Professional Documents
Culture Documents
Keywords
Pregnancy, placenta, cells, chemokines, Treg,
adaptive immunity
Correspondence
Ana Claudia Zenclussen, Experimental
Obstetrics and Gynecology, Medical Faculty,
Otto-von-Guericke University Magdeburg,
Gerhart-Hauptmann-Str 35, 39108,
Magdeburg, Germany.
E-mail: ana.zenclussen@med.ovgu.de
Submission January 23, 2013;
accepted January 23, 2013.
Citation
Zenclussen AC. Adaptive immune responses
during pregnancy. Am J Reprod Immunol
2013; 69: 291303
doi:10.1111/aji.12097
291
ZENCLUSSEN
actively protect them during pregnancy. This transient state is only specific to paternal antigens.11
Since this publication, much effort has been done in
understanding how paternal antigens are recognized.
The review by Peggy Petroff and collaborators extensively revises this issue, as also do Drs. Tilburgs and
Strominger. In the last years, special attention has
been paid to minor histocompatibility antigens
(mHAgs). Its role in eliciting an immune response
has been clearly highlighted in transplantation studies. It is known that they modulate graft rejection
and graft versus host disease in HLA-matched transplant recipients.13 mHAgs can be both protective and
dangerous for the transplant acceptance.14 The role
of mHAgs for pregnancy has been first suspected
after observing that parous female donors are more
likely to elicit graft-versus-host disease in transplant
recipients when compared to either non-parous or
male donors (reviewed in ref.15). In mice, presentation of fetal antigens to maternal T cells can begin,
as already discussed, as early as at copulation
(reviewed by Sarah Robertson). In women, T cells
specific for mHAgs were described (reviewed in
Lindscheids review). These cells can be still present
up to 20 years after birth. The current hypothesis is
that these cells are of tolerogenic or suppressive nature, which at pregnancy allows the survival of the
fetus. Whether at later stages their persistence is
beneficial or rather detrimental because of the possibility of eliciting autoimmune responses is a matter
of debate.
Where it all begins: antigens present in the
seminal fluid activate the adaptive immune
response that tolerates the fetus
After the emergence of the new concept that postulates the existence and the need of a protective
adaptive immune response necessary to protect the
fetus,11 investigators concentrated on the cells
responsible for this state of active tolerance. It is of
general consensus that Treg mediate in large part
the state of active immune tolerance that prevent
maternal lymphocytes to cause cytotoxic damage to
the fetus.1621 It was first wrongly believed that the
expansion of this unique cell subpopulation was driven by pregnancy itself, for example, hormones, and
not by alloantigens.16 This could, however, not
explain why Treg are necessary before implantation17,22 and the fact that Treg from non-pregnant
mice or from pregnant females carrying third party
American Journal of Reproductive Immunology 69 (2013) 291303
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PD-1 but not TGF-b or CTLA-4 are relevant for pregnancy.23,44 In humans, however, CTLA-4 expressed
in Treg cells up-regulates IDO expression on decidual
and peripheral blood DC and monocytes by the
induction of IFN-c production.45 Decidual Treg seem
to work by cellcell contact46 and suppression of Tcell responses.47 Dr. Saito extensively revises the
type of Treg present during pregnancy and discusses
the importance of correctly identifying their phenotypes for future clinical applications.
The identification of Th17 cells has improved our
understanding of the cellular regulation during
pregnancy.48 IL-17 acts mainly against extracellular
bacteria or fungal pathogens. It seems that an imbalance of Th17/Treg proportion is associated with
recurrent pregnancy loss and pre-eclampsia.48,49
Tolerance from the fetus toward the mother
In the last years, we have learned more and more
how Treg protect the fetus from immunological
attack by the maternal immune system, but it was
not until recently that it became clear that the fetal
immune system is also active and could potentially
danger the mother.9,50 This does not happen because
the fetus actively generates tolerance to maternal
antigens, mostly mediated by fetal Treg.9 As discussed in Dr. Burts review, Treg are abundant in
the developing fetus. In fact, the frequency of Treg
in fetal tissues is much higher than the frequency of
Treg in any tissue compared with any other time in
development (Dr. Burt). Maternal cells were found
to be present in fetal lymph nodes and in cord
blood.9 In vitro, fetal immune cells were rather suppresive against maternal antigens as compared to
responses against unrelated alloantigens.9 This suggested that fetal immune cells are already primed
against maternal antigens. The existence of a normal
immune response toward maternal antigens upon
depletion of CD25+ fraction in the fetal T cells
revealed the existence of fetal Treg that are educated
to react toward maternal antigens.9 Although the
nature of fetal Treg is still a matter of debate, it is
tempting to speculate that fetal Treg are derived
from conventional T cells that become functional
suppressor cells, thus Treg, upon antigen stimulation
(Dr. Burt). It is a challenge for the near future to
understand how and at which time point of pregnancy this system comprised mostly of cells that are
programmed to suppress convert into a system with
a majority of cells with fully potential to elicit a nor-
294
by immune polypeptides that also contribute to tolerance maintenance. Regulated on activation, normal T
cell expressed and secreted (RANTES) can suppress
maternal allogenic immune responses to paternal
antigens in mixed lymphocyte cultures.63 RANTES is
produced by the peri-implantation endometrium, by
human endometrial T cells and by trophoblasts
(reviewed by Perez Leiros and Ramhorst). This molecule can additionally induce apoptosis of potentially
harmful maternal CD3+ cells and increases the frequency of Treg.64 Another molecule in the focus of
the review by Perez Leiros is vasoactive intestinal
peptide (VIP), whose anti-inflammatory and tolerogenic effects were already known.65 It is now known
that VIP levels rise at the fetalmaternal interface at
early gestation peaking at placentation begin.66 Its
role in embryogenesis was revealed after observing
that its blockade during midgestation ends in
induced growth retardation and microcephaly.66 This
is further confirmed in VIP / fetuses that highlights
the role of maternal VIP for early neural development.67 Current data position VIP as an important
immunomodulatory molecule as it can increase the
frequency of Treg and LIF at implantation sites in
mice68 and supports a tolerogenic macrophage phenotype.64 It seems that both hormones and polypeptides are involved in the recruitment of immune
cells into the fetalmaternal interface and in the
generation of a tolerogenic immune response toward
the fetus.
Accumulating evidence points galectins, a family of
endogenous glycan-binding proteins as an important
regulator of pregnancy, and this is discussed in detail
in the Review by Drs. Blidner and Rabinovich within
this Special Issue. It has been shown that the interaction between endogenous glycan-binding proteins
and glycosylated receptors is of crucial importance for
immunological homeostasis (reviewed in ref.69).
Within these processes, galectins emerge as important
regulators in several physiological and pathological
processes (reviewed in Blidner and Rabinovich). In
particular, galectins were lately reported as regulators
of feto-maternal tolerance. Galectin-1, expressed in T
and B cells, inflammatory macrophages tolerogenic
DCs, uterine NK cells, uterine MCs, and Treg, gained
much attention over the last 5 years in the reproduction research field. Gal-1 is known to define autoimmunity,70 inflammatory neurodegeneration,71
cardiac inflammation,72 and tumor escape.73 Lgals1 / mice, lacking Gal-1 expression, show increased
Th1 and Th17 responses, more immunogenic DCs,
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296
hypertension.107 As for the mechanisms of AT1-AAinduced pathology, it could be demonstrated that IgG
isolated from pre-eclamptic women (a fraction containing AT1-AA) activates the complement system in
kidney and placenta when administered to mice.108
Besides, animals exposed to AT1-AA presented preeclampatic symptoms109 as well as elevated levels of
soluble fms-related tyrosine kinase (sFlt-1) and soluble endoglin (sEng),110 which directly links AT1-AA
to two well-characterized PE markers. Federico Jensen and colleagues recently described the subtype of
B cells, which is able to secrete AT1-AA in PE
patients, the B1aB cells. These cells produce without
antigenic stimulus antibodies that are polyreactive
and can turn autoreactive depending on the conditions. hCG, reported to be elevated in PE patients,
was identified as one factor modulating the AT1-AA
production by B1aB cells.111 The application of an
antibody that reduces the B-cell population could
restore blood pressure and endothelin production in
a rat model for PE.112
Methodological advances in studying immune
cells at the fetal-maternal interface
The study of immune cells at the fetalmaternal
interface fascinated immunologists many years ago
already. The first methods employed to study cells
and their distribution were based on their immunohistochemical staining in fixed samples. This allowed
understanding which immune cells were present at
the fetalmaternal interface and whether there were
differences between normal and pathological specimens. Later, with the description of techniques to
isolate and keep in culture different immune cells,
we could learn more about their function. The use
of flow cytometry allowed and allows a better characterization of their phenotype. With growing
knowledge of the role of immune cells at the fetal
maternal interface, it became clear that the interaction of cells and not one single cell was responsible
for physiological or pathological processes. This led
to the establishment of co-culture systems and system employing chambers to understand both the
interaction between cells and the migration of cells
to gradients or other cell types. Seminal work on
this field has been performed by the group of Dr.
Mor who could show how trophoblast cells secrete
molecules and educate the immune system to best
tolerate the conceptus.113 The more we learned from
the cells we studied, the more became clear that
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these cells may act differently in vivo as isolation protocols and mostly their maintenance in culture
change their phenotype and therefore most probably
their functionality as well. The review by Drs. Olivieri and Tadokoro deals with this interesting topic.
One of first experiments to visualize processes in vivo
at isolated organs was described by Ruttner et al. in
a superfusion chamber at which the microvascular
flow could be observed.114 Later, a skin transplanted
uterus was in vivo analyzed, and the effects of several agents were observed mostly for endometriosis
research.115 Dr. Tadokoro recently described for the
first time the in vivo imagining of immune cells at
the uterus and the placenta by using a 2-photon
microscopy.116,117 This amazing method will help us
understand how cells behave in their natural environment. With this method, Dr. Tadokoro described
that DCs accumulate at the estrus phase of the estrus
APC
Paternal antigens
(seminal vesicle)
Initial contact and antigen
presentation
CD8
B cells
Teff
uMCs
Antibodies
Macrophages
uNKs
DCs
Fetal Treg
Th17
Maternal Treg
TGF-beta
Tolerogenic DCs
B cells
uNKs
uMCs
Treg
Gal-1
Maternal Treg
Vaginal lumen
Secondary antigen
presentation
hCG
Maternal
Treg
Fetal Treg
DCs
CD8 cells
hCG
HO-1
RANTES
PSG-1
Teff
Treg
Tolerogenic DCs
Th17
Fetal Treg
Peripheral blood
Feto-maternal interface
Fig. 1 This hypothetical scenario depicts the current knowledge about the pathways involved in recognition and tolerance of the foreign fetus as
discussed throughout this Special Issue. Paternal antigens are presented to the maternal immune system in the vaginal lumen after the encounter
of maternal/paternal immune cells with antigens present in the seminal fluid. The seminal fluid contains also substances that promote the
conversion of dendritic cells (DCs) in tolerogenic ones. This promotes the conversion and expansion of regulatory T cells (Treg). The continuous
release of paternal antigens to the circulation allows that Treg continue emerging and expanding throughout pregnancy in, for example, the paraaortic lymph nodes. In peripheral blood, Treg are likely involved in the suppression of maternal effector T cells as, for example, Th17 cells that
could be harmful to fetal antigens present here as well as in several maternal tissues. In a normal pregnancy, B cells secrete antibodies that, once
at the feto-maternal interface, protect paternal antigens present in the trophoblast. Treg migrate to the fetalmaternal interface via human
chorionic gonadotropin(hCG). At the fetomaternal interface, a broad spectrum of molecules produced or secreted by the trophoblast itself like
hCG, HO-1, RANTES, and PSG modulate the phenotype of function of immune cells, that is, DCs, that turn or stay immature and thus tolerogenic.
Additionally, molecules secreted by cells of the innate immune system like Gal-1 secreted by uNKs and uMCs can positively influence the
physiology of the trophoblast while helping maternal T cells to become or stay tolerant toward the fetus. The presence of CD8+ cells at the feto
maternal interface is well documented, but their function is still under investigation. This overview does not pretend to cover all information
available but the research topics covered within this Issue.
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