1
|
Raja Xavier JP, Okumura T, Apweiler M, Chacko NA, Singh Y, Brucker SY, Takeda S, Lang F, Salker MS. Placental growth factor mediates pathological uterine angiogenesis by activating the NFAT5-SGK1 signaling axis in the endometrium: implications for preeclampsia development. Biol Res 2024; 57:55. [PMID: 39152497 PMCID: PMC11330076 DOI: 10.1186/s40659-024-00526-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 06/26/2024] [Indexed: 08/19/2024] Open
Abstract
After menstruation the uterine spiral arteries are repaired through angiogenesis. This process is tightly regulated by the paracrine communication between endometrial stromal cells (EnSCs) and endothelial cells. Any molecular aberration in these processes can lead to complications in pregnancy including miscarriage or preeclampsia (PE). Placental growth factor (PlGF) is a known contributing factor for pathological angiogenesis but the mechanisms remain poorly understood. In this study, we investigated whether PlGF contributes to pathological uterine angiogenesis by disrupting EnSCs and endothelial paracrine communication. We observed that PlGF mediates a tonicity-independent activation of nuclear factor of activated T cells 5 (NFAT5) in EnSCs. NFAT5 activated downstream targets including SGK1, HIF-1α and VEGF-A. In depth characterization of PlGF - conditioned medium (CM) from EnSCs using mass spectrometry and ELISA methods revealed low VEGF-A and an abundance of extracellular matrix organization associated proteins. Secreted factors in PlGF-CM impeded normal angiogenic cues in endothelial cells (HUVECs) by downregulating Notch-VEGF signaling. Interestingly, PlGF-CM failed to support human placental (BeWo) cell invasion through HUVEC monolayer. Inhibition of SGK1 in EnSCs improved angiogenic effects in HUVECs and promoted BeWo invasion, revealing SGK1 as a key intermediate player modulating PlGF mediated anti-angiogenic signaling. Taken together, perturbed PlGF-NFAT5-SGK1 signaling in the endometrium can contribute to pathological uterine angiogenesis by negatively regulating EnSCs-endothelial crosstalk resulting in poor quality vessels in the uterine microenvironment. Taken together the signaling may impact on normal trophoblast invasion and thus placentation and, may be associated with an increased risk of complications such as PE.
Collapse
Affiliation(s)
- Janet P Raja Xavier
- Department of Women's Health, University of Tübingen, 72076, Calwerstraße 7/6, Tübingen, Germany
| | - Toshiyuki Okumura
- Department of Obstetrics and Gynaecology, Juntendo University School of Medicine, Tokyo, Japan
| | - Melina Apweiler
- Department of Women's Health, University of Tübingen, 72076, Calwerstraße 7/6, Tübingen, Germany
| | - Nirzari A Chacko
- Department of Women's Health, University of Tübingen, 72076, Calwerstraße 7/6, Tübingen, Germany
| | - Yogesh Singh
- Department of Women's Health, University of Tübingen, 72076, Calwerstraße 7/6, Tübingen, Germany
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany
| | - Sara Y Brucker
- Department of Women's Health, University of Tübingen, 72076, Calwerstraße 7/6, Tübingen, Germany
| | - Satoru Takeda
- Department of Obstetrics and Gynaecology, Juntendo University School of Medicine, Tokyo, Japan
| | - Florian Lang
- Department of Physiology, University of Tübingen, Tübingen, Germany
| | - Madhuri S Salker
- Department of Women's Health, University of Tübingen, 72076, Calwerstraße 7/6, Tübingen, Germany.
| |
Collapse
|
2
|
Tanaka H, Tanaka K, Takakura S, Enomoto N, Maki S, Ikeda T. Placental growth factor level is correlated with intrapartum fetal heart rate findings. BMC Pregnancy Childbirth 2022; 22:215. [PMID: 35300623 PMCID: PMC8932326 DOI: 10.1186/s12884-022-04562-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 03/10/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Here, we tested the correlation between maternal placental growth factor (PlGF) and fetal heart rate (FHR) monitoring findings. Methods We included 35 women with single pregnancies from 35 to 42 weeks of gestation who were hospitalized owing to onset of labor. Blood samples were collected at the start of labor. Intrapartum FHR monitoring parameters included total deceleration area, average deceleration area (mean deceleration area per 10 min), and five-tier classification level. Results Of the 35 women, 26 (74%) had vaginal delivery and 9 (26%) had cesarean section. After excluding 2 women who had cesarean section for arrest of labor, we analyzed 26 women who had vaginal delivery (VD group) and 7 who had cesarean section for fetal indications (CSF group). PlGF level was significantly higher in the VD group (157 ± 106 pg/ml) than in the CSF group (74 ± 62 pg/ml) (P = 0.03). There were no significant correlations between PlGF and total (r = -0.07) or average (r = -0.08) deceleration area. There was a significant negative correlation (r = -0.42, P = 0.01) between PlGF and the percentage of level 3 or higher in the five-level classification. Conclusion PlGF was correlated with FHR monitoring findings and might be a promising biomarker of intrapartum fetal function.
Collapse
Affiliation(s)
- Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University, Tsu, Japan.
| | - Kayo Tanaka
- Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
| | - Sho Takakura
- Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
| | - Naosuke Enomoto
- Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
| | - Shintaro Maki
- Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
| |
Collapse
|
3
|
Hu J, Gao J, Liu J, Meng H, Hao N, Song Y, Ma L, Luo W, Sun J, Gao W, Meng W, Sun Y. Prospective evaluation of first-trimester screening strategy for preterm pre-eclampsia and its clinical applicability in China. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:529-539. [PMID: 33817865 DOI: 10.1002/uog.23645] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/05/2021] [Accepted: 03/25/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To evaluate, in a Chinese population, the performance of a screening strategy for preterm pre-eclampsia (PE) using The Fetal Medicine Foundation (FMF)'s competing-risks model and to explore its clinical applicability in mainland China. METHODS This was a prospective, multicenter, observational cohort study including 10 899 women with singleton pregnancy who sought prenatal care at one of 13 hospitals, located in seven cities in mainland China, between 1 December 2017 and 30 December 2019. Mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI) and maternal serum levels of placental growth factor (PlGF) and pregnancy-associated plasma protein-A (PAPP-A) at 11 + 0 to 13 + 6 weeks' gestation were measured and converted into multiples of the median using Chinese reference ranges. Individualized risk for preterm PE was calculated using the FMF algorithm. Prior risk was calculated based on maternal demographic characteristics and obstetric history. We evaluated the efficiency of the screening strategy using various combinations of biomarkers and analyzed its predictive performance for a composite of placenta-associated adverse pregnancy outcomes, including PE, placental abruption, small-for-gestational age (SGA) and preterm birth, at fixed false-positive rates for preterm PE. RESULTS We identified 312 pregnancies that developed PE, of which 117 cases were diagnosed as preterm PE (< 37 weeks' gestation). There were 386 pregnancies complicated by severe composite placenta-associated adverse outcome, including preterm PE, 146 cases of severe SGA (birth weight < 3rd percentile) neonate, 61 cases with placental abruption and 109 cases of early preterm birth < 34 gestational weeks. The triple-marker model containing biomarkers MAP, UtA-PI and PAPP-A achieved, at fixed false-positive rates of 10%, 15% and 20%, detection rates for preterm PE of 65.0%, 72.7% and 76.1%, respectively, and detection rates for severe composite placenta-associated adverse outcome of 34.7%, 41.7% and 46.4%, respectively. Replacing PAPP-A with PlGF or adding PlGF to the model did not improve the performance. Of women screening positive for preterm PE at a fixed 5% false-positive rate, an estimated 30% developed at least one placenta-associated adverse pregnancy outcome, including PE, placental abruption, SGA (birth weight < 10th percentile) and preterm birth < 37 weeks. CONCLUSIONS The FMF competing-risks model for preterm PE was found to be effective in screening a mainland Chinese population. Women who screened positive for preterm PE had increased risk for other placenta-associated pregnancy complications. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- J Hu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - J Gao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - J Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - H Meng
- Department of Ultrasonic Diagnosis, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - N Hao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Y Song
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - L Ma
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - W Luo
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - J Sun
- Department of Obstetrics and Gynecology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - W Gao
- Department of Obstetrics and Gynecology, Beijing Daxing People's Hospital, Beijing, China
| | - W Meng
- Department of Obstetrics and Gynecology, Tongzhou Maternal and Child Health Hospital of Beijing, Beijing, China
| | - Y Sun
- Department of Obstetrics and Gynecology, Beijing Shunyi District Maternal and Child Health Hospital, Beijing, China
| |
Collapse
|
4
|
Sin AWT, Poon LC, Chaemsaithong P, Wah YMI, Hui SYA, Ting YH, Law KM, Leung TY, Sahota DS. Impact of replacing or adding placental growth factor on Down syndrome screening: A prospective cohort study. Prenat Diagn 2021; 41:1111-1117. [PMID: 34166535 DOI: 10.1002/pd.5986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/17/2021] [Accepted: 05/23/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To assess whether adding placental growth factor (PlGF) or replacing pregnancy-associated plasma protein-A (PAPP-A) improves the first trimester combined test performance for trisomy 21. METHODS A total of 11,518 women with a singleton pregnancy who underwent the first trimester combined test between December 2016 and December 2019 were included. PlGF was measured and estimated term risk for trisomy 21 was calculated by (1) adding PlGF to the combined test and (2) replacing PAPP-A with PlGF. RESULTS Twenty-nine pregnancies had trisomy 21. The combined tests detection rate (DR), false positive rate (FPR) and screen positive rate (SPR) were 89.7%, 5.7% and 6% respectively. DR when adding PlGF to the combined test or replacing PAPP-A remained unchanged. Replacing PAPP-A by PlGF increased FPR and SPR to 6.2% and 6.4% respectively. Adding PlGF to the combined test gave FPR and SPR rates of 5.5% and 5.7% respectively. Change in FPR and SPR was not significant (p > 0.1 for all). CONCLUSION Adding PlGF to the combined test or replacing PAPP-A with PlGF did not improve trisomy 21 DR and resulted in a non-significant marginal change in FPR and SPR.
Collapse
Affiliation(s)
- Angela Wing To Sin
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
| | - Liona C Poon
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
| | - Piya Chaemsaithong
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
| | - Yi Man Isabella Wah
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
| | - Shuk Yi Annie Hui
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
| | - Yuen Ha Ting
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
| | - Kwok Ming Law
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
| | - Tak Yeung Leung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
| | - Daljit Singh Sahota
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
| |
Collapse
|
5
|
Simón E, Herraiz I, Villalaín C, Gómez-Arriaga PI, Quezada MS, López-Jiménez EA, Galindo A. Correlation of Kryptor and Elecsys® immunoassay sFlt-1/PlGF ratio on early diagnosis of preeclampsia and fetal growth restriction: A case-control study. Pregnancy Hypertens 2020; 20:44-49. [PMID: 32172169 DOI: 10.1016/j.preghy.2020.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 03/01/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The measurement of the soluble fms-like tyrosine kinase-1 to placental growth factor (sFlt-1/PlGF) ratio on automated platforms has improved the detection of preeclampsia and fetal growth restriction (PE/FGR). The cut-off points of >38 and ≥85 has been defined for "rule in" and "aid in diagnosis", respectively, using the Elecsys® platform. We aimed to compare the performance of these cut-offs between the Elecsys® and Kryptor platforms at 24-28 weeks. STUDY DESIGN Observational case-control study of singleton pregnancies at high risk for PE/FGR and sFlt-1/PlGF measurement at 24-28 weeks' gestation: 21 cases (9 early PE/FGR with delivery <32 weeks) were 1:1 matched for body mass index and parity with 21 controls. Correlations of the sFlt-1, PlGF and sFlt-1/PlGF values and diagnostic accuracy of the >38 and ≥85 cutoffs for early and late PE/FGR using Elecsys® and Kryptor assays were evaluated. MAIN OUTCOME MEASURES PE/FGR cases showed significantly higher median (IQR) sFlt-1/PlGF values at 24-28 weeks vs. controls, using both Elecsys® and Kryptor platforms: 55 (13-254) and 97 (13-530) vs. 4.1 (2.0-6.5) and 3.9 (1.8-7.7), respectively. The sFlt-1/PlGF correlation between both methods was excellent (r2 = 0.95) although lower PlGF and higher sFlt-1/PlGF values were observed with Kryptor. The higher diagnostic accuracy was obtained for early PE/FGR with the ≥85 cutoff (95.2%; 95%CI: 83.8-99.4%) in both platforms. CONCLUSION sFlt-1/PlGF measurements correlates well between Elecsys® and Kryptor platforms, and the cutoffs of >38 and ≥85 exhibit high diagnostic accuracy for assessing early PE/FGR at 24-28 weeks with both methods.
Collapse
Affiliation(s)
- Elisa Simón
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
| | - Ignacio Herraiz
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain.
| | - Cecilia Villalaín
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
| | - Paula Isabel Gómez-Arriaga
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
| | - María Soledad Quezada
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
| | - Elena Ana López-Jiménez
- Department of Clinical Biochemistry, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
| | - Alberto Galindo
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
| |
Collapse
|
6
|
Hendrix M, Bons J, van Haren A, van Kuijk S, van Doorn W, Kimenai DM, Bekers O, Spaanderman M, Al-Nasiry S. Role of sFlt-1 and PlGF in the screening of small-for-gestational age neonates during pregnancy: A systematic review. Ann Clin Biochem 2019; 57:44-58. [PMID: 31762291 DOI: 10.1177/0004563219882042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Fetal growth restriction, i.e. the restriction of genetically predetermined growth potential due to placental dysfunction, is a major cause of neonatal morbidity and mortality. The consequences of inadequate fetal growth can be life-long, but the risks can be reduced substantially if the condition is identified prenatally. Currently, screening strategies are based on ultrasound detection of a small-for-gestational age fetus and do not take into account the underlying vascular pathology in the placenta. Measurement of maternal circulating angiogenic biomarkers placental growth factor, sFlt-1 (soluble FMS-like tyrosine kinase-1) are increasingly used in studies on fetal growth restriction as they reflect the pathophysiological process in the placenta. However, interpretation of the role of angiogenic biomarkers in prediction of fetal growth restriction is hampered by the varying design, population, timing, assay technique and cut-off values used in these studies. Methods We conducted a systematic-review in PubMed (MEDLINE), EMBASE (Ovid) and Cochrane to explore the predictive performance of maternal concentrations of placental growth factor, sFlt-1 and their ratio for fetal growth restriction and small-for-gestational age, at different gestational ages, and describe the longitudinal changes in biomarker concentrations and optimal discriminatory cut-off values. Results We included 26 studies with 2514 cases with small-for-gestational age, 27 cases of fetal growth restriction, 582 cases mixed small-for-gestational age/fetal growth restriction and 29,374 reference. The largest mean differences for the two biomarkers and their ratio were found after 26 weeks of gestational age and not in the first trimester. The ROC-AUC varied between 0.60 and 0.89 with sensitivity and specificity matching the different cut-off values or a preset false-positive rate of 10%. Conclusions Most of the studies did not make a distinction between small-for-gestational age and fetal growth restriction, and therefore the small-for-gestational age group consists of fetuses with growth restriction and fetuses that are constitutionally normal. The biomarkers can be a valuable screening tool for small-for-gestational age pregnancies, but unfortunately, there is not yet a clear cut-off value to use for screening. More research is needed to see if these biomarkers are sufficiently able to differentiate growth restriction on their own and how these biomarkers in combination with other relevant clinical and ultrasound parameters can be used in clinical routine diagnostics.
Collapse
Affiliation(s)
- Mle Hendrix
- Department of Obstetrics & Gynecology, GROW School of Oncology and Developmental Biology, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Jap Bons
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - A van Haren
- Department of Obstetrics & Gynecology, GROW School of Oncology and Developmental Biology, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Smj van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Wptm van Doorn
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - D M Kimenai
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - O Bekers
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Mea Spaanderman
- Department of Obstetrics & Gynecology, GROW School of Oncology and Developmental Biology, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - S Al-Nasiry
- Department of Obstetrics & Gynecology, GROW School of Oncology and Developmental Biology, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| |
Collapse
|
7
|
Dunn L, Sherrell H, Bligh L, Alsolai A, Flatley C, Kumar S. Reference centiles for maternal placental growth factor levels at term from a low-risk population. Placenta 2019; 86:15-19. [PMID: 31494398 DOI: 10.1016/j.placenta.2019.08.086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/16/2019] [Accepted: 08/24/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Placental growth factor (PLGF) is a biomarker of placental function. The aim of this study was to define reference ranges for maternal PLGF levels in a normotensive cohort ≥36 + 0 weeks. METHOD Prospective observational data from Mater Mothers' Hospital, Brisbane. PLGF levels were measured in women at ≥36 + 0 weeks with singleton, non-anomalous pregnancies. Women with hypertension and fetal growth restriction were excluded. PLGF (pg/mL) was assayed using DELFIA® Xpress (PerkinElmer Inc). The Generalised Additive Model for Location, Shape and Scale (GAMLSS) method was used for the calculation of gestational age-adjusted centiles. Data analysis was performed with Stata 13 (StataCorp, LLC) and R software (R Foundation for Statistical Computing, Vienna, Austria). In all women, PLGF was measured within 2 weeks of delivery. RESULTS The study cohort comprised of 845 women (36 weeks n = 73, 37 weeks n = 230, 38 weeks n = 214, 39 weeks n = 172, 40 weeks n = 115, 41weeks n = 41). PLGF levels were negatively correlated with gestational age (r = -0.20, p < 0.001). Median PLGF levels dropped significantly from 36 weeks to 41 weeks (169.0 pg/mL to 96.6 pg/mL, p < 0.001). Gestational age specific maternal PLGF centiles were reported using fractional polynomial additive term and Box-Cox t distribution. PLGF did not perform adequately as a predictive test for adverse perinatal outcomes (AUC <0.6). DISCUSSION We have created gestational centile reference ranges for maternal PLGF from a normotensive cohort. These novel data suggest maternal PLGF levels decline ≥36 + 0 weeks. The utility of PLGF as a predictor of adverse perinatal outcomes at term, should be further investigated with clinical trials.
Collapse
Affiliation(s)
- Liam Dunn
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
| | - Helen Sherrell
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
| | - Larissa Bligh
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
| | - Amal Alsolai
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
| | - Christopher Flatley
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia; Faculty of Medicine, The University of Queensland, 288 Herston Road, Herston, Queensland, 4006, Australia.
| |
Collapse
|
8
|
Zhang J, Han L, Li W, Chen Q, Lei J, Long M, Yang W, Li W, Zeng L, Zeng S. Early prediction of preeclampsia and small-for-gestational-age via multi-marker model in Chinese pregnancies: a prospective screening study. BMC Pregnancy Childbirth 2019; 19:304. [PMID: 31426761 PMCID: PMC6700825 DOI: 10.1186/s12884-019-2455-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 08/12/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Recent evidence suggests early screening of preeclampsia and small-for-gestational-age (SGA) would benefit pregnancies followed by subsequent prophylactic use of aspirin. Multi-marker models have shown capability of predicting preeclampsia and SGA in first trimester. Yet the clinical feasibility of combined screening model for Chinese pregnancies has not been fully assessed. The aim of this study is to evaluate the applicability of a multi-marker screening model to the prediction of preeclampsia and SGA in first trimester particularly among Chinese population. METHODS Three thousand two hundred seventy pregnancies meeting the inclusion criteria took first-trimester screening of preeclampsia and SGA. A prior risk based on maternal characteristics was evaluated, and a posterior risk was assessed by combining prior risk with multiple of median (MoM) values of mean arterial pressure (MAP), serum placental growth factor (PLGF) and pregnancy associated plasma protein A (PAPP-A). Both risks were calculated by Preeclampsia PREDICTOR™ software, Perkin Elmer. Screening performance of prior and posterior risks for early and late preeclampsia by using PREDICTOR software was shown by Receiver Operating Characteristics (ROC) curves. The estimation of detection rates and false positive rates of delivery with both preeclampsia and SGA was made. RESULTS Eight cases developed early preeclampsia (0.24%) and 35 were diagnosed as late preeclampsia (1.07%). Five with early preeclampsia and ten with late preeclampsia later delivered SGA newborns (0.46%); 84 without preeclampsia gave birth to the SGAs (2.57%). According to ROC curves, posterior risks performed better than prior risks in terms of preeclampsia, especially in early preeclampsia. At 10% false positive rate, detection rates of early and late preeclampsia were 87.50 and 48.57%, detection rates of early and late SGA were 41.67 and 28.00%, respectively. For SGA, detection rates in cases with preeclampsia were much higher than those in absence of it. CONCLUSIONS This study demonstrates that combined screening model could be useful for predicting early preeclampsia in Chinese pregnancies. Furthermore, the performance of SGA screening by same protocol is strongly associated with preeclampsia.
Collapse
Affiliation(s)
- Jing Zhang
- Department of Clinical Laboratory, Shenzhen Nanshan Maternity and Child Healthcare Hospital, No.1 Wanxia Road, Nanshan District, Shenzhen, Guangdong People’s Republic of China
| | - Luhao Han
- Department of Clinical Laboratory, Shenzhen Nanshan Maternity and Child Healthcare Hospital, No.1 Wanxia Road, Nanshan District, Shenzhen, Guangdong People’s Republic of China
| | - Wei Li
- Department of Clinical Laboratory, Shenzhen Nanshan Maternity and Child Healthcare Hospital, No.1 Wanxia Road, Nanshan District, Shenzhen, Guangdong People’s Republic of China
| | - Qiaobin Chen
- Department of Clinical Laboratory, Shenzhen Nanshan Maternity and Child Healthcare Hospital, No.1 Wanxia Road, Nanshan District, Shenzhen, Guangdong People’s Republic of China
| | - Jie Lei
- Department of Clinical Laboratory, Shenzhen Nanshan Maternity and Child Healthcare Hospital, No.1 Wanxia Road, Nanshan District, Shenzhen, Guangdong People’s Republic of China
| | - Min Long
- Department of Clinical Laboratory, Shenzhen Nanshan Maternity and Child Healthcare Hospital, No.1 Wanxia Road, Nanshan District, Shenzhen, Guangdong People’s Republic of China
| | - Weibin Yang
- Department of Clinical Laboratory, Shenzhen Nanshan Maternity and Child Healthcare Hospital, No.1 Wanxia Road, Nanshan District, Shenzhen, Guangdong People’s Republic of China
| | - Wenya Li
- Department of Clinical Laboratory, Shenzhen Nanshan Maternity and Child Healthcare Hospital, No.1 Wanxia Road, Nanshan District, Shenzhen, Guangdong People’s Republic of China
| | - Lizhen Zeng
- Department of Clinical Laboratory, Shenzhen Nanshan Maternity and Child Healthcare Hospital, No.1 Wanxia Road, Nanshan District, Shenzhen, Guangdong People’s Republic of China
| | - Sifan Zeng
- Department of Clinical Laboratory, Shenzhen Nanshan Maternity and Child Healthcare Hospital, No.1 Wanxia Road, Nanshan District, Shenzhen, Guangdong People’s Republic of China
| |
Collapse
|
9
|
Frang H, Hurskainen P, Nicolaides K, Sairanen M. PlGF isoform 3 in maternal serum and placental tissue. Pregnancy Hypertens 2019; 18:9-13. [PMID: 31442830 DOI: 10.1016/j.preghy.2019.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 07/15/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Four isoforms originating from alternative splicing of PGF gene have been reported for placental growth factor (PlGF). Main PlGF isoforms 1 and 2 have been associated with screening and diagnosis of pre-eclampsia (PE). Despite of the vast amount of research around PlGF in PE, protein levels of isoforms PlGF-3 and -4 have not been reported in human serum samples. STUDY DESIGN In this study a PlGF-3 specific DELFIA research immunoassay based on a custom recombinant Fab binder was developed and characterized. Serum levels of a third PlGF isoform during pregnancy were determined and screening performance of PlGF-3 for PE and small for gestational age (SGA) was investigated. MAIN OUTCOME MEASURES Levels of serum and placental tissue PlGF 3 and predictive power of PlGF-3 for Pre-eclampsia and SGA. RESULTS PlGF-3 was below the detection limit of 1.6 pg/mL in most of the serum samples collected during pregnancy. Detected protein levels of PlGF-3 were not associated to be predictive for PE or SGA. However, measurable, and relatively higher amounts of PlGF-3 was extracted from placental tissue samples. CONCLUSION Data obtained indicates that very low amounts of PlGF-3 is present in blood but significantly higher amounts of protein is present in placental tissue where it is prominently associated with cellular membranes.
Collapse
Affiliation(s)
| | | | - Kypros Nicolaides
- The Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | | |
Collapse
|
10
|
Dabrowski FA, Lipa M, Bartoszewicz Z, Wielgos M, Bomba-Opon DA. Maternal and neonatal serum expression of the vascular growth factors in hyperglycemia in pregnancy. J Matern Fetal Neonatal Med 2019; 34:1673-1678. [PMID: 31307255 DOI: 10.1080/14767058.2019.1639666] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Hyperglycemia in pregnancy (HIP) occurs in up to 8-17% of pregnancies. Unfavorable impact of the pregnancy induced hyperglycemia on both maternal and fetal tissues is associated with adverse pregnancy outcomes. Vascular growth factors, especially in the early phase of gestation, are considered as one of the most significant molecules that regulate pregnancy course and their serum expression may be altered in patients affected with HIP. MATERIAL AND METHODS Fifty-five consecutive pregnant patients who underwent elective cesarean section were incorporated into this study. During the surgery, maternal and cord blood samples were collected. Serum expression levels of vascular growth factors: PlGF, VEGF, THBS-2 and Ang-2 were compared among non-HIP and pregnancies affected by gestational diabetes. Subsequently, laboratory results were correlated with obstetric outcomes. RESULTS There were no statistical differences in maternal characteristics, neonatal outcomes and maternal or neonatal serum levels between study and control groups. However, our results revealed significant differences between fetal and maternal levels of VEGF (p = .028 and .0001), THBS-2 (p = .013 and .0014) and Ang-2 (p = .035 and .048) for HIP and non-HIP group, respectively. CONCLUSIONS Similar serum expressions of vascular growth factors in and non-HIP and HIP pregnancies point that normal glycemia due to thorough prenatal surveillance may result in normal angio- and vasculogenesis associated with good pregnancy outcomes.
Collapse
Affiliation(s)
- Filip A Dabrowski
- 1st Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Michal Lipa
- 1st Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Zbigniew Bartoszewicz
- Department of Endocrinology and Internal Medicine, 1st Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Miroslaw Wielgos
- 1st Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Dorota A Bomba-Opon
- 1st Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
11
|
Cheng YKY, Poon LCY, Shennan A, Leung TY, Sahota DS. Inter-manufacturer comparison of automated immunoassays for the measurement of soluble FMS-like tyrosine kinase-1 and placental growth factor. Pregnancy Hypertens 2019; 17:165-171. [DOI: 10.1016/j.preghy.2019.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/10/2019] [Accepted: 06/18/2019] [Indexed: 11/28/2022]
|
12
|
Dunn L, Kumar S. Changes in intrapartum maternal placental growth factor levels in pregnancies complicated by fetal compromise at term. Placenta 2018; 74:9-13. [PMID: 30594309 DOI: 10.1016/j.placenta.2018.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/28/2018] [Accepted: 12/21/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Intrapartum fetal compromise (IFC) may result from the gradual decline in placental function during labour and can precipitate adverse neonatal outcomes. Placental growth factor (PlGF) is a biomarker of placental function. This study aims to investigate maternal PlGF levels and adverse perinatal outcomes in term labour. METHODS Prospective observational study (Mater Mothers' Hospital, Brisbane). Eligibility: 37+0- 42+0 weeks gestation, singleton, cephalic, non-anomalous pregnancies. Cases of pre-eclampsia and fetal growth restriction were excluded. Maternal PlGF was sampled at the onset of the first stage of labour (1st PlGF) and again at the second stage (2nd PlGF). RESULTS Sixty-three participants met inclusion criteria. Women requiring operative delivery (n = 11) for IFC had lower 1st PlGF (90.8 vs. 111.8 pg/ml) and 2nd PlGF (65.8 vs. 83.7 pg/ml) compared to the no-IFC cohort (n = 52). PlGF levels decreased significantly during labour in both the IFC (90.8 vs. 65.8 pg/ml, p = 0.021) and no-IFC (111.8 v 83.7, p < 0.001) cohorts, although the decline in PlGF levels was greater in the IFC cohort (-41.8% vs. -23.4%, p = 0.385). Maternal PlGF levels were significantly lower in those with an abnormal fetal heart rate pattern, cord arterial pH < 7.2, nursery admission and composite adverse neonatal outcome (CANO). PlGF decline was not correlated to duration of labour but was influenced by nulliparity and induced labour. CONCLUSIONS Maternal PlGF levels are lower in pregnancies complicated by IFC and CANO, and declines more sharply during labour compared to the no-IFC cohort. The utility of PlGF as a predictor of IFC should be further investigated with clinical trials.
Collapse
Affiliation(s)
- Liam Dunn
- Mater Research Institute - University of Queensland, South Brisbane, Queensland, QLD 4101, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Sailesh Kumar
- Mater Research Institute - University of Queensland, South Brisbane, Queensland, QLD 4101, Australia; Mater Mother's Hospital, Raymond Terrace, South Brisbane, Queensland, QLD 4101, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia.
| |
Collapse
|
13
|
Bækgaard Thorsen LH, Bjørkholt Andersen L, Birukov A, Lykkedegn S, Dechend R, Stener Jørgensen J, Thybo Christesen H. Prediction of birth weight small for gestational age with and without preeclampsia by angiogenic markers: an Odense Child Cohort study. J Matern Fetal Neonatal Med 2018; 33:1377-1384. [PMID: 30173595 DOI: 10.1080/14767058.2018.1519536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Purpose: To investigate the predictive performance of placental growth factor (PlGF) and soluble FMS-like kinase 1 (sFlt-1) on birth weight and small for gestational age (SGA), in a large, population-based cohort.Methods: Women enrolled in the population-based, prospective Odense Child Cohort Study with early (GA < 20 weeks) and/or late (≥20 weeks) pregnancy blood samples (n = 1937) were included. The association between log-transformed values of the biomarkers and birth weight Z-score was studied using multivariate regression models. The prediction of SGA overall, and in women developing preeclampsia, by biomarkers was evaluated using receiver operating characteristic analyses.Results: No substantial associations between early pregnancy biomarkers and SGA were seen. PlGF measured in late pregnancy demonstrated the strongest association with birth weight Z-score (adjusted β-coefficient = 0.43 [95%CI = 0.35; 0.50]). The area under curve (AUC) for predicting SGA was higher for sFlt-1/PlGF compared to sFlt-1 (0.74 versus 0.63, p = .006) and reached excellent prediction for SGA after preeclampsia (AUC 0.94). Optimal sFlt-1/PlGF ratio cut-offs had higher negative predictive value (NPV) and positive predictive value (PPV) for SGA (cut-off > 5.0; NPV = 99.1%, PPV = 5.4%) compared to each marker individually.Conclusion: The sFlt-1/PlGF ratio is a potential predictor of SGA in population-based screening, particularly when preeclampsia is also present.
Collapse
Affiliation(s)
- Lena Heidi Bækgaard Thorsen
- Hans Christian and Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Louise Bjørkholt Andersen
- Hans Christian and Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Obstetrics and Gynecology, Herlev Hospital, Copenhagen, Denmark
| | - Anna Birukov
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark.,Experimental and Clinical Research Center, Max-Delbrück Center and Charité University Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Sine Lykkedegn
- Hans Christian and Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Ralf Dechend
- Experimental and Clinical Research Center, Max-Delbrück Center and Charité University Berlin, Berlin, Germany
| | - Jan Stener Jørgensen
- Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark.,Odense Child Cohort, Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Odense Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Henrik Thybo Christesen
- Hans Christian and Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Odense Child Cohort, Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Odense Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| |
Collapse
|
14
|
Huang T, Meschino WS, Rashid S, Dennis A, Mak-Tam E, Cuckle H. Enhanced First Trimester Aneuploidy Screening with Placental Growth Factor and Alpha Feto-Protein: Detection of Trisomies 18 and 13. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:1295-1301. [PMID: 30025867 DOI: 10.1016/j.jogc.2018.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/03/2018] [Accepted: 01/03/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To assess the performance of first trimester combined screening (FTS) when enhanced with placental growth factor and alpha feto-protein in the detection of trisomies 18 and 13. METHODS A retrospective case-control study. Marker parameters were derived using frozen serum samples. Multivariate Gaussian modelling predicted the detection rate (DR) and false-positive rate (FPR) for trisomies 18 and 13 with FTS and enhanced first trimester screening (eFTS) using the risk of trisomy 21 alone and an additional risk cut-off for trisomy 18, or trisomies 18 or 13. RESULTS There were 83 trisomy 18, 22 trisomy 13, and 588 controls. The median placental growth factor levels in trisomies 18 and 13 were 0.75 and 0.65 multiple of the median of controls, respectively (both P < 0.0001). There were no statistically significant differences in alpha feto-protein levels. Modelling predicts that using a trisomy 21 risk cut-off alone, at FPR of 3%, eFTS increases the DR for trisomies 18 and 13 by 0.6-0.8% compared with FTS. Additionally using a trisomy 18 risk cut-off, at an extra FPR of 0.2%, eFTS increased the DR by 0.6-0.9% over FTS; using a trisomy 18 or 13 risk cut-off did not further increase detection for FTS or eFTS. The increase in DR was greater at higher FPR. CONCLUSION eFTS increases the detection of trisomies 18 and 13 to a small extent.
Collapse
Affiliation(s)
- Tianhua Huang
- Genetics Program, North York General Hospital, Toronto, ON; Better Outcomes Registry & Network (BORN) Ontario, Ottawa, ON; The Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON; Department of Obstetrics & Gynaecology, University of Toronto, Toronto, ON.
| | - Wendy S Meschino
- Genetics Program, North York General Hospital, Toronto, ON; Department of Paediatrics, University of Toronto, Toronto, ON
| | - Shamim Rashid
- Genetics Program, North York General Hospital, Toronto, ON
| | - Alan Dennis
- Genetics Program, North York General Hospital, Toronto, ON
| | - Ellen Mak-Tam
- Genetics Program, North York General Hospital, Toronto, ON
| | - Howard Cuckle
- Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| |
Collapse
|
15
|
Wataganara T, Leetheeragul J, Pongprasobchai S, Sutantawibul A, Phatihattakorn C, Angsuwathana S. Prediction and prevention of pre-eclampsia in Asian subpopulation. J Obstet Gynaecol Res 2018; 44:813-830. [PMID: 29442407 DOI: 10.1111/jog.13599] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/31/2017] [Indexed: 12/20/2022]
Abstract
The benefit of the early administration of aspirin to reduce preterm pre-eclampsia among screened positive European women from multivariate algorithmic approach (ASPRE trial) has opened an intense debate on the feasibility of universal screening. This review aims to assess the new perspectives in the combined screening of pre-eclampsia in the first trimester of pregnancy and the chances for prevention using low-dose aspirin with special emphasis on the particularities of the Asian population. PubMed, CENTRAL and Embase databases were searched from inception until 15 November 2017 using combinations of the search terms: preeclampsia, Asian, prenatal screening, early prediction, ultrasonography, pregnancy, biomarker, mean arterial pressure, soluble fms-like tyrosine kinase-1, placental growth factor, pregnancy-associated plasma protein-A and pulsatility index. This is not a systematic review or meta-analysis, so the risk of bias of the selected published articles and heterogeneity among the studies need to be considered. The prevalence of pre-eclampsia and serum levels of biochemical markers in Asian are different from Caucasian women; hence, Asian ethnicity needs to be corrected for in the algorithmic assessment of multiple variables to improve the screening performance. Aspirin prophylaxis may still be viable in Asian women, but resource implication needs to be considered. Asian ethnicity should be taken into account before implementing pre-eclampsia screening strategies in the region. The variables included can be mixed and matched to achieve an optimal performance that is appropriate for economical restriction in individual countries.
Collapse
Affiliation(s)
- Tuangsit Wataganara
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Jarunee Leetheeragul
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Suchittra Pongprasobchai
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Anuwat Sutantawibul
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Chayawat Phatihattakorn
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Surasak Angsuwathana
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| |
Collapse
|
16
|
Dunn L, Flatley C, Kumar S. Changes in maternal placental growth factor levels during term labour. Placenta 2018; 61:11-16. [DOI: 10.1016/j.placenta.2017.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 11/01/2017] [Accepted: 11/06/2017] [Indexed: 01/08/2023]
|
17
|
First-trimester placental thickness and the risk of preeclampsia or SGA. Placenta 2017; 57:123-128. [DOI: 10.1016/j.placenta.2017.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 06/13/2017] [Accepted: 06/17/2017] [Indexed: 01/02/2023]
|
18
|
Romero R, Erez O, Hüttemann M, Maymon E, Panaitescu B, Conde-Agudelo A, Pacora P, Yoon BH, Grossman LI. Metformin, the aspirin of the 21st century: its role in gestational diabetes mellitus, prevention of preeclampsia and cancer, and the promotion of longevity. Am J Obstet Gynecol 2017; 217:282-302. [PMID: 28619690 DOI: 10.1016/j.ajog.2017.06.003] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 05/30/2017] [Accepted: 06/05/2017] [Indexed: 12/16/2022]
Abstract
Metformin is everywhere. Originally introduced in clinical practice as an antidiabetic agent, its role as a therapeutic agent is expanding to include treatment of prediabetes mellitus, gestational diabetes mellitus, and polycystic ovarian disease; more recently, experimental studies and observations in randomized clinical trials suggest that metformin could have a place in the treatment or prevention of preeclampsia. This article provides a brief overview of the history of metformin in the treatment of diabetes mellitus and reviews the results of metaanalyses of metformin in gestational diabetes mellitus as well as the treatment of obese, non-diabetic, pregnant women to prevent macrosomia. We highlight the results of a randomized clinical trial in which metformin administration in early pregnancy did not reduce the frequency of large-for-gestational-age infants (the primary endpoint) but did decrease the frequency of preeclampsia (a secondary endpoint). The mechanisms by which metformin may prevent preeclampsia include a reduction in the production of antiangiogenic factors (soluble vascular endothelial growth factor receptor-1 and soluble endoglin) and the improvement of endothelial dysfunction, probably through an effect on the mitochondria. Another potential mechanism whereby metformin may play a role in the prevention of preeclampsia is its ability to modify cellular homeostasis and energy disposition, mediated by rapamycin, a mechanistic target. Metformin has a molecular weight of 129 Daltons and therefore readily crosses the placenta. There is considerable evidence to suggest that this agent is safe during pregnancy. New literature on the role of metformin as a chemotherapeutic adjuvant in the prevention of cancer and in prolonging life and protecting against aging is reviewed briefly. Herein, we discuss the mechanisms of action and potential benefits of metformin.
Collapse
|
19
|
Bhuwapathanapun M, Pratumvinit B, Lahfahroengron P, Hanyongyuth S, Phaophan A, Pooliam J, Wataganara T. Serum-free placental growth factor isoform 1 at 11–13-week gestation: effects of maternal factors, mean arterial pressure, placental volume, and uterine artery pulsatility index. J Matern Fetal Neonatal Med 2017; 31:2813-2819. [DOI: 10.1080/14767058.2017.1357168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Maolee Bhuwapathanapun
- Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Busadee Pratumvinit
- Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Piyaporn Lahfahroengron
- Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sithikan Hanyongyuth
- Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Amprapha Phaophan
- Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Julaporn Pooliam
- Division of Clinical Epidemiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tuangsit Wataganara
- Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
20
|
Romero R, Erez O, Maymon E, Chaemsaithong P, Xu Z, Pacora P, Chaiworapongsa T, Done B, Hassan SS, Tarca AL. The maternal plasma proteome changes as a function of gestational age in normal pregnancy: a longitudinal study. Am J Obstet Gynecol 2017; 217:67.e1-67.e21. [PMID: 28263753 PMCID: PMC5813489 DOI: 10.1016/j.ajog.2017.02.037] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/10/2017] [Accepted: 02/23/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Pregnancy is accompanied by dramatic physiological changes in maternal plasma proteins. Characterization of the maternal plasma proteome in normal pregnancy is an essential step for understanding changes to predict pregnancy outcome. The objective of this study was to describe maternal plasma proteins that change in abundance with advancing gestational age and determine biological processes that are perturbed in normal pregnancy. STUDY DESIGN A longitudinal study included 43 normal pregnancies that had a term delivery of an infant who was appropriate for gestational age without maternal or neonatal complications. For each pregnancy, 3 to 6 maternal plasma samples (median, 5) were profiled to measure the abundance of 1125 proteins using multiplex assays. Linear mixed-effects models with polynomial splines were used to model protein abundance as a function of gestational age, and the significance of the association was inferred via likelihood ratio tests. Proteins considered to be significantly changed were defined as having the following: (1) >1.5-fold change between 8 and 40 weeks of gestation; and (2) a false discovery rate-adjusted value of P < .1. Gene ontology enrichment analysis was used to identify biological processes overrepresented among the proteins that changed with advancing gestation. RESULTS The following results were found: (1) Ten percent (112 of 1125) of the profiled proteins changed in abundance as a function of gestational age; (2) of the 1125 proteins analyzed, glypican-3, sialic acid-binding immunoglobulin-type lectin-6, placental growth factor, C-C motif-28, carbonic anhydrase 6, prolactin, interleukin-1 receptor 4, dual-specificity mitogen-activated protein kinase 4, and pregnancy-associated plasma protein-A had more than a 5-fold change in abundance across gestation (these 9 proteins are known to be involved in a wide range of both physiological and pathological processes, such as growth regulation, embryogenesis, angiogenesis immunoregulation, inflammation etc); and (3) biological processes associated with protein changes in normal pregnancy included defense response, defense response to bacteria, proteolysis, and leukocyte migration (false discovery rate, 10%). CONCLUSION The plasma proteome of normal pregnancy demonstrates dramatic changes in both the magnitude of changes and the fraction of the proteins involved. Such information is important to understand the physiology of pregnancy and the development of biomarkers to differentiate normal vs abnormal pregnancy and determine the response to interventions.
Collapse
Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI.
| | - Offer Erez
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Eli Maymon
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Piya Chaemsaithong
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Zhonghui Xu
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI
| | - Percy Pacora
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Bogdan Done
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI
| | - Sonia S Hassan
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Adi L Tarca
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI.
| |
Collapse
|
21
|
Clegg LE, Mac Gabhann F. A computational analysis of in vivo VEGFR activation by multiple co-expressed ligands. PLoS Comput Biol 2017; 13:e1005445. [PMID: 28319199 PMCID: PMC5378411 DOI: 10.1371/journal.pcbi.1005445] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 04/03/2017] [Accepted: 03/08/2017] [Indexed: 12/16/2022] Open
Abstract
The splice isoforms of vascular endothelial growth A (VEGF) each have different affinities for the extracellular matrix (ECM) and the coreceptor NRP1, which leads to distinct vascular phenotypes in model systems expressing only a single VEGF isoform. ECM-immobilized VEGF can bind to and activate VEGF receptor 2 (VEGFR2) directly, with a different pattern of site-specific phosphorylation than diffusible VEGF. To date, the way in which ECM binding alters the distribution of isoforms of VEGF and of the related placental growth factor (PlGF) in the body and resulting angiogenic signaling is not well-understood. Here, we extend our previous validated cell-level computational model of VEGFR2 ligation, intracellular trafficking, and site-specific phosphorylation, which captured differences in signaling by soluble and immobilized VEGF, to a multi-scale whole-body framework. This computational systems pharmacology model captures the ability of the ECM to regulate isoform-specific growth factor distribution distinctly for VEGF and PlGF, and to buffer free VEGF and PlGF levels in tissue. We show that binding of immobilized growth factor to VEGF receptors, both on endothelial cells and soluble VEGFR1, is likely important to signaling in vivo. Additionally, our model predicts that VEGF isoform-specific properties lead to distinct profiles of VEGFR1 and VEGFR2 binding and VEGFR2 site-specific phosphorylation in vivo, mediated by Neuropilin-1. These predicted signaling changes mirror those observed in murine systems expressing single VEGF isoforms. Simulations predict that, contrary to the 'ligand-shifting hypothesis,' VEGF and PlGF do not compete for receptor binding at physiological concentrations, though PlGF is predicted to slightly increase VEGFR2 phosphorylation when over-expressed by 10-fold. These results are critical to design of appropriate therapeutic strategies to control VEGF availability and signaling in regenerative medicine applications.
Collapse
Affiliation(s)
- Lindsay E. Clegg
- Institute for Computational Medicine, Institute for NanoBioTechnology, and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Feilim Mac Gabhann
- Institute for Computational Medicine, Institute for NanoBioTechnology, and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, Maryland, United States of America
| |
Collapse
|
22
|
Bolnick JM, Kohan-Ghadr HR, Fritz R, Bolnick AD, Kilburn BA, Diamond MP, Armant DR, Drewlo S. Altered Biomarkers in Trophoblast Cells Obtained Noninvasively Prior to Clinical Manifestation of Perinatal Disease. Sci Rep 2016; 6:32382. [PMID: 27660926 PMCID: PMC5034887 DOI: 10.1038/srep32382] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/08/2016] [Indexed: 12/17/2022] Open
Abstract
A contributing factor to poor placental perfusion, leading to intrauterine growth restriction and preeclampsia, is the failure of invading extravillous trophoblast (EVT) cells to remodel the maternal uterine arteries during the first and second trimesters of pregnancy. Noninvasive assessment of EVT cells in ongoing pregnancies is possible beginning three weeks after conception, using trophoblast retrieval and isolation from the cervix (TRIC). Seven proteins were semi-quantified by immunofluorescence microscopy in EVT cells obtained between gestational weeks 6 and 20 from pregnancies with normal outcomes (N = 29) and those with intrauterine growth restriction or preeclampsia (N = 12). Significant differences were measured in expression of PAPPA, FLT1, ENG, AFP, PGF, and LGALS14, but not LGALS13 or the lineage marker KRT7. These findings provide for the first time direct evidence of pathology-associated protein dysregulation in EVT cells during early placentation. The TRIC platform provides a novel approach to acquire molecular signatures of EVT cells that can be correlated with pregnancy outcome.
Collapse
Affiliation(s)
- Jay M Bolnick
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Hamid-Reza Kohan-Ghadr
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Rani Fritz
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Alan D Bolnick
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Brian A Kilburn
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Georgia Regents University, Augusta, GA, USA
| | - D Randall Armant
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA.,Program in Reproductive and Adult Endocrinology, NIH, NICHD, DHHS, Bethesda, MD, USA
| | - Sascha Drewlo
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| |
Collapse
|
23
|
van Helden J, Weiskirchen R. Analytical evaluation of the novel soluble fms-like tyrosine kinase 1 and placental growth factor assays for the diagnosis of preeclampsia. Clin Biochem 2015; 48:1113-9. [DOI: 10.1016/j.clinbiochem.2015.06.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 06/25/2015] [Accepted: 06/26/2015] [Indexed: 11/25/2022]
|
24
|
Noninvasive detection of trophoblast protein signatures linked to early pregnancy loss using trophoblast retrieval and isolation from the cervix (TRIC). Fertil Steril 2015; 104:339-46.e4. [PMID: 26051097 DOI: 10.1016/j.fertnstert.2015.05.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/08/2015] [Accepted: 05/08/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To examine the expression pattern of biomarker proteins in extravillous trophoblast (EVT) cells obtained noninvasively by trophoblast retrieval and isolation from the cervix (TRIC) in patients with early pregnancy loss compared with control patients with uncomplicated term delivery. DESIGN Case-control study. SETTING Academic medical center. PATIENT(S) Women with either early pregnancy loss (EPL, n = 10) or an uncomplicated term delivery (N = 10). INTERVENTION(S) Endocervical specimens obtained from ongoing pregnancies at gestational ages of 5-10 weeks to generate an archive of EVT cells isolated by TRIC, with medical records examined to select specimens matched for gestational age at the time of endocervical sampling. MAIN OUTCOME MEASURE(S) Known serum biomarkers for adverse pregnancy outcome that are expressed by EVT cells were evaluated by semiquantitative immunocytochemistry, using antibodies against endoglin (ENG), FMS-like tyrosine kinase-1 (FLT-1), α-fetoprotein (AFP), pregnancy-associated plasma protein-A (PAPP-A), galectin-13 (LGALS13), galectin-14 (LGALS14), and placental growth factor (PGF). RESULT(S) The EVT purity was over 95% in all specimens, based on chorionic gonadotropin expression; however, the number of EVT cells obtained was significantly lower in women with EPL than the control group. There was a statistically significant elevation of AFP, ENG, and FLT-1, and statistically significant reduction of PAPP-A, LGALS14, and PGF in the EPL group compared with controls. CONCLUSION(S) In this pilot study, EVT cells isolated by TRIC early in gestation exhibited altered protein expression patterns before an EPL compared with uncomplicated term pregnancies.
Collapse
|
25
|
Andersen LB, Frederiksen-Møller B, Work Havelund K, Dechend R, Jørgensen JS, Jensen BL, Nielsen J, Lykkedegn S, Barington T, Christesen HT. Diagnosis of preeclampsia with soluble Fms–like tyrosine kinase 1/placental growth factor ratio: an inter–assay comparison. ACTA ACUST UNITED AC 2015; 9:86-96. [DOI: 10.1016/j.jash.2014.11.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 11/10/2014] [Accepted: 11/30/2014] [Indexed: 11/28/2022]
|
26
|
Nucci M, Poon LC, Demirdjian G, Darbouret B, Nicolaides KH. Maternal serum placental growth factor isoforms 1 and 2 at 11-13, 20-24 and 30-34 weeks' gestation in late-onset pre-eclampsia and small for gestational age neonates. Fetal Diagn Ther 2014; 35:249-57. [PMID: 24642536 DOI: 10.1159/000358595] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 12/30/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To compare the maternal serum concentrations of placental growth factor (PlGF)-1 and PlGF-2 in the first, second and third trimesters in normal pregnancies and in those complicated by pre-eclampsia (PE) or the delivery of small for gestational age (SGA) neonates after 37 weeks. METHODS Serum PlGF-1 and PlGF-2 were measured at 11-13, 20-24 and 30-34 weeks' gestation in 50 cases of PE, 99 cases of SGA and 298 controls. The values of PlGF-1 and PlGF-2 at 11-13 weeks were expressed as multiples of the median (MoM) after adjustment for maternal characteristics. The distributions of PlGF-1 and PlGF-2 in cases and controls at 20-24 and 30-34 weeks were converted to MoM of the values at 11-13 weeks and compared. RESULTS Serum PlGF-1 and PlGF-2 levels were highly correlated and both increased with gestational age. At 30-34 weeks, the median MoM values for PlGF-1 and PlGF-2 in the late PE (4.2 and 4.3) and late SGA (7.2 and 6.0) groups were significantly lower than in the controls (12.8 and 9.9). Combining the two isoforms did not improve the prediction of late PE and late SGA provided by PlGF-1 alone. CONCLUSIONS The performances of serum PlGF-1 and PlGF-2 in the prediction of late PE and late SGA are similar.
Collapse
Affiliation(s)
- Marta Nucci
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | | | | | | | | |
Collapse
|