Review: Leptin gene expression in the placenta--regulation of a key hormone in trophoblast proliferation and survival

Leptin is a 16000 MW protein originally described as an adipocyte-derived signaling molecule for the central control of metabolism. However, pleiotropic effects of leptin have been identified in reproduction and pregnancy. The leptin gene is expressed in placenta, where leptin promotes proliferation and survival of trophoblast cells. Study of the major signaling pathways known to be triggered by leptin receptor has revealed that leptin stimulates JAK/STAT, MAPK and PI3K pathways in placental cells. Leptin also exerts an antiapoptotic action in placenta and this effect is mediated by the MAPK pathway. Moreover, leptin stimulates protein synthesis by activating the translational machinery via both PI3K and MAPK pathways. Expression of leptin in placenta is highly regulated, suggesting that certain key pregnancy molecules participate in such regulation. An important hormone in reproduction, hCG, induces leptin expression in trophoblast cells and this effect involves the MAPK signal transduction pathway. Moreover, the cyclic nucleotide cAMP, which has profound actions upon human trophoblast function, also stimulates leptin expression and this effect seems to be mediated by crosstalk between the PKA and MAPK signaling pathways. Estrogens play a central role in reproduction. 17β-estradiol upregulates leptin expression in placental cells through genomic and non-genomic actions, probably via crosstalk between estrogen receptor-α and the MAPK and PI3K signal transduction pathways. Taken together these findings give a better understanding of the function of leptin and the regulatory mechanisms of leptin expression in human placental trophoblast and further support the importance of leptin in the biology of reproduction.     

Placental leptin and pregnancy pathologies

Leptin, the protein encoded by the Ob gene, is produced by the white adipose tissue and by the placenta during pregnancy. Placental leptin production makes a substantial contribution to maternal circulating levels during pregnancy which rapidly decrease and return to normal after delivery. Leptin has been detected in fetal plasma as early as week 18 of gestation, and umbilical leptin concentrations are closely related to birth weight. This has led to the hypothesis that fetal fat mass mainly determines fetal circulating leptin. Placental leptin production is increased in choriocarcinoma, preeclampsia and type 1 diabetes. Estrogens, hypoxia and insulin have been suggested as positive regulators of placental leptin production. Maternal leptinemia might act as a sensor of energy balance during pregnancy. The presence of both leptin and leptin receptors in the placenta suggests that leptin can act by autocrine or endocrine pathways in the human placenta. The roles of fetal leptin and consequences of increased placental leptin production in pathological pregnancies have yet to be elucidated.     

Placental leptin

Placental tissues from humans, rodents and farm animals contain leptin and its receptor. Leptin produced by the human placenta has the same size, charge and immunoreactivity as leptin produced by adipose tissue. However, the expression of human placental leptin appears to be regulated by a placenta-specific upstream enhancer. In this review the occurrence of leptin and its receptor in a range of species and placental types is described, and its significance during pregnancy discussed. Placental leptin contributes to the increase in maternal circulating concentrations of leptin during late pregnancy when it is likely to have an endocrine role in regulating maternal energy balance. Placental leptin may have angiogenic and immunomodulatory activities, which affect the placenta in an autocrine or paracrine manner. It also appears to affect fetal growth and development by binding to leptin receptors present in fetal organs.     

Placental leptin receptor isoforms in normal and pathological pregnancies

Alternate mRNA splicing of human leptin receptor generates four membrane isoforms with different C-terminal sequences. They differ by the length of their intracellular domain which include specific motifs crucial for the specificity of leptin signalling. As a step towards functional studies, we have characterized leptin receptors in human placenta from normal pregnancies and pregnancies associated with diabetes and pre-eclampsia. Leptin and leptin receptors were visualized by immunohistochemistry of placentas obtained from first and third trimester pregnancies. Antibodies against N and C-terminal epitopes showed signals in the apical membrane of the syncytiotrophoblast in early and term placental villi as well as in JAr and BeWo derived trophoblast cells. In addition, a distinct isoform recognized by its extracellular juxtamembrane epitope was exclusively localized in cytotrophoblast cells and likely stains the soluble receptor. At contrast with the transmembrane receptors, the expression of this isoform is increased in placentas of pre-eclamptic and diabetic women which synthesize more leptin than placenta from uncomplicated pregnancy.These data demonstrate that short and long transmembrane leptin receptors are expressed in the trophoblast and indicate that leptin synthetized within the placenta can act locally through both receptor isoforms. Being also accessible to leptin from maternal origin, these transmembrane receptors may signal differently in pregnancy with normal and increased leptin production. The co-localization of leptin and the soluble receptor isoform suggests that this isoform serves for modulating maternal free leptin levels through modification of leptin binding capacities.     

Maternal Asthma as a Model for Examining Fetal Sex-specific Effects on Maternal Physiology and Placental Mechanisms that Regulate Human Fetal Growth

Studying the effect of maternal asthma during pregnancy on placental function and fetal development has highlighted that there is a strong interaction between mother, placenta and fetus and these interactions appear to be sex-specific. This work has found that the female fetus alters maternal asthma during pregnancy by upregulating maternal inflammatory pathways. When asthma-associated inflammatory pathways are not treated with inhaled steroids during pregnancy, the female fetus has reduced growth and adrenal function due to alterations in placental glucocorticoid metabolism. When the mother uses inhaled steroid for the treatment of her asthma during pregnancy, female fetal growth and placental function are comparable to the control population. The growth of the male fetus appears to be unaffected by asthma or inhaled steroid use. These findings indicate there may be different mechanisms regulating placental glucocorticoid and immune mechanisms depending on fetal sex in both asthmatic and non-asthmatic pregnancies.     

Epigenetic features of the mouse trophoblast

Trophoblast cells are required for the growth and survival of the fetus during pregnancy, and failure to maintain appropriate trophoblast regulation is associated with placental insufficiencies and intrauterine growth restriction. Development of the trophoblast lineage is mediated by interactions between genetic and epigenetic factors. This review will focus on new insights that have been gained from analysis of mouse models into the epigenetic mechanisms that are required for the early establishment of the trophoblast lineage and for the development of specialized cell types of the fetal placenta. In particular, the importance of DNA methylation, 5-hydroxymethylcytosine and histone modifications in orchestrating trophoblast gene expression and functional outcome will be discussed. These insights are beginning to be extended towards human studies and initial results suggest that the causes and consequences of a variety of placental pathologies are related to epigenetic processes. Furthermore, the epigenetic landscape that regulates trophoblast cells seems to be particularly vulnerable to perturbation during development. This has major implications for diet and other environmental factors during pregnancy.The placenta is required for the growth and survival of the fetus during pregnancy. Placental insufficiencies, including pre-eclampsia and intrauterine growth restriction, occur in ～10% of pregnancies and are associated with serious complications for mother and baby. Better understanding of how the placenta is formed is critical for the development of early diagnoses and therapies for treatment. Studies of animal models have revealed several critical pathways that are required for the proper development and function of the placenta. In particular, epigenetic processes, which determine how genes are switched on and off, are necessary for the early establishment of the placental lineage and also for the development of specialized cell types within the mature placenta. These crucial and recent insights form the basis for this review. Importantly, much of our understanding gleaned from animal models are now beginning to be extended towards human studies. Initial results suggest that the causes and consequences of a variety of placental pathologies are related to epigenetic pathways. As epigenetic processes can be susceptible to alterations by environmental factors, these studies have major implications for diet and other external influences during pregnancy.     

The Fascinating and Complex Role of the Placenta in Pregnancy and Fetal Well‐being

Existing evidence implicates the placenta as the origin of some common pregnancy complications. Moreover, some maternal conditions, such as inadequate nutrition, diabetes, and obesity, are known to adversely affect placental function, with subsequent negative impact on the fetus and newborn. The placenta may also contribute to fetal programming with health consequences into adulthood, such as cardiovascular, metabolic, and mental health disorders. There is evidence that altered placental development, specifically impaired trophoblast invasion and spiral artery remodeling in the first trimester, is the origin of preeclampsia. Prenatal care providers who understand the relationships between placental health and maternal‐newborn health can better inform and guide women to optimize health early in pregnancy and prior to conception. This article reviews the current understanding of placental function; placental contributions to normal fetal brain development and timing of birth; and impact of maternal nutrition, obesity, and diabetes on the placenta.     

The 2 differentiation pathways of the human trophoblast

The trophoblast is the major component of the human placenta. It is directly involved in blastocyst implantation and in feto-placental growth and development. Human trophoblast follows two major pathways of differentiation: the villous trophoblast, bathing in maternal blood of intervillous spaces and involved in matemo-fetal exchanges and in placental endocrine functions; the extra-villous trophoblast involved in uterine spiral arteries remodeling and in the placental anchorage into the uterine wall. It is essential to understand the cellular and molecular mechanisms involved in human trophoblast differentiation: cellular proliferation, migration, invasion and differentiation by cell-cell fusion. Abnormal trophoblast differentiation is implicated in the major pathologies of human pregnancy such as pre-eclampsia and intrauterine growth retardation.     

Immunological aspects of pathological pregnancy (infertility immunology)

As, theoretically, any of the many mechanisms that appear to operate in normal pregnancy to maintain maternofetal immunologic balance could be altered in pathologic pregnancy, a detailed study of the known immunological aspects of pathological pregnancy is given. After looking into the parental genetic heterozygosity and fertility, a good explanation of the antifetal immunoresponse by the pregnant mother including the antibody formation is shown. The placental transport versus trapping of immunoglobulins is described in detail and it is also shown that the placenta is a source of a number of agents that inhibit cell-mediated immunity (HCG, HPL and steroids). These substances may affect a local inhibition of maternal cell-mediated immunity in the vicinity of the trophoblast. The placenta serves as an effective barrier for transfer of immunocompetent maternal lymphocytes to the fetus. The paramount role of the trophoblast as a barrier, while itself escaping immunologic destruction, calls for further studies.     

Leptin and its influence on the main gynecoobstetric diseases

Leptin is a protein hormone synthesized and secreted by adipose tissue and also probably in other organs and systems in human body. It has multiple functions such as to regulate feed intake and energy balance, gonadal regulation, action in the hypothalamo-pituitary-gonadal axis, regulates the metabolism of the fetal-placental unit in the pregnancy, fertility and reproductive systems, actions in the endometrium, mammary gland with corresponding influences on important physiologic processes such as menstruation, pregnancy and lactation. In the gynecologic surgery the serum leptin concentration is also modified. The knowledge of serum leptin concentration in the oncological diseases is going-up. Leptin is modified in the choriocarcinoma, Meigs' syndrome and other tumors. A better understanding of regulatory mechanisms will have direct clinical significance, as leptin has been proposed to impact on those causes of human perinatal morbidity and mortality that are associated with abnormalities of fetal maturity and development, general concept growth, trophoblast endocrinology, and placental sufficiency. Further investigations in this area will be necessary to improve new knowledge and a better understanding of the actions about this hormone.     

Leptin secretion to both the maternal and fetal circulation in the ex vivo perfused human term placenta

The contribution of placental leptin, if any, to both the fetal and maternal circulation and its role in pregnancy remains to be determined. In an experiment to investigate this, 27 placentae from term pregnancies were perfused ex vivo (gestational age=39.5 s.d. 1.2; range=38-42 weeks: fetal weight=3285 s.d. 482; range=2480-4420; birthweight centile range=4th to the 98th) at both the maternal and fetal interface. Placental leptin was exported into both the maternal and fetal circulations. The log leptin production by the maternal side of the placenta was significantly greater (P=0.001) than that for the fetal side (5.193 s.d.1.049 versus 4.387 s.d. 0.768 ng/placenta/min). There was no significant relationship between maternal and fetal log leptin production and maternal body mass index, birthweight, birthweight centile, ponderal index or gestational age or with cord blood pO(2), pCO(2) and pH. There was however, a significant increase in the maternal log leptin production with increasing fetal to placental weight ratio (P=0.017; r(2)=20.7 per cent) but no corresponding relationship for fetal leptin production. It is proposed that such a mechanism would allow the placenta to modulate fat supply to the fetus in response to the fetal demand relative to placental supply.     

Morphological variability and placental function

In mammals, the blastocyst defines with the maternal organism, a structure which allows embryonic development during gestation: the placenta. The structure of this organ varies remarkably across species. In this review the different type of placentation have been described in a comparative manner using terms of classification such as: placental materno-fetal interdigitation, matemofetal blood flow interrelationships, layers of the placental interhemal barrier, trophoblast invasiveness and decidual cell reaction, formation of syncytiotrophoblast. The human hemomonochorial placenta is characterized by a strong decidualization of the uterus and a major invasiveness of the extravillous trophoblast. Furthermore, there is a spectrum of placental endocrine activities across species. In some mammals (e.g., mouse and rat) the placenta eclipses the pituitary in the maintenance of ovarian function. In the human and in the sheep, horse, cat and guinea pig, the placenta acquires the ability to substitute for the ovaries in the maintenance of gestation at various time during pregnancy. The human placenta is characterized by a high rate of stero?dogenesis (progesterone and estrogens) and by the production of a primate specific trophoblastic hormone: human chorionic gonadotropin (hCG). Recently, it was demonstrated that mutation of many genes in mice results in embryonic mortality or fetal growth restriction, due to defects in placental development. Furthermore, distinct molecular pathways regulate the differentiation of various trophoblast cell subtype of the mouse placenta. An important question is whether or not placental differentiation in other mammals is regulated by the same molecular mechanisms. Due to the striking diversity in placental structure, endocrine function and gene expression, caution must be exercised in extrapolating findings regarding placental function and development from one species to another.     

Examination of distinct fetal and maternal molecular pathways suggests a mechanism for the development of preeclampsia

In pregnancy, the maternal spiral arteries must widen to nourish the growing fetus. It is this critical step in placental development that is commonly defective in the pathology of preeclampsia. Other features often observed in the placental pathology of preeclampsia include fewer invasive trophoblasts, shallow trophoblast invasion and placental thrombosis and atherotic-like changes. In this review, we propose that there are two distinct pathways, maternal and fetal, which converge on narrow spiral arteries. The unmodified (along the fetal pathway) or blocked (along the maternal pathway) spiral artery, or a combination of the two, may in turn lead to placental insufficiency and induce the maternal cascade of events leading to preeclampsia. We suggest a paradigm for the molecular developmental events that cause preeclampsia through narrow spiral arteries and focus on early events that may cause failed remodeling or blockage of the arteries, which then lead to placental insufficiency and ultimately the hypoxic placenta associated with preeclampsia. We propose that examination of the molecular mechanisms of maternal and fetal pathways that lead to the development of preeclampsia may aid researchers to focus on new potential factors in this molecular basis and ultimately in treatment of this disease.     

The placenta cytokine network and inflammatory signals

Throughout its entire lifespan, the placenta is able to produce as well as respond to a variety of inflammatory stimuli. Many signaling molecules and concurrent pathways responsible for the propagation of an inflammatory response have been identified in placental cells. From early developmental stages onward, the secretory activity of placenta cells clearly contributes to increase local as well as systemic levels of cytokines and inflammatory molecules. Two aspects of the progression of an immune response have been particularly investigated: the highly regulated process of invasion and implantation and, the induction of preterm labor associated with infections. With the progression of pregnancy, the physiological role of most placental cytokines is more uncertain. Many placental cytokines are similar to adipose tissue derived cytokines. One possibility is that they contribute to the low grade systemic inflammation developing during the third trimester of pregnancy. The prevalent hypothesis is that activation of some inflammatory pathways is necessary to induce maternal insulin resistance which is required for the progression of normal gestation. As an integrative organ, the placenta may relay or enhance the contribution made by the cells of the adipose tissue and immune system in non-pregnant individuals. In pregnancy complicated with obesity or diabetes mellitus, continuous adverse stimulus is associated with dysregulation of metabolic, vascular and inflammatory pathways supported by increased circulating concentration of inflammatory molecules. It is believed that maternal adipose tissue and placental cells both contribute to the inflammatory situation by releasing common molecules. For example, the accumulation of leptin and TNF-alpha is associated with an increased production for markers of inflammation, fibrotic response, vascular remodeling and proteins facilitating lipid storage within the placenta.     

The influence of leptin on placental and fetal volume measured by three-dimensional ultrasound in the second trimester

For a couple of years mechanisms influencing placental and fetal growth and the functioning of leptin, the protein product of the ob/ob gene, have been subjects of intensive research. This study's aim was to investigate whether maternal serum leptin and amniotic fluid leptin have an influence on placental and fetal size measured by three-dimensional ultrasound in the second trimester. To determine this, 40 women with a singleton intrauterine pregnancy at the time of the amniocentesis were included in the study. Placental and fetal volume measurements were obtained and correlated to maternal serum leptin, amniotic fluid leptin, body mass index and gestational age. Multiple regression analysis identified amniotic fluid leptin as an independent negative predictor of placental and fetal volume (r = -2.29, p = 0.032 and r = -0.95, p = 0.011, respectively). In contrast, there was no correlation between maternal serum leptin and placental or fetal volume. The median leptin level in amniotic fluid (9.5 ng/ml) was significantly lower than in maternal blood (18.6 ng/ml). However, there was no significant correlation between maternal serum leptin and amniotic fluid leptin (r = 0.208, n.s.). Body mass index did not reveal any significant influences on placental or fetal volume. The relatively high level of amniotic fluid leptin and its inverse correlation on placental and fetal volume in the second trimester suggest that it possibly plays a role as an anti-placental growth hormone or feedback modulator of substrate supply to the fetus and placenta.     

Defective implantation and placentation: laying the blueprint for pregnancy complications

Normal implantation and placentation is critical for pregnancy success. Many pregnancy-related complications that present late in gestation (such as pre-eclampsia and preterm labour) appear to have their origins early in pregnancy with abnormalities in implantation and placental development. Implantation is characterized by invasion of the maternal tissues of the uterus by fetal trophoblast, and the degree to which trophoblast invades these tissues appears to be a major determinant of pregnancy outcome. Excessive invasion can lead to abnormally firm attachment of the placenta to the myometrium (placenta accreta) with increased maternal and perinatal morbidity. Inadequate invasion, specifically restricted endovascular invasion, has been implicated in the pathophysiology of such conditions as pre-eclampsia (gestational proteinuric hypertension), preterm premature rupture of membranes, preterm labour, and intrauterine growth restriction. The molecular and cellular mechanisms responsible for implantation remain enigmatic. This review will include an overview of implantation followed by a discussion of a number of molecular mechanisms implicated in defective implantation and placentation including the role of decidual prostaglandins and haemorrhage in regulating trophoblast invasion. An improved understanding of the molecular mechanisms responsible for abnormal implantation and placentation will likely improve clinicians' abilities to treat disorders that occur along this continuum, including infertility, recurrent pregnancy loss, pre-eclampsia, and preterm birth.     

Indoleamine 2,3-dioxygenase (IDO) expression in invasive extravillous trophoblast supports role of the enzyme for materno-fetal tolerance

It is still not understood how the fetus escapes from being attacked by the maternal immune system. Recent reports based on mouse and in vitro models have suggested that the enzyme indoleamine 2,3-dioxygenase (IDO) is important for materno-fetal tolerance. IDO activity in the human placenta is known to be high and might lead to inhibition of T-cell proliferation, thus preventing fetal tissue from rejection by the maternal immune system. In an attempt to elucidate the precise location of IDO at the feto-maternal junctional zone, we investigated human placental and decidual tissue of first and third trimester of pregnancy using an immunohistochemical approach. In placental tissues, only syncytiotrophoblast and endothelial cells showed moderate expression of IDO. This pattern was observed regardless of whether first or third trimester tissue was investigated. In early and term decidua, cells with the typical morphology of invasive extravillous trophoblast (EVT) were strongly positive for IDO. Blocking immunohistochemical experiments with cytokeratin and IDO antibodies identified invasive EVT as the location of predominant IDO expression. Since EVT are the fetal cells with the closest contact to the maternal immune system, our results suggest that it is EVT which protects the fetus from rejection by downregulating local maternal T-cell responses.     

The role of placental Fas ligand in maintaining immune privilege at maternal-fetal interfaces.

It is now recognized that immunosuppressive factors synthesized by placenta may play a critical role in the maintenance of pregnancy. Over the last several years our group and others have formulated a hypothesis that trophoblast Fas ligand (FasL) plays an important role in maintaining fetal immune privilege in human pregnancy by actively promoting apoptosis (programmed cell death) of activated maternal lymphocytes bearing Fas (i.e., the FasL receptor). This review initially provides background information and updates aspects of the Fas/FasL signaling system, including the role of caspases and molecules recruited to the Fasl/Fas signaling complex and the revised functions ascribed to membrane and soluble forms of FasL. Information is then presented concerning the role of FasL at immune-privileged sites including the eye and testis. Pathways through which the placenta and tumors avoid may avoid immune clearance vis-à-vis the FasL/Fas signaling cascade are described. A model is then presented through which FasL production by human syncytiotrophoblasts and extravillous trophoblasts may protect the fetus against the cytolytic actions of activated Fas-bearing maternal lymphocytes in the intervillous space and in the placental bed, respectively. We conclude with a review of studies in support this model that specifically demonstrate trophoblast expression of FasL and identify potential lymphocyte targets (i.e., Fas-expressing maternal immune cells) of trophoblast FasL.