- Open Access
Plasmodium falciparum exposure in utero, maternal age and parity influence the innate activation of foetal antigen presenting cells
- Nadine Fievet†1, 2,
- Stefania Varani†3, 4,
- Samad Ibitokou1,
- Valérie Briand2,
- Stéphanie Louis6,
- René Xavier Perrin5,
- Achille Massougbogji5,
- Anne Hosmalin6, 7,
- Marita Troye-Blomberg3 and
- Philippe Deloron2Email author
© Fievet et al; licensee BioMed Central Ltd. 2009
Received: 06 May 2009
Accepted: 05 November 2009
Published: 05 November 2009
Malaria in pregnancy is associated with immunological abnormalities in the newborns, such as hampered T-helper 1 responses and increased T-regulatory responses, while the effect of maternal Plasmodium falciparum infection on foetal innate immunity is still controversial.
Materials and methods
The immunophenotype and cytokine release by dendritic cells (DC) and monocytes were evaluated in cord blood from 59 Beninese women with or without malaria infection by using flow cytometry.
Accumulation of malaria pigment in placenta was associated with a partial maturation of cord blood myeloid and plasmacytoid DC, as reflected by an up-regulated expression of the major histocompatibility complex class II molecules, but not CD86 molecules. Cells of newborns of mothers with malaria pigment in their placenta also exhibited significantly increased cytokine responses upon TLR9 stimulation. In addition, maternal age and parity influenced the absolute numbers and activation status of cord blood antigen-presenting cells. Lastly, maternal age, but not parity, influenced TLR3, 4 and 9 responses in cord blood cells.
Our findings support the view that placental parasitization, as indicated by the presence of malaria pigment in placental leukocytes, is significantly associated with partial maturation of different DC subsets and also to slightly increased responses to TLR9 ligand in cord blood. Additionally, other factors, such as maternal age and parity should be taken into consideration when analysing foetal/neonatal innate immune responses.
These data advocate a possible mechanism by which PAM may modulate foetal/neonatal innate immunity.
Pregnancy-associated Plasmodium falciparum malaria (PAM) results, sometimes, in massive intervillous inflammation that contributes to placental insufficiency, impaired intra-uterine growth and consequently to low birth weight in the newborns and a higher risk of dying early in life [1–4].
Infants born to women with PAM are more predisposed to P. falciparum infection in their first year of life [5–7]. Immunological mechanisms are generally considered to play an important role in causing this susceptibility. In utero sensitization to transplacentally transferred soluble P. falciparum antigens may constitute the basis for increased susceptibility to malaria episodes in early life. Importantly, it has been demonstrated that cord blood mononuclear cells (CBMC) of neonates born to mother with PAM specifically respond to plasmodial asexual stage antigens, and that cord blood B cells produce anti-malaria specific IgM and IgE antibodies [5, 8–10], providing irrefutable evidence of in utero sensitization.
In this context, active infection in the placenta by P. falciparum was associated with hampered T-helper 1 (Th1) responses, as reflected by reduced IFN-γ production upon T-cell stimulation . In addition, the anti-inflammatory IL-10 cytokine is more frequently produced by CBMC of those born to mothers with PAM compared with non-infected mothers . CD4+CD25high regulatory T-cells (Treg) are a principal source of IL-10 in such cases . Treg are found at higher frequency in cord blood (CB) of neonates born to mothers with PAM at delivery as compared to unexposed newborns .
Because of their key function in the initiation and regulation of adaptive immune responses, it is reasonable to assume that antigen presenting cells (APC), such as monocytes and dendritic cells (DC), contribute to the modulation of foetal immune responses upon exposure to P. falciparum in utero. Indeed, DC seem to play an important role in both protective and dysfunctional immune responses against malaria in murine models [13, 14]. DC comprise a heterogeneous population of cells; myeloid DC (MDC) that orchestrate T-cell responses through a fine modulation of IL-12 secretion, while plasmacytoid DC (PDC) are an essential component of innate and adaptive immunity through secretion of type I interferons (IFN) in response to pathogens . A minor blood MDC population, blood DC antigen (BDCA)-3+ cells, has been described sharing the same ontogeny as the more frequent BDCA-1+ MDC subset [16, 17].
The foetal/neonatal immune system exhibits quantitative and functional differences from the adult one and neonatal DC have reduced ability in delivering co-stimulatory signals to T-cells as a consequence of their incomplete maturation . They also exhibit a markedly decreased capacity in secreting IL-12 and IFN-α [19, 20]. This probably contributes to the development and relative predominance of Treg in CB , although seemingly less marked in Africans vs. Europeans .
Whether and how P. falciparum infection in the mother may affect foetal innate immunity is poorly understood. One study conducted in The Gambia reported lower lipopolysaccharide (LPS)-induced IFN-γ and IL-12 activity in CBMC of newborns of mothers with PAM as compared to uninfected mothers . A more recent study revealed that CBMC of neonates born of Gabonese mothers with P. falciparum infection exhibit significantly increased IFN-γ responses upon stimulation with toll-like receptor (TLR)3 and TLR4 ligands .
Contrasting findings have also been reported on the characterization of DC subsets in CBMC of neonates born to P. falciparum-infected mothers. One study reported a significantly higher frequency of MDC , while another reported profoundly reduced numbers of PDC  as compared to unexposed newborns.
The mechanistic hypothesis behind the present study is that malaria infection in the mother may cause a dysfunctional activation of foetal APC by parasite-derived products that cross the placenta. An altered activation of foetal APC could be responsible for the impaired T-cell response that is observed in infants born to mothers with PAM.
Using flow cytometry, subpopulations of DC and monocytes were evaluated in CB of neonates from Beninese women with or without malaria infection. In addition, the impact of P. falciparum exposure in utero, on the innate activation of foetal APC was examined by stimulating CBMC with specific TLR ligands; LPS was employed to activate TLR4 on monocytes and BDCA-1+MDC, polyinosine-polycytidilic acid (PolyI:C) to selectively stimulate TLR3 expressed in MDC, and CpG-A ODN to specifically activate TLR9 expressed in PDC [16, 17, 25].
Pregnant women were enrolled after informed consent from July 2006 to January 2007; in the Hospital "Mother and Child Lagune", the main obstetrical referring hospital in Cotonou. This study was approved by the Science and Health Faculty Ethics Committee. To identify women with malaria infection, a rapid immuno-chromatographic test (Cypress®, Langdorp, Belgium) was performed on finger-pricked capillary blood before delivery. Thirty P. falciparum-infected women and twenty-nine uninfected women matched for parity and age were enrolled in the study. Twenty-five ml heparinized CB were collected immediately after delivery. According to national policy, pregnant women receive intermittent preventive treatment with sulphadoxine-pyrimethamine (SP). Despite this usage of SP was declared by only 47% of the women, while the remaining mothers declared having taken chloroquine (CQ) as chemoprophylaxis.
Determination of P. falciparum status of the mothers at delivery
Summary of the study population.
P. falciparum -positive
P. falciparum -negative
Number of subjects n = 59
Age of mother, mean ± SD, years
25.4 ± 6.1
26.3 ± 5.2
Pregnancies, no., mean ± SD
2.2 ± 1.5
2.1 ± 1.1
1-2 pregnancies (n = 41)
≥ 3 pregnancies (n = 18)
Ratio of malaria prevention (CQ/SPa) (30/27)
Declaration of malaria infection during pregnancy (%)
Reported use of bednet (%)
Neonate birth weight, mean ± SD, g
3052.8 ± 443.3
3059.6 ± 412.5
Neonate gender, female/male (21/34)
P. falciparum density at delivery:
peripheral blood, mean ± SD, iRBCb/μl
19,037 ± 55,257
intervillous blood, mean ± SD, iRBC/μl
245,764 ± 475,906
cord blood, mean ± SD, iRBC/μl
intervillous blood leukocytes with MPc, n = 59
Mononuclear cells were isolated from CB by centrifugation over Ficoll-Hypaque (Pharmacia Uppsala, Sweden). Cells were washed twice and resuspended in RPMI 1640 medium with L-glutamine (Gibco Eragny, France) supplemented with 10% foetal bovine serum (FBS, Gibco) and 50 μg/ml gentamycin to a final concentration of 2 × 106 CBMC/ml. Viability was > 99% in all tested samples as determined by Trypan blue staining.
To assess production of IL-12, CBMC were stimulated for 8 hours with LPS (100 ng/ml; Sigma Aldrich, St. Louis MO), PolyI:C (20 μg/ml; Sigma Aldrich), or synthetic haemozoin (Hz, 5 μg/ml) in the presence of Brefeldin-A (BD Pharmingen, San Diego, CA) during the last five hours of incubation. Hz was prepared from haemin chloride as described . Endotoxin levels in the Hz preparation were found to be below the threshold (<0.125 units/ml) by the Limulus-amoebocyte lysate assay (Biowhittaker, Cambrex). To assess cytokine production by CBMC upon contact with TLR9 ligands, CpG-A ODN 2216 (3 μg/ml; Metabion GmbH, Martinsried, Germany) was employed.
Immunophenotype of APC
Intracellular cytokine staining for IL-12
After stimulation, cells were incubated with FcR blocking reagent and stained with anti-HLA-DR-PerCP, anti-CD14-FITC, anti-CD19-FITC, anti-BDCA-1-PE, anti-BDCA-3-PE or isotype controls for 10 min at 4°C. Cells were then fixed with FACS lysing solution, washed and incubated in a permeabilization buffer (staining buffer with 0.25% saponin and 5% AB human serum) for 15 min at 4°C. After centrifugation, cells were stained with anti-IL-12-APC (BD Pharmingen) or alternatively APC-conjugated isotype control for 30 min at 4°C, and then analysed by flow cytometry. BDCA-1+ and BDCA-3+ cells that did not express CD19 and CD14 were gated together as MDC.
Determination of cytokine levels in plasma samples and supernatants
IFN-α levels were measured with an ELISA kit (PBL Biomedical Laboratories, Piscataway, NJ). The assay sensitivity was 12.5 pg/ml. A panel of pro-inflammatory and anti-inflammatory cytokines including IL-6, IL-10, IL-12, (MIP)-1α/CCL3; TNF-α and IFN-γ were quantified by the Human Cytokine Cytometric Bead Array Kit (BD Pharmingen) using flow cytometry. The assay sensitivity was 1.6 pg/ml; 0.13 pg/ml; 0.6 pg/ml; 0.2 pg/ml; 1.2 pg/ml; and 1.8 pg/ml for IL-6, IL-10, IL-12, MIP-1-α/CCL3, TNF-α and IFN-γ respectively. Results were formatted using the BD CBA Analysis Software.
Background values on cytokines in supernatants obtained from unstimulated cells were subtracted from data acquired from cultures in the presence of stimuli. Normally distributed variables were analysed by unpaired t test. Data that were not normally distributed even after log-transformation were analysed by the non-parametric Mann-Whitney test. To test if the age of the mother was related to parity, Spearman rank correlation was employed. Linear regression analysis on log-transformed data was used to identify dependent variables for a multivariate analysis. The significance limit was P < 0.05.
Partial activation of foetal DC is related to the presence of MP in placenta
APC absolute numbers and immunophenotype in cord blood samples.
Parameter: median (± interquartile)
% of total CBMC
13.00 ± (7.10)
0.62 ± (0.42)
0.19 ± (0.18)
0.25 ± (0.18)
624,787 ± (571,630)
23,850 ± (30,430)
8,160 ± (12,225)
9,680 ± (9,032)
% HLA-DR+ cells
93.87 ± (7.09)
93.53 ± (11.01)
59.95 ± (28.55)
82.64 ± (31.69)
132.71 ± (17.69)
162.50 ± (18.81)
118.26 ± (40.81)
129.9 ± (39.59)
% CD86+ cells
50.28 ± (34.37)
44.67 ± (22.15)
35.95 ± (20.98)
18.47 ± (13.41)
62.36 ± (30.17)
57.51 ± (21.12)
45.54 ± (17.80)
33.29 ± (13.77)
Segregation on the basis of maternal malaria infection (i.e. presence of parasites in placental and/or maternal peripheral blood) did not show differences either in the absolute number of foetal APC or in the expression levels of MHC class II and CD86 molecules in different APC subsets studied (additional file 1). However, foetal APC status segregated on the basis of presence or absence of MP in the placenta, revealed a significant up-regulation of the MHC-class II expression, but not of CD86, on BDCA-1+ and BDCA-2+ DC in CB obtained from MP-positive mothers as compared to MP-negative mothers (Figure 1B). Thus, a partial activation of foetal DC is related to the presence of MP in the placenta, and not to maternal infection at delivery.
Impact of age and parity of the mother on the frequency and activation status of foetal APC
As expected, maternal age and multiparity were related (Spearman coefficient = 0.47; P = 0.0002). The multivariate analysis showed an effect of both age and parity on CB monocytes and BDCA-1+ cells absolute numbers (age: β = +0,55 (0,10-1,00) with P = 0,02 and parity: β = +0,42 (-0,06-0,90) with P = 0,08).
Malaria status of the mother does not affect immunophenotype of foetal APC upon TLR and Hz stimulation
Immunophenotype of fetal APC upon TLR and Hz stimulation.
median (± interquartile)
% HLA-DR+ cells
89.34 ± (13.90)
89.33 ± (16.57)
89.79 ± (7.27)
88.78 ± (19.83)
87.33.40 ± (19.83)
92.62 ± (20.13)
91.03 ± (10.10)
90.46 ± (11.97)
92.27 ± (8.31)
90.99 ± (12.22)
89.40 ± (13.55)
91.37 ± (7.88)
96.73 ± (6.22)
96.73 ± (7.61)
96.45 ± (3.14)
93.24 ± (11.08)
93.24 ± (11.66)
93.38 ± (15.23)
96.79 ± (4.68)
96.79 ± (7.99)
96.70 ± (2.27)
93.99 ± (12.57)
93.08 ± (9.54)
92.09 ± (16.42)
120.81 ± (20.14)
121.15 ± (24.36)
119.54 ± (16.48)
143.85 ± (23.19)
143.57 ± (21.28)
149.29 ± (22.77)
122.08 ± (20.42) *
125.36 ± (23.00)
121.47 ± (15.15)
146.96 ± (14.93)
151.30 ± (14.69)
156.06 ± (20.47)
135.72 ± (16.78)*
137.56 ± (18.02)
133.23 ± (13.82)
152.40 ± (16.28)*
145.49 ± (19.31)
150.67 ± (13.84)
136.53 ± (15.66)*
137.27 ± (19.29)
136.41 ± (13.51)
150.16 ± (14.93)*
150.61 ± (16.72)
149.60 ± (16.35)
Plasmodium falciparum infection in the mother induces amplification of TLR9 response in foetal leukocytes
Cytokine secretion in APC is triggered by the recognition of microbial pathogens through TLR . The ability of foetal APC to secrete cytokines by stimulating CBMC with different TLR ligands was investigated. IFN-α was evaluated in supernatants of unstimulated, CpG-A- and Hz-stimulated CBMC cultures. As previously reported [19, 27], unstimulated and synthetic Hz-stimulated CBMC did not secrete any IFN-α, while CpG-A-stimulated cells, most likely PDC, produced low levels of this cytokine (0.12 ± 13.79 pg/ml; median ± interquartile). No difference was observed in IFN-α production upon CpG-A stimulation when CBMC were segregated according to accumulation of MP in placenta: (0.01 ± 12.04 pg/ml vs 1.90 ± 18.21 pg/ml; MP-negative vs MP-positive women; p = 0.45).
Accumulation of MP in placenta does not affect IL-12 production by APC upon TLR3 and TLR4 stimulation.
median (± interquartile)
IL-12 (% positive cells)
3.55 ± (4.13)
2.70 ± (3.15)
3.13 ± (3.72)
2.13 ± (1.72)
2.33 ± (3.37)
3.99 ± (4.49)
1.95 ± (4.01)
2.38 ± (3.09)
Thus, cytokine responses to TLR3, 4 and 9 ligands and to Hz were observed, with amplification of TLR9-mediated responses in CBMC from MP-positive mothers.
Maternal age influences TLR3, 4 and 9 responses of foetal leukocytes and cytokine levels in foetal plasma
Significant differences were also observed in CB cytokine levels according to maternal age. Foetal plasma from mothers > 25 years of age exhibited significant lower levels of IL-10 as compared to younger mothers (Figure 4C). Thus, productions of cytokines by CBMC and plasma levels for IL-10 were higher in children born to the younger mothers.
When an effect of both MP-positivity in placenta and maternal age on cytokines in supernatants was observed, the multivariate analysis showed that maternal age was predominant and that effect of MP-positivity disappeared for IL-10 in response to TLR9 ligands (β = 1.23 (0.56-1.89) P = 0.001). However, both MP-positivity and maternal age had an effect on TNF-α secretion upon TLR9 stimulation (MP: β = 0.88 (0.024-1.74), P = 0.04; Age: β = 1.04 (0.23-1,74), P = 0.04).
The consensus view is that in utero sensitization to P. falciparum antigens is a common phenomenon during PAM. Parasites do not usually cross the placental barrier and such sensitization is most probably caused by the transplacental passage of soluble P. falciparum antigens [8, 28]. Accordingly, no parasite-positive smears were detected in CB samples of malaria-infected women in this study population.
Pregnant women declared to receive either SP or CQ as malaria prevention during pregnancy. In contrast to a previous study performed in the same area , no differences were observed for P. falciparum infection rate according to the type of prophylaxis used by the mothers. However, the number of subject included in this study was low and the project was not designed to examine this matter.
In this study, the foetal BDCA-1+ and BDCA-2+ DC subsets expressed significantly higher levels of MHC class II molecules upon PAM, as indicated by the presence of P. falciparum MP in placenta, which is in agreement with previous data . The observation that CD86 expression on foetal DC was unaffected by PAM suggests that P. falciparum stimulation in utero induces only partial activation of these cells. Failure to provide DC with a sufficiently strong costimulatory signals can impair the ability to form stable interactions with T-cells, as recently shown in a murine model of malaria . Partial DC maturation can lead to altered T-cell activation and induction of tolerance [31–34], possibly contributing to impaired immune responses that have been observed in the offspring of mothers with PAM [9, 11].
The findings presented in this study diverge from those of studies on peripheral blood DC from children with acute malaria, where expression levels of MHC class II on the BDCA-1+ DC are reduced compared to healthy controls [35, 36]. Also, no increase in foetal BDCA-3+ DC was detected upon maternal malaria infection in this study like others have shown in children with severe malaria . Circulating APC are continuously exposed to P. falciparum-infected erythrocytes during malaria episodes in children, which may exert a contact-mediated inhibitory effect on DC functionality, as demonstrated by in vitro studies [4, 37]. Conversely, infected erythrocytes are rarely detected in CB of those born to mothers with PAM [23, 38]. Thus, foetal APC would rarely if ever encounter parasitized red-blood cells, but would be primarily exposed to and influenced by parasite-derived soluble compounds.
Interestingly, TLR9 stimulation led to increased pro- and anti-inflammatory responses of CBMC of neonates whose mothers had MP accumulating in placentas, and there was a tendency towards increased IFN-γ response upon TLR3 stimulation in the same group. Responses via other TLR ligands, such as LPS were amplified in CBMC but did not change appreciably as a function of maternal malaria infection. Thus, foetal different TLR responses are independently modulated by in utero exposure to P. falciparum, consistent with a recent study .
In humans only PDC and B cells express TLR9 . In this study, CpG-A, a TLR9 ligand that specifically stimulates PDC [25, 40], was employed. In concordance with the findings presented in this study, MP or alternatively plasmodial DNA bound to MP activate the TLR9 pathway in human and murine PDC [27, 41, 42]. This would suggest a role for MP derived from maternal parasitic infection in inducing foetal BDCA-2+ DC partial maturation and increased sensitization to TLR9 ligands. Nevertheless, only low levels of IL-10 and TNF-α were detected in CBMC cultures upon TLR9 stimulation. This was not unexpected given the low frequency of cells able to specifically respond to such stimulus. The biological significance of a slightly increased release of IL-10 and TNF-α by CBMC upon TLR9 stimulation after in utero exposure to P. falciparum is uncertain.
Notably, MP was the only indicator of maternal malaria infection that was significantly associated with partial activation of foetal DC and to amplified innate response to TLR9 ligation, while other markers of maternal parasitization at delivery such as the presence of parasites in peripheral and/or placental blood, were unrelated to DC activation in the exposed newborns. It has been recently postulated that accumulation of MP in leukocytes is a good indicator of total parasite burden, including parasite sequestration , and therefore we can consider accumulation of MP in placenta as a marker of high intensity of maternal malaria infection and/or of prolonged parasite exposure. In addition, accumulation of MP in placental leukocytes has been associated with increased monocyte activation and inflammation . As a hypothesis, accumulation of MP may represent a specific activation stimulus and inflammation at the placental level and this may cause partial and inadequate activation of APC in the foetal compartment.
Additionally, maternal age and parity should be taken into consideration when analysing foetal/neonatal innate immunity. Women of higher parity and increased age delivered babies in whom significantly fewer blood APC were found, but these cells exhibited an enhanced activation status. Maternal age but not parity also influenced the APC cytokine responses upon TLR stimulation, such that CBMC of offspring of younger mothers exhibited an increased ability to respond to TLR3, 4 and 9 ligands. These data are in agreement with published data on African  and Caucasian  women and suggest that maternal age and obstetric history may influence foetal/neonatal immune parameters.
Consequences of increased maternal age and/or multiple parities in terms of neonatal responses to pathogens are poorly understood. Two recent studies indicate that the frequency of malaria episodes is higher among infants of malaria-infected multigravidae as compared to primigravidae [6, 7]. The intrinsic effect of multiple pregnancies on malaria susceptibility in the offspring may be at least partially explained by our finding of a significantly reduced number of myeloid APC in foetal blood from multigravidae. How maternal age or alternatively parity can affect the number, activation status and cytokine secretion capacity of cord blood APC is presently unknown.
In conclusion, placental parasitization, as indicated by the presence of MP in placental leukocytes, is significantly associated with partial maturation of different DC subsets and to slightly increased responses to a TLR9 ligand in cord blood. As semi-maturation of DC leads to tolerance , such partial foetal APC activation may contribute to the altered T-cell responses often observed in newborns of mothers with PAM [5–7].
These observations advocate a possible mechanism by which PAM may modulate foetal/neonatal innate immunity. Further evaluation of APC activation and downstream T-cell responses is ongoing in a large cohort of newborns and infants from mothers with PAM to assess the impact of altered DC activation on the neonatal cell-mediated immunity.
As it is known that neonatal immune responses are largely dependent on the innate branch of immunity and can be improved through selective TLR stimulation [47, 48], our results should be considered in the development of effective vaccine strategies for infants living in areas where malaria is endemic.
Conflict of interests
The authors declare that they have no competing interests.
We thank the maternity staff of Mother and Child Lagune hospital in sample collection for their support. We are grateful to the mothers who participated in the study. We acknowledge the IRD research unit in Cotonou, especially Pepin Kounou, Sebastien Dechavanne, Bertin Vianou, Martin Amadoudji for practical support. We are also grateful to Adrian Luty for scientific support. The work received financial support from the IMEA, NATIXIS, the French Ministry of Research (FSP REFS) and from SIDA/SAREC (Sweden). S. Louis. was the recipient of an ANRS fellowship.
Informed consent was obtained from all donors. The "Faculté des Sciences de la Santé" Committee of Beninese University approved this study.
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