Preeclampsia: a defect in decidualization is associated with deficiency of Annexin A2

Am J Obstet Gynecol. 2020 Apr;222(4):376.e1-376.e17. doi: 10.1016/j.ajog.2019.11.1250. Epub 2019 Nov 15.


Background: Decidualization defects in the endometrium have been demonstrated at the time of delivery in women with severe preeclampsia and to linger for years, which suggests a maternal contribution to the pathogenesis of this condition. Global transcriptional profiling reveals alterations in gene expression, which includes down-regulation of Annexin A2 in severe preeclampsia patients with decidualization resistance.

Objective: We investigated the functional role of Annexin A2 deficiency during endometrial decidualization and its potential contribution to shallow trophoblast invasion during implantation and subsequent placentation using in vitro and in vivo modeling.

Study design: Annexin A2 gene and protein levels were assessed during in vitro decidualization of human endometrial stromal cells isolated from biopsy specimens that were collected from women with previous severe preeclampsia (n=5) or normal obstetric outcomes (n=5). Next, Annexin A2 was inhibited with small interference RNA in control human endometrial stromal cells that were isolated from endometrial biopsy specimens (n=15) as an in vitro model to analyze decidualization defects at the morphologic level and the secretion of prolactin and insulin-like growth binding protein-1. Annexin A2-inhibited cells were used to evaluate motility and promotion of embryo invasion. Decidualization and placentation defects of Annexin A2 deficiency were confirmed with the use of an Annexin A2-null mouse model.

Results: Annexin A2 gene and protein levels were down-regulated during in vitro decidualization of human endometrial stromal cells from women with previous severe preeclampsia compared with control individuals. To assess its role in the endometrial stroma, we inhibited Annexin A2 expression and detected decidualization failure as evidenced by impaired morphologic transformation, which was associated with altered actin polymerization and low prolactin and insulin-like growth binding protein-1 secretions. Functionally, in vitro models demonstrated that Annexin A2 inhibition failed to support embryo invasion. This finding was corroborated by reduced trophoblast spreading through human endometrial stromal cells, lack of motility of these cells, and reduced trophoblast invasion in the presence of conditioned media from Annexin A2-inhibited cells. Extending our discovery to an animal model, we detected that Annexin A2-null mice have a functional deficiency in decidualization and placentation that impairs fetal growth as a feature that is associated with severe preeclampsia.

Conclusion: Together, in vitro and in vivo results suggest that endometrial defects in Annexin A2 expression impair decidualization of endometrial stromal cells as well as the uterine microenvironment that promotes embryo implantation and placentation. Our findings highlight the maternal contribution to the pathogenesis of severe preeclampsia and suggest that evaluation of Annexin A2 may provide a novel strategy to assess a woman's risk of experiencing this disease and perhaps discover therapeutic interventions to improve decidualization.

Keywords: ANXA2 deficiency; ANXA2-null mice; decidualization resistance; human endometrial stromal cells; placentation; severe preeclampsia.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Actins / metabolism
  • Animals
  • Annexin A2 / antagonists & inhibitors
  • Annexin A2 / deficiency
  • Annexin A2 / genetics*
  • Annexin A2 / metabolism*
  • Cell Movement
  • Cells, Cultured
  • Decidua / pathology
  • Decidua / physiopathology*
  • Disease Models, Animal
  • Embryo Implantation
  • Female
  • Gene Expression / drug effects
  • Humans
  • Insulin-Like Growth Factor Binding Protein 1 / metabolism
  • Mice
  • Placentation / genetics
  • Pre-Eclampsia / genetics*
  • Pregnancy
  • Prolactin / metabolism
  • RNA, Small Interfering / pharmacology
  • Stromal Cells
  • Trophoblasts / physiology


  • ANXA2 protein, human
  • Actins
  • Annexin A2
  • Anxa2 protein, mouse
  • IGFBP1 protein, human
  • Insulin-Like Growth Factor Binding Protein 1
  • RNA, Small Interfering
  • Prolactin