotensin II mimics the hypoxic effect on regulating trophoblast
proliferation and differentiation in human placental explant cultures. Life Sci
2008;82(1e2):59e67.
[41] Wallukat G, Homuth V, Fischer T, Lindschau C, Horstkamp B, Jupner A, et al.
Patients with preeclampsia develop agonistic autoantibodies against the
angiotensin AT1 receptor. J Clin Invest 1999;103(7):945e52.
[42] Karumanchi SA, Epstein FH. Placental ischemia and soluble fms-like tyrosine
kinase 1: cause or consequence of preeclampsia? Kidney Int 2007;
71(10):959e61.
[43] Kendall RL, Thomas KA. Inhibition of vascular endothelial cell growth factor
activity by an endogenously encoded soluble receptor. Proc Natl Acad Sci U S
A 1993;90(22):10705e9.
[44] Tsatsaris V, Goffin F, Munaut C, Brichant JF, Pignon MR, Noel A, et al. Over-
expression of the soluble vascular endothelial growth factor receptor in
preeclamptic patients: pathophysiological consequences. J Clin Endocrinol
Metab 2003;88(11):5555e63.
[45] Maynard SE, Min JY, Merchan J, Lim KH, Li J, Mondal S, et al. Excess placental
soluble fms-like tyrosine kinase 1 (sFlt1) may contribute to endothelial
dysfunction, hypertension, and proteinuria in preeclampsia. J Clin Invest
2003;111(5):649e58.
[46] Psychoyos A. Hormonal control of ovoimplantation. Vitam Horm 1973;31:201e56.
[47] Redman CW, Sargent IL. Placental stress and pre-eclampsia: a revised view.
Placenta 2009;30(Suppl. A):S38e42.
[48] Naruse K, Lash GE, Bulmer JN, Innes BA, Otun HA, Searle RF, et al. The
urokinase plasminogen activator (uPA) system in uterine natural killer cells in
the placental bed during early pregnancy. Placenta 2009;30(5):398e404.
[49] Kjoller L, Kanse SM, Kirkegaard T, Rodenburg KW, Ronne E, Goodman SL, et al.
Plasminogen activator inhibitor-1 represses integrin- and vitronectin-medi-
ated cell migration independently of its function as an inhibitor of plasmin-
ogen activation. Exp Cell Res 1997;232(2):420e9.
[50] Caniggia I, Winter J, Lye SJ, Post M. Oxygen and placental development during
the first trimester: implications for the pathophysiology of pre-eclampsia.
Placenta 2000;21(Suppl. A):S25e30.
[51] Caniggia I, Mostachfi H, Winter J, Gassmann M, Lye SJ, Kuliszewski M, et al.
Hypoxia-inducible factor-1 mediates the biological effects of oxygen on
human trophoblast differentiation through TGFbeta(3). J Clin Invest 2000;105
(5):577e87.
[52] Karmakar S, Das C. Regulation of trophoblast invasion by IL-1beta and TGF-
beta1. Am J Reprod Immunol 2002;48(4):210e9.
[53] Bauer S, Pollheimer J, Hartmann J, Husslein P, Aplin JD, Knofler M. Tumor
necrosis factor-alpha inhibits trophoblast migration through elevation of
plasminogen activator inhibitor-1 in first-trimester villous explant cultures.
J Clin Endocrinol Metab 2004;89(2):812e22.
[54] Huber AV, Saleh L, Bauer S, Husslein P, Knofler M. TNFalpha-mediated
induction of PAI-1 restricts invasion of HTR-8/SVneo trophoblast cells.
Placenta 2006;27(2e3):127e36.
[55] Qian D, Lin HY, Wang HM, Zhang X, Liu DL, Li QL, et al. Normoxic induction of
the hypoxic-inducible factor-1 alpha by interleukin-1 beta involves the
extracellular signal-regulated kinase 1/2 pathway in normal human cyto-
trophoblast cells. Biol Reprod 2004;70(6):1822e7.
[56] Hellwig-Burgel T, Rutkowski K, Metzen E, Fandrey J, Jelkmann W. Interleukin-
1beta and tumor necrosis factor-alpha stimulate DNA binding of hypoxia-
inducible factor-1. Blood 1999;94(5):1561e7.
[57] Lash GE, Otun HA, Innes BA, Percival K, Searle RF, Robson SC, et al. Regulation
of extravillous trophoblast invasion by uterine natural killer cells is dependent
on gestational age. Hum Reprod 2010;25(5):1137e45.
[58] Zhou J, Fandrey J, Schumann J, Tiegs G, Brune B. NO and TNF-alpha released
from activated macrophages stabilize HIF-1alpha in resting tubular LLC-PK1
cells. Am J Physiol Cell Physiol 2003;284(2):C439e46.
[59] Taylor CT, Cummins EP. The role of NF-kappaB in hypoxia-induced gene
expression. Ann N Y Acad Sci 2009;1177:178e84.
[60] Jung YJ, Isaacs JS, Lee S, Trepel J, Neckers L. IL-1beta-mediated up-regulation of
HIF-1alpha via an NFkappaB/COX-2 pathway identifies HIF-1 as a critical link
between inflammation and oncogenesis. FASEB J 2003;17(14):2115e7.
[61] Jung YJ, Isaacs JS, Lee S, Trepel J, Neckers L. Microtubule disruption utilizes an
NFkappa B-dependent pathway to stabilize HIF-1alpha protein. J Biol Chem
2003;278(9):7445e52.
[62] Cindrova-Davies T. Gabor Than Award Lecture 2008: pre-eclampsia e from
placental oxidative stress to maternal endothelial dysfunction. Placenta
2009;30(Supp. A):S55e65.
[63] Caniggia I, Grisaru-Gravnosky S, Kuliszewsky M, Post M, Lye SJ. Inhibition of
TGF-beta 3 restores the invasive capability of extravillous trophoblasts in
preeclamptic pregnancies. J Clin Invest 1999;103(12):1641e50.
[64] Lysiak JJ, Hunt J, Pringle GA, Lala PK. Localization of transforming growth
factor beta and its natural inhibitor decorin in the human placenta and
decidua throughout gestation. Placenta 1995;16(3):221e31.
[65] Graham CH, Lala PK. Mechanism of control of trophoblast invasion in situ. J
Cell Physiol 1991;148(2):228e34.
[66] Bass KE, Morrish D, Roth I, Bhardwaj D, Taylor R, Zhou Y, et al. Human
cytotrophoblast invasion is up-regulated by epidermal growth factor:
evidence that paracrine factors modify this process. Dev Biol 1994;
164(2):550e61.
[67] Fafet P, Rebouissou C, Maudelonde T, Vignais ML. Opposite effects of trans-
forming growth factor-beta activation and rho-associated kinase inhibition on
human trophoblast migration in a reconstituted placental-endometrial
coculture system. Endocrinology 2008;149(9):4475e85.
[68] Gorlach A, Diebold I, Schini-Kerth VB, Berchner-Pfannschmidt U, Roth U,
Brandes RP, et al. Thrombin activates the hypoxia-inducible factor-1 signaling
pathway in vascular smooth muscle cells: role of the p22(phox)-containing
NADPH oxidase. Circ Res 2001;89(1):47e54.
 J. Patel et al. / Placenta 31 (2010) 951e957
[69] McMahon S, Charbonneau M, Grandmont S, Richard DE, Dubois CM. Trans-
forming growth factor beta1 induces hypoxia-inducible factor-1 stabilization
through selective inhibition of PHD2 expression. J Biol Chem 2006;281
(34):24171e81.
[70] Han VK, Bassett N, Walton J, Challis JR. The expression of insulin-like growth
factor (IGF) and IGF-binding protein (IGFBP) genes in the human placenta and
membranes: evidence for IGFeIGFBP interactions at the feto-maternal inter-
face. J Clin Endocrinol Metab 1996;81(7):2680e93.
[71] Westwood M, Gibson JM, Davies AJ, Young RJ, White A. The phosphorylation
pattern of insulin-like growth factor-binding protein-1 in normal plasma is
different from that in amniotic fluid and changes during pregnancy. J Clin
Endocrinol Metab 1994;79(6):1735e41.
[72] Forbes K, Souquet B, Garside R, Aplin JD and Westwood M. Transforming
growth factor-{beta} (TGF{beta}) receptors I/II differentially regulate TGF
{beta}1 and IGF-binding protein-3 mitogenic effects in the human placenta.
Endocrinology 151(4):1723e1731.
957
[73] Forbes K, Westwood M, Baker PN, Aplin JD. Insulin-like growth factor I and II
regulate the life cycle of trophoblast in the developing human placenta. Am J
Physiol Cell Physiol 2008;294(6):C1313e22.
[74] Feldser D, Agani F, Iyer NV, Pak B, Ferreira G, Semenza GL. Reciprocal positive
regulation of hypoxia-inducible factor 1alpha and insulin-like growth factor 2.
Cancer Res 1999;59(16):3915e8.
[75] Zelzer E, Levy Y, Kahana C, Shilo BZ, Rubinstein M, Cohen B. Insulin induces
transcription of target genes through the hypoxia-inducible factor HIF-
1alpha/ARNT. EMBO J 1998;17(17):5085e94.
[76] Pringle KG, Kind KL, Thompson JG, Roberts CT. Complex interactions between
hypoxia inducible factors, insulin-like growth factor-II and oxygen in early
murine trophoblasts. Placenta 2007;28(11e12):1147e57.
[77] Kwon YW, Kwon KS, Moon HE, Park JA, Choi KS, Kim YS, et al. Insulin-like
growth factor-II regulates the expression of vascular endothelial growth
factor by the human keratinocyte cell line HaCaT. J Invest Dermatol 2004;
123(1):152e8.