Hypoxia inducible factor-1α (HIF-1α) stimulates expression of genes associated with angiogenesis and is associated with poor outcomes in ovarian and other cancers. In normoxia, HIF-1α is ubiquitinated and degraded through the E3 ubiquitin ligase, von Hippel-Lindau; however, little is known about the regulation of HIF-1α in hypoxic conditions. FBW7 is an E3 ubiquitin ligase that recognizes proteins phosphorylated by glycogen synthase kinase 3β (GSK3β) and targets them for destruction. This study used an ovarian cancer cell model to test the hypothesis that HIF-1α phosphorylation by GSK3β in hypoxia leads to interaction with FBW7 and ubiquitin-dependent degradation. Expression of constitutively active GSK3β reduced HIF-1α protein and transcriptional activity and increased ubiquitination of HIF-1α in hypoxia, whereas pharmacologic inhibition of GSK3 or expression of siGSK3β promoted HIF-1α stabilization and activity. A mechanism through FBW7 was supported by the observed decrease in HIF-1α stabilization when FBW7 was overexpressed and both the elevation of HIF-1α levels and decrease in ubiquitinated HIF-1α when FBW7 was suppressed. Furthermore, HIF-1α associated with FBW7γ by co-immunoprecipitation, and the interaction was weakened by inhibition of GSK3 or mutation of GSK3β phosphorylation sites. The relevance of this pathway to angiogenic signaling was supported by the finding that endothelial cell tube maturation was increased by conditioned media from hypoxic SK-OV-3 cell lines expressing suppressed GSK3β or FBW7. These data introduce a new mechanism for regulation of HIF-1α during hypoxia that utilizes phosphorylation to target HIF-1α for ubiquitin-dependent degradation through FBW7 and may identify new targets in the regulation of angiogenesis.

Objective Pregnancy induces rapid, progressive and substantial changes to the cardiovascular system. The low recurrence risk of preeclampsia, despite familial predisposition, suggests an adaptation associated with pregnancy that attenuates risk for subsequent preeclampsia. We aimed to evaluate the persistent effect of pregnancy on maternal cardiovascular physiology. Study Design Forty-five healthy nulliparous women underwent baseline cardiovascular assessment preconception and repeated an average of 30 months later. After baseline evaluation, 17 women (Preg) conceived singleton pregnancies and all delivered at term. The remaining 28 women comprised the non-pregnant control group (NP). We measured mean arterial blood pressure (MAP), cardiac output (CO), plasma volume (PV), pulse wave velocity (PWV), uterine blood flow (UBF), and flow-mediated vasodilation (FMD) at each visit. Results There was a significant decrease in mean arterial pressure from the prepregnancy visit to postpartum in women with an interval pregnancy (prepregnancy: 85.3±1.8, postpartum: 80.5±1.8 mm Hg), with no change in NP subjects (visit 1: 80.3±1.4, visit 2: 82.8±1.4 mm Hg), (p = .002). Pulse wave velocity was significantly decreased in women with an interval pregnancy (prepregnancy: 2.73±0.05, postpartum: 2.49±0.05 m/s), as compared to those without an interval pregnancy (visit 1: 2.56±0.04, visit 2: 2.50±0.04 m/s), (p = .005). We did not observe a residual effect of pregnancy on cardiac output, plasma volume, uterine blood flow or flow-mediated vasodilation. Conclusion Our observations of decreased mean arterial pressure and reduced arterial stiffness following pregnancy suggest a significant favorable effect of pregnancy on maternal cardiovascular remodeling. These findings may represent a mechanism by which preeclampsia risk is reduced in subsequent pregnancies.

Objective To evaluate vascular dysfunction using both physiologic measures and biochemical markers, longitudinally, prior to and during pregnancy, in nulliparous women who had uncomplicated pregnancies compared to those who developed complicated hypertension during pregnancy. Methods Twenty healthy nulliparous women were studied during the follicular phase and in early (EP) and late (LP) pregnancy. All had singleton conceptions and delivered at term, seventeen with uncomplicated pregnancies (NP) and three who developed complicated hypertension (HP) after the LP evaluation. We compared prepregnancy, EP and LP pulse wave velocity (PWV) and soluble vascular cell adhesion molecule (sVCAM-1) between the NP and HP groups. PWV was measured using ultrasound and simultaneous echocardiogram tracing then calculated as the estimated distance divided by interval between EKG r-wave peak and peak brachial artery flow. SVCAM-1 was measured using a commercially available kit. Data are means ± SE, significance accepted as p < 0.05. Results The NP group had significantly lower prepregnant PWV (NP: 2.66 ± 0.06 m/s, HP: 3.00 ± 0.04, p=.02), but PWV was not different at the EP or LP time points. SVCAM-1 was significantly lower prior to pregnancy and during EP and LP in the NP group (Prepregnancy: NP: 712 ± 32 ng/mL, HP: 1058 ± 107, p < .001; EP: NP: 695 ± 31 ng/mL, HP: 924 ± 52, p = .004; LP: NP: 663 ± 25 ng/mL, HP: 946 ± 36, p < .001). Conclusions PWV and sVCAM-1 may be important prepregnancy discriminators useful in assessing risk for preeclampsia prior to pregnancy.

Stillbirth remains a global health challenge which is greatly affected by social and economic inequality, particularly the availability and quality of maternity care. The International Stillbirth Alliance (ISA) exists to raise awareness of stillbirth and to promote global collaboration in the prevention of stillbirth and provision of appropriate care for parents whose baby is stillborn. The focus of this ISA conference was to share experiences to improve bereavement support and clinical care. These issues, relevant throughout the globe, are not discrete but closely interrelated, with both similarities and differences depending on the specific country and cultural context. Counting stillbirths and understanding the causes of stillbirth are essential not only for providing optimal care and support to parents whose babies die, but also for reducing the future burden of stillbirth. This summary highlights novel work from obstetricians, midwives, psychologists, parents and peer support organizations that was presented at the ISA meeting. It covers topics including the bereavement process, peer support for parents, support and training for staff, evidence for clinical care, and the need for accurate data on stillbirths and perinatal audits. Representatives from the maternity services of the region presented their outcome data and shared their experiences of clinical and bereavement care. Data and developments in practice within stillbirth and bereavement care must be widely disseminated and acted upon by those responsible for maternity care provision, both to prevent stillbirths and to provide high-quality care when they do occur.

We examined the relationship between prepregnant pulse pressure (PP), mean arterial pressure (MAP), cardiac output (CO)/PP, a measure of arterial compliance, and development of complicated hypertension during pregnancy (CH) with the goal of identifying a potential predictor of CH. Twenty nulliparous subjects were studied before pregnancy; seventeen had normal pregnancies (CTL) and three CH. Blood pressure monitoring was performed using tonometry. CO was determined by Doppler echocardiograph. Data are expressed as mean±SD. Prepregnant PP was significantly higher in CH subjects (CH: 58.3±6.3, CTL: 46.2±1.7 mmHg; p = 0.02). CO/PP was significantly lower in CH subjects (CH: 6.9 ± 1.8, CTL: 10.6 ± 2.8; p = 0.04). MAP was not significantly different. Increased PP before pregnancy may suggest increased risk for CH. With accurate prediction of CH before pregnancy initiation of preventative measures could begin earlier, either prior to, or in early pregnancy, potentially increasing preventative efficacy and decreasing CH.

We evaluated the relationship between prepregnancy and early pregnancy uterine blood flow (UBF) and resistance index (RI). Nineteen nulliparous subjects were studied during cycle day 8 ± 4, and early pregnancy (13.4 ± 1.6 wks). Color Doppler ultrasound of both uterine arteries and maternal heart was performed to calculate uterine RI, volumetric UBF and cardiac output (CO), respectively. We observed a strong negative association of uterine RI with prepregnancy UBF (r = −0.82, p < 0.001) that weakened, but remained significant in early pregnancy (r = − 0.48, p = 0.04). Prepregnancy uterine index (UBF/CO) was significantly associated with early pregnancy uterine index; r = 0.48, p = 0.04). There was also a trend associating prepregnancy and early pregnancy volumetric UBF (r = 0.44, p = 0.068). Prepregnancy UBF may be a determinant of early pregnancy UBF and UBF may have independent value as a predictor of adverse pregnancy outcome.

Interprofessional care teams are the backbone of intensive care units (ICUs) where severity of illness is high and care requires varied skills and experience. Despite this care model, longitudinal educational programmes for such workplace teams rarely include all professions. In this article, we report findings on the initial assessment and evaluation of an ongoing, longitudinal simulation-based curriculum for interprofessional workplace critical care teams. The study had two independent components, quantitative learner assessment and qualitative curricular evaluation. To assess curriculum effectiveness at meeting learning objectives, participant-reported key learning points identified using a self-assessment tool administered immediately following curricular participation were mapped to session learning objectives. To evaluate the curriculum, we conducted a qualitative study using a phenomenology approach involving purposeful sampling of nine curricular participants undergoing recorded semi-structured interviews. Verbatim transcripts were reviewed by two independent readers to derive themes further subdivided into successes and barriers. Learner self-assessment demonstrated that the majority of learners, across all professions, achieved at least one intended learning objective with senior learners more likely to report team-based objectives and junior learners more likely to report knowledge/practice objectives. Successes identified by curricular evaluation included authentic critical care curricular content, safe learning environment, and team comradery from shared experience. Barriers included unfamiliarity with the simulation environment and clinical coverage for curricular participation. This study suggests that a sustainable interprofessional curriculum for workplace ICU critical care teams can achieve the desired educational impact and effectively deliver authentic simulated work experiences if barriers to educational engagement and participation can be overcome.

Hale SA, Weger L, Mandala M, Osol G. Reduced NO signaling during pregnancy attenuates outward uterine artery remodeling by altering MMP expression and collagen and elastin deposition. Am J Physiol Heart Circ Physiol 301: H1266 -H1275, 2011. First published August 19, 2011 doi:10.1152/ajpheart.00519.2011.-Recent findings indicate that endothelial nitric oxide (NO) plays a key role in uterine artery outward circumferential remodeling during pregnancy. Although the underlying mechanisms are not known, they likely involve matrix metalloproteinases (MMPs). The goal of this study was to examine the linkage among NO inhibition, expansive remodeling, and MMP expression within the uterine vascular wall. Adult female rats were treated with N G -nitro-L-arginine methyl ester [L-NAME (LPLN)] beginning on day 10 of pregnancy and until death at day 20 and compared with age-matched controls [late pregnant (LP)]. Mean arterial pressure of LPLN rats was significantly higher than controls. LPLN fetal and placental weights were significantly reduced compared with controls. Main uterine arteries (mUA) were collected to determine dimensional properties (lumen area and wall thickness), collagen and elastin content, and levels of endothelial nitric oxide synthase (eNOS) and MMP expression. Circumferential remodeling was attenuated, as evidenced by significantly smaller lumen diameters. eNOS RNA and protein were significantly (Ͼ90%) decreased in the LPLN mUA compared with LP. Collagen and elastin contents were significantly increased in LPLN rats by ϳ10 and 25%, respectively, compared with LP (P Ͻ 0.05). Both MMP-2 and tissue inhibitors of metalloproteinase-2 as assessed by immunofluorescence were lower in the endothelium (reduction of 60%) and adventitia (reduction of 50%) of LPLN compared with LP mUA. Membrane bound MMP-1 (MT1-MMP) as assessed by immunoblot was significantly decreased in LPLN. These data suggest a novel contribution of MMPs to gestational uterine vascular remodeling and substantiate the linkage between NO signaling and gestational remodeling of the uterine circulation via altered MMP, TIMP-2, and MT1-MMP expression and activity. matrix metalloproteinase; extracellular matrix; hypertension; pregnancy; nitric oxide DURING PREGNANCY, THE UTERINE vasculature undergoes significant expansive remodeling to accommodate the dramatic increase in uteroplacental blood flow that is requisite for normal pregnancy outcome. Studies from our and other laboratories (40,41,44,46,50,61) have established that nitric oxide (NO) is a key molecule involved in vascular remodeling during pregnancy and that expression of endothelial nitric oxide synthase (eNOS) is increased during pregnancy, leading to increased synthesis and release of NO from the endothelium.The importance of NO and NO signaling during pregnancy is underscored by the vascular and reproductive implications evident in mouse knockouts for endothelial NO synthase and in rats treated with the NO inhibitor N G -nitro-L-arginine methyl ester (L-NAME) during pregnancy (50, 64). Tre...