Pathophysiology of the Clinical

Manifestations of Preeclampsia
1. Michelle Hladunewich*,
2. S. Ananth Karumanchi ,
3. Richard Lafayette

+ Author Affiliations

1. *
Division of Nephrology, University of Toronto, Toronto, Ontario, Canada; Division
of Nephrology, Beth Israel Deaconess Medical Center and Harvard Medical School,
Boston, Massachusetts; and Division of Nephrology, Stanford University, Stanford,
California

1. Address correspondence to:

Dr Richard A. Lafayette, Stanford University, Division of Nephrology, 300 Pasteur
Drive, Stanford, CA 94305. Phone: 650-723-6247; Fax: 650-723-7917; E-mail:
czar@stanford.edu

Five to 7% of all pregnancies are complicated by preeclampsia. Proteinuria and hypertension

dominate the clinical picture, because the chief target organ is the kidney (glomerular
endotheliosis). The pathogenesis of preeclampsia is complex; numerous genetic,
immunologic, and environmental factors interact. It has been suggested that preeclampsia is a
two-stage disease (1). The first stage is asymptomatic, characterized by abnormal placental
development during the first trimester resulting in placental insufficiency and the release of
excessive amounts of placental materials into the maternal circulation. This in turn leads to
the second, symptomatic stage, wherein the pregnant woman develops characteristic
hypertension, renal impairment, and proteinuria and is at risk for the HELLP syndrome
(hemolysis, elevated liver function enzymes and low platelets), eclampsia, and other end-
organ damage. This review focuses on the pathophysiology of stages 1 and 2 and then
considers the potential that changes in soluble angiogenic factors may underlie much of the
disease process.

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Placentation Abnormalities (Stage I)

On the basis of the observation that the only definitive cure for preeclampsia is delivery of
the placenta and that women who experience a molar pregnancy, in which a placenta
develops without a fetus, frequently develop severe preeclampsia, it is reasonable to assume
that the placenta plays a central role in the pathogenesis of the disease. Pathologic
examination of placentas from preeclamptic pregnancies generally reveals placental infarcts
and sclerotic narrowing of arteries and arterioles, with characteristic diminished endovascular
invasion by cytotrophoblasts and inadequate remodeling of the uterine spiral arterioles (2).
Although gross pathologic changes are not always seen in the placentas of women with
preeclampsia, placental profiles including abnormal uterine artery Doppler and placental
morphology have been used to identify a subset from a cohort of high-risk women who go on
to develop the syndrome (3). Uterine artery Doppler studies that assess the pulsatility index
(PI) reveal increased uterine vascular resistance well before the clinical signs and symptoms
arise (4,5). Moreover, mechanical constriction of the uterine arteries produces hypertension,
proteinuria, and, in some species, glomerular endotheliosis, supporting an causative role for
placental ischemia in the pathogenesis of preeclampsia (6).

Mammalian placentation requires extensive angiogenesis to establish a suitable network for

the supply of oxygen and nutrients in the fetus. A variety of pro- and antiangiogenic factors
are elaborated by developing placentas. It is believed that placental angiogenesis is defective
in preeclampsia, as evidenced by failure of the cytotrophoblasts to convert from a more
epithelial to endothelial phenotype, based on cell surface marker studies (6,7). Normally,
invasive cytotrophoblasts downregulate the expression of adhesion molecules that are
characteristic of their epithelial cell origin and adopt a cell-surface adhesion phenotype that is
typical of endothelial cells, a process that is referred to as pseudovasculogenesis (7,8). In
preeclampsia, cytotrophoblast cells fail to undergo this switching of cell-surface integrins and
adhesion molecules (5). This abnormal cytotrophoblast differentiation is an early defect that
may eventually lead to placental ischemia. Others have demonstrated that hypoxia-inducible
factor-1 is upregulated in preeclampsia and suggest that it and its target genes may play a
central role in the abnormal differentiation phenotype of preeclampsia (9,10). Whether this
lack of conversion of cytotrophoblasts to an endothelial phenotype in women with
preeclampsia is a primary or secondary event remains uncertain (11).

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The Maternal Syndrome (Stage II)

The abnormal placentation that results from failure of trophoblast remodeling of uterine spiral
arterioles is thought to lead to the release of secreted factors that enter the mother's
circulation, culminating in the clinical signs and symptoms of preeclampsia. All of the
clinical manifestations of preeclampsia can be attributed to glomerular endotheliosis,
increased vascular permeability, and a systemic inflammatory response that results in end-
organ damage and/or hypoperfusion. These clinical manifestations typically occur after the
20th week of pregnancy.

Hypertension

Accommodation to normal pregnancy includes a decrease in both systolic and diastolic BP as

a result of a decrease in systemic vascular resistance primarily secondary to vasodilation.
Relaxin, which is released from the ovaries under the influence of human chorionic
gonadotrophin, upregulates nitric oxide synthase (NOS) (12), the enzyme that generates NO
from arginine, via the endothelial endothelin B receptor (13). In preeclampsia, derangement
of endothelial-derived vasoactive factors is thought to result in the predominance of
substances that are vasoconstrictors (endothelin, thromboxane A2) over vasodilators (NO,
prostacyclin). Hypertension, defined as repeat BP measurements 140/90 mmHg, results
from abnormal vasoconstriction.

Normal pregnancy in the rat is accompanied by increased production of NO and its second
messenger, cyclic guanosine 35 monophosphate (14) with a parallel increase in renal
expression of constitutive NOS (12,15). In the pregnant rat, an infusion of NG-nitro-l-
arginine methyl ester (L-NAME), an exogenous inhibitor of NOS, has been shown to
replicate some of the hemodynamic features of preeclampsia (16). l-Arginine
supplementation reversed these adverse effects of L-NAME on pregnancy, attenuating
hypertension, significantly decreasing proteinuria, and reducing the proportion of injured
glomeruli (17). However, in humans, evidence to support a role of NO deficiency in the
pathogenesis of the hypertension in preeclampsia has been conflicting. Although elevated
circulating levels of asymmetric dimethyl arginine, an endogenous inhibitor of NOS, has
been a consistent finding in pregnancies that are complicated by preeclampsia, plasma
concentrations are typically very low with a narrow distribution among healthy adults,
making quantification extremely challenging and the clinical significance of the finding
uncertain (1820). Furthermore, l-arginine supplementation has not conferred significant
benefit in women with pregnancies that are complicated by preeclampsia (21,22).

Another hypothesis considered the possibility that an early gestational exaggeration of the
normal accommodation to pregnancy can be used to identify and may be pathogenic in
preeclampsia (23). A longitudinal study that used Doppler echocardiography in 400
primigravidas throughout pregnancy noted a significantly increased cardiac output without
any difference in peripheral vascular resistance in the 24 women who eventually developed
preeclampsia compared with healthy control subjects (24). This increased cardiac output was
followed by a marked reduction in the cardiac output and increased peripheral vascular
resistance with the onset of the clinical syndrome. This notion of a crossover in the
hemodynamic profile in women who develop preeclampsia resulted in a handful of studies
that used blockers in a preventive manner (2527). These studies were typically small
and/or uncontrolled. Furthermore, reduced fetal growth was noted in the women who
received the blockers, possibly because of an overaggressive decrease in the cardiac output
(26,27).

More recently, attention has again turned to the renin-angiotensin system (RAS) to provide a
pathophysiologic understanding for the hypertension of preeclampsia. In normal pregnancy,
all components of the RAS are upregulated, but resistance to the pressor effects of
angiotensin II (AngII) allows for normal to low BP (18,19). Similarly, reduced sensitivity of
the renal circulation has been demonstrated in pregnant rats as AngII infusion failed to
decrease GFR, renal plasma flow (RPF), and urine flow (28). One explanation may be
increased plasma levels and urinary excretion rates of Ang(1-7), a potent counterregulator of
AngII, documented in human pregnancy (29,30). Ang(1-7) was demonstrated to be
significantly decreased in women with preeclampsia compared with normal pregnant control
subjects (29).

It is interesting that evidence supports decreased levels of renin, AngI, and AngII in women
with preeclampsia compared with normal pregnancy (31). Despite this, enhanced vascular
sensitivity to components of the RAS is seen in women with preeclampsia. Enhanced
vascular sensitivity to an angiotensin infusion can identify women who are at increased risk
for the development of preeclampsia (32,33).

Recent studies have identified an autoantibody of the IgG subclass in the plasma of women
with preeclampsia that is capable of stimulating the AT1 receptor (34). When serum from
preeclamptic women was added to cultured neonatal rat cardiac myocytes, the chronotropic
effect could be blocked by losartan, confirming the effect was mediated via the AT1 receptor
(35). Furthermore, the autoantibody might stimulate heterodimerization between the AT1
receptor and the B2 receptor for bradykinin (36). This may play an important role in the
enhanced vascular sensitivity to angiotensin. It might also induce the production of reactive
oxygen species, which block cytotrophoblast invasion in vitro and may relate to shallow
trophoblastic implantation, thus accounting for several of the clinical features of preeclampsia
(37). This autoimmune activity wanes after delivery (34). More recently, these antibodies
also were found in patients with acute vascular rejection (38), suggesting that they may play a
role in other forms of endothelial injury as well.

Decreased GFR

Healthy pregnant women exhibit marked glomerular hyperfiltration, peaking above normal,
nongravid levels by 40 to 60% (39,40). This hyperfiltration seems to result primarily from
depression of the plasma oncotic pressure (GC) in the glomerular capillaries. The reduction
of GC in pregnancy is attributable to two phenomena. The first is a hypervolemia-induced
hemodilution that lowers the protein concentration of plasma that enters the glomerular
microcirculation. The second is an elevated rate of RPF. Hyperperfusion of glomeruli blunts
the extent to which the oncotic pressure can increase along the glomerular capillaries during
filtrate formation. In preeclampsia, variable degrees of renal insufficiency are associated with
a characteristic glomerular lesion, glomerular endotheliosis.

Precise physiologic measurements in conjunction with immediate postpartum biopsies were

used to examine the determinants of the GFR in women with preeclampsia as compared with
healthy gravid control subjects (41). The GFR was significantly depressed to 91 ml/min per
1.73 m2 in women with preeclampsia compared with a value of 149 ml/min per 1.73 m2 in the
control subjects. Of interest, no significant differences were found in either RPF or GC. The
morphometric analysis revealed significant ultrastructural differences, including swelling of
the endothelial cells, subendothelial fibrinoid deposition, and mesangial cell interposition
(Figure 1). Scanning electron microscopy was used to characterize the endothelial fenestral
dimensions, allowing the authors to conclude that a reduction in the density and the size of
the endothelial fenestrae and subendothelial accumulation of fibrinoid deposits severely
lowered glomerular hydraulic permeability in patients with preeclampsia. Mesangial cell
interposition also decreased available surface area for filtration, thereby resulting in a
cumulative depression of Kf that was exactly proportional to the GFR. A more controversial
conclusion was that the hypofiltration in preeclampsia does not have a hemodynamic basis.

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Figure 1.

Transmission electron microscopy of a representative glomerular capillary enumerating

pathologic changes associated with preeclampsia: 1, endothelial cell body; 2, swollen,
nonfenestrated endothelium; 3, subendothelial fibrinoid deposition; 4, mesangial cell
interposition.

A recent study used a semiquantitative scale to grade the endotheliosis that was present on
biopsy specimens that were taken from women with preeclampsia approximately 1 wk before
delivery (42,43). They noted moderate to severe endotheliosis in all women with significant
hypertension and proteinuria before delivery. Of interest, women with nonproteinuric
gestational hypertension and normal pregnant women also exhibited endotheliosis but to
lesser degrees, suggesting that pregnancy-induced hypertension may in some cases reflect an
earlier or milder form of the same pathology (44). Subendothelial fibrinoid deposits and
mesangial cell interposition were found only in women with preeclampsia. Unfortunately, the
authors never published any images or acquired confirmation from a second blinded
pathologist to ensure interobserver reliability. In a second article that examined the same
patient population, the authors found a linear trend between glomerular volume reflecting the
degree of endotheliosis and cystatin C (42), suggesting that the basis for the hypofiltration in
preeclampsia is largely secondary to structural changes in the glomerulus as opposed to renal
vasoconstriction and a depression in RPF. However, the utility of cystatin C as a marker of
GFR is unclear in this patient population. A recent study found that cystatin C correlated
poorly with third-trimester creatinine clearance (r = 0.27) (45), and another study that used
inulin clearances for comparison found that the measurement is not independent of body
composition as previously assumed (46). To date, cystatin C has not been validated as a
marker of GFR in pregnancy, with several studies suggesting that it may be imprecise.

Proteinuria

In 1843, John Lever of Guy's Hospital in London discovered the presence of albumin by
boiling the urine from pregnant women with puerperal convulsions. Preeclampsia is
differentiated from gestational hypertension by the presence of proteinuria and is the most
common cause of nephrotic syndrome in pregnancy. The quantity of protein that is excreted
in the urine varies widely. Significant protein excretion is defined as 300 mg in a 24-h urine
collection or 1+ or greater on urine dipstick testing of two random urine samples that are
collected at least 4 h apart (47).

Numerous studies have used a variety of methods to examine the biochemical constitution of
preeclamptic urine, including protein selectivity indices, with variable results. Generally,
urine from preeclampsia has demonstrated poor selectivity and has not differed significantly
from other forms of primary renal disease (48). Glomerular proteins of intermediate size,
such as albumin, have been identified alone or in combination with varying degrees of
tubular proteins, such as B2-microglobulin, reflecting the tubular damage that can occur in
severe preeclampsia (49,50).

Unfortunately, the exact role of the endothelial cell layer in the regulation of glomerular
permselectivity remains the least well defined. Endothelial cells are difficult to acquire for in
vitro studies, and, unlike the podocyte, there are no specific markers for this cell line.
Perforated by large fenestrae, the endothelial cell layer does not contribute to size selectivity,
allowing the passage of neutral molecules with a radius up to approximately 375 .
Therefore, the mechanism for proteinuria in preeclampsia is not well understood. The
glomerular basement membrane and podocytes typically appear normal (33,36). Few
investigators have used dextran-sieving techniques to elucidate the properties of the
glomerular filtration barrier in women with preeclampsia. In the 1970s, MacLean et al. (51)
confirmed the glomerular origin of proteinuria in preeclampsia demonstrating dextran-sieving
coefficients in the intermediate range. This finding was corroborated by a more recent study
that demonstrated a loss of size selectivity significant for bands 31 to 39 (P < 0.0001) as
well as 41 to 49 (P < 0.01) (52). Without more specific studies, the authors alluded to the
fact that loss of charge selectivity was likely the primary defect in the glomerular filtration
barrier in women with preeclampsia. New insights into the role of angiogenic factors in the
maintenance of an intact glomerular filtration barrier may reconcile the presence of
nephrotic-range proteinuria in an endothelial cell disease (see Circulating Angiogenic Factors
in Preeclampsia).

Coagulopathy and HELLP Syndrome

In preeclampsia, endothelial injury may also become manifest as a low-grade coagulopathy

with increased fibronectin, increased platelet aggregation, shortened platelet survival, and
depressed antithrombin III levels (53). The HELLP syndrome develops in up to 10% of
pregnancies with severe preeclampsia, and evidence exists to suggest that it is not simply an
epiphenomenon of extreme hypertension. Plasma concentrations of cellular fibronectin have
been shown to be consistently higher throughout pregnancy in woman who develop
preeclampsia compared with healthy control subjects. In addition, markers of platelet
activation, including -thromboglobulin, as well as assays of platelet aggregation have been
demonstrated to precede the clinical manifestations of the disease (54,55).

Eclampsia

Seizures with other neurologic symptoms, including headache and visual disturbances,
complicate approximately 5 of every 10,000 live births, with a declining incidence as a result
of improved prenatal care with expedited delivery and, possibly, the widespread use of
magnesium sulfate (56). The precise mechanism that is responsible for the development of
seizures is not clear, but proposed theories include cerebral vasospasm, edema, and the
possibility that severe hypertension might disturb cerebral autoregulation and disrupt the
bloodbrain barrier. The cerebral edema of eclampsia predominantly involves the posterior,
parieto-occipital lobes and is similar to images described in reversible posterior
leukoencephalopathy syndrome (57). This finding on magnetic resonance imaging has been
noted to correlate better with markers of endothelial dysfunction, including lactate
dehydrogenase, red blood cell morphology, and creatinine than the level of hypertension
(58,59). Of interest, reversible posterior leukoencephalopathy syndrome in patients with
thrombotic thrombocytopenic purpura has also been found to be independent of the level of
hypertension in some cases (60).

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Circulating Angiogenic Factors in Preeclampsia

Recently, two endogenous antiangiogenic proteins of placental origincirculating soluble
fms-like tyrosine kinase 1 (sFlt1) and soluble endoglin (61)have been suggested, on the
basis of rodent models, to play a causal role in the pathogenesis of preeclampsia (62,63).
sFlt1 is a secreted protein, a splice variant of the vascular endothelial growth factor (VEGF)
receptor Flt1, which lacks the transmembrane and cytoplasmic domain of the membrane-
bound receptor. Circulating in the blood, it acts as a potent antagonist to VEGF and placental
growth factor (PlGF). Both VEGF and PlGF are made by the placenta and circulate in high
concentration during pregnancy. Circulating sFlt1 levels are greatly increased in women with
preeclampsia even before the onset of clinical symptoms (64). Consistent with the action of
the circulating protein to bind PlGF, free PlGF levels are also decreased in preeclamptic
women before the onset of clinical symptoms (64). When administered to pregnant and
nonpregnant rats, sFlt1 produces a syndrome of hypertension, proteinuria, and glomerular
endotheliosis that resembles preeclampsia (62). It has also been shown that VEGF induces
endothelial fenestrae in vitro, and the loss of 50% of VEGF production in the mouse
glomerulus leads not only to glomerular endotheliosis but also to loss of glomerular
endothelial fenestrae similar to what is noted in human preeclampsia (65). Antagonists of
VEGF, used in antiangiogenic oncology trials, sometimes produce hypertension and
proteinuria in humans (66,67). Finally, higher circulating levels of the chromosome 13
encoded gene product sFlt1 in pregnancies with trisomy 13 may explain the increased risk for
preeclampsia in women who carry fetuses with trisomy 13 (68).

In addition to its role in the pathogenesis of preeclampsia, circulating concentration of sFlt1

and PlGF may have important predictive and diagnostic implications. The concentration of
sFlt1 starts to rise near the end of the second trimester in women who are destined to have
preeclampsia, a full 4 to 5 wk before clinical manifestations are first detected (64). By the
time preeclamptic manifestations are pronounced, plasma concentrations of sFlt1 are greatly
elevated, from two to four times the levels found in normal pregnancy, and are greatest in
patients with severe preeclampsia. In women who develop preeclampsia, there is a modest
but significant decrease in PlGF levels beginning as early as the first trimester. From
midpregnancy onward, the concentration of unbound PlGF in plasma falls significantly lower
at the time when sFlt1 levels are rising. Unbound PlGF is also freely filtered into the urine
and thus may also serve to predict the subsequent development of preeclampsia (69).

Endoglin (Eng) is an angiogenic receptor that is expressed on the surface of endothelial cells
and placental syncytiotrophoblasts. Eng acts as a co-receptor for TGF-, a potent
proangiogenic molecule. Eng mRNA is upregulated in the preeclamptic placenta (63).
Moreover, the extracellular region of Eng is proteolytically cleaved, and soluble Eng (sEng)
is released in excess quantities into the circulation of preeclamptic patients. In pregnant rats,
sEng exacerbates the vascular damage that is mediated by sFlt1, resulting in severe
preeclampsia-like illness, including the development of a HELLP-like syndrome and fetal
growth restriction (63). In explant cultures of trophoblasts from 5 to 8 wk of gestation, mAb
to Eng and antisense Eng oligonucleotides stimulated trophoblast outgrowth and migration
(70). TGF1 and/or TGF-3 inhibits trophoblast migration and invasion, and it seems that
Eng mediates this effect. Therefore, it has been speculated that production of sEng by the
placenta may be a compensatory mechanism to limit the effects of surface Eng. In recent
clinical studies, sEng was elevated not only during the disease but also before onset of
symptoms (71). Elevations in sEng were particularly pronouncedand, therefore, potentially
most useful for predictionin women who developed preterm preeclampsia or preeclampsia
with an infant who was small for gestational age. Although the gestational pattern of sEng
concentration tended to parallel the trajectory of the sFlt1/PlGF ratio, multivariate analysis
indicated that each was significantly associated with preeclampsia. Indeed, a composite
measure that incorporated all three angiogenic molecules (sFlt1, sEng, and PlGF) was more
strongly predictive of preeclampsia than the individual biomarkers (71) (Figure 2).

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Figure 2.

Adjusted odds ratios for preterm (A) or term (B) preeclampsia according to soluble fms-like
tyrosine kinase 1:placental growth factor (sFlt1:PlGF) ratios and soluble endoglin levels.

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Conclusion
Preeclampsia remains a common complication of pregnancy that leads to unacceptable
increases in fetal and maternal morbidity and mortality, particularly in less developed nations.
Efforts continue to understand better the pathophysiology of the clinical manifestations of the
disease. Recent findings on the role of circulating antiangiogenic factors have generated great
optimism for being able to predict better the disease and develop therapeutic advances. If
subsequent trials validate these theories, then future work should lead to renewed efforts
finally to explain and treat this complex disease.