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Chaemsaithong P, Gil MM, Chaiyasit N, Cuenca-Gomez D, Plasencia W, Rolle V, Poon LC. Accuracy of placental growth factor alone or in combination with soluble fms-like tyrosine kinase-1 or maternal factors in detecting preeclampsia in asymptomatic women in the second and third trimesters: a systematic review and meta-analysis. Am J Obstet Gynecol 2023; 229:222-247. [PMID: 36990308 DOI: 10.1016/j.ajog.2023.03.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/09/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVE This study aimed to: (1) identify all relevant studies reporting on the diagnostic accuracy of maternal circulating placental growth factor) alone or as a ratio with soluble fms-like tyrosine kinase-1), and of placental growth factor-based models (placental growth factor combined with maternal factors±other biomarkers) in the second or third trimester to predict subsequent development of preeclampsia in asymptomatic women; (2) estimate a hierarchical summary receiver-operating characteristic curve for studies reporting on the same test but different thresholds, gestational ages, and populations; and (3) select the best method to screen for preeclampsia in asymptomatic women during the second and third trimester of pregnancy by comparing the diagnostic accuracy of each method. DATA SOURCES A systematic search was performed through MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform databases from January 1, 1985 to April 15, 2021. STUDY ELIGIBILITY CRITERIA Studies including asymptomatic singleton pregnant women at >18 weeks' gestation with risk of developing preeclampsia were evaluated. We included only cohort or cross-sectional test accuracy studies reporting on preeclampsia outcome, allowing tabulation of 2×2 tables, with follow-up available for >85%, and evaluating performance of placental growth factor alone, soluble fms-like tyrosine kinase-1- placental growth factor ratio, or placental growth factor-based models. The study protocol was registered on the International Prospective Register Of Systematic Reviews (CRD 42020162460). METHODS Because of considerable intra- and interstudy heterogeneity, we computed the hierarchical summary receiver-operating characteristic plots and derived diagnostic odds ratios, β, θi, and Λ for each method to compare performances. The quality of the included studies was evaluated by the QUADAS-2 tool. RESULTS The search identified 2028 citations, from which we selected 474 studies for detailed assessment of the full texts. Finally, 100 published studies met the eligibility criteria for qualitative and 32 for quantitative syntheses. Twenty-three studies reported on performance of placental growth factor testing for the prediction of preeclampsia in the second trimester, including 16 (with 27 entries) that reported on placental growth factor test alone, 9 (with 19 entries) that reported on the soluble fms-like tyrosine kinase-1-placental growth factor ratio, and 6 (16 entries) that reported on placental growth factor-based models. Fourteen studies reported on performance of placental growth factor testing for the prediction of preeclampsia in the third trimester, including 10 (with 18 entries) that reported on placental growth factor test alone, 8 (with 12 entries) that reported on soluble fms-like tyrosine kinase-1-placental growth factor ratio, and 7 (with 12 entries) that reported on placental growth factor-based models. For the second trimester, Placental growth factor-based models achieved the highest diagnostic odds ratio for the prediction of early preeclampsia in the total population compared with placental growth factor alone and soluble fms-like tyrosine kinase-1-placental growth factor ratio (placental growth factor-based models, 63.20; 95% confidence interval, 37.62-106.16 vs soluble fms-like tyrosine kinase-1-placental growth factor ratio, 6.96; 95% confidence interval, 1.76-27.61 vs placental growth factor alone, 5.62; 95% confidence interval, 3.04-10.38); placental growth factor-based models had higher diagnostic odds ratio than placental growth factor alone for the identification of any-onset preeclampsia in the unselected population (28.45; 95% confidence interval, 13.52-59.85 vs 7.09; 95% confidence interval, 3.74-13.41). For the third trimester, Placental growth factor-based models achieved prediction for any-onset preeclampsia that was significantly better than that of placental growth factor alone but similar to that of soluble fms-like tyrosine kinase-1-placental growth factor ratio (placental growth factor-based models, 27.12; 95% confidence interval, 21.67-33.94 vs placental growth factor alone, 10.31; 95% confidence interval, 7.41-14.35 vs soluble fms-like tyrosine kinase-1-placental growth factor ratio, 14.94; 95% confidence interval, 9.42-23.70). CONCLUSION Placental growth factor with maternal factors ± other biomarkers determined in the second trimester achieved the best predictive performance for early preeclampsia in the total population. However, in the third trimester, placental growth factor-based models had predictive performance for any-onset preeclampsia that was better than that of placental growth factor alone but similar to that of soluble fms-like tyrosine kinase-1-placental growth factor ratio. Through this meta-analysis, we have identified a large number of very heterogeneous studies. Therefore, there is an urgent need to develop standardized research using the same models that combine serum placental growth factor with maternal factors ± other biomarkers to accurately predict preeclampsia. Identification of patients at risk might be beneficial for intensive monitoring and timing delivery.
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Affiliation(s)
- Piya Chaemsaithong
- Department of Obstetrics and Gynecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - María M Gil
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain; Faculty of Health Sciences, Universidad Francisco de Vitoria, Madrid, Spain
| | - Noppadol Chaiyasit
- Maternal Fetal Medicine Division, Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Diana Cuenca-Gomez
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
| | - Walter Plasencia
- Department of Obstetrics and Gynecology, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Spain
| | - Valeria Rolle
- Biostatistics and Epidemiology Unit, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Liona C Poon
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region.
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Deng J, Zhao HJ, Zhong Y, Hu C, Meng J, Wang C, Lan X, Wang X, Chen ZJ, Yan J, Wang W, Li Y. H3K27me3-modulated Hofbauer cell BMP2 signalling enhancement compensates for shallow trophoblast invasion in preeclampsia. EBioMedicine 2023; 93:104664. [PMID: 37331163 DOI: 10.1016/j.ebiom.2023.104664] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Preeclampsia (PE) is a common hypertensive pregnancy disorder associated with shallow trophoblast invasion. Although bone morphogenetic protein 2 (BMP2) has been shown to promote trophoblast invasion in vitro, its cellular origin and molecular regulation in placenta, as well as its potential role in PE, has yet to be established. Additionally, whether BMP2 and/or its downstream molecules could serve as potential diagnostic or therapeutic targets for PE has not been explored. METHODS Placentas and sera from PE and healthy pregnant women were subjected to multi-omics analyses, immunoblots, qPCR, and ELISA assays. Immortalized trophoblast cells, primary cultures of human trophoblasts, and first-trimester villous explants were used for in vitro experiments. Adenovirus expressing sFlt-1 (Ad Flt1)-induced PE rat model was used for in vivo studies. FINDINGS We find globally decreased H3K27me3 modifications and increased BMP2 signalling in preeclamptic placentas, which is negatively correlated with clinical manifestations. BMP2 is derived from Hofbauer cells and epigenetically regulated by H3K27me3 modification. BMP2 promotes trophoblast invasion and vascular mimicry by upregulating BMP6 via BMPR1A-SMAD2/3-SMAD4 signalling. BMP2 supplementation alleviates high blood pressure and fetal growth restriction phenotypes in Ad Flt1-induced rat PE model. INTERPRETATION Our findings demonstrate that epigenetically regulated Hofbauer cell-derived BMP2 signalling enhancement in late gestation could serve as a compensatory response for shallow trophoblast invasion in PE, suggesting opportunities for diagnostic marker and therapeutic target applications in PE clinical management. FUNDING National Key Research and Development Program of China (2022YFC2702400), National Natural Science Foundation of China (82101784, 82171648, 31988101), and Natural Science Foundation of Shandong Province (ZR2020QH051, ZR2020MH039).
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Affiliation(s)
- Jianye Deng
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, 250012, China; Medical Integration and Practice Center, Shandong University, Jinan, Shandong, 250012, China
| | - Hong-Jin Zhao
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Cardiology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, 250021, China
| | - Ying Zhong
- Cardiovascular Research Center of the General Medical Services, Massachusetts General Hospital, Boston, MA, 02129, USA
| | - Cuiping Hu
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, 250012, China
| | - Jinlai Meng
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, 250021, China
| | - Chunling Wang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China
| | - Xiangxin Lan
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, 250012, China
| | - Xiyao Wang
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, 250012, China
| | - Zi-Jiang Chen
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, 250012, China
| | - Junhao Yan
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, 250012, China.
| | - Wei Wang
- Division of Neonatology, Department of Pediatrics, Massachusetts General Hospital, Boston, MA 02115, USA.
| | - Yan Li
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, 250012, China; Medical Integration and Practice Center, Shandong University, Jinan, Shandong, 250012, China.
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Kifle MM, Dahal P, Vatish M, Cerdeira AS, Ohuma EO. The prognostic utility of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PIGF) biomarkers for predicting preeclampsia: a secondary analysis of data from the INSPIRE trial. BMC Pregnancy Childbirth 2022; 22:520. [PMID: 35761268 PMCID: PMC9238141 DOI: 10.1186/s12884-022-04817-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Objective To compare the prognostic performance of biomarkers soluble fms-like tyrosine kinase-1 (sFlt-1), Placental Growth Factor (PIGF), and sFlt-1/PIGF ratio as continuous values or as a binary cut-off of 38 for predicting preeclampsia (PE) within 7 days. Design Secondary analysis of a randomised clinical trial. Setting Oxford University Hospitals, Oxford, United Kingdom (UK). Population Pregnant women between 24+0 to 37+0 weeks of gestation with a clinical suspicion of preeclampsia. Main outcome Onset of preeclampsia within 7 days of the initial biomarker test. Methods Logistic regression model for onset of preeclampsia using: (i) sFlt-1 (ii) PIGF, (iii) sFlt-1/PIGF ratio (continuous), and (iv) sFlt-1/PIGF ratio as a cut-off above or below 38. Results Of the total 370 women, 42 (11.3%) developed PE within 7 days of screening. Models with sFlt-1 and sFlt-1/PIGF ratio (continuous) had greater overall performance than models with PIGF or with sFlt-1/PIGF ratio as a cut-off at 38 (R2: sFlt-1 = 55%, PIGF = 38%, sFlt-1/PIGF ratio = 57%, sFlt-1/PIGF ratio as cut-off at 38 model = 46%). The discrimination performance was the highest in sFlt-1 and sFlt-1/PIGF ratio (continuous) (c-statistic, sFlt-1 = 0.94, sFlt-1/PIGF ratio (continuous) = 0.94) models compared to PIGF or sFlt-1/PIGF cut-off models (c-statistic, PIGF = 0.87, sFlt-1/PIGF cut-off = 0.89). Conclusion Models using continuous values of sFlt-1 only or sFlt-1/PIGF ratio had better predictive performance compared to a PIGF only or the model with sFlt-1/PIGF ratio as a cut-off at 38. Further studies based on a larger sample size are warranted to substantiate this finding.
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Affiliation(s)
- Meron M Kifle
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Prabin Dahal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Manu Vatish
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Ana Sofia Cerdeira
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Eric O Ohuma
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK. .,Maternal, Adolescent, Reproductive and Child Health Centre, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
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Shahid R, Bari MF, Hussain M. Serum biomarkers for the prediction and diagnosis of preeclampsia: A meta-analysis. J Taibah Univ Med Sci 2021; 17:14-27. [PMID: 35140561 PMCID: PMC8802864 DOI: 10.1016/j.jtumed.2021.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/19/2021] [Accepted: 07/06/2021] [Indexed: 12/02/2022] Open
Abstract
Objective Preeclampsia is a major risk factor for maternal and foetal mortality and morbidity. There have been tremendous efforts to identify serum biomarkers which can reliably predict the occurrence of preeclampsia. The study aims to assess the biomarkers that have the greatest utility in the diagnosis of preeclampsia. Methods A systematic search was performed on the PubMed literature database, and chain references were retrieved. Original research articles composed of case controls, cohorts, randomised control trials, and cross-sectional studies were included. The recorded variables included each study's design, type, year, and location; the value (mean ± standard deviation) of the markers in the patients and the pregnant controls; and the p-value, unit of measurement, and the sample size of each study. The results were interpreted based on the standardised mean difference (SMD) values. Results A total of 398 studies were retrieved from the PubMed database. After further analysis, 89 studies were selected for this review. An additional 47 studies were included based on chain referencing. Later, 136 full-text articles were reviewed in detail and their data were entered. Finally, 25 studies, in which 13 serum biomarkers were assessed, were selected for this meta-analysis. The levels of the angiogenic markers fms-like tyrosine kinase (sFlt), sFlt/placental growth factor (PlGF), and endoglin were significantly higher in patients with preeclampsia than in the pregnant controls. The levels of PlGF and the lipid biomarkers high density lipoprotein (HDL) and adiponectin were significantly lower, while the levels of triglycerides, apolipoprotein B (APO-B), and leptin were elevated in the preeclamptic patients compared to the pregnant controls (p < 0.05). Conclusion In our study, the values of the serum biomarkers sFlt, PlGF, sFlt/PlGF, HDL, adiponectin, leptin, triglycerides, and APO-B differed significantly between preeclampsia patients and the pregnant controls. These findings demand advanced evaluation of biomarkers to enhance diagnostic screening for preeclampsia.
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5
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Biomarkers and the Prediction of Adverse Outcomes in Preeclampsia: A Systematic Review and Meta-analysis. Obstet Gynecol 2021; 137:72-81. [PMID: 33278298 DOI: 10.1097/aog.0000000000004149] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/20/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To systematically review the performance of soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), and the sFlt-1/PlGF ratio in predicting adverse outcomes in women with preeclampsia. DATA SOURCES We performed a systematic search of MEDLINE, EMBASE, CINAHL, Cochrane, Scopus, ClinicalTrials.gov, and Emcare databases from 1989 to March 2019 to identify studies correlating sFlt-1, PlGF, and the sFlt-1/PlGF ratio with the occurrence of adverse outcomes in women with preeclampsia. METHODS OF STUDY SELECTION Two independent reviewers screened 3,194 studies using Covidence. Studies were included if they examined the performance of sFLT-1, PlGF, or the sFLT-1/PlGF ratio in predicting adverse outcomes in women with suspected or confirmed preeclampsia. TABULATION, INTEGRATION, AND RESULTS We extracted contingency tables with true-positive, false-positive, true-negative, and false-negative results. We calculated sensitivity, specificity, diagnostic odds ratios, and area under the summary receiver operating characteristic curve (area sROC) through a bivariate mixed-effects meta-analysis. Our literature search identified 3,194 articles, of which 33 (n=9,426 patients) were included. There was significant variation in the included studies with regard to the biomarkers and outcomes assessed. As such, few studies (n=4-8) were included in the meta-analysis component with significant heterogeneity between studies (I2=33-99). Nonetheless, both PlGF and the sFlt-1/PlGF ratio demonstrated area sROC values between 0.68 and 0.87 for the prediction of composite adverse maternal and perinatal outcomes, preterm birth and fetal growth restriction. CONCLUSION Placental growth factor and the sFlt-1/PlGF ratio show prognostic promise for adverse outcomes in preeclampsia, but study heterogeneity limits their clinical utility. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42019136207.
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Sun G, Xu Q, Zhang S, Yang L, Liu G, Meng Y, Chen A, Yang Y, Li X, Hao D, Liu X, Shao J. Predicting hypertensive disorders in pregnancy using multiple methods: Models with the placental growth factor parameter. Technol Health Care 2021; 29:427-432. [PMID: 33682779 PMCID: PMC8150465 DOI: 10.3233/thc-218040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Placental growth factor (PlGF), one of the biomarkers, has a certain predictive effect on hypertensive disorders in pregnancy (HDP). OBJECTIVE To study the HDP prediction effect of different methods for variable selection and modeling for models containing PlGF. METHODS For the model containing PlGF, the appropriate range of PlGF parameters needed to be selected. Step-logistic regression and lasso were used to compare the model effect of twice range selection. The PlGF model with good predictive effect and appropriate detecting gestational age was selected for the final prediction. RESULTS The effect of the model containing PlGF tested at 15-16 weeks was better than the PlGF value without comprehensive screening. The sensitivity of both methods was over 92%. By comprehensive comparison, the final model of lasso method in this study was more effective. CONCLUSIONS In this study, a variety of methods were used to screen models containing PlGF parameters. According to clinical needs and model effects, the optimal HDP prediction model with PlGF parameters in the second trimester of 15-26 weeks of pregnancy was finally selected.
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Affiliation(s)
- Ge Sun
- Faculty of Environment and Life Sciences, Beijing University of Technology, Beijing 100124, China.,Beijing International Science and Technology Cooperation Base for Intelligent Physiological Measurement and Clinical Transformation, Beijing 100124, China
| | - Qi Xu
- Peking University People's Hospital, Beijing 100044, China
| | - Song Zhang
- Faculty of Environment and Life Sciences, Beijing University of Technology, Beijing 100124, China.,Beijing International Science and Technology Cooperation Base for Intelligent Physiological Measurement and Clinical Transformation, Beijing 100124, China
| | - Lin Yang
- Faculty of Environment and Life Sciences, Beijing University of Technology, Beijing 100124, China.,Beijing International Science and Technology Cooperation Base for Intelligent Physiological Measurement and Clinical Transformation, Beijing 100124, China
| | - Guoli Liu
- Peking University People's Hospital, Beijing 100044, China
| | - Yu Meng
- Faculty of Environment and Life Sciences, Beijing University of Technology, Beijing 100124, China.,Beijing International Science and Technology Cooperation Base for Intelligent Physiological Measurement and Clinical Transformation, Beijing 100124, China
| | - Aiqing Chen
- Beijing Yes Medical Devices Co. Ltd., Beijing 100152, China
| | - Yimin Yang
- Faculty of Environment and Life Sciences, Beijing University of Technology, Beijing 100124, China.,Beijing International Science and Technology Cooperation Base for Intelligent Physiological Measurement and Clinical Transformation, Beijing 100124, China
| | - Xuwen Li
- Faculty of Environment and Life Sciences, Beijing University of Technology, Beijing 100124, China.,Beijing International Science and Technology Cooperation Base for Intelligent Physiological Measurement and Clinical Transformation, Beijing 100124, China
| | - Dongmei Hao
- Faculty of Environment and Life Sciences, Beijing University of Technology, Beijing 100124, China.,Beijing International Science and Technology Cooperation Base for Intelligent Physiological Measurement and Clinical Transformation, Beijing 100124, China
| | - Xiaohong Liu
- Beijing Yes Medical Devices Co. Ltd., Beijing 100152, China
| | - Jing Shao
- Beijing Yes Medical Devices Co. Ltd., Beijing 100152, China
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Takeshita S, Kakita H, Toriuchi K, Aoki H, Ueda H, Wakatsuki A, Yamada Y, Aoyama M. Insufficient thrombopoietin due to hepatic dysmature results in thrombocytopenia in small-for-gestational-age rats. Br J Haematol 2021; 192:e105-e108. [PMID: 33403676 DOI: 10.1111/bjh.17294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/26/2020] [Accepted: 12/01/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Satoru Takeshita
- Department of Pathobiology, Nagoya City University Graduate School of Pharmaceutical Sciences, 3-1 Tanabe-dori, Mizoho-ku, Nagoya, Aichi, 467-8603, Japan.,Department of Perinatal and Neonatal Medicine, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Hiroki Kakita
- Department of Pathobiology, Nagoya City University Graduate School of Pharmaceutical Sciences, 3-1 Tanabe-dori, Mizoho-ku, Nagoya, Aichi, 467-8603, Japan.,Department of Perinatal and Neonatal Medicine, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Kohki Toriuchi
- Department of Pathobiology, Nagoya City University Graduate School of Pharmaceutical Sciences, 3-1 Tanabe-dori, Mizoho-ku, Nagoya, Aichi, 467-8603, Japan
| | - Hiromasa Aoki
- Department of Pathobiology, Nagoya City University Graduate School of Pharmaceutical Sciences, 3-1 Tanabe-dori, Mizoho-ku, Nagoya, Aichi, 467-8603, Japan
| | - Hiroko Ueda
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Akihiko Wakatsuki
- Department of Obstetrics and Gynecology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Yasumasa Yamada
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Mineyoshi Aoyama
- Department of Pathobiology, Nagoya City University Graduate School of Pharmaceutical Sciences, 3-1 Tanabe-dori, Mizoho-ku, Nagoya, Aichi, 467-8603, Japan
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Ukah UV, Payne BA, Hutcheon JA, Chappell LC, Seed PT, Conti-Ramsden FI, Ansermino JM, Magee LA, von Dadelszen P. Placental growth factor for the prognosis of women with preeclampsia (fullPIERS model extension): context matters. BMC Pregnancy Childbirth 2020; 20:668. [PMID: 33153436 PMCID: PMC7643272 DOI: 10.1186/s12884-020-03332-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/09/2020] [Indexed: 12/12/2022] Open
Abstract
Background The fullPIERS risk prediction model was developed to identify which women admitted with confirmed diagnosis of preeclampsia are at highest risk of developing serious maternal complications. The model discriminates well between women who develop (vs. those who do not) adverse maternal outcomes. It has been externally validated in several populations. We assessed whether placental growth factor (PlGF), a biomarker associated with preeclampsia risk, adds incremental value to the fullPIERS model. Methods Using a cohort of women admitted into tertiary hospitals in well-resourced settings (the USA and Canada), between May 2010 to February 2012, we evaluated the incremental value of PlGF added to fullPIERS for prediction of adverse maternal outcomes within 48 h after admission with confirmed preeclampsia. The discriminatory performance of PlGF and the fullPIERS model were assessed in this cohort using the area under the receiver’s operating characteristic curve (AUROC) while the extended model (fullPIERS +PlGF) was assessed based on net reclassification index (NRI) and integrated discrimination improvement (IDI) performances. Results In a cohort of 541 women delivered shortly (< 1 week) after presentation, 8.1% experienced an adverse maternal outcome within 48 h of admission. Prediction of adverse maternal outcomes was not improved by addition of PlGF to fullPIERS (NRI: -8.7, IDI − 0.06). Discriminatory performance (AUROC) was 0.67 [95%CI: 0.59–0.75] for fullPIERS only and 0.67 [95%CI: 0.58–0.76]) for fullPIERS extended with PlGF, a performance worse than previously documented in fullPIERS external validation studies (AUROC > 0.75). Conclusions While fullPIERS model performance may have been affected by differences in healthcare context between this study cohort and the model development and validation cohorts, future studies are required to confirm whether PlGF adds incremental benefit to the fullPIERS model for prediction of adverse maternal outcomes in preeclampsia in settings where expectant management is practiced.
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Affiliation(s)
- U Vivian Ukah
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, H3A 1A2, Canada.
| | - Beth A Payne
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer A Hutcheon
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Frances Inez Conti-Ramsden
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - J Mark Ansermino
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Anaesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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Giardini V, Rovelli R, Algeri P, Giunti L, Lazzarin S, Callegari C, Roncaglia N, Vergani P. Placental growth factor as a predictive marker of preeclampsia - PREBIO study - PREeclampsia BIOchemical study. J Matern Fetal Neonatal Med 2020; 35:3029-3035. [PMID: 32689860 DOI: 10.1080/14767058.2020.1792878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION To evaluate the clinical utility of placental growth factor (PlGF) for the prediction of preeclampsia (PE). MATERIALS AND METHODS This prospective cohort study included women divided into three groups: (1) pregnancies without preconceptional risk of developing PE; (2) pregnancies with a preconceptional and/or current risk of developing PE; (3) PE-complicated pregnancies (control group). Blood samples were collected every 4-5 weeks or during hospitalization from early second trimester until delivery in the group 1 and 2, at the diagnosis of PE in the group 3. Plasma levels of PlGF were measured using The Triage PlGF test (Alere) and considered pathological under the 5th centile for gestational age. Sensitivity (Sn), specificity (Sp), positive and negative predictive value (PPV, NPV) were calculated. RESULTS In group 1, 30% of women (3/10) had pathological test but none of them developed PE (Sp 70%, NPV 100%). In group 2 (n = 75), none of the patients with normal test developed PE (0/24), while 39% of women with PlGF < 5th centile (20/51) developed PE (Sn 100%, Sp 44%, PPV 39%, NPV 100%). In group 3 (n = 11) all women except one had a pathological PlGF test (Sn 90%, PPV 100%). CONCLUSIONS Our data support recent studies which identify PlGF as a biochemical marker not only of PE, but also of placental dysfunction. In fact, it is useful for ruling out PE in women at risk because of the high Sn and high NPV: a normal PlGF is related with a positive pregnancy outcome. Therefore, the measurement of this biomarker would simplify PE clinical management and would reduce costs.
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Affiliation(s)
- Valentina Giardini
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, MBBM Foundation, S. Gerardo Hospital, Monza, Italy
| | - Roberta Rovelli
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, MBBM Foundation, S. Gerardo Hospital, Monza, Italy
| | - Paola Algeri
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, MBBM Foundation, S. Gerardo Hospital, Monza, Italy
| | - Laura Giunti
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, MBBM Foundation, S. Gerardo Hospital, Monza, Italy
| | - Sara Lazzarin
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, MBBM Foundation, S. Gerardo Hospital, Monza, Italy
| | - Clelia Callegari
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, MBBM Foundation, S. Gerardo Hospital, Monza, Italy
| | - Nadia Roncaglia
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, MBBM Foundation, S. Gerardo Hospital, Monza, Italy
| | - Patrizia Vergani
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, MBBM Foundation, S. Gerardo Hospital, Monza, Italy
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Abstract
PURPOSE OF REVIEW Preeclampsia remains an important cause of maternal and neonatal morbidity and mortality. Recent interest in angiogenic biomarkers as a prognostic indicator is reviewed, together with analgesic, anaesthetic and critical-care management of the preeclamptic patient. RECENT FINDINGS There has been recent interest in the angiogenic biomarkers placental growth factor and soluble fms-like tyrosine kinase-1 in establishing the diagnosis of preeclampsia and guiding its management. Neuraxial blocks are recommended for both labour and operative delivery if not contraindicated by thrombocytopenia or coagulopathy, although a safe lower limit for platelet numbers has not been established. For spinal hypotension phenylephrine is noninferior to ephedrine in preeclamptic parturients and may offer some benefits. When general anaesthesia is required, efforts must be made to blunt the hypertensive response to laryngoscopy and intubation. Transthoracic echocardiography has emerged as useful technique to monitor maternal haemodynamics in preeclampsia. SUMMARY Improvements in the diagnosis of preeclampsia may lead to better outcomes for mothers and babies. Peripartum care requires a multidisciplinary team approach with many preeclamptic women receiving neuraxial analgesia or anaesthesia. Women with severe preeclampsia may require critical-care support and this should meet the same standards afforded to other acutely unwell patients.
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Moresi S, Martino C, Salvi S, Del Sordo G, Fruci S, Garofalo S, Lanzone A, De Carolis S, Ferrazzani S. Perinatal outcome in gestational hypertension: Which role for developing preeclampsia. A population-based cohort study. Eur J Obstet Gynecol Reprod Biol 2020; 251:218-222. [PMID: 32559606 DOI: 10.1016/j.ejogrb.2020.05.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To analyze perinatal outcome in singleton pregnancies complicated by gestational hypertension (GH), to investigate the rate of women developing preeclampsia (PE) and to describe maternal features associated with progression to PE. STUDY DESIGN This is a population-based retrospective cohort-study involving 514 singleton pregnancies with a diagnosis of GH at admission. RESULTS In pregnancies with GH, a poorer pregnancy outcome in comparison to healthy controls was observed in terms of gestational age at delivery, birthweight and birthweight percentile. The observed overall rate of developing PE was 11.7 %. Of all pregnancies with GH at admission, two different groups were identified based on the diagnosis at delivery: GHPE, i.e. women who developed PE (60/514; 11.7 %), and GHnoPE, i.e. women who did not develop PE (454/514; 88.3 %). In the GHPE group it was observed that the 62 % of the women with diagnosis of GH earlier than 28 weeks developed PE while only 2% developed PE if the diagnosis of GH was performed later than 36 weeks. The observed rate of developing PE was 14.7 % in pharmacologically treated hypertensive women, whereas the diagnosis of PE has been made in only 3% of non-treated women. CONCLUSION Pregnant women with raised blood pressure are at risk of having a less favourable perinatal outcome. The risk is mainly associated with the progression to PE. Major determinants of the risk of developing PE are the earlier gestational age at diagnosis of GH, the necessity of treatment and the number of anti-hypertensive drugs needed for controlling blood pressure.
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Affiliation(s)
- Sascia Moresi
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Carmelinda Martino
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Silvia Salvi
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Gelsomina Del Sordo
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Stefano Fruci
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, L.go Francesco Vito 1, Roma, Italy.
| | - Serafina Garofalo
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Antonio Lanzone
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy; Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, L.go Francesco Vito 1, Roma, Italy.
| | - Sara De Carolis
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy; Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, L.go Francesco Vito 1, Roma, Italy.
| | - Sergio Ferrazzani
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy; Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, L.go Francesco Vito 1, Roma, Italy.
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Enengl S, Mayer RB, Le Renard PE, Shebl O, Arzt W, Oppelt P. Retrospective evaluation of established cut-off values for the sFlt-1/PlGF ratio for predicting imminent delivery in preeclampsia patients. Pregnancy Hypertens 2020; 19:143-149. [DOI: 10.1016/j.preghy.2020.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 01/06/2020] [Accepted: 01/12/2020] [Indexed: 10/25/2022]
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13
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Affiliation(s)
- Basky Thilaganathan
- From the Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, United Kingdom (B.T.).,Molecular and Clinical Sciences Research Institute, St George's University of London, United Kingdom (B.T.)
| | - Erkan Kalafat
- Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara University, Turkey (E.K.)
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Dunn L, Sherrell H, Bligh L, Alsolai A, Flatley C, Kumar S. Reference centiles for maternal placental growth factor levels at term from a low-risk population. Placenta 2019; 86:15-19. [PMID: 31494398 DOI: 10.1016/j.placenta.2019.08.086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/16/2019] [Accepted: 08/24/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Placental growth factor (PLGF) is a biomarker of placental function. The aim of this study was to define reference ranges for maternal PLGF levels in a normotensive cohort ≥36 + 0 weeks. METHOD Prospective observational data from Mater Mothers' Hospital, Brisbane. PLGF levels were measured in women at ≥36 + 0 weeks with singleton, non-anomalous pregnancies. Women with hypertension and fetal growth restriction were excluded. PLGF (pg/mL) was assayed using DELFIA® Xpress (PerkinElmer Inc). The Generalised Additive Model for Location, Shape and Scale (GAMLSS) method was used for the calculation of gestational age-adjusted centiles. Data analysis was performed with Stata 13 (StataCorp, LLC) and R software (R Foundation for Statistical Computing, Vienna, Austria). In all women, PLGF was measured within 2 weeks of delivery. RESULTS The study cohort comprised of 845 women (36 weeks n = 73, 37 weeks n = 230, 38 weeks n = 214, 39 weeks n = 172, 40 weeks n = 115, 41weeks n = 41). PLGF levels were negatively correlated with gestational age (r = -0.20, p < 0.001). Median PLGF levels dropped significantly from 36 weeks to 41 weeks (169.0 pg/mL to 96.6 pg/mL, p < 0.001). Gestational age specific maternal PLGF centiles were reported using fractional polynomial additive term and Box-Cox t distribution. PLGF did not perform adequately as a predictive test for adverse perinatal outcomes (AUC <0.6). DISCUSSION We have created gestational centile reference ranges for maternal PLGF from a normotensive cohort. These novel data suggest maternal PLGF levels decline ≥36 + 0 weeks. The utility of PLGF as a predictor of adverse perinatal outcomes at term, should be further investigated with clinical trials.
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Affiliation(s)
- Liam Dunn
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
| | - Helen Sherrell
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
| | - Larissa Bligh
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
| | - Amal Alsolai
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
| | - Christopher Flatley
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia; Faculty of Medicine, The University of Queensland, 288 Herston Road, Herston, Queensland, 4006, Australia.
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15
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Ngene NC, Moodley J, Naicker T. The performance of pre-delivery serum concentrations of angiogenic factors in predicting postpartum antihypertensive drug therapy following abdominal delivery in severe preeclampsia and normotensive pregnancy. PLoS One 2019; 14:e0215807. [PMID: 31022243 PMCID: PMC6485032 DOI: 10.1371/journal.pone.0215807] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 04/09/2019] [Indexed: 01/07/2023] Open
Abstract
Background The imbalance between circulating concentrations of anti- and pro-angiogenic
factors is usually intense in preeclampsia with severe features (sPE). It is
possible that pre-delivery circulating levels of angiogenic factors in sPE
may be associated with postpartum antihypertensive drug requirements. Objective To determine the predictive association between maternal pre-delivery serum
concentrations of angiogenic factors and the use of ≥3 slow- and/or a
rapid-acting antihypertensive drug therapy in sPE on postpartum days zero to
three following caesarean delivery. Study design Women with sPE (n = 50) and normotensive pregnancies (n = 90) were recruited
prior to childbirth. Serum samples were obtained from each participant <
48 hours before delivery to assess the concentrations of placental growth
factor (PIGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) using the
Roche Elecsys platform. Each participant was followed up on postpartum days
zero, one, two and three to monitor BP and confirm antihypertensive
treatment. The optimal cut-off thresholds of sFlt-1/PIGF ratio from receiver
operating characteristic curve predictive of the antihypertensive therapy
were subjected to diagnostic accuracy assessment. Results The majority 58% (29/50) of sPE had multiple severe features of preeclampsia
in the antenatal period with the commonest presentation being severe
hypertension in 88% (44/50) of this group, followed by features of impending
eclampsia which occurred in 42% (21/50). The median gestational age at
delivery was 38 (Interquartile range, IQR 1) vs 36 (IQR 6)
weeks, p < 0.001 in normotensive and sPE groups
respectively. Notably, the median sFlt-1/PIGF ratio in normotensive and sPE
groups were 7.3 (IQR 17.9) and 179.1 (IQR 271.2) respectively,
p < 0.001. Of the 50 sPE participants, 34% (17/50)
had early-onset preeclampsia. The median (IQR) of sFlt-1/PIGF in the early-
and late-onset preeclampsia groups were 313.52 (502.25), and 166.59(195.37)
respectively, p = 0.006. From postpartum days zero to
three, 48% (24/50) of sPE received ≥ 3 slow- and/or a rapid-acting
antihypertensive drug. However, the daily administration of ≥ 3 slow- and/or
a rapid-acting antihypertensive drug in sPE were pre-delivery 26% (13/50),
postpartum day zero 18% (9/50), postpartum day one 34% (17/50), postpartum
day two 24% (12/50) and postpartum day three 20% (10/50). In sPE, the
pre-delivery sFlt-1/PIGF ratio was predictive of administration of ≥3 slow-
and/or a rapid-acting antihypertensive drug on postpartum days zero, one and
two with the optimal cut-off ratio being ≥315.0, ≥181.5 and ≥ 267.8
respectively (sensitivity 72.7–75.0%, specificity 64.7–78.6%, positive
predictive value 40.0–50.0% and negative predictive value 84.6% - 94.3%).
The predictive performance of sFlt-1/PIG ratio on postpartum day 3 among the
sPE was not statistically significant (area under receiver operating
characteristic curve, 0.6; 95% CI, 0.3–0.8). Conclusion A pre-delivery sFlt-1/PIGF ratio (< 181.5) is a promising predictor for
excluding the need for ≥3 slow- and/or a rapid-acting antihypertensive drug
therapy in the immediate postpartum period in sPE.
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Affiliation(s)
- Nnabuike Chibuoke Ngene
- Department of Obstetrics and Gynaecology, University of KwaZulu-Natal,
South Africa
- * E-mail:
| | - Jagidesa Moodley
- Women’s Health and HIV Research Group, Department of Obstetrics and
Gynaecology, University of KwaZulu-Natal, South Africa
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Wiles K, Bramham K, Seed PT, Kurlak LO, Mistry HD, Nelson-Piercy C, Lightstone L, Chappell LC. Diagnostic Indicators of Superimposed Preeclampsia in Women With CKD. Kidney Int Rep 2019; 4:842-853. [PMID: 31194119 PMCID: PMC6551530 DOI: 10.1016/j.ekir.2019.03.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 02/11/2019] [Accepted: 03/11/2019] [Indexed: 12/23/2022] Open
Abstract
Introduction Diagnosis of superimposed preeclampsia in women with chronic kidney disease (CKD) is complicated by the presence of hypertension and proteinuria due to renal disease. The aims of this study were to determine mechanistic links between superimposed preeclampsia and renin-angiotensin system activation, endothelial pathology, complement dysfunction, and tubular injury, and to explore the role of diagnostic indicators of superimposed preeclampsia. Methods Plasma and urinary biomarkers derived from the renin-angiotensin system (active renin, angiotensinogen), endothelial glycocalyx (hyaluronan, intercellular adhesion molecule, vascular cell adhesion molecule [VCAM], P-selectin, E-selectin), complement activation (C3a, C5a, complement factor H, C5b-9), and tubular injury (kidney injury molecule-1, urinary lipocalin-2) were quantified in 60 pregnant women with CKD including 15 women at the time of superimposed preeclampsia diagnosis and 45 women who did not develop superimposed preeclampsia, 18 women with preeclampsia, and 20 normal pregnancies. Correlation with placental growth factor was assessed. Results Plasma concentrations of hyaluronan (67.5 ng/ml vs. 27.5 ng/ml, P = 0.0017, receiver operating characteristic area 0.80) and VCAM (1132 ng/ml vs. 659 ng/ml, P < 0.0001, receiver operating characteristic area 0.86) distinguished women with CKD and superimposed preeclampsia from those without superimposed preeclampsia, and correlated with placental growth factor concentration. The diagnostic discrimination of markers of the renin-angiotensin system was reduced by adjustment for chronic hypertension, antihypertensive drug use, and black ethnicity. Other markers offered limited or no diagnostic discrimination for superimposed preeclampsia. Conclusion This study suggests that endothelial dysfunction contributes to the pathophysiology of superimposed preeclampsia and a diagnostic role for plasma hyaluronan and VCAM is hypothesized.
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Affiliation(s)
- Kate Wiles
- Department of Women and Children's Health, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Kate Bramham
- Department of Renal Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, King's College London, London, UK
| | - Lesia O Kurlak
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Hiten D Mistry
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Catherine Nelson-Piercy
- Guy's and St Thomas' NHS Foundation Trust and Imperial College Healthcare NHS Trust, London, UK
| | - Liz Lightstone
- Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, London, UK
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Almaani SJ. Placental growth factor in pre-eclampsia: friend or foe? Kidney Int 2019; 95:730-732. [PMID: 30904058 DOI: 10.1016/j.kint.2019.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 02/11/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Salem J Almaani
- Department of Medicine, Division of Nephrology; Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
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Flint EJ, Cerdeira AS, Redman CW, Vatish M. The role of angiogenic factors in the management of preeclampsia. Acta Obstet Gynecol Scand 2019; 98:700-707. [PMID: 30667052 DOI: 10.1111/aogs.13540] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 01/03/2023]
Abstract
Preeclampsia is a pregnancy disorder causing substantial maternal and fetal morbidity and mortality. In the UK, its diagnosis currently depends upon new onset hypertension and proteinuria. There is a clinical need for enhanced screening to prevent unnecessary resource use and improve outcomes. Here, the current practice in preeclampsia diagnosis will be summarized, with assessment of the evidence that angiogenic factors could improve its management. Although the combination of new onset hypertension and proteinuria define and hence diagnose the disorder, separately they are poorly predictive. Preeclampsia is ultimately a placental disease caused by syncytiotrophoblast dysfunction. The angiogenic factors placental growth factor, soluble fms-like tyrosine kinase 1 and soluble endoglin, all originating at least in part from the syncytiotrophoblast, are biomarkers with predictive potential for preeclampsia and related adverse outcomes. Recent work with the soluble fms-like tyrosine kinase 1/placental growth factor ratio has identified key measurement cutoffs, with one having a high negative predictive value for preeclampsia. The soluble fms-like tyrosine kinase 1/placental growth factor ratio seems particularly promising as a screening measure, able to predict accurately the short-term absence of preeclampsia and suggest the likelihood of adverse events within 4 weeks. The ratio could be used to allocate specific management plans to patients according to risk. An understanding of angiogenic factors may also lead to new therapeutic options for a condition currently only curable by delivery, although it must be remembered that the factors are markers of underlying syncytiotrophoblast stress, which would not be resolved by targeting them.
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Affiliation(s)
- Emma J Flint
- Wadham College, University of Oxford, Oxford, UK
| | - A Sofia Cerdeira
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Christopher W Redman
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Manu Vatish
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
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Shahid S, Khalid E, Fatima SS, Khan GM. Evaluation of soluble TNF-like weak inducer of apoptosis (sTWEAK) levels to predict preeclampsia in early weeks of pregnancy. Eur J Obstet Gynecol Reprod Biol 2019; 234:165-170. [PMID: 30708268 DOI: 10.1016/j.ejogrb.2019.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/02/2019] [Accepted: 01/14/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Soluble tumor necrosis factor-like weak inducer of apoptosis (sTWEAK) is linked to endothelial dysfunction; a key factor in pre-eclamptic pathogenesis. This study aimed to compare sTWEAK levels during pregnancy to assess for its prognostic ability. MATERIALS AND METHODS Sixty three high risk pregnant women were followed up from 12 weeks of gestation till term. Serum levels of sTWEAK and platelet derived growth factor (PlGF), blood pressure, serum glucose, uric acid, urea/creatinine and liver function tests were measured. Subjects were stratified according to the ACOG criteria as women who developed PE, or PIH or remained normotensive at term. A negative control group of normotensive healthy pregnant women (n = 17) was also recruited for comparison. RESULTS Baseline sTWEAK levels were lower (4.03 ± 0.37 ng/dl) in HR cohort that developed PE and further reduced at term (1.93 ± 0.23 ng/dl) as compared to HR subjects who remained normotensive and negative control group (30.53 ± 0.79 ng/dl; p < 0.01). Likewise PlGF levels were significantly lower (74.22 ± 10.11 pg/ml) in HR cohort that developed PE (p = 0.013). At term 39.68% (n = 22) HR subjects with low sTWEAK developed PIH and 34.92% (n = 24) developed PE. In terms of high risk characteristics observed in the HR group; 73% of the subjects were multiparous, whereas 26.98% reported to have developed PE in previous pregnancies. CONCLUSION sTWEAK levels at early pregnancy weeks were found to be low in high risk females who developed PE at follow up versus normotensive pregnant women. Baseline TWEAK might serve as an independent variable for prediction of pre-eclampsia; however longitudinal studies with larger sample size are required to ascertain the causal relation.
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Affiliation(s)
- Sana Shahid
- Department of Physiology, Sir Syed College of Medical Sciences for Girls, Karachi, Pakistan
| | - Erum Khalid
- Department of Obstetrics and Gynecology, Taj Medical Complex, Hamdard University, Pakistan
| | - Syeda Sadia Fatima
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan.
| | - Ghulam Mustafa Khan
- Department of Physiology, Basic Medical Science Institute, Karachi, Pakistan
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Huppertz B. Biology of preeclampsia: Combined actions of angiogenic factors, their receptors and placental proteins. Biochim Biophys Acta Mol Basis Dis 2018; 1866:165349. [PMID: 30553017 DOI: 10.1016/j.bbadis.2018.11.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/07/2018] [Accepted: 11/22/2018] [Indexed: 12/13/2022]
Abstract
Although massive efforts have been undertaken to elucidate the etiology of the pregnancy syndrome preeclampsia, its developmental origin remains a mystery. Most efforts of the last decade have focused on biomarkers to predict and/or diagnose preeclampsia, including the anti-angiogenic factor sFlt-1 (soluble fms-like tyrosin kinase-1), the angiogenic factor PGF (placental growth factor) and PP13 (placental protein 13). The origins of these marker proteins are still under debate, and so far their actions have only been describe separate from each other. This study will focus on the origins and actions of all three markers during pregnancy and outside pregnancy and will describe a scenario where all three markers act synergistically to rescue the mother from the deleterious effects of the debris that is released from the placenta during preeclampsia. This more holistic approach may open new avenues to think about maternal-fetal interactions and putative therapies.
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Affiliation(s)
- Berthold Huppertz
- Division of Cell Biology, Histology and Embryology, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria.
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21
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Huppertz B. An updated view on the origin and use of angiogenic biomarkers for preeclampsia. Expert Rev Mol Diagn 2018; 18:1053-1061. [PMID: 30413130 DOI: 10.1080/14737159.2018.1546579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: The last decade has seen massive efforts towards the identification and the potential use of predictive biomarkers for the pregnancy pathology preeclampsia. The angiogenic factors sFlt-1 and placental growth factor (PGF) have been in focus and have been massively supported. Areas covered: This review describes preeclampsia and intra-uterine growth restriction (IUGR), focusing on sFlt-1 and PGF, their sources during and outside pregnancy and the application of these markers in diseases outside pregnancy. Finally, the specificity of the angiogenic markers for preeclampsia is discussed. Expert commentary: The admixture of the two independent syndromes preeclampsia and IUGR has not helped in identifying the etiologies of either. Rather, it has made the search for new markers and pathways much more complicated as has the constriction on the angiogenic markers. The current markers sFlt-1 and PGF have a clear value once an adverse outcome is diagnosed but are not specific for preeclampsia. Also, they are mostly derived from the maternal vascular system rather than the placenta and are already in use as markers outside pregnancy. A new holistic approach using disease maps and interoperable workflows based on topic-related big data will help in broadening our understanding of the etiology of preeclampsia and hence, develop new markers and therapies.
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Affiliation(s)
- Berthold Huppertz
- a Division of Cell Biology, Histology and Embryology , Gottfried Schatz Research Center, Medical University of Graz , Graz , Austria
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22
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Higgins LE, Myers JE, Sibley CP, Johnstone ED, Heazell AEP. Antenatal placental assessment in the prediction of adverse pregnancy outcome after reduced fetal movement. PLoS One 2018; 13:e0206533. [PMID: 30395584 PMCID: PMC6218043 DOI: 10.1371/journal.pone.0206533] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 10/15/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To assess the value of in utero placental assessment in predicting adverse pregnancy outcome after reported reduced fetal movements (RFM). METHOD A non-interventional prospective cohort study of women (N = 300) with subjective RFM at ≥28 weeks' gestation in singleton non-anomalous pregnancies at a UK tertiary maternity hospital. Clinical, sonographic (fetal weight, placental size and maternal, fetal and placental arterial Doppler) and biochemical (maternal serum hCG, hPL, progesterone, PlGF and sFlt-1) assessment was conducted. Multiple logistic regression identified combinations of measurements (models) most predictive of adverse pregnancy outcome (perinatal mortality, birth weight <10th centile, five minute Apgar score <7, umbilical arterial pH <7.1 or base excess <-10, neonatal intensive care admission). Models were compared by test performance characteristics (ROC curve, sensitivity, specificity, positive/negative predictive value, positive/negative likelihood ratios) against baseline care (estimated fetal weight centile, amniotic fluid index and gestation at presentation). RESULTS 61 (20.6%) pregnancies ended in adverse outcome. Models incorporating PlGF/sFlt-1 ratio and umbilical artery free loop Doppler impedance demonstrated modest improvement in ROC area for adverse outcome (baseline care 0.69 vs. proposed models 0.73-0.76, p<0.05). However, there was little improvement in other test characteristics (baseline vs. best proposed model: sensitivity 21.7% [95% confidence interval 13.1-33.6] vs. 35.8%% [24.4-49.3], specificity 96.6% [93.4-98.3] vs. 94.7% [90.7-97.0], PPV 61.9% [40.9-79.3] vs. 63.3% [45.5-78.1], NPV 82.8% [77.9-86.8] vs. 85.2% [80.0-89.2], positive LR 6.3 [2.8-14.6] vs. 6.7 [3.4-3.3], negative LR 0.81 [0.71-0.93] vs. 0.68 [0.55-0.83]) and wide confidence intervals. Negative post-test probability remained high (16.7% vs. 14.0%). CONCLUSION Antenatal placental assessment may improve identification of RFM pregnancies at highest risk of adverse pregnancy outcome but further work is required to understand and refine currently available outcome definitions and diagnostic techniques to improve clinical utility.
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Affiliation(s)
- Lucy E. Higgins
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Jenny E. Myers
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Colin P. Sibley
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Edward D. Johnstone
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Alexander E. P. Heazell
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
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23
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Novelli GP, Vasapollo B, Valensise H. Hemodynamic Prediction and Stratification of Hypertensive Disorders of Pregnancy: A Dream That Is Coming True? J Am Heart Assoc 2018; 7:JAHA.118.010084. [PMID: 30007938 PMCID: PMC6064850 DOI: 10.1161/jaha.118.010084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- Gian Paolo Novelli
- Department of Cardiology, Ospedale San Sebastiano Martire, Frascati, Rome, Italy
| | - Barbara Vasapollo
- Department of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Herbert Valensise
- Department of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy.,Department of Obstetrics and Gynecology, Tor Vergata University, Rome, Italy
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24
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McLaughlin K, Zhang J, Lye SJ, Parker JD, Kingdom JC. Phenotypes of Pregnant Women Who Subsequently Develop Hypertension in Pregnancy. J Am Heart Assoc 2018; 7:JAHA.118.009595. [PMID: 30007936 PMCID: PMC6064839 DOI: 10.1161/jaha.118.009595] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hypertensive disorders complicating pregnancy are a major cause of maternal death. Our objective was to evaluate maternal clinical, hemodynamic, and placental prognostic indicators in a consolidated manner to identify women who develop hypertension in pregnancy. METHODS AND RESULTS Twenty-six normotensive pregnant women from a specialized Placenta Clinic at increased risk of developing de novo hypertension and 20 normotensive healthy pregnant controls were recruited at 22 to 26 weeks' gestation. Fourteen maternal clinical, hemodynamic, and placental characteristics were assessed in the second trimester and aggregated. Principal component analysis of this combined data set determined that 3 dimensions accounted for 56% of the cohort variability. The first dimension accounted for 31% of the cohort variability, with significant contributions from total peripheral resistance, endoglin, and cardiac output. The second dimension was predominantly influenced by body mass index and mean arterial pressure, while uric acid and myeloperoxidase mainly contributed to the third dimension. Unsupervised clustering identified 3 groups within this combined data set. Total peripheral resistance was the most significant distinguishing parameter between these groups (P<0.0001), followed by placental growth factor, endoglin, and cardiac output (P<0.0001). Using these 4 parameters, a receiver operating curve was constructed with an area under the curve of 0.975 (95% confidence interval 0.93-1) for the prediction of developing hypertension in pregnancy. CONCLUSIONS Consolidated assessment of prognostic indicators in the second trimester of pregnancy may be useful to characterize and distinguish pathways by which women may develop hypertension in pregnancy. This approach could contribute to the development of pathway-specific preventative and antihypertensive treatment strategies.
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Affiliation(s)
- Kelsey McLaughlin
- Division of Cardiology, Department of Medicine, Sinai Health System University of Toronto, Canada.,The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute Sinai Health System, Toronto, Canada
| | - Jianhong Zhang
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute Sinai Health System, Toronto, Canada
| | - Stephen J Lye
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute Sinai Health System, Toronto, Canada.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sinai Health System University of Toronto, Canada
| | - John D Parker
- Division of Cardiology, Department of Medicine, Sinai Health System University of Toronto, Canada
| | - John C Kingdom
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute Sinai Health System, Toronto, Canada .,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sinai Health System University of Toronto, Canada
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25
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Hypertension Editors' Picks: Preeclampsia, Pregnancy, and Hypertension. Hypertension 2018; 72:e1-e18. [PMID: 29899140 DOI: 10.1161/hypertensionaha.118.11037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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26
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Nagai R, Takahashi Y, Iwagaki S, Chiaki R, Asai K, Koike M, Katsura D, Yasumi S, Furuhashi M, Hara A. Monochorionic twin with neovascularization proven on collagenized fibrotic amniotic membrane after fetoscopic laser photocoagulation. Eur J Obstet Gynecol Reprod Biol 2018; 225:263-264. [PMID: 29703579 DOI: 10.1016/j.ejogrb.2018.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 04/19/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Ryuhei Nagai
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Gifu-City, Gifu, Japan.
| | - Yuichiro Takahashi
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Gifu-City, Gifu, Japan
| | - Shigenori Iwagaki
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Gifu-City, Gifu, Japan
| | - Rika Chiaki
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Gifu-City, Gifu, Japan
| | - Kazuhiko Asai
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Gifu-City, Gifu, Japan
| | - Masako Koike
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Gifu-City, Gifu, Japan
| | - Daisuke Katsura
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Gifu-City, Gifu, Japan
| | - Shunsuke Yasumi
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Gifu-City, Gifu, Japan
| | - Madoka Furuhashi
- Department of Fetal-Maternal Medicine, Nagara Medical Center, Gifu-City, Gifu, Japan
| | - Akira Hara
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu-City, Gifu, Japan
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27
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Sherrell H, Dunn L, Clifton V, Kumar S. Systematic review of maternal Placental Growth Factor levels in late pregnancy as a predictor of adverse intrapartum and perinatal outcomes. Eur J Obstet Gynecol Reprod Biol 2018; 225:26-34. [PMID: 29631209 DOI: 10.1016/j.ejogrb.2018.03.059] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/29/2018] [Accepted: 03/29/2018] [Indexed: 12/17/2022]
Abstract
AIM This systematic review evaluates the utility of maternal Placental Growth Factor (PlGF) when measured in late pregnancy (>20 weeks) as a predictor of adverse obstetric and perinatal outcomes. METHODS Pubmed and Embase were searched using the term "placental growth factor" in combination with relevant perinatal outcomes. Studies were included if they measured PlGF levels in pregnant women after 20 + 0 weeks gestation and reported relevant adverse obstetric or perinatal outcomes related to placental insufficiency (excluding pre-eclampsia). RESULTS Twenty-six studies were eligible for inclusion with 21 studies investigating the relationship between PlGF and small for gestational age (SGA) and 7 studies investigating PlGF for the prediction of other adverse perinatal outcomes. In all studies, maternal PlGF levels were significantly lower in the SGA group compared to controls. Other outcomes investigated included caesarean section (CS) for fetal compromise, low Apgar score, neonatal intensive care unit (NICU) admission, neonatal acidosis, stillbirth, and intrapartum fetal compromise. The results generally showed a significant association between low PlGF levels and CS for fetal compromise, NICU admission and stillbirth. CONCLUSION Low maternal PlGF levels in late pregnancy are strongly associated with SGA. Findings across studies were variable in relation to PlGF and the prediction of other adverse intrapartum and perinatal outcomes, however there was a consistent association between low PlGF levels and CS for fetal compromise, NICU admission and stillbirth. This review suggests that the use of PlGF for the prediction of adverse outcomes is promising. Its predictive value may potentially be enhanced if used in combination with other biomarkers or biophysical measures of fetal well-being.
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Affiliation(s)
- Helen Sherrell
- Mater Research Institute, University of Queensland, Level 3 Aubigny Place, Raymond Terrace, South Brisbane, Queensland, QLD 4101, Australia
| | - Liam Dunn
- Mater Research Institute, University of Queensland, Level 3 Aubigny Place, Raymond Terrace, South Brisbane, Queensland, QLD 4101, Australia
| | - Vicki Clifton
- Mater Research Institute, University of Queensland, Level 3 Aubigny Place, Raymond Terrace, South Brisbane, Queensland, QLD 4101, Australia
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, Level 3 Aubigny Place, Raymond Terrace, South Brisbane, Queensland, QLD 4101, Australia; Mater Mothers' Hospital, Raymond Terrace, South Brisbane, Queensland, QLD 4101, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia.
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