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June 09-41-2.Indd June 2009 KUWAIT MEDICAL JOURNAL 93 Review Article The Immune System in Pregnancy: Friend or Foe? Raj Raghupathy Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait Kuwait Medical Journal 2009; 41 (2): 93-102 ABSTRACT Pregnancy is an intriguing immunological paradox; how in the field of immunology of pregnancy has opened up the does an allogeneic fetus survive despite a potentially possibility of cellular immune effectors that might underlie antagonistic maternal immune system, while tissue allografts these pregnancy complications. Particularly interesting are succumb to rapid immunological rejection? While several the effects that pro-inflammatory and anti-inflammatory hypothetical models have been proposed in the last five cytokines have on the conceptus and thus on the success and decades to explain the immunological success of pregnancy, failure of pregnancy. This review focuses on the association the model that has survived the test of experimentation between some cytokines and successful pregnancy on the is the one that proposes a state of immunomodulation one hand, and between other cytokines and complications of during pregnancy. Several factors appear to prevent the pregnancy as also the possible pathways of effector function rejection of the fetus. Yet, pregnancy can be compromised of cytokines in pregnancy loss. This review proceeds to by a variety of complications such as recurrent spontaneous discuss the therapeutic redirection of cytokine profiles miscarriage, preeclampsia and preterm delivery. Research towards one that is favorable to the success of pregnancy. KEY WORDS: allogeneic fetus, cellular immune effectors, immunomodulation in pregnancy INTRODUCTION rejection; one of these was that pregnancy induces a One of the basic tenets of immunology is that state of immunosuppression in the mother because the host immune system recognizes anything that is of which rejection reactions are either not induced foreign or “non-self”, mounts an immune response or are not effective[1]. Subsequent experimentation against it and then eliminates it. Thus, pathogens, has demonstrated the lack of a generalized, toxins and foreign antigens in general are recognized systemic state of immunosuppression, though a and eliminated. This holds true for foreign cells and sort of immunomodulation, or manipulation of tissues as well, which is why tissues from other maternal immunity towards a less harmful and individuals are recognized as foreign and then more conducive status seems to be in effect. In fact, rejected. How then is the fetus not rejected? The some immune system factors actually act as positive fetus is derived from both paternal and maternal growth factors for the placenta, as we shall see later; genes, thus the fetus expresses both paternal and thus, the maternal immune system may actually maternal antigens. Paternal antigens, such as the contribute to nurturing the conceptus and to the strongly antigenic human leukocyte antigens (HLA) success of pregnancy. could well be foreign to the maternal host and could stimulate maternal immune responses which could The Maternal Immune System during Normal potentially lead to the immunological rejection of Pregnancy the fetus. The fact that pregnancy does succeed has Evidence from animal experiments and clinical long been considered an immunological paradox, evidence from humans indicate that humoral a puzzle of sorts, which prompted the British responses are enhanced during pregnancy[2]. On the immunologist Peter Medawar more than 55 years other hand, cell-mediated immune reactions such as ago to ask “How does the mother contrive to nourish delayed-type hypersensitivity, natural killer (NK) within herself an antigenically foreign fetus?” activity, cellular responses to intracellular infections Medawar went on to propose several mechanisms and the course of cell-mediated autoimmune for the protection of the fetus from maternal immune disorders are downregulated. These observations Address Correspondence to: Dr Raj Raghupathy, PhD, FRCPath, Department of Microbiology, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait. Tel: 25319602, Fax: 25332719, E-mail: [email protected] 94 The Immune System in Pregnancy: Friend or Foe? June 2009 suggest that there is a downregulation of membranes, cytotrophoblast and both maternal Th1-type immunity and upregulation of Th2- and fetal endothelial cells[10]. type immunity during pregnancy[2]. Th1-type IL-13, an anti-inflammatory Th2 cytokine has immunity is primarily mediated by Th1 cells and the capacity to limit inflammatory reactions that Th2-type immunity is induced by Th2 cells. Th1 may arise locally at the site of implantation and and Th2 cells are the two major subsets of CD4+ within the placenta during pregnancy. Dealtry T helper cells; these two subsets have different et al[11] demonstrated the expression of IL-13 by patterns of cytokine production and different human trophoblast cells and suggested that IL- roles in immune responses. Each subset induces 13 may play important roles in this dialogue that immune responses that are effective at handling aids in the establishment and maintenance of the certain types of pathogens, but can be ineffective, placenta. There are reports of significantly higher or even pathological if made in response to other IL-10 production by mitogen-activated PBMC in types of pathogens[3,4]. Th1 cells secrete the pro- pregnant women as compared with non-pregnant inflammatorycytokinesinterferon-γ (IFN-γ), tumor women[12]. Using a sensitive on-line quantitative necrosis factor-β (TNFβ), interleukin (IL)-2 and RT-PCR Kruse et al[13] reported significantly reduced TNFα; these Th1 cytokines activate macrophages expression of Th1 cytokine mRNA during normal and cell-mediated reactions important in resistance human pregnancy. Th1/Th2 ratios revealed a to infection with intracellular pathogens, and shift to a pronounced Th2 status. Significantly in cytotoxic and delayed-type hypersensitivity increased IL-4-producing CD4+ and CD8+ T cells (DTH) reactions. Th2 cells secrete IL-4, IL-5, IL-6, were demonstrated in normal pregnant women IL-10 and IL-13; these Th2-type cytokines induce as compared to non-pregnant women. In contrast, strong antibody production and are therefore Th1 cytokine-producing T cells were significantly commonly found in association with strong reduced in pregnancy, which is suggestive of a Th2 antibody responses that are important in combating shift in pregnancy[14]. Th2-type cytokine production infections with extracellular organisms. Which reportedly predominates in the second and third type of reactivity, Th1 or Th2, is activated first may trimesters of pregnancy[15,16] leading to a hypothesis influence the subsequent outcome; if a particular that successful pregnancy is correlated with and T cell subset is activated first or preferentially in perhaps depends on the preferential stimulation of a response, it can suppress the development of Th2 cytokine-producing T cells. the other subset. The overall effect is that certain Besides an anti-inflammatory effects mediated responses are dominated by either humoral (Th2) by Th2 cytokines, several other non-Th2 cytokines or cell-mediated (Th1) immunity[3,4]. Furthermore, have positive influences on the conceptus; Th1 cytokines such as IL-2, TNF-α and IFN-γ cytokines such as IL-3, granulocyte-macrophage generally tend to provoke inflammatory cellular colony-stimulating factor (GM-CSF) and colony- immune reactions and are thus also referred to as stimulating factor-1 (CSF-1) have been shown to act pro-inflammatory cytokines, while Th2 cytokines as growth factors for the placenta[2]. such as IL-10, IL-13 and IL-4 are considered Thus, we can view normal, successful pregnancy anti-inflammatory cytokines as they tend to as a situation in which the maternal immune system downregulate inflammatory reactions. acts in a “friendly” manner, either not generating What is the Th1/Th2 status during normal strong rejection reactions or keeping such reactions pregnancy? Pregnancy seems to bring about a under check. We can view this as a sort of a shift towards Th2 bias. Th2 cytokines have been “friendly”, protective role of the immune system in detected in post-partum human placental tissue[5], nurturing the conceptus and ensuring the success amniotic fluid[6], endometrium and decidua of of pregnancy. early pregnancy[7], and in supernatants from cultures of endometrial cells, decidual stroma[7], Maintenance of a Protective Th2 Status during cytotrophoblast[5] and amnion epithelial cells. Pregnancy Piccinni et al[8] demonstrated significantly If pregnancy brings about a protective Th2-bias, higher levels of IL-4- and IL-10-producing T cell how is this bias maintained? Cytokines, hormones clones from the decidua of women with normal and other molecules appear to play critical roles in pregnancy than from women with unexplained directing the immune reactivity towards a Th2 bias recurrent spontaneous miscarriage (RSM). Some and then maintaining it that way. The Th2-inducing Th2 cytokines have been shown to be expressed effect of IL-4 predominates over other cytokines, in the human placenta; IL-10 is synthesized by the so that if IL-4 levels reach a given threshold, decidua, chorion and amnion cells of the placenta[9], differentiation of Th cells into the Th2 phenotype IL-4 is expressed by the decidua, amniochorionic occurs. June 2009 KUWAIT MEDICAL JOURNAL 95 One of the most vital cytokines that helps in the presence of lower levels of the Th1 cytokines
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