Cell-Free Total and Fetal DNA in First Trimester Maternal Serum and Subsequent Development of Preeclampsia

Maternal cell-free DNA in early pregnancy for preeclampsia screening: a systematic review

PURPOSE

To quantify the separation between maternal blood cell-free (cf)DNA markers in preeclampsia and unaffected pregnancies and compare with existing markers. This approach has not been used in previous studies.

METHODS

Comprehensive systematic literature search of PubMed to identify studies measuring total cfDNA, fetal cf(f)DNA or the fetal fraction (FF) in pregnant women. Included-studies of asymptomatic pregnancies with subsequent preeclampsia (cases) and unaffected pregnancies (controls) tested in the first or second trimester and before the clinical onset of preeclampsia. Excluded-studies not reporting the median or mean, standard deviation, inter-quartile range or range in cases and controls. Information from 26 eligible studies was entered into a meta-analysis to estimate, for each marker, the Mahalanobis distance, a measure of separation between the overlapping distributions in preeclampsia and unaffected pregnancies. This was compared with estimates for mean arterial pressure (MAP), uterine artery Doppler pulsatility index (UtA-PI), pregnancy associated plasma protein (PAPP)-A and placental growth factor (PlGF).

RESULTS

The mean Mahalanobis distance for total cfDNA was 0.44 (95% CI 0.12-0.76), which fell between UtA-PI (0.53) and the absolute value of PAPP-A (- 0.36). For cffDNA the distance was 1.03 (0.37-1.69), which is superior to MAP (0.74), UtA-PI, PlGF (- 0.57) and PAPP-A. The distance for FF was - 0.34 (- 0.56 to - 0.12), similar to PAPP-A.

CONCLUSION

All three markers have a potential preeclampsia screening role, particularly cffDNA. However, to estimate the screening performance in combination with existing markers further large studies are needed. The current analysis will help in the power calculation for such studies.

Circulating bacterial DNA in cardiovascular disease

Cardiovascular disease (CVD) remains a global health burden despite advances in prevention and treatment. Conventional biomarkers, while effective for a number of patient groups, fail to provide personalized diagnosis and prognosis, necessitating the exploration of novel markers. Advancements in sequencing technology have unveiled the role of cell-free DNA (cfDNA) as a reservoir of genetic information from all cells within the body, and associations between elevated cfDNA levels and CVD risk factors and status have been reported. Recent attention has turned to a subset of cfDNA, circulating bacterial DNA (cbDNA), derived from gut microbiota, as a potential biomarker. Investigations into microbial translocation from the gut, particularly the phenomenon of 'leaky gut,' reveal its association with CVD and provide a potential source for cbDNA. Here, we review the existing literature on cbDNA in CVD, highlighting its potential diagnostic and prognostic value. Current studies have largely been carried out in small, disparate cohorts, using different sample types and a range of methodologies. While cbDNA shows potential as a diagnostic and prognostic biomarker, the lack of consensus in methodologies and populations studied calls for standardized approaches and large cohorts to establish cbDNA as a reliable CVD biomarker. Future research should focus on identifying the source of cbDNA and its pathological relevance, utilizing advanced sequencing techniques and standardized cohorts for conclusive findings.

Diagnostic potential of cell-free fetal nucleic acids in predicting pregnancy complications: A systematic review and meta-analysis on trisomy, pre-eclampsia, and gestational diabetes

Background

Recent studies reveal an association between increased cell-free fetal (cff) nucleic acid in maternal blood and pregnancy challenges like loss, pre-eclampsia, growth restriction, and preterm labor.

Objective

This article assesses the role of cff nucleic acids as potential diagnostic markers for the prediction and monitoring progression of severe pregnancy-related complications.

Materials and Methods

In this systematic review and meta-analysis, various databases were searched. Original articles reporting on the role of cff nucleic acids in predicting the complications of pregnancy were included. I square test and funnel plot were used to analyze heterogeneity and publication bias, respectively. The quality of studies was assessed using the critical appraisal checklists for studies created by the Joanna Briggs Institute.

Results

70 publications were selected for the final qualitative analysis. Articles were published between 2010 and 2023, and most studies were conducted in the USA and China. The majority of studies were conducted on the quantity of cff-DNA (n = 40), and the remaining on microRNA (n = 18), messenger RNA (n = 11), and cell-free RNA (n = 1). The pooled sensitivity of cff nucleic acids for detecting trisomy was found to be 90.9 (95% CI: 80.9-100%). MicroRNA levels were significantly increased in participants with gestational diabetes mellitus, with a standardized mean difference of 1.22 (95% CI: -0.90-3.34).

Conclusion

Fetal nucleic acids can serve as accurate noninvasive diagnostic tools for predicting serious complications during pregnancy.

A Reliable Method for Quantifying Plasma Cell-Free DNA Using an Internal Standard Strategy: Evaluation in a Cohort of Non-Pregnant and Pregnant Women

The use of plasma cell-free DNA (cfDNA) as a useful biomarker in obstetric clinical practice has been delayed due to the lack of reliable quantification protocols. We developed a protocol to quantify plasma cfDNA using an internal standard strategy to overcome difficulties posed by low levels and high fragmentation of cfDNA. cfDNA was isolated from plasma samples of non-pregnant (NP, n = 26) and pregnant (P, n = 26) women using a commercial kit and several elution volumes were evaluated. qPCR parameters were optimized for cfDNA quantification, and several quantities of a recombinant standard were evaluated as internal standard. Absolute quantification was performed using a standard curve and the quality of the complete method was evaluated. cfDNA was eluted in a 50-μl volume, actin-β (ACTB) was selected as the target gene, and qPCR parameters were optimized. The ACTB standard was constructed and 1000 copies were selected as internal standard. The standard curve showed R2 = 0.993 and E = 109.7%, and the linear dynamic range was defined between 102 and 106 ACTB copies/tube. Repeatability and reproducibility in terms of CV were 19% and up to 49.5% for ACTB copies per milliliter of plasma, respectively. The range of cfDNA levels was 428-18,851 copies/mL in NP women and 4031-2,019,363 copies/mL in P women, showing significant differences between the groups. We recommend the application of internal standard strategy for a reliable plasma cfDNA quantification. This methodology holds great potential for a future application in the obstetric field.

Cell-Free DNA As Peripheral Biomarker of Alzheimer's Disease

Alzheimer's disease (AD) and Alzheimer's disease-related disorders (ADRD) are progressive neurodegenerative diseases without cure. Alzheimer's disease occurs in 2 forms, early-onset familial AD and late-onset sporadic AD. Early-onset AD is a rare (~1%), autosomal dominant, caused by mutations in presenilin-1, presenilin-2, and amyloid precursor protein genes and the other is a late-onset, prevalent and is evolved due to age-associated complex interactions between environmental and genetic factors, in addition to apolipoprotein E4 polymorphism. Cellular senescence, promoting the impairment of physical and mental functions is constituted to be the main cause of aging, the primary risk factor for AD, which results in progressive loss of cognitive function, memory, and visual-spatial skills for an individual to live or act independently. Despite significant progress in the understanding of the biology and pathophysiology of AD, we continue to lack definitive early detectable biomarkers and/or drug targets that can be used to delay the development of AD and ADRD in elderly populations. However, recent developments in the studies of DNA double-strand breaks result in the release of fragmented DNA into the bloodstream and contribute to higher levels of cell-free DNA (cf-DNA). This fragmented cf-DNA can be released into the bloodstream from various cell types, including normal cells and cells undergoing apoptosis or necrosis and elevated levels of cf-DNA in the blood have the potential to serve as blood blood-based biomarker for early detection of AD and ADRD. The overall goal of our study is to discuss the latest developments in circulating cell-free DNA into the blood in the progression of AD and ADRD. Our article summarized the status of research on double-strand breaks and circulating cell-free DNA in both healthy and disease states and how these recent developments can be used to develop early detectable biomarkers for AD and ADRD. Our article also discussed the impact of lifestyle and epigenetic factors that are involved in DNA double-strand breaks and circulating cell-free DNA in AD and ADRD.

The association between fetal fraction and pregnancy-related complications among Chinese population

To examine the association of fetal fraction with a wide spectrum of pregnancy-related complications among Chinese population, we carried out a single-institution retrospective cohort study of women with negative Noninvasive prenatal testing (NIPT) results and singleton pregnancies between May 2018 and May 2020. Indicators of pregnancy-related complications were examined individually, including preterm birth, low birth weight, hypertensive disorders of pregnancy, gestational diabetes, oligohydramnios and intrahepatic cholestasis. We evaluated disease odds ratios (ORs) and 95% confidence intervals (CIs), after controlling for potential confounders including body mass index (BMI), maternal age and gestational week at NIPT. A total of 3534 women were included in our analyses. Women with fetal fraction<15.15% had increased risk of gestational hypertension (OR 4.41, CI [1.65, 12.45]) and oligohydramnios (OR 2.26, CI [1.33, 3.80]) compared to women with fetal fraction≥15.15%. No significant associations with fetal fraction were found for preterm birth, low birth weight, gestational diabetes, and intrahepatic cholestasis. In Summary, fetal fraction is inversely associated with the risk of gestational hypertension and oligohydramnios.

Circulating Total Cell-Free DNA Levels Are Increased in Hypertensive Disorders of Pregnancy and Associated with Prohypertensive Factors and Adverse Clinical Outcomes

Previous studies have described increased circulating cell-free DNA (cfDNA) in hypertensive disorders of pregnancy (HDP). Here, we aimed first to confirm this information using a simple, but sensible fluorescent assay, and second to investigate whether total cfDNA is associated with circulating factors known to be linked to the pathophysiology of HDP as well as with poor maternal-fetal outcomes. We studied 98 women with healthy pregnancies (HP), 88 with gestational hypertension (GH), and 91 with preeclampsia (PE). Total DNA was extracted from plasma using the QIAamp DNA blood mini kit and quantified using Quant-iT™ PicoGreen® dsDNA fluorescent detection kit. We found higher total cfDNA levels in GH and PE (197.0 and 174.2 ng/mL, respectively) than in HP (140.5 ng/mL; both p < 0.0001). Interestingly, total cfDNA levels were elevated in both male and female-bearing pregnancies diagnosed with either HDP, and in more severe versus less severe HDP cases, as classified according to responsiveness to antihypertensive therapy. In addition, total cfDNA was independently associated with HDP, and a cutoff concentration of 160 ng/mL provided appropriate sensitivity and specificity values for diagnosing GH and PE compared to HP (70-85%, both p < 0.0001). Moreover, high total cfDNA was associated with adverse clinical outcomes (high blood pressure, low platelet count, preterm delivery, fetal growth restriction) and high prohypertensive factors (sFLT-1, sEndoglin, MMP-2). These findings represent a step towards to the establishment of cfDNA as a diagnostic tool and the need to understand its role in HDP.

Association between Levels of Total Cell-Free DNA and Development of Preeclampsia-A Literature Review

Objectives  The aim of the study is to synthesize the evidence and evaluate the total cell-free deoxyribonucleic (cfDNA) associated with the prediction of preeclampsia (PE). Total cfDNA is constituted by both cell-free fetal DNA (cffDNA) originated mainly from the placenta, and maternal cfDNA derived from maternal leukocytes. Methods  A systematic review was conducted by searching PubMed and Medline. Literature reporting levels of total cfDNA in the development of PE was included. Studies that only reported cffDNA, but no cfDNA concentrations were not included in this review. Results  Eight studies were included. Seven reported values of cfDNA in PE patients, regardless of early or late onset PE, six of which demonstrated a significant increase of cfDNA in patients who subsequently developed PE. Seven studies evaluated cfDNA levels in the first trimester, six of which showed significant increase of cfDNA concentrations in women who later developed PE. Five studies investigated cfDNA levels in the second trimester, all presenting increased total cfDNA levels in the PE group compared with normal controls. Conclusion  Total cfDNA may play a role as a biochemical marker of PE, compared with fetal cfDNA. Large prospective studies with homogeneous populations and standardized methodology are needed to further confirm its predictive value.

Maternal total cell-free DNA in preeclampsia with and without intrauterine growth restriction

Elevation of total cell-free DNA (cfDNA) in patients with preeclampsia is well-known; however, whether this change precedes the onset of symptoms remains inconclusive. Here, we conducted a nested case-control study to determine the elevation of cfDNA levels in women who subsequently developed preeclampsia. Methylated HYP2 (m-HYP2) levels were determined in 68 blood samples collected from women with hypertensive disorders of pregnancy, along with 136 control samples, using real-time quantitative PCR. The measured m-HYP2 levels were converted to multiples of the median (MoM) values for correction of maternal characteristics. The m-HYP2 levels and MoM values in patients with preeclampsia were significantly higher than in controls during the third trimester (P < 0.001, both), whereas those for women who subsequently developed preeclampsia did not differ during the second trimester. However, when patients with preeclampsia were divided based on the onset-time of preeclampsia or 10th percentile birth weight, both values were significantly higher in women who subsequently developed early-onset preeclampsia (P < 0.05, both) and preeclampsia with small-for-gestational-age (SGA) neonate (P < 0.01, both) than controls. These results suggested that total cfDNA levels could be used to predict early-onset preeclampsia or preeclampsia with SGA neonate.

Maternal Serum sEndoglin and Cell-Free Fetal DNA as Probable Markers of Preeclampsia: A Study in Single Center, Egypt

Background: This study was conducted to compare the levels of maternal serum soluble endoglin (sEng) and cell-free fetal DNA (cffDNA) in pregnant females with PE to normotensive pregnant ones, together with relating these levels to preeclampsia (PE) severity and onset. Method of the study: It was a comparative study in Mansoura University Hospital, Egypt, to detect the levels of serum sEng by ELISA besides the levels of cffDNA by quantitative real-time polymerase chain reaction in 80 pregnant females suffering from PE in addition to 80 normotensive pregnant ones that were included as control. Results: Levels of serum sEng and cffDNA were higher in PE cases than control (p < 0.0001٭ both) and were significantly related to the severity of the disease. Levels were also higher in early than late onset PE (p < 0.003٭ and <0.002٭, respectively). Sensitivities, specificities, positive, and negative predictive values in addition to accuracy of serum sEng and cffDNA were 97.5%, 98.8%, 98.7%, 97.5%, and 98.1% and 97.5%, 93.8%, 94.0%, 97.4%, and 95.6%, respectively. Conclusion: Maternal serum sEng and cffDNA can be good markers for diagnosis of PE in Egyptian patients. They are positively related to the disease severity. Abbreviations: cffDNA; Cell-Free Fetal DNA, sEng; soluble Endoglin, PE; preeclampsia, qRT PCR; Quantitative real-time polymerase chain reaction.

Clinical Presentation of Preeclampsia and the Diagnostic Value of Proteins and Their Methylation Products as Biomarkers in Pregnant Women with Preeclampsia and Their Newborns

Preeclampsia (PE) is a disorder which affects 1-10% of pregnant women worldwide. It is characterised by hypertension and proteinuria in the later stages of gestation and can lead to maternal and perinatal morbidity and mortality. Other than the delivery of the foetus and the removal of the placenta, to date there are no therapeutic approaches to treat or prevent PE. It is thus only possible to reduce PE-related mortality through early detection, careful monitoring, and treatment of the symptoms. For these reasons the search for noninvasive, blood-borne, or urinary biochemical markers that could be used for the screening, presymptomatic diagnosis, and prediction of the development of PE is of great urgency. So far, a number of biomarkers have been proposed for predicting PE, based on pathophysiological observations, but these have mostly proven to be unreliable and inconsistent between different studies. The clinical presentation of PE and data gathered for the biochemical markers placental growth factor (PlGF), soluble Feline McDonough Sarcoma- (fms-) like tyrosine kinase-1 (sFlt-1), asymmetric dimethylarginine (ADMA), and methyl-lysine is being reviewed with the aim of providing both a clinical and biochemical understanding of how these biomarkers might assist in the diagnosis of PE or indicate its severity.

Repeated failed non-invasive prenatal testing in a woman with immune thrombocytopenia and antiphospholipid syndrome: lessons learnt

We present a case of a 37-year-old Chinese woman (gravida 4 para 0) with a history of immune thrombocytopenia and type IIb antiphospholipid syndrome. She was started on 100 mg of aspirin, 20 mg of prednisolone and 20 mg of subcutaneous low-molecular-weight heparin daily for her fourth pregnancy. She opted for non-invasive prenatal testing for aneuploidy screening but had failed results three times consecutively from insufficient fetal cfDNA initially or high variance in cfDNA counts on redraws. She declined invasive karyotyping. Her pregnancy was complicated by severe pre-eclampsia and fetal growth restriction at 19+6 weeks of gestation and was terminated. Subsequent fetal karyotyping revealed a normal karyotype of 46XY with no apparent abnormalities.