Modified multiple marker aneuploidy screening as a primary screening test for preeclampsia

Background

Abnormal levels of maternal biochemical markers used in multiple marker aneuploidy screening have been associated with adverse pregnancy outcomes. This study aims to assess if a combination of maternal characteristics and biochemical markers in the first and second trimesters can be used to screen for preeclampsia (PE). The secondary aim was to assess this combination in identifying pregnancies at risk for gestational hypertension and preterm birth.

Methods

This case-control study used information on maternal characteristics and residual blood samples from pregnant women who have undergone multiple marker aneuploidy screening. The median multiple of the median (MoM) of first and second trimester biochemical markers in cases (women with PE, gestational hypertension and preterm birth) and controls were compared. Biochemical markers included pregnancy-associated plasma protein A (PAPP-A), placental growth factor (PlGF), human chorionic gonadotropin (hCG), alpha feto-protein (AFP), unconjugated estriol (uE3) and Inhibin A. Logistic regression analysis was used to estimate screening performance using different marker combinations. Screening performance was defined as detection rate (DR) and false positive rate (FPR). Preterm and early-onset preeclampsia PE were defined as women with PE who delivered at < 37 and < 34 weeks of gestation, respectively.

Results

There were 147 pregnancies with PE (81 term, 49 preterm and 17 early-onset), 295 with gestational hypertension, and 166 preterm birth. Compared to controls, PE cases had significantly lower median MoM of PAPP-A (0.77 vs 1.10, p < 0.0001), PlGF (0.76 vs 1.01, p < 0.0001) and free-β hCG (0.81 vs. 0.98, p < 0.001) in the first trimester along with PAPP-A (0.82 vs 0.99, p < 0.01) and PlGF (0.75 vs 1.02, p < 0.0001) in the second trimester. The lowest first trimester PAPP-A, PlGF and free β-hCG were seen in those with preterm and early-onset PE. At a 20% FPR, 67% of preterm and 76% of early-onset PE cases can be predicted using a combination of maternal characteristics with PAPP-A and PlGF in the first trimester. The corresponding DR was 58% for gestational hypertension and 36% for preterm birth cases.

Conclusions

Maternal characteristics with first trimester PAPP-A and PlGF measured for aneuploidy screening provided reasonable accuracy in identifying women at risk of developing early onset PE, allowing triage of high-risk women for further investigation and risk-reducing therapy. This combination was less accurate in predicting women who have gestational hypertension or preterm birth.

Role of pregnancy-associated plasma protein A (PAPP-A) and human-derived chorionic gonadotrophic hormone (free β-hCG) serum levels as a marker in predicting of Small for gestational age (SGA): A cohort study

Background:

Small-for-gestational-age (SGA) is one of the most important conditions, which is associated with the risk of perinatal mortality and morbidity. The levels of pregnancy-associated plasma protein A (PAPP-A) and β-human-derived chorionic gonadotrophic (β-hCG) in the first trimester can predict this adverse outcome, considering the controversial nature of studies in this area, this cohort study was conducted to investigate the role of PAPP-A and freeβ-hCG levels for predicting SGA.

Materials and Methods:

In this cohort study, from 16 randomly selected health centers in Isfahan, Iran, 4605 volunteer pregnant women who had performed first-trimester fetal anomalies screening tests were chosen based on the census, from July 2016 to June 2018. The multiples of the median (MoM) PAPP-A <0.4 and MoM β-hCG >3 were considered as abnormal; the samples were followed up after childbirth. The biomarkers' serum levels, relative risk, and odds ratio (OR) of SGA were compared in both SGA and appropriate for gestational age (AGA) groups.

Results:

In the SGA group, the mean of MOM PAPP-A was significantly lower (0.96 vs. 1.1 with P = 0.001) and MoM βhCG was significantly higher (1.24 vs. 1.15 with P = 0.01) than the AGA group. Odds for SGA in subjects with MoM PAPP-A <0.4 were 3.213; P = 0.001 and for subjects with MoM βhCG >3 reported as 0.683; P = 0.111.

Conclusion:

The results of the study showed that the low levels of PAPP-A would cause 3.213 times increase in the chance of developing SGA and no association between high level of βhCG >3 with SGA. Therefore, low level of the PAPP-A is a warning indicator for SGA.

Pregnancy-associated plasma protein A mRNA expression as a marker for differentiated thyroid cancer: results from a "surgical" and a "cytological" series

PURPOSE

Pregnancy-associated plasma protein A (PAPPA) is a metalloproteinase initially described for its role during pregnancy. PAPPA regulates IGF ligands 1 (IGF1) bioavailability through the degradation of IGF-binding protein 4 (IGFBP4). After the cleavage of IGFBP4, free IGF1 is able to bind IGF1 receptors (IGF1R) triggering the downstream signaling. Recently, PAPPA expression has been linked with development of several cancers. No data have been published on thyroid cancer, yet.

METHODS

We evaluated PAPPA, insulin-like growth factor (IGF1), IGF1 receptors (IGF1R) and IGF-binding protein 4 (IGFBP4) mRNA expression levels in a "Surgical series" of 94 thyroid nodules (64 cancers, 16 follicular adenomas and 14 hyperplastic nodules) and in a "Cytological series" of 80 nodules from 74 patients underwent to fine-needle aspiration cytology (FNAC). In tissues, PAPPA was also evaluated by western blot.

RESULTS

We found that PAPPA expression was increased in thyroid cancer specimen at mRNA and protein levels and that, adenomas and hyperplastic nodules had an expression similar to normal tissues. When applied on thyroid cytologies, PAPPA expression was able to discriminate benign from malignant nodules contributing to pre-surgical classification of the nodules. We calculated a cut-off with a good specificity (91%) which reached 100% when combined with molecular biology.

CONCLUSION

These results show that PAPPA could represent a promising diagnostic marker for differentiated thyroid cancer.

Pregnancy-associated plasma protein A - a new indicator of pulmonary vascular remodeling in chronic thromboembolic pulmonary hypertension?

Background

In chronic thromboembolic pulmonary hypertension (CTEPH) impaired pulmonary hemodynamics lead to right heart failure. Natriuretic peptides reflect hemodynamic disease severity. Pregnancy-associated plasma protein-A (PAPP-A) might address another aspect of CTEPH - chronic tissue injury and inflammation. This study assessed dynamics of PAPP-A in CTEPH patients who undergo therapy with pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA).

Methods

The study included a total of 125 CTEPH patients scheduled for treatment (55 PEA/ 70 BPA) and a control group of 58 patients with pulmonary hypertension other than CTEPH. Biomarker measurement was performed at baseline and follow-up in the CTEPH cohort, prior to each BPA in the BPA cohort and once in the control group.

Results

The median PAPP-A level was slightly higher (p = 0.05) in CTEPH patients [13.8 (11.0–18.6) mU/L], than in the control group [12.6 (8.6–16.5) mU/L], without a difference between the BPA and PEA group (p = 0.437) and without a correlation to mean pulmonary artery pressure (p = 0.188), pulmonary vascular resistance (p = 0.893), cardiac index (p = 0.821) and right atrial pressure (p = 0.596). PEA and BPA therapy decreased the mean pulmonary artery pressure (p < 0.001) and pulmonary vascular resistance (p < 0.001) and improved the WHO-functional-class (baseline: I:0/II:25/III:80/IV:20 vs. follow-up: I:55/II:58/III:10/IV:2). PAPP-A levels decreased after PEA [13.5 (9.5–17.5) vs. 11.3 (9.8–13.6) mU/L; p = 0.003) and BPA treatment [14.3 (11.2–18.9) vs. 11.1 (9.7–13.3) mU/L; p < 0.001). The decrease of PAPP-A levels is delayed in comparison to N-terminal pro-B-type natriuretic peptide.

Conclusion

PAPP-A is overexpressed in CTEPH and decrease significantly after surgical or interventional therapy, however without association to hemodynamics. Further investigation is needed to define the underlying mechanism of PAPP-A expression and changes after therapy in CTEPH.

A risk model of prenatal screening markers in first trimester for predicting hypertensive disorders of pregnancy

Background

We aimed to construct a risk model to assess the diagnostic value of predicting hypertensive disorders of pregnancy (HDPs) by screening a range of prenatal markers, including pregnancy-associated plasma protein A (PAPP-A), free beta-human chorionic gonadotropin (free β-hCG), and fetal nuchal translucency (NT).

Method

We analyzed 902 women, classified into four groups: healthy gravidas (n = 680, controls), gravidas with gestational hypertension (n = 61; GH), gravidas with preeclampsia (n = 90; PE), and gravidas with severe preeclampsia (n = 71, SPE). We then compared the multiple of median (MoM) of PAPP-A, free β-hCG, and NT. A risk model was constructed and receiver operating characteristic curve (ROC) analysis was used to diagnose HDPs.

Results

Levels of PAPP-A and free β-hCG levels in the GH, PE, and SPE groups were significantly lower than those in the control group (χ ² = 7.522, P = 0.001; χ ² = 17.775, P < 0.001). NT did not differ significantly when compared across all four groups (χ ² = 1.592, P > 0.05). When the cut-off values for PAPP-A and free β-hCG were 0.795 MoM and 1.185 MoM, the corresponding sensitivities and specificities were 0.514 and 0.635, and 0.734 and 0.450, respectively. The best risk calculation featured PAPP-A, free β-hCG, and NT; this model exhibited the highest diagnostic value in the SPE group, followed by the GH group and then the PE group.

Conclusion

The use of prenatal screening markers during early pregnancy can identify fetal aneuploidy and can also predict HDPs. The development of innovative screening strategies for gravidas and the targeted prevention of HDPs in high-risk gravidas are essential for perinatal care and early intervention, thus creating significant opportunities for predictive and preventive personalized medicine. In our study, we found that the combination of a series of prenatal screening markers in early pregnancy is better than a single marker; our data clearly demonstrate the diagnostic value of combining PAPP-A, free β-hCG, and NT for patients with SPE.

Nasal bone in screening for Trisomy 18 and 13 at 11-13 + 6 weeks of gestation - own experiences

OBJECTIVES

The objective of the paper is the suitability assessment of screening for Trisomy 18 and 13 on the basis of NT measurement, FHR, double test and assessment of Nasal Bone.

MATERIAL AND METHODS

The study was performed in 6,661 singleton pregnancies. In each fetus NT, FHR, DV-PIV were examined. Double test from maternal blood was examined. These ultrasound and biochemical factors were in combined screening investigated. Additional ultrasound marker - Nasal Bone was and its impact on Trisomies 18 and 13 screening was examined.

RESULTS

Two groups of patients were compared - with chromosomal normal and chromosomal abnormalities - Trisomy 18 and 13. Detection Rate of Trisomies 18 and 13 at the risk cutoff 1/300 using combined screening was 84.1% and FPR was 7.1%. Detection Rates of examined chromosomal abnormalities using screening with additional marker - NB was 93.2% and False Positive Rate - 5.6%.

CONCLUSIONS

It should be noted that the qualitative analysis of the assessment of NB in the first trimester significantly influences the improvement of screening values focusing on Trisomy 18 and 13 detection. In summary, our research indicates a more effective type of Trisomy 13 and 18 screening using NT, double test, maternal age, CRL and FHR as well as nasal bone presence and absence.

The Significance of Pregnancy-associated Plasma Protein a Serum Concentration in Clear Cell Renal Cell Carcinoma

BACKGROUND/AIM

Proteinase pregnancy-associated plasma protein A (PAPP-A) modulates the cell growth and carcinogenesis process. Its role in clear cell renal cell carcinoma (ccRCC) remains unclear. This study aimed to evaluate the significance of PAPP-A serum concentration in diagnosis, follow-up and prognosis of ccRCC patients.

MATERIALS AND METHODS

In a prospective study including 121 patients who underwent radical or partial nephrectomy for ccRCC [localized ccRCC without relapse (n=80), localized ccRCC with later relapse (n=26), primary metastatic cancer (n=15)] PAPP-A serum concentration was assessed preoperatively and in certain subgroups also postoperatively.

RESULTS

PAPP-A serum concentration showed no statistically significant difference between ccRCC and controls and among ccRCC subgroups, respectively. Disease stage and Fuhrman's grade were not shown to affect PAPP-A concentration. The dynamics of postoperative PAPP-A concentrations did not reveal any significance and PAPP-A was not a prognostic factor for cancer related or overall survival.

CONCLUSION

PAPP-A serum concentration does not seem to be a useful biomarker in ccRCC.

Clinical Importance of Low Level of PAPP-A in First Trimester of Pregnancy - An Obstetrical Dilemma in Chromosomally Normal Fetus

BACKGROUND:

A variety of recent evidence exists about the clinical implication of low level of Pregnancy-associated plasma protein A (PAPP-A) in pregnancy. This glycoprotein is a protease, which releases the Insulin-like growth factor from IGFBP 4. Its role is a trophoblastic invasion of decidua, stimulation of cell mitosis and differentiation. It has an immunosuppressive effect in the placenta, inhibition of coagulation and complex role for integration of all these processes in the placenta. Level of PAPP-A (under 0.4 MoM-Multiple of Medians) in first-trimester screening in chromosomally and morphologically normal fetuses, could influence fetal weight, preeclampsia, premature birth and stillbirth. As a result of the complications mentioned above, there is implication on timing, mode of delivery and condition of the newborn.

AIM:

The study aims to evaluate the influence of low PAPP-A, measured in the first trimester on the outcome of pregnancy, with accent disorders which are the result of placental insufficiency. Also, gestational week, mode of delivery and condition of newborn secondary underlying conditions will be evaluated.

MATERIAL AND METHODS:

After given information and consultation about the expectation from the screening, pregnant women with a singleton pregnancy were tested for First Trimester Screening to estimate the risk for Trisomy 21, 13, 18- the most frequent chromosomopathies. After exclusion of chromosomopathies and congenital malformations, one hundred and fourteen patients enrolled in the study. The target group (n = 64) with PAPP-A below 0.4 MoM and control group (n = 50) with PAPP-A equal and above 0.4 MoM. An assessment of mode and time of delivery and presence of small for gestational age newborns, preeclampsia, premature birth and newborn condition at delivery was made.

RESULTS:

The percentage of the patients delivered in term was similar between the target group (n = 64) and the control group (n = 50), 82.81% vs 82.0% respectively. The rate of cesarean section was 29.7 % in the target group vs 32% in the control group. A significant difference was found about elective vs urgent cesarean section in favour of the target group. The difference was present about the complication in pregnancy before delivery, 56% vs 22%, p = 0.023, which were the main indication for cesarean section. The difference in newborn outcome was not significant.

CONCLUSION:

There is a difference in frequency of complications, in the cases with PAPP-A under 0.4 MoM, such as premature birth, preeclampsia compound with SGA fetuses versus the control group. The difference for SGA newborn and premature birth among the groups has statistical significance. The patients delivered with cesarean section were with the main indications SGA or elevated blood pressure, often occurred combined with prematurity. Apgar score and birth weight were similar in target and control group, but the newborns with a birth weight under 2500 g. were more frequent in the target group. Because these results did not show another significance among two groups, probably lower cut-off is needed, combining with another test (Doppler of uterine arteries in the first trimester, biochemical test). Presence of other diseases which could hurt placental function should be emphasised.

Clinical Importance of Low Level of PAPP-A in First Trimester of Pregnancy - An Obstetrical Dilemma in Chromosomally Normal Fetus

BACKGROUND:

Idiopathic epiretinal membrane (iERM) is an avascular proliferation of different types of cells between the posterior vitreous cortex and the internal limiting membrane. That causes visual impairment including blurry, distortion, scotoma. Many studies of iERM were done to describe the clinical characteristics and investigate the histopathology of this disease. Nonetheless, there has not been a study of iERM histopathology in Vietnam.

AIM:

To describe clinical characteristics and histopathological results of idiopathic retinal membrane and the association between them.

METHODS:

A cross sectional decriptive study of 35 iERMs (33 patients) in Vietnam National Institute of Ophthalmology (VNIO).

RESULTS:

High morbidity incidence was in group age >50 years (32/35), female gender (26/35), limited movement works (27/35), and high educational levels (28/35). Distortion was the highest (77.14%), scotoma and floater was less frequent (28.5%, 45.7%). Macular edema in all cases and PVD and exudate were high frequent (65.7%, 62.8%). Symptom duration was 8.2 ± 4.7 months, (1-21 months). Mean of central macular thickness was 468.51 ± 97.24 µm (656-274 µm). Six types of cell were detected, including glial cell (35/35), fibroblast (23/35), myofibroblast (23/35), macrophage (13/35), lymphocyte (5/35) and neutrophil (2/35). The number of cell types in one sample ranged from 1-5 types (2.85 ± 1.28 cell types). Number of cell types were correlated to symptom duration (r = 0.47, p = 0.004, Pearson’s test) and central macular thickness (r = 0.72, p < 0.001, Pearson’s test).

CONCLUSION:

There were 6 types of cells in iERM. Glial cell was the most frequent cell, inflammatory cells (macrophage, lymphocyte, neutrophil) was also detected. The number of cell types was stastitically correlated to symptom duration and CMT.

Parity predisposes breasts to the oncogenic action of PAPP-A and activation of the collagen receptor DDR2

Background

Women who had children at a young age (less than 25) show a reduced overall risk of breast cancer. However, epidemiological studies showed that for all other women, pregnancy increases the risk of breast cancer and the risk remains higher for decades. Further, even in women who had children at a young age, there is a transient increase risk that peaks 6 years after pregnancy. Women diagnosed with breast cancer following pregnancy show a higher rate of metastasis. Yet, the factors that increase the predisposition of post-partum breasts to more aggressive cancers remain unknown. Pregnancy-associated plasma protein A (PAPP-A) is a secreted protease that is overexpressed in more than 70% of breast cancers. However, PAPP-A is a collagen-dependent oncogene. We initiated this study to test the effect of PAPP-A on the predisposition of post-partum breasts.

Methods

We used PAPP-A mouse models for the analysis of its effect on virgin, involuting, or post-partum mammary glands. We performed second-harmonic generation microscopy for the analysis of collagen, defined tumor-associated collagen signature (TACS), the rate of mammary tumors, and the status of the collagen-DDR2-Snail axis of metastasis. We knockdown DDR2 by CRISPR and performed invasion assays. A transcriptomic approach was used to define a PAPP-A and parity-dependent genetic signature and assess its correlation with breast cancer recurrence in humans.

Results

We confirmed that post-partum mammary glands have a higher level of collagen than virgin glands and that this collagen is characterized by an anti-proliferative architecture. However, PAPP-A converts the anti-proliferative post-partum collagen into pro-tumorigenic collagen. We show that PAPP-A activates the collagen receptor DDR2 and metastasis. Further, deletion of DDR2 by CRISPR abolished the effect of PAPP-A on invasion. We defined a PAPP-A-driven genetic signature that identifies patients at higher risk of metastasis.

Conclusions

These results support the notion that information about pregnancy may be critical in the prognosis of breast cancer as passage through a single pregnancy predisposes to the oncogenic action of PAPP-A. Our data indicate that history of pregnancy combined with the expression of PAPP-A-driven genetic signature may be useful to identify patients at higher risk of metastatic disease.

Electronic supplementary material

The online version of this article (10.1186/s13058-019-1142-z) contains supplementary material, which is available to authorized users.

Obstetric Outcome in Pregnant Patients with Low Level of Pregnancy-Associated Plasma Protein A in First Trimester

BACKGROUND

Pregnancy-associated plasma protein A (PAPP-A), is a protease which releases Insulin-like growth factor. The role of this factor is stimulation of cell mitosis, differentiation and trophoblastic invasion of deciduas. Identification of patients with low PAPP-A (under 0.4 MoM in the first trimester has an influence on birth weight, attenuation of fetal growth, preeclampsia, birth and fetal demise.

AIM

The main issue in the study is evaluating an influence of PAPP-A, calculated in the first trimester on the unfavourable outcome of pregnancy.

MATERIAL AND METHODS

Seventy pregnant women with singleton pregnancy underwent first-trimester biochemical screening. The target group were women with PAPP-A below 0.4 MoM, and in control group, PAPP-A were over 0.4 MoM. There was an assessment of the influence on the mode of delivery, gestational week, the presence of intrauterine growth restriction, preeclampsia, temporary birth, intrauterine fetal demise and newborn condition.

RESULTS

In target group, consisted of 35 patients, 16 were delivered at term. From 28 to 37 g.w.- were 7 patient, 22-28 g.w.- 4 and 8 patients were under the 22 g.w (all with fetal demise) there were 19 pretemporary deliveries - 9 with Cesarean Section (SC). In the target group: 5 newborn were with IUGR, 6 women had preeclampsia, 1 had placental abruption. In control group were 35 patients: 28 delivered at term, 9 with SC, 26 vaginal deliveries; with IUGR were 4 newborns. Two newborns were hypertrophic.

CONCLUSION

There is a significant difference in unfavourable outcome in the cases with PAPP-A under 0.4 Mom, particular in the group, with a PAPP-A value under 0.2 MoM. The patients delivered with SC with the main indications in utero hypoxia, growth restriction and elevated blood pressure had PAPP-A between 0.3-0.4 MoM. The patients with intrauterine fetal death and placental abruption in the most of the cases have PAPP-A value under 0.2 MoM. There is a need to be aware in these pregnancies to achieve the preventions of adverse outcome, to decrease perinatal morbidity and mortality.

Meta-regression analysis to evaluate relationships between maternal blood levels of placentation biomarkers and low delivery weight

BACKGROUND

Caution is required for women at increased risk of low neonatal delivery weight.

OBJECTIVE

To evaluate relationships between maternal placentation biomarkers and the odds of low delivery weight.

SEARCH STRATEGY

Databases including PubMed/MEDLINE were searched up to May 2017 using keywords involving biomarker names and "low birthweight."

SELECTION CRITERIA

English language studies providing true- and false-positive, and true- and false-negative results of low delivery weight classified by maternal blood levels of placentation biomarkers (in units of multiple of the mean [MoM]) were included.

DATA COLLECTION AND ANALYSIS

Coefficients representing changes in log odds ratio for low delivery weight per 1 MoM increase in maternal blood placentation biomarkers, and those adjusted for race, sampling period, and/or study quality were calculated.

MAIN RESULTS

Adjusted coefficients representing changes in log odds ratio for low delivery weight per 1 MoM increase in maternal blood levels of α-fetoprotein (AFP) and β-human chorionic gonadotropin (β-hCG) were significantly greater than 0 (both P<0.001), whereas that for pregnancy-associated plasma protein A (PAPP-A) was significantly less than 0 (P=0.028). Adjusted models explained the higher proportion of between-study variance better than non-adjusted models.

CONCLUSIONS

Elevated AFP and β-hCG, and reduced PAPP-A in maternal blood were positively associated with odds of low delivery weight.

Pregnancy-Associated Plasma Protein A Levels in Late First Trimester Pregnancies with Small-for-Gestational Age Neonates: A Prospective Case-Control Study

OBJECTIVE

We aimed to investigate the association of pregnancy associated plasma protein A (PAPP-A) levels in late first trimester with small for gestational age (SGA) neonates and adverse pregnancy outcomes in a low-income setting.

METHODS

The inclusion criteria were late first trimester (11-13 + 6 weeks) women with singleton and non-anomalous pregnancy. Enrolled participants were sampled for PAPP-A and prospectively followed up for delivery outcome and antenatal complications. A multiple of median (MoM) was calculated and statistically compared between groups.

RESULTS

Out of total 284 subjects, 14.54% delivered SGA babies and formed cases (Group A), 66.5% delivered appropriate for gestational age (AGA) neonates with uneventful antenatal period (controls, Group B), and 19.3% were AGA group with adverse pregnancy complications (Group C). The late first trimester median PAPP-A MoM was significantly lower (0.61) in Group A compared to Group B (1.47). Using receiver operating characteristic (ROC) curve for PAPP-A MoM, optimal cutoff value was found at 0.45 MoM, with positive predictive value of 56.2%, specificity of 92.6% and sensitivity of 45%. The median interquartile range (IQR) of PAPP-A MoM value in Group C in comparison with Group B was significantly lower except for abruption. At PAPP-A MoM cutoff value <1, <0.8, <0.6 and <0.4, the odds ratio for adverse pregnancy outcome was 8.30, 7.29, 10.97 and 10.60, respectively, indicating an inverse relationship.

CONCLUSION

With 0.45 MoM cutoff of PAPP-A, the detection rate, specificity and positive predictive value for SGA were 45, 92.6 and 56.2%, respectively. As PAPP-A MoM values decreased, the odds ratio of having adverse pregnancy outcomes increased.

Gestational diabetes mellitus and first trimester pregnancy-associated plasma protein A: A case-control study in a Chinese population

AIMS/INTRODUCTION

To investigate the relationship between pregnancy-associated plasma protein A (PAPP-A) and gestational diabetes mellitus (GDM), and to determine whether PAPP-A has improved value for predicting GDM in a Chinese population.

MATERIALS AND METHODS

Clinical data for 599 GDM patients and 986 unaffected pregnant women undergoing both antenatal examinations and delivery were retrospectively analyzed. First-trimester serum PAPP-A levels were compared between the groups. Binary logistic regression analysis was used to explore the risk factors for GDM, and the area under the receiver operating characteristic curve was used to determine the value of PAPP-A for predicting GDM.

RESULTS

GDM-affected and unaffected pregnant women were significantly different in terms of age (P < 0.001), BMI (P < 0.001), family history of diabetes (P = 0.002), α-thalassemia trait (P < 0.01), parity (P < 0.001), conception methods (P < 0.001), gestational weeks at the time of labor (P < 0.001) and corrected PAPP-A multiples of the median values (P < 0.001). Binary logistic regression analysis showed that PAPP-A levels were negatively related to the subsequent development of GDM (odds ratio 0.798, 95% confidence interval 0.647-0.984). The area under the receiver operating characteristic curve for maternal factors was 0.684 (95% CI: 0.657-0.711), and did not significantly differ from that for the combination of maternal factors and serum PAPP-A levels, which was 0.686 (95% CI: 0.660-0.713; χ² = 0.625, P = 0.429).

CONCLUSIONS

Serum PAPP-A was an independent factor for the development of GDM in pregnant Chinese women. Serum-PAPP-A does not have improved value with respect to predicting GDM when combined with other maternal factors.

Maternal serum placental growth factor and pregnancy-associated plasma protein A measured in the first trimester as parameters of subsequent pre-eclampsia and small-for-gestational-age infants: A prospective observational study

Objective

To examine the first-trimester maternal serum placental growth factor (PlGF) and pregnancy-associated plasma protein A (PAPP-A) levels in pregnancies associated with pre-eclampsia (PE) or small-for-gestational-age (SGA) infants, and determine the predictive accuracy of PlGF and of PAPP-A for either PE or SGA infants.

Methods

This prospective, observational study included 175 pregnant women, and of these women, due to participant withdrawal or loss to follow-up, delivery data were collected from the medical records of 155 women, including 4 who had twin pregnancies. The women's maternal history was recorded, and the PlGF and PAPP-A levels at 11 to 13 gestational weeks were measured. During the second trimester, the maternal uterine artery's systolic/diastolic ratio was measured. Multiples of the median (MoM) of PlGF and PAPP-A were determined, and the associations of these values with the risk factors of SGA and PE were evaluated. Logistic regression analysis was used to determine whether PlGF and PAPP-A are useful markers for predicting SGA infants.

Results

The PAPP-A MoM level was significantly lower in women with advanced maternal age, multipara women, and women with gestational diabetes than in their counterparts. The PlGF and PAPP-A MoM levels were higher in women with a twin pregnancy than in those with a singleton pregnancy. There was a significant relationship between the maternal serum PAPP-A MoM level in the first trimester and the uterine artery systolic/diastolic ratio in the second trimester. Results of logistic regression analysis showed that low PlGF and PAPP-A MoM levels were predictors of SGA infants (odds ratio, 0.143; 95% confidence interval, 0.025 to 0.806; odds ratio, 0.191; 95% confidence interval, 0.051 to 0.718, respectively).

Conclusion

PlGF and PAPP-A are potentially useful as first-trimester markers for SGA infants and some hypertensive disorders of pregnancy.

Early Prognostic Factors for the Progress of Preeclampsia - Our Experience in the Period 2010-2011

AIM:

To determine the prognostic value of the low Pregnancy-associated plasma protein A (PAPP-A) levels in the early stages of pregnancy (11–13 weeks GA) independently and in combination with a Doppler test of the uterine arteries during the second half of pregnancy (22–23 weeks GA).

MATERIAL AND METHODS:

The study covered the period 2010–2011 and included 106 pregnant women, aged 35–40, with a single child pregnancy. The research excluded pregnant women with anomalies of the fetus, smokers and women taking prophylactically low doses of aspirin.

RESULTS:

Thirty-six pregnant women had PAPP-A level below 0.4 MoM, whereas 20 of them developed preeclampsia and 7 – early preeclampsia. The combination of the low PAPP-A values and the abnormal Doppler test of the uterine arteries is with a considerably better prognostic value in regards to the risk of developing preeclampsia.

CONCLUSION:

The Doppler test is a non-invasive, quick and easy method for assessment of the uterine-placental blood flow.

First-trimester biochemical markers of placentation in screening for gestational diabetes mellitus

OBJECTIVE

To investigate whether first-trimester biochemical markers of placentation, including pregnancy-associated plasma protein-A (PAPP-A) and placental growth factor (PLGF), are altered in women that subsequently develop gestational diabetes mellitus (GDM) and to examine their potential value in improving the performance of screening for GDM by maternal characteristics and medical history.

METHODS

The study population of 31,225 singleton pregnancies, including 787 cases that developed GDM, was drawn from women undergoing routine prospective screening for pregnancy complications at 11-13 weeks' gestation. Maternal serum PAPP-A and PLGF were measured and the levels were expressed as multiples of the median (MoM) after adjustment for maternal characteristics and medical history. The performance of screening for GDM by maternal factors and MoM values of PAPP-A and PLGF was evaluated by receiver operating characteristic (ROC) curves.

RESULTS

In the GDM group, compared to the unaffected group, the median PAPP-A was reduced (0.949, 95% CI 0.913-0.987 MoM) (p=0.0009) and median PLGF was increased (1.053, 95% CI 1.023-1.083 MoM) (p=0.004). The performance of screening for GDM by maternal factors was not improved by the addition of PAPP-A and/or PLGF.

CONCLUSIONS

First trimester maternal serum PAPP-A and PLGF are not useful in screening for GDM.

The prognostic value of serum pregnancy-associated plasma protein A, S100 and high sensitivity C-reactive protein in acute ischemic stroke patients without heparin administration

OBJECTIVES

The concerns regarding the pre-analytical bias caused by medicine treatments have been raised in the diagnosis and prognosis of ischemic stroke recently. The aim of this study was to examine the prognostic value of serum pregnancy-associated plasma protein A (PAPP-A), S100 and high sensitivity C-reactive protein (hs-CRP) in heparin-naïve patients of acute ischemic stroke.

DESIGN AND METHODS

Serum levels of PAPP-A, S100 and hs-CRP were determined in 205 heparin-naïve patients of acute ischemic stroke and 50 healthy controls. Clinical information and radiological information were collected. Unfavorable outcomes (stroke recurrence, myocardial infarction or death) were also recorded after six months. The associations between serum biomarker levels and stroke severity/outcome were assessed.

RESULTS

Serum PAPP-A, S100 and hs-CRP levels increased in patients compared with controls (P<0.05). S100 and hs-CRP levels were significantly higher in patients with larger cerebral infarction sizes (P<0.05) and more severe neurological impairment (P<0.05). Serum PAPP-A level showed a progressive increase with the increase of stroke severity (P<0.05). Serum hs-CRP and National Institutes of Health Stroke Scale (NIHSS) scores were identified as independent predictors for unfavorable outcomes with odds ratios of 2.884 (1.154 to 7.210, P=0.023) and 2.887 (1.146 to 7.273, P=0.024), respectively.

CONCLUSION

Serum PAPP-A, S100 and hs-CRP were associated with stroke severity or outcome after ischemic stroke and may offer complementary information, essential for clinical decision making. Serum PAPP-A showed a potential value for the evaluation of stroke clinically.

A historical and practical review of first trimester aneuploidy screening

There have been tremendous advancements over the past three decades in prenatal screening for aneuploidy and we have changed our practice from screening by maternal age alone to 'combined' first trimester screening and circulating cell-free fetal DNA. We currently use the nuchal translucency and biochemical markers of free β-hCG and PAPP-A to determine the risk of fetal aneuploidy. The primary goal is to identify higher risk women for fetal aneuploidy early in pregnancy and give them the option to pursue invasive testing in a timely manner if desired.

Cys327Cys polymorphism of the PAPP-A gene (pregnancy associated plasma protein A) is related to mortality of long term hemodialysis patients

OBJECTIVES

PAPP-A is an independent mortality predictor of long term hemodialysis patients and a prognostic marker of acute coronary syndrome in general population. Cys327Cys PAPP-A polymorphism (SNP) (rs12375498) was found to be of significance in preeclampsia and the C allele of the PAPP-A C/G SNP (rs13290387) was defined as an independent risk factor for acute myocardial infarction. The aim of the study was to test the role of these PAPP-A SNPs in long term hemodialysis patients.

DESIGN AND METHODS

The studied group consisted of 464 subjects - 319 long term hemodialysis patients (183 men, 136 women, 62±14years) and 145 controls (65 men, 80 women, 49±14years). A subgroup of 211 hemodialysis patients (118 men, 93 women, 63±13years) was prospectively followed up for 4.5years. During the follow up, 111 patients died, 51 of them due to cardiovascular events. PAPP-A SNPs were analyzed by DNA sequencing and serum PAPP-A was measured by TRACE.

RESULTS

Both SNPs were in Hardy-Weinberg equilibrium. Allelic and genotype frequencies did not differ between patients and controls and were not related to serum PAPP-A concentrations. Cys327Cys SNP was significant for patients' survival (HR (95% CI): 1.616 (1.110-2.353), nominal p=0.012, corrected p=0.036) while C/G SNP was not.

CONCLUSIONS

Our study shows for the first time the significance of Cys327Cys PAPP-A SNP (rs12375498) for overall mortality of long term hemodialysis patients. Although it does not influence the concentration of PAPP-A it still could affect the correct function of this enzyme which has to be clarified in further studies.

First trimester hyperglycosylated human chorionic gonadotrophin in serum - a marker of early-onset preeclampsia

INTRODUCTION

Recent studies indicate that treatment with low-dose aspirin may reduce the risk of preeclampsia. Thus, early prediction of preeclampsia is needed. Low serum concentrations of hyperglycosylated human chorionic gonadotrophin (hCG-h) are associated with early pregnancy loss. We therefore studied whether it may serve as an early marker of preeclampsia.

METHODS

A nested case-control study included 158 women with subsequent preeclampsia, 41 with gestational hypertension, 81 normotensive women giving birth to small-for-gestational-age (SGA) infants and 427 controls participating in first trimester screening for Down's syndrome between 8 and 13 weeks of gestation. Gestational-age-adjusted multiples of medians (MoMs) were calculated for serum concentrations of hCG-h, the free beta subunit of hCG (hCGβ) and pregnancy-associated plasma placental protein A (PAPP-A) and the proportion of hCG-h to hCG (%hCG-h). Clinical risk factors including mean arterial pressure (MAP) and parity were also included in the risk calculation.

RESULTS

In women with subsequent preeclampsia %hCG-h was lower than in controls (median MoM 0.92, P < 0.001), especially in 29 cases with early-onset preeclampsia (0.86, P < 0.001), in which PAPP-A also was reduced (0.95, P = 0.001). At 90% specificity for prediction of early-onset preeclampsia, sensitivity was 56% (95% confidence interval, 52-61%) for %hCG-h, 33% (28-37%) for PAPP-A, and 69% (51-83%) for the combination of these with first trimester MAP and parity. The area under the receiver-operating characteristic (ROC) curve for the combination of all these was 0.863 (0.791-0.935).

CONCLUSIONS

hCG-h is a promising first trimester marker for early-onset preeclampsia. Addition of PAPP-A and maternal risk factors may improve the results.

Maternal plasma biomarkers for down syndrome: present and future

Down syndrome is the most common cause of mental retardation and has an incidence of between 1:600 and 1:800 pregnancies. It is the condition for which prenatal diagnosis is requested the most and most developed countries have adopted a screening program based around maternal plasma/serum testing and ultrasound. Advances have been made recently to eliminate invasive testing for genetic diagnosis of this condition based on the analysis of free fetal DNA in maternal plasma. But, routine noninvasive prenatal diagnosis for trisomy 21 still appears to be years away. Screening based on assessment of various biomarkers present in maternal plasma represents a front-line test to assess the risk of the mother carrying an aneuploid fetus. Recent comparative proteomics techniques have resulted in studies that have assessed maternal plasma from mothers carrying normal and trisomy 21 fetuses and various gestational ages. Over 100 biomarker candidates have been described, but little consensus has emerged. This may be due to a number of compounded factors, but interesting to note that other neurological disorders have overlapping biomarkers. This article describes these developments and how these biomarkers could contribute to future screening in an emerging era where next-generation sequencing of free fetal DNA will be established in prenatal diagnostics, which appears imminent.

The correlation between follicular fluid pregnancy-associated plasma protein A levels, fertilization, and embryo quality in GnRH agonist and GnRH antagonist protocols in ART cycles

BACKGROUND

Determination of oocyte fertilization and embryo quality are one of the most important purposes in ART cycles. Follicular fluid provides an important microenvironment for development of oocytes and some biochemical characteristics of the follicular fluid, such as pregnancy-associated plasma protein-A (PAPP-A), may play an important role in prediction of success rate of ART.

OBJECTIVE

This study was performed to evaluate whether there was any difference in follicular fluid PAPP-A, fertilization, and embryo quality between GnRH agonist long protocol and flexible GnRH antagonist multiple-dose protocol in ART cycles.

MATERIALS AND METHODS

A total of 100 women who were candidates for ART were enrolled the study and were divided into two groups, GnRH agonist (GnRHa) long protocol (n=51) and flexible GnRH antagonist (GnRHant) multiple-dose protocol (n=49). Follicular fluid sample was obtained from a single mature follicle and follicular fluid PAPP-A level, fertilization and embryo quality of the same oocyte were evaluated in both groups.

RESULTS

There was no significant difference in the mean levels of follicular fluid PAPP-A between the GnRHa protocol and GnRHant protocol (3.5±1.4 vs. 3.8±1.9, respectively). The mean levels of follicular fluid PAPP-A in fertilized oocyte and good quality embryo were comparable in GnRHa and GnRHant protocols.

CONCLUSION

Our data indicated that no differences of follicular fluid PAPP-A levels were observed between cycles using GnRHa long protocol and those of using flexible GnRHant multiple-dose protocol.

Diagnostic performance of high-sensitivity troponin T, myeloperoxidase, and pregnancy-associated plasma protein A assays for triage of patients with acute myocardial infarction

Background

Early diagnosis is the cornerstone of management of acute myocardial infarction (AMI). We aimed to compare the diagnostic accuracy of high-sensitivity troponin T (hs-cTnT) with myeloperoxidase (MPO) and pregnancy-associated plasma protein A (PAPP-A) for early diagnosis of AMI in patients at the time of presentation to the emergency department (ED).

Methods

We enrolled 289 patients who presented at the ED of the National Institute of Heart Disease (NIHD) Rawalpindi, Pakistan, within 4 hr of onset of chest pain. Clinical assessment, electrocardiography (ECG), and angiography were carried out. Blood samples were collected at 0, 3, 6, and 12 hr. Analyses of plasma hs-cTnT, MPO, and PAPP-A were carried out using commercial kits.

Results

Out of 289 subjects who presented to the ED, we diagnosed 180 patients with coronary heart disease as having AMI (N= 61) and 119 as without AMI (stable coronary artery disease, N=61; unstable angina, N=58). Compared to non-AMI patients, the patients with AMI had significantly higher levels (represented here as median [inter quartile range]) of plasma hs-cTnT (136 [39-370] vs. 12 [7-21] ng/L), MPO (906 [564-1,631] vs. 786 [351-1,299] pmol/L) and PAPP-A (5.78 [2.67-13.4] vs. 2.8 [1.8-4.9] mIU/L). Receiver operator characteristic curves (95% CI) for hs-cTnT (0.952 [0.909-0.978]) were significantly higher (P<0.001) than those for MPO (0.886 [0.830-0.929]) and PAPP-A (0.797 [0.730-0.854]), with AMI sensitivity and specificity percentages of 87% and 98% (hs-cTnT), 82% and 84% (MPO), and 65% and 87% (PAPP-A), respectively.

Conclusions

The diagnostic performance of hs-cTnT was superior to that of MPO and PAPP-A for early triage and diagnosis of AMI among patients of coronary heart disease presenting with chest pain to the ED.