Angiogenic markers and their longitudinal change for predicting adverse outcomes in pregnant women with chronic hypertension

Maternal PlGF and sFlt-1 are Associated with Low Birth Weight and/or Small-for-Gestational Age Neonates in Pregnancy with or without Preeclampsia

Objective

To evaluate the association of PIGF and sFlt-1 with low birth weight and/or small-for-gestational age neonates in pregnancy with or without preeclampsia.

Methods

Singleton pregnancies with sFlt-1/PlGF tested were included and set into four groups for case-control analysis. Distribution of sFlt-1/PlGF, sFlt-1, PlGF, and PGF% were evaluated, Kruskal-Wallis test and Mann-Whitney U test were adopted for significance analysis.

Results

Maternal sFlt-1/PlGF, PlGF, PlGF%, and sFlt-1 were statistically associated with low birth weight and/or small-for-gestational age in pregnancy complicated or uncomplicated with preeclampsia. A significant difference was shown on sFlt-1/PIGF ( p  = 0.0082), PIGF% ( p  = 0.0326), PIGF ( p  = 0.0128), and sFlt-1 ( p  = 0.0469) in pregnancy with small-for-gestational age and/or low birth weight neonates. A significantly higher median of sFlt-1/PlGF (448 vs. 61.6, p  < 0.0001) and sFlt-1 (15499 vs. 3226, p  < 0.0001), a significantly lower median of PlGF (33.92 vs. 115.2, p  < 0.0001) and PlGF% (-76.63 vs. -20.31, p  < 0.0001) were demonstrated, respectively, when preeclampsia with small-for-gestational age and/or low birth weight neonates was compared with preeclampsia with normal birth weight neonates. No significant difference was demonstrated between low birth weight and small-for-gestational age on sFlt-1/PlGF, PlGF, PlGF%, and sFlt-1.

Conclusion

sFlt-1/PlGF seems to be a promising biomarker in predicting low birth weight and/or small-for-gestational age neonates in pregnancy with or without preeclampsia.

A mitochondrial regulator protein, MNRR1, is elevated in the maternal blood of women with preeclampsia

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.

Prediction of adverse maternal and perinatal outcomes associated with pre-eclampsia and hypertensive disorders of pregnancy: a systematic review and meta-analysis

Background

Hypertensive disorders of pregnancy are a leading cause of maternal and perinatal morbidity and mortality. If women at high risk for developing complications could be identified early, level of care could be triaged, limited resources could be correctly allocated and targeted interventions to prevent complications could be implemented.

Methods

We updated a systematic review and meta-analysis and added single outcomes. Women with hypertensive disorders of pregnancy were included. Exposures were tests predicting adverse maternal and/or perinatal outcomes. We searched Medline, Embase, CINAHL, and Cochrane library from January 2016-February 2024. We included studies identified from the previous review. We calculated effect measures. For similar predictive tests and outcomes, area under the receiver-operating-characteristic curve (AUROC) were pooled. This study was registered by PROSPERO: CRD42022336368.

Findings

Of the 2898 studies identified, 80 were included. Thirty were added from the previous review resulting in 110 included studies with 506,178 women. Despite more than 1500 tests being performed, most outcomes could not be pooled due to heterogeneity in populations, tests, and outcome definitions. For maternal outcomes, only studies reporting on the Pre-eclampsia Integrated Estimate of RiSk (fullPIERS) model could be pooled. For the composite outcome within 48-h the AUROC was 0.78 (95% CI 0.71-0.86, N = 8). There was significant heterogeneity (I 2  = 95.7%). For perinatal outcomes, data were pooled for pulsatility index in the umbilical artery and soluble FMS-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) ratio. Biomarkers like the sFlt-1/PlGF ratio showed promising predictive performance for some outcomes but were not externally validated.

Interpretation

Despite including over 100 studies with more than 1500 predictors, we were unable to pool any single maternal outcomes and only a few individual perinatal outcomes. The fullPIERS model was externally validated, showing moderate accuracy which varied across studies and should be validated in each new population. Angiogenic biomarkers showed promise but need validation. Future studies should use standardized outcome measures and validate promising tests.

Funding

VB is supported by the Swedish Research Council, Grant number 2020-01481. University of Gothenburg.

Racial/ethnic differences in pre-pregnancy conditions and adverse maternal outcomes in the nuMoM2b cohort: A population-based cohort study

OBJECTIVES

To determine how pre-existing conditions contribute to racial disparities in adverse maternal outcomes and incorporate these conditions into models to improve risk prediction for racial minority subgroups.

STUDY DESIGN

We used data from the "Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b)" observational cohort study. We defined multimorbidity as the co-occurrence of two or more pre-pregnancy conditions. The primary outcomes of interest were severe preeclampsia, postpartum readmission, and blood transfusion during pregnancy or up to 14 days postpartum. We used weighted Poisson regression with robust variance to estimate adjusted risk ratios and 95% confidence intervals, and we used mediation analysis to evaluate the contribution of the combined effects of pre-pregnancy conditions to racial/ethnic disparities. We also evaluated the predictive performance of our regression models by racial subgroup using the area under the receiver operating characteristic curve (AUC) metric.

RESULTS

In the nuMoM2b cohort (n = 8729), accounting for pre-existing conditions attenuated the association between non-Hispanic Black race/ethnicity and risk of severe preeclampsia. Cardiovascular and kidney conditions were associated with risk for severe preeclampsia among all women (aRR, 1.77; CI, 1.61-1.96, and aRR, 1.27; CI, 1.03-1.56 respectively). The mediation analysis results were not statistically significant; however, cardiovascular conditions explained 36.6% of the association between non-Hispanic Black race/ethnicity and severe preeclampsia (p = 0.07). The addition of pre-pregnancy conditions increased model performance for the prediction of severe preeclampsia.

CONCLUSIONS

Pre-existing conditions may explain some of the association between non-Hispanic Black race/ethnicity and severe preeclampsia. Specific pre-pregnancy conditions were associated with adverse maternal outcomes and the incorporation of comorbidities improved the performance of most risk prediction models.

Preeclampsia at term: evidence of disease heterogeneity based on the profile of circulating cytokines and angiogenic factors

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.

Preeclampsia at term can be classified into 2 clusters with different clinical characteristics and outcomes based on angiogenic biomarkers in maternal blood

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.

One-third of patients with eclampsia at term do not have an abnormal angiogenic profile

OBJECTIVES

An abnormal angiogenic profile is present in about one-half of women with preeclampsia at term. Few studies examined the roles of angiogenic biomarkers in eclampsia. The aims of this study were to determine (1) whether the degree of an anti-angiogenic state, reflected by a low placental growth factor (PlGF) to soluble fms-like tyrosine kinase-1 (sFlt-1) ratio, in women with eclampsia differed from that of women with severe preeclampsia; and (2) the prevalence of women who had an abnormal angiogenic profile at the diagnoses of preterm and term eclampsia.

METHODS

A cross-sectional study was conducted to include women in the following groups: (1) uncomplicated pregnancy (n=40); (2) severe preeclampsia (n=50); and (3) eclampsia (n=35). Maternal serum concentrations of PlGF and sFlt-1 were determined by immunoassays.

RESULTS

Women with preterm, but not term, eclampsia had a more severe anti-angiogenic state than those with severe preeclampsia (lower PlGF and PlGF/sFlt-1 ratio, each p<0.05). However, the difference diminished in magnitude with increasing gestational age (interaction, p=0.005). An abnormal angiogenic profile was present in 95% (19/20) of women with preterm eclampsia but in only 67% (10/15) of women with eclampsia at term.

CONCLUSIONS

Angiogenic biomarkers can be used for risk assessment of preterm eclampsia. By contrast, a normal profile of angiogenic biomarkers cannot reliably exclude patients at risk for eclampsia at term. This observation has major clinical implications given that angiogenic biomarkers are frequently used in the triage area as a test to rule out preeclampsia.

Hypertensive disorders of pregnancy share common cfDNA methylation profiles

Hypertensive disorders of pregnancy (HDP) contribute substantially to perinatal morbidity and mortality. Epigenetic changes point towards cardio-metabolic dysregulation for these vascular disorders. In early pregnancy, epigenetic changes using cell free DNA (cfDNA) are largely unexplored. We aimed to investigate these in HDP between 11 and 14 weeks of gestation by analysis of cfDNA methylation profiles in patients with hypertensive disorders. We identified patients without chronic hypertension but with subsequent development of preeclampsia (PE) (n = 11), with chronic hypertension (HT) but without PE development (n = 14), and lacking both PE and HT (n = 422). We matched patients according to PE risk factors into three groups (n = 5 each group): (1) PE: no HT but PE development, (2) HT: chronic hypertension but no PE and (3) Control: no PE or HT. We successfully optimized our cfDNA isolation process prior to whole genome bisulfite sequencing. Analysis of cfDNA methylation changes indicate a common predisposition in PE and HT groups, chiefly of maternal origin. Assessment of significant differentially methylated regions and annotated genes point towards a common cardiovascular predisposition in preeclampsia and hypertension groups in the first trimester. We postulate the pivotal role of the maternal cardiovascular system in HDP, which is already evident in the first trimester.

Placental growth fActor Repeat sampling for Reduction of adverse perinatal Outcomes in women with suspecTed pre-eclampsia: study protocol for a randomised controlled trial (PARROT-2)

BACKGROUND

Pre-eclampsia is a complex pregnancy disorder, characterised by new or worsening hypertension associated with multi-organ dysfunction. Adverse outcomes include eclampsia, liver rupture, stroke, pulmonary oedema, and acute kidney injury in the mother, and stillbirth, foetal growth restriction, and iatrogenic preterm delivery for the foetus. Angiogenic biomarkers, including placental growth factor (PlGF) and soluble fms-like tyrosine kinase 1 (sFlt-1), have been identified as valuable biomarkers for preterm pre-eclampsia, accelerating diagnosis and reducing maternal adverse outcomes by risk stratification, with enhanced surveillance for high-risk women. PlGF-based testing for suspected preterm pre-eclampsia has been incorporated into national guidance. The role of repeat PlGF-based testing and its effect on maternal and perinatal adverse outcomes have yet to be evaluated.

METHODS

The PARROT-2 trial is a multi-centre randomised controlled trial of repeat revealed PlGF-based testing compared to repeat concealed testing, in women presenting with suspected pre-eclampsia between 22+0 and 35+6 weeks' gestation. The primary objective is to establish whether repeat PlGF-based testing decreases a composite of perinatal severe adverse outcomes (stillbirth, early neonatal death, or neonatal unit admission). All women prior to enrolment in the trial will have an initial revealed PlGF-based test. Repeat PlGF-based tests will be performed weekly or two-weekly, depending on the initial PlGF-based test result, with results randomised to revealed or concealed.

DISCUSSION

National guidance recommends that all women presenting with suspected preterm pre-eclampsia should have a single PlGF-based test when disease is first suspected, to help rule out pre-eclampsia. Clinical and cost-effectiveness of repeat PlGF-based testing has yet to be investigated. This trial aims to address whether repeat PlGF-based testing reduces severe maternal and perinatal adverse outcomes and whether repeat testing is cost-effective.

TRIAL REGISTRATION

ISRCTN 85912420 . Registered on 25 November 2019.

A machine-learning-based algorithm improves prediction of preeclampsia-associated adverse outcomes

BACKGROUND

Preeclampsia presents a highly prevalent burden on pregnant women with an estimated incidence of 2% to 5%. Preeclampsia increases the maternal risk of death 20-fold and is one of the main causes of perinatal morbidity and mortality. Novel biomarkers, such as soluble fms-like tyrosine kinase-1 and placental growth factor in addition to a wide span of conventional clinical data (medical history, physical symptoms, laboratory parameters, etc.), present an excellent basis for the application of early-detection machine-learning models.

OBJECTIVE

This study aimed to develop, train, and test an automated machine-learning model for the prediction of adverse outcomes in patients with suspected preeclampsia.

STUDY DESIGN

Our real-world dataset of 1647 (2472 samples) women was retrospectively recruited from women who presented to the Department of Obstetrics at the Charité - Universitätsmedizin Berlin, Berlin, Germany, between July 2010 and March 2019. After standardization and data cleaning, we calculated additional features regarding the biomarkers soluble fms-like tyrosine kinase-1 and placental growth factor and sonography data (umbilical artery pulsatility index, middle cerebral artery pulsatility index, mean uterine artery pulsatility index), resulting in a total of 114 features. The target metric was the occurrence of adverse outcomes throughout the remaining pregnancy and 2 weeks after delivery. We trained 2 different models, a gradient-boosted tree and a random forest classifier. Hyperparameter training was performed using a grid search approach. All results were evaluated via a 10 × 10-fold cross-validation regimen.

RESULTS

We obtained metrics for the 2 naive machine-learning models. A gradient-boosted tree model was performed with a positive predictive value of 88%±6%, a negative predictive value of 89%±3%, a sensitivity of 66%±5%, a specificity of 97%±2%, an overall accuracy of 89%±3%, an area under the receiver operating characteristic curve of 0.82±0.03, an F1 score of 0.76±0.04, and a threat score of 0.61±0.05. The random forest classifier returned an equal positive predictive value (88%±6%) and specificity (97%±1%) while performing slightly inferior on the other available metrics. Applying differential cutoffs instead of a naive cutoff for positive prediction at ≥0.5 for the classifier's results yielded additional increases in performance.

CONCLUSION

Machine-learning techniques were a valid approach to improve the prediction of adverse outcomes in pregnant women at high risk of preeclampsia vs current clinical standard techniques. Furthermore, we presented an automated system that did not rely on manual tuning or adjustments.