Placenta 35 (2014) 77e84

Contents lists available at ScienceDirect

Placenta
journal homepage: www.elsevier.com/locate/placenta

Current opinion

Can we fix it? Evaluating the potential of placental stem cells for the
treatment of pregnancy disorders
J.L. James*, S. Srinivasan, M. Alexander, L.W. Chamley
Department of Obstetrics and Gynaecology, University of Auckland, New Zealand

a r t i c l e i n f o a b s t r a c t

Article history: In pregnancy disorders such as pre-eclampsia, intrauterine growth restriction (IUGR) and recurrent
Accepted 22 December 2013 miscarriage a poorly functioning placenta is thought to be a major component of the disease process.
However, despite their prevalence, we currently have no way to fix dysfunctional placentae or directly
Keywords: treat these disorders. Over the past two decades our understanding of the role that stem cells play in
Placenta organ development and regeneration has expanded rapidly, and over the past 5 years the therapeutic use
Stem cell
of stem cells to both regenerate damaged tissues, and act as potent modulators of diseased microenvi-
Regenerative medicine
ronments, has become a reality in many organs including the heart, kidney, liver, skin and eye. Over its
Pre-eclampsia
IUGR
short lifespan the placenta undergoes rapid and continuous growth and differentiation, meaning that
placental ‘organogenesis’ only truly ends at delivery, and thus stem cells are likely to play important roles
in placental function for the duration of pregnancy. Two populations of stem cells exist in the placenta
that contribute to this on-going growth and differentiation: trophoblast stem cells and mesenchymal
stem cells. This review will address our current understanding of how each of these stem cell populations
contributes to successful placental function, how epithelial and mesenchymal stem cell populations are
being translated to the clinic in other fields, and whether these advances can teach us anything about
how placental stem cells could be used to fix faulty placentae in the future.
Ó 2013 Elsevier Ltd. All rights reserved.

1. Introduction significant and on-going part of medical practice in many different

In diseases of pregnancy such as intrauterine growth restriction
(IUGR) a poorly functioning placenta is thought to be a major
component of the disease process. However, despite our absolute
reliance on the placenta, we do not understand the basic biological
processes that underpin placental formation, nor why these may
fail, and we cannot effectively treat faulty placentae. Imagine that
we could fix the failing placenta by redirecting cell lineage differ-
entiation or, by implanting stem cells to replace poorly functioning
parts of the placenta. To do this requires harvesting the enormous
potential of stem cells to improve placental function. At present,
stem cell therapies to treat placental disorders seem like a far-
fetched idea, but in reality there are currently hundreds of clin-
ical trials investigating the use of stem cells as therapeutics regis-
tered on the US clinical trial database (clinicaltrials.gov), and it is
likely that advances in stem cell biology will lead to major changes
in medical care in the future. As stem cell therapies become a
* Corresponding author. Department of Obstetrics and Gynaecology, FMHS,
University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland, New
Zealand. Tel.: þ64 93737599.
E-mail address: j.james@auckland.ac.nz (J.L. James).
medical fields in the future, how do we ensure that obstetric
medicine is not left behind? This review aims to address our cur-
rent understanding of how stem cells contribute to successful
placental function, how similar mesenchymal and epithelial stem
cell populations are being translated to the clinic in other fields, and
whether these advances can teach us anything about how placental
stem cells could be used to fix faulty placentae in the future.
2. How do stem cells contribute to normal placental
function?
Following conception the newly fertilised oocyte undergoes a
series of divisions producing equipotent daughter cells until at the
32/64 cell stage the trophectoderm separates from the inner cell
mass. At nidation, following contact with the decidua the outer
trophectoderm layer begins to form the first primitive trophoblast
populations e the primitive cytotrophoblast and primitive syncy-
tiotrophoblast [1]. As the early cytotrophoblast populations pro-
liferate they form invaginations into which mesenchymal cells
derived from the differentiating inner cell mass invade, forming the
first placental villi at around 12 days post-fertilisation [1]. There-
fore, our current understanding is that the placenta is originally

0143-4004/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.placenta.2013.12.010
78 J.L. James et al. / Placenta 35 (2014) 77e84
formed from two stem cell populations; 1) trophoblast stem cells
(TSC) derived from the trophectoderm that go on to form all the
differentiated trophoblast lineages of the placenta, and 2) mesen-
chymal stem cells (MSC) that form all non-trophoblast cells of the
villous core. As the placenta continues to develop it undergoes an
intricate programme of organogenesis well in advance of the
development of individual fetal organs. Indeed, the placenta is the
first fetal organ in which de novo blood vessel development occurs,
with the first blood vessels evident in tertiary villi at just 15 days
post-fertilisation, a time when the embryo exists only as the three
ectodermal, endodermal and mesodermal layers and contains no
blood vessels [1,2].
2.1. Mesenchymal stem cells
Mesenchymal Stem Cells (MSC) are multipotent cells that are
precursors to tissues of mesodermal lineages. MSCs were first iso-
lated from bone marrow in 1974 [3], and have now been identified
in almost all tissues, including muscle, adipose tissue, lung,
Wharton’s Jelly, umbilical cord blood and placenta [4,5]. In order for
cells to be characterised as MSCs they must be capable of adhering
to plastic and differentiation into the three major mesenchymal
lineages; adipocytes, chondrocytes or osteocytes [6]. MSCs must
also express characteristic cell surface markers including CD73,
CD90, CD105 and HLA-A2 and lack expression of makers of other
cell lineages including CD34, CD45, CD14 or CD11b, CD79a or CD19
and HLA-DR [6].
Placental MSCs have been postulated to play an important role
in placental development and function by developing the branch-
ing villus structure of the placenta and contributing to vasculo-
genesis and angiogenesis. Vasculogenesis (the de novo synthesis of
blood vessels) begins in the placenta with a change in morphology
of MSCs at around 15e20 days post-fertilisation, which coincides
with the appearance of haemangiogenic stem cells that aggregate
into cell cords [7,8]. These haemangiogenic stem cells then differ-
entiate into CD34 positive endothelial cell cords in which primitive
lumens are evident from 23 to 26 days post-fertilisation [7,8]. These
vessels are connected by microvascular tubes, and by day 30 post-
fertilisation (six and a half weeks of gestation) a connecting
network of larger vascular structures with clear lumens are evident
within the placenta [7]. In an adult, vasculogenesis occurs during
tissue remodelling, wound healing and tumour growth and in-
volves the differentiation of existing bone marrow derived endo-
thelial progenitor cells into endothelial cells [9]. However, no bone
marrow derived endothelial progenitor cells exist in the placenta at
the beginning of pregnancy, and therefore placental vasculogenesis
occurs under very different circumstances. Instead, it has been
proposed that placental vasculogenesis is initiated by the differ-
entiation of placental MSCs [8] (Fig. 1).
MSC plasticity is influenced by the tissue of origin, and corre-
spondingly placental MSCs demonstrate limited potential to
differentiate into unrelated cell types such as cardiomyocytes and
skeletal muscle, and are less efficient at differentiating into osteo-
cytes and adipocytes than their bone marrow derived counterparts
[10]. However, several MSC populations, including those derived
from bone marrow and amniotic membrane, have demonstrated an
inherent predisposition to differentiate into an endothelial
phenotype [11,12], and the pro-angiogenic environment generated
by trophoblast secretion of angiogenic factors such as VEGF family
members, angiopoietins, FGF and PDGF, strongly suggests that
MSCs within placental villi are likely to have a similar predisposi-
tion [13]. Bone marrow-derived MSC treated with VEGF can be
induced to differentiate into endothelial-like cells that express both
vWF and Flt1 [14,15]. In a similar manner, MSC isolated from first
trimester placental villi and cultured in commercial endothelial
growth media also adopt an endothelial-like cobblestone
morphology and up-regulate early endothelial lineage cell surface
markers including VEGFR2, but to date conditions have not been
established to induce the up-regulation of late endothelial markers
such as CD31 or vWF by cells derived from placental MSC [10].
As placental MSC reside in a peri-vascular niche in the placenta
throughout gestation, it is likely that they also continue to support
the expansion of the placental vascular network by contributing to
the process of angiogenesis, which takes over from vasculogenesis
as the dominant mechanism for vascular development at around 32
days post-fertilisation [4,16,17]. This switch coincides with the
onset of circulation between the placenta and fetus via the um-
bilical cord [17], thus opening up the possibility that both MSC
originating in the placenta, and MSC circulating in fetal blood can
begin to contribute to placental vascular development from that
time point. There are two forms of angiogenesis that contribute to
the placental vascular network. Branching angiogenesis, which
involves the proliferation and migration of endothelial cells to
elongate and form lateral extensions from existing endothelial
tubes, leads to the formation of a branching vascular tree and is the
predominant mechanism of angiogenesis in the placenta between
weeks 6e24 of gestation. Branching angiogenesis results in the
formation of terminal capillaries, which are evident as highly coiled
blood vessels with a dilated lumen located close to the overlying
trophoblast to ensure efficient exchange between the maternal and
fetal circulations [17]. After 24 weeks of gestation non-branching
angiogenesis predominates, which results in the elongation of
vascular capillary loops as a result of endothelial cell proliferation,
and ensures that the placenta is able to keep up with fetal growth
demands during the third trimester of pregnancy [17].
2.2. Trophoblast stem cells
Trophoblasts are epithelial cells that are unique to the placenta.
There are at least three mature subtypes of trophoblast in the hu-
man placenta; cytotrophoblasts, extravillous trophoblasts and the
syncytiotrophoblast, each of which have separate functions that are
required to ensure pregnancy success. All of these three mature
trophoblast populations are derived initially from the trophecto-
derm lineage of the pre-implantation blastocyst. In the mouse, TSCs
that give rise to all murine trophoblast types have been isolated
from the trophectoderm, and as a result of experiments employing
these TSCs we have a good understanding of murine trophoblast
differentiation [18]. However, the murine placenta is anatomically
very different to the human placenta and murine trophoblast lin-
eages bear little resemblance to human trophoblast lineages [18].
Obtaining human TSCs would be of great value to better understand
how mature trophoblast populations are formed in the human
placenta and ultimately how human TSCs may be used to fix faulty
placentae.
Traditionally villous cytotrophoblasts were termed ‘stem like
cells’ that were believed to be multi-potent and give rise to all the
mature trophoblast lineages. However, many groups including ours
have presented evidence to challenge the multi-potent nature of
villous cytotrophoblasts, and have instead suggested that different
cytotrophoblast sub-populations primed to differentiate into syn-
cytiotrophoblast or extravillous trophoblast exist [19e21]. Indeed, a
feature of other epithelial stem cell populations is their generation
of highly proliferative progeny, referred to as transiently amplifying
cells, that are intermediate between stem and terminally differ-
entiated cells. The transiently amplifying cells divide actively for a
period of time to expand the pool of progenitor cells able to
differentiate into the terminal cell lineages of the tissue, thus
increasing the number of differentiated progeny a stem cell can
produce, and enabling the stem cell itself to divide infrequently and
 J.L. James et al. / Placenta 35 (2014) 77e84 79

avoid the accumulation of replication-associated damage [22]. In
the human placenta, it is likely that villous cytotrophoblasts
represent such a transiently amplifying population, and consensus
is now growing that a ‘true’ TSC population must exist that drives
cytotrophoblast expansion. Despite this theoretical consensus, in
practice, attempts by researchers to isolate and study human TSCs
in vitro have encountered many difficulties (reviewed in Ref. [18])
and to date a true human trophoblast stem cell remains elusive.
3. Is placental stem cell function perturbed in pregnancy
disorders?
In diseases of pregnancy such as pre-eclampsia and IUGR a
poorly functioning placenta is thought to be a major component of
the disease process. This placental dysfunction incorporates inad-
equate differentiation and function of cells derived from both the
trophoblast and mesenchymal lineages [17]. Whilst our under-
standing of the end-stage pathophysiology of pre-eclampsia and
IUGR has come a long way in the past decade, there is still a huge
amount we do not understand about the root cause of these dis-
orders, and understanding how stem cells contribute to normal and
abnormal placentation has significant promise to rectify this.
However, perhaps because the application of stem cell biology to
the placenta has largely been a recent phenomenon, at present we
have almost no understanding of how either trophoblast or
mesenchymal stem cell dysfunction may contribute to defects in
placentation.
The lack of a validated human TSC is an obvious road block to
understanding whether TSC deficiencies contribute to placental
diseases. However, even for MSCs, which can be readily isolated
from placentae throughout gestation, only a handful of studies
directly examining differences in placental MSC phenotype/

Fig. 1. Schematic diagram illustrating how MSC may contribute to placental vasculogenesis and angiogenesis during pregnancy. As no bone marrow derived endothelial progenitor
cells (EPC), which contribute to vasculogenesis in adult tissue, exist at the time of placental vasculogenesis, it has been hypothesised that early in pregnancy placental EPC/
endothelial cells are derived from placental MSC. (VSMC: vascular smooth muscle cells).
80 J.L. James et al. / Placenta 35 (2014) 77e84
function in pregnancy disorders have been published. All of these
studies highlight the potential importance of MSC in pregnancy
disorders. Placental MSCs isolated from pre-eclamptic placentae
have a more pro-inflammatory cytokine profile in comparison to
those from normal placentae, and conditioned media from pre-
eclamptic MSCs increased sFlt1 and macrophage migration inhib-
itory factor (MIF) secretion by villous explants, indicating that
either free or exosome bound factors released from MSCs may
induce a pre-eclamptic placental phenotype [23]. Defects are also
observed in MSCs isolated from the decidua of pre-eclamptic
placentae, which produce higher levels of soluble ICAM-1, a cyto-
kine associated with inflammation, and SDF-1, a cytokine that
stimulates MSC migration [24]. MSCs derived from the decidua of
pre-eclamptic pregnancies also show increased expression of miR-
16, which has anti-angiogenic consequences as miR-16 over-
expressing MSCs produce less VEGF-A and endothelial cells
exposed to microparticles from these cells have a reduced capacity
to form vascular networks in vitro [25].
In IUGR pregnancies, endothelial progenitor cells derived from
cord blood have reduced vasculogenic capacity in comparison to
those isolated from cord blood from normal pregnancies [26].
Furthermore, endothelial colony forming cells from low birth
weight pre-term babies have a reduced ability to migrate, prolif-
erate or form angiogenic tubes in vitro, and have increased
expression of anti-angiogenic genes such as thrombospondin-1
[27]. Such endothelial progenitor cells are also thought to exist in
the placenta prior to the establishment of the feto-placental cir-
culation [2,28], and thus functional differences in fetal derived
endothelial progenitor populations may also hint at differences in
placental MSC function, particularly if such differences are a result
of genetic or epigenetic mechanisms common to both fetus and
placenta. Therefore, it is surprising that differences in MSC between
normal and IUGR pregnancies have never been directly compared,
and this is an area which should be the focus of future research.
4. Stem cells and regenerative medicine e the future of
therapeutic interventions?
Over the past two decades our understanding of the role that
stem cells play in organ development and regeneration has
expanded rapidly, and over the past 5 years the therapeutic use of
stem cells to both regenerate damaged tissues, and act as potent
modulators of diseased microenvironments, has become a reality in
many organs including the heart, kidney, liver, skin and eye. Whilst
many adult stem cell populations exist in the body, this review will
focus on those directly applicable to the placenta e MSC and
epithelial stem cells.
4.1. Mesenchymal stem cells
On the public clinical trials database (www.clinicaltrials.gov)
there are currently over 350 registered clinical trials utilising MSC-
based cell therapies. MSCs have shown particular promise in the
treatment of tissue injury and degenerative diseases. One of the
main areas of interest has been in myocardial repair, where MSC
therapy has been shown to improve cardiac function [29,30],
although the exact mechanism by which they are able to do this
remains controversial. After reaching the heart, MSCs may incor-
porate into and contribute to the specific functions of cardiac tis-
sue; this is known as engraftment. However, whilst MSCs are
capable of persisting in different tissues for several months
following systemic administration, the proportion of cells that
actually engraft is relatively small [31]. Interestingly, injury appears
to improve engraftment of MSC and following systemic delivery
MSC engraftment in ischaemic cardiac tissue is significantly higher
than engraftment into healthy cardiac tissue [32]. However,
engraftment rates are still low (0.1e3%), suggesting that thera-
peutic benefits are mediated by an indirect primary mechanism
rather than structural integration and differentiation into cardiac
myocytes [31,33].
It is becoming increasingly apparent that rather than just
directly contributing to cell regeneration, the therapeutic effects of
MSC may arise as a result of their ability to modulate the local
environment, resulting in both the suppression of inflammation
and the promotion of vascularisation [34,35]. Preferential migra-
tion of MSC appears to be mediated by the release of chemotactic
signals from injured tissues, and MSC express a wide range of
chemokine receptors (CCR1, CCR2, CCR5, CXCR1, CXCR4 and CXCR5)
that appear to be important in site-directed migration of MSC
[36,37]. Once at the site of injury, MSC have unique immunomod-
ulatory properties that may reduce immune-mediated damage to
chronically inflamed tissues by altering the activities of different
cells of the innate and adaptive immune systems (Fig. 2). Specif-
ically, MSC secrete soluble factors such as prostaglandins (PGE2),
indoleamine 2,3-dioxygenase (IDO) and nitric oxide (NO) that
inhibit proliferation of T lymphocytes and down regulate T and B
lymphocyte production of IFNg and TNFa, while up-regulating their
production of IL-10, resulting in an anti-inflammatory environment
[38e40]. Additionally, MSC inhibit the proliferation of Natural Killer
cells and modulate the immune profile of macrophages, both of
which are important in regulating the placental and uterine envi-
ronment [41,42].
MSC promote vascularisation by the secretion of both pro-
angiogenic factors such as VEGF and TGFb that stimulate endo-
thelial growth [43], and anti-apoptotic factors such as IGF-1 and
SFRP1 which may prevent endothelial cell death [44,45]. In
response to hypoxia-reperfusion injury, MSC stimulate nearby cells
to increase their expression of VEGF, which in turn causes MSC to
up-regulate VEGF receptors 1 and 2 [46]. Concomitant expression of
these VEGF family members stimulates angiogenic organisation of
endothelial tubes in capillary networks. Indeed, incubation of MSC-
conditioned medium with cardiomyocytes subjected to hypoxia
reperfusion injury demonstrates a cardioprotective effect by
reducing the severity of cell damage [47].
4.2. Epithelial stem cells
Epithelial stem cells are responsible for the continuous regen-
eration and repair of squamous epithelial layers in the skin, lung,
cornea, colon and glandular tissue. However, in contrast to the
accelerating pace of MSC use in therapeutic medicine, there are less
than twenty registered trials employing stem cells from epithelial
tissues on the public clinical trials database (www.clinicaltrials.
gov). The application of epithelial stem cells to regenerative med-
icine differs from MSC as they do not home to sites of inflammation
and act in an immunomodulatory manner, nor have they been
shown to exhibit the same paracrine effects to restore tissue
function. Thus therapies involving epithelial stem cells are largely
aimed at either the generation of epithelial tissue in vitro for future
transplant into patients, or direct engraftment of stem cells
following in vivo administration in order to regenerate damaged
tissue or replace genetically defective cell populations.
Skin has been at the forefront of regenerative medicine using
epithelial stem cells. Stratified epithelial stem cells were first used in
regenerative medicine in the early 1980’s for the treatment of burn
patients [48], and subsequent advances and refinements in such
therapies now improve the lives of severe burn patients worldwide
[22]. However, such ex vivo organ culture and transplant is not an
option applicable to in utero treatment of placental disorders. In vivo
regeneration of epithelial tissues has also been undertaken in a
 J.L. James et al. / Placenta 35 (2014) 77e84
Fig. 2. Schematic diagram demonstrating how MSC modulate the activities of a range of immune cells populations.
number of models, the most successful of which is the cornea of the
eye. The cornea consists of a transparent flat epithelial layer that is
formed from a specific population of epithelial stem cells, termed
limbal stem cells, which reside in the corneal limbus, a narrow zone
found at the border of the cornea and the sclera (the white of the
eye). Corneal transplants involve allogenic stromal engraftment,
after which the outer surface of the cornea is eventually replaced by
host-derived epithelium generated by undamaged autologous
limbal stem cells [49]. However, if the limbus is damaged, the
epithelium is derived from invasion of conjunctival cells, resulting
in vascularisation, inflammation and corneal opacification.
Engraftment of limbal stem cells is able to overcome this problem,
and has been shown to restore corneal integrity and visual acuity in
78% of patients over the past decade of use [49].
As in the cornea, a defining characteristic of epithelial cells
across a range of tissues is their close apposition to the underlying
mesenchymal cells. Due to the close proximity of these cells it is
perhaps not surprising that interactions between them are a key
part of tissue morphogenesis. Mesenchymal cells are able to control
epithelial cell-fate in a number of tissues [50], and in turn epithelial
cells have been shown to ‘talk back’ to MSCs to facilitate the
organisation of tissue structure [22,51]. In a similar manner, the
importance of interactions between MSCs and TSCs throughout
pregnancy means that transplanting MSC into the placenta may
also help promote trophoblast function, highlighting the need to
better understand how these cells interact to result in successful
placentation.
5. Stem cells in the obstetric clinic e can we fix pregnancy
disorders?
Unlike most organs, the placenta undergoes extremely rapid
growth and differentiation throughout its entire lifespan until its
‘death’ at the time of delivery. This is perhaps why it has shown
such promise as a rich source of MSCs, and highlights the oppor-
tunity that stem cells have to make significant impact on placental
function.
81
5.1. Practical applications
As so little is known about the exact role of human TSCs in
pregnancy disorders, the most obvious therapeutic applications of
stem cells to pregnancy disorders at present revolve around MSCs.
An important therapeutic effect of MSCs is the induction of a pro-
angiogenic environment. Insufficient and disordered placental
angiogenesis is a common feature of IUGR placentae [52]. In such
cases re-establishment of an efficient blood supply that maximises
nutrient exchange is crucial for the fetus to reach its optimal
growth potential. As MSCs are thought to play a normal physio-
logical role in placental angiogenesis, MSCs transplanted into IUGR
placentae may preferentially migrate to sites of oxygen deficit
within the placenta where they may act on placental blood vessels
to stimulate angiogenesis and improve nutrient transfer and fetal
growth.
A number of pregnancy complications also involve placental
lesions that damage the vascular tree and impair nutrient transfer,
and stem cell therapies aimed at tissue regeneration may be
particularly effective in the treatment of these disorders. Placental
infarction affects around 30% of hypertensive pregnancies [53],
resulting in the interruption of fetal blood supply to a region of the
placenta and subsequent ischaemic tissue damage [54]. Such in-
farcts can exacerbate placental insufficiency and further contribute
to the development of IUGR. In animal models of myocardial
infarction, transplantation of placental MSCs results in increased
blood flow, increased vessel density and delayed necrosis, sug-
gesting that the transplanted MSCs are responsible for inducing
angiogenesis [55,56]. By extrapolation, administration of MSCs to
an infarcted placenta may result in enhanced angiogenesis and
regeneration of the villous tissue.
In all pre-clinical and clinical studies using MSCs, migration into
the damaged tissue is a crucial process for the efficacy of treatment.
Therefore, understanding the tissue and cell specific factors that
regulate MSC trafficking, both from the site of administration and
to/from their stem cell niche within the placenta, will be crucial for
effective administration of MSCs. In vivo, MSCs have been delivered
82 J.L. James et al. / Placenta 35 (2014) 77e84
by both intravenous injection and local intra-arterial injection, with
the former demonstrating that circulating MSCs can specifically
mobilise to sites of injury or inflammation, while the later can
enhance the accumulation in specific target organs [32,57]. The
ability of MSCs to be delivered through an arterial route suggests
that they could be administered to the placenta in utero via the
umbilical artery, a delivery method previously established for fetal
transfusions in rhesus disease [58]. Such a route would be more
favourable than maternal systemic administration in which a sig-
nificant maternal ‘first pass’ effect is likely to occur whereby stem
cells would traffic into maternal tissue prior to reaching the uterine
circulation, leaving a potentially small proportion of cells available
to cross into the placenta.
5.2. Allogenic transplantation or therapeutic targeting?
Whilst the isolation of MSCs from fetal cord blood in the third
trimester may be an option for autologous treatment of pregnancy
disorders, due to the relatively short window of treatment limiting
the time these cells could be expanded in culture, and the potential
for autologous MSCs to suffer from the same underlying defects as
those that resulted in inadequate placental function in the first place,
allogenic transplantation of stem cells is likely to be necessary to treat
placental disorders. Fortunately due to their unique immunopheno-
type, allogenically transplanted MSC are well tolerated. A recent
clinical trial comparing the effects of allogeneic and autologous MSC
in patients with ischaemic cardiac damage found that improvements
in cardiac tissue structure were comparable between the two groups,
and only 3.7% of patients generated donor-specific antibodies in the
absence of immune suppression [30]. The placenta is the only natu-
rally occurring tissue transplant and consequently placental MSCs
may induce an even greater level of immunotolerance than those
derived from other tissue types due to their lack of expression of
major histocompatibility class-II (MHC II) and the co-stimulatory
molecules (CD80, CD86, CD83 and CD40) [19,18].
When considering the situation in utero it is unlikely the pri-
mary host e the fetus itself - would reject the transplanted cells, as
its immune system is relatively immature and still learning to
recognise self from non-self antigens. Indeed, allogenic haemato-
poietic stem cell transplantation in utero is able to induce donor
specific tolerance in mice [59]. However, a secondary host must
also be considered e the mother. The placental barrier is somewhat
permeable, with maternal leukocytes able to traffic into the fetus in
response to intra-uterine transplantation of haematopoietic stem
cells in mice [60], and fetal cells, including MSC, released from the
placenta may also engraft in maternal tissues resulting in maternal
microchimerism [61], thus the ability of allogenically transplanted
placental stem cells to successfully hide from the maternal immune
system is imperative to the success of such treatments.
If allogenic transplantation does not prove to be therapeutically
viable, an alternative approach could be to stimulate stem cell
function pharmacologically using peptides or nanoparticles specific
to placental stem cell populations [62,63]. This may be of particular
importance for the therapeutic targeting of TSC as it is unclear
whether epithelial stem cells transplanted outside their niche are
able to migrate within tissue to sites of action. The organised
manner in which the migration of epithelial stem cells away from
their niche regulates their differentiation programme, combined
with the fact that epithelial stem cells do not circulate in the blood
like MSC, and are not found outside epithelial tissues, suggests that
their ability to function as stem cells is much more niche dependent
than MSC. Therefore epithelial stem cells are unlikely to be suitable
targets for intravenous injection, and in organs such as the placenta
where site-specific transplantation is unlikely to be feasible, phar-
macological stimulation of these cells rather than direct
transplantation may be the more effective treatment option.
Further understanding of TSC function in the future will help
elucidate the potential for these cells to be targeted therapeutically,
with potential implications for the function of downstream mature
trophoblast lineages in the placenta.
5.3. Safety
The mantra of ‘first do no harm’ is never more true than when
treating pregnancy disorders, and such caution around adverse
fetal outcomes means that the field of obstetric medicine has
rightly been extremely cautious in developing new therapies.
Therefore, one of the major questions that must be addressed in
considering stem cell based therapies for the treatment of placental
disorders is the potential risks involved. Important precedents to
evaluate the potential efficacy and safety of such therapies may
come from the field of fetal medicine, where allogenic intra-uterine
transplantation of haematopoietic and neural stem cell populations
has been trialled in a number of animal models in order to develop
treatments for a range of lymphohematopoietic, neural, metabolic
and genetic disorders [64]. Indeed, successful treatment of osteo-
genesis imperfecta (a degenerative bone disorder) was achieved by
the injection of allogeneic MSC into the umbilical vessels at 32
weeks of gestation, with no signs of fetal distress and successful
preservation of the pregnancy [65].
Treatments for placental disorders would clearly need to be
extensively validated, first in in vitro models to understand how
stem cells injected into the placenta directly or via the umbilical
circulation may migrate and function within the tissue, and then in
haemochorial animal models in order to evaluate not only their
safety and efficacy, but the potential for fetal chimerism as a result of
cellular engraftment outside the placenta, and the long term effects
that this may have. However, the more we understand about stem
cell therapies in adult regenerative medicine, the more we may be
able to circumvent any potential issues in intra-uterine stem cell
delivery by reducing engraftment, priming stem cells for specific
tasks, rendering cells non-proliferative prior to administration, or
alternatively developing pharmaceutical agents that specifically
target stem cells within the placenta to correct deficiencies in their
function or induce proliferation and/or differentiation.
6. Conclusions
So the question remains e can we fix it? The significant promise
that stem cell therapies have for the clinical treatment of pregnancy
disorders means that surely we must try. Both MSC and TSC have
therapeutic potential, but the differences in function of these stem
cell types mean that while MSC may be able to be directly trans-
planted into the placenta and migrate to sites of action, placental
inadequacies arising from potential TSC dysfunction may be better
treated by exogenously stimulating stem cells already resident in
the placenta. Many fields of medicine have advanced by adminis-
tering treatments that have shown to be effective and safe without
fully understanding the mechanisms of action behind their efficacy.
However, due to the plasticity of the fetus in utero, in obstetrics we
must take the more measured approach and obtain a comprehen-
sive understanding of how stem cells function in both healthy and
dysfunctional placentae, before we can determine how best to tap
into their therapeutic potential to treat pregnancy disorders.
Acknowledgements
Dr James is supported by a grant from the Auckland Medical
Research Foundation. The authors wish to thank Dr Olivia Holland
for allowing the use of her image of a first trimester placenta.
 J.L. James et al. / Placenta 35 (2014) 77e84 83

References [27] Ligi I, Simoncini S, Tellier E, Vassallo PF, Sabatier F, Guillet B, et al. A switch
toward angiostatic gene expression impairs the angiogenic properties of
endothelial progenitor cells in low birth weight preterm infants. Blood
[1] James JL, Carter AM, Chamley LW. Human placentation from nidation to 5
2011;118(6):1699e709.
weeks of gestation. Part I: what do we know about formative placental
[28] Demir R, Kayisli UA, Cayli S, Huppertz B. Sequential steps during vasculo-
development following implantation? Placenta 2012;33(5):327e34.
genesis and angiogenesis in the very early human placenta. Placenta
[2] Boyd J, Hamilton W. The human placenta. Cambridge: W. Heffer & Sons Ltd;
2006;27(6e7):535e9.
1970.
[29] Przybyt E, Harmsen MC. Mesenchymal stem cells: promising for myocardial
[3] Friedenstein AJ, Deriglasova UF, Kulagina NN, Panasuk AF, Rudakowa SF,
regeneration? Curr Stem Cell Res Ther 2013;8(4):270e7.
Luria EA, et al. Precursors for fibroblasts in different populations of hemato-
[30] Hare JM, Fishman JE, Gerstenblith G, DiFede Velazquez DL, Zambrano JP,
poietic cells as detected by the in vitro colony assay method. Exp Hematol
Suncion VY, et al. Comparison of allogeneic vs autologous bone marrow-
1974;2(2):83e92.
derived mesenchymal stem cells delivered by transendocardial injection in
[4] Castrechini NM, Murthi P, Gude NM, Erwich JJ, Gronthos S, Zannettino A, et al.
patients with ischemic cardiomyopathy: the POSEIDON randomized trial.
Mesenchymal stem cells in human placental chorionic villi reside in a vascular
JAMA 2012;308(22):2369e79.
Niche. Placenta 2010;31(3):203e12.
[31] Devine SM, Cobbs C, Jennings M, Bartholomew A, Hoffman R. Mesenchymal
[5] Wei X, Yang X, Han ZP, Qu FF, Shao L, Shi YF. Mesenchymal stem cells: a new
stem cells distribute to a wide range of tissues following systemic infusion
trend for cell therapy. Acta Pharmacol Sin 2013;34(6):747e54.
into nonhuman primates. Blood 2003;101(8):2999e3001.
[6] Dominici M, Le Blanc K, Mueller I, Slaper-Cortenbach I, Marini F, Krause D,
[32] Barbash IM, Chouraqui P, Baron J, Feinberg MS, Etzion S, Tessone A, et al.
et al. Minimal criteria for defining multipotent mesenchymal stromal cells.
Systemic delivery of bone marrow-derived mesenchymal stem cells to the
The International Society for Cellular Therapy position statement. Cytotherapy
infarcted myocardium: feasibility, cell migration, and body distribution. Cir-
2006;8(4):315e7.
culation 2003;108(7):863e8.
[7] Demir R, Kayisli UA, Seval Y, Celik-Ozenci C, Korgun ET, Demir-Weusten AY,
[33] von Bahr L, Batsis I, Moll G, Hagg M, Szakos A, Sundberg B, et al. Analysis of
et al. Sequential expression of VEGF and its receptors in human placental villi
tissues following mesenchymal stromal cell therapy in humans indicates
during very early pregnancy: differences between placental vasculogenesis
limited long-term engraftment and no ectopic tissue formation. Stem Cells
and angiogenesis. Placenta 2004;25(6):560e72.
2012;30(7):1575e8.
[8] Demir R, Kaufmann P, Castellucci M, Erbengi T, Kotowski A. Fetal vasculo-
[34] Kinnaird T, Stabile E, Burnett MS, Shou M, Lee CW, Barr S, et al. Local delivery
genesis and angiogenesis in human placental villi. Acta Anat (Basel)
of marrow-derived stromal cells augments collateral perfusion through
1989;136(3):190e203.
paracrine mechanisms. Circulation 2004;109(12):1543e9.
[9] Asahara T, Masuda H, Takahashi T, Kalka C, Pastore C, Silver M, et al. Bone
[35] Hung SC, Pochampally RR, Chen SC, Hsu SC, Prockop DJ. Angiogenic effects of
marrow origin of endothelial progenitor cells responsible for postnatal vas-
human multipotent stromal cell conditioned medium activate the PI3K-Akt
culogenesis in physiological and pathological neovascularization. Circ Res
pathway in hypoxic endothelial cells to inhibit apoptosis, increase survival,
1999;85(3):221e8.
and stimulate angiogenesis. Stem Cells 2007;25(9):2363e70.
[10] Meraviglia V, Vecellio M, Grasselli A, Baccarin M, Farsetti A, Capogrossi MC,
[36] Honczarenko M, Le Y, Swierkowski M, Ghiran I, Glodek AM, Silberstein LE.
et al. Human chorionic villus mesenchymal stromal cells reveal strong
Human bone marrow stromal cells express a distinct set of biologically
endothelial conversion properties. Differentiation 2012;83(5):260e70.
functional chemokine receptors. Stem Cells 2006;24(4):1030e41.
[11] Warrier S, Haridas N, Bhonde R. Inherent propensity of amnion-derived
[37] Ringe J, Strassburg S, Neumann K, Endres M, Notter M, Burmester GR, et al.
mesenchymal stem cells towards endothelial lineage: vascularization from
Towards in situ tissue repair: human mesenchymal stem cells express che-
an avascular tissue. Placenta 2012;33(10):850e8.
mokine receptors CXCR1, CXCR2 and CCR2, and migrate upon stimulation
[12] Tremain N, Korkko J, Ibberson D, Kopen GC, DiGirolamo C, Phinney DG.
with CXCL8 but not CCL2. J Cell Biochem 2007;101(1):135e46.
MicroSAGE analysis of 2,353 expressed genes in a single cell-derived colony of
[38] Tse WT, Pendleton JD, Beyer WM, Egalka MC, Guinan EC. Suppression of
undifferentiated human mesenchymal stem cells reveals mRNAs of multiple
allogeneic T-cell proliferation by human marrow stromal cells: implications in
cell lineages. Stem Cells 2001;19(5):408e18.
transplantation. Transplantation 2003;75(3):389e97.
[13] Lash GE, Naruse K, Innes BA, Robson SC, Searle RF, Bulmer JN. Secretion of
[39] Augello A, Tasso R, Negrini SM, Cancedda R, Pennesi G. Cell therapy using
angiogenic growth factors by villous cytotrophoblast and extravillous
allogeneic bone marrow mesenchymal stem cells prevents tissue damage in
trophoblast in early human pregnancy. Placenta 2010;31(6):545e8.
collagen-induced arthritis. Arthritis Rheum 2007;56(4):1175e86.
[14] Gang EJ, Jeong JA, Han S, Yan Q, Jeon CJ, Kim H. In vitro endothelial potential of
[40] Aggarwal S, Pittenger MF. Human mesenchymal stem cells modulate alloge-
human UC blood-derived mesenchymal stem cells. Cytotherapy 2006;8(3):
neic immune cell responses. Blood 2005;105(4):1815e22.
215e27.
[41] Spaggiari GM, Capobianco A, Abdelrazik H, Becchetti F, Mingari MC, Moretta L.
[15] Oswald J, Boxberger S, Jorgensen B, Feldmann S, Ehninger G, Bornhauser M,
Mesenchymal stem cells inhibit natural killer-cell proliferation, cytotoxicity,
et al. Mesenchymal stem cells can be differentiated into endothelial cells
and cytokine production: role of indoleamine 2,3-dioxygenase and prosta-
in vitro. Stem Cells 2004;22(3):377e84.
glandin E2. Blood 2008;111(3):1327e33.
[16] Sung HJ, Hong SC, Yoo JH, Oh JH, Shin HJ, Choi IY, et al. Stemness evaluation of
[42] Abumaree MH, Al Jumah MA, Kalionis B, Jawdat D, Al Khaldi A, Abomaray FM,
mesenchymal stem cells from placentas according to developmental stage:
et al. Human placental mesenchymal stem cells (pMSCs) play a role as im-
comparison to those from adult bone marrow. J Korean Med Sci 2010;25(10):
mune suppressive cells by shifting macrophage differentiation from inflam-
1418e26.
matory M1 to anti-inflammatory M2 macrophages. Stem Cell Rev 2013;9(5):
[17] Benirschke K, Kaufmann P. Pathology of the human placenta. New York:
620e41.
Springer-Verlag; 2000.
[43] Shohara R, Yamamoto A, Takikawa S, Iwase A, Hibi H, Kikkawa F, et al.
[18] James JL, Carter AM, Chamley LW. Human placentation from nidation to 5
Mesenchymal stromal cells of human umbilical cord Wharton’s jelly accel-
weeks of gestation. Part II: tools to model the crucial first days. Placenta
erate wound healing by paracrine mechanisms. Cytotherapy 2012;14(10):
2012;33(5):335e42.
1171e81.
[19] James J, Stone P, Chamley L. The isolation and characterization of a population
[44] Gnecchi M, Zhang Z, Ni A, Dzau VJ. Paracrine mechanisms in adult stem cell
of extravillous trophoblast progenitors from first trimester human placenta.
signaling and therapy. Circ Res 2008;103(11):1204e19.
Hum Reprod 2007;22(8):2111e9.
[45] Mirotsou M, Zhang Z, Deb A, Zhang L, Gnecchi M, Noiseux N, et al. Secreted
[20] Telugu BP, Adachi K, Schlitt JM, Ezashi T, Schust DJ, Roberts RM, et al. Com-
frizzled related protein 2 (Sfrp2) is the key Akt-mesenchymal stem cell-
parison of extravillous trophoblast cells derived from human embryonic stem
released paracrine factor mediating myocardial survival and repair. Proc
cells and from first trimester human placentas. Placenta 2013;37(7):536e43.
Natl Acad Sci U S A 2007;104(5):1643e8.
[21] Aboagye-Mathiesen G, Laugesen J, Zdravkovic M, Ebbesen P. Isolation and
[46] Chen CP, Lee MY, Huang JP, Aplin JD, Wu YH, Hu CS, et al. Trafficking of
characterization of human placental trophoblast subpopulations from first
multipotent mesenchymal stromal cells from maternal circulation through
trimester chorionic villi. Clin Diagn Lab Immunol 1996;3:14e22.
the placenta involves vascular endothelial growth factor receptor-1 and
[22] Blanpain C, Horsley V, Fuchs E. Epithelial stem cells: turning over new leaves.
integrins. Stem Cells 2008;26(2):550e61.
Cell 2007;128(3):445e58.
[47] Xiang MX, He AN, Wang JA, Gui C. Protective paracrine effect of mesenchymal
[23] Rolfo A, Giuffrida D, Nuzzo AM, Pierobon D, Cardaropoli S, Piccoli E, et al. Pro-
stem cells on cardiomyocytes. J Zhejiang Univ Sci B 2009;10(8):619e24.
inflammatory profile of preeclamptic placental mesenchymal stromal cells:
[48] Grafting of burns with cultured epithelium prepared from autologous
new insights into the etiopathogenesis of preeclampsia. PLoS One 2013;8(3):
epidermal cells. Lancet 1981;1(8211):75e8.
e59403.
[49] Pellegrini G, Rama P, Mavilio F, De Luca M. Epithelial stem cells in corneal
[24] Hwang JH, Lee MJ, Seok OS, Paek YC, Cho GJ, Seol HJ, et al. Cytokine expression
regeneration and epidermal gene therapy. J Pathol 2009;217(2):217e28.
in placenta-derived mesenchymal stem cells in patients with pre-eclampsia
[50] Birchmeier C, Birchmeier W. Molecular aspects of mesenchymal-epithelial
and normal pregnancies. Cytokine 2010;49(1):95e101.
interactions. Annu Rev Cell Biol 1993;9:511e40.
[25] Wang Y, Fan H, Zhao G, Liu D, Du L, Wang Z, et al. miR-16 inhibits the pro-
[51] Hardy MH. The secret life of the hair follicle. Trends Genet 1992;8(2):55e61.
liferation and angiogenesis-regulating potential of mesenchymal stem cells in
[52] Clausson B, Gardosi J, Francis A, Cnattingius S. Perinatal outcome in SGA births
severe pre-eclampsia. FEBS J 2012;279(24):4510e24.
defined by customised versus population-based birthweight standards. BJOG
[26] Sipos PI, Bourque SL, Hubel CA, Baker PN, Sibley CP, Davidge ST, et al. Endo-
2001;108(8):830e4.
thelial colony forming cells derived from pregnancies complicated by intra-
[53] Salgado SS, Pathmeswaran A. Effects of placental infarctions on the fetal
uterine growth restriction are fewer and have reduced vasculogenic capacity.
outcome in pregnancies complicated by hypertension. J Coll Physicians Surg
J Clin Endocrinol Metab 2013;98(12):4953e60.
Pak 2008;18(4):213e6.
84 J.L. James et al. / Placenta 35 (2014) 77e84
[54] McDermott M, Gillan JE. Chronic reduction in fetal blood flow is associated
with placental infarction. Placenta 1995;16(2):165e70.
[55] Kong P, Xie X, Li F, Liu Y, Lu Y. Placenta mesenchymal stem cell accelerates
wound healing by enhancing angiogenesis in diabetic Goto-Kakizaki (GK) rats.
Biochem Biophys Res Commun 2013;438(2):410e9.
[56] Tran TC, Kimura K, Nagano M, Yamashita T, Ohneda K, Sugimori H, et al.
Identification of human placenta-derived mesenchymal stem cells involved in
re-endothelialization. J Cell Physiol 2011;226(1):224e35.
[57] Freyman T, Polin G, Osman H, Crary J, Lu M, Cheng L, et al. A quantitative,
randomized study evaluating three methods of mesenchymal stem cell de-
livery following myocardial infarction. Eur Heart J 2006;27(9):1114e22.
[58] Schumacher B, Moise Jr KJ. Fetal transfusion for red blood cell alloimmuni-
zation in pregnancy. Obstet Gynecol 1996;88(1):137e50.
[59] Ashizuka S, Peranteau WH, Hayashi S, Flake AW. Busulfan-conditioned bone
marrow transplantation results in high-level allogeneic chimerism in mice
made tolerant by in utero hematopoietic cell transplantation. Exp Hematol
2006;34(3):359e68.
[60] Nijagal A, Wegorzewska M, Jarvis E, Le T, Tang Q, MacKenzie TC. Maternal T
cells limit engraftment after in utero hematopoietic cell transplantation in
mice. J Clin Invest 2011;121(2):582e92.
[61] Pritchard S, Wick HC, Slonim DK, Johnson KL, Bianchi DW. Comprehensive
analysis of genes expressed by rare microchimeric fetal cells in the maternal
mouse lung. Biol Reprod 2012;87(2):42.
[62] Harris LK, Kotamraju VR, Teesalu T, Ruoslahti E. Identification of novel
placental homing peptides. Placenta 2012;33(9):A44.
[63] Jones H, Klanke C, Ayres N, Habli M, Shaaban A, Keswani S, et al. Nanoparticle-
mediated trophoblast-specific gene transfer in an in vitro model of human
trophoblast. Reprod Sci 2013;20(3):303A.
[64] Fauza D. Tissue engineering and transplantation in the fetus. Elsevier; 2014.
pp. 511e29.
[65] Le Blanc K, Götherström C, Ringdén O, Hassan M, McMahon R, Horwitz E, et al.
Fetal mesenchymal stem-cell engraftment in bone after in utero trans-
plantation in a patient with severe osteogenesis imperfecta. Transplantation
2005;79(11):1607e14.