Extracellular Vesicles and Preeclampsia: From Pathogenesis to Diagnostics and Therapeutics

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Preeclampsia is a major contributor to premature birth. How might extracellular vesicles play a role in pathogenesis, prediction, and treatment?

What is preeclampsia? And what causes it?

Preeclampsia is a hypertensive and inflammatory condition of pregnancy which carries an increased risk of thrombosis and subsequent organ failure. Preeclampsia is also dangerous for the fetus, carrying an increased risk of growth restriction and stillbirth. Preeclampsia occurs in around to 4.6% of pregnancies worldwide1, with over 70,000 of these pregnancies resulting in death for the pregnant woman/person and half a million of them resulting in infant deaths each year. If left untreated, preeclampsia can develop into eclampsia, which is an even more dangerous disorder than preeclampsia. Despite the obvious need for therapeutics in this area, there are currently no treatments beyond symptom management. The only cure for preeclampsia is the delivery of the baby or, more precisely, the delivery of the placenta. This often means iatrogenic preterm delivery, for which preeclampsia carries an increased risk (adjusted odds ratio 5.30).2  

The pathogenesis of preeclampsia is not fully elucidated but is thought to involve several potentially concurrent and intertwined pathogenic routes. The first is the inadequate remodelling of the uterine spiral arteries. These tightly coiled arteries supply blood to the placenta and must be remodelled by extravillous trophoblasts and immune cells into wide, low-pressure vessels (Figure 1). Failure of this process is associated with placental damage and hypoxia. Furthermore, the placenta has been shown to release anti-angiogenic factors such as the soluble vascular endothelial growth factor receptor 1 (sFlt-1), and a proinflammatory environment prevails.  

Figure 1. Schematic representation of spiral artery remodelling. Extravillous trophoblast cells (EVTs) migrate out from the tops of anchoring placental villi and invade into the decidual spiral arteries. Here they work with immune cells to remodel the arteries into wide, high conductance, low pressure vessels. EVTs line the lumen of remodelled vessels, replacing the endothelium. In preeclampsia this remodelling is incomplete and does not reach the myometrium, leaving high pressure, low conductance vessels such as the spiral artery depicted on the left side of the image.  

The search for biomarkers

A biomarker does exist for preeclampsia and is used widely in clinical practice. The ratio between sFlt-1 and placental growth factor (PlGF) has been shown to distinguish well between preeclamptic and normal pregnancies.3,4 However, in practice the sFlt-1:PlGF ratio is utilised only in the third trimester, and has been shown to be more effective at predicting short term outcomes.5 This late predictive window is despite preeclampsia having its roots much earlier in pregnancy, which would suggest that earlier prediction might be possible. This is where researchers have turned to extracellular vesicles (EVs), which are released from the placenta and from all cells, possibly allowing for peripheral sampling to give a window into early preeclampsia pathogenesis.

Indeed, a study by McElrath et al. (2020) identified a panel of altered proteins within later first trimester circulating EVs that differed between those pregnancies which went on to develop preeclampsia and those which did not.6 Interestingly, the analysis in this study identified two clusters of preeclamptic patients long before diagnosis. The first cluster was enriched for alterations in proteins involved in coagulation and platelet degranulation and a second cluster enriched for dysregulated immune responses (e.g., complement proteins). This second cluster was associated with a more severe preeclamptic phenotype, with significantly earlier gestational age at delivery and higher proteinuria, and a trend towards worsened hypertension.6 This gives hope that not only could an EV-based biomarker predict preeclampsia in early pregnancy, but that severity may also be predicted, guiding clinical management.  

NX Prenatal is driving forward with this research, leading in the development of an EV-based biomarker test to predict preeclampsia in early pregnancy. Brian Brohman, CEO of NX Prenatal, reflects on NX Prenatal’s work to date and its potential implications:

"Our studies to date suggest that first trimester risk stratification and sub-typing are feasible with EV-derived multiplexed protein panels from maternal plasma. The potential impact of this approach for the future optimisation and development of prophylactic and therapeutic interventions for preeclampsia compels us to actively pursue commercialisation of these tests. We also now understand that EVs are providing us a snapshot of important molecular crosstalk occurring at the utero-placental interface, enabling further breakthroughs in conditions such as placenta accreta."

Could EVs be involved in the pathogenesis of preeclampsia?

EVs have been shown to hold power in the prediction and stratification of preeclampsia, which begs the question: what roles do EVs play in pathogenesis? This is particularly of interest, given these EVs were found to contain inflammatory proteins.6  

One route of investigation can be found by considering that placental removal is an effective treatment for preeclampsia. It follows, therefore, that factors promoting disease are released from preeclamptic placentas. Indeed, there is evidence that syncytiotrophoblast EVs from preeclamptic placentas cause endothelial damage7,8, partly via the modulation of nitric oxide synthase. Placental EVs in preeclampsia reduce the availability of nitric oxide (a key vasodilator and antioxidant) for endothelial cells by carrying less nitric oxide synthase compared to EVs from healthy placentas, and by carrying increased miR-155 which reduces expression of endothelial nitric oxide synthase.8,9  

In addition to potentially decreasing nitric oxide availability for endothelial cells, syncytiotrophoblast EVs from preeclamptic placentas also have a prothrombotic effect, inducing platelet clotting.10 Given that there are more syncytiotrophoblast EVs released in preeclampsia11,12, especially in early-onset preeclampsia13, the impact of placental-derived EVs in preeclampsia could be a significant contributor to pathogenesis.  

Are EV therapeutics a potential treatment for preeclampsia?

If EVs contribute to preeclampsia pathogenesis, could other EVs be harnessed for treatment? One way in which EVs could be used therapeutically in preeclampsia is to deliver beneficial molecules; for example, the delivery of the long non-coding RNA H19. Preeclamptic placentas have higher levels of the miRNA let-7c which downregulates FOXO1, potentially inhibiting extravillous trophoblast migration (See Figure 1 for the importance of this).14 H19 binds to let-7c, preventing its binding to FOXO1. Mesenchymal stem cell EVs containing H19 improved migration and invasion of an extravillous trophoblast model cell line, suggesting that H19 could be a promising therapeutic.14 Some EVs in their native state are also beneficial to trophoblast migration and proliferation, such as mesenchymal stem cells from the chorion and umbilical cord, and those from endometrial cells.15-17 Human umbilical cord mesenchymal stem cell EVs also increased endothelial cell tube formation in vitro by modulating vascular endothelial growth factor signalling, potentially combatting some of the negative impacts of preeclampsia on endothelia.18-20 These studies provide hope that EV based treatments for preeclampsia could prove fruitful.  

Clinically relevant EVs in pregnancy: A pathway worth pursuing

As research into EV biomarkers and therapeutics for preterm birth and preeclampsia continues to grow, there are ongoing focused efforts to pursue relevant tests, for example by NX Prenatal who have made significant progress in their biomarker discovery and validation efforts. Such developments are not without challenges, given the cause of preterm birth is largely unknown and is likely to be multifactorial, as are the causes of major risk factors such as preeclampsia. This is likely because both are endpoints which may be arrived at by more than one route of pathogenesis. However, it is a pathway worth pursuing, with potential significant benefits for many. For successful biomarker discovery and therapeutic success then, stratification of patient populations is required to ensure that results are not clouded by varying routes of pathogenesis.21 Therefore, identifying tools to adequately stratify patients for this purpose is likely key to advancing this research to clinically meaningful endpoints.

Learn more about Extracellular Vesicles as Predictors of Premature Birth


  1. Abalos, E., Cuesta, C., Grosso, A. L., Chou, D. & Say, L. Global and regional estimates of preeclampsia and eclampsia: a systematic review. European Journal of Obstetrics & Gynecology and Reproductive Biology 170, 1-7 (2013). https://doi.org:10.1016/j.ejogrb.2013.05.005
  2. Davies, E. L., Bell, J. S. & Bhattacharya, S. Preeclampsia and preterm delivery: A population-based case-control study. Hypertension in Pregnancy 35, 510-519 (2016). https://doi.org:10.1080/10641955.2016.1190846
  3. Nikuei, P. et al. Diagnostic accuracy of sFlt1/PlGF ratio as a marker for preeclampsia. Bmc Pregnancy and Childbirth 20 (2020). https://doi.org:10.1186/s12884-020-2744-2
  4. Perales, A. et al. sFlt-1/PlGF for prediction of early-onset pre-eclampsia: STEPS (Study of Early Pre-eclampsia in Spain). Ultrasound in Obstetrics & Gynecology 50, 373-382 (2017). https://doi.org:10.1002/uog.17373
  5. Dathan-Stumpf, A., Rieger, A., Verlohren, S., Wolf, C. & Stepan, H. sFlt-1/PlGF ratio for prediction of preeclampsia in clinical routine: A pragmatic real-world analysis of healthcare resource utilisation. PLoS One 17, e0263443 (2022). https://doi.org:10.1371/journal.pone.0263443
  6. McElrath, T. F. et al. Late first trimester circulating microparticle proteins predict the risk of preeclampsia < 35 weeks and suggest phenotypic differences among affected cases. Sci Rep 10, 17353 (2020). https://doi.org:10.1038/s41598-020-74078-w
  7. Cronqvist, T. et al. Syncytiotrophoblast derived extracellular vesicles transfer functional placental miRNAs to primary human endothelial cells. Sci Rep 7, 4558 (2017). https://doi.org:10.1038/s41598-017-04468-0
  8. Shen, L. et al. Placenta‑associated serum exosomal miR‑155 derived from patients with preeclampsia inhibits eNOS expression in human umbilical vein endothelial cells. Int J Mol Med 41, 1731-1739 (2018). https://doi.org:10.3892/ijmm.2018.3367
  9. Motta-Mejia, C. et al. Placental Vesicles Carry Active Endothelial Nitric Oxide Synthase and Their Activity is Reduced in Preeclampsia. Hypertension 70, 372-381 (2017). https://doi.org:10.1161/HYPERTENSIONAHA.117.09321
  10. Tannetta, D. S. et al. Syncytiotrophoblast Extracellular Vesicles from Pre-Eclampsia Placentas Differentially Affect Platelet Function. PLoS One 10, e0142538 (2015). https://doi.org:10.1371/journal.pone.0142538
  11. Germain, S. J., Sacks, G. P., Soorana, S. R., Sargent, I. L. & Redman, C. W. Systemic inflammatory priming in normal pregnancy and preeclampsia: The role of circulating syncytiotrophoblast microparticles. Journal of Immunology 178, 5949-5956 (2007). https://doi.org:10.4049/jimmunol.178.9.5949
  12. Chen, Y. et al. Association of placenta-derived extracellular vesicles with pre-eclampsia and associated hypercoagulability: a clinical observational study. Bjog-an International Journal of Obstetrics and Gynaecology 128, 1037-1046 (2021). https://doi.org:10.1111/1471-0528.16552
  13. Knight, M., Redman, C. W., Linton, E. A. & Sargent, I. L. Shedding of syncytiotrophoblast microvilli into the maternal circulation in pre-eclamptic pregnancies. Br J Obstet Gynaecol 105, 632-640 (1998). https://doi.org:10.1111/j.1471-0528.1998.tb10178.x
  14. Chen, Y. et al. MSC-Secreted Exosomal H19 Promotes Trophoblast Cell Invasion and Migration by Downregulating let-7b and Upregulating FOXO1. Molecular Therapy-Nucleic Acids 19, 1237-1249 (2020). https://doi.org:10.1016/j.omtn.2019.11.031
  15. Wang, D., Na, Q., Song, G. Y. & Wang, L. Human umbilical cord mesenchymal stem cell-derived exosome-mediated transfer of microRNA-133b boosts trophoblast cell proliferation, migration and invasion in preeclampsia by restricting SGK1. Cell Cycle 19, 1869-1883 (2020). https://doi.org:10.1080/15384101.2020.1769394
  16. Tan, Q. et al. Endometrial cell-derived small extracellular vesicle miR-100-5p promotes functions of trophoblast during embryo implantation. Molecular Therapy-Nucleic Acids 23, 217-231 (2021). https://doi.org:10.1016/j.omtn.2020.10.043
  17. Li, Y. et al. Chorionic villus-derived mesenchymal stem cells induce E3 ligase TRIM72 expression and regulate cell behaviors through ubiquitination of p53 in trophoblasts. FASEB J 35, e22005 (2021). https://doi.org:10.1096/fj.202100801R
  18. Zhu, Y. et al. Extracellular vesicles derived from human adipose-derived stem cells promote the exogenous angiogenesis of fat grafts via the let-7/AGO1/VEGF signalling pathway. Sci Rep 10, 5313 (2020). https://doi.org:10.1038/s41598-020-62140-6
  19. Wei, Q. et al. Extracellular Vesicles from Human Umbilical Cord Mesenchymal Stem Cells Facilitate Diabetic Wound Healing Through MiR-17-5p-mediated Enhancement of Angiogenesis. Stem Cell Rev Rep 18, 1025-1040 (2022). https://doi.org:10.1007/s12015-021-10176-0
  20. Chinnici, C. M. et al. Extracellular Vesicle-Derived microRNAs of Human Wharton's Jelly Mesenchymal Stromal Cells May Activate Endogenous VEGF-A to Promote Angiogenesis. Int J Mol Sci 22 (2021). https://doi.org:10.3390/ijms22042045
  21. Aplin, J. D., Myers, J. E., Timms, K. & Westwood, M. Tracking placental development in health and disease. Nat Rev Endocrinol 16, 479-494 (2020). https://doi.org:10.1038/s41574-020-0372-6

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