1
|
Edvinsson C, Björnsson O, Erlandsson L, Hansson SR. Predicting intensive care need in women with preeclampsia using machine learning - a pilot study. Hypertens Pregnancy 2024; 43:2312165. [PMID: 38385188 DOI: 10.1080/10641955.2024.2312165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 01/02/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Predicting severe preeclampsia with need for intensive care is challenging. To better predict high-risk pregnancies to prevent adverse outcomes such as eclampsia is still an unmet need worldwide. In this study we aimed to develop a prediction model for severe outcomes using routine biomarkers and clinical characteristics. METHODS We used machine learning models based on data from an intensive care cohort with severe preeclampsia (n=41) and a cohort of preeclampsia controls (n=40) with the objective to find patterns for severe disease not detectable with traditional logistic regression models. RESULTS The best model was generated by including the laboratory parameters aspartate aminotransferase (ASAT), uric acid and body mass index (BMI) with a cross-validation accuracy of 0.88 and an area under the curve (AUC) of 0.91. Our model was internally validated on a test-set where the accuracy was lower, 0.82, with an AUC of 0.85. CONCLUSION The clinical routine blood parameters ASAT and uric acid as well as BMI, were the parameters most indicative of severe disease. Aspartate aminotransferase reflects liver involvement, uric acid might be involved in several steps of the pathophysiologic process of preeclampsia, and obesity is a well-known risk factor for development of both severe and non-severe preeclampsia likely involving inflammatory pathways..[Figure: see text].
Collapse
Affiliation(s)
- Camilla Edvinsson
- Division of Obstetrics and Gynecology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Division of Anaesthesia and Intensive Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Ola Björnsson
- Division of Mathematical Statistics, Centre for Mathematical Sciences, Lund University, Lund, Sweden
- Department of Energy Sciences, Faculty of Engineering, Lund University, Lund, Sweden
| | - Lena Erlandsson
- Division of Obstetrics and Gynecology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Stefan R Hansson
- Division of Obstetrics and Gynecology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund/Malmö, Sweden
| |
Collapse
|
2
|
Suksai M, Romero R, Bosco M, Gotsch F, Jung E, Chaemsaithong P, Tarca AL, Gudicha DW, Gomez-Lopez N, Arenas-Hernandez M, Meyyazhagan A, Grossman LI, Aras S, Chaiworapongsa T. A mitochondrial regulator protein, MNRR1, is elevated in the maternal blood of women with preeclampsia. J Matern Fetal Neonatal Med 2024; 37:2297158. [PMID: 38220225 DOI: 10.1080/14767058.2023.2297158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 12/15/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVE Preeclampsia, one of the most serious obstetric complications, is a heterogenous disorder resulting from different pathologic processes. However, placental oxidative stress and an anti-angiogenic state play a crucial role. Mitochondria are a major source of cellular reactive oxygen species. Abnormalities in mitochondrial structures, proteins, and functions have been observed in the placentae of patients with preeclampsia, thus mitochondrial dysfunction has been implicated in the mechanism of the disease. Mitochondrial nuclear retrograde regulator 1 (MNRR1) is a newly characterized bi-organellar protein with pleiotropic functions. In the mitochondria, this protein regulates cytochrome c oxidase activity and reactive oxygen species production, whereas in the nucleus, it regulates the transcription of a number of genes including response to tissue hypoxia and inflammatory signals. Since MNRR1 expression changes in response to hypoxia and to an inflammatory signal, MNRR1 could be a part of mitochondrial dysfunction and involved in the pathologic process of preeclampsia. This study aimed to determine whether the plasma MNRR1 concentration of women with preeclampsia differed from that of normal pregnant women. METHODS This retrospective case-control study included 97 women with preeclampsia, stratified by gestational age at delivery into early (<34 weeks, n = 40) and late (≥34 weeks, n = 57) preeclampsia and by the presence or absence of placental lesions consistent with maternal vascular malperfusion (MVM), the histologic counterpart of an anti-angiogenic state. Women with an uncomplicated pregnancy at various gestational ages who delivered at term served as controls (n = 80) and were further stratified into early (n = 25) and late (n = 55) controls according to gestational age at venipuncture. Maternal plasma MNRR1 concentrations were determined by an enzyme-linked immunosorbent assay. RESULTS 1) Women with preeclampsia at the time of diagnosis (either early or late disease) had a significantly higher median (interquartile range, IQR) plasma MNRR1 concentration than the controls [early preeclampsia: 1632 (924-2926) pg/mL vs. 630 (448-4002) pg/mL, p = .026, and late preeclampsia: 1833 (1441-5534) pg/mL vs. 910 (526-6178) pg/mL, p = .021]. Among women with early preeclampsia, those with MVM lesions in the placenta had the highest median (IQR) plasma MNRR1 concentration among the three groups [with MVM: 2066 (1070-3188) pg/mL vs. without MVM: 888 (812-1781) pg/mL, p = .03; and with MVM vs. control: 630 (448-4002) pg/mL, p = .04]. There was no significant difference in the median plasma MNRR1 concentration between women with early preeclampsia without MVM lesions and those with an uncomplicated pregnancy (p = .3). By contrast, women with late preeclampsia, regardless of MVM lesions, had a significantly higher median (IQR) plasma MNRR1 concentration than women in the control group [with MVM: 1609 (1392-3135) pg/mL vs. control: 910 (526-6178), p = .045; and without MVM: 2023 (1578-8936) pg/mL vs. control, p = .01]. CONCLUSIONS MNRR1, a mitochondrial regulator protein, is elevated in the maternal plasma of women with preeclampsia (both early and late) at the time of diagnosis. These findings may reflect some degree of mitochondrial dysfunction, intravascular inflammation, or other unknown pathologic processes that characterize this obstetrical syndrome.
Collapse
Affiliation(s)
- Manaphat Suksai
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
| | - Mariachiara Bosco
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Francesca Gotsch
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Eunjung Jung
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Piya Chaemsaithong
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Adi L Tarca
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Computer Science, Wayne State University College of Engineering, Detroit, MI, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA
| | - Dereje W Gudicha
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Nardhy Gomez-Lopez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA
- Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Marcia Arenas-Hernandez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Arun Meyyazhagan
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | - Lawrence I Grossman
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA
| | - Siddhesh Aras
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA
| | - Tinnakorn Chaiworapongsa
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| |
Collapse
|
3
|
Wong NKL, Wah IYM, Wong STK, Nguyen-Hoang L, Lau CSL, Ip PNP, Leung HHY, Sahota DS, Poon LC. A point-of-care urine test to predict adverse maternal and neonatal outcomes in Asian women with suspected preeclampsia. Arch Gynecol Obstet 2024; 310:981-990. [PMID: 37882870 DOI: 10.1007/s00404-023-07257-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/05/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVES To assess clinical utility of the urine Congo red dot test (CRDT) in predicting composite adverse maternal and neonatal outcomes in women with suspected preeclampsia (PE). METHODS CRDT result and pregnancy outcomes were prospectively documented in women with new onset or pre-existing hypertension, new or pre-existing proteinuria, PE symptoms and suspected PE-related fetal growth restriction or abnormal Doppler presenting from 20 weeks' gestation between January 2020 and December 2022. Participants and clinicians were blinded to the CRDT result and managed according to internally agreed protocols. Composite maternal outcome was defined as PE, postpartum hemorrhage, intensive care unit admission, and maternal death. Composite neonatal outcome was defined as small for gestational age, preterm birth, 5-min Apgar score < 7, neonatal intensive care unit admission, and neonatal death. RESULTS Two hundred and forty-four women out of two hundred and fifty-one (97.2%) had a negative CRDT. All seven women with positive CRDT had both adverse maternal and neonatal outcomes, giving positive predictive values (PPV) of 100%. Rates of composite adverse maternal and neonatal outcomes in CDRT negative women were 103/244 [42.2%, 95% confidence interval (CI) 36.2%-48.5%] and 170/244 (69.7%, 95% CI 63.6%-75.1%), respectively. CRDT negative predictive values (NPV) for adverse maternal and neonatal outcomes were, respectively, 141/244 (57.8%, 95% CI 48.6%-68.2%) and 74/244 (30.3%, 95% CI 23.8%-38.1%). CONCLUSION CRDT had low NPV but high PPV for adverse maternal and neonatal outcomes in women with suspected PE. Its role in clinical management and triage of women with suspected PE is limited as it cannot identify those at low risk of developing adverse outcomes.
Collapse
Affiliation(s)
- Natalie K L Wong
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, 1/F Special Block E, Shatin, Hong Kong, China
| | - Isabella Y M Wah
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, 1/F Special Block E, Shatin, Hong Kong, China
| | - Sani T K Wong
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, 1/F Special Block E, Shatin, Hong Kong, China
| | - Long Nguyen-Hoang
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, 1/F Special Block E, Shatin, Hong Kong, China
| | - Caitlyn S L Lau
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, 1/F Special Block E, Shatin, Hong Kong, China
| | - Patricia N P Ip
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, 1/F Special Block E, Shatin, Hong Kong, China
| | - Hillary H Y Leung
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, 1/F Special Block E, Shatin, Hong Kong, China
| | - Daljit S Sahota
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, 1/F Special Block E, Shatin, Hong Kong, China.
| | - Liona C Poon
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, 1/F Special Block E, Shatin, Hong Kong, China.
| |
Collapse
|
4
|
Patel E, Suresh S, Mueller A, Bisson C, Zhu K, Verlohren S, Dadelszen PV, Magee L, Rana S. sFlt1/PlGF among patients with suspected preeclampsia when considering hypertensive status. AJOG GLOBAL REPORTS 2024; 4:100359. [PMID: 39005612 PMCID: PMC11239699 DOI: 10.1016/j.xagr.2024.100359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND In high-resource settings, biomarkers of angiogenic balance, such as the soluble fms-like tyrosine kinase-1 (sFlt1)/placental growth factor (PlGF) ratio, have been studied extensively to aid in evaluation of patients with suspected preeclampsia (PE), and have been incorporated into the 2021 International Society for the Study of Hypertension in Pregnancy definition of PE. The utility in under-resourced settings has not been as well characterized. OBJECTIVE This analysis sought to identify the role of the sFlt1/PlGF ratio in the evaluation of patients with or without hypertension who are suspected of having PE without other diagnostic information. STUDY DESIGN This is a secondary analysis of a prior prospective study of patients who were presented with suspected PE at ≥20+0 weeks' gestation at a single academic tertiary care center. Patients were recruited in the parent study from July 2009 to June 2012. In the original study, clinicians were masked to biomarker results, and patients were followed by chart review. In this analysis, the performance of the sFlt1/PlGF ratio (≤38, >38, or >85) was assessed alone in identifying both hypertensive and non-hypertensive patients at risk of evolving into PE with severe features (PE-SF; American College of Obstetricians and Gynecologists' definition) within two weeks of the triage visit (PE-SF2). Hypertension was defined as a blood pressure (BP)≥140/90 mmHg. RESULTS There were 1043 patients included in the analysis; of whom, 579 (55.5%) and 464 (44.5%) presented with or without hypertension, respectively. In triage, 332 (75.4%) of hypertensive patients presented due to BP concerns, and the remainder were evaluated due to other features (new-onset headache, proteinuria, or edema). On triage evaluation, 66.8% of all patients had a normal sFlt1/PlGF ratio ≤38, and 17.0% had an elevated ratio >85. Among hypertensive patients, a sFlt1/PlGF ratio ≤38 was a good rule-out test for PE-SF2 (negative likelihood ratio [LR-] of 0.15), and a ratio >85 was a good rule-in test (positive likelihood ratio [LR+] of 5.75). Among normotensive patients, sFlt1/PlGF was useful as a rule-in test for ratio >38 (LR+ 5.13) and >85 (LR+ 12.80). Stratified by gestational age, sFlt1/PlGF continued to be a good rule in and good rule out test at <35 weeks among those with hypertension but did not have good test performance ≥35 weeks. sFlt1/PlGF had a good test performance as a rule in test for >85 regardless of gestational age. In triage, 4.3% (30/693) of patients with sFlt1/PlGF ratio <38 had concurrent laboratory evidence of PE, compared with 15.9% (28/176) patients with ratio >85. CONCLUSION These findings support the potential for the use of sFlt1/PlGF and BP measurement alone in resource-limited settings where other laboratory tests or clinical expertise are unavailable for risk stratification. Performance of the biomarker varied by the presence of hypertension and gestational age.
Collapse
Affiliation(s)
- Easha Patel
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL (Dr Patel, Ms Mueller, Drs Bisson, Zhu, Rana)
| | - Sunitha Suresh
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, IL (Dr Suresh)
| | - Ariel Mueller
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL (Dr Patel, Ms Mueller, Drs Bisson, Zhu, Rana)
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Ms Mueller)
| | - Courtney Bisson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL (Dr Patel, Ms Mueller, Drs Bisson, Zhu, Rana)
| | - Katherine Zhu
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL (Dr Patel, Ms Mueller, Drs Bisson, Zhu, Rana)
| | - Stefan Verlohren
- Charité - Universitätsmedizin Berlin, Berlin, Germany (Dr Verlohren)
| | - Peter Von Dadelszen
- Institute of Women and Children's Health, Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, United Kingdom (Drs Dadelszen, Magee)
| | - Laura Magee
- Institute of Women and Children's Health, Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, United Kingdom (Drs Dadelszen, Magee)
| | - Sarosh Rana
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL (Dr Patel, Ms Mueller, Drs Bisson, Zhu, Rana)
| |
Collapse
|
5
|
Antonia Lorenz-Meyer L, Thoma J, Scherfeld V, Sroka D, Aigner A, Henrich W, Verlohren S. The sFlt-1/PlGF-ratio and the risk of preeclampsia-related adverse outcomes in subsequent pregnancies with signs and symptoms of a preeclampsia. Pregnancy Hypertens 2024; 37:101140. [PMID: 38964026 DOI: 10.1016/j.preghy.2024.101140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 05/14/2024] [Accepted: 06/26/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVES This study characterizes the outcome of two subsequent pregnancies with suspected preeclampsia (PE). We investigated the diagnostic accuracy of clinical signs, Doppler examinations, and the soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF)-ratio to predict PE-related adverse outcomes (AO). The sFlt-1/PlGF-ratio of the first pregnancy was compared to the outcome of the subsequent pregnancy. STUDY DESIGN A total of 1928 patients at risk for preeclampsia were screened, of them 1117 were eligible for inclusion. Of these, 84 women presented with suspected PE in two subsequent pregnancies. OUTCOME MEASURES Diagnostic accuracy of clinical markers was assessed. Associations between the sFlt-1/PlGF-ratio in the first and the odds of an AO in the subsequent pregnancy were investigated with logistic regression. RESULTS The prevalence of AOs decreased from 27.4 % in the first to 17.9 % in the second pregnancy. Comparison of the accuracy of the different clinical markers for an AO showed a high specificity for an sFlt-1/PlGF-ratio at the cut-off of ≥ 85 in both pregnancies (81.3 %, 95 % CI 63.6-92.8 vs 92.6 %,95 % CI 83.7-97.6), but a lower sensitivity in the second pregnancy (92.9 %, 95 % CI 66.1-99.8 vs 33.3%, 95 % CI 11.8-61.6). An elevated sFlt-1/PlGF-ratio in the first did not increase the odds of an AO in the subsequent pregnancy. CONCLUSIONS The prevalence of AOs decreases in subsequent pregnancies. Our finding that the sFlt-1/PlGF-ratio of the first was not related to the outcome of the subsequent pregnancy suggests that angiogenic markers are only a within-pregnancy short-term tool to assess AOs.
Collapse
Affiliation(s)
- Lisa Antonia Lorenz-Meyer
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Julie Thoma
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Valerie Scherfeld
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dorota Sroka
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Annette Aigner
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Stefan Verlohren
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| |
Collapse
|
6
|
Hong J, Crawford K, Cavanagh E, da Silva Costa F, Kumar S. Prediction of preterm birth in growth-restricted and appropriate-for-gestational-age infants using maternal PlGF and the sFlt-1/PlGF ratio-A prospective study. BJOG 2024; 131:1089-1101. [PMID: 38196326 DOI: 10.1111/1471-0528.17752] [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: 07/23/2023] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE To assess the utility of placental growth factor (PlGF) levels and the soluble fms-like tyrosine kinase-1/placental growth factor (sFlt-1/PlGF) ratio to predict preterm birth (PTB) for infants with fetal growth restriction (FGR) and those appropriate for gestational age (AGA). DESIGN Prospective, observational cohort study. SETTING Tertiary maternity hospital in Australia. POPULATION There were 320 singleton pregnancies: 141 (44.1%) AGA, 83 (25.9%) early FGR (<32+0 weeks) and 109 (30.0%) late FGR (≥32+0 weeks). METHODS Maternal serum PlGF and sFlt-1/PlGF ratio were measured at 4-weekly intervals from recruitment to delivery. Low maternal PlGF levels and elevated sFlt-1/PlGF ratio were defined as <100 ng/L and >5.78 if <28 weeks and >38 if ≥28 weeks respectively. Cox proportional hazards models were used. The analysis period was defined as the time from the first measurement of PlGF and sFlt-1/PlGF ratio to the time of birth or censoring. MAIN OUTCOME MEASURES The primary study outcome was overall PTB. The relative risks (RR) of birth within 1, 2 and 3 weeks and for medically indicated and spontaneous PTB were also ascertained. RESULTS The early FGR cohort had lower median PlGF levels (54 versus 229 ng/L, p < 0.001) and higher median sFlt-1 levels (2774 ng/L versus 2096 ng/L, p < 0.001) and sFlt-1/PlGF ratio higher (35 versus 10, p < 0.001). Both PlGF <100 ng/L and elevated sFlt-1/PlGF ratio were strongly predictive for PTB as well as PTB within 1, 2 and 3 weeks of diagnosis. For both FGR and AGA groups, PlGF <100 ng/L or raised sFlt-1/PlGF ratio were strongly associated with increased risk for medically indicated PTB. The highest RR was seen in the FGR cohort when PlGF was <100 ng/L (RR 35.20, 95% CI 11.48-175.46). CONCLUSIONS Low maternal PlGF levels and elevated sFlt-1/PlGF ratio are potentially useful to predict PTB in both FGR and AGA pregnancies.
Collapse
Affiliation(s)
- Jesrine Hong
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Kylie Crawford
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Erika Cavanagh
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
| | - Fabricio da Silva Costa
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Maternal Fetal Medicine Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- NHMRC Centre for Research Excellence in Stillbirth, Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
| |
Collapse
|
7
|
Graupner O, Verlohren S, Groten T, Schlembach D, Stepan H, Kuschel B, Karge A, Pecks U. Significance of the sFlt-1/PlGF Ratio in Certain Cohorts - What Needs to be Considered? Geburtshilfe Frauenheilkd 2024; 84:629-634. [PMID: 38993800 PMCID: PMC11233204 DOI: 10.1055/a-2320-5843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/05/2024] [Indexed: 07/13/2024] Open
Abstract
The sFlt-1/PlGF ratio is an established tool in clinical practice, where it is part of a diagnostic algorithm and informs the prognosis of preeclampsia (PE). Maternal and gestational comorbidities can affect the performance of the sFlt-1/PlGF ratio and its constituent elements, and a good understanding of the potential pitfalls is required. The objective of this paper was to provide a current narrative review of the literature on the diagnostic and predictive performance of the sFlt-1/PlGF ratio in specific patient cohorts. Potential factors which can negatively affect the clinical interpretability and applicability of the sFlt-1/PlGF ratio include chronic kidney disease, twin pregnancy, and maternal obesity. Pathophysiological mechanisms related to these factors and disorders can result in different concentrations of sFlt-1 and/or PlGF in maternal blood, meaning that the use of standard cut-off values in specific cohorts can lead to errors. To what extent the cut-off values should be adapted in certain patient cohorts can only be clarified in large prospective cohort studies. This applies to the use of the ratio both for diagnosis and prognosis.
Collapse
Affiliation(s)
- Oliver Graupner
- Klinik und Poliklinik für Frauenheilkunde, Universitätsklinikum rechts der Isar, Technische Universität München, München, Germany
| | - Stefan Verlohren
- Klinik für Geburtsmedizin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tanja Groten
- Klinik für Geburtsmedizin, Universitätsklinikum Jena, Jena, Germany
| | - Dietmar Schlembach
- Klinik für Geburtsmedizin, Klinikum Neukölln, Vivantes Netzwerk für Gesundheit GmbH, Berlin, Germany
| | - Holger Stepan
- Klinik für Geburtsmedizin, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Bettina Kuschel
- Klinik und Poliklinik für Frauenheilkunde, Universitätsklinikum rechts der Isar, Technische Universität München, München, Germany
| | - Anne Karge
- Klinik und Poliklinik für Frauenheilkunde, Universitätsklinikum rechts der Isar, Technische Universität München, München, Germany
| | - Ulrich Pecks
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Würzburg, Würzburg, Germany
| |
Collapse
|
8
|
Marijnen MC, Kamphof HD, Damhuis SE, Smies M, Leemhuis AG, Wolf H, Gordijn SJ, Ganzevoort W. Doppler ultrasound of umbilical and middle cerebral artery in third trimester small-for-gestational age fetuses to decide on timing of delivery for suspected fetal growth restriction: A cohort with nested RCT (DRIGITAT). BJOG 2024; 131:1042-1053. [PMID: 38498267 DOI: 10.1111/1471-0528.17770] [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: 11/07/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE To assess the association of the umbilicocerebral ratio (UCR) with adverse perinatal outcome in late preterm small-for-gestational age (SGA) fetuses and to investigate the effect on perinatal outcomes of immediate delivery. DESIGN Multicentre cohort study with nested randomised controlled trial (RCT). SETTING Nineteen secondary and tertiary care centres. POPULATION Singleton SGA pregnancies (estimated fetal weight [EFW] or fetal abdominal circumference [FAC] <10th centile) from 32 to 36+6 weeks. METHODS Women were classified: (1) RCT-eligible: abnormal UCR twice consecutive and EFW below the 3rd centile at/or below 35 weeks or below the 10th centile at 36 weeks; (2) abnormal UCR once or intermittent; (3) never abnormal UCR. Consenting RCT-eligible patients were randomised for immediate delivery from 34 weeks or expectant management until 37 weeks. MAIN OUTCOME MEASURES A composite adverse perinatal outcome (CAPO), defined as perinatal death, birth asphyxia or major neonatal morbidity. RESULTS The cohort consisted of 690 women. The study was halted prematurely for low RCT-inclusion rates (n = 40). In the RCT-eligible group, gestational age at delivery, birthweight and birthweight multiple of the median (MoM) (0.66, 95% confidence interval [CI] 0.59-0.72) were significantly lower and the CAPO (n = 50, 44%, p < 0.05) was more frequent. Among patients randomised for immediate delivery there was a near-significant lower birthweight (p = 0.05) and higher CAPO (p = 0.07). EFW MoM, pre-eclampsia, gestational hypertension and Doppler classification were independently associated with the CAPO (area under the curve 0.71, 95% CI 0.67-0.76). CONCLUSIONS Perinatal risk was effectively identified by low EFW MoM and UCR. Early delivery of SGA fetuses with an abnormal UCR at 34-36 weeks should only be performed in the context of clinical trials.
Collapse
Affiliation(s)
- Mauritia C Marijnen
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Hester D Kamphof
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Stefanie E Damhuis
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Maddy Smies
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Aleid G Leemhuis
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hans Wolf
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Sanne J Gordijn
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| |
Collapse
|
9
|
Palma Dos Reis CR, O'Sullivan J, Ohuma EO, James T, Papageorghiou AT, Vatish M, Cerdeira AS. The ratio of soluble fms-like tyrosine kinase 1 to placental growth factor predicts time to delivery and mode of birth in patients with suspected preeclampsia: a secondary analysis of the INSPIRE trial. Am J Obstet Gynecol 2024:S0002-9378(24)00673-2. [PMID: 38897339 DOI: 10.1016/j.ajog.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 05/23/2024] [Accepted: 06/12/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND The ratio of soluble fms-like tyrosine kinase 1 to placental growth factor is a useful biomarker for preeclampsia. Since it is a measure of placental dysfunction, it could also be a predictor of clinical deterioration and fetal tolerance to intrapartum stress. OBJECTIVE We tested the hypothesis that soluble fms-like tyrosine kinase 1 to placental growth factor ratio predicts time to delivery. Secondary objectives were to examine associations between the soluble fms-like tyrosine kinase 1 to placental growth factor ratio and mode of birth, fetal distress, need for labor induction, and birthweight z score. STUDY DESIGN Secondary analysis of the INSPIRE trial, a randomized interventional study on prediction of preeclampsia/eclampsia in which women with suspected preeclampsia were recruited and their blood soluble fms-like tyrosine kinase 1 to placental growth factor ratio was assessed. We stratified participants into 3 groups according to the ratio result: category 1 (soluble fms-like tyrosine kinase 1 to placental growth factor ≤38); category 2 (soluble fms-like tyrosine kinase 1 to placental growth factor >38 and <85); and category 3 (soluble fms-like tyrosine kinase 1 to placental growth factor ≥85). We modeled time from soluble fms-like tyrosine kinase 1 to placental growth factor determination to delivery using Kaplan-Meier curves and compared the 3 ratio categories adjusting for gestational age at soluble fms-like tyrosine kinase 1 to placental growth factor determination and trial arm with Cox regression. The association between ratio category and mode of delivery, induction of labor, and fetal distress was assessed using a multivariable logistic regression adjusting for gestational age at sampling and trial arm. The association between birthweight z score and soluble fms-like tyrosine kinase 1 to placental growth factor ratio was evaluated using multiple linear regression. Subgroup analysis was conducted in women with no preeclampsia and spontaneous onset of labor; women with preeclampsia; and participants in the nonreveal arm. RESULTS Higher ratio categories were associated with a shorter latency from soluble fms-like tyrosine kinase 1 to placental growth factor determination to delivery (37 vs 13 vs 10 days for ratios categories 1-3 respectively), hazards ratio for category 3 ratio of 5.64 (95% confidence interval 4.06-7.84, P<.001). A soluble fms-like tyrosine kinase 1 to placental growth factor ratio ≥85 had specificity of 92.7% (95% confidence interval 89.0%-95.1%) and sensitivity of 54.72% (95% confidence interval, 41.3-69.5) for prediction of preeclampsia indicated delivery within 2 weeks. A ratio category 3 was also associated with decreased odds of spontaneous vaginal delivery (Odds ratio [OR] 0.47, 95% confidence interval 0.25-0.89); an almost 6-fold increased risk of emergency cesarean section (OR 5.89, 95% confidence interval 3.05-11.21); and a 2-fold increased risk for intrapartum fetal distress requiring operative delivery or cesarean section (OR 3.04, 95% confidence interval 1.53-6.05) when compared to patients with ratios ≤38. Higher ratio categories were also associated with higher odds of induction of labor when compared to ratios category 1 (category 2, OR 2.20, 95% confidence interval 1.02-4.76; category 3, OR 6.0, 95% confidence interval 2.01-17.93); and lower median birthweight z score. Within subgroups of women a) without preeclampsia and with spontaneous onset of labor and b) women with preeclampsia, the log ratio was significantly higher in patients requiring intervention for fetal distress or failure to progress compared to those who delivered vaginaly without intervention. In the subset of women with no preeclampsia and spontaneous onset of labor, those who required intervention for fetal distress or failure to progress had a significantly higher log ratio than those who delivered vaginaly without needing intervention. CONCLUSION The soluble fms-like tyrosine kinase 1 to placental growth factor ratio might be helpful in risk stratification of patients who present with suspected preeclampsia regarding clinical deterioration, intrapartum fetal distress, and mode of birth (including the need for intervention in labor).
Collapse
Affiliation(s)
| | | | - Eric O Ohuma
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Tim James
- Department of Clinical Biochemistry, Oxford University Hospitals NHS Foundation Trust, UK
| | | | - Manu Vatish
- Nuffield Department of Women's and Reproductive Health, University of Oxford, UK
| | - Ana Sofia Cerdeira
- Nuffield Department of Women's and Reproductive Health, University of Oxford, UK
| |
Collapse
|
10
|
Hong J, Crawford K, Cavanagh E, Clifton V, Kumar S. Prediction of preterm birth in women with fetal growth restriction - Is the weekly change in sFlt-1/PlGF ratio or PlGF levels useful? Acta Obstet Gynecol Scand 2024; 103:1112-1119. [PMID: 38483020 PMCID: PMC11103152 DOI: 10.1111/aogs.14831] [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: 11/30/2023] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION To assess the rate of change in soluble fms-like tyrosine kinase-1/placental growth factor (sFlt-1/PlGF) ratio and PlGF levels per week compared to a single sFlt-1/PlGF ratio or PlGF level to predict preterm birth for pregnancies complicated by fetal growth restriction. MATERIAL AND METHODS A prospective cohort study of pregnancies complicated by isolated fetal growth restriction. Maternal serum PlGF levels and the sFlt-1/PlGF ratio were measured at 4-weekly intervals from recruitment to delivery. We investigated the utility of PlGF levels, sFlt-1/PlGF ratio, change in PlGF levels per week or sFlt-1/PlGF ratio per week. Cox-proportional hazard models and Harrell's C concordance statistic were used to evaluate the effect of biomarkers on time to preterm birth. RESULTS The total study cohort was 158 pregnancies comprising 91 (57.6%) with fetal growth restriction and 67 (42.4%) with appropriate for gestational age controls. In the fetal growth restriction cohort, sFlt-1/PlGF ratio and PlGF levels significantly affected time to preterm birth (Harrell's C: 0.85-0.76). The rate of increase per week of the sFlt-1/PlGF ratio (hazard ratio [HR] 3.91, 95% confidence interval [CI]: 1.39-10.99, p = 0.01, Harrell's C: 0.74) was positively associated with preterm birth but change in PlGF levels per week was not (HR 0.65, 95% CI: 0.25-1.67, p = 0.37, Harrell's C: 0.68). CONCLUSIONS Both a high sFlt-1/PlGF ratio and low PlGF levels are predictive of preterm birth in women with fetal growth restriction. Although the rate of increase of the sFlt-1/PlGF ratio predicts preterm birth, it is not superior to either a single elevated sFlt-1/PlGF ratio or low PlGF level.
Collapse
Affiliation(s)
- Jesrine Hong
- Mater Research InstituteUniversity of QueenslandSouth BrisbaneQueenslandAustralia
- Faculty of MedicineThe University of QueenslandHerstonQueenslandAustralia
- Department of Obstetrics and Gynecology, Faculty of MedicineUniversiti MalayaKuala LumpurMalaysia
| | - Kylie Crawford
- Mater Research InstituteUniversity of QueenslandSouth BrisbaneQueenslandAustralia
- Faculty of MedicineThe University of QueenslandHerstonQueenslandAustralia
| | - Erika Cavanagh
- Mater Research InstituteUniversity of QueenslandSouth BrisbaneQueenslandAustralia
| | - Vicki Clifton
- Mater Research InstituteUniversity of QueenslandSouth BrisbaneQueenslandAustralia
| | - Sailesh Kumar
- Mater Research InstituteUniversity of QueenslandSouth BrisbaneQueenslandAustralia
- Faculty of MedicineThe University of QueenslandHerstonQueenslandAustralia
- NHMRC Centre for Research Excellence in Stillbirth, Mater Research InstituteUniversity of QueenslandBrisbaneQueenslandAustralia
| |
Collapse
|
11
|
Espinoza J, Calsavara VF, Kilpatrick S, Rana S, Costantine MM, Boggess K, Wylie BJ, Moore Simas TA, Louis JM, Gaw SL, Murtha A, Wiegand S, Gollin Y, Singh D, Silver RM, Durie DE, Panda B, Norwitz ER, Burd I, Plunkett B, Scott RK, Lemoine E, Thadhani R, Karumanchi SA. Plasma soluble fms-like tyrosine kinase 1 to placental growth factor ratio of 11.5 multiples of median predicts preeclampsia with severe features within 2 weeks of testing. Am J Obstet Gynecol 2024:S0002-9378(24)00659-8. [PMID: 38825028 DOI: 10.1016/j.ajog.2024.05.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/28/2024] [Accepted: 05/28/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Angiogenic imbalances, characterized by an excess of antiangiogenic factors (soluble fms-like tyrosine kinase 1) and reduced angiogenic factors (vascular endothelial growth factor and placental growth factor), contribute to the mechanisms of disease in preeclampsia. The ratio of soluble fms-like tyrosine kinase 1 to placental growth factor has been used as a biomarker for preeclampsia, but the cutoff values may vary with gestational age and assay platform. OBJECTIVE This study aimed to compare multiples of the median of the maternal plasma soluble fms-like tyrosine kinase 1 to placental growth factor ratio, soluble fms-like tyrosine kinase 1, placental growth factor, and conventional clinical and laboratory values in their ability to predict preeclampsia with severe features. STUDY DESIGN We conducted a cohort study across 18 United States centers involving hospitalized individuals with hypertension between 23 and 35 weeks' gestation. Receiver operating characteristic curve analyses of maternal plasma biomarkers, highest systolic or diastolic blood pressures, and laboratory values at enrollment were performed for the prediction of preeclampsia with severe features. The areas under the curve were compared, and quasi-Poisson regression models were fitted to estimate relative risks. The primary outcome was preeclampsia with severe features within 2 weeks of enrollment. Secondary outcomes were a composite of severe adverse maternal outcomes (elevated liver enzymes, low platelets count, placental abruption, eclampsia, disseminated intravascular coagulation, and pulmonary edema) and a composite of severe adverse perinatal outcomes (birth weight below the third percentile, very preterm birth [<32 weeks' gestation], and fetal or neonatal death). RESULTS Of the 543 individuals included in the study, preeclampsia with severe features within 2 weeks was observed in 33.1% (n=180) of them. A receiver operating characteristic curve-derived cutoff of 11.5 multiples of the median for the soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio provided good sensitivity (90.6%), specificity (76.9%), positive predictive value (66.0%), negative predictive value (94.3%), positive likelihood ratio (3.91), negative likelihood ratio (0.12), and accuracy (81.4%) for preeclampsia with severe features within 2 weeks. This cutoff was used to compare test positive cases (≥ cutoff) and test negative cases (< cutoff). Preeclampsia with severe features (66.0% vs 5.7%; P<.001) and composites of severe adverse maternal (8.11% vs 2.7%; P=.006) or perinatal (41.3% vs 10.14%; P=.001) outcomes within 2 weeks were more frequent in test positive cases than in test negative cases. A soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio ≥11.5 multiples of the median was independently associated with preeclampsia with severe features (adjusted incidence rate ratio, 9.08; 95% confidence interval, 6.11-14.06; P<.001) and a composite of severe adverse perinatal outcomes (adjusted incidence rate ratio, 9.42; 95% confidence interval, 6.36-14.53; P<.001) but not with a composite of severe adverse maternal outcomes (adjusted incidence rate ratio, 2.20; 95% confidence interval, 0.95-5.54; P=.08). The area under the curve for the soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio in multiples of the median (0.91; 95% confidence interval, 0.89-0.94) for preeclampsia with severe features within 2 weeks was significantly higher (P<.001 for all comparisons) than either plasma biomarker alone or any other parameter with the exception of absolute soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio values. CONCLUSION A soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio ≥11.5 multiples of the mean among hospitalized patients with hypertension between 23 and 35 week's gestation predicts progression to preeclampsia with severe features and severe adverse perinatal outcomes within 2 weeks.
Collapse
Affiliation(s)
- Jimmy Espinoza
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX.
| | - Vinicius F Calsavara
- Department of Computational Biomedicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sarah Kilpatrick
- Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center, Santa Monica, CA
| | - Sarosh Rana
- Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medical Center, Chicago, IL
| | - Maged M Costantine
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kim Boggess
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Blair J Wylie
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University, New York, NY
| | - Tiffany A Moore Simas
- Departments of Obstetrics and Gynecology, Pediatrics, Psychiatry, and Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA; Department of Obstetrics and Gynecology, UMass Memorial Health - UMass Memorial Medical Center, Worcester, MA
| | - Judette M Louis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL
| | - Stephanie L Gaw
- Division of Maternal-Fetal Medicine and Reproductive Genetics, Department of Obstetrics and Gynecology, University of California at San Francisco, San Francisco, CA
| | - Amy Murtha
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California at San Francisco, San Francisco, CA
| | - Samantha Wiegand
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Miami Valley Hospital, Dayton, OH
| | - Yvonne Gollin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA
| | - Deepjot Singh
- Department of Obstetrics and Gynecology, Torrance Memorial Medical Center, Torrance, CA
| | - Robert M Silver
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Medical Center, Salt Lake City, UT
| | - Danielle E Durie
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA
| | - Britta Panda
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA
| | - Errol R Norwitz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA; Department of Obstetrics and Gynecology, Newton-Wellesley Hospital, Newton, MA
| | - Irina Burd
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Johns Hopkins Medical Center, Baltimore, MD
| | - Beth Plunkett
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, NorthShore University Health System (Endeavor Health), Evanston, IL
| | - Rachel K Scott
- Department of Obstetrics and Gynecology, MedStar Health Research Institute, Washington, DC
| | - Elizabeth Lemoine
- Department of Obstetrics and Gynecology at University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - S Ananth Karumanchi
- Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center, Santa Monica, CA; Department of Medicine, Cedars-Sinai Medical Center, Santa Monica, CA
| |
Collapse
|
12
|
Satorres-Pérez E, Martínez-Varea A, Novillo-Del Álamo B, Morales-Roselló J, Diago-Almela V. The sFlt-1/PlGF Ratio at 12, 24, and 32 Weeks Gestation in Twin Pregnancies as a Predictor of Late Preterm Birth and Perinatal Event Secondary to Prematurity. J Clin Med 2024; 13:2699. [PMID: 38731228 PMCID: PMC11084454 DOI: 10.3390/jcm13092699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/24/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Preterm birth impacts 60% of twin pregnancies, with the subsequent risk of complications in both newborns secondary to the immaturity of organs. This study aims to assess the utility of the sFlt-1/PlGF ratio throughout pregnancy in predicting late preterm birth and adverse perinatal outcomes related to prematurity in twin pregnancies. Methods: This is a prospective cohort study developed at a tertiary hospital. All pregnant women with a twin pregnancy who signed the informed consent were included. The sFlt-1/PlGF ratio was measured at 12, 24, and 32 weeks' gestation. Results: Seventy patients were included, from which 54.3% suffered late preterm birth. Results revealed a significant difference in sFlt-1/PlGF ratio at week 32 between term and preterm groups, with a one-unit increase associated with a 1.11-fold increase in the probability of preterm birth. The sFlt-1/PlGF ratio at week 32 alone presented considerable predictive capacities (sensitivity of 71%, specificity of 72%, a PPV of 75%, and an NPV of 68%. Similarly, at week 24, a one-unit increase in sFlt-1/PlGF ratio was associated with a 1.24-fold increase in the probability of adverse perinatal events due to prematurity. Combining parity, maternal age, conception method, BMI, and chorionicity, the model yielded better predictive capacities (sensitivity of 82%, specificity of 80%, PPV of 58%, NPV of 93%). Conclusions: The potential of the sFlt-1/PlGF ratio as a predictive tool for preterm birth and adverse perinatal outcomes secondary to prematurity in twin pregnancies is underscored.
Collapse
Affiliation(s)
- Elena Satorres-Pérez
- Department of Obstetrics and Gynecology, La Fe University and Polytechnic Hospital, Avenida Fernando Abril Martorell 106, 46026 Valencia, Spain; (E.S.-P.); (B.N.-D.Á.); (J.M.-R.); (V.D.-A.)
| | - Alicia Martínez-Varea
- Department of Obstetrics and Gynecology, La Fe University and Polytechnic Hospital, Avenida Fernando Abril Martorell 106, 46026 Valencia, Spain; (E.S.-P.); (B.N.-D.Á.); (J.M.-R.); (V.D.-A.)
- Department of Pediatrics, Obstetrics and Gynecology, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
- Department of Medicine, CEU Cardenal Herrera University, 12006 Castellón de la Plana, Spain
- Faculty of Health Sciences, Universidad Internacional de Valencia, 46002 Valencia, Spain
| | - Blanca Novillo-Del Álamo
- Department of Obstetrics and Gynecology, La Fe University and Polytechnic Hospital, Avenida Fernando Abril Martorell 106, 46026 Valencia, Spain; (E.S.-P.); (B.N.-D.Á.); (J.M.-R.); (V.D.-A.)
| | - José Morales-Roselló
- Department of Obstetrics and Gynecology, La Fe University and Polytechnic Hospital, Avenida Fernando Abril Martorell 106, 46026 Valencia, Spain; (E.S.-P.); (B.N.-D.Á.); (J.M.-R.); (V.D.-A.)
- Department of Pediatrics, Obstetrics and Gynecology, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
| | - Vicente Diago-Almela
- Department of Obstetrics and Gynecology, La Fe University and Polytechnic Hospital, Avenida Fernando Abril Martorell 106, 46026 Valencia, Spain; (E.S.-P.); (B.N.-D.Á.); (J.M.-R.); (V.D.-A.)
| |
Collapse
|
13
|
Che M, Moran SM, Smith RJ, Ren KYM, Smith GN, Shamseddin MK, Avila-Casado C, Garland JS. A case-based narrative review of pregnancy-associated atypical hemolytic uremic syndrome/complement-mediated thrombotic microangiopathy. Kidney Int 2024; 105:960-970. [PMID: 38408703 DOI: 10.1016/j.kint.2023.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 12/07/2023] [Accepted: 12/14/2023] [Indexed: 02/28/2024]
Abstract
Atypical hemolytic uremic syndrome is a complement-mediated thrombotic microangiopathy caused by uncontrolled activation of the alternative complement pathway in the setting of autoantibodies to or rare pathogenic genetic variants in complement proteins. Pregnancy may serve as a trigger and unmask atypical hemolytic uremic syndrome/complement-mediated thrombotic microangiopathy (aHUS/CM-TMA), which has severe, life-threatening consequences. It can be difficult to diagnose aHUS/CM-TMA in pregnancy due to overlapping clinical features with other thrombotic microangiopathy syndromes including hypertensive disorders of pregnancy. However, the distinction among thrombotic microangiopathy etiologies in pregnancy is important because each syndrome has specific disease management and treatment. In this narrative review, we discuss 2 cases to illustrate the diagnostic challenges and evolving approach in the management of pregnancy-associated aHUS/CM-TMA. The first case involves a 30-year-old woman presenting in the first trimester who was diagnosed with aHUS/CM-TMA and treated with eculizumab from 19 weeks' gestation. Genetic testing revealed a likely pathogenic variant in CFI. She successfully delivered a healthy infant at 30 weeks' gestation. In the second case, a 22-year-old woman developed severe postpartum HELLP syndrome, requiring hemodialysis. Her condition improved with supportive management, yet investigations assessing for aHUS/CM-TMA remained abnormal 6 months postpartum consistent with persistent complement activation but negative genetic testing. Through detailed case discussion describing tests assessing for placental health, fetal anatomy, complement activation, autoantibodies to complement regulatory proteins, and genetic testing for aHUS/CM-TMA, we describe how these results aided in the clinical diagnosis of pregnancy-associated aHUS/CM-TMA and assisted in guiding patient management, including the use of anticomplement therapy.
Collapse
Affiliation(s)
- Michael Che
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah M Moran
- Department of Nephrology, Cork University, Cork, Ireland
| | - Richard J Smith
- University of Iowa Molecular Otolaryngology and Renal Research Laboratories, Iowa City, Iowa, USA
| | - Kevin Y M Ren
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Graeme N Smith
- Department of Obstetrics and Gynecology, Queen's University, Kingston, Ontario, Canada
| | - M Khaled Shamseddin
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Carmen Avila-Casado
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jocelyn S Garland
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada.
| |
Collapse
|
14
|
Hong J, Crawford K, Cavanagh E, da Silva Costa F, Kumar S. Placental growth factor and fetoplacental Doppler indices in combination predict preterm birth reliably in pregnancies complicated by fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:635-643. [PMID: 37820083 DOI: 10.1002/uog.27513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/25/2023] [Accepted: 10/02/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE To assess the association between placental biomarkers (placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1)/PlGF ratio) and fetoplacental Doppler indices (umbilical artery (UA) pulsatility index (PI) and uterine artery (UtA) PI) in various combinations for predicting preterm birth (PTB) in pregnancies complicated by fetal growth restriction (FGR). METHODS This was a prospective observational cohort study, performed at Mater Mother's Hospital in Brisbane, Queensland, Australia, from May 2022 to June 2023, of pregnancies complicated by FGR and appropriate-for-gestational-age (AGA) pregnancies. Maternal serum PlGF levels, sFlt-1/PlGF ratio, UA-PI and UtA-PI were measured at 2-4-weekly intervals from recruitment until delivery. Harrell's concordance statistic (Harrell's C) was used to evaluate multivariable Cox proportional hazards regression models featuring various combinations of placental biomarkers and fetoplacental Doppler indices to ascertain the best combination to predict PTB (< 37 weeks). Multivariable Cox regression models were used with biomarkers as time-varying covariates. RESULTS The study cohort included 320 singleton pregnancies, comprising 179 (55.9%) affected by FGR, defined according to a Delphi consensus, and 141 (44.1%) with an AGA fetus. In the FGR cohort, both low PlGF levels and elevated sFlt-1/PlGF ratio were associated with significantly shorter time to PTB. Low PlGF was a better predictor of PTB than was either sFlt-1/PlGF ratio or a combination of PlGF and sFlt-1/PlGF ratio (Harrell's C, 0.81, 0.78 and 0.79, respectively). Although both Doppler indices were significantly associated with time to PTB, in combination they were better predictors of PTB than was either UA-PI > 95th centile or UtA-PI > 95th centile alone (Harrell's C, 0.82, 0.75 and 0.76, respectively). Predictive utility for PTB was best when PlGF < 100 ng/L, UA-PI > 95th centile and UtA-PI > 95th centile were combined (Harrell's C, 0.88) (hazard ratio, 32.99; 95% CI, 10.74-101.32). CONCLUSIONS Low maternal serum PlGF level (< 100 ng/L) and abnormal fetoplacental Doppler indices (UA-PI > 95th centile and UtA-PI > 95th centile) in combination have the greatest predictive utility for PTB in pregnancies complicated by FGR. Their assessment may help guide clinical management of these complex pregnancies. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- J Hong
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - K Crawford
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - E Cavanagh
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
| | - F da Silva Costa
- School of Medicine and Dentistry, Griffith University and Maternal Fetal Medicine Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - S Kumar
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- NHMRC Centre for Research Excellence in Stillbirth, Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
| |
Collapse
|
15
|
Rakisheva A, Sliwa K, Bauersachs J, Van Linthout S, Chopra VK, Bayes-Genis A, Fruzzetti F, Cannatà A, Deniau B, Mebazaa A, Savarese G, Ray R, Vitale C, Metra M, Rosano GMC. Multidisciplinary care of peripartum heart failure: A scientific statement of the Heart Failure Association of the ESC. Eur J Heart Fail 2024; 26:742-753. [PMID: 38679896 DOI: 10.1002/ejhf.3246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/22/2024] [Accepted: 04/04/2024] [Indexed: 05/01/2024] Open
Abstract
Heart failure is the most common cardiovascular complication during pregnancy and the postpartum period. It is associated with increased risk of maternal morbidity and mortality as well as potentially life-threatening foetal pathology. Management of heart failure in pregnancy requires expert knowledge of cardiovascular disease as well as obstetrics which underscores the importance of multidisciplinary cardio-obstetrics teams in order to optimize diagnosis, treatment and outcome. This includes counselling of women at risk before and during the course of pregnancy in order to strengthen the relationship between medical specialists and patients, as well as to allow patient-centred delivery of care and improve quality of life.
Collapse
Affiliation(s)
- Amina Rakisheva
- Department of Cardiology, City Cardiology Center, Almaty, Kazakhstan
- Qonaev City Hospital, Almaty, Kazakhstan
| | - Karen Sliwa
- Cape Heart Institute, Department of Cardiology and Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Sophie Van Linthout
- Berlin Institute of Health (BIH) at Charité - Universitätmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Berlin, Berlin, Germany
| | | | - Antoni Bayes-Genis
- CIBERCV, Carlos III Institute of Health, Madrid, Spain
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Franca Fruzzetti
- Department of Obstetrics and Gynecology, Pisa University Hospital, Pisa, Italy
| | - Antonio Cannatà
- King's College London, British Heart Foundation Centre of Research Excellence, School of Cardiovascular Medicine & Sciences, London, UK
| | - Benjamin Deniau
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis - Lariboisière, AP-HP, Paris, France
- INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
- FHU PROMICE, DMU Parabol, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis - Lariboisière, AP-HP, Paris, France
- INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
- FHU PROMICE, DMU Parabol, Paris, France
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Robin Ray
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, St George's Hospital, London, UK
| | - Cristiana Vitale
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, St George's Hospital, London, UK
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | |
Collapse
|
16
|
CHAIWORAPONGSA T, ROMERO R, GOMEZ-LOPEZ N, SUKSAI M, GALLO DM, JUNG E, BERRY SM, AWONUGA A, TARCA AL, BRYANT DR. Preeclampsia at term: evidence of disease heterogeneity based on the profile of circulating cytokines and angiogenic factors. Am J Obstet Gynecol 2024; 230:450.e1-450.e18. [PMID: 37806612 PMCID: PMC10990810 DOI: 10.1016/j.ajog.2023.10.002] [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: 08/08/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Intravascular inflammation and an antiangiogenic state have been implicated in the pathophysiology of preeclampsia. On the basis of the profiles of their angiogenic/antiangiogenic factors, women with preeclampsia at term may be classified into 2 subgroups with different characteristics and prevalence of adverse outcomes. This study was undertaken to examine whether these 2 subgroups of preeclampsia at term also show differences in their profiles of intravascular inflammation. OBJECTIVE This study aimed to determine the plasma profiles of cytokines and chemokines in women with preeclampsia at term who had a normal or an abnormal angiogenic profile. STUDY DESIGN A nested case-control study was conducted to include women classified into 3 groups: women with an uncomplicated pregnancy (n=213) and women with preeclampsia at term with a normal (n=55) or an abnormal (n=41) angiogenic profile. An abnormal angiogenic profile was defined as a plasma ratio of placental growth factor and soluble fms-like tyrosine kinase-1 multiple of the median <10th percentile for gestational age. Concentrations of cytokines were measured by multiplex immunoassays. RESULTS Women with preeclampsia at term and an abnormal angiogenic profile showed evidence of the greatest intravascular inflammation among the study groups. These women had higher plasma concentrations of 5 cytokines (interleukin-6, interleukin-8, interleukin-12/interleukin-23p40, interleukin-15, and interleukin-16) and 7 chemokines (eotaxin, eotaxin-3, interferon-γ inducible protein-10, monocyte chemotactic protein-4, macrophage inflammatory protein-1β, macrophage-derived chemokine, and thymus and activation-regulated chemokine compared to women with an uncomplicated pregnancy. By contrast, women with preeclampsia at term and a normal angiogenic profile, compared to women with an uncomplicated pregnancy, had only a higher plasma concentration of monocyte chemotactic protein-4. A correlation between severity of the antiangiogenic state, blood pressure, and plasma concentrations of a subset of cytokines was observed. CONCLUSION Term preeclampsia can be classified into 2 clusters. One is characterized by an antiangiogenic state coupled with an excessive inflammatory process, whereas the other has neither of these features. These findings further support the heterogeneity of preeclampsia at term and may explain the distinct clinical outcomes.
Collapse
Affiliation(s)
- Tinnakorn CHAIWORAPONGSA
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Roberto ROMERO
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
| | - Nardhy GOMEZ-LOPEZ
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
| | - Manaphat SUKSAI
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Dahiana M. GALLO
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, University of Valle, Cali, Colombia
| | - Eunjung JUNG
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Stanley M. BERRY
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Awoniyi AWONUGA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Adi L. TARCA
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
- Department of Computer Science, Wayne State University College of Engineering, Detroit, Michigan, USA
| | - David R. BRYANT
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| |
Collapse
|
17
|
Burwick RM, Rodriguez MH. Angiogenic Biomarkers in Preeclampsia. Obstet Gynecol 2024; 143:515-523. [PMID: 38350106 DOI: 10.1097/aog.0000000000005532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/04/2024] [Indexed: 02/15/2024]
Abstract
Preeclampsia contributes disproportionately to maternal and neonatal morbidity and mortality throughout the world. A critical driver of preeclampsia is angiogenic imbalance, which is often present weeks to months before overt disease. Two placenta-derived angiogenic biomarkers, soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF), have proved useful as diagnostic and prognostic tests for preeclampsia. Recently, the U.S. Food and Drug Administration approved the sFlt-1/PlGF assay to aid in the prediction of preeclampsia with severe features among women with hypertensive disorders of pregnancy at 24-34 weeks of gestation. In this narrative review, we summarize the body of work leading to this approval and describe how the sFlt-1/PlGF ratio may be implemented in clinical practice as an adjunctive measure to help optimize care and to reduce adverse outcomes in preeclampsia.
Collapse
Affiliation(s)
- Richard M Burwick
- Division of Maternal Fetal Medicine, San Gabriel Valley Perinatal Medical Group, Pomona Valley Hospital Medical Center, Pomona, California
| | | |
Collapse
|
18
|
Giardini V, Santagati AAF, Marelli E, Casati M, Cantarutti A, Vergani P. Predicting Time to Delivery in Hypertensive Disorders: Assessing PlGF and sFlt-1 with the Novel Parameter 'Mtp-Multiples of a Normal Term Placenta'. J Clin Med 2024; 13:1899. [PMID: 38610664 PMCID: PMC11012921 DOI: 10.3390/jcm13071899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 03/16/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Imbalanced angiogenesis is characteristic of normal placental maturation but it also signals placental dysfunction, underlying hypertensive disorders during pregnancy. This study aimed to investigate the relationship between angiogenic placental aging, measured by markers placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) using the new index "Multiples of a normal term placenta" (Mtp) and the duration of pregnancy. Methods: A retrospective observational study was conducted, including singleton pregnancies diagnosed or suspected of hypertensive disorders after the 20th gestational week. Mtp measures how far a single dosage of angiogenic marker deviates from the expected value in an uncomplicated full-term pregnancy (Mpt = sFlt-1/sFlt-1 reference value or PIGF/PIGF reference value). We considered the 90th, 95th, and 97.5th centiles for sFlt-1 and the 2.5th, 5th, and 10th centiles for PlGF as references. Results: The categories with longer time to delivery, regardless of gestational age, were: Mtp PlGF 10th c ≥ 2, ≥3 and Mtp sFlt-1 90th c ≤ 0.5 (median days of 9, 11, 15 days, respectively). These two categories Mtp sFlt-1 90th c ≥ 3 and Mtp sFlt-1 97.5th c ≥ 2 allow the identification of women at risk for imminent delivery within 1 day. Women who were deemed at low/medium risk based on the sFlt-1/PIGF ratio appeared to be at high risk when considering the individual values of sFlt-1 and/or PIGF. Conclusions: This new Mtp index for sFlt-1 and PlGF could be employed to assess the degree of placental aging in women with hypertensive disorders. It represents a valid tool for evaluating the risk of imminent birth, irrespective of gestational age, surpassing the current stratification based on the sFlt-1/PIGF ratio.
Collapse
Affiliation(s)
- Valentina Giardini
- Department of Obstetrics, IRCCS San Gerardo dei Tintori Foundation, University of Milano-Bicocca, 20900 Monza, Italy
| | | | - Elisabetta Marelli
- Department of Obstetrics, MBBM Foundation Onlus, University of Milano-Bicocca, 20900 Monza, Italy
| | - Marco Casati
- Laboratory Medicine, IRCCS San Gerardo dei Tintori Foundation, 20900 Monza, Italy;
| | - Anna Cantarutti
- Division of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milano, Italy
| | - Patrizia Vergani
- Department of Obstetrics, MBBM Foundation Onlus, University of Milano-Bicocca, 20900 Monza, Italy
| |
Collapse
|
19
|
Llurba E, Crispi F, Crovetto F, Youssef L, Delgado JL, Puig I, Mora J, Krofta L, Mackova K, Martinez-Varea A, Tubau A, Ruiz A, Paya A, Prat M, Chantraine F, Comas C, Kajdy A, Lopez-Tinajero MF, Figueras F, Gratacos E. Multicentre randomised trial of screening with sFlt1/PlGF and planned delivery to prevent pre-eclampsia at term: protocol of the PE37 study. BMJ Open 2024; 14:e076201. [PMID: 38458783 DOI: 10.1136/bmjopen-2023-076201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2024] Open
Abstract
INTRODUCTION Pre-eclampsia affects ~5%-7% of pregnancies. Although improved obstetric care has significantly diminished its associated maternal mortality, it remains a leading cause of maternal morbidity and mortality in the world. Term pre-eclampsia accounts for 70% of all cases and a large proportion of maternal-fetal morbidity related to this condition. Unlike in preterm pre-eclampsia, the prediction and prevention of term pre-eclampsia remain unsolved. Previously proposed approaches are based on combined third-trimester screening and/or prophylactic drugs, but these policies are unlikely to be widely implementable in many world settings. Recent evidence shows that the soluble fms-like tyrosine kinase-1 (s-Flt-1) to placental growth factor (PlGF) ratio measured at 35-37 weeks' gestation predicts term pre-eclampsia with an 80% detection rate. Likewise, recent studies demonstrate that induction of labour beyond 37 weeks is safe and well accepted by women. We hypothesise that a single-step universal screening for term pre-eclampsia based on sFlt1/PlGF ratio at 35-37 weeks followed by planned delivery beyond 37 weeks reduces the prevalence of term pre-eclampsia without increasing the caesarean section rates or worsening the neonatal outcomes. METHODS AND ANALYSIS We propose an open-label randomised clinical trial to evaluate the impact of a screening of term pre-eclampsia with the sFlt-1/PlGF ratio followed by planned delivery in asymptomatic nulliparous women at 35-37 weeks. Women will be assigned 1:1 to revealed (sFlt-1/PlGF known to clinicians) versus concealed (unknown) arms. A cut-off of >90th centile is used to define the high risk of subsequent pre-eclampsia and offer planned delivery from 37 weeks. The efficacy variables will be analysed and compared between groups primarily following an intention-to-treat approach, by ORs and their 95% CI. This value will be computed using a Generalised Linear Mixed Model for binary response (study group as fixed effect and the centre as intercept random effect). ETHICS AND DISSEMINATION The study is conducted under the principles of Good Clinical Practice. This study was accepted by the Clinical Research Ethics Committee of Hospital Clinic Barcelona on 20 November 2020. Subsequent approval by individual ethical committees and competent authorities was granted. The study results will be published in peer-reviewed journals and disseminated at international conferences. TRIAL REGISTRATION NUMBER NCT04766866.
Collapse
Affiliation(s)
- Elisa Llurba
- Obstetrics and Gynecology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Fatima Crispi
- BCNatal, Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | | | | | - Juan Luis Delgado
- Unidad Medicina Fetal Murcia, IMIB Arrixaca, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Isabel Puig
- Unidad Medicina Fetal Murcia, IMIB Arrixaca, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | | | - Ladislav Krofta
- Institute for the Care of Mother and Child, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Katerina Mackova
- Institute for the Care of Mother and Child, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Albert Tubau
- Obstetrician, Son Llàtzer Hospital, Palma de Mallorca, Illes Balears, Spain
| | - Aina Ruiz
- Obstetrician, Son Llàtzer Hospital, Palma de Mallorca, Illes Balears, Spain
| | | | | | | | | | - Anna Kajdy
- Centre of Postgraduate Medical Education, Obstetrics and Gynecology and Perinatal Medicine, Warsaw, Poland
| | | | - Francesc Figueras
- BCNatal, Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | | |
Collapse
|
20
|
Mecacci F, Romani E, Clemenza S, Zullino S, Avagliano L, Petraglia F. Early Fetal Growth Restriction with or Without Hypertensive Disorders: a Clinical Overview. Reprod Sci 2024; 31:591-602. [PMID: 37684516 DOI: 10.1007/s43032-023-01330-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023]
Abstract
Early onset fetal growth restriction (FGR) is one of the main adverse pregnancy conditions, often associated with poor neonatal outcomes. Frequently, early onset FGR is associated with early onset hypertensive disorders of pregnancy (HDP), and in particular preeclampsia (PE). However, to date, it is still an open question whether pregnancies complicated by early FGR plus HDP (FGR-HDP) and those complicated by early onset FGR without HDP (normotensive-FGR (n-FGR)) show different prenatal and postnatal outcomes and, consequently, should benefit from different management and long-term follow-up. Recent data support the hypothesis that the presence of PE may have an additional impact on maternal hemodynamic impairment and placental lesions, increasing the risk of poor neonatal outcomes in pregnancy affected by early onset FGR-HDP compared to pregnancy affected by early onset n-FGR. This review aims to elucidate this poor studied topic, comparing the clinical characteristics, perinatal outcomes, and potential long-term sequelae of early onset FGR-HDP and early onset n-FGR.
Collapse
Affiliation(s)
- Federico Mecacci
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
| | - Eleonora Romani
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
| | - Sara Clemenza
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | - Sara Zullino
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
| | | | - Felice Petraglia
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Florence, Italy
| |
Collapse
|
21
|
Montenegro-Martínez J, Camacho-Carrasco A, Nuñez-Jurado D, Beltrán-Romero LM, Fatela-Cantillo D. Longitudinal changes of angiogenic factors as a potential predictive tool in women with suspected preeclampsia. Pregnancy Hypertens 2024; 35:66-72. [PMID: 38245918 DOI: 10.1016/j.preghy.2024.01.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/13/2024] [Indexed: 01/23/2024]
Abstract
OBJECTIVES To investigate whether longitudinal changes of angiogenic factors (AF) sFlt-1, PlGF, and the sFlt-1/PlGF ratio, measured following identification of symptoms of preeclampsia (PE), could provide complementary information to the isolated measurements used in current clinical practice. STUDY DESIGN Retrospective observational study. Sixty women with suspected PE and two AF results measured before gestational week (GW) 34 were included. Daily variation (DV) of AF was calculated from delta values and days elapsed between measurements. Through ROC analysis, the predictive performance of DV for PE-related events was estimated. Kaplan-Meier survival curves resulting from applying cutoff values were assessed. RESULTS The sFlt-1, PlGF, and sFlt-1/PlGF ratio baseline levels showed significant differences between women without PE and women who developed early-onset PE (P < 0.001). DV of sFlt-1 and sFlt-1/PlGF ratio increased according to the severity of PE, showing significant differences in both pairs of groups compared (p < 0.001), so they were selected as potential predictors. Higher AUC values resulting from ROC analysis were 0.78 for early-onset PE, 0.88 for early-onset severe PE, 0.79 for occurrence of adverse maternal outcomes, and 0.89 for delivery before 37 GW, with sensitivity and specificity values higher than 0.71 and 0.80, respectively. The Kaplan-Meier analysis yielded significantly different curves (log-rank < 0.05), with shorter time-to-delivery as DV increased. CONCLUSION Our results support the existence of a correlation between a progressive PlGF and sFlt-1 imbalance and a more aggressive clinical course of PE, detectable from the finding of PE symptoms. Its monitoring could be a useful predictive tool in women with suspected PE.
Collapse
Affiliation(s)
- Jorge Montenegro-Martínez
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, Laboratory Building, 4th Floor, Manuel Siurot Avenue, 41013 Seville, Spain.
| | - Ana Camacho-Carrasco
- Internal Medicine, Virgen del Rocío University Hospital, General Hospital Building, 2th Floor, Manuel Siurot Avenue, 41013 Seville, Spain
| | - David Nuñez-Jurado
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, Laboratory Building, 4th Floor, Manuel Siurot Avenue, 41013 Seville, Spain
| | - Luis M Beltrán-Romero
- Internal Medicine, Virgen del Rocío University Hospital, General Hospital Building, 2th Floor, Manuel Siurot Avenue, 41013 Seville, Spain
| | - Daniel Fatela-Cantillo
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, Laboratory Building, 4th Floor, Manuel Siurot Avenue, 41013 Seville, Spain
| |
Collapse
|
22
|
Thadhani R, Cerdeira AS, Karumanchi SA. Translation of mechanistic advances in preeclampsia to the clinic: Long and winding road. FASEB J 2024; 38:e23441. [PMID: 38300220 DOI: 10.1096/fj.202301808r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/30/2023] [Accepted: 01/09/2024] [Indexed: 02/02/2024]
Abstract
As one of the leading causes of premature birth and maternal and infant mortality worldwide, preeclampsia remains a major unmet public health challenge. Preeclampsia and related hypertensive disorders of pregnancy are estimated to cause >75 000 maternal and 500 000 infant deaths globally each year. Because of rising rates of risk factors such as obesity, in vitro fertilization and advanced maternal age, the incidence of preeclampsia is going up with rates ranging from 5% to 10% of all pregnancies worldwide. A major discovery in the field was the realization that the clinical phenotypes related to preeclampsia, such as hypertension, proteinuria, and other adverse maternal/fetal events, are due to excess circulating soluble fms-like tyrosine kinase-1 (sFlt-1, also referred to as sVEGFR-1). sFlt-1 is an endogenous anti-angiogenic protein that is made by the placenta and acts by neutralizing the pro-angiogenic proteins vascular endothelial growth factor (VEGF) and placental growth factor (PlGF). During the last decade, this work has spawned a new era of molecular diagnostics for early detection of this condition. Antagonizing sFlt-1 either by reducing production or blocking its actions has shown salutary effects in animal models. Further, in early-stage human studies, the therapeutic removal of sFlt-1 from maternal circulation has shown promise in delaying disease progression and improving outcomes. Recently, the FDA approved the first molecular test for preterm preeclampsia (sFlt-1/PlGF ratio) for clinical use in the United States. Measuring serum sFlt-1/PlGF ratio in the acute hospital setting may aid short-term management, particularly regarding step-up or step-down of care, decision to transfer to settings better equipped to manage both the mother and the preterm neonate, appropriate timing of administration of steroids and magnesium sulfate, and in expectant management decisions. The test itself has the potential to save lives. Furthermore, the availability of a molecular test that correlates with adverse outcomes has set the stage for interventional clinical trials testing treatments for this disorder. In this review, we will discuss the role of circulating sFlt-1 and related factors in the pathogenesis of preeclampsia and specifically how this discovery is leading to concrete advances in the care of women with preeclampsia.
Collapse
Affiliation(s)
- Ravi Thadhani
- Woodruff Health Sciences Center, Emory University School of Medicine, Atlanta, Georgia, USA
- Departments of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ana Sofia Cerdeira
- Nuffield Department of Women's Health and Reproductive Research, University of Oxford, Oxford, UK
- Fetal Maternal Medicine Unit, Queen Charlotte's and Chelsea Hospital, London, UK
| | - S Ananth Karumanchi
- Departments of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| |
Collapse
|
23
|
Dijmărescu AL, Tănase F, Novac MB, Siminel MA, Rotaru I, Caragea DC, Manolea MM, Văduva CC, Boldeanu MV, Boldeanu L. Longitudinal 8-Epi-Prostaglandin F2-Alpha and Angiogenic Profile Mediator Evaluation during Pregnancy in Women with Suspected or Confirmed Pre-eclampsia. Biomedicines 2024; 12:433. [PMID: 38398035 PMCID: PMC10886743 DOI: 10.3390/biomedicines12020433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/31/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
Background: In this exploratory study, we aimed to evaluate the dynamics of angiogenic [soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), soluble Endoglin (sEng), and sFlt-1/PlGF, PlGF/sFlt-1, and sEng/PlGF ratios] and oxidative stress [8-epi-prostaglandin F2 alpha (8-epi-PGF2α) and 8-epi-PGF2α/PlGF ratio] mediator levels in women with suspected or confirmed pre-eclampsia (PE) at least two times during pregnancy. We also wanted to identify the possible correlations between 8-epi-PGF2α and angiogenic mediator levels at the time of inclusion of pregnant women. Methods: We included 40 pregnant women with suspected or confirmed PE, with a mean age of 29 years (range between 18 and 41 years) and gestational age between 18 and 28 weeks at inclusion in this study. The Enzyme-Linked Immunosorbent Assay (ELISA) method to measure the levels of serum angiogenic and oxidative stress mediators was used. Results: The evaluation of baseline sFlt-1/PlGF ratios using a cut-off of 38 suggested that 25 pregnant women had a sFlt-1/PlGF ratio of >38 (sFlt-1/PlGF ratio of >38 group) and 15 had a sFlt-1/PlGF ratio of ≤38 (sFlt-1/PlGF ratio of ≤38 group). The increases in sFlt-1/PlGF ratio in the sFlt-1/PlGF ratio of >38 group were caused by both an increase in sFlt-1 (2.04-fold) and a decrease in PlGF levels (2.55-fold). The 8-epi-PGF2α median levels were higher in the sFlt-1/PlGF ratio of >38 group (1.62-fold). During follow-up after pregnancy, we observed that the mean values of sFlt-1 and sEng and the median values of 8-epi-PGF2α and sFlt-1/PlGF, sEng/PlGF, and 8-epi-PGF2α/PlGF ratios increased directly proportional to gestational age for each measurement time until delivery in both groups. For five women who had a sFlt-1/PlGF ratio ≤38 at inclusion, sFlt-1/PlGF ratio was observed to increase to >38 later in pregnancy. We observed that, in the sFlt-1/PlGF ratio >38 group, baseline 8-epi-PGF2α levels better correlated with angiogenic mediator levels. Conclusions: Our study shows that 33.33% of pregnant women evaluated for suspected or confirmed PE with a sFlt-1/PlGF ratio of ≤38 displayed a rise in sFlt-1/PlGF ratio in subsequent weeks. In addition, together with angiogenic mediators, 8-epi-PGF2 α can be utilized as an independent predictor factor to help clinicians identify or predict which pregnant women will develop PE.
Collapse
Affiliation(s)
- Anda Lorena Dijmărescu
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.L.D.); (F.T.); (M.M.M.); (C.-C.V.)
| | - Florentina Tănase
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.L.D.); (F.T.); (M.M.M.); (C.-C.V.)
| | - Marius Bogdan Novac
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mirela Anişoara Siminel
- Department of Neonatology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Ionela Rotaru
- Department of Hematology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Daniel Cosmin Caragea
- Department of Nephrology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Maria Magdalena Manolea
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.L.D.); (F.T.); (M.M.M.); (C.-C.V.)
| | - Constantin-Cristian Văduva
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.L.D.); (F.T.); (M.M.M.); (C.-C.V.)
| | - Mihail Virgil Boldeanu
- Department of Immunology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Medico Science SRL—Stem Cell Bank Unit, 200690 Craiova, Romania
| | - Lidia Boldeanu
- Department of Microbiology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| |
Collapse
|
24
|
Pluta K, Januszewski M, Ziuzia-Januszewska L, Kudan M, Suchocka M, Kuśmierczuk K, Issat T, Jakimiuk AJ. sFlT-1/PlGF ratio as a predictor of preeclampsia in COVID-19 pregnant patients. BMC Pregnancy Childbirth 2024; 24:94. [PMID: 38297191 PMCID: PMC10829318 DOI: 10.1186/s12884-024-06263-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/07/2024] [Indexed: 02/02/2024] Open
Abstract
The association between SARS-CoV-2 infection in pregnancy and preeclampsia is widely debated in numerous studies. The aim of our study was to investigate whether an increased sFlt-1/PlGF ratio is a good marker of preeclampsia in pregnant patients with COVID-19 infection. This single centre prospective study was conducted in the Department of Obstetrics and Gynaecology, at the Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw. The study group consisted of 68 COVID-19 pregnant patients and 57 SARS-CoV-2 negative pregnant controls. Serum sFlt-1/PlGF ratio was assessed. The two groups did not differ in terms of the frequency of IVF, nulliparity, history of hypertension, pre-gestational diabetes and chronic kidney disease. The primary outcome was the diagnosis of preeclampsia. Preeclampsia was diagnosed in 10 patients in both groups. The sFlt-1/PlGF ratio higher than 38, considered highly suggestive of developing preeclampsia, was found in 20 patients in the COVID-19 group and 15 patients in the control group. The odds of developing preeclampsia in patients with sFlt-1/PlGF ratio > 38 was approximately 4-fold higher in COVID-19 group and 11-fold higher in controls. Sflt-1/PlGF ratio does not differ significantly between the SARS-CoV-2-positive and SARS-COV-2-negative pregnant patients. The sFlt-1/PlGF ratio > 38 is associated with higher odds of the diagnosis of preeclampsia in both of these groups, and therefore may serve as its marker regardless of COVID-19 infection status.
Collapse
Affiliation(s)
- Kamil Pluta
- Department of Obstetrics and Gynecology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Marcin Januszewski
- Department of Obstetrics and Gynecology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Laura Ziuzia-Januszewska
- Department of Otolaryngology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Michał Kudan
- Department of Obstetrics and Gynecology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Maria Suchocka
- Department of Obstetrics and Gynecology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Kinga Kuśmierczuk
- Department of Obstetrics and Gynecology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Tadeusz Issat
- Department of Obstetrics and Gynecology, Institute of Mother and Child, Warsaw, Poland
| | - Artur J Jakimiuk
- Department of Obstetrics and Gynecology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland.
- Center for Reproductive Health, Institute of Mother and Child, Warsaw, Poland.
| |
Collapse
|
25
|
Kryczka KE, Demkow M, Dzielińska Z. Biomarkers in Peripartum Cardiomyopathy-What We Know and What Is Still to Be Found. Biomolecules 2024; 14:103. [PMID: 38254703 PMCID: PMC10813209 DOI: 10.3390/biom14010103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/20/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a form of heart failure, often severe, that occurs in previously healthy women at the end of their pregnancy or in the first few months after delivery. In PPCM, the recovery of heart function reaches 45-50%. However, the all-cause mortality in long-term observation remains high, reaching 20% irrespective of recovery status. The incidence of PPCM is increasing globally; therefore, effort is required to clarify the pathophysiological background of the disease, as well as to discover specific diagnostic and prognostic biomarkers. The etiology of the disease remains unclear, including oxidative stress; inflammation; hormonal disturbances; endothelial, microcirculatory, cardiomyocyte and extracellular matrix dysfunction; fibrosis; and genetic mutations. Currently, antiangiogenic 16-kDa prolactin (PRL), cleaved from standard 23-kDa PRL in the case of unbalanced oxidative stress, is recognized as the main trigger of the disease. In addition, 16-kDa PRL causes damage to cardiomyocytes, acting via microRNA-146a secreted from endothelial cells as a cause of the NF-κβ pathway. Bromocriptine, which inhibits the secretion of PRL from the pituitary gland, is now the only specific treatment for PPCM. Many different phenotypes of the disease, as well as cases of non-responders to bromocriptine treatment, indicate other pathophysiological pathways that need further investigation. Biomarkers in PPCM are not well established. There is a deficiency in specific diagnostic biomarkers. Pro-brain-type natriuretic peptide (BNP) and N-terminal BNP are the best, however unspecific, diagnostic biomarkers of heart failure at the moment. Therefore, more efforts should be engaged in investigating more specific biomolecules of a diagnostic and prognostic manner such as 16-kDa PRL, galectin-3, myeloperoxidase, or soluble Fms-like tyrosine kinase-1/placental growth factor ratio. In this review, we present the current state of knowledge and future directions of exploring PPCM pathophysiology, including microRNA and heat shock proteins, which may improve diagnosis, treatment monitoring, and the development of specific treatment strategies, and consequently improve patients' prognosis and outcome.
Collapse
Affiliation(s)
- Karolina E. Kryczka
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, 04-628 Warsaw, Poland
| | | | | |
Collapse
|
26
|
Sentilhes L, Schmitz T, Arthuis C, Barjat T, Berveiller P, Camilleri C, Froeliger A, Garabedian C, Guerby P, Korb D, Lecarpentier E, Mattuizzi A, Sibiude J, Sénat MV, Tsatsaris V. [Preeclampsia: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:3-44. [PMID: 37891152 DOI: 10.1016/j.gofs.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
OBJECTIVE To identify strategies to reduce maternal and neonatal morbidity related to preeclampsia. MATERIAL AND METHODS The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and recommendations were formulated as a (i) strong, (ii) weak or (iii) no recommendation. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. RESULTS Preeclampsia is defined by the association of gestational hypertension (systolic blood pressure≥140mmHg and/or diastolic blood pressure≥90mmHg) and proteinuria≥0.3g/24h or a Proteinuria/Creatininuria ratio≥30mg/mmol occurring after 20 weeks of gestation. Data from the literature do not show any benefit in terms of maternal or perinatal health from implementing a broader definition of preeclampsia. Of the 31 questions, there was agreement between the working group and the external reviewers on 31 (100%). In general population, physical activity during pregnancy should be encouraged to reduce the risk of preeclampsia (Strong recommendation, Quality of the evidence low) but an early screening based on algorithms (Weak recommendation, Quality of the evidence low) or aspirin administration (Weak recommendation, Quality of the evidence very low) is not recommended to reduce maternal and neonatal morbidity related to preeclampsia. In women with preexisting diabetes or hypertension or renal disease, or multiple pregnancy, the level of evidence is insufficient to determine whether aspirin administration during pregnancy is useful to reduce maternal and perinatal morbidity (No recommendation, Quality of the evidence low). In women with a history of vasculo-placental disease, low dose of aspirin (Strong recommendation, Quality of the evidence moderate) at a dosage of 100-160mg per day (Weak recommendation, Quality of the evidence low), ideally before 16 weeks of gestation and not after 20 weeks of gestation (Strong recommendation, Quality of the evidence low) until 36 weeks of gestation (Weak recommendation, Quality of the evidence very low) is recommended. In a high-risk population, additional administration of low molecular weight heparin is not recommended (Weak recommendation, Quality of the evidence moderate). In case of preeclampsia (Weak recommendation, Quality of the evidence low) or suspicion of preeclampsia (Weak recommendation, Quality of the evidence moderate, the assessment of PlGF concentration or sFLT-1/PlGF ratio is not routinely recommended) in the only goal to reduce maternal or perinatal morbidity. In women with non-severe preeclampsia antihypertensive agent should be administered orally when the systolic blood pressure is measured between 140 and 159mmHg or diastolic blood pressure is measured between 90 and 109mmHg (Weak recommendation, Quality of the evidence low). In women with non-severe preeclampsia, delivery between 34 and 36+6 weeks of gestation reduces severe maternal hypertension but increases the incidence of moderate prematurity. Taking into account the benefit/risk balance for the mother and the child, it is recommended not to systematically induce birth in women with non-severe preeclampsia between 34 and 36+6 weeks of gestation (Strong recommendation, Quality of evidence high). In women with non-severe preeclampsia diagnosed between 37+0 and 41 weeks of gestation, it is recommended to induce birth to reduce maternal morbidity (Strong recommendation, Low quality of evidence), and to perform a trial of labor in the absence of contraindication (Strong recommendation, Very low quality of evidence). In women with a history of preeclampsia, screening maternal thrombophilia is not recommended (Strong recommendation, Quality of the evidence moderate). Because women with a history of a preeclampsia have an increased lifelong risk of chronic hypertension and cardiovascular complications, they should be informed of the need for medical follow-up to monitor blood pressure and to manage other possible cardiovascular risk factors (Strong recommendation, Quality of the evidence moderate). CONCLUSION The purpose of these recommendations was to reassess the definition of preeclampsia, and to determine the strategies to reduce maternal and perinatal morbidity related to preeclampsia, during pregnancy but also after childbirth. They aim to help health professionals in their daily clinical practice to inform or care for patients who have had or have preeclampsia. Synthetic information documents are also offered for professionals and patients.
Collapse
Affiliation(s)
- Loïc Sentilhes
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France.
| | - Thomas Schmitz
- Service de gynécologie-obstétrique, hôpital Robert-Debré, AP-HP, Paris, France
| | - Chloé Arthuis
- Service d'obstétrique et de médecine fœtale, Elsan Santé Atlantique, 44819 Saint-Herblain, France
| | - Tiphaine Barjat
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Saint-Etienne, Saint-Etienne, France
| | - Paul Berveiller
- Service de gynécologie-obstétrique, centre hospitalier intercommunal de Poissy St-Germain, Poissy, France
| | - Céline Camilleri
- Association grossesse santé contre la pré-éclampsie, Paris, France
| | - Alizée Froeliger
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France
| | - Charles Garabedian
- Service de gynécologie-obstétrique, University Lille, ULR 2694-METRICS, CHU de Lille, 59000 Lille, France
| | - Paul Guerby
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Toulouse, Toulouse, France
| | - Diane Korb
- Service de gynécologie-obstétrique, hôpital Robert-Debré, AP-HP, Paris, France
| | - Edouard Lecarpentier
- Service de gynécologie-obstétrique, centre hospitalier intercommunal de Créteil, Créteil, France
| | - Aurélien Mattuizzi
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France
| | - Jeanne Sibiude
- Service de gynécologie-obstétrique, hôpital Louis-Mourier, AP-HP, Colombes, France
| | - Marie-Victoire Sénat
- Service de gynécologie-obstétrique, hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - Vassilis Tsatsaris
- Maternité Port-Royal, hôpital Cochin, GHU Centre Paris cité, AP-HP, FHU PREMA, Paris, France
| |
Collapse
|
27
|
Fang H, Li X, Lin D, Wang L, Yang T, Yang B. Inhibition of intrarenal PRR-RAS pathway by Ganoderma lucidum polysaccharide peptides in proteinuric nephropathy. Int J Biol Macromol 2023; 253:127336. [PMID: 37852403 DOI: 10.1016/j.ijbiomac.2023.127336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/25/2023] [Accepted: 10/08/2023] [Indexed: 10/20/2023]
Abstract
Excessive proteinuria leads to renal dysfunction and damage. Ganoderma lucidum polysaccharide peptide (GL-PP) and Ganoderma lucidum polysaccharide peptide 2 (GL-PP2) are biologically active compounds extracted from Ganoderma lucidum. GL-PP has a relative molecular weight of 37,121 with 76.39 % polysaccharides and 16.35 % polypeptides, while GL-PP2 has a relative molecular weight of 31,130, composed of 64.14 % polysaccharides and 17.73 % polypeptides. The xylose: mannose: glucose monosaccharide ratios in GL-PP and GL-PP2 were 4.83:1:7.03 and 2.35:1:9.38, respectively. In this study, we investigated the protective effects of GL-PP and GL-PP2 on proteinuria-induced renal dysfunction and damage using rat and cell models. Both compounds reduced kidney injury, proteinuria, and inhibited the (pro)renin receptor (PRR)-renin-angiotensin system (RAS) pathway, inflammatory cell infiltration, oxidative stress, and fibrosis. GL-PP2 showed stronger inhibition of cyclooxygenase-2 and inducible nitric oxide synthase proteins compared to GL-PP. In cell models, both compounds displayed anti-inflammatory properties and improved cellular viability by inhibiting the PRR-RAS pathway. GL-PP2 has higher feasibility and productivity than GL-PP in pharmacology and industrial production. It shows promise in treating proteinuria-induced renal disease with superior anti-inflammatory effects and economic, safe industrial application prospects. Further research is needed to compare efficacy, mechanisms, clinical applications, and commercial feasibility of GL-PP and GL-PP2.
Collapse
Affiliation(s)
- Hui Fang
- Key Laboratory of Applied Pharmacology in Universities of Shandong, Department of Pharmacology, School of Pharmacy, Weifang Medical University, Weifang 261053, Shandong, China.
| | - Xinxuan Li
- Key Laboratory of Applied Pharmacology in Universities of Shandong, Department of Pharmacology, School of Pharmacy, Weifang Medical University, Weifang 261053, Shandong, China
| | - Dongmei Lin
- National Engineering Research Center of JUNCAO Technology, Fujian Agriculture and Forestry University, Fujian, Fuzhou 350002, China
| | - Lianfu Wang
- National Engineering Research Center of JUNCAO Technology, Fujian Agriculture and Forestry University, Fujian, Fuzhou 350002, China
| | - Teng Yang
- Key Laboratory of Applied Pharmacology in Universities of Shandong, Department of Pharmacology, School of Pharmacy, Weifang Medical University, Weifang 261053, Shandong, China
| | - Baoxue Yang
- State Key Laboratory of Natural and Biomimetic Drugs, Department of Pharmacology, School of Basic Medical Sciences, Peking University, Beijing 100083, China
| |
Collapse
|
28
|
Hackelöer M, Schmidt L, Verlohren S. New advances in prediction and surveillance of preeclampsia: role of machine learning approaches and remote monitoring. Arch Gynecol Obstet 2023; 308:1663-1677. [PMID: 36566477 PMCID: PMC9790089 DOI: 10.1007/s00404-022-06864-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/18/2022] [Indexed: 12/26/2022]
Abstract
Preeclampsia, a multisystem disorder in pregnancy, is still one of the main causes of maternal morbidity and mortality. Due to a lack of a causative therapy, an accurate prediction of women at risk for the disease and its associated adverse outcomes is of utmost importance to tailor care. In the past two decades, there have been successful improvements in screening as well as in the prediction of the disease in high-risk women. This is due to, among other things, the introduction of biomarkers such as the sFlt-1/PlGF ratio. Recently, the traditional definition of preeclampsia has been expanded based on new insights into the pathophysiology and conclusive evidence on the ability of angiogenic biomarkers to improve detection of preeclampsia-associated maternal and fetal adverse events.However, with the widespread availability of digital solutions, such as decision support algorithms and remote monitoring devices, a chance for a further improvement of care arises. Two lines of research and application are promising: First, on the patient side, home monitoring has the potential to transform the traditional care pathway. The importance of the ability to input and access data remotely is a key learning from the COVID-19 pandemic. Second, on the physician side, machine-learning-based decision support algorithms have been shown to improve precision in clinical decision-making. The integration of signals from patient-side remote monitoring devices into predictive algorithms that power physician-side decision support tools offers a chance to further improve care.The purpose of this review is to summarize the recent advances in prediction, diagnosis and monitoring of preeclampsia and its associated adverse outcomes. We will review the potential impact of the ability to access to clinical data via remote monitoring. In the combination of advanced, machine learning-based risk calculation and remote monitoring lies an unused potential that allows for a truly patient-centered care.
Collapse
Affiliation(s)
- Max Hackelöer
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Leon Schmidt
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Stefan Verlohren
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| |
Collapse
|
29
|
Binder J, Palmrich P, Kalafat E, Haberl C, Schirwani N, Pateisky P, Khalil A. Longitudinal assessment of angiogenic markers in prediction of adverse outcome in women with confirmed pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:843-851. [PMID: 37265117 DOI: 10.1002/uog.26276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/05/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Angiogenic marker assessment, such as the ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF), is known to be a useful tool in the prediction of pre-eclampsia (PE). However, evidence from surveillance strategies in pregnancies with a PE diagnosis is lacking. Therefore, we aimed to assess the predictive performance of longitudinal maternal serum angiogenic marker assessment for both maternal and perinatal adverse outcomes when compared to standard laboratory parameters in pregnancies with confirmed PE. METHODS This was a retrospective analysis of prospectively collected data from January 2013 to December 2020 at the Medical University of Vienna. The inclusion criteria were singleton pregnancy with confirmed PE and post-diagnosis maternal serum angiogenic marker assessment at a minimum of two timepoints. The primary outcome was the predictive performance of longitudinal sFlt-1 and PlGF assessment for adverse maternal and perinatal outcomes compared to conventional laboratory monitoring at the same time in pregnancies with confirmed PE. Composite adverse maternal outcome included intensive care unit admission, pulmonary edema, eclampsia and/or death. Composite adverse perinatal outcome included stillbirth, neonatal death, placental abruption, neonatal intensive care unit admission, intraventricular hemorrhage, necrotizing enterocolitis, respiratory distress syndrome and/or mechanical ventilator support. RESULTS In total, 885 post-diagnosis sFlt-1/PlGF ratio measurements were obtained from 323 pregnant women with confirmed PE. For composite adverse maternal outcome, the highest standalone predictive accuracy was obtained using maternal serum sFlt-1/PlGF ratio (area under the receiver-operating-characteristics curve (AUC), 0.72 (95% CI, 0.62-0.81)), creatinine (AUC, 0.71 (95% CI, 0.62-0.81)) and lactate dehydrogenase (LDH) levels (AUC, 0.73 (95% CI, 0.65-0.81)). Maternal platelet levels (AUC, 0.65 (95% CI, 0.55-0.74)), serum alanine aminotransferase (ALT) (AUC, 0.59 (95% CI, 0.49-0.69)) and aspartate aminotransferase (AST) (AUC, 0.61 (95% CI, 0.51-0.71) levels had poor standalone predictive accuracy. The best prediction model consisted of a combination of maternal serum LDH, creatinine levels and sFlt-1/PlGF ratio, which had an AUC of 0.77 (95% CI, 0.68-0.85), significantly higher than sFlt-1/PlGF ratio alone (P = 0.037). For composite adverse perinatal outcome, the highest standalone predictive accuracy was obtained using maternal serum sFlt-1/PlGF ratio (AUC, 0.82 (95% CI, 0.75-0.89)) and creatinine (AUC, 0.74 (95% CI, 0.67-0.80)) levels, sFlt-1/PlGF ratio being superior to creatinine alone (P < 0.001). Maternal serum LDH levels (AUC, 0.65 (95% CI, 0.53-0.74)), platelet count (AUC, 0.57 (95% CI, 0.44-0.67)), ALT (AUC, 0.58 (95% CI, 0.48-0.67)) and AST (AUC, 0.58 (95% CI, 0.48-0.67)) levels had poor standalone predictive accuracy. No combination of biomarkers was superior to maternal serum sFlt-1/PlGF ratio alone for prediction of composite adverse perinatal outcome (P > 0.05 for all). CONCLUSIONS In pregnancies with confirmed PE, longitudinal maternal serum angiogenic marker assessment is a good predictor of adverse maternal and perinatal outcomes and superior to some conventional laboratory parameters. Further studies should focus on optimal surveillance following diagnosis of PE. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- J Binder
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - P Palmrich
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - E Kalafat
- Department of Obstetrics and Gynecology, School of Medicine, Koc University, Istanbul, Turkey
| | - C Haberl
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - N Schirwani
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - P Pateisky
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| |
Collapse
|
30
|
Lau KGY, Kountouris E, Salazar-Rios L, Nicolaides KH, Kametas NA. Prediction of adverse outcome by ophthalmic artery Doppler and angiogenic markers in pregnancies with new onset hypertension. Pregnancy Hypertens 2023; 34:110-115. [PMID: 37925874 DOI: 10.1016/j.preghy.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 07/31/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES To compare the ophthalmic artery Doppler peak systolic velocity ratio (OA PSV-ratio) and soluble fms-like tyrosine kinase-1/placental growth factor ratio (sFlt-1/PlGF ratio) in predicting adverse maternal and perinatal outcomes in women presenting with new onset hypertension. STUDY DESIGN Prospective cohort study in a specialist hypertension clinic, within a tertiary referral centre. MAIN OUTCOME MEASURES Comparison between the OA PSV-ratio and sFlt-1/PlGF ratio in predicting delivery within one week from presentation and adverse maternal and perinatal outcomes e.g. severe hypertension, neonatal unit admission, small for gestational age. RESULTS Women who delivered within one week, compared to those who did not, had a higher OA PSV-ratio (0.82 vs 0.71, p < 0.01) and sFlt-1/PlGF ratio (93.3 vs 40.5, p = 0.08). Independent predictors of the OA PSV-ratio included mean arterial pressure and maternal weight and predictors of the sFlt-1/PlGF ratio included diastolic blood pressure and use of antihypertensive medications. Prediction of adverse outcomes with both ratios were similar and only modest e.g. AUROC for predicting delivery within one week for OA PSV-ratio was 0.57 (95% CI 0.47-0.67) and for sFlt-1/PlGF ratio was 0.61 (95% CI 0.52-0.70) (p = 0.53). CONCLUSIONS In women presenting with new onset hypertension, the OA PSV-ratio and sFlt-1/PlGF ratio have similar and modest performance in predicting adverse outcomes.
Collapse
Affiliation(s)
- Katherine G Y Lau
- Antenatal Hypertension Clinic, King's College Hospital, London, UK; Harris Birthright, Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | | | | | - Kypros H Nicolaides
- Harris Birthright, Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - Nikos A Kametas
- Antenatal Hypertension Clinic, King's College Hospital, London, UK; Harris Birthright, Research Centre for Fetal Medicine, King's College Hospital, London, UK.
| |
Collapse
|
31
|
Álvarez SC, Zurita AR, Del Carmen De Ganzo Suárez T, De Luis Escudero JF, Medina NS, Pérez CC, de Basoa CMF, Montesino JLT, Masip MTC, Bello MÁG. Is a sFlt-1/PlGF cutoff of 38 suitable to predict adverse outcomes in pregnancies with abnormal uterine artery Doppler velocimetry in the second trimester? Pregnancy Hypertens 2023; 34:13-18. [PMID: 37778280 DOI: 10.1016/j.preghy.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 07/03/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE To determine the optimal cutoff value for the soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) ratio to predict maternal and fetal adverse events in pregnancies with uterine artery Doppler scans results above the 95th percentile in the late second trimester. STUDY DESIGN Retrospective, observational cohort study on 116 asyntomatic patients with abnormal uterine artery Doppler scans at gestational week 25. The sFlt-1/PlGF ratio was determined within the weeks 25 to 29 of gestation and ROC curve analysis performed. The diagnostic validity of different cutoff values to predict severe maternal and fetal complications, i.e. preeclampsia, fetal growth restriction, placental abruption, and fetal death, was analyzed. MAIN OUTCOME MEASURES An ideal cutoff for sFlt-1/PlGF ratios in pregnancies with abnormal uterine artery Doppler in the second trimester. RESULTS Applying a cutoff point of 38, the area under the ROC curve was 0.89, generally considered low risk in fetal and maternal complication prediction. The sensitivity was 32.1%, the specificity 98.4%, the positive predictive value (PPV) 94.4%, and the negative predictive value (NPV) 63.3%. A cutoff value of 10, leading to the highest Youden index, performed best at detecting overall complications, increasing sensitivity to 69.8% and the NPV to 76.8%. at the cost of a reduced specificity and PPV. CONCLUSIONS In pregnancies with abnormal uterine artery Doppler in the second trimester, an sFlt-1/PlGF cutoff value greater than equal to 38 improves its predictive power for adverse events.
Collapse
Affiliation(s)
- Sara Caamiña Álvarez
- Department of Obstetrics and Gynecology, University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain.
| | - Alicia Rodríguez Zurita
- Department of Obstetrics and Gynecology, University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | | | - José Fernando De Luis Escudero
- Department of Obstetrics and Gynecology, University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Nieves Sierra Medina
- Department of Obstetrics and Gynecology, University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Carolina Chulilla Pérez
- Department of Obstetrics and Gynecology, University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Cecilia Martín Fernández de Basoa
- Prenatal Screening and Preeclampsia Unit, Clinical Analysis Service, University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - José Luis Trabado Montesino
- Department of Obstetrics and Gynecology, University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - María Teresa Concepción Masip
- Prenatal Screening and Preeclampsia Unit, Clinical Analysis Service, University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Miguel Ángel García Bello
- Department of Clinical Psychology-Psychobiology and Methodology, University of La Laguna, Santa Cruz de Tenerife, Spain
| |
Collapse
|
32
|
Grimaldi B, Kohan-Ghadr HR, Halari CD, Nandi P, Kingdom JC, Drewlo S. Rosiglitazone-Mediated Activation of PPARγ Restores HO1 Expression in the Human Preeclamptic Placenta. Hypertension 2023; 80:2386-2396. [PMID: 37702083 PMCID: PMC10581437 DOI: 10.1161/hypertensionaha.123.21645] [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: 06/12/2023] [Accepted: 08/14/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Preeclampsia is a hypertensive disorder of pregnancy characterized by chronic placental ischemia and suppression of proangiogenic proteins, causing oxidative stress, hypertension, and maternal systemic organ damage. The transcription factor, PPARγ (peroxisome proliferator-activated receptor-γ) promotes healthy trophoblast differentiation but is dysregulated in the preeclampsia placenta. Our study identifies the beneficial impact of Rosiglitazone-mediated PPARγ-activation in the stressed preeclampsia placenta. METHODS We used first trimester placentas, preeclamptic and preterm control placentas, and human trophoblast cell lines to study PPARγ activation. RESULTS Induction of PPARγ activates cell growth and antioxidative stress pathways, including the gene, heme oxygenase 1 (Hmox1). Protein expression of both PPARγ and HO1 (heme oxygenase 1) are reduced in preeclamptic placentas, but Rosiglitazone restores HO1 signaling in a PPARγ-dependent manner. CONCLUSIONS Restoring disrupted pathways by PPARγ in preeclampsia offers a potential therapeutic pathway to reverse placental damage, extending pregnancy duration, and reduce maternal sequelae. Future research should aim to understand the full scope of impaired PPARγ signaling in the human placenta and focus on compounds for safe use during pregnancy to prevent severe perinatal morbidity and mortality.
Collapse
Affiliation(s)
- Brooke Grimaldi
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI (B.G., H.-R.K.-G.)
- Department of Epigenetics, Van Andel Institute, Grand Rapids, MI (B.G.)
| | - Hamid-Reza Kohan-Ghadr
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI (B.G., H.-R.K.-G.)
| | - Chidambra D. Halari
- Biological Sciences Platform, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Canada (C.D.H., P.N., S.D.)
| | - Pinki Nandi
- Biological Sciences Platform, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Canada (C.D.H., P.N., S.D.)
| | - John C. Kingdom
- Department of Obstetrics and Gynecology, Temerty Faculty of Medicine, University of Toronto, Canada (J.C.K., S.D.)
- Department of Maternal-Fetal Medicine, University of Toronto, Canada (J.C.K.)
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada (J.C.K., S.D.)
| | - Sascha Drewlo
- Department of Obstetrics and Gynecology, Temerty Faculty of Medicine, University of Toronto, Canada (J.C.K., S.D.)
- Biological Sciences Platform, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Canada (C.D.H., P.N., S.D.)
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada (J.C.K., S.D.)
| |
Collapse
|
33
|
Ullah A, Zhao J, Singla RK, Shen B. Pathophysiological impact of CXC and CX3CL1 chemokines in preeclampsia and gestational diabetes mellitus. Front Cell Dev Biol 2023; 11:1272536. [PMID: 37928902 PMCID: PMC10620730 DOI: 10.3389/fcell.2023.1272536] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/09/2023] [Indexed: 11/07/2023] Open
Abstract
Diabetes-related pathophysiological alterations and various female reproductive difficulties were common in pregnant women with gestational diabetes mellitus (GDM), who had 21.1 million live births. Preeclampsia (PE), which increases maternal and fetal morbidity and mortality, affects approximately 3%-5% of pregnancies worldwide. Nevertheless, it is unclear what triggers PE and GDM to develop. Therefore, the development of novel moderator therapy approaches is a crucial advancement. Chemokines regulate physiological defenses and maternal-fetal interaction during healthy and disturbed pregnancies. Chemokines regulate immunity, stem cell trafficking, anti-angiogenesis, and cell attraction. CXC chemokines are usually inflammatory and contribute to numerous reproductive disorders. Fractalkine (CX3CL1) may be membrane-bound or soluble. CX3CL1 aids cell survival during homeostasis and inflammation. Evidence reveals that CXC and CX3CL1 chemokines and their receptors have been the focus of therapeutic discoveries for clinical intervention due to their considerable participation in numerous biological processes. This review aims to give an overview of the functions of CXC and CX3CL1 chemokines and their receptors in the pathophysiology of PE and GDM. Finally, we examined stimulus specificity for CXC and CX3CL1 chemokine expression and synthesis in PE and GDM and preclinical and clinical trials of CXC-based PE and GDM therapies.
Collapse
Affiliation(s)
- Amin Ullah
- Joint Laboratory of Artificial Intelligence for Critical Care Medicine, Department of Critical Care Medicine, Institutes for Systems Genetics, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Zhao
- Joint Laboratory of Artificial Intelligence for Critical Care Medicine, Department of Critical Care Medicine, Institutes for Systems Genetics, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Rajeev K. Singla
- Joint Laboratory of Artificial Intelligence for Critical Care Medicine, Department of Critical Care Medicine, Institutes for Systems Genetics, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India
| | - Bairong Shen
- Joint Laboratory of Artificial Intelligence for Critical Care Medicine, Department of Critical Care Medicine, Institutes for Systems Genetics, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
34
|
Mills RM. Heart Failure With Preserved Ejection Fraction in Women: A Less "Cardio" and More "Vascular" Disease? Am J Cardiol 2023; 205:512-513. [PMID: 37679193 DOI: 10.1016/j.amjcard.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 09/09/2023]
|
35
|
Gómez Fernández C, Otero Naveiro A, Raña Mayán A, Álvarez Fernández R, Pérez Fernández R, Paz Fernández E. Angiogenic biomarkers for the follow-up of singleton pregnancies with suspected preeclampsia. Minerva Obstet Gynecol 2023; 75:412-423. [PMID: 35758095 DOI: 10.23736/s2724-606x.22.05083-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Preeclampsia (PE) is a hypertensive disorder of pregnancy and one of the leading causes of maternal and fetal morbidity and mortality worldwide. While the underlying cause of remains unknown, abnormal placentation in early stages of pregnancy is thought to be a main triggering event for the more severe and early-onset forms. A consequence of placental insufficiency is an imbalance of angiogenic factors in the maternal circulation. The objective was to assess the utility of the angiogenic biomarker sFlt-1/PlGF for the diagnosis, follow-up and prognosis of preeclampsia. METHODS This was a retrospective cohort study based including 65 consecutive singleton pregnancies with suspected preeclampsia referred to our hospital between January 2018 and February 2019. PE was defined as early-onset (20-33+6 weeks) and late-onset (≥34 weeks). The main independent variable was sFlt-1/PlGF classified in women with early or late onset PE, respectively, as low when <38 or <38, intermediate when 38-84 or 38-109, and high when ≥85 or ≥110. RESULTS PE was confirmed in 14 (4 early-onset, 10 late-onset) of the participants. 122 sFlt-1/PIGF ratio determinations were requested. The optimal sFlt-1/PlGF to predict PE was ≥86 with a sensitivity of 93% and a specificity of 96% (AUC 0.95; CI 95% 0.90-1.0; P<0.001). A multilevel logistic model for the diagnosis of PE was adjusted for age, Body Mass Index, diabetes, proteinuria and mean arterial pressure. Women were 16.5 times (P=0.013) more likely to develop PE if they had intermediate sFlt-1/PlGF levels and 451 times (P<0.001) more likely if they had high biomarker levels compared to those with levels below 38. The probability of PE was 3.73 times (P=0.046) greater in those with maternal and/or fetal complications. CONCLUSIONS The biomarker proved useful to diagnose PE and assess its prognosis. Patients diagnosed with PE had a higher frequency of complications and their newborns were of lower birth weight.
Collapse
Affiliation(s)
| | - Ana Otero Naveiro
- Department of Ginecology and Obstetrics, Lucus Augusti University Hospital, Lugo, Spain
| | - Andrea Raña Mayán
- Department of Ginecology and Obstetrics, Lucus Augusti University Hospital, Lugo, Spain
| | | | | | - Eugenio Paz Fernández
- Department of Ginecology and Obstetrics, Lucus Augusti University Hospital, Lugo, Spain
| |
Collapse
|
36
|
Velegrakis A, Kouvidi E, Fragkiadaki P, Sifakis S. Predictive value of the sFlt‑1/PlGF ratio in women with suspected preeclampsia: An update (Review). Int J Mol Med 2023; 52:89. [PMID: 37594116 PMCID: PMC10500221 DOI: 10.3892/ijmm.2023.5292] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/13/2023] [Indexed: 08/19/2023] Open
Abstract
Preeclampsia (PE) is a major complication of pregnancy with an incidence rate of 2‑8% and is a leading cause of maternal mortality and morbidity. The various consequences of severe preeclampsia for the fetus, neonate and child include intrauterine growth retardation (IUGR), fetal hypoxia, oligohydramnios, intrauterine fetal demise, increased perinatal mortality and morbidity, neurodevelopmental disorders and even irreversible brain damage (cerebral palsy). A number of studies have demonstrated that differences in maternal serum concentrations of angiogenic factors between preeclampsia and normotensive pregnancies can be used as biomarkers, either alone or in combination with other markers, to predict the development of PE. The presence in the maternal circulation of two proteins of placental origin, placental growth factor (PlGF) and soluble fms‑like tyrosine kinase 1 (sFlt‑1), has been shown to be of clinical value, as the sFlt‑1/PlGF ratio appears to be the optimal predictive tool for the development of PE. The measurement of their concentration in maternal serum in screening models, serves as predictive marker for the development of PE or IUGR later in gestation. However, further research is required to improve its clinical applicability and provide guidelines for its use worldwide to achieve more consistent clinical management of women with PE.
Collapse
Affiliation(s)
- Alexandros Velegrakis
- Department of Obstetrics and Gynecology, University Hospital of Heraklion, 71500 Heraklion, Greece
| | - Elisavet Kouvidi
- Genesis Genoma Lab, Genetic Diagnosis, Clinical Genetics and Research, 15232 Athens, Greece
| | - Persefoni Fragkiadaki
- Laboratory of Toxicology, Medical School, University of Crete, 71003 Heraklion, Greece
| | | |
Collapse
|
37
|
Bisson C, Rajan RS, Rana S. Angiogenic Biomarkers for Preeclampsia in Clinical Setting: A New Era. Hypertension 2023; 80:2029-2032. [PMID: 37729636 DOI: 10.1161/hypertensionaha.123.21686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Affiliation(s)
- Courtney Bisson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, IL (C.B., S.R.)
| | - Revathi S Rajan
- Department of Maternal Fetal Medicine, Mirror Health, Bengaluru, India (R.S.R.)
| | - Sarosh Rana
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, IL (C.B., S.R.)
| |
Collapse
|
38
|
De Oliveira L, Roberts JM, Jeyabalan A, Blount K, Redman CW, Poston L, Seed PT, Chappell LC, Dias MAB. PREPARE: A Stepped-Wedge Cluster-Randomized Trial to Evaluate Whether Risk Stratification Can Reduce Preterm Deliveries Among Patients With Suspected or Confirmed Preterm Preeclampsia. Hypertension 2023; 80:2017-2028. [PMID: 37431663 PMCID: PMC10510842 DOI: 10.1161/hypertensionaha.122.20361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 06/19/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Early delivery in preterm preeclampsia may reduce the risks for the patient, but consequences of prematurity may be substantial for the baby. This trial evaluated whether the implementation of a risk stratification model could safely reduce prematurity. METHODS This was a stepped-wedge cluster-randomized trial in seven clusters. Patients presenting with suspected or confirmed preeclampsia between 20+0 and 36+6 gestational weeks were considered eligible. At the start of the trial, all centers were allocated in the preintervention phase, and patients enrolled in this phase were managed according to local treatment guidance. Subsequently, every 4 months, 1 randomly allocated cluster transitioned to the intervention. Patients enrolled in the intervention phase had sFlt-1 (soluble fms-like tyrosine kinase-1)/PlGF (placental growth factor) ratio and preeclampsia integrated estimate of risk assessments performed. If sFlt-1/PlGF ≤38 and preeclampsia integrated estimate of risk <10%, patients were considered low risk and clinicians received recommendations to defer delivery. If sFlt-1/PlGF >38 and preeclampsia integrated estimate of risk ≥10%, patients were considered not low risk, and clinicians received recommendations to increase surveillance. The primary outcome was the proportion of patients with preterm preeclampsia delivered prematurely out of total deliveries. RESULTS Between March 25, 2017 and December 24, 2019, 586 and 563 patients were analyzed in the intervention and usual care groups, respectively. The event rate was 1.09% in the intervention group, and 1.37% in the usual care group. After prespecified adjustments for variation between and within clusters over time, the adjusted risk ratio was 1.45 ([95% CI, 1.04-2.02]; P=0.029), indicating a higher risk of preterm deliveries in the intervention group. Post hoc analysis including calculation of risk differences did not show evidence of statistical differences. Abnormal sFlt-1/PlGF was associated with a higher rate of identifying preeclampsia with severe features. CONCLUSIONS The introduction of an intervention based on biomarkers and clinical factors for risk stratification did not lead to reductions in preterm deliveries. Further training on the interpretation of disease severity in preeclampsia and the development of additional risk stratification is needed before adoption into clinical practice. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03073317.
Collapse
Affiliation(s)
- Leandro De Oliveira
- Botucatu Medical School, Obstetrics Department, Botucatu Sao Paulo State University, SP, Brazil (L.D.O.)
| | - James M. Roberts
- Magee-Womens Research Institute Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, Pittsburgh, PA (J.M.R., A.J., K.B.)
| | - Arundhathi Jeyabalan
- Magee-Womens Research Institute Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, Pittsburgh, PA (J.M.R., A.J., K.B.)
| | - Kasey Blount
- Magee-Womens Research Institute Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, Pittsburgh, PA (J.M.R., A.J., K.B.)
| | - Christopher W. Redman
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, United Kingdom (C.W.R.)
| | - Lucilla Poston
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College of London, United Kingdom (L.P., P.T.S., L.C.C.)
| | - Paul T. Seed
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College of London, United Kingdom (L.P., P.T.S., L.C.C.)
| | - Lucy C. Chappell
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College of London, United Kingdom (L.P., P.T.S., L.C.C.)
| | | |
Collapse
|
39
|
Suvakov S, Kattah AG, Gojkovic T, Enninga EAL, Pruett J, Jayachandran M, Sousa C, Santos J, Abou Hassan C, Gonzales-Suarez M, Garovic VD. Impact of Aging and Cellular Senescence in the Pathophysiology of Preeclampsia. Compr Physiol 2023; 13:5077-5114. [PMID: 37770190 DOI: 10.1002/cphy.c230003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
The incidence of hypertensive disorders of pregnancy is increasing, which may be due to several factors, including an increased age at pregnancy and more comorbid health conditions during reproductive years. Preeclampsia, the most severe hypertensive disorder of pregnancy, has been associated with an increased risk of future disease, including cardiovascular and kidney diseases. Cellular senescence, the process of cell cycle arrest in response to many physiologic and maladaptive stimuli, may play an important role in the pathogenesis of preeclampsia and provide a mechanistic link to future disease. In this article, we will discuss the pathophysiology of preeclampsia, the many mechanisms of cellular senescence, evidence for the involvement of senescence in the development of preeclampsia, as well as evidence that cellular senescence may link preeclampsia to the risk of future disease. Lastly, we will explore how a better understanding of the role of cellular senescence in preeclampsia may lead to therapeutic trials. © 2023 American Physiological Society. Compr Physiol 13:5077-5114, 2023.
Collapse
Affiliation(s)
- Sonja Suvakov
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea G Kattah
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Tamara Gojkovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth A L Enninga
- Division of Research, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Jacob Pruett
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ciria Sousa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Janelle Santos
- Division of Research, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Coline Abou Hassan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
- Division of Research, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| |
Collapse
|
40
|
Melo DCS, Sousa RP, Pais MSJDR, Felix LM, Pinto FF, Moura JPSA. The role of the soluble fms-like tyrosine kinase-1/placental growth factor (sFlt-1/PIGF) - ratio in clinical practice in obstetrics: diagnostic and prognostic value. J Perinat Med 2023; 51:896-903. [PMID: 37163520 DOI: 10.1515/jpm-2022-0353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 03/25/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVES Analyze the diagnostic and prognostic value of the sFlt-1/PlGF ratio in pregnant women with at least one sign/symptom of suspected/diagnosed pre-eclampsia. METHODS This retrospective observational study included 170 pregnant women with at least one sign/symptom of pre-eclampsia, who had sFlt-1/PlGF ratio values. The following information was evaluated: pregnant women's demographic data and clinical history; laboratory data (urine protein/creatinine ratio; sFlt-1/PlGF ratio); signs and symptoms presented; clinical outcome; fetal complications; data related to childbirth. Statistical analysis was performed by R Software Version 3.5.2. RESULTS Among the 170 patients, 78 presented pre-eclampsia. The median sFlt-1/PlGF ratio was significantly higher [143.1 (2.2-2,927.1)] for women who presented pre-eclampsia than for women without pre-eclampsia [33.5 (0.8-400.2)]. The negative predictive value of sFlt-1/PlGF ratio <38 was 83.9 % (95 % CI, 71.7-92.4 %) and the positive predictive value of sFlt-1/PlGF ratio >85 or 110 (for late onset pre-eclampsia) was 76.4 % (95 % CI, 66.2-84.8 %). sFlt-1/PlGF >85 or 110 was associated with pre-eclampsia clinical development, fetal complications, shorter gestational age at birth, higher number of caesarean deliveries and lower birth weight. CONCLUSIONS The sFlt-1/PlGF ratio, together with the standard diagnostic criteria, can be used to rule out pre-eclampsia, identify high-risk patients and predict the occurrence of adverse outcomes.
Collapse
Affiliation(s)
- Daniela C S Melo
- Department of Obstetrics-A, Coimbra Hospital and University Centre, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- University Clinic of Gynecology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Raquel P Sousa
- Department of Obstetrics-A, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Maria S J D R Pais
- Department of Obstetrics-A, Coimbra Hospital and University Centre, Coimbra, Portugal
| | | | | | - José P S A Moura
- Department of Obstetrics-A, Coimbra Hospital and University Centre, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| |
Collapse
|
41
|
Williamson C, Nana M, Poon L, Kupcinskas L, Painter R, Taliani G, Heneghan M, Marschall HU, Beuers U. EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy. J Hepatol 2023; 79:768-828. [PMID: 37394016 DOI: 10.1016/j.jhep.2023.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 07/04/2023]
Abstract
Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver Disease invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, specialists in training and other healthcare professionals who provide care for this patient population.
Collapse
|
42
|
Eddy AC, Chiang CY, Rajakumar A, Spradley FT, Dauer P, Granger JP, Rana S. Bioflavonoid luteolin prevents sFlt-1 release via HIF-1α inhibition in cultured human placenta. FASEB J 2023; 37:e23078. [PMID: 37405762 PMCID: PMC10348062 DOI: 10.1096/fj.202300611r] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/31/2023] [Accepted: 06/22/2023] [Indexed: 07/06/2023]
Abstract
Preeclampsia (PE) is a serious hypertensive complication of pregnancy and is a leading cause of maternal death and major contributor to maternal and perinatal morbidity, including establishment of long-term complications. The continued prevalence of PE stresses the need for identification of novel treatments which can target prohypertensive factors implicated in the disease pathophysiology, such as soluble fms-like tyrosine kinase 1 (sFlt-1). We set out to identify novel compounds to reduce placental sFlt-1 and determine whether this occurs via hypoxia-inducible factor (HIF)-1α inhibition. We utilized a commercially available library of natural compounds to assess their ability to reduce sFlt-1 release from primary human placental cytotrophoblast cells (CTBs). Human placental explants from normotensive (NT) and preeclamptic (PE) pregnancies were treated with varying concentrations of luteolin. Protein and mRNA expression of sFlt-1 and upstream mediators were evaluated using ELISA, western blot, and real-time PCR. Of the natural compounds examined, luteolin showed the most potent inhibition of sFlt-1 release, with >95% reduction compared to vehicle-treated. Luteolin significantly inhibited sFlt-1 in cultured placental explants compared to vehicle-treated in a dose- and time-dependent manner. Additionally, significant decreases in HIF-1α expression were observed in luteolin-treated explants, suggesting a mechanism for sFlt-1 downregulation. The ability of luteolin to inhibit HIF-1α may be mediated through the Akt pathway, as inhibitors to Akt and its upstream regulator phosphatidylinositol-3 kinase (PI3K) resulted in significant HIF-1α reduction. Luteolin reduces anti-angiogenic sFlt-1 through inhibition of HIF-1α, making it a novel candidate for the treatment of PE.
Collapse
Affiliation(s)
- Adrian C. Eddy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago, IL, USA
| | - Chun Yi Chiang
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago, IL, USA
| | | | - Frank T. Spradley
- Department of Surgery and Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS USA
| | - Patricia Dauer
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago, IL, USA
| | - Joey P. Granger
- Department of Physiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Sarosh Rana
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago, IL, USA
| |
Collapse
|
43
|
Shi H, Kong R, Miao X, Gou L, Yin X, Ding Y, Cao X, Meng Q, Gu M, Suo F. Decreased PPP1R3G in pre-eclampsia impairs human trophoblast invasion and migration via Akt/MMP-9 signaling pathway. Exp Biol Med (Maywood) 2023; 248:1373-1382. [PMID: 37642261 PMCID: PMC10657594 DOI: 10.1177/15353702231182214] [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: 12/22/2022] [Accepted: 03/28/2023] [Indexed: 08/31/2023] Open
Abstract
Pre-eclampsia (PE) is a severe pregnancy complication characterized by impaired trophoblast invasion and spiral artery remodeling and can have serious consequences for both mother and child. Protein phosphatase 1 regulatory subunit 3G (PPP1R3G) is involved in numerous tumor-related biological processes. However, the biological action and underlying mechanisms of PPP1R3G in PE progression remain unclear. We used western blotting and immunohistochemistry to investigate PPP1R3G expression in gestational age-matched pre-eclamptic and normal placental tissues. After lentivirus transfection, wound-healing, Transwell, cell-counting kit-8 (CCK-8), 5-ethynyl-2'-deoxyuridine (EdU), and TdT mediateddUTP Nick End Labeling (TUNEL) assays were used to assess trophoblast migration, invasion, proliferation, and apoptosis, respectively. The relative expression levels of PPP1R3G and the proteins involved in the Akt signaling pathway were determined using western blotting. The results showed that PPP1R3G levels were significantly lower in the placental tissues and GSE74341 microarray of the PE group than those of the healthy control group. We also found that neonatal weight and Apgar score were lower at birth, and peak systolic blood pressure and diastolic blood pressure were higher in the PE group than in the non-PE group. In addition, PPP1R3G knockdown decreased p-Akt/Akt expression and inhibited migration, invasion, and proliferation in HTR-8/SVneo trophoblasts but had no discernible effect on cell apoptosis. Furthermore, PPP1R3G positively regulated matrix metallopeptidase 9 (MMP-9), which was downregulated in placental tissues of pregnant women with PE. These results provided the first evidence that the reduced levels of PPP1R3G might contribute to PE by suppressing the invasion and migration of trophoblasts and targeting the Akt/MMP-9 signaling pathway.
Collapse
Affiliation(s)
- Huimin Shi
- Department of Obstetrics, Xuzhou Cancer Hospital, Xuzhou 221005, Jiangsu Province, China
| | - Renyu Kong
- Department of Cell Biology and Neurobiology, Xuzhou Key Laboratory of Neurobiology, Xuzhou Medical University, Xuzhou 221004, China
| | - Xu Miao
- Department of Cell Biology and Neurobiology, Xuzhou Key Laboratory of Neurobiology, Xuzhou Medical University, Xuzhou 221004, China
| | - Lingshan Gou
- Center for Genetic Medicine, Maternity and Child Health Care Hospital Affiliated to Xuzhou Medical University, 46 Heping Road, Xuzhou 221009, Jiangsu Province, China
| | - Xin Yin
- Center for Genetic Medicine, Maternity and Child Health Care Hospital Affiliated to Xuzhou Medical University, 46 Heping Road, Xuzhou 221009, Jiangsu Province, China
| | - Yuning Ding
- Department of Cell Biology and Neurobiology, Xuzhou Key Laboratory of Neurobiology, Xuzhou Medical University, Xuzhou 221004, China
| | - Xiliang Cao
- Department of Urology, Xuzhou No. 1 People’s Hospital, the Affiliated Xuzhou Municipal Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Qingyong Meng
- Department of Obstetrics, Xuzhou Maternal and Child Health Hospital Affiliated to Xuzhou Medical University, Xuzhou 221009, Jiangsu Province, China
| | - Maosheng Gu
- Center for Genetic Medicine, Maternity and Child Health Care Hospital Affiliated to Xuzhou Medical University, 46 Heping Road, Xuzhou 221009, Jiangsu Province, China
| | - Feng Suo
- Center for Genetic Medicine, Maternity and Child Health Care Hospital Affiliated to Xuzhou Medical University, 46 Heping Road, Xuzhou 221009, Jiangsu Province, China
| |
Collapse
|
44
|
Lopian M, Kashani-Ligumsky L, Many A. A Balancing Act: Navigating Hypertensive Disorders of Pregnancy at Very Advanced Maternal Age, from Preconception to Postpartum. J Clin Med 2023; 12:4701. [PMID: 37510816 PMCID: PMC10380965 DOI: 10.3390/jcm12144701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/31/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
The decision to postpone parenting has gained momentum in recent years, a shift driven by evolving social dynamics and improved access to fertility treatments. Despite their increasing prevalence, pregnancies at advanced maternal ages are associated with increased risks of adverse maternal and neonatal outcomes. This article addresses the association between advanced maternal age and hypertensive disorders of pregnancies (HDPs), which are more prevalent and a significant cause of maternal morbidity and mortality in this population. This review explores the biological mechanisms and age-related risk factors that underpin this increased susceptibility and offers practical management strategies that can be implemented prior to, as well as during, each stage of pregnancy to mitigate the incidence and severity of HDPs in this group. Lastly, this review acknowledges both the short-term and long-term postpartum implications of HDPs in women of advanced maternal age.
Collapse
Affiliation(s)
- Miriam Lopian
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Lior Kashani-Ligumsky
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ariel Many
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| |
Collapse
|
45
|
Espinoza J. Evolutionary perspective of uteroplacental malperfusion: subjacent insult common to most pregnancy complications. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:7-13. [PMID: 37391928 DOI: 10.1002/uog.26218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/24/2023] [Accepted: 03/31/2023] [Indexed: 07/02/2023]
Abstract
Linked article: There is a comment on this article by Yagel et al. Click here to view the Correspondence.
Collapse
Affiliation(s)
- J Espinoza
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Fetal Intervention, UTHealth, McGovern Medical School, University of Texas, Houston, TX, USA
| |
Collapse
|
46
|
Chaiworapongsa T, Romero R, Gotsch F, Suksai M, Gallo DM, Jung E, Krieger A, Chaemsaithong P, Erez O, Tarca AL. Preeclampsia at term can be classified into 2 clusters with different clinical characteristics and outcomes based on angiogenic biomarkers in maternal blood. Am J Obstet Gynecol 2023; 228:569.e1-569.e24. [PMID: 36336082 PMCID: PMC10149598 DOI: 10.1016/j.ajog.2022.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND An antiangiogenic state has emerged as a mechanism of disease in preeclampsia. Angiogenic biomarkers are used in the risk assessment of this syndrome, particularly of early disease. The role of an antiangiogenic state in late preeclampsia is unclear. OBJECTIVE This study aimed to determine the prevalence, characteristics, and clinical significance of angiogenic/antiangiogenic factor abnormalities in women with preeclampsia stratified according to gestational age at delivery. STUDY DESIGN Two studies were conducted: (1) a longitudinal nested case-control study comprising women with preeclampsia (n=151) and a control group (n=540); and (2) a case series of patients with preeclampsia (n=452). In patients with preeclampsia, blood was collected at the time of diagnosis. Plasma concentrations of placental growth factor and soluble fms-like tyrosine kinase-1 were determined by enzyme-linked immunosorbent assays. An abnormal angiogenic profile was defined as a plasma ratio of placental growth factor and soluble fms-like tyrosine kinase-1 expressed as a multiple of the median <10th percentile for gestational age based on values derived from the longitudinal study. The proportion of patients diagnosed with preeclampsia who had an abnormal angiogenic profile was determined in the case-series participants and stratified by gestational age at delivery into early (≤34 weeks), intermediate (34.1-36.9 weeks), and term (≥37 weeks) preeclampsia. The demographics, clinical characteristics, and pregnancy outcomes of women with preeclampsia with and without an abnormal angiogenic profile were compared. RESULTS The prevalence of an abnormal angiogenic profile was higher in preterm than in term preeclampsia (for early, intermediate, and term in the case-control study: 90%, 100%, and 39%; for the case series: 98%, 80%, and 55%, respectively). Women with preeclampsia at term who had an abnormal angiogenic profile were more frequently nulliparous (57% vs 35%), less likely to smoke (14% vs 26%), at greater risk for maternal (14% vs 5%) or neonatal (7% vs 1%) complications, and more often had placental lesions consistent with maternal vascular malperfusion (42% vs 23%; all, P<.05) than those without an abnormal profile. Women with preeclampsia at term who had a normal angiogenic profile had a higher frequency of chronic hypertension (36% vs 21%) and were more likely to have class ≥2 obesity (41% vs 23%) than those with an abnormal profile (both, P<.05). CONCLUSION Patients with early preeclampsia had an abnormal angiogenic profile in virtually all cases, whereas only 50% of women with preeclampsia at term had such abnormalities. The profile of angiogenic biomarkers can be used to classify patients with preeclampsia at term, on the basis of mechanisms of disease, into 2 clusters, which have different demographics, clinical characteristics, and risks of adverse maternal and neonatal outcomes. These findings provide a simple approach to classify preeclampsia at term and have implications for future clinical care and research.
Collapse
Affiliation(s)
- 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, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI.
| | - 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, 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; Detroit Medical Center, Detroit, MI.
| | - Francesca Gotsch
- 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, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Manaphat Suksai
- 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, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Dahiana M Gallo
- 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, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Eunjung Jung
- 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, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Arthur Krieger
- 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, Bethesda, MD, and 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, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - 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, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, HaEmek Medical Center, Afula, Israel
| | - 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, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Computer Science, Wayne State University College of Engineering, Detroit, MI
| |
Collapse
|
47
|
Peguero A, Fernandez-Blanco L, Mazarico E, Benitez L, Gonzalez A, Boada D, Borràs C, Youssef L, Crispi F, Hernandez S, Figueras F. Prediction of adverse neonatal outcome at admission for early-onset preeclampsia with severe features. Pregnancy Hypertens 2023; 32:64-69. [PMID: 37116297 DOI: 10.1016/j.preghy.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/05/2023] [Accepted: 04/20/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Preeclampsia remains the leading cause of maternal morbidity and mortality. Consequently, research has focused on validating tools to predict maternal outcomes regarding clinical and biochemical features from the maternal compartment. However, preeclampsia also leads to neonatal complications due to placental insufficiency and prematurity, being the early-onset type associated with the poorest outcome. Hence, it is imperative to study whether these existing tools can predict adverse neonatal outcome. OBJECTIVE To assess the predictive value for adverse neonatal outcome of Doppler ultrasound, angiogenic factors and multi-parametric risk-score models in women with early-onset severe preeclampsia. STUDY DESIGN This is a prospective cohort study of consecutive singleton pregnancies complicated by early-onset (developed before 34 week's gestation) severe preeclampsia. RESULTS 63 women with early-onset severe preeclampsia, 18 (28.6%) presented an adverse neonatal outcome. Placental growth factor (PlGF) showed the best discrimination between neonatal outcomes among angiogenic factors. PREP-L score is a multi-parametric risk-score for the prediction of complications in early-onset preeclampsia which includes maternal characteristics and clinical and analytical data obtained at admission. Good predictive values for the prediction of neonatal complications were found with the combination of PREP-L score with advanced Doppler (AUC ROC 0.9 95% CI 0.82-0.98]) and with PlGF levels (AUC ROC 0.91 [95% CI 0.84-0.98]). CONCLUSIONS The combination of maternal risk scoring (PREP-L score) with angiogenic factors or fetal Doppler ultrasound at the time of diagnosis of early-onset preeclampsia with severe features performs well in predicting adverse neonatal outcome.
Collapse
Affiliation(s)
- Anna Peguero
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Lorena Fernandez-Blanco
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Edurne Mazarico
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Leticia Benitez
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Alba Gonzalez
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - David Boada
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Cristina Borràs
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Lina Youssef
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Fàtima Crispi
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | - Sandra Hernandez
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Francesc Figueras
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain.
| |
Collapse
|
48
|
Huang X, Jia L, Jia Y, Xu X, Wang R, Wei M, Li H, Peng H, Wei Y, He Q, Wang K. sFlt-1-enriched exosomes induced endothelial cell dysfunction and a preeclampsia-like phenotype in mice. Cytokine 2023; 166:156190. [PMID: 37062152 DOI: 10.1016/j.cyto.2023.156190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/18/2023]
Abstract
Preeclampsia (PE) is a hypertensive disorder of pregnancy characterized by maternal endothelial dysfunction and end-organ damage. Our previous work demonstrated that PE patient-derived exosomes contained higher levels of soluble FMS-like tyrosine kinase-1 (sFlt-1) and significantly induced endothelial dysfunction and PE development. However, the mechanisms underlying the effect of sFlt-1-enriched exosomes (sFlt-1-Exo) on PE development are poorly characterized. Here, we revealed that trophoblast-derived sFlt-1-Exo treatment induced significant inhibition of human umbilical vein endothelial cell (HUVEC) migration and tube formation, as well as an increase in sFlt-1 secretion. Mechanistically, we found that the increased sFlt-1 secretion in the cell culture medium was attributed to enhanced transcription of sFlt-1 in HUVECs. Importantly, we observed that treating pregnant mice with sFlt-1-Exo or recombinant mouse sFlt-1 triggered a preeclampsia-like phenotype, characterized by elevated blood pressure, proteinuria, increased plasma sFlt-1 and adverse pregnancy outcomes. These results strongly suggested that sFlt-1-Exo-induced endothelial dysfunction could be partially attributed to the upregulation of sFlt-1 in endothelial cells, potentially leading to the development of a preeclampsia-like phenotype in mice.
Collapse
Affiliation(s)
- Xiaojie Huang
- Clinical and Translational Research Center, Shanghai First Maternity and Infant Hospital, School of Life Sciences and Technology, Tongji University, Shanghai, China; Clinical and Translational Research Center, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Linyan Jia
- Clinical and Translational Research Center, Shanghai First Maternity and Infant Hospital, School of Life Sciences and Technology, Tongji University, Shanghai, China; Clinical and Translational Research Center, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yuanhui Jia
- Clinical and Translational Research Center, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xianghong Xu
- Department of Biobank, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ruixue Wang
- Clinical and Translational Research Center, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Mengtian Wei
- Clinical and Translational Research Center, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Han Li
- Clinical and Translational Research Center, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hao Peng
- Clinical and Translational Research Center, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yingying Wei
- Clinical and Translational Research Center, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qizhi He
- Department of Pathology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China.
| | - Kai Wang
- Clinical and Translational Research Center, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China.
| |
Collapse
|
49
|
Beckett AG, McFadden MD, Warrington JP. Preeclampsia history and postpartum risk of cerebrovascular disease and cognitive impairment: Potential mechanisms. Front Physiol 2023; 14:1141002. [PMID: 37064920 PMCID: PMC10102351 DOI: 10.3389/fphys.2023.1141002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/22/2023] [Indexed: 04/03/2023] Open
Abstract
Hypertensive disorders of pregnancy such as preeclampsia, eclampsia, superimposed preeclampsia, and gestational hypertension are major causes of fetal and maternal morbidity and mortality. Women with a history of hypertensive pregnancy disorders have increased risk of stroke and cognitive impairments later in life. Moreover, women with a history of preeclampsia have increased risk of mortality from diseases including stroke, Alzheimer's disease, and cardiovascular disease. The underlying pathophysiological mechanisms are currently not fully known. Here, we present clinical, epidemiological, and preclinical studies focused on evaluating the long-term cerebrovascular and cognitive dysfunction that affect women with a history of hypertensive pregnancy disorders and discuss potential underlying pathophysiological mechanisms.
Collapse
Affiliation(s)
- Ashtin G. Beckett
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, United States
| | - Mia D. McFadden
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, United States
| | - Junie P. Warrington
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, United States
| |
Collapse
|
50
|
Biwer LA, Lu Q, Ibarrola J, Stepanian A, Man JJ, Carvajal BV, Camarda ND, Zsengeller Z, Skurnik G, Seely EW, Karumanchi SA, Jaffe IZ. Smooth Muscle Mineralocorticoid Receptor Promotes Hypertension After Preeclampsia. Circ Res 2023; 132:674-689. [PMID: 36815487 PMCID: PMC10119809 DOI: 10.1161/circresaha.122.321228] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 02/16/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Preeclampsia is a syndrome of high blood pressure (BP) with end organ damage in late pregnancy that is associated with high circulating soluble VEGF receptor (sFlt1 [soluble Fms-like tyrosine kinase 1]). Women exposed to preeclampsia have a substantially increased risk of hypertension after pregnancy, but the mechanism remains unknown, leaving a missed interventional opportunity. After preeclampsia, women have enhanced sensitivity to hypertensive stress. Since smooth muscle cell mineralocorticoid receptors (SMC-MR) are activated by hypertensive stimuli, we hypothesized that high sFlt1 exposure in pregnancy induces a postpartum state of enhanced SMC-MR responsiveness. METHODS Postpartum BP response to high salt intake was studied in women with prior preeclampsia. MR transcriptional activity was assessed in vitro in sFlt1-treated SMC by reporter assays and PCR. Preeclampsia was modeled by transient sFlt1 expression in pregnant mice. Two months post-partum, mice were exposed to high salt and then to AngII (angiotensin II) and BP and vasoconstriction were measured. RESULTS Women exposed to preeclampsia had significantly enhanced salt sensitivity of BP verses those with a normotensive pregnancy. sFlt1 overexpression during pregnancy in mice induced elevated BP and glomerular endotheliosis, which resolved post-partum. The sFlt1 exposed post-partum mice had significantly increased BP response to 4% salt diet and to AngII infusion. In vitro, SMC-MR transcriptional activity in response to aldosterone or AngII was significantly increased after transient exposure to sFlt1 as was aldosterone-induced expression of AngII type 1 receptor. Post-partum, SMC-MR-KO mice were protected from the enhanced response to hypertensive stimuli after preeclampsia. Mechanistically, preeclampsia mice exposed to postpartum hypertensive stimuli develop enhanced aortic stiffness, microvascular myogenic tone, AngII constriction, and AngII type 1 receptor expression, all of which were prevented in SMC-MR-KO littermates. CONCLUSIONS These data support that sFlt1-induced vascular injury during preeclampsia produces a persistent state of enhanced sensitivity of SMC-MR to activation. This contributes to postpartum hypertension in response to common stresses and supports testing of MR antagonism to mitigate the increased cardiovascular risk in women after PE.
Collapse
Affiliation(s)
- Lauren A. Biwer
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
| | - Qing Lu
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
| | - Jaime Ibarrola
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
| | - Alec Stepanian
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston MA
| | - Joshua J. Man
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston MA
| | - Brigett V. Carvajal
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston MA
| | - Nicholas D. Camarda
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston MA
| | | | | | - Ellen W. Seely
- Division of Endocrinology, Brigham and Women’s Hospital, Boston MA
| | - S. Ananth Karumanchi
- Department of Medicine, Beth Israel Deaconess Hospital, Boston MA
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles CA
| | - Iris Z. Jaffe
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston MA
| |
Collapse
|