The potential role of the E SRRG pathway in placental dysfunction

in Reproduction
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  • 1 Maternal and Fetal Health Research Centre, University of Manchester, St Mary’s Hospital, Manchester, UK
  • 2 Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
  • 3 Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
  • 4 St Mary’s Hospital, Manchester Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK

Correspondence should be addressed to Z Zou; Email: zhiyong.zou@postgrad.manchester.ac.uk

Normal placental development and function is of key importance to fetal growth. Conversely aberrations of placental structure and function are evident in pregnancy complications including fetal growth restriction (FGR) and preeclampsia. Although trophoblast turnover and function is altered in these conditions, their underlying aetiologies and pathophysiology remains unclear, which hampers development of therapeutic interventions. Here we review evidence that supports a role for estrogen related receptor-gamma (ESRRG) in the development of placental dysfunction in FGR and preeclampsia. This relationship deserves particular consideration because ESRRG is highly expressed in normal placenta, is reduced in FGR and preeclampsia and its expression is altered by hypoxia, which is thought to result from deficient placentation seen in FGR and preeclampsia. Several studies have also found microRNA (miRNA) or other potential upstream regulators of ESRRG negatively influence trophoblast function which could contribute to placental dysfunction seen in FGR and preeclampsia. Interestingly, miRNAs regulate ESRRG expression in human trophoblast. Thus, if ESRRG is pivotally associated with the abnormal trophoblast turnover and function it may be targeted by microRNAs or other possible upstream regulators in the placenta. This review explores altered expression of ESRRG and upstream regulation of ESRRG-mediated pathways resulting in the trophoblast turnover, placental vascularisation, and placental metabolism underlying placental dysfunctions. This demonstrates that the ESRRG pathway merits further investigation as a potential therapeutic target in FGR and preeclampsia.

Abstract

Normal placental development and function is of key importance to fetal growth. Conversely aberrations of placental structure and function are evident in pregnancy complications including fetal growth restriction (FGR) and preeclampsia. Although trophoblast turnover and function is altered in these conditions, their underlying aetiologies and pathophysiology remains unclear, which hampers development of therapeutic interventions. Here we review evidence that supports a role for estrogen related receptor-gamma (ESRRG) in the development of placental dysfunction in FGR and preeclampsia. This relationship deserves particular consideration because ESRRG is highly expressed in normal placenta, is reduced in FGR and preeclampsia and its expression is altered by hypoxia, which is thought to result from deficient placentation seen in FGR and preeclampsia. Several studies have also found microRNA (miRNA) or other potential upstream regulators of ESRRG negatively influence trophoblast function which could contribute to placental dysfunction seen in FGR and preeclampsia. Interestingly, miRNAs regulate ESRRG expression in human trophoblast. Thus, if ESRRG is pivotally associated with the abnormal trophoblast turnover and function it may be targeted by microRNAs or other possible upstream regulators in the placenta. This review explores altered expression of ESRRG and upstream regulation of ESRRG-mediated pathways resulting in the trophoblast turnover, placental vascularisation, and placental metabolism underlying placental dysfunctions. This demonstrates that the ESRRG pathway merits further investigation as a potential therapeutic target in FGR and preeclampsia.

Introduction

Placental dysfunction describes when the placenta fails to develop and/or function adequately to support the nutritional demands of the fetus, and is central to the development of both fetal growth restriction (FGR) and preeclampsia (Redman 1991, Spinillo et al. 2019). FGR describes a fetus that does not reach its genetic growth potential. In clinical practice, this is often identified as a small for gestational age infant i.e. a baby whose estimated fetal weight (EFW) or birthweight is less than the 10th percentile for that stage of pregnancy (ACOG 2019). However, being small for gestational age is not synonymous with FGR. True FGR affects 5%-10% of fetuses and is associated with both short-term and long-term complications including stillbirth, neonatal death, abnormal neurodevelopment, and cardiovascular and metabolic disorders in later life (Bernstein et al. 2000, Gardosi et al. 2005, Crispi et al. 2010, Ramirez-Velez et al. 2017, Pels et al. 2019). The majority of cases of FGR are mediated by abnormal placental structure and function (Spinillo et al. 2019). FGR may also co-exist with preeclampsia, which is defined as an elevation of maternal blood pressure with proteinuria occurring after 20 weeks’ gestation (Brown et al. 2018). In addition to adverse effects on the fetus, preeclampsia is associated with maternal morbidity and mortality (Souza et al. 2013, Brown et al. 2018). Presently there are no effective therapies to treat FGR or preeclampsia, leaving a decision between expectant management or delivery indicated by deterioration in fetal or maternal condition. Therapeutic advances are in part impaired by an incomplete understanding of the mechanisms underlying the placental dysfunction evident in FGR and preeclampsia. Therefore, the identification of key causal pathways amenable to therapeutic manipulation is an important goal for research in this area. Here we review the evidence for involvement of one such pathway, that of estrogen-related receptor gamma (ESRRG) in the human placenta (Kumar & Mendelson 2011).

Estrogen-related receptor-gamma is a member of the ERR family of orphan nuclear receptors, which is highly expressed in the human placenta (Takeda et al. 2009). Evidence suggests that ESRRG serves an important role in trophoblast differentiation, proliferation, and invasion, and may be involved in blood pressure homeostasis (Luo et al. 2014, Zhu et al. 2018a). In addition, deficient expression of ESRRG is linked to impaired placental mitochondrial function (Poidatz et al. 2012), which could lead to inadequate energy supply and thus reduced energy expenditure within the placenta. Due to its wide range of functions in relevant biological processes, it is plausible that ESRRG may also play a role in placental dysfunction underlying pregnancies complicated with FGR or preeclampsia.

To consider whether the ESRRG pathway has a causal role in placental dysfunction we have reviewed the literature to: (i) summarize knowledge regarding the role of ESRRG in trophoblast, placental vascularisation and placental metabolism, (ii) discuss the evidence for aberrant expression of constituents of the ESRRG pathway in pregnancy complications, including FGR and preeclampsia, and (iii) consider the implications of altered ESRRG expression and how this may contribute to placental dysfunction.

Placental dysfunction underlying pregnancy complications

To assess whether a pathway may be involved in the pathophysiology of FGR and/or preeclampsia, its role in normal placental development requires consideration, followed by evaluation of whether the aberrant placental phenotype seen in these conditions is consistent with disruption of that pathway.

Normal placental development

In normal placental development, appropriate differentiation of cytotrophoblast cells, the trophoblast stem cell population of the placenta, is important; two different pathways arise within the developing placental villus: the extravillous and villous lineages. The extravillous trophoblasts (EVT) differentiate from cytotrophoblast cell columns and invade the uterus (interstitial invasion) and spiral arteries (endovascular invasion) to remodel the maternal blood vessels and produce dilated and compliant uterine arterioles (Fig. 1A), thereby ensuring an adequate supply of oxygen and nutrients to support fetal growth (Pijnenborg et al. 1983). Proliferation, differentiation and fusion of villous cytotrophoblast maintains the syncytiotrophoblast, the multinucleated outer layer of the placenta responsible for placental transport, protective and endocrine functions (Jones & Fox 1991) (Fig. 1A and B). The villous cytotrophoblast and syncytiotrophoblast, together with a core of villous stromal cells containing fetoplacental blood vessels form the villous tree, which is the functional unit of the placenta (Jones & Fox 1991) (Fig. 1A and B). There are five different types of villi, including mesenchymal villi, immature intermediate villi, stem villi, mature intermediate villi, and terminal villi. Terminal villi, which represent the final branches of the villous tree, exhibit a high degree of capillarization and fetoplacental vessels are separated from maternal blood by a thin layer of syncytiotrophoblast and endothelial cells termed the vasculo-syncytial membrane, which is optimised for gas and nutrient exchange in human placenta (Kingdom et al. 2000). Consequently, there is a close relationship between terminal villous structure and function.

Figure 1
Figure 1

Schematic showing villous structure, trophoblast lineages and localization in the human placenta. (A) Extravillous trophoblast that are situated at the end of the cell column invade the decidua and remodel the maternal spiral arterioles to produce dilated and compliant uterine vessels. Villous cytotrophoblast differentiates and fuses to form the outer multinucleated syncytiotrophoblast which transports nutrients and gases from the maternal to fetal circulation. (B) Light micrograph showing immunostaining of in first trimester placental explants. ESRRG is mainly observed in the cytoplasm of the syncytiotrophoblast and cytotrophoblast. Arrows indicate villous cytotrophoblast, syncytiotrophoblast and villous stroma. Scale bar represents 25 µm.

Citation: Reproduction 161, 3; 10.1530/REP-20-0272

Placental changes in FGR and preeclampsia

Compared to placentas from normal pregnancies, placentas from pregnancies complicated by FGR and/or pre-eclampsia may exhibit a number of structural and functional changes, including evidence of an unfolded protein response, increased trophoblast apoptosis and autophagy, and reduced trophoblast proliferation and metabolic function (Heazell et al. 2008, 2011, Curtis et al. 2013, Burton & Jauniaux 2018, Yung et al. 2019). In the syncytiotrophoblast, some nuclei are aggregated to form syncytial knots with features of apoptosis and a disordered proliferation, and the increased formation of syncytial knots is related to the conditions of placental dysfunction which have been found in the FGR placentas (Macara et al. 1996, Heazell et al. 2007). FGR placentas also show decreased volume and surface area of terminal villi, with elongated and less-branched capillary loops (Jackson et al. 1995, Krebs et al. 1996). It is hypothesized that some of these changes in villous tissue are secondary to reduced invasion of extravillous trophoblast earlier in pregnancy, leading to impaired perfusion of the intervillous space. There may also be abnormalities of the fetal-placental vasculature and a reduction in placental weight, all of which combine to result in insufficient delivery of nutrients to the developing fetus (Roberts & Post 2008).

The placenta is a metabolically active organ that consumes a large volume of oxygen throughout gestation, with energy provision mainly dependent on mitochondrial activity by glucose utilization (Diamant et al. 1975, Malek et al. 1996). An imbalance of placental mitochondrial function with excessive generation of reactive oxygen and nitrogen species in placentas is observed in pregnancy complications such as FGR, and pre-eclampsia (Atamer et al. 2005, Biri et al. 2007, Leduc et al. 2010). Taken together with the observation of altered perfusion of the intervillous space the critical relationship between hypoxia, reactive oxygen species (ROS), and how this leads to placental dysfunction needs to be considered.

A possible role of hypoxia/ROS in placental dysfunction in FGR and preeclampsia

As stated above, hypoxia and hypoxia-reoxygenation can contribute to the elevation of reactive oxygen species (ROS), which can lead to increased oxidative DNA damage and depletion of local antioxidant defenses (Hung & Burton 2006, Kimura et al. 2013). Placental hypoxia has been reported in both FGR and preeclampsia (Kimura et al. 2013). Furthermore, a hypoxic environment can reproduce elements of the trophoblast phenotype seen in these conditions. Culture in 2% or 9% O2 reduces differentiation and induces apoptosis in third trimester primary cytotrophoblast (Alsat et al. 1996, Levy et al. 2000). Culture in 2% O2 impaired differentiation and invasion in first-trimester primary cytotrophoblast (Genbacev et al. 1996), and term placental villous explants also exhibited reduced proliferation and induction of apoptosis when cultured at 1% compared to 6-8% O2 (Heazell et al. 2008). Therefore, oxygen tension can modulate both the development of villous structure and trophoblast function. The molecular mechanisms responsible for these changes in trophoblast phenotype are still elusive, but recent reports suggest that it may, in part, be linked to activation of an unfolded protein response (UPR) by placental oxidative stress (Yung et al. 2008, Yung et al. 2019).

To understand the potential contribution of the ESRRG pathway in the pathogenesis of placental dysfunction underlying FGR and preeclampsia, the functions of ESRRG in pregnancy will be described, and the evidence that ESRRG signalling might be involved in the occurrence of placental dysfunction will be reviewed.

The ERR family

Estrogen-related receptors (ERRs) are an NR3B (nuclear receptor 3B) group of the nuclear receptor subfamily, including ESRRA, ESRRB, and ESRRG, which are encoded by ESRRA, ESRRB, and ESRRG, respectively. The NR3B group of nuclear receptors is one of the larger NR3 classes and includes the hormone receptors for estrogen, androgens, progesterone, aldosterone, and cortisol (Giguere et al. 1988, Giguere 1999). Although ERRs share sequence homologies with the estrogen receptor (ER), the transcription of ERRs is not activated by estrogen, and information on the nature of endogenous ligands for ERRs remains to be established (Vanacker et al. 1999). ERRs can regulate transcription by binding to estrogen-related receptor elements (ERRE) in target genes, which include several molecules involved in the cellular energy metabolic pathway (Giguere 2008).

Structure of ERRs

According to their sequence homology and function, the structural features of ERRs include an activation function (AF)-1 domain/N-terminal domain (NTD), a DNA-binding domain (DBD), a ligand-binding domain (LBD), and an AF-2 domain (Giguere 1999). The NTD is a non-conserved domain and it includes an AF-1 domain and a variable amino acid domain. In ESRRG and ESRRA, the NTD contains phosphorylation-dependent sumoylation sites that are embedded in a synergy control motif and may serve a role in regulating the transcriptional activity of ERRs (Tremblay et al. 2008). The synergy control motif may have a role in modulating higher-order interactions among transcriptional factors (Iniguez-Lluhi & Pearce 2000). The ERRs’ DBD exists the highest sequence homology in the three ERR isoforms: ESRRB and ESRRA share 99% and 93% identical amino acid sequence with ESRRG respectively, which suggests that more than two ERRs might share some target genes (Heard et al. 2000). DBD contains two highly conserved zinc finger motifs, which recognize and bind a specific DNA sequence (TCAAGGTCA), denoted as an ERR response element (ERRE). The ERRE can be either a monomer, a homodimer, or a heterodimer, which can modulate the translational activities of ERRs (Johnston et al. 1997, Dufour et al. 2007). Moreover, ERRs and ERs have high homology in the DBD region (Giguere et al. 1988); ERRs can recognize the ERRE embedded in estrogen response elements (ERE), but only 21% of ESRRA target promoters can be recognized by ESR1 in breast cancer cell lines (Deblois et al. 2009). Despite this, several genes can be regulated by both ESR1 and ERRs, including the human lactoferrin gene and monoamine oxidase B (Yang et al. 1996, Zhang et al. 2006b).

The final structural part of ERRs is the LBD, a less conserved domain; there is a 77% sequence homology between the LBDs of ESRRB and ESRRG, and 61% homology between the ESRRA and ESRRG (Heard et al. 2000). The homodimerization or heterodimerization of LBD in ESRRG can also influence the translation of ERRs; the homodimerization of ESRRG via LBD can enhance the activity of translation; conversely, heterodimerization with ESRRA inhibits the activity of both receptors (Huppunen & Aarnisalo 2004). The interaction between the LBD and its coactivator is ligand-independent (Greschik et al. 2002). However, the crystal structure also showed that the LBD can interact with ligands by a flexible ligand-binding pocket and importantly from the perspective of understanding receptor signalling pathways, several synthetic molecules can inhibit or stimulate the transcriptional function of ERRs by LBD, including proliferator-activated receptor coactivator 1-alpha, diethylstilbestrol (DES), and 4-hydroxytamoxifen (4-OH) (Tremblay et al. 2001a, Tremblay et al. 2001b, Kallen et al. 2004, Chao et al. 2006). Bisphenol A (BPA) is a chemical and environment contaminant used to produce plastics, which strongly binds to ESRRG–-LBD (Takeda et al. 2009). As the level of BPA in maternal blood and placental tissue is inversely related to fetal weight in human pregnancy (Troisi et al. 2014), BPA-mediated upregulation of placental ESRRG may provide a mechanistic link to explain the association between elevated BPA levels and FGR (Takayanagi et al. 2006, Okada et al. 2008).

Thus, the structure of the ERRs, specifically that of the LBD and DBD, is vital to the regulation of ERR signalling, including that of ESRRG. Furthermore, abnormal placental expression of ESRRG in FGR and preeclampsia suggests a potential role for ESRRG in the development or potentiation of these pregnancy complications (Luo et al. 2014, Zhu et al. 2018a). This review will consider how ESRRG is regulated, its effects in trophoblast and how this may contribute to the phenotypes of placental dysfunction observed in FGR and preeclampsia.

ESRRG

Both fetal and adult organs abundantly express ESRRG (Heard et al. 2000), including the placenta, heart, and brain (Heard et al. 2000, Takeda et al. 2009, Misra et al. 2017). ESRRG can regulate blood pressure homeostasis, due to the high expression of ESRRG in kidneys which mediate aldosterone-stimulated sodium and water reuptake (Alaynick et al. 2010). In Esrrg null mice, the genes that regulate serum potassium and blood pressure were decreased in the kidney; RNA expression of the potassium channels, Kcnj1, Kcne1, and Kcne2, and kallikrein-kinin system genes kallikrein 1 (Klk1) and kallikrein 6 (Klk6), were significantly reduced in the kidneys of Esrrg null mice (Alaynick et al. 2010). Other potential mechanisms by which Esrrg can regulate maternal blood pressure homeostasis during pregnancy are related to steroid 11β-hydroxylase (Cyp11b1) and aldosterone synthase (Cyp11b2) (Luo et al. 2014). In Esrrg heterozygous (Esrrg+/-) pregnant mice, expression of Cyp11b1 and Cyp11b2 is decreased in the mouse adrenal cortex, resulting in reduced production of aldosterone and a reduction in blood pressure; conversely, expression of Cyp11b1 and Cyp11b2 in WT pregnant mice is increased after exposure to the Esrrg agonist DY131, which increased maternal blood pressure (Luo et al. 2014). Given that development of preeclampsia involves abnormal elevation of maternal blood pressure, dysregulation of ESRRG signaling in the kidney and adrenal cortex may contribute to this phenomenon.

Placental ESRRG expression also plays an important role in the maintenance of pregnancy. Placenta has the highest expression of ESRRG in the human reproductive system (Fig. 1B) (Takeda et al. 2009); expression of ESRRG increases over gestation and is higher in villous compared to extravillous trophoblast (Poidatz et al. 2012). ESRRG expression is dramatically increased during human cytotrophoblast cell differentiation, indicating a potential regulatory role (Kumar & Mendelson 2011). Moreover, ESRRG also regulates genes involved in cellular energy homeostasis and metabolism; expression of key regulator genes involved in mitochondrial biogenesis (PGC1A and NRF1) and energy metabolism (PDK4 and MCAD) decreased after silencing ESRRG in human first trimester placental primary cytotrophoblast (Poidatz et al. 2012). As these studies indicate that ESRRG signaling may influence multiple aspects of normal placental function, we will review the evidence for the involvement of ESRRG in regulating trophoblast function, hypoxic responses, placental vascularisation, placental metabolism, and other regulators in the human placenta (Fig. 2 and Table 1).

Figure 2
Figure 2

Diagrammatic representation of known upstream regulators and downstream effectors of ESRRG in the placenta. Expression of the depicted genes is known to be altered in the FGR or preeclampsia placenta, where a red arrow indicates a positive effect and a black line indicates a negative effect. Meanwhile, a black dot arrow suggests an unclear relationship between ESRRG and downstream effectors. CYP11B1: cytochrome P450 family 11 subfamily B member 1; HSD11B2: hydroxysteroid 11-beta dehydrogenase 2; HSD17B1: hydroxysteroid 17-beta dehydrogenase 1; PLAC1: placenta-specific 1; VEGFA: vascular endothelial growth factor A; PDK4: pyruvate dehydrogenase kinase 4; MCAD: medium-chain acyl-CoA dehydrogenase; BPA: bisphenol A; PCG1A/B: peroxisome proliferator-activated receptor-γ coactivator-1 alpha/beta; HIF1A: Hypoxia-inducible factor 1-alpha.

Citation: Reproduction 161, 3; 10.1530/REP-20-0272

Table 1

Relationship of ESRRG to upstream regulators and downstream effectors demonstrated in studies of placenta.

Tissue/cell type/subjectReferenceStudy MethodsMain findingInfluence on trophoblast functionDefinition of FGR/preeclampsia (where applicable)
Downstream
CYP19A1Mid-trimester primary cytotrophoblastsKumar & Mendelson (2011)RT-PCR; WB; ChIPESRRG is an oxygen-dependent transcription factor and mediates CYP19A1 expression in trophoblast differentiation.Differentiation
CYP11B1Late-onset PE placenta;

Mouse model
Luo et al. (2014)RT-PCR; IHC;

WB; ChIP; LRA
ESRRG is increased in placenta in PE and can influence the blood pressure in pregnant mice by targeting Cyp11b1.Reduced production of aldosteronePE defined as maternal blood pressure (≥140/90 mmHg) and proteinuria (proteinuria ≥300mg per 24 hours or ≥1+ protein by dipstick from 2 random urine specimens or ≥2+protein by 1 dipstick) after 20 weeks of gestation.
 K+ channelsMid-trimester primary trophoblast cells; Term FGR placentaCorcoran et al. (2008), Luo et al. (2013)RT-PCR; WB; ChIP; LRA; Whole-genome gene expression arraysHypoxia inhibits the expression of ESRRG and K+ channels;

ESRRG can regulate K+ channels that may be associated with PE and identified three ESRRG potential effectors, including HSD11B2, HSD17B1, and PLAC1;

Oxygen-sensitive K+ channel gene KV9.3 was increased in FGR placenta and KV2.1 was increased in FGR placental vein
DifferentiationFGR defined as the individualized birth weight ratio (IBR) ≤ 5th centile for gestational age.
HSD11B2Cytotrophoblast from mid-trimester placenta;

Early-onset FGR placenta (n=15) and later-onset FGR placentas (n=4)
McTernan et al. (2001), Luo et al. (2013)RT-PCRHSD11B2 mRNA is decreased in ESRRG knockdown mid-trimester cytotrophoblasts.

HSD11B2 is decreased in both early-onset and later-onset FGR placentas, when compared with gestational matched normal placentas.
Not reportedFGR are diagnosed with at least three of four following ultrasound features: 1) fetal abdominal circumference ≤ 3rd centile for weeks of gestation, 2) abnormal fetal growth velocity 3) severe oligohydramnios (amniotic fluid index ≤3rd percentile for gestational age), 4) absent or reversed velocities in umbilical artery Doppler waveforms.
PLAC1Placental villi of the human first trimester and term placentaChang et al. (2016)RT-PCR; IHC;

WB
PLAC1 is increased during the trophoblast differentiation and low expression inhibits the cell fusion.DifferentiationFGR were diagnosed as a fetus with reduced growth velocity, which is less than 10th centile after 20 gestational weeks.
Later-onset FGR placentaSifakis et al. (2018)RT-PCRPLAC1 is increased in FGR placenta.Not reported
HSD17B1Late-onset FGR placenta;

HTR-8 cell lines
Zhu et al. (2018)RT-PCR; IHC;

WB; LRA
ESRRG can regulate HSD17B1 that is associated with FGRDecrease invasion; proliferationFGR defined as estimated fetal weight is less than 10th centile.
VEGFAMouse modelLuo et al. (2014)RT-PCRThe expression of Vegfa is decreased in Esrrg deficient mice placentaNo detection reported
PDK4Primary trophoblast

Bewo cell line
Poidatz et al. (2012)RT-PCR, IHCThe expression of ESRRG is increased during trophoblast differentiation;

PDK4 is decreased after inhibiting ESRRG expression.
Differentiation
MCADFirst trimester human primary cytotrophoblast;

Bewo cell line
Poidatz et al. (2012)RT-PCR, IHCMCAD is decreased after inhibiting ESRRG expression.Differentiation
Upstream
 BPAPlacentas from low birth weight infant; 587 childrenMiao et al. (2011), Troisi et al. (2014)GC-MS analysis, InterviewNegative relationship between BPA and fetal weight; ESRRG is a receptor of BPA in the placenta.Not reportedLow birth weight defined as the infant weight less than 2500g at birth;
PGC1AFGR and PE placenta;

Late-onset FGR placenta
Poidatz et al. (2015)IHC, RT-PCR, Quantification Mitochondrial DNAIn FGR and PE placenta, the expression of ESRRG, PGC1A and SIRT1 is decreased.No detection reportedFGR defined as a birth weight less than 10th centile.

PE was diagnosed as an elevated maternal blood pressure (systolic and diastolic blood pressure ≥140/90mmHg) and proteinuria (≥ 300mg per 24 hours) after 20 weeks of gestation.
SIRT1FGR and PE placenta;

Late-onset FGR placenta
Poidatz et al. (2015)IHC, RT-PCR, Quantification Mitochondrial DNAIn FGR and PE placenta, the expression of ESRRG, PGC1A and SIRT1 is decreased.No detectionFGR defined as a birth weight less than 10th centile.

The definition of PE has been mentioned in the part of GC1A.
 miR-320aLate-onset PE placenta; HTR‐8/SVneoGao et al. (2018)RT-PCR; IHC; WB; LRAmiR-320a regulates ESRRG in PEDecreased invasion; No change in proliferation and migrationPE defined as increased diastolic and systolic maternal blood pressure with proteinuria.
HTR‐8/SVneo; HUVECsLiu et al. (2018)RT-PCR; WB; LRAmiR-320a directly target ESRRG and may indirectly control the expression of VEGFA to influence the function of both trophoblast and vein endothelial cells.Decreased invasion, proliferation and migration; Increase in apoptosis
HIF1AMid-trimester primary trophoblast cellsKumar & Mendelson (2011)RT-PCR; WB; ChIP assayHIF1A can mediate ESRRG expression in trophoblast differentiationDifferentiation

ESRRG, estrogen related receptor gamma; CYP19A1, cytochrome P-450; RT-PCR, reverse transcription polymerase chain reaction; WB, western blot; CHIP, chromatin immunoprecipitation; FGR, fetal growth restriction; CYP11B1, cytochrome P450 family 11 subfamily B member 1; IHC, immunochemistry; LRA, luciferase reporter assay; PE, preeclampsia; HSD11B2, hydroxysteroid 11-beta dehydrogenase 2; HSD17B1, hydroxysteroid 17-beta dehydrogenase 1; PLAC1, placenta-specific 1; VEGFA, vascular endothelial growth factor A; PDK4, pyruvate dehydrogenase kinase 4; SGA, small for gestational age; MCAD, medium-chain acyl-CoA dehydrogenase; BPA, bisphenol A; GC-MS, gas chromatography-mass spectrometry; PGC1A, peroxisome proliferator-activated receptor-gamma coactivator-1 alpha; HUVECs, human umbilical vein endothelial cells; HIF1A, Hypoxia-inducible factor 1-alpha.

The effect of ESRRG on trophoblast function

Proliferation

ESRRG knockdown has been shown to reduce proliferation of the extravillous-like trophoblast cell line HTR-8/SVneo, via decreasing the expression of its downstream gene, 17β-hydroxysteroid dehydrogenase type 1 (HSD17B1) (Zhu et al. 2018a). HSD17B1 is an enzyme capable of converting estrone to 17β-estradiol in the metabolism of estrogen. Abnormal expression of HSD17B1 has been reported in both FGR and preeclampsia (Zhu et al. 2018a); previous studies have revealed that a reduced plasma HSD17B1 expression level could be considered a potential prognostic factor for preeclampsia (Ishibashi et al. 2012, Ohkuchi et al. 2012). Ohkuchi et al. (2012) examined 128 normal pregnant women and 30 pregnancies complicated with preeclampsia and found that reducing maternal plasma levels of HSD17B1 correlated with the occurrence of preeclampsia, implicating HSD17B1 in the pathogenesis of the disease, possibly by influencing the process of estrogen metabolism. Since estrogen can reduce the proliferation of HTR-8/SVneo cell line (Patel et al. 2015), this might suggest a relationship between low level of HSD17B1 in maternal serum, placental estrogen metabolism, and trophoblast proliferation. Moreover, the mRNA and protein level of HSD17B1 was decreased in placentas complicated with FGR (Zhu et al. 2018a). Therefore, aberrant regulation of HSD17B1 by ESRRG may contribute to placental dysfunction, by its ability to regulate the proliferation of cytotrophoblast cells which is disrupted in FGR and preeclampsia.

Differentiation

There is also evidence that ESRRG may influence cytotrophoblast differentiation via its role as a regulator of the aromatase CYP19A1, the voltage-gated potassium (KV7) channel family, or via interactions with two other downstream genes, placenta specific-1 (PLAC1), and 11β-hydroxysteroid dehydrogenase 2 (HSD11B2).

The cytochrome P-450 (CYP) family members include CYP11A1 and CYP19A1, and hydroxysteroid dehydrogenases (HSDs), such as 3β-HSD and 17β-HSD; these enzymes play a vital role in placental hormone synthesis and metabolism (Payne & Hales 2004). C19 steroid precursors can be converted into estrogen via activating aromatase P450, which is encoded by the CYP19A1 gene and only expressed in the syncytiotrophoblast, not in trophoblast stem cells or cytotrophoblast (Fournet-Dulguerov et al. 1987, Kamat et al. 1998). Notably, ESRRG has been shown to stimulate the expression of CYP19A1 in vitro, via binding to its promotor to increase estrogen levels in a 20% O2 culture environment, which promotes trophoblast differentiation. When human second-trimester primary cytotrophoblasts were cultured in a hypoxic environment (2% O2), both ESRRG and CYP19A1 expression decreased; however, elevating ESRRG expression restored CYP19A1 expression (Kumar & Mendelson 2011).

ESRRG also induces mRNA and protein expression of the KV7 family of potassium channels to regulate the differentiation of cytotrophoblast in second-trimester placentas. Voltage-gated KV7 channels are encoded by the KCNQ1-5 (α-subunit) and KCNE1-5 (β-subunit) genes. The human placenta expresses many potassium channel genes, including the KCNQ and KCNE families, and the expression of KCNQ3 and KCNE5 is markedly increased in placentas from pregnancies complicated with preeclampsia, particularly in the syncytiotrophoblast (Mistry et al. 2011). ESRRG induces mRNA and protein expression of the potassium channels KLK1, KCNQ1, KCNE1, KCNE3 and KCNE5 during primary cytotrophoblast differentiation, the effect of which was blocked by hypoxia (Luo et al. 2013). After examining the promoter, an ERRE located in the upstream region of the KCNE1 and KLK1 genes was identified, to which ESRRG can bind (Luo et al. 2013). In addition, expression of the oxygen-sensitive K+ channel gene KV9.3 was increased in FGR placentas, and expression of KV2.1 was increased in chorionic plate veins from the same placentas (Corcoran et al. 2008). However, the relationship between ESRRG and expression of K+ channels in functionally deficient placentas remains unclear.

There is also evidence that PLAC1 and HSD11B2 are downstream effectors of ESRRG, and these two genes can regulate cytotrophoblast differentiation (Luo et al. 2013). The expression of PLAC1 is elevated during trophoblast differentiation and conversely, reduced expression of PLAC1 attenuates fusion of term primary human cytotrophoblast in vitro (Chang et al. 2016). Contrary to expectations, Sifakis et al. found high PLAC1 expression in FGR placentas at term (Sifakis et al. 2018), although this may be linked to the aberrant differentiation and trophoblast turnover reported in FGR (Heazell et al. 2011, Huppertz 2011). Combined with the observations of Luo et al. these data suggest that the effect of PLAC1 on trophoblast differentiation might be mediated via ESRRG.

Another downstream gene of ESRRG is HSD11B2, an enzyme that converts active cortisol to inactive cortisone, which is expressed in villous syncytiotrophoblast (Pepe et al. 1999). Both mRNA and protein expression of HSD11B2 is induced during term primary cytotrophoblast differentiation, and it is considered a marker for trophoblast differentiation (Hardy & Yang 2002, Homan et al. 2006). During pregnancy, HSD11B2 acts as a critical placental glucocorticoid barrier that protects the fetus from the harmful effects of excessive maternal glucocorticoids (Benediktsson et al. 1993, Zhu et al. 2018b). Placental HSD11B2 expression correlates with fetal weight and postnatal growth velocity (Benediktsson et al. 1993). McTernan et al. (2001) showed that placental HSD11B2 expression is decreased in FGR and demonstrated the importance of placental HSD11B2 in regulating fetal growth. Studies of SGA placentas also reported low HSD11B2 expression, which further revealed the relationship between HSD11B2 and fetal weight (Struwe et al. 2007). Placental HSD11B2 expression at birth is positively associated with fetal length at birth, whereas its expression is inversely related to growth velocity in the first year of life, and might therefore be a predictor of postnatal growth of fetuses with FGR (Tzschoppe et al. 2009). These studies support the relationship between abnormal differentiation of cytotrophoblast seen in FGR and preeclampsia and expression of HSD11B2, although the roles of HSD11B2 in trophoblast function are still unclear. As ESRRG regulates HSD11B2 (Luo et al. 2013), the reduced effect of HSD11B2 on trophoblast differentiation might be due to reduced levels of ESRRG in the presence of placental dysfunction.

Invasion

Invasion of the extravillous trophoblast into the uterine wall and subsequent remodeling of the uterine arterioles is critical for normal placental development and optimal uteroplacental perfusion. Knockdown of ESRRG resulted in the deficient invasion of the extravillous-like HTR-8/SVneo cell line (Liu et al. 2018, Zhu et al. 2018a). Liu et al. showed that overexpression of microRNA (miR)-320a inhibited HTR-8/SVneo invasion by regulating ESRRG signalling (Liu et al. 2018). Furthermore, Zhu et al. demonstrated that reduced expression of ESRRG in HTR-8/SVneo cells significantly impaired invasion via regulation of HSD17B1 (Zhu et al. 2018a). Although a potentially significant finding, the relationship between ESRRG and the invasive capacity of extravillous trophoblast needs to be explored further using primary tissues.

The effect of ERRγ on response to hypoxia

A hypoxic environment alters the expression of many genes which are associated with trophoblast differentiation. The most well-studied oxygen sensor in trophoblast is hypoxia-inducible factor 1α (HIF1A), which is reported to be elevated in FGR and pre-eclampsia (Rajakumar et al. 2004, Robb et al. 2017). HIF1A regulates ESRRG expression in human trophoblast: culture in a 2% O2 environment activates HIF1A and decreases the expression of ESRRG and CYP19A1 (Kumar & Mendelson 2011). Conversely, knockdown of HIF1A in trophoblast prevents ESRRG suppression under hypoxic conditions (Kumar & Mendelson 2011). Collectively, these findings demonstrate that ESRRG serves as an oxygen-dependent transcriptional factor regulated by HIF1A to control the expression of downstream CYP19A1. This relationship appears to be maintained in vivo, as low ESRRG expression has been reported in placentas from FGR pregnancies, which often show evidence of hypoxia and/or oxidative stress (Takagi et al. 2004). A preliminary study in a south Chinese population examined the mRNA and protein level of ESRRG in 28 FGR placentas and 30 matched appropriate for gestational age (AGA) placentas, and reported lower expression of ESRRG in FGR placentas (Zhu et al. 2018a). Poidatz et al. (2015) also reported lower mRNA expression of ESRRG in 39 FGR placentas compared with a 30 controls in a European population. These studies support the hypothesis that ESRRG might play a role in placental dysfunction originating from placental hypoxia.

The effect of ESRRG on placental vascularisation

Although the trophoblast is critically important to the placental function, it is also widely acknowledged that impaired placental blood vessel development may be important in the aetiology of FGR (Hitschold et al. 1993). Several genes have been implicated in regulating placental vascularisation, including vascular endothelial growth factor A (VEGFA) (Ylikorkala et al. 2001, Burton et al. 2009). Maternal serum levels of VEGFA, an angiogenic factor that is crucial for placental angiogenesis during early gestation, are decreased in the 2nd and 3rd-trimester in pregnancies complicated with FGR (Bersinger & Odegard 2005). Expression of VEGFA in primary vascular endothelial cells is also reduced in FGR placentas (Chui et al. 2014). The altered vascularisation seen in the placentas of women with FGR can potentially be attributed to dysregulated ESRRG expression. In mice, placentas from Esrrg-/-fetuses have significantly increased mRNA levels of Vegfa, compared with placentas from wild type fetuses (Luo et al. 2014), and in Esrrg+/- pregnant mice, circulating levels of the angiogenic, soluble receptor for VEGF, soluble fms-like tyrosine kinase-1(sFLT1), were significantly reduced (Luo et al. 2014). In the mouse myoblast cell line C2C12, suppression of Esrrg can block the transcriptional expression of Vegfa, whilst in HEK-293T cells, ESRRG has been shown to activate the VEGFA promoter (Matsakas et al. 2012). This indicates that ESRRG may affect placental vascularisation via its regulation of VEGFA, however further studies are required in humans to confirm this.

ESRRG and placental metabolism

There is accumulating evidence that ESRRG plays a role in the regulation of several mitochondrial functions, including mitochondrial biogenesis, oxidative phosphorylation, and fatty acid oxidation, in the heart, kidney, skeletal muscle, and placenta (Huss et al. 2002, Alaynick et al. 2007, Dufour et al. 2007, Kubo et al. 2009, Alaynick et al. 2010, Fan et al. 2018). In the human placenta, ESRRG regulates mitochondrial function by controlling gene networks involved in mitochondrial biogenesis and fat and glucose metabolism in the villous trophoblast, including pyruvate dehydrogenase kinase 4 (PDK4), medium chain acyl-CoA dehydrogenase (MCAD), sirtuin 1 (SIRT1) and peroxisome proliferator-activated receptor gamma (PPARG) coactivator 1 alpha (PGC1A) (Poidatz et al. 2012).

In human term primary villous cytotrophoblast, expression of PDK4 and MCAD was decreased after knockdown of ESRRG expression (Poidatz et al. 2012), which implicates ESRRG as a potential regulator of placental fatty acid oxidation and glucose metabolism mediated via these genes. PDK4 can phosphorylate the pyruvate dehydrogenase complex (PDC), which facilitates the conversion of pyruvate to acetyl-CoA in mitochondria, to inhibit the activity of PDC (Sugden & Holness 2003); MCAD is an enzyme which catalyzes the initial step of mitochondrial fatty acid oxidation (FAO) (Schulz 1991). ESRRG can stimulate the expression of PDK4 in human liver cell lines (HepG2 cells) and rat hepatoma cells (Zhang et al. 2006a, Lee et al. 2012); regulation of the promoter of PDK4 by ESRRG has been observed in mammary epithelial cells by using both ChIP and luciferase reporter assays, and the activation of the ESRRG–-PDK4 pathway attenuates glucose oxidation and decrease cell death and apoptosis (Kamarajugadda et al. 2012). Thus, a reduction in ESRRG would be expected to be associated with increased apoptosis and cell death, as is observed in FGR. This suggests that the ESRRG–-PDK4 signalling pathway in human placentas might contribute to the placental dysfunction. MCAD is one of the targets of ESRRA and the increased expression of the ESRRA–-MCAD pathway serves an important role in the decidualization of human primary endometrial stromal cells (Bombail et al. 2010). As ESRRG is similar to ESRRA, it is possible that ESRRG also contributes to the regulation of MCAD, however further studies are needed to investigate this and to determine the role of the pathway in placental dysfunction.

SIRT1, PGC1A, and PGC1B are also coactivators of ESRRG that have known roles in regulating placental metabolism. SIRT1, a NAD(+)-dependent protein deacetylase, is expressed ubiquitously in different organs and is required for many cellular processes related to differentiation and metabolism (Leibiger & Berggren 2006). SIRT1 is expressed in both the syncytiotrophoblast and cytotrophoblast (Lappas et al. 2011). Findings from two recent studies in mice indicate that SIRT1 plays a key role in trophoblast differentiation and placental development (McBurney et al. 2003, Arul Nambi Rajan et al. 2018). The differentiation of mouse trophoblast stem cells obtained from SIRT1-null mice was blunted in vitro (Arul Nambi Rajan et al. 2018), resulting in fetuses with FGR, and smaller placentas with deficient morphology including a thickened chorion and a more hypercellular labyrinth were observed (McBurney et al. 2003, Arul Nambi Rajan et al. 2018). Wilson et al. found SIRT1 can deacetylate and increases ESRRA DNA-binding activity by interacting with ESRRA in vivo and in vitro, which also suggests a potential interaction between ESRRG and SIRT1 (Wilson et al. 2010), as ESRRA and ESRRG have structural and functional similarities. In HepG2 cells, small heterodimer partner interacting leucine zipper protein (SMILE) expression and its ability to repress ESRRG transactivation and downstream signaling, is dependent on the expression of SIRT1 (Xie et al. 2009). SIRT1 can also positively regulate the expression of another ESRRG coactivator, PGC1A (Gerhart-Hines et al. 2007, Amat et al. 2009). PGC1A and its family member, PGC1B, act as transcriptional co-regulators of ESRRA and ESRRG to influence metabolism in many diseases, such as cardiovascular disease and cancer (Huss et al. 2002, Liu et al. 2005, Torrano et al. 2016, Luo et al. 2017). In human placental tissue, the mRNA expression level of PGC1A and SIRT1 correlated with that of ESRRG in pregnancies complicated with preeclampsia and FGR (Poidatz et al. 2015); low mRNA levels of ESRRG, PGC1A and SIRT1 have all been reported in FGR placentas (Poidatz et al. 2015). Together, these studies suggest that methods to modulate both ESRRG and its transcriptional co-regulators, may provide a potential therapeutic strategy to improve placental metabolism and fetal growth. Therefore, we will conclude by reviewing the miRNAs that have been identified as upstream regulators of ESRRG, and which may also contribute to the etiology of placental dysfunction.

Regulation of ESRRG in the human placenta by miRNAs

miRNAs are short non-coding RNAs with 19-23 nucleotides which post-translationally reduce gene expression in both animals and plants by mediating argonaute (AGO) binding to the 3’-untranslated-region (3’-UTR) of mRNA (Baek et al. 2008). The miRNA-induced silencing complex (miRISC), which includes the miRNAs and AGO, degrades target mRNA and represses protein translation. Different miRNAs are expressed in specific tissues, and by regulating different sets of target genes, specific miRNAs can mediate many cellular processes, such as differentiation, proliferation, and invasion (Anton et al. 2013, Li et al. 2014). In humans, more than 60% of protein-coding genes are thought to be regulated by miRNAs, many of which are specifically expressed in the placenta (Friedman et al. 2009). Expression of numerous miRNAs is altered in pregnancy complications such as FGR and preeclampsia, which are associated with placental dysfunction (Friedman et al. 2009, Zhang et al. 2010, Hromadnikova et al. 2015). The following miRNAs are associated with placental dysfunction and have been identified as potential upstream regulators of ESRRG.

miR-320a

miR-320a levels are increased in the placentas of women with late-onset preeclampsia, and overexpression of miR-320a in HTR-8/SVneo cells inhibits mRNA and protein expression of ESRRG (Gao et al. 2018). Key functional roles for ESRRG in the placenta appear to be modulated by miR-320a: direct regulation of ESRRG by miR-320a inhibits migration, invasion, and proliferation and indirectly modulates levels of VEGFA in both HTR-8/SVneo cells and human umbilical vein endothelial cells (HUVECs) (Gao et al. 2018, Liu et al. 2018). However, to our knowledge, expression levels of miR-320a in FGR placentas has yet to be assessed.

Other ESRRG regulatory miRNAs

Several other miRNAs have been implicated in placental dysfunction by regulating proliferation, invasion, or invasion of trophoblastic-like cell lines, and by reducing ESRRG expression in other cell lines, these include miR-378a-5p, miR-424, miR-377, and miR-204-5p (Eichner et al. 2010, Cheng et al. 2018, Zou et al. 2019). miR-378a-5p inhibits both mRNA and protein levels of ESRRG in the breast cancer cell line, BT-474 (Eichner et al. 2010); it also enhances the invasion and migration of HTR8/SVneo cells and reduces BeWo cell differentiation (Luo et al. 2012, Nadeem et al. 2014). miR-424 expression was increased in FGR placentas (Huang et al. 2013) and miR-424 overexpression inhibited protein expression of ESRRG in HTR/8SVneo cells. However, this study did not identify a regulatory relationship between miR-424 and the 3’UTR of ESRRG, thus more in-depth studies of miR-424 are required in the future (Zou et al. 2019).

miR-377 is more highly expressed in human term placentas compared with first-trimester placentas, and overexpression of miR-377 in the first-trimester placental explants reduced cytotrophoblast proliferation (Farrokhnia et al. 2014). Furthermore, miR-377 inhibits the expression levels of SIRT1 in human retinal endothelial cells; taking into account the reported interaction between ESRRG and SIRT1 in the human placenta, miR-377 may also regulate ESRRG expression (Cui et al. 2019). As overexpression of miR-204-5p reduced the invasion of BeWo cells and JEG3 cells (Yu et al. 2015), and miR-204-5p overexpression reduced the differentiation of C1C12 myoblast cells by directly targeting 3’UTR of ESRRG, this data suggest that a direct regulatory relationship may also exist between miR-204-5p and ESRRG in the placenta (Cheng et al. 2018). Since the above studies only used cell lines to assess trophoblast function, more data derived from primary placental models are needed; specifically those that focus on the relationship between individual miRNAs, ESRRG and its downstream effectors, and their roles in the etiology of FGR; these relationships have been summarized in Fig. 3.

Figure 3
Figure 3

Proposed mechanism by which placental ESRRG expression and function is altered in pregnancies complicated by FGR and preeclampsia. The hypoxic environment of the maternofetal interface in FGR results in upregulation and activation of HIF1A in the placenta, resulting in inhibition of ESRRG expression. The expression of several miRNAs is upregulated in FGR and we propose that amongst these are key ESRRG regulatory miRNAs. Binding of these miRNAs to the 3’UTR of ESRRG results in mRNA degradation and inhibition of ESRRG protein translation. This leads to reduced expression of genes downstream of ESRRG, including CYP19A1, HSD17B1, HSD11B2 and PLAC1. These downstream genes play an important role in placental hormone production and regulating different aspects of cytotrophoblast function, including villous cytotrophoblast proliferation and extravillous trophoblast invasion.

Citation: Reproduction 161, 3; 10.1530/REP-20-0272

Manipulation of the expression of miRNAs upstream of ESRRG may represent an additional approach to correct placental dysfunction; accumulating studies in vivo and in vitro indicate the possibility of developing an inverse agonist of ESRRG as a promising treatment for ESRRG-related anaplastic thyroid cancer, breast cancer, and type 2 diabetes (Kim et al. 2012, 2019, Vernier et al. 2020). Our group has demonstrated that targeted miRNA inhibitors can be used to selectively manipulate placental function: targeted inhibition of trophoblast miR-145 and miR-675 expression promoted cytotrophoblast proliferation in human first-trimester villous placental explants and increased fetal and placental weight when administered intravenously to pregnant mice (Beards et al. 2017). Therefore, exploring the regulatory pathway of ESRRG in the human placenta could inform the development of potential new therapeutic approaches for pregnancy complications involving placental dysfunction, like FGR or preeclampsia.

Summary

Even though many studies have focused on the pathogenesis of placental dysfunction underlying FGR and preeclampsia, the precise pathophysiological mechanisms and biochemical pathways in the placenta are still unclear, which limits options for therapeutic discovery, making a better understanding of the underpinning placental pathways a priority. The most obvious changes in the placenta in FGR and preeclampsia include abnormal trophoblast function, increased cell death, altered metabolism and nutrient transport, hypoxia and oxidative stress, and aberrant villous structure. Since ESRRG is highly expressed in the human normal term placenta, and it holds key roles in the regulation of cell invasion, differentiation, cellular energy homeostasis, hypoxic responses and metabolism, we argue that involvement of the ESRRG pathway in the placental dysfunction underlying FGR and preeclampsia is plausible, and thorough exploration may offer new therapeutic options. In support of this hypothesis, several studies have revealed significantly lower levels of ESRRG mRNA and protein in the human placenta in FGR, and ESRRG can regulate the invasion and proliferation of human trophoblast cell lines. Furthermore, additional evidence of disruption of both upstream regulators and downstream effectors of ESRRG provides evidence that the pathway is intact, and functions as expected in the human placenta. These data highlight that ESRRG may be involved in the development and pathogenesis of placental dysfunction by influencing trophoblast function and further studies of the regulation of this pathway are needed. By better understanding the intrinsic role of ESRRG as a regulator of trophoblast function, metabolism, and cell turnover, this in turn might provide new ideas for the treatment of placental dysfunction underpinning FGR and preeclampsia in the future.

Declaration of interest

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this review.

Funding

This student is supported by the joint scholarship of University of Manchester and Chinese government. A E P H is supported by Tommy’s charity.

Author contribution statement

Z Z, L K H, K F, and A E P H conceived and designed the research. Z Z drafted the manuscript. All authors read and approved the final manuscript.

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    Schematic showing villous structure, trophoblast lineages and localization in the human placenta. (A) Extravillous trophoblast that are situated at the end of the cell column invade the decidua and remodel the maternal spiral arterioles to produce dilated and compliant uterine vessels. Villous cytotrophoblast differentiates and fuses to form the outer multinucleated syncytiotrophoblast which transports nutrients and gases from the maternal to fetal circulation. (B) Light micrograph showing immunostaining of in first trimester placental explants. ESRRG is mainly observed in the cytoplasm of the syncytiotrophoblast and cytotrophoblast. Arrows indicate villous cytotrophoblast, syncytiotrophoblast and villous stroma. Scale bar represents 25 µm.

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    Diagrammatic representation of known upstream regulators and downstream effectors of ESRRG in the placenta. Expression of the depicted genes is known to be altered in the FGR or preeclampsia placenta, where a red arrow indicates a positive effect and a black line indicates a negative effect. Meanwhile, a black dot arrow suggests an unclear relationship between ESRRG and downstream effectors. CYP11B1: cytochrome P450 family 11 subfamily B member 1; HSD11B2: hydroxysteroid 11-beta dehydrogenase 2; HSD17B1: hydroxysteroid 17-beta dehydrogenase 1; PLAC1: placenta-specific 1; VEGFA: vascular endothelial growth factor A; PDK4: pyruvate dehydrogenase kinase 4; MCAD: medium-chain acyl-CoA dehydrogenase; BPA: bisphenol A; PCG1A/B: peroxisome proliferator-activated receptor-γ coactivator-1 alpha/beta; HIF1A: Hypoxia-inducible factor 1-alpha.

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    Proposed mechanism by which placental ESRRG expression and function is altered in pregnancies complicated by FGR and preeclampsia. The hypoxic environment of the maternofetal interface in FGR results in upregulation and activation of HIF1A in the placenta, resulting in inhibition of ESRRG expression. The expression of several miRNAs is upregulated in FGR and we propose that amongst these are key ESRRG regulatory miRNAs. Binding of these miRNAs to the 3’UTR of ESRRG results in mRNA degradation and inhibition of ESRRG protein translation. This leads to reduced expression of genes downstream of ESRRG, including CYP19A1, HSD17B1, HSD11B2 and PLAC1. These downstream genes play an important role in placental hormone production and regulating different aspects of cytotrophoblast function, including villous cytotrophoblast proliferation and extravillous trophoblast invasion.

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