The perinatal implications of angiogenic factors

PURPOSE OF REVIEW: To summarize recent findings relating maternal circulating levels of proteins associated with angiogenesis and the outcome of pregnancy. RECENT FINDINGS: In preeclampsia, levels of placental growth factor (PlGF) become abnormal prior to soluble fms-like tyrosine kinase 1 (sFlt-1). Longitudinal measurement of changes in protein level are better predictors of disease than measurement at a single time point in pregnancy and also appear to be more strongly associated with early-onset disease. The levels of angiogenic proteins provide additional predictive information over abnormal uteroplacental Doppler. The preeclampsia-like phenotype of rats overexpressing sFlt-1 can be ameliorated by administration of a protein which binds and inactivates sFlt-1. Animal models demonstrate that uteroplacental ischemia leads to elevated maternal serum levels of sFlt-1 and decreased PlGF. Similarly, studies of human trophoblast cells demonstrate that hypoxia stimulates release of sFlt-1. Autocrine vascular endothelial growth factor (VEGF) has a trophic effect on the endothelium, distinct from its control of angiogenesis. By blocking this effect, elevated sFlt-1 could lead to systemic endothelial cell dysfunction, one of the key features of preeclampsia. Low levels of PlGF are associated with intrauterine growth restriction. However, in the first trimester of pregnancy, high levels of sFlt-1 were associated with reduced rates of growth restriction, preterm birth and stillbirth. SUMMARY: Regulators of the VEGF system may have a causal role in the sequence of events leading to preeclampsia and may be targets for novel therapies. However, better knowledge of the biology is required prior to clinical trials of interventions.