Circulating soluble endoglin and placental abruption

Comparison of maternal neonatal outcomes of normotensive and hypertensive placental abruptions: A novel approach

To analyze maternal and neonatal effects of placental abruption (PA) through a novel classification in the presence of hypertension. Initial hemoglobin parameters were also compared to predict pregnancy outcomes in addition to hypertension. This retrospective cohort designed study was conducted on 115 pregnant women with PA. The main parameters scanned and recorded from the hospital database and patient medical files. Two groups were classified regarding of presence or absence of hypertension (53 hypertensive, 62 normotensive). Maternal demographical and clinical characteristics (abdominal pain, vaginal bleeding) were recorded. APGAR scores below 5 at 1st and 5th minute, fetal or neonatal death, admission and length of stay in Neonatal Intensive Care Unit were also investigated and compared between the groups. Stillborn to live-born ratio and lower APGAR scores < 5 at 5th minute were significantly higher in hypertensive group than normotensive group (P = .006 and 0.047, respectively). Poor maternal outcomes were detected in the hypertensive group than normotensive group regarding rate of blood transfusion (27/53, 50.9%; 18/62, 29%, respectively, P = .017). More abdominal pain and less vaginal bleeding were seen in PA with HT. Higher lymphocyte count, mean platelet volume, and platelet distribution width were reported in hypertensive group. Poorer maternal and neonatal outcomes of hypertensive patients with PA were detected. These patients should deserve greater attention to assess not only the possible risks associated with abruption but also the accompanying complications.

Maternal Cardiovascular and Cerebrovascular Health After Placental Abruption: A Systematic Review and Meta-Analysis (CHAP-SR)

Placental abruption and cardiovascular disease (CVD) have common etiological underpinnings, and there is accumulating evidence that abruption may be associated with future CVD. We estimated associations between abruption and coronary heart disease (CHD) and stroke. The meta-analysis was based on the random-effects risk ratio (RR) and 95% confidence interval (CI) as the effect measure. We conducted a bias analysis to account for abruption misclassification, selection bias, and unmeasured confounding. We included 11 cohort studies comprising 6,325,152 pregnancies, 69,759 abruptions, and 49,265 CHD and stroke cases (1967-2016). Risks of combined CVD morbidity-mortality among abruption and nonabruption groups were 16.7 and 9.3 per 1,000 births, respectively (RR = 1.76, 95% CI: 1.24, 2.50; I2 = 94%; τ2 = 0.22). Women who suffered abruption were at 2.65-fold (95% CI: 1.55, 4.54; I2 = 85%; τ2 = 0.36) higher risk of death related to CHD/stroke than nonfatal CHD/stroke complications (RR = 1.32, 95% CI: 0.91, 1.92; I2 = 93%; τ2 = 0.15). Abruption was associated with higher mortality from CHD (RR = 2.64, 95% CI: 1.57, 4.44; I2 = 76%; τ2 = 0.31) than stroke (RR = 1.70, 95% CI: 1.19, 2.42; I2 = 40%; τ2 = 0.05). Corrections for the aforementioned biases increased these estimates. Women with pregnancies complicated by placental abruption may benefit from postpartum screening or therapeutic interventions to help mitigate CVD risks.

The comparison of placental abruption coupled with and without preeclampsia and/or intrauterine growth restriction in singleton pregnancies

BACKGROUND

To compare the clinical features of placental abruption coupled with and without preeclampsia and/or intrauterine growth restriction in singleton pregnancies.

METHODS

A retrospective study of 229 cases of placental abruption was performed and the subjects were collected from Tianjin Central Hospital of Gynecology and Obstetrics between January 2016 and December 2017. The abruption cases were divided into two groups: the abruption with other conditions of ischemic placental disease (IPD group) and the abruption without them (non-IPD group). The clinical features, such as maternal age, gravidity, parity, gestational age at delivery, maternal complications, bleeding volume, fetal gender, sensitivity of ultrasonography, primary symptoms, onset-to-delivery time, mode of delivery, birth weight, and Apgar score at 1 min, were compared between two groups.

RESULTS

The primary symptoms in the top three were the central nervous system symptoms involving headache, dizziness or blurred vision (55.0%), decreased fetal movements (13.75%), and abdominal pain (10.0%) in IPD group, while in non-IPD group the top three were vaginal bleeding combined with abdominal pain (31.54%), abdominal pain (22.82%), and vaginal bleeding (16.11%). Compared with non-IPD group, the neonatal outcomes including birth weight, Apgar score at 1 min, and gestation age at delivery were significantly poorer in the IPD group (p < .000, p = .044, and p = .001, respectively). And the sensitivity of ultrasonography was significantly higher in non-IPD group (p = .002). In both preterm and term abruption in IPD group, compared with non-IPD group, it was significantly different in terms of gestation age at delivery, onset-to-delivery time, and birth weight (p < .05). In preterm abruption, IPD group had a significantly higher cesarean section rate than non-IPD group (p = .019). It seemed patients in IPD group had a higher incidence of uterine apoplexy and disseminated intravascular coagulation (DIC), but there was no statistical difference between the two groups in maternal complications including uterine apoplexy, blood transfusion, and DIC (p = .310, p = .585, and p = .121, respectively). It seemed preterm abruption had a poorer maternal prognosis than term abruption in IPD and non-IPD group, but the result had no significant difference (p > .05).

CONCLUSIONS

Placental abruption complicated with preeclampsia and/or intrauterine growth restriction had a poorer prognosis of newborns, while there was no significant difference in maternal prognosis. And patients with preeclampsia and/or intrauterine growth restriction deserved careful observation during pregnancy, especially when they had central nervous system symptoms of headache, visual changes, or dizziness.

Understanding biological mechanisms underlying adverse birth outcomes in developing countries: protocol for a prospective cohort (AMANHI bio-banking) study

Objectives

The AMANHI study aims to seek for biomarkers as predictors of important pregnancy–related outcomes, and establish a biobank in developing countries for future research as new methods and technologies become available.

Methods

AMANHI is using harmonised protocols to enrol 3000 women in early pregnancies (8–19 weeks of gestation) for population–based follow–up in pregnancy up to 42 days postpartum in Bangladesh, Pakistan and Tanzania, with collection taking place between August 2014 and June 2016. Urine pregnancy tests will be used to confirm reported or suspected pregnancies for screening ultrasound by trained sonographers to accurately date the pregnancy. Trained study field workers will collect very detailed phenotypic and epidemiological data from the pregnant woman and her family at scheduled home visits during pregnancy (enrolment, 24–28 weeks, 32–36 weeks & 38+ weeks) and postpartum (days 0–6 or 42–60). Trained phlebotomists will collect maternal and umbilical blood samples, centrifuge and obtain aliquots of serum, plasma and the buffy coat for storage. They will also measure HbA1C and collect a dried spot sample of whole blood. Maternal urine samples will also be collected and stored, alongside placenta, umbilical cord tissue and membrane samples, which will both be frozen and prepared for histology examination. Maternal and newborn stool (for microbiota) as well as paternal and newborn saliva samples (for DNA extraction) will also be collected. All samples will be stored at –80°C in the biobank in each of the three sites. These samples will be linked to numerous epidemiological and phenotypic data with unique study identification numbers.

Importance of the study

AMANHI biobank proves that biobanking is feasible to implement in LMICs, but recognises that biobank creation is only the first step in addressing current global challenges.

Total and Fetal Circulating Cell-Free DNA, Angiogenic, and Antiangiogenic Factors in Preeclampsia and HELLP Syndrome

BACKGROUND

Preeclampsia (PE) is a hypertensive disorder of pregnancy characterized by hypertension and proteinuria. The HELLP syndrome is the most severe form of PE. The aim of the present study was to determine different potential biomarkers that may help us perform an early diagnosis of the disease, assess on the severity of the disease, and/or predict maternal or fetal adverse outcomes.

METHODS

We measured serum levels of total and fetal circulating cell-free DNA (cfDNA), soluble endoglin, soluble form of vascular endothelial growth factor receptor, and placental growth factor in a healthy control group of pregnant women (n = 26), patients with mild (n = 37) and severe PE (n = 25), and patients with HELLP syndrome (n = 16).

RESULTS

We observed a gradual and strong relationship between all the biomarkers mentioned and the range of severity of PE, with the highest levels in patients with HELLP syndrome. Nevertheless, only the values of total cfDNA were able to significantly differentiate severe PE and HELLP syndrome (20957 ± 2784 vs. 43184 ± 8647 GE/ml, P = 0.01). Receiver operating characteristic (ROC) curves were constructed (i) for the healthy group with respect to the groups with PE and (ii) for patients with PE with respect to the group with HELLP syndrome; sensitivity and specificity values at different cutoff levels were calculated in each case. The maximum ROC area under the curve value for PE and HELLP syndrome (with respect to controls) was 0.91 (P < 0.001).

CONCLUSIONS

The measured biomarkers of cell damage, angiogenesis, and antiangiogenesis may reflect the severity of PE, with higher levels in patients who develop HELLP syndrome. In addition, these biomarkers may also help predict adverse fetal and maternal outcomes.

Maternal Early Pregnancy Serum Metabolomics Profile and Abnormal Vaginal Bleeding as Predictors of Placental Abruption: A Prospective Study

Background & Objective

Placental abruption, an ischemic placental disorder, complicates about 1 in 100 pregnancies, and is an important cause of maternal and perinatal morbidity and mortality worldwide. Metabolomics holds promise for improving the phenotyping, prediction and understanding of pathophysiologic mechanisms of complex clinical disorders including abruption. We sought to evaluate maternal early pregnancy pre-diagnostic serum metabolic profiles and abnormal vaginal bleeding as predictors of abruption later in pregnancy.

Methods

Maternal serum was collected in early pregnancy (mean 16 weeks, range 15 to 22 weeks) from 51 abruption cases and 51 controls. Quantitative targeted metabolic profiles of serum were acquired using electrospray ionization liquid chromatography-mass spectrometry (ESI-LC-MS/MS) and the Absolute IDQ® p180 kit. Maternal sociodemographic characteristics and reproductive history were abstracted from medical records. Stepwise logistic regression models were developed to evaluate the extent to which metabolites aid in the prediction of abruption. We evaluated the predictive performance of the set of selected metabolites using a receiver operating characteristics (ROC) curve analysis and area under the curve (AUC).

Results

Early pregnancy vaginal bleeding, dodecanoylcarnitine/dodecenoylcarnitine (C12 / C12:1), and phosphatidylcholine acyl-alkyl C 38:1 (PC ae C38:1) strongly predict abruption risk. The AUC for these metabolites alone was 0.68, for early pregnancy vaginal bleeding alone was 0.65, and combined the AUC improved to 0.75 with the addition of quantitative metabolite data (P = 0.003).

Conclusion

Metabolomic profiles of early pregnancy maternal serum samples in addition to the clinical symptom, vaginal bleeding, may serve as important markers for the prediction of abruption. Larger studies are necessary to corroborate and validate these findings in other cohorts.

Biochemical markers of placental dysfunction in assisted conception

A possible mechanism for poor perinatal outcomes in singleton pregnancies conceived following assisted reproductive technologies (ART) and those conceived naturally following a period of infertility (>12 months) is thought to be placental dysfunction. This was investigated by measuring plasma concentrations of biochemical markers: (i) soluble fms-like tyrosine kinase1 (sFlt1); (ii) placental growth factor (PlGF); (iii) leptin; and (iv) plasminogen activator inhibitor 2 (PAI-2), serially at four antenatal time points. Baseline concentrations of each marker after delivery were also measured. The control group was naturally conceived singleton pregnancies with no history of infertility. Non-smoking, age-matched nulliparous women with no significant medical history were recruited to all groups. The ART group had significantly lower mean plasma concentrations of PlGF at all antenatal time points compared to the control group (p < 0.001). The subfertility (SF) group had significantly higher mean serum concentrations of leptin than the other groups at all time points (p < 0.001), even after correction for body mass index. There were no significant differences in sFlt1 and PAI-2 concentrations between the groups. Low plasma PlGF concentrations in the ART group might suggest abnormal placentation and/or abnormal function in ART pregnancies with relevance to pathogenesis of pregnancy complications in these women.

Ischemic placental syndrome--prediction and new disease monitoring

The last decade has seen an improved understanding of the cause of the development of pathologies such as gestational hypertension, preeclampsia, intrauterine growth restriction, intrauterine fetal death or placental abruption. Nowadays, we know that most conditions within this group share the same pathogenesis, the cause of which is placental ischemia. The following review is an attempt to propose a new method for prediction, diagnosis and--above all--appropriate monitoring of pregnant women and fetuses developing the ischemic placental syndrome with the use of tests that are new but yet widely available in clinical diagnosis. They are closely related to the condition's pathogenesis, therefore their elevated levels may predate clinical symptoms, and--most importantly--they correlate with syndrome aggravation and the occurrence of complications. Perhaps, the new look will allow us to improve perinatal results by reducing mortality and severe complications in pregnant women and fetal deaths resulting from sudden intrauterine fetal death or placental abruption.

Response to Plasmapheresis Measured by Angiogenic Factors in a Woman with Antiphospholipid Syndrome in Pregnancy

An imbalance of angiogenic and antiangiogenic placental factors such as endoglin and soluble fms-like tyrosine kinase 1 has been implicated in the pathophysiology of preeclampsia. Extraction of these substances by plasmapheresis might be a therapeutical approach in cases of severe early-onset preeclampsia. Case Report. A 21-year-old primigravida with antiphospholipid syndrome developed early-onset preeclampsia at 18 weeks' gestation. She was treated successfully with plasmapheresis in order to prolong pregnancy. Endoglin and sflt-1-levels were measured by ELISA before and after treatment. Endoglin levels decreased significantly after treatment (p < 0.05) and showed a significant decrease throughout pregnancy. A rerise of endoglin and sflt-1 preceded placental abruption 4 weeks before onset of incident. Conclusion. Due to the limited long-term therapeutical possibilities for pregnancies complicated by PE, plasmapheresis seems to be a therapeutical option. This consideration refers especially to pregnancies with early-onset preeclampsia, in which, after first conventional treatment of PE, prolongation of pregnancy should be above all.

Retrospective study of risk factors and maternal and fetal outcome in patients with abruptio placentae

Introduction:

Abruptio placentae (AP) which is a major cause of maternal morbidity and perinatal mortality globally is of serious concern in the developing world. We retrospectively analyzed the AP cases and evaluated its impact on fetal and maternal outcomes.

Materials and Methods:

The present study was undertaken from September 2007-August 2009 at a tertiary care center attached to medical college; patients of AP were selected from all cases with minimum of 28 weeks of gestation, presenting with antepartum hemorrhage. Patients underwent complete obstetrical investigations and were managed according to maternal and fetal condition.

Results:

4.4% incidence rate of AP was documented accounting for 318 cases during the study period. Most of cases were unbooked, with an average age of 34.5 years (range, 18-44) and nearly two-third of the patients were from lower socioeconomic class. Anemia was observed in 96% of patients, with 3.5 and 68% incidence of maternal and fetal mortality, respectively.

Conclusion:

We observed a higher than expected frequency of AP and neonatal mortality in our study population, which is of major concern. We envisage need for mass information regarding the importance of antenatal maternal care and improvement in nutritional status, which may reduce the frequency of maternal and fetal morbidity and mortality associated with AP.

Angiogenic factors in preeclampsia: potential for diagnosis and treatment

PURPOSE OF REVIEW

The review summarizes new observations of key roles for circulating angiogenic factors in diagnosing, managing, and treating preeclampsia.

RECENT FINDINGS

Alterations in circulating angiogenic factors (soluble fms-like tyrosine kinase-1 and placental growth factor) in preeclampsia correlate with the diagnosis and adverse outcomes, particularly when the disease presents prematurely (<34 weeks). Measurement of these angiogenic biomarkers further helps differentiate preeclampsia and its complications from other disorders that present with similar clinical profiles. A ratio of soluble fms-like tyrosine kinase-1/placental growth factor greater than 85 appears ideal as the cut-off for both diagnosis and prognosis. There is also evidence that modulating these factors has therapeutic effects, suggesting a future role for angiogenic factors in treatment and prevention of preeclampsia.

SUMMARY

Circulating angiogenic biomarkers help in diagnostic and prognostic profiling of preeclampsia and may facilitate better management of these patients.

Second- and third-trimester biochemical and ultrasound markers predictive of ischemic placental disease

Ischemic placental disease is a recently coined term that describes the vascular insufficiency now believed to be an important etiologic factor in preeclampsia, intrauterine fetal growth restriction, and placental abruption. Given the increased risk for poor maternal and fetal outcomes, early prediction and prevention of this disorder is of significant clinical interest for many. In this article, we review the second- and third-trimester serum and ultrasound markers predictive of ischemic placental disease. Limited first-trimester data is also presented. While current studies report a statistical association between marker levels and various adverse perinatal outcomes, the observed diagnostic accuracy is below the threshold required for clinical utility. An exception to this generalization is uterine artery Doppler for the prediction of early-onset preeclampsia. Metabolomics is a relatively new analytic platform that holds promise as a first-trimester marker for the prediction of both early- and late-onset preeclampsia.

New developments in the pathogenesis of preeclampsia

Preeclampsia affects 3% to 5% of all pregnancies and is a major cause of maternal and perinatal morbidity and mortality worldwide. This disorder is characterized by a constellation of signs and symptoms, most notably new-onset hypertension and proteinuria during the last trimester of pregnancy. In this review, the molecular mechanisms of preeclampsia with an emphasis on the role of circulating antiangiogenic proteins in the pathogenesis of preeclampsia and its complications will be discussed.

Soluble endoglin specifically binds bone morphogenetic proteins 9 and 10 via its orphan domain, inhibits blood vessel formation, and suppresses tumor growth

Endoglin (CD105), a transmembrane protein of the transforming growth factor β superfamily, plays a crucial role in angiogenesis. Mutations in endoglin result in the vascular defect known as hereditary hemorrhagic telangiectasia (HHT1). The soluble form of endoglin was suggested to contribute to the pathogenesis of preeclampsia. To obtain further insight into its function, we cloned, expressed, purified, and characterized the extracellular domain (ECD) of mouse and human endoglin fused to an immunoglobulin Fc domain. We found that mouse and human endoglin ECD-Fc bound directly, specifically, and with high affinity to bone morphogenetic proteins 9 and 10 (BMP9 and BMP10) in surface plasmon resonance (Biacore) and cell-based assays. We performed a function mapping analysis of the different domains of endoglin by examining their contributions to the selectivity and biological activity of the protein. The BMP9/BMP10 binding site was localized to the orphan domain of human endoglin composed of the amino acid sequence 26-359. We established that endoglin and type II receptors bind to overlapping sites on BMP9. In the in vivo chick chorioallantoic membrane assay, the mouse and the truncated human endoglin ECD-Fc both significantly reduced VEGF-induced vessel formation. Finally, murine endoglin ECD-Fc acted as an anti-angiogenic factor that decreased blood vessel sprouting in VEGF/FGF-induced angiogenesis in in vivo angioreactors and reduced the tumor burden in the colon-26 mouse tumor model. Together our findings indicate an important role of soluble endoglin ECD in the regulation of angiogenesis and highlight efficacy of endoglin-Fc as a potential anti-angiogenesis therapeutic agent.

Angiogenic factors and preeclampsia

Preeclampsia, a hypertensive disorder peculiar to pregnancy, is a systemic syndrome that appears to originate in the placenta and is characterized by widespread maternal endothelial dysfunction. Until recently, the molecular pathogenesis of phenotypic preeclampsia was largely unknown, but recent observations support the hypothesis that altered expression of placental anti-angiogenic factors are responsible for the clinical manifestations of the disease. Soluble Flt1 and soluble endoglin, secreted by the placenta, are increased in the maternal circulation weeks before the onset of preeclampsia. These anti-angiogenic factors produce systemic endothelial dysfunction, resulting in hypertension, proteinuria, and the other systemic manifestations of preeclampsia. The molecular basis for placental dysregulation of these pathogenic factors remains unknown, and as of 2011 the role of angiogenic proteins in early placental vascular development was starting to be explored. The data linking angiogenic factors to preeclampsia have exciting clinical implications, and likely will transform the detection and treatment of preeclampsia.

The role of serum markers and uterine artery Doppler in identifying at-risk pregnancies

Measures of placental dysfunction, including maternal serum analytes and Doppler studies, have been linked to adverse pregnancy outcomes, although the predictive ability of any single one is poor. Improved knowledge of the multifactorial nature of many of the adverse outcomes of pregnancy has sparked interest in the use of multi-parameter models that combine maternal serum analytes with measures of placental structure and blood flow. The combination of various first-trimester and second-trimester analytes and uterine artery Doppler screening show promise as potential screening tools, but large prospective studies are needed to further define their role in clinical practice.

Midpregnancy levels of angiogenic markers in relation to maternal characteristics

OBJECTIVE

The purpose of this study was to describe relations among maternal demographic and lifestyle characteristics and midpregnancy levels of angiogenic markers (soluble Fms-like tyrosine kinase-1, placental growth factor, soluble endoglin).

STUDY DESIGN

In a large pregnancy cohort, linear models were used to evaluate relations among maternal characteristics and midpregnancy angiogenic markers with and without covariate adjustment. Associations were examined in a subcohort that included term and preterm deliveries (n = 1302) and among "normal" term pregnancies (n = 668).

RESULTS

Concentrations of all factors declined with increasing maternal body mass index. Multiparous women had lower soluble Fms-like tyrosine kinase-1 levels than primiparous women. Higher placental growth factor and slightly lower soluble endoglin levels were observed among women who smoked at enrollment, but not among those women who quit before enrollment. African American women had higher levels of all markers.

CONCLUSION

Understanding relations among maternal characteristics and levels of angiogenic factors may improve studies that use these markers to examine etiology and/or to predict adverse pregnancy outcome.

Previous preeclampsia and risks of adverse outcomes in subsequent nonpreeclamptic pregnancies

OBJECTIVE

We hypothesized that preeclampsia partly shares pathophysiology with stillbirth, placental abruption, spontaneous preterm birth, and giving birth to a small-for-gestational-age infant, and that women who develop preeclampsia in the first pregnancy may have increased risks of the other outcomes in the second pregnancy, even in the absence of preeclampsia.

STUDY DESIGN

In a nationwide Swedish cohort (n = 354,676) we estimated risks of adverse outcomes in the second pregnancy related to preterm (< 37 weeks) and term (≥ 37 weeks) preeclampsia in the first pregnancy, using women without preeclampsia in the first pregnancy as reference.

RESULTS

Women with prior preterm preeclampsia had, in second pregnancy, more than doubled risks of stillbirth, placental abruption, and preterm births, and an even greater risk of giving birth to a small-for-gestational-age infant.

CONCLUSION

Women with previous preterm preeclampsia have increased risks of adverse pregnancy outcomes in a second pregnancy despite the absence of preeclampsia.

Abnormal placentation, angiogenic factors, and the pathogenesis of preeclampsia

Preeclampsia is a common complication of pregnancy with potentially devastating consequences to both the mother and the baby.It is the leading cause of maternal deaths in developing countries. In developed countries it is the major cause of iatrogenic premature delivery and contributes significantly to increasing health care cost associated with prematurity. There is currently no known treatment for preeclampsia; ultimate treatment involves delivery of the placenta. Although there are several risk factors (such as multiple gestation or chronic hypertension), most patients present with no obvious risk factors. The molecular pathogenesis of preeclampsia is just now being elucidated. It has been proposed that abnormal placentation and an imbalance in angiogenic factors lead to the clinical findings and complications seen in preeclampsia. Preeclampsia is characterized by high levels of circulating antiangiogenic factors such as soluble fms-like tyrosine kinase-1 and soluble endoglin, which induce maternal endothelial dysfunction. These soluble factors are altered not only at the time of clinical disease but also several weeks before the onset of clinical signs and symptoms. Many methods of prediction and surveillance have been proposed to identify women who will develop preeclampsia, but studies have been inconclusive. With the recent discovery of the role of angiogenic factors in preeclampsia, novel methods of prediction and diagnosis are being developed to aid obstetricians and midwives in clinical practice. This article discusses the role of angiogenic factors in the pathogenesis, prediction, diagnosis, and possible treatment of preeclampsia.

First-trimester assessment of placenta function and the prediction of preeclampsia and intrauterine growth restriction

Preeclampsia and intrauterine growth restriction (IUGR) are major contributors to perinatal mortality and morbidity worldwide. Both are characterized by impaired trophoblastic invasion of the maternal spiral arteries and their conversion from narrow muscular vessels to wide non-muscular channels. Despite improvement in the understanding of the pathophysiology of these conditions, ability to accurately identify pregnant woman who will develop them is limited. This greatly impairs the development and testing of preventive interventions. While different measures of placental dysfunction have been associated with increased risk for adverse pregnancy outcomes, the ability of any single one to accurately predict these outcomes is poor. Developing predictive tests is further challenged by difficulty in the timing of the measurements, as both the structural and biochemical characteristics of the placenta change with increasing gestational age. The ideal screening test would accurately predict the development of adverse pregnancy outcomes early enough to provide a window for preventive interventions. Improvement in ultrasound technology provides potentially useful novel tools for evaluating placental structure, but measurements need to be standardized in order to be useful. Maternal serum analyte screening is a noninvasive test of placental biochemical function, but present serum marker alone is not sufficiently accurate to suggest its routine use in clinical practice. The use of first trimester biochemical markers in combination with uterine artery Doppler screening is promising as a potential screening tool. Prospective longitudinal studies using standardized methodology are necessary to further evaluate the choice of parameters and strategies of combination to achieve the best predictive models.

New-onset maternal gestational hypertension and risk of retinopathy of prematurity

PURPOSE

To evaluate associations between conditions of maternal new-onset gestational hypertension (mHTN) and the features imparting risk of severe retinopathy of prematurity (ROP) in preterm infants.

METHODS

Hospital databases and charts of all preterm inborn infants at the University of North Carolina from 1996 to 2007 were retrospectively reviewed. The presence or absence of mHTN (e.g., pre-eclampsia) and infant factors (birthweight, gestational age, erythropoietin use, and zone and stage of ROP) were analyzed for independence of association.

RESULTS

Of the 5143 infants, 323 had ROP and 76 had mothers with mHTN. Infants with ROP were more likely to have mothers with mHTN and to be younger and smaller at birth. At initial examination, more infants of mothers with mHTN had vascularization into the lower zones than did infants of mothers without mHTN (P < 0.001). However, at the examination in which the most severe ROP was present, there was no association between mHTN and ROP stage (P = 0.2342). Analysis of stage and zone together showed that infants born to mothers with mHTN were more likely to have ROP at initial examination, after adjustment for gestational age, but not for birth weight. The use of erythropoietin was not associated with ROP zone or stage, even after adjustment for maternal condition, infant birth weight, or gestational age.

CONCLUSIONS

Although larger avascular areas or higher severity scores were associated with mHTN after adjustment for gestational age at initial examination, no associations were found between mHTN and ROP severity score at the examination when ROP was most severe. There were no associations between ROP severity and treatment with erythropoietin.

Angiogenic proteins as aid in the diagnosis and prediction of preeclampsia

Preeclampsia/eclampsia remains a major cause of maternal and fetal morbidity worldwide. It also remains a leading cause of iatrogenic prematurity as delivery is currently the only way to successfully treat the disorder. The mechanisms that initiate preeclampsia in humans have been remarkably elusive, but some parts of the puzzle have begun to come together. Recently, it has been suggested that its major phenotypes, such as hypertension, proteinuria and endothelial dysfunction, are due to circulating anti-angiogenic proteins such as soluble fms-like tyrosine kinase-1 and soluble endoglin. Abnormalities in these circulating angiogenic proteins are not only present during clinical preeclampsia, but also antedate clinical symptoms by at least 5-6 weeks. The availability of automated platforms for the measurement of these angiogenic proteins has allowed clinicians to evaluate the role of these biomarkers as an aid in the diagnosis and prediction of preeclampsia. This review will highlight the recent clinical studies that have evaluated the utility of these biomarkers in preeclampsia and its related complications.

A prospective cohort study of the value of maternal plasma concentrations of angiogenic and anti-angiogenic factors in early pregnancy and midtrimester in the identification of patients destined to develop preeclampsia

OBJECTIVE

Changes in the maternal plasma concentrations of angiogenic (placental growth factor (PlGF) and vascular endothelial growth factor (VEGF)) and anti-angiogenic factors (sEng and vascular endothelial growth factor receptor-1 (sVEGFR-1)) precede the clinical presentation of preeclampsia. This study was conducted to examine the role of maternal plasma PlGF, sEng, and sVEGFR-1 concentrations in early pregnancy and midtrimester in the identification of patients destined to develop preeclampsia.

METHODS

This longitudinal cohort study included 1622 consecutive singleton pregnant women. Plasma samples were obtained in early pregnancy (6-15 weeks) and midtrimester (20-25 weeks). Maternal plasma PlGF, sEng, and sVEGFR-1 concentrations were determined using sensitive and specific immunoassays. The primary outcome was the development of preeclampsia. Secondary outcomes included term, preterm, and early-onset preeclampsia. Receiving operating characteristic curves, sensitivity, specificity, positive and negative likelihood ratios, and multivariable logistic regression were applied. A p-value of <0.05 was considered significant.

RESULTS

(1) The prevalence of preeclampsia, term, preterm, (<37 weeks) and early-onset preeclampsia (<34 weeks) was 3.8 (62/1622), 2.5 (40/1622), 1.4 (22/1622) and 0.6% (9/1622), respectively; (2) Higher likelihood ratios were provided by ratios of midtrimester plasma concentrations of PlGF, sEng, and sVEGFR-1 than single analytes; (3) Individual angiogenic and anti-angiogenic factors did not perform well in the identification of preeclampsia as a whole; in particular, they perform poorly in the prediction of term preeclampsia; (4) In contrast, a combination of these analytes such as the PlGF/sEng ratio, its delta and slope had the best predictive performance with a sensitivity of 100%, a specificity of 98-99%, and likelihood ratios for a positive test of 57.6, 55.6 and 89.6, respectively, for predicting early-onset preeclampsia.

CONCLUSIONS

(1) The PlGF/sEng ratio and its delta and slope had an excellent predictive performance for the prediction of early-onset preeclampsia, with very high likelihood ratios for a positive test result and very low likelihood ratios for a negative test result; and (2) Although the positive likelihood ratios are high and the positive predictive values low, the number of patients needed to be closely followed is 4:1 for the PlGF/sEng ratio and 3:1 for the slope of PlGF/sEng.