This study demonstrated dynamic changes in urinary metabolomic profiles during normal pregnancy. By means of machine learning algorithms, we constructed a predictive model that used urinary metabolite data to estimate gestational age during the progression of normal pregnancy. Moreover, we found that the predicted gestational age was significantly older than actual gestational age in cases with HDP.
To the best of our knowledge, this is the first attempt to predict gestational age in normal and complicated pregnancies by means of urinary metabolomics. Although a few studies have analyzed urinary metabolites in pregnant women, fewer than 50 metabolites were analyzed in each of those studies [16–18].
We initially analyzed urine samples that were collected longitudinally from 187 healthy pregnant women, with the aim of elucidating urinary metabolite profiles during pregnancy. Hierarchical clustering showed that urinary metabolites comprised three distinct clusters (Fig. 1). The levels of metabolites contained in cluster 1, the largest cluster, increased with gestational age. These increased urinary metabolites during pregnancy might reflect the increased those in blood due to the reduction of maternal energy consumption associated with fetal and placental growth [19, 20]. In a previous study, Diaz et al. used untargeted nuclear magnetic resonance-based metabolomics to examine temporal changes in the levels of 21 urinary metabolites during pregnancy; they identified 11 metabolites for which the levels significantly increased from the second trimester to the third trimester [21]. Three of those 11 metabolites (i.e., alanine, lactic acid, and threonine) were also identified in our study; all were included in cluster 1. Monosaccharides (e.g., glucose and lactose) were also included in cluster 1. The increased glucose level is consistent with the increased maternal insulin resistance that occurs during pregnancy [22]. A cohort study of 823 healthy pregnant women also showed similar results with respect to urinary lactose [23]. The increased lactose level was also present in blood metabolomics analyses; this was presumed to reflect maternal physiological changes to enable breastfeeding after delivery [24].
Sixty-eight of the 184 metabolites with dynamic systematic changes consistently contributed to the predictive model; the coefficient of each metabolite never reached zero during leave-one-out cross validation. Therefore, these 68 metabolites are presumed to strongly reflect the progression of normal pregnancy. Enrichment analysis showed that 36 of the 68 metabolites (all in cluster 1) were related to cysteine metabolism. This suggests that homocysteine metabolism, which is located upstream of cysteine metabolism, is upregulated to maintain a healthy pregnancy [15]. Moreover, methionine, which is produced from homocysteine in the methionine cycle, was also classified in cluster 1, further supporting the potential upregulation of homocysteine metabolism.
The levels of metabolites classified in cluster 3 exhibited downward trends during pregnancy. This cluster included pyrimidines (e.g., cytosine, thymine, and uracil) and hydrophilic basic amino acids (e.g., histidine and lysine). Only a few previous studies have described the roles of, or changes in, these metabolites during pregnancy [18, 25]. Furthermore, enrichment analysis of metabolites selected by the predictive model revealed significant enrichment of metabolites related to vitamins in cluster 3. Water-soluble vitamins (e.g., B6, B12, and C) play critical roles during pregnancy. For example, vitamin B12 is an important cofactor for DNA synthesis; it also participates in metabolic processes involving amino acids and fatty acids [26]. During pregnancy, vitamin B12 is supplied to the fetus by the mother through the placenta; the blood concentration of vitamin B12 is approximately twofold greater in the fetus than in the mother [27]. In addition, levels of vitamins B6, B12, and C in maternal blood have been reported to decrease during pregnancy [27], which is consistent with our results. Because vitamins B6 and B12 are involved in homocysteine metabolism, the results of enrichment analysis for cluster 1 may reflect both maternal and fetal metabolism.
Using urinary metabolites, we successfully established a predictive model to estimate gestational age that exhibited performance equivalent to that of previously reported models involving plasma metabolites [11]. Therefore, gestational age could presumably be estimated from urinary metabolites. Because urine samples can be collected in a minimally invasive manner at each routine antenatal visit in most clinical settings, our results have potential clinical applications (e.g., in telemedicine using a medical examination kit).
Our predictive model mainly uses metabolites that demonstrate linear changes in levels during pregnancy. However, some metabolites demonstrate non-linear changes in levels. For example, fatty acids play important roles in normal pregnancy; fatty acids reportedly accumulate in the mother during the first and second trimesters, then are released in the third trimester [28]. In the present study, many fatty acids were classified in cluster 2, such that they did not extensively contribute to the predictive model. However, the incorporation of metabolites with complex behaviors into our predictive model might enable more accurate prediction of gestational age.
The predicted gestational age was significantly older in cases who subsequently developed HDP. This result might be due to the presence of circulating metabolites caused by premature placental aging [29]. Premature placental aging associated with elevated oxidative stress and mitochondrial damages is known to cause placental insufficiency leading to HDP, including preeclampsia [29–31]. Urinary metabolite profiles also reportedly change with cellular senescence [32]. Therefore, the older predicted gestational age in the HDP cases, which implies aberrant acceleration of pregnancy, might be caused by changes in the urinary metabolite profile due to placental aging.
Importantly, we identified metabolites that were associated with the onset of HDP. For example, the increased level of 3-hydroxy-3-methylglutaric acid was significantly associated with the onset of HDP. In a rat model, 3-hydroxy-3-methylglutaric acid was able to induce physiological oxidative stress [33]. In addition, Nemeth et al. reported that the onset of HDP, including gestational hypertension, is related to increased maternal oxidative stress [34]. They indicated that insufficient capacity for glutathione recycling in patients with HDP might lead to reduced protection against oxidative stress. Furthermore, elevated oxidative stress is regarded as a manifestation of preeclampsia; for example, in the placentas of patients with preeclampsia, increased lipid peroxidation and decreased activities of some antioxidant enzymes have been identified [35]. Our results are suggestive of such physiological aberrations.
The increased levels of isocitric and urocanic acids also showed significant associations with HDP onset. Although isocitric acid is a component of the tricarboxylic acid cycle, the level of succinic acid (located downstream of isocitric acid) did not significantly differ between the healthy and HDP groups. This suggests reduced conversion of isocitric acid to oxalosuccinic acid, which requires nicotinamide adenine dinucleotide (NAD+). Therefore, the cellular NAD+ level may be reduced in cases who develop HDP [36]. Because NAD+ is required for DNA repair, DNA damage in the placenta caused by elevated oxidative stress associated with HDP might lead to a reduction of the NAD+/NADH ratio [37]. Urocanic acid is a histidine metabolite and a major component of ultraviolet light absorption in the skin. Its concentration in the plasma is reportedly elevated in cases with preeclampsia [38], in agreement with our results.
In this study, we demonstrated that the predicted gestational age calculated by combining multiple metabolite levels could more accurately predict the onset of HDP, compared with each metabolite level alone (Fig. 5). This finding suggests that a combination of metabolites—each with weak explanatory power—could more accurately predict the risk, compared with individual metabolites; this was similar to the previously described polygenic risk score, which comprised the weighted sum of alleles associated with some traits [39].
There were no significant differences in predicted gestational age or the levels of metabolites between the healthy and SPTB groups. Previous studies reported an association between urinary phthalate metabolites and SPTB [40, 41]. Unfortunately, the metabolites could not be detected by gas chromatography-tandem mass spectrometry (GC-MS/MS) in our study. Although associations between maternal urinary or blood metabolites and SPTB development have rarely been described, various metabolites in cervicovaginal fluid, amniotic fluid, and neonatal urine are reportedly associated with SPTB [42–44]. SPTB often involves inflammatory changes caused by local bacterial infection in organs or tissues such as the vagina, decidua, placenta, and amniotic cavity [45]. Therefore, manifestations of SPTB may not be detected with urinary metabolites.
The present study had several limitations. First, all study participants were recruited at a single facility in Japan; therefore, our predictive model must be validated in separate facilities and in cohorts of patients with different ethnicities [46]. Second, we studied physiological changes in pregnant women solely on the basis of urinary metabolites; thus, comprehensive analyses that consider other omics data are warranted. In a previous prospective cohort study (i.e., the Maternity Log [MLOG] study), we obtained multi-omics information including the plasma metabolome, blood transcriptome, and urinary metabolome [46]. We hope that the validity of our predictive model will be verified by the analysis of relationships among urinary metabolites and other multi-omics data in the future. Third, the number of healthy pregnant women available for construction of the predictive model in this study was insufficient. In the TMM BirThree Cohort Study, which is a parent cohort of the MLOG study, 23,406 pregnant women were recruited [47, 48]; moreover, urine samples were collected twice during pregnancy from each participant for use in the quantification of urinary metabolites. Urinary metabolite information from a very large number of pregnant women could further elucidate metabolomic changes during pregnancy; this might improve the predictive performance of our model.
In conclusion, this is the first study to elucidate dynamic changes in urinary metabolomic profiles of 184 metabolites during pregnancy; it is also the first study to construct a predictive model using urinary metabolite information to estimate gestational age at the time of urine specimen collection. The results suggested that urinary metabolite information is useful for understanding the normal progression of pregnancy, as well as for predicting the development of pregnancy complications. Minimally invasive urinary metabolomics might lead to breakthroughs in the analysis and management of healthy and complicated pregnancies in various clinical settings in the future.