Association of Low Maternal Pregnancy-associated Plasma Protein A with Adverse Perinatal Outcome

Clinical value of prenatal screening markers in early pregnancy combined with perinatal characteristics to predict fetal growth restriction

Background

Due to the incomplete standardization of the etiology and diagnostic criteria for fetal growth restriction (FGR), there has been uncertainty in the early prediction of FGR. The comprehensive estimation of FGR was mainly based on various factors, such as maternal characteristics and medical history, nuchal translucency (NT), and serum biochemical markers [pregnancy-associated plasma protein-A (PAPP-A) and free beta human chorionic gonadotropin (free β-hCG)]. Herein, we performed a retrospective cohort study to investigate the correlation and diagnostic value of maternal markers such as PAPP-A, free β-hCG, and NT in the first trimester with maternal characteristics, so as to provide theoretical basis for perinatal care and the application of low-dose aspirin.

Methods

A retrospective cohort study was conducted to analyze the data of an FGR group and a non-FGR group. Chi-square test and Mann-Whitney U test were used for univariate analysis of qualitative or quantitative data, respectively. Modified Poisson regression calculated the relative risk (RR) and 95% confidence interval (CI) of perinatal variables; P<0.05 was considered statistically significant.

Results

The multiple of median (MoM) of PAPP-A level and NT in the FGR group were lower than those of the non-FGR group [0.63 (0.12-2.08) vs. 1.01 (0.28-2.41) MoM, 1.30 (0.80-2.07) vs. 1.40 (0.80-2.20) cm, P<0.05]. The weight, score, and length of newborns in the FGR group were lower than those in the non-FGR group (all P<0.001). Modified Poisson regression analysis showed that gestational hypertension (GH) [RR =1.836 (95% CI: 1.188-2.836)], oligohydramnios [1.420 (95% CI: 1.022-1.973)], premature rupture of membranes (PROM) [0.641 (95% CI: 0.425-0.969)], female infant [1.539 (95% CI: 1.098-2.157)], low infant length [5.700 (95% CI: 3.416-9.509)], low birth weight [1.609 (95% CI: 1.012-2.559), and increased PAPP-A MoM [0.533 (95% CI: 0.369-0.769)] were associated with FGR. The cut-off value of PAPP-A + free β-hCG + NT for predicting FGR was 0.190, with a sensitivity of 0.547 and a specificity of 0.778.

Conclusions

Early screening markers combined with perinatal characteristics have better diagnostic value in predicting FGR and provide a scientific basis for the clinical use of low-dose aspirin to prevent FGR.

The role of pregnancy associated plasma protein-A in triple negative breast cancer: a promising target for achieving clinical benefits

Pregnancy associated plasma protein-A (PAPP-A) plays an integral role in breast cancer (BC), especially triple negative breast cancer (TNBC). This subtype accounts for the most aggressive BC, possesses high tumor heterogeneity, is least responsive to standard treatments and has the poorest clinical outcomes. There is a critical need to address the lack of effective targeted therapeutic options available. PAPP-A is a protein that is highly elevated during pregnancy. Frequently, higher PAPP-A expression is detected in tumors than in healthy tissues. The increase in expression coincides with increased rates of aggressive cancers. In BC, PAPP-A has been demonstrated to play a role in tumor initiation, progression, metastasis including epithelial-mesenchymal transition (EMT), as well as acting as a biomarker for predicting patient outcomes. In this review, we present the role of PAPP-A, with specific focus on TNBC. The structure and function of PAPP-A, belonging to the pappalysin subfamily, and its proteolytic activity are assessed. We highlight the link of BC and PAPP-A with respect to the IGFBP/IGF axis, EMT, the window of susceptibility and the impact of pregnancy. Importantly, the relevance of PAPP-A as a TNBC clinical marker is reviewed and its influence on immune-related pathways are explored. The relationship and mechanisms involving PAPP-A reveal the potential for more treatment options that can lead to successful immunotherapeutic targets and the ability to assist with better predicting clinical outcomes in TNBC.

Importance of Low Pregnancy Associated Plasma Protein-A (PAPP-A) Levels During the First Trimester as a Predicting Factor for Adverse Pregnancy Outcomes: A Prospective Cohort Study of 2636 Pregnant Women

OBJECTIVES

The aim of this study is to investigate the predictive value of low levels of pregnancy associated plasma protein-A (PAPP-A) during the first trimester on adverse pregnancy outcomes, namely pregnancy induced hypertension (PIH), preeclampsia (PE), intrauterine growth restriction (IUGR), and fetal loss.

METHODS

This is a prospective cohort study including 2636 women with singleton pregnancies that attended the Prenatal Diagnosis Unit of the First Department of Obstetrics and Gynecology of National and Kapodistrian University of Athens in "Alexandra Hospital" between 2017 and 2019 for the first trimester combined screening routine scan. The study population was divided into two groups according to their PAPP-A levels. The cut-off value of the PAPP-A level was defined as the 0.4 multiple of median (MoM) which is in correspondence with the fifth centile. The women were followed-up prospectively until delivery and the primary outcome measures were the incidence of PIH, PE, IUGR (<10th centile), and fetal loss.  Results: PAPP-A levels of ≤0.4 MoM were associated with increased maternal body mass index (BMI), increased uterine arteries pulsatility index (PI), and lower birth weight. Women with PAPP-A levels ≤0.4 MoM were more likely to develop PE (2.3% vs. 0.2%, p<0.001), PE or PIH (2.3% vs. 0.4%, p=0.003), IUGR (2.3% vs. 0.4%, p=0.003), and combined adverse outcome (25.5% vs. 1.9%, p<0.001) compared to women with PAPP-A>0.4 MoM.

CONCLUSIONS

This study confirms that among women with PAPP-A levels ≤0.4 MoM in the first trimester, there are increased odds for PE or PIH, IUGR, and combined composite pregnancy outcome.

PAPPA Expression in Indeterminate Thyroid Nodules as Screening Test to Select Patients for Molecular Testing

Pregnancy-associated plasma protein A (PAPPA) acts as an oncogene, and its expression is increased in multiple malignancies, including thyroid cancer. Molecular tests represent a useful tool in the management of indeterminate thyroid nodules; however, they are not conducted in all centers, and they contribute to increase the per-patient cost of nodule evaluation. In this study, we examined whether PAPPA expression could represent a promising new screening test in the management of indeterminate thyroid nodules. Toward this aim, PAPPA expression was evaluated in 107 fine needle aspiration cytologies (FNAC) belonging to Bethesda III–IV categories that had been sent to molecular biology to discriminate the nature of the nodules. We found that the PAPPA expression increased and showed an elevated sensitivity (97.14%) and negative predictive value (98%) in indeterminate cytological samples positive for mutations. The enhanced expression was not linked to a specific oncogene. Our findings demonstrated that assessing the PAPPA expression in indeterminate thyroid cytologies could represent a useful screening tool to select all patients that effectively need to be sent to molecular testing, thereby, leading to a potential cost reduction in the management of patients.

The Pivotal Role of the Placenta in Normal and Pathological Pregnancies: A Focus on Preeclampsia, Fetal Growth Restriction, and Maternal Chronic Venous Disease

The placenta is a central structure in pregnancy and has pleiotropic functions. This organ grows incredibly rapidly during this period, acting as a mastermind behind different fetal and maternal processes. The relevance of the placenta extends far beyond the pregnancy, being crucial for fetal programming before birth. Having integrative knowledge of this maternofetal structure helps significantly in understanding the development of pregnancy either in a proper or pathophysiological context. Thus, the aim of this review is to summarize the main features of the placenta, with a special focus on its early development, cytoarchitecture, immunology, and functions in non-pathological conditions. In contraposition, the role of the placenta is examined in preeclampsia, a worrisome hypertensive disorder of pregnancy, in order to describe the pathophysiological implications of the placenta in this disease. Likewise, dysfunction of the placenta in fetal growth restriction, a major consequence of preeclampsia, is also discussed, emphasizing the potential clinical strategies derived. Finally, the emerging role of the placenta in maternal chronic venous disease either as a causative agent or as a consequence of the disease is equally treated.

The expression of pregnancy-associated plasma protein-A (PAPP-A) in human blastocoel fluid-conditioned media: a proof of concept study

Purpose

The aim of this study was to determine if pregnancy-associated plasma protein-A (PAPP-A), typically measured in maternal serum and a potential predictor of adverse maternal and fetal outcomes such as spontaneous miscarriage, pre-eclampsia, and stillbirth, is expressed in blastocoel fluid–conditioned media (BFCM) at the embryonic blastocyst stage.

Design

This is an in vitro study.

Methods

BFCM samples from trophectoderm-tested euploid blastocysts (n = 80) from in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) patients were analyzed for PAPP-A mRNA. BFCM was obtained from blastocyst stage embryos in 20 uL drops. Blastocysts underwent trophectoderm biopsy for preimplantation genetic testing for aneuploidy prior to blastocyst vitrification and BFCM collection for snap freezing. cfDNA was synthesized using BFCM collected from 80 individual euploid blastocysts. Next, real-time qPCR was performed to detect expression of PAPP-A with GAPDH for normalization of expression in each sample.

Results

PAPP-A mRNA was detected in 45 of 80 BFCM samples (56.3%), with varying levels of expression across samples.

Conclusion

Our study demonstrates the expression of PAPP-A in BFCM. To our knowledge, this is the first study to report detection of PAPP-A mRNA in BFCM. Further studies are required and underway to investigate a greater number of BFCM samples as well as the possible correlation of PAPP-A expression with pregnancy outcomes of transferred euploid blastocysts. If found to predict IVF and obstetric outcomes, PAPP-A may provide additional information along with embryonic euploidy for the selection of the optimal blastocyst for embryo transfer.

A survey to assess the incidence of Down syndrome risk in rural southwestern Romania

Despite the significant evolution in recent years in the medical field, many fetal conditions that can be detected in the early stages, remain a social and economic burden due to a lack of diagnostic and treatment programs. The main objective of the present study was to realize a screening program related to the early detection of Down syndrome, by analyzing biochemical and imaging markers, in women from the rural areas of Southwest Romania. Accordingly, data from 269 pregnant women were taken into evaluation for maternal age, maternal weight, smoking and diabetic statuses, along with ultrasound measurements that were performed to establish fetal nuchal translucency (FNT) and biochemical analysis of free β-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein (PAPP-A). Patients at high risk for trisomy 21 (≥1:250) were counseled and the optimal protocol was established for each case. Of the 269 patients studied, 5.6% were included in the risk group based on β-hCG-associated MoM (multiple median approaches) analysis, sonographic measurements and maternal age correlation. Specifically, 60% of patients at risk presented a β-hCG MoM value >1.5 and 20% of patients at risk presented a value ≤0.5 for PAPP-A MoM, and the average maternal age was 33. Measurement of FNT and serum markers, together with associated MoM intervals, was not sufficient to establish the diagnosis of trisomy 21 and to make a risk group inclusion. In summary, the association between sonographic measurements and serum marker values, together with maternal age, are predetermined and indispensable conditions for the most accurate classification in a high-risk group.

Predictive value of PAPP-A for ectopic pregnancy and analysis of related factors

The present study was designed to analyze the expression of pregnancy-associated plasma protein-A (PAPP-A) in the serum of patients with ectopic pregnancy (EP) and related factors inducing this condition. Seventy-five patients with EP admitted to the Affiliated Hospital of Jining Medical University from January 2018 to February 2019 were selected as the research group, and another 59 healthy pregnant women of the corresponding age, gravidity and gestational week were enrolled in the control group. ELISA was employed to detect the serum expression levels of PAPP-A and inflammatory factors such as interleukin-8 (IL-8) and tumor necrosis factor-α (TNF-α). ROC was adopted to evaluate the diagnostic value of serum PAPP-A in patients with EP, and Pearson correlation coefficient was applied to analyze the correlation of PAPP-A with inflammatory factors IL-8 and TNF-α. Serum PAPP-A expression was significantly lower in EP patients than those in the control group. The area under the curve (AUC) of serum PAPP-A in diagnosing EP patients was 0.812, and the PAPP-A value in the control group was significantly higher than that of the research group at 7-8 weeks and ≥9 weeks. With regard to the expression of inflammatory factors, the research group presented markedly higher IL-8 and TNF-α levels than the control group. PAPP-A was negatively related to inflammatory factors IL-8 and TNF-α in the research group. In addition, it was revealed that patients with a history of genital surgery, salpingotomy, pelvic infection, EP or low PAPP-A expression were at high risk of EP. In conclusion, PAPP-A was revealed to be lowly expressed in the serum of EP patients, and to negatively be correlated with inflammatory factors IL-8 and TNF-α, which may serve as a useful marker for the diagnosis and prognosis of EP.

Evaluation of Maternal Reproductive Outcomes and Biochemical Analysis from Wistar Audiogenic Rats (WAR) and Repercussions in Their Offspring

The objective of the present study was to evaluate maternal reproductive performance, body weight, and frequency of external and internal anomalies of newborns of Wistar Audiogenic Rat (WAR) females as compared with Wistar rats. The adult WAR and Wistar rats were mated within their respective strains. After confirming the pregnancy, the body weights were weekly evaluated. On day 21 of pregnancy, the female rats were anesthetized and sacrificed to evaluate the maternal reproductive outcomes and biochemical profile, newborn weight, and external and internal anomalies. The WAR strain gained less weight during the pregnancy and presented hyperproteinemia, hypertriglyceridemia, and embryonic losses concerning Wistar rats, suggesting an inadequate intrauterine condition for embryonic development and fetal viability. WAR also presented a higher percentage of newborns classified as small for gestational age related to intrauterine growth restriction, which was confirmed by the lower number of ossification centers. There was a higher percentage of skeletal anomalies compared with fetuses of the Wistar dams, confirming their greater susceptibility during the formation and development of their skeletal system. Thus, the WAR presents physiological alterations compromising the viability of their embryos and fetuses, leading to impaired development of the newborns.