Association between aneuploidy screening analytes and adverse outcomes in twin gestations

OBJECTIVES

To evaluate associations between serum analytes used for genetic screening and obstetric complications among twin pregnancies.

METHODS

This cohort included twins delivered at a tertiary care hospital from 2009 to 2017. Abnormal levels of pregnancy associated plasma protein (PAPP-A), first and second trimester human chorionic gonadotropin (hCG), alpha fetoprotein (AFP), estriol, and inhibin, reported as multiples of the median (MoM), were defined as <5 %ile or >95 %ile for our cohort. Associations between abnormal analytes and preterm delivery, small for gestational age, and pregnancy-associated hypertension were calculated using Fisher's exact test.

RESULTS

A total of 357 dichorionic/diamniotic and 123 monochorionic/diamniotic twins were included. Among dichorionic/diamniotic twins, elevated AFP (>3.70 MoM) was associated with increased preterm delivery <34 weeks (44.4 vs. 16.5 %, p=0.007), while elevated inhibin (>4.95 MoM) was associated with increased preterm delivery<37 weeks (94.1 vs. 58.8 %, p=0.004). For monochorionic/diamniotic twins, elevated inhibin (>6.34 MoM) was associated increased preterm delivery <34 weeks (66.7 vs. 24.8 %, p=0.04) and hypertension (66.7 vs. 21.4 %, p=0.03).

CONCLUSIONS

Selected abnormal analyte levels were associated with increased rates of adverse outcomes in twin pregnancies, which differed by chorionicity. Our findings assist providers in interpreting abnormal analyte levels in twin pregnancies and may help to identify those at increased risk for adverse outcomes.

Reconsidering the use of race adjustments in maternal serum screening

The use of race in maternal serum screening is problematic because race is a social construct rather than a distinct biological classifier. Nevertheless, laboratories offering this testing are encouraged to use race-specific cutoff values for maternal serum screening biomarkers to determine the risk of fetal abnormalities. Large cohort studies examining racial differences in maternal serum screening biomarker concentrations have yielded conflicting results, which we postulate may be explained by genetic and socioeconomic differences between racial cohorts in different studies. We recommend that the use of race in maternal serum screening should be abandoned. Further research is needed to identify socioeconomic and environmental factors that contribute to differences in maternal serum screening biomarker concentrations observed between races. A better understanding of these factors may facilitate accurate race-agnostic risk estimates for aneuploidy and neural tube defects.

The Impact of Maternal Predisposing Factors on Level of Maternal Serum Pregnancy-Associated Plasma Protein A and Free Subunit Human Chorionic Gonadotropin and Nuchal Translucency

Background

This study aimed to investigate the relationship between maternal predisposing factors with the level of maternal serum pregnancy-associated plasma protein A and free subunit human chorionic gonadotropin and nuchal translucency.

Materials and Methods

We performed a cross-sectional-analytical study on 762 pregnant women who referred to the Gene Azma Medical Genetics Laboratory in Isfahan for amniocentesis. All pregnant women at high risk of screening in the first trimester of pregnancy for trisomy 21 and other aneuploidy were referred to a gynecologist for amniotic fluid sampling (amniocentesis). Multiple of the means (MoM) of PAPPA ≤0.5, 0.5 ≥ MoM free β-hCG >2.5, and NT ≥3.5 mm were considered abnormal. We used Chi-square method and Mann-Whitney U-test to compare data qualitative and quantitative, respectively.

Results

In individuals with less pregnancies and deliveries, the value of abnormal NT was higher (P < 0.01, P < 0.001, respectively). On the other hand, the highest abnormal rate of NT was observed in pregnant women under 35 years (21, 84%, P < 0.012). In addition, abnormal levels of free β-hCG are more common in women < 35 years of age (186, 66.9%, P < 0.02) and female fetuses (171, 58.8%) (P < 0.006).

Conclusion

According to the results of this study, it can be said that considering the underlying factors of pregnant mothers in performing tests related to screening in the first trimester of pregnancy can lead to a reduction in false positive rates.

Correlations between maternal hepatitis B virus carrier status and Down's syndrome prenatal screening indicators and their effects on the screening results

The aim of this study was to determine the correlation between maternal hepatitis B virus (HBV) carrier status and pregnancy-associated serum screening indicators, as well as their implications on the prenatal screening results of Down's syndrome (DS). This retrospective cohort study included two groups, namely the healthy gravidas group (n = 19804) and the maternal HBV carrier group (n = 792). Serum pregnancy-associated plasma protein A (PAPP-A), alpha-fetoprotein (AFP), and free beta subunit of human chorionic gonadotropin (free β-hCG) levels, as well as the foetal nuchal translucency (NT) thickness, were measured. Multivariatebinary logistic regression analysis was used to evaluate the association between the HBV carrier status and prenatal screening biomarkers. The PAPP-A multiple of the medium (MoM) and free β-hCG MoM in the first trimester were significantly higher in the HBV carrier group than in the control group (both P < .05). Multivariate binary logistic regression analysis showed that HBV carrier status was identified as a risk factor for PAPP-A and the intrahepatic cholestasis of pregnancy (ICP), with adjusted odds ratios (aOR) of 1.363 (1.216-1.527) and 3.255 (2.356-4.499), respectively. Pregnant women with HBV carrier status had higher influence on serum PAPP-A level and ICP, and the risk calculation algorithm for DS in HBV carriers should be corrected in the first trimester of pregnancy. IMPACT STATEMENTWhat is already known on this subject? The maternal serum levels of pregnancy-associated plasma protein A (PAPP-A), alpha-fetoprotein (AFP), and free beta subunit of human chorionic gonadotropin (free β-hCG), as well as the foetal nuchal translucency (NT) thickness, have been collectively used in the prenatal screening of Down's syndrome (DS), Edward's syndrome (ES), and open neural tube defects (ONTD). However, many factors, including the maternal age; maternal weight; gestational age; race; history of smoking and so on can affect those serum biomarker levels. Our aim is to know whether there is a difference for HBV status to pregnancy-associated serum screening indicators hoes.What the results of this study add? The PAPP-A multiple of the medium (MoM) and free β-hCG MoM in the first trimester were significantly higher in the HBV carrier group than in the control group (both p < .05). Multivariate binary logistic regression analysis showed that the PAPP-A and intrahepatic cholestasis of pregnancy (ICP) were risk factors for HBV carriers, with aORs of 1.363 (1.216-1.527) and 3.255 (2.356-4.499), respectively.What the implications are of these findings for clinical practice and/or further research? The PAPP-A MoM in maternal HBV carriers was significantly higher than that in healthy gravidas, and the risk calculation algorithm for DS in maternal HBV carriers should be corrected in the first trimester of pregnancy.

Placental protein levels in maternal serum are associated with adverse pregnancy outcomes in nulliparous patients

BACKGROUND

The Eunice Kennedy Shriver National Institute of Child Health and Human Development Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be was established to investigate the underlying causes and pathophysiological pathways associated with adverse pregnancy outcomes in nulliparous gravidas.

OBJECTIVE

This study aimed to study placental physiology and identify novel biomarkers concerning adverse pregnancy outcomes, including preterm birth (medically indicated and spontaneous), preeclampsia, small-for-gestational-age neonates, and stillbirth. We measured levels of placental proteins in the maternal circulation in the first 2 trimesters of pregnancy.

STUDY DESIGN

Maternal serum samples were collected at 2 study visits (6-13 weeks and 16-21 weeks), and levels of 9 analytes were measured. The analytes we measured were vascular endothelial growth factor, placental growth factor, endoglin, soluble fms-like tyrosine kinase-1, A disintegrin and metalloproteinase domain-containing protein 12, pregnancy-associated plasma protein A, free beta-human chorionic gonadotropin, inhibin A, and alpha-fetoprotein. The primary outcome was preterm birth between 20 0/7 and 36 6/7 weeks of gestation. The secondary outcomes were spontaneous preterm births, medically indicated preterm births, preeclampsia, small-for-gestational-age neonates, and stillbirth.

RESULTS

A total of 10,038 eligible gravidas were enrolled in the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be cohort, from which a nested case-control study was performed comparing 800 cases with preterm birth (466 spontaneous preterm births, 330 medically indicated preterm births, and 4 unclassified preterm births), 568 with preeclampsia, 406 with small-for-gestational-age birth, and 49 with stillbirth with 911 controls who delivered at term without complications. Although levels of each analyte generally differed between cases and controls at 1 or 2 visits, the odds ratios revealed a <2-fold difference between cases and controls in all comparisons. Receiver operating characteristic curves, generated to determine the relationship between analyte levels and preterm birth and the other adverse pregnancy outcomes, resulted in areas under the receiver operating characteristic curves that were relatively low (range, 0.50-0.64) for each analyte. Logistic regression modeling demonstrated that areas under the receiver operating characteristic curves for predicting adverse pregnancy outcomes were greater using baseline clinical characteristics and combinations of analytes than baseline characteristics alone, but areas under the receiver operating characteristic curves remained relatively low for each outcome (range, 0.65-0.78).

CONCLUSION

We have found significant associations between maternal serum levels of analytes evaluated early in pregnancy and subsequent adverse pregnancy outcomes in nulliparous gravidas. However, the test characteristics for these analytes do not support their use as clinical biomarkers to predict adverse pregnancy outcomes, either alone or in combination with maternal clinical characteristics.

Quantitative and qualitative Ductus Venosus blood flow evaluation in the screening for Trisomy 18 and 13 - suitability study

OBJECTIVES

The objective of the paper is the suitability assessment of screening for Trisomy 18 and 13 on the basis of nuchal translucency (NT) measurement, Fetal Heart Rate (FHR), double test, quantitative [Ductus Venosus (DV) Pulsatility Index for Veins (PIV)] and qualitative (the A-wave assessment) blood flow evaluation in the DV.

MATERIAL AND METHODS

The study was performed in 7296 singleton pregnancies. In each fetus NT, FHR, DV-PIV were examined. Double test from maternal blood was examined. These ultrasound and biochemical factors were in combined screening investigated. Additional doppler ultrasound markers such as abnormal a-wave in Ductus Venosus and Pusatility Index for Veins of Ductus Venosus were and their impact on Trisomies 18 and 13 screening were examined.

RESULTS

Two groups of patients were compared - with chromosomal normal and chromosomal abnormalities - Trisomy 18 and 13. Detection Rate of Trisomies 18 and 13 at the risk cutoff 1/300 using combined screening was 90.2% and FPR was 6%. Detection Rates of examined chromosomal abnormalities using contingent screening were: 92.1% using DV abnormal a-wave and 94.84% using DV-PIV. FPR's for booths parameters 5.8% and 5.4% respectively.

CONCLUSIONS

Quantitative analysis of the flow - assessment of DV-PIV in the first trimester significantly influences the improvement of screening values focusing on Trisomy 18 and 13 detection.

Quality control of ultrasonography markers for Down's syndrome screening: a retrospective study by the laboratory

OBJECTIVES

Quality control of ultrasonography markers is necessary to ensure greater efficacy of prenatal aneuploidy screening. The aim of this study was to assess the quality of the crown-rump length (CRL) and nuchal translucence (NT) measurement accuracy by the laboratory according to quality indicators.

METHODS

Retrospective observational study on 4,908 single-foetus pregnant women who underwent prenatal aneuploidy screening in the first trimester of pregnancy. Euploid foetuses with CRL between 45 and 84 mm were included, while those with NT≥3.5 mm were excluded. CRL measurement was considered to be accurate if the median multiples of the median (MoM) for pregnancy-associated plasma protein A (PAPP-A) was between 0.90 and 1.10. Fifteen sonographers participated in the study, six of whom comprised the control group. Systematic error for a sonographer was considered when CRL measurement was greater than ±2 mm with respect to the control group. Quality for NT was assured by means of the WHIRI method and each sonographer cumulative sum control chart (CUSUM).

RESULTS

For CRL accuracy, five sonographers underestimated the measurements, while another four overestimated them, with no statistical differences. For smaller sized foetuses, all sonographers met the established specifications. Regarding NT control, three sonographers did not meet the quality criteria for the median MoM. All sonographers met the specifications for the logarithmic standard deviation of the NT MoM levels. Thirteen sonographers met the CUSUM specifications.

CONCLUSIONS

Evaluation of a quality control of ultrasonography parameters by laboratory professionals is necessary to avoid under- or overestimation tendencies for CRL and NT measurements. CUSUM is a useful tool for the immediate correction of errors in NT measurements.

PAPP-A functions as a tumor suppressor and is downregulated in renal cell carcinoma

Pregnancy‐associated plasma protein A (PAPP‐A) is a proteolytic enzyme produced by the placenta. The expression and role of PAPP‐A in renal cell carcinoma (RCC) remain elusive. The aim of this study was to investigate the role and the molecular mechanisms of PAPP‐A in RCC. Initially, we evaluated the expression of PAPP‐A in samples from patients with RCC and cell lines by quantitative PCR, western blot and immunohistochemical staining, and examined the role of PAPP‐A in RCC cells by cell viability, colony formation and Transwell assays. Next, we investigated the molecular mechanisms regulating the tumor suppressor function of PAPP‐A. Our results demonstrated that PAPP‐A is expressed at low levels in RCC tissues and cells. Clinical data analysis revealed a significant correlation between PAPP‐A expression and RCC‐related death (P < 0.0115). Overexpression of PAPP‐A inhibited viability, proliferation, migration and invasion of RCC cells. Furthermore, PAPP‐A overexpression significantly increased phosphorylation of c‐Jun N‐terminal kinase and decreased the expression of cyclin D1, phosphorylated glycogen synthase kinase‐3β and β‐catenin. This study is the first to report that downregulation of PAPP‐A is associated with poor prognosis in patients with RCC. In conclusion, PAPP‐A may serve as a novel prognostic marker and potentially as a therapeutic target in patients with RCC.

Longitudinal changes in maternal left atrial volume index and uterine artery pulsatility indices in uncomplicated pregnancy

BACKGROUND

Data on the relationship between longitudinal changes in maternal volume-dependent echocardiographic parameters and placentation in uncomplicated pregnancy are limited.

OBJECTIVE

This study aimed to evaluate changes in volume-dependent echocardiographic parameters in uncomplicated pregnancy to test the hypothesis of the existence of an association between volume-dependent echocardiographic parameters and Doppler ultrasound parameters of fetal circulation and the uterine artery in uncomplicated pregnancy and to establish which of the volume-dependent echocardiographic parameters best depicts volume changes and correlates best with Doppler ultrasound of fetal circulation and the uterine artery in healthy pregnancy.

STUDY DESIGN

Data from 60 healthy pregnant women were analyzed. A complete echocardiographic study was performed at 11 to 13, 20 to 22, and 30 to 32 weeks' gestation: left ventricular end-diastolic volume, early diastolic peak flow velocity, late diastolic peak flow velocity, left atrial area, and left atrial volume index were assessed. Obstetrical assessment was performed including fetal growth and uterine artery pulsatility index. Fetal well-being was assessed by umbilical and middle cerebral artery blood flow. Serum pregnancy-associated plasma protein A and free β-human chorionic gonadotropin were assessed during the routine first-trimester scan (11-13 weeks' gestation).

RESULTS

Left ventricular end-diastolic volume and left atrial area increased significantly between 11 to 13 and 20 to 22 weeks' gestation but not between 20 to 22 and 30 to 32 weeks' gestation. Left atrial volume index measured at 30 to 32 weeks' gestation correlated with uterine artery pulsatility indices in 3 trimesters. Changes in the left atrial volume index between the third and first trimesters correlated significantly with the uterine artery pulsatility index measured at 20 to 22 weeks' gestation (r=-0.345; P=.020) and at 30 to 32 weeks' gestation (r=-0.452; P=.002). Changes in the left atrial volume index between the second and first trimesters significantly correlated with the uterine artery pulsatility index measured in the first trimester (r=-0.316; P=.025).

CONCLUSION

Our study showed that in an uncomplicated pregnancy, among volume-dependent echocardiographic parameters, left atrial volume index increased between both the first and second trimesters and the second and third trimesters and correlated with parameters of Doppler ultrasound of the fetal circulation and the uterine artery. Our results expand on the previous observation on the relationship between maternal cardiovascular adaptation and placentation in women with heart diseases to the population of healthy women with uncomplicated pregnancy.

Marginal placental cord insertion: the need for follow up?

Objective: The objectives of this study were (1) to estimate the association between marginal placental cord insertion (PCI) and small for gestational age (SGA) and other adverse perinatal outcomes and (2) to determine if pregnancy-associated plasma protein A (PAPP-A) levels was altered in these patients.Methods: It was a retrospective cohort study of singleton pregnancies undergoing ultrasound between 2016 and 2018. Marginal PCI was defined as a distance of ≤2 cm from placental edge to PCI site, visualized in both sagittal and transverse planes, and diagnosed between 16 and 32 weeks. Velamentous PCI were excluded. The primary outcome was SGA, defined as birthweight below 10th percentile for gestational age. Pregnancies with marginal PCI were compared to those with normal PCI with respect to maternal characteristics, PAPP-A levels and adverse perinatal and delivery outcomes.Results: The incidence of marginal PCI was 4.2% (76/1819). Compared to those with a normal PCI, patients with a marginal PCI were more likely to be nulliparous and less likely to be African American or morbidly obese (p < .05). SGA rate was similar between the groups (17.6% vs. 18.1%). There was a trend toward an increased incidence of oligohydramnios, polyhydramnios and breech presentation in patients with marginal PCI; however, these did not reach statistical significance. The incidence of low PAPP-A level was comparable between the groups (18.4% vs. 14.3%, p > .05).Conclusion: Our study did not demonstrate any increase in adverse pregnancy outcomes in the presence of marginal PCI. These findings may provide reassurance for counseling patients with this sonographic finding.

Pregnancy-associated plasma protein A as a predictor of all-cause mortality and cardiovascular events in patients with chronic kidney disease: a meta-analysis of prospective studies

INTRODUCTION

The aim of the study was to assess the association of elevated serum pregnancy associated plasma protein A (PAPP-A) and the risk of all-cause mortality, cardiovascular events and mortality due to infection in patients with chronic kidney disease (CKD).

MATERIAL AND METHODS

We systematically searched the Medline database up to March 2017. A random effects model was used to pool the relative risks (RRs) and their 95% confidence intervals (CIs). Sensitivity analysis and subgroup analysis were performed to explore the potential sources of heterogeneity.

RESULTS

Six studies involving 2034 subjects were included. The pooled RRs for the risk of all-cause mortality and cardiovascular events were 1.50 (95% CI: 1.17-1.92), 1.26 (95% CI: 0.95-1.69), respectively. Sensitivity analysis by excluding each individual study showed no influence on the main results. Subgroup analysis showed that age, male proportion, follow-up term, and assay methods were not modifiable factors.

CONCLUSIONS

Our study suggests that elevated serum PAPP-A is associated with the risk of all-cause mortality in patients with CKD.

Association of pregnancy-associated plasma protein A and vascular endothelial growth factor with pregnancy-induced hypertension

The present study aimed to evaluate changes of pregnancy-associated plasma protein A (PAPP-A) and vascular endothelial growth factor (VEGF) in pregnancy-induced hypertension (PIH). A total of 105 cases (observation group) with complete data that underwent delivery and suffered from PIH in The Affiliated Hospital of Xuzhou Medical University from February 2015 to February 2017 were retrospectively analyzed. The observation group was further divided into the mild observation and severe observation groups according to severity degree of the disease. Another 65 asymptomatic pregnant women were recruited as the healthy control group. Basic data, obstetric data, PAPP-A and VEGF and data of perinatal infants were compared and analyzed. The Logistic regression model was adopted to screen out risk factors for PIH. In the observation group, the rate of periodic antenatal care was lower, and there were more primigravidas and housewives, with lower education level and economic income (P<0.05). In the observation group, the occurrence rates of placental abruption as well as turbid and bloody amniotic fluid were higher than those in the healthy control group (P<0.05). The neonatal birth weight was lower in the observation group than that in the healthy control group, while the occurrence rates of neonatal department transfer, small for gestational age (SGA), neonatal asphyxia and survival rates of perinatal infants were higher (P<0.05). PAPP-A levels at 34–40 gestational weeks in the observation group were significantly higher than those in the healthy control group (P<0.05). VEGF levels were lower than those in the healthy control group (P<0.05). Multivariate analysis revealed that high PAPP-A value [odds ratio (OR)=3.736] and identity of housewife (OR=2.514) were risk factors for PIH, while high VEGF value (OR=5.258), non-primigravid (OR=2.173), higher economic income (OR=4.162) and periodic antenatal care (OR=1.201) were regarded as protective factors. Therefore, enhancement of gestational management, early discovery and early treatment are critical for improving the prognosis of pregnant women and infants.

Prediction of large-for-gestational-age infants in pregnancies complicated by obesity: A population-based cohort study

INTRODUCTION

Infants born large for gestational age (LGA) have increased risks of adverse perinatal outcomes. Maternal obesity, defined as body mass index (BMI) ≥30 kg/m² , is one of the most prevalent risk factors for LGA and the proportion of pregnancies complicated by obesity is increasing. Early identification of women with BMI ≥30 kg/m² at increased risk of giving birth to an LGA infant may open possibilities for prevention, aiming at decreasing the incidence of LGA.

MATERIAL AND METHODS

A population-based cohort study using information from the first-trimester screening database, which was cross-linked with the Swedish Medical Birth Register. The database included 139 277 full-term singletons without fetal anomalies born between 2006 and 2015 to mothers without prepregnancy diabetes. Of these, 9.1% (n = 12 704) were infants of mothers with BMI ≥30 kg/m² . For all women with BMI ≥30 kg/m² , a prediction model for LGA to be used in early pregnancy was constructed based on information on biochemical markers and maternal characteristics. A similar model, as well as a prepregnancy prediction model, were constructed for parous women with BMI ≥30 kg/m² . In parous women, data from the previous pregnancy were also used. Receiver operating characteristic curve and area under curve (AUC) were calculated.

RESULTS

The predictive models for LGA in parous women with BMI ≥30 kg/m² prepregnancy and in early pregnancy had AUCs of 0.80 (95% CI 0.78-0.82) and 0.81 (95% CI 0.79-0.82), respectively. For all women with BMI ≥30 kg/m² , the prediction of LGA in early pregnancy had an AUC of 0.66 (95% CI 0.64-0.67).

CONCLUSIONS

Performance of the prepregnancy and early pregnancy prediction models for LGA in parous women with BMI ≥30 kg/m² was good. The predictive capacity was largely driven by previous child's birthweight. First-trimester measurements of fetal size did not improve the predictive capacity in parous women. Predictions of LGA in all women with BMI ≥30 kg/m² in early pregnancy, without taking previous child's birthweight into account, remain difficult.

Relative value of serum pregnancy-associated plasma protein A (PAPP-A) and GRACE score for a 1-year prognostication: A complement to calculation in patients with suspected acute coronary syndrome

BACKGROUND

The Global Registry of Acute Coronary Events (GRACE) study produced a scale for risk stratification in acute coronary syndromes (ACSs). Pregnancy-associated plasma protein A (PAPP-A) serum concentration was implicated as a marker of unstable atherosclerotic plaques.

OBJECTIVES

We hypothesized that the measurement of the concentration of PAPP-A on admission may improve the stratification of cardiovascular risk in suspected ACS patients.

MATERIAL AND METHODS

We studied 70 patients with chest pain suggesting ACS diagnosis on admission. Serum cardiac biomarkers and PAPP-A were measured on top of the standard biochemical panel, and the GRACE risk score was calculated. A 12-month follow-up was completed to major adverse cardiac events (MACE): death, myocardial infarction (MI), need for percutaneous coronary intervention (PCI)/coronary artery bypass grafting (CABG), unplanned cardiovascular hospitalization.

RESULTS

In hospital/6-month GRACE, low risk was found in 35 patients (50%)/37 patients (53%), intermediate risk in 23 patients (33%)/21 patients (30%) and high risk in 12 patients (17%)/12 patients (17%). Mean PAPP-A was 39.64 mlU/L (standard deviation - SD 24.2), and median PAPP-A values for in hospital/6-month GRACE were 21.49 mlU/L (quartile 1st; 3rd - 13.41; 32.65) and 22.61 mlU/L (14.03; 34.1) for low risk patients, 51.76 mlU/L (35.18; 59.99) and 51.76 mlU/L (28.9; 62.1) for intermediate risk patients, and 68.82 mlU/L (58.54; 83.76) for high risk patients. The PAAP-A concentration with specific cut-off points had 66.7% positive predictive value (PPV) and 95.5% negative predictive value (NPV) for death, 33.3% PPV and 80.6% NPV for MI, 71.4% PPV and 57.1% NPV for any event. Intermediate and high in hospital/6-months GRACE had 14.3%/15.2% PPV and 100%/100% NPV for death, 34.3%/33.3% PPV and 94.3%/91.9% NPV for MI, 74.3%/72.7% PPV and 65.7%/62.2% NPV for any event.

CONCLUSIONS

The PAPP-A serum concentration represents a promising prognostic biomarker with significantly improved PPV. The GRACE score is superior to stratification based on PAPP-A with regard to combined cut-off point for 1-year mortality.

Pregnancy-associated plasma protein A and mortality in haemodialysis

BACKGROUND

Elevated pregnancy-associated plasma protein A (PAPP-A) levels are associated with increased risk of death in ischaemic heart disease as well as in haemodialysis patients. Previous research indicates that the prognostic value of PAPP-A may be stronger in patients with concomitant diabetes mellitus or signs of inflammation. We studied the association between PAPP-A and outcomes in prevalent haemodialysis patients and hypothesized that diabetes mellitus and inflammation status act as effect modifiers.

MATERIALS AND METHODS

Circulating PAPP-A levels were quantified using ELISA. Cox proportional hazards and quantile regression models were used for associations between PAPP-A and mortality. PAPP-A levels were log-transformed for Normality.

RESULTS

During 60-month follow-up, 37 (40%) of the 92 participants died. Higher PAPP-A was associated with increased risk of mortality in unadjusted analysis (HR per SD = 1.4, 95% CI = 1-1.9, P = .03) and when adjusted for confounders and cardiovascular risk factors (HR = 1.8, 95% CI = 1.18-2.73, P = .006). An interaction between PAPP-A levels and diabetes mellitus on mortality was found (HR for the multiplicative interaction term = 2.74 95% CI = 1.02-7.37, P = .05). In a quantile regression adjusted for age and sex, one SD increase in PAPP-A was associated with 22 months shorter estimated time until 25% of the patients died (95% CI -35 to -9.1 months).

CONCLUSIONS

Increased PAPP-A levels are associated with higher all-cause mortality in prevalent haemodialysis patients with concomitant diabetes mellitus.

Prognostic relevance and performance characteristics of serum IGFBP-2 and PAPP-A in women with breast cancer: a long-term Danish cohort study

Measurement of circulating insulin‐like growth factors (IGFs), in particular IGF‐binding protein (IGFBP)‐2, at the time of diagnosis, is independently prognostic in many cancers, but its clinical performance against other routinely determined prognosticators has not been examined. We measured IGF‐I, IGF‐II, pro‐IGF‐II, IGF bioactivity, IGFBP‐2, ‐3, and pregnancy‐associated plasma protein A (PAPP‐A), an IGFBP regulator, in baseline samples of 301 women with breast cancer treated on four protocols (Odense, Denmark: 1993–1998). We evaluated performance characteristics (expressed as area under the curve, AUC) using Cox regression models to derive hazard ratios (HR) with 95% confidence intervals (CIs) for 10‐year recurrence‐free survival (RFS) and overall survival (OS), and compared those against the clinically used Nottingham Prognostic Index (NPI). We measured the same biomarkers in 531 noncancer individuals to assess multidimensional relationships (MDR), and evaluated additional prognostic models using survival artificial neural network (SANN) and survival support vector machines (SSVM), as these enhance capture of MDRs. For RFS, increasing concentrations of circulating IGFBP‐2 and PAPP‐A were independently prognostic [HR_{biomarker doubling}: 1.474 (95% CIs: 1.160, 1.875, P = 0.002) and 1.952 (95% CIs: 1.364, 2.792, P < 0.001), respectively]. The AUC_RFS for NPI was 0.626 (Cox model), improving to 0.694 (P = 0.012) with the addition of IGFBP‐2 plus PAPP‐A. Derived AUC_RFS using SANN and SSVM did not perform superiorly. Similar patterns were observed for OS. These findings illustrate an important principle in biomarker qualification—measured circulating biomarkers may demonstrate independent prognostication, but this does not necessarily translate into substantial improvement in clinical performance.

Pregnancy-associated plasma protein-A (PAPP-A) levels in patients with severe allergic asthma are reduced by omalizumab

BACKGROUND

Remodeling is a crucial feature of severe asthma and may be associated with activation of the allergic cascade by immunoglobulin E (IgE). Omalizumab, an anti-IgE monoclonal antibody, effectively targets the severe allergic asthma phenotype. Pregnancy-associated plasma protein-A (PAPP-A) is an insulin-like growth factor binding protein-4 (IGFBP-4) protease, increasing local insulin-like growth factor (IGF)-1 concentrations, which in turn initiating a cascade involved in the regulation of cell growth, differentiation, and proliferation in various tissues. In the present study, we evaluated the effects of omalizumab on serum PAPP-A, IGFBP-4, and IGF-1 levels in subjects with severe allergic asthma.

METHODS

We studied 36 asthmatic subjects and 36 healthy controls. An ultrasensitive enzyme-linked immunosorbent assay (ELISA) kit was used to measure serum PAPP-A levels, and routine commercial ELISA kits were employed to assess serum levels of IGF-1, IGFBP-4 in control subjects and asthmatic subjects before therapy (baseline) and after six months of omalizumab therapy in patients with severe asthma.

RESULTS

Compared to control subjects, serum PAPP-A and IGFB-4 levels were significantly higher in asthmatic subjects (both p values < 0.001). However, the serum IGF-I levels of asthmatic subjects were similar to those of control subjects (p > 0.05). In asthma subjects, 6-month omalizumab treatment significantly decreased the serum PAPP-A (p < 0.001), IGF-I (p = 0.031), and IGFB4 (p = 0.025) levels.

CONCLUSION

PAPP-A level may be a useful biomarker for predicting airway remodeling in patients with severe asthma receiving omalizumab, and may also reflect the response to treatment.

Aspirin for Evidence-Based Preeclampsia Prevention trial: influence of compliance on beneficial effect of aspirin in prevention of preterm preeclampsia

BACKGROUND

The Aspirin for Evidence-Based Preeclampsia Prevention trial was a multicenter study in women with singleton pregnancies. Screening was carried out at 11-13 weeks' gestation with an algorithm that combines maternal factors and biomarkers (mean arterial pressure, uterine artery pulsatility index, and maternal serum pregnancy-associated plasma protein A and placental growth factor). Those with an estimated risk for preterm preeclampsia of >1 in 100 were invited to participate in a double-blind trial of aspirin (150 mg/d) vs placebo from 11-14 until 36 weeks' gestation. Preterm preeclampsia with delivery at <37 weeks' gestation, which was the primary outcome, occurred in 1.6% (13/798) participants in the aspirin group, as compared with 4.3% (35/822) in the placebo group (odds ratio in the aspirin group, 0.38; 95% confidence interval, 0.20 to 0.74).

OBJECTIVE

We sought to examine the influence of compliance on the beneficial effect of aspirin in prevention of preterm preeclampsia in the Aspirin for Evidence-Based Preeclampsia Prevention trial.

STUDY DESIGN

This was a secondary analysis of data from the trial. The proportion of prescribed tablets taken was used as an overall measure of compliance. Logistic regression analysis was used to estimate the effect of aspirin on the incidence of preterm preeclampsia according to compliance of <90% and ≥90%, after adjustment for the estimated risk of preterm preeclampsia at screening and the participating center. The choice of cut-off of 90% was based on an exploratory analysis of the treatment effect. Logistic regression analysis was used to investigate predictors of compliance ≥90% among maternal characteristics and medical history.

RESULTS

Preterm preeclampsia occurred in 5/555 (0.9%) participants in the aspirin group with compliance ≥90%, in 8/243 (3.3%) of participants in the aspirin group with compliance <90%, in 22/588 (3.7%) of participants in the placebo group with compliance ≥90%, and in 13/234 (5.6%) of participants in the placebo group with compliance <90%. The odds ratio in the aspirin group for preterm preeclampsia was 0.24 (95% confidence interval, 0.09-0.65) for compliance ≥90% and 0.59 (95% confidence interval, 0.23-1.53) for compliance <90%. Compliance was positively associated with family history of preeclampsia and negatively associated with smoking, maternal age <25 years, Afro-Caribbean and South Asian racial origin, and history of preeclampsia in a previous pregnancy.

CONCLUSION

The beneficial effect of aspirin in the prevention of preterm preeclampsia appears to depend on compliance.

Is there any relationship between low PAPP-A levels and measures of umbilical vein and placental thickness during first trimester of pregnancy?

OBJECTIVE:

Low pregnancy-associated plasma protein A (PAPP-A) level is associated with adverse perinatal outcomes. The purpose of this study was to evaluate relationship between umbilical cord diameter (UCD), umbilical vein and artery diameters (UVD, UAD), placental thickness, and PAPP-A level at gestational age of between 11 and 14 weeks.

METHODS:

UCD, UVD, UAD, and placental thickness of 246 women were assessed during ultrasound examination at between 11 and 14 weeks of gestation, as well as measurement of nuchal translucency (NT) and crown-rump length (CRL). Patients were divided into 2 groups according to PAPP-A percentile. Group 1 comprised 23 patients who had low PAPP-A (<0.44 multiple of medians [MoM], <10^th percentile) and Group 2 was made up of 223 patients with PAPP-A of >0.44 MoM, >10^th percentile. Calipers used for measurement were placed inner edge to inner edge of echogenic boundaries of the vessel. Largest sections of all vessels (UV and both arteries) were evaluated. Thickest part of the placenta was used for placental thickness measurement.

RESULTS:

Narrow UCD (<4.5±0.6 mm) was associated with low PAPP-A level (p=0.02). There was no significant difference in UVD, UAD, or placental thickness between groups. There was no significant difference in gestational age, CRL, or NT between groups. Fetal birth weight was significantly lower in Group 1 (p=0.03).

CONCLUSION:

Closer attention to women with low-risk, healthy pregnancies and low PAPP-A level in first trimester screening results is recommended. They should be routinely screened for background medical risk factors and umbilical cord morphology in first trimester scan.

The maternal plasma proteome changes as a function of gestational age in normal pregnancy: a longitudinal study

OBJECTIVE

Pregnancy is accompanied by dramatic physiological changes in maternal plasma proteins. Characterization of the maternal plasma proteome in normal pregnancy is an essential step for understanding changes to predict pregnancy outcome. The objective of this study was to describe maternal plasma proteins that change in abundance with advancing gestational age and determine biological processes that are perturbed in normal pregnancy.

STUDY DESIGN

A longitudinal study included 43 normal pregnancies that had a term delivery of an infant who was appropriate for gestational age without maternal or neonatal complications. For each pregnancy, 3 to 6 maternal plasma samples (median, 5) were profiled to measure the abundance of 1125 proteins using multiplex assays. Linear mixed-effects models with polynomial splines were used to model protein abundance as a function of gestational age, and the significance of the association was inferred via likelihood ratio tests. Proteins considered to be significantly changed were defined as having the following: (1) >1.5-fold change between 8 and 40 weeks of gestation; and (2) a false discovery rate-adjusted value of P < .1. Gene ontology enrichment analysis was used to identify biological processes overrepresented among the proteins that changed with advancing gestation.

RESULTS

The following results were found: (1) Ten percent (112 of 1125) of the profiled proteins changed in abundance as a function of gestational age; (2) of the 1125 proteins analyzed, glypican-3, sialic acid-binding immunoglobulin-type lectin-6, placental growth factor, C-C motif-28, carbonic anhydrase 6, prolactin, interleukin-1 receptor 4, dual-specificity mitogen-activated protein kinase 4, and pregnancy-associated plasma protein-A had more than a 5-fold change in abundance across gestation (these 9 proteins are known to be involved in a wide range of both physiological and pathological processes, such as growth regulation, embryogenesis, angiogenesis immunoregulation, inflammation etc); and (3) biological processes associated with protein changes in normal pregnancy included defense response, defense response to bacteria, proteolysis, and leukocyte migration (false discovery rate, 10%).

CONCLUSION

The plasma proteome of normal pregnancy demonstrates dramatic changes in both the magnitude of changes and the fraction of the proteins involved. Such information is important to understand the physiology of pregnancy and the development of biomarkers to differentiate normal vs abnormal pregnancy and determine the response to interventions.

A coronary proatherosclerotic marker: Pregnancy-associated plasma protein A and its association with coronary calcium score and carotid intima-media thickness

BACKGROUND

Atherosclerosis, a chronic inflammatory disorder of the arteries, is responsible for the greatest number of deaths in westernized societies, with numbers increasing at a marked rate in developing countries. Coronary calcium score (CCS), carotid intima-media thickness (CIMT) and pregnancy-associated plasma protein A (PAPP-A) are predictors for the development of atherosclerosis.

OBJECTIVES

This study was aimed to investigate the relationship between CCS, CIMT and PAPP-A for earlier diagnosis of atherosclerosis.

MATERIAL AND METHODS

A total of 99 patients were included in the study. Coronary computerized tomography (CT) angiography was performed on all patients. The calcium scoring technique was performed using a sequential scanning mode. CIMT measurement was done through the area 1 cm distal of the bulbus arteriosus with carotid Doppler ultrasound. PAPP-A values were analyzed by double immunoenzymatic technique.

RESULTS

Out of 99 patients, 63 were found with coronary atherosclerosis using multislice computed tomography (MSCT) coronary angiography. When the cut-off point for CCS was taken to be 0.40, the sensitivity of this parameter was 97% and its specificity was 68.3%. When the cut-off point for CIMT was taken to be 0.60, the sensitivity and the specificity of these parameters were 75.0% and 87.3%, respectively, for the right measurements and 75.0% and 79.4%, respectively, for the left measurements.

CONCLUSIONS

This data support the conclusion that PAPP-A, like CCS and CIMT, is a parameter that can be used to detect subclinical atherosclerosis.

Risk of Adverse Outcomes in Euploid Pregnancies With Isolated Short Fetal Femur and Humerus on Second-Trimester Sonography

OBJECTIVES

The purpose of this study was to evaluate pregnancies with isolated short fetal femur and humerus on second-trimester sonography. Short fetal long bones are known to be associated with aneuploidy and structural anomalies. In this study, we wanted to show the risk of adverse pregnancy outcomes in euploid and nonanomalous pregnancies.

METHODS

Singleton pregnancies with short femur and humerus were included. Pregnancies with normal fetal bone lengths and age-matched mothers were selected as controls.

RESULTS

The study group included 30 pregnancies with short fetal femur and humerus, and the control group included 60 normal pregnancies. The overall odds ratio for an adverse pregnancy outcome in the study group was 24.9. Preterm delivery occurred significantly more frequently (odds ratio, 20.8; P < .001), and one-third of pregnancies were complicated by preeclampsia. In the group with short long bones, the odds ratio for a pathologic umbilical Doppler flow pattern was 45.2 (P < .001), and birth weight was significantly lower (P < .001). Also, 3 (10.3%) stillbirths and 4 (13.3%) cases of early neonatal death were recorded in this group. These complications were not recorded in the control group. The risk of emergency cesarean delivery was significantly higher in the group with short long bones (odds ratio, 11.8; P < .001).

CONCLUSIONS

The risk of adverse pregnancy outcomes is significant in euploid and nonanomalous pregnancies with isolated short long bones. Close follow-up is needed during pregnancy.

Serum pregnancy-associated plasma protein A levels in the first, second and third trimester of pregnancy: relation to newborn anthropometric parameters and maternal tobacco smoking

INTRODUCTION

The purpose of this study was to evaluate the associations of the first, second and third trimester serum pregnancy-associated plasma protein A (PAPP-A) concentrations with neonatal anthropometric parameters. The effect of tobacco smoking during pregnancy on PAPP-A level was also studied.

MATERIAL AND METHODS

One hundred and fifty healthy pregnant women were divided into smoking and tobacco-abstinent groups. Serum PAPP-A level was measured with the KRYPTOR rapid random-access immunoassay analyzer. The relationship between PAPP-A and newborn related outcome as well as markers of estimated intensity of cigarette smoking was evaluated by univariate and multivariate linear regression.

RESULTS

Pregnancy-associated plasma protein A concentration was positively correlated with birth weight in the first (β = 31.6; p < 0.001), second (β = 10.6; p < 0.05), and third (β = 4.6; p < 0.001) trimester of gestation. A significant association between PAPP-A and birth body length and head circumference in the second (β = 0.02; p < 0.05) and third trimester (β = 0.01; p < 0.01) was also found. The serum PAPP-A levels were significantly lower in the smoking than in the tobacco-abstinent group in each trimester of pregnancy (p < 0.001). The largest impact of the number of cigarettes smoked per day on PAPP-A level was found in the second (β = -1.2; p = 0.004) and third trimester (β = -2.6; p = 0.001).

CONCLUSIONS

Maternal serum PAPP-A levels during gestation might be significant predictors for birth weight. Increased PAPP-A concentrations in the second and third trimester appeared to also be predictive for newborn body length and head circumference. Smoking alters maternal PAPP-A levels in all trimesters, with the greatest impact related to the number of cigarettes smoked per day.

The relationship between first-trimester pregnancy-associated plasma protein-A levels and intrapartum fetal distress development

OBJECTIVE

To investigate the relationship between the development of intrapartum fetal distress and serum pregnancy-associated plasma protein-A (PAPP-A) levels measured during first-trimester aneuploidy screening tests.

MATERIAL AND METHODS

This retrospective study included 283 uncomplicated pregnancies that resulted in full-term live births via spontaneous labor or with the induction by oxytocin. Cases were divided into two groups based on whether their first-trimester PAPP-A multiple of the median (MoM) levels were ≤0.5 (Group 1, n=75) or >0.5 (Group 2, n=208). As primary end points, the rate of cesarean section (C/S), the rate of C/S due to fetal distress, and the umbilical artery blood pH values in cases of C/S for fetal distress were compared between the two groups. Statistical analyses were performed using the Chi-square test and independent samples t-test. P≤0.05 were considered statistically significant.

RESULTS

The mean gestational age at birth and the birth weights were significantly lower in Group 1 than in Group 2 (p=0.002 and p=0.007, respectively). Although the rate of C/S was similar between the groups (p=0.823), the rate of C/S due to fetal distress was significantly higher in Group 1 than in Group 2 (68.4% vs. 42%, respectively; p=0.050) and the mean umbilical artery blood pH value for C/S deliveries indicated by fetal distress was lower (p=0.048) in Group 1 than in Group 2. When the mode of delivery was analyzed according to the application of labor induction, both the C/S delivery rates (31.6% in Group 1 and 31.7% in Group 2; p=0.992) and C/S delivery rates due to fetal distress (66.7% in Group 1 and 46.2% in Group 2; p=0.405) were similar in both groups.

CONCLUSION

Low PAPP-A levels (≤0.5 MoM) in the first trimester are associated with the risk of intrapartum fetal distress development and the likelihood of C/S for fetal distress. Nonetheless, this risk is not affected by labor induction.

Genetic relationship between serum pregnancy-associated plasma protein-A gene polymorphism and ischemic cerebrovascular disease in a Northern Han Chinese population

The present study recruited 193 patients with ischemic cerebrovascular disease from Inpatient and Outpatient Departments at the Affiliated Hospital of Qingdao University Medical College, China from August 2008 to May 2010, as well as 120 healthy volunteers from the Medical Examination Center at the Affiliated Hospital of Qingdao University Medical College, China, who served as controls for this study. Patients and control subjects were from the Han population in northern China. Enzyme- linked immunosorbent assay analysis revealed increased levels of serum pregnancy-associated plasma protein-A (PAPP-A) in ischemic cerebrovascular disease patients compared with healthy controls. In addition, the patients exhibited greater frequency of genotype CC and C alleles in a missense A/C (Tyr/Ser) polymorphism (dbSNP: rs7020782) of exon 14 in the PAPP-A gene. Multiple-factor logistic regression analysis on correction of age, gender, history of smoking, hypertension, diabetes mellitus, hypercholesteremia, and ischemic stroke family history showed that the risk for ischemic cerebrovascular disease in the population without the A allele at the A/C genetic locus in exon 14 of the PAPP-A was 2-folds greater than the population expressing the A allele. These experimental findings suggested that ischemic cerebrovascular disease correlated with the C allele in exon 14 of PAPP-A. In addition, the A allele is likely a protective gene; individuals carrying the A allele were less prone to ischemic cerebrovascular disease compared with individuals without the A allele.

Serum pregnancy-associated plasma protein A correlates with inflammation and malnutrition in patients treated with maintenance hemodialysis

Advanced chronic kidney disease (CKD) leads to complications such as anemia, electrolyte abnormalities, bone and mineral disorder, and malnutrition-inflammation-atherosclerosis (MIA) syndrome, that result in high cardiovascu- lar mortality. One of the biomarkers associated with inflammation and cardiovascular events is pregnancy-associated plasma protein A (PAPP-A). The aim of the study was to measure serum PAPP-A in hemodialyzed CKD patients, and to investigate its correlations with the laboratory markers of the complications. We enrolled 78 consecutive stable adult CKD patients treated with maintenance hemodialysis for median period of 60 months. PAPP-A concentrations were measured with by electrochemiluminescence immunoassay. Average serum PAPP-A in hemodialyzed patients was almost two times higher than the upper reference limit. It positively correlated with N-terminal pro-brain natriuretic peptide (NT-proBNP), serum sodium, and the markers of inflammation and malnutrition. In conclusion, serum PAPP-A seems a useful biomarker associated with cardiovascular dysfunction, inflammatory state and malnutrition in hemodialysis patients.

First-trimester screening biochemical markers (free beta-subunit human chorionic gonadotropin, pregnancy-associated plasma protein-A) and risk of early fetal loss

AIM

The aim of this work was to assess the risk of early fetal loss (first trimester of pregnancy, 8-13 weeks of gestation) using the results of first-trimester screening (FTS) biochemical markers independently and combined.

METHODS

FTS results of 152 women who suffered early fetal loss were compared to a control group of 150 women with normal pregnancy outcomes. FTS biochemical markers were measured with a Delfia Xpress 6000 analyzer and biochemical risks for Down's and Edward's syndromes were calculated using Prenatal-Lifecycle version 3.0 software. Marker levels were standardized by calculating the gestational-specific multiple of the medians (MoM), further adjusted by maternal age, maternal weight, cigarette consumption and pre-existing type 1 diabetes mellitus. Receiver-operator curves were built to evaluate each marker and its combination.

RESULTS

Our results show that values of biochemical risk of t21 of more than 1 in 310 have a poor sensitivity to predict early fetal loss (31.4%) with a positive predictive value (PPV) for fetal loss of 67.7%. Values of pregnancy-associated plasma protein A (PAPP-A) MoM of less than 0.48 show a sensitivity of 62.1% and a PPV of 84.5% for early fetal loss; whereas for free β-human chorionic gonadotropin, values of MoM of less than 0.44 have a sensitivity of 66.4% with a PPV of 85.3%. A novel algorithm, consisting in the multiplication of both markers, shows for values of less than 0.48 a sensitivity of 83.1%, a specificity of 78.7% and a PPV of 77.1%.

CONCLUSION

Combined analysis of PAPP-A and free β-hCG appears to be a potential candidate to predict early fetal loss.

A combination of plaque components analyzed by integrated backscatter intravascular ultrasound and serum pregnancy-associated plasma protein a levels predict the no-reflow phenomenon during percutaneous coronary intervention

AIMS

Previous studies reported that integrated backscatter intravascular ultrasound (IB-IVUS) provides high diagnostic accuracy for tissue characterization of coronary plaques and that pregnancy-associated plasma protein A (PAPP-A) could be a marker of adverse cardiac outcome in patients with cardiovascular disease. We examined whether IB-IVUS and PAPP-A levels could predict the incidence of no-reflow during percutaneous coronary intervention (PCI) METHODS AND RESULTS: About 176 consecutive patients (138 men, mean age 68 ± 11 years) who underwent PCI with IB-IVUS were prospectively enrolled. Combined no-reflow, including transient filter no-reflow by using distal protection devices, was observed in 31 patients. The percentages of coronary lipid volume (%LV) analyzed by IB-IVUS and serum PAPP-A were significantly higher in patients with combined no-reflow than normal-reflow. To predict no-reflow, a receiver operating characteristic (ROC) analysis determined cut-off values of %LV as 62% and serum PAPP-A as 7.71 ng/mL. The multivariate logistic regression analysis showed that %LV (hazard ratio 4.5, 95% confidence interval 1.6-13.4, P < 0.01) and PAPP-A (hazard ratio 4.32, 95% confidence interval 1.5-12.7, P < 0.01) were independent predictors of combined no-reflow

CONCLUSIONS

%LV analyzed by IB-IVUS and serum PAPP-A levels were closely associated with the coronary no-reflow phenomenon. © 2014 Wiley Periodicals, Inc.

Efficiency of first-trimester uterine artery Doppler, a-disintegrin and metalloprotease 12, pregnancy-associated plasma protein a, and maternal characteristics in the prediction of preeclampsia

OBJECTIVES

The purpose of this study was to estimate the efficiency of first-trimester uterine artery Doppler, A-disintegrin and metalloprotease 12 (ADAM12), pregnancy-associated plasma protein A (PAPP-A), and maternal characteristics in the prediction of preeclampsia.

METHODS

We conducted a prospective cohort study of patients presenting for first-trimester aneuploidy screening between 11 and 14 weeks' gestation. Maternal serum ADAM12 and PAPP-A levels were measured by an immunoassay, and mean uterine artery Doppler pulsatility indices were calculated. Outcomes of interest included preeclampsia, early preeclampsia (defined as requiring delivery at <34 weeks' gestation), and gestational hypertension. Logistic regression analysis was used to model the prediction of preeclampsia using ADAM12 multiples of the median (MoM), PAPP-A MoM, and uterine artery Doppler pulsatility index MoM, either individually or in combination. The sensitivity, specificity, and area under the receiver operating characteristic curves were used to compare the screening efficiency of the models using nonparametric U statistics.

RESULTS

Among 578 patients with complete outcome data, there were 54 cases of preeclampsia (9.3%) and 13 cases of early preeclampsia (2.2%). Median ADAM12 levels were significantly lower in patients who developed preeclampsia compared to those who did not (0.81 versus 1.01 MoM; P = .04). For a fixed false-positive rate of 10%, ADAM12, PAPP-A, and uterine artery Doppler parameters in combination with maternal characteristics identified 50%, 48%, and 52% of patients who developed preeclampsia, respectively. Combining these first-trimester parameters did not improve the predictive efficiency of the models.

CONCLUSIONS

First-trimester ADAM12, PAPP-A, and uterine artery Doppler characteristics are not sufficiently predictive of preeclampsia. Combinations of these parameters do not further improve their screening efficiency.

Elevated pregnancy-associated plasma protein A predicts myocardial dysfunction and death in severe sepsis

BACKGROUND

Pregnancy-associated plasma protein A (PAPPA) is an emerging biomarker used in various medical fields but has yet to be evaluated in critical care medicine. This study evaluates the value of PAPPA as a biomarker in predicting myocardial dysfunction and 28-day mortality in patients with severe sepsis.

METHODS

Serum concentrations of PAPPA and traditional cardiac biomarkers including cardiac troponin I (cTnI) and B-type natriuretic peptide (BNP) were measured on admission in 118 severely septic patients. The value of PAPPA for the diagnosis of sepsis-related myocardial dysfunction (SRMD) and for the prediction of 28-day mortality was subsequently evaluated using statistical methods.

RESULTS

PAPPA was elevated (≥4.5 ng/mL) in 76 (64.4%) patients; patients with elevated PAPPA were more likely to have SRMD (76.3% vs. 38.1%, P < 0.001). By comparison of the area under the curve (AUC) in receiver operating characteristics analysis, PAPPA had comparable value (AUC 0.661, P = 0.003) to conventional biomarkers (BNP: AUC 0.699, P < 0.001; cTnI: AUC 0.647, P = 0.007) in the diagnosis of SRMD and offered superior value (AUC 0.771, P < 0.001) over them (all AUC<0.7, P > 0.05) in the prediction of 28-day death. Increased PAPPA (≥5.4 ng/mL) was associated with lower 28-day survival (χ(2) = 19.78, P < 0.001) and independently predicted 28-day mortality in septic patients.

CONCLUSIONS

Serum PAPPA concentration frequently increases in patients with severe sepsis and appears to be associated with SRMD. PAPPA can be used as a novel biomarker for the diagnosis of SRMD and the prediction of outcomes in critically ill patients.

Pregnancy-associated plasma protein A predicts adverse vascular events in patients with coronary heart disease: a systematic review and meta-analysis

INTRODUCTION

Prospective studies about the association between elevated circulating pregnancy-associated plasma protein A (PAPP-A) and adverse vascular events in patients with coronary heart diseases (CHD) are inconsistent. We performed a meta-analysis to clarify this issue.

MATERIAL AND METHODS

We identified prospective studies by searching MEDLINE. The vascular outcomes included all-cause mortality, combination of all-cause mortality and non-fatal myocardial infarction (MI), and combined cardiovascular events. Prospective studies providing multivariable adjusted relative risks (RRs) and their 95% confidence intervals (CIs) of pre-mentioned outcomes were included. A random-effects model was used to calculate the pooled RRs. Subgroup and sensitivity analyses were used to explore the potential sources of heterogeneity or modifiable factors.

RESULTS

Fourteen studies with a total of 12 830 participants were included. Elevated PAPP-A level was associated with all-cause mortality (pooled RR 1.74, 95% CI: 1.45 to 2.09, p < 0.001), combined all-cause mortality and non-fatal MI (RR 1.59, 95% CI: 1.37 to 1.85, p < 0.001) and combined cardiovascular events (RR 1.50, 95% CI: 1.22 to 1.85, p < 0.001). There was no significant heterogeneity. Subgroup and sensitivity analyses showed that the positive association was not affected by follow-up term, CHD type, different assay methods of PAPP-A, or studies with less than 5 adjusted variables.

CONCLUSIONS

Elevated serum PAPP-A level is associated with adverse vascular outcomes in patients with CHD.

A correlation analysis between the expression of pregnancy-associated plasma protein A in basal decidual cells and recurrent spontaneous abortion

The aim of this study was to investigate the correlation between the expression of pregnancy-associated plasma protein A (PAPP-A) in basal decidual cells and recurrent spontaneous abortion (RSA). A total of 39 patients with a history of RSA were enrolled into the RSA group. A further 30 females who had experienced normal pregnancy were enrolled into the control group. The mRNA expression of PAPP-A in basal decidual cells was analyzed using real-time PCR. The distribution and expression of PAPP-A protein levels in basal decidual cells were analyzed by immunohistochemistry. The correlation between PAPP-A protein levels and RSA was analyzed. The levels of PAPP-A mRNA in the RSA group were significantly decreased, compared with the control group (P<0.05). Consistent with the mRNA levels, the protein levels of PAPP-A were also significantly lower in the RSA group compared with the control group (P<0.05). Multivariate logistic analysis indicated that the suppression of PAPP-A was one of the risk factors for RSA. Furthermore, Hosmer-Lemeshow analysis suggested that the expression levels of PAPP-A is an important factor for predicting RSA. In conclusion, the expression levels of the PAPP-A protein were significantly reduced in basal decidual cells of the RSA group compared with the control group. Therefore, PAPP-A is likely to play an important role in RSA.

Plaque characteristics and serum pregnancy-associated plasma protein A levels predict the no-reflow phenomenon after percutaneous coronary intervention

OBJECTIVES

To investigate the relationship between serum plasma pregnancy-associated plasma protein A (PAPP-A) and coronary plaque characteristics, and their prognostic value for coronary no-reflow after percutaneous coronary intervention (PCI).

METHODS

Patients with unstable angina undergoing PCI were divided into a normal reflow group and a no-reflow group after stent deployment. Coronary blood flow was measured angiographically; plaque components were detected by virtual histology intravascular ultrasound. Serum PAPP-A and high-sensitivity C-reactive protein (hsCRP) were measured before PCI. Cardiac troponin T (cTnT) was measured before and 24 h after PCI.

RESULTS

A total of 166 patients with unstable angina undergoing PCI were included: normal reflow group (n = 145) and no-reflow group (n = 21), after stent deployment. Baseline coronary blood flow was similar in the two groups. The no-reflow group had plaques with less-fibrotic tissue and a larger necrotic core, more thin-cap fibroatheromas and plaque ruptures, and higher serum PAPP-A, hsCRP and post-PCI cTnT levels than the normal reflow group. Serum PAPP-A was correlated negatively with plaque fibrotic area and positively with necrotic core area.

CONCLUSION

High serum PAPP-A and plaque lesions with a large necrotic core are associated with the no-reflow phenomenon after PCI, in patients with unstable angina.

Examination of serum pregnancy-associated plasma protein A clinical value in acute coronary syndrome prediction and monitoring

INTRODUCTION

Chronic vascular inflammatory process promotes and intensifies all atherogenic events. The aim of this research was to estimate the clinical value of pregnancy-associated plasma protein A (PAPP-A) measurement associated with plaque destabilization and rupture in prediction and monitoring of acute coronary syndromes (ACS) as well as to assess the predictive value of this biomarker in comparison to traditional myocardial infarction (MI) risk markers.

MATERIAL AND METHODS

The study included 119 patients in 2 investigated groups and one control group. PAPP-A assay was performed using manual ELISA kit, DRG. All other parameters were determined using automatic analyzers: Olympus and Dade Behring.

RESULTS

A statistically significant difference between PAPP-A concentration median value was found in the investigated group MI individuals' serum and control group individuals' serum (11.42 ng/ml and 7.22 ng/ml respectively, p = 0.003). PAPP-A assay had the highest specificity (83.3%) and sensitivity (53.8%), and therefore the highest clinical value. In patients with clinically and laboratory confirmed MI we proved that PAPP-A serum level is a clinically useful biomarker in ACS prediction, better than C-reactive protein (hsCRP) and fibrinogen (FBG) level.

CONCLUSIONS

The highest diagnostic efficiency for ACS prediction was proved for simultaneous panel assays consisting of 2-3 parameters (PAPP-A - hsCRP, PAPP-A - FBG, PAPP-A - hsCRP - FBG), while PAPP-A itself does not show characteristics necessary for it to be used as a biomarker for MI dynamic monitoring. It is possible that prothrombotic component is mainly responsible for repeated major adverse cardiac events, more than inflammatory process.

Effect of routine heparins treatment in acute coronary syndrome on serum pregnancy-associated plasma protein a concentration

BACKGROUND

Pregnancy-associated plasma protein A (PAPP-A) has been suggested as a useful marker of acute coronary syndrome (ACS). Serum PAPP-A concentrations are affected by unfractionated heparin (UFH) in ACS population, and we tried to investigate the time profile of effects of routine heparins treatment on serum PAPP-A concentrations in ACS population thoroughly and give advice to sample collection of related study.

METHODS

Twenty cases were involved in this study: ten patients with acute myocardial infarction received subcutaneous low molecular weight heparin (LMWH) twice a day (group A), and the other ten percutaneous coronary intervention patients with stenting received intravenous UFH (group B). Samples were collected before and after heparin administration and serum PAPP-A concentrations were analyzed in these samples.

RESULTS

Serum PAPP-A concentration increased in both group A and B. In group A, PAPP-A concentration elevated gradually (14.5 to 29.4 mIU/L, P<0.05) throughout the observation period and normalized at 48h after drug discontinuation. In group B, there was a rapid and intense increase after intravenous heparin injection (13.1 to 49.3 mIU/L, P<0.05), and a new PAPP-A peak was induced by additional heparin administration.

CONCLUSIONS

Heparins-induced increase in serum PAPP-A concentration lasted until 48h after drug use was discontinued. We recommend that samples from these patients for PAPP-A measurement should be collected at least 48h after the last administration if its not available before the administration of heparins.