Soluble fms-like tyrosine kinase-1 to placental growth factor ratio: ruling out pre-eclampsia for up to 4 weeks and value of retesting

OBJECTIVES

The soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) ratio is generally elevated some time before and at the clinical onset of pre-eclampsia. The PROGNOSIS study validated a sFlt-1/PlGF ratio cut-off of ≤ 38 to rule out the onset of pre-eclampsia within 1 week of testing in women with suspected disease. The aim of this study was to assess the predictive value of the sFlt-1/PlGF ratio to rule out the onset of pre-eclampsia for up to 4 weeks, and to assess the value of repeat measurements.

METHODS

This was an exploratory post-hoc analysis of data from the PROGNOSIS study performed in pregnant women aged ≥ 18 years with suspected pre-eclampsia, who were at 24 + 0 to 36 + 6 weeks' gestation at their first clinic visit. Serum samples were collected at the first visit and weekly thereafter. sFlt-1 and PlGF levels were measured using Elecsys® sFlt-1 and PlGF immunoassays. Whether the sFlt-1/PlGF ratio cut-off of ≤ 38 used to rule out the onset of pre-eclampsia within 1 week could predict the absence of pre-eclampsia 2, 3, and 4 weeks post-baseline was assessed. The value of repeat sFlt-1/PlGF testing was assessed by examining the difference in sFlt-1/PlGF ratio 2 and 3 weeks after the first measurement in women with, and those without, pre-eclampsia or adverse fetal outcome.

RESULTS

On analysis of 550 women, sFlt-1/PlGF ratio ≤ 38 ruled out the onset of pre-eclampsia 2 and 3 weeks post-baseline with high negative predictive values (NPV) of 97.9% and 95.7%, respectively. The onset of pre-eclampsia within 4 weeks was ruled out with a high NPV (94.3%) and high sensitivity and specificity (66.2% and 83.1%, respectively). Compared with women who did not develop pre-eclampsia, those who developed pre-eclampsia had significantly larger median increases in sFlt-1/PlGF ratio at 2 weeks (∆, 31.22 vs 1.45; P < 0.001) and at 3 weeks (∆, 48.97 vs 2.39; P < 0.001) after their initial visit. Women who developed pre-eclampsia and/or adverse fetal outcome compared with those who did not had a significantly greater median increase in sFlt-1/PlGF ratio over the same period (∆, 21.22 vs 1.40; P < 0.001 at 2 weeks; ∆, 34.95 vs 2.30; P < 0.001 at 3 weeks).

CONCLUSION

The Elecsys® immunoassay sFlt-1/PlGF ratio can help to rule out the onset of pre-eclampsia for 4 weeks in women with suspected pre-eclampsia. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Determination of pH or lactate in fetal scalp blood in management of intrapartum fetal distress: randomised controlled multicentre trial

OBJECTIVE

To examine the effectiveness of pH analysis of fetal scalp blood compared with lactate analysis in identifying hypoxia in labour to prevent acidaemia at birth.

DESIGN

Randomised controlled multicentre trial.

SETTING

Labour wards.

PARTICIPANTS

Women with a singleton pregnancy, cephalic presentation, gestational age >or=34 weeks, and clinical indication for fetal scalp blood sampling.

INTERVENTIONS

Standard pH analysis (n=1496) or lactate analysis (n=1496) with an electrochemical microvolume (5 mul) test strip device. The cut-off levels for intervention were pH <7.21 and lactate >4.8 mmol/l, respectively.

MAIN OUTCOME MEASURE

Metabolic acidaemia (pH <7.05 and base deficit >12 mmol/l) or pH <7.00 in cord artery blood.

RESULTS

Metabolic acidaemia occurred in 3.2% in the lactate group and in 3.6% in the pH group (relative risk 0.91, 95% confidence interval 0.61 to 1.36). pH <7.00 occurred in 1.5% in the lactate group and in 1.8% in the pH group (0.84, 0.47 to 1.50). There was no significant difference in Apgar scores <7 at 5 minutes (1.15, 0.76 to 1.75) or operative deliveries for fetal distress (1.02, 0.93 to 1.11).

CONCLUSION

There were no significant differences in rate of acidaemia at birth after use of lactate analysis or pH analysis of fetal scalp blood samples to determine hypoxia during labour.

TRIAL REGISTRATION

ISRCT No 1606064.

Neurochemical and cellular markers in human cervix of late pregnant, postpartal and non-pregnant women

BACKGROUND

The aim was to evaluate the peptidergic innervation and the dendritic cell content in the cervix uteri.

METHODS

Cervical biopsies were obtained from late pregnant (n=5), postpartal (n=5) and non-pregnant (n=5) women. The samples were prepared for immunohistochemistry using antibodies to protein S-100 (S-100), calcitonin gene-related peptide (CGRP), vasoactive intestinal polypeptide (VIP), human peptide histidine isoleucine amide (PHM 27), neuropeptide tyrosine (NPY), and human histocompatibility complex class II subregion DR (HLA-DR).

RESULTS

Nerve fibers positive for protein S-100, and dendritic cells positive for S-100 and HLA-DR were abundant in the cervix, especially at late pregnancy. CGRP, VIP, PHM-27 and NPY positive nerve fibers were present in non-pregnant, short nerve fibers and scattered immunoreactivity at term, and further scattered immunoreactivity after parturition. NPY positive nerve fibers were decreased at term, and after parturition a scattered immunoreactivity was observed.

CONCLUSIONS

The abundant protein S-100 positive nerve fibers implies an impact of myelinated nerves in the cervix uteri during pregnancy. The abundant dendritic cells, positive for HLA-DR and S-100, especially at term, indicates a general activation of the immune system until late pregnancy and parturition. The changed occurrence and distribution of immunoreactivity for CGRP, VIP and PHM-27 suggest a release of these neuropeptides until term. The changes in NPY immunoreactivity indicate a release of NPY around parturition.

Protein gene product 9.5-immunoreactive nerve fibers and cells in human cervix of late pregnant, postpartal and non-pregnant women

BACKGROUND

The aim of this study was to examine the occurrence and distribution of the general neuronal marker protein gene product (PGP) 9.5 in the cervix uteri.

METHODS

Cervical biopsies were obtained from late pregnant (n=5), postpartal (n=5) and non-pregnant (n=5) women. The samples were prepared for immunohistochemistry using antibodies to PGP 9.5.

RESULTS

Nerve fibers were found consistently in all biopsies. There were differences in the occurrence and distribution of PGP 9.5 immunoreactive nerve fibers and cells between the three groups. Immunoreactive nerve fibers were observed at a moderate to abundant frequency in the stroma and around arterial vessel walls, in all groups. Immunoreactive nerve fibers were also observed at high frequency within and around glandular epithelium in the late pregnant and postpartal groups. PGP 9.5 immunoreactive cells were seen occasionally in the stroma of the non-pregnant group, but at a high frequency in the stroma, around arterial blood vessel walls, around and within the glandular epithelium in the late pregnant and postpartal groups. The total frequency of immunoreactive nerve fibers and cells was the highest in the late pregnant group, slightly lower in the postpartal group, and the lowest in the non-pregnant group.

CONCLUSIONS

These findings show that changes in the general innervation take place during human cervical ripening until late pregnancy and parturition.

Cervical fetal fibronectin correlates to cervical ripening

AIM OF STUDY

It is well established that the cervical ripeness is of great prognostic value at labor induction. The available methods of measuring the cervical ripeness are not satisfactory. This study was therefore initiated to investigate if there is any correlation between cervical fetal fibronectin and cervical ripening at term.

METHOD

Three groups were included in this study: women with unripe cervices, women with spontaneous cervical ripening and those with PGE2-induced cervical ripening. Fetal fibronectin was measured by ELIZA after sampling from the cervical canal.

RESULTS

The cervical fetal fibronectin was low in women with unripe cervices. In women with favorable cervices a ten fold higher level was found. The fibronectin level was even higher after PGE2-induced ripening.

CONCLUSION

Conclusively an increased amount of cervical fetal fibronectin is registered during the cervical ripening process. A level of > 0.80 microgram/ml of cervical fetal fibronectin seems to indicate a favorable cervix.