Maternal serum alpha-fetoprotein values in type 1 and type 2 diabetic patients

Evaluation of Low-Molecular-Weight Heparin Treatment on First- and Second-Trimester Screening Test Results

Background The serum markers used in first- and second-trimester screening tests can be affected by different causes such as smoking, infertility treatment, and the presence of diabetes mellitus, which should be considered by obstetricians when giving information to patients. Low molecular weight heparin (LMWH) has a critical importance in the prophylaxis of deep vein thrombosis both in the antenatal and postnatal period. The aim of the current study is to investigate the effect of LMWH use on the first- and second-trimester screening results. Methods A retrospective analysis in our outpatient clinic between July 2018 and January 2021 of first- and second-trimester screening test results was conducted to assess the impact of LMWH treatment for patients with thrombophilia who started LMWH after pregnancy was detected were included. Test results were obtained as a multiple of median (MoM) combined with ultrasound measurements, maternal serum markers, and maternal age in addition to the nuchal translucency first-trimester test. Results The pregnancy-associated plasma protein-A (PAPP-A) MoM was lower and alpha-fetoprotein (AFP) and unconjugated estriol (uE3) MoMs were higher in patients treated with LMWH than in the control group (0.78 MoM vs 0.96 MoM; 1.00 MoM vs 0.97 MoM; and 0.89 MoM vs 0.76 MoM, respectively). Human chorionic gonadotropin (HCG) levels did not differ between groups at either time point. Conclusions Treatment of pregnant women with LMWH for thrombophilia may change the MoM values of serum markers for both first- and second-trimester screening tests. Obstetricians should be aware of this when advising screening tests to thrombophilia patients and should consider offering fetal DNA tests for this group instead.

Jazf1 acts as a regulator of insulin-producing β-cell differentiation in induced pluripotent stem cells and glucose homeostasis in mice

Genetic susceptibility of type 2 diabetes and Juxtaposed with another zinc finger protein 1 (Jazf1) has been reported; however, the precise role of Jazf1 in metabolic processes remains elusive. In this study, using Jazf1-knockout (KO)-induced pluripotent stem cells (iPSC), pancreatic beta cell line MIN6 cells, and Jazf-1 heterozygous KO (Jazf1^+/- ) mice, the effect of Jazf1 on gradual differentiation was investigated. We checked the alterations of the genes related with β-cell specification, maturation, and insulin release against glucose treatment by the gain and loss of the Jazf1 gene in the MIN6 cells. Because undifferentiated Jazf1-KO iPSC were not significantly different from wild-type (WT) iPSC, the size and endoderm marker expression after embryoid body (EB) and teratoma formation were investigated. Compared to EB and teratomas formed with WT iPSC, the EB and teratomas from with Jazf1-KO iPSC were smaller, and in teratomas, the expression of proliferation markers was reduced. Moreover, the expression of the gene sets for β-cell differentiation and the levels of insulin and C-peptide secreted by insulin precursor cells were notably reduced in β-cells differentiated from Jazf1-KO iPSC compared with those differentiated from WT iPSC. A comparison of Jazf1^+/- and WT mice showed that Jazf1^+/- mice had lower levels of serum insulin, pancreatic insulin expression, and decreased pancreatic β-cell size, which resulted in defects in the glucose homeostasis. These findings suggest that Jazf1 plays a pivotal role in the differentiation of β-cells and glucose homeostasis.

Risk of Severe Maternal Morbidity or Death in Relation to Prenatal Biochemical Screening: Population-Based Cohort Study

OBJECTIVE

This study aimed to examine whether prenatal biochemical screening analytes are associated with an increased risk of severe maternal morbidity (SMM) or maternal mortality.

STUDY DESIGN

This population-based cohort study includes all women in Ontario, Canada, who underwent prenatal screening from 2001 to 2011. Increasing fifth percentiles of the multiple of the median (MoM) for alphafetoprotein (AFP), total human chorionic gonadotropin, unconjugated estriol (uE3), dimeric inhibin-A (DIA), and pregnancy-associated plasma protein A were evaluated. An abnormally high concentration (>95th percentile MoM) for each analyte, individually and combined, was also evaluated. The main outcome assessed was the adjusted relative risk (aRR) of SMM or maternal mortality from 20 weeks' gestation up to 26 weeks thereafter.

RESULTS

Among 748,972 pregnancies, 11,177 resulted in SMM or maternal mortality (1.5%). Except for uE3, the aRR of SMM or maternal mortality increased in association with increasing fifth percentiles of the MoM for all analytes. AFP (aRR: 2.10; 95% confidence interval [CI]: 1.97-2.25) and DIA (aRR: 2.33; 95% CI: 1.98-2.74) > 95th versus ≤ 5th percentile of the MoM were especially associated with SMM or death.

CONCLUSION

Women with abnormally high concentrations of certain prenatal biochemical analytes may be at a higher risk of SMM or death in pregnancy or postpartum.

Diagnostic accuracy of maternal serum multiple marker screening for early detection of gestational diabetes mellitus in the absence of a gold standard test

Background

Gestational diabetes mellitus (GDM) is associated with adverse diabetic complications for both mother and child during pregnancy. The common Gold Standard (GS) for diagnosis of GDM is 75 g oral glucose tolerance test (OGTT) during 24–28 gestational weeks which seems a little late for any proper intervention. This study aimed to employ the Bayesian latent class models (LCMs) for estimating the early diagnostic power of combination of serum multiple marker in detecting GDM during 14–17 weeks of gestation.

Methods

Data from a sample of 523 pregnant women who participated in gestational diabetes screening tests at health centers affiliated to Shahid Beheshti University of Medical Sciences in Tehran, Iran from 2017 to 2018 were used. The beta-human chorionic gonadotropin (β-hCG), unconjugated estriol (uE3), and alfa-fetoprotein (AFP) values were extracted from case records for all participants. The Bayesian LCMs were applied for estimating sensitivity, specificity, and area under receiver operating characteristic curve (AUC) of combining the three biomarkers’ results in the absence of GS, adjusting for maternal age and body mass index.

Results

The mean (standard deviation) maternal age of the participants was 28.76 (±5.33) years. Additionally, the mean (standard deviation) BMI was 24.57 (±3.22) kg/m². According to the Bayesian model, the cSensitivity, cSpecificity, and cAUC for the optimal composite diagnostic test were estimated as 94% (95% credible interval (CrI) [0.91–0.99]), 86% (95% CrI [0.80–0.92]), and 0.92 (95% CrI [0.87–0.98]), respectively.

Conclusions

Overall, the findings revealed that the combination of uE3, AFP, and β-hCG results might be considered as an acceptable predictor for detecting GDM with a rather high level of accuracy in the early second trimester of pregnancy without a GS.

Prenatal biochemical screening and long term risk of maternal cardiovascular disease: population based cohort study

OBJECTIVE

To examine whether abnormal prenatal biochemical screening results are associated with an increased risk of premature cardiovascular disease after pregnancy.

DESIGN

Population based cohort study.

SETTING

The entire province of Ontario, Canada, where healthcare is universally available.

PARTICIPANTS

Women aged 12-55 years, without pre-existing cardiovascular disease, who underwent prenatal screening between 1993 and 2011. One pregnancy per woman was randomly selected.

EXPOSURES

Low (≤5th centile multiple of the median) serum total chorionic gonadotropin, unconjugated estriol, and pregnancy associated plasma protein A and high (≥95th centile multiple of the median) alphafetoprotein and dimeric inhibin-A.

MAIN OUTCOME MEASURES

Composite of hospital admission or revascularisation for coronary artery, cerebrovascular, or peripheral arterial disease or hospital admission for heart failure or dysrhythmia at least 365 days after pregnancy.

RESULTS

Among 855 536 pregnancies, and after a median of 11.4 (interquartile range 6.8-17.5) years of follow-up, 6209 women developed the main cardiovascular disease outcome. Abnormal results for each of the five prenatal biochemical screening analytes, especially dimeric inhibin-A, were associated with a higher risk of cardiovascular disease. Women with an abnormally high dimeric inhibin-A (≥95th centile) had the highest rate of cardiovascular disease (30 events or 8.3 per 10 000 person years versus 251 events or 3.8 per 10 000 person years for those <95th centile; multivariable adjusted hazard ratio 2.0, 95% confidence interval 1.4 to 3.0). Compared with women without any abnormal biochemical measure, the hazard ratio for the cardiovascular disease composite outcome was 1.2-1.3 times higher with one abnormal analyte and 1.5-2.0 times higher with two or more abnormal analytes.

CONCLUSIONS

Women with abnormal prenatal biochemical screening results, especially for dimeric inhibin-A, may be at higher risk of cardiovascular disease. If these findings are replicated elsewhere, a massive amount of data exists that could aid in identifying women at higher risk of premature cardiovascular disease and that could be conveyed to them or their healthcare providers.

First Trimester Aneuploidy Screening Markers in Women with Pre-Gestational Diabetes Mellitus

OBJECTIVE

To investigate whether maternal serum pregnancy associated plasma protein-A (PAPP-A), total β human chorionic gonadotropin (hCG) levels and nuchal translucency (NT) measurements differ in women with pre-gestational diabetes mellitus (PGDM) compared to non-diabetic controls and to assess whether correction factors are needed for diabetic women in calculation of aneuploidy risks.

STUDY DESIGN

We performed a retrospective study of all women who underwent first trimester aneuploidy screening (11 + 0 to 13 + 6 weeks) from 2005 to 2011. The primary study outcome was the difference in PAPP-A, β-hCG and NT multiples of median between women with PGDM and non-diabetic women.

RESULTS

Of 6741 eligible patients, 103 patients with PGDM were using insulin and 4 patients were using oral hypoglycemic agents; the latter were excluded due to small number. There was 12% reduction of median PAPP-A (p = 0.001) and 18% reduction of median hCG (p = 0.006) in women with PGDM receiving insulin. There was no difference in NT.

CONCLUSIONS

In women with PGDM receiving insulin, PAPP-A and β-hCG levels are significantly lower compared to non-diabetic women. This suggests that when calculating risks for aneuploidy, correction factors should be considered to adjust PAPP-A and β-hCG concentrations to those seen in non-diabetic women.

Effect of mild hepatic or renal impairment on maternal serum screening biochemical measures

BACKGROUND

Integrated maternal serum screening (MSS) is commonly used to screen for fetal trisomies and neural tube defects in early pregnancy. The kidney and liver each play an important role in hormone metabolism, and anecdotal data suggest that MSS biochemical measures may vary with a mother's health status. We examined the correlations between kidney and liver function parameters and MSS markers and the possible association of mild renal or hepatic impairment with MSS measures.

METHODS

We completed a prospective cross-sectional study of 257 consecutive women who underwent integrated MSS at a single hospital. Serum analytes (pregnancy associated plasma protein A [PAPP-A], hCG, creatinine [Cr], and alanine aminotransferase [ALT]) were drawn at approximately 12 weeks' gestation, and alpha-fetoprotein and unconjugated estriol were drawn at 16 weeks' gestation. Creatinine clearance was calculated using the Cockcroft-Gault formula. Abnormally elevated serum Cr and ALT were each defined as ≥ 90th percentile among all women. A low creatinine clearance (CrCl) was set at ≤ 10th percentile.

RESULTS

Serum hCG, PAPP-A, and alpha-fetoprotein were negatively correlated with CrCl, but not after correction for maternal age, weight, and ethnicity. No association between MSS and serum ALT was observed. The median serum concentrations of both PAPP-A (P = 0.04) and alpha-fetoprotein (P = 0.02) were significantly higher among those whose CrCl was ≤ 10th percentile. At the more extreme concentrations of PAPP-A and alpha-fetoprotein, no significant association with a low CrCl or an elevated serum ALT was seen.

CONCLUSIONS

Among a group of apparently healthy pregnant women, mild renal or hepatic impairment had little or no significant correlation with individual MSS markers. Further work should focus on the effect of more severe renal or hepatic dysfunction on MSS measures.